V > Columbia ®mber£tt|> v^o mtfjeCttpofi^ettjgorfe COLLEGE OF PHYSICIANS AND SURGEONS Reference Library Given by K)aA"VTX^M - (yet. •*** A MANUAL OPERATIVE SURGERY. BY LEWIS A. STIMSON, B.A., M.D., SURGEON TO THE NEW YORK AND HUDSON STREET HOSPITALS J CONSULTING SUR- GEON TO BELLEVUE, ST. JOHN'S, AND CHRIST'S HOSPITALS ; PROFESSOR OF SURGERY IN CORNELL UNIVERSITY; CORRESPONDING MEMBER OF THE SOCIETE DE CHIRURGIE, PARIS. JOHN ROGERS, Jr., B.A., M.D., SURGEON OF GOUVERNEUR HOSPITAL, NEW YORK; INSTRUCTOR OF SURGERY IN CORNELL UNIVERSITY. FOURTH AND REVISED EDITION. WITH TWO HUNDRED AND NINETY-THREE ILLUSTRATIONS. PHILADELPHIA : LEA BROTHERS & CO. Entered according to the Act of Congress, in the year 1900, by LEA BKOTHERS & CO., In the Office of the Librarian of Congress. All rights reserved. PREFACE TO FOURTH EDITION. In this fourth edition the principles which guided the preparation of the third have again been followed, and the part given to conclusions drawn from personal experi- ence has again been somewhat increased. The size of the book has been reduced by omission of portions of the text and of about forty cuts which seemed to ha% r e outlived their usefulness. LEWIS A. STIMSON. CONTENTS. PART I. TIIK ACCESSORIES OF AN OPERATION. Anesthesia. Local, General, Administration of the anaes- thetic, Rectal, Arrest of hemorrhage, Ligature, Torsion, Pressure, Cold or heat. Position, Artificial ischemia. Sutures, Interrupted, Continuous, PAGE PALE 17 Sutures, twisted, 25 17 Preparation of materials used in an 18 operation. 26 Catgut, 26 19 chromicized, 26 20 Silk, 26 20 Silkworm-gut, 26 20 Sponges, 26 20 Absorbent gauze, 27 20 Bichloride gauze. 27 22 Iodoform gauze, 27 22 Drainage-tubes, 28 23 Absorbent cotton, 28 25 Rubber tissue, 28 25 Sterilization, 28 25 The wound and its treatment, 29 PART II. LIGATURE OF ARTERIES. General directions, 33 Anatomy of the supra-clavicular region, 35 Ligature of the innominate artery, 37 Anatomy, 37 Operation, ::7 Ligature of the subclavian artery, ::;i 1st portion, left subclavian, 39 1st portion, right subclavian, 40 2d portion, 40 3d portion, 40 Ligature of the superior thyroid, 41 Ligature of the inferior thyroid, 42 Ligature of the vertebral artery, 43 Ligature of the axillary artery, 43 Under the clavicle, 44 In the axilla, 44 Ligature of the brachial artery, 45 Anatomy, 4.~> Operation, 47 Ligature of the radial artery. 47 Anatomy, 47 Operation, upper third, 48 Operation, lower third. 4s Ligature of the ulnar artery. V.i Anatomy, 4'J Operation at the junction of the upper and middle third-. 49 Operation in the lower third, 49 Ligature of the common carotid, At the place of election, Ligature of the external carotid, Anatomy. Operation. Ligature of the internal carotid. Ligature of the lingual artery. Anatomy, Operation, Ligature of the facial artery. Ligature of the occipital artery. Ligature of the temporal artery, Ligature of the abdominal aoi ta. Ligature of the common iliac, Anatomy of the common, inter- nal and external iliac arteries. Extra-peritoneal, Intra-peritoneal, Ligature of the internal iliac, Ligature of the external iliac. Ligature of the gluteal, sciatic and internal pudic arteries, Ligature of the femoral artery, Anatomy, Operation, At the apex of Scarpa's tri- angle, In the middle of the thigh, In Hunter's canal, VI CONTENTS. Ligature of the popliteal artery, Ligature of the anterior tibial, Anatomy, Operation, Ligature of the dorsalis pedis, PA OF. 65 65 65 66 67 PAGE Ligature of the posterior tibial, 67 Outline's method, 67 Lateral method, 67 In the lower third and behind the ankle, 69 PART III. AMPUTATIONS. Circular method, 1st step, 2d step, (6) Cutaneous sleeve, 3d step, Oval method, Flap method, .Skin flaps and circular division, Long anterior flap, Teale's method, Amputation of the fingers, Phalanges, Through the metacarpo-phalan- geal articulation, Amputation of the metacarpal bones, Amputation at the wrist, Circular method, Antero-posterior flaps, External lateral flap, Amputation of the forearm, Amputation at the elbow-joint, Anterior flap, (a) The joint opened from behind, (tf) The joint opened from in front, Lateral Map, Circular, Amputation of the arm, Amputation at the shoulder-joint, < ieneral considerations, Oval method (Baron I.arrey), Double flap method (Lisfrauc), Spence'e method, Amputation of the arm, scapula, and clavicle, Amputation of the toes, Distal phalanx of the great toe, Disarticulation of the great toe, Two adjoining toes, Amputation of a metatarsal b< Disarticulation of the i>tor 5tb metatarsal, Disarticulation of all the metatar- sal bones i Lisfranc's amputa- tion l, Modifications, tfedio-tarsal amputations (< impart;, 97 100 100 101 104 105 105 105 105 106 Sub-astragaloid amputation, Tripier's modification, Amputation at the ankle-joint (Syme), Modifications, A. Internal lateral flap (Koux), B. Pirogoff's amputation, Comparison of the different methods of partial and total amputation of the foot. Amputation of the leg, A. Lower third, 1. Circular method, Brun's 2. Modified circular, 3. Long anterior flap (Bell), 107 4. Elliptic posterior flap (Guyon), 107 B. Middle" third, 108 1. Long anterior curved flap, 108 2. Single posterior flap, 108 3. Skin flaps and circular division, 108 C. Upper third, 109 1. Long anterior rectangular flap (Teale), 109 2. Long posterior rectangu- lar flap (Lee), 110 :;. Modified flap (Bell), 110 Comparison of the different methods, 110 Amputation at (he knee, ill A. Disarticulation, ill Lateral Haps. 112 B. Amputation througb the condyles, oval, Anterior flap (Car den |, Oritti's modification, Am|iiitai ion of tin- thigh, Teale and < larden, Modified flap, in lower third (Syme), 116 Long anterior flap, 1 16 Circular, 117 Amp itation at the bip-Joint, 1 18 Anterior racket or oval, 120 External racket or modified oval, 121 \ nterlor flap, 122 Senn'8 method. 123 112 112 118 115 116 C0N1ENTS. VI 1 PART IV. EXCISION OF JOINTS AND BONES. PAGE General considerations, 125 Major articulations, 128 Excision of the shoulder-joint, 12$ Ollier's method, 12!) Yon Langenbeck's method, 130 By a transverse incision, 131 Excision of the elbow-joint, 131 Central longitudinal incision (v. Langenbeck), 132 Ollier's method, 133 Nelatou's method, 134 Long radical incision (Hueter), 135 Osteoplastic method, 136 Bilateral incisions (Vogt), 137 Partial excision, 137 Excision of anchylosed elbow, 137 Ollier's method, 138 P. Heron Watson's method, 138 Operative reduction of old disloca- tion, 139 Excision of the wrist. 140 Bilateral incisions (Lister), 141 Radial incision (Oilier), 144 Dorso-radial incision (von Lan- genbeck), 145 Excision of the hip-joint, 14B Savre's method,' 146 Ollier's method, 148 Langenbeck, 148 Anterior incision, 149 Arthrectomy, 150 Anchylosis of the hip-joint, treated by subcutaneous division of the neck of the femur (Adams), 150 Division below the trochanter, 152 Excision, 152 Excision of the knee-joint, 153 Semilunar incision, 153 Transverse incision, 154 Arthrectomy, 154 Excision of the ankle-joint, 155 Vogt's method by removal of the astragalus, 157 Osteoplastic excision of foot (Mikulicz), 15S Operative reduction of old Pott's fracture, 160 Excision of the bones and smaller articulations, 161 Excision of the superior maxilla, 161 Operation by a median incision, 163 Subperiosteal excision (Oilier), 165 Excision of lower portion, 166 Excision of upper portion, 167 Simultaneous excision of both su- perior maxilla?, 168 Partial and temporary excisions of the superior maxilla to facili- tate the removal of naso- pharyngeal polyps, 168 Osteoplastic resection of an- terior portion of hard palate (Chalot), 169 PAGE Partial resection of the upper por- tion (von Langenbeck), 170 Other methods of gaining access to the pharynx through the nose, 171 Boeckel, Oilier, Excision of the inferior maxilla, General considerations, Resection of the anterior portion of the body, Resection of the lateral portion of the body, Resection of the ramus and half the body, Excision of the entire bone, Subperiosteal method, Partial excisions, Anchylosis of the jaw, Excision of the condyle, Resection of the sternum, Resection of the ribs, Estlander's operation for empy- ema, Excision of the clavicle, Excision of the scapula, Subperiosteal method (Oilier), I Opening of the joint 171 173 173 173 176 177 178 178 178 178 179 180 180 180 181 182 183 185 Partial excisions of the scapula, 185 Resection of the humerus, 185 Upper portion, 185 Middle portion, 186 Lower portion, 186 Total excision, 186 Excision of the ulna, 186 Excision of the radius, 186 Partial excisions of the ulna and radius, 187 Excision of the metacarpal bones and phalanges, 187 Resection of a phalanx, 1S7 Resection of the bones of the pel- vis, 188 Excision of the coccyx, 188 Resection of the shaft of the fe- mur. 189 Resection of the shaft of the tibia, 189 Resection of the fibula, 190 Of its upper extremity, 191 ( If the lower portion, 191 Excision of the entire fibula, 192 Excision of the bones of the foot, 192 Calcaneum, 192 Subperiosteal method (Oi- lier), 192 Farabeuf, 193 Astragalus, 194 Ollier's method, 194 When dislocated, 195 When shattered, 195 Metatarsal bones and phalanges, 195 Operations upon the cranium, 195 Trephining, 195 Trephine, 195 VI 11 CONTENTS. Trephining — Chisel, Gigli saw. Temporary . bj omega Hap, Craniectomy, In fracture, Relation of brain to overlying parts I Reid), Relation of brain lo overlying parts (Kocher), Position of lateral sinus, To open lateral sinus, J.OE PAGE Trephining— 196 I'm- cerebral abscess due t MISCELLANEOUS OPERATIONS. Division and resection of nerves. Supra-orbital nerve. Subcutaneous division, Excision of a port ion, A. Above the eyebrow, B. Below the eyebrow, Snpra-trochlear nerve, 8 ipei ior maxillary nerve, A. Division of the nerve on the face, 1. Subcutaneously, 2. Through the mouth, :i. By external excision, B. le -eel inn of the i II lYa-nl'l li I al portion, TDlau \- method, LUcke'a method, inferior dental nerve, A. Al the mental foramen, p.. win. in the canal, i Bi tore lu entry into the canal, 1. Prom within the ne. iilli, 2. Through the ohi el . Ai the foramen "•• ale, Buccal oerve, Lingual nerve, Moore' - in. thod, Facial nerve, Brachial plexus, Cen leal plexus. 215 Spinal accessory, 226 215 First, second, and third nerves for •_'!.; wry-neck, 227 216 Median nerve, 228 216 Ulnar nerve, 228 217 Musculo-spiral uerve, 229 217 Great sciatic nerve, 229 217 1 ni. -nial popliteal nerve, 229 External popliteal nerve, 220 218 Anterior crural nerve, 220 218 Neurorrhaphy, 280 21 S Tenotomy, 2:to 218 I leneral considerations, 230 Tendo-Achillia, 231 218 l ibialis post icus, 231 218 \. Lbove the malleolus, 231 21 '.I it. On the Bide of the fool 232 220 Tibialis anticus, 282 220 Peronei, 282 2211 1 lexer lemh.n- al the tc 1, 282 Sterno-eleido-mastoid, 282 221 Tenorrhaphy, 232 221 i >f teotomj . 221 Shaft, 286 222 lei 286 22:; Supra-condyloid, 286 22 1 i or hallux \ algus. 286 22 1 i uneifoi m, tor talipes, i Operations for ununited fracture 287 22.". 210 22.-. Suture of patella, 211 220 . ii. .i anon, 242 221'. Laminectomy, 242 Ml-( l.l.l, Wl.oi s OPER mONS. II inc. Separation of web-fli :> Lai flex Ion oi phaianget 2 1 8 I mpiiylren's coni raei inn, 248 i n grown toenail. 246 Remot al of ceri leal glands, 217 217 248 CONTENTS. IX PART VI. PLASTIC OPERATIONS ON THE FACE. TAGE The dift'erent methods and then- history, 251 General principles, 25Z Cheiloplasty, «» A. Lower lip, 2o3 1. V-incision, 253 2. Oval horizontal incision, 253 3. Method of Celsus or Serres, 254 4. Dieffenbach, 255 5 Syme-Buchanan, 255 6. Buck's method, 257 7. Square lateral Haps, Mal- gaigne, 258 8. Square vertical Haps, 259 B Angle >>f the mouth (stomato- plasty), 260 Buck, 200 C. Upper lip, 262 1. Vertical flaps, 262 2. Infero-lateral flap, 262 Harelip, 263 Single harelip, simple, 263 1. Double flaps, 264 2. Nelaton'a method, 265 :■•,. Single Bap, 265 4. Gir aides' S method, 265 Double harelip, simple, 266 Complicated harelip, 267 Rhinoplasty, 268 1. Superficial defect, not involv- ing the bones or septum, 269 Lateral, oblique, and vertical Haps, 269 Denonvillier's method, 270 Von Langenbeck's method, 270 Michon's method, 271 Restoration of columna, 271 2. Loss of the septum and nasal bones, the skin remaining entire, 272 Dieifenbach's ease, 272 Ollier's osteoplastic method, 273 Double layer, or superposed flaps, ' 274 Pancoast's subcutaneous me- thod, 275 3. Loss of more or less of the sur- face and the septum, 276 A. Indian method, 276 Modifications, 277 PAGE Rhinoplasty— B. Ollier's osteoplastic me- thod. 279 C. Alquie's method, 281 D. Italian method, 281 Operations upon the eyelids, 282 Blepharorrhaphy, 282 Canthoplasty, 283 Blepharoplasty, 284 1. In ectropion, 284 Wharton Jones, 284 Aiphonse Guerin, 284 Von Graefe, 285 Dieffenbach, Adams, and Amnion, 2s.i Richet, 286 Knapp, 287 Burow, 287 Dieffenbach, 288 Indian method, 288 Richet, 289 Ilasner d'Artha, 289 Denonvillier, 290 Ectropion due to excess of conjunctiva, 291 2. Entropion, 291 Canthoplasty, Ligature, . 291 Excision or cauterization of a fold of the skin, 291 Spasmodic entropion, Von Graefe, 292 Division of tarsal carti- lage, 293 Vertical division, 293 Longitudinal divi- sion (Amnion), 293 Excision of part of tarsal cartilage, 298 3. Symblepharon, 294 Ligature, 294 Arlt's method, 294 Teale's method, 295 Ledentu's method, 295 4. Pterygion, 296 Excision, 296 Ligature, 296 5. Trichiasis, 297 Von Graefe, 297 Anagnostakis, 297 CONTENTS. PART VII. SPECIAL OPERATIONS. CHAPTER I. OPERATIONS UPON THE EYE AND ITS APPENDAGES. PAGE 299 299 301 301 302 302 The cornea, Removal of a foreign body, Puncture of the cornea. Evisceration for staphyloma, The iris, Iridotomy, Simple incision (Cheselden, Bowman), 302 Simple iridotomy, Wecker, 303 Double iridotomy, Wecker, 303 Iridectomy, 308 Antiphlogistic iridectomy, 304 Iridesis, 307 Corelysis, 308 Operations undertaken for the relief of cataract, 309 Depression or couching, 310 Scleronyxis, 310 Keratonyxis, 311 Division, Discission, or Solution, 311 Division through the cornea, 312 Division through the scle- rotic (Havs), 312 Ex 1 raft ion, 313 Flap extraction, 313 Von Graefe's method, 317 its PAGE Operations undertaken for the relief of cataract — Gayett and Knap]., Linear extraction, Scoop extraction. Removal by suction, Removal of the lens in capsule, Pagenstecher'e method, Secondary cataract, Operations for the relief of strahis- mu8, Internal rectus, Subconjunctival method, Secondary strabismus, Enucleation of the eyeball, Extirpation of the contents of theorbit, 329 Operations upon the lachrymal ap- paratus, 329 Extirpation of the lachrymal gland, 329 Lachrymal sac, duct, and canal- iculi, 380 Slitting up the canaliculus. :'.:il Puncture of the sac, '■'<*■! 820 320 321 322 323 824 824 826 326 327 328 CHAPTER II. OPERATIONS UPON THE BAB AND ITS APPENDAGES. Occlusion of the external auditory Catheterization of the Eustachian canal, :;:;| tube, 335 Introduction of speculum, 334 Opening of mastoid antrum, 886 Paracentesis of the drum-head, 334 | CHAPTER III. OPERATIONS UPON THE MOUTH AND PHARYNX. Excision "i the tonsils, 337 Staphylorrhaphy, 338 Qranoplasty, 345 isson'e osteoplastic method, :;i s Dai lee-Colley's method, 848 Excision ol the tongue, 849 l hrougb the mouth, 350 Kocher, 352 Excision of the tongue— x'dil lot's method, Division of the fraeuum, Kami ht, Salivary fistula, i leguise's method, Van Buren'e method, CHAPTER IV. .,11 BATIOME PI l:10RMED UPON THE NECK. Bronchotomy, 357 Subhyoid laryngotomy, 867 old laryngotomy, .-thyroid laryngotomy, B69 Laryngo-tracheotomy. 860 hi < lermaln's method, 881 Tracheotomy, B61 By galvano- or thermo-cau- tery, •"' ,;:; tomy, i omplete, Partial, Pharyngotomy, \ ..I. I .angenbeck, Mikulicz, Cheever, i Esophagotomy, i aternal, 353 355 355 355 866 356 364 364 365 366 866 367 368 368 369 CONTENTS. CEsophagotoiny — External, 370 Operations upon thyroid gland, 371 Ligation of arteries, 373 Operation upon thyroid gland— Enucleation of a portion, 374 Removal of a portion, 374 Removal of isthmus, 375 CHAPTER V. OPERATIONS PERFORMED UPON THE THORAX. Amputation of the breast, Halsted, 376 Paracentesis of the thorax, 376 Paracentesis of the pericardium, 377 378 CHAPTER VI. OPERATIONS PERFORMED UPON THE ABDOMINAL WALL, STOMACH, AND INTESTINES. Paracentesis of the abdomen, Laparotomy, Operations on the intestines, Anatomy, Continuous suture, Right-angled continuous, Interrupted (Lembert), Czerny, Halsted's quilt suture, Circular euterorrhaphy, Intestinal anastomosis, Senn's plates, Murphy's button, By intussusception, Enterostomy, Right inguinal, Colostomy, Right inguinal, Lumbar, Closure of an artificial anus or fecal fistula, Removal of vermiform appendix, McBuruey, During period of suppura- tion, Stomach, Gastrostomy, Kader, Gastrotomy, For stenosis of pyloric or cardiac orifice, Gastrorrhaphy, Gastroplication, Pylorectomy, (instroenterostomy, Jejanostomy, Herniotomy, kelotomy, General directions", A. Recognition of the sac and bowel, B. Opening of the sac, C. Division of the stricture, D. Examination and return of the bowel, E. Treatment of the omen- tum, 379 Herniotomy, kelotomy — 380 Strangulated inguinal hernia, 426 383 Femoral hernia, 428 383 Fmbilical hernia, 430 385 Obturator hernia, 432 386 Radical cure of inguinal hernia, 432 386 Czerny, 432 :;ss Bassini, 434 388 Halsted, 439 :-;ss MeBurney, 439 390 Radical cure of umbilical hernia 440 393 Radical cure of femoral hernia, 440 393 Operations upon the rectum, 441 394 Imperforate anus or rectum, 442 395 Prolapse, 444 395 Rectopexy, 446 397 Ablation, 446 398 Torsion, 447 399 Rectotomy, 447 Fistula, 447 401 Hemorrhoids, 448 402 Ligation, 448 404 Whitehead, Excision of anus and part of rec- 448 404 tum, 449 405 A. Removal from below, 449 407 B. Removal from below 409 leaving sphincter, 451 411 C. Hueter's method, D. Removal from behind 452 412 Kraske, 453 414 Liver, 456 415 Abscess, 457 416 Hydatids, 459 418 Cholecystostomy, 460 421 Operations on bile ducts, 461 421 Cholecystenterostomy. 462 422 Cholecystectomy, 464 Spleen, 464 422 Splenectomy, 465 423 Kidney, 465 424 Exposure of, 466 Lnmbai methods, 466 425 Nephrotomy, 469 Nephrolithotomy, 469 426 Lumbar nephrectomy, 471 CONTENTS. Kidney— Abdominal nephrectomy , Nephropexy, PAGE I Ureter, •172 Operations on, 474 Wounds of, PAGE 474 475 477 CHAPTER VII. OPERATIONS UPON THE GENITO-URINAUY ORGANS OF THE MALE. ( last ration, Hydrocele, Puncture of the sac, Radical cure, Varicocele, Excision of the scrotum, Subcutaneous ligature, Open ligation, Amputation of the penis, Operations for phimosis, Dorsal incision, Circumcision, Paraphimosis, Division of the fraenuin, Epispadias, Nrlaton's method, Thiersch's method, Hypospadias, Urethroplasty, i ln'opliili- A user's method, I >u play's method, Urethral fistula, ( leneral considerations, Urethrorrhaphy, Urethroplasty, Nrlaton's me! hod. Key bard, Dieffenbach, and Delore, ■ISO Urethral fistula — 481 Delpcch and Alliot, 500 481 Sir Astley Cooper, 500 482 Arlaud, 500 482 Sedill.it, 501 482 Rigaud, 501 483 Theophile Anger, 501 483 Scynianowski, 501 484 McBurney, 501 485 Internal urethrotomy, 502 485 External perineal urethrotomy, 503 485 A. With a guide, 503 487 B. Without a guide, 505 487 Exstrophy of the bladder, 507 487 Catheterization, 509 488 Puncture of the bladder, 511 490 Litholapaxy, 511 492 Lithotomy, 51 fi 403 Lateral lithotomy, 517 494 Median lithotomy, 521 49G Supra-pubic lithotomy, 523 497 Prostatectomy, supra-pubic, 52G 497 Perineal, 527 198 Combined supra-pubic and peri 499 ncal, 527 199 Tumors of bladder, 527 Removal of seminal resides, 530 CHAPTER VIII. i.PKU \Tlo\S ri-nN THE GEXITO-rKIMARY ORGANS OF THE FEMALE. Catheterizal ion, External urethrotomy, Lithotomy, i Irethral lithotomy, Veaico-vaginal lithotomy, Occlusion, or at resia vaginas, P( i iiieorrhaphy , Prolapse of the posterior wall ol the vagina, 1st variety, 2d variety, Elegar's method, Laceration Of the perineum and sphincter ani. -\ aginal fistula, [i o-i aginal fist ula. Obliteration of the vagina: kolpox- ■. Ing of i be vagina ; elj i ror- rtaaphy, Post* i rrbaphj oi colpop- i baphj ■ Hegar), Martin,' La< • rated cervix, 533 588 585 585 635 586 537 538 540 oil 548 :. 19 554 557 558 659 Posterior section of the cervix, Operations on the uterus and ad- uexa, Anatomy, ( Ovariotomy, Oophorectomy, Salpingo-ooplioroctomv, Tumors beneath broad ligament, For ectopic gestal ion, l [ysteropexy, Intra-abdominal shortening ////: ACCESSORIES OF AS OPERATION. about the trunk of a nerve. As it is dangerously toxic only small quantities should be used. When the skin is uninflamed the best method is to insert a hypodermic needle very obliquely into the skin and force a lew drops of the solution through it; the needle can then be ad- vanced painlessly along the welt raised by the injection, and additional drops injected until the needle has been introduced to its full length. It is then withdrawn and inserted afresh at the furthest point reached by the injec- tions until the entire distance to be occupied by the in- cision has been rendered insensitive. The action of the drug is hastened and prolonged, and the chance of poi- soning diminished, by temporarily cutting off the blood- supply from the part ; in the case of a limb this is most conveniently done by circular elastic constriction. Injection into inflamed parts is very painful because of the increased tension, and it is, therefore, better in such cases to seek to benumb the nerves supplying the part by injection beneath the skin on the proximal side of the pro- posed incision. General Anaesthesia. — The agents in common use for producing general amesthesia are ether, chloroform, and nitrous oxide. The great advantage of ether is in its safety. Chloro- form is more rapid in its action and more easily taken, hut it is distinctly more liable to cause death during its administration. On the other hand, ether acts unfavor- ably upon kidneys that are already diseased, and it is not well borne by the elderly with chronic pulmonary complications. Its vapor is inflammable; that of chloro- form is not. Hither agent may cause death by suffocation, through obstruction of the air passages by the relaxed and de- pendent tongue or by the lodgment of vomited matter; but chloroform may also kill by specific action upon the respiratory and circulatory centers. The indication when suffocation threatens and the face i- blue and swollen 18 to clear the air passages, usually by drawing the tongue forward or by pressing the lower jaw ANESTHESIA. 19 forward with the fingers placed below and behind its angles. If vomited matter or other foreign body has lodged over or within the larynx the patient should be so placed that his head and shoulders are dependent and should then be forcibly shaken. Death by the toxic action of chloroform comes in the form of syncope with a pale face, and sometimes after only a small quantity has been given, one or two drachms. This sudden early poisoning is best guarded against bv intermitting the administration whenever the patient struggles and not renewing it until after he has taken at least one full breath. The condition is to be met by suspending the patient head downward and practicing artificial respiration. Administration of the Anaesthetic. — Chloroform is best given by letting it fall drop by drop upon a single layer of muslin stretched upon a small wire frame and held close over the mouth and nostrils. This is thought to be somewhat safer than pouring a drachm or two upon a handkerchief and renewing it as it evaporates. Ether is commonly given from a " cone " made by wrapping a towel about several thicknesses of paper folded in a strip about eight inches wide and one and a-half or two feet long, and then folding it again into a roll which will fit snugly over the chin and nose. The upper end of the roll should bo elosed by pinning its edges together, and a handkerchief or bunch of absorbent cotton should be pressed into it that it may retain a larger amount of the ether. Special apparatuses composed of a rubber bag and a mouthpiece and receptacle which permits the admixture of air with the ether vapor in any desired proportion are in quite common use in hospitals and have many advantages. The method recently introduced by Dr. Thos. L. Bennett of first producing insensibility by nitrous oxide and then continuing with ether has removed the discomforts and inconveniences which made the preliminary stage of etherization so disagreeable for both the patient and the surgeon. 20 THE ACCESSORIES OF AN OPERATION. Rectal Etherization. — It was shown by Molliere, in 1884, that genera] anaesthesia could be readily obtained by the administration of ether by the rectum. The method was at once widely tried, but has been abandoned, except in special cases, for it was found to be more dan- gerous than the method by inhalation. The dangers are that the anesthetization may unwittingly be made too profound and prolonged, and that the contact of the ether with the intestinal mucous membrane may cause a bloody diarrhoea. The ether is placed in a bottle provided with a tightly- fitting cork through which passes a rubber tube. The free end of the tube is inserted in the rectum, and the bottle placed in warm water. The precautions to be observed are that the water should not be warmer than 100° Fahr., and that as soon as anaesthesia is obtained the tube should be withdrawn from the rectum, to be reapplied if necessary. The tube should be large, and should extend downward from the anus to the bottle without loops or coils in which the ether might condense. ARREST OF HEMORRHAGE. Hemorrhage is arrested: by ligature; by torsion; by pressure ; by cold or heat ; by position. Ligature. — The vessel or I deeding point is seized by for- ceps (Figs. 1, - and •'!) with as little of the surrounding tissue as possible. It is encircled by silk or catgut, which is tied in a square knot (Fig. 1). < >r, if the vessel can- not be seized or held, the ligature is passed under it on a curved needle. Torsion. — Thevessel is isolated, grasped by the forceps, drawn out and twisted till it parts. It is not in general USe except for small vessels. Pressure made by sponges, gauze pads, or clamps left in place for a lew- minutes will frequently be found suffi- cient to arresl oozing, venous hemorrhage, or the bleeding from small arteries. ARREST OF HEMORRHAGE. 21 Fig. l. Artery forceps. Fig. 2. Self-holding hemostatic forceps. Fig. 3. Self-holding haemostatic forceps; curved. 22 THE .\r< i;\sni; I i;s or .|.\ OPERATION. Very great, crushing pressure by :> specially con- structed instrument (Fig. 5) has been successfully used and of late even to secure vessels as large as the femoral artery. It has thus far been used almost exclusively in Fig. 4. quarc knot. vaginal hysterectomy and its use has been followed in a rather large proportion of cases by late bleeding. Cold or Heat. — Hemorrhage may he checked by the actual cautery at a dull-red heat, by ice-cold water or by water at a temperature of 110° to 120° F. Fig. Angiol ribi Position, either alone or combined with pressure, is a valuable haemostatic. Elevation of a limb will diminish the blood pressure and often allow a coagulum lo form in a divided vessel, where it would otherwise be washed away by the force of the blood flow. ARTIFICIAL TSCHJEMIA. 23 ARTIFICIAL ISCHEMIA. Loss of blood during ;ui operation upon a limb may be prevented by pressure upon the main artery on the proxi- mal side of the incision. This pressure may be made with the finger, tourniquet, or elastic cord. The tourniquet (Fig. (i) is composed of a pad, band, and screw ; by turning the screw the band may be tight- ened at will. The principle of its application is the com- Fig. (i. Petit's tourniquet. pression of the artery against the underlying bone. A point should be selected in the course of the artery where such compression can be made ; a roller bandage, an inch in diameter, placed over the vessel and parallel to its course, the tourniquet then applied as shown in Figs. 7 and 8 and the screw tightened. Some surgeons prefer to place the pad of the tourniquet upon the roller bandage itself and not on one side as shown in the figure. The 24 THE .U'CKSSOUIKX <>F AX OPERATION. buckle <>n (ho band should always be much further front the roller than is represented in the figures. The elastic tourniquet is applied after holding the limb till- ;i short time in an elevated position to diminish the amount of blood in it. Then, without changing- the posi- tion, a soft but stout rubber cord or band is wrapped sev- eral times about the limb sufficiently tight to occlude all the vessels and fastened in position by a single knot. Fig. 7. Fig. 8. if application of tourniquet. It should be applied :it -a eon venieiit point, well above the seal of operation. Or the Esmarch rubber bandage, usually two or more inches broad, is applied from the fin- gers or toes of an extremity spirally upward, each upper turn overlapping the one below from a quarter to half an inch. It is wound tightly enough completely to empty all the vessels of blood a- it advances and i- carried to the point where the rubber tourniquet can be best ap- SUTURES. or, plied, which is then done as already described. The spiral bandage is then removed. The objections to the rubber bandage and tourniquet are the possibility of pressure paralysis and the certainty of temporary vasomotor paralysis, with its consequent troublesome oozing. The advantages are that an opera- tion can be performed upon the living body with as much ease and accuracy as upon the cadaver. It is very useful whenever careful dissection is necessarv. SUTURES. The continuous suture (Fig. 9) is passed in the same manner as the interrupted, but the stitches are not cut apart and tied. It is conveniently fastened at the last by Fui. 9. Continuous suture. drawing it double through the last puncture and using the free end to make a knot with the double part attached to the needle. Fig. in. r >^ Twisted suture. The twisted or figure-of-8 suture (Fig. 12) is made bv transfixing the lips of the incision with a pin, about the two ends of which a thread is then twisted (Fig. 10). Tension or relaxation suture is the name given to one 26 THE ACCESSORIES OF AN OPERATION. employed to relieve strain on the sutures approximating the edges of the wound. The points of entry and emer- gence should be at a considerable distance from the in- cision. The thread is passed double, and in order to lessen the tension at any one point its extremities are tied over buttons or plates of lead or pads of gauze. PREPARATION OF MATERIALS USED IN AN OPERATION. Catgut ranges from the smallest size, Xo. 1, up to No. li. It is first soaked in ether for twenty-four hours to free it from fat, then wound on glass spools which have been recently boiled. The hands which do the winding must be thoroughly scrubbed and disinfected, and during the winding the catgut must touch nothing which is not surgically clean. The catgut is then boiled in alcohol for one hour, and stored for use in boiled absolute alcohol in a sterilized glass vessel. The spools of catgut are some- times soaked for twenty-four hours in a 1 : 1000 aqueous solution of bichloride of mercury before boiling. Chromicized catgut is made by soaking for twenty-four to forty-eight hours 200 parts of catgut by weight in a mixture of carbolic acid, 200 parts, boiled water 2000 parts and chromic acid i part. It is then boiled in alco- hol and stored in boiled absolute alcohol. Silk i> used in sizes from the smallest, No. I, to No. 18, the sizes mosl convenienl for average use ranging from 7 to 10. It is wound on sterilized spools, boiled in water for half an hour, and stored in boiled absolute alcohol in a sterilized glass vessel. Silkworm-gut is -imply boiled in alcohol for one hour, and Stored in boiled absolute alcohol in ;i sterilized glass vessel. Sponges. — Ordinary sponge- are prepared as follows: Decalcify in a solution of one volume of commercial hy- drochloric acid and three volumes of water. Kxaniine each sponge separately for pieces of stone or coral, which musl b<- cui or torn out. Then wash in running water to PREPARATION OF MATERIALS. '-'7 remove every particle of sand. Place them in a solution of permanganate of potassium of a strength of about 1 to 16 of water till they are stained a chestnut brown. Wash again in running water to remove the excess of permanganate. Place them in a solution of hyposnlphide nt* soda and oxalic acid — about 3j of each to a pint of water, and stir the sponges till they are bleached. Then wash in running water to free from acid and precipitated sulphur. Rinse out in a solution of sodium bicarbonate — about 1 part to 25 of water. This neutralizes any acid and renders the sponge texture more absorbent. Wash again in sterilized water and store in a 1 : 20 car- bolic solution or in a two per cent, solution of formal- dehyde. Simple pads of sterilized absorbent gauze, with the margins loosely hemmed, make excellent and cheap sponges ; they should be sterilized by steam for half an hour immediately before use. Absorbent gauze is best purchased from the manufac- turers. It should be cut into convenient lengths and sterilized by steam for half an hour immediately before use. Bichloride gauze is conveniently made by wringing out the sterilized absorbent gauze in a solution of bichloride of mercury 1 part, common salt 1 part, and water 1000 parts. The salt prevents the bichloride from changing to calomel. It can then be sterilized by steam and kept in a sterilized tiF AS OPERATloS. adhere to the gauze. The basin in which the mixing of the gauze, soapsuds, and iodoform is carried out must be previously cleaned and sterilized. Some prefer to sterilize the prepared gauze by steam ; but this sometimes decomposes part of the iodoform, and the iodine thus liberated is very irritating to the skin. Drainage tubes are most conveniently made of ordinary rubber tubing — the red is the best — or of glass. These should be boiled and stored in boiled alcohol or a bichloride or formaldehyde solution, and immediately before use boiled again. Absorbable bone drainage tubes are sometimes used. They can be obtained from the instrument makers. Absorbent cotton is best purchased of the manufactur- ers. This and plain cotton can be sterilized by dry heat in an oven at 300° F. maintained for half an hour. Rubber tissue is prepared by washing thoroughly in a 1 : 20 aqueous carbolic solution and soap. It is then washed in alcohol and stored in 1 : 1000 bichloride of mercury solution. STERILIZATION. The Arnold steam sterilizer is most efficient for general sterilization. It is so constructed that the steam is con- densed after it is used and the water needs only infre- quent renewal. Gowns, dressings, etc., should be ex- posed to tin' steam for from half an hour to three hours, according to the compactness of the bundle. A very serviceable sterilizer can be made from an ordinary as- paragus cooker — a covered tin vessel aboui twice as long a- it i- wide mid deep — furnished with a removable tray. [nstruraents, which rust badly when exposed t<> -team. should be sterilized by boiling in water to which about one per cent. <»(' sodium carbonate has been added (to di- minish rusting) and should be used from trays of sterile water or a weak carbolic solution. Cutting instruments, which lose their altfc under boiling, may be sterilized by dry heal <>r by passing through a flame or by ;i brief ex- posure ton niir or two per cent, formaldehyde solution. WOUND MADE AND ITS TREATMENT. 29 THE WOUND MADE BY THE SURGEON AND ITS TREATMENT. The secret of success in operative surgery lies in abso- lute cleanliness of the operator and his assistants, the wound and its surrounding parts, and of all instruments, dressings, and accessories which come directly or indirectly into contact with the wound. On the morning of the day before the operation the skin should be washed and scrubbed with green soap, shaved it necessary, and sponged off with a 1 : 1000 solu- tion of bichloride of mercury. It is then spread with a layer of green soap, and covered with compresses saturated in the same material. Over this is placed a piece of rubber tissue to prevent drying, and the " soap poultice " is left in place till the evening before the operation, or for about twelve hours. It is then removed, and the area washed carefully with a 1 : 1000 bichloride solution, and a w r et 1 : 5000 bichloride dressing applied and not removed till the patient is on the table — at least twelve hours later. The surface is then washed with ether, and again with the 1 : 1000 bichloride solution. The surgeon, his assistants, and any attendants in the operating room should have their arms bare to the elbow, and wear sterilized gowns reaching to the feet. All these persons must thor- oughly scrub with a sterilized brush, green soap, and hot water their arms, hands, and finger-nails. Then clean the finger-nails with a clean instrument, and wash again with chloride of lime and sodium carbonate (washing powder). Then soak hands and arms in 1 : 1000 bichlo- ride of mercury. It is still better to use rubber gloves, sterilized by boiling or by washing in 1 : 1000 bichloride of mercury. The incision should be clean and smooth, and large enough to give plenty of room and permit easy recogni- tion of all the parts as they are reached. If the operator attempts to work through too small an opening his manip- ulations and efforts at retraction and clamping are liable to cause bruising of the margins of the wound. In order 30 THE ACCESSORIES OF AN OPERATION. to minimize the amount of foreign material the ligatures should be as few and small as possible. Much of the hemorrhage can be stopped by simple pressure, as by clamps left in place for a few moments, or by temporary packing with sponges or pads of gauze. Strong antiseptics and rough handling in a perfectly clean wound are to be avoided. After all bleeding has been checked, every por- tion of the wound surface should be brought into contact with some other, and held there immovably for from five to ten days. A well-applied dressing, aided by a few sutures, will generally be found sufficient for this purpose. Buried sutures should be used with caution. They un- favorably modify the nutrition of the parts, and thereby conduce to the development of such septic germs as may be present. The question of drainage depends upon a number of considerations. A large effusion of blood or serum may be expected to follow some operations, and, by separating the apposed surfaces of the wound, prevent primary union. A well-applied dressing and sutures sufficiently far apart — half an inch to an inch — to allow the effusion to escape between them will generally suffice. This may be supple- mented by a Hat strip of sterilized rubber tissue intro- duced into the depths of the wound and brought out between the sutures. If it is thought necessary to use a drainage tube in an aseptic wound the tube should be removed with every antiseptic precaution at the end of twenty-four to thirty- six hours. Pre-existing suppuration in the wound or its vicinity always calls for drainage. If suppuration occurs in a previously aseptic wound, every facility must be given for the escape <>f pus at the earliest moment. The whole wound may Deed to be laid wide open and lightly packed with gauze. An aseptic wound is closed by any suitable one of the different kind- of suture and covered with a ~iri|» of ster- ilized rubber tissue, over which is placed a layer of iodo- form gauze, or the rubber tissue may be omitted. Apply next to the iodoform gauze compresses of sterilized ab- WOUND MADE AND ITS THE ATM EXT. 31 sorbent gauze, cover these with sterilized absorbent cot- ton, which acts as a filter against germs coming from without and also absorbs leakage from the wound. Bandage tightly enough to cause an even pressure and immobilization, and yet not interfere with circulation. PART IT. LIGATURE OF THE ARTERIES. GENERAL DIRECTIONS. A point for the application of the ligature should be chosen, if possible, not nearer than half an inch to any named branch above or below it. The operator should Fig. 11. This diagram represents throe distinct operations. A. Opening the sheath. B. Drawing ligature round the artery. ('. Tying artery. make himself thoroughly familiar with the anatomical re- lations of the parts and the landmarks of the operation ; he should proceed methodically, in accordance with a 34 LIGATURE OF THE ARTERIES. definite plan, and seek for and recognize each layer, each landmark in its order. The incision should be free, and, so far as possible, its center should correspond with the point at which the ligature is to be applied. It should go fairly through the skin and be carried down to, and then through, the enveloping fascia by repeated applications of the knife. The knife may then be laid aside and the artery sought for by separating the tissues with the fingers or a direc- tor. The sheath is recognized by the communicated pul- sation and by the absence of the pinkish-white color and smooth shining surface which characterize the artery. When found, it is pinched up with the forceps, the flat of the knife laid upon it and a hole one-quarter of an inch lonjr carefully made in it. A distinct sheath is found only about the main trunks and is replaced in the others by a layer of cellular tissue, which is more readily separated by tearing with the point of a director or with two forceps. When the pinkish-white coat of the vessel has been fairly exposed, each edge of the hole in the sheath is grasped in turn with forceps and the sides of the vessel gently separated from the sheath by tearing through the slight attachments with the point of a director. Fig. 12. A 1 1 • 1 1 n- n ill' A threaded aneurism needle is then entered on that side where the parts li<- thai are most to be avoided ami passed behind the artery, care being taken not to raise the hitter from its lied, until it- eye appears upon the other Bide ; the thread is then picked up with forceps and drawn through while the needle is withdrawn. The precaution should never be omitted of trying if compres- sion of the vessel between the finger and the ligature ar- ANATOMY OF THE SUPRA-CLAVICVLAR REGION. 35 rests pulsation in its distal branches, for the best sur- geons have mistaken a nerve or strip of fascia for the artery. The main trunks can be readily distinguished from the veins by their appearance — the veins being blu- ish, while the arteries are white and feel like a cord or band under the finger — and by their known anatomical relations ; but it is often very difficult to recognize the smaller arteries, since they closely resemble the veins. The operator has to depend upon three indications : (1) the fact that when there are two satellite veins the artery is placed between them; (2) pulsation; (3) alternate compression of the vascular bundle at the two ends of the incision. Pressure at the proximal end causes the artery to shrink and the veins to swell ; pressure at the distal end has the contrary effect. The ligature is then tied with a square knot (Fig. 4), tightly enough to cut the inner coats of the vessel, both ends cut short and the wound closed. ANATOMY OF THE SUPRA-CLAVICULAR REGION. The superficial fascia underlies the platysma, and in- closes the sterno-cleido-raastoid in a reduplication of itself. The middle, or sterno-clavicular, fascia has a common origin with the superficial fascia in the linea alba between the two sterno-thyroid muscles, divides into three layers to form sheaths for the sterno-thyroid and sterno-hvoid, unites and again divides to form a sheath for the omo- hyoid, unites again and finally joins the superficial fascia between the trapezius and sterno-cleido-mastoid. This middle fascia is strong and resisting, and incloses all the vessels of the region except the external jugular vein, which is subcutaneous throughout its course until it turns inward to join the subclavian above the clavicle. These two fascia' are separated from each other and from the skin by loose cellular tissue, in which a large amount of fat may be deposited, and it is of prime importance that tiny should be recognized in the search for the vessels. Tin,' vessels which are approached through this region 36 LIGATURE OF THE ARTERIES. are the innominate, the subclavian, and the common ca- rotid. The bifurcation of the innominate corresponds with the sterno-clavicular articulation, and in old people, as well as in exceptional cases, rises from five to ten milli- meters above it. It lies in front and on the right side of the trachea, and is crossed anteriorly by the left innomi- nate vein. At the bifurcation the subclavian lies behind and to the outer side of the carotid, and is crossed by the pneumogastrie and phrenic nerves close to its origin, the Fig. 13. . 10, p. (188. LIGATURE OF THE SUBCLAVIAN ARTERY. 30 The periosteum is cut in the median line, the left innom- inate vein is pushed down and the right drawn to the right side, and the aneurism needle passed from right to left to avoid the pleura. The innominate has been tied only for aneurism of itself, of the subclavian, or of the primitive carotid; but as the treatment of aneurism by distal ligature yields satisfactory results, this operation is seldom justifiable. LIGATURE OF THE SUBCLAVIAN ARTERY. The anatomical difference between the right and left subclavian is confined to the first portion of the artery, which in the left is much longer, more vertical in its direction, and situated more posteriorly even than the in- nominate; a separate description therefore is required only for the first portion. Operation. — 1st Portion. Left Subclavian. — A V-shaped incision similar to that described for ligature of the innominata (Fig. 14) is made upon the left side and carried through the sterno-cleido-mastoid and outer fibers of the sterno-thyroid and sterno-hyoid muscles and the middle cervical fascia as before described. The carotid is then recognized and, together with the internal jugular, drawn outward with a blunt hook. The mus- cles are now relaxed by bending the head and neck for- ward and the cellular tissue torn through with forceps and director. The knife should no longer be used, on account of the risk of injury to the thoracic duct, which is imbedded in the loose tissue between the vessels and the vertebrae and is rendered very difficult of recognition by its small size and thin walls. It runs directly across the route to the artery while passing from the bodies of the vertebrae to the anterior border of the scalenus anti- cus and can best be avoided by making the search below and to the outer side of it in the lower angle of the wound. The finger, passed downward and backward behind the carotid, soon feels the artery by pressing it against 40 LIGATURE OF THE ARTERIES. the side of the spinal column, the loose cellular tissue surrounding it is easily separated with the director, the vessel cleaned and the needle passed from the inner side. The needle should have a short curve and its point should be kept close against the vessel, so as to avoid in- juring the pleura. 1st Portion. Right Subclavian. — It is exposed in the same manner as the innominate artery, and the ligature passed from the outer side, the pneumogastric and phrenic nerves being pressed inward toward the carotid. The great danger of this operation lies in the proximity of collateral branches. 2i> Portion. — This operation, first proposed and per- formed by Dupuytren, is rendered dangerous by the fact that one and sometimes several large branches are given off from this part of the artery. The preliminary steps are the same as those employed in ligature of the 3d por- tion ; after the middle cervical fascia has been divided, the tubercle of the first rib and the external border of the scalenus anticus are sought, the muscles bared and divided upon a director, the phrenic nerve which lies upon its anterior aspect being carefully avoided. As soon as the muscular fiber- are cut they retract and leave the artery in full view. .;ii Portion. Anatomy. — The 3d portion of the sub- clavian lies between the outer border of the scalenus an- ticus and the tubercle of the first rib in front and the brachial plexus behind, and below the posterior belly of the omohyoid ; it i- crossed on a much more superficial plane by the external jugular, which enters the subclavian Dear the middle of the clavicle. In muscular subjects the clavicular insertions of the trapezius and sterno-cleido- mastoid muscles lie near to. or may even join, one another; in others they arc from two to three inches apart. Ordinarily the vessel lie- at a depth of one or one and a-half inches below the surface, bnt in very fat persons, or when the clavicle has been pushed upward by an axillary aneurism, this distance may be increased t<< three inches. LIGATURE OF SUPERIOR THYROID ARTERY. 41 Operation. — Beginning an inch outside of the sterno- clavicular articulation, make an incision three or four inches long parallel to and half an inch above the clavicle (Fig. 14, B). Divide the skin and the platysma; when the external jugular is exposed draw it aside or divide it between two ligatures. Divide the superficial fascia, and the clavicular portion of the mastoid muscle if necessary, and seek the posterior belly of the omohyoid. Draw this muscle outward and upward, and feel for the tubercle of the first rib, following down the outer border of the scalenus anticus. Depress the shoulder as much as possible, denude the artery with the point of a director, and pass the needle from below, taking care not to in- clude the lowest bundle of the brachial plexus in the liga- ture. In order to avoid mistaking this bundle for the artery, the tubercle of the first rib should always be found; the artery lies against it, between it and the nerve. Skey prefers, in difficult cases, a curved incision " com- menced about two and a-half or three inches above the clavicle, upon, or immediately on the outer edge of, the mastoid muscle. This incision is carried slightly out- ward and downward, toward the acromion, and then curved inward along the clavicular origin of the mastoid muscle." (Fig. 14, C.) Ordinarily the external jugular is left to the outer side of the incision. LIGATURE OF THE SUPERIOR THYROID ARTERY. It arises close to the bifurcation of the common carotid at the upper border of the thyroid cartilage, and is in rela- tion with the superior laryngeal nerve on its inner side. Operation. — A two-inch incision is made along the ante- rior border of the sterno-mastoid muscle, with its center opposite the upper border of the thyroid cartilage. The skin, fascia, and platysma are divided, the sterno-mastoid drawn out, and the carotids recognized. The superior thyroid artery will be found springing from the anterior surface of the external carotid close to the bifurcation of the common carotid arterv. Pass the 42 LIGATURE OF THE ARTERIES. needle from above down, avoiding the superior laryngeal nerve. LIGATURE OF THE INFERIOR THYROID. Anatomy. — After passing vertically upward, the artery curves inward to reach the under surface of the thyroid gland. The highest point of its curve is half an inch below the prominence on the transverse process of the sixth cervical vertebra, named by Chassaignac the carotid tuber- cle. In old people it is somewhat higher. It lies behind the common carotid and internal jugular, and is separated from them by more or less dense cellular tissue. The guides to the vessel are the carotid and Chassaignac's tubercle. Operation. — Make an incision three and a-half or four inches in length along the anterior border of the sterno- cleido-mastoid, ending an inch above the clavicle (Fig. 14, 1>). Lay bare the border of the muscle, and draw it out- ward, tear through or divide the middle fascia, and draw the carotid and internal jugular outward, with a retractor. Flex the head slightly to relax the parts, feel with the finger for the carotid tubercle, and seek the artery below it, separating the cellular tissue with a director. Pass the needle between the artery and vein. Drobeck 1 makes an incision along the outer border of the sterno-mastoid muscle from the clavicle to the thyroid cartilage. The omohyoid muscle and, just below and par- allel to it, the transversalis colli artery cross the wound transversely beneath the sterno-mastoid, and overlie the phrenic nerve as it passes vertically down on the scalenus anticus. At the inner border of the latter is the ascend- in- cervical artery. The sterno-mastoid and great vessels are drawn toward the median line, and either the ascend- ing cervical or transversalis colli artery is followed back to the thyroid axis. The inferior thyroid artery will be found at the inner side of die ascending cervical close to the inner border of the scalenus anticus just below the carotid tubercle. The recurrent laryngeal nerve lies still '< fcntralbl. far Chirunrie, L887. i>. 592. LIGATURE OF AXILLARY ARTERY. 43 nearer the median line; the ligature should be passed from within outward. LIGATURE OF THE VERTEBRAL ARTERY. Anatomy. — The vertebral artery passes from the first portion of the subclavian upward and backward to the transverse process of the sixth cervical vertebra. It is ac- companied by a vein which lies in front, and is covered by the deep cervical fascia. The guide to it is the carotid tubercle. Operation. — The incision is the same as for ligature of the inferior thyroid (Fig. 14, D). The anterior edge of the sterno-cleido-mastoid is exposed and drawn outward. The middle fascia is divided, and the carotid and jugular drawn inward. The gap between the longus colli and the scalenus anticus is then felt for about half an inch below the carotid tubercle, the deep fascia covering it torn through, the muscles separated, the vertebral vein pushed aside, and the artery exposed. Chassaignac prefers an incision along the posterior bor- der of the mastoid muscle, and reaches the carotid tubercle by drawing the muscle and vessels inward. If the muscle is very broad some of its clavicular fibers must be divided. LIGATURE OF THE AXILLARY ARTERY. Anatomy. — The axillary extends from the middle of the clavicle to the lower edge of the tendon of the teres major. The axillary vein lies on the inner side and in front of it and the brachial nerves invest its lower por- tion closely. It can be tied below the clavicle in the clavi-pectoral triangle formed by the clavicle, inner bor- der of the pectoralis minor and the thorax or in the axilla. The strong fascia which unites the coracoid process and clavicle and forms the suspensory ligament of the axilla, the costo-coracoid fascia, sends a prolonga- tion about the upper portion of the axillary vein which keeps its walls from sinking in ; the cephalic vein as- cending in the groove between the deltoid and pectoralis 44 LIGATURE OF THE ARTERIES. major perforates this fascia and joins the axillary vein at the inner border of the tendon of the pectoral is minor, close by the origin of the acromial thoracic artery. A. Ligature Under the Clavicle. (Fig. 14, E.) — Make an incision extending from the summit of the coracoid process four or four and a-half inches along the lower border of the clavicle. Divide successively the skin, subcutaneous tissue, superficial fascia and pectoralis major, and then tear carefully through the costo-coracoid fascia, avoiding injury to the cephalic vein at the outer part of the wound. The pectoralis minor is now ex- posed, and after separating the cellular tissue with the point of a director the axillary vein is seen crossing from Fig. 15. B I > A A. Ligature of the axillary artery. /:. Ligature of the brachial artery. the upper edge of the muscle to the clavicle. The artery is completely hidden by it, lying on the outer side and a little behind. The vein must now be drawn inward, the needle entered between it and the artery and the ligature applied as near as possible to the clavicle on ac- eniuit of the proximity <>f the acromial thoracic branch. B. Ligature in the Axilla. Anatomy. — The (issues and organs on the outer side of the axilla are arranged in the following order : (1) the skin; ('2) the subcutaneous cel- lular tissue; (3) the fascia; (1) the axillary vein; (5) the internal cutaneous and ulnar nerves ; (li) the axillary artery; i7) the median nerve; (8) the coraco-brachialis ; (9) the humerus and articular capsule. 'Flic old rule for exposing the artery here was to make a longitudinal in- LIGATURE OF BRACHIAL ARTERY. 45 cision at the junction of the anterior and middle thirds of the axilla, find the vein, count two nerves and look for the artery just beyond the last one. This is a difficult and dangerous method and a much simpler one has been substituted by Malgaigne, who was the first to point out that the coraco-braehialis muscle is the real guide to the artery. Operation. — The arm is abducted completely, the in- cision commenced at the inner border of the coraco- braehialis over the head of the humerus and carried two and a-half or three inches down the arm parallel to the course of the artery. It should involve the skin only, so as to avoid injury to the basilic vein. If the edge of the coraco-braehialis cannot be distinguished, the incision should be made according to the old rule, at the junc- tion of the anterior and middle thirds of the axilla. The aponeurosis is now divided upon a director over the coraco-braehialis, and the fibers of the inner border of this muscle exposed. The parts are then relaxed by bringing the arm nearer the trunk, and the posterior side of the wound, including the vein, ulnar and internal cutaneous nerves, is drawn back with a retractor ; and the artery, overlain by the median nerve, usually appears at the bot- tom, covered, perhaps, by the posterior part of the sheath of the coraco-braehialis. LIGATURE OF THE BRACHIAL ARTERY. Anatomy. — The brachial artery runs from the junction of the anterior and middle thirds of the axilla to the mid- dle of the anterior aspect of the elbow. It occupies, when the forearm is supinated, the groove between the biceps and triceps, being partly covered by the former in mus- cular subjects, and separated from the bone by the inner edge of the coraco-braehialis, and of the brachialis an- ticus. It lies in the anterior loge of the arm, which is bounded posteriorly on this side by a prolongation of the enveloping aponeurosis, extending down to the bone be- tween the biceps in front and the triceps behind. It lies, consequently, within the sheath of the biceps, and the inner edy;e of this muscle is the sure 2-uide to it. It lies 46 LIGATURE OF THE ARTERIES. between two satellite veins, which anastomose frequently, and has the median nerve in immediate relation with it on the side next the skin. The basilic vein directly overlies it between the skin and the aponeurosis. The artery presents frequent anomalies. The most common is Fig. 16. Transverse section of the arm at its middle (Tillaux). i. Skin. 'J. Subcuta- neous tissue. '■'•■ Enveloping aponeurosis, i. Aponeurosis separating the anterior and posterior loges on trie inner side. 5. Division on the outer side. 6. Brachial artery and veins. 7. Median nerve. 8. Basilic vein. 9. Internal cutaneous nerve. 10. ulnar nerve. II. Its artery and veins. 12, Muscular cutaneous nerve, i::. Muscular spinal nerve. 14. Superior profunda artery. i">. Cephalic vein. it> premature bifurcation into the radial and ulnar, which may take place as high as in the axilla, in which case one of the branches is superficial, perhaps even subcutaneous, while the other follows the usual course. The median nerve occupies the same sheath with the artery, lying first LIGATURE OF RADIAL ARTERY. 47 on the outer side and then crossing, in front or behind, very obliquely to the inner. The ulnar nerve, accompanied by an artery and two veins, lies in the substance of the triceps immediately behind the brachial artery and median nerve, separated from them only by the above mentioned prolon- gation of the enveloping aponeurosis, and as they form a group differing from the other only in size, the artery may be mistaken for the brachial if met with (Fig. 16). This error will not be made if the fibers'of the biceps alone are exposed and the incision confined to the anterior loge. Operation. — Arm abducted, forearm snpinated. Make an incision three inches long in the middle third of the Fig. 17. Ligature of the brachial artery. arm, along the inner border of the biceps through the skin and subcutaneous cellular tissue, taking care not to injure the basilic vein, which should be kept posterior to the incision. Divide the aponeurosis and expose the fibers of the biceps. If the muscle is large draw it forward, and the sheath inclosing the artery, nerve, and veins will be disclosed. This is opened carefully, the median nerve separated and pushed aside, the artery separated from its veins, and the ligature passed from the side of the nerve. LIGATURE OF THE RADIAL ARTERY. Anatomy. — The radial artery extends in a straight line from a point half an inch below the center of the fold of 48 LIGATURE OF THE ARTERIES. the elbow to the ulnar side of the styloid process of the radius ; it occupies the groove bounded on one side by the supinator longus, on the other by the pronator radii teres and flexor carpi radialis. It is covered only by the skin, cellular tissue, and aponeurosis ; but in muscular subjects the muscular interstice in which it lies may be very deep. It is accompanied by two veins and by no nerve. It oc- cupies in its upper third the sheath of the pronator, and consequently the fibers of the supinator longus should not be exposed in the search for the artery, although the edge of the muscle may be taken as a guide to it. The radial nerve lies within the sheath of the su- pinator longus, and at first comes quite close to the artery ; it then passes behind and to the outer side of the tendon of the muscle. It should not be seen during the operation. Operation. In the Upper Third. — Make an incision two and one-half inches long in the line above mentioned, begin- ning one and one-half inches below the fold of the elbow. Avoiding the super- ficial veins, carry the incision to the fascia. Recognize the edge of the supi- nator longus, and divide the fascia along the ulnar side of it, exposing the fibers of the pronator. Tress apart the two muscles if necessary, separate the artery fr it> veins, and pass the ligature. In THE LOWER THIRD (Fig. 18). — Make an incision in the above-mentioned line, if the position of the artery cannot be made out by its pulsations, two inches long, ending an inch above the wrist. Divide the fascia in the 9ame line, separate the artery from the two veins and pass the ligature. Ligature <ivide the skin, platysma, cellular tissue, and aponeurosis, mid seek tor the interstice between the sterno- cleido-mastoid and the sub-hyoid muscles. When found, the hitter must be pressed inward, and the artery will appear ;it the edge of the sterno-cleido-mastoid, the vein, which i- external to it, remaining covered. The ueedleis passed from without inward. If, instead of pressing the trachea and its muscles in- ward, the ?terno-mastoid i^ drawn outward, the vein is encountered, almosl completely overlying the artery. LIGATURE OF THE EXTERNAL CAROTID. 51 LIGATURE OF THE EXTERNAL CAROTID. The free anastomoses which exist within the cranium between the two internal carotids render ligature of the common carotid insufficient certainly to arrest hemorrhage from the external carotid ; the ligature must be applied to the vessel itself, despite the number of its branches and the difficulty of recognizing them at the bottom of the incision. The operation is a difficult one, for there are Fig. 19. DiuioD carotid at t lie place of election. many important organs to be avoided, and there is no direct guide to the vessel. Anatomy. — The common carotid divides opposite the upper border of the thyroid cartilage (a little lower in females) into the external and internal carotids, which occupy nearly the same an tero- posterior plane, the former being in front. At about three-quarters of an inch above the bifurcation the arteries cross, the external becoming posterior, the internal anterior. The internal carotid gives off no branches outside the cranium, while the external gives off eight. Of these the superior thyroid arises at or very near the bifurcation, the lingual, facial, ascending pharyngeal, and occipital near the point where 52 LIGATURE OF THE ARTERIES. the artery passes under the digastric, about an inch above the bifurcation, the others at a considerable distance above. The hypoglossal nerve looping around the occip- ital artery at its origin crosses the external carotid send- ing a branch, the descendens noni, down the outside of the artery. There are thus three means of distinguishing the ex- ternal carotid : (1) its branches ; (2) its position with reference to the internal carotid ; (3) its immediate rela- tions with the hypoglossal nerve, the internal carotid oc- cupying a deeper plane. In a search for the external carotid the operator may be satisfied with either of these guides, accordingly as one or the other presents itself. Should the nerve be first encountered, he will tie the vessel upon which it lies ; should both vessels lie at the bottom of the incision, he will know that the anterior one is the external carotid ; and if the vessel which he isolates has a branch, he knows it cannot be the internal carotid. Although the risks arising from the proximity of a ligature to a large branch are greatly reduced by asepsis, vet it is still desirable that a certain interval should be maintained ; and from this point of view the first half- inch of the artery and the portion underlying the digas- tric are the places of election, and of these two the former alone is practicable. The connective tissue surrounding the two arteries at their origin is, however, unusually compact, rendering their denudation so difficult that any search lor branches would be dangerous to the nutrition of. the vessel's wall. M. (iiiyon 1 has .-how n that, while the lingual and superior thyroid arteries vary greatly in their points of origin, the average distance between them is from 12 to IN millimeters, or over half an inch ; he calls the portion of the vessel between them the " trunk of the external caro- tid," and suggests thai the ligature should be applied (! nun. below the point at which the hypoglossal nerve crosses the artery, this nerve being, in the greal majority 1 M6moircs de la ><■<•. <|< < birurgie, 1864, p. 655. LIGATURE OF Till: INTERNAL CAROTID. 63 of cases, in immediate relation with the origin of the lin- gual artery. Operation. — When the head is extended and the face turned to the opposite side, an incision carried from the angle of the jaw to the anterior border of the sterno- cleido-mastoid opposite the top of the thyroid cartilage will cross the artery obliquely (Fig. 20, B). It must be carried through the skin, platysma, and subcutaneous cel- lular tissue, the external jugular being drawn aside when Fig. 20. Ligature of — A. Lingual art< />'. External carotid. C Occipital. 1>. Temporal. A'. Facial. encountered. The fascia is then divided in the line of the incision, care being taken not to deviate to the right or left, and when the artery has been thus exposed and cleaned, the needle is passed from behind forward. The lymphatic glands of the region are numerous and often large, and may be mistaken for the artery. There is no objection to removing any that may interfere with the search for the vessel. LIGATURE OF THE INTERNAL CAROTID. This is to be done according to the method described for the external carotid. • r >4 LIGATURE OP THE ARTERIES. LIGATURE OF THE LINGUAL ARTERY. Anatomy. — The lingual artery arises from the external eamtid, on a level with the great horn of the hyoid bone, and passes between the middle constrictor of the pharynx and the hyoglossus upward and forward. It is occasion- ally accompanied by a small vein, but the lingual vein is separated from it by the thickness of the hyoglossus mus- cle. Its one important branch, the sublingual, sometimes has its origin at or near the point where the lingual is usually tied, and may be mistaken for it. The artery may be tied near its origin, between the great horn of the hvoid bone and the posterior belly of the digastric, but its depth at this point, and the presence of large veins. make the operation difficult and dangerous. The place of election is in the triangle bounded posteriorly by the pos- terior belly <>f the digastric, anteriorly by the posterior border of the mylo-hyoid, and above by the hypoglossal nerve. It is covered at this point by the skin, platysma, cervical aponeurosis, submaxillary gland, and the hyo- glossus muscle, the libers of which form the Moor of the triangle just described. Operation. — Make a curved incision two inches long, its concavity directed upward, its center one-quarter of an inch above the hvoid bone at a point midway between the median line and the extremity of the great horn | Fig. 20, .1 1. Di- vide the skin and platysma and then the cervical aponeu- rosis, which may be very thin. Raise the submaxillary gland, find the posterior belly of the digastric, it- attach- ment to the hyoid bone, the posterior border of the mylo- hyoid, and the hypoglossal nerve ac< panied by the 1+ug^ial vein. Draw the hyoid bone slightly downward with a blunt hook fixed in the lower angle of the triangle bounded by these organs, and then, pinching up the fibers of the hyoglossus with a pair of forceps, divide them care- fully along a line parallel to the nerve, mid midway between it and the bone. A- the cul liber- retract, the artery i- disclosed beneath them •, separate it from its vein, it' there be one, and pass the ligature. LIGATURE OF THE FACIAL ARTERY. ;>;> LIGATURE OF THE FACIAL ARTERY. The facial artery crosses the inferior maxilla just in front of the anterior edge of the niasseter, from which it is separated by the facial vein (Fig. 21). The artery can he exposed by a vertical incision along its course, or by a horizontal one along the lower border of the maxilla. Fig. 21. PAROTID aiA, No Occipital a._ Facial a. Mylohyoid n. Submental a. Hypoglossal n Descendcns noni n Lingual a Internal jugular v. Superior thyroid a Common carotid Anatomies] relations of the lingual and facial arteries. Operation. (Fig. 20, E.) — Beginning at the lower edge of the maxilla, make an incision one inch in length along the course of the artery ; divide the skin, subcu- taneous tissue and fascia ; separate the artery from the vein and pass the needle between them. If the horizontal incision is used, it should extend three-quarters of an inch on each side of the artery, the anterior edge of the masseter should be recognized and the vessel sought for immediately in front of it. 56 LIGATURE OF THE ARTERIES. LIGATURE OF THE OCCIPITAL ARTERY. At the Mastoid Process. — The guides to the vessel are the apex and posterior border of the mastoid process, the digastric groove on its inner surface and the digastric muscle. Operation. (Fig. 20, (7.) — Starting from a point half an inch below and in front of the apex of the mastoid process, carry the incision two inches obliquely backward parallel to the border of this process. Divide the skin and enveloping fascia, and then the sterno-mastoid and its insertion throughout the entire length of the incision. Then divide the splenius and its shining aponeurosis and feel for the digastric groove. Pinch up and carefully di- vide a thin fascia which covers the anterior face of the splenius. Starting from the belly of the digastric, sepa- rate the cellular tissue in the anterior angle of the wound with a director, denude the artery and tie. (ChauvelJ) LIGATURE OF THE TEMPORAL ARTERY. (Fig. 20, D.) Make a transverse incision one inch long, extending from the tragus of the car forward over the zygomatic arch. Separate the subcutaneous cellular tis- sue, which i> very dense and fibrous, with a director, and seek the artery imbedded in it about a quarter of ;m inch in front of the ear. Press the vein backward, pass the needle from behind forward, taking care not to include in the ligature the temporal branch of the auriculo-temporal nerve, which i- sometimes in close relations with the artery. LIGATURE OF THE ABDOMINAL AORTA. This operation has been performed about a dozen time-, with :i liitiil resull iii every case. The patients survived for periods varying from ;i few hour- to ten days. The artery may be reached through the abdominal cavity by an incision in the median line, or, without dividing the peritoneum, by an incision in the flunk similar to Ki'mig's for extirpation of the kidney ('/. r.). The application of :i ligature, even under the most favorable circumstances, LIGATURE OF THE COMMON ILIAC •>< alter the artery has been exposed by the latter method, requires the utmost dexterity, the chance of exciting peri- tonitis is great, and the presence of the aneurism and the displacements and adhesions it has caused may render it impossible to reach the vessel. Operation. THROUGH THE PERITONEAL CAVITY. — An incision in the linea alba, from a point three inches above the umbilicus to one three inches below it ; press the intestines aside with flat sponges, carefully incise the peritoneum covering the aorta, separate the nerves from its anterior surface, and pass the ligature from the outer side. LIGATURE OF THE COMMON ILIAC. Anatomy of the Common, Internal, and External Iliac Arteries. — The aorta bifurcates usually on the left side of the fourth lumbar vertebra, and the direction of the com- mon and external iliacs is i"epresented by a line drawn from a point an inch above the umbilicus to another one-half an inch external to the center of Poupart's ligament. The common iliac is usually two inches long, and bifurcates at thesacro-iliac synchondrosis, but this bifurcation may take place at any point between one and a-lialf and three or even four inches from the origin of the artery. The com- mon iliac gives off no branches. The external iliac runs downward and outward along the brim of the pelvis from the bifurcation to a point under Poupart's ligament midway between the anterior superior spine of the ilium and the symphysis pubis. Its two branches, the epigastric and circumflex ilii, are given oft* nearly opposite each other, a short distance above Pou- part's ligament, sometimes much higher. The internal iliac runs downward and backward into the pelvis for one and a-half inches, dividing at the upper border of the great sacro-sciatic foramen into two large trunks. The ureter crosses the vessels at or just below the bifurcation of the common iliac, the vas deferens two and a-half or three inches lower. Both are more closely adherent to the peritoneum than to the arteries. The iliac veins lie upon the inner side and posterior to the arteries ; 58 LIGATURE OF THE ARTERIES. both pass behind the right common iliac, the right vein at its bifurcation, the left vein much higher up. The sper- matic vessels and genito-crural nerve lie in front of the external iliac at the lower part of its course, and the cir- cumflex iliac vein crosses it at the same place. The abdominal wall at the points where the incisions are made is composed of the following layers in the order named: skin, subcutaneous cellular tissue, fascia, external oblique or its aponeurosis, internal oblique, transversalis, and transversalis fascia. Extra-peritoneal Operation. — Beginning at a point a finger's breadth above Poupart's ligament and just outside Fig. 22. Ligature of A. Coi on Iliac. B. External iliac, C. Femoral in Scarpa's space. of the external iliac artery, make an incision four, five, or six inches in length, according to the thickness of the abdominal wall, parallel at first to Poupart's ligament, and curving upward after passing the anterior superior spine of the ilium ( Fig. 22). J divide the skin, subcutaneous tissue, and fascia, exposing the aponeurosis of the external oblique, divide the latter throughout the whole extent of the in- cision, and then divide the fibers of the internal oblique and transversalis by pinching them up with the forceps and cutting carefully with repeated touches of the knife, until the fascia transversalis, which varies much in density. LIGATURE OF nil' ixri:i:\M. iliac 59 is exposed. Raise the fascia at the lower angle of the wound, where it is most dense, with forceps, and make a hole in it largo enough to admit the finger. Pass the fore- finger through this hole, press back the peritoneum with it, and enlarge the hole upward in the line and to the full extent of the incision, the finger being kept between the peritoneum and the knife. The peritoneum is now raised from the psoas and rliacus muscles and drawn upward and inward by an as- sistant, while the operator seeks for the external iliac and passes the forefinger of his left hand along it to the com- mon iliac, the thighs being flexed t<> relax the abdominal wall-. As it is seldom that a good view of the artery can be obtained, the finger must be kept upon it and the loose cellular tissue in which it is imbedded very gently separated with the point of a director. When the artery has been properly cleaned, pass the needle from within outward. Intra-peritoneal Operation. — Open the abdomen in the median line by an incision extending from the symphysis pubis to or a little above the umbilicus and, after pushing- aside the intestines with flat sponge- or pads, aided by the Trendelenburg position, cut through the peritoneum overlying the artery and pass the ligature from within outward. ('are must be taken not to include the ureter, which usually crosses the vessel at its point of bifurcation. In the extra-peritoneal operation there is less danger of this accident, as the ureter is adherent to the peritoneum and is lifted out of the way a- this membrane is stripped up. LIGATURE OF THE INTERNAL ILIAC. Its accompanying vein lies behind and on the inner side. Extra-peritoneal Operation. — Same as for ligature of the common iliac. After the peritoneum has been lifted up, the finger i- passed along the external iliac to the bifur- cation and then downward for half an inch along the internal iliac. The vein being carefully protected, the artery is bared and the ligature passed from within outward. 60 LIGATURE OF THE ARTERIES. The intra-peritoneal operation does not differ enough from that for tying the common iliac to require a sepa- rate description. Ligature of the internal iliac has been seldom employed except for traumatic gluteal aneurism, and in these eases, as Van Buren 1 pointed out, the treatment should be to cut down upon the sac, and tie both ends of the artery, hemorrhage being controlled by digital pressure made upon the internal iliac from within the rectum. LIGATURE OF THE EXTERNAL ILIAC. Various cutaneous incisions have been recommended for this operation. Sir Astley Cooper's extended from the external abdominal ring to within a short distance of the superior spine of the ilium ; the objections to it arc that it involves the division of the superficial epigastric, and, per- haps, of the internal epigastric also, and that the ligature can be applied only to the lower part of the artery. Abernethy's extended outward from the internal inguinal ring parallel to Poupart's ligament ; by it the vessel is reached at a greater depth, but it has the great advan- tage of allowing extension, so that if it should prove necessary the ligature may be applied even to the com- mon iliac. By curving the outer portion of the incision upward away from the superior spine of the ilium, the main branches of the circumflex ilii may be avoided. Operation. — Beginning over the outer side of the artery :i finger's breadth above Poupart's ligament, make an in- cision three or four inches in length, at first parallel with Poupart's ligament, and then curving upward (Fig. 22). Carry this incision through the abdominal wall, and raise the peritoneum from the surface of the iliacus and psoas muscles in the same manner as lor ligature of the common iliac. Flex the thighs so as to relax the abdominal iniis- cles, and, while mi assistant draws the peritoneum and tin contained intestines upward and inward, seek the artery upon the inner border of the psoas, (lean it with 'Report on "Aneurism," Proceedings of the International Medical ( ongresB, 1876. LIGATURE OF INTERNAL PUDIC ARTERIES. 61 a director or pair of forceps, and pass the needle from within outward. For the intra-peritoneal operation an incision along the lower part of the linea semilunaris would generally be better than one in the median line, and possibly McBnr- ney's inter-muscular method of reaching the appendix (7. r.) would give sufficient room. LIGATURE OF THE GLUTEAL, SCIATIC, AND INTER- NAL PUDIC ARTERIES. The proper treatment of injury to either of these arteries is to enlarge the wound and tie both ends of the divided vessel, but it may happen that this would be impossible, Fig. 23. Ligature of— J. Gluteal artery. />'. Sciatic and internal pudic. and that ligature in continuity is required. The necessary incisions are those shown in Fig. 2-*>. The place at which the gluteal artery emerges from the great sciatic notch may be roughly stated as opposite a point at the junction of the upper and middle thirds of a line joining the pos- terior superior spine of the ilium with the great trochanter. 62 LIGATURE OF THE ARTERIES. The sciatic, where it crosses the spine of the ischium, lies opposite the junction of the middle and lower thirds of a line joining the tuberosity with the posterior superior spine of the ilium. After division of the skin and faseia, the fibers of the gluteus maximus are separated and held apart with long retractors, the deep fascia torn through, and the artery sought for. The gluteal artery is to be sought for above the pyri- formis muscle at the upper border of the great sacro-sciatic notch, where it can be felt near a small bony tubercle. It is covered by many large veins, which require very care- ful handling. The ligature should be applied as close to the notch as possible. The sciatic and internal j)iiv the femoral vein, which, at first, lies u|>"ii the inner side, and then becomes posterior. They ii separated at first by a distinct septum, which disap- pears in the lower third. The anterior crural nerve emerges from below Poupart'a ligament, about half an inch external to the artery ; it divides up rapidly, and one of LIGATURE OF THE FEMORAL ARTERY. 63 its branches, the internal or long saphenous, enters the sheath of the vessels three or four inches below the groin, and leaves it again after the artery has entered Hunter's canal ; this name being given to the condensed sheath for a short distance above and below the point where it passes through the tendon of the adductor inagnus. The artery passes under the sartorius at about the junction of its upper and middle thirds. Ligature of the femoral above the origin of the pro- funda has proved unsatisfactory and has been generally abandoned for that of the external iliac. The artery may be tied at any part of its course, but the point generally Fig. 24. Ligature of the femoral arterj . chosen is at the apex of Scarpa's triangle, next that in the middle of the thigh and, lastly, in Hunter's canal. Operation. A. At the Ai-kx of Scarpa's Tri- angle (Figs. 22 and 24). — Make an incision three or four inches long, the center of which shall be a little- above the point where the inner border of the sartorius crosses a line drawn from the middle of Poupart's liga- ment to the inner tuberosity of the femur. The internal saphenous vein should be out of danger on the inner side of the incision. Divide the skin, subcutaneous tissue and the fascia lata, exposing the fibers of the sartorius, which may be recognized by their direction downward and in- 64 LIGATURE OF THE ARTERIES. ward, those of the adductors, on the contrary, being downward and outward. The limb should now be slightly Hexed, the vessels recognized by the touch at the inner border of the sartorius, this muscle drawn outward and the sheath of the vessels pinched up with forceps on the outer side (the vein lying on the inner) and opened. The needle is then passed from within outward. B. In the Middle <>f the Thigh. — Here the vessel lies underneath the sartorius which overlaps it on both sides. The incision is made in the line above mentioned, it- center being a little above the middle of the thigh; the sartorius i^- exposed and drawn outward after the leg has been further flexed. The vessel is then sought for, exposed and tied as before. ( '. Ix Hunter's Canal. — Abduct and Hex the thigh, and rotate it outward so as to make the adductors tense ; feel for the tendon of the adductor magnus and make an incision three or four inches long, the center of which is at the junction of the lower and middle thirds of the thigh, in the direction of the tendon, which is that of a line drawn from the spine of the pubis to the tuberch the inner condyle of the femur. Divide the skin and subcutaneous tissue carefully so as not to wound the in- ternal saphenous vein, and then the fascia upon a director. Recognize the libers of the sartorius and of the vnstus in- tertill- which are at right angles with one another, and by pressing the former inward or the latter outward the tendon of the adductor and the curved glistening fibers arching from it to the vastus internus are exposed. If the saphenous nerve is now encountered it should be traced upward, a director passed into the orifice through which it emerges, and the aponeurosis divided upward ; if the nerve is not seen it should not be sought for, but the aponeurosis should lie pinched up and divided close to the tendon of the adductor. The sheath of the vessels i> now opened, and the artery is separated from the closely ad- herent Vein. The needle should be pa-.-cd from witllill outward. LIGATURE OF ANTERIOR TIBIAL ARTERY. 65 LIGATURE OF THE POPLITEAL ARTERY. The artery lies very deep between the condyles of the femur, imbedded in fat, and directly covered by the vein, the walls of which are thick and stiff like those of an artery. The short saphenous vein perforates the fascia near the center of the popliteal space, and empties into the main trunk. Operation. — Make an incision three or four inches long in the vertical diameter of the popliteal space, the center of which shall correspond to the point at which the liga- ture is to placed. Divide the skin and cellular tissue, taking care not to injure the saphenous vein, and then the fascia to the full extent of the cutaneous incision. Flex the leg-, have the sides of the wound drawn widely apart, ami work down through the fat and lymphatic glands to the artery, leaving first the nerve and then the vein upon the outer side. Protecting the vein with one finger, de- nude the artery and pass the needle from without inward. If for any reason it is not convenient to place the patient face downward, the upper portion of the artery can be readily reached through an incision on the inner aspect of the thigh passing between the tendon of the ad- ductor magnus on one side, and the sartorius, semi-mem- branosus, and semi-tendinostis on the other. The artery is found lying close to the femur. LIGATURE OF THE ANTERIOR TIBIAL ARTERY. Anatomy. — After perforating the interosseous mem- brane at the upper part of the leg, the anterior tibial runs in a direction which is that of a line drawn upon the anterior aspect of the leg from the upper tibio-fibular articulation to a point midway between the malleoli. It lies at first between the belly of the tibialis anticus and that of the extensor communis digitorum upon the inter- osseous membrane, afterward between the tibialis anticus and the extensor proprius pollicis or their tendons upon the tibia. It is accompanied by two veins and the an- terior tibial nerve, which latter lies first upon the outer 66 LIGATURE OF THE ARTERIES. side and then w*>s*erv4tr-frorit to the mueFsfde. It may be tied at any point in its course. Operation. — Make in the above-mentioned line an inci- sion the length of which will vary according to the depth Fig. 25. Transverse section of the leg, upper third. (Tillaux.) T. Tibia. /•'. Fibula. /./■: Enveloping fascia DF. Deep fascia 'li\i'liirj to Inclose /'/'. Posterior tibial artery and nerve, and PA. Peroneal artery. TA. Tibialis anticus sole. AT. Interior arterj and nerve. /.'/. [nteross - membrane. P. Peroneus longus muscle. TS. internal saphenous vein. ES. External saphenous vein and nerve. ;it which the artery is placed. Divide the skin and cellu- lar tissue, lay bare the fascia, and divide it along (lie firsl muscular interstice, which shows as a while line under ii ; make also ;i transverse incision through the fascia from t he middle of the longitudinal one to the crest of the LIGATURE OF THE POSTERIOR TIBIAL. 67 tibia, so as to give more room. Flex the foot upon the leg, separate the muscles from below upward with the finger, draw them apart with retractors, isolate the artery without raising it, and pass the needle from the side of the nerve. LIGATURE OF THE DORSALIS PEDIS. This artery is the continuation of the anterior tibial, and passes through the posterior end of the first metatarsal space to the plantar aspect of the foot. It lies on the j outer side of the tendon of the extensor proprius poliieis-, and i^ crossed in its lower portion by the inner tendon of the extensor brevis. It is covered by the skin, superficial fascia, the edge of the extensor brevis, or its tendon, and a deep fascia. Its direction is that of a line drawn from a point midway between the malleoli to the posterior end of the first metatarsal space. The incision should be in this line, and the tendon of the extensor proprius pollici- should be left on the inner side. LIGATURE OF THE POSTERIOR TIBIAL. The posterior tibial artery in its upper and middle por- tions lies upon the tibialis posticus and the flexor com- munis digitorum, and is covered by the soleus, from which it is separated by the deep fascia. Near the ankle it is covered only by the integument and fascia. In its upper portion it can be reached by two routes : (1) the one em- ployed by Guthrie, and approved of by Spenceand Holmes, through the middle of the calf; (2) the one in more com- mon use, from the inner side of the calf. Operation (GUTHRIE). — Beginning at the lower angle of the popliteal space, make an incision six inches in length directly downward, avoiding as far as possible the super- ficial veins, cany this incision through the soleus, divide the deep fascia, separate the artery from the vein and nerve, which are superficial to it, and pass the needle from their side. Lateral Method. — Beginning in the middle of the upper third of the leg, make an incision downward from *JLs^et^_ C-AJfcc-i«-^c*UtA^«/*M «A«^u^. ^•«Aa-a<*aaJL<> Ia» *&Jr* ^*v^c|>Hv- •7 **j»-«>va«. 1*ia*1 ~K> \^un^U- ikcaJL^cL^ \$ .. .«-=*« -j* " IXAeXtCM,. UJ^tse origins are most distant must be cut long to allow for their greater retraction. OH* b. f CUTANEP TTK ftT.T.K.HF. ^ The skin flnd cellular tissue are s eparate * ! cleanly fr om the deep fas cia and tu rned back over the limb, the raw surface outward. The glpnyp tliiw_J'o |-nied is lengthened by drawing it up and di- viding its attachments to the fascia, care being taken to i nclude all the subcutaneous cellular tissue in it, until the dissection has nearly reached the height at which the bone is to be divided. The fascia and muscles are then cut through to the bone transversely with a single sweep of the knife, held as for making the cutaneous incision. 3d Step. Division of the Bone. — The s pft par ts being dvM^yn up-, and protected )w a m unlin H"d four inches wide and two feet long, split for half its length so as to pass on each side of the bone (called the retractor), and the periosteum having been divided circularly with the knife along or a little below the line to be traversed by the saw, 1 the operator places the heel of the saw upon the bone, steadies its edge with the thumb-nail of his left hand, and draws it slowly toward himself, cutting a deep groove in the bone; he then completes the division with rapid strokes of the instrument, while the limb is firmly held by two assistants so as to prevent binding of the saw or splintering of the bone. [f there are two bones the retra ctor shoul d be split into t hrecJi i.-le.nl of tun parts, and the central one passed be- tween the bonis. The saw should be first appl ied to tin- lanrcr boiil ', and, after cutting a deep groove in it, should be inclined backward or forward, so as entirely to divid e t he secinul hof my com plet ii|o- the division of the firs t. Gigli'fi rou ghened wirj ', which is so convenient a sub- 1 The plan sometimes employed of shinning up a sleeve of lu-ri - ostenm and dividing the bone al ii^ hase is without value in tl.i ami is h ighly objectionable in the voui iif, because it is likely to lend to the production, within the periosteal sleeve, of B spike of hone. This i- the common cause of conical si p." nol the disproportionate growth of the bone al the epiphysis, as has been alleged. FLAP METHOD. 73 stitute for the chain saw, may be used for the division of even the largest bones of the limbs, and is sometimes more convenient than a saw because of difficulty in keep- ing the soft parts out of the way of the latter. In using the wire it should be held taut and in a widely-opened angle about the bone. The slight charring of the flesh as the wire becomes heated does no harm ; it can be pre- vented by pouring water upon the wire. OVAL METHOD. A scalpel is used instead of the amputating knife ; the incision is commenced at the level at which the bone is to be divided, is carried downward on one side, across the back of the limb, and upward on the opposite side to the point at which it began. The details will be given in connection with certain disarticulations to which this method is especially applicable. FLAP METHOD. The flaps may be single or double, antero-posterior, bi- lateral, long rectangular (Teale), or skin flaps with cir- cular division of the muscles (modified flap operation). They may be made by transfixion or from without in- ward. In making a flap .by transfixion it is well first to mark its outlin e by an incision through the skin and cel- lular tissue with a scalpel, as otherwise there is danger of making its point too narrow or its edges jagged. The point of the amputating knife is then entered at the near- est angle of the incision and passed through to the other, hugging the bone on its way, and the cut made steadily downward to the apex, with sawing movements of the knife. It is then reentered and brought out at the same points, but passing on the opposite side of the bone, and the second flap cut in the same manner as the first. The fibers on each side of the bone which have escaped are then divided, the retractor applied, and the bone sawed through as above. In cutting- a flan from without inward the scalpel must be entered at one of the angles of the base of the proposed 74 AMPUTATIONS. flap, carried along a curved line down to the apcxof the flap, and thence up to the other angle of the base. The presence of a tumor, or injury to, or disease of, the soft parts may render it necessary to modify the shape of the flap or vary the obliquity of the incision, so as not to include any unfit tissue in the former. Skin Flaps and Circular Division of the Muscles. — In this operation the flaps include p ply tln> ^-in mul milu-nfM- n eons cellular tissue dissected off from the deep fasci a ; the latter and the muscles are divided transversely by a sweep of the knife at the base of the flap, the retractor applied, and the bone cleaned and divided a little higher up. Long Anterior Flap. — An anterior fhrp . its length some- ulint oTi'jihT tli:n- | the antero-posterior diameter of the lhn , l> at its base, is cut by transfixion, or from without inward ; the p osterior n inscles and segment of skin are cut straight across a l ittle below the point of division of the ho ne, and the anterior flap brought down to cover their cut surface. This method furnishes a good covering for the bone, and a well-placed cicatrix. In every amputation it is well to dissect out the mam nerve trunks , and cut them off high up between the mus- cles, so that their ends may not become imbedded in the cicatrix. The choice of one or another method will often be deter- mined by the anatomical and pathological circumstance- of the case. When any one may be used, the preference is usually given now to the skin flap with circular division of the muscles. Teale's Method. — In the method to which Mr. Teale's name has been given a very long rectangular anterior flap . co mprising half th e circumference of the limb and all the t issues down to the boia\ i- made and doubled back upon itself, thus furnishing a thick pad for the bone and a pos- terior cicatrix. The method of operating is as follows: i Fig. II. /.') A rectangular anterior Mjip (posterior in the forearm), e nmal in length and bread \U to h ajf the, cirenm- ference of the limb at the base of the flap , is marked out by one transverse and two parallel longitudinal incisions, AMPUTATION OF THE FlNGtiRS. 75 the latter involving only the skin, the former being carried down to the bone. The l ongitudinal incisions should be s o plac ed that the p rincipal vessels and nerves will m ^t he i ncluded in this flap , but in the posterior on e, which is afso bounded by a transverse incision carried" down to the bone, and is only one-fourth as l ong as the anterior one. The two flaps are now in turn dissected up close to the bone, and the saw applied at their base. After the vessels have been secured the I on" 1 flap is doubled back npoj i itself, and its square end fastened to that of the other with sutures; two or three points of suture are also required to keep the sides of the short flap and of the reversed portion of the long flap in contact with the rest of the latter. It is found that Jjy retraction of the short posterior flap the cicatrix is drawn up behind and out of the way of the bone, and that a soft mass without any large ves- sels or nerves is the result of the partial atrophy of the long flap and forms an excellent, non-sensitive stump. The principal objectio n to this method, one which greatly restricts its applicability, is the great length of the anter- ior flap, which can be obtained in many cases only by di- viding the bone at a much higher point than would other- wise be necessary. AMPUTATION OF THE FINGERS. Phalanges. — When the injury or disease is limited to one or two fingers and is of such a nature that the mem- ber will be useless, if [(reserved, the affected phalanx or finger should be removed without hesitation ; but usually it is desirable to save as much as possible of the parts and, therefore, whenever a choice can be made amputa- tion in continuity is to be preferred to disarticulation higher up. The incisions should be SO arranged that the cicatrix will not lie upon the palmar su rface, and for this, as well as for anatomical reasons, the principal flap should be taken from the flexor aspect. Xo special directions are required for amputation or disarticulation of the mid- dle and distal phalanges. For amputation through the shaft the incision may be circular with a longitudinal ad- 76 AMPUTATIONS. dition one-third of an inch long on each .side, or the sin- gle anterior flap by transfixion may be used. In disar- ticulation it is best to enter the joiyt from the dorsnl sifje with a narrow-bladed knife and cut the anterior flap bv c arrying the knife through the joint and then forward. hugging the bon e. It must be remembered that the folds on the palmar surface of a finger do not correspond exactly to the joints ; the first being half an inch hevono 1 . the middle one a line above , and the distal one a quarter of an ine h nhovTf the a rticular surface s, and also that the prominence of a knuckle when the finger is flexed is formed entirely by the head of the proximal and not by the base of the distal phalanx. When the tissues have not become thickened and infiltrated the articular depressions can be felt upon the sides. Amputation Through the Metacarpo-phalangeal Articu- lation. — The articular depression can be found very easily bypassing the thumb and forefinger along the sides of the finger, especially if the latter be at the same time drawn forcibly away from its metacarpal bone. The incision should be commenced over the dorsum of t he meta carp al boin? a ^juarter of an inch above the artic- ulation, c arried through the interdigital wcj >, and then b ack on the palmar faqe . {o a point a quarter of an incj i above the flexor fold ( Fig. 28, C)\ a similar incision, be- ginning and ending at the same points, is made on the other side of the finger, the flaps dissected back, the lat- eral ligament- divide] while the finger is drawn firsl to one side and then to the other so as to facilitate access to them and at the same time make them tense, and then the tendon- and the remainder of the capsule divided as the finger ifi withdrawn. (Jx an in cision may be made only on the si de corre- sponding to the right hand of the operator, the flap dis- Bected back to the joint, the lateral Ligament divided; the k nife, carried transversely t hrough the j oint, dividing the tendonsand the other lateral ligament, and th e other fla.p. cut from within outwmxl, care being taken to make it Bllf- ficiently broad. AMPUTATION OF THE METACARPAL BONES. 77 The head of the metacarpal bone should he removed only in eases where it is more desirable to diminish the deformity than to preserve the strength of the hand. The incisions may be advantageously modified for the index and little fing e rs by making a full lateral flapj m t he fr ee side and carrying the incision transversely across Fig. 28. A. Disarticulation of the phalanx, anterior flap. />'. Amputation in continuity, circular. C! Metacarpophalangeal disarticulation. /'. Amputation of a metacar- pal hone in continuity. E. Disarticulation of little finger. F. Disarticulation of fifth metatarsal. G. Amputation of wrist, circular. /A Amputation of wrist. (DUBBUEIL. ) the palmar surface to the angle of the web, and thence obliquely back to the knuckle (Fig. 28, E). AMPUTATION OF THE METACARPAL BONES. As the articulations of the first and fifth metacarpal bones with the carpu s do not communicate with the othe r and larger synovial sacs, these bones may be entirely re- 7^ AMPUTATIONS. moved without much danger of setting up inflammation within the wrist-joint, but in the case of the ot her thro e a mputation in continuity is p referable to disarticulation il l unclean ca- cs. The relations of the synovial sheath s t >S the flexor tcndo ijs are also of importance in the opera- tion. There is op commu nication betwe en the main s in ath in the palm of the han^l and the sheaths of the inde x, middlcj an d ring J fingers, and consequently, if those ten- dons are divided as low down as the metacarpophalangeal articulation, inflammation of the main sheath with all its disastrous consequences will probably be avoided. The incisions are the same as for amputation thr ough the m etacarpophalangea l articulation, wi th a pr olongation u pward as far as may be necessary oyer the back of tnn bpjia,(Fig. 28, D). After its posterior and lateral sur - faces have been bared , the b juie is cut thr ough with pliers at the point determined on (or i- disarticulated from the carpus), the distal fragment is raised from its bed, and, beginning at the upper end, i ts palmar surface is car efully s eparated from the soft par t s . In disarticulation of the fifth metacarp al, the incision should be made along the inner border of the hand, and e;i frie d down to the b one betw een the skin a nd the abduc- to r_minimi d i^iti_ rather than through the fibers ot the latter (Fig. 28, F). This gives easier access to the palmar ligaments uniting the bone to the carpus. T he lower end of_tlic incision should form :i [qqd with i ts center iii th e int erdig ita ) vj -!j. and it- p >inl on the line of the knuckle. AMPUTATION AT THE WRIST. (Radio-carpal Disa rticulation.) Circular Method (Fig. 28, G). — While an assistant re- tracts the skin upon the forearm, the operator -weeps his knife transversely around the wrist, half an ineh_ helow the point of the st yloid process of the radius . The skin and as much cellular tissue as possible a re divide d and dissected back as far a- the joint, which is then o pene d by entering ETie poiul of the knife jusf below the styloid AMPUTATION OF THE FOREARM. -'.) process of the radius, and the disarticulation completed while the hand is drawn firmly away from the arm. Antero-posterior Flaps. — The absence of muscular fi- bers at the wrist deprives this method of most of the ad- vantages which it offers at other points, and the projec- tion on the palmar surface of the trapezium and pisiform bones renders its execution difficult and makes it prac- tically identical with the circular method supplemented by lateral incisions. It should be reserved for cases in which the skin is s ( , infiltrated that it cannot be readily dissected back. A,n incision curved downward^ is carried across the back of the wrist from one styloid process to the other, the flap dissected up, the hand flexed forcibly, the exten- sor tendons divided, the joint opened beneath them and the palmar flap, which should extend as far down as th e base of the metacarpal bones, cut from within outward. Or the palmar flap muv be made from without inward, or by transfixion, before the joint has been opened. External Lateral Flap. — Dubrueil ' (Fig. 28, H). The hand is pronated and the operator mak es a curved inci - sion, which, beginning on the dorsal aspfvt a quarter of an inch below the radio-carpal artic ular line, at the junc- tion of the outer and middle thirds, passes downward, eros-es the outer side of the first metacarpal bo ne at it s cente r and r eturns to a point on the palmar surface op - posite that at which it began . Its t wo ends are then joined by a transverse incision passing a round the inne r s ide below the end of the ulna . The e xternal flap ls dis - s ected u p, the jo int opened at the radial sid e and the dis- a rticulation complet ed . AMPUTATION OF THE FOREARM. The forearm may be divided, with reference to sur- gical considerations, into upper, middle, and lower thirds. It~ shape is cylindrical near the elbow and gradually Battens and narrows toward the wrist. The lower half of the radius and the whole length of the ulna are subcu- 1 Mperatoire, p. 171. AMPUTATIONS. taneous. The coverings of the lower third are composed almost exclusively of skin and tendons, while thick mus- cular masses cover the upper two-thirds, especially on thf anterior aspect. The absence of suitable coverings in the lower third and the presence there of so many synovial sheaths, the inflammation of which might give rise to dangerous complications, led older surgeons to ad- vise strongly against amputating at this part. But these objections have been greatly diminished by modern meth- ods of treatment which favor rapid uneventful healing and so, unhampered by any other considerations than those established by the extent of the injury or disease that necessitates the operation, we are free to save as much as possible of the limb. Every additional inch adds to the usefulness of the stump. For the reasons stilted, the only method applicable to the l ower third is the circular one , and if the conicity of the limb or the infiltration of the parts should otherwise render it impossible to carry the dissection of the cutane- ous sleeve to a sufficient height, the circular incision must be supplemented by a short longitudinal one in front. Tin d ivisi uu_ oi' the tendon s should be on the same level wi th that of the hon e, and is best accomplished by pass- ing the knife under them, and cutting directly outward. In the middle third the difficulty of dissecting a cuta- ueous sleeve is likely to be still greater, and has led to general rejection of the circular method. As lateral flaps are Impossible, and the bone-; have a tendency to project at the angles ifantero-posterior flaps are made, i t is best to us e s hort lateral skin Maps with short muscular fla^ g by trans- fix ion ( Ti I lau x ),(M^_dmihirdTvisioi^ s i ycly higher le vols, and still higher division of the bones. High up^in the upper third, where the position of the bones is more central, and thick muscular nia.