HX64054438 RD32 ESS Surgical technic; a Columtiia ^nibergitp Course of ^ijpsiicians; anb ^urgeonfi ^titxtntt ILitirarp SURGICAL TECHNIC :V>^° SURGICAL TECHNIC H Crxt^troofe on OPERATIVE SURGERY BY FR. VON ESMARCH, M.D. Professor of Surgery at the University of Kiel, and Surgeon-General of the German Army AND E. KOWALZIG, M.D. Late First Assistant at the Surgical Clinic of the Universit\' of Kiel TRANSLATED BY PROFESSOR LUDWIG H. GRAU, Ph.D. Formerly of Leland Stanford Junior University- AND WILLIAM N. SULLIVAN, M.D. Formerly Surgeon of U.S.S. "Corwin" Assistant of the Surgical Clinic at Cooper Medical College, San Francisco EDITED BY NICHOLAS SENN, M.D. Professor of Surgery at Rush Medical College, Chicago '■'■ Kurz unci Bii II dig'" WITH FOURTEEN HUNDRED AND NINETY-SEVEN ILLUSTRATIONS AND FIFTEEN COLORED PLATES THE MACMILLAN COMPANY LONDON: MACMILLAN & CO., Ltd. I9OI All rights reserved Copyright, 1901, By the MACMILLAN COMPANY. XortoooB IBxcss J. 8. Cuehin? a Co. — Berwick & Smith Norwood Mats. U.S.A. SUMMARY OF THE PREFACES OF THE FIRST FIVE GERMAN EDITIONS For promoting the interests of humanity in times of peace under the symbol of the Red Cross, p!rr iHajrst^ tijc ^rrman Empress, on the occasion of the Vienna World's Exhibition, offered two prizes, one of them to be awarded for the best Handbook of Surgical Technic. The regulations of competition were the following : " The book should present in as concise and intelligible a form as possible the various methods of bandaging and dressing, as well as all surgical operations ; but above all it should comprise the present advanced status of Surgical Technic, in order to become the indispensable Guide Book and practical compan- ion of every surgeon." The jury selected to award the prize consisted of Professor B. von Lan- genbeck in Berlin, Professor Billroth in Vienna, and Professor Socin in Basle. Unanimously they awarded the first prize to the author of this Surgical Technic. The author strictly fulfilled the requirements of the competition, but at the same time he purposed to make this handbook a practical aid to memory. In his opinion this could be better accomplished by illustrations than by a cumbersome text. A glance at an illustration representing a dressing, an operation, or an anatomical preparation, enables one to recall to memory most rapidly all former knowledge concerning the same. Hence the book contains manv illustrations and as concise a text as vi AUTHOR'S PREFACE possible. The author of course endeavored to iijcorporate all the extraor- dinary progress which Surgery, and especially Surgical Technic, has made during recent years. At the end of the work three indexes of names, subject-matter, and illustrations will largely facilitate the use of this book. FRIEDRICH VON ESMARCH. Skptembek 3, 1900. PREFACE OF THE AMERICAN EDITOR Professor von Esmarch, the senior author of this book, needs no introduction to the medical profession of this country. His name and fame are familiar to every educated physician. As an author and teacher he has few equals. During the last few years he has been ably assisted in his literary work by his former first assistant, Dr. Kowalzig. It was a happy idea when the publishers decided to present the English reading profession with a translation of the great works of Professor von Esmarch in one volume. The translator had a difficult task. The motto, " Kurz und biindig," characterizes the text. No superfluity of words, the language is concise and precise. If there are any shortcomings in the translation, it is an attempt on part of the translator to reproduce the language of the authors as faithfully and as accurately as possible. The great feature of this book are the numerous excellent illustrations which embellish the text and which enable the reader to follow with his eyes every step of all minor and major operations. The American editor has added notes which appear in brackets in places where he deemed it necessary to add to the text or to indicate his own views or methods of practice. N. SENN. Chicago, 1901. TRANSLATOR'S PREFACE The translator believes he is rendering an important service to Ameri- can and English surgeons in presenting an English translation of von Esmarch's " Surgical Technic." Its excellence is acknowledged by all European surgeons, and now that it has received the careful revision and valuable notes from the hands of its learned editor, it may confidently be regarded as the best handbook on the subject of Surgical Technic in the English language. L. H. GRAU. San Fran'CISco, May, 1901. TABLE OF CONTENTS The Treatment of Wounds . , . PAGE Asepsis ......... Preparations for Aseptic Operations and Dressings 2 Purifying the Operating Room Asepsis of the Surgeon and his Assistants Sterihzation of Instruments Sterilization of Sutures and Ligatures Sterihzation of Sea and Gauze Sponges Disinfection of the Patient . 13 Sterilization of the Dressing Materials j^ Aseptic Operations ... o Antisepsis ....... Antiseptic Solutions . . •••••••.. 23 Antiseptic Powders The Drying a7id the Draining of the Wound Dressings of the Wound Changing the Dressings The Position of the Patient The Position of the Patient in Bed Secondary Antisepsis Permanent Antiseptic Irrigation . . . ■ The Antiphlogistic Treatmejit " * 61 Open Treatment of Wounds gg Bandaging Bandages ....... /-o Bandages for the Head Bandages for the Arm ' . Bandages for the Trunk * * o Bandages for the Leg ' c Cloth Bandages ....... o Bandages for the Head _ _ ' ?,c Bandages for the Arm o Bandages for the Trunk .' ' " 8q Bandages for the Leg * So Splints ••..... Wooden Splints Sheet Zinc Splints '.'.''" loi Wire Splints . . Glass Splints ^ 105 TABLE OF CONTENTS Pasteboard Splints Plastic Splints Plastic Dressings Starch Dressing . Potash Silicate Dressing Plaster of Paris Dressing Application of Plaster of Paris Dressing Removable Plaster of Paris Dressing Strengthening Plaster of Paris Dressing Fenestrated Plaster of Paris Dressing Interrupted Plaster of Paris Dressing Plaster of Paris Suspension Splints . Position Dressings Extension Dressings . Extension by Weights Elastic Extension and by Adhesive Plaster Temporary Dressings Temporary Splints Antisepsis in War The Soldier's Antiseptic Dressing Package PAGE 1 06 no no III 112 "3 117 119 121 126 127 133 138 146 147 •53 159 160 168 170 Narcosis General Anesthesia ...... Chloroform Antcsthesia .... Course of Chloroform .An.^sthesia . Awakening from Chloroform Aneesthesia Unpleasant Occurrences after Anesthesia Unpleasant Accidents during Anaesthesia Action of Surgeon during Serious Accidents Ether Anasthesia .... Methods of Ether Anesthesia Course of Ether Anesthesia Danger from Ether Anesthesia Awakening from Ether Anesthesia . Combined Anesthesias Other Anesthetics . Local Ancesthesia (Analgesia) Regionary Analgesia Infiltration Analgesia 172 172 176 178 179 179 182 188 188 190 191 192 192 194 195 Si.MPLE Operations Incision ................. 197 Puncture ................. 201 Tissue Destruction ............... 203 Union of Margins of the Wound ............ 209 Suture ................ 209 Removal of Foreign Bodies ............ 218 Removal of Bullets 219 TABLE OF CONTENTS xi Operations for Prevention and Arrest of Hemorrhages and their Consequences PAGE Saving of Blood ............... 224 Bloodless Method .............. 225 Compression of Main Trunk of the Artery . . . . . . . . - . . 235 By Pressure of the P'inger (Digital Compression) ........ 235 By Artery Compressors or Tourniquets .......... 236 Improvised Artery Compressors ............ 240 Arresting Hetnorrhages in the Wound ........... 242 Compression of Wound .............. 242 Medicinal Hemostatics (Styptics) ........... 243 Ligation of Vessels (Ligature) ............ 243 Hemorrhage from Punctured and Gunshot Wounds ........ 247 Ligation of Arteries at the Place of Selection . . . . . . . . . .251 General Rules ............... 251 Ligation of Principal Trunks of Arteries .......... 254 Ligation of Common Carotid Artery ........... 256 External Carotid Artery ............. 257 Internal Carotid Artery ............. 258 Lingual Artery ............... 259 Subclavian Artery .............. 260 Vertebral Artery .............. 262 Axillary Artery ............... 263 Brachial Artery ................ 264 Radial Artery ............... 266 Ulnar Artery ............... 266 Superficial Palmar Arch ............. 267 Abdominal Aorta . 268-269 Common and Internal Iliac Arteries ........... 270 Superior Gluteal Artery . . . . . . . . . . . . .271 Sciatic Artery ............... 271 External Iliac Artery .............. 272 Femoral Artery ............... 272 Popliteal Artery ............... 274 Anterior Tibial Artery ............. 275 Posterior Tibial Artery ............. 276 Transftisio7i and Infusion ............. 277 Bleeding ................. 282 Venesection ............... 282 Operation for Aneurisftis .............. 283 Ligation of Artery 285 Operation for Varices .............. 287 Ligation for Long Saphenous Vein ........... 288 Extirpation of Varices 288 Injuries of Walls of Blood Vessels 289 Operations on Tendons Tenotomy ................. 290 Tenotomy of the Tendo Achillis 291 xu TABLE OF CONTENTS PAGE Tendinorrhaphy ............... 292 Tendinoplasty 295 Operations on Nerves Neurorrhaphy ................ 296 Neuroplasty ................ 297 Operations on Skin .Skin Grafting (Transplantation) ............ 298 Skin Grafting according to Thiersch ..... ..o ... . 299 Plastic Operations .............. 301 Operations on Nails ............... 302 Operations on Bones Osteoclasis ..... Osteotomy ...... Subtrochanteric Osteotomy Supracondylic Osteotomy of the Femur .Supramalleolar Osteotomy . Direct Fixation of Bone Fragments . Necrotomy ..... Osteoplastic Necrotomy Amputations and Disarticulation Indications ...... General Rules ...... Preparations ..... Division of Soft Parts Circular Amputation (by One Incision) Circular Amputation (by Two Incisions) Amputation by forming Skin Flaps Muscular Flaps . Oval Incision Sawing off Bones Union of Wound General Rules for Disarticulation Reamputation Protheses .... 305 307 308 308 309 309 312 315 316 3'7 3'7 3'8 3>S 320 324 325 326 326 331 334 Amputation and Disarticulation of Upper Exiremities Disarticulation of Fingers .............. 336 Disarticulation of Third Phalanx 336 Disarticulation of Second Phalanx 336 Disarticulation at Metacarpophalangeal Joint 337 Disarticulation of All Fingers 339 Disarticulation of Thumb at Carpal Joint 340 TABLE OF CONTENTS xiii PAGE Oval Incision ............... 340 Lateral Plap Incision according to von Walther ......... 341 Disarticulation of Last Four Metacarpal Bones 341 Disarticulation of Wrist .............. 342 Circular Incision . 342 Flap Incision ............... 343 Radial Flap Incision .............. 344 Amputation of Forearm .............. 344 Disarticulation of Elbow Joint ............. 346 Circular Incision .............. 346 Flap Incision ............... 347 Oblique Incision .............. 347 Amputation of Arm ............... 348 Disarticulation of Arm at Shoulder Joint 350 Flap Incision ............... 350 Circular Incision . . . . . . . . . . . . . . 352 Oval Incision ............*... 353 Amputations and Disarticulations of Lower Extremities Disarticulation of Toes .............. 354 In the Phalangometatarsal Joint ............ 354 Amputation of all Metatarsal Bones ............ 355 Disarticulation of Great Toe together with its Metatarsal Bone ....... 355 Disarticulation of Fifth Toe with its Metatarsal Bone ........ 356 Lisfranc's Disarticulation in Tarso-Metatarsal Articulations ... .... 357 ChoparCs Disarticulation at Tarsus . . . . . . . . . . • , . 359 Malgaigne' s Disarticulation of Foot below Astragalus ........ 362 Syme^s Disarticulation of Foot ............. 364 Pirogoff's Disarticulation of Foot ............ 367 Giiniher^s Modification of Pirogoff's Amputation ......... 368 Le Fort and von EsniarcKs Modification of Pirogoff's Amputation ...... 370 Amputation of Leg ............... 372 Bier^s Osteoplastic Amputation ............. 374 Disarticulation of Leg at Knee Joint ............ 377 Circular Incision .............. 377 Flap Incision ............... 378 Oblique Incision .............. 379 GrittVs and Others' Osteoplastic Amputation ......;.. 380 Amputation of Thigh .............. 380 Disarticulation of Thigh .............. 383 By an Anterior Large and a Posterior Small Flap ........ 383 Transfixion, Manec's Puncture Method .......... 383 VeiscJi's Circular Method . . ............ 386 Resection of Joints Indications ................ 389 General Rules for Resections 390 xiv TABLE OF CONTENTS Resection of Upper Extremities PAGE Resection of Fingers 394 Resection of Lower Articular Ends of Radius and Ulna ........ 395 Total Resection of Wrist .............. 399 By V071 Langenl'eck's Dorsal Radial Incision ......... 399 By Kocher's Dorso-Ulnar Incision ........... 401 Resection of Elbow Joint .............. 403 By Listoii's T Incision ............. 403 By von Laugenbeck's Simple Longitudinal Incision ........ 40^ By Hueterh Bilateral Longitudinal Incision ......... 406 By Ollier's Bayonet Incision ............ 407 By Nelatoti's Angular Incision ............ 408 By Kocher's Hook-shaped Incision ........... 408 Resection of Olecranon .............. 409 Resection of Shoulder Joint . . . . . . . . . . . . .411 By Z'(?w Za«^^«i^^(:-^'j Longitudinal Incision . . . . . . . . .411 By von Langenbeck' s .'\nterior Longitudinal Incision (Old Method) . . . . -413 By C//z>r'j Anterior Oblique Incision. .......... 415 By Kocher''s Posterior Curved Incision . . . . . . . . . .415 Resection of Articular Surface and Neck of Scapula {von Esiiian/i) ...... 417 Resection of Scapula By von Langenbeck' s Angular Incision „ . . . . . . . . .418 By Ollier's Subperiosteal Resection . . . . . . . . . . .418 Partial Resection of Scapula . . . . . . . . . . . . .419 Resection of Clavicle ............... 419 Resection of Lower Extremities Resection of Articulations of the Toes ........... 420 Peterson's Resection of Articulation of the Great Toe ........ 420 Resection of Ankle Joint .............. 421 By von Langenbeck' s Bilateral Incision . . . . . . . . . .421 By Konig's Bilateral Incision ............ 425 By Kocher's External Lateral Transverse Incision ........ 426 By Girard's External Oblique Incision .......... 427 By Lauenstein's Curved Incision ........... 428 By Hueter's Anterior Transverse Incision .......... 428 Resection of Astragalus .............. 428 By Vbgt's Anterior Longitudinal Incision .......... 428 Resection of Os Calcis .............. 429 By Ollier's External Angular Incision .......... 429 By Guerin's Spur Incision ............. 430 By Kocher's Angular Incision . . . . . . . . . . . .4^0 Tarsectomy ••••............ 430 Resection of Remaining Tarsal Bones .......... 430 Osteoplastic Resection at the Tarsus, according to yl/?Vi//zV3- ^F/«a'm/;-(7^ . . . .431 Operations for Clubfoot •••........... 433 Operations for Flatfoot 434. TABLE OF CONTENTS xv PAGE Resection of Knee Joint 435 By Textor's Anterior Curved Incision 435 By Hahji's Curved Incision ............ 439 By von Volkmann'' s Transverse Incision .......... 440 By von Langetibeck' s Curved Lateral Incision ......... 440 By Hueter^s Internal Longitudinal Incision ......... 442 By Kocher's External Curved Incision .......... 443 Puncture of Knee Joint .............. 444 Drainage of Knee Joint .............. 444 Resection of Hip Joint .............. 445 By A. Wkiiis Posterior Curved Incision 445 By V071 Langenbeck' s External Longitudinal Incision ........ 446 By Kocher^s Posterior Longitudinal Incision ......... 449 By Lilcke-Schede's Anterior Longitudinal Incision ........ 450 By Hueter's Anterior Oblique Incision . . . . . . . . . -451 By Oilier^ s Resection of the Trochanter .......... 452 Arthrotomy for Congenital Dislocation of Hip Joint ......... 453 Resection of Ilium 454 Operations on the Head Resection of the Vault of the Cranium . . . •' . . . . . . . 455 Trephining ................ 457 Craniectomy ............... 461 Osteoplastic Resection of the Skull ........... 463 Cerebral Topography .............. 465 Opening of the Skull at the Base of the Squamous Portion of the Temporal Bone . . 468 Exploratory Perforation of the Skull ........... 469 Lumbar Puncture .............. 470 Ligation of the Middle Meningeal Artery .......... 470 Opening of the Mastoid Process ............ 473 Opening of the Lateral Chambers of Antrum ......... 474 Opening of the Frontal Sinus ............ 475 Resection of the Maxilla .............. 476 Resection of the Alveolar Process ........... 476 Resection of the Whole Upper Jaw ........... 477 Resection of Both Upper Jaws ............ 481 Osteoplastic Resection of the Upper Jaw .......... 482 Osteoplastic Resection of Both Upper Jaws ......... 483 Opening of the Antrum of Highmore . . . . . . . . . . . 485 Resection of the Lower Jaiv ............. 487 Resection of the Alveolar Process 487 Resection of One-half of the Lower Jaw .......... 487 Resection of the Maxillary Arch 489 Resection of the Articulation of the Lower Jaw 491 Resection in Ankylosis ............. 491 Subperiosteal Resection of the Lower Jaw 492 xvi TABLE OF CONTENTS PAGE AWve Stretching and Nerve Resection 493 Supraorbital Nerve 494 Supramaxillary Nerve 49^ With Temporary Resection of the Malar Bone 49^ Inframaxillary Nerve 499 Retrobuccal Method 5^2 Temporary Resection of the Lower Jaw 5°^ Temporary Resection of the Zygomatic Arch 504 Lingual Nerve 5°" Mental Nerve 5o6 Intracranial Resection of the Ganglion CJasseri 5^7 Facial Nerve 5^9 Nervus Accessorius Willisii (Spinal Accessory Nerve) 510 Brachial Plexus 5" Crural Nerve 5" Sciatic Nerve 5^2 Popliteal Nerve 5^3 Plastic Operations on the Face 5 '4 Blepharoplasty (Plastic Surgery of the Eyelids) 514 Cheiloplasty (Plastic Surgery of the Lips) 517 Stomatoplasty (Plastic Surgery of the Mouth) 526 Meloplasty (Plastic Surgery of the Cheeks) 5^7 Rhinoplasty (Plastic Surgery of the Nose) 53° Total Rhinoplasty 53° Partial Rhinoplasty 539 Correction of Saddle or Collapsed Noses 54' Plastic Operations fur Congenital Fissure Formations of the Oral Region Harehp and Maxillary Fissure . " 544 Single Cleft of Lip (Harelip) 544 Double Harelip 54^ Double Harelip and Maxillary Fissure 54^ Single Harelip and Cleft Palate . . , 55° Cleft Palate 55^ Staphylorrhaphy (Closing Cleft of Soft Palate) 551 Uranoplasty (Closing Cleft of Hard Palate) 555 Palatal Protheses, Obturators 55^ Oi'kkations involving the Facial Cavities In the Orbit 5^1 Extirpation of the Eyeball 5^2 Enucleation of the Eyeball ......••••••• 5"^ Exenteration of the Bulb .........•.•• 5^3 In the Ear 5^3 Foreign Bodies in the External Auditory Meatus 5^3 TABLE OF CONTEXTS xvii PAGE In the Xares -c.. Inspection of Xares •■•.......,.. -5- Tamponing the X'ares ,55 Removal of X'asal and X'asopharyngeal Polypi -5j; Removal of Mucoid Polypi _ ,gg Removal of X^'asopharyngeal (Fibrous) Polypi -yi Division of the N^ose in the Median Line rjz Resection of X'asal Process of the Upper Jaw -y2 Temporary Detachment of the N'ose ---, Turning X'ose upward -_ . Adenoid Vegetations in X'asopharyngeal Cavity ^yy Contraction of X'ostrils ... --^ Deviation (Scoliosis) of the Septum of the X'ose -go Subperichondrial Resection of the Septum (Petersen) ego In the Oral Cavity .gj For Inspecting the Cavity of the Mouth rgj Extraction of Teeth •••......... rg. Acquired Defects of the Palate rgo Tonsillotomv ..... -^t Extirpation of Tonsils ......" cq. Amputation of the Uvula ........... co- operations on the Tongue , cn- Excision of a Wedge-shaped Portion from the Tip of the Tongue :g- Amputation of the Tongue -gg Temporary Lateral Resection of the Lower Jaw 600 Temporary Resection of the Lower Jaw in the Median Line 602 Operation for Ranula 504. Extirpation of the Parotid go- Extirpation of the Submaxillary Gland go- Salivary Fistula gQ_ Subhyoid Phar}-ngotomy go8 Lateral Pharyngectomy gjo Retropharyngeal Abscesses gjo OPEK.A.TIOXS ox THE X'eck Opetiing of the Air Passages, Bronchotomy gj, Laryngotomy gj2 Median Thyrotomy gj2 Transverse Thyrotomy gj . Infrathyroid Laryngotomy gj . Subhyoid Laryngotomy gjc Tracheotomy •••........ gi- High Tracheotomy gjg Intubation gj Inferior Tracheotomy g2o Tamponade of the Trachea g2o Extirpation of Larynx g2j xvni TABLE OF CONTENTS Operations for Goitre {^Struma) Parenchymatous Injection . Puncture with Subsequent Injection Incision with Suturing Cyst Wall to Sl> Extirpation of Struma Resection of Goitre Enucleation of Goitre . Ligation of Arteries . Palliative Operations . Ligation of the Isthmus of the Thyroid Gland Operations on the (Esophagus Introduction of the Oesophageal Tube Foreign Bodies in the (E^sophagus Strictures of the CEsophagus . External (Esophagotomy Oesophageal Diverticula . Tenotomy of the Sternocleidomastoid Extirpation of Sternocleidomastoid Operations for Cervical Ttimors PAGE 625 625 625 626 626 630 631 631 633 633 635 635 637 639 640 644 644 646 646 Operations on the Breast Ligation of the Innominate Artery Ligation of the Internal Mammary Artery Resection of the Manubrium Sterni Resection of the Ribs Opening of the Thoracic Cavity Thoracocentesis . Puncture with Aspiration Thoracotomy Pneumotomy Pericardiotomy . Operations on the Mammary Gland Incision of the Mammary Gland Extirpation of the Mammary Gland Amputation of the Breast with Clearing out of the Axilla 651 652 653 655 657 657 659 661 664 666 666 666 666 667 Operations on the Abdomen Opening Abdominal Cavity by Puncture ........... 672 Laparotomy (Coeliotomy) .......... .... 673 Laparotomy for Ileus .............. 676 Operations on the Stomach and the Intestines 678 Gastrotomy 678 Gastrorrhaphy ............... 679 Gastrostomy ............... 680 By Establishing an Oblique Fistula 682 TABLE OF CONTENTS xix PAGE Resection of the Pylorus 685 Gastro-enterostomy . . . . . . . . . . . . . . 690 Pyloroplasty ............... 696 Enterotomy ............... 697 Enterostomy (Colostomy) ............. 697 Formation of an Artificial Anus ............ 699 Enterorrhaphy ............... 702 Resection of the Intestine ............. 706 Enteroanastomosis .............. 708 Local Exclusion of Diseased Intestine .......... 710 Resection of the Vermiform Appendix . . . . . . . . . • 711 Anus Pr?eternaturalis .............. 712 Operations for Hernia . . . . . . . . . . . . . .714 Taxis ................. 717 Herniotomy ............. . . 718 Radical Operation for Hernia ............ 722 For Inguinal Hernia ............. 722 For Femoral Hernia ............. 730 For Umbilical Hernia , . . . . . . . . . . . -731 Operations on the Liver and the Gall Bladder .......... 732 Operation for Echinococcus of the Liver .......... 732 Cholecystotomy ............... 733 Cholecystostomy ............... 734 Cholecystectomy ............... 735 Choledochotomy ............... 736 Operations on the Spleen .............. 738 Splenectomy ............... 738 Splenopexy ................ 739 Operations on the Kidney .............. 740 Nephrotomy ................ 740 Nephrectomy ............... 740 Nephropexy ............... 745 Ureterotomy ............... 746 Operations on the Pelvis Operations on the Urethra and the Bladder . . . . . . . . . . 747 Calheterism ............... 747 Stricture of the Urethra ............. 754 Internal Urethrotomy. ............. 759 External Urethrotomy .......'...... 761 L^rethroplasty ............... 764 Foreign Bodies in the Urethra and the Bladder 766 Suprapubic Puncture of the Bladder 768 Suprapubic Cystotomy ............. 770 Subpubic Cystotomy .............. 776 Extirpation of Urinary Bladder 776 Perineal Cystotomy .............. 777 XX TABLE OF CONTENTS Prostatotomy Lateral Prostatectomy Galvanocaustic Excision of the Prostate Gland Lithotripsy . Litholapaxy Opej'ations for Congenital Cleft Formation of the Anterior In Ectopia Vesicae (Cystoplasty) Epispadias ...... Hypospadias ..... Operations on the Penis and the Scrotum . Operation for Phimosis Operation for Paraphimosis Amputation of the Penis Operations for Hydrocele Testis . Operation for Varicocele Castration ...... Resection of the Vas Deferens . Operations on the Rectum and the Anus Examination of the Rectum Proctoplasty ..... Strictures of the Rectum Strictures of the Anus Operations for Rectal Fistula Prolapsus Recti ..... Resection of the Prolapse of the Rectum Operation for Hemorrhoids Operation for Cancer of the Rectum . Extirpatio Ani . Resection of the Rectum Resection of the Sacrum Parasacral Incisions Palliative Operations . Pelvi c Region 778 781 781 782 784 784 784 788 791 792 792 794 796 797 800 801 802 803 803 806 807 809 809 812 813 814 817 818 818 819 823 825 ILLUSTRATIONS FIG. I. 2. 3- 4- 5- 6. 7- 8. 9- lo. 13- 14. 16. 17- 18. 19- 20. 21. 23- 24. 27. 28. 29. 30- 31- 32- 33- 34- 35- Atomizer for Carbolated Spray. Cabinet for Instruments and Dressings. Small Dressing Table. Aseptic Operating Table. Surgeon's Gowns. Metal Retractor. Metal Retractor. Z^Ietal Retractor. Bistoury with Removable Blades. Forceps with Smooth Arms : («) Surgical, {i) Anatomical. Aseptic Knife. Forceps with Removable Lock. Instrument Sterilizer. Instrument Tray Stand (of Glass) . Schimmelbusch's Tin Box for Sterilized Silk, Glass Box for Catgut Ligatures. Tampon. Portable Hospital Bath (Am. Model). Arm Bath of Sheet Zinc. Leg Bath of Sheet Zinc. Rubber Blanket. Combination Sterilizer : (rt) closed, (6) open, (c) in operation. Beck's Portable Compact Sterilizer. Kny-Sprague's Perfection Surgical Dressing Sterilizer. Improved Irrigator. Irrigator. " Irrigateur a vide bouteille." Fritsch's Steam Sterilizer. Dressing Basin. Large Dressing Basin. Inversion Suture. Inversion Suture. Rubber Drainage Tube. Decalcified Bone Drainage Tube. Lister's Dressing Forceps. Curved Drainage Trocar. Drainage Openings in the Skin. Last irri- gation. Large Dressing Pad. Elastic Compressive Bandage. Antiseptic Dressing of Large Lateral Wounds on the Xeck. Antiseptic Cushioned Dressing of Stump after Amputation. Dressing Scissors. McBurney's Adjustable Telescopic Hip Rest. Improvised Position Apparatus. Adjustable Back Rest. Protector. The Same in Straight Form for Transporta- tion. Invalid Lift (a and 6). Suspension Stretcher. Von Volkmann's Suspension Frame. Siebold's Apparatus for Lifting a Patient. Roser's Dilator : (a) open, (d) closed. Von Langenbeck's Small Blunt Retractor. Von Langenbeck's Large Blunt Retractor. Sharp Spoon, Curette. Starke's Apparatus for Permanent Irrigation. Von Volkmann's Drop Canula. Von Volkmann's Suspension Splint. Suspension of the Hand according to von Volkmann. Suspension of a Fenestrated Plaster of Paris Dressing. » Ice Bag. Cooling Box for the Vertebral Column of the Neck. Esmarch's Cold Coil. Leiter's Cold Head Coil. Irrigation. Fenestrated Plaster of Paris Dressing; Open Treatment of Wounds. Constriction caused bv Bandage. ' xxu ILLUSTRATIONS FIG. 68. 69. 70. 71- 72. 73- 74- 75- 76. 77- 78. 79- 80. 81. 82. 83- 84. 85- 86. 87. 88. 89. 90. 91. 92. 93- 94- 95- 96. 97- 98. 99- 100. lOI. 102. 103. 104. 105. 106, 107. 108, 109, no Gaping Bandage. Rolling a Bandage. Bandage Roller. Circular and Serpentine Turns. Spiral Bandage. Testudo Inversa. Testudo Reversa. Funda Bandage. Scultet's Many-tailed Bandage. T Bandages. Double-headed Union Bandage (Fascia uniens). Sagittal Bandage. Cross-knot Bandage (Fascia nodosa). Mitra Hippocratis. Halter Bandage. Halter Bandage. Eye Bandage (Monoculus). Bandage for the Nose. Funda Maxillse. Chirotheka. Chirotheka. Spica Manus. Spica Humeri. Bandaging of the Hand and the Arm. Narrow Spica Bandage. Desault's Bandage for Fracture of the Clavi- cle : (a) First Bandage. Desault's Bandage for Fracture of the Clavi- cle : (d) Second Bandage. Desault's Bandage for Fracture of the Clavi- cle : (c) Third Bandage. Velpeau's Bandage for Fracture of theClavicle. Stellated Bandage (Stella Dorsi). Bandage of the Thorax (Quadriga). Suspensorium Mammae. Double Suspensory Mammary Bandage. Stapes. Double Anterior Spica for the Hip : a. As- cending ; d. Descending. Bandaging the Whole Leg. Von Esmarch's Triangular Cloth. Sailor's Knot. Granny's Knot. Triangular Head Cloth (Anterior view). Triangular Head Cloth (Posterior view). Funda Bandage for the Temporal Region. Funda Bandage for the Occiput. FIG. III. 112. "3- 114. "5- 116. 117. 118. 119. 120. 121. 122. 123. 124. 125- 126. 127. 128. 129. 130. 131- 132. ^33- 134. 135- 136. 137- 138. 139- 140. 141. 142. 143- 144, I45' 146, 147, Large Square Head Cloth. Large Square Head Cloth. Eye Bandage. Funda Bandage for the Chin. Cravat or Kerchief. Cravat with inserted Pasteboard. Cross Bandage for the Hand. Shoulder Cloth, Hand Cloth, Elbow Cloth, and Small Sling. Head Cloth, Breast Cloth, Shoulder Cloth. Breast Cloth, Shoulder Cloth. Mitella Triangularis. Other Form of Mitella. Cloth for carrying the Arm. Mitella Bandage. Square Cloth for carrying the Arm. Szymanowsky's Bandage for Fracture of the Clavicle : (a) Posterior view, (/') Anterior view. Roser's Apron Bandage for the Chest. Cloth Bandage for the Lateral Region of the Chest. Cingulum Pectoris. Large Breast Cloth, anterior view. The same, posterior view, see Fig. 119. Bandage for the Pelvis. , Cloth for the Buttocks. Hip Cloth. Unna's Gauze Sash. Roser's Apron Bandage for the Inguinal Region. Knee Cloth. Foot Cloth. Mayor's Cloth Bandage for P"racture of the Patella. Mayor's Cloth Bandage for Fracture of the Patella. Fixation Dressing for the Broken Arm. Wooden Splint with Tin Socket. Gooch's Flexible Wooden Splints. Schnyder's Cloth Splints for the Lower Ex- tremity. Von Esmarch's Splint Material (can be cut). Stromeyer's Hand Splint. Stromeyer's Splint for the Arm at an Obtuse Angle. Roser's Dorsal Splint for Fracture of the Lower End of the Radius. ILLUSTRATIONS xxm 14S. Carr's Radius Splint. 149. Clover's Radius Splints. 150. Bell's Hollow-moulded Splints for the Leg. 151. Bell's Four Splints for the Thigh (a, b, c, d). 152. Von Volkmann's Supination Splint. 153. Watson's Splint for Resection of the Knee Joint. 154. Watson- Vogt's Splint for Resection of the Knee Joint. 155. Von Volkmann's Tin Splint. 156. Salomon's Tin Splint. 157. Splints of Sheet Zinc. 158. Splints of Sheet Zinc. 159. Roser's Wire Splint for the Leg. 160. Wire Splint for the Leg with Handles for Suspension. 161. Cramer's Flexible Wire Splint. 162. Splints of Wire Cloth. 163. Splints of Wire Cloth Applied. 164. Leg Splint of Telegraph Wire with Foot Support. 165. Arm Splint of Telegraph Wire. 166. Neuber's Arm Splint of Glass. 167. Neuber's Leg Splint of Glass. 168. Pasteboard Splint for the Arm. 169. Model for Arm Splint. 170. Pasteboard Splint for Injuries on the Volar Side of the Wrist. 171. Pasteboard Splint for Fractures of the Humerus. 172. Dumreicher's Alar Splint. 173. Dumreicher's Alar Splint. 174. Danger from a Circular Bandage in Frac- tures of Both Bones of the Forearm (ac- cording to Albert). 175. Merchie's Models for Plastic Splints for the Arm. 176. Merchie's Models for Plastic Splints for the Arm. 177. Merchie's Models for Plastic SpUnts for the Leg. 178. Merchie's Models for Plastic Splints for the Leg. 179. Schede's Radius Splint. 180. Divided Starch Dressings. 181. Strips of Plaster of Paris Bandage (accord- ing to Pirogoff). FIG. 182. Double Pieces of Linen for Plaster of Paris Compressions for the Leg. 183. Plaster of Paris Compress. 184. Board for making Plaster of Paris Bandages. 185. Beely's Plaster of Paris Bandage Machine. 186. Wywodzoff's Plaster of Paris Bandage Ma- chine. 187. Plaster of Paris Tin Box. 188. Plaster of Paris Bandage with Cotton Band- ages for Padding. 189. Plaster of Paris Dressing with Turned-up Margins. 190. Plaster of Paris Knife. 191. Plaster of Paris Scissors. 192. Case containing Plaster of Paris Knife and Scissors. 193. Plaster of Paris Tutor for the Knee. 194. Beely's Plastic Plaster of Paris Splint. 195. Braatz's Spiral Splint for Fracture of the Radius. 196-197. Wood-shaving Plaster of Paris Dressing on the Humerus. 19S— 199. Wood-sha\"ing Plaster of Paris Dressing on the Forearm. 200-201. Wood-sha\ang Plaster of Paris Dressing for Resection of the Elbow Joint. 202. Von Esmarch's Pelvic Support. 203. Von Esmarch's Heel Support. 204. Von Bardeleben's Pelvic Support. 205-207. Wood-shaving Plaster of Paris Dress- ings for the Leg. 208. Stirrup Plaster of Paris Splint for the Knee. 209. Stirrup Plaster of Paris Splint for the Elbow. 210. Beely's Plaster of Paris Hemp Splint for the Knee. I. 211. Beely's Plaster of Paris Hemp Splint for the Knee. II. 212. Bridge Plaster of Paris Splint with Wooden Laths. 213. Pirogoff's Bridge Plaster of Paris Splint. 214-216. Von Esmarch's Plaster of Paris Suspen- sion Splint for Resection of the Elbow- Joint. 217-219. Von Esmarch's Plaster of Paris Suspen- sion Splint for Resection of the Wrist. 220-222. Watson's and von Esmarch's Plaster of Paris Suspension Splint for Resection of the Knee Joint. XXIV ILLUSTRATIONS 223-225. Von Esmarch's Plaster of Paris Suspen- sion Splint for Resection of the Ankle Joint. 226-228. Von Esmarch's Suspension Splints made of Telegraph Wire. 229-230. Von Volkmann's Dorsal Splint. 231-232. Von Esmarch's Interrupted Splint for Resection of the Wrist. 233-234. Von Esmarch's Interrupted Splint for Resection of the Ankle Joint. 235-236. Von Esmarch's Double Splint for Re- section of the Elbow. 237-238. Von Esmarch's Sectional Iron Suspen- sion Splint for Resection of the Elbow Joint. 239. Pott's Lateral Position. 240. Bonnet's Wire Breeches. 241. Wire Breeches flattened for Packing. 242. Double Inclined Plane. 243-244. Von Esmarch's Double Inclined Plane. .245. Dobson's Adjustable Wooden Frame. 246. Von Renz's Abduction Box. 247. Petit and Heister's Fracture Box. 248. Maclntyre's Splint (improved by Listen) for Compound Fractures of the Leg. 249-250. Fialla's Rod Splint. 251. Scheuer's Fracture Box. 252. Stromeyer's Arm Pillow. 253. Stromeyer's Arm Pillow in Position. 254. Middeldorpf 's Triangular Pillow. 255. Middeldorpf 's Triangle. 256. Lister's Wooden Splint for Resection of the Wrist. 257. Desault-Liston's Wooden Splint for Fracture of the Femur. 258. Dupuytren's Splint for Fracture of the Ankle. 259. Foot Board. 260. Manner of applying Strips of Adhesive Plaster. 261. Fastening Strips of Adhesive Plaster. 262. Extension by Weight for Fractures of the Femur. 263. Von Volkmann's Sleigh Apparatus. 264. Fastening the Extension Splint by Two Wet Bandages. 265. Konig's Gliding Stirrup. 266. Extension of the Wrist by Weight. 267. Von Volkmann's Extension Apparatus for the Cervical Portion of the Spine. FIG. 268. Extension for Scoliosis. 269. Glisson's Sling. 270. Sayre's Extension Apparatus for Scoliotic Spine. 271. Barw-ell's Lateral Extension in Scoliosis. 272. Grooved Wooden Plug. 273. India Rubber Hose with Hooks. 274. Von Esmarch's Stretcher Extension Dressing for Transportation in Gunshot Wounds of the Femur. 275. Iron Hook for Separable Wooden Splint. 276. Von Esmarch's Separable Wooden Splint for Elastic Extension of the Thigh. 277. Elastic Extension of the Wrist. 278. Sayre's Adhesive Plaster Dressing (First Strip). 279-280. Sayre's Adhesive Plaster Dressing (Sec- ond Strip). 281-282. Landerer's Adhesive Plaster Dressing with Elastic Extension. 283. Miculicz's Extension Dressing for Genu Valgum. 284. Club-foot Shoe with Elastic Extension. 285. Sayre's Extension Dressing for the Knee Joint. 286. Sayre's Jury Mast. 287. Taylor's Extension Splint. 288. Fastening the Adhesive Plaster Strips. 289. Cloth Bandage of Skirt of Coat. 290. Bandage of Coat Sleeve cut open. 291. Bandage of Sleeve fastened with Safety Pins. 292. Temporary Splints for Fractured Leg. 293. Splint of Trellis of Flower Pot. 294. Splint of Small Branches tied in Bundles. 295. Flat Splint of Twigs arranged Side by Side. 296. Splint of Transverse Pieces of Wood fas- tened with Twine. 297. Straw Splint. 298. Straw Splint. 299. Straw Mat for Splint. 300. Reed Mat for Splint. 301. Porter's Wire Splint. 302. Protecting Frame for Wounded Limb. 303. Military Cloak used for Splint. 304. Boot cut open lengthwise used as Foot Splint. 305. Joined Bayonets used as Splints. ILLUSTRATIONS XXV FIG. 306. 307- 308. 309- 311- 313- 314- 315- 316. 317- 318. 319- 320. 321. 322. 323- 324- 325- 326- 328. 329- 330-, 332. 333- 334- 335- 336. 337- 338- 340. Bayonet Splint. Scabbard used for Splint. Musket used for Splint. Dressing Table (Military Model). Von Volkmann's Suspension Apparatus used for Injured Arm. Von Bardeleben's Wire Suspension Appara- tus for Fractured Leg. Cubasch's Suspension Apparatus of Stocking cut open. Von Esmarch's Chloroform Mask. Chloroform Mask packed in Case. Schimmelbusch's Chloroform Mask. Junker's Chloroform Apparatus. Lifting the Lower Jaw. Gutsch's Lower Maxilla Holder. Protraction of Tongue with Forceps. Von Esmarch's Tongue- holding Forceps. Championniere's Hooked Tongue-holding Forceps. Sponge Holder, Nelaton's Inversion and Sylvester's Artificial Respiration (Inspiration). Nelaton's Inversion and Sylvester's Artificial Respiration (Expiration). Juillard's Ether Mask. 327. Wanscher-Grossmann's Ether Mask. (Old Form — Modern Furm.) Flask containing Ethyl Chloride. Syringe and Canulie for Infiltration Anaes- thesia. 331. Holding the Knife like a Pen. (a) in anatomical Dissection; (i) in cutting from within outward. Holding the Knife like a Violin Bow. Holding the Scalpel like a Table Knife. Shape of Knife Blades: i, 2 — curved; 3,4 — -pointed; 5 — straight; 6 — blunt- pointed. Stretching Margins of Wound for External Incision. Grooved Director. Conducting the Knife along the Grooved Director. 339. External Incision by raising a Fold of Tissue. Von Volkmann's Sharp Retractor. FIG. 341- 342. 343- 344- 345- 346. 347- 349- 350- 351- 352. 353- 354- 355- 356. 357- 359- 360. 361. 362. 363- 364- 365- 366. 367- 368- 371- 372- 373- 374- 375- 376. 377- 378. 379- 380. 381. 382. 383- 384- Von Langenbeck's Blunt Retractor : (a) small, (/') large. Improvised Retractor. Straight Scissors. Cooper's Scissors. Angular Scissors. Trocar. Von Esmarch's Trocar for Akidopeirastik. Syringes for Subcutaneous Injection : (a) Pravaz's syringe, {6) Overlach's syringe, (f) Koch's syringe. Subcutaneous Injection. Sharp Spoon. Cautery Iron. Brandis's Cautery Irons of Telegraph Wire. Paquelin's Thermo-cautery. Immersion Battery. Galvano-caustic Wire Loop. Porte-caustique. Surgical Needles : (a) ordinary eye, (d) springy eye. Dieffenbach's Needle Holder. Hegar's Needle Holder. Kiister's Needle Holder. Roux's Needle Holder. Hagedorn's Needle Holder. Hagedorn's Needles. Interrupted Suture. Sailor's or "Reef Knot." False or " Granny's Knot." Surgeon's Knot. -370. Mode of applying Sutures. Superficial and Interrupted Sutures. Removing Suture. Continued or Glover's Suture. Tying a Continued Suture. Languette Suture. Laced Suture, with turned inward. Laced Suture, with turned outward. Folding Suture. Quilt Suture. Quilted Suture. Button Suture. Pearl Suture. Twisted Suture. Dressing Forceps. Margins of Wound Margins of Wound XXVI ILLUSTRATIONS FIG. 3^5- 386. 387- 388. 389- 391- 392- 394- 395- 396- 397- 398. 399- 400. 401. 402- 404. 405- 407- 409. 410. 411. 412. 413- 414. 415- 416. 417. 418. 419. 420. 421. 422. 423- 424. 425- 426. Anatomical Forceps. Splinter Forceps. Removing a Ring by Means of a Narrow Tape wound in a Downward Direction. Flexible Zinc Probe. 390. Von Langenbeck's Bullet Forceps. American Forceps for Soft Lead Bullets. -393. Forceps for Jacketed Bullets. Liebreich's Electric Bullet Probe. Longmore's Bullet Probe. Chassaignac's Ecraseur. Von Esmarch's Elastic Constrictor. Clamp Buckle. Elastic Bandage and Constrictor. Limb rendered Bloodless on removing Elas- tic Bandage. Elastic Constrictor. •403. Nicaise's Constrictor. Von Esmarch's Apparatus for " Bloodless Method." ■406. Von Esmarch's Clamp for fastening Elastic Tube. ■408. Bloodless Method for Disarticulation of the Shoulder Joint. Unger rendered Bloodless. Bloodless Method used in Operation on Penis and Scrotum. Bloodless Method in High Amputation of the Thigh. Von Esmarch's Brass Spiral Constrictor. Tourniquet Suspender (von Esmarch). Applying a Tourniquet Suspender. Desmarre's Clamp. Dieffenbach's Ring Forceps. Compression of the Carotid Artery by Finger Pressure. Compression of the Subclavian Artery by Finger Pressure. Compression of Right Subclavian Artery. Compression of Brachial Artery. Compression of Femoral Artery. Compression of Brachial Artery by Tourni- quet. Compression of Femoral Artery by Tourni- quet. Petit's Screw Tourniquet. Spanish Windlass. Pancoast's Aorta Tourniquet. 427. 428. 429. 430- 431- 432. 433- 434- 435- 438- 440. 441. 442. 443- 444. 445- 446. 447- 448. 449- 451- 452. 453- 454- 455- 456. 457' 458. 459- 460. 461. 462. 463- 464. 465. 466. 467. 468. Von Esmarch's Aorta Tourniquet. Von Esmarch's Aorta Tourniquet. Compression of the Aorta with Pad and Rubber Bandage. Brandis's Method of compressing Aorta. Compression of External Iliac Artery. Improvised Spanish Windlass. Compression of the Brachial Arter\\ Volcker's Stick Tourniquet. •437. Spencer Well's Artery Forceps. -439. Ligation between Two Hemostatic For- ceps. Ligation with Many Hemostatic Forceps. Ligation of a Blood Vessel. Ligation of Artery by Indirect Ligature. Closing an Artery by Torsion. Koeberle Pean's Clamp Forceps. Doyen's Angiotribe. Arteries of Head, Neck, and Axilla. Arteries of the Thigh. Arteries of the Arm. •450. Arteries of the Leg: (a) posterior side, {l>) anterior side. Division of Cellular Tissue between Two Forceps. Opening the Sheath of an Artery. Introducing Curved Probe. Introducing Aneurism Needle. Syme's Aneurism Needle. Tying Ligature. Situation of the Carotid Artery (Cervical Section). Branches of External Carotid Artery. Ligation of the Common Carotid Artery. Ligation of the Common Carotid Artery be- tween the Two Heads of the Sternocleido- mastoid. Ligation of the External Carotid Artery. Ligation of Lingual Artery. Ligation of Subclavian Artery in the Supra- clavicular Fossa. Ligation of the Subclavian Artery in the Infraclavicular Fossa. External Incisions for Ligations of Arteries of the Arm. Topography of the Axilla. Ligation of the Axillary Artery. Topography of the Arteries of the Arm. ILLUSTRATIONS XXVll 469. Ligation of the Brachial Artery. 470. Ligation of the Arteria Anconea. 471-472. Ligation of the Radial Artery. 473-474. Ligation of the Ulnar Artery. 475-476. Superficial Palmar Arch : (i?) topog- raphy, (^b) external incision. 477. Iliac Arteries and Veins. 478. Topography of the Femoral Artery. 479. Ligation of the Common and Internal Iliac Arteries. 4S0. Ligation of the Superior Gluteal Artery and the Sciatic Artery. 481. Ligation of the External Iliac Artery. 482-483. Ligation of the Femoral Artery : (<2) under Poupart's Ligament, {b) below the Profunda Femoris Artery. 484. Ligation of the Femoral Artery in the Mid- dle of the Thigh. 485. Topography of the Right Popliteal Space. 486. Ligation of the Popliteal Artery. 487. Ligation of the Anterior Tibial Artery above the Middle of the Leg. 488. Ligation of the Anterior Tibial Artery in the Lower Third of the Leg. 489. Ligation of the Posterior Tibial Artery above the Middle of the Leg. 490. Ligation of the Posterior Tibial Artery be- hind the Internal Malleolus. 491. Intravenous Infusion, introducing the Ca- nula. 492. Infusion with a Graduated Glass Cylinder. 493-494. Syringe Bottles for Subcutaneous Infu- sion : (a) Sahli's apparatus with hollow needle and thermometer, {b) Fiirbringer's apparatus with trocar. 495. Autotransfusion. 496. Bleeding with the Phlebotome. 497. Bleeding with the Lancet. 498. Dressing after Bleeding. 499. Pole Pressure for Compressing the Femoral Artery in Popliteal Aneurism. 500-503. Ligation of the Artery in Aneurisms. 504. Ligation of the Long Saphenous Vein. 505. Lateral Ligature and Suture of Blood Vessel. 506-508. Tenotomes : {a) Dieffenbach's, {b) Stro- meyer's pointed, (c) blunt-pointed. 509. Subcutaneous Tenotomy. FIG. 510-51 1. Open Tenotomy of the Tendon of Achilles. 512. Phelps's Operation for Clubfoot. 513. Dupuytren, Contraction of Fingers. 514-517. Tendinorrhaphy, (a^ according to Made- lung, {b, c) Hueter's paratendinous suture, {d) quilt suture; (f) according to Kocher. 518. Tendinorrhaphy. 519. Tendinorrhaphy, {a, b) according to Wolfler. 520. Tendinorrhaphy, {c, d) according to Trnka. 521. Tendinorrhaphy, («) according to Nebinger. 522. Tendinoplasty, («) according to Tillaux. 523-524. Tendinoplasty, {b, f) according to Hue- ter. 525. Tendinoplasty, (a') according to Gluck. 526. Tendinoplasty, (f) according to Barden- heuer. 527. Tendinoplasty, (a) according to Sporon. 528. Tendinoplasty, ((5) according to Bayer. 529. Neurorrhaphy, («) direct. 530. Neurorrhaphy, (^b) indirect. 531. Neurorrhaphy, (^r) paraneurotic. 532-533. Neuroplasty, (c/, e) Hueter's. 534-536. Neuroplasty. 537-538. Anastomosis of Nerves. 539-540. Skin Grafting, according to Thiersch. 541-544. Plastic Operations, Covering Defects by stretching the Margins of Skins. 545-546. Plastic Operations, Relaxation Incisions. 547. Plastic Operation, according to Celsus. 548-551. Plastic Operation by Sliding and Stretch- ing of Flaps. 552-555. Plastic Operations with Pedunculated Flaps. 556. Operation on Nails. 557. Schneider-Mennel's Extension Apparatus. 558. Von Esmarch's Osteoclast. 559. Rizzoli's Osteoclast. 560. Robin's Osteoclast. 561. Macewen's Osteotome. 562. Adams's Metacarpal Saw. 563. Subtrochanteric Osteotomy. 564. Supracondyloid Osteotomy. 565. Supracondylic Osteotomy. 566. Supramalleolar Osteotomy. 567. Bone Drill. 568. Dental Bur. 569. Electromotor. XXVlll ILLUSTRATIONS FIG. 570. 571- 572- 574- 575- 576. 577- 578- 579- 5«3. 584. 585- 586. 587- 590. 591- 592. 593- 594- 595- 596. 597- 598. 599- 600. 601. 602. 603. 604. 605. 606. 607. 608. 609. 610. 611. 612 Bone Suture. Steel Nails. 573. Gussenbauer's Bone Clamps. Cuneiform Vivifying. Bone Union with Silver Wire. Aluminum Splints for Bone Union. Ivory Cylinders. Marshall's Osteotribe. 582. Chisels and Hammer for Necrotomy. Opening an Involucrum of the Tibia with Chisel and Hammer. Nat ural Size of Bevel of Chisels for Necrotomy. Shallow Cavity after Necrotomy. Raspatory. Sequestrum Forceps. 589. Neuber's Inversion Suture, {a) after the operation, (6) after healing. (Jsteoplastic Necrotomy. Amputation of Limb. Amputating Knives. Circular Amputation by One Incision. Retleclion of Periosteum. Stump after Circular Amputation by One Incision. Circular Amputation by Two Incisions; Di- viding the Skin. Circular Amputation by Two Incisions ; Loosening the Skin in the Form of a Cuff. Wrong Mode of Incision. Circular Amputation by Two Incisions; Di- viding Muscles. Stump after the Circular Amputation by Two Incisions. Petit's Circular Incision. Amputation by Three Circular Incisions de- taching Muscular Cone. Von Langenbeck's Flap Knife. Two Lateral Flaps of Skin of Equal Length. Long Anterior and Short Posterior Flap. Anterior Skin Flap with Semicircular Poste- rior Incision. Muscular Flap Incision (von Langenbeck's Method). Reiner's Amputating Saw. Nyrop's Amputating Saw. Helferich's Amputating Saw. Sawing off the Bone. -613. Divided Compresses: (a) for limbs with one bone; (d) for limbs with two bones. 614. Reflection of Soft Parts by Means of Divided Compress. 615-616. Knives for dividing Soft Parts in the Interosseous Space (Catline). 617. Method of carrying Knife in the Interos- seous Space. 618. Sawing off Both Bones; Retraction of Soft Parts by a Divided Compress for Limbs with Two Bones. 619. Liston's Bone-cutting Forceps. 620. Liier's Gouge Forceps: (a) straight, (/^) curved. 621. Amputating Saw. 622. Suturing Periosteum and Deep Muscular Layers. 623. Buried Muscular Suture. 624. Suture of the Skin Margins. 625. Conical Stump. 626-628. Protheses, Claw Hands. 629-630. Peg Legs for Amputated Thigh. 631. Peg Leg. 632. Artificial Limb for Amputated Leg. 633. Skeleton of Finger. 634. Position of Lines of Articulations of the Finger. 635. Disarticulation of First Phalanx. 636-637. Disarticulation of Third Phalanx. 638-639. Disarticulation of Second Phalanx. 640. Disarticulation at the Metacarpophalangeal Joint (Oval Incision). 641-642. Disarticulation at the Metacarpopha- langeal Joint by an Oval Incision. 643-644. Disarticulation of the Metacarpophalan- geal Articulation a, of the thumb, second and fifth fingers. Forming large flaps of unequal size on the fourth finger. Forming two equal flaps on the third. Oval incision from the volar side, d, Wound from the oval and flap incision. 645. Disarticulation of All Fingers. 646-648. Disarticulation of the Thumb by Oval Incision. 649-650. Von Walther's Radial Flap Incision. 651-653. Disarticulation of the Last Four Meta- carpal Bones : a, volar incision ; i>, dorsal incision. ILLUSTRATIONS XXIX FIG. 652. Volar Incision by Transfixion. 654. Stump after Disarticulation of the Last Pour Metacarpal Bones. 655. Disarticulatioiji of the Hand by Circular In- cision. 656. Stump after Disarticulation of the Wrist by Circular Incision. 657-658. Disarticulation of the Hand by Two Skin Flaps. (Ruysch.) 659. Disarticulation of the Hand by von Walther's Method. 660. Stump resulting from von Walther's Method. 661. Transverse Section of the Right Forearm at its Lower Third. 662. Transverse Section of the Right Forearm at its Middle Part (see also Plate XI). 663. Transverse Section of the Right Forearm at its Upper Third (see also Plate XII). 664. Disarticulation of the Elbow Joint by Circular Incision. 665. Stump after Disarticulation of the Elbow Joint by Circular Incision. 666. Transverse Section of the Right Elbow Joint in the Line of Condyles (see also Plate XII). 667. Disarticulation of the Elbow Joint by Flap Incision. 668. Disarticulation of the Elbow Joint by Ko- cher's Oblique Incision. 669. Transverse Section of the Right Arm at its Lower Third (see also Plate XIII). 670. Transverse Section of the Right Arm at its Middle Third (see also Plate XIII). 671. Transverse Section of the Right Arm in Front of the Axilla (see also Plate XIV). 672. Disarticulation of the Shoulder Joint (Flap Incision). 673. Disarticulation of the Shoulder Joint by forming a Second Flap on the Inner Sur- face. 674. Stump after Disarticulation of the Shoulder Joint by Flap Incision. 675-676. Disarticulation of the Shoulder Joint by Circular Incision and Longitudinal : a, dis- articulation of the stump of the arm ; b, sutured stump. 677. Disarticulation of the Shoulder Joint by Lar- rey's Oval Incision. FIG. 678. 679. 680. 681. 685. 686. 687. 688. 689- 691. 692- 695- 696- 701. 702. 703- 705- 709. 710. 711- 715- 716. 717- 720. 721, Disarticulation of the Shoulder Joint (Oval Incision). Disarticulation of the Shoulder Girdle. Disarticulation of All Toes (Plantar Incision). Disarticulation of All Toes (Dorsal Incision). Stump after Disarticulation of All Toes. Amputation of Foot through the Metatarsal Bones by Sawing. Wound resulting from Sawing off Metatarsal Bones. Disarticulation of the Great Toe with its Metatarsal Bone. Disarticulation of the Fifth Toe with its Metatarsal Bone. Skeleton of the Foot. Lisfranc's Disarticulation of the Tarsometa- tarsal Articulation. -690. Lisfranc's Disarticulation of the Foot : a, dorsal incision ; b, dividing articulation. Lisfranc's Disarticulation. Opening Second Metatarsal Articulation. ■694. Lisfranc's Disarticulation : a, forming plantar flaps ; b, wound surface ; c, stump. Lisfranc's Disarticulation, preserving Hallux. •700. Chopart's Disarticulation at the Tarsus. Chopart's Disarticulation at the Tarsus (Fin- ishing Plantar Flap). Stump after Chopart's Disarticulation at the Tarsus. -704. Chopart's Disarticulation. Preserving Toes (Witzel). -708. Malgaigne's Disarticulation between Astragalus and the Os Calcis (below the Astragalus). Disarticulation of the Foot below the Astraga- lus. Stump after Disarticulation of the Foot below the Astragalus. -714. Syme's Amputation of the Foot. Syme's Amputation of the Foot (Disarticulat- ing the Os Calcis). Sawing through the Bone. -719. Syme's Amputation of the Foot: a, wound surface ; b, recent stump, anterior view ; c, healed stump, lateral view. Pirogoff's Disarticulation of the Foot (Saw- ing off the Os Calcis). Sawing off Bones by Pirogoff's Operation. ILLUSTRATIONS FIG. I FIG. 722. Wound Surface of Pirogoff's Operation. I 757. 723. Stump resulting from Pirogoff's Operation. \ 724-726. Giinther's Modification of Pirogoft''s 758. Operation. 1 727. Giinther's Mettiod of Dorsal Incision. , 759. 728. Giinther's Method of Dividing Bones by Sawing. 76°- 729-731. Le Fort's Modification of Pirogoff's 761. Operation. 732. Le Fort's Dorsal Incision. I 762. 733. Sawing through the Bones in Le Fort's | Operation. 763. 734. Von Bruns's Method of Dividing Bones by Sawing. 764. 735. Stump resulting from Le Fort's Method. 765. 736. Kiister's Modification of Le Fort's Operation. 737-738. Von Langenbeck's Amputation of the ' Leg by forming a Lateral Skin Flap. , 766. 739-741. Bier's Osteoplastic Amputation of the 767- Leg. 742. Transverse Section of the Right Leg at its 769. Lower Third (see Plate XV). 770. 743. Transverse Section of the Right Leg at its 771. Middle Third (see Plate XV). 772. 744. Transverse Section of the Right Leg at its 773. Upper Third. 774. 745. Transverse Section of the Left Thigh through 775. the Condyles. 776. 746. Disarticulation of the Knee Joint (Circular 777. Incision). 778. 747-748. Stump resulting from Disarticulation of 779. the Leg at the Knee Joint by Circular 780. Incision. 781. 749. Disarticulation at the Knee Joint by forming Two Flaps. 782. 750. Stump resulting from Disarticulation of the Leg at the Knee Joint by Flap Incision. 783- 751. Disarticulation of the Leg at the Knee Joint (Oblique Incision). 785. 752. Garden's Intracondyloid Amputation. 753. Gritti's Supracondyloid Osteoplastic Ampu- tation. 786. 754. Sabanejeff's Intracondyloid Osteoplastic Amputation. 755. Transverse Section of the Right Thigh at its 787. Lower Third. 788. 756. Transverse Section of the Right Thigh at its 789. Middle Third. Transverse Section of the Right Thigh at its Upper Third. Position of Patient in changing the Dressings after Amputation. > Disarticulation of the Thigh by an Anterior Large, and a Posterior Small Flap. Forming an Anterior Flap by Transfixion. Disarticulation of the Thigh. Forming Pos- terior Flap. Stump resulting from Disarticulation of the Thigh at the Hip Joint by Flap Incision. Disarticulation of the Thigh at the Hip Joint (Circular Incision). Disarticulation of the Thigh at the Hip Joint. Stump resulting from Disarticulation of the Thigh at the Hip Joint (by Circular and Vertical Incisions). Resection Knife. 768. Von Langenbeck's Elevator : (a) small, (^d) broad. Lever-like Elevator. Sayre's Elevator. Von Langenbeck's Claw Forceps. Fergusson's Lion Jaw Forceps. P'araboeuf 's Forceps. Metacarpal Saw. Von Langenbeck's Metacarpal Saw. Metacarpal Saw. Chain Saw. Helferich's Amputation Saw. Von Langenbeck's Sharp Hook. Replacing a Resected Metacarpal Bone. Resection of the Lower Ends of the Bones of the Forearm ( Bourgery 's Bilateral Incision) . Muscles and Tendons on the Ulnar Side of the Left Wrist (according to Henke). 784. Ligaments of the Right Wrist : (a) dor- sal side ; {l>) volar side. Muscles and Tendons on the Radial Side of the Left Wrist in Dorsal Flexion (accord- ing to Henke). Muscles and Tendons on the Radial Side of the Left (extended) Wrist (according to Henke). Sawing off the Articular End of the Radius. Frontal Section of the Right Wrist. Von Langenbeck's Method of Resecting the Wrist. ILLUSTRATIONS XXXI FIG. I 790. Tendons on the Dorsal Side of the Hand. 791. Carpal Bones. 792-793. Kocher's Resection of the Wrist. 794. Resection of the Right Elbow Joint (Liston's T Incision). 795. Ulnar Nerves on the Posterior Side of the Left Elbow Joint. 796. Resection of the Elbow Joint ; denuding the Internal Condyle. 797-798. Ligaments of the Right Elbow Joint : («) inner side, (^b) outer side. 799. Resection of the Right Elbow Joint by von Langenbeck's External Incision. 800. OUier's Resection of the Elbow Joint. 801. Nekton's Resection of the Elbow Joint. 802-803. Kocher's Resection of the Elbow Joint. 804. Socin's Supporting Apparatus for a Loose, Freely Movable Joint after Resection of the Elbow Joint. 805-808. Von Langenbeck's Resection of the Shoulder Joint. 809. Muscular Insertions of the Greater and the Lesser Tuberosities of the Humerus. 810-81 1. Sawing off the Head of the Humerus. 812. Ligaments of the Shoulder Joint. 813. Ramification of the Axillary Nerve (Poste- rior View). 814. Ollier's Resection of the Shoulder Joint. 815-816. Kocher's Resection of the Shoulder Joint. 817. Von Esmarch's Resection of the Articular Surface and Neck of the Scapula. 818. Ollier's Resection of the Scapula. 819-820. Petersen's Arthrectomy of the Articula- tion of the Great Toe. 821. Hook-shaped Incision (von Langenbeck). 822. Henke's External Side of the Left Ankle Joint. 823. Disarticulation of the Lower End of the Fibula. 824. Ligaments of the Ankle Joint (Posterior Side). S25. Ligaments of the Ankle Joint (External Side). 826. Incision upon the Internal Malleolus (An- chor Incision). 827. Inner Side of the Ankle Joint (according to Henke). 828. Ligaments of the Ankle Joint (Inner Side). 829-830. Kocher's Resection of the Ankle Joint. 831. Gerard's Resection of the Ankle Joint. 832. Lauenstein's Method of Opening Ankle Joint. 833. Hueter's Resection of Ankle Joint. 834. Ollier's Resection of the Os Calcis. 835. Guerin's Spur Incision. 836. Kocher's Resection of the Os Calcis. 837-840. Miculicz-Wladimiroff's Osteoplastic Re- section. 841. Cuneiform Tarsectomy. 842. Textor's Resection of the Knee Joint. 843. Crucial Ligaments of the Knee. 844. Position of the Popliteal Artery and Vein behind the Wound Surface. 845. Nailing the Resected Knee. 846. Helferich's Method of Sawing out a Curve- shaped Wedge. 847. Flower-pot Trellis as a Splint after Resection of the Knee Joint. 848. Hahn's Curved Incision for Resection of the Knee Joint. 849. Von Langenbeck's Curved Incision for Re- section of the Knee Joint. 850. Inner Side of the Knee Joint. 851. Ligaments of the Knee Joint (Inner side). 852. Ligaments of the Knee Joint (Outer side). 853. Kocher's Arthrectomy of the Knee Joint. 854. Resection of the Hip Joint (A. White's curved incision). 855. Posterior Side of the Hip Joint (Muscles and Sciatic Nerve) . 856. Resection of the Hip Joint. Sawing off Head of Femur with the Chain Saw. Re- flection of Soft Parts with a Strip of Zinc. 857. Resection of the Hip Joint. 858-859. Muscular Insertions on the Upper End of the Right Femur : {a) anterior side, (/;) Posterior Side. 860. Ligaments on the Anterior Side of the Hip Joint. 861-862. Kocher's Resection of the Hip Joint: (i) resection of the ilium, (2) resection of the hip joint. 863-864. Resection of the Hip Joint : a, accord- ing to Liicke and Schede ; b, according to Hueter. 865. Lobker's Spoon Elevator. XXXll ILLUSTRATIONS FIG. 866. Nipping off the Osseous Margin of a Cranial l-raclure with Liier's Gouge Forceps. 867. Hoffman's Kongeur Forceps. 868. Chiselling out Point of Sword. 869. Hand Trephine. 870. Trephining. 871. Blood Vessels on the Internal Side of the Cranium. 872. Bone Screw with Roser's Hook. 873. Stille's Bone-nipping Forceps. 874. Circular Saw and Electromotor. 875. Craniectomy. 876. W. Wagner's Osteoplastic Resection of the Skull. 877. Wagner's Osteoplastic Resection of the Skull. 878. Osteoplasty in Cranial Defects. 679. Cerebral Topography : 1. Region of the oculomotor nerve : Levator palpebrae, movements of the bulb, dilatation of the pupils, turning the head to the opposite side. 2. Upper Extremity: (a) adductor and abductor muscles, (i) extensors, (c) ((/) flexors, supinators, pronators, {e) muscles of the hand. 3. Lower Extremity : (a) flexors, (/') extensors. 4. Facial Nerve : Region of the face, («) muscles of the mouth. 5. Speech Centre and Lingual Move- ments (anteriorly, aphasia; posteriorly, re- gion of the hypoglossus). 6. Visual Centre. See also Tillmans H. i, 70, 122 ; Keetley, " Index of Surgery," 207, 209 ; Senn, " Principles," 276. 880. Locating Central Sulcus according to Thane and Bennet. 881. Kohler's Cephalometer for locating the Cen- tral Sulcus. 882. Kocher's Method of Ascertaining Important Cerebral Localizations on the Surface of the Brain. 883. Opening the Skull at the Temporal Region : {/>) below the localizations for opening the transverse sinus and the mastoid antrum, (i) locating the middle meningeal artery (Steiner). 884. Locating the Middle Meningeal Artery (Vogt). 885. Kronlein's Method of Trephining for Injury of the Middle Meningeal Artery. 886. Course of Middle Meningeal Artery and its Localization for Trephining according to Steiner (S), to Vogt (V), and to Kronlein (K). 887. Opening Mastoid Process. 888. Mastoid Process opened. Showing Mastoid Antrum, Mastoid Cells, and Facial Canal. 889-890. Gimlet and Bone Drill. 891. Drainage Trocar. 892. Drainage of the Frontal Sinus. 893. External Incisions for Resection of Upper Jaw. 894. Kocher's External Incision. 895-896. Saw Incisions for Resection of Upper Jaw. 897. Outward Rotation of the Upper Jaw after Resection. 898. Cavity of the Wound after Resection of the Upper Jaw. 899-9CXD. Von Langenbeck's Osteoplastic Resec- tion of the Upper Jaw: (a) external in- cision, ((^) dividing bone by sawing. 901-902. O. Weber's Osteoplastic Resection of the Upper Jaw. 903. Kocher's Osteoplastic Resection of Both Upper Jaws : External Incisions, Bone Sections. 904. Diagram : Frontal Section of the Right An- trum of Highmore and the Nares (Henle). 905. Opening of the Antrum of Highmore with a Chisel. 906. Stilette according to Miculicz. 907-908. Resection of One Half of the Lower Jaw: (a) external incision and sawing through the bone, (/') twisting hone out of the articulation. 909. Metal Strips used as Prothesis after Resec- tion of the Maxillary Arch according to Partsch. 910-91 1. Bardenheuer's Osteoplasty after Resec- tion of the Lower Jaw. 912. Topography of the Temporo-maxillary Ar- ticulation. 913. Thiersch's Forceps for Extracting Nerves. ILLUSTRATIONS XXXlll 914. Diagram of the Divisions of the Trigeminal Nerve, Zygomatic Arch, and Mandibular Plate, resected according to Kronlein's Method. 915-916. Exposure of the Supraorbital Nerve. 917-918. Exposure of the Infraorbital Nerve. 919. Wagner's Hollow Refractor. 920. Neurectomy of the Infraorbital Nerve by Liicke-Braun-Lossen's Temporary Re- section of the Malar Bone, {b) By Thiersch's method of exposing the infra- orbital nerve for extraction (a). 921-922. Kocher's Method of Exposing the Su- pramaxillary Nerve at the Foramen Rotun- dum. 923. Sonnenburg-Liicke's Method of Exposing Inframaxillary Nerve. 924. Internal Half of Left Lower Jaw. a, a, saw incisions according to Bruns. 925. External Half of Right Lower Jaw with Velpeau-Linhart Fenestra. 926. Kronlein's Retrobuccal Method. 927-928. Miculicz's Method of Exposing In- framaxillary Nerve. 929-930. Kocher's Method of Exposing the Infra- maxillary Nerve at the Foramen Rotundum. 931. Kronlein's Method of Resecting the Second and the Third Branches of the Trigeminus. External incision ; saw inci- sions. 932. Kronlein's Method of Exposing the Second and the Third Branches of the Trigeminus. 933. Roser's Method of Exposing Lingual Nerve. 934. Paravicini's Method of Exposing the Man- dibular and Lingual Nerves. 935. Exposure of the Mental Nerve. 936-937. Krause's Intracranial Resection of the Gasserian Ganglion. 938. Lobker-Hueter's Method of Exposing the Facial Nerve. 939-940. Exposing Spinal Accessory Nerve. 941-942. Exposing Brachial Plexus. 943-944. Exposing Crural Nerve. 945-946. Exposing Sciatic Nerve. 947-948. Exposing Popliteal Nerve. 949-950. Dieffenbach's Blepharoplasty (Plastic Surgery of the Eyelids). 951-952. Wolfe's Blepharoplasty, 953-954. Ammon and von Langenbeck's Ble- pharoplasty. 955. Fricke's Blepharoplasty. 956-957. Hasner von i\rtha's Blepharoplasty. 958-959. Von Dieffenbach's Blepharoplasty. 960-962. Tripier's Blepharoplasty. 963-964. Shallow Excision of a Tumor of the Lower Lip — Suture. 965-966. Removal of the Margin of the Whole Lower Lip (by the bloodless method by means of parallel forceps). 967-968. Cuneifornj Excision of a Tumor of the Lower Lip — Suture. 969-970. Grafting Lower Lip restored by Plasty with the Vermilion Border of the Upper Lip — Suture. 971-972. Brun's Method of Cheiloplasty (For- mation of lips). 973-974. Estlander's Method of Cheiloplasty. 975-976. Dieffenbach's Method of Cheiloplasty. 977-978. Jaesch's Method of Cheiloplasty. 979-980. Trendelenburg's Method of Cheilo- plasty. 981-982. Brun's Method of Cheiloplasty. 983-984. Burow's Method of Cheiloplasty. 985-986. Blasius's Method of Cheiloplasty. 987-988. Langenbeck's Method of Cheiloplasty. 989-990. Morgan's Method of Cheiloplasty. -993. Dieffenbach's Sinuous Incision. -995. Brun's Method of Cheiloplasty. -997. Sedillot's Method of Cheiloplasty. -999. Dieffenbach's Method of Stomatoplasty (Plastic surgery of the mouth). Artificial Mouth (according to Hueter). -1002. Meloplasty (Plastic Surgery of the Cheek), by Stretching a Pedunculated Flap. -1004. Meloplasty by Sliding Two Peduncu- lated Flaps. -1006. Kraske's Method of Meloplasty. -1009. Israel's Method of Meloplasty. Models for Rhinoplasty (Plastic surgery of the nose). (i) Original Hindoo model ; (2 and 5) Dieffenbach's models ; (4) Ammon-Zeis's Model ; (3, 6, 7, and 8) von Langenbeck's models. -1012. Total Rhinoplasty by a Flap from the Forehead (Hindoo method). 991- 994. 996- 1000. lOOI- 1005- 1007 lOIO. XXXIV ILLUSTRATIONS FIG. 1013. Thiersch's Rhinoplasty. 1014. Verneuil's Rhinoplasty. 1015-1016. Von Langenbeck's Osteoplastic Nasal Framework. 1017-1018. Schimmelbusch's Rhinoplasty. 1019. Nelaton's Rhinoplasty by Flaps from the Cheek (French method). 1020. Tagliacozza and von Grjife's Rhinoplasty by a Flap from the Arm. 1021. Israel's Rhinoplasty. 1022-1023. Tiemann's Nasal Protheses. 1024-1025. Von Langenbeck's Method of Re- storing an Ala of the Nose from the Other Half of the Nose. 1026-1028. Restoring an Ala of the Nose by Pedunculated Flaps from the Cheeks. 1029-103Q. Forming Nostril by Sliding a Small Flap. 1031. W. Busch's Method of Restoring Tip of the Nose and One Ala. 1032-1033. Dieffenbach's Method of Restoring the Septum. 1034-1035. Von Langenbeck's Method of Re- storing the Septum. 1036-1037. Hueter's Method of Restoring the Septum. 1038-1041. Von Langenbeck's Method of Cor- recting Collapsed Noses. 1042-1043. Konig's Rhinoplasty. 1044. Restoring Nose and Upper Lip in Conse- cjuence of Syphilis and Lupus. 1045-1047. Nelaton's Operation for Harelip — Vivifying — Wound — Suture. 1048-1050. Von Langenbeck's and Wolfe's Method of Distortion of the Margins of the Lips — Vivifying — Wound — Suture. 1051-1053. Malgaine's Method — Vivifying — Wound — Suture. 1054-1056. Mirault's (von Langenbeck's) Method — Vivifying — Wound — Suture. 1057-1059. Giralde's Method — Vivifying — Wound — Suture. 1060-1062. Konig's Method — Vivifying — Wound — Suture. 1064-1065. Maas's Method — -Vivifying — Wound — Suture. 1066-1068. Hagedorn's Method — Vivifying — Wound — Suture. FIG. 1069- 1071- 1074- 1077- 1079. 1080. 1081- 1084. 1085. 1086. 1087- 1089. 1090. 1091. 1092. 1093- 1070. Von Esmarch's Method — Vivifying — Suture. 1073. Maas's Method — Vivifying- — Wound — - Suture. 1076. Hagedorn's Method — Vivifying — Wound — Suture. 1078. Von Bardeleben's Method of Forcing back Premaxillary Bone. Forcing back Premaxillary Bone by Elastic Pressure. Blandin's Method of Resecting Cuneiform Portion from the Vomer. 1083. Simon's Method- — Vivifying —Tem- porary Stitching of Lateral Flaps — Suture. Von Langenbeck's Instruments for Per- forming Staphylorrhaphy, (rt) Two-edged pointed knife for vivify- ing in staphylorrhaphy. {b, c) Pointed and probe-pointed knives for detaching the soft palate from the pituitary membrane and from palate bone. ((/) Curved knife for making lateral in- cisions. {e,/) Sickle-shaped knife for dividing palatine muscles. {g) Sharp hook. {h) Oral retractor. (/) "Diadem." Staphylorrhaphy (Closure of clefts of the soft palate by suture). Muscles of the .Soft Palate. (^a) Incision for dividing muscles branching off from the hamular process of the sphenoid. (/>) Incision for separating muco-peri- osteal flaps in uranoplasty. 1088. Von Langenbeck's Needle and Suture Carrier. Applying the Suture. Operation Completed. Hagedorn's Needle Holder. Von Brun's Needle provided with Handle. 1094. Staphylorrhaphy and Uranoplasty in Congenital Cleft of the Palate by Slid- ing Two Pedunculated Muco-periosteal Flaps. ILLUSTRATIONS XXXV 1095-1096. Kiister's Method of Staphylorrhaphy. 1097-1098. Siiersen's Obturator : (a) lateral view; {b) applied from below. 1099. Kingsley'5 Obturator. 1 100. Wolfil-Schlitsky's Obturator. iioi. Brandt's Obturator. 1 102. Enucleation of the Eyeball. Dividing Optic Xerve. 1 103. Artificial Eyes. 1 104. Ear Speculum. 1 105. Leroy d'Etiolles' Adjustable Curette. 1 106. Juracz's Nasal Speculum. I107-I108. Franckel's Nasal Speculum. 1 109. Protector for the Finger. II 10— nil. Application of Bellocq's Canula. 1 1 12. Polypus Forceps. 1113. Removing Polypus. 1 1 14. Wilde-Duplay's Cold Wire Snare. 11 15. Levret's Wire Snare. 11 1 6. Removing Polypus with Double Canula. 11 17. Von Langenbeck's Method of Ligating Polypus. 1 1 18. Konig and Baracz's Method of Dividing Nose Longitudmally. 1 1 19-1 120. Von Langenbeck's Method of Resect- ing Nasal Process of Upper Jaw : (rt) ex- ternal incision ; (^b) saw incisions. 1 121. Rouge's Temporary Detachment of the Nose. 1 1 22. Ollier's Temporary Resection of the Nose. 1123-1124. Von Brun's Method of Temporary Resection of the Nose : {a) external inci- sion ; {b) nose turned up. 1 125. Gussenbauer's Temporary Resection of the Nose. 1 126. ^lotais's Sharp Finger. 1 1 27. Annular Knives: {a) Meyer's, {b) Scholz's, (c) Lange's, (a') Gottstein's. 1 1 28. Michael's Naso-pharyngeal Forceps. 1 1 29. Brown's Pharyngeal Syringe. I130-1131. Dilating Contracted Nostrils. 1 132. Adams' Rhinopiastos. 1 133. Juracz's Compression Forceps. 1 134. Screw Wedge. 1 135. Konig-Roser's Mouth Gag. 1136. Heister's Mouth Gag. 1 137. Pitha's Mouth Wedge. 1138-1139. Whitehead's Oral Speculum. 273, front view when applied; 274, closed and viewed from above. 1 140. Tillmans's English Speculum. 1141. Bruns's Automatic Mouth Gag. 1 1 42. Tongue Spatula. 1 143. Tiirck's Tongue Spatula. 1144. Tongue Spatula of Glass. 1145. Rose's Operation on the Head hanging down. 1 146. Tooth Key. 1 147. Lecluse'b Elevator. 1 148. Alveoli of the Upper Jaw. i, 2, incisors. 1 149. Skeleton of the Jaw with exposed teeth. 3, canine tooth; 4, 5, bicuspids; 6, 7, molars. 1 1 50. Alveoli of the Lower Jaw. 8, wisdom tooth. 1 15 1. Forceps for Teeth in the Upper Jaw: (a) right molars, (^b) bicuspids, (c) in- cisors and canine teeth, (1/) left molars. 1 152. Tooth Forceps for the Lower Jaw: («) right molars, (^b) molars on both sides, (f) left molars. 1 153. L'niversal Forceps. 1 154. Instruments for Extracting Roots of the Teeth : () wound. 1238. Resection of a Rib with Metacarpal Saw. 1239. Gluck's Costal Scissors (Costotome). 1240. American Prune Shears. 1241. Anterior View of Thorax. Intercostal Artery and Internal Mammary Artery are visible. 1242-1243. Kussmaul's Trocar with Stop-cock. 1244. Reybard's Trocar. 1245. Frantzel's Trocar. 1246. Billroth's Trocar. 1247. Dieulafoy's Aspirator. 1248. Potain's Aspirator. 1249. Fiirbringer's Aspirator. 1250. Biilau's Permanent Aspirator. 1 25 1. Schede's Thoracoplasty. 1252. External Incision in Amputation of the Breast, clearing out the Axilla. 1253. Clearing out the Axilla. 1254. Suture and Drainage after Amputation of the Breast, clearing out the Axilla. 1255. Puncture of the Abdomen. 1256. Abdominal Supporter after Laparotomy. 1257. Gastrostomy (Suturing Wall of the Stom- ach). 1258. Food administered to a Patient on whom Gastrostomy had been performed (accord- ing to Trendelenburg). 1259. Gastrostomy. 1260. Witzel's Oblique Fistula. 1 261-1263. Kader's Gastrostomy. 1 264- 1 266. Frank's Gastrostomy. 1 267- 1 270. Intestinal Clamps: 1267, Billroth's; 1268, Hahn's; 1269, Rydygier's; 1270, Wehr and von Heineke's. 1271-1272. Parallel Forceps: 1271, Gussen- bauer's; 1272, Kiister's. 1273-1274. Billroth-Wolfler's Resection of the Pylorus. 1273. Incisions. 1274. Suture: (a) occlusion suture, {b) circular suture. 1275-1276. Rydygier's Resection of the Pylorus: (rt) incisions, {b) suture. 1277. Resection of Pylorus and Gastro-enteros- tomy (Billroth). 1 278-1 279. Kocher's Resection of the Pylorus and Gastro-duodenostomy. 1280. Duodenojejunal Fold; Transverse Colon and Omentum turned upward. 1281-1282. Gastro-enterostomy : («) incisions; ((^) coronary artery. 1 28 1. Wolfler's Method. 1282. Socin's Method. 1283. Von Hacker's Gastro-enterostomy. 1284-1286. Diagram of Gastro-enterostomy. 1 287-1 288. Wolfler's Gastro-enterostomy. 1289. Liicke's Gastro-enterostomy. 1290-1292. Kocher's Gastro-enterostomy: («) incisions; (^h) suture. 1293-1295. Doyen's Gastro-enterostomy. 1 296-1 297. Von Heineke's Pyloroplasty (Dia- gram of Suture). 1298. Gastroplasty: in Hour-glass Contraction of the Stomach. 1299. Gastroanastomosis : in Hour-glass Con- traction of the Stomach. 1300-1301. Inguinal Colostomy. 1300. Suturing Intestine. 1301. Method of applying Suture (Sectional View). 1302-1303. Inguinal Colostomy. (i) Intestinal loop drawn forward. (2) Divided completely. («) proximal end, (1^) distal end. 1 304- 1 306. Von Esmarch's Needle Case for Intes- tinal Suture. 1307-1309. Enterorrhaphy. 1307. Lembert's Method, (a) Interrupted Suture. 1308. (/'). Continuous Suture. 1309. Cushing's Method, (.r) Quilt Suture. 1310-1311. Diagram of Enterorrhaphy. 1 3 10. Lembert's Method. 131 1. Czerny's Method. 1312-1313. Wolfler's Internal Enterorrhaphy. 1314. Neuber's Decalcified Bone Tube. 1 31 5. Brokaw's Catgut Ring. 1316. Jobert's Enterorrhaphy (Invagination). 131 7-1320. Murphy's Intestinal Button. 1321-1322. Kocher's Method of detaching Mes- entery. (rt) cuneiform excision. {b) Applying suture and forming longitu- dinal fold. XXXVlll ILLUSTRATIONS 1323. Senn's Entero-anastomosis : (a) decalcified boneplate, {l>) introducing plates, (c) suture; bone plates in position. 1 324- 1 329. Various Methods of Local Enterec- tomy (von Eiselsberg). 1347- 1324-1327. Exclusion of an Iliocffical Section; 1348. in the caecum exists an abdominal fistula. 1349. 1325, 1328. Exclusion and Circular Suture of a 1350- Section of the Small Intestine, firmly Adhe- rent to Sigmoid Flexure. I350- 1329. Total Exclusion of an Ilioccecal Section. 1352. 1330. Csecal Incision. 1353- 1331. Dupuytren-Blasius's Intestinal Clamps. I354- 1332. Anus prjEternaturalis : (a) intestinal clamp applied ; (i) sectional view of spur ; 1355- (c) after operation. 1333-1334. Von Bergmann's Double Rubber Ball. 1358- 1335. German Truss. 1336-1337. German Truss applied. 1361. 1336. Truss for Inguinal Hernia. 1337. Truss for Femoral Hernia. 1362- 1338. Truss with Glycerine Pad. 1362. 1 336- 1 340. English Truss. 1363. 1341-1343. Umbilical Trusses. 1344. Anatomy of the Inguinal Region: 1364. Femoral vessels and epigastric artery; 1365. external orifice of inguinal canal and 1366. spermatic cord. 1367- The femoral fascia and saphenous open- ing (.fo), through which the saphen- 1368. ous vein passes to join femoral vein. 1369. 1345. Anatomy of the Inguinal Region (Internal Abdominal Side). B. bladder; P. Pou- 1370. part's ligament ; G. Gimbernat's liga- 1371. ment ; Oi. internal orifice of inguinal 1372. canal ; A. V. femoral artery and vein ; Ae. epigastric artery ; Ao. obturator \ 1373- artery (taking its origin at the left ab- | normally from the epigastric artery); F5. spermatic vessels; ^'rz. vas deferens : 1373. I, middle hypogastric fold ; 2, hypo- 1374. gastric fold ; 3, epigastric fold. 1375- Between l and 2 lies the internal inguinal fossa ; between 2 and 3 the middle in- 1376. guinal fossa; exteriorly to 3 the external inguinal fossa. 1346. Frontal Section of the Crural Arch. 1377- A^. crural nerve; A.V. femoral artery and 1380. vein ; Ac. crural ring (place of exit of femoral hernias-crural septum); G. (V\m- bernat's ligament; P. Poupart's ligament; 7\ pubic spine. Herniotomy (External incision). Hernia Knives (Herniotomes). Herniotomy (Relieving strangulation). 1353. Macewen's Radical Operation for In- guinal Hernia. External Incision. Suturing the Hernial Sac. Suturing Inguinal Canal. Macewen's Radical Operation for Congeni- tal Inguinal Hernia. 1357. Bassini's Radical Operation for In- guinal Hernia. 1360. Kocher's Radical Operation for In- guinal Hernia. Anatomy of the Lower Surface of the Liver (according to Henle). 1363. Nephrotomy. Transverse Lumbar Incision. Lateral Lumbar Incisions. I, according to von Bergmann ; 2, according to Konig. Simon's Position for Exposing Kidney. Lange's Position for Exposing Kidney. Topography of Renal Region. R, Kidney. Horizontal Section of the Left Renal Region. Thiersch's Ivory Spindle. (a) Lange's Forceps; (/') Thiersch's Spindle for applying Ligatures in Deep ^^'ounds. Male Urethra (Home's Wax Cast). Triangular Ligament. Triangular Ligament; M. Levator ani; M. Perinei prof, according to Luschka. 1374. Musculus Compressor; Urethroe with- in the Urogenital Diaphragm (Henle) according to Maclise. Lateral View. Internal View. Metallic Catheters, {n) common; (/') end- ing in two tubes at the handle. Prostatic Catheters, {a) strongly curved; {b) with simple inflexion; {c) or double inflexion according to Mercier. 1379. Various Modes of Catheterization. Catheterization in the Female. ILLUSTRATIONS XXXIX FIG. 1381. Flexible Catheters: (a) common, cone- shaped or probe-pointed; (l>) inflexed, according to Mercier. 1382. Clove Hitch. 1383-1384. Dittel's Method of fastening Reten- tion Catheter. 1385. Otis's Scale for Urethral Instruments. 1386. Olive -pointed Bougies according to Otis. 1387. Urethrometer : («) open; (/?) closed; (c) rubber cover. 1388. Filiform Bougies. 1389. Bougies: (i) probe-pointed; (2) with conical end; (3) with common point. 1390. Catgut Strings with Curved Ends, according to Leroy d'Etiolles. 1 39 1. Introducing Bougie into Stricture of Eccen- tric Location. 1392. Otis's Endoscope. 1393. Endoscope filled with Catgut Strings (see also Fig. 1391,^/). 1394. Holt's Divulsor. 1395. Oberlander's Dilator. 1396-1397. Maisonneuve's Urethrotome : Civiale's. 1398. Otis's Dilating Urethrotome: (a) little knife. 1399. Syme's Guide Staff. 1400. Wooden Yoke for Lithotomy Position. 1401. Lithotoiny Position. 1402. Anatomy of External Urethrotomy. 1403. Diagram of External Urethrotomy : (a) transverse section; (/;) longitudinal section; U, urethra; P, perineum. 1404. Dieffenbach's Urethroplasty. 1405. Nelaton's Urethroplasty. 1406. Von Esmarch's Urethroplasty with Under- lining : (a) circumscribing with the knife margins of fistula; (/.) turning margins inward; (c) suture; ( Fig. ^8. Vux Volkmann's Suspension Splint 62 SURGICAL TECHNIC IiG. 59, Slspensiun of the Hand according to \on Volkm\nn For a high elevation of the leg, either the various fixation splints {Pctifs fracture box, double incUned plane, etc.), may be used, or, after fixation of the limb by means of a few cords and wooden boards, the limbs may be suspended in such a way that the foot is sus- pended higher than the rest of the body (Fig. 60). For the same reason, in injuries of the back, the ventral position, and in injuries of the head and neck, the half reclining position, are to be recommended. For the reduction of tem- perature in inflamed parts, cold, or the abstraction of heat, is employed in various ways : — I. In the form of cold compresses. These, if they are really to abstract heat Fig. 60. Suspension of Fenestrated Plaster of Paris Dressing THE TREATMENT OF WOUNDS 63 constantly, must be changed very frequently ; if they remain in position long enough to become warm, they disturb the injured part, and pro- duce an irritating effect {Priessnitz' s com- presses). It is best to use two compresses, one, well wriuig out, being used while the other lies in a basin of cold water near the bed. It is well to place a few pieces of ice in the water. If a sufficient quantity of cold water cannot be had, it is advisable to use a refrigerating mixture (i part of am- monia and 3 parts of saltpetre, coarsely powdered with a mixture of 6 parts of vine- gar and 12-24 parts of water) {Schniucker). 2. As dry cold, preferably by means of ice in rubber bags (ice bags). These ice bags must be securely closed by wooden tampons or large corks (cham- pagne corks), around which the closed ori- fice of the bag is securely fastened by means of a narrow band (Fig. 61). Ice bags provided with a screw cap do not keep waterproof very long, and are more expensive. If the cooling becomes excessive, a few layers of linen or gause are placed between the ice bag and the body; other- wise, either congelation or gangrene might set in. The cold should at all times prodnce a pleasant sensation, for it is then that it relieves pain most effectually. It is not advisable to use bladders, as they are not perfectly waterproof, and, moreover, they soon decompose. To be made water-tight, before being used, they are either painted outside and inside with varnish or rubbed thoroughly with fat. Decomposition is prevented by washing them in anti- septic solutions before each new filling. Glass bottles and tin boxes, filled with ice or cold water, abstract the heat even more energetically than rubber bags, but they do not adapt themselves so well to the part to which they are applied. In practice among the poor, however, or as a makeshift, the cold bottles can be very well employed — for instance, on the perineum, in the axilla, and the inguinal region. In the treatment of inflammatory diseases of the vertebras (spondylitis), Ice Bag 64 SURGICAL TECHNIC tin boxes moulded to the shape of the body and filled with cold water render excellent service iyvoii Esniarch), both because the patients can lie upon them comfortably and because the abstraction of heat is very con- siderable. Figure 62 shows a cooling box for the vertebral column of the neck. Fig. 62. CotJLiN'G Box for the Verte- bral COLUMX OF THE XeCK Fig. 6^. Esmarch's Cold Coil "m n inflammations of the extremities, a very decided efTect can be ex- pected from the cold coil {von EsmarcJi — Fig. 63), a long rubber tube wrapped in coils about the inflamed part. One end of this coil, provided with a stone or a perfo- rated tin block, is placed in a pail filled with ice water, whilst the other end is conducted into an empty pail. Through suction at the lower end, circulation of the ice water is produced, and this circulation can be regulated by tying a string around the lower portion of the tube. If the upper pail has become empty, ^ (D fi'iiiii Fig. 64. Letter's Cold Head Coil it is filled again by pouring into it the water that has flowed off. For the same purpose, Z^zV^r used thin flexible lead tubes, which refrig- THE TREATMENT OF WOUNDS 65 erate still more rapidly and efficiently, because metal, as we know, con- ducts heat better than rubber (Fig. 64). In order to abstract heat from the ivJiole body in febrile diseases, it may be covered with a cooling cover, consisting of a linen cover, one side of which is sewed with closely running coils of a rubber tube {von Esmarch). It is simpler to fill a large water bag with water of the desired temperature and to place the patient upon the same. This constant effect of the cold, of course, is then felt to be more unpleasant than a cold pack in wet sheets or the short stay in a full cool bath, wherewith similar results may be produced. 3. By irrigation with cold water (Fig. 65). From an irrigator hung up over the bed, cold water is allowed to trickle in drops upon the injured part, covered with a bandage in which the water is diffused. The rapidity of the faUing of the drops is regulated by a straw placed in the point of the irrigator. In- stead of an irrigator, a rubber tube may be used, one end of which is provided with a stop- cock, while the other, provided with a perforated tin plug, is lowered into the pail filled with water. The tube works like a siphon, and must be set to work by suction. Smaller siphons of glass or tin tubes may also be used for this purpose. The heat-abstracting effect of the irrigation is very great, in consequence of the evaporation of the water. Hence, water of very low temperature need not be used. The water that flows off must be caught on an inclined plane or on a waterproof sheet (oil cloth), placed beneath it, and be conducted into a pail placed under it. 4. By cold local permanent baths (immersion). For this purpose, tubs are used for the arms and the legs (Figs. 19, 20). F Irrigation 66 SURGICAL TECHNIC The injured limb is placed in the tub on strips of bandages fastened to the tub by buttons on each side. A very low degree of temperature is not required, since the effect of the permanent bath is very powerful. Water from 69° to 72° Fhr. cools very perceptibly in a bath continued for a long time. Generally the regulation of the temperature by the addition of cold water may be left to the patient himself. JSfote. — Through the experiments of Volckcr and Zcrssen, it has been proved that it is possible to cool a part of the body to a greater depth by the local withdrawal of heat. A thermometer introduced 3-5 centimeters into the interior of the tibia — after necrotomy — showed that in this place the temperature was decreased : by the application of ice bags 50° Fhr. in 9 hours ; by the permanent bath in water gradually becoming cooler (86°- 54°) 54° in 14 hours; by irrigation with cold well water (46°-50°) 52° in 9 hours. The temperature of the body taken in the rectum sank during this time hardly perceptibly, and did not reach the normal minimum {Esmarch, " Verbandplatz und Feldlazareth," 2d edition, 1871, pp. 140-143). If the irrigation and the immersion in antiseptic solutions just described are employed in the treatment of wounds, they can very well serve as a sub- stitute for permanent irrigation. Especially by means of the permanent bath do cleansing of infected wounds and inclination toward healing set in rapidly. OPEN TREATMENT OF WOUNDS Before the antiseptic treatment of wounds became generally known, by far the most successful of all prior methods was the ''Open Treatment'' {BartscJier, Biirozv). This left the wound without any medical assistance, — so to say, to itself — and provided only for a constant discharge of the secretions from the open wound, devoid of all dressings. Its advatitages consist : in drying by a constant escape of the secretions, in the drying up of these secretions, and in the forming of scabs, which do not furnish a favorable nutritive soil for the germs of infection ; in securing rest for the wound, which is mostly disturbed by the frequent changes of dressings — often with unclean material, lint, old linen, adhesive plaster, etc. This method has, however, great disadvantages. The surgeon from the beginning does not expect any primary healing of the wound and allows the air free access to its surface. In consequence of this, in badly ventilated, dirty rooms, infection and decomposition of the secretions may easily ensue. For this reason, the method is employed only when for some reason the THE TREATMENT OF WOUNDS 67 antiseptic treatment of the wounds cannot be carried out. For war it is not at all suitable. After the wound has been cleansed from gross impurities and after all hemorrhage has been arrested, the limb is elevated, and under it is placed a Fenestrj\.ted Plaster of Paris Dressing small basin to receive the secretions. To protect the wound against insects and dust, linen in a single layer or gauze may be placed over it. If fixation dressings are necessary — as in complicated fractures, severe contusions, and after resections of joints — the place over the wound must be left open in the dressings by cutting a fenestra (Fig. 72), or the object is attained by the application of interrupted suspended splints (see below), which are especially useful for this purpose. BANDAGING A bandage must not only be practical and good, but must also be well applied ; for it is the only part of the operation that the layman sees, and from it he may often form an opinion of the surgeon's skill. In pre- antiseptic times, especial value was attributed to bandages applied according to the rules of technique and according to exact regulations. Now, we must pay especial attention to the condition of the materials for dressing, and 68 SURGICAL TECHNIC since most modern materials are very soft and pliable, only little skill is necessary to apply them well. Nevertheless, without spending too much time in applying the dressings, the surgeon should always aim, not only to make them practical, but also to make them appear well. Even without special natural ability, dexterity and a light hand may to some extent be acquired by practice. For bandaging single portions of the body, for fastening on the wound the dressings, the splints, etc., bandages and cloths are usually used. Band- ages are used exclusively for the first dressing of the wound and for larger dressings that are to remain in position for some time ; cloths are used for smaller dressings that are to be changed often, and especially as a valuable substitute for dressings where no bandages are at hand or where their appli- cation would require too much time and expense. Moreover, since the cloth dressings can be applied more easily and simply than the bandages, they are, in the hands of laymen, especially suitable for a temporaiy bandage. BANDAGES The application of the bandages — that is, tJie bandaging itself — must be performed with very great care and exactness, since a badly applied bandage ahvays does Jiann. If the bandage is applied too loosely, it does not fulfil its purpose. The several turns become displaced, come to lie one upon the other, and thus produce pressure. If the bandage is applied too tig/itly, then from the constriction under violent pains venous stasis immediately occurs in the parts below the con- striction ; and if this is not soon relieved gangrene (Fig. Gj), or an incurable degeneration of the fi- bres of the muscle, cut off for some time from the circulation of the blood, will occur (is- chemic paralysis of the Fig. 67. CoxsTKicTioN caused by Bandace muscles and contrac- ture — von ]'^olkinan?i). Poorly fitting also is the bandage if it gapes largely — that is, if one margin is drawn tight and presses into the skin, while the other stands off from the surface of the body (Fig. 68). This occurs most frequently when the bandage is "tortured" — that is, when, neglecting the prescribed rules, THE TREATMENT OF WOUNDS 69 Gaping Bandage the operator forces it to take a course that it does not take of itself. A bandage should be applied with moderate tightness, so that it does not get out of place, nor yet cause pressure ; the right measure for this can be learned only by practice. Bandages that have been applied dry, but that have afterward become wet (from com- presses, irrigation), contract greatly and may then cause stasis ; on the other hand, band- ages applied wet (starch bandages) become loose from subsequent drying. The latter, therefore, may be drawn more tightly from the beginning ; while the former are best applied wet. Rubber bandas^es must not be drawn at all, since even slight elastic pressure in time becomes unbearable. Before a bandage is applied, it must be rolled firmly and smoothly : First, make a small stiff roll by simply winding and turning between the fingers one end of the bandage ; next, place this upon the inner surface of one hand so that the part to be rolled passes between the thumb and the fore finger or between the fore finger and the middle finger ; then, with the other hand, by means of supination movements in the hollow of the hand, gradu- ally roll up the free end of the bandage until it can be forced through the fingers only with difficulty (Fig. 69). The more firmly a bandage is rolled, the more easily can it be applied. If a larger number of bandages are to be rolled up quickly, it is better to use a bandage roller (Fig. 70). Bandages rolled up from beginning to end are called "one-headed,'' those rolled from each end to the middle are called "■ tivo- headedr To apply the bandage, hold one end firmly with the left thumb to the portion of the body to be bandaged ; roll the bandage around this from left to right until its beginning is covered, and thereby held in posi- tion ; next, carry it as closely as possible along the body, preferably allowing it always to unroll of its own accord upon the body itself slowly in the tours Fig. 69. Rolling a Bandage 70 SURGICAL TECHNIC described below, but always centripetally and corresponding to the lymph current. Y ox fastening the end of the bandage, a pin, or, better, a safety pin, may be used. If such is not to be had, or if the surgeon wishes to do without it, he divides the end of the bandage by tearing it lengthwise — especially the gauze bandage — and ties it together in front with the other end. Fig. 70. Bandage Roller To unwrap the bandage, catch it loosely at one end, like a skein, and pass the rolled-off part carefully from one hand to the other. In this way, the bandage is made to pass in the air around the limb without touching it, or without drawing it to and fro. Inexpensive gauze bandages are divided with scissors. THE TREATMENT OF WOUNDS 71 We distinguish the following turns : — I. The circular turn {circular bandage, fascia circularis) surrounds the portion of the body in the form of a ring in tours covering one another completely (Fig. 71 below). 2. The screw or spiral course {screw or spiral bandage, dolabra ascendens) encircles the limb in the form of a screw, gradually ascending ; the sev- eral tours cover one another about one-half (Fig. 72). 3. The serpentine turn (dolabra repens) ascends in steeper spiral turns, covering the limb only incompletely. On limbs with an increasing circumference (cone-shaped), these tours form themselves of their own accord if the head of the bandage is allowed to run along the skin and, as it were, to roll off of its own accord (Fig. 71 above). In order to secure an even envelopment on parts of increasing thickness (lower arm, thigh, and leg), as soon as the bandage begins to ascend too steeply, the operator must turn it down again on the other side. This is the — 4. Reversion (dolabra reversa, renverse). To make this tour : — At the place where the bandage no longer covers the preceding turn, place the tip of the left thumb upon its lower margin. Next, with the right hand guiding, chano-e the bandag-e from Fig. 71. Circular and the pronation to the supi- Serpentine Turns , • •, • ^ . ,i nation position, and, at the same time, so bring it in contact with the limb that, though previously drawn tight, it now becomes per- fectly loose. Turn the head of the bandage once in a downward direction so that the hand is again prone. Having thus formed a smooth fold in the bandage, guide the rolling end in a descending direction around the limb, and turn it over again in line with the former fold. If, in making these turns, many inversions of the bandage follow each other, their angles — for the sake of good appearance — should form a regular zigzag line in the axis of the limb. The several turns cover each other about one-half Fig. 72 Spiral Bandage To 72 SURGICAL TECHNIC make these reversed turns well and rapidly requires practice and skill. The bandage applies itself almost of its own accord, if it is held loosely and drawn tight again immediately after the reversion has been made. Strong tension in making the reversed turns produces unsightly projections. 5. The cross turn, figure-of-8 {spica tour), is used where the bandage passes over a joint toward another portion of the body where, owing to a great difference in circumference, simple ascending turns of the bandage cannot be made. In this case, the bandage is carried obliquely over one side of the joint, transversely to the other side; and then, ascending obliquely, is carried across the first oblique turn. The point of crossing lies about in the median line. The several turns do not cover one another completely, but only about two-thirds (Fig. 89). In accordance as they are repeated in ascending or in descending lines, spica ascendens or descendens is obtained. The crossings form a figure faintly resembling the position of the grains in an ear of corn. If the places of crossing, however, cover one another and if the turns of the several tours extend on both sides like a fan, there is produced — 6. The fan turn {ray, turtle turn, testudo). This is used only for band- aging the bent knee and the elbow joint. In accordance as the operator commences with the turns from the sides, advances toward the middle, and ends here with a circular tour, or commencing with a circular tour gradually covers both sides (the open- ing or the closing of a fan), we distinguish the testudo invcrsa and the testudo rc- versaiYxg^. 73, 74). Of bandages that were formerly much used, though now but seldom employed, the following are to be mentioned for special purposes : — The double-headed band- age, rolled up from each end, was especially used on the head and on amputation Fig. 75. FcNDA Bandage stumps. It can be employed also for the approximation of the margins of the wound and in ulcers of the leg (see Fig. "]%). Fig. 73. Testudo Inversa Fk;. 74. Testl'do Re\ersa THE TREATMENT OF WOUNDS 73 The many - headed h2inda.ge( Scu/tet's baVid- age), which consisted of many short strips cover- ing each other one-half, was sometimes used for bandaging complicated Hr- f ractures and for plaster ][" of paris dressings (Fig. 'j 76). The funda bandage, about I meter long and divided from each end to the middle with the exception of a small joint - piece, makes a very practical dressing for smaller projections (nose, chin) ; the mid- dle portion is applied to the part to be protected, the two lower ends are carried upward and the two upper ends down- ward (Fig. 75). Fig. 76. Scultet's Many-tailed Bandage Fig. 77. T Bandages The r bandage, a strip of muslin to the middle of which another strip has been fastened at a right angle, is used for some dressings on the pelvis and on the head (Fig. 77). 74 SURGICAL TECHNIC BANDAGES FOR THE HEAD The double-headed union bandage {fascia njiiens — Fig. y^). The middle part of this bandage is ajDplied opposite to the place of injury ; the heads are passed by each other and then back to the point of starting ; in this way turns are repeated several times and are allowed to cover each other in turns anteriorly and posteriorly. The sagittal bandage {fascia sagittalis — Fig. 79), a T bandage, is especially suitable for uniting transverse wounds of the skull. The cross-knot bandage {fascia nodosa — Fig. 80) is a double-headed bandage. At right angles and under strong traction, its turns are allowed to cross the wound covered with a thick compress, as in tying up a package. Fin. 78 Double-headed Union Bandage Fig. 79 Sagittal Bandage Fig. 80 Cross-knot Bandage {^Fascia nodosa') It is especially suitable as a temporary bandage for wounds which bleed profusely and upon which a stronger pressure is to be exerted (tourniquet). A cravat firmly drawn around the limb or a rubber bandage answers the same purpose. The mitra Hippocratis (Fig. 81) is a double-headed bandage. One end of this bandage is carried around the forehead and the occiput by circular turns and so fixes the turns of the other end, which, covering one another one-half, are carried in turns over the right and the left parietal bone. The halter bandage {capistrum — Figs. 82, 83). The first turn com- mences on the vertex, descends on the right cheek, and passing under the chin ascends on the left cheek to the vertex. The second turn passes in a posterior direction behind the right ear to the neck, on its left side ante- riorly under the chin, and over the right cheek up to the vertex ; thence closely again behind the left ear to the nape of the neck, past the right side of the neck, under the chin and over the left cheek back to the vertex. THE TREATMENT OF WOUNDS 75 After these turns have been repeated two or three times, covering one another Hke the tiles of a roof, about two-thirds, they are fastened by a cir- cular turn around the forehead and the occiput, v/hich turn can if necessary be repeated several times. In antiseptic surgery, this bandage is well adapted to the treatment of injuries of the jaw, and is preferable to all others after operations on the head : since, in using broader bandages, the whole head and neck, with the exception of the face, may be enveloped with its turns (Fig. 83). If it is applied with moist starch bandages, the essential course of the turns must be observed in order that the bandage may fit well. Fig. 81 Fig. 82 Fig. 83 MiTRA HippocRATis Halter Bandage Halter Bandage The eye bandage {mojtoculiis — Fig. 84), to cover the region of the eye, commences with a circular turn around the forehead and the occiput ; to this is added an oblique turn over the parietal bone to the other side below the ear. These two turns of the bandage are repeated several times so that the circular turns always cover one another ; but the oblique turns are spread fanlike on the parietal region and below the ear, and across each other in front of the nose over the glabella. To cover both eyes, the turns are applied on both sides, so that a star of six rays is formed, with the root of the nose as centre (binoculus). Bandage for the nose (Fig. 85) is made in the simplest manner with a roller 60-70 centimeters long, the middle of which is placed upon the nose. The ends on both sides of the nose are turned once around their axis, carried obliquely across the cheek and the occiput, and tied there. This dressing can also be applied with a funda bandage, the ends of which, crossing each other at the side of the alas of the nose, extend above and below the auricle to the occiput. The funda maxillae (Fig. 86), for fixing the broken lower jaw and for smaller wounds of the region of the chin, is applied with a roller about i 7^ SURGICAL TECHNIC meter long and 6 centimeters wide. By tearing from each end to the middle portion about 5 centimeters wide, it is turned into a funda bandage. The middle portion, provided with a slit, is placed on the middle of the chin ; Fig. 84 Eye Bandage (Monoculus) Fig. 85 Bandage for the Nose Fig. 86 Funda Maxill.-e the upper ends are conducted horizontally backward to the occiput, and crossing here are carried obliquely in an anterior direction to the forehead ; the lower ends ascend across the cheek to the vertex, and descend again on the other side. BANDAGES FOR THE ARM For bandaging the several fingers (chirotheka), it is best to use a small flannel or cambric bandage (finger bandage). From a circular tour around the wrist, the turns pass obliquely across the back of the hand to the base of the fingers. The finger is bandaged by serpentine tours to its point ; thence the bandage ascends in spiral tours to the base of the finger, and, cross- ing the first turn on the back of the hand, it returns to the wrist. The manner of bandaging all the fingers may be in- ferred from what has just been said : Starting from the wrist, the surgeon may begin bandag- ing the forefinger or the little finger ; after bandaging each finger, he 1 K.. S7. ( IIIKOTHEKA Fig. 88. Chirotheka THE TREATMENT OF WOUNDS 77 Spica Manus carries the bandage in an upward direction to the wrist so that finally it forms a spica on the back of the hand over each metacarpal bone (Figs. ?>7, 88). The cross bandage of the hand {spica mamis — Fig. 89), for covering the back and the palm of the hand, commences with a circular turn over the wrist or around the base of the fingers, and passes thence in several ascending and descending spica turns around the middle of the hand. In a similar manner is ap- plied the spica pollicis, which envelops the base of the thumb. Similarly, with a circular turn commenc- ing around the four points of the fingers, continuing in spica turns, and advancing to the wrist, the whole hand together zuith the thtimb may be bandaged. The testudo cubiti is applied on the flexed elbow, as described above, so that the several turns cross one another on the flexure of the joint. The spica humeri (Fig. 90) commences with a circular turn in the upper third of the humerus, passes from the left, across the eminence of the shoulder and the back, to the axilla of the other side, and crossing, on the diseased shoulder, the first turn, returns to the beginning end of the bandage ; thence it takes its course again parallel to the first turn, and covering it one-half, continues to the axilla of the other side ; here the turns should cover each other completely, and so forth until the whole region of the shoulder is bandaged. Finally, a few turns are carried around the first circular turn on the humerus or around the chest. The bandaging of the whole arm {involntio brachii — Fig. 91) commences with bandaging the several fingers and the thumb with a long narrow roller. With a broader bandage, the spica manus is next applied across the many small turns of the bandage on the back of the hand, and ends with a circular turn around the wrist. In one or two spiral turns, it ascends along the forearm — to which a series of reversed turns is added — as far as the elbow, which is bandaged by figure-of-8 turns ; ascending thence to the arm, it runs Fig. 90. Spica Humeri 78 SURGICAL TECHXIC in continuous spiral turns to the axilla ; the shoulder is bandaged with a spica turn. General rules for bandaging in injuries of the Jiand and of the fi7igers : Xo strangulation ! untie the buttons of the shirt I cut open the sleeves of the shirt and of the undershirt to the axilla ! do not commence the bandaging of the hand "v\-ith a tight circular turn around the wrist ! avoid the hanging posi- tion of the hand ! \x\. fresh sijnple woiuids, secure union by means of English court plaster, wet or dry gauze bandages saturated with traumati- cin or collodion, or fine sutures (epidermis suture — Donders). Hemorrhage must be arrested mostly by pressure (bandaging). In contused n'ounds of the fingers, band- age with small gauze bandages that have been dipped into a weak antiseptic solu- tion and moisten them from time to time. It is better, however, to use reliable anti- septic dressings. In fractures of the fin- gei's, use either plaster of parts dressings — bandage over small flannel bandages ; or splint dressings — small w^ooden splints padded with cotton and fastened with wet starch bandages or with dn,' gauze bandages saturated with traumaticin or collodion. In fractures of single metacarpal bones, a large cotton ball is placed in the palm of the hand. On this, the hand is firmly wTapped with flannel bandages (ball band- ages). In case of strong retraction, an extensioji dressing with strips of adhesive plaster is practical ; these are made tense by means of a rubber ring on a hand board (see Fig. 266). After exarticulation of a finger, the narrow spica bandage may be used (Fig. 92). In fracture of the clavicle, the displacement of the fragments may be corrected, even if not permanently, by the bandage of Desault. It is true Fig. 91. BaXDAGIXG of the H.A>T) .(LSD THE Arm THE TREATMENT 01^ WOUNDS 79 that this is no longer in fashion, but it is an excellent object lesson ; its several turns are used in nearly all the bandages of the shoulder. T\vQ. first bandage (Fig. 93), by means of turns encii- cling the chest, fastens g zvedgc-shaped pad in the ax- illa of the abducted arm. After the arm has been brought to the side against the pad, it is fixed against the thorax by the second bandage (Fig. 94) and is, at the same time, forced back- ward, while the shoulder is drawn away from the trunk over the pad. The third bandage supports the arm in the form of a mitella (Fig. 95). It takes its course from the axilla of the healthy side to the shoulder of the diseased side ; and, pass- ing around the elbow of the same, it returns to the axilla. These three Fig. 92. Narrow Si'iCA Bandage Fig. 93. Desault's Bandage for Fracture of the Clavicle. («) First bandage Fk;. 94. Desault's Bandage for Fracture OF THE Clavicle. (^) Second bandage Fig. 95. Desault's Bandage for Fracture OF the Clavicle. (<:) Third bandage 8o SURGICAL TECHNIC points are always touched in the same order — axilla, shoulder, elbow. The last end of the bandage is carried from the healthy shoulder downward around the wrist and to the diseased shoulder, and is fastened there. To prevent the displacement of the turns of the bandage, impregnate the bandage with starch paste, or for the last turn use starch or plaster of paris bandages. The bandage of Velpeau (Fig. 96) — which fixes the hand of the diseased side upon the healthy shoulder and fastens the elbow in front of the ensiform process — is useful as well in fractures of the clavicle, as also in chronic inflammations of the shoulder joint. It consists of horizontal turns encircling the thorax and the arm, and of vertical turns which take their course from the diseased shoulder, around the elbow, to the healthy axilla. The elbow rests as if in a sling, and is drawn upward. The turns, applied alter- nately, cross each other in front of the dis- eased arm in the form of a spica. Concerning the adhesive plaster bandage according to Saj're, see page 155. Fig. 96. Velpeau's Bandage for Fracture of the Clavicle BANDAGES OF THE TRUNK In the stellated bandage for the chest and the back (fascia stcllata, Stella — Fig. 97), the turns are carried on both sides in spica or figure-of-8 turns around the supraclavicular region and under the two axillae, in such a way that they cross one another in the median line in front of the sternum and behind the vertebral column. A few turns placed around the trunk or both shoulders serve for fixation. In this way a similar bandage, formerly much used, can be made — namely, the quadriga, which, according to rules, is applied with a double- headed bandage (Fig. 98). The bandaging of the thorax and the abdomen becomes very simple if a broad bandage is applied in spiral turns. In order that the bandage may be applied firmly, and especially that it may not become displaced laterally, it is well to place a few spica turns (figure-of-8 turns) around the shoulder or the hip. Bandages in the region of the pelvis are mostly applied in spica THE TREATMENT OF WOUNDS 8i coxse turns (anterior — for instance, after operations for hernia, on the bladder, penis, scrotum, etc.). For operations on the anus, the T bandage is best. It is, moreover, just as practical to use so-called bathing drawers, which apply themselves well everywhere and which are not expensive. Fig. 97. Stellated Bandage (Stella Dorsi) Fig, Bandage of the Thorax (Quadriga) The compressive bandage for the female breast can be applied in various ways : either in several single oblique turns, which pass from the healthy shoulder below the diseased mamma, and, covering each other in the form of overlapping turns or in the manner of a testudo, extend to the axilla of the diseased side ; or else in turns which are applied around the healthy axilla and allowed to cross each other over the shoulder (Fig. 99). In arranging the turns of the breast ascending from below upward, the mamma is not only compressed but also supported {covipressoriuvi et sus- pejisoriiim niamincB^. A sjispensoriiini viamrn(B duplex (Fig. 100) is best applied with the turns of the above described stellated bandage (Fig. 97), to which a few circular turns around the lower mammarv region are added. The bilateral compressive bandage for the breast {compressoriuni mammcB duplex) is made in spica or figure-of-8 turns, which cross each other in front of the sternum. The bandage is carried from the superior side of one mammia to the inferior side of the other ; across the back to the 82 SURGICAL TECHNIC inferior side of the first and to the superior side of the other ; thence across the back again to the superior side of the first. This process is continued in such a way that the turns, like a testudo, always approach more and Fig. 99. Sl'spensoku'm Ma.m.m.e Fig. icx). Double Si'spensory Mammary Bandage more a central point — namely, the nipple. For a firmer fixation of the bandage, either the final tours are carried around the shoulders or a few circular turns are added around the thorax. BANDAGES OF THE LEG The toes are covered together with a circular bandage, and bandaging each toe separately is dispensed with. The stapes (Fig. 10 1), for bandaging the dorsum of the foot, consists of two or three spiral turns, fastened by a spica turn carried across the ankle joint. The spica pedis is applied in the same manner as the spica manus : to the circular turn over the malleoli are added three or four circular turns across the dorsum of the foot. The zvJwle foot can be bandaged very well by increasing the number of these turns with a broad bandage — only the heel is left imperfectly covered. If the heel is also to be well protected, then the foot is Fig. ioi. Stai-es bandaged in the following manner {involntio pedis): — THE TREATMENT OF WOUNDS 83 The bandage begins immediately above the toes with a circular turn ; then follow two or three reversed turns on the dorsum of the foot, next three spica turns around the dorsum of the foot and the malleoli. Having arrived closely in front of the ankle joint, the bandage now takes its course from the plantar surface to the right (of the patient), around the calcaneus over the Achilles tendon, anteriorly from the left to the right again over the Achilles tendon, on the left around the calcaneus toward the plantar surface, anteriorly over the ankle joint, posteriorly around the heel ; it then ascends across the malleolus to the leg. The testudo genu has been de- scribed above on page 72. The spica coxae for the hip (Fig. 102) resembles essentially the spica humeri. After a circular turn around the upper third of the thigh, there fol- low three or four spica turns, encir- cling the pelvis. The crossings may be placed upon the anterior, lateral, or posterior region of the hip. Applied on both sides, this spica coxcB duplex is the best bandage for the pelvis. Fig. 102 shows a bilateral Ascending spica coxae anterior ascendens, on the right leg — descendens on the left leg. Bandaging of the whole leg {invohitio TJiedenii — Fig. 103) commences with the bandaging of the foot described above. Thereupon follows the bandaging of the leg, by a broader ascending spiral bandage with reversed Fig. 102. Descending Double Anterior Spica for the Hips Fig. io'^!. Bandaging the Whole Leg turns ; of the knee, by a testudo ; of the thigh, by an ascending spiral bandage with reversed turns ; of the region of the hip joint, by a spica coxae completed with a few circular turns around the hypogastric region. 84 . SURGICAL TECHNIC Many of the bandages here described are obsolete, and are used in practice little or not at all. They can all be very well made use of, how- ever, in practice work ; and although the application of a moist gauze bandage is easier than that of a stiff linen one, nevertheless, for exact anti- septic bandaging, a thorough knowledge of the technique of bandaging is indispensable. CLOTH BANDAGES With linen or cotton (shirting, stouts) of triangular (kerchief) or square (handkerchief, napkin) form, most dressings may be applied just as well as with bandages, many even better. For the application of cloths, only little practice is necessary, since the danger of strangulation and stasis even in a poorly appHed bandage is less than when gauze bandages are used ; the cloth bandages are especially suitable for temporary dressings, particularly when made by laymen who render the first assistance (Samaritan). But they can also be well employed for bandaging wounds — for instance, for amputation stumps, for fixation of small dressings, compresses, splints, etc. Fig. 104. VuN Esmakch's Triangular Cloth Cloth bandages had already been most favorably mentioned sixty years ago by Gerdy and Mayor ; but they were forgotten, and were brought into common use only by the introduction of my triangular cloth (Fig. 104). This is printed with figures on which the various bandages are illustrated. By these, the expert obtains a quick survey of what he has learned, while THE TREATMENT OF WOUNDS 85 Fig. 105. Sailor Knot an inexperienced person obtains a good object lesson for his action, a lesson of great advantage, especially to soldiers on the battle-field. We make a distinction between square cloths and large and small tri- angular cloths. The former must consist of square pieces, the sides of which are from 90 to 130 centimeters long. The latter (large triangles) are obtained by an oblique cut ; by cutting from the point to the middle of the base, they may be divided again into two halves (small triangles). A triangular cloth has a point, two extremities, two small sides, and one long- side. For fastening the extremities to- gether, it is best either to use the sailor knot (Fig. 105), which holds more se- curely than Xh-Q, granny s knot (Fig. 106), or by the use of safety pins. As can be seen from the pictures printed upon the cloths, they can be used for various purposes in different forms and sizes ; now, as a cloth bandage folded together from the point to the base into a long and small cravat ; now, as an open triangle with a manifold application of the extremities, by doubhng them, inverting them, tying them together, or fastening them with safety pins. On the several parts of the body, the cloths are used in the following manner : — For bandages of the head, the following are serviceable : — I. The triangular head cloth (capitium triangulare — Figs The middle of this triangular cloth is applied over the vertex so that the long side hangs down transversely in front of the forehead, while the point hangs down over the neck. Next, the two extremities are carried across both ears in a posterior direction and allowed to cross each other over the occiput and over the point which hangs down; thence they are carried again anteriorly Fig. 106. Granny's Knot Fig. 107. Triangu- lar Head Cloth (Anterior view) Fig. 108. Triangu- lar Head Cloth (Posterior view) 86 SURGICAL TECHNIC Fn;. 109. Fi'NDA Bandage for THE Temporal Region Fig. iio. Funda Bandage for THE Occiput and are knotted together over the forehead. Finally, the point hanging down posteriorly is drawn forcibly downward, turned up over the occiput, and fastened over the vertex with a safety pin. 2. The funda capitis (Figs. 109, no). This is a square cloth, 60 centi- meters long and 20 centimeters wide, split on the two small sides like a divided funda bandage. If the operator desires to use it in fastening a dressing over the pari- etal region, he knots the two posterior extremities below the chin and ties the two anterior together over the nape of the neck (Fig. 109). But if the dressing is to be fastened over the occiput, the anterior ex- tremities are tied together under the chin and the posterior over the forehead (Fig. no). In a similar manner, a funda capitis is made for the frontal region. 3. The large square head cloth (capitium magnum quadrangulare — Figs. 111-112). This covers, Hke a hood, not only the skull but also the whole auricular region, the neck, and the throat. It is, therefore, a very practical protective dressing in bad and in cold weather. A large cloth (napkin) about i meter square is folded together diagonally, so that the long margin of the upper half recedes behind the long margin of the lower part as much as the width of the hand. In this way, a rectangle is formed. This is applied to the head of the patient as follows: The mid- dle line of the cloth cov- ers the sagittal suture; the free margin of the lower surface hangs down to the tip of the nose ; ^'^^<}. -"^^'1 the margin of the upper 112. Large Square Head Cloth surface extends to the superciliary region; the narrow margins fold themselves upon the two shoulders. Of the four extremities hanging down anteriorly upon the breast, first the two exterior are tied together under the chin ; next, the margin of the lower surface hanging down in front of the eyes is turned up toward the forehead, and the two inner extremities of the same are Cloth THE TREATMENT OF WOUNDS 87 drawn backward over the ears and tied together over the nape of the neck. With the triangular cloth folded in the shape of a cravat there can be very easily formed a frontal bandage, a buccal bandage, and an eye bandage (Fig. 113). With two such cloths, also a four-tailed bandage for the chin may be extem- porized (Fig. 114). This is done by placing the middle of one cloth upon Fig. 113 Eye Bandage Fig. 114 FuNDA Bandage FOR THE Chin Fig. 115 Cravat or Ker- chief Fig. 116 Cravat with in- serted Pasteboard the anterior surface of the chin and by tying together the ends over the nape of the neck, while the other cloth is carried up to the vertex from the lower surface of the chin. For fastening the bandage over the neck, the kerchief is of service (Fig. 115). This is a triangular cloth folded together in the form of a cravat. If 2^ piece of stijf paste- board ox leather, etc., is incorporated, the bandage becomes still more secure, and the head can then be bent toward the injured side (transverse wounds), provided the maxil- lary margin of the healthy side has been raised by a suffi- ciently high insertion (Fig. 116). For bandages of the arm, we use : — 1. The vincidnm carpi, cross bandage for the hand (Fig. 117). This is a folded cloth, which is placed around the metacarpus in spica or figure-of-8 turns. The cross- ing is made over the place of the injury. 2. The hand cloth, gauntlet (Fig. 118). This is used for bandaging the whole hand. Upon the middle of the long side of the unfolded cloth, the flat hand is so applied that the wrist lies upon the margin, while the fingers correspond with the apex. This apex Fig. 117. Cross Band- age FOR the Hand 88 SURGICAL TECHNIC is turned over the dorsal portion of the hand, the lateral extremities are tied over the wrist, and the apex is used for covering the knot. Amputation stumps may be bandaged in the same way (Fig. 1 19). 3. The elbow cloth. This is applied folded, and bandages the region of the elbow joint in circular and spica or figure-of-8 turns. 