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MANUAL 
 
 OP 
 
 Operative Surgery 
 
 BY 
 
 JOSEPH D. BRYANT, M.D. 
 
 PROFESSOR OF INATOUCS AND CLINICAL ETTRGERY, AMD ASSOCIATE PROFESSOR 
 
 OF ORTHOPEDIC SURGERY, BELLEVUE HOSPITAL MEDICAL COLLEGE; VISITINQ 
 
 SURGEON TO BELLEVUE HOSPITAL, AND CONSULTING SURGEON TO 
 
 THE NEW YORK LUNATIC ASYLUM AND THE OUT-DOOB 
 
 DEPARTMENT OF BELLEVUE HOSPITAL 
 
 WITH ABOUT 800 ILLtlSTMTIONS 
 
 Volume I 
 
 BERMINGHAM & COMPANY 
 
 98 Union Sqtjake, East I 20 King William St., Stband 
 
 New York I London 
 
 1884 
 
Copyright, 1883, by Bkrmingham & Co, 
 
 \'^I1 3 2, 
 ft ?^1. 
 
 V. \ 
 
TO 
 
 STEPHEN SMITH, M.D., 
 
 AND 
 
 To my Preceptor, 
 
 GEORGE W. AVERT, M.D., 
 
 THIS VOLUME IS RESPECTFULLY INSCRIBED, 
 
 THOUGH BUT A MEAGRE RECOG^aTION OF THE 
 
 MANY KINDNESSES SHOWN 
 
 BY THEU TO 
 
 THE AUTHOR. 
 
PREFACE. 
 
 The frequent request on the part of those whom it has 
 been my pleasure to instruct in operative surgery during 
 the last few years, to make a book based somewhat upon 
 the plan employed in teaching this subject, has been the 
 principal incentive to my action. The field of operative 
 surgery is too well cultivated already for one in this brief 
 space to hope to do more than to aid the student in acquir- 
 ing established facts, rather than to add to the art itself. 
 The works of Ashhurst, Gross, Erichsen, Holmes, Packard, 
 Smith, Esmarch, Stimson, and others, have been fully con- 
 sulted, and in some instances their language has been em- 
 ployed or paraphrased. The illustrations, which are nu- 
 merous, have been in most instances selected from the works 
 of the authors just mentioned, although a considerable 
 number of original cuts have been introduced. The author 
 desires to acknowledge the aid derived from the sources 
 mentioned, and trusts that the reader will find something 
 to commend in the pages that are to follow. The operations 
 peculiar to the female, and the eye and ear, have not been 
 considered, since they are, in the opinion of the author, en- 
 titled to a far more extended consideration than the inten- 
 tional scope of this work will admit of. 
 
 J. D. Bryant. 
 
 66 West 35TH St., New York, December, 1883. 
 
Digitized by the Internet Archive 
 
 in 2010 with funding from 
 Columbia University Libraries 
 
 http://www.archive.org/details/manualofoperativ01brya 
 
OPERATIVE SURGERY. 
 
 Operative surgery treats of the manual procedures 
 necessary to properly accomplish the surgical object in 
 view. The operation to be done is the execution upon the 
 part of a verdict that is, or should be, based upon surgical 
 principles and laws in a comparative sense of legal pro- 
 ceedings in the Courts of Justice. The surgeon, in most 
 instances, however, holds the threefold position of judge, 
 jury and executioner. It is, therefore, very essential for 
 the welfare of the patient that he properly interpret the 
 surgical laws and principles relating to the case, in order 
 that the verdict to follow may be just, and its execution 
 cast no opprobrium upon himself or his profession. To be 
 able to operate understandingly requires not only a thor- 
 ough knowledge of the principles of surgery, but a fair 
 knowledge of the ways and means of accomplishing the 
 desired purpose. 
 
 It is not enough to be able to remove, in a scientific man- 
 ner, an offending member or disease, but it is equally 
 important for the surgeon to so prepare the patient and 
 himself that no unanticipated complication can occur im- 
 mediately prior to, during, or subsequent to the operation. 
 
 Regarding the principles of surgery proper, the reader is 
 referred to the many works upon that subject; since it is 
 not the intention of the author to intrude upon this depart- 
 ment of surgery, except, in so far as it may be found ex- 
 pedient to apply them to the immediate safety of the 
 patient during and subsequent to the operation. 
 
 Prior to an operation, especially if it be one of any mag- 
 nitude, it is essential that the following facts be ascertained: 
 
 First. The physical condition of the heart, lungs, kidneys, 
 brain and great vessels. 
 
 Second. If there be an acute surgical or other complica- 
 
18 OPERATIVE SURGERY. 
 
 tion of the essential organs of the body, joints, serous 
 cavities, etc. 
 
 Third. If the patient be suffering from shock. 
 
 Fourth, If the patient be anaemic or scorbutic. If he 
 has syphilis, phthisis, epilepsy, diabetes, or be in danger 
 of delirium tremens. 
 
 Fifth. If he be willing and ready for the operation. 
 
 Upon the healthful condition of the heart, lungs, brain, 
 etc., may depend the expediency of giving an anaesthetic, 
 and the choice between them. If the kidneys be diseased, 
 it may be inadvisable to operate upon the urethra or blad' 
 der, or even to give an anaesthetic; if the great vessels be 
 dilated or atheromatous, much discretion must be employed 
 in its selection and administration. It should not be for- 
 gotten, however, that the mental emotion and physical suf' 
 fering attendant upon an operation, when performed with- 
 out anaesthesia, may be of greater moment than with its 
 use. 
 
 If the injury demanding an operation be recent, and the 
 patient be suffering from a severe shock, it should be de- 
 ferred until reaction is established. If the shock be out of 
 proportion to the visible injury, a careful examination of 
 the patient must be made to ascertain its cause. If a com- 
 plicating injury be discovered, which of itself imperils the 
 life of the patient, all idea of an immediate operation must 
 be deferred. These thoughtful attentions lessen the right- 
 eousness of the oft-repeated satirical expression, " The 
 operation was successful, but the patient succumbed." 
 
 If the patient be already anaemic, or scorbutic, the loss 
 of blood added to the shock of the operation may expose 
 him to greater dangers than if the operation be postponed. 
 Unfortunately, however, in a majority of cases, the condi- 
 tions calling for operative interference are the prime fac- 
 tors which determine the degree of the blood changes, and 
 will not, of themselves, admit of any delay. 
 
 The existence of syphilis, phthisis, diabetes, etc., exert a 
 marked influence on the recovery, and their importance 
 must not be underestimated in connection with this fact. 
 If a patient be addicted to the continuous use of intoxi- 
 cating beverages, and worse still, if he receives an injury 
 during a prolonged debauch, it seriously complicates his 
 case, not only directly from the previous effects upon his 
 bodily vigor, but from the impending danger of delirium 
 tremens. 
 
GENERAL CONSIDERATIONS. I9 
 
 It is not necessary to the successful issue of an operation 
 that the patient be ready and willing ; yet, if such a fortu- 
 nate combination be present, it will weigh heavily in favor 
 of ultimate success. It is prudent, however, that he should 
 be ready in a legal sense ; that is, that his consent be 
 gained. 
 
 If the operation be a dernier ressori.^ he should be given 
 the opportunity of adjusting his business and spiritual 
 affairs. If they be prematurely adjusted — if such be possi- 
 ble — the knowledge of it, and the quiet of mind resulting 
 therefrom, will become valuable aids to his recovery. 
 
 Season of the Year. — Autumn and spring are the best 
 seasons for operating. Still it is not always practicable to 
 render this knowledge available. It is best to avoid, as far 
 as possible, extremes of temperature. Fair weather with 
 an ascending barometer is more propitious than the re- 
 verse. 
 
 Time of day should be such as to secure a good light 
 until the completion of the operation. 
 
 The surroundings of the patient subsequent to the operation 
 are to be studied with great care. The sick room should 
 be commodious and sunny, and when possible be on the sec- 
 ond floor with a southern exposure, and with the door and 
 windows so arranged that it can be easily ventilated with- 
 out exposure to improper air-currents. All sewer-con- 
 hected wash-basins or other receptacles of waste must be 
 excluded from the room. The plainer the walls and ceil- 
 ings the better ; for, if the patient become delirious, the out- 
 lines and figures of modern decorations may invite, and 
 form the basis of exciting delusions. It is better at all 
 times, for hygienic reasons, that the room be as plain as 
 possible, and that all unnecessary articles be removed 
 therefrom, especially when it is to be reoccupied for a 
 similar purpose. During convalescence, and after all 
 dangers from septic influences are passed, objects of 
 interest may be placed upon the mantels and walls, which 
 can be varied from time to time to please the fancies of the 
 patient. 
 
 The temperature of the room should be maintained at 
 about 70 degrees Fahrenheit. Pure air 13 quite as essential 
 to a rapid recovery as good food. It should be thoroughly 
 ventilated at least once each day; this can be readily done 
 by opening the windows and doors, thereby creating a 
 through-and-through current, at the same time using cau- 
 
20 OPERATIVE SURGERY. 
 
 tion that the patient be protected from direct draughts, 
 and be well covered till the temperature shall have resumed 
 a suitable standard. The presence of flowers and other 
 odoriferous agents are not to be encouraged in the sick 
 room, although they may exert a good moral influence, in 
 that they remind the patient of the existence of sympathiz- 
 ing friends without. It must always be made as cheerful 
 as possible, consequently all annoyances are to be removed 
 whenever the fancies of the patient indicate their presence. 
 
 Place for a7i Operation. — The office of the surgeon is not 
 a proper place to do operations of any magnitude, or 
 even those requiring the use of an anaesthetic, because the 
 rest and quiet that should follow the former cannot be had 
 if the patient be removed; and, moreover, anaesthesia is often 
 followed by persistent nausea and vomiting, and not infre- 
 quently by prolonged noisy delirium. 
 
 Nursing. — All who require the services of a nurse should, 
 if possible, secure those of an experienced and professional 
 one. The well-intended attentions and observations of 
 solicitous friends are often burdensome to the patient 
 and misguiding to the surgeon, and are as apt to be con- 
 trolled by their sympathy for the patient as by the desire 
 to consult the express wishes of the medical attendant. It 
 is well to remember, however, that a discreet friend is a far 
 better attendant than a garrulous self-sufficient nurse. 
 The attendant who proffers his views and experience in 
 the sick-chamber, hoping thereby to honestly impress all 
 present with his worth, is as detrimental to the moral at- 
 mosphere of the room, as closed windows and doors are to 
 the physical. 
 
 Preparatory Treatment. — This should be directed to the 
 improvement of the patient's general condition, also, to di- 
 rectly combating the constitutional diseases which may 
 effect the ultimate result. 
 
 Diet. — Precisely the variety and amount of food to be 
 given, are matters which must be determined by the re- 
 quirements of the individual cases. Milk, eggs, milk-punch, 
 stimulants, etc., are stereotyped articles, the usefulness of 
 which is well established. They should not, in any in- 
 stance, if it be possible to avoid it, be substituted by the 
 traditional beef tea, and more elaborate chemical extracts 
 with which the market is cloyed. The requirements neces- 
 sary to secure satisfactory results in surgical operations 
 may be divided into the essential and precautionary. 
 
GENERAL CONSIDERATIONS. 2! 
 
 The essential requirements consist of such implements, 
 agents and information as are necessary to the proper per- 
 formance of an operation, as well as to a due consideration 
 of the result. The precautionary are those which are useful 
 in the various emergencies that may complicate an opera- 
 tion; and it is necessary, if they are to be of practical 
 utility, that they should be at hand and be prepared for 
 immediate use. 
 
 ESSENTIAL REQUIREMENTS. 
 
 First. A knowledge of the usual result of the operation 
 
 about to be performed. 
 
 Second. A practical knowledge of the anatomy of the 
 parts involved in the operation. 
 
 Third. Anaesthetics; proper means of administering, and 
 their dangers. 
 
 Fourth. The necessary implements and a knowledge of 
 their use. 
 
 Fifth. Suitable trays to hold instruments. 
 
 Sixth. Operating table, sponges, empty vessels and an- 
 tiseptic solutions. 
 
 Seventh. Agents for controlling hemorrhage. 
 
 Eighth. Assistants of suitable number and proficiency. 
 
 Ninth. A patient properly prepared for the procedure. 
 
 Tenth. Proper materials for dressing wounds and a 
 knowledge of their use. 
 
 A knowledge of the usual result of the operatioti about to be 
 perfor?ned, is one of the chief factors to be employed to de- 
 termine its propriety ; and is, therefore, entitled to be first 
 considered. This knowledge can be gained from only two 
 sources: First, the personal experience of the operator and 
 of those from whom he may be able to receive an opinion. 
 Second, the recorded experience of the profession. The 
 first implies the calling of a consultation, which should 
 always be done whenever a doubt exists in the mind of the 
 operator; such a course not only offers to the patient every 
 available chance, but in unfortunate results, frequently 
 serves to soothe the feelings of disappointment experienced 
 by all concerned. If a consultation be not feasible, the 
 surgeon must then rely upon the recorded practical knowl- 
 edge of the profession. 
 
 A practical understanding of the anatomy of the part in- 
 volved in an operation is always essential to the comfort of 
 
22 OPERATIVE SURGERY. 
 
 the operator, and often to the safety of the patient. This 
 knowledge is somewhat difficult to obtain and is always of 
 uncertain tenure. In the case of the general practitioner, 
 it consists chiefly of that which can be gleaned from text- 
 books and anatomical plates; often called, "Flat Anatomy," 
 added to the anatomical knowledge retained since gradu- 
 ation. Those who reside in large cities can avail themselves 
 of the ample opportunities afforded, to rehearse important 
 operations. When the dead can be made generally subser- 
 vient to the welfare of the living, then all medical men can 
 avail themselves of the only means of becoming fully able 
 to surgically, *' Do unto others as they would be done by." 
 
 Ancesthetics. — The anaesthetics in established use are ether, 
 chloroform, and nitrous oxide or laughing-gas. The first is 
 employed far more in surgery, than the others combined. 
 The chief objections to its use are its pungency; the liability 
 of nausea and vomiting; inflammability, and the production 
 of cerebral excitement. 
 
 Its disagreeable pungency can be lessened, in fact, almost 
 entirely obviated, by allowing a good volume of air to min- 
 gle with it during the first moments of its administration. 
 One has but to cover his own face with the well-charged 
 ether cone in common use, to realize the sense of impending 
 suffocation, which is experienced by the unwary patient, 
 whose struggles to resist it are often violent, and suggest- 
 ive of the belief that, upon his part, the struggle is for life. 
 Scenes of this kind should always be avoided, more espe- 
 cially when the patient is suffering from any complications 
 which will expose him to an additional peril. The nausea 
 and vomiting following, are not of sufficient importance to 
 contra-indicate its use, except in such cases as it would be 
 otherwise objectionable. 
 
 The resultant vomiting is chiefly dangerous, where solid 
 food has been recently taken, often causing suffocation by 
 its entering the larynx and trachea. 
 
 Inflaminability. — This is only to be regarded while operating 
 in the presence of artificial light, or with the actual cautery. 
 There is, however, but little danger, since the weight of 
 the vapor causes it to create a downward current, thereby 
 tending to remove it from contact with the igniting agent. 
 It is safer, however, for all concerned, to treat it on such 
 occasions as if it were only awaiting the slightest oppor- 
 tunity to assert its power. The strong cerebral excitement 
 which often precedes complete anaesthesia may be due to 
 
ANESTHETICS. 
 
 23 
 
 an idiosyncrasy, or be excited by surrounding circumstances. 
 The patient should be assured that no harm will attend its 
 administration; it should be given in a gentle manner, 
 slowly in the beginning, that the mucous membranes may 
 not suffer too great irritation; and complete quietude on 
 the part of all present should be maintained, since talking 
 often serves to excite the inebriated fancies, and forms the 
 basis of disorderly actions. The handling of the part to be 
 operated upon, prior to complete insensibility, is a fertile 
 source of annoyance, and is often suggestive to the patient 
 of the impending operation. These are precautions which 
 
 Fig. I.— Chloroform Inhaler. (Esmarch.) 
 
 should be observed during the administration of all anaes- 
 thetics. 
 
 Chloroform is more dangerous than ether, and should 
 not be used, unless the contra-indications to the use of 
 ether are exceedingly strong. Although it has a pleasant 
 odor and is devoid of pungency, less liable to induce vom- 
 iting and cerebral excitement, non-inflammable and 
 quicker of action than ether, yet these facts w1:igh but lit- 
 tle as against the additional dangers incurred by its use. 
 At the present time its application as an anaesthetic is 
 almost entirely limited to children, and to obstetrical prac- 
 tice. Chloroform can be administered by pouring a few 
 drops on a napkin which is held at a short distance from 
 the nose, or by the agency of an inhaler figured by Esmarch 
 (Fig. i), which consists simply of a properly shaped wire 
 
24 OPERATIVE SURGERY. 
 
 framework, covered by flannel and fastened to the head. 
 Nitrous oxide is the most agreeable and least dangerous of 
 the anaesthetics in general use. Its employment is limited 
 to operations of short duration. It cannot be classed as a 
 practical anaesthetic, since its expense, the cumbersome 
 apparatus for administration, and transient effects unfit 
 it for general use. It is, however, often employed where 
 the presence of cardiac or other organic diseases contra- 
 indicate the use of ether or chloroform. 
 
 Inhalers.-^Tht variety of inhalers for administering anaes- 
 thetics is large. It is no part of my intention to discuss 
 the comparative virtues of the various forms; but rather to 
 select those in common use, so that the general practitioner 
 residing at a distance from the basis of surgical supplies, 
 can be able to extemporize at least one of the many which 
 will meet the pressing indications. 
 
 The simplest method of administering any anaesthetic, 
 and the one generally employed with chloroform, is upon 
 a towel or napkin. In the case of ether, this is very unsat- 
 isfactory; inasmuch as it involves an unnecessary expendi- 
 ture of time and ether, and produces a less satisfactory an- 
 aesthesia than any other method. There are other perti- 
 nent objections to it, but those already mentioned are of 
 sufficient weight to dismiss its further consideration. 
 
 The simplest form of ether cone, or inhaler, is the one 
 that has been for a long time in common use in many of 
 the hospitals of this city. 
 
 The method of its construction is 
 simple and the materials employed 
 are always accessible. A sheet of 
 paper of strong texture, or three or 
 four layers of an ordinary news- 
 paper, two feet in length and eigh- 
 teen or twenty inches in width, to- 
 gether with a strong piece of cloth, 
 the dimensions of which shall ex- 
 ceed those of the paper two or three 
 ^''^- *• inches, and a dozen ordinary pins, 
 
 are all that is required to construct it. Place the cloth — a 
 towel is usually employed — and the paper on a table, with 
 the paper uppermost; fold them in the centre of their long 
 diameter, which will bring the cloth on the outer surfaces 
 and the paper within. Then fold them in the short diam- 
 eter, the length of the fold corresponding to the distance 
 
ANESTHETICS. 2$ 
 
 from the lower border of the symphysis mentis to the root 
 of the nose of the patient; when thus folded, pin the outer 
 and inner extremities firmly through the whole texture of 
 the sides, using care that the pins be so placed that they 
 will not stick the patient's face, or the hands of the one ad- 
 ministering the anaesthetic, Several pins are now to be 
 passed through all the textures in various situations to hold 
 them firmly together. One end of this tube must now be 
 closed, which is easily and quickly accomplished by turning 
 inwards its borders, and securely pinning them to each 
 other. It is better to close the end corresponding to the 
 free extremities of the material, thereby giving a firmer 
 basis to the cone. Into the top of the cone is then crowded 
 a good-sized sponge, or a piece of coarse-textured cloth, 
 always observing that it be beyond the reach of the nose 
 and face of the patient Absorbent cotton or several layers 
 of muslin may be interposed between the surfaces of the 
 upper end, instead of their being closed by turning and pin- 
 ning as just described. If this material be now confined 
 in position by means of pins and the end covered with a 
 layer of thin gauze, the ether can then be poured upon the 
 interposed material and administered without removing 
 the cone from the face. It likewise admits the requisite 
 amount of air. The advantages which this simple affair 
 possesses over the permanent and more expensive ones, are 
 quite numerous. It cannot be damaged by the patient, nor 
 will the face be bruised by its borders during his struggles; 
 it is a temporary' affair, and therefore need never be used a 
 second time — a fact which is obviously of considerable im- 
 portance in a fastidious and hygienic sense. It does not, 
 however, admit of the easy regulation of the amount of 
 ether to be given, or the amount of air to be admitted; it 
 is also liable, unless care be used in replenishing it with 
 ether, to permit the anaesthetic to flow into the eyes and 
 upon the face of the patient; yet these are objections which 
 can be easily surmounted by a requisite amount of caution. 
 The amount of ether required with this apparatus is less 
 than if a napkin be used alone, while it exceeds that em- 
 ployed in the more perfect inhalers. 
 
 Allis' inhaler, which consists of a penetrated metallic 
 framework for the support of cloth partitions, surrounded 
 by an adjustable leather or rubber covering, is simple, 
 efficient, portable, and can be quite easily cleansed (Figs. 3 
 and 4). Its advantages, briefly stated, are the following: 
 
26 
 
 OPERATIVE SURGERY. 
 
 It allows a free admission of air from above, which becomes 
 saturated with ether, the evaporating surface is great, 
 causing thereby a rapid vaporization, which hastens an- 
 aesthesia and saves ether. The ether can be replenished 
 
 Fig. 3. 
 
 Allis' Inhaler. 
 
 Fig. 4. 
 
 through the top, which obviates the necessity of removing 
 the inhaler and interrupting the administration. 
 
 The cloth partitions can be readily changed whenever 
 propriety and cleanliness demand it. The inhalers of 
 
 Lente, Squibb, Noyes, Chis- 
 holm, and others, are all 
 serviceable, and whoever 
 possesses either of them 
 can, so far as the apparatus 
 is concerned, administer 
 ether with safety. It is not 
 necessary to the safety of 
 the patient that either of 
 them be employed. It is, 
 however, necessary to the 
 safety of the patient, no 
 matter which one be em- 
 ployed, that the giver of the 
 anaesthetic shall rely more 
 upon his knowledge of the 
 principles governing its administration than upon the mech- 
 anism of the apparatus. With a proper knowledge of these 
 principles, it matters but little whether one or another 
 form of inhaler be used. 
 
 Fig. s. — Lentk's Inhaler. 
 
ANESTHETICS. 
 
 27 
 
 Lenie's Inhaler (Fig. 5). — The construction of this appa- 
 ratus is so simple that space is not necessary to describe 
 it. The modified inhaler has additional advantages, how- 
 ever. Either answers the purpose admirably. 
 
 Squibb' s Inhaler (Fig. 6). — This consists of an hour-glass- 
 shaped muslin bag, one end of which is cut off to fit the 
 face of the patient. The narrow portion is made to receive 
 a tin tube several inches in length and two in diameter ; 
 the round end serves the purpose of an air-chamber. 
 When the bag is to be used it should be wetted with 
 water and thoroughly squeezed, to render it only partially 
 pervious to the passage of air or other vapor. Into the tin 
 tube a piece of flannel and blotting-paper rolled together, 
 each about six inches wide and eighteen inches long, are 
 thrust, after which they are saturated with ether; or it 
 
 Fig. 6.— Squibb's Inhaler. 
 
 may be done before the introduction. The open end of 
 the apparatus is then placed over the mouth and nose of 
 the patient and the administration commenced. One to 
 two and a half ounces are quite enough to properly 
 anaesthetize the patient. 
 
 Noyes' Inhaler (Fig. 7). — This apparatus is simple of con- 
 struction. It consists of a flexible air-cham.ber at one end 
 and a face piece at the other. Between the two is a small 
 tin chamber to contain the ether. The bag or air-chamber 
 is perforated by a small hole, which allows the entrance of 
 a sufficient amount of air, which enters the lungs along 
 with the ether at each effort of inspiration. The amount of 
 ether with this is about the same as with the preceding. 
 
 The amount of ether required to produce insensibility de- 
 pends upon several conditions, the most important of which 
 are, the susceptibility of the patient, the manner of admin- 
 istering, and the purity of the anaesthetic. Some persons 
 
2S 
 
 OPERATIVE SURGERY. 
 
 can be completely anaesthetized by an ounce, and even 
 less, if it be not wasted; on the other hand, those are occa- 
 sionally met with who " take ether badly," and cannot be 
 rendered quiet unless a large amount be given; rarely, a 
 
 Fig. 7. — NoYES' Inhalkr. 
 
 case is encountered which will not yield to its influence, and 
 the surgeon is forced to desist, from fear of destroying the 
 patient. It is not prudent to determine in advance the defi- 
 nite amount that will be used, except possibly in some pe- 
 culiar cases. Anaesthesia is never to be attempted unless 
 the surgeon can be certain he has a sufficient amount to 
 
 Fig. 8. — Chisholm's Inhaler. 
 
 complete the operation, for nothing can be more humiliat- 
 ing than to be obliged to discontinue an operation for the 
 purpose of procuring additional ether. It is not politic to 
 begin an operation that requires much time and care, with- 
 out at least one pound of ether be at hand. 
 
ANESTHETICS. 2g 
 
 Purity of the Anesthetic. — It is important that the anaes- 
 thetic be pure, in order that the amount taken may be suita- 
 bly judged, and a proper interpretation placed upon the 
 effect produced. Those manufactured by Squibb, of Brook- 
 lyn, are generally considered to be of a superior quality. 
 
 Dangers from the Use of Ether. — The dangers attending 
 the use of anaesthetics may be reduced to a minimum, pro- 
 vided proper attention be given to the physical conditions 
 recognized as contra-indicatingor requiring caution in their 
 use, together with a display of ordinary care in administer- 
 ing. Before giving it, the heart, lungs, brain, and kidney 
 vessels, etc., should be interrogated, even though there be 
 no apparent evidences of disease. If they have undergone 
 organic changes, or, if the patient have laryngeal obstruc- 
 tion from any cause, bronchitis, or be pregnant, the great- 
 est caution must be employed in the administration even 
 if it be given at all. The degree of the disease, and the 
 condition of the patient dependent thereon, together with 
 the necessity of an immediate operation and its severity, 
 must determine the advisability of its use. If the patient 
 have advanced heart and kidney disease, phthisis, or 
 aneurism, it is better to use nitrous oxide; chloroform, even, 
 has been used under such circumstances instead of ether, 
 on account of its causing less excitement and vomiting. 
 The danger from a full stomach is great, especially if the 
 ingesta be solid; since, if vomiting occur, the food may be 
 sucked into the larynx and trachea, causing death by suffo- 
 cation ; moreover, nausea and vomiting are more frequent 
 and persistent when the stomach is partially filled with 
 food. It is impracticable to lay down all the important re- 
 lations existing between the use of an anaesthetic and the 
 various complications that may exist as contra-indications. 
 The surgeon must be largely controlled by the circumstances 
 surrounding the individual case. If it be determined toad- 
 minister ether or chloroform to a patient suffering from a de- 
 bilitated heart, the latter's action must be strengthened by 
 the administration of digitalis some days prior to the opera- 
 tion, as well as by stimulants during it. If the patient have 
 laryngeal obstruction, from spasm of the glottis or other 
 causes, the pungency of the ether, and spasm of the respira- 
 tory muscles, when added to the already lessened area of 
 the respiratory chink, and the diminished aeration of the 
 blood resulting therefrom, may be often sufficient to produce 
 rapid unconsciousness and impending death from asphyxia. 
 
30 OPERATIVE SURGERY. 
 
 In my opinion, chloroform is the better anaesthetic under 
 such circumstances. 
 
 How to Prepare a Patient for Anasthesia. — First. Inform 
 yourself of the state of the brain, heart, lungs, kidneys, 
 vessels, etc.; if disease be found, inform the patient or the 
 friends of the additional dangers incurred. 
 
 Second. Count the pulse and respiration, noting the 
 character of each, and making due allowance for the excite- 
 ment dependent upon surrounding circumstances. These 
 observations will be far more valuable if they have been 
 taken some time prior to the immediate operation. 
 
 Third. See that no solid food has been taken for at least 
 six to eight hours before; if so, evacuate the stomach by 
 means of a simple and rapid emetic. The practical way of 
 having the stomach in a proper condition is to omit the 
 meal preceding the operation. If the time be too long for 
 this, a glass or two of milk three or four hours before will 
 meet the indications. 
 
 Fourth. Remove all false teeth from the mouth, or 
 whatever else might fall into the larynx. 
 
 Fifth. Loosen all constricting bands which surround 
 the abdomen, chest, and throat. 
 
 Sixth. Cause the evacuation of the contents of the blad- 
 der and rectum; this will often prevent the soiling of the 
 clothes and patient. 
 
 Seventh. Place the patient upon the back with the head 
 and shoulders slightly raised; neck not bent. 
 
 Eighth. If the patient have a beard, wet it to prevent the 
 rapid escape of the ether through it. 
 
 Ninth. Adjust windows and doors to admit fresh air, 
 without exposing the patient to a draught. 
 
 Tenth. Disarm the patient of all fears of danger attend- 
 ing its use. 
 
 The one who is to administer the anaesthetic should have 
 at his convenience a basin, towel, and a tenaculum or for- 
 ceps. The first for the reception of the dejections from 
 the stomach ; the towel to remove the saliva, etc., from the 
 mouth and face; the tenaculum or forceps, to pull forward 
 the tongue if it fall backward over the glottis. 
 
 It is recommended, and with much force, to administer 
 hypodermically or otherwise a dose of morphia an hour 
 or so before anaesthesia is to be commenced. It quiets the 
 nervous excitement of the patient, reduces the amount of 
 ether otherwise necessary, and prolongs its effect; lessens 
 
ANESTHETICS. 
 
 31 
 
 the tendency to nausea and vomiting, and diminishes shock. 
 Moderate inebriation has been produced immediately in 
 advance of an operation by giving brandy or whisky, and 
 for substantially the same reasons. 
 
 Method of Adininistering Ether. — Commence by pouring a 
 small amount, an ounce or so, into or upon the inhaler, 
 and adjust it so that a good volume of air shall mingle with 
 the ether, for the first fe\' moments of the administration. 
 After the sense of pungency has somewhat subsided, the pa- 
 tient should be told to "cough," "breathe deeply," at the 
 same time the fresh air is to be quite rapidly excluded. The 
 patient soon becomes oblivious, and may be fully anaesthe- 
 
 FiG. g. — Drawing the Tongue Forward. (Esmarch.) 
 
 tized without further trouble. This is recognized by the 
 insensibility of the conjunctiva, or, what is better, a relaxed 
 muscular system, which is ascertained by noting the ab- 
 sence of any resistance to flexing or extending the extremi- 
 ties. If an extremity be raised from the bed, it will fall 
 directly downward and lie motionless. Stertorous breath- 
 ing is likewise a concomitant of complete anaesthesia. More 
 often, however, the patient will be seen to pass through the 
 three distinct stages of anaesthesia, which will vary in their 
 length and manifestations, according to his peculiarities. 
 The attention of the giver of the anaesthetic should always 
 be directed to the character of the respiration and pulse, 
 
32 
 
 OPERATIVE SURGERY. 
 
 the color of the surface and its temperature. The respira- 
 tion is often temporarily stopped or impeded by the tonic 
 stage, causing marked cyanosis. This is quite readily re- 
 lieved by making sudden and forcible pressure in the epi- 
 gastrium, or slapping the chest with the naked hand or a 
 wet towel. The respiration may be obstructed or prevented, 
 at any period of anaesthesia, by foreign bodies in the larynx 
 and trachea; such as false teeth, vomited matter, etc. In 
 complications of this character the obstructing agent must 
 be removed immediately or death will ensue, unless tracheot- 
 omy be performed. The glottis may become stopped by 
 the falling backwards of the tongue; this usually occurs 
 during the stage of complete anaesthesia, and is to be in- 
 
 FiG. 10.— Pushing the Jaw Forward. (Esmarch.) 
 
 stantly remedied by drawing the tongue forward by the aid 
 of a tenaculum or dry towel or forceps. 
 
 If the jaw be pressed forward during the administration 
 of the anaesthetic, by the one giving it (Fig. lo), the muscular 
 attachments of the base of the tongue are separated, and 
 its base depressed and drawn forward. 
 
 The treatment for the relief of poisoning, due either to an 
 overdose of ether or chloroform, is substantially the same. 
 Successful treatment will depend not only upon the pres- 
 ence of mind of the surgeon, but upon the precautionary 
 preparations which have been made for such a contingency, 
 as well as the rapidity and force with which the remedies 
 are applied. 
 
ANESTHETICS. 33 
 
 The anaesthetic must be stopped at once; the head low- 
 ered and the tongue pulled forward; windows and doors 
 opened to admit fresh air; artificial respiration (Figs. 11 and 
 12); flagellation of the face and chest by towels wet with 
 cold water; hypodermic injections of brandy, whisky, or 
 ammonia; inhalation of nitrite of amyl, and the use of elec- 
 tricity. It is not intended that these remedies shall be 
 used in the order mentioned; but the surgeon and his as- 
 
 FiG. II. — Artificial Respiration— First Movement. (Esmarch.) 
 
 sistants will find their time and thoughts occupied in carry- 
 ing them into execution — such of them as may admit of 
 instant application. Under no consideration must the 
 efforts of resuscitation be allowed to flag, or be stopped, 
 until every hope of saving the life has some time since 
 passed.* 
 
 *In performing artificial respiration the movements should be done 
 slowly and with a regularity similar to the normal act of respiration. 
 
34 
 
 OPERATIVE SURGERY. 
 
 Fig. 19. — Artificial Respiration — Second Movement. (Esmarch.) 
 
 Local AncBsthesia. — Although there are numerous agents in 
 use for this purpose, ether possesses the greatest number 
 of practical advantages. The following instrument (Fig. 
 
 Fig. 13.— Richardson's Spray. 
 
 To move the arms upward and downward with the rapidity of a pump- 
 handle is irrational and inopperative ; yet under the influence of ex* 
 citing surroundings such a manner is not infrequently to be seen, 
 
INSTRUMENTS IN GENERAL USE. 
 
 35 
 
 13) is the one commonly used for purposes of local anaes- 
 thesia, and is employed in those minor operations which 
 can be quickly done. The pain that follows the return of 
 sensibility to the benumbed parts is often more severe and 
 prolonged, than the immediate suffering from the operation 
 without its use. The tissues should not be frozen, but 
 be numbed; since to freeze them increases the pain and 
 retards repair. 
 
 INSTRUMENTS NECESSARY FOR THE PERFORMANCE OF 
 OPERATIONS. 
 
 The instruments necessary for the performance of an 
 operation must, of necessity, be regulated by its magnitude 
 and nature. They can, however, 
 for the sake of brevity, be divided 
 into those in general use and those 
 for special purposes. The ones in 
 general use include scalpels and 1^ 
 bistouries of various forms (Fig. 
 14), thumb forceps, groved directors, 
 and scissors. Those for special pur- 
 poses are used in performing the 
 operations which, in most instances, 
 caused their creation. These will 
 be considered in connection with 
 the operations to which they are 
 particularly adapted. 
 
 Method of holding the Scalpel. — 
 Three positions are commonly rec- 
 ommended, each of which is sub- 
 divided into two. The basis of the 
 positions rests upon the manner of 
 holding the ordinary table knife, the 
 pen, and violin bow. 
 
 Figs. 15 and 16 represent the subdivisions of the first 
 
 Fig. 14. 
 scalfkls and bistouries. 
 
 Fis. 15. 
 
36 
 
 OPERATIVE SURGERY. 
 
 Fig. i6. 
 
 Fig. I 
 
 position; they indicate that force or firmness are desired. 
 Figs. 17 and 18 represent the subdivisions of the secon4 
 
INSTRUMENTS. 
 
 37 
 
 positions; these are taken when quick, delicate and precise 
 movements are required. Figs. 19 and 20 are the subdi- 
 visions of the third position, and are employed when 
 caution is used in conjunction with delicacy in cutting. 
 . These positions are more essential to graceful, than to 
 successful operating. 
 
 Thumb forceps (Fig. 21) are used in connection with the 
 
 Figs. 19 and 20. 
 
 scalpel or scissors. They are employed to pick up tissues, 
 like the fascia, etc., which are to be incised at the point 
 grasped for the purpose of inserting the grooved director. 
 The scalpel or bistoury should beheld at nearly an angle to 
 the forceps when the incision is made, especially when im- 
 portant structures lie immediately beneath (Fig. 22). 
 
 The grooved director (Fig. 23) is used to raise the tissues 
 
 Fig. 21. — Thumb Forceps. 
 
 which are to be divided with caution. It should be five or 
 six inches in length, depending upon the length of the in- 
 cision and the depth of the wound into which it is to be 
 inserted; flexible, with a broad extremity to grasp, and a 
 pocket at the end of the groove to arrest the point of the 
 knife or scissors. It should not be pushed beyond the ex- 
 tremities of the external incision because of the danger 
 of making pockets in the soft parts, which will impede 
 drainage. The tissues raised upon the director must not 
 
38 OPERATIVE SURGERY. 
 
 be divided beyond the angles of the external incision. 
 Care should be taken when the director is passed between 
 a serous membrane and its superimposed fascia that the 
 membrane does not fold over the advancing extremity, 
 thereby causing it to be punctured or divided by the knife 
 or scissors. 
 
 The Scissors. — They are used as a substitute for the 
 scalpel in incisions of great depth, JBmbined with limited 
 
 Fig. as.— Nicking Fascia. 
 
 space and a necessity for caution. Less hemorrhage fol- 
 lows their use than from the scalpel, owing to the crushing 
 nature of their force. They should be more or less angular, 
 to accommodate them to the depth of the operation wound 
 (Figs. 24 and 24^?). 
 
 Incisions.— The varieties of incisions are numerous, and 
 are named from the shape which they take. The outlines 
 of incisions are controlled very largely by the underlying 
 anatomy; the desire to secure good drainage, and to avoid 
 disfiguring the patient. There is a greater danger of mak- 
 ing an incision too short than too long; and of the two, the 
 
INSTRUMENTS. 
 
 39 
 
 former is the greater evil. A long, deep, clean-cut incision 
 will drain better and heal more quickly than a short deep 
 one, bounded by tissues which have been disturbed by the 
 efforts to accomplish a definite purpose within a too lim- 
 ited space. The various forms of incisions will 
 appear in connection with the operations to which 
 they are applicable. 
 
 Fig. 23. 
 
 Fig. 
 
 Fig. 24a. 
 
 Instruments should be Plain. — All instruments associated 
 with surgery should, when practicable, be constructed in a 
 plain and substantial manner. The handles and shanks of 
 the knives should be smooth and closely fitted. The in- 
 equalities of instruments tend to catch impurities, and 
 
40 OPERATIVE SURGERY. 
 
 should never be tolerated when they but serve to embellish 
 the implement. 
 
 Receptacle for Instruments. — It is better that all instruments 
 be made aseptic before they are used; for this purpose, a 
 shallow tray of suitable dimensions should be filled with an 
 aseptic fluid, and the instruments be immersed therein for 
 an hour or two before they are used. This tray, with the 
 contents, should be placed at a convenient distance, in 
 order that the instruments may be taken directly from it 
 when needed. If they are to be again required, they should 
 be returned to the tray as soon as used. 
 
 Operating Table. — The patient should always be placed 
 upon a genuine, or an extemporized table, of sufficient 
 height to suit the convenience of the surgeon. To operate 
 upon abed or lounge, as is often done, not only cripples the 
 resources of the surgeon, but robs him, too often, of a suit- 
 able light, to say nothing of the soiling of the bedding. 
 There are numerous styles of operating tables, many of 
 which are of very ingenious construction; they are, how- 
 ever, much better suited for hospital than private practice. 
 The ordinary table, covered by an old quilt and rubber 
 cloth, will meet all common indications. 
 
 Empty Vessels. — There should always be a good supply of 
 empty pails and basins to receive the waste-water, soiled 
 linen, amputated parts, etc. At least one empty basin 
 should be provided to receive the soiled sponges, otherwise 
 they may fall upon the floor or table, and be stepped or 
 pressed upon, or lost. A pail or two each of water, hot and 
 cold, should be provided to wash the sponges during, 
 and the hands and instruments after, the operation; for the 
 latter purpose hot water is better. 
 
 Clean Toivels and Old Linen. — An abundance of these should 
 be at hand, and for obvious reasons. However, if the opera- 
 tion is being conducted on strict antiseptic principles, they 
 must not be used until after the wound is dressed; unless 
 .they be, at first, saturated with the antiseptic solution. 
 
 Antiseptic solutions must be abundantly provided and be 
 used in the place of water, by all who are obliged to handle 
 the undressed wound, or the instruments which are to be 
 brought in contact with it. Carbolic acid is more often 
 used than all the others combined. It is cheap, efficient, 
 and easily obtained. Two solutions are commonly em- 
 ployed: one, called the weaker, and the other the stronger 
 
ANTISEPTIC SOLUTIONS. 4I 
 
 solution. The latter can be made in the following man- 
 ner: 
 
 Carbolic acid crystals i part. 
 
 Alcohol I " 
 
 Water 20 parts. 
 
 This is employed to wash the wound before and subse- 
 quent to an operation. It is used with the spray, and to 
 purify all the instruments ; it may be used to wash the 
 hands prior to operating, but this strength is objectionable, 
 since it often benumbs the keen sense of touch and other- 
 wise causes them to feel disagreeable. The weaker solu- 
 tion is made by taking — 
 
 Carbolic acid crystals i part. 
 
 Alcohol I " 
 
 Water 40 parts. 
 
 This is employed for general purposes of cleanliness, and 
 has, therefore, a somewhat more extended range of use- 
 fulness. 
 
 Carbolic acid is often combined with oleaginous sub- 
 stances in the proportions of one to five or ten. Ligatures 
 may be soaked in these preparations, and lint be saturated 
 with them and applied directly to the granulating surfaces. 
 The objections to carbolic acid are its offensive odor, and 
 liability to produce poisoning. The former can be tol- 
 erated, while the latter can be prevented in nearly all in- 
 stances by not allowing the strong solution to become con- 
 fined within the tissues. Solutions of the chloride of zinc 
 (1-15); sulpho-carbolate of zinc (1-80); bichloride of mer- 
 cury (1-2000), and a saturated solution of boracic acid, 
 pure or diluted (1-2); sulphurous acid; a saturated solu- 
 tion of iodoform and ether, are employed as washes, or 
 modified applications for wounded surfaces. The objec- 
 tionable odor of iodoform may be improved by adding to 
 it one tenth its weight of thymol. Tonka bean, or balsam 
 of Peru. 
 
 Sponges.— The variety known as "surgeon's sponges" are 
 the best, although expensive. The larger sponges of a 
 proper texture can be cut into pieces of a suitable size, 
 thoroughly cleansed and disinfected, when they will answer 
 all purposes. No sponge of whatever quality should be 
 used till it has been thoroughly deprived of all foreinn 
 
4Z OPERATIVE SURGERY. 
 
 matters and disinfected. It is a good practice to select 
 and cleanse a number of sponges, and keep them in a closed 
 jar containing a strong solution of carbolic acid, until 
 needed. They should not be repeatedly used; it is far 
 more consistent with careful surgery to get a new supply 
 in each individual case, than to use them, even a second 
 time, under the most favorable circumstances. 
 
 Agents for controlling Heniorrhage. — The agents that arrest 
 hemorrhage are multifarious and suited to all of its 
 phases. They may be divided into the natural and arti- 
 ficial, each of which may be subdivided into the temporary 
 and permanent. A natural agent is one interposed by 
 nature; one which results as a natural consequence, from 
 an interference with the inherent tendencies or endowments 
 of the vessels and blood. The principal temporary natural 
 hemostatics consist of the contraction and retraction of the 
 inner coat of a divided or ligatured vessel, accompanied by 
 the formation of a blood clot within it. The contraction 
 and retraction, if perfect, require that the coats of the ves- 
 sels be not diseased; and that they be properly constricted 
 by the ligature, or other force. The formation of the in- 
 ternal clot requires that a suitable distance, depending 
 upon the size of the vessel, shall exist between the ligature 
 and the collateral branches; also, that the coats of the ves- 
 sel be not greatly diseased. 
 
 These points are of importance in determining the site 
 and feasibility of an operation. The permanent natural 
 agent is the organization and contraction of the clot; there- 
 by completely occluding the artery; this result will depend 
 largely upon the condition of the coats of the vessel, and 
 has a very important bearing upon the possibility of that 
 much to be dreaded sequel of an operation, secondary 
 hemorrhage. 
 
 Artificial Heniastatics. — This class is always temporary. 
 The following. are the well-recognized ones in constant use: 
 Cold, styptics, position of injured part, bandages of vari- 
 ous forms, digital and instrumental pressure; also, pressure 
 by a simple or graduated compress; acupressure, torsion, 
 forceps, serresfines, compressors, cautery, etc.; finally, and 
 best of all, the ligature. 
 
 Styptics, such as liquor ferri sub-sulphatis, tannin, etc., 
 are frequently employed to check oozing; hot water being 
 especially indicated when the patient is debilitated, or suf- 
 fering from severe shocks. Liquor ferri sub-sulphatis is 
 
BANDAGES. 43 
 
 decidedly objectionable where union by first intention is 
 desired, but is very serviceable when an antiseptic styptic 
 is required. 
 
 Position. — Elevation or flexion of a limb serves to impede 
 its circulation, and thereby lessens the tendency to hem- 
 orrhage. The reverse of this principle directs us to lower 
 the head in prostration from loss of blood. 
 
 Bandages. — These may be divided into two distinct 
 classes, the inelastic and elastic. The inelastic, or ordinary 
 roller, can be used to check capillary and venous oozing by 
 applying it firmly over the bleeding part. 
 
 Elastic Bandage — of which Esmarch is the projector — is 
 made of elastic webbing the width of an ordinary roller, 
 
 Fig. 25. 
 
 and of sufficient length to meet the requirements (Fig. 25). 
 It is to be applied in a spiral manner to the limb, firmly from 
 the distal extremity upward (Fig. 26) to a good distance 
 above the point to be operated upon, where it is supple- 
 Ijiented by a rubber cord, or strap, passed firmly around the 
 limb at this point, and fastened by a clasp or hook adapted to 
 that special purpose (Figs. 27, 28 and 28^;). The bandage 
 is then removed by unwinding it from above downward; 
 the clamp devised by Langenbeck (Fig. 29) can be applied 
 to the upper turns of the bandage, which is then removed 
 from below upward, or to an independent cord or strap as 
 in the preceding instances. After the removal of the band- 
 ages the limb will have a cadaverous aspect, being entirely 
 devoid of blood; and the necessary operation can be per- 
 
44 
 
 OPERATIVE SURGERY. 
 
 formed and the wound dressed even without the least hem- 
 orrhage. This, like many other useful agents, has objec- 
 tionable features. Its removal is often followed by a large 
 amount of persistent oozing; its application may force into 
 the circulation deleterious elements which will form the 
 
 Fig. 26. 
 
 Fig. 27. 
 
 basis of disease; it has temporarily paralyzed the part to 
 which it was applied, and caused transient disturbances of 
 the general circulation. These latter are not, however, suf- 
 ficiently important to contra-indicate its use. The ten- 
 dency to severe oozing is an objection which must stand 
 against it; but its power to force improper products from 
 
BANDAGES. 
 
 45 
 
 Fig. 28. 
 
 Fig. 28a. 
 
 CASWELCHAZARD. aCO.WJ.F0aQ. 
 Fig. 29. 
 
 diseased or injured parts into the general circulation can 
 be obviated by omitting its application to those parts; that 
 
46 
 
 OPERATIVE SURGERY. 
 
 is, by raising the limb and holding it till well depleted by 
 the force of gravity, then applying it to the sound parts, 
 above the seat of injury or disease, and using the rubber 
 band as before. The elastic bandages can be made to serve 
 another, and very important purpose; that of forcing into 
 the circulation of the trunk the blood in the extremities 
 in cases of extreme prostration from hemorrhage. Martin's 
 bandage (Fig. 30) is simply a rubber roller, and is used to 
 
 Fig. 30. 
 
 meet the same indications as the former. It can be, how- 
 ever, more readily cleaned than a webbed one, and in this 
 particular is preferable to it. Solid rubber rings of 
 suitable size to pass firmly over an extremity have been 
 used as a substitute for the rubber bandage. In connection 
 
 Pig. 31. 
 
 Fig. 32. 
 
 with the digits, and even the foot, hand and wrist, they act 
 quite well, but have not as yet gained the support of the 
 profession. 
 
 Compresses. — Two kinds of compresses are in common 
 use; the simple and the graduated. The former consists 
 only of two or three thicknesses of cloth, or other suitable 
 substance, folded into small dimensions and placed over 
 the vessel, or upon the part which it is desired to compress, 
 
COMPRESSES. 
 
 47 
 
 and held in position by a tightly drawn bandage or strip of 
 adhesive plaster. 
 
 The graduated compress may be of the form of an inverted 
 
 Fig. 33. 
 
 Fig. 34. 
 
 Fig. 34a. 
 
 pyramid or cone, and oblong (Figs. 31, 32, and 33). Its 
 apex should be firm and unyielding, to give an equal and 
 constant pressure. The whole structure can be made of 
 superimposed layers of cloth, antiseptic gauze, or adhesive 
 
48 
 
 OPERATIVE SURGERY. 
 
 plaster, of a size and shape to symmetrically form its struc- 
 ture. It is employed to press upon the deep-seated vessels 
 of the soft parts, and to arrest hemorrhage from within a 
 deep wound or cavity. Care must be employed in properly 
 adjusting it, else it may impede venous return, or cause 
 pain by pressing upon large nervous trunks. 
 
 Digital pressure is the most available of all the pressure 
 haemostatics. It is constantly at hand, and often intuitively 
 seeks to arrest the flow of blood. It is necessary only to 
 add to a sensitive finger and a sensible brain a knowledge 
 
 Fig. 35. 
 
 of where and how to apply the force, to rencfer this form 
 of pressure of inestimable value. The vessel should be 
 pressed against some resisting part; as, where it lies in 
 contact with bone. If the bone be deeply seated, the vessel 
 must always be pressed towards it; unless, as is done in 
 many cases, the limb be grasped so as to bring the ends of 
 the fingers against the vessel (Figs. 34 and 34^). If blood 
 flows from an open wound, direct pressure must be made 
 upon the bleeding points with one hand, while the other 
 hastens to compress the main artery above the point 
 
TOURNIQUETS. 
 
 49 
 
 of hemorrhage. It is not necessary to use great force to 
 interrupt the blood current; moreover, to do so tires the 
 arm and hand, and causes the patient much pain; use just 
 force enough to interrupt all blood flow. The thumb of 
 the right hand is the best digit to apply at first; after- 
 wards it may be relieved in various ways by the aid of the 
 fingers and thumbs of those in attendance. If secondary 
 hemorrhage be anticipated, or have occurred, the proper 
 point for pressure must be indicated by some indelible 
 
 Fig. 36 
 
 Fig. 36a. 
 
 substance so that in case of a sudden flow any attendant 
 can arrest it; with this object in view, all of the attendants 
 must be instructed in the details of making it, and be thor- 
 oughly impressed with the necessity of instant action. 
 
 Vessels that are inaccessible to digital compression can 
 be controlled often by the handle of a key or a short 
 crutch; the applied extremity of either should always be 
 covered by some soft material to prevent injuring the 
 vessel. 
 
 Instrumental Pressure. — Under this heading is included the 
 
50 
 
 OPERATIVE SURGERY. 
 
 various forms of tourniquets and such other devices as are 
 not directly connected with the adjustment of ligatures to 
 bleeding vessels. The one in common use was devised by 
 Petit, and is no doubt familiar to all (Figs. 35, 36, and 36^:). 
 It should be cautiously applied, and so directed that the 
 pressure will compress the vessel against the bone, when 
 possible. A simple and effective tourniquet can be extem- 
 porized by placing a roller bandage over the site of the 
 vessel, confining it in position by a handkerchief passed 
 around the arm. If the handkerchief be then tied, and 
 twisted by a stick the circulation will be effectually 
 stopped (Fig. 37). 
 
 Fig. 37. 
 
 Davy's Lever is an implement devised by the surgeon 
 whose name it bears. It is employed for the especial pur- 
 pose of controlling hemorrhage in amputations at the hip- 
 joint. It is passed up the rectum in the direction of that 
 canal a sufficient distance to make pressure on the com- 
 mon iliac artery, on the side from which the limb is to be 
 removed. The upper extremity is then carried to the right 
 sufficiently to lie between the bodies of the lumbar verta- 
 brae and the posas magnus muscle. The lower extremity 
 must then be raised sufficiently to bring the requisite press- 
 ure upon the vessel (Fig. 38). 
 
 It has been employed by its designer and other surgeons 
 with signal success. It can be more safely applied to the 
 
Davy's lever. 
 
 51 
 
 left than the right side on account of the left iliac artery- 
 being nearer to the rectum than the right. Its introduc- 
 tion must be preceded by an injection of sweet-oil, after 
 
 Fig. 38. 
 
 which it must be cautiously introduced, and held in posi- 
 tion by a gentle, though firm pressure. If unnecessary- 
 force be used it may tear or perforate the gut. The in- 
 
52 
 
 OPERATIVE SURGERY. 
 
 /i 
 
 / 
 
 strument in question is round, turned from ebony, and 
 from eighteen to twenty inches in length. The surface is 
 smooth, and its extremities rounded; 
 its largest diameter is about five eighths 
 of an inch. It can be graduated so that 
 the surgeon will be able to estimate the 
 exact extent of its entrance to the bowel. 
 Its shape has been variously modified 
 to meet the requirements suggested by 
 its more extended use. 
 