-.-es lie upon the sides, the short flaps should be later al AMPUTATION AT THE ELBOW-JOINT. The irinde^ to the articulation are the opitroohloa on the inner, the epicoudyje and the head of the radju- on the AMPUTATION AT THE ELBOW-JOINT. 81 outer sid e. The smooth rounded prominence formed by the latter can be readily felt about half an inch below the cpieondyle ; and the i nterarticnlar ling starting from it ft**" fl**~* passes at first transversel y and then downward and in , r ward toward a point an inch below the epi trochlea , and forms an angle, opening- inward, with the transverse diameter of the lower end of the humerus. It is there- fore u nnecessary to expose the epicondvle and epitrochj en. i n disarticulatin g ; and these relative positions should be constantly kept in mind during the operation. The skin is freely movable in front, but is adherent to the ulna behind. The methods in common use are the anterior fla p, lateral Hap, and circular. Anterior Flap. — The joint may be opened (a) from be- hind, or (b) from in front. '/. From Behind. (SidUlot.) — The forearm is flexed, and an incision , sli ghtly convex downward and interesting only the p osterior third of the circumference, is made one and a- half inches below the tuberosities of the humerus . The skin is dissected up to the tip of the olecranon , the te ndon of the triceps clivk led, the p oint of the knife p assed into the join t and carried first to one side and then to the other, cutting the posterior and lateral ligament s. A l ongitudinal incision t wo and a-half inches long iis then carried downward from the outer end of the first , the forearm, still flexed, is pressed backward and inward, and the disarticulation readily completed by passing the knife through the joint, and cutting down and out on the an- terior aspect while the skin is forcibly retracted. b. From ix Front. (Fig. 29, J.')— The flap, may be made by tra nsfixi on, or from with out in ward ; in either case it should b e at least three inches long, and its base -ho iild be parallel to and three-quarters of"an inch below a l ine draw n through the epicondy l e and the epitro chlea. The p osterior incision should be s lightly convex down - ward, and should begin and end at the same points as the anterior one ; it is made from without inwar d, not by transfixion. 82 AMrUTATIOSS. The head of the. radius is then sought foiyand the joint_ opened by entering the knife between it and the humerus and completely dividing the external lateral ligament. The '>int of the knife under the acromion, it is better to divide it near its center by drawing the edge of the knife across the upper surface of the head of the humerus; and in all incisions beginning between the acromion and coracoid process the point of the knife should be passed 'Jour. Am. Med. A--"'.. Februan 7, L891. A.vrrr \rif>\ at tin-: SBOULDEH-JOTNT. 85 directly down to the humerus so as to divide the strong fibrous arch connecting the two processes. Oval Method (Baron Larrey). (Fig. 30, A). — A l ongitudinal incision involvin g nil the tissue s down to the, bone is made on the outer aspect of the shoulder from th , e edge of the acromion to a point one inch below the neck o f the humeru s, and an oval on e interesting the skin onl y is then carried from its lower end around the arm , cross- ing its inner side about an inch below . the border of t.l,)(» axilla . The flaps thus marked out are dissected up, the anterior one carefully, until the tendon of the pectora lis major is exposed and d ivided close to its insertio n, the pos terior on e more boldly, but close to the bo ne, so as to avoid injury to the trunk of the circumflex artery. The capsule is freely divided across the head of the humerus, the arm rotated inward and then outward, so as to facili- tate division of the tendons of the articular muscles, which is best accomplished by cutting directly upon the tuberosities, the humerus thus liberated is thrown out- ward by adducting the elbow, the knife is passed behind it and carried down and out through the cutaneous inci- sion on the inner side, while an assistant compresses the artery in the wound. After cutting through the tendon of the pectoralis major, Yemeni 1 isolates the biceps and coraco-brachialis with his lingers, divides them, seeks for the artery, and ties it rather high up before continuing the operation. It is sometimes not easy to reach and divide the broad tendon of the subscapulars ; and when the humerus is broken it is, of course, impossible to use it as a lever to force the head of the bone out of the socket, and this part of the operation may thereby be rendered somewhat diffi- cult. This and the hemorrhage from the branches of the posterior circumflex are the principal objections to this method, which has, nevertheless, yielded excellent results. The articulation is uncovered more freely by any of the double flap methods in which an external flap is fashioned out of the deltoid muscle. Of these the Lisfranc method Sfi AMPITATlOXs. may be taken as the type, premising only thai while the opening of the articulation by transfixion is very easy of execution upon the cadaver, it is sometimes impossible upon the living subject, and inapplicable to eases of ma- lignant disease of the humerus. Under such eirenni- stances the flaps must be made by dissection from without inward. Double Flap Method (Lisfranc). (Fig. 30, B.) — Right shoulder. While the arm is abducted the surgeon enters Fk 30. Disarticulation al the shoulder. A. Oval method. /.'. Method by double Saps the point of a two-edged amputating knife at the outer side of the eoracoid process, carries it across the outer aspect of the head of the humerus, and brings it out a little below the posterior border of the acromion, lie then raises the fibers of the deltoid with his left hand, works the knife downward around the head of the bone, and cuts a broad flap about five inches long. In this manoeuvre the joint should be opened :it its upper part, the tendons of the siipra-spinatns and long head oft he biceps entirely divided, and those of the subscapularis and infra-spinatus partly divided. The arm is then adducted, the knife passed AMPUTATION AT THE SHOULDER-JOINT. 87 and a loiio- innei fla Fig. 31. through the joint to the inner side cut from within outward. Left shoulder. The knife is passed in the opposite direction, that is, from below the acromion behind to the eoracoid process in front, and the operation completed as on the right side. Spence's Method. — Prof. Spence introduced a method, for which he claims the following advantages : 1st. The better form of the stump. 2d. The division of the pos- terior circumflex artery only in its terminal branches in front. 3d. The great ease with which disarticulation can be accomplished. Another advan- tage is that an operation for excision of the head of the humerus can be easily transformed into a disarticula- tion by its means, should that be found necessary. He describes the operation as fol- lows (Fig. 31) : x " The arm being slightly abducted, and the humerus rotated outward, I cut down upon the head of the humerus immediately ex- ternal to the eoracoid process, and carry the incision down through the clavicular fibers of the deltoid and v • i ,.ii x l Disarticulation at the pectoralis major muscles, till 1 reach shoulder. Spence's method, the humeral attachment of the latter muscle, which I divide. I then, with a gentle curve, carry my incision across and fairly through the lower fibers of the deltoid toward, but through, the posterior border of the axilla. Unless the textures be much torn, I next mark out the line of the lower part of the inner section by carrying an incision through the skin and fat only, from the point where my straight incision terminated, across the inside of the arm to meet the incision at the outer part. If the fibers of the deltoid have been thor- oughly divided, the flap, together with the posterior cir- 1 Lectures on Surgery, 2d ed., Vol. II., p. 662. Edin., 1876. 88 AMPUTATIONS. cuniflex artery, can be easily separated by the point of the finger from the bone and joint, and drawn upward and backward so as to expose the head and tuberosities with- out further nse of the knife. The tendinous insertions of the capsular muscles, the long head of the biceps, and the capsule are next divided by cutting directly on the bone. Disarticulation is then accomplished, and the limb removed by dividing the remaining soft parts on the axillary aspect. " In cases where the limb is very muscular I dissect the skin and fat from the deltoid at the lower part and then divide the muscular fibers higher up by a second in- cision, so as to avoid redundancy of muscular tissue." AMPUTATION OF THE ARM, SCAPULA, AND PAET OR ALL OF THE CLAVICLE. Make an incision along the outer two-thirds of the front of the clavicle ; carry the incision through the peri- osteum. Divide the periosteum transversely at the inner angle of the wound, strip it as far as possible from the middle third of the bone and saw through the bone, pref- erably with Gigli wire, at the inner end of this denuded surface. Raise the sawn end of the outer fragment, strip off the periosteum from its deeper surface and saw it through again at about the junction of the outer and mid- dle thirds. Through the gap thus made the great vessels are exposed and divided between separate double liga- tures for each, close to the first rib. A second incision is made from the center of the first downward and outward, along the groove between the pectoral and deltoid muscles, to the junction of the ante- rior axillary fold with the arm ; thence across the inner surface of the arm to the junction of the posterior axillary fold with the arm and thence downward and inward be- tween the tens major and latissimus dorsi to the inferior angle of the scapula. The skin and subcutaneous tissue over the anterior fold of the axilla is raised and the pectoralis major cw\ where it begins to become tendinous. The pectoralis minor is severed close to the coracoid AMPUTATION OF PART OH ALL OF CLAVICLE. 89 process and after division of the cords of the brachial plexus at the level where the great vessels were cut, only the muscles attached to the trunk and scapula retain the limb. The patient is then turned toward the opposite side. Another incision, through the skin and subcutane- ous tissue, is carried from the outer end of the first cla- vicular incision at the acromioclavicular joint, across the spine of the scapula to terminate in the second incision at the inferior angle of the scapula. The skin and subcu- taneous tissue on the inner side of the incision are raised Fig. :;•_'. Amputation of the arm, scapula ami part or all of the clavicle. (The dotted lines represent the part of the incision which lies on the posterior aspect of the body.) (Treves.) sufficiently to permit division of the clavicular and scapu- lar attachments of the trapezius. Then, starting at the outer end of the superior border of the scapula, the omohyoid, levator anguli scapulae, rhomboideus minor and major, and the serratus magnus are divided in this order close to the bone, and the limb detached. The early ligation of the subclavian vessels prevents any great loss of blood. The sutured wound forms an ob- lique line running from above downward, outward, and backward. 90 AMPUTATIONS. AMPUTATION OF THE TOES. The different phalanges of the toes may be removed by the same methods, and at the same points, as those of the fingers, but experience has shown that, except for the great toe, it is better to disarticulate at the metatarso- phalangeal joint, the preservation of a portion of a toe being a source of discomfort rather than an advantage. In the case of the great toe it is desirable to save as much as possible, and amputation in continuity is to be preferred to disarticulation. In all operations upon the foot the in- cisions should be so arranged that the cicatrices will not occupy the plantar surface. It must be remembered that the web between the toes lies far below the metatarso- phalangeal joint. The incision should be commenced on the dorsal sur- face a little above the joint, carried directly down the bone for about an inch, and then, diverging abruptly into the web, straight across in the digito-plantar fold, and back on the other side to the point of divergence (Fig. 33, A). If the strong flexor tendons have been com- pletely divided it will then be found easy to disarticulate by entering the knife at the side of the joint. This oval incision is better than the two lateral semilunar flaps, be- cause its cicatrix does not extend into the sole of the foot. The distal phalanx of the great foe may be removed ac- cording to the methods described for the corresponding part of the thumb and fingers (p. 75). Disarticulation of the great toe at the metatarso-phalan- geal joint may be done according to the method just de- scribed for the other toes, or with a large internal flap. In the latter case an incision (Fig. 34, A) is begun on the outer side of the extensor tendon just below the joint, and carried straight down to the head of the first phalanx. From its lower end a transverse incision is carried around the inner Bide of the toe to the outer edge of the flexor tendon, and, the toe being then forcibly extended, a plantar excision is carried from the end of the trans- verse incision (Fig. 34, B), along the outer side of the flexor tendon to the digito-plantar fold, and thence trans- AMPUTATION OF THE TOES, 91 versely around the outer side of the toe to rejoin the firsl incision near its center. The internal Hap is then dissected from below upward, the extensor tendon divided high up, the lateral liga- ments divided, the knife passed through the joint, and the remaining soft parts cut from within outward. The same incisions made somewhat lower down may be Fig. 33. Fro. .'5-1. -A Amputation nf the great toe. used for amputation in contin- uity, but usually the shape and position of the flaps will be de- termined by the nature and ex- tent of the injury which makes the operation necessary. Amputation of the Two Adjoin- ing Iocs. — The dorsal incision should begin in the intermeta- tarsal space just above the level of the joint (Fig. 33, B), extend down to the beginning of the web, diverge obliquely to the adjoining- web, cross the plantar surface in the digito-plautar fold of both toes, and return through the other adjoining web to the point of divergence. Each toe is then removed separately after division of its tendons and lateral ligaments. AMPUTATION OF A METATARSAL BONE. Amputation in continuity is much to be preferred to disarticulation on account of the extent of some of the Amputation of the toe metatarsal bones. ami 92 i IMPUTATIONS. synovia] sacs, the attachments of certain muscles, and the importance of Mime of the bones in preserving the rela- tions of the other-. The synovial sac which forms part <>f the articulation between the first cuneiform and first metatarsal hones is isolated from the others, bnt the at- tachment of the peroneus longns to the base of the latter bone renders its preservation especially important. There is also a separate synovial sac for the articulation between the cuboid and the fourth and fifth metatarsals. The base of the fifth metatarsal is easily recognized by the promi- nence which it forms on the outer side of the foot; that of the first metatarsal is three-fourths of an inch anterior to the other, and is the first prominence encountered by the finger when it is passed from before backward along the inner side of the bone. The incision begins on the dorsal aspect at, or a little below, the point at which the bone is to be divided, is carried down well below the metatarso-phalangeal joint (Fig. •'!.;, C), diverges into the web, crosses the plantar surface in the digito-plantar fold, and returns through the other web to the point of divergence. A short transverse incision is made through the skin at its upper end to facil- itate division of the bone, which is then effected with cutting pliers or a Gigli wire after the soft parts have been separated on both sides. The toe is then pressed backward, the cut end of the bone raised, the knife passed behind it, and the operation completed by cutting from within outward. The first and fifth metatarsal bones should be cut obliquely so ; i> to diminish the prominence of the Stump. For disarticulation oj the first <>,■ fifth metatarsal hones the only modification Deeded is to begin the incision at a correspondingly higher point — at or a little below the tarso-metatarsal join! (Fig. •'!•'!, I>). After the flaps have been dissected up, the .joint i> opened by dividing the dorsal and interosseous ligaments, and the bone raised and separated from the remaining soft parts. LISFRANCS nil ///.)'> AMPUTATION. 93 Fig. 35. DISARTICULATION OF ALL THE METATARSAL BONES. TARSOMETATARSAL DISAR- TICULATION; LISFRANCS OR HEY'S AMPUTATION.) The position and general direction of the tarso-metatar- sal articulations, a- well as the peculiarity presented by the base of the second metatarsal bone, are sufficiently well shown in Fig. 35 to render a detailed description unnecessary. The guides to the ar- ticulation are the projecting liases of the first and fifth metatarsal bones. The skin being retracted by an assistant, the surgeon makes with a scalpel a curved incision across the dorsum of the foot from the base of the fifth to the base of the first meta- tarsal bone. (For the left foot the direction of this incision should be reversed.) The incision should in- volve the skin only ; its center should lie half an inch or more below the center of the line of the articulations, and it should begin and end upon the sides of the foot at their junction with the sole. (Fig. 35.) A plantar flap should then be marked out by a curved incision be^inninu- and ending at the same , , r, 5 ... .4. Lisfranc's amputation. A*, points a.- the first and CrOSSing the Chopart's amputation. sole near the origin of the toes. The dorsal -kin flap i- then dissected back to the line of the articulation, the tendons and muscular fibers of the short extensor divided, the joints between the fifth, fourth, and third metatarsals, and the corresponding bones of the tarsus opened successively from the outer side, and that between the first metatarsal and first cunei- form from the inner side. With the point of the knife 94 AMPUTATIONS. directed transversely across the dorsal aspect of the base of the second metatarsal, the joint between that bone and the second cuneiform is sought from below upward, and after it has been found and opened the interosseous Ligaments uniting the second to the first and third meta- tarsals are divided by thrusting the point of the knife well down between them, the flat of its blade being held parallel to the long axis of the foot, and the toes being forcibly depressed. After the bone has been thus disengaged, the knife is passed through the articulation, and the plantar flap cut from within outward. Modifications. — The plantar flap may be cut (1) from without inward, or (2) by transfixion, before the articula- tions have been opened. Instead of disarticulating it, the base of the second metatarsal may be cut off with pliers or a saw and left in place. Hey sawed off the projecting part of the first cuneiform after disarticulating, but this weakens the attachment of the tibialis anticus, a disad- vantage which is not offset by the improvement in the outline, f MEDIO-TARSAL OR CHOPARTS AMPUTATION. This name is given to the operation of disarticulation through the joints formed by the astragalus and calcaneuni behind, the scaphoid and cuboid in front. The guides to the joint are the tubercle of the scaphoid on the inner side of the foot, the head of the astragalus on the dorsum and the anterior end of the calcaneum on the outer bor- der. The first named is one-eighth of an inch in front of the articulation and is the firsl bony prominence found on drawing the linger from the inner malleolus forward along the side of the foot ; the sharp edge of the second can be readily felt when the anterior portion of the foot i- forcibly depressed ; the latter can usually be made out by adducting the toes and inverting the sole, nearly mid- way between the tip of the external malleolus and the base of the fifth metatarsal bone, or nearer the latter. When the foot ie .ii righl angles with the leg, the ante- MEDIO TARSAL AMPUTATION. 95 rior articular surfaces of the astragalus and calcaneum arc in the same plane, cue crossing the foot transversely at the points indicated. Operation. (Figs. 35, 36, 37.) — The surgeon places the thumb and forefinger of his left hand upon the tuber- cle of the scaphoid and the lower and outer border of the cuboid, with the palm against the sole and makes a curved incision from one to the other, passing an inch anterior to the head of the astragalus and terminating on each side just below the level of the joint. The plantar flap is next marked out by an incision beginning Fig. 36. Outer side. .1. Chopart's amputation. B. Syme's amputation. C. Subastraga- loid amputation. D. Line of section of the bones in Syme's amputation. and ending at the same points as the first and crossing the sole of the foot four or five finger-breadths nearer the toes. The dorsal flap is next dissected up, the joint entered at either of the points mentioned as guides (pref- erably between the astragalus and scaphoid on the inner side, after dividing the tendons of the tibiales), opened widely by dividing the dorsal and interosseous ligaments and depressing the toes and the plantar flap cut from within outward. Syme preferred to make the plantar flap by transfixion before disarticulating. 96 AMPUTATIONS. The anterior tendons should be stitched to the deep tissues and the dressing should keep the foot in extreme dorsal flexion at the ankle in order that these tendons may SO unite with the stump that their muscles will pre- vent the heel from being raised by the unopposed action of the muscles of the calf. SUB-ASTRAGALOID AMPUTATION. (Figs. 36, ( ', and 37, C.) The guides to this operation are the tip of the external malleolus and the head of the Fig I inn i- side. .1.' Ihopart's loid amputal ion. imputal ioi ;ilil|iill;itiip|i. Subasl raga- astragalus. The joint must be entered from in front on the fibular side, and the strong interosseous ligament which forms th<' key to the articulation must be divided step by step from before backward and inward. The posterior tibial vessels lie behind the inner malleolus, and must be carefully avoided. Beginning at the outer side of the heel, nearly an inch below the tip of the external malleolus, an incision, extend- ing through to the bone, is carried straight forward to the base of the fifth metatarsal bom': thence, curving forward across the dorsum of the foot to die base of the first meta- AMPUTATION AT THE ANKLE-JOINT. 97 tarsal ; thence obliquely backward and outward across the sole of the foot and around its outer border, rejoining the first and horizontal part of the incision at the calcaneo- cuboid articulation. The soft parts must he separated from the outer surface of the calcanenm and cuboid with division of the peroneal tendons, the dorsal flap dissected back to the head of the astragalus and, on the inner side, beyond the tubercle of the scaphoid, thus dividing the tendon of the tibialis autieus and the anterior portion of the internal lateral ligament. The interosseous ligament can then be easily reached by depressing the toes, passing the knife between the astragalus and scaphoid, and cutting backward and inward along the under surface of the former. The soft parts mi the inner side are then sepa- rated from the calcanenm, injury to the vessels being avoided by keeping close to the bone, between it and the tendon of the flexor communis, the foot depressed, and the tendo Achillis divided. This last is a very difficult part <>f the operation, and great care must be taken to keep the edge of the knife close to the bone, s<> as not to cut through the skin. The posterior tibial nerve should be dissected out and cut off as high up as possible, so that it -hall not be pressed upon the stump. Tripier has modified this by leaving the upper portion of the calcaneum : the incision is the same ; then after dis- articulating at the medio-tarsal joint and freeing the lower surface and side- of the calcanenm, he saws through the latter horizontally, the cut passing from the postero- superior to tin- antero-inferior angle. AMPUTATION AT THE ANKLE-JOINT. Syme's Amputation, Tibio-tarsal Amputation. (Figs. 36, 37. F>.) — Amputation through the ankle-joint by the circular method, lateral flap-, or a long anterior flap taken from the dorsum of the foot, as proposed by Baudens, did not meet with favor, because the delicacy of the coverings or the vicious position of the cicatrix rendered the stump 98 AMPUTATIONS. practically useless ; and, although occasional successes were reported, the choice still lay between Chopart's operation and amputation of the leg, until Prof. Syme, in 1843/ showed how the excellent plantar flap could be obtained. About the same time Jules Roux, of Toulon, met the same indication by means of a large internal lateral flap carried across the plantar aspect of the heel. By greatly restricting the necessity for amputation of the leg this operation has become one of the most impor- tant and frequently performed of all amputations. The objections urged against it, and the unfavorable results that have sometimes followed its use, seem to have had their origin in a failure to understand or carry out all the details of its execution, or in the introduction of improper modifications. Tt has seemed desirable, therefore, to re- produce here Prof. Syme's directions for performing it, as published in 1848, 2 six years after he had first put it into practice. " Succeeding experience taught me that a much smaller extent of flap than had originally been considered neces- sary was sufficient for the purpose, and that hence the operation could not only be simplified in performance, but increased in safety from bad effects. " The foot being placed at a right angle to the leg, a line drawn from the center of one malleolus to that of the other, directly across the sole of the foot, will show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus, 3 and carried to a point on the same level of the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two points just mentioned at an angle of 4o° to the sole of the foot, and long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then 1 Loud, and Kdin. Monthly Joiini. of Med. Science, Feb., L848. I ontributionstothePath. and Practice of Surgery. Edinburgh, 1848. '"The tip of the external malleolus, or a little posterior to ii ; rather nearer the posterior than the anterior margin of die hone." Byrne, in Lancet, I - AMPUTATION AT THE ANKLE-JOINT. 99 cut between the nail of the thumb and tuberosity of the os calcis, so as to avoid lacerating the soft parts, which he at the same time gently, but steadily, presses back until he exposes and divides the tendo Acliillis. 1 The foot should be disarticulated before the malleolar projections are removed, which it is always proper to do, and which may be most easily effected by passing a knife round the exposed extremities of the bones and then sawing off a thin slice of the tibia connecting the two processes." Disarticulation is accomplished by opening the joint in front and dividing the lateral ligaments by entering the point of the knife between the sides of the astragalus and the malleoli. The essentials of the method, as pointed out by the more recent Scotch writers (Lister, Spence, and Bell), are that the plantar incision should run from the tip of the external malleolus directly across the heel, should on no account incline forward, and should terminate at least half an inch below the tip of the internal malleolus (behind and below, according to Lister). In case the heel is un- usually long the incision may even incline backward. It is not only unnecessary, but actually dangerous, to make the flap longer than this, for it then becomes impossible to dissect out the calcaneum without scoring the subcuta- neous tissue in all directions, and increasing the chances of sloughing. If the incision is made further back and carried any higher on the inner side, the posterior tibial will be cut before its division into the two plantar arteries. Erichsen and Lister both claim that the integrity of the posterior tibial is not of great importance, the vitality of the flap depending mainly upon anastomosing branches of high origin which lie quite near the bone. Erichsen 2 calls attention to the existence of a " branch of consider- able size which arises from the posterior tibial artery, about one and a-half to two inches above the ankle-joint, and 'It is now generally considered better to divide the tendon from above downward, after disarticulating, keeping the edge of the knife close to the upper and posterior aspect of the bone. -'Science and Art of Surgery, Vol. I., p. 77. Lea, Phila., 1873. 100 AMPUTATIONS. passes down to the inner side of the us calcis," communi- cating freely above, below, and behind this hone with the peroneal artery on the other side. As these anastomosing loops lie much nearer the hone than the skin, great num- bers of them will be divided, and the vitality of the flap endangered, unless the edge of the knife is kept close against the hone during the dissection. Lister goes so far as to say that sloughing of the flap is always the fault of the surgeon, and Bell intimates the same thing. Rous ' has shown that this elose dissection is not with- out its dangers from the other side. In two of his cases osteophytes developed within the stump from portions of the periosteum left adherent to the flap. The autopsy in one of these cases showed that six osteophytes had formed and become carious within a year after the operation. A short longitudinal incision through the deep parts along the middle of the plantar aspect of the ealcaneum will sometimes render this step of the operation easier and be less disadvantageous than the employment of great force. Modifications. A. Internal Lateral Flap. — When the (.liter side of the foot has been so altered by injury or disease that the heel flap cannot be obtained, a very good substitute may he had in the large internal flap suggested by Jules Rous and adopted with Blight changes by Sedil- lot, Mackenzie, and others. Spenee says this stump can hardly he distinguished from Syme's. An incision (Fig. 38) is commenced at the outer side of the tendo Aehillis, a little above its insertion, carried straight forward under the outer malleolus, then in ;i curved line across the instep half an inch in front of the anterior articular edge of the tibia and backward to a point just in front of the inner malleolus; thence directly downward to the sole, across it obliquely backward to its outer border and then backward and upward around the heel t" the point al which it began. The edges of the flaps are aexl dissected up for a shorl distance, the joint entered at the outer side and the internal flap completed from within outward after disarticulation. 1 Hull. .1.- I:, Hoc. 'I- Chirurgie, Tom. III., p. 191, L853. AMPUTATION AT TEE ANKLE-JOlMT 101 Sedillot's modification of this consists in making the flap more quadrilateral than triangular, by a semicircular incision across the dorsum three finger-breadths in front of the malleoli and by carrying the posterior end of the external horizontal incision across the tendo Achillis to its inner border. Mackenzie's method differs only in beginning the in- cision at the inner border of the tendon and a little higher up. It is probable that a serviceable external flap could be Fig. 38. Amputation through the ankle-joint by large internal lateral Hap. (Roux.) made in the same way, although its vascular supply would be scantier. B. Pirogoff's Amputation. — This is a much more important modification, since it involves not merely the method of performing the operation, but also the reten- tion of the posterior portion of the calcanenm, and its ultimate union with the tibia. The only additional ana- tomical point that needs mention in connection with it is that the long axis of the calcanenm is directed upward as well as forward. An incision (Figs. 39 and 40, A) is made from the tip of the inner malleolus to a point a little above and in front of the tip of the onter malleolus, crossing the instep 102 iMPUTATIONS. half an inch in front of the anterior edge of the tibia. A second incision crossing the sole at the level of the calca- ueo-cuboid articulation unites the extremities of the first, Fig. 39. Piroeoff's amputation. A. Cutaneous incision (outer side). B. Line of section of the Dones. Fig. 40. >ff 'b amputation. A. Cutaneous Incision (inner Bide), B. Parallel section ..i the bones [Bt dillot's modification I. and should be carried boldly down to the bone. The plantar Bap ia then dissected l»;iel< for a quarter of an inch, and the dorsal flap to the edge of the joint, the malleoli AMPUTATION AT THE ANKLE-JOINT. 103 well exposed, and the joint opened widely by dividing the lateral ligaments. By drawing the foot forward and depressing it a narrow saw or Gigli wire can be passed through the joint, and applied to the ealcaneura behind the posterior lip of the astragalus, and the bone sawn through downward and forward in such a direction that the section will terminate half an inch behind the lower edge of the calcaneo-cuboid articulation. The malleoli and a slice of the tibia are then removed as in Syme's operation, and enough of the anterior angle of the calca- neus removed to make the length of its surface of section correspond with that of the tibia. Some surgeons prefer to reverse this order, and remove the malleoli before saw- ing through the calcaneum. x The cut surface of the calcaneum must then be brought up against that of the tibia, and if the section of the former has been sufficiently oblique, and has commenced far enough back, this can be done without making excessive tension upon the tendo Achillis, otherwise another slice must be removed from one of the bones or the tendon di- vided subcutaneousl v. Suturing together of the bones has been occasionally tried, as has also fastening them to- gether by a long steel pin driven through the sole and the calcaneum into the tibia. Several modifications of this operation have been sug- gested, but they can hardly be considered as improve- ments. Vertical division of the calcaneum, as originally proposed by Pirogoff and Ure, 2 deprives the stump of the advantages of the heel pad by swinging the latter too far forward, and bringing the weight of the body upon the thinner skin covering the insertion of the tendo Achillis. It also causes undue tension of the tendon when the bones are brought together. Sedillot suggested an oblique sec- tion of the tibia upward and backward, parallel to that of 1 Pirogoff' s incisions were nearly identical with Syme's. He also divided the calcaneum vertically, and retained the articular surface of the tibia unless it was diseased. 2 Ure's conception of the operation seems to have been original witli him. His case was published in the Lancet about the time of the ap- pearance of PirogofTs book at Leipzig, 1854. H>4 AMPUTATIONS. the calcaneum (Fig. 40, B). This avoids any stretching of the tendon, and insures a well-placed pad under the heel, but it shortens the limb somewhat, and places the point of support behind the axis of the leg. Pasquier saws both tibia and calcaneum horizontally ; this is diffi- eult of' execution, endangers the Hap, and also leaves the point of the heel too far back. The suggestion which is occasionally made to retain the malleoli is unsurgical and unprofitable — unsurgical, because union between two cut surfaces of cancellous bone is speedier, stronger, and not exposed to greater risks than when one surface is covered with articular cartilage ; unprofitable, because nothing is gained in accuracy of adjustment or length of limb. Comparison of the Different Methods of Par- riAL and Total Amputation ok the Foot. — As an offset to the advantage of their less extensive mutilation, Lisfranc's and Chopart's amputations are open to the ob- jection that the unopposed action of the muscles of the calf may raise the heel permanently and bring the weight of the body upon the end of the stump and the cicatrix, and, furthermore, when these amputations have been per- formed for disease of the bones, those bones which were left behind, even if apparently healthy at the time of the operation, have ultimately become affected. Byrne's amputation gives an excellent stump and the shortening of the limb is no more than is necessary to permit the adaptation of an artificial foot and a spring under the heel, but it is comparatively difficult of execu- tion and the flap is liable to pouch and favor infection. PirogofPs method is easier of execution and gives a longer limb, but an artificial foot cannot lie fitted to it so advan- tageously : it brings the heel pad a little too far forward and requires a longer time for recovery from the opera- tion. The subastragaloid disarticulation gives a longer limb and a -j'""! stump, which share- with Chopart's the advantages accruing from preservation of the ankle joint. (See also Mikulicz's osteoplastic excision of the heel.) AMJTTATIOS OF THE LEG. 105 AMPUTATION OF THE LEG. . I. Lower Third. — This may be done by the pure or modified circular, or with a long anterior flap made to overhang the square-cut posterior segment of the limb, or with a long elliptic posterior flap, including the whole of the tendo Achillis. The former results in a central adher- ent cicatrix ; in all the coverings are liable to be thin and tender and the artificial limb must be so adjusted that the weight will be received by the sides of the leg and not upon the face of the stump. The compensatory advan- tages are that the control of the limb is more perfect than with a shorter stump. 1. Circular Method. — A circular incision is made through the skin, and a cutaneous sleeve one inch long behind, two inches in front, is dissected up ; the soft parts are cut straight through to the bone at the base, and then retracted with a two or three-tailed band, according to the breadth of the interosseous membrane, and the bones sawn through, beginning and ending with the tibia. Bruns's Method. 1 — While the skin is strongly drawn up, a circular incision is made down to the bone at a dis- tance below the future saw-line equal to two-thirds of the diameter of the leg at the saw-line. Liberating incisions about two inches long are carried upward from the circular incision, dividing all the soft parts over the inner border of the tibia and the outer aspect of the fibula. Without disturbing the attachments of the overlying soft parts, the periosteum is carefully raised from the tibia and fibula as high as the lateral liberating incisions extend, and first the fibula and then the tibia are sawn through, the latter ob- liquely to prevent projection of the crest. The vessels are then ligated, the extremities of the tendons excised, and buried sutures passed, uniting the muscles and periosteum, and, after rounding off the corners, the wound is closed with a drain in the upper angle of the lateral incisions. In the upper half of the leg the circular incision is made first through the skin, and then the muscles are divided a finger's breadth higher up. This preservation of the peri- ^eitrage zur klin. Chip., 1893, p. 492. 106 AMPUTATIONS. osteum is to be deprecated in the young for the reasons given in the toot note on page 72. 2. Modified Circular. (Fig. 41, A.) — Circular in- cision through the skin, met by a liberating longitudinal one on the antero-external aspect. The soft parts of the Fig. 41. Fig. 42. 11 Imputation of leg. A. Modified circular. /;. Rectangular flaps (Teale). ■■ ro-posterior flaps, upper third ( Ui.i.i ). -Amputation of leg. i. Long anterior flap. B. Bupra-malleolar ampu- tation i>y long posterior flan (Guyoh). 0. A.1 the upper third [St ox), D skin flap's and circular division <>f the muscles, AMPUTATION OF THE LEG. 107 posterior portion are divided rather lower than those of the anterior portion, and all are dissected back to the line at which the bones are to be divided. Instead of a single liberating: incision two may be made, one on each side; and then by rounding off the corners we may have double skin flaps with circular division of the muscles, the " modified flap " operation. 3. Long Anterior Flap (Bell). (Fig. 42, A.) — An anterior flap, equal in length to the diameter of the leg at its base, is marked out by a curved incision through the skin, beginning at the posterior edge of the tibia on the inner side, a little below the point at which the bones are to be divided, and ending at a point directly opposite over the fibula. The anterior muscles are divided transversely half an inch above the lower end of the flap, and carefully dissected off the bones and interosseous membrane as high as the base of the flap. The separation from the interos- seous membrane should be made with the finger or handle of the knife, in order that the anterior tibial artery which lies immediately upon the membrane may not be injured. The posterior flap is then made by transfixion and cutting transversely outward, and, the soft parts being retracted, the bones are sawn across a little higher up. The resulting cicatrix is posterior and not adherent to the end of the bone. Bell l reports five cases, in all of which there was complete and rapid recovery, with a useful stump. 4. Elliptic Posterior Flap (Guyon 2 ). (Figs. 42 and 43, £.) — The incision is made in the form of an ellipse, whose lower end crosses the heel below the inser- tion of the tendo Achillis, and whose upper end is about an inch above the anterior articular edge of the tibia. Beginning at the lower end and dividing the tendo Achillis at its insertion, and hugging the bone all the way, the flap is dissected up posteriorly as high as the upper end of the ellipse. The anterior muscles are then divided by transfixion, the bones sawn through, and the posterior tibial nerve resected. 1 Manual of Surg. Operations, 3d ed., p. 85. Edinburgh, 1874. 2 Bulletin de la Soci^te" de Chirurgie, 1868, p. 337. 108 MPVTATIONS. In thi- operation the sheath of the tendo Achillis is not opened, and the tendon itself serves afterward as a cover- ing for the end of the bone. Fig. 43. B. Middle Third. — 1. Long an- terior curved flap. 2. Simple pos- terior flap. 3. Skin flap and circu- lar division of the muscles. 1. The Long Anterior Curved Flap is made according to the meth- od described for its use in the lower third. The principal points to be borne in mind are to separate the anterior muscles from the interos- seous membrane with the finger or handle of the knife, to make the flap long enough to fall over and cover the broad posterior surface of section without tension, and to saw off ob- liquely the prominent angle made by the crest of the tibia. 2. SlNGLE POSTERIOE FLAP. "When the muscles have become atrophied a single posterior Hap may lie safely made. A transverse inci- sion is made across the front of the leg from the posterior edge of one bone to that of the other, and a long posterior flap cut from within out- ward, by transfixion. Its length should l)i' equal to the diameter of the leg at its base. :}. Skin Flaps and ( Jirculae Amputation of the leg and Division OF THE MUSCLES. (Fig. at tbe knee. A. Long \»<^- . , ... ectanaular flap (Lee). p> /).) — Longitudinal incisions are /.• -.i|.i i - m;ill. •■; ° . C At the upper third (Sedil- made on t lie anterior and posterior ii illation :it ,. , i i •! i (he knei oval Incision, aspects ol the leg, midway hetween the tibia and fibula. They should extend downward from a point about an inch below the future Baw-line to a point at a distance from the saw-line AMPUTATION OF THE LEO. 109 equal to two-thirds of the diameter of the leg where the hone is to be divided. These are joined by transverse in- cisions with the corners slightly rounded. The incisions are carried through the skin and subcutaneous tissue, and the flaps thus formed are turned back, drawn up, and dis- sected from the fascia, with care to include all the subcu- taneous cellular tissue, till the point of bone division is nearly reached. The muscles are then cut transversely to and between the bones, the interosseous membrane divided, a three- tailed retractor applied, and, after circular division of the periosteum, the bones are sawn, finishing with the fibula first. The cicatrix will lie between the tibia and fibula. This is generally the best method for amputation of the leg. C. Upper Third. ("Place of Election." )— The bones should never be divided above the attachment of the liga- mcntum patellae to the tuberosity of the tibia, and it is better to divide two inches below it, when possible, so as not to open the sheaths of the flexor muscles of the thigh. The circular and the various flap methods may be em- ployed. 4. Long Anterior Rectangular Flap (Teale). 1 (Fig. 41, B.) — This and the following method have been practically abandoned on account of the great sacrifice of sound parts which they entail. From each end of the transverse diameter of the leg at the point at which the bones are to be divided an incision, equal in length to half the circumference of the leg at that point, is made down- ward and slightly backward, so that the two shall be as far apart as they are at their upper ends, measuring across the front of the leg. Their lower extremities are then united by a transverse anterior incision carried through to the bones and interosseous membrane. The flap thus marked out is dissected up to its base, the separation from the interosseous membrane being made with the finger or handle of the knife so as not to injure the anterior tibial artery. A posterior flap, one-fourth the length of the anterior 1 See also page 74. 110 AMPUTATIONS. one, i> next cut by a transverse incision straight down to the bones, and disserted back to the same point, the inter- osseous membrane divided, the bones cleaned and sawn through. The long - flap is then doubled back upon itself, its lower end sewed to that of the posterior flap, and the edges of the lateral incisions fastened together. 5. Long Posterior Rect angular Flap (Lee). (Fig. 13, A.) — The incisions are similar to those used in Teale's method, but they involve only the skin, and the short flap is anterior, the long one posterior. The posterior flap contains only the gastrocnemius and soleus, while the deeper layer of muscles, together with the large vessels and nerves, is cut transversely as high as the lateral in- cisions permit. 1. Modified Flap (Bell). (Fig. 41, (J.)— Two equal semi-lunar flaps of skin three inches long, one antero- external, the other postcro-internal, their extremities meet- ing at opposite points about two inches below the tuber- osity of the tibia. These must be reflected up, and with them another inch of skin, embracing the whole circum- ference of the limb, must be dissected up. The anterior muscles must be cut as high as exposed, and the posterior ones about the middle of their exposed surface. The bones must then be sawn as high as exposed, the fibula being finished first, and the sharp prominence of the edge of the tibia removed. COMPARISON OF THE DIFFERENT METHODS. Amputation in the lower third gives better command of tlif limb, but the coverings of the stump arc liable to be too thin ami tender. The circular and double flap meth- ods formerly gave central cicatrices and stumps that would bear no weight upon their face, and were sometimes so sensitive that even the pressure of a stocking could hardly lie borne. Guyon's long posterior flap taken from the heel promises well ; in the first case reported the cicatrix, six Weeks after the operation, was two inches above the end of AMPUTATION AT THE KNEE. Ill the stump, upon which forcible pressure could be made without causing any pain.' The long anterior flap also yields a cicatrix which is placed posteriorly and out of the way of pressure, and in short it may be said that the reasons which made the upper third the place of election have lost their force since ampu- tation by a long single flap has been shown to be practi- cable at any point, and since asepsis during healing has improved the character of cicatrices. After amputation in the upper third the weight of the body may be borne upon the tough skin below the patella, the patient kneeling upon his artificial leg ; or the stump may fit into the hollow end of an artificial limb, the upper edge of which will receive the weight from the lower edge of the patella and the broader bony surfaces near the joint. In either case motion at the joint is preserved, and there is no pressure upon the cicatrix. In children methods of amputating which retain in the flap a considerable strip of the periosteum of the removed bone should be avoided, because of the probability of an objectionable formation of bone by it, giving the stump a shape which, because of an erroneous theory of its pro- duction, has been termed "physiological conicity." AMPUTATION AT THE KNEE. Under this head are ranged pure disarticulations and amputations through the condyles of the femur. In dis- articulating, the lateral and crucial ligaments should be divided near their attachments to the femur, and the semi- lunar cartilages removed. A. Disarticulation. Long Anterior Flap. (Fig. 44, A.) — A tongue-shaped flap is marked out by an incision beginning half an inch below the line of the articulation nearly as far back as the posterior border of the condyle on one side, and ending at the corresponding point on the ^n a letter to me, dated June, 1S77, Prof. Guyon states that he has amputated four times by this method, and has every reason to he satisfied with the result. The patients bore their weight upon the stump as freely as upon the other foot. Two cases are reported in the Butt, de In Sloe de Chirurge, 1877, p. 321.— L. A. S. 112 AMPUTATIONS, other, alter crossing the leg five inches below the patella. A transverse posterior incision unites the sides of the first an inch below its ends. The flap is dissected up and the disarticulation completed as before. Lateral Flaps (Smith). — "Commence an incision about an inch below the tubercle of the tibia and cut to the bone ; carry it downward and forward beyond the curve of the sides of the leg, thence inward and backward to the middle of the leg, thence upward to the middle of the popliteal space ; repeat this incision upon the opposite side ; raise the flap consisting of all the tissues down to the bone until the articulation is reached, divide the lat- eral ligaments, enter the joint and sever its connections internally and externally." I',. Amputation Through the Condyles. Oval Method. — An oval incision crossing the front of the leg three fin- ger-breadths below the end of the patella and the back three finger-breadths higher than in front is made through the skin, which is reflected, and the joint opened above instead of below the patella, which is not included in the flap. The line of incision is similar to that in Fig. 4v>, />, but higher. After disarticulation has been effected, the posterior soft parts divided and the artery tied, the con- dyle- are -awn through above the edge of the articular cartilage. Or the saw may be applied without having previously disarticulated. Anterior Flap (Carden). 1 (Fig. -14, B.) — "The op- eration consists in reflecting a rounded or semi-oval Hap of -kin and fat from the front of the joint ; dividing everything else straight down to the bone and sawing the bone slightly above the plane of the muscles, thus form- ing a flat-faced stump with a bonnet of integument to fall over it. "The operation is simple and is performed easily in two ways. "The operator, standing on the right > i < b • of the Limb, seizes it between his left forefinger and thumb at the spots selected for the base of the flap and enters the point • British Med. Journal, April 16, 1864. AUPUTATIOX AT THE KNEE. 113 Fig. 44. of his knife close to his finger, bringing it round through skin and fat below the patella to the spot pressed by his thumb j then turning the edge downward at a right angle with the line of the limb, he passes it through to the spot where it first entered, cutting outward through everything behind the bone. The flap is then reflected and the re- mainder of the soft parts divided straight down to the bone; 1 the muscles are then slightly cleared upward and the saw is applied. * " Or the flap may be reflected first and the knee examined, par- ticularly if the operator be unde- cided between resection and am- putation. In amputating through the condyles, the patella is drawn down by flexing the knee to a right angle before dividing the soft parts in front of the bone ; or if that be inconvenient the patella may be reflected downward. * * " The flap falls easily over the end of the bone, and, when united to the posterior integuments by a few pins and sutures, is drawn strongly upward and backward by the greatly retracted flexors, and has a somewhat puckered and re- dundant appearance at first. (I ritti's Modification. — This is the analogue of Pirogoff's modification of Syme's amputa- tion at the ankle. The articular surface of the patella is removed and the cut surface of the bone applied against that of the femur. The natural mobility of the skin over the patella is preserved, and the usefulness of the stump in- 1 Lister and Bell recommend a posterior skin flap one inch long. 8 Amputation at the knee and lower third of thigh. A. Disar- ticulation, long anterior Hap. B. Amputation through the condy- les (Caeden). C. Modified Map amputation at the lower third of the thigh. 114 AMPUTATIONS. creased thereby; but it not unfrequently happens that the patella is drawn upward by the quadriceps femoris, and union docs not take place between the two bones. Gritti Fig. 4o. i Qritti's amputation at the knee ; A'. Lines of division of the bone. //. Long anterior flap (8£dillot). W . Division of bone. C. Amputation al lower third Division of the bone. D. Disarticulation at the hip. sawed through the femur al the upper edge of the articular surface, but I have alwaysfound it advisable to go nearly an inch higher in order to prevent tilting of the patella. Von Linharl ' claims that the stump is better than that AMPUTATION OF THE THIGH. 115 obtained by amputation in the lower third of the femur, but not better than thai obtained by disarticulation. A rectangular anterior flap (Fig. 45, A) extending from the center of the condyles to the tuberosity of the tibia is marked out, and dissected up after division of the ligamentum patellae as near as possible to its insertion ; the skin covering the back of the knee is divided trans- versely, or by an incision curved slightly downward, the anterior Hap turned hack, the synovial membrane sepa- rated from its attachment to the femur, and the bone sawn through well above the edge of the articular carti- lage. The remaining soft parts are then divided from within outward, and the vessels secured. The artic- ular surface of the patella is then sawn off and its cut surface laid against that of the femur and secured by two or three sutures passed through the periosteum. AMPUTATION OF THE THIGH. The central position of the femur, and the abundance of the soft parts, have made it possible to employ a great variety of methods of amputation, but the superiority of the flap operation is now generally admitted, with certain modifications depending upon the portion of the limb se- lected for amputation. Thus, in the lower third when the skin over the patella is uninjured, Garden's method is to be preferred ; when, on the other hand, that portion of skin is unavailable, the long anterior flap or Syme's mod- ified flap operation should be used ; and in order to com- pensate for the greater retraction of the posterior muscles they should be cut obliquely instead of transversely in the former operation, and on a lower level than the anterior muscles in the latter. In the middle third the long an- terior flap is to be preferred. Lateral flaps should be avoided on account of the tendency of the bone to project at the anterior angle. The muscles are more abundant on the inner and pos- terior aspects, and this disproportion increases toward the hip. The femoral artery will be found in the posterior 'Compend. v. Operationslehre, 1867, p. 401. 116 AMPUTATIONS. flap below the middle of the thigh, in the anterior flap above; care must be taken not to include the internal saphenous nerve in the ligature placed upon it. The pro- funda artery lies close behind the bone, but divides early iuto its branches. The sciatic nerve lies between the short head of the biceps and the adductor magnus j it should be drawn gently downward and divided again high up. Sometimes the band of the tourniquet prevents the mus- cles from retracting sufficiently to allow the bone to be cleared to the proper height. Under such circumstances the bone should be divided wherever it is most convenient, and the excess sawn off after the vessels have been tied. Garden's Method has been sufficiently described. (See p. 112.) Modified Flap Operation in the Lower Third ( Svme). (Fig. 44, C.) — Two equal semilunar flaps of skin and fat, one anterior, the other posterior, are made, raised from the fascia, and retracted two inches further ; " the muscles should then be divided right down to the bone, on a level as high as they are exposed in front, as low as they are exposed behind." The bone i- then cleared and sawn through two inches above the level of division of the ante- rior muscles. Long Anterior Flap. — Se'dillot,' writing in 1854, says he has used this method exclusively for the preceding seven years. Spence J describes a method as first practised by himself in 1 858, and claims that his " flap is formed on ;i principle essentially different from that which regulates the construction " of S&lillot's, a difference which is not _ ni/able in the descriptions, the length of the flap in each case being equal to the diameter of the limb, the breadth of its base "almosl two-thirds of the circumfer- ence " according to Se'dillot, " fully equal to one-half the circumference" according to Spence, and the muscle con- tained in it cut obliquely by both, so that it shall Dot be too thick. Sedillot divides the posterior segment of the limb transversely. Spence divides it obliquely from with- 1 Me"decine Op^ratoire, 2d edition, VoL [., p. 466. ' Lectures on Surgery, 2d edition, VoL I., p. 621, Edinb., L876. AMPUTATION OF Till. TIll'.ll 117 out inward beginning two inches below the base of the anterior flap, and BOmetimes takes an additional inch of skin, a difference which approximates his method to Teak's. Benjamin Bell also describes a method which is nearly identical, and O'Halloran used a similar one in 1 765, but his flap was too short to accomplish its purpose. Sedillot's description is as follows (Fig. 45, B): The flesh of the anterior aspect of the limb is grasped in the left hand and an incision made through the skin, marking out a flap whose length is equal to one-third and its base to almost two-thirds of the circumference of the limb. The muscles are then divided obliquely upward and backward so that the flap shall not be too thick, the posterior segment of the limb divided transversely, the bone cleared an inch or two higher and sawn through. He also removes the anterior edge of the bone obliquely. as was recommended for the tibia. Spenoe recommends the long anterior flap as especially applicable to amputation in the lower third, and he make- it as low as possible, so that its lower margin is on a level with or below the patella. After dissecting up the skin to the upper end of the patella, he cuts obliquely upward through the anterior muscles to the bone immediately above the condyles (Fig. 4o, C). While the soft parts are retracted and after the bone has been cleared circu- larly, he elevates the femur so as to project it fully and divides it two inches above the base of the flap. Modified Circular Amputation en the Lower Third. — The incision, involving only the skin, is begun at the outer part of the anterior surface of the thigh, at a distance below the proposed saw-line equal to one-third of the diameter of the limb at the level where the bone is to be divided. It is carried obliquely downward across the front of the thigh and then transversely across the inner and posterior aspects at a distance below the proposed saw-line equal to two-thirds of the diameter already taken and finally upward on the outer aspect to the point at which it began. The skin is next retracted and freed all around for about tM"o inches. 118 AMPUTATIONS. The superficial muscles on the inner and posterior as- pects of the thigh are divided at the level of the retracted skin and then the outer and deeper muscles are severed < low 11 to the bone at the highest possible level. In cutting the muscles the obliquity of the original incision is to be maintained. Retractors are now applied ami the bone sawed, taking care not to leave a projecting spike at the linea aspera. AMPUTATION AT THE HIP- JOINT. The affections which render this most serious operation necessary are often of such a nature that the surgeon's choice of a method of performing it is greatly restricted ; he must take his flaps where he can get them, and must regulate his incisions by existing lesions. Moreover, the problem is not to obtain a flap that will bear pressure, but to remove the limb in the manner that involves the Leasl risk to life. This risk, which has proved very great, is due not only to the gravity of the lesions which render surgical interference necessary, but also to three causes which originate in the operation itself. These are loss of blood, shock, and septicemia. The first two are the prin- cipal dangers, as modern methods have minimized the chances of infection, although formerly they were con- siderable The opinion, held by many, that the amount of shock varied directly with the length of time employed in re- moving the limb, led to the introduction of operative methods characterized by extreme rapidity of execution, not more than thirty seconds being allowed for the re- moval of the limb from the body ; the type of these is the method by a long anterior flap made from within out- ward by transfixion. To prevent hemorrhage many expedients have been employed: the same rapidity of execution; compres- sion of the femoral artery upon the pubis, or within the flap by an assistant, who passes his lingers into the wound behind the knife; compression of the aorta ; pre- liminary Ligature of the femoral artery ; ligature of each AMPUTATION AT THE HIP-JOINT. 119 vessel when encountered in the wound ; laparotomy and digital compression or ligation (q. v.) of the common iliac ; compression by an elastic tourniquet applied above steel pins thrust through the thigh. The hemorrhage most to be feared is that from the numerous vessels of the posterior segment of the thigh, for, while the femoral artery can usually be controlled without much difficulty, there is no way of preventing the flow of blood from the others except by compression of the aorta or common iliac through the walls of the abdomen, or of the internal iliac through the rectum, or by previously securing the common iliac either extra- or intra-peritoneally. The latter device, first suggested as a means of hemostasis during operation for gluteal aneurism, has been employed in one or two amputations with success ; compression of the aorta, although effectual and entirely harmless in some cases, has proved dangerous or impracticable in others 1 by exciting peritonitis or interfering with res- piration. A simple, efficient, and probably safe method is one recently devised and successfully employed by Dr. Mc- Burney : direct compression of the common iliac artery by the finger introduced through an incision in the anterior abdominal wall. Dr. AVyeth 2 uses two steel mattress-needles which are thrust through the thigh to prevent the slipping of an elastic tourniquet fastened above them. The first needle is entered one and a-half inches below and just to the inner side of the anterior superior spine of the ilium. It passes externally to the neck of the femur, and comes out just behind the great trochanter about half-way between it and the posterior superior iliac spine. The second needle is entered an inch below the level of the groin in- ternal to the saphenous opening, and, passing through the adductors, emerges about one and a-half inches in front of the tuber ischii. A stout rubber tube is then wound 'See Erskine Mason, "Two Successful Cases of Amputation at the Hip-joint," N. Y. Med. Journ., Dec, 1876. 2 Journal Am. Med. Assoc, Feb. 7, 1891. L20 AMPUTATIONS. tightly enough around the thigh above these pins to occlude the vessel-. Dr. McBurney has also used in two eases, and appar- ently with great advantage, intra-venous injection of a large quantity of normal salt solution during the operation. The position of the joint may be determined by that of the anterior inferior spine of the ilium, which is three- quarters of an inch above its upper margin. Nearly all of the numerous methods for performing amputation at the hip-joint may be considered as varia- tions to a greater or less extent from the operation by Maps, which may be either external and internal or ante- rior and posterior, and by the anterior and the external oval — sometimes called racket — incision. Disarticulation by external and internal flaps is not to be commended except for cases in which sound tissue cannot be obtained elsewhere. The knife is entered about a hand's breadth vertically below the anterior superior spine of the ilium and made to transfix the thigh from before backward just below the great trochanter ; it is then carried down and out, cutting a flap four or five inches long. The muscles are then separated from the great trochanter, and after disarticulation the inner flap is cut of a similar length. Hemorrhage is controlled by the pressure of an assistant's finger- entered in the track of the knife and by ligation of each vessel as soon as possible after it is divided. When the nature of the disease or injury permits, the operation by the external racket incision is generally given the preference. In this the bone is approached through the least vascular area, and the incision can also be used Ibr exploration before proceeding to amputation. 1. A.NTERIOB Racket ob Oval Method. — The patient having been anaesthetized and placed upon the table, an Esmarch's elastic band is applied from the toes a- far upward as isallowed by the nature of the lesion and the line of the proposed incision. I. An incision, beginning a finger's breadth below Pou- part'fi ligament, is carried down along the course of the femoral artery for about four inches ; thence outward and AMPUTATION AT THE HIP .JOINT. L21 downward, a little below the base of the great trochanter to the gluteal fold ; thence transversely along this fold to the inner side of the thigh, and thence obliquely upward five full finger-breadths below the genito-crural fold to the point where it diverged from the line of the artery. The incision should involve only the skin and the cellular tissue ; any vessels that are divided should be immediately tied. 2. The sheath of the vessels is opened, the artery iso- lated and denuded, and its point of bifurcation determined. A ligature is then applied methodically to the vessel above the origin of the profunda, and a second lower down, in- cluding both branches en masse, and the artery divided between them. The femoral vein is also carefully de- nuded and divided between two ligatures at about the same level. 3. The incision is carried down through the muscles, beginning on either the outer or inner side, as is most con- venient ; on the inner side, after having cut through the adductors at the junction of their fleshy and tendinous portions, seek and tie the obturator vessels, divide the pectineus and psoas on a line with the neck of the femur, and secure all the bleeding points. On the outer side, divide the sartorius and the fascia lata, and then invert the thigh so as to throw the great trochanter forward and facilitate the. division of the muscles attached to it. 4. Open the articulation in front and divide the poste- rior portion of the capsule as close as possible to the femur, together with the remaining tendons that are inserted in the great trochanter. 5. Division of the posterior segment of the limb. De- press the thigh beyond the border of the table, so as to make the wound gape widely, and divide the remainder of the adductors and the muscles attached to the ischium with gentle strokes of the knife, tying each vessel when it is recognized or divided. It is well also to resect the ex- tremity of the sciatic nerve. II. External Racket Incision or Modified Oval Method. (Fig. 45, D.) — The patient is laid upon his side, 122 AMPUTATIONS. his hips at the foot of the table. A straight incision four inches long is begun one inch above the summit of the great trochanter, and carried along its posterior border, and a circular incision is then carried from the lower end of the first around the thigh, passing three inches below the tuberosity of the ischium. These incisions should interest the skin only, their borders should be dissected up for about an inch, and the muscles of the outer aspect divided obliquely upward toward the joint. In front this division should not be carried beyond the outer edge of the rectus muscle, but posteriorly it should be as extensive as possible and close to the bone. The thigh being flexed and adducted, the capsule is opened, first longitudinally on the finger as a guide, then forward and backward along the edge of the cotyloid cavity, the head of the femur dislocated backward and outward, the knife passed around it and brought down along the inner side of the bone nearly to the level of the circular incision, and then made to cut its way rapidly out on the inner side. Esmarch's method differs slightly from this last. Hemorrhage is controlled by digital pressure on the femoral in the groin. Five inches below the top of the great trochanter divide everything circularly down to the bone, which is at once sawn aero-.-. The vessels are then secured. Next the stump of the femur is steadied and the knife entered about two inches above the tip of the tro- chanter and carried down along its outer surface till it reaches the first circular incision. The bone i- \'viw (P. Heron Watson 1 ). — This method is intended only for the removal of the artic- ular end of the humerus, in cases of more or less complete anchylosis following injury. The advantages claimed for it are that it leaves the attachments of the triceps and brachialis anticus undisturbed, and limits the area of the operation almost exclusively to within the capsular liga- ment, and thereby seems to secure a more speedy healing of the wound. Watson has used it in six cases, in all of which the results were satisfactory. 1. A linear incision is made over the ulnar nerve at the inner side of the olecranon. 2. The nerve is carefully turned over the inner condyle. 3. A probe-pointed bistoury i- introduced into the elbow-joint in front of the humerus ' Edinburgh Med. Journ., May, 1ST::, p. 98G. i:\crSION OF ANCHYLOSED ELBOW 139 Fig. 50. and then behind that bone, and carried upward so as to divide the upper capsular attachments in front and behind. 4. A pair of bone-forceps are next employed to cut off the entire inner condyle and trochlea of the humerus [from above downward] , and then introduced in the opposite direction [from below upward and outward] , so as to de- tach the external condyle and capitellum of the humerus from the shaft. 5. The angular end of the humerus is turned out through the incision and sawn off' square, 6. The external condyle and capitellum are removed partly by twisting, partly by dissection, without any division of the skin on the outer side of the arm. If there is dense osseous union that cannot be overcome by flexion and extension under chloroform, the humerus must be divided through the condyle with bone- pliers, and the operation completed as above. Operative Reduction of Old Unreduced Backward Dislo- cation of the Elbow. 1 — The first incision is made on the outer side (Fig. 50), beginning well up (in the supinator ridge and passing downward to and across the head of the radius, and then for one or two inches posteriorly in the interval between the radius and ulna. Through this the newly formed bone (Fig. 50, A) on the back of the humerus is exposed and chiseled away, and the outer aspect of the external con- dyle freed by dividing its fibrous attachments to the radius and ulna until the capitellum is freely exposed. The sides of the upper portion of the wound are then retracted, the olecranon exposed, and the sigmoid cavity cleared of the mass of fibrous tissue which, more or less, fills it and binds it to the back of the humerus. »L. A. Stimson: N. Y. Med. Journ., Oct. 24, 1891. Incision for the operative treatment of old unreduced dis- location of the elbow. A. Peri- osteal bridge and new tissue occupying the posterior surface of the lower extremity of the humerus. L40 EXCISION OF JOINTS AND BONES. A second incision is now made on the inner side. It is about four inches long - and slightly curved, with its concavity forward, and it passes close behind the internal epicondyle or its site if it has been broken off and dis- placed. The ulnar nerve is found on dividing the fascia, and is carefully drawn forward over the internal condyle. The fibrous bands between the condyle and olecranon are divided. If the epicondyle has been torn from its posi- tion and is attached to the humerus bigher up, it must be freed and brought back with its attached internal lateral ligament. The division of the soft parts must be con- tinued until the trochlear surface of the humerus is freely exposed. If the injury is of long standing, and thereby the flexor muscles permanently shortened, they must be separated from the internal condyle before reduction can lie accomplished. Occasionally a mass of bone of new for- mation is found also at the back of the internal condyle and must be cut away. After the wound is closed the arm i- dressed at right angles in an immobilization apparatus. EXCISION OF THE WRIST. Posteriorly and laterally the wrist is covered only by skin and tendons, with no arteries or nerves of importance except the radial artery, which winds around the outer side to pass again through the first metacarpal space to the palmar aspect of the hand and form the deep palmar arch just below the bases of the metacarpal bones. Be- tween the extensor tendons of the thumb and of the fore- finger exists a triangular interval, shown in Fig. 51, the apex (.f which is directed upward and lies near the mid- dle of the dorsal aspect of the epiphysis of the radius. Within this space are found only the tendons of the long and -holt extensores carpi radiales, with their insertions into the second and third metacarpals, and as experience hae shown that these tendons can he detached or divided without prejudice to the subsequent usefulness of the hand, the articulation can he safely approached through this space. The extensor tendon- are lodged in deep grooves upon EXCISION OF THE WRIST. 141 the surface of the radius, from which they cannot be raised without opening' their sheaths and, therefore, if it is necessary to take more than a thin slice from the bev- elled end of the bone, it .should be done with a gouge and as a late step in the operation. In this way it is possible to leave the tendons unhurt and even unseen. On the inner side the tendon of the extensor carpi ul- naris covers the ulna, in front of it passes the flexor carpi ulnaris on its way to its insertion into the pisiform bone and the base of the fifth metacarpal. The anterior aspect is occupied by the numerous and important flexor ten- dons, the median and ulnar nerves and several arteries or arterial branches of considerable size. Toward the outer side the tendon of the flexor carpi radialis passes through a groove on the surface of the trapezium, to be attached beyond the base of the second metacarpal. An ulnar incision should pass between the flexor and exten- sor carpi ulnaris at the anterior border of the ulna. Bilateral Incisions (Lister 1 ). (Figs. 51 and 52, .1, />.) — All adhesions are first broken down by freely moving all the articulations of the hand. The radial inci- sion is made in the situation indicated by the line L L in Fig. 51, or Fig. 52, A. It commences above at the mid- dle of the dorsal aspect of the radius on a level with the styloid process. Thence it is at first directed toward the inner side of the metacarpophalangeal articulation of the thumb, running parallel to the tendon of the extensor secundi internodii ; on reaching the radial border of the second metacarpal bone it is carried downward longitudi- nally for half the length of the bone. The soft parts on the radial side of the incision are next detached from the bones with the knife guarded by the thumb-nail, so as to divide the tendon of the extensor carpi radialis longior at its insertion into the base of the second metacarpal, and raise it along with that of the ex- tensor brevior, previously cut across, and the extensor secundi internodii, while the radial artery is thrust some- what outward. The trapezium is then separated from the 'Lancet, 1865, p. 3:55, slightly abridged. 142 EXCISION OF JOISTS AXD BOXES. rest of the carpus by means of cutting-forceps applied in line with the longitudinal part of the incision. The re- moval of the trapezium is reserved till the rest of the car- pus has been taken away. The soft parts on the ulnar side of the incision are now dissected up as far as is convenient, Fig. 51. Excision of the wrist, Lister. A. The radial artery. /.'. Extensor secundi inter- nodii pollicis. D. Ext. comm. digitorum. E. Ext. min. '. Oilier. vator, divide the insertions of the muscles at this point, keeping close to the bone, and afterward separate the re- maining periosteum as far as can be done without tearing- it. Then adduct the leg slightly and raise the head of the femur gently out of the acetabulum ; this will detach the last of the periosteum and allow the finger to be passed around the bone as a guide for the saw, which should be applied just above the lesser trochanter. If the bone cannot be readily dislocated, saw it through first and then remove the head with the forceps or elevator. I 18 EXCISION OF JOINTS AND BONES. It' the acetabulum is perforated, the edges must be chipped off very carefully down to the point at which the periosteum on the pelvic side is still adherent. Ollier's Method. (Fig. 53, />'.) — Oilier makes a somewhat similar incision. It begins four finger-breadths below the crest of the ilium, and the same distance behind the anterior superior spine, runs downward to the most prominent part of the great trochanter, and thence directly down the shaft of the femur. Its upper part should in- volve the skin and fascia only. The posterior lip, includ- ing the glutaeus maximus, is drawn back, exposing the glutseus medius, the fibers of which are then separated without cutting them. This permits the attachments of the glutseus medius to be preserved, and the glutseus min- imus can be exposed by drawing apart the edges of the opening made in the other, and then divided in the same manner or drawn forward with a blunt hook. The capsule is split from the edge of the cotyloid cavity to the digital fossa, and detached together with the ten- dinous insertions. The head of the femur is dislocated backward, the ligamentum teres divided, and the denuda- tion continued downward to the lesser trochanter. The bone is then protruded and sawn oil' with a wire or com- mon saw. Langenbbck's Method. — The thigh is flexed at an angle of 45° and rotated inward. The knife is entered ju-1 below a point opposite the junction of the upper and middle thirds of a line joining the posterior superior spine of the ilium and greal trochanter; in other words, just below the most anterior portion of the greal sciatic notch. Thence following the long axis of the Hexed lemur it is curried in a straight line over the out it surface of the -rent trochanter, making an incision which penetrates to the hour throughoul and i- about four or live inches long. The glutei are thus divided in the direction of their libers, the margins of the wound retracted, and the capsule opened by a longitudinal aided by a transverse incision close to the edge of the acetabulum. Alter severing (lie attach- ments of the muscles t<> the ereat trochanter the head <»{' EXCISION OF THE HIP-J0IN2. 149 the bone is dislocated backward and brought oul of the wound and sawed off. Anterior Incision. — Roser recommends, in order to preserve the trochanter, an anterior incision in the line of the neck of the femur, beginning just outside the crural nerve, and dividing the iliacus, rectus, sartorius, and tensor vaginse femoris. The capsule is divided in the same line, the head turned forward into the wound by rotating the thigh outward, and sawn off. Lucke and Schede have modified, this by making the incision vertical instead of transverse, beginning outside the crural nerve a little below and to the inner side of the anterior superior spine of the ilium, and running directly downward. The inner borders of the sartorius and rectus are exposed and drawn outward, and then the outer border of the psoas-iliaeus exposed and drawn inward. Then the thigh is flexed, abducted, and rotated outward, and the capsule divided. .V similar incision and approach to the joint may be used in the operative reduction of old thyroid or dorsal dislocation. Barker 1 employs the following method : The incision begins on the front of the thigh half an inch below the anterior superior spine of the ilium, and extends about three inches downward and a little inward. The muscles arc recognized as the successive layers of tissue are divided. The tensor vaginse femoris and glutsei are drawn to the outer side, the sartorius and rectus to the inner, and the neck of the femur exposed. The external cutaneous nerve will be encountered in the upper angle of the incision ; lower down and deeper are the external circumflex vessels. The deeper part of the incision need not be made as long as the more superficial. Any abscess which may be opened should be thoroughly washed out before proceed- ing further. The neck of the femur is divided with a narrow saw in the direction of the external wound, and the diseased head removed with sequestrum-forceps. The acetabulum 'Brit. Med. Journ.. 19, 1889. 150 EXCISION OF JOINTS AND BOXES. and all other parts of the joint-cavity are explored by the forefinger, and any diseased tissue cut or scraped away. Mr. Barker fills the wound with iodoform emulsion and generally closes it up tight. The patient is placed upon a double Thomas splint for several weeks. Abthbectomy of the Hip- joint by Chiseling through the Great Trociiaxter (Tiling). — An in- cision three or four inches long is made along the anterior Fig. 54. Subcutaneous dn ision of iliu neck <>f tin 1 femur. border of the great trochanter, which is chiseled off and laid hack. The capsule of the joint is divided longitudi- nally, the periosteum elevated from the neck of the femur, and the head of the femur dislocated. Then the lesser trochanter is also chiseled off and the acetabulum cavity i- freely accessible. ANCHYLOSIS OF THE HIP-JOINT. 1 When the anchylosis is no1 associated with the loss of a greal pari of the head and neck of the femur — that is, when it followe inflammation of the join! due to rheuma- 1 Tlii- Bubject, which properly belongs under osteotomy, Lb placed here ■ in account of its intimate relations with excision of the joint ANCHYLOSIS OF THE HIP-JOINT. 151 tism, pyaemia, traumatism, or chronic disease that has been arrested at an early stage — Mr. Adams's operation of sub- cutaneous division of the neck of the femur may be appli- cable, but usually division below one or both of the trochanters, or excision of the head and neck is to be preferred. Division below the lesser trochanter is only undertaken to remedy a faulty position of the limb, for there can be no question of establishing a new joint below the insertion of the psoas and iliacus. It is doubtful also if a perma- nently movable joint can be obtained by division at a higher point ; it certainly cannot unless a portion of the bone is removed, and probably not even then, for the tendency of the cut ends to unite after a time is very great. Subcutaneous Division of the Neck of the Femue (Adams 1 ). — The only special instrument needed is a saw somewhat resembling a tenotomy knife, the cutting part being one and a-half inches long and three- eighths of an inch wide, and the shank about two and a-half inches long. (Fig. 55.) A tenotomy knife is entered a little above the top of the great trochanter and pushed straight in to the neck of Fig. 55. Adams's saw for subcutaneous division of the neck of the femur. the femur, dividing the muscles and opening the capsule freely. The soft parts being tixed by the thumb and lingers of the left hand, the knife is withdrawn and the saw passed promptly down to the bone through the track made by it. The bone is then sawn through from before backward, so that the line of section shall be at right angles to the 1 An operation for bony anchylosis of the hip-joint with malposition of the limb, by subcutaneous division of the neck of the thigh bone, by William Adams. London, 1871. Reprinted from the British Medical Journal of December 2-4, 1870. 152 EXCISION OF JOINTS AND BONES. long axis of the neck, care being taken to avoid cutting obliquely through the neck, or in a direction parallel with the -haft of the bone. Subtrochanteric Osteotomy. 1 — An incision is made from one to two inches long on the outer aspect of the thigh an inch to an inch and a-half below the great tro- chanter, according to the size of the patient. It should expose the external surface of the femur just below the site of the lesser trochanter. The blade of the osteotome is introduced through this incision, and the bone divided just below the trochanter minor. After each stroke of the mallet the chisel is loosened and its direction slightly changed to cut forward or backward. The bone should not be cut entirely through, but when it seems evident that only a thin shell is left it should be carefully frac- tured. The after-treatment consists in simple exten- sion. These two operations are the ones most generally em- ployed for the correction of deformity following anchy- losis at the hip in a faulty position. Adams's method is, of course, only applicable to those cases in which the femur still possesses a neck, and inasmuch as the disease which most frequently calls for this kind of interfer- ence — namely tuberculosis — generally causes more or less destruction of the head and neck of the femur, the second, subtrochanteric osteotomy, has a wider use. Excision. — Posterior incision as above described, with such modifications as may be made necessary by disloca- tion; division of the neck with the saw, if possible; otherwise with the chisel : then removal of the head, or wlrnt remains of it, by chiseling. The upper end of the bone is then lodged In the acetab- ulum, after subcutaneous division of such muscles and -oft parte as interfere and removal of the upper part of the trochanter, if necessary. Traction by weight and pulley musl be kept up for a long time. 'i, miii- "Science and Practice of Sprgery," 1886. EXCISION OF THE KNEE-JOINT. 153 EXCISION OF THE KNEE-JOINT. This should always be complete to this extent, that a slice should be taken from each bone, but it is not always accessary to remove the entire articular surface of the femur. In children the amount removed should be as small as is consistent with the removal of all that is dis- eased. The patella may be dissected out and removed entire, or the diseased portions extirpated with the gouge or rongeur, or it may be sawn through parallel with its articular surface. As a general thing the latter method is preferable, unless the bone is so extensively affected that the preservation of even its anterior surface is incompatible with a thor- ough removal of all the disease. As anchylosis should always be aimed at, the incision may cross the front of the joint and divide the liga- mentum patella? or the patella. Semilunar Incision. (Fig. 56, .1.) — The knife is entered on one side of the limb at the posterior part of the condyle and carried across midway between the patella and the tuberosity of the tibia to a corresponding point upon the other side. This incision should extend down to the bone throughout, dividing the ligamentum patellae. The flap is reflected, the crucial ligaments divided close to their attachment to the tibia, the lateral ligaments divided, the end of the femur cleared as far as may be nec- essary, with especial care for the safety of the popliteal vessels, protruded through the wound and sawn off". The line of section must be parallel to the line of the artic- ulation, not at a right angle to the axis of the shaft, for that is directed inward and downward. If necessary, ad- ditional slices of the bone are removed, or the gouge is used. All the articular cartilages should be removed. The end of the tibia is next projected, cleaned, and sawn Excision of the knee-joint. .1. Semilunar incision. B. < >llier's incision. l.M i:\risin\ OF JnlXTS AM) JiOXES. off about halt' an inch below its upper surface. In the young every effort must be made to save each conjugal cartilage ami the adjoining portion of the epiphysis in order that the growth of the limb may not be checked. In sawing the bones it is best not to make a complete section with the saw, but to stop a little short of the pos- terior surface and complete the separation by fracturing what is left. Finally, the patella is taken out, and diseased portions of the synovial membrane scraped or clipped off, or the articular surface of the patella may be removed with the saw ur rongeur, and the anterior bony shell which is at- tached to the quadriceps tendon left. The operation is completed by suturing in position the divided ligamentum patelbe. Transverse Incision. — The incision should cross the patella at or just below its center and extend beyond the center of the condyle on each side ; at each end should be made a longitudinal incision extending two inches above ami one inch below the transverse one ; the patella is then divided at its center transversely, the fragments turned up and down, and the joint thus opened and cleaned. At the close of the operation the patella is replaced and united with sutures ; the patella maybe entirely removed ; or, in the first place, after exposing the bone, the patella may be dissected out, and at the close of the operation the quadriceps tendon reunited. A.RTHRECTOMY, OR EXTIRPATION OF Till: K NEE- JOINT. — This term ha- been given to the systematic re- moval of the synovial membrane and any small portions of the rest of the articulation which may on inspection be found to be diseased. The above-described semilunar in- cision 18 employed, and the anterior flap containing the patella reflected. After removing all pulpy and degener- ated tissue in the subcrural pouch'the lateral and crucial ligaments, if necessary, are cut, although the latter should l.e spared whenever possible. The joint is thus thor- oughly exposed, and all the diseased parts in its interior excised, together with the semilunar cartilages. Foci of KXClsloy OF TllF AS'KLE-.IOINT. 155 Fig. inflammation in the bone must be removed with the sharp spoon. The field of operation is then flushed out with some antiseptic solution, the ligamentum patellae sutured in position, and the cutaneous wound loosely united. Whenever it is deemed desirable drainage-tubes may be inserted in the posterior angles of the incision. Immobil- ization of the leg in extension must bo maintained for sev- eral weeks. EXCISION OF THE ANKLE-JOINT. The results of excision of the ankle-joint have been, on the whole, unfavorable. When the operation has been undertaken on account of caries, the disease has usually returned in the tarsal bones, and rendered secondary amputation necessary. When, on the other hand, it has been performed on ac- count of injury, secondary amputa- tion has been frequently required, and the position of the foot in the cases that recovered has usually been faulty. As anchylosis is to be expected, the rule in excision is to remove the smallest possible amount of bone, and to make partial instead of complete excision when the dis- ease does not extend to the whole joint. The retention of one or the other malleolus is a great help in preventing shortening, and in the use of a plaster splint. The inter- osseous membrane between the tibia and fibula must be preserved carefully. It not only has a great tendency to ossify, but also seems to favor the reproduction of bone. Operation (Total Excision). — An incision involving only the skin is begun two inches above the external mal- leolus and a little behind the middle of the fibula, carried Excision of ankle. 156 EXCISION OF JOISTS AND BONES. directly down to the end of the bone, and thence forward and slightly upward toward the instep for an inch (Fig. 57). The periosteum covering the fibula is divided throughout and dissected up from the bone with the at- tachment of the lateral ligaments, especial care being taken not to open the sheath of the peroneal muscles at the pos- terior border of the malleolus, and to remove all the thick periosteum and the interosseous membrane on the inner side. If necessary, a transverse liberating incision may be made through the periosteum at the upper end of the cut. The bone is then divided with a keyhole saw or chisel, the upper end of the lower fragment drawn out of the wound to expose and facilitate the separation of the remaining attachments, and the piece removed. The soft parts are then held out of the way with retrac- tors, and the upper articular surface of the astragalus sawn off with the keyhole saw, but not removed. The foot is next turned upon its outer side, and a longi- tudinal incision two or three inches long made along the side of the tibia, ending half an inch below the tip of the malleolus, where it is then crossed by a short horizontal one involving the skin only. The periosteum of the tibia is divided in the line of the incision and transversely at its upper end, and dissected off, the bone sawn through, and the piece removed. Langenbeck makes the line of section oblique downward and outward, because it is easier to do so, but most surgeons prefer to have it trans- verse. The upper part of the astragalus, which has been previously sawn off, is then removed through the same incision. The gouge is used to scrape away any diseased parts found on the cut surface of the astragalus, or the bone may be seized with strong forceps and dissected out int i rely. If the injury has affected the a-tragalus only (as in -nine gunshot wounds), its splinters are best removed through a longitudinal incision upon the dorsum of the foot between tic extensor tendon- of the first and second t,„ a, EXCISION OF THE ANKLE-JOINT. 157 Vogt's Method, by Removal of the Astragalus. (Fig. 69.) — A serious objection to the use of the preceding operation in cases of tuberculous disease lies in its insuf- ficient exposure of the interior of the joint to view, and it has been proposed by Hueter to return to the old method of an anterior transverse incision with division of all the extensor tendons, and by Busch to open the joint by cut- ting across the sole and sawing through the calcaneum. Vbgt, 1 however, has proposed and employed another method, which avoids the extensive division of the soft part and which enables the surgeon to explore the joints thoroughly, and, if necessary, to excise the synovial membrane. It consists in primary methodical extirpation of the astragalus without resection of the malleolus. Operation. — A longitudinal incision on the outer side of the extensor tendons, three or four inches long, beginning above between the tibia and fibula, and ending below at the line of the calcaneo-cuboid joint ; after division of the fascia the tendons are raised in their sheaths, carefully sep- arated from the underlying parts, and strongly retracted to the inner side. The extensor brevis is then cut, the outer side of the incision retracted, the capsule split longi- tudinally to its full extent and separated on both sides from the bone with knife and elevator, the head and neck of the astragalus cleared, and the astragalo-scaphoid ligament divided. A second incision is made from a point somewhat below the center of the first backward below the external malle- olus, dividing everything down to the astragalus, but spar- ing the peroneal tendons. The foot is then supinated, the anterior ligaments cut away from the external malleolus, and the strong interosseous ligament divided by thrusting a small strong knife into the groove between the astragalus and calcaneum. The head of the astragalus is then drawn forcibly outward with a stout hook, while the foot is supi- nated, the deep portion of the internal lateral ligament cut by passing a knife between the malleolus and the astragalus, the latter drawn forward into the incision, and its poste- rior attachments cut. 1 Centralblatt fiir Chirurgie, 1883, p. 289. 1 .-» EXCISION OF JOINTS AND BONES. The remainder of the operation will vary with the ex- tent and character of the disease. All the adjoining bones arc freely exposed to inspection, and can be scraped, gouged out, or sawn off. 1 have found the execution of this operation easy, even when the capsule was much thickened by disease, and its exposure of the interior of the joint is very satisfactory. OSTEOPLASTIC EXCISION OF THE FOOT (HEEL AND ANKLE) (MIKULICZ). This ingenious operation, the results of which have proved very satisfactory, was introduced by Mikulicz in Fig. 58. Icopliulic excisiou of Hie foot, (Mikulicz.) OSTEOPLASTIC EXCISION OF THE FOOT. 159 1881. l It is specially applicable to cases in which the in- tegument about the heel has been extensively destroyed. Operation. (Fig. 58.) — Abdominal decubitus. An in- cision beginning a little in front of the tubercle of the scaphoid is carried directly across the sole of the foot to a point just behind the base of the fifth metatarsal bone. From each end of this one another incision is carried back- ward and upward to the base of the corresponding malle- olus, and the upper ends of the last two incisions arc then Fig. 59. External incision for the operative treatment of old unreduced Pott's fracture. The astragalus is displaced backward. Its articular surface is partially in contact with the new bone developed under the periosteal bridge at the lower end of the posterior surface of the tibia. united by a fourth which passes horizontally across and divides the tendo Achillis. In all the incisions the knife is made to touch the bone throughout. The lateral ligaments of the ankle arc next divided, the joint opened from behind, and the calcaneum and astra- galus carefully dissected from the tissues in front of the incisions and removed by disarticulating at the medio- tarsal joint. Finally, the malleoli and lower articular surface of the tibia and the posterior portion of the cuboid and scaphoid 1 Archiv fur klinische Chirurgie, Vol. XX YL, p. 191. 160 EXCISION OF JOINTS AND BOXES. are sawn off, as shown by the dotted lines in the figure, the cut being made from behind forward. The cut surfaces of bone are then brought into apposi- tion and fastened together with nails or sutures, and the wound closed. Fig. 58, B, represents the result. Operative Treatment of Old Unreduced Pott's Fracture. 1 — The Esmarch rubber bandage or tourni- quet is applied and tied below the knee. An incision is begun on the outer side three inches above the ankle, and carried down along the front of the fibula to the mal- leolus, and thence in a curve forward toward the fifth metatarsal (Fig. .VJ). The seat of the fibular fracture is exposed, and the lower fragment again separated with the chisel. Fig. 60. [nternal incision for the operative treatment of old unreduced Pott's fracture. 11m astragalus is represented as displaced backward, A second longitudinal incision about five inches lone is made over the inner side, extending past the malleolus to the tubercle of the scaphoid (Fig. 60). Through it the mass of new tissue that has formed between the astragalus and the internal malleolus is removed or the broken and displaced malleolus is mobilized. By now working through both incisions the hack of the lower end of the til>i:i can be WnA of sncli cicatricial tissue 'Stimson; N. Y. Medical Journal, June 25, 1892. EXCISIOH OF THE SUPERIOR MAXILLA. 161 or new bone as has formed there, and the foot so mobilized that it can be brought back to its proper place. The peri- osteum and ligaments are sutured in position with catgut, the wound loosely closed without drainage, and after ap- plying a bulky dressing the tourniquet is removed. EXCISION OF THE BONES AND SMALLER ARTICULATIONS. EXCISION OF THE SUPERIOR MAXILLA. This operation may be required on account of malig- nant tumors of the bone or antrum, or to give access to the base of implantation of a naso-pharvngeal polyp. In total excision the bony connections that require to be divided are : (1) The one with the malar bone below the outer angle of the orbit. (2) That with the opposite bone along the center of the hard palate. (3) Those formed by the nasal process near the inner angle of the orbit ; and (4) that with the palate bone and pterygoid process of the sphenoid (Fig. (31). The first may be divided by nick- ing the anterior surface of the bone with a saw, and com- pleting the division with cutting forceps, or with chisel and mallet, or by passing a Gigli wire around it, through the spheno-maxillary fissure in the orbit and zygomatic fossa. The second is divided, after having drawn one or both in- cisor teeth, by means of a saw passed into the nostril, or with cutting forceps with long narrow blades, or a chisel. The third is easily divided with forceps or a chisel, and the fourth by twisting the bone downward after all the other connections have been severed. The periosteum, covering the floor of the orbit, is thick and easily detached ; that on the hard palate is thick and difficult of removal, on account of the irregularities of the surface. There is but little danger of injury to the in- ternal maxillary artery, and it is seldom necessary to ap- ply more than one or two ligatures to its divided branches. Oozing is arrested by packing with aseptic or iodoform gauze. 11 162 EXCISION OF JOINTS AND BONES. In partial excision the orbital plate is left, the line of division of the bone passing through the anterior wall of the antrum from the nostril to the lower corner of the union with the malar bone. The remaining attachments are then broken as before. There are also other varieties Fig. 01. Lines of bony division in the different operations "'i the superior and inferior \ I'.. ' . ["otal excision of the superior maxilla. I>. Meckel's operation. . ri.r- operatl >n. I - I Langenbeck'a operation i"'»r naso-pharyngeal poly- Excision mi' Inferior maxilla. II. Removal of a portion of the ■ (• -/., for epulis). I. Esmarch's operation for anchylosis of Inferior maxilla. ..I' partial excision for the removal of naso-pharyngeal polypi; removal of the nasal process with the nasal bone; removal of pari of the hard palate I Nelaton) ; and tempo- rary removal of different portion-, preserving the connec- EXCISION OF THE SUPERIOR MAXILLA. 163 tion with the soft parts, and replacing them after the polyp has been removed. The incisions that have been proposed may be classed as (1) external and (2) median ; the former extending from the angle of the mouth upward and outward to the malar bone ; the latter passing from or near the middle of the lip up toward the inner angle of the eye. The former are open to the objections that they divide the branches of the facial nerve, endanger Steno's duct and leave a conspicuous scar. The preference is now gener- ally accorded to the median incisions. These follow the outline of the side of the nose more or less closely and some of them are supplemented by a transverse incision, passing a quarter of an inch below the lower margin of the orbit. For partial excision Guerin recommends an incision passing from the side of the wing of the nose along the naso-labial fold to the angle of the mouth (Figs. 61, 63). In order to avoid the swallowing of blood, it is well not to carry the incision through the lip or divide the gingivo-labial fold until after the anterior face of the bone has been denuded as far as possible. It is possible to remove the superior maxilla through the mouth without making any cutaneous incisions, but it is a very difficult and painful operation and the hemor- rhage is most embarrassing. Larghi has removed both bones through the mouth, upon the cadaver, and says it is easier to remove both together than one alone in this way. In simultaneous excision of both superior maxillte, the same incisions may be made on both sides as for the re- moval of only one, or Dieffenbach's median incision may be made along the ridge of the nose and the middle of the upper lip. Operation by a Median Incision. (Fig. 62, B.) — The usual method of operation is as follows : The incision is begun half an inch below the inner canthus of the eye. It is carried down the line of the junction of the nose with the nice and along the groove which limits the ala 164 EXCISION OF JOISTS AXD BONES. nasi, thence transversely to the septum and so down to the free border of the lip in the median line. This Incision may be supplemented, if accessary, by one joining it at the inner canthus and following- the edge of th 'bit outward. The cartilage of the nose is separated from the bone and reflected inward with the small internal flap, the edge of the orbit cleared and the external flap dissected out- ward as far as to the malar bone above and the tuberosity of the maxilla below, if possible, the infra-orbital nerve being divided at its point of emergence from the foramen. Fi.i. 62. Excision of Buperior maxilla. .1. Externa] incision. B. Nfilaton's incision, c. Boeckel's incision. The periosteum of the floor of the orbit is then detached with the handle of the knife, as far as the spheno-maxil- larv fissure, the malar process or bone cut through with iIm- -aw or forceps, and the thin plate of bone forming the floor of the orbit divided with the knife obliquely inward and forward from the anterior end of the sphenomaxil- lary fissure. The superior maxillary nerve, which can !