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SAUNDERS'
MEDICAL HAND-ATLASES.
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The same careful and competent editorial supervision has been
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ATLAS AND EPITOME
OF
OPERATIVE SURGERY
BY
DR. OTTO ZUCKERKANDL
Privat-docent in the University of Vienna
/
AUTHORIZED TRANSLATION FROM THE GERMAN
EDITED BY
J. CHALMERS DaCOSTA, M. D.
Clinical Professor of Surgery- in Jefferson Medical College, Philadelphia;
Surgeon to the Philadelphia Hospital, etc.
With 24 Colored Plates and 217 Illustrations in the Text
PHILADELPHIA
W. B. SAUNDERS
925 \Vai,nut Street
1898.
Copyright, 1898,
By W. B. SAUNDERS.
'3)oU|=lc) threads
arc passed tliroiioli tlie lips ut* the wound and tied. The
suture is intntdueed at right angles to the direetion of the
wound, passing through eorresponding points on o})posite
sides. The needles are })assed either with the free hand or
are grasped and direeted by forceps-like instruments,
needle-holders (Fig. 31). In so-called pedunculated
.»«*^^W■<•<.^^■^e tend(tn may be established by means of an auxiliary operation, teno-
plastij. From the side of one of the extremities of the divided tendon a
small i)ortion is so freed that it ean be turned over toward the other ex-
tremity, with which it is united by suture (Fig. 35).'
Nerve-sutarey as first practised by Robert and Nelaton,
may be enipk)yed in cases of recent injnries attended
with division of nerves, as well as a secondary procedure
after isolation and freshening of the divided extremities.
The object of nerve-suture is the approximation of the
Fig. 35. — Hiiter's tenoplasty.
transverse edges of the divided nerve-strand. To this
end fine threads are passed either directly through the
substance of the nerve, and the transverse surfaces of the
divided extremities are brought in apposition, or the ex-
tremities are so united that they overlap one another upon
their lateral surfaces (paraneural siitare).
The extremities of the divided nerve may be so united
that the sutures are not passed through the substance of
the nerve, but through the surroundinir connective tissue.
In this way the extremities are brought indirectly in ap-
proximation (perineural suture).
Neuroplastj/, based upon the same principle as the
tenoplasty of Hiiter, may also be employed successfully
in the union of divided nerves.
^ Instead of silk, we can employ kangaroo- tendon or chromic gi't. —
Ed.
52
OPERATIVE SURGERY.
The position and fixation of the extremity operated
upon should prevent all disturbance of the nerve after the
operation.
The union of hones is effected by suture in a manner
analogous to that in which the soft tissues are united
(Fig. 36), except that wire is employed with especial ad-
vantage as suture-material. The channels for the pas-
FiG. 36.— Suture of the patella with wire.
sage of the sutures must be made by means of a drill
or an awl. The Avires are fastened by twisting their ex-
tremities together. Braces or clamps also may be em-
ployed in the same way as they are used in securing
boards in scaffolding (Gussenbauer's clamp, Fig. 37).
Severed bones may further be united by means of nails
or ivory pegs (Fig. 38). Nails may also be driven into
REUMos or Till-: rissvKs.
63
the bone tlirouuli the ovcrlyiiii^ soft tissues in m-ilci- U)
maintain the iVaL»;nients in :i|)|)<>silirtion of the muscular layer, as in this way the serous
folds are made firmer and can be brought in closer
approximation.
Suture of the bI((fJ(Jer, when the injury involves the
intraperitoneal ])ortion of this viscus, is effected upon
principles similar to those that have been just laid down,
except that in this event it is advisable, in order to avoid
incrustations, to use catgut instead of silk as the suture-
material. One row of sutures will accurately approxi-
mate the muscular layer of the bladd(M', which is often
from one-half to one centimeter thick. It is customary
to exclude the mucous membrane from the suture. A
second ro\y of Lembert's sutures unites the serosa. In
56 OPERATIVE SURGERY.
the closure of wounds of the bladder, as in closure of
those of the intestine, the continuous suture or closely
applied knotted sutures may be employed.
Wounds of the extraperitoneal portion of the bladder
are to be so united that the thick layer of muscular tissue
is brought in firm apposition by means of catgut sutures,
with exclusion of the mucosa.
The various methods of suture for closure of wounds
of the bladder have been largely supplanted by the simple
method just described.
Wounds of the gall-bladder may be closed by suture in
a manner analogous to those of the bowel.
LIGATIOX OF VESSELS IS coyTiyUITY. 57
I. OPERATIONS ON THE EXTREMITIES.
I. Ligation of \ esse Is in Continuity.
An injured and bleeding vessel may be seized directly
within a wound and the hemorrhage controlled bv liga-
tion. Another mode of pnx}e<:lure consists in exjxisure
of the central extremity of the divided vessel for the
piu-pose of its ligation. This variety of ligation of
vessels in continuity will n«»\v l»e considered.
Indications. — {!) Injuries. — {a) ^^iab-woundsj gun-
shof-icoundsy contused icoundsy and lacerated wounds of
the large arteries. If possible, ligation is to be under-
taken at the site of injury. This is dit!icult in lacerated
tissues suffused with Ijhxxl, when the wound is uutavorablv
situated, or when the artery is injured directly at its origin
from a main branch.
(b) Subcutaneous laceration of large vessels; also when
ligation at the site of the lesion is impossible.
(2) Hemorrhages fr(.>ni suppurating wounds through
erosion of laro:e vessels : further arterial hemorrhagre
from gangrenous tissues or dismteo-rating new-growths.
(3) In order to render an operation bloodless the main
arterial branch of the operative area may be previously
ligated — e. g.^ the lingual artery preceding extirpation of
the tongue, the femoral artery preceding enucleation of
the hij>-joint, and preceding extirpation of cavernous
tumors.
(4) In order to induce retrogression of morbidly altered
organs or neoplasms the blood-supply is cut off by ligation
of the main artery — e. g.y of the thyroid artery in the
presence of goiter, of the spermatic artery in the presence
of tumors of the testicle, of the internal iliac artery- in
the presence of hypertrophy of the prostate, etc. In the
same category belongs the treatment of elephantiasis of
the les: bv ligation of the external iliac or the femoral
58 OPERATIVE SURGERY.
artery, with -which some surgeons have secured good
results.^
(5) Aneurysms. — According to the method of Hunter,
the afferent artery is ligated in the treatment of aneurysm,
but on account of the supply of bh)od to the aneurysmal
sac throuoh the collateral circulation this method is not
so reliable as that of Antyllus.
In cases of trigeminal neuralgia resisting other operative
measures, ligation of the carotid artery has been repeatedly
practised (Patruban).
The treatment of epilepsy by ligation of the vertebral
artery has also been proposed.
Method of I^igation. — At definitely determined
points upon the surface of the body the skin is divided
and with careful protection of important structures the
sheath of the vessel is exposed. This is then opened, and
the artery, separated from the accompanying veins for a
small portion of its extent, is raised from its bed for the
purpose of ligation. Two ligatures are now applied, and
the artery is divided transversely between them with a
sincrle cut of the scissors. The wound in the skin is
closed by suture.
The cutaneous incisioni< are made in selected situations
in a definite direction so as to render possible access to
the artery by the sliortest route. Usually the incision in
the skin corresponds witli the course of the artery. Thus, in
the extremities this incision, with a few minor exceptions,
coincides with the longitudinal direction of the vessel.
In order that the incision in the skin may be placed in
the proper situation, it is necessary to make careful scrutiny
of the surface of tlie body. To facilitate this, prominent,
readily palpable points of the skeleton, as well as nuiscular
prominences, and the intervening depressions, are selected
as landmarks.
1 In some regions extirpation of a vessel is better tlian ligation, if we
wish to arrest the growth of a tumor. Davvbarn has recently pointed
out that ligation of the external carotid is of slight value in sarcoma of
the tonsil, as the anastomotic circulation is so quickly established, but
extirpation of this vessel causes great shrinking of the growth. — Ed.
LIGATION OF VESSELS IX CONTISUirV. .',9
The k'litrth of tin* cutaiK'oiis incision will he regulated
by the de})th to w liieh aecess is desired : the deeper the
\vonn(l tlic hirtrcr must he the openiuir in tlic skin. Tlie
incision ior exposure of the internal iliac artery will meas-
ure from 15 to 20 cm. (6 to 8 in.), while that for the ra-
dial artery at the wrist-joint need not he more than 1 (jr
1.0 em. (^ or ^ in.).^
A\'hen the skin and the suhcutaneous connective tissue
have heen penetrated (the base of the wound is no longer
moved with movements of the margins of the skin), the
sheath of the vessel is carefully approached by dissection
either w ith the free hand, between two pairs of forceps,
or with the aid of the grooved director. Muscles, nerves,
and veins that obstruct the way are displaced with 1)1 unt
hooks. If a vessel prevents access to the arter}', it may
be ligated in two places and divided between.
The sheath of the vessel is detached from the artery for
a short distance by blunt dissection with anatomic forceps,
or it is divided upon the grooved director, in accordance
with the character of the tissues. After the sheath has
been opened, either a single vessel will be exposed .], the ligating
instrument, armed witli a ligature, is passed beneath the
artery, the ligature wound about the vessel and tied. A
second ligature is applied in similar manner at about a
distance of 1 cm. (^ in.^ from the first, and, between the
two, the artery, raised from its bed, is cut squarely with
a single stroke of the scissors. The divided ends of the
vessel retract somewhat in either direction (Fig. 39).
The application of two ligatures and cutting between
possess some advantages, but are not always necessary.
The retraction and the relaxation of the extremities of
the divided vessel afford more favorable conditions for
thrombus-formation, through narrowing of the lumen,
than simple occlusion of the lumen of the vessel. Beside,
by division of the vessel Ijetween the ligatures a view
is obtained of the posterior wall of the artery, and in this
way ligature of the artery just in advance or just beyond
the orio^in of a lateral branch can be avoided. Either
contingency is equally unfavorable to thrombus-forma-
tion. The small wound made is closed with knotted
sutures.
The knot of the ligature is tied as follows : after the
ligature has been made to surround the arter}' the free
end on either side is grasped with the fingers of the cor-
responding hand. Before the knot is tied the ends are so
crossed that the right passes behind the left and is re-
ceived into the left hand, while the left passes in front of
the right and is received into the right hand. When the
extremities have been thus crossed a sinq^le knot is tied.
Before the second knot is placed upon the first the free
extremities must again be changed and in such a manner
that that upon the left is passed in front of that upon the
62
OPERATIVE SURGERY.
right. Tlie sailor^s knot (Fig. 40) thus fijrmed is more
secure than the ordinary granny^ s knot (Fig. 41).
If in the first part of the knot the extremities are
twisted twice, instead of once, there results the so-called
surgical knot (Fig. 42).
The sailor's knot is employed not only in the applica-
tion of ligatures, but whenever it is desired to tie a secure
knot.
lyigations in the Upper Extremity. — The arter\^
supplyino' the arm, the forearm, and the hand may be
Fig. 40. — Sailor's knot [reef-knot].
Fig. 41. — Granny's knot.
Fig. 42. — Surgical knot.
exposed for purposes of ligati3)._
This triangle, formed by the elevations of three mus-
cles, is the situation in which the artery is to be exposed.
It would be a mistake to look for the vessel in the axil-
lary cavity, which forms a space filled with flit, connective
tissue, and lymphatic glands next to the lateral wall of
the chest. The artery, which lies close to the humerus,
is therefore to be looked for in relation with this bone at
the apex of the axillary cavity.
The incision is made along the line of the coracobrach-
ialis muscle in the continuation of the internal bicipital
sulcus (Fig. 43). After the subcutaneous connective
tissue has been passed the thin fascia of the arm will be
exposed, through which the fibers of the coracobrachial
muscle will be visible. The fascia is divided upon the
grooved director and the lower (inner) lip of the wound
in skin and fascia retracted with tenacula. There now
comes into view the median nerve embedded in loose
cellular tissue, and this is drawn out of the way with a
simple blunt hook. The artery is now exposed and can
be readily isolated and ligated (Plate 2). Care must be
taken that the ner^^e alone is grasped and drawn out of
the way, as otherwise the artery, which lies directly behind
it, may also be displaced and removed from the field of
vie\v.
Tab. 2.
LUh.Anst F. Reichhold, Mimchen.
LIGATION OF VESSELS IN CONTINUITY. 65
After division oi' tlic i'ascia of the coracobraclnal imis-
c'l(^ the orcatcr internal cntancuns nerve sometimes pre-
sents itself. 'I'liis small nerve can scarcely be eonfoundeil
with the median nerve, which comes into view after
fnrther retraction of the lower (inner) margin of the
wonnd.
The artery is accompanied by one or several, sometimes
by a whole ])lexus of veins.
Ligation of the Bracliial Artery. — The continuation of
the axillary artery from the surgical neck of the humerus
to its point of division at the flexure of the elbow is
known as the bracJikd (irtcry. The vessel lies in the in-
ternal bicipital sulcus, and it is often accompanied by a
network of veins. The median nerve lies over the upper
half of the artery, which it conceals, while in their fur-
ther course the nerve lies upon the ulnar side of the ves-
sel. The basilic vein, which likewise lies in the internal
bicipital sulcus, is separated from the group of large
vessels and ni^rves by the fascia. The sheath of the
vessel consists of loose cellular tissue.
The patient occupies the same position as in ligation of
the axillary artery. The incision is made at about the
middle of the arm, slightly over (external to) and parallel
with the internal bicipital sulcus (Fig. 43). Skin and
subcutaneous connective tissue are divided and the fascia
of the biceps muscle is opened in the same direction and
throughout the same extent. The fibers of this muscle
must be clearly exposed to view. The lower (inner) lip
of the wound in the fascia is drawn downward (inward)
with a tenaculum and the median nerve thus exposed.
The nerve is lifted from its bed and drawn aside with a
blunt hook, when tlie brachial artery is exposed accom-
panied by veins. The artery is isolated by means of two
pairs of forceps and is ready for ligature (Plate 2).
The rule to make the incision somewhat above (ex-
ternal to) the bicipital sulcus in order to reach the
median nerve below is to be recommended on account
of the difficulties encountered in reaching the artery
5
66 OPERATIVE SURGERY.
throiigli a mass of structures, includinu: the greater in-
ternal cutaneous nerve, the median nerve, and the ])asilic
vein, when the incision is made directly over the vessels
and nerves. If the incision is made below (internal to)
the bicipital sulcus, an inexperienced person may err by
failing to recognize the exposed ulnar nerve and looking
in vain for the artery behind it.
The relations bet\\'een the median nerve and the brachial
artery are varia])le within certain limits. In rare in-
stances the artery lies in front of the nerve. In cases
of high division of the radial and ulnar arteries one of
the vessels lies in front of and the other behind the nerve.
The presence behind the median nerve of an artery pro-
portionately small, as compared with the rest of the body,
is suggestive of such high division of the brachial artery.
Ligation of the Cubital Artery. — The continuation of
the brachial artery in the iiexure of the elbow is known
as the cubital artery. The vessel lies in the internal
cubital sidcus, and, covered by the aponeurosis of the bi-
ceps muscle, is embedded in the depression between the
pronator radii teres and the biceps. The artery is in this
situation accompanied by two symmetrically placed veins.
The median nerve does not occupy the same intimate re-
lation with the artery as it does higher up, but lies at
some distance upon the idnar as})ect of the artery. Sepa-
rated from the artery l)y the bicipital fascia and situated
subcutaneously is the cubital plexus of veins (median ba-
silic, median cephalic), which communicate in the flexure
of the elbow with the veins accompanying the artery.
The simplicity of the relations existing in the arm in
consequence of the prominences formed by the biceps and
the triceps and the presence of the internal and external
bicipital sulci, is replaced at the flexure of the elbow-
joint by complexity resulting from the presence of the
two large groups of forearm-muscles. The s])indle-shaped
belly of the biceps, which gradually diminishes in size, is
separated by a sulcus upon the right and the left respec-
tively from the muscular prominences of the extensors
LIGATION OF VESISELS IN CONTINUITY. 67
and Hoxurs »)!' tiic fbrcarin, wliidi oricrinate in this situa-
FiG. 44.— Arrangement of the
muscles in the upper extremity :
Shi, internal l)icipital sulcus; f^be,
external bicipital sulcus; Sci, in-
ternal cubital sulcus; ^V, radial
sulcus; Sn, ulnar sulcus.
tion. There results tluis a Y-shaped formation, of which
the two limbs, in some degree the continuations of the
68 OPERATIVE SURGERY.
Plate 3.— Exposure of the Cubital Artery.
L, transverse section of the aponeurosis of the biceps muscle ; A, cubital
artery accompanied by veins ; 31, median nerve ; V, cubital veins.
Exposure of the Radial and Ulnar Arteries.
A)\ radial artery ; Au, ulnar artery at the inner side of the tendon of the
internal ulnar muscle {U).
bicipital sulci of the arm, are designated the internal and
external cubital sulci. The inner furrow of the flexure
of the elbow is bounded by the biceps or the brachialis
internus and the pronator radii teres, the outer by the
biceps and the supinator longus. The internal bicipital
sulcus is covered by the radiating aponeurosis of the biceps
(Fig. 44).
To ligate the bicipital artery the forearm is extended at
the elbow-joint and held in a position of maximum supina-
tion. Information as to the direction and situation of the
internal bicipital sulcus is sought through palpation. The
incision is made in the continuation of the internal bicipital
sulcus and passes from within and above downward and
outward, corresponding to the direction of the internal
cubital sulcus (Fig. 45). After division "of the skin con-
sideration should be given to the network of veins at the
flexure of the elbow. When possible the way is cleared
bv retraction of the veins with blunt hooks. The shining
aponeurosis of the biceps muscle now appears in the
wound and it is divided upc^n the grooved director in the
direction of the cutaneous wound. The artery lies im-
mediately beneath the aponeurosis, accompanied by two
veins, in a bed of loose connective tissue. The median
nerve lies to the ulnar side of the artery (Plate 3).
In case of high division of the brachial artery one or both
branches may lie ujwn the bicipital fascia. This possi-
bilitv is to be thouglit of when bleeding from the veins at
the flexure of the elbow is to be undertaken, or when one
of the median veins in this situati(m is to be exposed and
opened for infusion with a saline solution or for transfusion
of blood.
/h..inst. K HeichhflUl. UtincJ
LIGATION OF VESSKLS IN CONTINUITY.
69
In the ]tr.icti<'e of phlehoio
about thr niiddlt' of tl
]thlehi)t()}ity a cloth or handaK*' is hound circularly
ahout tlic niKKlU' oi llu- arm in such a niauiicr that the return of hlood
throujih the veins from the forearm is prevented witiiout ohliteration of
the radial pulse. With the forearm extended, a sharp-pointed knife is
introdiu-ed obli(|Uely into one of the tensely distcndrtl median veins
(Fig. 4t»), so thai the hlood spurts from the wound in a stream. When the
Fig. 45. — Incisions for exposure of the cubital, radial, and ulnar
arteries.
desired amount of blood has escaped the compress is released, and the
small wound is covered with a dressing and a bandage.
Transfusion uf blood or venous infusion of saline solution also is prac-
tised through the median basilic vein. Through an incision analogous to
that made for ligation of the cubital artery the vein, lying subcutaneously.
is exposed for a distance of several centimeters and isolated by blunt
70
OPERATIVE SUROERY.
dissection. The vessel is grasped with a pair of anatomic forceps and
snipped with the scissors, without being totally divided. The vein is
now closed by ligature on the peripheral side of the incision. Through
the opening thus made the cannula is introduced into the vein in a cen-
tripetal direction and fixed. To make the infusion a sterilized rubber
tube armed with a funnel is most advantageously employed, attached to
the cannula. From a half-liter to a liter and a half of fluid are per-
FiG. 46. — Phlebotomy at the flexure of the elbow : opening of the
median basilic vein by puncture with a sharp-pointed knife.
mitted slowly to flow into the vein under a low degree of pressure. Fox
purposes of infusion sterilized physiologic (0.6 per cent.) solution of
sodium chlorid or defibrinated human blood may be employed. After
the infusion has been completed the vein is ligated upon the central side
of the, opening and the small wound is closed by suture.
Ligation of the Radial and Ulnar Arteries. — The
LIGATIoy OF VESSELS IN COXTIMITY. 71
imiseles iipmi tlic palmar aspect of the ionariii are
(livisll)l(' into tlii'cc ^inuips, 'Hie main mass is inrmcd l)v
the tlc'xors of tlic tinii'crs, wliicli arise by a common head
iVoni tlie inner aspect of the lower extremity of the
hnmerns. The forearm is honnded upon the ulnar side
by the flexor carpi ulnaris, u})ou the radial side by the
supinator longus. Between the tendons of these muscles
and the mass of the flexofs of the fingers there is thus
formed in the lower third of the foreariu upon either side
a longitudinal furrow or depression which is used as a
guide in finding the radial and the ulnar artery respec-
tively (Fig. 45).
The r(((Vml arferjf corresponds in its course with the
direction of the radius. In the upper third of the fore-
arm the artery lies in close relation with the supinator
longus muscle and is deeply situated. In the lower third
it lies more superficially in the sulcus between the tendons
of the flexors and that of the supinator longus. Just
above the wrist-joint the artery, with its accompanying
two veins, lies upon the lower extremity of the radius,
covered only by skin and the thin fascia.
The ulnar artery, after it?s origin from the brachial,
crosses the common head of the flexors, among which it
pursues its course, until it reaches the tendon of the flexor
carpi ulnaris, along the inner side of which it reaches the
wrist-joint.
The typical situation for the ligation of both arteries is
just above the wrist-joint. The forearm is placed in a
position of maximum supination, with the hand in slight
dorsal flexion. To expose the radial artery an incision is
made just above the wrist-joint corresponding to the de-
jH'ession between the tendon of the su])inator longus and
those of the flexors (Fig. 45). After division of the skin,
the artery, covered by delicate translucent fascia, is seen,
situated between two veins. After division of the fascia
the artery can be isolated and ligated (Plate 2).
The ulnar artery is reached through a short incision in
the ulnar sulcus just above the wrist-joint somewhat to
72
OPERATIVE SURGERY.
the mdial side of the readily palpable tendon of the flexor
carpi ulnaris. Tlie radial margin of this tendon is ex-
posed and drawn to one side with a tenaculum. The deep
Fig. 47.— Arrangement of the muscles of the thigh : A, ahductor group;
Q, quadriceps femoris.
layer of fascia enclosing the flexors is brought into view
aiid divided upon a grooved director. The artery, accom-
panied by two veins, is now disclosed. In close relation
with the* artery upon its ulnar side lies the ulnar nerve.
LIGATIOy OF VESSELS IS COSTISUITY.
73
The radial arton , in its further eourse, is conveniently
accessible upon tht* chasuni of the hand between the
tendon of the tlexor longus jx)llieis and that of the exten-
sor brevis }X)llieis, in the so-called tabatiere.
Fig. 4S. — Coarse of mc ~.ii tonus muscle (S).
In the palm of the hand the snperticial palmar arch of
the ulnar artery can be exposed after division of the
tough palmar aponeurosis. The cutaneous incision in the
palm passes from the middle of the root of the hand
toward the base of the little finger.
74 OPERA TIVE SUEGEB Y.
Plate 4.— Exposure of the Femoral Artery.
Below Poupart's ligament, in the opened sheath of the vessels, are to be
seen upon the median side the femoral vein, and upon its outer side the
femoral artery. In the middle of the thigh the sartorius muscle (S ) is
drawn outward, the deep layer of the fascia Vjeiug divided, and the ar-
tery is exposed, with the vein behind it.
lyigations in the I/Ower Extremity. — The mus-
cles of the thigh are so grouped tliat Ijetween the exten-
sors and flexors, which are ari'anged symmetrically upon
the anterior and posterior aspects of the femur, on the
median side one group of muscles passes from the pelvis
to the inner aspect of the femur, .separating the quadriceps
from the flexors. The depression thus formed between
the extensors and the abductors (Fig. 47) sei-^'es as a path-
way for the vessels passing over the margin of the peh'is
and corresponds in its direction with the course of the
vessels. The sartorius muscle bridges over this gutter
(Fig. 48) and constitutes thus an important landmark in
locating the vessels.
The femoral artery, the continuation of the external
iliac, emerges from the pelvis under Poupart's ligament
at a point midway Ijetween the symphysis pubis and the
anterior superior iliac spine. The femoral vein at its
entrance into the pelvis lies to the median side of the
artery. The artery passes downward and inward, and in
its course follows the depression between the extensors
and tlie adductors. From the middle third of the thigh
onward the sartorius muscle lies in front of the artery,
which in this situation is covered by the tense fibers of
the deep layer of the fascia lata. The artery, with its
accompanying vein, enters the popliteal space through an
opening in the adductor magnus (Hunter's canal), at the
junction of the middle and lower thirds of the thigh.
The femoral vein below Poupart's ligament lies to the
median side of the artery. In the further cour.-e of the
vessels they cross in such a way that the vein comes to lie
behind the arterv. This relation is attained in the middle
Tab 4.
Lith. Anst /.' Reuhhold. iiiinchen
LIGATION OF VESSELS IN CONTINUITY. 75
of tlu' thij^li, and tlie vessels thus pass t1ir()iio;li Iliintcr's
caiuil. Ill ciitcrlng the })()j)liteal spae(! I'rom the jjosterior
aspect the vein comes first into view, while iu front of it,
in intimate relation, lies the artery.
The femoral artery may he li*j:;ate(l :
(1) In the subinguinal depression, directly below Pon-
part's ligament.
(2) In its conrse behind the sartorins mnscle, at the
junction of the middle and upper thirds of the thigh.
(3) In Hunter's canal.
I. Ligation of the Femoral Artery below Poupart's Liga-
ment. — The incision into the skin is made parallel N\'ith
the axis of the thigh from Poupart's ligament doNvnward
for a distance of from 5 to 8 cm. (2-3 in.). The upper
extremity of the incision corresponds with a point mid-
way between the symphysis pubis and the anterior supe-
rior iliac spine (Fig. 49, a). After division of the skin and
the fatty connective tissue careful dissection is made
downward in a vertical direc^tion until the sheath of the
vessels is recognized by its fibrous structure and whitish
appearance. The sheath is divided upon a grooved
director and the artery isolated for a short distance with
two pairs of forceps and raised from its bed. The
femoral vein can be brought into view upon the median
side of the artery. The crural nerve is some distance to
the outer side of the vessels, covered by the deep layer
of the fascia lata.
II. Ligation of the Femoral Artery at the Junction of
the Middle and Upper Thirds of the Thigh. — By inward
rotation of the thigh the depression following the course
of the sartorius muscle, from above and without down-
ward and inward, upon the inner aspect of the femur,
can be brought into view. The incision in the skin is
begun at the junction of the middle and upper thirds of
the femur, and follows the line of this (lej)ression along
the inner border of the sartorius muscle (Fig. 49, b). After
the subcutaneous connective tissue has been passed the
delicate fascia of the thigh comes into view and should
76
OPERATIVE SURGERY.
Plate 5. — Exposure of the Femoral Artery in the Adductor
Canal.
Vi, vastus iaternus; S, sarttirius. The fibrous covering of Hunter's canal
(ff) is divided, with exposure of the femoral artery and vein.
Fig. 49. — Cutaneous incision for ligation of the femoral artery : n, be-
low Poupart's ligament ; b, below the sartorius muscle ; c, in the adductor
canal.
Tab. 5.
\
J.Uh, AfL-it K Rji'ichliciU. Mn.
LIUATIOS OF VESSELS AV CUSTIMITy. 11
ho divided in the direction of the eiitniieons iiK'ision. If
the incision he ]>ro|)erly phieed, the sartorins ninx'h' comes
into view ixWvv (Hvision ol' tlie i'ascia, heing recooni/cd hy
its niuscuhir tihers rnnninii; j)aranel with the ontanoons
incision. It" the HIkts of the exposed nmscle pass from
within antl al)ove outward and downward, or the reverse,
it may he known that the incision lias been made too
far inward or outward, and tliat the muscle disclosed is
the adductor niairnus or the vastus internus. The median
IxM'dcr of the sartorius jnuscle is expose
r=3
P4
AMPUTATIONS AND ENUCLEATIONS.
93
AMPUTATIONS AND ENUCLEATIONS. 95
end tlio knife is n])|)lierevented. In sawiuii' throuirh the bone care should
be taken that the division is etfected as far from the
periphery as possible ; that the sawed surface is at right
angles to the louiiitudinal axis of the bone ; and that the
soft parts are protected from all injury. The muscles
are drawn with tenacula out of reach of the saw or
the stump is wrapped in suitable compresses and thus
protected.
In applying the saw the nail of the thumb of the left
hand is placed vertically upon the denuded bone (Fig.
58), and the support thus atibrded is used as a guide for
the blade of the saw. At first the saw is manipulated
without pressure. Only after a groove has been formed
in the bone may the sawing be proceeded with more
mpidly, with the application of a certain degree of press-
ure. An assistant, stationed at the periphery, holds the
extremity in a position of extension and aims to keep the
sawed surfaces apart in order that the blade of the instru-
ment shall not become impacted. The irregular edges of
the divided bone are trimmed by means of bone-forceps,
and small projections are cut off.
After complete removal of the amputated part atten-
tion is directed to the definite control of hemorrhage. The
main arterial and venous trunks, recognizable by their
position, are isolated in the stump with the aid of two
pairs of dissecting-forceps, clamped in sliding-forceps, and
ligated. In addition to the main arterial branches all
vessels that can be seen running in the connective-tissue
interstices of the muscles are also ligated. The Esmarch
bandage can now be freed, and it may be necessary to
apply additional lig-atures. Parenchymatous hemorrhage
is controlled by compression.
The care of the icound has for its object accurate ap-
110 OPERATIVE SURGERY.
proximation of the wound-surfaces, with the avoidance of
dead spaces, as well as exact approximation of the margins
of the skin. The muscles may be separately united by
buried sutures or large areas of surface by means of
gauze-pad sutures, while the skin is closed by superficial
Fig. 64. — Cutaneous suture after amputation of the leg through a
circular incision.
knotted sutures, or by a continuous suture (Figs. 64 and
65).
If it has been possible to effect the amputation under
complete aseptic conditions, the wound may be closed
entirely by suture ; otherAvise drains may be brought to
the surface out of the depth of the wound. A like pur-
pose may be served by the introduction of strips of sterile
or antiseptic gauze.
In the performance of exarticulation the same general
principles may be observed as in the performance of
amputation. The operator stands at the periphery of the
extremity, holding the part to be removed in the left
hand, while the exarticulation is eifected with the right.
In the majority of cases the joint is opened from its ex-
tensor aspect. Flap and oval incisions are generally
employed, less commonly circular incisions, with the
A MP I TTA TIONS A NJ) KN UL 7> KA TIONS.
Ill
formation of a cuff. T\w Haps are so formed that their
base c'orres]K)n(ls with tlie phme of tlie joint at which the
separation is to be made. As a rub', Haps of unusual siz(.'
are made. Upon that side of tlie joint on wliich the cap-
sule is first opened the flap may l)e made by transfixion
or by dissection from without inward. AVhen the exar-
tieulation is completed the soft j)arts upon the opposite
side of the joint are diyided from within outward. To
^'"
Fig. 65. — Cutaneous suture after flap-amputation of the thigh,
this end the operator draws upon the extremity, grasped
with the left hand and already freed at the articulation,
in such a way that the bridge of skin still uniting the
part wnth its central attachment is made smootli and
tense. The knife is introduced into the wound and
divides the tissues transversely. In making the division
care should be taken that the muscles are first divided
and then, somewhat further toward the periphery, the
112 OPERATIVE SURGERY.
skin. The methods of performing exarticulation are in
part so carried out that Avith the last incision of the knife,
which passes from the Avound and forms tlie flap, the
main vessels are severed. During the process of division
the artery may be closed by pressure with the finger in
the wound. A method of exarticulation (Esiliarch) often
employed with large joints consists in circular division of
the soft parts in the upper third of the extremity down to
the bone after application of the Esmarch bandage. The
bone also is divided at the level of the incision through
the muscles. After ligation of the vessels the constrict-
ing band is removed. A longitudinal incision is made
through the soft parts down to the bone from the joint to
the primary wound in such a w'ay that large vessels and
nerves are not divided. With the wound thus made
held open by means of hooks, the joint is opened and the
remainder of the bone removed with the utmost care.
This combination of circular and longitudinal incisions
constitutes a variety known as the racket-incision.
Amputations and Bxarticulations of the I/Ower
Extremity. — Amputation of the Leg. — The removal of
the leg may be undertaken at varying levels. It was
formerly the custom to amputate the leg under all cir-
cumstances in its upper third at the site of election.
This method had for its object the use of a wooden leg,
upon which the flexed knee Avas comfortably received
after the wound had healed. At present, hoAvever, the
principle is folloAved to be as conservative as possible in
amputations of the leg, and in the remoA^al to take the
greatest care of tlie healthy portion of the extremity.
For this reason amputations are no longer performed at
the site of election, but at the site of necessity.
Among the methods of amputation of the leg employed
are the circular incision in two steps, Avith the formation
of a cufF; and A^arious forms of flap-operations: tAvo
lateral tegumentary flaps; two lateral musculotegu-
mentary flaps ; one anterior tegumentary periosteal flap ;
and a posterior short musculotegumentary flap from the
- 1 ^frl 'T. 1 77' K\s . I yj} j:y i v lk. i tjoxs. 1 1 3
calf (Heine). A simple larire ninsculotegumentarv flap
from the substance of the calf also may serve to cover the
stump.
Amputation of the Leg with a Circular Incision in Two
Steps. — An assistant rotates the leg towanl the operator
and a circular incision is made throuirh the skin, begin-
ning at a [)oint most remote from the ojx*rator, and pro-
gressing toward himself, until the entire circumference of
the part is dissected and a cutf is formed. When this
has been separated for a sufficient distance all around and
folded back the layer of muscles is divided. The incision
through the muscles of the calf is made in three steps.
Finally the muscles upon either side of the interosseous
ligament are divided. This complex incision should be
made exactly in the same plane, .so that the vessels are
not divided at varying levels.
In making the figure-of-eight incision the knife is
placed horizontally, with its heel upon the upper surface
of the tibia, so that its pointed extremity is directed
toward the operator. It is steadily held in a horizontal
position and drawn from heel to toe, introduced into the
interosseous space close to the tibia up to its handle, and
the soft tissues between the two bones divided. The
fibula being reached, the knife is drawn from heel to toe
around this bone and passed horizontally ag-aiu into the
interosseous space, with its point directed from the ope-
rator and its blade upward, dividing any remaining mus-
cular fibers from the fibula toward the tibia. The ope-
rator now introduces the index-finger and t-he thumb of
his right hand into the wound and grasps the intero.sseous
ligaments to assure himself that all of the muscles have
been transversely divided. Before the saw is used the
assistant rotates the member inward. The periosteum is
detached from the bone with the raspatory- at the line of
division. The saw is applied upon the til)ia in such a
manner that the fibula also is brought within the range of
its action. A groove is first carefully sawed in the tibia,
and when the blade of the saw has thus secured a good
d
114 OPERATIVE SURGERY.
Plate 8.— Transverse Division of the Right Leg in its
Middle Third.
t, tibia; /, fibula; E, group of extensors (tibialis auticus, extensor
digitorum communis, extensor hallucis) ; S, soleus; G, gastrocnemius;
Tp., tibialis posticus; Pi:, perouei ; Ta., anterior tibial artery, with the
corresponding vein and the deep peroneal nerve ; T, posterior tibial
artery, with the corresponding veins and the posterior tibial nerve ; P,
peroneal artery and vein.
grasp the fibula also is brought within the sphere of its
activity and both bones are divided simultaneously (Fig.
58).
The stump thus made shows the cross-section of the
two bones, with the interosseous ligaments stretched
between them. Anteriorly, lying upon the ligament, is
the group of extensors, while upon the opposite side lie
the flexors. Surrounding the fibula the peroneal group of
muscles is visible. The powerful mass of the calf-muscles
forms the most superficial layer upon the flexor aspect.
Between this and the flexors pass the posterior tibial and
peroneal arteries. Lying upon the anterior aspect of the
interosseous ligament is the anterior tibial artery. The
center of the field is occupied by the tibialis posticus mus-
cle, which is a useful landmark in looking for the vessels.
In front of this, but separated by the interosseous liga-
ment, is the anterior tibial artery, and closely behind it
are the posterior tibial and peroneal arteries to the fibular
and tibial sides respectively.
Flap-amputations of the Leg. — Two Lateral Tegument-
ary Flaps of Equal Size. — The base of the flaps corre-
sponds with the level at which the bones are to be di-
vided. Anteriorly the margins of the flaps meet in the line
of the crest of the tibia. The shape of the flaps is out-
lined Avith the knife introduced down to the fascia, when
the flaps are dissected from the subjacent structures and
turned back (Fig. 61). The incisions through the mus-
cles are to be made in the typical manner described at
right angles to the axis of the extremity. The muscles
of the calf are divided in three steps ; then those of the
Tab. 8.
0.
LUh. Anst /.' HeuMwld. Muncheti
AMPUTATIONS AND ENUCLEATIONS.
115
interosseous space ])y the fi^iire-of-ei<;lit incision; finally
{\\v hone is divided in the manner descrihech To prevent
tlic ])r()jcction of the sharp anterior crest of the tihia after
division Avith the saw this j)roniinence is either broken
ofl' witli forceps or sawed off*. To this end the crest is
sawed into in an o])liqiie direction, from above downward
Fig. 66. — Incisions for amputation of the
leg: a, circular incision for amputation at
the site of election ; 6, lateral flap-incisions.
and backward, for some distance, before the bone is
removed. A\'hen the tibia is now divided transversely a
])ortion of the bone at the crest falls out and the previous
prominence is removed.
Two Lateral 3Iusculotegumentary Flaps. — The shape of
the flaps is the same as that just described. An incision
116
OPERA TIYE S URGER Y.
is made through the skin and the fascia down to the mus-
cle. After the skin has been retracted the flaps are formed
either by transfixion or by incision from without inward.
AVhen the flaps are folded back the muscles are divided
Fig. 67. Fig. 68.
Figs. 67, 68. — Cutaneous incisions for amputation of the leg, after Heine :
showing anterior and lateral aspects.
bv a figure-of-eio^ht incision and the bone is sawed through
at the level of the base of the flaps.
Anterior Long Tegumentary Periosteal Flop, with, a Pos-
terior Short JIusculotegumeniari/ Flap (Heine). — A broad
quadrangular flap with rounded corners is made upon the
anterior aspect of the leg (Figs. 67 and 6S). In the situa-
A Mr I 'TA Tioys A M) EX I X'LEA TIOSS. 1 1 7
ium to w hieh the Hap, after diviHon of the skin, i.s retraeted
tile jH'rior»teuni of tlie anterior >iirfa(e nf the til>ia is inci>ey means
of a raspatory and tluis retains its connection with the
freed skin. After the anterior flap has been dissected to
its base the bone is raised and a shorter arched flap con-
sisting: of the skin and the muscles of the calf is formed
u]X)n the |X)Steri(ir aspect of the leg by an incision from
without inward. The muscles of the interosseous space
are then divided and the bones are sawed through in the
usual manner.
A ft'uiffle lateral jfap is made correspond i ugly longer and
with a broader base. It may be constituted of skin, on
the inner side of skin and periosteum, or finally of skin
and muscle. When the tiap has been dissected a circular
incision through the skin is made upon the opposite por-
tion of the circumference of the leg unitintr the extremi-
ties of the flap and after retraction of this the muscles are
divided in the usual manner.
To increase the su})poning power of the stump follow-
ing amputation of the leg Bier, after healing of the woimd,
removes a wedge-shaped portion of bone above the level
of the stiunp, so that the lower extremity of the latter can
be turned forward and upward through an arc of ninety
degrees and be permitted to unite in this position. By
this means closure of the medullary cavity is efl^c^'ted and
the supporting surface is formed of healthy, well-padded
skin, free from cicatrices, whose muscles do not undergo
atrophy by reas<»n of preserving their natund attachment
to the bone. The principle upon which the method is
based is illustrated l)y the accomi)anying diagrammatic
representation (Fig. 69). The medullary cavity of the
divided bone may, according to Bier, be closed also with
118
OPERATIVE SURGERY.
a loose piece of periosteum or Avith a foreign body, such as
stanniol-paper.
Supramalleolar Amputation of the Leg by Syme's
Method. — The ankle-joint is opened and the bones of the
leg divided just above the malleoli and the wound covered
Avith a cutaneous flap obtained from the heel. The patient
occupies the dorsal decubitus. The foot is raised above
the horizontal and the operator stands to its peripheral
side. Grasping and fixing the foot by the heel Avith his
left hand the operator makes an incision, ahvays begin-
ning on the left side, from the apex of the malleolus ver-
tically toAvard the sole of the foot, then transversely
Fig. 69. — Diagrammatic representation of amputation of the leg after
the method of Bier.
through the sole and again vertically upward to the other
malleolus, dividing the tissues down to the caicaneum
(stirrup-incision). A second incision, nuide over the an-
terior aspect of the ankle-joint unites the extremities of
the first, Avith which it makes a riglit angle and it also
extends down to the bone. This incision should open the
joint betAveen the trochlear surface of the astragalus and the
lower extremity of tlie ti])ia and the fi])ula. In order to
expose the joint fully the lateral ligaments must be divided
on either side. The incision through the capsule has the
folloAving form : / ~\ , the short limbs passing through
the lateral ligaments. Only after the lateral ligaments (at
the outer malleolus, the anterior and posterior astragalo-
AMPUTAI loy.s , 1 M) KX UCLEA TIONS.