 Trendelenbtirg s Rod. — This is likewise 
 used for the same purpose, but in an 
 entirely different manner (Fig. 39). It 
 is passed through the soft parts at such 
 a depth as to include the whole thick- 
 ness of the proposed flap. A stiff rubber 
 cord is then passed over its extremities 
 with sufficient force to compress the 
 vessel in the tissues above it. The 
 flap can then be made and the vessels 
 ligatured without loss of blood, after 
 which the rod is withdrawn and the re- 
 maining portion of the operation com- 
 pleted in a similar manner. The 
 principle is a feasible one, but it has not 
 yet been enough practiced to become an 
 established method. 
 
 Acupresszire. — This plan, as a means 
 of controlling hemorrhage, was devised 
 by Sir James Y. Simpson, and is used 
 much less in this than foreign coun- 
 tries. It is variously modified to meet 
 the common indication; the modifica- 
 tions may, however, be reduced practi- 
 cally to two in number: one, where 
 the pin is carried through the soft parts 
 under the vessel, and the point elevated 
 and pushed through at an angle suffi- 
 cient to cause it to close the tube of the 
 canal (Fig. 42). 
 
 If this be not effective, additional 
 pressure can be made by passing 
 beneath each extremity of the pin several turns of cotton 
 yarn or ordinary silk ligature. This method is often 
 
 Fig. 39. 
 
ACUPRESSURE. 
 
 53 
 
 employed to arrest hemorrhage from small branches in 
 the palm of the hand and similar situations, and should 
 be supplemented by Buck's pin conductor (Fig. 43), which 
 is passed beneath the vessel and out through the integu- 
 ment, when the pin is inserted into its open extremity and 
 
 Fig. 40. 
 
 Fig. 41. 
 
 Fig. 42; 
 
 carried through by withdrawing the needle. The second 
 method is the reverse of the first (Figs. 40 and 41), the pin 
 resting upon and pressing the vessel downward upon the 
 deep-seated tissue, instead of upward against the superficial. 
 The distance from the end of the vessel at which the press- 
 
 FlG. 43. 
 
 ure is applied depends upon its size; if large, within one 
 half inch; if smaller, the distance can be lessened propor- 
 tionately to its size. 
 
 Circumclusion, torsoclusion, and retroclusion are varia- 
 tions of the method of pin-pressure produced either by 
 
54 OPERATIVE SURGERY. 
 
 twisting or compressing the calibre of the vessel. These 
 various methods seem to possess but one distinct practical 
 advantage over the occlusion of the same channels by cat- 
 gut ligature; they can be more safely applied to vessels 
 with brittle coats due to atheromatous and other changes. 
 The minute descriptions of the various modifications of 
 acupressure can be found in the various text-books of the 
 day. The pins are made of gold, silver, steel and iron; are 
 of various lengths; having glass heads and variously shaped 
 points. A further description or an illustration is not nec- 
 
 FlG. 44. 
 
 essary, since they can be satisfactorily ordered. Shawl- 
 pins, ordinar}' pins and needles, can be substi':uted, if the 
 exigencies of the case require it. 
 
 Torsion. — This is not as modern a procedure as its limited 
 employment would warrant the belief. It consists in thor- 
 oughly isolating and drawing down the vessel, seizing it 
 firmly by a pair of forceps, about one half inch above its 
 extremity, and twisting the end several times till its re- 
 sistance is overcome (Fig. 44); care being taken to not 
 twist it off. The blood is then allowed to impinge upon 
 the twisted portion before the vessel is released, to test the 
 
TORSION. 
 
 55 
 
 completeness of the occlusion. The twisting produces a 
 mutilation and breaking up of the coats of the vessel, 
 which occludes its calibre, and causes a rapid formation 
 of the internal clot. It is evident, if the coats be diseased 
 
 CA5WELLXAZAR0. &CO.VfSSQBD. 
 
 Fig. 45. 
 
 and brittle, that much caution is necessary in twisting 
 them, else a good basis for the occurrence of secondary 
 hemorrhage will be established. Torsion-forceps, which 
 combine in one instrument the holding and twisting forceps, 
 
 Fig. 46. 
 
 are far more convenient (Fig. 45). Torsion as a substitute 
 for the ligature is not considered with much favor in this 
 country, except in individual instances. It is commonly 
 
 Fig. 47. 
 
 employed, however, to check the small bleeding points 
 seen on the surface of freshly cut wounds. 
 
 Forceps, Serrefines and Tenacula. — Since these instru- 
 ments are closely associated in common usefulness, they 
 
56 
 
 OPERATIVE SURGERY. 
 
 can be best spoken of in connection with each other. The 
 spring-catch fenestrated forceps are the better. There are 
 two patterns of these, the common (Fig. 46), and those de- 
 vised by Prof. Hamilton (Fig. 47). 
 
 The expansion of the fenestrated extremity carries the 
 ligature around the vessel, and it is practically impossible 
 
 Fig. 48. 
 
 to tie the end of the instrument, as in the case of the sim- 
 ple Liston forceps (Fig. 48). 
 
 Listen's forceps, while they are not suitable for the com- 
 mon purpose of catching bleeding points, are nevertheless 
 of great service by securing bleeding points on fiat sur- 
 faces. 
 
 The serresfine are of great utility to 
 control bleeding points during an 
 operation. They can be easily and 
 quickly adjusted, and by their pressure 
 on the coats of the small vessels, the 
 necessity of using a ligature thereafter 
 may be obviated. They can be used to 
 catch and control bleeding points to 
 which the application of a ligature is 
 impossible, and even be allowed to re- 
 main upon the vessel till all danger of 
 bleeding has subsided. There are seve- 
 ral varieties of these instruments. The 
 forcep-serrefine, which is the largest 
 (Fig. 49); the angular and straight, 
 and those of Langenbeck. The first 
 are admirably adapted to controlling 
 large vessels, and by their grasping 
 and self-retaining forces can be em- 
 ployed in connection with other tis- 
 sues. Dr. J. L. Little, of this city, has 
 devised a forcep-serrefine having a 
 fenestrated biting extremity, resembling in all practical 
 respects the extremity of the fenestrated artery forceps. 
 The one devised by Gross (Fig. 52) can be attached to the 
 bleeding point, handle unscrewed, and the blades per- 
 mitted to remain until all danger of bleeding has ceased. 
 
 Fig. 
 
TORSION. 
 
 57 
 
 The smaller ones (Figs. 50 and 51) are employed to catch 
 small bleeding points. 
 
 Fig. 52. 
 
 Milne's compressing forceps 
 (Fig- 53) are closely allied in 
 principle to the serrefine; they 
 are, however, used to compress 
 the smaller arteries in their 
 course through the soft tissues, 
 as the coronary arteries in the 
 operation for hare-lip. 
 
 Tenaculum (Fig. 54). — This 
 is used to pick up and draw 
 
 GASWCL.L JUUiUn) &C]&.WXFORir« 
 
 Fig. S3. 
 
 vessels from the soft parts. If a vessel be too short to 
 be ligatured by the aid of forceps, it can be transfixed 
 along with a small portion of the contiguous soft parts 
 by the tenaculum, and a ligature thrown around the com- 
 bined tissues (Fig. 56a.) If a niche be made in the tissues 
 raised by the tenaculum at either side, the ligature can be 
 more securely applied and the vessel more firmly grasped. 
 Prince's tenaculum forceps combine the principles of 
 both instruments, and can be used with advantage (Fig. 
 
 55)- 
 
 The arterial compressor of Spier, of Brooklyn (Fig. 56), 
 is an instrument of undoubted efficacy, but the advantages 
 
58 
 
 OPERATIVE SURGERY. 
 
 which it is said to possess over the ordinary ligatures are 
 not of enough importance to commend it to general use. 
 A small portion of the vessel is isolated and 
 its hook-like extremity passed around it, 
 the handle is then turned until the coats 
 are compressed sufficiently to divide the 
 innermost, as in the tightening of the or- 
 dinary ligature. 
 
 Cautery. — This remedy, once a universal 
 means of controlling hemorrhage, has now 
 but a limited application. There are three 
 varieties of cautery in common use: the 
 actual, the thermo, and galvano cauteries. 
 The first requires the cautery irons (Fig. 57), 
 which should be accompanied by the blow- 
 pipe (Fig. 58), although they can be heated 
 by ordinary means. The blow-pipe is far 
 better, since, during the summer months, 
 
 ? 
 
 3 
 
 Fig .56. 
 
 Fig. 56a. 
 
 Fig. 57. 
 
 or in unfavorable situations, when great haste is necessary, 
 the domestic means of heating them will be inadequate. 
 
THERMO-CAUTERY. 
 
 59 
 
 The irons can be made incandescent, or of a dull red color; 
 the latter is the better, since it burns more deeply and is 
 less liable to be followed by secondary hemorrhage. 
 
 Therm o-cautery. — The instrument designed by M. Paque- 
 lin for this purpose is exceedingly ingenious. It consists 
 of a thoroughly isolated hollow handle, provided with 
 
 Fig. 55. 
 
 three movable platinum cauteries, into which, after they 
 have been heated in the flame of a spirit lamp, a stream of 
 benzine vapor is introduced by the means of a spray bulb 
 connected by a tube with the bottle containing it (Fig. 59); 
 this brings the cauteries quickly to the required tempera- 
 ture, which can be maintained for an indefinite length of 
 
 Fig. 58. 
 
 time by squeezing the rubber bulb. The range of the use- 
 fulness of this instrument is more extended than the for- 
 It is used not only for the same purposes, but can 
 
 mer. 
 
 be employed as a cutting implement for the removal of 
 morbid growths, etc., when union by first intention becomes 
 a lesser consideration than the annoyance from primary 
 hemorrhage. 
 
'6o 
 
 OPERATIVE SURGERY. 
 
 Galvano-cauiery. — This method is chiefly employed in 
 connection with uterine surgery, although it is a proper ex- 
 pedient in connection with all operations where the use of 
 the ecraseur is admissible. 
 
 Ligatures. — The ligature is by far the best general 
 agent for controlling hemorrhage. It can be readily ap- 
 plied, is easily portable, and can always be obtained in 
 some form. Ligatures may be classified according to their 
 nature into organic and inorganic. The latter are very 
 nfrequently used, and then in the form of fine silver or 
 
 Fig. s9. 
 
 iron wire, which is looped rather than tied around the 
 vessel. The organic comprise the hemp, silk, and catgut 
 varieties, which should be made at least from twelve to six- 
 teen inches in length, depending somewhat on the depth of 
 the wound into which they are to be applied. They must 
 be of sufficient strength to withstand the traction neces- 
 sary to cause complete occlusion of the vessel; also, their 
 size must depend somewhat upon the force to be employed 
 in tying. The requisite force to properly occlude a ves- 
 sel cannot be estimated by ounces or pounds, but is large- 
 
LIGATURES. 
 
 6i 
 
 ly a matter of experience. The traction should be made 
 steadily, and over the ends of the forefingers or thumbs 
 without disturbing the relations of the vessels to its sur- 
 rounding parts (Fig. 60). The giving away of the inner 
 
 Fig. 60. 
 
 coat of a vessel indicates that the ligature is drawn suffi- 
 ciently tight. This cannot be felt, however, except in con- 
 nection with the large vessels. Great caution is to be ex- 
 ercised to prevent any tissues other than the walls of the 
 vessel being included in the grasp of the ligature. If a 
 nerve be seized the patient will be tormented by constant 
 pain, which may not cease even with the disappearance of 
 the constricting agent. All tissues other than the coats of 
 the vessel not only cause additional irritation, but delay the 
 separation of the ligature. 
 
 The Knots. — The variety of the knot tied exercises an im- 
 portant influence in the security of a ligature. The sur- 
 geon's knot is tied by making two turns of the ligature at 
 first, instead of one (Fig. 61); it will not slip when drawn 
 
 Fig. 61, 
 
 tightly, and should always be employed when the knot is 
 beyond the sight of the surgeon, otherwise the first half 
 of it may slip without his knowledge, thereby resulting in 
 
62 
 
 OPERATIVE SURGERY. 
 
 an imperfect ligaturing of the vessel. It sometimes hap- 
 pens, owing to the ligature becoming soaked, that it can- 
 not be drawn as tightly as one with a single turn. If it 
 
 Fig. 62. 
 
 binds in this manner, the tying of the second part will leave 
 the whole very insecure. 
 
 Fig. 63. 
 
 _The Reef or Square Knot. — Either this or the preceding 
 must always be employed in tying a vessel. The reef-knot 
 
 Fig. 64. 
 
 (Fig. 62) is easily confounded with the " granny knot" (Fig. 
 63), which is insecure. The following description of the 
 
LIGATURES. 
 
 63 
 
 method of tying the reef-knot, taken from Heath, is too 
 graphic to be substituted by another. " The ligature is to be 
 
 Fig. 63 
 
 held in the palm of the right hand between the thumb and 
 finger; the end is then to be thrown around the forceps 
 
 Fig. 66. 
 
 closely and caught with the left hand, and carried across 
 the right thumb and inserted between the third and fourth 
 
64 OPERATIVE SURGERY. 
 
 fingers of the right hand (Fig. 64). The left at the same 
 moment seizes the other end, and the ends of the threads 
 are drawn out as is being done in Fig. 65. There will now 
 be no difficulty in drawing the knot thus formed tight with 
 the forefingers, or, if preferred, with the thumbs (Fig. 66). 
 To complete the knot by making another tie, the same 
 manoeuvre is to be affected, taking care always to begin 
 with the opposite hand to that which began before. It 
 is quite immaterial which hand begins the first part of the 
 knot, so long as the opposite one always begins the second 
 part; in this way with a little practice the reef-knot may be 
 unerringly tied with the greatest rapidity." When the knot 
 is completed, it will be seen that the ends of the ligatures 
 lie parallel with and in contact with the portion of the liga- 
 ture which surrounds the vessel. (See Fig. 62.) 
 
 The silk and hemp ligatures should be well purified be- 
 fore their application by a strong solution of carbolic acid, 
 or other suitable disinfectant. If both ends are to be cut 
 short and the ligature allow^ed to remain in the wound, 
 they should have been soaked for some time — eight or ten 
 days at least — in a solution of bichloride of mercury 
 (igVtf)- ^^ they be thus treated in a strong solution of 
 carbolic acid their strength may be impaired. If uncar- 
 bolized, they should be freshly waxed. After tying, one end 
 may be cut short and the other allowed to hang from the 
 wound. 
 
 Carbolized catgut ligatures are now an established fact 
 in surgery; they, like other ligatures, vary in size and 
 strength, and a selection must be made in accordance with 
 the purpose in view. If a proper choice be made they can 
 be relied upon to fulfil the ordinary indications of the silk 
 ligature. The requisite sizes can be obtained of the surgical 
 instrument-makers of this city. Catgut can be tied by the 
 surgeon's, or the reef-knot; but is less secure than silk. A 
 third tie should always be added to whichever of the two is 
 employed. The ends are cut close to the point of tying, 
 and the wound closed irrespective of the presence of the 
 ligature. 
 
 Chrotnacized catgut is thought by some to be superior in 
 many respects to the carbolized. It is more flexible, and 
 can be carried and used like the ordinary silk ligature, re- 
 quiring only to be moistened in some aseptic fluid before 
 it is applied. 
 
 Crude catgut can be purchased of those who deal in 
 
ASSISTANTS AT OPERATION. 6$ 
 
 surgical supplies, and aseptacized to suit the fancy of the 
 surgeon. 
 
 A good plan, however, is that recommended by Lister in 
 his inaugural address of June 28, 1881. 
 
 "Dissolve one part of chromic acid in 4000 parts of dis- 
 tilled water, and add to the solution 200 parts of pure car- 
 bolic acid; into this liquid immediately put catgut equal in 
 weight to the carbolic acid. At the end of forty-eight hours 
 it is sufficiently prepared. Then it is to be removed from 
 the solution, dried, and placed in one-to-five carbolized 
 oil. It is then fit for use." 
 
 Assistants. — The number of efficient assistants necessary 
 to conduct an operation with ease is modified by its 
 character. 
 
 To one must be intrusted the giving of the anaesthetic, 
 and watching the pulse, respiration, and circulation of 
 the patient. By combining these duties the giver of the 
 anaesthetic becomes the immediate observer of its effects, 
 and he must always be prepared to carry into execution 
 the various expedients that are recommended in the com- 
 plications attending anaestliesia. If the temporal and radi- 
 al pulsations be compared before its administration, the as- 
 sistant will be able to judge of one from the character of the 
 other. He can then give the anaesthetic, hold forward the 
 lower jaw to prevent swallowing the tongue (see Fig. 10), 
 and with the finger on the temporal artery, he will be able 
 to attend to the cares of the case without any interruption. 
 
 To a second should be assigned the care of the instru- 
 ments; giving them to the surgeon when asked for, and re- 
 turning them to a place of safety after being used. 
 
 To a third may be intrusted the care of the sponges; he 
 must always observe that a suitable number be well 
 squeezed and placed at the convenience of the operator. 
 
 To a fourth the ligatures should be given. He should 
 first hold the limb, after which he may either sponge or 
 ligature the vessels, as best suits the circumstances of the 
 case or the fancy of the operator. The securing of the 
 bleeding points and the necessary sponging are best done 
 by the operating surgeon; however,'these are matters which 
 will become self-regulating as the operation progresses. 
 All assistants must be proficient, especially the one who 
 ligatures the vessel and administers the anaesthetic. When 
 the surgeon is not able to avail himself of a suitable num- 
 ber of assistants, he must then draw upon his own resour- 
 ces. This can by done by placing the sponges and instru- 
 
66 
 
 OPERATIVE SURGERY. 
 
 ments where they can be conveniently reached, when he 
 can sponge, secure, and tie the vessels. If the circumstan- 
 ces demand it, he can at the same time control the giving of 
 the anaesthetic. The patient should be prepared for the opera- 
 tion. The physical, legal, and spiritual aspects of a prepa- 
 ration have been heretofore considered 
 under various headings, consequently 
 little remains to be done other than to 
 properly cleanse and shave the part to 
 be operated upon. 
 
 The proper materials for uniting and 
 dressing wou7ids and a knowledge of their 
 use must always be had. 
 
 As soon as the operation is completed 
 the wound should be washed thoroughly 
 with the strong solution of carbolic acid 
 or other antiseptic, which not only puri- 
 fies it, but serves to check the capillary 
 oozing of the cut surfaces. The proper 
 securing of the cut surfaces and the 
 dressing of the wound involve three im- 
 portant considerations: (i) The retentive 
 coaptation of the divided tissues; (2) 
 perfect drainage; (3) the application of 
 some suitable protective dressing. If 
 union by first intention be a desideratum 
 the cut surfaces must be kept in a per- 
 fect coaptation. For this purpose there 
 are numerous means employed. The 
 part bearing the wound may be so placed 
 as to avoid all muscular contraction, or 
 undue tension of the soft parts. Strips 
 of adhesive plaster with or without roller 
 bandages or sirriple compresses may 
 meet the indications. These agents 
 constitute the common dressings of a 
 less recent date, and are at the present time open to the 
 strong objection of interfering with union by first intention, 
 except they be of an antiseptic nature. 
 
 Sutures may be classified with reference to their compo- 
 sition or method of arrangement. They are of either or- 
 ganic or inorganic nature. 
 
 Those of an organic nature are most commonly used; 
 but which of these is the better is more a matter of personal 
 preference than a surgical requirement. The silk, hemp. 
 
 Fig. 67. 
 
SUTURES. 
 
 tl 
 
 catgut and horse-hair sutures belong to this class, and are 
 respectively employed as best suits the preference of the 
 surgeon. The silk and the hemp varieties are constantly 
 employed, and if they are carbolized they cause but little 
 irritation, and can be removed without pain. The proper 
 introduction of sutures under all conditions requires 
 needles of various shapes and sizes. The curved, straight ; 
 
 those with round and edged extremities. These are too 
 familiar with all to require other than a passing mention. 
 The curved are used in cavities and depressions ; the 
 straight on plain surfaces. Those with an edged extremity 
 cut the tissues they pass through, while the smoother 
 separate the tissues and avoid the hemorrhage that so often 
 follows the track of the former. The latter are, however, 
 inserted with greater difhculty. Needle forceps^ or holders 
 (Figs. 67, 68, and 69), should always be at hand to aid 
 
 CASWEIL HAVi^RD SCO .W.F.FORD- 
 Fig. 69. 
 
 in conducting the needles steadily through the tissues. 
 The instrument bearing the artery forceps at one end 
 and the holder at the other (Fig. 70) is an admirable and 
 compact implement. 
 
 Horse-hair. — When carbolized these cause but slight irri- 
 tation, and are admirably adapted to those cases requiring 
 but little force to maintain coaptation and where scarring 
 from sutures is to be avoided. 
 
 Catgut as a suture possesses the same special advantages 
 that belong to it as a ligature. It rarely produces irritation, 
 and if allowed to remain will become absorbed without 
 ulceration. If, however, much force is required to unite 
 the wound, the catgut is less reliable than the silk ligature. 
 
 Inorganic or MetaUic Sutures. — Those in common use are 
 
68 
 
 OPERATIVE SURGERY. 
 
 the silver and iron wire. They can be retained in situ 
 longer than the uncarbolized silk or hemp, with less danger 
 
 Fig. 70. 
 
 from ulceration. Their application and removal, however, 
 are attended with more pain than either of the others. 
 The silver wire is more expensive than the iron; aside 
 from this it matters little which be used. The depth to 
 which all sutures should be passed, the distance between 
 them and their tension, depend upon the depth of the 
 wound and the tendency of its lips to separate. The object 
 of all sutures is to hold the surfaces of wounds in close 
 
 contact until union occurs. 
 To accomplish this they must 
 be carried to that depth and 
 be placed at such distances 
 from each other as will best 
 ••* >'fc*-««l accomplish the purpose. 
 
 "T^ H^ '"^"" They can be supplemented 
 
 •»*»i»rj f«#9M |i«'*^^ by strips of adhesive plaster 
 
 passed between them (Fig. 
 71). They must not be drawn 
 too tightly, or the tissues 
 within their grasp will be 
 strangulated, causing ulcera- 
 tion and disfigurement. 
 If the integument within the grasp of the suture remain 
 white after it is tightened, the suture must be loosened 
 before the final dressing is completed. The length of time 
 they should remain is to be governed by the danger of ulcer- 
 ation and disfigurement, also the tendency of the wound to 
 open. In exposed portions of the body they should be re- 
 moved as soon as notable irritation is observed. The 
 rapidity and extent of the ulcerative process can be lessened 
 by relieving any undue traction upon them by means of 
 adhesive plaster or other restricting influences. 
 
 Different Forms of Sutures. — The interrupted, continuous, 
 quilted, hare-lip, etc., are the forms in common use. The 
 
 Fig. 71. 
 
SUTURES. 
 
 69 
 
 Fig. 72, 
 
 special varieties for intestinal sewing will be shown in con- 
 nection with operations upon the 
 
 intestines. 
 
 The interrupted suture is the one 
 
 in every-day use, and has a more 
 
 general application than the other 
 
 form (Fig. 72). It is made by passing a needle armed 
 with a well-prepared suture through 
 the integument from a line to a 
 third of an inch or more from the 
 borders of the wound, depending 
 '^^ ^1, upon its size, depth, and retractive 
 
 ^^l^" force. The ends should then be 
 
 united by a reef-knot drawn with 
 sufficient force to oppose the sur- 
 faces without puckering the skin 
 (Fig. 73.) The ends of the suture 
 can be united in alternate sides of 
 the wound or at one of its points 
 of exit alone. The latter is the bet- 
 ter, since, if the dressings cling to 
 
 the extremities, their removal is less liable to interfere 
 
 with the line of coaptation. 
 
 The conti7iuous suture, sometimes called 
 
 the glover's (Fig. 74), is used to unite i 
 
 superficial wounds and such others as 
 
 require little force to secure a proper 
 
 adjustment of the divided surfaces. 
 
 This is made by passing the needle 
 
 diagonally from one side of the wound 
 
 over to the other. 
 
 The Quilled Suture. — This is made by pass- 
 ing several strong double threads through 
 
 Fig. 73. 
 
 Fig. 74. 
 
 Fig. 75. 
 
70 
 
 OPERATIVE SURGERY. 
 
 the lips of the wound a half an inch or so apart, and tying 
 ^ I them over quills, wood, etc., while they lie 
 
 ^ ^ parallel with the cut (Fig. 75). This is 
 used about the vagina, perineum, etc., when 
 deep gaps are to be closed. 
 
 The Twisted or Hair-lip Suture (Fig. 76). — 
 
 This is made by pushing a pin through the 
 
 edges of the wound and passing cotton 
 
 yarn around it to confine it in position 
 
 (Fig. 77). The yarn should be changed 
 
 as often as it becomes soiled. If it be 
 
 properly carbolized before application, it 
 
 lessens its tendency to cause irritation. 
 
 An ordinary pin or needle can be used. 
 
 Fig. 76. although those specially adapted for the 
 
 purpose are preferable (Fig. 78). They can be, if not 
 
 spear- pointed, pushed or drawn through the tissues by 
 
 ^^ 
 
 Fig. 77. 
 
DRAINAGE. ^I 
 
 aid of Post's or Buck's needle carrier (Fig. 79). After 
 which the points should be nipped off and separated from 
 the skin by a small strip of adhesive plaster. Pins with 
 adjustable spear-shaped points can be employed and be 
 
 C, H. 2< C9 
 
 Fig. 78. 
 
 Fig. 79. 
 
 carried into position by the fingers of the operator (Fig. 
 
 There are various other special forms of sutures which 
 
 will be considered under their proper .^^ 
 
 headings. Fig. 80. 
 
 Drainage is not only of greatest importance in securing 
 successful union of the divided surfaces, but also to the 
 safety of the patient. Good drainage to a wound is as 
 potent to its cleanliness as is the good drainage of a 
 dwelling to the healthfulness of its occupants. No 
 one local condition will interfere so materially with the 
 process of healing or expose the patient to greater consti- 
 tutional danger than the collection and decomposition of 
 fluids in a wound. Drainage may be secured through de- 
 pendent incisions, or, better still,"by introduction into the 
 wound of a drainage tube. Horse-hairs or threads intro- 
 duced into the wound in some cases answer quite well. 
 The long extremities of the silk or linen ligatures, if allowed 
 to extend from its most dependent portion, will drain it, 
 though somewhat imperfectlv. 
 
 'CASWELLHAZARD. ftCCWJ-JORO. 
 Fig. 81. 
 
 £/h's's Drainage Spiral {F\g. 81), or that which is still more 
 practical, the rubber drainage tube (Fig. 82), will fulfil the in- 
 dications more perfectly. 'An ordinary piece of black or 
 white rubber tubing, of about one fourth of an inch in di- 
 
7i OPERATIVE SURGERY. 
 
 ameter,"with holes in the sides at irregular intervals, can be 
 inserted into the bottom of the wound cavity through its most 
 dependent portion. Another can be introduced into the up- 
 per portion of the cavity through the uppermost angle of 
 the wound. The size should vary with the dimensions of 
 the wound. They are more often too small than too 
 large. They must be fastened in position, or they may 
 slip into the wound; this can be done by passing a thread 
 through the projecting extremity and tying it around the 
 limb or fastening it securely by adhesive plaster. If a sin- 
 gle tube be passed so as to protrude from both sides of the 
 wound, it can be securely fastened by passing an ordinary 
 safety pin through each extremity. However, it is better 
 to use two short tubes instead of one long one ; the latter 
 introduces into the wound a superfluous amount of rubber, 
 which does not perform a duty sufficient to compensate for 
 
 Fig. 82. 
 
 its presence. In either case it is necessary to allowfor the 
 swelling of the parts, else the pins or threads may cause 
 constriction of the injured parts. The outer extremities 
 should then be cut off flush with the soft tissues. The 
 wound can be washed through the upper tube, while all 
 discharges will pass from the lower one. The length of 
 time they should remain must depend upon the character 
 and amount of the discharge. If the amount be small and 
 of inoffensive nature, they can be removed. It must not 
 be forgotten that they, as foreign bodies, may excite the 
 discharge for which they are retained to carry off. 
 
 Protective Dressings. — These include the ordinary dress- 
 ings, such as one who is a long wa}' from the basis of sup- 
 plies, or not a believer in the modern methods, would 
 employ: as covering the wound with a linen cloth kept 
 moist with a weak solution of carbolic acid, or water; the 
 application of adhesive plaster, and covering it with medi- 
 cated cloths held in position by bandages or plasters. Of the 
 modern methods, the one bearing the name of Lister, its 
 designer, is deserving of especial mention, not only on ac- 
 count of its acknowledged worth, but also from the fact 
 
ANTISEPTIC SYSTEM. 
 
 73 
 
 that other methods involving similar principles are advo- 
 cated, the result being sought by the aid of different agents. 
 
 The requirements for the Lister treatment are the atom- 
 izer, or spray, carbolic acid solution, drainage tube, protec- 
 tive, antiseptic gauze, Mcintosh, catgut ligatures; and that 
 everything to be brought in contact with the wound be 
 made antiseptic by a strong solution of carbolic acid. 
 
 The Aiitiseptic Spray Apparatus consists of a kettle, lamp, 
 spray tube, and a bottle to contain the solution of strong 
 carbolic acid (Fig. 83). The spray is produced and directed 
 
 Fig. 83. 
 
 upon the site of the operation before the first cut is made. 
 It should be continued through the whole operation, and 
 until the wound is surrounded by the protective dressing. 
 It is always to be used when the wound is redressed. 
 The arteries are tied with catgut; the wound is united by 
 the same material and washed with the carbolic solution, 
 and the drainage tube is inserted as before described. 
 
 The protective (which somewhat resembles oiled-silk) is 
 placed over the wound and extended an inch or so from 
 its border, with openings for thenmouths of the drainage 
 tubes. A small piece of the ant septic gauze wet in the 
 strong solution of carbolic acid can be laid over and beyond 
 the protective. Numerous layers of the antiseptic gauze 
 are then made to cover the part, their borders extending 
 a good distance or so beyond the edge of the w^ound. 
 Around the whole is wrapped the Mcintosh, which is con- 
 fined in position by bandages made of tlie antiseptic gauze. 
 
74 OPERATIVE SURGERY. 
 
 This dressing can be removed on the second or third day, 
 the wound washed out, protective and Mcintosh purified, 
 and unsoiled gauze substituted, after which it need not be 
 examined again — other things being equal — within a week 
 or ten days, unless the discharges soak through the dressing. 
 
 At the present time, more often than otherwise, the spray 
 is not employed. If the spray be omitted, the surface to 
 be operated upon should be thoroughly scrubbed with soap 
 and water and afterwards washed with a strong solution 
 of carbolic acid or some other suitable disinfectant, and the 
 surfaces contiguous to it covered by towels saturated by 
 the same disinfecting solution, which should be kept 
 thoroughly wetted by it during the operation. The opera- 
 tion wound must likewise be thoroughly douched with some 
 disinfecting fluid during the entire course of the procedure. 
 In all other respects, however, the preceding details are 
 carried out. 
 
 Cotton-batting Dressing. — Cotton batting, or that which is 
 better, borated, or salicylated cotton, is frequently em- 
 ployed as a protective dressing in place of the antiseptic 
 gauze. The results obtained warrant the belief that it is 
 entitled to be considered worthy of an extended applica- 
 tion. It exerts a very desirable uniform pressure upon the 
 parts to which it is applied, thereby aiding coaptation and 
 fostering union. 
 
 Iodofor7n Dressing. — Iodoform is dissolved in ether, and 
 after the operation it is thrown upon the cut surface by 
 means of an ordinary atomizer. The ether evaporates, 
 leaving the iodoform evenly deposited over the cut surfaces. 
 
 It can be better applied if pulverized and blown into the 
 wound by an insufflator. The wound is then closed by 
 antiseptic sutures, drainage tubes introduced, and the whole 
 surrounded by antiseptic gauze, upon the surface of which 
 iodoform has been freely sprinkled, corresponding to the 
 vacuity of the wound. This is bandaged in place and 
 allowed to remain until the dressing becomes solid, when 
 it is redressed as before. 
 
 The odor of the iodoform and its occasional deleterious 
 effects upon the nervous system of the patient has made its 
 use infrequent and cautious. 
 
 Iodoform gauze is made use of in many instances. 
 
 Peat Dressing. — Into a small carbolized gauze bag the 
 light peat or turf is introduced, combined with 2\ per cent 
 of iodoform; over this a larger bag filled with carbolized 
 
ANTISEPTIC SYSTEM. 75 
 
 peat is applied, and the whole bandaged firmly in position. 
 The fine peat serves admirably to make equitable pressure 
 and absorb the discharges, and need not be re-applied until 
 it has become soiled. 
 
 Bichloride of Mercury Dressing. — By this method the 
 dangers attending the use of carbolic acid and iodoform 
 are avoided; at the same uime a cheap and inoffensive sub- 
 stance is utilized. It is used with the spray (3-^07) or as 
 a wash for the wound (-joVo)- Sponges, ligatures and su- 
 tures are soaked in solutions varying in strength from 10 
 to 75 grains to the pint of water or alcohol, the latter being 
 used for the ligatures and sutures, in which they are kept 
 for three or four hours, thence removed to a much weaker 
 one. Catgut can be treated in substantially the same man- 
 ner by allowing it to remain ten or twelve hours in the 
 alcoholic solution, from which it is to be taken and intro- 
 duced into a weaker one (one half of i per cent) containing 
 a drachm or so of gl5xerine. 
 
 The protective dressing can be saturated with a strong 
 solution (50 gr. to the pint) and applied in the same man- 
 ner as before. 
 
 Instruments can be purified with it, although it lessens 
 their cutting power. 
 
 This dressing can be recommended as one possessing 
 efficiency and safety. Alcohol, thymol, eucalyptol, and the 
 essential oils have been recommended as antiseptic agents, 
 but with insufficient assurance to warrant their employ- 
 ment in place of the other well-established agents. 
 
 Open Dressing. — The so-called open dressing consists in 
 washing the wound cavity with the strong carbolic acid 
 solution at the completion of the operation, after which it 
 is placed upon a suitable cushion of oakum, and over it is 
 laid a thin piece of gauze, which is kept moistened with a 
 solution of carbolic acid. The wound is washed two or 
 three times daily by gentle irrigation with a carbolic solu- 
 tion, after which balsam of Peru is poured into it. All the 
 dressings are to be kept clean. 
 
 The success which attended this method in the hands of 
 the late Prof. James R. Wood can but cause the skeptical 
 surgeon to wonder at the necessity of the tedious details 
 of the Lister and other methods. 
 
 Precautionary Requirements. — These requirements, and 
 their importance were stated some time since. 
 
 Stimulants, of which brandy, whisky, champagne, ammo- 
 
'j6 - OPERATIVE SURGERY. 
 
 nia, and nitrite of amyl, etc., etc., are examples, enter into 
 common use. Some one or more of these should be at 
 hand in all operations, irrespective of its length or require- 
 ments. 
 
 For purposes of administration the hypodermic and 
 Davidson's s)''ringes are most convenient. Under no cir- 
 cumstances must fluids be administered by the mouth, if 
 the patient be unconscious, except by the medium of a 
 stomach tube. 
 
 Tenaculum. — Its use has been sufficiently emphasized to 
 render the importance of its presence evident. 
 
 Electric Battery. — This must always be thought of when 
 the nature of the operation or condition of the patient may 
 give rise to the subsequent failure of the circulatory or res- 
 piratory powers. 
 
 Tracheotoffiy Tube. — Although this is not necessary to the 
 performance of tracheotomy or laryngotomy when indica- 
 tions suddenly arise calling for either, yet it is better it be 
 at hand. The surgeon must not overlook the fact that the 
 death of a patient due to the absence of a tube or to the 
 loss of time consumed in seeking for one is most unpardon- 
 able, and, to say the least, entitles him to censure. 
 
 Elastic Bandages. — These are not only important in pre- 
 venting the loss of blood, but, as heretofore stated, doubly 
 important when applied to the limbs in forcing the blood 
 contained in them into the centre of circulation, as in cases 
 of impending death from shocks due to the loss of blood. 
 They are, in my opinion, of greater practical utility for im- 
 mediate use than the more elaborate instruments employed 
 in transfusion. They will certainly bridge over the inter- 
 val of time necessary to prepare for the use of the transfu- 
 sion apparatus better than any other expedient. 
 
 Artificial Respiratio7i. — No one can be safely intrusted to 
 administer an anaesthetic, or to attempt any operative pro- 
 cedure, who is not familiar with the manipulations neces- 
 sary to the proper performance of this act. It is, in fact, 
 the only one of the requirements which can and should be 
 continuously employed until the safety of the patient is 
 assured, or until death is an established fact. 
 
 Finally, a surgeon should never begin an operation, be 
 it of greater or lesser magnitude, without having carefully 
 rehearsed its various steps in his mind, together with the 
 possible complications that may arise and the best means 
 of combating them. 
 
LIGATURE OF ARTERIES. 'J'^ 
 
 Preparations of this kind serve to distinguish the careful 
 and conscientious surgeon who places a proper value upon 
 human life and a just professional reputation, from the one 
 who operates only because the opportunity is offered, and 
 considers the details tedious or worthless because he has not 
 had sufficient patience or faith to practice them. He trusts 
 to luck, and attributes his results to an inscrutable Provi- 
 dence ; more especially when the patient succumbs. 
 
 LIGATURE OF ARTERIES. 
 
 Arteries are ligatured in their continuity or at their di- 
 vided extremities. Under this heading, however, will be 
 considered the ligaturing in their continuity only. Nearly 
 all arteries to which ligatures are thus applied can, from 
 their association with the soft and hard parts, be said to 
 possess certain guides, which, when carefully adhered to, 
 indicate with precision their position beneath the surface. 
 
 The guides to ligaturing arteries in the living subject are 
 practically four in number, (i) The linear guide. (2) The 
 muscular guide. (3) The contiguous anatomical guide. 
 (4) The pulsation and color of the vessel. 
 
 The linear guide to an artery is a line drawn upon the ex- 
 ternal surface so as to correspond with the established 
 course of the vessel beneath. Its extremities are usually 
 indicated by the relations which the vessel bears to fixed 
 bony prominences. 
 
 The muscular gtiide is based upon the relation which the 
 vessel bears to some portion of a well-developed superficial 
 muscle, the outline of which can be quite readily traced if 
 the muscle be placed upon the stretch. If the border of a 
 muscle be given as the guide, it must not be forgotten that 
 in case it be unusually developed, or have a broader origin 
 and insertion than common, it will overlap the vessel, and 
 thus may lead the surgeon astray. Under these circum- 
 stances he must direct his attention unerringly to the con- 
 tiguous anatomical guides, which include the relations that 
 a vessel bears to its immediate surrounding parts; and when 
 taken in connection with its pulsation, lead directly to it. 
 The contiguous guides may be muscular, if a muscle be 
 ascertained to bear an established relation to it; or bony, 
 when a bony prominence is in close contact with it; or 
 
78 
 
 OPERATIVE SURGERY. 
 
 nervous, when a certain nerve is known to lie in a definite 
 relation with it; or vascular, when veins of an established 
 arrangement exist. And finally, the sheath of the vessel 
 itself, when it is present. Some of the large vessels, of 
 which the common carotid and femoral arteries are the 
 most striking examples, possess well-developed sheaths. 
 The smaller arteries are surrounded by a greater or lesser 
 amount of areolar tissue. The larger arteries, as the popli- 
 teal, femoral, and subclavian, are each accompanied by a 
 single vein which commonly runs in a definite relation with 
 them. The smaller ones, those of the extremities, etc., are 
 attended by satellite veins, known as the venae comites, 
 
 Fig. 84. 
 
 usually two in number; however, that is not invariable, 
 since three or more are often seen. The vessels are distin- 
 guished from each other by the darker color of the veins 
 and the lighter or pinkish color of the artery. If three ves- 
 sels are seen, the middle one is almost certain to be the 
 artery; if more than three exist, the third vein usually rests 
 upon the artery; if pressure be made upon them, the veins 
 are distended and the artery is collapsed beyond the point 
 of pressure. If to these facts be now added the pulsation 
 of the artery, its location is assured. The operator who 
 relies exclusively upon the arterial impulse as a guide, may 
 be led astray by the transmitted pulsations of other vessels, 
 or by the functional movements of the parts in which the 
 artery is located. 
 
 Having determined the anatomical details, the portion 
 of the body in which the vessel is contained is placed in 
 position to afford all available room and the best possible 
 
LIGATURE OF ARTERIES. 79 
 
 light; the portion of the vessel is then selected at which the 
 surgeon feels best assured of the absence of a branch of 
 sufficient size to interfere with the formation of an internal 
 clot. The primary incision is then made, the centre of 
 which should, if possible, correspond to the point of the 
 vessel to which the ligature is to be applied. The length 
 of the incision will depei.d upon the depth of the vessel, 
 and should always be of sufficient extent to afford easy ac- 
 cess to it. If the thumb and finger be employed to make 
 tense and to steady the integument, great care must be 
 taken to make the traction equal on the respective sides 
 
 Fig. 8s. 
 
 (Fig. 84), Otherwise, after the tissues are released, the cut 
 will be outside the line of the vessel, which, if not noticed, 
 will lead the surgeon astray; besides, its irregularity will 
 interfere with the necessary space and light as well as 
 the subsequent drainage. The external incision should be 
 made with one sweep of the knife, rather than by repeated 
 cuts, which tend to chop the tissues, increasing the danger 
 of suppuration, and correspondingly lessening the prospects 
 of union by first intention. 
 
 The fascia is pinched up by the thumb forceps, or tenac- 
 ulum, and carefully nicked with a scalpel, after which a 
 grooved director is cautiously passed beneath it, upon which 
 
8o 
 
 OPERATIVE SURGERY. 
 
 it is then divided. The fascia should not be incised the full 
 length of the integumentary cut. The nearer the approach 
 to the vessel, the shorter should be the line of the separa- 
 tion of the tissues, so that when the vessel is reached the 
 bottom of the wound will somewhat resemble an inverted 
 triangle, with its apex corresponding to the artery. 
 
 The tissues beneath the fascia are to be gentl)^ separated 
 by the fingers, handle of the scalpel, or director; using the 
 knife only when necessary, until the sheath of the vessel is 
 reached, when a small opening is made into it — about one 
 fourth of an inch being ample — of sufficient size to pass the 
 needle with ease. This opening is made by picking up the 
 sheath or condensed tissue with the thumb forceps, and 
 with the scalpel at, or nearly at right angles with the for- 
 ceps, carefully cutting out a button-hole-shaped piece of a 
 suitable size (Fig. 85). 
 
 The borders of this opening are then to be separately 
 raised, to inform the operator if deeper tissues still surround 
 the vessel; if so, they should be incised in a similar manner. 
 When the peculiar pinkish white appearance of its coats 
 are seen, the side of the cut in the sheath nearest to the 
 contiguous vein should be grasped and raised by the for- 
 ceps, and the aneurism needle, or probe, armed with a liga- 
 ture, carefully passed around the vessel, being carried from 
 the contiguous vein (Fig. 86). When its extremity ap- 
 pears at the other side the ligature is 
 seized by the forceps and one end 
 drawn through, while the other ex- 
 tremity is retained in position by the 
 withdrawal of the needle. If the ves- 
 sel be sufficiently superficial, the liga- 
 ture can be passed through the eye of 
 the needle after its passage beneath 
 the artery (Fig. 87). If now all 
 
 Fig. 87. Fig. 86. 
 
 doubts be settled as to the identity of the vessel, the liga- 
 
INSTRUMENTS USED IN LIGATION. 
 
 ture is tied by making either the surgeon's or the reef-knot. 
 If the ligature be of catgut, cut both ends short and dress 
 the wound; if silk, cut one extremity short and allow the 
 other to hang from its most dependent position. This ex- 
 tremity should be secured, so that it will not be unneces- 
 
 ffli 
 
 CflSWEUJHAZAfiiJ, &CO.yiFJOHa 
 
 Fig. 88. 
 
 sarily drawn upon when the wound is dressed. The length 
 of time the ligatures are to remain depends upon the size 
 of the vessel, and will be considered in connection with the 
 ligaturing of the individual arteries. 
 
 Insimments required to Ligature Arteries. — An ordinary 
 scalpel, a flexible grooved director, thumb-forceps, tenacu- 
 
 FlG. 89. 
 
 la, retractors, and an aneurismal needle armed with a liga- 
 ture. 
 
 Retractors vary in size and shape. The ones recommended 
 by Profs. Mott (Fig. 88) and Parker (Fig. 89) are appro- 
 priate for all practical purposes. If neither be at hand, one 
 
 CASWEIXHAZABD. &CO.VJ.Fi^0RQ. 
 
 Fig. 90. 
 
 can be devised by bending the handle of the common table- 
 spoon to the necessary angle. 
 
 Aneurismal Needle. — These vary in size, shape, and ar- 
 rangement. The simplest form is combined with a direc- 
 tor (Fig. 90); another in common use has a broader ex- 
 
82 
 
 OPERATIVE SURGERY. 
 
 1C^^^^^ 
 
 Fig. 91. 
 
 Fig. 92. 
 
 Fig. 93. 
 
LIGATION OF ABDOMINAL AORTA. 83 
 
 tremity with a suitable handle (Fig. 91); still another with 
 adjustable points for the purpose of securing deep-seated 
 vessels. The points must be securely screwed into posi- 
 tion, else the turning and twisting of turns necessary to 
 pass it may loosen the points, causing it to become a source 
 of annoyance instead of an advantage (Fig. 92). Also 
 one with a lateral curvature may be employed. Fig. 93 
 is a representation of the safest needle with movable points 
 now in use. It is known as the " Movable Immovable 
 Aneurismal Needle," and also as the " Student's Aneurismal 
 Needle." It was devised by Dr. S. W. Fletcher, of Pepper- 
 ell, Mass., while a student; hence the name sometimes 
 given to it. 
 Ligature of the Abdominal Aorta, — This vessel can be liga- 
 
 FlG. 94. 
 
 tured at its lower two inches — that is, below the origin of 
 the inferior mesenteric — by two or three methods. 
 
 Linear guide is the linea alba. 
 
 The omentum, intestines, and mesentery lie in front; the 
 left lumbar veins, receptaculum chyli, thoracic duct, and 
 vertebral column behind, on the right the inferior vena 
 cava, vena azygos, and thoracic duct. At the left no struc- 
 tures are liable to be injured (Fig. 94). 
 
 Operation. — First method {Cooper s). — An incision is made 
 three or four inches in length a little to the left of the um- 
 bilicus, its centre corresponding to it. (See "A," Fig. 95.) 
 The peritoneum is divided to the same extent on a grooved 
 
84 
 
 OPERATIVE SURGERY. 
 
 director; the omentum, mesentery, and intestines are then 
 pushed upward, the peritoneum scratched through with the 
 finger-nail, or a director; the finger is passed beneath the 
 vessel, and the needle carried around it from right to left, 
 the ligature tied and the wound closed. 
 
 Second Method [Murray's). — Linear guide: From the apex 
 of the tenth rib to within an inch of the anterior superior 
 spinous process of the ilium. (Fig. 95, "B"), 
 
 The left ureter lies to its outer side. 
 
 Operation: Divide the various tissues on a grooved direc- 
 tor down to the subserous tissue; the hand is then inserted, 
 
 Fig. 95. 
 
 and the peritoneum, intestines, and ureter are raised upward 
 and inward, readily exposing the vessel to view. The 
 artery is then raised with the finger and the ligature passed 
 as before. It can be reached through an incision extending 
 from the end of the last rib to the anterior superior spinous 
 process of the ilium. 
 
 Results. — It has been ligatured ten times, and in every 
 instance has proved fatal; death occurring from within 
 three or four hours to ten days. 
 
 Cofnmofi Iliac Arteries. — These vessels average about two 
 
Ligation of common iliac. S5 
 
 inches in length, and should be ligatured at a point nearest 
 to their middle. They commonly begin at the left of the 
 middle of the body of the fourth lumbar vertebra, and pass 
 downward and outward to the sacro-iliac synchondroses. 
 A line drawn between the highest portions of the iliac crests 
 corresponds very nearly tc their point of origin. Two lines 
 drawn a little to the left of the centre of this one, and car- 
 ried downward and outward between, but a little nearer 
 the pubes, than the anterior spinous process of the ilium, 
 mark the course of the vessels downward. 
 
 There are two general methods of access to them; one, by 
 entering the abdominal cavity in front, the other by raising 
 the peritoneum through an incision made at the side of the 
 abdomen. 
 
 First method : At this time this method is not favorably 
 considered as a substitute for the latter, except in cases 
 
 Fig. 96. 
 
 where the latter is inadmissible. If the surgeon be able 
 to command complete asepsis, the advisability of the latter 
 operation is greatly enhanced; if otherwise, it should not 
 be attempted unless the situation of the disease calling for 
 it renders the former impracticable. The outer side of the 
 rectus muscle, or more properly the linea semilunaris, is the 
 best superficial guide to the vessel in this method. The 
 linea semilunaris extends from the lower portion of the 
 seventh rib in a slightly outwardly arched direction down- 
 ward to the spine of the pubes. In a normal abdomen 
 these lines are about three inches from the umbilicus. An 
 incision through the linea alba below and even extending a 
 little above the umbilicus, maybe employed likewise. The 
 relations of the common iliac arteries and veins are intricate 
 and dissimilar (Fig. 96), and should be carefully memorized. 
 
OPERATIVE SURGERY. 
 
 IMPORTANT ANATOMICAL RELATIONS. 
 
 Plan of the Relations of the Common Iliac Arteries. 
 In fro7it. In front. 
 
 Peritoneum. 
 Rectum. 
 
 Superior hemorrhoidal artery. 
 Ureter. 
 
 Peritoneum. 
 Small intestines. 
 Ureter. 
 
 ( Right ) 
 < Common V 
 ( Iliac, j 
 
 Outer side. 
 Vena cava 
 Right common 
 
 iliac vein. 
 Psoas muscle. 
 
 Inner side. 
 
 Left common 
 
 iliac vein. 
 
 ( Left 
 \ Common 
 / Iliac. 
 
 Outer side. 
 Psoas muscle. 
 
 Behind. 
 
 Right and Left common 
 
 iliac veins. 
 
 Behind. 
 
 Left common 
 
 iliac vein. 
 
 Operation : An incision five inches in length and three 
 inches to the left of the median line is made into the ab- 
 dominal cavity; intestines are pushed aside, and a small 
 
 Fig. 97. 
 
 opening is scratched through the peritoneum; and the ves- 
 sel ligatured by passing the needle from without inward 
 on the right and within outward on the left side. That is 
 to say, pass it f^-om the veins nearest the vessel. The 
 wound is then closed as in ovariotomy. 
 
LIGATION OF COMMON ILIAC. 
 
 87 
 
 Results : They are thus far sufficiently satisfactory to war- 
 rant its employment when other methods are inadmissible. 
 
 Second method: Without opening into the abdominal 
 cavity. 
 
 Linear Guide to Operation. — (i.) (Crampton.) A line drawn 
 from the apex of the last rib, downward and a little for- 
 ward nearly to the crest of the ilium, then carried forward 
 parallel with it to the anterior superior spine (Fig. 97). 
 
 (2) Is a line drawn downward from the tip of the 
 eleventh rib to one and a half inches within the anterior 
 
 Fig. 98. 
 
 superior spine, then carried downward and forward and 
 curved sharply upward, sharply terminating above the in- 
 ternal abdominal ring (Fig. 98). 
 
 Muscular Guide. — There is no superficial muscular guide 
 except the rectus in the median operation. The inner border 
 of the psoas magnus is, however, an undeviating and mark- 
 edly prominent deep muscular guide. The contiguous 
 anatomy in this method is indicated by the plan of the 
 preceding. 
 
 Operation. — Place the patient on the back, inclined to the 
 
88 OPERATIVE SURGERY. 
 
 opposite side, with the thighs flexed sufficiently to relax 
 the abdominal walls. By repeated divisions on the grooved 
 director, the various layers of the tissues composing the 
 abdominal walls are divided down to the fascia transver- 
 salis, which is cautiously raised from the peritoneum at the 
 upper end of the wound, where it is less dense and less 
 firmly attached, and a small opening made into it, through 
 which the finger or a large grooved director can be passed, 
 upon which it is divided to the full extent of the wound. 
 The hand of an assistant, who must stand on the opposite 
 side of the body, is then introduced into the wound and 
 the peritoneum raised gently upward and outward, while 
 the operator by the aid of the finger or handle of the scalpel 
 separates it carefully from the tissues beneath; when the 
 psoas magnus is reached, the surgeon will then know the ex- 
 act location of the artery. If the external iliac be first felt, it 
 is to be followed upward to the common; when the common 
 iliac is reached, and the areolar tissue surrounding it 
 scratched aside by the finger or a director, the needle is 
 passed; the one with the adjustable end being the better. 
 
 Dangers. — The dangers attending this operation are con- 
 siderable. The peritoneum may be lacerated; the ureter 
 included in the ligature; the veins punctured by the needle. 
 The assistant who raises the membrane should keep the 
 fingers closely approximated, using both hands, if necessary, 
 and being careful that the fingers do not become too much 
 flexed, else they may lacerate it. If the patient struggle, 
 vomit, or cough, the membrane should be permitted to re- 
 turn to its normal site, until quiet is again restored. The 
 traction necessary to separate and elevate it cannot be made 
 too carefully, and it is better if it be done during the acts 
 of expiration, since at this time less downward pressure 
 will be made by the abdominal contents; large, broad, re- 
 tractors are sometimes employed for this purpose, but they 
 are much less reliable than intelligent hands. 
 
 The ureter passes across the artery at the point of bifur- 
 cation; it is in little danger, since it is usually raised along 
 with the peritoneum and its subjacent tissue. The veins 
 can be avoided by always remembering to pass the needle 
 from them. This will be somewhat difficult on the right 
 side, owing to the large venous trunks in close contact with 
 it. If the vein obscures the arterial trunk, pressure upon 
 it below the point to be ligatured will diminish its size. 
 