><■ readily distinguished through the bone, should also be divided as far back as possible, finally, the nasal proc- ess is divided. The incision i- then carried through the lip, and the detachmeni of the externa] -oft parts completed. The mucous membrane of the roof of the mouth is divide. I transversely on a line with the last molar tooth. EXCISION OF THE SUPERIOR MAXILLA. it;:, and longitudinally in the median line. An incisor tooth is then drawn, and the hard palate divided with saw or forceps close to the septum. If the mucous membrane of the roof of the mouth is not diseased it may be retained. Instead of the incisions through it just mentioned, one is made along the inner border of the alveolar process, its edge raised, and the membranes detached inward and backward to the median line. After the removal of the bone it unites with the Fig. 63. A. Guerin's incision for partial removal of superior maxilla. B. Oilier' s incision for subperiosteal excision of superior maxilla. C. Dieffenbach's median incision for removal of both bones. L. Langenbeck's incision for naso-pbaryngeal polypus. K. Boeckel's incision for uaso-pharyngeaJ polypus. cheek, closes in the mouth as before, and may become strengthened by a deposit of bone. Finally, the bone is grasped with strong forceps, twisted downward to break its posterior connections, and removed, generally bringing with it part of the palate bone, the hamular process of the pterygoid, and some at- tached muscular fibers. Subperiosteal Excision (Oilier). — This method can be employed with the median incision above mentioned, but Oilier prefers an external one (Fig. 63, B). An incision is made from the middle of the malar bone to a point on the upper lip one-third of an inch from the 166 EXCISION OF JOINTS AND BONES. angle of the mouth, [f necessary, a second incision must be made at the middle of the lip and carried up around the nostril. An incision in the mucosa is begun on the outer surface at the interval between the second incisor and the canine tooth (he does not remove the intermaxillary bone, that which supports the incisor teeth) close to the edge of the gum, carried back around the last molar, then forward on the inside to a point corresponding to that at which it was begun, and thence obliquely backward to the median line. A short incision through the periosteum is next made from the anterior external extremity of the former upward and inward to a point a quarter of an inch external to the anterior nasal spine. The periosteum of the anterior surface is then detached with an elevator, care being taken, however, to divide the infra-orbital nerve with a knife at its point of emergence, and the denudation is carried along the floor of the orbit. Unless it is necessary to remove the nasal process of the maxilla, the lachrymal sac and duct can be left uninjured and adherent to the periosteum. The periosteum of the roof of the mouth is then separated from without inward as far as the median line. The nasal and malar processes are divided with forceps, chisel, or chain-saw, as before described, the canine tooth drawn, the edge of the chisel Inserted in the gap left by it, and pressed gently backward and inward to the median line, thence directly backward along the suture. The bone is then twisted out, the palatal sutured to the external periosteum, and the wound closed. Excision of the Portion of the Superior Maxilla Lying Below the Infra-orbital Foramen (Guerin's Operation). (Figs. 61, E ( '. 63, A). — An incision, slightly convex externally, is made from the ala of the nose to the angle of the mouth, following the crease Usually present in the features at this situation. The alveolar mucous membrane is divided at the point of reflection on to the cheek from the level of the lasl molar tooth to the middle line anteriorly. The -oft parte are dissected up and the nostril opened in front. EXCISION OF THE SUPERIOR MAXILLA. 167 A narrow saw is passed through the Dares and the maxilla sawn horizontally outward. The saw cut passes below the infra-orbital canal well above the teeth and through the malar process and maxillary tuberosity ; or the bone may be chiseled through on this line. The soft palate is de- tached i'rom the hard by a transverse incision at the last molar tooth. A middle incisor tooth is next removed and the hard palate divided in the median line with a saw, chisel, or forceps introduced through the nostril. The detached piece of bone is loosened with a periosteal eleva- tor and wrenched out. This operation may be performed subperiosteally (usu- ally for naso-pharyngeal polypus), either by the above- described or by a median incision. The muco-periosteum is divided along the free margin of the inner and outer faces of the alveolar process on the affected side, from the anterior nasal spine around behind the last molar tooth, and detached to the middle line of the hard palate and to its posterior border and upward to near the infra-orbital foramen on the outer surface of the superior maxilla. The lower half of the latter is next removed as indicated above, and at the close of the operation the mucous mem- brane is united as far as possible by sutures, thus shutting off the nasal from the oral cavity. This operation affords an excellent view of the naso- pharynx. Removal of the Superior Maxilla Above the Alveolar Process (Berard's Operation). — The median incision is used from below the inner canthus of the eye, following the junction of the nose and face through the center of the upper lip (Fig. 62, B). The soft parts on the affected side are raised as for total extirpation of the maxilla and the periosteum of the floor of the orbit is detached as far as the sphcno-maxillary fissure. The malar process is di- vided and then the orbital plate inward and forward from the anterior end of the spheno-maxillary fissure. The su- perior maxillary nerve is cut as far back as possible and, finally, the nasal process. A horizontal saw-cut is then made outward from the 168 EXCISION OF JOINTS AND BONES. nose above the alveolar process. Any adherent structures between the outer extremity of this cut and that through the malar process are freed with the knife or periosteal elevator and the piece of bone thus mapped out is pried or wrenched away. The sound aveolar process is left in 8ttll. SIMULTANEOUS EXCISION OF BOTH SUPERIOR MAXILLA. An incision may be made from each angle of the mouth to the malar bone and the broad flap reflected toward the forehead, or Dieffcnbach's incision made along the ridge of the nose (Fig. 63, C), with or without a transverse one passing across it and below the margin of each orbit. The bones are removed together, not separately. The malar processes or bones are divided in the usual manner, the nasal processes divided with a chain-saw passed from one orbit to the other through the lachrymal bones, and the vomer separated with cutting forceps. The periosteum of the hard palate is separated from the gums by a semi- circular incision and dissected back, the posterior connec- tions broken, and the bone removed by twisting it down- ward and forward. PARTIAL AND TEMPORARY EXCISION OF THE SUPERIOR MAXILLA TO FACILITATE THE REMOVAL OF NASOPHARYNGEAL POLYPS. Resection of Posterior Portion of Hard Palate ( Xclaton). — The soft palate is first divided from before backward along the median line, and the incision prolonged forward through the periosteum of the hard palate as far as may be judged uecessary. A transverse incision is next made on one Bide from the anterior extremity of (he first toward the teeth, and the flap, including half the .-oft palate, dis- sected oil' the bone from the median line outward. The muCOUS membrane on the floor of the corresponding nos- tril i- then divided close to the septum, the bone perforated at the anterior corners of the denuded surface, and the EXCISION OF THE StJPEMOR MAXILLA. 169 separation of the quadrilateral piece accomplished with cutting forceps. After removal of the polyp the soft parts are replaced and stitched together. The bone is sometimes reproduced. A little larger opening may be obtained by making the transverse incision extend from one side of the hard palate Fig. 64. Resection of hard palate to expose nasal fossae. A. Nelaton's operation. B. Chatot's operation. to the other, and then chiseling away the included bone — in other words, nearly the whole of the bony floor of the nasal cavity (Fig. , and Fig. 63, K.) — The incision begins near the root of the nose slightly to one side of the median line. It passes in a curved direction 172 EXCISION OF JOINTS AND BONES. down to the lower free border of the nasal bone; from here to the junction of the ala and cheek and a short dis- tance outward on the cheek. The second incision passes from the origin of the first at the root of the nose along the edge of the orbit to the infra-orbital foramen. It must clear the. lachrymal sac. This tongue-shaped flap is raised with the periosteum and exposes a triangular sur- face of bone. After retracting the soft parts a chisel is driven through the superior maxilla so as to divide it vertically just inside the infra-orbital foramen between the margin of the orbit and the upper surface of the hard palate. The chisel should be obliquely directed and enter the nasal cavity near the vertical plate of the palate bone. Fig. 65. Ollier's operation for removal ofa aaso-pharyn&eal polyp, /•'. Mi very large polyp. ilicatioi] for a The nasal process of the superior maxilla and the nasal bone are cut very nearly in the line of the upper cutaneous incision. The lachrymal sac must be spared. The bony division is carried down to the lower free border of the nasal bone. Finally the chisel is driven into the nasal cavity through the anterior and inner walls of the antrum on a line reaching from the lower termination of the first bony incision to the floor of (he nose. The inferior and middle turbinated bones are removed with the mass thus marked out, which is more or less pyramidal in shape with the apex toward the posterior oares. EXCISION OF THE INFERIOR MAXILLA. 173 At the close of the operation the periosteum and skin are replaced and sutured in position. Oilier turns the whole nose downward. He begins his incision at the edge of the hone close behind theala of the nose, carries it upward along its side to the highest part of the depression between the eyes, then across and down to the corresponding point on the other side (Fig. (V), A). The bone is sawn through in the line of the incision, the necessary liberating incisions made in the septum or the sides, and the nose turned down. The septum is pressed aside, the polyp extracted, its base of implantation scraped and the nose replaced. A modification which is sometimes desirable on account of the size of the polyp or the distance of its implantation is indicated in Fig. 65, B. The incision runs more ob- liquely backward and a transverse one is made from each end of the ala of the nose. The bone is divided in the direction of the cutaneous incisions, in the vertical one as before described, in the horizontal one by passing a fine saw across the nostrils through holes made between the bone and cartilages and sawing backward. This line of section must be high enough to avoid the roots of the teeth. In some cases it is sufficient to mobilize the lower end of the nose by an incision under the lip in the gingivo- labial fold and then by carrying it and the lip upward very free access to the nasal fossa? is obtained. Aint1 is the ordinary amount removed for epulis ; this can be accomplished through the month. ANCHYLOSIS OF THE JAW. The mOSl Common cause of anchylosis of the jaw is found in cicatricial retraction or adhesions left behind by I N( HYLOSIS OF THE J A W. 1 79 intra-buccal ulceration. Kizzoli (1858) was the first to point out that the proper aim of an operation intended to relieve this infirmity should be the establishment of a pseudarthrosia in front of the adhesions or cicatricial bands when the cause itself could not be removed. His operation consisted in the division of the inferior maxilla behind the last molar tooth by means of a specially con- structed osteotome introduced through the mouth. Bony union of the fracture was then to be prevented by motion. Esmarch (1859) proposed the removal of a wedge-shaped piece of the bone. By some surgeons the base of the wedge is taken from the alveolar process, by others from the lower border of the jaw. Dieffenbach proposed to di- vide the ascending ramus horizontally from before back- ward by means of a chisel passed through the mouth to the anterior border of the ramus. Operation (removal of wedge-shaped piece). — An inci- sion is begun at the angle of the jaw and carried two inches forward along the lower border. A narrow strip of bone is then cleared on both sides up to the edge of the gum, just anterior to the masseter and in front of the con- tracted tissues, a tooth drawn if necessary, and the bone sawed through. The anterior fragment is then depressed and protruded through the wound, and a wedge-shaped piece from one-third to one-half of an inch in width at its widest part cut off with cutting forceps. (Fig. 61, J.) Excision of the Condyle. — This may be required for the relief of anchylosis due to bony or fibrous union between the condyle and the temporal bone. The incision is be- gun at the lower margin of the zygoma close in front of the temporal artery where it adjoins the ear and carried forward along the zygoma about one and a-quarter inches, the tissues being divided layer by layer until the bone is reached. A second incision, involving only the skin, is then carried from the center of the first directly down- ward for about an inch. The soft parts are next care- fully separated with knife and elevator from the margin of the zygoma and the outer surface of the joint and drawn downward with a hook, thus preserving the 180 EXCISION OF JOINTS AND BONES. parotid, nerves and vessels from injury. The neck of the condyle is then freed by working around in front and behind with a small elevator, keeping close to the bone, so as to avoid injury to the internal maxillary artery and finally divided with the chisel and rongeur. If there is bony union between the condyle and temporal bone the chisel must be again used to separate them, its edge being kept directed somewhat downward, so as not to break through into the cavity of the cranium. The condyle is then grasped with forceps and twisted out. The knife or scissors may be used to sever any remaining connections, but must be kept close to the bone. RESECTION OF THE STERNUM. It is occasionally necessary to remove a central or lat- eral portion of the sternum in order to evacuate pus that has formed behind. The bone is exposed by a longi- tudinal incision, the periosteum detached and a trephine applied, or if the bone is soft the opening can be made with a gouge. RESECTION OF THE RIBS. This is best performed in those regions where the mus- cular layer covering the bone is thin. In the middle third of the rib the intercostal artery lies in a groove on the inner side of the lower border. The incision should correspond in length and direction with the portion of bone to be removed, and may be crossed at each end by a short transverse one. The Haps are then dissected up, the periosteum separated as far as possible, a wire-saw passed at the limits of the diseased portion, and the piece removed. Instead of the saw, cutting-pliers may be used. In EsUander's operation for empyema (thoraco-plastik), in which portions of several adjoining ribs are resected to allow the chest wall to sink inward and unite with the vis- ceral pleura, the position of the incision is usually deter- mined by that of the (istula. The incision is made along the intercostal space occupied by the fistula, and the ad- EXCISION OF THE CLAVICLE. 181 joining ribs dissected as above described. The limits of the cavity are then determined, and other ribs resected, if necessary, through a vertical incision made from the center of the first, If the costal pleura is so thick as to prevent the attainment of the desired object, it must be cut away from a sufficient part of the area of resection. From three to six ribs have been thus resected, in lengths varying from one to three inches. The operation has been restricted to the ribs between the third and eighth, but in one case a small portion of the clavicle also was removed. Sometimes the thickened visceral pleura has also been dissected off. EXCISION OF THE CLAVICLE. On account of the proximity of the large vessels of the neck this has been considered the most dangerous of all the excisions. The danger, however, varies greatly with the nature and extent of the disease which renders the operation necessary. Thus, when there is osteitis with thickening and loosening of the periosteum, the operator can easily keep close to the bone, and the danger of injury to the vessels, as well as of exciting diffuse inflammation below the deep fascia, is reduced to the minimum. On the other hand, when caries has existed for a long time, the soft parts have become infiltrated and bound down, and the bone thickened and roughened, the difficulties are immensely increased ; and when the bone is the seat of a malignant tumor, extending in all directions, its removal may tax the powers of the most skilful. Valentine Mott spoke of his case as the most difficult and tedious opera- tion he had ever witnessed or performed ; it lasted four hours, and more than forty ligatures were applied, in- cluding two upon the internal jugular vein. As only the inner half of the bone is in close relation with the vessels, and the danger is especially great at the sterno-elavicular joint, it is advisable first to raise the outer end of the bone from its place by opening its artic- ulation with the acromion or by dividing it a little to the inner side of that joint, and then, after clearing the pos- terior surface from without inward, to divide the attach- 182 EXCISION OF JOINTS AND HONES. nients of the inner end while twisting the bone upward about its loog axis, and keeping the edge of the knife against it. When this is impracticable the periosteum must be carefully separated near the middle, and the bone sawn through with the usual precautions against injury to the underlying parts. Each half is then raised in turn and dissected out. For the removal of a tumor no fixed rules can be given. In other eases the directions are as follows : Operation. — The subperiosteal method must be em- ployed throughout. The incision is made along the ante- rior surface of the bone, and corresponds in length with the portion to be removed. A short transverse incision is then made at each end of the first, the flaps dissected up, and the denudation carried as far as possible around the bone above and below. The bone is then freed at its acromial end, or divided in the middle, and the separation completed as above de- scribed. EXCISION OF THE SCAPULA. It is impossible to lay down fixed rules for making the incision when the operation is rendered necessary by a tumor of the bone. They will be determined by the cir- cumstances of the case, and especially by the extent of the disease, for while in some cases the acromial end of the clavicle must also be removed, in others the acromion and neck of the scapula may be left behind. Mr. Holmes 1 says: " The surgeon turns down appro- priate skin flap-. * * * When the whole tumor is thus exposed, the muscles inserted into the vertebral border of the bone should be rapidly divided, as also those which are attached to the spine of the scapula. The tumor should lie lifted well up and freed from its other attach- ments, commencing from its lower angle. The subscapu- lar artery is divided Dear the end of the operation, and can be held till the tumor is removed, or can be at once tied. The Ligaments of the shoulder are then easily divided and the mass removed." 'A System <>f Surgery, Vol. V., p. 669. EXCISION OF THE CLAVICLE. 183 Gross 1 made a vortical incision sixteen inches long downward from the superior angle of the scapula, and circumscribed an oval portion by a second curved inci- sion, beginning five inches below the upper end of the first and ending about the same distance above its lower end, and removed the bone after sawing through the acromion and neck of the scapula. Velpeau 2 recommends three incisions : one along the spine of the scapula, the others starting from the ante- rior extremity of the first and running, one toward the root of the neck, the other toward the axilla behind. Syme made two incisions crossing each other near the center of the tumor. Other surgeons have made triangular or semilunar flaps. In January, 1878, Dr. George A. Peters removed, at the New York Hospital, the entire scapula for malignant dis- ease, leaving the arm. He made an incision along the spine of the scapula, divided the fibers of the deltoid and trapezius, and exposed the tumor, which involved only the acromion and adjoining portion of the spine. He then made a vertical incision across the center of the first, beginning; two inches above it and extending; to the inferior angle of the scapula, reflected the flaps, dissected out the under surface of the bone from behind forward, sepa- rated the acromion from the clavicle and humerus, and then, raising the lower angle of the scapula toward the head, approached the coracoid process from below, and found no difficulty in separating it from its attachments. Only two vessels required ligation, the supra-scapular and a large branch of the subscapular. The result was very good ; six weeks afterwards the wound had closed, and the patient possessed a certain degree of control over the humerus. Subperiosteal Excision of the Scapula (Oilier). (Fig. 67.) 1. IXCISIOX OF THE SKIN AND MUSCTTLAB INTERSTICES. — An incision is made along the whole length of the spine of the scapula, and from its posterior extremity two others 'Gross's System of Surgery, Vol. II., p. 1078. 2 Me'decine Operatoire, Vol. II., p. 659. 184 EXCISION OF JOISTS A XI) BOXES. are made, one following the posterior border clown to the interior angle, the other running obliquely forward and upward for about an inch. A short transverse incision may also be needed at the anterior end of the first. •2. Denudation of the Boxe. — The attachments of the deltoid and trapezius to the acromion and spine are separated, the periosteum of the posterior border of the scapula divided in the interstice between the rhomboideus and infra-spinatus, and the infra-spinous fossa carefully Fig. 67. Excision of 1 1 1 < - scapula. denuded. The periosteum is very thin in its lower third. The lower angle is freed by detaching the teres major and serratus magnus, the bone raised, and the subscapularis detached from below upward. If the marginal cartilage ig nol completely ossified and united with the bone, it should be separated and left adherent to the periosteum. The BUpra-spinous fossa is then cleared, care being taken not to injure the supra-scapular nerve in the supra- scapular notch, but to raise it up with the periosteum and it- fibroue sheath. The posterior part of the bone is then UKSE0T10N OF THE HUMERUS. 185 carried upward and forward and the denudation of its under surface and anterior border completed. If the extent of the disease permits, the denudation should stop at the neck of the scapula, which is then di- vided with a chain-saw or cutting forceps. 3. Opening ok the Scapueo-humeral Joint. De- tach mkxt OF THE AeTICULAE CAPSULE AND DENUDA- TION of the Coeacoid Peocess. — The acromion is next separated from the clavicle, the scapula turned upward, the joint opened from below, and as the bone is pressed steadily upward everything that holds is detached with an elevator. After the coracoid process has been thus separated from most of its muscular and ligamentary at- tachments, the few that remain can be broken by twist- ing the bone away. In suitable cases the coracoid proc- ess may be divided at its base and left in place, and thus the most difficult and laborious part of the operation done away with. The partial excisions of flic scapula do not require de- tailed description. The acromion, spine and posterior border are reached by straight or slightly curved incisions along the portion to be removed. A crucial or \\ incision is required at the angles. RESECTION OF THE HUMERUS. The position of the musculo-spiral nerve is the most im- portant element in this operation. In its passage around the posterior aspect of the humerus the nerve lies close to the bone within the sheath of the triceps muscle, and leaves the latter on the outer side of the arm to enter that of the supinator longus at its origin. In approaching the bone, therefore, on the outer side near the junction of the middle and lower thirds, the operator should lay bare the outer border of the braehialis anticus and follow down within its sheath to the bone. Upper Portion. — Same incision as in Ollier's method of excision of the shoulder carried further down along the outer edge of the biceps. The cephalic vein must be sought for and drawn aside. Periosteum and capsule di- 186 EXCISION OF JOINTS AND BONES. vided, ltinic denuded and removed as in excision of the shoulder-joint (q. /•.). Middle Portion. — Incision along the posterior border of the deltoid and outer edge of the biceps. Outer border of the brachialis anticus laid bare and followed down to the bone. Division of the periosteum and denudation of the bone, with especial care for the safety of the musculo- spiral nerve. Oilier prefers to seek the nerve and draw it aside. He also recommends that whenever it is possible to leave a portion of the shaft connecting the extremities it should be done, as a precaution against shortening and the forma- tion of a pseudarthrosis. If this is not possible the chain- saw is passed at two points, and the intermediate piece removed. Lower Portion. — Incision on outer side of the posterior aspect of the arm, between the triceps and supinator longus, as in Ollier's excision of the elbow (/j. v.). Total Excision. — Combination of incisions for upper and lower portions. After the ends have been denuded of peri- osteum the middle portion can be cleared by pushing one end out through its incision and peeling the periosteum back like the finger of a glove until the middle is reached. The bone is then -awn off, and the other half removed in a similar manner through the other incision. EXCISION OF THE ULNA. Longitudinal incision along the posterior aspect of the bone, joined at its upper end by a short one running ob- liquely upward and outward between the triceps and anco- neus. The triceps is drawn to the inner side, and the olecranon Freed. After separation of the periosteum the bone ig Bawn through in the middle, and each piece is dis- sected out in turn. EXCISION OF THE RADIUS (OLLIER). An incision involving the skin only i- made from the styloid process of the radius along the outer border of the forearm to the radio-humeral articulation. The fascia is METACARPAL BONKS AND PHALANGES. 187 divided and the posterior border of the supinator longus found. By following it toward the wrist the knife can be kept between it and the extensor tendons of the thumb, which can then be drawn backward and saved from injury. By following it upward the interstice between it and the extensores carpi radiales is found, through which the oper- ator penetrates to the radius now covered only by the supinator brevis. The latter muscle is then divided longi- tudinally and the periosteal sheath opened. The periosteum is detached laterally, the bone sawn through at its middle, and each fragment removed sepa- rately. Partial Excisions of the Ulna and Radius. — The incisions and methods are the same as those above described. EXCISION OF THE METACARPAL BONES AND PHALANGES. The metacarpal bones should be exposed by a longitu- dinal incision along the dorsum. As the extensor ten- dons cross the bones obliquely this incision should in- volve only the skin at first, the tendon is then drawn aside and the incision carried down to and through the periosteum, which must be retained when possible. It is advisable that the joints, especially the metacarpopha- langeal, should not be opened. The bone is then divided in the middle with cutting- forceps and each end dissected out, or the gouge alone may be used. The after-treatment is important. Extension must be made upon the corresponding finger for a long time to keep it from being drawn up into the hand. In the case of the metacarpal bone of the thumb lateral pressure must also be made. For resection of a phalanx the incision should be made on the side of the finder near the dorsum. For the ter- minal phalanx the incision should be U-shaped, the arms passing along the sides of the phalanx, the curve around its end. Resection of the different portions of the thumb, even 188 EXCISIOX OF JOINTS AND JWN8S. if not subperiosteal, is to be preferred to amputation, but the contrary is true of the phalanges of the other fingers. Lateral pressure, by means of splints or an India-rub- ber glove finger, and extension by weight must be made to insure the necessary length and proper shape of the member. RESECTION OF THE BONES OF THE PELVIS. Oilier' reports a case in which he removed the as- cending ramus of the ischium and most of the pubis for suppurative osteo-arthritis of these bones and the pubic synchondrosis. The incision was about four inches long and extended from a fistula in the genito-crural fold up toward the pubis. The periosteum was detached, the as- cending ramus of the ischium removed and then the as- cending ramus, body and part of the horizontal ramus of the pubis. The bone that w r as removed was eroded and rarefied, but not necrotic. EXCISION OF THE COCCYX (OLLIER). This may be required on account of disease of the coccyx, of coccygodynia, or as a preliminary to operations upon the rectum. The limits of the bone are determined by the finger in the rectum, and a longitudinal incision made through the skin and fibrous covering of the bone, from a quarter of an inch above its upper to the same distance below its lower end, and a transverse incision made at the upper end of the first. The posterior surface of the bone is then denuded. The sacro-coccygeal articulation having been opened by this denudation, its fibro-cartilage is divided, and the cornua cleared. An elevator is then passed through the joint and used as a lever to force out the coccyx, peeling of]' ;it the same time the fibrous covering of its anterior surface. If tin' sacrum is also diseased, and the gouge is used upon it, it must be remembered that the sacral canal ex- 1 Dela R£g6n6ration des Ob, VoL II., |>. 180. RESECTION OF THE SHAFT OF THE TIBIA. 189 tends to its very end, and is there formed posteriorly not of bone, but of fibrous tissue. RESECTION OF THE SHAFT OF THE FEMUR. A longitudinal incision is made on the outer side in the groove between the vastus externus and biceps, with a transverse liberating incision at each end. Denudation is carried as far around as possible, the wire-saw passed at each end of the diseased portion, and the denudation com- pleted as the piece is raised from its bed. In the case of a child traction should be made, and the limb kept at the same length as the other ; in the case of an adult the fragments should be brought nearer together, for the patient is older and his power of regen- eration less ; and, in many cases, it is better to bring the fragments into contact. Shortening is less of an infirmity than pseudarthrosis. RESECTION OF THE SHAFT OF THE TIBIA. If the entire diaphysis of the tibia becomes necrotic it may be removed subperiosteally and a fairly useful limb obtained, especially in children. The incision is made parallel to and jnst in front of the internal border. At the upper end it lies behind the tendons of the sartorius, gracilis, and semitendinosus ; further down the internal saphenous nerve is recognized and drawn to one side. The periosteum is incised on this line, and raised with an elevator which should be well curved to get around the sharp angles of the bone. When the denudation has been completed, if the bone is not already detached, the elevator is used to press back and protect the soft parts behind, while the bone is chiseled or sawn through as close to the dead area as possible. A transverse incision through the periosteum at this point will save undesirable denudation of adjoining healthy bone. The operation is most frequently required to remove the necrosed fragments which may result from osteomy- elitis. If there is an involucrum, it must be chiseled away 190 EXCISION OF JOINTS AND BONES. very freely, so as practically to abolish the center cavity, and the sound bone at each end must be freely cut away, st i as to leave a surface sloping' easily down to the bottom (posterior wall) of the cavity. The object of this free re- moval of bone is to permit the soft parts to come every- where into contact with the bone when they are brought back and sutured together over it. No anxiety as to sub- sequent weakness of the bone need be felt, for the new for- mation of bone will be ample. If it is necessary to reach the tibia on its external sur- face the skin incision should lie a little to the outer side of the crest. The periosteum is cut into close to the anterior border of the bone, and elevated with the attached tibialis anticus muscle. When the gap after a compound fracture involves the entire thickness of a portion of the shaft, a corresponding length must be removed from the shaft of the fibula to seeure good apposition of the parts. The fibula is best approached at some distance above or below the site of the tibial injury, as thus there will be less danger of infecting this fresh wound, and subsequent im- mobility can be more readily secured. The posterior surface of the tibia is best approached around its internal border. At the upper extremity the incision is made as already described behind the sartorius, gracilis, and semitendinosus, and the periosteum elevated with the attached popliteus muscle. RESECTION OF THE FIBULA. The lower portion of the fibula is subcutaneous, its upper portion is covered by the peroneal muscles. The biceps is attached to its head, and the external popliteal or peroneal nerve, after following the posterior border of the tendon of that muscle, wind- around the outer side of the neck of the fibula, and divides into the anterior tibial and musculo- cutaneous, the latter of which soon becomes superficial. Sometimes tin- division and even the subsequenl ones, takes place a- high up a- the head of the fibula, and then there i- danger of dividing some of the branches during resection of the upper extremity of the bone, unless the method RESECTION OF THE FIBULA. 191 indicated by Oilier is strictly carried out. The earlier authors considered the division of this nerve unavoid- able. As the upper tibio-fibular articulation communicates in a large proportion of cases with that of the knee, it should not be opened, except when it shares in the disease. The head of the fibula should be divided or gouged out in such a way as to leave this articulation covered by a thin but complete plate of bone. Resection of the Upper Extremity of the Fibula (Oilier). 1 — A longitudinal incision is begun an inch above the head of the fibula at the posterior border of the tendon of the biceps, and carried down a little behind the bone along the interstice between the soleus and the peroneal muscles. The incision should involve only the skin and fascia. The nerve is then sought for where it passes around the neck of the fibula, and protected by two blunt hooks placed about an inch apart. While thus protected, it is freed from the cellular tissue, which binds it to the bone, and then drawn forward so as to permit the division of the periosteum. This division is made on the posterior border of the bone, and carried downward as far as is necessary in the interstice between the soleus and pero- neal muscles. The periosteum is then detached and the bone re- moved, either by dividing it at two points with a wire- saw or chisel and removing the intermediate portion, or by dividing it at the lower limit of the disease, and twist- ing out the upper fragment, or by modifying the latter method to the extent of dividing the head of the bone with a sharp chisel in such a manner as to leave the tibio-fibular joint unopened. Resection of the Lower Portion of the Fibula. — Longi- tudinal incision along the antero-external aspect of the bone. Denudation and removal of the bone in the usual manner. For other details, see excision of the ankle- joint. 1 Traite de In lJegencration des Os, p. 267. 192 EXCISION OF JOINTS AND BONES. EXCISION OF THE WHOLE FIBULA. As the incisions for the resection of the upper and lower portions lie on opposite sides of the peroneal muscles, they cannot be made continuous with each other. Each half of the bone must be removed separately. Fig. 68. EXCISION OF THE BONES OF THE FOOT. Calcaneum. — Disease in the calcaneum is usually cen- tral, leaving a sequestrum inclosed in a shell of rarefied vascular bone, or a cavity is formed within a similar shell by ulceration and discharge through one or more fistulse. The removal of the entire thick- ness of the bone has heretofore givcu better results than simple gouging out of the diseased por- tions, ividemeni de I'os, but the anterior portion should if pos- sible be left. Subperiosteal Method (Oilier). (Fig. 68, A.)— An in- cision involving only the skin is begun at the outer border of the tendo Achillis about an inch higher than the tip of the ex- ternal malleolus, carried down below the outer tuberosity of the calcaneum and then forward and slightly upward to the upper part of the base of the fifth metatarsal. The edge of the tendo Achillis and the upper border of the plantar muscles being recognized, the incision is carried down to the bone, care being taken not to cut the peroneal tendons. The posterior half of the bone is then denuded with an elevator, and the tendo Achillis detached and pressed to tin- inner side. The under surface and posterior third of the inner aurface are next cleared, the peroneal tendons drawn aside with blunt hooks, the external lateral liga- .1. Excision of the calcaneum. />'. Excision of i In- asl ragalus, EXCISION OF THE BONES OF THE FOOT. 193 ment detached, the anterior portion of the outer surface denuded, and the caleaneo-cuboid joint opened. The interosseous ligament is divided with a narrow bis- tonrv, the bone grasped with lion-forceps and turned downward so as to open the calcaneo-astragaloid joints and give access to the calcaneo-scaphoid and internal lateral ligaments and to the inner surface of the bone. Resection of the posterior portion alone can be accom- plished much more expeditiously. The portion to be re- moved is denuded and then sawn off, either directly or by perforating the bone and sawing it from above downward with a chain-saw. Fig. 69. c-H A. Excision of astragalus. (Vogt.) B. Excision of ankle. C. Excision of calcis. (Farabeuf.) Farabeufs Modification. (Fig. 69, C.) — The incision begins opposite the base of the fifth metatarsal bone exter- nally, and is carried horizontally backward just above the margin of the sole. It passes on the same level around the back of the heel and is prolonged forward about an inch on its internal aspect. A second incision extends from this about two inches vertically upward beside the external border of the tendo Achillis. These incisions involve the skin only. The vertical cut is now deepened and the periosteum divided in this line, taking care not to damage the peroneal tendons which lie just anteriorly. 13 194 I<:x< ISIOX OF JOINTS AND BONES. The periosteum with the associated ligaments is elevated first on the outer surface, aided by deepening the hori- zontal incision in this part down to the bone. The attach- ment of the tendo Achillis is cut and the posterior aspect cleared as far as possible. The periosteum of the anterior end is next separated together with its attached ligaments, and afterward the plantar area is denuded. The anterior extremity is grasped with forceps and twisted outward, while the remaining attachments are severed with the knife, which must be kept close to the bone. The superior surface is reached through the outer incision and the interosseous ligament cut. By careful work with the elevator the internal sur- face is freed from the periosteum and attached ligaments and the bone finally removed without damage to the ves- sels and nerves on its inner side. Astragalus. — Excision of the astragalus may be rendered necessary by dislocation, fracture, or tuberculosis, or it may be made as a preliminary step in excision of the ankle. Operation (Oilier). (Fig- 68, B.) — Curved incision across the dorsum of the foot, with convexity directed forward beginning on the inner side at the point where the tendon of the tibialis anticus crosses the tibio-tarsal articu- lation, running forward and outward to the middle of the scaphoid, and then backward to a point a little below the tip of the external malleolus. This incision must expose but not involve the tendons. The extensor tendons are lifted out of their sheaths and drawn aside, the extensor brevis cut across or detached at its origin, and the neck and outer non-articular surface of the astragalus cleared. The capsular and ligamentary at- tachments of the bone to the scaphoid and tibia arc sepa- rated, the interosseous ligamenl divided, and the foot being turned inward the insertion of the strong internal tibio- astragaloid ligamenl is detached. The remaining connec- tions are then ruptured by grasping the bone with strong forceps and twisting it out. The operation is made easier by cutting through the neck of the bone and first removing the head. OPERATIONS UPON CRANIUM— TREPHINING. 195 See also Vogt's excision of the ankle, p. 1")7. When dislocated the astragalus may be easily removed by a straight, curved, or crucial incision made over the most prominent part, and avoiding vessels, nerves, and tendons. When badly shattered, as in gunshot injury, the frag- ments may be removed through a longitudinal incision between the extensor tendons of the first and second toes. For simultaneous removal of the calcaneum and astrag- alus see Osteoplastic excision of the foot, p. 15). Barker advises one and one-half inches behind the cen- ter of the meatus and one inch below the base line, but Birmingham says a three-quarter-inch trephine would wound the occipital artery in many cases in this situation. PUNCTURE OF THE LATERAL VENTRICLES (KOCHERj. An inverted U-shaped incision is made to expose the skul] at T i Fig. 7 1 ). The enclosed flap should be about TREPHLNLNQ EOR MENINGEAL HEMORRHAGE. 211 one and one-half inches long by an inch wide. After turn- ing down the >kin and securing the vessels the periosteum is incised and elevated, and the point of the trephine entered just below and in front of T. The skull is thin in this g :i. This exposes the posterior end of the first tem- poro-sphenoidal fissure. The posterior horn of the lateral ventricle lies about 1 cm. distant from the bottom of the sulcus directly inward. Another method of locating the opening to be made in the skull (Keen) i- to measure one and one-quarter inches back of the external auditory meatus along- Reid's base line and then one and one-quarter inches vertically upward. At this point apply the pin of a half-inch trephine. After incising the dura push a grooved director or trocar in a straight line toward a spot about two and one-half or three inches above the opposite meatus. The ventricle will nor- mally be reached at a depth of about two inches — if dis- tended it lies somewhat nearer the surface — and can be recognized by the diminution of resistance offered to the instrument and the escape of fluid along the groove of the director. Drainage is provided for by inserting a small rubber tube or a folded strip of rubber tissue. TREPHINING FOR MIDDLE MENINGEAL HEMORRHAGE. An inverted [J-shaped incision is made from the upper part of the posterior border of the frontal process of the malar bone upward nearly to the temporal ridge, and thence backward and downward in a gentle curve, to terminate at the superior border of the posterior extremity of the zygoma. This flap, including a part of the temporal mus- cle, is turned down and the bone sufficiently bared of peri- osteum to admit the use of the trephine at the spot pres- ently to be indicated. Kocher makes an incision from the external angular process ot' the frontal bone to the eminentia articularis, thence upward and backward for about an inch in front of the ear. After the soft parts have been raised the skull is opened 212 EXCISION OF JOINTS AND BONES. over the anterior division of the artery by placing the pin of a three-quarter-inch trephine a thumb's breadth behind the external angular process of the frontal bone and two finger-breadths above the zygoma. Both divisions can be exposed simultaneously by applying the trephine im- mediately above the middle of the zygoma (Kocher). Kronlein determines the location of the branches by drawing a line through the upper border of the orbit backward parallel to Reid's base line. The anterior divi- sion of the artery lies on the upper line 3 to 4 cm. be- hind the external angular process of the frontal bone, and the posterior at the intersection of the upper line with an- other drawn perpendicular to the base line from a point 3 to 4 cm. behind the external auditory meatus — roughly, from about the posterior border of the mastoid process. The following may be taken as accurate enough for all practical purposes : To expose the anterior division of the artery apply the pin of a three-quarter-inch trephine one inch above the middle of the zygoma and then enlarge the opening downward with the rongeur if it is found necessary to secure the trunk of the vessel. If for the latter purpose the method by osteoplastic resection of the skull is employed, the bone should be chiseled through in the lines of the lower extremities of the inverted U inci- sion, down to the level of the zygoma or nearly to the pterygoid ridge on the greater wing of the sphenoid. To expose the posterior division of the artery apply the trephine just below the most prominent portion of the parietal eminence. The common indication, however, is rather to remove a clot than to arrest hemorrhage by securing the trunk of the artery, and the guide to the site of this clot is usually to be found in the relations of the motor centers to the ob- served paralysis or to a line of fracture. Ordinarily a trephine opening al the lower end of the motor area will expose the clot directly or permit it to be reached by gently separating the dura from the bone about the opening. I have -ecu no case in which it became necessary to secure the artery because of hemorrhage persisting after evacuation of the clot. OPENING OF THE FRONTAL SINUS. 213 RESECTION OF THE SECOND AND THIRD DIVISIONS OF THE FIFTH NERVE WITHIN THE SKULL. 1 The omega-shaped incision is used with its base on the zygoma and the top of the curved part at the temporal ridge. It starts at the external angular process of the frontal bone, and passes horizontally along the upper border of the zygoma for about half an inch. Thence in the curved portion upward to the temporal ridge and down to the zygoma and again horizontally about half an inch to the tragus of the ear. The periosteum is divided and the bone chiseled through and turned down with its attached soft parts, as already described. The middle meningeal artery is secured by passing a sharply curved needle and ligature beneath it, and the dura is carefully separated from the bone below so as to expose the middle fossa of the skull. Any hemorrhage is checked by pressure. With broad retractors the dura and brain are lifted, taking great care to avoid injury to the other cranial nerves in the immediate vicinity. The first, second, and third divisions of the fifth nerve, as well as the carotid artery and cavernous sinus are well exposed. The dura is stripped back from the second and third divisions to be- yond the Gasserian ganglion, and the parts lying between it and the foramen ovale and rotund um are excised. The flap is then replaced and united with interrupted silk sutures. OPENING OF THE FRONTAL SINUS. The eyebrow is shaved. The incision starts at the cen- ter of the supra-orbital ridge and follows the curve of the upper border of the eyebrow to the median line above the root of the nose. Everything is divided down to the bone — the periosteum is raised on each side and the trephine or chisel entered at the inner end of the superciliary ridge. Antrum of Highmore. — A very small trephine should be used, and, in order to avoid a scar, it should be ap- plied through the mouth after dividing the gingivo- 1 Hartley: N. Y. Med. Journ., 1893, Vol. 55, p. 317. 214 EXCISION OF JOINTS AND BONES. labial fold, and dissecting- up the soft parts as far as to the infra-orbital foramen, just below and to the outer side of which the opening into the antrum should be made. The antrum may also be opened by drawing the first or second molar tooth, and enlarging its socket with a drill. No additional directions are needed for trephining the flat bones or the epiphyses of the long ones. PART V. NEUROTOMY, TENOTOMY, OSTEOTOMY AND MISCELLANEOUS OPERATIONS. DIVISION AND RESECTION OF NERVES." Division of a nerve of sensation, or even of a mixed nerve in extreme cases, may be required for the relief of neuralgic pain. It is seldom that a simple division is more than temporarily sufficient. At least half an inch of the trunk of the nerve should be excised, and, as addi- tional security against reunion, the end of the distal seg- ment may be bent back upon itself. Professor Weir Mitchell 2 has seen severe constant pain follow the bend- ing back of the end of the proximal segment. SUPRA-ORBITAL NERVE. The frontal nerve, main branch of the first division of the trigeminus, divides just behind the upper margin of the orbit into the supra-orbital and supra-trochlear nerves ; both branches are distributed to the forehead, the former emerging from the orbit through the supra-orbital notch or foramen, the latter a little nearer the nose. The former is much the larger and more important of the two, the latter supplying only a narrow strip of integu- ment near the median line. The supra-orbital notch or foramen is found at the junction of the inner and middle thirds of the supra-orbital arch, or a little to the inner side of the junction. When it is a notch it can be readily 1 A description of all known operations on cranial nerves, with the bibliography, can be found in Chir. Operat. du Svst. Nerveux, bv Chipault. Paris : Rueff & Co., 1894. 2 Oral communication. 215 216 VISC ELL ANEO US OPERA TIONS. fell through the skin, and is then an important guide in the operation. The nerve may be divided subcutaneously after its emergence from the notch, or it may be exposed by a trans- verse incision above or below the eyebrow. Subcutaneous Division. — A tenotomy knife is entered between the eyebrows midway between the nerve and the median line, and passed horizontally beneath the skin until its point has passed beyond the nerve. Its edge is then turned backward and pressed against the bone, and the nerve, lying between it and the bone, divided by with- drawing the knife. Or the knife may be entered at the A, /:. Resection of supra-orbital nerve. C. Resection of superior maxillary nervo- sa me point, but passed close to the bone instead of just under the skin, its edge turned downward toward the margin of the orbit, and the nerve divided by sweeping the knife downward across the mouth of the supra-orbital foramen. Excision of a Portion of the Nerve. A. ABOVE THE EYEBROW. (T'ig. 77, A.) — An incision one to one and a- half inches long is made just above and parallel to the eye- brow, it- center corresponding to the position of the nerve. This incision is carried down to the hone, the distal end of the nerve recognized, seized with forceps, dissected out, and cut off. SUPERIOR MAXILLARY NERVE. 217 B. Below the Eyebrow. (Fig. 77, B.) — The eye- brow being drawn up and the eyelid down, the surgeon makes an incision one to one and a-half inches in length along the edge of the supra-orbital arch, dividing succes- sively the skin, orbicular muscle, ami tarsal ligament. He then seeks the nerve in the notch, traces it back as far as necessary, while depressing the eye and levator palpebra? with a retractor, and cuts out a portion with curved scis- sors. Supra-trochlear Nerve. — K5nig resected this nerve by making a curved incision under the eyebrow at the upper inner edge of the orbit, and seeking the trochlea and the superior oblique muscle. On making the latter tense with a hook the two fine nerves became visible, were seized with forceps, and resected. SUPERIOR MAXILLARY NERVE. After leaving the cavity of the cranium by the foramen rotundum, the superior maxillary nerve crosses the spheno- maxillary fossa, traverses the infra-orbital canal, and ap- pears upon the face at the infra-orbital foramen, where it at once divides up into numerous branches distributed over the cheek, nose, lip, and lower eyelid. Within the infra- orbital canal it gives off the anterior dental branch, and posterior to this canal it gives off the posterior dental, and, through branches to the spheno-palatine ganglion, the palatine nerves distributed to the palate and nasal fossa. The point at which the nerve should be divided will vary according to the region affected ; but in this, as in other cases, simple division has usually proved insufficient, and it has been found necessary to excise all that portion of the trunk which lies in the canal. Sometimes the nerve has been cut above the branches going to the ganglion, and the latter torn out forcibly. The roof of the infra-orbital canal is composed in its posterior half of fibrous tissue, in its anterior half of thin bone, which becomes thicker as it approaches the margin of the orbit. The infra-orbital foramen lies directly above the second bicuspid tooth and from one-quarter to one-half 218 MISCELLANEOUS OPERATIONS. an inch below the margin of the orbit. The nerve is ac- companied on its passage through the canal by the infra- orbital artery. A. Division of the Nerve ox the Face. — This may be done : (1) subcutaneously ; (2) through the mouth ; (3) by an externa! incision, 1. Subcutaneously. — A tenotomy knife is entered about an inch to the outer side of the foramen, carried below it into the canine fossa, hugging the bone, and then swept upward along the surface of the bone so as to divide the nerve close to the foramen, the lip being drawn downward and forward to make the tissues tense. 2. Through the Mouth. — An incision is made in the gingivo-labial fold, and the soft parts dissected away from the bone until the nerve is reached and divided. 3. By External Incision. — The incision may be trans- verse, oblique, or curved ; it is only necessary that its center should correspond to the foramen. The tissues are divided successively until the bone is reached and the nerve found either by following up one of its branches or by seeking it at its point of emergence. B. Resection of the Infra-orbital Portion. (Tillaux 1 .) (Fig. 77, C.) — A vertical incision is made along the side of the nose from the lachrymal tubercle or the bony ridge of the nasal process of the superior max- illa, which is continuous with the lower edge of the orbit, down to the ala of the nose. A second horizontal one is thru begun at the upper portion of the first and carried outward along the lower margin of the orbit beyond its center. These incisions should involve all the soft parts down to the bone. The lower flap is dissected up, the nerve found, and a silk ligature thrown around it close to the foramen. Tin' upper flap is then raised, together with the lower eyelid and eyeball, exposing the floor of the orbit as far back as possible, upon which the infra-orbital canal can lie recognized as a grayish line running obliquely back- ward and inward. 'Tr;iit<' d'Anat. Topographique, p. 310, and Bull de la Society de Chirurgie, 1878, j>. US. SUPERIOR MAXILLARY A/.// 17. 2H) The canal is opened with a knife or chisel, the nerve isolated from the artery, raised from its bed with a small hook, and dissected out as far back as may be considered accessary. It is then divided with curved scissors, and the distal portion drawn out by means of the ligature applied to it in the beginning. The length of the portion removed by Tillaux was six centimeters. Dolbeau l divided the nerve with curved scissors on the central side of the branches going to the spheno-palatine ganglion, and tore out the ganglion by drawing upon the nerve. Lucke J s Method. 2 — An incision, beginning one centimeter above the outer angle of the eye and close behind the margin of the orbit, is carried downward and slightly for- ward across the malar bone, dividing its periosteum ; from its lower end a second incision is carried backward and upward, terminating over the outer surface of the zygomatic process of the temporal, about a quarter of an inch behind its junction with the malar bone. The latter bone is next divided in the line of the first incision by means of a saw or chisel, after preliminary division of the soft parts and periosteum on its under and inner surface with a small knife, and the zygoma then cut through at its posterior extremity. The attachments of the masseter to the intermediate piece are then separated, and the flap of bone and soft parts raised with a sharp hook. If necessary, some of the anterior fibers of the temporal muscle should now be divided in order to expose the sphenomaxillary fossa thoroughly, the fat occupying the fossa pressed backward with a retractor, and the spheno- maxillary fissure recognized with a probe. The nerve and artery can be distinguished by the difference in their course, the former running downward, outward, and for- ward, the latter upward, inward, and forward. The nerve is seized with forceps and divided with a tenotome well forward in the fissure, and then again with scissors as near as possible to the foramen rotundum. The flap is J Oral communication. 2 Deutsche Zeitschrift fur Ohirurgie. Vol. 4, p. 322. 220 MISCELLANEOUS OPERATIONS. then put back, and the wound drained at its lower angle. An objection to this method is that, in consequence of its interference with the masseter and temporal muscles, the mouth subsequently cannot be freely opened. Lossen and Braun ' avoid this difficulty by leaving the attach- ments of the masseter untouched and turning the flap downward instead of upward, after making the second in- cision from the upper end of the first instead of from its lower end and separating the temporal fascia from the malar bone. Czerny 2 has employed this modification five times with good results. If wounded vessels cannot be seized and tied, the hem- orrhage must be arrested by plugging with antiseptic gauze. INFERIOR DENTAL NERVE. This nerve may be divided (A) after its exit from the dental canal, (B) in the canal, (C) before its entrance into the canal. The nerve enters the canal by the inferior dental foramen on the inner side of the ascending ramus of the lower jaw at the level of the crowns of the lower teeth ; the canal runs obliquely downward and forward just below the alveoli and the nerve emerges through the mental foramen which lies midway between the alveolar process and the lower margin of the jaw below the second bicuspid tooth. A. At the Mental Foramen. — An incision is made in the gmgivo-labial fold above the foramen and the soft parts dissected off until the nerve is reached, usually about one-third of an inch below the bottom of the fold. B. WlTHIN the Canal. — An incision is made through the skin down to the bone along the course of the nerve in front of the masseter, the periosteum raised, and the canal opened with a chisel or small trephine. After re- moval of the outer table of the bone the nerve is easily found in the canal and divided. < )r flu: canal may be opened at two points and the inter- mediate portion of the nerve excised. 1 ' Viitni]l>l;itt I'iir < liirur^ic, 1S78, pp. (io and 148. [bid., 1882, p. 249. INFERIOR DENTAL NERVE. 221 Another method is to make a curved incision behind and below the angle of the jaw, and elevate the periosteum and masseter on its outer surface as far as the alveolar margin. Then chisel into the middle of the exposed bone. The oral cavity should not be opened. C. Before its Entry into the Canal. 1. From vithin the mouth. — The mouth being held widely open and the commissure of the lips drawn backward and outward, an incision extending from the last upper to the last lower molar tooth is made one-third of an inch on the inner side of the sharp anterior border of the coronoid process, and carried through the mucous membrane to the tendon of the temporal muscle. The surgeon passes his finger into the incision and along the inner surface of the bone, between it and the internal pterygoid muscle, until he touches the bony point which marks the orifice of the canal. Passing a blunt hook along the finger, he raises the nerve upon it, isolating it if possible from the accompanying artery, and divides it with blunt-pointed scissors or knife. Or, without intro- ducing the finger, the hook may be passed back beyond the nerve, its point constantly in contact with the bone, then rotated inward so as to carry its point across and behind the nerve, and then withdrawn. 2. Through the check. — A curved incision is made around the angle of the jaw r or around the lower anterior insertion of the masseter and carried through to the bone along its lower portion ; then with the elevator and knife the muscle is detached from below upward, and the flap raised with a hook until the level of the inferior dental foramen is reached. The bone is then cut away with a chisel or small trephine and the nerve exposed and excised. With the same curved incision around the angle of the jaw the inner surface of the latter may be freed from the periosteum and internal pterygoid muscle upward till the lingula is felt; then, with or without dividing this proc- ess the nerve can be isolated and divided. Or a vertical incision may be made through the skin and fascia, the fibers of the masseter separated, and the bone thus exposed. 222 MISCELLANEOUS OPERATIONS. At the Foramen Ovale. — Bnum's modification of Liicke's method for exposing the superior maxillary nerve can be employed with slight changes for this purpose. The temporal muscle must be retracted or partially divided near its insertion, or the eoronoid process cut through at its base. Kronlein ' suggests the following method : An incision is made from half an inch behind the angle of the mouth to terminate a similar distance in front of the lobule of the ear. Only the skin and subcutaneous fat are divided, the buccinator and oral mucous membrane being spared. The masseter is cut back to the anterior border of the parotid gland, thus sparing the latter and Steno's duct, which lies well above the line of incision. The eoronoid process is bared at its base with a periosteal elevator, divided from the semilunar notch downward and forward, and drawn upward, together with the attached temporal muscle. The branches of the inferior maxillary nerve are then exposed by a blunt dissection on the outer surface of the internal pterygoid muscle. The external pterygoid is drawn upward and the nerves traced back to the base of the skull. At the close of the operation the eoronoid proc- ess and divided masseter muscle are sutured. He exposes the superior and inferior maxillary nerves simultaneously at their exit from the skull in the follow- ing manner 2 : A curved incision, concavity upward, is made, starting from the most prominent portion of the malar bone, passing down to the level of the lobule of the ear, thence backward and upward in a gentle curve, to terminate over the posterior extremity of the zygoma. The flap of skin and subcutaneous fascia is turned up, the temporal fascia divided along the upper border of the zygoma, and the latter sawn through at its anterior and posterior extremities, as in Liicke's operation. The eoro- noid process i> exposed and cut through at its base down- ward and forward, and drawn upward with the attached temporal muscle. The internal maxillary artery is secured 1 Archiv. f. klin. Chir., Bd. X 1,1 1 1., |>. L3. Dentsch. Zeitsch. f. Chir., L884, Vol. XX.. \>. 484. BUCCAL NERVE. 223 and the attachment of the external pterygoid muscle sep- arated from the under surface of sphenoid bone. This exposes the inferior maxillary nerve at the foramen ovale,, and by working along the sphcno-maxillary fissure the superior maxillary nerve is found and followed back to the foramen rotundum. At the close of the operation the parts are replaced and sutured in their proper position. Salgcr l recommends a curved incision, convexity up- ward, extending from one extremity of the zygoma to the other. Everything is divided down to the skull, the zygoma sawn through at each extremity, and the flap of skin, fascia, temporal muscle, and zygoma turned down. The coronoid process is depressed by opening the mouth, and the nerve found below the external and on the outer surface of the internal pterygoid muscle, and divided as high up as desired. BUCCAL NERVE. The buccal nerve, a branch of the inferior maxillary, may be the seat of painful and persistent neuralgia. It is best approached through the mouth by the following method : The surgeon places his finger-nail upon the outer lip of the anterior border of the ascending ramus of the lower jaw at its center, and divides in front of this border the mucous membrane and the fibers of the buccinator verti- cally. He then seeks for the nerve, separating the tissues with a director, and divides it. Zuckerkandl exposes the nerve from the outside of the cheek. A horizontal incision a finger's breadth below the zygoma is made from the anterior border of the masse ter muscle nearly to the canine eminence. The fascia over- lying Steno's duct is divided, and the latter exposed and drawn downward with its accompanying nerves. The fat on the posterior part of the buccinator muscle is torn through, and the nerve found to the inner side of the in- sertion of the temporal muscle on the front of the coronoid process. It lies about an inch back of the anterior border of the masseter muscle. ■Wien. med. Wochenscbr., 1887, Vol. XXXVII., p. 461. 224 MISCELLANEOUS OPERATIONS. LINGUAL NERVE. Division of this nerve may be required for the relief of pain in cases of carcinoma of the tongue. When the mouth is opened widely the pterygo-maxil- lary ligament can be readily seen and felt as a prominent fold behind the last lower molar, and the lingual nerve can be felt just below the attachment of the ligament on the inner side of the lower jaw, close to the bone below the last molar tooth. The tongue should be drawn aside by an assistant, the mucous membrane divided for about an inch parallel to the margin of the alveolar process, beginning at the last molar tooth over the position of the nerve, or, according to Chauvel, 1 one-fifth of an inch from the attachment of the mucous membrane to the side of the tongue. The nerve is then readily found in the submucous tissue, raised upon a hook and divided, or a portion excised. Moore's Method. — Mr. Moore has employed the follow- ing method successfully in five cases : He cuts the nerve about half an inch from the last molar tooth, at a point where it crosses an imaginary line drawn from that tooth to the angle of the jaw. He enters the point of the knife nearly three-quarters of an inch behind and below the tooth, presses it down to the bono and cuts toward the tooth. This necessarily divides the nerve. This projec- tion of the alveolar ridge might protect the nerve from a straight bistoury, and therefore a curved one should be used. The lingual nerve may also be reached from outside the mouth by any one of the methods for resecting the inferior maxillary, or by an incision along the lower border of the jaw just in front of the massetcr muscle. In the latter case (Lobker) the upper margin of the wound is drawn up and a portion of the inferior maxilla, where the alveolar process adjoins the ramus, is exsected and the nerve exposed on the outer surface of the internal ptery- goid. ( )r the dissection caD be carried up under the inner 1 I'n'cis d'< )|i('r:itions do Cliinirgie, p. 435, BRACHIAL PLEXUS. 225 surface of the jaw (Luschka). The submaxillary gland is displaced downward and forward, the posterior border of the mylohyoid muscle divided and the nerve found under the posterior end of the sublingual gland. Thence it can be followed backward and upward and divided as high as desired. FACIAL NERVE. This nerve has occasionally been stretched and crushed for the relief of clonic spasms of the corresponding mus- cles. A semilunar incision is made around the lower attachment of the ear with a short liberating incision downward from its center ; the flaps are dissected back, and the nerve exposed by drawing the parotid forward and outward. The nerve is more easily exposed at the posterior border of the ramus. For this an incision is made from just in front of the tragus of the ear to the angle of the jaw. After dividing the parotid fascia the cervico-facial branch will probably be exposed first, and can then be followed back to its junction with the temporo-facial. BRACHIAL PLEXUS. This plexus consists of the four lower cervical nerves and the greater part of the first dorsal. It crosses the floor of the subclavian triangle of the neck, and lies be- tween the anterior and middle scaleni muscles. Its shape is triangular, with the base at the spine and the apex to the outer side of the subclavian artery below the clavicle. Operation. — The head and neck are extended, and the face turned to the opposite side. An incision, starting half an inch above the clavicle in the interval between the sterno-cleido-mastoid and trapezius, is carried forward, for about three inches, parallel to the anterior border of the latter. The skin and platysma are divided and the ex- ternal jugular vein either cut between two ligatures or drawn to one side. The deep cervical fascia is divided in the line of the external incision, avoiding the supra- 15 22 ( '» .1/ [S( EL L . 1 NEO US OPERA TIONS. clavicular branches of the cervical plexus, and the outer border of the anterior scalenus muscle recognized. The plexus is felt with the finger just outside the latter and isolated by a little careful dissection. Any particular cord can he identified by tracing it to its point of emer- gence from the spine through the interval between the scaleni muscles. Resection of the Posterior Roots of the Brachial Plexus. — This operation has been performed several times for severe neuralgia of the peripheral branches. An incision about six inches long, with its ceuter just above the spine of the seventh cervical vertebra, is made parallel and close to the ligamentum nucha? and deepened alongside of the spines till the laminae of the fifth, sixth, and seventh vertebra? are reached. These lamina? are then bared of soft parts on the affected side out to the bases of the artic- ular processes, and removed with the chisel, rongeur, or bone forceps, thus exposing the posterior roots of the nerves previous to their exit from the intervertebral foramina. CERVICAL PLEXUS. An incision about two inches in length is made parallel to and over the posterior border of the sterno-mastoid muscle. Its center should correspond to the center of the muscle. The skin, superficial fascia, and platysma are divided and the superficial branches of the cervical plexus are exposed at the middle of the posterior border of the sterno-mastoid muscle and can be traced back toward the spine. SPINAL ACCESSORY NERVE. After passing outward beneath the digastric and stylo- hyoid muscles and occipital artery, the nerve about half an inch below the apex of 1 1 x? mastoid process enters the under surface of the sterno-mastoid muscle in its upper part, leaves it at about the center of its posterior border, and passes beneath the trapezius at about the junction of the middle and lower thirds of its anterior border. In the substance of the sterno-mastoid muscle it communi- SPINAL ACCESSORY NERVE. 227 ontos with the second cervical nerve, in the occipital tri- angle with the second and third, and beneath the trapezius with the third and fourth cervical nerves. Operation. — An incision about three inches long is made downward from the tip of the mastoid process along the anterior border of the sterno-mastoid muscle, the cervical fascia divided and the muscle strongly retracted to put the nerve on the stretch. The nerve is then sought for external to the jugular vein about an inch and a-half be- low the tip of the mastoid process on the fascia covering the rectus capitis auticus major. Section of the Posterior Divisions of the First, Second and Third Cervical Nerves for Spasmodic Wry Neck. — The chief posterior cervical rotators of the head and their nerve supply are as follows : The rectus capitis posticus major is supplied by the suboccipital or posterior division of the first cervical nerve. The inferior oblique is sup- plied by the posterior divisions of the first and second cervical nerves and the splenitis capitis by the posterior divisions of the second and third cervical nerves. Operation. (Modified from Keen.) 1 — A transverse in- cision about three inches long is made extending hori- zontally outward from the middle line of the neck, or slightly overlapping it, an inch and a-half below the ex- ternal occipital protuberance. It is carried through the trapezius and posterior border of the splenius capitis muscles until the complexus is recognized, the trapezius is dissected up from the complexus and the occipitalis major nerve found at the upper part of the complexus. Divide the complexus transversely and follow the nerve back to its origin from the posterior division of the sec- ond cervical nerve and divide the latter as near the verte- bra as possible. Recognize the suboccipital triangle, which is bounded by the superior and inferior oblique and the rectus capitis posticus major muscles. Within this lies the suboccipital nerve close to the occiput and vertebral artery ; it must be traced and severed close to the spine. The posterior 1 Annals Surg., Jan., 1891. 22S MISCELLANEOUS OPERATIONS. division of the third cervical nerve is found beneath the complexus about an inch lower down than the occipitalis major, and must be cut close to the bifurcation of the main trunk. Smith ' made a longitudinal incision about three inches long; from the occiput downward about an inch and a-half to one side of the middle line. It passed through the trapezius to the edge of the splenius, then through the complexus, and eventually exposed the posterior divisions of the cervical nerves. The great occipital nerve was recognized, separated, and drawn aside ; a part of the exter- nal branch of the posterior division of the second nerve was excised ; the splenius and complexus separated from the parts beneath, and the entering nerve filaments divided. The suboccipital nerve Mas not divided. The result of this operation seems to have been perfect. Median Nerve. — In the arm it is exposed by the method given for ligation of the brachial artery. At the wrist it is reached by an incision about an inch and a-half long, parallel to and just to the ulnar side of the tendon of the palmaris longus. Ulnar Nerve. — Except in the extreme upper part of its course the nerve closely accompanies the triceps and is completely separated from the median nerve and brachial artery by the fascial septum that passes down to the bone between the biceps and triceps. Except near the elbow, it should be sought through an incision parallel to and a little posterior to the brachial artery, and after exposure of the triceps. At the elbow it can be easily found through an incision an inch and a-half long, curving upward between the in- ternal epieondylc and the olecranon. In the forearm its course is indicated by a line drawn from the space between the internal epieondylc and the olecranon to the radial side of the pisiform bone. At first, it lie- over the flexor profundi!- beneath the flexor carpi ulmuis. At the wrisl it is superficial, and lies on the annular ligament with the ulnar artery on its radial 1 Brit Med. Journ., 1891, VoL I., p. 752, MUSCULO-SPIRAL NERVE. 229 side. It is easily reached at the wrist by an incision about two inches long extending upward through the skin and fascia from the pisiform bone. The incision is parallel to and close to the radial side of the flexor carpi ulnaris tendon. MUSCULO-SPIRAL NERVE. It winds around the humerus in the musculo-spiral groove between the internal and external heads of the triceps, and reaches the outer side of the arm at about the junction of the middle and lower thirds, and is accom- panied by the superior profunda artery. It then pierces the external intermuscular septum and descends in the groove between the brachialis anticus and supinator longus to the front of the external condyle. At this point it is most easily found. Operation. — An incision about three inches long is made at the upper part of the supinator groove, the fascia di- vided, and the nerve sought in the bottom of the groove ; it is then followed upward or downward, according to the circumstances of the case. Great Sciatic Nerve. — An incision three or four inches long is made downward from the gluteal fold, midway be- tween the tuberosity of the ischium and the great tro- chanter. After division of the skin and fascia the lower border of the gluteus maximus is observed and the ham- string muscles recognized. The nerve lies on the external rotators of the thigh just in front of and to the outer side of the hamstring muscles. Internal Popliteal Nerve. — It is reached by the incision for ligation of the popliteal artery. It is superficial to the vein and artery and slightly external. External Popliteal Nerve. — This nerve lies close behind and to the inner side of the tendon of the biceps, and is exposed by an incision two or three inches long parallel to and close to the inner side of that tendon. Anterior Crural Nerve. — A longitudinal incision about two inches in length is made downward from Poupart's ligament, about an inch to the outer side of the femoral 230 MISCELLANEOUS OPERATIONS. artery. The superficial circumflex iliac vessels will be di- vided ; the nerve will be found close beneath the fascia. NEURORRHAPHY. I. Primary Suture. — An incision is made in the course of the nerve, exposing it at the point of division. The ends are brought together by a couple of fine sutures of silk or catgut passed directly through the substance of the nerve or through the nerve sheath. They must be so placed and tied as not to strangulate the fibers. II. Secondary Suture. — A long incision will probably be necessary ; it should be made in the normal course of the nerve and extend well above and below the point of di- vision. The trunk of the nerve should be sought for both above and below the cicatricial tissue of the original wound, and traced downward and upward respectively to the divided and separated ends. Such part of each end as is bulbous or imbedded in cicatricial tissue should be cut away and the divided surfaces brought into apposition and sutured. Tension should be relieved by freeing the nerve above and below and by flexing adjoining joints. It is not absolutely necessary to success that the divided ends should be brought close together ; reunion has taken place across gaps of considerable length, one or two centime- ters ; it has been thought to be favored under such circum- stances by the presence of a suture connecting the two ends. When there has been a considerable loss of nerve sub- -t ; 1 1 )< •*', rendering it impossible to bring the divided ends near together, flaps have been cut from the proximal and distal stumps and unfolded, and their extremities united as in tenorrhaphy (Fig. 82) ; or the distal stump may be freshened and then sutured between the fibers of a neigh- boring uninjured nerve of similar, or at least partly similar, character. TENOTOMY. The blade of a tenotomy knife should be one inch long, it- shank one and three-quarters, its handle strong and marked in such a way that the surgeon can see at a glance TENOTOMY. 231 in which direction the edge of the blade is turned. The blade may be straight or curved, it should be thick at the heel, very narrow, and the point should be somewhat rounded and sharpened from side to side like a wedge or chisel. (Say re.) A fold of skin should be pinched up at the side of the tendon, and the knife entered at its base, so that a con- tinuous track will not be left on its withdrawal. A pre- liminary puncture may be made with a sharp-pointed knife or lancet to facilitate the entry of the tenotome. The knife must be entered " on the flat " and passed either under the tendon or between it and the skin ; its edge is then turned toward the tendon and the division effected with gentle sawing movements, the thumb being pressed firmly against the tendon if the knife has been passed under it. During the entry of the knife and the division of the tendon the latter must be kept firmly upon the stretch, and as soon as the division is complete the knife must be turned upon its side and withdrawn, while the surgeon follows its point with his thumb or finger so as to force out any blood that may be in its track and to prevent the entrance of air. Seal the wound with plaster or collodion, and then bring the member into the desired position. Tendo Achillis. — The knife should be entered on the in- ner side of the tendon near its border, about one inch above the upper surface of the calcaneum. In this way the pos- terior tibial artery, which lies between the tendon and the inner malleolus and below the deep fascia, is secured from injury. The heel must be depressed as much as possible, so as to make the tendon more prominent and give addi- tional security to the artery. Tibialis Posticus. — The tendon of this muscle may be divided (A) above the malleolus, or (B) on the side of the foot just behind its insertion into the scaphoid. A. Above the Malleolus. — The muscle is made tense by everting the foot ; the knife is entered at the in- ner side of the tendon and passed behind it. 232 MIS( 'EL L. 1 XEO US OPERA TIOXS. B. Ox the Side of the Foot. — Same position given to the foot. The knife should be directed from above downward and passed under the upper border of the ten- don at a point half an inch below and in front of the tip of the malleolus. Bell ' prefers to cut toward the bone. Tibialis Anticus. — Can be easily made prominent and isolated. Peronei. — May be divided at the posterior face of the lower end of the fibula, or on the side of the foot below and in front of the tip of the outer malleolus. Flexor Tendons at the Knees. — It must be remembered that the external popliteal nerve accompanies the tendon of the biceps closely, lying upon its inner side. Sterno-cleido-mastoid. — The danger to be avoided in this operation is that of injury to the external jugular vein at the outer border of the muscle, or to the anterior jugular vein at its inner border. The first can usually be seen under the skin and avoided, the other leaves the muscle about three-quarters of an inch above the sternum and passes backward. The muscle should be divided about half an inch above the top of the sternum, and most au- thorities agree in preferring to divide from before back- ward. The knife should be entered at the outer border of the muscle. The open operation is now generally pre- ferred as less dangerous and more likely to give a good result. TENORRHAPHY. Primary. — Performed immediately after the injury. The wound, which is usually transverse, should be en- larged by an incision crossing it in the line of the tendon and carried through skin and fascia. The distal portion <>f the tendon can be made to appear in the wound by moving its distal joints in the direction taken when its muscle contracts (e. //., flexing the fingers when the flexor tendon- have been divided), but to find the proximal end it i- often accessary to seek we]] above the line of division, and it is therefore well to expose the region 1 Manual of Surgical Operations, :!<1 edition, p. 288. TENOHRHAPHY. 233 freely. The divided tendon ends are drawn into apposi- tion and stitched together with fine silk, silkworm-gat, or catgut. The common forms of suture are represented in Fiffs. 78-81. Fio. 78. Tenorrhaphy by a suture passed through the substance of each segment. Fig. 79. Tenorrhaphy. The tendon ends cut obliquely to increase the surfaces in contact. Fl«. 80. Tenorrhaphy. Showing the method of inserting a suture which does not readily pull out. Ingrafting of portions of tendon taken from another region or even another animal has been performed, and it is said successfully. (Bulletin de la Soe. de Chir., 1886, p. 3.57.) 234 MISCELLA NEO I rs OPERA TIONS. It is important to immobilize the limb during healing in the position of greatest relaxation of the sutured tendon. Secondary. — Performed after a considerable interval of time has elapsed since the injury. The divided tendon Fig. 81. Tenorrhaphy by four ligatures inserted and tied (.1) in each Stump, and their free ends then uuited (B). ends will have to be sought for amid cicatricial tissue and brought into the best possible apposition. The ends can be split and lengthened, as shown in Fig. 82 ; if this will Fig. 82. Tenorrhaphy by flaps i" bridge over a gap between the tendon ends not do, or if the proximal end of the tendon cannot be found the distal end may be sutured to a neighboring tendon having the same general anatomical course. The surface from which union is expected should be freshened by .-craping. OSTEOTOMY, ■j.\r> OSTEOTOMY. Osteotomy of the Femur — I. Through the Neck (Adams's operation), described on page 151. II. Below the Great Trochanter, described on page 152. III. Osteotomy of the Shaft of the Femur. In a normal femur the lower epiphyseal line is about on a level with the tubercle of the adductor magnus and trans- verse in direction. But in cases of genu valgum it is Fig. 83. Frontal section through the lower end of the femur in a case of severe genu val- gum. A. Epiphyseal line. B. Transverse line drawn through the adductor tuber- cle. C. Line of bone section in Macewen's operation. oblique and parallel with the articular surface. This is due to the fact that genu valgum is produced by an over- growth of the diaphysis of the femur and not of the epi- physis (Fig. 83). Osteotomy of the Shaft of the Femur from the Outer Side. — The knee is partially flexed and supported on a sand- bag beneath its inner surface. A longitudinal incision down to the bone is made on the outer aspect of the thigh about two inches above the top of the external condyle 236 MISCELLANEOUS OPERATIONS. and well in front of the tendon of the biceps. The peri- osteum is divided transversely, and stripped back suffici- ently to expose the base of the wedge of bone that is to be removed, and then with a chisel this wedge is cut away piecemeal, care being taken throughout to remove the cor- responding part of the anterior and posterior shell of the bone. The chisel may be used until the division is com- plete, or the last part may be broken by forcibly adduct- ing the fully extended leg. At the conclusion of the opera- tion the wound is closed and dressed antiseptically, and the limb is immobilized in the corrected — straight — position. Supra-condyloid Osteotomy of the Femur. — The hip and knee are flexed, and the thigh supported on its outer side. A longitudinal incision two or three inches long is made on the inner side of the thigh close above the condyle and carried through the fascia, the fibers of the vastus interims are drawn forward and the bone exposed at their attach- ment. The periosteum is divided and a wedge of bone removed as described in the preceding section. After ar- rest of the bleeding, which may be quite free at the lower angle, the wound is closed and the limb immobilized with plaster of Paris. Some prefer, in both these operations, simply to divide the bone by driving the chisel straight across, without removing a wedge of bone. (MacEwen.) OSTEOTOMY FOR HALLUX VALGUS. A longitudinal incision about two inches long is carried down to the periosteum on the mesial surface of the lower part of the first metatarsal bone opening the joint. The lioiic is divided and a wedge of tissue removed from it sufficient to allow the toe to be brought into line. Usu- ally the head of the metatarsal bone is deformed by over- growth on its mesial side, in which case it should be freely cut away. No troublesome limitation of motion is to be feared if infection of the wound is avoided. CUNEIFORM OSTEOTOMY. 237 CUNEIFORM OSTEOTOMY FOR TALIPES EQUINO- VARUS. A horizontal incision is made along the outer side of the foot from about the center of the anterior portion of the outer surface of the os calcis across the cuboid to the base of the fifth metatarsal bone. If necessary this is joined at its center by a liberating incision passing per- pendicularly to the horizontal incision across the outer surface and dorsum of the foot to or over the scaphoid. The base of the wedge of bone to be removed will con- sist mainly of the cuboid with portions of the os calcis, the astragalus, and perhaps a part of the external cuneiform and base of the fifth metatarsal. The apex will corre- spond to a point on the inner surface of the scaphoid. The amount of bone which may need removal will of course depend upon the extent of the deformity, but in extreme cases it may include portions of all the tarsal and some of the metatarsal bones. In every case the cuboid will form a large proportion of the wedge. With a blunt periosteal elevator all the soft parts are detached from the bone that is to be removed ; the peronsei tendons are retracted or protected ; a thin blunt elevator may be pushed close under the plantar surface of the bones to protect the soft parts of the sole. The chisel is then driven in for the first bone cut, generally at the an- terior end of the outer surface of the cuboid. It is di- rected toward the lower part of the scaphoid tubercle. The second line of bony division will usually need to pass just behind the anterior articular surface of the os calcis and through the neck of the astragalus to meet the first incision at the scaphoid tubercle. This wedge of bone is then pried or wrenched out entire, while any remaining attachments beneath are severed with blunt-pointed scissors or a knife kept close to the bone. If then it is found that the foot cannot be made to assume the proper position without tension another slice of bone is chiseled olf, espe- cially toward the apex of the wedge. This may be sup- plemented by tenotomy of any resisting tendons. The 238 MISCELLANEOUS OPERATIONS. thickened epidermis and the bursa usually found over the site <>f the cuboid may be excised if there is found to be a redundancy of skin after straightening the foot. No wiring of the bones is necessary. The soft parts are sutured and the wound dressed antiseptically. Any oozing which may subsequently occur will dry and make of a simple antiseptic dressing a very efficient splint. Of the great number of other operative procedures which may be used singly or in combination with each other or with cuneiform osteotomy for correcting pes varus or equino-varus mention should be made of tenot- omy of resisting tendons (7. v.), extirpation of the astraga- lus (7. r.), extirpation of the cuboid or of several tarsal bones simultaneously, linear osteotomy of the tibia and fibula just above ankle-joint (7. v.), and Phelps's ' opera- tion. The latter, although not an osteotomy, will be de- scribed here. 2 It is extensively used for remedying talipes equino- varus, and consists in a simple division of all structures which resist correction of the deformity. The tendo Achillis is first divided subcutaneously ; then, while the foot is flexed dorsally, abducted and everted, an incision through the skin is made from just in front of the in- ternal malleolus vertically downward across the inner third of the sole of the foot. After making the parts tense the tibialis anticus and posticus, the deltoid liga- ment, pari of the abductor pollicis, the plantar fascia, and the flexor brevis and longus digitorum are severed as en- countered in the wound. The plantar vessels and nerves .in spared if possible, although their internal branches have been cut without bad effect. A- each structure is divided an attempt is made forcibly to place the foot in its proper position. Phelps employs a powerful system of Levers, and ruptures any resisting ligamentary or fibrous bands. When all opposition has been properly overcome the anterior segment of the foot 1 New England Medical Monthly, L891. 'This operation is discussed and the results detailed in Transactions Am. Orthopaedic Asso>, Vol. \ II., p. 43i CUNEIFORM OSTEOTOMY. 239 can he bent backward in overcorrection, thus probably opening the astragalo-scaphoid and calcaneo-cuboid joints. Only in about 10 per cent, of all cases, according to the originator of this operation, will osteotomy be required. When necessary to correct the deformity after all the re- sisting soft parts have been cut, the neck of the astragalus should be divided from the inside ; then, if this is insuf- ficient, a wedge may be removed from the anterior portion of the os caleis ; the base of the wedge lies externally, the apex where the neck of the astragalus has been divided. The open wound on the inner side of the foot is either lightly packed with iodoform gauze or allowed to heal under a moist blood clot ; over this an antiseptic dressing is applied and encased in plaster of Paris, the foot being maintained in a slightly overcorrected position. CUNEIFORM OSTEOTOMY FOR TALIPES EQUINUS. Two incisions are employed. The inner incision passes along the mesial surface of the neck of the astragalus and across the scaphoid to ter- minate at the internal cuneiform bone. The external in- cision extends from the middle of the anterior portion of the outer surface of the os caleis across the cuboid to ter- minate at the base of the fifth metatarsal bone. The soft parts are raised from the dorsum of the foot, and a flat periosteal elevator can be passed close beneath the plantar surface of the bones to protect the soft parts of the sole. A wedge is then cut from the tarsal bones with the base on the dorsum of the foot. Its extent will depend on the degree of the deformity, but the apex must reach to the plantar surface of the bones. A metacarpal saw or chisel can be used. The wedge, which may be extracted in one piece, will consist chiefly of the scaphoid and cuboid bones, with per- haps portions of the anterior extremities of the astragalus and os caleis. At the close of the operation the soft parts which have been divided are sutured and the foot immobi- lized with the bones in apposition. 240 MISCELLANEOUS OPERATIONS. CUNEIFORM OSTEOTOMY FOR TALIPES VALGUS OR PES PLANUS. An incision is begun just below the apex of the internal malleolus and carried forward two inches. The soft parts are carefully raised from the inner and under surface of the astragalus and a suitable wedge removed from it. The base of the wedge should lie below and include either the neck alone of the astragalus or the articular surfaces of the astragalus and scaphoid. OPERATIONS FOR UNUNITED FRACTURE. The aim of the operative treatment for old ununited fracture is to place the freshened ends of the bone in con- tact and to keep them immobilized in this position. A free incision is necessary. In general it should be in the long axis of the limb, and so placed as to reach the point of fracture by the shortest route with the least pos- sible damage to nerves and vessels. Any tissue which may be found intervening between the ends of the bone is dissected out and removed. It will often be found advan- tageous to protrude the ends of the bone through the wound. The extremity of each fragment is then pared off with the rongeur or chisel till fresh cancellous tissue is exposed over the whole section of the shaft and the two surfaces can be opposed throughout. If the fragments override, enough bone is removed to allow the ends to be brought into apposition without tension. Wiring is to be condemned as superfluous. It will seldom be found nec- essary to do more than freshen the ends of bone and main- tain them in quiet apposition with a suitable splint. If there is any doubt about their remaining in this position while the splint is applied and subsequently, it is better to drill a small hole about half an inch from the fracture line on each side and tie the ends together with a piece of kangaroo-tendon or stout chromicized catgul or silk. If the limb is handled carefully this will keep the bones in contact and prevent the interposition of soft parts till the Limb has been immobilized. In addition to this the peri- SUTURE OF THE PATELLA. 241 osteins is as far as possible preserved, and any divided soft parts in the neighborhood should be placed in proper position and reunited. This will serve as a sling for the bones to rest in. The wound is then closed layer by layer and dressed antiseptically, with provision for temporary drainage. If pegs or nails have been used they should reach to the skin surface and be included in the dressings, and should be removed in about a week. SUTURE OF THE PATELLA. Fig. 84. Mediate suture for fracture of tlie patella. Mediate Silk Suture. (Fig. 84.) — A longitudinal median incision is made extending well above and below the frac- ture. Clots are washed from the joint with salt solution, and the fibro-periosteal fringe lifted up if one has formed. Then, with a full-curved needle, a stout silk ligature is passed transversely through the ligamentum patella? close to the apex of the patella, then transversely in the opposite direction through the tendon of the quadriceps close to its insertion, and then drawn tight and tied while the frag- ments are held together. One or two catgut sutures may be placed in the torn capsule on each side. The incision is then closed without drainage. Many other more or less complicated methods of hold- ing the fragments together have been devised ; this one is as simple as any, and has proved to be efficient and safe in about one hundred personal eases. In a number of cases catgut sutures passed through the fibro-periosteum near the edge of the fracture have given good results. A transverse 16 242 MISCELLANEOUS OPERATIONS. or curved incision permits more exact suturing of the torn capsule but divides several large veins and is more likely to become adherent along the line of fracture. Wire sutures are, in my judgment, to be condemned as unneces- sary and as unduly complicating the operation and the repair. OPERATION FOR NON-UNION AFTER FRACTURE OF THE OLECRANON PROCESS. A median longitudinal incision is made over the poste- rior surface of the olecranon and ulna, exposing the bone at the point of fracture. The interposed fibrous tissue is cleared away and the ends of the fragments freshened. The olecranon and ulna are drilled obliquely without per- forating the articular surface. The holes start on the pos- terior surface about one-quarter of an inch from the edge of the fracture and terminate in the fractured surface. The fragments are drawn together with a silk suture and the limb immobilized by an antiseptic dressing in complete extension. Mediate suture, with silk passed through the tendon of the triceps and a hole drilled transversely through the shaft of the ulna half an inch or more below the fracture or even through the periosteum, has given me good results and i- probably to be preferred to direct suturing. LAMINECTOMY. 1 An incision five or six inches long is made in the median line over the summit of the spinous processes in question, and quickly deepened close to one side of them till the lamina' are exposed, from which the periosteum with the attached muscles is raised with an elevator out to the articular and transverse processes. The bases of the spinous processes are next cut through with a chisel or bone forceps, and the opposite laminae \'\ % cc(\ in the same way of periosteum and muscle, without disturbing the muscular attachments of the spinous processes. 'Thorburn: Surg. of spin. Cord. Lloyd: Amer. Journ. Med. Sciences, 1891, Vol. 102, p. •_'•"». THIERSCH'S SKIN GRAFTING. 243 Some operators prefer to make two parallel incisions on each side of the spinous processes, which are then excised, and Horslcy, to better expose the laminae, divides the lumbar aponeurosis and muscles at right angles to the middle of the longitudinal incisions. The sides of the wound are well retracted and the laminae are divided close to the transverse processes with a rongeur, bone forceps, or chisel, and the posterior arch thus removed. If the trouble is not then apparent, before opening the dura a probe should be passed up and down to make sure that the cord has been exposed in the proper locality. If then it is considered necessary, the dura is pinched up and opened longitudinally in the median line behind. Subsequently the wound in the dura is closed with fine catgut or silk sutures and the overlying parts brought together by buried and superficial sutures over a drainage- tube placed in the deepest portion of the wound. MISCELLANEOUS OPERATIONS. THIERSCH'S SKIN GRAFTING. The wound to which the graft is to be applied must be fresh, clean, dry and perfectly aseptic. If it is already a granulating surface all pus must be carefully scrubbed away and the granulations freely shaved away with a knife. It is then thoroughly washed with a sterilized salt solution (about 3j of common salt to Oj of water). Bleeding is checked by the pressure of a sterilized com- press maintained until the grafts are ready to be applied, in order to preserve the asepsis and to prevent the forma- tion of clots of blood which would separate the graft from contact with the raw surface. The graft is commonly taken from the front or outer surface of the thigh, as this presents a conveniently broad surface of skin of the requisite thickness. It must be previously shaved and scrubbed, then rinsed off with al- cohol and finally with sterilized water. The skin of the thigh is drawn tense and Mat by one hand grasping the 244 MISl 'EL LANEO US OPERA T10NS, thigli just above the knee and pulling down. W i t ] i the other hand a broad-bladed razor 3 ground flat on the sur- face held next the thigh, is drawn downward toward the knee by quick sawing motions through the skin parallel to and just beneath its surface. The cutting must be done with accuracy and the razor's cdov must lie always in the papillary layer of the skin. Practically it must pass just deep enough to leave the cut surface studded with minute specks of blood which do not coalesce for an appreciable length of time. If the knife exposes any particle of the subcutaneous fat the corresponding part of the intended graft must be rejected. The sterilized salt solution is allowed to trickle on the skin immediately in front of the advancing razor-edge and serves to float the graft up into the concavity on the anterior surface of the razor and with a little practice facilitates the cutting. A strip six or eight inches long and one and a-half or two inches wide can be cut and retained on a broad blade. The attached end of the graft is severed with scissors. The graft is then immediately unfolded on the prepared wound surface by retaining the whole width of the free end against one margin of the area to be covered and gently withdrawing the razor while its edge is kept con- stantlv in contact with the wound surface. If any portions of the graft get turned over so as to op- pose the epidermic layer to the wound surface, they must be carefully unfolded. In addition all air bubbles must be pressed out toward the edges; and, in short, every part of the freshly cut surface of the graft must be Wrought into accurate contact with the underlying raw surface which is to be covered. Successive grafts are cut and applied until the entire Mii-face is covered. The grafts are then covered completely with strips of sterilized rubber tissue about an inch wide (after rinsing them in the sterilized salt solution), placed side by side with the edges slightly overlapping. This arrangement permits drainage and allows the graft to be kept damp with the next applied sterilized com- SEPARATION OF WEB-FINQERS. 245 presses, wrung' out in either the sterilized salt solution or a sterilized saturated solution of boric acid. The compresses are covered with a sheet of sterilized rubber tissue to prevent drying. This dressing must be vrs oi >i:n i ri oxs. intercligital angle. By this means a bridge of integument is formed which prevents reunion of the sides. These two methods answer very well when there is a distinct interdigital membrane, but some other is required when the fingers are closely approximated. The one which yields the best results is represented in Fig. 85, B, and Fig. 8b\ A rectangular flap is dissected up from the Fig. 86. • i - 1 1 1 : 1 1 i . > ■ i and adjustment of Baps in operation for web-fingers. dorsum of one ringer, and a similar flap from the palmar surface of the other finger, each being left adherent by its long side. The ringers are then separated and each flap turned in to cover one of the raw surfaces. CICATRICIAL FLEXION OF THE PHALANGES. The cicatrix must be thoroughly divided to allow com- plete extension, and then if skin flaps can be obtained from the sides they may be turned in to cover the palmar surface opposite the joints. In dissecting up the flaps care musl !><■ taken not to go deeply enough to involve tin- artery which runs along the side, otherwise the end of the finger may slough. Instead of -mall lateral flaps lor the flexures of the joints the skin covering the sides of the finger may be mobilized by lateral or dorsal Longitudinal incisions and broughl together in the median line of the palmar surface, tli<- ii:i|>- created on the sides by their removal being left to Inal bv Granulation. INGROWN TOENAIL. 247 DUPUYTREN'S CONTRACTION OF THE FINGERS. Open Method. — A Longitudinal incision is made through the skin along the entire length of the constricting band, and crossed at each end by a transverse incision. The flaps thus marked out are dissected up from the aponeu- rosis, which is then divided transversely or excised. Resultant gaps in the skin should be closed by flaps or skin grafts. INGROWN TOENAIL. The base of the toe is constricted with a rubber tourni- quet and a few minims of a 2 per cent, solution of cocaine injected on the sides and dorsum. The nail is then torn out (in all cases) with forceps, one blade of which is pushed up under it to free it from the matrix. Fig. 87. ingrown toenail. A. A, B. I>. C, flap operations (parts removed shown in B. A'. B', r', |)'). B. R, I)', s. wedge operation— M', N', showing part removed In- Cot- ting's operation. I. A rectangular Hap, D, E, F, B (Fig.' 87, A), about one-quarter of an inch square, is made and reflected. The strip of matrix underlying it (Fig. 87, A, B, D, (') and the corresponding part of the nail in front, is then thor- oughly dissected off, care being taken to carry the dissec- tion entirely beyond the base and side. The flap is next replaced and secured and a light dry dressing applied. 