4. The shoulder cloth. This is ap- plied : either folded together in a spica tour around the shoulder, the ends being tied in the healthy axilla ; or unfolded, the. apex upon the shoulder and the extremities tied together in the other axilla. In this way, the brachium (arm) is also covered, and a restful position is thereby secured. It is very well to employ this method after exarticulation of the shoulder joint (Fig. 120). It is more practical, how- ever, to use tzvo clotJis, placing one, folded as a loose sling, around the neck — or around the neck and the healthy axilla — and under this the other with its apex unfolded is carried and fastened, while the extremities are tied around the brachium (arm) (Figs. 118, 119). Cloths are most frequently used to meet the following indications : — I. To support the arm {mi- te II a). The viitella pm^va is a sUng made of the folded cloth (Fig. 118). Generally, how- ever, the cloth is unfolded {mitella triangidaris). It is Fig. 119. Head Ci.oTii.JJKEAsx Cloth, ShuulderClutu Fig. 118. SHotTLDKR * i.iiMi, Hand Cloth, Elbow Cloth, and Sal\ll Sling THE TREATMENT OF WOUNDS 89 grasped at the apex and at one extremity. This extremity is carried over the healthy shoulder, while the apex is carried behind the elbow of the diseased arm; the arm itself is placed horizontally upon the cloth; the extremity hanging down is turned upward to the diseased shoulder and tied together with the other extremity over the neck; finally, the apex is drawn from behind the elbow and fastened in front of the arm with a safety pin (Fig. 121). When the shoulder of the diseased side cannot tolerate any pressure, the two extremities may also be carried over the healthy shoulder (Fig. 122). If, however, the healthy arm is to remain entirely free, then the two ends are tied together over the diseased shoulder (Fig. 123). For a safer and firmer position of the arm — for instance, after reducing a dislocation of the shoulder, or in case of fracture of the clavicle — a broad cravat, applied across the mitella, is added ; this presses the arm against the breast (Fig. 124). The large square cloth for carrying the arm {mitella quadrmigidaris — Pig. 125) is applied with a napkin, etc. The ends are fastened with safety pins, since the knots easily cause pressure, especially over the nape of the neck. 2. To bandage a fractured clavicle. According to Szymanozvsky this bandage is made with three cloths; it draws the injured shoulder backward and upward (Fig. 126). 3. To bandage the trunk. In various ways, bandages for this purpose can easily be made with several cloths ; e.g. the cingulum pectoris (Fig. 129), Roser s apron bandage (Fig. 127). 4. To bandage the whole chest. For this purpose, the cloth is so applied that the apex can be carried over the shoulder ; the extremities on both sides are carried around the thorax to the back, where the three corners are knotted together (Figs. 119, 130). The back bandage is made by applying the cloth inverted. Bandagijig the region of the pelvis (Fig. 131). For this purpose, the apex of the cloth is carried from in front across the perineum, the extremi- ties are tied around the hips, and the apex is fastened to them (improvised bathing drawers). The cloth for the buttocks is inverted (Fig. 132). Unnds gauze sash (Fig. 134) consists of two strips, one of which sur- rounds the hips, while the other, fastened to it, supports the penis and the scrotum, as if in a bag (suspensorium). 6. To bandage the leg. For this purpose, the following are service- able : — 90 SURGICAL TECHNIC Fig. 1 20. Breast Cloth, Siioi-lder Cloth Fig. 121. MiTELLA Tkiangilaris Fig. 122. Other Form of Muklla Fig. 12^. Cloth for Carrying the Arm THE TREATMENT OF WOUNDS 91 Fig. 124. MiTELLA Bandage Fig. 125. Square Cloth for Carrying THE Arm a. Posterior view b. Anterior view Fig. 126. Szymanowsky's Bandage for Fracture of the Clavicle 92 SURGICAL TECHNIC Fig. 127. Roser's Apron Bandage FOR THE Chest Fig. 128. Cloth Bandage for the Lateral Region uf the Chest Fig. 129. CiNGULUM Pectoris Fig. 130. Large Breast Cloth Anterior view The same, posterior view, see Fig. 119 THE TREATMENT OF WOUNDS 93 {a) The hip cloth (Fig. 133). This is applied with an unfolded and a folded cloth, in the same manner as the shoulder cloth and Rosers apron bandage (Fig. 135). Fig. 131. Bandage for the Peim^ Fig. 133. Hip Cloth Fig. 132. Cloth for the Buttocks Fig. 134. Unna's Gauze Sash {U) The knee cloth (Fig. 136). This, folded together, is carried around the region of the joint in a spica or figure-of-8 turn. 94 SURGICAL TECHNIC Fig. 136. Knee Cloth Fig. 135. Roser's Apron Band- age FOR THE Inguinal Region YiG. 137. Foot Cloth Fig. 1^8. Mayor's Cloth Bandage for Fracture of the Patella Fig. 139. Mayor's Cloth Bandage for Fracture of ihk Patella (c) The patella bandage. T\\\?,'v& w&q,^ for fracture of tJu- patella. It is made with three cloths according to Mayor; but it is not especially effective, though very good for instruction on bandaging (Figs. 138-139). THE TREATMENT OF WOUNDS 95 {d) The foot cloth (Fig. 137). This is applied in the same manner as the hand cloth described above, by turning the apex over the dorsum of the foot, while the extremities, crossing each other, are carried over the dorsum and over the ankle joint. SPLINTS Splints are used for the purpose of securing rest for injured limbs, especially when their bones and joints are diseased or injured. The missing internal support of the limb is supplied by the splint until the disease or the injury has been repaired. These supporting bandages, therefore, must embrace not only the diseased bone, but also the two neighboring joints and a portion of the fol- lowing section of the limb, in order to secure com- plete rest and immobility for the injured part. Of the large number of splints formerly used for the most various purposes, now comparatively few are in use. The most common are the fol- lowing : — I. WOODEN SPLINTS Simple boards, well padded, are fastened by means of cloths or bandages to the limb, previ- ously wrapped with bandages. Figure 140 shows such a fixation dressing for the broken brachium (arm). If such splints at their ends are provided with tijt sockets and joints {von Esmarc/i), any F^°- ^40- Fixation Dressing . /' ^ PQj^ Tjj£ Broken Arm desired size can be made by joining these together (for instance, for the whole leg). This wooden splint, wJiicJi can be taken apart, can be very easily packed up, and occupies but little space. It is especially suitable for an extension splint during transportation (see below). T Fig. 141 Goocli s flexible wooden splints consist of thin strips of fir (6 millimeters), cut into parallel strips i centimeter wide by means of light, not perfectly 96 SURGICAL TECHNIC penetrating, parallel cuts, and glued upon leather or canvas. They are per- fectly flexible transversely, and perfectly firm longitudinally (Fig. 142). Fig. 142. Guoch's Flexible Wooden Splints Through the attached strips of leather, straps with buckles are passed ; these serve for fastening. t ri Fig. 143. Schnyder's Cloth Splints for the Lower Extremity Sclmyder s cloth splints consist of thin tablets of flexible walnut (veneer) from 2 to 2.5 centimeters wide and 3 millimeters thick, sewed THE TREATMENT OF WOUNDS 97 closely side by side between two pieces of canvas or cotton cloth (Fig. 143)- Similar is von Esmarch's splint material, which can be cut (Fig. 144). It consists of two layers of material (stouts, shirting, canvas), between which Fig. 144. Von Esmarch's Splint Material. (Can be cut) thick paper strips are placed side by side at intervals of 5 millimeters and firmly agglutinated with silicious varnish, paste, or glue. This splint material is very light, can be made rapidly and inexpensively, can be cut with the scissors, and, rolled up, can be packed away in large quantities, since it requires but little space. As a temporary splint for transportation, it is very serviceable. Stronieyer' s padded strips of wood are very much used for injuries and diseases of the arm. They consist of light wood padded with cotton and covered with canvas or some waterproof material. The simple board for Fig. 145. Stromeyer's Hand Splint the hand (Fig. 145), to secure perfect rest for the hand and the fingers, is used everywhere, not only in fractures, but also especially in serious felon, phlegmonous inflammation, etc. Nelatons abduction splint (pistol splint) serves for fractures at the lower ■end of the radius. 98 SURGICAL TECHNIC First, the hand is fastened securely upon the anterior part of the splint ; next, the splint is turned so that it comes in close contact with the forearm, to which it is fastened. The abducted position of the hand draws apart the two ends of the fracture, which lie one upon the other. The splint for Fig. 146. Stromeyek's Splint F(.)K the Arm at an (.)BTr.sE Angle the forearm serves for fractures of the forearm when the elbow joint has to be held at a right angle ; it is supported by a mitella. The splint for the arm at an obtuse angle (Fig. 146) is useful in contusions, sprains, inflamma- tions of the elbow, where ice bags are to be employed, and where the patient is confined to his bed. Fig. 147. Roser's Dorsal Splint for Fracture of the Lower End OF THE Radius Roser's dorsal splint for fracture of the low^er end of the radius is applied on the extensor side of the arm ; by a special padding, the dorsal part of the hand is bent toward the volar; the fingers remain free (Fig. 147)- Carr' s radius splint has an exca- vation for the wrist, while the fingers, which remain free, grasp the trans- verse bar (Fig. 148). Clover s radius splints (Fig. 149) are provided with an excavation for the wrist, and the part for the hand bent off at an angle. Carr's Radius Splint THE TREATMENT OF WOUNDS 99 Jr'iG. 149. CuAER's Radius Splints The English hollow-moulded splints {Bell^ Pott, Cline) are very neatly carved and fitted to the contour of the limb ; at their external surface, Fig. 150. Bell's Hollow-moulded Spljm.^ i- .■.. iiil LtG Fig. 151. Bell's Four Splints for the Thigh leather strips are fastened ; through these are drawn straps provided with buckles, which serve for fastening the splints to the Hmb. The hollow lOO SURGICAL TECHNIC Fig. 152. \'().N Volkmann's Sipinatiun Si'UNT Fig. 153. WatsuiN's Splint for Resection of the Knee Joint Fig. 154. \\atson-Vogt's Splint for Resection of the Knee Joint Fig. 155. Von Volkmann's Tin Splint THE TREATMENT OF WOUNDS lOI internal surface, of course, should be padded. Figure 150 shows two of Bell's splints for tJie leg. Figure 151 shows iowx splints for t lie thigh ; these are so applied that a, b, c, d, come to lie on the anterior, the interior, the posterior, and the external side of the limb respectively. Vo7t J^//^;/m«;2'i' supination splint (Fig. 152), suitable for all injuries of the forearm, is a wooden arm splint. The part for the hand is fastened at a right angle to its surface, so that the hand occupies a position halfway between pronation and supination. Von Volkmamis knee splint is a short splint similar to Bell's (Fig. 151, c)\ it is fastened to the popliteal space in order to prevent the knee joint from moving after extravasations into the same, and in order to prevent the pressure of the applied bandages upon the vessels in the popliteal space. Watson- Vogt's splint for resection of the knee joint (Figs. 153, 154) is suitable only for cases in which a more frequent change of dressings is required. It is applied with starch or plaster of paris bandages. In the normal course of wound-healing, von Volkinann s splint may be substituted for it (Fig. 155). 2. TIN SPLINTS Splints made of tinned sheet iron have long been used as hollow splints, especially for the leg. For the arm, the lighter kinds of splints are better, especially when the patient can walk about. Petit' s boot, a flat, hollow-moulded splint, with a foot board and an open- ing for the heel, was improved by von Volkmann ; he simplified it and pro- vided it with a T-shaped adjustable iron foot support, to prevent the foot from turning over laterally. This T splint of von Volkmann is now used everywhere in the treatment of large wounds of the leg. It is a substitute for the numerous suspension and resection splints, since in cases which take an aseptic course, the bandages may remain in position for weeks until healing has been completed. In the Danish Fig. 156. Salomon's Tin Splint army, Salomon intro- duced flat splints of thin tin plate, 35 centimeters long and 10 centimeters wide. These have at one end two small projections, each divided in three parts ; on the other end are two slits, into which these projections can be inserted and fastened I02 SURGICAL TECHNIC by bending ; in this way splints of any desired length can be easily and rapidly made (Fig. 156). For immediate use, splints may be cut from sheet zinc by means of strong scissors. These may be bent with the hand and moulded to the Pig. 157. Splints of Sheet Zinc contour of the limb (Figs. 157, 158). Models for these splints were men- tioned by ZW71 Hoeter, ScJiocn, Port, and others. We must mention here also Lee's flexible, perforated, nickel-plated metal splints. They adapt themselves well to any flexion of the surface of the body, and are, moreover, light, durable, and inexpensive. Still lighter would be splints of aluminium, which, on account of the growing cheapness of the metal, will probably soon be in general use. Splints of Sheet Zinc Tin splints, on account of the ease with which they are made and packed, aside from their great cleanliness, are especially suitable for military use ; also, in time of peace, they are in great favor on account of their practical adaptation. They are surpassed, however, by WIRE SPLINTS These have the following merits : they are very light and clean ; they allow every infection of the dressing to be noticed at once ; they do not THE TREATMENT OF WOUNDS 103 prevent the secretions from evaporating ; and they hold the bandages in place better than smooth tin. Roser has mentioned several splints of iron wire. Figure 1 59 shows one for the leg. More recently, other models of tinned wire have been used Fig. 159. Roser's Wire Splint for the Leg more extensively {e.g. Fig. 160). Cramer's flexible wire splint (Fig. 161) is most excellent and is applicable for all purposes. It consists of strong Fig. 160. Wire Splint for the Leg, with Handles for Suspension tinned wires, between which finer wires have been stretched, like the rounds of a ladder. The several pieces can be fastened in front one above another ; they can be bent on the flat and on the edge ; wherever desired, openings can be made by breaking out several of the thin wires ; or thinner portions can be formed by bending the wires — ■ in short, there is no form of a splint which could not be rapidly extempo- rized with Cramer's splint. Moreover, it is light, clean, and elegant. Almost as useful are the splints of wire cloth {von EsmarcJi) (Figs. 162, 163), which are light, inexpensive, and flexible. Splints of telegraph wire {Porter^ probably will not be used so frequently Fig. 161. Cramer's Flexible Wire Splint I04 SURGICAL TECHNIC Fig. 162. Splints of Wire Cloth Fig, 163. Splints of Wire Cloth Applied Fig. 164. Leg Splint of Telegi^ph Wire with Foot Support Fig. 165. Arm Splint of Telegraph Wire THE TREATAIENT OF WOUNDS 105 in the future, because the telegraphic circuits are now made with cast bronze wires, which cannot be so well bent. With telegraphic wire, the most com- mon wood and tin splints can be very well substituted, but the making of such splints is always laborious and requires time and especially practice. Figures 164 and 165 show some splints which are frequently used, but for which the wire splints described above may be substituted more easily and inexpensively. 4. GLASS SPLINTS The splints for the arm and the leg mentioned by Nciiber, made of thick cast glass, are very clean and, to a certain degree, aseptic ; they also allow Fig. 166. Neuber's Arm Splint of Glass the smallest infection or penetrating secretion to be recognized at once ; but they have the disadvantage of being heavy, very expensive, and fragile. Fig. 167, Neuber's Leg Splint of Glass In large and rich hospitals they may be of advantage. Figures 166 and 167 show glass splints for the arm and the leg. io6 SURGICAL TECHNIC SPLINTS OF PASTEBOARD From thick gray pasteboard, splints of any desired form can easily be cut with a sharp knife ; the straight edges in which the splint is to be bent to form a groove must be sufficiently incised from the outside with a knife, Fig. I Pasteboard Splint for the Arm SO that the edge can be turned over evenly. If the pasteboard is strong enough, the splints have sufficient power of resistance ; this, however, may be increased by painting the pasteboard with glue, silicious varnish, or lin- seed varnish, or by nailing thin wooden laths upon the splints. Fk;. 169. Model for Arm Splint Pasteboard is used especially for fixation of the arm. Figure 168 shows a pasteboard splint for the arm, which is very practical for all injuries of the elbow joint, forearm, and wrist; it can be easily and quickly made from the model (Fig. 169), either as a semicircular or as an THE TREATMENT OF WOUNDS 107 angular tube. In wounds on the palmar surface of the hand with injuries of the tendons and nerves (after the ends have been sewed), the end of the splint projecting beyond the hand is bent upward like a cap and holds the hand in supination bent toward the volar side (Fig. 170). Fig. 170. Pasteboard Splint for Injuries on the Volar Side of the Wrist In fractures of the humerus, especially at its upper end, it is advisable to make at one end of the broad pasteboard splint four longitudinal cuts at equal intervals. The five small projections thereby formed are bent over the shoulder in the form of a cap, and the whole is fastened with a spica humeri (Fig. 171). In fractures of the lower end of the humerus, the pasteboard splint is sufficient (Fig. 168). The alar splint, according to DiunreicJier (Figs. 172, 173), is an excellent method of fixation for fractures of both bones of the forearm, since by it the forearm is held in a half-pronated position with the elbow flexed, whereby as satisfactory a healing of the two injured bones as possible is ob- tained. One rectangular pasteboard splint is firmly pressed to the volar and another to the dorsal side of the half-supinated fore- arm ; and for fastening them, a narrow splint provided with square alar processes is ap- plied to the ulnar side. The whole dressing Fig. 171. Pasteboard Splint for Fractures of the Humerus io8 SURGICAL TECHNIC is fastened with bandages. By means of the pressure of the lateral splints upon the muscles, the bones which run parallel to each other are forced apart at the places of fracture. Without them (for instance, upon a com- mon pasteboard splint, in full pronation) the ends of the bones would be Fig. 172. Dimreicher's Alar Splint Fig. 173. Dumreicher's Alar Splint forced by a circular bandage in the direction of the intra-osseous space, and would either heal together in the shape of an X, or perhaps cross each other completely (Fig. 174). The method described above should be followed in applying all the other splints for the forearm. Fig. 174. Danger from a Circular Bandage in Fractures of both Bones of the Forearm (according to Albert) Moulded pasteboard splints, which can be well applied to the contour of the body, are made over arm and leg models. The moistened pasteboard is allowed to dry upon the model, and is afterward painted with varnish ; by this means it becomes hard. McrcJiie has recommended such bivalve splints (Figs. 175-178). They may serve as models for all splints that can be made by moulding. More practical, however, are materials so prepared that they will soften when heated and harden when rapidly cooled. Packed in flat sheets, they occupy little space ; and, cut to the required size, they make accurately fit- ting spHnts for the patient. THE TREATiMENT OF WOUNDS 109 Fig. 175. Merchie's Models for Plastic Splints tor the Arm. Fig. 176 Fig. 177. Merchie's Models for Plastic Splints for the Leg. Fig. 178 no SURGICAL TECHNIC These are called : — 6. PLASTIC SPLINTS Plastic pasteboard, according to P. Bnms, is obtained by saturating common pasteboard with a strong solution of shellac ; it softens when ex- posed to the vapor of boiling water or by the dry heat of the oven or hearth, and after a short time becomes as hard as wood. Plastic cellulose sheets {R. De Fischer) consist of thick, factory-made wood-fibre plates, which on one side are saturated with siUcious varnish. If they are moistened on the varnished side with boiling water, they become soft and can be exactly moulded to the limb, and rapidly become firm ; they are fastened with moist gauze bandages, the moistened side being placed exteriorly. Glued cellulose sheets {HubscJier) are especially suitable for producing plastic corsets. Plastic felt {Brims), poro-plastic felt, is made of common thick sole felt, painted with an alcohohc shellac solution until it is completely saturated ; it is then dried in a warm place. Before it is completely dry, it is ironed and smoothed with a hot flat-iron. Dry or moist heat renders it soft ; in this condition, it is moulded to the body, and is rapidly hardened by pouring cold water over it or by dipping it into cold water. Gutta percha sheets (2-3 millimeters thick) may likewise be rendered flexible by carefully dipping them into hot water at 190° Fhr., so that they can be easily cut and moulded in the desired form. Dipped into cold water, they harden rapidly. These splints, it is true, are rather expensive ; but they are suitable not only for making fracture splints, but also as substitutes for other splints mentioned for certain , „ „ purposes, which, having fulfilled their 179. Schede's Radius Splint . . . indication, may again be used. Fig- ure 179 shows, for instance, the radius splint according to ScJiedc. Upon this the hand rests bent toward the volar and ulnar sides ; and by this means, the lower portion of the fracture of the radius, displaced in an upper direction, is best replaced into its natural position. PLASTIC DRESSINGS These surround the limb completely in the form of a firm capsule, like a coat of mail, and cannot be easily removed ; for they are " imimovibleT By a special procedure, however, during their application, viz, by dividing or THE TREATMENT OF WOUNDS III separating them, they can be made " ainovibW; hence, as may be deemed necessary, the limb can either be made freely movable or be fixed in the dressings in an immovable position. The dressings are '' amovo-inamovibW {Seutui). Fixed dressings of materials that become resistant by hardening have been used for a long time ; the procedure, however, in most cases was very complicated (gum arabic, albumen, adhesive plaster, etc.) until starch and plaster of paris were introduced. These essentially simplified the applica- tion of such bandages. THE STARCH DRESSING was invented by Seutm (1840). Preparation of the starch : Stir starch with cold water until an even mass is formed ; while stirring it continuously, add sufficient boiling water to form a clear thick paste. Starch bandages consist of strips of shirting drawn through the fresh paste and rolled. Starch splints are made of strips of pasteboard which are quickly drawn once through hot water ; then starch is applied thickly on both sides. Application of a starch dressing. The limb is first very carefully wrapped with a moist flannel bandage, after the depressions about the joints have been padded with cotton. Over this, a starch bandage is applied, and upon this the soft starch splints are laid and fastened with a starch bandage. Finally, the whole dressing is covered with a dry cotton or gauze bandage. Instead of the bandages, strips of paper may be used. These are drawn through the paste and are applied in the manner of a Scidtef s bandage. Burggrdve s cotton pasteboard dressing is very simple and practical. Splints of pasteboard are cut according to the contour of the limb. After starch is applied to them, a layer of cotton is placed on one side. The splint is applied with the cotton side next to the limb, to which it is securely fastened with muslin bandages commencing with serpentine turns. Over the muslin bandage, starch paste is liberally applied either with the hands or with a large brush ; and finally the whole dressing is covered with a dry calico bandage. It takes from two to three days for the starch bandage to become per- fectly dry and hard ; the drying may be accelerated by exposure or by the heat of the sun or the oven. To make the dressings removable, they are divided throughout their whole length with a pair of strong scissors ; the capsule is bent apart, and 112 SURGICAL TECHNIC calico bandage strips, painted on one side with starch, are pasted over the margins of the clefts Next, the dressing capsule is again applied and fastened with a few straps provided with buckles (Fig. i8o). Fig. iSo. Divided Starch Dressings Of similar construction is the glue dressing ( Vcic/, Brims) in which, instead of starch, common carpenter s glue is used for saturating the band- ages and the splints; glue dries more rapidly than starch. It is still more difficult to make gum arable chalk dressings (Bryant, Wolflcr) with a mix- ture of gum arabic paste and chalk, and paraflEin dressings (Z- >n>///t) 'i t> i ii>i i t //njl>/n'rr7r Fig. 228 Von Esmarch's Suspension Splints made of Telegraph Wire Von Volkniann' s wooden dorsal splint (Figs. 229, 230), which is firmly applied with plaster of paris or starch bandages at the superior surface of the limb, affords the diseased joint a firm support and is especially suitable for all cases in which large wound surfaces, fistulae, or decubitus are on the lower side of the limb. THE TREATMENT OF WOUNDS Fig. 229 135 Fig. 230. Vo.x Volkmaxn's Dorsal Spun' Fig. 221 Fig. 232 Von Esmarch's Iron Arch Splint for Resection OF THE Wrist 136 SURGICAL TECHNIC But if the whole contour of the limb is to remain free, a dorsal and a volar splint may be connected by strong wire arches {von EsviarcJi). These iron arch splints are especially suitable for the wrist joint and ankle joint; they are fastened with plaster of paris bandages and are light and com- fortable (Figs. 231-234). Fig. 2.\x ^HsTP^^*^? Fig. 234 Von Esmarch's Iron Arch Splint for Resection of the Ankle Joint For the elbow joint, my double splint, which can be easily constructed, is very useful (Figs. 235, 236). In changing the dressing, the interrupted padded arch splint upon which the arm rests is lifted from the lower board. My divided iron suspension splint for the clboiv joint is very convenient but somewhat large and heavy ; it consists of three folding sphnts, the arms of which, movable on hinges, are fastened to an iron pole ; in applying the dressing, the middle splint is removed (Figs. 237, 238). THE TREATMENT OF WOUNDS 137 Fig. 235 Fig. 236 Von Esmarch's Double Splint for Resection of the Elbow Joint 138 SURGICAL TECHNIC Fig. 237 Fig. 238 Von E.sMAKCH'ii Divided Iron Suspension Splint for Resection of Elbow Joint POSITION DRESSINGS These serve for a comfortable and secure position of the injured limbs, either alone or in connection with other dressings. They essentially lessen the sufferings of the patient, especially in exten- sive and serious wounds. But since they are rather heavy and bulky, they are not so well adapted to transportation as to hospital treatment. For military service, the most practical are those which are not too heavy, nor too complicated and expensive, and which can be made by any mechanic from a drawing;. THE TREATMENT OF WOUNDS 139 If, in serious injuries of the leg, other conveniences are not available, then as the sim- plest temporary position use the side position according to Pott (Fig. 239); that is, place the patient's leg on pil- lows, with the half-bent knee and hip joint on the exter- nal side ; the muscles thus become relaxed and im- pediments to circulation are avoided. If the injured person is to be transported in this posi- tion, the pillows are fastened around the limb with cords. For the further transpor- tation of such severely injured persons, especially when both lower extremities are injured, Bonnef s wire breeches are use- ful (Fig. 240). This splint consists of a well-padded wire frame, in which the broken limbs are fairly well immo- bilized. Openings can be ^ig. 239. Pott's Side Position made in it, for bandaging the wound without moving the limb from its posi- Fig. 240. Bonnet's Wire Breeches tion. At the foot end are appliances for extension. This apparatus is very I40 SURGICAL TECHNIC comfortable for the patient, but too expensive and bulky, and hardly answers the present requirements of surgical cleanliness. Fig. 241. Wire Breeches flattened for Packing (according to von Esmarch) Of woven wire cloth (wire gauze), which can be purchased, wire splints can be made, which are lighter than Boiincfs and so flexible that they occupy but little space when flattened (Fig. 241). Moreover, they can be more readily cleaned. r\ DorBi.E Inclined Plane The double inclined plane (planum inclinatum duplex) is especially suit- able for serious injuries and fractures of the leg ; it is constructed either, as Figure 242 indicates, according to Petit' s fracture box, or more simply, as THE TREATMENT OF WOUNDS 141 Figure 243 indicates, of a few boards provided on their lateral margins with wooden pegs by which the margins of the cushion upon which the leg rests are pressed against it. Fig. 243 Fig. 244 Von Esmarch's Double Inclined Plane If the wound is on the posterior side of the limb, a piece is sawed out of the board on that side (Fig. 244). Two longer wooden pegs, between which a bandage is stretched in figure-of-8 tours, serve as a support for the foot. By means of Dobsoiis wooden frame (Fig. 245), placed under the mattress in the region of the knee, a practical double in- clined plane for both legs can be extemporized. Von Renz's abduction box (Fig. 246) is especially adapted to cases of compound fractures p.j^__ ^^^^ Dobson's Wooden Frame of the femur, in which the upper fragment is in a strongly abducted position. Since the splint can 142 SURGICAL TECHNIC Fig. 246. VuN Rent's Abduction Bux Fig. 247. Petit and Heistek's Fracture Box THE TREATMENT OF WOUNDS 143 easily be made by any carpenter, it might prove valuable in practice in small places situated at some distance from large cities, where the physi- cian must help himself. Openings are made over the wounds. During defecation, the round pillow, which occupies the part of the splint corre- sponding with the perineal region, is removed. For compound fractures of the leg, previous to antiseptic times, Petifs fracture box, introduced into Germany by Heistcr, was extensively used (Fig. 247). The leg is wedged in between straw cushions by means of the movable side pieces ; for the change of dressings, each side of the lower portion of the leg can be made ac- cessible, one after the other, without changing the position of the leg. By means of the mova- ble supports, the angu- lar position of the knee joint can be easily regu- lated In England, Macln- tyre s splint, improved ^^^- ^ by Listen and made of sheet iron, is used in preference for the same purpose (Fig. 248). The same has a movable foot board, which can be changed in various directions ; by means of a screw on the back, the angular position of the knee joint can be changed very gradually. The transverse board at the lower end gives the splint a secure position. The portion for the thigh can be lengthened or shortened. Fialla s rod splint (Figs. 249, 250) con- sists of a row of thin rods which, by means of a screw, can be pressed together into any desired position around a common axis. It may serve as a substitute for the leg splints and the double inclined planes, especially since it can be easily folded, occupies little space, and can be placed in various angular positions. The fracture box devised by Scheiier has this advantage : it can be very rapidly constructed with a few wooden laths (Fig. 251). In modern times, the hollow straight splints with foot board (Fig. 155) MacIntyre's Splint (improved by Liston) for Com- pound Fractures of the Leg ^J-. \\p t4i rlr *-ft XI i \ Fig. 249. Fi aula's Rod Splint 144 SURGICAL TECHNIC are probably preferred by most physicians to all kinds of fracture boxes. Fig. 250. Fialla's Rod Splint Fk;. 251. Scheuer's Fr.\cture Box In compound fractures of the humerus and in injuries of the shoulder joint, Stromeyer s arm pillow is very useful. This is a triangular soft upholstered horsehair pillow, covered with some waterproof material (Fig. 252). The apex of the pillow edge is placed in the axilla and fastened in front and behind with safety pins to a strip of bandage, which is carried over the opposite shoulder. The arm, bent at a right angle, and the pil- low upon which it is placed are fast- V /£..,itm miir" ■^fer«--- --*-''tiss.?a ened together with a sUng (Fig. 253). inu 253. biKoMi \Ek^ ak.m I'illunn Fig. 252. Stromever's Arm Pillow THE TREATMENT OF WOUNDS 145 It secures rest for the arm by preventing the movements of breathing from being conducted to the fracture. In fractures of the upper end of the humerus with an obstinate abduc- tion of the upper fragment, the whole humerus can be placed in an abducted position by Middeldorpf s triangle, a triangular wedge-shaped pil- low (Fig. 254), or a double inclined plane made of three boards (Fig. 255), the base of which is fastened to the trunk with belts or bandages, while the Fig. 254. Middeldorpf's Triangular Pillow Fig. 255. Middeldorpf's Triangle arm, bent at an obtuse angle, is placed upon the short sides and fastened there. This triangle can also be made from wire splints. On account of the dependent position of the arm, oedema is likely to ensue ; hence, the whole arm must be very carefully bandaged from below upwards. Lister's leather-covered wooden splint (Fig. 256), for resection of the wrist, secures a proper position for the hand and the fingers during the after treatment, when more frequent movements of the fingers become necessary. Many of the hand splints described above are superior, consequently it can almost be dispensed with. Modern surgery, especially in the case of injured 146 SURGICAL TECHNIC limbs, rarely makes it necessary to resort to all of these position appliances, and contents itself with the cleaner modern splints. For special and very tedious cases, they might be used advantageously even to-day. vWW>i'wv^ !;! y^?^>SS-;-'<-^^ -''-'^'"^^" "'"" I""iG. 256. Lister's Wooden Splint eor Resection of Wrist EXTENSION DRESSINGS (distraction dressings) These permanently exert an extending force on some part of the body and are frequently employed with great advantage : — 1. For removing great displacements in simple and compound fractures. 2. For correcting diseased cojitraction of the mnscles and the consequent increased pressure upon diseased bones and joints and for the after treat- ment of some resections. 3. For removing or rather stretching cnrvatnirs. To the incomplete but simple extension appliances, which may eventu- ally be used as a temporary dressing for transportation, belongs Desanlt- Listons wooden splint iox femoral fractures (Fig. 257). A cloth fastens the foot to the lower end — improved by Hayncs Walton (Fig. 257, a) — while a second cloth conducted over the perineum secures counter extension. By means of a third cloth (girdle cloth), the upper end of the spHnt is fastened to the pelvis. By means of a fourth and a fifth cloth, the thigh and leg are fastened laterally to the splint. Similar is Dupnytren' s splint for fracture of the ankle. This splint, provided with a thick pad, is fastened laterally to the calf of the leg, while by means of cloths or bandages, the foot is fastened THE TREATMENT OF WOUNDS 14; Fig. 257. Desault-Liston's Wooden Splint for Femoral Fractures at the lower end in such a manner that the broken ends of the bone are brought in proper position (Fig. 258). For extension, however, the use of weigJits and elastic extensors is much better. To make these means effective it is necessary, by a careful dis- tribution of the points of attach- ment over a large surface, to make the permanent extension endurable for the patient. This has been accomplished by Cros- by s adhesive plaster loop. Since this method is preferably and most frequently employed in fractures of the femur, the extension dressing for the thigh may serve as an illustration of this method of treatment. Crosby s adhesive plaster loop consists of a strong, broad strip of adhesive plaster (spread upon canvas), which is applied along both sides of the leg as far as the frac- tured part of the femur. In the loop against the plantar Fig. 258. Dupuytren's Splint for Fracture of THE Ankle Fig. 260. Applying Strips of Adhesive Plaster 259. Foot Board surface of the foot is placed a small foot board provided with a ring (Fig. 259), to prevent pressure against the malleoli and furnish a point of attach- ment for the cord, and by means of a second strip of adhesive plaster, which encircles the leg spirally, the two strips of plaster are held in place (Fig. 260). 148 SURGICAL TECHNIC Next, with a cambric bandage the whole leg is firmly bandaged from the toes as far as the upper ends of the first adhesive plaster strip. These ends are turned over the last turn of the bandage (Fig. 261 ). By means of a cord Tk;. 261. Fastening Strips of Adhesive Plaster running over pulleys, a weight is fastened to the ring of the foot board ; by means of this weight, the leg is drawn toward the lower end of the bed. The increase of the weight must be made very gradually ; preferably only after 10 to 12 hours, in order that the adhesive plaster may become firmly attached to the skin. If the leg were left without any further support, it would sink into the mattress, and the friction would either entirely or partly neutralize the effect m Fig. 262. Extension by Weight for Fractures of the Femur of the extension. The fragments would, moreover, suffer a rotation from the lateral movements of the foot. To prevent both these results, the leg may be placed on ?fon Volkmaiui s sleigh apparatus (Fig. 263), a short, hollow, iron splint provided with an THE TREATMENT OF WOUNDS 149 opening for the heel, a foot board, and under the same a narrow transverse bar, resting and sliding upon two smooth, triangular wooden bars. If this splint is not at hand, a prismatic transverse piece of wood may be fastened transversely to the dorsal side of the tibia by means of a plaster of paris bandage, which is also carried around the foot ; this transverse piece is allowed to slide on the two wooden prisms connected by parallel iron wires (Fig. 262). In most cases, however, von Volkniann s tin splints are provided with such prismatic transverse pieces of Avood. In many patients, com- mon adhesive plaster causes a troublesome itching of the Fig. 263. Von Volkmann's Sleigh Apparatus skin and eczema; hence, it is better to use non-irritant adhesive plaster; for instance, the excellent though expensive adhesive india-rubber plaster, or the zinc plaster muslin. In cases where not even this is well borne, or where no adhesive materials can be used, a substitute must be found. The extension splint can be fast- ened very well by two wet bandages, each double the length of the whole leg, in the middle of which a small slit is cut for the ring of the foot board. Two of the four ends hanging therefrom are carried in an anterior and the other two in a posterior direction in serpentine turns around the limb (Fig. 264). If another dry bandage is carefully wrapped over them as far as the fracture, considerable extension is secured without causing the bandages to slip ; by coating the bandages with paste or flour, they can be made still more Fig. 264. Fastening the Extension Splint i;v 'Y.\\^> Wet Landages secure. By sewing ox fastening the several turns of the bandage with safety pins, a firm hold is secured even with a common bandage. Likewise, the trellis finger catcher, made of fibres of the palm leaf (" Fingerfanger," " Madchenfanger "), which under tension becomes tighter, ISO SURGICAL TECHNIC and which cannot be stripped again from the limb, can be used in case of necessity as a substitute for adhesive plaster. Although a plaster of paris bandage applied on the bare skin adheres, it is less to be recommended. The traction by the attached weight varies from 2 to 12 kilograms, accord- ing to circumstances ; for most cases 5 to 8 kilograms are sufficient. Very powerful muscles sometimes cannot be overcome by means of weight extension. Counter extension is made by means of a padded cord carried over the perineum and the groin, or by means of a thick India rubber cord wrapped with cotton, and fastened laterally to the head of the bed ; this prevents the patient from being drawn down in his bed by the weight. Or the weight of the body is used for this purpose by raising the foot of the bed with blocks of wood or bricks placed under it. In the treatment of coxitis by extension, the counter extension is made in the abducted position of the limb on the diseased side, and in the adducted position on the liealthy side. After resection of the hip joint, extension must be made with the limb in the abducted position. Von DnnireicJicj- used the weight of the limb for an extension by placing it upon a single inclined splint with rollers (railway apparatus). Much simpler and more practical is Konig's gliding stirrup (Fig. 265), a dorsal splint which allows the leg to be suspended upon two iron arches fastened laterally. To pre- vent outward rotation of the frag- ments, the thigh is fixed with short splints ; for instance, those of Gooch (Fig. 140) and ^i'//(Fig. 151). If the upper fragment is dis- placed much anteriorly, or if on account of uncleanliness the patient's dressings become greatly soiled from the prolonged supine position (which is the case in fractures of the femur in little children), it is advisable to make vertical extension. The leg is drawn up straight on a gallows, so that the body exerts the extension (Schede). For extension of the arm, the adhesive plaster strips are fastened on the internal and external side of the arm, so that the cross-board is placed under the elbow, with the forearm bent at a right angle. If the forearm is sup- ported by a sling, the weight can be fastened to the cross-board, and the patient can walk about. Or the arm is fastened on a suspension splint. Fig. 265. k'onig's Glidinc; Stirrup THE TREATxMENT OF WOUNDS 151 similar to von Volkmamis, at the elbow part of which the extension cord is carried over a pulley ; the patient must then remain in bed. For extension of the wrist in the treatment of inflammation, as well as resection of the same, loops of equal length of adhesive plaster strips are fastened to all the fingers in the form of a gauntlet (Fig. 88), and through these loops a thin rod is inserted. A weight carried over a pulley is fast- FiG. 266. Extension of the Wrist ened to this by means of fine cords. The counter extension can be effected by a large adhesive plaster loop, applied to both sides of the forearm, and fastened by means of a cord with an India rubber ring to the head of the bed. The arm rests on an inclined plane (Fig. 266). Extension of the trunk is resorted to more especially in the treatment of diseases or curvatures of the spine, and can only be accomplished by a complicated apparatus. Among these numerous appliances, the following will be mentioned briefly : — Von Volkmann' s extension apparatus for the cervical portion of the spine in the treatment of spondyHtis (Fig. 267). Fig. 267. Von Volkmann's Extension Apparatus for the Cervical Portion of the Spine The head is extended in a horizontal direction by means of Glisson's sling, which encircles the chin and the occiput ; to this sling, provided with 152 SURGICAL TECHNIC Glisson's Sling a curved iron cross-bar, the extending weight is fastened and carried over a pulley at the head of the bed. If it becomes necessary to increase the exten- sion, this can be done by attaching weights to both lower extremities. Instead of the weights, counter extension is made by raising the head of the bed. For Glissons suspension sling, two loops of adhesive plaster may be substi- tuted ; these are placed around the chin and the occiput, united over the head, and kept apart by a transverse piece of wood. With Glissons suspension sling, according to Sayre, an extension can also be exerted on the scoliotic spine. By means of a pulley the patient lifts himself with both arms until only his toes touch the floor, the weight of the body becoming thus the extending force (Fig. 268). In this position, in which the spine is stretched as much as possible, a fixa- tive dressing (plas- ter of paris felt corset) is applied in cases in which such treatment is indicated. The extension is more endurable and still more effective if axillary extensors are added to Glis- soji s sling (Fig. 269). By this com- bined extension the whole upper section of the vertebral column is lifted (Fig. 270), so that the cur- vature is diminished or corrected. These suspension exercises are re- peated daily, and the time is gradu- ally increased. Scoliotic curvatures may also be removed temporarily by a lateral extension. Barwell places the patient with the prominence of the curva- ,, c , tt a ^ Pig. 270. Sayre's Extension Apparatus for ture into a girth sling, which, when Scoliotic Spine Fig. 268. Extension FOR Scoliosis THE TREATMENT OF WOUNDS 153 traction is made by weight and pulley, presses the curvature into its normal position (Fig. 271). This position is also suitable for applying plastic corsets in an " over correction" (^Peterson). DRESSINGS WITH ELASTIC EXTENSION AND WITH ADHESIVE PLASTER Although elastic extension becomes very effective on account of its active force, its effect can be less easily gauged than that of extension by weight and pulley ; on the other hand, it has the advantage of being lighter and more comfortable. For elastic extension, either strong india- rubber rings, such as can be bought every- where, are used ; or, if such are not available, fig. 271. Barwell's Lateral "exten- a piece of india-rubber hose. sion in Scoliosis Small grooved wooden plugs, provided with hooks, are fastened at both ends (Figs. 272, 273). The simple knot- ting of the ends is less secure, since these knots easily get loose. For a distant transportation, the wounded person is placed at once 7tp07i a stretcher and supplied with such an elastic extension by fastening with an Fig. 272. Groca'ed Wooden Plug Fig. 273. India-rubber Hose with Hooks india-rubber ring the carefully bandaged limb to the lower end of the stretcher ; for counter extension, the belt of the patient, or, in case of neces- sity, the leg of his trousers, cut open at the inner and the outer seam and Fig. 274. Von Esmarch's Stretcher Extension Dressing f|^ for Transportation in Gunshot Wounds of the Femur rolled up to the perineal region, is fastened with an elastic cord or a sus- pender to the head of the stretcher (Fig. 274). 154 SURGICAL TECHXIC For the same purpose, the separable wooden splint (Fig. 139) can be used ; five sections of the same joined together are sufficient. An iron hook, to which the extension ring is fastened, is appHed, when used, at the lowermost part (Fig. 275). At the upper section are two slots, to which are fastened both the pelvic belt and, by means of a second india-rubber ring, the perineal band. If the leg of the trousers is not used for a counter exten- sion, it is carefully folded and used as a padding between the splint and the leg (Fig. 276). The splint, which can be taken apart and which is supplied with a hook and two india-rubber rings, occupies very little space and can be easily packed. Fig. Irun Hook for Separable Wooden Splint Fig. 276. Von Esmarch's Separable Wooden Splint for Elastic Extension OF the Thigh In the same manner the ivrist can be provided with a very effective elastic extension. The hand and the forearm, after having been bandaged as described above (Fig. 266), are placed upon a hand splint provided in front and behind with rollers. Next, the extension cords under the splint Fk;. 277. Elastic Extension of the Wrist are stretched tight by means of an india-rubber ring (Fig. 277). The patient can walk about with this dressing. THE TREATMENT OF WOUNDS 155 Fig. 278. Sayre's Adhesive Plaster Dressing (First Strip) Sayres adhesive plaster dressing for fractiurs of tJie clavicle is also an extension dressing, as by lifting the shoulder outward, backward, and upward, it corrects the overlapping of the fragments. Cut two strips, 8 to 10 centi- meters wide, of strong adhesive plaster spread upon canvas, one strip long enough to be carried around the arm and also around the thorax, the other long enough to be car- ried from the healthy shoulder over the elbow of the diseased side, and thence back to the healthy shoulder. Apply the first strip below the margin of the axilla around the arm ; next, on the posterior side of the arm, sew it together to form a loop wide enough to leave poste- riorly a portion of the arm free ; this pre- vents strangulation. By means of this loop, draw the arm downward and backward, until the internal sternal fragment of the clavicle has been drawn sufficiently downward by stretching the pectoralis major muscle. Fix the arm in this position by carrying the strip of adhesive plaster around the chest and fasten its end posteriorly to the strip (Fig. 278). Cut in the middle portion of the second strip a small longitudinal slit to receive the olecranon process. Next, place the patient's forearm, bent at an acute angle, upon his breast ; (while an assistant forces the elbow forward and inward, completely reducing the fracture) fix the arm in this position by the second strip, the middle of which receives the tip of the elbow. Carry both ends across the breast and back over the opposite shoulder, where they cross each other, and fasten them with a few safety pins (Figs. 279, 280). In the case of unruly children, apply over this a Desault starched bandage. Similar is Landerer' s adhesive plaster dressing iox fractures of the clavicle. Sew a broad strip of adhesive plaster, cut several times lengthwise at one end, together with another strip of equal length by means of a broad piece of strong india-rubber bandage (Fig. 281). Next, apply the first strip upon the diseased shoulder so that its fingerlike attachments come to lie anteri- orly, carry it posteriorly and obliquely across the back, and apply the second strip of adhesive plaster, under strong tension, like a girdle around the healthy side, and fasten it there. The elastic bandage then draws the 156 SURGICAL TECHNIC Fig. 279 Fig. 280 Sayre's Adhesive Tlaster Dressing (Second Strip) diseased shoulder backward, and hence produces an extension force upon the fragments. In the same manner Landcrcr appHes his extcnsio7i dressing for genu valgmn {knock-knee\ Two broad strips of adhesive plaster encircle the thigh and the leg ; at the inner side of the knee a broad elastic band is stretched tensely between them, or into the ends of the bands of adhesive plas- ter, at the knee, transverse pieces of wood are fastened and are gradually Fig. 281 P"iG, 282 Landerer's Adhesive Plaster Dressing with Elastic Extension contracted more and more by india-rubber rings. The same end may be obtained also by means of a buckle arrangement in the elastic middle piece. THE TREATMENT OF WOUNDS 157 More effective, however, is Miciilicz s extension dressing for genu valgum (Fig. 283). The whole leg is bandaged with a plaster of paris dressing, into the posterior and the anterior sides of which iron splints with hinges are incorpo- rated, so that the hinges correspond to the region of the knee joint; at the inner side of the plaster of paris dressing, over the thigh and leg, a hook is fastened with a plaster of paris bandage ; after the dress- ings have set, a wedge is cut out of the dressings in the region of the knee with its base inward ; thereby two plaster of paris dressings are formed, which can be moved laterally on the hinges of the splints; by- means of an elastic extension connecting the two hooks, the leg is gradually straightened. Club-foot shoe with elastic extension (Fig. 284), used in the after treatment of corrected club-foot, consists essen- tially of a solid lace shoe, with lateral steel braces, from the upper end of which an elastic cord extends to the point of the shoe. This exten- sion is to replace artificially the muscles which have become atrophied. According to these principles, it may be changed to meet the require- ments of individual cases. Finally, in connection with more or less complicated appli- ances, extension can be made by means of screw splints ; as exam- ples, may be mentioned here : — Say re's extension dressing for the knee joint (Fig. 285). Thigh and leg are covered with adhe- sive plaster strips in the manner of Sciiltet ' s bandage ; these two separate dressings are screwed Fig, 283. MicuLicz's Extension Dress iNG FOR Genu Valgum Fig. 284. Club-foot Shoe WITH Elastic Extension Fig. 285. Sayre's Extension Dress- ing for the Knee Joint 158 SURGICAL TECHNIC apart by means of an iron splint, attached on both sides at their extreme ends. Sayrc's portable extension apparatus for the treatment of cervical spondylitis (Minerva, Jurymast) consists of a curved steel rod incorporated in the posterior median line of a plas- ter of paris jacket, giving support to the head in a Glissons sling. By means of screw action the rod can be raised and lowered (Fig. 286). Taylor s extension apparatus for the ambulant treatment of coxitis (Fig. 287) consists of a strong steel shaft as long as Fig. 286. Sayre's ^^^ ^^^' ^^^^ ^ P^^^^^ ^^^^ ^^ ^^^ "PP^^ ^^^ JURYM.A.ST and a foot support at its lower end. By means of a screw, the splint can be extended, thus stretching the leg fast- ened to it. The apparatus is fastened by means of aiive- headed strip of adhesive plas- ter, so that its broad end comes to lie in a downward di- r e c t i o n and somewhat across the in- ner m a 1 1 e o- lus (Fig. 288). Over it, the whole leg is covered with a bandage. After the apparatus has been applied, the patient rides or sits on the perineal strap ; the foot hangs suspended in the air and the diseased joint is Fig. 287. Taylor's ExTEN.sa.N ^^^^ relieved from the weight of the body. Apparatus This original apparatus has undergone numerous Fig. 2S8. Fastexing the Adhesive Plaster Strips THE TREATMENT OF WOUNDS 1 59 improvements and has been largely changed {Sajre, Schaffer, Whitehead, and others j. TEMPORARY DRESSINGS If the ordinary articles of dressings so far described are not available for dressing wounds, arresting hemorrhage, immobilizing fractures of bones, the physician or the trained layman (Red Cross nurse, Samaritan) has to extem- porize a dressing quickly with luhatever material is at hand. Such emer- gencies occur often enough in time of peace (it is said that in Prussia alone considerably more than 100,000 serious injuries occur annually). Especially important, however, is the art of improvising rapidly and well in time of war. After large battles, with the murderous destructions which the most recent firearms cause and the infinite number of wounds, even the largest supply of materials for dressings becomes exhausted, and the otherwise ample number of trained persons becomes insufficient at least for the moment. In the treatment of wounds, the first principle to be observed is not to touch the wounds winecessarily, especially with iinclean (non-aseptic) hands, to forego all indiscreet examinations, probing, removing of foreign bodies, and not to apply any dressings which are not known to be surgically clean ; for to leave the wound open and unprotected from every dressing (the open treatment of wounds) is less hazardous than to cover it with unclean mate- rials. Slight hemorrhages also are more easily arrested by means of the scab which forms in the open air. In the neighborhood of inhabited places — in houses, however, with scanty means — an aseptic dressing can be made by boiling water for some time ; with this, the wound is cleansed from all im- purities ; next, it is covered with a clean (washed and ironed) cloth (handker- chief) and this dressing is fastened with another cloth. If no aseptic dressing materials are at hand, they may be obtained in a very simple manner by boiling some pieces of gauze, etc. Wound douches for a sufficient irrigation of the wound may be made with vessels open on the top (cooking utensils), into which the end of a rubber hose, weighted with a stone or some similar object, is lowered, while suc- tion is produced at the other end ; or by making a glass douche according to Fig. 28. Funnels and cans can also be used for this purpose. For bandages may be used strips of table cloths, sheets, and shirts. The cloth bandages may be made of a napkin or a handkerchief. An arm sling may be improvised, in want of cloths, from the skirts of a coat, the sleeves of a coat or a shirt cut open, or the uninjured sleeve fastened to the breast i6o SURGICAL TECHNIC with safety pins (Figs. 289-291). In the case of women place the arm into the apron thrown over the shoulder. Fig. 289 Cloth Bandage of Skirt OF Coat Fig. 290 Bandage of Coat Sleeve CUT OPEN Fig. 291 Bandage of Sleeve fast- ened BY Safety Fins When hemorrhages cannot be arrested by means of a firmly applied dressing, then, first of all, elevate the limb ; in case of necessity, compress the bleeding artery above the wound with the finger or with a tourniquet quickly improvised. In serious injuries of the large vessels, constrict the whole limb between wound and heart with an elastic tube, suspender, or a bandage which is subsequently moistened. If bones are fractured, in addition to the greatest gentleness and cir- cumspection possible in touching and moving the injured person, splints should be quickly procured. For temporary splints may be used : — (a) Wooden splints, rulers, laths, poles, boards (Fig. 292), strips of wood, trellis of flower pots (Fig. 293), flexible wooden covers (like Gooc/is flexible wooden splints — Fig. 140). Useful, also, are twigs or small brandies, tied together in bundles (Fig. 294), or arranged side by side smoothly, fastened by tying them together with transverse pieces of wood (Fig. 295), or wdth THE TREATMENT OF WOUNDS i6i Fig. 292, Tejiporary Splints for Fractured Leg Fig. 293. Splint of Trellis of Flower Pot Fig. 294. Splint of Small Branches tied in Bundles Fig. 295. Flat Splint of Twigs arranged Side by Side l62 SURGICAL TECHNIC twine in the form of a chain (Fig. 296). In a similar manner, the smooth bark of straight trees (willows, beeches), or the dried leaves of banana trees, or thin, flexible veneering may be used. Also, the splint cloth (illus- trated in Fig. 142), which can be cut, may easily be prepared; in lack of some adhesive substance, strips of wood, twigs, etc., are sewed to the material. {b) Straiv splints. Stalks of straw in as good condition as possible are tied together in bundles (Fig. 297). Two of these straw splints are wrapped into both ends of a cloth, placed under the limb in such a manner that they come to lie close to the limb on both sides, and can be fastened to it by means of boards {straw splint — Fig. 298). Also, straw, reeds, or rushes can be sewed into mats (von Beck), and the limb can be enveloped with them and a bandage applied over them ; when rolled up on each side they can also be used for lateral splints (Figs. 299, 300). Door mats, lino- leum, strips of carpet, etc., can be used in the same manner. (r) Pasteboard splints can be easily prepared everywhere according to the models mentioned on page 128. In lack of pasteboard, old book covers, maps, boxes, or layers of newspapers, pasted together, may be used. {a) With a pair of strong scissors, tin can be cut into any desired form of splints (Figs. 156, 157). A piece of roof gutter makes a very practical splint. {e) Wire splints are prepared from strong wire taken from fences, enclosures, or from woven wire gauze, which can be purchased. In time of war, the use of telegraph wire, from lines broken during battle, is of espe- cial importance. With a strong pair of pincers and a file, even with little experience, simple splints may be quickly prepared. They are light, clean, and transparent. Figure 301 shows Porte}'' s splint, which can be easily made. Figure 302 shows a protecting frame for wounded limbs. The construction of other splints from wire presents greater technical difficulties (see Figs. 164, 165). (/) Objects which the wounded man has on his person sometimes furnish very useful material for splints. Articles of clotJdng (for instance, coats, trousers, cloaks, bootlegs) may be employed. A military cloak, for instance, is rolled up on both sides and fastened to the limb by a belt or a cloth (Fig. 303). The sleeves, filled with straw, moss, or earth, can be used as splints. A boot cut open lengthwise and in front in its middle portion, the leather of the leg of which is wrapped about a piece of wood applied exteriorly, provides a foot splint, which, THE TREATMENT OF WOUNDS 163 Fig. 296. Splint of Transverse Pieces of Wood fastened with Twine Fig. 297. Straw Splint Fig. 298. Straw Splint Fig. 299. Straw Mat for Splint 164 SURGICAL TECHNIC Fig. 300. Reed Mat for Splint Fig. -;oi. Porter's Wire Splint Fig. ^02. Protecting Frame for Wounded Limb Fig. ^q-;. Military Cloak used as Splint THE TREATMENT OF WOUNDS 165 like Volkmami' s T, prevents the lateral movements of the injured foot (Fig. 304). Fig. 304. Boot cut open lengthwise used as Foot Splint Weapons like swords, cutlasses, bayonets, sabres, scabbards, muskets, rammers, lances, leather, felt of the saddle, spokes of wheels, canes, umbrellas, and parasols may be used for splints without any further prepa- ration (Figs. 305, 306, 307, 308). i^g) In cases of great emergency, when nothing at all is at hand, the healthy leg is used as a splint for the injured one, and the thorax for the diseased arm. Often there are to be had neither tables nor practical position apparatus for applying the bandages. The military model is excellent as an operating and dressing table (Fig. 309). Upon this, by a kind of double music stand, two men can be dressed at the same time. By means of boards and pillows this arrangement can easily be fixed to any large common table. Position appliances and means of sitspension for injured limbs may easily be made with wire and strips of cloth (Figs. 310, 311). A double inclined plane is made by two laths nailed together at an obtuse angle, a Heister's fracture box, by placing the leg upon a very low bench, the legs of which have been sawed off in a manner that accomplishes the object. A suspension apparatus for a fractured leg can be made by means of several triangular cloths, which as slings are carried across a transverse pole. It can be prepared in a still simpler manner if the stocking is cut open anteriorly and if two rods are fast- ened to its margins. These are hung up on a stronger rod or pole (Fig. 312). The position appliances in Figs. 243, 245, 246, 251, which can be made rapidly by any carpenter, are especially serviceable. i66 SURGICAL TECHXIC Fig. 305. Joined Bayonets used as Splint Fig. 307. Scabbard used as Splint Fig. 308. Mr^KET used as Splint THE TREAT.MEXT OF WOUNDS i6: Fig. 309. Dressing Table (Militan- rvlodel) Fig, 310. Von Volkmann's Suspension Appailitus foPv Injured Aiai Fig. 311. Von Bardeleben's Wire Suspension Apparatus for Fractured Leg Fig. 312. Cubasch's Suspension Apparatus of Stocking cut open l68 SURGICAL TECHNIC ANTISEPSIS IN WAR It is the urgent demand of humanity to have every wounded soldier, even in war, enjoy the protection and the blessings of the antiseptic treatment of wounds. To be able to fulfil this demand it is necessary that: — (a) Not only all military surgeons be perfectly familiar with the anti- septic treatment and the practical application of the same, (d) But also that all persons of the hospital corps (litter bearers, Red Cross nurses) are versed in the principles of antisepsis, and are competent to render efficient first aid. (c) Not only the field hospitals and the hospital corps, but also the wagons for medical supplies of the troops, the knapsacks for the dressings, and the pouches of the hospital assistants must be sufficiently provided with antiseptic material for dressings. (d) In time of war, every soldier should carry with him a packet of anti- septic dressings from which, in case of necessity, an aseptic protective dress- ing can be temporarily suppHed. These demands have been amply met by the supplement of Military Hospital Regulations of 1886. In accordance with them, the following antiseptics and dressings are used: — Carbolic acid, sublimate, iodoform, and materials for dressings charged with these chemicals. Carbolized gauze (see p. 24), subHmate gauze (see p. 26), iodoform gauze, 25% (see p. 33), carbolized and sublimate wound cotton (prepared like gauze). These materials made up in larger and smaller packages are compressed by machinery into a very small space, are fastened together, and wrapped in paper. (The large packages contain i kilogram of cotton; the smaller, 100 grams.) In addition, they contain sublimate catgut, sublimate silk, antiseptic sponges and tampons, moss pasteboard, wood wool, cambric bandages 5 meters long, muslin flannel, gauze, triangular cloths, etc. In field hospitals amply provided with all requisites, the treatment of wounds and the manner of operating do not essentially differ from those practised in large clinics in time of peace. The case is different, however, at the first dressing station and on the battle-field itself, where, on account of rapid changes of position, with the modern art of rapid warfare and with the far-reaching new guns, a change of dressing stations must very fre- quently occur. On account of the accurate aim of present weapons, more- THE TREATMENT OF WOUNDS 169 over, the number of the wounded in a short time becomes so great that not only the surgeons but also the materials for dressing at hand soon become insufficient. Here, where strict antisepsis cannot be performed, at least the first prin- ciple in the treatment of every wound should govern all action: ''Do no harm." Omit, therefore, every examination of the wound with fingers or instru- ments that are not surgically clean (aseptic). Only in the case of dangerous hemorrhage is it justifiable to make an exception to this rule ; for in such instances prompt action is the essential feature of the treatment. In no case should bullets be extracted without the strictest aseptic pre- cautions. A bidlet that has penetrated the body produces in itself only little injury. Many bullets become encysted without causing any subsequent harm. Experience teaches that even very serious internal injuries (of bones, joints, tendons, nerves, lungs, heart, brain, etc.) produced by the bullet in its course, can heal without any suppuration or fever and without any fur- ther complications, provided no germs of putrefaction have entered the wound at the time. Hence, the work of the hospital corps should be limited solely: — (i) To apply temporary dressings; that is, to cover the recent wound amply with antiseptic materials, in order to prevent germs of putrefaction from entering it. (2) To secure for the injured parts of the body a condition of rest {im- mobilization by means of cloths, splints, etc.). (3) To transport the injured thus treated as quickly as possible to the place where the wound can be treated in a strictly antiseptic manner. If the wound of the soldier, provisionally dressed, presents after his arri- val at the field hospital no symptoms necessitating a direct examination (fever, pain, hemorrhage, extravasation of the secretions), it is better to leave the wound tuitoucJied and not even to remove the first protective dress- ing ; for many gunshot wounds heal thus under the scab without any disturb- ance of normal wound healing. But if such symptoms appear as necessitate examination, the dressings must be removed immediately and the wound subjected to energetic anti- septic treatment. For this purpose (apart from major operations, amputa- tions, resections, etc., which may be found necessary), it is above all things necessary to enlarge the wound and establish drainage followed by thorough I/O SURGICAL TECHNIC disinfection with effective antiseptic preparations (such as sublimate, iodo- form, chloride of zinc, etc.); after this, the antiseptic dressings should be applied (see secondary antisepsis, p. 66). If a dressing station is near at hand, the stretcher bearers have no more important duty to perform than to transport the wounded as gently and as rapidly as possible to such a place. Only in cases where medical assistance is not near at hand or where no materials for dressings can be had should the materials which the soldiers carry with them be used either by the wounded themselves or by the stretcher bearers (especially in smaller cavalry divisions). THE SOLDIER'S ANTISEPTIC DRESSING PACKAGE According to the Military Sanitary Regulations of 1886, each soldier in time of war is supplied with a dressing material consisting of two antiseptic muslin compresses, 40 centimeters long and 20 centimeters wide, a cambric bandage 3 meters long and 5 centimeters wide, a safety pin, and waterproof material 28 centimeters long and 18 centimeters wide, for covering. Concerning the composition of this first aid dressing as well as concern- ing practical utility to supply the soldier with such a package for field service, very different opinions prevail among military surgeons. Some consider the same entirely unnecessary. I have heard, however, from many experienced military surgeons, that, during campaigns in distant countries (in the war against the Boers, in the Ashantee war in Egypt, in the Caucasus), the surgeons in dressing the wounded often had to depend entirely on the first aid package which each soldier carried with him. In our last war, especially among the cavalry, very often no other material for dressing was at hand than that which could be found in the pockets of the soldiers ; in my opinion, therefore, humane principles demand that each soldier shall carry with him in the time of war a practical first aid package of antiseptic dressings, with which his wound can be dressed antiseptically, if other material for dressing is not at hand. For many years I have been occupied with the subject of what the first aid package of the soldier should contain and how the material should be packed to be of the greatest practical use. In the year 1869 I published a little pamphlet under the title "The First Dressings on the Battle-field," which contained, as a supplement, a triangular cloth with an engraving rep- resenting the application of Major' s triangular cloth on the battle-field. THE TREATMENT OF WOUNDS 171 During the Franco-Prussian war, many antiseptic dressing packages were made in Kiel by the relief society, according to my directions, and were distributed among our soldiers. These contained, in addition to the triangular cloth with safety pin, two small packages each, filled with car- bolized cotton, and a gauze bandage, all wrapped up in parchment paper. When it was afterward found that carbolic acid evaporated rapidly, I used in its place salicylated cotton ; and since the salicylic acid after carry- ing the package for some length of time fell out from the meshes of the cotton, I substituted a roll of jute of chloride of zinc and afterward pack- ages of sublimated sawdust. But since, on the part of the military authorities, the objection was made to me that it was not advisable to give to the soldier going to war a picture in which the "horrors of the battle-field" were represented, I had another triangular cloth made of the cheapest cotton material, on which only six dif- ferent naked iigures are printed, from which figures the various modes of applying the cloth for dressings can be seen. This cloth is now used uni- versally as a means of instruction for first aid, not only in our Samaritan schools, but also by the large ambulance associations of England and America (Fig. 102). In the composition of these packages, I have always endeavored to fol- low the progress of antisepsis; hence, my latest package, named "Tem- porary Dressing for the Battle-field," contains, in addition to this cloth, two compresses of sodium chloride sublimate gauze (10 centimeters wide, 100 centimeters long), each wrapped in glazed paper, and a sodium chloride sublimate cambric bandage (10 centimeters wide, 2 meters long), so that, with the antiseptic material contained in the package, even large wounds can be dressed. The whole, greatly compressed and wrapped in very durable waterproof india-rubber material, presents a package 1.5 centimeters thick and 10 cen- timeters square, weighing exactly 100 grams. The following directions for use are printed on the same : — " For simple gunshot wounds, apply on each opening of the wound one of the compresses, after the glazed paper has been removed. For larger wounds, unfold the compresses and endeavor to dress the whole surface of the wound with the antiseptic gauze. Hold the gauze in place by a circular bandage. The triangular cloth serves to protect this dressing still further, and at the same time it serves a useful purpose in supporting the injured limb, and in applying temporary splints, illustrated on the cloth." By experiments, it was found that after prolonged storing even the subli- 172 SURGICAL TECHXIC mate evaporated from the materials for dressings ; the materials themselves, however, were found aseptic, so that this temporary dressing serves to meet the indications of primary aseptic occlusion. (The editor has devised a first aid package which is much more compact and which contains as the essential component parts a teaspoonful of boro- salicylic powder, compressed cotton, and a gauze handkerchief, to which are added two strips of adhesive plaster and safety pins. Without the adhesive plaster it is very difficult to hold the dressing in place.) In what part of the uniform these packages should be carried, I do not wish to offer an opinion. This is a matter for the military authorities to decide. I would say, however, that the contents of the package may be folded together to make a package twice as large but half as thick, so that it could be sewed to one side of the breast of the uniform, thus serving for padding. Note. — H. Beckmann, a surgical instrument maker in Kiel, furnishes these aseptic dressing packages for 12^ cents. (A number of years ago the editor suggested that the first aid package should be worn on the inside of the belt, as the belt is about the last thing the soldier will part with on a forced march or in a pitched battle.) NARCOSIS During every major operation, and every prolonged and painful exam- ination, especially when the relaxation of all the muscles is desirable or necessary, the patient should be rendered unconscious, that is, he should be placed under the influence of a general anaesthetic. GENERAL ANESTHESIA is produced by the inspiration of poisonous gases, of which chloroform and ether are the anaesthetics most generally used. CHLOROFORM AN.^STHESLA. Chloroform, CHCI3 (discovered by Liebig, first used by Simpson, in 1847), a clear, colorless liquid, very volatile, non-combustible, and of a characteristic not unpleasant odor, is a poison, the inspired vapors of which produce a paralyzing effect upon the ganglionic cells of the brain and the spinal cord, sometimes causing cessation of breathing and of the heart's action. The paralysis seems to advance in the brain from before backward, so that THE TREATMENT OF WOUNDS 173 first the frontal lobes (consciousness) become involved, and finally the func- tion of the medulla oblongata (respiratory centre) becomes extinct. At any stage of anaesthesia death may occur suddenly from paralysis of the heart. (The result of much experimentation and a large clinical experience appear to prove that the toxic effects of chloroform usually involve the respiratory centres.) Pure chloroform should be free from ether or alcohol, and should contain no methylic compounds (turns black on the addition of concentrated nitric acid), no free chlorine (bleaches moistened litmus paper), no acids (reddens blue litmus paper). If a few drops of chloroform are allowed to evaporate on Swedish filtering paper, a rancid acrid odor of the residuum indicates that the chloroform is impure or decomposed {Hepfs odor test). Since chloroform easily decomposes on exposure to light and air, it should be kept in yellow or dark bottles (25-50 g.) and be changed from one bottle to another as little as possible, and then only in a dark room. Any part of chloroform left over from one anaesthesia should not be used for another anaesthesia, except, perhaps, on the same day. By the presence of illumi- nating gas vapors are formed from the chloroform, which strongly irritate and cause coughing (Chlorwasserstoffsaure.^). By free admission of air and by saturating the room with steam (in a sterilizer), this inconvenience is partly removed. In the administration of chloroform various precautionary measures must be observed : — The stomach of the patient should be empty (no food during the last three or four hours) ; during the operation, the patient should lie upon his back or on one side with his head only slightly elevated, or best of all, perfectly hori- zontal with his limbs slightly elevated ; he should not lie on the abdomen, be- cause this position renders respiration more difficult ; he should not be in a sitting position, because this renders syncope more likely to occur. All tight- fitting articles of clothing (collar, belt, corset), which impede the respiratory movements, should be removed or loosened ; neck and breast should be free and the abdomen easily accessible. For all major operations it is best to place the patient perfectly naked upon the operating table. But since chloroform lowers the body temperature, the patient should be protected, especially in prolonged anaesthesias, from taking cold. Hence, cover his body with blankets, apply hot bottles or the " Warmetuch." Artificial teeth, chewing tobacco, etc., must be removed from the mouth (danger of asphyxia from aspiration) ; the bladder, rectum, under some circumstances also the stomach, should be evacuated before the operation. If the time for 174 SURGICAL TECHNIC an anaesthesia can be previously set the hours of the forenoon are decidedly preferable, because the stomach of the patient is then empty ; hence vomit- ing occurs more rarely and the after effects of anaesthesia are less unpleas- ant. Weak patients may sometimes receive a small glass of strong wine about half an hour before anaesthesia to stimulate the heart's action. If the operation must be performed without these preparations (in case of acci- dent) all precautionary measures on p. 182 must be especially observed, since vomiting nearly always occurs. The ancestJietizcr should attend only to the narcosis, and should pay special attention from the beginning of anaesthesia to the pulse and the res- piration. He must keep within reach, in addition to the chloroform appa- ratus, a mouth-gag, tongue forceps, towel, sponge provided with a handle, and a pus basin. Care must be taken that perfect quietude prevails in the room. All talk should cease, and especially with the patient, likewise all running to and fro. Previous to every anaesthesia the anaesthetizer should carefully examine the heart and lungs of the patient in order that special precautionary measures may be taken in case the heart or lungs of the patient are diseased. Patients having a serious defective cardiac action or a severe affection of the lungs should not be anaesthetized with chloroform. During every narcosis, several persons in addition to the surgeon should be present, partly as assistants, in accidents which suddenly occur, partly as witnesses for the defence, to testify against the hallucinations sometimes represented by patients as facts. Fig. 313. Von Esmakch's Chloroform Apparatus Concentrated chloroform vapors cause, after a very short time, cessation of respiration and of the heart's action. Hence, the administration of chloro- THE TREATMENT OF WOUNDS 175 form on a dense cloth or a saturated sponge, held in close contact with the mouth and the nostrils, is dangerous. Chloroform vapors used for inhalation should be ivell diluted zuitJi air. A very common method of inhalation is by means of Skinner' s apparatus, sim- plified by the author, and consisting of a wire frame, covered with wool- len tricot (mask), and a dropping bottle (Fig. 313). It can easily be carried in the pocket together with forceps for holding the tongue (Fig. 320), packed in a leather or a metal case (Fig. 314). Since the mask oc- casionally becomes soiled with blood, mucus, or vomited matter, it is well to renew the tricot cover before each anaesthesia ; this can easily be done with SchininielbnscJi s aseptic mask (Fig. 315). Likewise, during a prolonged anaesthesia it is well to change the tricot cover, whenever it has become moist from the expired air. Sufficient air is inspired with the chloroform vapors through the tricot cloth during each inspiration. Pour at first only a moderate quantity of the anaesthetic (10-20 drops) upon the mask, hold it lightly before the mouth and the nose, and instruct the patient to take full, deep inspirations, secur- FiG. 314. Chloroform Apparatus packed IN Case Fig. 315- Schimmelbusch's ChloroF(jk.m Mask ing at the same time his confidence by assuring and encouraging remarks. It is altogether a great mistake to pour at once upon the mask so much of the anaesthetic that it trickles down from the inner surface. Aside from the violent irritation of the air passages, indicated by coughing, dyspnoea, and restlessness, inflammation of the skin of the face and especially of the 176 SURGICAL TECHNIC eyelids is to be apprehended from this moistening with chloroform. The skin is protected from this inflammation by brushing it with vaseline or some similar demulcent. In the easiest manner, however, and with a very small quantity of chloroform, anaesthesia may be produced and the patient be kept under its influence for several hours without much danger, if, from the beginning, chloroform is administered only by the drop method (drop narcosis). From an ordinary dropping bottle, allow one drop to fall upon the mask every 5 to 10 seconds. Anaesthesia is often produced in 8 to 10 min- utes, provided a complete quietude prevails in the room while the chloroform is administered and the patient is not touched, for instance, for the purpose of rendering aseptic the field of operation ; nearly all un- pleasant symptoms are absent when anaesthesia is thus gradually in- duced. After anaesthesia has been fully induced it will suffice to admin- ister one drop of the anaesthetic upon the mask every ten seconds until the end of the operation. The quantity of chloroform used is about 25 to 30 grams an hour. In excep- tional cases the anaesthetizer may at times be obliged to administer chloroform more rapidly for the purpose of effecting and maintain- ing: full anaesthesia. Fig. 316. Junker's Chloroform Api'ar.\tus For the purpose of diluting the chloroform vapors at a like proportion by the admixture of zir, Junker s apparatus may be used (Fig. 316). Since the chloroform cannot evaporate in the air with this apparatus, its adminis- tration is more economical. The apparatus consists of a graduated bottle, half filled with chloroform, from which, by means of an atomizer, {a) the vapors mixed with air are forced into the mouthpiece, {b) held before the mouth and the nose of the patient. Kappelcr s apparatus of a similar con- struction can also be recommended. COURSE OF CHLOROFORM ANAESTHESIA After 'CciO. first inspirations, patients have subjective sensations, mostly of a pleasant nature; respiration somewhat increases, the pulse becomes fuller THE TREATMENT OF WOUNDS 1 77 and more rapid, and the eyes are filled with tears. An erythema resembling measles appears on a delicate skin on the neck and the upper portion of the thorax. The patients often cease breathing ; the ansesthetizer should then request them to inspire. Sensibility may have been decreased to such a degree that certain minor momentary operations can be performed without any reflex movements. With many patients, this moment has been reached when the arm, held in a vertical position, slowly sinks down. With feeble patients, men of good habits, women, and children, full narcosis and com- plete relaxation of the muscles will at once set in. In most cases, how- ever, it is preceded by a stage of excitation. Clonic and tonic contractions of the muscles occur ; the patient screams, sings, fights, and makes attempts to run away. This state is especially well marked in vigorous patients and in intemperate persons. To control the excitement from the beginning, it is well, about 15 to 20 minutes before the anaesthesia, to administer an injection of morphine (o.oi), whereby anaesthesia takes a considerably more tranquil course and is more rapidly completed. If the anaesthesia is now continued uninterruptedly, by administering chloroform by the drop method, this state of excitation gradually decreases, and, under deep, often stertorous, respiration, complete anaesthesia — relax- ation of all the muscles, arrest of all reflex movements (period of tolerance) — sets in. Last of all the cornea reflex disappears, as well as that of the mucous membrane of the nose and upon the inner side of the thigh. The pupil, which before relaxation was somewhat dilated, contracts, the eyeballs make asymmetric movements, the pulse becomes smaller and weaker, the body heat and the blood pressure become lower, the respira- tory movements quicker and shallower, and metabolism is retarded. If still more chloroform is inspired, the paralyzing effect may extend to the medulla oblongata and the motor ganglia situated in the heart it- self, and with a sudden dilatation of the pupil, cessation of the respiratory movements and of the heart's action may ensue. This dangerous stage can be avoided, if the patient is kept anaesthetized only to such a degree that the coimea reflex is Just extinct ; chloroform should then be ad- ministered by the drop method at greater intervals, and for some time not at all ; only on the return of the reflex should a few more drops be ad- ministered. Hence, a frequent test for tJie cornea reflex is necessary. Raise the upper eyelid with the third finger, and touch the cornea gently with the forefinger. If the pupil becomes dilated — complete relaxation of the muscles not having set in — it is a premonitory stage of vomiting, which at times may be prevented by administering drops of chloroform more rapidly. 178 SURGICAL TECHNIC With this careful and gradual method of using chloroform, threatening symptoms only rarely occur during anaesthesia. They are most to be apprehended in very excitable patients (hysteria) ; in feeble and anaemic and in stout persons (fatty degeneration of the heart); and in patients subject to pulmonary or heart disease ; in inveterate smokers and drinkers (alcohol, morphine, chloral); likewise, in patients having a diseased liver or kidneys, diabetes, diseases of the lymphatic glands, and thymic asthma (status thymicus). Whether an anaesthesia will take a normal course may be recog- nized after the first inspirations from the fact that the eyes close peacefully ; if the upper eyelid does not close entirely, or if the eyes remain half open, the surgeon must be prepared for unpleasant accidents. THE AWAKENING FROM AN/ESTHESIA VARIES The patient should never be roused from it by calling, shaking, or by beating his chest, etc. After anaesthesias of short duration, in which, however, the stage of fullest tolerance had been reached, the patients often rise sud- denly, are able to walk, and have no after pains. Still in most cases vomit- ing occurs sooner or later. If the patient must be put to bed, as it happens in by far the majority of cases, he should be placed comfortably, and con- tinued quietude should prevail, in the slightly darkened room. Only one person may watch at his bedside. Sometimes anaesthesia is followed by a natural sleep of varied duration. The longer the sleep lasts the milder are the sequelae of chloroform narcosis. In the majority of cases, however, the patient is disturbed in his slumber by vomiting or spasmodic efforts to vomit (nausea). At once turn the head well to one side and hold a folded napkin or a basin at the side of the mouth. Vomiting can become very obstinate and continue for days. The patient is relieved most rapidly, if not a drop of any fluid is given to him in spite of his most imploring entreaties. If his request is fulfilled vomiting will undoubtedly occur again. Should, however, circum- stances make it justifiable to accede to his request, to quench his thirst, it is well to give him small pieces of cracked ice, to place a slice of lemon on his tongue, or to administer a few teaspoonfuls of champagne. Injections of caffeine are also recommended against nausea. Lcivin warmly recommends covering the face of the patient with a cloth saturated with vinegar. This should be applied immediately at the end of anaesthesia over the mask, and the latter be removed from under it, so that no pure air is inspired. The cloth remains in position for several hours. As a rule this crapulence-like condition (" Katzenjammer "), similar to that resulting from the intoxication THE TREATMENT OF WOUNDS 179 of alcoholic drinks, is over on the following morning, and after a day of fast- ing the first meal is greatly relished. Unpleasant occurrences during the next few days are the following : Superficial inflammation of skin (eyes, chin) from chloroform having trickled down from the mask ; contusion of the tongue if it has been held for a long time with forceps, pain and swelhng in the region of the parotid gland, caused by an awkward and prolonged lifting of the lower maxilla ; lameness of one arm from having been raised forcibly in a lateral direction during anaesthesia, — the clavicle, having been turned around its longitudinal axis, contused the brachial plexus against the first rib {ErFs paralysis;, or the arm was carelessly pressed against the edge of the table or bed in taking the pulse (radial paralysis). Likewise similar symptoms may occur on the legs from pelvic high position. Chloroform as well as ether anaesthesias cause a considerable decrease of urinary excretion and albuminuria, the degree of which seems to depend less on the duration of anaesthesia and the quantity of the anaesthetic than on the individual sensibility of the patient (Drencke). Unpleasant accidents during anaesthesia are especially : — 1. Disturbances of respiration. Soon after the first few inspirations, many patients suddenly cease breathing, and must be urged to do so either by encouragement or command. With others, obstinate coughing occurs, which, however, generally ceases after a few very deep inspirations. Pa- tients with bronchial catarrh or asthma are afflicted most frequently by distressing cough. Long-contimied expiratioti {singing) interrupted only by short superficial inspirations becomes especially unpleasant because it prolongs anaestheti- zation. By addressing the patient or by a light blow upon the chest he often resumes the natural mode of breathing. 2. Vomiting may occur during partial as well as complete anaesthesia ; especially when the stomach is not empty, and when the mask for some time had been removed from the face and chloroform was again administered be- cause the patient showed signs of reaction. Even when the stomach is empty, patients are sometimes forced to vomit during the beginning of anaesthesia, on account of swallowing the saliva, which flows profusely and is mixed with chloroform vapors. In such a case, turn the patient's head at once well to one side, in order that the vomited matter may not be aspirated into the air passages ; next, the mucous membrane of the stomach must be rendered less sensitive by a more complete anaesthesia. Experiments have also been made to produce an immediate effect upon the pneumogastric and l8o SURGICAL TECHNIC the phrenic nerves by finger pressure directly behind the sternal end of the clavicle {Joes). When vomiting has ceased, the buccal cavity must be carefully cleansed with a sponge provided with a handle, or with a cloth. 3. A sudden eessation of the respiratory movements, which in the begin- ning of anaesthesia can generally be restored by encouraging the patient, may later on produce symptoms dangerous to life (reflex inhibition of the pneumogastric nerves by irritation of the trigeminus branches upon the mucous membrane of the mouth and the Schneiderian membrane of the nose). After a few stertorous inspirations and after violent spasmodic movements of the muscles, the glottis is closed by the muscular spasms ; the abdominal wall makes a few more inspiratory movements, then retracts and becomes as hard as a board; the jaws are iirmly pressed together; the tongue is drawn backward and upward, so that the passage to the larynx is obstructed. The face becomes flushed ; the lips bluish ; the veins swell ; the pulse at first becomes slow, then imperceptible. This state of asphyxia is caused by the spasms of the muscles of the larynx and the tongue (spastic asphyxia). Prompt action is now imperative to free the upper entrance to the larynx. The set jaws must be separated, the tongue must be drawn well out of the mouth; if this prove successful, respiration is often restored without further assistance, if not, artificial respiration should be made (see below). Relaxation of the rigid muscles is effected by adminis- tering more chloroform. In old people and children, during inspiration, the closed flaccid lips are sometimes drawn like valves toward the toothless jaws and the thin alae of the nose against the septum, preventing the entrance of air. To prevent the injurious reflex from the trigeminus of the mucous membrane of the nose upon the heart's action, Giierin had the chloroform vapors inspired only by the mouth (the nostrils having been occluded with clamp forceps or cotton). More recently Rosenberg recommends — as a pre- vention of asphyxia — to anaesthetize the ramifications of the trigeminus of the mucous membrane of the nose. With a spray he atomizes into the nos- trils at two different tempos 6 eg. of a xo'p cocaine solution a few minutes previous to general anaesthesia. 4. In XkiO. stage of tJie fullest tolerance, during the complete relaxation of all the muscles, the tongue, following gravitation, not rarely falls back and comes to lie upon the posterior pharyngeal space, thereby obstructing the upper entrance to the larynx (paralytic asphyxia). These accidents are the more dangerous because the symptoms of asphyxia do not occur in so violent a manner ; but, in a short time, the blood becomes subcharged with THE TREATMENT OF WOUNDS l8l carbonic acid. The respiration becomes heavy and stertorous ; or even re- spiratory retractions ("Einziehung") set in, the face becomes blue, the blood dark, and the pulse irregular and weak. With sufficient attention, these symptoms can be easily removed, by raising the lower jaw and by drawing out the tongue. 5. Disticrbmices of the circulation. The most dangerous accident that can occur in all the stages of chloroform anaesthesia is the sudden paraly- sis of the Jieart, which can produce death (syncope). The face very sud- denly turns as pale as death ; the pupil becomes dilated and fixed ; the cornea reflex disappears; the lower jaw falls as in a corpse; the pulse becomes rapidly imperceptible ; the heart beats are no longer audible ; the hemorrhage from the operating wound ceases. Respiratory movements may continue still for some time, although superficial and irregular, until, after a few short inspiratory efforts, they cease as in the dying. Fortu- nately, this distressing state very rarely occurs, and then mostly in anaemic persons and in those who are suffering from heart disease. Still, even robust persons in perfect health may become subject to it, especially when they have manifested great fear and excitement before the operation. If the cardiac function cannot be restored by artificial respiration and mas- sage, death ensues. The mortality from chloroform is about one in every ten to twenty thousand persons anaesthetized, and undoubtedly death from this cause is becoming more and more infrequent. Many fatal cases from chloroform are of course kept secret or reported as resulting from other causes. The cases heretofore published occurred especially during minor operations, which were to be performed rapidly with imperfect precaution and insufficient preparation. Likewise, all those cases of fatal shock during operations, which were observed before the discovery of chloroform, must be considered here. Fatal accidents from anaesthesia may happen in the practice of any surgeon with any patient ; and the blame should not be attached to the surgeon, provided he is familiar with and has followed all precautionary measures. Note. — According to the statistics collected by Gurlt and communicated to the last Surgical Congress, of 327,593 persons anaesthetized 134 deaths occurred ( i : 2444). Of the several narcotics, chloroform was fatal at the ratio of i : 2039 ; chloroform with ether, at I : 5090; ethylene bromide, at i : 5228; pental, at i : 199. With pure ether, no death occurred in 14,506 anaesthesias, and the same freedom from danger was observed with the mixture of chloroform, ether, and alcohol recommended by Billroth., at i : 3870, ether and chloroform, at i : 7594. (The statistics quoted by the author refer only to deaths resulting from the immediate effects of the anesthetic. The mortality would be much greater if all the fatal cases were 1 82 SURGICAL TECHNIC reported, and more especially if it would include deaths resulting from secondary compli- cations caused by the anzesthetic ; if this were done the dangers from ether anzesthesia would become more apparent.) Death from chloroform must be considered an accident for which every surgeon ought to be prepared if he uses chloroform. The statistics quoted show that this accident occurs rather frequently, even though some surgeons for years and tens of years had no fatal case during anaesthesia. Death from chloroform (poisoning) may even occur subsequently (after several days), especially after a very prolonged full and often repeated anccsthesia, from which the patient completely recovered. In such cases frequent vomiting, heematuria, icterus, albuminuria, weakness of the cardiac action, collapse, occur. Frequently these cases resulting from the after effects of chloroform are not rightly diag- nosed as such. The action of the surgeon during serious accidents is of the very greatest importance, since upon it often depends the life of the patient. He should see to it that the air can enter freely and that respiration not only does not cease, but, if necessary, is maintained artificially. The chloroform mask, of course, must be removed ivwiediately whenever grave symptoms make their appearance. Care for unobstructed respiration. Displacement of tJie entrance of the larynx occurs most frequently during full anaesthesia; in consequence of relaxation of the vinsclcs, the tongue falls toward the posterior pharyngeal wall, and the epiglottis closes the upper entrance to the larynx. This con- dition can easily be corrected by : — Lifting of the lower jaw. Standing behind the patient, apply both hands flat to the neck in such a manner that the forefingers come to lie behind the ascending rami of the lower maxilla ; push the whole lower maxilla for- ward until the lower row of teeth projects beyond the upper (subluxation. Fig. 317). By means of this manipulation, the muscles at the root of the tongue attached to the lower maxilla, to- gether with the epiglot- tis and the hyoid bone, Fig. 317. LiKHNG the Lower Jaw ^^^ ^^^^^^ forward in such a manner that the upper entrance to the larynx becomes free. The same effect is obtained also in the following manner : Stand before the THE TREATMENT OF WOUXDS 183 patient; place the forefingers of both hands, hook-like, behind the angle of the jaw and draw it forward {Kappele}-). Do not open the mouth too far during these manipulations, else the base of the tongue is not lifted forward but only upward. The operator should proceed very gently in lifting the lower maxilla, especially when the process must be continued for some time ; else, during the following days, violent pains occur in the temporo-maxillary articulation, together with swelling of this region, especially of the parotid gland, which causes greater trouble to the patient than the operation itself. For this purpose, Giitsch has mentioned a lower maxilla holder, with which the lower maxilla can be drawn forward permanently and easily (Fig. 318;. The rubber pad is placed behind the lower row of teeth, the wire ring under the chin ; the clasp is closed, and then the lower jaw is drawn forward by means of the ring. If, however, an obstruction to the respiratory passage occurs in conse- quence of spastic contraction of the muscles of the larynx, whilst also the other muscles of the body are forcibly contracted, the operator will not succeed in pushing forward the lower maxilla in the manner indicated ; in such a case the jaws must be separated {Heisters or Rosers gag — see Figs. 1 135, 1 1 36), the tongue must be grasped with the fingers or with Fig. 318. Gutsch's Lower Maxilla Holder Fig. 319. Protraction of Tongue with Forceps tongue-holding forceps (Fig. 320; and drawn out of the mouth as far as pos- sible (Fig. 319). As after a long use of the forceps sometimes a consider- able contusion of the tongue is produced, it is better to employ a tenaculum 1 84 SURGICAL TECHNIC forceps (Fig. 321), as its use is attended by less injury to the tongue. In case of necessity, a strong thread may be drawn through the tongue with a large needle and used as a substitute for forceps. If the jaws are set very tightly, Kappelo' recommends to grasp the Jiyoid bone with a little sharp hook from the outside and to draw it forward ; by this means the base of the tongue and the epiglottis yield to the traction. Fig. 320 Von Esmarch's Tongue HOLDING Forceps Fig. 321 Championniere's Hooked Tongue-holding Forceps Fig. 322 Sponge Holder If respiration still remains labored and stertorous, it is possible that this depends on the presence of viiicus or blood upon the glottis. The obstruct- ing substance should be removed with a sponge, which is carried to the larynx by means of curved dressing forceps or a sponge holder (Fig. 322). If, in spite of all these means, no marked relief in respiration is effected, then as a last resort tracheotomy should be quickly performed. If the respiratory movcjuents cease altogether, artificial respiration must be made immediately. An essential condition for being effective is that the entrance of air to the respiratory organs be completely free. Hence the lower jaw should be pushed forward by an assistant and held in this posi- tion ; or the tongue should be drawn forward as far as possible and held in this position (lower maxilla holder) ; or it should be fastened over the chin with a cloth, strip of linen, rubber band, etc., else tracheotomy should be performed. The most effective methods of artificial respiration are : — THE TREATMENT OF WOUNDS 185 I. Silvester's method. Stand at the head of the recumbent patient; take hold of both arms directly below the elbow; draw them slowly, but vigorously, upward and over the head of the patient ; hold them ex- tended in this position for about 2 seconds (Fig. 323) ; then bring them again downward, and press the bent elbows gently, but firmly, for 2 seconds in front of the thorax, the left one more toward the median line and the region of the heart (Fig. 324). Repeat these upward and downward move- ments of the arms about fifteen times (corresponding to the number of normal Fig. 323. N£laton's Inversion and Silvester's Artificial Respiration (Inspiration) respirations) a minute, quietly and regularly (counting i — 2 — 3 — 4) until the respiration is restored ; this sometimes requires several Jiours. If the respiratory movements are made properly, with each inspiration the air is heard entering the lungs with a hissing or sipping sound. 2. Schiiller's method. If the abdominal walls are completely relaxed and not too fat, stand at the patient's head, take hold of the costal arches with both hands, draw them vigorously outward, and compress them like a pair of bellows ; by this means very powerful respiratory movements are produced. 1 86 SURGICAL TECHNIC FlasJiar compresses the thorax by means of two straps (towels, belt) carried around it, which are equally drawn upon at the same time on both sides ; when the traction is discontinued the elastic thorax expands again. 3. Laborde's method. Seize the root of the tongue with the fingers or forceps, draw it forward as far as possible, and allow it to return. Continue this slowly and rhythmically fifteen or twenty times a minute, corresponding to the number of normal respirations. The excitation of the respiratory centre is affected in a reflectory manner by stretching rhythmically the superior laryngeal nerve. Fig. 324. Nelaton's Inveksiux and Silvester's Artificial Respiration (Expiration) The method of Marshall Hall (according to which the patient is rolled alternately from the abdominal position — expiration — to the lateral posi- tion — inspiration) and Howard's method (in which an assistant kneels upon the patient, seated as if on horseback, and presses with his whole weight upon the thorax — expiration) are of little value for the surgeon. 4. Rhythmic faradization of the phrenic nerve {Ducheiine, von Zievisseri) can be made only when everything is within reach and in readiness, but then THE TREATMENT OF WOUNDS 1 8/ most effectively. Apply the electrodes at both sides of the neck over the clavicle at the external margin of the sterno-cleido-mastoid muscle. By means of certain stimulants, the failing respiratory movements by reflex action may be excited again, or restored after complete cessation. The most effective are : dashing cold water into the face, beating the breast (and back) with a towel dipped in cold or hot water, stimulation of the nasal membrane by an electric current, rubbing the region of the stomach or the neck with cold water, ice, snow, distention of the anus by introducing one or several fingers, a rectal injection of cognac and water (i : 2); finally, vigor- ous rubbing with hot cloths, brushing the surfaces of the hand and the foot, inhalation of amyl nitrite. In sudden paralysis of the //£■«;'/ (syncope), N^elaton s inversion (1861) must first be attempted as the chief remedy. Place the patient in such a position that his head lies lower than his body, by raising the foot end of the table (Fig. 323); or hold the patient by his knees and place him over the shoulders so that his body hangs down perpendicularly (see also Fig. 1416). In this position the blood supply to the heart, which has become anaemic during anaesthesia, is promptly increased ; the flow of blood to the brain is also promoted, and the cerebral anaemia overcome. For the same reason, during artificial respiration, which must be made at once, the patient should be placed at least slightly in the inverted position, and during the compression of the thorax, the left elbow should be pressed forcibly against the region of the heart. Kbnig's massage of the cardiac region is most effective. Stand at the left side of the patient; compress the thorax with the thenar eminence of the right hand between the place of the apex beat and the left sternal margin with considerable force and as rapidly as possible {120 a minute), until the effect of the movements is recognized by the artificial carotid pulse and the contraction of the pupils. In most serious cases, where even massaging the cardiac region did not effect the desired result, life was saved by intravenous infusion of sodium cJiloride. Faradization of the heart by means of electro puncture (^Steinei-), formerly recommended, must be rejected as injurious. Rhythmic faradization of the exposed cardiac muscle has been suggested. i88 SURGICAL TECHNIC ETHER ANiESTHESIA Ethylic ether, sulphuric ether, C4HjqO, is the oldest anaesthetic. It was first used for anaesthesia in 1846 by Jacksoji and Morton. Only pure ether should be used for anaesthesia (aether purissimus pro narkosi, anhydrous ether, Pictet). If ether contains alcohol, it turns red by adding fuchsine ; if it contains water, powdered tannin will be dissolved into a thick mass on addition. Ether to be used for anaesthesias is best kept in dark bottles of 100 to 200 grams each. It should be brought in contact with air and light as Httle as possible. Any portion of ether remaining over from one anaesthesia should not be used for a subsequent narcosis. Ether evaporates very easily, its vapors are heavier than air and combustible to a high degree. Hence, it renders operations dangerous for the surgeon as well as for the patient, especially when they are performed with artificial light or the use of the thermo-cautery. Ether is much less poisonous than chloroform ; its largest toxic dose is about five to seven times greater than that of chloroform. According to Giirlfs statistics death from anaesthesia occurred at the rate of i to 5000. Still, in some clinics a much higher ratio of anaesthesias has been obtained ; for instance, Oilier at Lyons reports that since the introduction of ether no death occurred in 40,000 anaesthetized persons. On account of its less toxic qualities, Diuch larger quantities are required for a full anaesthesia. Ether does not act so rapidly and effectively as chloroform, but \\\\e.n p}vperly administered most of the dreaded and danger- ous symptoms are absent. Two 7iiet/wds of ether ancesthesia are used : — First, the asphyxiating form. For this purpose a large mask is used, covering the whole face. On its inner side the mask has several layers of gauze, flannel, or cotton, on its outside it is covered with some impermeable air-tight material (Fig. 325). Into the mask about 20 grams of ether are poured at a time ; the mask is then » firmly pressed upon the face, so that For the purpose of admittitig still as Fig. 325. Jlillaku's Ether Mask very little, if any, air is admitted. little air as possible a towel may be applied tightly around the margin of the THE TREATMENT OF WOUNDS 189 mask. Anaesthesia comes on almost as rapidly as with chloroform ; the apprehension that too much carbonic acid and too little oxygen is under the mask has no foundation {Dreser). When administering more ether the anaesthetizer should proceed as rapidly as possible, lest too much air is in- spired by raising the mask. This method is very convenient and simple. The amount of ether used is about 100 to 150 grams an hour. Sometimes even larger quantities can be administered without injury to the patient. Second, the intoxicating form. Pour the ether in a Wanschers mask, a large rubber bag whose opening can be applied almost air-tight to the mouth and nose (Figs. 326 and 327). Pour at first about 50 grams into the mask, hold it before the nose and mouth of the patient, and gradually apply it tight. By shaking the lower part of the mask more ether is caused to evaporate, hence the dose of ether can be regulated \o some degree. Anaesthesia, of course, comes on much less rapidly, but it has less unpleasant symptoms and after effects. The course of ether anaesthesia is es- sentially similar to that of chloroform. In the beginning of it the patient ap- pears excited, often in a cheerful frame of mind. The face turns red, large maculated exanthem appears on the neck and chest, coughing, singultus (hiccough), salivation, perspiration, and lachrymation occur from its irritating effect. Cyanosis of the face in most cases is very pronounced, tJie blood pressure is often increased to twice or three times its normal, the beats of the pulse mostly remain normal. The condition of the pupils is with ether less important than with chloroform ; in most cases they at first dilate and afterward contract, but not always. The occurrence of clonic contractions (" Aetherzittern ") is often very annoy- ing. When after more or less pronounced excitation the stage of tolerance occurs, inspiration is regular and stertorous. Dangers from anaesthesia involve less the heart, as in chloroform, than the respiration. The very profuse secretions of saliva are aspirated ; coarse crepitant rales are heard in breathing; the patient may die at the end of Fig. 326 Fig. 327 Old Form Modern P'orm Waxscher-Grossmann's Ether Mask 190 SURGICAL TFXHNIC anaesthesia or several days afterward of broncho-pneumonia. Hence, it is the principal duty of the anaesthetizer to see to it that the mucous secretions from the mouth are cleared. Place the patient in a position with his head very dependent and tiinicd ivcU to one side ; raise the angle of the lower jaw, place the forefinger hooklike behind the angle of the jaw, and draw it downward. Clear with a sponge the mucous secretions which have collected in the cavity of the mouth, this being the deepest point. With these pre- cautions the tracheal rale (for a long time considered characteristic of ether anaesthesia) is avoided. For ether, aside from a slight increase of saliva, produces no excitation whatever upon the mucous membrane of the air passages {HdlscJicr\ In the stage of fullest tolerance, when too large a dose has been admin- istered, primary cessation of respiration is to be apprehended. It should be treated according to the rules mentioned in chloroform asphyxia. Hence, it is even more important in ether anaesthesia than in chloroform anaesthesia to observe carefully the respiration of the patient. Any disturbance of the cardiac action which makes the use of chloroform so incalculable, is to be apprehended with ether only as a secondary cause. Hence, ether should not be used : In diseases of the air passages (bron- chitis, bronchiectasis, tuberculosis, and in the case of old patients with rigid thorax which renders expectoration difficult). Moreover, it is not preferably used in operations on the face, since the effects of ether anaesthesia become neutralized by frequently raising the mask. The awakening from an ether anaesthesia takes place more rapidly than from chloroform ; sometimes analgesia continues for some time after con- sciousness has been restored. With some patients subsequently great ex- citation occurs. Vomiting does not occur so regularly as with chloroform. For many patients the odor of ether (often lasting for days) of the expirated air is unpleasant ; still, according to DrescJier, the larger quantity of ether has been disassimilated one hour after anaesthesia. As after effects should be mentioned, above all, bronchitis, pneumonia, oedema of the lungs ("we lose our patients anaesthetized with chloroform on the operating table, those anaesthetized with ether in their beds"); more- over, albuminuria and acetonuria i Becker) ; apoplexy observed in the case of aged patients after ether anaesthesia (but also after chloroform) may be explained from the considerably increased blood pressure. EtJierization per rectum (Pij'ogoff), which was abandoned, has been recommended again recently {Starke). It will hardly be adopted generally. THE TREATMENT OF WOUNDS 191 COMBINED ANESTHESIAS Chloroform-ether anaesthesia. In prolonged anaesthesias chloroform and ether in succession have been used with the best results. The anaesthesia begins with chloroform, and when the stage of tolerance has occurred, it is kept up with ether, after the mask has been changed. The advantages of this method are : very little ether is required for keeping up anaesthesia ; the same can be continued for several hours ; no unpleasant consequences as in prolonged chloroform anaesthesia need be apprehended ; according to statis- tics the mortality is very low. Ether-chloroform anaesthesia {Madching) is used much more rarely, mostly with patients who from ether inhalations become exceptionally excited, who have a pronounced tracheal rale, cyanosis, and hiccough (singultus), or with whom the occurrence of full anaesthesia is retarded in spite of large doses of ether. It has the advantage of avoiding primary syncope caused by the effects of chloroform. If chloroform is administered, after ether anaesthesia has occurred, the subsequent part of anaesthesia takes an especially favorable course {K'dnig). Very frequently a subcutaneous injection of morphine is previously made (see p. 177) (with the addition of 0.03 grams oxyspartein (to regulate the action of the heart), or 0.00 1 gram atropin (to regulate respiration jj. The stage of excitation is thereby shortened, and with a smaller quantity of the anaesthetic narcosis takes a more tranquil course. After an injection of 0.01-0.03 morphine 15 to 20 minutes previous to ans;sthesia, the latter can be kept up with ether (morphine-ether anaesthesia, Riedel), or it can be brought on with a very small quantity of chloroform f morphine-chloroform anaesthesia). This kind of anaesthesia is of especial advantage in the case of very excitable, frightened patients; with drunkards, who become considerablv less excited from it ; and in all operations on the face or on the neck during which blood is liable to enter the air passages, because the patient is not completely unconscious and when requested coughs out the blood which has been aspirated, and yet the pain inflicted is slight (for instance, in re- section of the upper jaw, amputation of the tongue, etc.). Thus only anal- gesia with consciousness still partly preserved is produced. Instead of morphine 2 to 3 grams of chloral hydrate may be given. Anaesthesias with chloroform mixtures have the advantage of less danger than those of pure chloroform, but they are not frequently used in Germany. 192 SURGICAL TECHNIC BillrotJis 'ynixtiire is known best of all (chloroform-ether-alcohol, 3:1:1) from which one death occurred in 3370 anaesthesias. The EiiglisJi A. C. E. inixtiwe (i :2 : 3) brings on anaesthesia rapidly without causing any serious injury to the heart. Tilhnanns prefers chloroform and ether mixed in equal parts. For ancEsthesias of sJiort duration in operations which can be quickly performed, ethylene bromide has been used in modern times : 1 5 to 20 grams at a time, poured into an impermeable mask and inhaled with as complete an exclusion of air as possible produces, after one minute or less, anaesthesia which is complete for about 3 to 5 minutes. After this time analgesia can continue for some time. Sometimes, however, the desired relaxation of the muscles does not occur. During anaesthesia cyanosis, disturbance of respiration, nausea, and vomiting have been observed. On awakening the patient feels perfectly well, still the expirated air has for days an odor of garlic. If anaesthesia is to be prolonged, it is not advisable to administer again ethylene bromide ; it is better to use ether {etJiylcne- broniidc-ctJier ancBstJicsia, Koc/icr). Ethylene chloride i^Kclcn), which is syringed upon a common tricot mask, can also be recommended according to Soulier and LotJieisen for anaesthesias of short duration. Likewise bromoform has been used successfully. Pental, which has a pungent odor of oil of mustard, cannot be recom- mended for anaesthesia on account of its great dangerous qualities. The other numerous anaesthetics, nitrogen monoxide, methylic pichloride, dimethyl acetal, diethylene acetal, and their combinations with one another or with chloroform, ether, oxygen, and others, are of little importance for surgical purposes. LOCAL ANESTHESIA (aNALGESIA) For rendering only one certain part of the body as ancestJietic as possible, and hence for alleviating or removing the pain of an operation, strong pressure was, even in olden times, exerted either upon the principal nerve or upon the whole circumference of the limb ; by this means, aside from the partial interruption of the nerve transmission, the circulation of the blood becomes retarded, and thereby the hemorrhage diminished. In the same manner, the elastic bandage in the bloodless method, after some time, proves antalgic. The fact that frozen limbs are always without sensation led to the use of refrigeration as an anaesthetic. The part involved was treated with a freezing mixture, covered with a piece of ice or with ice bags. Richardson THE TREATMENT OF WOUNDS I93 used the ether spray, which quickly evaporates, for reducing the tempera- ture in a very short time to the freezing point. The cold, thus produced in a few minutes, renders the skin insensible. After a momentary redness, the place of the surface of the skin subjected to the spray turns white ; next, after prolonged spraying, the skin becomes wrinkled almost like parchment. Minor operations which have to be performed rapidly and which are confined mainly to the skin can then be performed in a painless manner. In conse- quence of the ether spray as well as of the thawing of the refrigerated part, very violent pricking pains generally occur, which often continue for a long time. Immersion of the part in warm water will somewhat mitigate the pain {Kochej'). In a similar manner liqidd carbonic acid and inctJiyl chloride, both in small siphons, have been used. Most convenient is ethyl chloride, a color- less liquid which boils at 11° C. It is sold in glass tubes with a capillary opening and an air-tight cover (Fig. 328). Likewise, mixtures of ethyl chloride and methyl chloride are used. On removing the cover the liquid Fig. 328. Flask cuntaining Ethyl Chloride begins to boil from the ordinary temperature of the room, and still more from that of the hand. It squirts forth in a fine spray. If the glass tube is held 10 to 20 centimeters distant from the portion of skin to be refriger- ated, the skin turns white almost instantly, and snow is formed on the cutaneous hair. This refrigeration is indeed painful, but it renders the skin antalgic for punctures or incisions. A disadvantage for handling the knife is the solid icy condition of the refrigerated part. After the thawing, which occurs rapidly, often a marked redness of the skin remains. This redness, as well as the pain, may be reduced during refrigeration by previously lubri- cating the portion of skin. By means of elastic constriction of the limb, and by ischaemia thus effected, refrigeration occurs more rapidly and continues for a long time. Cocaine and its salts, especially cocainum muriaticum, however, is mostly used for producing local anaesthesia (A'(5'//^r, 1884). It possesses the prop- erty of rendering antalgic mucous membranes and wounds, b2it not the 7m- injnred skin. It paralyzes the sensory nerve fibres, while, at the same time. 194 SURGICAL TFXHNIC a contraction of the lumen of vessels occurs. The anaesthetic is used in solutions of I /o to 20 ^jo. Cocaine solution heated to 50° F. is still more effect- ive {Costa). Since the solutions easily become mouldy, it is better to have them freshly prepared, or to use them when only a few days old. By steriHzing them in a temperature of 212° F. they lose in effectiveness. Mucous membranes, surfaces of wounds, and ulcers are rendered antalgic when brushed with a solution of 5 ^6 to 10 '/o. After a few minutes anaes- thesia will occur and minor operations can be made. If any part with uninjured skin is to be rendered antalgic the anaesthetic is administered ixom. a Pravaz syringe in and under the skin, and also into the deeper layers. For this purpose weaker solutions (i ^> to 5 ^0) are sufficient, of which not more than o. i gram of cocaine as the maximum dose should be administered, else toxic symptoms can occur. The place of puncture made by the syringe can be rendered antalgic by ethyl chloride. For direct analgesia by means of cocaine {Rcclus) inject about 0.05 to o. i of cocaine, distributed in one or several syringes, into the field of operation and its immediate neighborhood. The operation can begin after a few minutes. Analgesia will not last longer than 15 to 20 minutes. If ischae- mia can be brought on by elastic constriction (on the Hmbs), the effect of cocaine lasts longer. But the injection into tough, and especially inflamed, tissues is very painful before anaesthesia occurs, hence, a rapid incision, for instance, the division of a simple felon (panaritium), can be borne as easily as an injection. Regionary analgesia ( Ob erst) is quite especially adapted to such cases in which a portion of limb by means of clastic constriction can be ren- dered anaesthetic by injecting cocaine into the region of the Jierve trunks, cen- trally from the field of operation. Originally recommended by Oberst for the fingers and toes, this method has been extended to the hand and foot {Manz). Berndt amputated even an arm and a thigh under regionary analgesia. Analgesia for the fingers and toes is made as follows : First, encircle the base of the limb with a rubber tube or a small bandage, subsequently moistened, so firmly that complete ischaemia occurs. Next, under a spray of ether or ethyl chloride inject immediately at tJie place of constiiction in the direction of the tip of the forefinger and at the four sides of the limb i to -^ a Pravaz syringe filled with a i 'jo solution of cocaine. Wait five to ten minutes until anaesthesia has occurred, when the operation can begin. In operations on the hand and foot apply the constrictor directly above the joint and wait at least ten to twenty minutes after the injection has been made into the afferent nerve trunks. In the thigh the desired analgesia does not occur until thirty minutes after the injection. For producing deep THE TREATMENT OF WOUNDS 195 analgesia it is advisable to paralyze also the small cutaneous nerves by a circular oedematization with SchleicJis solution. This should be made close to the constriction band. Bier evidently went farthest centrally by cocainizing the spinal cord : Place the patient in a lateral position ; next, with a very fine hollow needle make Qidnckes lumbar puncture under infiltration anaesthesia. On removing the top which closes the needle, apply immediately the finger upon the open- ing to prevent the outflow of the cerebro-spinal fluid ; next, inject the cocaine solution with a Pravaz syringe fitting exactly the orifice. The hol- low needle and syringe remain in a position for two minutes to prevent the cocaine from oozing out of the punctured canal of the spinal membranes into the tissues. On removing the syringe the little puncture opening is closed with' collodium. Half a syringe to a full syringe of a i yo cocaine solution is sufficient (0.005-0.01 cocaine). After about twenty minutes paralysis to a Jiigh degree of the sense of pain and of touch, extending over the whole body (trunk and limbs), occurs from the effect of cocaine upon the sheathless spinal nerves ; perhaps also upon the ganglion cells. After about three-quarters of an hour sensibility is restored. This procedure might be adapted to become even a substitute for inhalation anaesthesia, if no unpleasant after effects occurred from it, such as nausea, vomiting, head- ache more prolonged than after chloroform anaesthesia. Cocaine is a nerve poison. Even in small quantities (especially on mucous membranes) it can often cause toxic symptoms and even death. In such a case occur : Paleness of the face, dizziness, headache, fainting, con- vulsions, delirium, small pulse (anaemia of the brain). Immediate inspira- tion of amyl nitrite is considered as the best antidote ; likewise morphine, potassium bromide, and antipyrine have been used. In addition the patient should be placed in a recumbent position. Hence, attempts have been made to substitute for cocaine the less toxic and more rapidly effective tropacocaijie and also eucaine, of which as much as two grams can be injected without injury. But in contradistinction to cocaine, it produces hyperaemia. Both remedies have not been able to supersede cocaine. The dangerous qualities of cocaine injections can be removed and still a complete analgesia in the field of operation be effected by Schleich's infil- tration anaesthesia. With very weak cocaine solutions all tissues involved are infiltrated (artificial cedematizatioii). For this purpose a syringe holding 10 grams and provided with a very fine canula is used with the following three ScJdeicJis solutions : — 196 SURGICAL TECHNIC I. Strong Cocain muriat. 