 Fallacies. — The external may be mistaken for the common 
 
LIGATION OF INTERNAL ILIAC. 89 
 
 iliac. The relation of the sacro-vertebral prominence to 
 the vessel should settle this doubt. The ligature may be 
 applied too near the bifurcation, owing to the difficulty of 
 finding it, on account of obscure light and the intimate re- 
 lation of the vessels. Gare only will solve this uncertainty. 
 
 Results. — This vessel has been ligatured sixty-eight times, 
 with sixteen recoveries, giving a rate of mortality of about 
 seventy-seven per cent. 
 
 Ligature of Internal Iliac. — This vessel is about an inch 
 and a half in length, extending from the bifurcation of the 
 common iliac downward and forward to near the upper 
 border of the great sacro-sciatic foramen. 
 
 Methods of Operation. — Two or three incisions are given 
 with a view of reaching this vessel. Either of the incisions 
 employed in the ligature of the common iliac, will easily 
 lead to it; or an incision five inches in length, parallel with 
 the epigastric artery, or a semicircular one about seven 
 inches in length, two inches to the left of the umbilicus, 
 with its convexity outwards, and ending just external to the 
 external abdominal ring. 
 
 This vessel possesses no practical linear or muscular 
 guide, other than it lies to the inner side of the psoas 
 magnus. 
 
 Plan of the Relations of the Internal Iliac Artery. 
 In front. 
 
 Peritoneum. 
 Ureter. 
 
 Outer side. ( Internal 
 
 Psoas magnus. 
 
 j Internal I 
 1 Iliac. S 
 
 Behind. 
 
 Internal iliac vein. 
 Lumbo-sacral nerve. 
 Pyriformis muscle. 
 
 Operation. — The tissues are successively divided as in the 
 primative iliac in the line selected for the primary incision; 
 the peritoneum is elevated in the same cautious manner, 
 the connective tissue scratched away, and the ligature 
 carried from within outward, taking care to avoid the 
 ureter, and the external iliac vein as it lies at the angle of 
 bifurcation of the primative iliac. 
 
 Fallacies. — It might be mistaken for the external iliac; 
 
go 
 
 OPERATIVE SURGERY. 
 
 however, this can be quickly rectified if the course of the 
 latter be considered. 
 
 Results of the Cases. — Eighteen terminated fatally; making 
 a rate of mortality of about seventy per cent. 
 
 Ligature of the Gluteal Artery. — This vessel passes out of 
 the pelvis at the upper border of the great ischiatic notch, 
 above the pyriformis muscle. 
 
 Linear guide to the vessel is a line extending from the 
 posterior superior spinous process of the ilium, to the tro- 
 chanter major when rotated inward. The artery is beneath 
 the junction of the upper and middle thirds of this line 
 ("A," Fig. 99). 
 
 Fig. 99. 
 
 Anatomically it lies in the upper border of the notch, 
 the concavity of which is a guide to it; it is accompanied 
 by its venae comites, and is covered by the gluteus maximus 
 muscle. 
 
 Operation. — Place the patient on his abdomen, with the 
 thigh extended; make an incision five inches in length in 
 the course of the line indicated. The line of separation 
 will pass between the fibres of the gluteus maximus, 
 down to the vessel; liberate it from its accompanying 
 
LIGATION OF SCIATIC AND INTERNAL PUDIC. 
 
 91 
 
 veins and pass the ligature in the most convenient 
 manner (Fig. 100). 
 
 Fallacies. — It might be mistaken for either of its venae 
 comites; otherwise no fallacy will 
 occur. 
 
 Results. — The operation itself im- 
 plies but little danger to the pa- 
 tient. 
 
 Ligature of the Sciatic Artery. — 
 This vessel escapes from the pelvis 
 below the pyriformis muscle, and 
 passes downward in the interval 
 between the tuberosity of the ischi- 
 um and the trochanter major. 
 
 Linear guides to the vessel are two 
 in number; one of which is drawn 
 parallel with the preceding, only 
 about an inch and a half lower 
 down. A second, extending from 
 the posterior superior spinous 
 process of the ilium to the outer 
 side of the tuberosity of the ischi- 
 um. (See B, Fig. 99.) 
 
 Its deep muscular guide is the lower border of the pyri- 
 formis, beneath which it descends from the pelvis. 
 
 Contiguous Anatomy. — It is covered by the gluteus maxi- 
 mus; the sciatic nerve accompanies it, and it is posterior to 
 the pudic artery. 
 
 Operation. — An incision is made three or four inches in 
 length on one of the lines indicated, down through the 
 fibres of the gluteus maximus, the 
 nerves and veins are pushed aside, and 
 the ligature is carried around it. Care 
 being used to avoid the vein which 
 lies to its outer side. (Fig. loi.) 
 
 Fallacies. — This artery might be mis- 
 taken for the pudic artery, which lies 
 internal to it; however, the direction 
 taken by the respective vessels should 
 make the distinction easy. 
 
 Results. — The prognosis to life is al- 
 ways good so far as the operation itself is concerned. 
 
 Ligature of the Inter7ial Pudic Artery. — This vessel escapes 
 from the pelvis through the greater sacro-sciatic foramen 
 
 Fig. 
 
92 
 
 OPERATIVE SURGERY. 
 
 below the pyriformis muscle, lying internal to the sciatic 
 artery; then enters the pelvis through the lesser sacro- 
 sciatic foramen, and runs along the inner surface of the 
 
 Fig. 102. 
 
 ramus of the ischium and pubes, till it divides into its ter- 
 minal branches. 
 
 It maybe ligatured in two situations: (i) At the greater 
 sacro-sciatic foramen; (2) in the 
 perineum. In the first situation 
 the incision for the sciatic is 
 sufficient, the pudic being found 
 internal to that arterj', and lower 
 down accompanied by its veins 
 and the pudic nerve. In the per- 
 ineum the linear guide to the 
 operation extends from the arch 
 of the pubes to the inner border 
 of the tuber ischii (Fig. 102). 
 The artery is situated about an 
 inch and a quarter above the 
 margin of the tuber ischii. 
 
 Contiguous Anatofuy. — It runs 
 along the outer side of the ischio- 
 rectal fossa, resting upon the 
 obturator internus muscle, covered by the obturator fascia, 
 and accompanied by the pubic veins and pudic nerve. 
 
 Fig. 
 
LIGATION OF EXTERNAL ILIAC. 93 
 
 Operation. — The patient is placed in the lithotomy posi- 
 tion and an incision is made in the course of the line 
 indicated, the tissues are carefully divided down to the 
 vessel, which is then isolated from its veins and nerves and 
 tied (Fig. 103). If care be not taken the crus penis will be 
 cut. The introduction of a sound into the urethra will so 
 positively define its outlines that the danger of cutting 
 will be obviated. 
 
 Ligature of the Dor sails Penis. — This maybe tied on the 
 dorsum of the penis by making an incision an inch in 
 length on a line corresponding to the centre of its long 
 axis. It is superficial, and is attended by its veins and 
 nerves, which should be carefully avoided in passing the 
 needle. 
 
 Ligature of the External Lilac Arteiy. — This vessel is about 
 four inches long and passes obliquely downward and out- 
 ward, nearly corresponding to a line drawn from the left 
 side of the umbilicus to midway between the anterior su- 
 perior spinous process of the ilium and the S3'mphisis pubis. 
 It is ligated at about the middle of its course. It has no 
 superficial muscular guide; however, the psoas magnus, at 
 the inner border of which it lies, is a most important deep 
 muscular guide. 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the External Iliac Artery. 
 
 In front. 
 
 Peritoneum, intestines. 
 
 ■VT r Spermatic vessels. 
 
 p f' J Genital branch. Genito-crural nerve. 
 
 J . P 1 Circumflex iliac vein. 
 
 ° ■ [Lymphatic vessels and glands. 
 
 Outer side. Inner side. 
 
 Psoas magnus. -I ii'|™ [ External iliac vein and vas 
 
 Iliac fascia. ' deferens at femoral arch. 
 
 Behind. 
 
 External iliac vein. 
 Psoas magnus. 
 Iliac fascia. 
 
 Operation. — Before beginning the operation evacuate the 
 contents of the bladder and rectum of the patient, then 
 place him in a recumbent position, with the thigh slightly 
 flexed. A curvilinear incision is then made, with the con- 
 vexity downward, beginning about an inch and a half 
 
94 
 
 OPERATIVE SURGERY. 
 
 above Poupart's ligament, and immediately to the outer 
 side of the external abdominal ring, and terminating on a 
 level with, but about two inches internally to the anterior 
 superior spinous process of the ilium (Fig. 104, C). The 
 superficial fascia, aponeurosis of the external oblique, the 
 muscular fibres of the internal oblique, and the transversalii 
 are separately divided upon a grooved director. The fascia 
 transversalis is now carefully picked up with the thumb 
 forceps, and a small opening made through it, into which 
 
 Fig. 104. 
 
 the director is inserted and the fascia divided. The peri- 
 toneum and its subserous tissue are then carefully raised 
 from the iliac fascia, and pressed upward and inward 
 until the outer border of the psoas magnus is ascertained, 
 when, after a little further separation, the vessel is felt 
 pulsating at its inner margin. 
 
 The condensed areolar tissue constituting its sheath is 
 then opened, and the needle careful!}'- inserted between the 
 vein and artery, from within outward. If the incision be 
 made about a half of an inch above Poupart's ligament 
 it will come upon the iliac fascia without coming in con- 
 
LIGATION OF EXTERNAL ILIAC. 95 
 
 tact with the peritoneum, since it is reflected upward and 
 downward into the pelvis a little above this point. 
 
 Fallacies. — The external oblique aponeurosis may be mis- 
 taken for the deep layer of fascia. The muscular fibres of the 
 internal oblique will then be mistaken for those of the exter- 
 nal oblique. If, howevc", the direction of the fibres of the 
 respective muscles be recalled, and furthermore, that the 
 external oblique has no muscular fibres in this situation, 
 the mistake will be quickly rectified. The fascia transver- 
 salis may be mistaken for the peritoneum; this fallacy is 
 easily detected by following it downward, when, if it be at- 
 tached to Poupart's ligament, or passes beneath it, it can- 
 not be the peritoneum, and must therefore be the transver- 
 
 ,.,#■ 
 
 < . ^ 
 M 
 |j'^ 
 
 Fig. 105. 
 
 salis fascia. If its relations to the previously divided 
 tissues be taken into account, together with its density and 
 opacity, this mistake can hardly occur. 
 
 The iliac fascia may be mistaken for the subserous tissue, 
 and be raised along with the peritoneum. Under such cir- 
 cumstances the vessel will be raised upward along with the 
 peritoneum and iliac fascia, and will be felt pulsating in 
 the roof rather than the floor of the operation wound. This 
 mistake can be avoided by remembering that the iliac and 
 psoas muscles are covered by a dense fascia, which passes 
 out of the pelvis beneath the Poupart's ligament and is 
 attached to it, and that the artery does not lie beneath 
 it. 
 
 If an irreducible inguinal hernia exist, or the vein be 
 adherent to the artery, then much difficulty may be 
 
96 OPERATIVE SURGERY. 
 
 experienced in properly depositing the ligature without 
 injury to the intestines or the vein. After ligation the 
 wound must be thoroughly closed by carrying the sutures 
 deeply down and close to the peritoneum, the superficial 
 tissues, integument, and fascia being united separately. If 
 this be not done the patient will be exposed to the danger 
 of the occurrence of a hernial protrusion due to the weak- 
 ening of the abdominal walls. This is a precaution which 
 should always be taken in operations involving the separa- 
 tion of the peritoneum. 
 
 Results. — This vessel has been ligatured 169 times, with 
 61 deaths; which have arisen from various causes connected 
 either with the operation itself, or the conditions calling 
 for it. 
 
 Ligature of the Epigastric Artery. — This vessel is ligatured 
 in one situation only. It arises from the lower portion of 
 the external iliac and runs upwards toward the umbilicus, 
 between the peritoneum and the fascia transversalis. It 
 lies at the inner border of the internal abdominal ring. 
 
 Linear Guide. — A line extending from the umbilicus to 
 the midddle of Poupart's ligament corresponds to the 
 course of the vessel. The guide to the first incision is the 
 middle of the upper border of Poupart's ligament. (See 
 A, Fig. 104.) _ ^ 
 
 Operation. — An incision is made about three inches in 
 length parallel with and about one inch above Poupart's 
 ligament. The various layers of the abdominal wall are 
 then divided separately upon a grooved director until the 
 fascia transversalis is reached, which is opened over the 
 artery, the veins separated from it, and the ligature prop- 
 erly placed. 
 
 The wound should then be carefully closed, and the pa- 
 tient kept quiet in a recumbent posture until the tissues 
 are firmly united, else a weak point in the abdominal walls 
 may follow. 
 
 Deep Circumflex Lliac. — This vessel may be secured in two 
 positions: (i) At the internal abdominal ring; (2) near the 
 anterior superior spinous process of the ilium. In the first 
 it may be tied through the same incision as the epigastric. 
 In the second it may be secured through an incision made 
 parallel to Poupart's ligament and just above it, through 
 the various tissues anterior to the transversalis fascia, 
 which is then opened, the artery isolated and tied. 
 
 Ligature of the Femoral Artery. — The femoral artery ex- 
 
LIGATION OF FEMORAL. 
 
 97 
 
 tends from Poupart's ligament to the lower extremity of 
 Hunter's canal, at the junction of the middle and lower 
 thirds of the thigh, where it terminates in the popliteal. It is 
 ligatured in three situations: (i) Just below Poupart's liga- 
 ment; (2) at the apex of Scarpa's triangle, or about four 
 inches below the ligam'^nt; (3) at its lower third, or in 
 Hunter's canal. The most favorable situations are at the 
 apex of Scarpa's triangle and in Hunter's canal. However, 
 circumstances often arise which necessitate its being tied, 
 irrespective of the stereotyped situations. 
 
 The linear guide to the artery throughout its whole 
 
 Fig. 106. 
 
 course is a line drawn from midway between the anterior 
 superior spinous process of the ilium and the symphysis 
 pubes to the inner condyle of the femur (Fig. 106, A). 
 
 A line drawn from the origin of the adductor longus to 
 the insertion of the adductor magnus tendon into the in- 
 ternal condyle of the femur, also corresponds to the femoral 
 at its lower third. (See Fig. 107.) 
 
 The Muscular Guide. — The sartorius is given as its mus- 
 cular guide; the artery is at its inner border in the upper 
 third, behind it in its middle, and at its outer side in its 
 
98 
 
 OPERATIVE SURGERY. 
 
 lower third. The better muscular guide to the lower third 
 is the inner border of the tendon of the abductor magnus. 
 Contiguous Anatomy. 
 
 Plan of the Relations of the Femoral Artery. 
 In front. 
 Fascia lata. 
 
 Branch of anterior crural nerve. 
 Sartorius (middle part). 
 Long saphenous nerve. 
 Aponeurotic covering of Hunter's canal (lower part). 
 
 j Femoral 1 
 ( Artery. \ 
 
 Inner side. 
 
 Femoral vein (at upper part), 
 Adductor longus. 
 Sartorius. 
 
 Behind. 
 
 Psoas muscle. 
 
 Profunda vein. 
 
 Pectineus muscle. 
 
 Adductor longus. 
 
 Femoral vein (middle part). 
 
 Adductor magnus. 
 
 Outer side. 
 Vastus internus. 
 Femoral vein (at lower part). 
 
LIGATION OF FEMORAL. 
 
 99 
 
 Operation. — First situation common femoral. The vessel 
 can be ligatured immediately below Poupart's ligament 
 through two incisions; one made in the long axis of the 
 vessel, the other parallel with the lower border of the liga- 
 ment. (See B, Fig. 104.) The former is, however, the 
 better method. The patient is placed upon his back, and 
 the thigh flexed and rotated outward. The pulsation of 
 the artery noted by the finger, when an incision about three 
 inches in length is made through the integument, and sub- 
 cutaneous tissues are divided, the fascia lata is divided on a 
 director in the usual manner, and the sheath, which is of 
 
 ^ \>'' 
 
 Ik 
 
 much density, is opened and the needle passed from with- 
 in outward (Fig. 108). The vein will be noticed at its 
 inner side, enclosed in a common sheath with it, but sepa- 
 rated from the artery by a fibrous partition (Fig. 109). 
 The attention of the surgeon should be directed to the 
 pinkish white pulsating vessel rather than to seeking for 
 the vein. If the attention and manipulations be directed 
 toward the artery, the vein will remain securely within its 
 apartment. The lymphatic glands which are encountered 
 are drawn aside. 
 
 Second situation: At tlie apex of Scarpa's triangle, or 
 
lOO 
 
 OPERATIVE SURGERY. 
 
 about four inches below Poupart's ligament. Tiie saphe- 
 nous vein runs along the inner side of this region; its loca- 
 tion can be determined by pressing above, which will cause 
 it to be distended. The limb is placed as in the preceding 
 operation, and an incision is made about four inches in 
 
 Fig. 109. 
 
 length along the inner border of the sartorius muscle: 
 divide the tissues down to the fascia lata, draw the sarto- 
 rius to the outer side, and the sheath of the vessel will be 
 seen with the pulsations of the artery beneath it; cau- 
 tiously open it, and pass the needle from within outward. 
 The vein lies to the inner side, somewhat more posteriorly 
 than above (Fig. no). 
 
LIGATION OF FEMORAL 
 
 lOI 
 
 Third situation: or in Hunter's canal. Flex the thigh 
 on the pelvis and the leg on the thigh, with thigh rotated 
 outward; an incision is then made along the outer border 
 of the tendon of the adductor magnus (see Fig. io6, A), 
 about four inches in length, down through the integument 
 and fascia, when the tendon will be readily felt. If the 
 sartorius be in the way it should be drawn to the outer 
 side. Any intervening soft parts are pushed aside, which 
 will expose the fibrous canal in which the artery is con- 
 tained, the fibres of the adductor magnus with the inner 
 
 Fig. ho. 
 
 border of the vastus internus. The canal is cautiously 
 opened, and the long saphenous nerve is seen resting upon 
 the vessel; this is drawn aside and the needle passed from 
 without inward; the vein now being located posteriorly 
 and externally (Fig. iii). The vessel can be ligatured in 
 this situation by making an incision of a similar length on 
 the linear guide above (Fig. io6); it is not so easily secured, 
 however, as by the method just stated. 
 
 Fallacies. — The sartorius may be mistaken for the other 
 
I02 
 
 OPERATIVE SURGERY. 
 
 muscles lying in its course. If, however, it be recollected 
 that no other muscles run in the same direction on the an- 
 terior surface of the thigh, and that it is superficial through- 
 out its whole course, no great confusion can arise from this 
 fallacy. The lymphatic glands that lie over the sheath of 
 the vessel in the upper portion of its course may be mis- 
 taken for the vessel itself, owing to their color and to the 
 transmitted pulsation. These are irregular, movable, can 
 be raised upward, when their apparent pulsation will cease. 
 Moreover, the artery is beneath the fascia lata, and they 
 are above it. 
 
 The tendon of the adductor magnus may be mistaken 
 for tendon of the semimembranous or semitendinosus. 
 This mistake will be avoided if the tendon be traced by 
 
 Fig. III. 
 
 palpation downward; the latter will pass behind the inter- 
 nal condyle, while the former will be found inserted into it. 
 Care must be taken in ligaturing it at the apex of Scarpa's 
 triangle not to make the incision too low down. The 
 width of the hand below Poupart's ligament is a good 
 practical guide to its apex. In ligaturing it in Hunter's 
 canal, it should be remembered that the canal is located 
 but a little below the middle third of the thigh, otherwise 
 the incision will be made too low down, and the upper por- 
 tion of the popliteal secured instead. 
 
 In a very small number of cases (four) the femoral has 
 been double; in a like number it passed behind instead of in 
 front of the thigh. If it be double, the portion found will 
 be smaller than normal, and the object for which the liga- 
 ture is applied will not be accomplished. If the vessel be not 
 
LIGATION OF PROFUNDA. 
 
 103 
 
 found in its common location it will be necessary to seek 
 for it elsewhere. Deep pressure may enable one to detect 
 the site of its deviation. 
 
 Results. — The common femoral has been ligatured eight 
 times for aneurism, with a rate of mortality of 25 per cent. 
 The superficial femoral has been tied 204 times, with a mor- 
 tality of 50 cases. 
 
 Deep Fe7jioral, or the Profunda. — This vessel usually comes 
 
 Fig. 112. 
 
 off from the common trunk one or two inches below Pou- 
 part's ligament. It may arise above or even four inches 
 below this ligament. There is no known manner of deter- 
 mining its site prior to an operation. It arises from its 
 outer side, running slightly outward, then downward and 
 inward, passing behind the superficial femoral, accompa- 
 nied by its vein, which lies in front of it (Fig. 112). 
 
104 
 
 OPERATIVE SURGERY. 
 
 Operation. — This is tied through the same incision for the 
 ligation of the common femoral, and is to be sought for at its 
 outer side. When found it should be carefully isolated, in 
 order to insure a sufficient distance from the giving off of 
 its circumflex branches, for the application of the ligature. 
 Fallacies. — It may arise from the inner or back portions 
 of the common femoral. If not 
 found in the usual place, it should 
 be sought after in these situations. 
 
 Ligature of the Popliteal Artery. — 
 This vessel may be ligatured in two 
 situations: at its upper and lower 
 portions. It is continuous with the 
 femoral, beginning at the junction 
 of the middle and lower thirds of 
 the thigh, at the termination of 
 Hunter's canal, and passes with a 
 slight obliquity downward and out- 
 ward to the lower border of the 
 popliteus muscle. 
 
 Linear Guide. — The linear guide 
 begins a little to the inner side of 
 the middle of the upper portion of 
 the popliteal space, and terminates 
 below between the heads of the gas- 
 trocnemius muscle, passing mid- 
 way between the condyles of the 
 femur. (Fig. 113.) 
 
 Muscular Guide. — In its upper 
 third it lies to the inner border of 
 the semimembranosus; at its lower 
 midway, between the heads of the 
 gastrocnemius. 
 
 Contiguous Anatojny. — In the upper 
 third the internal popliteal nerve is 
 more superficial than the vein and 
 artery. The vein lies in close contact with the artery, and 
 between it and the nerve. The artery is the innermost 
 of the three, is the most deeply situated, resting on the 
 posterior surface of the femur. In the lower third, the 
 nerve is still the most superficial, but lies upon and to its 
 inner side. The vein in this situation is to its inner side, 
 and more superficial than the artery, which rests upon 
 the popliteus muscle. This vessel should not be tied in its 
 
 Fig. 113. 
 
LIGATION OF POPLITEAL. 
 
 105 
 
 middle third, on account of the large number of branches 
 given off at this ooint, together with its contiguity with 
 the knee-joint. 
 
 Operation in the Upper Portion (Fig. [13, B). — The patient 
 can be placed upon the face; or, while on the back the thigh 
 can be well flexed and rotated outward. Tlie former posi- 
 tion is more convenient for the surgeon, but is objection- 
 able on account of safety to the patient. The patient may 
 be placed on the side corresponding to the limb to be oper- 
 ated upon, with that thigh extended and the opposite one 
 
 *f 
 
 Fig. 114. 
 
 Fig. 115. 
 
 flexed on the pelvis, when the safety and comfort of both 
 will be consulted. 
 
 An incision is made, about four inches in length, along 
 the inner border of the semimembranosus, through the in- 
 tegument and fascia, and is then continued downward by 
 separating the areolar tissue with the handle of the scalpel 
 or fingers. The nerve will no doubt be first seen, and 
 when pulled outward the vein will be found lying more 
 deeply and internal to it; if this be now carefully isolated 
 and pulled in the same direction, the artery will be seen at 
 its inner side, which must be separated from the surround- 
 
io6 
 
 OPERATIVE SURGERY. 
 
 ing tissue, and the needle carried from without inward 
 (Fig. 114.) 
 
 Operation in the Lower Portion, Fig. 113, C. — Make an inci- 
 sion midway between the heads of the gastrocnemius, 
 carefully avoiding the external saphenous vein and nerve, 
 which escape between the heads of that muscle; separate 
 the connective tissue with the handle of the scalpel, draw 
 the vein and nerve to the inner side, and pass the needle 
 from within outward. Its lower third may be tied below 
 the inner condyle of the tibia. The linear guide in this 
 situation is continuous with that of the posterior tibial 
 (see Fig. 117), and the limb should be placed in a similar 
 position as for ligaturing the posterior tibial. (Fig. 115.) 
 Fallacies. — The tendon of the semi- 
 tendinosus may be mistaken for the 
 semimembranosus. At the upper 
 portion the semimembranosus has a 
 large fleshy belly, which extends 
 much nearer to the median line of 
 the popliteal space than the semiten- 
 dinosus. 
 
 Sometimes there are two popliteal 
 veins, one on either side of the vessel. 
 
 Fig. 116. 
 
 Fig. 117. — Transverse Section, Middle Third. 
 
 I. Soleus. 2 and 3. Gastrocnemius. 4. Flexor lon^s 
 poUicis. 5. Peroneus longus and brevis. 6. Extensor 
 longus pollicis. 7. Extensor com. digitorum. 8. Tibi- 
 alis amicus. 9. Tibialis posticus. lo. Flexor longus 
 dig. II. Anterior tibial artery and venae comites. 12. 
 Anterior tibial nerve. 13. Posterior tibial artery and 
 venae comites. 14. Posterior tibial nerve. 15. Peroneal 
 artery and venae comites. 
 
LIGATION OF ANTERIOR TIBIAL. IO7 
 
 Results. — It is seldom ligatured unless it be ruptured, 
 when both ends must be tied. Of the three or four cases 
 thus reported, all terminated unfavorably. 
 
 Ligature of the Anterior Tibial Artery. — It arises from the 
 popliteal, just below the lower border of the popliteus 
 muscle, passes forward between the bones of the leg, 
 above the interosseous membrane, then downward on its 
 anterior surface to the ankle joint, where it becomes the 
 dorsalis pedis. This vessel can be tied in three situations: 
 at its upper, middle, and lower thirds; but two, the middle 
 and lower, are more than sufficient for all practical pur- 
 poses. 
 
 The lifiear guide of the vessel is drawn from the inner 
 border of the head of the fibula to midway between the 
 malleoli. (Fig. 116.) 
 
 The muscular guide is the outer border of the tibialis 
 anticus muscle. (Fig. 117.) 
 
 Cotitiguous Anatomy. 
 
 Plan of the Relations of the Anterior Tibial Artery. 
 
 In front. 
 Integument, superficial and deep fasciae. 
 Tibialis anticus (overlaps it in upper part of leg). 
 Extensor longus digitorum ) / , .. ,. . .., v 
 Extensor proprius pollicis [ (^^^'^^^P '^ slightly). 
 Anterior tibial nerve. 
 
 Inner side. Outer side. 
 
 Tibialis anticus. Anterior tibial nerve. 
 
 Extensor proprius pollicis j Anterior ) Extensor longus digitorum. 
 (crosses it at its lower ' Tibial. ) Extensor proprius pollicis. 
 part). 
 
 Behiftd. 
 Interosseous membrane. 
 Tibia. 
 Anterior ligament of ankle-joint. 
 
 Operations: Upper Third. — The great depth of the vessel 
 in this situation renders the tying of it one of the most 
 difficult. Unless circumstances demand it, the ligaturing 
 at this situation should not be attempted. The following 
 figure shows the deep relations of the vessel. (Fig. 117^.) 
 The linear and muscular guides are similar to those of the 
 middle third. 
 
 Middle Third. — The artery in this situation lies quite 
 deep, and a good light must be had to see the bottom of 
 
io8 
 
 OPERATIVE SURGERY. 
 
 the operation wound. Place the patient on the back with 
 the thighs extended, the leg turned inward, and the foot 
 forcibly extended to mark the outlines of the tibialis anti- 
 cus. Make an incision four or five inches in length on the 
 line indicating the course of the artery, down to the fascia, 
 which is then divided on a director. The aponeurosis is 
 divided along the line of apposition between the tibialis 
 anticus and the extensor longus digitorum; it should 
 likewise be divided transversely to admit of the wider 
 
 Fig, 117a, — Transverse Section, Upper Third. 
 
 1. Popliteus. 2 and 3. Gastrocnemius. 4. Soleus. 5. Peroneus longus. 6. Exten- 
 sor longus dig. 7. Tibialis anticus. 8. Tibialis posticus. 9. Posterior tibial artery 
 and venae comites. 10. Posterior tibial nerve. 11. Anterior tibial artery and venae 
 comites. 12. Anterior tibial nerve. 
 
 separation of these muscles. The foot is now flexed, and 
 with the finger or handle of the scalpel the line of sepa- 
 ration is extended directly down to the vessel; separate the 
 surfaces of the wound with a spatula, when the artery with 
 its nerve and veins will be seen, the nerve being in front 
 and to the outer side ; separate the veins, draw the nerve 
 aside and pass the ligature from without inward (Fig 
 118.) 
 
 Operation at the Lower TJiird. — With the limb as in the 
 preceding instance, extend the foot to mark the course of 
 the tendon of the tibialis anticus; make an incision along 
 the external border of the tendon on the linear guide, 
 about three inches in leno-th. Divide the fascia on a direc- 
 
LIGATION OF ANTERIOR TIBIAL. 
 
 109 
 
 tor, and seek with the finger for the space between the 
 tibialis anticus and the extensor proprius poUicis which has 
 crossed to the inner side of the vessel; flex the foot, sepa- 
 rate these muscles, and the artery will be seen accompanied 
 by its veins and nerve; the latter lying in front and a little 
 to the outer side; isolate the artery, and place the ligature 
 by passing from without inward. 
 
 Fallacies. — The outer surface of the head of the tibia may 
 
 Fig. 118. 
 
 Fig. 119. 
 
 be mistaken for the head of the fibula, which will bring the 
 linear guide too far to the inner side of the leg, and cause 
 the incision to be made over the belly of the tibialis anti- 
 cus muscle. To avoid this it must be remembered that the 
 head of the fibula is more posteriorly, and constitutes the 
 most external bony prominence at this joint. 
 
 The septum between the tibialis anticus and the extensor 
 longus digitorum may be indistinct or absent; then the 
 outer border of the tibialis can be determined, (i) by for- 
 
no OPERATIVE SURGERY. 
 
 cible extension of the tarsus; (2) by determining its limits 
 by the resistance to lateral pressure; (3) the line indi- 
 cating the interspace may be seen at the lower extremity 
 of the cut when not visible above. 
 
 The vessel may be rudimentary or absent; it may run 
 more superficially than common. So long, however, as it 
 keeps in the proper line its pulsations will lead to its de- 
 tection. 
 
 Ligature of the Dorsalis Pedis Artery, — This vessel is a 
 continuation of the anterior tibial, beginning at the ankle- 
 joint and passing downward between the metatarsal bones 
 of the great and second toes. It is tied in one situation, 
 and on a line which is a direct continuation of the linear 
 guide to the anterior tibial. 
 
 The Muscular Guide is the outer border of the tendon of 
 the extensor propriiis pollicis (Fig. 119). 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the Dorsalis Pedis Artery. 
 In front. 
 
 Integument and fascia. 
 
 Innermost tendon of Extensor brevis digitorum. 
 
 Tibial side. Fibular side. 
 
 Extensor proprius pollicis. J Dorsalis I Extensor longus digitorum. 
 
 ( Pedis, i Anterior tibial nerve. 
 
 Behind. 
 
 Astragalus. "* 
 
 Scaphoid. 
 
 Internal cuneiform, 
 and their ligaments. 
 
 Operation. — Extend the tarsus and forcibly flex the great 
 toe to make prominent the tendon of the extensor proprius 
 pollicis; make an incision about three inches in length 
 along its inner border, commencing from the bend of the 
 ankle; divide the fascia on a director, when the fleshy 
 under portion of the flexor brevis digitorum will be seen; 
 this should be drawn outward when the artery and its- 
 satellite veins will be seen; separate the artery from them, 
 and pass the needle as best suits the convenience of the 
 operator (Fig. 120). 
 
 Fallacy. — It may pass outside of the line indicating its 
 proper course. 
 
LIGATION OF POSTERIOR TIBIAL. 
 
 Ill 
 
 Ligature of the Posterior Tibial Artery. — It is an artery of 
 considerable size which comes from the popliteal at the 
 lower border of the popliteus muscle, passes obliquely to 
 the tibial side of the leg, going down between the super- 
 ficial and deep layers of muscles to a point midway be- 
 tween the internal malleolus and inner tuberosity of the 
 
 j1./4- 
 
 Fig. 12a 
 
 Fig. 
 
 OS calcis, where it terminates a little later in the external 
 and internal plantar vessels. It may be ligatured in three 
 situations: at its middle and lower thirds, and as it passes 
 behind the inner malleolus. 
 
 The linear guide of this vessel is drawn from the middle 
 of the popliteal space to midway between the inner 
 malleolus and tuberosity of the os calcis. This guide is not 
 a feasible one, since, to reach the artery by cutting upon 
 
112 . OPERATIVE SURGERY. 
 
 it necessitates the diversion of tlie fibres of the muscles 
 of the calf of the leg. 
 
 Li?iear guide to the operation is made by drawing a line 
 three fourths of an inch behind the posterior border of 
 the tibia in the upper and lower thirds, from its upper to 
 its lower extremity (Fig. 121). 
 
 The Afuscular Guide. — At its middle third it lies beneath 
 the soleus; at its lower third to the outer border of the 
 flexor longus digitorum. 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the Posterior Tibial Artery. 
 /« front. 
 Tibialis posticus. 
 Flexor longus digitorum. 
 Tibia. 
 
 Ankle-joint. 
 Inner side. Outer side. 
 
 Posterior tibial nerve, J Posterior I Posterior tibial nerve, 
 
 upper third. • TibiaL j lower two thirds. 
 
 Behind. 
 Gastrocnemius. 
 Soleus. 
 Deep fascia and integument. 
 
 Operation at its Middle Third (Fig. 122). — Place the 
 patient on the back, flex the leg on the thigh and the 
 thigh on the pelvis, so the leg will lie on the outer side. 
 Make an incision on the line indicated about four inches 
 in length; divide the deep fascia, recognize the inner border 
 of the gastrocnemius, beneath which will be seen the fibres 
 of the soleus, which should be divided on a director, down 
 to the pale yellow aponeurosis on its under surface; sepa- 
 rate the fibres of the soleus and make an opening through 
 its aponeurosis about one inch from the inner border of 
 the tibia, of sufficient size to expose the artery, which is 
 found beneath, attended by its veins and the posterior 
 tibial nerve; draw the nerve to the outer side, separate the 
 vessel from the veins and pass the needle from without 
 inward. 
 
 Operatio7i at the Lower Third (Fig. 123). — Place the limb 
 as before; make an incision in the course of the linear guide 
 about three inches in length; divide the integument and 
 fascia in the usual manner; separate the borders of the 
 wound, then divide the aponeurosis which binds do.wn the 
 
LIGATION OF POSTERIOR TIBIAL. 
 
 113 
 
 deep layer of muscles at about one inch from the posterior 
 border of the tibia, push aside the fat, and the vessel with 
 its nerve and veins will be found at the outer border of the 
 flexor longus digitorum. Separate the vessel, push the 
 nerve to the outer side and pass the needle from without 
 inward. 
 
 Operatio7i between the os calcis and internal malleolus. 
 Place the foot on the outer surface and make a curved 
 incision about three inches in length, with the convexity 
 uppermost, and its centre at a point midway between 
 the malleolus and the inner tuberosity of the os calcis. 
 
 Fig. 123. 
 
 (See Fig. 121.) Divide the fascia and the internal an- 
 nular ligament on a director, using caution with the 
 latter, since the artery rests beneath it; isolate the vessel 
 from the veins and pass the needle from without inward. 
 In passing through the superficial tissues some small 
 brandies of the long saphenous vein may be divided, unless 
 caution be used. In old people both these and the vena 
 comitis often become varicose, which increase the difficulty 
 of finding and isolating the artery. It is better not to 
 
114 OPERATIVE SURGERY. 
 
 attempt to ligature it in this situation if evidences of 
 varicosities exist. 
 
 Fallacies. — The posterior tibial may be rudimentary or 
 absent. In either instance the peroneal is usually increased 
 in size. 
 
 Ligature of the Peroneal Artery. — It arises from the pos- 
 terior tibial about an inch below the popliteus muscle, passes 
 obliquely outward to the inner border of the fibula, along 
 which it descends to the lower third of the leg, and is finally 
 distributed to the outer side of the ankle. It may be 
 ligatured at the middle third of the leg. 
 
 The lifiear guide is a line drawn from the posterior border 
 of the head of the fibula to the external border of the tendo- 
 achilles at its insertion. 
 
 Contiguous Anatomy. (See Fig. 117.) 
 
 Plan of the Relations of the Peroneal Artery. 
 
 In front. 
 Tibialis posticus. 
 Flexor longus pollicis. 
 Outer side. 
 Fibula. fi-^-'t 
 
 BeJiind. 
 
 Soleus. ^ 
 
 Deep fascia. 
 
 Flexor longus pollicis. 
 
 Operation. — Extend the foot and make an incision about 
 four inches in length along the line indicated, parallel with 
 the external border of the fibula. Separate the attach- 
 ments of the soleus and the flexor longus pollicis from each 
 other, when the artery will be found at the inner side of the 
 flexor longus pollicis close to the fibula. 
 
 Fallacies. — It may be absent: this is, however, very rare. 
 It may be overlooked, and the posterior tibial found in- 
 stead. If its close relation to the fibula be remembered, 
 this mistake will not occur. 
 
 Ligature of the Lfinonmiata Artery. — The innominata artery 
 arises from the beginning of the transverse arch of the 
 aorta in front of the left common carotid, passes obliquely 
 upward and outward to the upper border of the right 
 sterno-clavicular articulation, where it divides into the right 
 common carotid and right subclavian. It has no practical 
 linear or muscular guides. 
 
LIGATION OF INNOMINATA. 
 
 115 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the Innominate Artery. 
 
 In front. 
 Sternum. 
 
 Sterno-hyoid and Sterno-thyroid muscles. 
 Remains of thymus gland. 
 
 Left innominate and right ii ferior thyroid veins. 
 Inferior cervical cardiac branch from right pneumogastric nerve. 
 
 Right side. 
 Right vena innominata. 
 Right pneumogastric nerve. 
 Pleura. 
 
 ' Innominate i 
 Artery. ( 
 
 Behind. 
 Trachea. 
 
 Left side. 
 Remains of thymus. 
 Left Carotid. 
 
 Operations. — Numerous incisions have been given for 
 gaining access to the vessel. The one which is best cal- 
 culated to afford the requisite amount of room was em- 
 ployed by the late Valentine Mott (Fig. 124). Place 
 
 ^^^ 
 
 Fig. 124. 
 
 the patient on the back, with the shoulders somewhat 
 raised and the head turned to the opposite side. An 
 incision was then made three inches in length, extending 
 along the upper border of the clavicle to opposite the 
 centre of the epi-sternal notch. This is joined by another 
 of a similar length directed along the anterior portion of 
 
Il6 OPERATIVE SURGERY, 
 
 the sterno-mastoid muscle. This triangular flap, consisting 
 of the integument, superficial fascia, and platysma, is turned 
 upward and inward. The portions of the sterno-cleido- 
 mastoid, corresponding to the horizontal incision, and the 
 sterno-hyoid and sterno-thyroid muscles, are divided on a 
 director and turned aside. The inferior thyroid veins, if 
 they now come into view, must be carefully drawn aside, 
 the deep cervical fascia is carefully torn or cut through, 
 when the sheath of the common carotid artery, pneumogas- 
 tric nerve, and internal jugular vein is brought into view. 
 Open it, draw the vein and nerve to the outer side, and 
 follow the carotid down to the subclavian, the origin of 
 which should be exposed. The upper portion of the 
 innominata is then to be separated from its important 
 connections by the finger or a blunt director; the left vena 
 innominata is depressed, and the right vena innominata, 
 right internal jugular, and pneumogastric nerve are carried 
 to the right, and then the aneurismal needle is passed from 
 below upAvard and from behind, forward and inward, in 
 close contact with the vessel. 
 
 Fallacies. — If the innominata be shorter than usual, the 
 lower extremity of the common carotid may be tied instead. 
 If the aorta arches to the right side, the innominata will be 
 on the left side, instead of the right. 
 
 The necessity of treating all the veins and the pleura 
 with most judicious care is emphasized by the knowledge 
 of the fact that nearly all the fatal cases thus far have died 
 from pleuris}'' or secondary hemorrhage. 
 
 Results. — This vessel has been ligatured sixteen times, 
 with one recoverj\ 
 
 Ligature of the Subclavian Artery. — This vessel can be 
 ligatured in three situations: (i) Between the inner border 
 of the scalenus anticus and its origin; (2) behind the sca- 
 lenus; (3) between its termination at the lower border of 
 the first rib and the outer border of the scalenus anticus. 
 
 Ligature of the First Portion^ Left Side. — This portion has 
 no definite linear or muscular guide. The inner border of 
 the scalenus anticus is of use in leading to and limiting its 
 extent. Owing to its origin from the arch of the aorta it 
 is of great depth, almost beyond the reach of a ligature; 
 while its close relation to very important structures, injury 
 to which, of itself, maybe more grave than the condition for 
 which the vessel is tied, render it exceedingly difficult to 
 perform and of questionable expediency. 
 
LIGATION OF SUBCLAVIAN. Ii; 
 
 Contiguous Anatomy. 
 Plan of Relations of First Portion of Left Subclavian Artery. 
 
 In front. 
 Pleura and left lung. 
 
 Pneumogastric, cardiac, and phrenic nerves. 
 Left carotid artery. 
 
 Left internal jugular and innominate veins. 
 Sterno-thyroid, Sterno-hyoid, and Sterno-mastoid muscles. 
 Inner side. Outer side. 
 
 a:sophagus. j Left Subclavian Artery, j Pleura. 
 
 Trachea. "( First Portion. J 
 
 Thoracic duct. 
 
 Behind. 
 CEsophagus and thoracic duct. 
 Inferior cervical ganglion of sympathetic. 
 Longus colli and vertebral column. 
 
 Operation. — Place the patient on the back with the head 
 extended and turned to the opposite side; the left shoul- 
 der should be well depressed; make an incision three 
 inches and a half in length along the inner border of the 
 sterno-cleido-mastoid down to the sternum; another two 
 inches and a half in length along the inner extremity of the 
 clavicle, meeting the former near the trachea. It is seen 
 that this incision is substantially the same as for the liga- 
 turing of the innominata artery. The flap, consisting of 
 the integument, superficial fascia, and platysma, is turned 
 aside, one half of the clavicular portion of the sterno-mastoid 
 and its whole sternal portion are then divided on a direct- 
 or, bringing into view the sterno-hyoid, sterno-thyroid and 
 to the outer side the omo-hyoid. The sterno-thyroid and hy- 
 /oid should be divided with great care, after being liberated 
 from the fascia which covers them. The inner edge of the 
 scalenus anticas muscle is now sought for; when found it 
 will guide the finger directly to the vessel. The impor- 
 tant contiguous structures are now drawn in, pressed away 
 from the artery, using great caution to avoid the thoracic 
 duct, which will be in the line of search, and the needle 
 carefully passed from before backward. The great depth 
 of the vessel will make it exceeding difficult to pass the 
 needle, which should be the one with the adjustable ex- 
 tremity. 
 
 Results. — Tied by Dr. J. Kearney Rogers, 1845; patient 
 died from secondary hemorrhage on the fifteenth day. 
 
 Ligature of First Portion, Right Side. — The inner border 
 of the anterior scalenus leads to it upon this, the same as 
 upon the left side. 
 
Ii8 
 
 OPERATIVE SURGERY. 
 
 Contiguous Anatomy. 
 Plan of Relations of First Portion of Right Subclavian Artery. 
 
 In front. 
 Clavicular origin of Sterno-mastoid. 
 Sterno-hyoid and Sterno-thyroid. 
 Internal jugular and vertebral veins. 
 Pneumogastric, cardiac, and phrenic nerves. 
 
 Beneath, 
 
 j Right Subclavian Artery, I Pleura. 
 
 \ First Portion. J 
 
 Behind. 
 Recurrent laryngeal nerve. 
 Sympathetic. 
 Longus colli. 
 Transverse process of seventh cervical or first dorsal vertebra. 
 
 Operation. — The position of the patient, primary incisions, 
 and dissection are substantially the same as the preceding. 
 
 Fig. 125. 
 
LIGATION OF SUBCLAVIAN. 
 
 119 
 
 The internal jugular should be pressed aside and the needle 
 passed from below upward and from behind forward, 
 carefully avoiding the pleura, recurrent laryngeal, and 
 phrenic nerves. The ligature of the vertebral and internal 
 mammary at the same time will lessen the danger of secon- 
 dary hemorrhage. 
 
 Fallacies. — This vessel may arise from the arch of the 
 aorta, when it will be more deeply situated, often passing 
 behind the oesophagus or between it and the trachea. 
 
 Results. — Has been ligatured thirteen times; all the cases 
 proved fatal, of which eight died of hemorrhage. 
 
 Ligature of the Second atid Third Portions. — The linear 
 guide to the operation is drawn just above the upper border 
 of the clavicle, extending between the posterior border of 
 
 Fig. 126. 
 
 the sterno-cleido-mastoid and the anterior border of the 
 trapezius, and should be about four inches in length. (Fig. 
 
 125.) 
 
 Miiscidar Guides to the Artery. — This vessel has no super- 
 ficial muscular guide. The deep muscular guide is the 
 outer border of the scalenus anticus. The posterior belly of 
 omo-hyoid, while not in close contact with it, serves an im- 
 portant purpose in directing the attention of the surgeon 
 towards it. The outer border of the scalenus anticus is well 
 indicated by the posterior border of the sterno-cleido-mas- 
 
120 OPERATIVE SURGERY. 
 
 toid, provided the latter muscle be not uncommonly devel- 
 oped. The junction of the inner two inches of the clavicle 
 with its outer portion is a far more unvarying indication of 
 the approximate deep location of its outer border than the 
 former. 
 
 The tubercule on the first rib into which the scalenus an- 
 ticus is inserted is the direct guide to the vessel, the artery 
 being directly behind it. (Fig. 126.) 
 
 Contiguous Anatomy of Third Portion. 
 
 Relations of Third Portion of Subclavian Artery. 
 
 In front. 
 Cervical fascia. 
 
 External jugular, supra-scapular, and transverse cervical veins. 
 Ascending branches of cervical plexus. 
 Subclavian muscle and supra-scapular artery and clavicle. 
 
 Above. Below, 
 
 Brachial plexus. j ^^erv \ TiXiX. rib. 
 
 Omo-hyoid. 1 ) 
 
 Behind. 
 Scalenus medius. 
 
 Operation : Third Portion. — Place the patient on the back 
 with the shoulders elevated from the table, head turned 
 backward and to the opposite side. Draw the shoulder of 
 the corresponding side firmly downward and retain it in 
 that position. Compress the external jugular vein above 
 the clavicle long enough to cause its distension, thereby in- 
 dicating its exact situation. The integument is then drawn 
 evenly downward and incised upon the clavicle, which will, 
 when allowed to retract, carry the incision upward to its 
 proper situation — one half inch above the clavicle. The 
 superficial fascia and platysma are then divided upon a 
 director, being careful not to sever the external jugular, 
 which can be either pulled aside or divided between two 
 ligatures. The supra-scapular and transverse cervical veins 
 should be treated in the same manner. The omo-hyoid is 
 now sought for and drawn upward if necessary, and the 
 supra-scapular artery avoided. The deep cervical fascia is 
 torn asunder by the finger-nail or a director and the outer 
 border of the scalenus anticus felt for on a line with the 
 outer border of the sterno-cleido-mastoid, if it has not been 
 divided; if so, it should be located as described under the 
 head of " Muscular Guides." If the head be turned smartly 
 
LIGATION OF SUBCLAVIAN. 
 
 121 
 
 to the opposite side the scalenus anticus will be made tense 
 and more prominent. When found it should be followed 
 downward to its insertion, when the finger will rest upon 
 the tubercle of the first rib, immediately behind which the 
 pulsation of the artery will be felt. The vessel is now care- 
 fully exposed and the neodle passed from before backward. 
 (Fig. 127.) Great caution should be taken not to interfere 
 with the subclavian vein, which lies in front of, and on a 
 lower plane than the artery. 
 
 Fallacies. — The sterno-cleido-mastoid may have an un- 
 usual breadth of origin from the clavicle, thereby causing 
 the incision to be made too far posteriorly. The clavicular 
 
 Fig. 127. 
 
 measurement will prevent this error. The tubercle on the 
 anterior surface of a transverse process of one of the lower 
 cervical vertebra may be mistaken for the tubercle of the 
 first rib. This, however, is easily rectified by remembering 
 that the rib is located downward and backward, that no 
 contiguous pulsation is found, and that the outline of the 
 scalenus anticus is absent. The tubercle may be absent, 
 when the muscle inserted into the rib must be relied upon. 
 The artery may be in front of the tubercle and the vein 
 behind. The pulsation as well as the anatomical appear- 
 ances will determine the interchange of situation. The 
 inner cord of the brachial plexus may be mistaken for the 
 artery. A little attention to the distinctive physical char- 
 acteristics between nerves and arteries will quickly settle 
 this doubt. 
 
122 OPERATIVE SURGERY. 
 
 Results. — Two hundred and fifty-one cases tabulated, of 
 which one hundred and thirty-four, or fifty-three per cent, 
 died. 
 
 Ligature of the Second Portion. — All muscular and linear 
 guides are practically similar to those of the preceding. 
 
 Contiguous Anatomy. 
 Plan of Relations of Second Portion of Subclavian Artery. 
 
 In front. 
 
 Scalenus anticus. 
 Phrenic nerve. 
 Subclavian vein. 
 
 Above, Below. 
 
 Brachial plexus. \ ^SnTpon^on'^- \ Pleura. 
 
 Behind. 
 Pleura and Middle Scalenus, 
 
 Operation. — The proceedings essential to arrive at the 
 proper site in this instance are not varied from those given 
 for the third portion until the outer border of the scalenus 
 anticus is well determined; the phrenic nerve and sub- 
 clavian vein should then be pushed aside and the muscle 
 divided (see Fig. 127), when the retraction of its fibres will 
 expose the portion to view. The needle is then passed as 
 before, closely hugging the artery, to avoid the pleura be- 
 low and posteriorly. 
 
 Fallacies. — The vessels may be transposed. 
 
 Results. — Thirteen cases reported, of which nine, or sixty- 
 nine per cent, were lost. 
 
 The subclavian should always be tied in the third portion 
 when possible; if impossible, the second should be selected. 
 The ligature of the first portion is unwarranted in view of 
 the results heretofore gained. 
 
 Ligature of the Vertebral Artery — This artery arises from 
 the first portion of the subclavian and passes directly up- 
 ward along the anterior surface of the vertebral column 
 to the transverse process of the sixth cervical vertebra. It 
 may be ligatured in three situations: (i) Before entering 
 the vertebral canal; (2) between the atlas atid axis; (3) 
 between the atlas and the occipital bone. The first situa- 
 tion, however, is sufficient for all practical purposes. 
 
 The linear guide to the artery is drawn from the junc- 
 tion of the inner fourth with the outer three fourths of the 
 
LIGATION OF VERTEBRAL AND INT. MAMMARY. 1 23 
 
 clavicle, to the posterior border of the mastoid process. 
 The deep guide is the tubercle of the transverse process of 
 the sixth cervical vertebra, and the space between the bor- 
 ders of the longus colli and the scalenus anticus. 
 
 Contiguous Anatomy. 
 
 In front. 
 
 Internal jugular vein and its sheath. 
 
 Aponeurosis between longus colli and scalenus anticus. 
 
 Superior thyroid artery. 
 
 Vertebral vein. 
 
 Outer side. j Vertebral ) Inner side. 
 
 Scalenus anticus. 1 Artery. ( Longus colli. 
 
 Behind. 
 Vertebral column. 
 
 Operation. — The head should be turned to the opposite 
 side and an incision about three inches and a half in length 
 made along the anterior border of the sterno-cleido-mas- 
 toid, terminating at the upper border of the sternum. 
 The fascia and the connections between the sterno-mastoid 
 and sterno-hyoid are divided and these muscles separated, 
 which exposes the common sheath of the internal jugular 
 vein, common carotid artery, and pneumogastric nerve. 
 This sheath is now carefully separated from its connections 
 to the sterno-thyroid and longus colli muscles and drawn 
 outward. The parts are now relaxed by raising the head, 
 the inferior thyroid artery displaced, and the aponeurosis 
 covering the vessel torn through, the vein pushed aside, and 
 the ligature deposited from within outward. 
 
 Results. — This vessel has been tied eight or ten times, and 
 so far as the operation itself is concerned no ill results are 
 reported. 
 
 Ligature of the Internal Mammary Artery. — The internal 
 mammary arises from the first portion of the subclavian. 
 It descends behind the internal jugular and subclavian 
 veins to the posterior wall of the chest, resting upon the 
 costal cartilages about one half inch from the margin of 
 the sternum. It may be ligatured in any of the upper in- 
 tercostal spaces. 
 
 Lifiear Guide to the Artery. — About one half inch to the 
 outer side of the sternum is a fair indication of its locality. 
 It has no muscular guide. 
 
 Operation. — Make an incision two inches in length along the 
 
124 OPERATIVE SURGERY. 
 
 upper border of the costal cartilages and rib. The integu- 
 ment, fascia, and pectoralis major muscle are divided down 
 to the intercostal muscles. Beneath the internal intercostal 
 muscle, surrounded by the connective tissue, the artery, ac- 
 companied by the venae comites, will be found The vessel 
 is isolated, and the needle carefully passed to avoid pene- 
 trating the pleura. If the vessel be tied in the upper inter- 
 costal spaces a single vein will attend it. 
 