248 MISCELLANEOUS OPERATIONS. IT. The exuberant tissue and adjoining skin is pared off close up to the margin of the nail and matrix (M\ X'). The resulting wound is left to close by granulation. (Cotting.) (Fig. 87, B, M' 3 X'.) HI. In certain slight eases a wedge-shaped piece can lie excised from the side of the toe, and by closing this gap with sutures the irritated part is drawn away from the nail. (R, S, D', Fig. 87, B.) THE OPERATIVE TREATMENT OF DISEASED CER- VICAL GLANDS. The operations required in the treatment of diseased cervical glands comprise opening abscesses, scraping and slitting up sinuses, and partial or complete removal of the enlarged lymph nodes. AVhen the latter have not become matted together into an indistinct mass by inflammatory processes — in other words, when the glands can be felt as rounded, more or less movable tumors, each can be readily turned out after it has been clearly reached and exposed, but it is essential to this ease of execution that the dissection should pass entirely through the overlying connective tissue and expose the smooth, glistening sur- face of the gland. When the parts are matted together the internal jugular should first be sought for and clearly exposed above or below the mass in order that in dissecting away the mass of degenerated glands and infiltrated tissue about them the position of the vein may be accurately known. Removal is ordinarily accomplished through a more or less longitudinal incision which follows the general direc- tion of the underlying structures, and is placed over the mosl prominent part of the tumefaction. This is gener- ally along the anterior or posterior border of the sterno- mastoid muscle ; occasionally it may be necessary to make it along Dearly the whole length of both borders to obtain sufficiently lice access to all the glands. The incision 1 1 1 1 1 - 1 lie lon^r enough jo give a clear view of each struc- ture as it is encountered, and to permit of ready control of the hemorrhage. DISEASED < 'ER VI< * 1 1, a L. 1 NDS. 249 The difficulties attending a thorough removal of all dis- eased parts by even a double longitudinal incision are so great that Dr. Hartley, of New York, has devised an operation in which cutaneous flaps arc raised from the surface of the tumor. At first sight it appears unneces- sarily severe, but the results hitherto have been excellent, and the scarring is not so noticeable as to offset the great advantages gained by a complete exposure of all the important parts which are in close relationship with the enlarged glands. The incision is S-shaped (Fig. 88), and involves only the skin, subcutaneous tissue, and fascia ; starting below the chin it passes in a curve downward and backward to Fig. 88. B, C, D. Hartley's incision for the removal of enlarged cervical glands. A. Point where the sterno-mastoid is divided. the hyoid bone, then up behind the angle of the jaw to near the lobule of the car, whence it sweeps down along 251 1 M rSt 'EL L . 1 NEt > I 'S OPERA TIONS. the anterior border of the trapezius, forward over the sterno-mastoid, and downward and backward again to terminate above the middle of the clavicle. The flaps thus formed are dissected up, exposing nearly the whole length of the sterno-mastoid, and the latter is cut trans- versely near its center and the ends reflected, care being taken not to injure the spinal accessory nerve above. The point where the muscle is divided must not be in the line of the cutaneous incision, but under the middle of one of the flaps, preferably the upper. The great vessels are thus exposed from the mastoid process to the clavicle, and the operator can excise the adherent and diseased glands and avoid injury to the adjacent important structure-. At the close of the operation the divided ends of the sterno-mastoid are united with catgut, the flaps replaced and loosely sutured in position, and drainage provided for in the most dependent angles. This large incision is only used when the glands in the superior and inferior carotid and submaxillary triangles are involved simultaneously. For less extensive disease the upper or lower flap may be employed alone, or one may be fashioned with a pedicle in a position the reverse of that shown in the figure. The incision for a single flap should approximately correspond to the circumference of the tumor, which is then exposed in its entirety by di- vision of the sterno-mastoid below the joint where it is entered by the spinal accessory nerve. The flap consists of skin, subcutaneous tissue, platysma, and fascia, and after reflecting it the muscle is always cut beneath the center of the flap, and not in the line of the cutaneous in- cision. PART VI. PLASTIC OPERATIONS ON THE FACE. Plastic operations are required for the relief of eon- genital defects or for the restoration of parts lost by dis- ease' or injury. The methods most commonly employed are of two kinds : 1. By Approximation op the Edges. — This is ap- plicable to eases in which the loss of tissue is not great and the adjoining parts are supple. The edges of the gap are simply pared and brought together. It is sometimes necessary to make "liberating incisions" on one or both -ides for the relief of tension. 2. By Transfer of a Flap. — A Hap of suitable shape and size is dissected up and transferred, by turning it about its base, to the place where it is needed, its vital- ity being insured by the preservation of its base or ped- icle. This method admits of a great variety of modifica- tions in its details, from a simple sliding of a skin flap, which differs but slightlv from the method by approxima- tion, to the transfer of skin, muscle and bone, or the tak- ing of the flap from another limb or individual. The names Indian, Italian, French and German methods have been given to the different varieties, but Verneuil ' has pointed out the impropriety of continuing to employ them, especially since at least two of them, the French and German, have their origin in an oversensitive patriot- ism not mindful enough of the actual facts. The Indian and Italian methods were first employed for the restora- tion of the nose ; in the former a flap was taken from the 1 M£moires de Chirurgie, Vol. I. Chirurgie R£paratrice, \>. 401. 251 252 PLASTIC OPERATIONS ON THE FACE. forehead and brought down by twisting- the pedicle which occupied the space between the eyebrows. The term is now applied to any operation in which the Hap is made with a long pedicle situated at sonic distance from the space which the flap is to cover and in which also the flap is brought into place by rotation over a greater or less arc described about the base of the pedicle as a cen- ter (see Fig. 115). In the Italian method the flap is taken from a distant part of the body, as in restoration of the nose by a flap taken from the arm (Fig. 117). Tagliacozzi, of Bologna, the originator of this method, allowed the flap to suppurate for a few days, so as to increase its thickness, before fas- tening it in its new situation. Graefe sought for primary union, and gave, rather pompously, the name German method to this modification, ignorant of the fact that it had been suggested more than a century before by Reneaulme de la Garanne, and unmindful of the other fact that it con- tained no new principle, and must have been entertained by Tagliacozzi, and only rejected for the sake of another advantage incompatible with it. In the so-called French method, the principles of which are found in Celsus, the flap has a broad base, and is brought into place, not by rotation, but by traction in the direction of its axis (Figs. 99 and 110). The variations and combinations of these methods are now so numerous that the names no longer have much descriptive value. General Principles. — The edges of the flaps must be brought together without tension, and united very accu- rately by means of fine silk, catgut, or silver sutures. All hemorrhage must cease before the flaps are brought into place. Thepresence of a dot of blood under a trans- ferred flap may cause failure. Flaps must lie taken from healthy non-eiealricial skin, and whenever the skin is thin and not very vascular the subcutaneous layer should be taken with it to insure its vitality. The base of the flap should occupy the quarter from which the main supply of blood is received, and the direc- CHETLOPLASTY. 253 tion and shape of the flap should be such that it can be brought into place with the least amount of twisting of the base. The flap should be made considerably larger than the space it is to fill, and, to insure accuracy, it is well to cut it according to a pattern previously made' of paper or oil silk. It is well also to mark the angles by fine pins planted erect in the skin. 'The raw surface left by the dissection of a Hap may be partly covered by drawing its edges together with sutures; the remainder must be left to granulate or may be cov- ered by Thiersch grafting. If strict asepsis is maintained greater tension can he made with the sutures than would otherwise be safe, and the chances of failure and of cicatricial contraction are less. CHEILOPLASTY. A. Lower Lip. — Restoration of the lower lip is usually undertaken to make good the loss of substance occasioned by the removal of an epithelial tumor. The choice of a method depends upon the extent of the disease. 1. V-Incision. (Fig. 89.) — When the tumor is small, involving not more than one-quarter or one-third of the lip, it may be removed by a V -incision, and the sides of the gap brought together with one or two points of inter- rupted or twisted suture. The mucous membrane on the inside of the lip should be excised to the same extent as the skin, although it is not usually involved in the dis- ease, for otherwise it forms a disagreeable fold or pucker in the lip. The harelip pins or sutures must be deeply placed, passing close to the mucous membrane on the inside, for this insures confrontation of the raw surfaces throughout their entire breadth and prevents hemorrhage. '2. Oval Horizontal Incision. — When the tumor covers a considerable extent of surface, but does not pene- trate deeply, it may be safely excised by cutting under it with curved scissors. The mucous membrane and skin 254 PLASTIC OPERATIONS ON THE FACE. may then be stitched together, <»r the wound allowed to heal by granulation. Fig. 89. Cheiloplasty. V-incision. 3. Method of Celsus ob Serres. (Figs. 90 and 91.) -The y-incision is supplemented by a horizontal one on Fig. 90. Fig. 91. Cheiloplasty. < elsusV incisions. Cheiloplasty. Celsus' 8 flaps iu place, each side carried outward from the angle of the mouth for about two inches, ami comprising the whole thickness of CHEILOPLASTY. 255 the cheek for the first two-thirds of its length, Imt divid- ing the mucous membrane at a somewhat higher level than the skin. The lower gingivo-labial fold is divided close to the gum on both sides, and the dissection carried down- ward close to the periosteum, and backward toward the angle of the jaw until the edges of the gap in the lip can Fig. 92. Cheiloplasty. Dieffenbach's method. be brought together without tension. The sides of the V are then brought together, and the lip formed from the lower parts of the horizontal incisions (Fig. 91). The mucous membrane and skin are stitched together along the edge of the new lip, and the remaining portion of the lower flap on each side (that which remains external to the new angle of the mouth) is reunited to the upper flap. The mucous membrane at the outer end of the horizontal in- cision is stitched to the skin and covers the angle. 4. Dieffexbach (Fig. 92) adds a vertical incision at the end of each horizontal one, thus marking out two quadrilateral flaps which are brought together in the median line. The gaps left in the cheek by the transfer are allowed to close by granulation. 5. Syme-Buchaxan. (Figs. 93 and 94.) — The method by latero-inferior flaps is ascribed by some to Syme, by others to Buchanan, of Glasgow. After the tumor has been removed by the usual V-inci- sion, the incisions are prolonged downward and outward for nearly an inch and then curved upward and outward. 266 PJ.ASTic OPERATIONS OX THE FACE. These Maps are dissected off the bone and brought to- gether in the median line. The mucous membrane and Fig. 93. Fig. 04. Svrne-Buchanan incisions. Synie-Buchanan flaps in place. skin are stitched together along the upper edge, the gaps left below by the shifting of the flaps drawn together as much as possible and the remainder left to heel by granu- lation. Raxke and Tr£lat (Figs. 95 and 96) make the flap on one side longer and lift it over the other to form the Fig. 95. Fig. 9ti. Kanke Tn'hit Method. new lip, the shorter flap being used as a support for the former, ' tiElLOPLASTY. Wi 6. Buck's Method. (Figs. 97 and 98.) — Buck pre- ferred t<> make two operations. He first removed the tumor by the V-incision, brought the sides of the gap to- gether and allowed them to unite. After the union had become complete he restored the angle of the month and lengthened the lower lip with material taken from the upper one by the following method. 1 In Fig. 97, 11 B represent two pins inserted a ringer's breadth below the under lip border, one on either side of the ehin, a little to the outside of the angle of the mouth, and equidistant from the median line ; I) I> are also two Fig. ( .'7. Restoration of lower lip. Back's Incisions. pins inserted, one on either side, into the upper lip at the margin of the vermilion border, equidistant from the me- dian line, and at such distance apart as to include between them sufficient length of lip border for a new upper lip. The steps of the operation are then the following : With the forefinger of the left hand placed on the inside of the mouth, the left cheek is to be kept moderately on the stretch while it is transfixed with a sharp knife at the point B. An incision is then carried through the entire thickness of the cheek, upward and a little outward, a dis- tance of one inch and a-half to a point, E, near the mid- dle of the cheek. The corresponding side of the upper lip should next be transfixed at the point IK and the in- cision carried through the lip and cheek outward and a little upward to join the first incision at E. 1 Reparative Surgery, 1876, \>. '22 et seq. 258 PLASTIC OPERATIONS <>.x THE FACE. The next step is to transfer the triangular patch, thus marked out, from the cheek to the side of the chin. For this purpose an incision should be made on the side of the chin from B vertically downward to the edge of the jaw and to the depth of the periosteum. The edges of this incision, retracting wide apart, afford a V-shaped space for the lodgment of the triangular patch, which is now Fig. 98. Restoration (if the lower lii in place. brought around edgewise, and adjusted by sutures in its new position (see Fig. 98). The gap left in the cheek is closed by bringing its edges together and securing them in contact by sutures. By this adjustment a new and naturally shaped angle is formed for the mouth at the point 1). The incisions should be made with the utmost precision, and special care should be taken that the lining mucous membrane is divided exactly to the same extent as the skin. The sam? procedure may be applied to the other side of the mouth, and executed at the same operation. 7. Square Lateral Flaps. (Malgaigne.) (Fig. 99.) — The tumor is circumscribed by two vertical incisions carried downward from the edge of the lip, and a third horizontal one uniting the lower ends of the first two. To fill the square gap thus created, two horizontal inci- -ion- are made on each side — one from the angle of the mouth, the other from the lower corner of the gap. The flaps circumscribed by these incisions are brought forward CHEILOPLASTY 25A and united in the median line and the mucous membrane stitched to the skin along the edge of the lip and at the Fig. 99. Cheiloplasty. (Malgaigne. ) commissures. (See also 3. Method of Celms, p. 254, and Stomatoplasty, v. inf.) 8. Square Vertical Flaps. (Fig-. 100.) — Sedillot made the flap at right angles to the line of the mouth. Fir;. 100. Cheiloplasty. (Sex>illot. ) The incisions are shown in Fig. 100. Eaeh flap is swung around to meet the other in the median line, its inner vertical border becoming- the edge of the lip. In any of these operations in which a large portion of the lip is made by bringing in a flap from the cheek, the 260 PLASTIC OPEMATIOM <>.\ THE FACE. raw surface of the flap adjoining the angle of the mouth may be covered in by a second flap turned down (or up) from the other side of the angle SO as to create a new vermilion surface and border. The effect is much the same as in Buck's operation. Fig. its. B. Angle of the Mouth (Stomatoplasty). — An attempt to restore a large portion of either lip by means of ma- terial taken from the other, or to close a gap by simple approximation, not infrequently leaves the mouth small, rounded and pouting, with obliteration of one or both angles. This defeet can be overcome by the operation described (p. 257) as Buck's method of restoration of the lower lip, or by extending the mouth laterally by a hori- zontal incision involving both skin and mucous mem- brane and then preventing reunion by stitching the skin and mucous membrane together on both sides and at the angle of the incision. Sedillot considers it indispensable to excise a portion of the skin so as to have a compara- tive excess of mucous membrane, which when stitched to the skin will roll outward and form a vermilion border. This simple method was modified by Buck as follows : Buck's Operation 1 for Enlargement of the Mouth and Restoration of its Angle. (Fig. 101.) — An incision is made with great exactness along the line of the vermilion border circumscribing the circular half of the mouth and extending to an equal distance on the upper and lower lips (a to b). This incision should only divide the skin, without involving the mucous membrane. A sharp-pointed, double-edged knife should then be in- serted at the middle of this curved incision and directed flatwise toward the cheek, between the skin and mucous membrane, so as to separate them from each other as far as the new angle of the mouth requires to be extended. The skin alone is next divided from the commissure of the mouth outward toward the cheek. The underlying mucoilS membrane 1S then divided in the same line, but not bo far outward. The angles at the outer ends of the two incisions are then accurately united by a single Reparative Surgery, p. 28 el seq. CHEILOPLASTY 261 thread suture. The fresh-cut edges of skin and mucous membrane above and below, that are to form the new lip Fig. K"l. bening of the mouth. (Buck.) borders, are shaped by paring first the skin and then the mucous membrane in such a manner that the latter shall Fig. 102. Fig. 103. Cheiloplasty of upper lip. (Sepillot.) Sfidillot Flaps in place. overlap the former, after they have been secured together by tine thread sutures inserted at short intervals. 262 PLASTIC OPERATIONS ON THE FACE. C. Upper Lip. — The V-hicision and the oval horizontal incision (p. 253) may bo used when the loss of tissue will be small. Also the square lateral flaps (p. 258) when the gap to bo filled is in the center of the lip and rather large. 1. Vertical Flaps. (Figs. 102 and 103.) — These may be made with the base directed upward (Sedillot) or down- ward (Chauvel). Chauvel claims that the latter method is to be preferred because the retraction of the cicatrix in the former tends to draw the new lip upward and expose the teeth. The flaps comprise the entire thickness of the cheek, are turned inward at right angles to their former position and united in the median line. The gaps left in the cheek by their removal are brought together with sutures or left to granulate. 2. Infero-lateral Flap. (Buck.) (Fig. 104.) — For loss of the right half of the upper lip Buck employed the Fig. 101. Repair of upper lip by Infero-lateral Map. (Buck.) following method, enlarging the month afterward and re- establishing the angle by the method described above (p. 260). HARELir. 263 The extremity of the under lip, where it joined the right cheek, was divided through its entire thickness at right angles to its border, and the division carried to the extent of one inch from the border (a to b, Fig. 104). A second incision was made from the terminus of the first parallel to the lip border for a distance of one inch and a-half toward the chin, b to c. The quadrilateral flap thus formed from the under lip was folded edgewise upon itself, and made to meet the remaining half of the upper lip, and be adjusted to it by its free extremity. In order, how- ever, to made this fold, the under lip had first to be divided obliquely half across its base, e to . incision to Thread (>:isseil through the ends of the Baps. />'. Flaps turned down. C. horten and adjust (laps. ]•:. Then making one side of the cleft tense, by drawing upon its ligature, the lip is transfixed near the angle and ill' incision carried upward along the border of the cleft to it> top, or, if necessary, into the nostril, thus cutting • Hit ;i narrow flap which remains attached at its lower ex- tremity to the lip (Fig. 105, -1). A similar Hap is then made upon the other side, the two arc turned down, so that their raw surfaces face each other, and a thread passed through their free ends (Fig. L05, I''). TIk freshened edges of the cleft are then confronted, a harelip pin placed near the vermilion border and another UMii-iur. 265 near the nostril, and two or three fine silk or silver sutures inserted between them. The ends of the dependent Haj>s axe then cutoff obliquely, enough being left to form a dis- tinct projection on the lip after they have been united with fine sutures. By this means the formation of a notch by the retraction of the cicatrix is avoided. '2. When the cleft Mas shallow, Xelaton left the flaps attached to each other at the apex, turned them down, and brought the raw surfaces together as above described (Fig. 106). 3. Single Flap. (Fig. 107.) — A flap is made upon one side only, usually the shorter portion of the lip. The Fig. 106. Harelip. Nelaton's method. .1. Incision. />'. Flap tnrned down. opposite side of the cleft, and a portion of the free border of the lip adjoining it are freshened by the removal of a strip of skin and mucous membrane. The sides of the Fig. 107. Harelip. single flap. cleft are approximated, and the flap applied to the free border of the lip. 4. Giraldes's Method. (Fig. 108.) — This is ap- plicable only when the cleft extends into the nostril. The 266 PLASTIC OPERATIONS ON THE FACE. flap on the short side is made, as before described, with it- base below; that on the long side is reversed, being left attached at its upper end. A third, horizontal incision is carried outward from the edge of the nostril, at the Fig. L08. Harelip. Giraldes's method. point of the first flap, to make that portion of the lip more movable. The second flap is then turned upward across the nostril, the first brought down to take its place, and the two raw surfaces thus brought into contact united by sutures. The long side of the lip may also be mobilized, if desirable, by a horizontal incision running from the gap close below the columna and the corresponding nostril. Double Harelip, Simple. (Fig. 109.) — Flaps are made upon the lateral portions, .1 and B, as before described Fig. J on. Double harelip (p. 265, 3), and the sides of the central portion, ( \ are pared. The flaps are then brought together, as shown in HARELIP. 267 the figure, after mobilizing the lip by tree division of the gingivo-labial fold and carrying the dissection well up- ward and outward, pins passed to include the sides and the central portion at the base and apex of the latter, the Baps trimmed and united with fine sutures. If the parts arc too scanty to permit the use of this method, liberating incisions must be made around the alae nasi, or flaps obtained from the cheek. (See Upper Lip, p. 262 ct seq.) Complicated Harelip. — Harelip may be complicated by fissure of the palate and alveolar process. When the fissure is single the bone on the long side of the lip projects beyond its proper line. In very young children, it may sometimes be forced back into place by making pressure upon it with the thumb, but it is easier to fracture it first with Butcher's pliers, the bent blade of this instrument being applied upon the anterior surface near the further nostril. The two portions of the alveolar arch soon unite after they have been brought into contact, especially if the opposing surfaces have been pared. Sutures are not needed. When there is double fissure, the intermediate portion of bone containing the incisor teeth projects so far that it seems to be an appendage of the nose rather than of the mouth. In order to restore it to its place, it is necessary to divide the vomer with strong scissors, or, better, to cut a triangular piece out of the septum of the nose. It is not necessary to fasten the bones together with sutures. The portion of skin covering the projecting bone must be dissected off and used to lengthen the columna nasi or fill out the lip. In extreme cases it may be proper to cut away the pro- jection entirely ; but whenever it can be saved and brought into line, it renders valuable service by giving the upper jaw its proper length and furnishing a space into which artificial teeth can be fitted. The three or four teeth which are found in this piece are always so defective and irregularly placed that they have to be drawn. For uranoplasty, etc., see Operations upon the Mouth. 268 plastic OPERATIONS ON THE FACE. RHINOPLASTY. The different kinds of rhinoplastic operations may be classified according to the nature and extent of the loss which they are designed to repair: 1st. A superficial loss not involving- the bones or septum. 2d. Loss of the sep- tum and nasal bones, the skin remaining entire. 3d. Loss of more or less of the surface and septum. As the loss of tissue is always the result of injury or disease, it presents so many variations in form and ex- tent, that it is difficult in practice to determine the exact boundaries between the classes, and this classification is chosen for convenience of description, and not with the intention of limiting the choice of an operation in any given case to those described in the class to which the lesion might belong. For the same reason, a description of an operation as actually performed will sometimes be more serviceable than any general rules that might be laid down. A.s may be readily understood, the existence or non- existence of the septum and nasal bones affects materially, not only the method of operating, but also the result. If unsupported centrally, the new member tends constantly t<. shrink and flatten, and the surgeon has the mortifica- tion of seeing that he has merely substituted one de- formity for another. Oilier tried to meet this want by including the periosteum in the flap taken from the fore- bead by tin' Indian method. There was, however, no new formation of bone, and the operation in that respect w;is a failure. On another occasion he took a strip of healthy periosteum from one of the limbs, and tried to graft it under the skin of the forehead, hoping thereby to procure a lamella of bone, which could be used to give solidity to the new nose. Thinking the graft had failed, he withdrew the strip of periosteum after a lew days, and then discovered that it had united nicely at one point. There i- reason, therefore, to think that a more patient repetition of the experiment might be successful. On a third occasion, lie included the periosteum of the fore- miisoi'LAsrv 269 head in ;i flap transferred by a modification of the French method, and by folding it together longitudinally along the center lie got reproduction of bone where the two layers faced each other. 1. Superficial Defect not Involving the Bones or Septum. — If the loss of tissue is confined to the integument, that is if the cartilage is spared, as it usually is in eases of epi- thelioma, no plastic operation should he undertaken. The tumor must he carefully dissected off and the wound grafted or left to granulate. The slight mobility of the integu- ment of the region prevents deformity by cicatricial re- traction and the wound heals over, leaving a scar which does not contrast offensively with the neighboring skin. Ii\ on the other hand, there is a gap to be filled, one that is small and docs not involve the free border of the ala, square lateral flaps may be made by horizontal inci- sions (Fig. 110), and drawn together after they have been rendered freely movable by dissection from the underly- ing parts. Fig. 110. Rhinoplasty. Lateral flaj If the gap is larger, or if one of the alse is lost, suitable oblique or vertical flaps may be taken from the nose or cheek and transferred by rotation. Three of the many variations of this method are shown in Fio-s. Ill and 112. Fig. Ill, .1, represents a vertical flap taken from the cheek beside and below the nose and left adherent at 270 PLASTIC OPERATIONS ON THE FACE. its upper end. The flap should be cut long enough to al- low a natural appearance to be given to the five border of the ala by turning it in upon itself. The device will also prevent excessive cicatricial contraction of the border and consequent narrowing of the nostril. Fig. HI. Fig. 112. Rhinoplasty. A. single lateral flap. H. Langenbeck's method. Rhinoplasty. Denonvillier's method. Denonvilliee's Method (Fig. 112) sometimes makes it possible to secure this object more certainly by supply- ing a border that is already cicatrized. Supposing the lower portion of an ala to be lost, a triangular flap, left adherent to the lobe of the nose, is marked out by an in- cision which, starting from a point near the lobe on the unaffected side of the median line, is carried directly up- ward nearly to the root of the nose, and thence obliquely downward to the upper outer corner of the affected ala. The flap is mobilized by careful dissection of the bone and cartilage and transferred downward. The gap left by the transfer heals by granulation or can be closed by a Thiersch graft. For the sake of oivinjr more stiffness to the border, Denonvillier sometimes included a strip of cartilage in it. Von LANGENBECE ' restored an ala by taking a tri- angular flap from the opposite side of the nose (Fig. Ill, i- ill- < birnrgie Plastique d'apres lee Preceptes du Prof. B. von Longenbeck, Bruxelles, 1856, quoted by Verneuil. UH1N0PLA8TY. 271 /»'). The flap was left adherent at the apex of the trian- irlo, which lay near the inner angle of the eve of the al- fected side, while its base occupied the opposite ala. It was dissected up carefully so as not to include the car- tilage, transferred to the other side and fastened to the freshened edges of the gap. The wound left by the re- moval of the Hap healed by granulation and so perfectly that it was difficult to recognize there had been any loss of tissue at that point. MlOHON restored the ala by taking a triangular Hap from the septum. The base of the flap was placed ante- riorly, parallel to the ridge of the nose, and the apex lay near the junction of the septum with the floor of the nasal fossa. The flap was dissected up and attached to the margin of the loss of substance, its mucous surface di- rected outward, its apex made fast to the cheek. The coli'mxa, with or without the tip of the nose, can be restored from the upper lip. Dupuytren and Dieffenbach cut a vertical cutaneous flap, adherent at its upper end, immediately below the columna, turned it upward, twisting it upon its pedicle so that its cutaneous surface remained external, and secured it in place. As the twisting of the pedicle created considerable deformity, Sedillot and Blandin made the flap of the entire thickness and length of the lip, pared off its cutaneous surface, and turned it directly upward without twisting the pedicle, the mucous membrane thus forming the outer surface. The gap left in the lip was then closed with sutures. In Blandin's case the result was excellent, and the mucous membrane gradually assumed the characteristics of ordi- nary skin ; but in Sedillot's ease, in which the tip of the nose had also to be restored, the membrane remained red and covered with thick epidermic scales, and the end of the nose looked much like a cherry. 1 In all his rhino- plastic operations Liston made the columna separately by this method, and found that the mucous membrane soon took on the appearance of ordinary integument. 'Sedillot : Medecine Op&atoire, 2d ed., Vol. II., p. 233. 272 PLASTIC OPERATIONS ON THE FACE. 2. Loss of the Septum and Nasal Bones, the Skin Remaining Entire. — Baron Larrey, about 1820, operated upon a soldier the bridge of whose nose had been shat- tered and depressed by the explosion of a gun. He re- moved the deformity by dissecting up the adherent por- tions of skin and replacing them in their original position. The details of the operation are lacking. Dieffenbach published in 1829 the description of an op- eration by which he overcame the great deformity result- ing from the loss of the septum and bones of the nose by scrofulous disease. As the case is a classical one, quoted, Pig. 11.°.. Dieffenbach's operation. />'. Tli and often very incorrectly, in the text-hooks, and is an indication of whal may sometimes he accomplished in ex- treme eases, the following description of it is given :' The patient was a girl twelve years of age. She had lost th*' OSSa nasi, nasal process of the ethmoid, vomer, 1 A- the original work could no! be obtained, this description is made up from an English translation of the book, published in 1833, a French translation of the case, in the Gazette M£dicale, Vol. I., p. 65, 1830, and :i brief, description with plates, in a collection of Dieffenbach's Plastic Operations, published by two of his pupils in 1846. RHINOPLASTY. 273 and cartilages, and instead of a prominent nose there was a deep pit with a ridge at the bottom. The plan of oper- ation was to divide the remains of the <>ld sunken mem- ber into portions, raise them up, and secure them in the proper position. Dieffenbach passed a narrow-bladed knife first into one nostril and then into the other, and cut out, making two incisions, one on each side of the sunken ridge. (Fig. 113, C.) The strip of skin between these in- cisions was three times as broad at its lower end, where it was connected with the upper lip by the shortened columna, as at its upper part where it joined the forehead. The cheeks were next cut through down to the bones on each side by inserting the knife a few lines below the upper end of the first incision and carrying it obliquely downward, parallel and a little external to the side of the nose, and then around into the nostril, thus separating the lateral attachments of the ahe nasi. The columna, being too short, was then elongated by two slight incisions in the upper lip, and the cheeks rendered more movable bv di- viding their attachments to the bone through the lateral incisions. The flaps were then raised, the sides of the'in- cisions pared obliquely in a manner to which Dieffenbach attaches an importance that seems undeserved, reunited, and fixed with harelip pins and sutures, and the whole re- tained in place by drawing the cheeks toward the median line and fastening them there with two long pins passed under the nose and through the detached edges of the cheeks. This compression was aided by two splints of leather through which the pins passed. A quill covered with oiled lint was introduced into each nostril. Osteoplastic Method. — Oilier successfully treated a some- what similar ease by making a triangular Hap, its base constituted by the lower portion of the nose and the ad- joining cheeks, its apex situated one and a-half inches above the eyebrows. The frontal portion of the flap in- cluded the underlying periosteum. The left nasal bone and vomer having been destroyed by the disease, central support could be obtained for the new nose only by aid of the right nasal bone, which was accordingly loosened with is -7 1 PLASTIC OPERATIONS ON Till': FACE. a chisel and forced downward. The flap was then trans- ferred downward, pinched in laterally to increase its height at the bridge, and supported there by drawing the cheeks, previously loosened from their underlying attach- ments, toward the nose and fastening them there with long pins. 1 Double Layer, or Superficial Flaps. (Fig. 114.) — Ver- neiiil ' employed successfully a method suggested to him by Oilier, in which permanent elevation of the bridge of the cose was secured by superposing two Haps and thereby doubling the thickness. The patient had discharged a Fig. 114. VW >— Rhinoplasty, sunken □ Double layer, or superposed Baps. (Verneuil.) pistol into his i ith, causing the destruction of a portion of the hard palate and septum, the nasal bones, part of the nasal processes of the superior maxillary, the spine of the frontal, and the anterior wall of the frontal sinuses. The alffi and lobe were uninjured but much flattened ; above them was a broad deep groove extending to the middle third of the forehead. The two principal indica- 1 For farther detail* "f tin- operation the reader is referred to the original account in the Bulletin de la Soci&e* de Chirurgie, L862, \>. 62; ..i !., ii reproduction in Verneuil's ( hirurgie R. 279 of tin* manual. - ( hirurgie Reparatnce, p. 128, and Bull, de la Soc. de Chirurgie; 1862, p. 7". RHINOPLASTY. 275 tit his were to bring the lateral portions nearer the median line and to reconstitute the bridge of the nose. The latter could be permanently accomplished only by filling in the great cavity which would be left by raising the sunken parts. Verneuil made an incision along the median line of the depression and a transverse one at each end of the first, and dissected up the two lateral flaps thus marked out. Me then raised an oblong flap from the middle of the fore- head, its base remaining adherent between the eyebrows, and turned it directly downward so that its raw surface was directed outward, its tegumentary surface toward the nasal fossre. The two lateral flaps were then placed upon it and united in the median line. The raw surfaces united with each other, and the result was a nose elevated one- third of an inch above the adjoining surface. Subcutaneous Method. — Prof. Pancoast ' operated upon a similar case in the winter of 1842—4.*) by subcutaneous division of the adhesions. The ossa nasi and septum had been entirely destroyed by disease, and the nose was sunken far below the level of the face. "A narrow long- bladed tenotomy knife was introduced on either side by puncture through the skin over the edge of the nasal proc- ess of the upper maxillary bone. The knife was pushed up under the skin to the top of the nasal cavity, and then brought down, shaving the inside of the bony wall, so as to detach the adherent and inverted nose upon either side. The point of the nose could now be drawn out. * * * The nose still remained adherent to the top of the nasal chasm. The knife was a third time introduced under the skin in a direction corresponding nearly with the long diameter of the orbits of the eyes and the adhesions separated from the nasal spine and internal angular processes of the os froutis." The soft parts on the cheek were loosened bv sweeping the knife outward along the surface of the bone so far as to divide the infra-orbital nerve and artery on each side, drawn toward the median line, and held together with quilled sutures passed through the cavity of the nose. 1 Operative Surgery, l'hila., 1852, p. 858. 276 PLASTIC OPERATIONS OJV THE FACE. In two weeks the root of the new nose had sunk to the level of the face, but the patient was well satisfied, and refused any further operation, beyond the removal of an elliptical piece of skin to raise this portion again. The ultimate result is not known. Dubrueil 1 quotes a similar operation by Malgaigne, but without giving the date. As it is not mentioned in the hitter's Mideoine Opiratoire, edition of 1837, it is probable that Prof. Paneoast's operation antedates it. About 189o I successfully met the indication in a case of depression of the bridge due to fracture of the nasal bones by introducing a piece of guttapercha through a small incision on the side of the nose. See Fractures and Dislocations, 1898, p. 156. 3. Loss of more or less of the Surface and the Septum. A. Indian Method. — This method was introduced into Europe in 1814, by Carpue, an English surgeon, and the stimulus given by it to this class of operations was so great during the succeeding twenty-five or thirty years that this period has been called that of the renaissance of rhinoplas- ty surgery. The ultimate results, however, were not very favorable, and the method has fallen into compara- tive neglect. It was found that the noses, although suf- ficiently full, or even excessive at the time of opera- tion, underwent gradual atrophy, and, when central sup- port was lacking, sank to the level of the checks. The nostrils, too, closed sometimes to such an extent that they would hardly admit a probe; and, finally, the whole flap had a tendency to slide downward, and collect in a lump at the end of the nose alter division or excision of the pedidc. The scar left upon the forehead was a serious disfigurement, and the attempt to diminish it by drawing the sides of the gap together gave rise to complications which endangered the patient's life. The operation itself was not without danger. Dieffenbach lost two out of six patients upon whom he operated in Paris. The operation was originally performed as follows (Fig. I 15): A Hap, the size and shape of which were determined 1 Mldecine ' >p£ratoire, p. 151. RHINOPLASTY. 277 I >v a pattern previously made of paper or card, was marked out upon the forehead immediately above the nose, ('arc was taken to make it at least a quarter of an inch broader and half an inch longer than the space it was to fill. Its base was situated between the eyebrows and was half an inch broad. At the upper end of the flap was a project- Fig. 115. Rhinoplasty. Indian method unmodified. ing tab intended to form the columna. The flap, includ- ing all the tissues down to, but not through, the peri- osteum, was then dissected up, brought down by twisting the pedicle, placed in its new position with its raw surface inward and attached by sutures to the freshened edge- of the gap it was to fill. Prominence was given to the ridge by stuffing the nostrils with plugs of oiled lint, or draw- ing the cheeks toward the median line by means of long pins passed transversely through the edges and under the nose. The gap in the forehead was left to heal by granu- lation. After the flap had united, the pedicle was divided and returned to its original position. Modifications. 1 — Larrey (1820) pointed out the desira- 'The dates of these modifications ami the award of credit for their suggestion are mainly taken from Venn-nil's Chirurgie Reparatrice, to which the reader is referred f<>r farther details and documentary proof. 278 Pl.ASTlc OPERATIONS o.V Till] FACE. bility of saving even the smallest fragments of the original nose, especially If they belonged to the free border of the ala. Professor Bouisson ' formulated this principle and extended it to the other methods, as follows: 1st. Save as much as possible of the septum. 2d. Give lateral sup- port to the flaps by means of the healthy portion of the cartilage of the alae. 3d. Insure the regularity of the outline of the nostril by giving the lower border of the flap cartilaginous support. Dupuytren and Pieffenbach opposed the retraction and closure of the nostrils by fold- ing back upon itself that portion of the edge of the flap which was to form the free border. The torsion of the pedicle involves more or less danger of gangrene by obstructing the return of the venous blood. Lisfranc (1826) was the first to attempt to diminish this defect. By lengthening the incision on one side, the base or attachment of the pedicle was made oblique instead of transverse and the torsion correspondingly diminished at that point. Of course, the total amount of torsion re- mained the same, but, by being spread along the pedicle, it was made more spiral and less abrupt. Von Langen- beck (before 1856) went a step further and put the base upon the side of the nose close to the eye, the upper inci- sion ending at the eyebrow, the lower just below the tendo oculi. Labbat did about the same thing in 1827. Auvert, a Russian surgeon (date unknown, but long before 1850), made the flap oblique instead of vertical, still keeping the base between the eyebrows. Alquie, of Montpellier ( 1850), proposed to make the Hap horizontal, the lower incision being hidden by the eyebrow ; and Landreau even curved it somewhat upward at the end, so that the base of the pedicle was hardly twisted at all in bringing down the flap. Ward i 185 1) made a flap which was directed obliquely upward, ami Follin (1856) made a transverse one; in each ease the base of the pedicle was upon or near the median line of the forehead, a little above the eyebrows. Both cases did well. The objec- tion to a transverse flap is that the retraction of the cica- ' Ethinoplastie lat^rale. RHINOPLASTY 279 trix upon the forehead draws the corresponding eyebrow upward. The advantages arc that the torsion is less, and the scar somewhat disguised by the natural lines. Various means have been employed to prevent the descent of the Hap. Dieffenbach made a longitudinal incision on the side of the nose, and engaged the pedicle in it, paring off its prominences afterward. Blandin ex- cised the portion of skin intermediate between the base of the pedicle and the loss of substance, and thus obtained a raw surface to which the whole length of the pedicle was then united. Instead of excising this intermediate piece of skin. Buck left it attached by its upper end, and used it to cover part of the gap left upon the forehead. Vel- peau divided the pedicle close to its base, trimmed it to a point, and engaged it in a vertical incision made in the underlying skin. B. Oi-lier's Osteoplastic Method. 1 (Fig. 116.) — A lupus had destroyed the al;e, columna, lobe, cartilages, and part of the septum. The nasal bones were uninjured, but had suffered an arrest of development, and were bounded inferiorly by a strip of cartilage. The nose was not more than an inch long. The skin of the cheeks and lips had also been involved by the lupus, and, therefore, could not be used for the restoration. Starting from a point in the median line of the forehead two inches above the eyebrows, Oilier made two incisions diverging downward, each of which ended a quarter of an inch to the outer side of the lower border of the nasal orifice. In dissecting up the long triangular flap thus marked out, he included the periosteum from above downward as far as to the upper end of the nasal bones ; he then con- tinued the dissection along the right nasal bone, leaving the periosteum adherent to it, and on reaching the lower end of the bone he separated from it the cartilaginous strip above mentioned, leaving it adherent to the flap. On the left side he divided, with a chisel, the bony con- nections of the left nasal bone, leaving the bone attached 1 Traits de la Regeneration des Os, Vol. II., p, 469. 280 PL [STIC OPERATIONS ON THE FACE. to the Hap by its anterior surface; this was accomplished by introducing the chisel, first between the two nasal bones, then between the left nasal bone and the frontal, and finally between the left nasal bone and the nasal proc- ess of the superior maxillary. Drawing the flap down- ward, he then divided the cartilaginous septum from before Fig, IKi thinoplasty. Ollier's osteoplastic method, backward and downward with scissors, so as to have an anterc-posterior Hap of cartilage attached by its base to the cutaneous one, and able to furnish central support for the new nose by resting its free border upon the floor of the nasal fossa, or rather upon the remains of the lower portion of the original septum. lie next drew the whole Hap downward until the upper border of the left nasal bone came into line with the lower border of* the right nasal bone and then fastened the two bones together with a metallic suture. The sides of the flap were then united to the cheeks and those of the frontal incision- drawn together above the apex of the Hap. The pint- united, the space left by the removal of the left oasal bone was tilled with bone produced by the peri- osteum brought down from the forehead and the result w;i~ satisfactory. RHINOPLASTY. 28 I C. Al((iii»'- ii><'p6ratoire, Ith edition, p. 318. OPERATIONS I'I'oy THE EYELIDS. 285 extremities of these incisions he made a third and fourth parallel to the border of the lid. The two triangular flaps bounded by the 1st and .'M, and the 2d and 4th in- cisions were then dissected up, the lid raised to its normal position and held there by uniting the adjoining sides of these two flaps in such a manner that their apices and that of the inverted V llic t at a common point. The gaps left by the removal of the two flaps were allowed to gran- ulate, or covered with Thiersch grafts. For greater se- curity he also united the borders of the lids (blepharor- rhaphy). Fig. 1-21. ^^^^ Ectropion. .1. Von Graefe's method. B. Knapp'a method. Y< >x Graefe. ( Fig. 121, A.) — Make an incision along the border of the lid just outside of the lashes from the lachrymal point to the external commissure. From each extremity of this make a vertical incision downward from one-half to three-quarters of an inch in length. These incisions should involve only the skin. Cut off the upper inner corner of this Hap, not by a straight incision, but by one forming an angle, as shown in the figure, and fasten this angle by a suture to that formed by the border of the lid and the inner vertical incision. Reunite the edges of the transverse incision, cutting the ends of the sutures long enough to reach to the forehead and then fastening them there with adhesive plaster. The excision of the inner angle of the flap raises the eyelids by shortening its border. DlEFFENBACH, Adams, and Amm<>\ have proposed other methods of shortening the lid. They are indicated 286 PLASTIC OPERATIONS ON THE FACE. in Fig. 122, whore the shaded spaces represent the por- tions of skin to be removed, and the threads the manner Fir;. 122. Ectropion. A. Dieffenbach. H. Adams. C. Amnion. The shaded spaces indi- cate the portions of skin removed; the threads show how their edges arc brought together. in which the edges are afterward brought together. Adams's excision included the whole thickness of the lid. RlCHET. (Fig. 123.) — Richet made an incision parallel to the border of the lid, half an inch below it, and extend- Fro. 123. *Ukti2S& I let ropion. (Ri< in i . | ing nearly from one angle of the eye to the other. The lid, having been IVccd by this incision, was then united to the other (blepharorrhaphy \. H<- next made a second incision parallel to the first and one-third of an inch below it, divided tli<' intermediate strip of skin vertically in the middle and dissected up its two halves, [mmediately below the lower end of this vertical incision h<' removed from the lower border oi the -•■'•"iid incision a V-shaped flap of skin, its point directed OPERATIONS UPON THE EYELIDS. 287 downward. lie then raised the two halves of the middle flap, brought them again into contact with the border of the lid, excised their superfluous length, mid united them. The sides of the V are then brought together and the edges of the incisions reunited. Kxapp. (Fig. 121, B.) — Knapp employed the follow- ing method to remove an epithelioma occupying the inner portion of the lower eyelid, the free border of which was involved. He circumscribed the tumor by two vertical and two horizontal excisions and excised it. The hori- zontal incisions were then prolonged on both sides, the lower external one being inclined downward so as to make the base of the flap broader, the two flaps dissected up, drawn together and united by their vertical edges. BUKOW. (Fig. 124.) — The loss of substance is made triangular in shape, the apex directed downward ; the base Fig. 124. is then prolonged horizontally outward, and an equal and similar triangle marked out upon the upper side of the prolongation. The skin contained within the second tri- angle is then excised, and the irregular flap bounded by the outer sides of the two triangles and the prolongation of the horizontal incision dissected outward and downward. and then moved toward the median line until it cover- both the open spaces. It is not necessary that the two triangular spaces should 288 PLASTIC OPERATIONS ON THE FACE. touch at one corner ; they may be an inch, or even more, apart, but they must of course be connected by the hori- zontal incision. DieffenbajCH. (Fig. 125.) — When the cicatrix or tumor was large Dieffenbach gave the loss of substance a triangular shape, the apex directed downward. He pro- longed outward the horizontal incision forming the base of the triangle, and carried another incision downward and inward from its outer extremity. The quadrilateral flap thus marked out was dissected up and carried inward to Fjg. 12-"). Ectropion. ( DlEFFEXBAI II. ) cover the loss of substance. The gap left by its removal was then drawn partly together with sutures,'and the re- mainder left to granulate. Indian Method. — S&lillol refers the first blepharo- plasty by the Indian method to Yon Graef'e in 1809. As this was previous to the introduction of rhinoplasty by the same method, the idea was probably entirely original with Von Oracle. The case is mentioned in hi- Rhinoplastik, 1818, but without detail-. The flap can be taken from the forehead or cheek ; it should be very large and should include the subcutaneous cellular tissue. Fricke, of Ham- burg, took a vertical Hap from the temporal region to re- store the upper eyelid. One of tin- modifications of tin- method, intended to obviate the necessity of dividing the pedicle, i- shown in Fig. L26, .1. OPERATIONS UPON THE EYELIDS. 289 RlCHET. (Fig. 12, used to fill the gap occasioned by the removal of C Hasnek d'Artha (Fig. 127) employed the following method in a case where a tumor occupied the commissure and inner portion of each eyelid. He made a curved in- cision, a, beginning at the border of the upper eyelid be- yond the limit of the tumor, crossing the eyebrow to the forehead, and then crossing downward to terminate near the root of the nose. A second curved incision, e, began at the same point as the first and was carried along the upper and inner edge of the tumor to the point marked /'. A third curved incision, e, began on the border of the lower lid beyond the limit of the tumor and was carried along the lower margin of the latter to the point /'. A fourth curved incision, g, parallel to the border of the lower lid, was carried from the point outward to the cheek. The tumor and the portion of the lids circumscribed by the incisions c and e were then removed, and each of the Haps (1 and // dissected up to its base. The former was lowered, the latter raised, and the excess of each cut off. 19 290 /'/ [STIC OPERATIONS ON THE FACE. The upper border of the Hap h formed the free border of the lower Lid, and the lower border of the Hap d formed the free border of the upper lid and the commissure corre- Fig. 127 Ectropion. Hasner d'Artha's method, sponded to the apex of the flap h. The skin of the fore- head and cheeks was mobilized and reunited to the Haps ( Dubrueil). Denonvillier'a method " by exchange." (Kig;. 128.) In a case of ectropion of the lower lid, with deviation Fig. 128. Ectropion. Denonvillier'a method " bj exchan of the outer angle of the eve downward, Deuonvillier used the following method : By making three incisions to nK't in the form of Z. he marked out two adjoining tri- angular flaps : one of them included the outer angle of the OPERATIONS UPON THE EYELIDS. 291 eye, the apex of the other was situated upon the forehead just above the eyebrow. lie then dissected up the flaps, restored the angle of the eve to its proper position, brought the upper Hap down into the gap made by the lower incision, and the lower flap up into that made by the upper incision. Ectropion due /<> excess of the conjunctiva may he treated by cauterization of the conjunctiva, or by excision of a portion. The latter operation is simple ; a fold is pinched up with forceps and excised with knife or scissors. The edges of the gap may then he brought together by sutures or left to granulate. 2. Entropion. — Canthoplasty (7. v.) may be em- ployed to remedy moderate entropion, especially if it be due to spasm of the orbicularis. Ligature (Fig. 147), proposed by Gaillard to remedy trichiasis, is equally applicable to the cure of entropion. l'Ki. 129. Entropion ; ligaturi A transverse fold is pinched up, and a needle carrying a stout ligature passed through its base, shaving the ante- rior surface of the cartilage. The ligature is tied and allowed to cut through the skin. The resulting linear cicatrix maintains the lid in the position given it by the ligature. Uau has modified this by placing several ligatures in- stead of only one. Excision or cauterization of a fold of the skin is appli- cable to cases of entropion due to laxity of the skin of the eyelid. A transverse or a vertical fold is pinched up 292 PLASTIC OPERATIONS ON THE FACE. quite near to the margin of the lid and excised; the bor- ders of the wound are united by sutures. Instead of ex- cision, cauterization of the strip is sometimes used. Von Graefe (Fig. 130) treated a case of spasmodic en- tropion by removal of a triangular piece of skin. He made a cutaneous incision parallel to the free border of the lid and about a line from it, and excised a triangular cutaneous flap, the base of which occupied the median portion of the first incision. The sides of the wound left by the excision of the triangular piece were then drawn together with sutures. Division of the external canthus will sometimes relieve the condition. For spasmodic entropion of the upper lid, with retrac- tion of the tarsal cartilage, Yon Graefe modified the op- Fig. 130. P^ig. 131. Entropion— lower lid. (Von Gbaefe.) Entropion— upper lid. (Von Graefe.) eration as follows (Fig. 131): After excision of the tri- angular cutaneous flap, he drew the sides of the wound apart, divided the orbicular muscle horizontally near the edge of the lid and drew it upward, exposing the carti- lage. He then excised a triangular piece of (he cartilage, i lie apex being at its lower border, taking care not to in- clude the conjunctiva in the dissection. The sides of the cutaneous wound were then drawn together with three su- ture-, tin' middle one of which included also the sides "I' the gap h ii iii the cartilage. ( > 1 7.7/ AT In NS UPON 1 'Hi: E ) ' EL 1 1 >s 293 Division or Resection oj the Tarsal ( artilage. — \\ hen the entropion is caused or maintained by shortening or incurvation of the tarsal cartilage, the operation must be directed to the removal of this cause. Vertical division at one or two points of the entire thickness <>f the lid has been employed. After having Ween divided, the border of the lid is held in its proper position by ligatures passed through it and fastened to the forehead (upper lid) or cheek (lower lid), while the wound fills and heals by granulation. A horizontal incision through the conjunctiva from one vertical incision to the other makes it easier to turn the lid out and hold it in place. Longitudinal Tarsotomy. (Amnion.) — The eyelid hav- ing- been turned out, a knife is passed through it from the Fig. 132. Knapp's modification of Pesruarres's forceps. conjunctival side, a quarter of an inch from the border and on a line with the lachrymal point, and an incision made parallel with the border nearly to the outer angle. A longitudinal strip of skin is then excised and the edges of the gap left by the excision are drawn together. By this means the free border of the lid is drawn away from the surface of the eye, turning upon the longitudinal incision as upon a hiuge. Excision of Part of the Cartilage. (StreatfeUd.) (Fig. 133.) The eyelid is fixed with Desmarres's forceps (Fig. 132), the flat blade against the conjunctiva, and an incision made parallel to the border of the lid at the distance of one line from it, and carried to a depth sufficient to expose the 294 PLASTIC OPERATIONS ON THE FACE. bulbs of the eyelashes. The surgeon, raising the edge of the skin, passes around the bulbs to the tarsal cartilage, and then makes a second incision at a greater distance from the border of the lid than the first one was, meeting the first at its two ex- tremities and inclosing with it an oval strip of skin. These two incisions are carried into the cartilage, circumscribing a longitudinal wedge- shaped strip, the apex of which reaches nearly to the conjunctival side of the cartilage. The wound is left to heal by granulation, with the expectation that the contraction of the cicatrix will overcome the entropion. .*}. SYMBLEPHARON. — When the adhesion between the two layers of the conjunctiva is incomplete, that is, when it does not extend to the bottom of the sulcus between the lid and eyeball, it is sufficient to throw a lig- ature around it. After the; ligature has cut through, the tabs arc successively excised, and the borders of each wound drawn together or left to heal by granulation. To avoid reunion of the surfaces, the second tab should not he removed until after the wound left by the removal of the first has healed. When the adhesion is c plete, hut not broad, a thread or silver wire may lie passed through its base and tied Loosely around it. After the hole made by the wire has cicatrized the adhesion is divided. The narrow line of cicatrix left at the bottom of the fold by the wire favors the separate healing of the two sides of the incision. . I /•//'* M' and C, are then dissected up on opposite sides of the eyeball, their bases directed toward the symblepharon, their borders parallel to that of the cornea. These Hap- should not include the subconjunc- tival tissue The inner flap B is brought down and fast- Fig. 136. 1- Upe in place ened to the denuded surface of the eyelid, the outer flap C covers that of the eyeball. They are fastened in place by means of fine sutures, and the edges of the gaps left by their removal brought together in the same manner. Ledentu's Operation. — Where one lid was adherent throughout its entire length, Ledentu divided the adhesion 296 PLASTIC OPERATIONS <>.\ THE FACE. to a depth equal to thai of the normal fold, dissected a long conjunctival Hap from the other half of the eye, leaving it adherent at both ends, brought it down across the cor- nea, and applied it to the raw surface left on the eyeball by the division of the adhesion. This Hap should be at least one-third of an inch broad. A few successes have been obtained by Thiersch-graft- ing of the raw surface. 4. PteryGION. EXCISION. — The ptcrygion is pinched up with forceps, a knife passed Hatwise under it close to the cornea, and the portion of the growth which corres- ponds to the latter shaved off. The edges of the conjunc- tival wound are then drawn together with sutures. Scissors may be used instead of the knife ; in that ease the incision must begin at the point of the growth. Ligature, Szokalski. — A thread is passed under the ptervgion by means of two small curved needles, as shown Fig. 1:57. Pterygiou ; ligaturi in Fig. L37. The thread is cut close t<> the needles, and thus made to furnish three ligatures, one at each end, en- OPERATIONS UPON THE EYELIDS. 297 circling the growth at righi angles to its long axis, and our in the middle, encircling its implantation upon the sclerotic. The ligatures arc tied tightly, and the inclosed portion falls in n few days. 5. Trichiasis. — Temporary removal of the deviated lashes is seldom effectual. Permanent removal by destruc- tion of their bulbs, or excision of the border of the lid, is now considered unjustifiable. The direction of the lashes may be changed by operation upon the lid. The retrac- tion following excision of an oval strip of skin, or the use of ligatures as in entropion, is sometimes sufficient, but it may he necessary to act more directly upon the lashes. Simple splitting of the external canthus may be sufficient. Yon Gfraefefs JfdhorJ. — An incision is made along the free border of the lid on the conjunctival side of the devi- ated lashes. From each end of this a vertical incision is next made through the free border and the skin. The flap thus circumscribed and containing the lashes is dis- sected up a short distance. It is then easy to fasten it with sutures in such a position that the lashes can no longer touch the eyeball. Anagrwstakis made a cutaneous incision parallel to the border of the upper lid and one-eighth of an inch from it, exposed the orbicular muscle by drawing the skin up, and excised that portion of it which corresponded to the upper part of the tarsal cartilage. The lower edge of the cuta- neous incision was then drawn up and fixed to the fibro- cellular layer covering the cartilage by means of three or four sutures, which were then allowed to cut themselves out. FART VII. SPECIAL OPERATIONS. (MT A PTER T. OPERATIONS UPON THE EYE AND ITS APPENDAGES. In most operations upon the eye the lids should be held open by an eve-speculum (Fig;. 138), and the eye- Fn.. 138. Bye-spectrum. hall fixed by pinching- up a fold of the conjunctiva with toothed forceps. The instillation of a few drops of a 4 per cent, solution of the hydrochlorate of cocaine under the lids will make most operations painless, but the sensitiveness of the iris is not thereby abolished. THE CORNEA. Removal of a Foreign Body. — When the foreign body has penetrated to only a slight depth, it may be easily re- 299 31 K I SPECIAL OPERATIONS. Fig. 139. Fig. 140. Stop needle and prohe for puncturing the cornea. Acer's knife. THE CORNEA. 301 moved with the point of a knife or line forceps; but, if it lies so near the posterior surface of the cornea that there is danger of forcing it through into the anterior chamber by the efforts made for its extraction, a lance-shaped knife must be entered very obliquely and passed behind it, be- tween the layers of the cornea if there is sufficient space, otherwise within the anterior chamber. If the foreign body falls into the anterior chamber, not- withstanding these efforts to prevent it, the surgeon must wait until the aqueous humor has reaccumulated, and then make an incision three or four millimeters in length at the lower portion of the periphery of the cornea, in the hope that the foreign body will be washed out during the flow of the liquid. Puncture of the Cornea. — This may be made with a broad needle or a well-worn Beer's knife. It is advisable to employ anaesthesia, and to steady the eyeball with fixa- tion forceps. The surgeon stands behind the patient, raises the upper lid, and fixes it against the margin of the orbit with two ringers of his left hand, which also rest against the inner side of the eyeball and prevent it from rotating inward. The needle or knife is then entered a little in front of the edge of the cornea at the outer side. Its direction must be sufficiently oblique to avoid injury to the iris, and not so much so that the instrument will remain between the layers of the cornea and fail to pene- trate to the anterior chamber. By partly withdrawing the instrument and twisting it slightly, the incision is made to gape and allow the escape of the liquid ; or a fine blunt probe may be passed into the incision after entire withdrawal of the needle. Subsequent tappings are ef- fected by reopening the original wound with the probe. Figure 157 represents a combined needle and probe. The needle is provided with a shoulder to prevent its introduction to too great a depth. Evisceration of the Globe for Staphyloma. — The sclerotic is incised with a Beer's knife just in front of the insertion of the external rectus ; into the opening is passed one blade of a pair of small blunt-pointed scissors, and the 302 SPECIAL OPERATIONS. anterior portion of the globe is cut away, with the lens and all the vitreous humor. The wound is then closed with catgut sutures passed through the conjunctiva alone. THE IRIS. Iridotoray. — Incision of the iris may be performed for the purpose of establishing an artificial pupil. As its suc- cess depends upon the retraction of the divided fibers, it should be undertaken only when their contractility is not interfered with by too extensive adhesions or has not been destroyed by disease. The more common lesions to which the operation is applicable are central opacity of the cornea, occlusion of the pupil, and excessive prolapse of the iris after removal of a cataract; but the danger of in- jury to the lens is so great that the operation is practically restricted to the class of eases last mentioned. The best place for an artificial pupil is in the lower inner quarter of the iris, the second best in the lower outer quarter. As the portion of the cornea traversed by the knife or needle is likely to become more or less opaque in consequence, the incision in it should be made as far as possible from the point where the pupil is to be created. Simple Incision. — Cheselden, who was the first to per- form this operation, entered a narrow-bladed knife through the sclerotic just anterior to the insertion of the external rectus, the point directed toward the center of the globe of the eye. After the point had penetrated to the depth of one-eight li of an inch it was directed forward, passed through the iris to the anterior chamber and transversely across the latter, its edge looking backward. By pressing the c(\>j;c against the iris and withdrawing it a horizontal incision was made in that membrane. Bowman punctured the cornea midway between its center and external border, passed a narrow Uunt-pointed knife through the puncture into the anterior chamber, and thence through the pupil to the posterior surface of the inner half of the iris, which he then divided by cutting forward, fhe danger of injury to the cornea during the last step of the operation is very great. THE litis. 303 Bell 1 uses a double-edged needle which is "introduced through the cornea near its margin ; on arriving at the place where the pupil ought to he, one edge is drawn against the iris and divides it transversely, if possible, without injuring the lens." Wecker proposes simple iridotomy and double iridotomy ; the former in cases of central opacity of the cornea or lens, the latter when the pupil has become obliterated after re- moval of a cataract, lie uses a small lance-shaped knife with a shoulder, straight or bent upon the fiat, and n pair of forceps-scissors. Simple Iridotomy. (Wecker.) — The knife is entered mid- way between the center and border of the cornea on the side opposite to that on which the pupil is to be made. As soon as the cornea has been perforated the knife is withdrawn and the forceps-scissors passed through the wound to the further border of the pupil, where they are opened and one of the blades passed behind, the other in front of, the iris. By closing them sharply the circular fibers are divided from the margin of the pupil toward the periphery of the iris. The scissors are then withdrawn, the iris replaced if it engages in the wound, a few drops of a solution of atropine placed between the eyelids, and a compress applied. Double Iridotomy. (Wecker.) — The knife is passed perpendicularly through the cornea and iris one millimeter from the . 162. 31 » 1 S / 7.7 7.1 L OPERA TIOSS. employee] for the purpose of creating an artificial pupil (optical iridectomy), or for the relief of tension in glaucoma or irido-choroiditis (antiphlogistic iridectomy), or as a pre- liminary to the removal of a cataract. The size of the portion excised is determined by the length and position of the line of the incision on the posterior surface of the cornea ; the nearer this is to the margin of the cornea the larger will be the portion of the iris removed. In anti- phlogistic iridectomy, therefore, when the entire breadth of the iris from the pupil to its outer margin should be re- moved, the knife must be entered one millimeter outside of the clear portion of the cornea; in optical iridectomy, on the other hand, the excised portion should be small and the knife should be entered within the margin of the cor- nea. In antiphlogistic iridectomy at least one-fourth of the iris should be removed, the piece being taken from the upper segment in order that the loss may be hidden by the upper eyelid. In optical iridectomy the pupil should be made on the inner side of the lower segment unless corneal opacities are in the way. Fig. 141. Fig. U± Iridectomy knives. Operation for Antiphlogistic Iridectomy. — The instru- ments required are a lance-shaped knife, straighl (Fig. THE IRIS. 305 141) or bent (Fig. 142), iridectomy forceps (Figs. 143 and 144), and scissors curved upon the flat (Fig. 145). Fig. L43. Fig. 1 n. Iridectomy forceps and scissors [ridectomy. [ncision of cornea. Fig. 14.">. The patient having been anaesthetized and placed in a recumbent posture, the surgeon takes such a position in •20 306 SPECIAL OPERATIONS. front of or behind him as will facilitate the making of the first incision. The eye-speculum and fixation forceps having been applied, the latter immediately opposite the point of puncture, the knife is introduced perpendicularly to the surface of the sclerotic one millimeter outside of the margin of the cornea and passed steadily in until its point has entered the anterior chamber at its very rim ; its direction is then changed and it is carried along the anterior surface of the iris until its point reaches the cen- ter of the pupil, or until the length of the incision is con- sidered sufficient (Fig. 146). By inclining the point of the knife to each side, the length of the incision in the posterior surface of the cornea may be made equal to that of the anterior surface. The knife is then withdrawn and the aqueous humor allowed to run off very slowly in order that the relief of intra-ocular pressure may not be so sudden as to lead to congestion and hemorrhage. If the iris does not now present in the wound the iri- dectomy forceps must he introduced closed as far as to the margin of the pupil, which is then seized and drawn out gently through the incision. An assistant then cuts off with the curved scissors all the protruding portion of Fig. 148. T\ rrell's I i<. I ridcetomr, Excision of tin- in the iris close to the lips of the wound | Fig. 117). Or the fixation forceps may be confided to the assistant before the introducti »f the iridectomy forceps, and the sur- TEE IRIS. 307 geon left free to use the scissors himself. Instead of the iridectomy forceps, Tyrrell's hook (Fig. 148) may be used to draw the iris out through the incision. It must be introduced upon its side, hooked around the margin of the pupil, and then its point must be turned toward the cornea and away from the center of the eyeball so that it will not catch upon the posterior edge of the incision during its withdrawal. If any hemorrhage takes place into the anterior cham- ber the escape of blood before coagulation should be favored by separating the lips of the incision with a curette, and making gentle pressure upon the eyeball. The edges of the iris must be carefully replaced with a spatula and not left included in the corneal wound. Iridesis, or displacement of the pupil by ligature. Crit- chett, 1 the inventor of this operation, claims that by it the size, form, and direction of the pupil can be regulated to a nicety, and its mobility preserved. It is applicable to numerous groups of eases in which the natural pupil, or even a part thereof, is movable, and has a free edge; but the simplest class is that of central opacity of the cornea, in which it is only required that the natural pupil should be moved slightly to one side, so as to bring it opposite the transparent part of the cornea. It has also been used in cases of conical cornea, to change the shape of the pupil to that of a slit ; and in a case where the pupil had been rendered very small and narrow by broad synechia?, Critchett made it large and almost circular by drawing its sides apart at nearly opposite points. The operation is performed as follows : An opening is made with a broad needle through the margin of the cornea close to the sclerotic, and just large enough to admit the canula forceps. A small portion of the iris near lint not close to its ciliary attachment is seized and drawn out to the extent considered sufficient for the proposed enlargement of the pupil ; a piece of fine floss silk, previously tied in a small loop round the canula for- ceps, is slipped down, and carefully tightened around the 'Ophthalmic Hospital Reports, Vol. I., p. -J'Jo. 308 SPECIAL OPERATIONS. portion of iris made to prolapse, so as to include and strangulate it (Fig. 149). This manoeuvre is best accom- plished by holding each end of the silk with a pair of small broad-bladed forceps, bringing them exactly to the Fig. 149. [ridesis. spot where the knot is to be tied, and then drawing it moderately tight. The small portion of the iris included in the ligature speedily shrinks, leaving the little loop of silk, which may be removed on the second day. If it is desired to make the pupil extend to the periphery of the iris, the margin of the pupil must be seized with the forceps and drawn out through the in- cision. In this case Soelberg Wells prefers a blunt hook- to the canula forceps. Corelysis, or rupture of adhesions uniting the margin of the pupil and the lens. The operation was first performed by Streatfeild, as follows:' He punctured the cornea with a broad needle on the outer side near its margin, Fig. 150. -in atfeild'i Bpatula I k. passed his Bpatula (Fig. 1 50) along the anterior surface of the iris to the pupil, engaged the adhesions in the notch '< Ophthalmic Hospital Reports, Vol. I., i>. 6. OPERATIONS POR CATARACT. 309 on the edge of the spatula, and tore them. When the en- tire margin of the pupil was adherent, he passed the ueedle along the surface of the iris, across the pupil to its opposite margin, and cut the adhesions at that point. Then withdrawing the knife, he passed the spatula through the hole thus made, and easily broke up the remaining ad- hesions. When the adhesions were too strong- to be broken with the spatula, he used the eanula scissors. A few drops of a solution of atropine should be applied to the eye, both before and after the operation. OPERATIONS UNDERTAKEN FOR THE RELIEF OF CATARACT. A cataract is an opacity of the crystalline lens, or of its capsule, or of both : the former being the much more com- mon variety. It may be hard, soft, or semiliquid, and its condition, in this respect, has an important bearing upon the choiee of a method of operation. The lens is com- posed of a solid nucleus and a soft cortex ; the whole lying- free within the capsule which is itself attached to the vitre- ous humor. In eonsequence of the absence of adhesions behveen the lens and the capsule, moderate pressure is sufficient to force out the former after the latter has been divided. In operating upon a cataract, the patient should be re- cumbent : cocaine anaesthesia is sufficient except with young children or unruly patients, when ether may be necessary. The other eye should be covered with a band- age, unless its sight is entirely lost ; and an eye-speculum may be used to keep the lids apart, if the services of a trained assistant cannot be had. The objection to a spec- ulum is that it is somewhat in the way of the knife, can- not be removed promptly enough, and is apt to make dangerous pressure upon the eye. If used, the screw of the instrument should be loosened as soon as the incision has been made. A few drops of a solution of atropine should be placed under the lids a short time before the operation. 310 SPECIAL OPERATIONS. The methods of operation may be classified as: Depression or couching; Division, discission, or solution ; Extraction ; Operation for secondary cataract. Depression or couching, which was the original and, for many years, the only method of removing cataract, is now universally abandoned, on account of the danger that the displaced lens may set up inflammation of the eye by con- tact with the other parts, especially the iris and ciliary processes, and thus cause total loss of sight. Soelberg Wells states that about fifty per cent, of the eyes thus operated upon have been lost by chronic irido-choroiditis. The operation will be described, how- F IG - 151. ever, for the sake of reference. If the puncture is made in the sclerotic, the operation is called scleronyxis; if in the cornea, keratonyxis. Scleronyxis. — A curved couching needle (Fig. 151), its convexity turned upward, is passed through the sclerotic on the temporal side about four milli- h Y Fig. 15 < Imiching needl I tepreflsing cataract. meters Prom the margin of the cornea, and three millime- ters below the horizontal diameter of the eye. Its con- vexity i< then turned forward, and the needle carried be- hind and parallel to the iris across to the upper and inner OPERATIONS FOB CATARACT. 311 margin of the pupil (Fig. 152), when the handle i> lightlj tilted upward, and the lens slowly depressed by the eon- cave surface of the needle. After holding it in place for a moment, the needle is slightly rotated to disentangle its point, and withdrawn. Some authors recommend that the anterior capsule should l>e formally divided horizontally or vertically before the lens is depressed. Keratonyxis. — The needle is passed through the cornea a little below its horizontal diameter, and midway be- tween its center and margin, and carried backward and inward, through the pupil to the lens, which is then de- pressed as before. In the variety of depression called redinaMorif the upper edge of the lens is rotated backward about its transverse axis at the same time that it is depressed, so that its anterior becomes its superior surface. Division, Discission or Solution. — The object of this op- eration is to tear open the anterior capsule with a fine needle, and bv thus bringing the aqueous humor into con- tact with the lens to promote the gradual softening and absorption of the latter. The selection of the term dis- cission was made in consequence of an erroneous impres- sion, that the more completely the lens was broken up at first the more rapidly would the work of absorption go on, and surgeons, therefore, tried to cut the whole lens into fragments. Experience has since shown that in most cases the absorption must be gradual and the oper- ation frequently repeated, only a small amount of the substance of the lens being allowed to come into contact with the aqueous humor on each occasion. If the lens is all broken up at once, the numerous fragments swell and act as foreign bodies in the aqueous humor and set up in- flammation in the iris and cornea, with immediate arrest of the process of absorption. This operation is more es- pecially indicated in the cortical cataract of children and of young persons up to the age of twenty or twenty-five years, also in those forms of lamellar cataract in which the opacity is too extensive to allow of much benefit being 312 SPECIAL OPERATIONS. A Fig. 154. Bowman's fine - 1 « 1 1 j needle, derived from an artificial pupil. After the age of thirty- five or forty absorption is much slower and the iris much more irritable. There are two methods ol' performing the operation ; in one the needle is passed through the cornea, in the other through the sclerotic. Division Through the Cornea. — The pupil is widely dilated with atropine, the eyelids drawn apart by an assistant, or fixed with the eye-speculum, and a fold of conjunctiva on the inner side of the eye seized with the fixation forceps. A fine spear-shaped needle with a shoulder (Fig. 153) is passed through the outer lower quadrant of the cornea, almost per- pendicularly to its surface at a point well within the dilated pupil, so that the iris shall not be touched by the needle. One or more incisions, according to the effect desired, are then made in the anterior capsule of the ^ Ki - ]:,:: - lens, the needle withdrawn, A and a compressive bandage applied. The operation may be repeated as soon as all redness and irritability of the eye have disappeared. Division Through the Scler- otic. (Hays. 1 ) — The patient having been prepared as be- fore, the knife-needle (Fig. I 54), with its cutting edge upward, is passed through the sclerotic at a point on its transverse diameter three or four millimeters from the temporal margin of the cornea, and perpendicularly to the surface of the eyeball. Its direction is then changed and ite point carried between the iris and lens to the opposite 1 American Journal of Medical Sciences, July, L855, \>. 81. II iv. b kcifi-needl: OPERATIONS FOR CATARACT. 313 margin of the pupil. If it encounters :in")) or von Graefe's (Fig. L59) knife, fixation forceps, Graefe's cystotome and curette (Fig. 156) and a small blunt-pointed knife or pair of scissors for enlarging the wound, if neces- sary. The section may he made in the upper or lower half of the cornea ; the former is rather the more advantageous, the latter the easier of execution. Operation. ( Right eye, upper section.) First Stage. — Patient recumbent, the op- erator seated behind him. The eyelids are separated by an assistant standing; at the pa- tient's left side, and drawing the lids gently apart with the forefinger of each hand, with- out making any pressure upon the eye. The surgeon steadies the eyeball by pinching up a fold of conjunctiva, with fixation forceps, either just below the cornea, :is in Fig. 1~>7, or better, perhaps, just below its prolonged horizontal diameter on the inner side, and draws the eyeball gently down. lie then enters the point of the knife at the outer side of the cornea half ;i millimeter within its margin, and just on its transverse diameter, and carries it steadily across the anterior chamber, taking care to keep the Bide of the blade parallel to the iris, and to press slightly downward with it- back BO that it may always fill the in- cision completely and prevent the escape of the aqueous Von Graefe's cystol e and curette. OPERATIONS FOR CATARACT. 315 humor. The couiiterpuncture is made by the steady ad- vance of the knife at a point immediately opposite that <>l entry, the fixation forceps removed, and the knife pushed on in the same direction until the section is all but finished ; when only a small bridge of cornea remains undivided at Fig. 1">: Flap extraction of cataract. Mode of fixing the eye ami making the incision. its upper border, the edge of the knife is inclined slightly forward, and the section completed by withdrawing the knife. Close the eyelids for a moment before beginning the second stage. Second Stage. — The anterior capsule is next divided by introducing the cystotome through the incision while the patient looks downward, and drawing its point gently across that membrane. Care must be taken not to dis- place the lens by pressing the point too forcibly against it. Close the eyelids again for a moment. Third Stage. — The patient is again directed to look downward, and steady gentle pressure is made upon the eye with the forefinger or curette placed upon the lower lid (Fig. 158). This pressure should first be directed backward so as to tip the upper edge of the lens forward, and then upward and backward so as to force the lens through the dilated pupil into the anterior chamber and 316 SPECIAL 0PEUAT10NS. out through the incision. Ft should be gentle and very steady so as to avoid rupture of the posterior capsule and escape of the vitreous humor. Any portions of the cortical substance of the lens which may have been left behind in the capsule, or stripped off during the passage of the lens through the pupil and the incision, must then he removed, and the eye closed. Such was the operation employed for extraction of the ordinary, hard, senile cataract. The objections to it, as before mentioned, were the great size of the flap, the possi- ble prolapse of the iris during the after-treatment, and the Fig. 158. Flap extraction of cataract. Removal of the lens by pressure. risk of iritis excited by the bruising of the iris during the passage of the lens through the pupil. Yon Graefe was the first to suggest that this last risk would be diminished by the excision of a portion of the iris, iridectomy, and on putting the suggestion into practice he found that it also enabled him to remove the cataract safely through a much smaller incision. According to Mr. •Carter, 1 Von Graefe worked very sedulously during several years to exclude, one by one, the chief sources of the dangers by which extraction was beset, and he arrived at last at the 1 Holmes' b Surgery, its Principles and Practice, p. 724. OPERATIONS FOR CATARAC1. 317 Fig. lo<». Fig. 16(>. s-A Vol) Graefe's cataract knife. point of losing only four eyes out of one hun- dred operations. A few improvements in detail have been added since his death, but so far as principles and broad outlines arc concerned he had covered the ground. In view of the shortness of the incision, which occupies not more than one-quarter of the periphery of the cornea, the operation is generally spoken of as a " modified linear extraction" ; but the curved outline of the incision, and the fact that the lens is removed entire, cer- tainly bring it within the class of flap extractions. Von Graefe's Method. Modified Linear, or Modi- fied Flap Extraction. — The instruments required, be- sides the eye-speculum and fixation forceps, are a long, thin, narrow knife (Fig. 159), the blade of which is thirty millimeters long and two milli- meters wide, iridectomy for- ceps (Fig. 1 60), scissors, a cystotome (Fig. 156), and a small hard-rubber or tortoise- shell curette. The patient is etherized and recumbent ; the surgeon stands or sits behind him, holding the knife in his right hand for the right eye, in the left hand for the left eye. The eyeball is secured with the fixation for- ceps, and the point of the knife is entered in the sclerotic with its edge upward, one millimeter from the upper and outer mar- lridectoinv forceps. 318 SPECL \ L PER A TIONS. gin of the cornea, and two millimeters below a tangent to its circle drawn at the upper end of its vertical diameter (Fig. 161, A). The point of the knife is at first directed toward the center of the eyeball, but as soon as it has pen- etrated to the anterior chamber it is turned so as to pass parallel to and along the anterior surface of the iris down- ward and inward about seven millimeters to a point cor- responding to B in Fig. 161. The handle is then de- pressed, turning on the back of the blade in the incision, until the point is raised to the horizontal line of the punc- ture, when the handle must be inclined somewhat back- ward, and the point pushed sharply through the sclerotic Fig. 161. Fig. l()-_'. Iiiagrani u> illustrate the method >if making Von Graefe's incision. if Von Graefe's incision. and conjunctiva at C } Fig. 161. Great care must be taken not to make the counter-puncture too far back in the scler- otic, a mistake which may easily happen if the blade is carried too far downward and inward before it is turned up to make the counter-puncture. The edge is then directed forward, and the incision completed by steady advance and withdrawal of the knife. The incision is represented by the upper, undotted line in Fig. 1 62 ; its center should lie at the juncture of the cornea and sclerotic. The little bridge of conjunctiva which re- main.- at the center of the incision is then divided in such manner as to leave a conjunctival Hap two or three milli- meters l<»n^ adherent by its base to the cornea. If the cataract is large and hard, it may be advisable t<> use a broader knife, and make the points of puncture and counter-puncture one millimeter lower, so that it will not OPER. 1 TIONS FOR < '. 1 T- 1 II. 1 ' T. 319 be necessary to use a scoop or make much pressure on the eve to effect the removal of the lens. Many surgeons prefer t<> make the incision wholly in the cornea and close to it> edge, on the ground that the wound will heal more promptly and kindly, and be ac- companied by less risk of loss of the vitreous or of pro- lapse of the iris. The object of the iridectomy, which is the next step in the operation, is the neutralization of the circular fibers rather than the removal of a large portion of the iris, al- though some surgeons counsel the latter on account of the greater security it gives against subsequent inflammation. The iridectomy forceps are introduced closed and opened slightly when the point reaches the margin of the pupil. The margin rises between the branches, is seized, with- drawn gentlv, and cut off with scissors close to the for- ceps. If this is properly done the angles formed by the edges of the incision and the margin of the pupil will ap- 1 'iatriaiii nf the i Fig. 163. it and faultv sections of th pear in the anterior chamber as at A and B in Fig. 163. The portion of iris removed should extend quite to it- cil- iary insertion so that there may be none to engage in the external incision and prevent its primary union. The capsule is next freely divided by two successive lacerations made with the cystotome. Each should begin at the lower edge of the pupil and extend upward, one along the inner, the other along the outer side, to the upper border of the lens, where it has been exposed by the iridectomy. This upper border should also be torn to an extent corresponding to the external incision. This manoeuvre must be executed with great delicacy and light- 320 SPECIAL OPERATIONS. ness of touch, in order that the lens may not be displaced into the vitreous humor. The escape of the lens is aided by pressure upon the cor- nea with the curette. The fixation forceps are applied at the inner or outer side, and the curette placed upon the lower edge of the cornea and pressed slightly backward and upward so as to cause the upper edge of the lens to present in the section ; the pressure must then be made directly backward, in order that the lens may be rotated around its transverse axis and tilted well forward into the incision. The curette is then pushed slowly upward over the surface of the cornea so as to follow step by step the delivery of the lens. Any fragments scraped off during the passage may be removed by passing the curette again over the surface of the cornea. If the vitreous humor happens to be liquid it may escape as soon as the first incision is made. In such a case it is best to excise a portion of the iris and remove the lens in its capsule by passing a scoop behind it into the vitreous humor and lifting it out. Gayet and Knapp's Modification. — Instead of lacerating the capsule as above described these surgeons incise it with a knife-needle alono; the line of the corneal incision. This is followed in the great majority of cases by an unusually uneventful healing free from iritis and other complications, but leaves the pupillary area occupied by the capsule of the lens. In order to clear the pupil the capsule is subsequently (in the third week after the extraction, or later) split with the knife-needle, which permanently frees the pupil from both the anterior and posterior capsules. Linear Extraction. — Mr. Dixon suggests' recti- linear extraction as a more suitable name, because the in- cision in the cornea is a straight one, in contradistinction to that of a flap extraction which also forms a line, but a curved one. This operation is a modification of one in- vented by Gibson in 1811, which had fallen into entire disuse before its ^introduction by Von Graefe in 18. r >f). 1 Holmes's System of Surgery, Vol. IN-, p. 199. OPERATIONS FOR CATARACT. 321 It is designed for the removal of soft cataracts through a small corneal incision, especially the cortical cataract of individuals between ten and thirty years of age. It is also often employed with advantage as supplementary to the needle operation. It is performed as follows : A straight, vertical incision, from four to six milli- meters long, is made on the outer side of the cornea, about two millimeters within its margin, with a straight lance-shaped iridectomy knife, which is passed into the anterior chamber parallel to the surface of the iris. The capsule is then freely lacerated with the cystotome, and the escape of the soft lens facilitated by the introduction of a curette into the wound, and by making gentle pres- sure on the inner side of the eye with the finger. If por- Fig. 164. ) lflii. Critcfaett's scoop Bowman's scoops. tions of the cortex remain behind the iris they can be brought into the anterior chamber by closing the lids and making gentle pressure in circular lines upon them. If the iris protrudes, it must be gently replaced, or, if much bruised, excised. Scoop Extraction. — This is a modification of linear ex- traction, devised bv Waldau to obviate the dangers and difficulties occasioned by the presence in the lens of a hard nucleus of greater or less size. As the principal danger lies in the bruising of the iris, Yon Graefe met it by iri- dectomy, which afterward suggested to Waldau the idea of introducing a scoop and removing the lens without making any pressure upon the eyeball. The instruments required are a bent lance-shaped iri- dectomy knife ( Fig. 1 4 "2 ) , iridectomy forceps and scissors, 21 322 SPECIAL OPERATIONS. I ii rette and mouth- piece for removal of cataract by suet Ion, and a thin, flat, .slightly concave scoop. Waldau's scoop resembled a small spoon. Three different kinds are shown in Figs. 164, 165, 160. The eye-speculum and fixation forceps having been applied, an incision, eight or nine millimeters long, is made at the upper border of the cornea where it joins the sclerotic. The corresponding por- tion of the iris is removed, and the capsule freely torn with the cystotome, as before described. The scoop, with its convexity backward, is then introduced and carried carefully down behind the lens, until its extremity has passed the lower margin of the latter, and engaged it in its hook- like end. It is then withdrawn, care being taken not to press the lens against the iris and cornea. If a little of the vitreous humor escapes at the same time it must be snipped off and a compress ap- plied. It is better to remove any fragments of the lens that may be Left behind by gently rubbing the eyeball, rather than reintroducing the scoop. Removal by Suction. — Laugier suggested, in 1847, the removal of soft cataracts by aspiration through a hollow needle. Blan- chol modified the method by sub- atituting a small canula for the needle, and introducing it through an incision in the cornea, but the OPERATION* FOR CATARACT. 323 operation was not favorably received until after it had been again modified by T. Pridgin Teale, Jr., in 1863, who recommended it as a substitute for pressure in the re- moval of the harder portions of the cataract by linear ex- traction, and as supplementary to discission. The instru- ments required are a broad needle and a suction curette. The latter (Fig. 167) is described by Mr. Teale 1 as con- sisting' of three parts, a curette, handle, and suction tube. " The curette is of the size of the ordinary curette, but differs from it in being roofed in to within one line of its extremity, thus forming n tube flattened on its upper sur- face, and terminating, as it were, in a small cup. The anterior capsule is first ruptured with a fine needle passed through the cornea, and then an opening is made with a broad needle in the cornea through which the curette is passed to the center of the pupil. The soft matter is then withdrawn by suction. Soelberg Wells- says this operation has been employed at the Royal London Ophthalmic Hospital with great success, and that it is especially indicated in cases of soft cortical cataract. If the cataract is somewhat harder, it is well to break it up with the needle a few days before attempting to remove it. Removal of the Lens in its Capsule. — This operation is indicated when the capsule is opaque, and whenever the eye is exceptionally irritable, or has been chronically in- flamed, so that the accidental retention of any fragments of the lens would be a source of serious danger. When suc- cessful, this method gives very fine results, but its risks and dangers are so great that it is seldom employed. Originally introduced by Richter and Beer, it was revived by Sperino, Pagenstecher, and Wecker. The former em- ployed the ordinary flap operation without laceration of the capsule. Pagenstecher made a large Hap in the sclerotic together with iridectomy. Wecker's method was nearly identical, the Incision being made at the sclero- corneal junction. 'Ophthalmic Eospital Reports, Vol. IV., part '1, \>. 197. z On the Discuses oft lie Eye, p. 280. Philadelphia: II. C. Leu. 324 sri-X'IAL OPERATIONS. Pagenstecher's Method. — The patient having been thor- oughly anaesthetized, a large flap is made, usually down- ward, with a Beer's knife, a small bridge of conjunctiva being left temporarily at its apex. Iridectomy is then per- formed in the outer lower quadrant, and the conjunctival bridge divided with blunt-pointed scissors. Any pos- terior synechia) that may exist are torn through with a fine silver hook, and then the lens removed in its capsule by slight pressure upon the eyeball. If the hyaloid membrane should be ruptured and the vitreous escape, the lens must be removed with the aid of a small scoop passed in behind its lower edge. Secondary Cataract. — Secondary cataracts vary much in thickness and opacity. They may be produced by por- tions of the lens left behind and becoming entangled in the capsule, by the deposit of lymph upon the latter, or by the proliferation of the intracapsular cells. No oper- ation for secondary cataract should be performed, until, at least, three or four months after the removal of the primary cataract ; and if the pupil has become contracted, or if very extensive posterior synechia? have formed, a preliminary iridectomy should be made. Formerly the plan was to remove the opaque and thickened membrane entirely from the eye, but it has proved very much safer and equally efficacious to make a small opening in the membrane with a needle. Cocaine anaesthesia is necessary. The eye-speculum and fixation forceps having been applied, Bowman's fine needle (Fig. 1 5.*}) is passed through the cornea near its margin, and an effort made to tear a hole with it in the eciitcr of the membrane or at the part which is thinnest and least opaque. If the membrane yields before the needle, or if it is too tough to be torn, Mr. Bowman's device of a second needle must be employed. This is to be passed through tli< cornea on the side opposite to that occupied by the firsl needle, and then the operator, transfixing and steady- ing the membrane with one needle, tears it with the other. If :niv portion of the iris should happen to lie bruised or torn, it inii-t lie excised through ;i linear excision. 5THAS0T0MT. 325 Dr. Agnew passed a needle through the center of the membrane, thus steadying l><>th it and the eye. He then made a linear incision on the temporal side of the cornea through which he passed a small sharp-pointed hook, the point of which is passed into the same opening in the membrane as the needle. He next tore the membrane, rolled it up about the hook, and either drew it out alto- gether, or, if this could not be done, tore it widely open. OPERATION TO CORRECT STRABISMUS-STRA- BOTOMY. The tendon of the internal rectus is attached to the sclerotic at a distance of five millimeters from the border of the cornea, that of the external rectus at a distance of seven millimeters. Each tendon is seven or eight milli- meters broad and is contained in a firm sheath resembling a glove finger, a prolongation or depression of the capsule of Tenon at the point where it is traversed by the tendon about midway between the anterior margin of the orbit and the posterior pole of the eyeball. The capsule of Tenon is a reflection of the periosteum of the orbit from the anterior margin of the latter to the transverse meridian of the eyeball and thence backward to and along the optic nerve thus constituting the diaphragm which divides the orbit into an anterior and a posterior loge, the former of which contains the eyeball (received into a cup-like de- pression of the diaphragm), the latter the muscles and optic nerve. The capsule sends a prolongation, not only an- teriorly along the tendons, but also posteriorly along the muscles, and the union between the muscle and sheath is so firm that even after division of the tendon the muscle can move the eyeball by acting through the attachments of the capsule. If the body of the muscle itself is di- vided in the posterior loge, its influence upon the move- ments of the eyeball is entirely lost. This is the chief point to be borne in mind in performing strabotomy, the tendon must be divided, not the muscle, and the amount of deviation of the eye to be overcome is the measure of the extent to which the adjoining tissues must be divided. 326 SI 7.7 IA L OPERA TTOXS. The Operation for Division of the Internal Rectus will alone be described, that being the one commonly required. The special instruments required are : fine-toothed forceps (Fig. 168), blunt hook (Fig. 169), and blunt-pointed scissors, straight or curved on the fiat. A small but deep fold of conjunctiva and subconjunctival tissue is seized with the toothed forceps just above the lower extremity of the line of insertion of the tendon of the Fig. 168. Fig. 169. Strabotomy lmok. internal rectus, that is, two millimeters below a point on the equator of the eyeball five millimeters beyond the inner margin of the cornea, and divided with the scissors just below the forceps ; additional snips are made with scis- sors within this opening until the tendon or the sclerotic is exposed. The surgeon then passes the point of the stra- botomy hook, which should be somewhat bulbous, through the opening to the lower border of the tendon, and, keep- ing the point and side of the hook constantly upon the sclerotic, sweeps it at first backward, and then upward and forward around the insertion. When this manoeuvre is properly executed, the point of (lie hook can be seen un- der the conjunctiva above the upper border of the tendon, while it- course is hidden by the latter and prevented from being drawn forward to the margin of the cornea. I f the whole of the hook ean be seen under the conjunctiva, it i- imt under the tendon, and the sweep must he repeated. When the tendon has been secured, the conjunctiva may STRABOTOMY 327 be pressed hack over its point, and the tendon divided with scissors close to its insertion, beginning at its upper border; or, the conjunctiva being left in place, the scis- sors may he passed along the hook as a guide, one blade below the tendon, the other between it and the conjunc- tiva, and the tendon divided with repeated snips. After the tendon has heen completely cut through, the hook should he swept upward and downward to ascertain if the lateral expansions of the tendon have been divided, for the persistence of even a few of them might he sufficient to prevent the success of the operation. If it is feared that too great an effect has heen produced, a deep suture may be passed through the tendon and the Fig. 170. Fig. 171. B' Method of estimating the degree of squint. Double operation for strabismus. conjunctiva on the side toward the cornea so as to limit the amount of retraction. The accommodative movements of the eye should be tested immediately after the opera- tion, and if there is the slightest tendency to divergence when the object is six or eight inches distant from the eye a suture should be inserted. In the subconjunctival method the incision in the con- junctiva is made below the insertion of the tendon on a line with the lower border of the cornea, and the con- junctiva is not pressed away from the anterior surface of the tendon after the hook has been passed under the latter. 