0.2 Morph. mur. 0.0: Natr. chlorat. 0.2 Aq. sterilis. 100. o II. Medium Cocain mur. o. i Morph. mur. 0.025 Natr. chlorat. 0.2 Aq. sterilis. 100. o III. Weak Cocain mur. 0.02 Morph. mur. 0.02: Natr. chlorat. 0.2 Aq. sterilis. 100. o Solution I is used for the epidermis, being the most sensitive tissue to pain; solution III for the deeper, less sensitive tissues. Generally for minor operations solution II is sufficient. With the e.xception of the first puncture with the hollow needle, which, if necessary, can be rendered antal- gic by means of ethyl chloride, all subsequent injections are painless. Analgesia occurs at once. Elastic constriction is not required. Many surgeons mention as a disadvantage of this procedure the more difficult orientation in the oedematous tissues. Procedure : Make the infiltration by layers. First render the field of operation oedematous. Insert the syringe obliquely, very superficially, and intracutaiteotisly, so far that the opening of the syringe is in the cutis. Inject so much of the solution that a pale blotch of the size of a bean is raised. At the margin of this portion of skin, rendered instantaneously antalgic, insert the syringe again and raise a new blotch connected with the first. Continue in this manner until a field is infiltrated as long as the external incision is intended to be. From this field infiltrate the deeper layers and circumscribe, for instance, well-defined tumors, also in their depth (by means of a Fig. 329. Syringe and Canul/e for curved syringe (canula)). For tough tissues Infiltration An/Esthesl^ ^. , ,, sometimes a very strong pressure upon the piston is required. The external incision can now be made immediately, the patient feeling no pain. Often the whole operation, after a previous infiltration, may be made as in general anaesthesia. In most cases, how- ever, in advancing into the deep layers the knife must be changed for the syringe and a new infiltration be made, as soon as the patient feels any pain. The procedure is simple. Still, for a complete control of its technic, it is necessary to have seen it performed. If the surgeon is familiar with this procedure it is very convenient and adapted to make anaesthesia dispen- sable with in many cases, — for instance, in enucleation of benign tumors THE TREATMENT OF WOUNDS I97 in all parts of the body, in herniotomies, laparotomies, hemorrhoids, rectal fistulae, etc. In inflamed tissues pain is caused by increasing the pressure of the tissues, unless the surgeon cautiously approaches the focus of inflammation from the healthy surrounding tissue. Still, it is to be remembered that inflammatory stimulus may be pressed into the surrounding healthy tissue, and thus progressive inflammation (phlegmone) be caused. Wherever elastic constriction can be used regionary analgesia is certainly preferable in such cases. For anaesthetizing wound surfaces, burns, lacerations, and exposed nerve ends in general, recently, instead of toxic cocaine, the non-poisonous ortho- form has become very popular. Ort/ioform, a yellowish powder, is dusted upon the wound. It has antiseptic properties and renders anaesthetic the parts involved almost for a day, but surely for several hours. Other local anaesthetics, such as guajacol (i to 2 grams applied on the skin), solution of antipyrine (for mucous membranes), eucaine(io^ salve), etc., are less gener- ally used. Only briefly may it be stated here that the surgeon can, by psychical influence (suggestion), also render an expected pain much less severe to the consciousness of the patient, when he has been perfectly assured that " it will not hurt." The efficiency of the "suggestion," especially in the hyp- notic state, has been made manifest by many excellent examples. But even without a methodically induced hypnotic state, it is sometimes successful to anaesthetize a patient suitable for such treatment, by merely holding a dry mask or one moistened with a few drops of some ethereal fluid over the nose. In these experiments, which can sometimes be tried as an expedient, much, of course, depends on the personality of the physician as well as on that of the patient. SIMPLE OPERATIONS The operation wound, in the great majority of cases, is made by an incision with the surgeon's knife (scalpel). How this is to be held and manipulated depends on the personal practice and manual dexterity of the operator. Generally, however, we distinguish the following mctJiods of Jiolding tJie knife : — If fine shallow incisions are to be made, or if the operator wishes to pro- ceed by way of anatomical dissection, so to speak, the knife is held like a pen, the little finger resting on the surface of the body (Figs. 330, 331). If it is desirable to use more strength for making long, flat incisions, hold the 198 SURGICAL TECHNIC knife like a violin bow (Fig. 332); by holding the knife in this manner, the entire blade rather than its point is made effective. In using still greater power, in dividing tougher tissues, hold the scalpel like a table knife, the Fig. 330. (a) In anatomical dissection Fig. 331. (/') In cutting from witliin outward Holding the Knife like a Pen Fig. 332. Holding the Knife like a Violin Bow Fig. 333. Holding the Scalpel like a Table Knife forefinger resting on the back of the knife (Fig. 333). Finally, for dividing all soft parts with one firm stroke down to the bone, hold the knife with the whole hand like a sword. The shape or form of the blade (Fig. 334), whether curved or straight, and also the pre- scribed manner of holding it ac- cording to the rules of art, is a matter of little importance for one who knows how to handle a knife dexterously, gracefully, and easily, provided the wound made with it shows a smooth clean c 1^ -D J incision, which has everywhere 334. Shape of Knife Blades. 1-2, curved; ' ■' 3-4, pointed; 5, straight; 6, blunt-pointed uniform depth and no jagged, Fig THE TREATMENT OF WOUNDS 199 contused, and mangled margins. Especially uncomely are the " tail ends " in skin incision, — viz., when the angles of the wound are made only superfi- cially into the skin. In order to make smooth uniform incisions, it is of the \mmv Fig. 335. Stretching Margin of Wound for External Incision greatest importance to stretch the skin as tense as possible. In smaller in- cisions it is made tense by stretching the skin between two fingers applied near the margins of the wound (Fig. 335); in larger incisions, by applying both hands. In most cases the smooth incision of the knife is the most appropriate procedure in penetrating downward. If the operator reaches any muscular septa and other layers of connective tissue, he may advance Fig. 336. Grooved Director more rapidly in a bhmt inamier by tearing them apart with the handle of the knife or with the finger. If distinct layers are present, the grooved director (Fig. 336) may be used. Insert it under such a layer and conduct the knife along the groove (Fig. 337). The incision by raising a fold of tissue (Figs. 338, 339) is more conservative, and is especially to be recommended for the fine dissection of numerous thin layers. In incising the skin, raise it with two fingers at each side of the intended line of incision. Next, grasp with forceps a portion of the underlying layer of tissue. Let an assistant grasp another portion close by. The raised fold is superficially divided between the two forceps, and this is repeated layer after layer, until the desired depth has been reached. The operator proceeds in such a manner most frequently in exposing an artery or a hernial sac. Fig. 337. Conducting the Knife along the Grooved Director 200 SURGICAL TECHXIC Fig. 338 Fig. 339 External Incision by r.\ising a Fold of Tissle Retractors ( Figs. 340-342 ) should always be applied with great care ; if in smaller wounds they occupy too much space, light ligature loops may be practically substituted for them ; with these, the margins of the wound are retracted. The liga- tures are finally used in suturing the wound. In places where larger veins might be injured only blunt retractors should be used. Likewise, in resections, else from the large traction and the repeated insertion of the sharp prongs, the wound surface is unnecessarily irritated. The wound can also be deepened rapidly and easily with the scissors (Figs. 343, 344, 345). Fig. 340 Von Volkmann's SH.A.RP Retractor Fig. 341. Von Langen- beck's Blunt Retr.\c- TOKS. a, small; i^, large Fig. 342 Improvised Retr.\ctor THE TREATMENT OF WOUNDS 20I Scissors, however, cause contusion, and hence make rough incision mar- gins ; nevertheless, the operator can ven,^ conveniently and safely work with them ; for instance, in the enucleation of some tumors. In addi- FiG. 343. Straight Scissors Fig. 344. Cooper's Scissors Fig. 345. A>"Glxar Scissors tion to the straight scissors, the bent or angular scissors are also used for deepening and enlarging incisions. Cooper^ s scissors, which are sUghtly curved, are used especially for shallow or surface incisions. PUNXTURE This serves for evacuating fluids from the ca\-ities of the body, for recog- nizing pathological transformations in the deeper layers, and finally for administering medicines in fluid form. Larger puncture openings may be made with a small pointed knife held perpendicularly and pushed into the skin. If it is desirable, however, to avoid hemorrhage from the larger ves- sels, use round tubes pointed at one end. The trocar (acus triquetra) (Fig. 346) consists of a metal tube, the lumen of which is filled by a stylet that can be withdrawn ; the stylet is three-edged at its point. The instru- ment is inserted by one plunging movement, and the st\'let withdrawn, when the fluid can be evacuated through the canula. If it is desirable to make the puncture very small, so that it closes of its own accord on with- drawing the instrument and heals without any further treatment, long, fine trocars, pointed like a writing pen, are used, wdth a closely fitting syringe with which the fluid is removed by suction, and with which fluids can be 202 SURGICAL TECHNIC injected. For larger cavities use the various kinds of aspiration apparatus mentioned under Figs. 1 248-1 249. For diagnostic purposes (Akido-peirastik — Middcldorpf, 1856), trocar- shaped instruments are used. Behind the point of the stylet, they have a small circular groove, in which, while the stylet is inserted or withdrawn i Fig. 346. Troc.\r Fig. 347. Vox Esmarch's Trocar for Akido-pei- rastik Fig. 348. S\*RiN"GEs for Sibci'taneous Injection. «, Pravaz's syringe; /', Over- lach's syringe; c, Koch's syringe from the canula, small quantities of tissue sufificient for microscopic exami- nation are caught. There are also instruments with a divided point, which opens of its own accord when the canula is withdrawn (harpoon) (Fig. 347). For injecting medicines, syringes with a long line hollow needle are used. Pravaz s well-known and largely used syringe (Fig. 348) contains exactly one gram of fluid ; its cylinder is marked by a scale divided into ten equal parts, so that a definite quantity may be injected into the body by pushing forward the piston. The injection is made as follows : — Fill the syringe by suction with the desired quantity of solution, and expel the air which may have entered by pushing forward the piston with the point raised. Raise a fold of skin at some portion of the body ; insert the needle quickly through the base of the fold and into the superficial facia ; THE TREATMENT OF WOUNDS 203 convince yourself by a few lateral movements that the point did not enter the corium merely, or perhaps even a vein ; empty its contents by slowly pushing the piston forward ( Fig. 349J. Next, withdraw the needle and place the forefinger for a few moments upon the puncture, to prevent the injected fluid from flowing out. A slight pressure exerted simultaneously with the middle finger and the ring finger and a gentle rubbing promote the diffusion and resorption of the solution. Fig. 349. Subcutaneous Injection Preliminary even to this trifling operation, it is necessary carefully to cleanse and disinfect, not only the syringe and the fingers of the operator, but also the place on the skin selected for the injection. Otherwise, subcu- taneous abscesses may be caused from it. For some cases it is better to make the injection not merely subcu- taneously, but deep into the muscles (intramuscularly), — for instance, in the case of quicksilver solutions., which, injected subcutaneously, can cause gangrene. Insert with a quick movement the fine hollow needle perpendicu- larly to the surface of the skin dowTi to its hilt. The skin is drawn some- what laterally in order that the puncture of the skin does not form a straight line with the punctured canal in the deep layers. The same procedure is observed in injections of arsenic into malignant tumors and in injections of iodine into struma (parenchymatous injections). TISSUE DESTRUCTION This can be made mechanically, by thernio-caiitery or by cauterization with chemical substances. Soft tissues can be scraped away ^dth the sharp spoon {von Volkmann, Fig. 350;, especially lupus, fungous granulations, soft tumors, and caries. If the instrument is properly manipulated with firm repeated strokes over the whole diseased portion, it ser\-es at the same time for diagnostic purposes. 204 SURGICAL TECHNIC since only diseased tissues can be scraped away, while healthy tissues resist the action of the spoon. This operation is valuable and frequently resorted to in the treatment of lupus. During the operation, some portions of lupus Fig, 350. Sharp Spoon can be recognized as new foci from their characteristic softness. By boring movements with the spoon, fistulas and foci which penetrate downward, especially tubercular softening of the bone, can be followed, exposed, and removed. The cautery iron (cauterium actuale) was formerly used most extensively, not only for destroying tissues but also in arresting hemorrhage, and as a substitute for the knife. The cau- tery iron has a straight handle or one bent at an angle. The ends are variously shaped. It is heated on a coal basin, hearth fire, etc., until it is red hot or white hot. In many cases, the old cautery iron (Fig. 351) is often the best agent in effecting tissue destruction ; country physicians especially can- not do without it. Moreover, it can be easily improvised, — for instance, from a piece of iron shaped suitably for the purpose. Roll up a piece of thick wire (telegraph wire in time of war) at one end in the shape of a cone or disk ; fasten the other pointed end (by means of a file) into a wooden handle {Brandis, Fig. 352). On the whole, however, the cau- tery iron is not so much used since Paqnclin invented the thermo- cautery (Fig. 353), which can be handled more conveniently but which unfortunately is rather expensive. Its effect consists in a hollow cauterizing point made of platinum, con- taining a platinum sponge. It is brought to a bright red heat by benzole Cautery Iron r'iG. 352. Cai'tekv Ikon of Telegkai'ii Wire (according to Brandis) THE TREAT.MENT OF WOUXDS 20: or benzine vapors forced into the point from a bottle by a double rubber bulb. Heat the platinum point (a) over a spirit flame for a few minutes (Fig. 353); next, work the bulb (d), first slowly, then gradually more rapidly, until the platinum point becomes a bright red heat. By means of the bulbs the desired heat can be maintained for any length of time. Care must be taken to hold the bottle, containing the benzine, always perpendicularly and lower than the red-hot point, else an explosion may occur from benzine entering into the platinum point. If the thermo-cautery does not work, heat it for some time in a strong flame Avithout forcing any vapors into it. After using Fig. 353. Paquelin's Thermo-cautery it, do not dip it into cold water to cool it more rapidly. Since the introduc- tion of thermo-cautery, which appears comely and can be manipulated so easily, the actual cautery has lost its terror in surgery, and its application has vastly increased. Accordingly, as the operator selects ball-shaped, knife-shaped, or needle-shaped points, he may destroy surfaces with the instrument or make bloodless incisions, and hence, whenever it seems necessary, substitute it for the knife or make the finest punctures (with the so-called micro burner, to the platinum point of which a fine copper needle has been welded). White heat, to be sure, destroys the tissues more rapidly, but it cannot be rehed upon in preventing or arresting hemorrhage. Red heat chars the tissues more slowlv and thus becomes a potent hemo- 2o6 SURGICAL TECHNIC Static. If the points remain too long in the wound, the charred tissue frag- ments adhering to the red-hot metal often lessen its effect. Outside of the wound, the coating must be removed by increasing the heat. The eschars produced by the thermo-cautery do not necessarily interfere with the primary healing of the wound, especially when they are superficial ; for this reason, even in the abdominal cavity, the dull red-hot thermo-cautery is used for dividing adhesions, arresting hemorrhages of stumps, etc. Galvano-cautery {Middcldo7ff) purposes making a piece of platinum wire red hot by an electric battery. If the operator possesses the necessary Fig. 354. Immersion Battery Fic. 355. Galvanu-caustic Wire Loop apparatus, its application is comparatively simple. Since this battery, how- ever, is rather expensive, it will probably be used more in hospitals and by specialists than by the practising physician. At the present time, immersion batteries are especially used, for instance Voltolints, and the Jiandle recom- mended by Brims and Backer (Fig. 354), in which the various attachments are inserted. While, however, for surgical purposes, thermo-cautery can be substituted almost everywhere, the galvano-caustic wire loop (Fig. 355) has this great advantage over it : the wire can be introduced into the tissues while cold (for instance, in a fistula, or around a pedicle or a cord (" Strang") in the depth of the wound), and after the operator has convinced himself of its correct position, it is instantly brought to a red heat by closing the current. In this manner tissues can be divided bloodlessly by a fine THE TREATMENT OF WOUNDS 207 incision. Galvano-cautery is probably most frequently employed for the delicate operations in the nares, the larynx, and the ear. Galvano-puncture causes a slow destruction of tissues by introducing two platinum needles into the diseased portion ; the needles are connected with the electric battery. The galvanic current passes through the tissue from one needle to the other, causing a circumscribed linear destruction of the tissue. In this manner, small warts, hair follicles, etc., may be destroyed ; but even larger tumors, at least partly, may be caused to disap- pear (electrolysis). For the destruction of tissue, moreover, chemicals that form an eschar, or cauterize, are used (escharotics, caustics, cauteriiun potentiale). Kali causticum/d7/«i-i-(7, caustic potassa in white sticks about as thick as a pencil, very deliquescent when brought in contact with the tissues, cauter- izes deeply, and if the necessary care is not exercised in preventing its diffu- sion also attacks the surrounding tissues. The eschar is white. Solid nitrate of silver, argentum nitricum fusum, lapis ijifernalis, Itmar caustic, of like shape and color as the preceding, affects only the place touched with it ; it is especially used for touching profuse granulations, which it covers with a white eschar of silver albuminate. The mixture of lunar caustic and saltpetre (i : i or i : 2) is harder and produces a milder effect than pure lunar caustic {lapis viitigatiis). Cuprum sulphuricum {copper sulphate) in sticks (blue stick) cauterizes only superficially. Alumen ustum, dried alum, can be used only for very superficial cauterizations. Either the caustic sticks are held with the bare hand (the sticks are previously wrapped at one end with a little gauze or cotton) or instruments like penholders or pincers are used for holding them (porte-caustiques, Fig. 356). Care should be taken that the caustic stick is lodged firmly in the holder so that it cannot fall into the wound during appli- cation. Simple and very convenient are the quills and wooden sockets into which the caustic sticks have been inserted. They can be purchased anywhere. The application of the stick causes only moderate pains, especially if care is taken not to touch the tender white epithelial margin of a healing wound. Large ulcerating surfaces, tumors that cannot be removed with the knife, can be destroyed with the soft caustic pastes. Vienna caustic {pasta Viemiensis'). Stir 6 parts of quicklime and 5 parts of caustic potassa with alcohol into a paste ; apply it about 5 milli- 2o8 SURGICAL TECHXIC meters thick with a chip of wood; after 6 to lO minutes, the very deliques- cent paste has produced a firm gray eschar, which in its circumference appears as a gray line. Next, remove the paste and neutralize the cauter- ized part with acidulated water. The eschar is cast off in about 8 days after a severe inflammation. Paste of zinc chloride {Canqnoin). Powdered chloride of zinc and rye flour are kneaded with a Httle water into a dough in various proportions (according to the intended strength of the mixture, 1:2, 1:3, i : 4). It is applied in layers of \ : i centimeters thick, which are not removed until after 12 to 24 hours. At the place to be cauterized, the epidermis must be previously removed by means of a hot hammer, since chloride of zinc does not cauterize the intact epidermis. The cauterization is well defined and produces a leathery tough eschar ; but it causes violent pain, which may be mitigated by the addition of opium or morphine. After 8 to 10 days, the eschar is cast off and the wound presents good granulations. If necessary, the cauterization must be repeated by the application of freshly prepared paste. Arsenic paste {pasta arscnicalis Frcre Cosine), Cosme powder (originally arsenici albi, 3.5; sanguinis draconis, 0.7 ; cinnabaris, 8 ; cineris solearum antiquarum combustarum, 0.5), is mixed with a little water into a paste, or more simply i part of arsenic is mixed with 1 5 parts of starch and water. It is applied only as thick as the blade of a knife and not on a large surface (poisoning). Amidst the most violent pains, it produces a leatherlike eschar, which is cast off after 10-20 days, leaving a good granulating sur- face which soon becomes cicatrized. Poisoning by rapid absorption is especially to be apprehended in parts which are not covered with epidermis. Less poisonous and less painful, especially for destroying vascular tumors, is the application of arsenic caustic powder, consisting of : acid. arsenicos. morph. muriat. aa. 0.25; calomel, 2; gummi arab., 12. {von Esniarch). Ointment of tartrate antimony (i part tartarus stibiat., 4 parts adeps) is sometimes still used for superficial cauterization and revulsion. Sulphuric acid cauterizes the tissues so that they show a gray or brown eschar. Fuming nitric acid and chromic acid produce a yellowish green eschar (xanthoproteine). Chromic acid, however, even with careful appHca- tion, can cause general poisoning and death. Pure carbolic acid cauterizes without causing pain, leaving a whitish eschar. Sublimate (1:10 collodion) is applicable only for very small lesions (warts) on account of its poisonous tendencies. Lactic acid cauterizes tumors until they form a blackish mass ; THE TREATMENT OF WOUNDS 209 but it leaves normal tissues uninjured {yon Mosetig). Lactic acid paste, consisting of equal parts of the remedy and of silicic acid, is spread as thick as the blade of the knife on india-rubber paper, and applied to the diseased part; it remains in position 12 hours. In the application of all fluid and soft cauterizing agents, it is necessary to protect the surrounding parts from unintentional injuries by placing strips of adhesive plaster upon them, or by applying a thick layer of fat, collodion, etc. Union of the margins of the wounds is effected in clean, fresh wounds, and in such operation wounds as are not intended to close by granulation, by the SUTURE The suture is applied with straight needles or such as are curved surface, smooth at the point, with two cutting edges (Fig. 357). needles are managed with the free hand ; smaller ones are held with the needle holder, which affords a more safe and convenient guidance. DieffenbacJi s for- ceps-like needle holdei^ is most simple and useful for all purposes (Fig. 358). Hegars (Fig. 359) and Kiister's " sivan'' needle holders (Fig. 360) are on the Large Fig. 357. Surgical Needles, c, ordi- nary eye; b, springy eye Fig. 358 Dieffenbach's Fig. 359 Hegar's Needle Holders Fig. 360 Kiister's Swan pecially suitable for suturing deep wounds and in cavities. Roiixs needle holder (Fig. 361), the ends of which can be drawn apart and are closed by a sliding tube, is now less generally used ; but it is very practical. 210 SURGICAL TECHNIC Fig. 363. Hagedorn's Needles Hagcdorn recommended, in place of needles curved on the surface, needles bent on the edge and bevelled (like curved sabres — Fig. 363); this shape produces punctured canals, which do not gape when the suture is drawn tight, but remain in the form of a slit ; the operator can sew with them very easily and con- veniently, if he uses the needle holder specially adapted for them (Fig. 362) ; the holder can be taken apart and sterilized. The following materials are used for suturing : I . Catgut. Catgut cords of vary- ing thickness (vioHn strings) are prepared in factories. They swell in the tissues of the body and are gradually absorbed. The catgut is rendered free from living germs and made aseptic according to the rules laid down on page 10. If the cat- cfut sutures are not sterilized, this animal material will cause Fig. 362 suppuration in the punctured canals. Since suppuration may Hagedorn's occur even with the most careful sterilization, attempts have Holder been made to substitute for it less septic materials, such as, sutures made of tendons of the reindeer, kangaroo, and whale. 2. Silk unbleached, raw Chinese silk, can easily be rendered free from living organisms by boiling ; it is also saturated with antiseptics : carboliscd silk, by boiling it in a 5% carbolic solution and placing it in a 3% carbolic solution {Czerny)\ sublimated silk, by placing the boiled threads into a 1% sublimate solution ; iodoform silk, by placing it in iodoform ether. Best of all is plaited silk ( Turner). Silk is not absorbed, but causes no irritation. Still, sometimes after a long period buried sutures are eliminated like foreign bodies under slight suppuration. 3. Flax thread can be used as well as silk, and is a somewhat cheaper material. More recently it has been saturated with celluloid and thus has become similar to silk gut {Pagenstechcr). 4. Seegras, silk-worm gut, Fil de Florence (obtained from the silk-worm), long, smooth, white, shining threads about \ meter long, furnish a most excellent (and also not too expensive) suture material, since they can be left for a long time in the tissues of the body without causing any irritation and without being absorbed ; they can be easily tied ; moreover, they very rarely tear; hence, are of especial use in closing wounds in which after tying THE TREATMENT OF WOUNDS 211 the sutures much tension remains, and for relaxation sutures. Thev are steriHzed in a 3% carboHc solution and are kept in a dry state, or boiled shortly before being used. Repeated boiling makes them brittle. Horsehair is a cheap substitute for these materials, especially in military and country practice. (The horsehair suture is almost indispensable in coaptating the margins of the skin and more particularly in plastic operations. They are somewhat elastic and can remain in the tissues indefinitely without causing irritation.) 5. Metal wire. Silver wire and iron wire can easily be rendered free from living organisms by boiling them or heating them in a spirit flame ; they serve a useful purpose especially for relaxation sutures and for the union of wounds which are subsequently exposed to tension (laparotomies, neck of hernial sacj, and for bone sutures. The suturing is done in various ways : — I. The interrupted suture (Fig. 364) is the one most commonly used and the most practical because it effects a very exact union of the edges of the wound. After the thread has been passed through both sides, it is tied and cut off about i centimeter in front of the knot. Ahvays apply the knot lat- erally from the line of the wound, for if applied directly over the wound it causes slight pressure and thus impairs exact adhesion. It is also important to tie the suture with a safe double knot, which does not become loose. The "reef knot" (Fig. 365) senses for this purpose; in this, the two ends of the thread are passed through both loops in the same direction, whilst in the false ox granny's knot (Fig. 366), W'hich does not hold securely, the ends are passed through the loops in opposite directions. Fig. 364. Interrupted Suture Fig. 365. Reef Knot Fig. 366. Granny's Knot The " 7-eef hiot" is made in such a manner that in tying the first and the second knot the same end is placed uppermost, or lowermost. This is done in the simplest way as follows : — 212 SURGICAL TECHNIC Draw the right end from below over the left end and over the point of the left forefinger in such a manner that, after the first knot has been tied, the right hand comes to lie upwards to the left, and the left hand down- wards to the right (position "over the hand"). Next, bring the right hand back in the same way into the position first occupied, — that is to say, pass the right end over the left, and, below it, draw it out in a right upward direction. In another manner the knot can be tied with the hands by changing the ends of the sittiires. Of the ends of the loop hanging down, pass the left with the right hand over the right, held with the left hand, and draw it out to the right ; next, by changing hands, carry it over the right and toward the left, so that each hand now holds the end it first held. When the margins of the wound are very tense, it is necessary, for the first knot, to pass the threads twice around each other (surgeon's knot — Fig. 367), and to tie the second knot upon it as in a "reef knot." The first knot already holds the margins of the wound firmly together, whilst in the "reef" and "granny's" knots, the ends must be held tense when the second knot is tied ; else, they become Fig. 367. Surgeon's Knot loosened. If a large wound is to be closed with the interrupted suture, the pro- cedure is as follows : — First, approximate the margins of the wound and hold them as closely together as possible in the manner in which they are to be sutured ; next, apply the first suture in the middle ; the two subsequent sutures at the middle of both sides between the first suture and the angles of the wound ; and all subsequent sutures, according to requirements, always at the middle between two sutures, until the margins of the wound everywhere have been brought in close approximation. (The suturing of a large wound is much simplified and facilitated by inserting all of the deep sutures first; and by tying them in the order mentioned above, referring to their insertion. This is more especially true in cases requiring approximation of the deeper parts of the wound by buried sutures.) If the edges are everywhere equally thick, pass the needle through on both sides at an even depth. If, in tying the knot, you find that one margin of the wound lies deeper than the other, raise it somewhat with forceps or a fine hook ; or else, depress the other suffi- ciently (Fig. 368). If the margins of the wound are of unequal height, carry the needle superficially through the thicker margin, but more deeply through THE TREATMENT OF WOUNDS 213 the thinner and nearer to its edge (Fig. 369); if the thin edges of the wound turn up inwardly, introduce the needle close at their margin (Fig. 370), and in tying the knot, raise the edges of the wound with fine hooks ; or, if possible, press together with two fingers both margins of the wound into a Fig. 368 Fig. 369 Fig. 370 small fold, and unite them in this position. If one margin of the wound is a little longer than the other, make the interspaces on the longer one somewhat larger than on the shorter, the number of stitch openings being equal. In tying the sutures, compress somewhat the longer margin, and unite it with the other (" verkalten ndhen "). If it is desirable to obtain a very exact union, carry the needle through near the edge of the wound and only superficially ; for farther away from the margin of the wound and introduced more deeply, the suture relaxes rather the tension of the super- ficial line of suture and unites the deeper parts of the wound. Usually both kinds of sutures, in closing a deep wound, are used in such a manner that a few deep interrupted sutures are first applied ; the approximated edges are next exactly united with superficial sutures ; the necessary relaxation sutures, ac- cording to requirement, are finally added (Fig- 370- After the healing of the wound, it is easy to remove the sutures, if the operator has used good catgut for suturing ; the portion of the loop of the suture which lies in the wound has been absorbed ; the other portion with the knot lying on the skin is adhering to the dry dressing, and is removed with the same. If no absorption has occurred, or if other materials have been used for suturing, grasp one end of the knot with forceps, raise it gently and divide the suture with a pair of scissors between the knot and the skin, and extract it laterally toward the side which has been cut off (Fig. 372). The fresh adherent margins of the wound are not drawn apart in doing this, but pressed one against the Fig. 371. Superficial and Deep Interrupted Sutures Fig. 372. Removing A Suture 214 SURGICAL TECHXIC other. Sometimes silk sutures do not heal in without reaction in spite of careful asepsis, and very unpleasant suppuration may be caused by them in the punctured canal. The suture methods with extractable (buried) sutures try to remedy this disadvantage. The sutures are applied in such a manner that from some places externally of the wound a whole row of sutures can be removed at once. These experiments, however, have not met with such a success that they can be recommended for general use {Tonnasko, Link, Stapler, and others). 2. The continued or glover's suture (Fig. 373) can be applied much more rapidly than the interrupted suture, and it unites the margins of the wound very accurately. Commence at one angle of the wound with an interrupted suture ; do not cut off the thread after it has been tied ; at a little distance, introduce the needle again, and pass it vertically to the line of the wound through both edges. Make tense to some extent the thread taking then an oblique direction to the wound, and continue applying the sutures to the other angle of the wound in the manner already described. Finally, for tying the knot, do not draw the last suture tight, but tie its loop with the end of the thread carried through the other edge of the wound (Fig. 374); or apply the continued suture across the line of sutures just applied, returning thus to the beginning (in this way, the stitches are placed in the form of a cross); finally, tie the end of the suture with the other end of the inter- rupted suture first applied and kept long for this purpose. ^"^- 373- Continued or Glover's Suture Fig. 374. Tying a Con- tinued Suture f "^' 375' Languette Suture 3. A modification of the continued suture, often very useful, is the languette suture (Fig. 375); the point of the needle before it is drawn out is passed each time under the thread loop of the preceding suture. Deep sutures, which approximate and hold in contact the surfaces of deep wounds, are applied in order to obviate dead spaces at the base of the wound. If these spaces are of a very irregular form, and if the depth of the wound is considerable, buried or subcutaneous sutures (with catgut) are applied ; these unite the different layers of tissue separately, and are applied in successive rows (etage suture). They can be applied as contin- THE TREATMENT OF WOUNDS 21 5 ued or as interrupted sutures. At the same time, however, the deeper layers in simple wounds can be united with the overlying skin by deep interrupted sutures, provided the needle is carried properly and at a sui^cient distance from the edge of the wound, and provided all layers, one after another, are pierced separately with the needle. They are firmly pressed together by tying the knot. 4. The lace suture was especially used by DiejfenbacJi for closing smaller openings, fistulae, etc. He applied it as a subcutaneous suture by allowing the thread to take a circular course under the skin of the opening to be closed. He stitched about the circumference of the circle in three or four sections, when, by continuing the suture, the needle was carried back to the ■ first suture (" Ausstichoffnung "). Finally, the ends were tied loosely and thus the opening closed, or at least contracted. Similar is the tobacco pouch suture which is again used by Doyen and De Quervain, especially for closing peritoneal wounds (stomach, intestines, vermiform Fig. 376. Laced Suture with Margins Fig. 377. Laced Suture with Margins OF Wound turned inward of Wound turned outward appendix, gall bladder, peritoneum of the laparotomy incision). The inver- sion suture (Fig. 376) serves for closing a hollow organ covered exteriorly with serous membrane ; the eversion suture (Fig. 377) is especially adapted to close the lower portion of the abdominal cavity covered with displaceable serous membrane. As a rule the wound should not be longer than 8 to 10 centimeters. The part of the sutures lying toward the abdominal cavity should be as short as possible to effect a more extensive approximation of the peritoneal surfaces. When the first suture opening has been reached again, traction is made slowly and steadily on the ends, but not too firmly, to prevent necrosis. The following sutures are especially used as deep subcutaneous sutures : — (In uniting deep wounds without buried sutures, dead spaces can often be avoided by including in the deep sutures the floor of the wound. A large curved needle must be used for this purpose.) 5. The folding suture, "Faltennaht" (Fig. 378) serves especially for uniting very thin and flaccid edges of skin (for instance, on the eyelid). 2l6 SURGICAL TECHNIC The edges are raised to form a fold, and thus the surfaces of contact are made larger. 6. The quilt suture (Fig. 379) is like the preceding, only the needle is carried through much more deeply. It is sometimes used as a relaxation suture. Fig. 378. Folding Suture Fig. 379. Quilt Suture 7. The quilled suture (Fig. 380) is made with small, round rods (quills, portions of probes, catheters), which are firmly drawn together with silk or metal threads. 8. The button suture {^Lister — Fig. 381) is made with silver wires. The ends of each wire are attached to lead buttons perforated in the centre. They are fastened across the upturned ends or wings of the buttons by ficjure-of-S turns. ^^^*^.-. Fig. 380. Quilled Suture Fig. ^81. Button Suture 9. In the pearl suture ( Thiersch — Fig. 382) the silver wire is carried first through the lead buttons and next through glass pearls. It is fastened by winding around a little rod. 10. The shot suture, "Schrotkugel," is similar but simpler. The ends of the thread (silk, sil- ver wire) are passed through perforated shot, and with a pair of clamping forceps the latter are compressed with the wound margins in proper position upon the thread over the skin. These last sutures, as can be seen already from their appurtenances, can be made only after the necessary preparations ; they served for certain purposes, especially Fig. 382. Pearl Suture THE TREATMENT OF WOUNDS 21/ as sutures in the perineum, rectum, vagina, and are probably used very rarely now. Likewise : — II. The twisted suture (Fig. 383). It is applied with insect needles, the points of which are shaped like the head of a lance. After they have been passed through the skin, at some distance from the edges of the wound, sterilized thick cotton threads are wound around them in alternating circle and figure-of-8 tours in such a manner that the edges of the skin are evenly and uniformly drawn in apposition. Likewise little rubber bands Fig. 383. Twisted Suture may be stretched over the needles. The ends of the needles are then cut off with a pair of nippers. For a more uniform union of the margins of the wound, apply a few fine interrupted sutures in the interspaces between the needles. The stumps of the needles may be extracted on the second day by twisting movements with forceps. The roll of threads, which are mostly agglutinated with the skin by the dried wound secretions, remains in position several days longer. Very small stiperficial woiinds, the edges of which do not gape, may also be united without suture by means of small compresses of absorbent cotton, or small pieces of gauze, which are saturated with iodoform collodion or zinc paste (see also p. 37). Very convenient is also the greatly ad- hesive zinc oxide plaster. English plaster and ordinary adhesive plaster can be used for only very small wounds, provided the hemorrhage has been arrested completely and the wound is not infected ; for by occlusion with adhesive plaster the drainage becomes obstructed for the escape of the secretions, and inflammation, suppuration, etc., may set in. " A physician who closes up a fresh wound with adhesive plaster, with- out any antiseptic precautions, exposes himself to the risk of prosecution for damages " {von Ntissbanm), 21. SURGICAL TECHNIC REMOVAL OF FOREIGN BODIES If a foreign body has entered from without and is lodged only super- ficially in a cavity of the body or in a wound, so that it can be easily reached and grasped, it is not difficult to remove it. To prevent symptoms of inflara- FiG. 384. Dressing Forceps mation, this should be done as soon as possible ; and to prevent unintentional secondary injuries, it should be done as gently as possible. The foreign body is grasped with dressing forceps (Fig. 384); smaller ones with good anatomical forceps (Fig. 385). Sometimes, in narrow cavities, the operator Fig. 385. Anatomical Forceps succeeds better in passing around the body a wire loop (for instance, made of a hairpin) and extracting it by pressure from behind. Concerning for- eign bodies in the cavities and canals of the body, see details, under the various headings. Sharp-pointed objects which have penetrated under the skin often cause difficulty and sometimes render an enlargement of the generally small skin wound necessary ; this is especially the case with fragments of glass, which lacerate the wound with their sharp edges. Splinters of decayed wood, frequently entering beneath the nail, in most cases cannot be well grasped, since their projecting part generally has been broken off by attempts at removing them. Hence, either a small wedge must be excised from the margin of the nail, or else the portion of the nail over the splinter must be removed with the knife. It is simpler to grasp the foreign body with the pointed splinter forceps (Fig. 386). For the extraction of broken-off blades of knives, etc., which cannot be grasped very well on account of their smoothness, wind around the end of the dressing or other forceps a few THE TREATMENT OF WOUNDS 219 Splinter Forceps Strips of adhesive plaster ; else, use a needle holder with jaws lined with soft lead. Needles, provided they can be felt through the skin, can be pressed between two fingers against the skin in such a way that they pierce it from the inside. (The Rontgen ray has become almost indispensable in ascertaining the presence and exact location of metallic substances in the body, and hence it is a very valuable aid to the surgeon in finding and extracting them.j Crochet needles may be extracted without any difficulty by a vigor- ous pull. Fishhooks, arrow heads, and other similar foreign bodies with strong barbed hooks must be pushed forward in the direction of the point of entrance, or must be exposed by an incision. If small objects, splinters, needles, etc., are to be removed from the tissues by an incision, a resort to tJie bloodless metJiod is of very great advantage ; otherwise, the foreign body is either very hard to find in the bleeding wound, or is overlooked altogether. The exposure to the Rontgen rays furnishes the safest diagnosis concerning the presence and position of the foreign body. The removal of metal rings (finger rings, keys, etc.), which have been stripped over a finger or the penis, may sometimes cause a great deal of trouble, since the parts on the distal side of the circular compression begin to swell to such a degree that the strangulating ring is often not visible. In very easy cases, the operator will succeed, after the strangulated part has been lubricated with soap or fat, in removing the ring by turning movements ; the oedema, which prevents the removal of the ring, is reduced in the quickest and most efficient manner by bandaging it with a small rubber bandage. In the absence of such an elastic bandage, a thread or narrow tape is applied closely and firmly from the tip to the ring ; the end of the thread is passed below the ring and is now wound in a downward direction, whereby the ring is gradually drawn down (Fig. 387). If it is not possible to remove the ring in this man- ner, it must be divided with a pair of nippers or with a fine saw, and bent apart. In war, the removal of bullets from wounds is of special importance. Of course, with the great penetrating power of modern firearms, bullets will remain lodged in the body more rarely than formerly. Fig. 387. Remov- ing A Ring by Means of a Narrow Tape wound in a Downward Di- rection 220 SURGICAL TECHNIC If a bullet has not completely pierced the portion of the body, but has remained lodged in it, the wounded person desires most urgently to be freed from it, considers himself saved when this has been successfully done, and shows the greatest gratitude and due recognition to the surgeon. As simple as this operation is in most cases, as much as the young surgeon rejoices over its success and the gratitude of the wounded, it is, nevertheless, unpar- donable unless the surgeon is able to perform it aseptically, which on the battle-field and in field hospitals is generally difficult and in most cases unnec- essary. For experience teaches us that bullets can remain in the body for a long time without causing injury, and that gunshot wounds, even with an extensive comminuted fracture can heal under a simple antiseptic com- pressive dressing, provided the wound has not previously been examined with unclean or only seemingly disinfected fingers, probes, or forceps. The great difference between wounds which have been touched with the fingers and those which have been left untouched, the sad consequences which such a rash examination can have for their healing or even for the life of the wounded person, should always call to the mind of every surgeon (and most especially in war), the first principle of all medical action, "Z^*? no Jiarni ! " For the experience gained during the wars of the last fifteen years shows that even severe splintered fractures of joints healed smoothly under an aseptic occlusion dressing and immobilization of the limb, although the bullet was still in the body. For, according to Langenbuch, a gunshot wound is to be considered as aseptic. To extract a bullet which can be felt tinder the skin, is by no means a difficult operation. With a sharp knife, a bold cut is made down to the bullet, kept steady with the fingers of the left hand until it becomes visible in the wound, when it is extracted with dressing forceps or bullet forceps. If a soft lead bullet has become very deformed by meeting with resistance, oris very distended and jagged, the cellular tissue and the fascia must often be divided in several directions, in order to extract it without using force. The extraction of deep-seated bullets does not cause any especial difficul- ties under the protection of asepsis, since the operator need not hesitate to divide the soft parts to such an extent as may be required for finding the foreign body. (The Spanish-American, Philippine, and Boer wars have demonstrated the wisdom of abstaining from examining recent gunshot wounds and of pursuing a conservative course of treatment. There are very few cases, indeed, in which it is justifiable to search for and make attempts to remove the bullet. The modern bullet becomes more readily THE TREATMENT OF WOUNDS 221 encapsulated than the old leaden missiles. The best results are obtained by healing the wound with the first aid antiseptic dressing and immobilization of the injured limb or part.) In evacuating the blood clots from fresh wounds, the bullets which may have entered are removed at the same time, and no other instruments are needed for this purpose except the common dressing forceps or the American bullet forceps (Fig. 391) ; with these, the bullets can be readily grasped, since the sharp hooks of the same firmly penetrate the lead. Fig. 388. Flexible Zinc Probe But if it becomes necessary to remove bullets that are in the depth of gramdating wounds and that prevent the definite cicatrization of the same, that cause fistulas of long duration, or that cause trouble by pressing on the nerve trunks or other important organs, the extraction can, after all, become very difficult, especially when the bullets are very much deformed, are lodged at dangerous places, or firmly impacted in the bone. Sometimes the question must be first decided whether a foreign body is at all in the depth of the wound and of what quality it is. The safest information gives the exposure to the Rontgen rays, radioscopy and radiography, which already, in very many clinics, are used extensively to establish the presence of foreign bodies. Likewise in the last wars the procedure has rendered good service. If a bullet or a fragment of the same is present, it can be recognized at once in the skiagraph. The presence of small bullets healed in without causing any symptoms of inflam- mation etc., has established a new principle, namely, to disturb these foreign bodies as little as possible, but rather to promote their incapsulation. Shot and pistol bullets up to a calibre of 9 millimeters can remain in the body, even in the brain or the lungs, without causing any injury {yon Bergmami). Hence, the surgeon should well consider whether probing in the last two organs would not cause greater injury than the bullet itself. The removal of the foreign body, however, is necessary when great injury has been 222 SURGICAL TECHNIC caused ; for instance, when the bullet is lodged in a nerve or upon an articu- lar surface, when serious symptoms have occurred in the organ involved. It is often very difficult to see from the skiagraph at what depth the bullet is lodged, hence, by means of pictures taken from various positions the exact location of the bullet must be established. Else a probe must be introduced, if the canal caused by the gunshot is still open, or if any fistulous opening exists. The shadow of the probe will lead to the exact location of the bullet. But if the exposure to the Rontgen rays cannot be made, and if it is imperative to remove the bullet, probing for the same is justifiable. The operator should not use for this purpose the common thin silver probes, with which nothing can be felt distinctly and whose fine points are especially apt to lead in a wrong direction, but he should use the flexible zinc probes (Fig. 388), about i foot in length and as thick as a goosequill or a lead pencil, with which no injury is caused, if they are manipulated gently. Fig. 389 Fig. 390 Von Langenbeck's Bullet Forceps Fig. 391 American Forceps FOR Soft Lead Bullets Fig. 392 Fig. 393 Forceps for Jacketed Bi^llets If the bullet is felt, the operator should try to grasp it with one of the various bullet forceps (Figs. 389-393) and extract it carefully. If the bullet is lodged in a bone, it can be bored into with a bullet screw THE TREATMENT OF WOUNDS 223 and thus be extracted. But if it is found to be very firmly lodged in the bone, not too much force should be used, since dangerous inflamma- tions of the bone may be caused thereby. It is better either to wait until the bullet of its own accord is liberated by inflammatory absorption of the bone tissue, or, after an adequate incision of the soft parts, to remove with chisel and hammer enough of the surrounding bone to enable the bullet to be extracted with forceps without force. (In all future wars the Rontgen ray will be largely relied upon in ascer- taining the presence and exact location of bullets lodged in the body. It proved to be of inestimable value during the Spanish-American war.) If the operator is in doubt whether the hard body felt in the depth is the bullet or not, with the soft lead bullets of former wars, he could obtain assurance of it either by using Nelatoii s probe, tipped with an unglazed porcelain bulb, which, when rubbed against the bullet, is stained by the lead ; or by means of Lecojnte-L iiej^s exploring instrufnent for bullets with which a small particle of lead may be nipped off from the bullet ; or finally by the use of LiebreicJis electric bullet probe (Fig. 394), which sets the mag- netic needle of a galvanometer in motion as soon as the isolated points of the probe or of the forceps touch a metallic body. {Nelatons probe has lost much of its diagnostic value in searching for modern jacketed bullets, as the lead test no longer can be elicited since the lead part of the bullet has been encased by firmer metals. The changes in the construction of the modern bullets have rendered also the use of the old bullet forceps obsolete. The editor has devised a bullet forceps which grasps with certainty jacketed bullets of any size.) If the bullet cannot be felt in the wound, but can be felt at some other place tender the skin, and if the operator is in doubt whether he feels a bul- let or a piece of bone, he can assure himself by inserting two steel needles with handles (acupuncture needles), which are placed in connection with LiebreicJi's electric bullet probe. More recently electric microphonic bullet probes have been mentioned, for instance, by Fozvler and Klein, by means Fig. 394. Liebreich's Electric Bullet Probe 224 SURGICAL TECHNIC of which a small sound is produced in a little telephone as soon as a needle touches the bullet. Of a similar construction is Wells's telephonic bullet probe and forceps. If an electric bullet probe is not at hand, it can be improvised (according to Longmore) from a copper coin and a bent piece of zinc, which are kept apart by a piece of flannel dipped into diluted acid. One of the two insu- lated copper wires which end in acupuncture needles is wound several times around a pocket compass, the needle of which moves as soon as the current is closed by coming in contact with the bullet (Fig. 395). Fig. 395. Longmore's Bullet Probe If bullets which have been imbedded in the bone for years or which in necrotic portions of bone lie in so-called "coffins" (involucra) are to be removed (after osteomyelitis, a very frequent occurrence in consequence of contusion of the bone by gunshot), then the broad opening in the bone (necrotomy) must be performed. OPERATIONS FOR THE PREVENTION AND ARREST OF HEMORRHAGES AND THEIR CONSEQUENCES SAVING OF BLOOD From all times, surgeons have endeavored in operations and injuries to limit the loss of blood to a minimum. In olden times, before amputations, the Hmb was encircled with cords, the cautery iron was next used for arrest- ing the hemorrhage, or the stumps were dipped into boiling pitch. Until THE TREATMENT OF WOUNDS 225 Fig. 396 Chassaignac's ecraseur about twenty-five years ago, surgeons confined themselves to reducing the loss of blood in amputations by preventing the arterial flow of blood to the wound. This was effected by compressing the trunk of the artery, either with the finger or with the pad of the tourniquet. With the same agencies they tried to combat arterial hemorrhage in acci- dental injuries. The attempts to remove a large portion of the body in a bloodless way by ligature {I'on Grdfe) and by crush- ing them with a chain {ecrasement — Chassaignac, Fig. 396) have met only with temporary success. Not until the bloodless method was invented were surgeons enabled to avoid the loss of blood in all operations on the extremities, to keep off during the operation the disturbing flow of blood, and thus to operate on the living body with the same ease as on a cadaver. The bloodless method, temporary ischceinia {von Esniarch, 1873), purposes two things: — {a^ To expel the blood present in the vessels from the portion of the body to be operated upon. (^) To prevent the afferent flow of blood through the arteries. The procedure is as follows : — I. The limb from the points of the fingers or toes upward and beyond the field of operation is firmly bandaged with an elastic band, preferably of pure india-rubber. The several tours of the bandage overlap each other about one-half. Crossed and reversed turns are not made ; it is unnecessary to bandage the several fingers and the heel according to the rules of bandaging. The compression bandage is carried up as far as the place where the elastic constrictor is to be applied, and here it is fastened by placing the head of the bandage under the last tour. For practical reasons, it is advisable to carry the bandaging always as far as the upper part of the arm or the thigh (Figs. 399, 400). Such parts as contain ///j-, sanious jnatter, or soft tumor tissue, must 7iot be bandaged, because thereby infectious matter might be pressed into the cellular tissue and the lymph channels. In such cases, the operator must be satisfied to hold the Hmb up perpen- dicularly for a few minutes until it has become visibly pale. Light superfi- cial stroking with the hand promotes the return of blood from the veins. (Very few surgeons now make an attempt to render the limb bloodless by elastic compression as a preliminary step to elastic constriction, as the limb is rendered practically bloodless by holding it for five minutes in a ver- tical position.) Q 226 SURGICAL TECHNIC 2. At the place where the bandaging ends the constrictor is applied. For this purpose, it is best to use an elastic band 5 centimeters wide and about 140 centimeters long with inwoven rubber threads (rubber bandage), which Fig. 397. F]lastic Constrictor (according to von Esmarch) Fig. 398. Clamp Buckle under continued tension is carried around the limb in circular turns so that the several turns cover each other. In this manner, each turn strengthens the effect of the preceding titrii ; it is, therefore, not always necessary, espe- FiG. 399. Elastic Bandage and Constrictor cially with new elastic bandages, to stretch them to the limit of their elas- ticity, because, especially in the arm, considerable pain is caused, sometimes even paralysis. The right measure of force to be used is learned by practice. FiG. 400. Limb rendered Bloodless on removing Elastic Bandage In applying the elastic band, its starting end is pressed firmly with the thumb against the limb and held in position by the next turn, which passes over it. The rolled-up head of the band does not descend closely upon the turns of THE TREATMENT OF WOUNDS 227 the limb as in the appHcation of a common bandage ; but, in order to secure the requisite tension, it is carried around the Hmb at a distance of 6 to 8 inches. The end is, fastened hy a clamp buckle, which is pushed toward the \ Fig. 401. Rubber Constrictur hook fastened to the upper end of the band (Figs. 401, 402), or else the end of the band is pushed under the last turn, best of all over the main trunk of the artery, and fastened thus (Fig. 398). Nicaise's elastic band is also practical. It consists of a hook and a number of rings sewed in a row at one end of the band (Figs. 401, 402). In case of necessity, the end of the constrictor can be fastened with a safety pin (Fig. 401). 3. When the elastic bandage below the constricting band is removed, the limb pre- sents a perfect post mortem pallor. Any operation can be performed upon it without the loss of blood. The operator is not hin- dered by the flow of blood from seeing or from recognizing the diseased tissues, and is not obliged to do much wiping or spong- ing ; hence, he operates with less assistance, and with the same facilities as on the cadaver, even if the operation should be a prolonged one. Experience has taught that the flow of blood can be interrupted in this manner for several hours without causing any essen- tial injury or fear of gangrene. Cases are even known in which the constrictor re- mained in position from 7 to 10 or 12 hours without resulting in gangrene or paralysis. yig. 402 Fig. 40- 4. At places where the application of a Nicaisk's Elastic Band SURGICAL TECHNIC Fig. 404. Vox EsjfARCH's Apparatus FOR Bloodless Method broad constrictor is difficult, as in the iliac region and the axilla, it is advisa- ble to use the thick elastic tube which was originally used for constricting the limb, and which, under strong tension, is carried in circular turns two or three times around the part of the body, when its ends are tied or fastened with hooks and chain (Fig. 403). For fastening the ends of the elastic tube, a clamp can be used, for instance, a metal ring with an opening lengthwise from the diameter of the tube (Fig. 404); in the cleft of this ring, both stretched ends can easily be pressed. But if the ten- sion is relaxed, they become fixed by pressing upon each other from opposite directions (Fig. 405). (The simplest manner to fasten the ends of an elastic constrictor band or tube is to apply a strong forceps over the crossing of the two ends after the constriction has been made in a satisfactory manner.) In the application of the elastic con.-trictor on limbs which are the seat of an cedematous swelling, attention must be paid to the fact that the effect upon the vessels often ceases as soon as the serum has been displaced from the tis- sues at the con- stricted place. In such cases, as soon as the limb assumes a reddish color, the /'/ constrictor must be quickly removed and immediately re- applied at the deep Fig. 405 Fig. 406 Cl.\mp for Fastening Ela.stic Tibe (von Esmarch) groove caused by it. In operations in and on the shoulder joint, an elastic tube as thick as a finger, after it has been carried through below the axilla under strong tension, must be kept in position on the THE TREATMENT OF WOUNDS 229 shoulder by a strong hand or by a tube clamp (Figs. 407, 408). By draw- ing the ends toward the neck, they are prevented from slipping off. Care Fig. 407 Fig. 408 Bloodless Method for Disarticulation OF Shoulder Fig. 409 Finger Rendered Bloodless must also be taken not to divide the elastic tube and to guard against its slipping over the wound (after a very high amputation or disarticulation of the humerus). Fig. 410. Bloodless Method used in Operation on Penis and Scrotum Fig. 411. Bloodless Method in High Amputation OF Thigh For tying off the circulation from a finger, a rubber tube as thick as a goosequill is sufficient ; this is applied as represented in Fig. 409. 230 SURGICAL TECHNIC Fi(j. 412. Brass Spiral Bandage (von Esmarch) With a similar elastic tube, the root of the penis and the scrotum can be tied off, if the operator desires to perform operations on the external male organs of generation without any loss of blood (Fig. 410). In high amputations of the thigh, the elastic tube is carried closely below the crural arch once or twice with considerable force around the thigh; the ends are made to cross over the inguinal re- gion, and are then carried around the posterior sur- face of the pelvis and finally hooked together by a chain in the hypo- gastric region (Fig. 411). In disarticulations at and resections of the hip joint, provided the intes- tines have been previously evacuated thoroughly, the arterial flow may be most safely controlled by compressing the aorta in the umbilical region (see p. 236). Of course, elastic constriction with a rubber tube may also be applied in any other place, instead of the regular constrictor. Still, the latter is pref- erable, since its elasticity is more limited, and hence its effect never so powerful as that of the tube apphed under the greatest tension. Moreover, the pressure of a broad bandage is more agreeable and can be borne without any dangerous consequences, since the circle of compression is a wider one. In fact, constriction produced by an excessively stretched tube may cause pa- ralysis of long duration, which occurs only very rarely when the broad con- strictor is applied, and with ordinary care in applying the same hardly ever occurs. If, in operations under local anaesthesia, the pressure caused by the con- striction is found to be too painful, apply, either above or below, a new constrictor and then release the constricted part. It is a deplorable fact, however, that rubber bandages and textile fabrics, when kept for any length of time, especially in a very hot or cold cHmate, become brittle and unfit for use. Hence it is more practical (for expeditions, voyages on shipboard, in the tropics, and in the polar regions, for preser- vation in military arsenals, etc.) to have the constrictors made of fine brass spirals, laid side by side, covered with glove leather and provided with a clamp buckle (Fig. 412). This constrictor is not liable to deteriorate, and THE TREATMENT OF WOUNDS 2.^1 its elasticity answers every purpose in substituting it for the ordinary rubber elastic constrictor. It is to be hoped that, just as in the various armies of foreign countries, so also in Germany, the constrictor of this simple and durable form will be introduced and that it will displace the old-fashioned tourniquet, which is not by any means as safe and effective. For the advantages of elastic constric- tion are apparent. They consist chiefly in the fact that it is unnecessary, even injurious, to place a pad upon the main trunk of the artery as is done in the use of the tourniquet. SucJl a pad is altogether foreign to the bloodless method. In making use of elastic constriction, the surgeon desires to produce an effect not only tipon the artery but uniformly ttpon all vessels ; it interrupts the entire circulation in the constricted part, and, for this reason, can be used in major operations as well as in arresting seri- ous arterial and venous hemorrhage from accidental wounds; in fact, it serves a useful purpose in the treatment of poisoned wounds by preven- ting absorption of the poison, without presupposing an exact anatomical knowledge. These considerations suggested the idea of supplying laymen with an elastic constrictor in the form of a pair of suspenders as an aid in sudden accidents. The tourniquet suspender {von Esmarch, 1881) consists of an elastic band 150 centimeters long, 4 centimeters wide, provided at each end with hooks and eyelets ; by untying three loops it is transformed into a very light and comfortable band (Fig. 413). Its elasticity is sufficient to constrict successfully the thigh of a powerful man. If this inexpensive wearing apparel were worn by every workman and soldier, then, with proper instruc- tion, many accidents could be mitigated by a proper application of the bandage ; and especially death from hemorrhage might be prevented. Indeed, a very large number of such cases have been reported already, both by physicians and by laymen. P"lG. 41^ Tourniquet Suspenders (von Esmarch) 232 SURGICAL TECHNIC Fig. 414. Applying a Tourniquet Suspender In emergency eases, when an elastic bandage is not at hand, apply a linen bandage in circular turns as firmly as possible around the limb, and then moisten it with water; the swelling of the bandage caused by the moisture increases the constriction. The ascending bandaging of the limb may also be made more effective with a cloth bandage subsequently mois- tened. Likewise, the Spanish zvindlass, represented in Fig. 425, can be made use of for circular constriction without any pad. When the eonstriction bandage is removed at the end of the operation, the limb, which until then presented a deadly pallor, turns as red as a boiled lobster, and a very considerable hemorrhage occurs in the wound, because the walls of the blood vessels were in a state of paresis and had become flaccid from the continued pressure upon the vasomotor nerves ; hence, they allow more blood to pass through them than in their normal condition. The consequence is that the blood gushes forth from the operating wound as from THE TREATMENT OF WOUNDS 233 a sponge. The arteries spirt forcibly, and even the finest capillary vessels bleed almost twice as much as without the use of elastic constriction. The hemorrhage is, of course, most violent if the constrictor is removed slowly, because the blood immediately enters the arteries of the part which was constricted ; but since it cannot return immediately through the veins, which are still compressed by the last turns of the bandage, as in the operation of bloodletting, venous congestion is likely to occur in addition to the paralysis of the vasomotor system. Hence, it is necessary to remove the constrictor not slozvly, but quickly. The profuse parenchymatous secondary hemorrhage, which is the greatest disadvantage of elastic constriction, can be avoided, before removing tJie constrictnre : — 1. If all visible vessels that have been divided are Most carefully ligated ; next, 2. If the wound in its depth and at its margins is sntiired so that no dead spaces remain anywhere ; and finally, 3. If a uniform compressive bandage, Qv^ry^h^xQ firmly applied, is placed upon the sutured wound. Cavities of the wound which must heal by granula- tion, or which are intended to be closed by secondary sutures, are firmly tamponed. The constriction band is not removed until the dressing has been completely applied ; hence, it is advisable to apply the constrictor from the beginning as high above the field of operation as possible, in order not to cause any difficulty in removing it rapidly. 4. If, after the removal of the constrictor, the linib is raised and placed in a vertical position for several hours ; in suitable cases, also, the com- pressive bandage can be strengthened by an elastic bandage under moderate tension. If these rides are observed, a secondary hemorrhage Jieed not be apprehended. If the surgeon, however, from excessive fear of secondary hemorrhage, or because he thinks himself not sufificiently skilled in finding smaller divided vessels, does not venticre to suture the wound and to bandage it before the constriction is removed, then, after removal of the bandage, with the limb held in a vertical position, a large compiessive bandage or a sponge must be firmly pressed for several minutes upon the surface of the wound, and the vessels which are still bleeding or spirting must next be sought for and tied. If the parenchymatous hemorrhage, however, continues, it is arrested by irrigating the wound with a sterile or antiseptic fluid as cold as ice. For this purpose, an ice douche is used, — that is, a glass irrigator in the middle of which a glass tube filled with a cold mixture (pounded ice and salt) is 234 SURGICAL TECHXIC inserted. Digital compression of the principal artery is also useful in arrest- ing parenchymatous hemorrhage. The advantages of elastic constriction over former methods, — especially the advantages of the application of the tourniquet, — are generally known ; they consist chiefly in the fact : — 1 . That the blood interruption is safe and can be maintained conveniently for a long time. 2. A displacement during transportation, as is the case with the pad of the tourniquet, need not be apprehended. 3. The constrictor can be applied on any desirable part of the limb. 4. For applying the constrictor band, no anatomical foiozuledge is neces- sary. In contradistinction to these advantages, it is hardly necessary to refute the assertions again and again made by some persons that the procedure had the following disadvantages : — 1. More profuse parenchymatous hemorrhage. 2. Gangrene of the margins of the wound, or even of the whole con- stricted limb. 3. Paral)^sis of the nerves from the pressure of the constrictor. 4. The danger of infection from pus or tumor cells from compression of the limb. A^one of these disadvantages exist, if the above simple 7'nles are obseii'ed in applying the bandages. Only briefly may it be mentioned here that formerly a successful attempt was made to interrupt the flozv of blood by pressu)-e limited to the field of operation. Desmarres invented his clamp for opera- tions on the eyelids ; these are clamped upon the plate by means of the ring (Fig. 415). DieffenbacJi used forceps ending in two rings, between which he clamped the cheek, the tongue, or the lip, in order to remove bloodlessly angiomata, etc. (Fig. 416). In the operation for harelip or the cutting out of a wedge-like portion in cancer of the lips, the flow of blood from iG. 415 ^^ coronary arteries can be arrested on Desmarres s -' Clamp both sides of the field of operation with Fig. 416 Dieffenbach's Rinl; Forceps THE TREATMENT OF WOUxNDS 235 two long hemostatic forceps. In the same manner operates the constriction of the root of the tongue in amputations of the tongue, and the stitching about of the neighborhood of the wound in tumors of the tongue and cheek, and in tracheotomy. We may mention here also Ricord's forceps for phimosis operation. The transverse and parallel forceps for compress- ing the pedunculated base of many tumors and as an aid in circular gastror- rhaphy and enterorrhaphy, etc. Finally, may be mentioned the application of the rubber tube in most recent times, in amputation of the rectum, in supra-vaginal amputation of the uterus, and in the Caesarean operation. Compared with the bloodless method, the other blood-saving methods of former times are used only in exceptional cases, since they are performed with difficulty and are uncertain in their results. They all have for their object THE COMPRESSION OF THE MAIN TRUNK OF THE ARTERY above the wound. I. By pressure of the finger (digital compression), the artery can be com- pressed effectually only in places where a hard base is furnished by the bone and where the vessel lies not too deeply concealed in the soft parts. The most suitable places for digital compression are : — For the common carotid artery, the anterior lateral region of the neck between the larynx and the median margin of the sterno- cleidomastoid, where the finger presses the artery against the cervical column (Fig. 417). For the subclavian artery, the supraclavicular fossa on the lateral margin of the sterno- cleidomastoid, where the artery is behind the scalenus anticus muscle and is pressed against the first rib. The access of the finger is facilitated by press- ing forward the shoulder and the clavicle (Fig. 418). The subclavian artery also can be compressed by strong retrac- •^ ° riG. 417. COxMPRESSION OF THE CaROTID ARTERY tion of the shoulder m a pos- by Finger Pressure 236 SURGICAL TECHNIC terior direction and with the aid of the other arm, between the clavicle and the first rib (like a compression stopcock). The hand is made to grasp from behind the bend of the elbow of the healthy arm ; the latter is pressed forward and both arms are tied together in this position by cloths or bandages (Fig. 419). For the axillary artery, the anterior margin of the axillary space (the anterior border of the axillary hair) where the artery can be compressed against the head of the humerus when the arm is raised. For the brachial artery, the internal side of the humerus in its whole length, where the artery can be everywhere compressed easily against the humerus along the internal margin of the biceps muscle (Fig. 420). The abdominal aorta with flaccid abdominal walls and empty intestines can be compressed at the level of the umbilicus against the vertical column. In most cases, however, the pressure cannot be tolerated long without anaesthesia. The same is to be said of the external iliac artery in its upper part, where it can be compressed against the lateral margin of the inlet of the pelvis. It can be compressed more easily and for a longer time a little in front of its exit from the pelvis above the middle of Pouparf s ligament against the superior border of the horizontal ramus of the pubis. The femoral artery is most easily compressed directly below Poupart's ligament against the iliopectineal eminence (Fig. 421). The vessel is found in the middle of a line drawn from the anterior superior spinous process of the ilium to the symphysis of the pubis. In its further course as far as the lower third of the femur, it can be compressed against the femur ; digital compression, however, on account of the thickness of the soft parts lying between, is difficult and unsafe, especially in stout and very muscular subjects. Since a successful digital compression can be performed for some time only by a well-trained and strong hand, but during the transportation of seriously injured persons, not at all, attempts have been made to supply the same by various appliances. 2. By artery compressors or tourniquets; they consist essentially of a bandage with which a hard pad {pclottc) or a roller is firmly pressed against the trunk of the artery. The tourniquet can be applied correctly only by a surgeon who is familiar with the anatomic conditions. It must be constantly watched, for if it becomes displaced by imprudent movements or during trans- portation, it does not operate any longer and can even become injurious by causing stasis by pressure on large veins, which always accompany the artery. THE TREATMENT OF WOUNDS 237 Fig. 418. Cu.MPREysiON of the Subcla\'ian Artekv BY Finger Pressure Fig. 419. Compression of Right SuBCLA'i'iAN Artery Fig. 420. Compression of Brachial Artery Fig. 421. Compression of Femoral Artery 238 SURGICAL TECHNIC The tourniquet is applied in the places mentioned above for digital com- pression selected on the limbs, and of these again, the arm and the thigh near the trunk, because here the artery can be found rather easily and can be most successfully compressed (Figs. 422, 423). Fig. 422. Compression of Brachial Artery by Tourniquet Fig. 423. Compression of Femoral Artery by Tourniquet Petifs screw tourniquet was most generally used (Fig. 424); in this, the circular band is stretched by a strong screw, and the pressure exerted by the pad upon the artery can be increased at pleasure. The Spanish windlass (Fig. 425 ) consists of a strap with a buckle, to which a hard pad is fastened, a plate, and a short stick. After the pad has been appUed over the trunk of the artery, the strap is buckled loosely around the limb and then firmly drawn tight across the plate by twisting with the stick. Pancoasfs aorta tourniquet (Fig. 426) is operated with a long screw, which moves a broad pad against the posterior cushion. Of similar construction is : — Von EsinarcJis aorta tourniquet (Figs. 427, 428). Its pad, provided with a handle, is pressed against the vertebral column by elastic bandages, which are stretched between the adjustable hooks of the posterior cushion. The steel handle of the pad is provided with a slit, through which the turns of THE TREATMENT OF WOUNDS 239 240 SURGICAL TECHNIC rubber bandage can be drawn, and with two pads of different size. The upper pad is kept in position by the hand of an assistant, so that the lower one cannot sHp off from the aorta. IMPROVISED ARTERY COMPRESSORS The aorta can also be successfully compressed with a Hnen bandage 8 meters long and 6 centimeters wide, firmly wound around the middle of a stick as thick as the thumb and a foot in length. This pad, applied over the aorta below the umbilicus, is held in position by an assistant, and is pressed forcibly against the vertebral column by a number of turns of a rubber bandage 6 centimeters broad, carried around the body (Fig. 429). If circular constriction of the ab- domen is to be avoided, the linen band- age is wound, according to Brandts, around the middle portion of a longer stick, and its ends are pressed downward through the turns of the rubber bandage and passed under the plate of the operating table (Fig. 430). In a similar manner, a tourni- quet can be made for compres- '^/ /'^ sion of the external iliac artery, Fig. 429. Compression of the Aorta by Pad AND Rubber Bandage Fig. 430. Brandis's Method of Compressing Aorta Compression of External Iliac Artery directly above Pouparfs ligament, with a bandage and a pad firmly pressed upon the artery by a strong rubber bandage, applied in cross turns (Fig. 43 1 ) for high amputations of the thigh. THE TREATMENT OF WOUNDS HI A stick tourniquet (Spanish windlass) can also be improvised by wind- ing around the limb a handkerchief or a triangular cloth, which is tied into Fig. 432. Improvised Spanish Windlass Fig. 433. Compression of the Brachial Artery a firm knot or in which a flat, smooth stone has been wrapped ; by twist- ing it with a stick or some similar object (sword, ramrod, key) inserted under the cloth, it can be firmly constricted (Fig. 432). For compressing the brachial artery, a com- paratively light pressure exerted with a thick stick against the internal surface of the arm is sufficient (Fig. 433); this pressure forces apart the bellies of the muscles in an anterior and posterior direction, and presses the artery flat against the bone. The arm is pressed firmly against the body by a cloth or a bandage. The arm can also be very effectually compressed between two sticks tied together on both sides ( Volcker's stick tourniquet — Fig. 434). 3. By position: Adelmaim recommended as a remedy for arresting arterial hemorrhages hyperflexion of the limbs. By this, the arteries become so strongly bent that they do not per- mit the passage of blood. If, for instance, in R Fig. 434. Volcker's Stick Tourniquet 242 SURGICAL TECHNIC arterial hemorrhages from the forearm or the hand, the forearm in supina- tion is strongly flexed and firmly tied against the arm by a bandage or a cravat, the pulse in the radial artery ceases immediately. In the same manner, by a forcible flexion of the knee, hemorrhage from the vessels of the leg and the foot, and, by a hyperflexion of the thigh, hemorrhage from the femoral artery, can be momentarily arrested. In cases where other means for arresting hemorrhage are not at hand, hyperflexion can be re- sorted to successfully. Still, it must not be forgotten that such a strongly flexed position as is required for safely arresting the hemorrhage cannot, in most cases, be endured for a long time, and if the bones are broken at the same time, it cannot be made use of at all. 4. Lastly, the blood supply is very considerably decreased by raising the limb vertically. At times, venous hemorrhage yields to this simple expedient, provided all articles of clothing, garters, etc., which tend to promote congestion have been previously removed. ARRESTING HEMORRHAGES IN THE WOUND Violent hemorrhage from injured vessels endangers life directly, and must be arrested as rapidly as possible. In the simplest manner, at least temporarily, the hemorrhage is arrested by compressing the wound : — 1. By the finger or the hand, which, of course, must be clean. In some cases of serious injuries, the injured person may compress the wound with his own finger. Since, however, the pressure of the finger, for any length of time, cannot be well continued — for instance, during transportation and when the hemostatic resources discussed in the preceding section are not at hand, or cannot be applied — it is necessary that — 2. A dressing be substituted for them, which shall exert suflficient pressure upon the wound. Before applying such a compressive dressing, the wounded limb must be bandaged carefully and completely from below upward, to prevent the dangerous collection of blood in the meshes of the cellular tissue {dijfiise bloody infiltration). Next, a firm dressing is laid upon the wound, and fastened in place under considerable pressure by a bandage — prefer- ably an elastic bandage. In deep wounds, the hemorrhage can be arrested still more effectively. 3. By tamponade. The cavity of the wound is packed firmly by forcing with the finger the middle portion of a piece of antiseptic gauze (iodoform gauze) as deep into the wound as possible, and, after the finger has been withdrawn, the cavity is firmly packed with sterilized gauze. In tubular THE TREATMENT OF WOUNDS 243 wounds, first smaller, then larger, tampons can be introduced into the cavity packed with gauze, until the last reach far beyond the surface of the skin. The tampons are firmly pressed upon the wound by a bandage, if possible an elastic bandage ; this, if packed with aseptic material, can remain in position for many days, until the bleeding vessel or vessels have become occluded by thrombosis. This is especially the procedure in hemorrhages from the cavities of the body — for instance, from the nose, vagina, uterus, rectum. It is necessary to provide these several tampons, or portions of gauze, with a long thread by which they can be removed again in the gentlest manner. The inflation of a small elastic bag, introduced in a collapsed condition, with air or ice water (Rhineurynter, Colpeurynter, see Fig. 141 2) is likewise very effective, but it is not so simple as the common tamponade. MEDICINAL HEMOSTATICS (STYPTICS) These partly promote the coagulation of the blood, and the contraction of the vascular walls, partly produce a firmly adhering crust. They should be used only in case of greatest necessity, when the hemorrhage cannot be arrested by tamponade, for fresh wounds are more or less irritated, and even strongly cauterized, by all these agents, so that healing by primary intention is made impossible. To the oldest agents of this kind belong agaric, the cautery iron (see page 26), and the soliUion of ferric chloride {liquor ferri sesqiiichlorati) ; even now the latter is used in the form of a dry, yellow, styptic cotton, just like Penghawar Yanibi. To this class of agents belong also vinegar, solution of alum, of creosote (i : 100 — aqua binelli), oil of turpentine {Bawn, Billroth), chloride of zinc in saturated solution, tannin (^Graf) in powder form, peroxide of hydrogen {von Nnssbaunt). To the more modern styptics belong antipyrine in a 20% solution, or in powder form {Bosworth), 2L 20% cocaine solution, fibrin ferment solution {Wright), cornn- tine, sclerotinic acid, ferripyrine and gelatine. Irrigation with ice cold or hot sterile water and the use of steam (vaporization, Atmokausis, Zestokausis) may be mentioned here. The best and safest procedure for arresting hemorrhage permanently is : — LIGATION OF THE VESSELS (LIGATURE) All bleeding vessels, arteries, and veins in a wound (after operations or injuries) are grasped and clamped with hemostatic forceps. These instru- ments are now relied upon exclusively in grasping bleeding orifices, and are 244 SURGICAL TECHXIC variable in their construction, the principal object of all of them being to seize and compress the bleeding vessel (Figs. 435-437). In major operations — for instance, in amputations — large vessels are drawn somewhat forward Fig. 437 Spencer Well's Artery Forceps from the surface of the wound with forceps, and are then securely closed by torsion with the aid of a second transversely applied forceps. If larger vessels cross the field of operation, they are grasped transversely with two hemostatic forceps, and divided between them (Figs. 438, 439). As many Fiu. 439 Ligation between Two Hemostatic Forceps hemostatic forceps as are required are applied, and allowed to remain in position. Ligation with catgut does not commence until all the bleeding vessels have been temporarily secured with forceps (Fig. 440). The pro- cedure is as follows : — THE TREATMENT OF WOUNDS 245 Make slight traction on the instrument which grasps the vessel ; pass a simple knot around its point ; push it with the tip of the forefingers over the vessel (Fig. 441), draw it tight, place a second knot (" reef knot ") upon it, next cut off the two threads closely in front of the knot with a pair of curved scissors, and remove the forceps. For ligat- ing large vessels it is advisable not to use too heavy catgut, because its knots loosen more easily, especially if the threads have been cut off very closely. Many surgeons prefer silk for ligatures. (The editor has for the last ten years applied a double ligature ^ to ^ of an inch apart in ligating arteries the size of the brachial. The bloodless space between the two liga- tures is securely closed in the course of 7 days by definitive obliteration of the lumen of the vessel. The proximal liga- ture includes the accompany- ing vein or veins.) Ligation. If a bleeding vessel cannot be well drawn forward from its surrounding tissue, or if it cannot be grasped — for instance, in the scalp or in hardened cicatricial tissue — it must be ligated with an ordinary round curved needle armed with the liga- ture. The needle is carried through the connective tissue surrounding the bleeding portion, and with the loose connective tissue included the ligature is tied (Fig. 442). If many vessels are found in tough, broad layers of connective tissue, they can be grasped separately with care and time. The same object can be accomplished more rapidly, however, and with the same degree of certainty by ligating Fig. 440. Ligation with Numerous Hemostatic Forceps Fig. 441. Ligation of Blood Vessel 246 SURGICAL TECHNIC tissues, including the vessels, in sections by indirect ligatures. Thinner layers are clamped with hemostatic forceps, and secured with a double ligature (Ligature en masse). If only a few or no ligatures are on hand, smaller arteries can also be closed by torsion. Grasp the artery with torsion forceps, draw it forward, Fig. 442. Ligation of Artery BY Indirect Ligature Fk;. 443. Closing Artery by Torsion and, according to its thickness, twist it from six to eight times around its axis, holding the central end of the projecting portion with the fingers or, better, with another pair of forceps {Ajmissafs clamp forceps — Fig. 443). By this procedure, the inner coat of the artery (tunica intima) is torn, and is rolled up in an upward direction, thereby forming a very safe valvular occlusion, strengthened by the twisted tissues. The same effect is produced by a veiy strong press- iire exerted upon the artery. Kdbcrle and Pcan have devised for this purpose clai)ip or pressure forceps (Fig. 441) similar to small dressing forceps, which greatly contuse the grasped tissue by the fixation of its compressed ends. After a quarter of an hour the forceps may be removed without any previous ligature, since the contused inner coat (tunica intima) is rolled up like a cuff in the lumen of the vessel, and the tissues, from the strong pressure, become as desiccated as if they were burned {forci- pressui'e). The clamp forceps are used especially in places where a ligature can 444. KOBERLfe- „, , „ c- ' be applied only with difficulty or not at Pkan's Clamp For- ' ' -^ _ -' _ cEPs all, and as a substitute for the ligatures Fig. 445. Doyen's Angiotribe THE TREATMENT OF WOUNDS 247 en masse. As the contused tissue does not become necrotic, forcipressure has the advantage over the ligature of not introducing any foreign substance into the wound. When applied to large arteries the forceps must remain in situ from 12 to 24 hours. A still greater effect is produced by angiotripsy {Doyen). Bv means of it, with YQxy strong forceps (vasotribe, Fig. 445 ) under an immense pressure (up to 2000 kilometers), not only the vessels, but also all tissues grasped by the forceps (as in hgations of pedicles and "en masse"), are crushed to plates as thin as paper, from which no hemorrhage can occur any more. HEMORRHAGE FROM PUNCTURED AND GUNSHOT WOUNDS If the injury in question is a hemorrhage from a larger vessel which, in the depth of a punctured or a gunshot wound, manifests itself directly or after some time by a continued oozing of blood through the bandages, or which occurs in the subsequent course of the wound from erosion of the vascular wall or from thrombosis of the veins (phlebostatic hemorrhage, Styo7neyer), no time should be lost in exposing at once the bleeding vessel at the place of ijijnry and in ligating it in the wound itself (direct ligation). Before this often very difficult task is attempted the anatomical posi- tion of the trunks of the vessels should always be called to mind. Figs. 446-450 may serve to recall the anatomical locations and surgical relations of the principal arterial trunks. The paramount condition for executing such operations easily, rapidly, and thoroughly is a la^-ge external i?icisioTi, which is made from the wound in an upward and downward direction and longitudinally to the limb in such a manner that it corresponds to the course of the injured vessel. Where it is a matter of Hfe it is indifferent whether the incision is an inch or a foot in length. If arresting the hemorrhage meets with success and the wound remains aseptic, the large incision heals as well and as rapidly without suppuration as a small one. As to the rest, the procedure is exactly the same as that described in secondary antiseptics (page 57). Ha\-ing incised the skin to the requi- site extent, the operator penetrates in the depth of the wound with the left forefinger, divides with a probe-pointed knife the deeper layers, the cellular tissue, the fascias and muscles as far as necessary ; the divided parts are then retracted with large sharp or blunt retractors. Next, the blood clots filling the whole cavity of the wound (the so-called aneurysma traumaticum diffusum) are quickly and thoroughly removed with 248 SURGICAL TECHNIC the fingers and sponges, and in most cases in the depth of the wound the injured vessel or at least a bloody infiltrated layer of tissue is found, in 27^-3? ^■■■"■^ ■ n <.''- — ••^-.Mmaxf^^^:- \ Fig. 446. Arteries of Head, Neck, and Axilla which the artery, veins, and nerves can eventually be found and identified. The operator should try to separate these several parts by careful dissection. The finding of the injured vessels is essentially facilitated by making use of the bloodless nictJwd. If, however, the trunks of the veins are entirely empty and have collapsed, it may be difficult to distinguish them from the THE TREATMENT OF WOUNDS 249 \ layers of cellular tissue. For this purpose it is advisable to form a blood reservoir below the wound by placing, for instance, before the elastic. bandag- ing of the injured arm, _ _ a constrictor band around the wrist. If this con- strictor is subsequently removed, and if the arm is raised, the blood which had remained confined in the hand fills the veins, and, in case one of the veins is injured, gushes from the vein wound. When the injured place of the artery or the vein has been found, and has been exposed so far that the whole extent of the injury can be sur- veyed or inspected, the vessel must be isolated and firmly and securely ligated in the healthy part above and below the injury with catgut or silk ("reef knot"). Next, if the continuity of the vessel is not already in- terrupted by the injury, it is divided in the mid- dle between the two liga- tures, and the operator convinces himself that no principal branches of the vessel are interposed between the two Hgatures. If such branches are found they must also be well isolated, ligated, and separated from the trunk of the vessel. In order to proceed with absolute safety the injured portion of the vessel lying between the two ligatures can be excised. Fig. 447. Arteries of the Thigh 250 SURGICAL TECHXIC Next, the constrictor band is removed, and all the vessels from which blood is still oozing are carefully ligated, while the limb is raised in order to limit the parenchymatous hemorrhage. 1.^ Fig. 44S Arteries of Arm Fig. 449 Fig. 450 Arteries of Leg. a, posterior side; h, anterior side THE TREAT-MEXT OF WOUNDS 25 1 LIGATION OF ARTERIES AT THE PLACE OF SELECTION (hunter's indirect ligation; The ligation of an artery above the wound is hardly ever resorted to at the present 'ixm.o. for arrestmg hemorrhages ; but it is much to be recom- mended for practising the technique and for testing the knowledge of topo- graphical anatomy. Ligation of arteries, however, is often made to prevent permanently the flow of blood to certain parts of the body in important and bloody operations, or to heal diseased conditions. Thus the carotid artery is ligated in resection of the upper jaw; the lingual, in operations on the tongue; the thyroid arteries, in struma vasculosa (vascular goitre); the sub- clavian, in the disarticulation of the shoulder joint; the common iliac, in disarticulation of the thigh ; the hypogastric, in tumors of the pelvis and hypertrophy of the prostata. (Preliminary ligation of large arteries in performing the operations mentioned above is seldom performed at the present time, since the surgeon has been placed in possession of local hemostatic resources which, if properly applied, make him master of the situation in arresting the hemorrhage.) The following rules should be observed in finding and ligating the trunks of the principal arteries : — 1. The surgeon should recall very exactly and vividly to his memory the anatomical relations of the place of ligation before commencing the oper- ation. The direction and length of the skin incision is made accordingly. It is of advantage to indicate the incisions by a line drawn upon the surface of the skin. (This advice may be of some benefit to the novice in surgery, but no experienced surgeon would think for a moment of adopting it. ) 2. The portion of the body is placed in the most advantageous position for the operation, and in the best light. 3. If the operation is to be performed on one of the extremities, it is advantageous to constrict the same previously, and to citt off the flow of blood with the modification mentioned above in direct ligation. As soon as it is of importance to feel the pulsation of the artery, the upper con- strictor is removed. 4. The external incision is made either free hand, while the fingers of the left hand stretch well the surrounding integument and the knife pene- trates everywhere the whole thickness of the skin (Fig. 335), or when the artery or other important parts are lying directly under the skin, by raising 2 C2 SURGICAL TECHXIC a transvci'se ciUaneous fold, which is divided with one sweep of the knife (Fig. 338). 5. In penetrating deeply, with care, the operator and his assistant grasp with two good forceps the uppermost layer of cellular tissue on both sides of the axis of incision, and at the same time raise the cellular tissue so that the air can enter into its meshes (emphysema). One sweep with the knife divides the raised cellular tissue (Fig. 451). Immediately both forceps release their hold and grasp, now above and now below, the slit thereby made ; again the layer of cellular tissue is lifted up toward the knife, which divides the fibres until the layer is divided from one angle of the wound to the other. This procedure is repeated in dividing the remaining layers until the sheath of the artery is reached. Any veins, small arteries, nerves, and muscles which are met are drawn aside wdth blunt retractors. 6. As soon as the sheath of the artery has been exposed, the forceps grasp the middle of the sheath of the artery, lift it upward, and raise it in the form of a cone ; the handle of the knife is lowered laterally and so far in an exterior direction that the lateral surface of the blade is turned against the artery, while the point of the knife enters at a right angle to the point of the forceps, and under it into the grasped cone (Fig. 452). Fig. 451. Division of Cellular Tissue be- ■nvEEN Two Forceps Fig. 452. Opening Sheath oi hil Akilry A small incision opens the sheath, and while the forceps lift up the tri- angular segment formed thereby, the point of the knife carefully separates the sheath of the artery from the arterial wall. (In ligating large vessels, their sheaths should be incised freely, as it facilitates their isolation from adjacent important structures, and does in THE TREATMENT OF WOUNDS 253 453. Introducing Curved Probe Fig. 454. Introducing Aneu- rism Needle no way interfere with the nutrition of the ligated ends. By applying the ligature through a small slit in the sheath, important structures are often included in the ligature.) 7. In the case of large arteries, this procedure is con tinned as follows : while the surgeon still holds the divided cone, he introduces with his right hand another pair of closed for- ceps into the opening at the base of the cone between the artery and the cellular sheath ; here he grasps the inner wall of the cellular sheath and draws it forward. By this means, the artery is gently rolled around its axis, and the cellular tissue fibres, which fasten the sheath to the lateral and posterior wall of the artery, appear to view ; they are detached in the same careful manner and only as far as the opening first made. If the sheath of the artery is detached too far, the artery can become necrotic, and then sec- ondary hemorrhage occurs at the place of ligation. (In his experiments on the lower animals, the editor isolated arteries the size of the common carotid to the extent of 2 inches or more, and after double ligation never observed necrosis or sec- ondary hemorrhage.) In case of the largest arteries, the procedure must also be repeated on the other side after one-half of the circumference has been liberated. 8. As soon as the artery has been freed on all sides, a curved p7'obe (or a strabismus hook) is carefully intro- duced, and always carried around the v&ssqY from the side on which the principal vein lies, while with a forceps the margin of the incision of the sheath is held taut (Fig. 453). 9. With a probe, the artery is lifted up so far that a small Coopers or Syme s aneurism needle (Fig. 455) with an eye at its point can be passed around the same in an opposite direction (Fig. 454). Fig. 455 10. Next, the probe is removed, a strong cats^nt or silk thread is ^^"^^^'^ 1 Aneurism passed through the eye of the needle, and the needle is with- needle 254 SURGICAL TECHNIC drawn ; the middle portion of the ligature remains in position under the artery. II. The ligature is tied around the artery and tied in a "reef knot" — see Fig. 365 (not with a '^ gt-amiy knot'' — see Fig. 366) and ivithoiit dis- placing the artery ; the knots must be tied in the depth of the wound with the points of the two index fingers (Fig. 456). Fig, 456. Tying Ligature 12. It is advisable to ligate the artery doubly and to divide the vessel- between the two ligatures so that the two ends can retract into the sheath of cellular tissue. (Dovible ligation of an artery in its continuity without division of the ves- sel, if the operation is performed under the necessary aseptic precautions, furnishes absolute protection against secondary hemorrhage.) LIGATION OF THE PRINCIPAL TRUNKS OF THE ARTERIES CAROTID ARTERY The common carotid takes its course from the sternoclavicular articula- tion behind the sternocleidomastoid perpendicularly upward, and is crossed opposite the lower margin of the cricoid cartilage by the omohyoid muscle on a level with the sixth cervical vertebra (tuberculum caroticum — Chas- saigiiac). Below the omohyoid muscle it lies behind jDlatysma, fascia, sterno- mastoid muscle, sternohyoid, sternothyroid, and the anterior jugular vein ; in front of it lies the inferior thyroid artery and the recurrent laryngeal nerve. Above the omohyoid muscle, the artery lies only behind the pla- tysma, cervical fascia, and the internal margin of the sternocleidomastoid. The strong sheath of the artcjy contains, toward the median line, the caro- tid, laterally the internal jugular vein, and in a posterior direction between the two the nervus vagus (pneumogastric); the descendant branch of the THE TREATMENT OF WOUNDS 255 hypoglossal nerve passes over it, and closely behind it the sympathetic nerve (Fig. 457). At the height of the third cervical vertebra opposite the superior mar- gin of the thyroid cartilage, the common carotid divides into the external and the internal carotid. The external carotid is covered at its ori- gin from the common carotid at the height of the superior margin of the thyroid carti- lage, only by skin, platysma, cervical fascia, sternocleidomastoid, and the facial vein, as- cends in a gentle curve to the height of the neck of the lower jaw (collum mandibulae), Fig. 45 and is crossed in its course at the height of the hyoid bone by the biventer muscle, the hypoglossal nerve, and further up by the stylohyoid muscle. Upon its external mar- gin, the descending ramus of the hypoglossal nerve takes its course. At its Situation of the Carotid Artery (Cervical Section), i, carotid; 2, jugular vein; 3, pneumogastric nerve; 4, hypoglossal nerve; 5, brach- ial plexus; 6, sympathetic nerve; 7, vertebral artery A. iemporalis^ A. maxUlaris int.- A. auricularis post.- 3^ IV' A. pliaryngea asc. A. hngualis I A. maxilla} is externa I I AT. hiienfer 1^1 I '^^ mylohyoideus II AM - h M. stylohyoideus— ^M. hiventei - A. cccipiialis- Carotis iiiterna - Carotis externa - Carolis communis - M. oniohyoideus - M. sternothyreoideus . Fig. 458. Branches of the External Carotid Artery posterior surface it is crossed by the superior laryngeal nerve, a branch of the lingual artery, and the glossopharyngeal nerve above the biventer 256 SURGICAL TECHXIC muscle. It can be ligated most easily between the branches given off as the superior thyroid artery and the lingual artery. The internal carotid ascends from the bifurcation of the common carotid as its continuation to the carotid canal in the petrous portion of the tem- poral bone, and lies somewhat posteriorly and externally from the external carotid (Fig. 458). LIGATION OF THE COMMON CAROTID (rt) On a level with the cricothyroid ligament (Fig. 459, Plate I. i). I. After a pillozv has been placed under the shoulders, the head {■s, well extended. Fig. 459. Ligation of the Common Carotid Artery Fig. 460. Ligation of the Common Carotid Artery between the Two Heads of the Sternocleidomastoid 2. External incision 6 centimeters in length, along the inner margin of the sternocleidomastoid, commencing on a level with the superior margin of tJie thyroid cartilage {YX^Xq. Li). 3. Division of tJie platysma and the cellular tissue (avoiding the super- ficial veins). 4. The sternocleidomastoid (st) is drawn outxvard ; the omohyoid {0), downward (Fig. 459). 5. The descending branch of the hypoglossal nerve {Ji), which passes over the artery in a downward direction, is drawn outivard. 6. Opening of the common sheath over the middle portion of the artery. The same (^) lies iniuardly ; the internal jugular vein {J), externally and a PLATE I External Incisions for ligating the arteries, i, 2, Common Carotid. 3, Lin- gual. 4, Masseteric. 5, Temporal. 6, Occipital. 7, Subclavian. v^^^X' '^' Ligation on a level with the crico- thyroid ligament. Ligation between the two heads of the sterno-cleido mastoid muscle. Ligation of the Common Carotid Artery THE TREATMENT OF WOUNDS 257 little more superficially ; t)i& p7ieitmogastric nerve (r'), deeply between the two. The sympathetic nerve courses behind the carotid (Fig. 457). 7. The artery needle with a silk thread must be carried around itfroiii the oiLtside. Great care should be taken not to injure the pneumogastric nerve. {b) Between the two (Plate I. 2) heads of the ster- nocleidomastoid muscle (Fig. 460 j. 1. External incision, 6 centimeters in length ; between the two heads of the sternocleidomastoid downward to the clavicle, 2 centimeters outward from the sternal articulation (Plate I. 2). 2. Division of the platysma. The slit between the sternal and the clavicular portion of the sterno- cleidomastoid is enlarged with tJie fingers until the internal jugular vein appears to view (Fig. 460,7"). 3. The vein, with the clavicular portion {cl), is drawn carefully oiitivard by the finger of the assist- ant ; the stei'nal portion {st), with the sternohyoid and the sternothyroid muscles, is drawn imvard. 4. At the inner side of the vein appears the pnen- viogastric nerve (v) ; a little more inwardly and deeply lies the artery (e). On account of the deep position of the artery this place is selected for liga- tion only in exceptional cases. Fig. 461. Ligation of the External Carotid Ar- tery. //, skin; nk, h>-po- glossal nerve; o/i, hyoid bone (greater cornu) ; zf, facial vein; sm, sterno- cleidomastoid LIGATION OF THE EXTERNAL CAROTID (Plate II. I) 1. Position as described above. 2. External incision 6 to y centimeters in length, along the inner margin of the sternocleidomastoid, from the level of the thyroid cartilage toward the angle of the lower jaw. 3. Division of Xh^ platysma and the sipeificial fascia. 4. The digastric muscle and the hypoglossal nerve in the superior angle of the wound are drawn Jipward ; the superior thyroid vein and the facial vein in the lower angle are drawn downward ; the intertial carotid and the jugular vein are drawn outward. 5. After the artery has been exposed, the artery needle is carried around it from without inwardly, guarding against any injury to the superior laryn- geal nerve. 258 SURGICAL TECHNIC LIGATION OF THE INTERNAL CAROTID 1. External incision 6 centimeters in length, parallel to the anterior margin of the sternocleidomastoid, a little more outward than the preceding incision. 2. After division of these several layers of tissue, the external carotid is exposed and drawn inward ; the digastric muscle is drawn upward. 3. Opening of the sheath covering the internal carotid, which is now exposed. The artery needle is carried around it carefully from without in- ward, since the internal jugular vein, the pneumogastric nerve, the sympa- thetic, and the ascending pharyngeal artery are lying close to the vessel. Kocher exposes the bifurcation of the carotids and the branches of the external carotid by means of a transverse incision (Plate II. a, i ), as follows: — 1. External incision, a finger's breadth below and behind the angle of the jaw in a line extending from the anterior extremity of the mastoid pro- cess to the middle of the hyoid bone. 2. After division of the platisma the external jugular vein and the great auricular nerve coursing behind it are drawn backward. 3. By division of the fascia, the anterior margin of the sternocleido- mastoid is exposed and drawn backward, whereby the common facial vein appears to view as far as its place of anastomosis with the common jugular vein. It is drawn downward and outward. 4. The external carotid is now exposed, distinguishable by the superior thyroid artery branching off directly above its origin ; at its side and behind it lies the internal carotid (without branches). 5. In exposing the external carotid care must be taken not to injure the descendant ramus of the hypoglossus (anteriorly upon the artery), and the superior laryngeal nerve (coursing obliquely behind the artery). At the point of exit of the external maxillary artery the hypoglossal nerve sur- rounds the external carotid from behind and exteriorly. From this incision also the trunk of the Hngual artery, the external maxillary artery, and the occipital artery can be ligated (Fig. 457). The external maxillary artery (facial) is found at the lower margin of the inferior maxillary bone, near the anterior niargin of the masscter under the skin (Plate I. 4). The temporal artery is exposed by a vertical incision 2 centimeters in length upon the zygomatic arch between the tragus and the condyle of the lower jaw (Plate I. 5). PLATE II Ligation of the External Carotid Artery ■^ Ligation of the Lingual Artery THE TREATMENT OF WOUNDS 259 The occipital artery is found in the line between the posterior margin of the mastoid process and the external occipital protuberance (Plate I. 6). LINGUAL ARTERY The ling2ial artery, as the second branch from the external carotid (2 cen- timeters above its bifurcation) arising on a level with the greater cornu of the hyoid bone (Fig. 458), ascends a short distance, is crossed by the digastric and the sternohyoid muscles, passes transversely upon the my- lohyoid muscle beneath the posterior margin of the hyoglossus muscle, behind which it takes its course along the upper border of the greater cornu of the hyoid bone, parallel to the hypoglossal nerve, passing over it and upon the hyoglossus muscle, thence upward to ramify at the under surface of the tongue (ranine artery). LIGATION OF THE LINGUAL ARTERY (Plate II) 1. External ijicision 4 centimeters along the upper margin of the greater cornu of the hyoid bone. 2. Division of the platysma ; the posterior facial vein is drawn out- ward. 3. The external belly of the digastric mnscle is nozv exposed (Fig. 462, d), behi7id and beneath which the hypoglossal nerve {hp) appears. The submaxillary gland {gl) is drawn tipzuard. 4. The hypoglossal nerve passes in front of the hyoglossus muscle {hg) accom- panied by the lingual vein ; beneath the nerve, the lingual artery {a) lies behind the hyoglossus muscle. 5. Between- the hypoglossal nej-ve and the greater cornu of the hyoid bone (oh\ the fibres of the hyoglossus muscle are carefully divided ; directly behind it lies the lijigual artery, accompanied by a vein. Also, in the trigonum linguale (lingual triangle) between the external belly of the digastric and the lateral margin of the mylohyoid muscle {mil), the artery can be ligated after division of the hyoglossus muscle (^Htceter). Fig. 462. Ligation of Lingual Artery 26o SURGICAL TECHNIC SUBCLAVIAN ARTERY The subclavian artery takes its origin on the left from the arch of the aorta, on the right from the innominate artery, courses in a shght curve be- hind the clavicle between the scalenus anticus and medius muscles, thence crossing obliquely over the surface of the first rib to the axilla. The scalenus medius and posticus muscles lie behind and across the artery. Beneath and in front of the scalenus anticus muscle will be found the subclavian vein. LIGATION OF THE SUBCLAVIAN ARTERY (fl) In the supraclavicular fossa (Plate III. i). 1. The arm is drawn downward ; the head, toward the healthy side ; a pillow is placed under the back. 2. External incision 6 to 8 centimeters in length in the form of a curve from the external margin of the sternocleidomastoid to the external third por- tion of the clavicle, obliquely across the supraclavicular fossa. 3. ThQ platysma is divided ; the margin of the sternocleidomastoid (st) is exposed ; the external jugular vein (_;') must not be injured ! (Fig. 463.) 4. Division of the superficial layer of the fascia of the neck and of the adipose cellular tissue in the supra- clavicular fossa. 5. The omohyoid (0) is sepa- rated and drawn upward. 6. Incision through the adipose and cellular tissue (with veins!) to the scalenus muscle {^sc\ the tendon of which can be felt at the side of the tubercle of the first rib. 7. The internal margin of the brachial plexus {pi) appears to view and is drawn upward and out- ward. 8. Between the scalenus mus- cle and the brachial plexus, but a little deeper than the latter, lies the artery ; it becomes visible after division of the deep layer of the deep fascia of the neck. Fig. 463. Ligation of Subclavian Artery in THK Supraclavicular Fossa PLATE III 1, Above the Clavicle 2, Below the Clavicle I, Above the Clavicle in the Supra-Clavicular Fossa 2, Below the Clavicle in the Infra- Clavicular Fossa Ligation of the Sub-Clavian Artery THE TREATMENT OF WOUNDS 261 9. The subclavian vein {vs) lies in front and beneath the tendon of the scalenus muscle and closely beJmid the clavicle. Injury to the external jugular vein (along the external margin of the sternocleidomastoid), to the suprascapular artery (near the clavicle), to the transverse cervical artery (upon the brachial plexus), to the phrenic nerve (/) (which descends upon the scalenus), must be avoided. {b) In the infraclavicular (Plate III. 2) fossa. 1. The shoulder is forced upward. 2. An external incision 6 to 8 centimeters in length, beginning at the coracoid process parallel to the external half of the clavicle, exposes the triangular depression between the deltoid and the pectoralis major muscles (trigonum Mohrenheimii, Moh- renheim's fossa), in which the cephalic veiii joins the subclavian vein. 3. The cephalic vein {ce^ is drawn externally with the mar- gin of the deltoid imcscle{d), the margin of the pectoralis major muscle {pmj ) (which in case of necessity is freed to some extent from the clavicle) is drawn in- ward (Fig. 464). 4. After division of the adipose cellular tissue, the coracoclavictdar fascia appears in the depth of the opening ; this is carefully divided. In most cases, the external thoracic artery must be ligated. 5. The pectoralis minor muscle (^pmi) can be seen ; its internal (upper) margin forms with the subclavius muscle an angle opening inward. The artery lies deeply in this angle between the brachial plexus {pi) and the subclavian vein (vs), the vein lying inward, the nerve outward. In case of necessity, the pectoralis minor muscle may be detached from the coracoid process, and the artery ligated nearer the axilla. Temporary resection of the clavicle and drawing apart the bone, after it has been sawed through, may also facilitate the operation in difficult cases, and enlarge the field of operation {von Langenbeck). This is especially of great advantage in punctured wounds of the artery behind the clavicle {Rotter). Fig. 464. Ligation of Subclavian Artery in the Infraclavicular Fossa 262 SURGICAL TECHNIC VERTEBRAL ARTERY The vertebral artery takes its origin from the superior and posterior cir- cumference of the subclavian opposite the external mammary artery, passes close to the inner edge between the internal margin of the scalenus anticus muscle and the longus colli muscle in an upward direction, in order to enter the opening of the intertransversary canal in the transverse process of the sixth cervical vertebra ; immediately behind its entrance into the canal lie the sympathetic and the transverse process of the seventh cervical vertebra (carotid tubercle). /;/ front of it are located the internal jugular vein, the vertebral vein, and the inferior thyroid artery. LIGATION OF THE VERTEBRAL ARTERY {a) According to Chassaignac. The patient is placed in position, with thorax elevated. His head is turned toward the opposite side ; the arm is drawn downward. Fig. 465. External Incisions for Ligations of Arteries of the Arm 1. Exte7'nal incision 5 centimeters in length from the clavicle upward along the posterior margin of the sternocleidomastoid. 