 Ligature of the I?iferior Thyroid. — This vessel arises from 
 the thyroid axis, passes in a somewhat irregular course up- 
 ward and inward behind the sheath of the common caro- 
 tid and internal jugular vein to the thyroid gland. 
 
 The linear guide to the operation is along the anterior 
 border of the sterno-mastoid, as in ligaturing the common 
 carotid. The body of the fifth cervical vertebra opposite to 
 which it enters the gland is an approximate bony guide 
 to the vessel. 
 
 Contiguous Anatomy. — In front the common carotid sheath 
 and its contents and the sympathetic nerve on the inner 
 side; on the left, the recurrent laryngeal and the oesopha- 
 gus; if low in the neck, carefully avoid the thoracic duct. 
 The respective tissues are pulled aside and the needle 
 passed. No dangers attend the ligaturing other than those 
 incurred by the manipulation^necessary to arrive at the 
 vessel. 
 
 Ligature of the Axillary. — This vessel begins at the lower 
 border of the first rib and extends to the lower border of the 
 tendon of the latissimus dorsi. It may be tied in three 
 situations: (i) Above the pectoralis minor; (2) behind; (3) 
 below that muscle. The first and last, however, are the 
 only ones at which the vessel can be practically secured. 
 
 First Portion. — There is no linear guide to the vessel. 
 The linear guide to the operation is located about one half 
 inch below the lower border of the clavicle, extending 
 from within an inch or so of the sternal extremity, outward 
 three or four inches. 
 
 The muscular guides are superficial and deep. The former 
 is the space between the border of the deltoid and pectoralis 
 major muscles. The latter is the pectoralis minor; its 
 upper border corresponding to the first portion, etc., etc., 
 as before stated. 
 
LIGATION OF AXILLARY. 
 
 I2S 
 
 Contiguozis Anatomy. 
 
 Relations of the First Portion of the Axillary Artery. 
 hi fro7it. 
 
 Pectoralis major. 
 
 Costo-coracoid membrane. 
 
 Subclt-vius. 
 
 Cephalic vein. 
 
 Outer side. 
 Brachial plexus. 
 
 I Axillary ) 
 ■< Artery. > 
 I First portion, j 
 
 Inner side 
 Axillary vein. 
 
 Behind. 
 First Intercostal space, and Intercostal muscle. 
 First serration of Serratus magnus. 
 Posterior thoracic nerve. 
 
 In this situation the artery lies very deeply, and it is bet- 
 ter, if possible, to ligature the third portion of the subclav- 
 ian. 
 
 n/flj/jniiT'''^'' 
 
 ••=^*^(ri L. 
 
 Fig. 128. 
 
 Operation (Fig. 128). — Place the patient upon the back with 
 the head turned to the opposite side; raise the shoulder 
 and carry the arm from the side of the chest somewhat. 
 Make an incision about four inches in length on the line 
 given, down through the integument, fascia, andplatysma; 
 separate the fibres of the pectoralis major, or divide them 
 the full length of the wound; tear apart the underlying 
 fascia, when the pectoralis minor muscle will be brought 
 in view; bring the arm to the side to relax it, then draw 
 it to the outer side; displace the areolar tissue carefully 
 
126 
 
 OPERATIVE SURGERY. 
 
 with the finger or a director, when the vein will be seen, 
 which should be carried upward and outward with a 
 blunt hook, and the artery will be noticed beneath and 
 above it, in close contact with the inner cord of the brachial 
 plexus, which lies to its outer side and above. The needle is 
 then passed from below upward. The cephalic vein which 
 empties into the axillary vein should be cautiously avoided, 
 as it passes between the borders of the pectoral and deltoid 
 muscles to its termination. 
 
 Fallacies. — The inner cord of the brachial plexus may be 
 mistaken for the artery. Before tightening the ligature 
 pressure should be made upon the vessel, and the effect 
 upon the radial pulse noted. 
 
 The vessel may be reached by making an incision be- 
 
 FiG. 129. 
 
 tween the borders of the deltoid and pectoral muscles about 
 three inches in length, which shall connect with the one 
 previously made below the lower border of the clavicle. 
 The fat and cellular tissue can then be removed or dis- 
 placed as in the previous instance. 
 
 Results. — No definite records are given of the results of 
 the operation. 
 
 Ligature in the Third Portia ft. — Linear guide to the artery is 
 a line extending upward into the axilla corresponding to the 
 junction of its anterior and middle thirds. (Fig. 129.) 
 
LIGATION OF BRACHIAL. 
 
 127 
 
 Muscular Guide. — The inner border of the coraco-brachia- 
 
 lis. 
 
 Contiguous Anatomy. 
 
 Relations of the Third Portion of the Axillary Artery. 
 
 In front. 
 Integument and fascia. 
 Pectoralis major. 
 
 Outer side. 
 Coraco-brachialis. 
 Median nerve. 
 Musculo-cutaneous nerve. 
 
 Inner side. 
 Ulnar nerve. 
 I Artery. \ Internal cutaneous nerve. 
 
 Axillary vein. 
 
 Behind. 
 Subscapularis. 
 
 Tendons of latissimus dorsi and teres major. 
 Musculo-spiral and circumflex nerves. 
 
 130). — The arm should be adducted and 
 Make 
 
 Operation (Fig. 
 rotated outward, 
 an incision three inches 
 in length along the inner 
 border of the coraco-bra- 
 chialis in line of the 
 arterial pulsation, ob- 
 serving that its centre 
 be above the fold of the 
 axilla; cautiously divide 
 the tissue upon a direct- 
 or, drawing the median 
 nerve to the outer, and 
 the veins to the inner 
 side; pass the needle 
 from within outward. ^'°' ^3°- 
 
 Fallacies. — Large branches may be given off at this 
 situation, which will confuse the operator. Pressure upon 
 the vessel prior to the tightening of the ligature will deter- 
 mine the influence upon the circulation beyond. 
 
 Results. — The operation implies in itself no particular 
 danger to the patient. 
 
 Ligature of the Brachial Artery. — The brachial artery ex- 
 tends from the lower border of the tendon of the latis- 
 simus dorsi to about one inch below the bend of the elbow 
 joint. 
 
 The linear guide is drawn from the junction of the middle 
 
128 
 
 OPERATIVE SURGERY. 
 
 and anterior thirds of the axilla to midway between the 
 apices of the bony condyles of the humerus. (Fig. 131.) 
 
 Muscular Guide. — At its upper third it lies at the inner 
 border of the coraco-brachialis; in the middle third, at the 
 
 Pig. 131. 
 
 inner border of the biceps; in the lower third, the inner 
 border of the biceps tendon. It may be ligatured in three 
 situations: at its upper, middle, and lower thirds. 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the Brachial Artery. 
 
 In f7-ont. 
 Integument and fasciae. 
 Bicipital fascia, median basilic vein. 
 Median nerve. 
 Outer side. 
 Median nerve. 
 Coraco-brachialis. 
 
 Biceps. 
 
 Inner side. 
 Internal cutaneous 
 and ulnar nerve. 
 Median nerve. 
 
 J Brachial I 
 j Artery. J 
 
 Behind. 
 Triceps. 
 
 Musculo-spiral nerve. 
 Superior profunda artery^ 
 Coraco-brachialis. 
 Brachialis amicus. 
 
 Operation : Upper Third. — Adduct the arm, and rotate it 
 outward; make an incision about three inches in length 
 along the inner border of the coraco-brachialis. The ar- 
 tery being very superficial is quickly reached. The median 
 nerve is drawn to the outer, and the ulnar nerve and ba- 
 
LIGATION OF BRACHIAL. 
 
 I2g 
 
 silic vein to the inner side; separate it from the vein, and 
 pass the needle from within outward. 
 
 Operation in the Middle Third 
 (Fig. 132). — Place the arm as before; 
 make an incision three inches in 
 length along the inner side of the 
 biceps muscle. The median nerve 
 is found lying upon and a little to 
 its outer side ; push it aside, iso- 
 late the artery from the venae comi- 
 tes, and pass the needle in the same 
 direction as before. 
 
 Operation in the Lower Third 
 (Fig. 133). — Abduct the arm and 
 supinate the forearm. Compress 
 the arm above to distend the medi- 
 an basilic vein; make an incision 
 about three inches in length along 
 the inner border of the tendon of 
 the biceps; draw aside the median 
 basilic vein, when the artery will 
 be felt pulsating beneath the bicip- 
 ital fascia; a suitable sized opening is now cut through 
 
 Fig. 132. 
 
 Fig. 133. 
 
 this fascia; the fore-arm partially flexed; the vessel sepa- 
 rated from its veins, and the needle passed from within out- 
 wards. 
 
 Fallacies. — The arteries of the fore-arm may be given off 
 from the axillary, or the brachial may bifurcate high up, 
 thereby increasing the large vessels in the arm. This is to 
 be told by the comparative size of the brachial, and the in- 
 
I30 
 
 OPERATIVE SURGERY. 
 
 fluence of pressure on the circulation beyond the point 
 of proposed ligature. The brachial may run along with 
 the ulnar nerve behind the inner condyle. If it be not in 
 its normal site, deep pressure may detect its pulsations else- 
 where; which, together with its effect on the circulation 
 
 beyond, will determine the size 
 and site of the vessel. The in- 
 cisions in the upper two thirds 
 may be made too far inward, 
 leading the surgeon to mistake 
 the ulnar for the median nerve. 
 If the forearm be flexed and trac- 
 tion be made upon either, its 
 course will be determined and 
 the mistake corrected. 
 
 The median nerve may pass 
 behind the artery instead of in 
 front; when, if the circulation 
 from above be obstructed, the 
 artery may escape notice. 
 
 Anomalous muscular slips and 
 unusual muscular development 
 may obscure the artery in its 
 normal course. In such instances 
 the pulsation will determine its 
 location. 
 
 Occasionally, especially in fe- 
 male subjects, when the extrem- 
 ity is markedly concave on its 
 outer surface, due to an unusual 
 length of the internal condA'le, 
 the primary incision may be 
 made to the outer side of tke 
 vessel. If, however, it be made 
 midway between the tips of the 
 bony condyles, irrespective of 
 the overhanging soft parts, this 
 error will not arise. 
 
 Results. — It has been ligatured 
 seventy-six times for hemorrhage, with fifty-five recoveries. 
 Ligature of the Radial Artery. — This artery arises from 
 the brachial, is an apparent continuation of it, and is 
 superficial in its entire course. It may be ligatured in any 
 portion of its course: it is, however, usually ligatured in 
 
 Fig. 134. 
 
LIGATION OF RADIAL. I3I 
 
 three situations: at the upper and lower thirds, and at 
 th« wrist. 
 
 The linear guide (Fig. 134) to this vessel is drawn from 
 »idway between the tips of the bony condyles of the hum- 
 erus to the inner side of the extremity of the styloid pro- 
 cess of the radius. The muscular guide is the inner border 
 of the belly of the supinator longus muscle. 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the Radial Artery. 
 In front. 
 
 Integument — superficial and deep fasciae. 
 Supinator longus. 
 Inner side. Outer side. 
 
 Pronator radii teres, j Radial ) Supinator longus. 
 
 Flexor carpi radialis. j Forearm \ Radial nerv^e (middle third). 
 
 Behind. 
 Tendon of Biceps. 
 Supinator brevis. 
 Pronator radii teres. 
 Flexor sublimis digitorum. 
 Flexor longis pollicis. 
 Pronator quadratus. 
 Radius. 
 
 Operation: Upper Third (Y\^. 135). — Supinate the forearm; 
 press upon the arm above to distend the superficial veins; 
 make an incision about three inches in length along the lin- 
 ear guide to the vessel. After going through the fascia, the 
 inner edge of the supinator longus will be found extending 
 beyond, m'erlapping the line; separate and pull this outward, 
 when the artery will be seen lying between its veins, with the 
 nerve to the outer side; separate the artery, and pass the 
 needle from without inward. 
 
 Operation in the Lower Third {F\g. 136). — In this situation 
 the vessel is very superficial; its well-known pulsation 
 being the best guide to it; with the arm placed as in the 
 preceding position, make an incision two inches in length 
 along the course of the vessel. After the division of the 
 integument and fascia, the artery will be seen surrounded 
 by loose areolar tissue, accompanied by its veins, and lying 
 to the inner side of the tendon of the supinator longus. 
 Separate and ligature it, passing the needle from the nerve. 
 
 Operation at Apex of Styloid Process. — In this situation the 
 vessel is found in a triangular-shaped space bounded ante- 
 
132 
 
 OPERATIVE SURGERY. 
 
 riorly by the tendon of the extensor primi internodii pollicis; 
 externally by that of the second! internodii pollicis, and the 
 base corresponding to the apex of the styloid process of 
 the radius. If the thumb be forcibly extended the outlines 
 of the space will be well marked. 
 
 Operation. — Place the hand midway between the supina- 
 tion and pronation, and having ascertained the exact situ- 
 
 FlG. 136. 
 
 ation of the tendon of the extensor primi internodii pollicis, 
 make an incision along its outer border about an inch in 
 length; use care not to divide the superficial veins. The are- 
 olar tissue and the extensor primi internodii pollicis are 
 pushed aside and the vessel found somewhat deeply situa- 
 ted. The needle can be carried in either direction. (Fig. 
 
 I37-) 
 
LIGATION OF ULNAR. 1 33 
 
 Fallacies. — The radial artery may be upon the fascia and 
 supinator longus instead of beneath them; it may pass over 
 the extensor tendons of the thumb instead of beneath them. 
 
 Results. — During the late war it was tied twenty times; 
 four died. 
 
 Ligature of the Ulnar Artery. — This vessel is larger than 
 the radial. It is given off from the brachial about one 
 inch below the bend of the elbow, passes obliquely inward 
 and downward deeply beneath the superficial flexors of the 
 
 Fig. 137. 
 
 forearm, and gains the ulnar side a little above its middle; 
 becoming superficial, passes along the outer side of the 
 flexor carpi ulnaris to the radial side of the pisiform bone, 
 where it terminates in the superficial palmar arch. It may 
 be ligated in three situations. 
 
 The li7iear guide is drawn from the extremity of the inter- 
 nal condyle to the pisiform bone. (See Fig. 135.) 
 
 The muscular guide is the outer border of the flexor 
 carpi ulnaris. 
 
 Contiguous Anatomy. 
 
 Plan of Relations of the Ulnar Artery in the Forearm. 
 In front. 
 
 Superficial layer of flexor muscles. | TjoDer half 
 Median nerve. ) '^^ 
 
 Superficial and deep fasciae. 
 Inner side. Outer side. 
 
 Flexor carpi ulnaris. j Ulnar ) Flexor sublimis digitorum. 
 
 Ulnar nerve (lower two thirds). \ porlZm" ) 
 
 Behind. 
 Brachialis amicus. 
 Flexor profundis digitorum. 
 
134 
 
 OPERATIVE SURGERY. 
 
 Operation: Junction Middle and Upper Third (Fig. 138). — 
 Supinate the forearm and make an incision about three 
 inches in length, beginning about four finger-breadths below 
 
 Fig. 138. , 
 
 the internal condyle, on the linear guide to the vessel. Di- 
 vide the fascia on a director; seek for the line of connection 
 between the borders of the flexor carpi ulnaris and the 
 
 Fig, I40- 
 
 flexor sublimis digitorum. It is of a yellowish-white color. 
 Divide it on a director, and pull the muscles apart, when 
 the ulnar nerve will be seen, to the outer side of which will 
 
LIGATION OF PALMAR ARCH. 
 
 135 
 
 be found the arter}'' with its accompanying veins; separate 
 the artery and pass the needle from within outward. 
 
 Operation in the Lower Third (Fig. 139). — Place the arm 
 as in the preceding operation; extend the hand to make 
 the tendon of the flexor carpi ulnaris tense; make an incis- 
 ion about three inches !n length along the radial border 
 of this muscle down to the fascia, which should be 
 divided on a director, exposing the tendon of the flexor 
 carpi ulnaris, which should be drawn inward, and the ar- 
 tery is seen beneath it. Isolate the vessel from its veins and 
 pass the needle from within outward. 
 
 Operation at the Wrist (Fig. 140). — Place the hand on its 
 dorsal surface and make a curved incision about two inches 
 in length along the radial side of the pisiform bone, with its 
 convexity outward; carry it down- 
 ward along the side of that bone 
 through the fascia and fatty tissue 
 to the vessel. Flex the hand and 
 pass the ligature from within out- 
 ward. 
 
 Fallacies. — In the upper third 
 the interspace between the flexor 
 carpi ulnaris and flexor sublimis 
 may be mistaken for the one be- 
 tween the flexor carpi radialis 
 and the palmarislongus or flexor 
 sublimus digitorum. If the hand 
 and fingers be moved alternately, 
 the proper muscles can be ascer- 
 tained. 
 
 The artery may run beneath the fascia, or otherwise vary 
 in its course; if not in its normal situation, deep pressure 
 may define it. 
 
 Results. — The ulnar artery was ligatured during the war 
 ten times, with three deaths. 
 
 The Superficial Palmar Arch can be tied at the seat of in- 
 jury. It must be remembered, however, that beneath it 
 lie the tendons of the flexors of the fingers and the divisions 
 of the median and ulnar nerves. 
 
 Linear Guide (Fig. 141). — Extend the thumb at a right 
 angle to the carpus, and draw a line transversely across 
 it corresponding to its palmar border; this will denote 
 the lower limit of the arch. 
 
 Ligature of the Cofumon Carotid. — The right common 
 
 Fig. 141. 
 
136 
 
 OPERATIVE SURGERY. 
 
 carotid comes from the innominate artery, and the left 
 from the arch of aorta. The left is consequently longer 
 and more deeply situated in the chest. The left after 
 leaving the aorta passes obliquely upward to a point oppo- 
 site the left sterno-clavicular articulation ; and, from this 
 point upward the right and left common carotids main- 
 tain substantially the same course to the upper border 
 of the thyroid cartilage, where each divides into the internal 
 and external carotids. 
 
 Fig. 142. 
 
 Each vessel may be ligatured in three situations: (i) At 
 the root of the neck; (2) below the omo-hyoid muscle; (3) 
 above that muscle. The last two are the situations com- 
 monly selected, the first not being employed except under 
 forced circumstances. (Fig. 142.) 
 
 The linear guide to the vessel is a line drawn from the 
 sterno-clavicular articulation to midway between the angle 
 of jaw, and mastoid process. (See Fig. 125.) 
 
 The muscular guide to the operation is the anterior border 
 of the sterno-cleido mastoid. 
 
LIGATION OF COMRIOM CAROTID. 
 
 137 
 
 Contigzwus Anatomy. 
 
 Plan of the Relations of the Common Carotid Artery. 
 In fro7it. 
 
 Integument and fascia. 
 
 Platysma. 
 
 Sterno-mastoid. 
 
 Sterno-hyoid. 
 
 Sterno-thyroid. 
 
 Externally. 
 Internal jugular vein. 
 Pneumogastric nerve. 
 
 j Common I 
 I Carotid. ) 
 
 Longus colli. 
 
 Behind. 
 
 Omo-hyoid 
 
 Descendens noni nerve. 
 Sterno-mastoid artery. 
 Superior thyroid, lingual, and fa- 
 cial veins. 
 Anterior jugular vein. 
 
 Internally. 
 Trachea. 
 Thyroid gland. 
 Recurrent laryngeal nerve. 
 Inferior thyroid artery. 
 Larynx. 
 Pharynx. 
 
 Rectus capitis anticus major. Infe; 
 
 Recurrent laryngeal nerve 
 
 Operation below the Omo-hyoid. (Fig. 143.) 
 
 Sympathetic nerve. 
 Inferior thyroid artery. 
 
 Fig. 143. 
 
 Place the patient on the back, with the shoulders slightly 
 elevated, and the head tiarned to the opposite side; make 
 an incision three inches in length, beginning a little above 
 
138 OPERATIVE SURGERY. 
 
 the cricoid cartilage, on the line stated, and carry it down- 
 ward along the anterior border of the sterno-mastoid; 
 divide the superficial fascia, platysma, and deep fascia on a 
 director, thus exposing the anterior border of the sterno- 
 mastoid. If the sterno-mastoid artery be divided, ligature 
 it. If otherwise, push it aside, together with the thyroid 
 veins; draw the sterno-mastoid outward, and the sterno- 
 thyroid and hyoid inward, when the lower border of the 
 omo-hyoid will be seen above; divide the fascia beneath 
 these muscles and draw it apart, when the descendens 
 noni nerve will be seen resting upon the inner portion of 
 the common sheath of the carotid, internal jugular vein, 
 and the pneumogastric nerve: the artery being to the inner 
 side, the nerve behind and between the two and out of 
 sight. Place the finger upon the sheath, to ascertain the 
 exact location of the artery; raise a portion of the sheath 
 at its inner side corresponding to the site of the artery 
 with a tenaculum or the thumb forceps, cut a small open- 
 ing into it, and pass the needle from without inward, cau- 
 tiously insinuating it between the vessel and its sheath. 
 This manipulation should be carefully done, else the vein, 
 pneumogastric, and recurrent laryngeal nerves may be im- 
 plicated. 
 
 Operation above the Omo-hyoid. — The vessel is more super- 
 ficial in this situation; which is sometimes denominated 
 "the site of election." (See Fig. 125^.) 
 
 Place the patient as before, and make an incision along 
 the anterior border of the sterno-mastoid, beginning at 
 about the angle of the lower jaw, and extending it a little 
 below the cricoid cartilage; divide the superficial fascia, 
 platysma, and deep fascia on a director, carefully avoiding 
 the small veins; expose the anterior border of the sterno- 
 mastoid and slightly flex the head to relax the tissues of 
 the neck; draw the edges of the wound apart, and the 
 artery will be felt pulsating in its sheath. If the jugular 
 vein overlap it, it should be emptied by pressure above and 
 below, and be pressed outward; then carefully open the 
 sheath as before, avoiding the descendens noni nerve; pass 
 the needle carefully from without inward. It is well to 
 observe the upper border of the omo-hyoid muscle before 
 opening the sheath, that the exact location to apply the 
 ligature be assured. 
 
 Fallacies. — The artery may bifurcate at the cricoid 
 artilage, and even lower; however, this is extremely rare; 
 
LIGATION OF COxMMON CAROTID. 
 
 139 
 
 under such circumstances both branches should be secured. 
 If the vessel be pressed upon before the ligature is tied, it 
 will determine the influence of the ligaturing upon the 
 branches above. 
 
 The jugular vein may be much dilated, lie over and re- 
 ceive the impulse of the artery, hence be mistaken for it. 
 This fallacy may be detei mined if that vessel be emptied 
 of its blood in the manner before described. The thyraid 
 gland may be enlarged and obscure the artery by disptac- 
 
 FlG. 144. 
 
 ing or overfapping it. Under these conditions it should be 
 pushed aside. It is reported that the omo-hyoid muscle 
 has been mistaken for the artery; the fact of its being mus- 
 cular, taken in connection with the direction of its fibres, 
 together with other obvious reasons, should eliminate any 
 danger of this mistake. If branches arise from the main 
 trunk, it may be mistaken for the external carotid. The 
 comparative size of the vessel and the influence of pressure 
 on the circulation of the internal carotid will effectually 
 solve the question. If branches be given off from the com- 
 
I40 OPERATIVE SURGERY. 
 
 mon carotid near the site of the proposed ligaturing, they 
 should be tied also. 
 
 Results. — This vessel has been tied 789 times for various 
 reasons, of which 323, or about 41 per cent, have perished. 
 
 Ligaii(?-ing of both cot?imon carotids, either simultaneously or 
 at variable intervals, has been done 2>^ times. The shortest 
 interval between the operations in which recovery has 
 taken place is four and one half days. Instances where 
 the interval varied from thirteen to thirty days are re- 
 ported, with recovery of the patients. 
 
 Ligature of the External Carotid. — This artery arises from 
 the common carotid at or just above the upper border of 
 the thyroid cartilage. It ascends in a slightly curved 
 course, with the convexity forward, to a point midway 
 between the neck of the condyle of the lower jaw and the 
 external auditory meatus. The upper part of its course lies 
 in the substance of the parotid gland (Fig. 144). 
 
 This artery may be tied in two situations: (i) Between 
 the posterior belly of the digastric and its origin; (2) above 
 the belly of the digastric. The former situation is the one 
 to be selected, if possible. 
 
 The linear and the muscular guides are substantially the 
 same as for the common carotid. 
 
 Contiguous Anatomy. 
 
 Plan of the Relations of the External Carotid. 
 In front. Behind. 
 
 Integument, superficial fascia. Superior laryngeal nerve. 
 
 Platysma and deep fascia. Stylo-glossus. 
 
 Hypoglossal nerve. | External 1 Stylo-pharyngeus. 
 
 Lingual and facial veins. ' Carotid. ) Glosso-pharyngeal nerve. 
 
 Digastric and stylo-hyoid muscles. Parotid gland. 
 
 Parotid gland, with facial nerve and 
 temporo-maxillary vein in its sub- 
 stance. 
 
 Internally. 
 Hyoid bone. 
 Pharynx. 
 Parotid gland. 
 Ramus of jaw. 
 
 Operation. — Below the digastric muscle, with the patient 
 on the back, head slightly extended and turned to the op- 
 posite side, make an incision along the anterior border of 
 the sterno-mastoid, beginning opposite the angle of the 
 lower jaw, and carry it downward to a point opposite the 
 
LIGATION OF EXTERNAL CAROTID. I4I 
 
 cricoid cartilage. Divide the superficial fascia, platysma, 
 and deep fascia on a director; expose the anterior border 
 of the sterno-mastoid. The edges of the wound should be 
 well drawn apart, when the hypoglossal nerve and the 
 digastric and stylo-hyoid muscles will come into view. 
 
 The end of a grooved director should now be employed 
 to separate and push aside the lingual and facial veins, to- 
 gether with the areolar tissue and lymphatic glands that 
 rest upon the vessel. Expose the artery and pass the liga- 
 ture from without inward. The internal jugular vein oft- 
 times overlaps the vessel, and should be carefully drawn 
 aside, or treated as recommended in ligaturing the com- 
 mon carotid. 
 
 Before the ligature is tied the following facts should be 
 carefully observed: (i) If it be the external carotid around 
 which the ligature is passed, this can be told by pressing 
 upon the vessel and observing its effect upon the circula- 
 tion of the facial ; (2) the distance of the seat of the liga- 
 ture from collateral branches; this can only be deter- 
 mined by carefully exposing the vessel for half an inch 
 above and below the seat of the ligature. If vessels be 
 found within this extent, they too should be ligatured to 
 destroy the possibility of any interference with the forma- 
 tion of the internal clot; (3) that the ligature be not car- 
 ried around both the external and internal carotid at or 
 just above their point of bifurcation; if it be around both, 
 pressure will check the pulsation of both; if but one it will 
 have a like effect on its circulation. 
 
 Other Fallacies. — Enlarged lymphatic glands resting on 
 the vessel may be mistaken for it. They need cause but 
 momentary thouglit, since their circumscribed outline and 
 mobility will determine their nature. If large they should 
 be removed, otherwise they can be pushed aside. The 
 superior thyroid branch may be confounded with the 
 lingual. If the course of the respective vessels be observed 
 they can be readily told apart; the superior thyroid arises 
 nearest the bifurcation, arches upward and forward, then 
 passes quite directly downward. The lingual does not 
 arch downward, but passes upward and inward to gain the 
 upper border of the greater cornu of the hyoid bone, which 
 can be easily outlined by the finger. 
 
 Operation aboi'e the Digastric. — Make an incision from the 
 lobe of the ear to the greater cornu of the hyoid bone, 
 along the anterior border of the sterno-mastoid. Divide 
 
142 OPERATIVE SURGERY. 
 
 the superimposed tissues as before down to the digastric 
 muscle; pull it, along with the stylo-hyoid, downward, and 
 the jugular vein outward, if it be in the way, and pass the 
 ligature from without inward. 
 
 Results. — The external carotid has been ligatured seventy- 
 one times, with three deaths. 
 
 Ligature of the Superior Thyroid Artery. — This vessel 
 comes from the external, or from the common carotid near 
 the point of its bifurcation. It passes upward and for- 
 ward at first quite superficially, then runs downward and 
 less superficially to enter the thyroid gland. 
 
 Operation. — Make an incision about three inches in length 
 along the anterior border of the sterno-mastoid, its centre 
 corresponding to a point opposite the thyro-h3^oid space. 
 The carotid sheath should be exposed as in the ligaturing 
 of that vessel, and the artery sought for along its inner bor- 
 der. 
 
 Ligature of the Lingual Artery. — This vessel arises from 
 the external carotid opposite the h5^oid bone, and runs up- 
 ward and inward to about one quarter of an inch above 
 the upper border of its greater cornu, and passes horizon- 
 tally parallel with it, resting upon the middle constrictor of 
 the pharynx, and being directly covered first by the digas- 
 tric and stylo-hyoid muscles, and more internally by the 
 hyo-glossus. It then ascends between the hyo-glossus and 
 genio-hyo-glossus muscles and terminates in the ranine 
 artery. 
 
 It has no superficial muscular guide; a linear guide may 
 be drawn parallel with, and a fourth of an inch above the 
 greater cornu of the hyoid bone; practically, however, 
 the upper border of the greater cornu of the hyoid bone 
 marks its situation. It may be ligated in three situations: 
 (i) At apex of greater cornu; (2) between that cornu and 
 the posterior bell}^ of the digastric; (3) in the triangle made 
 by the digastric, mylo-hyoid, and hypo-glossal nerve. 
 
 Operation between the digastric and the greater cor?iu. Place 
 the patient on the back, and turn the head to the oppo- 
 site side; carefully define the greater cornu of the hyoid 
 bone. If the neck be fleshy, this will be somewhat difficult. 
 It can be made more prominent on the side of the opera- 
 tion by pushing against its body on the opposite side, 
 being careful to press it directly towards that point, other- 
 wise it may mislead the operator. After the patient is 
 thoroughly anaesthetized to prevent spasmodic movements 
 
LIGATION OF LINGUAL. 
 
 143 
 
 of the hyoid bone, make an incision about two or three 
 inches in length parallel with the upper border of the cor- 
 nu, which should pass downward and outward to nearly 
 the anterior border of the sterno-mastoid (see Fig. 125^). 
 Divide the superficial fascia, platysma, and deep fascia on a 
 director; draw upward the sub-maxillary gland and divide 
 the deep aponeurosis, and the digastric and stylo-hyoid 
 muscles, and the hypoglossal nerve will be exposed. Ac- 
 curately locate the greater cornu with the finger, draw up 
 the digastric and the stylo-hyoid muscles, and hypo-glossal 
 nerve with a blunt hook, push aside the lingual vein if seen, 
 and pick up the fibres of the hyo-glossus with a pair of 
 forceps, and incise them in the direction of the external 
 
 ..-SSSSJ 
 
 Fig. 145. 
 
 incision about one quarter of an inch above the greater 
 cornu ; beneath them will be found the vessel, sometimes 
 accompanied by the lingual vein (Fig. 145). Pass the 
 needle from the vein. Before tj'ing the ligature, ascertain 
 if pressure will stop its pulsation. 
 
 Ligature in the Third Situation. — This is often called the 
 place of election. Make an incision transversely two inches 
 long, concavity upward, and its centre just within the mid- 
 dle of the cornu of the hyoid bone. Divide the integument, 
 
144 OPERATIVE SURGERY. 
 
 superficial fascia and platysma, carefully avoiding the super- 
 ficial veins; divide the deep fascia and pull upward the 
 sub-maxillary gland, when the posterior belly of the digas- 
 tric will come into view; also the posterior border of the 
 mylo-hyoid and the hypoglossal nerve, accompanied usu- 
 ally by the lingual vein. Carefully outline the triangle 
 before mentioned, pinch up the fibres of the hyo-glossus, 
 and divide them midway between the h3^oid bone and the 
 nerve, when the artery will be seen beneath. Separate it 
 from the vein, if it has not been seen before, and deposit 
 the ligature (Fig. 147), 
 
 Fig. 146. 
 a. Hyoid Bone. I. Hyo-glossus Muscle, c. Sub-maxillary Gland, d. Digastric 
 
 Muscle. (T. Stylo-hyoid. f. Mylo-hyoid. g. Lingual Artery passing Beneath the Hyo- 
 glossus Muscle. Its course beneath it is indicated by dotted lines. The hypoglossal 
 nerve and lingual vein are seen above the artery, the nerve passing upon and the vein 
 beneath the muscle (the latter is unusual), h. Hypoglossal Nerve. 
 
 Ligatwe of the First Portion. — In this situation the vessel 
 is tied between the point of its giving off and the tip of the 
 greater cornu of the hyoid bone. 
 
 Operation. — Make an incision three inches in length run- 
 ning obliquely downward and backward, its centre corre- 
 sponding to the greater cornu. The various tissues are 
 carefully divided as before, the ninth pair of nerves exposed. 
 The numerous veins located in the course are now pushed 
 aside and the artery carefully sought for at the point of the 
 cornu, and ligatured. This operation, on account of the 
 absence of a definite deep guide to the location of the vessel 
 
LIGATION OF FACIAL. 1 45 
 
 and the uncertainty of its point of origin, together with the 
 great number of large veins in the course of the search, is 
 much less feasible than either of the other two. 
 
 Fallacies. — The hypo-glossal nerve may be mistaken for 
 the arter)^ The nerve rests on the hyo-glossus; the artery 
 runs beneath it. This, together with the pulsation of the 
 arter}' and other distinctive anatomical features, should ren- 
 der the discrimination easy. It is well to know, however, 
 tliat the movements of the tissues dependent on the acts 
 of respiration ftiake it somewhat difficult and often im- 
 possible to detect the arterial impulse. If, however, the 
 supposed artery be carefully isolated, ligature passed 
 around it, and a good light thrown into the wound, its 
 tortuous outline Avill be noticed with each pulsation. The 
 pulsation can be seen the best in the interval of the respira- 
 tory acts, when the tissues are quiet. 
 
 The lingual vein may be mistaken for the artery. This 
 vessel sometimes runs with the artery behind the hyo- 
 glossus; more frequently, however, it rests on this muscle. 
 It has the characteristic color of a vein, and is larger than 
 the artery. After the division of the fibres of the hyo- 
 glossus, the search for the vessel must be conducted cau- 
 tiously to avoid opening into the pharynx. 
 
 Results. — It has been tied repeatedly for the purpose of 
 controlling haemorrhage from the tongue, and delaying a 
 morbid growth of the same, and with great advantage. 
 
 Ligature of the Facial Artery. — The facial is one of the 
 large branches of the external carotid. It arises from it 
 just above the tip of the greater cornu, or about one inch 
 from the bifurcation of the common carotid, passes forward 
 and upward beneath the ramus of the lower jaw, going 
 through the substance of the sub-maxillary gland, and 
 gains the external surface of the ramus at the anterior in- 
 ferior angle of the masseter muscle, lying in a groove in 
 tiie outer border of the bone. The masseter muscle, there- 
 fore, becomes its muscular guide in a portion of its course. 
 It may'be ligatured in two situations: in the neck, and as 
 it crosses the ramus of the jaw; this being the better. 
 In the former, the head is turned to the opposite side 
 and an incision of about three inches in length is made 
 obliquely downward and forward a little in front of the 
 anterior border of the sterno-mastoid, its centre being at a 
 point about one fourth of an inch above the tip of the 
 greater cornu. The dissection is carefully made as in the 
 
146 
 
 OPERATIVE SURGERY. 
 
 preceding instance, pushing aside the facial and other con- 
 tiguous veins, drawing up the digastric and passing the 
 ligature. 
 
 Operation on the Ramus of the Jaw. — Place the patient as 
 before, draw the skin upward over the ramus, so when re- 
 traction occurs the scar will be beneath the jaw; make 
 an incision about two inches in length along the border of 
 the jaw, divide the tissues on a director (Fig. 125), down 
 to the vessel; isolate it and pass the ligature. If a re- 
 sulting scar be of no moment, the primary incision can be 
 made in the long axis of the vessel along the anterior 
 border of i^he ♦"asseter muscle. (Fig. i47«) 
 
 Fig. 147. 
 
 Fallacies. — At its origin this vessel may be mistaken for 
 the lingual. Interruption of the circulation will easily de- 
 termine the difference. 
 
 Ligature of the Tefuporal Artery. — The temporal is one of 
 the terminal branches of the external carotid. It begins in 
 the substance of the parotid gland between the neck of the 
 lower jaw and the external meatus and passes upward 
 across the root of the zygoma, subcutaneously where its 
 pulsation can be distinctly felt; about two inches above 
 the zygoma it divides into its terminal branches. 
 
 The Zygoffia is the guide to it. 
 
 Operation (see Figs. 125 and 147). — Make an incision 
 in the line of the vessel, as indicated by its pulsation, 
 about one fourth of an inch in front of the tragus, and 
 
LIGATION OF OCCIPITAL. 
 
 147 
 
 one inch in length; divide the skin and fascia; expose the 
 vessel and pass the needle so as to avoid the vein and 
 nerve. 
 
 The Ligature of the Occipital Artery. — This artery arises 
 from the external carotid a trifle above the facial, passes 
 upward and outward between the transverse process of the 
 atlas and the mastoid process of the occipital bone. It then 
 passes over the posterior portion of the skull midway be- 
 tween the external occipital protuberance and the mastoid 
 process. (Fig. 126.) It has no muscular guide. It may be 
 tied at its origin or behind the mastoid process. 
 
 Fig. 148. 
 
 Operatio7i at its origin. — Make an incision along the inner 
 border of the sterno-mastoid, about three inches in length, 
 its centre corresponding to a point a little above the apex 
 of the greater cornu of the hyoid bone. Divide the super- 
 ficial tissues carefully on a director; separate the areolar 
 tissue with the blunt end of a director; push aside the 
 veins and find the posterior belly of the digastric. A little 
 below this will be seen the ninth pair of nerves, winding 
 around the object of search. Pass the needle from the 
 nerve. 
 
 Operation Behind the Mastoid Process {¥'1^. 148). — Make an 
 incision about two inches in length one half inch behind 
 
148 OPERATIVE SURGERY. 
 
 and a little below the mastoid process. Divide the in- 
 tegument, and attachments of the sterno-mastoid and the 
 splenius muscles, feel the pulsation at the bottom of the 
 wound. Isolate the artery and pass the ligature. 
 
 Ligaturing of Veins. 
 
 Veins, like arteries, maybe ligatured in their continuity or 
 at their divided extremities. Large venous trunks, when di- 
 vided in the course of an operation, should always be tied, 
 otherwise they ma)'' give rise to an objectionable amount 
 of oozing, which will interfere with the rapidity of the 
 union of the divided surfaces, and possibly require the 
 re-opening of the wound to secure the bleeding points. If a 
 large vein be nicked during an operation — as the internal 
 jugular — during the removal of growths from the neck, 
 ligatures may be thrown around it, above and below the 
 nick, rather than to tie the nicked portion. The latter pro- 
 cedure is liable to be followed by secondary hemorrhage. 
 The practice of ligating the nick, or of sewing its divided 
 borders by fine catgut, is strongly extolled by many writers. 
 If it be determined to tie the vessel, it should be done above 
 and below the cut, else the return circulation will cause 
 secondar)' hemorrhage. If it be possible to surround the 
 patient with the degree of surveillance necessary to detect 
 and treat secondary hemorrhage at the onset, I am of the 
 opinion that the practice of sewing the cut with the con- 
 tinuous or other suitable form of suture offers the better 
 opportunity for rapid recovery. Aside from the ligaturing 
 of veins on account of traumatism, they are ligated in their 
 continuity for the purpose of causing their occlusion in those 
 cases where they are in a dilated or varicose condition. 
 
 Operations for Varicose Veins. 
 
 When the veins of the lower extremities become too 
 much distended to be amenable to palliative measures, it is 
 often necessary to resort to operative interference, which 
 has for its object the occlusion of the distended canals. 
 Injection, acupressure, and ligation are the common means 
 employed. 
 
 Injection. — The vein is compressed above and below the 
 proposed point of injection by the fingers, leaving an in- 
 tervening space of an inch or less, or by small pads con- 
 
LIGATION OF VEINS. 149 
 
 fined in position with adhesive piaster; the latter being the 
 better. The isolated portion is then slowly injected with 
 twenty or thirty drops of a twenty per cent solution of 
 liqi or-ferri subsulphatis and water. Almost immediately 
 the contents of the vessel will become coagulated, when 
 the pressure can be remtved. The limb should be kept 
 quiet for a few days; and any tendency to undue inflam- 
 mation combated. The results of this operation, while not 
 so favorable as other expedients, are, nevertheless, very 
 satisfactory. Of the 103 cases, some time since reported, 
 79 were cured, one perished, and, of the remainder, 16 were 
 failures 
 
 Acupressure. — There is substantially no difference between 
 this method and the application of the same means for ar- 
 resting the circulation of arterial trunks. (See Fig. 43.) It 
 consists simply of carrying a thoroughly purified needle or 
 pin, which may or, may not have been constructed for the 
 purpose, beneatli the vein at various situations, and com- 
 pressing the intervening tissues by means of a carbolized 
 thread of silk or cotton yarn. The pins are removed on the 
 sixth or seventh day, depending on the degree of ulceration 
 produced. Caution should be observed that the pins be 
 not passed through instead of beneath the vein, otherwise 
 a serious phlebitis may follow, 
 
 Subcutajieous Ligation. — This is accomplished by passing a 
 carbolized needle, armed with a fine wire or catgut liga- 
 ture, in front of and across the vein; after which the direc- 
 tion is changed so as to carry it beneath the vessel and out 
 at the point of entrance. The wire is then twisted and cut 
 short, and the opening closed antiseptically. If catgut be 
 employed, it is to be tied and cut in the same manner. 
 Three or four of these constrictions may be applied at in- 
 tervals of an inch. If the blood in the intervening spaces 
 becomes necrosed, giving rise to fluctuation, it should be 
 evacuated; since absorption is then impossible. 
 
 A varicose condition of the hemorrhoidal veins causes a 
 disease denominated hemorrhoids, or piles; for the cure of 
 which various radical measures are recommended. The 
 patient is prepared by a saline cathartic, followed by an in- 
 jection, a few hours prior to the operation. He should then 
 be etherized, placed upon a table of suitable height, with 
 the buttocks drawn down to the edge; the thighs are then 
 elevated, drawn apart, and the nates separated. If the 
 growths be of the external variety, and not inflamed, they 
 
I50 
 
 OPERATIVE SURGERY. 
 
 can be nipped off with a pair of scissors; being careful not 
 to cut them too closely, else the resulting cicatrization may 
 cause a narrowing of the anal orifice. Local anaesthesia is 
 sufficiently potent to meet the indications of the operation. 
 If the hemorrhoid be distended, tender, and painful, it may 
 be necessary to employ general anaesthesia. The tumor 
 should then be taken between the thumb and finger, raised 
 up, drawn out, transfixed near the base, and cut outward; 
 the pressure will then evacuate its contents, after which a 
 pellet of fine oakum saturated with balsam of Peru should 
 be placed in the bottom of the sack, and the operation is 
 completed. When the transfixing incision is made, it 
 should be done in the direction of the radiating folds of 
 the anus, to facilitate union. 
 
 Operations for internal hemorrhoids are quite numerous, but 
 the following are believed to secure the best results: 
 
 Excision. — This method is reckoned among those which 
 
 j t_ ^^^— -^^ 
 
 Fig. 149. 
 
 secure the best results in selected cases. It causes little 
 after pain, and recovery takes place within a week or ten 
 days. It is applicable to those cases wher» but three or 
 four tumors exist, which are not very large, and have well 
 defined bases. The sphincter should be well dilated and 
 the anus opened with a speculum or retractor. The pile is 
 then seized at the base with a vulsellum, and cut off with a 
 pair of scissors above the point grasped, Avhich should be 
 held till all arterial hemorrhage is stopped by twisting the 
 bleeding points. After it has ceased a pledget of lint satu- 
 rated with tannin and water, or with liquor ferri subsulpha- 
 
INTERNAL HiEMORRHOIDS. I51 
 
 tis, is applied to the cut surfaces, and the patient kept quiet 
 for t\Yenty-four to forty-eight hours. 
 
 This operation has been frequently performed, and with 
 eminent success. 
 
 Crushing. — This method consists in crushing the pedicle 
 of the growth in the instrument especially constructed for 
 that purpose (Fig. 149). It is not suitable for universal 
 application, but rather to those tumors which possess well- 
 defined bases. If the integument be connected with the 
 tumor it should be incised, otherwise too great pain is 
 caused. The patient being prepared as in the preceding 
 instance, the pile is pulled between the bars of the instru- 
 ment by the aid of a hook or a vulsellum, after which the 
 screw is turned tightly against it. The projecting portion 
 is then cut off. The instrument is retained in position for 
 half a minute or so, to insure against the danger of hemor- 
 rhage. While this method may be classed among the satis- 
 factory ones, it possesses no superiority over the treatment 
 by ligature; and as a rule causes more pain, less speedy re- 
 covery, and exposes the patient to the probable danger of 
 subsequent hemorrhage. 
 
 Ligation. — This method may be employed with or without 
 incision. The latter being far preferable. The treatment 
 without incision is to pass a needle, armed with a double 
 ligature of stout carbolized silk, through the base of the 
 growth, tying each half separately; after which the pile is 
 cut off below the ligature. If strong catgut be used, the 
 ends should be divided close to the pedicle; while with silk 
 one end may be allowed to hang from the anus. 
 
 Ligature with incision consists in drawing down the tumors 
 by aid of forceps or volsellum to the anus, or beyond it, and 
 with a pair of curved scissors dividing them from their con- 
 nection with the sub-mucous membrane from below up- 
 ward, parallel with the bowel, far enough to leave the pile 
 connected only by a slim pedicle, around which a strong 
 ligature should be cast and securely tied. The ligature 
 portion is thus cut off and the parts returned. The vessels 
 connected with the growth enter it from above downward, 
 parallel with the gut, and are therefore secure from injury, 
 if ordinary caution be taken. The injection of carbolic acid 
 and astringent agents, together with the application of 
 caustics, is hardly entitled to the dignity of being consid- 
 ered an operation. Nor are the results, notwithstanding 
 the claims of some to the contrary, on the whole better than 
 
152 
 
 OPERATIVE SURGERY, 
 
 by ligature, either with or without incision. The occa- 
 sional severe inflammatory reaction, often followed by 
 abscesses and gangrene, detract from that which might 
 otherwise become an extremely satisfactory remedy. The 
 full explanation of these methods can be found in syste- 
 matic treatises upon the subject. 
 
 Varicocele. — This is caused by a varicose condition of the 
 spermatic veins (Fig. 150). The treatment of the varicose 
 veins of the cord, like that in other 
 situations, is divided into the pallia- 
 tive and radical methods; the object 
 of the latter being to obliterate the 
 lumen of the vessels. The same 
 dangers appertain to operations upon 
 these veins, as upon those of other 
 portions of the venous system. Ery- 
 sipelas, phlebitis, pyaemia, to which 
 may be added a consequent atrophy 
 of the testicle depending upon the oc- 
 clusion of the vein and artery, may 
 follow ; therefore radical measures 
 directed to the vessels should not be 
 entertained until the disease becomes 
 a source of great discomfort and even 
 distress. The palliative treatment 
 consists in shortening the cord by 
 raising the scrotum and its contents, 
 which lessens the weight of the col- 
 umn of blood contained in the ves- 
 sels, This is achieved by the various 
 forms of suspensories, as Morgan's 
 (Fig. 151), and the one in ordinary 
 use. Should these serve to relieve 
 the urgent symptoms, the patient 
 may not deem it desirable to submit 
 to an operation of any kind. If, how- 
 ever, the characteristic symptoms 
 recur or continue, then the palliative operation for shorten- 
 ing the scrotum should be done. 
 
 Excision of the Scrotum. — The instruments required for this 
 simple operation are the scrotal clamp — the one devised 
 by Dr. Henry being in every way suitable (Fig. 152) — a 
 sharp bistoury, needles armed with silver wire, or carbolized 
 silk, artery forceps, and catgut ligatures. The scrotum 
 
EXCISION OF SCROTUM. 
 
 153 
 
 should be thoroughly cleansed and the patient anaesthetized; 
 the clamp is then applied to the side afflicted by drawing 
 the bottom of the scrotum between the blades, which 
 should be applied as nearly as possible parallel with the 
 raphe; all danger of including the testicle is obviated by 
 pressing it upward to the ex- 
 ternal abdominal ring. When 
 a sufficient amount of tissue 
 is grasped to meet the indica- 
 tion, the blades are tightened 
 to cut off all circulation, at 
 the same time securely hold- 
 ing the scrotal tissues; the pro- 
 truding portion is then trans- 
 fixed, on a level with the ad- 
 justable bar (Fig. 152-2), by 
 a sharp and narrow-bladed 
 scalpel, and cut off. Before the 
 blades are loosened it is bet- 
 ter to pass the sutures, which 
 should be at least ten inches in length, through the divided 
 borders. Having adjusted them, remove the clamp, tie 
 the bleeding points, and close the wound. Caution must 
 be taken always to stop all bleeding points before the edges 
 of the wound are united; else, owing to the looseness of 
 
 Fig. 151. 
 
 Fig. 152. 
 
 the scrotal tissues, an ordinary oozing may cause the forma- 
 tion of large bloody clots, which must be removed. If a 
 drainage tube be introduced throughout its course and 
 allowed to protrude at its most dependent extremity, this 
 danger will be avoided. Place the patient in bed, elevate 
 
154 
 
 OPERATIVE SURGERY. 
 
 the scrotum, and dress the wound antiseptically. It usually 
 heals quickly, and affords sufficient relief to amply recom- 
 pense the patient for the annoyance incurred. If the in- 
 strument just described be not at hand, the operation 
 should not be delayed for this reason. A clamp of great 
 practical utility may be extemporized from long-bladed 
 forceps, or by adjusting to the scrotum two narrow bars of 
 metal or stiff wood, the extremities of which can be firmly 
 held by the hands of an assistant. 
 
 Radical Treatment for Varicocele. — The means employed 
 to obliterate the dilated vessels are quite numerous. They 
 all, however, accomplish the result by compression. Only 
 such as are considered practically consistent with the safety 
 of the patient are here described. In all the operations 
 
 Fig. 153. 
 
 Fig. 154. 
 
 great care must be exercised to avoid the vas deferens and 
 artery. They lie posteriorly to the enlarged and worm-like 
 congeries of vessels, around which the compression is to be 
 applied. If the patient be caused to lie down with the hips 
 elevated, the blood will return from the varicose veins into 
 the general circulation, after which the vas deferens and 
 artery can be easily isolated and pulled aside. If the 
 patient then assume an erect position the veins will again 
 become distended, when, if pressure be maintained upon 
 the cord at the external ring, the vessels can be distinctly 
 outlined if the patient be placed in the recumbent position. 
 The operator having thus carefully located the vas deferens, 
 the patient can be etherized and the operation be pro- 
 ceeded with. 
 
RADICAL CURE OF VARICOCELE. 155 
 
 Compressio?i by Pins (Fig. 153). — This consists simply of 
 passing a strong pin in front of the vas deferens and artery, 
 and throwing around its protruding extremities an elastic 
 ligature, or cotton yarn, drawn sufficiently tight to cut off 
 the circulation. This should be duplicated at about one 
 inch from the first application. The pins can be withdrawn 
 at the end of three or four days. 
 
 Compression by Wires (Videl's). — This is done by passing 
 a stout wire either in front of or behind the veins, prefer- 
 
 FiG. 155, 
 
 ably the latter, then passing a second but thinner one at 
 the opposite side, but through the same opening in the in- 
 tegument (Fig. 154). They are then twisted together till 
 the veins are thoroughly compressed and rolled around 
 them (Figs. 155 and 156). 
 
 Subcutaneous Ligation. — This is accomplished by carry- 
 ing a needle armed with silver wire between the 
 veins and cord, returning it at the point of entrance, 
 going in front of the veins. The wire is then twisted 
 firmly. A strong silk ligature can 
 be applied in similar manner. 
 However, the amount of tissue in 
 their grasp renders the separation 
 somewhat tedious. The process 
 of separation can be hastened by 
 tying the ligature over a small 
 cylinder of elastic tubing, the re- 
 sistancy of which will exercise a 
 constant traction (Fig. 157). If 
 this be done, a button should be 
 introduced between the tissues and tubing to protect the 
 skin. 
 
 A strong catgut ligature can be carried around the dilated 
 veins and caused to emerge at the point of entrance by 
 means of a curved needle, tied, ends cut short, and permit- 
 ted to remain until it is absorbed, which will take place in 
 five or six days. This is. in my opinion, the safest and 
 simplest method and equally efficacious. 
 
 T/ie Double-Loop Compression of Ricord (Fig. 158). — This 
 is an excellent plan, and can be readily done by passing 
 
156 
 
 OPERATIVE SURGERY. 
 
 a needle armed with a silk ligature between the veins and 
 the vas deferens ; to this is fastened a double ligature, 
 
 Fig. IS7. 
 
 which is drawn through and left in position. The needle 
 with its silk ligature is then passed in front of the veins in 
 the opposite direction, entering 
 and emerging at the points pre- 
 viously made. A second double 
 ligature is then drawn through and 
 left in position. The extremities 
 on the respective sides are now 
 Fig. 158. tucked through the loops on the 
 
 same side and drawn tight, and tied over a narrow roller 
 or piece of elastic tubing. The ligatures will cut a way 
 through in five or six days. The methods of exposure, 
 division, and exsection of the vessels are more dangerous, 
 and not infrequently result in death from pyaemia. 
 