328 SPECIAL OPERATIONS. It' the squint exceeds five <»r six millimeters, as esti- mated by the method shown in Fig. 170, both eyes should !>c operated upon, hut at separate times, the insertion of tlie internal rectus being set back in each case. Thus, if the degree of squint represented in Fig. 171 were cor- rect ed by setting back the tendon of the internal rectus from (" to D, the muscle could only work at a great dis- advantage as compared with the internal rectus of the other side, and the result would be the appearance of di- vergent squint Avhenever the attempt was made to look at an object near the eye, because the muscles could not turn the eye far enough inward. The condition must there- fore be divided between the two eyes, the internal rectus on one side being set back to E, on the other side to E' . Secondary Strabismus following Tenotomy of the op- ponent is treated by advancing the insertion of the tendon of the latter ( Prorrhaphy). Thus, supposing divergent squint to have followed division of the internal rectus, an incision half an inch long is made in the conjunctiva in the line of the horizontal diameter of the cornea, and the conjunctiva and subconjunctival tissue dissected up as far back as to the caruncle. A hook is then passed around the insertion of the internal rectus, and the tendon di- vided as before ; a suture is passed through it, and it is drawn toward, and fastened t<», the strip of conjunctiva adjoining the inner border of the cornea. The tendon of the external rectus must then be divided according: to the rules laid down for division of the internal rectus, re- membering that its attachment to the sclerotic is distant seven millimeters from the edge of the cornea. ENUCLEATION OF THE EYEBALL. Afl the globe of the eye lies somewhat nearer the inner thai! the outer side of the orbit, it will be found easier to approach it from the latter quarter. Tillaux ' divides the conjunctiva and subconjunctival fascia with curved scis- sors along the attachment of the external rectus, divides ' Anatomie Topographique, p. 190. OPERATIONS UPON LACH&YMAL APPA&ATUS. 329 the tendon of thai muscle, carries the scissors backward through the incision, their concavity turned toward the globe, and cuts the optic nerve close to the eyeball. Me then seizes the posterior pole of the globe with pronged forceps, draws it out through the conjunctival incision, and divides the remaining conjunctival attachments and tendons close to the sclerotic. Other surgeons prefer to seek and divide each tendon in turn before cutting the optic nerve. Extirpation of the Entire Contents of the Orbit. — In order to gain additional room, it is well first to divide the external commissure of the lids. A bistoury is then entered at the inner angle, carried well back toward the apex of the orbit, and swept along the floor to the outer angle, then reintroduced at the inner angle, and car- ried along the roof of the orbit to the outer angle. The muscles and optic nerve, which still remain attached to the eye and apex of the orbit, are finally divided with curved scissors introduced from the outer side. Hemorrhage should be arrested by packing the cavity with antiseptic gauze. OPERATIONS UPON THE LACHRYMAL APPARATUS. Extirpation of the Lachrymal Gland (Fig. 172). — The principal portion of the lachrymal gland lies just behind the junction of the upper and outer margins of the orbit, enveloped in a fibrous capsule formed by a reflection of the periosteum or capsule of Tenon. The " accessory " portion, together with the ducts, occupies the adjoining eyelid, and is composed of isolated granulations of granu- lar tissue, which, if left behind after removal of the main portion, may continue to secrete tears and discharge them into the wound, thus causing abscesses and fistuhe. Tillaux ' has pointed out that the existence of the fibrous capsule renders it possible to enucleate the gland without opening the posterior loge of the orbit, a defect in the older methods which included division of the external commis- 1 Anatomie Topographique, p. 237. 330 SPECIAL OPERATIONS. sure. Make an incision one inch in length along the upper and outer portion of the bony margin of the orbit. Carry this incision through all the soft parts, including the peri- osteum, down to the bone; separate the periosteum from the bone at the under side of the incision, and depress it. The gland can then be distinctly seen through the thin layer of periosteum which separates it from the roof of the orbit, and can be removed with great ease after the latter has been torn through. Lachrymal Sac, Duct, and Canaliculi. — The lower cana- liculus passes downward from the punctum for two milli- meters, then turns at a right angle, and passes horizon- Extirpation of the lachrymal eland, x skin. /'. Periosteum. B. Frontal bone. <.. Lachrymal gland. /'. Capsule of Tenon. /.'. Reflected periosteum forming the capsule or the gland. /■:. Eyeball. O. Conjunctiva. /.. Eyelid. /. incision. tally inward to the lachrymal sac, a distance of about five millimeters; the upper canaliculus passes at first upward for two millimeters, and then downward and inward to the sac. This sharp turn in the course of the canalic- ulus, which is an obstacle to catheterization, can be tem- porarily removed by drawing the border of the lid out- ward. The lachrymal sac lies just behind the tendooculi, and receives the canaliculi by a common duel two or three millimeters below it- upper extremity, their relations thus resembling those of the ileum and caecum, a resemblance OPERATHi.xs UPOH LACHRYMAL APPARATUS. 333 which is increased by the presence of a valve at the opening of the duct into the sac. This valve, described by Huschka, is thought to prevent the reflux of the contents of the sac into the canaliculi. The direction of the sat' is downward and backward at an angle of 45°; it occupies the lachrymal groove, which is hounded anteriorly by a ridge on the nasal pro- cess of the superior maxillary bone at the inner angle of the Fig. 17:*. orbit, and is crossed by the tendo oculi just at the junction of its upper and middle thirds. The nasal duct is the direct continuation of the sac and passes downward, backward, and outward ; the combined length of the duct and sac is about one inch. Tt may become necessary to slit a j> tlir canaliculus in order to correct a malposition of the punctum, or to facilitate cathe- terization of the sac and nasal duct. This little operation is best performed as followsf right eye. lower lid) : The surgeon stands behind the patient, who is recumbent, and introduces a tine grooved director) Fig. 1 73) vertically through the punc- tum for a distance of two milli- meters. Then drawing the border of the lid outward and somewhat downward with the forefinger of his left hand, he passes the director horizontally, with its groove upward, along the canaliculus to the inner Fig. 174. Sharp-pointed canaliculus di- rector, Bowman's probe- pointed canaliculus knife. 332 SPECIAL OPERATIONS. side of the sac. Then, shifting the director to the left hand, he engages a sharp-pointed knife in the groove, and slits up the canaliculus throughout its entire length. Bowman's probe-pointed canaliculus knife (Fig. 174) may be substituted for the director and knife. It should be very narrow, and its probe point very small. When one pnnctum has been entirely obliterated, a plan suggested by Mr. Streatfeild may be employed. He di- vides the other canaliculus, passes a fine director, suita- bly bent, through the wound into the obliterated canalic- ulus and cuts down upon it. If the divided lower canaliculus remains everted, Mr. Fig. 17;'). Puncture of tlio lachrymal sac Critchett advises that the posterior lip of the incision be cut off with scissors, ''effecting the treble object of draw- ing the canal further inward, of forming a reservoir into which the tears may run, and of preventing reunion of the parts." Puncture of the Sac. (Fig. 175.) — The three guides are the tendooculi,the anterior margin of the lachrymal groove, and the direction of the sac. While an assistant draws the external commissure outward, so as to make the tendo oculi tense and plainly visible, the surgeon places his left forefinger upon the inner and lower margin of the orbit, BO a- to have the bony edge between the nail and the pulp OPERA TIONS UPON L. 1 ( 'Hi: YMA L 1 PP. 1 /,'. 1 77 x 333 of the finger, and holding the knife in the direction of the canal, that is, nearly parallel to the median plane, and at an angle of 45° with the horizon, he passes it along his finger-nail into the sac just below the tendon. [t is important to mark the position of the anterior mar- gin of the canal so as to avoid the not infrequent mistake of passing the knife entirely outside of the orbit between the soft parts of the face and the bone. CHAPTER II. OPERATIONS UPON THE EAR AND ITS APPENDAGES. OCCLUSION OF EXTERNAL AUDITORY CANAL. CONGENITAL occlusion of the external meatus is usu- ally associated with the absence of defective development of the other portions of the auditory apparatus. Before operating upon such an occlusion, therefore, the hearing power should be tested, and the permeability or imper- meability of the bony portion of the canal determined by puncture with a needle. If the occlusion consists of a simple membranous dia- phragm it should be divided crucially, and the flaps ex- cised. For deeper and more extensive obstructions cau- terization with nitrate of silver is to he preferred. INTRODUCTION OF SPECULUM. The upper portion of the auricle is grasped between the ring and middle fingers of the left hand and drawn gently upward and backward. Into the canal thus straightened the speculum is introduced with the right hand, and then held in place with the thumb and forefinger of the left, the hand being steadied by resting its ulnar border against the patient's head. Complete control of the speculum is thus obtained, and it can be easily moved about so as to bring every part of the tympanum and canal into view. Light should be thrown into it from a concave mirror perforated in the center and having a local distance of -i\ inches. PARACENTESIS OF THE MEMBRANA TYMPANI. This should be performed while the head of the patient i- well supported and a good light is thrown upon the i 'ATHETERIZA TION OF EUSTAt 11IAX TUBE. 335 membrane by a mirror attached to a forehead band. A cataract needle is the instrument usually employed, and the opening should be made in the posterior inferior quad- rant of the membrane. Tillaux ' calls attention to the fact that all the impor- tant elements of the membrane occupy its upper half, and that an incision or rupture near the handle of the hammer may give rise to troublesome and even dangerous hemor- rhage. The lower half i- less vascular and less sensitive. If it is desired to maintain the opening for several days, a crucial incision may lie made, or a triangular flap excised, but, as a rule, even these incisions heal very quickly. CATHETERIZATION OF THE EUSTACHIAN TUBE. The Eustachian tube is from one and a-half to two inches long, its course is from the pharynx upward, backward, and outward. Its pharyngeal orifice is oval and well- marked except on the lower border, and is situated just above the base of the soft palate. Behind the orifice, between it and the posterior wall of the pharynx, is a de- pression (Rosenmuller's fossette) in which the beak of the catheter, if carried too far back, may lodge and give the same sensation to the surgeon's hand as if it were engaged in the tube. Of the two mistakes most frequently made in performing catheterization, one is to pass the beak of the instrument between the middle and inferior turbinated bones instead of along the floor of the nasal fossa, and the other is to mistake Rosenmuller's fossette for the orifice. According to Roosa, the first mistake is best avoided by drawing down the patient's upper lip with the left hand, and entering the catheter while it is held in an almost vertical position, its concavity directed toward the median line. After the beak has fairly entered the meatus the stem of the catheter is gradually raised to the horizontal position and passed backward, its beak resting on the floor of the meatus close to the septum, its convexity upward. Tillaux 2 gives the following directions for finding the 'Anatomie Topographique, p. 111. 2 Ibid., p. 14n. 336 OPERATIONS UPON THE EAB. orifice : 1st. Carry the catheter directly backward, its concavity downward, until it touches the posterior wall of the pharynx. 2d. Withdraw it until the beak rests again upon the hard palate. 3d. Carry the catheter again very gently backward, and feel with its beak for the posterior border of the palatine aponeurosis, the firm fibrous con- tinuation of the palatal bone. This aponeurosis feels as hard as bone, and its posterior border can be easily recog- nized by the softness of the adjoining tissues. 4th. Rotate the beak of the catheter outward and upward, and it will enter the Eustachian tube. OPENING OF THE MASTOID ANTRUM. 1 The incision begins just above the apex of the mastoid process and is carried upward one and one-half inches parallel to the attachment of the ear, and about one-half an inch behind it. Everything is divided down to the bone, the periosteum elevated, and the posterior margin of the meatus recognized. A one-quarter-inch drill is driven straight inward at such a point that the hole it makes shall lie as near as possible to the back of the bony meatus and its upper border be not more than one-twelfth of an inch above the level of the upper margin of the meatus. It must not penetrate deeper than three-quarters of an inch or the external semicircular canal will be damaged. Deep perforations back of* a line one-quarter of an inch behind the posterior margin of the meatus are liable to wound the lateral sinus. The antrum, which is about the size of a pen, is usually reached at a depth of three-fifths of an inch. Or, preferably, the gouge is used and the antrum sought at the point above indicated by freely cutting away the bone behind the meatus including the posterior wall of the latter a- far a- to the middle ear. 1 Birmingham. Dub. .lour. Med Sci., 1891, p. 116. CHAPTER III. OPERATIONS UPON THE MOUTH AND PHARYNX. EXCISION OF THE TONSILS (AMYGDALOTOMY). The tonsils may be excised with a knife and volsella, or with a specially contrived instrument, the tonsilotome or guillotine. Anaesthesia is not required. If the patient is young or nervous it is well to put a large piece of cork between the jaws on each side to prevent the mouth from being closed. The tonsilotome (Fig. 176) is composed of two rings and a fork mounted upon stems so arranged that they can be Fig. 176. G.T/e/WA/V/V &. CO. Tonsilotome. worked with the thumb and fingers of one hand. The two rings slide flatwise upon each other, and the inner edge of one is sharp, so that when drawn across the other it divides anything lying within it. The fork is thrust forward across the ring and drawn away vertically from it by the same movement which draws one ring across the other. The rings having been placed over the tonsil, the hook is driven into the latter by a quick movement of the thumb and finger and draws it further into the ring, hold- ing it tense as the other blade cuts across its base. The pain is very slight. If the tonsilotome cannot be used the tonsil must be seized with pronged forceps, and excised between them 22 337 338 OPERATIONS UPON MOUTH AND PHARYNX. and the pillars with a probe-pointed knife, the posterior portion of the blade being guarded with diachylon plaster so as to avoid injury to the tongue. STAPHYLORRHAPHY. At the conclusion of his historical account of this operation Verneuil ' states that it has been invented four different times. The earliest record of the operation is found in a French book published in 1766, 2 in which it is said that a dentist, named Lemonnier, closed a fissure of both hard and soft palates by freshening its edges with a knife and bringing them together with sutures. He also closed perforations of the hard palate by exciting suppuration of their borders. In 1791) Eustache, a physician of Beziers, proposed to reunite by sutures the edges of an incision which he had made the day before in the soft palate of a patient for the purpose of removing a pharyngeal polyp. The patient refused the operation. Four years later, in 1803, Eus- tache sent to the Academic Royale de Chirurgie at Paris a remarkable paper upon congenital fissures in the soft palate, and asked the Society's approval of the operation by which he proposed to close them. The approval was withheld, and there is no record of any further steps hav- ing Ween taken. In December, 1816, Yon (iraefe said, before the Med- ico-Chirurgica] Society of Berlin, that, after many unsuc- cessful attempts to close fissures of the soft palate, he had at last succeeded by drawing the edges together with suture.- after freshening them by applying muriatic acid and the tincture of cantharides. This remark was re- ported in the proceedings of the Society in Hufdand's Jmu-nal, January, 1817. Between 1816 and L 820 Von Graefe repeated the operation three times, each time without success. In L819, Etoux, apparently in entire ignorance of Von Graefe'fi attempt, closed a fissure by paring the edges and 'Chirurgie Re*paratrice, 1*77. An. Staphylorrhapie. • : Tr:iii<' Ilea Principalis objetsde MeMecine, par Robert. STAPHYLORRHAPHY 330 applying; sutures. The case at once became very widely known, and had much influence in popularizing the operation. AVhen the extent of the lesion which staphylorrhaphy is designed to repair is considered, the operation seems to be very simple. It is only necessary to freshen the edges of the gap and draw them together with sutures. Prac- tically, however, the operation is a difficult one ; the parts lie at a considerable distance from the surface, the Fig. 177. Whitehead's modification of Smith's gag. manipulations are constantly interfered with by involun- tary movements of deglutition, the flow of blood increases the obscurity, and the practical difficulties in the way of placing the sutures are great. Finally, unless some of the muscles of the palate arc divided, the tension exerted by them upon the sutures is sufficient to prevent union. A great variety of methods have been suggested to over- come these difficulties. Mr. T. Smith diminished the first by the invention of a gag (Fig. 177), designed to hold the jaws apart during the operation. Van Buren avoided 340 OPERATIONS UPON MOUTH AND PHARYNX. the passage of blood into the trachea during the employ- ment of anaesthesia by placing the patient so that the head should hang down over the end of the table, and the blood escape through the nose. The same device was afterward employed by Trelat. Sir William Fergusson relieved the tension by dividing the levator palati on each side. He did this by passing a knife, bent at a right angle, through the cleft and dividing the muscle from behind forward, without touching the mucous membrane on the anterior face of the palate. The incision should be perpendicular to the center of a line joining the hamular process and the orifice of the Eusta- chian tube. The former can be readily felt just behind Hi. 180. Incisions. the last upper molar tooth, the latter can usually be seen through the deft in the palate. He also recommended division of the palato-pharyngeus muscle. S.'dillot ' divided the muscle from before backward. He drew the velum downward and inward with pronged forceps, and made an incision downward and outward about one centimeter above and on the outer side of the base of the uvula, and just behind and on the inner side of the last upper molar, crossing the Levator palati at right angles (Fig. 17!»). A length of one centimeter is usually 1 Mi'ilrciiK- Oplratoire, Y<>1. II., p. 65. SrAPUYI.iiIlIllfAPIlY. 341 sufficient, but it must l>c increased if the muscular con- tractions persist. The relaxation of the parts produced by these incisions is shown by a comparison of Figs. 178 and 180. Unless the incisions are exceptionally large their sides remain in contact ; in any case they promptly Division of muscles >>f soft palate. reunite. He then divided the anterior and posterior pillars, seizing each in turn near its center with pronged forceps, and cutting it with scissors. Mr. George Pollock 1 has modified this slightly by mak- ing the incision on the anterior surface of the palate 1 Holmes's System of Surgery, Vol. IV., p. 426. 342 OPERATIONS rrnx MOTJTB AND PHARYNX. smaller. One (it* the halves of the palate is drawn toward the median line by means of a ligature passed through it near the base of the uvula, and a thin narrow knife is en- tered close to the hamnlar process, a little in front of it and <>n its inner side, and its point carried upward, back- ward, and somewhat inward, until it can be seen through the cleft, having divided on its way part, if not all, of the tendon of the tensor palati. The blade now lies above most of the fibers of the levator (Fig. 181), and by rais- ing the handle and cutting downward, as the knife is withdrawn, an incision of considerable length, including the greater portion of the levator, is made on the posterior surface of the palate, while that on the anterior surface need not be greater than the breadth of the knife. If the muscle has been effectually divided the palate will be pendulous and flaccid, and will not contract spasmodically when pulled upon. If any resistance should persist the knife must be introduced again through the wound and the incision enlarged downward. Ronx placed his sutures by putting a needle at each end of the thread, and passing them from behind forward. Trelat used a needle fixed upon a long handle, the point bearing the eye and curved in the form of a U- After having been threaded the point of the needle was passed through the palate from behind forward, the thread Avas drawn through with a hook or forceps, and the needle, still threaded, withdrawn and passed in the same manner on the opposite side. The objection to these and to all other methods in which the needle is passed from behind forward, is that, since the point can- not be seen, it is very difficult to make the punctures on one side correspond properly with those on the other. It' silk sutures are used each end may be passed from be- fore backward, the two tied together loosely, and the knot polled back through one of the punctures, thus bringing the loop behind the palate. The method now usually employed is the one intro- duced by Berard. A curved needle fixed on a long han- dle i- threaded with a ligature three feet long, and its STAPHYLORRHAPHY 343 point passed through the palate from before backward ; the thread is caught with hook or forceps on the poste- rior side, and its end drawn out through the mouth, the needle is then withdrawn and slipped oft" the thread. It is next threaded with a second ligature and passed in the same manner through the opposite half of the palate, the loop seized as before, drawn through a short distance, and held while the needle is withdrawn, leaving* the thread double in the puncture — the loop behind the palate, the two ends in front. The posterior end of the first ligature is then passed through the loop of the second one (Fig. Fig. 1X2. Staphylorrhaphy : passing the sutures. 182, />), and, by the withdrawal of the latter, drawn through the second puncture (Fig. 182, a). Instead of using the same needle to pass both ligatures, it is more convenient to have two curved spirally in the opposite di- rections, one for each side. If silver sutures are used, thread loops should be passed from before backward on each side, one end of the wire engaged in each and drawn through. After a suture has been passed, the ends should be brought out through the mouth, and tied together for safety. "When all have been passed, the anterior one is 344 OPERATIONS UPON MOUTH AND PHARYNX. drawn upon to bring- the edges of the cleft together, and the knot tied. The knot may be an ordinary square one, an assistant holding the first twist with dressing forceps until the second is made, or it may be a noose, as shown in Fig. 182, c, secured by a second knot. If silver wire is used, it may be fastened by twisting it, or by clamping a small lead button upon it. Verneuil first passes the ends of the wire through the eyes of a shirt button, and then ties or twists. He thinks this favors more accurate adjustment of the edges, and facilitates removal of the wire. The edges of the cleft are pared by seizing the tip of the uvula with toothed forceps, making it tense, entering the point of a narrow-bladed knife one or two millimeters back from the edge, and cutting down to the tip ; then turning the knife and cutting up to the anterior angle of the cleft. Care should be taken to do this thoroughly. When the cleft is very short (bifid uvula), Nelaton em- ployed the method already described under his name for single uncomplicated harelip. The flaps were left adhe- rent to each other at the apex (angle of the cleft) and to the uvula at their bases, turned down, and the raw sur- faces drawn together. When the cleft was too long for this he separated the flaps at the apex, shortened them by trimming off the free ends, turned them down, and united as before. There is no settled rule of practice establishing the order in which the different steps of the operation shall be exe- cuted, except that most surgeons are agreed upon the ad- visability of paring the edges of the cleft before passing the sutures. Mr. Callender recommended that the muscles should be divided a day or two before the attempt to close the cleft, on the ground that the second operation is much simplified by the freedom from the bleeding occasioned by division of the muscles. Mr. Smith, on the other hand, stretched the palate by drawing upon all the sutures, di- vided the palato-pharyngeus and levator palati, and then, if the edges of die cleft did not come easily together, made two lateral oblique cuts, one on either side, above the URANOPLASTY. ">+•"> higher suture, .separating, to a limited extent, the soft from the margin of the hard palate. Bonfils, aecording to Dubrueil, elosed an opening left at the upper part of the palate by the partial failure of an operation for staphylorrhaphy, by taking a flap from the hard palate, according to the Indian method of autoplasty (7- '••)• URANOPLASTY. Verneuil l attributes the success of modern uranoplastic operations to the use of the method by double flaps, ad- herent at both ends and brought together laterally (lambeaux tit pout), and to the retention of the periosteum in the flaps. He ascribes the first use of double flaps to Dieffenbach, and thinks the retention of the periosteum was brought about by Ollier's most valuable experimental and clinical researches upon the properties of this tissue. To Von Langenbeck, by whose name the method is usually known, he gives only the credit of being the first to adopt Ollier's suggestion, and to make it a rule of practice. This estimate of the facts does not seem to be entirely correct. It is true that Dieffenbach used double lateral flaps, but a large part of the success of the modern method is due to the greater breadth now given to the flaps. Tillaux has shown that the branches of the pos- terior palatine artery are given off like the plumes of a feather, and that to avoid division of these branches, and insure the nutrition of the flap, the incision must be made close to the alveolar process. This necessity is as absolute in the case of a small perforation as in that of a larger one. As for the retention of the periosteum, Von Langenbeck was certainly the first to point out its im- portance as a means of preventing gangrene of the flap. Ollier's investigations turned upon its value in favoring reproduction of the bone. Fissure of the hard and soft palate endangers an in- fant's life by interfering with the ingestion of food. The exact measure of this danger has not vet been established 1 Chirurgie Reparatrice, Art. Uranoplastie. 346 OPERATIONS UPON MOUTH AND PSAEYNX. by statistics, hut it is certainly considerable. 1 On the other hand, all recorded operations for cleft palate upon children less than one month old have terminated fatally, and those undertaken during; the first five or six months of the child's life, although not so fatal, show but few successes. Billroth and Simon think the operation should be performed about the eighth month, but most surgeons are agreed upon the propriety of postponing it until the third or fourth year. If a child has lived six months without operation, it has certainly learned to overcome the mechanical difficulties in the way of its nourishment, and there is, consequently, no reason to interfere sur- gically until the second indication arises. That is found in the defective articulation and phonation occasioned by the lesion, and, as children with cleft palate do not begin to speak before the third or fourth year, the operation may be safely postponed until that time. The special instruments required arc a speculum oris, or two blunt hooks to be placed at the angles of the month and fastened together by a rubber band passing behind the head, pronged forceps with long handles, curved needles of the pattern selected, a periosteum ele- vator bent at a right angle on the flat, a small knife simi- larly bent, and sponges on long handles. The edges of the perforation or fissure arc first fresh- ened by the removal of a strip one or two millimeters thick. An incision is then made on each side close to the gum, extending from the last molar tooth forward as far as may be necessary, and exposing the bone throughout. The elevator is introduced into this incision and the per- iosteum separated from without inward, care being taken imi to injure the palatine arteries at the anterior and pos- terior palatine foramina. If the cleft involves the soft palate its sides will be found to round off toward the hainular processes, and the velum to be tightly adherent to the posterior portion. The flaps cai t lie brought together until the attachments of the two halves of the velum at these points are entirely 1 Lannelongue : M6m. de la Soc. de Chirurgie, L877,p. 170. U&ANOPLASTY. :u; Separated, a step which may be accomplished by means of a small, curved, sharp elevator introduced through the lateral incisions, or by the bent knife introduced through the fissure. The bleeding during this stage of the operation is very free, but, as Ehrmann ' has remarked, usually ceases as soon Fig. 183. Incisions in uranoplasty. as the Maps are completely liberated. If it continues pres- sure should be made for a few moments with the finger, or ice applied. Trelat carries his incisions farther back, stopping from one-fourth to one-half an inch behind the posterior border of the hard palate, and entirely disregard- ing the posterior palatine artery. The flaps are brought together in the median line and 1 M^moires de 1' Acad, de MMecine, Vol. XXXI. 348 OPERATIONS UPON MOUTH AND PHARYNX. the sutures applied, beginning at the anterior extremity of the cleft. The sutures should be left in at least four days and then removed, not all at once, but by installments. If the fissure is unilateral, the vomer remaining attached on the other side, Yon Langenbeck recommends that the lateral incision along the gum should be made only upon the side occupied by the fissure. The flap on the other side should be dissected up from the median line outward. If the fissure extends through the dental arch and is wide at the point, Rouge r recommends that one of the flaps should be detached in front also and swung in sideways upon the posterior attachment as a center. This method of operating has practically superseded all others for closing congenital defects in the hard palate. A great number have been proposed and more or less exten- sively used, but are now so seldom resorted to that only a few need be briefly mentioned for purposes of reference. Sir Wm. Fergusson's 2 osteoplastic method consisted in cutting through the alveolar margin of the hard palate on each side, fracturing the anterior extremity of the strips of bone covered with their muco-periosteum and uniting them in the median line. Schonborn ''' made a flap base down from the upper part of the posterior wall of the pharynx. It comprised all the soft parts in front of the vertebra? ; this was turned and brought forward into the cleft. Lan- nelongue turned down a flap of muco-periosteum from each Bide of the septum of the nose and united the free edges to the freshened margins of the gap in the hard palate. More recently Davies-Colley 4 has fashioned muco-peri- osteal flaps of nearly equal size from the whole of the under surface of the rudimentary palatine processes of the superior maxilla and palate bones. The pedicle of flap No. 1 occupies the whole length of one side of the cleft. The pedicle of No. 2 corresponds to the posterior border of :is much hard palate as exists on that side. Xo. 1 is turned over into the gap, thus placing its raw surface in- 1 L' L'ranoplastie et les Divisions Conduit, fin Palais, 1871, p. 108. » British Bled. Jonr., April 1, 1874 3 Langenbeck 1 s Arrhiv, 187!'), Vol. XIX., p. 527. ♦British Med. Jour., October 25, 1890, and April 28, 1894. EXCISION OF THE TONGUE. 349 feriorly ; No. 2 is then slid over this raw surface as far as possible without tension, and sutured. The denuded lateral areas are left to heal by granulation. Acquired losses of substance in the hard palate, if of any magnitude, are best treated by an "obturator" or vulcanized rubber plate, which a dentist can fit into the roof of the mouth. EXCISION OF THE TONGUE. Exeision of the tongue, partial or complete, may be rendered necessary by hypertrophy of the organ or by the presence of a tumor. The hemorrhage is controlled by ligation of the vessels as they are divided or by prelimi- nary ligation of one or both lingual arteries. Langen- buch l devised a method of so placing two temporary ligatures upon the tongue that bleeding is entirely pre- vented during the removal by the knife of any portion of the anterior half or even two-thirds of the member. He enters the point of a well-curved needle carrying a stout ligature a little to the left of the median line of the tongue behind the part which is to be removed, passes it deeply down through the substance of the tongue, and brings it out on the right side through the floor of the mouth so as to include the branches of the lingual artery in its loop. To prevent slipping, the needle is then passed through the edge of the tongue ; another is passed in the same manner on the opposite side, and each tied tightly. The ends may then be used to draw the tongue forward. It has also been suggested that, when it is necessary to operate very far back upon the tongue, its base can be brought forward by dislocating the lower jaw downward and forward on both sides. The tongue is drawn well forward, the tumor or portion to be removed seized with double-pronged forceps and rapidly excised by a V-shaped incision made with a blunt- pointed bistoury so as to avoid injury to the vessels in the 1 Aivliiv fur klinische Chirurgie, Vol. XXII., Tart I., 1878, p. 7± 360 OPERATIONS UPON MOUTH AND PHARYNX. floor of the mouth; all bleeding points arc then .secured and the sides of the wound brought together with sutures. It' a larger portion, say a lateral half, of the tongue is in be removed, the operation may he done as follows : Two stout ligatures arc passed through the tip, one on each side of the median line, to he used to draw the organ forward ; the tip then raised, the frsenum cut with scissors, and the scissors then pushed along under the tongue and mucous membrane to free them as far hack as necessary. Then the tongue is split along the median line, from be- fore backward, completely freed from the underlying parts by tearing with the finger, the mucous membrane of the floor divided with the scissors, and the posterior section made with knife or scissors. Complete through the Mouth. — This operation has been extensively employed by Whitehead, 1 and bears his name. He does not practise a preliminary ligation of the lingual arteries, but secures them as they are divided. The mouth is made as aseptic as possible and the face and neck shaved and cleaned. The lingual artery on each side is ligated ; and through these incisions, which may be extended if necessary, any enlarged or suspicious glands, including one or both submaxillaries, are removed. The wounds are then closed and dressed antiscptically. After this the patient's head is placed in a more or less erect position with a slight inclination forward, to allow the blood to escape from the mouth. The jaws are held well apart with a suitable mouth-gag and a ligature passed through the tongue in the median line about an inch from the tip. With this the tongue is drawn out and up, while first the frsenum and then the anterior pillar of the fauces are divided by blunt-pointed scissors. With short snips of the scissors all the muscles with the overlying mucous membrane on the under surface of the tongue are cut on a plane with the lower border of the inferior maxilla and as far back as the safety of the epi- glottis permit.-. It may be necessary to draw the lower incisor teeth and thus gain more room for manipulating 1 Uncet, L881, Vol. I., p. 698. EXCISION OF THE TONGUE 351 the scissors. The tongue is then drawn upward by the ligature passed through it.- substance and the posterior section completed with knife or scissors. The dorsalis linguae vessels can be readily secured in the stump. Regnoli's Method. — Regnoli, of Pisa, published in 1838 the description of a method by which he success- fully removed the anterior portion of the tongue. He made a semicircular incision through the skin along the lower border of the jaw, beginning and ending at the angle.-, and added a second one to it in the median line, extending to the hyoid bone. The tegumentary flaps were dissected back, and the muscles divided at their at- tachments to the inferior maxilla. The tongue was then drawn down through the large opening thus made, its anterior portion readily excised, and the wound closed. Billroth has revived and modified Regnoli's operation and employed it in several eases. It has the advantage of furnishing free drainage, allowing the wound to he treated antiseptically, and facilitating the removal of implicated lymphatic gland-. Billroth'* Method. — A semicircular incision is made along the lower border of the inferior maxilla from one angle to the other. The flap, containing the skin, fascia, and platysma, is diss ected back and the lingual arteries tied beneath the hyoglossus muscle, as described on page 54. Enlarged or suspicious glands, including the submaxil- lary and sublinguals, are dissected out. After transfixing the tip of the tongue with a ligature to prevent its falling- back and closing the opening of the larynx, a knife is thrust up through the floor of the mouth close behind the symphysis and swept backward on both sides as far as the anterior pillars of the fauces. It should divide the mu- cous membrane and muscles attached to the jaw near enough to the bone to clear all disease and yet leave suffi- cient tissue to permit the divided muscles to be at least partially sutured in position again. After the attachment- of the geniohyoid, geniohyo- glossus, and digastric muscles have been severed, together 352 OPERATIONS UPON MOUTH AND PHARYNX. ■with the anterior part of the hyoglossus, the tongue is drawn out through this gap and excised. A drain is in- troduced, the muscles sutured in position, and the wound closed. Lateral Supea-hyoid Method. (Kocher. 1 ) (Fig. 184.) — This method has for its object the very thorough removal of all diseased tissues of the tongue and pharynx and all infected glands in the neck. Preliminary laryngo- Fig. 184. Removal of the tongue. K. [tocher's incision. S. S6dillot's incision'. tracheotomy is advantageous to facilitate the operation and permit antiseptic treatment of the wound. The incision is made from the under border of the lower jaw near the symphysis, in the direction of the anterior belly of the digastric, to the hyoid bone, thence along its greater cornu, and then upward to the angle of the jaw ; after division oi* the platvsma and fascia I he triangular Hap is turned up. The submaxillary fossa is then emptied by removal of 1 Deutsche Zeiteehrift furChir., 1880, 134. EXCISION OF THE TONGUE. 353 the submaxillary and diseased lymphatic glands, the facial and lingual arteries and veins having- been divided be- tween double ligatures. The larynx and oesophagus are then covered with a sponge forced in behind the tongue, and an incision made into the floor of the month bv cutting- through the mylo- hyoid muscle close to the jaw, and carried along the bone as far as may be necessary. The tongue is now freely accessible through the wound, and can be drawn out through it and split, and cut oif as near its base as is desirable, or it can be entirely removed in the same manner, the opposite lingual artery being readily secured when divided. The side, and even the posterior part of the pharynx, are also accessible. The tracheotomy tube should be retained, the wound packed with antiseptic gauze, and the patient fed through an oesophageal tube. S^dillot's Method. (Fig. 184.) — Sedillot, comment- ing upon Regnoli's ease, expresses the opinion that the ex- cision could have been accomplished quite as readily through the mouth, and, as he also found by experiments upon the cadaver that the tongue cannot be brought far enough forward through such an opening to facilitate ex- cision at or near its base, he suggested and employed division of the inferior maxilla in the median line as a preliminary operation. One of the median incisor teeth on the lower jaw hav- ing been drawn, an incision is made in the median line from the free border of the lower lip to the hyoid bone, and the jaw sawn through in the line of the incision, or, better, by two oblique lines forming a =», the apex di- rected to one side. The attachment of the genio-hyo-glossus muscles to the bone are next divided, the two halves of the jaw drawn apart, the tongue pulled forward and to one side, and its attachments to the hyoid bone divided on the other side, in doing which the lingual artery is divided and must be tied at once. The tissues on the other side are then divided in a similar manner, and the other lingual 23 354 OPERATIONS UPON MOUTH AM) PHARYNX. artery having been tied the remaining attachments are severed and the tongue removed. The divided maxilla is fastened tog-ether again with silver sutures passed through holes pierced in it with a drill, the sides of the incision in the lip accurately ad- justed to each other, and the lower angle of the wound left open for drainage. The bone has sometimes been divided on the side in- stead of in the median line. Yon Langenbeck makes an incision from the angle of the mouth vertically down to the thyroid cartilage. Through this the submaxillary and lymphatics are extir- pated, the digastric and hyoglossus muscles cut through, the lingual artery tied, and the jaw sawn obliquely in front of the masseter from above downward and back- ward. After drawing apart the segments the mucous membrane is severed from the inner surface of the poste- rior one as far back as the anterior pillar of the fauces. Through this gap not only the tongue but also the tonsil and soft palate can be removed if necessary. The oper- ation is concluded like Sedillot's. Billroth's modification of this consists in dividing the jaw and overlying soft parts on both sides, and turning down the intermediate chin segment. Crespi and Bastianelli ' have still further modified Langenbeck's operation as follows : An incision is carried vertically down through the middle of the lower lip and chin t<> the lower border of the jaw, along the latter hori- zontally to near the angle, and thence vertically down tor about an inch to the anterior border of the sterno-mastoid muscle. The soft parts arc separated from the outer sur- face of the jaw to within an inch of the insertion of the masseter, the facial and lingual arteries ligatcd, the sali- vary and lymphatic glands removed, and the jaw divided obliquely from behind forward in front of the second mil- iar tooth. This affords access to the retrobuccal and phar- yngeal region, and permits of removal of the tonsil and adjoining parts. ■Centralb. f. Chir., 1890, p. 556. SALIVARY FISTULA. 355 DIVISION OF THE FRjENUM. The tip of the tongue is raised upon the handle of a director, in the slit of which the frsenum is engaged, and divided with curved scissors close to the director. Only the semi-transparent edge of the constricting hand should he cut, and then the rest torn by pressing the tongue up toward the roof of the mouth. If the ranine vessels should chance to be divided the bleeding can be controlled by torsion or ligation or by touching the points with nitrate of silver, or, if necessary, with the actual cautery. J. L. Petit reported a case of suffocation caused by the tongue falling back upon the glottis after division of the frsenum, and (inerin mentions another. RANULA. The anterior wall of the cyst should be caught up with toothed forceps and excised. A director should be passed at intervals between the sides of the incision to prevent reunion, and the filling up of the sac may be hastened by painting its interior with nitric acid or tincture of iodine. In some cases it is sufficient to pass a thread or wire seton through the cyst. SALIVARY FISTULA. Salivary fistula communicating directly with portions of the parotid gland can usually be closed by cauterization and compression, but when the fistula communicates with Steno's duct the cure is much more difficult. If the distal portion of the duct is still permeable a leaden wire may be passed through it from the mouth into the proximal por- tion of the duet. The saliva will follow the wire, and if the fistula does not close spontaneously its edges should be pared and brought together with sutures. The orifice of the duct is readily found opposite the second upper molar tooth. When the distal portion of the duet is obliterated sev- eral methods may be employed. One is that of Deguise, and consists in the formation of a new channel in the 356 OPERATIONS UPON MOUTH AND PHARYNX. cheek for the saliva ; another is that of Van Bnren, and consists in the bodily transfer of the fistulous orifice from the outer to the inner surface of the cheek. Deguise's Method. — Deguise made a puncture through the fistulous opening obliquely backward to the inner surface of the cheek and passed one end of a leaden wire through it ; he next made through the same opening a second puncture directed obliquely forward, brought the other end of the wire through it and tied the two ends together. The loop of the wire being thus drawn into the fistula the saliva followed its two branches into the mouth, and the fistula healed at once. Some surgeons use a silk ligature and tie it tightly so as to cut through the tissues included in the loop. Agnew's method of doing this is by the passage of a curved needle around the duct from within the mouth. Van Bikex ' cured a salivary fistula, the result of a gunshot wound, by passing two fine silver wires through the skin at opposite points on its edge, then isolating the duct and fistulous opening for half an inch by dissection backward from the latter, making an incision through the wound to the inner side of the cheek, drawing the fis- tulous opening through it, and fastening it there by means of the wires. The gap left on the cheek was then closed with fine silver sutures. The duct was so short, the fistula being an inch behind the anterior margin of the masseter, that it could not be brought quite to the inner surface of the cheek. The wires, however, which were left in place until the fifth week, kept open a track, which became permanent, for the pas- gage of the saliva from the end of the duct to the mouth. ■New York Medical Journal, Vol. I., p. •">•!, and Contributions i<> Practical Surgery, 1865, p. 205. C HA PT E R I V. OPERATIONS PERFORMED UPON THE NECK. BRONCHOTOMY. This is a general term covering operations undertaken to open the larynx or cervical portion of the trachea. These operations are : Laryngotomy, tracheotomy, and laryngo- tracheotomy. Laryngotomy is further subdivided into xii/)- hyoid pharyngotomy or laryngotomy (called supra-laryn- geal bronchotomy by Sedillot, and indirect laryngotomy by Planchon), thyroid laryngotomy or thyrotomy, erico-thyroid laryngotomy, and tracheotomy, which is further subdivided into high and low, depending upon whether the trachea is opened above or below the isthmus of the thyroid gland. The names indicate the points at which the opening is made into the air-passages. Sub-hyoid Pharyngotomy or Laryngotomy. — This opera- tion, originally performed upon animals by Bichat for the purpose of studying the movements of the vocal cords, was afterward proposed by Yidal to give access to an abscess situated in the glotto-epiglottidean folds, and by Malgaigne to allow the removal of a foreign body lodged in the upper part of the larynx. It is also applicable to the removal of polyps situated at the same point and not accessible through the mouth. Follin thus removed ten from the anterior surface of the arytenoid cartilages. The shoulders arc raised and the head extended. A transverse incision two inches long, its center in the median line, is made through the skin immediately below the hyoid bone, and the platysma, scerno-hyoid, and thyro- hyoid muscles, and thyro-hyoid membrane divided. The mucous membrane lying between the epiglottis and the base of the tongue then presents in the incision, is drawn 357 358 OPERATIONS UPON THE NECK. downward with forceps, and opened with the knife or scissors. The epiglottis is then seized with a hook or pronged forceps and drawn out through the wound, freely exposing the larynx to view. Velpeau made the first incision in the median line, divided the thy ro-h void membrane transversely, and then plunged the knife backward and downward, making a ver- tical incision in the base of the epiglottis through which he passed the blades of a pair of forceps and withdrew the foreign body. Aplavi/n ' has modified this operation as follows : With the head well extended the trachea is opened and plugged by a tampon-can ula — a tracheotomy tube surrounded by a rubber bag, which is inflated after its introduction till it fills the lumen of the trachea. The pharynx is incised transversely as above described and the hyoid bone cut through with scissors on each side from one-half to three- quarters of an inch in front of its extremities. Jf there i- fear of wounding the lingual vessels a part of the hyo- glossus muscle is cut close above the hyoid bone and the vessels recognized and drawn up. By raising this segment of bone and depressing the thyroid cartilage, pretty free access can be obtained to the parts close around the open- ing of the larynx. At the conclusion of the operation the mucous mem- brane is sutured first ; then external to it a silk suture is passed on each side through the skin and upper border of the thyroid cartilage behind and over the hyoid bone about one-half an inch in front of its points of division. After uniting the thyro-hyoid membrane and overlying soft part- the two silk ligatures are knotted externally and thn- prevent undue tension on the other sutures. Thyroid Laryngotomy or Thyrotomy. — In this operation the thyroid cartilage is divided vertically in the median line, between the anterior attachments of the vocal cords. It i- suitable for the removal of foreign bodies or polyps from the interior of the larynx and for fractures, stenosis, or disease of i his organ. 1 Aivhiv f klin. Chir., Vol. XLL, p. 324. BRONCHOTOMT. 359 The head is well extended, or allowed to hang from the vdgv of the table. A preliminary tracheotomy and nluerfiring of the trachea may be necessary. Stead vino- the larynx with the thumb and forefinger of his left hand, the surgeon makes an incision along the pro- jecting angle of the thyroid cartilage in the median line, from its upper border to the cricoid cartilage. As soon as the crico-thyroid membrane is exposed, he makes a small opening in it near its upper border and passes one blade of a strong blunt-pointed pair of scissors through it to the upper border of the larynx, keeping exactly in the median line, and thus divides the thyroid cartilage throughout its entire length. Or a grooved director may be passed through the opening made in the crico-thyroid membrane, and the cartilage divided upon it with a curved bistoury. Or, again, the division may be made with the knife, layer by layer, from before backward : but whenever possible the upper border of the larynx should be left uncut to preserve the relation of the vocal cord>. The conoid and thvro-hvoid ligaments and tliyro-hyoid membrane must often be separated to a greater or less extent from the upper and lower border of the thyroid cartilage to permit its lateral halves to be retracted suffi- ciently to expose thoroughly the cavity of the larynx. At the conclusion of the operation the wound may either be closed immediately with silk or silver-wire sutures, or left open and packed for a couple of days. Crico-thyroid Laryngotomy. — In this operation the open- ing is made in the crico-thyroid membrane. The French writers, Sedillot, Dubrueil, Chauvel speak of this method as having been entirely abandoned because the opening cannot be made sufficiently large. Holmes, on the other hand, considers it suitable in all cases in which only the vocal cords or the tissues above them are involved, and says it is practiced in spasm of the glottis from any cause, in erysipelatous affections spreading down the throat, and in cases of foreign body lodged in or above the glottis. If the opening proves to be too small it can be enlarged 360 OPERATIONS UPON THE NECK. downward through the cricoid cartilage (laryngo-trache- otomy). The operation may be required in cases of urgency when no tube is at hand. A pair of forceps or scissors, a hair-pin, or pieces of bent wire will suffice to keep the wound open, and the incision can be made with a penknife. Operation. — Dorsal decubitus, shoulders raised upon a cushion or narrow pillow so that the head may fall back and keep the throat tense. The surgeon, standing at the patient's right side, fixes the larynx with his left thumb and middle finger placed on either side, and the index upon its upper border, and makes a cutaneous incision in the median line corresponding to the crico-thyroid mem- brane. He draws the sterno-thyroid muscles apart, lays bare the membrane, and divides it transversely or verti- cally ; in the latter case the incision should begin a short distance below the inferior border of the thyroid cartilage, so as to avoid a small artery which crosses at that point, and extend to the cricoid cartilage. (For the method of inserting the canula, see Tracheotomy.) Laryngo-tracheotomy. — The opening occupies part of the crico-thyroid membrane, the cricoid cartilage, and the first two or three rings of the trachea. The upper border of the isthmus of the thyroid usually corresponds to the second ring of the trachea; it should not be divided. In children under six years it commonly rises to the lower border of the cricoid cartilage. Dorsal decubitus, with shoulders raised, head thrown back, and neck slightly stretched. The larynx is fixed as for crico-thyroid laryneotomy, and an incision made through the skin exactly in the median line from the mid- dle of the thyroid cartilage to about one inch below the cricoid. The muscles arc carefully drawn apart, the isth- mus of the thyroid depressed if necessary, after nicking and tearing with blunt hooks the suspensory fascia at its upper border, the trachea steadied and drawn upward with a sharp hook thrust into the upper part of the crico-thy- roid membrane, and the point of the bistoury entered close below the hook and made to cut downward through BRONCHOTOMY. 361 the cricoid cartilage and one or two of the rings of the trachea. The edges of the incision are then held apart and the cannla introduced, or the forceps if the operation has been undertaken with a view to the removal of a for- eign body or a polyp. De Saint Germain's Method. — Dorsal decubitus, shoul- ders raised, neck extended. The surgeon feels for the 1 cricoid and thyroid cartilages, and the depression between them. Then, standing upon the patient's right side, he places his left thumb and middle finger on either side of the larynx, and by pressing them in between it and the vertebral column, pushes the larynx forward, makes tense the skin covering it, and at the same time marks the sit- uation of the lower border of the thyroid cartilage with the nail of his left forefinger. The knife, a straight, sharp-pointed bistoury, is held like a pen, its back directed upward, and the middle finger so placed upon its side as to limit to half an inch the depth to which the point can penetrate. It is then en- tered with a quick sharp stab in the median line close against the nail of the left forefinger and made to cut downward with a sawing motion through the cricoid car- tilage and one or two tracheal rings, care being taken to make the incision in the skin fully as long as that in the trachea. The wound is held open with a " dilator," and the canula introduced between its branches ; the pressure of the latter is usually sufficient to arrest hemorrhage, but ligatures can be easily applied if necessary. In only one case out of ninety-seven did Saint Germain injure the posterior wall of the trachea, and in only three did hemorrhage occur. 1 Tracheotomy. — The trachea may be opened at any point between the cricoid cartilage and the upper border of the sternum, a distance averaging in the adult from two and one-half to three inches, in the child under ten years of age from one and one-half to two and one-half inches. Its course is obliquely backward as well as downward, so that while its upper end is almost subcutaneous it be- 1 Bull, de la Socie'te de C'hirurgie, 1877, pp. 271 and 327. 362 OPERATIONS UPON THE NECK. comes deeply placed before it passes behind the sternum. It is crossed at its upper end by the isthmus of the thy- roid gland, the breadth, thickness, and vascularity of which vary within very wide limits, although its upper border usually corresponds to the second ring of the trachea. A communicating branch uniting the two in- ferior thyroid arteries crosses just below the lower border of the isthmus. The lower portion is covered anteriorly by the thyroid veins, always greatly distended Avhen the respiration is obstructed, and by the thymus gland in children under two years of age, and occasionally in un- healthy older ones. To the dangers depending upon the normal arrangement of the parts are added those of not infrequent anomalies in the origin and course of the arteries and veins. Thus, the left brachio-cephalic vein may cross the trachea well above the sternum, the left carotid may arise from the in- nominate, and sometimes a thyroidea ima artery is given off from the transverse portion of the arch of the aorta, and ascends along the anterior surface of the trachea in the median line. Finally, an aneurism of the innominate, or of the arch of the aorta, may rise in front of this por- tion of the trachea. Operation. — The patient is placed upon his back with shoulders raised and head thrown back. A trustworthy assistant, standing behind the head, holds it firmly in a Straighl line with the body ; others control the patient's limbs if he has not been anaesthetized. The surgeon, standing at the patient's right side, recognizes with his finger the hyoid bone and thyroid and cricoid cartilages, and, marking with his left forefinger the upper border of tli«' cricoid cartilage, makes an incision downward from it in the median line from one and one-half to two inches in length, according to the size of the patient. lie carries the incision through the skin ami fascia, separates the Bterno-hyoid and sterno-thyroid muscles with the handle "f In- knife, and lays bare the isthmus of the thyroid. If any large veins are encountered, they must be carefully drawn aside or divided between two ligatures, but bleed- BRONCHOTOMY. 363 ing from smaller ones may be safely disregarded, for, as Trousseau pointed out, it will cease as soon as the trachea is opened, and the venous congestion relieved by the ad- mission of air to the Lungs. It is well to have one or two assistants hold the sides of the incision apart during- the disseetion, if they can be depended upon to do so without disturbing the relation- of the parts by drawing too forcibly toward one side or the other. The isthmus of the thyroid is next drawn upward with a blunt hook, and three or four ring's of the trachea ex- posed below it, and divided from below upward. If for any reason it is desirable to make the incision higher up, or if the isthmus is unusually broad, it may be divided between two ligatures, in which case the incision of the trachea should be made from the lower border of the cri- coid cartilage downward. The incision in the trachea should always be free enough to admit the canula readily, and should be made by a quick thrust with a sharp-pointed knife, which must be prevented from penetrating too deeply at first, by holding- it close to its point. After the puncture has been thus made, it is enlarged by gentle sawing movements of the knife, or with scissors. The knife is retained in the trachea as a guide, until the dilator has been introduced. The best dilator is the three- bladed one ; it is introduced closed, its blades then ex- panded, and the permanent canula passed in between them. The canula should be curved, double to facilitate cleaning, and provided with an opening on its convexity through which the expired air can pass to the larynx. Some surgeons steady the trachea by drawing it toward the chin with a tenaculum introduced at the lower edge of the cricoid cartilage. Gurdon Buck used for this pur- pose a rather narrow lance-shaped knife, bent at a right angle on the Hat, and also grooved on the back for use as a director. G-alvano- or Thermo-cautery. — The danger of hemor- rhage, especially in the adult, has led many surgeons to •')<'»4 OPERATIONS UPON THE NECK. use the galvano- or thermo-cautery. Its hemostatic ad- vantages, however, are offset by a large eschar which it causes, and the possible necrosis of the tracheal cartilages." The cautery should be used only to divide the soft parts, the trachea should be opened with the knife. LARYNGECTOMY. 2 Complete. — A preliminary tracheotomy is necessary. A pad is placed under the shoulders and the head thrown well back. The incision is in the median line, and ex- tends from the thyro-hyoid space to the second or third tracheal ring. A transverse incision joins this at the up- per end and passes outward parallel to the hyoid bone as far as each sterno-mastoid muscle. The skin, fascia, and platysma are drawn aside and the superior thyroid arteries secured at the posterior margin of the thyro-hyoid muscle beneath the sterno-hyoid close to the upper border of the thyroid cartilage. Next the inferior thyroid arteries are ligated below, beneath the posterior edge of the sterno- thyroid muscles. By means of a periosteal elevator or blunt-pointed scis- sors entered beneath the fascia in the middle line the crico- thyroid, sterno-thyroid, and thyro-hyoid muscles on each side are detached and retracted with the other soft parts. The thyroid cartilage is drawn first to one side and then to the other, and the inferior constrictor muscle separated. All cutting should be done with the blunt-pointed scis- sors kept close to the cartilages. The superior laryngeal nerves and the thyro-hyoid membranes and ligaments are divided, the epiglottis drawn out and its extra-laryngeal attachments cut. The larynx is next pulled forward and separated from any remaining connection with the phar- ynx or oesophagus to a point just below the cricoid carti- lage. Great care is necessary to avoid opening the oesoph- agi i.-. The trachea is secured from slipping down by a temporary suture on each side and is cut across below the 1 See the discussion in the Societe" , No. 2G0. LA R YNGECTOMY. 365 cricoid cartilage. The divided end is secured at the sur- face in the wound with interrupted silk sutures and the mucous membrane sutured to the margins of the skin incision. When there is doubt about the extent of the laryngeal disease, the thyroid cartilage should be split in the middle line as soon as it has been exposed. This is done by steadying the larynx and cutting from before backward with the knife or from below upward with blunt-pointed scissors entered through the crico-thyroid membrane. Ii' then on inspection it is found that the whole larynx must be sacrificed the operation is proceeded with as already described. It is usually recommended to remove the cricoid cartilage in all cases of total extirpation, as it is of no functional value and its retention interferes with the act of swallowing. Partial. — An incision is made in the median line as in total laryngectomy, and from its upper end a second is made parallel to and just below the hyoid bone on the affected side as far as the sterno-mastoid muscle. This involves the skin, fascia, and platysma. The thyroid car- tilage is then divided vertically exactly in the median line with the knife or scissors. After separation of the ala? Mr. Butlin ' advises, if the disease is of limited extent, that it be cut away, with a wide margin of healthy tissue, meaning that it be scooped out of the concavity of the ala with the surrounding mu- cous membrane. The ala of the thyroid is then restored to its place. Mr. Butlin claims that cancer does not infil- trate the cartilage, and therefore it is only necessary to scrape and cauterize the part adjacent to the disease. If one-half of the thyroid cartilage must be removed, the sterno-thyroid muscle is cut at its upper end and laid back. The thyro-hyoid, sterno-thyroid, and crico-thyroid muscles are carefully detached with the elevator or blunt- pointed scissors. The thyroid and crico-thyroid mem- branes and superior laryngeal nerve are cut close to the cartilage, and vessels are secured as they are divided. ■Op. Surg. Malig. Disease. 366 OPERATIONS UPON THE NECK The superior corau of the thyroid cartilage is cut through at its base. The whole or part of the epiglottis is left and the aryteno-epiglottic fold of mucous membrane spared as much as possible. The pharyngeal Avail must be freed with great care. The inferior cornu is divided, any remaining attachments severed with short snips of the scissors and the ala removed. The parts are then sutured in their proper positions as nearly as possible after placing over the denuded surface all the mucous membrane obtainable. PHARYNGOTOMY. This is an operation required for the removal of foreign bodies or diseased tissue from the pharynx or immediately adjoining parts which are not accessible through the mouth. Langenbeck's (page 354), or the Crespi-Bas- tianelli methods (page 354), for reaching the base of the tongue are also useful for exposing the tonsil and posterior pharyngeal wall. Aplavin's sub-hyoid pharyngotomy (page 358) gives a somewhat limited view of the parts around the entrance to the larynx. Gaps left after excision of portions of the wall of the pharynx must be left to granulate ; if the epiglottis has been disturbed its attachments must as far as possible be replaced and sutured in their proper position. Von Langenbeck's Method. 1 — After a preliminary tracheotomy the head is extended and chill turned to the side opposite to the one to be operated upon. The incision extends from the middle of the lower border of the body of the inferior maxilla downward across the greater corn 11 of the hyoid bone along the posterior border of the thyro- hyoid muscle to the cricoid cartilage or a little further. After division of the superficial fascia, platysma, and omohyoid, the lingual, and superior thyroid arteries and facial vein arc cut and secured. Both branches of the superior laryngeal nerve are divided. After freeing the attachments of the digastric ami stylo-hyoid from the hvoid bone the pharynx is laid open through the whole 'Archiv f. klin. Chir., 1879, Bd. 24, p. 825. P1IARYNG0T0MY. 367 length of the wound. The thyroid cartilage can be turned on its long axis so that its posterior surface is visible in the wound and the pharynx is accessible as high as the soft palate. Another method of the same surgeon's is as follows: A U -"Shaped flap of skin and subcutaneous tissue is made, the base of which is above and corresponds in width to the length of the zygoma. Its sides and bottom follow the anterior border of the masseter muscle, the posterior border of the ramus, and the intervening portion of the lower border of the jaw, respectively. The inferior maxilla is sawn through in front of the insertion of the masseter, and the ramus dislocated by turning it outward and upward. Butlin ' describes an operation by Czerny, which is virtually the same as Von Langenbeck's for excision of the tongue. The incision extends from the angle of the mouth to the extremity of the hyoid bone, and the jaw is sawn through obliquely from above and without down- ward and inward between the second and third molar teeth. MIKULICZ'S Method. 2 — After a preliminary trache- otomy and plugging of the fauces or larynx an incision is made from the tip of the mastoid process to the level of the greater cornu of the hyoid bone. The periosteum and overlying parts are raised from the outer and inner surface of the ascending ramus of the inferior maxilla, special care being taken to avoid injury if possible to the facial nerve, parotid gland, and external carotid artery. The ascend- ing ramus is then divided horizontally just above the angle, and partially or entirely excised after severing the tendon of the temporal muscle. After drawing aside the both - of the jaw, together with the masseter, internal pterygoid, digastric, and stylo-hvoid muscles, the region of the tonsil is exposed. The lateral wall of the pharynx is then incised and access thus ob- tained to the palate, base of the tongue, and posterior 'Operat. Surg. Malig. Disease. 2 Deut. med. Wochens., 1886, Vol, XII., y. 157, 368 OPERATIONS UPON THE NECK. pharyngeal wall as far up as the naso-pharynx. If the digastric muscle and hypoglossal nerve are divided the entrance of the larynx can be reached. The disease is re- moved with the knife or scissors, the mucous membrane drawn together, and the wound closed and drained. Ciieever's Method. — An oblique incision is made from the lobule of the ear downward along the anterior border of the sterno-mastoid muscle to the hyoid bone or below it. A second is carried forward from this along the lower border of the body of the inferior maxilla. The tissues are divided layer by layer, and the vessels secured. Enlarged lymphatic glands are removed as they are en- countered. The branches of the facial nerve are recog- nized and drawn to one side. The hypoglossal nerve lies behind and in the lower end of the incision, and is drawn outward and backward with the great vessels. The glosso- pharyngeal nerve lies anteriorly. The fascia investing the posterior part of the submax- illary gland is slit up, and the facial artery tied. The digastric and stylo-hyoid muscles are divided, the sub- maxillary gland drawn forward and the parotid up, and the wall of the pharynx thus exposed. The tonsil and the surrounding mucous membrane are then removed. Bird ' dispensed with the incision along the lower border of the jaw, but slit the cheek from the angle of the mouth to the angle of the jaw and removed the tonsil, using one finger in the mouth for a guide. (ESOPHAGOTOMY. The oesophagus begins in front of the sixth cervical vertebra in the median line, or just behind the cricoid cartilage; at first it inclines slightly toward the left, then returns to the median line as it passes behind the sternum, inclines to the right at the arch of the aorta, and again to tin' lift as it approaches the diaphragm. The left recur- rent laryngeal nerve lie- between its cervical portion and the trachea, the right recurrent nerve lies upon its outer side. It i- covered anteriorly by the trachea and left 'Clin. Soc. Trans., Vol. XVI., i). 9. ' KSOPHA GOTOM Y. 369 lobe of the thyroid gland, and crossed by the left inferior thyroid artery and vein. The guide to it is the trachea. Internal (Esophagotomy. — Dr. Sand- employed an in- strument constructed <>n the principle of the Otis urethra- tome. It consisted of a long shank carrying a bull) with a sheathed knife which could be made to project not more than an eighth of an inch from the surface of the envelop- ing bulb by turning a -crew in the handle. Other sur- geons have used similar instruments, but on account of the danger of perforating the (esophagus operations per- formed by the knife from the interior of the organ have been practically abandoned in favor of Abbe's "string- saw *' method, 1 which is one of combined dilatation and division. It is used for cicatricial strictures which are undilat- able and generally impermeable to any instrument passed from above, but which reason and experience have shown may be passed from below, where tbe tube is contracted and funnel-shaped, while above it is dilated and pouched. Gastrostomy is first performed, the opening into the stomach being made large enough to admit two fingers with the exploring instrument to the cardiac orifice of the stomach. Into the latter a bougie carrying a long silk cord is passed and brought out at the mouth ; the other end of the cord remains in the abdominal wound. Then the stricture is made tense by engaging a conical bougie in it, and the string, held well back at either end in the pharynx and stomach, is drawn tight and sawed up and down a few times. After this bougies are passed up to the largest size or till firm resistance is encountered. In Abbe's first ease external (esophagotomy was performed, and after division and dilatation of the stricture as above described a rubber tube was drawn up from tbe stomach and wedged into the contraction for twenty-four hours, thus maintaining the dilatation. When there is no further trouble in the passage of bou- gies from above, the gastrostomy wound is closed, but in- struments must subsequently be introduced through the 'New York Medical Record. February 25, 1893. •J-i 370 OPERATIONS UPON THE NECK stricture at regular intervals till the danger of recontrac- tion is <»vcr.' External (Esophagotomy. — -The operation of external cesophagotoray may be required for the relief of stricture, or the removal of a foreign body. In the former case, it may be performed above or at the level of the stricture for the purpose of dividing or dilating it, or below the stricture so as to allow the introduction of food into the .stomach. The left side of the oesophagus is more accessi- ble in the neck than the right, and the incision may lie made in the median line or parallel to the inner border of tin Bterno-cleido-mastoid muscle. As the walls of the oesophagus are flaccid, a guide should be used if it is pos- sible to introduce one. A sufficiently convenient one is a pair of long curved forceps, or even a urethral sound, introduced through the mouth ; the point can be made to press the wall toward the approaching knife. Lateral Incision. — Dorsal decubitus, head extended, face turned slightly to the right. The surgeon, standing at the patient's left, makes an incision through the skin, subcutaneous cellular tissue, and the platysma a little on the inner side of the inner border of the sterno-clcido- mastoid from a point one inch above the sternum to the level of the upper border of the thyroid cartilage. If the external or anterior jugular is encountered, it must be drawn aside or divided between two ligatures. The fascia is then divided, the omo-hyoid muscle drawn aside, and then the side of the thyroid gland followed downward. The Bterno-cleido-mastoid and the great vessels arc drawn outward with a blunt hook, the trachea and thyroid gland to the right, and then the surgeon, working with blunt instruments, separates the tissues at the bottom of the wound and exposes the oesophagus, which can be recognized bv it- flattened appearance and thick wall. If more room is needed, the -ternal head of the Bterno-cleido-mastoid iiui-t be divided. Then a guide is introduced through 'A resume* of this operation with a report of cases and description <>f ili.- various expedients which may !><• necessary will !><• found in the Annals of Surgery, March, 1895, p, '_'•">■;. Dr. Woolsey. OPERATIONS ON THE THYROID GLAND. 371 the mouth, and the wall of the oesophagus pressed up at the bottom of the wound. The surgeon, having satisfied himself that the recurrent laryngeal nerve and inferior thyroid artery are out of the way, punctures the oesophagus by picking it ii|> with two hooks Or toothed forceps and cutting between them, and enlarges the opening with scissors or a blunt-pointed bistoury. At the close of the operation the wound in the oesopha- gus is closed with catgut, that in the overlying- parts be- ing left open and packed ; the patient is fed by the rectum or with the stomach tube for several days ; or a tube, through which the patient should be fed for several days, is passed through the wound well into the (esophagus and carefully packed about. The capital point is to insure drainage of the wound which will certainly be infected from the oesophagus during the operation or shortly there- after. If a permanent fistula is desired (below a malignant contraction, for instance) the margins of the cutaneous and (esophageal wounds are united with sutures. THE OPERATIONS ON THE THYROID GLAND. Anatomy. — Normally the isthmus is about half an inch broad and covers the second and third tracheal rings, while the lateral lobes extend upward and backward to the lower end of the pharynx, lying on each side of the larynx, and downward, in contact with the upper end of the oesophagus. The thyroid is enveloped by the fascia of the neck and possesses a capsule enclosing the gland tissue proper. When enlarged the organ is covered with a plexus of veins ; the most constant and important of these are represented diagrammatically in Figs. 185 and 186 and need no further explanation. The gland is over- lapped by the sterno-mastoid and has resting on its sur- face the sterno-hyoid, omo-hyoid, and sterno-thyroid mus- cles in this order from before backward. One or more accessory thyroids may be found above or below the lateral lobes, and it should be noted that the latter mav, when 372 OPERATIONS UPON THE NECK. enlarged, extend downward behind the sternum. The lateral lobes overlap the great vessels of the neck with their accompanying nerves, and are in contact at their lower posterior portions with the inferior thyroid artery, the recurrent laryngeal nerve, and middle cervical gan- glion of the sympathetic. The artery passes horizontally inward from the inner border of the scalenus anticns Fig. 185. a. Chin. b. Sterno-mastoid. c. Omo-byoid. x THE THYROID CLAM). 375 the tumor and secure each as it is divided, as in this way there is less danger of injuring the recurrent laryngeal nerve which is in close relationship with it on each side. Furthermore, on the left side the main portion of the artery lies in contact with the (esophagus ; and the thoracic duct, which is at first posterior to the artery, arches over it to reach the left subclavian vein. Or the trunk of the interior thyroid artery may be tied, preferably by Dro- beck's method, as described on page A'2. The dissection is continued close to the capsule, which must nowhere be opened ; every vessel, as it is en- countered, is tied and cut separately after careful inspec- tion, and the lateral surface of the tumor cleared. Its margin is lifted up, starting at one side above and work- ing downward and inward ; the trachea and (esophagus are separated with special regard for the recurrent laryn- geal nerve which lies in the groove between these struc- tures. Thus the dissection is carried from the side as far as the middle line posteriorly. The gland is then drawn forward and upward. The vessels entering it from below are secured and divided and the gland removed. Removal of the Isthmus. 1 — A median longitudinal in- cision is employed. It extends from the upper to the lower border of the enlarged isthmus and involves the in- tegument and superficial fascia. The anterior jugular vein, if encountered, is secured and cut between a double ligature. The interval between the sterno-hyoid and sterno-thyroid muscles is opened up and the muscles drawn aside. The isthmus is exposed after ligating sepa- rately each one of the enlarged veins which may be en- countered in front of it. It is then freed on its upper and lower border and posteriorly with a blunt instrument. The capsule itself must not be opened and every vessel should be tied as it is encountered. An aneurism-needle threaded with a double ligature is then made to perforate the isthmus on each side from be- hind forward at its junction with the lateral lobes, the ligatures are tied, and the intermediate segment of the isthmus removed. 'Jones : Lancet, 1875, Vol. I., p. 120. CHAPTER V. OPERATIONS UPON THE THORAX. AMPUTATION OF THE BREAST. The patient is placed upon her back, inclined some- what toward the opposite side, and the arm abducted so as to make the skin and pectoral muscle tense. Two curved incisions are made, enclosing an elliptical strip of skin of greater or less breadth according to the extent of its implication in the disease, the long axis of which is di- rected toward the axilla ; that is, upward and backward. The upper and lower skin flaps are then dissected off the anterior surface of the gland, its upper border turned, ex- posing the pectoral muscle, and the loose cellular tissue between it and the muscle rapidly divided with a few strokes of the knife, beginning at the upper border of the inner angle, while the gland is drawn away from the chest wall, and the removal completed along the lower in- cision, or at the axillary angle of the wound. Bleeding during the operation must be controlled by clamps upon the bleeding points, and the vessels secured afterward with ligatures or by torsion. The incision is then prolonged just posterior to the anterior fold of the axilla, up to the arm. The axillary vein is exposed at the outer end of the incision, where it is most superficial and is kept constantly in sight as the dissection progresses. The axillary glands whether perceptibly enlarged or not, together with the surrounding fat and connective tissue, are removed en masse. II ai.stkd's Operation. 1 — Halsted's method, in which the greater pari of the pcetoralis major is systematically 1 Annuls of Surgery, 1894. 376 PARACENTESIS OF THE THORAX. -''.77 removed in all cases of carcinoma, is now generally em- ployed, with or without modifications of the skin incision. The main incision broadly encircles the nipple and in- volved skin and is prolonged to the arm along the front of the anterior fold of the axilla ; a second incision passes from the outer part of the first toward the middle of the clavicle. The skin flaps are dissected back, and all the narrower part of the pectoralis, except, perhaps, the fibers coming from the clavicle, is divided close to the humerus. The muscle, with the overlying gland, is then cut away from the chest, the pectoralis minor divided if necessary, and then a very clean dissection made of the axilla, re- moving all the fat and lymphatic glands and the bundle of tissue connecting them with the mamma and pectoralis major. PARACENTESIS OF THE THORAX. Each of the lower posterior intercostal arteries enters its corresponding intercostal space near the spinal column, and passes obliquely from below upward across the space to shelter itself in a groove on the inner side of the lower border of the upper rib. It occupies this groove until it reaches the anterior third of the space, when it leaves it to anastomose with the branches of the anterior intercostal artery coming from the internal mammary. At this point, however, it is so small that its division is not of much consequence. The only part of its course where its injury is to be feared is in the posterior third of the intercostal space before it has passed behind the lip of the rib. Con- sequently, if an opening is to be made into the pleural cavity, cither with a knife or trocar, a point in the middle third of one of the intercostal spaces should be selected, preferably the seventh, certainly not higher than the sixth, nor lower than the eighth on the right side, the ninth on the left. After determining the position of the intercostal space, often a matter of considerable difficulty in consequence of the infiltration of the parts, make an incision parallel to it, one or one and one-half inches in length. Divide the 378 OPERATIONS UPON THE THORAX. tissues layer by layer, until the rib can be distinctly felt with the finger introduced into the wound. Place the end of the finger upon the upper border of the lower rib, and, keeping the knife close to the border, divide the muscles and pleura. If a trocar or the aspirator is used, it must be thrust in with a sharp push so as certainly to penetrate the pleura, which is often thick and tough. The outer end of the canula is then connected with a Dieulafoy or Potain aspirator by means of a rubber tube and the effusion drawn off. A better method is to make use of the prin- ciple of the siphon. After filling the canula and tube, previously rendered aseptic and filled with sterilized water, the end of the tube is occluded and the canula thrust into the pleural cavity. The tube is then conducted beneath the surface of a 1:50 solution of carbolic acid below the level of the patient's bed, and released, thus siphoning off the liquid in the chest. PARACENTESIS OF THE PERICARDIUM. Normally the pericardium is in contact with the chest wall only in the median line under the sternum ; but when its sac is distended with liquid the area of contact becomes much larger, especially by extension downward and to the left. The heart is at the same time pressed upward and backward. The limits of the pericardium can be ascertained with great accuracy by percussion and auscultation, and this should always be done before punc- turing. At the point selected for puncture the pulsations (if the heart should be imperceptible, or at least very faint, and it should be absolutely Hat on percussion. It should also be remembered that the internal mammary artery runs parallel to the side of the sternum, and a finger's breadth from it. If the knife is used the tissues must be divided layer by layer, and the linger should always be introduced into the wound before the pericardium itself is incised, to make -lire thai tie' heart is not in contact with it. C H A P T E R V I . OPERATIONS UPON THE ABDOMINAL WALL. STOMACH, AND INTESTINES. PARACENTESIS OF THE ABDOMEN. In order to avoid injury to the different viscera, and especially to the internal epigastric artery, which runs from the middle of Poupart's ligament toward the um- bilicus, the puncture should be made either in the median line midway between the umbilicus and the symphysis pubis, or midway between the umbilicus and the anterior superior spine of the ilium. The instrument used is a trocar and canula or the needle of an aspirator. The depth to which it shall be allowed to penetrate is regu- lated by the finger placed upon its side, and it should be plunged in sharply, without a preliminary incision, at the selected point, which should be absolutely flat upon per- cussion. As there is a possibility of syncope occurring during the operation, in consequence of the withdrawal of pressure, it is prudent first to pass a broad, many- tailed flannel bandage about the abdomen, crossing its ends behind, so that an assistant standing at each side can draw upon them and tighten the bandage as the liquid escapes. It is usually sufficient, however, to have an as- sistant make steady pressure with one hand on each side of the abdomen. During the operation the patient should be seated or inclined toward one side. Should hemorrhage ensue, the attempt must first be made to control it by the pressure of the canula. This failing, the entire thickness of the abdominal wall must be pinched up and compressed, or, in extreme cases, the wound must be enlarged and the vessel tied. 379 380 A&DOMtNAL WALL STOMAOB, AND INTESTINES. When it is necessary to practice paracentesis upon a pregnant woman, Ollivier recommends the selection of the neighborhood of the umbilicus for the puncture ; Scarpa preferred the left hypochondrium, Velpeau the left flank. LAPAROTOMY. If time permits, preparatory treatment with baths and laxatives is continued for several days, and in a female pelvic case the vagina is rendered as aseptic as possible by numerous 1 : 2000 bichloride douches. An aperient is given the evening before and an enema in the morning of the operation ; the patient passes water or is catheterized immediately before being placed on the table. The prep- aration of the skin surface, the surgeon, the attendants, instruments, and accessories has been already given. Sterilized sponges, round and fiat, and a few on clamps or handles, and pads of gauze should be at hand, and two sterilized basins of warm boiled water, one to contain the clean sponges, and the other, which will need frequent changing, to rinse the soiled sponges. All parts of the patient, except the abdominal snrfaee, all the tables for instruments, sponges, and dressings, and everything not previously sterilized, which may be touched by any person or thing concerned in the wound, are covered with sterilized towels, dry or wet in a 1 : 1000 bichloride of mercury solution. The numbers of clamps. sponges, and pads are written down immediately before tin' operation and verified at the Close. The incision may be made in almost any part of the ab- dominal wall, but is most often median and should divide tin- tissues layer by layer. The linea alba is indistinct below the umbilicus, and if the incision is median one or other rectus sheath will generally be opened. It will (hen be found convenient immediately to unite by a catgut suture the anterior and posterior layers of the opened sheath, and the linea alba can thus be more quickly re- formed at the close of the operation. The preperitoneal fat i- recognized and all bleeding stopped. The perito- neum is then nicked ami the opening enlarged with blunt- LAPAROTOMY. 381 pointed scissors to the length of the abdominal wound, which must be made large enough to permit easy recogni- tion of everything as it is encountered. The position of the bladder must be remembered. The field of operation is then fenced in like a well with ster- ilized gauze pads or Hat sponges, and the viscera outside of the spot in question entirely hidden in the rest of the unopened abdominal cavity. Pelvic operations are much facilitated by the Tren- delenburg position — the hips elevated above the shoulders, thus causing the viscera to gravitate out of the way. Each vessel is secured separately, if possible, before division ; there must be no cutting in the dark and no ligation or large masses of tissue en masse. In general catgut is preferable to silk for almost all pedicles or vessels. At the close of an aseptic laparotomy the perfectly dry and clean wound is inspected for a few moments to be sure that there is no more bleeding ; the clamps, sponges, and pads are removed and counted, and the viscera are then allowed to resume their normal positions. A flat sponge or pad is placed over the viscera in the abdominal wound to protect them and to absorb such blood as may flow from the needle punctures, and over this the wound is closed by various methods. Silk, silver wire, or silkworm-gut can be passed through the whole thickness of the abdominal wall and periton- eum, from half an inch to an inch from the margin of the wound, and about the same distance apart ; the amount of tension necessary in tying them will vary with the thickness of the abdominal wall, its laxity, or distention. Before the last one or two arc tied the protecting sponge is withdrawn. ( )r the peritoneum may be first sutured over the sponge by the continuous or interrupted catgut suture and the sponge withdrawn before it is entirely closed, then sutures of silk, silver wire, or silkworm-gut are passed ;i- before, but only through the parts in front of the peritoneum ; or after closing the peritoneum and re- moving the sponge the overlying parts can be sutured with catgut, layer by layer. Schede l recommends buried 1 Centrulblatt fur Chirurgie, 1893. 382 ABDOMINAL WALL, STOMACH, AND INTESTINES. sutures of silver wire for all the layers except the perito- neum and skiu. In a continuously aseptic wound the sutures should not be removed for at least seven days, and then with every antiseptic precaution, especially if they include the peritoneum. The sutured wound may he covered with a strip of sterilized rubber tissue. Iodoform gauze is next applied, and over this layers of plain, sterilized, or bichloride gauze. This is held in place with a couple of transverse strips of adhesive plaster and covered with a layer of sterilized absorbent gauze, and the dressing completed by a broad abdominal binder or a broad roller bandage applied cir- cularly around the body and each thigh in the form of a spiea to prevent slipping. The sponges contaminated in the course of a lapar- otomy, where any form of sepsis or noxious element is present, should be kept apart from the others as far as possible, and only used in the contaminated area, which latter must be kept separated by sterilized sponges or pads, with the utmost care, from the rest of the abdominal cavity. The towels in the neighborhood of the wound are changed or covered with clean ones as fast as they become soiled, and the wall of pads or sponges surround- ing the operation area must be replaced by fresh ones when they become saturated with the noxious materials, and without disturbing the position of the protected viscera. The wound at the finish is made as clean and dry as possible. Wherever peritoneum has been divided or stripped up it should be replaced and secured with fine catgut sutures. There may remain a large denuded area liable to infection or studded with line bleeding points, as, for instance, after dissection of an adherent tumor. This can be convenient!}' treated with a large; square of iodoform or sterilized gauze, the center of which is tucked down into contact with this area, and the edges brought out of the abdominal wound. Other strips of sterilized gauze are packed into this as into a bag. If pus has been OPERATIONS ON THE INTESTINES. 383 present one or more sterilized drainage tubes of rubber or glass with lateral perforations must be run down from the surface to the bottom of the infected region. Sometimes a strip of gauze is packed inside of the tubes to aid the escape of fluid on the principle of capillarity. And this strip is frequently changed with every antiseptic pre- caution. In female pelvic cases it may be desirable to pass a tube through a counter-opening in the vault of the vagina. Hence the necessity of the preliminary cleansing of the vagina in every case where there is even a possibility of pelvic complications. The vagina is afterward packed with sterilized or iodoform gauze, the vulva covered with an antiseptic dressing, and the patient catheterized for several days subsequently. After inserting the tubes, and with as little displacement of the protected viscera as possible, the sponges or pads are removed and counted and their places supplied by a light packing of strips of iodoform or simple sterilized gauze, the ends of which protrude through the incision. Before packing the wound it may be advisable to flush out the infected region with warm boiled water or sterilized salt solution, and some- times a large part of or the whole peritoneal cavitv is thus treated and counter-openings for drainage, with packing, are made. At the close of the operation the peritoneum is first sutured over a sponge or pad down to the point of exit of the tubes and packing, and the sponge then removed. The overlying parts are drawn together to a correspond- ing extent with silk, silkworm-gut, or silver wire passed through everything in front of the peritoneum, and a dressing which covers the euds of any tubes is then ap- plied, as in an aseptic case. OPERATIONS ON THE INTESTINES. Anatomy. (Fig. 1ST.) — The parts of the intestines which have a mesentery are completely covered by peritoneum except along a narrow interval where the laminae of the mesentery diverge to encircle the bowel 384 ABDOMINAL WALL, STOMACH, AND INTESTINES. Fig. 187. ( Fig. 187, 2). Thus the outer wall of the gut, along the line where the mesentery meets it, is formed by a strip of the muscular coat about five-sixteenths of an inch wide (Fig. 187, 3), and this is apt to be the weak point in a row of sutures involving this portion of the circumference of the bowel. The arteries in the mesentery form freely anastomosing loops from which, close to the intestine, arise straight vessels with little or no intercommunication, and having a circular and fairly well-defined distribution, so that, while a portion of the mesentery at a distance from the intestine may be destroyed with comparative im- punity, an injury to the smallest part in immediate proximity to the gut involves a probability of sloughing of a corresponding ex- tent of intestine. An anatomical knowledge of the mesentery is of value in a search for the upper or lower end of the small intestine. The pari- etal attachment of the mesentery extends from the left side of the second lumbar vertebra downward to the right iliac fossa, and, if the finger trace the left layer of the mesentery of a loop of intestine back toward the spine, it passes off toward the left side of the abdo- men, and the right layer will lead to the right side of the abdomen. This will show which end is the upper or Lower iii any particular loop. Also the upper part of the small intestine has a greater di- ameter, is thicker walled (valvulae conniventes), and more vascular than the lower part. The coats of the intestine from without inward are: (1) the peritoneal, (2) the lon- gitudinal, (3) circular muscular, (-T) the submucosa, a tough fibrous membrane, (5) the muscularis mucosae, and Section of smalt intestine and mesentery. 1. Mesentery. 'J. Triangular space between di- verging layers of the mesentery. 3. its base resting on m, tne muscular coal of the gut, /'. Peritoneum, m. m. M u co ii a membrane. OPERATIONS ON THE INTESTINES. 385 (6) the mucosa, the latter making- up about two-thirds of the thickness of the wall. Unless the suture includes a shred of the submucosa it is very apt to tear out. This coat is recognizable by the increased resistance which it offers to the passage of the needle after the peritoneal and muscular layers have been transversed. 1 The colon and sigmoid flexure are recog- nizable by their corrugations, their more or less fixed positions, the appendices epiploic^ which are most numer- ous in the transverse colon, and by the longitudinal bands of muscular fibers. The anterior band is the largest and most prominent, and lies in front of the caecum, colon, and sigmoid flexure. In the transverse colon it corre- sponds to the attachment of the great omentum, and in the ascending colon and caecum it is the unfailing guide to the appendix vermiformis, from the attachment of which to the caecum the anterior, inner, and posterior longitudinal bands all start. The appendix lies about opposite a point indicated on the abdomen by the center of the line passing from the right anterior superior spine of the ilium to the umbilicus. It may or may not have a mesentery and commonly lies behind the lower end of the ileum, and often in close relation with the iliac ves- sels and ureter, and is not infrequently found in the pelvis. To be successful the closure of an intestinal wound must be water-tight, and no stitch may perforate all the coats ; there must be no subsequent giving way of any part of the wound, either from slipping of a suture or ulceration or sloughing at the site of its insertion, and the lumen of the bowel must not be unduly narrowed. A round sewing needle and black silk are generally used. The continuous suture is applied like the ordinary con- tinuous suture already described, and is carried a short distance beyond the extremities of a longitudinal wound. The needle penetrates the peritoneal and muscular coats of the intestine, catching up a few fibers of the submu- cosa, but nowhere perforating the mucosa. The stitches are placed at intervals of about a quarter of an inch close to 'Enilsted : American Journal Medical Sciences, 1887, p. 4:'.f>. 386 ABDOMINAL WALL, STOMACH, AND INTESTINES. the margins of the wound, which are turned in to bring the peritoneal surfaces in apposition. The right-angled continuous suture (Fig. 188) differs from this last only in having the buried portions parallel to the line of the wound and the exposed portions at right angles to it. The continuous suture can be rapidly applied, and is useful for reinforcing weak points in an interrupted suture Fig. ism. 11 8 Right-angled continuous intestinal suture. (Geeig Smith.) line, hot it is inapplicable for closing a complete trans- verse division of the bowel. All parts of the continuous suture may not be drawn equally tight, and the contrac- tion of the gill tends to loosen if and allow the wound to Tin interrupted suture oj Lembert is the most approved and generally used intestinal suture. The needle pene- trates a fold of tln> peritoneal, muscular, and a few shreds OPERATIONS ON THE INTESTINES. 387 of the submucous coat of the gut on opposite sides of the wound, the margins of which are inverted and the perito- neum brought together. The sutures .should be placed about on eighth of an inch from the margin of the wound Fig. 189. Diagram representing the method of inserting the Czerny-Lenibert suture. The Lembert suture is below, the Czerny at the cut edge, and about the same distance apart, and each should grasp a fold of the intestine about one-tenth or one-twelfth of an inch wide. None must touch the mucosa. Fig. llio. Ualsted quill suture for the iutestiui 388 ABDOMINAL WALL, STOMACH, AND INTESTINES. ( \tilt suture* (Fig. 1!'<)) will hear a eonsider- ahle strain. It is a modification of Lembert's method. The needle penetrates the superficial coats of the gut twice on eacli side of the wound and is then knotted. CIRCULAR ENTERORRHAPHY. This is the usual term for designating an end-to-end suture of the intestine from which a segment has been re- moved. Operation. — The loop of intestine is carefully drawn out of the abdomen and surrounded by warm pads or sponges while the opening into the peritoneal cavity is protected by a gauze or sponge packing. The feces are squeezed out of the loop, and about an inch above and be- low the limits of the segment of gut to be removed the in- testine is constricted tightly enough to close its lumen, either by the lingers of an assistant or by one of the specially designed clamps, or by a strip of iodoform gauze, which is passed through a small hole made in the mesentery by ;i bllini instrument at :i little distance from the Mnt and tied snugly about it. After thoroughly pro- tecting the exposed peritoneal surface, at the spot selected on the lower side of the disease, the intestine is divided squarely across and its interior immediately irrigated with warm boiled water. With :i dean pair of scissors, the mesentery of the diseased part i> cut as close to the gut :i- possible up to the intended upper point of the intestinal division, where tin' intestine is then cut squarely across, and the interior below the constricting gauze band im- mediately irrigated ;is before. 1 \ 1 1 1 • ■ i j < ;i 1 1 Journal Medical Sciences, October. 1887. < li;< 7 7.. I /,' ENTERORRK I /'//)' 389 The divided mesentery, if broad, may be partly resected triangularly and its sides sutured together. Bleeding is checked I>y separate Ligation with tine catgut of each vessel. Meanwhile every portion of* peritoneum is scrupulously protected from infections matter, and before the next step instruments which have touched infections Fig. 101. ( Jirenlar enterorrhaphy. matter or the interior of the intestine arc discarded and the hands carefully washed. The ends of the gut are then brought into apposition and the mucous membrane united evenly all around by a continuous catgut or silk suture. The mesenteric border of the gut is drawn together by a Lembert silk suture, and then the opposite free border. By gentle traction on the ends of these sutures (Fig. 191) the gut is flattened out and on the line thus indicated the necessary number of 390 ABDOMINAL WALL, STOMACH, AND INTESTINES. Lembert sutures arc added, but uot tied till the last is in place. The peritoneal surfaces must be very carefully brought into contact at the mesenteric attachment of the bowel to avoid leakage into the areolar tissue between the diverging layers of the mesentery ; but weak points must not be so reinforced by continuous or interrupted sutures that the lumen of the intestine becomes unduly narrowed. The fold of detached mesentery is drawn together at its cut edge with catgut, and if long enough it is sometimes advised to suture its peritoneal surface over the line of in- testinal union as far as it will reach without tension. Scnn sutures the great omentum over the outer row of Lembert sutures and has thus covered a circular enteror- rhaphy with a detached omental graft an inch wide and long enough to encircle the bowel. ' The parts arc again irrigated with warm boiled water, the intestinal clamps or gauze bands are removed together with the protective sponge packing, and after returning the gut to the abdo- men the parietal wound is closed in the usual way. INTESTINAL ANASTOMOSIS. This is the formation ofa lateral communication between the lumina of two different portions of the gut. Owing to the contraction in the calibre of the intestine which follows circular enterorrhaphy, this operation of anastomosis is frequently adopted in its place; though it was originally introduced as a palliative means of relieving an irremov- able obstruction of the bowel by uniting the parts above and below the obstruction. Operation. — Above and below the obstructions healthy portions of the gut are selected which can be brought into apposil ion without tension, along several inches of surface. The rest of the peritoneal cavity is walled oil' wit h sponges, and if possible the selected loops of intestine arc drawn out of the abdomen ami surrounded by warm cloths. About one-quarter of an inch to the under side of the center of the Convex i'vrc border as \\\c intestine lies e\- ■Trans. Im. Med. Cong., 9th sessi Washington, L887, Vol. I., p. 485. INTESTINAL ANASTOMOSIS. 