2. After division of the fascia (external jugular vein !), the sternocleido- mastoid and the sheath of the carotid are drawn inivard ; the external jugu- lar vein, oiitwaid. 3. Palpating in an upward direction along the scalenus anticus muscle, the operator seeks the carotid tubercle, and advances beneath it into the space between the scalenus anticus and the longus colli muscles. 4. The artery lies here behind the vertebral vein, which should be drawn aside ; the aneurism needle is carried around it from without, inward. ((^) According to Kocher {Y\2i\.Q II. a, 2). I. Trafisverse incision from the clavicle across the sternocleidomastoid obliquely outward and upward. THE TREATxMENT OF WOUNDS 263 2. The anterior border of the sternocleidomastoid is forcibly reflected outward ; the omohyoid and sternohyoid downward and inward. The common jugular vein, the carotid, and the pneumogastric nerve are re- flected outward at their inner border. 3. Between this bundle of vessels and the thyroid gland, which, after division of its external capsule, is drawn inward and elevated, the inferior thyroid artery is reached, which ascends tortuously upward and inward. Above the same divide the prevertebral fascia longitudinallv ; on the longus coUi muscle below the carotid tubercle (of the sixth cenncal vertebra) pal- pate for the vertebral arteiy ascending perpendicularlv beJiind the inferior thyroid artery. In an outward dii'ection from it courses the phrejiic nerve upon the scalenus anticus, in an inward direction the recurrent nerve. THE AXILLARY ARTERY The axillary artery lies laterally to the uppermost portion of the thorax, and from thence passes obliquely through the axilla, the anterior border of which is made up by the pectoralis major muscle, the posterior, the latissi- mus dorsi, and the teres major muscles. The artery lies in the axilla along the lower median border of the coracobrachialis under the integument and the fascia of the axilla, covered by the crossing of the bifurcated median nerve. In front of it, the internal cutaneous nerve hes toward the median side ; beneath it lies the ulnar nerve. Toward the middle from these, the great axillary vein takes its course. Fig. 466. Topography of the Axilla Fig. 467. Ligation of the Axillary Artery 264 SURGICAL TECHNIC LIGATION OF THE AXILLARY ARTERY (Plate IV) 1. Exte7-nal mcision 5 centimeters in length with the arm raised high, along the inner margin of the coracobrachialis, commencing where this muscle crosses at an obtuse angle the border of \.\\q. pcctoralis major. 2. After division of the fascia, a plexus of nerves containing the artery- appears to view (Fig. 467). The axillary vein (v) lies at thefosterior border of the plexus and a little more superficially. 3. Divide tJie sheath of the nerve plexns ; draw the anterior cords (the median nerve and the internal cutaneous nerve) forward ; the posterior (the ulnar and the radial nerve) (musculospiral), backward ; and open the sheath of the artery. In the middle of the axilla, the subscapular arteries {ss) and the circum- flex (circumflex humeri) (f/") branch off from the subclavian artery in a pos- terior direction. BRACHIAL ARTERY The brachial artery, accompanied by two veins, lies internal to the humerus, along the inner margin 4.?. of the biceps muscle, behind the median nerve and the internal cutaneous nerve. Toward the median Hne from it lies the ulnar nerve. At the flexure of the elbow joint, it crosses the internal brachialis anticus muscle under the bicipital fascia (lacertus fibrosus). The tendon of the biceps lies at its outer side ; the median nerve, at its inner side. The brachial artery divides opposite the neck of the radius in the bend of the elbow, into the radial and the ulnar artery. The radial aj'tery takes its course from here almost in a direct line to the styloid process of the radius and lies in its 7/pper half deeply between the supina- tor longus muscle and the pronator radii teres ; in its lower half near the deep fascia of the forearm. It is accompanied on both sides by the vense comites ; the Fig. 468. Topography of j. , / , -in • •, 1 • THE ARTERIES OF THE ^^^^^^ "ervc (musculo spiral) accompanies it only in Arm the middle of the forearm. PLATE IV Ligation of the Axillary Artery Ligation of the Brachial Artery J^ Ligation of the Cubital Artery Ligation of the Axillary and the Brachial Artery THE TREATMENT OF WOUNDS 26; The ulnar artery lies in its upper half beneath the superficial flexors, pronator radii teres, the flexor carpi radiahs, the palmaris longus, and the flexor subHmis digitorum; in the middle part of the forearm beneath the flexor carpi ulnaris, closely above the wrist, bet^^een the flexor carpi ulnaris and the flexor subHmis digitorum, upon the flexor profundus digi- torum, near the deep fascia, accompanied on its ulnar side by the ulnar ner\-e. LIGATION OF THE BRACHLA.L ARTERY (Plate IV. i) The Dudian (a) At the middle of the arm. 1. External incision 4 centimeters in length, along the inner margin of the biceps muscle. 2. T\xQ biceps (b) IS, ^xz.\\-\\ outzi'ard \;\1\y blunt retractors. nerve (ni), lymg directly upon the artery, appears to view. 3. The median nerve is Hberated and drawn out^vard (Fig. 469) with a blunt hook, the sheath of the artery is opened ; it Ues between two veins (brachial veins). Sometimes the brachial artery divides into the ulnar and the radial in the upper third part of the arm ; in this case, the latter is generally more superficial and lateral (upon the biceps), and the former is re- markablv small. Fig. 469. Lia\Tiox OF THE Brachial Artery (b) At the bend of the elbow Carteria anconea) ' Plate I\'. 2). 1. External incision 3 centimeters in length, 5 millimeters inrcard from the in- ternal margin of the tendon of the biceps < Fig. 470). This incision must be made with care lest the median vein {v) should be injured. The median vein is drawn dozcnward. 2. Division of the aponeurosis of the biceps (a). Directly under it lies the artery upon the internal brachialis anti- cus between two veins. The median nerve {ni) lies a few millimeters farther invuard and passes down beneath the pronator teres muscle. Fig. 470. Liga- tion OF Arte- RIA An'cone.\ 266 SURGICAL TECHNIC LIGATION OF THE RADIAL ARTERY (Plate V. I. 3) {a) In the upper third of the forearm. 1. All external incision, beginning 3 centimeters below the bend of the elbow, takes its course 4 centimeters in length, along a line dividing the radial third of the flexor side of the forearm in supination, from the middle third. 2. After division of the antibracJiial fascia, the space between the bellies of the supinator longus {s) and the flexor carpiradialis (/) is sought for, and the incision is enlarged with the tip of the index finger (Fig. 471). 3. In the depth lies the artery accom- panied by two veins ; on its radial side, the superficial branch of the radial nerve (r). {b) Above the wrist joint. I . External incision 3 centimeters in length at the radial side of the flexor carpi radialis. 2. Careful division of the superficial layer of the deep fascia of the forearm. 3. The artery, accompanied by two veins, lies between the flexor carpi radialis — or radialis internus(/) — and the supinator longus {bracJiioradi- alis) {s) (Fig. 472). Fig. 471 Fig. 472 Ligation of the Radial Artery LIGATION OF THE ULNAR ARTERY (Plate V. 2, 4) {a) In the upper third of the forearm. 1. An external incision, commencing 3 centimeters below the band of the elbow, courses 4 centimeters in length on a line dividing the ulnar third of the flexor side of the forearm placed in supination from the middle third. 2. After division of the deep fascia, the space between the bellies of the flexor carpi ulnaris (c) and the flexor sublimis digitorum (d) is sought for and enlarged with the point of the forefinger and blunt retractors (Fig. 473). 3. In the depth hes the artery accompanied by two veins ; on its ulnar side, the ulnar nerve («). PLATE V At the upper third of the forearm Above the T\-rist joint 1 I 1 / At the upper third of the forearm Above the wrist joint Ligation of the Superficial Palmar Arch Ligation of the Radial and the Ulnar Arteries THE TREATMENT OF WOUNDS 267 {b) Above the wrist joint. 1. External incisio7i 3 cen- timeters in length along the tendinous radial margin of the flexor carpi iibiaris (ulnaris in- ternus), which is inserted into the pisiform bone. 2. Careful division of the superficial layer of the deep fascia of the forearm (Fig. 474)- 3. The artery, accompanied by two veins, lies between the tendon of \k\.^ flexor carpi iclnaris (/") and the tendon of the flexor siiblimis digitonini {a), which lie in most cases toward the ulnar side. On its ulnar side lies the nervits tilnaris volaris {11). Fig. 473 Fig. 474 Ligation of the Ulnar Artery SUPERFICIAL PALMAR ARCH The superficial palmar arch, the anastomosis of the superficial branch of the ulnar artery with the volar branch of the radial artery, lies under the palmar fascia and courses below the middle transverse palmar fold, sur- rounded by two smaller veins. Under it Hes the median nerve and its anastomosis with the ulnar nerve and the palmar bursa on the ulnar side (Fig. 475). LIGATION OF THE SUPERFICIAL PALMAR ARCH Longititdinal incision from the place of union of the thenar eminence and hypothenar eminence to the fourth finger {Koc/ier, Plate V. 5). Beneath the crossing of this incision with the middle transverse fold of the skin the artery is felt, which, after division of the adipose tissue and the palmar fascia, appears to view. If it is not found here, the strong ulnar branch on the pisiform bone can be ligated. According to Bockel, the arch is found by means of a transverse incisioji in the middle of the palm, i.e. in the centre of a line drawn from the web of the greatly hyperextended thumb obliquely across the palm and the middle palmar fold (Fig. 476). 268 SURGICAL TECHNIC Vb£-i makes a cm'ved incision from the limit of the middle and lower third of the line of the thumb to the middle of the communicating line between the pisiform bone and the base of the ring finger. Fig. 475 Fig. 476 Superficial Palmar Arch, a, topography; b, external incision In injuries of the deep volar arch, which, on account of its deep posi- tion, can be isolated and ligated only with difficulty, hemorrhage is best arrested by firm tamponing. AORTA, ILIAC, AND FEMORAL ARTERIES The abdominal aorta, descending along the anterior surface of the ver- tebral column a little more to the left, near the vena cava, divides at the level of the lower margin of the fourth lumbar vertebra into the common iliac ai'teries, descending on both sides of the fifth lumbar vertebra along the inner margin of the psoas muscle covered by the perito- neum, only loosely connected with it to the sacro- iliac synchondrosis, where they divide into the hypogastric artery (internal iUac) and the external iliac artery. The cojnmon iliac vein lies on the left to the inner side, on the right behind the artery (Fig. 477). The ureter passes obliquely from without inward over the bifurcation of the common iliac artery. Fu;. 477. Iliac Arteries and Veins PLATE VI \ External Incisions, i, External Iliac Artery. 2, Common and Internal Iliac Arteries Ligation of the External Iliac Artery .-../" Ligation of the Common Iliac and the External Iliac Artery THE TREATMENT OF WOUNDS 269 A V Nc The internal iliac artery, the trunk of which is only 2 to 4 centimeters in length, descends obliquely in an anterior direction in front of the sacro- iliac synchondrosis and into the true pelvis. The external iliac artery takes its course obliquely outward upon the iliac fascia cover- ing the psoas muscle to the groin, covered on its anterior and internal side by the parietal peritoneum and crossed by the spermatic ves- sels. The lumbar nerves take a lateral course. The femoral artery begins at the middle of Poiiparfs ligament, and passes to the lower end of the middle third of the thigh, along its anterior and internal side in an almost straight ys line drawn from the middle of Poupart's liga- ment to the epicondylus internus femoris ; in the upper third of the thigh lies the artery, with the vein of the same name on its inner side traversing Scarpa' s triangle, bounded on the outside by the sartorious muscle, on the inside by the adductor longus. At the lower end of Scarpa's triangle it gives off a large branch, the deep femoral artery (profunda). In the middle of the thigh the femoral artery lies upon the vein beneath the sartorious mus- cle, between the vastus internus and the adductor magnus muscle, perforates next the insertion of this muscle {Himters canal), in which behind the long saphenus nerve it enters on the posterior surface of the thigh the pop- tt o r,. r a r r Y\g. 478, Topography of Femoral liteal space. Artery LIGATION OF THE ABDOMINAL AORTA BELOW THE RENAL ARTERIES {a) Extraperitoneally {Maas, Murray). 1. External incision along the anterior margin of the left quadrat us lumborum, from the last rib to the crest of the ilium. 2. After division of the abdominal muscles and the transversalis fascia, the wound is drawn apart with blunt retractors, so far that the retroperitoneal space can be inspected below the kidney and the aorta can be exposed. 270 SURGICAL TECHNIC (^) Tj'aiispcritoncally (^Cooper, von Nnssbaiiin). 1. External i7icisio7i, 15 to 20 centimeters in length, in the linea alba, as in laparotoi7iy . 2. After the abdominal cavity has been opened, the intestines are displaced to the right, the posterior layer of the parietal peritoneum is incised over the artery, which then can be easily reached ; next, the aorta is ligated. LIGATION OF THE COMMON AND INTERNAL ILIAC ARTERIES (Plate VI. 2) I. External incision, 10 to 12 centimeters in length, beginning 3 centi- meters inward and downward from the anterior superior spine of the ilium and ascending in a slightly concave curve vertically and near to the last rib. Fig. 479. Ligation ok the Common and Ixteknai, Iliac Arteries 2. Division of the fatty layer of the thin superficial fascia of the muscular layer of the obliqiius externus, the obliqutis internus, the horizontal fibres of the transversalis and the thin transversalis fascia, until the peritoncuvi is exposed. 3. The, peritoneum (p)\s CdLVQiuWy Yiwsh&d ijizvard tozuard the umbilicus, and, with the fingers, drawn toward the internal margin of the wound (Fig. 479). PLATE VU Below Poupart's Ligament At the middle of the thigh behind the Sartorius Below the Profunda Femoris Artery External Incisions At the orifice at the lower end of Hunter's canal Ligation of the Femoral Artery THE TREATMENT OF WOUNDS 271 4. The ureter {ti) usually remains in contact with the peritoneum, else it is seen coursing together with the external spermatic nerve (sp) obliquely across the bifurcation of the common iliac artery. Care must be taken not to injure it. 5. The whole coninion iliac m'tery is now exposed at the internal margin of the iliopsoas muscle {m) from the aorta to its bifurcation. The iliac vein lies to the left on its inner side ; on the right it lies behind the artery. For ligating the internal iliac artery, draw the external iliac artery and the common iliac vein inward ; carry the needle from within around the trunk of the internal iliac artery. On account of the great depth of the operating wound and the extensive detachment of the peritoneum, it is better to expose this artery by means of laparotomy (" transperitoneally " in pelvic high position). The external incision extends, then, either toward the median line in the linea alba, or along the outer border of the rectus. LIGATION OF THE SUPERIOR GLUTEAL ARTERY (Plate VIII. I) 1. External incision obliquely ,./• across the gluteal in a line be- K, tween the posterior superior spine of tJic ilium and the great trochan- ter (Fig. 480). 2. After division of the fascia and the fibres of the gluteus maxi- tnus, the lower border of the glu- teus inediiis is exposed and drawn tipward. 3. Along the upper margin of the greater sciatic notch above the pyriforviis, the artery is found at the side of the superior gluteal nerve. Fig. 480. Ligation of the Superior Gluteal AND OF the Sciatic Artery LIGATION OF THE SCIATIC ARTERY (Plate VIII. 2) 1. External incision, 8 to 10 centimeters in length, from Vat posterior infe- rior spine of the ilium to the outer margin of the tuberosity of the ischiujn. 2. After division of the fascia and the fibres of the gluteus maximus^ the pyriform muscle and the great sacrosciatic ligament are exposed. 2/2 SURGICAL TECHNIC 3. The artery is found on the inner border of the pyrifonn muscle after its exit from the inferior margin of the sciatic notcJi. LIGATION OF THE EXTERNAL ILIAC ARTERY (Plate VI. I) 1. External incision, I centimeter above Poupart's ligament and parallel to the same, 8 to 10 centimeters in length, begins in 2i flat convex manner, 3 centimeters inward from the anterior superior spine, and ends over the internal inguinal ring {without exposing it and the spermatic cord). 2. Division of tJie fatty layer of the thin snperfcial fascia, of the strong tendinous aponeurosis of the obliqnus extermis, next the viuscnlar fibres of the obliqiius internits ; next the hori- zontal innsc7ilar fibres of the transversalis abdoinijiis in the external angle of the wound (Fig. 481). 3. Careful division of the thin transversalis fascia, fol- lowed in the corpulent by still another thin layer of fat. 4. The pei'itonenin (/>) must be pushed carefully toward the 7imbilicHs with the fingers bent like a retractor (without stripping the iliac fascia and the larger vessels from the pelvic wall !). 5. The artery Hes on the inner border of the iliopsoas muscle ; on its inner side the vein {v), on its external side the crural nerve (;/), covered by the iliac fascia. The external spermatic nerve {sp) passes obliquely across the artery. LIGATION OF THE FEMORAL ARTERY (Plate VII. 1-4) {a) Under Poupart's ligament. 1. The external incisio7i begins in the middle between the anterior siiperior spine and the symphysis, 2 millimeters above Poupart's ligament, and is extended 5 centimeters downward. 2. Division of the superficial fascia. 3. Division of the fatty layer ; removal of the lyrnphatic glands, either by drawing them aside or by extirpating them. 4. Division of the fascia lata. Fig. 481. Ligation of the External Iliac Artery PLATE Vm Artery External Incision Ligation Ligation of the Popliteal Artery 2 I External Incisions Ligation of the Sciatic Arterv Ligation of the Superior and Inferior Gluteal Arteries THE TREATMENT OF WOUNDS 273 5. Division of the sheath of the vessel, i centimeter belozv Poupart's liga- ment (/) (because the deep circumflex iliac artery {ac) and the deep epigas- tric artery {ae) branch off directly under it — -Fig. 482). 6. Th.Q femoral vein (v) lies inside, the crural nerve (n) o?itside, of the artery. {b) Below the profunda femoris artery {at the inferior poiiit of the trigo- iinm ilio feniorale, Scarpa's triangle). 1. External incision, 5 centimeters in length along the internal margin of the sartorius muscle, commences six fingers' breadth (8 to 10 centimeters) below Poupart's ligament (Fig. 172, 2). 2. The border of the sartorius vuiscle (s) is exposed and drawn outzvard. Fig. 482. Ligation of the Femoral Artery under Poupart's Ligament Fig. 483 oral Ligation of the Fem- Artery below the Profunda Femoris Artery r.c. Fig. 484. Ligation of the Femoral Artery in the Middle of the Thigh 3. Opening of the sheath of the vessel. Tho. femoral vein (v) lies to the i^iner side and somewhat beJiind the artery ; the femoral nerve {11) on the outer side (Fig. 483). {c) In the middle of the thigh {behind the sartorius^. 1. Skin ijicision 8 to 10 centimeters long dozvn to the sartorius in the middle of a line drawn /"rt^w the ajitei'ior superior spine to the internal condyle of the femur. 2. The sheath of the sartorius is divided. The muscle {i) is freed and drazvn outzvard, until the posterior zvall of the sheath of the tnuscle appears to view, which covers the vessels. 3. After the sheath has been opened, the artery is exposed. The saphenus nerve passes over it («); th.Q femoral vein is behind it {vc). The saphenus vein iys) lies superficially and more inwardly (Fig. 484). 74 SURGICAL TECHNIC {d) At the orifice at the lower end of Hunter's Canal. 1. External incision lO centimeters long at the beginning of the lower third of the thigh, flexed at the hip and knee, and abducted at the outer border of the sartorius muscle (long saphenus vein !). 2. Division of fascia. The sartorius vuiscle is drawn inward; under it lies, on the inner surface of the internal vastus muscle, the white shining tendinous band of the abductor viagnus muscle (cover of Hunter's canal). 3. Division of the tendons on a grooved director from below. The artery appears to view (rather close to the bone), ijiwardly and behind it the vein ; above it lies tJie internal saphenus nerve. Semitend. — Pr p Semimemb. Gracilis Sartorius THE POPLITEAL ARTERY ThQ popliteal artery occupies the middle of the popliteal space surrounded by adipose tissue, usually a little toward the inner side of the middle line. The popliteal vein and the tibial nerve lie on its outer side (Fig. 485). Along the upper border of the soleus muscle, often in the popliteal space, the artery divides into the anterior and posterior tibial arteries. The former, cov- ered by the soleus muscle, crosses the interosseous ligament in a line drawn between the external con- dyle of the tibia and the first intermetatarsal space, on the an- terior side of the leg downward between the tibialis anticus and the flexor communis digitorum. At the ankle joint it lies between the tendons of the tibialis anticus and the extensor hallucis. It passes then as the dorsalis pedis artery along the dorsum of the foot between the tendons of the extensor hallucis longus and brevis obliquely in the space between the first two metatarsal bones. The larger posterior tibial artery passes along the inner side of the leg, covered by the peroneus muscles, between the tibialis posticus and the flexor C7JJ. int. C astrocnemii saph. ext. Fig. 485. Tt)r()i;KAi'iiY OF THE Right Popliteal Space PLATE IX \ Ligation above the middle of the leg Jf Ligation at the lower third of the leg Ligation of the Anterior Tibial Artery THE TREATAIENT OF WOUNDS 275 longus digitorum. It is accompanied by two veins; the tibial nerve takes its course along its external side. Behind the internal malleolus the artery lies superficially under the integument and fascia, between the accompanying veins and beneath the plantar nerve. LIGATION OF THE POPLITEAL ARTERY (Plate VIII) 1. External incision 8 centimeters in length along the external border of the semi-mem- branosus, down through the whole popliteal space. 2. Division of the thick adipose layer, until the tibial nerve appears to view (Fig. 486). 3. The tibial nerve {11) is drawn in a lateral direction ; behind it and a little toward the median lies the popliteal vein (v), which is freed and drawn somewhat aside ; behind the vein and a httle toward the median lies the „ „^ , Fig. 486. Ligation of the artery. Popliteal Artery LIGATION OF THE ANTERIOR TIBIAL ARTERY Fig. 487. Ligation of the Anterior Tibial Artery above the Middle of the Leg (Plate IX) ia) Above the middle of the leg (Plate IX. I)- 1. External incision 6 to 8 centimeters in length, 3 centimeters outward from the crest of the tibia (in the middle between the tibia ^^S and the fibula). 2. Division of the fascia in the direction of the tendinous white line, which indicates the space betzveen the tibialis antic?is (^tdy and the extensor hallucis longus innscles {eh). This intermuscular space is sought for and enlarged with the point of the iji- dex finger, until the deep fascia is reached (Fig. 487). 3. After a careful division of the deep 2/6 SURGICAL TECHNIC fascia, the artery is exposed between the two accompanying veins ; on its outer side lies the anterior tibial nerve (;/). {b). In the lower third of the leg (Plate IX. 2). 1. External incision 5 to 6 centimeters in length, vertical, a finger's breadth outward from the crest of the tibia. 2. Division of the fascia. In the space between the tibialis anticns (ta) and the extensor hallncis longns {eh), the index finger is inserted, and by upward and downward strokes separates the bellies of the muscles as far as the interosse- ous membrane (2 to 3 centimeters deep) (Fig. 488). 3. On this lies the artery between two veins, accompanied in front and on the inside by the deep branch of the anterior tibial nerve (//). {c) On the dorsum of the foot (Dorsal artery of the foot; (Plate IX. 3). 1. External ificision 4 centimeters long closely at the outer border of the tendon of the extensor longus hallucis from the sca- phoid bone downward. 2. The musculo-cutaneous ner\'e is drawn outward. Division of the fascia and the cru- ciate ligament ; the tendon of the extensor Jiallucis is drawn inward ; the artery appears between two veins, in an inward direction and upon it the anterior tibial nerve. Fig. 488. Ligation of the Ante- rior Tibial Artery in the Lower Third of the Leg LIGATION OF THE POSTERIOR TIBIAL ARTERY (Plate X) a. Above the middle of the leg (Plate X. i). 1. External incision 8 to 10 centimeters in length, i centimeter to the inner side of the internal border of the tibia. 2. After division of the fascia, the border of the gastj-ocneviiiis{g) is drawn backward ; the salens is separated from the flexor longus digitoruvi, and the space between these muscles is enlarged with the point of the finger until the deep aponeurosis is reached, which consists of the tendinous fibres of the soleus and the deep fascia of the leg. PLATE X Above the middle of the leg Behind the Internal Malleolus Ligation of the Posterior Tibial Artery THE TREATxMENT OF WOUNDS 277 3. After divisioji of this apo7teicrosis, the artery appears between two veins ; under it lies the tibial nerve (n). b. Behind the internal malle- olus (Plate X. 2). I. External incision 3 to 4 cen- timeters in length in the middle between the interjial malleolus and the tendon of Achilles. 2. Division of the sural fas- cia { f),&\iQ,ngth.- ened by the fibres of the li- gatnentimt laci- niatu^n (Fig. 490, 1). 3. Directly beneath lies the artery between the two accompanying veins, behind it the tibial nerve (;/). The sheatJis of the tendons of the tibialis posticus, of the flexor longus digi- torum, and '^o. flexor longus hallucis must not be opened. Fig. 490. Ligation of THE Posterior Tib- ial Artery behind the Internal Mal- leolus Fig. 489. Ligation of the Posterior Tiblai. Artery above the Middle of the Leg TRANSFUSION AND INFUSION After a sudden great loss of blood from injuries or from long-continued bloody operations, especially in weak patients, the arterial blood pressure, on account of the defective filling of the blood vessels, soon sinks to such a degree that the heart is no longer able to propel the contents of the vascular system. It acts like an empty pump, without producing any effect, and hence death ensues from excessive hemorrhage at a time when there still remains in the vessels a sufficient quantity of blood for the preservation of life. It is, therefore, of importance to fill the vascular system sufficiently to enable the heart to perform its function effectually. The direct transfusion of blood from the artery of a healthy human being into the vein of a person who is bleeding to death fills the arteries again, and 278 SURGICAL TECHNIC thus saves life. Unfortunately, however, in doing this it is not possible, in the conducting canula, to prevent absolutely the formation of coagula, which seriously obstruct the vessels of the patient receiving the blood. Moreover, the surgeon succeeds only in rare cases in obtaining a willing, healthy person to furnish the blood supply for the purpose of saving the life of another. The direct transfusion of blood from an animal into the veins of a human being is absolutely to be rejected, because by mixing various kinds of blood a poison is formed, which rapidly dissolves the red and the white corpuscles, and causes not only coagulation, but also hemoglobinaemia and hemoglo- binuria, which, in most cases, are fatal. Moreover, according to more recent investigations {Kohle}' and others), the tj'ansfiision of defibrinated blood even from human beings is just as dangerous, because during the beating of the blood, the fibrin ferment, having been set free, produces coagula in the circulation and dissolves the blood corpuscles (ferment intoxication, KoJilcr). Hence, according to modern views, transfusion of blood whole and defibrinated is to be rejected. On the other hand, the intravenous infusion of an alkaline solution of sodium chloride is sufficient in increasing the blood pressure in the blood vessels to such a degree that the heart can again projoel the blood column and convey nutrient material to the organs {Kronecker). The sodium chloride solution is prepared as follows : Dissolve 7 grams of pure salt in one liter of sterilized water ; add three drops of a solution of soda or one gram of sodium carbonate. Landerer {Lndwig) adds to this 3 % to 5 % of sugar, which best preserves the blood corpuscles, and serves as a nutrient material ; the blood pressure is rapidly raised by an active endosmosis. In performing the operation, a subcutaneous vein (for example, the median basilic vein at the bend of the elbow, or the great saphenous vein in front of the internal malleolus) is exposed by incising a fold of skin, and isolating it to such an extent that tivo catgut ligatures can be passed under it. With one ligature, the peripheral side of the portion of the vein is ligated ; the other ligature is pushed under the central part. The exposed vein is opened ; the upper wall is lifted with fine tenaculum forceps, and an oblique incision is made with the scissors, so that a small flap wound results (Fig. 491). By raising the flap, the vein is made to gape, and into the central end of the vein a canula, rounded at its point (of glass, hardened caoutchouc, or silver), is introduced and securely tied with the second catgut ligature. The canula and the rubber tube fastened to it, together with the hard THE TREATMENT OF WOUNDS 279 rubber tip, are completely filled with the sodium chloride solution, and closed by means of a stopcock. For pouring in the sodium solution, either a glass funnel or a graduated glass cylinder (Fig. 492), of the capacity of 300 to 400 fluid grams, is used, terminating below in a perforated olive-shaped point, over which a rubber tube 30 centime- ters long is drawn. To the lower end of the latter a small perforated attachment of hard- ened caoutchouc or glass is fastened, which fits exactly into the connecting piece. Fig. 491. Intravenous Infusion INTRODUCING THE CaNULA Fig. 492. Infusion with a Graduated Glass Cylinder After the vessel has been most carefully cleansed and sterilized, it is filled with the chloride of sodium solution heated to 40° C. ; the end of the tube is lowered until the fluid escapes, and securely inserted into the canula. 280 SURGICAL TECHNIC After all air bubbles have been removed from the tube by pressing and stroking it upward, the operator raises the glass cylinder with one hand about half a meter high (corresponding to the blood pressure in the veins), and with the other hand opens the stopcock to such an extent that the column of water is seen to enter the vein very slozvly (at the rate of lO cubic centimeters a second). The stopcock can also be removed entirely, and the rapidity of the injection can be regulated by raising and lowering the glass cylinder. For preventing the fluid from coohng during the injection, the hand which holds the glass cylinder can hold against it a rubber bag filled with hot water (Fig. 492). As soon as the cylinder is nearly empty, the tube is closed by the pressure of the finger, and detached from the canula. Next, the canula is withdrawn from the vein, the central end is ligated, the wound is carefully cleansed and disinfected, and an antiseptic dressing applied. The use of a syringe for infusion is not to be recommended ; first : it might cause too much pressure ; second : by its piston the fluid is easily contaminated (rancid oil, dry fluid collections from using it previously, etc.); third: there is greater danger of the entrance of air into the vein. During transfusion sometimes cyanosis, dyspnoea, and syncope occur, so that the operation must be interrupted. In most cases, fever, chills, pains in the lumbar region, moreover, blood and albumen in the urine, occur after its conclusion. The subcutaneous infusion of the sodium chloride solution can be made in a simpler manner. Connect the tube of the glass vessel, containing the sodium chloride solution (for instance, syringes. Figs. 493, 494, in which, under a stopper of loose cotton, the infusion fluid is kept sterile ; it must be warmed when used), with an aspiration needle or a fine trocar ; insert the instrument by raising a cutaneous fold on any portion of the body (for ex- ample, the breast), and by elevating the vessel, allow the fluid very slowly to infiltrate the loose cellular tissue ; it is further distributed by pressure and kneeding (effleurage). Generally a liter is sufficient, still even three to four liters have been infused {Sa/ili). Cantani has used this method success- fully as a hypodermoclysma in the inspissation of blood causing desiccation in the algid stage of cholera ; likewise it has proved successful in exten- sive burns, carbonic oxide poisoning (after previous venesection), also after prolonged laparotomies ; but the intravenous infusion produces a better effect even in this case. THE TREAT-MENT OF WOUNDS 281 If the hemorrhage has not been so great that life is in immediate dan- ger, but if only great weakness and syncope exist, an attempt is made to Fig. 493 Fig. 494 Syringe Bottles for Subcutaneous Infusion, a, Sahli's apparatus with hollow needle and thermometer; b, Fiirbringer's apparatus with trocar revive the patient by placing him in the dorsal recumbent position with the head low to prevent anaemia of the brain, and by means of administering stimulants (smelling salts, camphor, ether, alcoholic stimulants) to rouse the Fig. 495. AUTOTRANSFUSIUN cardiac function ; the external applications of dry heat (hot bottles, blankets) to counteract the lowering of the body temperature should never be neg- 282 SURGICAL TECHNIC lected, and large quantities of liquid nourishment, which is very rapidly absorbed, will prove valuable in increasing the contents of the vascular system. The latter is also effected by autotransfusion, by raising one or more limbs, or by rendering them temporarily bloodless by elastic constric- tion in the. manner described before. The blood still present in the limbs is thereby forced into the other parts of the vascular system, and the blood pressure is raised to such a degree that the heart is capable of performing its function (autotransfusion, Fig. 495). By this procedure, transfusion can sometimes be dispensed with ; some- times, at least, the ebbing life can be sustained until transfusion can be made. BLEEDING was resorted to in former times very frequently in the treatment of the most various diseases, especially in combating inflammation and in subduing congestion in different parts of the body. For this purpose, aside from puncturing, scarifications, leeches, and cupping, there was employed venesection {phlebotomy), which is now but rarely (oedema pulmonum pneumonia) performed. The operation is made exclu- sively on the arm and on that vein which is most distinctly prominent under the skin. This is mostly the median basilic vein. Since, how- ever, the latter, as a rule, is crossed by the brachial artery, and is divided from it only by the thin aponeurosis of the biceps muscle, it is advisable to feel for the pulsation of the artery before the operation, and to make venesection either above or below the point of crossing. 1. The patient lies on his back with the arm in a hanging position in order that the veins may become distended with blood. 2. A bandage (or a folded cloth) is placed around the middle of the arm with sufficient firmness so that the return flow of the venous blood becomes Fio. 496. Bleeding with the Phlebotome (Phlebotomy) THE TREATMENT OF WOUNDS 283 Fig. 497. Bleeding \\ith the Lancet arrested, but not the afferent flow of the arterial blood (the radial pulse must not disappear) ; the knot of the bandage must be arranged in such a manner that it can be loosened by making traction on the end which hangs down (Fig. 496). The surgeon fixes the arm by forcing his hand between it and the breast ; the vein is fixed by pressure of his thumb below the place of puncture. 3. With a lancet (Fig. 497), or better with Lorinsers phlebotome (Fig. 496), an incision is made through the skin into the vein, and the first cut is enlarged sufficiently by raising the point of the phlebotome to divide the anterior wall of the vein about 5 centimeters in an oblique direction. 4. The blood must flow in a free jet. If the flow intermits because the wound, having been made too small, has become obstructed or was displaced under the skin (diffuse haematoma), it can be in- creased by alternate opening and closing of the hand, 5. When a sufficient quantity of blood has been abstracted, the constric- tion bandage is removed, the skin wound is somewhat displaced above the vein with the thumb ; a small antiseptic com- press is applied, and fastened by a figure- of-8 bandage, with the forearm slightly flexed (Fig. 498). Fig, 498, Dressing after Bleeding OPERATION FOR ANEURISMS Fusiform or saclike dilatations of the wall of an artery occur in conse- quence of injuries or disease of the arteries. In a few rare cases they may heal of their own accord without surgical interference. In this case lami- nated coagula are deposited in the interior of the pouch, which are finally changed into a firm swelling, which gradually contracts. This condition is aimed at by all methods which endeavor to effect artificially coagulation of the blood in the aneurism. 284 SURGICAL TECHNIC I. By a temporary lessening of the arterial current : — {a) By digital compression upon the proximal side of the artery involved (see p. 235). (d) By tourniquets, which have been mentioned especially for this pur- pose (see also p. 239). Since the continuous compression with the finger, whereby several per- sons have to alternate at fixed intervals, day and night, is very tedious and troublesome for the patient, and since the tourniquets in most cases are not well tolerated, compression is replaced, especially on the femoral artery, in popliteal aneurism occurring so frequently, by the more practical — ic) Pole pressure {iwn Esinare/i). A long pole, crutch, or broomhandle, propped against the ceiling or a bedpost (Fig. 499), is applied, with its lower end carefully wrapped with Fig. 499, Pole Pressure for compressing the P^emoral Artery IN Popliteal Aneurism some soft material, upon the trunk of the artery of the leg, which is wrapped with a bandage, and rotated outward. If the pressure is not well tolerated in one place it is changed to another. In most cases the patient himself learns in a short time to regulate the pressure correctly, especially when the points of pressure are marked by India ink. By this simple method a considerable number of even large popliteal aneurisms have been healed. THE TREATMENT OF WOUNDS 285 2. By arresting the circulation {Reid). The limb is encircled with an elastic bandage close to the swelling ; the same is left free, and the bandaging is continued above the swelling. Simpler still is the treatment by elastic constriction above the aneurism. The constrictor should be applied as often as possible in the daytime ; it can remain in position almost an hour uninterruptedly. Before the constrictor is removed the limb, according to recent methods, must be again bandaged loosely with an elastic bandage to prevent subsequent hyperaemia after the constriction has been removed {Billrot/i). 3. Ligation of the artery in modern times is the safest procedure and the one most frequently employed. Antyllus Fig. 500 Fig. 501 Fig. 502 Ligation of the Artery in Aneurisms (a) According to Antyllus (Fig. 500). He exposed the aneurism in its whole extent by a longitudinal incision, ligated the artery closely above and below the aneurism, divided the sac, cleaned out its contents, and tamponed the wound. His contemporary, PhilagidiLs, went still farther by excising the aneurism after double ligation. (b) According to Anel and Hnnter (Fig. 501). The afferent central end of the artery is ligated either closely above the sac {Ajiel) or more distant from it at some easily accessible place {at the place of selection — Hitnter\ owing to the fear that the ligature would cut its 286 SURGICAL TECHNIC way through the diseased wall of the artery near the aneurism, and thereby incur the risk of secondary hemorrhage. Since, however, with the more elastic catgut — the material now usually employed — this danger is no longer to be apprehended, the ligature, as closely above the sac as possible, is preferable on account of the greater probability that the circulation in the aneurism is not restored by collateral vessels. Moreover, some time after ligation of the afferent artery, when the aneurism has been decreased only moderately, the longitudinal division of the sac can be made. In that case remove all coagula and apply a compressive bandage for several weeks {Mikulicz). If it is not possible to ligate the central part, for instance, in aneurisms of the aorta, innominate, subclavian, etc., then — (r) Kzzox^v!\gX.o Brasdor and Waidrop {Y\g. 502), the efferent periph- eral portion of the artery can be ligated. Brasdor tried to ligate the efferent portion as closely to the aneurism as possible. Wardrop contented himself with ligating the main trunk at an easily accessible place at a greater distance, thereby effecting a diminution in the force of the arterial current. Fearn ligated successively all efferent branches below the aneurism (Fig. 503). A large experience, however, has proved that healing by ligation is ob- tained with certainty only after all afferent and efferent branches have been ligated. Otherwise the aneurism nearly always remains permeable through the collateral circulation which is established in a short time. Hence, the only procedure that can be recommended is the very old method of Antylhis, performed under aseptic precautions with the aid of the bloodless method, and the extirpation of the sac, on account of the certainty of the result and the ease with which it can be performed. If the wall of the sac is too firmly agglutinated with its neighborhood, partial resection is sufficient (especially in the neighborhood of a vein) after double ligation ; this is made with catgut, because silk thread cuts through the thin vascular wall ; the wound is tamponed to prevent secondary hemor- rhages. Sometimes grangrene of the peripheral section of the limb occurs if a sufficient collateral circulation has not been developed. To prepare this, so to say, it is advisable in all cases, where the operation (on account of in- flammation, perforation, and others) is not urgent, to use for a few days pre- viously the compression method (finger or pole pressure). In aneurism of the leg, pole pressure should be first tried, and, if it fails, extirpation should be made. The numerous methods formerly employed to effect direct coagulation in the aneurism (injection of ferric chloride, fibrin ferment, ergotin, alcohol. THE TREATMENT OF WOUNDS 28/ tannin, solution of subacetate of lead, wax, moreover filipuncture, introduc- tion of needles, watchsprings, magnesium wire, silkworm, gut, horse hair, catgut threads) are dangerous to life, and should justly be abandoned. Acupuncture and electropuncture, however, are praised by several as having proved successful. Having arrested the circulation by appl3dng the elastic band, Macewen inserted an acupuncture needle into the aneurism, and moved it to and fro, whereby gradual coagulation of the contents of the sac occurred. If the needle is connected with an electric battery of 20-30 amperes (anode in the aneurism, cathode plate on the chest), the contents of the sac, by the galvanic current, coagulate after several applications. Lanccrcaiix and other Frenchmen report a very good success with the injec- tion of a gelatine solution (2 grams gelatine : 100 grams physiological sodium chloride solution). This solution increases the coagulability of the blood. It is injected into the sac or its immediate neighborhood {Laborde), but can also be infused sjibciitaneously (250 grams of a 2^ solution at the highest, every 10 to 14 days, into the vascular region). Still, even wdth this method fatal cases have occurred {HucJiard). OPERATION FOR VARICES Extensive dilatations of the wails of the veins (varices), which involve especially the veins of the leg in the course of the long saphenous vein, cause great inconvenience to the patient (muscular spasms, eczema, phlebitis, ulcers) ; and, by a sudden rupture of their wall, which is often very thin, cause violent hemorrhages. In milder cases, some improvement of the condition, or at least some alleviation, is effected by bandaging the leg with a flannel or elastic bandage (elastic stocking). (Bandages of pure rubber are harmful, as they frequently produce maceration of the epidermis and eczema by retention of the secre- tions of the skin. The ideal bandage for such cases is the rubber webbing bandage, which is much cheaper and more effective than the elastic silk stocking.) Likewise, the varix bandage of Landcrer, a pad or compress, which is fastened over the inside of the leg upon the vein below the knee joint, forms, so to say, an artificial valve of the vein and sometimes renders good service. In the more aggravated forms of varices, and in those cases where press- ure upon the trunk of the saphenous vein, after the veins have been made bloodless by elevation of the limb, prevents the blood from again filHng the varices immediately, the best method of treatment is — 288 SURGICAL TECHNIC LIGATION OF THE LONG SAPHENOUS VEIN {Trendelenburg) I. External incision 3 centimeters in length over the inner side of the thigh about the junction of the middle with the lower third ; the vein at this point is almost subcutaneous (see also Fig. 504). 2. With the handle of the knife or a blunt hook, the vein is isolated to the extent of about 2 centimeters, and a double catgut ligature is car- ried around it with an aneurism needle. 3. The leg is then raised vertically to empty the vein ; the ligatures are then tied and the vein divided between them. 4. The little skin wound is sutured throughout. After the ligation, the whole peripheral section of the vein becomes thrombosed, and contracts in the course of time into thin cords. The obliteration of tJic diseased veins by a multiple division, that is to say, the excision of numerous small pieces, and by double ligation, by percutancons ligature, and by compression of the walls with small pieces of rubber tube tied upon them {Sehede) usually fail and are no longer used. Tillvianns recommends ignipuncture, that is, puncturing with the needle thermocautery. For the ligation of all superficial veins Petersen makes a circular incision through the skin of the circum- ference of the limb, which he carefully sutures again after ligation of all lumina. Instead of it, if the ligation of the saphenous t:- t vein, which can easily be made, should be fol- FiG. 504. Ligation of the ' -' ' Lung Saphenous Vein lowed by relapse, then EXTIRPATION OF THE VARICES {zwii Langenbeck, Madelimg) is made as a radical operation. I. In order to make the vein very prominent, the constriction band- age is applied around the thigh firmly but slozvly, while the patient is standing. THE TREATMENT OF WOUNDS 289 2. A flap is formed by a curved incision along the whole length of the leg ; after a careful dissection of this, all dilated veins are exposed (Fig. 504). In most cases this is very difficult, since the thin wall of the veins is easily nicked, resulting in the collapse of the veins through loss of blood. In mak- ing the dissection, the blade of the knife should always be directed somewhat toward the skin, and each vein wound should be closed at once with hemo- static forceps. 3. After the trunks have been doubly ligated in the upper portion of the wound, the varicose veins are enucleated, in part bluntly, in part with the knife ; and after ligation of the lower ends of all lateral branches, they are excised. 4. The large wound of the skin is closed by careful suturing. INJURIES OF THE WALLS OF THE BLOOD VESSELS If a vessel is divided in its whole circumference or to a large extent by a transverse wound, it must be grasped with hemostatic forceps on both sides of the wound and ligated. But if the injury involves only one side of the wall of the vessel, the opening can be closed without obliterating the permeability of the vessel. Smaller openings in the venous zvall are grasped with the hemostatic forceps and a ligature is placed around it, which constricts the small cone of the wall of the vessel (lateral ligature of the veins). Since the latter, however, can be applied only in small wounds, and since, moreover, there is some danger of slipping of the ligature, for instance, on the jugular vein, during vomiting and coughing, it is better to close such openings in the vessels by the continuous suture {Sckede 1882) (Fig. 505). In difficult extirpations of tumors of the neck, in the axilla, etc., an injury of the great veins often cannot be avoided, especially when the tumor is firmly attached to the wall of the vessel. While the vein is held compressed by the finger ligature loop, or hemostatic forceps above and below the wound, the longitudinal incision is united with fine catgut, or, still better, with the finest silk ( Tichozv), by a close continuous suture. The closure is safe ; it is indifferent whether the wall of the vein is grasped in its whole thickness or whether the tunica is not perforated ; hemorrhage from the needle punctures in consequence of the rapid swelling of the catgut does not occur, and the lumen of the vein u Fig. 505. Lat- eral Ligature AND Suture of Blood Vessel 290 SURGICAL TECHNIC remains permeable. In this manner, often the internal jugular vein, the sub- clavian vein, and recently even the inferior vena cava {Schede) have been sutured with the best success. Small wounds of large arteries can also be successfully closed by suturing. Jassiviotvski sutures them according to Lembeyfs method by protecting the tunica intima. OPERATIONS ON THE TENDONS (tenotomy) Shortened tendons can be elongated by a transverse section, since the extravasated blood between the two retracted ends is changed in the course of healing into tough fibrous connective tissue. (The extravasated blood is not con- verted into connective tissues, but serves the useful purpose of a temporary scaf- folding for the granulations which project into it from the adjacent wound surfaces.) The dangers of open wounds of ten- dons, which were very much feared in former times, were eliminated by subcuta- neous tenotomy, which Stronieycr intro- duced in the year 1833. He used for this operation small narrow-pointed or blunt-pointed tenotomes (Figs. 506-508), which are inserted underneath the skin either above or below the tendon to be divided, with the blade lying fiat, and are pushed forward until the point can be felt at the oppo- site margin of the tendon. While the assistant draws the tendon as rigidly as possible, the blade of the knife is raised perpendicularly to the tendon, and the latter is divided with easy, sawing movements, or by simple pressure with the tenotome (Fig. 509). Fig. 509. SuBcrxANEous Tenotomy Fig. 506 Fig. 507 Fig. 508 Tenotomes, a, Dieffenbach's; b, Stro- meyer's pointed; c, blunt -pointed ■-^J^d'^^ THE TREATMENT OF WOUNDS 291 Since, however, in this "operation in the dark," the tendon is sometimes divided only incompletely and a few fibres remain in connection, which interfere with the intended elongation of the tendon, and since, moreover, by an unintentional injury of large vessels in the immediate neighborhood, a considerable hemorrhage may occur, in spite of all the advantages and rapidity of subcutaneous tenotomy, still, at the present time, under the pro- tection of asepsis, it has become customarv^ to make open tenotomy after exposing the tendon or tendons by a free incision. The open operation is performed as follows : — TENOTOMY OF THE TEXDO ACHILLIS FOR CLUBFOOT 1. The foot is held in strong dorsal flexion ; an external incision 2 centi- meters in length is made over the posterior side of the tendon, and extended down to the white, shining tendinous tissue. 2. A strabismus hook or a curved probe is inserted from the side trans- versely underneath the tendon (Fig. 510;; the instrument is carried through Fig. 510 Fig. 511 Open Tenotomy of the Tentdon of Achilles as closely to the tendon as possible until it appears on the opposite side ; all tissues lying on the probe are divided by slow sawing movements of the knife, after which the tendon ends retract considerably, and the foot can be flexed more freely in the dorsal direction (Fig. 51 ij. 3. The little wound is closed by interrupted sutures. In applying the dressing, it is above all important that over the place of operation no harm- ful pressure should be made, — as, for instance, by the margin of a small bandage too firmly applied, — because the formation of an adequate coagulum would be impaired thereby. The foot must be bandaged with a broad bandage. After the healing of the wound, methodic passive movements to extend the foot may be begun gradually. Concerning the 292 SURGICAL TECHNIC extension of the tendon of Achilles {Bayer) in paralytic talibes equinus, see p. 296. Phelps obtained in suitable cases the same result by dividing all tense resisting structures (tendons and soft parts) at the internal border of the plantar side of the foot. I. After a previous tenotomy of the tendon of Achilles a transverse incision is made at the internal border of the foot, parallel to the astragalo- navicular articulation. 2. Division of the plantar fascia, of the tendons of the flexor longus digitorum, of the flexor longus hallucis, of the abductor hallucis, and, if necessary, of the flexor brevis digitorum communis. These are drawn forward one after the other with a strabismus hook and divided (Fig. 512). 3. Sometimes the division of the deltoid liga- ment and the chiselling through of the neck of the astragalus are necessary. 4. The foot is placed in its normal position ; the wide gaping wound is tamponed ; and immediately a plaster of paris dressing is applied under which Fig. 512. Phfxps's Operation ^^^q wound must heal by granulation with a broad FOR Clubfoot . . t^ . , / Cicatrix. During the after treatment passive move- ments and massage are made daily, and the foot is kept in its correct position by strips of galvanum plaster, subsequently by a rubber tube. Very similar is the operation for dividing contracted fascias (fasciotomy), for instance, of the plantar fascia on the inner side of the plantar surface of the foot or of the palmar fascia {Dnpuytren, contraction of fingers, Fig. 513)- Since, in the latter case, a recur- rence after a simple division is the rule, it is better to expose the whole portion by a longi- p,^. ^j^ tudinal incision, and to separate and excise the contracted fascia with all its processes from the skin and the underlying tissue {Kocher). TENDINORRHAPHY If a tendon has been divided transversely by an injury, its ends must be united again as soon as possible, or else the function of the corresponding muscle becomes seriously impaired, if not completely destroyed. THE TREATMENT OF WOUNDS 293 In recent wounds, the peripheral end can be easily found. The central muscular end, in most cases, however, has retracted into its sheath. It can be drawn forward by grasping it in its sheath with tenaculum forceps or a fine tenaculum ; if this does not succeed after a faithful trial, the sheath must be carefully divided longitudinally, but not farther than is absolutely necessary. To prevent unpleasant coalescence Sedillot recommended to make the necessary external incisions not directly over the tendon, but in a lateral direction from it. Sometimes it is also beneficial to lengthen the contracted muscle by vig- orous rubbing toward its periphery, or to force it out of its sheath by band- aging it with an elastic band from above. But if this, too, is not successful, the division of the sheath of the tendon may still be avoided by cutting a Fig. 514 Fig. 515 Fig. si6 Fig. 517 Tendinorraphy. a, according to Madelung; b, c, Hueter's paratendinous suture; d, quilt suture; Fig. 531 Fig. 532 Neurorrhaphy, a, direct; b, indirect; c, paraneurotic; J, e, Hueter's neuroplasty by turning over a small lateral tongue-shaped flap on one or both stumps (^Letie'vant) (Fig. 533). With thicker nerves, tzvo little flaps can be formed for each stump and sutured together (Fig. 534). Since the ends of the nerves very rapidly produce proliferations which unite with the fibres tl!it!l Fig. 534 Fig. 535 Fig. 536 Neuroplasty Fig. 537 Fig. 538 Anastomosis of Nerves of the other end growing toward them, on the whole it is only essential to give to the growing fibres the right direction and to prevent that no connec- nective tissue conies to lie between, whereby the success is impaired, if not 298 SURGICAL TECHNIC prevented. Vanlair and Ghick did this by placing the two stumps into a decalcified bone tube (tubular suture, Fig. 535); they also succeeded in restor- ing the continuity of nerves in animals by interposing between the ends a bridge of catgut threads (suture a distance, Assaky). For nerves of medium size it seems to suffice to connect the ends with one catgut thread (Fig. 536). The nerve fibres then grow along this thread until they unite. Similarly as described in tendons the anastomosis of nerves in very large deficiencies is made by suturing together the neighboring nerve ends (Fig. 537), or by uniting \\\q peripheral Qwd, of the defective nerve with the neigh- boring healthy nerve trunk : Either place it between the separated nerve fibres or suture it to the trunk vivified laterally at one place (Fig. 538). Concerning the stretching, division, and resection of nerves, see OPERATIONS ON THE SKIN Extensive losses of the substance of the soft parts, caused by accidental injuries or by operative removal of diseased parts, can heal after a long time by granulation, but they leave such large cicatrices that it is better, if possible, to close the defect by skin grafting, whereby the time of healing is considerably shortened, the deformity diminished, and the functional result improved. This is done either by skin transplantation or by plastic opera- tions. SKIN TRANSPLANTATION, that is, Vcio. grafting of portions of skin, can be made in various ways. J. Reverdin applied small pieces of skin the size of a lentil upon granu- lating surfaces ; he excised these from suitable parts of the body with scis- sors. The skin is grasped superficially with tenaculum forceps, and some- what raised ; then the little elevation is removed with Cooper' s scissors. The little portion (Greffe epidermique) contains, in addition to epidermis and corium, a little of the Malpighian layer. After the granulating surface has been covered with these grafts, it is covered with protective silk, and a light dressing is appHed. From each grafted piece as a centre of epidermization the epidermis grows, and finally spreads as a thin film over the granulating surface, upon which the grafted pieces can be distinguished Hke raised islets of skin. Many of these grafts die before they can form vascular connec- tions with the underlying wound surface. (The best method of performing Reverdin' s skin grafting is to transfix the superficial layers of the skin with an ordinary sewing needle, and after THE TREAT.MEXT OF WOUNDS 299 elevating it in the form of a small cone remove it with a razor and transfer it with the needle at once upon the granulating surface, where it is carefully spread out and embedded with the point of one or tv;o needles.) Wolfe grafted larger pieces of skin than Reverdin by excising with the knife from some portion of the body a piece of skin corresponding in shape to the defect, but somewhat larger ; he very carefully detached every vestige of fat tissue with a razor or a pair of scissors until it had the appearance and the thickness of fine white glove leather. He then fastened it with a few sutures into the skin defect. The place from which it is taken is closed by sutures like a recent wound. This procedure gives very beautiful results when siLccessfiil. It is especially adapted for covering defects without a floor of adipose tissue (forehead, nose). Still, the flaps are inchned to contract subsequently. Recently, even without detaching the subcutaneous adipose tissue, large non-pedunculated flaps have healed successfully {^Kraitse); their contraction is considerably less. But the best results are obtained by SKIX GRAFTING ACCORDING TO THIERSCH in which very tJmi strips of skin taken from other parts of the body are used for covering even large wound surfaces of all kinds of tissue. The large skin grafts unite with fresh wound surfaces or with such as have been tam- poned for a few days, and with granulating surfaces after the superficial Xoo^Q. grannlation layer has been removed ^\\\\ the sharp spoon. It is essen- tial for a satisfactory healing that heinorrJiage should be completely arrested before grafting, which is accomplished either by pressure, or, if necessary, by torsion. Catgut ligatures interfere with speedy healing. It also appears desirable, and in most cases possible, to take the pieces of skin from the patient, for these heal in regularly. Attempts at grafting pieces of skin taken from other persons, from freshly amputated limbs, from fresh corpses, or from animals, have often proved failures. The operation is performed as follows : — 1. In the case of fresh wound surfaces hemorrhage is arrested by press- ing upon them a gauze compress or a sponge for several minutes. Granula- tion surfaces are scraped with the sharp spoon ; on bones by means of flat, level-Hke chiselling, the spongy tissue must first be exposed. 2. From the skin of the external side of the arm, thoroughly disinfected beforehand, or from the anterior surface of the thigh or trochanteric region, 300 SURGICAL TECHNIC Strips about 8 to lo centimeters in length are removed by sawing movements with a sharp razor. The left hand during this procedure encircles the limb from below and draws the skin tense ; it is also necessary to have the skin drawn upward by an assistant at the place where the incision is to begin. Next, a large moistened razor, ground flat at its posterior surface but hollow on its anterior surface (microtome blade), is applied as fiat as possible, and drawn in rapid sawing movements toward itself, whereby the uppermost cut-off layer of skin is folded in transverse folds upon the blade of the razor (Fig. 539). The length, breadth, and thickness of these grafts depend alto- FiG. 539 Fig. 540 Skin Grafting according tu Thiersch gether upon the dexterity and practice of the surgeon. According to Thiersch, epidermis, Malpighian layer, and papillary layer should be included in the graft, together with a smooth layer of stroma ; still, even thinner grafts heal just as readily. These contain, in addition to the epidermis, only the points of the papillary layer {Hiibschcr). The strips can be 2 to 5 centimeters broad and 10 to 20 centimeters long. 3. The blade of the knife with the folded strip of skin is applied fiat to the margin of the surface to be covered; the end of the strip is drawn down with a probe or a dissecting needle and held in position (Fig. 540), while the knife is drawn slowly across the surface of the wound, the strip is spread out fiat, and smoothed with a probe and a brush if necessary. In this manner strip after strip is applied until the whole surface is grafted. Nowhere should a defect remain, and it is even well that the strips overlap each other at their margins like the tiles of a roof, and they should at the same time cover the margins of the wound. 4. Either dusting with iodoform powder, or an application of moist iodoform gauze, or little pieces of Hnt with boric vaseline, which are gently pressed upon the surface by loose " kruell " gauze or a compress, are ser- viceable for a dressing. Sometimes it is necessary to immobilize the limb THE TREATMENT OF WOUNDS 301 with splints. The dry dressing remains in position from 8 to 10 days, until the heahng is completed ; the salve dressing must be changed between the third and the fifth day. The wounds between the grafts heal under one dry dressing, leaving very little scar tissue. The dressings in transplantations are made in a very different manner. T/iiej'sck recommended during the whole after treatment the use of the physiological solution of sodium chloride, and covered the grafted portion with salt water compresses, which were changed daily. The application of antiseptics, however, seems not only harmless, but even necessary in prac- tice, since the practising physician can make use of strict aseptic measures only in rare cases. To cover the grafts with impermeable materials (pro- tective silk, gutta-percha) prevents, it is true, the adhesion of the grafts to the dressing, but it necessitates a more frequent change of dressings, since the secretions cannot be absorbed readily by the dressings. (This difficulty can be overcome by leaving linear spaces between the protective strips.) Soci7i uses strips of tinfoil with 2% of salicylic oil for a covering. The dry iodoform dressing is just as safe as it is convenient and simple. Large defects of the skin, which are either congenital or caused bv injuries, burns, ulcerative processes, and removal of neoplasms, are closed by IT '^ ffH- TTT PLASTIC OPERATIONS by using the neighboring skin for covering defects of the same in the most various ways. In general, the following kinds of plastic operations are distinguished : — I. By stretching the mar- gins of the skin, which, if necessary, have been dis- sected from the underlying tissues, and have been made movable. Lancet-shaped and rhomboid-shaped defects can be sutured in a straight line; triangular and square defects are sutured from the corners, Fig. 544 so that finally the long sides ^ ^ r^-.r,. i.-u -' ° Plastic Operations. Covering defects by stretching the touch each other (Figs. 541- margins of skin Fig. 542 Fig. 542 302 SURGICAL TECHNIC Fic. 545 Fig. 546 Plastic Operations. Incisions to relieve tension 544). If necessary, a square defect is changed into a lancet-shaped one by excision of two triangles on its small sides, or else, on one or both sides, deep incisions are made to relieve tension (Figs. 545, 546). 2. By the sliding of flaps ( Celsus) : by straight or curved incisions, one or several flaps are formed, which, after having been detached and mobilized, are sutured over the defect (Figs. 547-55 0- B II row formed mova- ble flaps by excising corre- sponding triangles, where- by very fine results can be obtained ; unfortunately, however, too much healthy skin is sacrificed, so that this method is very rarely used (Figs. 552, 553)- The sliding is finally made 3. By twisting, after the flaps have been cut in such a manner that they remain in connection with the vascular supply only on one side as 2^ pedicle with the wound surface {pedunculated flaps, Figs. 554, 555). According to Thiersch, pedunculated flaps can be lined over the wound surface with mucous membrane or skin ; large flaps can also be doubled by turning over their margins, and thus be used for covering defects in the walls of the body. The details of plastic operations on the face to cover defects of the eyelids, cheek, lips, nose, etc., are given on pp. 514 et scq. Of the OPERATIONS ON NAILS the most important and frequent treatment is for ingrown nail of the great toe. Since this very painful affection recurs often, it is all-important not only to remove the diseased portion of the nail, but also to resort to suitable measures to prevent a recurrence. The following operation yields the best results : — I. Under local anaesthesia or under the influence of a general anaesthetic, the pointed blade of a pair of strong, straight scissors is inserted under the THE TREAT-AIEXT OF WOUXDS 303 ^ \ M+f' I +« HHi. TTTT 304 SURGICAL TECHNIC middle of the free anterior edge of the nail, pushed forward as far as its posterior margin, and the nail divided with one stroke (Fig. 556). The two halves are grasped one after the other with strong forceps, and, by twisting them around their axis, in an outward direction over the margin of the bed of the nail, they are extracted. 2. Next, the diseased (internal) edge of the matrix is grasped with for- ceps, and removed by sawing movements with a sharp knife ; the incision is extended along the inner granulating margin of the soft parts as far as the point of the toe, whereby all diseased tissue is removed at the same time (Fig. 556). The wall of the nail fold is thereby made completely even. 3. The little wound and the exposed nail bed are covered with iodoform gauze, and left to heal by granula- tion. Or, after vivifying the nail bed with the knife con- FiG. 556 ducted in a flat manner, skin grafting is made immediately according to Thiersch (from the thigh). Healing by primary intention occurs. In subsequent dressings it is advisable to allow the lowermost layer of gauze which covers the nail bed to remain in position as a protective dressing. Subsequently it falls off of its own accord. The patient can walk without pain after three to four days. Hdgclcr obtained an eminence of the toe covered only by skin in this manner : He extracted the nail, and removed by a deep cuneiform incision on both sides the lateral nail folds. Having excised the transverse fold and scraped off the nail bed, he united by sutures the movable lateral flaps upon the middle of the dorsum of the toe. This procedure, to be sure, is very radical ; but it yields the best perma- nent results. All others are likely to fail. The simple j-emoval of the whole nail or its diseased half, without removing the corresponding matrix segment, the insertion of foreign bodies between the granulating nail fold and the sharp edge of the nail pressing upon it, recommended for ages, the scraping out of a shallow longitudinal groove in the middle of the nail to render it more elastic, and the application of an elastic clamp, which raises the edge of the nail from the tissues beneath it, prove unsuccessful in most cases. In milder cases, where the inflammation of the lateral nail fold is not far advanced, success is obtained by ciitting the nail either straight or in a concave manner, and by inserting cotton under both corners. THE TREATMENT OF WOUNDS 305 OPERATIONS ON BONES Osteoclasis, that is, the subcutaneous fracturing of bones, is made for vicious union after fractures ; if not. too much time has elapsed since the injury, in most cases (especially in children) the still soft callus yields to extension and manual redressment. Under some circumstances, it is neces- sary to infract the bone like a green stick across the knee or the edge of Fig. 557. Schneider-Mennel's Extension Apparatus a table to effect correction of the deformity. In some cases of badly united and not too old fractures, especially of the femur, Wagner has again recommended the extension apparatus of Schneider-Mennel, which was originally mentioned for setting old irreducible luxations, to correct the shortening and irregularity. In this apparatus the patient is securely fixed, and the fragments are brought in proper position by cog-wheel extension (Fig- 557)- But if the fractured ends 2^x0. firmly nnited by bony callus^ in most cases this method of treatment is inadequate, and greater force must be employed. Von Bardeleben extended the lever arms formed by the ends of the bones by fastening long laths to the ends of the fracture by a strong plaster of paris dressing; for instance, in a fracture near the ankle joint, a wooden splint 2 feet long was fastened to the foot and leg, below the fracture, whereby the ankle joint was immobilized, while the seat of fracture remained free. While an assistant held the upper portion of the leg immovable, pressure was exerted upon the free end of the splint, and the callus was easily fractured by manual force. 3o6 SURGICAL TECHNIC Simple and very effective also is von EsniarcJi s osteoclast (Fig. 558), a one-armed long zvooden lever, which is pressed forcibly upon the limb placed between two firm cushions. a Fi / • / vi, •" mon large carpenter s chisel with a wooden handle is more useful than the surgical chisels consisting of one piece of steel. At any rate, in lack of the latter, the tools may be bor- rowed from the next best carpenter or joiner shop. In the clinic at Kiel, THE TREATMENT OF WOUNDS 313 chisels are used for these purposes, the cutting surface or bevelled edge of which is 5 centimeters in width (Fig. 584). Fig. 579 iG. 580 Fig. 581 Chisels and Hammer for Necrotomy Fig. 582 1. Under elastic constriction the affected bone is freely exposed over the seat of the disease by a longitudinal incision ; the divided peri- osteum is reflected with the raspatory on both sides (Fig. 586), and the involucrum opened with chisel and hammer to such an extent that the dead bone is freely exposed ; in order to advance more rapidly, much benefit is derived from the use of very large gouges (Figs. 580, 584). 2. With the seqiiestrnm fo7xeps (Fig. 587) the dead bone is now extracted ; and all granulations sur- rounding it are thoroughly scraped out with the sharp spoon. Since the surgeon can never be sure whether still smaller or larger portions of sequestra have remained ;n the angles and sinuses of the opened involucrum, or whether the grajiidating Fig. 583. Openixg an Involucrum of the Tibia with Chisel and Hammer 314 SURGICAL TECHNIC canals extend deep into the bone, it is necessary to remove enough from the lateral edges of the involucrum to change the cavity of the bone into an open shallow cavity (alveolus), in which no accessory cavities can remain undiscovered (Fig. 585). The surface of this shallow cavity is finally smoothed with a chisel and the sharp spoon. Fig. 584. Natural Size OF Bevel of Chisels FOR Necrotomy Fig. 585. Shallow Cav- ity AFTER Necrotomy Fig. 586 Raspatory Fig. 587 Sequestrum Forceps 3. At the end of the operation, the margins of the wound are sutured together if possible to effect healing by aid of a moist blood clot, or the bony cavity is firmly packed ; a copious dressing is applied over it and fastened with a bandage. If copious bleeding follows the operation, the whole dressing can be more firmly applied with an elastic bandage. Then only the elastic constriction is rapidly removed. (Most of the surgeons prefer to remove the elastic constrictor before the dressing is applied, as in doing so many of the bleeding vessels can be tied, THE TREATMENT OF WOUNDS 315 leaving only the parenchymatous hemorrhage to be arrested by tampon and dressing. The limb should always be immobilized and kept in an elevated position for at least 24 hours.) The wound heals by forming granulation, which, moreover, with large and deep cavities, takes a very long time. Fig. 588 , Fig. 589 Neuber's Inversion Suture, a, after the operation; b, after healing To promote the healing process, the skin can be detached on both sides of the wound from the fascia and drawn over the surface of the bone, where it is fastened with small steel nails or with a suture {inversion sntnre — Neiiber, Fig. 588). The healing then takes place by adhesion ; the flaps of skin, at first pressed deep into the bone, gradually rise to their normal position by the mass of bone forming underneath it (Fig. 589). Attempts have also been made to fill the gap immediately after the operation with bone chips made by the chiselling, and to sew the skin over them. Senn used in a similar manner decalcified chips of the tibia or femur of an ox; these decalcified chips are preserved in alcohol or iodoform ether. Still, aside from some good successes, many failures have occurred from the fact that some chips did not heal in and were eliminated by suppuration. (Failures after pack- ing bone cavities with decalcified bone chips are due entirely to imperfect disinfection of the cavity or the use of fine material which has not been thoroughly sterilized. Extru- sion of bone chips never takes place from perfectly aseptic cavities.) It is much better, after a complete suturing of the margins of skin, to allow the cavity to be filled with blood and to let it heal by the aid of a -moist blood clot ( Schede^. With Liicke and Bier s osteoplastic necrotomy, aside from great rapidity and ease of inspection, sometimes even a con- siderably more rapid and better healing of the wound is osteo l ^° ic obtained and with a minimum amount of scar tissue. Necrotomy 3i6 SURGICAL TECHNIC If the tibia is the seat of necrosis, as is most often the case, an incision is made around the thiclcened part on three sides down to the bone (Fig. 248). In line with the short transverse incisions, the thickened bone wall is divided at its anterior circumference with a metacarpal sazv. The longitudi- nal incision is chiselled deep wdth a broad straight chisel. With the last strokes of the hammer, by forced leverage, the skin-periosteal-bone flap of the diseased bone is turned up like the cover of a box (whereby the bone at the base of the flap is infracted), and then with one glance the large bone cavity can be inspected and examined as to sequestra, granulations, and abscesses (Fig. 590). After removal of the sequestrum the granulations are scraped out with a large sharp spoon ; the cavity of the bone is cleansed, and the portion of bone turned up with the soft parts is replaced in its former position and fastened by a few sutures. Complete healing has set in, in some cases even where the necrosis was extensive, in 3 or 4 weeks. In other cases after a long interval fistulae occurred again, so that the broad opening with an alveolar formation is indeed more tedious, but surer of success. AMPUTATIONS AND DISARTICULATIONS Amputation of a limb in general should be made only when by this muti- lation the prospect of saving the life of the patient appears to be essentially better than without it in attempts to save the limb. A portion of the limb is amputated : — 1. In &x\.Qns\\& coin7>nnution of the bone and laceration of the large blood vessels and nerves. 2. In lacerations of the whole viusculature, even when the bone is involved only to a small extent. 3. In very extensive destruction ^///f j'/^z« (ulceration), when the limb has become thereby useless, and a formation of skin grafting is impos- sible. 4. In gangrene of a part of a limb (frost-bites, burns, senile gangrene). 5. In malignant tumors, to prevent general infection. 6. In serious septic or pyczmic infections, if the surgeon by other methods fails in removing the source of infection. 7. In suppurations of long duration, when the strength of the patient has been reduced to such a degree that apparently he can not resist the prolonged drain, and when by an amputation of the limb health can be restored in a shorter time ; finally, as a favor. THE TREATMENT OF WOUNDS 317 8. In atrophied paralytic limbs, when the patient desires of his own accord the removal of such portions of his body as have become not only entirely useless, but an incumbrance. GENERAL RULES PREPARATIONS I. The patient is placed in such a position that he can be well anaesthe- tized, and that the surgeon and his assistants have sufficient room. The cut surface of the limb to be amputated must be turned toward the full light. Fig. 591 2. Each assistant receives a certain position and a certain work to per- form. The assistant who takes care of the wound stands opposite to the operator. The assistant handling the instruments stands close to him with- out hindering his movements or interfering with the Hght. A third assistant holds the part of the limb to be amputated with outstretched arms. The anaesthetizer stands at the head of the patient. If a sufficient number of assistants are not present, the operator must be content with fewer or even with only one. In such a case, the surgeon himself takes the instruments 3l8 SURGICAL TECHNIC from the basin, while the assistant holds the limb and subsequently the stump. 3. It is best for the operator to take such a position that the amputated limb falls to his right side. 4. Previous to the operation, the skin is shaved extensively in the region of the field of operation, cleansed with soap and brush, and thoroughly dis- infected as described on pages 13-16. As soon as anaesthesia has set in, the Hmb is constricted above the place of amputation, and after removal of the bandage is once more disinfected. In inflammations and tumors it suffices to hold the Hmb for some time in a vertical position, so that the circulation of the blood becomes decreased. The constrictor is then applied, but always so far in an upward position, that it can be easily removed after application of the dressings. Fistulous openings and suppu- rating or gangrenous surfaces are covered with compresses dipped in anti- septic solutions to prevent any possible infection of the instruments and hands from carelessness. Of course, during the amputation, all rules of antisepsis and asepsis must be strictly observed. DIVISION OF THE SOFT PARTS The soft parts must be so divided that they will cover the sawed-off bone without tension. The muscles are divided vertically to the axis of the limb ; the incision must not be made by pressure, but by see-saw motions of the knife, as in cutting roast beef. By an oblique section of the muscles the blood vessels are also divided obliquely, rendering their ligation more diffi- cult. For this reason, of all methods most to be recommended are the circular incisions of the skin and muscles. CIRCULAR AMPUTATION (by one I^'CISION — CelsHs) While an assistant holds the limb encircled with both hands over the place of amputation, and thereby fixes skin and muscles, all soft parts are divided by one circular sweep of the amputating knife (Fig. 592) down to the bone; the length of the knife depends on the thickness of the limb (Fig. 593); the bone is then sawed through at once. The surgeon should hold the long amputating knife with his whole hand, in order to reach around the whole circumference of the hmb ; the point of the knife is applied upon the anterior side of the limb turned toward him, vertically and transversely THE TREATMENT OF WOUNDS 319 to its axis ; next it is pushed with a slight pressure toward his own breast, whereby the blade, dividing all soft parts down to the bone, enters as far Fig. 592. Amputating K.ntve.s as the handle, when it is carried by short sawing movements around the bone and back to where the incision was commenced. Others divide with the knife, applied near the handle, in a long sweep, first the soft parts of the Fi*^' 593- Circular Ajiputation by One Incision limb on the side opposite to the operator, then apply the knife in an opposite direction at the beginning of the incision, and divide the soft parts on the operator's side. The bone is then sawed through at once. In order that the soft parts may be united without tension over the bone, the end of the bone must be again sawed off to the extent of half of the diameter of the limb. For this purpose, the bone stump is grasped with lion-jawed forceps, and while the 320 SURGICAL TECHNIC soft parts are well retracted, t\\e periosteum is reflected with a gouge-shaped raspatory (Fig. 594), until the bone is sufficiently exposed {vo7i EsviarcJi). Fig. 594. Reflection of Periosteum In limbs with one bone, this is the best of all methods in creating the smallest and most even wound surface ; it is adapted not only to limbs sup- plied with powerful muscles, but especially to emaciated patients, who are exhausted from long-continued suppuration. For a limb with two bones circular ampu- tation by one incision is not well adapted ; in such cases adequate reflection of the soft parts and of the periosteum after division of the interosseum is accomplished by a lateral longitudinal incision on each side after com- pletion of the circular operation. The wound can be united by sutures in each direction. Figure 595 shows the appear- ance of the fresh stump after a transverse suturing ; Fig. 624, after a vertical closure of the wound. A modification of this operation is circular amputation (by two incisions ^ — Petit, 171 8), by which the skin and the muscles are divided in two planes by separate circular incisions. By a circular incision the skin is divided down to the fascia (Fig. 596); next, the skin is loosened all around, while an assistant retracts the skin upward by repeated incisions made perpendicularly to the axis of the limb Fig. 595. Stump after Circular Amputation by One Incision THE TREATMENT OF WOUNDS 321 down to the fascia (Fig. 597, not as in Fig. 598). The skin is freed to such an extent that its margin can be grasped with the fingers of the left hand and Fig. 596. Circular Amputation by Two Inxisioxs. (Dividing the skin) be turned upward hke a cuff. The length of the manchette or cuff imist eqiial nearly half the diameter of the limb. If the margin of the incision of Fig. 597. Circular Amputation by Two Incisions. (Loosening the skin) the skin is too narrow, because the limb increases in circumference above the place, the skin can be divided by a short longitudinal incision at one 322 SURGICAL TECHXIC or two opposite places. Close to the place of reflection of the skin cuff, by a second circular incision, all muscles are divided down to the bone (Fig. 599); the periosteum '\^ piisJicd back with the raspatory, and then the bone is sawed throug-h. Fig. 59S. Wrong Mode of Incision Figure 6cxd shows the appearance of a fresh stump. Amputation made by two circular incisions has been described in various modifications. Petit and CJieseldcn first divided only the skin in a circular manner ; next, while all the soft parts were drawn forcibly upzvard Fig. 599. CiKCiLAR Amputation by Two Incisions. (Dividing muscles) (Fig. 601), they divided them close to the margin of the retracted skin down to the bone in one sweep. Louis divided all soft parts in one cut down to the bone, but detached from the bone by a second circular incision the small viuscitlar cone, which after the retraction of the superficial muscles is formed THE TREATMENT OF WOUNDS 323 by the deep muscles more firmly attached to the bone. Desatilt went farther by dividing in layers first the skin, next the superficial muscular layer, and Fig. 600. Stump after Circular Amputation by Two Incisions finally the deeper layer, on a level to which the former had retracted (amputation by three circular incisions) (Fig. 602). The wound then forms Fig. 601. Petit's Circular Incision a funnel. Much better, however, than the several divisions of the muscles, is the reflection of the periosteum and' sawing off the bone at a higher plane Fig. 602. Amputation by Three Circular Incisions. (Detaching muscular cone} {vo7i Esmarck), whereby abundant soft parts are secured for covering the stump. 324 SURGICAL TECHNIC Fig. 603. Von Langenbeck's Flap Knife (All methods of circular amputation have become unpopular owing to the scar which always forms in the centre of the stump over the end of the bone to which it becomes attached. An ideal stump is only obtained by suturing the wound, not over, but to one side, of the end of the bone or bones, and this can only be accomphshed by the flap methods.) AMPUTATION BY FORMING SKIN FLAPS {Lowdkaill, 1 679) With a broad scalpel or 2l flap knife, according to voii Lajigcnbcck (Fig. 603), semilunar flaps of skin are formed and detached from the fascia by incisions directed vertically to their surface as far as their base, when they are reflected. Either tzvo lateral flaps of skin of equal length are formed (Fig. 604), after the union of which the cicatrix takes its course across the middle of the stump, or, what is more preferable, a long anterior 2J\^ a sJiort posterior flap (Fig. 605) are made, so that the subsequent cicatrix comes to lie on one side of the stump, where it is less liable to be subjected to pressure. The operation can also be modified so that, in the wearing of an artificial limb, after a long anterior skin flap has been made, the skin over the posterior aspect of the limb can be divided by a semicircular in- cision {¥\g.6o6), when it is de- tached and re- flected in the form of a short flap. In this case, the base of the anterior large flap must be a little small- er than half the Fig. 605. Long Anterior and Short Posterior Flap circumference Fig. 604. Two Lateral Flaps of Skin of Equal Length THE TREATMENT OF WOUNDS 325 of the limb ; its length, however, must be equal to the sagittal diameter of the same. Close to the place of reflection of the flaps of skin all muscles are divided by a circular incision down to the bone, and the latter is sawed Fig. 606. Anterior Skin Flap with Semicircular Posterior Incision off. The anterior flap hangs then like a curtain over the surface of the wound, and permits good drainage for the secretions, as well as a favorable lateral position for the subsequent scar. MUSCULAR FLAPS The methods by which muscles and skin are utilized in making the flaps are not to be recommended, because they result in larger wound surfaces, and above all, on account of the obliqice section of the arteries. The flaps can be cut either from without inward {Langenbeck — Fig. 607), for which very sharp flap knives are used, or from within outward {Verdiiin), by transfixhig the soft parts at the base of the flap close to the bone with a long two-edged knife, and carrying the same obliquely downward and out- ward from the bone with long sawing movements toward the surface. (See disarticulation of the thigh. Fig. 760.) The latter method is seldom resorted to at the present time ; in amputa- tions for gunshot fractures, it is especially to be avoided, because the knife is easily arrested by bullets concealed in the soft parts or by splinters of bone. Moreover, two-edged knives are not safe, because the edge of the 326 SURGICAL TECHNIC back, if the knife is carried unsteadily, may nick the blood vessels in the flap at several places. Moreover, two-edged knives are more difficult to grind than a one-edged knife, with which the formation of flaps can be made just as well from within outward, especially when the point of the knife is always directed in such a manner as to form a straight line with the back of the knife. Fig. 607. MusciJLAR Flap Incision (von Langenbeck's method) A modification of amputation by the muscular flap incision is the oval incision {Lajtgenbeck). In the operation by this method two flaps join posteriorly in a transverse incision so that the wound has the form of a heart (Fig. 643). It is espe- cially adapted for disarticulating smaller joints (fingers and toes). In other localities, aside from the rapidity of its execution, which, with the use of chloroform and the "bloodless method," is of little consideration, it has no advantage over other methods. For an exact execution of the operation, much practice and very sharp flap knives are required. SAWING OFF OF THE BONES After division of all soft parts, the operator changes the knife for an amputation sazv (Figs. 608-610), applies the nail of his left thumb upon the bone to steady the blade of the saw (Fig. 611), and saws along it with long, very light movements, making first a guiding furrow ; then with long, vigor- ous movements, he saws through the bone with moderate rapidity, without exerting any pressure. During the sawing, the soft parts are retracted by the first assistant using his hands or by means of a sterilized divided compress (Figs. 612, 613), THE TREAT.AIEXT OF WOUNDS 327 Fig. 608. Reiner's Amputation Saw Fig. 609. Nyrop's Amputation Saw Fig. 610, Helferich's Amputation Saw Fig, 611. Sawing off the Bone 328 SURGICAL TECHNIC while the second assistant holds the lower portion of the limb firmly and securely, but loivcrs it toward the end of the sawing, lest the blade of the saw should become xvcdged between the yielding bone surfaces. When the bone has been nearly sawed through, the saw is used carefully and more slowly, while the section of the limb is no longerXowoxo,^ by the assistant, or else the bone easily breaks ojf 2SiA becomes splintered. [' V Fig. 6i2 Fig. 613 Divided Compresses, a, for limbs with one bone; b, for limbs with two bones In limbs with two bones, the soft parts must be completely divided in the interosseous space before the sawing of the bone. A small one-edged or a two-edged knife (Catline)(Figs. 615, 616) is inserted, sliding along one bone, first from one side and then from the other, and the edge is made to cut as indicated in Fig. 617. The knife, lying with its back close to one bone, is inserted from below into the interosseous space, carried transversely through the interosseous space to the other bone, guided with its edge along its inner surface, and then drawn out in a downward direction. Next, the edge is turned against the opposite bone, and the same procedure is repeated. With a doubly split compress, the middle flap of which is drawn through the interosseous space with dressing forceps, the soft parts are drawn up- THE TREATMENT OF WOUNDS 329 Fig. 616 Knives for dividing Soft Parts in THE Interosseous Space (Catline) Fig. 614. Retraction of Soft Parts by Means of Divided Compress Fig. 617. Method of carrying Knife in the Interosseus Space (z) ward (Fig. 618), and both bones are divided at tJie same time. If, as on the leg, one bone is considerably thinner than the other, the saw is so conducted as first to make a guiding groove in the tibia to prevent the splintering of the fibula ; next, the fibula is divided, and then with the last move- ments the tibia also. (In amputations of the lower ex- tremity above the ankle joint it is exceedingly important to perform the operation with a view of obtaining, besides satisfactory wound healing, an ideal, painless conical stump well adapted to the wearing of an artifi- cial limb. These conditions must be complied with to obtain such a result : I. Lateral position of scar. 2. Cover end of bones with periosteum. 3. Saw through the fibula at least an inch 1.1 ,, ,1 ^.-T . , Fig. 6x8. Sawing off both Bones. Retraction higher than the tibia.) c u ^ , c a- -a a ■ t '^ ' 01 soft parts by means of divided compress for After the bone has been sawed limbs with two bones 330 SURGICAL TECHNIC off, any projecting portions of bone are nipped off with Z/j-/-?;^'^- bone forceps (Fig. 619), or with Liicr s gouge forceps (Fig. 620) ; sharp edges are removed with a fine saw (Fig. 621) or smoothed with a file. Next, all divided blood vessels, arteries and veins which can be recog- nized as such, and the position of which, if necessary, has been called to mind by sectional drawings (Plates XI-XVIII), are ligated (Fig. 440). The larger blood vessels can easily be recognized ; the smaller vessels must be looked for in the interjuuscnlar septa. It is also advisable to dmzu forzmrd with forceps the ends of the trunks of large nerves projecting into the wound Fig. 619 Liston's Boxe- cuTTiNG Forceps Fig. 620. Luer's Gouge Forceps a, straight; /', curved Fig. 621 Amputation Saw and to resect them with a pair of sharp scissors ; by doing so, the pains in the wound or in the cicatrix are prevented, or at least alleviated. A surgeon who has the necessary practice in ligating can then proceed to unite the wound, and to leave the constrictor in position until the dressing is applied. If the surgeon does not dare to pursue such a course for fear of subsequent hemorrhage, proceed as indicated on page 233. (We now recognize more than ever the importance of careful hemostasis as an essential element in the satisfactory healing of wounds. Hence it is under all circumstances necessary to remove the constrictor before sutur- THE TREATMENT OF WOUNDS 33 1 ing the wound, and resort to the most pedantic measures in arresting the bleeding before the wound surfaces are brought in contact by sutures.) UNION OF THE WOUND This must be made in such a manner that blood and serum cannot collect in it, but must at once appear at the surface, where they are quickly absorbed by the antiseptic or aseptic compressive dressing. With careful hemostasis and perfect asepsis, it is sufificient to unite the margins of the skin over the soft parts by suture ; the angles of the wound should be left open, or supplied with drainage tubes, and a firm, compres- sive bandage should be applied, which presses the surfaces of the wound upon each other, and prevents the collection of secretions. If drainage is to be made, the drainage tubes should be supplied with a long thread which is brought out through the dressing, and by means of which the tube can be extracted on the second or third day without chang- ing the dressing. These drainage tubes, provided with threads {Kocher), have the advantage of securing the drainage of the secretions as any other drainage tube, while their canals, after the tubes have been withdrawn, at once become closed by the apposition of their walls, so that, in spite of the drainage, complete healing can take place in ten to twelve days. If it is not desirable to insert any drainage tubes, then the lowermost angle of the wound is left open in order that any secretions may drain off, or the several layers are stitched together in layers by deep or buried sutnres, whereby all sinuses in the surface of the wound are avoided, and the collec- tion of secretions prevented. The following illustrations show the applica- tion of the sutures after an amputation of the thigh with a single circular incision : — First, the retracted periosteum is drawn forward and united with a few catgut sutures over the sawed surface of the bone (Fig. 622). Next, with long, slightly curved needles and heavy catgut sutures, first the deeper (Fig. 622), then the superficial, layers of the muscles (Fig. 623) are sutured, and finally the margins of the skin are carefully stitched together with a double glover's suture (Fig. 624), whereby only the lowermost angle of the wound is left slightly gaping. (In suturing this amputation wound the periosteal flap should be first fastened over the end of the bone by two or three fine catgut sutures. Next a few strong catgut sutures must be used to supply the end of the muscles with a temporary point of anchorage to prevent undue retraction, and finally the 332 SURGICAL TECHNIC flaps are sutured with silk or silkworm gut and horsehair. Drainage should be established where it is most needed, at the most dependent part of the wound, preferably through a separate buttonhole at the base of the posterior flap.) Only after a permanent dressing, as described on page 43, and illus- trated in Fig. 41, has been applied, is the constriction band removed. Fig. 622. Suturing Periosteum AND Deep Muscular Layers Fig. 623. Buried Mus- cular Suture Fig. 624. Suture of Skin Margins As a rule the dressings can remain in place for several lueeks, until complete healing by primary intention has taken place ; and finally all blood that the patient has lost since the amputation is found in the form of a small, dry, odorless crust on the inner surface of the dressing. (The stump, after amputation, should be immobilized upon a hollow, well- fitting and well-padded splint, and kept in an elevated position at an angle of 40° for at least twelve to twenty-four hours.) GENERAL RULES FOR DISARTICULATION 1. In most cases of disarticulation it is best for the operator to take a position with his face turned toward the patient, and to seize with his left hand the limb to be removed. 2. For division of the soft parts the circular incision is not as well adapted as the flap incision. Since in this operation it is generally necessary to cover a large surface of hone, comparatively large flaps must be formed either from the skin alone, or consisting of skin and the underlying muscles. In many cases, an anterior large flap and a posterior small flap (knee, shoulder, hip) are most advantageous ; in some cases (ankle joint, metatarsus) the posterior flap must be the longest to protect the cicatrix from pressure. THE TREATMENT OF WOUNDS 333 For small joints (fingers, \.QQ,'&)t\\^ ovalincision is especially well adapted. 3. Having divided the covering soft parts, the artiaUatioii is opened by forcibly stretching the exposed tendons by suitable movements, and by divid- ing them with a flap knife. 4. By dividing the other tendons and the capsular ligaments all around, the disarticulation is completed, and if necessary a portion is sawed off from the opposite articular end of the bone. On the whole the procedure is the same as in an amputation. RE AMPUTATION 1. If in an amputation insufficient soft parts have been saved, or if they have retracted during the healing in consequence of osteitis, or have been lost by gangrene, a so-called conical stump (Fig. 625) is the result; that is, the end of the bone projects so far that a complete cicatrization cannot be effected (ulcus prominens); or, finally, the thin cicatrix produced breaks down again and again as soon as the patient wears an artificial limb. Similar difficulties arise in stumps which are the result of frost-bite, burns, or gangrene. The bone of every, even, well-formed stump becomes atro- phied after some time from inactivity, and conical. 2. In such cases, operators formerly per- formed another amputation higher up, or they sought to cover the cicatrix by the transplantation of skin flaps. The former procedure is in most cases unnecessary, and is just as dangerous as the first amputation ; while the latter procedure only rarely yields a satisfactory result, because the skin on the extremities is not well adapted to plastic operations. 3. It is far better to make the subperiosteal resection of the bone stump — that is, the cicatrix or the ulcerated surface implicated is circumscribed with a strong knife, the soft parts of the stump are divided downward, or on two sides (avoiding the region where the large blood vessels and princi- pal trunks of nerves are located) down to the bone, and the periosteiim is reflected upward so far with a raspatory that a sufficiently large por- tion of the bone can be removed with a metacarpal saw or a chain saw. The hemorrhage, as a rule, is inconsiderable. The wound is united with Fig. 625. Conical Stump 334 SURGICAL TECHNIC deep and superficial sutures after a drainage tube, if necessary, has been in- serted as far as the end of the bone. The wound generally heals by primary intention, and the result is a good stump completely covered with healthy soft parts. 4. When the first amputation was made near a joint, the subperiosteal disarticulation may follow in the same manner under similar circumstances (compare Fig. JZJ). In a perfect aseptic course the disadvantage just mentioned of the conic diaphysis stump will not occur. Still, the surface of the stump is always more or less sensitive to pressure. Hence, in making the prothesis atten- tion should be paid that no pressure is exerted upon the stump. Bier has remedied this disadvantage by osteoplastic amputation. He closed the ampu- tated bone surfaces by means of a bone cover (see p. 374) and thereby effected non-sensitive stumps, which were well able to bear pressure. More recently Hirsch has shown that the same success can be obtained likewise with a stump amputated in the ordinary manner if, immediately after the wound has healed, massage and pressure movements by walking are made daily. PROTHESES For rendering the limb mutilated by amputation somewhat useful again, or at least for supplementing its former shape, the patient wears an artificial limb, a prothesis. Protheses are made in various forms, from the simplest apparatus to artistic and most perfect machines. In general, for patients who must work with their protheses, the simplest apparatus is to be recom- mended. The artificial limbs, in form and power of motion often strikingly similar to the missing limb, are rather ornamental, and must be often repaired for injuries which easily occur. An amputated hand, together with the arm, can be replaced by a claw hand (Figs. 626-628), a hook, clamp, plate, or something similar, attached to the end of a well-fitting leather case, with which the patient, after some practice and ingenuity, can perform a great deal of ordinary work most skilfully. A hand made of wood and covered with a glove can likewise be attached to the leather stump ; it serves more for ornamentation than use. The artificial arms provided with movable fingers, in which the mus- cles are imitated by means of spiral springs and threads, are adapted only to lighter work. They are very expensive, and easily get out of order. THE TREATMENT OF WOUNDS 335 An amputated leg is replaced in the simplest and most durable manner by a peg leg; that is, a firm wooden stump fastened to a well-fitting case. When the leg has been ampu- tated very high the patient kneels upon it (Fig. 631). When the thigh has been amputated very high he sits upon the well-padded margin of the support (Figs. 629, 630). The "artificial leg," made of light, firm wood, is movable at the knee and the ankle joint by a hinge joint (Fig. 632). As beautiful as it may appear, still, if the patient wishes to walk rapidly and for a long time, the simple support is mostly preferred, ^^^- ^^^ because it is more durable and can be repaired more easily and inexpensively than an artificial leg. r*^ Fig. 627 Claw Hands Fig. 629 Peg Legs Fig. 630 for amputated thigh Fig. 631. Peg Leg Fig. 632. Artificial Leg for amputated leg 336 SURGICAL TECHXIC (If, after an amputation of the leg or thigh, the patient can bear the expenses of an artificial limb, the stump must be properly prepared. Arti- ficial atrophy should be induced by systematic bandaging, and the skin properly prepared by washing with diluted alcohol for at least three months.) AMPUTATIONS AND DISARTICULATIONS OF THE UPPER EXTREMITIES DISARTICULATIONS OF THE FINGERS DISARTICULATION OF THE THIRD PHALANX (By forming a volar flap from without inward) I. The hand is held in pronation toward the operator. He takes hold of the point of the finger and flexes the third phalanx. Fig. 633. Skeleton of Finger Fig. 634. Position of Lines of Articulations of the Finger Fig. 635. DiSARTICL'LATION of First Phalanx 2. A flat curv^ed incision 2 millimeters below the eminence of the joint (Fig. 634), made transversely across the head of the second phalanx, opens the capsular ligament (Fig. 635). 3. The point of the knife divides both lateral ligaments ; the blade is inserted with its edge turned downward behind the volar surface of the third phalanx (Fig. 636), and a well-rounded flap is formed by saw- ing movements from the skin of the volar Fi<;. 636 Fig. 637 ^-^^^ (^^ig. 637). In suturing the wound the cicatrix comes to lie on the dorsal surface, while the new finger tip is covered with normal skin. DISARTICULATION OF THE SECOND PHALANX (By forming a flap from within outward by transfixion) I. The hand is held in supination toward the operator ; he takes hold of the extended point of the finger, inserts a small knife below the fold of the THE TREATMENT OF WOUNDS 337 joint from one side to the other between skin and joint, and carries the blade by sawing movements first tow- ard himself, then upward, so that a well-rounded flap is formed (Fig. 638). 2. The flap is turned upward, the joint is forcibly stretched, and from the wound the knife divides in one sweep the capsular ligament, the lat- eral ligaments, and the skin on the dorsal side of the joint in a transverse direction (Fig. 639). Fig. 63S Fig. 639 DISARTICULATION AT THE METACARPOPHALANGEAL JOINT (a) Oval incision. I. The operator, standing on the left side of the limb, with his back toward the face of the patient, seizes, while an assistant draws aside with his left hand the two neighboring fingers, the diseased finger, hyperextends it so far that he can see the volar surface, carries a small knife from the Fig. 640. Disarticulation at the Metacarpophalangeal Joint (oval incision) right to the volar surface of the first phalanx, divides here at the level of the tense web the soft parts transversely, carries the knife around the right side of the phalanx to the dorsal side, and here in a curve upward as far as the head of the metacarpal bone (Fig. 640). 338 SURGICAL TECHNIC 2. The knife is carried under the left hand around the left side of the finger as far as the beginning of the first incision ; here it penetrates down to the bone ; it is then carried at the level of the web around the left side of the first phalanx to the dorsal side, and here it is drawn upward in a curve to the end of the first incision (Fig. 641). Fig. 641. DiSARTicrLATioN at the Metacaki'opiialangeai. Joint with Oval Incision 3. Both incisions are made in the same order, but penetrating more deeply toward the joint. They divide, while the finger is always inclined toward the opposite side, the tendons, the lateral ligaments, and the capsular ligament. The wound is heart-shaped (Fig. 642). {b) Flap incision. 1. This incision is best adapted to the first, second, and fifth fingers, because they are more easily accessible on one side. A large half-oval flap is made, the base of which corresponds with the level of the articulation from the volar, dorsal, or lateral skin of the first })halan.\, and is reflected upward. 2. Next, a smaller skin flap is formed on the opposite side, and likewise turned up. 3. Finally, the tendons are divided at the level of the articulation, and the latter is completely disconnected (Fig. 643). THE TREATMENT OF WOUNDS 339 If the metacarpus of the finger involved must be removed at the same time, it is best to extend the dorsal angle of the wound to the carpus. The Fig. 643 Fig. 644 Disarticulation of the Metacarpophalangeal Joint, a, of the thumb, second and fifth fingers. Formation of flaps of unequal size on the fourth finger; of two equal flaps on the third. Oval incision from the volar side, b, Wound from the oval incision and flap incision metacarpal bone is then disarticulated without great difficulty from the carpometacarpal articulation. The wound is sutured completely. DISARTICULATION OF ALL FINGERS 1. If the last four fingers must all be amputated, they may be singly dis- articulated in the manner just described; more useful, however, is a dorsal circular incision and the formation of a volar flap. 2. Under strong volar flexion of the fingers a transverse incision is made through the skin and tendons across the base of the four fingers from one margin of the hand to the other. 3. Next, the knife cuts along the volar side (the fingers being flexed dorsally), in the fold of the joint, along the margin of the web a small flap, the ends of which meet the dorsal incision. 4. Each finger is then disarticulated singly, and next the margins of the wound are sutured (Fig. 645). The cicatrix occupies the dorsal side. Fig. 645. Disarticui^tion of all Fingers 340 SURGICAL TECHNIC DISARTICULATION OF THE THUMB AT THE CARPAL JOINT (a) Oval incisio7i. 1. The first incision begins at the ulnar side of the first phalanx at the level of the web, is carried obliquely across the phalangometacarpal joint as far as the radial side of the metacarpal bone, and along this as far as its base. 2. The second incision, carried from the same point around the radial side, meets the first at the middle of the metacarpal bone (Fig. 646). Fig. 646 Fig. 647 Fig. 648 Disarticulation of the Thumb (oval incision) 3. By repeated incisions in the same direction along the bone, the latter is freed from the muscles. It is of importance to preserve as much as possible of the muscles, and especially of the periosteum, in order to obtain a somewhat movable stump. 4. From the ulnar side, the articulation is opened between the trapezium and the metacarpal bone, whereby the edge of the knife must be carried close to the base of the latter for fear of opening the articulation between the metacarpal bone of the index and the trapezium, connected with the other carpal joints. 5. The division of the articular ligaments on the radial side (Fig. 647) completes the operation, which leaves a linear scar after the wound has been sutured (Fig. 648). Since a hand without a thumb is not very useful, a stump should be preserved on the metacarpus wherever it is possible, no matter how small. If it is impossible, according to Laiienstein, the meta- carpus of the second and fifth fingers can be sawed through transversely by THE TREATMENT OF WOUNDS 341 dorsal longitudinal incisions. The two fingers are then turned 180° around their axis and healed in this position. They then stand in opposition to the third and fourth fingers (as in a parrot's footj. ib) Latej'al flap incision according to von Walther. I. The thumb is held in abduction, the knife is applied over the middle of the web, and carried upward by sawing movements between the first and Fig. 649 Von Walther's Radial Flap Incision Fig. 650 second metacarpal bones until it reaches the ulnar margin of the base of the first metacarpal bone (Fig. 649). 2. By avoiding the joint between the metacarpal bone of the index and the trapezium, the point of the knife is carefully carried under the base of the bone, and thereby the carpometacarpal joint is opened. 3. The thumb can be abducted even more forcibly ; the knife penetrates the joint to the radial side of the metacarpal bone, and is again carried on this downward, forming a radial flap, the rounded point of which ends at the level of the web (Fig. 650 j. DISARTICULATION OF THE LAST FOUR METACARPAL BONES (with PRESERVATION OF THE THUMB) 1. On the palmar surface a semilunar flap is circumi scribed by an oblique curved incision, beginning at the web of the thumb and ending at the ulnar margin of the base of the fifth metacarpal bone (Fig. 651). The flap can also be formed from within outward by transfixion at its base (Fig. 652). 2. An incision is made upon the dorsal side of the hand, beginning at the web of the thumb and extending obliquely upward as far as the upper third of the second metacarpal bone ; thence it extends at the same level across 342 SURGICAL TECHNIC the last three metacarpal bones; at the ulnar margin of the hand, it meets the volar flap (Fig. 653). 3. After both flaps have been dissected back as far as the region of the carpometacarpal articulations, the latter are opened from the ulnar side under forcible abduction of the metacarpus, until also the connection of the second Fig. 651 Fig. 653 Disarticulation of the Last Four Metacar- pal Bones, a, volar incision; b, dorsal incision Fig. 652. Volar Inci- Fig. 654. Stump sign by Transfixion after Disartic- ulation OF THE Last Four Meta- carpal Bones carpometacarpal bone with the trapezium is divided. During the last act, the incision must be made very carefully and always be directed toward these two bones in order to avoid injury of the articulation between the trapezium and the metacarpal bone of the thumb. 4. It is exceedingly advantageous to preserve the thumb for working purposes (Fig. 654). DISARTICULATION OF THE WRIST {d) Circular incision. 1. A circular incision circumscribes the hand upon the middle of the metacarpus 4 centimeters below the styloid processes. 2. The skin is separated all around by vertical incisions until it can be turned back like a cuff or manchette over the styloid processes. 3. The pronated hand is strongly flexed; a slightly curved incision with the convexity directed upward, across the wrist from one styloid process to the other, divides the extensor tendons and opens the wrist. THE TREATMENT OF WOUNDS 343 4. The lateral ligaments are divided under both styloid processes, and finally the anterior capsular wall and all flexor tendons are divided with one t ^ sweep of the knife (Figs. 655, 656). {b) Flap incision. 1 . The operator takes hold of the lower portion of the hand in pronation, flexes it, and makes from the point of one styloid process to the other a semilunar incision across the middle of the dorsal side of the hand (Fig. 657)- 2. The skin flap is detached from the ex- tensor tendons, turned and the joint is opened in the same manner as in the circular Fig. 635. Disarticulation of the Hand BY Circular Incision Fig. 656. Stump after Disar- ticulation OF the Wrist bv Circular In- cision upward, incision. Fig. 657 Fig. 658 Disarticulation of the Hand with Two Flaps of Skin (Ruysch) 3. The fasciculus of the flexor tendons is forced forward with the point of the left forefinger into the wound from the volar surface, and carefullv 344 SURGICAL TECHNIC divided by to and fro motions of the knife ; next, a small skin flap is made on the volar side (Fig. 658). It is advisable by an incision to indicate the volar flap at the beginning of the operation. (c) Radial flap {von Walthcr, 18 10). 1. From the skin covering the metacarpal region of the thumb, a semilunar flap is formed, the base of which comprises the radial third portion of the carpus, the j^oint of which reaches the base of the first phalanx. 2. After the flap has been dis- sected off from the muscles of the thumb and turned upward, a half- circular incision circumscribes the two remaining thirds of the carpus at the ulnar side (Fig. 659). 3. The skin is drawn forcibly upward, and the carpus, as described Stump resclt- above, is separated from the bones of '„ ' *\' ' ^ _ \\ A L T H E R'S the forearm. Figure 660 shows the Method Fig, 660 Fig. 659. DisARTicrLATioN OF THE Hand (von Wal- iher's method) appearance of the sutured stump. AMPUTATION OF THE FOREARM For amputating the forearm, the circular incision in two tempos (Figs. 599-600) and the skin flap incision (Fig. 605) are adapted. During the _ _ vl- mf.d- Tiuu-e. ne.b. eH c Fig. 661. Section of the Right Forearm .aT n>, Lower Third. />./. palmar, long.; n.m. nerv. medianus; /.;-./. tendo rad. int.; a.r. art. radialis; i. brachioradialis; ti.r.s. nerv. radial, superf. ; a.p.t. abductor pollicis longus; r.eJ. radialis ext. longus; r.e.i. radialis ext. brevis; e.i/.c. extensor dig. comm. ; m.u.e. muse, ulnaris extern.; a.u. art. ulnaris; tn.f.d. muse, flex, dig. comm. prof. PLATE XI At its lower third At the middle of the right fore-arm Sections of the right fore-arm THE TREATMENT OF WOUNDS n.p.l. 345 ^a.iL m.e.p Fig. 662. Section of the Right Forearm at its Middle Part (see also Plate XI). m.pJ. muse. " palmaris longus; ti.m. ne^^^ medianus; a.r. art. radialis; m.pJ. muse, pronator teres; n.r. nerv. radialis; /.r. tendo radialis ext. long.; ot.^./. muse, ext ens. poll, long.; rt.z^ art. ulnaris n.r.s ■n.u. n.r.p. Fig. 663. Section- of the Right Forear-M at its Upper Third (see also Plate XII). a.r. art. radialis; «.r.5. nerv. radialis superf.; w.r./. nerv. radialis profundus; «./. art. interossea; a.u. a.n. ulnaris; n.u. nerv, ulnaris; ti.fu. nerv. medianus 346 SURGICAL TECHNIC operation, the forearm must always be held in full supination, especially in sawing off the bones; else the radial stump becomes somewhat shorter. If flaps are formed, it is best to select a volar and a dorsal flap, or only a volar flap, which must correspond to the diameter of the limb. Directly above the wrist, it is often difficult -to divide the tendons; they must be drawn for- ward with tenaculum forceps, and cut off with a pair of scissors. The union of the wound is best made in a vertical direction, while the arm is placed in pronation. As little as possible should be removed from the forearm, and especially when the amputation must be made very high and close to the elbow joint, a small forearm stump should always be preferred to disarticulation of the elbow, which can be made more easily. The stump is subsequently of great importance for the movement of any prothesis which may be applied. (a) I. DISARTICULATION OF THE ELBOW JOINT Circular incision. A circular incision divides the skin 4 centimeters below the condyles of the humerus; the manchette is dis- sected back and re- flected. 2. A transverse incision across the vo- lar side opens widely the hyper -extended articulation. 3. An incision above the Jicad of the radijis divides the external lateral lig- ament ; an incision below the internal con- dyle divides the inter- nal lateral ligament. 4. The articula- tion gapes widely ; the DisAKTicn-ATioN OF THE Elbow oigcranou Is f orccd T(J1NT (circular incision) . , , mto the wound ; an incision above its point separates the tendon of the triceps from it (Fig. 664). Figure 665 shows the form of the stump sutured transversely. Fig. 664 Fig. 665. Stump after Disarticulation of THE Elbow Joint by Circular Incision PLATE XII At its upper third Through the elbow joint in the line of Condyles Sections of the Right Fore-arm THE TREATMENT OF WOUNDS 347 (J?) Flap incision. I. A curved incision, beginning 2 centimeters below one condyle and ending 2 centimeters below the other circumscribes on the volar side of the nee V m. n.c.z.m. n.r. m.r. n*a>. Fig. 666. Section of the Right Elbow Joint in the Line of Condyles (see also Plate XII). w.fT.i?. nerv. cutaneus ext.; z'.c. vena cephalica; w.r. nerv. radialis; w.w. vena mediana; v.b.\&na. basilica; it.c.i.m. nerv. cutaneus int. major; n.t)i. nerv. medianus; m.r. muse, radialis int.; n.u. nerv. ulnaris forearm a large semilunar skin flap, which is detached from the fascia and turned upward. 2. The arm is strongly flexed and turned in such a way that the posterior side of the articulation faces anteriorly. 3. A shallow curved incision across the olecra- non exposes its tip (Fig. 66y). 4. A transverse incision from one condyle to the other divides the tendon of the triceps and the two lateral ligaments ; a second, all the soft parts on the volar side of the articulation. (c) Oblique incision. I. While the elbow joint is held flexed at an angle of about 135°, the incision penetrating imme- diately down to the bone extends from the hne of ^^«- ^^7. Disarticulation ^ _ OF THE Elbow Joint articulation of the elbow (beginning over the head (flap incision) '-'^'..n^ 348 SURGICAL TECHNIC of the radius) parallel to the axis of the arm and a hand's breadth below the tip of the olecranon along the dorsal side and around the limb back to the elbow. 