119
fibular, and the calcaneofibular ; at the internal malleolus,
rhe deltoid liiranient) have been divided will tlie head of
the astragidus l^e free, even with .-flight plantar Hexion of
the joint. If the posterior wall of the capsule be divided,
the upper surface of the ealeaneuni comes into view. The
tuberosity of the calcaneus is freed from its coverings by
vigorous incisions made vertically upon the bone, with the
foot bent in maximum plantar flexion (Fig. 70j. When
Fig. to. — Amputation of the foot by the method of Syme : enucleation
of the tuberosity of the calcaneum from its coverinors.
the foot is thus freed and detached the lower extremities
of the tibia and the fibula are freed from the soft tissues,
surrounded by a circular incision, and sawed through
transverselv.
The operation is attended with certain disadvantages, the excavated
heel-flap not being properly adapted to approximation with the leg, while
the excavation is further favorable to the accumulation of considei-able
quantities of secretion. Although Syme's operation no longer receives
the recognition which was formerly accorded it, it still deserves con-
120
OPERA TIVE S UR GER Y
sideration, as it represents the predecessor of a number of admirable
operations (PirogotI'. Gritty, etc.).
Amputation of the Foot by the Method of Pirogoflf. —
PirogoiTs operation consists in osteoplastic supramalleolar
Fig. 71. — PirogoflTs amputation: detachment of the soft parts from
the posterior aspect of the lower extremity of the leg; the blade of the
knife is directed against the bones.
amputation of the lee:, with the formation of an osseous-
tegumentary flap from the heel. This procedure over-
A MP I ' TA TIOXS A XP EX I TIE A TIOXS.
121
comes the ilisiulvantairos and ditlit'iiltics of Synie's ffpfra-
tion hy not scpanitinix tlic tulKTo.sity of the calcaneum,
l)nt sawing through the l)one so that its posterior segment
retains its connection with the skin and enters into the
formation of the flap. The operator occupies the same
position as in the operation of Syme and the incisions
throngli the skin are made in a similar manner. The
operator fixes the foot with his left hand and, beginning
on the left side, cuts from* the apex of one malleolus ver-
tically toward the sole of the foot (Fig. 72j, then trans-
FiG. 72 — PirogoflTs amputation : cutaneous incisions.
versely through the sole, and again vertically upward to
the ajX'X of the other malleolus, dividing the soft tissues
down to the bone (stirrup-incision). An anterior trans-
verse incision unites the extremities of the primary stir-
ru|>-incision. This incision divides the tendons of the
extremities transversely and opens the capsule of the
ankle-joint. In order to open widely the joint between
the head of the astragalus and the lower extremities of
the tibia and the fibula the lateral ligaments must first be
122
OPERATIVE SURGERY.
divided. In effecting this division, especially upon the
inner aspect, the incision should be made close to the
astragalus, in order to avoid injuring the posterior tibial
artery. After the joint has been freely exposed the
posterior wall of the capsule comes into view, after
division of which the upper surface of the tuberosity
of the calcaneum is exposed. The operator, who until
now has stood at the periphery of the foot, changes his
Fig. 73.— PirogoflTs amputation : division of the calcaneum with the
saw.
position, grasps the foot with his left hand and applies
the saw to the upper surface of the tuberositv of the cal-
caneum (Fig. 78). This process is divided in a plane
corresponding to that of the stirru])-ineision, when the
foot appears to be separated. The lower extremities of
the tibia and the fibula are prepared for division with the
saw, the soft parts upon the posterior aspect being first
dissected close to the bone. This incision demands es-
pecial care iii order to avoid division of the posterior
AMPUTATIOyS ASD ENVCLEATIOSS.
123
t- r.
AMPrTATinxs AXD EXUCLEATIOXS. 125
tibial artery, which is essential for the nutrition of the
heel-portion of the flap. The surgeon grasps the flap
between the thunil) and the index-iingcr of his left hand,
flexes it backward in maximum degree and separates the
Fig. 75. — Stump left after PirogoflTs amputation.
soft parts from the posterior aspect of the tibia in such a
way that the blade of the knife is brought in direct con-
tact with the bone (Fig. 71).
Upon the anterior surface it suffices to di.splace the ten-
dons, when the bones of the leg may be divided circularly
126 OPERATIVE SURGERY.
just above the malleoli. In sawing through the bones
the leg is held horizontally, the operator standing as if
amputating, with the member to be amputated to his
right. An assistant grasps one of the malleoli with Lan-
genbeck's forceps, when the division of the bone trans-
versely to the longitudinal axis of the leg may be pro-
ceeded with (Fig. 74). The stumps of the tendons are
grasped with forceps and divided with scissors at the level
of the wound. The vessels are secured by ligatures. The
only vessels concerned are the anterior and posterior tibial
arteries. The first is readily found upon the anterior sur-
face of the tibia at the side of the tendon of the extensor
hallucis. If the successive steps of the operation have
been properly followed, the posterior tibial artery will be
found to have been divided on the inner aspect of the heel-
flap, somewhere about the middle of the vertical limb of
the stirrup-incision. In closing the wound the heel is
moved through an arc of 90° and the sawed surface of
the calcaneum brought in simple apposition with that
of the tibia or fixed by bone-sutures or jDcrcutaneous
pegs. The cutaneous wound is united transversely
(Fig. 75).
The operation of Pirogoff has undeniable advantages
over deep amputation of the leg, as exemplified by Syme's
operation. The shortening is reduced to a minimum by
the preservation of the posterior extremity of the calca-
neum, which forms a prolongation of the bones of the
leg. The strong, well-cushioned skin of the heel makes
an admirable walking-surface, while the cicatrix does not
lie within this area.
Pirogoff in his first communication upon the subject
had already called attention to the fact that after making
the flrst incision into the sole of the foot the division of
the calcaneus could be proceeded witli immediately from
the sole (Figs. 76 and 77), and exarticulation at the ankle-
joint next effected. He also had made the suggestion to
give an oblique direction to the heel-flap in order to bring
a larger portion of the calcaneum and the skin of the
AMriTA TlOys AMJ Jjy UCLEA TIONS.
12'
Fig. 76. — Giinther's modification of Pirogoff's amputation : division of
the calcancum from the sole of the foot.
Fig. 77.— Configuration of the foot after division of the calcancum.
AMri'TATfONS AM> KSrcLKATlONS. 129
Plane of tiik Sawkd Suufacks in riuoooFF's Upeuation.
Fig. 80.— Lefort's modification.
AMPLTATIOyS AM> LMCLLATJOXS. 131
sole into the po.stiricM* flap. Therate(l hy (Jiinthcr and Lcfort.
\\'liik' the c'litaiirnii^ incision and the phines of the two
incisions thrunuli the l)ones are at riiiht anirk's to each
other in Pirogotf's operation (Fiu:- "t^), the tul)erosity of
the calcanonni is diviikcl ol)liqnely from Ijehind above
forward and downward in Giintiiers modification ; also,
the lower extremities of .the tibia and the fibnla are not
sej)anited in the tbrm of a plate, but in that of a wedge,
and in such a manner that the base of the wedoe corre-
sponds with the posterior and the apex with the anterior
bonndary of the tibia. As a matter of course, the cuta-
neous incisions are to be modified accordinsrly. The
stirrup-incision will pass from the posterior boundary of
the malleoli, not vertically downward, but obliquely for-
ward toward the sole, so that a larger portion of the skin
of the sole is contained in the heel-flap. The stump is
thus changed in so far that not only does the tnl^erosity
of the calcaneum form the walking-surface, but also a
portion of the sole, the natural walking-surface, serves as
a su})port for the stump.
The walking-surface becomes still broader if the calca-
neus is divided almost horizontally in accordance with
the modification of Lefort (Fig. 80). The stirru{>-
incision passes obliquely forward to Chopart's joint, while
the dorsal incision forms a flap with its convexity directed
forward, and it extends also to the line of Chopart's
joint. The dorsal flap is dissected back, the ankle-joint
opened, and the calcaneum sawed through from its tuber-
osity forward in the direction of the cutaneous incision
into the calcaneocuboid joint, the foot being held in a
position of maximum plantar flexion. The foot is now
separated at Chopart's joint and tlie lower extremities of
the tibia and fibula are divided in the manner described.
Bruns recommends horizontal divisi(^n of the calcaneinn,
though in an arched direction. The sawed surface of the
calcaneum is thus concave, while that of the tibia pre-
sents a corresponding convexity.
132 OPERATIVE SUBGERY.
Tlie limitations of Lefort's modification are naturally
narrower than those of the typical operation of PirogofF.
If the calcaneum is perfectly healthy, and tliis is a neces-
sary condition for the employment of Lefort's o]^)eration,
it would beem preferable to select the less serious pro-
cedure of exarticulation at Chopart's joint.
As a preliminary step in the performance of Pirogoflf 's operation di-
vision of the tendo Achillis (AchVloteuotomy) is undertaken. The ten-
don is divided, either through an open wound or subcutaneously, in a
transverse direction, a finger's breadth above its attachment to the tuber-
osity of the OS calcis.
In performing subcutaneous tenotomy the knife ''tenotome) is passed
through the skin and the tendon is divided by cutting either toward or
from the skin. Under the condition fii-st named the operator grasps the
tenotome, as a table-knife is held in paring fruit, with the flexed four
fingers of the right hand, while the thumb is supported on the heel (Fig.
&lj ; the knife is passed from right to left in front of the tendon. The
latter is subjected to passive tension and is divided by short rocking
movements of the knife toward the thumb, which is placed upon the
tendon as a guide and to aftord resistance (Fig. 62). The jerk with
which the extremities of the divided tendon separate indicates the
completion of the operation.
When, on the other hand, the tendon is to be divided from without
inward the foot is so adjusted that the tendon is completely relaxed.
The tenotome is grasped between the thumb, the index, and the middle
finger and introduced upon the flat, from right to left, between the skin
and the tendon 'Fig. 12 , The tendon is thus brought beneath the blade
of the knife and is gradually divided by rocking movements, while an
assistant subjects it to maximum tension by corresponding movement
of the joint.
Exarticulations and Amputations of the Foot. — Exarticu-
lations of the Toes in the Interphalangeal or Metatarso-
phalangeal Joints. — Doi\ml Opining of the Joint, tcith the
formation of a Plantar Teguraentary Flap by Incision from
zvithin Outirard. — The operator grasps with the index-
finger and the thumb of the left hand the toe flexed at the
joint of separation, and the joint is opened by a transverse
incision upon the extensor aspect, somewhat toward the
periphery from the highest prr)minence of the joint. Then
the lateral ligaments are completely severed until the
joint is fully opened. Next a flap is formed from the
plantar tissues by an incision from the wound outward.
The length of the flap will be governed by the transverse
extent of the exposed bone.
AMPUTATIONS ASU ESUCLEATIOSS. 133
Fig. si. — Achilloteiiotomy : the tenotome is passed beneath the relaxed
tendon.
AMPUTATIUXS AM) ENUCLEATIONS.
135
AMPUTATIONS AXD ENUCLEATIONS. 137
^•l larr/e (lorstil and d short phrninr ttrf^imndtiry jlap may
al.so he eniployeti advantageuii.^ly in tlie removal of toes ;
as well as tirolaiertd Jiapfiof equal nize ; or a miff le lateral
tef/uinentart/ flap. In all cases the flaps are carefully out-
lined with the knife, se{xiraten
the dorsal asj)ect somewhat behind the line of the joint.
The incision then runs ])arallel with the longitudinal
axis of the int of origin. The joint is exposed upon its dorsal
aspect by dissecting the two sides of the oval, and opened
transversely, when removal may be effected after division
of the plantar tendons.
Amputation of a Toe through the Metatarncd Bone. — An
oval incision is made, its ajx^x corresjx)nding Avith the
point at which the metatarsal bone is to be sawed thr(jugh.
The incision passes longitudinally over the metatarsus
beyond the metatarsophalangeal joint. It then passes
around to the flexor as}xct and back again on the opj)osite
side, to return to its point of origin. The nietatarsus is
dissected free in the course of the lontjitudinal inci^ion and
divided with the phalangeal saw or the chain-saw. The
distal extremity is grasjx'd and enucleated, and if this pro-
cedure has been carried out to the transverse incision in
the flexor fold of the metatarsr)phalangeal joint the sej^a-
ration will have been completed.
Amputation of (dl Toes through the Metatarsus. — A large
semicircular plantar and a >hort dorsal cutaneous flap are
made. The ojxrator >tands at the periphery of the ex-
tremity, with the foot held in maximum dorsal flexion,
138
OPERATIVE SURGERY
and a plantar flap is cut and separated from the metatarsal
])ones. The dorsal tegumentary flap is then outlined and
likewise dissected free. The metatarsal bones are sur-
rounded totally by a circular incision, the muscles in the
interosseous spaces divided, the periosteum of each bone
individually pushed back at the place at which it is to be
sawed through, and the saw finally applied from the
dorsum of the foot to all of the bones simultaneously.
*-*^2x
Fig. 83.
Ainputatiou of the toes tlirougli the metatarsus: plantar
iQusculo-tegumeutary flap.
The plantar flap may also be formed by cutting out-
ward from the wound after the bones have been salved
through. The dorsalis pedis artery and the digital arte-
ries will require ligation.
Exarticulation of the Great Toe, together irifh the Jleta-
tnrsnj Bone. — An oval incision is made Avith a prolonged
apex. The dorsal incision begins on the extensor aspect
over the metatarsophalangeal joint and passes in the longi-
tudinal axis of the metatarsus to the head of this bone,
where it deviates to one sidcj then surrounds the entire
AMPUTATIONS AND ENUCLEATIONS. 139
baseof tlie too, and thus a^aiii readies tlic dorsal aspect of
the toe, joininti; the original longitudinal incision. The
inciision at all points is made down to the bone. Hooks are
introduced on either side of the longitudinal incision, and
the muscles are separated from the metatarsus. While
the toe is raised the metatarsal boiu; can also Ix; freed from
the muscles npon its under surface, when the joint between
the internal cuneiform bone and the base of the metatarsus
can be opened on its dorsal aspect. Linear closure of the
wound is finally effected.
Ex articulation of the Little Toe, together with the Meta-
tarsal Bone. — A lateral fla}) is formed according to the
method of A\ alther. The oj^erator grasps the abducted
little toe and a])plies the l)lade of the knife vertically in
the interdigital fold between this and the adjacent toe,
when the soft parts of the interspace are divided, by saw-
ing movements of the knife held close to the metatarsal
bone of the little toe, to the tarsus. From this point, with
abduction of the toe and the metatarsus, entrance is gained
into the joint between the fifth metatarsus and the cuboid
bone, w^hen the toe is bent outward at the joint at a right
angle or more. The operator incises the tissues around
the tuberosity of the metatarsal bone close to the bone,
and with sawing-movements detaches the soft parts from
the outer side of the metatarsal bone until a flap has been
secured of sufficient extent to cover the wound made.
The flap is cut transversely from the wound outward.
The little toe may also be exarticulated at the tarso-
metatarsal joint by means of an oval incision, the apex of
Avhicli is made upon the dorsum of the foot, as in removal
of the great toe. The apex of the oval, as well as the
longitudinal incision, may also be placed advantageously
upon the lateral border of the toot.
Removal of the Foot at the Tarsometatarsal Joint. Lis-
franc's Operation. — It is important to determine the situa-
tion of the ends of the line of the tarsometatarsal joint
upon the inner and outer borders of the foot. The outer
extremity corresponds with a point just behind the readily
140 OPERATIVE SURGERY.
palpable tuberosity of the fifth metatarsal bone, Avhile the
inner extremity is about a thumb's breadth in advance of
the prominent tuberosity of the scaphoid bone. The line
of the tarsometatarsal joint is not a directly transverse
line between the two points named, but it pursues a com-
plex course. From the fifth metatarsal bone it passes for-
ward at an angle of 45° ; then it passes inward along the
base of the fourth metatarsal bone. The next joint, be-
tween the external cuneiform and the base of the meta-
tarsal bone of the middle toe, is directly transverse, but
projects somewhat forward. The articulation between the
metatarsal bone of the second toe and the middle cunei-
form bone is also transverse, somewhat behind that of the
third metatarsal bone and in the line of that between the
fourth metatarsal and the cuboid bone. The internal
cuneiform bone projects forward (Figs. 84 and 85).
Steps of the Operation. — The principle of the operation
consists in dorsal opening of the joint and the formation
of a musculotegumentary flap from the sole by an incision
from within the wound outward. The operator stands at
the periphery of the foot to be amputated, which he grasps
from the sole, and with thumb and middle finger he marks
the extremities of Lisfranc's articular line. Then an in-
cision through skin and fascia is made on either margin
of the foot do^vn to the muscles between these two points
— a thumb's breadth in advance of the scaphoid tuberosity
on the inner side and just behind the tuberosity of the
fifth metatarsal bone — on the outer side and carried for-
ward beyond the heads of the metatarsal bones. An
incision convex anteriorly over the dorsum of the foot
then unites the posterior extremities of these lateral in-
cisions. After division of the skin and the subcutaneous
connective tissue the dorsal flap is somewhat retracted.
At the point of retraction the tendons and muscles of the
dorsum of the foot are divided accurately in the direction
of the cutaneous incision. There are thus exposed upon
the dorsum of the foot the bones and the ligaments of the
joints throughout a small extent. The delicate dorsal cap-
AMPUTATToy.S AM) EyUCLKAllONS.
11
Fig. 84. — Lisfranc's articular line : exposed articular line upon the foot.
Fig. 85. — Course of Lisfranc's articular line Rafter van Walsen) : 0«,
cuboid bone; A'l, K2. A'3, external, middle, and internal cuneiform bones.
/, //, ///, IV, r, articular surfaces of the corresponding metatarsal bones.
I, metatarsal bone of the great toe.
AMPI'TATIOSS AM) KMX'LKATlOSS. 143
EXAKTICULATIoN OF THE FOOT BY LiSFRANC'S METHOD.
Fig. 86. — The foot is flexed on the sole at Lisfranc's joint : formation
of the plantar musculotegumeutary flap by incision from within outward.
^^?5»!>i'^..
P^G. 87. — Stump left by Lisfranc's operation.
AMrUTATIONS AM) KMJCLEATIONS. 145
sulcs of tho joints arc now slit open, with the foothold in
slic:ht plantar flexion. The opening; of the joints is always
Ix'gnn at the external border, at the artienlation hetMcen
the fifth metatarsal bone and the lateral facet of the
enboid bone, as this can always be readily found if the
knife is introduced behind the prominence of the fifth
metatarsal bone and the incision is directed obliquely for-
ward and inward. According to Bergmann, tins joint
coincides with the direction of a line passing from the
tuberosity of the fifth metatarsal bone to the head of the
first metatarsal bone. After this first joint has been
opened the course of the remainder of the complex articu-
lar line can be made out from the landmarks mentioned.
The operator therefore directs his knife more toward the
middle line of the foot and opens the almost transverse
joint between the cuboid bone and the fourth metatarsal.
The next also transverse joint is situated somewhat
further forward. The transverse line of the joint between
the second metatarsal bone and the middle cuneiform bone
is readily found, corresponding with a prolongation inward
of the articular line of the fourth metatarsal bone (Fig. 85).
The joint between the first metatarsal bone and the in-
ternal cuneiform bone also is situated further forward.
The articular surfaces must be exposed by short incisions
directed against the bone. The longitudinal articular
surfaces are likewise exposed, and with increasing plantar
flexion of the foot the short ligaments that unite the
bones in the depth, as well as the ligaments of the sole,
in so far as these fall within the range of the incision,
are divided, until the whole series of joints is opened
to a maximum degree. It is now still necessary to form
a plantar flap. This must be so constituted as to include
at its base the soft parts of the entire sole. The substance
of the flap gradually diminishes in amount toward its
periphery, so that at its extremity it consists only of skin
and subcutaneous connective and fatty tissue, and it is
thus readily united with the delicate skin of the dorsum
of the foot (Fig. 87). With a long knife an incision is
10
146 OPERATIVE SURGERY.
made horizontally through the sole around the sesamoid
bones at the head of the metatarsal bone of the great toe,
the knife being brought out of the wound transversely
beyond the head of the metatarsal bone (Fig. 88). The
Fig. 88. — Form and extent of the plantar flap in Lisfranc's operation.
dorsalis pedis and the internal plantar artery are to be
ligated in the stump.
The stump left by Lisfranc's operation yields good
functional results. The flap is firm and well padded, and
the cicatrix lies upon the dorsal aspect quite out of the
area of the walking-surface. The extensors of the ankle-
joint (tibialis anticus, peroneus brevis), important as antag-
onists of the triceps, are maintained in their attachments.
Intertarsal Amputation. — The joint between the anterior
surface of the scaphoid bone and the three cuneiform
bones is opened, and the cuboid bone is sawed through
transversely in the lateral prolongation of the joint named.
The cutaneous incisions are the same as in Lisfranc's
operation. The joint in front of the scaphoid bone, recog-
nizable by its articular surface with three facets, is opened
from the dorsum of the foot and made to gape widely.
The periosteum upon the dorsal surface of the cuboid
bone is incised transversely and the bone divided accord-
ingly with the phalangeal saw. The bone is held in
plantar flexion and the jilantar flap is made as in Lis-
franc's operation.
AMPUTATIOXS ASD EXUCLEATIOyS.
U'
Fig. 89.— Chopart's articnlar line: T. head of the astragalus: X,
scaphoid bone : Cit, os calcis; Cu, cuboid bone. The calcaneoscaphoid
interosseous ligament is exposed by dissection.
AMPUTATIONS AND ENUCLEATIONS. 149
Intertarsal Exarticulation. Chopart's Operation. — The
a.stra<»al()S('aj)hni(l articulation upon the one liainl and the
eal('an('o<'ul)oi(l articuhition upon the other liand constitute
approximately a transverse line in ^vhich the foot may be
(livi(hMl within the tarsus. The extremity of tliis articu-
lar line upon the inner l)order of the foot lies just hehind
the tuberosity of the scaphoid bone ; while upon the outer
side the calcaneocuboid iirticulation will be entered if the
incision is made a thumb's breadth behind the tuberosity
of the fifth metatarsal bone. Chopart's joint is not repre-
sented by a directly transverse line between these two
points, but is curved somewhat as follows : the head of
the astragalus is directed with its convexity forward,
while the anterior articular surface of the os calcis is on
the contrary excavated (Fig. 89). The calcaneoscaphoid
interosseous ligament maintains the bones in apposition
after division of the articular capsule.
The operator occupies the same position as in Lisfranc's
operation and lateral incisions are made along the borders
of the foot outlining the plantar flap, the posterior ex-
tremities of which are united by an incision passing trans-
versely over the dorsum of the foot. The joint between
the head of the astragalus and the scaphoid bone- is
always opened first. It is not to be mistaken, as its situ-
ation is indicated by the prominent head of the astragalus,
in advance of which the incision is made, as ^yell as by
the tuberosity of the scaphoid bone, behind which the
incision passes. In order to divide the calcaneoscaphoid
interosseous ligament and to open the calcaneocuboid
articulation, the point of the knife is inserted in the outer
extremity of the already opened astragaloscaphoid articu-
lation, and the blade is directed toward the middle of the
small toe, and the tensely stretched ligament is divided
with a slight degree of pressure. The foot is flexed in
the line of the o])en joint; the ligaments of the sole of
the foot are divided in the line of the incision, and the
plantar flap is made similar to that in Lisfranc's opera-
tion, though correspondingly smaller, a finger's breadth
150 OPERATIVE SURGERY.
behind the head of the metatarsal bone. In the stamp
the dorsalis pedis and the internal and external plantar
arteries will require ligation.
If the directions given be not strictly followed, it is
possible that instead of entering the astragalocuboid joint
the operator may enter that between the anterior surface
of the scaphoid and the three cuneiform bones. The
retention of the scaphoid bone would scarcely be a dis-
advantage, inasmuch as the posterior tibial muscle is
Fig. 90. — Subastragaloid enucleation of the foot : tegumentary
incision.
attached to it. Jobert has recommended this method of
prescaphoid enucleation as a regular procedure.
The stump left by Chopart's exarticulation has a ten-
dency to fix itself in a position of club-foot. This defect,
it is thought, can be overcome by certain modifications,
such as Jobert's prescaphoid exarticulatiou, as well as
intertarsal amputation, inasmuch as the attachment of
the tibialis anticus muscle to the scaphoid bone is pre-
served and dorsal flexion is rendered possible.
Subastragaloid Enucleation of the Foot. — (Textor, Gun-
AMPUTATIOSS AND ENUCLEATIONS.
151
ther, Malgaigne.) — It'af'tcr ciiuclcatioii of the foot at Cho-
l)art's joint tlu' calcaiicimi is additionally removed, tlie as-
tragidiis alone of the tarsus is lei't in eonneetion with the
leg. This form of enucleation of the foot, which is known
as exarticulatio pedis sub talo, was performed and introduced
Fig. 91. — Subastrajjaloid enucleation of the foot : dissection of the
flap from the inner surface of the calcaneuui : T, astragalus ; C, calca-
neum.
by Malo:aigne as a regular procedure. In the original ope-
ration the incisions were like those in Syme's operation,
altliough the dorsal tegumentary flap extended beyond
Chopart's joint. The foot was removed at this joint, and
then the os calcis was extirpated. The best incision for
amputation of the foot at the calcaneo-astragaloid and
152
OPERATIVE SURGERY.
astragaloscaphoid joints is that of Giinther, who em-
ploys an internal flap extending to the sole to cover the
wound.
The incision (Fig. 90) begins over the tuberosity of the
OS calcis in the middle line of the heel, passes thence in
Fig. 92. — Stumji following Malgaigne's operation.
an arched direction below the external malleolus, and
turns at the level of Chopart's joint toAvard the median
line, to continue transversely across the dorsum of the
foot to its inner border, whence it courses over the sole
of the foot to the middle line. From this point the
incision is continued backward at an oblique angle,
AMPIJTATIOXS AM) ENUCLEATIONS.
153
thn)iiii:li the skin of tlie .sole, to reach the point of origin
over the tuherosity of the (js ealeis. The incision every-
w luTe reaches down to the bone.
The articuhition between the liead of the astragahis
and the scaphoid bone is first opened, and then the eon-
n(H'tions between the astrac^ahis and the os calcis are
divided in the tarsal sinus. If the under surface of tlie
astragahis is thus freecl, the flap outlined is separated
Fig. 93. — Enucleation at the knee-joint: outline of the flaps.
close to the bone from the inner surface of the os ealeis,
while the foot is rotated outward upon its longitudinal
axis (Fig. 91). In opening the joint between the head of
the astragalus and the concavity of the scaphoid bone the
calcaneocuboid articulation should not be included within
the range of the incision. The articulation between the
trochlear surface of the astragalus and the bones of the
leg should also be protected.
Exarticulation of the Leg at the Knee-joint. — An anterior
154 OPERATIVE SURGERY.
tegumentary flap is made upon the extensor aspect of the
leg, and the joint opened from this surface. A short mus-
culotegumentarv flap is formed upon the flexor aspect by
an incision from the wound outward. The teo-umentarv
flap has a broad h'ASQ, and its lower extremity extends
below the tuberosity of the tibia.
The operator stands at the periphery of the member.
The anterior flap is outlined by incision with the knife.
The incisions, passing vertically downward from the most
prominent points of the external and internal condyles of
the femur, extend three or four fingers' breadth below the
tuberosity of the tibia, at which level they are united by
a transverse incision. The corners of the flap thus formed
are rounded. The flap is now dissected from the subja-
cent structures to the level of the patellar ligament. \Yith
the extremity flexed at the knee the operator grasps the
leg with his left hand, divides the patellar ligament with
a single transverse incision, and enters the joint. The
lateral ligaments and the crucial ligaments of the knee-
joint are next divided, so that the leg is attached to the
thigh by only the posterior wall of the capsule of the joint
and the soft parts of the popliteal space. A long knife is
introduced into the wound behind the tibia, and its edge
is directed toward the periphery of the extremity, avoid-
ing the head of the fibula, a short musculotegumentary
flap being formed from the soft parts of the flexor aspect
by incision from within outward. By these means the
popliteal artery is not divided till the last stage of the
operation. The patella remains connected Avith the ante-
rior flap.
Pollosson recommends that the operation be so performed that the cap-
sule of the joint is opened close to the tibia in order that after separation
of this bone the capsule may be again closed by suture. In this way a
cavity is formed above the stump. Recovery is said to take place
promptly and the stump is believed to gain in usefulness.
Amputation of the Thigh. — Among methods of ampu-
tation of the thigh that may be employed advantageously
are : the circular incision in two steps, with the formation
AMPl'TATIONS AND ENUCLEATIONS. 155
of a ciilV; and ol' ilap-incisions an ant( ri<»i- and a posterior
niiiscnlott'iiuniciitarv flap of (Mpial si/c, or a lon^- anterior
and a short posterior niusenloteguincntary Hap.
Anqjutiitioii of the Thi(//i bi/ Matnn of a Circuhir Inci-
sion in Two tStrps. — The pelvis of the subject is brought
to the edge of the tal)h'. In amputating tli(^ riglit thigli
the operator stands upon tlie outer si(U' ; and in amputa-
tion of the left thigh, upon the inner side of the extremity,
Avhieh is lieUl securely in a horizontal position. At a suf-
ficient distance toward the periphery from the point at
which the bone is to be divided a circular incision is made
through the skin down to the fascia, and a cuff turned
back. At the point of reflection of this cuff the muscles
are divided down to the bone in four steps A\ith vigorous
strokes of a long knife. The bone is divided with the
saw at a point somewhat proximal to the incisions through
the muscles. For this purpose the operator with the index-
finger and thumb of his left hand pushes back the mus-
cles upon the bone and divides the latter somewhat fur-
ther from the periphery. The periosteum in the path of
the incision is detached from the bone by means of a raspa-
tory in the area to be saw'ed through, and the bone is di-
vided with a saw, while the muscles are retracted by means
of either tenacula or a divided bandage. In the center of
the stump (Plate 9) may be seen the transverse section of
the femur, around which the muscles are so grouped that
upon the anterior surface lies the quadriceps femoris,
while u})on the posterior surface lie the flexors. To the
inner side the group of adductors lie wedged between the
flexors and the extensors. The depression between the
adductors and the extensors is covered by the sartorius
muscle. In the space enclosed by these muscles, which is
triangular in cross-section, are to be found the femoral
artery and vein, as well as the saphenous nerve. Between
the flexors is the sciatic nerve, always accompanied by
vessels. In" the connective-tissue interstices of the mus-
cles are small arterial vessels divided transversely or visi-
ble in longitudinal sections. After control of hemorrhage
156 OPERATIVE SURGERY.
Plate 9. — Transverse Incision through the Left Thigh at its
Middle Third.
Q, quadriceps femoris muscle ; S, sartorius ; Ad, group of adductors ; F,
group of flexors; G, gracilis; A.C., femoral arterj' in a common sheath
with the profunda artery, the femoral veins, and the saphenous nerve;
Xi, sciatic nerve.
the muscles are to be so united bv buried sutures that the
Fig. 94. — Diagrammatic representation of Gritty's operation.
formation of cavities and dead spaces is avoided. The
skin is united by deep and superficial sutures.
Fig. 95. — Diagrammatic representation of Ssabanajeffs operation.
Flap -amputations of the Thigh. — Anterior and Posterior
AMPUTA TIOXS . I \n IJNUCLKA TIOXS.
157
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AMrVTATlOSS AXD ENUCLEATIONS.
159
^-XC'SS.'^w"-
AMrCTATlOXS AM) KMJCLEATIOSS. Kil
MiLSCulotegumcntary Fl<(j)s. — The H:ij)s arc semicircular
and well roiuidcd. 15(>tli Haps incft upon the lateral as-
pects of the thigh in such a manner that the base of ca(;h
corresponds to half the circumference of the part. The
operator marks the outlines of the flaps by incisions pass-
ins: throusch skin, fatty connective tissue, and the fascia lata,
down to the muscles. Both Haps may be formed l)y trans-
fixion or by incision froQi the periphery to the base. The
flaps are reflected at their bases, and the muscles attached
to the bone are divided by a circular incision. The bone
is sawed throuo^h in the usual manner and the wound is
closed by suture.
Osteoplastic Supracondylar Amputation of the Thigh by
the Method of Gritty. — Gritty has ingeniously applied the
osteoplastic principle of PirogoflPs operation to amputa-
tions at the knee-joint, the freshened surface of the patella
being approximated to the sawed surface of the femur, and
union taking place.
3Iocle of Procedure. — An anterior flap is made as for
exarticulation of the leg. This is dissected free to the
level of the patellar ligament and the joint is opened
transversely in this situation. At the same time the
lateral attachments of the capsule attached to the con-
dyles of the femur are divided so that the flap, with the
patella contained within it, can be reflected. The patella
is surrounded by an incision on the synovial surface of
the flap, and freshened by removal of its cartilaginous
articular surface with the phalangeal saw (Fig. 96). The
flap is now somewhat retracted, so that the supracondylar
portion of the femur is exposed. An incision is made
around the bone in this situation, the bone is sawed
through, and a short tegumentary flap is formed from
the soft parts of the popliteal space by an incision from
within outward. The patella is approximated to the
sawed surface of the femur and fixed in this situation
by bone-sutures or percutaneous pegs. The stump (Fig.
98) yields a functionally good result by reason of closure
11
162
OPERA TIVE S UR GER Y.
of the medullary cavity of the femur Avith l^one and the
favorable situation of the cicatrix.
Ssabanajeif has modified the method of amputating the
leg at the knee by bringing a segment of the tibia in ap-
proximation with the sawed extremity of the femur, and
the results are said to be superior to those of Gritty 's
operation. An incision is made through the skin on the
anterior aspect of the leg, as in Gritty's operation. A
Fig. 99. — The •wound made in SsabanajeflTs operation : T, sawed seg-
ment of the tibia for approximation to the femur ; F, sawed surface of
the femur.
short flap is outlined in the popliteal space with an arched
incision and dis.sected free, the knee-joint being opened
from the popliteal space. The leg is so bent at the knee-
joint that the .surface of the tibia is brought in apposition
with the anterior aspect of the thigh. From the articular
surface a transverse plate of bone is removed from the
upper extremity of the tibia as low down as its tuberosity,
and this remains connected with the anterior flap. The
thigh is further divided transverselv throuo-h its condvles.
AMPUTATIOXS AXD EXVCLEATIOyS. 163
The sup|x>rting surface of the stump is thus formed by
the tuberosity of the tibia, and clinical rejKnis are in
accord in the statement that it s^^rves this puqx)se ad-
mirably (Figs. 95 and W).
Exarticulation of the Pemur at the Hip-joint by the
Method of Esmarch. — The CMmbinatiun of circular ampu-
tatiuii of the thigh with a luugitudinal incision (Esmarch)
permits the removal of Jthe femur with a minimum loss
of blood. The pelvis of the subject extends beyond the
border of the table and the operator stands as in the per-
formance of amputation. After the application of an
Esmarch bandage as close to the tnmk as possible a cir-
cular incision is made through the skin down to the muscles
in the upper third of the thigh. At the point of retraction
of the skin the muscles are divide-d typically in a circular
manner down to the bone. The periosteum is likewise
incised and the bone is sawed through. The next step
consists in thorough ligation of the vessels in the trans-
verse incision. After the lumen of all the visible vessels
is closed by ligature the bandage is removed. Then a
longitudinal incision is made upon the lateral aspect of
the thigh, |xissing over the great trochanter, dividing the
soft parts down to the bone, and extending to the level of
the wound (Fig. 100). Hooks are introduced into the
margins of the incision and the bone is freed fix)m its
attachments. When the separation has been effected
throughout a sufficient extent, the operator grasps the
bone with his left hand, opens the joint, dislocates the
head of the femiu*, and severs the round ligament, Avhen
the central portion of the femur can be removed. The
whole operation can be performeerformance of enucleation, witli the
formation of two larr/e musculotegumentary jlaps by trans-
tixion, renders possible rapidity of exarticulation, although
the control of hemorrhage is difficult. The mode of pro-
164
OPERATIVE SURGERY.
cedure occupied a prominent position in surgery at a time
when rapidity of operation, ^Yhich had to be undertaken
without anesthesia, was a primary consideration. At
Fig. 100.— Exarticulation at the hip-joint:
combination of circular incision and external
longitudinal incision.
present, however, it is considered more important in an
operation to reduce the loss of blood to a minimum. Thus,
in exarticulation of the hip by the method of Verneuil the
AMPUTATIONS ASn ESVCLEATI02iS.
1G5
/
\
Fig. 101.— Enucleations of the finders: enucleation of the middle
finger at the iiiterphalangeal joint : opening of the joint on its dorsal
aspect. Formation of a palmar flap by incision from within outward.
Upon the thumb : line of incision for removal of the thumb at the
carpometacarpal joint by means of an oval incision. Upon the index-
finger : flap-incisions.
AMPUTATIONS AND ENUCLEATTONS. 1 G7
muscles are divided, step by step, with iiii ordinary scalpel,
divided vessels being inniiediately rt fcC 2 rrt M
.2 s o g ts s a
■J^ .2 'x ^ ^ c3 J3
s S !r^
iH M a a 'l^^ +3
•7^ bC '^ Ui
OS = 2=2^^
*^ la ^ -^i .S 3 tM
0.2
AMPUTATIONS AND ENIJCLEATTONS. 173
A large dorsal and a. sJiort plantar tegmnentary flap may
also be made advantageously, as well as two lateral flaps
of equal size or a, .vngle lateral tegumentary flap.
The outline of the Hap is always first carefully made
with a knife ; the flap is then dissected free from the sub-
jacent tissues, and the joint is opened from the extensor
aspect. The flaps should be so situated that their bases
correspond with the line of the articulation at which re-
moval is to be effected.
In making an ovalincision the operator applies the knife
upon the extensor aspect somewhat to the proximal side of
the line of the articulation and divides the tissues in the
middle line parallel with the longitudinal direction of the
finger until the joint has been passed. On the distal side
of the joint the incision turns toward the right to run
transversely through the flexor fold of the joint and
it returns upon the opposite side of the finger, to termi-
nate at its point of origin (Fig. 102). By detaching the
tissues on either side of the oval from the subjacent struct-
ures the joint is exposed upon its extensor aspect and the
removal of the finger can be readily effected. Hemor-
rhage will be controlled by ligation of the digital arteries,
which run on either side near the palmar surface. The
wound left after oval incision is closed in a linear
direction.
For enucleation of the thumb at the carpometacarpal
joint an oval incision is best suited. The apex of the
oval is situated upon the extensor aspect of the thumb at
a point corresponding to that at which removal is to be
effected. At the metacarpophalangeal joint the incision
deviates toward the flexor aspect, passing transversely
through the flexor fold of this joint and ascends upon the
opposite side of the finger to join the longitudinal incision
at an acute angle (Fig. 101). The incisions extend
throughout down to the bone, from which the soft parts
of the thenar eminence are carefully dissected. After the
metacarpal bone has been freed the joint between the
trapezium and the base of the metacarpal bone of the
174 OPERATIVE SURGERY.
thumb is opened from the dorsal aspect and the finger is
separated.
Exarticulation of the little finger togetlier icith its meta-
carpal hone by means of a flap from the integument of
the ulnar border by the method of ^^'alther. The fourth
and fifth fingers are extended and held in a position of
maximum abduction. AVith the dorsum of the hand
directed toward the operator, the blade of the knife is
introduced at the middle of the commissure between the
fourth and fifth fingers and passed with sawing-move-
ments through the soft parts of the interosseous space
between the fourth and fifth metacarpal bones to the root
of the hand. With the point of the knife, now directed
toward the radial border, the ligaments uniting the bases
of the two metacarpal bones are first divided, while the
little finger is held in a position of marked abduction,
after which, by traction in the direction of abduction, the
finger can be bent outward in the joint between the
unciform bone and the metacarpus. The operator noAv
surrounds the base of the metacarpal bone and forms a
flap from the soft parts of the hypothenar eminence by
incision from within outward (Fig. 103). Often the flap is
cut too short. The operation may also be performed with
the aid of an oval incision. The apex of the oval, as well
as its longitudinal incision, may be situated either upon the
dorsal aspect or upon the ulnar border of the metacari:)us.
Amputation of one finger through the metacarpus is
effected, like amputation of a toe through the metatarsus,
through an oval incision. The apex of the oval is placed
upon the dorsal aspect at a point corresponding to the site
of amputation. The longitudinal incision passes along
the metacarpal bone somewhat beyond the metacarpo-
phalangeal joint, where it encircles the finger through the
flexor fold, to ascend on the opposite side and meet the
longitudinal incision. The muscles are detached from the
metacarpal l^one, which is divided with the phalangeal or
the arched saw. The peripheral extremity of the bone is
enucleated and removed (Fig. 63).
AMPUTATIONS AM) KS UCl.KATIONS.
175
Enucleation of all four finc/crH fltroiif/h the meUuutrpdl
bones is Ix'st cftc'ctcd, like the iinaloi^oiis operation upon
the foot, through a short dorsal and a h)ng pahnar tej^u-
nientarv flap. After the Haps have been formed the
metacarpus is surrounded with a circular incision, the
muscles in the interossc!ous spaces are divided with a
knife, and division of the bones is effected with the saw.
Fig. 105. — Exarticulation of the
hand : circular incision in two
steps.