391 posed, the apposing loops arc united for about five inches by a continuous silk suture through the peritoneal coats alone. About an inch above and below this suture line, on each loop, an iodoform-gauzc band is passed through the mesentery, at a little distance from the intestine, and tied around the gut just tightly enough to prevent the en- trance of fecal matter. Each loop is then opened along its convex free border for nearly the same distance (about four inches) parallel to and immediately in front of the Fig. 192. Senn's plates, n, a. Lateral or fixation suture, b, ft. End or apposition suture. Thread passed through 2 is brought out through 1, and thai through 4 out through 3. (Treves.) row of sutures already in place. The openings should terminate opposite each other about half an inch short of the end of the suture line. The interior of each isolated loop is immediately irrigated clean with warm boiled water while the exposed peritoneal surface is protected as far as possible. Soiled towels or protecting sponges are then replaced by clean ones, anything which has touched the interior of the intestine or its contents is discarded and the hands 392 ABDOMINAL WALL, STOMACH, AM) TNTESTINES. carefully washed. Alter this the edges of the two open- ings are united to each other all around by a continuous catgut or silk suture. The exposed parts are again irri- gated and the protectives and instruments changed. Fig. 193. Intestinal anastomosis, with Senn's plates, ». u. Lateral or fixation sutures, /», b End or'apposition sutures c. Posterior sutures. (Senn.) Finally, a continuous silk hiIiiiv, beginning and ending with the one already placed, is applied along the skin- Bide of the opening. In cases of enterectomy the segment of gut to be re- moved i~ excised :i~ described in circular enterorrhaphy. INTESTINAL ANASTOMOSIS 393 Theopen endsofthe intestine are then turned in to bring peritoneal surfaces into contact, and closed by a continu- ous silk suture curried hack and forth once or twice and in no spot entering the mucosa. The constricting gauze hands are removed from the intestine and the anastomosis proceeded with. Senn ' reinvented and greatly improved the forgotten method of uniting' different portions of the gut laterally by means of perforated absorbable plates which bring into contact broad areas of peritoneum around a central opening. Two contiguous loops of intestine are opened to the same extent longitudinally, on the side opposite the at- tachment of the mesentery, and sufficiently to admit the plates edgewise. After introduction the plates arc rotated enough to make their perforations correspond to the open- ings made in the intestine. About a quarter of an inch from the margins of the openings on each side, the wall of the intestine is perforated by the two lateral sutures which are armed with needles. The other two sutures are tied across the extremities of the openings without perforating the intestinal wall. The sutures serve the double purpose of holding the parts in apposition and keeping the openings patent. After the parts are brought together union is further secured by a continuous or interrupted suture through the peritoneal coat around the margins of the plates. The plates, which Senn made of decalcified bone, are supposed to become absorbed or disintegrated between the third and tenth days. This method has been largely abandoned in this coun- try on account of the later eontraction of the fistula. The Murphy " button " has attained great and growing popularity as a means of uniting different portions of the intestine. A description of the device and its application will be found in the paragraphs on cholecystenterostomy. Quite recently a satisfactory substitute has been found in 'Trans. Int. Med. Cong., 9th session, Washington, 1887, Vol. I., p. 435. 304 ABDOMINAL WALL, STOMACH, AND fNTESTJNES. a piece of raw potato perforated and fashioned into simi- lar shape. Various methods have been devised for uniting por- tions of gut of unequal diameter, but they have now been generally superseded by closing the transversely divided ends and performing lateral anastomosis. Union of Divided Intestine by Tntussusception. (Maun- sell.) 1 — The disease is excised by transverse division of the gut as described in circular enterorrhaphy. The cut ends of the intestine are united by one suture through the entire wall at the point of the mesenteric attachment and Fig. 194. Maunsell's method; fir. 245. NELATON'S OPERATION. 395 ENTEROSTOMY, [nstead of excision of a portion of the gut with imme- diate restoration of its continuity by circular enterorrhaphy or lateral anastomosis, circumstances such as an uncertain amount of gangrene, the had condition of the patient, etc., may require that the bowel be simply freed from its con- striction and the damaged part left outside the abdomen till the slough separates. It is fastened to the margins of the abdominal wound by a couple of sutures. In course of time it is treated by the method described for the closure of an artificial amis. Maunsell's method; protruding ends ready for suture. RIGHT INGUINAL ENTEROSTOMY I NELATON S OPERATION). As long- ago as 1819, it was proposed to establish an artificial amis in the ileum in ease the intestinal obstruction could not be found or removed by laparotomy ; but Nela- ton was the first (1840) to substitute this for the other operation, giving up the search after the obstruction en- tirely. His theory was that many obstructions would relieve themselves in time, if a temporary outlet should be furnished to the accumulation above; in some cases, on the other hand, where the obstruction is permanent, an 396 ABDOMINAL WALT,. STOMA elf. AND INTESTINES. artificial anus in the ileum meets the "vital indication perfectly — for example, when the obstruction is in the lower portion of the small intestine; while in others, again, where the occlusion occurs below the ileo-caecal valve, and the relief afforded would, consequently, be im- perfect, the obstruction is usually due to malignant dis- ease, which in itself would soon destroy life and against which neither laparotomy nor any other operation would avail. It is also essential to the proper nourishment of the patient that the greater part of the small intestine should remain serviceable; that is, that the opening should be made in the lower part of the ileum. ( )f course, this can- not be accomplished when the obstruction is situated high up, but, in other cases, Nelaton found that the intestinal loops nearest the obstruction always occupied the right iliac fossa, and he, therefore, cut through the abdominal wall just above the outer half of Poupart's ligament on the right side, and opened the first loop that presented in the incision. The portion of the intestine below an obstruction is always empty and shrunken, and docs not come into contact with the anterior abdominal wall, so that there is no danger of making the opening in it by mistake. It occasionally happens when the obstruction is situated in the colon that the distended caecum fortu- nately presents in the incision, and the artificial anus is established below the ileo-caecal valve. Operation. — Make an incision parallel to and about an inch above Poupart's ligament, beginning at the anterior superior spine of the ilium and ending opposite the in- ternal abdominal ring. Divide the tissues layer by layer, pick up and nick the peritoneum and open it for about one and a-half inches. The first distended intestinal loop which presents is drawn out till its free border is on a level with the skin, and re- tained by two silk suture.-, which, at the same time, draw together the extremities of the abdominal wound. Bach suture passes through all the parietal tissues and the peri- toneal and muscular coats of the intestine. The skin ami COLOSTOMY 397 bowel are closely united all around by interrupted sutures, none of which must enter the lumen of the gut. The suture line is covered by a strand of iodoform gauze pasted down with flexible collodion, and the center of the protruding intestinal wall opened in its long axis for about half an inch. The parietal peritoneum can be drawn out and stitched to the skin before the bowel is sutured in place, thus bringing into contact a larger surface of parietal and vis- ceral peritoneum. COLOSTOMY. Left Inguinal Colostomy. — Make an incision between two and three inches long, according to the thickness of the abdominal wall, parallel to and about an inch above Poupart's ligament, with its center at the level of the an- terior superior spine of the ilium, or a little lower. The tissues are divided layer by layer, the peritoneum opened, and the skin and parietal peritoneum united by a few sutures, not including the muscles. The sigmoid flexure, which is recognized by its anterior longitudinal band, its convoluted surface, or appendices epiploic*, is drawn into the opening and retained by a couple of silk or silkworm- gut sutures passed about two inches apart through both lips of the wound at its extremities and the longitudinal band of the colon. The gut is then closely united to the margins of the wound by fine silk sutures passing through the already joined skin and peritoneum and the outer coats of the intestine. No suture should penetrate to its interior. The amount of the circumference of the gut to lie external to the sutures is about half an inch when the operation is for the temporary relief of obstruction. For a permanent artificial anus two-thirds of the circumference of the bowel should lie anterior to the suture line. The center of the exposed intestinal wall is then opened longi- tudinally with a knife or thermo-eautery for about half an inch and drainage tubes inserted. Before opening the bowel the suture line can be cov- ered with a strip of iodoform gauze pasted over with flexi- 398 ABDOMINAL WALL. STOMACH, AND INTESTINES. ble collodion. It" there is no urgency the opening can !><■ deferred for five or six days till adhesions have shut oft" the general peritoneal cavity. Some surgeons prefer not to unite the skin and parietal peritoneum, but to suture the outer coats of the intestine to the skin alone. The gut adhering to all parts between the skin and parietal peritoneum is thought less liable to retract than it' adherent only to the intervening parietal peritoneum with its movable subserous areolar tissue. Maydl ' hangs the intestine on a sterilized rod passed through the mesentery close to the bowel and laid on the skin transversely to the wound. The apposing walls of this loop are united by a few interrupted sutures through the peritoneal coats and the rest of the walls left to ad- here to the abdominal wound ; but if immediate opening is intended, the sutures are passed through the skin and peritoneum around the margins of the incision, and through the serous and muscular coats of the nut. com- pletely shutting off the peritoneal cavity. The exposed wall of the intestine is opened transversely for one-third of its circumference, and drainage tubes placed within it. Two or three weeks later the bowel is entirely divided on tin- line and the cut edges sutured to the skin for a per- manent artificial anus. If the operation is merely temporary the intestine is Opened longitudinally, and when adhesion- have formed the rod is withdrawn, and the bowel retracts and the Hstula sometimes closes spontaneously. Right inguinal colostomy only diners from the last oper- ation in that t he abdominal incision i> placed on the righl Bide and the caecum is opened instead of the sigmoid flexure. Iii either righl or left inguinal colostomy the opening in the abdominal wall may be made by the " inter-mus- cular" method devised bv Dr. McBurney for operations upon t he appendix (q. v.). It seem- probable that a certain amount of sphincteric control of the opening may be thus obtained. ■Central!), i. < Mr.. 1---. So. 24. COLOSTOMY. 309 Lumbar Colostomy. — This operation was first suggested by Callisen, 1 in 1797, as a substitute for Littre's or in- guinal colostomy with a view to avoiding the dangers in- cidental to an incision through the peritoneum. He pro- posed to open the descending colon in the posterior third of its periphery, where it is not covered by peritoneum. So far as known, Amussat was the first to perform the operation in 1839, and although he opened the ascending colon, and by a transverse instead of a vertical incision, the operation was essentially the same as that proposed by Callisen. All that portion of the descending colon which lies above the crest of the ilium is usually uncov- ered by peritoneum on its posterior aspect, and although the actual breadth of the uncovered portion varies with the degree of distention of the bowel, it usually amounts to one-third of the entire circumference, and is bounded on each side by one of the three longitudinal bundles of unstriped muscle characteristic of the colon. In position it corresponds nearly to the outer border of the quadratus lumborum, and very exactly to a vertical line drawn a full half inch behind the center of a transverse one, unit- ing the anterior and posterior superior spines of the ilium (Mason). On the right side (ascending colon) the un- covered portion is more often smaller, and the existence of an actual meso-eolon, although rare, is yet more fre- quent than upon the left side. Callisen proposed a vertical incision a little external to the outer border of the erector spina? ; Amussat made a transverse one midway between the last rib and the crest of the ilium, while Baudens used an oblique one passing downward and outward at an angle of 45°. The latter is to be preferred, because, while giving sufficient room, it inflicts less injury upon the vessels and nerves of the parts, the general direction of which is the same as that of the incision. The operation is performed as follows : The patient is etherized, and placed in a position midway between the 1 Erskine Mason: Six Cases of Lumbar Colotomy, A hut. Journ. of Med. Sciences, < M., 1873. 400 ABDOMINAL WALL, STOMACH, AND INTESTINES. prone and right lateral, a hard cushion being placed trans- versely under the right loin to keep the spine straight or slightly curved toward the left. Mason says the opera- tion has been performed with the patient seated and lean- ing forward over the back of another chair, local anaes- thesia being obtained by means of the ether spray. The anterior and posterior superior spines of the left ilium are then recognized, and a vertical line drawn upward from a point one-half to three-quarters of an inch behind the center of a transverse line drawn from one to the other. This vertical line should be marked with iodine or nitrate of silver, in order to serve as a guide during the operation. If the occlusion of the intestine has not been complete, and there is reason to suppose that the colon will be found empty, it may now be distended by injecting air through the rectum. A transverse or an oblique incision four or five inches long is then made, its center lying in the vertical line above mentioned midway between the last rib and the ilium. The underlying tissues arc recognized and divided layer by layer, until the fascia transversalis and quadratus lumborum arc reached. The former is next carefully di- vided, and, if the adipose tissue covering the colon does not then appear in the wound, the latter should be enlarged on the inner side by dividing the outer fibers of the quad- ratic. The intestine must alwavs be sought for in the angle of the wound nearest the spine, and whenever it is desired to increase its exposed area this must be done in the same direction. The colon can usually be recognized l>v its distention and shape, and possibly by one of its longitudinal bands. Two stout ligatures arc next passed by means of curved needles through the presenting portion of intestine and used to draw it up into the wound, and fasten it to the skin at the sides of the incision. The wound is then filled with sponges or gauze, and the bowel opened by a longitudinal or crucial incision. A.s soon as the discharge hag ceased, the sponges or gauze are withdrawn, the parts cleaned, th< extremities of the tegumentary wound closed CLOSURE OF AS ARTIFICIAL ANUS. 401 with sutures, and the edges of the opening in the intestine made fast to the skin with a few sutures of fine silk. CLOSURE OF AN ARTIFICIAL ANUS OR FECAL FISTULA. If the opening in the gut is large, the remaining part of the intestinal wall is pressed forward into it and forms a sort of valve or spur, which prevents more or less com- pletely the descending current of feces from entering the lower segment of the bowel. If this spur were absent the fistula might close sponta- neously, and to accomplish its removal Dupuytren's enter- otome was formerly introduced through the opening and Fig. 196. Dupuytren's enterotome. clamped upon the spur, which was thus cut through by four or five days of continued pressure. Immediately before undertaking any operation the lumen of the gut above and below the fistula is plugged by a sponge tied to a string which serves to withdraw the sponge when all is ready to close the intestinal opening. The interior of the gut is then irrigated clean and the skin surrounding the fistula thoroughly scrubbed and washed with bichloride solution. In most cases the fistulous tract between the intestine and skin is lined with mucous membrane, and if the spur is slight or absent; an attempt to close the fistula should 26 402 ABDOMINAL WALL. STOMACH, AND INTESTINES. first be made by separating the mucous membrane at its junction with the skin, and after removing the sponge plugs, inverting it. and uniting the freshened surfaces with tine catgut. Over this the pared edges of the ab- dominal opening are sutured with tine silk, aided, if necessary at the sides, by liberating incisions through the skin and fascia. If this fails or a more elaborate operation seems neces- sary, an incision two or three inches long is carried across the fistula in any suitable direction, and layer by layer down to the peritoneum. This is opened at one ex- tremity of the incision and a finger inserted into the abdomen to determine the limit of the adhesions; and as soon as possible the peritoneal cavity is walled off by sponges packed in around the open intestine, which has been previously plugged above and below as already de- scribed. Cutting on the linger as a guide, the gut is separated from its parietal attachment around the fistula, and if possible drawn out of the abdomen and constricted above and below the pings by gauze bands passed through the mesentery. The sponge plugs are withdrawn, the interior of the gut irrigated, and, if the opening Is -mall, its edges are fresh- ened and inverted, and the peritoneal coat drawn together over it with Lembert sutures. The constricting bands are removed and the gut returned to the abdomen, which i- closed in the usual way. If the opening is extensive, the damaged segment of the gut is excised and circular enterorrhaphy or lateral anastomosis done. The fistulous tract is then dissected out of tin- ab- dominal wall and the wound closed. THE OPERATION FOR THE REMOVAL OF THE VER MIFORM APPENDIX. [n a case of appendicitis operated on in the period of quiescence, an incision three or four inches long is made at the outer border of the right rectus muscle, with its .•enter about on the line joining the umbilicus and the an- terior superior -pine of the right ilium. The lower ex- REMOVAL OF THE VERMIFORM APPENDIX. 403 treinity of the incision should not reach the deep epigastric artery, the course of which is indicated by a line drawn from the femoral ring to the umbilicus. The tissues are divided layer by layer, all bleeding stopped, and the peritoneum pinched up and opened. Adhesions arc separated by the finger-nail or blunt- pointed scissors, and it' necessary divided between ;i double ligature. The anterior longitudinal band of the colon is traced to its origin at the root of the appendix. After walling- off the surrounding peritoneum with a sponge packing, the appendix is isolated and a double ligature of stout catgut passed by an aneurism needle through its mesentery close to the root of the appendix. The needle is withdrawn, the loop of the ligature cut, and on one side the mesentery, which usually contains a single artery, is tied off, and on the other side the ap- pendix is ligated as close to the caecum as possible. The mesentery and appendix are then excised close to the dis- tal side of the ligatures. The csecal stump of the appen- dix is held isolated and in view till thoroughly cauterized with the Paquelin or pure carbolic acid, but in using the latter care must be taken to prevent its spreading to the neighboring surface of the csecum. The sponge protectives are then removed, the parts al- lowed to assume their normal position, and one end of a strand of iodoform gauze is placed in contact with the cauterized stump and the other end brought out of the abdominal wound. The peritoneum and overlying parts are closed in the usual way except where the gauze drain emerges. Here a suture of silk is passed through the entire thickness of the abdominal wall, including the peritoneum, and left un- tied till the drain is removed forty-eight hours later. This must be done with every antiseptic precaution, and only done if no inflammatory symptoms exist. The dressings then applied are left undisturbed about ten days. Instead of ligating the appendix as described it may be inserted into the colon as follows : A fine silk suture is passed circularly a little beyond the base of the appendix, 404 ABDOMINAL WALL, STOMACH, AND INTESTINES. in and out through the serous and muscular layers of the colon, like a purse-string. The appendix is cut off about half an inch from its base, and a silk suture tied across the cut end at its center. Against this suture is enk~ for closing gastrostomy fistula. CASTnOTOMY. 411 In cases where the stomach need not he opened for some days it is sufficient, after uniting the skin and pari- etal peritoneum, to pass a couple of harelip pins through its outer coats, enclosing a portion of the stomach wall about three-quarters of an inch square. The pins are simply laid upon the skin transversely to the abdominal wound, and the opening made in the center of the square they enclose after adhesions have formed. A crucial abdominal incision below the ensiform proc- ess was used by Scdillot. Others have employed a vertical incision in the linea alba, in the substance of the outer part of the left rectus, or in the left linea semi- lunaris. Halm opened and fixed the stomach in the eighth in- tercostal space after first entering the abdomen by an in- cision parallel with the lowest rib. 1 GASTROTOMY. This is the operation in which the surgeon opens the stomach and then closes the opening at the conclusion of the operation. Operation. — If it is performed for the removal of a for- eign body which can be felt through the anterior abdom- inal wall, the incision, at least two inches long, is made over the tumefaction and in the direction which inflicts the least damage on the intervening tissues. Otherwise the incision is made in the median line just below the ensiform process or parallel to the left costal cartilages, as in gas- trostomy. The tissues are divided layer by layer, the peritoneum opened, and one finger introduced to locate the foreign bod v. After protecting the surrounding peritoneal surface by gauze pads or sponges, the part of the stomach wall to be opened is carefully drawn into the abdominal wound and held there by a couple of temporary retention sutures passed through the peritoneal and muscular coats on each side of the intended opening, which is then made parallel to the course of the blood vessels, that is, transversely to iCentraJb. f. Chir., 1890, p. 193. 412 ABDOMINAL WALL, STOMACH, AND INTESTINES. the lon»r axis of the stomach. The foreign body is re- moved gently, with due regard for its sharp points, or the ulceration or sloughing which may exist, and if necessary the stomach is washed out. There must be as little spong- ing or irritation of its interior as possible. The incision in the stomach is closed by a continuous silk suture of the mucous membrane, then by a row of Lembert sutures, which are reinforced by a continuous silk suture through the peritoneal coat. After the region of the wound has been made dry and clean, the temporary retention sutures are withdrawn, the protecting sponges are removed from the abdominal cavity and the parietal wound closed and dressed as described for an aseptic lapa- rotomy. Greig Smith does not suture the mucous membrane of the stomach, but closes the wound by a row of Lembert sutures reinforced by a continuous or interrupted suture of the peritoneal coat. The continuous suture prevents gap- ing of the wound during expansion of the stomach. By gastrotomy Bull ' and Richardson successfully re- moved foreign bodies impacted in the oesophagus near the cardiac orifice of the stomach. Richardson demonstrated that the lower three inches of the oesophagus are thus accessible by an incision parallel to the left costal carti- lages, through which he introduced his whole hand into the stomach and extracted a set of false teeth from the lower end of the gullet." Gastrotomy for Benign Stenosis of the Pyloric or Cardiac Orifices. (Sometimes called Loretta's operation.) — Before the operation the stomach is washed out repeatedly with an alkaline solution. The pylorus is reached by an in- cision four or five inches long, usually in the linea alba between the xiphoid appendix and the umbilicus ; or else approximately parallel to and about an inch from the right costal cartilages, starting an inch below and an inch and a-half to the left of the xiphoid appendix and ter- minating near the Level of the cartilage of the ninth rib. 1 New V<»rk Medical Journal, October -'.>, 1887. 1 Lancet, October 8, 1887. GASTROTOMY 413 The tissues are divided layer by layer, and the peri- toneum opened. The surrounding peritoneal surface is protected and held out of the way in the usual manner, while the pylorus is sought for, and such adhesions as may exist are divided between double catgut ligatures. The anterior wall of the stomach is drawn into the abdominal wound, and after again carefully protecting the surrounding peritoneal surface is incised transversely for from one to three inches between its two curvatures near the pylorus, but outside of the inflammatory zone ad- joining it. Guided by two fingers grasping the pylorus externally, the forefinger of the right hand is passed through the stomach into the pyloric orifice. This may Fig. 201. B A Pyloroplasty. A. The incision, A, B, alone the contracted pylorus. B. (Insure of this wound transversely. The point A united to B. require considerable force, or the orifice may have be- come so contracted that preliminary dilatation with some small instrument is necessary. McBurney used a small bivalve anal speculum. Dilatation is continued till it is felt that any further stretching would threaten a rupture of the viscus. The wound in the stomach is then sutured as described in gastrotomy for a foreign body, and, after cleansing and drying the field of operation and removing the protective pads or sponges, the parietal wound is closed as usual. To reach the cardiac orifice, the abdominal incision is made obliquely from a point just below the ensiform proc- 414 ABDOMINAL WALL, STOMACH, AND INTESTINES. ess parallel to and about one inch from the left costal curtilages. The anterior wall of the stomach is opened l)v a longitudinal incision made between the two curva- tures and as near the cardiac end as possible. Pyloroplasty. — Instead of performing gastrotomy and divulsion of the pylorus, the stricture can be relieved by longitudinal division followed by transverse reunion. (Fig. 201.) The median or right oblique abdominal incision is employed, any adhesions about the pylorus are separated, and after carefully walling off the surrounding peritoneum with sponges an incision opening the lumen of the viscera about an inch and a-half long is carried across the py- loric ring, through the neighboring anterior wall of the stomach and first part of the duodenum. The opposite extremities of this incision are then united to each other to form the center of an apparently transverse wound, which is closed by the Czerny-Lenibert suture. The parietal incision is then closed tight in the usual way. GASTRORRHAPHY. This is the operation for closing a wound or opening in the stomach, or to diminish its capacity by creating a permanent longitudinal fold in its anterior wall (Gastro- plication ). Operation. — If it is undertaken to close a gastric fistula, the interior of the stomach, the fistulous tract, and sur- rounding skin are made as clean as possible. A sponge tied to a string is pushed through the fistula and held by an assistant against its interior orifice. An incision is then made not less than two inches long in any conve- nient direction across the fistula and through the abdom- inal wall, layer by layer, until the peritoneum is reached. This is opened ;it line extremity of the wound and a fin- ger inserted to determine the limit of the adhesions. < >n this finger as a director, the peritonea] incision is enlarged around the fistula, which is then surrounded l>y sponges packed into the abdominal cavity. The Liberated -loin- aeh i- drawn into the abdominal wound, and the margins of the opening in the stomach freshened and closed as GASTBOBRHAPHY. 415 described in gastrotomy, after withdrawing the sponge from the interior of the stomach. The fistulous tract is excised from the abdominal wall, and, after the operation area has been thoroughly cleansed and dried, the wound is closed in the usual way with or without a gauze packing. If the operation is undertaken for a perforating wound or ulcer of the stomach, immediately after opening the peritoneal cavity by an ample incision, either median, just below the ensiform process, or parallel to the left costal cartilages, all extra vasated material must be sponged away or irrigated out of the peritoneal cavity with boiled water, and the opening in the stomach closed as described in gastrotomy. The operation area is walled around by sponges or pads and a sponge is then passed into the lesser peritoneal sac through a small opening made in the great omentum, between the stomach and transverse colon. If the lesser sac is found infected, or there is even a suspicion of an opening on the posterior surface of the stomach, this opening must be sought for and closed. If it cannot be reached and sutured through the great omentum (between the stomach and transverse colon), rather than leave it unclosed, Greig Smith advises an incision in the anterior wall of the stomach, through which the opening in the pos- terior wall may be closed from within. After everything has been made as clean as possible, and all sponges re- moved from the abdominal cavity, tubes surrounded by a plentiful gauze packing should extend into all the infected regions in the greater and lesser peritoneal sacs and con- nect them with the skin surface. The parietal wound is then partially closed and dressed antiseptically. Gastroplication. — To diminish the capacity of the stomach, it is exposed by one of the incisions above de- scribed and its anterior wall drawn well out through the wound. Two points, several inches apart according to the size to be given to the tuck, are caught up and, the inter- mediate portion being depressed in a longitudinal fold, are fastened together by a broad Lembert silk suture, Similar 416 ABDOMINAL WALL, STOMACH, AND INTESTINES. sutures are placed on each side at half-inch intervals to lengthen and maintain the fold. The stomach is then dropped back and the parietal opening closed. PYLORECTOMY. The stomach should be repeatedly washed previously and should be empty at the time of operation. The ab- dominal incision is made in the linea alba between the ensiform process and umbilicus, or over the most promi- nent part of the tumor, and more or less transversely, from just to the left of the median line in the direction of the free border of the right costal cartilages and not less than an inch from them. Other forms of incision that have been employed are longitudinal at the outer border of the right reetus, transverse over the tumor, or crucial. At first the incision is only made large enough for exploration; if then the operation is deemed feasible, it is enlarged till it is from three to five inches long. Sponges are packed into the abdomen around the tumor, which is drawn as much as possible into the abdominal wound. The great and small omenta are cut close to the greater and less curvatures of the stomach, after first se- curing the vessels between double ligatures, till the point toward the left is reached where the stomach wall is to be divided. Great care must be taken not to wound the portal vein, hepatic artery, or common bile duct which lie behind the pylorus, and no damage must be done to the transverse mesocolon. If the disease involves this struc- ture the operation should be abandoned. Fresh sponges are now packed around the liberated pyloric \ tcarine throned] the transverse meso-colon with as lit- HERNIOTOMY, KELOTOMY. 421 tie injury as possible to its vessels. Tins modification lias many advantages. Jejunostomy for inoperable cancer of the pylorus has been performed a few times. A longitudinal incision is made to the left of the umbilicus, the omentum and trans- verse colon pressed upward, and a loop of the upper por- tion of the jejunum brought into the wound and secured there by sutures as in gastrostomy. The opening made in the intestine should be only large enough to admit the tube through which food is to be introduced. Maydl 1 has proposed a more complicated method, as follows : The abdomen is opened transversely about four finger- breadths below the ensiform process, a loop of jejunum some ten or twelve inches long extracted, and, with every antiseptic precaution, divided transversely. The proxi- mal segment is then connected with the distal a few inches below the point of division by an anastomosis operation to preserve the biliary and pancreatic secretions, and the distal segment fixed in the abdominal wound as in gastrostomy, or the distal segment may be attached to the stomach, thus making a gastroenterostomy. HERNIOTOMY, KELOTOMY. Under this head are to be described the operations for the relief of strangulated inguinal, femoral, umbilical, and obturator hernias, and those for the radical cure of the first three varieties. It has been well said that there is no operation in which the unforeseen has a larger share than in herniotomy, none in which the surgeon is called upon to show more skill, sagacity, and decision. The causes of this are to be found in the absence of absolute guides to the hernial sac, the changes in the sac and overlying tissues brought about by inflammation or time, the character of the hernia — whether composed of omentum, intestine, caecum, or bladder, and, lastly, the difficulty of determining not only the extent of the injury done to the strangulated 'Maydl: Wien. tued. "Wochensch. , 1892, p. 697. 422 ABDOMINAL WALL, STOMACH, AND INTESTINES. tissues, but even, in some cases, the route taken by the hernia in its descent. It is desirable, therefore, that the account of the different operations should be preceded by some general considerations upon these subjects. General Directions. A. Recognition of the Sac and BOWEL. — The first difficulty encountered in the course of the operation is that of recognizing the sac. The thick- ness of the connective tissue covering it varies greatly in different cases ; each layer must be pinched up with for- ceps, opened with the knife lying upon its side, as in opening the sheath of an artery, then raised upon the finger or a director, and divided to the full extent of the cutaneous incision, after having been carefully scrutinized. Occasionally a cyst containing liquid is found in front of the hernia, and may at first be mistaken for it, for usually the sac contains a certain amount of serum. Careful ex- amination of the tissues before division is absolutely neces- sary, because in those rare cases where there is no sac (hernia of the cascum or of the bladder), and in others where it is quite undistinguishable, it is only by recogniz- ing the muscular coat when he reaches it, that the surgeon avoids opening the intestine or bladder by mistake. As the sac is approached, each layer should be pinched up in a narrow fold and moved gently across the underlying parts ; if a smooth globular tumor is felt below, the sur- geon makes an opening in the fold, confident that the wall of the intestine is not included in it ; but if he is unable to pinch up the fold, or if, instead of the sensation of a smooth globular mass, he gets only that of an empty space, he examines the surface again, divides any fibrous bands he may find at the neck of the hernia, and tries to Introduce his finger through it into the abdominal cavity. If he succeeds, he knows the sac has been opened ; if lie does not succeed, he renews the examination and continues the dissection. Maisonneuve said the surgeon may know he has not reached the intestine bo long as he is not certain of having done 80 ; but tlii- i~ not true of all cases; the intestine is not always smooth and shining ; it may be dark, dull, HERNIOTOMY, KELOTOMY. 423 congested, and thickened, and in bernia of the caecum or sigmoid flexure it may have no peritoneal coat. When the hernia is small and recent the sac is bluish, and can be pinched up between the thumb and finger, so that its smooth opposing surfaces can he felt to glide upon one another. When it is large and of long standing, the sue may he exceedingly thin and unrecognizable, or very thick and adherent, li' small, it should be thoroughly isolated, and its boundaries everywhere defined ; if large and adherent, its neck alone should be cleared. B. Opening of the Sac. — The propriety of opening the sac used to be a subject of dispute. The only objection to it, but that a serious one, was the danger of thereby setting nj) peritonitis. On the other side there was the danger of returning the hernia into the abdomen in a gangrenous condition, or unreduced when the stricture was formed by the sae itself. Now, however, the rule is always to open the sac with every antiseptic precaution and relieve any constriction which may be found by cutting- down upon it layer by layer from without. Then either immediately or after an interval a radical cure is performed. The liquid which is usually contained in the sac may not only serve to call attention to its accidental opening, but may also be taken advantage of to open it safely when it has been recognized. It, of course, collects at the most dependent point, and there intervenes between the sac and the bowel, so that the former can be pinched up and opened without injury to the latter. When this is not the case, the surgeon must pinch up a very small fold of the sac wherever he can do so, or do as Mr. Liston did in a ease where, as he says, "there was no possibility of pinch- ing up the sac, either with the finger or forceps ; it con- tained no fluid, and was impacted most firmly with bowel ; very luckily the membrane was there ; and, observing a pelleton of fat underneath, I scratched very cautiously with the point of the knife in the unsupported hand, until a trifling puncture was made, sufficient to admit the blunt point of a narrow bistoury." l The opening should be en- 1 ( >p. Surgery, p. 4(52, quoted by Jos. Hell, Manual of Surgical Opera- tions, p. 231. \24 ABDOMINAL WALL. STOMACH, AND INTESTINES. larged until the finger can be introduced, and then the sac slit up on it as a guide. If the omentum is then found tilling the sac, it must be cautiously unfolded or incised, for it is probable, especially in umbilical hernia, that a strangulated loop of intestine will be found in its center. ( '. I H visk »N op THE Stricture. — The left forefinger is passed up into the neck of the sac by which the stricture is usually constituted, the pulp upward, the nail pressing against the intestines ; if the stricture lies or can be drawn outside the opening in the abdominal wall through which the hernia made its escape, it may be divided freely with- out risk, but if it lies within the opening the division must be made with reference to the anatomy of the region. If the division cannot be made at the desired point, but only at some other where an incision of the necessary ex- Fig. 205. Hernia knife. tent would be dangerous, the stricture must be slightly nicked at that point, and advantage then taken of the par- tial liberation to make a second cut in the proper place. The end of the finger, or its nail, is gently engaged in the stricture, its pulp against the selected point of divi- sion, and the knife, a probe-pointed, slightly curved bis- toury, passed on the Hat along its palmar surface until the point has passed through the stricture. The surgeon then turns its edge upward and presses it against the stricture with the end of the finger on which it rests. A slight crackling announces the division, which must be extended or repeated at different points until the linger can be passed freely through into the abdomen. Instead of an ordinary probe-pointed bistoury, a spe- cially constructed hernia knife (Fig. 205) is often used. It i- probe-pointed and its cutting c<\^c not more than an // E&NIO TOM F, KEL TOM Y. 425 inch long. The knife may also be guided upon a director instead of the finger. The " hernia director" is broader than the ordinary one, and sometimes has a broad flange on each side to keep the bowel from rolling over against the edge of the knife. It is, however, more surgical to cut down upon the constriction layer by layer and then divide it from without, the gut being protected by the ringer or a director. J). Examination and Return of the Bowel. — The bowel should be gently drawn out about an inch in order that the constricted part itself may be examined, for it is very likely to be badly damaged. If the entire loop is in suitable condition it must be carefully cleaned of all blood and gradually returned into the cavity of the abdomen. It is not always easy to decide, however, whether or not its condition is suitable for return, and some surgeons have recommended that in eases of doubt it should be covered with warm, wet cloths and kept under observation for some time, the stricture, of course, having been previously divided. A very great change in the color of the loop is far from proving the existence of gangrene. A deep red vinous color does not preclude recovery, especially if the surface has not lost its lustre ; but if it is black, or deep brown, or grayish-yellow, or if it is dull, flaccid, or wrinkled, it is certainly gangrenous. Of course, when the characteristic gangrenous odor, or the fecal odor con- sequent on perforation, exists, there can be no doubt. Occasionally, when in doubt as to the vitality of a small part of the intestine, I have covered it in by a few Lem- bert sutures as if it were a cut in the wall. It is not always easy to return the intestines even after the stricture has been divided. The surgeon should try to reduce one end at a time, by squeezing its contents back into the abdomen and pushing the gut in afterward. If rupture occurs, and the bowel is otherwise in good condition, it must be closed with Lembert sutures and returned into the abdomen. If the intestine is gangrenous, an artificial anus must 426 ABDOMINAL WALL, STOMACH, AND TNTEST1NES. be formed or the damaged portion excised and the divided ends united to each other (enterorrhaphy). E. Treatment of the Omentum. — If only a small amount of omentum is found in the sac, and if it is in good condition, it may be returned ; but if there is much of it, or if it is inflamed, or gangrenous, it must be drawn further out and resected through normal parts after care- ful ligation in small bundles of the entire breadth. Fig. 206. Bernia. The relations of the femoral and interna] abdominal rings, seen from rithin tin- abdomen. Right side. Strangulated Inguinal Hernia. — Iuguiual hernia may be oblique or direct, The former Leaves the abdomen at the interna] (deep) abdominal ring, having the deep epigastric artery on the inner side (Fig. 206), passes down the ingui- nal canal, and emerges at (lie external abdominal ring I Fig, 207); the latter makes its way through I lesselbaeh's triangle, a space bounded by the epigastric artery, Pou- part'fl ligament, and the rectus abdominis muscle (Fig. HERNIOTOMY, KELOTOMY 427 206), and also emerges at the external abdominal ring. The former is by far the more common variety. Operation. — The parts having been well shaved and dis- infected, the patient is anaesthetized and placed upon his back, with his shoulders slightly raised. An incision is Flo. '2117. Internal . abdominal riin Epiy utric ar'sry Inguinal hernia, showing the transversalis nm the internal abdominal ring. tlie transversalis fascia, and then made from a point a little above and external to the external ring along the summit of the swelling to its lower end, and carefully deepened until the sac is reached. This is then opened by pinching it up and incising as above described. The best point for opening it is at its extreme lower end, because a little serum is usually collected there, 428 ABDOMINAL WALL. STOMACH, AND INTESTINES. separating it from the bowel, but if no such point is found the neighborhood of the neck should be tried, because that part is usually free from adhesions. The constriction, which is usually in the neck of the sac if the hernia is old, is then sought for, and, if found above the external ring-, must be nicked or divided directly upward, or cut down upon from without. If it can be positively made out that the hernia is of the oblique variety, the cutting should be done on the outer side, for the epigastric artery lies close to the inner side of the internal ring, through which this variety passes ; and if it is known to be of the direct variety, the cutting must be done upon the inner side. But, unfortunately, in most cases the dragging of the hernia brings the two rings im- mediately opposite each other, so that the inguinal canal can no longer be said to exist, and the diagnosis cannot be made with certainty. The incision must then be made upward, parallel to the course of the epigastric artery. The intestine must next be examined to ascertain if it is in a fit condition to be returned ; and here it must not be forgotten to draw down an inch or more of each end so that the part which has undergone constriction may also be examined. If the condition is satisfactory, the bowel is returned gradually, not en nntssc } and the wound closed by one of the methods about to be described for radical cure, preferably Bassini's. If it cannot be safely returned, it is resected or fastened in the wound, as in enterostomy. Strangulated Femoral Hernia. — The intestine in its descent occupies a canal which begins at the femoral ring under Poupart's ligament, between the free arched border of Gimbernat's ligament and the femoral vessels (Fig. 206), and ends at the saphenous opening in the fascia lata of the thigh. After passing through the opening it turns upward over the groin. The normal length of the canal i- about an inch, but in hernia- of long standing it is much shortened by the approximation of its two end-. Tin- seal of Stricture is now thought to lie in most cases at the saphenous opening, or just above it, and not at the HEBNIOTOM Y, KELOTOM 1 ". 429 base of Gimbernat's ligament, as was formerly supposed; free division is possible at the former point on the upper and inner side without the risk of injury to any organ, except possibly the spermatic cord, and that is at such a distance as to be practically out of harm's way. Under ordinary circumstances, Gimbernat's ligament can also be safely divided on the inner side, but in about one and one- half per cent, of cases the obturator artery pursues the anomalous course shown in Fig. 208, and then lies directly in the way of the knife. The neck of the sac under such circumstances is entirely surrounded ; on its outer side are femoral vessels, above is the common trunk of the epigas- tric and obturator arteries, on its inner side the obturator Variations in origin and course Of obturator artery. artery, below it the bone. The only safe plan of relieving the stricture, therefore, is to nick it slightly, to the depth of one *>r two millimeters, at several points on its upper and inner borders, or fully to expose the ring and divide its upper inner part layer by layer from without inward. The coverings of the hernia are thin and composed of the skin, subcutaneous tissue, cribriform fascia sometimes, septum crurale, and peritoneum. The incision may be straight or curved, the convexity directed downward and outward, or T-^hapcd, the hori- zontal branch being made along Poupart's ligament, the other passing directly downward over the saphenous open- ing, and should be made from without inward. The -ingle straight incision just to the inner side of the 430 ABDOMINAL WALL, STOMACH, AND INTESTINES. femoral vessels is the one usually employed. The under- lying tissues must be divided, and the sac exposed or opened in the manner described under General Directions, and the seat of stricture sought for and divided accord- ing to the rules above laid down. The gut is then pulled down and examined, and if its condition is satisfactory it is returned and a radical cure performed. W not, it is resected or fastened in the wound. Strangulated Umbilical Hernia. — Tt is generally claimed that true umbilical hernia, that is, hernia through the um- bilical ring, is almost always congenital, and that the hernias which occur during adult life emerge, not through the ring, but through an accidental opening in the linea alba near it, and therefore deserve the name of peri-um- bilical given them by Gosselin. While this condition, that is, of escape through a chance opening in the linea alba, may exist in some cases, Richet 1 has sought to prove by anatomical considerations and by the results of the examination of three cases of hernia, that true um- bilical hernia, on the contrary, is the rule, and the other is the exception. He shows that the weak point of the ring is its upper portion, and (hat when the cicatrix is pressed downward and given a semicircular form by the hernia, a complete ring, which seems to be situated above that corresponding to the vein and arteries, is constituted by the cicatrix below and the upper part of the opening above, and exactly resembles a distended accidental per- foration. The coverings of the hernia are the skin, cellular tis- 3Ue, and peritoneum ; its contents are the small intestine, sometimes the transverse colon, and in the adult the omentum. On account of the pathological changes which take place in the sic and its contents, it is best to undertake a formal laparotomy if the hernia is strangulated or irre- ducible. An incision i- made gently curving outward around one side of the base of the hernial tumor, and pro- longed a couple of inches above and below it in the me 1 Anatomie Mddico-C'hirurgicale, Pari II.. p. 378 HERNIOTOMY, KELOTOMY. 431 dian line. The incision is deepened layer by layer and the peritoneum opened in the median line above and be- low the neck of the hernial sac, and in the intermediate space divided on the finger as a guide, in the line of the cutaneous incision close outside the neck of the sac, spar- ing the margin of the rectus muscle as much as possible. A sponge protective packing is placed on the surrounding viscera, and an incision is made through the neck and body of the sac, including the overlying skin, at right angles to the center of the curved incision around the base of the hernial tumor, exposing the hernial contents without damaging them. The constriction is thus relieved, and the dissection is continued till the hernial contents are freed from ad- hesions to each other and the sac. If they consist of omentum alone, the excess is excised on the proximal side of the strangulation and the abdominal wound treated as described below. If of intestine, the gut is surrounded by warm cloths or placed in the abdomen on sponge protectives. Then the hernial sac, together with the overlying skin and the umbilicus, is excised with di- vision of the peritoneum close around the neck of the sac. The intestine is next inspected, and if gangrene is pres- ent the gut is resected or left outside the partially closed abdominal wound for the slough to separate. A couple of Lembert sutures, or a stout silk loop through the mes- entery, serve to retain the healthy part above and below the damaged area in the margins of the wound. If the gut is healthy, after excision of the excess of omentum and of the sac with its overlying skin and um- bilicus, the sponge protective packing is removed, the edges of the sheaths of the recti muscles are freshened, and the abdominal wound closed in the usual way with close approximation of the recti. The wound is then dressed in the ordinary manner. If the hernia is very large it is better that the first in- cision should be made in the median line and prolonged upward an inch or two above the hernial orifice. The sac should be freely but very carefully opened in the line of 432 ABDOMINAL WALL, STOMACH, AND INTESTINES. the incision, for extensive adhesions are often present ; or the abdominal cavity may be opened just above the hernial orifice, and the wall of the latter divided at its upper part. After reduction of the hernia the entire circuit of the ori- fice is excised, and the wound closed as after laparotomy. Strangulated Obturator Hernia. — A long incision is made parallel to the femoral vessels and about an inch from them on the inner side. The pectineus muscle is exposed and divided, as are also any fibers of the obturator externus whose division may be necessary to give access to the seat of the stricture. The relations of the artery and nerve to the neck of the sac must be determined, and the division made in such a direction that they will not be injured. If the gut can be returned into the abdomen a radical cure can then be attempted. This consists simply in iso- lation of the sac, its ligation as high as possible after re- duction of the hernia, excision of the distal portion, closure of the orifice with silkworm-gut, and suture of the wound in the overlying soft parts. The same may be said of hernia occurring in such un- usual localities as Petit's triangle, the great sacrosciatic foramen, etc If the gut is gangrenous it must be fastened in the wound as in enterostomy, or resected if the condition of the patient permits. RADICAL CURE OF INGUINAL HERNIA. Czerny's Operation.' — An incision is made three or four inches long over the inguinal canal and upper end of the hernial sac, with its center opposite the external abdominal ring. The aponeurosis of the external oblique muscle and (lie sac arc exposed, and the neck of the latter dissected free from the surrounding parts. This is most easily done after the body of the sac has been opened and tin; hernial < tents freed from adhesions and reduced, and one finger passed through the interior of the neck of the sac to make it tense and serve as a guide in the dissection. The neck of the sack is drawn down ami tied off as i W'i.n. med. W'nrli.. 1S77, N,,. 21. RADICAL CUBE OF INGUINAL HERNIA. 133 high up as possible or at the internal abdominal ring, with a stout catgut ligature, which is drawn tight over the tip of the finger placed inside the neck to prevent prolapse of the hernia and its inclusion in the ligature. Czerny drew the serous surface together by a continuous (purse-string) silk suture passed from the inside. The sac distal to the Ligature is excised, though any part or the whole of it can be left undisturbed if it seem advisable. The sides of the opening in the abdominal wall are drawn together with catgut or silkworm-gut sutures passed through all the layers between the skin and peri- toneum, and closed over the cord, which is left to emerge through as small an opening as possible at the lower angle of the suture line. The skin wound is closed with in- terrupted fine silk sutures, and if it seem necessary a strip of rubber tissue is placed in the lower angle of the wound for drainage. Ball ' applied torsion to the sac and its neck before ligating and excising the distal portion. Barker 2 dissects out and divides the neck of the sac, transfixes and ties it off with a silk ligature, and then uses the long ends of the latter as a suture to close the internal ring and over- lviuo- wound. He does not remove the body of the sac. The rest of the wound is closed by both as in Czerny's operation. Macewen 3 dissects out the sac, its neck, and the immediately adjoining peritoneum. He then in- verts and reinverts the apex of the sac into its neck, transfixes and ties together with a firm catgut or silk liga- ture the mass thus formed and fastens it on the inner sur- face of the internal abdominal ring. The latter is closed by suturing the conjoined tendon to the inner surface of Poupart's ligament. The external ring is narrowed as much as possible by silkworm-gut stitches and the cuta- neous wound united over it. The main feature of the last three operations is the attempt, to obliterate the funnel-shaped depression leading 'Brit. Med. Jour., 1887, II., p. 1272. « Ibid., p. 1203. "Ibid., i>. L263, 28 I.; I ABDOMINAL WALL, stomach. AND INTESTINES. into the Deck of the hernial sac and to substitute at this point an elevation. Kocher's ' method has yielded excellent results, and is as follows : An incision three or four inches long is made in the long axis of the hernial tumor ; its center is over the external ring ; only the skin and subcutaneous tissue are divided ; none of the external oblique muscle is cut. After dissecting out the body and neck of the sac up to the internal abdominal ring and reducing the hernia, a iino-er i- passed up the inguinal canal and on its tip as a director an artery clamp is forced through the external and internal oblique and transversal is muscles at a point about half an inch to the outer side of the internal ring. Without removing it from the puncture the clamp is passed <>n down the inguinal canal and made to seize the apex of the sac, which is then drawn up and pulled through the puncture and twisted into a round cord. The latter is laid upon the outer surface of the external oblique and lower down in the inguinal canal and secured there by five or six sutures passed through all the structures (except the skin, subcutaneous tissue, and peritoneum) on each side of the inguinal canal. The last one or two sutures through the extremity of the twisted sac and the pillars of the external ring draw the latter together. The cutaneous wound is then closed and dressed antiseptically. Bassini's Operation.- — An incision three or four inches long is made from the level of the upper part of the in- ternal abdominal ring obliquely downward over the long axis of the hernial tumor. The aponeurosis of the ex- ternal oblique muscle is exposed and divided from the upper border of the internal abdominal ring over the whole length of the inguinal canal, and the neck of the hernial sac isolated from the cord and surrounding part-. (Fig. _!<•'.•.) The body of the sac is nicked and opened sufficiently to free its contents from possible adhesions, and to permit reduction of the hernia by a linger passed through the interior of the neck of the sac to it- abdominal 1 Annals Surg., 1892, Vol. 16, p. ■"»'»;,. tralb. i. ' air., 1-'.'". Vol. I", p. 129. RADICAL CURE OF INGUINAL HERNLA. 4:;.-> orifice. The neck is then drawn down, dissected free, and encircled or transfixed as high nj) as possible by a stout catgut ligature, which is drawn tight over the tip of the finger still kept inside the neck of the sac to prevent the prolapse of any visens and its inclusion in the ligature. Fig. 209. .1. A, A. Subcutaneous cellular tissue. E. Spermatic c»nl. r /;, <\ Aponeurosis of external oblique divided and turned back. <•. Epigastric vessels. /•'. Internal oblique and transversalis muscles ami vertical fascia of Cooper. The lower portion of the sac is then dissected out and excised. The margins of the wound, including the divided apo- neurosisof the external oblique muscle, are well retracted, and on the outer side of the internal abdominal ring and inguinal canal, the upper border of Poupart's ligament is 136 ABDOMINAL WALL, stomach. AND INTESTINES. exposed; and on the inner side the conjoined edge of the internal oblique and transversalis muscles and the trans- versalis fascia. After raising the cord these structures on the inner side of the internal abdominal ring and inguinal canal are united beneath the cord to Poupart's ligament Fig. 210. Suture of the conjoined tendon and I ransversalis fascia | /•') i" the posterior bor- dei of Poupart's ligament (/>). E. The cord. B, C. Aponeurosis of the external oblique, by interrupted silkworm-gul <>r catgut sutures extending upward from the cresl of the pubes (ill only enough space In Hi,' upper and outer pari (if tin- internal abdominal ring is 1 1 - ft for the cord to pass without undue compres- sion. The lower two suture- should include the outer border of the reel us muscle. ( Fig. 210.) TtADICAL CURE OF TNGUINAL HERNIA. 431 The cord is then placed on this new posterior wall oi the inguinal canal and the divided aponeurosis of the external oblique muscle united over it by catgut sutures, 1 wing as small an aperture as possible at the lower angle for the cord to emerge. (Fig. '2\ 1.) The skin wound is sutured with interrupted silk and dressed antiseptically Fro. 211. Suture of the divided aponeurosis of the external oblique i. />'. C) over the sper- matic cord (/■:). without drainage, and in children it is wise to add a plaster-of-Paris spica. Bassini uses silk for the buried sutures and forms the new internal abdominal ring about half an inch to the inner side of the anterior superior spine of the ilium; that is, he divides the internal oblique and transversalis t38 {BDOMINAL WALL, STOMACH, AND INTESTINES. muscles above and to the outer side of the internal abdominal ring, transplants the cord to the outer extrem- ity of this incision, fastens the internal oblique and trans- versalis under it and the external oblique over it. If the hernia is complicated by undescended testicle Bassini un- folds the vas deferens by a careful dissection and brings the testicle down from the inguinal canal and sutures it to the bottom of the scrotum. If this is impossible castra- tion is performed. Lauenstein places the testicle in the abdomen along with Fig. 212. Fig. 213. Fig. 214. Method "l' tying off omentum in sections. the stump of the sac. In congenital hernia enough of the fundus of the sac should be left to form a tunica vaginalis. In direct inguinal hernia the orifice of the hernia is formed by the external abdominal ring, the neck of the sac i- shorl and passes over the cord and lies to the inner side of the deep epigastric artery. Alter tying off the neck of the sae of a direct inguinal hernia, the parts on the inner aide of the abdominal orifice, between the peri- toneum ami external oblique tendon, are sutured, as in ili«' indirect variety, to I 'uu | tart'.- ligament. RADICAL CURE OF INGUINAL HERNIA. 439 If the hernia is an epiplocele the excess of omentum is tied off with stout catgut close to the neck of the sac and excised. If it is very large, the pedicle should be spread out and tied in sections, as illustrated in Figs. 212, 213, '214. ffalsted's operation ' is as follows : The aponeurosis of the external oblique and the external abdominal ring- are exposed by an incision starting some 5 centimeters above and external to the internal ring and extending to the spine of the pubes. In this line the aponeurosis of the external oblique and the fibers of the internal oblique and transversalis muscles and the transversalis fascia are cut from the external ring to a point about 2 centimeters above and external to the internal ring. The peritoneum and neck of sac are thus exposed, the latter opened, the hernia reduced, and the neck of the sac ligated or sutured and the distal portion excised. The cord is then isolated, and, after removing all but one or two of its veins, it is transplanted to the outer angle of the incision. Beneath it mattress sutures are passed : on the inner side through the aponeurosis of the external oblique, the internal oblique and transversalis muscles, and transversalis fascia ; on the outer side through the aponeurosis of the external oblique, Poupart's ligament, and the transversalis fascia. This obliterates the canal and places the cord on the outer surface of the external oblique aponeurosis, where it is covered by skin and subcutaneous tissue only. The cutaneous wound is then closed by superficial sutures and dressed antiseptically without drainage. M'Burney's Operation.- — The incision, division of the aponeurosis of the external oblique muscle, and the treat- ment of the sac are the same as in Bassini's operation. Sutures are then passed through the skin, the aponeu- rosis of the external oblique (including the inner pillar of the external ring), and the conjoined tendon firmly binding these structures together with deep inversion of the skin and usually covering in the cord. On the oppo- 1 Annals of Surgery, 1893, Vol. 17, p. 542. 2 N\-\\ York Medical Record. 1889, Vol. 35, p. 312. I Mi ABDOMINAL WALL. STOMACH, AND INTESTINES. site side of the wound the skin is inverted and sutured to Poupart's ligament, including at the lower part the outer pillar of the external ring ; the lower angle of the wound is sutured with silk and drawn together above with two or more tension sutures passed through the skin and superficial fascia and tied over pledgets of iodoform gauze. The space of about one-fifth of an inch left be- tween the lips of the wound is packed snugly with iodo- form gauze down to the peritoneum to insure healing by granulation and the obliteration of the inguinal canal by dense cicatricial tissue. This operation was at first ex- tensively used, but of late has largely yielded place to Bassini's ; it is, however, a safer and surer operation for the less experienced, and for strangulated and infected eases in which the wound cannot safely be closed. It is also worthy of remembrance in the history of the evolu- tion of radical cure that this was the first method in which the aponeurosis of the external oblique was divided and the internal ring freely exposed in the effort to ensure complete removal of the sac. Eadical Cure of Umbilical Hernia. — If the hernia is irre- ducible, the treatment is the same as that described for strangulated umbilical hernia. If reducible, an incision is made which encircles the base of the hernial tumor, extending an inch or two above and below it in the median line, and deepened layer by layer till the abdominal cavity is opened at one extremity ni' the incision. A Hat sponge is inserted, and on the linger as a guide the peritoneum is divided in the line of the cutaneous incision around the neck of the sac, and the latter excised together with the body of the sac, the over- lying skin, and the umbilicus. The peritoneum is then sutured with catgut, the edges of the sheaths of the sepa- rated recti muscles are freshened throughout the whole length of the wound, and the recti closely approximated with interrupted catgut or silkworm-gul sutures. < >ver thifi the superficial fascia and skin are united with silk iil'tcr excision of any redundant portions. Radical Cure of Femoral Hernia. — Starting from Pou- UECTUM. -1-11 part's ligament a vertical incision some three or four inches long is made jusl to the inner side of the femoral vessels. It musl be deepened carefully, as the coverings of the hernia in iv be very thin and consist only of skin and superficial fascia if the hernia has passed through the cribri- form fascia. After exposing and opening the sac and re- turning the bowel or possibly excising the omentum, the neck of the sac is isolated and tied off high up with silk or stout catgut. Various procedures have been adopted for the succeed- ing steps in the operation. Billroth removed the portion of the sac distal to the ligature and sutured the middle third of Poupart's ligament to the fascia covering the abductor muscles, or to that on the inner aspect of the femoral vessels. Berger united Poupart's ligament to the pubic portion of the fascia lata covering the pecti- nens muscle. A flap cut from the latter muscle has been turned up and fastened in the femoral ring - . Macewen employs the same principle as for the cure of inguinal hernia (7. v.); i. e., the sac is folded into a pad and secured on the inner surface of the femoral ring, which is then drawn together with silk or silkworm-gut passed through the available soft parts adjoining its boun- daries. Koeher exposes the sac and saphenous opening by a vertical incision, but does not divide the fascia lata overlying the canal ; the sac is then drawn through a puncture in Poupart's ligament just over the canal and twisted, and its extremity is brought down over the liga- ment into the canal again, and secured there by two or three silk sutures passed through it and Poupart's liga- ment and the pectineal fascia. After obliterating the track of the hernia by whatever method is adopted, the external wound is closed. RECTUM. Anatomy. — The rectum is from six to eight inches long, and for about its first three inches is supplied with a mesorectum. In front the peritoneum descends to within about three inches, and behind about five inches 442 ABDOMINAL WALL. STOMACH, AND INTESTINES. from the anus. The second portion of the rectum is in relation in front, in the male, with the trigonum of the 1 (ladder, the vcsicula? seminales, and the vasa deferentia and the prostate, the posterior margin <>f which can normally he reached by the finger. In the female this portion of the rectum is attached to the posterior vag- inal wall. Below the prostate the levatores ani join the rectum from one and a-half to two inches from the anus, at a point just above the internal sphincter. The superior hemorrhoidal artery lies on the outer surface of the rectum behind, a little to the left of the middle line, till within about four inches of the anus. It then divides into its terminal branches, which have a longitudinal distribution between the mucous and muscular coats and communicate freely about the anus. The veins have a similar distribution, and communicate through the superior hemorrhoidal with the portal system, and through the middle and inferior hemorrhoidal with the internal iliac veins. The sphincter is supplied by the fourth sacral nerve. IMPERFORATE ANUS OR RECTUM. In order to understand their different congenital deform- ities, ii i- essential to bear in mind the manner in which ill-' rectum and anus are developed. The rectum, like the rest of the intestine, is formed by the third blastodermic layer of the ovule, mid originally communicates with the pedicle «>f the allantoid vesicle, that which afterward becomes the bladder and the posterior portion of the urethra. The anus, mi the other hand, is formed by a dimple in the outer blastodermic layer, the one which form- the epidermis. In the ordinary course of evente the communication between the rectum and the bladder or urethra closes, and another forms between the rectum and anus by absorption of the layer of tissue between them. The malformations are the result of arrest of de- velopment of the colon, rectum, or anus, or of the persist- ence of the septum, and present several varieties. IMPERFORATE ANUS OR RECTUM. 443 The first, and slightest, is not a true aires! of develop- ment, but a simple closure of the orifice of the anus by a tegumentary layer or by adhesion of its sides, the deep oommunicatioD between it and the rectum being complete This requires only separation of the adherent edges with a director, or division of the layer with a knife. 2. The rectum and anus may be fully developed, but the thin membranous diaphragm between them may per- -i~t. like the hymen in the vagina. The treatment of this also is simple : crucial incision or large puncture of the membrane. '■'>. The anus may be entirely absent, while the rectum is normally developed ; the distance between the lower end of the latter and the surface being from half an inch to an inch. 4. The anal cul-de-sac being properly developed, the rectum or colon may terminate at any distance above it, or may even not exist at all, being represented by a fibrous cord extendino- from the ileo-ca?cal valve to the anus. 5. The arrest of development may involve both the anus and the rectum. (J. The rectum may open into the bladder, urethra, or vagina. It is often exceedingly difficult to determine the char- acter of the malformation during life, and yet it is very important that this should be done, for if the impervious- ness begins at a point too high up to be reached through the perineum, the only possibility of relief is in the estab- lishment of an artificial anus in the lumbar or inguinal region. Depaul ' says that when the obstruction begins at the ileo-ca?cal valve the transverse distention of the ab- domen is much less than in rectal obstruction. I? the surgeon decides to go in search of the blind end of the rectum and create an anus in the perineum, he must make an incision in the median line from the scro- tum to the tip of the coccyx, after having previously intro- duced a sound into the bladder if the patient is a boy, or 'Bull. .">•'>. 444 ABDOMINAL WALL. STOMACH, AND INTESTINES. into the vagina if a girl. He then divides the tissues layer by layer in the line of the incision, feeling- ;it each step for the distended rectum, which can sometimes be seen and felt to bulge downward when the child strains or cries. Or an exploratory puncture may he made, and the needle or trocar used as a guide if the bowel is reached by it. The search for the bowel should be made in the direc- tion of the axis of the anal cul-de-sac, if the latter is suffi- ciently developed, and advantage taken of the fact pointed out by M. Forget, ' that a fibrous cord, representing a ru- dimentary portion of the rectum, occupies more or less of the distance separating the two. If, on the contrary, the anus is lacking, the search must be made toward the con- cavity of the sacrum. Yerneuil proposed to excise the coccyx, so as to diminish the danger incurred during the search, but as this may be followed by prolapse of the rectum it should be practised only when a simple incision has proved insufficient. When the end of the bowel is reached it must be seized with pronged forceps, or two stout ligatures must be passed through it, and it must be partly separated from the ad- joining tissues, drawn down, opened, and made fast to the integument or the margin of the anus. The anterior and posterior portions of the cutaneous incision must finally be closed by sutures. It would be perfectly proper when in doubt as to the presence or position of the rectum to open the abdomen in the median line, and then, after ascertain- ing the conditions, if necessary perform a colostomy. When the rectum opens into the vagina it may be reached through a median or crucial incision in the perineum, separated from the vaginal wall with a knife or curved scissors, and drawn down and fastened as before. The former opening will then close spontaneously. PROLAPSE OF THE RECTUM. 'flic muCOUS membrane of the rectum is very loosely attached to the muscular coat, and when the sphincter is 1 Hull, de la SocteU de ( hirurgie. 1863 and 1S77. PROLAPSE OF THE RECTUM. 445 relaxed or disabled prolapse may occur to a degree that requires operative interference. This interference may in- volve the mucous membrane alone, or it may also include the anus or the entire rectum. In the first ease the indi- cation is to promote adhesions between the mucous and muscular coats, or to remove portions that may be in ex- cess ; in the second to narrow the anal orifice, or fasten the posterior portion of the bowel to the firm tissues near the sacrum by sutures. The former is accomplished by making deep longitudinal incisions through the mucous membrane, or by pinching up folds at three or four different points and tying a strong ligature about each. The incisions are likely to give rise to severe hemorrhage, and consequently the method has fallen into disuse ; the actual cautery, however, applied at points or in lines, has been used as a substitute as follows : In a slight or partial prolapse the bowels are emptied in advance' and the parts reduced and put ou the stretch with the bivalve speculum. The point of a Paquelin cautery is drawn the whole length of the prolapse in four longitudinal lines about a quarter of an inch wide and equally distant from each other, without destroying the entire thickness of the mucous membrane. To avoid penetrating too deeply Cripps advises that the cautery be used at a black heat only. If the skin about the anus is not touched the afterpain is slight. A tube reaching above the sphincter is inserted to give exit to flatus, while the bowels are kept confined for several days. For sev- eral weeks thereafter the patient must defecate in the recumbent position and avoid straining efforts, while the adhesions caused by the cauterization become firm between the mucous and muscular coats. There are two methods of narrowing the anal orifice. Dupuytren pinched up with forceps several of the radiat- ing folds of integument and cut them off with curved scissors, trusting to cicatricial retraction for the narrow- ing he desired. Robert made two incisions, extending from the extrem- ities of the transverse diameter of the anus to the tip of 440 ABDOMINAL WALL, STOMACH, AND INTESTINES. the coccyx, removed the skin, subcutaneous tissue, and portion of the sphincter contained within the V thus marked out, and brought the sides of the gap together with sutures. Rectopexy.— In cases of extensive prolapse the rectum has been secured in the concavity of the sacrum behind or to the abdominal wall in front or in the left inguinal region. For the first procedure an incision is made in the me- dian line from just behind the anus to the tip of the coccyx, and deepened backward and upward till the concavity of the sacrum is reached. A catgut suture is then passed through the fibrous tissue in front of this bone, and through the back of the rectum without enter- ing its lumen, and the wound either closed immediately or after two or three days, during which it is lightly packed. To secure the rectum to the anterior abdominal wall, the peritoneal cavity is opened in the median line just above the pubes, and the gut secured at the peritoneal edge (if the wound, as in hysteropexy, by a silk suture passed through the whole thickness of the abdominal wall, and the anterior longitudinal band of muscular fibers in the rectum. The lumen of the latter, of course, must not be entered. In the left inguinal region the abdomen is opened as for colostomy, and the upper end of the rectum fastened to the wall near the wound in a similar manner, or by a suture passed through the whole thickness of the meso- reetum and parietal peritoneum. 1 Ablation. — For pronounced cases with gangrene pres- ent or threatening Treves z divides the rectum circularly layer by layer at the mueo-eutaneous junction, taking care to avoid injury to any small intestine which may have be- come herniated into the pouch formed by the prolapse. The <-iit ed^es of the skin and intestinal mucous mem- brane arc then united with catgut. If the peritoneum is opened the wound must be immediately closed. ' Berg. Annala Surg., 1893, Vol. XVII., p. ■"-7:;. Lancet, L890, Vol. I., ]>■ 37G. FIST I' LA. 447 Torsion. — When the sphincter has been destroyed or removed Gerster 1 supplies a substitute by twisting the rectum on its long axis till it:- walls form a rather close spiral. After isolating from two to five inches of its lower end the gut is turned through half a circle or more, and it- free extremity sutured t<» the margin of the skin. Rectotomy. — There is occasionally found, especially in women, a form of stricture occupying the lumen of the rectum like a thin perforated diaphragm, which is prob- ably the result of a partial persistence of the foetal mem- brane between the anal portion which is developed from below upward by the dimpling of the -kin, and the rectal portion which comes down from above to meet it. For the treatment of this, after emptying the bowels, the sphincter is first very thoroughly dilated and then a blunt director is forced through the base of the stric- ture in the posterior median line and brought back into the rectum in the same line above it. By hook- ing the finger or a loop of stout wire over the point of the director the stricture can be drawn down within reach from the anus ami divided layer by layer, and all bleed- ing point- secured with ligature-. A drainage tube and light packing are passed through the anus to the point of division. Stricture- more extensive than these, yet not suitable for excision, arc divided with the knife or cautery in the median line posteriorly carrying the division through the rectal wall below the stricture, and the sphincter toward the coccyx, to secure the most perfect drainage possible. A tube and packing are placed in the incision. FISTULA. After having thoroughly dilated the sphincter a blunt director is passed from without till its point is felt within the rectum, or if no aperture exists it is thrust through the mucous membrane where the least tissue intervenes. The point is then pulled down out of the rectum, or, if this i- impossible, the anus is held open with a speculum, 1 Annals Surg., 1894, Vol. XIX.. p. 612. 44£ ABDOMINAL WALL stomach, AND INTESTINES. and the parts on the director divided at right angles to the anal margin. If there is no external orifice, the director is bent to a sharp angle and passed with the assistance of the speculum from the internal opening, the skin incised on its point and the parts on the director cut as before. Sinuses in all directions must be slit up and granulations scraped away. Multiple fistula? should be opened into each other if possible, and if more than a single complete division of the sphincter is necessary one division should be allowed to heal before the next is made. In women the sphincter decussates in front with the sphincter vagina 1 and cannot be completely divided at this point without considerable loss of power. HEMORRHOIDS. Ligation, — Concerning the treatment of hemorrhoids by ligation there are a few points which deserve mention. The sphincter should be temporarily paralyzed by forcible dilatation. Every pile that is more than half an inch in diameter must be transfixed by a needle carrying a double ligature, and then strangulated by tying it at its base ; the smaller piles do not need to be transfixed, it is sufficient to throw a single ligature about each. When the tegu- mentary margin would be included in the ligature it should be cut through it with scissors. The ends of the ligatures should not be cut off' as soon as they are tied, but after three Or four have been placed at opposite points of the circumference, it will be found easy to get an excellent view of the interior by drawing them outward and apart. Whitehead's Operation.* — The sphincter is well dilated, and the mucous membrane, stalling posteriorly, is divided at its junction with the skin by blunt-pointed scissors around the entire circumference of the bowel. It is dis- sected up with the dilated veins to the interna! sphincter, or till all the pile-bearing mucous membrane is drawn outside of the anus. The mucous membrane is then divided transversely by short snips of the scissors close to its still attached upper border, and each pari as it is cut is sutured 1 British Medical J mil. 1887, Vol [., p. 449. EXCISION OF ANUS AND PART OF UECTUM. 449 to the edge of the skin. The vessels are secured as they are divided. EXCISION OF THE ANUS AND PART OF THE RECTUM. This operation may be rendered necessary by disease otherwise incurable. The resulting condition is seldom satisfactory, owing to the loss of the sphincter if the anus is excised, and its almost certain paralysis from injury to the nerves during- the manipulation, if the anus is left. It must be remembered that the peritoneum descends upon the anterior surface of the rectum to within about an inch of the prostate, but not quite so far upon the sides or be- hind ; its average distance from the anus is from two to two and one-half inches in front and five inches behind. If the upper limit of the tumor on the posterior side can- not be reached by the end of the finger introduced through the anus, its removal should not be attempted from below. The nature and extent of its connections xvith the impor- tant organs on the anterior surface must also, of course, be carefully determined. A. Removal from below of the Anus and Part of the Rectum. — Two curved incisions, meeting in front and be- hind in the median line, are made through the skin, one on each side of the anus, and at a distance of about one inch from it. They are carried down to the rectum, re- maining of course, external to the neoplasm if it has broken through the rectal wall, and the rectum is then dissected upward as far as necessary, using the ringers in- stead of the knife for this purpose whenever possible. A sound should be introduced into the bladder as a guide if the patient is a man, and a finger into the vagina if the patient is a woman. When the upper limit of the tumor is reached, the rectum is drawn well down, its posterior wall divided longitudinally, and the diseased portion removed. If the disease extends upward more than one and a- half inches, it is advisable to prolong the incision back- ward to the tip of the coccyx, and perhaps even along the side of this bone. 450 ABDOMINAL WALL, STOMACH, AND INTESTINES. Velpeau took the precaution to pass a number of threads through the intestine above the proposed line of excision, bringing them out through the skin beyond the external limits of the disease. After the removal of the tumor, he had only to tighten and tie these threads to bring the edges of the incisions through the intestine and the skin together. Richard Volkmann ! lias modified this operation some- what and claims that by thorough drainage and the strict- est attention to disinfection of the wound during and after the operation, excision of the rectum can be carried to a very considerable height, and even the peritoneal cavity opened, without danger to the patient. He empties the bowel thoroughly, makes a circular incision about the anus, a straight one in the median line back from the cir- cular one to the coccyx, and, if necessary, another in the median line of the perineum ; the bowel itself must not be cut into. He then draws the rectum down, dissects it out circularly to the necessary height, passes ligatures through the healthy portion after Yelpeau's plan, and cuts off the lower portion containing the tumor. Bleeding points are temporarily secured by self-retaining forceps, and afterward with eatgnt. If the peritoneal cavity is opened, a sponge sterile or wet with an antiseptic solution is kept pressed against the opening, until the excision is completed ; then if the opening is -mall i t - edges are drawn out with artery for- ceps, and a ligature thrown around it as if it was a ves- sel ; if it is large, it is closed with catgut sutures. The upper end of the gut is then drawn down and fast- ened to the -kin very accurately with alternate deep and superficial sutures, two or three drainage tubes are in- serted, en! off close to the surface, and stitched fast. During the operation, the bleeding surface is constantly protected againsi infection by irrigation with an antiseptic solution, and for the firsl three or four days constant antiseptic irrigation is kepi up through a tube passed well 1 Uebei den Mastdarmkreba nnd * I i * - Exstirpatio recti in Klinischer Vortrage, No. 13] (Chirurgie, No, 42), p. 111:;. 13th March, 1878, EXCISION OF ANUS AND PART OF RECTUM. 451 into the wound near one of the drainage tubes ; daily antiseptic injections are afterward made through the drain- ace tubes until the wound lias healed. Volkmann claims that these precautions strictly carried out insure the patient against the chief danger of the operation, that of exciting diffuse pelvic cellular inflam- mation, which spreads rapidly upward behind the peri- toneum, and causes death by sepsis. Although the bleed- ing during the operation is very severe, he has never known it to have fatal consequences. He thinks, also, that cancer is much less likely to re- turn locally after excision of the anus than it is when the sphincters are preserved, and, therefore, he prefers total excision of the anus and of the rectum to the upper limit of the disease, even when the anus itself is not involved. B. Resection of the Rectum from below, leaving the Sphincter. — After thoroughly emptying the bowels in ad- vance the patient is placed in the lithotomy position, or on the side with the hips and knees flexed. An incision is made in the median line posteriorly through the anus and rectal wall below the disease, and carried to the coc- cyx. With a sound in the urethra or finger in the va- gina, another incision in the median line in front is carried through the anus and lower healthy rectal wall into the perineum. The buttocks are separated and the lips of these incisions drawn apart with blunt retractors. The sound rectum is then divided transversely below the disease and above the sphincter by lateral incisions joining the upper extremities of the incisions through its anterior and posterior walls. By working with the fingers and blunt-pointed scissors from within outward through the transverse incisions in the rectal wall, the diseased rectum above is separated all around on its outer surface from the surrounding tissues and drawn down. The ves- sels are tied as they are cut, but if the dissection is made mostly by tearing with the fingers the greater part of the hemorrhage can be arrested by pressure. A temporary suture with the ends left long is then passed through the anterior and posterior walls of the rectum above to pre- 452 ABDOMINAL WALL, STOMACH, AND INTESTINES. vent it- retraction, while the diseased part is excised by a transverse division of the bowel in the healthy tissue below tlic retention sutures. The <-ut ends of the rectum are united all around by in- terrupted sutures passed with a sharply curved needle, and then the incisions in its anterior and posterior walls. A large drainage tube surrounded by light packing and reach- ing above the point of division is placed in the rectum, the wounds in the perineum and behind, including the sphincter, are closed with dee]) sutures and a drainage tube placed in the lower angle of each. Fig. 21-"). Resection of the rectum, showing Bueter's curved incision. The straight Incision i- thai I'M posterior rectotomy. C. Hueter's Operation by a Perineal Flap. (Fig. 215.) — The patient occupies the lithotomy position and a sound i- introduced into the urethra. A Hap, including the anus and adjoining part of the perineum, is marked out of an inverted U-shape, having the anus a little in front of the eent< r of the base, which is posterior. To form thi- an incision is made through the skin and subcu- taneous tissue, starting al the level of the posterior end of the tuber ischii outside of the outer border of the sphinc- ter ani, passing forward and crossing the perineum close t<> the posterior insertion of the scrotum, then backward to terminate on the other side of the anus outside the EXCISION OF ANUS AND PART OF RECTUM. 153 sphincter opposite the starting point. The incision is deepened; and anteriorly, in the bend of the U, the junction of the accelerator iirinse with the compressor urethra? muscles cul through, and the flap including the sphincter ani turned down. Working in from in front the reef inn is isolated on all sides and the diseased portion excised by transverse divis- ion of the bowel through healthy tissue above and below the disease. The bleeding in this large wound is stopped by ligation or pressure. The cut ends of the rectum are brought together all around with sutures, and the flap replaced, with a drain and light packing in each lower angle. A tube and pack- ing reaching above the line of division is then inserted through the anus. The mucous membrane might first be united by a separate row of sutures not entering the mus- cular coat, which is afterward brought together by sutures of catgut penetrating the muscular coat alone, so as to bring the suture line in the mucosa below that in the muscularis and thus make communication less easy for the feces from the interior of the bowel to the perirectal tissue. Zucker- kandl's method for reaching the seminal vesicles (. Siio. 454 ABDOMINAL WALL, STOMACH, AND INTESTINES. the third sacral foramen and including the fourth without opening the sacral canal. The anterior branches of the fourth and fifth sacral nerves arc necessarily divided in this procedure. The posterior branches and the fifth nerve are of no importance, but the nerve-supply of the levator ani, coc- cygeus, and sphincter anion the left side is of course cut off. Hochenegg's modification of the bone removal is rep- resented in Fig. 21 G. Bardenheuer still further modified it by the removal of all the sacrum below the third sacral foramen, which de- stroys the possibility of subsequent restoration of the func- tion of the sphincter. The rectum is now freed by division of the connective tissue binding it to the sacrum, and drawn downward so far as may be necessary to bring the subsequently cut ends of the gut into apposition without undue tension on the sutures. To give more room and greater protection to the important male organs lying close in front of the rectum, the sphincter and rectal wall from the anus up to the tumor can be cut posteriorly in the median line; but it is not always necessary. The growth is then freed by the finger and blunt- pointed scissors from its lateral and anterior connections and excised with a margin of healthy tissue, by transverse! division of the rectum above and below. If the relations of the tumor make it necessary, the peritoneal cavity must be opened and involved portions of the peritoneum, together with any glands which can be felt, removed with the tumor. The peritoneum is then drawn together with line catgut sutures and secured against infection l>v an iodoform-gauze packing. The anterior half of the divided bowel is united by silk su- ture- through its mucous and muscular coats, while the posterior half i.- left open and, if possible, sutured to the -kin :it the margins of the wound; it can afterward he closed by n secondary operation. [f the anus and adjacent rectal wall have been split posteriorly, the rectal part of the wound is closed l>v in- EXCISION OF ANUS AND PART OF MECTUM. 155 terrupted catgut sutures and the sphincter drawn together by (Iccp silk or silver-wire sutures passed in the manner described for restoring a completely ruptured perineum. The overlying parts and the upper and lower angles of Fig. 216. \ZUppcr half of fiffh j, posterior sacral foramen. Resection of the rectum from behind. A. It. Portion of the sacrum removed in Kraske's operation. A. ('. Hoehenegg's modification. the posterior wound arc drawn together with silk sutures, and a drainage tube and packing placed in each angle. The center of the wound, with the open half of the rec- tum, is packed and a drainage tube passed into the bowel 156 ABDOMINAL WALL. STOMACH, AND INTESTINES. above. Afterward the patient will have to be kepi on a water-bed. A colotomy performed a week or two before this oper- ation is of great assistance in keeping the wound aseptie and avoiding the very frequent and early dressings other- wise necessary. Heineke recommends an [_-shaped incision from the anus to the coccyx, then along the left border of the sacrum up to the fourth sacral foramen, and then trans- versely to the right border of the sacrum. The bone is chiseled through in this line and the flap] turned down and to the right. Rydygier dispenses with the trans- verse incision in the skin. Levy divides the sacrum transversely a finger's breadth above its lower extremity, and from each end of the trans- verse incision carries one downward toward the ischial tuberosities, the soft parts attached to the side of the sa- crum below its point of transverse division are cut, and the bone-and-skin flap turned down. Hegar employs a V-*l>:ip e( l incision starting at the pos- terior inferior spines of the ilia and following the sides of the sacrum to the tip of the coccyx. The periosteum is separated from the anterior surface of these bones ; the sacrum sawed transversely and turned up. Almost any of these methods of operation gives access to the female pelvic organs. LIVER. Anatomy. — The level of the upper surface of the liver is indicated by a line drawn through the fifth ehondro- sternal articulation on the right side and through the -i\ih mi the left. It is uncovered by the ribs where it crosses the subcostal angle, from the ninth righi to the eighth li'ft costal cartilage. The lefl lobe extends one and a-half !<» two indies beyond the left margin of the sternum. The lung descends over the upper surface of the diaphragm and liver on the right side to the lower border of the sixth rib in the mammary line, in the mid- :i \ ilia rv line to i he upper border of t he eighth rib, and in LIVER. 4:>7 the scapular line to the upper border of the tenth rib. The pleura descends about lialt* an inch lower, following the costo-chondral junction, or the bony extremities of the ribs, and the lower border of the eleventh rib. As the twelfth rib is sometimes very short, it may be overlooked. Therefore the ribs should be counted, and the lower edge of the pleura will be found passing- horizontally from the lower border of the twelfth dorsal vertebra to the lower border of the eleventh rib. The gall-bladder is about four inches long and an inch wide, and normally holds about an ounce. Its fundus touches the abdominal wall immediately below the ninth costal cartilage near the outer border of the right rectus muscle. The cystic duct is about an inch long, and the common duct three inches long. The latter descends in the right border of the lesser omentum behind the first portion of the duodenum, in front of the portal vein and to the right of the hepatic artery ; it then passes between the pancreas and duodenum, behind the pancreatico-duo- denalis artery, to empty into the middle of the inner side of the second portion of the duodenum. Abscess of the Liver. — An incision, preferably longi- tudinal, three or four inches long is made over the most prominent part of the tumor below the ribs. The inci- sion is deepened to the peritoneum, and if the liver is found adherent beneath this incision the abscess is simply incised for about an inch and drained with a large tube, and packing if necessary, bearing in mind the very friable character of the abscess-walls. If the liver is not adher- ent where the abdomen has been opened, but is found to be so at some other spot below the ribs, another incision is made through the parietes over this spot, and the ab- scess reached through the safely adherent area. The first incision, having served as a guide, is closed in the usual way and well protected from infection before the abscess is opened. If the abscess must be opened immediately, and there are no adhesions to the parietal peritoneum, a sponge packing is inserted to protect the rest of the abdominal t58 ABDOMINAL WALL. STOMACH, AND INTESTINES. cavity, and the point of an exploring-needle buried in the liver. The piston is immediately withdrawn and the medic slowly pushed on in a straight line. By with- drawing the piston as soon as possible pus will flow into the cylinder when it is first reached, and by pushing the needle always in a straight line unnecessary and easily-in- flicted damage to the gland is avoided. If the first ex- ploration fail, the needle must be taken out and reinserted in different straight directions till pus is found. With the needle as a guide, a knife is then passed through the liver-substance into the abscess-cavity, while the liver is kept in as close contact with the abdominal wall as possible, rolling the patient on one side if neces- sary. The index-finger is quickly passed along the track of the knife and the opening enlarged to an inch or more and hooked up without force into the abdominal wound. Hemorrhage is controlled by packing. After the pus has been evacuated, the interior or the abscess-cavity is irri- gated with warm boiled water ; its opening is then plugged with a sponge, and the parietal peritoneum and the skin around the margins of the abdominal wound are united with catgut. After removal of the protective packing from the abdomen the liver is fastened in the wound by interrupted catgut or fine silk sutures passed through its substance at a little distance outside of the abscess-opening, i" -hut off its communication with the general peritoneum. If the stitches show a tendency to tear out, sterilized gauze must be packed around the opening in the liver ami the cuds brought out of" the abdominal wound. The sponge plug is then removed and a large drainage tube inserted, [mmediately before incising the liver an attempt can be made to unite the parietal and visceral peritoneum with catgut sutures around the proposed area of the incision, lint the stitches may tear out or puncture and cause leakage from the abscess into tin- general peri- toneal cavity. A- the liver ascends and descends with respiration it cannot be fastened to the abdominal wall at a less distance than half an inch from the free border of l lie nli- and COStal cartilage-. HYDATID CYST OF THE LIVER. 459 Whenever there is time it is always best to secure firm adhesions of the liver to the parietes in the selected region before evacuating- the pus. A longitudinal incision two or three inches long is carried down layer by layer and the peritoneum opened and the liver exposed. After carefully protecting the surrounding viscera with sponge, the pres- ence of pus is verified with a fine aspirating needle, and the point of puncture is then covered with an iodoform - gauze packing large enough to hold the margins of the abdominal wound apart and in contact with the liver. In addition, the parietal peritoneum and skin can be united with catgut around the margins of the incision. A fairly tight antiseptic dressing is applied, and in the course of two or three days adhesions will have shut off the abdom- inal cavity and the abscess can be safely opened without an anaesthetic. It is generally unwise to approach an abscess of the liver through the thoracic cavity; but if unavoidable, the selected intercostal space should be enlarged by resection of a rib, and the layers of the parietal and diaphragmatic pleura carefully united with catgut sutures around the proposed line of drainage. The surface of the liver is then exposed by an incision through the diaphragm and the future drainage track packed with iodoform gauze till adhesions have formed. If the liver and diaphragm are already adherent, the abscess can be opened immediately, provided the pleural cavity is secured from infection. It is unsafe to aspirate a possible abscess of the liver through the unopened abdominal or thoracic wall. HYDATID CYST OF THE LIVER. The operative treatment of hydatid cyst of the liver is almost identical with that of abscess. After partial evac- uation of its contents by a trocar and canula or aspirating needle the cyst wall can be more readily drawn into the abdominal wound and sutured there, and thus the rest of the abdominal cavity is more effectually protected than in the case of an abscess, and a cyst can be more safely opened immediately. 460 ABDOMINAL WALL, stoma elf, AND INTESTINES. Cholecystectomy. (Fig. 217.) — An incision three or lour inches long is made vertically downward from the lower border of the liver opposite the tip of the cartilage of the tenth rib, and deepened layer by layer and the peritoneum opened. If an extensive dissection or an operation on the cystic or common duct is anticipated more room will be needed, and it is better to use an in- cision about four inches long, starting from the median line an inch below the ensiform process, extending obliquely downward and outward, and terminating hori- zontally. If the liver is enlarged the oblique incision [ncisions for exposing the gall-bladder. should follow a line parallel to and just above its free border. Bevan ' recommends a F-shaped incision, the central portion of which lies beside the rectus, while the upper end curves partly across the rectus about three-quarters of :iu inch from the costal border, and lower portion curves outward at about the level of the umbilicus. He claims that while this gives ample exposure it largely spares the nerve-supply of the rectus. When a distended gall-bladder is encountered it is care- fully surrounded with a protective sponge packing and 1 Anna]* of Surg., July. L899. HYDATID CYST OF THE LIVER. 