2. The dorsal flap is detached, together with the muscles (triceps, anconeus tissue), and the periosteum as far as the posterior surface of the humerus. 3. After division of the external ligament follows the opening of the articulation, and finally, after division of the internal ligament, the forearm is disarticulated. 4. The flap is turned into the elbow and sutured in this position ; the cicatrix comes to lie laterally and is protected from the pressure of the stump. On account of the very uneven articular surface of Fig. 668. Disarticula- the humerus, it is advisable also to saw off its lower TioN OF THE Elbow gxtremltv and extirpate the articular capsule (transcon- JoiNT (kocner s ob- ■' '■ lique incision) dj'larj aniputatiou, Pirogoff). AMPUTATION OF THE ARM In emaciated subjects, a single circular incision with the soft parts forcibly reflected and a sufficient high subperiosteal division of the bone by sawing 7i.r TLCe.S. Fig. 669. Section of the Right Arm at its Lower Third (see also Plate XIII). v.c vena cephalica ;«.;-. nerv. radialis; «.f.f.^. nerv. cutan. ext. superfic; m.c.i?. nerv. cutaneus ext.; a.b.zxt. brachialis; n.ni. nerv. medianus; v.b. vena basilica; n.c.i.m. neiv. cutan. int. major; n.u. nerv. ulnaris PLATE XIII )(l ^^P" At its lower third At its middle third In front of the Axilla Sections of the Right Arm THE TREATMENT OF WOUNDS 349 X ^ — < ^ 'r. s "ri rt rt is H o 'J ^ rt fe >■ r-. ^ r, CJ ;; > H ?^ ^ • ^ ^ S o ^ ^ ■^ -i rt ■^ < a; <2 > H n > C Pi C <1) tf! > M Ei C ^ _; •<^ ci ■^ r^ ^-x :<- ' — ' ti r.^ > ,^ 3J c X X - .2 'A c O Qi. > rt H C3 u S u (^ — ' ^ ,^ ~ ^ 350 SURGICAL TECHNIC (Fig. 594) is the simplest and most rapid procedure. In muscular patients it is better to make a circular flap. The skin flap incision is made either with two flaps (Fig. 605) or with one long anterior flap and a half posterior circular incision (Fig. 606). In reflecting the periosteum and in sawing, injury to the radial nerve, which lies directly upon the bone, must be care- fully avoided. The same is forcibly drawn forth before the wound is sutured and cut off as high up as possible. DISARTICULATION OF THE ARM AT THE SHOULDER JOINT (,^ Disarticulation of the Fifth Toe together with its Metaiarsal Bone THE TREATMENT OF WOUNDS 357 the point of which must be rounded off exactly at the level of the first incision in the web (Fig. 686). 6. In the same manner, the second, third, and fourth toes, together with their metatarsal bones, can be extirpated. lisfranc s disarticulation in the tarso-metatarsal articulations (exarticulatio tarsometatarsea) 1. Along the external border of the foot, between the cuboid bone and the metatarsal bone, the joint lying directly i7i front of the tuberosity of this bone is sought ; at the internal border of the foot, the articulation is sought for between the internal cunei- form bone and the first metatarsal bone, which is 4 centimeters in front of the tuberosity of the scapJioid bone. The line is marked by small incisions with the knife. 2. From one of these points to the other (from left to right), while the foot is raised, a large semilunar flap is circumscribed with the knife on the plantar sniface, the convexity of which passes over the heads of the metatarsal bones. 3. The foot is lowered and strongly flexed, the knife is carried from one point of the plantar flap to the other in a shallow curve, across the dorsum of the foot, dividing all soft parts down to the bone (Fig. 689). 4. The small dorsal flap is drawn upward, the point of the knife searches gropingly, to open the articulation farthest to the Fig. 687. Skeleton THE Foot Fig. 688. Lisfranc's Disarticulation of Tarsometatarsal Articulation left (on the right foot, the fifth metatarsal joint), while the left hand flexes the front of the foot strongly toward th.Q plantar surface. 5. As soon as the joint gapes, the knife is carried farther in a curve slightly convex anteriorly ; the knife opens the fourth and third joints {a), slides across the 358 SURGICAL TECHNIC base of the second metatarsal bone and opens the first articulation (r) (Fig. 690). 6. The articulation of the second metatarsal bone, located about one centi- vietcr JiigJier 'Ccizx^ that of the first, is opened by a small transverse incision {b)\ the lateral connections of the bone with the internal and external cuneiform bones, be- tween which the base of the bone articulates, are divided by inserting the knife with its edge directed upward (Fig. 691). 7. All articulations are now gaping more extensively ; the knife divides the remaining connections of the joint along the lateral borders and on the plantar side, and divides the muscles on the plantar surface for the greater part ; next, its edge is directed forward in completing the plantar flap (Fig. 692). Figure 693 shows the appearance of the wound before its union ; Fig. 694, that of the stump. If the well-defined extent of the disease permits it, the surgeon should endeavor to preserve the healthy meta- carpal bone or bones (atypi- cal amputation. Kilstcr ob- tained a good success by dis- articulating the second to the fifth metatarsal bones. He preserved the first metatarsal bone as well as the great toe, Fig. 691 whereby the important sup- port of the foot, the condyle of the first metatarsus, was preserved (Fig. 695). Else the surgeon can disarticulate the first metatarsus and saw off Fig. 689 Fig. 690 LisFRANc's Disarticulation of the FtKxr. incision; b, dividing articulation a, dorsal LisFRANc's Disarticulation Opening Second Metatarsal Articulation THE TREATMENT OF WOUNDS 359 only a portion from the other metatarsal bones, whereby likewise the impor- tant support of the tuberosity of the fifth metatarsus is left in position. If the tJiree ameifdnn bones must be removed, the cuboid bone, together with Fig. 692 Fig. 693 Fig. 694 LiSFRANC's Disarticulation. «, forming plantar flap ; iJ, wound surface; c, stump Fig. 695. LiSFRANC's Disarticulation. Preserving hallux the tuberosity of the fifth metatarsus, can be preserved. But it is better to make in that case a transverse amputation by dividing transversely the cuboid bone at an equal height with the anterior line of articulation of the scaphoid bone (intertarsal disarticulation, yii>£'r, Bona). CHOPART S DISARTICULATION AT THE TARSUS MEDIOTARSAL DISARTICULATION 1. The disarticulation is made in the joint connecting the scaphoid bone with the head of the astragalus, and the cicboid bone with the as calcis (Fig. 696). 2. The line of the joint is found and marked along the internal border of the foot, I centimeter above the tuberosity of the scaphoid bone, and at the external border of the foot, 2 centimeters above the tuberosity of the fifth metatarsal bone. 3. Across ^ho. plantar surface of the raised foot, a cin-ved skin incision is made, extending from the point marked on the left anteriorly along the border of the foot, a thumb's breadth behind the heads of the metatarsal bones, transversely across the plantar surface, and along the other border of the foot back to the point on the right side (Figs. 697-699). \6o SURGICAL TECHNIC 4. The foot is lowered and forcibly pressed downward, the knife is in- serted in the left angle of the wound and carried in a small curve across the Fig. 696 Fig. 697 Fig. 698 Fig. 699 Fig. 700 Ch(Jpart's Disarticulation at the Tarsus dorsum of the foot, only through the skin, as far as the right angle of the wound of the plantar incision (Fig. 700). 5. The little dorsal flap is retracted forcibly, a deep incision transversely across the articulation divides all tendons, and penetrates at once into the THE TREATMENT OF WOUNDS 361 articular connection (most safely, first above the tuberosity of the scaphoid bone, ivhicJi can be distinctly felt). 6. Under the edge of the knife, carried across the union of the joint (slightly ~-shaped curve), the joints are opened with a cracking noise. The point of the knife divides the tense ligaments everywhere, last on the plantar side, until the front of the foot can be completely pressed downward against the heel. 7. After a somewhat deeper incision has been made of the plantar flap on both borders of the foot, the edge of the knife, directed forward, is applied to the lower side of the freed scaphoid and cuboid bones, and drawn forward by sawing movements until the plantar flap is com- pleted (Fig. 701). 8. Figure 702 shows the appearance of the stump. The anterior inferior edge of the os calcis, which projects conspicuously and is apt to produce decubitus of the stump, can be chiselled off to some extent (Helfericli). During the healing pro- cess the foot must be placed in strong dorsal flexion (if necessary, by making tenotomy of the tendon of Achilles). After the healing, a sole extending obliquely upward is useful for walking, since the stump is apt to assume the talipes-equinus position. To prevent the same, Hclferich advises, after a previous tenotomy of Achilles, to open the astragalo-crural articu- lation from Choparfs wound, and, after removal of its cartilaginous surfaces, to effect a coalescence (arthrodesis), the limb being placed in a right-angular position. If the disease involves only the metatarsus, the dis- articulation can be made in CJwpm'f s joint, thus preserving the toes {Linck, 1887, Witzel). From the extremities of the dorsal transverse incision longitudinal Fig. 701. Chopart's Disarticulation AT THE Tarsus. Finishing plantar flap Fig. 702. Stump af- ter Chopart's Disarticulation AT THE Tarsus 362 SURGICAL TECHNIC incisions are made along the exterior and interior border of the foot toward the toes and beyond the diseased portion. The extremities of these incisions are connected by a dorsal transverse incision, so that a square soft-part flap is produced thereby (Fig. 703). 2. Disarticulation in CJioparf s joint and amputation of the diseased bones from the plantar soft parts, after the metatarsal bones have been sawed through either transverse!}", or after they have been disarticulated in the joints of the toes. Fig. 703 Fig. 704 Chopart's Dlsarticclation preserving Toes (Witzel) 3. Ligation of the dorsal artery of the foot and of the communicating branch of the plantar arch in the metatarsal interstice. 4. The portion of toe hanging loosely at the plantar bridge is united by wire suture with the skin of the upper dorsal flap, whereby a strong trans- verse roll of soft parts is formed on the plantar side (Fig. 704), which con- tracts after a few weeks. It is drained on both sides, and an immobilization dressing is applied for 4 weeks. 5. The result is a well-formed, but considerably shortened, small foot without any arch ; it does not assume any talipes-equinus position, and is well movable in the astragalo-crural articulation. The dorsal extension of the toes, of course, does not take place, since the sutures of the tendons have been omitted. MALGAIGNE's disarticulation of the foot — BELOW THE ASTRAGALUS I. Two lateral flaps are formed by an incision, beginning behind directly above the tuberosity of the os calcis and detaching the tendon of Achilles from it ; encircling the external malleolus in a large curve, it extends across the lower half of the os calcis (Fig. 705) and thence ascends across the middle of the cuboid bone to the dorsum of the foot, over the anterior margin of the scaphoid bone (Fig. 706) ; it then descends perpendicularly downward along the internal side of the metatarsus (Fig. 707), until it reaches the middle of the plantar surface (Fig. 708); from here it turns at THE TREATMENT OF WOUNDS 363 a right angle backward, meeting the beginning of the incision at the inner border of the tendon of Achilles. Fig. 705 Fig. 706 Fig. 707 Fig. 70S Malgaigne's Disarticulation between the Astragalus and the Os Calcis (below the astragalus) 2. The two flaps are detached from the bone until both lateral surfaces of the calcaneum and of Choparf s articulation are exposed. Care must be taken not to come too near the tips of the malleoli, for fear of injuring the tibiotarsal articulation. 364 SURGICAL TECHNIC 3. By the disarticulation of CJwparf s joint, the amputation is completed. 4. With bone forceps, the anterior border of the os calcis is grasped, and while the bone is pressed downward and held in supination, the calcaneo- fibular ligament is divided with a small knife i centi- meter below the tip of the external malleolus ; it next enters the joint, divides the firm intertarsal liga- ment, while the bone ro- tates around its long axis ; Fig. 709. Disarticulation of the Foot below the astragalus finally the external astrag- alocalcaneal ligament is freed about 3 centimeters below the internal malleolus (see illustrations of ligaments in resection of the ankle joint). 5. In spite of the very irregular form of the inferior surface of the astragalus (Fig. 709), this operation yields a very useful stump for walking (Fig. 710). 6. To improve this form of the stump, especially in cases in which the soft parts are scanty, the head of the astragalus can be sawed off. Hancock applied osteoplastically the sa wed-off tubercle of the os calcis to the vivified inferior surface of the astragalus. After disarticulation below the astragalus Ssabanejejf \\q.2\q^ that part of the foot in front of Chopart's joint (having been sawed off in Lisfranc's line) to the vivified surface of the astragalus (similarly as in Fig. 704). Fig. 710. Stump AP'TER Disarticu- lation OF THE Foot below the Astragalus SYME S DISARTICULATION OF THE FOOT MALLEOLAR AMPUTATION 1. The foot flexed at a right angle is well elevated, and an incision pene- trating everywhere down to the bone is made from the tip of one (the left) malleolus to that of the other (the right) transversely across the plantar sur- face (Figs. 71 1-713). 2. The foot is lowered and forcibly pressed downward with the left hand, and a second incision is made from one tip of the malleolus to the other, transversely across the anterior side of the tibiotarsal articulation (Fig. 714). 3. A transverse incision across the articular surface of the astragalus opens the articulation in front ; two incisions below the two malleoli divide THE TREATMENT OF WOUNDS 365 the lateral ligaments, and the superior articular surface of the astragalus is freely exposed. 4. The left hand forces the foot more and more toward the posterior side of the leg ; next, while it is rotated around its axis in turns, first to one Fig. 711 Fig. 713 Fig. 712 Fig. 714 Sy.me's Disarticulation of the Foot side and then to the other, the os calcis is enucleated from the skin covering the heel, " Fersenkappe " (sustentaculum tah), and detached from the tendon of Achilles by incisions closely following each other, and alternating, now from above, now from the sides, and finally from behind and below, but always directed toward the bone. (Care should be taken not to injure the posterior tibial artery behind the internal malleolus.) (Fig. 715.) 3^^ SURGICAL TECHNIC In inflammatory diseases, it is well to enucleate the os calcis from the periosteum, not with the knife, but subperiosteally with the elevator and the raspatory ( Oilier). 5. The heel flap and the skin are drawn up- ward all around over the malleoli ; a circular incision closely above the articular surface of the tibia divides the other soft parts (tendons and periosteum). 6. The sazo divides the bones in such a man- ner that only the two malleoli and a tJiin layer of cartilage are removed from the articular surface of the tibia (Figs. 716, 717). ^^'^- 7i6. saw- ^, ,, ,. 1 . ■> rr • 1 1 ..• r I^'G THROUGH The malleoli can be nipped off with bone-cutting forceps, ^^^ j^^^.j, as was done repeatedly by Syme. Fig. 715. Syme's Disarticulation of the Foot (Disarticulating the os calcis) Fig. 717 Fig. 718 Fig, 719 Syme's Disarticulation of the Foot, a, wound surface; b, fresh stump, anterior view; c, healed stump, lateral view THE TREATMENT OF WOUNDS 367 7. After ligation of all bleeding vessels, the skin over the outer side of the tendon of Achilles is divided with a small knife, a drainage titbe is inserted through the opening, and the wound (Fig. 717) is united by suture (Figs. 718, 719). pirogoff's disarticulation of the foot (amputatio tibiocalcanea osteoplastica) 1. The soft parts are divided in the same manner as in Symes method (page 209). 2. After disarticulation of the joint, the foot is forcibly flexed until the posterior border of the astragalus appears to view. Fig. 720. Pirogoff's Disarticulation of THE Foot (Sawing off the os calcis) Fig. 721. Sawing off Bones by Pirogoff's Operation 3. Immediately behind it, the saw is applied upon the upper surface of the OS calcis, and the same is sawed through vertically and exactly in the plane of the plantar incision (Figs. 720, 721). 4. The two malleoli and a thin layer of the articular surface of the tibia are sawed off, as in Symes method. 5. The tendo7i of Achilles is rt'z^'^(^£•^ transversely, closely above its inser- tion, and the skin is fenestrated at the same place to make space for a drainage tube. 6. Figures 722 and 723 show the appearance of the surface of the wound and of the stump. zes SURGICAL TECHXIC Rydygicrs procedure is worthy of notice for suitable cases, namely, to make Pirogoff's operation with a very large plantar flap, which serves for covering a large loss of substance (incurable ulcer) on the anterior surface of the leg. Fig. 722. Wound Surface of Pirogoff's Operation Fig. 7; Stump resulting from Piro- goff's Operation GUXTHER's modification of pirogoff's AMPUTATION' 1. The f/antar incision begins and ends closely in front of the malleoli, passing transversely across the plantar surface in the region of the posterior margin of scaphoid bone (Figs. 724-726). 2. The dorsal incision forms a small semilunar flap, extending as far as the scaphoid bone (Fig. 727). 3. After the articulation has been opened, the soft parts are dissected off on both sides of the os calcis obliquely upward in a posterior direction as far as the insertion of the tendon of Achilles ; injury to t\\Q posterior tibial artery must be carefully avoided. 4. Immediately in front of the insertion of the tendon of Achilles, a metacarpal saw is applied upon the os calcis ; and the same is sawed through obliquely from behind, above, forward, and downward. 5. In the same manner, the tibia and the fibula are divided obliquely from behind, above, forward, and downward (Fig. 728). THE TREATMENT OF WOUNDS 369 6. The sawed surfaces of the bone can easily be brought in apposition by this procedure withotit dividing the tendon of Achilles. (Division of the tendon of Achilles is superfluous if the necessary mechanical precautions are practised to prevent retraction of the heel. Fig. 724 Fig. 726 Gunther's Modificatiox of Pirogoff's Operation Fig. 728 Gunther's Method of dividing Bones by Sawing Fig. 725 Fig. 727 The two bone surfaces can be kept in accurate uninterrupted contact by : (i) Suturing of extensor to flexor tendons ; (2) direct fixation of os calcis to tibia with an ivory nail; (3) silver wire suture.) 370 SURGICAL TECHNIC LE FORT AND VON ESMARCH's MODIFICATION OF PIROGOFF'S AMPUTATION I. T\\Q. plantar incision begins 2 centimeters below the tip of the external malleolus (on the right foot), extends in a shallow convex manner across the Fig. 731 Le Fort's Modification of Pirogoff's Operation Fig. 730 t^K- 733 Le Fort's Method of dividing Bones by Sawing Fig. 732 plantar surface of the cuboid and scaphoid bones, and ends at the inner side, 3 centimeters in front and below the internal malleolus (Figs. 729-731). THE TREATxMENT OF WOUNDS 371 2. The dorsal incision from the same points forms a slightly curved flap, the anterior border of which passes across Choparf s line of articulation (Fig. 732). 3. The dorsal flap is dissected upward as far as the tibiotarsal articula- tion, and the joint is opened as in Pirogojf's method. 4. The foot is turned backward, and the upper surface of the os calcis is dissected free far enough to enable a metacarpal saw to be inserted behind the upper border of the tuberosity of the os calcis and the upper third of the bone to be removed by a horizontal ijicision from behind, for- ward and backward (Fig. 733). 5. As soon as the saw has penetrated into Choparf s articulation, the bones of this articulation are separated in the same manner as by Choparf s method. 6. The two malleoli and the articular surface of the tibia are sawed off as in Pirogojf's operation. 7. According to von Bruns, the os calcis can also be sawed off in a concave manner with the metacarpal saw, and the bones of the tibia and fibula convexly (Fig. 734). By this method the stump receives a very broad surface for walking (Fig. 735). 8. In all these op- erations it is advisable, after union of the soft parts, to fasten the bones together with a long steel nail (Fig. 571), driven in from the plantar surface through the os calcis deep into the tibia. If the wound is and remains aseptic it heals rapidly by primary intention ; the nail does not interfere with an ideal healing of the wound. It can be extracted easily after three weeks. If only the external or the internal side of the foot Fig. 735. biuM? re^ult- . J. J 7-) • /i-> ^- i- n 1 j-_c 1 II^'G FROM LE FoRT'S is diseased, Pirogoff s operation may nnally be modified method in this manner : the os calcis is sawed through in a sagittal line, its healthy surface is laterally turned upon the sawed surface of the leg ( Tanber). Or else, with Malgaignc' s mode of incision, the inte- rior half, well rounded off at its borders with the bone-cutting forceps, can Fig. 734. Von Bruxs's Method of DIVIDING Bones by Sawing \ 372 SURGICAL TECHNIC be inserted into the bifurcation of the malleoli which has been left unin- jured {Quimby). Kuster recommends as a good substitute for Le Forfs op- eration to open the ankle joint from the incisions indicated in Figure 736, to remove the astragalus, to disarticulate the foot between os calcis, cuboid, and sca- phoid, and to heal firmly the os calcis left Fig. 736. Ki-sTER's Modification of uninjured into the malleolar bifurcation Le Fort's Operation without removing any portion of bone. AMPUTATION OF THE LEG Circular amputation by tivo incisions and the skin flap incision are best adapted to the amputation of the leg. In the lower third (above the malleoli), two lateral skin flaps of equal length are especially suitable (Fig. 604); an anterior skin flap can easily be perforated by the sharp spine of the sawed-off tibia ; a posterior skin flap draws the margins of the wound apart by its weight. (The spine of the tibia should always be removed with the saw. If this is done, and the posterior flap is well supported by dress- ing and bandage, and the limb immobilized upon a posterior splint, there is little or no risk of pressure decubitus occur- ring.) In the middle, likewise, two skin flaps are formed, or, ac- cording to von Langenbeck, one long oval lateral flap (on the inner side) with half a circu- lar incision on the opposite side, whereby the cicatrix is placed laterally (Fig. 738). This method is also well adapted to the upper third, where the amputation is usually made below the tuberosity of the tibia (place of selection). l-io. 737 Fig. 738 Von Langenbeck's Amputation of the Leg by FORMING A Lateral Skin Flap THE TREATMENT OF WOUNDS 373 (The best stump for the wearing of an artificial Kmb is obtained by per- forming the amputation at the junction of the lower with the middle third. The skin flaps should include the strong muscular -fascia, and must be taken from the side of the limb where the tissues are best adapted to a suitable covering for the wound, in preference to a long oval anterior and a short oval posterior flap.) Von Bardeleben formed at this place a large anterior skin flap, in which he included at the same time t\\Q periostezmt {ctt,t around in the shape of a flap) of the anterior smooth surface of the tibia ; the sawed surface of the tibia is covered with this periosteal flap, and by the new formation of bone the sharp edge of the tibia is somewhat rounded off. The same object is obtained by sawing off the sharp border of the tibia obliquely. Helferich forms on the inner side of the leg an oval flap in which the fascia and the whole periosteum of the circumsected tibial surface is pre- served ; the periosteum is carefully elevated from the bone. Next, a circular incision is made through the skin at the base of the flap, the soft parts and the interosseum are divided vertically ; the bones are sawed off. When the suture is applied a cuneate lobule is formed over the eminence of the tibial surface by the abundant skin. This lobule protects the bone. The band of periosteum covers the sawed surfaces. Hater proceeded as follows : — ■ Longitudinal incision upon the crest of the tibia, corresponding in length to the manchette (cuff) to be formed ; the incision penetrates through the periosteum down to the bone. At its lower end, across the free surface of the tibia, a short transverse incision is made as far as the inner margin, and from this angular incision the skin, together with the periosteum, is reflected from the tibia ; the broad strip of periosteum thus formed is sub- sequently applied upon the sawed surface of the tibia. The transverse incision is next completed into a circular incision through the skin down to the fascia, and the rest of the operation is made in the same manner as in circular amputation. The amputation at the place of selection {yon Esmarch) produces stumps which can support most, and with which the patient, kneehng on a simple wooden leg (broom-handle fixed in a plaster of paris dressing) can walk about very well (Fig. 631). Hence, if the patient has not the means to buy an expensive artificial Hmb, which must be often repaired, it is advis- able to make the amputation at the place of selection, even if a healthy part of the leg must be sacrificed. To make longer stumps of the leg useful in directly supporting the 374 SURGICAL TECHXIC weight of the body upon a peg leg, the primary closure of the opened medullary cavity is advisable by means of a bone cover taken from the tibia. bier's osteoplastic amputation I. Skill flap incision. Beginning a thumb's breadth in an outward direction from the anterior border of the tibia and ending at the opposite side, a large skin flap is circumsected, the base of which corresponds to half the circumference of the limb. Without injuring the periosteum it is dis- sected back in an upward direction as far as its base (Fig. 739). Fk;. 739 Fig. 740 Bikr's Osteoplastic Amputation of the Leg 2. Formation of bone cover. From the periosteum of the tibia a square! I flap is excised, large enough to cover the sawed surfaces of the tibia and fibula. The longitudinal incisions lie a little beyond the tibial borders. From the transverse incision the flap is reflected in an upward direction for about I" centimeter. Next, a fine amputation saw with its blade placed obliquely is inserted in the transverse incision and a fine furrow is sawed. From this furrow a lamella is sawed out from the tibial surface in an upward direction, while an elevator keeps the saw incision gaping. Arrived at the base of the skin flap, the saw is carried more toward the periosteum for the purpose of completing the bone flap ; the periosteal bone portion is then deflected, and the periosteum only is somewhat reflected at its upper end. The pedunculated bone flap is inverted in an upward direction (Fig. 739). 3. The amputation is then made from the e.xtremities of the skin flap with a deep circular incision through the calf ; division of the interosseus space, sawing off the tibia close at the border of the inverted bone flap, next of the fibula at an equal height {zuitJioiit reflecting the periosteum). PLATE XIV At its lower third At its middle third At its upper third Through the knee-joint (Line of Condyles) Sections of the Right Leg THE TREATiVIENT OF WOUNDS 375 n.p.s. t.a. v.s.e.^^ " n.5S. m. Fig. 742. Section of the Right Leg at its Lower Third (see Plate XV). n.p.s. nerv. peron. superf. ; «./. art. peronjea; p./. peron. long.; v.s.e. vena saphena ext.; n.ss.m. nerv. suralis major; t.a. tendo achillis; i.p. tendo plantaris; n.t.pt. nerv. tib. post.; a.t.p. art. tib. post.; v.s.i. ven. saph. int.; 7i.spk.m. nerv. saph. major; a.t.a. art. tib. antica. a.t.a. m.f. d.c.t n.c.p^ Fig. 743. Section of the Right Leg at its Middle Third (see Plate XV). a.t.a. art. tibial, antica; m.e.h.l. muse. ext. hall, long.; ni.fh. muse. flex, hall.; a.p. art. peronaea; n.c.p. nerv. cutan. post, ext.; n.ss.m. nerv. suralis major; v.s.e. vena saph. ext.; t.p. tendo plantaris; n.sph.m. nerv. saph. major; v.s.i. vena saph. int.; a.t.p. art. tibialis post.; m.f.d.c.l. muse. flex, dig. comm. long. 37^ SURGICAL TECHXIC 1-1 — -J c fti - M s -s "5^ i; V. -^i H ss c o -; ■■=. s m > a C/3 c U «0 z "". • C c •- .S z j; r *-i c o ^. S o rt > H "^ C ^ — 1) 8 4^ sx) o O c 1) ^r ^ rt <, 3 t-.> . • u\ t Fig. 789. Von Langenbeck's Fig. 790, Tendons on the Dorsal Side of the Hand Method of Resecting the Wrist 2. An incision, beginning at the middle of the ulnar margin of the meta- carpal bone of the index finger divides the skin 9 centimeters upward as far as and over the median line of the dorsal surface of the epiphysis of the radius (Fig. 789). 3. On the radial side of the extensor tendon of the forefinger, and with- out injuring its sheath, the incision penetrates more deeply, continues farther 400 SURGICAL TECHNIC above on the ulnar margin of the tendon of the extensor carpi radiaUs brevis (where it is inserted at the base of the third metacarpal bone), and divides the ligamentum carpi dorsale exactly between the tendon of the extensor longus pollicis and the extensor digiti indicis as far as the limit of the epiphysis of the radius (Fig. 790). 4. While an assistant draws apart the soft parts with fine retractors the capsular ligament is divided lengthwise, and next detached from the bone in connection with the remaining ligaments in the following manner : — 5. First, the fibrous sheaths containing the tendons of the extensor longus pollicis and the extensor carpi radialis longus et brevis lying in the grooves of the radius, and the ten- don of the brachioradiaHs (supinator longus), must be detached from the bone toward the radial side partly with the knife, partly with the elevator. 6. Next, in the same manner, toward the ulnar side, the tendons of the extensor communis digitorum, together with the ensheathing cellu- lar layers of the ligamentum carpi dorsale, in connection with the peri- osteum and the articular capsule, must be detached and drawn toward the ulna. 7. The radiocarpal articulation is now exposed. The hand is flexed so that the articular surfaces of the up- per carpal bones become prominent. 8. The scaphoid bone is detached from the trapezium and the trapezoid, the semilunar and cuneiform bones from the os magnum and the unciform bone by dividing the intercarpal ligaments, and raising them gently with a small elevator ; the trapezium and the pisiform bone can be left in position (Fig. 791). 9. Next, the bones of the anterior carpal row are disarticulated. The globular articular surface of the os magnum is grasped with the fingers of the left hand or with the dressing forceps, and, while an assistant abducts the thumb, the articular connection of the trapezoid with the trapezium is Cari'al Bunes THE TREATMENT OF WOUNDS 4OI divided, and from here the operator tries to penetrate toward the ulnar side into the carpometacarpal articulation by dividing the ligaments on the extensor side of the upper heads of the metacarpal bones, while an assistant flexes the latter forcibly. Thus the three carpal bones of the anterior row (trapezoid, os magnum, and unciform bonej can be lifted out and removed together. In fungus disease of the carpus, the ligaments connecting the several bones are mostly destroyed, so that it is comparatively easy to remove the carpal bones singly with the sJiarp spoon alone. 10. If the bones of the forearm are also diseased, then, finallv, the hand being in volar flexion, the epiphyses of the radius and ulna are made to project from the wound, and all soft parts detached from them (as described above), when they are sawed off. Care must be taken not to injure the large dorsal branch of the radial artery passing over the trapezium to the first metacarpal interspace (Fig. 786 j. 11. After completion of the operation, and after the application of the dressing, the limb must be placed upon one of the splints illustrated in Figs. 219, 232, and 256, and must be immobilized in proper position with the hand extended and fingers flexed. As soon as possible the extension treatment should commence (see Figs. 266, 277; with passive motion of the fingers. For the purpose of protecting the insertion of the extensor carpi radialis, and also for inverting the articulation, thereby obtaining a better inspection, it is advisable to open BY kocher's dorso-ulxar ixcisiox 1. With the hand in slight radial flexion, an incision 7-8 centimeters long is made from the middle of the interspace between the fourth and the fifth metacarpal bones across the middle of the wrist on the dorsal surface of the forearm ; the dorsal branch of the ulnar nerve must be pre- served (Fig. 792). 2. After division of the fascia and the posterior annular ligament of the wrist, the operator penetrates between the tendons of the extensor digiti minimi and the extensor communis, opens the capsule at the base of the fourth metacarpal bone upon the unciform bone and the ulna, and detaches them toward both sides, after the tendons of the extensor digiti minimi and the extensor ulnaris have previously been drawn forward from the groove of the ulna in) and the tendon of the extensor ulnaris has been detached from the fifth metacarpal bone. 402 SURGICAL TECHXIC 3. Next, the operator penetrates into the cleft between the pisiform and the semilunar bones (/), and leaves the tendon of the flexor carpi ulnaris in connection with the latter bone. 4. The unciform process is freed ; next the bundle of the flexor tendons is raised from its groove ; the capsule along the third to the fifth metacarpal bones on the palm and the tight capsular insertion on the volar border of the radius are detached ; the tendinous insertion of the flexor carpi radialis on the second metacarpal bone, however, is preserved. 5. Upon the dorsal border of the radius, the capsule is detached as far as and beneath the tendons of the extensor carpi and the extensor longus pollicis and lifted out of their grooves. The insertion of the supinator longus is detached from the styloid process of the radius. 6. The hand is then forcibly dislocated in the radiovolar direction until the thumb touches the ra- dial side of the forearm (Fig. 793); the radio- carpal articulation can then be completely in- spected. The removal of the diseased bones of the wrist, the re- moval of as thin a layer as possible from the bones of the forearm, cause no difficulty. Gritti opened the wrist by a long trans- verse incision across the dorsal side of the car- pus, dividing all tendons at the same time. By forcible volar flexion, the articular surfaces can be sepa- rated from each other; after removal of all diseased portions, the hand is placed in its normal position, and the divided tendons are carefully sutured. Cattcrina reached the (anterior) parts of the carpus by dividing the metacarpus anteriorly. He divided the web between the third and fourth metacarpus and split their interstices. The volar incision is only 5 centi- meters long (volar arch !); the dorsal incision, 15 centimeters long, extends over the carpus. The halves of the hand are then turned apart and the diseased portions removed. Fig. 792 Fig. 793 Kocher's Resection of the ^VRIST THE TREATMENT OF WOUNDS 403 During the after treatment, it is necessary in all resections of the wrist to place the hand upon a spHnt, fixing the wrist in dorsal Jlexion but permit- ting; the movements of the fingers. RESECTION OF THE ELBOW JOINT LISTOX'S T-INXISIOX 1. The posterior side of the elbow bent at an obtuse angle is presented to the operator by an assistant, holding the forearm with one hand and the arm with the other (Fig. 796 j. 2. A longitudinal incision 8 centimeters in length, the middle of which corresponds with the inner margin of the olecranon, opens the articular capsule between this and the internal condyle (Fig. 794). trici^ extensor carpi . rad. Uingus anconaeus^ quartus a^ensor carpi ^ ulnaris — n. ulnaris flexor carpi ulnaria Fig. 794. Resection OF THE Right El- bow Joint (Lis- ten's T-incision) Fig. 795. Ulnar Xera^e on the Dorsal Side of the Left Elbow Joint 3. While the nail of the left thumb forcibly draws the soft parts from the internal condyle inwardly, a short knife divides them completely by incisions made vertically upon the bone, until the epicondyle projects free from the wound (Fig. 796). During this procedure, the forearm must be flexed more and more by the assistant. The ulnar nerve lies in the middle of the parts dissected off and does not appear to view (Fig. 795). 404 SURGICAL TECHNIC 4. By a semicircular incision made below the internal condyle, the internal lateral ligament (Fig. 797) and the origins of the flexor muscles are divided. 5. The arm is then extended, and the external incision is made trans- versely across the olecranon from the lower border of the external condyle to the middle of the first incision (see Fig. 794). 6. Upon the posterior side of the ulna, the periosteum is detached with the elevator from the internal margin, but remains in connection with the Fig. 796. Resection of the Elbow Joint denuding Internal Condyle tendon of the triceps, which must be separated from the tip of the olecranon with the knife. 7. Both are pushed outward over the external condyle ; the articulation then gapes ; a few incisions in the articular connection between the head of the radius and the articular surface of the external condyle above divide the annular ligament of the radius and the external lateral ligament (Fig. 798). 8. The articulation is now more freely exposed ; the free articular end of the humerus is grasped with bone forceps, and sawed off at the limit of the cartilaginous covering. 9. By an incision toward the point of the coronoid process of the ulna, the superior fibres of the internal brachial muscle are detached ; the ole- THE TREATMENT OF WOUNDS 405 cranon is grasped with the forceps, and the denuded part of the ulna, as far as it is covered with cartilage, is sawed off. 10. Next, the head of the radius is excised. Fig. 797. Inner side Fig. 7 Ligaments of the Right Elbow Joint Outer side II. After the hemorrhage has been arrested, the tendon of the triceps is first stitched with catgut sutures to the periosteum of the ulna ; next, the transverse incision is united by sutures, the longitudinal incision, however, only at its two ends. A drainage tube can be inserted into the middle of the wound down to the resected ends. VON LANGENBECK S SIMPLE LONGITUDINAL INCISION RESECTION SUBPERIOSTEAL 1. An incision 8 to 10 centimeters in length, extending over the extensor side of the articulation a little inwardly from the middle of the olecranon, begins 3 to 4 centimeters above the tip of the olecranon and ends $ to 6 cen- timeters below the same upon the posterior border of the ulna; it penetrates the muscle, tendon, and periosteum everywhere down to the bone (Fig. 799). 2. With the raspatory and elevator, the periosteum of the ulna is first pushed toward the inner side ; the internal half of the tendon of the triceps. 406 SURGICAL TECHNIC / I I in connection with the periosteum, is divided (by short parallel longitudinal incisions always directed toward the bone). 3. With the nail of the left thumb, the soft parts covering the internal condyle and including the ulnar nerve are drawn toward the tip of the epi- condyle and detached by curved incisions close to each other, always directed toward the bone, until the epicondyle projects and is freely exposed. The last incisions encircle the inner condyle, and divide the origins of the flexor muscles, as well as the internal lateral ligament from the same, without destroying the connection of these parts with the periosteum. f/'' ,' ' I 4. After the detached soft parts have been replaced into their former positions, the external part of the ten- don of the triceps is drawn outward, detached by short incisions from the olecranon, but left in connection with the periosteum of the external side of the ulna, which, together with the anconeus muscle, is elevated from the bone. 5. By incisions made close to each other and di- rected toward the bone, the fibrous articular capsule is detached from the margin of the articular surface of the humerus, first at the trochlea, next at the head of the bone, until the external condyle appears to view. 6. Next, the external lateral ligament, as well as the origins of the extensor muscles, are so detached from it that all these parts remain in connection with each other and the periosteum of the humerus. 7. After the external condyle has thus been divested from all attach- ments of soft parts, the joint can be strongly flexed ; the articular ends are forced out of the wound and sawed off in the manner described above. 8. If it appears desirable to saw off the ulna below the coronoid process, the superior fibres of the tendon of the brachialis internus must be detached from it without destroying the connection of the tendon with the periosteum of the ulna. Fig. 799. Resection OF Right Elbow Joint by von Lan- genbeck's External Incision BY HUETER S BILATERAL LONGITUDINAL INCISION I. A longitudinal incision 2 centimeters in length exposes the internal condyle ; a curved incision, encircling its base, divides the internal lateral ligament. THE TREATMENT OF WOUNDS 407 2. A longitudinal incision over the outer surface of the joint 8 to 10 centimeters in length extends over the external condyle and the head of the radius. 3. The soft parts are drawn apart, and the external lateral ligament, together with the annular ligament of the radius, is divided. 4. The head of the radius is cleared of all attachments and removed with the metacarpal saw. 5. The insertion of the capsule of the joint is detached from before back- ward, first from the border of the rotula, then from the trochlea. 6. By abducting the forearm toward the ulnar side, the humerus is forced out of the wound when the ulnar nerve slips off from its posterior surface, and its articular end is excised with the saw. 7. The olecranon is then cleared and removed with the saw. BY OLLIER S BAYONET INCISION 1. With the forearm flexed (130°), the external incision on the pos- terior side of the elbow between the externus anconeus and the supinator longus, beginning 6 centimeters above the articulation, is made down to the lateral epicondyle ; from here, it turns downward at an obtuse angle to the olecranon, and then descends 4 to 5 centimeters along the posterior border of the ulna (Fig. 800). The middle oblique portion of the incision corresponds about to the inter- space between the triceps and the anconeus quartus muscles. 2. In the upper portion of the incision, after division of the fascia, the operator advances between the triceps and the supinator longus and the extensor carpi radialis longus down to the bone, and divides the articular capsule in the direction of the skin incision. 3. With the arm slightly extended, the tendon of the tri- ceps, together with the periosteum, which must be carefully oreserved, is detached from the bone with the raspatory. The irticulation is then opened behind after the olecranon has »een exposed. 4. On the humerus, the periosteum, together with the lateral accessory Igament, is reflected with the raspatory, and the humerus is luxated laterally by dividing the median and anterior articular ligaments. 5. Finally, the articular surfaces of the humerus, radius, and ulna are excised with the saw. Fig. 800. Olli- er's Resec- tion OF THE Elbow Joint 4o8 SURGICAL TECHXIC Xelaton made an angular incision extending along the outer side of the humerus as far as the head of the radius, and turning from here at a right angle backward as far as the ulna (Fig. 8oi ). It is true that the articulation and especially the head of the radius are well exposed thereby, but the anconeus muscle is trans- versely divided ; this disadvantage can be avoided by making the resection BY kocher's hook-shaped inxisiox ' I. An incision beginning at the radial posterior side 4 centimeters above the line of articulation extends on the l; / outer side of the inferior border of the humerus as far as the p; '': head of the radius, and 4 to 6 centimeters below the tip of |; the olecranon, and turns here about i to 2 centimeters upward as far as the median side of the ulna (Fig. S02). 2. The knife penetrates between the brachioradial mus- OF THE Elbow ^^ (supinator longus), extensor carpi radialis longus and brevis, and the extensor carpi ulnaris in front, and the anco- neus muscle behind as far as the lateral border of the humerus and the cap- sule of the head of the radius, and deviates upon the lower third of the anconeus as far as the lateral side of the ulna. Fig. 801. N£la- ton's Resection Fig. S02 Fig. 801 Kocher's Resection of the Elbow Joint, a, m. anconeus quartus; II, extensor carpi ulnaris; t, m. triceps; s, supinator longus 3. After division of the capsule the olecranon is divided at its base with a chisel transversely in the line of incision (more deeply on its posterior THE TREAT.MEXT OF WOUNDS 409 side), next turned up with the triceps and the anconeus toward the ulna, and subsequently enucleated if it is diseased. 4. If the olecranon is to be preserved, the external head of the triceps, with the periosteum and the capsular insertion, is detached from the humerus, also the anconeus from the external surface of the ulna, the insertion of the triceps from the tip of the olecranon, and a portion of the internal ulnar muscle from the internal surface of the ulna; this triceps anconeus flap is turned inward like a cap over the olecranon with the arm extended (Fig. 803). 5. After the detachment of the external lateral ligament and of the cap- sule on the external condyle of the humerus and on the neck of the radius, the articulation is opened freely. 6. Before the bones are sawed off, the internal lateral ligament must be carefully detached from the internal border of the ulna and the median surface of the trochlea, and the muscles, together with the periosteum, must be freed from the internal and the external condyle. The articular ends are sawed off in a light curve to guard against any subluxation which might occur during the healing process. RESECTIOX OF THE OLECRANON This can be made, according to voii Langenbeck, by a posterior longi- tudinal incision (Fig. 799). The soft parts and the periosteum are then detached with the raspatory on both sides, and the olecranon is removed with the metacarpal saw or chisel and hammer. TEMPORARY RESECTION OF THE OLECRANON {TrcudelcJlburg) can be made, aside from the incisions mentioned heretofore, also from behind, by chiselling off the olecranon, and by subsequently reuniting it with the bone suture. For this purpose a curved incision is made with the convexitv directed upward across the extensor side of the articulation from one epicon- dyle to the other. The skin flap is detached from the tendon of the triceps and the olecranon, and the soft parts are elevated bluntly from the internal side of the olecranon, preserving carefully the periosteum and the ulnar nerve. The portion of the capsule of the joint lying under it is divided transversely ; the olecranon is chiselled off transversely, and finally, in the same plane, the anconeus muscle and the portion of the articular capsule lying under it are divided transversely. The olecranon can then be turned in an upward direction ; with a flexed position of the arm a free inspection of the inside of the joint is obtained. 4IO SURGICAL TECHNIC The olecranon is finally united with the ulna by a bone suture, the external incision is sutured, and the arm is bandaged in an extended position. It seems just as well to form the skin flap with an 2ipper base, and to turn it up in connection with the olecranon to be sawed off. In the after treatment, the advice of Roscr to bandage the resected elbow joint first in the cxtcjidcci position to prevent the dislocation of the ends of the bone (subluxation), and to guard against the formation of a loose freely mov- able joint, must be strictly observed. The splints illus- trated in Figs. 146, 152, 216, 236, and 238 can be used for this purpose. But also with a right-angular position a loose, freely mov- able joint can be avoided if the surgeon, in as exten- sive a manner as possible, places in apposition only the extremities of the bone. Thereby the resected bones of the forearm are prevented from coming to lie in front of the humerus. For this purpose ulna and humerus can be sawed off obliquely and placed in apposition, or the humerus end can be in- cised in the form of a A (or be divided longitudinally), the ulna cut out in the form of a wedge be inserted into the fissure. The radius can be sawed off to such an extent that it comes to lie upon the humerus {BardenJiener). To prevent anchylosis with the limb in this position the forearm, as soon as the wound has healed or nearly healed, must be gradually flexed at the elbow with each change of dressings, and must be kept in the new position from one dressing to another until the desired degree of flexion is reached. If a loose, freely movable joint has formed after resection of the Fig. 804. Socin's Supporting Apparatus for a Loose, Freely Movable Joint after Resection of the Elbow Joint THE TREATMENT OF WOUNDS 411 elbow, firmness and usefulness can be restored by Socins supporting appa- ratus (Fig. 804), to which are attached rubber rings which accomplish flexion. (In all resections of the elbow joint temporary resection of the olecranon should be practised unless it is the seat of disease. After the resection has been completed the olecranon is united with the shaft of the ulna by a bone or ivory nail. In young subjects fixation by durable catgut sutures embracing the periosteum and the tissues outside of it will answer the purpose.) RESECTION OF THE SHOULDER JOINT BY VON LANGENBECk's ANTERIOR LONGITUDINAL INCISION (OLDER METHOD) 1. The patient is placed on his back, the shoulder pressed forward by a pillow, and the arm held in such a manner that the external condyle of the humerus is directed forward. 2. An incision, beginning at the anterior border of the acromion, very near its articu- lar connection with the clavi- cle and extending 6 to 10 centimeters vertically down- ward, penetrates through the deltoid muscle down to the capsule of the joint and the periosteum (Fig. 805). 3. The margins of the muscular incision are drawn apart with blunt retractors ; the tendon of the long head of the biceps is seen lying in its sheath (Fig. 806). 4. An incision along the external side of the tendon ^ Fig. 807 Fig. 808 opens its sheath ; the knife, ,^ ^ , ^ ^ ... Von Langenbeck's Resection of the Shoulder Joint with its back in the bicipital groove, divides the whole sheath of the tendon and the capsule as far as the acromion. 412 SURGICAL TECHNIC 5. The tendon of the biceps is lifted from its groove and drawn outward with a blunt retractor. 6. While an assistant slowly rotates the arm outward a curved incision across the lesser tuberosity of the humerus is made with a strong knife applied vertically to the bone. This incision divides the capsule and the insertion of the subscapular muscle (Fig. 807). 7. The arm is then rotated inward ; the tendon of the biceps is drawn inward and buried there. Sttpraspinatus 0r infraspinatus teres minor- suhscapularis (endo hicipitis •■ teres major Fig. S09. Insertions of the Muscles of the Greater and Lesser TUBEROSriY OF THE HUMEKUS 8. The knife is again carried in a larger circle from the capsular division above the greater tuberosity of the humerus, and divides the capsule with the insertions of the supraspinatus, the infraspinatus, and the teres minor muscles (Figs. 808, 809). 9. The head of the humerus is forced out of the wound by pressure from below, grasped with strong forceps (best of aU, Faradceuf's forceps — Fig. 810), and after the posterior portion of the capsule is divided, it is excised with a metacarpal saw (Fig. 811). THE TREATMENT OF WOUNDS 413 10. When the head of the humerus has been separated from the diaphy- sis by a bullet, it must be seized with a sharp bone hook and ex- tracted (see Fig. 779). If the head is crushed into several pieces, the fractured portions can be grasped singly with forceps and enucleated with a blunt-pointed knife or a probe-pointed knife. 11. After this method of oper- ating, in most cases a flail joint with displacement of the humerus toward the thorax is formed, or a poor and defective articular con- nection with the coracoid process is established. Free active motion is more likely to be restored if the connections of all muscles sur- rounding the articulation with the capsule and the periosteum of the Sawing off Head of Shoulder diaphysis are carefully preserved during the operation. This is effected by Tig 810 Fig. 81 r THE SUBPERIOSTEAL OR SUBSCAPULAR RESECTION BY VON LANGENBECK's ANTERIOR LONGITUDINAL INCISION 1-4. As in the foregoing operation. 5. Along the internal border of tkg bicipital groove, the periosteum is divided with the scalpel and carefully reflected with a small elevator from the spine of the lesser tuberosity of the humerus as far as the lesser tuberosity (Fig. 812). 6. With the knife and tenaculum forceps, the tendon of the subscapular muscle (Fig. 809) is freed from the bone without dividing the connections of the capsule with the detached periosteum. During this procedure the arm must be slowly rotated outward, and during the further progress of detach- ment the knife must be frequently exchanged for the elevator. 7. The arm is then rotated inward, the tendon of the biceps is raised from its groove and buried inward. 8. The periosteum of the external surface of the neck of the humerus is detached in connection with the insertions of the supraspinatus, infraspi- 414 SURGICAL TECHNIC Fig. 8 1 2. natus, and teres minor at the larger tuberosity in the same manner as described under 6. This detachment is somewhat difficult in primary- resections, because the periosteum is usually very thin. 9. The head of the humerus is forced out of the wound, and sawed off as in the preceding operation. If it is deemed neces- sary to resect only the head of the humerus at the upper extremity of the tubercle (which always yields the best functional result), re- flection of the periosteum is superfluous. In this case, the insertions of the muscles are detached from the bone as much as neces- sary, commencing from the articular cavity. Attention must be paid that the muscles are not cut off transversely, but retain their con- nection with the bone below. Since the head, however, under these circumstances cannot be forced from the wound, it must be sawed off with a fine metacarpal saw or with the chain saw. 10. After the hemorrhage has been ar- rested, an opening is cut in the posterior side of the wound in the skin, at the posterior border of the deltoid muscle ; through this opening a drainage tube is inserted into the wound. The anterior wound can then be completely united by buried and superficial sutures. An antiseptic dressing is applied and re- tained by a bandage, the tours of which fasten the arm, flexed at the elbow, to the side of Fig. 814. Ramification of axil- the chest in the manner of a mitella, which ^ary Nkrve. Posterior view, i, cir- rr £ .1 r .■ r . t ti cumflex nerve; 2, cutaneous nerve; surnces tor the fixation of the hmb. ^ . • , ,-1 3, teres minor muscle; 4, radial nerve; In order better to protect the deltoid mus- 5, ramilications coursing towards the cle and the branches of the circumflex nerve ^"""''l'' ^"'^ anconeus (axillary. Fig. 814), and consequently avoid paralysis of this muscle, the joint should be opened. Ligaments of the Shoul- der Joint THE TREATMENT OF WOUNDS 415 BY OLLIER S ANTERIOR OBLIQUE INCISION 1. With the knife directed toward the head of the humerus, the incision is made to correspond with the course of the fibres of the deltoid, from the external border of the coracoid process obliquely down- ward and outward across the lesser tuberosity and as far as the shaft of the humerus, dividing all of the soft tissues down to the bone (Fig. 814). 2. The lesser tuberosity and the bicipital groove are immediately exposed, and can be easily cleared of the attached soft tissues. Next, the arm is rotated inward, and the greater tuberosity is detached. On the whole, the procedure is the same as described in the preceding operation. Since from an anterior incision only the head of the humerus can be removed conveniently (decapita- tion), while the other portions of the articulation, espe;.cially the glenoid cavity, can be inspected or resected in a somewhat unsatisfactory manner, it is better in all cases in which a more extensive disease of the whole articulation necessitates free access to all its parts, to expose the articulation of the shoulder by Fig. 814. Ollier's Resection OF THE Shoulder Joint KOCHER S POSTERIOR CURVED INCISION 1. External incision from the acromioclavicular articulation over the eminence of the shoulder to the middle of the spine of the scapula and in the form of a curve downward toward^ the posterior axillary fold. Division of the acromioclavicular articulation (Fig. 815, c). Longitudinal incision through the fascia at the posterior border of the deltoid muscle. The inferior portion of it is exposed and forcibly drawn forward ; the fibres inserted farther on at the crest are divided. 2. The insertion of the cucullaris (trapezius) is detached from the spine of the scapula upward, and the supraspinatus is raised with the elevator ; the infraspinatus is detached downward until the external border of the spine can be encircled. 3. After an elevator has been placed under the neck of the acromion for protection, the crest {so') is divided with a chisel (from above downward) (Fig. 815); an injury of the subscapular nerve coursing beneath the supra- spinatus and infraspinatus muscles should be guarded against. 4i6 SURGICAL TECHNIC 4. After division of the bone, the acromial portion is rolled forcibly- forward with a sharp bone hook, and dislocated in the acromioclavicular articulation (Fig. 816), whereby the deltoid muscle (d) is elevated from the muscles of the scapula. 5. The prominent head of the humerus is now exposed, covered by the tendons of the supraspinatus and infraspinatus {ss, is) and of the teres minor (/w). 6. At the anterior border of the insertions of these muscles (on the great tuberosity and its spine), and at the posterior border of the palpable groove of the biceps, a longitudinal incision is made over the bone, dividing Fig. 815 Fig. S16 Kocher's Resection of the SnorLDER Joint above the capsule {k) over the head of the humerus, and exposing the ten- dons as far as the superior margin of the glenoid cavity. 7. The insertions of the supraspinatus and infraspinatus and teres minor muscles are detached from the greater tuberosity and drawn back- ward ; the tendon of the biceps, exposed in the bicipital groove, is drawn forward ; the arm is rotated outward. 8. The insertion of the subscapular muscle, now appearing to view, is detached anteriorly and posteriorly from the lesser tuberosity ; the vessels passing below the teres minor and the axillary (circumflex) nerve must be protected. THE TREATMENT OF WOUNDS 417 9. When the head has been completely exposed and forced out from the wound, an excellent view of the interior of the joint is obtained, espe- cially of the glenoid cavity. All diseased portions can be easily recog- nized and removed ; if necessary, the head can be resected. Finally, the chiselled-off portion of the acromion is united again with the scapula by bone suture. This procedure also enables the surgeon by a partial resection to pre- serve intact the anterior capsular portion, the subscapular muscle and the coraco-humeral Hgament; thereby the frequent partial dislocation toward the coracoid process is avoided. If the articular portion of the scapula alone is injured, while the head of the humerus has remained intact, it is necessary only to make VON ESMARCH S RESECTION OF THE ARTICULAR SURFACE AND NECK OF THE SCAPULA 1. A curved incision encircHng the posterior border of the acromion and dividing the fibres of the deltoid muscle from it exposes the posterior superior surface of the capsule of the joint (Fig. 817). 2. From the middle of the same, the knife penetrates as far as the posterior superior border of the glenoid process of the scapula, divides in a sagittal direction the articular capsule between the tendon of the supraspinatus and infraspi- natus muscles as far as the middle of the g/eater tuberosity, and at the same time the skin and the deltoid muscle in the direction of its fibres. 3. While the soft parts are forcibly drawn apart with retractors, from the border of the glenoid process the operator detaches the ten- don from the long head of the biceps and the capsule, in connection with the periosteum of the neck of the scapula, all around to such an extent that the articular end can be removed with the metacarpal saw, or the fractured por- tions of the comminuted bone can be liberated with the knife. 4. The after treatment is the same as in resection of the shoulder joint. 2 E Fig. 817. Von Esmarch's Resec- tion OF THE Articular Surface AND Neck of the Scapula 41 8 SURGICAL TECHNIC RESECTION OF THE SCAPULA BY VON LANGENBECK S ANGULAR INCISION This operation is performed only in the case of tumors ; the muscles covering the scapula are not preserved (extirpation of the scapula). 1. One line of the angle takes its course on the upper side, the other over the centre of the scapula downward ; the skin flap formed thereby is detached from the underlying tissues in the direction of its base, and turned outward. 2. Next, the insertions of the rhomboid muscles and of the levator anguli scapulae are detached from the internal border, those of the cucullaris (trapezius) and deltoid from the acromion and spine, the omohyoid from the superior border, the teres major and minor from the external and inferior border. While the bone is elevated at its middle border from the thorax, the knife detaches it with shallow sweeps from its base (serratus magnus and subscapular muscles). 3. An incision in the form of a horseshoe across the head of the hu- merus divides the capsule of the shoulder joint, the insertions of the supra- spinatus and infraspinatus muscles on the greater tuberosity, and the acromioclavicular articulation. 4. The bone can then be elevated outward ; and after the remainder of the articular capsule, the insertions of the biceps and triceps muscles, have been detached from the border of the glenoid cavity, and the pectoral minor muscle and the coracobrachial from the coracoid process, it is removed. 5. After careful ligation of all the bleeding vessels, the large wound is covered with the skin flap and sutured, and a drainage tube is inserted into the lower angle of the wound. But if the overlying soft parts must be preserved, for instance, in oper- ations for jiecrosis of the bone, this can be readily done by removing the se- questered scapula subperiosteally. OLLIER S SUBPERIOSTEAL RESECTION 1. A transvo'sc incision is made over the spine of the scapula from the acromion to the inner border, penetrating down to the bone ; the insertions of the cucullaris are detached with knife and elevator. 2. A vertical incision takes its course along the inner border of the scapula, exposing the median insertion of the supraspinatus and infraspinatus muscles (Fig. 818). THE TREATMENT OF WOUNDS 419 3. By blunt dissection, the soft parts of the fossa infraspinata are dis- placed outward ; then, in the same manner, those of the fossa supraspinata are detached from the bone and retracted upward and outward. 4. While the bone is elevated from the thorax, the underlying soft parts are detached with the raspatory as far as its anterior border and the neck. 5. Next, as described above, the oper- ator divides the acromioclavicular articu- lation from below ; likewise, the articular capsule and the muscular insertions ; fi- nally, the insertions of the muscles and ligaments of the coracoid process ; it is easier, however, to remove this process by detaching it from the scapula with the ^^, o o /> , t^ ^ ^ tiG. 818. Ollier's Resection of the saw. Scapula PARTIAL RESECTION OF THE SCAPULA This operation must be adapted to each individual case. Portions of the spine and the acromion can be chiselled or sawed off through a simple incision; likewise, the flat portion of the scapula can be removed, leaving the articulation intact (amputation of the scapula). RESECTION OF THE CLAVICLE This can be made very easily by an incision extending along the whole length of the bone, from which the periosteum is reflected toward both sides. The operation is facilitated by dividing the periosteum transversely on both sides, I 1. Next, the middle portion to be removed can be easily excised with the metacarpal or chain saw. Resection of the articular extremities offers no especial difficulty. The sternal end is divided by a longitudinal incision down to the articulation ; the bone is sawed through at the external angle of the wound upon an elevator very carefully inserted subperiosteally to protect the large veins lying directly behind it; the short portion is drawn forward, detached at its posterior and inferior surface from the soft parts adhering to it, and finally the articular capsule is divided. In resecting the acromial end, an incision is made from the extreme end 420 SURC;iCAL TECHNIC of the clavicle to about the coracoid process ; at its inner border, an elevator is inserted behind the bone, and the latter is divided ; next, the acromio- clavicular articulation is disconnected, and finally the portion of bone is enucleated from the periosteum. If the zvliole clavicle must be removed, the operation can be facilitated by sawing the bone through in the middle, and by extirpating each half separately. The temporary resection of the clavicle for ligating the sub- clavian artery is mentioned on page 261. RESECTIONS OF THE LOWER EXTREMITIES RESECTION OF THE ARTICULATIONS OF TOES is made according to the same rules as those which have been laid down in the resection of fingers, with longitudinal incisions extending laterally along the extensor tendon (Fig. 819, i and 2). Of frequent necessity is the ARTHRECTOMY OF THE ARTICULATION OF THE GREAT TOE in inflammations, tuberculosis (and in some cases of Jiallnx valgus). Ferdi- nand Peterseiis broad opening furnishes a very good survey. Instead of a longitudinal incision made at the median side of the articulation, he divides Fig. 819 Fig. 820 Petersen's Arthkectomy of the Articulatujn of the Great Toe I, 2, resection of the articulations of the toes; 3, resection of the metatarsus the web between the first and the second toes as far as the neck of the con- dyle of the metatarsus and a little nearer toward the great toe (Fig. 819). The two toes are forcibly reflected, and the first articulation of the toes of the metacarpus is opened. With resection incisions, the soft parts are detached THE TREATMENT OF WOUNDS 42 1 in a dorsal and plantar direction by preserving the insertions of the muscles and tendons until the toe can be more and more extended, and finally be turned over completely (Fig. 820). The articulation is then exposed. All vestiges of disease can easily be removed, all proliferations of the bone can be nipped off with the forceps, etc. Finally, the toe is reposed in its natural position and the skin wound is completely closed by a few sutures. In the same manner, the articulation of the little toe can be opened. The resection of a metatarsal bone is made as in that of the fingers, from a longitudinal incision passing over the bone and extending beyond the next articulations (Fig. 819, 3). For the removal of all metatarsal bones an incision is used as in Fig. 703. The articular surfaces of the tarsal bones and the toes can be vivified for the purpose of producing a firmer coales- cence, in case the surgeon is not content with the simple disarticulation, which is made similar to Fig. 704. RESECTION OF THE ANKLE JOINT SUBPERIOSTEALLY BY VON LANGENBECK's BILATERAL INCISION 1. After the foot has been placed upon its inner side, an incision 6 centi- meters long is made vertically along the posterior border of the fibula down- ward, turning at the tip of the external malleolus, next along its anterior border i^ centimeters, and penetrating every- where down to the bone (hook-shaped incision. Fig. 821). 2. With the raspatory and the eleva- tor, the periosteum, in connection with the skin, muscles, and sheaths of the tendons, is detached at the anterior and posterior surface from the bone until the metacar- Fig. 821 pal or chain saw can be inserted behind the fibula at the upper end of the incision (Fig. 822). The tendon sheath of the peroneus longus muscle must be preserved if possible. 3. The fibula is sawed through ; the sawed-off portion is grasped with bone forceps, gradually drawn forward more forcibly (Fig. 823), and detached from the interosseous ligament ; finally, from within and above, the posterior ligament of the external malleolus (the inferior, very firm end of the inter- osseous ligament. Fig. 824), and the three strong accessory ligaments 422 SURGICAL TECHNIC Fig. 822. Exterior Side of the Left Articulation of the Foot (according to Henke) FibiUa lig. inteross^ lig. malleoli ext. post. lig.fib.calcan. Tibia Calcaneus Fig. 823. DisARTicirLATiox of the Lower Fig. 824. Ligaments of the Ankle Joint Extremity of Fibula (Posterior side) « lig. deUdd. lig. tali fib. post. THE TREATMENT OF WOUNDS 423 (Fig. 825) (the talofibular ligaments and the caicaneofibular ligament) are cut close to the malleolus. 4. The foot is then placed upon its external side ; around the inferior border of the internal malleolus a semilunar incision 3 to 4 centimeters in length is made (Fig. 826), and from its middle a vertical in- cision 5 centimeters long as- cends upward over the inner side of the tibia (anchor incision). Fig. 825. Ligaments of the Ankle Joint (Outer side) Fig. 826. Incision upon the Internal Malleolus (Anchor incision) 5. The incisions penetrate through the periosteum down to the bone. The periosteum is elevated ivitJi the skin from the inner surface in the form i. Achill.— lig. tibio-naviciiL m. tib. post..- m. flex, dig.— m. jtex. hal.— art. tib. post.-- Fig. 827. Inner Side of the Ankle Joint (according to Henke) of two triangular flaps (Fig. 827), tuith the tendinous sheaths of the dorsal flexors from the anterior surface, zvith the tendinous sheaths of the plantar 424 SURGICAL TECHNIC flexors from the posterior surface of the tibia, and, finally, the deltoid liga- ment is cut off from the margin of the malleolus (Fig. 828). 6. At the upper end of the longitudinal incision, the tibia is sawed through with the metacarpal saw or the chain saw (in an oblique direction on account of the limited space); the sawed-off portion is grasped with bone forceps ; and, while the elevator retracts the periosteal surface of the inter- osseous ligament from above, it is gradually rotated out of the wound. The protection of the interosseous membranes is of especial importance for the subsequent regeneration of the bone {von La}igcnbtxk). 7. The bone is then held only by the anterior and posterior insertions of the articular capsule. They are divided with the knife, but the tendon of the tibialis posticus must not be injured. 8. If the superior articular surface of the astragalus is to be removed, the excision is made with the metacarpal saw ; in the direction of the semilunar skin incision, the trochlear surface is sawed off from before backward, while the plantar surface is pressed firmly with both hands upon the plate of the table. ( Von Langcnbcck advises saw- ing off from the first incision the superior articular surface of the astragalus directly after the division of the fibula, but not to the detached bone until the articular end of the tibia has been excised.) 9. If the astragalus is severely comminuted or splintered as far as and into its tarsal articular surfaces, or diseased, the whole bone must be removed. (The modern treatment of comminuted gunshot fractures of joints does not justify primary resection or even extraction of the fragments. Such injuries are repaired m a most satisfactory manner by conservative treatment under strict antiseptic precautions.) 10. For this purpose, the vertical incision is extended on the inner side from the tip of the internal malleolus in a downward convex curve and par- allel with the tendon of the tibialis posticus as far as the tuberosity of the scaphoid bone; the tendon of the tibialis anticus and the anterior tibial Y\Q. 828. Ligaments of the Ankle Joint (Inner side) THE TREATMENT OF WOUNDS 425 artery are retracted outward, the tibionavicular ligament (Fig. 827; and the astragaloscaphoid ligament (Fig. 828; are divided, and the joint is opened over the scaphoid bone from above inward. 1 1. On the outer side, the incision is carried from the tip of the external malleolus horizontally over the sinus tarsi; its firm masses of ligaments are divided (the anterior talofibular ligament and the external and internal astrag- alocalcaneal ligaments (Figs. 825 and 828), and, finally, by rotating the bone out of the joint with the elevator the remaining portions of the articular capsule. 12. After careful ligation of all the bleeding blood vessels, a short drain- age tube is inserted on both sides as far as the division of the bone, and the wound is united by the suture. 13. If the entire astragalus is to be removed, it is advisable to drive in a long nail through the os calcis into the tibia from the plantar surface, to effect fixation between the bones at a right angle to one another. 14. After applying the usual dressing, the limb is placed upon a ]^olk- 'tnann splint with the foot placed at a right angle; in cases where great sup- puration necessitates a frequent change of dressings, the interrupted or arch splints fsee Figs. 225, 229, 234) will meet the additional indications. Opening of the ankle joint by konig's two anterior lateral inxisioxs is also applicable in many cases. 1. The internal incision begins 3 to 4 centimeters above the ankle joint over the tibia, to the inner side of the extensor tendons, and extends along the a7tterior malleolar border to the tuberosity of the scaphoid bone ; the external incision begins at the same level as the internal, and extends over the anterior malleolar border to the sinus tarsi (joint line; at a level with the astragalonavicular articulation. The articulation is opened directly by these incisions. 2. The bridge of soft parts formed between these two incisions is elevated from the underlying bones, tibia, and astragalus with the knife and the elevator, and the anterior synovial bursa is extirpated, if it is diseased. 3. While the bridge flap is strongly elevated with a blunt retractor, the foot being in dorsal flexion, the entire anterior field of the articulation can be well inspected, and diseased portions are removed with the chisel or the sharp spoon. The astragalus can easily be extirpated. If the removal of the malleolar ends is necessarv, first the external lamellse are detached 426 SURGICAL TECHNIC with a broad chisel applied obliquely ; next, the articular end of the tibia is removed with the chisel, and, finally, also the astragalus, or at least its trochlear surface, is chiselled away or sawed off. 4. By strong extension of the foot, the posterior capsular wall becomes, finally, accessible for extirpation. For a better inspection of the articular cavity, such methods are practical, which, after the division of the soft parts, permit inversion of the foot suf- ficiently so that the articular surface of the astragalus and the tibia can be surveyed with one glance. For this purpose, the articulation is opened by kocher's external lateral transverse incision I. An external incision is made at a level with the line of the ankle joint from the outer border of the extensor tendons {Ec) in a curve across the tip of the external malleolus as far as the tendon of Achilles (Fig. 829). Fig. S29 2. After division of the fascia, the extensor tendons and the peroneus tertius (/) are drawn inwardly. The capsule of the joint and the ligaments are detached from the anterior border of the tibia and the fibula and closely around the external malleolus. 3. At the posterior border of the malleolus, the sheath of the peroneus muscles is opened upward as far as and over the line of articulation ; the tendons of the peronei {P) are forcibly retracted backward, or, if sufficient space is not created thereby, divided (and subsequently united by suture). The external saphenous nerve (S) passing behind these tendons must be protected as far as possible. 4. Next, the posterior wall of the sheath of the extensor tendons and the capsule (k) on the anterior and posterior border of the tibia are detached as far as the internal malleolus. THE TREATMENT OF WOUNDS 427 5. The foot can then be dislocated by a strong lever movement across the internal malleolus toward the median line, so that the internal border of the plantar surface lies in apposition to the inner side of the leg, and is directed upward (Fig. 830). 6. If from the projecting tip of the inter- nal malleolus the ligaments are carefully detached, all parts of the articulation can be freely inspected, and all diseased parts can be removed, and the astragalus can easily be resected. If the astragalus is to be saved the operator has to guard against opening the astragalocalcaneal articulation on the posterior and lateral circumference of the astrasralus. Fig. 830. Kocher's Resection of THE Ankle Joint BY GIRARD S EXTERNAL OBLIQUE INCISION I . The external incision begins on the external side vertically above the tip of the external malleolus between the tibia and the fibula, and descends obliquely downward as far as and over the tip of the malleolus, meeting an oblique incision extending from the external border of the tendon of Achilles, past the tip of the exter- nal malleolus to the tendon of the peroneus tertius (Fig. 831). 2. The tendons of the peroneus longus and brevis are exposed and divided between two silk ligatures ; the skin flaps are dissected back until the ankle joint and the astrag- alus are exposed. Fig. 831. Girard's Resection of Joint the Ankle 3. The capsule of the joint is divided and detached with the ligaments so that the foot can be strongly supinated. 4. The astragalus can then be extirpated without any difficulty, and, if nec- essary, the foot can be adducted sufficiently to expose the joint cavity freely, when all diseased tissue can be removed through the large gaping wound. 5. Finally, the foot is replaced into its normal position, the divided tendons are united by sutures, the cavity of the wound is drained, and the external incision is sutured. 428 SURGICAL TECHNIC Fig. 8^,2. Lauenstein's Method of opening Ankle Joint Laiienstein opens the ankle joint by a long curved incision on its outer side, extending from the middle of the fibula over the external malleolus, across the heads of the extensor brevis digitorum and behind the tendon of the peroneus tertius in front, to a level with the astragalonavicular joint (Fig. 832). The skin is dissected off in front and behind, the fascia at the anterior border of the fibula is divided, the ankle joint is opened in front of the external malleolus. After elevation of the extensor tendons, the ligamentum cruciatum is divided, and the anterior capsular insertion is detached as far as and over the middle of the tibia. Next, the fascia is divided on the posterior border of the fibula, and the sheath of the peroneal tendons, which, together with the other muscles, is drawn backward with a blunt retractor. If next the talofibular and calcaneo- fibular ligaments are divided, the surfaces of the ankle joint can be conveniently separated by strong supination, and all visibly diseased parts of the joint can be removed. KocJicr uses recently a similar incision. Hnetcr exposed the ankle joint by an anterior transverse incision from one malleolus to the other (Fig. 833), whereby all tendons and nerves are divided ; at the end of the opera- tion, these are united by sutures. This method, it is true, affords a very good survey of the diseased articulation, espe- cially of tJie astragalus, but it produces very considerable accessory injuries, which are avoided by making lateral incisions. RESECTION OF THE ASTRAGALUS Fig. 833 Hueter's Resec- tion OF Ankle Joint can be made by one of the incisions for resection of the ankle joint; it is simpler and more conservative, however, if the astragalus alone is to be extir- pated, to make VOGT's anterior LONGITUDINAL INCISION over the ankle joint parallel with the extensor tendons as far as the astragalonavicular articulation (see Fig. 822). THE TREATMENT OF WOUNDS 429 1. Subcutaneous cellular tissue, fascia, and crucial ligament are divided ; the extensor tendons, separated in a bundle, are elevated and drawn forcibly toward the median line; the extensor brevis digitorum is incised and retracted. 2. After division of the capsule and detachment of the insertions of the ligament, the neck and head of the astragalus are exposed by a transverse division of the astragalonavicular ligament. 3. A transverse incision is now made from the longitudinal incision, ex- tending to the tip of the external malleolus, and the soft parts are divided in layers down to the astragalus without injuring the peroneal muscles. 4. After division of the anterior and posterior astragalofibular ligament and the ligaments of the sinus tarsi, with the foot strongly supinated, the astragalus can be turned very much outward by traction with resection for- ceps, and after detaching the internal lateral ligament and the connection with the OS calcis, it can be removed. 5. After disarticulation of the bone all diseased portions can be inspected and removed from the articular cavity ; the wound of the skin is sutured, and since the articulation of the os calcis very well fits into the bifurcated upper articular surface of the joint, the patient subsequently walks very well in spite of the missing astragalus. RESECTION OF THE OS CALCIS BY OLLIER's external ANGULAR INCISION 1. The incision extends from the external border of the tendon of Achilles, beginning 2 centimeters above the external malleolus, down to the inferior margin of the os calcis, and, turning from here at a right angle, forward along the inferior bor- der of the os calcis as far as the base of the meta- tarsus (Fig. 834). 2. Under protection of the peroneal tendons the incision is 'extended everywhere through the perios- teum down to the bone ; then the soft parts are ele- vated everywhere on its outer, lower, posterior, and ^^^' ^^^' O^lier's Resec- . ^^ , TION OF THE Os CaLCIS mner surfaces. Next, the connection of the bone with the cuboid and astragalus is divided, and finally the ligamentous con- nection with the scaphoid and the cuboid bone. 3. The wound of the skin can be sutured in its whole extent. A drain- age tube is inserted in its most dependent angle or into a buttonhole cut expressly for this purpose. 430 SURGICAL TECHXIC GUERIX S SPUR INCISION encircles first the plantar surface of the heel in the form of a curve; a small vertical incision extends from the transverse incision in the median line and ascends over the tendon of Achilles (Fig. 835). A'oc/^er excises the os calcis from a similar incision, which extends from the tuberosity of the fifth metatarsal bone parallel to the plantar surface around the heel and extending upward on the inner side in the form of a right angle along the internal bor- der of the tendon of Achilles (Fig. 836). Landerer makes a pos- terior median incision from the tendon of Achilles across the heel into the plantar surface. On the whole, the pro- cedure is the same as described on the preceding page. In inflammations and in necroses it is rather easy to detach the perios- teum everywhere ; but if the operation is performed for tubercular foci it is simpler and just as useful to scrape out thoroughly with the sharp spoon the spongy softened bone tissue, and to leave in position only a thin cortical layer together with the periosteum. The success of this operation is very good if the whole cavity is allowed to be filled with blood at the end of the operation. TARSECTOMY Fig. 835. GtiRiN's Spir Incision ¥\G. S;6. Kucher's Resection of the Os Calcis RESECTION OF THE REMAINING TARSAL BONES in tubercular diseases. This must be made in an entirely atypical man- ner, and by an incision which affords free access to the diseased bones and ligaments ; it must aim at the complete removal of every vestige of disease. BardenJiencr proceeds as follows : A t7-ansverse incision across the dorsum divides all soft parts and tendons down to the bone. The tendons, however, leading to the great toe can be saved in most cases. After the bones have been sufficiently cleared, they are divided transversely in front and behind the diseased part, together with the periosteum, with the saw or with the hammer and chisel, and detached from the soft parts of the plantar surface. Any remaining articular surfaces must be vivified to expedite the THE TREATMENT OF WOUNDS 43 1 healing process. The large wound is then packed with iodoform gauze ; the resected surfaces are brought in contact later, or the external wound is at once sutured, and the bone surfaces are held firmly pressed against each other by the dressing. After healing has taken place, it is true the foot is somewhat shorter, but very well adapted to walking (see also Fig. 704). The posterior parts of the tarsus can be made accessible also by a median incision, according to Landerer. Obalinski forms a way from before by splitting the part of the foot in front of Chopart's joint between the third and fourth metatarsus and by extending the two halves. OSTEOPLASTIC RESECTION AT THE TARSUS ACCORDING TO MICULICZ-WLADIMIROFF In extensive injuries of the posterior part of the tarsus as far as the ankle joint, as well as in large defects or ulcers of the skin on the dorsum of the foot, the anterior part of the foot can be saved by this operation, and union between the resected bones is secured in talipes equinus position, so that the patient can walk on the heads of the metatarsal bones. It is made in the following manner : — r. A transverse incision, beginning at the internal border of the foot in front of the tuberosity of the scaphoid bone, and ending at the external border behind the tuberosity of the fifth metatarsal bone, divides the soft parts of the plantar surface down to the bone (Fig. 837). 2. A second transverse incision made above the os calcis from the posterior border of the internal malleolus to the posterior border of the external malleolus divides the tendon of Achilles, together with the other soft parts, on a level with the tibiotarsal articulation. 3. The ends of these two transverse incisions are connected by two incisions extending on both sides obliquely from behind, above, forward, and downward, penetrating directly down to the bone. 4. With the foot in the hyperextended position the posterior portion of the capsule and the lateral ligaments of the tibiotarsal articulation are divided. 5. The astragalus and os calcis are carefully freed from the soft parts of the dorsum of the foot, and disarticulated at Chopart's joint. 6. The malleoli, with the articular surface of the tibia, and subsequently also the articular surfaces of the scaphoid and cuboid bones, are sawed off (Fig. 838). 432 SURGICAL TECHNIC 7. All divided vessels, especially the posterior tibial artery and the peripheral ends of the external and the internal plantar arteries, are carefully ligated. Fig. 8j7 Fig. 8-,S Fig. 839 Fig. 840 Miki-licz-Wladimiroff's Osteoplastic Resection of the Astragalus 8. The foot is placed in a strong equinus position, the sawed surfaces of the cuboid and scaphoid bones are brought in contact with the resected sur- faces of the bones of the leg, to which they are fastened, either at once with strong catgut sutures, or after the union of the wound, by long steel nails driven in obliquely (Fig. 839). THE TREATMENT OF WOUNDS 433 9. The tendons of the plantar flexors are divided subcutaneously, so that the toes can be placed in rectangular dorsal flexion. 10. With deep catgut sutures the abundant soft parts of the dorsal surface are brought together in folds, and next the margins of the wound are united by superficial sutures, leaving sufficient space for drainage. Figure 840 shows the appearance of the stump. If the surgeon desires to make this extensive tarsectomy on account of disease of the tarsus (the skin being healthy), then the skin of the heel need not be sacrificed, if a long external curved incision is made, from which all parts can be made accessible. OPERATIONS FOR CLUBFOOT The treatment for clubfoot by mechanical appliances requires persever- ance and conscientiousness, as well on the part of the surgeon as on that of the patient. Mild cases can be improved gradually during the first years of life by applying splints {Little, Konig s plastic splints). Under some circumstances the deformity must ht forcibly corrected by compressing the bones on the outer side, and bv lacerating the ligaments or bone inser- tions on the inner side of the foot. This is done by a forcible pronation (lowering of the internal border of the foot), followed by dorsal flexion and abduction. The foot vields with a distinct cracking noise. With the foot held in the corrected position, a plastic splint is applied for 2 to 3 weeks. This treatment is essentially aided by massage and active and passive movements. In some cases it is necessary to perform tenotovij' of the tendon of Achilles and of the supinators. In the great majority of cases, with some patience and repetition of this procedure, even in difficult cases, success may be obtained. Concerning Tenotomy according to Phelps see page 292. In chronic or recurrent clubfoot of adults, the surgeon, however, is often obliged to attack the bone itself : by the simple or cuneiform osteotomy on the external side of the tarsus, osteotomy of the tibia and fibula above the ankle joint (see page 30S), extirpation of the astragalus (see page 428), or of the cuboid bone, or of several tarsal bones. Prince made cuneiform excision of the tarsus (^tarsectomy) through a trans- verse T-incision over the most prominent part on the external side. The soft parts are divided down to the bone, and close to the retracted margins of skin a straight chisel is driven obliquely through the ankle joint toward the inte- rior side, so that, after removal of the wedge-shaped piece of bone, the front part of the foot can be placed in the normal (abducted) position (Fig. 841). 434 SURGICAL TECHNIC Phelps obtained the same result in an opposite manner by dividing all tense resisting structures at the internal border and plantar side of the foot. (Phelps insists that all resisting structures should be divided until the foot can be brought in proper position. He does not hesitate to cut nerves and blood vessels in the line of incision, or ^ to open the tarsal joints.) 1. After a previous tenotomy of the tendon of Achilles, a transverse incision is made at the inter- nal border of the foot, parallel to the astragalo- navicular articulation. Fig. 841. Cuneiform Iarsectomy T-^• • 2. Division of the plantar fascia, of the flexor longus digitoram, of the flexor longus hallucis, of the abductor hallucis, and if necessary of the flexor brevis digitorum pedis. These are drawn forward one after the other with a strabismus hook and divided (Fig. 512). 3. Sometimes the division of the deltoid ligament and the chiselling through of the neck of the astragalus are necessary. 4. The foot is placed in its normal position ; the wide gaping wound is tamponed ; and immediately a plaster of paris dressing is applied, under which the wound must heal by granulation with a broad cicatrix. During the after treatment passive movements and massage are made daily, and the foot is kept in its corrected position by strips of adhesive plaster, subsequently by a rubber tube. • OPERATIONS FOR FLATFOOT In flatfoot good results are obtained by restoring the arch of the foot to normal by manual force, and by fixing the foot in the corrected position by removable plastic dressings, followed by passive motion and massage. It is absolutely necessary that patients treated in this manner should wear shoes or boots, the inner margin of the sole of which has been raised, and are sup- ported by a metallic sole which supports the feeble plantar arch. In the wear- ing of common shoes, this can also be effected by insertiiig layers of soft rubber. In aggravated cases, Trendelenburg s supramalleolar osteotomy (page 146), or OGSTON's ARTHRODESIS OF THE ASTRAGALONAVICULAR ARTICULATION is indicated. I. The foot is placed upon the external side, and the articulation between the astragalus and the scaphoid bone is located. It lies a little farther in front than in the normal foot. THE TREATMENT OF WOUNDS 435 2. The external incision is made parallel to the plantar surface, begin- ning at the inner side, 3 centimeters in length and a finger's breadth below the tibia down to the bone. 3. From the gaping articulation, the astragalonavicular ligament, to- gether with the capsule of the soft parts, is detached from the scaphoid bone and turned downward. 4. With a small flat gouge, the cartilage and the thin layer of bone are cut off from the two articular surfaces, until the surfaces in a normal posi- tion of the foot can be brought in accurate contact ; in old cases, the lower eminence of the astragalus must also be removed. 5. With a fine drill, two perforations are made from the scaphoid bone into the astragalus about 2 to 3 centimeters deep, the first penetrating on the upper and inner side, the second on the lower internal side of the scaphoid bone. Two ivory pegs of the thickness of ivory knitting needles are driven into these perforations. The projecting ends of the pegs are nipped off wnth the bone-cutting forceps, and the wound sutured over them. To secure firm, bony consolidation between the bone surfaces it is neces- sary to confine the patient to bed from 3 to 4 months. RESECTION OF THE KKEE JOINT BY TEXTOR's anterior CURVED INCISION 1. With the knee flexed at a right angle, an incision (Fig. 842) is made from the posterior border of one epicondyle to the other in a curve extending to the tuber- osity of the tibia, dividing directly the liga- ment of the patella and the anterior wall of the capsule of the joint. 2. Under increased flexion of the leg, the two lateral ligaments and next the crucial ligaments (Fig. 843) are cut off from the femur; the joint is then opened widely. 3. By careful incisions always di- rected toward the bone, the posterior capsular wall is detached from the fe- mur (Fig. 844). By incisions made care- FiG. 842. Textor's Resectiox of the Knee Joint 436 SURGICAL TECHXIC lessly in a backward direction, the large blood vessels in the popliteal space may be injured. 4. The articular surface of the femur is forced forward, and, as far as it is covered by cartilage, sawed off parallel to its articular surface. 5. In the same manner the articular end of the tibia is sawed off without injuring the fibular articulation, which, as a rule, has no connection with the knee joint. 6. The patella is detached and cut off from the extensor tendon. The upper recess of the synovial sac (bursa extensorum) must be carefully dis- sected out, if diseased. Fig. 843. Crucial Ligaments OF THE Knee Fig. 844. Position of the Popliteal Artery and Vein behind the Surface of the Wound (The best incisions for exposing the knee joint for arthrectomy, typical and atypical resections, is by making Hahn's curved external incision with the convexity directed upward reaching the upper border of the patella and von Volkmann's transpatellar section.) 7. If the patella is in a healthy condition it can be nailed upon the con- dyles after its cartilaginous surface has been sawed off. 8. Since, in typical resection of the knee joint, it is of prime importance to secure bony consolidation with the limb in a useful position, the sawed THE TREATMENT OF WOUNDS 437 surfaces of the bone must be coaptated accurately upon each other, in which position they must be properly immobilized. 9. For this purpose, with a fine bone drill i^\^. 567), with a perforation at the point, both bone ends can be perforated obliquely at several correspond- ing places, and strong catgut ligatures or silver wire can be drawn through the perforations with the drill, with which the bone ends are approximated and held in proper position. 10. According to Hahn, it is preferable to nail the bone ends, by insert- ing, after the union of the wound and before applying the dressing, long nickel-plated or silver-plated steel nails (Fig. 571) (of which various sizes must be on hand) on both sides of the femur through the skin and by driving them ob- liquely through both bones with the hammer (Fig. 845). (Direct fixation of the resected ends by suturing, or bone or metallic nails, is seldom necessary if the wound is closed by buried and superficial sutures and a proper fixation dressing is applied.) 11. If the wound heals by primary intention, bony consolidation is firm where the dressings are removed in the fourth or fifth week ; the nails, having become loose in the meantime, can be extracted by slight rotary movements without great difficulty, and the small punctured openings heal in a few days. Especial care must be bestowed upon the sazuing and coaptation of the bone ends, as mentioned above. In order to secure a firm anchylosis, various methods (described on page 146) of using the saw have been devised. The straight sawing off with subsequent nailing in most cases offers good prospects of success. But if, according to Kocher, the articular ends are sawed off with a small saw in a ligJit curve, the nailing can be obviated, since a lateral dislocation is less to be apprehended. Hclferich, likewise, in resections for angular anchy. losis, sawed out a curve-shaped w^digo. (Fig. 846). (The first one to suggest and practise concavo- convex section of the articular ends in resection ot the knee joint was Professor Fen wick, of Montreal, Canada.) (The step bone section and impaction of the resected ends are not appli- cable to this joint, as they require too much loss of healthy bone tissue.) Fig. 845. Nailing the Resected Knee Fig. 846. Helper I ch's Method of Sawing out A Curve-shaped Wedge 43S Sl'RC.lCAL TECHXIC It the sawed surfaces are of unequal size, the fosffrior edges must be fitted to each other, because a projecting sharp bone edge in the popliteal space might cause erosion (wearing away) of the popliteal vessels. 12. For draina^v of the resected knee joint, two short drainage tubes should be inserted, one on each side, into the angle of the wound, and a third tube, which is introduced in front into the eminence of the bursa extensorum (upper synovial recess). V>\ the use of deep (buried) catgut sutures, which are applied before the closure of the external wound at various places, the operator endeavors to avoid as much as possible dead spaces in the depth of the wound. If all di\ii,!cil bUmd vessels, which, in a careful and bloodless operation, can easilv be recognized as such, have been most carefully ligated, drainage tubes can be dispensed with and ///«" iUii^h's of tJic ii.'0!iiid can be left to gape. 13. Of especial ini[H>rtance are the dressings, which hold the bones securch' in their jiositiiMi, compress the winind cquall\' on all sides, and pre- vent the entrance of bacteria. When thev lultil these indications they can remain \\\ f^'aee until the wound has healed, from 5 to 6 weeks. 14. \'ery useful is 2. fad dressing {sqc page 43), which is ap[ilied in the position illustrated in Fig. 44, as follows : — 15. F"irst, in all jilaces where the soft parts can be decplv depressed with the t'mgers, small paJ.s or gau/e ctimpresses are applied, and over them a moderatelv large cushitMi, encircling on all sides the whole region of the knee joint. Below the dressing, the leg is en\eloped with aseptic cotton as far as the malleoli, and above as far as the elastic constrictor at the base of the thigh ; the dressing and the cotton are then tirmly bandaged with a sterilized gauze bandage. Fk;. S47. l-"l.O\VKK-l\H' rKELl.lS .\S .\ SiUlM AmiKU .XKIKK RksKCTION OK TUK KNKK JoINT 16. Over this inner dressing, a well-disinfected flower-pot trellis is applied (Fig. S47), and fastened upon it with gauze bandages. This gives such firm- TH] TREATMENT OF WOUNDS 439 ness to the dressinzTS that the limb can be raised at the heel without affecting the position of the resected bones. 17. Over this, a large external cushion is applied, encircling the whole iniemal dressing, and is fastened with moist starched muslin bandages. iS. Next, the limb is very carefully placed upon a flat splint (see Figs. 155, 160, 163, 222), on which the padding must be so distributed that the parts not bandaged are well supported, and especially in a way that does not subject the heel to harmful pressure ; it is then fastened with moist muslin bandages, after the constrictor has been removed. 19. At the same time, the leg is raised perpendicularly to diminish the blood supply at the seat of operation, and after the patient has been carried to his bed, the elevated position is maintained for several hours. By due attention to details the loss of any considerable quantity- of blood can nearly always be prevented (compare pages 2 3 2-2 3 3\ If, however, the bleeding vessels have not been carefully ligated, the blood which oozes out may, several hours after the extremits^ has been lowered, penetrate the dressings and appear at the posterior surface. (This can be seen at once in fenestrated wire splints (Figs. 160, 164), while with tin splints (Fig. 155) it does not become \-isible until it has reached the superior posterior border of the splint.) In such a case, the outer dressing must be changed without dela}*. After di\'ision of the outermost bandage, the leg is lifted out of the splint; the external large cushion is removed and replaced bv a new one, and the limb is again placed on the repadded splint. (In such cases the ad\-antage of the inner wire splint is especialiv obvious, since it enables a change of dressing without causing pain to the patient and without changing the relative positions of the resected bones. ) In cases where, aside from a disease of the bones, an extensive capsule of the joint is extensively involved, especially the bursa extensorum, it is advisable to make the resection by E. hahn's curved ixcisrox with the convexit}* directed upward. The incision extends from the inner side of the line of articulation in a cur\'e upward, divides the tendon of the quadriceps above the patella, and ends at the outer border of the line of the joint (Fig. 84S ). F1G.&4.S Hah>-"s CrR\-ED Ivct- SIOX FOR RESECTTXG THE K>~EE To EST 440 SURGICAL TECHNIC The upper recess of the articular capsule is directly exposed after the flap has been turned down, and can be extirpated with ease. It is advisable to proceed here as carefully as in the extirpation of a malignant tumor, and to enucleate the capsule from its surrounding parts, if possible, " in toto." To protect the tendinous extension apparatus of the knee, after the divi- sion of which a perfect union rarely occurs, it is advisable, more especially in children, to expose the articulation by VON volkmann's transverse incision through the patella 1. The incision extends transversely from the anterior surface of one epicondyle across the centre of the patella to the other, and opens the articu- lation on both sides of the patella, which is at once sawed or cut through upon the forefinger placed under it ; its halves are drawn upward and down- ward with retractors. 2. After division of the lateral and crucial ligaments, the articular end of the femur is sawed off ; next, the articular surface of the tibia is fo'rced forward into the wound, then cut around with a strong scalpel and resected. At the completion of the operation, the bone surfaces are placed in ap- position, and the patella fragments are united with catgut. In 14 days they are firmly united. In more extensive resections and in diffuse infiltration of the soft parts, it is necessary to make on both sides of the transverse incision two small longitudinal incisions (| — | incision). VON LANGENBECK'S SUBPERIOSTEAL RESECTION BY A CURVED LATERAL INCISION does not afford the same advantages of inspecting the interior of the knee joint ; it should be made use of only in injuries of the joint. 1. On the inner side of the extended joint, a curved incision, 15 to 18 centimeters in length, is made, beginning 5 to 6 centimeters above the patella over the internal margin of the rectus femoris muscle, extending with its convexity directed backward over the posterior border of the internal epicon- dyle, and ending at the internal side of the crest of the tibia 5 to 6 centimeters below the patella (Fig. 849). 2. In the upper part of the wound lies the vastus internus, under which the tendon of the abductor magnus presents itself ; in the lower part, the tendon of the sartorius muscle is visible ; neither of these tendons must be injured (Fig. 850). THE TREATMENT OF WOUNDS vastus rectus 441 sartor, add. magn. ;kf — gracilio ^ semimemir. •-aemitendin. Fig. 849 Von Langenbeck's Curved Incision FOR Resection of the Knee Joint Fig. 850 IxNTERioR Side of the Knee Joint 3. The internal lateral ligament is divided in the line of the joint; the internal capsular insertion is detached from the anterior border of the internal condyle as far as and beneath the vastus internus ; likewise the in- ternal alar ligament, from the anterior border of the tibia to the median line (Fig. 851). 4. The knee is flexed ; and while it is slowly extended, the patella is dis- located outward by strong direct pressure. 5. The crucial ligaments are divided; in detaching the posterior crucial ligament from the intercondyloid eminence of the tibia, the internal condyle must be rotated forward. 6. The external lateral ligament, together with the neighboring capsular portions, is detached by a semilunar incision, made a few lines below the epicondyle of the external condyle (Fig. 852). 7. The articulation gapes widely ; the posterior capsular wall is divided ; the articular ends of the femur and the tibia are brought forward from the wound one after the other, and as much as appears necessary is excised with the saw. 8. If the patella is to be removed, the border of its cartilaginous surface must be circumscribed with the knife, and then freed with the raspatory and the elevator from its periosteum, so that the latter remains in connection with the ligament of the patella and the extensor tendon. 442 SURGICAL TECHNIC Before the wound is united, a large drainage tube is inserted into the most dependent part of the wound. It is well to make a small counter opening on the outside, from which the other end of the drainage tube is Fig. 851. Ligaments ok the Right Knee Joint (Interior side) Fig. 852. Ligaments of the Right Knee Joint (Exterior side) allowed to project, and to carry a drainage tube through the upper bursa of the articular capsule. The knee joint is opened in a similar manner by HUETER S INTERNAL LONGITUDINAL INCISION 1. With a strong knife, the knee being extended, a longitudinal incision is made from the superior border of the inner condyle along the anterior bor- der of the lateral ligament, across the head of the tibia, to the insertion of the sartorius muscle. The soft parts are divided down to the bone ; a few fibres of the vastus internus muscle are divided in the upper angle of the wound. 2. The lateral internal ligament is divided by a transverse incision, and the articular capsule is thereby opened. 3. Next, the capsular insertion is detached from the anterior part of the internal condyle to the superior border of the articular surface with a probe- pointed knife, and the vastus internus is elevated from the bone. THE TREAT.MENT OF WOLWDS 443 4. After the internal alar ligament has been detached from the anterior border of the tibia, it is easy to dislocate the patella outward. On the whole, the procedure is as described above on page 441, 4 to 8. When, after the extirpation of the capsjile alone, the bone being fairlv healthy, there is hope of preser\-ing a movable joint for the patient (arthrec- tomy, see also page 389), it is above all important to leave the tendon of the quadriceps tininjured. The transverse incision through the patella effects this only in part ; hence, it is better to detach with the chisel the tuberosity of the tibia with the patellar ligament obliquely from below upward, to turn it upward, and finally to unite it again with the tibia. Bonv union nearly always sets in in this place. Furthermore, KOCHER S EXTERIOR CURVED IN'CISIOX is to be recommended. 1. External incision a hand's breadth above the patella, beginning at the vastus externus and extending vertically downward tn^o fingers wide along the external margin of the patella in a flat curve to the spine of the tibia (Fig. 853). 2. Di\ision of the fascia lata and the border of the vastus externus in the upper angle of the wound ; in the lower angle the spine of the tibia is detached super- ficially with the chisel and reflected backward, together with the ligament patellae. 3. Upon the external condyle the articular capsule is di\dded longitudinally, and thereby the bursa extensorum is opened. 4. Next, the external meniscus is detached from the crucial ligaments, and the articular capsule, together with the periosteum, is dissected off from the external con- dyle of the tibia. 5. On the internal condyle, the operator proceeds with the meniscus and the articular capsule in a like manner, while the patella is drawn laterally with sharp hooks, so that finallv it can be inverted in an inward direction. 6. The knee is more and more flexed, the insertion of the crucial liga- ments is detached on the tibial surface so that they remain in connection with the menisci. 7. The required operation can then be made. If, a priori, the bone appears to be diseased to a greater depth, the insertions of the Hgaments Kocher's Ar- thrzctomy of the Knee Toint 444 SURGICAL TECHXIC are chiselled off subcortically with one stroke and are reposed to the place where they are to be sawed off. If only a synovial arthrectomy is required, dissect off the articular capsule (if possible unopened) connectedly from femur, tibia, and patella. 8. Finally, the capsule is carefully sutured, if it can be preserved ; the wound of the skin is closed by deep and superficial sutures ; or the cavity of the wound is packed with iodoform gauze to be united later by secondary suturing 48 hours after the operation. PUNCTURE OF THE KNEE JOINT in serous or bloody extravasation Uiydrartliros and heinarthros), is made at the superior border of the patella. On either side, a medium-sized trocar is inserted in such a direction that it comes to lie transversely between the patella and the condyles of the femur. W^ith the left hand the effusion or extravasation from the superior bursa and on the side lying opposite to the puncture should be forced and pressed toward the canula by the left hand. If the skin is very thick, it is better to make at the point of puncture a small incision with the knife, in order that the trocar may be inserted more easily. After the products of effusion have been removed, the joint is washed out with a boric solution until the escaping fluid is clear ; next, an injection of 3% carbolic solution (in hydrarthros) is made, or a i Voo sublimate solution (if the contents are purulent) (or a 10 % emulsion of iodoform if it is a case of tubercular hydrops). The puncture in the skin is then sealed with a small compress of iodoform gauze, and a compressive bandage is applied with a knee splint. For the purpose of increasing the pressure which is to prevent the return of the effusion, a rubber bandage is applied over it with moderate pressure. DRAINAGE OF THE KNEE JOINT 1. \xi pyarthrosis, to be able thoroughly to irrigate the joint with antiseptic solutions and to secure free drainage for the accumulated pus, it is sufficient in milder cases to make incisions 2 to 3 centimeters long on both sides of the patella and to insert into them short drainage tubes, which are cut off at a level with the skin, and are kept in position by a suture or by a safety pin. 2. After the joint has been thoroughly washed out through these drain- age tubes with sodium chloride solution and then with I'^/ouoi sublimate solution, an efficient compressive antiseptic dressing is applied ; this dressing, by equable continuous pressure, forces all secretions out of the joint into THE TREATMENT OF WOUNDS 445 the absorbent dressing ; the Umb is then immobiHzed in the same manner as after a resection. 3. When the temperature of the body is reduced to normal, and when the pain has subsided, the dressings can remain in place for several days ; otherwise, the dressings must be changed every day, and the antiseptic irri- gation must be repeated. 4. In more serious cases, the upper recess of the joint, the bursa extenso- rum, must be drained separately by incisions on both sides above the patella; and if the bursa has already been perforated, and the pus has penetrated beneath the quadriceps muscle, this part of the abscess cavity must also be drained by adequate incisions and the insertion of a large transverse tubular drain on a level with the upper limits of the deep-seated phlegmonous abscess. RESECTION OF THE HIP JOINT BY ANTHONY WHITE'S POSTERIOR CURVED INCISION (1818) 1. The patient is placed on his healthy side; the incision begins at the middle between the anterior superior spine of the ilium and the great tro- chanter. It is carried in a curve over the tip of the latter and about 5 centimeters downw^ard along its posterior border (Fig. 854). 2. With a strong short knife, the tendi- nous insertions of the gluteus medius and minimus, of the obturators, of the pyriform and the quadratus femoris muscles (Fig. 855), are detached from the trochanter ; and the muscular masses are drawn apart with retractors until the posterior superior sur- face of the neck of the femur and of the acetabulum is exposed. 3. A deep incision along the border of the cartilaginous limbus (border) of the ace- tabulum opens the joint ; the femur is flexed and adducted ; with a smacking noise, the head of the femur is twisted out from the acetabulum. 4. With a narrow knife, entered from behind outward into the acetabu- lum, the ligamentum teres is divided in the direction of its insertion into Fig. 854. Resection' of the Hip Joint (A. White's curved incision) 446 SURGICAL TECHNIC the head of the femur, and the latter is then delivered en- tirely from the acetabulum. 5. With a strip of zinc, placed behind the neck of the femur, the soft parts are re- tracted ; the neck of the femur is sawed through with a metacarpal Fig. 855. Posterior Side of the or chain saw, Fu;. 856. Resection of Hip Joint. Hip Joint, Muscles, and Sciatic yy^jjg ^Yiq head Sawing off head of femur with chain saw Nerve . , ^ . (Reflection of soft parts bv a strip of tin) of the femur is firmly held with bone forceps (Fig. 856). (See the following operation for the rest.) SUBPERIOSTEAL RESECTION OF THE HIP JOINT BY VON LANGENBECK's EXTERNAL LON- GITUDINAL INCISION I. With the thigh half flexed (at an angle of 45°), a straight incision is made from the middle of the trochanter in the extended axis of the thigh, about 12 cen- timeters behind and above in the direc- tion of the posterior superior spine of the ilium (Fig. 857). (Temporary osteoplastic resection of the trochanter major should always be performed as a preliminary help to re- section of the hip joint, as this part of Fig. 857. Resection of the Hip Joint (Von Langenbeck's longitudinal incision) THE TREATMENT OF WOUNDS 447 the femur is seldom the seat of disease, and its preservation adds much to the functional result of the operation. After completion of the resection, it is united with the shaft of the femur by a number of buried heavy catgut sutures.) pyriform. ohturat. int. — ilio-psoas — cruralis ilio-psoas pectinaeus adductor brevis — glut. med. -i|#- quadrat, fem. glut. max. adductor magnua vast, int.' u Fig. 859. Posterior side Insertions of Muscles on the Upper End of the Right Femur 2. The incision penetrates between the bundles of fibres of the gluteus maximus muscle, and divides the femoral fascia and the periosteum of the trochanter. 3. While the margins of the wound are well retracted, all the muscles inserted on the trochanter (on the anterior surface, gluteus minimus, pyri- form, obturator internus, and gemelH, Fig. 858; at the posterior surface, 440 SURGICAL TECHXIC gluteus medius and quadratus femoris, Fig. 859) are detached with the knife from the same ; but their connection with the femoral fascia and the perios- teum should be carefully preserved. This tedious step of the operation can be greatly facilitated by detach- ing (according to Konig) by two incisions with the chisel the corticalis of the anterior and posterior borders of the great trochanter, without divid- ing at the same time the periosteum of the lower border of the incisions and by breaking off the lamina on both sides by lever movements of the chisel. The triangular middle portion of the trochanter which remains is excised by a transverse chisel section at its base, whereupon the neck of the femur is freely exposed. 4. With a strong knife a longi- tudinal incision is made upon the neck of the femur and repeated as often as necessary, until the tough fibres of the capsule of the joint and the periosteum are completely divided. 5. From this incision the perios- teum is detached with elevator and knife all around from the neck of the femur, in connection with the cap- sule and the insertion of the obturator externus muscle (Fig. 860). 6. The cartilaginous labrum(rim) is divided, and a portion is removed with the knife on both sides. 7. The femur is then adducted and rotated inward, half of the head of the femur then escapes from the acetabulum with a smacking noise. 8. A long narrow knife is introduced into the acetabulum from behind and outward, and divides by an incision made inward and forward toward the head of the femur the tense ligamentum teres, whereupon the whole head of the femur is completely dislocated and can be sawed off as described above. 9. If the neck of the femur has been shot off, the head must be grasped and removed with the resection forceps or a sharp resection hook. 10. If the great trochanter is injured at the same time, a portion of it with the neck of the femur is removed by making the bone section obliquely. 1 1. After hemorrhage has been arrested, a large drainage tube is inserted Pig. 860. Ligaments on the Anterior Side OF the Hip Joint THE TREATMENT OF WOUNDS 449 into the acetabulum, and fastened in the middle of the wound. The remain- ing part of the wound is closed by sutures. In operations for tuberculosis it is necessary to tampon the deep wound and aim at healing by granulation. In such cases the wound is closed only in part. BY KOCHER's posterior LONGITUDINAL INCISION I. The incision extends from the base of the external surface of the great trochanter to the anterior border of the tip of the trochanter obliquely upward and forward, and then in the direction of the fibres of the gluteus maximus muscle upward and backward (Fig. 86 1, 2). Fig. Fig, Kocher's Resection of the Hip Joint, i, resection of the ilium; 2, resection of the hip joint 2. On the external surface of the great trochanter (/), the fascia of the gluteus maximus muscle is divided, and the periosteum, together with the insertion of the gluteus medius muscle, is exposed. 3. After division of the fibres of the gluteus maximus {Gm) and of the adipose layer under it, along the inferior border of the gluteus medius muscle {gmd), the superior border of the pyriform muscle (/>) is reached. If the latter is drawn downward, the posterior surface of the capsule at the pos- terior acetabular rim is exposed ; in front the gluteus medius is elevated 450 SURGICAL TECHXIC from the bone at the superior border of the tendon of the pyriform muscle, and the upper margin and external surface of the trochanter are cleared (Fig. 862). 4. Along the anterior border of the trochanter, the gluteus medius and minimus are drdiwn foi-ward ; at the internal surface, the pyriform, gemelli, the externus obturatur (0), and the periosteum are drawn together in a posterior direction. 5. After the whole posterior surface of the head, neck, and trochanter of the femur has been exposed, it is not difficult to dissect free the synovialis, as far as it is diseased, before it is opened, and to detach it from its insertion on the acetabulum and the neck of the femur. 6. With the femur strongly adducted after division of the ligamentum teres, the head is dislocated backward, when the cavity of the joint can be freely inspected and the extent of the disease ascertained. Every vestige of disease can now be thoroughly removed. 7. If arthrectomy alone is required, the capsule is directly opened with- out detaching first the muscular insertions from the trochanter {k) along the upper border of the pyriformis, and the insertions of the muscles are detached with the capsule from the neck and the trochanter. If in injuries of the hip joint (from gunshot wounds) the head or the neck of the femur is comminuted from the front or shot off, or if at the anterior side of the suppurating hip joint an abscess has formed, or if in inflamma- tion the femur alone is implicated and the acetabulum is healthy, the joint can be reached most conveniently anteriorly ; but only a limited inspection of the whole joint is thereby obtained. The joint is exposed by LIJCKE AND SCHEDE's ANTERIOR LONGITUDINAL INCISION 1. The incision begins immediately below and a finger's breadth to the inner side of the anterior superior spine of the ilium, and is made straight downward for about 10 to 12 centimeters (Fig. 863). 2. The internal margin of the sartorius muscle and the rectus femoris is exposed and drawn outward. 3. Advancing in the loose cellular tissue of the muscular interspace with the finger or forceps, the external border of the iliopsoas is found and drawn outward with a tenaculum. 4. If the leg is somewhat flexed, abducted, and rotated outward, the capsule is exposed. 