 Venesection. — While the withdrawing of blood from a vein 
 can hardly be classed as an operation of much moment in 
 a surgical sense, yet the infrequency of its employment at 
 the present time is quite apt to render the details connected 
 therewith somewhat uncertain in the minds of a majority 
 of the practitioners of the present generation. The veins 
 selected for the procedure are the internal saphenous at the 
 ankle, median basilic, median cephalic, and external jugu- 
 lar. The instruments required are the ordinary thumb lan- 
 cet, or a curved or sharp-pointed bistoury, the first, however. 
 
VENESECTION. 
 
 157 
 
 possessing the greater number of traditional virtues. If 
 these be not at hand, either of the others can be used as 
 satisfactory substitutes. If the region of the elbow be se- 
 lected, the median cephalic is preferred on account of its 
 greater distance from the brachial artery. The arm should 
 be constricted by a bandage drawn sufficiently tight to ob- 
 struct venous return, without interfering with arterial circu- 
 lation: this will cause the veins to become prominently dis- 
 tended, unless the patient be very fleshy. The veins should 
 be well defined by the finger, and held in position by the 
 thumb or finger placed just below the point for incision, 
 which is made obliquely to the transverse diameter, and of 
 sufficient depth to freely open the vessel, without severing 
 it (Fig. 159). The flow may be increased by causing the 
 
 Fig. 159. 
 
 patient to firmly grasp a stick or broom-handle; it may be 
 impeded by the interposition of the subcutaneous fat, 
 which should be pushed aside. The amount drawn will be 
 governed by the strength of the patient, as well as his 
 position. If standing or sitting its effects will be sooner 
 felt than if in a recumbent posture. Usually, however, 
 from half a pint to a pint will suffice. The flow is stopped 
 by removing the bandage above and applying the finger to 
 the bleeding point; after which a small compress is placed 
 
158 
 
 OPERATIVE SURGERY. 
 
 over the incision, and confined in position by adhesive 
 plaster, so arranged as not to impede the venous return. 
 
 These directions will apply with equal force to venesection 
 in all situations other than of the external jugular. If this 
 vein be selected, the compress is placed just above the. 
 clavicle, and confined in position by a bandage carried un- 
 der the opposite axilla. The finger is then placed above 
 
 Fig. i6o. 
 
 the point of proposed incision, and the vessel opened at 
 right angle with the fibres of platysma myoides muscle. 
 The finger must always be placed on the opening before 
 the compress is removed, in order to prevent the entrance 
 of air into the circulation. 
 
 Transfusioji. — This is a means sometimes employed to 
 
TRANSFUSION. 
 
 159 
 
 overcome the exhaustion produced by disease, or loss of 
 blood; the latter being the only condition to which it can, 
 thus far, be said to be practically adapted. It consists in 
 conveying the blood from one person to another, either 
 directly, or by collecting it in a suitable receptacle, remov- 
 ing the fibrin, and introducing the resulting blood plasma 
 and corpuscles. The dangers to be avoided, are, the intro- 
 duction of air, blood clots, and too great a quantity of 
 blood, which might overpower an already weakened heart. 
 From six to eight ounces are usually sufficient, and it should 
 be thrown slowly and carefully, watcliing its effects upon 
 the circulation, respiration, and sensorium of the patient. 
 If its introduction causes a depression of the pulse, or gives 
 rise to nervous tremors, or difficulty in breathing, it should 
 cease at once. The blood, to be transfused, should be 
 
 Fig. 161. 
 
 taken from a person of strong physique, and free from any 
 constitutional taint. 
 
 Direct Transfusion from arm to arm. The requirements 
 for tliis are, an apparatus for the transmission of the 
 blood, together with a pair of forceps and a scalpel to 
 open the vessels. A basin of water or saline solution at 
 a temperature of about 100° F., into which the instrument 
 should be laid to impart to it the requisite degree of 
 warmth, and to exclude the air. The arm of the donor 
 and receiver are constricted above the point for incision, as 
 in phlebotomy; the skin covering the distended vessels is 
 pinched up, transfixed, and cut out, leaving the veins ex- 
 posed at bottom of the wounds; they are then seized with 
 a pair of forceps, and a V-shaped opening made with the 
 scissors (Fig. 160). The tube A (Fig. 161) is then taken 
 from the bottom of the basin, and with the thumb applied 
 
i6o 
 
 OPERATIVE SURGERY. 
 
 to its larger extremity to keep it filled, is inserted into the 
 opening in the vein of the receiver; the tube B is inserted 
 in like manner into the vein of the donor (Fig. i6i), after 
 which the propelling power of the apparatus, likewise filled 
 with fluid and kept so by turning the stop-cocks, is attached 
 to the two tubes; the cocks are now opened, and the fluid 
 contained in the instrument is thrown into the circulation 
 by squeezing the bulb C, while the tube D is compressed 
 (Fig. i6i). After the bulb C is emptied, and before it is 
 permitted to expand, the compression should be changed 
 from d to d' . If the bulb be now allowed to expand it 
 will become filled with the blood of the donor, which can 
 be pushed into the circulation as in the preceding instance. 
 The 'bulb should be allowed to fill slowly, and the amount 
 
 introduced is estimated by counting the number of times 
 it is emptied. After the operation is completed, the in- 
 cisions are treated the same as in phlebotomy. The instru- 
 ment devised by Fryer (Fig. 162) differs from the former in 
 being cast whole, with an additional bulb, which does 
 away with the metallic couplings, and presents a continu- 
 ously smooth surface to the blood current; and, moreover, 
 the additional bulb saves time by producing an almost con- 
 tinuous current. It will be seen that a funnel is added to 
 this instrument which allows it to be employed in mediate 
 transfusion. 
 
 Mediate transfusion is collecting the blood from the arm 
 
TRANSFUSION. 
 
 i6i 
 
 Fig. 163. 
 
 Fig. 164. 
 
l62 OPERATIVE SURGERY. 
 
 of the donor and injecting it into the circulation, either 
 with or without the removal of the fibrin. For this pur- 
 pose the instrument devised by Collins (Fig. 163) can be 
 especially recommended. It consists of a pump attached 
 to a funnel, in such a manner as to carry the blood easily, 
 and without danger of coagulation, or the introduction of air. 
 It can be used equally well with the defibrinated and with the 
 unwhipped blood: in the latter it is particularly convenient, 
 since the blood can be caught in the funnel and injected 
 while flowing from the donor; this saves time, and avoids 
 the blood changes induced by its exposure. In the use of 
 this, and all other implements brought in contact with the 
 blood, the temperature of the instrument, and of the blood 
 injected, should be kept at about 100° F. by means of water, 
 or a saline solution.* 
 
 If defibrinated blood be employed, it should be prepared 
 by agitation, after being collected in a vessel of the 
 temperature stated (Fig. 164), then strained (Fig. 165) into 
 the funnel of the instrument and pumped into the system. 
 
 The introduction into the funnel, or into the bulbs, of 
 two or three ounces of the saline solution; or of a carbonate 
 of ammonia solution, four to six grains to the ounce, pre- 
 vents the entrance of air to the instrument, and also has a 
 stimulating effect upon the patient. 
 
 Intra-venous injection of milk has been done to counteract 
 the conditions similar to those calling for the use of blood. 
 The milk should be freshly drawn from the cow and covered 
 with fine gauze; the carbolized being the better, through 
 which it is strained into a transfusion instrument, which 
 can be extemporized by joining to one end of a rubber 
 tube a glass funnel, and to the other a small conducting 
 canula. 
 
 If the canula be introduced into the vein, and the funnel 
 be raised after having been filled with six or eight ounces 
 of milk, the force of gravity will become the propelling 
 agent. 
 
 Arterial transfusion has been advocated on the basis that 
 
 * I^ Chloride of Sodium 3 i- 
 
 Chloride of Potassium. gr. vi. 
 
 Phosphate of Soda gr. iii. 
 
 Carbonate of Soda 3 i- 
 
 Aqua I XX. 
 
 TtL — Heat to 100 F. 
 
TRANSFUSION. 
 
 163 
 
 it conveys the blood more equably to the heart, with less 
 danger of exciting undue disturbance of the circulation. 
 The admission of a small amount of air does no harm, and 
 the danger of phlebitis is avoided. The vessels selected 
 are the radial, or the posterior tibial at the ankle, which 
 is exposed, and three ligatures are placed around it; the 
 proximal one is tied, ana the distal tightened sufficiently to 
 cut off collateral circulation. The vessel is then opened, 
 
 Fig. 165. 
 
 the tube inserted, and tied in position by the middle or third 
 ligature; the distal one is then relaxed and the blood forced 
 into the circulation. As soon as this is completed the dis- 
 tal ligature is tied, and the intervening portion of the vessel 
 removed with the tube. The vein may be tied in venous 
 transfusion by placing two ligatures. Tie the distal one, 
 open the vein, introduce the tube, then tie the proximal one; 
 this will prevent all loss of blood. 
 
 Capillaries, — This system of vessels, like the venous, may 
 
1 64 OPERATIVE SURGERY. 
 
 undergo dilatation of sufficient size to create distinct but 
 slowly developing and painless deformities, or tumors. 
 The morbid process may be, and usually is, limited entirely 
 to the capillaries of the integument; however, the larger 
 vessels are not infrequently involved, in the beginning, or 
 during their development; they likewise vary in size, shape, 
 and color. The simplest form is known as the "mother's 
 mark," '' birth-mark," etc. 
 
 A iDirth-mark can be treated by pressure, caustic, hot 
 needles, vaccination, etc., depending upon its size and situa- 
 tion. It is not well to interfere with them at all except by 
 simple means, unless they increase rapidly in size. The 
 majorit)^ of these growths will disappear of themselves be- 
 fore their presence will become a source of annoyance or 
 regret to the possessor. There are, however, several simple 
 means which will often hasten their departure. The use of 
 simple compresses, repeated application of collodion, vac- 
 cination, if it be located suitably therefor. The method in- 
 troduced by Squire some time since, which bade fair at one 
 time to meet the desired end, can be employed. 
 
 The " mark" is frozen with an ether spray, and numerous 
 parallel incisions are made about one sixteenth of an inch 
 apart, and extending the same depth, and the whole cov- 
 ered with blotting-paper, held upQn it with sufficient force 
 to prevent an}'- gaping of the cuts and escape of blood; 
 after fifteen or twenty minutes the paper is thoroughly wet 
 with water and removed. Sometimes a thin underljnng 
 clot of blood will be found; this must be carefully washed 
 away with water and a soft brush. It is sometimes neces- 
 sary to repeat the operation, when the incisions should be 
 made in the opposite direction. If proper care be taken, in 
 suitable cases a perfect cure is secured without any scar- 
 ring. The injection of ergot, liquor ferri subsulphatis, and 
 various other astringents, have been recommended. They 
 are, however, uncertain in their action, and are liable to be 
 followed by inflammation, ulceration, and sometimes by 
 embolism. The solutions can be injected by aid of the or- 
 dinary hj^podermic S}'ringe, three or four drops at a time, 
 in various portions of the growth, or hot needles can be in- 
 troduced at various points. The application of red heat 
 around the base and over the surface of the growth by 
 means of the Paquelin cautery is an admirable method, pro- 
 vided it involves the skin alone, or only the capillaries in 
 the tissue immediatelv beneath it. It is usuallv followed 
 
NAEVI. 
 
 165 
 
 In it the 
 
 by more or less disfigurement, depending upon the extent 
 of the cautery. 
 
 If it be of large size, persistent, of a dark color and 
 markedly elevated, it is suitable for subcutaneous ligation. 
 This is done in several ways, depending upon the size and 
 shape of the tumor, and fancy of the operator. 
 
 (Fig. 166.) This represents a simple method, 
 needle, armed with a strong, well-car- 
 bolized hemp or silk ligature, is thrust 
 through the integument at its base, and 
 carried as far as possible around the 
 base, and passed out, to be again intro- 
 duced at the point of exit, and carried 
 still further around, and pushed through 
 as before, and so on until it is caused to 
 emerge at the first point of insertion; 
 the ends are then tied in a firm, hard knot. 
 
 (Fig. 167.) In this a double ligature is carried through 
 the base and divided; each portion is then carried around 
 its half of the base as before, and tied. This is applicable 
 to those having a larger base. Fig. 168 represents the ap- 
 
 FlG. 166. 
 
 Fig. 167. 
 
 Fig. iC 
 
 plication of the ligature to quarter-sections of the base. It 
 is employed when the growth is large. Pass a double liga- 
 ture through the centre of the base, cut the loop near to its 
 centre, leaving one end of the divided thread in the eye of 
 the needle; then, after threading the needle with the other 
 end of the portion of the ligature which was liberated by 
 the division of the loop (Fig. 169), pass the needle through 
 the base at right angles to its primary course. The ends 
 are then to be firmly tied after the integument has been in- 
 cised, to allow the' ligature to sink deeply into the base, 
 as well as to avoid the pain and ulceration incident to the 
 constriction of the integument (Fig. 170). It will simplify 
 the selection and uniting of the proper extremities if one 
 half the ligature be colored before its primary introduction. 
 
i66 
 
 OPERATIVE SURGERY. 
 
 Fig. 171 represents the ligation of a growth with an elon- 
 gated base. In this the double ligature is required, and 
 should be colored as before; pass it through the base from 
 side to side, commencing and terminating just outside of 
 the extreme limits of the growth; if the white loops be now 
 divided on one side and the black on the other, independ- 
 
 FlG. 169. 
 
 Fig. 170. 
 
 Fig. 171- 
 
 ent sets of ligatures will be had, which should be tied; the 
 skin coming within the grasp of each ligature is incised an 
 in the preceding instance. The separation of the growth 
 is hastened by the use of an elastic or rubber ligature, ap- 
 plied in a similar manner. 
 
 NERVOUS SYSTEM. 
 
 The brain, spinal cord, and the nerves arising from the 
 cerebro-spinal axis, owing to the various morbid processes 
 and injuries to which they, together with their coverings, 
 are subjected, are often the seat of common and yet im- 
 portant surgical procedures. 
 
 Hydrocephalus. — Tapping for the removal of the. super- 
 fluous fluid is the only practical surgical procedure to 
 which this condition is amenable. This may be done with 
 a small aspirating trocar, or, what is better, with an aspira- 
 tor. In either instance the puncturing agent is introduced 
 through the anterior fontanelle, close to its outer border, 
 and passed perpendicularly into the fluid accumulation. 
 The fluid must be slowly withdrawn, accompanied by mod- 
 erate and equable pressure upon the external surface. 
 Whenever any manifestations referable to the circulatory 
 or nervous centres appear, the needle should be withdrawn 
 
MENINGOCELE AND HYDRO-RACHIS. 167 
 
 and the puncture carefully closed. Often the removal of 
 less than three or four ounces will cause feebleness of the 
 pulse, contraction of the pupil, and evidences of approach- 
 ing convulsion. After the withdrawal of the fluid, gentle 
 and universal pressure should be maintained by aid of band- 
 ages, adhesive plaster, or tightly-fitting perforated rubber 
 cap. Care is necessary, else the combined pressure of re- 
 accumulating fluid and external dressing will cause alarm- 
 ing symptoms. 
 
 Meningocele is a protrusion of the meninges of the brain, 
 caused by an accumulation of hydrocephalic fluid within 
 the cranium, and must of necessity occur before the clos- 
 ure of the fontanelles. It may be present at any point of 
 separation between the cranial bones, although more fre- 
 quently at the posterior fontanelle than elsewhere. As a 
 rule, little can be done, other than to protect the tumor 
 from external irritation. If it have a well-defined pedicle, 
 it can be clamped and the fluid withdrawn, either by incis- 
 ion, or with a small trocar. The clamp must be applied 
 with caution, else the pressure caused by tightening of its 
 blades may produce convulsions or other nervous phenom- 
 ena. If it be determined to puncture it, a small amount 
 of fluid may be withdrawn, when the clamp can be the 
 more readily adjusted. As long as the pedicle is open, any 
 operative interference is liable to be followed by death 
 from a resulting meningitis. If the pedicle be occluded, 
 incision may be done and the tumor removed. In all in- 
 stances where it is removed, sufficient integument should 
 be left to insure a complete and proper closure of the di- 
 vided surfaces. 
 
 Hydro-rachis. — This is a congenital defect, comprising a 
 cleft in the laminae of the vertebrae, and a protrusion of the 
 membranes of the spinal cord. It occurs more frequently 
 in the lumbar region, although it is found in the other por- 
 tions of the spinal column. Various operative expedients 
 have been employed to cure the defect, nearly all of which 
 have, at one time or another, resulted in isolated cures. 
 
 The two methods which have secured the best results 
 are: i. Repeated punctures with a small needle at various 
 intervals through the sides of the sack, followed b}^ gentle 
 and uniform pressure to the surface. 2. Consists of inject- 
 ing into the sack, which should be partially emptied of its 
 fluid, one or two drachms of the iodo-glycerine solution, 
 which is made by dissolving ten grains of iodine and thirty 
 
i68 
 
 OPERATIVE SURGERY. 
 
 grains of iodide of potassium in one ounce of glycerine. 
 Exercise caution that none of the fluid escapes after the 
 operation. This must be repeated from time to time, al- 
 ways allowing the irritation due to the previous operation 
 to subside before it is again repeated. This method has 
 been very successful. Of forty-four cases treated, thirty- 
 five were cured. 
 
 Trephining the cratiium is an operation which is, without 
 doubt, performed more frequently than the requirements 
 of the majority of cases will warrant. In every instance, 
 before attempting it, the indications should be most care- 
 fully studied. 
 
 The special instruments required for the operation are 
 the trephine (Figs. 172, 173, 174), the 
 conical being by far the safer; an ele- 
 vator (Figs. 175, 176, 177) and rongeur 
 (Fig. 178), sequestrum forceps (Figs. 
 179 and 179^), gouges and mallet (Figs. 
 180, 181, 182, 183, 184). The traditional 
 tooth-pick, and the brush, to remove the 
 dust from the track of the trephine, 
 while not absolutely necessary, have, 
 nevertheless, especially the former, be- 
 come so closely associated with the op- 
 eration as to be entitled to a most re- 
 spectful consideration. The patient is 
 
 Fig. 173. 
 
 Fig. 174. 
 
 Fig. 172. 
 
 prepared by shaving the head for a considerable distance 
 around the seat of the proposed operation. If unconscious, 
 an anaesthetic is unnecessary. 
 
 Operation. — Make an incision through the scalp down to 
 the bone of a size and shape as to best expose the portion of 
 bone to be attacked, and at the same time to avoid large 
 vessels and to secure good drainage. Lay back the integu- 
 mentary flap, along with the periosteum covering the por- 
 tion of bone to be removed. Lower the centre-pin a little 
 below teeth of the trephine, and fasten it firmly in position 
 by means of its adjusting screw; place the point of the 
 centre-pin as nearly as practicable upon that portion of 
 
TREPHINING- 
 
 169 
 
 Fig. 175. 
 
 CA5'A'EU_.P>AZAaQ3;C0.Wf.EORa , 
 
 Fig. 178. 
 
 Fig. 179. 
 
 Fig. 179a. 
 
 CASWELL.HAZARD.i.CO .Vy.F.FORO. 
 
 Fig. 180, 
 
I70 
 
 OPERATIVE SURGERY. 
 
 Fig. 183. 
 
 Fig. 184. 
 
 the solid and undepressed bone which, when removed, 
 will allow the best opportunity of elevating that which is 
 depressed; provided, however, that it be not placed over 
 the course of the middle meningeal artery, or a large 
 sinus (Fig. 185). The trunk of the middle meningeal artery 
 is located an inch and a half behind the external angular 
 process of the frontal bone, and the same distance above 
 the zygoma. The median line of the skull from the root 
 •of the nose to the occipital protuberance corresponds to 
 the superior longitudinal sinus. The course of the lateral 
 sinus is indicated by a line drawn from the occipital pro- 
 tuberance to the anterior border of the mastoid process. 
 Bear firmly upon the instrument, at the same time turn it 
 quickly from right to left, till a suitable track is established 
 to retain it in position (Fig. 186). The centre-pin is then 
 
TREPHINING. I7I 
 
 withdrawn, and fastened in place, otherwise it may perfor- 
 ate the membranes. 
 
 The instrument must be held perpendicularly to the point 
 of section, and the pressure evenly distributed; if not, one 
 side will be penetrated more quickly than the other, thereby 
 endangering the laceration of the membranes. During 
 the process, the trephine must be frequently raised from 
 the track, that it may be cleared of bone-dust, the color 
 of which should be carefully noticed; at first it is of a pale 
 white, but as soon as the diploe are reached it becomes red- 
 dened; from this time on the tooth-pick must be frequently 
 used to clear out the track as well as to detect the first point 
 of complete section. But little pressure is now allowable, 
 since to use it might force the crown of the instrument 
 
 through the membranes and the brain structure itself, es- 
 pecially if it be of a horizontal pattern. If the button of 
 bone be percussed with the handle of a scalpel or forceps, 
 it will emit a low pitched sound, and vibrate when a con- 
 siderable portion of the circle is divided; moreover, it can, 
 probably, be raised from its bed at this time by the aid of 
 the elevator. As soon as the button is removed, the ele- 
 vator is inserted beneath the depressed portion, and it is 
 raised to its pfpper level. 
 
 This is sometimes difficult to accomplish, owing to the 
 dovetailing of the fragments. The solid bone is used as a 
 fulcrum, when much force is necessary. If great force be 
 used, and a fragment be suddenly loosened, its sharp or 
 
172 
 
 OPERATIVE SURGERY. 
 
 jagged border may cut through the membranes; it is there- 
 fore necessary that force be used in a guarded manner. 
 
 All loose fragments are to be removed; those that will 
 retain their position when replaced, owing to continuity of 
 structure, may be allowed to remain. All projecting points 
 of bone must be cut away, else the pulsation of the brain 
 
 Fig. i86. 
 
 may cause them to perforate the dura-mater. Clots of blood 
 and pus are likewise to be cleared out. If the compress- 
 ing agents be below the dura-mater it may be opened 
 sufficiently to admit of their escape; before it is done, 
 however, their presence should be clearly established. If 
 the dura-mater be lacerated, it may be closed by fine cat- 
 gut sutures, especially when the opening is large enough 
 
OPERATIONS UPON NERVES. 1 73 
 
 to endanger the formation of hernia cerebri. If the me- 
 ningeal branches be divided or a sinus opened, the hemor- 
 rhage is controlled by antiseptic compresses, so applied as 
 not to exert undue pressure on the brain. If the mem- 
 branes be lacerated, the fragments of bone removed must 
 be fitted to each other in order that the absence of any- 
 osseous portion may be ascertained and sought after. 
 
 The wound should now be thoroughly cleansed with car- 
 bolic acid, the flaps adjusted, suitable drainage established, 
 and the antiseptic dressing applied. It is often possible to 
 elevate the fragments without the use of the trephine, an 
 expedient that should always be tried, if any reasonable 
 prospect of success be apparent. 
 
 Nerves of the Cerebro- Spinal Axis. — Owing to neuralgia, 
 spasm, tremor, etc., it may be become necessary, after all 
 ordinar)'- means have failed, to operate upon the trunk of 
 the nerve involved, either by division, excision, or stretch- 
 ing. The first method can afford but temporary relief, 
 since the divided extremities will speedily unite. 
 
 If excision be done, not less than two inches, if possible, 
 should be removed from the continuity of the trunk, other- 
 wise at a greater or lesser period the extremities will be- 
 come united. If the nerve be a small one, the tendency to 
 union is less; but the rule to remove a long piece must not 
 be deviated from. Stretchitig consists in cutting down on 
 the affected nerve, seizing it with the fingers, and making 
 firm and steady traction for a minute or two. This is ap- 
 plied more properly to the large nerves, and those which 
 cannot be divided without the sacrifice of important func- 
 tions. 
 
 Supra- Orbital Nerve. — This may be divided or excised at 
 its exit from the supra-orbital foramen or notch. Locate 
 the notch by the fingers of the left hand, then pass the point 
 of a narrow bistoury beneath the integument, from its inner 
 to its outer side; turn the edge backward, and cut firmly 
 down and across the opening upon its inferior wall. 
 
 Resection. — This can be done by elevating the brow, and 
 making an incision between it and the lid, one inch in 
 length, down upon the site of the nerve; its branches are 
 then sought for, and exsected or stretched, as seems better. 
 The nerve may be pulled out with a small blunt hook from 
 the roof of the orbit, and excised before it enters the for- 
 amen; or, it may be stretched and allowed to remain. 
 
 The infra-orbital nerves are the terminal branches of the 
 
174 OPERATIVE SURGERY. 
 
 supra-maxlllary division of the fifth pair: they escape from 
 the infra-orbital foramen. 
 
 The infra-orbital foramen is about four lines below the 
 lower edge of the orbit, and nearly on a line extending 
 from the bicuspid teeth to the supra-orbital foramen. The 
 nerve may be divided through the mouth by first recog- 
 nizing the location of the foramen, and placing the finger 
 upon it; then make a narrow incision, beginning at the fold 
 of the cheek and maxilla, carrying it upward in the line 
 before indicated, till within a short distance of the for- 
 amen, when with a sharp-pointed pair of scissors the nerves 
 are divided as they emerge. They may also be divided 
 through an external incision made directly down upon the 
 foramen. 
 
 The Superior Maxillary Nerve. — This may be excised, 
 divided, or stretched in its course along the floor of the 
 orbit, or at its exit from the foramen rotundum. It maybe 
 attacked on the floor by passing a tenatome about two 
 thirds of an inch backward in the line of its course, turn- 
 ing the edge downward, and cutting upon and through 
 the thin floors of the orbit. Its terminations at the infra- 
 orbital foramen, are then exposed, and the several portions 
 pulled out. Through a narrow incision of the soft parts in 
 this situation a blunt hook can be introduced, the nerve 
 caught up and stretched. The whole of the nerve can be 
 removed from the canal, and sometimes further posterior- 
 ily if an incision be made about an inch and a half in 
 length along the lower border of the orbit; the tissues 
 raised and the nerve isolated from the artery, raised on a 
 hook and divided; or by pulling out the central portion, 
 either by a ligature previously applied, or with a pair of 
 forceps. If the more formidable operation of its division, 
 as it escapes from the foramen rotundum, be attempted, 
 the initiatory incision through the soft parts should be of a 
 shape and extent to best expose the site of the proposed 
 operation; the V, -|-, U, -\ shaped ones are selected, 
 according to the fancy of the operator. In either instance, 
 its central portion should correspond as nearly as possible 
 to the infra-orbital foramen. After the flap is raised the 
 crown of a small trephine or drill is applied to the bone so 
 as to open into the antrum along the course of the nerve, 
 which is carefully followed backward to the spheno-maxil- 
 lary fossa by cutting away the floor of the canal with a small 
 sharp chisel. It is then carefully isolated from the tissues 
 
OPERATIONS UPON NERVES. 175 
 
 in the fossa back to the foramen of exit, and divided with 
 a pair of curved scissors; the internal maxillary artery runs 
 through the fossa, and should be carefully avoided. If it 
 be cut, it should be ligated if possible; not infrequently firm 
 pressure will check the hemorrhage. 
 
 The Inferior Dejital Nerve. — This nerve may be divided, 
 excised, or stretched before it enters the jaw; in its course 
 through it, and at its exit from the mental foramen. In 
 the first situation, an incision is made about an inch and a 
 half in length along the anterior border of the ramus of 
 the jaw, within the mouth, down to the anterior fibres of the 
 internal pterygoid muscle; the connective tissue between 
 this muscle and the inner surface of the ramus is now 
 pushed aside, and the nerve detected as it enters the canal. 
 The small spine surmounting the opening for the entrance 
 of the vessel and nerve can be quite readily detected, and 
 will be a valuable guide to the nerve as it enters the dental 
 canal. It can now be isolated, hooked up, and divided. 
 About an inch and a half can be easily excised in this situa- 
 tion, if after its isolation a strong ligature be thrown around 
 it and tied. It can then be divided by curved scissors as it 
 enters the canal; traction by means of the ligature can then 
 be made which will not only draw the nerve down to admit 
 of the division of one, but also aid the good that may be 
 derived from stretching process. 
 
 It may be approached in this situation from without by 
 making an incision from the sigmoid notch to the angle of 
 the jaw, the parotid gland is turned aside, and the mas- 
 seter muscle detached from the ramus sufficiently to allow 
 the application of a trephine. When the button of bone is 
 removed, about one half an inch of the nerve can be isola- 
 ted, exposed, and excised. However, this is not a suit- 
 able substitute for the internal method. 
 
 The nerve may be exposed in its course through the 
 body of the jaw, by raising the soft parts upward, and 
 making an incision through them, about two inches in 
 length, beginning in front of the facial artery. After the 
 bone is thoroughly bared, a trephine is applied in two or 
 more situations, and the bone removed down to the canal, 
 when the intervening portions may be chiselled out, and the 
 whole nerve removed; or it may be resected at each open- 
 ing. 
 
 The former is the surer course. It may also be divided 
 as it emerges from the mental foramen, by turning the 
 
176 OPERATIVE SURGERY. 
 
 lower lip outward, and making an incision at the junctioil 
 of the buccal fold, about an inch in length, in the line of 
 the bicuspid teeth downward, three fourths of an inch, 
 when a careful search will disclose the filaments as they 
 escape from the opening. Seize them with the forceps, 
 draw them slowly and carefully out, and cut them off. 
 
 The Lingual Nerve. — This may be reached in two situa- 
 tions: I. As it passes just below the insertion of the 
 pterygo-maxillary ligament. 2. Beside the tongue and 
 sublingual gland. In the former, the mouth is opened 
 widely, and the fold of mucous membrane covering the 
 ligament is readily seen behind the last molar tooth. The 
 nerve can be felt just below the insertion of the ligament, 
 and close to the tooth. Make an incision backward from 
 the tooth over the course of the nerve, about one inch in 
 length, carefully push aside the submucous tissue, and the 
 nerve will appear in the wound, when it can be raised and 
 cut. It has been successfully divided on several occasions 
 near this situation by entering the point of a curved bis- 
 toury, three fourths of an inch behind, and below the last 
 molar, cutting downward and outward to the bone in an 
 imaginary line, extending from the angle of the jaw to the 
 last molar tooth. In the second situation, the tongue 
 should be drawn forward, and to the opposite side, and an 
 incision made about one inch in length, parallel with the 
 tongue, and one fourth of an inch from the attachment of 
 the mucous membrane to it; push aside the submucous 
 tissue, and the nerve wall be readily seen. 
 
 Brachial Plextis. — It may become necessary on account of 
 a severe neuralgia involving the branches of this plexus, or 
 located in a painful stump, to exsect, or stretch the cords 
 near their origin. It is best done prior to its division 
 into its three terminal cords ; that is, where only two cords 
 are found. Place the patient upon the back, raise the 
 shoulders, and turn the head backward and to the oppo- 
 site side. The course of the external jugular is determined 
 by pressure, just above the clavicle. Make an incision 
 along the posterior border of the sterno-mastoid, three 
 inches in length, extending doAvn to the clavicle ; a second 
 incision of the same length is now made from this point, 
 along the upper border of the clavicle, carefully avoiding 
 the external jugular ; turn the flap upward and seek for 
 the posterior belly of the omo-hyoid ; when found, draw it 
 upward with a hook or ligature, push aside the loose con- 
 
OPERATIONS UPON NERVES. 1 77 
 
 nective tissue, and the two cords will appear located above 
 and to the outer side of the third portion of the subclavian 
 artery, which should be carefully avoided. The inner cord 
 is cautiously hooked up, and a ligature applied to it, by 
 which it can be raised from its bed and divided with a pair of 
 scissors near the outer border of the scalenus anticus mus- 
 cle; being careful to avoid the muscle and the phrenic 
 nerve. If gentle traction be made upon the ligature the 
 distal extremity will be raised, and can be again divided 
 an inch or so from the point of the first section, and re- 
 moved. The second or outer cord is then divided in the 
 same manner, 
 
 Musculo-ciitaneoiis Nerve. — Make an incision two and one 
 half inches in length, between the biceps and the supinator 
 longus, through the integument, fascia, and aponeurosis; 
 separate the muscles and the nerve will be readily seen. 
 
 Miisculo-spiral Nerve. — This can be exposed in two situa- 
 tions. I. By making an incision about four inches in 
 length, between the outer border of the triceps and the 
 brachialis anticus muscles, beginning it two and one half 
 inches above the external condyle. Divide the fascia on a 
 director, separate the connective tissue with the handle of a 
 scalpel or by the finger, and the nerve will be easily found, 
 2. Make an incision, three inches in length, in the space 
 between the supinator longus and the brachialis anticus 
 muscle ; divide the fascia, separate the connective tissue 
 beneath it, and the nerve will be quickly found. 
 
 Mediafi Nerve. — It can be easily exposed in its course 
 along the arm and lower one half of the forearm by modi- 
 fying either of the incisions for ligaturing the brachial to 
 correspond to the relations of the nerve to that vessel. 
 
 In the forearm, by making an incision about three inches 
 in length, along the inner border of the tendon of the 
 flexor carpi radialis, beginning about two inches above the 
 wrist joint. Divide the tissue in the usual manner. Sepa- 
 rate the tendons of the flexor carpi radialis and palmaris 
 longus, when the nerve will be discovered emerging from 
 beneath the fleshy fibres of the flexor sublimis digitorum. 
 
 The Radial a7id Ulnar Nerves — like the median in the arm — 
 can be reached readily through the same incisions employed 
 to ligature the vessels referred to above. 
 
 Great Sciatic Nerve. — This is best exposed just after its 
 escape beneath the lower border of the gluteus maximus. 
 Place the patient on the abdomen and make an incision 
 
178 OPERATIVE SURGERY. 
 
 three or four inches in length, beginning at the gluteal 
 fold, at a point midway between the tuber-ischium and 
 trochanter major ; divide the integument and fascia 
 on a director, separate the connective tissue with the 
 fingers and handle of the scalpel down to the nerve. It 
 can then be stretched by passing one or two fingers around 
 it, and making firm and steady traction upon it for a min- 
 ute or so. Division or exsection can be done easily through 
 the same opening. The wound should be carefully closed 
 and dressed under antiseptic precautions. 
 
 Internal Popliteal Nerve. — This can be reached by the 
 same method and with the same caution as the popliteal 
 artery. It is, however, less deeply situated and somewhat 
 nearer the centre of the popliteal space than the vessels. 
 Extreme caution should be exercised in operating upon it, 
 on account of its nearness to the popliteal vein, which lies 
 beneath it and to its inner side. 
 
 External Popliteal Nerve. — It can be easily reached by 
 making an incision, two or three inches in length, along the 
 inner side of the tendon of the biceps cruris, when the 
 nerve can be readily found beneath the fascia, surrounded 
 by fat. 
 
 The Small Sciatic, Anterior and Posterior Tibial Nerves 
 can be exposed through the incisions adopted in ligaturing 
 the vessels of the same name. 
 
 Internal Sphenous Nerve — is given off from the anterior 
 cryral and supplies the inner surface of the leg. It is ac- 
 companied by a vein of the same name in its course along 
 the leg. It can be reached easily in many situations, but 
 practically, however, it is best exposed at the inner side of 
 the knee, where it escapes beneath the sartorius, and in 
 the middle of the leg. In the former situation recognize 
 the tendon of the sartorius. Press upon the internal saphe- 
 nous vein above this point to distend it, make an incision 
 two inches in length close to and parallel with the vein, 
 draw it aside, and the nerve will be found emerging from 
 beneath the tendons of the sartorius and gracilis. In the 
 middle of the leg make an incision three inches in length, 
 parallel with the properly distended vein, which should 
 then be pulled aside, and the nerve is found beneath it. 
 
 The External Saphenoiis Nerve arises from the internal 
 popliteal, escapes between the heads of the gastrocnemius, 
 pierces the fascia below the middle of the leg and becomes 
 subcutaneous, passes down on the fibular side of the poste- 
 
TENOTOMY. I79 
 
 rior surface to the malleolus, accompanied by the external 
 saphenous vein. Distend the vein by pressure, make an 
 incision close to and parallel with it, near the border of 
 the tendo-Achillis; pull the vein aside, and the nerve will be 
 seen beneath. 
 
 The Plantar Nerves. — T"hese are the terminal branches of 
 the posterior tibial, and are given off just after the nerve 
 winds around the internal malleolus. They can be ex- 
 posed by making an incision about three inches in length, 
 beginning just in front of the centre of a line extending 
 from the anterior border of the internal malleolus to the 
 inner tuberosity of the os-calcis, and extended forward 
 along the external border of the abductor pollicis. If the 
 space between the short flexor and the abductor be now 
 opened at the posterior portion, the nerves will be found 
 accompanied by the arteries of similar name. 
 
 Perifieal Nerve. — This may be exposed in the perineum 
 of the male by making an incision along the rami of 
 the pubes and ischium, in the same manner as directed 
 for ligaturing the pudic artery at this situation. In 
 the female perineum the nerve may be exposed either 
 by an incision made without or within the vagina. In the 
 former, make it through the superficial tissues, about three 
 inches in length, in the groove between the labium and the 
 perineum, just inside the rami of the pubes and ischium. 
 The nerve is surrounded by connective tissue, and it is 
 difficult to find it in this situation ; however, if the blade of 
 the knife be turned inward and the outer coats of the 
 vagina be divided down to the inner one, the nerve will 
 not escape section. 
 
 It is more easily severed from without the vagina. If 
 the finger be introduced an inch or more, and lateral pres- 
 sure be made, the nerve will be felt, cord-like in character 
 and sensitive to touch. Make a vertical incision through 
 the coats of the vagina, and the nerve will be exposed for 
 division or excision. 
 
 TENOTOMY. 
 
 Tenotomy consists in making a subcutaneous division 
 of the tendons of muscles to overcome or alleviate a defor- 
 
i8o 
 
 OPERATIVE SURGERY. 
 
 mity. In order to accomplish this successfully, the exact 
 location of the offending structure must be known, together 
 with its important contiguous vessels, nerves, etc. Many 
 of the large tendons are easily located by their natural 
 prominence. Others that ordinarily lie 
 concealed become apparent if contrac- 
 tion has occurred, and still more con- 
 spicuous if they be placed upon the 
 stretch. The principles governing tenot- 
 omy should be well considered ere a 
 tendon be divided, otherwise an expedi- 
 ent of great good becomes mischievous 
 and even destructive in its results. Mus- 
 cles and fascia, either singly or conjointly, 
 are also the direct causes of, or may be 
 indirectly connected in causing deformi- 
 ties. They, too, are amenable to similar 
 treatment. 
 
 The instruments employed are few in 
 number and simple in character. Figure 
 i86a represents the tenotomes devised 
 by Dr. L. A. Sayre. They are excellent 
 instruments for the purpose. 
 
 (Fig. 187,) This represents the ordinary tenotome found 
 in the pocket-cases of the day. It is too fragile to be safely 
 
 Fig. 186a. 
 
 Fig. 187. 
 
 employed in the division of tissues requiring any outlay 
 of force. A detailed description of either is unnecessary, 
 since they can be ordered from the instrument-maker by 
 simply naming the designer. 
 
 The blade of the tenotome used for dividing fascia 
 and muscles (Fig. 188) is of necessity much longer than 
 either of the former ; the principles embodied in it, how- 
 ever, are substantially the same. An observance of the fol- 
 
TENOTOMY. 
 
 i8i 
 
 lowing simple rules will obviate the possibility of doing 
 violence to other than the tissues directly concerned in the 
 operation: i. Mark the handle to indicate the di- 
 rection towards which the cutting edge looks. 2. A 
 Carefully note the length of the blade, that it 
 may be inserted only fa'' enough to divide the 
 contracted tissues. 3. Place the structure to be 
 divided upon the stretch (Fig. 189). Pinch up, or 
 press aside the skin over the part to be cut, so 
 that when it is released, after the completion of 
 the operation, the opening will not correspond to 
 the divided tissues. 4. The blade should be made 
 aseptic before being used. 5. Pass the knife blade 
 fro7n important vessels and nerves. 6. Insert the 
 blade on the flat, closely to the surface of the tis- 
 sue to be divided; turn the edge towards it, and 
 carefully sever it by a guarded sawing motion, 
 aided by pressing the tendon upon the cutting 
 surface of the knife. If unguarded force be used, 
 the tendon and its superimposed tissues may be 
 divided, which will seriously complicate the recov- 
 ery. 7. Withdraw the blade upon the flat, follow- 
 ing it by firm pressure upon the parts with the 
 thumb, which should finally rest upon the incision; 
 this will press out all blood and exclude the air. 
 8. Seal the wound carefully with adhesive plaster 
 or collodion; or, stitch it with asepticised silk, and 
 apply the antiseptic dressing. 9. Rectify the de- 
 formity and confine the part to which the tendon 
 is attached until repair shall have commenced. 
 10. Avoid the division of a tendon as it passes 
 through its sheath, if possible. 11. Divide the 
 offending tissue at the point of greatest forced 
 prominence; provided, it be consistent with its 
 relation to important structures. If reflex spasm 
 results from " point pressure" the tendon should 
 be divided; and, at the pressure-point inciting 
 the reflex action. 
 
 Tenotomy of Upper Extremities. — The tendons of 
 the flexors sublimus and profundus digitorum 
 may be divided by a transverse, subcutaneous 
 incision carried through them down to the bone, 
 at about the middle of the first row of anatomical phal- 
 anges. Antiseptic precautions should be observed care- 
 
 FlG. 188. 
 
l82 
 
 OPERATIVE SURGERY. 
 
 fully in this instance, otherwise severe inflammation of the 
 tendons of the sheath may follow. After the division of 
 the tendons reduce the deformity and keep the parts quiet 
 for five or six days, till the danger from inflammation has 
 subsided, when they may be cautiously extended. 
 
 Extensor Communis Digttomm. — The tendons of this mus- 
 cle can be readily divided as they pass along the carpus or 
 upon the dorsum of the phalanges. In the former instance, 
 pinch up the skin, pass the knife beneath the tendon as be- 
 fore directed, and cut towards the surface. They may be 
 divided by passing the blade above the tendons and cut- 
 ting down upon the bone. On the dorsum of the phalan- 
 
 PlG. 189. 
 
 ges the blade should be passed beneath the skin, and the 
 tendons divided upon the bone. In the division of the ten- 
 dons of both flexor and extensor muscles, the joints and 
 palm of the hand above the transverse line should be 
 avoided, also the course of the veins and the spaces be- 
 tween the metacarpal bones. 
 
 Extensors prinii, secundi, and ossis, metacarpi pollicis tendons 
 can readily be made prominent by forcible extension of 
 the thumb in the living subject, with the forearm midway 
 between supination and pronation. The primi and ossis 
 tendons form the inner boundary of the *' snuff-box" at 
 the apex of the styloid process of the radius, the ossis being 
 the innermost of the two. The tendons of the extensor 
 secundi form its outer boundary. They can be divided 
 
TENOTOMY. 1 83 
 
 in this situation by first making them as prominent as pos- 
 sible, then introducing the knife beneath from the anterior 
 surface of the wrist and cutting towai'ds the integument. 
 The radial artery is to be avoided as it passes beneath them, 
 and likewise the radicle of the radial vein as it crosses the 
 intervening space. 
 
 Flexor Carpi Radialis. — The tendon of this muscle is 
 situated immediately to the inner side of the radial artery, 
 at the lower third of the forearm, and can be readily 
 divided by passing the knife from the artery beneath the 
 tendon. 
 
 Flexor Carpi Ulnaris. — This is the most internal tendon 
 on the anterior surface of the forearm, and has the ulnar 
 artery at the outer border. It can be easily cut by passing 
 the knife beneath it, from without inward. 
 
 Biceps Muscle at the Forearm. — The tendon of insertion of 
 this muscle may be divided either above or below the 
 giving off the bicipital fascia. The former being the 
 safer. Make the veins in the region prominent by con- 
 stricting the arm above, extend the forearm to make the 
 tendon prominent and tense; enter the knife at its inner 
 border, pass it cautiously between it and the brachial artery, 
 and cut upward, being careful not to injure the distended 
 veins. 
 
 Latissimus Dorsi. — The tendon of this muscle may be 
 divided separately at the lower border of the axilla, or con- 
 jointly with that of the teres major, a short distance below 
 their insertion into the humerus. 
 
 In either instance the arm is forcibly raised to render 
 them tense and prominent, and a long narrow-bladed teno- 
 tome is inserted along the anterior border, and they are 
 carefully severed by a sawing motion. 
 
 It may likewise be divided at the lower angle of the 
 scapula. Make the muscle tense as before, pass a long 
 strong tenotome beneath it, and cut carefully outward; 
 close the opening with a compress. 
 
 Tenotomy in the Lower Extremities: Tibialis Posticus. — The 
 tendon of this muscle is intimately associated with the de- 
 formity talipes varus. It runs along the inner border of 
 the tibia, behind the internal malleolus, in a separate 
 sheath; being the innermost tendon at this situation, after 
 leaving the internal malleolus, it goes beneath the calcaneo- 
 scaphoid articulation to its insertions. 
 
 In the normal foot it lies well concealed within its closely 
 
1 84 OPERATIVE SURGERY. 
 
 fitting groove; it can be readily outlined between the tip of 
 the malleolus and the calcaneo-scaphoid articulation. 
 
 In talipes varus it is raised from its groove and be- 
 comes more prominent above the tip of the internal mal- 
 leolus, as well as below it. It can be divided in either 
 situation, but is better done at a point about one and a 
 half inches above the tip of the malleolus in the adult, and 
 one inch in the child or infant. The tendon is made tense 
 by strongly abducting the foot, and the knife is passed 
 with the usual precautions between the posterior border of 
 the tibia and the tendon; the division is made by cutting 
 outward. 
 
 The section between the tip of the malleolus and the cal- 
 caneo-scaphoid articulation is not advised, on account of 
 the contiguity of the ankle-joint and the internal plantar 
 artery; if, however, it be thought advisable to operate at this 
 situation, the foot should be strongly abducted, and the 
 point of the tenotome carefully insinuated beneath the 
 tendon, and between it and the internal plantar artery; the 
 handle is then depressed so as to carry the point away from 
 the joint, and the section be made from within outward. 
 
 Flexor Longus Digito7-u7n. — The tendons of this muscle 
 are sometimes productive of contraction of the toes, after 
 the correction of the deformity of the tarsus caused by the 
 tibialis posticus. It lies immediately posterior to the ten- 
 don of the muscle, behind the internal malleolus, and is 
 often divided by the same cut which severs this tendon. 
 It can, however, be divided independently. 
 
 If, after the division of the posticus tendon, the influence 
 of the flexor longus digitorum be objectionable, it may be 
 divided by introducing the tenotome beneath it through 
 the same incision, and cutting towards the surface as be- 
 fore. The posterior tibial artery and its venae comites, 
 which in the adult are often varicose, in this situation must 
 be carefully avoided by pressing them outward with the 
 finger. If from contraction of the toes, unassociated with 
 deformity due to the tibialis posticus, it be deemed advis- 
 able to sever its tendon, the posterior tibial vessels must be 
 first detected, pushed outward by the thumb, which should 
 then be pressed firmly between them and the tendons at 
 the inner side; pass the tenotome perpendicularly through 
 the integument, midway between the posterior margin of 
 the tibia, and the end of the thumb; carefully insinuate it 
 between the tendons of the posticus and the flexor longus 
 
TENOTOMY. iS^ 
 
 digitorum down to the borie, turn the edge upward, and 
 carefully divide it towards the surface. 
 
 Flexor Longics Pollicis. — It may become necessary to 
 divide the tendon of this muscle, on account of the crippled 
 action of the foot in walking, dependent upon undue flex- 
 ion of the great toe. 
 
 The toe should be forcibly extended, and the knife care- 
 fully inserted beneath it at the point of its greatest promi- 
 nence, which will be at the anterior and inner side of the 
 foot. The instrument must always be passed from the 
 planter artery. 
 
 Tendo-Achillis is the most prominent tendon of the human 
 system, and is divided at its narrowest portion. The pos- 
 terior tibial artery is at the front and inner side, but suffi- 
 ciently remote to be secure, if ordinary care be exercised. 
 The short saphenous vein lies superficially and closely to 
 its outer border. 
 
 It can be readily divided if the foot be forcibly flexed, to 
 render it tense; pinch up the skin, push it outward to 
 protect the vein, enter the knife beneath it from within 
 outward, turn the edge towards the tendon and carefully 
 sever it with a sawing motion while the foot is firmly 
 flexed and the tendon pressed upon the edge of the knife 
 by the finger. Great care is necessary, else a sudden 
 giving away of the tendon may cause the knife to sever the 
 superimposed tissues. All the precautions enjoined in 
 tenotomy should be carefully observed in this instance. 
 
 Peroneus Lofigus and Brevis. — Their tendons pass in a 
 common groove behind the external malleolus, and are 
 enclosed by the same sheath; the latter being the most 
 anterior. It leaves its fellow after passing behind the 
 malleolus, and is inserted into the base of the metatarsal 
 bone of the little toe on the outer side. The longus, after 
 passing behind the malleolus, gains the sole of the foot, 
 enters the calcaneo-cuboid groove, and is inserted into the 
 base of the metatarsal bone of the great toe at its outer 
 side. The tendon of either may be divided in two situa- 
 tions: (i) About one and one half inches above the tip of 
 the malleolus: (2) three-fourths of an inch in front of it. 
 It is commonly divided in the first situation. They can be 
 severed connectedly or singly in either situation. 
 
 If it be decided to sever both simultaneously above the 
 malleolus, seek the anterior and external border of the 
 fibula, about an inch and a half above its tip, pass the knife 
 
186 OPERATIVE SURGERY. 
 
 between the bone and the tendons, turn the edge outward 
 and cut towards the surface. The short saphenous vein 
 should be pushed inward to avoid injury. 
 
 If either be divided separately, push the integument 
 backward with the thumb, to protect the vein, then push 
 the thumb firmly down to the bone behind the tendons; 
 pass the tenotome perpendicularly midway between the 
 end of the thumb and the external border of the fibula, 
 carefully insinuate it between the tendons, after which it is 
 passed outward or inward, as the case may be, beneath 
 the tendon to be severed, the edge turned upward, and 
 the division made as in the preceding instances. 
 
 If the division be made below the malleolus, make the 
 tendons tense, enter the knife about one half or three 
 fourths of an inch in front of the tip of the malleolus, be- 
 tween the tendons, when either or both may be divided. 
 
 Tibialis Afiticus. — This muscle, like the posticus, is of im- 
 portance in connection with the deformity of talipes varus. 
 
 It is the innermost tendon of the leg and foot on its 
 anterior surface, and can be easily outlined unless the foot 
 be fat and chubby, when some difficulty may be experi- 
 enced. 
 
 In well-marked cases of talipes varus it is displaced con- 
 siderably to the inner side, and if the foot be abducted 
 will become quite prominent. It is best divided about one 
 inch above its insertion into the internal cuneiform bone. 
 Make the tendon tense, pass the knife from without inward, 
 to avoid the dorsalis pedis artery. 
 
 Extensor PropriusPollicis. — As it passes across the dorsum 
 of the foot, it can, like the preceding, be quite easily dis- 
 tinguished. It may become necessary to divide it after the 
 division of the extensors of the tarsus, on account of its 
 causing undue extension of the great toe. The toe should 
 be forcibly flexed, and the tenotome carried beneath it from 
 without inward, to avoid the dorsalis pedis vessels. 
 
 Extensor Longiis Digitorum. — The tendons of this muscle 
 may not only cause an obstinate extension of the toes, but 
 aid in maintaining the tarsus in a state of forced flexion. 
 They can be divided separately, as they pass along the 
 dorsum of the foot, provided either require it. If all be 
 cut at once, it is done by flexing the toes, entering the 
 knife beneath them, a little below the bend of the ankle, 
 from within outward, to avoid the dorsalis pedis vessels. 
 
 JPeroneus Tertius. — This ma}' be divided along with the 
 
TENOTOMY. 187 
 
 extensor longus digitorum, of which it is a part, as before 
 described; or it can be done separately before its insertion 
 into the dorsum of the metatarsal bone of the little toe, by 
 extending the tarsus, and passing the knife beneath it, 
 from without inward. It is the most external tendon on 
 the dorsum of the foot, ir front of the external malleolus. 
 
 Biceps of the Leg. — This tendon forms the external ham- 
 string, and is inserted into the head of the fibula and 
 tuberosity of tibia. The external popliteal nerve is located 
 immediately at the inner side. To divide it, the leg should 
 be extended, and the tenatome passed from within out- 
 ward, beneath the tendon about an inch and a half above 
 the head of the fibula. 
 
 The inner hamstring tendons are the semi-tendinosis, semi-inem- 
 branosus, gracilis, and sartorius; the two first, however, are 
 the ones principally concerned. The tendon of the semi- 
 tendinosus is felt as the longest, smallest, and nearest to 
 the median line of the popliteal space; that of the semi- 
 membranosus is internal to it, somewhat less superficial, 
 and runs parallel with it. Either of these tendons can be 
 divided by extending the leg to make it tense, and entering 
 the knife beneath and from the outer side, at the most 
 prominent portion, and cutting towards the surface. Their 
 division to relieve forced flexion will not always admit of 
 complete extension, due, among other things, to the con- 
 traction of the heads of the gastrocnemius, which are in- 
 serted into the condyles of the femur. The forced extension 
 of the leg under these circumstances, often causes a tearing 
 asunder of the attachments of this muscle, especially the 
 inner head, which is larger, stronger, and inserted higher 
 than the external. The hemorrhage resulting therefrom 
 may be severe enough to infiltrate the calf of the limb, even 
 extending througliout the popliteal space. The liability to 
 this rupture and consequent bleeding may be lessened, if 
 not obviated, by first dividing the tendo-Achillis; or, which 
 is perhaps better, by first dividing the hamstring tendons, 
 when, if the foot becomes extended, on attempting to 
 straighten the limb, the tendo-Achillis can then be divided. 
 