Fig. 106.— Exarticulation of
the hand : dorsal and palmar
flaps.
The oval incision also may be advantageously employed,
the apex of the oval being situated upon one or other
border of the hand.
Exarticulations at the Wrist. — The styloid processes of
the radius and the ulna constitute the bony landmarks for
locating the line of the wri.st-joint. The radiocarpal joint,
at which the hand is removed, corresponds accurately with
176
OPERA TIVE S UR GER Y.
a transverse line upon the dorsum of the hand uniting the
two styloid processes, when the hand is flexed upon the
palm.
Enudeation of the Hand by Means of a Circular Incision
and the Formation of a Guff. — The forearm is placed in a
position midway between pronation and supination. The
operator occupies the same position as in amputation. A
Fig. 107.— Exarticulation of the baud : tegumentary flap formed from
the thenar eminence.
circular incision is made through the skin two fingers'
breadth beyond the apex of the styloid process of the
radius (Fig. 105). After a cuif of the tissues has been
dissected back the tendons are divided with long strokes
of an amputation-knife. The operator stands at the
periphery and grasps the member to be removed with his
left hand, opening the wrist-joint upon its dorsal aspect,
AMrUTATloyS ASD KMCLEATloyS.
t i
o
^
Ji
»
00
o
12
AMPUTATIOSS ASD ESLX'LEATIOSS.
179
•a
9
O
0U
.£3 S
'■z ^
a
8
A MP I rjw Tfoys A yi> kx uclka noys. 1 8 1
while tlic liaiid is Iidd in :i j)()siti(»ii of inaxiimiin palmar
flexion, the capsnlc l)('ini>; divided npon the palmar asjxct.
The radial ann
the flexor aspect the two branches of the brachial artery
are to be ligated.
The circular incision for exarticulatiou of the elbow-
joint is made abt)ut three or four fingers' breadth below
the line of the articulation, and a cutY is dissected in the
usual manner to the level of this line and reflected up-
184
OPERATIVE SURGERY
Plate 11. — Transverse Incision through the Right Arm at its
Middle Third.
B, biceps muscle ; Br. i., brachialis anticus ; T, triceps ; A. h., brachial
artery in a common sheath with the corresponding vein and the median
ner\"e {M} ; U., ulnar nerve ; i?., radial nerve ; M. c, musculocutaneous
nerve.
ward. The joint is opened and the exarticnlation effected
in the manner described.
Amputation of the Arm. — ^^A circular incision may be
employed, as well as the formation of two musculotegu-
mentarv flaps.
The circular incision (Fig;. 112) is made either in the
customary manner in two steps, with the formation of a
\
Fig. 112. — Amputation of the arm: circular incision.
cuflP, or with a sincrle stroke of the knife after the soft
parts have been vigorously retracted. In the stump of
Tab 11.
Brj —^
I
T.
Ldh,A/iSl r Htunnvui Mun^fir'^
AMI' UTA TIOSS A SD ES UCLEA TIOXS.
18o
the amputation (Plate 11) the brachial arten- is to be
ligiited in the interval between the Ijieep.-? anni hial arteiy- (Figs. 113 and 114).
Exarticulation of the Humerus. — In oix-ratious ujxju the
shoulder, as in operations about the hiivjoint, the applica-
tion of the Esmarch bandage to control hemorrhage is
attended with considerable difficulty, and the methods
186
OPERATIVE SURGERY.
employed are modified accordingly. The artery is either
ligated in advance, or it is divided at the last stage of the
operation while digital compression is made.
Exarticulation by Means of a Deltoid 3Iusculotegu-
mentary Flap. — The trunk of the subject is elevated and
the operator outlines a flap in the deltoid region with a
U-shaped incision whose upper extremities correspond
/
Fig. 115. — Exarticulation of the humerus: formation of an axillary mus-
culotegumeutary flap by iucision from within the wound outward.
with the acromion and the apex of the coracoid process,
and which extends as low as the insertion of the deltoid
muscle (Figs. 113 and 114). After the tissues are divided
down to the muscles the flap retracts somewhat. The
musculotegumentarv flap is dissected from the bone by.
long strokes of the knife. By dissection of the flap the
shoulder-joint is exposed. The operator grasps the arm
AMPVTATIOSS AyD ENUCLEATIUSS.
187
with his loft hand, and divides the oaj)sulo of the joint by
applyinir tlic knife vertically upon the head of the humerus
and passing it in an arehed direction over the most promi-
nent convexity of the bone (Fig. 117). The head of the
humerus is forced out of tlie wound, the attachment of
the ])osterior wall of the; capsule se])arated from the l)one,
and the surgical neck of the humerus, as well as the upper
Fig. 116. — Exarticulation of the humerus by a combination of circular
and longitudinal incisions.
extremity of the shaft of the bone, is freed from the soft
tissues. In this way a bridge is formed of the soft tissues
of the axilla in which the ves.sels are contained. While
an assistant grasps this bridge between the thumb and
index-finger of each hand in such a way as to compress
the artery, a flap is cut from the . EM'CLEATKJSS. 189
Fig. 117. — Exarticulation of the humerus by Esmarch's method; di-
vision of the articular capsule.
IlE^J'XrWS^ AT JOISTS OF THE EXTRKMITIEIS. 191
III. Resections at the Joints of the Extremities.
By resection of a joint is understood the systematic
removal of its constituent parts, with conservation of
contiguous structures. In the presence of tuberculous
disease, as well as of severe injuries about the large
joints, resection promised to be a conservative substitute
for amputation. It can thus be realized that this mode
of procedure Avas expected to prove a great advance in
surgery, in times of both "war and peace. The methods of
operation were so selected that compensation for the loss
of the parts removed could reasonably be hoped for.
AVith this thought Langenbeck devised operations for all
of the joints in which the capsule was permitted to retain
its connection with the periosteum, for whose osteoplastic
capability experimental proof had been furnished (sub-
periosteal resection). Langenbeck's incisions are still
largely used in the performance of resections. The intro-
duction of asepsis, as well as a more precise knowledge
concerning the nature and the distribution of the tubercu-
lous process in joints, has changed our views of these
operations fundamentally. Antisepsis has rendered pos-
sible conservative treatment Avith success of injuries to
joints, even without resection, for which previously
amputation would have been undertaken. The nature of
the tuberculous process and the extent of its distribution
in the joints, further, make it undesirable to adopt the
routine plan of procedure in every case of removing the
bones entering into the constitution of the joint, while the
capsule as such is permitted to remain. Resection of
tuberculous joints is no longer regarded as a typical pro-
cedure to be employed in every case, as, for instance, is the
extirpation of tumors ; nevertheless, opening of the joints
of the dead subject in a typical manner is practised, as by
this means the surgeon familiarizes himself with methods
by which it is possible to o])en the joints with great care,
and which render accessible throughout their whole extent
192 OPERATIVE SURGERY,
the parts that enter into the formation of the joint, as well
as the synovial surfaces of the capsule. Thus, in a certain
sense, the preliminary operation is performed, with which
clinically in the individual case the special operation of
removal of tuberculous disease is conjoined. The capsule
of the joint is widely opened [cuihrotomy), the synovial
sac freed throughout its w^hole extent, and in accordance
with the extent of the morbid process the extirpation of
the synovia (^synovial artJrrecfomy), excochleation of areas
of bone, possibly after exposure by means of the chisel
and mallet, or resection of the articular extremities (os-
seous arthredomy) is undertaken. When the disease is ad-
vanced the bones are sawed through. In some joints
division of one of the bones entering into the articulation
w^ith a saw must be undertaken in order that the joint may
be made accessible throughout its whole extent for the
effectuation of the necessary operative measures.
Indications :
1. Injuries, complicated destruction of the constituents
of the joint, especially if large portions of bone are com-
pletely severed from their attachments.
2. Tuberculosis of joints, if conservative measures (rest
and fixation of the joint, treatment with iodoform, blood-
stasis, minor local measures) have failed.
3. Deformities of the joints. Orthopedic resections for
the correction of severe, otherwise irreparable alterations
in form (contractures, ankyloses).
4. Luxaiions, if irreducible and attended Avith marked
limitation of function.
5. Acute infiammatory processes in bones, osteomyelitis
with epiphyseal separation and suppuration of the affected
joint.
6. Flail-joints which it is desired toankylose artificially
(arthrodesis).
The incisions are made with short, strong knives,
through the soft parts, down to the bone. After division
of the capsule this, together with the periosteum, is sep-
arated from its attachment to the bone and the latter is
RESECTIOXS AT JOIXTS OF THE EXTREMITIES. 193
divided with tlio saw. The ineisions tliroiigh the soft
parts are so arranged that transverse division, espeeially of
muscles, tendons, large nerves and vessels, is so far as
possible avoided. Langenheck's incisions for resection
correspond mostly with the longitudinal axis of the ex-
tremities. The articular capsule is opened as freely as
possible in the direction of the cutaneous incision. The
margins of the wound in the capsule being separated
widely by means of tenacula, the operator ])egins, by
means of a series of closely approximated incisions with
a resection-knife, which is always applied vertically upon
the bone, to separate the attachments of the capsule to-
gether with the periosteum. The bones are forced out of
the wound and divided by means of the arched saw, the
metacarpal saw, or the wire saw, or the chain-saw. The
plane of the sawed surface varies with the individual
joints.
For the correction of angular contractures wedge-shaped
excision of bones is necessary. In place of this, arch-
shaped resection (Helferich) may be employed, in con-
junction with which the shortening is slighter.
After resection of the bone has been effected the sawed
surfaces are brought in apposition and fixed by means of
nails or clamps, or even without these in a bandage. The
division of the capsule, of the muscles, and of the skin
is closed by sutures. By the introduction of drainage-
tubes or of capillary drains escape of possible secretion
is ])rovided for.
Resections of the Joints of the Upper Extrem-
ity. — Resection of the Shoulder-joint by the Method of
Langenbeck. — The patient is placed upon the operating-
table in a sitting posture in such a manner that the
shoulder projects somewhat beyond the border of the
table. The operator stands upon the side of the trunk,
with his face directed toward the shoulder. He grasps
the upper arm at its middle with the left hand and with
the arm hanging naturally he enters the resection-knife
held almost vertically into the coraco-acromial trigone
13
194
OPERATIVE SURGERY.
(Fig. 11). The incision is made in the lonofitudinal axis
of the arm through the deltoid muscle almost to its inser-
tion into the humerus and down to the capsule (Fig. 118).
The upper extremity of the incision divides the tense
band between the acromion and coracoid processes. After
the margins of tlie wound have been widely separated by
hooks the lateral ^^all of the capsule is exposed. With
slisrht rotaticm outward of the arm the tuberosities of the
Fig. 113. — Resoctidn of the shoulder: longitudinal incision.
humerus and the bicipital groove are brought to the level
of the wound. The capsule is incised and divided upon
a o;rooved director in a line corresponding to this groove
upward to the glenoid cavity, and downward to the sur-
gical neck of the humerus. The tendon of the biceps
thus exposed is raised from its bed by means of blunt
hooks and displaced inward over tlie head of the humerus.
From thiG incision in the capsule made to free the tendon
RESECTIONS AT JOINTS OF THE EXTREMITIES. 195
BEiiECTIOyS AT JUIST:^ UF TllK EXTliEMlTIES. 1'J7
Fig. 120. — Eesection of the shoulder: division of the head of the
humerus with the saw ; the head of the boue is fixed by means of Lau-
geubeck's forceps.
nESEcrioxs at joints of the extremities. 199
of the biceps the separation of the capsule from tlie bone
is nndertakon. Witli the aid of a liook introduced into
the slit in the capsule the latter is elevated and dissected
free from the humerus close to the bone. The operator
progresses step by stepj while the arm is rotated toward
the knife. After the capsule has been divided through-
out half of its circumference the remainder is similarly
detached from the bone, tlie operator proceeding from the
original slit in the capsule in the oj)posite direction. In
connection with the capsule, into whose formation enter
fibers of the shoulder-muscles (supraspinatus, infraspina-
tus, subscapularis), the latter are at the same time de-
tached from the bone at their insertion. ^Vhen the head
of the bone has been thus freed it is lifted out of the
Avound (Fig. 119), and divided at the level of the surgical
neck of the humerus by means of the chain-saw, or, after
being fixed with Langenbeck's forceps, with the arched
saw (Fig. 120). The tendon of the biceps muscle is by
this procedure preserved intact. After removal of the
head of the humerus the glenoid cavity, as well as the
whole interior of the capsule, is sufficiently exposed for
whatever further operative procedures may be necessary.
Vessels of considerable size are not injured in per-
forming resection of the shoulder through a longitudinal
incision.
Resection of the Elbow-joint through a Dorsal Longi-
tudinal Incision. — The arm is flexed at a right angle at
the elbow-joint and thrown over the thorax in such a
manner that the extensor aspect of the joint is turned up-
ward. The operator stands upon the side of the thorax
that corresponds witli the healthy member. The incision
is made upon the doi^al aspect of the joint through the
lower extremity of the triceps muscle over the olecranon
(Fig. 122). Langenbeck makes this longitudinal incision
rather nearer the inner border, while C'hassaignac makes
it upon the outer border of the olecranon, although it
may also be made satisfactorily in the middle line (Park).
The incision passes through the triceps muscle down to
200
OPERATIVE SURGERY.
the bone. While the lips of the Avoiind in the mnscle are
energetically separated by means of hooks, the posterior
wall of the capsule of the elbow-joint bulges into view
and is divided in the direction of the cutaneous incision.
With strokes of the knife directed vertically toward the
bone the tendon of tlie triceps is detached from the olec-
ranon close to the bone. At the same time the muscles
Fig. 121.— Eesection of the elbow-joiut: exposure of the elbow-joint
on its inner aspect ; the olecranon and the inner extremity of the troch-
lea come into view ; the ulnar nerve has slipped from the inner epicon-
dyle after retraction of the margin of the wound.
inserted upon the dorsal aspect of the upper extremity of
the ulna are detached in conjunction with the periosteum.
Upon the outer side the radial head of the humerus and
the head of the radius come into view, and the strong
fibrous lateral ligament is to be freed close to the bone.
On the inner side the detachment of the tendon of the
triceps from the olecranon is begun. At the same time
the muscles are dissected free also from the upper ex-
EESECTIoyS AT JOINTS OF THE EXTREMITIES. 201
RESECTIONS AT JOINTS OF THE EXTREMITIES. 203
tremity of the ulna, ^^'llik' the frco niareration. The resection-knife is introduced at a point
midway between the anterior superior iliac spine and the
apex of the trochanter, vertically, down to the concavity
of the ilium. The incision surrounds the anterior three-
fourths of the ]x*ri]ihery of the trochanter and at all }x>ints
extends down to the bone (Fig. 128). Care should be
208 OPERATIVE SURGERY.
taken that the ghiteal muscles are divided in a vertical
direction. If the margins of the wound are separated at
its depth, the fibrous capsule of the joint becomes visible.
Over the highest prominence of the liead of the femur
the capsule is divided by an arched incision corresponding
with the cutaneous incision. The articular cartilai>:e is
incised and after division of the ligamentum teres the
head of the femur is luxated upon the ilium and removed.
Fig. 128. — Eesection of the hip: external arched incision by the method
of Velpeau.
If the removal of the head is to be effected at a higher
point between the trochanters, or on the shaft of the femur,
the tendons inserted into the trochanters must be detached
from the bone with the knife. After the head of the
bone has been sa^ved off the acetabulum is exposed for
such further surgical interference as may be necessary.
The extremity is placed in an extended position and a
drainage-tube is passed into the depths of the acetabulum.
Konig has modified Langeuheck's operation })y removing with a chisel
the liead of the femur vi situ before it is hixated. Further, tlie attach-
ments of the muscles to the greater trochanter are not separated from
the bone, but are removed, in conjunction with the cortical structure of
RESECTIOA'S AT JOJSTS OF THE EXTREMITIES. 209
the troch;iiitcr upon its anterior and posterior sides, with chisel and
mallet.
Liicke's and Seliede's anterior longitudinal incision jiasses downward
from the anterior sujierior iliac spine. The joint is entered to the outer
side of the erural nerve.
The anterior transverse incision of Roser is attended with the disad-
vantage that the libers of numerous muscles are divided transversely.
Resection of the Knee-joint through an Anterior Trans-
verse Incision. — The operator grasps the leg of the ex-
FiG. 129. — Resection of the knee-joint: anterior arched incision by the
method of Textor.
tremity flexed at the knee-joint and unites the most
prominent points on the lateral aspects of the condyles
of the femur by an anterior arched incision passing from
left to right and dividing the patellar ligament (Textor,
Fig. 129). The incision enters the joint, which is opened
adequately upon its anterior aspect (Fig. 130). The
thumb of the left hand is passed into the articular interval
between the patella and the femur, and separates the at-
14
210
OPERATIVE SURGERY.
tachments of the capsule laterally to the condyles of the
femur, when by reflecting the patella the sacculated diver-
ticulum of the capsule is visible from above. The crucial
ligaments and the accessory lateral ligaments are now
divided. The lower extremity of the femur is thus
exposed and, after the perio.-teum has been incised cir-
FiG. 130. — Knee-joint opened through the anterior arched incision.
cularly above the condyles, the bone is fixed with Langen-
beck's forceps and divided transversely. Konig makes
the saAved surfaces in such a })]ane that the joint is placed
in a position of slight flexion. If it be necessary to re-
move also the ipper articular surface of the tibia, this is
brought out of the wound, surrounded by a circular
incision, and removed in the fonn of a plate. In sawing
RESECTFoys AT JOINTS OF THE EXTREMITIES. 211
the bone it is o;ras])0(l witli tho f<)rce])s at the intercondyloid
oniiiU'iu'c and fixed. It" the patella in to he removed, it
is surrounded by an incision and treed with strokes of the
knife passed close to the bone. The sawed surfaces of
the bones are approximated and fixed in apposition by
means of sutures, clamps, or \)v^s.
According to the method of Volkmann, the anterior
transverse incision passes from one condyle to the other
over the middle of the patella. The periosteum is in-
cised transversely and the patella is sawed through on a
line with the cutaneous incision. In the prolongation of
the incision through the patella the capsule is incised to
the right and the left and the joint is widely opened. The
knee is now strongly flexed at an acute angle, so that the
incision into the joint is made to gape widely and the
lateral ligaments, as well as the lateral attachments of
the capsule, are divided. The crucial ligaments are
divided from behind forward. The upper segment of
the patella is reflected by traction, and the interior of th(^
capsule becomes accessible. The lower extremity of the
femur is surrounded by a circular incision, grasped with
forceps at the inner condyle, and divided transversely
with a saw.
In Hahu's modification the transverse incision passes above the pa-
tella (Fig. 131).
Kocher recorameuds a lateral hooked incision for arthrotomy and
resection of the knee-joint. The incision begins at the vastus externus
muscle, a hand's breadth above the patella, two fingers' breadth from
whose outer border it passes downward, to terminate upon the inner aspect
of the tibia below its spine. The articular capsule is divided on its outer
aspect and the patellar ligament removed out of the way by separation
of the spine of the tibia. The patella with its ligament is made so mov-
able that it can be reflected inward. Division of the crucial ligaments
permits a satisfactory view of the joint when placed in a position of
flexion. Adequate access to the joint is had also for the performance of
resection of the articular elements.
Resection of the Ankle-joint. — Bilateral Longitudinal In-
cision after Langenbcch. — The longitudinal incisions begin
on either side, a hand's breadth above the malleoli, and
pass along the tibia and fibula beyond their lower extremi-
ties. The incisions pass through skin and periosteum.
212
OPERATIVE SURGERY.
AVith the foot lying upon its inner border, the fibula is
dissected free beneath the periosteum ^vith a knife or a
raspatory on its outer and inner aspeets, and is divided in
a linear direction above the malleoli with chisel and mallet
or with the chain-saw. The peripheral fragment of the
bone is reflected outward and separated from its attach-
ments. In an analogous manner the lower extremity of
the tibia is excised through the internal longitudinal in-
FiG. 131. — Hahn's suprapatellar incision for resection of the knee-joint.
cision. By the removal of the malleoli a view can be
had of the interior of the joint, and the trochlear surface
of the astragalus, as well as the walls of the cap.sule, is
rendered accessible for further operative procedures.
Lanofenbeck has obtained the most admirable results
with this conservative method of resection following gun-
shot-injuries of the ankle-joint, and especially transverse
RESECTIONS AT JOINTS OF THE EXTREMITIES. 213
wounds Avith destruction of both malleoli. The operation
is less well adapted for the modern j)roe('dure of arthrec-
tomy, as the lower extremities of the libula and tibia are
sacrificed, at any rate, and, besides, the opportunity for
inspection of the joint afforded through the incisions is
not adequate to meet the needs of extirpation of the
capsule.
Konig^s Bilateral Longitudinal Incision. — The incision
on the inner aspect begins 3 or 4 cm. above the level of
Fig. 132. — Kesection of the ankle-joint by Konig's bilateral longitudinal
incision.
the articulation upon the tibia, somewhat internal to
the extensor tendons, and it opens the joint close to the
anterior boundary of the inner malleolus. It passes over
the body and neck of the astragalus, to terminate at the
inner border of the foot at a point corresponding with the
tuberosity of the scaphoid bone. The outer incision runs
parallel with the inner, along the anterior surface of the
214 OPERATIVE SURGERY.
tibia, opens the joint at the malleolus, and terminates at
the level of the astragaloscaphoid articulation (Fig. 132).
The anterior bridge of skin, which contains the extensor
tendons, the vessels, and the nerves, is dissected from the
subjacent tissues, the insertion of the capsule being at the
same time detached transversely from the trochlea of the as-
tragalus and the border of the tibia, and if necessary the
anterior portion of the synovial membrane is excised. By
lifting up the bridge-like flap, with dorsal flexion of the
foot, the individual portions of the joint may be made
accessible to the eye and to instrumental manipulation.
The removal of the astragalus is readily eflPected through
the inner incision, when the articular surface of the tibia
and the posterior wall of the capsule become visible.
Reverdin-Kocher 3Iethod of Luxation through an Ex-
ternal Transverse Arched Incision. — The incision begins
at the tendo Achillis about a hand's breadth above the
malleolus, passing downward, surrounding the external
malleolus, and terminates on the outer border of the foot
along the outer margin of the extensor tendons (Fig. 133).
After division of the skin and exposure of the external
malleolus the accessory ligaments of the capsule inserted
in this situation are divided. The attachment of the
capsule is freed, with displacement of the extensor ten-
dons, and, if necessary, division of the peroneal tendons
upon the anterior and posterior aspects of the tibia, when
the foot is flexed upward in such a manner over the in-
ternal malleolus that its inner border is brought in contact
with the inner aspect of the tibia (Figs. 134 and 135).
The joint is thus made accessible to inspection, and neces-
sarv operative procedures upon the articular extremities,
as well as upon the capsule, may be undertaken.
Resection of the Foot by the Method of Wladimiroff and
Mikulicz. — Indications :
(1) Caries of the foot localized in the calcaneum, the
astragalus, and the astragalocrural articulation.
(2) Extensive loss of substance al)out the heel.
(3) Injuries of the heel, especially gunshot-wounds.
RESECTIONS AT JOINTS OF THE EXTREMITIES. 215
Fig. 133. — Resection of the ankle-joint by the method of Reverdin-
Kocher: cutaneous incision ; exposure of the ankle-joint from its outer
aspect.
Fig. 134. — First stage of rotation of the foot at the ankle-joint about the
inner malleolus.
Fig. 135. —Completed
rotation ; the lower
extremities of the tibia
and the fibula, as well
as the trochlea of the
astrajralus, are com-
pletely exposed.
RESECTIONS AT JOINTS OF THE EXTREMITIES. 217
(4) ^Falignant tumors about the heel (osteosarcoma,
melanosareonia) (l^riins).
(5) Shortening of the extremity, following luxations of
the liip-joint (Caselli) ; after resections of the knee-joint
(Rydygier).
(6) Paralytic club-foot (Bruns).
The parts removed in the resection include the lower
extremities of the tibia and the fibula, the astragalus, the
calcaneum, and a portion of the cuboid and scaphoid
bones in conjunction with the skin of the heel. The
anterior portion of the foot is maintained in relation with
the leg by means of a dorsal bridge containing the ten-
dons and vessels.
Mode of Procedure. — A transverse incision is made
through the sole of the foot corresponding to the extremi-
ties of Lisfranc's line, and a second transverse incision is
made transversely above the malleoli on the posterior
aspect of the leg ; the extremities of both being united by
additional lateral incisions (Fig. 136). The astragalo-
crural joint is opened from the dorsal aspect and stretched
widely, and the bones of the leg are divided transversely
above the malleoli. The root of the foot is grasped at
the trochlea of the astragalus, and it is freed close to the
bone from the dorsal soft parts, with maximum dorsal
flexion of the foot. In accordance with the extent of
tissue to be removed the tarsus is sawed through in the
region of the cuboid and scaphoid bones, or further to
the distal (at the base of the metatarsal bones) or to the
proximal side. When the operation is performed for
orthopedic reasons, only the lower extremities of the tibia
and the fibula and the tuberosity of the calcaneum are
removed, together with the trochlea of the astragalus.
Inasmuch as after the resection has been effected the
sawed surfaces of the bones of the leg and the tarsus are
approximated and united by bone-suture, there results an
artificial club-foot to such a degree that the dorsum of the
foot lies in the same plane as the anterior aspect of the
leg (Figs. 137 and 138).
218 OPERATIVE SURGERY.
In performing tihiocalcaneal resection by the method of Bruns, the
ankle-joint is opened through an arched dorsal incision, the astragalus
freed, and the lower extremities of the tibia and the fibula, as well as
the upper surface of the calcaneum, sawed through transversely, when
the sawed surfaces are nailed together.
Osteotomy. — Osteotomy consists in linear division by
bloody means of the long bones. Originally performed
through an open wound, the operation has since the time
of Langenbeck been performed, like tenotomy, through a
small incision in the skin, in a measure subcutaneously.
The division of the bone is effected with the aid of sculp-
tor's chisels.
The extremity is placed upon a board or upon a sand-
bag, the Esmarch apparatus is applied, and the operation
of osteotomy is undertaken. A short incision through the
soft structures penetrates down to the bone. AVith slight
blows of the mallet the chisel is driven into the bone.
After it has penetrated it is removed, and a similar pro-
cess is gone through in a neighboring situation. In this
manner the cortical structure of the bone is successively
divided transversely throughout almost its entire circum-
ference. The remainder is fractured by forcible bending,
and the extremity, after the cutaneous wound has been
properly united, is fixed in an appropriate position in a
plaster-of-Paris dressing.
In cases in which simple linear osteotomy will no longer
suffice, wedge-shaped excisions are undertaken for the
correction of ankylosis, or curvatures of high degree.
The base of the wedge corresponds always with the con-
vexity of the curvature to be corrected. After adequate
exposure of the bone and division and detachment of the
periosteum, the wedge is removed with the chisel or the
saw, when the correction of the deformity may be readily
eifected.
A special form of osteotomy employed for the correc-
tion of marked arcuate curvature of the long bones con-
sists in longitudinal division, the bone being divided in a
direction parallel with its long axis. The displacement
RESECTIOSS AT JOiyTS OF THE EXTREMITIES. 219
Resection of the Foot by the Method of Wladimiroff-
MlKULlCZ.
Fig. 136.
Cutaneous incisions.
Fig. 137.
Configuration of the
foot after resection has
been effected. The
sawed surfaces of the
bones of the leg, as well
as those of the cuboid
and scaphoid bones, are
exposed.
Fig. 138.
Appearance of the
stump.
Fig. 136.
r
-'%
Fig. 137.
Fig. 138.
RESECTIONS AT JOINTS OF THE EXTREMITIES. 221
of the segments of bone in the axis of the part renders
possible to a certain degree correction of deformity.
Odcotomy of the femur at the upper extremity of the bone
is undertaken in cases of contracture of the thigh, if the
correction of the faulty position is attended with difficulty
after division of the contractured soft parts. Linear
osteotomy under these circumstances is undertaken either
at the neck of the femur (osteotomia colli femoris), or at a
point between the two trochanters (osteotomia intertro-
chanterica). For the exposure of the upper extremity of
the femur a longitudinal incision over the trochanter is
made upon the postero-external aspect of the joint. In
this situation the neck of the femur can be exposed for
osteotomy, as well as a deeper portion of the bone after
separation of the muscular attachments to the greater
trochanter.
Supracondylar osteotomy of the femur has been recom-
mended by Macewen as a routine procedure in the treat-
ment of genu valgum. According to Mace wen's recom-
mendation, the short cutaneous incision on the inner aspect
of the lower extremity of the femur is made at a point
corresponding to the intersection of two lines, of which
one passes a finger's breadth above the upper border of
the external condyle, and the other in the longitudinal
axis of the bone two fingers' breadth in advance of the
tendon of the adductor magnus. At the point of inter-
section of these two lines a short longitudinal incision is
made down to the bone, the chisel introduced through the
wound, applied transversely, and the cortical structure of
the bone successively divided throughout two-thirds of its
circumference. The remainder of the bone is severed by
manual means. Supracondylar osteotomy of the femur
may also be undertaken from the outer side of the bone
in a corresponding situation.
Linear osteotomy, as well as excision of wedge-shaped
portions, may be undertaken upon the bones of the leg
for the correction of deformities at the knee-joint, or of
excessive curvature. The tibia is exposed at its upper
222 OPERATIVE SURGERY.
extremity, from 4 to 6 cm. below the articular line, by
means of a transverse incision around the inner circum-
ference of the bone (Kocher). After detachment of the
periosteum the bone is divided with the chisel in the
direction of the cutaneous incision.
Excision of a Avedge-shaped portion of the tibia may
also be effected through the same incision.
Tni:i'iiis'[NO. 223
II. OPERATIONS ON THE HEAD AND NECK.
Trephining". — Trcpliining consists in resection of the
l)ones ol'tlic skull in their contimiity. The term is M|)])li('(l
equally to the excision of small circular segments and the
establishment of a penetrating defect in the skull, to the
temporary removal of a , portion of the bone in conjunction
with the periosteum and the skin, as well as to the re-
moval of loose depressed splinters, the elevation of the
indented calvarium, and the correction of irregularities
in wounds following injuries of the skull.
Indications :
(1) Injuries. — Open, or subcutaneous fractures of the
skull ; if the bones exhibit depression ; if local or general
symptoms referable to the brain are present (extravasation
of blood in cases in which the middle meningeal artery is
injured).
(2) Tumors of the cranial bones, of the dura, and of the
brain.
(3) Cerebral abscess.
(4) Epilepsy/ (for the extirpation of cortical centers or
for the removal of cicatrices and foreign bodies).
(5) Caries and necrosis of the cranial bones.
Finally, trephining has been recommended for the relief
of chronic increase of intracranial pressure, and in cases
of progressive paralysis of the insane.^
In general, the operation is performed in such a way
that after division of the scalp, the aponeurosis of the
occipitofrontal muscle, and the pericranium, a suitable
segment of bone is removed with the crown of the tre-
phine, the chisel and mallet, or the circular saw. The
exposed dura is either opened with a crucial incision or is
reflected back as a flap, and after the operation has been
^ In insanity of traumatic origin, in which the seat of initial trouble is
made manifest by a scar, a persistent headache, or muscular iihcnonieiia
of a local character, it may be proper to trephine. The operation is,
however, rarely justifiable in insanitj^, and wiU not often be productive
of benefit. — Ed.
224 OPERATIVE SURGERY.
finished it is closed with catgiit-siitures. The deficiency
in the bone established either remains open or it is closed.
Under the condition first named, the skin being utilized to
cover the defect in the bone, the opening becomes closed
by connective tissue, a result that is attended with certain
disadvantao-es. It has therefore become the rule, whenever
the nature of the case renders it permissible, to close the
trephine-opening by means of bone. This may be effected :
1. By reimplantation of the piece of bone trephined ;
2. By autoplasty or heteroplasty ;
3. By temporary resection of the cranial bones, em-
ployed from the outset as a substitute for typical tre-
phining.
The restored button of bone should at the present time,
under aseptic conditions, heal in place in all cases ; but
reimplantation has been successfully undertaken by Ph.
v. Walther.
Autoplasty, an ingenious procedure devised by Kdnig,
consists in the transplantation upon the defect of a pedun-
culated flap consisting of skin, periosteum*, and a portion
of the cortical structure separated with a chisel. The
defect resulting from the formation of the flap is covered
with a pedunculated cutaneous flap removed from the ad-
jacent region.
Covering in the defect in the bone with foreign bodies —
metallic plates, bone, celluloid plates — is designated het-
eroplasty}
Steps of the Opjeration of Trepkining. — A linear," semi-
circular, or crucial cutaneous incision is made down to the
bone.^ The periosteum is removed with a raspatory. If
the removal of the bone is to be effected with a circular
saw, or with mallet and chisel, the extent of tissue to be
1 The observations of Barker indicate that after a piece of living bone
has been transplanted it undergoes anemic necrosis. Xew, living tissue
takes its place, but the transplanted piece does not live. In fact, it seems
probable that dead bone is as valuable in filling a defect as is living
bone. — Ed.
2 In most cases, a U-shaped flap, the base of which is the dura, gives
the best exposure and is followed by the most rapid union. — Ed.
TREPHTXTXG.
225
Temporary Resection of thk Ski'll.
Fig. 139. — Form of the cutaneuus flap : the }H»itii>ii <>!' huuc to be leiiiuved
has been outlined with the chisel.
Fig. 140. — The flap of bone, in conjunction with the skin, has been
reflected and the dura is exposed.
15
TREPIIiyiSG. 2T1
removed is first outlinetl, and the incision through the
bone is deepened equally at all parts. In the groove thus
made the operator can determine with tlie aid of the probe
when the vitreous plate has been passed. As soon as the
plate of bone is freed throughout its eireumference it is
raised with an elevator and removed from its place. The
circular saw and the diisel may be advantageously used
together, the boundary of the part to be removed being
outlined with the saw, and the groove being deepened
down to the dui*a with the chisel.
By means of a trephine a Ijutton of bone is removed
from the skull as large as the opening in the crown of the
instrument. The crown is evenly and firmly applied upon
the bone with its teeth while the head is fixed. After the
teeth of the instrument have entered the bone the pressure
and the rotation are continued in even, though slighter,
degree. The groove made by the saw is frequently cleaned
and examined as to its depth. As soon as the fragment
of bone is loosened it is grasped with the tirefond, a gim-
let-like instrument, and is removed.^ Bv means of a
special knife, known as the lenticular, it was customary in
the past to smooth the margins of the opening. The mode
of procedure does not follow this typical course in cases
of fracture of the skull. Completely separated splinters
that have been forced into the brain are to be removed,
depressed portions of bone are to be raised, and sharp
margins are to be cut off, etc. For elevating and re-
moving fragments of bone rongeur-forceps are employed ;
for enlaro^incr fissures in bones the chisel and mallet are
employed exclusively.
Temporary resection qftheshuU (Wagner, ^Volif, Oilier)
has of late almost entirely replaced the classic mode of
trephining. AVagner incises the skin in the shape of a
lyre or of an omega fi?-shaped) (Fig. 139), the incision
passing down to the bone at all points. A furrow is cut
1 Instead of employing a special instrument to lift out the button, the
bit of bone can be forced out by means of a periosteum-elevator or a blunt
dissector used as a lever. — Ed.
228 OPERATIVE SURGERY.
into the bone with the cireidar saw corresponding with the
cutaneous incision, and the groove is gradually deepened
by means of chisel and mallet until the dura is reached.
At the base, corresponding with the narrowest portion of
the flap, the bone is divided with a single stroke upon the
chisel, when the flap of integument, periosteum, and bone
can be reflected (Fig. 140). After the intracranial
manipulation has been completed (opening of an abscess,
resection of a cortical center, removal of a foreion bodv,
ligation of the middle meningeal artery, etc.), the boue
is replaced in the artificial opening and the cutaneous
wound is closed by suture.
To facilitate the localization of the anterior and posterior branches of
the middle meningeal artery Steiner has suggested the following ana-
tomic guides : a line is drawn from the middle of the glabella to the
apex of the mastoid process. Upon the middle of this line another, verti-
cal line is erected. Where the latter intersects a third line passing hori-
zontally through the glabella the crown of the trephine is applied, and
on removal of the button of bone the trunk of the anterior branch of
the middle meningeal artery will be reached (Fig. 141).
At the point where a vertical line passing in fi'ont of the mastoid pro-
cess intersects the horizontal line already spoken of a trephine-opening
"will reach the posterior branch of the middle meningeal artery.
Since the introduction of temporary resection of the skull by means of
the chisel, the making of a number of isolated trephine-openings for the
exposure of the two branches of the middle meningeal artery is obviated.
By the formation of a flap of suitable size, with its base above the malar
bone (Krause'sflap for intracranial exposure of the Gasserian ganglion),
it has become possible to expose the branches of the middle meningeal
artery throughout a sufficient extent (Fig. 141). The length and width
of the flap spoken of are about 6 cm. ; the former measured from the zygo-
matic i^rocess, the latter a thumb's breadth external to the margin of the
orbit.
The upper extremity of the Rolandic fissure lies in an
anteroposterior plane, 1.2 cm. behind tlie middle of a line
uniting the root of the nose with the occipital protuber-
ance.^
^ In the making of an osteoplastic flap the bone can be sectioned with
great neatness and considerable rapidity by the use of the Gigli wire-saw
after the plan of Obalinski. Such a saw consists of rough steel wire with
a loop at each end. The handles of a chain-saw tit the loops. Two or
more small trephine-openings are made, the dura between the openings
is separated from the skull, a piece of silk is carried from opening to
opening by means of a probe, the saw is pulled through by means of the
silk, the handles are attached, and the bone is sawed from within out-
ward. — Ed.
RESECTWyS OF THE J A WS.
229
Resections of the Jaws. — Resection of the Upper Jaw.
— Till' ui)jK'r jaw is iviuuvcil partially or wholly wluii the
seat of malignant disease.
Temporary reHevtirm of the iipjx?r jaw may be undertaken
to expose the naso])harynx or tlie sphenomaxillary fossa,
the temporal fossa, lor i)iirposes of operative intervention.
The body of the upper jaw presents three processes through
5
y
Fig. 141. — Diao:rammatic representation of the method of finding the
upper and middle branches of the middle meningeal artery.
which it articulates with neighboring bones. The palatal
process unites in the middle line with a similar process of
the bone of the opposite side. The frontal or nasal pro-
cess unites the upper jaw with tlie Irontal bone, and the
zygomatic process unites it with the malar bone. The
posterior surface of the body of the upper jaw is united
with the descending wing of the sphenoid and with the
230
OPERATIVE SURGERY.
,r-r,4.--*^
pyramidal process of the palatine bone. These processes
must all be severed if the upper jaw is to be separated
from its attachments.
Ste-ps of the Operation. — The head of the patient is
placed on a lower level than the trunk. Preliminary
tracheotomy and the introduction of a tampon-cannula
are not necessary. The cutaneous incision (Weber) is
immediately made at all points down to the bone. It
begins at the middle of the upper lip, which it divides
vertically ; after reaching the septum it surrounds the
nasal ala on the side to be operated upon to its upper ex-
tremity ; it then continues vertically upward to the inter-
nal canthus of the eye, and thence at an acute angle it
passes outward in a curved direction along the lower mar-
gin of the orbit to end at the external canthus of the eye
(Fig. 142). The flap thus formed from the soft tissues
of the cheek is dissected from the upper jaw so that the
canine fossa, as well as the malar process, is exposed.
The inferior tarso-orbital meml:)rane Ls Jncised alonsf the
infra-orbital
TEeentir^coiSenS~(3'^ffi
the floor of the orl)it, from which the chain-saw or the
^wire;;^sa3vjsj)^ process through the
infra-orbital fissure (Fig. 143)^iKniie process is thus
divided. The connection between the nasal process of
^thejjipperjaw and the frontal bone is divided transversely
with the chisel. The cfiv^ision of the palate and of the
alveolar process must yet be effected. To this end the
mucous:j2£XiS5tea^^ of the^ palate js incis ed a t the
alve()lain2I2£S^5§--2i3il-d£t^^^ ^^^^ bone to the median
7)fTn(r~arcli of the palate. The chain-saw is intro-
duced througli the pyriform aperture, and brought into
the moutli at the junction of the hard and the soft ])alate.
Before the palatal plate is sawed through the middle in-
cisor tooth of the corresponding side should be removed.
The jaw is now attached posteriorly only to the pterygoid
process and the pyramidal process of the palate bone, and
above to the ethmoid bone. It is freed from these con-
RESECTIONS OF THE J A WS.
231
nortioiis, the alvcolnr process l)CMn<^ tj^raspcd witli Lani^on-
Ixrk's bone-foircps and irniovcd with slightly rocking
movements.
In the large wound exposed thQ_j^inMijxulJiifVa^C)i^
artery must l)c cauulit and liii'atcd. The marjjfiiis of the
cutaneous wound are accurately approximated and united
Fig. 142. — Incisions for resection if tlic upper jaw: a, by Weber's
method ; b, by Velpeau's method.
by suture. If it has been possi])le to preserve the mucous
covering of the hard palate, this is united to the mucous
membrane of the cheek after the jaw has been completely
extirpated. The wound-cavity is in all cases tamponed
with gauze. If the cavity is separated from that of the
UKHith by the preservation of the mucous covering of the
palate, the ends of' the gauze arebrough^mit oft^^
^
232
OPERATIVE SURGERY.