461 enough fluid drawn off with an aspirator to allow the walls thus relaxed to be pinched up on each side of the needle by the fingers or padded forceps and drawn into the abdominal wound. Sponges are wedged around it to prevent leakage into the peritoneum, and the fluid is evacuated by a trocar and canula, or a knife plunged into the bladder wall at the point of puncture made by the needle. In selecting this point of puncture allowance must he made for retraction of a distended bladder. If the bladder is not distended, a finger is passed along its inner surface following the cystic and common duct, to explore for the trouble as far as the intestine. A careful dissection with the finger nail and blunt-pointed scissors may be necessary to separate adhesions to surrounding viscera and even to find the gall-bladder. After protecting the rest of the abdominal cavity with a sponge packing the fundus of the bladder is drawn as far as possible into the abdominal wound and opened enough to admit one finger. All stones are then gently scooped or irrigated out, the abdominal wound partly closed in the usual way, and the protective sponges re- moved. The gall-bladder is fastened in the wound by a continuous silk suture passed through the skin, perito- neum, and the whole thickness of the bladder wall around the margin of the opening in it. The suture line must be far enough away from the fret' border of the ribs to allow for the respiratory movements of the liver. A large rubber drainage tube is passed into the fistu- lous opening and an abundant absorbent dressing applied which will need frequent renewal. It is not advisable to close a wound of the gall-bladder by the Czerny-Lembert method of suture and leave no communication with the parietal incision. Operations Involving the Cystic or Common Bile Duct. (Fig. 217.) — The oblique incision is used, or the vertical changed later if necessary into a crucial or J-shaped in- cision. After locating the stone by the exploring finger and protecting the rest of the abdomen by a spouge-pack- ing, an attempt is made to manipulate the calculus buck 462 ABDOMINAL WALL, STOMACH, AND INTESTINES. into the bladder or forward into the intestine, but bear- ing in mind that the duets are easily lacerated and very slightly distensible. If it seem feasible to reach the stone from the interior of the gall-bladder, this viseus is opened in the manner already described, and one of the specially devised chole- lithotomy forceps used to clip or nibble the stone into fragments, guided by the other hand in the abdomen. The operation is completed as described for cholecyst- ostomy. On the same principle an impacted calculus has been crushed by padded forceps applied to the exterior of the duct, and has been broken by the point of an aspir- ating needle puncturing the duet. Dr. McBurney ex- tracted one after splitting the distal portion of the duct through an opening made in the duodenum for the pur- pose. For a stone otherwise irremovable from the cystic duct cholecystectomy is preferable to needling or crushing externally with padded forceps. But there must be no doubt about the patency of the common duct. For a calculus impacted below the cystic duct, the ob- lique abdominal incision is used and the surrounding vis- cera arc well protected and retracted by a sponge packing. The duct is opened in its long axis over the stone suffi- ciently to extract the latter, and the opening then closed by interrupted Czerny-Lembert sutures, which because of the generally increased thickness of the duct wall from the irritation caused by the presence of the calculus is not very difficult. A drainage tube and iodoform gauze packing is carried from the abdominal wound down to the neighborhood of the suture line and the abdominal wound partly closed in the usual way. W an opened gall-bladder must be sutured in the ab- dominal wound ;it the same time, its opening must be separated as far as possible from the drainage tube by in- termediate suturing. CHOLECYSTENTEROSTOMY. Tlii- term is used to designate the establishment of a permanent fistulous communication between the gall-bind- t 'HOLECTSTENTEROSTOMT. 463 derand the intestine. The operation is designed to create a nmte by which the bile can pass into the intestine when the common duet is permanently obstructed, and when both the cystic and hepatic duets are patent and com- municate, and for some cases of persistent biliary fistula. The abdomen is opened, preferably by the vertical in- cision, and a convenient loop of intestine as near the duo- denum as possible is isolated by iodoform-gauze bands tied around the gut above and below, and to this isolated loop the gall-bladder is sutured and the communication established in the same manner as described for intestinal anastomosis. The bladder is first emptied by an aspirating needle entered as near as possible to the site of the future fistula. A continuous fine silk suture is passed uniting the serous coats of the bladder and the intestine at the convex free border of the latter for a distance of about an inch and a- half, and in front of this, as the parts lie exposed, a row of Lembert sutures is inserted. After carefully protect- ing the surrounding parts by a fresh sponge packing, the opposing- surfaces of the gall-bladder and intestine are opened longitudinally for about an inch close in front of the Lembert sutures, and the interior of each irrigated clean. The mucous membranes are united by a continu- ous fine silk or catgut suture, and a row of Lembert sutures continuous with those already in place completes the serous apposition all around. The gauze constricting bands and sponges are removed and an iodoform-gauze packing placed around the suture line and the ends brought out of the abdominal wound, which is partly closed in the usual way. Murphy's "button" has proved peculiarly valuable in cholecystenterostomy. The button can be made small enough to be easily passed otf by the intestine, and at the same time leave a communication with the gall-bladder large enough to be useful in spite of any probable subse- quent cicatricial contraction. The abdomen is opened by the vertical incision, the bladder is aspirated, and a -elected loop of intestine iso- 1'W ABDOMINAL WALL, STOMACH, AND INTESTINES. lated a> usual, and ;i protective sponge packing placed in tin- abdomen. A "puree-string" suture "I' line -ilk i> passed through the -emu- coai of the bladder and intes- tine enclosing an area on each large enough to contain a -lit the length of the diameter of the buttons. The 1 > 1 1 1 — tons are inserted in the longitudinal slits then made in the bladder and gut, ami the wounds are drawn tight around the central cylinder by tying the sutures. The buttons are -imply pressed together, and the wounds, with the suture in each, are -hut within the concavity bounded by the margins of the buttons holding the serous surfaces in apposition. The calculi are not disturbed, but lefl to be defecated with the button, and the abdominal wound is closed with- out drainage after removing the -j ges. CHOLECYSTECTOMY. The abdomen is opened by the oblique incision ami the gall-bladder surrounded with sponges. Starting at the fundus, an incision is made on each side of the bladder through the peritoneum at a little distance from the liver, and the bladder dissected out with blunt-pointed scissors a- far a- the cystic duet. The latter i- divided between a double ligature of silk, and the peritoneal Saps closed over the liver by a continuous catgul suture. The abdominal wound is partly closed around a tube, and light iodofbrm- gauze packing carried down to the former site of the gall- bladder. SPLEEN. Anatomy.— The pedicle of the spleen will lie formed by the gastro-splenic omentum passing from the hilum to the stomach and. continuous with this above, the suspensory ligament passing to the diaphragm. The splenic arterj lie- above the vein behind the upper border of the pan- creas. The gastro-splenic omentum contains it- terminal or -i\ branches which arise at a variable distance from the spleen and may enter it- hilum over a consider- able area. Most of the vasa brcvia arise from these and KIDNE] turn backward to the stomach, and near the termination of the main splenic artery the gastro-opiploicn sinistra i> given off. The venous branches correspond to the arterial, SPLENECTOMY A vertical incision three or tour inches long is made along the outer border of the left rectus muscle above the umbilicus, and the peritoneum opened, [fthe spleen has prolapsed into an already existing wound, the latter ia simply enlarged ;i> much a< necessary. Adhesions art 1 separated or divided between double catgut ligatures, and the tumor, which must be very gently handled, is fully exposed. Alter surrouuding it with a sponge packing it i- turned out of the abdominal wound, general h the lower end first. The abdominal opening should be made large enough to allow the tumor to pass without force, and the margins of the wound should he held back to avoid all traction on the pedicle. Starting at it- lower edge, successive pairs of artery clamps are applied to the peui cle in advance of the line of division which is then made between them. The spleen is then removed and the vessels in the grasp of each clamp are ligated separately with silk, \- each clamp is removed bleeding point- are sought for and seen red : after this Greig Smith advises that the whole pedicle be surrounded by a ligature drawn moderately tight to lessen the arterial pressure distal to it on the ligatures of each vessel. The abdominal wound is then closed tight in the usual way, KIDNEY. Anatomy. — 'The kidney lies imbedded in fatty tissue which is more abundant behind than in front] and from which it can be easily enucleated. Posteriorly the upper half rests against the diaphragm and the lower half upon the transversalis aponeurosis, and is crossed posteriorly by the last dorsal, the ilio-hypogastrio, and ilioinguinal nerves. In front, from above downward, the- liver, du- 30 466 ABDOMINAL WALL, STOMACH, AND INTESTINES. odcnum, and hepatic flexure of the colon arc in contact with the right kidney ; the stomach with the spleen ex- ternally, the pancreas and descending colon are in relation with the anterior surface of the left kidney. Thus the colon generally lies vertically in front of a renal growth on the right side, and on the left side crosses i( obliquely from above downward and outward. The peritoneum over such a tumor can be divided on the outer side of the colon, but not on the inner, without interfer- ing with the blood-supply of the bowel. The renal artery, which may divide into one or more branches before entering the hilum, subdivides into ter- minal branches, which are said commonly to lie in front of the veins. The renal vein subdivides earlier than the artery, and the left vein receives the left spermatic and left inferior phrenic veins which are within reach of in- jury during treatment of the renal pedicle. The vessels lie in front of the ureter, which terminates near the lower border of the kidney in its pelvis. The latter subdivides in the hilum into two or three short trunks (infundibula), which in turn subdivide into the ealices opening over the papilla? ; so that a finger cannot pass from the pelvis into the first subdivision and much less into the second or ealices. As the twelfth rib may be rudimentary or absent the ribs should always be counted before a lumbar operation, in order to avoid the pleura, which is generally found to pass horizontally from the lower border of the twelfth dorsal vertebra to the lower border of the eleventh rib. EXPOSURE OF THE KIDNEY. Lumbar Methods. — The patient lies upon the sound side with a sand-bag under tin; loin to widen the opposite cx- posed costo-iliac space. A. Till-: LONGITUDINAL [NCISIOK is made along the outer border of the muscular mass formed by the erector spina; and sacro-lumbaliS; which is about two and a-half to three inches from the vertebral spines, and it should extend through the skin from the eleventh rib to the iliac. EXP()SrilE OF THE KIDNEY. 467 crest. (Fig. 218.) It is deepened through the middle layer of the lumbar fascia or the aponeurosis of the trans- versalis, and the posterior surface of the quadratus lum- boruni is exposed. The outer border of the muscle is cleared and drawn toward the spine, and after retraction of the sides of the wound, the peri-renal fat can usually he seen through the thin anterior layer of the lumbar fascia, moving synchronously with respiration. Space can l>e advantageously gained by dividing the outer por- tion of the quadratus close to its attachment to the ilium. Fig. 218. UK 1 Incision for exposing the kidney. L. Longitudinal or vertical incision. Transverse or oblique incision. K. Konig's incisioD. T. On division of the thin intervening fascia the fatty cap- sule of the kidney is reached, and by tearing through it and stripping it toward the sides the posterior surface of the middle and lower portions of the kidney and its pelvis are exposed to sight and touch. At the outer border of the quadratus muscle the last dorsal, the ilio- hypogastric, and ilio-inguinal nerves will be encountered, and one or all may be divided if they cannot be suffi- ciently retracted. Some additional space can be gained by drawing the last 468 ABDOMINAL WALL, STOMACH, AND INTESTINES. rib forcibly upward with a blunt hook, which is safer than resection of a portion of the twelfth and even the eleventh rib, as has been done in a few cases. If the pleural or peritoneal cavity is accidentally opened, the rent should be immediately closed with fine catgut sutures and protected by an iodoform-gauze packing. Except in persons who are very fat, this incision gives ample room for exploration, nephropexy, nephrotomy, and even for nephrectomy when the kidney is not very much enlarged. B. The transverse incision (Fig. 218, T) is begun just within the outer margin of the sacro-lumbalis, a little below the twelfth rib, and carried outward parallel to the rib for about four inches. The muscular and aponeurotic layers are successively divided after recognition, until the retro-peritoneal layer is reached, and the kidney exposed by division of its fatty capsule, as in the preceding descrip- tion. Additional space can be gained by a short longi- tudinal cut at the inner (vertebral) end of the main incision. This incision is advantageous in nephrectomy when the kidney is much enlarged, and whenever it may be neces- sary to insert a hand into the peritoneal cavity. C. The combined longitudinal and transverse incision consists of the longitudinal incision joined at any part by the transverse. I). KdNIG's INCISION. 1 (Fig. 218, K.) — Starting from the last rib, the incision passes vertically downward along the oilier border of the sacro-liinibalis and erector spin;e, curves forward just above the highest part of the iliac crest, and passes horizontally toward the umbilicus to end at the outer border of the right rectus. The vertical part of the incision is deepened first and carried down layer by layer until the peritoneum is reached in front of the anterior layer of the lumbar fascia. After the lingers are placed in the lower angle of this wound to protect the peritoneum beneath (he horizontal part, the latter is deepened through the successive muscular layers until the peritoneum is ex- [K)sed, It may often he advisable to make the vertical 'Centralb. I'. Chir., L886, No. 35, \>. 593. EXPOSURE OF THE KIDNEY. 469 part of the incision run obliquely into the horizontal in the form of a flattened curve. This incision affords very free access to the kidney and a good part of the ureter, and the size of the wound docs not materially add to the risks, hut rather lessens them by the increased facility afforded for dealing with the pedicle or any complications. At the close of the operation the divided muscles in the horizontal and curved parts of the incision arc united by deep sutures and heal readily, while the vertical part can hi' packed and drained if necessary. In any ordinary case the horizontal part of this incision need not he extended beyond the vertical prolongation of the anterior axillary line. Nephrotomy. — The kidney is exposed by the longitudinal lumbar incision, and if the abscess or cyst which has made the operation necessary is perfectly apparent it only re- mains to cut into the most prominent part of the diseased tissue with the knife or thermo-cautery. But if there is any doubt about the presence or location of the disease it must be sought by an aspirating needle passed through the convex border of the kidney and its track followed by a knife. A finger then plugs and enlarges this incision while, if necessary, an assistant makes counter-pressure through the anterior abdominal wall to lift the kidney into the incision ; then if the cavity is very irregular, or if there are separate pouches, the septa should be freely broken down to secure efficient drainage, and the interior of the cavity thoroughly scraped with a sharp spoon if its condition requires it. Occasionally it Mill be possible and desirable to draw the edges of the sac into the parietal wound and stitch them to the skin or deeper tissues. Rubber tubes packed around with iodoform gauze are passed into all parts of the abscess cavity for drainage, and into any spaces in the cellular tissue about the kidney which may have been opened up and infected. The extremities of the external wound are drawn to- gether with silk, and a large absorbent dressing applied, Nephrolithotomy. — After the kidney has been exposed. 470 ABDOMINAL WALL, STOMACH, AND INTESTINES. preferably by Konig's incision, which also gives access to the upper part of the ureter, the surgeon proceeds to seek for signs of the presence and location of a calculus ; the horizontal part of this incision should not be made at first of the full length, but later it is prolonged if found necessary. The posterior surface of the gland is freed and the kid- ney palpated between the thumb and finger and any click or spot of especial density noted. A fine needle is then passed systematically through the cortex or wall of the pelvis at intervals of half au inch, and not deeper than two and a-half inches in a normal adult kidney, in order to avoid possible injury to the main vessels. Should this fail to detect the stone, the finger may be introduced through an incision in the cor- tex and thus a thorough digital examination be made of the interior of the pelvis and calices. If no stone is found the wound is closed with catgut sutures passed through the substance of the kidney, and the external wound is brought together around a drainage tube placed in contact with the renal wound. AVhen a stone is felt by the needle, an incision is made with the knife or thermo-cautcry through the cortex lon- gitudinally. Unless it is very manifestly better to open the pelvis directly, an incision through the cortex is pre- ferable to one through the walls of the pelvis on account of the less danger of a urinary fistula and troublesome hemorrhage. Bleeding from the parenchyma is readily controlled at the last by deep sutures closing the wound in the kidney. Through the opening thus made the stone is picked or scooped out. If it is large or branched it may have to be crushed with a lithotrite or strong sequestrum forceps; septa should be divided with blunt-pointed scissors J oc- casionally stones have been encountered so large, or so numerous and diflicull of removal, that nephrectomy has been considered wiser than nephrolithotomy. After re- moval of the stone Hie orifice of the ureter is sought and thai canal explored to determine whether it is free or KIDNEY. 171 whether plugged by a stone or mass of fibrin. If such an obstruction is found it may be pushed back into the kidney, or washed out by a stream of water directed into the distended ureter through the renal wound, or perhaps poshed downward into the bladder. The stone or stones having been extracted from the kidney, the wound in its substance or in the pelvic wall is closed with catgut sutures unless there is so much suppu- ration present that every facility must be given for the escape of pus. Sometimes the gland will have become a mere abscess cavity containing the stone. Rubber tubes and iodoform-gauze packing are placed in contact with the kidney wound or in its interior, as its condition may re- quire, and in the space possibly opened up behind it. A strip of gauze is carried down to the peritoneum beneath the curved part of the external wound, if Konig's incision has been used, and the wound closed with silk sutures up to the space where the drainage emerges. Lumbar Nephrectomy. — The kidney is exposed by Konig's incision, but, if there is any doubt about its re- moval, it should first be explored by the longitudinal incision, and afterward a transverse incision of the neces- sary length can be added at any convenient part of the longitudinal. The length of the transverse or horizontal part of Konig's incision is regulated by the size of the tumor. If inflammation has not materially changed the tissues immediately surrounding the kidney, it is compara- tively easy, after reaching its posterior surface, and tearing through the perirenal fat, to work the fingers in close contact with the capsule around the convex border and the two extremities and enucleate the kidney from its bed by separating all the attachments except the pedicle con- stituted by the renal vessels and the ureter. In cases of long-continued suppuration where every- thing has become matted together, as, for instance, after nephrotomy for abscess, it may be easier to open the cap- sule and separate the kidney from its interior. The manipulations must be gentle and without undue traction on the pedicle, and if abnormal vessels are encountered 472 ABDOMINAL WALL, STo.MAcJL AND /.V 7 V:\77. VAX at the extremities of the gland they should he divided between double catgut ligatures. After isolation of the pedicle it may be tied off in sections by silk ligatures passed on a large full curved aneurism pedicle needle ; occasionally the main artery can be recognized by sight or touch, and it is desirable that it, as well as the ureter, should receive a separate ligature whenever possible. If the pedicle cannot be isolated and brought into view or reached on account of the condition or situation of the adhesions, the entire pedicle can be tied &n masse, pref- erably by the elastic ligature, which is drawn tight by the lingers in the depths of the wound and retained by a knot or clamp. The part of the kidney substance distal to the ligature is then cut away, leaving enough margin to prevent slip- ping of the ligature, and the large stump which some- times remains when the adhesions to the anterior surface have been very extensive is scraped as much as is safe and the elastic ligature is left to slough out. Occasion- ally the pedicle may be secured by a long, strong clamp till the kidney is excised and then the pedicle is tied by one or more ligatures on the proximal side of the clamp. If the ureter has been separately divided it is well to close it with a ligature, and if necessary to disinfect the stump or fix it in the external wound. The pedicle is finally again inspected to avoid any chance of hemorrhage, and then after the insertion of rubber drainage tubes and iodo- form-gauze packing the external wound is partially closed. During the course of a nephrectomy it may be necessary to enter the abdominal cavity ; this can be done through the anterior extremity of Konig's or of the transverse in- cision ; the surrounding peritoneal cavity is protected by the usual sponge-packingj ami after removal of the latter :ii the close of the operation an iodoform-gauze packing is inserted unless there is a certainty of asepsis, in which case the peritoneum can be again closed tight. Abdominal Nephrectomy. — The place of selection for the parietal incision is al the outer border of the rectus muscle, where it i- sometimes called Langenbuch's incision. It KIDNEY. 473 should not be less than four inches long, and should have its center as nearly as possible opposite the center of the tumor. The incision is sometimes made parallel to this, but further outward with the idea of making the operation wholly extra-peritoneal, and then it is only a modification of lumbar nephrectomy by the Longitudinal incision. Sometimes the abdomen is opened in the median line. After division of the tissues in successive layers, including the peritoneum, the visceraare pushed aside and protected by Hat sponges or brought out of the abdomen and wrapped in warm cloths. The peritoneum over nearly the whole length of the en- larged kidney is then incised longitudinally on the outer side of the colon in order not to interfere with the blood- supply of the latter. This must always be done in this way unless the size of the tumor and the position of the colon make it impracticable. Occasionally it is possible, as shown by Halsted, to attach the edges of the divided peritoneum covering the kidney to those of the divided anterior parietal peritoneum, and thus entirely to shut off the general peritoneal cavity from the field of operation. By working with the fingers or blunt-pointed scissors the peritoneum is stripped from the anterior surface of the gland and the structures at the hilum exposed. All ves- sels, as they are encountered, are secured in advance whenever possible and divided between double ligatures. It may even be advantageous to go directly to the artery through a special incision in the peritoneum and tic it as the first step in the operation. The ureter is then isolated between two ligatures, and if extensively diseased it is brought out of the abdomen behind and fastened to the skin through the wound made in the loin for drainage ; or if healthy the stump is simply disinfected and left. During the removal of the kidney every effort must be made to avoid infection of the peritoneal cavity by its contents or those of the ureter. After this the gap in the posterior parietal peritoneum may be rapidly closed with a continuous catgut suture, and lumbar drainage provided for the space formerly occupied by the kidney by the in- sertion of a rubber tube and gauze, if necessary, through 474 ABDOMINAL WALL, STOMACH, AND INTESTINES. ■a small incision made in the loin. The abdominal wound is closed in the usual way, with or without drainage, ac- cording to the necessities of the case. The presence and condition of the other, presumably sound, kidney should always be ascertained as soon as the peritoneal cavity is opened in abdominal nephrectomy. In cases of floating kidney in which the gland is fully pedunculated and invested by peritoneum, its removal will be conducted as in the case of any other pedunculated abdominal tumor, without stripping off the peritoneum. Nephrorrhaphy or Nephropexy. — This is the operation by which an abnormally movable kidney is permanently fixed in its proper position by suturing it to the abdominal wall. The kidney is exposed by the longitudinal lumbar in- cision at the outer border of the sacro-lumbalis, and the fatty capsule divided longitudinally and stripped back from the surface of the kidney. Three or four stout catgut or silkworm-gut sutures are then passed with a curved needle from the anterior to the posterior surface, well within the convex border, at intervals of about half an inch, and then through the cut edge of the lumbar fascia in the inner lip of the wound, so that when tied they hold the kidney snugly up against the abdominal wall. The wound may then be closed for primary union, or packed with iodoform gauze to heal by granulation. Guyon sought to strengthen the cicatricial connection by removing a long strip of the fibrous capsule ; and Sulzer ' recommends that the capsule be split and reflected so as to form a flap which can be stitched in the parietal wound. Others have sought to avoid sutures and increase the extent and strength of tin' adhesion by holding the kidney up against the sides of the wound by means of a gauze loop passed around its lower portion and left in place for a week or more. URETER. Anatomy.- — The ureter lies behind the peritoneum on the psoas muscle and genito-crural nerve in the upper part 1 I'.ut. Zeit r. Chir., Vol. XXXI. 2 (' it l)iii : American Journal of the Medical Sciences, L892, Vol. (III.. p. 43. URETKR. 475 of its course, and is crossed from within outward by the spermatic or ovarian vessels. As the ureters approach the pelvis they lie close to the spine between the psoas and the bodv of the vertebra, the right ureter being a little further outward than the left, owing to the interposition of the inferior vena cava, with which it is in close relationship. When the peritoneum in this region is stripped up from the parts beneath the ureter will always be found adher- ing to its under surface and on the left side, about half an inch to an inch outside of the point where the peritoneum becomes attached to the spine ; on the right side the dis- tance is slightly greater. The ureters cross the common or external iliac vessels to enter the pelvis, where they lie pretty closely over the lateral edges of the sacrum. They then run in the recto-vesical fold of peritoneum to enter the base of the bladder at a distance of two inches from each other and pass for a half to three-quarters of an inch between the mucous and muscular coats of the viscus be- fore terminating. The vas deferens is between the ureter and the bladder. The narrowest part of the canal is close to the bladder, and this region, which is the most difficult of access, is also the one where a calculus is most likely to lodge. In the female the ureter for the last two, and in some cases three, inches of its course, lies in the broad ligament in close relationship with the cervix and vault of the vagina, and it can be reached by an incision in the vault extending outward and backward within the layers of the broad ligament. Operations on the Ureter.' — Almost the only indications for operations upon the ureter are found in wounds of it or in the necessity for the removal of an impacted cal- culus. The ureter should always be opened extra-peri- toneally for the removal of a stone, inasmuch as the wound cannot be satisfactorily closed with sutures, and it has been proven that at least a longitudinal wound will in time, if there is proper drainage, spontaneously close and allow the urine to pass in its natural channel. •A summary of this subject with the bibliography will be found in the Annals of Surgery, 1894, p. 257. 47ti ABDOMINAL WALL. STOMACH, AND INTESTINES. The ureter should generally first be explored through :i median abdominal opening made below the umbilicus, and always thusexplored if there is doubt about the loca- tion of the stone. In some instances it has thus been possible to manipulate the calculus up into the pelvis of the kidney or down into the bladder, and even when it was soft to break the stone into fragments with the fingers and then get them into the bladder. [f the ureter must he opened, an incision is made three or tbnr inches long wherever necessary in a line drawn from a point on the anterior edge of the sacro-lumbalis a finger's breadth below the twelfth rib, parallel to the rib as far as its tip, thence downward toward the middle of Poupart's ligament till about opposite the anterior superior spine of the ilium. From this point the line again turns inward to end at the outer border of the rectus muscle. The tissues arc divided layer by layer till the perito- neum is reached, and then the latter membrane is gently raised by the fingers from the parts beneath till the ureter i-; exposed adhering to. its under surface. In the middle third of the course of the ureter it will be found about half an inch to an inch from the spinal attachment of the peri- toneum. The ureter is incised longitudinally over the stone sufficiently to extract the latter. In several in- stances this wound has then been closed by a continuous suture of fine silk through the outer wall of the ureter, but not penetrating its lumen, and with one end of the suture left within reach from the parietal opening to re- move it in case of suppuration. This may at any rate narrow the opening and so hasten its repair, though ( 'abot ' considers suturing a wound of the ureter unnecessary. A rubber tube and iodoform -gauze packing is placed in contact with the ureteral wound for drainage of escaping urine, ami the ends brought out of the external incision which is partially closed around them. In some cases where the -tone can be felt through the vault of the vagina, and it i- between the layers of the broad ligament not more than an inch or an inch and a- 1 Loc. Annals Surgery, L892, Vol. XVI., ]». 193. 'Markoeand Wood, Annals of Surgery, June, 1899. 'Annals Surgery, 1894, |>. 7<». URETER. 479 the latter the lumen of the distal segment is opened longi- tudinally sufficiently to permit the upper segment to be inserted into the lower. A couple of sutures in the cut edge of the proximal stump are threaded on needles and passed through the slit into the lumen of the lower stump and out through its walls just below the longitudinal opening and used to draw the upper into the lower por- tion of the tube. The ends of these sutures are tied, and one or two others inserted at the point where the stumps are in contact. Gauze is then packed around the suture line and brought out of the abdominal wound for drainage. CHAPTER VII. OPEKATIOXS UPON THE GENITO-URINARY OR- GANS OF THE MALE. CASTRATION. The usual preparations for an antiseptic operation are made, and a sterilized towel wet in a 1:1000 solution of bichloride of mercury is wrapped around the penis and pinned to the loose skin at its root. The scrotum on the affected side is grasped by the thumb and fingers of the left hand and drawn tight in such a way as to make the diseased testis and its cord prominent and tense. An in- cision is then made from the external abdominal ring along the entire length of the anterior portion of the scrotum; but if the skin is involved this incision should be made elliptical in the direction required to include the diseased area. After division of the skin and dartos the testicle is slipped out of the wound, and the cord is dissected out until a healthy portion is reached ; it may be necessary to follow it into the inguinal canal, splitting the apon- eurosis of the external oblique for the purpose. It is then divided by repeated cuts of the knife and the vessels are caught and tied with catgut as they bleed. Hemorrhage from the scrotal wound must be completely checked by ligation or by torsion and pressure. Drainage is unnecessary unless the wound lias been ex- posed to infection, in which ease a small rubber tube with lateral perforations is placed in its depths and brought out at the mosl dependent angle, while the surface is partly drawn together around an iodofbrm-gau/e packing. Sometimes :i healthy part of the cord cannot be reached :uid ii musl be li.-d through diseased tissue. It is then 180 HYDROCELE. 481 especially necessary to ligate each vessel separately, and an iodoform-gauze packing is placed in contact with the stump. A drv dressing is applied with a hernia bandage, over which is placed a sheet of rubber tissue, perforated for the penis, to prevent soiling by urine, and the whole retained by a flannel spica bandage. HYDROCELE. The operations for the relief of hydrocele are palliative or radical. The object of the former is simply to remove the liquid from the sac; that of the latter to prevent its reaccumulation by excising the sac, or by obliterating its cavity by exciting adhesive inflammation of its walls. Injection of the tincture of iodine is the means most com- monly employed for the latter purpose. The position of the testicle within the sac should always be ascertained, in order that it may not be injured by the trocar. This is best accomplished in most cases by examining the sac by transmitted light, the testicle appearing as an opaque spot in the general translucency ; its usual position is at the lower posterior portion of the sac. Puncture of the Sac. — The tumor is grasped at its up- per portion in such a manner as thoroughly to stretch the shin covering it, and a sterilized trocar is plunged into the center of its anterior surface, supposing the testicle to occupy its usual position below and behind. The depth to which the trocar enters is regulated by the finger placed along its side, and the surgeon satisfies himself that the point is well within the sac by moving it freely in all directions. The cannla should fit the trocar snugly in order that its anterior end may not push the tissues be- fore it instead of penetrating them. If the intention is only to remove the liquid, the cannla is withdrawn as soon as the flow has ceased, and the puncture closed with adhesive plaster or collodion ; but if a radical cure is to be attempted, the tincture of iodine must first be thrown in. (are must be taken that the injection is not thrown into the subcutaneous connective tissue, an accident that 482 GENITO-URINABY ORGANS OF THE MALE. is very likely to be followed bv slouching of the scrotum ; the surest way of avoiding this accident is to throw in the injection before the liquid has entirely ceased to flow out. If the accident does occur, free incisions must be made at once into the scrotum at the seat of the infiltra- tion. Radical Cure by Excision. (Volkmann.) — With every antiseptic precaution the sac is freely laid open by a longi- tudinal anterior incision and the cut edges of the skin and tunica vaginalis stitched together all around. The cavity is then lightly packed and allowed to heal by granulation, a process which requires a couple of weeks. If the sur- geon is sure of the asepsis the packing may be withdrawn at the end of three days, and then by applying firm pres- sure, the wound can be caused to heal much sooner. VARICOCELE. The treatment of varicocele may be palliative or radi- cal. By the former, support is given to the testicle and the over-distended veins ; by the latter, it is sought to obliterate the lumen of the veins at one or more points. There are several risks involved in the radical treatment, which, when taken in connection with the usual harmless- ness of the affection and the efficacy of palliative measures, should make the surgeon slow to employ it. The risks are : Possible sepsis, possible atrophy of the testicle, in consequence of the obliteration of all the veins or the in- clusion of the artery in the ligature ; and, finally, the re- turn of the affection if all the veins are not obliterated. The palliative treatment consists in wearing a suspensory bandage, or in excising a large portion of the scrotum, with the expectation that what is left will act as a natural suspensory. Excision of the Scrotum. — A long clamp is required, between the blades of which a large fold of the Scrotum is pinched up parallel to and including the raphe. This fold i- i In n cut off about one-eighth of an inch from the outer Bide "I* the blades, and numerous interrupted sutures ap- plied before the clamp is removed. If bleeding i- feared, VARICOCELE. 483 these sutures should be cut about a foot long, and not tied until after the clamp has been taken off and all bleeding points secured. The radical treatment consists in obliterating the lumen of the veins by dividing them, excising a portion, com- pressing and strangulating them by means of ligatures or clamps, or simply exposing them to the air. Of these ex- cision is the only method to be commended. Subcutaneous Ligature. — A needle carrying a catgut or aseptic silk ligature is passed through between the veins and the cord, reentered at the point of emergence, passed around the other side of the veins close under the skin and brought out and tightly tied at the first point of entry. If this is very exactly done, so as not to include the deeper part of the skin at either puncture in the loop, and is treated antiseptically, it will usually heal without suppuration. Its execution is facilitated by making the punctures with a knife. Open Method of Ligation. — A fold of the scrotum over the enlarged veins above the globus major is pinched up and divided with scissors, making a longitudinal incision about an inch long. The thumb and forefinger of the left hand grasp the vas deferens, pushing it backward, while the veins at the same time are forced forward into the cutaneous wound. The veins are isolated by a slight dissection with the knife or blunt-pointed scissors and a ligature of catgut or fine silk is passed under them by an aneurism needle. After another inspection to make cer- tain the vas is not included, the ligature is tied tightly and the ends cut short. The small incision is then closed without drainage and closed antiseptically. Some surgeons pass the ligature double, tying off a segment of the vein, which is then excised and the divided ends brought into apposition by the long ends of the lig- ature, which are then cut short. Others thoroughly expose a single vein, divide it, and then dissect out and excise an inch or two of it ; this is repeated with one or several others according to circum- stances, 4S4 GENITO-URINABT ORGANS OF THE MALE. AMPUTATION OF THE PENIS. Partial. — The root of the penis is constricted by a piece of rubber tubing and the skin is slightly drawn back to- ward the pubes and divided by a circular sweep of the knife. With a sound in the urethra the corpora caver- nosa are cut transversely at the level of the retracted skin down to the corpus spongiosum, which is then dissected out by a few strokes of the knife, and, after withdrawal of the sound, is cut transversely, including the urethra, about half an inch longer than the corpora cavernosa to allow for retraction of the urethra. The cut ends of the vessels in sight, including the two dorsal arteries and the arteries of the eorpora cavernosa, which lie in the center of these bodies, are tied with fine catgut, the tourniquet removed, and, after checking the hemorrhage by ligation or torsion, the cut edges of the urethra and skin are united with fine silk. To prevent cicatricial contraction of the mouth of the urethra, the latter should be split longitudinally for about half an inch on its under surface before stitching it to the skin. Complete. — The patient is placed in the lithotomy posi- tion, a sound introduced into the bladder, and the scrotum is split from before backward along its raphe. The corpus spongiosum is dissected out as far as the triangular liga- ment, and divided about an inch in front of the latter after withdrawal of the sound. A circular incision continuous with the anterior ex- tremity of the scrotal incision is next made through the skin around the root of the penis ; the suspensory liga- ment is divided, and by dragging on the penis and re- tracting the sides of the scrotal wound, the corpora caver- no-;! and their posterior prolongations, the crura, are removed from the rami of the pubes and ischium by the knife or periosteal elevator. All the attachments of the penis having thus been severed and the bleeding points tied. ;i- they are encountered, with fine catgut, the urethra ie -|>lit for half an inch on its floor and sutured to the edges of the wound well forward in the perineum, and the OPERATIONS FOR PHIMOSIS. 485 remainder of the wound is united between the testicles so as to form a separate scrotum for each of them. When this extensive operation is undertaken for cancer of the penis the inguinal glands on both sides should be removed at the same time, whether perceptibly enlarged or not. OPERATIONS FOR PHIMOSIS. Dorsal Incision. — A director is passed through the pre- putial orifice along the dorsum of the glans to the corona, a curved sharp-pointed bistoury guided along it, the skin transfixed at the point of the director and divided straight down to the preputial orifice. Nothing more is absolutely required, for the wound left to itself will heal promptly; but it is well to round off the corners and to unite the edges of the mucous membrane and skin by fine sutures. This is a very satisfactory operation when the prepuce is not redundant, but if there is much excess of tissue the foreskin will present an awkward, lop-eared appearance for many years, and in such cases, therefore, circumcision is to be preferred. This operation is often required in cases of sub-preputial chancroid, and care should then be taken to prevent or correct infection of the wound by the chancroidal virus. Circumcision. — A number of instruments have been in- vented and a great variety of methods proposed, which do not need to be repeated here, for the object they had in view, that of insuring division of the skin and mucous membrane of the prepuce at the same level, is not a mat- ter of much importance, since any excess of the latter can be readily removed afterward. There is, however, one modification introduced by Dr. Keyes ' which is of im- portance, for it insures the removal of the constriction and protects the wound from being harmed by erections while healing. This modification consists in an addi- tional longitudinal division of the skin for about half an inch along the dorsum of the penis (Fig. '219, AC). The 'Van Buren and Keves : Genito-Urinary Diseases, with Syphilis, New York, 1874, p. 11. 481) GENFTO-TJRINARY OIK I ASS OF THE MALE. Fig corners left by this incision arc rounded off, and the ef- fect is to increase the circumference by twice the length of the incision. Operation. — A probe is first introduced and swept over the surface of the glans to break up any adhesions that may exist, and the edge of the preputial orifice is then caught at opposite points with the thumb and forefinger of eacli hand and drawn forward, care being taken to make the tension upon the less elastic mucous membrane, and not only upon the skin. While the prepuce is thus drawn forward, an assistant clasps a pair of long narrow- bladed forceps vertically upon it just in front of the apex of the glans, directing the blades forward as well as downward (the penis being horizontal) parallel to the general direction of the corona, and the glans should then be moved freely behind them to make sure that it is not caught between the blades. The portion of prepuce in front of the forceps is then cut away with scissors or a knife and the forceps taken off. It will then be seen that the glans is still covered by a more or less tightly fitting sheath of mucous membrane, while the looser and more elastic skin retracts to or beyond the corona, leaving a belt of raw surface below (Fig. 21 9). The mucous membrane is next divided with scissors along the dorsum back to the corona (Fig. 21i>, BD), and the skin divided in the same direction along the dorsum for a distance of half an inch from its cut edge (Fig. 219, AC). The corners arc rounded off, and the edges of the mucous membrane and skin fastened together with numer- ous fine sutures, the first being placed exactly in the me- dian line in front, the second at the fraenum. If fine silk is used, and the sutures placed close to the edge, they may lie left to cut their way out and come away in the dressings. If broad adhesions exist between the glans and prepuce, Circumcision. Raw surface left by retrac- tion after Brsl incis- ion. EPISPADIAS. 487 and it is feared that the raw surfaces left by their division will reunite, all the mucous membrane may be removed, except a ring about one-eighth of an inch wide adjoining the corona; the skin is then drawn forward, and united to the narrow ring of mucous membrane The raw sur- face on the glans, having nothing to adhere to, cicatrizes naturally. PARAPHIMOSIS. A description of the methods of reduction by taxis or by compression of the engorged prepuce and gland does not lie within the proposed scope of this work, and the operation of division of the constricting band hardly needs to be described, for it consists simply in dividing the band from without inward at one or more points, until the con- striction is sufficiently relieved to allow the prepuce to be drawn forward. It is well to make the first incision in the median dorsal line so as to profit by it afterward, if an operation for phimosis is considered necessary. DIVISION OF THE FR.ENUM. Yerncuil ' employs the following method : He makes the frsenum tense, transfixes it close to its attachment to the glans with a narrow bistoury or tenotome held with its side parallel to the surface of the penis, and cuts out backward, making a triangular flap nearly half an inch long, with its apex directed backward. The liberated glans is drawn forward, the flap disappears, and the edges of the wound, which assumes the shape of a lozenge, are united by sutures. EPISPADIAS. The deformity known as epispadias is characterized by fissure of the roof of the urethra. In its complete form it is associated with separation of the symphysis pubis, and often with exstrophy of the bladder, in which case its treatment is subordinate to that of the more important defect (q. v.). In its slightest degree it is confined to a fissure occupying the dorsal portion of the glans penis, 1 Chirurgie R^paratrice, 1887, p. 730. 48S GENITO URINARY ORGANS OF THE MALE. and extending from the meatus to the corona (epis- padias balanique). The existence of this form has been y freshen- ing the surface about its edge and covering it with a flap taken from the adjoining skin. When the anterior por- tion exists only in the form of a more or less shallow groove, it may be transformed into a complete canal by one of the methods of urethroplasty hereinafter described. The two other modes of operating, urethrorrhaphy and perforation, have now been discarded ; in the former the edges of the groove were pared and brought together with sutures, in the latter a trocar was passed along through the tissues of the under side of the penis from the extremity of the glans to the abnormal opening of the urethra, and the route thus created kept open by the frequent passage of sounds. If the penis is incurvated it must be straightened as a preliminary to auy operation. To accomplish this it is not sufficient to divide only the fibrous band on its under surface, for the retraction is partly maintained by the shortness of the inferior portion of the sheaths of the corpora cavernosa and the septum between them. If the skin on the under surface is flexible enough to allow the penis to be straightened after the internal bands have been divided, this division may be made subcutaneously, following the example of Bouisson, by introducing a teno- tome and pressing its edge against the sheath of the cor- pora cavernosa and the septum while the glans is drawn steadily away from the scrotum. Ordinarily, however, this is not possible, and one or two transverse incisions one centimeter long must be made through the skin and deeper parts. By the straightening of the penis these transverse incisions are transformed into longitudinal ones, and their sides are then drawn together by sutures. Several months must then be allowed to elapse before the subsequent plastic operation is undertaken, in order that the cicatrix may become perfectly soft and attain its full vitality. In the earlier operations of urethroplasty the floor of the urethra was formed by a long narrow vertical flap taken from the scrotum, its base adjoining the orifice of the 494 GENITO-URINARY ORGANS OF THE MALE. urethra, and its borders fastened to the edges of two lon- gitudinal incisions on the under side of the penis. In short, the method resembled that already described as em- ployed by Nelaton for the relief of epispadias, even to the reinforcement of the flap by a transverse one taken from the skin above the root of the peuis. The results of these attempts were so unsatisfactory that Avhen Nelaton was consulted in 1872, concerning a patient affected with hypospadias, he advised that nothing should be done, saying that he had made many canals through which the urine was carried to the end of the penis, but they inter- fered with erection, and did not facilitate fecundation. 1 The surgeon who received this advice, Theophile Anger, thereupon devised another method, ignorant that a similar one had been employed shortly before by Thiersch in epispadias and by Scymanowski for urethral fistula, and, having put it into execution, obtained an excellent result. Theopile Anger's Method. — In this case the urethral opening was at the penoscrotal angle, the anterior portion of the canal was entirely lacking, and the penis was so curved that the extremity of the glans was not more than half an inch from the opening. The penis was first straightened by two short transverse incisions carried to such a depth that the corpora cavernosa were exposed at the bottom of the wound ; the bleeding was slight, and the wound healed promptly. The plastic operation was per- formed nearly four months afterward, and was only par- tially successful, the posterior portion of the flap disap- pearing by absorption. A second operation six months later, was entirely successful, and the condition of the parts, when the patient was shown to the Societe de Chi- purgie five mouths afterward, was entirely satisfactory ; the tissues were supple, there was no stricture in the canal, and erection was perfect, except for a very slight incurva- tion downward. The first plastic operation was as follows : An incision, extending from the glans to the scrotum, was made 'Theophile Anger in Bull, de la Soc. make the sec- tion exactly in the median line of the roof. The knife is blunted on its summit and is supposed to divide only the narrowed portions of the canal. After a stricture beyond four and a-half inches from the meatus has been cut in this way, the patient is placed in a lithotomy position, the per- ineal region thoroughly disinfected and shaved, and a broadly-grooved staff, about the size of a No. 2s-:{(> F. sound, i- passed to the bladder. It is so held in the median line by an assistant a- to make the curved part of the staff prominent in the perineum. RfcBurney's gorget ( Fig. 226), with the knife protruded, i- then plunged into the center of the perineum, opening the membranous ure- thra and striking the gi ve in the staff, into which the gorget i- pushed, sheathing the knife which is then with- drawn, whileat the same time, by -lightly tilting the stall' and advancing the gorget, the latter -lip- into the bladder as evidenced by the gush of urine. A soft-rubber catheter i- inserted into the bladder on the gorge! through the peri- nea] puncture and retained by a -ilk suture through the -kin. ami the gorgel is withdrawn. The bladder and ure- thra are thoroughly irrigated with a saturated solution of boric acid, and the catheter connected with a tube termin- EXTERNAL PERINEAL URETHROTOMY. 503 utility beneath the surface of a 1 : GO solution of carbolic acid in a bottle under the bed. A slight dressing retained by a split f-bandage around the catheter is sufficient, and at the end of five days a sound is passed through the whole length of the urethra entering the bladder alongside of the Fig. 22G. McBiirney's gorget and grooved sound. catheter, which if all goes well, is removed twenty-four hours later, and a single antiseptic pad placed on the punctured wound in the perineum. When the bladder and urine are not extensively dis- eased and there are no other complications, such as mul- tiple fistula?, this method of treating deep strictures is generally preferred to the usual external urethrotomy. EXTERNAL PERINEAL URETHROTOMY. A. With a Guide. — Prof. Syme, who introduced this operation, employed as a guide a staff, the straight 504 GENITO-UMINARY ORGANS OF THE MALE. portion of which was of full size, and its curved portion much smaller and grooved on the convexity. The change from the full to the small size was abrupt, not gradual (Fig. 227). This instrument has been superseded, in the United States at least, by the tunnelled instruments in- troduced by Van Buren, 1 which are passed into the blad- der over a tine whalebone bougie as a guide, the beak of the instrument being bridged over or drilled out for a distance of about one-quarter of an inch, so that it can be slipped over the bougie (Fig. 228). If a Synic's staff or a tunnelled catheter cannot be had, any instrument may be used which can be got into the bladder, but it is a great advantage to be able to pass a full-sized instrument step by step as the stricture is divided. The patient is placed in the lithotomy position (dorsal decubitus, thighs flexed upon the abdomen), 2 the perineum shaved, the whalebone guide introduced into the bladder, a tunnelled silver catheter of full size, grooved on the con- vexitv, passed down over it to the stricture and confided Fig. 227. Syme'.s shift' for perineal -ci-tioii. to an assistant, who also draws the scrotum forward out of* the way. An incision, varying in length according to the position of the stricture, is made in the median line, and the end of the catheter exposed. If the stricture i< deeply placed the sides of the incision must now be held apart, while the guide is carefully followed from before backward with short, cautions strokes of the knife in the median line, and the catheter pushed along as the route 1 \';ui Buren and Keyes, Genito-Urinary l>isc;is«s, p. 127. ' \ convenient method of keeping the thighs 6xed is to puss m stent cane under tin- knee and fasten it with :i <1 or roller bandage pasa ■ ! fron tend around the patient's neck to the other end. An instru- ment has been specially constructed i'm- the purpose ' Fig. 229), but a jtOUl tick line- verv well. EXTERNAL PERINEAL URETHROTOMY 505 Fig. 228. is opened, until the posterior limit of the stricture having been passed, it slips into the blad- der. Care must be taken not to divide the whalebone guide by a careless stroke of the knife. [f Syme's staff is used, the in- cision is carried down until the groove in the curve of the staff can be felt by the finger; the handle of the staff is then grasped with the left hand, the point of a narrow bistoury passed into the groove behind the stricture, and the latter divided by cutting from behind forward. Any bands that are found on the roof of the urethra must be divided, and a full-sized steel sound passed to make sure that the stricture has been thoroughly relieved. B. Without a Guide. — The cases are rare in which a fili- form whalebone bougie cannot be passed through a stricture which allows urine to pass, and con- sequently external urethrotomy without a guide is not often re- quired. The patient is placed in the lithotomy position, the perin- eum shaved, and a full-sized sound, preferably grooved, passed down to the stricture and confided to an assistant, who also draws the scrotum forward, keeping its raphe exactly in the median line. An incision, two and a-half to three inches long, is made in the median line, and the end of the '""'S^gS! " d 500 GENITO-UR1NARY ORGANS OF THE MALE. sound exposed by opening the urethra half an inch in front of the stricture. The sound is then partly with- drawn, the sides of the wound held widely apart by means of ligatures passed through the cut edges of the Fig. 229. Clover's crutch, for operations upon the perineum. urethra, and an effort made to pass a fine probe or whale- bone bougie through the stricture from before backward ; if the effort succeeds, the operation becomes one "with a guide," and is completed as before described. If the probe cau be passed for only a short distance, a line or two, the tissues are divided upon it, and the attempt re- newed until the canal behind the stricture is reached. Success depends largely upon full exposure of the end of the stricture in order that the search for the opening may be aided by the eye. [f these efforts fail entirely, the urethra must besought h'XSTL'oriiv OF THE -BLADDER. 507 for behind the stricture — a most difficult task unless ;i perineal fistula exists through which a guide can be passed into the bladder, or unless this portion of the urethra is distended with urine and can he punctured in the median line. The bottom of the wound should be freely exposed by retraction of the sides, the index-finger passed well into the rectum and pressed up toward the center of the pubic arch as a guide, and the wound then deepened by succes- sive cuts directly in the center. After the urethra has been thus opened it must be slit forward through the stricture. Occasionally surgeons have opened the bladder above the pubes and passed a sound from within outward to the stricture as a guide. EXSTROPHY OF THE BLADDER. The first operation for the relief of this deformity was performed, according to Gross, by Prof. Pancoast, of Philadelphia, in 1858; according to Erichsen, by Dr. Daniel Ayres, of Brooklyn, in 1859. The deformity is much more frequent in males than in females, and the operative indication is to cover in as much as possible of the exposed mucous membrane and facilitate the adapta- tion of a urinal by making the urine escape through a comparatively small opening ; for, as the sphincter cannot be restored, there will always be incontinence. The method at first employed was the same as Nelaton's for epispadias : a tegumentary flap was raised from the abdo- men above the bladder, reversed so as to cover the latter, and then covered itself in turn by lateral flaps, one from each side. The first flap (Fig. 230) should be square, its base ad- joining and slightly broader than the upper margin of the opening, its length should be sufficient to cover in the bladder completely when turned down over it. A pyri- form flap is dissected upon each side, its breadth equal to the length of the first Hap, and its base directed downward and inward, as shown in Fig. 230, or downward and out- 508 GEMTO-URWA&¥ ORGANS OF THE MALI-:. ward so as to require less twisting and include more of the cutaneous branches coming from the femoral artery. These two flaps are then drawn across the reversed um- bilical flap, meeting in the median line, and are fastened to each other with twisted sutures, the pins including a portion of the thickness of the umbilical flap also, so as to keep the raw surfaces in contact (Fig. 231). Fig Fig. 231. Wood's operation fur exstrophj bladder. Incisions. Flaps in plac The cducs of the gaps left by the removal of the flaps are drawn together as well as possible with twisted and wire sutures, broad strips of adhesive plaster applied to give support and relieve tension, and the patient kept in bed in a sitting posture with the knees drawn up. The sutures may be removed at the end of a week. Healing may be hastened by using Thiersch skin grafts on granu- lating surfaces. Of late years many other devices have been tried, some of them with gratifying success. When the symphysis is absent Trendelenburg first per- forms an operation to remedy tin; epispadias. Later he divides the sacro-iliac synchondrosis on each side from behind forward, sufficiently to mobilize the iliac bones and allow the gap in front to be closed by pressing together the sides of the pelvis. Subsequently the margins of the t '. I THE Th'R IX. I Tin X. 509 defect in the soft parts are freshened and brought together with sutures. This may need to be supplemented by a flap operation and Thiersch skin grafts. Czerny, starting at the edges of the detect, frees the wall of the bladder from the underlying parts and sutures its margins together to form a closed sac. Then this is covered in by two lateral flaps, base down, as in the first operation described. Afterward the neck of the bladder and the freshened edges of the prostatic portion of the urethra are brought together, and then the epispadias i> attended to. Rutkowski and Mikulicz l have successfully used a por- tion of the intestine to enlarge the bladder, and in a few cases the ureters have been transplanted into the rectum or colon. CATHETERIZATION WITH CURVED METAL CATHETER). The obstacles to the passage of a catheter, exclusive of stricture and of false passage, are found either at the tri- angular ligament, in the membranous, or in the prostatic portion of the urethra. As the fixed portion of the canal begins anteriorly at the opening in the subpubic or trian- gular ligament, the flaccid pendulous portion in front of this point may be carried aside if the catheter is held im- properly, and doubled upon itself in front of the beak of the instrument. This difficulty is overcome by drawing the penis gently up the shaft of the instrument so as to straighten out the portion of the canal yet to be traversed, and by keeping the beak in the median line and making- it follow the roof rather than the floor of the urethra, so as to avoid especially the normal pouch-like dilatation found on the under side just in front of the opening in the ligament. The obstacle in the membranous portion is caused by the spasmodic contraction of the muscles which envelop this part of the canal. The nature of the obstruction is 1 Centralblatt fur Chir., 18Q9. Nog. 16and22. 510 GENITO-UMINARY ORGANS OF THE MALE. recognized by the tight grasp of the instrument by the muscles and the quivering of the fibers transmitted tli rough it to the hand of the surgeon. The Fig. 232. difficulty is overcome by making gentle pressure with the beak of the catheter in the proper di- rection, so as to tire out the muscles. The most serious obstacle is found in the pro- static portion, and is due either to inflammatory swelling of the mucous membrane or of the gland (abscess of the prostate), or, much more com- monly, to senile change in the shape and size of this organ. A description of the nature of these changes and lesions does not come within the scope of this work, and the reader is referred for them to special treatises upon the subject. It is sufficient here to say that in the former case the inflammation must be reduced or the abscess evacuated secundum artem, or, failing this, the bladder must be punctured above the pubes, or through the rectum. In the other case, catheters of different curves should be tried, such as Mott's long catheter of large curve, or Mercier's soft, single or double-elbowed catheter. It is also well lo pass the forefinger of the left hand into the rectum to make sure that the catheter lias en- tered at the apex of the prostate, and that it has not passed out of the canal into a false passage, and to try to lift its beak over the obstacle by making direct pressure upon the curve in front of the prostate, while the handle is simultane- ously depressed. Mercier'a If these mean- fail, and soft instruments of eatheter ed •-'"" or vwlca 11 ! 26 ^ rubber cannot be introduced, the bladder must lie punctured. Passage of the Catheter. — The patient having been brought to the side of the bed or placed upon a lounge, the Burgeon, standing on one side, separates the lips of the meatus with the thumb and forefinger of the left hand, introduces the beak of the catheter, previously well warmed IATIIOLAPAXY. - r >ll and oiled, and passes it down to the penoscrotal angle, holding- the shaft of the instrument parallel to the groin. He then sweeps the handle around to the median line of the abdomen, keeping it close to the surface, draws the penis gently up the shaft, and presses the instrument bodily downward toward the feet ; as soon as the beak reaches the lower border of the symphysis he draws the scrotum up and presses the catheter gently onward, still holding it parallel to the body, and then when the beak has closely approached or engaged in the opening in the triangular ligament he gradually raises the handle, brings it forward in the median line, and depresses it between the thighs. Failure to enter the opening in the triangular ligament is indicated by the bulging of the curve of the instrument in front of the symphysis, its rebound when the slight pressure on the handle is removed, and the mo- bility of the beak when the handle is gently rotated about its longitudinal axis. As the shaft passes the vertical line the root of the penis and the integument covering the symphysis should be pressed down with the palm of the hand laid broadly upon it, so as to stretch the suspensory ligament. PUNCTURE OF THE BLADDER. Above the Pubes. — The only instrument required is a straight, or, better, a curved trocar and canula, or aspira- tor needle. The surgeon satisfies himself by percussion that the distended bladder rises well above the pubes, and then making the skin tense with the thumb and ringers of his left hand, he plunges in the trocar close above the symphysis pubis in the median line, the concavity of the instrument turned toward the bone. Some surgeons prefer to make a preliminary incision in the median line, and others even continue the use of the knife until the bladder can be felt at the bottom of the wound. LITHOLAPAXY. It is the operation of introducing a lithotrite into the bladder through the urethra and with it crushing a stone 512 GEXrrO-UBIXARY ORGANS OF THE MALE. into fragments, which arc then removed by the wash bottle and evacuators represented in Fig. 236. The modern lithotrite is a steel instrument consisting of a straight shaft eleven inches in length, having at one end a " beak " about an inch long inclined at an angle of from 110° to 130°, and at the other a cylindrical roughened handle containing a screw. It is composed throughout of two parts, one fitting accurately in a deep groove in the other, and having at the handle a male screw which can be thrown into and out of gear by means of a button upon Fig. 233. sir Henry Thompson's lithotrite. Fig. 2.34. the other part. While trying to catch a stone the screw should be out of gear, in order that the male blade may lie advanced and withdrawn more rapidly, but when the stone has been fairly caught the button must be pressed back and the screw-power u>((\ to crush it. Many different patterns have been proposed for the beat or ja\\~ with the view either of securing the thor- ough pulverization of the fragments, or of preventing the clogging of the instrument l>v the impaction of the inor- LITHOLAPAXY. 513 tar-like detritus between the jaws. The latter difficulty can be overcome by leaving the jaw of the female blade entirely open, that is, with a large fenestra extending from side to side and from the extremity of the beak to its angle, and by making the male shaft long enough to allow its jaw to be passed through the female one. In its simplest terms, then, the jaws should consist of two parallel bars, one-fourth of an inch apart, between which a third one fitting loosely in the gap, can be forced. A small fenestra at the angle of the beak will not pre- vent clogging, although it may diminish it if there is a corresponding projection at the heel of the male jaw, as in Fig. 235. " Scoop" lithotrite. Fig. 235 ; and it is open to the objection that it may lodge a sharp angular fragment, which, projecting beyond its edges, will lacerate the neck of the bladder and the floor of the urethra during the withdrawal of the instrument. For catching and crushing small fragments the "scoop" lithotrite is commonly used; the jaw of its female blade is broad and shallow, with no fenestra or with only a small one at its angle. The edges of both jaws should be bevelled, and the male considerably narrower than the female, so that they may be brought together with the least possible danger of including a fold of mucous mem- brane between them. Operation. — The patient is anesthetized and placed upon his back, with his hips raised upon a firm pillow or cushion in order that the stone may gravitate away •*>14 GENITO-TJRINABY ORGANS OF THE MALE. from ths Deck of the bladder. If the urine is turbid, and especially if it is ammoniacal, it should be drawn off be- fore the operation and the bladder thoroughly washed with a borax solution (one or two drachms to the pint), of which from two to four ounces should be left in the blad- der to facilitate the crushing. The surgeon, standing at the patient's right side, introduces a freshly boiled litho- tritc after greasing the instrument with vaseline. Care must be taken not to depress the handle too soon, a mistake which is likely to be made on account of the apparently great depth to which the instrument has to penetrate be- fore the bladder is reached. As soon as the instrument has entered the bladder, it is allowed to glide across it, its shaft being held steadily in one position, and if the stone is free it will generally be touched on the way. The surgeon then gently turns the beak away from the stone, withdraws with his right hand the male blade for a distance determined by pre- vious measurement of the stone, presses the jaw of the female blade gently against the floor and posterior wall of the bladder, rotates the beak toward the stone, and closes the male blade upon it. As soon as the stone is felt to be firmly caught, the beak is rotated back to the vertical position, and the screw thrown into gear by pressing back the button on the handle with the thumb of either hand. The Iithotrite with the stone in its grasp is then drawn away from the posterior wall and rotated to either side to make sure that the mucous membrane is not caught between its jaws, and then, grasping the cylindrical handle firmly with his left hand, the surgeon crushes the -tone by turning the screw with his right, and continues this action until the register upon the handle shows that tie male blade has been driven well home. The screw i- then thrown out of gear, the male blade drawn back, the beak turned again toward the spot where the stone was caught, and the instrument closed whether the frag- ments are felt or not, for it may he confidently expected that they will he found there. After crushing the stone in this manner several times LITHOLAPAXY 515 the smaller fragments arc washed out by the evacuating tube and washing-bottle (Fig. -}•"><>) and the lithotrite re- introduced ; and this alternation in (he use of the instru- ments is continued until the bladder is emptied. This frequent washing is important because by the removal of Evacuating-tube unci washius-bottli the smaller fragments it is made easier to seize and crush the larger ones. The washing is done as follows : The washing-bottle is p © filled with tepid water, then the tube is introduced, and as soon as the urine begins to flow through it the bottle is coupled to it. Or the coupling may be done just before the tube has entered the bladder, and the air in the tube al- lowed to rise to the top of the bottle, by turning the stop- cock, before the introduction is completed and the washing is begun. By quick compression and relaxation of the rubber bulb the water is rapidly forced into the bladder and drawn back again, bringing the fragments with it ; these fragments sink to the bottom of the bottle and are not returned with the 516 GENITO-TJRINARY ORGANS OF THE MALE. returning stream. The amount of water driven back and forth at each movement will vary with the sensitiveness and distensibility of the bladder; two or three ounces are sufficient to wash effectively. If the curved tube is used, its eye should be in turn directed to different quarters of the bladder ; if the straight tube with a square end is used, it must be passed just through the neck, and its outer end well depressed between the thighs. At the close of the operation the surgeon should place his ear upon the hypogastrium and listen while washing, to detect the click against the tube of any fragments that may remain. This is a more delicate test than the use of the searcher. LITHOTOMY. The anatomy of the perineum is sufficiently well shown in Fig. 237 to render a detailed description unnecessary. The dimensions of the prostate have been studied with much attention, and were the basis of many of the modi- fications of perineal lithotomy, for it has been held that the incision should not be carried beyond the limits of the gland. The greatest radius, measuring from the urethra, is one inclined about 30° backward and downward from the transverse diameter, and in the normal adult prostate this measures about three-quarters of an inch at the largest part of the gland, that which adjoins the neck of the bladder. But, as the diameter of the prostate diminishes :is the distance from the bladder increases, an incision which remains within its limits at one point may extend far beyond them at another; and this fact, taken in con- oectioa with the great variations in the size of the gland, indicates the futility of attempts to regulate the incision with mathematical precision. Fortunately, the depth ofthe incision is not a measure of the size of the stone which can In' safely removed through it, for the neck of the bladder and the prostatic portion of the urethra are normally di- latable to a diameter of nearly an inch. If the Stone is Large and the traction made with too much force, the neck of the bladder may be torn off, but LITHOTOMY 517 more commonly the incision is Lengthened by tearing at its outer end, an accident which is less dangerous than extending the incision with the knife would be, for it spares the rich plexus of veins about the prostate. Fig. 2:;:. Avtery of corpus cavernosum Dorsal artery of penis A rtery of bulb. Internal piiriic artery Cowper's gland A view of the jirisit ion of the viscera at the outlet of the pelvis. Lateral Lithotomy. — The instruments required are a staff with a long curve, deeply grooved on its convexity (Fig. 238), a stout scalpel with a cutting edge of one and one-half inches (Fig. 239), a Blizard's knife (Fig. 240), a blunt gorget (Fig. 241), if the patient is fat, a scoop (Fig. 242), forceps of different patterns (Figs. 243, 244, 245), a syringe and tube for washing out fragments, and a shifted canula (Fig. 24(3) to control hemorrhage. The 518 genito-Xjrinary organs of the male. latter can be readily made bypassing the beak of a female silver catheter through the center of a piece of iodoform Fig. 238. Fig. 239. Fig. 240. Fig. 241. Fig. 24-2. Gorget, Scoop. Lithotomy Btaff. gauze eight inches square, and tying the two firmly to- gether, as Bhown in the figure. It is then introduced LITHOTOMY. 519 into the wound, the beak of the catheter in the bladder, the pouch tightly packed afterward with pledgets of gauze, and the whole kept in place by a J-bandage. Three as- sistants, at least, are required : one to administer the anaesthetic, the others to hold the knees and the staff. Operation. — The patient, having had his bowels emptied by an enema, is placed upon his back, his ankles bound last to his wrists, the staff introduced, and the stone touched with it. It is not necessary that the beak of the staff should rest upon the stone during the operation; on Fig. 24:;. Figs. 244, 245. Fio. 246. the contrary, it is better to hook the staff up under the symphysis bo as to keep it steady, with its curve bellied out in the median line of the perineum, and the integu- ment stretched over it by drawing the scrotum up around the staff. 520 GENITO-XJR1NARY ORGANS OF THE MALE. The operator passes his index-finger into the rectum, and satisfies himself that the staff enters at the apex of the prostate and passes centrally through it, and that the rectum is empty. Then withdrawing his finger he feels along the raphe of the perineum for the groove in the staff, aiding himself, if necessary, by depressing and rais- ing the handle several times. Having found the groove he confides the staff to his chief assistant, enters the scalpel a little to the patient's left of the raphe, from one and one-quarter to one and one-half inches in front of the anus, and passes it in al- most parallel to the rectum so as to enter the groove about half an inch in front of the apex of the prostate, guiding it, if he thinks best, by keeping his left index- finger upon the prostate in the rectum. (If the knife should be passed directly in to the nearest point on the staff, the bulb would be involved to an unnecessary ex- tent.) As soon as the point of the knife has entered the groove, it is pushed along for half an inch, dividing the floor of the urethra to that extent, and then withdrawn, cutting steadily downward and outward so as to make a cutaneous incision about three inches long, passing mid- way between the anus and left tuber ischii. The probe-pointed Blizard's knife, guided upon the left index-linger, is passed into the groove, and the surgeon takes the handle of the staff from the assistant, depresses it somewhat, and pushes the knife along until its point is arrested at the termination of the groove at the end of the staff. Then depressing the handle of the knife, and hear- ing in mind the shape and position of the prostate, he makes an incision in it downward and outward at an angle of about 30° with the horizon. The index-finger is next introduced, the staff withdrawn, and the neek ad< along the groove so as certainly to open the urethra and nick the end of the prostate, then brought for- SUPRAPUBIC CYSTOTOMY. 523 ward, dividing the membranous portion of the urethra, and swept around the bulb by raising the handle, making an external incision upward along the raphe* for about one and a quarter inches. The director is next passed along the staff into the bladder, the two separated angularly to make partial dilatation of the neck, the staff withdrawn, and the dilatation completed with the finger. The forceps are then introduced and the stone removed as in lateral lithotomy. SUPRAPUBIC CYSTOTOMY FOR VESICAL CALCULUS. The patient and the skin surface arc prepared in the usual way for an aseptic operation, and after etherization the bladder is irrigated clean with a warm saturated solu- tion of boric acid. The viscus is then distended with as much of this solution as can be ejected from an irrigator vessel elevated not more than two feet ; such a pressure is harmless, while the injection of a fixed amount of fluid or the use of a hand syringe may not be, owing to the uncertainty as to the capacity of the bladder and the condition of its walls. The catheter is then withdrawn from the urethra and a thin-walled soft-rubber bag (colpeurynter), is placed in the rectum above the sphincter and cautiously distended by a Davidson syringe, using not more than eight or ten ounces of water. This simply presses the bladder for- ward and brings its floor more within reach, but it does not materially alter the relation of the peritoneum to its anterior wall, and hence this use of the colpeurynter can generally be dispensed with. An incision two or three inches long is then made from just below the upper border of the symphysis pubis up- ward in the median line and deepened layer by layer as nearly as possible between the recti, and the underlying fascia is divided. If more space is required the recti and fascia can be cut transversely to a greater or less extent close to the pubes. The peritoneum does not descend on the anterior 524 GENITO-UMNARY ORGANS OF THE MALE. wall of the bladder below the urachus, which can some- times be felt as a cord attached to a knot on the fundus, and by carrying the dissection directly inward through the prevesical fat with blunt-pointed scissors, aided by the finger, and avoiding unnecessary laceration of the tissues, the bladder is exposed ; after pushing upward the fatty and cellular tissue which carries the peritoneum with it, a tenaculum is inserted in the highest-exposed part of the bladder wall and a knife is plunged into it just below the tenaculum, opening the bladder mesially downward for about an inch. Each side of the incision is grasped by catch forceps which serve to hold the opening in the abdominal wound. The peritoneum may descend as a fold nn usually low in front, and this must be recognized in the dissection, which in such cases should be first downward and inward behind the pubes and then up over the anterior surface of the blad- der, pushing the unopened peritoneum out of the way ; the numerous veins which are encountered are drawn aside or ligated as they are divided, but it is unnecessary to waste time searching for bleeding points, as the hemorrhage generally ceases spontaneously on opening the bladder. The interior of the latter is then explored by sight and touch, and any loose stones are picked up with instruments, preceded, if necessary, by crushing; the mouth of a di- verticulum containing a stone may have to be gently di- lated, but never cut, and the stone scooped or irrigated out, or first nibbled into fragments by forceps ; project- ing portions of the prostate preventing the free escape of urine are excised as described under prostatectomy, and finally the interim- of the bladder is washed free from all clots and dibris with warm boric solution. A- a general rule, a wound in a comparatively normal bladder wall should be closed with sutures, but if there is much pus or inflammatory change present it is better to Leave the wound open. To insert the sutures a blunt tenaculum IS placed in each extremity of the incision in the bladder, lifting up and steadying it. Interrupted sutures of chroiiiicized cat- SUPBAPUBK ' CYSTOTOM Y. 525 gut arc then inserted by a fine, curved needle at intervals of a quarter of an inch close to the edges of the wound and passing through the cut surface without entering the thin mucous membrane ; over and between these is placed a row of chromicized catgut Lembert sutures extending a short distance beyond the extremities of the incision, and after all the sutures have been tied the bladder is filled with boric solution to test their efficacy. Fig. 250. Muscular coat Mucous coat Method of suturing a wound of the bladder. Weak points are then reinforced by additional Lembert sutures. An iodoform-gauze packing is placed in contact with this suture line, and if considered necessary one or more rubber drainage tubes can be added ; the abdominal wound is then partially closed with silk sutures, a couple of which are left untied till the drainage is removed sev- eral days later if all goes well, when the wound can be closed tight. An antiseptic dressing is applied and a catheter for con- tinuous drainage is fastened in the bladder through a peri- neal puncture as described under external urethrotomy by McBurney's gorget. Some surgeons prefer to leave the urine to escape by its natural path, or tie a catheter in the urethra for a day or two. In about half of the properly selected cases primary union of the bladder may be expected. If the bladder wound must be left open its lips may be temporarily fastened in the margins of the abdominal inci- sion, and the latter is partially closed above and below, 526 GENITO-UBINABY ORGANS OF THE MALE. while a light iodoform-gauze packing is placed in any pockets which may have become infected around the open- ing in the bladder. A rubber drainage tube with lateral perforations near its lower extremity is then inserted into the deepest part of the bladder, and the other extremity passing out of the wound is connected with a tube which terminates below the surface of a 1:60 carbolic solution contained in a bottle under the bed. To favor the action of the tube, it is surrounded at its exit from the bladder by a tight iodoform-gauze packing, bat still a large proportion of the urine will inevitably escape into the dressings ; no other drainage is required. The tube is prevented from slipping out by a silk suture passed through it and the skin. Transverse Incision. — If the bladder is very contracted and it is deemed unsafe to use the rectal bag, so that the bladder must be sought at a greater depth than usual, a transverse incision dividing both recti gives easier access to it. This incision, slightly convex downward, is made close along the upper margin of the symphysis and extended about two inches to either side of the median line. After it has been carried through the recti and fascia into the prevesical space the subsequent operations are as above described. Langenbuch divides the suspensory ligament of the penis and exposes the lower part of the bladder below the I ml xs by an inverted 1-incision. The vertical limb lies over the symphysis and the oblique ones follow the edges of the descending rami of the pubes. PROSTATECTOMY. Suprapubic. — The rectal bag is inserted and Idled, and the bladder is opened and washed out, as already described, and if the enlargement is pedunculated i( is simply sur- rounded with or withoui transfixion by a silk ligature, the ends of which are left long and brought out of the abdom- inal wound, while the mass is left to slough away or is immediately excised w ith scissors. PROSTATECTOMY. 527 When the projection cannot be ligated it may be re- moved with the ecraseur or galvano-cautery. The uniform "collar" projection of the prostate is excised by dividing its margins transversely above and below, and shelling out each semi-circular half with the fingers after incising the mucous membrane on the summit of the ridge. Keves strongly recommends the use of the rongeur for- ceps to cut away the hypertrophied posterior lip of the orifice. In no case should any portion of the projecting valve be left behind, and finally the patency of the ureth- ral canal is ascertained by the passage of the finger as far as the first joint. Hemorrhage is controlled by packing with iodoform gauze or by the cautery. At the close of the operation the extremities of the abdominal wound are drawn together around the opening in the bladder, which, if possible, is sutured to the margins of the wound, while all spaces which are liable to infection are packed with iodoform gauze, and a siphon drain is placed in the bladder. Perineal Prostatectomy. — The urethra is opened in the membranous portion for about an inch or an inch and a- half by an external urethrotomy, and after inserting a gorget the finger is passed to the bladder by gradual dila- tation of the urethra and the projection located and ex- plored. The finger must then be withdrawn to make room for the ecraseur, galvano-cautery, or one of Thompson's forceps by which the growth is snared or torn from its at- tachments. Hemorrhage is checked by irrigation with very hot or very cold water, or by packing, and the subsequent treat- ment is the same as for external urethrotomy. This method is seldom used because of its limited applicability and the difficulty of manipulation. For hypertrophy of the lateral lobes of the prostate Dittcl ! proposes an incision from the coccyx to the median line of the perineum, passing around one side of the sphincter. The dissection is carried down to the prostate in front and at the sides of the rectum, which is rendered 1 Wien. med. Woch., 1890, Nos. 18 19, 528 GENTTO-URINARY ORGANS OF THE MALE. prominent by packing-, and a cuneiform section is removed from the enlarged portions of the gland like a tumor, -with- out opening the urethra. The resulting wound is then drawn together with catgut and a strand of iodoform gauze inserted for drainage. Or a curved incision circumscrib- ing the anterior half of the anus may be made ; the flap is turned down, and the prostate reached by working along the front of the rectum. Combined Suprapubic and Perineal Method. — Belfield ' and Alexander 2 first open the bladder above the pubes and then reach the prostate by a median incision in the perin- eum opening the membranous urethra. The capsule of the prostate is opened at its apex and stripped off back to the base, and one lobe separated from above downward and removed, while the prostate is pressed into the perin- eal wound by the finger of an assistant within the bladder. Nicoll 3 carries the perineal incision backward past one or both sides of the anus. Enlarged Prostate Treated by Castration. — Cases of hy- pertrophied prostate complicated by retention and cystitis have been successfully treated by castration. The pros- tate atrophies within a year or less and the obstruction to the escape of urine thus disappears. The operation is simple and less dangerous than prostatectomy, and the results have been satisfactory in the soft forms. TUMORS OF THE BLADDER. The bladder is rendered as aseptic as possible by wash- ing and is then explored by a suprapubic cystotomy. When malignant disease is found lying near the fundus (which is its rarest location), and of limited extent, a sponge is placed in the interior of the bladder to soak up all the urine, and if the peritoneal cavity must he opened to effect a thorough removal of the disease, it is protected by a sponge packing and the bladder wall divided with scissors, 1 \m. . I. ,mii. Med. s,i., Nov., 1890. *N. Y. Med Record, Dec. 12, 1896. ; Lancet, April 1 I. 1894. TUMOBS OF THE BLADDER. 529 including the peritoneum, if necessary, well outside the limits of the growth. The peritoneal part of the wound in the bladder is then elosed by Lembert silk sutures, which must not enter the mucous membrane, the protective packing removed, after thorough cleansing of the abdominal cavity, and the peri- toneum above the bladder drawn together with catgut. The rest of the bladder wound is treated as in simple suprapubic cystotomy. If the cancer occupies the sides or base of the bladder most surgeons, in this country at any rate, advise against an attempt at radical removal and arc content with curet- ting to ameliorate symptoms. A few successful cases are reported in which the disease has been removed with the surrounding mucous mem- brane, but leaving the muscular coat from which the growth is sometimes found separated by a layer of fat. Helferich l resects the pubes through a transverse in- cision above the symphysis and so gains access to the an- terior surface of the bladder. Niehans 2 performs a very similar operation which he calls an osteoplastic resection of the pubes. ZuckerkandF exposes the base and adjacent posterior surface of the bladder by a curved transverse incision through the perineum in front of the anus and rectum, which are turned down and drawn back. (See removal of seminal vesicles.) Bramann ' chisels out a small piece of the symphysis, in- cluding the portion connected with the recti, by a T-shaped incision, the horizontal limb lying above the pubes be- tween the cords and the vertical over the symphysis ; at the conclusion of the operation the bone is sutured back in position and the patient fixed in a half-sitting position with the legs flexed. For total extirpation of bladder or its mucous mem- brane, see American Journal of the Medical Sciences, Jan- 1 Arcliiv f. klin. (hir., 1888, p. 625. *Centralb. f. Chir., 1888, p. -",21. 8 Wien. med. Presse, 1889, Nos. 21-22, •Centralb. f. Chir., 1893, No. 17. 34 530 GENITO-UBINABY ORGANS OF THE MALE. iiai-v, 1891, p. 101, and Wien. med. Presse, 1889, Nos. 27-28. Benign growths which arc more or less pedunculated are treated in the manner described for suprapubic pros- tatectomy and their bases scraped or cauterized or touched with a ten per cent, solution of chloride of zinc. If the tumor has a small enough pedicle, the latter can be grasped by a pair of forceps close to the bladder wall, and the tumor twisted off on the distal side of the forceps, which are held immovable ; but unless all portions of the growth are removed it is liable to recur. Benign tumors can occasionally be torn from their attachments by forceps introduced through an external urethrotomy wound, but care must be taken not to force the bladder wall into the grasp of the instrument by pressure on the hypogastrium. There is less danger of rupturing the bladder than might be supposed, owing to the usual hypertrophy of the mus- cular coat underlying the tumor. REMOVAL OF THE SEMINAL VESICLES. 1 ZuCKERKANDl/s INCISION. 2 — The patient is placed in the lithotomy position with a sound in the urethra to mark it- position and the bladder partially filled with a satu- rated solution of boric acid. A slightly curved incision with its concavity towards the anus is made transversely across the perineum, having its center about one inch and a-half in front of the anus. From each extremity of this a straight diverging incision about an inch and a-half long passes back on either side of the amis to end near the tuber ischii. After division of the skin and subcutaneous tissue a linger is placed in the rectum and the perineal septum cut through, avoiding the anterior rectal wall. The dissection is deepened till above the sphincter ani, which is then turned down with the rectum while the bulb of the urethra is pushed forward, and the pubic portion of the levator ani i> divided on each side of the prostate. 'See also DTlmann: Centralb. f. Chir., Feb. 22, 1890. 2 Wien. med. I'- e L889, p, B56. BEMO VA L OF SEMIS. 1 1 \ r ESI( 'L ES. 531 Free hemorrhage may be expected from the hemorrhoidal and prostatic plexus of veins, but it is easily controlled by pressure or clamps. Then, by tearing through tin- loose connective tissue, the rectum is easily separated a little more fully from the bladder, the base of which can be Fig. 261. Zackerkandl's incision for removal of the seminal vesicles. P. Prostate. IV. Vas deferens. Vs. Vesieula seminalis. J/. Rectum. made more prominent by manipulating the sound, and the prostate, vasa deferentia, and seminal vesicles are brought into clear view. It only remains to dissect off one or both vesicles and to ligate the corresponding vas deferens with catgut. The wound is closed and dressed antiseptically with a rubber drainage tube and light iodoforin-gauze packing in its most dependent angles. The seminal vesicles can also be reached by an incision beside the sacrum and coccyx as in Kraske's operation for cancer of the rectum (Bolton). The vas deferens, cord, and testicle can be extirpated at the same time by an incision starting over the internal abdominal ring and passing down through the inguinal 532 GENITO-URINARY ORGANS OF THE MALE. canal into the scrotum. This incision is deepened layer I iy layer above the pubes, the peritoneum recognized and pushed up, and then by working with the fingers from above and below (through Zuckerkandl's incision) thevas can be separated from the bladder and pulled out through the opening in the abdominal wall. CHA PTER VIII. OPERATIONS UPON THE GENITO-URINARY ORGANS OF THE FEMALE. CATHETERIZATION. The surgeon, standing on the right side of the patient and holding- the catheter in his right hand, with its convex- ity lying on the palmar surface of the index-finger and its beak not quite reaching to the end of the distal phalanx ( Fig. 252), separates the nymphse with the thumb and middle finger of his left hand, introduces his right index- finger at the fourchette and brings it forward, recognizing the entrance to the vagina and its anterior border, and stopping when he feels the pouting orifice of the urethra. Then keeping the pulp of the finger below and in contact with the orifice he passes the catheter in. Fig. 252. Mode of holding the catheter. EXTERNAL URETHROTOMY. The Buttonhole Operation (Emmet) (Fig. 253). — The patient is anaesthetized and placed on the left side, and the fourchette retracted with a small Sims's speculum. A full- sized metal sound is introduced into the urethra, then the 533 534 GENlTO-VRtNARY ORGANS OF THE FEMALE. tissues in the vaginal surface are caught up with a tenacu- lum and divided longitudinally midway between the meatus Fig. 253. External uretbrotom and the neck of the Madder. The incision may then be extended with scissors. Neither the neck of the bladder Fig. 254. Emmet's buttonhole scissors, nor the meal us should be divided. If the incision is to be kept open, the urethral mucous membrane must be drawn l.lTUnTOMY 535 out through it and stitched with catgut to the edge of the divided vaginal surface. The incision may be conveni- ently made with Emmet's buttonhole scissors (Fig. 254). LITHOTOMY. Besides the suprapubic, which is performed in the man- ner already described, there are the urethral and vesico- vaginal operations. In the former the stone is removed through the urethra after the calibre of this canal has been increased by an incision along its anterior (upper) wall, or on one or both sides, incisions which do not extend into the vagina. In the latter the stone is removed through an incision made in the vesico-vaginal septum. Urethral Lithotomy. — The only instruments actually re- quired are a director, a probe-pointed knife, and forceps, but some surgeons prefer to make the incision with a sin- gle or double lithotome introduced alone or upon a direc- tor. Lateral incisions should incline upward rather than downward ; consequently, if the double lithotome is used, it- concavity should be turned toward the symphysis. The extraction of the stone requires no additional de- scription. Vesico-vaginal Lithotomy. — The patient may be placed in the usual lithotomy position, or upon the side, or upon Fig. 255. Sinis's speculum. the face. A Sims's speculum (Fig. 255 ) is pressed against the posterior wall of the vagina, and a grooved catheter 536 GENITO-UBINABY ORGANS OF THE FEMALE. introduced into the bladder and confided to an assistant, who keeps it pressed well against the vesico- vaginal septum. Guiding his knife upon the groove the surgeon makes an antero-posterior incision in the median line of the an- terior wall of the vagina, about one inch in length, and not involving the neck of the bladder, passes in his index- finger, and then the forceps upon the ringer as a guide. Emmet places no sutures, but allows the wound to close spontaneously, keeping the bladder clean by fre- quent washings. Guy on closes the incision immediately with sutures. In a discussion in the Societe de Chirurgie ' the fact was brought out that lithotomy and lithotrity upon the female are more dangerous operations than they are usually said to be. The fatal complications are of two kinds: peritonitis in patients who have previously been affected by it ; and pyaemia, originating in inflammation of the spongio-vascular tissue constituting part of the vesico-vaginal septum. Speaking generally, it may be said that lithotrity - is more dangerous in the female than lithotomy, that the supra-pubic operation should be used for large calculi, dilatation of the urethra for small ones, and, with crushing, for large friable ones when the in- flammation is not high and there has been no previous peritonitis; urethral or vesico-vaginal lithotomy in other cases. As to the comparative merits of urethral and vesico-vaginal lithotomy opinions are divided ; the former is followed occasionally by permanent incontinence; the latter by fistula ; probably, too, the latter is somewhat more dangerous than the former. OCCLUSION, OR ATRESIA VAGINA. When the occlusion is due simply to an imperforate hymen it may be relieved by successive punctures with a 1 Hull, de la Socfcte" de Chirorgie, 1*77, pp. 182 and WO. :! ln thia remark reference is made i<> the old operation of lithotrity. 'I'lic few cases of litholapaxy in the female of which I have knowledge have been successful. PERINEORRHAPHY. 537 small trocar or aspirator, and when all the accumulated menstrual blood has been thus removed, and the cavity well washed out with a two per cent, solution of carbolic acid, the hymen may be excised, or a large puncture made, and kept open by frequently passing a sound. It must be remembered that very serious complications, such as peritonitis and septic poisoning, may follow this simple operation when there has been a large accumulation of menstrual blood above the obstruction. When, on the other hand, this occlusion is due to in- complete development of the vagina, a more systematic operation is required. The surgeon first assures himself by digital examination through the rectum of the existence of the uterus, then places the patient upon her back with her thighs flexed and abducted, and introduces a sound into the bladder and confides it to an assistant. He next passes his left index-finger into the rectum, and makes a transverse incision across the center of the obliteration, and carries it in the direction of the uterus by successive short cuts with the knife or by tearing with a director or his fingers, guiding his course by the sound in the bladder and the finger in the rectum. As soon as fluctuation can be felt in front of the uterus he punctures with a trocar and enlarges the puncture with a probe-pointed bistoury. PERINEORRHAPHY. Dr. Emmet l has shown that the lesion previously known as " partial rupture of the perineum," and supposed to be a laceration along the posterior median line of the tissues at the lower part of the vagina and perineum, is actually a transverse rent at or within the ostium vagina?, which, by the dropping and eversion of the lower lip of the wound, is made to present the appearance of a longitu- dinal one. He also recognized and described a variety of this lesion in which the laceration is submucous, in which the muscular and fascial diaphragm, constituted in part by the sphincters and closing the outlet of the pelvis, is 1 Principles and Practice of Gynecology, 188-t, p. 364. 538 QENIT0-XJR1NARY ORGANS OF THE FEMALE. turn away from the supporting fascia 1 and muscles which run upward to attach its center to the inner side of the bony pelvis, and, having thus lost its support, allows the posterior part of the vulva to be everted, with production of a rectocele by protrusion of the rectum through the (sub- cutaneous) gap. To this latter condition he gives the name prolapse of flic posterior wall of the vagina. The two conditions, the subcutaneous and the complete rents, arc essentially the same, and require for their relief nearly the same denudation of the surface. The aim of the operator in either case is to lift up the depressed everted lower lip, unite its edge to that of the mucous membrane of the vagina at the crest of the rectocele, and thus cover in the latter and renew its anterior support. Laceration of the vulvar orifice in the posterior median line may occur without coexistence of the above-described lesion, beginning at the fourchette and extending back- ward, but such laceration is unimportant because it in- volves only parts that lie outside the real support of the viscera. A third form is the important one in which laceration of the sphincter ani in the median line takes place. In non-instrumental delivery this begins as a longitudinal slit in the recto-vaginal septum and extends from within outward and forward. When caused by the forceps it begins at the fourchette and extends backward. To this form Dr. Emmet limits the term ruptwre of the pervnewm. Accepting this classification, I shall describe the oper- ation for, 1st, prolapse of the posterior wall of the vagina — two varieties, with and without laceration of the mucous membrane of the vagina; and, 2d, rupture of the peri- neum (and the sphincter ani). Prolapse of the Posterior Watt of the Vagina. (1st variety, without surface laceration.) Operation. — Thighs flexed on abdomen and supported under the arm of an assistant on each side, who also draw aside the labia and hold the tenacula during the act of denudation. The operator seizes with a tenaculum the muCOUS membrane of the vagina a1 the cresl of the rectocele in the median PERINEORRHAPHY :>:;•.! line at a point which can be drawn down to the urethral orifice by gentle traction, and having thus drawn it down, lias it held in place by the assistant. Then, with two other tenacula, he hooks up the lowest caruncle or vestige of the hymen, on each side, and draws them upward and outward to the first tenaculum. This movement creates an inverted, crescentic, transverse fold within the vagina just below the first tenaculum, its horns shading gradually into the sulcus on each side, and a shallow longitudinal fold in the median line between the last two tenacula. The opposed surfaces of these folds eonstitute the area to be denuded. Dropping one lateral tenaculum, he gives the other to an assistant who draws it gently outward to define by this traction the limits of the denudation on that side, and then the surgeon denudes by catching up the mucous membrane with a hook or pronged forceps and removing it with scissors in successive strips. The process is then re- peated on the opposite side. Care must be taken not to denude too high on the posterior wall. Sutures are then passed to unite the parts in the posi- tions given them by the first approximation of the three Fig. 256. Diagram showing the line of union and direction of the sutures. tenacula, producing the line of union indicated in Fig. 256. The sutures of the crescentic part should be of sil- ver wire ; those of the central line may be of silver, silk, or catgut. A final silver suture should be passed through 4 540 GENITO-URINAMY ORGANS OF THE FEMALE. the labium uear the caruncle on one side, across to the posterior wall of the vagina, under its mucous membrane for nearly an inch just above the edge of the denudation, and then through the other labium at a point opposite to that at which it began. In passing the sutures a thick, straight sewing-needle armed with silk should be used, and the tissue- to be traversed by it should be pressed forward by the finger in the rectum. The sutures should not be buried throughout their course, but should cross the fold midway be- tween its free edge and its bottom. The silver wire is drawn through in the loop of the silk. The appear- ance, when the operation is com- pleted, is shown in Fig. '2o~, the crescentric part being hidden within the vagina. 