 The Gracilis and Sartorius. — They may be divided, after 
 forcible extension of the leg. Pass the tenotome close at 
 the inner side of the tendon of the semi-membranosus, 
 between it and the gracilis, depress the handle outwards or 
 inwards as the case may be and divide these structures 
 towards the skin. 
 
1§8 OPERATIVE SijilGERY. 
 
 Quadriceps Extensor Tendon may be divided above the 
 patella, by making an incision down to the tendon and 
 parallel with it, entering the point of the knife above it, 
 cautiously and with a sawing motion divide the tendon. 
 A careful and continuous attempt should be made to flex 
 the leg while the tendon is being cut, that its deepest 
 fibres may be ruptured, thus avoiding the possibility of 
 entering the synovial extension of the knee-joint, which lies 
 beneath it. However, the limb should not be flexed fur- 
 ther than is necessary for this purpose, and after the divi- 
 sion should be placed in a comfortable position till repair 
 is well advanced. 
 
 Pectineus. — This muscle, which acts as a flexor and 
 adductor of the thigh, may require division on account of 
 malposition of the limb. The pelvis is steadied, thigh ex- 
 tended and adducted, which causes the fibres to become 
 tense and prominent. A long-bladed tenotome is then 
 introduced at the outer border, about an inch below its 
 origin, and carried inward and upward, till the division 
 is complete. The internal circumflex artery, which runs 
 between the psoas magnus and the outer border of the 
 pectineus, is the only vessel of any size exposed to injury. 
 The danger to this is obscure, unless it arises higher than 
 usual. 
 
 Adductor Longus is situated further to the inner side of 
 the thigh than the preceding, forming the inner border of 
 Scarpa's triangle. It is, however, located on about the same 
 plane as the pectineus. It is tendinous at its origin from 
 the pubes, and can be easily divided, when made tense, 
 by passing the knife beneath its outer border, and cutting 
 upward and inward. 
 
 Tensor Vagince Femoris can be severed without difficulty, 
 by introducing a long-bladed tenotome beneath it, from 
 either border of the muscle, about an inch below its origin, 
 and cutting towards the surface. 
 
 Sartorius forms the outer boundary of Scarpa's triangle, 
 and can be divided by making its fibres tense, by strong 
 abduction ; then introducing a long tenotome beneath it, 
 by way of its anterior border, two or three inches from its 
 origin, and cutting upward towards the surface. 
 
 Multifidus Spince. lies on either side of the spinous pro- 
 cesses, in the groove formed by the spines and transverse 
 processes, from the sacrum to the axis. It is quite super- 
 ficial i/i the sajcral, region, opposite to the posterior superior 
 
TENOTOMY. 189 
 
 Spinous process of the ilium. Raise a fold of skin parallel 
 with the long axis of the muscle; pass a long-bladed teno- 
 tome from the spine outward to the outer border of the 
 muscle, and cut towards the spine. 
 
 Erector spines forms the principal portion of the muscular 
 prominences on either s'de of the spine, to be seen in the 
 lumbar region. It is a thick, strong muscle, which arises 
 from the sacrum and contiguous structures, and divides at 
 the lower border of the last rib, into the longissimus-dorsi 
 and sacro-lumbalis, which are inserted into the angle of the 
 ribs and the transverse processes of the dorsal vertebrae. 
 The^erector-spinae can be divided by a long tenotome passed 
 from within outward, to the outer border of the muscle, 
 just below the last rib, and carried downward and in- 
 ward towards the spine. 
 
 Trapezius. — This is a muscle possessing an extensive ori- 
 gin. The portion which arises from the inner third of the 
 superior curved line of the occipital bone is often divided, 
 on account of deviations of the head. 
 
 This is readily accomplished by making the muscle 
 tense, and severing it with a tenotome entered beneath it, 
 and below the occipital protuberance; the edge turned to- 
 wards the integument. 
 
 Sterno-cleido-mastoid. — Division of this muscle is often 
 necessary in cases of wry neck, dependent upon abnormal 
 muscular force. It is divided at its lower extremity, either 
 at its sternal or its clavicular attachment; often at both. 
 For the division at either, the muscle is put on the stretch 
 by turning the head, and a blunt-pointed tenotome passed 
 beneath it from the outer side, about a half inch above its 
 insertion, and divided towards the surface. The division 
 of the clavicular portion may be ample to correct the de- 
 formity; if not, the sternal portion should be severed in 
 the same manner. It is necessary to closely hug the under 
 surface of the portions to be divided, else the deep seated 
 and important vessels may be injured. It is not safe to 
 attempt a subcutaneous section of the muscle above this 
 point, on account of its relation to the common carotid 
 artery, and the internal jugular vein. 
 
 Plantar Fascia. — This tissue is an exceedingly dense, 
 white fibrous membrane of great strength, with the fibres 
 arranged longitudinally. It is divided into three portions: 
 the middle and two lateral. The former is the one 
 especially concerned in those deformities requiring division. 
 
tQO OPERATIVE SURGERY. 
 
 It is narrow behind and attached to the inner turbercle of 
 the os-calcis. Broader and thinner in front, and divides 
 into five processes opposite the middle of the metatarsal 
 bones; being one for each of the toes. Each of these pro- 
 cesses divide opposite the metatarso- phalangeal articula- 
 tions into tw^o slips, which embrace the sides of the flexor 
 tendons, and are inserted into the sides of the metatarsal 
 bones and the transverse ligament. It likewise sends pro- 
 longations between the groups of the plantar muscles. 
 This fascia serves the important function of assisting in 
 maintaining the integrity of the plantar arch. 
 
 It is divided by placing it upon the stretch, and passing 
 a tenotome beneath the inner border of the most prominent 
 portion, and cutting towards the sole. The deformity is 
 then overcome as much as is practicable; and the foot is 
 placed and fixed in the corrected position. 
 
 Palmar Fascia. — Like the plantar fascia, this is divided 
 into three portions: two outer and a middle part; the mid- 
 dle division being the one of special significance. It is 
 narrow above, and attached to the lower border of the an- 
 nular ligament; below it is broad and thinner, and opposite 
 the heads of the metacarpal bones divides into four slips, 
 one for each finger. Each slip subsequently subdivides into 
 two processes, which enclose the tendons of the flexor mus- 
 cles, and are attached to the sides of the first phalanx, and 
 to the glenoid ligament. This fascia is intimately con- 
 nected with the integument of the palm, and sends vertical 
 septa between its muscles. From various causes it may 
 undergo structural changes, which result in contractions of 
 the fingers on the palm, as well as shortening of the palm 
 itself. The anatomical arrangement of the fascia fully ex- 
 plains the mechanism of the deformity. It must be care- 
 fully diagnosticated from paralysis of the extensors, also, 
 contraction of the common flexors. The contracted bands 
 are divided, by placing them on the stretch, and passing a 
 narrow bladed tenotome beneath, and cutting towards the 
 surface. The deformity is then reduced, and the rectified 
 part placed in a fixed position until danger of inflamma- 
 tion has subsided. 
 
 The fascia in other situations may become contracted, 
 as the fascia lata, at its upper or lower extremities. When- 
 ever these contractions -cause a persistent deformity they 
 should be divided, and upon the same principles as like 
 tissues in other portions of the body. The employment of 
 
OPERATIONS ON BONES. I9I 
 
 an anaesthetic is advisable in tenotomy, especially when 
 the section is to be extensive or contiguous to important 
 structures. 
 
 OPERATIONS ON BONES. 
 
 The injuries and diseases to which bones are liable, al- 
 though not differing in any essential particular from the 
 same conditions, when occurring to the soft parts, require 
 an independent consideration, on account of their dissimi- 
 larity of function and structure. Tendons, muscles, nerves, 
 and fascia are divided and resected; so is bone. The in- 
 tegument and soft parts generally, become the seat of 
 inflammation, ulceration, and gangrene. Bony tissue is 
 likewise preyed upon by the same morbid processes; 
 named, however, quite differently: ulceration of the soft 
 parts being comparable to caries of bone; necrosis of bone 
 finds its synonym in gangrene of soft parts. To preserve 
 the function of a tissue unimpaired, is the greatest 'end that 
 can be attained. To relieve a patient of the local effects of 
 an injury, or disease, and keep him in possession of his 
 natural endowments, constitutes conservative surgery in 
 its fullest sense. 
 
 The functions of bones being, in a practical sense, to sup- 
 port the body, protect important organs, and act as levers 
 for purposes of prehension and locomotion, we have but 
 to act with a knowledge of these facts, and of the methods 
 to maintain them, to give to the patient the full benefit of 
 our art. 
 
 The operations upon bone are denominated, gouging, 
 sequestrotomy, exsection, osteotomy, and osteoplasty. 
 
 Gouging is applied to the removal of carious bone, and 
 should not be attempted until the process has become 
 chronic. 
 
 The instriimenfs required to meet the exigencies of a case 
 are gouges (Figs. 189^;, 190, 191, and 192), scoops, and 
 chisels (see Figs. 180, iSi, 182, and 183), of various sizes 
 and shapes, together with a suitable mallet. 
 
 Operation. — Having arranged the patient suitably for the 
 convenience of the operator, administer an ansesthetic, ap- 
 ply the elastic bandage, carrying it lightly over the site of 
 
tgi 
 
 OPERAtiVE SURGERY; 
 
 the disease, make a free incision down upon the carious 
 bone, separate the soft parts with retractors; and, with the 
 drills, gouge, etc., remove all the diseased structure. 
 
 It is important to be able to determine the line between 
 the healthy and diseased bone; and this is often very diffi- 
 cult. If the portions removed, when washed, present a 
 
 m 
 
 Fig. 
 
 Fig. igo. 
 
 Fig. 191. 
 
 Fig. 192. 
 
 whitish, grayish, or blackish appearance; are porous and 
 fragile, instead of being vascular, red, and tough, then the 
 operation should be continued. If the gouged surfaces 
 bleed freely from numerous points, and have a normal 
 firmness and color, then the operation should cease. 
 
 It is important in gouging the extremities of bones to 
 use extreme caution, or the joint cavity may be opened 
 
SEQUESTROTOMY. 
 
 193 
 
 directly, or become secondarily involved. After the re- 
 moval of the elastic constriction, all bleeding should be 
 stopped; the wound washed thoroughly with a suitable an- 
 tiseptic solution, good drainage secured, the parts united, 
 and dressed antiseptically. 
 
 SEQUESTROTOMY. 
 
 This operation is employed to remove dead bone en masse, 
 therefore applicable to necrosis. The additional instru- 
 ments necessary, are small crowned trephines, bone-cutting 
 forceps of various shapes (Figs. 193, 194 and 195), gnawing 
 
 Fig. 194. 
 
 Fig. 195. 
 
 Fig. X93. 
 
 forceps, small saws, (Figs. 196 and 197), periosteal elevator, 
 (Fig. 198), etc. There are two methods employed, depend- 
 ing on the nature of the case, viz.: direct and indirect. 
 The Direct. — Having detected the situation of necrosed 
 
194 
 
 OPERATIVE SURGERY. 
 
 bone, and being satisfied, either from the long course of 
 the disease, or by movement of the dead portion, that de- 
 tachment has occurred, apply the elastic bandage, using 
 care not to force deleterious matters into the circulation, 
 select a strong knife (Fig. 199), and connect the fistulous 
 openings with each other, down to the bone; selecting such 
 openings, of course, as will cause the connecting incision to 
 be consistent with good drainage, easy access to the dis- 
 
 ^^^j^^m^smmss^^^^^^l^z 
 
 .t.UAAMATHUMIAn/wiMUUUMMJtl 
 
 ifllUt>UVMII 11^ 
 
 Fig. 197. 
 
 Fig. 198. 
 
 Fig. 196. 
 
 eased parts, and safety to the underlying structures. The 
 surfaces of the incision should now be separated with re- 
 tractors, to fully expose the openings in the involucrum 
 (Fig. 200). If the sequestrum can be drawn out of the 
 opening with suitable forceps, it should be done carefully; 
 otherwise the reparative tissue upon which it rests will be 
 injured, and the process of recovery deterred. If it be too 
 large, or be interlocked with healthy bone, the opening 
 m Jst be enlarged sufficiently to admit of its withdrawal; or^ 
 
SEQUESTROTOMY. 
 
 195 
 
 if this be impracticable, an incision through the periosteum 
 should be made, corresponding to the long axis of the 
 sequestrum. The periosteum should be carefully raised 
 upon either side of the incision sufficiently to permit the 
 application of a small crowned trephine, with which the in- 
 volucrum should be perforated a sufficient number of times, 
 to admit the easy removal of the dead portion; either with 
 or without the chiselling away of the irregular borders. 
 The gnawing forceps (see Fig. 179), chisels, and mallet, 
 
 Fig. 199. 
 
 Fig. 199a. 
 
 Fig. 20a 
 
 and even the small saws may be used in lieu of, or in con- 
 junction with the trephine. 
 
 If there be but one sinus, and evidences of disease exist 
 above and below it, the centre of the incision should corre- 
 spond to the sinus, if the anatomical relations will admit of 
 it. Much caution is often essential in making these in- 
 cisions in the vicinity of joints, or their synovial pouches 
 will be opened. After the removal of the dead bone, the 
 wound, through its whole extent, should be thoroughly 
 cleansed, suitable drainage provided, the lips of the wound 
 closed, and antiseptic dressing applied; or, after washing it 
 can be lightly filled with oakum saturated with balsam of 
 
196 OPERATIVE SURGERY. 
 
 Peru, or carbolic acid and oil, and the whole confined in 
 place by a mass of carbolized oakum, held in position by a 
 roller bandage. In the latter instance it should be dressed 
 frequently to secure proper cleanliness. If the antiseptic 
 plan be employed, the rules applicable to the method should 
 be carried out. When the portion of bone removed is large, 
 or the remaining part is small and fragile, the limb must 
 always be supported by a splint; otherwise it may bend or 
 break, and thereby complicate the ultimate prognosis. 
 
 If the sequestrum be as yet unseparated from the healthy 
 bone, it should be allowed to remain until the process of 
 separation is completed, when it can be removed. 
 
 The ifidirect method is preferable when the bone is super- 
 ficial and its disease progressive, as in periostitis of the 
 lower jaw, clavicle, bones of the arm, forearm or tibia; 
 in fact, all the long and many of the flat bones can be re- 
 produced by this method. It consists in making a free 
 incision down upon the diseased bone, through the sur- 
 rounding periosteum, and separating the membrane by 
 means of the handle of a scalpel, spatula, periosteal ele- 
 vator, or any instrument of a like character. This must 
 be done at intervals, and not extend beyond the diseased 
 portion; the length of the intervals will depend entirely 
 upon the rapidity of the morbid process. This plan is neces- 
 sarily tedious, both in detail and in time; yet sooner or 
 later the dead bone can be raised from its new osseous 
 trough, which will soon become filled, and serve the pur- 
 poses of its predecessor. The free incision necessary to 
 expose the dying bone will provide good drainage; other 
 than this, it should be kept clean by ordinary means. 
 
 Excision. — Excision of bone is a conservative operation, 
 directed to the extraction of such portions of it as are 
 inconsistent with its future usefulness or the symmetry of 
 the patient, together with the removal of the condition 
 directly demanding the operation. It is employed in lieu 
 of the more radical measure — amputation. It may be 
 directed to the articular extremities or to the shaft of a 
 bone; and, in either instance, it vn.Q.y he partial or co7njlete. 
 The articular extremities or joints are excised on account 
 of injury, disease, or anchylosis in a faulty position. In 
 estimating the prognosis for life, the surroundings of the 
 patient, his previous habits, present condition, and the ex- 
 istence of constitutional taints, must be considered; also, the 
 nature and extent of the cause demanding it. The prospec- 
 
EXCISION OF BONES. I97 
 
 tive usefulness of the limb will depend on the ability to 
 leave the muscular attachments intact; also the condition 
 of the nerv-es that animate, and the blood-vessels that nour- 
 ish them. If the patient be a manual laborer, or be one over- 
 sensitive of a deformity, it is well then to consider if ad- 
 ditional advantages can be derived from artificial limbs 
 and appliances; when, it may be deemed the wiser to rele- 
 gate the offending member to the relief afforded by amputa- 
 tion. The incision preparatory to the necessary exposure of 
 the parts to be removed should be free, and, when possible, 
 be made in the long axis of the bone. They are often, how- 
 ever, varied, to suit the peculiar demands of the individual 
 cases. They are likewise varied for the different joints, 
 being in one instance longitudinal, in another U, H, or - 
 
 shaped, according to the proposed extent of the operation 
 and the contiguous anatomy of the part. In every instance, 
 however, they should be made with view to good drainage, 
 when the same incision will render the parts accessible, and 
 not expose adjacent important structures to unwarranted 
 danger. The future usefulness being one of the most im- 
 portant factors to be gained, the insertion of all muscles, 
 having especially defined functions, as fiexion or extension, 
 must be religiously respected. If it be necessary to divide 
 tendons, it should be done obliquely; the better to facil- 
 itate subsequent union. If it be necessary to remove 
 the bony surfaces, into which they, or the ligaments are in- 
 serted, the periosteum covering these surfaces should be 
 carefully peeled off, along with the tendinous attachments. 
 All diseased and loose pieces of bone should be removed, 
 together with irregularities and isolated portions of artic- 
 ular cartilages. The synovial membrane should be pre- 
 served, unless it be diseased; and its diseased portions be 
 cut or scraped off. The removal of the entire shaft of a 
 bone may be necessary on account of injury or disease, 
 notably the latter. In such cases the incision should be a 
 •free one, and be made over its most superficial aspect, pro- 
 vided that important structures do not intervene ; the 
 periosteum is then removed proportionately to the extent 
 of the disease, gradually or rapidly, as the circumstances 
 indicate, and the diseased bone removed, leaving, if pos- 
 sible, the epiphyseal extremities. If the epiphyseal carti- 
 lage be destroyed the growth of the bone in its long axis 
 will be interrupted. This is very important to observe in 
 operations upon the bones of adolescents, since to destroy 
 
198 
 
 OPERATIVE SURGERY. 
 
 this cartilage will cause a subsequent shortening of the 
 limb. The consultation of any standard work on anatomy 
 will enable the surgeon not only to accurately locate the 
 epiphyseal junctions, but likewise inform him of the age at 
 which the shafts become united to their epiphyses. 
 
 The tt?ne of operating must be governed by the condition 
 of the patient, and also the part to be operated upon. If 
 the patient be suffering from shock, reaction should take 
 place prior to operative interference. If inflammation of 
 the bone occurs, good drainage should be established, and 
 the operation deferred until it subsides. If for necrosis, the 
 diseased bone should have separated before the attempt is 
 made. 
 
 The instruments required for resection are varied in num- 
 ber and shape, and must be selected according to the 
 peculiarity of the case. The knives should be broad and 
 strong (see Fig. 199). The retractors (see 
 Fig. 200) must likewise be strong and pos- 
 sess a hook-like curve, otherwise they will 
 slip from the wound. A sharp-pointed one 
 may be employed (Fig. 201). The peri- 
 osteotome, or elevators (Fig. 202), vary in 
 shape; but should possess a blunt, non- 
 cutting edge; if compactness be desired, it 
 may be connected with the handle of the 
 knife (see Fig. 1991a!). However, it is not so 
 handy or efficient as the independent in- 
 strument. They must be used with care, 
 otherwise the function of the periosteum 
 will be destroyed, and may even be fol- 
 lowed by sloughing. The bone-cutting in- 
 struments are forceps, saws of various sizes 
 and shapes. The straight bone forceps are 
 the most available for general purposes. 
 The blades should fit accurately, and be 
 sufficiently sharp to make as clean a cut as 
 possible. In order that bone intricately 
 located may be reached, the blades are 
 bent at various angles. The gnawing for- 
 ceps or ronguer are of inestimable value in removing bony 
 projections. 
 
 Bone-holding Forceps (Fig. 203) vary much in their grasp- 
 ing and holding powers; consequently, the surgeon will 
 be governed in his selection of an instrument by its 
 
 Fig. 201. Fig. 202. 
 
EXCISION OF BONES. 
 
 199 
 
 w. r. roPvD 
 
 Fig. 206. 
 
200 
 
 OPERATIVE SURGERY. 
 
 suitability for the purpose. The varieties of saws are 
 numerous, among which are the chain saw (Fig. 204V 
 the straight saw, with an adjustable back (Fig. 206); 
 and the curved, for right and left 
 sawing. These are of use in re- 
 moving portions of thin bones from 
 fiat surfaces. The chain saw, as 
 the name indicates, is composed of 
 numerous links or sections, having 
 attached to each extremity a han- 
 dle for working it. To apply the 
 saw, remove the handle from the 
 hooks and carry it beneath the 
 bone by means of a thread and 
 curved needle, with the cutting 
 edge upward, or an instrument 
 known as the " chain-saw carrier" 
 may be employed instead (Fig. 
 205), readjust the handle, and draw 
 it from side to side at an angle of 
 about 45° with the bone. It should 
 not be jerked, or be allowed to 
 kink, for fear of clamping or 
 breaking it. This instrument is 
 employed in dividing those bones 
 which are nearly surrounded by 
 the soft parts. Fig. 207 repre- 
 sents a saw of great practical 
 worth. The blade is adjustable, 
 and its cutting surface can bte 
 turned in any direction ; it has 
 therefore a universal application, 
 which renders it superior to the 
 chain saw, except in isolated 
 cases. The gauges, chisels, and 
 mallet are required to thoroughly 
 remove all diseased bone. They 
 vary in size and shape, in order 
 that the intricacies of the wound 
 may be reached. The instru- 
 ments to seize the fragments of 
 bone are also variously turned, to be better able to grasp 
 them. 
 
 Treatment of excision wounds is in nearly all instances 
 
 Fig. 207. 
 
EXCISION OF BONES. 20l 
 
 substantially the same. Rest and thorough drainage, to- 
 gether with strict antiseptic measures, constitute the basis 
 of the future treatment. Rest can be secured by the various 
 forms of splints, either movable or immovable in character. 
 The common dressing of the wound consists of oakum, 
 lint, marine lint, or a fin-^ silken oakum, either with or with- 
 out saturation with carbolic acid and oil, or balsam of 
 •Peru. The wounds should be dressed with sufficient fre- 
 quency to prevent any septic infection, once daily being 
 usually enough. If the antiseptic methods be adopted, the 
 rules governing their readjustment should be enforced. 
 
 Excision of the Upper Jaw. — This operation is done for 
 various purposes, connected either with the bone structure 
 itself or the cavities with which it is associated. In all 
 instances the periosteum should be preserved, except in 
 such as are associated with malignant diseases. 
 
 The special instruments requisite, in addition to those al- 
 ready enumerated for exsections, are a trephine, or a bone 
 drill and a strong pair of forceps to turn out the bone, to- 
 gether with forceps to draw the teeth in the line of section. 
 The patient is anaesthetized and placed upon the back, 
 either with the head slightly raised or markedly depressed. 
 In the latter the blood does not escape into the larynx, but 
 into the upper and posterior part of the pharynx. This 
 position, however, impedes respiration by undue stretching 
 of the tissues of the anterior cervical region. However, 
 this may be obviated in a great degree, if the front of the 
 table be raised, as in the reduction of the abdominal con- 
 tents by taxis. If the head be elevated, the blood can, with 
 care, be kept from the larynx, either by constant sponging 
 or tamponning the pharynx around a large catheter or 
 rubber tube, or allowing the patient sufficient consciousness 
 to dislodge it. Still another method is to confine the pa- 
 tient in a rocking-chair, which can be tipped forward or 
 backward as circumstances require. The surest of all is to 
 perform a preliminary tracheotomy, and then close the floor 
 of the pharynx. This is not as a rule necessary, unless the 
 operation be complicated with a very vascular morbid pro- 
 cess requiring a separate removal. If the important asso- 
 ciated anatomy be carefully considered before beginning 
 the operation, it will save much time and not a little amount 
 of blood. 
 
 In complete removal, the bony connections which must 
 be divided are: i. With the malar, below the outer angle of 
 
202 
 
 OPERATIVE SURGERY. 
 
 the orbit; 2. with the fellow of the opposite in the roof of 
 the mouth; 3. the nasal process of the bone, with its body 
 below the inner angle of the orbit; 4. the slight connection 
 between it and the palate bone and pterygoid processes of 
 the sphenoid. The internal maxillary in the spheno-maxil- 
 lary fossa and the branches of the facial running through 
 the external soft parts are the only vessels that will cause 
 troublesome hemorrhage. Steno's duct must be avoided, 
 as it runs from the parotid gland to empty into the mouth 
 opposite to the second molar tooth, on a line extending 
 
 Fig. 208. 
 
 from the lobe of the ear to midway between the border of 
 the lip and the ala of the nose. The superior branches of 
 the seventh pair may be divided unnecessarily, if the course 
 or extent of the incisions be too great. No anticipated 
 complication should be permitted to occur. Loss of blood, 
 however, is the only one outside the common shock of all 
 operations that requires close attention. Haemorrhage from 
 the facial and internal maxillary, while often profuse, can 
 be easily controlled. 
 
 The Lines of hicision. — They may be made within or 
 without the buccal cavity. 
 
EXCISION OF BONES. 203 
 
 To attempt the removal from within is too tedious, the 
 room being limited and the ability to control hemorrhage 
 entirely inadequate. At the present time the external in- 
 cisions are the only practical ones. These can be classed 
 as outer and median. The former commencing at the 
 angle of the mouth and prssing in a curved course upward 
 and outward to the malar process; this exposes Steno's 
 duct and the branches of the seventh nerve to injury, and 
 is followed by a conspicuous scar (Fig. 208, A). The lat- 
 ter is made at the middle of the: upper lip, and following 
 the furrows between the cheek and nose, terminates about 
 one half an inch below the inner angle of the eye (B). To 
 this may be added an incision of an inch or so in length, 
 extending outward half an inch below the orbit, and at a 
 right angle with the vertical one. In this incision the 
 coronary and angular arteries only are divided. 
 
 Operation by tJie median incision, with removal of the whole 
 bone. The middle incisor tooth corresponding to the side 
 to be operated upon is drawn, and the facial artery com- 
 pressed on both sides by an assistant. The incision is 
 begun at the border of the lip, but not carried through it 
 until later, to prevent blood entering the mouth; from the 
 upper attachment of the lip, through the remainder of the 
 course, the incision is rapidly made down to the bone, and 
 the flap dissected outward as far as the malar bone above, and 
 the tuberosity of the maxilla below; during the dissection 
 the bleeding points are controlled by the fingers of the as- 
 sistant or by the serrefine forceps. They should be ligated 
 with catgut before the bone is moved. The cartilage 
 of the 7wse is separated from the bone and turned in- 
 ward, the edge of the orbit gained, and the periosteum on 
 the floor separated, and pushed backward and upward by 
 means of an elevator or handle of a scalpel to the border 
 of the spheno-maxillary fissure. The malar process is now 
 divided by sawing, or cutting through it with bone forceps, 
 from the outer extremity of the spheno-maxillary fissure. 
 The thin floor of the orbit is divided with a scalpel from 
 the spheno-maxillary fissure obliquely forward and in- 
 ward, and the nasal process severed with forceps. The 
 mucous membrane of the roof of the mouth is then divided 
 transversely from the centre inward, on a line with the 
 last molar tooth, then from the centre forward, in the median 
 line, to the incisor teeth. The hard palate is divided at the 
 side of the septum, corresponding to the bone to be removed, 
 
204 OPERATIVE SURGERY. 
 
 by a saw or bone forceps, and the bone seized and pressed 
 downward to break up its posterior connections, after which 
 it is raised and twisted slightly from side to side and pulled 
 out, bringing with it some portix)ns of the palate and ptery- 
 goid process of the sphenoid, together with the muscular 
 fibres connected with them. If the mucous membrane of 
 the mouth be not diseased, it can be saved by making an 
 incision through it along the alveolar border, and pushing 
 it inward along with the periosteum to the median line. 
 After the removal of the bone it can be stitched to the side 
 of the cheeks. 
 
 JExsection Below the Floor of the Orbit. — After the exposure 
 of the external surface of the superior maxilla, as in the pre- 
 ceding method, perforate the anterior wall of the antrum 
 with a drill or trephine; then with the bone forceps or saw 
 inserted into the opening, divide the bone through into the 
 nasal fossa, and separate it from its outer connections by 
 sawing or cutting through the malar bone. Aside from 
 this the steps of both are similar. 
 
 After the operation, the wound is washed with carbolic 
 acid, and all bleeding points checked either by ligature, 
 pressure, or cauter}^, the former being the best. The ex- 
 ternal incision is then closed with sutures, or pins, and 
 readily unites in three or four days. The raw surfaces 
 within should be kept thoroughly cleansed while repair is 
 taking place. These cases make a satisfactory recovery 
 from the operation, although some deformity will remain. 
 
 The stitches are removed from the soft parts the third or 
 fourth day, union, as a rule, being complete. The results 
 of this operation are good, so far as immediate loss of life 
 is concerned. About one in six or seven will perish. If 
 the removal be done for malignant growths, the prognosis 
 for ultimate recovery is unfavorable. 
 
 Subperiosteal Excision. — This can be done with any of 
 the median incisions, but an external one is preferred by 
 some (Fig. 209). The external 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. It is some- 
 times necessary to make a second cut from the middle 
 of the lip upward, as in the preceding operation. The 
 mucous membrane on the external surface of the alveolar 
 process is divided down to the bone: beginning at the line 
 of junction between the lateral incisor and canine teeth 
 and carried backward to and around the posterior molaf 
 
EXCISION OF BONES. 
 
 205 
 
 to the inner surface of the alveolar process, forward paral- 
 lel with the external incision to a point opposite the com- 
 mencement of the external, then obliquely backward and 
 inward on a line corresponding to the intermaxillary su- 
 ture of that side to the median line. The anterior extremi- 
 ties of the external and internal incisions are now connected 
 to each other by a transverse one, carried on a line extend- 
 ing between the lateral incisor and canine teeth. The 
 periosteum is then peeled of the external and orbital sur- 
 faces of the bone, and also from the inner surfaces of the 
 alveolar process, and the hard palate of that side. The 
 
 Fig. 209. 
 
 nasal and malar processes are divided as before, the canine 
 tooth drawn, and the intermaxillary bone separated, to- 
 gether with the hard palate of the maxilla to be removed, 
 from the contiguous bone, by a chisel, saw, or forceps. 
 The maxilla is then twisted out, and the periosteum from 
 the inner and outer surfaces of the alveolar process united. 
 The superior maxillcz may be removed simultaneously by either 
 of two methods, i. Make an incision from each angle of 
 the mouth to the middle of the malar bone on the re- 
 spective sides (Fig. 210, A), and dissect upward the in- 
 
2o6 
 
 OPERATIVE SURGERY. 
 
 tervening flaps; or, 2, make a vertical one along the ridge 
 of the nose through the lip, beginning at a point one fourth 
 of an inch below the lower border of the orbit. To this 
 maybe added a transverse one extending between the mid- 
 dle of each orbit, one fourth of an inch below it, across the 
 upper end of the vertical one, B; the outer bony attachments 
 are divided as in the single operation; the nasal processes 
 are divided either by forceps or the saw, and both bones 
 removed at once — not separately. About fifty per cent of 
 those perish from whom both bones are removed simul- 
 
 FlG. 
 
 taneously. In all operations for the complete removal, the 
 superior maxillary nerve should be divided as far back as 
 possible. 
 
 Excision of the Inferior Maxilla. — The operations on the 
 lower jaw require no additional instruments, and the pre- 
 cautions referrible to the patient in the former case are 
 almost equal in importance in this, and the contiguous 
 anatomy is even greater. The facial artery runs beneath 
 and across its lower border and outer surface at the ante- 
 
EXCISION OF BONES. 20^ 
 
 rlor border of the masseter muscle; the parotid gland lies 
 behind the ramus, and often sometimes overrides it. The 
 external carotid artery, as it passes through the gland, is 
 closely associated with its posterior border. The internal 
 maxillary artery passes closely behind and to the inner 
 side of the neck of the condyle. The inferior dental artery 
 runs along the inner surface of the ramus to enter its canal. 
 The superior division of the seventh pair of nerves pass 
 across the outer border of the neck of the condyle. Steno's 
 duct passes across the masseter muscle to the opening op- 
 posite the second molar tooth, on a line parallel with and a 
 half inch below its lower border. The lingual nerve runs 
 along the inner surface of the ramus, close to the bone just 
 below the last molar tooth. 
 
 The genio-hyo-glossus muscle is attached to the superior 
 genial tubercles, and if incautiously detached will permit 
 the tongue to fall backward, and close the glottis. It is very 
 important, when possible, to respect the attachments of the 
 muscles of mastication, on account of their action on the 
 resultant tissues. The operation may be directed to a com- 
 plete or partial removal of the bone. A partial removal 
 may include any fractional portion of it. 
 
 The incisions for the removal may be made within the 
 mouth or on the external surface. If the whole or a lateral 
 half be removed, an external incision must be made. The 
 portion in front of the molar teeth, and even in front of the" 
 ramus, can be excised by internal incisions alone; the latter 
 is, however, often attended by vexatious difficulties, and is 
 hardly warrantable, except in isolated cases. The ramus 
 and portions of the body behind the teeth can be removed 
 through an external incision without opening into the 
 buccal cavity, provided the periosteum be carefully raised 
 from its surface. In the same manner the body, or any 
 portion of it, can be taken away if the teeth be absent. If 
 the teeth be present, the periosteum may be carefully de- 
 tached and the bone with the teeth removed; after which 
 the openings into the buccal cavity, caused by the with- 
 drawal of the teeth, can be closed with sutures applied in- 
 ternally. If the jaw be suffering from phosphorous or a 
 similar necrosis, it may be gradually enucleated by the in- 
 direct method, through an external opening, from its 
 surrounding involucrum, and the teeth may even remain 
 in the new growth. Unfortunately, however, when pro- 
 cesses of a malignant nature call for the operation, these 
 
208 OPERATIVE SURCERY. 
 
 conservative methods are of no avail, since the Operation 
 must be directed to the removal of all the diseased tissues. 
 When possible, the incisions in the buccal lining should 
 be closed and the wound drained externally. This will 
 keep the wound clean and prevent swallowing of the dis- 
 charges. 
 
 Excision of the Central Portion. — Pass a stout ligature 
 through the tongue well behind its tip, to prevent tearing 
 out, and tie the ends to form a loop, which will be conven- 
 ient for holding it. The assistant stands behind the head 
 of the patient, holds it firmly, at the same time compressing 
 the facial arteries wher^ they pass across the jaw; or, seizes 
 the lower lip at the angles between the thumbs and fingers, 
 rendering it tense, and at the same time arresting its circu- 
 lation. The operator, standing in front, makes a vertical in- 
 cision through the median line down to the bone, extending 
 it to the lower border of the symphysis mentis, raises the 
 periosteum from its surfaces, if practicable, to the extent of 
 the proposed section, draws a tooth at each point where the 
 bone is to be divided, saws it at these points, and draws the 
 fragment forward, and separates the attachments of the 
 muscles as closely as possible to their insertion. The flaps 
 are then united with silver wire, extending through the 
 mucous membrane. The vermilion border of the lip is 
 carefully adjusted, and united with pins or silver sutures. 
 If the tongue fall backward, its severed muscular attach- 
 ments can be drawn forward, and connected with the cut in 
 the median line by a deep suture passed through the lip.. 
 The bone can be easily reached through a curved incision, 
 made along its lower border, or by an internal one cor- 
 responding to the fold of the buccal membrane. The lip- 
 is depressed over the symphysis mentis, and the bone is re- 
 moved. 
 
 Excision of the Lateral Portion of the Body. — Make an ex- 
 ternal incision along the under border of the portion to be; 
 removed, down to the bone. If necessary, it may be turned, 
 upward at a right angle towards but not through the lip. 
 If the condition of the parts will permit, the periosteum is 
 reflected off, the bone divided in front, external to the 
 insertion of the genio-hyo-glossis, and if possible turned, 
 outward, and the tissues separated back to the point of 
 posterior section; it is then removed with a chain saw, and 
 dressed as before. 
 
 Mxcision of Half of the Lower Jaw. — Commence the in- 
 
EXCISION OF BONES. 209 
 
 cision about an inch below the arch of the zygoma, and 
 carry it downward at the posterior border of the ramus, 
 and around beneath the body of the jaw to the symphysis 
 mentis, carefully exposing the facial artery and tying 
 it. If the operation be for necrosis, this incision will be 
 sufficient ; if for other disease, the lower lip is cut per- 
 pendicularly through its centre to meet the longitudinal 
 incision (Fig. 211). The bone is exposed in front by 
 
 Fig. 211 
 
 peeling off the periosteum or otherwise, and sawn through 
 just outside the insertion of the genio-hyo-glossus if possi- 
 ble, the end pulled outward, and the remaining attached 
 tissues separated either by cutting or by a periosteotome, 
 back to the beginning of the incision. Depress the frag- 
 ment forcibly, and if possible detach the temporal muscle 
 with scissors or osteatome, then turn it outward, and divide 
 the insertions of the pterygoid muscles in the same manner, 
 carefully avoiding cutting the lingual nerve, draw the bone 
 forward forcibly and twist it from its socket. 
 
 If it be impossible to accomplish its removal in this 
 manner, extend the incision upward to the ne<:k of the 
 
210 OPERATIVE SURGERY. 
 
 bone, avoiding if possible the division of Steno's duct and 
 the branch of the seventh pair of nerves, and enucleate the 
 condyle. In this situation, the condyle must be closely fol- 
 lowed, otherwise the internal maxillary artery may be in- 
 jured, as it passes immediately behind it. If the primary 
 incision be sufficient to expose the bone above the seat of 
 the disease, it should be sawn through at this point and the 
 upper portion allowed to remain. 
 
 Excision of the Entire Lower Jaw. — Remove the left half 
 first, or the right if it best suits the convenience of the 
 operator, in the manner before described. A ligature is 
 then passed through the tongue, given to an assistant, 
 and the remainder exsected in a similar manner. Stop all 
 hemorrhage, and close the wounds with sutures in such a 
 way as to accurately coapt the divided buccal borders. 
 
 In all situations, when the nature of the disease will per- 
 mit, the periosteum should be reflected by a careful yet 
 vigorous use of the elevator. The insertion of ligaments 
 and tendons only will afford an obstacle, and these should 
 be carefully detached by a sharp knife, that a continuity of 
 the periosteal and fibrous tissues will remain. 
 
 The periosteum in young subjects may reproduce enough 
 bony material to give a fair outline to the face and serve an 
 important function in mastication. 
 
 If bone be not reproduced, the membrane will furnish a 
 firm fibrous base, which may be utilized for artificial appli- 
 ances. If the anterior portion of either or both sides be 
 removed, the gap may be filled in by an artificial dental ap- 
 pliance, which will often happily maintain the symmetry of 
 the face and become useful in mastication. 
 
 Excision of the Alveolar Process. — When the extent of the 
 disease will permit, the alveolar process can be removed 
 down to the body of the jaw through either an external or 
 internal incision, the former being the better. The dis- 
 eased part is then removed, and the wound closed as be- 
 fore. After recovery, the body of the jaw will form an ex- 
 cellent foundation for a compensatory dental appliance. 
 Whenever the disease is malignant, the periosteum should 
 be removed with the bone, and care taken that none of the 
 diseased membrane remains in the wound. It is also neces- 
 sary in such cases to remove all associated structures when 
 diseased — such as glands, floor of the mouth, and even the 
 tongue itself. 
 
 Results. — Out of 246 exsections in the continuity, 46 died. 
 
EXCISION OF BONES. 211 
 
 Of 153 disarticulations of one half the bone, :^6 died. In 
 20 operations for removal of the entire jaw, i died. It will 
 be seen that death has followed in 20 per cent of all the 
 cases. Pyaemia, erysipelas, and exhaustion, were the prin- 
 ciple causes. 
 
 Operation for Anchylos's of the Inferior Maxilla. — This 
 consists in establishing a false joint in front of the cause 
 of the immobility which is usually dependent on cicatricial 
 contraction, irreducible dislocation, and anchylosis. The 
 removal of a wedge-shape piece from the lower border of 
 the jaw has been practised; also, from the alveolar process; 
 transverse section of the ramus with a sharp chisel intro- 
 duced through the mouth, likewise, fracture of the neck 
 when the condyle is involved. 
 
 Operation for Removal of a Wedge-shaped Piece. — Make an 
 incision two inches in length down to the bone, along the 
 lower border of the jaw, beginning at or in front of its 
 angle, depending upon the location of the cause of the im- 
 mobility. Avoid or tie all important vessels in the course 
 of the incision ; expose both surfaces of the bone up to the 
 summit of the alveolar process, and pull a tooth if neces- 
 sary. Divide it with a chain saw at one extremity of the 
 exposed surface, force the other extremity through the 
 wound, and remove the wedge-shaped piece with the ron- 
 geur or saw, the base of which should not exceed a third or 
 half an inch. While the patient is still under the influence 
 of the anaesthetic and before the wound is closed, ascertain 
 the distance the liberated portion can be separated from 
 the upper jaw with moderate force. Provide suitable 
 drainage, close the wound, and prevent union of the bones 
 by passive motion. 
 
 Exsection of the Stermtm. — No definite plan for this opera- 
 tion can be outlined. The form and length of the incisions 
 must be governed by the location and extent of the disease. 
 The diseased bone should be freely exposed, and removed 
 in the usual manner. Care must be observed, else the 
 pleural cavity will be opened. When possible, subperios- 
 teal excision should be done, as the bone is quite readily 
 reproduced. 
 
 Excision of a portion of a Rib. — This ma)'- be done for the 
 removal of necrosed bone, or to make a permanent opening 
 into the thorax for the escape of pus. If for diseased bone, 
 make an incision in the middle of its long axis of sufficient 
 length to include the diseased portion. This may be crossed 
 
212 OPERATIVE SURGERY. 
 
 at the middle by a transverse incision. Separate the perios- 
 teum along with the superimposed tissues, liberate the bone, 
 and raise it from its bed. If the sequestrum be not loose, 
 time should be allowed for its separation. If the operation 
 be for pyo-thorax, select the sixth or seventh rib; make an 
 incision about two or three inches in length down upon its 
 middle, through the periosteum in a line with the axilla, 
 bisect this by a horizontal one the width of the rib, expose 
 the bone on both surfaces by raising the periosteum along 
 with its surrounding tissues, being careful as yet not to 
 open into the pleural cavity; exsect one half or three fourths 
 of an inch, dividing it with a chain saw. If the intercostal 
 artery, which lies beneath its lower border, be cut, tie it; 
 then make a suitable opening through the intervening struc- 
 tures into the pleural cavity. 
 
 It is well to make the first incision for the purpose cor- 
 responding to the long axis of the rib, and thus avoid the 
 intercostal vessels and nerves. The wound should be 
 dressed antiseptically. 
 
 Excision of the Clavicle. — This operation is performed for 
 necrosis and for morbid growths. The patient is placed on 
 the back, with the shoulders elevated from the table and 
 head turned to the opposite side. 
 
 Contiguous A?iat07ny. — Its muscular and ligamentous at- 
 tachments must be carefully studied, for it is by a knowl- 
 edge of these that the surgeon is enabled to raise the bone 
 from its more important relations. 
 
 In front. 
 
 Attachments of 
 Pectoralis major. 
 Sterno-mastoid, 
 Trapezium and Deltoid. 
 
 Above. 
 External jugular. 
 
 Branches of thyroid axis. J ria • i \ Below. 
 
 Subclavian artery. \ ^"^ ^' j Cephalic vein. 
 
 Brachial plexus. 
 
 Behind. 
 
 Internal mammary artery — Sternal half. 
 Subclavian vein artery, " " 
 
 External jugular. 
 
 Innominate vein on the right half. 
 Thoracic duct on the left half. 
 Pleural cavity. 
 
EXCISION OF CLAVICLE. 213 
 
 Its intimate association to important arteries, veins, 
 nerves, etc., surrounds its removal with great difficulties 
 and dangerous complications; especially, if it be attempted 
 for a well-developed malignant, or other morbid growth. 
 With the patient in the position assumed for the operation, 
 the foregoing plan shows the important anatomical rela- 
 tions of the clavicle. 
 
 The whole or a portion can be removed. If the whole be 
 removed, it may be raised by its scapular extremity, or di- 
 vided, and each half taken away separately. 
 
 Removal of the E?itire Clavicle. — Anaesthetize and place the 
 patient in the position just described; if for necrosis, make 
 an incision the whole length of the bone parallel with its 
 long axis. If necessarj^, a short transverse incision is added; 
 expose the bone, divide the periosteum, and with the ele- 
 vator enucleate it from the surrounding tissues. It can be 
 divided through the centre and each half removed sepa- 
 rately, or the acromial end can be detached and the whole 
 raised by it. In either instance the articular ends, and 
 their connective ligaments should be preserved if possible. 
 
 If the involucrum be weak and liable to bend or break 
 after the bone is removed, the shoulder must be held out- 
 ward, backward, and upward by the methods employed in 
 fracture of that bone. The indirect method of sequestrot- 
 omy can be employed in some instances. 
 
 If the operation be for the removal of a tumor of the 
 bone, especially one acutely malignant, and involving any 
 considerable portion of the surrounding tissues, it is certain 
 to be an exceedingly tedious and bloody one. 
 
 The smaller the size of the tumor and the less its vascu- 
 larity, the easier its removal. Make an incision in the long 
 axis of the bone, from the sternal to the acromial extremity; 
 if necessary this is crossed by a vertical one, extending 
 from the posterior border of the sterno-mastoid to the up- 
 per third of the pectoralis major. Carry these incisions as 
 deeply as the nature of the growth will permit, and refect 
 the flaps from off the tumor; separate the insertions of the 
 deltoid and trapezius muscles on a director, cutting them 
 either with a knife or strong curved scissors, being careful 
 to avoid the cephalic vein which lies at the inner border of 
 the deltoid. Divide the coraco- and acromio-clavicular liga- 
 ments; raise the acromial extremity of the clavicle, thus 
 elevating the morbid growth, which should be separated 
 cautiously from the surrounding tissues. The nearer the 
 
214 
 
 OPERATIVE SURGERY. 
 
 approach to the sternal extremity, the greater necessity for 
 caution, since the growth may be connected with the im- 
 portant structures there; finally, divide the sterno-mastoid 
 insertion, the pectoralis major, and rhomboid ligament, and 
 carefully disarticulate while the tumor is lifted upward and 
 inward. 
 
 Either extremity may be excised by making a crucial 
 incision corresponding to the portion to be removed down 
 to the bone, exposing and dividing it with a chain saw, and 
 removing with the same precautions as before described. 
 The results of the operation of complete excision have 
 
 Fig. 212. 
 
 been very unfortunate, nearly all having perished from ex- 
 haustion, due to loss of blood, erysipelas, etc. 
 
 The entrance of air into the veins is especially to be 
 guarded against, on account of their near proximity to the 
 chest. 
 
 Excision of the Scapula. — This bone is excised on account 
 of gun-shot injuries, necrosis, and morbid growths. 
 
 The whole bone may be removed, or its body, angles, and 
 spines can be removed separately. Its contiguous anatomy 
 is extensive, but not of the dangerous character found asso- 
 ciated with the clavicle. To its spines, borders, and sur- 
 faces, are attached numerous and powerful muscles. 
 
 At the upper border are found the supra-scapular vessels 
 gnd nerves; the posterior scapular passes down its vertebral 
 
EXCISION OF SCAPULA. 
 
 215 
 
 border; while at the axillary border the subscapular, dor- 
 salis scapulse, and even the axillary artery itself, and the 
 brachial plexus, are in close connection with it. 
 
 Removal of the Entire Scapula (Fig. 212).— Make an in- 
 cision from the top of the acromion process along the spme 
 to the posterior border, a, b. Join it by a second from near 
 its centre to the inferior angle of the bone, c, dj turn aside 
 the flaps thus formed. 
 
 Separate the attachments of the deltoid and trapezius; 
 disarticulate the acromio-clavicular articulation; secure the 
 subscapular artery; divide the ligaments and tendons around 
 
 Fig. 213. 
 
 the glenoid cavity; raise up the coracoid process and care- 
 fully sever its ligaments and muscular attachments; raise 
 the bone upward and divide the remaining muscular at- 
 tachments with a knife or strong pair of scissors, carefully 
 avoiding the subscapular and posterior scapular vessels; 
 tie all the bleeding points; wash with an antiseptic solution; 
 provide drainage, close the wound with suitable sutures, 
 and dress antiseptically. 
 
 Removal of the Body of the Scapula (Fig. 213).— Make an 
 incision the whole length of the spine, a, bj begin a second 
 
2l6 OPERATIVE SURGERY. 
 
 at the posterior superior spine, and carry it along the pos- 
 terior border of the bone to its inferior angle, c, dj dissect 
 the resulting triangular flaps from their corresponding 
 fossae, carefully avoiding the supra-scapular artery and 
 nerve; saw through the acromion close to the body, divide 
 the muscles attached to the anterior and superior borders; 
 raise the bone upwara and saw through the anterior supe- 
 rior angle behind the coracoid process, turn the bone out- 
 ward and sever its posterior connections with the knife. 
 
 Acromion Process aftd Angles may be separately removed. 
 For the former, make an incision along its upper border, 
 which may be curved, if necessary: expose this portion of 
 
 Fig. 214. 
 
 the bone, divide the muscles attached to It, and with a pair 
 of bone forceps remove the desired amount. The acromion 
 can be removed by making a curved or crucial incision 
 over it; expose its upper surface, divide the muscles con- 
 nected therewith, disarticulate the clavicle, and remove with 
 a chain saw. 
 
 To remove an angle, make a V-shaped incision over it, 
 dissect off the flaps, separate the muscles, and divide with 
 the bone forceps. 
 
 Subperiosteal Excision of the Scapula (Fig. 215). — Make 
 an incision from the apex of the acromion process along 
 the spine to the posterior border of the scapula, a, b. Carry 
 
EXCISION OF SCAPULA. 21/ 
 
 a second from the posterior superior angle along the pos- 
 terior border, crossing the former, to the inferior angle, f, d. 
 Sever the muscular attachments to the acromion and spine; 
 divide the periosteum at the posterior border between the 
 attachments of the rhomboideus major and infra-spinatus, 
 and separate it from the iufra-spinous fossa. Separate the 
 inferior angle from its muscular attachments. The perios- 
 teum is then raised from the supra-spinous fossa in the 
 same manner; be careful to not injure the supra-scapular 
 vessels, as they pass in close contact with the foramen; dis- 
 connect the muscles around its borders, closely hugging 
 the bone, raise it upward by its inferior angle, denude the 
 subscapular fossa, leaving its periosteum connected with the 
 subscapularis; liberate the posterior border, allowing its car- 
 tilaginous border to remain — when present. Turn the bone 
 upward and forward, and remove the remaining periosteum 
 from its under surface to the neck of the scapula, which is 
 divided with the chain saw. If the disease will not permit 
 this, the neck can be enucleated, leaving the ligaments con- 
 nected with the periosteum. If the bone be retnaved for a 
 malignant or other morbid growth, make an incision from 
 the posterior superior angle to the lower border of the 
 tumor, carrying it downward, forward, and inward, with 
 the convexity posteriorly. A second, beginning five inches 
 or so in front of the preceding, carried downward and back- 
 ward, crossing the other at or near its middle, and termi- 
 nating at the lower border of the growth. The flaps are 
 then reflected from the tumor, and the muscular attach- 
 ments of the spine separated, and the acromion process 
 sawn through behind the clavicle; expose the superior and 
 posterior borders, and free them of their attachments; raise 
 the bone upward and forward by its posterior border, and 
 sever the serratus magnus from it; free the axillary border, 
 and divide the neck with a saw, if practicable. When neces- 
 sary, complete the entire removal by disarticulation. 
 
 It is not possible to lay down absolutely practical rules to 
 govern the number, extent, or direction of the incisions; all 
 this must depend on the size and situation of the growth, 
 together with the amount of bone to be removed, and the 
 ease and safety with which it can be done. After the re- 
 moval, arrest hemorrhage, provide good drainage, unite the 
 cut surfaces, and dress antiseptically. 
 
 The results of the operation are flattering: 27 per cent 
 died after complete removal for injuries, and 19 per cent 
 
218 
 
 OPERATIVE SURGERY. 
 
 when due to disease. The mortality was 26 per cent in 
 partial excisions for disease, and about 20 per cent when 
 done for injury. 
 
 Excision of the Humerus. — This can be removed entirely 
 or in part. 
 
 The Important Associated Anatomy. — The insertions of the 
 muscles acting upon the upper end of the bone, course of 
 the superior profunda, and circumflex arteries, of the cir- 
 
 FlG. 315. 
 
 cumflex, musculo-spiral and ulnar nerves; points of inser- 
 tion of the ligaments of the joints, together with the con- 
 nections of the flexors and extensors, must be carefully con- 
 sidered before attempting the operation. This operation 
 has been done for the relief of old dislocations, caries, ne- 
 crosis, gun-shot injuries, arthritis, malignant disease, etc. 
 Excision of the Upper End. — Place the patient upon the 
 
EXCISION OF HUMERUS. 
 
 219 
 
 back, with the shoulders raised; make an incision from 
 the anterior border of the acromion process, close to the 
 articulation with the clavicle, downward, about four inches, 
 in the line of the bicipital groove (Fig. 215). The bone 
 at this region is quite superficial; liberate the long head of 
 the biceps tendon from the groove, by carrying the point 
 of the knife upward in it at the outer side, through the 
 capsule to the acromion, and raise it out of the groove (Fig. 
 216); rotate the arm outward and divide the subscapularis 
 tendon and inner portion of the cap- 
 sule; tken inward, cutting the ex- 
 ternal rotators and posterior por- 
 tion of the capsule (Fig. 217); force 
 the head of the bone, through the 
 opening, seize it with a strong pair 
 of forceps, divide the inferior por- 
 tion of the capsule and remove ih?. 
 head of the bone with a chain or 
 a small straight saw (Fig. 218). 
 