The various method.- of resection of the upper jaw dif-
fer from oue another only in the form of the cutaneous
incision, the procedure uponds with that of median division. In both instances,
after completion of the operation, the divided halves of
the jaw are reunited with metallic sutures. The cuta-
neous wound is closed with knotted sutures.
Reseetion of the Lower Jaw in its Continuity. — For the
removal of portions of the lower jaw in its continuity the
cutaneous incision is made down to the bone at its mar-
gin. The soft tissues are detached from the outer and
inner surfaces of the jaw, until the mucous membrane of
the lips, as well as that of the floor of the mouth, is
divided close to the bone. At the two points through
which the jaw is to be salved a tooth is withdra^vn, and
the segment of bone of determined size is removed with
RESECTIONS OF THE J A WS
241
Fig. 147. — Median temporary division of the lower jaw by the method
of Sedillot.
16
OPERA no Xa ox rilK TOXGUE. 243
the chain-saw. In siniihir manner the middle portion of
the jaw is removed. In addition to the incision at the
margin of the hone, it is recomnR-ndc*! that tlie lower
lip in this sitnation he divided vertically in the middle
line in such a manner that an incision of the foUowinur
form results : I . Alter resection of the middle portion
the stumps of the genioglossus muscles, separated from
the chin, must be fixed -in the cntaneous wound by sutnre,
so that the tongue thus deprived of its attachment to the
chin does not fall backward, a contingency not unattended
with danger.
Operations on the Tongue. — Extirpation of tumors
of the tongue are atypical })rocedures that are not carried
ont according to generally applicable rules. It is of the
greatest importance that the removal of the tumor be
effected through healthy tissue, and that the wound-tlefect
be so made that union through suture or closure of the
wound with healthy tongue-substance is possible. The
preliminary operations performed for the pui-pose of
facilitating total extirpation of the tongue and rendering
the floor of the mouth more convenient of access have
already been considered in part (temporary resection of
the lower jaw).
In performing operations upon the tongue the patient
is placed upon the table with the upper part of the body
elevated. The neck is stretched and the head is fixed in
this position. The mouth is held open with a suitable
speculum or gag. The tongue is grasped with a strong silk
ligature passed through its structure and drawn forward.
Circumscribed tumors at the margin of the tongue are
excised in the form of a wedge through the mouth from
healthy tissue with the scalpel or with scissors. The
wound can be closed by linear approximation through
deep and superficial sutures.
In advance of extirpation of half or the whole of the
tongue ligation of the lingual artery upon one or both
sides is undertaken to prevent hemorrhage.
If the extirpation is to be effected through the poste-
244
OPERATIVE SURGERY.
Plate 12.— Lateral Temporary Division of the Ramus of the
Jaw by the Method of Langenbeck.
The wound is made to gape by separation of the segments of the jaw :
M, sawed surfaces of the ramus of the jaw; Oh, hyoid bone; Bv, digastric
muscle, with its tendon divided ; 3Ih, mylohyoid muscle ; Hg, hyoglossus
muscle ; H, hypoglossal nerve ; L, lingual nerve ; Sni, submaxillary
gland ; SI, sublingual gland.
rior portion of the tongue, or if together with the whole
tongue the floor of the mouth and the sublingual glands
are also to be removed, the field of operation is rendered
more conveniently accessible by preliminary procedures.
These preliminary operations consist in :
Fig. 148. — Incision for extirpation of the tongue by the method of
Kocher.
1. Division of the cheek from the angle of the jaw ;
2. Submental incision (Regnoli-Billroth) ;
3. Temporary division of the lower jaw :
(a) In the middle line (Sedillot-Syme) ;
(6) Through the ramus of the jaw at a point cor-
responding with the first molar tooth (B. v.
Langenbeck).
Tal.
)
\
■s.
\
Luh. .A/is! h Reichhold. Mtindu
OPERATIONS ON THE TONGUE.
245
Fig. 149. — Submental exposure of the tongue by the method of Billroth.
OPERATIONS ON THE TONGUE.
247
Wedge-shaped Incision of the Lower Lip. Linear
Union.
^
Fig. 150.— Showing the defect in the soft parts.
/
f IQ. 151.— Showing the defect united by linear suture.
OPERATIONS ON THE TONGUE.
249
Cheiloplasty (Dieffenbach).
Fig. 152.— Triaugular detect in the lower lip with contiguous
rhomboid flaps.
Fig. 153. — The flaps approximated by displacement toward the
middle line : suture.
OPERATIONS ON THE TONGUE. 251
Division of the cheek in a horizontal direction from the
angle of tlic inoiitli renders tlie operation more convenient,
inasmuch as tlie Held of operation is made roomier, and it
can also be better illuminated. After the operation on
the tongue has been completed the incision in the cheek
can be united by suture.
Suh)ncntal removal of the tongue^ first performed by
Regnoli of Pisa, is effected through a semilunar incision
made upon the neck along the ramus of the lower jaw.
Regnoli conjoined with this arched incision a second,
vertical incision passing from the chin to the middle of
the hyoid bone. Billroth made only the simple arched
incision. Access is gained to the inner side of the ramus
of the jaw, the attachments of the mylohyoid muscle are
separated laterally, and those of the genioglossus, genio-
hyoid, and digastric muscles in the middle, and the
mucous membrane of the buccal cavity is opened through-
out the entire extent of the incision. The tip of the
tongue is caught with a thread and drawn through the
wound. By these means the structures of the floor of the
mouth, as well as the tongue down to its base, are con-
veniently accessible for operative attack (Fig. 149).
Temporary resection of the lower jaw is effected in
accordance with the rules laid down on page 234. The
divided portions of the lower jaw are held apart by means
of sharp hooks, in consequence of which the field of
operation is rendered more extensive. The division of
the lower jaw may be linear, or, to facilitate approxima-
tion in suturing the bone, it may be made in steps.
In the presence of extensive disease of the tongue
Kocher effects extirpation of the organ from the base.
He first performs preliminary tracheotomy. The cuta-
neous incision passes from the mastoid process along the
anterior border of the sternomastoid muscle to the level
of the hyoid bone, and from this })oint, in the furrow
between the floor of the mouth and the neck, forward, to
end in the median line at the chin (Fig. 148). The flap
thus outlined is reflected back, when, after ligation of
252 OPERATIVE SURGERY.
the external maxillary and lingual arteries, the submaxil-
lary glands are removed. The buccal cavity is opened
through the mylohyoid muscle and the raucous membrane
detached from the lower jaw. The tongue must yet be
separated from the hyoid bone, after which the whole
organ can be brought forward and divided through
healthy structure.
Plastic Operations. — Plastic operations include those
accessory operations by means of which existing wound-
defects are covered with integument, as well as such pro-
cedures as are intended for the correction of congenital or
acquired deformity. In the first category belongs, for
instance, the formation of pedunculated flaps for the
closure of defects left by wounds ; in the latter, operations
for harelip, rhinoplasty, blepharoplasty, etc.
In covering wound-defects the adjacent skin is drawn
over either directly or after being freed by incisions and
attached in place. In other cases flaps taken from neigh-
boring structures must be separated from the subjacent
tissues, and either displaced laterally or rotated about
their base, in order that they may be brought in apposition
with the defect, and fixed in place.
A triangular defect that is not too large is covered directly by means
of deep sutures parallel to the base, and linear union is thus eflFected.
(Linear union after wedge-shaped excision of the lower lip is illustrated
in Figs. 150 and 151.) If the defect be greater, rhomboid flaps symmetri-
cally situated on either side may be drawn toward the middle line to
cover the defect (Diefienbach, Figs, 15-2 and 153). In place of the rhom-
boid flap an arched incision passing from the base of the defect on either
side may outline a portion of adjacent skin, which is brought over the
defect and attached in place. Quadrilateral or oval defects may be cov-
ered by one or two symmetrically formed flaps from the immediate
neighborhood (cheiloplasty by the method of Bruns,or by thatof Langeu-
beck, Figs. 154 and 155).
The flap is made to correspond in shape with that of
the defect, though somewhat larger. These methods, in
accordance with which the flaps are obtained from the
immediate neighborhood of the defect, stand in contra-
distinction with that in which a pedunculated flap belong-
ing to a remote portion of the body remains attached in
PLASTIC OPERATIOSS.
253
its orifrinal situation thmuirli tlic pofliclc until the flap has
healed in the deteet (rhinoplasty by means of a flap re-
moved from the arm, aceording to the method of Tag-
liacozzi).
Another nietlKwl for eovering in defieieneies by means
of skin removed from remote portions of the body con-
r
-^
^>
Fig. 154.— Oval defect in the lower lip : outline of the flap (by the
method of Langenbeck).
sists in the formation of a bridge-shaped flap, beneath
which the part to be covered is pu.terygoid muscles. On the inner aspect of the
ramus of the lower jaw it enters, with the arteiy of the
same name, into the dental foramen and passes through
the dental canal, to make its exit at the mental foramen
as the mental nerve. The lingual nerve in the first part
of its course passes downward with the dental nerve. At
the anterior border (^f the internal pterygoid muscle it
turns forward, and passing over the mylohyoid muscle
reaches the lateral border of the tongue.
Extrdhuccal Exposure of the Buccinator Xen'e (E.
Zuckerkandl). — A cutaneous incision is made in the direc-
tion of a line passing from the tragus to the middle of
the nasolabial fold. The duct of Stenon apj)ears in the
wound and is drawn downward. After division of the
270 OPERATIVE SURGERY.
masseter fascia the buccal pad of fat comes into view, and
is freed from its attachments and removed. In the wound
there are now visible the coronoid process of the lower
jaw, with the prominent lower portion of the tendon of
the temporal muscle. At the inner border of this tendon,
surrounded by loose cellular tissue, lies the trunk of the
buccinator nerve.
The inferior dental nerve may be exposed before its
entrance into the dental canal, within the canal, and after
its exit at the mental foramen. Prior to its entrance into
the canal, at the lingula, the nerve is accessible from
without (Sonnenburg-Lucker) as well as from Avithin the
cavity of tlie mouth (Paravicini). Sonnenburg makes an
incision around the angle of the lower jaw, separates the
insertion of the internal pterygoid muscle from the bone,
and advances along the inner surface of the ramus of the
jaw to the lingula, where the nerve is gmsped Avith a
blunt hook, brought out and resected, or extracted with
forceps. This method is attended with difficulties in so
far as it is necessary to operate at a considerable depth ;
even operating upon the dependent head simplifies the
procedure only in inconsiderable degree. Paravicini has
recommended exposure of the nerve from the buccal
cavity by separation of the internal pterygoid muscle
from the inner surface of the ramus of the jaw at the
lingula.
Exposure of the Inferior Dental Nerve within the Dental
Canal. — The nerve is most conveniently reached by chis-
elling out a piece of the outer plate of the bone at the
point of junction between the body and the ramus, and in
this manner exposing the dental canal. An arch-shaped
cutaneous incision is made at tlie angle of the jaw.
The attachment of the masseter muscle is freed and
separated from the bone in the neighborhood of the
angle of the jaw by means of a raspatory. In the mid-
dle of a line uniting the angle of the jaw with the last
molar tooth a piece of bone as large as a lentil is gouged
out of the outer wall of the jaw. After the cortical
OPERATIONS ON NERVES.
271
striK'turo lias Ixni passed profuse arterial heniurrliage
from the injured interior dental arterv will indieate that
the eanal has been oi)ened. With a blunt hook the nerve
can be readily raised from its bed, and it is either resected,
or, better, it is extracted with forceps.
The lingual nerve is most readily reached from tlie
buccal cavitv. An incision is made uix>n the side of the
tongue at the point of i-eflection of the mucous membrane
from the inner side of the lower jaw upon the tongue.
Fig. 175. — Exposure of the infra-orbital nerve.
The large nerve-trunk lies immediately l)eneath the
mucous membrane. The methods of Sonnenburg and
Paravicini for exposure of the inferior dental nerve also
permit access to the lingual nerve in its upper part.
The mental nerve can be made accessible at its point of
exit from the lower jaw, from either within or without
the buccal cavity. Extrabuccal exposure is accomplished
by means of a cutaneous incision through the chin at the
level of, and several centimeters external to, the incisor
272 OPERATIVE SURGERY.
tooth of the corresponding side. The incision reaches
down to the bone, and the soft parts are detached from the
jaw, when the nerve can be seen making its exit as a
tense cord from the mental foramen. To gain access to
the nerve from within the cavity of the mouth an analo-
gous procedure is followed. The incision is made at the
point of reflection of the mucous membrane from the
r
./
Fig. 176. — Intrabuccal exposure of the mental nerve.
inner surface of the lower lip upon the lower jaw^ (Fig.
176).
Operation for Exposure of the Second and Third Divis-
ions of the Fifth Nerve at the Base of the Skull by the
Method of Krbnlein. — A semicircular flap, with its con-
vexity downward, is formed from the tissues of the cheek,
its base corresponding to the upper boundary of the zygo-
matic arch. The cutaneous flap is dissected upward, the
temporal fascia divided transversely over the malar bone,
then the zygomatic arch sawed through in advance of the
articular tubercle and through the body of the bone and,
with the attachment of the masseter muscle, reflected
OVKHATIONS ON NERVES. 273
downward. Tlic exposed coroiioid process oi' tlie lower
jaw is hroUeii ihroiigli and, t()«!,'elljer with tlie tendon of
the temporal niusi^h', is disphieed n])\\aie l)y
means of a ln>ok inserted on either side, and if uecessarv
the ligament is, further, notched. The cannula is intro-
duced into the opening thus made and the h(^)oks are re-
moved from the wound. By this mcxle of procedure there
is no loss of blood and the cannula lies so snugly within
the wound as to constitute a sort of tampon. If there be
surticient time for the performance of the openition the
cutaneous incision is made longer and the cricothyroid
ligament is laid bare by careful dissection. After the
subcutaneous connective tissue has been passed the cervi-
cal fascia is divided and the cricothyroid lig-ament is ex-
posed. The lower border of the cricoid cartilage is raised
up by means of a simple sharp tenaculum, which is intro-
duced inti^ the middle line, when the ligament is divided
vertically and a cannula is introduced. If necessary, the
longitudinal incision in the ligament is notched on the right
and the left. Through the crucial incision thus formed
the cannula is readily introduced. The latter is held in
place in the wound by means of linen tapes attacheil to
the shield of the cannula, and tied at the nape of the
neck.
Extirpation of the Larjmx. — If removal of the larynx
is to be conjoine<:l with larvngotissure, to the longitudinal in-
cision a transverse incision is added at the level of the hyoid
bone, when, after division of the muscular attachments to
the lower surface of the hyoid bone, the thyrohyoid mem-
l)rane is divided in corresi>i^ndence with the superficial
transverse incision. The soft parts on the outer side are
to be separated close to the laryngeal cartilages. Ujxm
the j)05terior aspei't the cricoid cartilage is freed from its
loose attachment to the anterior wall of the esophagus.
If the upper and lower boundaries of the larynx also
have been incised upon the mucous surface, the larynx is
completely freeil after transverse division of the trachea
278 OPERATIVE SURGERY.
below the larynx. Tlie deficiency left in the anterior
portion of the pharynx and esophagus is reduced to a
niininiuni l)y suture. The cannula is left in the trachea.
The wound remains open and is tamponed.
Tracheotomy. — Tracheotomy consists in properly open-
ing the trachea through incision. The procedure is in all
cases attended with the introduction of a cannula through
the opening into the trachea.
Indications :
(1) Injuries of the larynx (punctured, incised, and gun-
shot-wounds, fractures of the laryngeal cartilages with dis-
location of the fragments).
(2) The presence of foreign bodies in the trachea which
cannot be removed by endolaryngeal procedures.
(3) Stenosis of the larynx and the trachea :
(a) Compression-stenosis (goitrous tumors, aneurysms) ;
(6) Occlusion-stenosis (obstruction of the lumen of the
larynx or the trachea, swelling of the laryngeal mucous
membrane — diffuse submucous laryngitis ; tuberculous,
syphilitic, and typhoid disease of the larynx). Narrow-
ing of the lumen of the larynx, or of the trachea, through
exudates (diphtheric croup), through neoplasms (carci-
noma, papilloma, granulation-tumors) ;
(c) Cicatricial narrowing of the larynx (after healing
of ulcerative processes ; after operative procedures upon
the larynx.
(4) As a preliminary operation, or in conjunction with
other operations upon the larynx and the pharynx, trache-
otomy is performed :
{a) To prevent the entrance of blood into the bronchi
(tampon-cannula) ;
(6) Following operations upon the larynx, without
leaving an opening or with closure by tampon, in order
to supply the patient with air.
(5) Asphyxia or intoxieation, to render possible and
to institute artificial respiration.
The trachea is the direct contmuation of the larynx,
passing in the middle line of the neck toward the upper
OPERATIONS ON THE AIR-PASSAGES. 279
npcM'tnrc of tlic tlioi-.tx. Tlic ii])|)('r ])<)rti(>n of'tlic traclica
lies iiniiicdiatcly Ix-ncath tlie .supcrlicial .structures of" tlic
neck. The su})rastL'riial portion is separated from the
skin, in addition to the two layers of cervical fascia, by a
considerable layer of cellular tissue containing numerous
veins. The thyroid gland overlies the trachea between
the third and sixth cartilaginous rings ^vith its lateral
lobes connected by the isthnuis. Often a pyramidal lobe
of the thyroid gland covers also the upper portion of the
trachea. The anterior surface of the trachea and of the
thyroid gland is covered by the muscles passing from the
sternum to the hyoid bone and the thyroid cartilage
(sternohyoid, sternothyroid). In the middle line, between
the muscles, a strip of trachea is covered only by the
cervical fascia. It is through this " white line of the
neck " that the trachea is attacked. The isthmus of the
thyroid gland divides the trachea into two parts, a supra-
thyroid and an infrathyroid. The opening through the
former constitutes superior tracheotomy ; that through
the latter, inferior tracheotomy.
Superior Tracheotomy. — The patient lies in the dorsal
decubitus, with the neck over-extended, and a cylindric
pillow is placed beneath the shoulders. The operator
stands upon the right side of the patient and his assistant
upon the opposite side. The cutaneous incision is made
accurately in the median line of the neck from the middle
of the thyroid cartilage to below the thyroid gland.
After the skin and the subcutaneous connective tissue
have been passed the tense fascia of the neck is divided
upon a grooved director. The inner borders of the sterno-
hyoid nniscles come into view, and are retracted sym-
metrically with blunt hooks. The situation of the trachea
is determined by palpation with the finger, and its first
cartilaginous ring is exposed by detaching the cellular
tissues from the trachea by means of two pairs of ana-
tomic forceps. The field of operation is extended through-
out a sufficient extent by incising the layer of fascia
stretched between the upper border of the thyroid gland
280 OPERATIVE SURGERY.
Plate 14. — Inferior Tracheotomy.
The wound is bounded laterally by the sternohyoid muscles. The
trachea is exposed and opened upon its anterior aspect for the introduc-
tion of the cannula. Venous branches (middle thyroid veiusj are seen
passing downward from the thyroid gland. Lying close to the right of
the trachea in the depth of the wound is the innominate artery.
and the trachea, and dislocating the gland downward by
means of blunt hooks. Before proceeding with the open-
ing of the trachea the upper rings must be thoroughly
exposed by dissection. Then the trachea is grasped just
below the cricoid cartilaginous ring accurately in iho
middle line with a simple sharp tenaculum, raised some-
what and held fixed in this position. The trachea is then
incised accurately in the middle line from below upward
for a distance of al^out 1 cm. with a sharp-pointed knife.
The opening thus made is distended by means of shai'p
tenacula and possibly nicked on either side. AVhile the
three tenacula are held, undisturl)ed, in place, the ope-
rator introduces the cannula into the trachea. The cuta-
neous wound is reduced in size by knotted sutures and
the cannula is firmly fixed in place by means of tapes.
Inferior Tracheotomy. — The patient is placed in the
same position as in the performance of superior trache-
otomy and a cutaneous incision is made from the lower
border of the thyroid gland to below the suprasternal
fossa (Fig. 177, c). After the skin and the subcutaneous
connective tissue have been penetrated the superficial
layer of the cervical fascia is exposed and divided upon a
grooved director in the direction of the cutaneous incision.
A considerable layer of loose connective tissue is passed
through by means of two pairs of anatomic forceps, while
the inner border of the sternoliyoid muscle on either side
is retracted. In the dense layer of connective tissue the
middle thyroid veins pass vertically downward to the left
innominate vein, and nuist be avoided or possibly ligated
in two ])laces and divided between. During the progress
of the blunt dissection the situation of the trachea, toward
Tab. 14.
Lith. Arist E Heichhold, Miiiuhen
OPERATIONS ON THE AIR-PASSAGES.
281
the convex aspect of which tlie operation proceeds, should
be constantly kept in mind by palpation with the index-
finger. Before the traehea is reaelicd the deep layer of
the cervical fascia is divided upon a grooved director.
Only after this has been done is it possible to isolate the
treaehea adecjuately. Before the lumen of the tube is
opened the trachea is grasped with a simple sharp tenacu-
X .•
,J
Fig. 177. — Cutaneous incisions on the neck : a, infrahyoid pharyngot-
omy ; b, cricothyrotomy ; c, inferior tracheotomy.
lum and raised and fixed at the level of the skin. AMiile
the trachea is incised from below upward the index-finger
of the left hand is placed in the lower angle of the woimd
behind the suprasternal notch, so that the left innominate
vein, which passes transversely across the trachea behind
the manubrium of the sternum, as well as the innominate
artery, whieh is in close relation with the traehea, is suf-
282 OPERATIVE SURGERY.
liciently protected. The tracheal wound is held Avidely
open by means of sharp tenacula, possibly incised to right,
and left, when the introduction of the cannula is under-
taken (Plate 14).
After the cannula has been introduced into the trachea
the tenacula are removed. The cannula is fixed by means
of tapes and the cutaneous wound is reduced by suture.
If the tracheotomy can be performed at leisure and under
favorable conditions, the typical mode of procedure is
unattended with difficulty. The reverse is the case, how-
ever, if the operation must be undertaken in the presence
of threatened danger to life or of severe dyspnea. Under
these circumstances all of the presence of mind of the
operator will bo required to maintain the mastery of the
situation, which is often a critical one. The smallest
veins of the neck are dilated and distended with blood.
In the presence of conditions like these the cutaneous
incision is enlarged, as by this means the isolation and
lio:ation of the veins are considerablv facilitated. The
thin walls of the distended veins are not readily recog-
nizable. Veins that interfere with deep dissection are
ligated in two places and divided between. At successive
stages of the dissection the position of the trachea is con-
stantly kept in mind. Neglect of this ])recaution may
lead to overlooking the trachea. Before the trachea, pre-
viously exposed sufficiently, is opened, all bleeding vessels,
are closed by ligature. A tenaculum is introduced into
the trachea for the purpose of placing the organ at rest
at the level of the Avound, as it would otherwise rise and
fall with the respiratory movements, especially in the
presence of dyspnea. The opening into the trachea should
be made exactly in the middle line, care being taken that
the incision enters the lumen of the tube and does not ]^ass
beyond. If the opening is incomplete, it may happen
that the tracheal cannula makes a false passage for itself
beneath the mucous membrane. A careless incision may,
further, injure the posterior wall of the trachea or even
the esophagus. After the trachea has been opened the
OPERATIONS ON THE AIR-PASSAGES.
283
incision is dilated hy means of tenacula, while at the same
time as the cannula is introduced the trachea is held
steadily. The latter precaution is important, as through
its neglect the o{X'ning may be lost to view in consequence
of the movements of the trachea. A])art from the fact
that such an event may render impossible the proper in-
troduction of the cannula, subcutaneous emphysema may
result and extend from* the wound to the cellular tissue of
the neck.
The cannula (Fig. 178) in accordance with its curvature
is introduced in an arched manner. The whistling sound
Fig. 178. — Tracheal cannula.
Fig. 179. — Trendelenburg's tampon-
cannula.
with which the air, after a short period of apnea, escapes
from the tube is the indication that the cannula is properly
placed. In tixing the cannula by means of the tapes the
tube must be held firmly in the wound.
Tracheotomy for the puqx)se of tamponade of the
trachea, with simultaneous insurance of access of air, is
sometimes ])ractised as a preliminary procedure in opera-
tions upon the mouth, the larynx, and the pharynx. The
tampon-cannula is intended to prevent the entrance of
blood in the course of operations and the aspiration of
284 OPERATIVE SURGERY.
secretion from wounds in the further progress of the case.
The so-called tampon-cannula employed for this purpose
is surrounded with compressed sponge (Hahn), which
swells in the trachea and completely occupies its lumen ;
or, the tube is surrounded l^y a small rubber bag (Tren-
delenburg) which can be filled with air by means of
bellows (Fig. 179). The l)ag is distended with air after
the cannula has l^een introduced, and adapts itself accu-
rately to the interior of the trachea, occluding its lumen
as a stopper does the neck of a flask.
Intubation. — Intubation is a bloodless procedure in-
tended to render the larynx patulous in the presence
of respiratory obstruction by the introduction of a rigid
tube. The operation was recommended a number of
years ago as a substitute for tracheotomy in cases of
laryngeal stenosis from croup, and it has in the course
of time secured more and more supporters.
The most important indication for intubation consists in
laryngeal stenosis such as is observed in conjunction with
laryngeal croup. Further indications are afforded by the
various forms of chronic stenosis of the larynx observed
in adults. Under these conditions intubation is a substi-
tute for tubage. Intubation has been recommended also
as a palliative measure in cases of whooping-cough and of
laryngeal spasm. The procedure is contraindicated :
(a) In the presence of complete occlusion of the naso-
pharyngeal space ;
(6) In the presence of intense edema of the glottis ;
(c) In cases of diphtheria complicated by retrophar^m-
geal abscess.
The original outfit of O'Dwyer is still the best, in spite
of numerous modifications. This consists of:
(1) A mouth-gag (Fig. 180).
(2) A series of metallic tubes of varying size (Figs.
181 and 182). Each tube presents at its upper extremity
a shoulder resembling the rim of a hat, by means of which
it rests upon the vocal bands. Upon the left side of this
shoulder is a small opening for the attachment of a thread.
OPKRATIOSS O.V Tin: mi:- PASSAGES.
285
Each tube i.s t'lirtlu'r provided with a conductor intended
to facilitate the iriiidance of the rigid tube.
(3) An intul)ator (Fig. 183), to which the conductor
spoken of is attached by means of a screw. Tube and
conductor should tit accurately. By means of a lever the
tube can be detached from the conductor at the proper
moment.
(4) An extubator (Fig. 184). The extremity of this
instrument, which is constructed similarly to the intuba-
tor, can be introduced into the lumen of the tube, and be
impacted there, and thus serve for the removal of the
tube.
ODWYEKS OUTFIT FOR INTUBATION.
Fig. 180.— Mouth-gag. Fig. 181 and Fig. 132.— Tubes with conductors.
The operation is j)erformed as follows :
A nurse takes the child to be intubated \\\)on her lap,
grasps its lower extremities between her knees, and with
her right hand holds its head, and with her left, its hands.
An assistant holds the mouth oj)en by means of the gag,
while the operator grasps the epiglottis with the index-
linger of his left hand and draws it forward so that the
entrance to the larynx is clear. The intulmtor, adapted
to the corresponding tube, is no'w introduced alongside the
finger. If after a slight movement upward it is certain
that the tube has entered the larvnx. the former is then
286
OPERATIVE SURGERY.
Plate 15. — Infrahyoid Pharyngotomy.
Preliminary inferior tracheotomy has been performed and a cannula
introduced. In the pharyngotomy-wound can be seen the stumps of the
divided hyoid muscles, as well as the hyoid bone iH ).
The epiglottis {E ) is drawn out of the wound and the aryepiglottic
folds {Ae) are made tense. The lloor of the wound is constituted by the
posterior wall of the pharynx.
pushed gently onward, detached from the intubator, either
M'itli the finger of the left hand or by means of slight
pressure forward upon a sliding arrangement connected
Avith the handle of the instrument, and with the index-
finger of the left hand forced deeply into the larynx. If
the child breathes freely, the thread attached to the tube
may be permitted to remain, being brought out of the
Fig. 184.— Extubator.
mouth and attached to the cheek by means of adhesive
plaster, or the index-finger is again introduced into the
mouth, the tube held in place, and the divided thread
slowlv removed.
Extubation is effected in much the same manner.
Under the guidance of the index-finger of the left hand
the extubator is introduced into the mouth and its closed
Tab. 15.
J.ith '"■•' A' /,'>
o
eS
O
C5
19
LIGATION OF VESSELS IN CERVICAL REGION. 291
ward. The deep layer of the cervical fascia is divided
ujxm a L;;rr instance, after extraction of foreiirn bodies —
the wall of the esophagus is approximated with knotted
sutures in two tiers. The first row of sutures approxi-
mates the mucous membrane and the second the muscular
layer. If the operation has been performed for the pur-
pose of establishing an esophageal fistula — for instance,
for dilatation of a stricture of the esophagus — the margins
of the mucous membrane are united to the skin by means
of knotted sutures.
lyigation of Vessels in the Cervical Region. —
Innominate Artery. — The innominate artery, the common
trunk of the carotid and the right subclavian artery, arises
from the arch of the aorta. Lying against the trachea,
the large vessel passes to the right and upward, dividing
into the two vessels named at the level of the sterno-
clavicular articulation. Covered bv the manubrium of
the sternum, the innominate artery is accessible from the
suprasternal fossa behind the free border of the sterno-
hyoid or of the sternothyroid muscle. The trunk of the
vessel is crossed by the left innominate vein as it passes
transversely. The recurrent laryngeal nerve winds around
the innominate artery. In ligating the vessel the patient
occupies the dorsal decubitus, with the neck extended.
According to Graefe, the cutaneous incision is made along
the anterior border of the sternomastoid muscle in such a
way that its lower extremity extends beyond the sternal
292 OPERATIVE SURGERY.
attachment of the muscle. The sheath of the muscle is
opened and the median fascia of the neck divided, when
the inner border of the sternohyoid becomes visible and
below tliis that of the sternothyroid. These muscles are
retracted witli blunt hooks. Along the right side of the
trachea progress is made downward, the common carotid
artery being first reached and further on the innominate,
lying by the side of the trachea. The artery can be iso-
latecl from the surrounding loose cellular tissues by blunt
dissection and it is then ligated.
The same plan of procedure is followed in looking for
the vessel through an incision made vertically in the mid-
dle line of the neck over the suprasternal notch^ instead
of the incision of Graefe.
Carotid Artery. — The carotid artery on the right is a
branch of the innominate, while upon the left it arises
directly from the arch of the aorta. The common carotid
artery on either side passes along the side of the trachea
and the larynx almost vertically upward upon the neck to
the level of the thyroid cartilage, where it divides into its
primary branches, the internal and the external carotid. In
its course the carotid artery holds such relations with the
jugular vein, the vagus nerve, and the descending branch
of the hypoglossal nerve in the loose cellular tissue that
the vein lies to the outer side of the artery. The vessels
are covered by fibrous fascia that also constitutes the poste-
rior w^all of the sheath of the sternomastoid muscle. To
render the artery accessible it will thus be necessary to
expose and retract the fibers of the sternomastoid muscle
and to divide carefully the posterior wall of its sheath.
Ligation of the Common Carotid Artery. — The patient
occupies the dorsal decubitus, Avith the neck stretched and
the head rotated toward the healthy side. By palpation
the situation of the larynx and the course of the sterno-
mastoid muscle are determined. The artery is best ex-
posed at the level of the cricoid cartilage just above the
point where it is crossed by the omohyoid muscle. The
cutaneous incision is made along the anterior border of the
LIGATION OF VESSELS IN CERVICAL REGION. 293
sternoinastcud from the thyroid ciirtihige for a distance
downward of 8 or 10 cm. (Fig. 186, />;). After the skin
and the platysma muscle are divided the sternomastoid
muscle, covered hy the fascia, comes into view. The
fascia is divided in the direction of the cutaneous incision
and the inner border of the exposed muscle is carefully
retracted outward, when the so-called middle fascia of the
Fig. 186. — Ligation of the vessel- tIiun ot the glossal nerve, accom-
panied by a vein, passes horizontally. The free border of
the mylohyoid muscle forms with the tendon of the digas-
tric muscle and the hypoglossal nerve a triangle whose floor
is constituted bv the fibers of the hvocflossus muscle. To
ex|X)se the lingual artery the fascia covering this lingual
trigone is first divided. Then the fibers of the hvoglossus
muser aperture of the thorax, and
296
OPERATIVE SURGERY.
Plate 17.— Exposure of the Lingual Artery.
The submaxillary gland (.S'm) is raised from its bed after division of
the skin and the fascia ; the lingual trigone is thus rendered visible. It
is bounded by the tendon of the digastric muscle (Bi, the outer border
'of the mylohyoid muscle (Mh), and the hypoglossal nerve (H ), which is
accompanied by a vein. The floor of the triangle is formed by the
hyoglossus muscle (Hg), the fibers of which are separated within the tri-
angle, and the artery (L) is thus rendered visible.
reaches the anterior surface at the first rib in the interval be-
tween the scalenus anticus and medius muscles (posterior
scalene interval, Fig. 187). From this situation it de-
FiG. 187. — Posterior scalene
interval (L), between the sca-
lenus anticus (.S'a) and the sca-
lenus medius {Sm) muscle.
scends toward the arm. The point at which the artery
crosses the first rib is marked by a slight elevation, the
Tab. 17.
B.
'fg-
II.
Mil.
LIGATION OF VESSELS IN CERVICAL REGION. 297
tiihcrclc ot" JiislVaiu; or the scalene liil)erele. The cords
of the brachial ])lexus also reach the arm through the in-
ters al between the two scalene muscles. The nerves lie
al)ove and to i\\v outer side of the artery (IMate 18).
The subclavian vein passes in the interval between the
sternomastoid and the scalenus anticus (anterior scalene
interval), to unite ^vith the internal jugular vein. The
subclavian vein is thus separated from the subclavian ar-
tery by the scalenus anticus muscle.
The subclavian artery is exposed for ligation above
and l)elow the clavicle ; in the supraclavicular fossa just
at the point where it lies upon the iirst rib after emerging
from the scalene interval ; below^ the clavicle at a point
corresponding Avith the lower margin of the first rib.
Liyutlon of the Subclavian Avtcry Above the Clavicle. —
The patient lies with the upper portion of the trunk ele-
vated and the head rotated toward the opposite side. The
arm lies against the trunk. Gentle traction on the arm
brings into view the boundaries of the supraclavicular
fossa. By this means the clavicle can be seen, forming
the base of the triangular space, whose anterior boundary
is formed by the outer border of the sternomastoid mus-
cle and the posterior boundary by the anterior border of
the trapezius. The plane of the supraclavicular fossa is
more or less depressed.
A transverse cutaneous incision is made parallel with
and a finger's breadth above the clavicle, from the outer
border of the sternomastoid muscle to the anterior border
of the trapezius (Fig. 186), dividing the skin, the pla-
tysma muscle, and the supraclavicular nerves. By blunt
dissection a passage is made through the loose connective
tissue of the supraclavicular fossa to the deep layer of
fascia that covers the scalenus muscles, the brachial
plexus, and the subclavian artery. After the fascia has
been divided, the position of the posterior scalene interval
is made out, and the situation of the artery is determined
by palpation with the finger just behind the attachment
of the scalenus anticus to the first rib, to the outer side
298 OPERATIVE SURGERY.
Plate 1 8. — Situation of the Subclavian Artery in the
Supraclavicular Fossa.
The anterior scalene interval is visible between the sternomastoid
{K ) and the scalenus anticus (Sa) ; also the posterior scalene interval
between the scalenus anticus and the scalenus medius {Sin). Through
the latter space pass the nerves of the brachial plexus (N), and to the
inner side of the nerves, lying upon the first rib, the artery.
of the scalene tubercle. The artery lies upon the first
rib at the deepest point of the interval, to the inner side
of the nerves of the brachial plexus, and can be isolated
for ligation between two pairs of anatomic forceps.
Ligation of the Subclavian Artery Below the Clavicle. —
The patient occupies the same position as in the operation
just described. The line of separation of the clavicular
portions of the deltoid and pectoralis major muscles is in-
dicated below^ the clavicle by a triangular depression (Moh-
renheim's triangle). By palpation ^vith the finger the
situation of the coracoid process of the scapula is care-
fully determined, and a cutaneous incision is made from a
finger's breadth belo^y the clavicle to above the apex of
the coracoid process. The clavicular portion of the pec-
toralis major muscle is divided in the line of the cuta-
neous incision and after division of the loose coracoclavic-
ular fascia the upper border of the pectoralis minor is
exposed and is retracted downward with blunt hooks. In
the loose connective tissue below the clavicle there appear
in the direction toward the anterior scalene interval above,
the readily accessible subclavian vein, and to its outer side
the great mass constituted by the brachial plexus. The
artery lies betw^een the vein and tlie nerves, closer to the
wall of the thorax, and can be separated from the loose
cellular tissue by blunt dissection (Plate 16). Following
another method, entrance is gained to Mohrenheim's tri-
angle, after making the same cutaneous incision, and the
artery is exposed without division of the pectoralis major.
The superficial fascia is divided and after separation of
the margins of the pectoralis major and deltoid muscles the
'WAk 1^
Sm.
LIGATION OF VESSELS IN CERVICAL REGION 299
fossa of JMohivnhciiii is rciulcrcd a(;('('ssil)U'. In the (l('j)th
of this fossil thv muss of vessels and nerves is visible below
the clavicle alter division of the coracoelavicular fascia.
Of the branches of the subclavian artcrv the follow inal vessels of tlic thyroid j^hirid, tlic siijH'rior and
interior thyroid arteries, and at the lower pole the middle
thyroid vein also, are grasped and diviitrous tumor, is freed from
the anterior wall of the trachea by blunt dissection and
secured with two lio~aturcs, between which the isthmus is
divided. In order to avoid injurino^ the recurrent laryn-
geal nerve in the process of detachint»: the thyroid gland
from the lateral wall of the trachea Kocher divides the
structure of the goiter parallel with the trachea and in
this way leaves behind a portion of the capsule of the
goiter as a protection against injury of the nerve (resection
of goiter).
302 OPERATIVE SUBGEEY.
III. OPERATIONS ON THE TRUNK AND
THE PELVIS.
Paracentesis Thoracis, Thoracotomy. — The thorax is
opened by puncture or by incision wlien the presence of
accumulations of fluid in the pleural cavity gives rise to
threatening symptoms by reason of either their quantity
or their character. In general the statement may be ac-
cepted that serous and hemorrhagic elFusions are to be
treated by puncture, and purulent exudates on the other
hand by incision.^ Either operation is therefore always
preceded by exploratory a.spiration of the pleural contents
by means of a hypodermic or similar syringe. The ope-
ration of thoracocentesis is performed by the introduction
of 8 trocar and cannula between two ribs into the pleural
space, either permitting the fluid simply to escape, or
aiding its removal by means of aspiration. If the cannula
is so constructed that the aspiration of air can be avoided
during the removal of the trocar, the first method of pro-
cedure meets all requirements. Billroth's cannula is
provided with a lateral branch for the escape of the fluid,
whicli can be controlled by a cock. To this branch a rub-
ber tube of suitable length is attached. The branch of
the cannula in which the stilet is introduced is also pro-
vided with a cock, which is closed after the stilet has been
removed. The patient is placed in the sitting posture
with the trunk bent somewhat forward. The trocar is
introduced, except in the presence of a sacculated efPusion,
at the most marked convexity of the ribs in the fourth,
fifth, or sixth intercostal space, and close to the upper
border of the lower rib. The operator marks accurately
the point of introduction with the index-finger of his left
1 If a hemorrhagic collection is very extensive and the life of the
patient is seriously threatened, it is proper to open the thorax after rib-re-
section and endeavor to arrest the hemorrhage by ligatures, by suture-
ligatures, by packing a small pulmonary wound, or by filling the pleura
with sterile gauze, to secure a point of counter-pressure, and packing
iodoform-gauze directly against the bleeding lung. — Ed.
OPERATIOy^ Oy THE TRVyK AM) THE PELVIS. 303
hand. Tho ])nnu'li of the caniiula for the escape of the
thiid is chtscd. Troear and caniiida are introdnced verti-
cally nntil disappearance of the resistance of the thoracic
wall indicates that the point of the instrnment has entered
the })lcnral ca\ity. The o]>erator now irras})s the instru-
ment with his left hand, removes the trocar, and permits
the fluid to escape through the lateral branch of the can-
nula. The extremity of* the rubber tube dips into a ves-
sel containing: aseptic fluid. The flow should take place
steadily antl shjwly. By this mode of procedure the
entrance of air is avoided with certainty.
If the discharge of fluid ceases suddenly, the flow can be facilitated by
changing the position of the cannula, if the obstruction be due to ap-
proximation of the lung. Occlusion of the tube by coagula may be
overcome by the introduction of a blunt probe.
The evacuation of the fluid can be better controlled
when with puncture is conjoined aspiration of the pleural
exudate. In place of the trocar and cannula a sharp hol-
low needle is employed, which is connected by means of a
tube with the neck of an airtight bottle from whose in-
terior the air is exhausted with the aid of a suitable pump
(Dieulafoy's aspirator). Fluid can thus be evacuated by
negative pressure when it would fail to flow spontaneously
from the pressure withiu the pleural cavity.