2d Variety. Prolapse with Surface Lacera- tion. — The position of the patient is the same as in the preceding form, and the area of denudation is determined Appearance ;it completion of operation. Diagram showing area ol denudation. The parts bearing corresponding figures are broughl into apposition by the sutures. in like manner ; speaking generally, it must extend down- Ward to the line of junction between the skin and thecica- PERINEORRHAPHY. 541 tricial mucous membrane. Its shape, when spread out, is that of a trefoil (Fig. 258). The sutures are passed in order from below upward, and none tightened till all are in place. The lower cues are buried throughout their course ; the upper ones are partly exposed on each side, as shown in Fig. *2oi». The suture marked J) includes about an Fig. 259. Emmet's operation for diminishing the vaginal outlet by external sutures. inch of the recto-vaginal septum ; the uppermost suture C passes through the mucous membrane of the septum above the denudation, and when tightened draws it down like a hood to protect the approximated edges, and also sustains all the traction while the opposed denuded surfaces are uniting. Dr. Emmet leaves the sutures in place for about three weeks. PERINEORRHAPHY. Method of Hegar or Simon-Hegar. INCOMPLETE RUP- TURE. — This is based on the principle that the rent J 542 GENITO-URINARY ORGANS OF THE FEMALE. when spread out has the form of a triangle with its apex in the posterior vaginal wall. (Fig. 2(50.) After every antiseptic precaution, bullet forceps arc hooked in the three following- points : in the crest of the rectocele in the posterior vaginal wall, and in the opposite lowest carun- cles, which lie on the inner surface of each labium raajus. Fig. 260. Mill .. ■ ■■ ■ [ncomplete rupture of the perineum. Peri rrhaphy by Simon's method, (Pozzi.) The labia are held apart and traction is made on the for- ceps, thus putting the tissues between them on the stretch, while a narrow strip of mucous membrane is removed on the lines made straight by traction, which join the crest of the rectocele with the two caruncles in the grasp of the forceps. 'I'll'' space between these limits is rapidly de- nuded, and the denudation is continued on the posterior vaginal wall and adjacent skin as far as the cicatricial tis- sue extends, so that the raw siy^qe, w,ljen flattened oul has PERINEORRHAPHY 543 the form of a triangle with its apex in the rectocele, and its base, which is slightly convex toward the anus, between the two lower forceps on the inner surfaces of the labia majora. Starting at the apex (Fig. -<>0), at intervals of about three-eighths of an inch, sutures of silver wire or silk- worm-gut are passed on a well-curved needle, so as to be just buried under the denuded surface, emerging about a quarter of an inch from its edge. At least two of these sutures should pass deeply enough in the upper lateral portions of the raw area to grasp some of the fibers of the levator ani muscle. Martin's continuous circular suture applied in tiers is considered better by many surgeons than the interrupted suture. Catgut is used, threaded on a sharply curved needle. Laceration of the Perineum, including the Sphincter Ani. — If the anterior wall of the rectum is ruptured for more than one or one and a-half inches above the upper margin Fig. 261. ?phincter. Ruptured sphincter, and suture. of the sphincter, it may be better to close it by a pre- liminary operation, leaving the restoration of the perineum for a subsequent one. Dr. T. Addis Emmet was the first to show why it is not sufficient simply to close the gap be- tween the vagina and rectum, and to demonstrate the need of bringing the ends of the severed sphincter into close 544 GENITO-URINARY ORGANS OF THE FEMALE. contact with each other, and with the end of the recto- vaginal septum. Let Fig. 261 represent the perfect sphincter, and Fig. -<> :2 the sphincter ruptured and spread out with the points of entrance and exit of needle AA, the dotted line show- ing the course of the suture, including the end of the recto-vaginal wall C. As the suture is twisted, the three points are brought nearer together, as in Fig. 263, until they finally unite, as in Fig. 264. If the first needle is Fig. 2(53. Fig. 2(34. Suture partly drawn. Suture fully drawn. passed in and ont at BB, complete union of the ends of the muscle will not be obtained, and loss of function will persist. The first suture is the important one, and must bring the torn ends of the muscle into contact with each other and with the end of the septum. In freshening the parts before passing the needles the two lateral triangles, forming the ruptured surface of the body of the perineum, are denuded, and the line of denu- dation is prolonged backward along the edge of the recto- vaginal septum. This denudation must extend along the edge of* the mucous membrane of the rectum, but not in- clude it. Fig. 265 is a schematic representation of the end of the ruptured bowel, the points of entrance and emergence of the needle, and the course of the first suture. The rule for passing the first suture, then, is to enter the needle as low down as the lower edge of the anus, pass li thence upward through the recto-vaginal septum, com- pletely encircling the rent, and bring it out alongside the lower edge of the anus on the other side. Its action, then, PERINEORRHAPHY. 545 is like that of a purse string, it puckers up the open parts, controls the action of the sphincter, and guards against the two principal sources of failure, recto-vaginal fistula and non-union of the sphincter (Fig. 266). Fig. 265. Fig. 266. Ruptured sphincter. First suture. Complete perineal rupture, First and second sutures in place. Dr. Emmet now recommends that this injury should be treated as if it were "a recto-vaginal fistula in the median line, with the sides easily approximated." The denudation is done with scissors, beginning at the outlet and near the rectal surface, and continuing from below upward, so as to avoid the flow of blood over the surface yet to be freshened. .Since the sides of the tear, after retraction, are not sufficiently broad to give a good surface for union, a portion of the adjoining vaginal mil- 546 QENITO-URINABY ORGANS OF THE FEMALE. cons membrane must be removed, and the angle must also l>e extended <»n the vaginal surface for half an inch or more beyond the rectal edge. Then, beginning at the angle, several transverse, interrupted silver sutures are passed from the vaginal edge on one side, under the de- nuded surface across the gap, and under the opposite de- nuded surface to the opposite vaginal edge, and two or three additional sutures are passed by the old method, that is, beginning in the skin near the lower edge of the anus, continuing up through the tissues alongside the rent, Fig. 2f>7. ' - ..-.: — * - asssssss Half-section through the pub through tin' septum, and down od the oilier side, so as completely to include the rent. Fig. 267 shows these different sutures. The lasl two mentioned are the 'id and It li in the figure, counting from below upward. Complete Laceration with Rupture of the Sphincter Ani. — A Blight modification of Heear's method is used in the PERINEORRHAPHY 547 gynecological service of Roosevelt Hospital, and it gives most excellent results. Before denuding the perineum the rectum is first sutured. The edges of the rent in the rec- tum are freshened and the raw surface is made a little broader below than above to thoroughly expose the ex- Fig. 268. Complete laceration of the perineum. Perineorrhaphy— Simon-Hegar method ; general disposition of the sutures. [Pozzi.) tremities of the sphincter muscle. The denuded areas of muscular and mucous tissue arc then brought into apposi- tion by interrupted sutures of chromicized catgut or silk- worm-gut passed just within the limits of denudation at intervals of about a quarter of an inch ami knotted in the rectum from above downward (Fig. 268). The ends are left long and protruding from the anus, and at the expira- tion of a couple of week's those sutures which can be reached 548 GENITO-UBINARY ORGANS OF THE FEMALE. are removed and the ends of the others are cut short and the sutures are left to cut their way out. The rest of the operation is then finished by Hegar's method for incomplete rupture with Martin's continuous sutures of catgut placed in tiers from the bottom of the rent just external to the rectal wall up to the original level of the vaginal mucous membrane (Fig. 269). A Fir;. 2G9. .1 li Complete laceration of the perineum. Perineorrhaphy— Martin's method, I. Deep plan of continuous suture. /:. Passage from the deep to the superficial. ( Pozzi.) tension suture of .-ilk should be passed through the skin of the perineum, without entering the rectum, a little be- yond the extremities of the freshly united sphincter and the ends of the suture fastened over lead buttons or balls, vvhicb will permit it to be loosened if there is much sub- sequent swelling or (edema. VES1C0-VAQINAL FISTULA. 549 VESICOVAGINAL FISTULA. The patient is prepared for the operation by measures directed to the improvement of her general condition, by regularly syringing the vagina with warm water, and by dividing any cicatricial bands that may have formed in it. Position. — The patient is placed upon the left side, with the thighs flexed, the right rather more so than the left, the left arm is drawn behind her back, and her chest brought Hat down upon the table. Some prefer the knee- elbow position, and Simon placed the patient flat upon her back, raised the hips, and flexed the thighs as far as possible upon the abdomen. Fig. 270. C ' C a. Vesical surface. //. Vaginal surface, ec. Line of paring. If the first position is employed, an assistant stands be- hind the patient, draws the posterior wall of the vagina back by means of a broad Sims's speculum held in his right hand, while with his left he raises the right side of the nates. The surgeon then pinches up, with toothed forceps or a tenaculum, the vaginal edge of the fistula at the point most difficult of access, and cuts off a piece including in breadth all between the vesical edge of the fistula and a point in the vagina at least one-third of an inch from the vaginal edge of the fistula. The cutting may be done with curved scissors or a narrow bladed knife. Successive portions of the edge are raised and removed in like man- ner, until the denudation is complete, the resulting raw surface being funnel-shaped, with its narrowest part at the edge of the vesical mucous membrane, the membrane itself not being included in it (Fig. 270). Or the point of the knife may be entered into the mucous membrane J 550 GENITO-TJRINARY ORGANS OF THE FEMALE. of the vagina one-third of an inch from the edge of the fistula, brought out at the vesical border, and then carried Fig. 271. Drawing down the uterus to facilitate the paring. righl and lefil around the opening so as (<» cui off a com- plete ring of tissue. [f the anterior wall of the vagina is freely movable, Simon brings the fistula into plain view by passing a VESICO-VAGINAL FlSTUl i. 551 stout ligature through the cervix of the uterus and draw- ing it down toward the vulva ( Fig. 271). He also pares the edges of the fistula very freely, and does not hesitate Fig. 272. cud a Vesica] surface. 6. Vaginal surface, e, Needle. Needle-holder. Passing the needle. to include the mucous membrane of the bladder in the incision. As soon as the hemorrhage has ceased, the sutures may be passed. The needle, three-quarters of an inch long, round, 5&2 <; i:\rn i URINARY ORGANS OF THE FEMALR slightly curved, and armed with a fine double silk suture, is fixed in a needle-holder, and entered at the angle of the wound which is most difficult of access, half an inch from the edge of the raw surface, and its point brought out at the edge of the vesical mucous membrane, but not includ- ing it (Fig. i>7. >: >) and there fixed with a blunt hook (Fig. 277), until it can be seized and drawn through with the Figs. 275, 276, 27 Fig. 278. L & I U needle forceps. It is then entered at the corresponding point on the opposite side, and brought out on the vagi- nal surface half an inch from the edge of the opening ( Fig. 274). The ends of the ligature are given into the charge of the assistant who holds the speculum, and another needle is passed in the same manner at the dis- tance of one-sixth of an inch from the first; and so on, until a sufficient number have been passed. During the VESWO VAGINAL FISTULA. ►53 passing of the needles the sides of the fistula are fixed by the tenaculum. Fig. 279. Simon's method of placing the suturi When the needle is seized with forceps and nulled through, counter-pressure must be made upon the tissues, and this is best done by means of the split rod or fork, represented in Fig. '11 6, its prongs passing on either side of the needle. 554 GEMT0-VR1NARY ORGANS OF THE FEMALE. After all the ligatures have been passed, a silver wire, about twelve inches long, is fastened to the loop of the first ligature (Fig. 278, C), and drawn through with the help of the fork. The silk is cut off, the ends of the wire drawn aside out of the way, and the others passed in the same manner. Simon used fine silk sutures (two rows when the fistula was large) tied in the ordinary manner, and often passing through the vesical mucous membrane (Fig. 279). The ends of the silver sutures being drawn together, and the edges of the wound carefully approximated, each thread is slightly twisted so as to keep the parts in apposition, and then the ends of the first are seized with forceps and twisted with the help of the shield (Fig. 275), as shown in Fig. 278 ; care being taken not to twist so tightly as to strangulate the tissues engaged in the loop. The other sutures are then twisted in the same manner, and the ends of each cut off about half an inch from the surface (Fig. 280). FiG. 280. -MrMv The bladder is then syringed to remove any blood that may have collected in it, ami a catheter passed into it and left" there. The sutures may be removed during the second week. Creation of . 43. VESH 10- VAO ISA L FISTULA . 555 half from its extremity, introduced through the urethra. While the director is held by an assistant with its point firmly pressing in the median line against the base of the bladder a little behind the neck, the surgeon seizes the projecting tissue on the vaginal surface with a tenaculum, Obliteration of the vagina. and exposes the beak of the director by cutting upon it with a pair of scissors. One of the blades of the scissors is then passed through the opening and a cut made back- ward in the median line. 556 GENITO-URINARY ORGANS OF Till-: FEMALE. If the opening tends to close spontaneously too soon, a hollow glass stud made of halt-inch tubing should be but- toned into it. The vesical rim of this stud need not be more than a slight flare, the vaginal rim should be larger. OBLITERATION OF THE VAGINA; KOLPOKLEISIS. (Fig. 2 knife. and a Sims's speculum introduced, the cervix is fixed by a tenaculum and its posterior lip divided with scissors as high as to the vaginal junction. The blade of a Sims's knife (Fig. 287) is then introduced through the os inter- 36 562 GENITO-TJRINARY ORGANS OF THE FEMALE. mini, and the tissues cut so as to lay open the pos- terior wall of the cervix (Fig. 288). The blade is then turned toward the anterior wall, and the little shoulder which, as Dr. Emmet has pointed out, usually exists there at the point of flexion is cut through. Instead of making this second incision Dr. Wylie practises and recommends divulsion with a strong steel dilator. Fig. 288. 1 :steri2r section cf the cervix A roll of cotton saturated with a solution of persul- phate of iron, one part to two of water, is placed so as to occupy the whole cervix, and retained by a plug of wet cotton in the vagina. OPERATIONS ON THE UTERUS AND ADNEXA. Anatomy. — The broad ligaments, consisting of two layer- of peritoneum, continuous with that which covers the uterus, are attached to its sides from the eornua to the level of the internal os; externally they are attached to the aides of the pelvis in a vertical but broader line, about midway between the obturator foramen and the great sciatic notch. The Fallopian tube passes outward OPEEATIOXS OF UTERUS AND ADNEXA. 563 from the angle of the uterus in the highest part of the broad ligament, while in front and a little lower down the round ligament diverges to the internal abdominal ring, and contains a branch of the epigastric artery passing to the uterus. Behind the Fallopian tubes are the ovaries which are subject to great variation in position — normally each occupies the apex of a ligamentous triangle directed backward, the base of which is in the broad ligament, and through which the branches of the ovarian artery and the pampiniform plexus of veins enter the gland. The inner angle of the ligamentous triangle passing to the fundus of the uterus is a rounded fold of peritoneum con- taining muscular liber, and called the utero-ovarian liga- ment. The outer angle blends with the upper border of the broad ligament, and is called the infundibulo-pelvic ligament. The ovarian arteries arise from the abdominal aorta, and at the brim of the pelvis cross the bifurcation of the common iliac vessels and the ureter, and run in a tortu- ous course in the upper border of the broad ligament, or more exactly in the infundibulo-pelvic ligament, to the cornua of the uterus, where they anastomose with the uterine arteries along the respective sides.. Each ureter crosses the common iliac artery near its bifurcation, and runs from behind downward, forward, and inward in front of the internal iliac artery and its anterior division, lying in the base of the broad ligament, which is limited by the levator ani muscle. Xear the level of the external os the ureter is crossed on its inner side by the uterine artery, and then runs along the side of the vagina about half an inch from the cervix, entering the bladder just above the middle of the anterior vaginal wall. The uterine artery arises from the anterior trunk of the internal iliac near the synchondrosis, and passes downward and forward to a point just above the spine of the ischium, where it leaves the pelvic wall, but still de- scends almost to the tuberosity of the ischium ; it then turns up toward the vagina, reaching the uterus at the utero-vaginal junction. Opposite the external os it gives 564 GEX1T0-UBIXARY ORGANS OF THE FEMALE. off the circular artery of the cervix and continues along the side of the uterus between the layers of the broad ligament, and at the superior cornu it anastomoses with the ovarian artery. The peritoneum is firmly adherent to the fundus of the uterus, but gradually becomes more loosely attached until it can be readily stripped up with the finger in the vesico- uterine depression. Posteriorly it descends about three- quarters of an inch on the vaginal wall, and is likewise easily peeled off to the same level as in front. With a normal uterus and an empty bladder, the latter lies upon the cervix for about half an inch. OVARIOTOMY. The patient is prepared in the usual way for a lapar- otomy, and immediately before the operation she is cathe- terized, the sponges, pads, and clamps are counted and the number of each written down. An incision three or four inches long is made in the median line between the umbil- icus and the pubes, which, if necessary, is later extended upward with a slight semicircular deviation, including the umbilicus and passing to the left of it to avoid the falci- form ligament. The incision is deepened layer by layer and the peritoneum first opened above by pinching up a fold with the fingers or forceps and nicking it, and then enlarging it downward by cutting on the fingers inside as a director, care being taken to avoid the bladder, which may be recognizable from within as a thickened fold lying near the pubes. When the peritoneum is adherent to the tumor it may be simpler to prolong the incision above the latter to make certain that the abdominal cavity has been opened and that the peritoneum is not simply stripped from the parieties. Sometimes, also, the bladder is drawn far up above its usual position, but it can be recognized by its vascularity or by a sound passed in through the urethra. A sponge protective packing is wedged around the exposed cyst, which is then punctured with a large trocar and eanula, OVARIOTOMY. 565 the latter being provided with a tube to conduct the fluid to one side, and as soon as possible the walls are grasped by the fingers or by forceps and drawn into the wound, while, at the same time, pressure is made on the parieties, or the patient is rolled on one side to favor the escape of the contents. If the latter are too thick to flow readily, the puncture may have to be enlarged sufficiently to per- mit them to be scooped out by hand, and through this opening other loculi are entered by the finger, knife, or trocar, and enough liquid evacuated to permit of an at- tempt to turn the cyst out of the abdomen. The adhesions are cautiously separated by the finger- nail and blunt-pointed scissors or divided between double catgut ligatures. The peritoneal cavity must be constantly protected by the addition of fresh sponges as the dissection progresses, though usually no harm follows from the escape into it of some of the cyst-contents. When the pedicle has been fully exposed, often by bringing the cyst out of the belly, if broad it is secured in sections by the interlocking silk ligature passed on a blunt-pointed aneurism needle, and the tumor or what remains of it is excised ; or the pedicle may be divided with scissors and the vessels secured as they are encountered by clamps, and after removal of the tumor ligated separately. A comparatively small pedicle can be ligated en masse with stout silk, but it is well also to secure by separate ligatures the vessels that appear on the cut surface. If there have been few or no adhesions and the cyst has been removed practically without opening it, the abdomi- nal wound can be closed entirely in the usual way, after taking out and counting the sponges and clamps. But drainage by rubber tubes and iodoform-gauze packing is imperative whenever there is even a possibility of infec- tion, and especially if a portion of the cyst wall has been necessarily left behind owing to its too firm adhesion to important structures. If there has been much peritoneal laceration accompanied by oozing from minute blood- vessels, drainage and hemostasis are conveniently pro- 566 GENITO-URIXARY ORGANS OF THE FEMALE. vided for by a large sheet of iodoform gauze placed in contact with the lacerated surface and having all its edges brought out of the abdominal wound. This pouch is then stuffed with strips of gauze which are subsequently removed one by one, to gradually reduce its bulk. The parietal opening is partially closed and dressed antiseptically in the usual way. OOPHORECTOMY. This term is used to designate the removal of macro- scopically normal ovaries and Fallopian tubes for hemo- static or analgesic purposes. After the usual preliminaries, including catheterization, the patient is placed in Trendelenburg's position, which greatly facilitates all intra-abdominal operations on the pelvic organs. An incision about three inches long is made in the me- dian line above the pubes, and deepened layer by layer till the peritoneal cavity is opened. Two fingers are passed through the incision to the fundus of the uterus and thence outward, following one Fallopian tube to its extremity, which is drawn up into the abdominal wound together with the ovary. Flat sponges are placed around them, and a ligature is placed about the ovarian artery and veins at the edge of the broad ligament. Others are placed upon the tube and the utero-ovarian ligament close to the uterus. The tissues distal to these ligatures are then cut, and the intermediate portion of the broad ligament tied in one or two ligatures. The ovary and tube are then excised, and after a final inspection of the pedicle for hemorrhage it is dropped back into the abdomen. The same proceeding is repeated upon the other side, the flat sponges are removed, and finally the abdominal incision is closed tight in the usual way and dressed with- out drainage. SALPINGO-OOPHORECTOM Y. 567 SALPINGO-OOPHORECTOMY, OR THE REMOVAL OF A TUBE DISTENDED WITH PUS, AND ITS OVARY. After the usual preliminaries, including antiseptic vagi- nal douches, the patient is catheterized and placed in Trendelenburg's position, as described for oophorectomy. An incision not less than four inches long is made in the median line above the pubes, afterward extended, if neces- sary, around the umbilicus to afford plenty of room for manipulation. The incision is deepened layer by layer, the bleeding stopped, and the peritoneum nicked in the upper angle of the wgund and opened downward on the finger as a guide, stopping short of the bladder, which can be recognized on the inside as a thickened fold near the pubes ; or, if there is any doubt, by a sound passed through the urethra. The omentum and intestines are pushed back, separating adhesions with the finger-nail or blunt- pointed scissors, till there is a full exposure of the uterus and its appendages, which are then surrounded with flat sponges or pads, completely shutting off the rest of the peritoneal cavity. The fingers are passed outward from the fundus of the uterus, following every crevice around first one tube and then the other, till some spot is found where, by slight pressure or tearing, the tip of the index-finger can be worked under or around the mass and the tube freed, gen- erally in company with its ovary. If pus should be dis- covered escaping, the dissection is stopped till it has been entirely sponged away, enlarging, if necessary, the hole from which it comes. The somewhat free oozing is con- trolled by sponge packing, and when a more or less dis- tinct pedicle has been formed, or the finger recognizes a dangerous amount of resistance to its progress, the strip- ping up and gently tearing process is stopped. With a blunt-pointed aneurism needle a stout catgut ligature is then passed under the infundibulo-pelvic liga- ment, or the outer attachment of the freed mass consisting of the ovary and diseased tube, tying off this ligament close to the mass and including the ovarian artery, the 568 GENITO-UBINARY ORGANS OF THE FEMALE. position of which can be ascertained in advance by pal- liating the broad ligament and noting the pulsation. Another catgut ligature is passed through the broad ligament in the angle formed by the junction of the uterus and Fallopian tube, and the latter is secured with the termination of the artery close to the uterus. Beginning on the uterine side of the outer ligature, the tissues attached to the under side of the tube are cut with blunt-pointed scissors, clamping each vessel or bleeding point as it is encountered, and in this way, when the tube alone is diseased, it is generally easy to leave the ovary undisturbed, and tins is always done by some surgeons ; but in such an instance there should be no preliminary ligature of the infundibulo-pelvic ligament with the ovar- ian artery, and the scissors must be kept close to the tube, while bleeding is controlled by individual ligature of each vessel as it is cut. The diseased mass is then excised on the distal side of the ligature next to the uterus and the stump disinfected. Before its division the tube is secured by a clamp to pre- vent the escape of pus if it has not already occurred. Ligature en masse of the pedicle, which is almost always bulky, is only mentioned to be condemned. After chang- ing the sponges and securing any vessels which still bleed, the cut edges of peritoneum forming the broad ligament are united with fine catgut sutures over the denuded area which lies under the Fallopian tube, and when it has been possible to perform the operation without the escape of a drop of pus, and without leaving a large oozing surface, the protective 3ponges arc removed and the abdominal wound closed tight in the usual way. Otherwise the peritoneal cavity is made as clean and dry as possible and rubber tubes with lateral perforations arc placed in the suspected regions, with one always in Douglas's pouch, and surrounded by strips of iodoform gauze, around the ends of which the abdominal wound is partially closed. Sometimes the Fallopian tube will be found changed into an abscess sac, with very firm adhesions, which only TUMORS BENEATH BROAD LIGAMENT. 569 permit the sac to be opened, or not more than partially removed ; very rarely it can be only partially exposed, but the pus can always be reached somewhere by a care- ful dissection, aided possibly by a guiding puncture with an aspirating needle. The surrounding parts are then carefully protected by a sponge packing and the abscess cavity thoroughly evacuated and washed out with boiled water, and drained with rubber tubes and iodoform gauze. Communication between the abdominal wound and the opening in the sac, which may be at a distance from the surface, is maintained by packing, which should also ex- tend into and protect all possibly infected regions around the abscess. Aided by an exploring finger in the vagina it will sometimes be possible and very advisable to force a blunt-pointed forceps from the bottom of the abscess cavity into the posterior fornix, and thus pass a tube to afford drainage in the most dependent regions as well as from the surface of the abdomen. The vagina is packed around the tube and a dressing is placed on the vulva, while every precaution is taken to prevent infection from the urine and feces. If the vermiform appendix is found involved or ad- herent to a diseased tube, as often happens, it should be excised at the same time. Whenever in a case in which the abdominal wound has been closed tight symptoms of secondary hemorrhage appear, the diagnosis should be at once verified by untying a stitch in the lower angle ot the wound and passing a small sponge on a holder into Douglas's pouch. If done with every antiseptic precau- tion this exploration is free from danger, even if no hemorrhage is found. TUMORS LYING BENEATH THE BROAD LIGAMENT. An opening is made in the overlying peritoneum gen- erally in front of the Fallopian tube, and through this the dissection, guided by the sense of touch, is carried out by the tip of the finger tearing through the loose con- nective tissue surrounding the capsule of the tumor, and 570 QENITO-JJBINART ORGANS OF THE FEMALE. the latter enucleated. The few vessels are clamped as they are encountered and tied later, and drainage is pro- vided for as after salpingo-oophorectomy. OPERATIONS FOR ECTOPIC GESTATION. In the early stages of this condition before the placenta has formed, the operation is conducted, according to the situation of the mass, in the same way as in ovariotomy or salpingo-oophorectomy, or for a tumor lying below the broad ligament. Later, after the formation of the placenta, the general rule is to open the abdomen in the median line below the umbilicus, and, after protecting the peritoneal cavity by a sponge packing, the sac is entered in front like an ovarian cyst, avoiding if possible the site of the placenta, which can usually be recognized by the surrounding vascularity. But sometimes the placenta may have to be perforated, and then the hemorrhage from it is controlled by clamps or deep sutures. The foetus and amniotic liquid are extracted while the surrounding parts are well guarded, and when it seems perfectly feasible the sac may be dissected out with the placenta, separating adhesions with the tip of the finger or blunt-pointed scissors and arresting the bleeding as it oc- curs ; but more often the complete removal is impossible, and the opening in the sac is either stitched to the margins of the abdominal wound or kept in communication with it by packing and drainage applied on the principles already enunciated, while the placenta is left to slough away with the attached umbilical cord. If the operation is performed for hemorrhage following rupture of an extra-uterine gestation, the abdomen is opened in the same way and one hand passed to the fun- dus of the uterus and thence outward to the boggy mass, which, if it can be raised to the surface, is easily secured and treated. But if this is impossible, an attempt, guided by the hand inside the belly, is made to seize one or both ex- tremities of the broad ligament with its contained vessels, by long-bladed clamps. HYSTEROPEXY. 571 The blood and dibria arc then rapidly scooped out of the peritoneal cavity and a search is made for bleeding points, which are immediately caught and tied, and then a decision can be made as to extirpation of the sac, which does not differ from an inherent tube or an ovarian cyst, except that the placenta in the great majority of cases should not be disturbed. The treatment of a case in which suppuration has occurred does not differ from that of an intra-abdominal or pelvic abscess. HYSTEROPEXY. The peritoneal cavity is opened by a median incision of about three inches just above the pubes, and the fundus of the uterus is brought up to the abdominal wall, to which it is fixed by three silk or silkworm -gut sutures passed transversely across the fundus and front of the Fig. 289. uterus, within the substance of which they are buried for about an inch, and then through the parietal peritoneum and muscles and tied in the wound (Fig. 289). The uter- ine peritoneum covering the sutures should be scraped slightly to provoke adhesions. Some carry the sutures 572 OENITO-VRTNARY ORGANS OF THE FEMALE. entirely through the abdominal wall, tie them outside and remove them after a fortnight. INTRA-ABDOMINAL SHORTENING OF THE ROUND LIGAMENTS. Wylie opens the abdomen in the median line and shortens the round ligaments as shown in Fig. 290. Polk Fig. 290. Hysteropexy. Wylie's method of shortening the round ligaments. ties the two ligaments together in front of the uterus, so that they form an X- ALEXANDER'S OPERATION 1 FOR SHORTENING THE ROUND LIGAMENTS. With every antiseptic precaution an oblique incision an inch and a-half or two inches long is made over the inguinal canal terminating near the spine of the pubis. The exter- nal abdominal ring is cleared and the inter-columnar fascia is divided, exposing the fine yellow fat in which the red- dish cord-like round ligament will be found near the up- per limit of the external abdominal ring. The other side i- treated in the same manner. A -light dissection may be necessary to isolate the round ligament, and, aided by a sound in the cavity of the uterus, enough traction is made on the cords to raise the uterus to the desired position. Often four or five inches 'Liverpool Med.-Chir. Journ., January, 1883, p. 113. LAPARO-IIYSTEROTOMY. 573 of the round ligament can thus be easily drawn out through the ring. The ligaments on each side are held in their new posi- tion by a couple of sutures of catgut or silkworm-gut passed through them and the external and internal pillars of each ring. The wound in the intereolumnar fascia is closed with fine catgut and the external wound is sutured and dressed antiseptieally without drainage. Tampons or pessaries must be worn for a month. LAPARO-HYSTEROTOMY. By this term is meant the making of an opening into the cavity of the uterus for any purpose, commonly the ex- traction of a foetus. In the latter instance the time of election, according to Senn, 1 is during the first stage of labor. The patient is catheterized, and with every antiseptic precaution, including preliminary antiseptic douches for the vagina, an incision about six inches long is made in the median line above the pubes, and, bearing in mind that the abdominal wall is apt to be very thin and that the enlarged uterus is in contact with it without the interposi- tion of other viscera, the incision is cautiously deepened layer by layer till the peritoneal cavity is opened in the whole extent of the wound and the surface of the uterus exposed. Sponges are packed around the latter and a longitu- dinal incision about an inch long is made in its anterior wall at a point midway between the junction of the Fallo- pian tubes with the uterus. To lessen the hemorrhage this incision is enlarged downward by tearing sufficiently to extract the child, head first, which must be done as rap- idly as possible after rupturing the membranes. As the bleeding is most free from the cervical region, the rent must not approach this too closely. The uterus is immediately turned out of the abdomen and protected by a warm towel, and its neck below the opening constricted by an elastic ligature tightly enough 1 Amer. Journ. Med. Sci., Sept., 1893. 574 GENJT0-UR1NARY ORGANS OF THE FEMALE. to arrest the bleeding;. The placenta is next peeled off with its attached membranes, and after cleansing the in- terior of the uterus the rent is closed by a row of inter- rupted stout catgut sutures passed at intervals of half an inch through the entire thickness of the uterine wall, ex- clusive of the peritoneum, and about half an inch from the torn edge. Another sow of sutures is placed between these in the same way, but including only half the muscular thick- ness and these are covered in by a row of catgut Lembert Fig. 291. < losure of the uterine wound after Cesarean section. A. reritoneuru. B. Mus- cular wall of the uterus. sutures which should pass through enough of the muscular tissue to secure good peritoneal apposition over the line of suture. (Fig. 291.) The abdominal cavity is cleansed and the elastic liga- ture removed from the uterus, but the latter is not replaced in the belly until after contraction has occurred or been induced by pressure, rubbing, or the subcutaneous injec- tion of ergot. The abdominal wound is then closed tight in the usual way and dressed without drainage, and an iodoform-gauze packing is placed in the interior of the litem- from the vagina. SYMPHYSIOTOMY. 1 The patient is eatlieteiized, and, after thorough disinfec- tion of the abdominal wall and the external genitals, a 1 Aforisani : Ann. dc Gynec. el d'Obst., April, 1892, p. 241. Char- pentier: Hull. :; Carotid, ligature of common, 50 of external, 51 of internal, 53 Castration, 480 Cataract, depression or couching, 310 division or solution, 311 extraction, 313 operations for, 309 Catheterization, female bladder, 533 male bladder, 509 Cervical glands, 248 plexus, 226 Cervix, amputation of, 591 lacerated, 559 posterior section, 561 Cheiloplasty. 253 Cholecystectomy, 464 Cholecy stenterostomy . 4G2 Cholecystostomy, 460 Chopart's amputation, 94 Circumcision, 4S5 Clavicle, excision, 181 Cleft palate. 338 Coccyx, excision, 188 Colostomy. 397 left inguinal, 397 lumbar, 399 Colporrhaphy, 55S Corelysis, 308 Cornea, operations on, 299 Craniectomy, 200 Cranium, operations upon, 195 Crural nerve, anterior, 229 Cystotomy, supra-pubic, 52:'. DORSALIS pedis, ligature, 67 Dressings, preparation of, 26 Dupuytren's contraction, 247 EAR, operations on, 334 Ectopic gestation, 570 Ectropion, 284 Elbow, amputation at, SO exeision, 131 of anchylosed, 137 reduction of dislocated, 139 Elytrorrhaphy, 557 posterior, 558 Euterorrhaphy, circular, 38S Enterostomy, 395 Entropion, 291 Epispadias, 487 Estlauder. resection of ribs, ISO Eustachian tube, 335 Excision of joints and bones. 125 Exstrophy of bladder, 507 Eye, operations on. 299 Eyeball, enucleation. 328 Eyelids, plastic operations. 282 FACE, plastic operations. 251 l'acial artery, ligature, 55 nerve, 225 Femoral artery, ligature, 62 583 5S4 INDEX. Femur, creation of false joint, 150 excision of head, 14G of shaft, 189 division of oeck, 151 osteotomy, 152, 235 Fibula, resection, 190 Fifth nerve, extra-cranial resection, 21G Lntra-cranial resection, 213 Fingers, amputation, 75 Dupuytren's contraction, 247 web, 245 Fistula in auo, 447 salivary, 355 urethral, 497 vesico-vaginal, 549 Foot, amputations, 93, 104 excision of bones, 192 Forearm, amputation, 79 Fracture, operation for ununited, 240 Frajnum of tongue, 355 of penis, 487 Frontal 8iuus, 213 GALL-BLADDER, operations on, 4G0 Gasseriau ganglion, 213 Gastro-entcrostomy, 418 Gastroplicatiou, 415 Gastrorrhaphy. 414 Gastrostomy, 407 Gastrotomy, 411 Genito-urinary operations in female, 533 in male, 480 Gigli wire saw, 197 Glands, cervical, 248 Gluteal artery, ligature, 61 Goitre, operations for, 371 (iritti, amputation at knee, 113 Guyon, amputation of leg, 107 HALLUX valgus, 23G Ealsted, inguinal hernia, 439 Harelip, 263 complicated, 2G7 double, 266 Hemorrhage, arrest, 20 Hemorrhoids, I is Hernia, radical cure of femoral, i hi Inguinal, 132 umbilical, no strangulated femoral, 428 inguinal, 426 obturator, 482 umbilical, 430 I terniotomy, 421 Hip, amputation at, 1 18 I Up-Joint, excision, 146 anchylosis, 150 Humerus, resect Ion, 185 Hydrocele. 481 Hypospadias, 192 Hysterectomy, abdominal, 576 vaginal, 579 ll \ steropexy, 571 ILIAC artery, ligature of common, .'.7 eternal, go ..i Internal, 59 I ii i Lnate artery, ligature, 87 Inferior dental nerve, 220 Inferior thyroid artery, ligature, 42 Intestines, "anastomosis, 390 operations on, 383 suture of, 385 Iridectomy, 303 Iridesis, 307 Iridotomy, 303 Iris, operations on, 302 Ischsemia, artificial, 23 JAW, anchylosis of, 178 Jejunostomy, 421 KELOTOMY, 421 Kidney, methods of exposure, 465 operations on, 464 Knee, amputation at, 111 through the condyles, 112 Garden, 112 Gritti, 113 disarticulation, 111 excision, 153 Kolpokleisis, 556 Kraske, excision of rectum, 453 LACHRYMAL apparatus, 329 gland, removal, 329 sac and duct, 330 Laminectomy, 242 Laparo-hysterotomy, 573 Laparotomy, 380 Laryngectomy, 364 Laryngotomy, 357 cricothyroid, 359 . thyroid, 358 La ryn go tracheotomy, 360 Leg, amputation, 105-110 Ligature of arteries, 33 Lingual artery, ligature, 54 nerve, 224 Lips, plastic operations, 253-267 Lisfranc's amputation, 93 Litholapaxy, ~>i l Lithotomy, 516 lateral, 517 median, 521 supra-pubic, 523 in female, 535 Liver, operations on, 456 abscess of, 457 hydatids of, 459 MASTOID cells, 336 Maxilla, inferior, anehvlosis, 178 excision, 173 superior, excision, 161 partial, 166, 167, 168 temporary, 168 McBll liny, ;i(i|p('iiili\, 404 Inguinal hernia, 43 ( j Median oerve, 228 Medio-tarsal amputation, 94 Metacarpal bone, amputation, 77 excision, 1 s7 Metatarsal i , amputal i'>u, 91 excision, 195 INDEX. 585 Mikulicz, excision of heel, 158 Mouth, operation on, 337 Musculospiral nerve, 229 Myomectomy, 575 NASO-PHARYNGEAL polyp, 168, 1/ Neck, operations on, 357 Nephrectomy, abdominal, 472 lumbar, 471 Nephrolithotomy, 469 Nephropexy, 474 Nephrotomy, 469 Neurorrhaphy, 230 Neurotomy. 215 Nose, plastic operations, 268 OCCIPITAL artery, ligature, 56 CEsophagotomy, 368 Olecranon, suture, 242 Oophorectomy, 566 Operation, preparation for, 26 Orbit, extirpation of, 329 Osteotomy, 235 cuneiform, for talipes, 237 for hallux valgus, 236 Ovariotomy, 564 PALATE, cleft, 338 Patella, suture of. 241 Paracentesis, abdomen, 379 thorax, 377 pericardium, 37S Paraphymosis, 487 Pelvis, resection of bones, 188 Penis, amputation of, 484 Pericardium, paracentesis, 378 Perineorrhaphy, 537 Hegar, 541 Perineum, laceration, 543, 546 Phalanges, contraction of, 246 excision, 187, 195 Pharynx, access to, 168-173 Phimosis, 485 Pharyngotomy, 366 subhyoid,"357 Pirogoff, amputation at ankle, 101 Plastic operations, 251 evelids, 282 face, 251 lip, 253 nose, 268 Popliteal artery, ligature, 65 nerve, 229 Pott's fracture, redaction of old, 160 Preparation for operation, 26, 29 Prostatectomy, 526 Pterygion, 296 Pudic artery, ligature, 61 Pylorectomy, 416 Pyloroplasty, 414 Pylorus, stricture of, 412 RADIAL artery, ligature, 47 Radius, excision, 186 Ranula, 355 Rectopexy, 446 Rectum, excision, 449 1 Rectum, operations on, 441 prolapse, 444 Rhinoplasty, 268 Kibs, resection, 180 Round ligaments, shortening, 572 Koux, amputation at ankle, 100 SALPINGECTOMY, 567 kj Salpingo-oophorectomy, 567 Scapula, excision, 182 Seminal vesicles, removal, 530 Sciatic artery, ligature, 61 nerve, 229 Senn, amputation at hip, 123 Shoulder, amputation at, 83 excision of, 128 Sinus, frontal, 213 lateral, 207 Skin-grafting, 243 Spinal accessory nerve, 226 Splenectomy, 465 Sponges, preparation of, 26 Staphylorrhaphy, 338 Sterilization, 28 Steruo-eleido-mastoid,"232 Sternum, resection of, 180 Stomach, operations on, 405 Strabismus, operation for, 325 Subastragaloid amputation, 96 Subclavian artery, ligature, 39 Superior thyroid artery, ligature, 41 maxillary nerve, 217 Supraclavicular region, 35 Supraorbital nerve, 215 Suprapubic cystotomy, 523 Sutures, 25 Symblepharon, 294 Syme, amputation at ankle, 97 Symphysiotomy, 574 TALIPES, osteotomy, 237 Tarso-metatarsal amputation, 93 Temporal artery, ligature of, 56 Tendo Achillis, 231 Tenorrhaphy, 232 Tenotomy, 230 Thiersch, skin-grafting, 243 Thigh, amputation, 115 Thorax, operations on, 376 paracentesis, 377 Thyroid artery, ligature of inferior, 42 superior, 41 gland, operations, :;71 Tibia, resection, 189 Tibial artery, ligature of anterior, 65 posterior, 67 Tibialis anticus, 232 posticus, 231 Toenail, ingrown, 247 Toes, amputation, 90 Tongue, excision, 349 Kocher, 352 Tonsils, amputation, 337 Torticollis, 227 Tracheotomy, 361 Trephining cranium, 195 omega nap, 199 for abscess, 208 for hemorrhage, 211 586 INDEX. Trephining to reach cerebellum, 210 Trichiasis, 297 Tympanum, paracentesis, 334 ULNA, excision, 186 Ulnar artery, ligature, 49 nerve, 228 Uranoplasty, 345 I'reter, operations on, 474 wounds of, 477 (Jretero-ureterostomy, 478 Urethral fistula, 497 " Urethroplasty, 499 Urethrorrhaphy, 498 Urethrotomy, external, 503, 533 internal, 502 Uterus, amputation of gravid, 579 of cervix, 580 laceration of cervix, 559 prolapse of, 557, 571 removal of, 576, 579 Uterus, removal of mucosa, 582 tumors of, 575 VAGINA, atresia of, 536 narrowing of, 557 obliteration of, 556 prolapse of posterior wall, 538 Varicocele, 482 Ventricles, puncture of, 210 Vermiform appendix, 402 Vertebral artery, ligature, 43 Vesico-vaginal fistula, 549 creation, 554 Vesicles, removal of seminal, 530 WEB-FINGERS, 245 Wrist, amputation at, 78 excision of, 140 Wound, its treatment, 29 Wry-neck, 227 CATALOGUE OF PUBLICATIONS OF LEA BROTHERS & COMPANY, 706, 708 & 710 Sansoin St., Philadelphia. Ill Fifth Ave. (Cor. 18th St.), New York. The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the United States, on receipt of the printed prices. "index. ANATOMY. _Gray, p. 11 ; Treves, 30 ; Gerriah. 11; Brockway, 4. DICTIONAKlES. Dunglison, p. 8 ; Duane, 8 ; National, 4 PHYSICS. Draper, p. 8 ; Robertson, 24 ; Martin & Rockwell, 20. PHYSIOLOGY". Foster, p. 10; Chapman, 5; Schofield, 25; Collins & Rockwell, 6. [Luff - , 19 ; Remsen, 24. CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Martin & Rockwell, 20; PHARMACY. Caspari, p. 5. [Bruce, 4 : Schleif, 25. MATERIA MEDICA. Culbretb, p. 6 ; Maisch, 19 ; Farquharson, 9 ; DISPENSATORY. National, p. 21. THERAPEUTICS. Hare, p. 13 ; Fothergill, 10 ; Whitla, 31 ; Hayem & Hare, 14 ; Bruce, 4 ; Schleif, 25 ; Cushny, 6. PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Malsbary, 20. DIAGNOSIS. Musser, p. 21 ; Hare, 12; Simon, 25; Herrick, 15; Hutchi- son & Rainey, 16 ; Collins, 6. CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. NERVOUS DISEASES. Dercum, p. 7 ; Gray, 11 ; Potts, 23. MENTAL DISEASES. Clouston, p. 5 ; Savage, 24 ; Folsom, 10. BACTERIOLOGY. Abbott, p. 2 ; Vaughan & Novy, 30 ; Senn's (Surgical), 25. Park, 22 ; Coates, 6. [Yale, 21. HISTOLOGY. Klein, p. 17 ; Schafer's, 25 ; Dunham, 8 ; Nichols & PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Nichols & Vale, 21 SURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29; Cheyne & Burghard, 5 ; Gallaudet, 10. SURGERY— OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. SURGERY— ORTHOPEDIC. Young, p. 31 ; Gibney, 10. SURGERY— MINOR. Wharton, p. 30. [BalleDger& FRACTURES and DISLOCATIONS. Stimson, p. 27. [Wippern, 3. OPHTHALMOLOGY. Nor ris & Oliver, p. 21; Nettleship, 21 ; Juler,17; OTOLOGY. Politzer, p. 23; Burnett, 5; Field, 9; Bacon, 4. LARYNGOLOGY and RHINOLOGY. Coakley.p. 6 ; DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri- can System. 2 ; Coleman, 6; Burchard 4. URINARY DISEASES. Roberts, p. 24 ; Black, 4. VENEREAL DISEASES. Taylor, p. 28 ; Hayden, 14 ; Cornil, 6 ; SEXUAL DISORDERS. Fuller, p. 10 ; Taylor, 29. [Likes, 19. DERMATOLOGY. Hyde, p. 16 ; Jackson, 16 ; Pye-Smith, 24 ; Mor- ris, 20 ; Jamieson, 16 ; Hardaway, 12 ; Grindon, 12. GYNECOLOGY. American System, p. 3 ; Thomas & Mundd, 29 Emmet, 9 ; Davenport, 7 ; May, 20 ; Dudley, 8 ; Crockett, 6. OBSTETRICS. American System, p. 3 ; Davis, 7 ; Parvin, 22 ; Play- fair. 23 ; King, 17 ; Jewett, 17 ; Evans, 9. PEDIATRICS. Smith, p 26 ; Thomson, 29 ; Williams, 31 ; Tnttle, 30. HYGIENE. Egbert, p. 9 ; Richardson, 24 ; Coates, 6. MEDICAL JURISPRUDENCE. Taylor, p. 28. QUIZ SERIES, POCKET TEXT-BOOKS and MANUALS. Pp. 18, 25 and 27. 1.15.00. Lea Brothers & Co., Philadelphia and New York. ABBOTT (A. C). PRINCIPLES OF BACTERIOLOGY: a Practical Manual for Students and Physicians. New (5th) edition thoroughly revised and greatly enlarged. In one handsome 12mo. vol. of 585 pages, with 109 engrav., of which 26 are colored. Just ready. Cloth, $2.75, net. cessfully. To those who require a condensed yet nevertheless complete work upon Bacteriology we most cordially recommend it. — The Thera- peutic Gazette. One of its most attractive charac- teristics is that the directions are so clearly given that anyone with a moderate amount of laboratory train- ing can, with a little care as to detail, make his experiments suc- AMERICAN SYSTEM OP PRACTICAL MEDICINE. A SYS- TEM OF PRACTICAL MEDICINE. In contributions by Various American Authors. Edited by Alfred L. Loomis, M.D., LL.D., and W. Gilman Thompson, M. D. In four very handsome octavo volumes of about 900 pages each, fully illustrated. Complete work now ready. Per volume, cloth, $5; leather, $6; half Morocco, $7. For tale by subscription only. Prospectus free on application. Every chapter is a masterpiece of cine" is a work of which every completeness, and is particularly ex- ! American physician may reasonably cellent in regard to treatment, many feel proud, and in which every prac- original prescriptions, formulse, I titioner will find a safe and trust- charts and tables being given for the 1 worthy counsellor in the daily re- guidance of the practitioner. sponsibilities of practice. — The Ohio "The American System of Medi- < Medical Journal. AMERICAN SYSTEM OF DENTISTRY. In treatises by various authors. Edited by Wilbur F. LlTCH, M.D., D.D.S. In three very handsome super-royal octavo volumes, containing about 3200 pages, with 1873 illustrations and many full-page plates. Per vol., cloth, $6; leather, $7 ; half Morocco, $8. For sale by subscription only. Pros- pectus free on application to the Publishers. AMERICAN TEXT-BOOKS OF DENTISTRY. In Contribu- tions by Eminent American Authorities. In two very handsome octavo volumes, richly illustrated : PROSTHETIC DENTISTRY. Edited by Charles J. Essig, M.D., D.D.S., Professor of Mechanical Dentistry and Metallurgy, Department of Dentistry, University of Pennsylvania, Philadelphia. 760 pages, 983 engravings. Cloth, $6 ; leather, $7. Net. No more thorough production will It is up to date in every particular. be found either in this country or in It is a practical course on prosthetics any country where dentistry "is un- ' which any student can take up dur- derstood as a part of civilization. — ing or after college. — Dominion Den- The International Dental Journal. I tal Journal. OPERATIVE DENTISTRY. Edited by Edward C. Kirk, D.D.S., Professor of Clinical Dentistry, Department of Dentistry, University of Pennsylvania. 699 pages, 751 engravings. Cloth, $5.50 ; leather, $6.50. Net. Just ready. Written by a number of practi- It is replete in every particular tionen as well known at the chair and treats the subject in a progressive as in journalistic literature, many of manner. It is a book that every them teachers of eminence in our progressive dentist should possess, colleges It shonld be included in | and we can heartily recommend it tin li«t of text-books set down as to the profession. — The Ohio Dental mod useful to the college student.— Journal. The Dental Newt. Lea Brothers A Co., Philadelphia and New York. 3 AMERICAN SYSTEMS OF GYNECOLOGY AND OBSTET- RICS. In treatises by the most eminent American specialists. Gyne- cology edited by Matthew P. Mann, A.M., M. D., and Obstetrics edited by Barton C. Hirst, M. D. In four large octavo volumes comprising 3612 pages, with 1092 engravings, and 8 colored plates. Per volume, cloth, $5 ; leather, $6 ; half Russia, $7. For sale by subscrip- tion only. Prospectus free on application to the Publishers. AMERICAN TEXT-BOOK OF ANATOMY. See Gerrish, page 11. ALLEN (HARRISON). A SYSTEM OF HUMAN ANATOMY; WITH AN INTRODUCTORY SECTION ON HISTOLOGY, by E. O. Shakespeare, M.D. Comprising 813 double-columned quarto pages, with 3S0 engravings on stone, 109 plates, and 241 wood cuts in the text. In six sections, each in a portfolio. Price per section, $3.50. Also, bound in one volume, cloth, $23. Sold by subscription only. A PRACTICE OF OBSTETRICS BY AMERICAN AU- THORS. See Jewett. page 17. A TREATISE ON SURGERY BY AMERICAN AUTHORS. FOR STUDENTS AND PRACTITIONERS OF SURGERY AND MEDICINE. Edited by Roswell Park, M.D. See page 22. ASHHURST (JOHN, JR.). THE PRINCIPLES AND PRACTICE OF SURGERY. For the use of Students and Practitioners. Sixth and revised edition. In one large and handsome octavo volume of 1161 pages, with 656 engravings. Cloth, $6 ; leather, $7. As a masterly epitome of what has text-book, we do not know its equal. been said and done in surgery, as a It is the best single text-book of succinct and logical statement of the surgery that we have yet seen in this principles of the subject, as a model country. — New York Post-Graduate. A SYSTEM OF PRACTICAL MEDICINE BY AMERICAN AUTHORS. Edited by William Pepper, M. D., LL. D. In five large octavo volumes, containing 5573 pages and 198 illustrations. Price per volume, cloth, $5 ; leather $6 ; half Russia, $7. Sold by subscrip- tion only. Prospectus free on application to the Publishers. ATTFTEID (JOHN). CHEMISTRY; GENERAL, MEDICAL AND PHARMACEUTICAL. New (16th) edition, specially revised by the Author for America. In one handsome 12mo. volume of 784 pages, with 88 illustrations. Cloth, $2.50, net. It i> replete with the latest inform- been adopted, bringing the work into ation, and considers the chemistry of close touch with the latest United every substance recognized officially States Pharmacopoeia, of which it is or in general practice. The modern a worthy companion. — The Pittsburg scientific chemical nomenclature has Medical Review. BALLENGER (W. L.) AND WIPPERN (A. G.). Shortly. A POCKET TEXT-BOOK OF DISEASES OF THE EYE, EAR, NOSE AND THROAT. In one handsome 12mo. volume of about 400 pages, with many illustrations. Lea's Series of Pocket Text-hooks, edited "by Bern B. Gallatidbt, M. D. See p. 18. BARNES (ROBERT AND FANCOURT). A SYSTEM OF OB- STETRIC MEDICINE AND SURGERY. Octavo, 872 pages, with 231 illuu. Cloth, $5 : leather, $6. 4 Lea Brothers & Co., Philadelphia and New York. BACON (GORHAM). ON THE EAR. One 12mo. volume, 400 pages, 109 engravings and a colored plate. Cloth, net, $2.00. Just ready. It is the best manual upon otology, i dents of medicine — Cleveland Jour- An intensely practical book for stu- j nal of Medicine. BARTHOLOW (ROBERTS). CHOLERA; ITS CAUSATION, PRE- VENTION AND TREATMENT. In one 12mo. volume of 127 pages, with 9 illustrations. Cloth, $1.25. BARTHOLOW (ROBERTS). MEDICAL ELECTRICITY. A PRACTICAL TREATISE ON THE APPLICATIONS OF ELEC- TRICITY TO MEDICINE AND SURGERY. Third edition. In one octavo volume of 308 pages, with 110 illustrations. BIIiLINGS (JOHN S.). THE NATIONAL MEDICAL DICTIONARY. Including in one alphabet English, French, German, Italian and Latin Technical Terms used in Medicine and the Collateral Sciences. In two very handsome imperial octavo volumes containing 1574 pages and two colored plates. Per volume, cloth, $6 ; leather, $7 ; naif Morocco, $8.50. For sale by subscription only. Specimen pages on application to the publishers. BLACK (D. CAMPBELL). THE URINE IN HEALTH AND DISEASE, AND URINARY ANALYSIS, PHYSIOLOGICALLY AND PATHOLOGICALLY CONSIDERED. In one 12mo. volume of 256 pages, with 73 engravings. Cloth, $2.75. A concise, yet complete manual, I Concise, practical, clinical, well treating of the subject from a prac- illustrated and well printed. — Mary- tical and clinical standpoint. — The\ land Medical Journal. Ohio Medical Jour nal. BLOXAM (C. Ii.). CHEMISTRY, INORGANIC AND ORGANIC. With Experiments. New American from the fifth London edition. In one handsome octavo volume of 727 pages, with 292 illustrations. Cloth, $2; leather, $3. BROCRWAY (F. J.). A POCKET TEXT-BOOK OF ANAT< >M V. In one handsome 12mo. volume of about 400 pages, with many illus- trations. Shortly. Lea's Scries of Pocket Text-books, edited by Bkrn B. Gallaudet, M. D. See page 18. BRUCE (J. MITCHELL). MATERIA MEDICA AND THERA- PEUTICS. New (6th) edition. In one 12mo. volume of 600 pages. Just ready. Cloth, $1.50, net. See Student's Series of Manuals, page, 27. PRINCIPLES OF TREATMENT. In one octavo volume. Pre- paring . BRYANT (THOMAS). THE PRACTICE OF SURGERY. Fourth American from the fourth English edition. In one imperial octavo vol. of 1040 pages, with 727 illustrations. Cloth, $6.50 ; leather, $7.50. BUROHARD (HENRY H.). DENTAL PATHOLOGY AND THER- APEUTICS. Handsome octavo, 575 pagi-H, with 400 illustrations. Cloth, net, $5.00; leather, net, $6.00. Lea Brothers & Co., Philadelphia and New York. 5 BURNETT CHARLES H. ). THE EAR : ITS ANATOMY, PHYSI- OLOGY AND DISEASES. A Practical Treatise for the Use of Students and Practitioners. Second edition. In one 8vo. volume of 580 pages, with 107 illustrations. Cloth, $4 ; leather, $5. CARTER (R. BRUDENELL) AND FROST (W. ADAMS). OPH- THALMIC SURGERY. In one pocket-size 12mo. volume of 559 pages, with 91 engravings and one plate. Cloth, $2.25. See Series of Clinical Manuals, page 25. CASPARI i CHARLES JR.). A TREATISE ON PHARMACY. For Students and Pharmacists. In one handsome octavo volume of 680 pages, with 28S illustrations. Cloth, $4.50. The author's duties as Professor student who cannot understand must of Theory and Practice of Pharmacy be dull indeed. The book is full of in the Maryland College of Phar- new, clean, sharp illustrations,which macy, and his contact with students tell the story frequently at a glance, made him aware of their exact The index is full and accurate. — wants in the matter of a manual. National Druggist. His work is admirable, and the CHAPMAN (HENRY C). A TREATISE ON HUMAN PHYSI- OLOGY. New (2d) edition. In one octavo volume of 921 pages, with 505 illustrations. Just ready. Cloth, $4.25 ; leather, $5.25, net. In every respect the work fulfils [ mirable work of reference for the its promise, whether as a complete physician. — North Carolina Medical treatise for the student or as an ad- Journal. CHARLES (T. CRANSTOUN). THE ELEMENTS OF PHYSIO- LOGICAL AND PATHOLOGICAL CHEMISTRY. Octavo, 451 pages, with 38 engravings and 1 colored plate. Cloth, $3.50. CHEYNE fW. WATSON). THE TREATMENT OF WOUNDS, ULCERS AND ABSCESSES. In one 12mo. volume of 207 pages. Cloth, $1.25. One will be surprised at the need at any moment. The sections amount of practical and useful in- devoted to ulcers and abscesses are formation it contains; information indispensable to any physician. — that the practitioner is likely to j The Charlotte Medical Journal. CHEYNE (W. W.) AND BURGHARD (F. F.). SURGICAL TREATMENT. In six octavo volumes, illustrated. Now ready. Volume 1, 299 pages and 66 engravings. Cloth, $3.00 net. Volume 2, 382 pages, 141 en-ravings. Cloth, $4.00 net. CLARKE (W. B.) AND LOCKWOOD (O. B.). THE DISSECTOR'S MANUAL. In one 12mo. volume of 396 pages, with 49 engravings. Cloth, $1.50. See Students' Series of Manuals, page 27. CLELAND . JOHN). A DIRECTORY FOR THE DISSECTION OF THE HUMAN BODY. In one 12mo. vol. of 178 pages. Cloth, $1.25. CLINICAL 3IANUALS. See Series of Clinical Manuals, page 25. CLOUSTON (THOMAS S. |. CLINICAL LECTURES ON MENTAL DISEA^E.S. New 5th edition. In one octavo volume of 750 pages, with 19 colored plates. Cloth, $4.L'. r >, net. Just ready. j^&-Folsom's Abstract of Laws of U. S. on Custody of Insane, octavo, $1.50, is sold in conjunction with Clouston on Mental Diseases for $5.00, net, for the two works. 6 Lea Bbothebs & Co., Philadelphia, and New Yoke. CliOWES (FRANK). AN ELEMENTAKY TREATISE ON PRACTI- CAL CHEMISTEY AND QUALITATIVE INORGANIC ANALY- SIS. From the fourth English edition. In one handsome 12mo. volume of 387 pages, with 55 engravings. Cloth, $2.50. COAKLEY (CORNELIUS G.). THE DIAGNOSIS AND TREAT- MENT OF DISEASES OF THE NOSE, THROAT, NASO- PHARYNX AND TRACHEA. In one 12mo. volume of 526 pages with 92 engravings and 2 colored plates. Just ready. Cloth, $2.75. net. COATES (W. E., JR.). A POCKET TEXT-BOOK OF BACTE- RIOLOGY AND HYGIENE. In one handsome 12mo. volume of about 350 pages, with many illustrations. Shortly. Lea's Series of Povh-ct Text-books, edited by Been B. Gallaudet, M. D. See page 18. COATS (JOSEPH). A TREATISE ON PATHOLOGY. In one vol. of 829 pages, with 339 engravings. Cloth, $5.50 ; leather, $6.50. COLEMAN (ALFRED). A MANUAL OF DENTAL SURGERY AND PATHOLOGY. With Notes and Additions to adapt it to Amer- ican Practice. By Thos. C. Stellwagen, M.A., M.D., D.D.S. In one handsome octavo vol. of 412 pages, with 331 engravings. Cloth, $3.25. COLLINS (C. P.). A POCKET TEXT-BOOK OF MEDICAL DIAGNOSIS. In one handsome 12mo. volume of about 350 pages, with many illustrations. Shortly. Lea 's Series of 'Pocket Text-books, edited by" Bern B. Gallaudet, M. D. Seepage 18. COLLINS (H. D.) AND ROCKWELL (W. H.). A POCKET TEXT-BOOK OF PHYSIOLOGY. 12mo. of 316 pages, with 153 illustrations. Just ready. Cloth, $1.50; flexible red leather, $2.00, net. Lea's Series of Pocket Text-books, edited by BEEN B. GALLAU- DET, M.D. See page 18. CONDIE (D. FRANCIS). A PRACTICAL TREATISE ON THE DIS- EASES OF CHILDREN. Sixth edition, revised and enlarged. In one large 8vo. volume of 719 pages. Cloth, $5.25 ; leather, $6.25. CORNIL (V.). SYPHILIS: ITS MORBID ANATOMY, DIAGNO- SIS AND TREATMENT. Translated, with Notes and Additions, by J. Henry C. Simes, M.D. and J. William White, M.D. In one 8vo. volume of 461 pages, with 84 illustrations. Cloth, $3.75. CROCKETT (M. A.). A POCKET TEXT-BOOK OF DISEASE* OF WnMEN. In one handsome 12mo. volume of about 350 pages, with many illustrations. Shortly. Lea's Series of Pocket Text-books, edited by BERN B. GaLLATTDET, M. D. Seepage 18. CROOK (JAMES K.) ON MINERAL WATERS OF THE I 'XI TED STATES. Octavo, 575 pages. Just ready. Cloth, $3.50, net. CULBRETH DAVID M. R.). MATERIA MEDICA AND PHAR- MACOLOGY. In one handsome octavo volume of 812 pages, with 445 illustrations. Cloth, $4.75. CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. Handsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.75, net. Lea Brothers & Co., Philadelphia and New York. DAI/TON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, $5 ; leather, $6. DOCTRINES OF THE CIRCULATION OF THE BLOOD. In one handsome 12mo. volume of 293 pages. Cloth, $2. DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual ot Gynecology. For the use of Students and Practitioners. New (3d) edition. In one handsome 12mo. volume of 387 pages, with 150 illustrations. Cloth, $1.75, net. Just ready. DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR STUDENTS AND PRACTITIONERS. In one very handsome octavo volume of 546 pages, with 217 engravings and 30 full-page plates in colors and monochrome. Cloth, $5 ; leather, $6. From a practical standpoint the thoroughly scientific and brilliant work is all that could be desired. A treatise on obstetrics. —Med. News. DAVIS (P. H.). LECTURES ON CLINICAL MEDICINE. Second edition. In one 12mo. volume of 287 pages. Cloth, $1.75. DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo volume of 700 pages, with 300 engravings. Cloth, $4. DENNIS (FREDERIC S.) AND BLLLJNGS (JOHN S.). A SYS- TEM OF SURGERY. In contributions by American Authors. Complete work in four very handsome octavo volumes, containing 3652 pages, with 1585 engravings and 45 full-page plates in colors and monochrome. Per volume, cloth, $6.00; leather, $7.00; half Morocco, gilt back and top, $8.50. For sale by subscription only. Full prospectus free on application to the publishers. It is worthy of the position which i American surgery aud is thoroughly surgery has attained in the great practical. — Annals of Surgery. Republic whence it comes. — The No work in English can be con- London Lancet. sidered as the rival of this. — The It may be fairly said to represent j American Journal of the Medical the most advanced condition of J Sciences. DERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON NERVOUS DISEASES. By American Authors. In one handsome octavo volume of 1054 pages, with 341 engravings and 7 colored plates. Cloth, $6.00; leather, $7.00. Net. Representing the actual status of The work is representative of the our knowledge of its subjects, and ! best methods of teaching, as devel- the latest and most fully up-to-date ! oped in the leading medical colleges of any of its class. — Jour, of Amer- of this country. — Alienist and Neu- ican Med. Association. j rologist. The most thoroughly up-to-date The best text-book in any lan- treatise that we have on this subject, guage. — The Medical Fortnightly. — American Journal of Insanity. DE SCHWEEVITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. Their Classification, History, Symptoms, Pathology aud Treatment. Very handsome octavo, 240 pages, 46 engravings, and 9 full-page plates in colors. Limited edition, de luxe binding, $4. Net. 8 Lea Brothers & Co., Philadelphia and New York. DRAPER (JOHN C.j. MEDICAL PHYSICS. A Text-book for Stu- dents and Practitioners of Medicine. In one handsome octavo volume of 734 pages, with 376 engravings. Cloth, $4. DRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the twelfth London edition, edited by Stanley Boyd, F. R. C. S. In one large octavo volume of 965 pages, with 373 engravings. Cloth, $4 ; leather, $5. DUANE (ALEXANDER). THE STUDENT'S DICTIONARY OF MEDICINE AND THE ALLIED SCIENCES. New edition. Com- prising the Pronunciation, Derivation and Full Explanation of Medi- cal Terms, with much Collateral Descriptive Matter. Numerous Tables, etc. Square octavo of 658 pages. Cloth, $3.00; half leather, $3.25; full sheep, $3.75. Thumb-letter Index, 50 cents extra. DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF GYNECOLOGY. New (2d) edition. Handsome octavo of 717 pages, with 453 illustrations in black and colors, and 8 colored plates. Cloth, $5.00, net; leather, $6.00, net. Just ready. The book can be safely recom- I tice of modern gynecology. — Inter- mended as a complete and reliable national Medical Magazine. exposition of the principles and prac- I DUNCAN i J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1.50. DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- ENCE. Containing a full explanation of the various subjects and terms of Anatomy, Physiology. Medical Chemistry, Pharmacy, Phar- macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By Robley Dunglison, M. D., LL. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. Edited by Richard J. DUNGLISON, A. M., M. D. Twenty-first edition, thor- oughly revised and greatly enlarged and improved, with the Pronuncia- tion, Accentuation and Derivation of the Terms. With Appendix. In one magnificent imperial octavo volume of 1225 pages. Cloth, $7 ; leather, $8 Thumb-letter Index for quick use, 75 cents extra. The most satisfactory and authori- scarcely be measured. — Med. Record. tative guide to the derivation, defini- Pronunciation is indicated by the tion and pronunciation of medical phonetic system. The definitions are terms.— The Charlotte Med Journal, unusually* clear and concise. The Covering the entire field of medi- book is wholly satisfactory. — Uni- cine, surgery and the collateral versity Medical Magazine. sciences, its range of usefulness can Dl NHAM (EDWARD K.). MORBID AND NORMAL HIS- TOLOGY. Octavo, 450 pages,with 363 illustrations. Cloth, $3.25, net. Tip- 1)' -t one-volume text or refer- 1 of published in America.— Virginia enee \»»>\i on histology that we know I Medical 8t mi-Monthly. EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA MEDICA. In one8vo. volume of 544 pages. Cloth, $3.50; leather, $4 .50. EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and Practitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings. Cloth, $3; leather, $4. Lea Bkothebs & Co., Philadelphia and New Yoke. 9 EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- TATION. In one 12ino. volume of 359 pages, with 63 illustrations. Just ready. Cloth, Net, $2.25. It is written in plain language, and, while primarily designed for physicians, it can be studied with profit by any one of ordinary intel- ligence. The writer has adapted it to American conditions, and his suggestions are, above all, practical. — The NewYork Medical Jour mil. ELLIS (GEORGE VINER). DEMONSTRATIONS IN ANATOMY. Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25 ; leather, $5.25. EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 150 original engravings. Cloth, $5 ; leather, $6. ERIOHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- GERY. Eighth edition. In two large octavo volumes containing 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American Text-Books of Dentistry, page 2. EVANS (DAVID J.). A POCKET TEXT-BOOK OF OBSTETRICS. In one handsome 12mo. volume of about 300 pages, with many illustra- tions. Short/;/. Lea's Series of Pocket Text-books, edited by Been B. Gallaudet/M. D. See page 18. PARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth American from fourth English edition, revised by Frank Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. FD3LD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75. FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE. Seventh edition, thoroughly revised by Frederick P. Henry, M. D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5.00 ; leather, $6.00. The work has well earned its lead- The best of American text-books ing place in medical literature. — on Practice. — Amer. Medico-Surgical Medical Record. Bulletin. A MANUAL OF AUSCULTATION AND PERCUSSION ; oi the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. In one handsome 12mo. volume of 274 pages, with 12 engravings. A PRACTICAL TREATISE ON TIJE DIAGNOSIS AND TREATMENT OF DISEASES OF THE HEART. Second edition enlarged. In one octavo volume of 550 pages. Cloth, $4. A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- EASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. ON PHTHISIS : ITS MORBID ANATOMY, ETIOLOGY, ETC. A Series of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50. 10 Lea Brothers & Co., Philadelphia and New York. FOLSOM (C. P.). AN ABSTRACT OF STATUTES OF U. S. ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. Cloth, $1.50. With Clouston on Mental Diseases (new edition, see page 6) $5.00, net, for the two works. FORMULARY, POCKET, see page 32. FOSTER MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New (6th) and revised American from the sixth English edition. In one large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50 ; leather, $5.50. Unquestionably the best book that This single volume contains all can be placed in the student's hands, that will be necessary in a college and as a work of reference for the course, and all that the physician busy physician it can scarcely be will need as well. — Dominion Med. excelled. — The Phi la. Polyclinic. Monthly. FOTHERGILL (J. MILNER). THE PRACTITIONER'S HAND- BOOK OF TREATMENT. Third edition. In one handsome octavo volume of 664 pages. Cloth, $3.75 ; leather, $4.75. FOWNES GEORGEi. A MANUAL OF ELEMENTARY CHEM- ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- bodying Watts' Physical and Inorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and 1 colored plate. Cloth, $2.75 ; leather, $3.25. FRANKLAND | E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. In one handsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75 ; leather, $4.75. FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- GANS IN THE MALE. In oue very handsome octavo volume of 238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. It is an interesting work, and one i tive and brings views of sound which, in view of the large and profitable amount of work done in this field of late years, is timely and pathology and rational treatment to many cases of sexual disturbance whose treatment has been too often well needed. — Medical Fortnightly. \ fruitless for good. — Annals of The book is valuable and instruc- Surgery. FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathologv, Physical Diagnosis, Symptoms and Treatment. From second English edition. In one 8vo. volume of 475 pages. Cloth, $3.50. <. A 1. 1, A I l)i:i BERN B.j. A POCKET TEXT-BOOK ON SUR- GERY, [none handsome 12mo. volume of about 400 pages, with many illustrations, shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallatjdet, M. I>. Bee page 18. GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75. GIBBEs H BSNBAGB). PRACTICAL PATHOLOGY AND MORBID HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. GD3NEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- tioners ;ui<1 Students. In one 8vo. vol. profusely illus. Preparing. Lea Brothers A Co., Philadelphia and New York. 11 GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. By American Authors. Edited by Frederic H. Gerrish, M. D. In one imp. octavo volume of 915 pages, with 950 illustrations in black and colors. Just ready. Clth,$6.50; flexible waterproof, $7; leath., $7.50, net. In this, the first representative treatise on Anatomy produced in America, no effort or expense has been spared to unite an authoritative text with the most successful anatomical pictures which have yet appeared in the world. The editor has secured the co-operation of the professors of anatomy in leading medical colleges, and with them has prepared a text conspicuous for its simplicity, unity and judicious selection of such anatomical facts as bear on physiology, surgery and internal medicine in the most compre- hensive sense of those terms. The authors have endeavored to make a book which shall stand in the place of a living teacher to the student, and which shall be of actual service to the practitioner in his clinical work, emphasizing the most important subjects, clarifying obscurities, helping most in the parts most difficult to learn, and illustrating everything by all available methods. GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. vol. of 589 pages. Cloth, $2. See Student's Series of 3fanuals, p. 27. GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. New and thoroughly revised American edition, much enlarged in text, and in engravings in black and colors. In one imperial octavo volume of 1239 pages, with 772 large and elaborate engravings on wood. Price of edition with illustrations in colors : cloth, $7 ; leather, $8. Price of edition with illustrations in black : cloth, $6 ; leather, $7. This is the best single volume upon Anatomy in the English language.— University Medical Mag- azine. Gray' s Anatomy affords the student more satisfaction than any other treatise with which we are familiar. — Buffalo Med. Journal. The most largely used anatomical text-book published in the English language. — Annals of Surgery. Particular stress is laid upon the practical side of anatomical teach- ing, and especially the Surgical Anatomy. — Chicago Med. Recorder. Holds first place in the esteem of both teachers and students. — The Brooklyn 3/edical Journal. The foremost of all medical text- books. — Medical Fortn ightiy. Gray's Anatomy should be the first work which a medical student should purchase, nor should he be without a copy throughout his pro- fessional career. — Pittsburg Medical Review. GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND MENTAL DISEASES. For Students and Practitioners of Medicine. New (2d) edition. In one handsome octavo volume of 728 pages, with 172 engravings and 3 colored plates. Cloth, $4.75 ; leather, $5.75. An up-to-date text-book upon nervous and mental diseases com- bined. A well-written, terse, ex- plicit, and authoritative volume treating of both subjects is a step in the direction of popular demand. — The Chicago Clinical Review. The descriptions of the various diseases are accui-ate and the symp- toms and differential diagnosis are set before the student in such a way as to be readily comprehended. The author's long experience renders his views on therapeutics of great value. — The Journal of Nervous and Men- tal Disease. 12 Lea Brothers & Co., Philadelphia and New York. GREEN oO pages, with 40 illustrations and 2 plates. Cloth, $2.25, net. Just ready. The best of all the .-mall books to day clinical experience. His great recommend to students and practi- strength is in diagnosis, descriptions tioners. Probably do one of our of Lesions and especially in treat- dermatologists ha- had a wider every- ment. — Indiana Medical Journal. HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE I 8E I >I" SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New lili) edition. In one octavo volume of 623 pages, with 20."> engravings and 11 full-page colored plates. Cloth, $5.00, net. Just ready. It is unique in many respects, and he will become a better diagnosti- the author has introduced radical cian. This is a companion to /Vac- changes which will be welcomed by Heal Therapeutics, by the same all. Anyone who reads this book author, and it is difficult to conceive will become a more acute observer, of any two works of greater practical will pay more attention to the simple utility. — Medical Review. yet indicative signs of disease, and Lea Brothers & Co., Philadelphia and New York. 13 HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Reme- dial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. New (7th) and revised edition. In one octavo volume of 776 pages. Cloth, $3.75, net; leather, $4.50, net. Its classifications are inimitable, it can be readily used in connection and the readiness with which any- with Hare's Practical Diagnosis. thing can be found is the most won- For the needs of the student and derful achievement of the art of in- general practitiouer it has no equal, dexing. This edition takes in all — Medical Sentinel. the latest discovered remedies. — The best planned therapeutic work The St. Louis Clinique. of the century. — American Prac- The great value of the work lies titioner and News. in the fact that precise indications It is a book precisely adapted to for administration are given. A i the needs of the busy practitioner, complete index of diseases and who can rely upon finding exactly remedies makes it an easy reference what he needs. — The National Med- work. It has been arranged so that ical Review. HARE (HOBART AMORY) ON THE MEDICAL COMPLICA- TIONS AND SEQUEL.E OF TYPHOID FEVER. Octavo, 276 pages, 21 engravings and two full-page plates. Just ready. Cloth, $2. to, net. A very valuable production. One read with great profit. — Cleveland of the very best products of Dr. Journal of Medicine. Hare and one that eveiy man can HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- TICAL THERAPEUTICS. In a series of contributions by eminent practitioners. In four large octavo volumes comprising about 4500 pages,with about 550 engravings. Vol. IV., just ready. For sale by sub- scription only. Full prospectus free on application to the Publishers. Regular price, Vol. IV., cloth, $6 ; leather, $7 ; half Russia, $8. Price Vol. IV. to former or new subscribers to complete work, cloth, $5 ; leather, $6 ; half Russia, $7. Complete work, cloth, $20 ; leather, $24 ; half Russia, $28. The great value of Hare's System of Practical Therapeutics has led to a widespread demand for a new volume to represent advances in treatment made since the publication of the first three. More than fulfilling this request the Editor has secured contributions from practically a new corps of equally eminent authors, so that entirely fresh and original matter is ensured. The plan of the work, which proved so successful, has been fol- lowed in this new volume, which will be found to present the latest devel- opments and applications of this most practical branch of the medical art. The entire System is an unrivalled encyclopaedia on the practical parts of medicine, and merits the great success it has won for that reason. 14 Lea Bbothebs & Co., Philadelphia and New Yobk. HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages, with 144 engravings. Cloth, $2.75 . A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25 ; leather, $5. HAYDEN ( JAMES R.). A MANUAL OF VENEREAL DISEASES. New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- gravings. Cloth, $1.50, net. It is practical, concise, definite ticularly thorough, and may be and of sufficient fulness to be satis- relied upon as a guide in the man- factory.— Ch tea go Clinical Review, agement of this class of diseases.— This work gives all of the prac- Northwestern Lancet. tically essential information about It is well written, up to date, and the three venereal diseases, gon- will be found very useful. — Inter- orrboea, the chancroid and syphilis, national Medical Magazine. In diagnosis and treatment it is par- HAYEM GEORGES) AND HARE H. A). PHYSICAL AND NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- tricity, Modifications of Atmospheric Pressure, Climates and Mineral Wate'rs. Edited by Prof. H. A. Hare, M. D. In one octavo volume of 414 pages,with 113 engravings. Cloth, $3. This well-timed up-to-date volume recognition. Within this large is particularlv adapted to the re- range of applicability, physical quirements of the general practi- agencies when compared with drugs tioner. The section on mineral are more direct and simple in their waters is most scientific and prac- results. Medical literature has long tical. Some 200 pages are given up been rich in treatises upon medical to electricity and evidently embody agents, but an authoritative work tin latest scientific information on upon the other gnat branch of the subject. Altogether this work therapeutics has until now been a is the cfearestand most practical aid desideratum. The section on climate, to the studv of nature's therapeutics rewritten by Prof. Hare, will, for that has yet come under our obser the first time, place the abundant vation.— The Medical Fortnightly, resources of our country at the in- For manv diseases the most potent telligent command of American remedies lie outside of the materia practitioners. — The Kansas City medica, a fact yearly receiving wider Medical Index. HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See Student's Series of Manuals, page 27. HERMANN L.i. EXPERIMENTAL PHARMACOLOGY. A Hand- book of the Methods for Determining the Physiological Actions of Drugs. Translated by Rohkrt Mkauk Smith, M. D. In one 12mo. volume of 199 pages, with 32 engraving's. Cloth, $1.50. Lea Brothers & Co., Philadelphia and New York. 15 HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome 12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. Excellently arranged, practical, concise, up-to-date, and eminently well fitted for the use of the prac- titioner as well as of the student. — Chicago Med. Recorder. This volume accomplishes its ob- jects more thoroughly and com- pletely than any similar work yet published. Each section devoted to microscopical examination to be em- ployed in each class. The technique of blood examination, including color analysis, is very clearly stated. Uranalysis receives adequate space and care. — New York Med. Journal. We commend the book not only to the undergraduate, but also to the physician who desires a ready means diseases of special systems is pre- , of refreshing his knowledge of diag ceded with an exposition of the l nosis in the exigencies of professional methods of physical, chemical and life. — Memphis Medical Monthly. HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. HILLIER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition. In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25. HIRST (BARTON C.) AND PBERSOL (GEORGE A.). HUMAN MONSTROSITIES. Magnificent folio, containing 220 pages of text and illustrated with 123 engravings and 39 large photographic plates from nature. In four parts, price each, $5. Limited edition. For sale by subscription only. HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. In one 12mo. volume of 520 double-columned pages. Cloth, $1.50 ; leather, $2. HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN INCLUDING DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50 HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). A MANUAL OF CHEMICAL ANALYSIS, as Applied to the Examination of Medicinal Chemicals and their Preparations. Third edition, entirely rewritten and much enlarged. In one handsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25. HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- ciples and Practice. A new American from the fifth English edition. Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- ume of 1008 4 'pages, with 428 engravings. Cloth, $6 ; leather, $7. A SYSTEM OF SURGERY. With notes and additions by various American authors. Edited by John H. Packard, M. D. In three very handsome 8vo. volumes containing 3137 double-columned pages, with 979 engravings and 13 lithographic plates. Per volume, cloth, $6 ; leather, $7 ; half Russia, $7.50. For sale by subscription only. 16 Lea Beothees & Co., Philadelphia and New Yoek. HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320 engravings. Cloth, $6. HUDSON (A.). LECTURES ON THE STUDY OF FEVER, octavo volume of 308 pages. Cloth, $2.50. In one HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL METHODS. A GUIDE TO THE PRACTICAL STUDY OF MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- ings and 8 colored plates. Cloth, $3.00. A comprehensive, clear and re- medical knowledge which receive markablyup-to-date guide to clinical recognition, we mention Widal's diagnosis. The illustrations are plentiful and excellent. As exam- ples of the more recent additions to test for typhoid and the Neuron theory of the nervous system. — Montreal Medical Journal. HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. See Series of Clinical Manuals, p. 25. HYDE ( JAMES NEVINS). A PRACTICAL TREATISE ON DIS- EASES OF THE SKIN. New (4th) edition, thoroughly revised. In one octavo volume of 815 pages, with 110 engravings and 12 full- page plates, 4 of which are colored. Cloth, $5.25; leather, $6.25. This edition has been carefully re- vised, and every real advance has been recognized. The work answers the needs of the general practitioner, the specialist, and the student. — The Ohio Med. Jour. A treatise of exceptional merit characterized by conscientious care and scientific accuracy. — Buffalo Med. Journal. A complete exposition of our knowledge of cutaneous medicine as it exists to-day. The teaching in- culcated throughout is sound as well as practical. — The American Jour- nal of the Medical Sciences. It is the best one-volume work that we know. The student who gets this book will find it a useful investment, as it will well serve him when he goes into practice. — Vir- ginia Medical Semi-Monthly. A full and thoroughly modern text-book on dermatology. — The Pittsburg Medical Review. It is the most practical hand- book on dermatology with which we are acquainted. — The Chicago Med- ical Recorder. JACKSON (GEORGE THOMAS). THE READY-REFERENCE HANDBOOK OF DISEASES OF THE SKIN. New (3d) edition. In one 12mo. volume of 637 pages, with 75 illustrations and a colored plate. Just ready. Cloth, $2.50, net. h- :i student's manual, it may be considered beyond criticism. The book is singularly full. — St. Lowit \fedical "ml Surgical Journal. Without doubt forms one of the best guides for the beginner in der- matology that is to be found in the English language. — Medicine. JAM1ESON (W. ALLAN). DISEASES OF THE SKIN. Third edition. In one octavo volume of 656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Cloth, $6. Lea Brothers & Co., Philadelphia and New York. 17 JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume of 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25. Just ready. An exceedingly useful manual for ing it in attractive and easily tangi- student and practitioner. The au- ' ble form. The book is well illus- thor has succeeded unusually well trated throughout. — Nashville Jour. in condensing the text and in arrang- of Medicine and Surgery. THE PRACTICE OF OBSTETRICS. By American Authors. One large octavo volume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored plates. Just ready. Cloth, $5.00, net ; leather, $6.00, net. A clear and practical treatise upon I the book abounds. The work is obstetrics by well-known teachers of sure to be popular with medical the subject. A special feature of students, as well as being of extreme this work would seem to be the value to the practitioner. — The excellent illustrations with which | Medical Age. JONES (C. HANDFIELD). CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Second American edi- tion. In one octavo volume of 340 pages. Cloth, $3.25. JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND PRACTICE. Second edition. In one octavo volume of 549 Sages, with 201 engravings, 17 chromo-lithographic plates, test-types of aeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, $5.50 ; leather, $6.50. The volume is particularly rich in color blindness, etc. The sections matter of practical value, such as devoted to treatment are singularly directions for diagnosing, use of j full and concise. — Medical Age. instruments, testing for glasses, for I KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, $2.50. From first to finish it is thoroughly cyclopedias. The well-arranged practical, concise in expression, well index renders the book useful to illustrated, and includes a statement the practitioner who is in haste to of nearly every fact of importance refresh his memory. ■ — Virginia discussed in obstetric treatises or | Medical Semi-Monthly. KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome octavo of 700 pages, with 751 illustrations. Just ready. See American Text-Books of Dentistry, page 2. We have only the highest praise tempted. We can heartily recom- for this valuable work. It is replete mend it to the profession. — The in every particular, and surpasses Ohio Dental Journal. anything of the kind heretofore at- I KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one 12mo. volume of 506 pages, with 296 engravings. Just ready. Cloth, $2.00, net. See Student's Series of Manuals, page 27. It is the most complete and con- This work deservedly occupies a cise work of the kind that has yet first place as a text-book on his- emanated from the press. — The Med- tology. — Canadian Practitioner. ical Age. 18 Lea Brothers & Co., Philadelphia and New York. LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. L New York. 23 PEPPER'S SYSTEM OF MEDICINE. See page 3. PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's Series of Manuals, page 27. SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. PICK (T. PICKERING . FRACTURES AND DISLOCATIONS. In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. See Series of Clinical Manuals, page 25. PliAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Seventh American from the ninth English edition. In one octavo volume of 700 pages, with 207 engravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. Jtist ready. In the numerous editions which obstetrician. It holds a place among have appeared it has been kept con- the ablest English-speaking authori- stantly in the foremost rank. It is ties on the obstetric art. — Buffalo a work which can be conscientiously Medical and Surgical Journal. recommended to the profession. — t An epitome of the science and The Albany Medical Annals. [practice of midwifery, which em- This work must occupy a fore- bodies all recent advances. — The most place in obstetric medicine as Medical Fortnightly. a safe guide to both student and THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- TION AND HYSTERIA. In one 12mo. volume of 97 pages. Cloth, $1. POCKET FORMULARY, see page 32. POCKET TEXT-BOOKS, see page IS. POLITZER ADA»L. A TEXT-BOOK OF THE DISEASES OF THE EAR AND ADJACENT ORGANS. Second American from the third German edition. Translated by Oscar Dodd, M. D., and edited by Sir William Dalby, F. R. C. S. In one octavo volume of 748 pages, with 330 original engravings. Cloth, $5.50. The anatomy and physiology of ment are clear and reliable. We each part of the organ of hearing can confidently recommend it, for it are carefully considered, and then contains all tl>at is known upon the follows an enumeration of the dis- subject. — London Lancet. eases to which that special part of A safe and elaborate guide into the auditory apparatus is especially every part of otology. — American liable. The indications for treat- Journal of the Medical Sciences. POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS AND MENTAL DISEASES. In one handsome 12mo. volume of about 450 pages. Shortly. Lra's S>'ri>s of Pocket Text-books, edited by Berx B. Gallavdet, M. D. See page 18. PROGRESSIVE MEDICINE, see page 32. PURDY (CHARLES W.\ BRIGHT'S DISEASE AND ALLIED AFFECTIONS OF THE KIDNEY. In one octavo volume of 28S pages, with 18 engravings. Cloth, $2. 24 Lea Brothers & Co., Philadelphia and New York. PYE-SMITH (PHILIP H.). DISEASES OF THE SKIN. In one 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. QUIZ SERIES. See Student's Quiz Series, page 27. RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See Student's Series of Manuals, page 27. RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- TICE OF OBSTETRIC MEDICINE AND SURGERY. In one imperial octavo volume of 640 pages, with 64 plates and numerous engravings in the text. Strongly bound in leather, $7. REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. In one handsome octavo volume of about 800 pages, richly illustrated. Preparing. REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- ISTRY. New (5th) edition, thoroughly revised. In one 12mo. vol- ume of 326 pages. Cloth, $2. A clear and concise explanation that the work has met with general of a difficult subject. We cordially favor. This is further established recommend it. — The London Lancet, by the fact that it has been trans- The book is equally adapted to the lated into German and Italian. The student of chemistry or the practi- treatise is especially adapted to the tioner who desires to broaden his laboratory student. It ranks unusu- theoretical knowledge of chemistry, ally high among the works of this — New Orleans Med. and Surg. Jour, class. This edition has been brought The appearance of a fifth edition fully up to the times.— Amer lean of this treatise is in itself a guarantee Medico-Surgical Bulletin. RICHARDSON (BENJAMIN WARD). PREVENTIVE MED1 CINE. In one octavo volume of 729 pages. Cloth, $4 ; leather, $5. ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. New (2d) edition. In one octavo volume of 838 pages with 473 engravings and 8 plates. Just ready. Oloth, >4.l'~>. net; leather, $5.25, net. THE COMPEND OF ANATOMY. For use in the Dissecting Room and in preparing for Examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth American from the fourth London edition. In one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. See Student's Series of Manuals, page 27. ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS SYSTEM. In one handsome octavo volume of 726 pagee, with 184 engravings. Cloth, $4.50 ; leather, $5.50. SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, with 18 typical engravings. Cloth, $2. See Series of Clinical Man- ual*, page 25. Lea Brothers & C!o., Philadelphia and New York. 26 SOHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- OGY, DESCRIPTIVE AND PRACTICAL. For the use of Students. New (5th) edition. In one handsome octavo volume of 359 pages, with 392 illustrations. Cloth, $3.00, net. Just ready. The most satisfactory elementary text-book of histology in the Eng- lish language. — The Boston Med. and Sur. Jour. Nowhere else will the same very moderate outlay secure as thoroughly useful and interesting an atlas of structural anatomy. — The American Journal of the Medical Sciences. A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, PRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo., 352 pages. Cloth, $1.50, net; flexible red leather, $2.00, net. Just ready. Lea's Series of Pocket Text-books. Edited by BERN K. Gallaudet, M. D. See page 18. SCHMITZ AND ZUMPT'S CLASSICAL. SERIES. Advanced Latin Exercises. Cloth, 60 cts. Schmidt's Elementary Latin Exer- cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 cents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents. SCHOFLELD (ALFRED T.). ELEMENTARY PHYSIOLOGY FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 engravings and 2 colored plates. Cloth, $2. SCHRELBER (JOSEPH). A MANUAL OF TREATMENT BY MASSAGE AND METHODICAL MUSCLE EXERCISE. Octavo volume of 274 pages, with 117 engravings. SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- tion. In one octavo volume of 268 pages, with 13 plates, 10 of which are colored, and 9 engravings. Cloth, $2. SERIES OF CLINICAL MANUALS. A Series of Authoritative Monographs on Important Clinical Subjects, in 12mo. volumes of about 550 pages, well illustrated. The following volumes are now ready : Yeo on Food in Health and Disease, new (2d) edition, $2.50; Carter and Frost's Ophthalmic Surgery, $2.25 ; Hutchinson on Syphilis, $2.25; Marsh on Diseases of the Joints, $2; Owen on SurgicalDis- eases of Children, $2; Pick on Fractures and Dislocations, $2; Savage on Insanity and Allied Neuroses, $2. For separate notices, see under various authors' names. SERIES OF STUDENT'S MANUALS. See page 27. SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- SCOPICAL AND CHEMICAL METHODS. New (2d) edition. In one very handsome octavo volume of 530 pages, with 135 engravings and 14 full-page colored plates. Cloth, $3.50. Just ready. This book thoroughly deserves its I In all respects entirely up to date, success. It is a very complete, authen- 1 — Medical Record. tic and useful manual of the micro- I The chapter on examination or scopical and chemical methods the urine is the most complete and which are employed in diagnosis, advanced that we know of in the Very excellent colored plates illus- English language. — Canadian Prac- trate this work. — New York Medical tilioner. Journal. 26 Lea Brothers & Co., Philadelphia and New York. SIMON (TV.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory Work for Beginners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. New (6th) edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 plates showing colors of 64 tests. Cloth, $3.00, net. Just ready. It is difficult to see how a better the covers of this book. — The North- book could be constructed. No man western Lancet. who devotes himself to the practice Its statements are all clear and its of medicine need know more about teachings are practical. — Virginia chemistry than is contained between Jled. Monthly. SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. SMITH (EDWARD). CONSUMPTION; ITS EARLY AND REME- DIABLE STAGES. In one 8vo. volume of 253 pp. Cloth, $2.25. SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- FANCY AND CHILDHOOD. Eighth edition, thoroughly revised and rewritten and much enlarged. In one large 8vo. volume of 983 {(ages, with 273 engravings and 4 full-page plates. Cloth, $4.50; eather, $5.50. A safe guide for students and phy- The most complete and satisfac- sicians. — The Am. Jour, of Obstetrics, j tory text-book with which we are For years the leading text-book on j acquainted. — American Gynecologi- children's diseases in America. — \ cal and Obstetrical Journal. Chicago Medical Recorder. SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- oughly revised edition. In one octavo volume of 892 pages, with 1005 engravings. Cloth, $4 ; leather, $5. One of the most satisfactory works dium for the modern surgeon. — Bos- on modern operative surgery yet I ton Medical and Surgical Journal. published. The book is a compen- | SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- TOLOGY. In one handsome octavo volume of 462 pages, with en- gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. Just ready. A clear and lucid summary of an accurate observer and practical what ifr known of climate in relation therapeutist. — Maryland Med. Jour. to its influence upon human beings. Every practitioner of medicine — The Therapeutic Gazette. should possess himself of a copy and The book is admirably planned, study it, and we are sure he will clearly written,and the author speaks never regret it. — St. Louis Medical from an experience of thirty years as and Surgical Journal. 8TILLE ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- MENT. In one 12mo. volume of 163 pages, with a chart showing routes of previous epidemics. Cloth, $1.25. THERAPEUTICS AND MATERIA MEDICA. Fourth and revised edition. In two octavo volumes, containing 1936 pages. Cloth, $10; leather, $12. Lea Brotheks A Co., Philadelphia and New York. 27 STILiLJE (ALFRED), MAISCH (JOHN M.) AND CASPAR! (CHAS. JR.). THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the latest Pharmacopoeias of the United States, Great Britain and Germany, with numerous refer- ences to the French Codex. Fifth edition, revised and enlarged, including the new U. S. Pharmacopoeia, Seventh Decennial Revision. With Supplement containing the new edition of the National Formu- lary. In one magnificent imperial octavo volume of about 2025 pages, with 320 engravings. Cloth, $7.25; leather, $8. With ready reference Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 engravings. Cloth, $3.75. A useful and practical guide for all students and practitioners. — Am. Journal of the 3Iedical Sciences. The book is worth the price for the illustrations alone. — Ohio 31edical Journal. STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND DISLOCATIONS. In one handsome octavo volume of 831 pages, with 326 engravings and 20 plates. Cloth, $5.00, net; leather, $6.00, net. Preeminently the authoritative I Taken as a whole, the work is the text-book upon the subject. The \ best one in English to-day. — St. vast experience of the author gives : Louis Medical and Surgical Journal. to his conclusions an unimpeachable | Pointed, practical, comprehensive, value. The work is profusely il- exhaustive, authoritative, well writ- lustrated. It will be found indis- j ten and well arranged. — Denver pensable to the student and the prac- Medical Times. titioner alike. — The Medical Age. STUDENT'S QUIZ SERD3S. Thirteen volumes, convenient, author- itative, well illustrated, handsomely bound in cloth. 1. Anatomy (double number); 2. Physiology; 3. Chemistry and Physics ; 4. Histol- ogy, Pathology, and Bacteriology; 5. Materia Medica and Thera- peutics ; 6. Practice of Medicine ; 7. Surgery (double number); 8. Genito- urinary and Venereal Diseases; 9. Diseases of the Skin; 10. Diseases of the Eye, Ear, Throat and Nose; 11. Obstetrics; 12. Gynecology; 13. Diseases of Children. Price, $1 each, except Nos. 1 and 7, Anatomy and Surgery, which being double numbers are priced at $1.75 each. Full specimen circular on application to publishers. STUDENT'S SERIES OF MANUALS. 12mos. of from 300-540 pages, profusely illustrated, and bound in red limp cloth. Herman's First Lines in Midwifery, $1.25; Luff's Manual of Chemistry, $2; Bruce's Materia Medica and Therapeutics (sixth edition), $1.50. net. Bell's Comparative Anatomy and Physiology, $2 ; Robert- son's Physiological Physics, $2; Gould's Surgical Diagnosis, $2; Klein's Elements of Histology (5tb edition), $2.00, net ; Pepper's Surgical Pathology, $2 ; Treves' Surgical Applied Anatomy, $2 ; Ralfe's Clinical Chemistry, $1.50; and Clarke and Lockwood's Dissector's Manual, $1.50. The following is in press : Pepper's Forensic Medicine. For separate notices, see under various author's name*. 28 Lea Brothers A Co., Philadelphia and New York. STURGES (OCTAVITJS). AN INTRODUCTION TO THE STUDY OF CLINICAL MEDICINE. In one 12mo. volume. Cloth, $1.25. SUTTON (JOHN BLAND). SURGICAL DISEASES OF THE OVARIES AND FALLOPIAN TUBES. Including Abdominal Pregnancy. In one 12mo. volume of 513 pages, with 119 engravings and 5 colored plates. Cloth, $3. TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL SURGERY. Vol. I. contains 546 pages and 3 plates. Cloth, $3. TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- EASES OF PREGNANCY. From the second English edition. In one octavo volume of 490 pages, with 4 colored plates and 16 engrav- ings. Cloth, $4.25 TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New American from the twelfth English edition, specially revised by Clark Bell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54 engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Just ready. To the student, as to the physician, I nesses, it strongly behooves them to we would say, get Taylor first, and then add as means and inclination enable you. — American Practitioner and News. It is the authority accepted as final by the courts of all English- speaking countries. This is the im- portant consideration for medical men, since in the event of their being summoned as experts or wit- be prepared according to the princi- ples and practice everywhere ac- cepted. The work will be found to be thorough, authoritative and modern. — Albany Law Journal. Probably the best work on the subject written in the English lan- guage. The work has been thor- oughly revised and is up to date. — Pacific Medical Journal. ON POISONS IN RELATION TO MEDICINE AND MEDI- CAL JURISPRUDENCE. Third American from the third London edition. In one octavo volume of 788 pages, with 104 illustrations. Cloth, $5.50 ; leather, $6.50. TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- MENT OF VENEREAL DISEASES. In one very handsome octavo volume of 1002 pages, with 230 engravings and 8 colored plates. < loth, $6.00, net; leather, $6.00, net. By Lone odds the best work on venereal diseases. — Louisville Medi- I'd \fonthly. In the observation and treatment of venereal diseases his experience has been greater probably than that of any Other practitioner of this con- tin >• 1 1 1, . - Ne w Yo rk Medicu I Journal. The clearest, most unbiased and ably presentee! in-atise as yet pub- lished on this vast subject. — The \fecttcal News. Droved methods of adminktering remedial agents. Strongly bound in lather ; with pocket and pencil. Price, $1.50, net. COMBINATION RATES: } $7 - 50 l $15.00 American Journal of the Alone. In Combination. Medical Sciences, .... $ 4.00 Medical News 4.00 Progressive Medicine .... 10.00 Medical News Visiting List . . . 1.25 Medical News Formulary . . . 1.50 net, In all #20.75 for $16.00 First four above publications in combination . . $15.75 All above publications in combination .... 16. OO Other Combinations will be quoted on request. Full Circulars and Specimens free. LEA BROTHERS & CO., Publishers, 706, 708 & 710 Sansom St., Philadelphia. Ill Fifth Avenue, New York. - J>^t. ***&*. ALi,--— y MAR 2 3 1365 H/b^ n ,o. 5L J-l A manual of oopratiup ainun, 2002109263