 Subperiosteal Excision of Head of 
 Hiwierus. — Expose the bicipital 
 groove and split up the capsular 
 ligament as in the preceding opera- 
 tion. Divide and raise the perios- 
 teum from the inner border of the 
 bicipital groove, passing inward 
 and separating it along with the 
 subscapularis and the fibrous cap- 
 sule from the lesser tuberosity. 
 Rotate the humerus outward and 
 complete the separation to the re- 
 quired extent with the elevator and knife; rotate the arm 
 inwards, displace the tendon of the biceps to the inner 
 side of the head and separate the periosteum in connection 
 with the capsule and the insertions of the external rotators, 
 being very careful not to sever its connection with the 
 bone below. To force the head through the external open- 
 ing is practically impossible without destroying the perios- 
 teal connections; it is necessary, therefore, to divide it with 
 a chain or narrow-bladed saw. Partial removal of the 
 upper extremity is often necessary on account of disease 
 or injury. 
 
 The variety and extent of the incisions to reach the part 
 must be governed by the amount of the disease. 
 
 Fig. 216. 
 
220 
 
 OPERATIVE SURGERY. 
 
 The vertical, V-, and U-shaped ones are selected as best 
 suits the exigencies of the case. 
 
 Excisio7i of the Glenoid Cavity. — This operation is only- 
 applicable to those conditions of injury or disease that are 
 limited to the glenoid articular surface of the scapula. If 
 a penetrating wound has ensued, its course should be fol- 
 lowed to reach the bone; if not, then a curved insertion is 
 made around the posterior border of the acromion which 
 
 Fig. 217. 
 
 divides the fibres of the deltoid, and exposes the pos- 
 terior and upper surface of the joint. A second incision 
 is then made, commencing at the centre of this one, at the 
 upper margin of the glenoid cavity, and, passing down- 
 ward through the capsule, upon the centre of the greater 
 tuberosity, between the supra and infra-spinatus tendons 
 through the deltoid in the direction of its fibres (Fig. 219). 
 Open the wound widely by means of retractors and divide 
 
' EXCISION OF HUMERUS. 
 
 221 
 
 the tendons of the biceps at its insertion; separate the 
 periosteum around the neck of the scapula if possible, 
 leaving the attachments of the capsular ligament. Cut 
 away the bone with a chain saw. The wound is then 
 dressed as usual in such cases. 
 
 Excision of the Shaft. — Unless great caution be obser\^ed, 
 the musculo-spiral nerve and the superior profunda artery 
 will be injured in their course along the musculo-spiral 
 
 Fig. 218. 
 
 Fig. aig. 
 
 groove. The circumflex nerves and vessels also, if tht 
 incision be extended (Fig. 220) upward too far. The up- 
 per portion of the shaft is easily exposed by making an in- 
 cision of sufficient length through the outer surface of the 
 deltoid, commencing at its lower third and dividing it con- 
 tinuously upward, to avoid the circumflex nerve and artery; 
 the bone is then denuded of its periosteum, or the morbid 
 
222 
 
 OPERATIVE SURGERY 
 
 growth circumscribed and removed. If it be the lower por- 
 tion of the shaft, make the incision along the outer border 
 of the brachialis anticus, carefully avoiding the musculo- 
 spiral nerves; expose the bone and remove it as before. 
 
 The Lower Extre7nity of the Humerus. — The relation of the 
 ulnar nerve to the internal condyle (Fig. 221) and of the 
 brachial artery to its anterior surface, must not be forgot- 
 ten; make an incision on the posterior and external surface 
 
 Fig. 220. 
 
 of sufficient length to well expose the bone; elevate the 
 periosteum and divide with a chain saw; pull the fragment 
 downward and disarticulate. 
 
 If it be required to remove the whole humerus, make in- 
 cisions as if to remove the upper and lower portions, ob- 
 serving the same precautions relative to the anatomy of 
 these parts. The musculo-spiral nerve in this is to be most 
 cautiously guarded. 
 
EXCISION OF ELBOW-JOINT. 
 
 223 
 
 In all the preceding operations, substantially the same 
 after-treatment is required: stop the hemorrhage, irrigate 
 with an antiseptic solution, provide drainage, close the 
 lips of the wound, and surround with antiseptic dressing. 
 Place the limb upon a splint affording an easy support at 
 the proper angle. Extension is often necessary to main- 
 
 trnS. Tlmgut^ 
 
 <iniiiiiMi I jj 
 
 tttBuoBiiBrsimi 
 
 frf^ffB 
 
 Aru&lOEft 
 
 0asi£Busi-Mliuab 
 
 Fig. 
 
 tain the limb at a suitable length during the healing pro- 
 cess. 
 
 The results depend much upon the nature of the injury 
 and the period of the operation. For gunshot wounds of 
 the bone requiring excision, about 35 per cent perish. 
 The rate of mortality being increased when the inflamma- 
 tory stage exists at the time of operation. 
 
 Excision of the Elbo^v Joint (Hueter). — With the forearm 
 extended make a straight incision about an inch in length 
 
224 
 
 OPERATIVE SURGERY. 
 
 1 
 
 t 1 
 
 \ 
 I 
 
 l\ 
 
 ( \ 
 I i 
 
 ■I 
 
 down upon the tip of the internal condyle, carefully avoid- 
 ing the ulnar nerve (Fig. 221). Through this opening sep- 
 arate the muscular and ligamentous attachments to the con- 
 dyle; make a second longitudinal incision from three to four 
 inches in length down to the head of the radius (Fig. 222). 
 Draw aside the soft parts and cut the external lateral and 
 orbicular ligaments (Fig. 223). Expose the head of the 
 radius and cut off with a saw or bone forceps. Separate 
 the capsular ligament from its attachments on the anterior 
 and posterior surfaces of the humerus, force the bone out 
 of the external wound; this movement admits of its divi- 
 sion, and at the same time raises the ulnar 
 nerve from its bed away from the bone. 
 Saw off the lower end of the humerus, care- 
 fully expose and remove the olecranon. 
 
 Subperiosteal Excision of Elbow (Lan- 
 genbeck). — Make a longitudinal incision 
 down to the bone, three to four inches 
 in length, a little to the inner side of the 
 olecranon (Fig. 224), about two thirds of its 
 length being below the tip of the olecranon. 
 Relieve that portion of the olecranon and 
 ulna at the inner side of the incision 
 of the periosteum. Separate by short 
 parallel incisions the attachments of the 
 inner half of the triceps tendon. Push 
 the tissues at the internal condyle, to- 
 gether with the ulnar nerve inward to- 
 wards the tip of the condyle, and elevate 
 the periosteum from the inner condyle 
 sufficiently to separate the internal lateral ligaments and 
 muscles from the bone, leaving them connected with the 
 periosteum. The liberated tissues are now permitted to 
 return to their former position, and the outer portion of 
 the tendon is drawn outward and disconnected from the 
 process by short transverse incisions, closely hugging the 
 bone and allowing it to remain continuous, with the 
 periosteum; which is reflected from the inner surface 
 of the olecranon and shaft of the ulnar; expose the ex- 
 ternal condyle by separating the capsular ligament at its 
 attachment, above the trochlear and capitillium, the tis- 
 sues, including the detached periosteum and tendons of 
 the biceps, are separated well from the bone by retractors. 
 Flex the forearm and force the extremities of the bones 
 
 Fig. 
 
EXCISION OF ELBOW-JOINT. 
 
 22$ 
 
 through the openings; saw off the head of the radius, 
 lower end of the humerus and finally the olecranon pro- 
 cess. It is important to remember that in all cases of ex- 
 cision about the elbow joint, to respect the insertions of im- 
 portant muscles, as the insertion of the brachialis anticus, 
 biceps, triceps, etc. To unnecessarily destroy the power of 
 one of these, is to be guilty of 
 an unpardonable oversight. 
 Variously formed incisions, 
 other than the longitudinal, 
 have been employed: as the H, 
 with the horizontal portions 
 corresponding to the articula- 
 tion; the T, with the horizon- 
 tal on a line with the condyle; 
 U-shaped or semilunar, with 
 the convexity downward. 
 
 Excision of the Joint by the 
 I — Shaped Incision (Liston's, 
 Fig. 225). — Flex the elbow to 
 an obtuse angle, the operator 
 facing its posterior surface 
 (Fig. 226), open the capsule 
 between the olecranon and in- 
 ternal condyle by a longitu- 
 dinal incision about four inches 
 in length along the inner 
 border of the olecranon, dis- 
 sect and draw the soft parts 
 over the internal condyle with 
 the thumb (Fig. 226), increas- 
 ing the flexion gradually till 
 the condyle is fully exposed, 
 divide the internal lateral liga- 
 ment, extend the arm and carry 
 a transverse incision from the 
 point of articulation of the ^"^- "3- 
 
 radius with the humerus directly across to the centre of i' 
 the former incision. 
 
 The periosteum on the inner surface of the olecranon 
 and ulna is raised and left connected with the tendon of 
 the triceps, which is carefully separated from the bone. 
 Open the flaps wide and divide the external lateral liga- 
 ment, flex the forearm, when the articular surfaces will 
 
226 
 
 OPERATIVE SURGERY. 
 
 separate. Seize and saw off the lower extremity of the 
 humerus and the olecranon process, finally the head of the 
 radius. Dress as in the preceding instance. 
 
 Excision of the Elboiv Joint has been done with such suc- 
 cess that its rank is thoroughly established. Although 
 when due to injury the rate of mortality is about 25 per cent, 
 when due to disease it is less than 11 per cent. Partial 
 excisions are followed by better results, so far as motion 
 is concerned, than complete ones. 
 
 It would appear that the saving of the synovial mem- 
 
 FiG. 224. 
 
 Fig. 225. 
 
 brane exerts a more conservative influence upon the useful- 
 ness of the joint than the saving of bone; provided, of course, 
 that the bony insertions of the muscles acting directly upon 
 the joint be respected. The amount of bone removed will 
 determine the usefulness of the joint. If too little, the 
 moTement will be limited and insufficient; if too great, it 
 will dangle, and be of little use except for carrying pur- 
 poses. If the operation be for traumatism, remove the 
 fragment; if for disease, remove only the diseased portion, 
 
EXCISION OF ULNA. 
 
 227 
 
 and in all, the wounds should be washed with a suitable 
 antiseptic solution, closed with proper drainage, dressed 
 antiseptically, and kept extended till repair is begun ; 
 when it should from time to time be placed at various 
 angles for a day or so. By this course the newly formed 
 
 Fig. 236. 
 
 tissue will conform more readily to the various positions of 
 the joint thereafter. 
 
 Excision of the Ulna. — An incision is made along the pos- 
 terior surface of sufficient length to expose the diseased 
 portion, the periosteum pushed aside, and section made at 
 the requisite point and the bone removed. 
 
228 
 
 OPERATIVE SURGERY. 
 
 If it be a partial excision of the upper extremity, ex- 
 pose that portion by incision in the same line, remove the 
 periosteum, leaving, if possible, the attachments of the 
 brachalis anticus and triceps. Respect the ulnar nerve, at 
 the inner condyle. 
 
 Excisio7i of the Radius. — Make an incision, extending from 
 the styloid process, along the outer side of the anterior 
 surface of the forearm to the radio-humeral articulation, 
 through the integument and fascia. Seek the inner border 
 of the supinator longus, pass upward separating it from the 
 flexor longus pollicis and going down to the bone, divide the 
 
 Fig. 227. 
 
 supinator brevis, also the periosteum in the long axis and 
 separate it; divide the bone in the centre, and remove each 
 portion separately. The insertion of the biceps and pronator 
 radii teres should be carefully preserved. If either ex- 
 tremity be exsected, expose the bone through an incision 
 made in the same line as the preceding; the periosteum 
 is reflected with equal caution, and the bone removed. 
 
 Excision of the Wi'ist Joint. — This joint properly consists 
 of the radius, articulated with the outer two of the first row 
 of carpal bones. In cases where excision is necessary, it is 
 not usual to find the disease or injury limited entirely to 
 these structures. It therefore becomes necessary to remove 
 
EXCISION OF WRIST. 229 
 
 all bony structures involved, even though it embraces the 
 two rows of carpal bones and the contiguous extremities of 
 the metacarpal. The intimate relation existing between 
 the carpal bones and the continuity of their synovia sur- 
 roundings, renders them especially liable to extending dis- 
 ease as well as inflammatory processes (Fig. 227). They are 
 intimately bound together by strong ligaments admitting of 
 but limited movement between their surfaces (Figs. 228 and 
 229). Since these bones are environed by the tendons of 
 
 Fig. 228. 
 
 important muscles, the sheaths of which should be scrupu- 
 lously preserved along with themselves, it surrounds this 
 operation with difficult and tedious details. 
 
 All diseased or detached bone should be removed. If a 
 portion of a carpal bone be diseased, it is better that the 
 whole be removed. The insertions of all muscles acting on 
 the carpus should be preserved, if possible. 
 
 No tendon is to be divided, except it be an unsurmount- 
 able obstacle to the incision necessary to the removal of the 
 bones. The radial and ulnar arteries and the branches 
 associated with the carpus should be cautiously avoided. 
 
 Complete Exeision of the JFri'st (Langenbeck). — Place the 
 forearm and hand of the patient with the palm downward 
 
230 OPERATIVE SURGERY. 
 
 on a table of convenient height for the operator and his 
 assistant. An incision is then made through the integu- 
 ment, beginning at the middle of the metacarpal bone of 
 the index finger at its ulna border, and extending lon- 
 gitudinally to three-fourths of an inch above the lower 
 extremity of the radius, at its middle (Fig. 230). The 
 deeper course of the incision passes to the radial side of 
 the extensor indicis without opening its sheath, upward, 
 either over the tendon of the extensor carpi radialis bre- 
 vior, or to the inner side of its insertion, depending on the 
 degree of adduction of the hand; then, if the tendons 
 going to the index finger be pushed to the ulnar side, 
 
 Fig. 229. 
 
 upward to the point of termination between the tendons 
 of the extensor secundi internodii pollicis and the extensor 
 indicis (Fig. 230), dividing the lower portion of the posterior 
 annular ligament. Draw the tissues apart with suitable 
 retractors and separate the fibrous sheaths of the extensors 
 of the carpus situated on the posterior surface of the radius 
 with a periosteal elevator, also, the insertion of the supinator 
 longus, annular ligament, periosteum, and capsular liga- 
 ment are then disconnected and drawn inward; the ten- 
 dons, ligaments, and periosteum on the posterior surface of 
 the ulna are separated in the same manner and drawn out- 
 
EXCISION OF WRIST. 23I 
 
 ward; open well the radio-carpal joint, flex the carpus 
 and expose the articular surfaces, and separate the bones 
 of the first row from their connection with each other, 
 leaving the periosteum if possible. Liberate the scaphoid 
 from the trapezium and trapezoid, the semilunar from the 
 
 Fig. 230. 
 
 OS magnum, and the cuneiform from the unciform; lift them 
 out, leaving, if possible, their periosteum and the trapezium. 
 The bones of the anterior row are taken out after severing 
 the connections between the trapezium and trapezoid and 
 the heads of the metacarpal bones. The extremities of the 
 
232 
 
 OPERATIVE SURGERY. 
 
 radius and ulnar can now be forced through the wound, 
 carefully stripped and sawn off, carefully avoiding the 
 radial and ulnar vessels. The resulting wound is treated 
 by antiseptic measures, attended when possible with exten- 
 sion. Continuous extension from the fingers should be 
 early and constantly employed during the after treatment. 
 Excision of the Lower Extremities of the Bones of the Fore- 
 arm (Bourgary). — Make an incision along the inner side 
 of the ulnar, from just below the apex of the styloid pro- 
 cess two inches along the inner border (Fig. 231). Divide 
 the periosteum at the interspace be- 
 tween the extensor and flexor carpi 
 ulnaris in the same line, and reflect 
 it from the bone inward to the inter- 
 osseous membrane. The denuded 
 extremity of the ulna is then re- 
 moved, and a second longitudinal 
 incision is made along the outer side 
 of the radius from just below the 
 apex of the styloid process two or 
 three inches upward, divide the 
 periosteum through the same inci- 
 sion, separate the attachment of 
 the supinator longus, and raise the 
 periosteum on the dorsal surface 
 along with the sheath of the exten- 
 sor tendons. 
 
 The periosteum is then elevated 
 from the like portion of the palmar 
 surface around to the interosseous 
 membrane. Protect the perios- 
 teum and soft parts while the bone 
 is being sawn through. 
 
 There are other i?icisions intended 
 to meet the indication, i. (Lis- 
 ter). Beginning on the dorsal 
 aspect of the radius, opposite the 
 styloid process. Carry it towards 
 Fig. 231. the inner side of the metacarpal 
 
 articulation of the thumb parallel with the secundi in- 
 ternodii pollicis (Fig. 232). When at the radial border 
 of the second metacarpal bone, carry it along one half 
 the length of that bone; separate the soft parts on the 
 radial side, divide the tendon of the extensor carpi radi- 
 
EXCISION OF CARPUS. 
 
 233 
 
 alls longior at its insertion, raise it along with the brevior 
 and secundi internodii pollicis, open the wound well and dis 
 connect the trapezium from the remaining bones, which are 
 then taken away. Extend the carpus and separate the soft 
 parts on the dorsum at the ulnar side of the incision. 
 
 Make a second incision along the anterior and internal 
 border of the forearm inside the flexor carpi ulnaris, be- 
 ginning about two inches above the styloid process and 
 extending to the middle of the metacarpal bone of the lit- 
 
 FlG. 332. 
 
 tie finger. Expose the dorsum of the ulna, divide the ten- 
 don of the extensor carpi ulnaris at its insertion, separate it 
 from the groove in the ulna, raise the extensors of the 
 fingers from the carpus, leaving their attachments to the 
 radius intact; expose the entire surface of the ulna, hugging 
 the bone closely; separate the pisiform bone with the flexor 
 carpi ulnaris; flex the hand and separate the flexor tendons 
 in the same cautious manner; divide the remaining liga- 
 ments connecting the bones of the forearm with the carpus. 
 
234 OPERATIVE SURGERY. 
 
 Separate the process of the unciform bone, also the 
 carpus from the metacarpus with cutting forceps; expose 
 the extremities of the radius and ulna through the ulnar 
 incision, remove with saw or forceps the diseased portions, 
 carefully avoiding the grooves for the passage of the ten- 
 dons; remove the trapezium without injury to the tendon 
 of the flexor carpi ulnaris. All articular surfaces of bones 
 — metacarpal bones, pisiform and between lower extremities 
 of radius and ulna — should be removed, as well as all dis- 
 eased portions of bone. Many other incisions are made 
 to affect the removal; but only such as admit of it being 
 done through longitudinal incisions are advisable, since 
 transverse incisions sacrifice the tendons which impart use- 
 fulness to the remaining portion. 
 
 All hemorrhage having ceased, the wound should be 
 closed, allowing the most dependent incision to remain open 
 for drainage and the introduction of supporting dressings. 
 Envelope the limb in antiseptic dressings, causing the whole 
 to be properly supported by a splint. The subsequent 
 treatment consists in cleanliness, extension, and passive 
 motion. 
 
 Results. — Seven per cent die after excision for disease ; 
 15 per cent for gunshot. In about 2)Z pe^'' cent of those who 
 recover, the operation is worthless. In about 11 per cent 
 entirely satisfactory; in the remainder, useful. The prog- 
 nosis for usefulness is better when due to injury than to 
 disease. 
 
 Excision of the Metacarpo-phalangeal Joints. — This can read- 
 ily be done by making an incision about one and one half 
 inches in length along the dorsum of the bones composing 
 the joint at one side of the extensor tendons. The tissues 
 in contact with the bone are carefully raised and turned 
 aside, the joint exposed, and the requisite amount of bone 
 removed by the chain-saw or cutting forceps. 
 
 The phalangeal articulations may be approached either 
 through a longitudinal incision made along the side of the 
 joint, or by a curved one corresponding to the outer surface 
 with the convexity downward. In either instance raise 
 the tissues by carefully clinging to the bones, which when 
 properly exposed can be caused to protrude through the 
 incision by lateral flexion and their extremities be re- 
 moved. 
 
 The dressing consists in placing them in an immovable 
 position properly protected by an antiseptic method, 
 
EXCISION OF JOINTS OF FOOT. 235 
 
 and when repair begins passive motion must be begun 
 and continued until the recovery is complete. 
 
 Excision of the Joints of the Lower Extrefnities. — The pha- 
 langeal joints of the tarsus are removed in a similar man- 
 ner to those of the upper extremity. 
 
 The Metatarso-phalangeal Joints 3.r& removed through lon- 
 gitudinal incisions made on the dorsal surface of the 
 bones constituting the joints at either side of the extensor 
 tendon, which is pushed aside along with the remaining sur- 
 rounding soft parts, the bones exposed, and their extremi- 
 ties severed by the chain-saw or bone-forceps. The re- 
 moval of the metatarso-phalangeal articulation of the 
 great toe can be and often is done differently. Make a 
 curved incision with the convexity downward, at the inner 
 side of the joint, its centre corresponding to the joint 
 centre, of sufficient length to freely expose the bones to 
 
 Fig. 233. 
 (■ 
 
 be removed (Fig. 233). Dissect the soft parts from 
 around the bones, carefully pushing aside the tendons; 
 expose and remove the necessary amount of bone with 
 chain-saw or forceps. If the operation be done for the 
 correction of the deformity caused by prominence of the 
 head of the metatarsal bone, enough bone is removed 
 from its extremity to permit the easy return of the dis- 
 placed toe to its natural position; where it is to be retained 
 quietly till repair is well advanced, when passive motion 
 is commenced. 
 
 The Metatarso-ta7-sal Joints can be exsected by raising a 
 semilunar flap over their dorsal surface; avoiding division 
 of the extensor tendons, which are raised and pushed aside, 
 while the dorsal ligaments connecting the bones are divid- 
 ed and the joint cavity exposed by forced flexion, after 
 
236 OPERATIVE SURGERY. 
 
 Which the extremities of the bones of the distal roW Can be 
 divided with a saw or bone forceps. The corresponding 
 extremities of the tarsal bones can be treated likewise. 
 
 Tarsal Joints. — When separate tarsal joints become in- 
 volved by disease or traumatic violence, they can be re- 
 moved by making an incision over the injured or diseased 
 portions, often following in the line of the course of the 
 violence, or in the tracks of sinuses leading therefrom. 
 
 This treatment is, however, better adapted to those joints 
 having a limited synovial membrane, than to those where 
 that membrane extends between several contiguous bone 
 surfaces; in the latter case it is often better to remove the 
 bones entire by aid of the chisel, saw, or gouge. In either 
 instance curved incisions are preferrible, provided they do 
 not divide important tendons and vessels. 
 
 Excision of the Ankle Joint. — This is a hinge-joint, having 
 
 Fig. 234. 
 
 no lateral movement, except the foot be well extended, and 
 then it is very limited. The indications calling for the 
 operation are numerous, and should be well considered be- 
 fore it is attempted. As in all excisions those procedures 
 which best preserve the tendons, vessels, nerves, and perios- 
 teum are to be adhered to, consequently those of a longi- 
 tudinal character are best employed. 
 
 Operation, Subperiosteal (Langenbeck). — Make an incision 
 down to the bone (Fig. 234), about three inches in length 
 along the posterior border of the lower extremity of the 
 fibula, carrying it forward in a hooked shape around the 
 lower end and upward along its anterior border about an 
 inch. The periosteum is reflected from the bone along 
 with the tissues in contact with it, thereby exposing the 
 lower extremity of the fibula without opening tke tendi- 
 
EXCISION OF ANKLE. 
 
 237 
 
 nous grooves of the peronei muscles (Fig. 235). The fibula 
 is then divided at the upper end of the cut with a narrow- 
 saw, pulled outward, and the ligamentous attachments along 
 its inner border and surfaces disconnected (Fig. 236), and 
 the bone removed. An incision is then made about an inch 
 and a half in length down to the bone, around the lower- 
 end of the inner malleolis (Fig. 237). A second and ver- 
 
 — LmkISZ. 
 
 Fig. 235. 
 
 tical one is next made about two inches in length, down to 
 the bone through the centre of tibia, connecting with the 
 semicircular one first made. The triangular flaps are turned 
 aside, including the periosteum, with the elevator, using 
 care to raise the sheath of all tendons from their grooves 
 (Fig. 238), push them aside, divide the tibia at the upper 
 end of the cut with a chain saw; pull it outward with the 
 forceps, free it from the interosseous membrane, as in the 
 preceding instance, and remove the bone. If it be neces- 
 
238 
 
 OPERATIVE SURGERY. 
 
 sary to remove the articular surface of the astragalus, it can 
 be done through either incision; the better, however, 
 through the internal one, on account of the greater amount 
 of room. Results: About 13 per cent die from excision of 
 
 Fig. 236, 
 
 this joint; the rule of mortality being about 50 per cent 
 greater from disease than from injury. 
 
 The prognosis for life is most favorable between one and 
 fifteen years of age. Most unfavorable between thirty and 
 forty. A large proportion of the recoveries from this results 
 
 Fig. 237. 
 
 in a more or less useful limb; about 9 per cent being worth- 
 less. 
 
 The treatment consists in the immovable dressing of the 
 joint, after the usual washing and drainage has been es- 
 tablished. 
 
EXCISION OF KNEE. 
 
 239 
 
 If it be desired to remove, by section or otherwise, por- 
 tions of either of the bones of the leg, the external incision 
 is governed, as to its location and extent, by the situation 
 and degree of the injury or disease. The bone should, 
 however, be reached by the shortest course, which should 
 be carried behveen the individual muscles, rather than 
 through their structures. After its removal, which should 
 always be subperiosteal, the limb must be so confined as to 
 permit the new structure, when completed, to fulfil the re- 
 quirements of its predecessor. 
 
 Excision of the Knee Joint. — This joint can be excised with 
 
 f. JtftfiL 
 
 fJh> Stx. hal. .. 
 pfl . Eh^ post., 
 
 ti^, UhhMSOlkiA' 
 
 Fig. 238. 
 
 comparative safety to the patient, and with a fair prospect 
 of recovery with a useful limb. As in the preceding, the 
 nature of the cause demanding the operation exercises a 
 marked influence on the result. 
 
 Resjilts : The mortality, when due to disease, is about 30 
 percent; when dependent upon injury, about 40 per cent. 
 
 If it be a gunshot injury, the mortality is increased to 75 
 per cent. The age of the patient is a consideration not to 
 be underestimated; being best from five to ten years, when 
 due to injury or disease; 15 to 20 per cent when done for 
 gunshot wounds. Complete excision gives a higher rate 
 than partial, when due to disease or injury. The removal 
 of about three inches insures the best prognosis for life. 
 
240 
 
 OPERATIVfi StJRGERV. 
 
 A less or greater amount increases the rate per cent. The 
 removal of the patella, when not diseased, increases the rate 
 of mortality slightl5^ The usefulness of the limb after the 
 operation can be briefly summed up as follows: 
 
 When due to disease, 14 per cent were perfect, 42 were 
 useful, and the remaining useless, of which 18 per cent 
 were amputated. 
 
 For injuries about 18 were perfect, about 65 useful, and 
 about twelve were amputated. 
 
 When due to gunshot injuries, about 60 per cent were use- 
 ful, and 24 were amputated, the remaining not accounted for. 
 
 When done for deformity, ig^ were perfect, and about 68 
 per cent had useful limbs; the remainder not reported. 
 
 It appears that the degree of usefulness does not depend 
 upon the amount of bone removed. 
 
 Fig. 239. 
 
 The removal of the patella increased the usefulness over 
 
 the retention about 45 per cent. 
 
 Contiguous Anatomy. — The articular vessels and those which 
 occupy the popliteal space are the ones to be avoided. The 
 latter are separated from all danger by the dense and un- 
 yielding ligamentum posticum Winslowii. The former can 
 be avoided by limiting the incisions to the space between 
 the origin and insertion of the lateral ligaments. There 
 are two well-known methods of excising this joint: i. The 
 non-subperiosteal, or the ordinary method; and 2, the sub- 
 periosteal. The former is employed when the tissues are 
 too extensively destroyed, or diseased to admit of the saving 
 of the periosteum. 
 
EXCISION OF KNEE. 
 
 241 
 
 Non-subperiosteal Excision of the Knee Joint. — Flex the leg 
 to a right angle and make a curved incision, beginning at 
 the posterior border and upper portion of one condyle, 
 around to the same point on the outer, with the convexity- 
 downward and corresponding to the insertion of the liga- 
 mentum patella (Fig. 239). This incision divides the tissues 
 down to and opens the anterior portion of the capsular 
 ligament. The limb should now be still more strongly flexed 
 and the lateral and crucial ligaments divided. A retractor 
 is then passed between the ligamentum posticus and the 
 posterior surface of the femur, the bone pushed forward 
 and cut off on a line parallel with the articular surface, pro- 
 vided the extent of the diseased bone will admit of it. The 
 head of the tibia is then treated in the same manner, being 
 careful to avoid the articulation of the fibula. 
 
 In this operation it is better to re- 
 move the patella, since its means of 
 attachment (the ligamentum patel- 
 la) has been severed. All inflamed 
 and degenerated synovial membrane 
 should be dissected away. 
 
 The bony surfaces should now be 
 united by passing annealed iron 
 wire or silver, through the con- 
 tiguous lateral borders; the wound 
 is then washed with the strong car- 
 bolic solution and a drainage tube 
 passed from side to side through the 
 joint behind the bones; the whole en- 
 veloped in the antiseptic dressing, and 
 the limb immovably fixed in a brack- 
 eted plaster splint, properly suspend- 
 ed. In sawing through the exposed ex- 
 tremities of either bone, the line of in- 
 cision must be made to include the 
 whole of the diseased osseous tissue. 
 The line of section through the bone 
 last sawn must correspond in direc- Fig. 240. 
 
 tion and be parallel with the line of section through the 
 bone to which its sawn surface is to be applied, otherwise 
 the union of the sawn surfaces will cause an angular de- 
 formity (Fig. 240). This applies more particularly to 
 those cases where anchylosis in the straight position is 
 sought. If for any reason it be thought better to anchylose 
 
242 
 
 OPERATIVE SURGERY. 
 
 it with slight flexion, then the thicker portion should be 
 taken from the posterior parts of the bone. 
 
 Subperiosteal Exsectio7i of Kne-e Joint. — Extend the limb and 
 make a curved incision (Langenbeck) on the inner side from 
 six to seven inches in length, with the convexity downward, 
 corresponding to the posterior border of the condyles and its 
 centre to the line of articulation, commencing at the inner 
 border of the rectus femoris and terminating below at the 
 crest of the tibia (Fig. 241). If the parts are now separated, 
 
 the vastus internus muscle and the 
 tendons of the adductor magnus 
 and sartorius will be seen (Fig. 
 242), and should be carefully 
 avoided. Divide the internal lat- 
 eral ligament in a line with the 
 articulation, with the periosteal 
 elevator, separate the capsular 
 ligament from the anterior surface 
 of the inner condyle of the femur 
 up to the vastus internus, and from 
 the tibia forward to the median 
 line, along with the internal alar; 
 extend the leg slowly and at the 
 same time dislocate the patella 
 outward by the thumb applied 
 to the inner border; divide the 
 crucial ligaments, also the exter- 
 nal lateral, and the corresponding 
 portion of the capsular by a semi- 
 lunar incision carried a few lines 
 below the tip of the external con- 
 dyle. Divide the posterior por- 
 tion of the capsule and force the 
 extremities of the femur and tibia 
 successively through the wound, 
 and saw them as before. The 
 patella remains unmolested, except it be diseased, when 
 the diseased portion is removed with a gouge, or the 
 bone can be enucleated from the periosteal surroundings 
 by the elevator and scalpel. A small opening should 
 now be made at the outer side of the joint, for the purpose 
 of establishing thorough drainage. A drainage tube should 
 be passed through the upper synovial pouch, or firm com- 
 pression be made thereon to prevent the collection of inflara- 
 
 FlG. 
 
EXCISION OF KNEE. 
 
 243 
 
 matory products. It is then cleansed, all hemorrhage 
 stopped, surrounded by antiseptic dressing, and immovably 
 fixed till future dressings become necessary. 
 
 _ .gracUii 
 — fimimtmSA 
 
 Fig. 242. 
 
 T^e subperiosteal of Oilier is made through an incision 
 commencing two inches above and to the outer side of the 
 patella, carried down to its upper and outer 
 angle, along the outer border to the apex and 
 outer side of the ligamentum patella below its 
 insertion, through the superimposed tissues 
 (Fig. 243). The outer condyle of the femur is 
 denuded of its periosteum along with the later- 
 al and capsular ligaments and the outer head 
 of the gastrocnemius; the anterior surface of 
 the femur is denuded, the crucial ligaments 
 cut, patella displaced inward over the inner 
 condyle, the leg is then flexed and carried in- 
 ward; causing the femur to protrude, when 
 it is isolated and sawn off. The upper end of 
 the tibia is then denuded from above down- 
 ward, pushed through the opening and like- 
 wise divided. If the patella be diseased, re- 
 move it, leaving its periosteum behind. 
 
 Excision of the Patella. — It may be neces- 
 sary, on account of necrosis or injury, to 
 
244 OPERATIVE SURGERY. 
 
 patella independently of the tibia and femur. In such 
 cases the deep incisions must correspond in extent to the 
 diseased bone-; for if they be greater the synovial cavity 
 may be opened. The periosteum should be raised, dead 
 bone carefully removed, if possible, without entering the 
 joint. If the joint be not involved, recovery will be speedy 
 and satisfactory under disinfectant dressing, with the limb 
 confined in the extended position till sufficient repair has 
 taken place to warrant flexion without fracture of the bone. 
 The results in eleven cases are two deaths and nine recov- 
 eries, of which eight were complete and three partial ex- 
 cisions. 
 
 Excisions of the Hip Joint. — It is well before attempting 
 this operation to give a brief survey of the important liga- 
 ments and muscular attachments to be respected. The 
 space is too limited to describe them in detail, and even 
 to do so would hardly be in keeping with the scope of this 
 work. 
 
 The ilio-femoral, capsular, cotyloid, and even the teres, 
 should be carefully considered in relation to their origin 
 and insertion, in order that their relations with the involu- 
 criypi or periosteum may be maintained. Those muscles 
 which are connected with the trochanters major and minor, 
 should likewise be preserved intact, in order that their as- 
 sociation with the new bone growth may give to the new 
 joint, so far as possible, the normal functions of the old 
 one. The results of this operation are approximately 
 as follows: 90 per cent die, when done for gunshot in- 
 juries. Of these, the greater percentage (48) followed the 
 intermediate operation; 15 per cent the secondary, and the 
 remainder the primar}^ For disease the mortality is 
 reported variously from 15 (Sayre) to 45 per cent. Is best 
 done from one to ten years of age; and is most favorable 
 when it has existed from ten to fifteen months. A greater 
 number die from complete than partial excisions. The 
 rate of mortality is but little modified by the removal of 
 the trochanters, and even the upper portions of the shaft, 
 diminishing, however, from the head of the bone down- 
 ward, and increasing in proportion to the extent of the 
 disease of the ilium. About 94 per cent secure useful 
 limbs, when excised for disease. Complete excision is fol- 
 lowed by a more useful limb than partial. 
 
 The hip joint may be removed with or without the pres- 
 ervation of the periosteum; giving two quite distinct forms 
 
EXCISION OF HIP. 
 
 245 
 
 of operating, i. The simple, when no effort is made to 
 save the periosteum, and the muscular and ligamentous 
 attachments are freely sacrificed. This method is applica- 
 ble to malignant disease of the bone, and to injuries caus- 
 ing extensive comminution and laceration. In the latter 
 case, a conscientious search will often be repaid by finding 
 
 Fig. 244. 
 
 periosteal tissue and muscular attachments worthy of care- 
 ful preservation. Under all circumstances the acetabulum 
 should be carefully scrutinized for the presence of dead 
 bone, which should, in all instances, be removed with care, 
 else the pelvic contents may be injured. 
 
 Operation (White). — The simple method is done by placing 
 
246 
 
 OPERATIVE SURGERY. 
 
 the patient on the healthy side, and making a deep curved 
 incision (Fig. 244) commencing at a point midway between 
 the anterior superior spinous process of the ilium and the tro- 
 chanter major, and passing backward around the top of the 
 trochanter, down its posterior border about three inches: 
 with a stout knife divide the insertions of the muscles con- 
 nected to the great trochanter (Fig. 245), draw them aside 
 
 Fig. 245. 
 
 with a spatula, and expose the posterior surface of the neck 
 of the femur and the acetabulum. The exposure will be still 
 more complete if the femur be rotated strongly inward. 
 If the cotyloid and capsular ligaments be now divided, and 
 the thigh be flexed and adducted, the head of the bone will 
 be raised from the acetabulum sufficiently to admit of the 
 division of the ligamentum teres, when the complete escape 
 of the head of the fernur will take place. The soft part§ 
 
EXCISION OF HIP, 
 
 247 
 
 are then protected by the spatula, the bone exposed the re- 
 quired extent, and sawn off (Fig. 246). 
 
 Subperiosteal Excision of the Hip Joint (Langenbeck). — 
 Place the patient on the sound side with the thigh flexed 
 at an angle of 45°; make an incision five or six inches in 
 length in the long axis of the great trochanter (Fig. 247) 
 
 Fig. 346. 
 
 upward and backward towards the posterior superior 
 spine of the ilium, through the fibres of the gluteus maxi- 
 mus, fascia lata, and periosteum of trochanter; separate 
 the surfaces of the wound with retractors, and with the ele- 
 vator and knife raise the periosteum and the attachments of 
 the muscles inserted into the trochanter major and the con- 
 tiguous surfaces, being careful to preserve their connections 
 with each other; next make a longitudinal incision along 
 the neck of the femur, through the capsular ligament and 
 
248 
 
 OPERATIVE SURGERY, 
 
 the periosteum. The periosteum of the neck is then sepa- 
 rated in connection with the attachments of the capsular 
 ligament, and the obturator externus in the same manner 
 as before. If a piece be now cut from the cotyloid liga- 
 ment, and the thigh be rotated inward and adducted, the 
 head of the bone will be elevated from the floor of the aceta- 
 bulum sufficiently to admit of the division of the ligamen- 
 tum teres, when it can be pushed through the opening and 
 sawn off. 
 
 The following admirable method of excision is recom- 
 
 mended by Prof. Lewis A. Sayre. It is subperiosteal in 
 
 all essential particulars, and possesses an advantage over 
 the one just described in that the primary incision is better 
 adapted to drainage. Place the patient on the sound side 
 and introduce a strong knife dov/n to the bone, midway 
 between the anterior spinous process of the ilium and top 
 of the trochanter major; carry it in a curved course upon 
 the bone to the top of the great trochanter midway between 
 
EXCISION OF tin?. 
 
 m 
 
 its posterior border and centre; complete it by carrying 
 the knife forward and inward, making the length of the 
 incision from four to six or eight inches, depending upon 
 the size of the thigh (Fig. 248). If it be not certain that the 
 periosteum of the trochanter 
 be divided by the first in-^ision, 
 the knife should be carried 
 along the same line a second, 
 and even a third time if needs 
 be. The soft parts are now' 
 drawn asunder, exposing the 
 great trochanter, when, with a 
 narrow, thick knife, a second 
 incision is made through the 
 periosteum only, at right an- 
 gles with the first, about an 
 inch or an inch and a half from 
 the top of the trochanter. At 
 the junction of the periosteal 
 incisions introduce the blade of 
 the elevator, and carefully peel 
 the periosteum from either side 
 as far as possible, together 
 with the ligamentous attach- 
 ments, until the digital fossa 
 is reached. The insertions of 
 the rotators into the trochanter 
 major and digital fossa are so firm that it will be impossi- 
 ble to peel them off; they must be carefully separated by 
 short parallel cuts, so directed as to remove the periosteum 
 with which they are blended. After the separation of the 
 tendinous insertions, continue to elevate the membrane 
 upon either side of the neck, using great care not to rup- 
 ture it. Its integrity is important to prevent infiltration 
 into the surrounding tissues, provide attachments for the 
 important ligaments and muscles, also as the basis for the 
 reproduction of bone which is hoped will take place; each 
 of which will exert an important influence in the formation 
 of a useful joint. Having separated the periosteum so far 
 as safely can be done, adduct the thigh carefully when it 
 will be raised from the acetabulum, and the remaining por- 
 tion can be detached. Adduct and depress the femur 
 slightly, being careful not to tear the periosteum, lift the 
 head of the bone out far enough to admit of a division just 
 
 Fig. 248. 
 
250 OPERATIVE SURGERY. 
 
 above the trochanter minor; care should be taken to not 
 expose a greater surface than is necessary, since necrosis 
 will follow and hinder recovery. It is better to remove the 
 trochanter major, even though it be not diseased, since it 
 will impede the escape of discharges, and is not essential 
 to a useful limb if its periosteal covering and muscular at- 
 tachments have been preserved. In all cases after the 
 operation, the wound should be well irrigated with a strong 
 solution of carbolic acid, thoroughly smeared with balsam 
 of Peru, and loosely filled with fine, well-shaken oakum; 
 good drainage provided, and extension applied to the limb 
 either by the Buck's apparatus or the wire breeches. 
 
 Excision of the Great Trochanter. — This is occasionally re- 
 quired on account of caries. A longitudinal or curved in- 
 cision is made down upon the bone, which is removed with 
 the usual instruments. The circumflex branches and the 
 capsular ligament are to be avoided. 
 
 Fig. 249. 
 
 Excision of the Calcaneum. — It is important that as much 
 as possible of the bone be saved, as it forms the posterior 
 pillar of the arch of the foot, also the attachment of the 
 tendo-Achilles, which exerts a powerful influence in locomo- 
 tion. When gouging fails to remove the diseased tissue, 
 excision becomes the final resort. A horseshoe-shaped 
 incision is carried from a little in front of the calcaneo- 
 cuboid articulation around the base along the side of the 
 foot to a corresponding point on the opposite side. This 
 flap, with the knife hugging the bone, is dissected up, ex- 
 posing its entire under surface (Fig. 249). A second 
 perpendicular incision about two inches in length is then 
 made through the middle of the tendo-Achilles down to the 
 preceding one ; the resulting flaps are dissected off closely 
 to the bone, and the posterior articulation between the cal- 
 
OSTEOTOMY. 25 1 
 
 caneum and the astragalus opened, the ligamentous con- 
 nections severed, together with those between it and the 
 contiguous bones, the os calcis taken away, and any ad- 
 ditional diseased bone removed. The larger majority of 
 cases recover with useful limbs. 
 
 Excision of the Astragalus. — This is accomplished through 
 a semilunar opening, with the convexity downward, ex- 
 tending between the malleoli in front. The tendons of 
 the extensor muscles must be carefully pushed aside; its 
 connections with the tibia, fibula, and os calcis severed; 
 finally, those with the scaphoid ; when, with the foot ex- 
 tended, the bone is pulled from its site and the calcaneum 
 4)laced in the resulting gap between the malleolus. About 
 75 per cent of these cases recover with useful limbs. 
 
 OSTEOTOMY. 
 
 In a liberal acceptation, osteotomy may be defined as a 
 section of bone. 
 
 In a limited sense, however, it is applied to the divisions 
 of bone that may be attempted for the relief of deformity, 
 dependent on anchylosis, rickets, badly united fractures, 
 
 Fig. 250. 
 
 etc., etc. It may be done either with or without antisep- 
 tics. The latter, however, is by far the better plan. 
 
 The instruments employed consist of especially designed 
 saws, chisels, osteotomes, mallets, scalpels, blunt hooks, 
 and sand pillows. . ..... 
 
252 
 
 OPERATIVE SURGERY. 
 
 There are various forms of saws employed, named usually 
 after the one who designed them. Langenbeck (Fig. 250), 
 Adams (Fig. 251). The blade is short and strong; one fourth 
 of an inch in width and an inch and a half in length, con- 
 nected to the handle by a strong shank three inches long. 
 Deviations from this one are to meet especial indications, 
 rather than to abrogate its use. 
 
 The objections to the use of the saw not only apply to 
 
 Fig. 251. 
 
 the danger of lacerating the contiguous tissue, but more 
 forcibly to the retention in the wound of the bone-dust, 
 which, failing to be absorbed, is followed by suppuration. 
 The saw devised by Dr. George F. Shardy, of this city, is 
 the best, and is described as follows by himself: 
 
 Fig. 252 (i, 2, and 3). 
 
 Figs. 252 and 253. The instrument consists of a trocar 
 (Fig. i) and a staff (Fig. 2), with a handle and blunt ex- 
 tremity. A portion of this shaft at a short distance from 
 the extremity is flattened, one edge (B) being made into a 
 knife blade, and the other (C) being provided with saw- 
 teeth. This shaft (Fig. 2) is intended to replace the trocar in 
 the canula after the latter is introduced. When in position 
 (Fig, 3) either the saw (C) or the knife (B) edge of the 
 
§HRADY*S SAW. 
 
 253 
 
 shaft, according to the way the latter is turned, corresponds 
 with the opening of the canula. The saw or knife can then 
 be worked to and fro within the canula by a piston-like 
 movement, the canula being steadied by grasping the flange 
 (D) at its base. If it be necessary 
 to work the instrument as an or- 
 dinary blunt-pointed sheathed saw 
 or knife, the shaft can be fixed in 
 the canula, and made into one 
 piece by a thumb-screw in the 
 handle. The portion of the canu- 
 la at the back of the opening is 
 made extra strong, and is of the 
 same thickness as the blade, so that 
 in sawing there is no stoppage of 
 the passage of the instrument 
 through any thickness of the bone. 
 The soft parts are protected from 
 injury, no matter which way the 
 instrument may be worked. The 
 saw-blade is blunt at its extremity, 
 and is guarded on all sides except 
 in its limited cutting surface. The 
 same may be said of the knife. 
 The working of the saw to and fro 
 in the canula is sufficient in sweep 
 to insure the division of any bone 
 having a diameter less than the 
 cutting edge. Still, as this pro- 
 cess is much slower than when 
 the saw is used in the ordinary 
 way, it ts perhaps better to restrict 
 its employment to operations on the 
 smaller bones, to cramped localities, 
 and to situations where there is 
 special danger of wounding some 
 neighboring vessels. All that is 
 necessary in using this saw is to 
 thrust the trocar and canula into 
 the limb, the fenestrum of the can- 
 ula being alongside of the bone upon which the operation 
 is to be performed. The trocar is then withdrawn, the 
 staff introduced in its place (Fig. 3), and worked as already 
 described. 
 
 Fig. 253. 
 
254 
 
 OPERATIVE SURGERY. 
 
 Since the above description was written the instrument 
 has been slightly modified by lessening the size of the fe- 
 nestrum through which the teeth of the saw are seen, which 
 strengthens the canula and facilitates its progress through 
 the bone (Fig. 253). 
 
 The Chisel is like that of the carpenter, but differing in 
 its temper; it has two parallel sides extending to its cutting 
 
 Fig. 254. 
 
 edge. The cutting surface has one side straight and the 
 other bevelled; it should be one eighth of an inch thick at 
 the base of the bevel. If thicker, it may splinter the bone. 
 The breadth varies according to the size of the bone, one 
 half an inch is suitable in the majority of cases. For nar- 
 row bones one fourth inch is better (Fig. 254). The width 
 should always be less than the bone to be attacked. 
 
INSTRUMENTS FOR OSTEOTOMY. 2^5 
 
 The temper of the tools of the hard-wood or ivory turner 
 is best suited for the purpose, and its efficiency should be 
 tested upon the thigh-bone of an ox or other animal before 
 using. 
 
 Its edge should be sharp, leaving a smoothly cut sur- 
 face. This instrument is employed only to remove a wedge- 
 shaped piece from the bone, since the shape of its cutting 
 extremity will, as with the carpenter's chisel, cause it to go 
 awry if a straight section be attempted. 
 
 The Osteotome. — This instrument is bevelled on both edges 
 (see Fig. 254), resembling a slender wedge; the handle and 
 the blade forming one piece. The top should have a round 
 head, against which the thumb is pressed to steady it. 
 One border of the blade is delicately marked in inches to 
 determine the depth of the incision. The edge should be 
 sharp enough to cut the finger-nails, and the temper of a 
 character to withstand the strain required. It can be tested 
 upon the thigh-bone of the ox; when, if it neither turn nor 
 chip, it is calculated to withstand the test of human bone. 
 Osteotomes should vary in thickness, in order that a section 
 begun by one of a given thickness may be continued on its 
 withdrawal by the substitution of one of a lesser thick- 
 ness. 
 
 The Mallet is made of hard wood, and can be constructed 
 for the purpose; or, an extemporized one maybe employed. 
 
 The Scalpel is an ordinar}' one, with a sharp point suitable 
 for penetrating at once to the bone. Blunt hooks to draw 
 the cut asunder are employed, without force. 
 
 The Sand Pillow. — Its dimensions should be about eigh- 
 teen inches by twelve; made of stout cloth, and filled suffi- 
 ciently to permit its contents being moved from one part of 
 the bag to another, without leaving a portion empty. It 
 should be dampened before being used, covered with car- 
 bolized cloth, and the limb laid upon, or rather embedded 
 in it. It forms an efficient support, and prevents the force 
 imparted to the bone by the mallet injuring the soft parts. 
 
 The opening through the soft parts leading down to the 
 point of proposed section should be limited in extent, and so 
 located as to avoid the division of vessels, or injury to a joint. 
 It should be made in the long axis of the fibres of any mus- 
 cle through which it passes when practicable, down to, but 
 not through the periosteum. The scalpel should remain in 
 the incision till the danger of muscular contraction ceases, 
 and then the chisel or osteotome is passed into the incision 
 
256 
 
 OPERATIVE SURGERY. 
 
 by the side of the blade, as a guide, when it can be with- 
 drawn. 
 
 It is better that the wound be large enough to admit the 
 finger, or even to permit inspection of the bone, than that 
 the tissues around a small incision be treated with violence, 
 in the effort to accomplish the purpose. 
 
 If chips of bone are to be removed, a larger incision is re- 
 quired than if a simple section be intended. The patient 
 should in all instances be anaesthetized and the limb ren- 
 dered bloodless by the elastic bandage of Esmarch or Mar- 
 tin. All cutting instruments employed must be made anti- 
 septic, and in all other respects the operation must be per- 
 formed with antiseptic care. 
 
 Subcutaneous Division of the Neck of the Femur (Adams). 
 — Place the patient upon the side, with the bone to be op- 
 erated upon uppermost. Introduce a long slender scalpel 
 or tenatome above the top of the great trochanter, straight 
 down to the neck of the femur; di- 
 vide the muscles and open the cap- 
 sule freely on the anterior and upper 
 surface; pass the small saw by the 
 side of the knife along the track 
 down to the anterior surface of the 
 neck, which is then sawed transversely 
 ~ through (Fig. 255) sufficiently from 
 before backward to be easily broken. 
 The limb is then placed in position, 
 the wound irrigated with a solution 
 of carbolic acid (i to 20), to render it 
 aseptic and wash out the bone-dust; 
 hemorrhage checked, a small drain- 
 age tube introduced, the remaining 
 portion of the incision closed, the 
 whole enveloped in antiseptic dress- 
 ing, and the limb placed in an im- 
 Such tendinous contractions as inter- 
 fere with the limb being placed properly, should be severed 
 subcutaneously. 
 
 This operation has been successful in thirty-one out of 
 thirty-four cases. 
 
 Maunder, Billoth, and others have used the chisel with 
 forcible fracture with good results. Another method 
 (Volkmann) consists in forming a false joint in the follow- 
 ing manner: 
 
 Fig. 255. 
 movable position. 
 
OSTEOTOMY. 
 
 257 
 
 Make an incision along the posterior surface of the great 
 trochanter,* and divide the bone one inch below its upper 
 border; fracture the interior of the neck of the femur and 
 scoop out the acetabulum with a gouge. Round off the 
 upper end of the femur, reducing it to the size of the shaft 
 below, and place it in the cotyloid cavity; apply extension 
 to the limb, and make early passive motion. Volkmann 
 has done this operation several times, resulting in useful 
 limbs in each instance. 
 
 Inter-irochanteric Osteotomy. — This operation consists in ex- 
 posing the anterior, outer, and posterior surfaces of bone 
 through an incision about six inches in length, beginning 
 just above the tip of the trochanter major, and carried lon- 
 gitudinally through the centre of its outer surface. A 
 short, transverse incision is then joined to the centre of the 
 posterior lip of the first; the respec- 
 tive surfaces are then exposed with 
 an elevator until the trochanter 
 minor can be felt, when a chain saw 
 is passed around the bone immediate- 
 ly above this process. The upper- 
 most, or curved incision (Fig. 256) is 
 made by first sawing upward and 
 outward, until the bone is one half 
 severed, then changing the direction 
 downward and outward and com- 
 pleting the section. 
 
 The second section is made by 
 sawing directly through the bone in 
 its transverse axis, removing a piece 
 one eighth of an inch thick at its 
 outer and posterior border, and three fourths of an inch of 
 its central part. 
 
 The upper end of the lower fragment is then rounded 
 to fit the concavity above. The limb is straightened out and 
 treated like a compound fracture. 
 
 This method was practiced by Dr. Sayre some time since 
 with eminent success. 
 
 The removal of a disk of bone in this situation has been 
 quite frequently practiced, but with indifferent success. 
 Out of the 17 cases reported, 7 died. While this method 
 displayed great ingenuity and resource on the part of the 
 
 Fis. 256. 
 
 * Ceatralblatt Chirurgie, Jan. 31st, 1880. 
 