Thoracotomi/, opening of the pleural cavity by incision,
is indicated when the pleural exudate is purulent in char-
acter. Unless the exudate be sacculated or circumscribed,
the incision is made in the fifth or sixth intercostal space
over the greatest convexity of the ribs. To avoid injury
of the intercostal vessels the knife is introduced close to
the upper border of the rib, dividing the two layers of
intercostal muscles, the endothoracic fiiscia, and the pleura
throughout the entire extent of the incision. By the in-
troduction of a rubber tube into the wound drainage of the
pleural cavity will be established. To permit of more
convenient access and to render possible adequate drainage
resection of from 3 to 4 cm. of a rib in its contin\iity is
recommended. Under these circumstances the incision
304 OPERATIVE SURGERY.
is made directly over the rib, dividing its periosteum
throughout a distauce of 5 or 6 cm. The periosteum is
reflected upward aud downward by means of a raspatory
from the anterior surface of the rib, and then with espe-
cial care from its posterior surface. The portion of the
rib thus exposed is resected throughout the given extent
by means of bone-shears. The uninjured pleura is incised,
the purulent contents permitted to escape, and drainage
established. If in the presence of a pleural fistula the
empyema cannot be made to close on account of the rigid-
ity of the thoracic wall, resection of a series of ribs is a
suitable procedure in order to render the wall of the chest
more yielding. The possibility thus established of ap-
proximating the parietal and visceral layers of the pleura
renders the conditions favorable for cessation of the long-
continued aud tedious suppui'ative process. A long, verti-
cal incision exposes the series of ribs, which are to be
subjected individually to subperiosteal resection through-
out an extent of from 3 to 10 cm.
Ligation of the Internal Mammary Artery. — The cuta-
neous incision is made in the third or fourth intercostal
space from the border of the sternum outward for a dis-
tance of 4 or 5 cm. The skin, the subcutaneous connec-
tive tissue, the pectoralis major, and the internal inter-
costal muscle are divided throughout the extent of the
incision. Lying in front of the pleura, in the angle
between the rib and the sternum, is the internal mammary
artery, which follows the axis of the body and is accom-
panied by two veins. The vessel can readily be isolated
from the loose connective tissue. Esmarch makes a longi-
tudinal incision alongside the sternum and enlarges the
field of operation by resection of a costal cartilage.
Removal of the Mammary Gland. — The mammary
gland is removed completely Avhen the seat of a malig-
nant neoplasm. AYith the gland are also removed en
masse the chain of lymph-glands extending from it to
the axillary cavity and the mass of axillary lymphatic
glands in conjunction Avith the fat by which they are
OPKIiATloys OX THE TJiUyK ASD Till-: PELVIS. 305
surroiiiKU'd. The patient CK'cupics tlic dorsal (kfuliitus,
with tilt' muK r part of tlu* body elevated and the arm on
the atfectcd side alxluetetl somewhat alx)ve the horizontal
line. Two ineisions, iorminj; an oval with its longitudi-
nal axis prising i'roni alxive and without downward and
inwaixl, are made from the free border of the peetoralis
major musele to the ensiform eiirtilage, ineluding the mam-
millarv areola (Fig. 1S§). The healthy skin is disseeted
free from the subjaeent structures and when the margin
Fig. 188. — Amputation of the breast : cutaneous incision.
of the gland has been reached this is removed from the
thoracic wall Avith the upper layers of the peetoralis
major, or in conjunctir>n with the whole muscle. The
separation is effected throughout the entire extent of the
mammary irland with the exception of the pole directed
toward the axilla. Then the axillary fat and the con-
tained lymphatic glands are removed en masse. The
group of glands remains in connection with the breast.
From the upper pole of the oval, which is directed toward
the axillarv cavitv, an incision is made alonj; the free
20
306 OPERATIVE SURGERY.
border of and down to the pectoralis major muscle. The
lower margin of the wound is retracted downward, and
the pectoralis major upward. Beginning at the pectoralis
major, the mass of fat is detached by means of anatomic
forceps from the group of large vessels and nerves. Of
especial importance in this connection is the large axillary
vein, which lies uppermost and whose separation is to be
effected with especial care. As the dissection progresses
it will become necessary to divide between t^^o ligatures
the trunks of arteries and veins passing between the
groups of glands drawn downward and the large vessels.
After the glands have thus been separated from the large
vessels, the subscapularis and latissimus dorsi muscles are
yet to be dissected. The connections between the group
of glands and these muscles are quickly divided with the
knife, when the entire mass of axillary fat may be removed
en masse in conjunction with the breast. Under some cir-
cumstances the subscapular artery and vein, the posterior
circumflex artery and vein, or the long thoracic artery and
vein may require ligation. Klister has called attention to
the importance of protecting the long thoracic nerve from
injury. If it prove impossible to free the axillary vein,
it often becomes necessary to sacrifice a portion of this
vessel. After the application of ligatures the vein is
resected throughout the necessary extent and removed
together witli the glands. For the removal of infiltrated
glands from the infraclavicular and supraclavicular fossae
accessory operations are necessary. Transverse division
of the pectoralis major and minor muscles will render the
infraclavicular fossa conveniently accessible. For the re-
moval of supraclavicular glands either an incision is made
as in ligation of the subclavian artery above the clavicle,
or the clavicle is divided temporarily at the junction of its
middle and outer thirds.^
^ The operation of Halsted is extensively employed in the United
States. In this operation the surgeon removes the entire breast and the
skin over it, the axillary glands and fat, and the pectoral muscles. The
mass is removed in one piece. In many cases the subclavicular glands
and fat are also removed. — Ed.
OPERATIONS ON THE TRUNK AND THE PELVIS. '607
Abdominal Puncture, Paracentesis Abdominalis. — The
aUlomiiKil cavity may he opciu'd by puiK'tiire to eticct
cvaouatioii ot Hiiid accuinulations, either free within the
peritoneal cavity, or saeenlated, or contained within cysts.
[f the Huid be free, the ]i()int of ^lonro, that is, a ])oint
midway between the uml)ilicii> and the left anterior iliac
spine, is as a rule seleeted as the situation for puncture.
Trzebizky has demonstrated tliat in a small })roporti()n of
eases the epigastric artery or one of its branches may be
injured in performino puncture by this method. If, liow-
ever, the troear is introduced into the outer half of the
line between the umbilicus and the superior iliac spine,
the possibility of this unpleasant occurrenee is safely
avoided. The reeommendation to make the puneture
upon the left side of the abdomen is not of primary ira-
portanee. If the liver be enlarged, the puncture will be
preferably made upon the left side. Enlargement of the
spleen of an}' considerable degree will justify making the
puncture upon the right side. The puncture may further
be made in the linea alba, midway between the umbilicus
and the symphysis pubis. The selection of the point of
puncture in the presence of cysts and of sacculated exu-
dates will be o'overned bv the situation of the accumula-
tion of fluid.
In performing puncture of the abdomen a straight
trocar and cannula with a lateral branch are employed.
The patient occupies a partial lateral position or the upper
portion of the body is elevated. Before the trocar is in-
troduced it should be determined by careful percussion
that the mtestine is not adherent to the abdominal wall at
the |X)int where the puncture is to be made. The index-
linger of the left hand is placed at the point of puncture,
and the trocar is introduced vertically through the ab-
dominal walls, then grasped Avith the left hand, while the
right removes the troear. By means of a tube attached
to tiie lateral branch of the cannula the fluid is permitted
to esca[)e slowly into a suitable receptacle. If the intra-
abdominal pressure falls, the escape of the fluid is favored
308 OPERATIVE SURGERY.
by compression of the abdomen with the hand or by
tightening a many-tailed bandage around the abdomen.
It is an old rule never to permit the escape of all of the
fluid contained within the abdominal cavity. The trocar
is therefore removed at a time when a certain amount of
fluid is yet present, and the wound is closed with a suit-
able dressing.
Celiotomy. — Opening of the abdominal cavity through
incision of the abdominal walls is designated celiotomy.
This procedure is a preliminary one in the performance
of intraperitoneal operations of all kinds. The abdominal
incisions are sometimes made longitudinally, sometimes
more or less obliquely, and sometimes even transversely.
Longitudinal incisions are made either in the linea alba,
or along the outer border of the rectus abdominis muscle.
In the epigastrium and the hypogastrium, both oblique
incisions parallel with the costal margin, or with Poupart's
ligament, and longitudinal and transverse incisions are
employed. The incision into the linea alba is indicated
in the presence of large formations occupying the abdomi-
nal cavity. The incision is made below the umbilicus
when the pelvic organs are the object of attack. Through
the epigastrium access is gained to the stomach, or upon
the right side to the liver and the gall-bladder. An
incision is made into the hypogastrium when it is intended
to reach upon the right the cecum or the vermiform appen-
dix, and upon the left the descending colon or the sigmoid
flexure (Fig. 190). In the performance of intraperitoneal
operations the patient is either placed horizontally or the
body is placed upon an inclined plane with the head at
the lowest and the pelvis at the highest level (Trendelen-
burg's position, Fig. 189). This position affords a clear
view of the arrangement of the pelvic organs after the
abdominal cavity has been opened, the intestmes sinking
down toward the epigastrium in the concavity of the
diaphragm. The position therefore permits careful in-
spection of the abdominal viscera and protects the intes-
tines from extrusion during the course of the operation.
OPERATIONS ON THE TRUNK AND THE PELVIS. 309
3fo(h' of M((hi)i(/ the Tncision tlwoiif/h the AhdouiiiKd
WalU. — Throiiiili the liiica alha, as in other portions of*
the abdominal wall, dissection is effected layer by layer
with the scali)el. The skin and the subcntaneous con-
nective tissue are divided and access is oaincd to the dense
fibrous U])per layer of the sheath of the rectus muscle or
between the two rectus muscles. As a rule, the median
borders of the recti muscles are exposed witliin the wound.
After division of the posterior layer of the sheath of the
rectus a layer of loose connective tissue comes into view,
and in obese persons a layer of fat often of considerable
Fig. 189.— Trendelenburg's position.
extent lying directly upon the peritoneum. All of the
tissues are carefully divided by blunt dissection with two
pairs of forceps. A fold of parietal peritoneum is ])icked
up and opened at one ])oint and the incision is enlarged
above and below throughout the extent of the superficial
wound by means of scissors or a blunt-pointed knife.
Longitudinal, oblirjue, or transverse incisions in the epi-
gastrium extend also, like those in the hy})ogastrium,
successively through the layers of the abdominal muscles
to the subserous fiit and the peritoneum. A fold of the
parietal peritoneum is picked up with two pairs of forceps
310
OPERATIVE SURGERY.
and snipped with scissors, and the incision is enlarged in
the manner already described. The closure of the ab-
dominal wall should be firm and resistant ; the resulting
cicatrix should display no tendency to ectasis and the
Fig. 190. — Ahdoniinal incisions: «, lonijitudiniil incision for opera-
tions on tliestoniacli ; h, incision for ujastrostoiny ; c, incision for oi)erat.ions
on the gall bladder; (L incision for epicystotoniy ; c, incision for ligation
of the external iliac artery; /, incision for colotomy ; g, incisions for ex-
posure of the cecum and the vermiform appendix.
formation of ventral hernia. Suture of the wound should
be eftected with silk or absorbable material introduced in
tiers. In the linea alba the deepest row of sutures in-
cludes the peritoneum only, care being taken that smooth
OPERATIONS ON STOMACH AND INTESTINES. 311
serous surfacos arc brought iu approxiuiatiou. Tlio second
row of sutures includes the rectus niusch' togetlicr with its
anterior tii)rous sheath; several deep sutures secure the
approximation of the muscles; more superticial ones pass-
ing through the anterior sheath a})proxiniate accurately
the a})(»neuroses. The most superiicial layer of sutures
unites the skin in the customary manner. In the same
way abdominal wounds* in other situations are closed by
three tiers of sutures. The deepest row unites the peri-
toneum, the middle the muscle and the aponeurosis, and
the upper the skin.
Operations on the Stomach and the Intestines.
— The Establishment of Gastric and Intestinal Fistulse. —
In general the operation consists in bringing the selected
portion of stomach or bowel out of the wound after celi-
otomy and uniting the parietal peritoneum at the margins
of the abdominal wound throughout a sufficient extent
with the visceral peritoneum of the stomach or intestine
by means of interrupted or continuous sutures. The stom-
ach or bowel is opened either at once, the gastric or
intestinal mucous nieml)rane being united to the skin, or
in the course of several days, after the abdominal cavity
has been closed through the formation of adhesions
throughout the extent of the wound. The method of
operation is subject to various modifications at different
portions of the gastro-intestinal tract.
The Formation of a Gastric Fistula ; Gastrostomy. — The
formation of a gastric fistula is indicated in the presence
of imj)ermeable constriction of the esophagus :
(a) In consequence of the presence of neoplasms ;
(h) In consecjuence of cicatricial stricture; as well as
for the introduction of nourishment into the stomach and
for purposes of dilating deep-seated strictures through the
wound.
The stomach is reached by division of the abdominal
\vall in the left epigastric region. The cutaneous incision
is made either parallel with the left costal margin or
vertically through the rectus abdominis muscle close to
312 OPERATIVE SURGERY.
Plate 19.
Gastrostomy.— Suturing one portion of the anterior wall of the stom-
ach into the wound in the abdominal wall. The serous margin of the
wound is united with the serous layer of the stomach by means of a
continued suture.
Colostomy.— A loop of the sigmoid flexure has been drawn forward
and fixed in the wound.
its outer border. In the first instance the incision begins
a thum])'s breadth to the left of the apex of the ensiform
cartilage and passes ont^vard and downward for a distance
of 6 or 8 cm. some 2 cm. from the costal margin. The
peritoneal cavity is opened throughout the extent and in
the line of the cutaneous incision, and a small portion of
the stomach is brought into the wound.
The stomach may be recognized by the characteristic radiation of the
vessels from the greater and lesser curvatures. The walls of the stom-
ach are thicker than those of the small intestine: and the organ is to
be distinguished from the large intestine by the absence of sacculation.
The stomach is most readily reached by grasping a portion of the great
omentum and following it from the periphery toward the greater curva-
ture.
The portir)n of strmiach brought into the wound is
suspended in position by means of two fixation-sutures
that do not penetrate its lumen. The parietal peritoneum
is then closely united to this portion of the stomach with
a continued suture, including not only the thin serous
layer, but al.-r^o the sul>.mc impossihk'; for instance, after ero-
sion or corrosion of the stomacli ; also when the stomach
is the scat of a new-formation, whose extent forl)ids either
its removal or gastro-enterostomy. The incision is made
in the linea alba, between the umbilicns and the sym-
physis pubis. After the' peritoneum has been divided the
transverse colon is brouoht forward at the attachment of
the greater omentum and reflected upward. The duodeno-
jejunal flexure appears at the root of the mesentery. One
of the up])ermost loops of jejunum that ean be readily
drawn into the wound is brought forward and fixed in the
wound by means of seroserous sutures. The intestinal
loop is opened either after the lapse of several days, or,
Ix'tter, at once, with the establishment of an oblique
fistula by the method of AYitzel. The nourishment of the
patient ean be effected without difficulty through the rub-
ber tube. As the oblique fistula closes accurately bile
and pancreatic secretion are not lost.
Resection of the Bowel. — It has been established clinic-
ally that considerable portions of the intestine (two meters
and more, Kocher) can be removed by resection without
detriment. After the resection has been effected the
continuity of the bowel can be restored by means of cir-
cular suture of the stunq^s, or these may be brought out
of the abdominal wound and an intestinal fistula or pre-
ternatural anus established. Resection of the bowel is
undertaken :
(1) In the presence of injuries of the intestine;
(2) In the presence of gangrene of the bowel ;
(3) In the presence of neoplasms ;
(4) In the presence of stenosis of the bowel ;
(5) For the cure of intestinal fistulfe.
The portion of intestine intended for resection must be
detached from its surroundings, so that it can be brought
out of the abdominal w^ound. The intestine is closed by
means of either clamps or pressure with the fingers or
316 OPERATIVE SURGERY.
strips of sterilized gauze tightened and tied. The con-,
tents of the bowel should have been furced backward and
forward before the intestine is incised. The division of
the bowel is effected with scissors. The plane of division
should be so made, according to the suggestion of Kocher,
that a greater portion of bowel is removed from the con-
vexity than from the mesenteric attachment, as by this
means the circular vessels of the bowel are less exposed
to injury. The mesentery is ligated in successive portions
and divided transversely at its attachment to the bowel,
or excised in the form of a wedge whose base is formed
by the resected bowel and imited in a linear direction.
After the mucous meml^rane projecting from the divided
surfaces has been dried with sterile gauze circular union
of the lumen of the two portions of bowel may be pro-
ceeded with. If the lumen of the two portions of bowel
is unequal, the smaller is divided obliquely, so that the
cut surface is elliptic in shape.
For the union of transversely divided bowel after resec-
tion, as well as in the formation of anastomoses, either
the intestinal suture or Murphy's anastomotic button may
be employed. The method of applying the intestinal su-
ture has already been described at page 53. Murphy's
button renders possible rapid effectuation of accurate
union of divided intestinal lumen, as well as the estab-
lishment of anastomoses between portions of the intestinal
tract. This ingenious device consists of two capsules
made of light sheet-iron and nickel-plated and provided
Avith a hollow cylinder internally and a slight shoulder
externally (Plate 20), which can be readily pushed the
one into the other with the lingers, when by reason of a
clamp-like arrangement they remain thus in secure appo-
sition. The transversely divided portions of intestine, or
the slits made in the establishment of anastomoses, are
picked up by continued sutures passing through all of the
layers of the intestinal wall, which are tied after the intes-
tine has been brought over the respective half of the but-
ton. After the second portion of the intestine has been
OPERATIONS ON STOMACH AND INTESTINES. 317
similarly treated the two halves of the button are pushed
one into the other and elanipcd Ix'tween the tinh)n, and nninn of the
opixtsed paits is ettected either hy suture or with the aid
of the Murphy button. The first row of sutures includes
the entire thickness of the intestinal and gastric walls, at
the margins of the resjx'ctive openings. A row of
Lembert serous sutures is applied over the first row.
Operations upon the Biliar>" Apparatus. — Beside
abscesses and cvsts of the liver, tor who-*.- operative treat-
ment no especial rules can be laid down, attacks u}xjn tlie
biliary apparatus are directed especially toward the
removal of calculi and their sequelae. The surgery of
the biliary apparatus, the youngest department of ab-
d«)minal surgery, has been systematically practised only
since the besrinninor of the eighties. The cutaneous
incisions throuofh which the transverse fissure of the liver
is reached are varied. At times it is made in the linea
alba between the umbilicus and the symphysis pubis. At
other times it is made along the outer border of the rectus
abdominis muscle. Czeruy makes an anirular incision,
whose vertical arm passes along the linea alba, and is
joined below the umbilicus by a horizontal incision pass-
ing towai\l the right and outward. In all cases after
opening the peritoneal cavity the right lobe of the liver
is reflected upward sseladder will escajx? after slight withdrawal of the soft
catheter.
Tlif iutrodiK'tinn of a rif/UJ cofhtirr info the bh/rJrlpr is a
much more difficult procedure, and its safe and proper
Fig. 198. — Introduction of a rifrifl iustrumLUt into the bladder, the tip
of the catheter obstructed at the bulbous portion.
execution requires a certain amount of skill. In general
the rule is to be ob.served that the beak of the instrument
be made to pass along the upper wall of the urethra. If
the urethra l)e normal, no difficulty is experienced in the
operation until tlie meml)ranous portion is reached, but at
the junction of the movable with the fixed membranous
j)ortion a slight obstruction is encountered l)v the beak of
the catheter (Fig. 198). Care must now be taken to pre-
328
OPERATIVE SURGERY.
vent the tip of the instrument engaging in the mucou«
meml)rane. The beak most therefore not deviate from
the median line, and with cautious movements the instru-
ment should be passed into the membranous portion,
naturally without any violence. After the resistance has
been overcome the instrument Avill be felt to enter the
membranous portion and pass through the urogenital
diaphragm.
From this point the catheter in a normal urethra en-
counters no further obstruction, and on dopressinuf the
Fig. 199.^Introduction of a rigid instrument into the bladder: by
depressing the shaft of the catheter its beak is forced iuto the bladder.'
handle of the instrument the tip enters the bladder with-
out further hindrance (Fig. 199).
Cdtheterizatioii with a 3[efa/lic Instrument. — The patient
is placed horizontally upon his })ack, with the pelvis some-
what elevated, and the operator standing upon his left
OPERATIONS UPON GEyiTO-URTXARY ORG ASS. 329
sicl(\ The penis is grasjx'il with three tinorers of the left
hand and the lips of the urethra are held apart V)v means
of the thumb and the inilex-finger. The catheter or the
solid sound is irrasped at its distal extremity with the first
three tiuirers of the right hand, its palmar aspect turned
upward, and resting with the little finger upon the middle
line of the body (Fig. *200j.
The ojX'rat<:)r permits the beak of the instrument to enter
the urethra and draws the penis, with a certain degree of
Fig. 200. — First position in the introduction of the catheter.
tension, over the curve of the catheter, which is, at the
same time being steadily kept in the middle line, orradu-
ally raised until it reaches a vertical position. With a
slight jerk the tip of the instrument passes the bulbous
portion and it yet remains to enter the membranous por-
tion and pass the urogenital diaphragm (Fig. 201).
In all cases a sense of obstruction is encountere<:l at this
point which is readily overcome by gentle pressure, while
330 OPERATIVE SURGERY.
the catheter is held accurately in the median line, and is
gradually depressed from the vertical to the horizontal
toward the lower extremities (Fig. 202).
If the instrument is at the same time pushed forward
slightly, its tip enters the bladder. At this moment urine
will escape from the catheter. AVith the rigid instrument,
as soon as the prostate has been passed and the bladder
has been entered, free movements can be made with the
tip of the instrument.
The method of introducing the catheter described is
attended with difficulty in obese individuals and in the
presence of meteorism and ascites. Under such circum-
stances it seems desiral)le to enter the catheter at ri^ht
angles to the axis of the body, with the penis raised ver-
tically. In this position the instrument is pushed forward
and at the same time rotated in an arc to the median line
and elevated to a position until the tip is grasped by the
bulbous portion (Fig. 203). In another mode of pro-
cedure the operator sits before the patient, who is placed
in the position for the operation of cutting for stone. The
catheter is introduced into the orifice of the urethra from
between the extremities of the patient, with its convexity
directed upward. The penis, raised vertically, is drawn
over the curve of the catheter and the instrument is
rotated through an arc of 180° t(^ward the right until
it reaches the median line. During the progress of these
manipulations the beak of tlie instrument enters the
urethra to the bulbous portion. Now, the handle of the
catheter is elevated and pushed forward in the median
line until its beak has passed the posterior urethra and
entered the bladder.
Ill a normal urethra an instrument of considerable weight, as for
instance a rigid sound of large caliber (lithotriptor), overcomes readily
the obstruction encountered on the distal side of the bulbous urethra
and glides easily, by reason of its own weight, into the bladder, without
further guidance. The guiding hand need only prevent the departure
of the instrument from the median line. In the presence of narrowing,
however, a certain amount of pressure in the direction of the urethra is
necessary, in order to urge the instrument ouAvard through the rigid
cicatricial tissue. If the urethra is narrowed in its deeper portion, or, if
OPERATIONS UPON GENITO-URINARY ORGANS. 331
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OPERATIONS UPON GENITO-URINARY ORGANS. 333
the prostate is enlar«;ed it will often be necessary to introduce the index-
finger of the left hand into the rectum as a guide. In the presence of
hypertrophy of the prostate, on account of elongation of the prostatic
portion of the urethra, and on account of elevation of the orifice of the
bladder, the catheter or the sound must be introduced for a greater dis-
tance and be more greatly depressed, iu order that the beak may reach
into the bladder.
Catheters for introduction into the female urethra cor-
respond with the shortness of this canal, and are either
Fig. 202. — Catheterization : the catheter has entered the mem-
branous portion and has passed the urogenital diaphragm; by pressing
the handle the tip enters the bladder.
straight, or slightly curved at their extremity. In intro-
ducing the instrument the labia are separated and the
handle is depressed while the catheter is ])ushed forward.
Only in the presence of pregnancy or of tumors of the
genital oro^ans may the female urethra be elongated or dis-
torted. The resulting difficulty in the introduction of a
catheter is to be overcome by the employment of par-
tially rigid instruments, as in males.
334
OPERATIVE SUBGEBY.
Retenilon-catheter. — A catheter may be permitted to
remain Avithin the urethra for days or even weeks. In
order to serve its purpose permanently it must be suitably
fixed in position. The introduction of a retention-catheter
into the urethra permits constant escape of urine, Avhich,
beside, does not come in contact with the wall of the
urethra. Such a form of catheter is therefore employed
when it is desired to place the bladder at rest, to secure a
Fig. 203. — Mode of introducing the catheter from the side.
permanent channel of escape for the urine and finally when
the urethra is to be spared irritation. The moderate but
constant pressure of the retention-catheter softens cica-
trices of the urethra and exerts a dilating influejice upon
circular strictures, and for this reason is a])plicable with
advantage in the presence of callous and cicatricial strict-
ures of the urethra. Finally, the retention-catheter is to
be recommended when catheterization that must be fre-
OPERATIONS UPON GENITO-URINARY ORGANS. 335
qucntly repeated is attended either with difficulty or with
iinpk'asant results, sueh as hemorrhage and urinary fever.
The soft catheter of vulcanized rubber is, as a rule, em-
ployed as a retention-catheter. The instrument is intro-
duced to a sufficient depth for the urine; to escape without
interruption. A suitable pin is introduced transversely
C
I
B
R
I I
Fig. 204. — Fixation of the retention -catheter by the method of Dit-
tel : A, B, C, forms of the strips of adhesive plaster ; I, II, III, modes
of applying the plaster to the penis.
through the catheter just in advance of the orifice of the
urethra and its point broken off. Strips of adhesive
plaster are prepared in the manner indicated in Fig. 204.
The square incised strip with an opening at its center is
applied upon the glans in such a way that it supj^orts the
pin passing through the catheter (Fig. 204, /). The
336 OPERATIVE SURGERY.
longer strip slit in the middle is drawn over the catheter,
and comes to rest upon the needle, being made to adhere
to the sides of the penis (Fig. 204, //). The entire ar-
rangement is made secure by circular turns of strips of
plaster passing around the oro^an from the glans to the
root (Fig. 204, ///).
Puncture of the Bladder. — Evacuation of the bladder
througli suprapul^ic puncture is undertaken as a pallia-
tive measure, and also for the puqiose of forming a vesical
fistula through the abdominal wall. Palliative puncture
is practised in the presence of complete retention of urine
in consequence of impermealjle stricture of the urethra
when it is desired to await a more favorable time for the
introduction of a sound or for the performance of a radical
operation for the relief of the obstruction. For the pur-
pose of establishing a vesical fistula the operation is
undertaken (1) in the presence of prostatic enlargement,
with complete or incomplete retention of urine, when
catheterization is attended with difficulty or is followed
by hemorrhage ; (2) when the mouth of the bladder is
obstructed by a tumor that cannot be removed by opera-
tive measures; (3i to effect drainage of the bladder in
cases of severe purulent cystitis. If the object of the
procedure is only evacuation of the bladder, the pimcture
is made with a thin, so-called exploratory trocar. The
operation is in itself of little significance and, if necessary,
can be frequently repeated. The patient lies upon his
back, with the pelvis somewhat elevated. As the punc-
ture is always undertaken by reason of retention of urine,
the bladder is distended to the maxinunn. and is readily
palpable as a tumor above the symphysis pubis. The
operator stands to the right of the patient, and marks with
the tip of his left index-finger a point in the middle line
just above the symphysis where the puncture is to be
made. The trocar is pushed vertically through the ab-
dominal wall, disappearance of the sense of resistance
indicating that the point of the instrument has entered
the bladder. The cannula is grasped with the thumb and
OPERATIONS UPON GENITO-VRINARY ORGANS. 337
the indox-tinger of tlie let't luiiul and the stilet iri removed
with the right. After the urine has eseaped, the eannula
is removed, its extremity being closed with the tip of the
thumb in order that the wound be not eontaminated.
Tlie wound of puncture invariably heals without compli-
cation.
If in conjunction with jnmcture a vesical fistula is to be
established in the abdominal wall the operation is to be
performed with the aid of the semicircularly curved
trocar of Fleurant (Fig. 205). The position of the
patient and of the operator is the same as that just de-
scribed. The index-finger of the left hand marks the
point accurately in the middle line just above the symphy-
sis, where the puncture is to be made. The instrument
Fig. 205. — Trocar for puncture of the bladder, after Fleurant.
is applied vertically and pushed forcibly through the ab-
dominal wall. When the disappearance of resistance
indicates that the abdominal wall has been passed the
instrument is pushed onward and its handle is raised so
that its extremity is directed toward the fundus of the
bladder. The stilet is now removed (Fig. 207) and a
suitable tube passed through the cannula. The cannula
remains in place for about a week, after which a Nelaton
catheter is introduced into the fistula and fixed in the
wound.
External Urethrotomy. — External urethrotomy consists
in entering the urethra through an incision in the abdomi-
nal wall. The operation is undertaken (1) in the presence
of calculi and foreign bodies in the urethra, whose removal
22
338
OPERATIVE SURGERY.
cannot be effected through the natuml passages ; (2) in the
presence of injuries of the urethra ; (3j in the presence of
strictures of the urethra which are either impermeable or
not accessible to treatment by dilatation for various rea-
sons ; (4) for the establishment of a urethral fistula ; (5)
as a preliminary operation to median section for stone.
Fig. 206.— Puncture of the bladder: position for making the puncture.
The mucous membrane of the urethra is readily reached
with the knife in its pendulous portion after division of
the skin, the dense fascia, and the corpus spongiosum.
The bulb of the urethra is accessil)le in the middle line
through an incision in the perineal raphe, after division
of the skin, the tunica dartos, the superficial perineal
fascia, and the bulbocavernosus muscle. The corpus
OPERA TIOXS UFOX GEyiTO-URINARY ORGAXS. 339
spongiosoum is thicker in this situation than elsewhere,
so that the urethra lies at greater depth than common.
To the central side of the bulb the urethra recedes more
and more from the superHcial level of the perineum, pass-
ing in an arch upward and backward to the orifice of the
bladder. The rectum lies with its anterior wall in close
Fig. 207.— Piiucture of the bladder: removal of the trocar.
relation to the prostate gland and is indirectly attached to
the bulb of the urethra at its perineal curve through some
fibers of the sphincter ani and bulbocavernosus mus-
cles. If it i.s desired to reach the membranous or the
prostatic portion, the muscular and fibrous connections
between the anus and the prostate gland must be divided
transversely, when after blunt dissection of the rectum,
340 OPERATIVE SURGERY.
which is reflected toward the sacrum, the proximal por-
tions of the urethra, the membranous portion and the
prostate are rendered visible and accessible to surgical
intervention.
The performance of urethrotomy is subject to'various
modifications in accordance with the indications for the
operation. The patient lies upon his back with the lower
extremities flexed at the knee and the hip (position for
cutting for stone). The operator is seated in front of the
patient. The urethra is invariably opened in the median
line through the raphe of the perineum.
Urethrotomy icith a Guide. — A metallic sound grooved
upon its convexity is introduced into the urethra to a point
beyond the constriction that is to be divided. The guide
is held by an assistant accurately in the middle line. If
the incision is to be made into the perineum, the scrotum
is lifted up. The operator determines by touch with the
finger the position of the resistant portion of the urethra,
which is perhaps a stricture surrounded by callus, and
makes an incision over it in the middle line. If the nar-
rowing be at the junction between the bulbous and mem-
branous portions, the incision passes from the root of the
scrotum almost to the anus. By dissecting layer by layer
in the median line the callous and narrowed portion of the
urethra is reached and an incision is made in the line of
the cutaneous wound until the groove in the guide is ex-
posed. The callus is divided up to a point where the
urethra is of normal caliber. The introduction of a re-
tention-catheter concludes the operation.
Urethrotomy icithout a guide is an incomparably more
difficult operation than that just described. The operator
occupies the same position as in cutting for stone. The
sound can be introduced only to the anterior portion of the
stricture if this be impermeable. The cutaneous incision
is made as in the operation just described, in the median
line through the perineal raphe. The portion of the
urethra lying to the distal side of the constriction is
incised and the margins of the wound are separated by
OPERATIONS UPON GENITO-URINARY ORGANS. 341
means of small tonaciila. An effort is made to find tiie
lumen of the constriction and to gain entrance by means
of a thin bulbous instrument. If this can be done, the
cicatricial tissue is dividcjd in the middle line on its under
surface to the sound, and the incision is continued beyond
the narrowing of the urethra.
As a rule, the detectipn of the canal of the urethra at
the distal extremity of the stricture is attended with diffi-
culty. The tissues are changed from the presence of
cicatrices, and the hemorrhage from the cavernous bodies
and from the bulb is often considerable, so that it can be
readily understood that the small lumen of the urethra
may escape detection in the limited field of operation.
Indiscriminate incision into the callus is not to be com-
mended. By means of manual expression of the bladder
it may be possible under circumstances to cause the escape
of a few drops of urine into the wound and in this way to
gain an idea as to the situation of the orifice of the strict-
ure. If it has been possible by this means, under guid-
ance of the eye, to introduce a bulbous bougie into the
orifice of the stricture, the division of the narrowed por-
tion of the urethra will be unattended with any further
difficulty.
After division of the stricture a catheter of consider-
able caliber can always be introduced with aid from the
Avound through the entire urethra into the bladder. In
the event of failure to divide the stricture through the
wound there remains yet the resource of retrograde sound-
ing of the stricture, j^ostenor catheterization. This may
be undertaken :
(1) Through the urethra, after exposure and incision of
the urethm to the proximal side of the stricture ;
(2) Through the bladder, after this has been opened by
means of a suprapubic incision.
In performing retrograde catheterization through the
urethra the deeper portions of this canal (the membranous
portion) are exposed by detaching the lowermost ex-
tremity of the rectum. To this end the perineal longi-
342 OPERATIVE SURGERY.
tudinal incision is either prolonged to the anus or the
detachment of the rectum is undertaken through a pre-
rectal curved incision. After division of the skin the
connections between the sphincter ani and the bulbocaver-
nosus muscles are divided transversely and then the
anterior wall of the rectum is freed by blunt dissection
from the cutaneous covering. If the bulb of the urethra
is retracted upward and the rectum downward, the mem-
branous portion can be dissected in the upper angle of the
wound. The meml^ranous portion, which is readily
palpable as a rounded prominence, is incised longitudi-
nally for a distance of about 1 cm., and retrograde sound-
ing can be practised through the narrovred portion, which
is then divided.
Retrograde sounding of the stricture can be practised
also from the bladder, after this has been opened through
a suprapubic incision. The patient lies upon his back,
with the pelvis elevated, and the bladder is opened in the
usual manner above the symphysis pubis. The incision
in the bladder is held open by tenacula and an English
catheter of small caliber is pushed forward under the
guidance of a finger through the neck of the bladder into
the urethra to the point of obstruction. The patient may
be placed in the position as for the operation for stone, the
wound in the perineum held open by tenacula and the
stricture is passed or merely entered by pushing the
catheter forward from the bladder. In the first event
the stricture is divided down to the catheter; in the
second, the portion of the urethra lying to the proximal
side of the stricture is opened and the stricture itself is
successively divided with scissors from behind forward.
The last step is, as a rule, effected without difficulty.
Urethrotomy is indicated after traumatic rupture of the
urethra, complete or incomplete, when catheterization is
attended with difficulty, or urinary infiltration is threat-
ened. The incision is made through the perineum in the
raphe, over the greatest prominence of the perineal bulg-
ing that is always present. After division of the skin
OPERATIOSS VPOX GEyiTO-VRiyARY ORGAyS. 343
and the snporfic-ial fa.-cia, ontniiico i- gtiinod to thewoiind-
t-avitv tillcllonged, as in the operation just described, by
means of the blunt-pointed knife to the prostatic portion.
The stone is now removed in the typical manner.
The lateral and median incisions for stone, which in the past were the
customary operations, possess to-day but a limited field of application,
having been almost completely displaced by the suprapubic incision. [Dis-
placed particularly by litholapaxy. — Ed.] The median incision, the more
recent of the two, was chosen in order to avoid the division of the ejacu-
latory ducts that has heen observed repeatedly as a result of the lateral
incision. Both methods are attended with the disadvantage that the
removal of large stones through the narrow wound-canal can be effected
only with difficulty, so that the wound itself is distorted and lacerated
in the efforts at extraction and dilatation and the conditions for recovery
are rendered less favorable than otherwise they would be. Finally, a
typical form of true incontinence, permanent dribbling of urine, is not
rarely observed after the median or the lateral incision, even when
union has proceeded smoothly.
Urethrostomy. — In cases of incurable stricture Poncet
excludes entirely the narrowed portion of the urethra by
means of perineal urethrostomy, dividing the urethra on
the proximal side of the stricture and permitting it to
open upon the perineum. The stricture is exposed by
means of the usual incision through the perineal raphe,
when the urethra is divided transversely on the proximal
side of the stricture, and is sutured in the lower angle of
the cutaneous wound. Poncet divides the central stump
throughout a slight extent on its under side before suturing
it in the wound. The peripheral stump of the urethra is
sutured and dropped into the wound, when the cutaneous
wound is closed by suture up to the opening of the fistula.
Litholapaxy. — Instrumental endovesical crushing of
stone in the bladder, followed immediately by evacua-
tion of the fragments, is designated litholapaxy. The
instrument for destroying the stone is made of steel,
346 OPERATIVE SURGERT.
shaped like a catheter, and consists of two blades fitting
one into the other and the tip of one of which is serrated.
The instrument grasps the stone between its two blades,
which can be secured firmly and are brought together by
means of a screw-mechanism ; the stone, thus grasped, is
crushed between them= To attain good results with the
operation of litholapaxy a careful selection of cases, as
well as skill in the use of the instrument, is required.
Mode of Procedure. — The patient occupies the dorsal
decubitus, with the pelvis somewhat elevated. The blad-
der is filled moderately with sterile solution of boric acid.
The lithotrite is introduced according to the rules laid
down for catheterization, the operator standing upon the
right side of the patient. An attempt is made to touch
the stone with the tip of the closed instrument, when the
blades are separated to grasp the stone. The blades of
the instrument are fixed by means of a sliding arrange-
ment on its handle, and the stone is crushed by means
of the screw-meclianism. Xow, the individual fragments
of the broken calculus are grasped separately and are
crushed. Finally, the residue is converted into a fine
powder by crushing. A rigid catheter is introduced and
the bladder is irrigated, with the escape of sand. With
the bladder moderately full the evacuation-catheter is
connected ^\ ith a pump, whose activity is continued as
long as fragments of stone are present in the bladder. If
a rather large fragment of stone can be felt, this must be
reduced further in size by means of the lithotrite. The
cystoscope permits confirmation by ocular inspection of
the fact that complete evacuation of the fragments has
been effected. AVith a proper selection of the cases the
results of litholapaxy may be admirable.
Operations on the Bladder. — The bladder, situated
in the true pelvis just behind its anterior wall, is attached
to the pubic arch through the prostate gland and the
pubovesical ligament. Beside, the organ is held in place
within certain limits by the visceral layer of the pelvic
fascia, by the vesico-umbilical ligaments and by the peri-
OPERATIONS ON THE BLADDER. 347
toiu'um. The jxritonoum pasH^es from the anterior al)-
dominal wall and troni the lateral walls of the pelvis upon
the bladder, whose fundus and posterior and lateral walls
it covers. AMien eni])ty, the bladder is concealed behind
the symphysis. A\ hen Idled, the up])er portion rises above
the pelvic brim, so that the anterior wall of the bladder
not covered by ])eritoneum comes to lie in immediate
juxtaposition with the abdominal wall. The bladder can
thus be opened above the symphysis without injury to the
peritoneum if filled to the maximum.
Suprapubic Cystotomy. — Opening of the bladder above
the symphysis pubis.
The operation is indicated :
(1) In the presence of calculi and other foreign bodies
in the bladder ;
(2) In the presence of tumors of the bladder ;
(3) In the presence of tuberculosis of the bladder ;
(4) In cases of vesical hematuria ;
(5) In cases of rupture of the bladder ;
(6) For the removal of hypertrophied lobes of the
prostate gland ;
(7) For the purpose of forming a fistula ;
(8) In cases of severe cystitis ;
(9) As a preliminary operation in the performance of
posterior catheterization.
The mode of procedure is subject to various modifica-
tions in accordance with the indications for its perform-
ance. Three types of operation are distinguished :
(1) Simple opening of the bladder for the removal of
calculi and other foreign bodies ;
(2j Opening of the bladder for the purpose of inider-
taking endovesical manipulations (extiq)ation of tumors,
etc.) ;
(3) Opening of the bladder for the purpose of estab-
lisliing a fistula.
In all cases the bladder is distended to the maximum
by the injection of fluid into its cavity, so that it rises
above the level of the symphysis. If it is impossible
348
OPERATIVE SURGERY.
thus to fill the bladder, the anteriDr wall of the visciis is
forced into the wound by means of a concave grooved
guide and incised.