5. The capsule is opened and incised upward and downward as far as possible with a probe-pointed knife. THE TREATMENT OF WOUNDS 451 6. The neck of the femur is now isolated with the elevator, and sawed through with a metacarpal saw introduced upon the forefinger perpendicu- larly to the axis of the bone (from above and the outer side to below inward). 7. The cartilaginous limbus (rim) is divided by short, deep incisions upon the acetabular border, and the head of the femur is ex- tracted with forceps or is lifted out with a spoon {Ldbker s spoon elevator, Fig. 865), after the ligamentum teres has been divided. ^jjp' Fig. 863 Fig. 864 Resection of the Hip Joint, a, according to Liicke and Schede; b, according to Hueter 11 Fig. 865 Lobker's Spoon Elevator BY HUETER S ANTERIOR OBLIQUE INCISION Hiteter has modified the procedure just described, so as to make the incision from the middle of the anterior superior spine and the trochanter obliquely downward and inward, 10 to 15 centimeters along the external border of the sartorious muscle (Fig. 864). The incision penetrates above directly down to the bone, whereby only the outermost fibres of the externus vastus are divided, but it is made more superficially in the inferior angle of the wound, to avoid the external cir- cumflex artery which passes transversely and closely beneath the trochanter. It is easier by this method than by the preceding one to remove at the same time the injured trochanter. 452 SURGICAL TECHNIC Drainage of the wound by these methods must be estabhshed from the cavity of the wound, as well as through counter openings over the middle of the gluteus maximus muscle, and on the inner side behind the adductors. Tiling made the longitudinal incision over the anterior border of the trochanter, in order to preserve the insertions of the glutei muscles, chiselled off from this incision the trochanter in connection with the periosteum and the muscular insertions, and had them drawn backward ; the capsule was then detached in front, and with the femur rotated outward the trochanter minor was chiselled off and the head of the femur dislocated. The detached trochanters are fastened again in their former position on the shaft at the end of the operation ; but they easily become necrotic if suppuration sets in. (Temporary resection of the great trochanter should precede all cutting operations for tuberculosis of the hip joint. It is unnecessary to detach the lesser trochanter. Direct fixation with catgut sutures almost invariably secures bony union.) Oilier divides the skin over the trochanter in the form of a curve, chisels the latter obliquely from without below to above within, and turns the detached piece with the skin and the glutei backward. Thereby the neck and head of the femur are well exposed. The sawed-off portion is fast- ened again to the shaft at the end of the operation (osteoplastic detachment of the trochanter). At the end of the operation, an extension dressing (see pages 50, 148) is immediately applied, and the counter extension is effected by raising the foot of the bed. In the after treatment it is very important to secure the leg in extension and abduction to guard as well as possible against undue shortening and its result, descent of the pelvis on the same side. The extending force need not be especially great, since from too much traction a useless, loose, and freely movable joint may form, whereas only a very vioderat'e motion of the new joint is desirable, which yields the best functional result. The sawed-off neck of the femur has also been firmly impacted into the vivified acetabu- lum, and thereby osseous anchylosis and a shorter period of healing have been effected. In changing the dressings, the patient is placed upon a pelvic support, while the extension dressing remains in action ; or, still better, Hase-Bcck's apparatus for raising a patient in bed is used, if one is at hand. As soon as the wound is healed, the patient is allowed to leave the bed and walk about with a plastic immobilization dressing (tutor), made of plaster of paris or starch. THE TREATMENT OF WOUNDS 453 (The best method of fixation after resection of the hip joint by any of the methods described is a fenestrated plaster of paris splint, including the whole limb and pelvis. The limb must be slightly abducted and rotated outward.) ARTHROTOMY FOR CONGENITAL DISLOCATION OF THE HIP JOINT Hoffa forms in children a new acetabulum in the following manner : — 1. After the joint has htQX\.o^^vvQ.^\)j von Langenbcck' smoAzioxviYxg. 857), all soft parts are detached subperiosteally from the great trochanter until the operator succeeds, by flexion of the thigh and by direct pressure, in reducing the head of the femur into the old acetabulum (this is impossible before the opening of the articulation, on account of the strong muscular tension). 2. For gradual extension of the shortened muscles (biceps, semimem- branosus, and semitendinosus) the femur which is flexed is slowly extended by an assistant ; in young children this succeeds in a few minutes ; in older children (after the sixth year) tenotomy of the tendons in the popliteal space, division of the fascia lata and of the muscles which have their origin from the anterior superior spine of the ilium, must be made in addition. Still, if at all possible, all vinscles shoicld be preserved. 3. With a sharp spoon (provided with a bayonet handle) the whole floor of the acetabulum, together with the connective tissue and the cartilage, is deeply excavated. The rim of the acetabulum must be carefully preserv^ed. 4. The head of the femur, which sometimes is very much deformed, receives the desired shape, with knife and chisel, and then by strong traction with the hands, or else Lorend's screw extension apparatus, can now be reduced with a cHcking sound into the excavated acetabulum, and is kept in abduction position of the leg after the wound has been dressed (tampo- nade and suture) by a plaster of paris dressing. In the adidt it is advisable, according to Konig, to detach a periosteum bone-flap from the pelvis with a chisel, to turn it downward, and unite it with the capsule by sutures. The thigh, of course, must have been ren- dered movable by a preUminary extension treatment. Aside from numerous good successes which Hoffa, Lorcnz, and Schede had with this operation, sometimes very unpleasant consequences occur (ankylosis, laceration of nerves, etc.). Hence, more recently the bloodless reposition {Lorenz) is preferred, which, in children up to the sixth year, has met with very good success. In anaesthesia, the head of the femur is 454 SURGICAL TECHNIC gradually brought down by screw traction until it catches into the acetabu- lum with a distinct dull sound {reposition). Next, the leg in strong abduc- tion, outward rotation, and flexion, is fixated by a pelvic plaster of paris dressing {rctcntioii). After a few days, the child is allowed to walk in order that through the fiiiictioiial weight the head of the femur itself deepens the acetabulum. Only very gradually and carefully should the abduction position be decreased. Concerning the correct position of the head to the acetabulum, nowadays radioscopy gives the best information. RESECTION OF THE ILIUM for caries or necrosis is best made tJiroiigJi a curved incision, extending along the pelvic border (Fig. 86i, i). The soft parts on the outer surface are detached subperiosteally from the ilium, and then as much as neces- sary is removed from the bone. From this incision also sequestra can be removed from the medullary cavity of the ilium by chiselling the external lamella of bone of the ilium along the crest and turning it downward, so that the medullary cavity is exposed for inspection {Bier). KocJier has resected even the entire half of the pelvis, together with the head of the femur. The total resection of the sacrum has likewise been attempted. Concerning the partial resection of this bone, for operations on the organs of the true pelvis, see page 780. OPERATIONS ON THE HEAD RESECTION OF THE VAULT OF THE CRANIUM Partial resection of the skull may become necessary : — 1. In injuries or diseases of the vault : — {a) For thoroughly cleansing complicated fractures of the skiill and for disinfecting the cavity of the wound. {b) For removing depressed portions of bone dangerous to life and for extracting fragnietits of bone, ox foreign bodies that have entered the skull. (f) For removing tninoi^s and sequestra {tuberctilar or syphilitic) of the cranial vault. 2. In diseases or injuries of the brain and its envelopes : — {a) For opening abscesses, foci of cerebral softening, and sinns throm- boses. (J?) For removing tumors, scar tissue, and foreign bodies. (yC) For excising a field o^ ^ _ y^ ^.-^^w the cerebral cortex mjacksonian reflex epilepsy ; for removing / chronic intracranial pressure / ^^; that is gradually increasmg. / ^-^^-Ti^ {d) For arresting intracra- / 1| ~^ nial hemorrhages — ligation of ^ the middle meningeal artery, w ^ I. In case of fracture of the cranium, when there is an outer opening smaller, as usual, than the depressed portion of bone, this opening must be en- larc^ed in order that the frao"- ^^'^' ^^^" ^'^^ppi^''^ o^^ the Osseous Margin of a Frac- '^ ^ , f. TURE OF THE CRANIUM BY MEANS OF LUER'S RON- ment may be elevated and if g^uj^ Forceps necessary extracted. This enlargement is best made by using Liler s gouge forceps (Fig. 866) or Hoffmann s rongeur forceps (Fig. 867) in cases where the outer opening is 455 456 SURGICAL TECHNIC just large enough for inserting one jaw of the forceps under the margin of the bone. By means of the forceps, small fragments are broken off from the margins of the defect, and thus the opening is readily enlarged in every direction. Fig. S67. Hoffmann's Rongeuk Forceps 2. If, instead of a large opening in the skull, there is only a small fissure, which must be enlarged, a gouge should be used — preferably the common carpenter s gouge with a wooden handle. The chisel is applied obliquely upon the margin of the bone and is driven by light short blows with a wooden mallet (Fig. 868). If the fissure has been thus carefully enlarged, so that the gouge forceps can be used, the opening is further enlarged with the same as described in paragraph i. Fk;. 868. Enlarging a Small Fissure for removing Broken-off Point of Sword As soon as the depressed substance, or the body embedded in the dura mater, is sufficiently exposed, it is raised with the elevator, grasped with dis- secting or dressing forceps, and extracted with great care. If it is lodged firmly in the dura mater, it must not be extracted with violence, but must be OPERATIONS ON THE HEAD 457 freed by an incision in the dura. If the depressed portion of bone is not completely broken through at its base it need not be removed. (Large fragments of the skidl can be saved and made useful in the sub- sequent restoration of the continuity of the skull, even when completely detached, provided the wound remains aseptic.) If a pointed metallic body, firmly impacted in the skull and broken off close to its surface, is to be extracted, by means of small cuts with the gouge (Fig. S6S) it can be made accessible from both sides, so that it can be grasped with strong forceps. In order that no exti'aneoiLS matter may remain in the wound, other foreign substances — such as hair, earth, pieces of cloth, etc., — wedged in the clefts of the fracture, must be chiselled out with the gouge. Protruding portions of the brain, unless crushed to a pulp, must not be cut off, since during cicatrization they may retract into the cranial cavity. But they should be care- fully disinfected. TREPHINING TREPHINING, THE OPENING OF THE INTACT SKULL, is performed with instruments made especially for this purpose. With these, a ciradar piece can be sawed out from the bones of the skull — trephining in a more limited sense of the word. For this purpose, a crown saw is used {trephine). The bow tre- phijie is operated with both hands, like a carpenter's auger. In most cases, however, the hand trephine {trepJiine, Fig. 869), operated with one hand only, is sufficient. With ^^^- ^^9. Hand Trephine this a piece of bone as large as a five-cent piece can be removed at one time. (Some American surgeons, chief among them Roberts, advocate the use of large trephines with which circular pieces of bone the size of a silver dollar can be removed.) 458 SURGICAL TECHNIC I. If, at the place where the skull is to be trephined, a wound in the scalp already exists, either enlarge it by an incision penetrating to the bone, or else make a seviicirciilar in- cision down to the bone, and then with the raspatory push back the periosteum together with the flap of the scalp, until the tre- phine can be applied (Fig. 870). To prevent hemorrhage, the region of the longitudinal and the transverse sinuses and that of the middle meningeal artery are avoided, if possible (Fig. 871). 2. In order that the vianipn- lation of the saw may be made more steady, the protracted cen- tre pin, tJie pyraviid, of the trephine is allowed to enter the bone. This procedure can be facilitated hy first boring a hole with a tire fond, or a common gimlet. As soon as the teeth of the saw have penetrated the bone a few milli- meters, the pin is withdrawn into the « crown. The sawing must be discontinued from time to time, partly for the pur- pose of examining with the flat end of a probe the depth of the groove, partly for the purpose of washing or brushing away the bone dust from the teeth of the saw. If the bone has been divided com- pletely at any place, the teeth must not enter farther. By an inclination of the crown of the saw, they are kept working " ^ 1 ,1 4. r 4.U • i. 1 *- -ui Fig. 871. Blood Vessels on the Inner Side only on those parts 01 the mternal table ' ., •,•.!• i- / ^ OF THE Skull, a, sinus longitudinalis; which are not yet completely divided. b, sinus transversus; c, art, mening. med. Fig. S70. Trephining OPERATIONS ON THE HEAD 459 Previously, however, a little bone screiv, Heine's tire fond (Fig. 872), is inserted into the central hole. 3. As soon as the bone disk has been freed on all sides, it is carefully Hfted out by inserting in the upper hole of the bone screw a hook bent at right angles. With this hook, also, it can be ascertained whether depressed fragments of bone are movable (Roser) ; and with it, or with a stronger elevator, or with forceps, the operator attempts to raise or remove them. If, during this operation, violent hemorrhage occurs from the abnormally dilated veins of the diploe, it is arrested by forcing into the bleeding openings a ball of carbolic wax softened in hot water, or by inserting a thick catgut thread. Hemorrhage from the branches of the middle meningeal artery can be arrested by a ball of wax, if it is impossible to grasp the divided artery and ligate it. (Spiking the arterial or venous channels in bone with an aseptic ivory or bone nail or a toothpick is a procedure which in troublesome cases can be relied upon.) Hemorrhage from a lacerated sijius is usually arrested by antiseptic tamponade, or by applying a com- pressive bandage. Most surgeons, in recent times, employ this method of trephining only in rare cases, preferring the operation zuith chisel arid hammer, whereby an opening of any size and shape can be obtained more rapidly and securely. Fig. 872. Bone Screw WITH Roser's Hook Fig. 873. Stille's Boxe-nipping Forceps Likewise, with Stille's "Knochenbeisszange," bone -nipping forceps (Fig. 873), a portion of the skull can be rapidly cut all around. (In this country the bone-cutting forceps of De Vilbiss is most popular.) 460 SURGICAL TECHNIC In hospital work a small rotating circular saw, operated by foot or electro- motor, which sets it in very rapid rotation (Fig. 874), is an instrument which lately has come into more general use. Fig. 874. Rotating Circular Saw and Electromotor TREPHINING FOR INTRACRANIAL DISEASE should be performed as follows : — 1. After a awvcd incision has been made in the soft parts, the vault of the skull, having been exposed, is opened with chisel and hammer. As it is impossible for the operator to know beforehand whether the cranial bones are thick and dense or thin and soft, he must use the chisel cautiously by short strokes ; and, after each stroke, he must ascertain the condition of the bone and the depth reached. It is best to use a sharp gouge of medium size, applied more or less obliquely. The strokes must not be made with too much force, because fissui'cs and other unintentional injuries to the underlying parts — the dura mater, the brain — or especially the so-called " Verhammerung," injury to the brain by hammering {Koch, Fi/ehne), and its consequences might ensue. These dangers are not to be feared when the circular saw is used. 2. When the dura mater has been exposed, it is best opened in the shape of a broad pedunculated flap by making an incision into the dura along the margin of the bony opening and about two millimeters in front of it ; the flap is then turned up. If the incision is made thus, any lacerated blood OPERATIONS ON THE HEAD 461 vessels can be grasped and ligated easily, since the peripheral end cannot recede under the bone {Horsley). 3. The surface of the brain is now exposed. After it has been carefully examined as to any changes — such as discoloration, fluctuation, hardness, scars, absence of pulsation — the operation on the brain itself begins with an incision made exactly vei'tical to the surface, since in this manner the blood vessels are least likely to be injured. If hemorrhage occurs, a compress of iodoform gauze is pressed upon it until it is arrested. 4. If a tumor is found, a circular incision is made around it in the healthy parts. The tumor is lifted out carefully with a knife, curved on the flat, or a spatula — Horsley uses flexible knives of soft iron ; and the cavity thus produced is tamponed. In case of cortical epilepsy, the surgeon should try first by a direct fara- dization of the surface of the brain to locate more definitely the field of the cerebral cortex involved. After this the diseased portion of the cortex is excised superficially. If an abscess is found, it is drained toward the open- ing witliont nnicJi irrigation. The shock arising from operating on the cortex can be obviated by irri- gation zvith hot water. If, in the neighborhood of a large venous sinus, its injury, together with the entrance of air, is to be feared, the danger can be avoided by double ligation, or by profuse irrigation of the field of operation. 5. The wound of the scalp is sutured, and a drainage tube is inserted. During the first days the dressings must be renewed daily. It is advan- tageous to remove the drainage tube even after 24 hoiirs ; if, after its removal, during the next few days, there appears any tension of the sutured margins in consequence of retained secretions, a small drainage opening is made with a probe between two of the sutures. In profuse hemorrhage from the brain, which cannot be arrested, it is advisable to tampon the whole wound with iodoform gauze from 2 to 3 days ; and, at the end of that time, to apply secondary sutures under anaesthesia {von Bergmanri). Craniectomy (craniotomy) {Lannelongne, Lane), the resection of portions of the vault for the purpose of creating more space for the brain, confined by a too premature ossification of the sutures and fontanelles in idiocy and microcephaliis, has been made in recent times with some degree of justifica- tion, but with varying success, when it becomes necessary to remove severe general or more or less localized cerebral affections. A long skin incision is made along the sagittal suture, — from the ante- rior to the posterior limits of the hairy scalp. The periosteum is divided 462 SURGICAL TECHNIC and pushed back on both sides to such an extent that with the chisel and the rongeur forceps (Fig. 867) a strip of bone as broad as the finger can be removed — craniectomie lineaire. The dura is not opened (Fig. 875). Finally, the skin is sutured over the groove of the bone. If necessar}', the same operation may be afterward performed on the other side. If some centres are especially involved, correspondingly large portions of the vault over them (disks) are removed in the same manner, as in resection of the skull, described on page 460. Sometimes it is advisable at the same time to remove \^& periosteum to the extent of the portion of bone to be removed for the purpose of preventing a premature closure of the opening by ossifi- cation. Pig. 875. CR-A.NIECTOMY Fig. 876. W. Wagner's Osteo- pi_\sTic Resection of the Skill Gersuny made the bone incision around the skull in the same manner as in a post-mortem, so that the whole vault could be raised in such a way as to make the vault of the skull lie movable upon the brain. After the healing of trephine wounds, although the periosteum has been preserved, the reproduction of bone to fill the opening very rarely takes place. Hence there is left in the skull a soft place covered only by skin and easily exposed to injury. A protector of some hard material should be worn to protect the opening in the skull against injury. To remedy this defect, various attempts have been made to close the opening with bone. OPERATIONS ON THE HEAD 46: OSTEOPLASTIC RESECTION OF THE SKULL The subsequent reposition of the round disks of bone as they fall out of the trephine, and the healing in of the same, have met with success only in rare cases. The procedure, moreover, is accompanied by danger, since retention of secretion in the underlying tissues may easily ensue. Macewen, therefore, fragmented the sawed-out bone disk into many smaller pieces, with which he filled the wound. Thus, in most cases, he secured healing and reproduction of bone. It is more practical, according to Semis procedure, to use decalcified bone chips, kept ready for use in sublimate alcohol. Likewise the fresh chips of bone obtained by gouging may be used for paving the exposed dura (aiitoplasty). Gerstein replaced a large fragment of bone, the result of an injury, and obtained healing with ossification. The attempt to implant celhcloid plates into the opening of the skull has also met with good success in some cases {Jieteroplasty). IV. Wagner iorms a bone flap from the portion of the skull to be opened, and turns it temporarily away from the brain like a door on its hinges. The soft parts are divided down to the periosteum in the form of the Greek letter Vt. At the margin of the somewhat con- tracting flap of the skin, he incises the periosteum and in the same line chisels through the bone. With a small, fine chisel, he first forms a gutter. This he deepens with a small tolerably thick chisel, with an oblique edge on one side, ap- plying it obliquely with bev- elled edge directed toward the margin of the defect. In the two angles only a gutter is gouged, growing deeper from without inwardly ; from this the bridge of bone still remaining is divided subperiosteally with a small chisel. The whole piece of bone can then be raised with the ele- vator and turned downward (Fig. 'i'J']^. The healing-in into the opening of the temporarily detached piece of bone is fairly well secured by the bridge, and by the uninjured condition of the soft parts covering it. When the Fig. 877. Wagner's Osteoplastic Resection of the Skull 464 SURGICAL TECHNIC operation is completed the wound is sutured and drained at only one or at both angles. Miiller proceeds in a similar manner by chiselling off only the external table of the skull {Konig), in the form of a flat disk, which he leaves in vascular connectioii with the soft parts that cover it and which is made to cover the cranial defect. Larger defects of the skull are best covered by the osteoplastic operation of Mailer and Konig as follows : — After incising the skin over the defect in the form of a broad pedunculated flap (^7), chisel out from the diploe a second reserve flap {b), lying near the first and somewhat larger, in connection with the underlying periosteum and a tJmi layer of bone. Preserve between the two flaps a spindle-shaped portion of intact skin, and over this slide the two flaps on their pedicles so that the periosteum-bone flap can be sutured over the defect. Plant the first simple skin flap over the surface of the diploe of the reserve flap. The reserve flap, placed over the opening, forms a bony covering, and in the course of time the continuity of the skull is restored. Before the surgeon decides to open the skull for intracranial disease, he must be perfectly sure as to tJie site of the diseased portion of the brain. hnportant symptoms ivJdch enable the suigeon to dctejnninc the seat of siicJi diseases are furnished by the manifestations of irritation or paralysis thereby produced {focal symptoms), concerning the origin of which, espe- cially in the cortical centres, experimental physiology and the experience of surgeons and pathologists shed more and more light. Figure 879 represents the position of the most important motor and sensory cortical areas in rela- tion to the principal convolutions and fissures of the cerebrum. By a knowledge of the cortical areas (localizations), their distribution on the brain surface, and their position relative to the outer surface of the skull, we are enabled to ascertain the exact place for the opening of the latter. Since these cortical areas are situated principally in the neighborhood of the central sulcus {sulcus centralis) and the Sylvian fissure {fossa Sylvii ), the exact location of that portion of the skull under which they are situated Fig. 878. Osteoplasty in Cranial Defects OPERATIONS ON THE HEAD 465 is imperative. The position of the other fissures and convolutions can then be judged more or less correctly. The location of the central fissure {fiss?ire of Rolando), according to Thane, is determined in the following manner : — S.praecentralis^ S.interparietalis S.parieto occipit- Fig. 879. Cerebral Topography 1, region of the oculomotor nerve. Levator palpebrae; motions of the eyeball; dilatation of the pupils; turning the head to the opposite side 2, upper extremity, a, adductors and abductors; 6, extensors; c, d, flexors, supinators, and prona- tors; e, muscles of the hand 3, lower extremity, a, flexors; b, extensors 4, facial nerve, region of the face, a, muscles of the mouth 5, speech centre and lingual motions (anteriorly, aphasia; posteriorly, region of hypoglossus) 6, visual centre. See also Tillmanns, II. I. 70, 122; Keetley, "Index of Surgery," 207, 209; Senn, " Principles," 276 From the root of the nose (glabella) to the inion (occipital protuberance), draw a line over the sagittal suture and divide it into two equal parts. From the middle of this line and 13 millimeters posteriorly from it, the Rolandic fissure begins, running forward and downward at an angle of 6'j\° . It is about 10 centimeters long (Fig. 880). Or, according to Bennet, draw two parallel lines 5 centimeters apart downward from the sagittal suture and at right angles to it. The anterior line (Fig. 880, cd) crosses the anterior margin of the external auditory meatus ; the posterior line {ef) traverses the posterior margin of the mastoid process. From the upper end of the latter Hne draw another line obliquely down- 466 SURGICAL TECHNIC Fig. 880. Locating the Sulcus Centralis (according to Thane and Bennet) ward and forward, traversing the former line 5 centimeters above the audi- tory meatus. This obHc|ue line marks the position of the central fissure (Fig. 880, eg, and Fig. 881). Catiian locates the upper extremity of the central fissure half an inch behind the middle of the sagittal suture, and its course thence to the zygomatic tubercle. Still more exact directions for as- certaining the upper extremity of the Rolandic fissure in skulls of various sizes in adults (in which the length of the sagittal suture varies from 28 centi- meters to 33 centimeters) is found in Hare — London Lancet, March 3, 1888 — and in Scnns " Principles of Sur- gery," 1890, p. 275. According to them, the point in question is situated 15} centimeters from the glabella, when the sagittal suture is 28 centimeters long, and 18^ centimeters from it, when that line is 33 centimeters long. The place of division of (. the fossa Sylvii into its two branches, near which the corti- cal areas of the facial and hypo- glossal nerves are situated, is found in the middle of the tem- poral plane at the same point where the trunk of the middle meningeal artery is exposed for ligation (see below). A large number of instru- ments for measuring these dis- tances have been devised, which are said to facilitate the meas- urements {Broca, Turner, Wil- son, Horsley, KdJder, Kocker). Kohler, for example, uses a stirrup of hoop-iron, on which two parallel flex- ible wires turning to the sides at right angles can be moved to and fro (Fig. 881). Of similar construction is Horsley s cyrtometer. Fig. 881. Kuhler's Ckanio-cephalometer locating the central sulcus OPERATIONS ON THE HEAD 467 Kocher has devised an instrument consisting of two elastic steel braces with a scale in centimeters. The instrument may be easily applied by means of an elastic band carried transversely across the skull. The band takes its course from the arch of the eyebrows across at a point above the upper insertion of the external ear to the occipital protuberance ; the first elastic brace stands vertical upon it from the glabella to the inion ; the second brace, provided with a circular scale, can be moved along the first brace at pleasure and can be fastened to it. If this brace is moved upon the middle portion of the perpendicular brace, at an angle of 60°, two oblique lines can be drawn upon the horizontal line, each of which is divided into three parts. A third line runs obliquely from the poste- rior third in an anterior direction. For finding its terminal point, the perpen- dicular arch is divided into three equal parts and its posterior half is divided. From the middle of the points thus ascertained, the line to be sought takes its course downward at right angles, and divides the horizontal line about I centimeter behind the anterior oblique line. If the latter is also divided into three equal parts, it has been ascertained that the following points and centres coincide : — Fig. 882. KocHER's Method of locating Important Cere- bral Localizations on the Vault of the Cranium J . . . anterior end of the fossa Sylvii. V . . . boundary between the temporal and the occipital lobes. C . . . uppermost point of the anterior cerebral convolution in front of the fissure of Rolando. G . . . boundary between the anterior central convolution and the first and second frontal convolutions. H . . . boundary between the anterior central and the third frontal convolution. 468 SURGICAL TECHNIC 5 T X Y Z Q D interparietal fissure, angular gyrus. parieto-occipital fissure, angular gyrus. posterior end of the horizontal part of the fossa Sylvii. anterior end of the first temporal fissure. first frontal convolution point of crossing of the coronal and saofittal sutures. On a shaved skull, however, the lines indicated may be drawn with suf- ficient accuracy by means of a tape line and a cyrtometer, and then traced with an aniline pencil. Treatment of cerebral abscesses (mostly otitic in the temporal lobe, tJironi- boses of the transverse sinus and infected fractures of the base of the skull through the petrous portion of the temporal bone, succeeds best with OPENING OF THE SKULL AT THE BASE OF THE SQUAMOUS PORTION OF THE TEMPORAL BONE {VOH BergviauJi) The field of operation is bounded : — Laterally, by the two lines of KdJilcrs stirrup (Fig. 88 1). Above, by a line running about three fingers' breadth above the zygomatic arch. Beloiv, by a line about i centimeter above the zygomatic arch (superior anterior surface of the pyramid) — see Fig. 883, B. 1. Skin incision around the upper portion of the insertion of the external ear to the base of the mastoid process ; thence extending from 2 to 3 centi- meters in a posterior and upper direction. The incision made at once down to the bone divides the temporal artery, branches of the posterior auricular, the small muscles of the ear, the temporal fascia, and the temporal muscle. 2. With the periosteal elevator the muscular fibres and the pinna are separated from the bone with the raspatory in a downward direction ; the skin-periosteal funnel covering the bony meatus is detached above and below toward the tympanum and drawn forward with the whole auricle. 3. In an upper direction, the squamous portion of the temporal bone to the extent of about 2 centimeters is exposed with the raspatory, until the long root of the zygomatic arch (linea temporalis) is exposed ; immediately above this, as along a ruler, the skull is chiselled or sawed open in a straight line as far as the mastoid angle of the parietal bone. OPERATIONS ON THE HEAD 469 4. From this cut, and above it, an opening 2 centimeters high and 4 centimeters long (Fig. 883, B) can be chiselled out from the squamous portion. From the superior anterior surface of the pyramid, the dura, together with Fig. S83. Opening the Skull at the Temporal Region. B, below the localizations for open- ing the transverse sinus and the mastoid antrum; S, locating the middle meningeal artery (Steiner) the temporal lobe, is separated with the elevator (elevated), until the region over the tegmen tynipani has been exposed as a starting-point for the removal of the condition mentioned above. From this point, the transverse sinns can be reached by enlarging the opening posteriorly. The sinus takes its course in the tentorium cerebelli, the tangible boundary Hne between the middle and the posterior cranial fossa ; or else it is sought by cJiisellijig open the mastoid process (see page 473). For diagnostic purposes especially, but also for removing cerebral pressure and hydrocephalus, the following small operations may serve: — In diseases of the brain, dangerous to life and indicating the presence of an abscess, Meinhardt Schmidt makes an exploratory perforation of the skull with subsequent puncture of the brain as follows : — With a pointed knife, an incision about 5 millimeters long is made in the skin down to the bone ; the periosteum is pushed back with a chisel or raspatory, and the perforation of the bone is then very cautiously begun with a small drill fastened in the trephine bow, or with a hand drill (Figs. 889-890), 470 SURGICAL TECHNIC and the bone is perforated without injuring the dura mater. Through the perforation the long needle of an exploratory syringe is inserted, and by making aspiration at various depths and in different directions search is made for the abscess cavity. Since the puncture leaves little if any scar in the brain, if necessary multiple punctures can be made without fear of any injury to the brain. If the supposed abscess is found, the opening of the skull may follow at once. (Spitzka has shown by his experimental work on dogs that the brain can be punctured in different directions without incurring any risk of hemorrhage if ordinary care is exercised. Trager first described in detail the technique and diagnostic value of systematic exploration of the brain for abscess.) The lumbar puncture {Qnijicke, 1891), in simple serous and tubercular 'ineniugitis — especially in children — and also in subdural /wi/iorr/iages, \s intended to diminish cerebral compression by puncturing the spinal canal in the lumbar region, where the spinal medulla terminates in the cauda equina. This little operation can generally be made without narcosis, especially on unconscious or semi-unconscious persons; only exceptionally local or general anaesthesia is required. The patient lies on his left side with the lumbar vertebral column strongly flexed. Below the arch of the third or fourth lumbar vertebra a thin exploring needle is inserted a few millimeters from the median line, in a somewhat oblique inward and upward direction, 2-4-6 centimeters deep, according to the size of the patient and the thickness of the soft parts. From the trickling or flowing out of the fluid the operator recognizes that the subarachnoid space has been reached. Since the contours of the bones vary in different persons, the operator, in inserting the needle, must be guided somewhat by the sense of feeling. LIGATION OF THE MIDDLE MENINGEAL ARTERY Circumscribed arterial extravasations of blood (that is, circumscribed epi- dural hcevtatoniata) between the vault and the dura mater most frequently take place in the median cranial fossa {Jiceinatoina viediiini sive temporo- parietale). Of much rarer occurrence are the posterior haematomata {JicBmatonia posticum sive parieto-occipitale), which occupy the region under the parietal eminence ; most rarely occur the anterior haematomata — that is, those lying under the frontal eminence {Jiceniatoina anticuni sive fronto- temporale) — Krbnlein. The seat of these extravasations depends above all on the place where the middle meningeal artery has been lacerated (trunk, anterior, or posterior OPERATIONS ON THE HEAD 471 branch) ; sometimes the vessel is lacerated in several places. In such cases, as a rule, diffuse haematomata originate, which spread over the whole surface of the cranial hemisphere involved. For exposing the trunk of the middle vieningeal artery, the cranial capsule must be opened in the middle of the temporal fossa, perpendicularly over the highest anterior convexity of the zygomatic arch (suture between the malar and the temporal bone), at a place where a line drawn J centimeters above and parallel to the zygomatic arch divides another liiie drazvn perpendicularly 2 centimeters behind the ascending {or frontal) process of the malar bone. Vogt determines these lines by drawing one a thumb's breadth behind the nasal process of the malar bone, and the other horizontally two fingers' breadth above the zygomatic arch. At the point of crossing of these two lines lies the trunk of the artery (Fig. 884). In case of an intact skull, the op- erator exposes the seat of ligature by a curved incision with the base directed downward by dividing the temporal muscle, after it has been laid bare, in the direction of its fibres, and by divid- ing the underlying periosteum, and detaching it with the raspatory from the underlying parts on both sides. The bone can then be resected with the trephine or with the chisel ; its extreme thinness in this place, how- ever, is to be considered (squamous portion of the temporal bone, wings of the sphenoid). The artery embedded in the dura mater must be ligated at two points by passing a needle armed with a catgut ligature around it. (Direct ligation is always difficult and sometimes impossible.) According to Kochcr, the anterior and posterior brancJi of the middle meningeal artery is best found by trephining di7'ectly over the 7niddle of the zygomatic arch the squamous portion of the temporal bone, the walls of which are very thin at this place (see also Fig. 883). 1. External incision from the frontal process of the malar bone obliquely downward to the extreme posterior end of the zygomatic arch, and then upward to the anterior margin of the ear {temporal iiicision, Fig. 929). 2. After the division of the tough temporal fascia, and after the liga- tion of the superficial temporal artery, the operator penetrates along the Fig. . Vogt's Method of locating the Middle Meningeal Artery 472 SURGICAL TECHNIC posterior margin of the temporal muscle down to the bone, and in an mite- rior direction elevates from the bone with the raspatory the muscle together with the periosteum. 3. Resection of the thin portion of the squamous portion is made with the chisel or the trephine ; ligation of the branches of the artery which are exposed. If the supposed hsematoma is not found in this place, a slightly curved grooved director or a (tube) catheter should be introduced between the bone and the dura mater, with which explorations for it are made ; but, in any event, the skull should be tre- pJiincd once more at anotJier place, preferably under the parietal eminence (posterior haematoma). Kronlein gives the follow- ing rule for determining the two locations where trephining is to be made : — Draw a line (Fig. 885, cd) through the supra-orbital mar- gin in a posterior direction and parallel to the horizontal line of the head (opening of the ear, line of the infra-orbital margin, Virchoiv s German hori- zontal, ab). In this line the two openings are said to lie, the anterior from 3 to 4 centimeters behind the zygomatic process of the frontal bone (rPORARY RESECTION OF THE MALAR BONE {Liickc-Braiin-Losscn) 1. The external incision is in tJie form of an angle. TJie first incision begins i centimeter above the external angle of the eye, and 2 to 3 milli- meters from the external orbital margin ; in an anterior direction it descends obliquely as far as the region of the third upper molar, where the zygomatic process of the upper jaw can be felt as a sharp angular projection. 2. With a small pointed knife, always kept close to the bone, the soft parts on the internal surface of the malar bone are detached from below upward, and the latter is sazvcd tJirongh with a metacarpal saw or with a chain saw obliqttely toward the viedian line. 3. The scco)id incision is made at a right angle to the first incision from its upper end, in a posterior direction along the icpper margin of the zygo- matic arch as far as the zygomatic process of the temporal bone, dividing the skin and the temporal fascia. 4. At its connection with the temporal bone the zygomatic arch is then divided with a saw or chisel (or merely nicked, Braun), and the skin flap, together with the zygomatic arch and the masseteric insertion, is turned in a downward direction (Fig. 920). 5. After the anterior fibres of the temporal muscle, if necessary, have been divided, the masses of fat bulging from the sphenomaxillary fossa, together with the venous plexus and the internal maxillary artery, are pushed backward with broad retractors ; if necessary, the fatty tissue lying below may be cut away. 6. The nerve is now sought for with a strabismus hook introduced into the infra-orbital groove, and an attempt is made to separate the ntrxQ. from the infra-orbital artery ; the artery, a branch of the internal maxillary, takes its course from ivithout backwaj'd 2cnd dowjiward ; the nerve take its course from behind inward and upivard, obliquely fori^'ard, downward, and out- ward, and may be traced centrally as far as the foramen roticnduni. 7. While the nerve is vigorously drawn forward with a tenaculum, it is divided with pointed curved scissors (" Hohlscheej-e") as near the foramen rotundum as possible; its peripheral branches, together with the severed pieces, are evulsed. Kocher reaches the foramen rotundum by avoiding the facial branches by turning the malar bone in an outward direction. I. External incision, beginning i centimeter towards the median line at the palpable infra-orbital foramen, takes its course forward and in an OPERATIONS ON THE HEAD 499 external direction, somewhiat obliquely downward as far as the zygomatic arch (Fig. 921); ligation of the angular artery, avoiding Steno's duct; division of the orbicular muscle of the eye, which together with the peri- osteum is raised as far as the orbit. The musculus quadratus of the upper lip is detached subperiosteally, and the infra-orbital nerve thereby exposed is grasped with a strabismus hook at the place of its exit. The insertions of the zygomatic muscles and of the anterior portion of the masseter are detached from the malar bone. Fig. 921 Fig. 922 Kocher's Method of exposing the Supramaxillary Nerve AT the Foramen Rotundum 2. The zygomatic arch is freed internally and externally, and chiselled through obliquely; the union with the upper jaw is divided so that the incision from the infra-orbital canal, which is opened lengthwise, extends as far as the anterior insertion of the masseter through the superior wall of the antrum of Highmore. The nasal process is chiselled through obliquely in an inward direction, 3. The malar bone is then turned upward and outward by means of a bone hook (Fig. 922), and the fatty orbital layer is raised with a blunt hook. The infra-orbital nerve may then be inspected with ease as far as the foramen rotundum, and may be grasped, divided, or extracted behind the spheno- palatine nerve coursing downward. 4. The turned-up malar bone is then replaced in its former position ; bone sutures are usually superfluous. The external wound is sutured throughout its whole extent. THE INFRAMAXILLARY NERVE The third branch of the trigeminus, or inframaxillary nerve, makes its exit from the cavity of the skull through the foramen ovale, and at once 500 SURGICAL TECH NIC divides into several branches, of which the most important sensory are : the auriculotemporal nerve, which ascends around the articular process of the lower jaw in front of the ear; the lijigiial nci've atid the viaxillary nerve, both of which course downward and forward behind the internal pterygoid muscle and the inner surface of the lower jaw. TJie lijigjial nerve then takes its course along the floor of the cavity of the mouth and in a lateral direction to the tongue ; tJie maxillary nerve enters, together with the accompanying artery, into the maxillary canal at the lijigula and together with the artery courses along the canal, and, as the mental nerve, leaves it through the foramen mentale below the depressor anguli oris muscle where it ramifies in the skin of the chin (Fig. 914, ///). Sonnciibcrg and Liicke obtained access to this nerve on the i)itcr)ial surface of the lozverjazv in the following manner : — The operation is made with the Jiead in Roses position, to afford a more satisfactory view of the parts of the lower jaw, situated on its inner surface. I. An incision in 'Cuo.form of an angle — botJi sides of ivhicJi are equal — from 5 to 6 centimeters long, through the skin and the periosteum, running clo.sely around the ajigle of the lower jaw (Fig. 923). 2. The periosteum on the internal surface of the lower jaw, together with the insertion of the internal pterygoid muscle, is detached with an elevator and pushed upward and back- ward until the projecting bony lamina of the canal is felt ( Fig. 909). 3. Guided by the finger, a tenaculum is now introduced upward and inward as far as the canal ; with a tenaculum, the nerve is sepa- rated from the accompanying artery, drawn strongly forward, and held firmly with torsion forceps. 4. Either the nerve can then be resected by dividing it first close to the opening of the canal and then as far toward the central portion as possible (centrally), or, according to Thiersch, it can be torn out with the Thiersch forceps instead of with the torsion forceps. Around these forceps, the whole peripheral part, as it issues from the dental canal, and also the central portion of the nerve as far as the base of the skull are twisted and forcibly extracted. Fig. 923. SOXNEXBERG - LiJCKE'S Method of exposixg Ixfra- MAXILLARY NeRA'E OPERATIONS ON THE HEAD 501 KiiJin and B runs removed portions of the angle of the lower jaw in order io expose the dental canal. Briins made a curved exterjial incision along the posterior margin of the lower jaw from the ear downward as far as the anterior insertion of the masseter. The parotid gland is pushed backward ; the detached masseter upward. From the angle of the jaw, now easily accessible, a rhomboid piece from I to li centimeters wide and from 3 to 3|^ centimeters long is sawed out from its posterior margin and detached from the internal pterygoid muscle (Fig. 924, ^) ; the nerv^e, lying in the open canal, can then be easily drawn forward with a tenaculum. Velpeau and Linhart chiselled an opening in the anterior surface of the lozuerjaw, through which the canal is opened (Fig. 925). For. oval. A err \ x \\ ■ »/ inframax N. Ungualis mt. Fig. 924. Internal Half of Left Lower Jaw. a, a, saw incisions according to Bruns Fig. 925. External Half of Right Lower Jaw with Velpeau-Linhart Fenestra 1. External incision from 3 to 4 centimeters long in the median line of the ascending ramus of the lower jaw. 2. After the masseteric fascia has been split and Steno's duct exposed, the latter is drawn upward together with the transverse facial artery ; the fibres of the masseter are divided IcngtJizvise. 3. The periosteum is split in the same direction, and pushed back with a raspatory until a sufficient portion of the jaw has been exposed. 4. With chisel and hammer, a rectangular piece is chiselled off from the anterior wall, layer by layer (Fig. 925), until the canal has beoi opened and the nerve, together with the artery, can be seen coursing through it ; here it may be grasped with facility. 502 SURGICAL TECHNIC Fig. 926. Kronlein's Retrobuccal Method The foramen ovale may be reached as follows : — (a) By the retrobuccal method of Kronlcin (Fig. 926). I. Transverse incision of the c/ieek, beginning I centimeter from the angle of the mouth and ending i centimeter in front of the lobule of the ear ; division of the fatty tissue. The buccinator muscle and the mucous membrane of the cheek remain unin- jured. Division of the anterior two- thirds of the masseter with careful avoidance of the parotid gland and Steno's duct. 2. The coronoid process of the lower jaw is freed with an elevator from the masseter and the internal pterygoid muscle covering it ; it is then divided as low down as possible in an oblique direction with bone-cutting forceps, and drawn upward together with the temporal muscle. 3. The nerves are made accessible bj blnnt dissection. Through the fatty layer of the cheek and through the internal and the external pterygoid muscles, the operator advances as far as the canal, where the inferior alveo- lar nerve and also the lingual nerve can be easily palpated and brought into view; farther upward lie the chorda tympani and the internal maxillary artery. If the external pterygoid muscle is drawn forcibly nfizuard, the auriculotemporal nerve is reached, encompassing the middle meningeal artery behind the lingual nerve and the inferior alveolar nerve. Thus the base of the skull is reached, where the nerves can be extensively resected, or where, according to TJiierscJi, they can be removed by extraction. By this method, also, single twigs of the third branch of the artery can be removed if desired : the buccinator nerve, the inferior alveolar, the lin- gual, and the auriculotemporal. {b) Mien lie: makes a temporary resection of the lower jaw: — 1. External incision along the sternocleidomastoid from the mastoid process as far as the level of the great cornu of the hyoid bone ; thence in a short curve upward to the anterior margin of the masseter and \\ centi- meters beyond the margin of the lower jaw (Fig. 927). 2. The bone and the cervical portion of the parotid gland are exposed ; the ligament extending from the lower jaw to the fascia of the sternocleido- mastoid is divided. OPERATIONS OX THE HEAD 503 3. The jaw is sazued through by the step inetJiod. Along the anterior margin of the masseter, the most anterior insertions of which must in most cases be also removed, the periosteum at the external and the internal sur- face of the lower jaw as far as and behind the last molar is exposed without injuring the mucous membrane of the mouth. With a chain or wire saw, the bone is divided perpendicularly half through from behind the molar ; I centimeter farther toward the front, the bone, from the outside, is also sawed half through with a metacarpal saw, and the middle portion is chis- elled through horizontally (Fig. 927 , ). Fig. 92S MicuLicz's Method of exposing Inframaxillary Nera'e 4. The portions of bone are forcibly drawn apart with hooks, the inser- tion of the internal pterygoid muscle is detached, the inframaxillary nerve behind the canal is drawn out, and the lingual nerve, running immediately below the mucous membrane of the mouth along the molar teeth, is sought for. By advancing bluntly upward along these trunks of ner^'es, during which procedure the external pterygoid muscle must be forcibly drawn inward and upward, the foramen ovale is reached (Fig. 928). 5. The nerves having been resected, the lower jaw is united by a bone suture of silver wire (the step form of the fracture prevents a displacement of the fragments by muscular traction); a gauze tampon is inserted behind the angle of the jaw, and the external wound as far as the drainage opening is sutured. 6. In the after treatment, care must be taken that the mouth be thor- oughly cleansed, in case the mucous membrane has been injured. 504 SURGICAL TECHNIC (c) Kocher reaches the foramen ovale after temporary resection of the zygomatic arch. 1. External incision from the frontal process of the malar bone obliquely downward as far as below the posterior end of the zygomatic arch, then up- ward at right angles in front of the ear ; ligation of the temporal veins ; division of the superficial and the temporal fascia, which are drawn down- ward (Fig. 929). 2. CJiiselling t/irough the zygomatic arch ; anteriorly directly behind the ascending frontal process and posteriorly immediately in front of the con- dyle of the lower jaw. The chiselled-out portion, together with the masse- teric insertion, is forcibly drawn downward. Fig. 929 Fig. 930 Kocher's Method of exposing the Supramaxillary Nerve at the FoiiAMEN ROTUNDUM 3. The tcnipo7'al muscle now exposed, covered by fat, is forcibly drawn forzuard with a blunt hook from behind ; in case of necessity, the coronoid process is divided with the bone-cutting forceps. 4. The periosteum of the infratemporal crest is divided from the root of the zygomatic arch in an anterior direction and together with the soft parts is pushed back tozvard the middle line from the base of the skull as far as the pterygoid process. The foramen ovale can be felt immediately behind the crest. 5. After the removal of the nerve at this place, the zygomatic arch, which has been turned down, is again replaced in its natural position and fastened with bone sutures ; the external wound is sutured throughout. Salzer proceeded similarly to Kocher, but from a curved incision with the convexity directed upward which penetrates the skin, fascia, and tem- OPERATIONS ON THE HEAD 505 poral muscle down to the bone a finger's breadth above the zygomatic arch. For the purpose of following up conjointly the second and the third branches of the trigeminus centrally as far as possible and as far as their exit from the crajiial cavity, Kronlein extended the method of Liicke-Braini- Lossen by resecting the coronoid process of the lower jaw in addition to the zygomatic arch (Figs. 914 and 931). 1. For this purpose, he forms a seniihuiaj^ flap in the teniporobiiccal re- gion with the base above the superior margin of the zygomatic arch and the apex of which meets a line drawn from the nostril to the lobule of the ear. 2. After the flap of skin has been turned up and the temporal fascia has been detached from the whole superior margin of the zygomatic arch, the arch is resected in the manner mentioned by Liicke, and turned doivn- ward with the masseteric attachment still adhering to it. Fig. 931, Kronlein's Method of resecting the ii and THE III Division of the Trigeminus. external incision: saw incisions Fig. 932. Krunlein's Method of exposing the II AND the III Division of the Trigeminus 3. The coronoid process of the lower jaw is exposed, chiselled off ob- liquely downward and forward, and then turned upward together with the insertion of the temporal muscle (Fig. 932). 4. After the internal maxillary artery coursing between the margins of the pterygoid muscles has been ligated, the superior insertion of the exter- nal pterygoid muscle is bluntly detached from the infratemporal crest ; the ijifraniaxillary is then accessible as far as the foramen ovale. 5. By penetrating deeper into the sphenomaxillary fossa, as above de- scribed, the snpramaxillary nerve is exposed as far as tJie foramen rotiindiim. The resection or extraction of both nerves can then be made. 5o6 SURGICAL TECHNIC THE LINGUAL NERVE This nerve can be made accessible from luithin the moutJi {intrabuccally) at the place where it enters the tongue hitei-ally from the side of the jaw. On account of its superficial location, it can be seen shining through the mucous membrane. It can be easily reached by a simple incision through the mucous membrane of the cheek at its point of reflection from the tongue. But in case the widely opened mouth does not offer sufficient access, the cJicek VI list be divided transversely from the angle of the mouth to the ascending ramus of the lower jaw (^Roser), in which case the external maxillary artery is severed (Fig. 933). If it is necessary to resect more of the nerve toward the brain, the resec- tion is best made extrabneealiy, accord- ing to the method of Sonnenbnrg-Liieke, described on page 500. The lijignal nerve is then found at the side of the in- fraviaxillary nej'i.'e, above the dental eajial, between the periosteum and the internal pterygoid muscle. This place may also be made accessible from the mouth, by the method proposed by Parai'icini for the excision of the inframax- illary nerve. The mucous membrane of the mouth is divided along the anterior margin of the ascending ramus of the lower jaw as far as the last molar tooth, the periosteum and the internal pterygoid muscle are elevated from the bone, and then the operator, start- ing from the opening of the canal, endeavors - J , 1 .1 r •, T Fig. 934. Paravicim's Method of to detach the nerve from its surroundmgs ^^^ ,, ^ ° EXPOSING Mandibular and Lin- with blunt instruments (Fig. 934). gual Nerves Fig. 933. Roser's Method of exposing Lingual Nerve MENTAL NERVE In order to lay bare the inframaxillary nerve at its place of exit from the mental foramen, the operator can proceed intra-orally or extra-orally. OPERATIONS OX THE HEAD 507 1. After the everted lower lip has been drawn forcibly downward, a horizontal incision from 2 to 3 centimeters long is made about i centi- meter below the insertion of the gums, between the first and second violars. From this incision, the surgeon penetrates carefully as far as the mental foramen, where the nerv^e, which makes its exit at that point, can be grasped. The nen^e, to- gether with its ramifications, is then either excised or torn out (Fig. 935). 2. If the removal of a larger portion is desired, it is better to make a horizontal incision through the skin over the chiii, without injuring the mucous membrane of the mouth ; the in- cision begins at the canine tooth and extends close to the anterior viargin of tJie viasseter (external maxillary artery ! ) and down to the bone. Next, the divided periosteum is detached in an upward direction, the foramen mentale is searched for, and the inframaxillary canal for some distance from this point is chiselled open in the form of a groove. If, in a severe form of neuralgia of the trigeminus, all remedies have proved witliout avail, finally, as a last resort, with a view to permanent success, there is left the Fig. 935. Exposing ^Iental Xek\"e INTRACRANIAL RESECTION OF THE GANGLION GASSERI {KrailSC, 1 893) As early as 1890, W. Rose, with a trephine, opened the base of the skull in front of the foramen ovale ; along the third branch, he bluntly detached the ganglion from the dura and removed it piecemeal with forceps or sharp spoon, after having divided the second and the third branches extradurally. 1. Opening of the cranial cavity. The external incisioti is made in the form of a uterus-shaped flap in the temporal region above the zygomatic arch in front of and near the external ear. After the hemorrhage has been carefully arrested, the surgeon penetrates through the fascia, muscles, and periosteum down to the bone and opens the latter Avith the trephine or with the chisel. According to JVagjier, the skin-muscle-bone flap thus formed is reflected in a downward direction. The serrated lower margin of bone sometimes remaining on the lower margin of the opening is smoothed with Liter s forceps and removed as far as the base of the skull (Fig. 936). 2. Ligation of the middle meningeal artery. Extending with the flnger and a blunt elevator between the dura mater and the base of the skull into 5o8 SURGICAL TECHNIC tJie median cranial fossa (hemorrhage ! is arrested by a temporary tampon- ade), the operator, after a double ligation, divides first the trunk of the middle meningeal artery near the foramen spinosimi. He raises the brain carefully with a broad spatula bent at right angles. 3. Exposure and removal of the ganglion (Fig. 937). Advancing deeper slowly and carefully raising with the spatula only so much of the brain as is absolutely required for inspection (brain pressure ! ), the operator succeeds Fig. 936 Fig. 937 Kr,\use's INTRACR.A.NIAL Resection of the Gasserian Ganglion in exposing with an elevator first the third brajich, next the second branch occupying the centre, and then the entire ganglion above, from the dura ; below, from the bone {\hQ first branch coursing in the sinus cavcrnosus must not be dissected free). The ganglion is grasped transversely with Thiersch's forceps ; next, the second and the third branches at the foramen rotundum and the foramen ovale are divided with a pointed tenotome, and then, by slow windings with the forceps, the ganglion with its branches and a more or less large portion of the trunk of the trifacial are twisted out (mostly throughout its whole extent as far as the pons Varolii). 4. The brain is then released, and the skin-bone cover is fastened in its natural position by a few sutures. After a small opening has been made by breaking off with the forceps a small piece of bone, it is to be recommended that the operator insert for two or three days a drainage tube into the depth OPERATIONS ON THE HEAD 509 of the wound between the dura and the base of the skull and at the pos- terior margin of the opening. With very weak patients, the duration of the operation may be essentially shortened if the bone is removed with chisel or Liier s forceps after the soft tissues have been detached and reflected. As a matter of course, this operation leaves a permanent depression in the temporal region. Doyen removes the ganglion in a similar manner (temporosphenoidal) by chiselhng open the skull after making Kronleiii s temporary resection of the malar bone. This procedure, however, is still more radical than the preceding. THE FACIAL NERVE This nerve can be exposed either after its exit at the stylomastoid foramen, or more anteriorly at the anterior margin of the lower jaw — about midway between the zygomatic arch and the maxillary angle. I. The external incision divides the posterior margin of the lobule of the ear from the auricle and takes its course downward along the posterior mar- gin of the jaw. After division of the parotid-masseteric fascia, the exposed parotid is drazvn foj'zvard, and the auricular posterior artery backward. At the anterior margin of the mastoid process, the operator advances deeper X].e2ix the insertion of the sternocleidomastoid, and finds the nerve on the side of the digastric muscle under which the external carotid takes its course. The facial nerve may be exposed more easily, according to Lobker- Hueter, in the parotid tissue. 1. External i?icision 5 centimeters long from the lobule of the ear along the posterior margin of the jaw, extend- ing downward. 2. After division of the parotid fas- cia, the parotid tisstie is carefully divided by means of oblique incisions directed toward the margin of the jaw {external carotid artery !^ until t\\Q inferior branch of the facial nerve is brought into view. 3. By following the latter in a back- ward direction, the operator reaches the superior branch and farther on the union of the two in front of the stylo- mastoid foramen (Fig. 938). Fig. 938. Lobker-Hueter's Method of EXPOSING Facial Nerve 5IO SURGICAL TECHNIC 4. For a better exposure of the latter, another oblique hicision 2 centi- meters long backward and upward may be made from the lower angle of the wound and beyond the mastoid process {Kaufviann). The stretcJiing of the trunk of the nerve thus found is carried out "oery caj'cftilly by means of a strabismus hook or a rubber tube placed under the nerve. In completing this chapter, mention may be made of other nerve trunks most frequently exposed for the purpose of stretcJiing. NERVUS ACCESSORIUS WILLISII (SPINAL ACCESSORY NERVe) This nerve leaves the cavity of the skull, together with the vagus nerve, through the jugular foramen, and whilst its anterior branch coalesces with the vagus nerve, its posterior branch behind the digastric and stylohyoid muscles descends obliquely downward between the internal jugular vein and the occipital artery, and about 5 centimeters below the mastoid process enters the sternocleidomastoid, which it pierces in order to branch off in the trapezius. N.access\—i Fig. 939 Exposing Spinal Accessory Fig. 940 1, External incision from 5 to 6 centimeters long along the anterior margin of the sternocleidomastoid muscle, from the mastoid process down- ward to the eminence of the angle of the jaw (Fig. 939). 2. After division of the fascia, the free anterior margin of the sterno- cleidomastoid is retracted. The surgeon can then either see or feel the nerve under the deep fascia immediately below the transverse process of the atlas, which can be felt in the upper angle of the wound covered by the digastric muscle. At the side of the accessory nerve there is also found in most cases a delicate twig of the second cervical nerve (Fig. 940). OPERATIONS ON THE HEAD 511 In exposing the nerve at its exit from the sternocleidomastoid, an incision from 4 to 5 centimeters long is made along the posterior margin of the muscle about a finger's breadth below the mastoid process. Here the nerve appears as an oblique loop embracing the posterior margin of the muscle. BRACHIAL PLEXUS I. The head is turned toward the opposite side, the arm is drawn down- ward (as in the ligation of the subclavian artery) from the external margin of the sternocleidomastoid, an incision from 5 to 6 centimeters long is made i centimeter above and parallel to tJie clavicle (Fig. 941). Fig. 941 Exposing Br.a.chial Plexus Fig. 942 2. After division of the platysma myoides and the superficial fascia of the neck, the operator penetrates bluntly through the fatty tissue until he reaches the omohyoid muscle . 3. The latter is drawn dozumuard ; the brachial plexus behijid it lies in loose cellular tissue (Fig. 942). THE CRURAL NERVE I. A longitudinal incision is made 4 centimeters to the inner side of the anterior superior spine of the ilium, taking a downward course from Pou- part's ligament to a distance of 6 centimeters (Fig. 943). 512 SURGICAL TECHNIC 2. Division of the fascia lata, under which Hes the bundle of nerves covered by several lymphatic glands — the femoral artery lies toward the median line (Fig. 944). Exposing Crural Nerve EiG, 945 Exposing Sciatic Nerve Fk;. 946 THE SCIATIC NERVE I. Perpendicular external incision 10 centimeters in length midway be- tween the greater trochanter and the tuberosity of the ischium (Fig. 945). OPERATIONS ON THE HEAD 513 2. Longitudinal division of the fascia at tiie side of the posterior cuta- neous nerve until the lower margin of the glutens maximus appears in the upper corner of the wound. 3. By penetrating with bkmt instruments between the biceps and tJte semitcndinosus vniscle, the nerve is reached ; the latter lies in its sheath upon the adductor magnus muscle (Fig. 946). 4. The nerve is isolated with a blunt instrument, drawn from the wound with the finger, and vigorously stretched. During this procedure, it is advis- able not to injure the accompanying ischiatic artery \N\{\<:h lies over the poste- rior surface of the sheath and which at times is very much increased in size. Under profound anaesthesia, the sciatic nerve may be stretched blood- lessly over the tuberosity of the ischium by extending the leg at the knee joint, flexing it at the ankle joint, and bending it slowly over the abdomen of the patient until the toes touch the face. THE POPLITEAL NERVE I. External incision from 5 to 6 centimeters long, taking its course down- ward in the median line from the upper angle of the popliteal space (Fig. 947)- Fig. 947 Exposing Popliteal Ner\-e Fig. 94S 2. After division of the fascia, the common sheath of the nerve and the vessels can be felt between the biceps muscle and the seniitendinosus. After this is opened, the nerve lies very superficially (Fig. 948). PLASTIC OPERATIONS ON THE FACE Plastic operations are intended to supply portions of the body that have been destroyed, by grafting other living portions into their plaee or by closing defects that are congenital or that originate from wounds, ulcerations, etc. BLEPHAROPLASTY (plastic surgery of the eyelids) This operation is intended to restore a lost eyelid : — 1. Caused by injury. 2. By the extirpation of tumors. 3. By ulcerations with cicatricial retraction and protrusion of the mucous membrane {ectropiuni). In ectropium (eversion) of the lower lid — which occurs most frequently — according to DieffenbacJi, tzvo incisions converging dowmvard to a point may be made from the corners of the eye. The triangular flap thereby formed Fig. 949 l-'iG. 950 DiEFFENBACn's BLEPHAROPLASTy (Plastic Surgery of the Eyelids) should be pushed so far upward that the tarsal border of the lid is not only replaced into its natural position, but a little above its normal level ; in this position the flap is sutured in place, the line of suturing assuming the form of a Y(Figs. 949, 950). 514 PLASTIC OPERATIONS ON THE FACE 515 Or, according to Wolfe, an incision is made parallel to the margin of the lid ; this margin is drawn upward and temporarily stitched with two or three sutures to the upper lid. A portion of skin from the arm of the patient is grafted into the wound thus formed, corresponding in size and shape to the Fig. 951 Wolfe's Blepharoplasty Fig. 952 wound, but somewhat larger. The graft must be carefully freed on its inner surface from all fatty tissue until it is as smooth atid thin as glove- leather, its margins are fastened to the edges of the defect with a few inter- rupted sutures (Figs. 951, 952). Even if these grafts unite by primary union, still in most cases they afterward contract considerably. Skin transplantation, according to Thiersch, is said to have met with better success, especially when the skin grafts are placed in the direction of the fissure, and after the hemorrhage has been completely arrested. To prevent contraction as much as possible a large gaping surface of the wound is obtained by temporary suturing of the palpebral fissure (^Plessing). Fig. 953 Fig. 954 A.MMON AND ^"o^" Langenbeck's Blepharoplasty Still less inchned to contraction are the pedunculated flaps of skin, which, according to Fricke, are taken from the temporal region (Fig. 955), or, accord- ing to Amnion and von Langenbeck, from the lateral aspects of the cheek (Figs. 953, 954). In forming the flap, care must be taken to direct the pedun- 5i6 SURGICAL TECHNIC cular incision externally in tJie form of a curve, whereby less distortion ensues in rotating the flap in position, and also to cut the flap sufficiently large, so that the eyelid can be turned inward suf- ficiently after the flap is brought into position. These methods are also applicable in covering defects after extirpation of tumors. If portions of both eyelids are to be restored, according to Hasner von ArtJia, the surgeon may cut from the neighbor- ing skin sickle-shaped flaps encircling the whole defect, and by sliding them together, restore the angle of the eye and the palpebral fissure without leaving a gaping wound (Figs. 956, 957). DieffeubacJis method of lateral sliding of rhomboid flaps can also be used in restoring defective eyelids. Every remnant of the conjunctiva ought to P'iG. 955. Fricke's Blepharoplasty Fig. 950 Fig. 957 Hasner vox Artha's Blepharoplasty be carefully used for the lining of the upper margin of the flap. The tri- angular wound remaining after the lateral sliding must be covered by skin transplantation as far as the wound cannot be closed by suturing (Figs. 958, 959). Finally, the restoration of an entire lid has met with good success by the process of sliding a double pedunculated flap taken from the healthy lid, according to Tripier. For instance, after excising the lower eyelid in its entire extent, he forms from the upper eyelid a double pedunculated flap, by two parallel incisions about i centimeter from each other, the lower of which takes its course exactly on the upper margin of the tarsal cartilage (Fig. 960). PLASTIC OPERATIONS ON THE FACE 517 At the same time, he penetrates bluntly from these incisions into the fibres of the orbicular muscle, detaches them from the tarsal cartilage together with the bridge of skin liberated entirely by an incision, and turns Fig. 958 Fig. 959 Von Dieffenbach's Blepharoplasty the imisculociitaneoiis flap thereby formed into the defect over the upper lid, where it is fastened with fine silk sutures (Fig. 961). The secondary defect on the upper lid may likewise be sutured tJirougJioiit (Fig. 962). By the transplantation of the muscular fibres the patient is enabled to open and close the lids in an almost natural manner. Fig. 960 Fig. 961 Tripier's Blepharoplasty With all these methods, permanent success of the operation can be expected only if so much of the conjunctiva has been saved that the new flap can be lined vf'ith. it throughout. If too much of the conjunctiva has been lost the surgeon may overcome the difficulty either by doubling (turning over) the free margin of the flap, or still better by transplanting a piece of nnicous monbrane ( Wolfler). CHEILOPLASTY (formation of the lips) Restoration of the lower lip becomes especially necessary after the extirpation of malignant tumors (carcinoma) or for the correction of dis- 5ii SURGICAL TECHNIC figuring cicatrices after tubercular or syphilitic ulcerations ; the restoration of the upper lip in most cases becomes necessary from the latter cause. Fig. 963 Fig. 964 Superficial Excision of Tumor of the Lower Lip — Suture In operations on the lips it is desirable to resort to the bloodless method : — {a) By compressing the coronary arteries at both angles of the mouth by digital compression or sliding forceps. (/;) Or by clamping off the field of operation with parallel forceps of special construction (Fig. 965). {c) By applying the indirect ligature {Langenb?{ch) at the portion to be removed — especially if an assistant cannot be present. With strong silk threads knotted as firmly as possible over the skin, the portion involved is encircled in the form of either a triangle or a square, so that each loop forms a crossing with the other. Aside from anaemia, anaes- thesia is also produced in the ligated portion. In the extirpation of cancer of the lips, the rule should prevail to make the incisions in the healthy tissue at least i J centivieteis from the demon- strable limits of the neoplasm. Fig. 965 Fig, 966 Extirpation of the Entire Vermilion Border of the Lower Lip (Using the bloodless method by means of parallel clamp forceps) I. Smaller tinnors of the margin of the lips may be grasped with the sliding forceps or with the transverse forceps, and then lifted up and excised with the curved scissors (Hohlscheere) or the knife. The wound is then united by a horizontal row of longitudinal sutures (superficial excision, Figs. 963, 964). PLASTIC OPERATIONS ON THE FACE 519 In this manner, extirpation of the whole vermilion border of the lips can be made, when the tumor is superficial and the wound may be lined with the mucous membrane of the lips (Figs. 965, 966). / U V Fig. 967 Fig. 968 Cuneiform Excision of Tumor of the Lower Lip — -Suture 2. Larger tumors occupying only a portion of the lips but extending considerably beyond their viargin are removed by tzvo lateral incisions meeting belozv {zvedge excision^. The wedge-shaped defect is closed by a perpendicular suture ; first, a few deep sutures are applied through the whole thickness of the lip, whereby the hemorrhage is arrested at the same time. Then the margins of the wound are carefully united by superficial sutures (Figs. 967, 968). If more than half the under lip has to be removed, the opening of the mouth becomes very narrow ; and, owing to the great retraction of the remainder of the under lip, the upper lip projects in the form of a snoutlike disfiguration ; however, that disappears in a short time on account of the great elasticity of the tissue of the lips. Fig. 969 Fig. 970 Grafting Lo\yer Lip, restored by Plasty, with the Vermilion Border of the Upper Lip — Suture 3. If the border of tJie lip is diseased thronghont its whole extent, and if the proliferation extends so deep into the tissues of the lip that, after surface 520 SURGICAL TECHNIC excision, tlie lip would become too short, the removed margin can be replaced by utilising a portion of tJic labial border of the upper lip. For this purpose, the whole upper lip is divided closely above the vermilion border in such a manner and to such an extent that the detached strip of the labial margin can be drawn around the opening of the mouth and that the under lip can be lined with, the same {Dieffetibach, von Langenbeck, Figs. 969, 970). Fig. 971 Fic. 972 BrUxXs's Cheiloplasty (Formation of lips) In a similar manner, Brujis restored a large portion of the lower lip. He encircled the buccal orifice by two curved incisions and united again the edges of the wound thereby made movable (Figs. 971, 972). ■/^ In like manner, Estlander uses the upper lip for forming the lozver lip. He cuts from the upper lip a triangular flap, the vascular bridge of which lies on the margin of the lip, and, by rotation, places the flap into the defect of the lower lip (Figs. 973, 974). Fiu. 973 Fiu. 974 E.stlander's Cheiloplasty For the restoration of the whole lower lip, many methods have been devised. I. DieffenbacJi, after a cuneiform excision of the diseased lower lip, made horizontal incisions from both anjrles of the mouth throusrh the whole thick- PLASTIC OPERATIONS ON THE FACE 521 ness of the cheek ; from the ends of these, he made obhque incisions downward and parallel to the margins of the wound. He united in the middle the rhomboid flaps thus obtained, and on the free margin of the new lip sutured the mucous membrane to the skin (Figs. 975, 976). After this procedure, gaping wounds are left at both sides of the lip ; these must heal Fig. 975 Fig. 976 Dieffenbach's Cheiloplasty by granulation. It is better, according toJciscJie, to make the incisions of the cheek hi a curve outzuard and then downward (Fig. 977). The margins of the wound which have been brought into approximation can be closed throughout by suturing after the formation of the lip (Fig. 978). Tre;/de/eu- burg modified the form of the incision, so that, by a greater curve of the Fig. 977 Fig. 978 Jasche's Cheiloplasty arch, its external point came to lie in front of the facial artery (Fig. 979). For the purpose of obtaining sufficient mucous membrane to cover the margin of the lip, he made the incision of the cheek only down to the mucous mem- brane, dissected the latter somewhat from the upper part of the cheek, and divided it abont \ a centiineter above the external incision ; the flap of 522 SURGICAL TECHNIC mucous membrane still adhering to the cheek was used for lining the surface of the wound. Fiu. 979 l-'iG. 980 Tkenuelenburg's Cheiloplasty 2. After a quadrangular excision of the lozver lip, Bruns forms, from the anterior upper portion of the cheek, two square flaps, which on both sides of the upper lip ascend to the alae of the nose. Having first circumscribed the tumor along its margin by a transverse incision through healthy tissue, he adds at the angles of the mouth two lateral incisions ascending from the angles ; from these two flaps are formed outside of the angles of the mouth. He turns these in the direction of the wound, and having united them by sutures, he lines the border of the lip with the freely movable mucous mem- brane of the cheeks adhering to them (Figs. 981, 982). But if the mucous Fig. 98 1 Fig. 982 Bkuns's Cheiloplasty membrane covering the flaps becomes too much stretched longitudinally, it is nicked at its base by transverse incisions. 3. Burow, with his method of lateral triangles, obtained very good results, although two JiealtJiy portions of skin are unnecessarily sacrificed thereby. PLASTIC OPERATIONS OX THE FACE 523 The mucous membrane of the triangles to be excised may, however, be saved and used very advantageously for lining the surface of the wound (Figs. 983, 984). Fig. 983 Fig. 984 BuRow's Cheiloplasty The skill of the cJiin may also be used for restoration of the lower lip ; this is best done according to the procedure of Blasius, Morgan, and von Langenbeck. From the middle of the lip, which has been excised in a semilunar form, Blasius makes two sciniliinar incisions into the sides of the chin. The flaps thus formed are transferred upward on the '^ spnr'' of the skin of the chin remaining between them and are thus reunited (Figs. 985, 986). Fig. 985 Fig. 986 Blasius's Cheiloplasty Von Langenbeck forms from the middle of the chin a flap zvith a lateral peduncle. He lifts it over the " spur " of skin which has remained on the opposite side and sutures it in this position. The "spur" itself is also detached and again united with the lower margin of the flap wound (Figs. 987, 988). The lip formed according to these methods has a tendency to swell and to draw in, sutce it is not sufficiently covered with vuicons' membrane. It is, 524 SURGICAL TECHNIC therefore, advisable to line the free margin with mucous membrane drawn over from the upper lip or from the mucous membrane of the cheeks {e.g. Figs. 969, 970). ( Fig. 9S7 Fig. 9S8 Von Langenbeck's Cheiloplasty Morgan (1829), in very extensive defects, restored the upper lip by utiliz- ing the skin of the chin or the submental region. Along the lower jaw he made a curved incision about 12 centimeters long and distant from the margin of the defect about i centimeter above the level of the extir- pated lower lip (removing any diseased glands). The cutaneous bridge formed by the incision is liberated by horizontal incisions from its basement membrane, turned up like the visor of a helmet and held in position by a few sutures. At its lower margin, it is stitched to the lower jaw to prevent it from descending. Strips of gauze are inserted between the wound surface of the flap and the jaw. The gaping defect of the submental region is / V Pig. 9S9 Fig. 990 Morgan's Cheiluplasty diminished by suturing, the rest of the wound is left to heal by granula- tion or is paved by skin grafts according to the method of Thiersch ( Wolflcr, Regnier). The result of this operation is good beyond expectation. Although the new lip does not become easily movable, there appears less inclination PLASTIC OPERATIONS OX THE FACE 525 to contraction and drawing in than in lips restored without any mucous membrane according to other methods. The upper lip can be restored either by sHding the surrounding parts or by forming lateral pedunculated flaps. Fig. 991 Fig, 992 Dieffexbach's Sincous In'cision Fig. 993 Dieffenbach makes incisions on both sides, which encircle the alae of the nose and ascend to one-half their height. Next, he detaches the soft parts sufficiently from the upper jaw, draws them down and over the margin of the teeth, and unites them in the median line under the nose {sinuous incision, Figs. 991-993)- If, by this means, the flaps do not become sufficiently movable, a curved incision may be added on each side in an outward direction (Fig. 991 ). Fig. 994 Fig. 995 BrUXS'S CHElLOPLAiTY It is better, however, to form two lateral flaps from the cheek, which, having been detached from the bone, may be united in the median line {Brims, Figs. 994, 995). The method of Sedillot is also applicable in certain cases. He cuts out from the lower region of the cheek tzvo lateral sqiiare flaps with upper bases, and turns them up over the under lip (Figs. 996, 997). 526 SURGICAL TECHXIC Fig. 996 Fig. 997 Sedillot's Cheiloplasty STOMATOPLASTY (STOMATOPOESIS OR PLASTIC SURGERY OF THE MOUTH) This is made in cases of contraction of the oral orifice, which most fre- quently ensues from cicatricial contraction after ulcerations, but which also occurs congenitally. The procedure of Dieffcnbach is as follows : From the oral orifice, tii.'o lateral incisions are made through the ivholc thickness of tJie cheek to answer the dimensions of the new mouth (Fig. 998). Next, tJie mucous vienibrane is sewed to the skin; if this does not succeed easily, on account of the Fig. 998 Fig. 999 Dieffenbach's Stomatoplasty (Plastic surgery uf the mouth) cicatricial condition of the skin and the mucous membrane, the latter for some distance is dissected off from the underlying tissues and thereby made more movable. A complete lining of mucous membrane should be carefully obtained especially at the nezu angles of the nioiith. Since a new contraction of the rima oris can be prevented only when the mucous membrane unites with the angles of the mouth by first intention, it is advisable to sew the PLASTIC OPERATIONS ON THE FACE 527 mucous membrane into the angle in the form of a small triangular flap {Roser, Fig. 999). To prevent recurrence of the contracture, the wear- ing of an artificial mouth {^Hiieter) for some time after the operation is advisable. The artificial mouth con- sists of a hard rubber tube, the size of which corresponds ' ^\'^„ , to the new mouth; it is similar in shape, as illustrated in cordingtoHueter) Fig. 1000. MELOPLASTY (plastic surgery of the cheeks) In extirpating tumors of the cheek, the cheek may be incised from the angle of the mouth as far as the margin of the masseter down to the adipose tissue ; this is partly removed and partly pushed aside. The tumor, in order that its limits may be more easily determined, is pushed outward with the finger introduced into the mouth, and with curved scissors is excised com- pletely by cutting through healthy tissue. The wound is sutured through- out ; the defect of the mucous membrane is tamponed, and, after four or five days, is cover'ed with TJnerscJi's grafts. These skin grafts in the course of time resemble the mucous membrane, and no contraction results {Ezvald- Albert). Smaller defects of the cheeks may be closed by detaching tht surrounding soft parts sufficiently from mucous membrane, so that the latter can be united by suture in any direction. Especial care must be taken, however, that the traction of the sutures does not cause other deformities (ectropium, distortion of the rima oris and the alas of the nose). If sufficient mucous membrane is still at hand, a smaller defect may be closed successfully by two pedunculated y?c7/'jr_//-6'w the mucous menibrane of the cheek and that of the lips {Ob erst). In larger defects, flaps must be formed from the surrounding parts ; by stretching and sliding \h& defect is covered; Figs, icxdi— 1004 may serve as examples. If the mticons membrane in these places is deficient, and the mouth can- not be opened, as is the case in most instances, this condition would be increased by a contraction of the flaps. To prevent this a portion of the lower jaw may be sawed out, so that 2^ false joint is formed {Es march, see page 492) ; or a flap of skin with the epidermis as a cover may be turned into the defect, and over this another flap of skin ; or, finally, the attempt 528 SURGICAL TECHNIC may be made by skin transplantation to cover with skin a pedunculated flap already formed at its wound surface before its transplantation into the defect ( Thiersch). Bayer forms a large-sized flap from the mucous membrane of Fu;. looi V\(;. icx)2 MELorLASTV (Plastic surgery of the cheeks) BY stretching a Pedincilated Flap the palate. The flap of skin to be applied over this surface is taken from the submaxillary region. From the immediate surroimdings of the defect Kraske forms a flap which is turned into the defect ; this flap may heal in, though its pedicle co)i- sists only of subcutaneous tissue {Gersuny). Having been sewed into the defect, its epidermal surface forms the inner side of the new cheek, while its wound surface, as well as the place from which it has been taken, is covered by Tliierscli's skin grafts (Figs. 1005, 1006). This procedure may Fiu 1003 Fig. 1004 Meloplasty by sliding Two Pedunculated Flaps result satisfactorily if performed in one sitting ; still, in the male, the hair of the beard growing into the buccal cavity causes great inconvenience. Although it has been observed several times that the inverted skin became PLASTIC OPERATIONS ON THE FACE 529 similar in structure to the mucous membrane, and that the follicles of hair were destroyed, still Israel and Hahn have devised procedures which, they Fig. icx)5 Fig. 1006 Kraske's Meloplasty claim, avoid this unpleasant condition by supplying large flaps of skin with- out hair, taken from viore remote parts of the body (neck, breast). Israel cuts a long flap 02ct of the skin on the side of the neck, which remains attached at the base. He turns this flap over and sews it with its anterior half to the margin of the mucous membrane of the defect, so that the epidermal surface lies inward toward the buccal cavity (Fig. 1008). Fig. 1007 Fig. 1008 Israel's Meloplasty Fig. 1009 ■After this piece has healed in — from fourteen to seventeen days — the pedicle is severed, and the posterior portion, which has now become free, is 530 SURGICAL TECHNIC likewise turned over, and, after all granulations have been scraped off, is sewed to the former (wound surface being in apposition to wound surface) so that the new-formed portion of the cheek consists of a double layer of skin (Fig. 1009). The angle of the mouth is covered with skin by displacing the vermilion border of the lips (see page 519), and the posterior opening at the place where it was turned over is vivified and sutured. In a similar case, I have taken a long flap from the skin of the neck, the pedicle of which lay directly by the side of the margin of the defect. By turning over the lower half, I doubled it and sewed it into the defect, so that the place where it was turned formed the new angle of the mouth. It is rather difficult, however, to apply the suture, since first the inverted end of the flap must be sewed to the remainder of the mucous membrane, and next the external part to the margins of the wound of the skin. The place from which the flap has been taken may be closed by suture throughout its whole extent. RHINOPLASTY (plastic surgery of the nose) Restoration of the nose may be attempted if it has been destroyed by trauma, tubereiilosis, syphilis, and neoplasms. According to the procedure by which either the whole nose or only por- tions of it are to be restored, we distinguish total and partial rhinoplasty. TOTAL rhinoplasty I. By forming a flap front the skin of the forehead {so-called Hindoo method). {a) In case of loss of the soft parts of the whole nose : — For determining the size of the flap, a model of leather or of adhesive plaster is made and fitted to the defect to be restored. In making the model, the following proportions are to be observed : — The lower dimension of the nose, measured over the tip, must be equal to the distance from the lower angle of the eye to the angle of the mouth — about 7 centimeters ; the length of the bridge of the nose must be equal to the distance from the limit of the hairy scalp to the glabella ; the longer the septum is made, the higher the nose becomes. In order to obtain a curved (Roman) nose, the lateral margins of the flap are somewhat curved; straight lateral margins produce a form more like the Grecian. PLASTIC OPERATIONS ON THE FACE 531 The flap of skin has been made in very different ways by various sur- geons ; compare Fig. lOio. After the form and the size of the flap have been determined upon and cut out in adhesive plaster, the model is fastened on the forehead over the Fig. loro. Models for Rhinoplasty (Plastic surgery of the nose), i, original Hindoo model; 2, 5, Dieffenbach's models; 4, von Ammon-Zeis's model; 3, 6, 7, 8, von Langenbeck's models nose, tJie pedicle of t lie flap being directed obliquely toward the margin of one of the orbits, so that the angular artery is included in the vascular bridge (Fig. loi i). The operation is then performed as follows : — The patient is placed in a half-sitting position under mixed chloroform narcosis (previous injection of maximum dose of morphine). By this means, during the entire operation, even when the application of the chloroform mask is no longer possible, a condition of painlessness is produced, whilst the patient still responds to requests. 1. First, the remainder of the diseased nose is vivified in equiangular form by making deep incisions along the margin of the defect as far as the site where the alae of the nose are to be implanted. Above the philtrum, a small triangular slit is made with the knife on the place where the new sep- tum is to be implanted. The margins of the lateral incisions as well as the upper lip are detached from the bone outwardly to the extent of about \ centimeter. 2. With a sharp knife, the model fastened to the forehead is circum- scribed accurately everywhere down to the bone. The internal or lower margin of the pedicle in the neighborhood of the angle of the eye is made to terminate in the upper angle of the wound of the vivified remainder of the nose ; the external or upper margin is deflected outwardly above the 532 SURGICAL TECHNIC eyebrow in the shape of a hook. By this means, traction and tearing in turning the pedicle are avoided as much as possible. The flap of skin thus circumscribed by the knife is detached from the bone together with tJie peri- osteum, and the adhesive plaster is removed ; the flap is then turned dozvn- ward so that it hangs in front of the nasal cavity. 3. Before the flap is sutured, it is advisable to reduce the large wound of the forehead by suturing the angles of the wound, as far as this is pos- sible without too much tension. The defect remaining in the middle can be covered immediately or at the end of the operation by Thiersch's or Wolfe s skin grafts (Fig. 1012). In the meantime, hemorrhage from the flap hanging down in front has ceased and it has turned pale ; it is then sutured in proper position. Fig. ioii Fig. 1012 Total Rhinoplasty (Hindoo method) by a Flap from the Skin of the Forehead 4. First, the piece of flap designed for the septum is vivified superficially with a sharp knife at its lower angles and is lightly folded lefigthwise ; it is then sewed with interrupted sutures into the triangular incision above the philtrum ; next, the alee of the nose are formed by tiwjiing over in an ijiward direction the two lateral angles. They are fixed in this folded condition by a loose quilt suture applied throughont the whole thickness of the new ala of the nose, and the posterior sides are stitched to the freshened lower angle of the wound of the defect by button sutures. Then, the lateral margins are carefully sewed into the fold of the wound with numerous button sutures. PLASTIC OPERATIONS ON THE FACE 533 Near the twisted pedicle, the sutures must not be applied too closely ; it is best to insert them alternately. Two rubber tubes, wrapped with iodoform gauze, are inserted into the newly formed nostrils to counteract the great tendency to form adhesions and also to press gently together the upturned margins of the skin (Fig. 1012). Even after the wounds have healed, the tubes must be worn for a long time. In order to remedy this troublesome inconvenience, iwn Volkmann advised not to sictiire tJie septum but to leave it hanging down ; in the course of heal- ing, it rolls up inwardly into the nose and leaves sufficient passage for the entrance of air. At the same time, by means of this round swelling, there is formed a passably good tip for the nose, the good appearance of which in all methods leaves more or less to be desired. If, afterward, an improve- ment of the deformity is desirable, the septum may be formed by a subse- quent operation (see page 541). The best dressings after rhinoplasty are small strips of iodoform gauze or small compresses of linen covered with boric salve, applied over the sutures so that the surgeon can always observe the condition and the color of the new nose. The sutured and grafted large wound in the forehead may be protected by a light antiseptic dressing. K pale c^/^r exhibited by the nose on the following day is rather a favorable sign ; during the next few days it turns pale-pink, and finally assumes the normal color. If, however, it is discolored, bluish red or dark brown, then, in most cases, a partial failure of the operation, on account of partial gangrene, is to be feared ; sometimes the application of leeches renders good service. The deformity from tzvisting of the pedicle, at first very disfiguring, is removed afterward by a simple excision of the prominence ; likewise, several smaller operations may become necessary to improve the cosmetic result. All these operations, however, must not be made too early ; at any rate, not before the fourth to the sixth week, since the new nose changes more and more by subsequent contraction (in most cases disadvantageously), especially if the hoped-for ossification of the pericranium is limited or does not set in at all. ib) In cases of the loss of the whole nose together with its bony structure, the new nose, formed in the manner described above, contracts from want of support, and becomes more and more flattened. To prevent this condition, surgeons have endeavored, by suitable lining with bone-producing tissue, to give greater support to the soft parts of the nose. 534 SURGICAL TECHNIC Vo7i Langoibeck thought that greater soHdity or strength might be given to the nose by including the periosteum in the soft tissues taken from the forehead. He conceived also the plan of forming a flap with a bony framework ( " knochenspange " ) corresponding to the new bridge of the nose ; this has been successfully done by von Hacker in recent times. Huetcr formed from the skin of the remaining portions of the nose a flap, which he turned downward so that its wound surface appeared exter- nally. Upon this the flap of skin taken from the forehead is applied. Owing to the tendency of the twisted flap to assume its former position, the bridge of the nose may remain somewhat raised {^elastic support flap — " federnder stiitzlappen " ) (see also Fig. 1014). Fig. 1013. Thiersch's Rhinoplasty Fiu. 1014. Verneuil's Rhinoplasty TJiierscJi used two lateral qnadrajigular flaps from the skin of the cheeks for lining the nostrils ; these flaps he sewed together in the median line with the wound surface outwardly, and over them applied the flap from the forehead ; the large defects thus caused are covered by skin grafts (Fig. 1013). Verncitil and Bonisson proceeded in a similar but reversed manner ; they used the flap of the foreJicad for lining and covered it by two lateral flaps from the cheeks (Fig. 1014). Von Langenbeck attempted to restore the bony frameivork of the nose by an osteoplastic p7'ocednre ; he raised the bony support of the nose, which in most cases was sunken in, but which still existed in fragments, together with the callous masses produced by the chronic course of former ulcerations. After the pyriform aperture has been laid free by a median incision running from the nasal process of the frontal bone downward, and the skin has been somewhat dissected backward toward both sides, the operator, with the PLASTIC OPERATIONS ON THE FACE 535 metacarpal saw, saws off from the margin of the pyriform aperture on both sides a small strip of bone which, at its lower end, remains in connection with the superior maxillary bone (Fig. 1015). The trabeculas thus formed are raised perpendicularly with the elevator, and the flaps of skin previously detached are fastened to them ; next, the depressed nasal bones are sawed off on both sides from the nasal process of the superior maxillary bone and slowly raised with the elevator ; the connective suture between the nasal and the frontal bones forms the hinge joint (ginglymus). Over tJiis supporting framework, arranged like the raftei's of a roof, the new nose formed from the skin of the forehead is now applied in the above-mentioned man- ner (Fig. 1016). In cases where the operator succeeds, in consequence of the great flexibility of the bone, in so raising these supports that their vascular bridge does not break off or does not become infracted, the result of this skil- ful operation is very beautiful ; but in most cases necrosis sets in. Kdnig took from the forehead a skin-bone flap by cutting from the gla- bella a small square strip ; he then chiselled out with a sharp chisel a thin lamella of bone from the cortical layer of the frontal bone which remained in close connection with the flap of the skin and represented its inner sur- face. This flap was turned downward over the nasal defect, and the flap consisting of the soft parts of the forehead was fastened to the new bridge of the nose thus formed (see page 542). In the following manner Schimmelbitsch obtained a perfectly bony nose with very good permanent results : — I. After division of the skin, the operator, with a broad chisel as sharp as a knife, chisels out from the most superficial layer of the frontal bone a skin-bone flap, the base of which is from 7 to 9 centimeters wide, with the upper border corresponding with the limit of the hairy scalp; great care should be taken that the thin lamella of bone does not break. This flap is elevated and wrapped with iodoform gauze. The defect of the forehead caused thereby is at once united by sliding the margins of the skin (Jasche). The incisions for the flap run in the form of a curve from the angles of the Fig. 1015 Fig. 1016 Von Langenbeck's Osteoplastic Framework of the Nose 536 SURGICAL TFXHNIC defect along the limit of the hairy scalp, which has been shaved as far as the temporal region (Fig. 1017). 2. After 4-6-8 weeks, when some portions have become detached by necrosis and the whole surface is covered with granulations, these granula- tions are removed with the knife, and the inner surface of the bone flap is covered with small skin grafts ( TJiierscJi). 3. If this skin grafting has succeeded, the flap is raised in the form of a nose and inserted with its vivified margins into the freshened remainders of the pyrlform aperture, in such a manner that the laminae of the bone are in exact apposition. For securing the elevation of the profile and for indicating at the same time the indentations of the alas of the nose, a metal wire is passed through Fig, 1017 Fig. 1018 Schimmelbusch's Rhinoplasty the lower portion of the new nose and is fastened on the outside by two but- tons or plates. If a sept2i.vi is also to be made, it is taken from the cutaneous covering of the pyriform aperture. Two thin lateral flaps are detached from the lower margin of the aperture toward the median line as far as the normal point of insertion of the septum. These are sewed together and to the tip of the nose (Fig. 1018). For saddle noses the procedure is the same, only the flap is not trans- planted but grafted outwardly with the scraped granulation surface and in- wardly with the surface of the skin. The skin of the former depressed nose, having been divided lengthwise in the median line, is drawn directly over the wound surface and detached widely on both sides. II. If, on account of cicatricial conditions, the skin of the forehead is not well adapted to plastic purposes, otJicr parts of the face must be utilized in furnishing the material for the defect. N'e'Iatoji restored the soft parts of PLASTIC OPERATIONS OX THE FACE 537 Fig. 1019. Nelaton's Rhinoplasty BY Flaps from the Cheek (French method) the nose by tivo quadrangiilar lateral flaps from the cheek, which had their base at the bridge of the nose and the inner angle of the eye ; for the formation of the septum, one of the flaps must have a square appendage (so-called French method. Fig. 1019;. III. If the entire face presents no available skin for transplantation, no choice is left but to form the new nosQfroni the skm of the arm, ac- cording to the method of Tagliacozza (professor at Bologna, 1597, " De curtorum chirurgia per insitionem ") and 6"r<2/k ( 1 8 1 6) (Italian method). For this purpose, a flap with a double pedi- cle is formed from the middle of the arm by two incisions ; a little gauze placed beneath the flap prevents it from uniting with the under- lying parts. When the cicatricial contraction commences in the flap, one bridge is divided, and the wound surface is sewed to the vivified nasal defect. If the healing proves successful, the other bridge on the arm is also divided (Fig. 1020). When the Italian method is employed, the arm must remain securely fastened to the head in a fixed position (by bandages or plaster of paris dressing) ; the patient inhales constantly the se- cretions of the granulating sur- faces of the wound, and the new nose, on account of the inferior value of the skin of the arm as compared with that of the face, is more heterotopic and possessed of less vitality, and progressive contraction is the rule. These disadvantages have prevented the Fig. 1020. Tagliacozza and Grape's Rhino- ^^^^^^ ^^^^^ ^^.^^ adopted to any considerable extent. At best, it substitute for the Hindoo method. 1020. Tagliacozza and Grape's Rhino- plasty BY A Flap from the Arm may, in case of necessity, serve as a 538 SURGICAL TECHNIC In recent times, however, it has been occasionally used with success. For example, Israel restored the nose in order to avoid the disfiguring frontal cicatrization by transplanting a skin-bone flap taken from the ulnar side of the foreaTui, the bon^; part of which consists of the border of the ulna lying directly vmder the skin (Fig. 1021). In the case of a saddle nose, he corrected the deformity by transplanting a fragment of bone sawed off from the tibia. With all these methods, nevertheless, the new-formed nose often leaves much to be de- sired. Moreover, it has still a tendency to slough, and, in many cases, to contract more and more in the course of time. Hence, a surgeon who desires to obtain permanent suc- cess is wise in making the nose from the start large enough to make due allowance for con- traction. A much better cosmetic result may be ob- tained by the nasal protheses now manufactured in excellent form from vulcanized rubber (Saner) or celluloid {Kleinmann), especially since, in fitting, the most suitable form may be found for the physiognomy of the patient by using noses cut out of masks (Kleinmann) or from the Fig. 1021. Israel's Rhinoplasty I'iij. 1022 Tiemann's Nasal Protheses Fig. 1023 models of ■s>z\\\^^X.ox's> {Gronzvald). These protheses are held in place by a spectacle frame (as in masks) or by two wires extending in the form of pincers with a support on the margins of the pyriform aperture, or the PLASTIC OPERATIONS ON THE FACE 539 remains of the turbinated bones. The line of application is made invisible as much as possible by colored collodium or zinc paste (" zinkleim "), etc. Simple pasting on without a supporting apparatus does not furnish the necessary support. PARTIAL RHINOPLASTY serves to supply separate portions of the nose ; for instance, one-half a nose, one ala, the tip, or the septum. If one side of the nose is lost by injury or disease, it can be supplied by the Hindoo method of turning down from the skin of the forehead a flap in the form of a divided nose model, and by sewing it into the defect. In the same manner, larger or smaller defects of the bridge of the nose can be cov- ered by narrow flaps from the forehead formed in accordance with the defect. If the loss involves the ala of the nose and the skin overlying the same, the flap is taken />'^;;/ the other half of the nose {von Langenbeck). Fig. 1024 Fig. 1025 Von Langenbeck's Method of restoring an Ala of the Nose FROM THE Other Half of the Nose A small rectangular flap is cut out from the healthy side, whose base is at the inner angle of the eye of the diseased side, whose sides extend obliquely over the bridge of the nose, and whose lower transverse incision terminates closely over the margin of the healthy ala of the nose ; the flap, detached from its base, and a few millimeters longer than the defect, is turned over the remaining " spur " toward the diseased side and sewed in position. By (cicatricial) contraction of its lower free margin, the new nostril assumes the same form as the healthy one, whilst the secondary defect heals by granulation or is grafted at once with skin ( TJiiersch). The success of this operation is excellent (Figs. 1024, 1025). 540 SURGICAL TECHNIC Smaller defects of the alae of the nose are covered either by drawing over pedunculated flaps from the neighboring skin of the cheek (Figs. 1026, 1027, 1028), or by shding down a V-shaped flap, and by applying a Y-shaped suture Fig. 1026 Fig. 1027 Fig. 1028 Restoring an Ala of the Nose by Pedunculated Flai-s FROM the Cheeks according to Dieffenbach, (Figs. 1029, 1030). From the upper lip also a restorative flap can be obtained as represented in Fig. 1027 {O. Weber). Smaller defects of the tip of the nose may be restored in many different ways by the tissues of the nose itself ; for example, by forming small flaps with a vascular bridge in a suitable position, and by sliding. Secondary defects become more and more obliterated, until they are scarcely noticeable. W. Busch covered a defect which occupied the tip and one ala of the nose "'^^ Fig. 1029 Fig. 1030 Forming Nostril by sliding a Small Flap Fig. 1 03 1 W. Busch's Method of restoring the Tip of the Nose and the Ala by a lateral pedunculated flap from the skin of the bridge of the nose and the glabella (Fig. 103 1). The procedure of Hiteteris original ; he transplanted as a substitute for the tip of the nose the plantar eminence of the little toe, excised by a cuneiform incision. PLASTIC OPERATIONS ON THE FACE 541 FOR RESTORING THE SEPTUM may be used : — I. The skin of the philtrum of the upper lip {Diejfenbach). By means of two perpendicular incisions throughout tJie ivhole tJiickness of the hp, its middle portion is excised and turned up so that the mucous membrane lies Fig. 1032 Fig. 1033 Dieffenbach's Method of restoring THE Septum Fig. 1034 Fig. 1035 Von Langenbeck's Method of restoring THE Septum externally. The flap is then sewed to the portion of the nostril, previously vivified, and the wound of the lip is closed completely by suture (Figs. 1032, 1033)- 2. The skin of the upper lip, from which an oblique flap is formed with an upper base. By lateral sliding, it is sewed into the nares ; the pedicle must be cut off subsequently and placed in the middle {yon Langenbeck, Figs. 1034, 1035). 3. The skin of the bridge of the nose, from which a small flap is formed and turned down laterally {Hueter, Figs. 1036, 1037). y^ Fig. 1036 Fig. 1037 Hueter's Method of Restoring the Septum The correction of saddle noses or of collapsed noses, the bones and carti- lages of which have been destroyed by ulcers or injuries (saddle noses), in most cases is not permanently successful, if only flaps of skin are employed without any solid support, because, owing to the contraction of the new skin structure, the deformity soon recurs. 542 SURGICAL TECHNIC In cases in which the cartilaginojis frmnework is still partly preserved, but the tip of the nose is deeply depressed and retracted (^retrousse'), von Langenbeck proceeded as follows : — By a convex transverse incision in an upper direction, he divided the tip of the nose one wing from the other, and with a sharp hook drawn down- ward and forward, he brought it out of its recess. In the defect thus produced, of a semilunar form, he implanted a pedunculated flap correspond- ing in shape, taken from the skin of the forehead, turned down and fastened by sutures to the lateral margins and the nasal eminence (Figs. 1038-1041). Fig, 1038 Fig. 1039 Fig. 1040 Fig. 1041 Von Langenbeck's Method of correcting Collapsed Noses Konig formed a bony bridge of the nose by a flap from the bone and the soft parts of the forehead. After a transverse division of the soft parts of the nose at its deepest point, a flap of skin about i centimeter wide is cut out from the middle of the forehead with its base at the glabella (Fig. 1042). This strip of skin, together tuith the periosteum and a thin lamella of bone, is detached with a small chisel from the frontal bone, turned straight downward in such a way that the bone surface lies outward, and sewed together with the eminence of the nose, which has previously been made movable (Fig. 1043); over this bony support, the new nose is then formed according to the Hindoo method. But in order to obtain the normal depression between forehead and nose and a narrower dorsum, he divided the connecting bridge of the frontal flap and implanted it more deeply. Israel allowed the skin-bone flap first to become covered with epidermis, then he divided the underlying skin of the nose lengthwise in the form of two door-shaped flaps, which he fastened laterally to the vivified bony sup- port, thus forming the lateral surfaces of the nose. The frontal flap consists of a lamella of bone only 4 millimeters wide, around which the portion of PLASTIC OPERATIONS ON THE FACE 543 skin at least 2 centimeters wide is united. Upon this newly formed nose, covered with epidermis, the skin of the saddle nose is implanted subsequently. Oilier made two incisions around the nose, which, beginning at the alae, converged at the glabella at an acute angle, included at this place the peri- osteum in the flap, and transplanted its point about 4 centimeters downward, fastening it in this position. Analogous to the blepharoplasty of DiejfenbacJi, the skin of the bridge of the nose thereby becomes more abundant anteriorly, and the tip is forced downward. Fig. 1042 Konig's Rhinoplasty Fig. 1043 Fig. 1044 Miciilicz formed a septum from the existing depressed soft parts. He detached them on the margin of the pyrif orm aperture by two lateral incisions, turned them toward the median line, and sewed their vivified surfaces together. Over this newly formed septum, which is in connection only with the mem- branous septum, a new nose was constructed. The procedures of Schwimel- busch Tpage 535) and of Israel (page 538), described above, have also been used for the correction of saddle noses. If all these attempts result unsatisfactorily, the surgeon must content him- self with artificial protheses, which are made of gold, caoutchouc, amber, etc. ^yrdpdd raised many saddle noses with permanent good success by wire, hard rubber, and soft caoutchouc protheses, which form a kind of artificial septum, and which are inserted from the inside through an opening in the hard palate. In a simultaneous destruction of the nose and the upper lip, which not seldom occurs in consequence of syphilis and lupus, the restoration of these parts can be made in one sitting (Fig. 1044). For this purpose as mucJi as possible of the existing useful portions of skin is saved, some of which are used for covering, others for lining, the nasal passage. PLASTIC OPERATIONS FOR CONGENITAL FISSURE FORMATIONS OF THE ORAL REGION I. HARELIP AND MAXILLARY FISSURES Most of these operations can be made ivinicdiatcly after birth. In serious cases, however, it is advisable to wait until the children have grown some- what older (one to two years), in order to have better-developed portions of skin at the disposal of the operator. Moreover, in maxillary fissures, by a preliminary operation and by properly applied pressure, the margins of the fissure can be approximated considerably. Older children may be operated upon under anaesthesia, and, if prefer- able, with the head in a dependent position {Rose) ; infants ought not to be chloroformed ; they should be either fastened in an upright position to the operating table or else held securely in a sitting position by an assistant. At each side, an assistant, by pressure with his fingers and with sponges, can control the hemorrhage from the lip ; and any blood flowing into the mouth is removed with sponges provided with a holder. A. SINGLE CLEFT OF THE LIP (hARELIP) The simple vivifying of the margins of the cleft with subsequent sutur- ing in most cases leaves a disfiguring depression from the ensuing contraction of the cicatrix. The following procedures, therefore, endeavor to avoid this depression and to procure an adequate length for the lip. Fig. 1045. Vivifying Fig. 1046. Wound Fig. 1047. Suture Nelaton's Operation for Harelip In incomplete clefts of less degree not extending to the nostril, the surgeon may proceed in various ways according to their depth. 544 PLASTIC OPERATIONS OF THE ORAL REGION 545 1. Nelaton divides the lip above the angle of the cleft parallel to its margins. Next, he draws down the angle of the cleft and unites the rhom- boidal wound lengthwise, in such a manner that a prominence is produced, which subsequently, by cicatricial contraction, disappears. 2. J. Wolff, according to von Langejibeck' s method, cuts off the entire border of the lip as far as and close to the angles of the mouth, draws it down, and unites the margins of the wound lengthwise. Bv a horizontal Fig. 1048. Vivifying Fig. 1049. Wound Fig. 1050. Suture Von Langenbeck's and Wolff's Method of Distortion of the Margins OF THE Lips suture he attaches the margin of the lip to the newly formed upper lip, after he has cut off as much from the vermilion border of the lips as to leave only a moderate projection. This is again united by a longitudinal line of sutures {^distortio7i of the margins of the lips). 3. Malgaigne makes a semicircular incision around the angle of the cleft. At both ends of this incision, he makes two smaller incisions on the Fig. 105 1. Vivifying Fig. 1052. Wound Malgaine's Method Fig. 1053. Suture lip obliquely outward and downward, turns the segments tJins formed down- ward, and sews together in the median line the margins of the cleft thereby extended. 4. Miranlt excises only one little flap from one margin of the cleft (best, the lateral). He vivifies the other margin correspondingly in the form of an 2 N 546 SURGICAL TECHNIC angle, and forms the margin of the Hp by sewing the flap to the oblique marefin of the wound of the other side. Fig. 1054. Vivifying Fig. 1055. Wound Fig. 1056. Suture MiiiAULT's (Vox Langenbeck's) Method 5. Giraldcs forms at the lateral margin a small flap ivitJi a lozvcr base ; from the apex of this, he makes an incision outwardly and beneath the ala of the nose. From the inner margin of the cleft, a small flap is cut witJi an upper base, which, on being drawn upward, forms the lower margin of the nostril, whilst the little flap of the other side is drawn down and used as a border for the lip. Fig. 1057. Vivifying Fig. 105S. Wound Giiij\Li)£s' Method Fig. 1059. Suture These older methods have been modified in many ways in recent times, and have been improved by Konig, Maas, and Hagedovn. The mode of making the incisions purposes to elongate the margins of the wound as much as possible ; the details of the method may be seen in Figs. 1060- 1068. Fig. 1060. Vivifying Fig. 1061. Wound Konig's Method Fig. 1062. Suture I, myself, since 1854, in all these formations of clefts (especially in somewhat older children, where sufficient soft parts are at the disposal of PLASTIC OPERATIOXS OF THE ORAL REGION 547 the surgeon) have proceeded according to "■ the principle of ecojiomy,"'' estab- Ushed by myself. That is, along all the margins of the cleft, I cut around Fig. 1063. Vivifying Fig. 1064. Wound !Maas's Method the flaps exactly at the limit of the vermilion border of the lips, retrovert the mucous membrane, and sew together with the finest sutures the flaps of the mucous membrane, so that thev form a basement membrane with the Fig. 1066. Vivifying Fig. 1067. "Wound Hagedorx's Method Fig. 1068. Suture surface of the wound turned in an anterior direction ; upon this, I slide the margins of the skin together and unite them by sutures (Figs. 1069, 1070). This procedure is more laborious and requires more time than any of the others, and on that account it is applicable only in the case of older Fig. 1069. Vivifying Fig. 1070. Suture Vox Esmarch's Method children ; but it produces by far the most satisfactory cosmetic results, especially when the lip is sufficiently detached from the jaw by deep incisions 548 SURGICAL TECHNIC beginning at the duplicature of the mucous membrane, thereby rendering the Hp more movable. The Hberation of the lip is of the greatest importance in all these operations. B. DOUBLE HARELIP In double harelip, the median peninsula is vivified according to the methods just described and then united with the lateral portions. For this purpose, it is especially important to be as economical as possible with the existing soft parts; that is, not to cut away anything that might be used. Fig. 107 1. Mvifyinj Fig. 1072. Wound ^L\As's Method Fig. 1073. Suture The median portion must be cut around along the margins of the mucous membrane, so that either a square margin {von Langenbcck) or a round margin (7'(?// EsmarcJi) oi the wound is secured; to this the fresh lateral Fig. 1074. Vivifyinii Y\G. 1075. Wound Hagedorn's Method Fig. 1076. Suture margins are sewed in various ways. If the margins are not sufificiently wide, they may be extended by lateral incisions and by sliding together Avithout any tension {Maas, Hagedorn, Figs. 1071-1076). C. DOUBLE HARELIP AND MAXILLARY FISSURE The protuberance (Biirzel), or premaxillary bone, which is present in these cases, as a rule projects considerably ; it is, therefore, necessary to force it back before the union of the clefts of the lip is made. PLASTIC OPERATIONS OF THE ORAL REGION 549 The procedure of Bardeleben is most suitable for this purpose. He divides the vomer siibperiosteally immediately beJiind the iitterniaxillary bone. For this purpose, he makes on the lower margin of the vomer and exactly in the median line an incision about i centimeter in length down to the bone, in order not to injure the nasopalatine arteries, which lie on each side (Fig. 1077), Next, with a fine spatula, he detaches on both sides the muco- periosteal covering, pushes the points of bone-cutting forceps perpendicularly upward under the periosteum on both sides of the vomer, and divides it throiigJiont its ivhole extent. By pressure upon the protuberance (Biirzel) anteriorly, the two bone plates are now made to overlap each other, pressing the projecting premaxillary bone back into the maxillary fissure (Fig. 1078). Fig. 1077 Fig. 1078 Bardeleben's Method of forcing back the Pre- maxillary Bone Fig. 1079. Forcing back Premaxillary Bone by Elastic Traction In order to retain the intermaxillary bone in its new position, the child is supplied with a little cap, to which a rubber band is fastened in such a manner that it comes to lie directly across the upper lip under the nose, keeping back the protuberance without preventing the child from taking nourishment (Fig. 1079). This arrangement is better than the " Thiersch butterfly,''' in which the rubber band is kept in position by strips of adhesive plaster, fastened to the cheek, since the adhesive plaster is very apt to produce eczema. When the protuberance is broader than the intermaxillary space, enough of the lateral margins of the premaxillary bone must be cut off with bone- cutting forceps to fit into the cleft; it is then fastened in position in the cleft with silver wire. If tooth germs are found when incisions are made, they may be scooped out with a small curette. The union of the clefts of the lips may be made at once ; it is better, however, to do this later, when the soft parts are more developed. 