258 OPERATIVE SURGERY. 
 
 originator, the fatality attending it, together with the intro- 
 duction of the chisel and osteotome, render it at the pres- 
 ent time impracticable. 
 
 The modification introduced by Volkmann in 1873 con- 
 sists in making an incision along the posterior surface of 
 the great trochanter and removing the periosteum from 
 two thirds of its circumference, when with chisels and 
 gouges a triangular piece is taken from just below the 
 trochanter, the bone broken, straightened, and placed in 
 proper position until union has taken place. Of the twelve 
 operations thus performed, all recovered. 
 
 Osteotomy for Bony Anchylosis of Knee Joint (supra-con- 
 dyloid). — Make a longitudinal incision, sufficient to admit 
 the osteotome, at the outer side of the rectus tendon, one 
 finger's breadth above the upper portion of the outer con- 
 dyle. The osteotome is introduced, and turned so its cut- 
 ting surface corresponds to the transverse axis of the bone 
 at the point to be divided; with the limb resting up on the 
 sand-bag, the bone is two thirds divided and the remainder 
 broken or bent. If performed from the inner aspect, the in- 
 cision is made along the anterior border of the tendon of 
 the adductor magnus, beginning one inch above the inser- 
 tion. The remaining steps of the operation are similar to 
 the preceding. It may be necessary to supplement the sec- 
 tion of the femur with that of the tibia, in order to correct 
 the deformity sufficiently. This is done by making an in- 
 cision through the skin over the tibial crest just below the 
 tuberosity. Through this opening, the subcutaneous and 
 posterior surfaces of the tibia are divided sufficiently to 
 admit of a fracture and the consequent correction of the 
 deformity. The fibula, owing to its mobile association with 
 the tibia, does not require division. It is often necessary, 
 however, to cut the hamstring tendons before the deformity 
 can be properly corrected. Supra-condyloid osteotomy has 
 yielded most satisfactory results. In 522 operations for all 
 causes, not a single death attributable to it has occurred. 
 All of the patients were benefited, and many were able to 
 take an active part in affairs from which they had been de- 
 barred. 
 
 Supra-co7idyloid osteotomy for Genu Valgum (Fig. 257). — In 
 this operation care is taken to avoid the popliteal vessels, 
 anastomotica magna, superior internal articular arteries, 
 and the synovial pouch. The incision in the soft parts is 
 rn^de at the inner side of the limb, beginning a finger's 
 
OSTEOTOMY. 
 
 259 
 
 breadth above the tendon of insertion of the adductor mag- 
 nus into the upper portion of the internal condyle and half 
 an inch in front of it, and carried upward sufficiently to 
 admit the osteotome. The course of this incision avoids 
 as far as possible any interference with the anastomotica 
 magna and the articular b'-anches. The osteotome is applied 
 to the bone transversely at the point indicated by the dotted 
 line in Figure 258, and so directed that its course will cor- 
 respond to a line extending across the posterior surface of 
 the femur to a point one finger's breadth above the external 
 condyle. The extent of the osseous incision depends upon 
 the density of the bone ; if the subject be young, it can be 
 bent or broken, if it be cut through two thirds of its diame- 
 
 FiG. 357. 
 
 Fig. 958. 
 
 ter. If it be dense, it will be necessary to carry the inci- 
 sion to the outer wall. The posterior and inner surfaces of 
 the bone are cut, if necessary, using a finer chisel to com- 
 plete the operation. When the bone is sufficiently divided, 
 the limb is straightened, all hemorrhage arrested, and the 
 limb treated as before indicated. The following figures 
 will aid in explaining the method : 
 
 Fig. 259 shows a long internal condyle in genu valgum ; 
 Fig. 260 a section through about three fifths of its diameter; 
 Fig. 261 the appearance of the bone with the limb placed 
 in position, showing the curvature rectified. The results 
 Qf this operation, with reference to usefulness of the limb. 
 
26o 
 
 OPERATIVE SURGERY. 
 
 cure of the deformity, and danger to life, are most flatter- 
 ing. 
 
 Osteotomy for Genu Varum. — In this deformity the opera- 
 tive proceedings are directed to the outer instead of the 
 inner side of the bones of the leg and thigh. The proced- 
 ure, precautions, and treatment are similar. The division 
 of bones through a small external opening can be applied 
 almost indiscriminately to such as present this deformity, 
 always remembering that thorough and complete antisep- 
 tic precautions should be taken. The results are most flat- 
 tering, and commend it to the consideration and practice of 
 the profession. 
 
 Bow-legs. — Genu varum may depend on an outward 
 curvature of the bones of the leg, wholly or in part. In 
 
 Fig. 259. 
 
 Fig. 360. 
 
 Fig. 261 
 
 either instance the deformity can be corrected by a sub- 
 cutaneous osteotomy of the tibia. If the patient be young 
 enough a green-stick fracture of the fibula will obviate the 
 use of the osteotome upon it. 
 
 Operation. — Make a longitudinal incision at the point of 
 greatest curvature, an inch or so in length, midway between 
 the borders of the subcutaneous portion of the bone. Sepa- 
 rate the tissues, introduce the osteotome and cut the bone 
 transversely until the remaining portion can be fractured. 
 Cut or bend the fibula, correct the deformity, and treat 
 antiseptically. It is sometimes necessary to divide the bone 
 in two situations to secure good position. If so, it should 
 be done at another time, and at the remaining point of 
 
OSTEOPLASTY — AMPUTATIONS. 261 
 
 greatest convexity. It is much safer to cut both tibiae than 
 to divide either in two situations at the same time. 
 
 OSTEOPLASTY, 
 
 Or transplantation of bone. 
 
 This has not gained the prominence as a surgical expedi- 
 ent that the knowledge of the laws governing the growth 
 of bone bids fair to lead to. 
 
 Bone associated with its periosteal and fibrous connec- 
 tions, has been transferred, as in the case of the operation 
 on the hard palate for the closure of a fissure, also the clos- 
 ure of the spaces between the ununited fragments of bone, 
 by the filling of them with freshly sawn sections from the 
 main shaft. The conditions necessary to a successful issue 
 of this operation are exceedingly numerous and exacting. 
 
 AMPUTATIONS. 
 
 Amputation consists in the removal of a limb either in 
 its continuity or at its articulation. The aims sought to 
 be gained by an amputation are : i. The saving of the life 
 of the patient. 2. The securing of a serviceable limb. 
 
 If the prospects of recovery be annulled by the presence 
 of a badly diseased or mangled limb, it is no opprobrium 
 upon the Art to remove it. If a limb be so badly injured or 
 diseased as to require removal, it is entirely proper that the 
 ability of the designer of compensative appliances be con- 
 sidered, that the patient may reap the combined benefit of 
 the art of the surgeon and the ingenuity of the mechanic. 
 A stump, to be serviceable, should be sound, unirritable, 
 with a good circulation and abundant leverage. The first 
 three qualities depend, all things being equal, very largely 
 upon its length, shape, and vascular supply of the flaps; the 
 last one depends entirely upon the length of the bone. The 
 flaps should be movable over the extremity of the stump 
 after healing is completed, not tightly drawn and smooth, 
 like a base-ball cover. Flaps tightly drawn at the initial 
 
262 
 
 OPERATIVE SURGERY. 
 
 dressing soon become more so, on account of inflammatory 
 action. At a later date, the normal shrinkage of the integu- 
 ment draws them against the end of the bone, to which they, 
 together with the cicatrix, become immovably united, and 
 form a good basis for a troublesome stump. The proper 
 length of the flaps, then, becomes an important point in es- 
 timating the prospective usefulness of the limb and comfort 
 of the patient. In cases where they can be made of similar 
 lengths, their extent should correspond to about one fourth 
 the circumference of the limb at the point where the bone is 
 to be divided. If one flap only be employed, it should be 
 
 Fig. 263. 
 
 double the length of the two. Any increase in the length 
 of one should be accompanied by a proportionate decrease 
 in the length of the other. The shape of the flaps largely 
 controls the site of the cicatrix. It is advisable that the 
 cicatrix be so placed as not to be subjected to pressure or 
 friction. If, however, the flaps be made of sufficient length 
 to admit of the formation of a non-adherent or movable 
 cicatrix, its location is a matter of secondary importance. 
 The length and location of the flaps also largely controls 
 their circulation. If they be too long, the circulation will 
 be enfeebled ; if, on the contrary, they be too short, the 
 tension will become the greater impediment, causing a 
 
AMPUTATIONS. 
 
 263 
 
 blue, cold, and shiny surface, sensitive to the slightest 
 injury. The circulation in the normal limb, or a portion 
 
 Fig. 263. 
 
 of it, may be such as to predispose to a small and sluggish 
 blood supply in flaps constructed from it. 
 
 Flaps are classified, according to the tissues entering into 
 them; into the cutaneous, integumentary, or skin flaps, mus- 
 
264 
 
 OPERATIVE SURGERY. 
 
 culo-cutaneous, muscular, and periosteal. The integumen- 
 tary is commonly employed in this city. 
 
 They are also classified, accordmg to their shape^ into 
 circular, modified circular, oval, rectangular, hood, etc. 
 
 Fig. 264. 
 
 The oval may be either unilateral, bilateral, anterior, or 
 posterior. Many of the preceding may be composed of 
 integument alone, or, combined with muscular tissue, and 
 even periosteum. 
 
 Circular Method (Fig. 262). — This method is followed by 
 
CIRCULAR AMPUTATION. 
 
 265 
 
 an admirable stump, is easiest of performance, and con- 
 sequently very frequently practised. It is done by mak- 
 ing a circular incision transversely around the long axis 
 
 Fig. 265. 
 
 of the limb, through the integument and subcutaneous tis- 
 sue down to the muscles, at a distance below the proposed di- 
 vision of the bone, corresponding to one fourth the circum- 
 ference of the limb at that point. The flap is then dissected 
 
266 
 
 OPERATIVE SURGERY. 
 
 up from the muscles with an ordinary scalpel; its edge 
 being directed towards the muscles (Fig. 263) rather than 
 parallel with them (Fig. 264), as the latter severs the capil- 
 lary connection between the integument and the deeper 
 tissues. The dissection should be done by circular sweeps, 
 rather than mincing cuts, which hack the tissues and pro- 
 voke suppuration. This careful manner of raising the flap 
 applies equally to all of the varieties which involve the 
 separation of similar tissues. 
 
 If the limb be conical, much difficulty will be experienced 
 in turning over the sleeve of integument, which can be ob- 
 
 FlG. 266. 
 
 viated by making a longitudinal cut at the most dependent 
 portion. 
 
 The flap should be turned upward to the point where 
 the bone is to be divided; then with the catling make a cir- 
 cular division of the muscles down to the bone (Fig. 265); 
 beginning far enough below the reflection of the flap to 
 allow for the retraction for the divided muscles. No def- 
 finite law can be assigned to this element, although they will 
 contract according to their size, length, degree of irritabil- 
 ity, etc. The suitable point of section will appear in con- 
 nection with the description of the special amputations, 
 
FLAP AMPUTATION. 
 
 267 
 
 Not infrequently the muscles are cut just below the reflec- 
 tion of the flap, as in Fig. 267; this is not, however, as good 
 a plan as the former, since sensitive stumps are more liable 
 to result therefrom. The bone is sawn at the highest point 
 of exposure. 
 
 Modified Circular Method (Fig. 267). — This plan was sug- 
 gested by Mr. Liston, who made semilunar flaps, which he 
 dissected up to their point of junction with each other, 
 when the muscles and bone were divided, as in the circular 
 method. This was afterward modified by Mr. Symes, who 
 dissected the flaps a short distance above their point of 
 
 Fig. 267. 
 
 juncture, and divided the muscles and bone, as before. In 
 either instance, however, it amounts to slitting up the cuff of 
 a circular flap, and trimming off the angles caused thereby. 
 
 Oval Method is in reality a modified circular, slit up at 
 one side and the angles trimmed off. It is employed princi- 
 pally in disarticulations, and will be described in connection 
 with those operations. 
 
 Single Flap Met/iod. — This is adapted to those cases 
 where the tissues of one side of the limb only, are suitable 
 for the purposes of a flap; as, in the case of unilateral lacer- 
 ations, ulcerations, etc. This flap is composed of the 
 muscular tissues and integument, and can be made either 
 
268 
 
 OPERATIVE SURGERY. 
 
 by transfixion or division from without. If possible, a 
 short convex flap is made on the opposite side of the limb. 
 Dotible Flap Operation is made by transfixion, and includes 
 the muscles down to the bone on either side of the limb 
 (Figs. 268 and 269). The tissues to be transfixed are raised 
 slightly by the left hand of the operator, who then enters 
 the point of the knife at the side nearest himself, pushing 
 it through slowly, in close contact with the anterior surface 
 of the bone, slightly raising the handle as it passes, thereby 
 causing its point to emerge at the opposite side of the limb 
 at a point exactly opposite to its entrance; the flap is then 
 made by cutting obliquely upward with a sawing motion. 
 
 and 269. 
 
 It is pulled backwards by an assistant, and the knife is re- 
 inserted at the original point of entrance, carried behind 
 the bone, handle depressed to cause the point to emerge at 
 the same situation as at the anterior transfixion, and the 
 posterior flap made by cutting obliquely downward. Each 
 flap should correspond to at least one half the diameter of the 
 limb. The retractor is then applied, and all the soft tissues 
 are drawn well upward; the remaining fibres in contact 
 with the bone are severed, and the bone carefully sawn 
 through. If lateral flaps be made, the outer should be 
 formed first. The flap containing the large vessels is to be 
 last divided. 
 
FLAP AMPUTATIONS. 
 
 269 
 
 The Mixed Double Flap is a modification of the preceding, 
 and sometimes called Sedillot's method. The flaps are 
 made by transfixion, as before, but are more superficial; 
 the knife not being brought in contact with the bone. The 
 remaining muscles and vessels are divided by a circular in- 
 cision, and the rest of the amputation is done as before 
 described. In this instance the flaps are thinner and shorter 
 than in the preceding. 
 
 Langenbeck's Method. — This differs from the last only in 
 the manner of obtaining the result; the flaps being cut 
 from without inward, which affords a better opportunity 
 
 Figs. 270 afld 271. 
 
 to shape them. Another combination of the method is 
 made by cutting the anterior flap from without inward, 
 and the posterior by transfixion. 
 
 The Rectangular, or Teale's Method (Figs. 270 and 271). — In 
 this two rectangular flaps are employed; one being four 
 times longer than the other; both flaps include the struc- 
 tures down to the bones. The longer flap is taken from 
 the side of the limb, where the bone is the most superficial. 
 The shorter contains the important vessels. Tlie length and 
 breadth of the long flap corresponds to half the circumfer- 
 
270 
 
 OPERATIVE SURGERY. 
 
 enceof the limb at the point of proposed amputation. The 
 width of the short flap is a half, and its length an eighth of 
 the circumference of the limb. Both flaps should be care- 
 fully marked out before beginning the operation. This 
 method makes an admirable stump, but sacrifices fulcrum- 
 age, and brings the bone section nearer the body than is con- 
 sistent with the additional dangers incurred. Mr. Lister 
 recommends that the longer flap be made a third and the 
 shorter flap a sixth of the circumference of the limb, which 
 brings the cicatrix at the edge of the stump. Also that the 
 posterior flap consist of the integument and subcutaneous 
 tissues alone. This, like Teale's, may be employed when the 
 loss of tissues is greater upon one side than upon the other. 
 The Hood Flap. — There is no substantial difference be- 
 tween this and the oval method, when the latter is slit up 
 at the most dependent part. This form meets the indi- 
 cations requisite to form a good stump as well as any other 
 variety. 
 
 Equilateral Flaps (Fig. 272) consist of equilateral skin 
 . flaps, oval in outline, the posterior incision 
 being made further up the limb, to im- 
 prove the drainage. The bone is divided 
 above the anterior point of junction of 
 the flaps, and the muscles by a circular 
 sweep at a suitable distance below the 
 point of reflection of the integumentary 
 flaps. 
 
 Periosteal Flap. — This consists in raising 
 the periosteum in conjunction with the 
 tissues which rest upon or are attached 
 to it sufficiently to cover the end of the 
 divided bones; when, it is allowed to fall 
 into place. It is best adapted to those 
 bones subcutaneously located; like the 
 tibia, and will be again referred to in 
 connection with amputations of the leg. 
 
 A periosteal flap will, if it becomes ad- 
 herent to the end of the bone, preserve it 
 from atrophy, and lessen the danger of 
 the formation of a conical stump; it like- 
 wise prevents the adhesion of the cicatrix 
 Fig. 272. ^Q ^j^g stump, thereby forming the basis 
 
 for a movable scar. 
 
 If the patient be young, new bone may be developed, 
 which lessens the sensibility and increases the usefulness 
 
AMPUTATING INSTRUMENTS. 27I 
 
 of the stump. It is claimed by some that bony spicula 
 often shoot into the soft tissues on the end of the stump, 
 and require a second operation for their removal. It is my 
 opinion, however, that if the membrane be removed entire 
 and in connection with its superimposed tissues, and be so 
 placed that the force of gravity will aid in holding its bone- 
 producing surface in cortact with the divided extremity, 
 that this danger will be obviated. 
 
 Comparative Me fits of different Forms, of Flaps. — The ends 
 sought to be gained in making flaps are: i. To secure good 
 drainage. 2. To make them of suitable length that the 
 circulation and movement of the cushion at the end may be 
 free. 3. To place the cicatrix beyond the point of friction, 
 and prevent its adhesion to the end of the bone. 4. To 
 guard against any danger of undue sensibility, by making 
 the flaps of proper length, and by drawing down and cutting 
 off the cutaneous and other nerves of larger size that may 
 exist in them. With these ends in view, it will be seen that 
 the old-fashioned circular flap affords equal advantages 
 with the others, and is further commended by its simplic- 
 ity. It is true that in this method the scar will fall on the 
 end of the stump, but with proper precautions as to the 
 length of the flaps and suitable attention any danger from 
 this source is reduced to a minimum. 
 
 Agents required for Amputation may be classed as those 
 for arresting hemorrhage ; for the division and trim- 
 ming of the bone and soft parts, and, those for uniting 
 and dressing of the wound. The preparation of the patient 
 for the operation; the agents for controlling and arresting 
 hemorrhage, together with the various methods of securing 
 and maintaining the coaptation of the cut surfaces, drain- 
 age, and various forms of dressing, antiseptic and other- 
 wise, have herein been previously considered; therefore, 
 there remains to be enumerated, under this heading only 
 those instruments especially adapted to the requirements 
 of the procedure. 
 
 Amputating Knives (Fig. 273). — The modern amputating 
 knives can be used for circular flaps, or for those made by 
 transfixion. They should be double edged for an inch or 
 two from the point. The length selected will depend upon 
 the size of the limb to be operated upon, and should be 
 about one and one half times its diameter. It may be in- 
 consistent with good taste, but it is entirely consistent with 
 good judgment and economy to amputate an arm or fore- 
 
2/2 
 
 OPERATIVE SURGERY. 
 
 arm with the catling intended for the thigh, and the result 
 will be equally satisfactory. The manner of holding the 
 catling, prior to and during the division of the soft parts, 
 adds much to the optical effect of the operation. It should 
 be, at first, lightly grasped between the thumb and two 
 
 Fig. 273. 
 
 Fig. 274. 
 
 first fingers, with the edge forward, near enough to the 
 shank to admit the upper end of the handle to play between 
 the heads of the metacarpal bones of thumb and finger, 
 when it is swung backward and forward (Fig. 274). There 
 are two methods employed of carrying it entirely around 
 
METHOD OF USING KNIFE. 273 
 
 the limb. Stand with the left side toward the patient, 
 seize the limb above the point of intended operation with 
 the left hand, an assistant holding its distal extremity; 
 place the left foot forward, slightly bend the right knee, 
 and with the catling held by the right hand, as before de- 
 scribed, stoop downward and forward sufficiently to carry 
 the knife and arm under, and the knife over the limb, plac- 
 ing its heel as near to the upper surface of the limb as is 
 convenient, when, with a sawing motion, it is drawn to- 
 ward the operator beneath the limb, then upward between 
 it and the operator, and so on around, until it joins the 
 beginning of the cut, making a complete circle (Fig. 275). 
 
 Fig. 375.. 
 
 If the knife be properly grasped it will pass readily be- 
 tween the thumb and forefinger, as the hand passes around 
 the limb; enabling the surgeon to make the section with 
 perfect ease, and without the least manifestation of the 
 stiffness. The method may be reversed by passing the 
 hand and knife over, instead of under the limb (Fig. 276); 
 otherwise the manipulations are the same. The latter, 
 however, is less natural, besides which it exposes the arm 
 of the operator, and the integument to be divided last to 
 the flow of blood. Still either of these methods is far 
 superior to the one commonly employed and figured in 
 text-books (Fig. 277). 
 
274 
 
 OPERATIVE SURGERY. 
 
 Double-Edged Catliftg {¥i^. 278). — This is chiefly employed 
 to divide the tissues in the interosseous space, in amputa- 
 tions of the leg and forearm. It can be readily supple- 
 mented by the single-edged narrow knife, provided the 
 latter be withdrawn to complete the division of the interos- 
 seous tissues, instead of changing the direction of the cut- 
 ting edge, while it remains between the bones. The latter 
 act will bruise and tear the tissues. To these should be 
 
 Fig. 376. 
 
 added two or three ordinary scalpels, for raising integu- 
 ment, flaps, etc. 
 
 A knife with a long narrow blade is the better for am- 
 putating at the phalangeal articulations (Fig. 279). 
 
 Saws. — The ordinary broad bladed saw (Fig. 280) and 
 the bow-backed (Fig. 281) are in common use. The first 
 meets all requirements except in certain exsections, when 
 the chain or butcher's saw (Fig. 282) must be employed. 
 
AMPUTATING INSTRUMENTS. 
 
 275 
 
 Fig. 277. 
 
 Pig. 279. 
 
 Fig. 280. 
 
 Fig. 278. 
 
276 
 
 OPERATIVE SURGERY. 
 
 The narrow movable backed saw is of use in sawing small 
 bones, removing spiculae, etc. 
 
 The proper method of using a saw should be given some 
 attention (Fig. 283). After the section of the soft parts, 
 
 Fig. 281. 
 
 Fig. 282. 
 
 the surgeon grasps the saw firmly, places its heel close to 
 the edge of the contracted muscles, in a line made through 
 the periosteum b}'^ the knife, and slowly and carefully draws 
 it towards himself along the first four or five inches of its 
 edge, raises it from the track, and places it as before; re- 
 
METHOD OF USING THE SAW. 2^/ 
 
 peating the operation until a track of sufficient depth is 
 made to retain it during the to-and-fro movements of saw- 
 ing, which should be done by quick, sharp strokes, until 
 
 Fia 981, 
 
 the bone is neany severed, when care must be exercised, or 
 the saw will be clamped and the remaining portion be broken 
 off. If the handle of the saw be raised and the remaining 
 
278 
 
 OPERATIVE SURGERY. 
 
 portion be divided at a different angle to the bone, the 
 danger of breaking is lessened. When two bones are to be 
 sawn off, the saw should be started in the one most immov- 
 able, and then turned so as to include both. If the movable 
 one clamp the saw, cut off the more solid one first, then 
 complete the other. 
 
 K'- 
 
 Fig. 284. 
 
 Fig. 285. 
 
 Bone Forceps. — Listen's cutting forceps (see Fig. 196) for 
 trimming off rough prominences. Ferguson's lion-jawed 
 (Fig. 284) and Farabeuf's forceps (Fig. 285) are excellent in- 
 struments for grasping the bone to steady the part. They 
 are also used for removing bone by twisting, when great 
 force is required. 
 
HOW TO OPERATE. 
 
 279 
 
 How to Operate. — Before beginning an amputation, the 
 operator should rehearse in his mind at least the entire pro- 
 cedure as lie contemplates it; by doing this he will be con- 
 fident, and be certain to anticipate the unimportant as well 
 as the important details. The preparation of the patient 
 and administration of anaesthesia are given on pages in the 
 fore part of the work. The surgeon should always plan his 
 work with careful precision, even to marking out upon the 
 limb the outlines of the flaps, and such other incisions as 
 may be required. I am aware that this is seldom practised, 
 
 Fig. 286. 
 
 even by the most experienced surgeons; but within my own 
 observations, had it been done more frequently better re- 
 sults would have been secured. The young surgeon too 
 often fancies that to do this argues himself ignorant and 
 inexperienced; such, however, is not always the case; it 
 rather serves to empliasize his cautious and painstaking 
 qualities. All operations should be done without haste, 
 when the safety of the patient will permit; remembering it 
 is done quickl}^, when done well. 
 
 The operator should stand in such a relation to the patient 
 that the left hand can readily control any undue hemor- 
 rhage by compressing the artery or otherwise. 
 
280 
 
 OPERATIVE SURGERY. 
 
 The primary incision should be so located, if possible, 
 that the escaping blood will not obscure the course of the 
 remaining ones. 
 
 The incision which will divide the important vessels 
 should be made last. 
 
 In circular amputations the tissues should not be re- 
 tracted until after the division of the integument. 
 
 In flaps by transfixion, the tissues to constitute the flap 
 can be raised or depressed, as the case may be. 
 
 ^^^;¥^sS5J,=SE|^^fiE^K&' 
 
 Fig. 388. 
 
 After the limb is removed, the open mouths of the ves- 
 sels should be caught by serresfines, forceps, etc. The tour- 
 niquet, or Esmarch's band loosened slowly, and all bleeding 
 points controlled in a like manner (Fig. 286). The sur- 
 geon can then proceed carefully to ligature the vessels thus 
 secured. 
 
 The retractor is made of linen, or ordinary muslin, torn 
 according to the size and anatomical arrangement of the 
 limb to which it is to be applied. If to one with two 
 bones, one extremity should be torn into three strips (Fig. 
 
HOW TO OPERATE. 
 
 281 
 
 Fig. 389. 
 
 Fig. 
 
 390. 
 
282 OPERATIVE SURGERY. 
 
 288). The middle one to pass between the bones (Fig. 289). 
 If for one alone, it is torn partially through the middle 
 (Fig. 287), and applied as shown in Fig. 290. 
 
 AMPUTATION OF UPPER EXTREMITIES. 
 
 General Remarks. — In all amputations of the hand and 
 fingers, it is important to remember that usefulness and 
 symmetry are the points sought to be gained. If strength 
 and usefulness be a desideratum, all of those points into 
 which the muscles and ligaments that endow the part with 
 important functions are inserted should be preserved. 
 
 It therefore becomes imperative for the surgeon to care- 
 fully study the functions of the muscles associated with the 
 hand; and to preserve as carefully as possible their points 
 of insertion. It is a well-established principle that every 
 portion of the hand of a laboring man which possesses 
 movements and can become of service to him should be 
 saved. In the case of one whose circumstances or avoca- 
 tions will permit the sacrifice of usefulness to symmetry, 
 the movements may be sacrificed with the concurrence of 
 the patient. 
 
 SPECIAL AMPUTATIONS OF HAND AND 
 FINGERS. 
 
 Amputation at the Inter-Fhalangeal Articulations. — The first 
 row of surgical phalanges is flexed by the terminal insertion 
 of the flexor profundus digitorum. The second by the flexor 
 sublimus digitorum. The third by the preceding, through 
 the vincula accessoria tetidimifn ; by dense fibrous bands con- 
 necting the tendons of the flexor sublimus, with the distal 
 extremity of that phalanx as it passes across it; also by the 
 secondary action of the lumbrical muscles (Fig. 291). The 
 terminal phalanx is amputated by seizing and flexing it at 
 right angles with the second (Fig. 292); a transverse incision 
 is then made on its dorsal surface, on a line corresponding 
 to the centre of the long axis of the second phalanx, 
 
AMPUTATION OF FINGERS. 
 
 283 
 
 which will open the joint; divide the lateral ligaments with 
 the point of the knife, separate the articular surfaces, and 
 pass the blade between them along the under surface of 
 the phalanx to be removed, close to the bone (Fig. 293) 
 far enough to make a palmar flap of sufficient length to 
 easily cover the end of the bone (Fig. 294). If the attached 
 extremity of the flap be commenced by dividing the tissues 
 at each side of the phalanx for three or four lines, down to 
 the bone, the knife can then follow its under surface with- 
 
 FiG. 991. — r. Extensor communis digitorum. 2. First surgical phalanx. 3. Fi- 
 brous bands between common flexor tendons and distal extremity of the third surgical 
 phalanx. 4. Tendons of flexor sublimus digitorum. 5. Tendon of fle.xor profundus 
 digitorum. 6. Vincula accessoria tendinum. 7. Head of metacarpal bone. 8. Joint 
 between second and third surgical phalanges, g. Second surgical phalanx. 
 
 out the danger of making the attached end of the flap too 
 narrow, owing to the extremities of the phalanges being 
 thicker than their bodies. The rule previously given re- 
 garding the length of flaps will ena le the operator to meet 
 this requirement. If any of the tissue of the flexor tendon 
 be in the flap, it should be removed. T!e the vessels, 
 place and hold the flap in position by two or three fine 
 sutures and adhesive strips; or dress antiseptically. 
 
284 
 
 OPERATIVE SURGERY. 
 
 Amputation of the Second Row can be done in precisely 
 the same manner as at the first, or by making a palmar-flap 
 first by transfixion with the finger extended, through the 
 palmar surface opposite the joint and cutting downward 
 until a well-rounded flap is formed (Fig. 295). Then 
 carry the knife between the articular surfaces and through 
 the soft parts on the dorsum (Fig. 296). 
 
 Fig. 292. 
 
 Fig. 293. 
 
 Fig. 294. 
 
 Either of the phalanges may be amputated at the centre, 
 by a short posterior and a long inferior or palmar flap. If 
 the third surgical (first anatomical) phalanges be ampu- 
 tated at the centre, the power of flexion is limited to the 
 lumbrical muscle, and the vincular tendons connecting it 
 with the flexor sublimus digitorum. In all cases where 
 symmetry is a subsidiary consideration, this amputation 
 
 Fig. 295. 
 
 Fig. 296« 
 
 may be made. In the case of the index and little fingers, 
 and thumb, everything possible adding to length should 
 be saved, as the range of motion of the thumb and little 
 finger is more extensive than the others, and the presence 
 of the index or its stump aids the crippled thumb in per- 
 formance of its functions. 
 
 Amputation at the Metacarpo-phalangeal Articulations. — It is 
 recommended by some that this operation be done in lieu 
 
AMPUTATION OF FINGERS. 
 
 285 
 
 of amputation at the middle of the third phalanges (surgi- 
 cal) of the second and third fingers, or even disarticulation 
 between their second and third phalanges. I am satisfied, 
 however, that the hand will be far stronger if the stumps be 
 allowed, since they soon become easy of flexion and exten- 
 sion, and the continuan-^e of these movements serves to 
 stimulate and nourish the common muscles engaged in 
 
 Fig. 297. 
 
 them, thereby strengthening the power of the remaining 
 fingers. 
 
 Amputation of the Second or Third Finger. — This is done by 
 the oval flap, which ought to be marked out before the 
 operation is commenced (Fig. 297). The flaps must be 
 taken from the finger to be removed, and should be of 
 generous dimensions. The limit of the incision above 
 corresponds to the head of the metacarpal bone; the 
 
286 
 
 OPERATIVE SURGERY. 
 
 lower limit, to the transverse line joining the fingers to 
 the web. Separating widely the contiguous fingers, the 
 surgeon seizing the condemned finger, extends it well and 
 carries his incision transversely along the line beneath, 
 then in a curved direction upward, along the side of the 
 finger to the head of. the metacarpal bone. This incision 
 is repeated on the opposite side; the tissue carefully dis- 
 sected up, ligaments and tendons carefully divided, and 
 the finger removed (Fig. 298). 
 
 Lateral Flap Operation. — This is best adapted to the 
 thumb, index, and little fingers (Fig.299); it can, however, 
 be employed at the ring and middle fingers. The limit of 
 
 Fig. 298. 
 
 Fig. 299. 
 
 the incision of the dorsum is the same as in the preceding. 
 The lower limit after crossing the transverse line of the 
 web extends towards the palm about a third of an inch. 
 The flaps are taken from the sides of the finger to be re- 
 moved. 
 
 In the case of the middle and ring fingers they should be 
 equilateral. For the thumb, index, and little finger, that 
 portion of each against which pressure is most liable to be 
 brought should be covered by a longer flap, which is taken 
 from the outer surface of the dorsum of the index and 
 little fingers and from the palmar aspect of the thumb, the 
 base being on a level with the joint. This is dissected off. 
 
AMPUTATION OF FINGERS. 
 
 287 
 
 after which the smaller one is made; divide the ligaments 
 and tendons, and remove the member. 
 
 Amputation of the Thumb at the Carpo-metacarpal Joint 
 (oval method, Fig. 300). — This can be employed equally- 
 well upon the thumb, index, and little fingers. The limit of 
 the dorsal incision in either instance is the proximal ex- 
 tremity of the metacarpal bone to be removed. Its palmar 
 limit is the transverse line at the junction of the finger with 
 the palm. Begin the first incision at the base of the meta- 
 carpal bone of the thumb, carrying it along in a slightly 
 curved direction to the outer side of the metacarpo- 
 phalangeal articulation; then inward through the line of 
 
 Fig. 300. 
 
 Fig. 301. 
 
 Fig. 302. 
 
 the web. The second one joins the first near the base of 
 the bone, and takes a corresponding course along its inner 
 side, meeting the former at the inner extremity of the trans- 
 verse line of the web. The flaps are dissected off, and the 
 articulation between the metacarpal bone and the tra- 
 pezium is opened from the ulnar side, to avoid injuring con- 
 tiguous joints (Fig. 301). The union of the flaps leaves a 
 linear cicatrix (Fig. 302). 
 
 The Lateral Flap Method (Fig. 303). — This method can 
 be more quickly and easily performed than the former, but 
 leaves the cicatrix in a less advantageous situation. Ab- 
 duct the thumb and enter the knife between the first and 
 
288 
 
 OPERATIVE SURGERY. 
 
 second metacarpal bones; carry it up between them with 
 a sawing motion, till the head of the first is reached. Cau- 
 tiously disarticulate it from within outward; increase the 
 abduction, and carry the blade through the joint and along 
 the outer side of the metacarpal bone, making the outer 
 flap, which should terminate opposite the web of the thumb 
 (Fig. 304). 
 
 The description of the oval method as applied to the 
 thumb is equally applicable to the index and little fingers, 
 if an interchange of digits be made. The lateral flap 
 method is not advised except in connection with the 
 thumb. 
 
 Fig. 303. 
 
 Fig. 304. 
 
 The bases oi the metacarpal bones of the index, middle, 
 and little fiyigers should be preserved in all possible in- 
 stances, as they afford attachment to the important extensor 
 and flexor muscles of the carpus. 
 
 Amputation thi'ough the Metacarpal Bones. — In amputation 
 through two or more of these bones, the principal flap 
 should be taken from the palmar surface. If but one be 
 removed, the incisions are the same as those made for am- 
 putation at the metacarpo-phalangeal articulation by the 
 oval method, only their upper limit will correspond to the 
 point of proposed section of the bone (Fig. 305). The 
 
AMPUTATION OF FINGERS. 
 
 289 
 
 bone in this instance is to be sawn through with a chain or 
 metacarpal bone saw. If neither of these be convenient, 
 the cutting bone forceps (Liston) can be used, although 
 with some risk of splitting the bone. This operation is 
 often performed in preference to disarticulation at its 
 head, in order to give symmetry to the hand. 
 
 The division of the transverse ligament, which extends 
 between the heads of the metacarpal bones, lessens the 
 strength of the grip. This operation is, therefore, not to 
 be recommended except in those of sedentarj' habits. 
 
 Fig. 305. 
 
 Amputation {^Disarticulation) of the Last Four Metacarpal 
 Bones (Fig. 306). — Make a semilunar flap from the palm 
 by a curved incision, beginning at the web of the thumb and 
 terminating at the ulnar border of the fifth metatarsal bone. 
 This flap can be made by transfixion, if desired (Fig. 307). 
 The dorsal incision (Fig. 30S) begins at the same point of 
 the web of the thumb, and is carried to the upper third of 
 the metacarpal bone of the index finger, and from there 
 transversely across until it meets the ulnar extremity of the 
 first incision. The flaps are now reflected from the carpo- 
 
290 
 
 OPERATIVE SURGERY. 
 
 metacarpal joint, the hand strongly abducted, and the 
 carpo-metacarpal articulation opened from the ulnar side, 
 using great caution not to injure the trapezium and the 
 
 Fig. 306. 
 
 Fig. 307. 
 
 Fig. 308. 
 
 Fig. 309. 
 
 metacarpal bone of the thumb. Without the thumb, this 
 operation would be of little avail in securing a useful 
 
AMPUTATION AT WRIST. 
 
 291 
 
 Stump. Unite the flaps with interrupted sutures, introduce 
 a drainage tube (Fig. 309), and treat antiseptically. The 
 results of amputations of the thumb and fingers are favor- 
 able, three to six per cent onl)?- perishing. 
 
 A7nputation of the Wrist [Disarticulation). — The bones en- 
 tering directly into this articulation are the radius, sca- 
 phoid, and semilunar. Ine location of the joint can be de- 
 termined (i) by forcibly bending the carpus backward, 
 when the summit of the angle on the dorsal surface formed 
 by the hand and forearm indicates the radio-carpal joint ; 
 (2) by drawing a line transversely from one styloid process 
 
 Fig. 3«». 
 
 to the other — the joint is about one fourth of an inch above 
 it. This operation can be done by the circular method, 
 single palmar, or radial flap, and the double flap. 
 
 Circular Method. — Ascertain one fourth of the circumfer- 
 ence of the articulation. Measure this distance downward 
 from the articulation, and divide the tissues at that point 
 by a circular incision ; dissect up the sleeve of integument 
 until opposite the joint ; pronate and forcibly flex the car- 
 pus, and open the wrist joint on the dorsal surface by an 
 incision extending between the styloid processes ; divide 
 the lateral ligaments, pass the blade through the articula- 
 
292 
 
 OPERATIVE SURGERY. 
 
 tion, and sever the remaining structures (Fig. 310). Unite 
 the flaps in the long axis of the joint, introduce drainage 
 tubes and sutures, and dress antisepti- 
 cally (Fig. 311). 
 
 Flap Method {Double). — Mark out the 
 distal limits of the flaps as in the circu- 
 lar method ; flex and pronate the hand ; 
 carry a semilunar incision over its dor- 
 sum, beginning at the styloid process 
 of the ulna and extending to the circu- 
 lar line indicating the dorsal extent of 
 the flap, terminating at the radial sty- 
 loid process (Fig. 312). Dissect up the 
 flap, allowing the tendons to remain, 
 flex the carpus firmly, and open the 
 '"^' ^"' articulation, as in the circular method ; 
 
 carry the blade of the knife through the articulation (Fig, 
 313) and make the anterior flap by cutting outward. 
 
 Single Palmar Flap. — This method is easily performed, 
 
 Fig. 312. 
 
 and makes as serviceable stump as any. Mark out a flap 
 on the palmar surface, semilunar in shape, and about three 
 and a half inches in length, its base being located just 
 
AMPUTATION AT WRIST. 293 
 
 below the apices of the styloid processes (Fig. 314) ; reflect 
 it upward ; divide the remaining tissues in front of the ar- 
 ticulation, open it, passing the knife through, and making 
 a short dorsal flap. The dorsal flap can be made first, 
 the joint opened from behind, and the long anterior flap 
 cut from the joint outwa'"d. 
 
 Radial Flap (Dubrueil). — Mark out a flap, semilunar in 
 shape, the base of which shall embrace the radial third of 
 the carpus and the ulna, corresponding to the base of 
 the first phalanx of the thumb (Fig. 315). Separate the 
 thumb flap, then connect the extremities by an incision 
 carried transversely around the ulnar side, draw the skin 
 upward, open the joint as before, remove the carpus, and 
 properly adjust the flaps and drainage tubes (Fig. 316). 
 
 Fig. 313. 
 
 The rate of mortality in amputation at the wrist joint is 
 about 29 per cent for gun-shot wounds, being eight per cent 
 greater than for amputation through the forearm. 
 
 It therefore follows that amputation at the wrist joint 
 cannot be recommended, on the ground of safety to the 
 patient. There are other objections of less importance, 
 which, with one just stated, should place the operation in 
 disfavor with the surgeon. It makes a stump, which, owing 
 to the feebleness of the circulation in the flaps, becomes 
 cold and even chill-blained; also its extremity is bulbous, 
 thereby preventing the application of properly fitting sock- 
 ets connected with artificial appliances. 
 
294 
 
 OPERATIVE SURGERY. 
 
 Amputation of the Forearm. — The forearm is best ampu- 
 tated by the circular flap method; although the equilateral 
 skin flap and musculo-cutaneous are often employed. 
 
 Circular Amputation. — Carefully lay out the length of the 
 proposed flap, based on a fourth of the circumference. 
 Divide the tissues down to the fascia surrounding the mus- 
 cles by a circular incision; the integumentary cuff is then 
 dissected upward by repeated incisions directed towards the 
 fascia surrounding the muscles (see Fig. 26). 
 
 If the cuff be too small to turn up readily, its most depend- 
 ent part, when dressed, can be slit up. After the flap is 
 
 ^ ^ 
 
 Fig. 315. 
 
 Fig. 316. 
 
 reflected sufficiently, the muscles are divided a half an inch 
 or so below the line of its reflection by a circular sweep of 
 the knife down to the bone, the bone sawn off, and the 
 wound dressed in the usual manner. The interosseous 
 membrane and its vessels should be divided a short dis- 
 tance below the point of proposed bone section and its 
 borders be separated from those of the contiguous bones 
 up to where they are to be sawn. This avoids the risk of 
 cutting the vessels too short, as when they are divided at a 
 level with the bones which permits them to retract above 
 the point of easy access. These remarks apply with equal 
 force to amputation of the leg. 
 
AMPUTATION AT ELBOW. 
 
 295 
 
 The equilateral skin flaps are raised from the anterior and 
 posterior or internal and external surfaces ; the latter 
 being by far the most frequently adopted. The length is 
 determined in the same manner as in the circular; in fact, 
 if the circular be first done, and its angles cut off down 
 to near the site of the muscular section, the lateral flaps 
 will be formed. It is better, however, to mark out their 
 outlines before beginning them; since, to make each with 
 the same curve and same breadth of base is not an easy 
 
 Fig. 317. 
 
 task without this precaution. The remaining procedures 
 are the same as those of the circular method. 
 
 Miisculo-cutaneous flaps are made by transfixion and cut- 
 ting outward; in other respects the steps do not differ from 
 the preceding operation. The rate of mortality in ampu- 
 tation of the forearm is about 21 per cent for all causes. 
 
 A?nputatioji at the Elbow Joint [Disarticulation). — The meth- 
 ods commonly employed are the circular and the single flap 
 ones. Before operating carefully define the most prominent 
 
296 
 
 OPERATIVE SURGERY. 
 
 portions of the condyles. Just below the outer, is felt the 
 movable head of the radius; about an inch below the inner, 
 the ulna joins the inner condyle; the articulation is there- 
 fore oblique; the inner portion being about a half an inch 
 the lower, owing to the inner condyle being that much 
 longer than the outer. 
 
 Circular Method. — Lay out the flaps in the usual manner, 
 measuring around the condyles. Divide the superficial tis- 
 sues down to the fascia surrounding the muscles, as before; 
 dissect the flap upward to a level with the joint, the bone 
 indications to which should be carefully determined. For- 
 
 FlG. 318. 
 
 cibly extend the arm and make an incision on the line of 
 the articulation (oblique) down to and into it; sever the 
 internal and external lateral ligaments, and press the arm 
 still further backward, and draw the olecranon process 
 forward into the wound, and sever its connection to the 
 triceps (Fig. 317). Unite the borders of the flap as indi- 
 cated in the figure (Fig. 318). The flaps can also be united 
 from before backward; this causes the cicatrix to fall between 
 the condyles, and likewise increases the drainage facilities 
 — two very important indications. 
 
 The shigle fiap fnethod c2Sih& made either of integument 
 
AMPUTATION OF ARM. 
 
 297 
 
 and subcutaneous tissue alone, or be musculo-cutaneous; 
 and formed by transnxion. In either instance it should be 
 taken from the anterior surface of the forearm. If by- 
 transfixion (Fig. 319) supinate and flex the forearm slight- 
 ly; raise the soft parts in front of the joint, and enter the 
 knife an inch below the internal condyle, pass it in front of 
 the bones obliquely outward, causing it to escape about 
 one and one half inches below the outer condyle. Cut the 
 anterior flap downward and outward, making it about 
 three and one half inches in length; dissect and draw the 
 flap up to a level with the joint in front. Make the poste- 
 rior flap by connecting the extremities of the first incision 
 by a transverse one (Fig. 320), and dissect this up, after 
 
 Fig. 319. 
 
 Fig. 390, 
 
 which the joint is opened from in front; the lateral ligaments 
 divided, olecranon process displaced forward, and the tri- 
 ceps cut off. It is advisable, when possible, to saw off the 
 olecranon, allowing it to remain with the triceps attached. 
 The stump will be stronger if it be possible to sever the 
 ulna below the insertion of the brachialis anticus, allowing 
 the fragment to remain along with its muscular attach- 
 ments. In amputations near the elbow, the tubercle of the 
 radius, along with the biceps tendon inserted into it, should 
 be carefully preserved. The deaths from this amputation 
 vary from 17 to 30 per cent. In the latter rate, the opera- 
 tion was done for gunshot injuries. 
 
 Amputation of the Arm. — Either the circular, double flap, 
 or the single circular incision method can be employed. 
 The former is usually preferred. In the second the flap 
 
298 OPERATIVE SURGERY. 
 
 may be anterior, posterior, or lateral; integumentary alone, 
 or combined with muscular tissue. The single circular 
 operation is seldom employed. 
 
 Circular Flap. — Plan the length of the flap upon the cir- 
 
 FlG. 321. 
 
 cumference of the limb at the point of proposed section. 
 Divide the superficial tissues down to the muscular fascia, 
 and turn the flap up as elsewhere; then divide the muscles 
 down to the bone, about one inch below the reflection of 
 
AMPUTATION OF ARM. 299 
 
 the flaps. Apply the two tailed retractor, saw off the bone, 
 and unite the flaps in the direction best calculated to pro- 
 vide dependent drainage. 
 
 Double Flap Method. — If skin alone be used the flaps 
 should be carefully mapped out upon the integument of 
 the arm, in the general manner before described. Dissect 
 
 Fig. 3!W 
 
 them up and make a circular section of the muscles down 
 to the bone; unite the flaps, and dress the stump as before. 
 Jf musculo-ctttaneous Jlap {l^dingtnbtck) be desired, they can 
 be made from within outward by transfixion, or from with- 
 out inward, with a scalpel. The latter plan secures the 
 more uniformity of outline in the flap. If they are to be 
 made from without inward, first mark them out carefully, 
 
300 
 
 OPERATIVE SURGERY. 
 
 then with a sharp scalpel form them as planned (Fig. 
 321); when dissected up the desired distance, complete the 
 operation by dividing the muscles as before. 
 
 Large anterior and small posterior skin flaps are some- 
 times made (Fig. 322), also a large anterior one, with 
 a posterior circular incision (Fig. 323). They possess the 
 
 Fig. 393. 
 
 advantage of good drainage, and placing the cicatrix where 
 it is well removed from irritation. The outline of these flaps 
 can be easily estimated on the same basis as if they were 
 to be equal in length, viz., if one be proportionately in- 
 creased in length, the other is to be shortened. The death 
 rate from amputation of the arm is over 27 per cent. Be- 
 ing greater than for excision of the elbow joint. 
 
 Amputation at the Shoulder Joint {JDisarticulatiofi) . — There 
 are various methods recommended for amputation at this 
 
AMPUTATION AT SHOULDER. 
 
 301 
 
 Fig. 334. 
 
302 
 
 OPERATIVE SURGERY. 
 
 joint. It is hardly necessary to enter into the details of 
 more than two or three of those commonly recognized and 
 employed. The remainder, while ingenious in many in- 
 stances, do not present differences of enough practical 
 worth to be introduced into a hand-book of operative 
 surgery. 
 
 Amputation by Internal and External Flaps. — Place the pa- 
 tient on the edge of the table, partially upon the healthy 
 side, with the body raised. An external oval flap is made 
 by an incision extending from the coracoid process down- 
 
 Fig. 3S5. 
 
 ward and outward to the insertion of the deltoid; then 
 upward and backward, terminating at the junction of the 
 acromion process with the spine of the scapula (Fig. 324). 
 The flap including the deltoid muscle is now raised as far 
 as the acromion, turned back, and the capsule of the joint 
 exposed, the head of the humerus pushed upward, capsule 
 divided above; then the arm is rotated outward and the 
 subscapularis severed, followed by the rapid division of 
 the external rotators attached to the greater tuberosity. 
 While the arm is rotated internally, the capsule is still 
 further divided, along with the tendon of the long head 
 
AMPUTATION AT SHOULDER. 
 
 303 
 
 of the biceps, the head ofr the humerus tilted outward, and 
 the blade of the knife passed beneath it (Fig. 325), the head 
 of the humerus seized and drawn outward, and the knife 
 carried along its inner surface until within about four 
 inches below the axillary fold, when its edge is turned in- 
 ward and the flap completed. The last sweep of the knife 
 severs the principal vessels, and this flap should be seized 
 by an assistant and tightly grasped before it is completed. 
 The vessels in this operation are controlled by either press- 
 ure upon the third portion of the subclavian, or by the elas- 
 
 FiG. 336. 
 
 tic band arranged as shown in the illustration. The appear- 
 ance of the wound after the operation is shown in Fig. 326. 
 Amputation by Circular Incision. — Control the circulation as 
 before. Abduct the arm and make a circular incision en- 
 tirely around it through all the tissues, down to the bone, 
 at a point corresponding to the insertion of the deltoid. 
 Saw off the bone and ligature the vessels. Make a second 
 incision longitudinally, from the anterior border of the 
 acromion, the whole length of the stump, down to the bone. 
 The bone is then held firmly and the soft parts separated 
 
304 
 
 OPERATIVE SURGERY. 
 
 from it (Fig. 327), after which it is rotated outward, then 
 inward to admit of the division of the muscular and fibrous 
 attachments to its head, when it can be removed. This 
 is a good operation and well calculated to provide favor- 
 able drainage (Fig. 328), and is done with a minimum 
 amount of injury to the soft parts. 
 
 Fig. 327. 
 
 Oval Method i^zxtty). — This method is well thought of, 
 and is performed by making a vertical incision from the 
 extremity of the acromion process, with the arm extended, 
 about three inches in length down to the bone; this inci- 
 sion should terminate about one inch below the head of the 
 humerus. Two oblique incisions are then made, starting 
 
AMPUTATION AT SHOULDER. 
 
 305 
 
 near the middle of the vertical cut, one on the anterior and 
 the other on the posterior aspect of the limb; which, when 
 carried through the structures composing the anterior and 
 posterior walls of the axilla, to the lower border of each, 
 divides their attachments to the humerus (Fig. 329). The 
 soft parts on the inner side of the humerus still remain 
 undivided. The lips of the wound are now drawn apart, 
 
 Fig. 328. 
 
 the joint exposed and opened above; the bone drawn down- 
 ward to separate the joint surfaces, and the blade of the 
 knife passed between them, behind the luxated bone, and 
 the operation completed by cutting the remaining tissues 
 at the inner side of the humerus intervening between the 
 lower extremities of the incisions previously made (Fig. 
 330). 
 
3o6 
 
 OPERATIVE SURGERY. 
 
 Spence's Method \\^as attracted some considerable attention, 
 and is certainly entitled to additional consideration. 
 
 It does not possess any advantages over the method by 
 single circular incision. It is done in the following man- 
 
 FlG. 329. 
 
 Fig. 
 
 ner: Abduct the arm slightly; rotate the humerus out- 
 ward; cut down upon the head, beginning immediately 
 external to the coracoid process, thence directly down- 
 ward through the fibres of the deltoid and pectoralis major 
 to the lower border of the latter, which 
 is divided; carry the incision with a 
 gentle curve across and through the 
 lower fibres of the deltoid, to, but not 
 through, the posterior border of the 
 axilla (Fig. 331). Begin the inner 
 incision at the lower extremity of the 
 vertical one, carry it around the inner 
 side of the arm, through the skin and 
 fat only, to meet the one made at the 
 outer side. If the fibres of the del- 
 toid have been thoroughly divided, the 
 flap, together with the posterior circum- 
 flex artery can be easily separated by 
 the finger, from the bone and joint, 
 drawn upward and backward until the 
 Fig. 331. head of the bone is exposed; when the 
 
 ligaments and muscular attachments are divided, and 
 
AMPUTATION ABOVE SHOULDLxv. 307 
 
 disarticulation accomplished, the remaining soft parts at 
 the axillary aspect are divided. 
 
 In very muscular subjects, a redundancy of that tissue 
 in the flap can be avoided by dissecting upward, a short 
 distance, the integument and subcutaneous tissues over the 
 deltoid, and dividing its fibres high up. 
 
 The rate of mortality varies from 37 to nearly 50 per 
 cent. 
 
 Amputation above the Shoulder Joint. — It may become nec- 
 essary on account of malignant growths to amputate the 
 scapula along with a portion or the whole of the clavicle. 
 
 The operation is often tedious and attended with great 
 loss of blood. Inasmuch as the situation of the disease or 
 injury calling for it will modify the location and direction 
 of the incisions, no definite plan can be prescribed. How- 
 ever, the aim should be to always save enough healthy in- 
 tegument to cover the wound and to avoid hemorrhage. 
 
 Fifty-one cases are reported, with a mortality of 25.5 per 
 cent. 
 
Manual of nDP,;,fn,p"^,,^-' '•' 
 
 2002129957 
 
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