1. Suprapubic Cystoiomy for Stone.-— T\\e patient occu-
pies the dorsal decubitus, with the pelvis somewhat raised
bv means of a pillow, and the operator stands to his
right side. After the abdominal wall has been cleansed
and shaved, a catheter is introduced and the bladder is
irrigated until the escaping fluid is clear. Sterile fluid
Fig. 208. — Suprapubic cystotomy : the anterior wall of the blarlder
is exposed; near its summit is the i)oint of reflection of tte peritoneum.
is now permitted to flow into the bladder through an
irrigator or a sufficient quantity is injected to cause the
bladder to become palpable as a tense swelling above the
symphysis pubis. The catheter is removed and the
penis is surrounded with a strip of gauze. The incision
is made in the linea alba just al)Ove the symphysis, and is
from 5 to 7 cm. long. Passing directly to the depth of
the wound the fatty layer is traversed and the anterior
rectus sheath or the fibrous linea alba is divided. The
rectus muscles are retracted, and in the space of Retzius
OPERATIoyS Oy THE BLADDKH. 349
thus exposed tlie l)la(l(U'r is palpable as a tense mass.
The prevesical fat is displaced Iruni the bladder In-
blunt dissection by means of two pairs of forceps, until
the anterior wall of the viscus, recognizable bv the differ-
ence in color and by the bundles of muscles and veins
ujxm its surl'ace, is ex{x»sed (Fig. 208).
Just below the transverse line of reflection of the
jK'ritoneum a simple pointed tenaculum is introduced into
the wall of the bladder, which is divided in the median
line with a slmrp-pointed knife, in the direction of the
symphysis. The margins of the wound are held apart by
means of two retractors. The ojx-rator introduces the
index-hnger of his left hand into the bladder, touches the
stone or the foreign body, and permits the stone-forceps
to follow the palmar aspect of the finger to the calcidus.
The blades of the forceps are now separated, the stone
grasped and removed from the wound. The wound in
the wall of the bladder can be closed at once by suture.
Various complicated methods of suture of the bladder
have been abandoned. The wotmd in the viscus is closed
by a series of interrupted catgut-sutures, including the
entire thickness of the wall of the bladder, with the ex-
ception of the mucous membrane.
Fixation of the sutured bladder to the abdominal wall
(ri/.^topexy) is not without advantage. Suture of the
wall of the bladder may be omitted and the wound in the
viscus be permitted to remain open. The urine is re-
moved by suction and the bladder is by this means kept
perfectly at rest.
2. Suprapubic Cystotomy for the Purpose of Zliderfak-
ing Intravesical Manipulations. — If opening of the bladder
is effected as a preliminary procedure to facilitate intra-
vesical manipulations, it is best to raise the pelvis as high
as possible. The preparations for the operation, and the
opening of the bladder, are made in the manner already
described. After the bladder has been opened a view of
its interior should be possil)le. To this end the margins
of the wound in the bladder are held apart by means of
350 OPERATIVE SURGERY.
Plate 21.— Suprapubic Cystotomy with the Pelvis Elevated.
The wouud is enlarged by the introduction of retractors and the in-
terior of the bladder is rendered visible. The wall of the viscus has
been provisionally attached to the skin by suture. There may be observed
the mouth of the urethra, the trigone, and the entrances of the ureters.
The wall of the summit of the bladder appears as a prominence above
the broad speculum.
retractors resembling vaginal specula, while a broad Simon
speculum is introduced in the upper angle of the Avound.
If, beside, the interior of the viscus is illuminated by
means of an incandescent lamp, inspection is readily pos-
sible and the operator may undertake a variety of manipu-
lations within the cavity of the bladder (excision of
tumors, control of hemorrhage, suture of deficiencies in
the mucous membrane, excochleations, etc.) (Plate 21).
if after extirpation of vesical tumors bleeding has been
completelv controlled, the bladder may be closed by suture.
After excochleation of malignant tumors, and after opera-
tions upon the prostate, drainage of the bladder is the pre-
feraVjle m(.>de of procedure.
Bv making a transverse incision through the skin and
opening the bladder in the same manner, after division of
the recti muscles, general access to the interior of the
viscus is possible.
Suggestions have been made by a number of operators
to expose the bladder throughout a greater extent by
means of operations upon the bony parts. To this end
Helferich resects a triangular portion of the symphysis
pubis, while Bramann recommended temporary partial
resection of the symphysis, and Xiehans lateral resection
of the pelvis.
3. Section of the Bladder for the Purpose of Establish ing a
Fisfida. — Crfsfostomi/. — In the performance of cystostomy
a short longitudinal incision is made above the symphysis
pubis according to the method of Poncet, and the bladder
is opened in the usual manner. The Avail of the bladder
is brouo:ht to the level of the skin and fixed in place by
Tab. 21
r^
X
St F Reichhold. Mund
OPERATIONS UPOy THE PROSTATE GLAND, ETC, 351
OPEEATIO^'S UPON THE PROSTATE GLAND, ETC. 353
"^ c3
23
OPERATIOXS UPON THE PROSTATE GLAND, ETC. 355
sutures. The cutaneous wound is closed in its upper por-
tion, while the vesical nuicous membrane is sutured in its
lower portion. The establishment of a fistula may be
effected also without suture of the vesical mucous mem-
brane, bv the employment of simple siphon-drainage.
The curved tube may in the further course of the case be
replaced by a soft catheter, which is introduced into the
bladder throiio'li the wound and is permitted to remain.
Operations upon the Prostate Gland, the Semi-
nal Vesicles, and the Vas Deferens. — Prostatotomy.
— Opening of the prostate through an incision in the peri-
neum is ijidicated in the presence of abscesses and for the
excochleation of tuberculous masses in the gland. After
the root of the penis and the superficial transverse perineal
muscle are exposed by an incision through the perineum
and the connections between the sphincter ani and bulbo-
cavernosus muscles are divided transversely, the anterior
wall of the rectum can be separated by blunt dissection
from the prostate gland and reflected toward the sacrum.
Between the triangular ligament of the urethra and the
rectum thus displaced the slightly convex posterior aspect
of the prostate lies exposed throughout its entire extent
(Fig. 210). Connected with the base of the prostate are
the seminal vesicles, and by continued detachment of the
rectum from the bladder the fundus of the latter will be
exposed, when the seminal vesicles and the vasa deferentia
will be visible in the wound.
The performance of prostatotomy in the presence of an
abscess is performed as follows : the patient occupies the
same position as in the operation for stone, and an English
catheter of large caliber is introduced into the urethra.
The operator sits in front of the patient and guides the
knife with his right hand, while the index-finger of the
left hand is introduced into the rectum, in order that in
the progress of the deep dissection the anterior wall of
the rectum shall be avoided (Fig. 209). A curved in-
cision 4 or 5 cm. long is made through the prerectal
tissues. After division of the skin and the subcutaneous
356 OPERATIVE SURGERY.
connective tissue the perineal septum is divided trans-
versely and blunt dissection is made between the rectum
and the urethra upward toward the prostate. When the
lower pole of this organ or a portion of its posterior wall
is exposed in the wound, a grooved director or a pair of
forceps with closed l)lades is introduced into tlie fluctuat-
ing portion, when the pus escapes through the wound.
The opening is now suitably enlarged and the abscess-
cavity is tamponed. If a communication exists between
the abscess-cavity and the urethra, the retention of a
catheter is necessary in the after-treatment.
Extirpation of the Seminal Vesicles. — In extirpation of
the seminal vesicles the perineal route just described
appears the most desirable. The patient and the operator
occupy the same positions as in the operation just con-
sidered. A large perineal flap-incision is made Avhose
posterior extremity on either side extends to the tuber-
osities of the ischium and whose anterior l^oundary lies in
front of the rectum. The mode of procedure in the
depth of the w^ound is analogous to that pursued in the
performance of prostatotomv. The detachment of the
rectum is undertaken through a considerable extent until
the seminal vesicles and the fundus of the bladder become
visible on displacement of the rectum toward the sacrum.
The altered seminal vesicles are j^eeled out of their sur-
roundings, dissected from the fundus of the bladder, and
removed. At the same time morbid collections in the
prostate gland can be excised.
Excisions of the Prostate ; Prostatectomy. — In cases
of hypertrophy of the prostate gland removal of the
enlarged middle and lateral lol^es has l^een recommended
for the relief of the difficulty in urhiation and has been
practised by numerous surgeons with varying success. The
question whether cure is effected by removal of the pros-
tatic obstruction is not as yet decided. At any rate, ad-
vanced cases in which secondary changes in the wall of
the bladder and of the upper urinary passages have taken
place are not adapted to the operation.
OPERATIONS UPON THE PROSTATE GLAND, ETC. 357
The enlarged middle lobe of the prostate, which often
attains the size of a walnnt and more, may ho extirpated
tln-oiigh the suprapubic incision into tiie ljhi(hler Q>{. C.
Gill). The hhidder is opened above the symphysis pubis
in the Usual maimer and the prominent tumor is removed
with the Paquelin cautery, or the galvanoeaustic loop, or
with curved scissors. . The base of the wound is cauter-
ized for the control of hemorrhage, and, if necessary, the
bladder is tamponed.
The enlarged lateral lobes of the prostate can be only
partially removed or excised, care being taken to avoid
opening the urethra. In the performance of partial resec-
tion adequate exposure of the body of the prostate is
essential. The glanxl is exposed either with the aid of the
perineal prerectal incision or through a sacral incision. The
details of the first method are given on page 35e5. The
sacral method of exposing the prostate has been recom-
mended l)y Dittel (lateral prostatectoiny). In this mode
of procedure an incision is made in the folds of the anus,
the rectum is displaced laterally and in this way the pos-
terior surface of the ])rostate is brought into view. The
patient occupies the right lateral decubitus and an English
catheter is introduced into the urethra. The incision be-
gins at the apex of the coccyx, passes in the middle line
to the posterior margin of the anus, which it surrounds
npon the right side, and terminates in the perineal raphe
in front of the amis. The operator gains entrance into the
ischiorectal fossa, and separates the rectum by blunt dissec-
tion from the ])rostate, so that the right lateral lobe of the
latter and, if the dissection be continued, the entire poste-
rior aspect are exposed to view. Wedge-shaped portions of
the gland are excised on either side. Dittel recommends
that so much of the gland be removed that only sufficient
remains to surround the urethra. The removal of the coc-
cyx is calculated to enlarge the field of operation.
Resection and Extirpation of the Vas Deferens. — Resec-
tion of the vas deferens in its contniuity has been recom-
mended recently in the treatment of hypertrophy of the
358 OPERATIVE SURGERY.
prostate gland, and has been performed in numerous cases.
The vas deferens is palpable through the skin as a round,
firm strand, and it may thus be separated from the re-
maining structures of the spermatic cord. The cutaneous
incision for the isolation of the vas deferens, 3 or 4 cm.
long, may be made either in front of the external inguinal
ring, or at the neck of the scrotum. The structures form-
ing the spermatic cord are forced out of the Avound, the
vas deferens is isolated by touch and a portion from 2 to
4 cm. long is excised 'svith scissors. Removal of the vas
deferens in connection with the testicle becomes necessary
when in the presence of tuberculosis of the epididymis the
vas deferens also is involved in the disease. Under these
conditions the incision for exposure of the testicle, which
passes longitudinally over the scrotum, is extended upward
and outward over the inguinal canal. Throughout the
range of the incision the skin and the anterior boundary
of the inguinal canal are divided so that the vas deferens
is exposed in its course through this canal, and is thus
rendered accessible to surgical removal. The pelvic por-
tion of the vas deferens would be accessible by this means
only after extended detachment of the peritoneum, entail-
ing injury of disproportionate degree. This portion of the
duct is therefore to be reached by the perineal route or
with the aid of an incision such as I)ittel has reconnnended
in the performance of lateral prostatectomy.
Biingner recommended, in place of extirpation, divuhlon
of the vas deferens. The duct is isolated and exposed
throughout a considerable extent by gradually increased
traction. AVith careful manipulation of this kind four-
fifths of tiie entire duct may be removed.
Extirpation of the Testicle. Castration. — The indica-
tions for this operation consist in tlie presence of neo-
plasms of the testicle and tuberculosis of the epididymis.
A new indication for castration is afforded by hypertrophy
of tlie prostate. Tlie cutaneous incision is always made
longitudmally over the greatest convexity of the tumor.
In making this incision the operator grasj^s the scrotum
OPERATIOXS UPOy THE PROSTATE GLAXD, ETC 359
with his left hand in such a manner that the overlying
skin is made tense. If the skin is involved in the disease-
process throughout a circumscril)ed area (fnjm extension
of a neoplasm, or the formation of a tuberculous fistula),
the diseased structure is included between the incisions
and is removed in conjunction with the testicle. The
incisions are made threuijch the skin and the dartos down
to the tunica vaginalis and the testicle, with its covenngs,
is freed from its bed by l)luut dissection, so that it remains
in connection with the body only througli tlie intermedia-
tion of the spermatic cord. By traction on the cord its
constituent structures are more clearly brought into view.
The vas deferens is isolated and ligated. The remaining
structures of the spermatic cord are ligated en masse in
two or three segments. The cord is then divided trans-
versely on the distal side of the ligatures, which are cut
short. The stump of the cord retracts into the depth of
the wound, and tlie cutaneous wound is closed by suture.
Operation for Hydrocele. — Hydrocele is treated in a
palliative way by simple puncture and in a radical Avay
by laying open the tunica vaginalis and excising it. Punct-
ure of a hydrocele is made in accordance with the rules
that govern the making of punctures in general. The
operator must, however, be assured of the position of the
testicle, in order to avoid injury of this organ in intro-
ducing the trocar. The scrotum is grasped firmly with
the supinated left hand and made tense. The introduc-
tion of the trocar is made upward through the anterior
wall close to the fundus of the scrotum at a point where
no vein is visible through the skin. At first the fluid is
expelled in a continuous stream. Later the escape must
be facilitated l^y alteration in the position of the cannula
and by kneading movements of the scrotum. The injec-
tion through the cannula of from 5 to 10 gm. of LugoPs
solution, in conjunction with the puncture, is a favorite
mode of radical operation for hydrocele. The procedure,
however, is extremely painful and with regard to the cer-
tainty of the result stands behind radical incision.
360 OPERATIVE SURGERY.
Radical Incision by the Method of Vollinann, — The
scrotum is grasped firmly and made tense with the left
hand and an incision is made longitudinally over the
greatest convexity of the tumor almost up to the fundus.
With careful dissection the incision is carried down to the
tunica vaginalis, which is divided in the direction and
throughout the extent of the cutaneous incision. After
the fluid has escaped, the tunica vaginalis is united to the
skin by a row of sutures and a strip of gauze is introduced
into the cavity that remains. The process of healing
often occupies a considerable period of time.
Radioed Operedion by the Methoel of Bergnumn. — Radi-
cal operation by the method of Bergmann is followed by
recovery within a short time, by reason of the fact that
the wound-conditions render possible union by primary
intention. A cutaneous incision is made in the manner
just described. Before the sac of the hydrocele is opened,
an endeavor is made to free it from the overlying skin
throughout a considerable extent. After this has been
adequately effected the sac is opened as in the operation
of Volkmann. After the fluid has escaped the opera-
tor grasps the margins of the incision through the tunica
vaginalis and separates this from the testicle on either side,
almost to the point of reflection. After this detachment
has been thoroughly effected the freed parietal layer of
the tunica vaoinalis is excised. The maro^ins of the in-
cision in the skin are accurately approximated by suture
over the testicle, which is dropped back into the wound.
Operation for Phimosis. — Operations for phimosis in-
clude surgical procedures of various kinds by means of
which congenital or acquired narrowing of the prepuce is
removed. In performing the operation either the prepuce
is divided longitudinally from its orifice to the glans [in-
cinion) or the entire prepuce is removed [circumcisioii).
By the first of these methods the incision is made in the
middle line of the d(u*sal surface, a grooved director, with
its concavity directed upward, being introduced into the
orifice between the prepuce and the glans. The two
OPERATIONS UPON THE PROSTATE GLAND, ETC. 361
layers of tlie prepuce are divided over the director with a
single stroke of the scissors almost up to the corona glandis.
After the division has been effected the prepuce must be
readily retractable. Over the glans throughout the extent
of the wound the mucous membrane of the ])repuce is
united with the skin by means of a series of interrupted
sutures, or of a continuous suture.
Circumcision may be effected in various ways. The
prepuce may be drawn forward as far as possible and be
Operation for Shortened Frenum.
Fig. -m.
Fig. 212.
Fig. 211. — Transverse division of the frenum.
Fig. 212. — Union at right angles to the direction of the division,
divided just in front of the glans, after which the margins
of the outer and inner layers of the prepuce are united by
suture. In another method of circumcision the usual
dorsal incision is first made, after which portions of the
prepuce on either side of the incision are removed with
scissors close to the point of reflection on the glans.
Throuo;hout the entire extent of the wound the skin is
united with the inner layer of the prepuce.
Operation for Shortened Frenum. — Congenital shortness
of the frenum, with a normal caliber of the prepuce, is
362 OPERATIVE SURGERY.
attended with numerous discomforts (pain in coitus, fre-
quent laceration, hemorrhage). Simple transverse division
of the band is not to be recommended on account of the
hemorrliage that follows. Division with the Paquelin
cauterv secures immunity from the hemorrhage, but a
considerable time is occupied in the healing of the wound.
Functionally good results, Avith the possibility of securing
union bv primary intention, are yielded by the following
minor plastic operation.
The frenum is divided with a single stroke of the scis-
sors to such a depth that the prepuce can be retracted to a
maximum degree without tension. The small wound
thus made is united at a right angle to the direction of
the incision (Figs. 211 and 212).
Amputation of the Penis. — Malignant neoplasms con-
stitute the exclusive indication for amputation of the penis.
This may be practised through the pendulous portion at a
selected level by means of a circular incision. Under
certain conditions the deeper portions of the member, the
roots of the cavernous bodies, must be removed by ope-
ration. In all cases, after ablation of the parts, the
uretlira must be suitably situated and fixed in the wound.
In amputating the penis through the pendulous portion
digital compression is exercised, while a circular incision
is made transversely. The skin is, after division, re-
tracted, when the operator divides the cavernous bodies
transversely Avith an amputation-knife, cutting from the
dorsal aspect toward the urethra. When the urethra is
reached it is dissected free for a short distance toward
the periphery and is divided transversely 2 cm. in
advance of the line of incision through the cavernous
bodies. The urethra is snipped through its inferior sur-
face with a single stroke of the scissors, spread upon the
wound and united by its free border with the margin of
the skin by means of a series of sutures.
In amputating the penis in conjunction with its
perineal connections the scotum is divided in a sagittal
direction. In the gaping wound the roots of the cavern-
OPERATIONS UPON THE PROSTATE GLAND, ETC. 363
ous bodies, with their attaclimcnts to tlic })n])i(' Imncs, are
roadilv ('.\j)()sc(l. The urethra is (livi(lear in the wound u])on one side
the groove of Poupart's ligament and upon tlu; other
side the outer border of the rectus muscle, together with
the muscular plate formed by the divided internal oblicpie
and transversalis muscles. This muscular layer is separ-
ated by blunt dissection from the subserous tissues, as well
as from the aponeurosis of the external oblique, so that it
is rendered sufficiently movable to be brought down to
Poupart's ligament. The muscular plate named is attached
to the posterior border of Poupart's ligament by sutures
(Plate 23, III). The sutures on the pubic bone include
also the external border of the rectus muscle. In this
way a posterior muscular wall of sufficient resistance is
formed, in which lies the newly created narrow internal
inguinal ring. The spermatic cord is })laced upon this
muscular layer, and over it the aponeurosis of the external
oblique is closed by suture except at its lower angle, wOiich
constitutes the new external inguinal ring (Plate 23, IV).
The inguinal canal thus formed is, after healing has taken
place, so resistant that the use of a supporting truss can
be dispensed with.
In Kocher's radical operation for inguinal hernia (displacement-
method) the cutaneous incision is made as in Bassini's operation, although
the aponeurosis of the external ol)lique is not divided, l)ut slit to the
outer side of the internal inguinal ring. Through this opening a i)air
of forceps is introduced and j)assed through the inguinal canal to tlie ex-
ternal inguinal ring. The apex of the isolated hernial sac is grasped, and
drawn outward through tlie small opening. The hernial sac is drawn so
that it appears sharply l)ent hackward at the internal inguinal ring. The
portion of the sac lying within tlie abdominal wall is surroundi'd and
strongly ligated. The hase of the sac thus folded together is attached
to the outer surface of the aponeurosis of the external oblique by means
of deep sutures, and the remainder is removed.
Radical Operation for Femoral Hernia.
The Femoral Cnxnl. — The interval between the internal and the ex-
ternal femoral ring, whicli constitutes the path for certain varieties of
hernia, is known as the femoral canal. Under normal conditions,
24
370 OPEBATIVE SURGERY.
Plate 23.— Bassini's Operation for Inguinal Hernia.
III. The muscular layer of the internal oblique and transversalis is
attached by suture to the inner border of Poupart's ligament. In this
way the internal inguinal ring and the posterior wall of the inguinal
canal are formed anew.
IV. The aponeurosis of the external oblique is united over the sper-
matic cord except in the situation of the new external inguinal ring.
however, this canal is not present as such. The inner orifice of the canal
(internal crural ring) lies at the inner angle of the opening for the
femoral vessels, between Poupart's ligament and the horizontal ramus of
the pubis. Thespace is bounded within by the free border of Gimberuat's
ligament (fan-shaped attachment of Poupart's ligament to the tubercle
of the pubic bone) and without by the large vessels and the crural vein.
The outer orifice of the crural canal corresponds with the loose connec-
tive tissue of the fascia lata (foramen ovale) through which the saphenous
vein passes to enter into the femoral. The tendinous boundary of this
opening has its concavity directed toward the middle line and is known
as the falciform process.
A femoral hernia, after passing the internal craral
ring, enters a space whose floor is formed by the
pectineal fascia, which is bounded internally by Gimber-
nat's ligament, externally by the crural vessels, and in
Avhich for a short distance the upper continuation of the
ftlciform process forms a resistant cover. If the free
border of this be passed, the hernia can push before it the
less resistant lamina cribrosa and in this way it reaches
the exterior through the foramen ovale. The coverings of
a femoral hernia are thus fewer and thinner than those of
an inguinal hernia. The hernial sac may under circum-
stances, in emaciated subjects, lie just beneath the subcu-
taneous connective tissue. For this reason, in making the
cutaneous incision, especially in further dissection at a
depth, great care will be required. In general the radical
operation consists, after making a cutaneous incision, in
isolation and opening of the liernial sac. Then follow
reposition of the hernial contents and ligature of the neck
of the sac, with or without torsion. By closure of the
hernial opening through suture the recurrence of the dis-
order is to be prevented. Radical operation for the relief
of femoral hernia is rendered difficult by the fact that the
Tnl^ 9*
fll.
I\'.
LUh. A/tsl r Reichlwltl, Miinclien
OPERATIoyS UPON THE rilOSTATE GLAM>, ETC. 371
internal opcninu; of the canal iy funned for tliree-fonrths
of its extent of tissues (Ponpart's ligament, (iinihernat's
ligament, horizonal ramus of the pubis) whose resistance
would interfere with closure of the hernial opening.
Mode of Fcrforiiiiiif/ the Radical Operaiion for Fe moral
Hernia. — A cutaneous incision is made by the method of
Bassini, vertically over the greatest convexity of the
tumor. The outer surface of the hernial sac and the fas-
cia to the peripheral side of the swelling are exposed.
The body and the neck of the sac are isolated to a point
above the level of the internal crural ring. Isolation of
the hernial sac upon its outer side, where it is in close
relation with the femoral vein, nuist be undertaken with
great care. The hernial sac is opened and its contents
replaced after separation of adhesions. The body of the
hernial sac is eh^vated, twisted, and ligated with a thread
passed around its neck. The sac is divided transversely
beyond the ligature. After replacement of the stump the
hernial ojiening, the plica falciformis, the internal open-
ing, with Giml)ernat's ligament, and the aponeurosis over
the pectineal crest are sufficiently exposed. Suture begins
close to the pubic tubercle and the sutures include the
pectineal aponeurosis and the posterior inferior portion of
the internal opening. In the further course of the opera-
tion the border of the falciform process is united with the
pectineal fascia. After all of the sutures have been
introduced they are tied, beginning with the innermost
and uppermost. The line of suture pursues the course of
an oblique C.
Fabricius closes the hernial opening by suture in cases of femoral
hernia after the fat as well as the lymphatic glands present in the fem-
oral canal are removed in such a way that Poupart's ligament is relaxed
and is attached by periosteal sutures to the horizontal branch of the
pubic bone.
Umbilical Hernia, Radical Operation. Operation for In-
carcerated Omphalocele. — The usual procedure consisted
until recently in closure of the hernial opening by suture
after opening the hernial tumor and replacement of the
372 OPERATIVE SURGERY.
intestine. Greater security against the recurrence of the
hernia and a more thoroiigii inspection during the opera-
tion are aiforded by excision of the umbilical ring {omph-
aledorni/, Condamin, Bruns). The umbilical region is
surrounded by two elliptic incisions, each of which ex-
tends to the inner l)order of the rectus muscle and opens
the abdominal cavity on either side of the hernial ring, so
that the entire hernial tumor, together with the neck of
the hernial sac, is removed. If, in addition, a portion of
the sac is divided from the margin of the Avound through
the hernial opening, the entire contents of the hernia are
exposed to view. In this way satisfactoiy scrutiny of the
conditions present is possible, inasmuch as the abdominal
viscera are rendered visible, both prior to the entrance
into the hernia, as well as within the hernial sac. Adhe-
sions that may be present are separated, and any existing
strangulation can be freed in the open wound. After re-
placement of the intestines the abdominal Avound is care-
fully approximated by interrupted sutures in three layers,
the first including the serous membrane, the second the
recti muscles and sheaths, and the third the skin.
Ligation of the Iliac Artery. — At the level of the fourth
lumbar vertebra the aorta divides into the two iliac arte-
ries, each of which in turn divides at the sacro-iliac articu-
lation into two branches, the external and internal iliac
arteries. The external iliac arters', the abdominal por-
tion of the femoral, passes along the outer side of the
corresponding vein along the psoas muscle to the opening
beneath Poupart's ligament for the vessels. The internal
iliac artery, also known as the hypogastric, passes from
the sacro-iliac symphysis down into the pelvis, to supply
the organs of this cavity, as well as the gluteal muscles
and the genitalia, with blood.
Ligation of the External Iliac Artery. — The artery- is
exposed in the subserous space just prior to its entrance
into the opening for the vessels. The cutaneous incision
is made parallel with, and over the middle of, Poupart's
ligament, and the fascia of the external obliq^ue muscle,
OPERATIOSS UPON THE PROSTATE GLAND, ETC. 373
the fibers of the internal ol^licjue and transversalis are
divided in thedireetion, and throii^rhout the extent, of this
ineision. Alter divi.^ion of the transversalis faseia the
subserous fat and the peritoneum are ex})osed to view.
The peritoneum is se})arate(l by blunt disseetion from
Poupart's li*iament and the pelvie margin, after whieh
the external iliae vessels surrounded by loose connective
tissue become visible upon the floor of the wound. The
artery (the vein lies to its inner side) is isolated Ijy l)lunt
disseetion with the aid of two anatomic forceps (Plate 24).
In ligating the internal iliac artery the cutaneous in-
cision passes from the apex of the last rib vertically down-
ward to the crest of the ilium and along this almost to
the anterior superior iliac spine. The layers of the
abdominal wall and the transversalis fascia are divided,
the peritoneum separated by blunt dissection from the
iliac fossa and displaced toward the median line by means
of broad spatula? or the palm of the hand. Between the
iliac and psoas muscles the external iliac artery is visible
and can be followed in a proximal direction as far as the
sacro-iliac symphysis, where the internal iliac artery is
accessible as it branches off toward the pelvis and can be
isolated for ligature. The vein lies to the inner side of
the artery. The mode of procedure just described serves
also for exposing the common iliac artery.
The manner of exposing the iliac vessels constitutes in
general the mode of procedure in accordance with which
the structures of the subserous space are reached. The
incision for ligation of the internal iliac artery exposes the
kidney and the ureter in its course. In the same way it
is possible, with conservation of the peritoneum, to evacu-
ate accumulations of ]nis in the subserous space (psoas
abscess, paratyphlitic abscess, parametric abscess).
If after opening the abdominal cavity by celiotomy the
parietal peritoneum upon the posterior wall of the abdo-
men is divided and in this way the retroperitoneal space
is exposed, the procedure is designated transperitoneal ex-
posure of the iliac artery, of the kidney, of the ureter,
374 OPERATIVE SURGERY.
Plate 24.— Exposure of the External Iliac Artery.
There are divided the aponeurosis of the external oblique muscle
(Q.e.), the fibers of the internal oblique {Q-i.), and the transversalis
fascia (F.t.)\ the peritoneum (P) is separated by blunt dissection and
raised up ; the iliac artery and vein are exposed in the subserous space.
etc. Under these conditions the peritoneum must be
divided at two corresponding points on the anterior and
the posterior abdominal walL
Operations on the Kidneys. — Operations on the
kidneys may be undertaken :
1. For the purpose of opening the kidney by incision
— nephrotomy ;
2. For the removal of the totally diseased kidney —
nephrectomy ;
3. For fixation of a movable kidney — nepjhropexy ;
4. For the exsection of portions of the kidney — resec-
tion of the kidney.
Nephrotomy and Nephrectomy. — Nephrotomy is indi-
cated in the presence of — 1, simple pyonephrosis ; 2,
stones in the pelvis of the kidney, if sufficiently function-
ally active parenchyma remain ; 3, severe renal hematuria;
4, hydronephrosis.
Nephrectomy is indicated in the presence of: 1, severe
pyonephrosis, if the kidney is transformed into a series of
pus-cavities (calculosis, tuberculosis of the kidney) ; 2, in-
juries of the kidney (rupture, laceration) ; 3, tumors of
the kidney ; 4, incurable ureteral fistulse.
For exposure of the kidney the patient is placed upon
the healthy side of his }x)dy over a pillow. The cuta-
neous incision begins at the twelfth rib and passes thence
vertically downward toward the crest of the ilium and
along this almost to the anterior superior spine. Skin,
fat, lumbodorsal fascia, the fibers of the latissimus dorsi
are divided, in order that, after division of the deep layer
of the fascia, the quadratus lumborum and, in the anterior
portion of the wound, the triplicate layer of the abdominal
muscles, may be divided. After the transversalis muscle
Tab. 24.
Lith^ Arist E Reichhvld. Mimchen .
OPERATIONS ON THE KIDNEYS. 375
also liiis \wvn j)mss(>(1 tlio fiitty ca[).sulc of the kidney is
exposed tliroiiohont u suHieient extent. This eai).sule is
divided and the kichiey is removed from its bed by bhmt
disseetion with tlie tinger until the organ, eompletely freed
at all points with the exeeption of its hilus, can be
brought by traction to the level of the wound.
For exploration of tlie pelvis of the kidney, for the
removal of stones from the pelvis, et<;., the kidney is
opened from its eonvex border. An incision is made
u])on the convexity, through the renal parenchyma, down
to the pelvis of the kidney, large enough to permit the
introduction of the index-finger, with which the pelvis is
examined. If necessary, this incision may be extended
toward the poles of the organ to a maximum degree
until the kidney can be separated in two halves. This
procedure is carried out with digital compression of the
large vessels at the hilus of the kidney. If the conditions
are so constituted that primary union can take place, the
wound in the kidney is closed by deep and superficial in-
terrupted catgut sutures, the organ dropped into place, and
the cutaneous wound closed, except for a small opening for
a drainage-tube. Provisional suture of the wound in the
kidney for the control of hemorrhage may also be under-
taken if in immediate conjunction with an exploratory
incision the removal of the entire organ is determined
upon. After extirpation of the kidney the large vessels
at its hilus must be exposed and carefully ligated. If
possible, the kidney is drawn forward and the artery and
the vein are isolated at the hilus (Fig. 216). If this is
not possible, the operator grasps the hilus of the organ
with the thumb and index-finger of the left hand and
witli the guidance of this hand a])plies a clamp-forceps
around the entire pedicle. The pedicle is divided beyond
the grasp of the forceps with scissors and ligated en masse
upon the proximal side. The large vessels exposed in
the transverse incision are further isolated and ligated
separately.
The large wound-cavity is closed after perfect control
1^76
OPERATIVE SUHGERY.
of hemorrhage, drained, and the wound closed by sutures
in tiers (muscles, fascia, skin).
To effect operative fixation of a movable kidney (nephro-
pexy, nephrorrhaphy) the organ is exposed in the usual
manner, the sutures (ten or twehe) for the fixation of the
organ being passed deeply through its parenchyma and
placed in the upper angle of the cutaneous incision on
%
■"'TV;''. I'"l
*
m
Fig. 216. — Lumbar incision : the kidney is brought out of the wound
in the abdominal wall and the structures of the hilus of the organ are
isolated and exposed for ligature.
either side and tied. In this manner the kidney is suitably
located and fastened. The method of retroperitoneal ex-
posure of the kidney described affords as a rule sufficient
access to the organ. In the presence, howeyer, of large
diffusely adherent tumors of tlie kidney, or in the case of
adipose indiyiduals, it may be necessary, to afford greater
accessibility, to make from the middle of the lumbar in-
cision a transyerse incision passing toward the umbilicus.
OPERATIONS ON THE KIDNEYS. Z11
Bardeiiheuer recoininonds the so-called (rajj-door incision. From the
upi)or and lower extifinitics of the vertical longitudinal incision i)assinK
from the costal arch to tlu- middle ol" the crest of the ilium transverse
incisions are made aloui^ tlu- rib and the iliac crest. IJardenheuer makes
three forms of trap-door incision, an anterior, | , a posterior, ^^, and
a two-sided one, ~i~ .
Ill contradistinction from the retroperitoneal method
described is the transpe;ntoneal method for exposing the
kidney. In this latter operation tlie a1)d()minal cavity is
opened in the usnal manner in the linea alba, the peri-
tonenni over the kidney is divided, and the organ is
enucleated out of its bed. The retroperitoneal method
has, on the (Ulier hand, the advantage of permitting, iii
conjunction with an exploratory procedure, of the estab-
lishment of a renal fistula, of the drainage of an abscess
of the kidney under favorable conditions, as well as total
removal of the entire organ.
Operations on the Ureters. — The ureter passes from the
kidney on either side in the subserous space just behind
the peritoneum to the fundus of the bladder. In its
upper portion it lies upon the psoas muscle, crossing at its
entrance into the pelvis the point of division of the com-
mon iliac artery and entering the pelvis in a direction for-
ward and inward to reacli the base of the bladder. Most
commonly injuries of the ureter in the course of opera-
tions furnish the indication for operations upon this struct-
ure ; less commonly impaction of stones in the ureter,
.occlusion of the lower extremity of the ureter from the
presence of a neoplasm, or kinking of the ureter in cases
of hydronephrosis.
Of operations tliere have been performed : linear open-
ing of the ureter for delivery of a stone, with subsecjuent
suture of the incision (ureteroUthofomi/) ; the displace-
ment of a stone present along the ureter into the ])elvis
of the kidney ; and, finally, digital attrition of soft stones
without opening the ureter. In the presence of injuries
of the ureter, restoration of the lumen of the tube by
suture of the stumps or grafting of the central stump of
the ureter into a neiffliboriup; oroan mav be undertaken to
378
OPERATIVE SURGERY.
effect closure of ureteral fistuhe. With this eud in view
the ureter has been united w ith the bowel {uretero-enter-
ostomy), with the ureter of tlie opposite side (uretcro-
iireterostomy) , and with a new portion of the bladder
(iiretero-neocystostomy). Anastomosis of the ureter with
-LUUi'Jf J>-J'-#---J- -■^.
Fig. 217. — Invagination-suture of the stumps of the divided ureter.
the bowel has also been undertaken for the correction of
ectopy of the bladder (Maydl). Circular union of the
transversely or obliquely divided stumps of the ureter has
the disadvantage, in view of the narrow caliber of the
ureter, of being followed by such contraction of the
cicatrix as to result in narrowing of the lumen of the tube.
OPEBATIOyS UPON THE RECTUM AND ANUS. 379
For this reason the invagiiuition-.siiturc of A an Hook is
to 1)1' prcicrrctl. The free end of the peripheral stump is
closed l)y a ligature, 2.5 mm. below whieh a longitudinal
incision is made through the thickness of the wall oi" the
uretei'. The central stump is caught with a catgut suture,
the ends of which are carried by means of a needle
through the longitudinal incision in the ])eripheral stump,
the needle being further. passed through the opposite wall
of this stump. By gentle traction on the suture the
centml stump of the ureter is drawn through the slit in
the peri])heral portion, and fastened in position by knot-
tino- the thread in this situation. A few additional sutures
on the outer side insure contiguity of the stumps (Fig.
217).
In the practice of implantation of the ureter by the
method of l^iidinger and M'itzel a normal canal is formed
in which the ureter is contained (oblique fistula), thus
most nearly imitatino; the natural mode of entrance of
the ureter. The divided ureter is implanted in the
wall of the selected organ in the same manner as is the
rubber tube in WitzeFs operation of gastrostomy, and is
fixed in position by suture. For exposure of the upper
portions of the ureter the lumbar incision, as for neph-
rectomy, may be made advantageously. The pelvic por-
tion of the ureter in the male is accessible through the
sacral route after enucleation of the coccyx and avoidance
of the rectum.
Operations upon the Rectum and the Anus. —
Amputation and Resection of the Rectum. — Operations for
the removal of tumors of the rectum will vary with the
seat and the extent of the morbid process. Circumscribed
or pedunculated tumors are surrounded by incisions at
their base, and severed through healthy tissue, the wound
created being closed by suture. It is difficult in the treat-
ment of cases of this kind to expose sufficiently the field
of operation. For more deeply seated tumors, in the re-
gion of the anus, it is sufficient to distend this portion of
the bowel by means of retractors or suitable specula.
380 OPERATIVE SURGERY.
Tiiiiiors seated high up require as a preliuiinarv operation
linear division of the sphincter^ which is practised on the
anterior and posterior aspects along the line of the raphe,
with marked retraction of the margins of the wound, and
renders accessible to the knife the portions of the rectal
mucous membrane above tlie sphincter. The anterior
wall of the rectum can be reached with the aid of a pre-
rectal incision by separation of the rectum from the
urethra (see Prostatotomy). By this means the entire
thickness of a circumscribed portion of the wall of the
rectum can be resected and the defect be closed by suture.
If the neoplasm involve the entire periphery of the lowest
portion of the rectum a circular incision is made around
the anus and tlie lower extremity of the rectum is freed
from its surroundings. The rectum is then divided trans-
versely upon the proximal side of the neoplasm. The
wound is so adjusted that the stump of the rectum, brought
to the level of the surface, is fixed to the skin by sutures
passing through all the layers of the wall of the bowel.
This method of amputation has a limited field of applica-
tion. If the upper border of the tumor can he reached
with the palpating finger, its removal by the method de-
tailed can be technically carried out ; but isolation of the
rectum in its upper portions and access to the sigmoid
flexure are quite impossible by this mode of procedure.
The cutaneous wound allows of limited access, so that
certainty in operation, especially control of hemorrhage in
the higher portions of the wound, encounters irremovable
obstacles.
Resection of the rectum^ with union of the stumps of the
intestine, l)y tlie method described, is difficult even if
access is afforded by anterior and posterior incisions
througli the raphe, also when the tumor is deeply seated,
and entirely impossible if this be situated in tlie upper
portion of the rectum.
The limits of operability of tumors of the rectum were
enlarged materially with atteni])ts, on Kraske's sugges-
tion, to expose the rectum sufficiently and also in its
OPERATIOSS UPON Till': IlhVTUM AND ANUS. 381
liiiiluT jxuMion tliroiinh tlic sacral route It is possible by
tills mode ol' priK'ediire to isolate tiie reetiiin even to its
intraperitonetil portion and to praclise resections of this j)or-
tion of the l)()\vel in its continuity, w ith an adeijuate lield
of (yperation. The rectum is reached from the posterior
aspect after division of the sacrotuherous and sacrospinous
liiraments through the wide interval on either side between
the margin of the sacrum,and the tuberosity of the ischium.
The accessibility is increased by removal of a portion of
the mariiin of the sacrum with a chisel.
Mode of Kffivthig Sdcral Krposurc of the Rectum
(HochenejriJ:). — The patient occupies the left lateral decu-
bitus with the lower extremities flexed at the hips and
the knees and the operator standing back of the patient.
The cutaneous incision begins at the middle of the left
sacro-iliac symphysis and passes over the middle line in
an arc whose convexity is directed toward the right and
terminates below the apex of the coccyx ; or, if the anal
portion also is to be removed, it surrounds the anus ellip-
tical 1 v. The incision is deepened down to the bone. The
soft parts are retained in connection with the skin and are
dissected from the bone so that the left half of the sacrum
and the coccyx are exposed in the wound. After enuclea-
tion of the coccyx access to the rectum will be already
relatively free and it becomes considerably greater after
division of the attachments of the sacrotuherous and sacro-
spinous ligaments. The extensive field of operation thus
exposed ])ermits of careful scrutiny with regard to the
extent and limits of the tumor, and even of the higher
portions of the rectum, not accessible through the usual
modes of procedure. Further extension of the field of
o]ieration can be effected by chiselling the left margin
of the sacrum.
After exposure of the rectum the second step of the
operation — that is, isolation of the tumor beyond its limits
— is undertaken. The rectum is separated from its sur-
roundings by blunt dissection and the visible vessels are
ligated in the wound. If high amputation of the rectum
382 OPERATIVE SURGERY.
is to be performed, the stump of the bowel is brought
clown and fastened to the skin in the upper angle of the
wound (sacral preternatural anus). This procedure is
indicated when the anal portion is involved in the new-
growth and must be removed in connection therewith.