550 SURGICAL TECHNIC TJie simple excision of a cimcifoi'm portion froju the vomer together with its coverings, according to Blandin, is less practical because the premaxillary portion remains movable and hemorrhage from the severed nasopalatine arteries may prove very troublesome. The artery, however, may escape injury in the de- tached periosteum if the cuneiform excision is made subperiosteally according to C::erny. The procedure of Simon does not produce good results. He liberated the lateral flaps by curved incisions around the alae of the nose and by lateral incisions so far that the flaps were sufficiently movable and could be sewed to the vivified lateral margins of the projecting premaxillary bone ; in this case, he did not pay attention at first to the defective appearance of the .lip thus formed ; only afterward, when by the stretching of the lateral flaps the premaxillary bone had been replaced backward sufficiently, was the lip restored. Fig. 1080. Blandin's Method of resecting cuneiform portion FROM THE Vomer Fig. 1081. Vivifying Fig. 10S2. Temporary stitch- ing of lateral flaps Simon's Method Fig. 1081. Suture The simple excision of the whole premaxillary bone is under no circum- stances justifiable, because permanent deformity of the oral region remains as an inevitable consequence. D. SINGLE HARELIP AND CLEFT PALATE In this case, tJie premaxillary bone projects very obliquely toward the other side and thus forms a great obstacle to the union of the soft parts. In order to make it movable and to displace it backward, a spoon-shaped gouge chisel, with some force, is pushed upward from below, at the place where the intermaxillary bone unites with the alveolar process, through the margin of the jaw, until the intermaxillary portion can be turned around its axis and pressed into the cleft of the jaw, where it is then held in position PLASTIC OPERATIONS OF THE ORAL REGION 551 by the elastic band attached to the cap ; the union of the soft parts can be made immediately or at a subsequent time. For the removal of the projecting premaxillary bone and the lateral deviation of the tip of the nose toward the healthy side, Saviter advises section of the cartilaginous septum of the nose with scissors by an incision ascending almost perpendicularly between the upper lip and the premaxillary bone, whereby the tip of the nose is made movable. On the other hand, J. Wolff does not employ any of the methods of reposition, because in his opinion the upper lip subsequently recedes too much. II. CLEFT PALATE This congenital defect very often presents itself in connection with harelip. Formerly surgeons postponed operative procedures until the children were sufficiently advanced in age so that they were intelligent enough to be subjected to the operation. In most cases, however, they desired the opera- tion of their own accord. In modern times ■z'£'7;r ea7'/j' closure has produced even better results ( Wolff), because children learn to speak with greater facilitv. At any rate, it seems to be safer not to operate on children during the first year, but somewhat later, — at the age of five to seven years. (Dr. Brophy, of Chicago, operates during early infancy, and his method of operating has yielded admirable results.) In order that the operation may be successful, it is of the greatest importance to make the child practise ai'ticulation methodically for some time. The operation is best performed with the head in a dependent position under partial anaesthesia. Adults may be operated upon in a sitting position, without chloroform, in which case they can spit out the blood from time to time, and cleanse the mouth with ice-water. Severe hemorrhages are arrested by temporary tamponade. STAPHYLORRHAPHY (closure of clefts of the soft palate by suture) The operation is performed in the following manner (von Grdfe, 1816): The patient sits on a chair opposite the light, whilst an assistant fixes the head of the patient steadily ; the operator sits in front of the patient. The mouth is kept patent either by the oral speculum of Whitehead or by a zuedge of India rubber forced between the molar teeth, whilst the oral 552 SURGICAL TECHNIC opening, as far as possible, is kept widely distended on both sides by von Langenbcck' s oral retractors (Fig. 1084, //). a b c d e f g '^ i Fig. 1084. Von Langenbeck's Instruments for Staphylorrhaphy, a, two-edged pointed knife for vivifying margins in staphylorrhaphy; b, c, pointed and probe-pointed knife for separating the soft palate from the mucous membrane of the nose and the palate bone; d, curved knife for making lateral incisions; e, f, sickle-shaped knives for dividing palatal muscles; g, sharp hook; h, oral retractor; i, " diadem " The mucous membrane of the whole palate and of the base of the tongue is rendered insensible by brushing it with a ten per cent solution of cocaine. I. Vivifying margins of the cleft. With FroJiliclis (Fig. 1085, a) long hooked forceps, or a little sharp hook (Fig. 1084, g), the left apex of the bifid uvula is grasped first, drawn downivard, and made tense ; next, near the place where the uvula has been grasped, and a few millimeters distant from its margin, a small pointed knife (Fig. 1084, a), with the edge turned upward, is pushed through the whole thickness of the uvula, and, zvitJi saw- ing movemejits, carried npivard as far as and a little above the angle of the cleft (Fig. 1085). That portion of the margin of the cleft of the uvula first grasped is cut off in a downward direc- TT Q c^. ,„ , „„,r „ , //•! f tion closely along the iaw of the for- FiG. 1085. Staphylorrhaphy (Closure of j' &> J clefts of the soft palate by suture) ceps, and the upper end of the margin PLASTIC OPERATIONS OF THE ORAL REGION 553 thus detached is severed from the angle of the cleft of the hard palate. In the same manner the right margin of the cleft of the soft palate is vivified. 2. In order to relieve the tension of the margins of the wound, there may be made according to Dieffenbacli some incisions throughout the whole thickness of the soft palate. These incisions are made on both sides of the margins, and at some distance from them. It is better, according to Fcrg2isso7i and von Lajigenbeck, to divide the palatal mnscles which ele- vate the soft palate and move the palatopharyngeal pillars of the fau- ces (namely, levator veli palatini et niuscidns pJiary7igo-palatinn.s) (Fig. 1086). A pointed knife, curved like a sickle (Fig. 1084, /"), is pushed, with its edge directed upward, closely below and a little to the outer side of the hamular process of the sphenoid {haninlns pterygoi- dciis), from without inward and from before backward through the soft palate and as far as the posterior pharyngeal wall. Next, with saw- ing movements, the soft palate is divided throughout its whole thick- ness as far as the posterior margin of the palate bone (Fig. 1086, a). The trunks of the pterygopalatine artery, which take their course more anteriorly through the pterygopalatine canals, are not injured thereby. Moreover, if the tension of the margins of the wound is not too great, these incisions are superfluous. 3. The suture is best applied with von Langenbeck' s needle holder, — a curved needle bent at an obtuse angle and provided with a handle (Fig. 1088). Closely behind the point of this needle, a very fine watchspring, bent at its end in the form of a hook, can be projected by making pressure upon a little disk on the handle. The needle is inserted from before backward, close to the vivified margin of the cleft, and when its point becomes visible in the cleft, the disk is pushed forward. By this means, the hook projects from the M. Levator veli palatini M. Thyreo-palatinus AL Pharyngo-palatinus M. Azygos uvuIk Fig. 10S6. Muscles of the Soft Palate a, incision for dividing muscles, taking their origin from the hamular process of the sphenoid; i5, in- cision for separating muco-periosteal flaps in uranoplasty 554 SURGICAL TECHNIC needle and enters the oral cavity //v;;/ bcJiind forivard, through the cleft of the palate. By means of a thread carrier, an instrument which carries the suture (a guiding staff terminating in two angles — Fig. 1087), an assistant carries the loop of the suture to the little hook, and as soon as the suture is behind it, the operator allows the watchspring to recede. The hook thus \l Fig. 10S9 Applying the Suture Fig. 1087 Fig. 1088 Von Langenbeck's Needle Holder and Guiding Staff for Suture Fig. 1090 Suture completed Fig. 1091 Fig. 1092 Hagedorn's Bruns's Needle, Needle Holder provided with A Handle grasps the suture and draws it forward. The instrument, by a combined posterior and anterior movement, is now drawn, together with the suture, from the margin of the cleft ; and, after the watchspring is pushed forward, the suture is liberated from the hook. The corresponding site on the other margin of the cleft is then perforated with the needle ; and the opposite end of the ligature stretched over the suture carrier is grasped with the little PLASTIC OPERATIONS OF THE ORAL REGIOX 555 hook, and, on withdrawing the needle, the suture is drawn out of the mouth (Fig. 1089). The suturing is done with silk, commencing from the angle of the cleft and proceeding toward the apex of the uvula. As soon as all tJie snhires have been inserted in the manner described above, they are tied with a surgeon's knot and a simple knot over it, in the same order in which they were introduced, and are then cut off close to the knot. In order that the numerous threads hanging out of the mouth may not become entangled, it is advisable to fasten them to a piece of pasteboard in notches arranged corre- spondingly. CClamping the corresponding ends of the sutures with hemo- static forceps is an excellent way of disposing of them until they are tied. The traction made by the weight of the forceps adds materially to the facility in adjusting the wound margins.) Still more convenient is von Langenbeck's suture holder, — a semicircular ring of tin with clamps riveted to them ; this ring, by means of an elastic band, is fastened like a diadem in front of the patient's forehead (Figs. 1084, i, and 1085). For staphylorrhaphy, rarely rnore than three to six sutures are required. Moreover, the sutures may be applied just as well with other instruments than von Langenbeck' s instrumentarium ; the simpler these instruments are, the better. Instead of the suturing apparatus, Roser and Strouieyer used plain needle holders and straight needles. The needle holder devised by Roitx is also very practical. If the operation is performed under anaesthesia with the head in a dependent position, the sutures may be inserted very conven- iently with Hagedorn s needles and needle holder for deep sutures — the so-called " schiefmaul " (Fig. 1091). A number of complicated suturing devices have been invented ; the best known of all is, perhaps, Passavanfs, which works like the needle of a sewing-machine. Bnins s needle, pro\'ided with a handle, is essentially similar to von Langenbeck' s (Fig. 1092). URANOPLASTY (closing clefts of the hard palate by bloody suture) (^Vo7i La7igenbeck, i860) This operation is made almost in the same manner as in closing clefts of the soft palate. I. After similar preparations, the margins of the cleft of the hard palate are vivified with a convex scalpel (Fig. 1084, d). 556 SURGICAL TECHNIC 2. To relieve tension of the margins of the zuound, two lateral incisions ( Warreii) are made through the coverings of the palate (mucous membrane and periosteum) down to the bone, running closely along the alveolar arcJi, beginning posteriorly at the hamular process of the sphenoid and ending anteriorly between the external and the middle incisors, so that anteriorly they form a bridge i centimeter wide adhering to the alveolar process, while posteriorly an uninterrupted connection with the soft palate remains (care should be taken of the palatine artery) (Fig. 1086, b). 3. Starting from these incisions, the operator detaches from the bone the whole covering of the palate and tJins forms two mucoperiosteal double pedunculated flaps. For this purpose, he inserts a curved raspatory in the lateral incision, presses it firmly against the bone, and then forces or pushes the periosteum with the mucous membrane from the bone toward the median line. If the detachment has been successful for about i centimeter along the alveolar margin, where the attachments ^xe. firmest, the median portions may be more easily separated from the bone by means of curved elevators. The flaps thus formed are approximated in the median line. Next follows :■ — 4. The insertion of the sutures exactly in the same manner as described on page 1 19. In single clefts of the palate — that is, when the other half of the palate has united with the vomer — often only ojie lateral incision is required on the corresponding side ; or the mucoperiosteal flap is formed from the side of the vomer facing the margin of the cleft and is united with the vivified margin of the fissure of the hard palate {Lannelongne\ If, in a very wide cleft and deep palate, the material for the flaps is com- paratively scanty, the proposition of Brandt is noteworthy ; namely, to extract all the molar teeth of the upper jaw a few months before the opera- tion, thereby obtaining a flat palate and more material. But if abundant material is present, so that the flaps can be easily united, von Langenbeck advises to make the lateral incisions in such a manner that a small vascular bridge remains standing in their middle portion (at about c of Fig. 1086) ; thus the flaps are retained in closer apposition with the palate and gravitate less toward the tongue. If, as in most congenital defects, the hard palate, as well as the soft palate, is defective, then, in the above described manner, staphylorrhaphy is com- bined with uranoplasty. TJic lateral incisions, which begin at the hamular process of the sphenoid, meet with the tension-relieving incision through the velum. In detach- ing the mucoperiosteal flaps, after the posterior margin of the palate bone PLASTIC OPERATIONS OF THE ORAL REGION 557 has been reached and after the velum of the palate has been lifted from it, the posterior mucous covering of the soft palate, facing the nasopharyngeal cavity, is divided throughout its whole breadth and detached from the palate bone. Von Langenbeck has recommended for this purpose a special curved probe-pointed knife (Fig. 1084, b, c). The tension-relieving incisions in the soft palate, however, are usually superfluous, provided the mucous membrane of the nose is sufficiently divided along the posterior margin of the hard Fig. 1093 Fig. 1094 Staphylorrhaphy and Uranoplasty in Congenital Cleft of the Palate BY sliding Two Pedunculated Mucoperiosteal Flaps palate {Kuster\ The detached large flaps, which are freely movable, hang down loosely into the cavity of the mouth (like "hammocks") and almost touch each other in the median line, so that no tension is produced in apply- ing the suture. No dressing is required. The gaping lateral incisions are usually tamponed with iodoform gauze ; but the apposition of the flaps and the healing take place more rapidly wzV/^ar- deitheuer. ) 2. After cutting through the siLperficial fascia, the operator penetrates between the sternohyoid muscles down to the thyroid cartilage (double ligation of the cricothyroid artery). Having divided the thyroid cartilage, it is advisable once more to make a careful inspection, to make sure of the necessity of total extirpation. 3. With the elevator the soft parts are bluntly detached from the sides of the larynx. The tendinous connection of tJie sternothyroid and thyrohyoid muscles is dissected off laterally, and, together with the lateral horns of the thyroid gland, is drawn outward with blunt hooks and kept open. The inferior laryngeal and the cricothyroid arteries are ligated on both sides. 4. Separation of the larynx from the pJiarynx by small, careful incisions with the scissors, keeping always close to the cartilage in order not to injure the external carotid and the superior thyroid arteries, which are in close proximity. 5. The larynx noiv exposed is drawn to one side, the soft parts are drawn to the other. After ligation of the siperior laryngeal arteiy, the lateral Jiyothyroid ligament is divided. The same procedure is followed on the other side. 6. Division of the middle hyothyroid ligament and the mucous membrane of the pharynx behind the arytenoid cartilages ; ligation of the two inferior laryngeal arteries ; the larynx, made completely movable on all sides below the cricoid cartilage, is cut off transversely from the trachea, which is held by a ligature loop. Preservation of the epiglottis in most cases offers no advantage. On the other hand, Maas advises leaving an annular portion of the cricoid cartilage in position if possible, because it facilitates very much the introduction of the canula, and secures a wide communicating opening between mouth and trachea, even without any apparatus. In case the larynx is to be extirpated from belozv jipivard {Billroth), it is detached from the trachea, first below the cricoid cartilage, after the lateral soft parts have been separated ; next it is drawn forward and upward with a sharp hook applied in the cricoid cartilage ; then its union with the pharynx and finally that with the hyoid bone are severed by incisions with scissors always closely directed against the larynx. If, in an advanced state of the disease, the tissues surrounding the larynx must also be removed, the operation becomes much more bloody and dan- gerous. The blood vessels to be divided in this operation are, in their order, counted from above downward : the hyoid branch of the lingual artery, the 624 SURGICAL TECHNIC superior laryngeal artery, the cricothyroid artery (a branch of the superior thyroid artery), the inferior laryngeal artery (a branch of the inferior thyroid artery), and the corresponding veins. Next the muscles are cut off from the larynx. The same is extirpated, and the surrounding parts are cleared of diseased glands lying along the inner margin of the sternocleidomastoid muscle on the sheath of the large vessels and below the submaxillary bone. The unilateral extirpation of the larynx is confined to the diseased side. In all other respects, however, it is made essentially according to the rules given for total extirpation. It is less dangerous, and the patient can speak distinctly even without a canula. The lateral incisions are sutured; the median incision is only tamponed. The wound of the pharynx is not sutured ; from it an oesophageal tube is introduced into the stomach, and the wound cavity is tamponed with iodo- form gauze. The patient remains in bed on his back; the dressings are changed daily. Even on the next day, an ordinary canula {Ha/ui) may be substituted for the tampon canula ; the wound above the canula is tamponed with antiseptic gauze. The cavity of the wound rapidly decreases in size if the case runs a favorable course ; patients are able to speak audibly in a whispering tone of voice. If it is desirable to wear a phonetic canula, an ^^ artificial larynx'' {Bruns- Beyerlc s, Gusscnbauer s, or Jnlins Wolff's) is to be recommended (Figs. 1194, 1 195). The patient can speak through these apparatuses with a loud voice. On account of the irritation produced by the canula, Fig. 1 194 Fig. 1 195 Phonetic Canula (Artificial Farynx). a, according to Gussenbauer; /', according to von Bruns however, many content themselves with whispering speech. Aside from recurrence, most patients that have been subjected to this operation have died from aspiration of secretions; the greatest care, therefore, must be bestowed upon the after treatment. OPERATIONS ON THE NECK 625 Bardenheiier obtained very good success by forming a septum between the oral cavity and the cavity of tJie wound after removal of the larynx. The anterior wall of the oesophagus is sutured to the margin of the mucous membrane (which is preserved as much as possible) below the epiglottis, or with the vivified free margin of the epiglottis. The cavity of the wound is tamponed. The patient is placed with his head lowered backward in such a position that the tracheal stump forms the highest point of the wound and no secretions can flow into the tracheal wound. Since the patient can swallow, he does not insert any oesophageal tube for the introduction of food, and thus the first tampon can remain in position as long as eight days with- out irritating the wound. J. Wolff employs the oesophageal tube, but removes the tampon canula directly after the operation, and sutures the tracheotomy wound. The superior margin of the tracheal stump is sutured all around to the skin, and a common canula is introduced into the trachea from above. Rotter closed the pharyngeal defect by a double row of sutures including the mucous membrane, sewed over it the muscles detached from the larynx in a second layer, and the skin as far as the angles in a third layer. The patient could swallow very well immediately after the operation. OPERATIONS FOR GOITRE (struma) I. Parenchymatous injections. Injections of tincture of iodine or of LngoVs solution (or alcohol, osmic acid, iodoform oil) may sometimes effect a decrease in simple, not too large, goitres (parenchymatous) (after a preceding inflammatory reaction) ; sometimes, however, they meet with no success. They are administered in intervals of from two to three days, in doses beginning with half a Pravaz's syringeful, but gradually increasing to a full syringe. Whether the syringe has been properly inserted into the tumor is recognized from the movements of the canula in an upward and downward direction during deglutition. It is dangerous to inject the solution into a vein, because sudden death (embolism) may ensue. Hence, it is necessary first to draw the needle a little before making the injection. The injection must be made vciy slozuly. II. Puncture with subsequent injection of tincture of iodine or LngoV s solution is of some value in struma cystica, only when the walls of the cyst 626 SURGICAL TECHNIC are rather thin and have not too many pouch-like distensions of the cyst wall. The puncture is made with a trocar under most careful aseptic precau- tions with the skin drawn tense. The trocar must not be too small, because the contents of the cyst are often composed of a thick (colloid) fluid. The evacuation must be made slowly, because by relieving the pressure too rapidly, hemorrhages are easily caused in the interior of the cyst. For dressing, iodoform-coUodion and a light compressive bandage are used. (Parenchymatous injections are useless in adenomata of the thyroid gland and seldom of signal value in cystic goitre. In miasmatic goitre paren- chymatous injections of a 5% solution of carbolic acid repeated at intervals of a week and combined with the internal and external use of iodine seldom fails in reducing the swelling.) III. Incision with suturing of cyst wall to skin (C/ie/n/s). In stninia cystica and abscesses. 1. Exte^nial incision over the most prominent part of the swelling with avoidance or double ligation of the larger veins. 2. Cutting through the superficial cervical fascia. 3. Stitching the exposed wall of the cyst and fascia to the margins of the skin by a continnoiis quilt suture. 4. Incision of the cyst in the line of the external incision, cleansing, tamponing. In larger cysts, if necessary, the exposed portion of the anterior wall is I'csected ; under some circumstances, thorough drainage without free incision proves successful in very large cysts. Profuse parenchymatous hemorrhage {in struma cystica parenchymatosa — Stronieyer) is arrested by firm packing with iodoform gauze, peroxide of hydrogen gauze, or zinc chloride gauze. If the extirpation of isolated cysts can be made easily, it is to be pre- ferred to incision {Miiller). IV. Extirpation of Struma (Strumectomy) {Billroth, Rose, 1878). The total extirpation of the thyroid gland, according to present experience, is no longer permissible, since, in consequence of the operation, epileptic fits, paralysis of the muscles of the larynx, cachexia, myxoedema, fatal tetany, and idiocy are caused or threatened (cachexia thyreopriva — Kocher). It should be considered only in the surgical treatment of malignant disease (sarcoma, carcinoma); and then the implantation of fresh glandular substance into the abdominal walls may prevent cachexia after complete extirpation, as well as the administration of the fresh gland or its extracts fthyroidin, iodothyrin — Banmann). OPERATIONS ON THE NECK 627 Hence, in all other cases, only the Unilateral extirpation is considered, and this only when still sufficient healthy glandular substance is present on tJie other side. KocJier proceeds as follows : — I. External incision according to the seat and the size of the tumor in the median line of the neck along the inner margin of the sternocleidomastoid ; Fig. 1 196 Fig. 1197 Kocher's Extirpation of Struma (Strumectomy). a, transverse incision; b, angular incision in very large strumas, angular ijieision or trap-door incision. A simple trans- verse incision, " Kragenschnitt,'' ascending more on the diseased side than on the healthy side, is followed by the slightest cicatrix (Figs. 1 196, 1 197). (A curved transverse incision with the convexity directed down- ward and following the lower border of the swelling is the one which is now generally resorted to in performing partial and com- plete strumectomy.) 2. After division of the platysma and the superficial fascia, and after a careful double ligation and division of all visible blood vessels, the sternohyoid, the sternothyroid, and the omohyoid mus- cles, if necessary, are separated in the median line close to their insertion into the larynx. If possible, they are divided only partly and in a transverse manner. The sternocleidomastoid, freed suffi- ciently at its anterior margin, is drawn aside with blunt retractors. The external capsule of the goitre now exposed as a thin layer of Fig. 1198 . . Kocher's connective tissue is incised. It is separated with the goitre c^.n-RE probe (Fig. 1198) from the struma (ligation of the veins), so Probe 628 SURGICAL TECHNIC that its posterior surface can be reached by passing one finger along the external margin of the goitre. 3. The goitre is turned out toward the median line (luxated) very care- fully and cautiously, in order not to lacerate the blood vessels, which are exposed to great tension. 4. TJie inferior tJiyn'oid artery, lying behind the turned-out goitre in the form of a curve from the outer side to its place of insertion on the trachea, is carefully freed (recurrent nerve) and ligated, but not divided ; likewise the accompanying vein. At the inferior margin, the very large thyroid vein is divided after a double ligation. Fig. 1 199. RioHf-biDLD Struma, showing THE Ramification of Superficial Veins (Kocher) Fig. 1200. Diagram showing Ligation of Large Veins Necessary in Extir- pation of Struma (Kocher) I, A. and V. thyreoidea sup.; 2, V. thyroid, sup. access; 3, V. thyroid, inf. access; 4, V, thyroid, inf.; 5, V. thyr. ima princeps and access. 5. Entering with Kocher's director above the isthmus at the medial border of the upper horn, the surgeon, after a double ligation, divides an ascending ramus of the superior thyroid vein in the median line, and draws the upper horn forcibly upward with the fingers until the siiperior tJiyroid vessels become very tense. He then isolates them with the director, and ligates them ; he divides the superior thyroid artery and vein. 6. On the superior and inferior borders of the isthmus, the superior and inferior communicating veins are ligated and divided ; the director is slowly OPERATIONS OX THE NECK 629 inserted between the isthmus and the trachea ; the isthmus is secured with two strong Hgatures, and divided between them. 7. The goitre is then raised with the left hand from the trachea and its posterior margin, still adhering to the trachea, and is detached from it, care being exercised not to injure the recurrent nerve ascending at this place. Since this nerve can be injured in spite of all precaution, it is more practical, by a vertical incision made parallel to the trachea, but a little distant from it, to leave in position a portion of the posterior portion of the cap- sule for its protection. Fig. 1 201, Posterior View of Larynx AND Trachea with Neighboring Trunks of Vessels (Course of re- current nerve) Fig. 1202. Recurrent Nerve and Inferior Thy- roid Artery (Wolfler). The recurrent nerve of the pneumogastric nerve, or tnfenor laryngeal nerve, arises from the vagus, on the right beneath the subclavian artery, on the left beneath the arch of the aorta, ascends behind these vessels, in the groove between the trachea and the oesophagus behind and toward the median line from the common carotid, upw-ard to the lower margin of the cricopharyngeiis muscle. Below this it enters the interior of the larynx from behind, across the upper margin of the lateral cricothyroid ligament, accompanied by the inferior thyroid artery (Figs. 1201. 1202). 630 SURGICAL TECHXIC 8. The external wound is sutured, leaving a space at the most dependent part for free drainage. Under a compressive bandage, the healing can take place in one to two weeks. V. Resection of Goitre {Micnlics) is made in diffuse colloid degeneration on both sides, for the purpose of avoiding the serious complications produced by total extirpation (recurrent paralysis), by allowing to remain a portion of healthv glandular substance in connection with the point of entrance of the inferior thyroid artery, whereby the recurrent nerve is most securely pro- tected, and remains uninjured. This procedure, however, can be modified variously, leavmg at times the inferior, at times the superior pole, at others the isthmus of the glands. After division of the skin, muscles, and fascia, one-half of the goitre is isolated bluntly ; next, at the superior cornu, the snpciior thyroid artcjy and vein are ligated ; at the inferior cornu only the superficial vessels are ligated. The isthmus, bluntly detached from the trachea, is divided after double ligation " en masse," while an assistant laterally compresses with his fingers the blood vessels entering into it. The lateral flap to be resected is detached with the scissors from the anterior and lateral surface of the trachea. The poj-tion situated at the angle between the traeJiea and the ccsopliagus is alioiced to remain. With the aid of strong clamp forceps, which squeeze out the parenchyma, it is ligated with strong catgut ligatures, and in several sec- tions tied off Uke a pedicle by ligatures " en massed The latter contracts to a nodule of the size of a chestnut in the angle between trachea and oesophagus. To avoid the separation of the tumor y>vw tJie lateral suifaee of the trachea, and also the contusion of the recurrent nerve, by the ligature " en masse,'" risks which are always to be apprehended, Kocher, w ith the knife, circumscribed the capsule of the gland near the isthmus (hilus) by a circular incision perpen- dicular to it (sagittal). The upper section of the circle, however, must lie completely above the cricoid cartilage. By this means, injuiy to the reeuj-rent lurvc is excluded almost with certainty. Finally, a small flap of the thyroid gland, similar to the normal one, is formed from the remaining stump. Next the pedicle of the detached half of the goitre is divided longitudinally in several sections with probe-pointed scissors ; each part is grasped with strong clamp forceps and ligated, and then the whole tied-off mass is divided with the scissors. VI. Enucleation or intraglandular extirpation ( Porta, Socin) in cysts and in well-circumscribed adenomatous nodules and in bilateral goitres. After cutting through the shin, fascia, capsule {capsula externa sivc fasciosa, deep OPERATIOiNS ON THE NECK 63 1 cervical fascia), and the overlying (healthy) attenuated glandular tissue {glandulaj' capsule), the several glandular nodules are enucleated bluntly. Sometimes the operator can proceed still more rapidly if, by a deep incision, the adenoma is at once divided into tzvo equal parts, and each half is enucleated with the fingers and the sharp spoon (evacuation, KocJicr) ; often, however, a very violent hemorrhage ensues. Hence it seems to be more advisable, according to Bose, by means of an elastic tube as thick as the little finger, to constrict the tumor behind its greatest diameter, whereby the hemorrhage is prevented ; at the same time, after the division of the capsule, the glandular tissue is squeezed out of the wound. Of course, in suitable cases, the methods of resection and enucleation just described can be practically combined. ENUCLEATION RESECTION (yKocher) which is to be employed for the removal of all isolated nodules. After the goitre has been luxated from a transverse or angular incision, as described on page 627, without ligating the large blood vessels, the isthmus is first divided after a double ligation. From this incision the internal cir- cumference of the goitrous nodule is separated. The veil of glandular tissue is undermined in an upward and downward direction with Kocher's director, and a double ligature applied in a horizontal line. Next, from this place, the nodule is enucleated with the finger first above and below, then also at its posterior surface from the glandular substance. The latter is then vertically divided with the scissors at its posterior surface as far as the ligatures on the anterior surface between the inferior and superior cornua. The nodule is then removed, together with the tissue covering it. VII. Ligation of the Afferent Arteries {yon IValther, Wolfler). In vasciilar goitre and Basedozv s disease. (a) Ligation of the superior thyroid artery. 1. External incision 4 centimeters long along the internal margin of the sternocleidomastoid across the great cornu of the hyoid bone as far as the thyroid cartilage. 2. Division of the platysma. The artery is fo2ind in front of the great cormi of the hyoid bone in the triangle between the omohyoid, digastric, and sternocleidomastoid muscles. Kocher and Rydygier searched for the artery from a transverse incision extending from the margin of the sternocleidomastoid to the body of the hyoid bone. The anterior branch of the artery is always to be felt on the 6^2 SURGICAL TECHNIC lar.sup. thy r. sup. median upper side of the superior cornu of the (enlarged) thyroid gland, passing downward at the side of the larynx. (d) Ligation of the inferior thyroid artery. Von Lajigcubcck made the cxtcrjial incision 6 centimeters long in the groove between t/ie tzuo heads of the sternocleidomastoid muscle. 1. Division of the platysma, ligation of the tj'ansverse cervical vein, the transverse vein of the scapula, the external jugular vein. Division of the deep cervical fascia, splitting the sternocleidomastoid muscle in an upward direc- tion. 2. The tendinous part of the omohyoid muscle appears in the middle of the wound, and is drawn outward or divided. The internal jugular vein, which is now exposed, is drawn toward the median line. The carotid, the pneumogastric nerve, and the anterior scalenus muscle covered by cellular tissue and fascia can be inspected. 3. After blunt division of the lat- ter, the phrenic nerve becomes visible and is pushed outward. Along the internal margin of the anterior scale- nus muscle, which is drawn a little toward the outer side, the arch of the inferior tJiyroid artery {sympathetic nerve !) is seen. (See also Fig. 1202.) To avoid the danger of injuring the sympathetic nerve, Wdlfler draws the large blood vessels and the pneumogastric nerve inward. Rydygier in ligating this artery proceeds as follows : — 1. TJie external incisioji 6-7 centimeters long extends 2 centimeters above and paj'allel to the clavicle, transversely across the clavicular portion of the sternocleidomastoid muscle and the supraclavicular fossa. 2. After incising the platysma and the superfcial ccj'vical fascia, both forefingers penetrate in a perforating manner through the loose cellular and adipose tissue behind the sternocleidomastoid as far as the margin of the anterior scalenus muscle. The lymphatic glands are removed. 3. The sternocleidomastoid with the large blood vessels of the neck and the pneumogastric nerve are lifted with long blunt \iOo\i^ forward and inward, so that the wound gapes widely. Then there appears on the internal margin of the anterior scalenus muscle the thyrocervical trunk, from which tJie cricoihyr. r. inf. ihyr. inf. Fig. 1203. Diagram of Arteries supplying Larynx and Thyroid Gland OPERATIONS ON THE NECK 633 inferior thyroid artery branches off in an inzuard direction. This vessel is secured by a double ligature. Kocher ligates the artery at a place where, behind the carotid, it curves toivard the thyi'oid gland inwardly. 1. External incision transversely across the clavicle (jugulum; in a curve obliquely upward and outward across the sternocleidomastoid. 2. Platysma and sternocleidomastoid are forcibly retracted outwardly, the omohyoid and the sternohyoid muscles are drawn downward and in- ward ; the jugular vein, the common carotid, and the pneumogastric nerve are isolated on the internal margin, and drawn outward. Then between the latter and the margin of the thyroid gland (or the sternothyroid muscle), the operator advances toward the vertebral column. 3. The thyroid gland is raised inwardly, and the convex arch of the artery is then seen lying upon the longus colli muscle beneath the recurrent nerve, which crosses it. If the extirpation of the diseased thyroid gland appears impossible or impractical, the following palliative operations may be attempted : — Jaboiilay raised the goitre from its natural position and lifted it, so to say, by his exothyreopexia. From a median incision, the goitre is carefully separated bluntly with the fingers from its connections, and the loosened lobes are luxated outward and surrounded with sterilized gauze. After the gauze is removed on the fourth day, the skin contracts over the goitre of its own accord, while the latter gradually contracts, because the distortion of the large vessels has impaired its nutrition. Since this procedure, however, may cause thrombosis, Wblflcr makes a dislocation of the goitre in a similar man- ner by drawing it out from its bed, where it causes functional disturbances (for instance, between trachea and sternum), and by fixating it under the skin and the sternocleidomastoid, mostly at a higher level. As a substitute for extirpation, which can no longer be performed, owing to the extent or location of the disease, he also recommends pimctiiring with the needle point of the thermo-cautery. LIGATION OF THE ISTHMUS OF THE THYROID GLAND was recommended by Gipp and Jones for the relief of dyspnoea and other pressure symptoms. The external incision extends in the median line from the tJiyroid cartilage downward. The isthmus is detached bluntly from the trachea, constricted by ligatures " en masse " on both sides of the trachea, and divided between them (or the whole portion pressing upon the trachea is resected). 634 SURGICAL TECHNIC Asphyxia is especially to be feared as a serious accident in operations for (goitre. It may be caused : — 1. By ancEsthesia. 2. ^y paralysis of the recurrent laryngeal nerves. 3. By a complete compression of the scabbard-shaped compressed trachea (when the head is turned laterally and the goitre is turned out; (Figs. 1204, 1205, 1206). ^ Fig. 1204 Fig. 1205 Fig. 1206 Scabbard-shaped Compressed Tkache.e (Demme) To prevent this compression-stenosis, either the lateral tracheal ivalls may, during the operation, be drazvn apart with sharp hooks, or the lumen of the trachea may be kept patent by simple pressure of tJie finger upon the anterior wall. For the more permanent removal of the stenosis, a strong catgut liga- ture with a curved needle is passed at two places through the lateral walls of the trachea and drawn together over the angular anterior margin in such a manner that the lateral walls are separated {Kocher). In dyspnoea of a high degree, chloroform anaesthesia must be avoided (not ether, on account of the aspiration of profuse tracheal secretions), and a moderate morphine anaesthesia or local anaesthesia must be attempted. The latter is to be recommended also for all operations for goitre of short duration. (At the present time, Kocher performs all his operations on goitres under Schleich's infiltration method.) OPERATIONS ON THE NECK 635 Tracheotomy should be avoided as viuck as possible in all these opera- tions, since it renders asepsis almost impossible {pJdeginonous mediastinitis ; aspiration). Fig. 1207. KdxiG's Flexible Canula for Tr.\cheotomy in Struma If, in substernal and firvily adherent goitres, the surgeon is compelled previously to the operation to perform tracheotomy above the seat of com- pression, on account of threatening asphyxia, a long flexible cannla must be introduced extending beyond the stenosis {Konig, Fig. 1207). OPERATIONS ON THE (ESOPHAGUS The introduction of the oesophageal tube is made for relieving the stomach of any injurious contents, or for conveying food into it. For this purpose, the oesophageal tube is connected by a rubber tube with a reservoir (douche, funnel, stomach pump) (Fig. 1208). The reservoir is filled with fluid ; the fluid flows into the stomach when the reservoir is lifted sufficiently ; the fluid and the contents of the stomach are siphoned out, when the reservoir is lozuered sufficiently. If the oesophageal tube is to remain in position for some time, or if, on account of the resistance of the patient, it cannot be introduced through the mouth, it must be introduced through the lower meatus of the nose and the pharynx into the oesophagus. It can remain in position for a long time without causing any especial inconvenience. The patient sits on a chair in front of the surgeon with his head extended, his mouth wide open, and his tongue projected. The surgeon depresses with his left forefinger the base of the tongue, and introduces the instrument held near its end with his right hand, like a penholder. Having previously lubricated the instrument well with oil, or, better, with glycerine, he introduces it carefully along the posterior pharyngeal wall into the ^^^ ^^^g '=;tom\ch stomach. (The cardiac orifice lies in the adult about 40 plmp 6^6 SURGICAL TECHNIC centimeters beyond the incisors.) In introducing the instrument, the sur- geon, as a rule, meets with some resistance in the region of the cricoid cartilage. This resistance can be removed by drawing with the point of the left forefinger the base of the tongue, together with the larynx, forward toward the lower jaw (Fig. 1209). It is also advisable to direct the instrument more toward the left side. If a stronger resistance is felt in the lower sections of the oesophagus (foreign bodies, tumors, strictures, aneurisms), great care must be taken not to use too much force. A perforation is easily caused in the surrounding tissue, which has nearly always undergone a change, lessening its resistance. Fig. 1209. Introducing CEsophageal Tube Should the instrument happen to enter the larynx instead of the oesopha- gus, a violent paroxysm of coughing and asphyxia at once ensues, whereas in most cases only choking sensations are caused by a proper introduction ; these may be mitigated by deep breathing and movements of deglutition. If the instrument has passed the larynx, it can be pushed forward without producing irritation. (In the adult the introduction of the oesophageal tube is very much facili- tated by cooperation of the patient. The unpleasant gagging is often entirely prevented if the patient will manage the tube himself and advance it during efforts at swallowing.) Foreign bodies in the oesophagus must be removed from it as soon as possible, since they provoke inflammation (and perforation) of the oesophag- eal wall, as well as dysphagia. If they are firmly impacted beJiind the larynx, they may be extracted either with the forefinger, bent like a hook, or with curved dressing forceps ; OPERATIONS ON THE NECK 637 if these prove of no avail, they must be exposed, if necessary, by subhyoid pharyngotomy (see page 608). If they are lodged in the tipper portion of the cesopJiagiis itself, the surgeon may, in many cases, succeed in grasping and extracting them with -^ Fig. 121 1. TiEMANx's Flexible Laryngeal Forceps Fig. 1212 Fig. 1213 Fig. 1214 Laryngeal Forceps Fig. 1215 curved long-billed forceps, which open and close in different directions ; great caution, however, must be observed in order not to cause any lacera- tions of the mucous membrane (Figs. 1210-1215). 638 SURGICAL TECHNIC Flat, hard, coinlike bodies are best grasped with Grdfc's coin-catclur (Fig. 12 1 7). The disklike movable blades at the end of this instrument are pushed past the body, and when the instrument is withdrawn, they catch and remove the foreign body. (Grafe's coin-catcher is a very dangerous instrument in removing foreign bodies that are or are Uable to become impacted.) Collins adjustable oesophagus hook (Fig. 1218) also renders excellent service. It consists of a flexible rod, at the end of which there is a small curette-like hook, which, by a screw arrangement on the han- dle, can be adjusted to any desir- able position so that the foreign body can be grasped or released at pleasure. Sharp-pointed bodies (needles and fish bones) are removed by szueeping out the oesophagus with suitable instruments. Weiss's fish- bone catcher (Fig. 12 16) has at its lower end a sponge, and over it a network of bristles which, by traction on the handle, open into an umbrella-shaped disk ; the in- strument is introduced closed, and withdrawn open ; by this means, the foreign bodies, if not pushed into the stomach by the sponge, are caught in the bristle work. If the operator does not suc- ceed in extracting the foreign body in spite of all these attempts, he must try to push it down into the stomach, best with a flexible whalebone rod, to the end of which a sponge or an ivory knob has been fastened (probang or oesophageal bougie, Fig. 12 17). For the pur- pose of facilitating the passage of the foreign body through the intestinal canal as harmlessly as possible, the patient should eat potatoes, rice, and bread Fig. 1216 Weiss's Fish-bone Catcher Fig. 1 21 7 Grafe's Coin-catcher Fig. 1 21 8 Collin's Adjustable OEs:)PHac;us Hook OPERATIONS ON THE NECK 639 exclusively ; these produce ample faeces to envelop the foreign body ; the stools, of course, must be carefully examined. In this manner, even large bodies with sharp edges (set of teeth) may pass through the intestines with- out causing injury or disease. It is not advisable, however, to increase by purgatives the peristaltic action of the intestines for hastening the passage of the foreign body. If the foreign body is so firmly impacted in the loivcr section of the oesophagus that it can neither be extracted nor pushed down into the stomach, the attempt must be made to extract it by external oesop]iagotoniy (see page 223). STRICTURES OF THE CESOPHAGUS To determine more accurately tJie seat of a stricture, a bougie of large caliber is introduced until arrested. Next, the distance of the obstruction from the incisors is measured. By selecting bou- gies of decreasing diameter, the operator endeav- ors successively to pass the stricture with them. Whether this has been successful is ascertained from the fact that the point of the bougie is grasped on being withdrawn. In most cases, it is then possible to pass a bougie of the next smaller diameter through the stricture, and thereby to ascertain its diameter. In attempting gradual dilation the bougie, after it has passed the stricture, is allowed to remain in position 10 to 20 minutes, producing in most cases a slight (inflammatory) softening of the surrounding tissue ; on the next day, after a previous introduction of the same bougie, the next larger one can be immediately introduced ; this, in turn, remains in position for the same length of time. This process is continued until the desired caliber of the lumen has been effected. The treatment with bougies is best conducted by using the elastic bougies with a piriform point and a thin neck ; whalebone probes, provided with ivory olive-shaped tips of varying sizes (Fig. 12 19) are in some cases also useful (more particularly in ascertaining the location and degree of the stenosis). Trousseau's probe (Fig. 1220) has at each end three olives of increasing size. Fig. 1219. Elastic Bougies with Ol- ive-shaped Tips Fig. 1220 Trousseau's Probe 640 SURGICAL TECHNIC Leydcn obtained good results by the use of permanent tubes — short, hard rubber tubes which remain in position in the constricted place and facilitate the introduction of food. They are introduced into the stricture by means of a probang with soft conical point ( Woljf), and can remain in position for months. They can be easily withdrawn by means of a silk thread fastened to them previously, which hangs out of the mouth while the canula remains in position (Fig. 1221). If the surgeon is not successful in dilating the stricture in the desired manner by treatment with bougies, he may attempt to remove the stricture at once by nicking it with instruments made for that purpose. They operate after the manner of urethrotomes and are similarly constructed {cesopJia- gotome) (Figs. 1222, 1223) {internal a^sopJiagotomy — Maisonneuve). It is better and less dangerous, however, in such cases to perform gas- trostomy. Sometimes it is possible subsequently to dilate (cicatricial) stric- tures from this opening in the stomach {retrograeie dilatation). Kraske introduced a ligature knot from the mouth through the stricture into the stomach ; he then w^ashed the thread out from the gastric fistula by irriga- tion ; next, by tying to the ligature ivory olives of gradually increasing size, and by passing them through the stricture, he dilated the stricture gradually and completely (Fig. 1224). Lange tied to such a ligature small three- edged knives (Fig. 1225), as in Alaisonneuve s urethrotome. Drawn up by the thread, they nicked the stricture from below upward. Sociji had the patient swallow a bird shot fastened to a ligature for dilating such constric- tions. When this has succeeded and the ligature has been brought out of the opening of the stomach, the surgeon can also make von Hacker s endless probings with stretched caoutchouc threads or drainage tubes stretched tense over a probe and hence made thinner. They are introduced by means of the ligature. When the traction is discontinued, they contract and become thicker. Next, in succession, larger tubes are tied to the thinner one in position in the stricture. These, drawn through the stricture, accomplish the desired dilatation in a very short time. EXTERNAL CKSOYV. AGOTO^IY {Go?irsa7ld, 1 738), the extcj-nal opening of the cervical portion of the oesophagus, is made : — 1. For removing firmly impacted /"cvcvV;/ bodies. 2. For bloody or forcible blunt dilatation of strictures, especially when they are situated very low down. The operation is performed on the left side of the neck, because the oesophagus lies more to the left behind the trachea. The patient is placed OPERATIONS ON THE NECK 641 Fig. 1221 Leyden's Probe WITH Perma- nent Tube Fig. 1222. Trelat's Fig. 1223. Collin's GEsophagotome Fig. 1224 Ivory Olive accord- ing TO Kraske Fig. 1225. Lange's Three-edged Knives FOR Retrograde Dilatation Fig. 1226. Von Hack- er's Drainage Tubes stretched o\'er a Probe and cut off laterally in a half-sitting position, with his head turned toward the right. If possi- ble, an oesophageal tube, as thick as possible, or a large probe (or tJie '^ ectropcesophag") is introduced into the oesophagus. 642 SURGICAL TECHXIC 1. The external incision, about 5 to 7 centimeters long, extends along the anterior margin of the sternocleidomastoid from a level with the cricoid cartilage downward (as in the ligation of the carotid) (Fig. 1228). 2. After cutting through the platysma and the superficial cervical fascia, care being taken not to injure the external jugular vein, the sternocleido- mastoid is drawn outward. 3. Division of the middle cervical fascia, with or without preserving the omohyoid muscle ; the left lateral lobe of the thyroid gland is drawn with blunt retractors toward the median line. Fig. 1227 Fig. 1228 External Q^sophagotomy. a, opening the resophagus, sheath of vessel drawn outward; /', external incision 4. The operator penetrates as bluntly as possible with two strabismus hooks in the depth of the wound, where he meets first the common sheath, enclosing the carotid, the Jugular vein, and the pneumogastric nerve ; over the latter passes tJie descending ramus of the hypoglossal nerve. If the whole sheath is draivn outzuard with a broad blunt retractor, the wall of the flat roundish oesophagus, with its longitudinal fibres lying behind it, is brought into view (Fig. 1227). 5. After the introduction of an oesophageal tube, the opening of the CBsophagus is made easily upon it. If the opening must be performed free hand, it is made best between two dissecting forceps, in which case the OPERATIONS ON THE NECK 643 strong muscular coat and the mucous membrane only, loosely connected with it, are lifted up and divided. The height and length of the opening depend on the seat and the nature of the trouble for which the operation is performed. 6. From this wound, the foreign body can now be exposed and removed. In difhcult cases, traction loops are applied through the margins of the wound to keep the visceral wound open {Billroth). In case of cicatricial stricture, the incision is best made closely above or below the same, and from this incision the dilatation is made ; in this case, the eye can survey the operation to be performed. The bbtnt dilatation should be made with dilating forceps (Roser), which are introduced, closed, and then opened (glove stretcher). Finally, with the probe-pointed knife, the cicatricial contraction may be nicked m several places, but very superficially, or the dilatation can be made with a hernia knife guided upon a grooved director (combined oesophagotomy — Gussenbaner). 7. After removal of the obstruction, an oesophageal tube is introduced from the nose into the stomach, and the several layers of oesophageal wall are closed over it by sutures. Duplay sutures only the mucous membrane. Fislier allows fluids to be swallowed zvitkout an oesophageal tube, a few hours after the operation. The external wound can be loosely sutured and drained, or, still better, packed, in order to prevent most effectually reten- tions and gravitation (mediastinitis). If the opening of the oesophagus has been made below a tumor, obstruct- ing the lumen of the oesophagus, and if it is not possible to extirpate the tumor from the wound, or, at least, to make the oesophagus permeable, the margins of the oesophageal wound are sutured to the external skin (oesopha- gostomy) ; a lip-shaped oesophageal fistula, through which the patient can be nourished, is thus established. This procedure can be recommended also for very narroiv strictures, deeply located, which must probably be treated for some time {von Hacker). In tumors of the oesophagus which are not too large and are well circum- scribed, the oesophagus may be resected {Czerny), i.e. transversely divided above and belozu the tumor ; if the removed portion is not too large, the two ends can be united by suture, else the operator attempts to bring the lower end by strong traction into approximation with the upper end ; but if this does not succeed, he must suture the lower end into the wound of the skin and thus form an artificial mouth (lip-shaped fistula). In tumors which are entirely inoperable, gastrostomy (see page 680) is indicated as a palliative operation. 644 SURGICAL TECHNIC CESOPHAGEAL DIVERTICULA can be extirpated. From an external incision extending as far as the clavicle (jugulum), the pouch is exposed, separated — in part, bluntly; in part, with the knife — from the surrounding tissues, and cut off where it is attached to the oesophageal tube. While this is being done, sutures, placed very closely together, are inserted through the mucous membrane of the oesophagus and tied after the removal of the pouch. Likewise, the connective tissue over- lying this row of stitches is sutured separately. A firm tampon is applied upon the oesophageal wound. Likewise, the remaining skin wound, w^hich is only in part sutured, is tamponed for about six days {vo7i Bcrginami). KocJier obtained primary healing of the oesophageal wound by applying a double ligature at the neck of the diverticulum before amputation ; he divided the pedicle with the thermo-cautery, and then cauterized the mucous membrane thoroughly. The stump of the mucous membrane was covered first by suturing the muscularis and adventitia, and finally sutured to the oesophageal wall in a longitudinal direction. (Esophagoplasty {von Hacker, HocJicncgg), after extensive resection, is intended to supply by skin flaps the defects which have been caused. By inverting two lateral flaps, first the posterior wall is formed ; after it has healed firmly, the anterior wall is formed by a flap with the skin side turned inward ; the raw surface of this flap is covered by sliding a lateral cervical flap. TEXOTOMV OF THE STERNOCLEIDO- MASTOID in congenital wryneck (torticollis, ca- put obstipum) under the protection of asepsis is no longer made snbcntane- onsly {Stromcyer), but openly by ex- posing the parts which must be divided {von ]^olkmann). The head is drawn toward the healthy side, so that the fibres of the clavicular and sternal insertions of the sternocleidomastoid are stretched forcibly. Fig. 1229. Tenotomy of the Sternocleido- mastoid OPERATIONS ON THE NECK 645 1. External incision, i to 2 centimeters long, extending over the promi- nent band, about a finger's breadth above the clavicle, first, along the inser- tion of the sternomastoid, until the muscle, often degenerated to a white shining tendon, appears to view. After it has been grasped with a tenacu- lum (Fig. 1229), it is lifted out and divided upon the instrument {external jtigtilar vein !). 2. If the cleidoniastoid causes tension, it is divided in the same manner, if possible, through the same skin wound. Fig. 1230. Stromeyer's Oblique Bed 3. The little wound is sutured completely. After the operation, the patient is placed upon an extension bed ; his head is drawn upward by a weight, fastened by means of a support to the chin and the neck (Glisson's sling), while the weight of the body itself makes the necessary counter extension, the bed being placed in an inclined position. Afterward, the patient is placed upon tJiis oblique bed for the greater part of the day {Stromeyer, Fig. 1 2 30); his head is kept in position by Glisson's sling, and is turned toward the diseased side by an oblique position of the curved crop piece. The extension of the muscle may be still further increased by having the arm of the diseased side extended by means of a weight and pulley. Since the cicatrix lying between the muscular ends and the connective tissue surrounding the muscle always tend to retract, Micidicz in serious cases made the 646 SURGICAL TECHNIC EXTIRPATION OF THE STERNOCLEIDOMASTOID {AUcu/icC, 1891) 1. External incision, 3 to 4 centimeters long, between the two heads of the muscle ; division of the platysma. 2. By retraction of the margins of the wound, both tendons are sepa- rated, one after the other, undermined, and cut off upon an elevator (internal jugular vein) immediately above their origin, from the clavicle and the sternum. 3. Each end is grasped with forceps, forcibly drawn upward, and enu- cleated as far as its point of conjunction, — in part, bluntly; in part, by pushing with the knife. 4. By inclining the head toward the diseased side, the operator succeeds, from the small skin wound, in freeing the diseased muscle as far as the mastoid process, and in cutting it off with the scissors as closely to the same as possible. But the posterior superior portion of the muscle, perforated by the spinal accessory nerve, must be preserved, else paralysis of the trapezius muscle ensues. 5. The head is then turned as much as possible toward the healthy side, and the tense fibres of the shortened muscular sheath are carefully dissected out. 6. The little wound is sutured throughout ; the mal-position of the head is temporarily but little improved. This operation is followed by a marked disfiguration in the external form of the neck, because the prominence given on that side by the sternocleido- mastoid has been removed ; but the time of treatment is shorter and the correction of the deviation permanent. OPERATION FOR CERVICAL TUMORS Encysted tumors of the neck (deep atJicromatoiis cysts) lying upon the vascular sheath, as a rule, require no extirpation, since they can nearly always be obliterated hy puncturing ivitJi subsequent inject io?is of iodine; it is necessary, however, to irrigate the sac of the cyst with boracic solutions through the canula of the trocar, until the irrigating fluid flows out clear ; not until then should the injection of LugoV s solution be made (see hydro- cele testis). (The removal of diseased cysts by enucleation is a comparatively easy and safe operation, and can always be relied upon in effecting a permanent cure.) OPERATIONS ON THE NECK 647 Fig. 1231. Topography of the Region of the Head and Neck (Superficial Layer), temp. A. and V. temporalis with N. auriculotempor; zygom. A. zygomatica; trans. A. transversa faciei; coron. A. coronaria from A. maxillaris ext.; angul. A. angularis; occip. A. and V. occipitalis major; access. N. accessorius Willisii; at its side supraclavicular nerves; N. auricularis magnus; N. subcutaneus colli med. 648 SURGICAL TECHNIC Fic. 1232. ToP(JGKAPHY OF THE Neck (Deeper Layer). (Heitzmann.) I, carotis communis; 2, art. subclavia; 3, carotis externa; 4, carotis interna; 5, A. maxillaris ext.; 6, art. occipitalis; 7, A. temporalis; 8, A. maxillaris interna; 9, A. lingualis; 10, A. thyreoidea sup. ; 11, truncus thyreo-cervic; 12, A. vertebralis; 13, A. thyreoidea inf.; 14, A. transversa scapulas; 15, A. cer- vicalis superfic. ; 16, A. transversa colli; 17, A. cervicalis ascend.; ad. Ram. descend, nervi hypoglossi; a, ^L sternocleiodomasteus; /', M. cucullaris; <:, ^L splenius capitis; L hyoglossus; h, ^L mylohyoideus; i, ^L biventer; k, M. sternothyreoideus; /, M. sternohyoideus; m, M. stylopharyngeus OPERATIONS ON THE NECK 649 Extirpation of solid tumors is an operation not attended by any special difficulties, if they are zueil encysted and not firmly attached to the surround- ing tissues. After the capsule has been exposed, they can be enucleated with the fingers or blunt instruments {Kochers director, or Cooper's scissors closed) with ease, and without any considerable hemorrhage. But the operation may become extremely difficult when the tumors are intimately connected with the surrounding tissues, more especially with the large blood vessels (jugular vein and carotid artery j. Injury to tlie veins is then always the principal danger, partly on account of the violent hemorrhage, partly on account of the possibility of air Altering the veins, an accident that may cause instant death by air embolism and cardiac insufficiency. Often an accidental nicking of the veins cannot be avoided, for, unless a vein is filled with blood, it cannot with certainty be distinguished from a band of cellular tissue ; hence, the incisions should ahuays be directed tozuard the tnmor, and when the edge of the knife is in the neighborhood of the larger blood vessels (the relative position of which in large tumors may have been materially changed), it is advisable frequently to discontinue the pressure and traction upon the tumor and to allow the veins to become filled with blood, which makes them discernible. In spite of all precautionary measures, sometimes a large vein is injured; the operator, believing that he is divid- ing a band of cellular tissue, may in reality cut off a portion of the jugular vein itself, or a lateral branch inosculating with the same, and make a round opening in the wall of the vessel. In such a case, the wound suddenly be- comes inundated with a flood of dark blood ; if air enters the vessel (in case the patient is in the act of inspiring), a hissing noise is heard, and with the next expiration, the blood, rushing from the central part of the vein, is frothy. Only the immediate application of the finger upon the vein wound or upon the vein on the proximal side of the wound can avert the threatened danger. The attempt must be made to grasp the injured wall of the vein with hemostatic forceps, and to close the open- ing, if it is not too large, by a lateral ligature with a fine, strong, silk ligature {lateral ligature. Fig. 1233); / otherwise, if the opening is too large, the vein is separated ( entirely from its surrounding tissue and ligated above and Fig. 1233. Lateral below the place of injury. Ligatlre of Veix (Such wounds of a vein have occasionally been closed successfully with the continuous suture.) 650 SURGICAL TECHNIC The accidental nicking of the artery can be avoided more easily on account of its thicker walls. If, however, the carotid passes through the tumor, or is firmly adherent to it, the portion of the artery involved must be included in a double ligature and resected with the tumor. Injury and ligature of the pneiimogastric nerve, which lies behind and between the artery and the vein, must be carefully avoided as far as possible. (Figures 123 1 and 1232 may serve to illustrate the topography of the region of the neck.) Snppttrating lyviphomata softened by easeons elegeneration can be cleanly enucleated from the surrounding tissues only in rare cases, because any injury to their capsule (which is often very thin) causes the contents to flow out and the tumor to collapse and lose its tension. In such a case the surgeon should incise them and scoop them out thoroughly with the sharp spoon. The pockets thus produced are dilated with dilating forceps, and smoothed. In the teeJinique of makmg the incisions, the following rules may be observed : In dissecting out, the edge of the knife s/iouhi akoays be directed tozvard the tumor, and the incisions should be made almost perpen- dicularly upon the capsule. Each vessel, as it becomes visible, is ligated doubly before its division. By traction on the portion to be removed, wher- ever it is possible, the operator should try to create an emphysema of the cellular tissue, which makes the limit of the healthy and the diseased tissue most easily discernible. In this case the surgeon can advance more rapidly with the handle than with the edge of the knife. Finally, never dissect "in the dark." If the tissues are flooded with blood, the blood must be removed by quick sponging before the surgeon proceeds with the operation. If the enucleation does not succeed well in one place and causes difficulties, the surgeon should try some other place. Hence, never persist too long ijt one certain place, but proceeding first in one place, then in another, as occasion demands, detach the tumor from its base. If muscles that cannot be drawn aside are in the way, they may be divided and subsequently reunited by sutures ; diseased portions of the same must be excised unhesitatingly. The wound, which is sometimes very extensive, can, as a rule, be completely closed by sjituring after all the tumors have been thoroughly extirpated. In the most dependent part of the wound cavity a drainage tube is inserted. If suppuration existed, the cavity of the wound is tamponed and subsequently closed by secondary sutures. (In cases in which the glands of the neck are extensively involved, the S-shaped external incision recommended by the editor a number of years OPERATIONS OX THE BREAST 65 1 ago exposes the field of operation most satisfactorily, and leaves the slightest disfiguration from the resulting scar.j Since the cicatrices resulting from extensive extirpations of the glands swell more and more in the course of time, and cause a very great disfigura- tion, Dollinger, for cosmetic reasons, makes subcutaneous extirpation by a skin incision extending from a level with the external auditory meatus along the limit of the hairy scalp, and i centimeter distant from it to the occiput. From here he succeeds in lifting out bluntly, not only the gland situated behind the superior portion of the sternocleidomastoid and behind the max- illary angle, after the skin has been undermined and elevated with the fingers, but also in enucleating in the same manner the glands lying on the vascular sheath and on the clavicle. After the wound of the skin has been sutured, nothing of the extensive radical operation is noticeable on the neck. OPERATIONS ON" THE BREAST LIGATION OF THE INNOMINATE ARTERY {Mott, 1818) The trunk of the innominate artejy, 2 centimeters long, lies behind the manubrium sterni in front of the trachea between the 7'igJit innominate vein and the left common carotid artery, close upon the right pleural dome. It is covered by the left innominate vein lying transversely over it. Behind the right sternoclavicular articulation it divides into tJie subclavian and the right common carotid arteries (Fig. 1234). V.A. "'^JU^ Fig. 1234. Ramification of the Large Fig. 1235. External Incisions for ligating Blood Vessels behind the Sternum Innominate Artery Von Langenbeck Bardenheuer The head is well extended and turned a little to the left over the edge of the operating table or a pillow for the neck. I. Curved external incision beginning above the left sternoclavicular articulation and ascending transversely across the upper margin of the 652 SURGICAL TECHNIC manubrium sterni, along the inner margin of the right sternocleidomastoid {yon Langeiibcck) ( Fig. 1235). 2. After division of the platysina and the superficial cervical faseia, if necessary, the rigJit stenioliyoid and tJie sternothyroid muscles are divided, and the sternal portion of the right sternocleidomastoid muscle is detached from the sternum. 3. Division of the deep cervical fascia ; the bulbus of the internal jugular vein, with the pneumogastric nerve and the common carotid, are then exposecj to light. 4. Whilst the vein and the nerve are carefully drawn ontivardly with blunt retractors, the carotid is followed centrally as far as the subclavian, and the latter is likewise followed, carefully avoiding the pneumogastric nerve, the recurrent nerve, and the phrenic nerve, as far as the trunk of the innoniinate artery. 5. With the artery hook a strong ligature is passed from below upward (injury to the pleura is thus avoided) around the artery as high as possible (toward the aorta). The ligature is tightened very gradually. Since access to the innominate artery is very difficult from above, and since, on account of the depth of the wound, the surgeon cannot obtain a sui^cient survey, the sternal end of the clavicle can be resected {von Berg- mann) if it seems necessary, or, according to Bardenhcuer, the artery maybe exposed by the resection of the manubrium sterni (see page 653) LIGATION OF THE INTERNAL MAMMARY ARTERY in injuries of the s,-SiVS\Q from gunshot or punctured loounds can be made only with difficulty, on account of the limited field of operation after the wound in the intercostal space has been enlarged. Resection of a costal cartilage over the vessel wound affords, however, more space. 1. External incision 5 to 7 centimeters long parallel with and near the sternal margin (Fig. 1236). 2. After division of the superficial fascia, the fibres of the pectoralis major muscle, and the perichondri?tm of the exposed rib, a piece about 2 centimeters long is excised from the latter with the knife (or costal scis- sors) (see also page 655). 3. Perpendicular division of the external intercostal muscle (ligamentum coruscans), aponeurotic at this place, and of the fibres of the internal inter- costal muscle in the two intercostal spaces. OPERATIONS ON THE BREAST 653 4. Closely below the muscular layer, about i centimeter distant from the sternal margin, the artery is found accompanied by two veins separated from the pleura by the muscular fasciculi of the triangnlaids sterni muscle (Fig. 1237). It is ligated at its central and its peripheral end (anastomosis with the inferior epigastric artery). Fig. 1236 Fig. 1237 Ligation of Internal Mammary Artery a, external incision /', wound Ligation of the artery in its continuity in the next upper and lower inter- costal space {Goyrand) by transverse incisions affords less space than the direct liaration and is not so safe. RESECTION OF THE MANUBRIUM STERNI may become necessary : — 1. For tJie ligation of the innominate aitery or vein (s^e page 651) in injuries and aneurisms of the same or their nearest branches w^hen the same are firmly adherent to tumors. 2. For opening the retrosternal space in order to extirpate tumors of this region (sarcomata, chondromata, struma) and to perform tracheotomy in inoperable retrosternal goitres, or to open abscesses. 3. For removing the diseased tJioracic zc^rt// (tumors, caries). The size of the portion to be removed must be governed by the cause for which the operation is made ; as far as possible, the periosteum should be preserved ; in diseases of the thoracic wall itself, it must always be removed with the same. 654 SURGICAL TECHXIC BardcnJiener makes the resection of the uppermost portion of the sternum in the following manner : — The head of the patient is forcibly extended and turned to the left. 1. Crucial incision ; upon a median incision about 8 to lo centimeters long across the jugulum and the manubrium sterni a transverse incision is made along the upper margin of the manubrium, the inner half of the right and the articular portion of the left clavicle (Fig. 1235 ). 2. After division of the platysma and the superficial fascia, the periosteum is detached from the anterior surface of the manubrium, beginning at the median line and extending toward both sides. Separation of the insertion of the sternocleidomastoid, of the anterior layer of the deep cervical fascia, of the sternohyoid and the sternothyroid muscles. 3. Division and detachmcjit of the pciiosteum from the right clavicle ; the latter is sazued through 3 to 4 centimeters from the sternal articulation ; likewise, at the same distance, the first and the second rib ; the same pro- cedure is repeated on the left side. 4. With strong bone hooks, the stumps of the clavicle and of the ribs are drawn forward, and from their posterior surface the periosteum is detached. Then the hook is inserted into the right margin of the sternum. The latter is strongly drawn forward, and the periosteum is freed from the posterior surface of the manubrium. 5. Upon a plate (of zinc) placed under it, a portion of the manubrium about 4 centimeters high is chiselled off transversely (or divided with a strong pair of costal scissors), and the loose portion of the bone is removed. 6. Cutting through the periosteum and the deep cervical fascia exactly in the median line. The internal jugular vein is now exposed and is pushed outward with the pncumogastric nerve until the common carotid artery and the subclavian artery become visible. By protecting the phrenic nerve, the pneumogastric and the recurrent nerves, and by advancing along the sub- clavian artery as far as its conjunction with the common carotid, the operator reaches the innouiinate arte?y. In exposing it, the left innominate vein and the middle and left thyroid veins are held to the left ; the right innominate vein, to the right ; and the two pleural layers, in a downward direction ; thereupon the sheath of the artery is dissected free and opened. This operation can be made also after a preliminary osteoplastic resec- tion ; viz., by chiselling through the sternum subcutaneously at the lower extremity of the vertical skin incision and by leaving it in connection with the skin covering it ; next, the chiselled-off portion of bone is turned in a downward direction. The large wound is tamponed, and subsequently, when RESECTION OF THE RIBS 6; 3!) the danger of niediastinitis has passed fafter about eight days;, the portion of bone is replaced into its original position. RESECTION OF THE RIBS — the excisio7i of a portion from 07ie or several ribs on account of disease of the same (caries, necrosis, neoplasms) or for sufficiently opening the thoracic cavity — is made in the following manner : — 1. An incision, made parallel to the costal axis about 5 to 6 centimeters long and over the middle of tJie nb, divides the skin and the muscles down to the periosteum. 2. With sharp hooks, the divided soft parts are drawn apart. The peri- osteinn is incised 2 to 3 centimeters in length in the direction of the skin in- FiG. 1238. Resection of a Rib with THE Metacarpal Saw Fig. 1239. Gluck's Costal Scissors (Costotome) cision. At each end of the periosteal incision, a transverse incision ( !) is made ; from one costal margin to the other and then with the raspatory, the periosteum is detached from the external surface of the rib in tzvo flaps in an upward and downward direction. 3. Next with a pointed and curved elevator, from the lower costal margin (avoid the ijitercostal artery in the costal groove) the periosteum is likewise carefully detached from the posterior costal surface until the point of the 656 SURGICAL TECHNIC instrument can be forced out at the upper intercostal space between the periosteum and the rib. 4. The periosteum is protected, and a sufficient portion of the rib is re- sected with a mctaca7'pal saxv {Y'\g. 1238), the costal scissors {Y'l'g. 1239), or the America Ji pruning sJicars (Fig. 1240). 5. If it is desirable to open the pleural cavity, the posterior wall of the periosteal cylinder, which is now exposed in the depth of the wound, together with th.& plenra costalis attached to it, is incised so far that one or two very thick drainage tubes can be inserted into the thoracic cavity (see page 661). Fiu. 1240. American Prun- ing Shears Fig. 1241. Anterior View of Thorax Intercostal Artery and Internal Mammary Artery are visible 6. In a similar manner 2\'s>o, portions of the sternum can be resected with Liter s gouge forceps, if it seems required for the free drainage of the pleural contents ; but the operator must not forget that the internal mammary artery lies on both sides of the sternum about i centimeter from its margin behind the costal cartilages (Fig. 1241). If, on account of disease of the ribs themselves (tumors, caries), portions of the same must be removed, the operation should not be made subpcrioste- ally, as just described, but, according to the extent of the disease, the soft parts surrounding the bone, periosteum, muscles, skin, and even, under some circumstances, portions of the lungs should be removed. OPENING OF THE THORACIC CAVITY 657 OPENING OF THE THORACIC CAVITY is made in exiLdations of the pleura, especially when, owing to their extejit (compression of the lungs and the heart) or their nature, they endanger the Hfe of the patient. First of all, accurate evidence concerning the extent of the exudation must be obtained by a careful physical examination (dulness or diminished resonance, weakened vocal fremitus, absence of respiratory murmur) and by exploratory puncture with a sterilized Pravazs syringe. In case the operator finds only sernni or blood, the exudation is evacuated by simple puncture ; if, however, the fluid drawn off by the exploratory puncture is purulent, puncture alone is not sufficient ; a permanent drainage for the escape of pus must be established (see page 661). THORACOCENTESIS, the opening of the thoracic cavity by puncture, is made in the following manner : — The patient Hes on the edge of the bed, with thorax shghtly elevated and inclined toward the healthy side. If the exudation were punctured at its lozvest place, the drainage opening would become obstructed in a short time by the movements of the diaphragm. Hence, it is advisable to select a somewhat higher place for puncturing, most frequently the fifth intercostal space in the line of the axilla, or the intercostal space between the seventh and eighth ribs in the scapular line on the back. To reach the intercostal space safely, the soft parts are pressed firmly into it with the tips of two fingers, and a trocar is inserted between the fingers, but not too deeply, in order to avoid injury to the lungs. The punc- ture should be made close to the iipper margin of the lower rib, in order not to strike the intercostal artery. The puncture of the thoracic cavity with a single trocar is a technical error; for, even if in the beginning a continuous drainage is effected by positive intrathoracic pressure caused by the exudation, nevertheless, after equalization of the unbalanced pressure in the pleural cavity, air would be aspirated with every deep inspiration (cough) {Jiydropfieumothorax\ Hence, tJiis suction of air must be prevented by suitable measures. The simplest procedure is the formation of a valvelike closure of the external opening of the canula by using a thin flaccid membrane, which at 658 SURGICAL TECHNIC each inspiration closes the canula, but which does not prevent the escape of fluid during expiration. Billroth used a piece of thin intestine of a calf ; Rcybard and others recommended pushing the trocar through a thin mem- brane of caoutchouc (condom) and fastening this to the shield of the canula so that it lies like a curtain in front of the opening, and with each inspira- tion is firmly pressed against it. The procedure is simple and reliable (Fig. 1244). The puncture can also be made with a trocar supplied witii a stop-cock (Figs. 1242, 1243). Fig. 1242 Fig. 1243 Kussmaul's Trocar with Stop-cock Fig. 1244 Reybard's Trocar Fig. 1245 Frantzel's Trocar Fii;. 1246. Bill- roth's Trocar After insertion of the trocar, the stylet is withdrawn behind the stop-cock ; the latter is then closed ; the stylet is removed, and over the end of the canula is attached a short rubber tube which extends to a vessel on the floor, filled with antiseptic solution {Bienncr). When the stop-cock is opened, the fluid drains off until the difference of pressure has been equalized; if negative pressure is produced through coughing, etc., a part of the fluid already drained is aspirated again, because the end of the tube is in the fluid. OPENING OF THE THORACIC CAVITY 659 PUNCTURE WITH ASPIRATION Since in simple puncture only so much is drained off as the pressure, existing in the pleural cavit}', permits (which is sometimes very slight), it is advisable to connect with the canula a siphon or an aspirator, bv which as much of the fluid is evacuated as is deemed desirable. In this procedure, it is to be borne in mind that congestion of the lungs and of the pleura, cough, and even fainting easily occur from a too free aspiration and the consequent fluctuation of pressure in the thoracic cavity. Hence, it is advisable never to evacuate the jinid completely at one sitting, but to interrupt the flow for a time. If the fluid shows a bloody tinge, the operation should be discontinued at once. For after the evacuation of even a small quantity, a resorption of the remainder of the serous transudation sometimes takes place. Frdntzel advises removing, even in ver}* large transudations, not more than 1500 citbic centimeters at one sitting. Yox pnnctnre zvith aspiration, various kinds of apparatus have been in- vented. The operation is performed in a most satisfactory manner with FrdntzeV s trocar (Fig. 1245) and Potains or Dienlafoy s aspirator (Y'lg?,. 1247, 1248). The stylet of FrdntzeVs trocar (Fig. 1245) can be with- drawn in an air-tigJit manner by means of a button attached to the handle, while the fluid is drained off through the canula attached laterally and provided with a stop-cock. If an obstruction of the canula occurs from fibrinous masses during aspiration, a simple insertion of the stylet suffices to remove mechanically this otherwise very annoying occur- rence. The little canula attached laterally is connected with the aspiration bottle by a rubber tube. In the latter, the air can be rarefied by the exhausting pump ; by this means, the fluid is aspirated into the bottle after opening the stop-cock in the canula. If the simpler aspiration needles (Figs. 1247, 1248), similar to the needle canulas of a Pravaz syringe, are used instead of this trocar, the flow may be suddenly stopped by obstruction from a small particle of fibrin ; in such a case, nothing else can be done than to withdraw the needle and to insert it in another place, — a procedure that is perfectly justifiable on account of the trifling operation, however unpleasant it may be for the surgeon and his assistants. Fig. 1247. DiEULA- foy's Aspir.\tor 66o SURGICAL TECHNIC Fiiybinger simplified the various kinds of aspiration apparatus by using for aspiration of the fluid a simple bottle, closed air-tight with a cork. Two glass tubes pass through the cork, one reaching through the antiseptic fluid at the bottom, the other ending just below the cork (syringe-bottle). The longer glass tube is connected by a rubber tube with the instrument for puncture. By means of a second tube fastened to the shorter tube and pro- FiG. 1248. Potain's Aspirator Fin. 1249. Furbinger's Aspir.\T()R vided with a stop-cock (so that it can be opened and closed at pleasure), the air in the bottle can be rarefied by aspiration with the mouth. After the operation has been completed, the little puncture is sealed with iodoform collodion, and a light compressive bandage is applied. PUNCTURE WITH PERMANENT ASPIRATION {Quincke, Bulmi) is used with very good success, especially in the young, in many forms of empyema (Fig. 1250). OPENING OF THE THORACIC CAVITY 66 1 A strong trocar {a) is inserted, preferably in the axillary line (if possible, at the lowest point of the empyema). The stylet is withdrawn, and a tight- fitting rubber tube {b) (Nelaton catheter) is inserted through the lumen of the canula ; over this the canula is then withdrawn so that the rubber tube alone remains in position in the thoracic wall. It is securely fastened to the thoracic wall with collodion, and connected by means of a short glass tube {c), provided with a longer thin rubber tube {d), the end of which extends into a bottle {e) filled with antiseptic fluid. The degree of aspiration of this siphon apparatus can be controlled at pleasure by lowering or elevating the bottle ; the flow of pus may be observed through the interposed glass tube. If the aspiration bottle is full, the rubber tube is compressed, while the bottle is cleansed or changed. In this manner, the evacuation of an empyema is made very slowly, while at the same time the lung, relieved from its pressure, can expand gradually. Under some circumstances, the patient may walk about, carrying the bottle in his pocket. THORACOTOMY The opejiing of the thoracic cavity by incision must be made in ■aSS. purulent or septic exudations to establish a permanent and sufficient drainage for the free escape of pus. Empyema is treated in the same manner as any other abscess ; viz., by free incision and drainage. Since the operation is concerned with a sup- purating cavity whose walls are in some places rigid, in others have essen- tially lost their elasticity, it is necessary to preserve the drainage opening until a visible decrease of the empyema by contraction or adhesion of its walls (pleura costalis et pulmonalis) has taken place. The patient, during this operation, is placed in a half-sitting position, inclined slightly toward the healthy side ; with a complete lateral position on the healthy side, sudden death may occur during the operation {Paget). The simple incision of the thoracic zvall in an intercostal space in most Fig. 1250. BiJLAu's Perjianent Aspirator 662 SURGICAL TECHNIC cases is not sufficient, since the wound closes up sooner than the empyema heals ; in consequence of this, there remains an obstinate empyema fistula. Even Hippocrates tried to establish a better drainage by trcpliiiiing a rib. More practical is the subperiosteal resection of about a finger's length of a rib. On the back, generally the seventh to ninth rib, in the axillary line, the fifth rib, is resected (see page 655). Into the wide opening thus made one or two very thick rubber drainage tubes are introduced ; these are prevented from slipping into the cavity by safety pins, placed transversely. For enlarging the opening, from the same incision the next higher rib may be similarly resected by making forcible traction ; the pleura is opened ; the soft parts lying between the two longitudinal incisions, and also the blood vessels, can be ligated with two ligatures passed with the aneurism needle ; and the pleural incisions can be connected by a perpendicular incision ; the opening then gapes in the form of x . The Jiealing of an empyemic cavity drained in this manner varies in length of time, and depends on the fact whether the compressed lung has still enough elasticity to expand and to approximate the pulmonary pleura to the costal pleura, thus producing adhesion. If the disease lasts a long time (for months), the lung generally loses this capacity almost entirely; the existing cavity, to be sure, has a drainage ; but it does not decrease in size, and the long-continued dyscrasia consumes the strength and life of the patient. In these cases it is important to make the rigid thoracic wall suffi- ciently elastic ("to mobilize it surgically ") that it can approach more easily the surface of the lung and resume its normal function. Simon attempted to obtain this result by resecting several ribs over the empyema over a large surface. Subsequently, Esthlander{Homen) devised his thoracoplasty on the same principle; he elimimshed \\\t resistance of the diseased portion of the thorax wall by resecting in the axillary line (where the overlying soft parts are thinnest) y^z^t^ to seven ribs to an extcjit of "^ to 12 centimeters, thus making an oval excision lengtJnvise in the solid fi-amework of tJie thorax. For this pur- pose, a huge vertical incision is made over the affected side of the chest ; the soft parts are dissected back from the ribs, and the latter are resected snbperiosteally. After making a free incision of the pleura, a sufficient survey concerning the extent of the empyema and the condition of the lung is obtained. During the healing process the ends of the ribs approach each other, and at the same time are drawn in the direction of the abscess cavity. In cases of very long-standing empyema, Schede proceeded boldly and with the best success by applying the tJioracic ivall, dept ived of the tinyieldiiig OPENING OF THE THORACIC CAVITY 663 parts, and thus rendered flaccid, directly upon the collapsed lung, and thus effected heaUng of the same. From the thoracic wall he formed a large Jlap with an tipper base (Fig. 125 1). The incision begins above the anterior margin of the pectoralis major on a level with the axilla, descends in form of a curve as far as the inferior limit of the pleura, and ascends on the back between the vertebral column and the scapula as far as the second rib. The flap, containing all the soft parts, together with the scapula, is dis- sected back in an upward direction. Next, all tJie ribs from the second downward are resected from their epiphysis to the tubercle of the ribs. A zvide incision of the costal pie? era in the whole extent of the wound affords a free inspection of the cavity of the pleura. The entire remaining portion of the thoracic wall (intercostal muscles, thickened pleura) is removed with a pair of strong scissors and bone-cutting forceps ; the costal arteries, pre- viously compressed by two fingers, are divided and ligated. After the pulmonary pleura has been cleansed, and all granulations and fibri- nous deposits have been removed with a large sharp spoon, the skin flap is placed in position over the lungs, and fastened in this position by a com- pressive bandage. The healing of the large wovmd in most cases takes place by primary intention ; the remittent fever previously present ceases at once. In the after treatment of empyema, it was formerly the custom to cleanse the cavity daily by thorough irrigations, etc. Roser even rolled the patient like a barrel to and fro in order to bring all parts of the cavity in contact with the antiseptic fluid. By these frequent irrigations, however, the healing (adhesion between the two pleural layers) is at least delayed, because the recent delicate tender adhesions are mechanically torn apart. Even sudden death has occurred during the irrigations. Hence, it is better to leave the interior of the cavity undisturbed, and to irrigate it only once (during the operation), but thorougJily, with a non-toxic antiseptic solution. Afterward, it is sufficient to renew the saturated dressings, to take out the drainage tubes, and to cleanse them from stagnant coagula ; otherwise, Fig. 1 25 1. Schede's Thoraco- plasty 664 SURGICAL TECHNIC the cavity of the wound is left alone (unless some additional putrefactive process demands a renewed disinfection). (In ordinary empyema, operated upon by the radical method, a primary disinfection does more harm than good except in cases of foetid empyema. Irrigation with non-toxic antiseptic solution becomes necessary if the amount of pus discharged does not decrease. Thiersch's solution and a saturated solu- tion of acetate of aluminum are best adapted to this purpose. The cavity should never be distended, and the fluid used should be at least heated to blood temperature.) PNEUMOTOMY, incision of the lung, has been practised in modern times, frequently with the best success : — {a) For removing tumors, cysts (echinococci), or a tubercular focus (very rarely possible). {b) For opening abscesses and larger (sac-shaped) broncJiiectases. {c) For xQx^o\m.g gangrene, caused by necrosed tissue (after injuries) or firmly lodged foreign bodies. {d) For causing tubercular cavities to heal or to contract — provided the tubercular focus is circumscribed — in a lung otherwise healthy, or nearly so. Pneumotomy is performed with the thermo-cautery ; an- essential condi- tion for the operation is to scc7tre previous adJiesion of the tivo pleural surfaces over the place of operation. After the seat of the disease has been carefully located by a physical examination, and by an exploratory puncture with a Pravaz syringe or a capillary trocar, an incision is made over this place in the thoracic wall, and a sufficiently large portion of one or several ribs is resected (see page 239). On account of the uncertainty of the diagnosis, it is often necessary to do this from a large flap incision. Whether adhesions of the pleura exist can never be determined with accuracy ; hence, it is best to suture the pleural layers directly in the opening ; or, after the costal pleura has been success- fully exposed, the operator tries to inform himself about the condition of the lung by extrapleural palpation ( Tufficr), or, according to Quincke, he operates in two stages by first securing pleural adhesions by cauterization with paste of zinc cJiloride, applied to the floor of the wound which has been made. The operator then penetrates with the red-hot knife point of the thermo- cautery, without any considerable hemorrhage, deep into the pulmonary tissue, until he reaches the focus of the disease ; the abscess cavity is drained through the external wound. Whether a drainage tube is to be OPENING OF THE THORACIC CAVITY 665 inserted, or the wound to be tamponed, depends on the location of the cavity and the character of the secretion. The artificial fistulous canal, after some time, closes of itself, while the patient's expectoration and general condition improve considerably. In tuberciUar cavities, the walls of which are surrounded by firm indu- rated tissues, and are hence less liable to contract than simple pulmonary abscesses, it is above all important, aside from cauterization with zinc chlo- ride, to perform rib resection including the periosteum in such a manner that the wound can heal by the formation of a yielding and retracted cicatrix {Qidncke). Since these cavities most frequently occur in the apices of the htngs, and since, in most cases, also firm pleuritic adhesions exist as far as the second intercostal space, they are usually opened through the first intercostal space. Sonnenburg proceeded as follows : — 1. The external incision extends at a distance of a thumb's breadth beneath the clavicle from the manubrium sterni to about 4 centimeters in front of the coracoid process. 2. After cutting through the deep thoracic fascia, the pectoralis minor muscle becomes visible. 3. After the intercostal space has been exposed bluntly with the fingers, the short costal arch of tJie first rib projecting from under the clavicle is resected with the costal scissors ; the intercostal muscles and the pleura are divided, and the exposed pulmonary tissue is perforated vi\\\\. the knife point of the thermo-cautery down to the cavity. Tubercular cavities seldom offer indications for operative interference {Sonnenburg). In a similar manner, larger portions of the lung (tumors) can be removed ; whether the resection of a lobe of the king (resection of the lungs) or even of a wJiole lung at the hilus is permissible (extirpation of the lung) cannot be decided with safety judging from present experience. Puncture of the pericardium in the treatmei.it of serous and bloody extrav- asation into the pericardium, if respiration and the cardiac function are considerably impaired by its size {Rose's heart-tamponade), is made in the same manner as puncture of the pleural cavity, but only zvith the aspiration apparatits. The trocar is best inserted perpendicularly in the fourth or the fifth inter- costal space, about 2 centimeters distant from the left sternal margin. The evacuation should be made very slowly (syncope!). {Dr. J. B. Roberts of this country has done much to introduce pericardial 666 SURGICAL TECHXIC puncture and aspiration into more general use, and the therapeutic value of these procedures in well-selected cases can no longer be questioned.) PERICARDIOTOMY is, however, safer. The opening of the pericardium by incision in piirulcjit extravasation is made by a transverse incisioji in the foiirtJi or the fiftJi inteivostal space, ad- vancing layer by layer. TJie ijiternal maniniary artery must be ligated dur- ing this operation. For exposing the pericardium to a greater extent, resection of the costal cartilage is advisable, which is performed in the same manner as in the ligation of the internal mammary artery (see page 652). From a similar incision, ReJin has successfully sutured a wound of the heart. OPERATIONS ON THE MAMMARY GLAND (lNX"ISIO MAMM/E) TJie incision of the mammary gland in abscesses after mastitis sometimes resembles the simple incision of a superficial abscess. If the pus is seated more deeply, the operation may become more diffi- cult and require anaesthesia. 1. External incision must extend in a radiate direction from the periphery of the gland toward the region of the nipple, for the purpose of injuring as few of the lacteal ducts as possible, which radiate in a similar manner. 2. After division of the adipose tissue which envelops the gland, — and which in most cases is well developed, — the abscess is opened by inserting the knife ; and while the contents escape, the finger is introduced and pal- pates the inner surface of the cavity, which is often very sinuous ; the bands and threads of connective tissue are torn ; thus smaller lateral cavities are opened, and all the pockets are reached and widely opened ; scraping with the sharp spoon may sometimes be required, and may induce a more rapid healing. 3. After a short time, the Iiemorrhagc is arrested by compression ; the cavity of the wound is loosely tamponed ; if the abscess cavity is large, and in retromammary abscesses, it is advisable, in addition, to make a counter opening in the most dependent part of the abscess for more efficient drainage. EXTIRPATION OF THE MAMMARY GLAND Benign neoplasms, if not too large, may be excised — that is, extirpated — from the mammary gland; but if they have invaded the glandular tissue OPERATIONS ON THE MAMMARY GLAND 66/ to a large extent, or if they lie scattered in several places in it, it is better to remove the whole gland (ablatio mammae). The skin is divided by two obHque curved incisions extending from above outward to below and inward, with the nipple between them. First the loiuer incision is made, and the margin of the pectorahs major is exposed ; next, the ztppei^ incision is made, and the skin is detached as far as the upper limit of the gland. The organ, circumscribed with the knife on all sides, is then grasped with the hand, and detached as bluntly as possible from its base (muscular fascia) by traction and by using the handle of the knife; thereby the hemorrhage is rendered less severe than by using the knife too freely. Breasts which are much hypertrophied or which are infiltrated by a number of benign tumors are reduced in size or can be made to disappear by a temporary detachment. They are circumscribed with the knife along the border of half their circumference, and detached from underlying tissues. If they are turned back into their former position after the hemorrhage has been arrested, the cicatricial tissue which forms and the thrombosis of the blood vessels induced result in a dim.inution of the blood supply. If, however, from the appearance and the course of the disease, there is a suspicion that the tumor is malignant, not only the whole mamma must be excised, but also tJie axilla innst be cleared out, even in the event that no diseased glands can be detected by palpation through the intact skin. AMPUTATION OF THE BREAST WITH CLEARING OUT OF THE AXILLA for malignant disease (carcinoma, sarcoma) is made in the following manner : — 1. The skin is incised as described above (page 666) by two curved in- cisions, leaving between them, not only the nipple, but also any portion of the tumor adhering to the skin. TJie lozuer elliptical incision is made first ; it penetrates at once down to the pectoralis major muscle. 2. From this incision, the operator enncleates the gland from below, {without distorting or contusing it), together with the muscular fascia, from the pectoralis major miiscle as far as its upper limit by incisions parallel with the muscular fibres. 3. Then the superior curved incisioji is miade through the skin, and like- wise extended down to the muscle ; the mammary gland, then detached, adheres only to the adipose tissue (or to tJie lobuli aberrantes extending into the axilla) in the upper and outer angle of the wound, and is not detached 668 SURGICAL TECHMC at this place. The JicmorrJiagc, which is rarely very profuse in amputation of the mammary gland, takes place from branches of the long thoracic artery, the external and internal vianu/iary arteries^ and the intorostal arteries. It is temporarily arrested by compression with a large sponge or by sterilized gauze tampons. The pectoralis major muscle is very carefully palpated for any diseased portions ; if even the slightest suspicion is aroused, the portion is excised by carrying the incisions through healthy tissue, and the diseased fibres are extirpated in their entire length ; if necessary, the whole muscle is removed — viz., from its insertion to its origin ; likewise, the pectoralis minor muscle must sometimes be transversely divided or entirely removed to facilitate the extirpation of diseased glands {Ha Is ted, Meyer). (Haide)ihein, from his investigations, has shown the necessity of liberal excision in all radical operations for carcinoma of the breast, as well as the channels through which infection is most likely to take place. Halsted has applied his teachings in practice, and does not hesitate in extirpating both pectoral muscles in attempts to reach beyond the limits of the disease.) 4. From the upper angle of the %vonnd, tJie skin incision is made in a slight curve between the margins of the pectoralis major and the latissimus dorsi muscles ijito the axilla (Fig. 1252). {^Dr. E. J. Senn has devised an incision above the border of the pecto- ralis major muscle through which the axillary space can be easily reached, and which offers decided ad- vantages in the preven- tion of wound infections, as it is made outside of the axillary space, a re- gion very difficult to dis- infect.) 5. After division of the axillary fascia and ex- posure of the^ margins of the two muscles, the operator advances along the lateral thoracic wall upon the serratus magnus muscle toward the axilla. All adipose and connective tissue, together with the lymphatic Fk;. 1252. External Incision in Amputation of the Breast and Clearing git the Axilla OPERATIONS OX THE MAMMARY GLAND 669 glands and lymphatic vessels contained therein, are removed in a corniected piece, partly in a bhmt 'inanner, partly with the knife. Special precau- tion is required when the operator approaches the external wall of the axilla, formed by the head of the humerus and the large vessels pass- ing over it. The axillary artery lies behind the large nerve trunks, which furnish a certain degree of protection. TJie large axillary vein, which is most superficial of all the important axillary contents, is most frequently injured; very often the surrounding cellular tissue and the embedded glands are adherejit to its walls. With forceps and grooved director, the vein wall Fig. 1253. Clearing out the Axilla is carefully separated in preference by blunt dissection ; should it be nicked, a lateral ligature is applied. If diseased portions must be excised from its wall, the opening caused by it is sutured longitudinally with the continuous suture. The pectoralis major must be forcibly drawn upward with blunt retractors ; the arm must not be raised too much, but must be kept rather in a horizontal position to the trunk, for lessening tension of the muscles. Likewise, care must be taken not to render the vein bloodless by too forcible traction on the tissue to be removed, else it cannot be distinguished from the bands of cellular tissue. 6/0 SURGICAL TECHNIC 6. As soon as the outer axillary wall has been exposed, and as soon as, at the posterior wall, the subscapular bundle of blood vessels lying deep upon the siibscapidaris muscle, and the subscapular ucrvc lying toward the median line, appear to view, the operator dissects bluntly along the latter in a down- ward direction, and thus reaches the nerve of the latissimus dorsi muscle. If possible, these nerves are all preserved {Kiister). Not until then should the clearing out of the space be completed ; the intercostohumeral jierve, coursing from the thoracic w-all to the axilla, is divided from the second in- tercostal nerve passing to the internal cutaneous nerve of the arm (Fig. 1253). 7. After the operation is completed, the axilla should present the appear- ance of an anatomical preparation in which can be seen only muscles, nerves, and blood vessels (axillary vein). The extirpated contents of the axilla remain attached in the form of a continuous ivedge-shapcd mass of adipose con7iective tissue to the enucleated mammary gland. It is only by following this course that the operator succeeds in protecting the wound, during the operation, from traumatic cancerous infection. 8. In a more extensive disease of the lymphatic glands, it is necessary to expose and remove the glands extending like a rosary from the axilla to the subclavicular space and into the same, by drawing either the pectoralis major muscle strongly upward, or by dividing it transversely and subsequently suturing it. Likewise, the supraclavicular glands must then alwa3's be extirpated ("temporary division by saw- ing of the clavicle). 9. After all of the bleed- ing vessels have been ligated, the large wound is sutured in its entire extent. A drainage tube is inserted into the axilla, or, still better, the skin is in- cised at the most dependent part of the wound (the patient being in the dorsal position); over a pair of introduced dressing forceps, a strong cat- gut thread is introduced through the opening; and, by tying the thread over the line of suturing the opening is made to gape so that the wound secretions can escape through it with facility (Maass-Hoffa) (Fig. 1254). Fig. 1254. SuTVRE and Dr.\inage after Amputation OF THE BRE.\.ST and CLEARING OUT THE AXILL.\ OPERATIONS ON THE MAMMARY GLAND 6/1 More beneficial, it seems, is the introduction of a thick drainage tube into this opening. A silk thread is fastened to the drainage tube ; and, on the second or third day, it is removed under the dressing by making traction on the thread. By a cusJiion dressing the surfaces of the wound are gently pressed against each other ; a ball-like compress presses the skin into the axilla ; the whole arm of the diseased side is fastened to the thoracic wall in an immovable position. After the healing, which in most cases ensues rapidly, oedema of the arm sometimes occurs from cicatricial contraction in the axilla, and the patient is unable to raise the arm. Kilster has attempted to remedy the latter in- convenience by saving the nerves mentioned above. Rydygier prevents cicatrization over the nerve-trunks by making the external incision in the axilla in the form of a flap toward the margin of the latissimus dorsi muscle. If it has been impossible to preserve enough skin to enable suturing of the wound throughout, the margins of the wound are mobilized and rendered more elastic by detaching them extensively from the underlying tissues ; or the defect is closed by a plastic operation or skin grafting ; or the wound is allowed to heal by granulation ; in this case, any recurrence that may take place is more easily recognized and removed. (The late 6". W. Gross taught the surgeons an important lesson in advo- cating extensive removal of skin. He relied on healing of the wound by granulation. In extensive skin defects resulting from the operation it is always advisable to cover the wound at once by a plastic operation.) OPERATIONS ON THE ABDOMEN (PUNCTIO abdominis) TJie opening of the abdominal cavity by pnnctnir is made in far advaticed dropsy {hydrops ascites) in the following manner : — The patient is placed in a sSmi-recumbent position at the edge of the bed ; a towel or broad bandage is so placed around his abdomen that the ends cross each other in the region of the umbilicus. The bladder must be previously evacuated, if necessary, with a catheter. 1. After the surgeon has once more ascertained by percussion the limit of the dull and the resonant region (the intestines float upon the fluid), a medium-sized trocar (on the canula of this trocar, the depth to which it is to be inserted is fixed by the forefinger of the hand which directs the trocar) is in- serted perpendicularly into the abdomi- nal cavity in the linea alba about midzvay betzveoi the umbilicus a)id the symphy- sis pubis (Fig. 1255). Sometimes the puncture can be made laterally in a line drawn from the umbilicus to the Fig. 1255. Opening the Abdominal Cavity . . ^ , ... ... . , BY Puncture anterior spme of the ilmm (mjury of the inferior epigastric artery may occur!). 2. When the stylet of the trocar is withdrawn, the fluid issues from the canula in a stream. To the end of the canula, a suitable rubber tube is fastened and placed into a receptacle placed below. If the pressure during the flow decreases, it may be somewhat increased by making traction on the bandage or towel; by this means, at the same time, the pressure fluctuation in the abdominal organs, caused by puncture and its conse- quences (cough, syncope), is prevented. 3. When the flow ceases, the canula is removed, and the little puncture is covered with adhesive plaster or sealed with iodoform collodion. A light compressive bandage is applied around the abdomen to prevent as much as 672 OPERATIONS ON THE ABDOMEN 6/3 possible the pressure relief and its consequences (hyperemia) and the recur- rence of the transudation. In very thick abdominal walls, it is advisable to incise the skin with the knife at the place of puncture ; under local anaesthesia, the trocar then penetrates more easily. Very feeble patients should be given some cognac or wine during the evacuation of the fluid. If syncope occurs, the flow is interrupted by com- pressing the rubber tube. If fibrinous flakes — or an intestinal loop — obstruct the flow, they can be removed from the end of the canula by strip- ping the rubber tube with jerking movements ; else, they must be carefully dislodged by a blunt instrument (probe, Nelaton catheter) inserted into the canula. Exploratory piinctitrcs with a Pravaz syringe can be made at any place. LAPAROTOMY (cCELIOTOMY) The abdominal cavity is opened hy incision : — {a) For making surgical operations on the abdominal viscera. {b) For diagnostic purposes. Preparations: Several days previously, if the disease permits, care must be taken to evacuate the intestinal canal thoroughly by purgatives and intesti- nal irrigations. Shortly before the operation, the patient must take a full bath and must have his bladder evacuated. Irrigation of the stomach is likewise always advantageous. The operation must be made as rapidly as possible, iji a zvarni room {yy° ¥.), the air of which has been previously charged with steam. To pre- vent the withdrawal of too much bodily heat, the patient is placed upon a warm water bed, and his extremities are covered with cotton or flannel. Since an infected peritoneum can never be disinfected completely, the strict- est asepsis must be observed during the operation. See chapter on Asepsis. After the abdominal cavity has been opened, irrigations with disinfecting solutions are generally not made ; the blood is wiped off with an aseptic sponge of absorbent gauze or cotton, made practically dry by forcibly squeez- ing out the absorbed fluid. Intestines that have been drawn forward are wrapped in zvarm sterilized gauze compresses until they can be replaced into the abdominal cavity. Irrigations of the abdominal cavity with salt water (0.6%), Tavel's solu- tion (Na. Carbon. Calcin. 2.5; Na. Chlorat. pur. 7.5; Aq. Dest. 1000), or non-toxic disinfecting solutions (boric, salicylic, Rotteriji), should be made only in cases in which an ijifection (pus, fasces) has occurred. In this 6/4 SURGICAL TECHNIC case, however, the careful sponging with sterilized moist gauze pads is better. 1. The external incision is made as long as seems necessary for the operation, preferably /;/ the linea alba ; if the incision extends above the umbilical region, the umbilicus is circumscribed on the left side. According to the organ which the operator desires to reach, incisions can also be made laterally from the linea alba along the external margin of the irctus abdoini- jiis muscle, or through its fibres. Under some circumstances, oblique or transverse ineisions may become necessary. By making the incision in the median line after division of the skin and the underlying adipose layer, tJie zuhite shilling linea alba is first reached. If fibres of the rectus abdominis are reached, in case the incision has not been made exactly in the median line, the margin of the sheath of the muscle is sought by the use of a probe ; by this means, the linea alba is located. 2. After its division, the layer of subperitoneal adipose tissue, more or less thick, in most cases is exposed; then the delicate, almost transparent peritoneum. 3. After all hemorrhage has been carefully arrested, a fold of the peri- toneum is raised between two dissecting forceps and incised with knife or scissors ; at once, a broad, flat, grooved director is introduced, and upon it the incision is enlarged far enough for the operator to penetrate into the abdominal cavity with two fingers of the left hand ; while these protect the intestines, the peritoneum between them is incised to the extent of the external incision. 4. The margins of the peritoneuni are stitched to the external skin by interrupted sutures placed at a distance of about 5 centimeters from each other ; their ends remain long. The hand can then be introduced into the abdominal cavity, and the necessary operations can be performed. The reunion of the wound must be made very carefully. If it is necessary to finish the operation rapidly, first several deep sutures are inserted embracing all of the tissues of the margins of the wound, and the skin between these sutures is united by several superficial catgut sutures. But, for the purpose of securing a firm and lasting union, the " e'tage'' or buried suture is made use of ; first, the serous surfaces of the peritoneum, next, the overlying parts, fascia or muscle, are united by interrupted or continuous sutures with catgut (or silver wire, Schede), and, finally, the margins of the skin are closed by sutures applied alternately with catgut and silk. (The best suturing OPERATIONS ON THE ABDOMEN 6/5 materials are : for the peritoneum, fine catgut sutures suffice, the deep inter- rupted sutures, including all other tissues except the peritoneum, are used, the fascia of the recti muscles is united with catgut, and the skin with horse- hair sutures.) Draiiiage in the form of rubber or glass tubes or iodoform wick is established only when an infection of the abdominal cavity has occurred. In such cases, it is even advisable not to suture the wound at all, in order to relieve the abdominal cavity from pressure and to secure the escape of the exudates. Israel, in diffuse, purulent peritonitis, made an ex- tensive crucial incision through the abdominal wall, and left it open ; an apron of sterilized muslin is inserted in front of the intestines. After some time, they retract into the abdominal cavity of their own accord. If, during the operation (for instance, after the removal of very large tumors), a '' dead space'' has been created in the abdominal cavity, from the walls of which a secondary hemorrhage might easily ensue, it is tamponed, according to JMiculicz, by packing it with a large piece of iodoform gauze. This gauze bag is then filled with sterilized gauze, the ends of which are brought out from an angle of the laparotomy wound, sutured except at this angle. This gauze is gradually drawn from the cavity, which is thereby slowly decreased in size and closed. The dressing can be applied either with iodoform collodion or with iodo- form gauze, cotton, or strips of adhesive plaster. Moderate compression of the abdomen by a broad bandage and compression by sand bags placed upon it are advantageous. If violent vomiting occurs after the operation, caffeine injected or tinc- ture of opium or ice pellets administered are sometimes very effective. If vomiting is very violent, irrigations of the stomach by siphonage may be advantageous. In the after-treatment, the nourishment is of the greatest importance, since after operations on the stomach and intestine, only such nourishment must be given as is easily absorbed and' does not cause irritation. Some- times, for the first days, nourishment must be administered "per rectum." The modern food preparations make it possible temporarily to supply a sufficient quantity of nourishment to the system by the stomach. For milder cases, the following simple bill of fare may be sufficient : — On the day of the operation : The mouth is washed out with cold water. First day : Half a liter of cold milk (one spoonful every hour). Second day: In addition, a biscuit ("zwieback") in the morning and another in the afternoon. Third day : In addition, a soft-boiled ^gg. 6/6 SURGICAL TECHNIC Fourth day : In addition, wine soup at noon. Fifth day : In addition, boiled pigeon or scraped meat lightly roasted, with mashed potatoes or boiled rice. Sixth day : From now on, daily, somewhat better and lighter food can be given — in addition, from the beginning, wine (champagne) may be taken. TJic dressings are generally removed on the tenth or twelfth day; the patient is dismissed during the third week after the operation. (In all abdominal operations the editor makes it an inflexible rule to con- iine patients to bed for at least four weeks.) Every patient that has had laparotomy performed must wear an abdomi- nal supporter in order to avoid a retraction of the margins of the wound (abdominal hernia, Fig. 1256). For examining the abdominal organs, BardenJieuer recommended the extraperitoneal explorative incision, ivithont invading the peritoneal cavity, in order to palpate the intestines through the thin parietal peri- toneum {diaperitoneal). For this purpose, he makes very large incisions down to the peritoneum, from which he detaches to a wide extent the abdominal wall in the form of a door (leaves of a door). Start- ing from a sacrolumbar incisioji along the anterior margin of the iliocostalis, he makes transverse inci- sions either above on the costal arch or below along the crest of the ilium [liwibar, costal, iliac, door inci- sion). To reach the organs of the small pelvis, he detaches the abdominal wall by a transverse incision at a varying distance from the anterior superior margin of the pelvis {snprasympkysis incisioji). Fig. 1256. Abdominal Sip- porter after lapa- ROTOMY LAPAROTOMY FOR ILEUS In ileus caused by mechanical intestinal obstruction (foreign bodies, neoplasms, cicatricial stricture, invaginations, intussusceptions, volvulus, retention by bands, etc.), if internal remedies have not yielded any relief, lapa- rotomy is indicated; if, however, septic intestinal paralysis has already set in, — that is, if no single floating intestinal loops can be any longer distin- guished in the barrel-like swollen abdomen, — and if the patient is almost exhausted, it is important, first of all, to secure an evacuation for the accu- mulated putrefied intestinal contents {enterostomy, see page 697). For this purpose, a place is selected as nearly above the obstruction as possible. By OPERATIONS ON THE ABDOMEN 677 i^civs, preliminary operation, the obstruction itself is sometimes removed per- manently; else the radical operation may be performed subsequently, when the patient has regained his strength. If the operator is sure of the exact location of the seat of the obstruction, he should make the incision for laparotomy preferably above the obstmctton. If, however, the same is unknowm, the incision is made iji the linea alba. The seat of the obstruction must then be sought ; the hand, introduced into the abdominal cavity, seeks to ascertain the seat and the cause of the obstruction by palpating the intestines as far as possible. If this is not successful, tJie intestine must be exventrated ajid examined. An assistant seizes any of the markedly inflated loops of intestine lying in the abdominal wound, and holds it securely all the time ; proceeding from the same, the operator continues to ex\^entrate other loops, which the assistant returns directly into the abdominal cavity. If, from the decrease of the inflammjation and the inflation of the intestinal loops, the operator is satisfied he is receding from the seat of strangulation, then, on the other side of the intestinal loop, firmly held by the assistant, the operator proceeds in the same manner until the obstruction is reached {Hulke, Miciilicz). The obstruction is most promptly found, however, when the operator, " a priori," makes a verv" long external incision. The intestines are received and placed in a hot compress {Kiimmell). On account of the rapid cooling of the intestines, the greatest speed is imperative in adopting this procedure. If the operator finds an invagination, or if an intestinal loop has passed through an opening in the mesentery, the attempt should be made to liberate the same by traction ; bands are divided after previous double ligation. If he finds neoplasms, the intestinal portion involved must be resected, or anastomosis must be established. If he finds a volvulus caused by elonga- tion of the mesentery, the intestine must be replaced into its normal position, and the mesentery must be shortened by forming a fold running parallel to the intestine ( Senn); the sigmoid flexure, reduced into its normal position, is sutured to the left abdominal wall ivon Niissbaiim ). After removal of the obstruction, the intestines must be returned into the abdomen as rapidly as possible, — a procedure that may become extremely difficult, on account of the distention of the intestines. By returning them slowly into the abdominal cavity and by gradually diminishing the external wound by suturing, this procedure can be accom- plished ; but it is not advisable to employ too much force, because, as a rule, the fatal collapse sets in rapidly, and, notwithstanding the removal of the obstruction, the paralyzed intestine cannot transport its decomposed contents. 