If, on the other hand, the anal portion is healthy, the
tumor being seated in the middle portion of the rectum,
the bowel on either side of the morbid process is isolated
by blunt dissection into healthy tissue, ligated and re-
moved by resection. The two stumps of the intestine are
united either primarily tln'oughout their entire extent, or
sutured only partially, so that a provisional artificial anus
is formed. This forms a mural fistula, Avhich may either
close spontaneously or be closed after a time by a plastic
operation. In introducing the sutures, both stumps must
be approximated without any tension. In the isokition
of tumors seated high up it is often necessary to open the
peritoneum of the vesicorectal cul-de-sac. The proximal
stump of the rectum is brought into the wound for the
formation of an artificial anus or for suture and the ante-
rior lip of the peritoneal wound is united at a suitable
level with the serous layer of the intestine, so that the
abdominal cavity is walled off' from the AAound. After
the introduction of circular intestinal sutures a large
drainage-tube is introduced tlirough the anus into the
rectum beyond the line of suture.
Operations for Rectal Fistula. — Rectal fistula can be
made to heal by division of the fistulous tract and the
conversion of the tubular ulcer into an open wound. In
the operation for complete fistula a slender probe is intro-
duced through the external fistulous opening, Avhile the
index-finger "of tlie left hand is applied to the internal
opening, which often is appreciable as a loss of substance.
The probe is thus passed through tlie tract and enters the
lumen of the bowel. A grooved director may be readily
passed through the fistula by the side of tlie probe into
the rectum and its extremity brought out through the
anus. The soft parts covering the fistula thus come to lie
OPlJRATrONS UPON TlIK RECTUM AND ANUS. 383
upon the director, upon wliicli tlicy are divided with the
knil'e. lly the iiitrodiietioii oi" teiiacuhi niter division of
the tissues the eharacter of the lining of the fistulous tract
ean he rendered visible. As a rule, the wound is ])er-
mitted to heal hy <»;ranulation, although after extirj)ation
of the entire fistulous })assage the wound can be closed
completely by suture.
Ineoni])lete fistuhe nfust be converted into complete
Hstuhe before being divided. In the presence of an in-
complete external fistula the grooved (lire(;tor is intro-
duced and pushed into the rectum through the deepest
portion of the fistula. Division of the fistula thus made
complete is effected in the manner (lescril)ed. In the
presence of an incomplete internal fistula, with its open-
ing upon the mucous membrane of the rectum the sound
or the grooved director is introduced from the rectum
toward the skin. When the head of the probe is felt
beneath the skin an incision is made down npon it and
the complete fistula thus established is divided in the
manner described. In the presence of extensive fistulous
formations it becomes necessary to follow the manifold
ramifs'ing passages often present and to open them
adequately.
Operation for Hemorrhoids. — Dilatations of the external
hemorrhoidal veins do not require operatives treatment.
Operation is indicated only in those cases of dilatation of
tli(,' internal hemorrhoidal veins, with consecutive changes
in the mucous membrane, in which prolapse of the mucous
membrane of the rectum has taken place, Avhich makes
itself apparent either only npon increased abdominal
pressure or habitually as a result of this influence. The
prolapsed masses of mucous membrane are either destroyed
with the actual cautery, or subjected to atrophy through
the elastic ligature, or excised by a bloody operation.
Caufeiizdtiou. — The patient occupies the position as in
the operation for stone, or the lateral decubitus. By
means of digital dilatation of the anus the hemorrhoidal
masses are exposed to view. They are grasped in seg-
384 OPERATIVE SURGERY.
ments with a clanip-forceps and their base is surrounded
by Langenbeck's flat forceps. The tumor lying upon the
broad ivory plate of the forceps is totally destroyed with
the tip of the Paquelin cautery^ after which the forceps is
carefully removed. In the same manner the swellings
throughout the entire circumference of the rectum are
destroyed.
EUiatic Ligature. — The patient occupies the lateral
decubitus. By means of a clamp polyp-forceps the ex-
truded mass of mucous membrane is grasped at its base
and brought forward. The elastic ligature is passed
around the neck of the nodule behind the forceps and
tightened and the nodule fixed by means of a silk thread
tied around it. In this way the whole series of folds is
included in three or four parts and ligated. The necrotic
nodules are thrown off* in the course of a week.
Excision may l)e practised upon each nodule individ-
uallv, or a circular incision is made through the skin
around the anus and also through the mucous membrane
of the rectum above the level of the nodules. The cylin-
der of mucous membrane, together with the dilated veins,
is dissected free from the sphincter and the margin of
the mucous meml)rane is united by suture with the skin
at the anus.
Operation for Atresia of the Anus. — The incision is
made in the perineal raphe from the apex of the coccyx
to the root of the scrotum (posterior commissure). The
operator advances into the depth layer by layer, always
keeping strictly in the middle line. As a rule, the bluish-
colorerl cul-de-sac of the rectum is soon reached, and it is
incised in the direction of the cutaneous incision. After
the meconium has been discharged the bowel is united
throughout its entire periphery to the skin by sutures pass-
ing through the entire thickness of the wall of the intes-
tine. If the cul-de-sac be situated high up, an effort
should 1)6 made to reach the rectum by the sacral route.
In the presence of atresia ani vesicalis, vaginalis, an
attempt is made to dissect free the lower end of the intes-
OPKliATloSS I' PON THE RECTUM AND ANUS. 385
tine l)y iiicims oi' the same incision. Tlic ahnorniiil com-
nnniicalion is divided with scissors and the rectum is
fixed in tile \\el, 17
Bicipital artery, ligation of, 68
387
388
ISDEX.
Bergmatin's operation for hydro-
cele, cSdO
Biers method of amputating leg,
117
Biliarv apparatus, operations upon,
319
Billroth's cannula, 302
method of submental removal of
tongue, 251
method of uranoplasty. 266
Bladder, operations on, 346
puncture of, 336
suture of, 55
Blood, transfusion of. 69
Bloodless approximation of wounds.
44
methods of dividing tissues, 39
Bloody suture, 44
Blunt dissection. 33
Blunt-pointed knife, 17
method of using, 34
Bone brace. Fig. 37
division of. 41
Bone-forceps, 43
Bone-shears, 43
Bones, division of. 17
percutaneous nailing of, 53
suture of, 52
Bowel, resection of, 315
suture of, 53, PI. 1
Brachial artery, ligation of, 65, PI.
2
Bramann's operation for exposure
of bladder. 350
Bruns on malignant tumors as an
indication for resection of
foot, 217
on paralytic club-foot as an indi-
cation for resection of foot.
217
Brauns's cheiloplastv, 252, Fig.
155
incision for resection of elbow,
204
method of tibiocalcaneal resec-
tion of foot. 218
modification of Pirogoff's ampu-
tation. 131
Buccinator nerve, extrabuccal ex-
posure of. 269
Biidinger and Witzel's method of
implantation of ureter, 379
Biingner, divulsion of vas deferens,
358
Butcher's saw, 42
Cannula for tracheotomy, 282, 283
Carotid artery, ligation of, 292
Caselli on shortening of leg after
luxations of hip as an in-
dication for resection of
foot, 217
Castration, 358
Catheter coude, 323, 325
metallic, introduction of, 328
retention. 334
rigid, mode of introducing, 327
soft, mode of introducing, 326
Catheterization, 322
posterior, 341
Catheters, varieties of, 323, 325
Cautery. a<'tual, 39
Celiotomy, 30S
mode of making incision in, 309
Chain-saw, 42
Chassaignac's incision for resection
of elbow-joint, 199
Cheek, plastic operations on. 259
Cheiloplasty. Bruns's, 252, Fig. 155
Dieffenbach's, 252, Figs. 152, 153
Langeubeck's, 252, Fig. 154
Chisel and mallet, 43
Cholecystectomy. 320
Cholecystendysis, 320
Cholecystenterostomy, 321
Cholecystoduodenostomy, 321
Cholecystojejunostomy, 321
Cholecystotomy, 319
Choledochoduodenostomy, 321
Choledochotomy. 321
Choparfs joint. 149
operation, 149
Circular saw, 43
Circumcision, 360
Colostomy, 314. PI. 19
Continuity, ligation in, 57
Cricothyrotomy. 275. 276
Cubital artery, ligation of, QQ, PI. 3
Cutaneous incisions, 25
forms of, 25
Cystopexy, 349
Cystotomy, 350
I su})rapubic, 347
for intravesical manipulations,
.349
} for stone, 348
Czerny's incision for reaching the
transverse fi.ssure of the
liver, 319
method of plastic operation on
cheek, 257
lyDEX.
389
Deep dissection, 26
Dieffenbach's cheiloplastv, 252,
Figs. 152, 153
methotl of uranoplasty, 266
Dieulafoy's aspirator, 303
Dissection between two forceps, 33,
Fig. 35
blunt, 33
deep, 26
free, 33
with aid of grooved director. 33,
Fig. 14
Dittel on lateral prostatectomy, 357
Division of hone, 41
of tissues, 17
bloodless methods, 39
by puncture, 3-':^
with scissors, 34, Fig. 17
Dorsalis pedis arterj-, ligation of,
85
ECRASEMENT. 41
Ecraseur, 41. Fig. 21
Elastic ligature, 41
Elbow-joint, resection of. 199
Elephantiasis, ligation of vessels
for, 57
Eiitero-anastoniosis, 317
Enterostomy, 313
Enucleation, 86 I
at ellxjw-joint, 182
at knee-joint, 153
of all four fingers through meta^
carpal bone, 175 j
of foot, subastragaloid, 150 |
of hand by circular incision, 176 i
by flap-incisions, 131 '
of thumb at carpometacarpal
joint, 173
Epilepsy, ligation of vertebral
artery for. oS
Esmarch's method of exarticulating
the humerus. 1S8
of exarticulation, 112
of femur, 163
Esophagotomy, external, 233
Exarticulatio pedis sub talo, 151
Exarticulation. 110 .
at the wrist. 175 I
of femur at hip-joint by method
of Esmarch, 163
of fingers at interphalangeal
joints and at metatarso- ,
phalangeal joints, 167
of foot, iutertarsal, 144
Exarticulation of great toe, together
with metatarsal bone, 138
with formation of anterior and
posterior flaps, 163
of humeru.s, 1"n5
by a circular incision and with
longitudinal incision by
I Esmarch's method, 188
I by a deltoid flap. Ie6
of leg at knee-joint, 153
of little finger, 174
of little toe. together with meta-
tarsal bone, 139
of toe in interphalangeal joint,
132
Excision of prostate, 356
Exclusion of intestine, 317
Extirpation of hip, 167
of seminal vesicles. 356
of testicle, 358
Extremities, operations on, 57
Extubator, 285
Fabrictts's method of operating
for femoral hernia. 371
Femoral artery, ligation of, at junc-
tion of middle and upper
thirds of thigh. 75. PI. 4
below Poupart's ligament. 75,
PI. 4
in adductor canal, 77, PI. 5
location of, 74
hernia, operation for. 365
radical operation for, 369
Femur, exarticulation of, 163. See
Exarticulation.
osteotomy of. 221
Fifth nerve, exposure of second and
third divisions by method
of Kronlein, 272
exposure of third division at base
of skull, -273
Finger, amputation of, 174
Fingers, exarticulation of, 167. See
Rrarticuhition.
resection of, 206
Fistula, gastric, formation of, 311
intestinal, formation of. 313
rectal, operation for, 3"*2
urethral, operation for, 363
Fleurant, trocar of, 337
Foot, amputation of. See Amputa-
tion.
resection of. 214
subastragaloid enucleation o^ 150
390
INDEX.
Forearm, amputation of, 181
Fowler on appendicitis. 322
Frank's method of gastrotomy, 313
Free dissection, 33
Frontal nerve, exposure and extrac-
tion of, 267
Gall-bladder, operations on, 319
extirpation of, 320
nature of, 56
Galvanocaustic suare, 41
Galvanocautery, 41
G^sseriau gangliou, extirpation of,
by method of Krause, 274
Grastric fistula, formation of, 311
Gastroenterostomy, 313
Gastrostomy, 311. PL 19
Genito-urinarv organs, operations
on, 322
Gersuny's method of plastic opera-
tion on cheek, 259
Gigli wire saw, 228
Gill (M. C.) on extirpation of en-
larged middle lobe of pros-
tate, 357
Goiter, operation for, 299
resection of. 301
Graefe's incision for ligation of in-
nominate artery, 291
Granny's knot, 62
Great toe, exarticulation of. See
Exarticulation.
Gritty's incision for resection of
wrist, 206
operation, 161
Grooved director, dissection with aid
of, 33, Fig. 14
Giinther's modification of PirogoflPs
amputation, 131, Figs. 76,
79
operation, 150
Gussenbauer's clamp, 52
Hahx's method of resection of
knee-joint, 211
Kalsted's operation for removal of
breast, 306
Hand, enucleation of. 176
Harelip, operations for, 260
Heine's method of amputation of
leg, 116
Helfrich's operation for exposure of
bladder, 350
Hemorrhage after operation, control
of, 109
Hemorrhoids, cauterization of, 383
excision of, 384
operation for, 383
removal by elastic ligature, 384
Hernia, adherent, treatment of, 367
femoral, operation for, 365
radical operation for, 369
inguinal, operation for, 365
radical operation for, 367
operations for, 364
radical operation for, 367
umbilical, radical operation for,
371
Herniotome, 34
Herniotomy, 365
Heteroplasty after trephining, 224
Hip-joint, resection of, 207
Hueter's incision for resection of
elbow, 204
Humerus, exarticulation of, 185.
See Exarticulation.
Hiiter's tenoplasty, 51
Hydrocele, operation for, 359
Ileocolostomy, 318
Iliac arterv, external, ligation of,
372
internal, ligation of, 373
ligation of, 372
Incisions of the skin, 25
Inferior dental nerve, exposure of,
270
exposure of, within dental
canal, 270
Infrahyoid pharyngotomy, 287, PI.
15
Infra-orbital nerve, exposure and
extraction of, 268
Inguinal hernia, operation for, 365
radical operation for, 367
Injections, parenchymatous, 39
subcutaneous, 39
Innominate artery, ligation of, 291
Intertarsal amputation of foot, 146
exarticulation of foot, 149
Intestinal fistula, formation of, 313
Intestine, exclusion of, 317
Intestines, operations on, 311
Intraglandular enucleation of thy-
roid gland, 300
Intubation of larynx, 284
indications for, 284
Intubator, 285
Israel's method of plastic operation
on cheek, 259
INDEX.
391
Ivory pegs, union of bones by, 52,
53
Jaw, lower, rcsoctiou of, 234
resection in its continuity, 240
temporary resection of, 239
upper, resection of, 229
Jejunostoniy, 315
Joints, resection of, 191
Kidney, excision of, 374
movable, fixation of, 376
operations on, 374
Knee-joint, resection of, 209
Knife, blunt-pointed, metbod of
using, 34
division of tissues with, 18
methods of using, 18
varieties of, 17, 18, 19
Knots, 62
Kocher on resection of bowel, 315,
316
Kocher's angular incision for resec-
tion of elbow, 205
incision for enucleation of thyroid
gland, 300
for unilateral strumectomy, 300
method of extirpation of tongue,
251
of resection of knee-joint, 211
operation for inguinal hernia,
369
Konig's autoplasty after trephining,
224
incision for resection of ankle-
joint, 213
method of resecting knee-joint,
213
modification of Langenbeck's re-
section of hip, 208
operation for saddle-nose, 256
Krause's flap for exposure of Gasse-
rian ganglion, 228
method of extirpation of Gasse-
rian ganglion, 274
sk i n -g r af t i n g, 254
Kronlein's method of exposing
second and third divisions
of fifth nerve, 272
Kiister on protection of thoracic
nerve in removal of mam-
mary gland, 306
Langenbeck's cheiloplasty, 252,
Fig. 154
Langenbeck's dorsoradial incision
for resection of wrist, 205
incision, 107
for infrahyoid pharyngotomy,
289
for resection of ankle-joint, 211
for resection of elbow-joint, 199
for resection of lower-jaw. 240,
PI. 12
method of excision of hip-joint,
207
of resection of shoulder -joint,
193
of resection of upper jaw, 233
Laryngofissure, 275
Laryngotomy, 275
Larynx, extirpation or removal of,
277
intubation of, 284
oi)ening of, 275
Lefort's modification of Pirogoflf's
amputation, 131, Fig. 80
Leg, amputation of, 112. See Ampu-
tation of leg.
exarticulation of. See Exarticida-
tion.
Lembert's suture, PI. 1, Fig. 1, b
Ligation, cutaneous incision for, 58
in continuity, indications for, 57
method of, 58
in upper extremity, 62
location and identification of ar-
tery in, 59
of axillary artery, 83, PI. 2
of bicipital artery, 68
of brachial artery, 65, PI. 2
of carotid artery, 292
of cubital artery, 66, PI. 3
of dorsal is pedis artery, 85
of femoral artery at junction of
middle and upper thirds of
thigh, 75
below Poupart's ligament, 75,
PI. 4
cutaneous incision for, Fig. 49
in adductor canal, 77, PI. 5
of iliac artery, 372
of innominate artery, 291
of internal mammary artery, 304
of internal saphenous vein for
varicose veins, 77
of lingual artery, 295, PI. 17
of popliteal artery, 77, PI. 6
cutaneous incision for. Fig.
51
392
INDEX.
Ligation of radial and ulnar arte-
ries, 70. PI. 3
of subclavian artery, 295
above the clavicle, 297
beloNV the clavicle, 298
of thyroid artery, 294
inferior, 299
of tibial arteries, 80, PI. 7
of vessels in continuity, 57
Ligature, elastic, 41
ku3t, method of tieing, 61
Lingual arterv, ligation of, 295, PI.
17
nerve, exposure of, 271
Lisfranc's articular line, 140, 141
operation, 139
Lister's dorso-ulnar incision for re-
section of wrist, 206
lead-plate suture, 49
Litholapaxy, 345
Little toe, exarticulation of. See
Exarticidation.
Liicke's and Schede's incision for
resection of hip, 209
Macewen on supracondylar oste-
otomy of femur, 221
Malgaigne's incision for resection
of upper jaw, 232
infrahyoid pharyngotomy, 287
operation, 151
for harelip, 260
Mammarv arterv, internal, ligation
of, 304
gland, removal of, 304
Maydl on uretero-enterostomy for
ectopy of bladder, 378
McBurney's incision for resection
of vermiform appendix.
321
Mental nerve, exposure of, 271
Mikulicz's method of exposing
third division of fifth
nerve, 273
Mirault-Langenbeck's operation for
harelip, 260
Mohrenheim's triangle, 298
Monro, point of, for abdominal
puncture, 307
Moreau's incision for resection of
elbow, 204
Murphy's anastomotic button, 316
Muscles, divided, suture of, 49
of leg, anterior, arrangement of,
81
Muscles of popliteal space and calf,
Fig. 50
of thigh, arrangement of, Fig.
47
of upper extremity, arrangement
of, Fig. 44
Nails for uniting severed bones, 52,
53
Xeedles, varieties of, Fig. 29
Xelaton's operation for harelip, 260
Nephrectomy, 374
Nephropexy, 376
Nephrorrhaphy, 376
Nephrotomy, 374
Nerve-suture, 51
Nerves, extraction of, 267
operations on, 266
Neurectomy, 267
Neurexairesis, 267
Neuroplasty, 51
Neurotomy, 266
Niehans's operation for exposure of
bladder, 350
I Nose, plastic restoration of, 254
O'Dwyek's outfit for intubation of
I larynx, 264, 285
I Ollier's bayonet-incision for resec-
I tion of elbow, 204
Omphalectomy, 372
Omphalocele, incarcerated, opera-
tion for. 371
Osseous arthrectomy, 192
Osteoclasis, 44
Osteoclasts, 44
Osteotomia colli femoris, 221
intertrochanterica, 221
Osteotomy, 218
of femur. 221
of tibia, 221
supracondylar, of femur, 221
Palate, hard, plastic operations
on, 266
soft, plastic operations on, 265
Paquelin, thermo-cautery of, 41,
Fig. 19
Paracentesis abdominalis, 307
thoracis, 302
! Paraneural suture, 51
Paratendinous suture, 50
Paravicini's method of exposing
inferior dental nerve, 270
; Parenchymatous injections, 39
INDEX.
393
Park's incision for resection of el-
bow-joint, 199
Penis, ampututioii of, 3()2
PtTc-iitaneous nailing of bones, 53
PiTicecal abscesses, opening of, 321
PiTimural suture, ")!
Pharyngotoniy, 287
infrahyoid. 2S7, PI. 15
Phimosis, operation for, 3(50
Plilebotomy, GO, Fig. 4()
Pirogoff 's amjJUtatioM of foot, 120
Plastic operations, 252
Point of Monro, 307
PoUoson's method >f exarticulating
leg at knee-joint, 154
Poncet's operation of urethrostomy,
345
Popliteal artery, ligation of, 77, PI.
6
Preternatural anus, formation of,
314
Primary suture, 44
Prostate, excision of, 356
Prostate gland, operation upon,
355
Prostatectomy, 3.56
lateral, 357
Prostatotomy, 355
Puncture, exploratory, 38
mode of performing, 38
of abdomen, .307
of bladder, 336
Racket incision, 112
Radial artery, ligation of, 70, PI. 3
Reamputation, indications for, 86
Rectal fistula, operations for, 382
Rectum, operations upon, 379
resection of, 380
sacral exposure of, 381
Reef knot. Fig. 40
Regnoli's method of submental re-
moval of tongue, 251
Resection knives, 18
knife, mode of using, 18, Fig. 11
of ankle-joint, 211
by Konig's incision, 213
bv Langenbeck's incision,
211
bv Reverdin-Kocher method,
214
of bowel, 315
of elbow-joint through a dorsal
longitudinal incision, 199
of fingers, 206
Resection of foot by method of
Wladimiroff' and Mikulicz,
214
of goiter. 301
of hip-joint, 207
of joints, indications for, 192
of the extremities, 191
of knee joint, 209
of lower jaw, 234
in its continuity, 240
temporary, 239
of rectum, 380
of shoulder-joint by method of
Langenbeck, 193
of skull, 227
of upper jaw, 229
of vas deferens, 357
of vermiform appendix, 321
of wrist-joint, 205
subperiosteal, 191
Retention-catheter, 334
Retractors, use of, in dissection,
26
Reunion of tissues, 44
Reverdin-Kocher method of re-
section of ankle-joint, 214
Rhinoplasty, 254
Rorer's incision for resection of hip-
joint, 209
Rydygier on shortening of leg after
resection of kuee as an in-
dication for resection of
foot, 217
Saddle-xose, operation for, 256
Sailor's knot, 62
Salzer on danger of excluded por-
tion of bowel in exclusion,
318
Salzer's method of exposing third
division of fifth nerve, 273
Sartorius muscle, course of, 48
Saw, Butcher's arched, 42
chain, 42
circular, 43
wire, 43
Scalpel, bellied, 17
Scissors, division with. 34, Fig. 17
Scoutetten's method of oral ampu-
tation, 108
Secondary' suture, 44
Sedillot's incision for resection of
lower jaw, 240
Seminal vesicles, 356
j Sharp-pointed knife, 17
394
INDEX.
Shoulder-joint, resection of, 193.
See Resection.
Skin, circular iucisiou of, 25
division of, from within outward,
25
method of holding knife in, 18
Skin-grafting, 54
Skull, temporary resection of, 227
Snare, galvauocaustic, 41
wire, 41, Fig. 20
Soft parts, division of, 17
Sonneuburg's method of exposing
inferior dental nerve, 270
Ssabanajefi"s operation, 162
Staphylorrhaphy. 265
Steiner on localization of branches
of middle meningeal
artery, 228
Stirrup incision, 113
Stomach, operations on. .311
Stone, lateral incision for. 344
median section for. 344
Strumectomy, unilateral, 300
Subastrasaloid enucleation of foot,
150
Subclavian artery, ligation of, 295
above the clavicle. 297
below the clavicle, 29S
Subcutaneous injections, method of
making. 39
Subperiosteal resection, 191
Supracoudvlar shortening of femur.
221
Suprapubic cystotomy, 347
Surgical knot, 62
Suture, bloody, 44
continuous, 49. Fig. 26
deep. 49
gauze-pad. 49, Fig. 30
glover's, 49
interrupted. 49. Fig. 25
Lister's lead-plate, 49
mattress. 49
of bladder. 55
of bones, 52
of bowel. 53. PI. 1.
of divided muscles, 49
of gall-bladder, 56
of nerves. 51
of patella with wire. Fig. 36.
of tendons. 49
paraneural. 51
paratendinous, 50
perineural. 51
primary, 44
Suture, secondary, 44
simple knotted, 44, Fig. 25
introduction of, 45, Fig. 31
Syme's method of supramalleolar
amputation, 118
Synovial arthrectomy, 192
Szymanowsky's incision for resec-
tion of elbow, 204
Tampon-canxula in tracheotomy,
283
Tenacula, use of, in surgical dissec-
tion, 26
Tendons, suture of, 49
Tenoplasty, 51
Tenotome, mode of using, 18, Figs.
12,13
Tenotomes, 18
Testicle, extirpation of, 358
Thermocauterv of Paquelin, 41,
Fig. 19
Thiersch's extraction of nerves, 267
skin-grafting, 254
Thigh, amputation of, 254. See Am-
pidntion.
Thoracotomy. 303
Thorax, paracentesis of, .302
Thumb, enucleation of, 173
Thvroid arterv, inferior, ligation of,
299
superior, ligation of 294
gland, intraslandular enuclea-
tion. 300
Thyrotomy, 275
Tibia, osteotomy of, 221
Tibial arteries, ligation of, 80, PI.
7
Tissues, division of, 17
by puncture, 38
reunion of, 44
Toes, amputation of. See Amputa-
tion of toes.
exarticulation of, in iuterpha-
langeal joint, 132
Tongue, operations on, 243
submental removal of, 251
Tracheal cannula, 283
Traclieotomy. 278
indications for. 278
inferior. 280, PI. 14
superior, 279
Transfixion. 107
Transfusion of blood. 69
Trendelenburg's tampon-cannula,
283
INDEX.
395
Trephiiiinp, 22.'i
iiidiratidiis fur, 2*23
TrigfiuiiKil UL-uralgia, ligation of
carotid artery lor, .">«
Trigeminus, operations ou, 274
Trocar, niotlc ol" using, 3d
Trzetizky on injury of vessels in
abdomiual puncture. 307
Tumors of tongue, excision of, 243
Ulnar artery, ligation of, 70,
PI. 3
Umbilical hernia, radical operation
for, 371
Unilateral strumectomy, 300
Uranoplasty, 2G()
Ureter, inflammation of, 379
operations on. 377
Uretero-enterostomy, 378
Ureterolithotomy, .377
Ureteroneocystostomy, 378
Urethral fistula, operation for.
Urethrostomy, .34.5
Urethrotomy, external, 337
indications for, 342
internal, 343
with a guide, 340
without a guide, 340
Van* Hook's invagination suture,
379
Vas deferens, divulsion of, 358
extirpation of, 358
resection and extirpation of, 357
Velpeau's incision for resection of
upper jaw, 232
method of resection of hip-joint,
207
Venous infusion of saline solution,
69
Vermiform appendix, 321
VerneuiTs operation, 164
Vogt's incision for resection of
elbow, 204
Volkmann's method of resection of
knee-joint, 211
operation for hydrocele, 360
Von Walther on reimplantation of
bone after trephining, 224
Walther's method of exarticu-
lating little finger, 174
Weber on cutaneous incision for re-
section of upper jaw, 2.30
Wire loop for division of tissues,
46, Fig. 20
saw, 43
Witzel's method of cystostomy, 313
Wladimirofl" and Mikulicz method
of resection of foot, 214
Wolff's method of uranoplasty, 266
Wolfler, incomplete exclusion of the
bowel, 317
Wolfler's gauze-pad suture, 49
Wrist-joint, resection of, 205
Zuckerkandl's operation for ex-
posure of buccinator nerve,
269
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CATALOGUE OF MEDICAL WORKS.
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF PHYSIOLOGY. Edited by
William II. IIowkll, Ph.D., M. D., rrofessor of Physiology in the
Johns Hopkins University, Baltimore, Md. One handsome octavo volume
of 1052 pages, fully illustrated. Prices : Cloth, ^6.00 net; Sheep or Half-
Morocco, $7.00 net.
This work is the most notable attempt yet made in America to combine in
■Mie volume the entire subject of Human Physiulogj' by well-known teachers
who have given especial study to that part of the subject upon which they write.
The completed work represents the present status of the science of Physiology,
particularly from the standpoint of the student of medicine and of the medical
practitioner.
The collaboration of several teachers in the preparation of an elementary text-
book of physiology is unusual, the almost invariable rule heretofore having been
for a single author to write the entire book. One of the advantages to be derived
from this collaboration method is that the more limited literature necessary for
consultation by each author has enabled him to base his elementary account
upon a compreliensive knowledge of the subject assigned to him; another, and
perhaps the most important, advantage is that the student gains the point of view
of a number of teachers. In a measure he reaps the same benefit as would be
obtained by following courses of instruction under different teachers. The
different standpoints assiimed, and the differences in emphasis laid upon the
various lines of procedure, chemical, physical, and anatomical, should give the
student a better insight into the methods of the science as it exists to-day. The
work will also be found useful to many medical practitioners who may wish to
keep in touch with the development of modern physiology.
The main divisions of the subject-matter are as follows : General Physiology
of Muscle and Nerve — Secretion — Chemistry of Digestion and Nutrition —
Movements of the Alimentary Canal, Bladder, and Ureter — Blood and Lymph
— Circulation — Respiration — Animal Heat — Central Nervous System — Special
Senses — Special Muscular Mechanisms — Reproduction — Chemistry of the
Animal Body.
C'OXTRIBl TORS :
HENRY P. BOWDITCH. M. D., WARREN P. LOMBARD, M.D.,
Professor of Physiology, Harvard Medi- Professor of Physiology, University of
cal School. I Michigan.
JOHN G. CURTIS, M. D | GRAHAM LUSK, Ph. D..
Professor of Physiology, Columbia Uni- Prnfe<;sor nf P .v<;inlr,P^ Ynle MeHiral
versity, N. Y. (College of Physicians Professor ot 1 li>siology, \ale Medica/
and Surgeons). I °°
IISNRY H. DONALDSON, Ph.D., W. T. PORTER, M.D.,
Hcad-Pr'.fc>>or of Neurology, Univer- Assistant Professor of Physiology, Har-
sity of (,'hicago. vard Medical School.
W. H. HOWELL, Ph.D., M. D., EDWARD T. REICHERT, M.D..
Professor of Physiology, Johns Hopkins , Professor of Physiology, University of
University. I Pennsylvania.
FREDERIC S. LEE, Ph. D.,
Adjunct Profes.sor of Physiology, Cohim- HENRY SEWALL, Ph.D., M. D..
bia University, N. Y. (College of 1 Profe.ssorof Physiology, Medical Depart
Physicians and Surgeons). I ment, University of Denver.
IV. B. SAUNDERS'
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF APPLIED THERAPEU-
TICS. For the Use of Practitioners and Students. Edited by
James C. Wilson, M. D., Professor of the Practice of Medicine and of
Clinical Medicine in the Jefferson Medical College. One handsome octavo
volume of 1326 pages. Illustrated. Prices: Cloth, ^7.00 net; Sheep or
Half- Morocco, $8.00 net.
The arrangement of this volume has been based, so far as possible, upon
modern pathologic doctrines, beginning with the intoxications, and following
with infections, diseases due to internal parasites, diseases of undetermined
origin, and finally the disorders of the several bodily systems — digestive, re-
spiratory, circulatory, renal, nervous, and cutaneous. It was thought proper to
include also a consideration of the disorders of pregnancy.
The list of contributors comprises the names of many who have acquired dis-
tinction as practitioners and teachers of practice, of clinical medicine, and of
the specialties.
COXTRIBUTORS :
Dr. I. E. Atkinson, Baltimore. Md.
Sanger Brown, Chicago, 111.
John B. Chapin, Philadelphia, Pa.
William C. Dabney. Charlottesville, Va.
John Chalmers Da'Costa, Philada., Pa.
I. N. Uanforth, Chicago, 111.
John L. Dawson, Jr., Charleston, S. C.
F. X. Dercum, Philadelphia. Pa.
George Dock, Ann Arbor, Mich.
Robert T. Edes, Jamaica Plain, Mass.
Augustus A. Eshner, Philadelphia. Pa.
J. T. Eskridge, Denver, Col.
F. Forchheimer, Cincinna'^i, O.
Carl Frese. Philadelphia, Pa.
Edwin E. Graham, Philadelphia, Pa.
John Guiteras. Philadelphia. Pa.
Frederick P. Henry, Philadelphia, Pa.
Guy Hinsdale, Philadelphia, Pa.
Orville Horwitz, Philadelphia, Pa.
W. W. Johnston, Washington, D. C.
Ernest Laplace, Philadelphia, Pa.
A. Laveran, Pans, France.
The articles, with two exceptions, are the contributions of American writers.
Written from the standpoint of the practitioner, the aim of the work is to facili-
tate the application of knowledge to the prevention, the cure, and the allevia-
tion of disease. The endeavor throughout has been to conform to the title of
the book— Applied Therapeutics— to ^indicate the course of treatment to be
pursued at the bedside, rather than to name a list of drugs that have been used
at one time or another.
While the scientific superiority and the practical desirability of the metric
system of weights and measures is admitted, it has not been deemed best to
discard entirely the older system of figures, so that both sets have been given
where occasion demanded.
Dr. James Hendrie Lloyd, Philadelphia, Pa.
John Noland Mackenzie, Baltimore, Md.
J. W. McLaughlin, Austin, Texas.
A. Lawrence Mason, Boston, Mass.
Charles K. Mills, Philadelphia, Pa.
John K. Mitchell. Philadelphia, Pa.
W. P. Northrup. New York City.
William Osier, Baltimore, Md.
Frederick A. Packard, Philadelphia, Pa.
Theophilus Parvin, Philadelphia, Pa.
Beaven Rake, London, England.
E. O. Shakespeare. Philadelphia, Pa.
Wharton Sinkler, Philadelphia, Pa.
Louis Starr, Philadelphia, Pa.
Henry W. Stelwagon, Philadelphia, Pa.
James Stewart, Montreal. Canada.
Charles G. Stockton, Buffalo, N. Y.
James Tyson, Philadelphia, Pa.
Victor C. Vaiighan, Ann Arbor, Mich.
James T. Whittaker, Cincinnati, O.
J. C. Wilson, Philadelphia, Pa.
CATALOGUE OF MEDICAL WORKS. 5
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF OBSTETRICS. Edited by
Richard C. Norris, M. D. ; Art Editor, Robert L. Dickinson, M. D.
One handsome octavo volume of over looo pages, with nearly 900 colored
and half-tone illustrations. Prices: Cloth, ^7.00; Sheep or Half-Morocco,
$8.00.
The advent of each successive volume of the series of the American Text-
Books has been signalized by the most flattering comment from both the Press
and the Profession. The high consideration received by these text-books, and
their attainment to an authoritative position in current medical literature, have
been matters of deep international interest, which finds its fullest expression in
the demand for these publications from all parts of the civilized world.
In the preparation of the "American Text-Book of Obstetrics" the
editor has called to his aid proficient collaborators whose professional prominence
entitles them to recognition, and whose disquisitions exemplify Practical
Obstetrics. While these wTiters were each assigned special themes for dis-
cussion, the correlation of the subject-matter is, nevertheless, such as ensures
logical connection in treatment, the deductions of which thoroughly represent
the latest advances in the science, and which elucidate the best modern methods
of procedure.
The more conspicuous feature of the treatise is its wealth of illustrative
matter. The production of the illustrations had been in progress for several
years, under the personal supervision of Robert L. Dickinson, M. D., to whose
artistic judgment and professional experience is due the most sumptuously
illustrated work of the period. By means of the photographic art, combined
with the skill of the artist and draughtsman, conventional illustration is super-
seded by rational methods of delineation.
Furthermore, the volume is a revelation as to the possibilities that may be
reached in mechanical execution, through the unsparing hand of its publisher.
COXTRIBUTORS :
Dr. James C. Cameron.
Edward P. Davis.
Robert L. Dickin.';on.
Charles Warrington Earle.
James H. Etheridge.
Henry J. Garnsues.
Barton Cooke Hirst.
Charles Jewett.
Dr. Howard A. Kelly.
Richard C. Norris.
Chauncey D. Palmer.
Theophilus Parvin.
George A. Piersol.
Edward Reynolds.
Henry Schwarz.
"At first glance we are overwhelmed by the magnitude of this work in several respects,
viz. : First, by the size of the volume, then by the array of eminent teachers in this depart-
ment who have taken part in its production, then by the profuseness and character of the
illustrations, and last, but not least, the conciseness and clearness with which the text is ren-
dered. This is an entirely new composition, embodying the highest knowledge of the art as
it stands to-day by authors who occupy the front rank in their specialty, and there are many
of tiiem. We cannot turn over these pages without being struck by the superb illustrations
which adorn so many of them. We are confident that this most practical work will find
instant appreciation by practitioners as well as students." — Nei.u York Medical Times.
Permit me to say that your American Text-Book of Obstetrics is the most magnificent
medical work that I have ever seen. I congratulate you and thank you for this superb work
which alone is sufficient to place you first in the ranks of medical publishers.
With profound respect I am sincerely yours, Alex. J. C. SKE>fE.
W. B. SAUNDERS'
For Sale by Subscription.
AN AMERICAN TEXT-BOOK ON THE THEORY AND
PRACTICE OF MEDICINE. By American Teachers. Edited
by William Pepper, M. D., LL.D., Provost and Professor of the Theory
and Practice of Medicine and of Clinical Medicine in the University of
Pennsylvania. Complete in two handsome royal- octavo volumes of about
looo pages each, with illustrations to elucidate the text wherever necessary.
Price per Volume : Cloth, $5.ck) net; Sheep or Half-Morocco, $6.00 net.
VOI.IJME I. CONTAINS:
Hygiene. — Fevers (Ephemeral, Simple Con- mycosis. Glanders, and Tetanus. — Tubercu-
tinued, Typhus, Typhoid, Epidemic Cerebro- \ losis. Scrofula, Syphilis, Diphtheria, Erysipe-
spinal Meningitis, and Relapsing). — Scarla- i las. Malaria. Cholera, and Yellow Fever. —
tina, Measles, Rotheln, Variola, Varioloid, ' Nervous, Muscular, and Mental Diseases etc.
V iccinia, Varicella, -Mumps, Whooping-cough, 1
Anthrax, Hydrophobia, Trichinosis, Acrino- |
VOL.1 ME II. CONTAINS:
Urine (Chemistry and Microscopy). — Kid-
ney and Lungs.— Air-passages (Larynx and
Bronchi) and Pleura.— Pharynx, (Esophagus,
Stomach and Intestines (including Intestinal
Parasites), Heart, Aorta, Arteries and Veins.
— Peritoneum, Liver, and Pancreas. — Diathet-
ic Diseases (Rheumatism, Rheumatoid Ar-
thritis, Gout, Lithaemia, and Diabetes.) —
Blood and Spleen. — Inflammation, Embolism,
Thrombosis, Fever, and Bacteriology.
The articles are not written as though addressed to students in lectures, but
are exhaustive descriptions of diseases, with the newest facts as regards Causa-
tion, Symptomatology, Diagnosis, Prognosis, and Treatment, including a large
number of approved formulae. The recent advances made in the study
of the bacterial origin of various diseases are fully described, as well as the
bearing of the knowledge so gained upon prevention and cure. The subjects
of Bacteriology as a whole and of Immunity are fully considered in a separate
section.
Methods of diagnosis are given the most minute and careful attention, thus
enabling the reader to learn the very latest methods of investigation without
consulting works specially devoted to the subject.
CONTRIBLTORS :
Dr. J. S. Billings, Philadelphia.
Francis Delafield, New York.
Reginald H. Fitz. Boston.
James W. Holland, Philadelphia.
Henry M. Lyman, Chicago.
William Osier, Baltimore.
Dr. William Pepper, Philadelphia.
W. Gil man Thompson, New York.
W. H. Welch, Baltimore.
James T. Whittaker, Cincinnati.
James C. Wilson, Philadelphia.
Horatio C. Wood, Philadelphia.
" We reviewed the first volume of this work, and said : ' It is undoubtedly one of the best
text-books on the practice of medicine which we possess.' A consideration of the second
".nd last volume leads us to modify that verdict and to say that the completed work ts, in our
opinion, the best of its kind it has ever been our fortune to see. It is complete, thorough,
accurate, and clear. It is well written, well arranged, well printed, well iilustrated, and well
bound. It is a model of what the modern text-book should be." — Nerv York Medical yournal.
" A library upon modern medical art. The work must promote the wider diffusion of
sound knowledge." — American Lancet.
" \ trusty counsellor for the practitioner or senior student, on which he may implicitly
rely." — Edinburgh Medical yournal.
CATALOGUE OF MEDICAL WORKS.
» —
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF SURGERY. Edited by Wil-
liam \V. Klen, M.D., LL.D., and J. William White, M. D., Ph. D.
Forming one handsome royal-octavo volume of 1250 pages (10x7 inches),
with 500 wood-cuts in text, and 37 colored and half-tone plates, many of
them engraved from original photographs and drawings furnished by the
authors. Prices : Cloth', $7.00 net; Sheep or Half- Morocco, ^8.00 net.
SECOND EDITION, REVISED AND ENLARGED,
With a Section devoted to "The Use of the Rbntgen Rays in Surgery."
The want of a text-book which could be used by the practitioner and at the
same time be recommended to the medical student has been deeply felt, espe-
cially by teachers of surgery; hence, when it was suggested to a number of
these that it would be well to unite in preparing a text-book of this description,
great unanimity of opinion was found to exist, and the gentlemen below named
gladly consented to join in its production. While there is no distinctive Amer-
ican Surgery, yet America has contributed very largely to the progress of modern
surgery, and among the foremost of those who have aided in developing this art
and science will be found the authors of the present volume. All of them are
teachers of surgery in leading medical schools and hospitals in the United States
and Canada.
Especial prominence has been given to Surgical Bacteriology, a feature which
is believed to be unique in a surgical text-book in the English language. Asep-
sis and Antisepsis have received particular attention. The text is brought well
up to date in such important branches as cerebral, spinal, intestinal, and pelvic
surgery, the most important and newest operations in these departments being
described and illustrated.
The text of the entire book has been submitted to all the authors for their
mutual criticism and revision — an idea in book-making that is entirely new and
original. The book as a whole, therefore, expresses on all the important sur-
gical topics of the day the consensus of opinion of the eminent surgeons who
have joined in its preparation.
One of the most attractive features of the book is its illustrations. Very
many of them are orip:inal and faithful reproductions of photographs taken
directly from patients or from specimens.
CONTRIBrXORS :
Dr. Charles H. Burnett, Philadelphia.
Phineas S. Conner, Cincinnati.
Frederic S. Dennis, New York.
William VV. Keen, Philadelphia.
Charles B Nancrede, Ann Arbor, Mich.
Roswell Park, Buffalo, N. Y.
Lewis S. Pilcher, New York.
Dr. Nicholas Senn, ('hicago.
Francis J. Shepherd, Montreal, Canada.
Lewis A. Stimson, New York.
William Thom.son, Philadelphia.
J. Collins Warren, Boston.
J. William White, Philadelphia.
"If this text-book is a fair reflex of the present position of American surgery, we must
admit it is of a very high order of merit, and that English surgeons will have to look very
carefully to their laurels if they are to preserve a position in the van of surgical practice."—
London Lancet.
Py. B. SAUNDERS'
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF GYNECOLOGY, MEDICAL
AND SURGICAL, for the use of Students and Practitioners.
Edited by J. M. Baldy, M. D. Forming a handsome royal-octavo volume,
with 341 illustrations in text and 38 colored and half-tone plates. Prices :
Cloth, 36.00 net; Sheep or Half-Morocco, $7.00 net.
SECOND EDITION, THOROUGHLY REVISED.
In this volume all anatomical descriptions, excepting those essential to a clear
understanding of the text, have been omitted, the illustrations being largely de-
pended upon to elucidate the anatomy of the parts. This work, which is
thoroughly practical in its teachings, is intended, as its title implies, to be a
working text-book for physicians and students. A clear line of treatment has
been laid down in every case, and although no attempt has been made to dis-
cuss mooted points, still the most important of these have been noted and ex-
plained. The operations recommended are fully illustrated, so that the reader,
having a picture of the procedure described in the text under his eye, cannot fail
to grasp the idea. All extraneous matter and discussions have been carefully
excluded, the attempt being made to allow no unnecessary details to cumber
the text. The subject-matter is brought up to date at every point, and the
work is as nearly as possible the combined opinions of the ten specialists who
figure as the authors.
COXTRIB1JTORS :
Dr. Henry T. Byford.
John M. Baldy.
Edwin Cragin.
). H. Etheridge.
William Goodell.
Dr. Howard A. Kelly.
Florian Krug.
E. E. Montgomery.
William R. Pryor.
George M. Tuttle.
"The most notable contribution to gynecological literature since 1887, .... and the most
complete exponent of gynecology which we have. No subject seems to have been neglected,
.... and the gynecologist and surgeon, and the general practitioner who has any desire
to practise diseases of women, will find it of practical value. In the matter of illustrations
and plates the book surpasses anything we have seen." — Boston Medical and Surgical
yournal.
" A valuable addition to the literature of Gynecology. The writers are progressive,
aggressive, and earnest in their convictions." — Medical News, Philadelphia.
" A thoroughly modern text-book, and gives reliable and well-tempered advice and in
struction." — Edinburgh Medical Journal.
" The harmony of its conclusions and the homogeneity of its style give it an individuality
which suggests a single rather than a multiple authorship." — Annals 0/ Surgery.
" It must command attention and respect as a worthy representation of our advanced
clinical teaching." — American yournal 0/ Medical Sciences.
CATALOGUE OF MEDICAL WORKS.
For Sale by Subscription.
AN AMERICAN TEXT-BOOK OF THE DISEASES OF CHIL-
DREN. By American Teachers. Edited by Louis Starr, M. D.,
assisted by TiiOMi'soN S. Westcott, M. D. In one handsome royaI-8vo
volume of 1250 pages, profusely illustrated with wood-cuts, halftone and
colored plates. Net Prices: Cloth, ^7.00; Sheep or Half-Morocco, 38.00.
SECOND EDITION, REVISED AND ENLARGED.
The plan of this work embraces a series of original articles written by some
sixty well-known podiatrists, representing collectively the teachmgs of the most
prominent medical schools and colleges of America. The work is intended to
be a TKAcriCAL book, suitable for constant and handy reference by the practi-
tioner and the advanced student.
Especial attention has been given to the latest accepted teachings upon the
etiology, symptoms, pathology, diagnosis, and treatment of the disorders of chil-
dren, with the introduction of many special formulse and therapeutic procedures.
Special chapters embrace at unusual length the Diseases of the Eye, Ear,
Nose and Throat, and the Skin ; while the introductory chapters cover fully the
important subjects of Diet, Hygiene, Exercise, Bathing, and the Chemistry of
Food. Tracheotomy, Intubation, Circumcision, and such minor surgical pro-
cedures coming within the province of the medical practitioner are carefully
Considered.
CONTRIBUTORS :
Dr. I'homas S. Latimer, Baltimore.
Albert R. Leeds, Hoboken, N. J.
J. Hendrie Lloyd, Philadelphia.
George Roe Lockwood, New York,
Henry AL Lyman, Chicago.
Francis T. Miles, Baltimore.
Charles K Mills, Philadelphia.
James E. Moore, Minneapolis.
F Gordon Morrill, Boston.
Dr. S. S. Adams, Washington.
John Ashhurst, Jr., Philadelphia.
A. D. Blackader, Montreal, Canada.
David l)Ovaird, New York.
Dillon Brown, New York.
Edward AL Buckingham, Boston.
Charles W. Burr, Philadelphia.
VV. E. Casselberry, Chicago.
Henry Dwight Chapin, New York.
W. S. Christopher, Chicago.
Archibald Church, Chicago.
Floyd M. Crandall, New York.
Andrew F. Currier, New York.
Roland G. Curtin, Philadelphia
J. M. DaCos^a, Philadelphia.
1. N. Danforth, Chicago.
Edward P. Davis, Philadelphia.
John B. Deaver, Philadelphia.
G. E. de Schweinitz, Philadelphia.
John Doming, New York.
Charles Warrington Earle, Chicago.
Wm. A. Edwards, San Diego, Cal.
F. Forchheimer, Cincinnati.
J. Henry Fruitnight, New York.
J. P. Crozer Griffith, Philadelphia.
W. A. Hardaway. St. Louis.
M. P Hatfield, Chicago.
Barton Cooke Hirst, Philadelphia.
H. Illoway, Cincinnati.
Henry Jackson, Boston.
Charles G. Jennings, Detroit.
Henr^' Koplik. New York.
John H. Miisser, Philadelphia.
Thomas R. Neilson, Philadelphia
W. P. Northrup, New York.
William Osier, Baltimore.
Frederick A Packard, Philadelphia.
William Pepper, Philadelphia.
Frederick Peterson, New York.
W. T. Plant, Syracuse, New York.
William M. Powell, Atlantic City.
B. Alexander Randall, Philadelphia.
Edward O. Shakespeare, Philadelphia
F. C. Shattuck, Boston.
J. Lewis Smith, New York.
Louis Starr, Philadelphia.
AL Allen Starr, New York.
Charles W. Townsend, Boston.
James Tyson, Philadelphia.
vV. S. Thayer, Baltimore.
Victor C. Vaughan, Ann Arbor, Mich
Thompson S. Westcott, Philadelphia.
Henry R. Wharton, Philadelphia.
J. William White. Philadelphia.
J. C. Wilson, Philadelphia.
lO JV. B. SAUNDERS'
A NEW PRONOUNCING DICTIONARY OF MEDICINE, with
Phonetic Pronunciation, Accentuation, Etymology, etc. By John
M. Keating, M. D., LL.D., Fellow of the College of Physicians of Phila-
delphia; Vice-President of the American Pediatric Society; Ex-President
of the Association of Life Insurance Medical Directors ; Editor " Cyclo-
paedia of the Diseases of Children," etc. ; and Henry Hamilton, author
of " A New Translation of Virgil's ^neid into English Rhyme ;" co-
author of "Saunders' Medical Lexicon," etc.; with the Collaboration of
J. Chalmers DaCosta, M. D., and Frederick A. Packard, M. D.
With an Appendix containing important Tables of Bacilli, Micrococci,
Leucomaines, Ptomaines, Drugs and Materials used in Antiseptic Sur-
gery, Poisons and their Antidotes, Weights and Measures, Thermometric
Scales, New Official and Unofficial Drugs, etc. One ver}' attractive volume
of over 800 pages. Second Revised Edition. Prices : Cloth, ;$5.oo net ;
Sheep or Half-Morocco, ^6.00 net; with Denison's Patent Ready- Refer-
ence Index ; without patent index, Cloth, $4.00 net ; Sheep or Half-
Morocco, 35.00 net.
PROFESSIOXAI. OPINIONS.
" I am much pleased with Keating's Dictionary, and shall take pleasure in recommending
it to my classes."
Henry M. Lyman, M. D.,
Professor of Principles and Practice of Medicine, Rush Medical College, Chicago, III.
" I am convinced that it will be a very valuable adjunct to my study-table, convenient in
size and sufficiently full for ordinary use."
C. A. LiNDSLEY. M. D.,
Professor of Theory and Practice of Medici7ie, Medical Dept. Yale University :
Secretary Connecticut State Board of Health, New Haven, Conn,
AUTOBIOGRAPHY OF SAMUEL D. GROSS, M. D., Emeritus Pro-
fessor of Surgery in the Jefferson Medical College of Philadelphia, with
Reminiscences of His Times and Contemporaries. Edited by his sons,
Samuel W. Gross, M. D., LL.D., late Professor of Principles of Surger)-
and of Clinical Surgery in the Jefferson Medical College, and A. Haller
Gross, A. M., of the Philadelphia Bar. Preceded by a Memoir of Dr.
Gross, by the late Austin Flint, M. D., LL.D. In two handsome volumes^
each containing over 400 pages, demy 8vo, extra cloth, gilt tops, with fine
Frontispiece engraved on steel. Price per Volume, ^2.50 net.
This autobiography, which was continued by the late eminent surgeon until
within three months of his death, contains a full and accurate history of his
early struggles, trials, and subsequent successes, told in a singularly interesting
and charming manner, and embraces short and graphic pen-portraits of many
of the most distinguished men — surgeons, physicians, divines, lawyers, states-
men, scientists, etc. — with whom he was brought in contact in America and in
Europe ; the whole forming a retrospect of more than three-quarters of a century.
CATALOGUE OF MEDICAL WORKS. II
SURGICAL PATHOLOGY AND THERAPEUTICS. By John
Collins \\ Akki.N, M. D., LL.D., I'rofosor of Surger)-, Medical Depart-
ment Harvard University; Surgeon to the Massachusetts General Hospital,
etc. A handsome octavo volume of 832 pages, with 136 relief and litho-
graphic illustrations, t^i of which are printed in colors, and all of which
were drawn by William J. Kaula from original specimens. Prices : Cloth,
$6.00 net ; Half- Morocco, 37.00 net.
"The volume is for the bedsfde, the amphitheatre, and the ward. It deals
with things not as we see them through the microscope alone, but as the prac-
titioner sees their effect in his patients; not only as they appear in and affect
culture-media, but also as they influence the human body ; and, following up
the demonstrations of the nature of diseases, the author [x>ints out their logical
treatment." {^Xew York Medical yotimal). " It is the handsomest specimen
of book-making * * * that has ever been issued from the American medical
press " {^American Journal of the Medical Sciences, Philadelphia),
Without Exception, the Illustrations are the Best ever Seen in a
"Work of this Kind.
"A most striking and very excellent feature of this book is its illustrations. Without ex-
ception, from the point of accuracy and artistic merit, they are tlie best ever seen in a work
of this kind. * * * Many of those representing microscopic pictures are so perfect in their
coloring and detail as almost to give the beholder the impression that he is looking down the
barrel of a microscope at a well-mounted section. " — Annals of Surgery, Philadelphia.
PATHOLOGY AND SURGICAL TREATMENT OF TUMORS,
By N. Senn, M. D., Ph. D., LL. D., Professor of Practice of Surgery and
of Clinical Surgen,-, Rush Medical College ; Professor of Surgen.', Chicago
Polyclinic ; Attending Surgeon to Presbyterian Hospital ; Surgeon-in-Chief,
St. Joseph's Hospital, Chicago. One volume of 710 pages, with 515
engravings, including full-page colored plates. Prices: Cloth, $6.00 net;
Half-Morocco, 37.00 net.
Books specially devoted to this subject are few, and in our te.xt-books and
systems of surgen.- this part of surgical pathology is usually condensed to a de-
gree incompatible with its scientific and clinical importance. The author spent
many years in collecting the material for this work, and has taken great pains
to present it in a manner that should prove useful as a text-book for the student,
a work of reference for the busy practitioner, and a reliable, safe guide for the
surgeon. The more difficult operations are fully described and illustrated. More
than one hundred of the illustrations are original, while the remainder were
selected from books and medical journals not readily accessible.
"The most exhaustive of any recent book in English on this subject. It is well illus-
trated, and will doubtless remain as the principal monograph on the subject in our language
for some years. The book is handsomely illustrated and printed, .... and the author has
given a notable and lasting contribution to surgery." — yournal 0/ Anterican Medical A r so-
ciation, Chicago.
12 tV. B. SAUNDERS'
MEDICAL DIAGNOSIS. By Dr. Oswald Vierordt, Professor of
Medicine at the University of Heidelberg. Translated, with additions,
from the Fifth Enlarged German Edition, with the author's permission, by
Francis H. Stuart, A. M., M. D. In one handsome royal-octavo volume
of 600 pages. 194 fine wood-cuts in the text, many of them in colors.
Prices: Cloth, $4.00 net; Sheep or Half-Morocco, $5.00 net.
FOURTH AMERICAN EDITION, FROM THE FIFTH REVISED AND
ENLARGED GERMAN EDITION.
In this work, as in no other hitherto published, are given full and accurate
explanations of the phenomena observed at the bedside. It is distinctly a clin-
ical work by a master teacher, characterized by thoroughness, fulness, and accu-
racy. It is a mine of information upon the points that are so often passed over
without explanation. Especial attention has been given to the germ-theory as a
factor in the origin of disease.
This valuable work is now published in German, English, Russian, and
Italian. The issue of a third American edition within two years indicates the
favor with which it has been received by the profession.
THE PICTORIAL ATLAS OF SKIN DISEASES AND SYPHI-
LITIC AFFECTIONS. (American Edition.) Translation from
the French. Edited by J. J. Pringle, M. B., F. R. C. P., Assistant Phy-
sician to, and Physician to the department for Diseases of the Skin at, the
Middlesex Hospital, London. Photo-lithochromes from the famous models
of dermatological and syphilitic cases in the Museum of the Saint-Louis
Hospital, Paris, with explanatory wood-cuts and letter-press. In 12 Parts,
at $3.00 per Part. Parts I to 8 now ready.
"The plates are beautifully executed."— Jonathan Hutchinson, M. D. (London
Hospital).
" The plates in this Atlas are remarkably accurate and artistic reproductions of typical^
examples of skin disease. The work will be of great value to the practitioner and student."
— William Anderson, M. D. (St. Thomas Hospital).
" If the succeeding parts of this Atlas are to be similar to Part i, now before us, we have
no hesitation in cordially recommending it to the favorable notice of our readers as one of
the finest dermatological atlases with which we are s.cqvL^xnx.eA."'— Glasgow Medical yournal,
Aug., 1895.
" Of all the atlases of skin diseases which have been published in recent years, the present
one promises to be of greatest interest and value, especially from the standpoint of the
general practitioner." — American Medico-Surgical Bulletin, Ffeb. 22, 1896.
"The introduction of explanator>' wood-cuts in the text is a novel and most important
feature which greatly furthers the easier understanding of the excellent plates, than which
nothing, we venture to say. has been seen better in point of correctness, beauty, and general
merit." — Neiv York Medical Journal, Feb. 15, 1896.
" An interesting feature of the Atlas is the descriptive text, which is written for each picture
by the physician who treated the case or at whose instigation the models have been made
We predict for this truly beautiful work a large circulation in all parts of the medical world
where the names St. Louis and Baretta have preceded it."— Medical Record, N. Y., Feb. i,
CATALOGUE OF MEDICAL WORKS. 1 3
PRACTICAL POINTS IN NURSING. For Nurses in Private
Practice. By Emily A, M, Stoney, Graduate of the Training-School
for Nurses, Lawrence, Mass.; Superintendent of the Training-School for
Nurses, Carney Hospital, South Boston, Mass. 456 pages, handsomely
illustrated with 73 engravings in the text, and 9 colored and half-tone
plates. Cloth. Price, ^^1.75 net.
SECOND EDITION, THOROUGHLY REVISED.
In this volume the author explains, in popular language and in the shortest
possible form, the entire range of private nursing as distinguished from hospital
nursing, and the nurse is instructed how best to meet the various emergencies of
medical and surgical cases when distant from medical or surgical aid or when
thrown on her own resources.
An especially valuable feature of the work will be found in the directions to
the nurse how to improvise everything ordinarily needed in the sick-room, where
the embarrassment of the nurse, owing to the want of proper appliances, is fire-
quently extreme.
The work has been logically divided into the following sections :
I. The Nurse : her responsibilities, qualifications, equipment, etc.
II. The Sick-Room: its selection, preparation, and management.
III. The Patient : duties of the nurse in medical, surgical, obstetric, and gyne-
cologic cases.
IV, Nursing in Accidents and Emergencies.
V. Nursing in Special Medical Cases.
VI. Nursing of the New-born and Sick Children,
VII. Physiology and Descriptive Anatomy.
The Appendix contains much information in compact form that will be found
of great value to the nurse, including Rules for Feeding the Sick ; Recipes for
Invalid Foods and Beverages ; Tables of Weights and Measures ; Table for
Computing the Date of Later; List of Abbreviations ; Dose-List; and a full
and complete Glossary of Medical Terms and Nursing Treatment.
"This is a well-written, eminently practical volume, which covers the entire range of
private nursing as distinguished from hospital nursing, and instructs the nurse how best to
meet the various emergencies which may arise and how to prepare ever^-thing ordinarily
needed in the illness of her patient." — American Journal of Obstetrics and Diseases of
ll'owen and Children, Aug., 1896.
A TEXT-BOOK OF BACTERIOLOGY, including the Etiolog>- and
Prevention of Infective Diseases and an account of Yeasts and Moulds,
Haemaiozoa, and Psorosperms, By Edgar M, Crookshank, M. B., Pro-
fessor of Comparative Pathology and Bacteriolog)', King's College, London.
A handsome octavo volume of 700 pages, with 273 engravings in the text,
and 22 original and colored plates. Price, 36.50 net.
This book, though nominally a Fourth Edition of Profe^^sor Crookshank's
" Manual of Bacteriology," is practically a new work, the old one having
been reconstructed, greatly enlarged, revised throughout, and largely rewritten,
forming a text-book for the Bacteriological Laboratory, for Medical Ofticers of
Health, and for Veterinary Inspectors.
14 IV. B. SAUNDERS'
A TEXT-BOOK OF HISTOLOGY, DESCRIPTIVE AND PRAC-
TICAL. For the Use of Students. By Arthur Clarkson, M. B.,
C. M., Edin., formerly Demonstrator of Physiolog}- in the Owen's College,
Manchester; late Demonstrator of Physiology in the Yorkshire College,
Leeds. Large 8vo, 554 pages, with 22 engravings in the text, and 174
beautifully colored original illustrations. Price, strongly bound in Cloth,
$6.00 net.
The purpose of the writer in this work has been to furnish the student of His-
tol<^, in one volume, with both the descriptive and the practical part of the
science. The first two chapters are devoted to the consideration of the gereral
methods of Histolc^' ; subsequent!}-, in each chapter, the structure of the tissue
or organ is first systemaiically described, the student is then taken tutorially over
the specimens illustrating it, and, finally, an appendix affords a short note of the
m^hods of jH-ej3aration.
"We would most cordialij^ recommend it to all students of histology." — Dublin Medical
yourna-l.
"It is pleasaot lo give unqualified praise to the colored illustrations ; . . . the standard is
hjg^. and many of them are not only extremely beautiful, but verj' clear and demonstra-
tive. . . . The plan of the book is excellent." — Liverpool Medical Journal.
ARCHIVES OF CLINICAL SKIAGRAPHY. By Sydney Rowland,
B. A., C::;.. . A series of collot\-pe illustrations, with descrij-'tive text,
-••--t--'- - -"cations of the New Photography to Medicine and Sur-
:, $1.00. Parts I. to V. now ready.
li^e -i/.^jci- ■ - • „Llication is to put on record in permanent form some of
the most str .ications of the new^ photography to the needs of Medicine
and Suigen.
The pit^ress of this new art has been so rapid that, although Prof. Rontgen's
discovery i= r' ' : of vesterday, it has already taken its place among the
approved ar 1 is to diagnosis.
WATER AND WATER SUPPLIES. By John C. Thresh, D. Sc,
M. B., D. P. H., Lecturer on Public Health, King's College, London;
Editor of the "Journal of State Medicine," etc. i2mo, 438 pages, illus-
trated. Handsomely bound in Cloth, with gold side and back stamps.
Price, $2.25 net.
This work will fiiTOish any one interested in public health the information
requisite for forming an opinion as to whether any supply or proposed supply
is sufficiently wholesome and abundant, and whether the cost can be considered
reasonable.
The WM-k does not pretend to be a treatise on Engineering, yet it contams
sufficient detail to enable any one who has studied it to consider intelligently any
schem« which may be submitted for supplying a community with water.
CATALOGUE OF MEDICAL WORKS. 15
DISEASES OF THE EYE. A Hand-Book of Ophthalmic Prac-
tice. By c;. K. i)K ScHWKiN'irz, M. D., Professor of Ophtlialiuology in
the JelTcrson Medical College, I'liiladelphia, etc. A handsome royal-
octavo volume of 679 pages, with 256 fine illastrations, many of which are
original, and 2 chromo-lilhographic plates. Prices : Cloth, $4.00 net ;
Sheep or Half-Morocco, $^.00 net.
The object of this work is to present to the student, and to the practitioner
who is beginning work in the fields of ophthalmology, a plain description of the
optical defects and diseases of the eye. To this end special attention has been
paid to the clinical .om an extended experience in
teaching, the author has been enabled, by classification, to group allied symp-
toms, and by the judicious elimination of theories and redundant explanations
to bring within a comparatively small compass a complete outline of the prac-
tice of medicine.
1 8 IV. B. SAUNDERS
MANUAL OF MATERIA MEDICA AND THERAPEUTICS.
Bv A. A. Stevens, A. M., M. D., Instructor of Physical Diagnosis in the
University of Pennsylvania, and Demonstrator of Patholog>' in the Woman's
Medical College of Philadelphia. 445 pages. Price, Cloth, $2.25.
SECOND EDITION, REVISED.
This whollv new volume, which is based on the last edition of the Pharma-
copceia, comprehends the following sections: Physiological Action of Drugs;
Drugs ; Remedial Measures other than Drugs ; Applied Therapeutics ; Incom-
patibility in Prescriptions ; Table of Doses ; Index of Drugs ; and Index of
Diseases ; the treatment being elucidated by more than two hundred formulse.
" The author is to be congratulated upon having presented the medical student with as
accurate a manual of therapeutics as it is possible to prepare."— Therapeutic Gazette.
" Far superior to most of its class ; in fact, it is very good. Moreover, the book is reliable
and accurate." — New York Medical Journal.
" The author has faithfuUj' presented modern therapeutics in a comprehensive work, . . ,
and it will be found a reliable guide."— l/nzversitj/ Medical Magazine.
NOTES ON THE NEWER REMEDIES: their Therapeutic Ap-
plications and Modes of Administration. By David Cerna, M. D.,
Ph. D., Demonstrator of and Lecturer on Experimental Therapeutics in
the University of Pennsylvania. Post-octavo, 253 pages. Price, $1.25.
SECOND EDITION, RE-WRITTEN AND GREATLY ENLARGED.
The work takes up in alphabetical order all the newer remedies, giving their
physical properties, solubility, therapeutic applications, administration, and
chemical formula.
It thus forms a very valuable addition to the various works on therapeutics
now in existence.
Chemists are so multiplying compounds, that, if each compound is to be thor-
oughly studied, investigations must be carried far enough to determine the prac-
tical importance of the new agents.
" Especially valuable because of its completeness, its accuracy, its systematic consider-
ation of the properties and therapy of many remedies of which doctors generally know but
little, expressed in a brief yet terse manner." — Chicago Clinical Review.
TEMPERATURE CHART. Prepared by D. T. L.mne, M. D. Size
8x i3j/< inches. Price, per pad of 25 charts, 50 cents.
A conveniently arranged chart for recording Temperature, with columns for
daily amounts of Urinary and Fecal Excretions, Food, Remarks, etc. On the
back of each chart is given in full the method of Brand in the treatment of
Typhoid Fever.
CATALOGUE OF MEDICAL WORKS. 1 9
SAUNDERS* POCKET MEDICAL LEXICON; or, Dictionary of
Terms and Words used in Medicine and Surgery. By John M.
Keating, M. D., editor of ** Cyclopcedia of Diseases of Children," etc. ;
author of the " New Pronouncing Dictionary of Medicine;" and Henrv
Hamilton, author of " A New Translation of Virgil's -^Eneid into Eng-
lish Verse ;" co-author of a " New Pronouncing Dictionary of Medicine.'"
A new and revised edition. 32mo, 282 pages. Prices: Cloth, 75 cents*
Leather Tucks, ^i.oo. '
This new and comprehensive work of reference is the outcome of a demand
for a more modern handbook of its class than those at present on the market,
which, dating as they do from 1855 ^^ 1884, are of but trifling use to the student
by their not containing the hundreds of new words now used in current Utera-
ture, especially those relating to Electricity and Bacteriology.
" Remarkably accurate in terminology, accentuation, and A.^^x{\\\on." —Journal of Anter^
ican Medical Association.
"Brief, yet complete .... it contains the very latest nomenclature in even the newest
departments of medicine." — Neiv York Medical Record.
SAUNDERS' POCKET MEDICAL FORMULARY. By William
M. Powell, M. D., Attending Physician to the Mercer House for Invalid
Women at Atlantic City. Containing 1800 Formulae, selected from several
hundred of the best-known authorities. Forming a handsome and con-
venient pocket companion of nearly 300 printed pages, with blank leaves
for Additions ; with an Appendix containing Posological Table, Formulae
and Doses for Hypodermatic Medication, Poisons and their Antidotes,
Diameters of the Female Pelvis and Foetal Head, Obstetrical Table, Diet
List for Various Diseases, Materials and Drugs used in Antiseptic Surgery,
Treatment of Asphyxia from Drowning, Surgical Remembrancer, Tables
of Incompatibles, Eruptive Fevers, Weights and Measures, etc. Fourth
edition, revised and greatly enlarged. Handsomely bound in morocco,
with side index, wallet, and flap. Price, $1.75 net.
A concise, clear, and correct record of the many hundreds of famous formulae
which are found scattered through the works of the most eminent physicians
and surgeons of the world. The work is helpful to the student and practitioner
alike, as through it they become acquainted with numerous formulae which are
not found in text-books, but have been collected from among the rising genera-
tion of the profession, college professors., and hospital physicians and surgeons.
"This little book, that can be conveniently carried in the pocket, contains an immense
amount of material. It is very useful, and as the name of the author of each prescription is
given is unusually reliable." — Ne-M York Medical Record.
" Designed to be of immense help to the general practitioner in the exercise of his daily
calling " — Boston Medical and Surgical journal.
20 IV. B. SAUNDERS'
DISEASES OF WOMEN. By Henry J. Garrigues, A. M., M. D.,
Professor of Gynecology and Obstetrics in the New York School of Clinical
Medicine ; Gynecologist to St. Mark's Hospital and to the German Dis-
pensary, New York City. In one handsome octavo volume of 728 pages,
illustrated by 335 engravings and colored plates. Prices : Cloth, ^4.00 net ;
Sheep or Half Morocco, $5.00 net.
A PRACTICAL work on gynecology for the use of students and practitioners,
written in a terse and concise manner. The importance of a thorough know-
ledge of the anatomy of the female pelvic organs has been fully recognized by
the author, and considerable space has been devoted to the subject. The chap-
ters on Operations and on Treatment are thoroughly modern, and are based
upon the large hospital and private practice of the author. The text is eluci-
dated by a large number of illustrations and colored plates, many of them being
original, and forming a complete atlas for studying embryology and the anatomy
of ih.^ female genitalia, besides exemplifying, whenever needed, morbid condi-
tions, instruments, apparatus, and operations.
Second Edition, Tlioroiighly Revised,
The first edition of this work rnet with a most appreciative reception by the
medical press and profession both in this country and abroad, and was adopted
as a text-book or recommended as a book of reference by nearly one hundred
colleges in the United States and Canada. The author has availed himself of
the opportunity afforded by this revision to embody the latest approved advances
in the treatment employed in this important branch of Medicine. He has also
more extensively expressed his own opinion on the comparative value of the
different methods of treatment employed.
"One of the best text-books for students and practitioners which has been published in
the English language; it is condensed, clear, and comprehensive. The profound learning
and great clinical experience of the distinguished author find expression in this book in a
most attractive and instructive form. Young practitioners, to whom experienced consultants
may not be available, will find in this book invaluable coimsel and help."
Thad. a. Reamy, M. D., LL.D.,
Professor 0/ Clinical Gynecology , Medical College of Ohio ; Gynecologist to the Good
Samaritan and Cincinnati Hospitals.
A SYLLABUS OF GYNECOLOGY, arranged in conformity with
"An American Text-Book of Gynecology." By J. W. Long, M. D.,
Professor of Diseases of Women and Children, Medical College of Vir-
ginia, etc. Price, Cloth (interleaved), $1.00 net.
Based upon the teaching and methods laid down in the larger work, this will
not only be useful as a supplementary volume, but to those who do not already
possess the text-book it will also have an independent value as an aid to the
practitioner in gynecological work, and to the student as a guide in the lecture-
room, as the subject is presented in a manner at once systematic, clear, succinct,
?jid practical.
CATALOGUE OF MEDICAL WORK'S. 21
A MANUAL OF PHYSIOLOGY, with Practical Exercises. For
Students and Practitioners. Hy (i. N. Si kwart, M. A., M. D, D. Sc
lately Examiner in Physiology, University of Aberdeen, and of the New'
Museums, Cambridge University ; Professor of Physiology in the Western
Reserve University, Cleveland, Ohio. Handsome octavo vokime of 800
pages, with 278 illustrations in the text, and 5 colored plates. Price,
Cloth, $3.50 net.
,." ^' ^''i '";*'^*^ 'f. y^y by sheer force of merit, and a,npiy deserves to do so. It is one of
the very best English text-books o^ the subject. ' '—London Lancet. ^
" Of the many text-books of physiology published, we do not know of one that so nearlv
comes up to the ideal as does Professor Stewart's volume."-Z.'r///^/, Medical Journal ^
ESSENTIALS OF PHYSICAL DIAGNOSIS OF THE THORAX.
By Arthur M. Curwin, A. M., M. D., Demonstrator of Physical Diagno-
sis in the Rush Medical College, Chicago; Attending Physician to the
Central Free Dispensary, Department of Rhinology, Laryngology, and
Diseases of the Chest. 200 pages. Illustrated. Cloth, flexible covers.
Price, $1.25 net.
SYLLABUS OF OBSTETRICAL LECTURES in the Medical
Department, University of Pennsylvania. By Richard C. Norris,
A. M., M. D., Lecturer on Clinical and Operative Obstetrics, University
of Pennsylvania. Third edition, thoroughly revised and enlarged. Crown
8vo. Price, Cloth, interleaved for notes, $2.00 net.
" This work is so far superior to others on the same subject that we take pleasure in call-
ing attention briefly to its excellent features. It covers the subject thoroughly, and will
prove invaluable both to the student and the practitioner. The author has introduced a
number of valuable hints which would only occur to one who was himself an experienced
teacher of obstetrics. Ihe subject-matter is clear, forcible, and modern. We are especially
pleased with the portion devoted to the practical duties of the accoucheur, care of the child
etc. Ihe paragraiphs on antiseptics are admirable; there is no doubtful tone in the direc-
tions given. No details are regarded as unimportant ; no minor matters omitted We ven-
ture to say that even the old practitioner will find useful hints in this direction which he can-
not afford to despise. '—New York Medical Record.
A SYLLABUS OF LECTURES ON THE PRACTICE OF SUR-
GERY, arranged in conformity with " An American Text-Book
of Surgery." By N. Senn, M. D., Ph. D., Professor of Surgery in Rush
Medical College, Chicago, and in the Chicago Polyclinic. Price, ;^2.00.
This, the latest work of its eminent author, himself one of the contributors
to ' An American Text-Book of Surgery," will prove of exceptional value to
the advanced student who has adopted that work as his text-book. It is not
only the syllabus of an unrivalled course of surgical practice, but it is also an
epitome of or supplement to the larger work.
.ivl^?'nYw°/HH^^^''''^^"''y 'P-'"'^'^ "l? ?^'"' '" '"^^'"g bis Syllabus thoroughly comprehen-
refc;.nrl !rAl= "^"^ ""^ Vi^' ^"'-^ ?""^^^ '° '^'^ '""^t '^^^^' ^"thors and Operations Full
22 ^, B. SAUNDERS'
AN OPERATION BLANK, with Lists of Instruments, etc. re-
quired in Various Operations. Prepared by W. W. Keen, M. D.,
LL.D., Professor of Principles of Surgery in the Jefferson Medical Col-
lege, Philadelphia. Price per Pad, containing Blanks for fifty operations,
50 cents net,
SECOND EDITION, REVISED FORM.
A convenient blank, suitable for all operations, giving complete instructions
regarding necessary preparation of patient, etc., with a full list of dressings and
medicines to be employed.
On the back of each blank is a list of instruments used — viz. general instru
ments, etc., required for all operations ; and special instruments for surger)' of
the brain and spine, mouth and throat, abdomen, rectum, male and female
genito-urinary organs, the bones, etc.
The whole forming a neat pad, arranged for hanging on the wall of a sur-
geon's office or in the hospital operating-room.
" Will serve a useful purpose for the surgeon in reminding him of the details of prepa-
ration for the patient and the room as well as for the instruments, dressings, and antisepdcs
needed " — New York Medical Record
" Covers about all that can be needed in any operation." — American Lancet.
" The plan is a capital one." — Boston Medical and Surgical JourncU.
LABORATORY EXERCISES IN BOTANY. By Edson S. Bastin,
M. A,, Professor of Materia Medica and Botany in the Philadelphia Col-
lege of Pharmacy. Octavo volume of 536 pages, 87 full-page plates. Price,
Cloth, $2.50.
This work is intended for the beginner and the advanced student, and it fully
covers the structure of flowering plants, roots, ordinary stems, rhizomes, tubers,
bulbs, leaves, flowers, fruits, and seeds. Particular attention is given to the gross
and microscopical structure of plants, and to those used in medicine. Illustra-
tions have freely been used to elucidate the text, and a complete index to facil-
itate reference has been added.
" There is no work like it in the pharmaceutical or botanical literature of this countrj', and
we predict for it a wide circulation." — American yournal 0/ Pharynacy.
DIET IN SICKNESS AND IN HEALTH. By Mrs. Ernest Hart,
formerly Student of the Faculty of Medicine of Paris and of the London
School of Medicine for Women ; with an Introduction by Sir Henrj'
Thompson, F. R. C. S., M. D., London. 220 pages; illustrated. Price,
Cloth, $1.50.
Useful to those who have to nurse, feed, and prescribe for the sick. In
each case the accepted causation of the disease and the reasons for the sp>ecial
diet prescribed are briefly described. Medical men will find the dietaries and
recipes practically useful, and likely to save them trouble in directing the dietetic
treatment of patients.
CATALOGUE OF MEDICAL WORKS, 23
HOW TO EXAMINE FOR LIFE INSURANCE. By John M.
Keating, M. D., Fellow of the College of Physicians and Surgeons of
Philadelphia; Vice-President of the American Paediatric Society; Ex-
President of the Association of Life Insurance Medical Directors. Royal
8vo, 2 1 1 pages, with two large half-tone illustrations, and a plate prepared
by Dr. McClellan from special dissections ; also, numerous cuts to elucidate
the text. Second edition. Price, Cloth, $2.00 net.
"This is by far the most useful bcxJk which has yet appeared on insurance examination, a
subject of growing interest and importance. Not the least valuable portion of the volume is
Part II., which consists of instructions issued to their examining physicians by twenty-four
representative companies of this country. As the proofs of these instructions were corrected
by the directors of the companies, they form the latest instructions obtainable. If for these
alone, the book should be at the right hand of every physician interested in this special branch
of medical science." — The Medical News, Philadelphia.
NURSING: ITS PRINCIPLES AND PRACTICE. By Isabel
Adams Hampton, Graduate of the New York Training School for
Nurses attached to Bellevue Hospital; Superintendent of Nurses and
Principal of the Training School for Nurses, Johns Hopkins Hospital,
Baltimore, Md. ; late Superintendent of Nurses, Illinois Training School
for Nurses, Chicago, 111. In one very handsome i2mo volume of 484
pages, profusely illustrated. Price, Cloth, $2.00 net.
This original work on the important subject of nursing is at once comprehensive
and systematic. It is written in a clear, accurate, and readable style, suitable
alike to the student and the lay reader. Such a work has long been a desidera-
tum with those entrusted with the management of hospitals and the instruction of
nurses in training-schools. It is also of especial value to the graduated nurse
who desires to acquire a practical working knowledge of the care of the sick
and the hygiene of the sick-room.
OBSTETRIC ACCIDENTS, EMERGENCIES, AND OPERA-
TIONS. By L. Ch. Boisliniere, M. D., late Emeritus Professor of
Obstetrics in the St. Louis Medical College. 381 pages, handsomely illus-
trated. Price, ^2.CHD net.
" For the use of the practitioner who, when away from home, has not the
opportunity of con.sulting a library or of calling a friend in consultation. He
then, being thrown upon his own resources, will tind this book of benefit in
guiding and assisting him in emergencies."
INFANT'S WEIGHT CHART. Designed by J. P. Crozer Griffith,
M. D., Clinical Professor of Diseases of Children in the University of Penn-
sylvania. 25 charts in each pad. Price per pad, 50 cents net.
A convenient blank for keeping a record of the child's weight during the first
two years of life. Printed on each chart is a curve representing the average weight
of a healthy infant, so that any deviation from the normal can readily be detected.
24 PV. B. SAUNDERS'
THE CARE OF THE BABY. By J. P. Crozer Griffith, M. D.,
Clinical Professor of Diseases of Children, University of Pennsylvania;
Physician to the Children's Hospital, Philadelphia, etc. 404 pages, with
67 illustrations in the text, and 5 plates. i2mo. Price, ^1.50.
SECOND EDITION, REVISED.
A reliable guide not only for mothers, but also for medical students and
practitioners whose opportunities for observing children have been limited.
" The whole book is characterized by rare good sense, and is evidently written by a mas-
ter hand. It can be read with benefit not only by mothers, but by medical students and by
•my practitioners who have not had large opportunities for observing children." — American
Jjurnal of Obstetrics.
THE NURSE'S DICTIONARY of Medical Terms and Nursing
Treatment, containing Definitions of the Principal Medical and Nursing
Terms, Abbreviations, and Physiological Names, and Descriptions of the
Instruments, Drugs, Diseases, Accidents, Treatments, Operations, Foods,
Appliances, etc. encountered m the ward or the sick-room. By Honnor
Morten, author of " How to Become a Nurse," " Sketches of Hospital
Life," etc. i6mo, 140 pages. Price, Cloth, ^i.oo.
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PENROSE'S DISEASES OF WOMEN
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SENN'S GENITO=URINARY TUBERCULOSIS
Tuberculosis of the Genito-Urinary Organs, Male and Female. By Nicholas
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Surgery, Rush Medical College, Chicago. Handsome octavo volume of ^20 pages
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M.D., B.Sc. Lond., F R.C.S. Edin., Assistant Surgeon to Chelsea Hospital, London.
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ANOMALIES
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MACDONALD'S SURGICAL DIAGNOSIS AND TREATMENT
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