6/8 SURGICAL TECHNIC If the intestine is not yet paralyzed, the peristaltic movements of its musculature often facilitate its reduction ; also, by irrigating the stomach with an open abdominal cavity {Rc/ui), more space can be created, and the return can be facilitated. In case of greatest necessity, the distended ex- posed intestinal loops must be incised at one place by a longitudinal incision, and the contents must be stripped out with the fingers, or are allowed to flow out gradually through a drainage tube fastened into it {Miciilics). If the reduction is successful after this, the visceral wound can be closed by enter- orrhaphy ; but if the intestines are paralyzed, it is better to fasten the loop in the external wound, and thus establish an artificial anus (see page 289). OPERATIONS ON THE STOMACH AND THE INTESTINES GASTROTOMY The scientific openi7ig of the stomach is made for removing foreign bodies which have been swallowed and which, on account of their shape and quality, cannot be expected to pass spontaneously. By incising the stomach, as early as 1635, Daniel Schwab successfully removed a knife that had been swallowed. If abscesses or adhesions with the abdominal walls are present, a simple incision suffices ; otherwise, the method is as follows : — 1. External incision either from the tip of the ensiform cartilage ob- liquely to the left, a thumb's breadth below and along the left costal arch ; or beginning in the median line, in the linea alba, a thumb's breadth below the ensiform process. Incision and stitching of thQ perito?iaim to the skin (see page 675). 2. The stomach is drawn forward with the two fingers; the anterior wall, if necessary, is held by two ligature loops passed only through the serous and the muscular coats. 3. The stomach is then opened, preferably, by a vertical incision, for the purpose of avoiding large blood vessels (gastric artery), either directly over the foreign body, if it can be felt, or in the free space between the Hgature loops. 4. If the opening is sufficiently large, the foreign body is extracted with the fingers or forceps, and the opening is closed by gastrorrhaphy, in which the ligature loops can be used. In recent times, gastrotomy has also been made for gastrorrhagia and gastric ulcers. After the stomach has been opened, the bleeding vessel can be sought for, and ligatcd ; ulcers are excised, and the fresh wound surfaces are united by suture {Rydygicj-). OPERATIONS ON THE ABDOMEN 679 (In the surgical treatment of gastric ulcers, U\ Audrezi's of Chicago raises a cone on the inside of the stomach with the ulcer as its apex, ap- plies a ligature at its back, and amputates the tissues on the gastric side of the point of ligation.) GASTRORRHAPHY is indicated : — (a) In wounds of the stomach. (d) \xi gastric fistulas caused by ulcers or injuries. (From punctured or incised wounds, the stomach in most cases prolapses, so that nothing of its contents reaches the abdominal cavity ; if this is the case, fatal peritonitis rapidly ensues.) According to Lemberfs metJwd (Fig. 1310), the suture passes only through the serous and the muscular coats ; the margins of the woitnd are inverted either by interrupted sutures or by rectangular continuous suture (see page 703). Contused portions of the margins of the wound are vivified, if necessary ; in gastric fistulas, the fistulous margins must be excised and their cicatricial surroundings must be removed prior to the insertion and tying of the sutures. Gastropexy is an operation which has for its object the stitching of the stomach to the opened anterior abdominal wall by sutures passing through its serous and muscular coats. Poncet makes it directly after stenoses of the oesophagus, that he may subsequently be able to open the stomach in case of necessity more easily at the place where it has become adherent to the abdominal wall. It can also be resorted to in elevating the stomach dislocated downward {gastroptosis). BircJier, Weir, Brandt, and others have, by gastroplication, successfully diminished the size of the stomach, when greatly dilated and when this con- dition resisted the usual treatment. The exposed anterior wall of the stomach is folded inwardly in the direction of the long axis of the organ with a probe, and the wall of the stomach is sutured over it, the sutures passing only through the serous coat. With several rows of buried sutures, a fold as broad as the hand and extending into the interior of the stomach can be formed and permanently retained. In the same way, several longi- tudinal folds can be made on the anterior and the posterior side. Similar is Tricomi's gastrostenoplasty. Von Hacker designates the operation of separation of adhesions and bands that often cause violent gastralgias, gas- trolysis. 68o SURGICAL TECHNIC GASTROSTOMY {Se'dil/ot, 1 849) an operation for establishing z. fistulous opening into the stomach tluvugJi the abdominal xvalls, is made : — {a) On account of stricture or obstruction of the cesopJiagns from ulcers or cicatrices situated so deeply that they cannot be reached from a wound in the oesophagus. ib) On account of large diverticula of the oesophagus. (<:) For the removal oi foreign bodies firmly impacted in the same. If, on percussion, the stomach is found to be very much contracted, — as it is in most cases, — it is advisable, if at all possible, to inflate it by some effervescent mixture shortly before the operation. 1. External incision 7 to 8 centimeters long from the median line and the ensiform process obliquely to the left downward, parallel to and 2 centi- meters below the left costal arch as far as the eighth costal cartilage {Fenger), or vertically 2 to 3 centimeters to the left from the linea alba through tJie fibres of the rectus abdominis muscle (which, after healing, forms a sphincter- like closure) {von Hacker). 2. Having incised the peritoneum and stitched its margins to the skin, the stomach is sought for, which, contracted in most cases, lies deeply behind. From the course of the gastro-epiploic artery and vein, the wall of the stomach is discernible, and can be distinguished from the transverse colon, which, moreover, is covered by the omentum. 3. A fold of the anterior wall of the stomach is drawn forward and stitched with about fifteen to twenty medium-sized silk sutures (which do not pass through the entire wall of the stomach, but only grasp the serous and the muscular coats, extending about i centimeter in the latter) all around to the margins of the skin wound, covered with the peritoneum, so that an oval portion (about 4 centimeters long and 3 centimeters wide) of the wall of the stomach forms the floor of the wound. The long ends of the sutures are spread all around (in the form of a star), and the wound is covered with an antiseptic dressing Fn;. 1257. Gastrostomy (Sutur- /pjp- ioc7\ ing wall of the stomach) ^ °' "-''/■ During the first days, the patient is nourished with nutrient rectal enemata {Leubes meat solution, tropone, somatose, etc.). F. Fischer at once administers nourishment by inserting a very fine OPERATIONS ON THE ABDOMEN canula obliquely into the stomach, and by injecting milk through the same ; by making the insertion of the needle obliquely for some time repeated every day, always at the same place, he establishes an oblique, well-retaining fistula. But when the danger of starvation is not very great, then, after three to five days after the peritoneal surfaces have become adherent with one another and have intimately united the anterior wall of the stomach to the abdominal wall, — 4. The opening of the stomach is made. After the dressings have been removed, the surface of the wound, not clearly distinguishable on account of the granulations, is lifted somewhat with dissecting forceps or with fine hooks between the outspread ligature ends, and now a simple or crucial in- cision is made with the knife or with the thermo-cautery {Hagedorn), just large enough to admit with some difficulty a rubber tube having a lumen of ^ centimeter to i centi- meter. If the strength of the patient has been brought to a low ebb (from inanition), it is often impos- sible to wait for peritoneal adhe- sions and to perform the operation in tzvo stages ; in such a case the stomach is opened imm,ediately after its wall is stitched, and a tube, through which nourishment can be at once administered, is introduced. Through this tube the patient takes nourishment, at first cau- tiously (eggs, scraped meat, pep- tones, etc.). Later on, the patient's taste and relish for food may be grati- fied, and at the same time the necessary insalivation and the reflex secretory function of the stomach may be utilized, by masticating the food and then conveying it through a tube into the stomach {Trendelenburg, Fig. 1258). Between meals the tube is closed by a wooden plug ; later on a hard rubber canula with suitable closure may be employed. If the opening in the stomach has not been made too large, the canula may be removed entirely in the interval. By the contraction of the margins of the wound a sufficient Fig. 1258. Mode of conveying Food to the Stomach of a Patient who had Gastrostomy performed 682 SURGICAL TECHNIC closure of the fistula is then effected, especially if, according to von Hacker, the opening has been made in the rectus muscle, whereby a kind of sphincter is formed. The latter object is obtained still more satisfactorily by Girard' s victJwd. He makes a vertical incision 15 centimeters long across the middle of the upper portion of the left rectus muscle, sutures to the middle of this incision the prolapsed wall of the stomach, detaches at both sides of the opening a bundle of muscular fibres from the rectus of about a finger's breadth from the deeper portion of the muscle, and places these two muscular bridges crosswise one over the other in such a manner as to grasp the sutured cone of the stomach between them like a sphincter. They are fastened in this position by sutures. E. Hahn stitches the stomach in tJie eighth hitcrcostal space in order to use the elastic costal cartilages like a compression stop-cock, and also to prevent an enlargement of the fistula. For this purpose he first makes an incision 5 to 6 centimeters long along the left costal arch, about i centimeter distant from it, and opens the peritoneal cavity to the same extent. He introduces into the opening a pair of curved dressing forceps, with which the eighth inter- costal space is perforated from behind upward. Next he cuts down upon the point of the forceps from the outside. Then, with the thumb and the forefinger, he draws from the lower wound a portion of the stomach as near as possible to the cardiac extremity (fundus), grasps it with dressing forceps, and draws it through the tunnel made m the intercostal space, where it is fastened by sutures. (Injury to the pleura and the diaphragm need not be feared in perforating the eighth intercostal space.) If a cicatricial stricture has contracted the oesophagus, the operator may attempt to dilate the same from the gastric fistula, first with catgut strings, and subsequently with a rubber tube passed over a fine whalebone bougie {yon Hacker) and with the common bougies. After the stricture has been sufficiently dilated (see also page 641), the gastric fistula can be closed. But in case of a malignant stenosis that cannot be removed, the patient is considerably relieved by establis/iing an oblique fistula according to JVitcel or Frank. Witzel sutures the wall of the stomach over a little rubber tube, so that it forms tivo longitudinal folds. This procedure forms a rcrw^?/, the course of which resembles the lower extremity of the ureter in the wall of the bladder. I. External incision a finger's breadth below the left costal arch and along the same as far as the sheath of the rectus. OPERATIONS OX THE ABDOMEN 683 2. The sheath is opened by a longitudinal incision; the fibres of the rectus are divided bluntly and longitudinally in the middle. 3. With the knife and the tip of the finger, the operator passes through the transversalis abdominis obliquely from the right to the left, down to the peritoneum. 4. The peritoneum is opened ; next, by a quiet, steady, somewhat pro- longed traction, a sufficiently large portion of the anterior wall of the stomach is drawn forward, and on it are raised two oblique folds extending from the left to the right upward to a distance of i-| to 2 centimeters. 5. At the lower extremity of this groove a small opening is made, and a rubber tube as thick as a pencil is inserted (Fig. 1259). 6. Over this tube, directed upward, the raised folds of the stomach are sutured to form a canal about 4 centimeters in length by four or five Lemberfs sutures. A few fine super- ficial sutures secure the complete closure of the groove (Fig. 1260). 7. Next follows the stitching of the stomach to the abdominal wound, as described on page 681. Through the fibres of the rectus and transversalis muscles the rub- ber tube, carried outward, is grasped as if by a cross-clamp. 8. The little tube can remain in position for weeks without escape of the stomach contents. Subsequently it can be removed, and is introduced only for the administration of food. The fistula is covered with a gauze pad. Marwedel modified this method by forming the oblique fistula intra- parietal between the mucous and the muscular coats. (This operation should be accredited to Professor E. Andrezi's of Chicago, who first de- scribed it in the medical press.) After a fold as broad as the thumb has been formed of the anterior wall of the stomach, its serous and muscular coats are incised for about 4 to 5 centimeters ; at the lower angle of the wound the mucous coat is punctured, a thin drainage tube is inserted into the stomach and fastened with a catgut suture ; next, the margins of the serous and muscular coats are united over the tube. The tube can be removed after 5 to 6 days, and is reinserted only for the introduction of food. Fig. 1259. Gastrostomy Fig. 1260. Oblique Fistula (accord- ing to Witzel) 684 SURGICAL TECHNIC Fig. 1 26 1 Fig. 1262 Kadek's Gastrostomy Fig. 126^ The oblique course of the fistula becomes perpendicular after some time, but the good closure is nevertheless maintained by means of serous surfaces hugging closely the rubber tube, the strong fold of the mucous membrane, and the muscular functions of the fibres of the rectus. Hence Kader formed from the beginning a serous fun- nel, perpendicular to the wall of the stomach. After the introduction of the tube he stitched the wall of the stom- ach in several folds over it by deep (Fig. 1261) and su- perficial sutures (Fig. 1262), closing sutures, which are covered in a third layer by fixation sutures (Fig. 1263). The abdominal incision is closed by deep and buried sutures. iyDr. E.J. Senn raises the anterior wall of the stomach in the form of a cone, incises the apex sufficiently to insert a small rubber tube, inverts the apex toward the lumen of the stomach, and sutures the margin of the in- verted cone firmly around the tube with a purse-string and superficial sutures. The valvular closure prevents leakage.) Frank forms from the stomach, which has been drawn forward, a kind of small subcutaneous oesophagus in the following manner : — I. From the common external incision a portion of the anterior wall of the stomach 3 to 4 centimeters in length is drawn forward, the apex of the cone thus formed is provided with a ligature loop, the base of which is closely stitched to the parietal peritoneum and the deep fascia {Kocher, Fig. 1264). Fig. 1264 Fig. 1265 Frank's Gastkosto.my Fig. 1266 2. A small skin incision i.] centimeters long is made above the costal arch, about 3 centimeters above the first incision ; the bridge of skin formed OPERATIONS ON THE ABDOMEN 685 between the two incisions is bluntly undermined, and the sutured part of the stomach is drawn beneath the bridge by the ligature loop into the upper opening (Fig. 1265). 3. The tip of this segment of the stomach is opened and fastened with a few sutures to the wound edges of the little buttonhole. 4. The first incision is sutured in its whole extent. The little canal can be very well used for the introduction of food ; owing to its curved course around the costal arch and the contraction of the rectus muscle (Fig. 1266), leakage is prevented. RESECTION OF THE PYLORUS {Billroth, 1 88 1) Excision of the pylorus is made in stricture of the same from tinnors {carcinoma) and extensive cicatrization, provided adhesions with the sur- rounding parts do not exist at all, or at least not to any considerable degree, and provided the strength of the patient has not been too much reduced. Preparations : after approximate information concerning the seat and the extent of the disease has been obtained by frequent prehminary exami- nations (under anaesthesia), and after the intestinal canal has been thoroughly evacuated by laxatives and enemata shortly before the operation, the stomach is irrigated several times with weak antiseptic solutions (boro-sali- cyhc); then the patient receives an enema of ten to twenty drops of tincture of opium. (Saline rectal enemata administered for 24 hours before the operation at intervals of 6 hours and strychnine hypodermatically before the anaes- thetic is given are potent prophylactic measures against shock.) . For preventing collapse during the long operation, it is advisable to avoid anaesthesia as much as possible and to operate, according to Schleich, as long as possible under local anaesthesia. As an analeptic, a warm mix- ture of good claret and water (i to 3) can be kept ready ; at intervals, this is injected into the rectum {Lange). Just as effective is an enema of a spoon- ful of cognac to half a liter of water (for the rest, see page 674). 1. External incision in the linea alba from the ensiform process to the umbilicus {Rydygier), or an oblique incision across the diseased portion, transversely through the recti muscles ( Woljler, Billroth). 2. After the peritoneum has been opened and a portion of the pylorus has been drawn forward, the operator ascertains by palpating the surround- ing parts whether a resection is at all possible, and especially whether adhe- sions with the transverse colon, the pancreas, and the liver are present. In case of necessity, by a sht made in the gastrohcpatic ligament or in the gas- 6S6 SURGICAL TECHxXIC trohepatic omentum, the posterior surface of the pylorus can be palpated with the finger. If it appears that the operation cannot be successfully performed, either the abdominal wound is closed again {diagnostic lapa- rotomy), or gastro-eiiterostomy is made. If, however, resection has been determined upon, then 3. The pylorus and the parts to be removed are isolated and detached from their surrounding parts ; detachment of the gastrocolic omentum from the greater curvature after a careful double Hgation of all blood vessels between two hemostatic forceps or with the thermo-cautery ( Woljicr). The separation must not be made any farther than the line of the intended resec- tion, else gangrene of the colon may ensue {Laiicnstein); likewise, the detachment of the gastrohcpatic ligament from the lesser curvature and that of the hepatoduodeual ligament are made in the same manner ; Hgations at this place are sometimes very difficult ; Hkewise, after any slight adhesions of the posterior side to the pancreas have been carefully divided or hgated, the now completely detached portion of the stomach is drawn forward entirely from the abdominal wound ; a sterihzed compress of gauze (or a flat sponge) is placed under it and warm compresses over it; everything else is returned into the abdominal cavity. 4. Excision of the pylorus : before the incisions are made, the lumen of the stomacJi and of the dnodejium must be closed to prevent the intestinal contents and putrid material of the carcinoma from escaping. This is best done by the fingers of an assistant; or the stomach and the duodenum are encircled with a thin rubber ligature or a silk thread {Schede), or strips of gauze {Billroth); special compression instruments {covpressoria) are also recommended for this purpose. Rydygiers intestinal clamps {Y\g. 1269) consist of two delicate steel rods covered by thin drainage tubes ; they are applied around the intestine, and are compressed at their ends by being tied together with a rubber band. Of similar construction is Wehr-Hcinekes compressoriu?n {Y\g. 1270), a steel clamp with a rubber tube stretched over it for compressing the intestines. Billroth'' s intestinal clamps {Y\g. 1267), Hahn's {¥\g. 1268), Gussenbaucr s parallel forceps (Fig. 1271), Kiister's (Fig. 1272), Liickcs, and others can be employed. These instruments are applied in such a manner that the portion of the pylorus can be excised at least 2 centimeters distant from the margins of the disease. The duodenum is compressed by one clamp ; the stomach by two clamps from above and from below. If the clamp cannot be well applied on the duodenum, on account of firm adhesions, two ligature loops OPERATIONS ON THE ABDOMEN 687 are drawn through the intestinal wall and the mesenteric insertion ; by means of these, the intestine is somewhat drawn forward and flexed. On Fig. 1267. Billroth's Fig. 1268. Hahn's Fig. 1269. Rydygier's FiG. 1270. Wehr and Heineke's Intestinal Cla.aips the other side of these clamps, the healthy part of the stomach is closed by the fingers of the assistant ; on the duodenum, however, a second clamp is applied. 5. The tumor is grasped with broad Miizcjixs forceps, and the stomach is cut tJirongh with a pair of straight scissors mostly in an oblique direction (Fig. 1273). The incision begins at the lesser curvature above on the left, and extends downward to the right ; each visible blood vessel is ligated after each sweep with the scissors ; when the lumen of the stomach has been opened, its con- tents are at once absorbed by a sponge, introduced into the stomach, and it is wiped antiseptically with a second sponge. At the greater curvature, the stomach is still left in connection with the pylorus corresponding about to the size of the circumference of the duodenum. 6. The wound of the stomach, commencing at the lesser curvature, is at once sutured by a double roiv of sutures according to Czei'iiy-Lcuibert (occlu- sion suture, Fig. 1274, <^). After that, the incision of the stomach at the greater curvature is completed. 688 SURGICAL TECHNIC 7. Parallel to the incision of the stomach, the operator then divides the diiodcnuni obliqiiely between the two clatnps, advancing step by step and carefully arresting the hemorrhage. (Obliquity of visceral incision at the expense of the convex border of the stomach.) Fig. 1 27 1. Gussenbauer's Fig. 1272. Kiister's Parallel Forceps Fig. 1274. a, occlusion suture; b, cir- cular suture Billroth-Wolp'ler's Resection of THE Pylorus 8. He then stitches the duodenum to the decreased wound of the stomach (circular suture) according to the rules of circular enterorrhaphy (see page 704). Commencing at the lesser curvature, he first applies the tnner mucous menibrane sutures as far as practical, and next over these a second row of siitures according to Lenibcrt (seromuscular). Whether he employs the interrupted suture or the continuous suture makes no differ- ence ; a continuous suture with silk is applied more rapidly, and closes the wound very well. 9. After the rows of sutures have been once more carefully examined and after such parts as appear weak have been strengthened by interrupted sutures placed between them, the surface is sponged with antiseptic solu- tion ; the compress placed beneath it is removed, and the stomach is OPERATIONS OX THE ABDOMEN 689 returned into the abdominal cavity. TJie sittiires of the external incision are applied as described on page 675. The patient is nourished during the first three or four days exclusively by nutrient enemata ; after that time, liquid nourishment is administered (see page 676). Fig. 1275 Fig. 1276 Rydygier's Resection of the Pylorus, a, incisions; b, suture The stitching of the duodenum to the greater curvature {Rydygier, Bill- roth, Wdljier) creates a more useful channel for the passage of the food than its insertion at the lesser curvature, — as was done first. The stomach, distended in most cases, becomes by the occlusion suture more like a cul de sac (Fig. 1276). For avoiding such saclike formation in case the lumina to be united differ too much in size, the operator must try to equalize these irregularities by making the incision through the stomach near the great curvature oblique (Fig. 1275, a). Implantation of the duodenum into the middle of the wound of the stomach offers no advantage. In some cases in which the neoplasm has become so extensive that the reunion of the resected parts would be impossible without very great tension, Billroth first made gastro-enterostomy, extirpated the tumor, and closed the opening in the stom- ach and the duodenum by suture (Fig. 1276). Kocher obtains very good success with pylorus resection and gastroduodenostomy. He divides first the duodenum between the two clamps ; next, the stomach along the clamps ; and closes the latter completely by continuous silk sutures extending through all layers (Fig. 1278). A row of Lemberfs sutures 2 Y Fig. 1277. Billroth's Resection of Pylorus and G.\stro-enterostomv 690 SURGICAL TECHNIC is applied over this row of sutures. The assistant then turns the poste- rior wall of the stomach anteriorly, pressing it at the same time toward the right margin of the external wound to the duodenum, which has been drawn forward, and which thereby becomes occluded. The posterior mar- gin of the duodenuhi is then sutured by serous sutures to the posterior wall of the stomach, and the clamp is removed from the duodenum. The posterior side of the stomach is incised longitudinally, about \ centimeter Fig. 127S Fig, 1279 Kocher's Resection of Pylorus and Gastroduodenostomy from this sutured place corresponding to the breadth of the duodenum, and after ligation of all bleeding vessels, first the posterior (Fig. 1279), ^^^f i^ con- nection with it, the circular, sutures are applied, extending through the whole thickness of the intestinal wall, the serous coat, the muscular coat, and the mucous membrane. Over this, the serous suturing of the anterior part is made in addition to the posterior serous sutures previously applied. The success of this procedure has been very good up to the present time. GASTRO-ENTEROSTOMY ( IVo/Jler, 1 88 1), //ie formation of a fistulous opening bctivcen the stomach and the small intestine by suturing a portion of the small intestine to the wall of the stomach, is made as a palliative measure in inoperable eanccr of the pylorus or in 7'ecurrence of the same after previous resection, and in strictures of the duodenum, for the escape of the contents of the stomach into the intestine. I. Longitudinal incision in the linea alba from the ensiform process to the umbilicus ; the peritoneum is divided and stitched with a few sutures to the external skin. OPERATIONS ON THE ABDOMEN 691 2. The transverse colon and the omenttcni are brought out with the fingers and placed in an upward direction to the right. The dnodenojcjimal fold of the peritoneum, from which the small intestine emerges, is now seen ; its mesentery always be- comes longer to the left ; and at a distance of 40 to 50 centimeters it is so long that the intestine can be applied to the stomach across the colon (Fig. 1280). 3. This portion of the small intestine is drawn from the ab- dominal wound ; a portion about 10 centimeters long is stripped empty with the fingers, and clam.ped on both sides with rub- ber bands, with thick silk liga- tures, or with Rydygier's clamps, which are passed through small slits made in the mesentery with forceps (" Schiebern"). Except the two parts which are to be incised, viz. the portion of the Fig. 1280. Duodenojejunal Fold, Transverse n-^^. 1,, 11 r Colon and Omentum placed in an Upward small mtestme and the wall of Direction the stomach, everything is re- turned into the abdominal cavity, and the whole abdominal wound is covered with sterilized warm compresses. 4. The clamped-off loop of the small intestine is opened by an incision 3 centimeters long at the side opposite to the mesenteric insertion ; the hemorrhage is arrested, and the inner surface is sponged antiseptically. It is advantageous to make the incision as small as possible, since large incisions promote subsequent " spur " formation. 5. The anteiior zvall of the stomach is grasped by the assistant, lifted up near the fundus, or even in the middle between the fundus and the pylorus ; it is securely clamped off with his fingers, with Gussenbaiier' s clamps, or with Brims' s clamp-forceps ; and then opened between the same by an incision 3 to 5 centimeters long at a place about 4 centimeters above the large curva- ture (where the coronary artery branches off into smaller ramifications). The hemorrhage is arrested, the inner surface of the stomach is irrigated with a weak antiseptic solution. The incisions in the wall of the stomach 692 SURGICAL TECHNIC and the portion of the small intestine may be made either longitudinally ( Wolfler, Fig. 128 1) or tratisversely {Socin, Fig. 1282). Fig. 1281. Wolfler's Fn;. 12S2. Socin's Gastro-ENTEROSTOMY. a, making incisions; /;, corunary artery 6. Applying the suture. First, the posterior margins of the wound are united by tJie internal mucous membra7ie suture ( Wbljicr, Fig. 13 12) as far as possible ; the remainder is closed by an external mucous membrane suture, and finally the serous coat is closed all around hy Lejnbcrf s suture or by CusJiings continuous rectangular quilt suture (see page 704). The following modifications of this procedure must be mentioned : — VoJi Hacker {and Courvoisier) recommends stitching the loop of the small intestine to the posterior ivall of the stojnach in order to prevent strangulation of the transverse colon by the loop of the small intestine laid over it. For this purpose, after the colon and the omentum have been turned up, he makes posteriorly in a blunt man- ner a slit in a non-vascular portion of the mesocolon, stitches its gaping mar- gins to the posterior wall of the stom- ach ; next, he sutures the loop of the small intestine in this opening to the posterior wall of the stomach (Fig. 1283). This can become very difificult ; the transverse colon with the great omen- tum remains iji its normal position in front of the loop of the small intestine. Even now, many surgeons recom- mend this as the best operation. Fig. 1283. Von Hackkk's Gastro- enterostomy OPERATIONS ON THE ABDOMEN 693 Wdlfler, to prevent vomiting caused by the bile flowing into the stomach and thence with the gastric contents into the /rc,r/;«\ Fig. 1 321 Kocher's Method of detaching Mesentery, a , cuneiform excision; b, applying suture and forming longitudinal fold 5. Next, the continuity of the intestine is restored by a circular enteror- rhapJiy, and is returned into the abdominal cavity ; the abdominal incision is closed in the usual manner. Voji Bergmann protects himself from failures in enterorrhaphy after resection by applying strips of iodoform gauze on both sides of the sutured portion. The ends of the strips are carried out of the abdominal wound. If gangrene (or peritonitis) sets in, it remains local- ized, as the pre-peritoneal cavity is protected by adhesions around the gauze. During the first days after the operation, the patient is kept under the influence of opium, and nourished only by enemata ; from the third day on, he may receive fluid nourishment ; the return to solid diet must be very gradual. If the intestinal resection appears to be impossible, because intestinal tumors are extensively adherent to the surrounding parts, or if fistulas and callosities render the extirpation of the intestinal section impossible, it is preferable to eliminate the diseased portion by making an artificial chan- nel between the intestinal portions lying above and below the tumor (entero- anastomosis), with the intestine apposed laterally (^Maisonneuve, 1854; Bill- roth, 1882), either in the manner described in gastro-enterostomy, or, more OPERATIONS ON THE ABDOMEN 709 rapidly and simply, according to Semis method. He introduces into each of the two longitudmal incisions that have been made in the intestinal zvall an oval decalcified bone plate, which has, in its middle portion, an oval open- ing, to the margins of which four aseptic silk threads are fastened ; the two threads at the long side of the bone plate are provided with fine needles (Fig. 1323, a)\ th-ese are passed /wwz the inside through the muscular and serous coats of the margins of the intestinal wound, and then the four cor- responding pairs of threads are tied together. Thereby the serous surfaces of the two intestinal portions are pressed against each other with moderate firmness, and the intestinal con- tents can pass through the openings of the bone plates fitting upon each other (Fig. 1323, b and c). Very soon Fig. 1323. Senn's Entero-anastomosis. a, bone plate; <^, introducing plates; 2. Exposure and incision of the hernial sac. Between two forceps at the eminence of the swelling, near the neck of the Jiernial sac, gradually all movable layers of cellular tissue covering the hernial sac are carefully raised and di- vided in the manner described in the chap- ter on ligation of arteries (page 251). The incisions must divide only the raised fold. As soon as the cellular tissue folds can be raised, with difficulty, or not at all, the operator may assume that he has reached the hernial sac ; into the short incision that has been made, a grooved director is intro- duced in the direction of the two angles of the wound, and upon it all of the layers of the hernial sac are divided until the entire anterior wall of the hernial sac is freely exposed. The hernial sac as a rule may be recognised by its smooth surface, by the small adipose lobules (subserous fat) lying scattered upon it, and by the serous effusion shining through the same. Hence, if the operator is in doubt whether the hernial sac or an intestinal loop lies before him, he should attempt to raise a small fold with his fingers, and rub the inner surfaces of the fold upon each other. If the membrane, on palpation, appears to be thin-walled, it is the exposed hernial sac, for the oedematous swollen intestinal walls are much thicker on palpation, and cannot be raised at all in folds. If the hernial contents are adherent to the hernial sac under the incision, so that no thin fold can be raised with the finger tips, the operator seeks and generally finds another place, the condition of which no longer leaves any Fig. 1347. Herniotomy (External incision) OPERATIONS ON THE ABDOMEN 719 doubt. Here the hernial sac is now raised between two forceps, so that a small fold is formed, and with the knife or scissors a small incision is made, from which the serous effusion immediately escapes with some force ; into this opening, the operator introduces a grooved director, upon which lie divides the hernial sac in its entire length, so that he is able to survey the entire hernial contents. 3. With the finger, introduced toward the neck of the hernial sac, he examines the scat of the strangulation, and ascertains whether any adhesions exist, by palpating the hernial contents on ail sides with the finger. If adhesions are found, they must be separated carefully and bluntly; but if they are too firm, they are detached with the knife in such a manner that thin portions of the wall of the hernial sac remain adherent to the intestinal wall. Fig. 1348. Hernia Knives (Herniotomes) Fig. 1349. Herniotomy (Relieving strangulation) 4. Relieving the Strangulation. K Jicmia knife {herniotome) {Y\g. 1348) is pressed lengthwise with the blade upon the volar surface of the left fore- finger, and the finger is advanced as far as possible toward the hernial opening, until its point feels the incarcerating ring. In this position, with a slowly increasing pressure, the oedema of the intestinal loop can often be displaced so far that the tip of the finger can penetrate into the constricted portion of the hernial canal. Next, the blunt end of the herniotome is pushed over the tip of the finger into the abdominal cavity ; the edge of the knife is directed against the strangulating margin ; and the margin ts mckcd by pressing \hQ back of the knife with the finger. Pulling and cutting move- 720 SURGICAL TECHNIC ments Diust be avoided. These nicks may be repeated at several places of the hernial ring ( Vidal) (and then only superficially), until the finger tip can be pushed with ease into the abdominal cavity alongside the strangulated intestine. The location of the stmngnlati/ig ling at which these nicks are made depends entirely on the kind of hernia. In external inguinal hernia, tJie hernial ring is incised in an ontzvard directioji ; in internal inguinal hernia, imvard {\.o avoid the epigastric artery). If any doubt exists as to which of the two kinds of hernia is present, the incision is made in an upward direction {Scarpa). In internal femoral hernia, the incision is made inward tozvard Giniber- nafs ligament ; and, since the obturator artery, springing from the epigastric artery, may take its course at this place (corona mortis) (Fig. 1345), the cut must be made only by pressure, — not by drawing movements of the knife, — so that the movable artery can recede from the knife and that only the rigid and tendinous parts are divided. By an incision made ontivard the great femoral blood vessels would be endangered if directed Jipward through Poupart's ligament, the epigastric artery, tJie spermatic cord, and the ligamen- tum rotundum or teres; i)iferiorly, the sapJiemnis vein might be injured. /;/ strangulations in the fossa ovalis, the operator incises tJie falcifonn process in an inward and upward direction. In the very rare variety of external femoral hernia, the incision is made outward. 5. Returning the hernial contents. If in this manner the strangulation has been removed, the operator has next to examine the condition of the strangulated intestinal loop and, above all, that part of the intestinal wall which had been subjected to direct pressure. For this purpose, the intestine must be somewhat drazvn forzvard. If at the place of strangulation a dis- colored gray streak is found, it is to be feared that perforation will occur at this place ; the same fear must be entertained if the intestinal loop itself presents a dark blnisJi, black, or brozvnisJi color, with a diill surface, having lost \X'& glistening, shiny appearance ; such a loop must not be returned. 6. If the intestine is still in good condition — that is, if it displays a smooth, glistening sniface, if it is colored /^/f red to dark bluish red {vqwows stasis), if it turns somewhat paler from pressure of the finger, and if peri- stalsis is excited on touching it with a crystal of sodium chloride — it is gently sponged zvith an antiseptic solution, and returned into the abdominal cavity by pressure of the fingers as in taxis. If any difficulties arise during this manipulation, the hernial sac is drazvn tense at its margin with dissecting forceps, whereby the obstructing formation of folds is removed. OPERATIONS ON THE ABDOMEN 721 7. The hernial sac and its neck can now be treated as described in the radical operation (see page 722). If, however, the intestine presents a stispicious appearance, it may per- haps be returned, but a drainage tube must be introduced into the neck of the hernial sac, and the wound must be tamponed Xo prevent retention of pus, and peritonitis. If a perforation is to be apprehended from gangrene of the intestinal loop, the intestine is not returned ; the operator allows it to remain outside of the abdominal cavity in order to see whether it recovers and gradually recedes into the abdominal cavity, or whether a perforation takes place {anus prcBterna tnra lis). But, if gangrene is already clea^'ly manifest, the intestinal loop must be prevented from slipping back, and must be fastened in front of the neck of the hernial sac, preferably by a thin bar or drainage tube wrapped with iodoform gauze. This bar is pushed through a buttonhole made in the mesentery (Fig. 1302); besides, the intestinal wall may be stitched to the surrounding parts by interrupted sutures, so that it cannot recede. If the gangrenous hernia has perforated into the hernial sac, a free iticision of the hernial sac is sufficient. The immediate resection of the gangrenous intestinal portion with subse- quent enterorrhaphy has often been made successfully. Since, however, it cannot be ascertained, with any degree of accuracy, how far the inflamma- tion extends into the intestinal wall, and since the sutures do not hold securely in the inflamed tissue, a failure of the operation is always to be apprehended. The long duration of such an operation under anaesthesia, with patients whose general condition has suffered from the strangulation, must also be well considered. The latter disadvantage, however, might be avoided by postponing enterorrhaphy (which takes a very long time) until the following day ; it is then made without ancEstJiesia, since the operation causes but little pain. Helferich makes above the gangrenous place an intestinal anastomosis, which can be rapidly effected. If other contents than the intestinal loop are found in the hernia, the operator must attempt to return the same into the abdominal cavity, if in a normal condition {ovary, bladder"). If he finds adherent, knotty, indurated, and hypertrophic {lipomatous) omentum, it is cut off near the neck of the hernial sac after previous multiple manifold ligations, and the pedicle is returned into the abdominal cavity. (The stump of the omentum, especially if it is large, should never be reduced into the free abdominal cavity, because it retracts and in the small 3A 722 SURGICAL TECHNIC intestinal area visceral adhesions are very liable to occur which may be- come the direct cause of intestinal obstruction. The stump should be anchored above the inguinal canal to the abdominal wall with a strong cat- gut suture.) RADICAL OPERATION FOR HERNIA is made (a) after Jierniotoniy, if the intestine and the surrounding tissues are in a favorable condition. {b) In reducible hernias, when they cause trouble and can be kept in position by means of trusses only with difficulty, or not at all. {c) In irreducible hernias, if they become troublesome. {a) IN INGUINAL HERNIA The procedure is as follows : — 1. External incision by raising a fold of integument over the eminence and largest diameter of the hernia. 2. Careful exposure of the hernial sac between two dissecting forceps in the manner described on page 718 ; likewise, the several layers of the loose cellular tissue surrounding the hernial sac, as far as they are not too firmly adherent, may be divided upon a grooved director, or upon a KocJicrs direc- tor, until the hernial sac itself is reached. From the same, the layers of cellular tissue are freed bluntly on all sides with the handle of a knife, or a Kocher's director, until the whole hernial sac is entirely exposed as far as its neck. 3. The neck of the hernial sac is detached bluntly on all sides of the inguinal canal, and as high up as possible. After the hernial contents have been returned into the abdominal cavity by gentle stroking and compressing manipulations, strong traction is made upon the empty hernial sac, and its neck is firmly ligated as high up as possible with strong catgut ligatures ; to guard against slipping of the ligature, its ends can be carried with a needle through the hernial sac closely below the ligature, and tied around it on both sides. 4. A little below the place of ligation, the hernial sac is cut off trans- versely with knife or scissors, and the stump is returned into the abdominal cavity through the hernial opening. If, in case of adhesions of the hernial contents, the hernial sac must be freely opened to enable the surgeon to find and separate the adhesion, Czerny recommends uniting, by a continuous suture from within, the serous sur- faces of the neck of the hernial sac, forciblv drawn forward. OPERATIONS ON THE ABDOMEN 723 5. Closure of the inguinal canal. Its pillars are united by interrupted sutures. For suturing, either strong silk thread or silkworm gut or, best of all, silver wire is used, the ends of which are not knotted, but twisted {Schede). If the operator sutures with silk, the contifutous bodice suttcre or Csernys lace suture may be used. Vivifying the pillars of the canal is unnecessary, as well as a complete closure of the same, which, in inguinal hernia, must be omitted even, in order not to compress the spermatic cord emerging from the lower angle of the canal. Provided the canal remains permanently contracted, the success of the operation is well assured. In congenital ingimial hernia, the spermatic cord is found attached to the entire length of the hernial sac, so that it is difficult to sepa- rate it. In this case, it is advisable to leave the hernial sac together with the testicles in the scrotum, and to detach it from the spermatic cord only above in front of the neck of the hernial sac, and to hgate the latter. The lower portion of the sac containing the testicle is incised, and obliterated by tamponing (Schede, Kraske, Konig). In adherent heniias, the adhesions must be separated after opening the hernial sac, and the hernial contents must be returned. If the operator finds degenerated omentum, it should be cut off after previous ligation. If the iso- lation of the hernial sac causes any difficulties — especially as is the case in large hernias in old people — or if the hernial sac is inflamed, which occurs in some herniotomies, it is advisable not to separate the hernial sac, but to tampon it after incision, and to close the wound later by secondary sutures. 6. The wound of the skin is closed in its whole extent by sutures ; for dressing, iodoform collodion, plaster of oxide of zinc gauze, etc., are very convenient ; or the usual antiseptic compress held in by a spica bandage is applied. During the first three or four days after the operation, the patient receives small doses of opium and fluid nourishment. The bowels should not move before the fourth or fifth day. The wound of the skin heals completely after eight or ten days. To secure the success of the operation, the patient is obliged in most cases to wear a truss to prevent a yielding of the cicatrix, and thereby a recurrence of the hernia. In spite of all these precautions, after the just- described simple ligation of the neck of the hernial sac and the suturing of the canal, relapse is comparatively frequent. Macewen, Bassini, and many others recently tried by another procedure to obtain permanent success without the zvearing of trusses after the operation. 724 SURGICAL TECHNIC Starting with the idea that by simply ligating or suturing the hernial sac a funnel-like poiicJi always remains on the peritoneal disk above the canal, into which, during coughing, etc., the contents of the abdominal cavity are impelled hke a wave, and which tends to enlarge the canal like a wedge, Macewen tried to prevent this unfortunate condition and the consequent relapse. He forms a plug of the folded hernial sac, which, having been returned into the abdominal cavity, resists the pressure of the abdominal contents like a pad. The walls of the canal, from which the neck of the hernial sac has been detached bluntly, are contracted by a double suture, drawing the internal pillar of the canal toward the external one and toward the strong ligament of Poupart. The operation in inguinal hernia is made in the following manner : — 1. After reduction of the hernia, the skin incision is made across the hernial neck, and the external inguinal ring is exposed (Fig. 1350); the finger penetrates into the inguinal canal, and locates the position of tJie epigasti'ic artery. 2. The hernial sac is detached, together with the adipose tissue adhering to it, and is drawn downward and made tense ; the iinger, introduced into ^ the inguinal canal, detaches the sac from the spermatic cord and all around from the abdominal walls as far as and above the internal inguinal ring (Fig. 1351). 3. Suturing of the hernial sac. A needle with a strong catgut thread knotted at the end is passed through the lower end of the hernial sac, and then carried through the sac in an up- ward direction several times in turns (Fig. 1352, a). By drawing the ligature tight, the sac is folded together into a puckered mass like a furled sail (Fig. 1352, b)\ the free end of the thread is inserted into a hernia needle provided with a handle, carried upward through the hernial canal, and brought out again i centimeter above the internal opening, through the anterior abdomi- nal wall, while the skin is drawn laterally (Fig. 1352, c, d). The ligature is taken out of the needle and drawn tight until the folded hernial sac disappears in the inguinal canal and places itself like a ball valve in front of the internal inguinal opening. The ligature is held firmly by an assistant until the inguinal canal is closed ; afterward it is fastened by several stitches through the superficial layer of the external oblique muscle. 4. Suturing of the inguinal canal. For this purpose Alaceiven uses two eye-needles provided with handles, one of which is bent off laterally to the right, the other to the left (Fig. 1353, a, c). The left forefinger is introduced into the canal, and searches for the OPERATIONS ON THE ABDOMEN 725 / / / Fig. 1350. External incision Fig. 1 35 1 Fig. 1352. Suturing Hernial Sac Fig. 1353. Suturing Inguinal Canal Macewen's Radical Operation for Inguinal Hernia 726 SURGICAL TECHNIC epigastric artery, which must be avoided. Guided by the finger, with the hernia needle (the one bent to the left) a strong ligature (silver wire) is carried through the internal pillar at two places, — first near the lower mar- gin from without inward, then above from within outward (Fig. 1353, a); the suture is held above, and the needle is withdrawn (Fig. 1353, b). The lower end of the ligature is inserted into the other hernia needle, and, guided by the finger, is carried from within outward through Poupart's ligament and the united aponeurosis of the three abdominal muscles opposite the lower suture opening of the other side. After the Hgature has been removed, the needle is withdrawn (Fig, 1353, r). In the same manner the upper end of the ligature is carried from within outward through a place lying opposite the internal side of the upper point of insertion. The two ends of the hgature are then tied together upon the external oblique muscle (Fig. 1353, d), after they have been drawn moderately tight upon the inserted finger so that the spermatic cord does not become strangulated. If the inguinal canal is large, the same suture can be applied once more farther down, whereby the pillars of the canal are pressed still more firmly against each other. 5. The ivoHud of the skin is sutured completely. The patient remains in bed from four to six weeks. He does not resume his work until after the eighth week, and has to take good care of himself as far as the third month. He wears a fight truss, which, after that time, becomes unnecessary. In congenital ingninal hernia, the sac is first detached from its connection with the canal, then opened, and divided transversely into two parts, care- fully avoiding the spermatic cord. From the lower portion, a tunica vaginalis is formed for the testicle ; the upper portion is drawn down as far as pos- sible, and incised behind, so that the spermatic cord can be isolated ; it is then closed by a few sutures. Next, it is folded together like a pouch in the same manner as in acquired hernia, drawn up over the internal inguinal ring, and the canal is closed, while the spermatic cord is pro- tected (Fig. 1354). Bassini effects the radical cure of hernia by restoring the inguinal canal just as it is in its physiological condition — that is, a canal with an anterior and a posterior zvall court- ing obliquely through the abdominal wall, which permits the spermatic cord to pass through, but which closes like a valve (like the mouth of the ureter in the wall of the bladder) when the muscles are in action, by which the abdomen is compressed (like the vesical Fig. 1354 Macewen's JIadi- CAL Operation FOR Congenital Inguinal Her- nia OPERATIONS ON THE ABDOMEN 727 aperture of the ureter in the wall of the bladder;. He proceeds in the fol- lowing manner : — 1. Skin incisio7i across the hernial region, exposing the aponeurosis of the external obhque muscle corresponding to the inguinal canal. 2. Division of tJie aponeurosis of the external oblique muscle from the external ring as far as, and beyond, the internal inguinal ring ; the same is detached in t^vo flaps from the muscle in an upward and downward direction (Fig. 1355, a). Fig. 1355 Fig. 1356 Fig. 1357 Bassixi's Radical Opefla.tion for Inguinal Hernia The hernial sac is then detached at this place from the spermatic cord as far as, and beyond, its orifice in the iliac fossa. Next, the floor of the sac is opened, and the hernial contents are returned after the detachment of any adhesions. The neck of the sac is twisted, and a straight needle with a double ligature is passed through it on a level with the internal inguinal ring. It is then ligated on both sides, and cut off \ centimeter in front of the ligature. The peritoneum ligated in this manner recedes into the iliac fossa. 3. After the spermatic cord has been raised and the two flaps of the aponeurosis of the external obhque muscle have been stretched, the groove, formed by Poupart's ligament, can be surveyed beyond the place of entrance of the spermatic cord. Then the external margin of the rectus abdominis muscle and the conjoined tendon (internal oblique muscle, transversalis, and Cooper's vertical fascia, or Scarpa's) are detached from the aponeurosis of the external obhque muscle (Fig. 1355, b\ and sutured for about 5 to 7 cen- timeters to the posterior free margin of Pouparfs ligament beginning at the pubis. The spermatic cord is transferred into the upper angle of the wound, and thus placed about i centimeter outward and upward ; thereby the ifiternal ring and the posterior zvall of the iiiguinal canal are reproduced (Fig. 1356, b). 728 SURGICAL TECHNIC 4. The spermatic cord is returned into its normal position ; the apo7icu- rosis is sutured over it as far as the lower angle of the wound, which remains open {external inguinal ring, Fig. 1357). The ivonnd of the skin is closed completely by sutures. Healing takes place in about fourteen days ; the patient need not wear a truss. Relapse after this operation, now made most frequently, has occurred o?ily in exceptional eases. Bottini incisQS the inguinal canal in the same manner as Bassini ; but, on the lower and upper side of the internal abdominal ring, he passes two or three strong catgut loops with a Hagedorn needle from within outward in such a manner that they grasp on the superior side the transverse muscle, the internal oblique, and the aponeurosis of the external oblique muscle, while on the inferior side they pierce the whole thickness of Ponpaj-fs liga- ment. Next, the loops are firmly tied together, and the closure, if necessary, is still further strengthened by another catgut suture. To avoid as much as possible the weak place, which is not overcome even by Bassini s method, Fj-ank proceeds as follows : — After division of the skin and the hernial sac, the latter is removed at its neck after double ligation. Next, the periosteum is reflected from the middle part of the horizontal ramus of the pubis ; the lateral margin of the rectus muscle is separated, and with a curved chisel, a groove is made in the ramus of the pubis in the direction of the spermatic cord, large enough to receive the little finger. Into this groove, the spermatic cord is placed. Next, the periosteum, the ex- ternal margin of the rectus, and finally the layer consisting of transverse fascia, the transversalis muscle, and the internal oblique muscle are, in their respective order, sutured to Pouparf s ligament ; the aponeurosis of the external oblique muscle is finally sutured continuously separately. If the hernial sac is firmly adherent it is not extirpated, but is tamponed like a hydrocele treated by incision. It heals by granulation. Wjljlers method is very much the same as Bassini s. After exposure of the external abdominal ring and division of the fascia- like layers above the neck of the hernial sac, the hernial sac, without being freed further, is divided on a grooved director, and the margins retracted with dissecting forceps ; the intestines are pushed back and retained above at the internal inguinal ring by a gauze tampon. With the pelvis elevated, after removal of the tampon, the neck of the hernial sac is sutured from within with the interrupted or purse-string suture (external iliac artery ! ) ; the internal surface of the sac is cauterized with the thermo-cautery. Next, the OPERATIONS ON THE ABDOMEN 729 hernial sac is sutured. The same remains in its position ; only when it can be detached very easily is it forced into the upper part of the inguinal canal. Then the spermatic cord is transposed ; the testicle is drawn from the scrotum after division of Hunter's hgament. It is placed behind the rectus muscle (which is dissected free) into the space between the two recti muscles, and returned finally into the scrotum, where it is sutured to Hunter's ligament. The spermatic cord then occupies a transverse position behind the rectus muscle and obliquely in front of it. Since the inguinal canal is no longer required, it can be sutured completely by stitching to Poupart's ligament the transversalis muscle and, if necessary, also the internal oblique muscle, and finally the external margin of the rectus. Over this follows the careful suturing of the aponeurosis of the external oblique muscle and the pillars of the external abdominal ring formed by it. Kocher also obtained the best results without dividing the abdominal muscles by transposing the hernial sac ; this can be easily done : — 1. The skin incision, made as usual, exposes the outer surface of the fascia of the external oblique and the neck of the hernial sac ; the hernial sac is isolated completely. 2. Into the fascia, a small opening is cut in a lateral direction from the middle of Poupart's Hgament (region of the internal inguinal ring) ; through Fig. 1358 Fig. 1359 Fig. 1360 Kocher's Radical Oper.a.tion for Inguinal Hernia this opening and the anterior wall of the inguinal canal, a pair of sHghtly curved dressing forceps is inserted and carried along the inguinal canal in front of the spermatic cord as far as the external inguinal ring. The exposed hernial sac is grasped with the forceps (Fig. 1358), and drawn back through the inguinal canal and out of the httle opening. 730 SURGICAL TECHNIC 3. While the hernial sac is drawn outward and upward, the portion of the hernial sac lying in the abdominal wall is firmly tied after passing the Hgature with a needle around it and through the abdominal wall. Closely above it, a second suture, applied through the whole thickness of the abdomi- nal wall, increases the resistance (Fig. 1359). 4. The hernial sac, folded together, is placed upon the external surface of the oblique abdominal fascia (anterior wall of the inguinal canal) toward the median line (Fig. 1360), and fastened here with two or three sutures reaching down as deep as possible (canal suture). The spermatic cord re- mains uninjured, if protected by the finger, and drawn tense in a downward direction. 5. To prevent ivitJi certainty the protrusion of the hernial sac in the direction of the spermatic cord, the sac can be sutured toward the anterior superior spine of the ilium, to the fascia; or an invagination displacement is made — that is, the little incision in the region of the internal abdominal ring is deepened dozvn to the peritonenvi. The latter is grasped with little hooks, and incised. The forceps are then inserted itito the abdoviinal cavity as far as the apex of the hernial sac, which is inverted toward it, so that it can be readily grasped. When the forceps are withdrawn, the hernial sac becomes inverted like the finger of a glove, and the peritoneal surface is outside. The hernial sac, having been drawn forward, is transfixed and ligated on both sides; a few sutures close the little wound in the abdominal wall. Next, by inverting the fascia of the external oblique, the inguinal canal can be contracted by a few superficial sutures. /// ivomen, large inguinal canals can be closed very readily by a pcri- ostewii bone flap turned upward {Borchardt, Kbrte). The soft parts of the pubis are detached by carefully preserving the periosteum ; and from the symphysis to the obturator foramen the superior layer of the pubis is chis- elled off; next, turned upward on the upper margin of the horizontal ramus of the pubis, and turned into the inguinal opening. The pillars of the inguinal canal are united over the bone plate, the divided adductor muscles are fastened to the pubis, and the deep wound of the soft parts is sutured in layers. ib) FEMORAL HERNIA Since the normal crural canal, a funnel tapering downward, is closed by the lamina cribrosa connected directly with the fascia lata, Poupart's liga- ment, and the pectineal fascia, Bassini established the normal position and OPERATIONS ON THE ABDOMEN 731 tension of these parts forced apart by the hernia, as follows. After the neck of the hernial sac has been exposed, Hgated, doubly divided, and re- turned into the abdominal cavity, he closes the canal with six to seven sutures in the following manner: — The first suture, close to the spine of the pubis, passes through Poupart's ligament and, at the side of the crest of the pubis, through the pectineal fascia. Likewise the two following sutures are appHed toward the crural vein; the three following sutures grasp the falciform process of the fascia lata and the pectineal fascia. The last suture is placed on the proximal side of the point of exit of the saphenous vein. If the sutures are tied by commencing from above, a C-shaped suture line is formed, which lies close to the pubis. The patient can leave his bed after eight or ten days, with- out wearing a truss. Fabrichis effects the closure of the femoral funnel and as firm a stitching as possible of Poupart's ligament to the horizontal ramus of the pubis in the following manner : — From a skin incision 10 to 12 centimeters long over Poupart's ligament as far as the spine of the pubis, he opens the hernial sac, returns its contents, and, finally, the ligated and cut-off neck of the hernial sac. He then pushes the vessels forcibly outward, and sutures the somewhat detached ligament of Poupart with a strongly curved needle to the horizontal ramus of the pubic bone through the pectineal fascia, the pectineus muscle, and the periosteum (epigastric artery and vein !). It is advisable, for strengthening the closure, to fasten again, with two or three sutures at the side of the large vessels, the superficial layer of the fascia lata to the pectineal fascia in the median side of the crural vein, and also to contract the external inguinal ring by a few sutures. In large femoral hernias Salzer closes the hernial canal over the ampu- tated neck of the hernial sac by z.. flap from the pectineal fascia. He forms this flap by a convex curved incision beginning at the pectineal crest and ending in a downward direction at Gimbernat's ligament ; this flap is turned upward, and sutured without any tension to the internal third of Poupart's ligament. if) UMBILICAL HERNIA Gers2i7iy strengthened the yielding fibrous linea alba in the following manner: Having transversely sutured the hernial opening (umbilical mar- gins), — which, of itself, has no permanent success, — he united over it the recti muscles, after having divided longitudinally their sheath at the free maro:in. 732 SURGICAL TECHNIC More certain in its results, hoiuever, is the excision of the umbilical ring, omphalectomy {Keen, Condamin, von Brnns), by including the whole thick- ness of the abdominal wall. The umbiUcal region is circumscribed by two semilunar incisions, extend- ing to the internal margin of the recti muscles, and advancing outside of the hernial sac to its neck ; these incisions open the abdominal cavity out- side of the hernial sac. From the wound, the hernial canal and neck of the hernial sac can be incised ; the hernial contents can be well inspected, and returned or removed (masses of omentum). The wound is closed in the same manner as after an ordinary lapa- rotomy. The peritoneum and the posterior sheath of the rectus, the recti and their anterior sheath, and, finally, the skin, are all united in order. OPERATIONS ON THE LIVER AND GALL BLADDER Operation for echinococcus of the liver can be made in various ways. Formerly (before antisepsis was introduced) these cysts were evacuated hy punctuj-e with the trocar and by aspiration ; the trocar canula remained in position ; and around it, by adhesions, a fistula was formed, out of which the purulent cystic contents slowly escaped. Simon opened the sac at two points with two trocars, so that between the two openings a bridge of skin 3 to 4 centimeters wide remained, which was divided, after adhesions had formed. Escharotics were also used to exclude the free peritoneal cavity by adhesions. Aseptically performed, the broad opening of the cyst in two stages {von Volkmann) is the best and safest procedure. 1. Over the most prominent part of the swelling, the abdominal wall is incised as far as seems necessary, parallel to the costal arch, at the external margin of the rectus muscle, or in the median line. After the hemorrhage has been arrested, the peritoneum is opened, and stitched to the margins of the skin. The cvst or the layer of hepatic tissue covering it is exposed. Next, the gaping wound is packed with gauze, and a protective dressing is applied. 2. After seven to nine days, within which time sufficiently firm adhesions between the layers of the peritoneum caused by the irritation have formed, the cyst is opened, either with the knife, if the sac itself is exposed, or with the thermo-cautery, if the incision has to be made through the hepatic tissue lying over the same ; by puncturing it with a Pravas syringe, information is obtained as to the thickness of the glandular tissue overlying the cyst OPERATIONS ON THE ABDOMEN 733 wall. The opening is made as large as the skin-incision ; while the fluid from the secondary cysts oozes out, the finger is introduced deeply and examines the wall of the primary cyst for any other firmly adhering second- ary cysts, which are removed with dressing forceps. Next, sufficient irri- gation (vi^ith sublimate solution) and tamponade or drainage of the cavity of the wound are made ; the wound closes gradually by granulation from below, after the wall of the primary cyst has been eliminated. Instead of the simple incision of the abdominal walls, Lcisrink recom- mended previous stitching of the cystic sac to the parietal peritoneum by a few qnilt sntnres, whereby the adhesions would take place sooner and with greater certainty (fourth to fifth day). Since an infection of the peritoneal cavity, if the same is not completely and perfectly shut out from the seat of operation, is to be apprehended from the dissemination of echinococcus germs, it seems less safe to make the operation in one sitting {^Lindemann, Laytdau); after the peritoneum has been opened, the cystic contents are evacuated by aspiration to such an extent that the cyst wall becomes flaccid ; it is then incised, and the margins of the incision are sutured to the peritoneum lining the incision. Traumatic abscesses of the liver are treated according to similar principles. The resection of portions of the liver for constricted lobe (" Schniirleber ") caused by constriction of the waist or tight lacing {Langenbnch) and in echinococci {Loreta) has been made recently with good success ; the hem- orrhage from the surfaces of the incision must be arrested by acupressure with round needles or by the thermo-cautery ; also the superior and the infe- rior margins of the hepatic wound can be sutured together. (Suturing of the liver as a hemostatic resource is a very unreliable agent, owing to the great f ragihty and vascularity of the organ. The iodoform gauze tampon is more effective and serves at the same time as a useful capillary drain when brought out of the abdominal incision.) Single pedunculated flaps are ligated by elastic constriction. Even after removal of more than half the liver, the lost portion is regenerated in a short time {Ponfick). CHOLECYSTOTOMY The opening of the gall bladder by incision may be made for biliary calculi, provided the gall bladder itself is healthy and not very firmly adherent to its surrounding parts. I. The incision of the abdominal wall extends along the external margin of the right rectus abdominis muscle from the costal arch downward {loiigi- 734 SURGICAL TECHNIC tndinal incision), or it extends as an obliqne incision from the tip of the tenth costal cartilage inward and downward toward the umbilicus ( Tait\ or it is made transversely a Httle above or upon the lower border of the liver [hepatic border incision) {Conrvoisier). 2. After incision of the abdominal wall, the liver, if possible, is turned over, and the gall bladder is drawn forward into the abdominal wound as far as possible, and is held firmly by means of a ligature loop passed through it ; it is punctured with a fine trocar. After its contents have been evacuated, the cavity is irrigated with a disinfecting solution (boric, sahcyHc). 3. Next, from the place of puncturing, the gall bladder is incised, prefer- ably transversely, and parallel to the lower hepatic border, until the finger can be inserted into the cavity. 4. Any biliary calculi present are removed with the finger or the forceps, retractors, etc. ; concretions firmly lodged in the cystic dnct or concealed in the pocket-like diverticula of the walls can be pushed upward from the out- side with the fingers ; or, if necessary, the operator may try to crush them by pressure. 5. After all the stones have been thus removed, the wound of the gall bladder is sutured with ''the most painstaking care possible " by a double row of serous sutures according to Cserny (see Fig. 1 3 1 1 ) ; the gall bladder is then returned into the abdominal cavity (cholecystendysis, Conrvoisier); or its sutured part is fastened to the parietal layer of the periosteum (cholecystopexia). 6. The abdominal walls are likewise completely united by suture. This so-called ideal cholecystotomy {Bernays) reproduces in the best pos- sible manner the original normal conditions, but can be resorted to with safety only when the walls of the gall bladder are healthy ; in inflamed tissue, the sutures would easily tear out, or leakage might take place from a subsequent occurrence of inflammatory hydrops. Hence, if in cholelithiasis the cystic wall is at the same time considerably diseased, and if such firm adhesions exist that the extirpation of the gall bladder seems not advisable, and if the operator is not perfectly sure whether calculi remain in the bile ducts, it is better to perform CHOLECYSTOSTOMY, that is, to establish a biliary fistula. After incision of the abdominal wall, drawing forward the bladder, puncturing and disinfecting its cavity, and removal of calculi as described above, the opened gall bladder is sutured to the margins of the abdominal wound. First, its serous coat is united with OPERATIONS ON THE ABDOMEN 735 the parietal peritoneum all around by sutures applied very closely, in order to close the abdominal cavity. Next, the mucous membrane of the gall bladder is sutured to the external skin, and thus a lip-shaped fistula is pro- duced. Into the same, a short drainage tube or an iodoform wick is introduced. In place of tJiis natural cJiolecystostomy {at one sitting) {Lazvson, Tait), the operation may be made also in two stages (Riedel, Bardenhener) ; first, the fundus of the gall bladder is stitched unopejicd to the abdominal wound with sutures, grasping only the walls without injuring its lumen; and, after a few days, when the adhesions have become firm and the closure of the abdominal cavity seems to be assured, the opening is made, and the calculi are removed. It is true this procedure offers the greatest safety, but it has the disad- vantage of often creating a permanent suppurating and biliary fistiUa. Its very long continuance often exerts an unfavorable influence upon the condi- tion of the patient, especially since further disadvantages are also caused by stitching the gall bladder to the abdominal wall. If, however, the fistula closes up (or if it is cured by an operation), conditions for the recurrence of the original disease have been thereby created (hthiasis). Hence, Langenbuch (1883) recommended removing all these compHca- tions and disadvantages with one stroke by CHOLECYSTECTOMY The excision of the entire gall bladder is indicated : — {a) In vesicular cholelithiasis of long standing and frequent recurrence. {b^ In dropsy of the gall bladder from obstruction of the cystic duct. {c) In serious disease of the wall of the gall bladder (empyema, ulcers, tumors). {d) In ruptures or zvounds of the gall bladder, which cannot be sutured, and in biliary fistrdas. On the other hand, the operation should not be made : — {a) In the case of firm adhesions with the surrounding parts, especially with the Hver. {b) In obstructions of the common duct, which cannot be removed. {c) In cases in which many small calculi are present in the bile ducts. I. A — \-like incision of the abdominal ivalls. Longitudinal incision 10 to 1 5 centimeters long along the outer margin of the right rectus muscle, upon which a transverse incision of equal length is made along the lower margin of the liver. 736 SURGICAL TECHNIC 2. The colon and the small intestines are pushed dowuzvard with a flat sponge, the right hepatic lobe is drawn upivard so that the hepatoduodenal ligament, in which the large bile ducts Ue and which can be palpated, be- comes tense. The ligament is incised; if a calculus is discovered in the common duct, the operation must not be performed. 3. After the gall bladder has been exposed as far as the cystic duct, the latter is encircled with an aneurism needle armed with a silk ligature, i to 2 centimeters distant from the hilum of the bladder, and doubly hgated. If the operator detects calculi in the same, they must first be pushed back- ward in the gall bladder. 4. Next, the gall bladder is de- tached from its recess in the fissure of the liver. After its peritoneal cov- ering has been carefully incised, the operator easily succeeds in separating it from the liver, bluntly, by trac- tion, or by cautious incisions with the scissors. Any hemorrhage from the liver substance is arrested either by pressure or with the thermo-cautery. 5 . Cutting off the bladder between the two ligatures in the cystic duct. The remaining stump is folded to- gether, and securely sutured. 6. Thereupon the abdominal wound is closed completely. If the common duct is obstructed by impaction of calculi, by cicatricial bands and adhesions to the surrounding parts, by the pressure of the largely distended gall bladder (on account of its contents), or by tumors of the neighboring parts {acute and chronic common duct obstruction), the sur- geon must endeavor to reestablish the escape of bile into the intestine, in order to remove the danger of choleemia. If it is a question of an im- pacted gall stone, the operator may try to render it movable by pressure with the fingers, or to crush it gently with forceps — the blades of which are covered with rubber tubing (choledocho-lithotripsy) — from the outside through the walls of the choledoch duct. Fig. 1361. Anatomy of Lower Surface of THE Liver (according to Henle). L.hd. hepato- gastric ligament (divided longitudinally) ; D.h. hepatic duct; /).<:. cystic duct ; Z).f/^. common bile duct; A.h. hepatic artery; V.p. portal vein This should be done very care- OPERATIONS ON THE ABDOMEN 737 fully, without injuring the internal wall of the canal, already in a state of inflammation. If this does not prove successful, it is better to open the wall of the gall duct over the stone by a longitudinal incision. The escaping bile is care- fully absorbed with sponges or gauze ; and after the removal of the obstruc- tion, the wound is closed again by 3-5 silk sutures (choledocho-lithectomy). The operator should never omit probing the gall duct upward and down- ward. A thick drainage tube is finally introduced as far as the place of suture. If the obstacle cannot be removed (extensive tumors and adhe- sions), an escape for the bile outward may be best established by cholecys- tostomy, and again administered to the patient with the food ; else, after ligation of the common duct, a fistula betiveen the gall bladder and tJie small intestine may be made by broadly suturing the gall bladder to the duodenum or the small intestine below, in a similar manner as described in gastro- enterostomy and in enteroanastomosis (cholecysto-enterostomy). This opera- tion was first made by von Winiwarter — "a triumph of surgical technique and perseverance" — and, after him, by Kappeler and others. Mnrphys button has also been employed successfully in this operation. (It has proved to be of special signal success in this operation.) 3 B OPERATIONS OiN THE SPLEEN SPLENECTOMY Excision of the spleen is justifiable in a complete prolapse, cysts and minors of the same, in abscesses, in floating spleen only when the incon- veniences caused by the same are very great and cannot be overcome by the wearing of well-fitting bandages. On the other hand, the extirpation of the spleen should not be made in tumors caused by serious changes in the blood {leuccemia, vialajia, amyloid degeneration, etc.). The difficulty of extirpation consists especially in the separation of the most extensive adhesions to the surrounding parts and the safe ligation of the pedicle. 1. The abdominal incision of the greatest service is in the linea alba and varies in length according to the size of the spleen to be removed. Some- times a transverse incision must be added to it. 2. After the peritoneal cavity has been opened, the hand is introduced into the abdominal cavity ; and the surgeon ascertains by direct palpation the existence of adhesions of the spleen, especially with the diaphragm. If he becomes convinced from this examination that very extensive adhesions may frustrate the success of the operation, it is advisable to abandon the extirpation and to close the abdominal wound. 3. If the operation is decided upon, the adhesions, especially of the spleno-phrenie ligament, are then detached. This is done with the knife after double ligation of isolated portions of the bands ; mostly, however, on account of broad surface adhesions, this method cannot be employed, and the separation must then be made with the thermo-cautery. Care should be taken under all circumstances that the capsule of the spleen is protected, as otherwise profuse parenchymatous hemorrhage may ensue. If any por- tion of its surface is adherent to any part of the neighboring organs (pancreas), it is preferable to remove a piece from the latter. Adhesions to the omentum maybe divided subsequently, — when the spleen, after a previous double ligation, has been detached on all sides, and can be rolled out of the abdominal wound. 738 OPERATIONS ON THE SPLEEN 739 4. Next follows the ligation of the pedicle of the gastrosplenic ligament, in which tJie splenic artery and vein take their course. If this pedicle is short, the greatest difficulties may arise in ligating it, and a portion of the spleen adhering to the pedicle must be left attached to the stump. For hgation, a strong silk thread or rubber band {OlsJiaiisen) can be especially recommended, in which case, two additional simple knots are placed upon a surgeon's knot ; the ends, if necessary, are brought around the pedicle once more, and tied on the other side. After division of the pedicle a finger's breadth in front of the ligature, the lumina of the several blood vessels are sought for in the surface of the incision, and are tied separately. 5. The stump of the pedicle is returned into the abdominal cavity or fastened in the wound, for the purpose of facilitating the arrest of bleeding in the event of secondary hemorrhage {Pe'an); the remaining portion of the wound is sutured. If the spleen removed is very large, after the removal of which a dead space remains in the abdominal cavity, tamponade (according to Miculics — see page 675) of the cavity produced is especially to be recommended on account of the danger of secondary hemorrhage from the separated adhesions (yLedderhose). Under some circumstances — for instance, in cysts or a partial crushing — only a portion of the spleen should be removed (resection); the hemor- rhage from the surface of the incision is arrested by tamponade, by indirect Hgature, or with the thermo-cautery ; also, by elastic constriction with a rubber tube, portions of the spleen can be ligated {Liicke). Splenoplexy — that is, the stitching of a floating spleen — in most cases proves unsatisfactory. The spleen, however, has been elevated and immo- bihzed by inserting it into a pouch cut into the parietal peritoneum and open in an upward direction (Rydygier), and by stitching it extraperitoneally under the costal arch {Bardenheiier). OPERATIONS ON THE KIDNEY NEPHROTOMY Incision of the kidney or its pelvis {pyelotomy) may become necessary: — {a) In foreign bodies and calculi, and in anuria and colic caused thereby. (b) In abscesses, echinococci, and single cysts. {c) In hydronephrosis and pyonephrosis. NEPHRECTOMY {Simon, 1869) Extirpation of one kidney is made, if the other kidttey is perfectly sound, and if no ''horseshoe kidney'' exists: — {a) In injuries (with violent continuous hemorrhages) of the kidney or the ureter. {b) In suppiirative affections (pyelitis and pyelonephrosis calculosa and tuberculosa). {c) In incurable ureteric fistulas. {d) In malignant neoplasms. (e) In migrating or movable kidney, but only if, after an unsuccessful nephrorrhaphy, the kidney causes serious symptoms, and is degenerated. Of the presence of the other kidney the surgeon assures himself by bimanual palpation, either in the dorsal position with the thighs and legs flexed, or better, in the lateral position, with the side to be examined upward, whereby the hip and the knees are slightly flexed. Simon palpated the kidney by rectal palpation. It is safer, however, to palpate the kidney by direct expos- ure from the abdomen or extraperitoneally {Foiger) in the lumbar region. KocJier introduces the hand into the abdominal cavity from the transverse incision made for extirpating the kidney, and palpates the other kidney ( Thornton). Of the normal condition of the opposite kidney, the surgeon can convince himself by obtaining the urine from each kidney separately, for examination, by catheterizing the ureter. This is accomplished most easily by the use of the cystoscope ; the older procedures — compressing one ureter or ligating it temporarily — have in most cases been rendered obsolete. 740 OPERATIONS ON THE KIDNEY 741 To expose the kidney extraperitoneally, various methods of incision have been devised, of which the following are the most important : — I. Simon s posterior vd'tical hLvibar incision {Y\g. 1364) along the exter- nal margin of the erector spinae muscle begins across the nth rib, extends over the 12th rib, and ends in the median Hne between the 12th rib and the crest of the ilium (exposes the hilum of the kidney most advantageously). Fig. 1362. Transverse Lumbar Incision Nephrotomy Fig. 1363. Lateral Lumbar Incisions I, von Bergmann's; 2, Konig's 2. TJie transverse Inmbar incision according to Czerny, Braiin, KocJier, Kiister, extends i centimeter below the last rib and parallel to the same from the margin of the erector spinse about 8 to lO centimeters forward as far as the axillary line (colon ! peritoneum!) (Fig. 1362). 3. Vojt Bergniann s lateral lumbar or obliqne Invibar incision extends from the anterior end of the 1 2th rib, descending obliquely forward and downward as far as ^^^^ ^364. Simon's Position for exiosing Kidney the junction of the external and middle third of Poupart's ligament (this incision affords the largest space) (Fig. 1363, I). 742 SURGICAL TECHNIC 4. Bardcn/icuej-'s renal incision extends from the end of the nth rib downward to the middle of the crest of the ihum. At its extremities, along the ribs and the crest of the ilium, transverse incisions are added (trap-door incision). Kbnigs retroperitoneal laparotomy incision extends from the 12th rib vertically along the margin of the sacrolumbar muscle toward the crest of the ihum, then in the form of a curve toward the umbilicus to the external border of the rectus muscle. The patient lies during the operation with his healthy side over a large circular cushion, so that the lumbar region on the side to be operated upon becomes prominent and is made tense (Fig. 1364). With his fist, an assistant may push the kidney in a backward and upward direc- tion by making well-directed pres- sure from the abdomen. Lange places the patient in the ventral position, inclined toward the dis- eased side, which is made to project by a pillow placed under the body opposite the kidneys (Fig. 1365). For most cases, as a normal procedure, Simon's method is to be recommended : — 1. External incision, see page 741. Having divided the superficial fascia and the lower margin of the latissimus dorsi muscle, the tough superficial fascia sheath of the sacrolumbalis {lumbodorsal fascia, lamina sjtperficialis) is incised ; the rounded margin of this muscle is exposed and the incision deepened until the 12th rib appears to view in the upper angle of the wound; the lamina profunda of the lumbodorsal fascia is then reached ; the same is incised ; after ligation of the XII intercostal artery and the I lumbar artery crossing the wound, the operator reaches the qnadratiis Inmborum inserted into the lower margin of the 12th rib. (Since, according to Pansch, there are cases in which the pleura extends as far as the level of the transverse process of the first lumbar vertebra, the incision through the deep layer of the fascia must be made only as far as 2-3 centimeters from the lower margin of the 1 2th rib.) 2. Division of the gnadratus Inniboriim in a longitudinal direction ; the divided margins are drawn apart with blunt retractors ; the entire muscle Fig. 1365. Lange's Position for exposing Kidney OPERATIONS ON THE KIDNEY 743 can also be drawn laterally ; under this lies the tough fibrous layer of the peritoneum, which divides the anterior surface of the muscle from the kidney. Having incised this fascia, the lower pole of the kidney appears embedded in loose fatty connective tissue (adi- pose capsule of kidney). 3. Exposure of the kidney. First, the superior half, situated under the ribs, is bluntly sepa- rated from its surrounding tissues with the forefinger; next, the kidney is grasped with three fin- gers, somewhat drawn forward, and slozvly and carefully enucle- •^^^- ^366 ated with the forefinger ; only the firmer adhesions at both poles are divided with knife or scissors. If the operation is performed for injury, the wound can be sutured and the hemorrhage arrested. If it is done for the removal of cal- T0POGR.A.PHY OF Renal Region. Mc, m. cucullaris; ]\Ild, latissimus dorsi; Sp, m. sacrospina- lis (sacrolumbalis) ; Ql, m. quadratus lumborum; Oe, m. obliquus ext. abd.; Oi, m. obliquus int. abd.; Ti-, m. transversus abd.; Fid, fascia lumbodorsalis; R, kidney; C, colon desc. 1 2 S^ 10m Fig. 1367. Horizontal Section thk* 4. After incision of the membranous portion, a — shaped grooved director is introduced into the bladder along the grooved staff, which is then removed. 5. The urethrotomy wound is enlarged toward the prostate, until the operator can enter it with the point of the right forefinger. 6. By slotv boring movements ivith the fin- ger or by the dilators of Simon and Hegar, or with the dilating forceps or a blunt gorget {Thompson), the prostate is so far dilated that the finger can enter the bladder and palpate the calculus or the tumor. 7. If the operation is performed for the removal of a calculus, a pair of lithotomy for- ceps (Fig. 1422) is introduced, using the left index finger as a guide, and the stone is grasped. After the operator has convinced himself, by turning movements of the for- ceps, that the mucous membrane has not been included, and if the distance of the blades of the forceps indicates that the stone has been grasped in its smallest diameter, then follows 8. The removal of the calcnliis by making slightly lever-like movements during traction. If the stone is too large, the prostate can either be nicked Fig. 1423. Ll'er's LiTHOTRlTE 7/8 SURGICAL TECHNIC with a probe-pointed bistoury (see page 779) or with a litliotj'itc (Fig. 1423) ; the calculus may first be crushed into smaller fragments ; the larger pieces are then evacuated with the forceps ; the debris is scooped out with a dull spoon. 9. Finally, after the bladder has been thoroughly irrigated with a warm boric solution, a Nelaton catheter (as large as possible) is introduced through the penis into the bladder, and the wound is tamponed in its whole extent. The catheter (it slips out very easily) is best fastened, according to Lauoistein, by tying a silk thread around the catheter in the wound and by tying the ends of the thread over the tampon. A better access, especially to the prostatic part of the nirthra (by which procedure, also, an injury to the bulb is better avoided), is gained by a curved transverse incision between the anus and the bulb of the urethra (see Fig. 1427). The bulb is exposed and next drawn upward with retractors ; the membranous portion of the urethra is carefully dissected free (Xelaton, Konig). In women, the extraction of calculi is considerably easier, on account of the shortness and dilatability of the nretht'a. Only in very large calculi, offering resistance even to lithotripsy, should %\ suprapubic lithotomy be made; in general, however, the dilatation "^S^ °^ ^^^ female urethra (5/;;/t';/) is sufficient. The same is made with the dilators mentioned by Simon (Fig. 1424); these are introduced Simon's ^^ gradually increasing sizes, until the forefinger can be inserted Dilator with ease into the bladder. In case of necessity, the external uri- ^^^^ nary meatus must be nicked by small incisions; this is a more Female Urethra gentle procedure than a dilatation made too violently. Thereby conditions are produced as in external urethrotomy in man (see above). The incontinence occurring during the next few days disappears after a short time. PROSTATOTOMY, that is, incision of tJie prostate, is indicated : — {a) In a considerable enlargement of the same (hypertrophy, inflamma- tion, abscesses). (^) In tnmors atid lithiasis. It is made in the same manner as median perineal section (see page 777). Through the incision of the membranous part of the urethra, the left fore- finger is introduced into the bladder, and upon it the posterior side of the prostatic portion of the urethra is divided with a probe-pointed knife in the OPERATIONS OX THE PELVIS 779 median line. Proceeding from this incision, it is sometimes possible to enucleate bluntly with the finger encapsulated circumscribed tumors (ade- nomata, fibromyomata), also to detach pedunculated tumors and swelHngs of the middle lobe with Landerers cutting forceps or Thompson s forceps (Fig. 1425). After the hemorrhage has been arrested, a thick rubber tube, wrapped with iodoform gauze, or a Watson hard rubber drainage tube (Fig. 1426; is introduced into the bladder, and left in position for six to eight weeks, until the swelling of the prostate has been reduced by pressure (atrophy from comx- pression). It is better to expose the entire posterior surface of the prostate bv ZnckerkandV s perineal prerectal incision (Figs. 1427, 1428). The left forefinger is Fig, 1425. Thompson's Forceps Fig. 1426. "Watson's Hard Rubber Drainage Tube for Hypertrophy of Prostate introduced into the anus to prevent injury to the anterior wall of the rectum. Next, 3 centimeters above the anus, a sUghtly curved transverse incision, 7 centimeters long, is made across the perineum, if necessarv', as far as the tuberosities of the ischium. After division of the superficial fascia and sepa- ration of the connection between the bnlbo-cavernosus and the sphincter aiii exteimiis, the insertions of the levator ani are separated on both sides from the rectum. The stumps recede toward the pelvis. Next, the operator penetrates bluntly into the connective tissue bet^^^een rectum, prostate, and bladder, as far as the reflection of the peritoneum. The exposed mem- branous portion of the urethra is then opened upon a lithotomy staff. The 78o SURGICAL TECHNIC finger penetrates through the urethra into the bladder. A probe-pointed knife, introduced upon the finger, sphts the posterior wall of the prostate exactly in the median line, close to the peritoneal duplicature. With sharp retractors, the two halves of the prostate are then drawn apart, and the median lobe, if enlarged, as well as portions of the lateral lobe, may be excised from the bisected prostate with knife, scissors, or the thermocau- tery ; any existing calcuh can be removed with ease. After the hemorrhage has been arrested, the incision is diminished by partial suturing, ample space being left for a drainage tube (as above). The external wound is likewise sutured in part, and the remaining space packed with gauze. Fig. 1427. Exlcrnal Incision FiG. 1428. Cavity of the Wound Zuckerkandl's Prerectal Incision From the perineal incision, even without incising the urethra and pros- tate gland, t/ie postevior wall of the gland can be made accessible for the incision and drainage of abscesses, and for the removal of tumors. By de- taching the rectum still farther, and with a temporary displacement toward the coccyx and by deepening the wound, even the seminal vesicles and the fundus of the bladder can be reached. Kochers prerectal poiiited arch incision (Figs. 1429, 1430) creates similar conditions of the wound, and a still better access to the organs mentioned. Recently, moreover, all these operations on the prostate have been made through a suprapubic incision, the patient being placed in Trendelenburg's position (suprapubic prostatectomy). For this purpose the bladder is opened in a more upward direction (at the apex). The cystotomy wound is drawn apart with strong retractors, so that the interior of the bladder can be well inspected. If a catheter is then introduced, the operator can see and deter- mine with the wound the location of the obstruction to the escape of the urine (nodules, lobes, wall-like elevations, etc.). All projections are removed {MacGill). A marked sacculation at the fundus behind the prostate can OPERATIONS ON THE PELVIS 781 be removed by deep, wedge-sJiaped excisions of the wall of the bladder with subsequent suture. Lateral prostatectomy {Dittel) exposes the prostate gland and its sur- roundino-s from behind. Fig. 1429. External Incision Fig. 1430. Cavity of the Wound Kocher's Prerectal Pointed Arch Inxision The patient, into whose urethra an elastic catheter has been introduced, is placed in the right lateral position. The external incision extends in the anal notch from the point of the sacrum to the right, around the margin of the anus as far as the raphe in front of the anus. In penetrating into the ischiorectal fossa, the rectum is detached bluntly from the prostate gland and drawn laterally until first the right lobe of the prostate and, finally, its entire posterior surface are exposed. More space, if necessary, can be gained by removing the coccyx. A procedure that deserves more consideration than it seems to have found until now {Ccerny, Kilmviell, Freudcjiberg) is the galvanocaustic excision of the prostate gland {Bottini) in hypertrophy. It is made with a lithotrite-like instrument, the movable arm of which consists of a little platinum knife about \\ centi- meters high ; this knife is made to project from the slit in the beak of the instrument by screw action (Fig. 143 1), the beak serving at the same time as a cooling tube. After the intro- duction of this instrument through the urethra previously anaes- thetized (5 cubic centimeters of a 1% cocaine solution), the knife, rendered red-hot by closing an electric current, is sloiuly drawn from behind forward through the prostate gland. In most cases it is necessary to make several linear cauterizations in various directions, for instance, upward, downward, and at the side of Fig. 1431 Beak of Prostatic Incisor 782 SURGICAL TECHNIC the greatest hypertrophy. The operation is completed in a few minutes ; in most cases, the patient can urinate spontaneously after a few hours. Up to this time but few if any failures have occurred. Likewise, tJic ligatioji of the different arteries and of the hypogastric arteries, according to Bier, is often followed by shrinking of the hypertro- phied prostate gland. The operation is made with the patient in Trendelen- burg's position and transperitoneally, but offers considerable difficulties. Fig. 1432 Fig. 1433 Civiale's Bigelow's LlTHOTKIlTOR LiTHOTKIPTOR LITHOTRIPSY, that is, tJie operation of reducing to fragments a cal- ciilits in the bladder W\\\\o\\\. injuring the bladder and the urethra, can be made if the ealcnii are not too large and not too hard, and if the urethra is of sufficient caliber (strictures, especially at the exter- nal urinary meatus, must be removed previously by dilatation or incision). To obtain good results with the operation, great practice and dexterity in manip- ulating the necessary instruments are required. The crushing is made with the lithotrite, a catheter-like metal instrument with a short, broad beak, consisting of two arms. One of them (the male) can be slid in a groove of the other (the female) like a sledge. The former has a strongly denticulated anterior end fitting into the fenes- trated end of the female blade. By screw power or strokes with a hammer the stone grasped by the arms is crushed (Figs. 1432-1433). For the operation., the patient is placed upon a low table, with his pelvis raised and his legs flexed. He is then anaesthetized. The bladder is several times washed out with boric acid solution, and finally about 50 to lOO cubic centimeters of the solution are left in the bladder. Thompson pre- fers to operate with the bladder empty. If it is desirable to operate without anaesthesia, the bladder can be rendered anaesthetic by injecting 40 to 50 cubic centimeters of a 2^ to 5% cocaine solution. OPERATIONS ON THE PELVIS 783 1. Introduction of the lithotrite exactly in the same manner as described in catheterization ; the weight of the instrument facilitates its insertion, pro- vided the urethra possesses the required width. 2. The operator stands at the right side of the patient, holding the cyhnder-like shaft of the instrument with his left hand, the handle at the end (wheel, ball) with his right hand. When the handle is raised, the beak of the instrument is gently pressed against the fundus of the bladder, and in this position the operator waits quietly for a few seconds ; when the slid- ing (male) arm of the instrument is withdrawn, its beak is opened so far that the operator feels it touch the neck of the bladder ; the handle is then pushed back again. From the firm resistance distinctly felt, the operator knows that the stone has fallen between the blades of the instrument. If this is not the case, the blades are opened again ; and the operator probes toward the right or the left, repeatedly opening and closing the instrument until the stone has been grasped. 3. Next, by bringing together the halves of the screw concealed in the handle, the "interrupted screw" becomes locked; and by slowly rotating the handle around its axis, the beak is made to operate, and is very forcibly screwed together until the crushing of the stone is felt and heard ; since the fragments fall toward both sides, the instrument can be completely closed again. During this procedure, the cylinder-Hke shaft is held firmly and steadily in its position with the left hand. 4. The instrument is at once opened again, and an attempt is made to grasp one of the fragments and to crush it in the same manner ; this pro- cedure is repeated until all of the larger fragments have been crushed ; it can then be taken for granted that the stone has been entirely crushed into small pieces. For grasping even the last portions, the beak is turned down- ward toward the neck of the bladder, so that it can grasp any fragments concealed behind the prostate. 5. If the stone is too hard to be broken by screw power, it may be broken by striking the handle with a hammer. If, in this manner, the stone has been broken into small fragments, another lithotrite is introduced, the female arm of which is not perforated at the end, but scooped out like a spoon {e.g. Fig. 1432). With this the fragments are grasped again, one after another, and ground to a fine gravel. After this has been accomplished,- a large evacnation catheter \Nith a large opening at its beak-like end is introduced (Fig. 1434, 3). Through it, the fluid present in the bladder generally flows out with a portion of the fragments of stone. 784 SURGICAL TECHNIC 6. The cvaataiion of the fragments of stone is then made at once (litho- lapaxy, Bigelow). For this purpose is used the evaaiator {Bigelozv, Otis, Fig. 1434), a suction pump, the end of which is screwed into the opening of the catheter. The whole apparatus is filled with boric solution ; and by compressing the elastic bulb a portion of the solution is forced into the bladder, from the bottom of which it whirls up the debris. If the pressure is discontinued, the bulb aspirates the fluid, bringing with it some of the fragments of stone ; these fall at once into the glass receiver (2) filled with glycerine and screwed Fig. 1434. Otis's Evacuator for Litholapaxy to the apparatus. The compression and suction by the elastic bulb are now slowly but rhythmically continued until no more fragments can be removed from the bladder. The interruption of the current of fluid in the glass receiver by means of a tube opening above and another opening below, prevents the fragments of stone withdrawn from returning into the bladder. If fragments of stone are no longer evacuated, the evacuator is removed, and the lithotrite is introduced once more, to search for any fragments that may have remained. If any are found, they are removed in the manner described before. OPERATIONS FOR CONGENITAL CLEFT FORMATION OF THE ANTERIOR PELVIC REGION (a) In ectopia vesicae, that is, exstrophy of the bladder. The congenital defect of the abdominal wall and the bladder exists nearly always in connection with a cleft of the pubis, with epispadias and inguinal hernias. For relieving to some extent the pitiable condition of the patient suffer- ing from these defects, — the continuous trickling of urine from the vesical OPERATIONS ON THE PELVIS 785 Fig. 1435. Receptacle for Urine apertures of the ureters freely exposed in the protruding posterior wall of the bladder, — the urine is collected in a suitable receptacle made of soft rubber (Fig. 1435). The operative closure, however, offers exceedingly great difficulties, and the operator can feel satisfied when he has covered the vesical defect so far that some urine may collect in the bladder, which has been forced back. The urine is retained by a trusslike appliance, and is evac- uated at pleasure by removal of the truss. Covering the protruding posterior wall of the bladder (cystoplasty) has been attempted by the formation of flaps ( Wood, Thiersch). The flaps of skin must be taken from the immediate neighborhood, that is, from the abdominal wall. They can be stitched di- rectly with their fresh wound surface to the vivified margins of the vesical defect. For this purpose, either one large flap {HirscJiberg) can be employed, or several, simultaneously, or one after another (^Thiersch). Underlining by turning over a sufficiently large flap (attempted by Nelaton)vs, not practical, because the epidermis side turned into the interior of the bladder furnishes the cause for obstinate stone formations by deposition of phosphates on the hair. It is sufficient to fasten over the cleft a large flap, with the wound surface toward the bladder. If its heahng succeeds, it is true, the flap sub- sequently contracts considerably ; but during cicatrization it partly draws the mucous membrane of the bladder toward its inner surface. Wood and Thiersch closed the cleft by Hning it zvith three flaps (Figs. 1436-1438). First, from the skin of the abdomen over the bladder, a large flap {A ) was excised, turned downward, its epidermis side toward the bladder, and sutured to the vivified margins of the bladder ; this flap was then covered by sliding and turning two pedunculated flaps {B and C\ obtained from the lateral inguinal regions. The annoying condition mentioned above — the forma- tion of concretions — might perhaps be removed by grafting (according to Wolfler) the large flap with mucous membrane, as a preliminary step to its transplantation (A), after a superficial removal of the epidermis, or by destroying the several hair follicles by electrolysis or galvanocautery. ThierscJi afterward proceeded as follows : He detached t^vo lateral flaps, having an upper and a lower bridge, near the margin of the bladder, 3E 786 SURGICAL TECHNIC and allowed them to granulate upon a plate of tinfoil, ivory, or glass, placed under them. When the flaps began to contract and fold, he divided the upper bridge, and sutured first one lap over the inferior portion of the bladder; after it had healed, he closed the superior portion by means of the flap of the other side, treated in the same manner ; by a final operation, he closed the transverse cleft remaining between the two flaps. The skin of the scrotum, often considerably enlarged by inguinal hernias, may also be very well used for such flaps ; the healing hardly ever succeeds completely. In most cases, small fistulas remain between the several sutures ; these must be closed subsequently. Fig. 1436 Fig. 1438 Fig. 1437 Wood's Cystoplasty. Fig. 1436, forming flaps; Fig. 1437, suturing lateral flaps over inverted middle flap; Fig. 1438, healing of wound Czeniy succeeded in directly suturing the margins of the defect by dissect- ing off, all around, the prolapsed mucous membrane of the bladder with the exception of a portion in the middle about as large as a ten-cent piece, and by turning it over and suturing the margins of the wound in the median line. Battle proceeded in a similar manner. Suturing of the margins of skin, however, must be effected by a plastic operation. Schlange and Rydygicr sutured the margins of the vesical cleft by including the recti muscles and portions of the pubes ; Pozzi proceeds in a similar manner. Miculicz sutures two bridge flaps, containing the recti and their chiselled- off pubic insertions, with silver wire over the bladder, previously detached and sutured to form a hollow sphere ; he subsequently forms the urethra and the penis by uniting the margins of the cleft vivified longitudinally, and OPERATIONS ON THE PELVIS 787 finally occludes the neck of the bladder by circumscribing it with the knife and inversion suture of the fistula. Poppert, after the bladder had been sutured, effected a rather good continence by allowing the posterior portion of the urethra (which contains the sphincter) to extend for a short distance into the lower wall of the bladder. Stretching of the ring of the sphincter muscle by intravesical pressure cannot then take place. Passavant advantageously employed Demme s suggestion, that is, to remove first the cleft of the piibes ; having the patient wear a rubber belt or a steel belt provided with screws, or having him lie upon a wooden log with a cuneiform excision FXZI. ^^ tried very gradually to force together the gaping margins of the pubes, so that they almost touched each other. Meanwhile, by suitable apparatus, he forced back into the abdominal cavity the wall of the bladder (elastic bulb with gutta-percha plate and rubber bandage). When the margins of the cleft had been approximated by this treatment (after several months), he sutured the cleft of the bladder after vivifying broadly ; next, he approximated the pubes by sutures, and then attempted the formation of a sphincter ring, which in its original position forms only a straight muscular band. Finally the groove of the urethra, open in an upward direction, was closed by suturing the corpora cavernosa of the penis, which had been turned upward. Trendelenburg effected reduction in the size of the cleft of the pubis in a 7nuch shorter time by dividing the sacroiliac articulations. For this pur- pose, the left forefinger is introduced into the rectum of the child lying on the abdomen, and the sciatic notch is sought for. Then the skin over the articulations is divided from without, and the operator penetrates in the same line through the posterior masses of ligaments, until the connection has been sufficiently loosened to enable a vigorous lateral pressure upon the two pelvic halves to rupture it, so that the stumps of the symphyses touch each other. The wounds are closed by skin sutures. The child is then placed for four to six weeks into an apparatus which keeps the pelvis laterally compressed. Then, after a broad vivifying, the approximated margins of the cleft are sutured with silver wire in a vertical line. If too great a tension is caused thereby, the skin can be made more movable by lateral incisions parallel to the margins of the cleft (as in Fig. 1404). Koch obtained good success with a similar procedure. He decreased the cleft of the symphysis hy forcibly rupturing the articulations. Konig approximates the divided symphysis after chiselHng through the horizontal and the ascending ramus of the pubis on both sides. 788 SURGICAL TECHNIC In exstrophy, with very marked protrusion, Sonnenbiirg removed the whole bladder, after having detached it carefully from above from the peritoneum (extirpation of the urinary bladder), and sutured the dissected- off ureters into the groove of the penis at the lower sutured extremity of the cavity of the wound covered by sliding lateral flaps. Langcnbnch pro- ceeded in a similar manner. After extirpation of the bladder, Maydl and others implanted the ureters, together with a portion of the vesical mucous membrane, into the sigmoid flexure. Even in healthy kidneys, Harrison extirpated the left one, implanted the ureter of the right kidney into a small skin-incision of the right lumbar region, and closed the bladder by a plastic operation. The success of all these operations consists in reducing the defect and thus in obtaining a smaller opening at the lower extremity of the covered defect, after the mucous membrane of the bladder, which, owing to its inflammation, is exceedingly painful, has been covered or removed. The small opening resulting from the operation can be closed by the stump of the penis turned upward, and by a S2t,it- able pad ; or, at least, it is better adapted for apply- ing a portable urinal, which is fastened laterally to the patient's leg (Fig. 1439). Finally, by removing the epispadias, which nearly always exists, the urine may also be evacuated through the thick stump of the penis, whereby approximately normal conditions are produced ; or, at least, the continuous irrigation of the scrotum and the perineum with decom- posing urine is lessened. (/;) EPISPADIAS The operation for epispadias consists in transforming the gutter on the upper surface of the penis into a closed urethral canal. This is done prefer- ably by THE METHOD OF THIERSCH, who proceeded at various sittings as follows : — I. Formation of the glans portion of the urethra: By two incisions, extending along the margins of the canal of the glans, obliquely inclined toward each other and penetrating deep into the substance of the glans, the latter is divided into three flaps (Fig. 1440, a, b). After the hemorrhage has Fig. 1439. Portable Uri NAL AFTER CySTOPLASTY OPERATIONS ON THE PELVIS 789 been arrested, the median flap, containing the mucous membrane of the canal, is depressed with a grooved director ; and the two elastic lateral flaps Fig. 1440. Forming Glaxs Portion of Urethra are folded over it and united with deep interrupted or continuous sutures (Fig. 1440, c). After the wound has healed successfully, the attempt is made 2. To close the penile portion of the gutter. On both sides of the gutter two oblong rectangular flaps (Fig. 1441) are excised from the skin of the dorsum of the penis. One of these flaps, the broader, is turned with its free Fig. 1441 Fig. 1442. Closure of Open Slit between Glans and Penis Closure of Penile Portion of Gutter Fig. 1443 margin {b) toward the gutter. The smaller of these two flaps with its base [a) (like the leaves of a door) is turned over the gutter in such a manner that its outer (epidermis) surface is directed toward the canal; the other, the broader flap, is turned over the smaller, flap, so that its wound surface comes to lie upon the wound surface of the smaller flap, which has been turned over. After the position of the two flaps has been secured by a fev\^ 790 SURGICAL TECHNIC quilt sutures, the margin of the larger flap, serving for a cover, is united by superficial sutures with the opposite margin of the wound of the wall of the penis (Fig. 1443). When, in this manner, after the healing of the flaps, the groove of the penis has been changed into a closed canal, then follows : — 3. The closure of the open slit between glans and penis, for which the prepuce, hanging down below the glans like an apron, may be used. The same is slit below the corona glandis by a transverse incision (Fig. 1443, c), and the glans is passed through it as through a buttonhole, so that the pre- puce comes to lie on the slit in the form of a ridge. After the margins of the prepuce have been vivified, they are stitched to the corresponding vivi- fied margins of the glans and the penile tube (Fig. 1442). There remains 4. The closure of the funnel existing at the root of the penis. This must be done by pedunculated flaps taken from the neighboring skin of the abdomen (Fig. 1444). ThicrscJi formed two lateral flaps, — a triangular and a rhomboidal flap, — which he placed over each other in a similar manner as in forming penile portion of the urethra (Fig. 1442). It is better to form only one flap, and before suturing it to graft its wound surface with mucous membrane by transplantation according to Thiersch, in case the existing mucous membrane of the funnel should not be sufficient for grafting (see page 765). Kiistcr effected transformation of the groove of the penis into a canal by dividing the inferior surface of the penis by a deep, longitudinal incision extending between the corpora cavernosa. He then turned the two halves upward. He If eric h divided even down to the mucous membrane. The deep incision wound is left to granulation. If the penis is very small and in very young subjects, Rosenbej-ger proceeded in such a manner as to turn the penis (having been sutured to the scrotum) upward toward the abdo- men, after having vivified the groove broadly ; here it healed into two vivi- fied margins (Fig. 1445). The penis directed upward was subsequently turned downward by excising a flap from the abdomen (Fig. 1446). The wound on the dorsal surface was covered with this flap, and the thin defect of the abdominal wall closed by suturing. Fig. 1444. Closure uf THE Funnel OPERATIONS ON THE PELVIS 791 (r) HYPOSPADIAS The operator proceeds according to the methods just described ; or he covers the defect according to the methods given in the operations for 7t,rethral fistulas (see page 765). By a simpler method and in considerably less time, Landerer's (Rosen- berger's) Procedure seems to bring about the desired end. Fig. 1445 Fig. 1446 Rosenberger's Operation for Epispadias He restores the missing lower urethral wall from the skin of tJie scrotum. First two strips about 3 to 4 milhmeters wide are vivified on both sides of the groove of the penis as far as and into the scrotum ; the penis is turned down upon the scrotum, its glans portion is sutured to the deepest point of the scrotal wound, and the remaining portion of the penis is fastened on both sides to the scrotum by three superficial sutures (similarly as in Fig. 1445). After the penis has become completely embedded in this position (after six to eight weeks), it is liberated from the scrotum and covered with skin on its lower surface. For this purpose, from the external urinary meatus of the penis drawn upward at the glans, two lateral incisions are made into the scrotum, a little longer than the penis is intended to be, and the rhom- boidal defect caused thereby is closed by suturing it longitudinally. OPERATIONS ON THE PENIS AND THE SCROTUM OPERATION FOR PHIMOSIS 1^^^ The abnormal stenosis of the preputial orifice can be removed : — 1. Bluntly, by repeatedly stretcJiing the contracted opening of the prepuce crosswise with dressing forceps, or by pushing it back forcibly several times, whereby any existing adhesions are separated at the same time. This procedure suffices nearly always in little boys, and gives better results than incision. 2. By incision, Roser's dorsal incision. Upon a grooved director, intro- duced between the prepuce and the dorsum of the glans, with a pair of scissors, the prepuce is divided longitudinally beyond the anterior half of the glans (Fig. 1447). (The division can also be made wnth a curved tenotome from within outward.) By draw- ing back the external layer of the prepuce, the internal layer remains still lying on the glans, its wound angle lies in front of the angle of the external layer. By two lateral incisions with the scis- sors from this angle of the wound, a triangular flap is formed (Fig. 1448, a\ whose point turned over in an up- ward direction is united by suture with the angle of the wound of the external layer {b). Finally, the two surfaces of the lateral margins can also be united by suture. The two flaps formed by the incision then hang down like a small apron. A better form of prepuce is obtained if similar but smaller incisions are made at both sides of the prepuce, and if the margins of the wound are 792 Fig. 1447 Fic. 1448 OPER-vnoN FOR Phimosis (Roser's dorsal incision) OPERATIONS ON THE PENIS AND THE SCROTUM 793 united transversely by fine sutures (Fig. 1449); or, in less serious cases, the prepuce is divided by a simple incision only to such an extent that it can be retracted as far as the corona glandis. There it remains until the wound has healed, which then extends in a transverse direction. In order not to soil the dressings, the patient may urinate through a wide tube (broken-off test-tube). Likewise, by several very shallow nickings, the opening of the prepuce may be enlarged until it can be retracted as far as the corona glandis. 3. By circumcision, especially if the length of the prepuce is excessive. The prepuce is steadied by two forceps grasping its margin, and held tense. Next, it is cut off with a pair of scissors parallel to its margin in front of the glans without injuring the latter. Still simpler is the procedure if the por- tion to be removed is grasped transversely with forceps, and cut off on the outer side of the same as along a ruler ; the internal and external layers are then united by a few sutures. Fig. 1449. Operation for Phimosis by suturino, transversely Two LATER.A.L Incisions (von Esmarch) The removal of the whole prepuce is rarely required. It is made for malignant disease or for elephantiasis. The dorsal incision is made as far as the corona glandis, and from the angle of the wound the prepuce is removed with the scissors by cutting on both sides close to the sulcus coro- narius as far as the fraenulum ; the internal layer is united by suture with the external layer. In children, sometimes, the whole internal surface of the glans is adhe- rent by epithelium to the prepuce. This can be removed easily soon after birth by retracting the prepuce or by using blunt instruments. But if this is not done, the internal lamella adheres so firmly to the glans that it can- not be detached from the same in this simple manner. If the adhesion were removed with the knife, the former condition would still recur from cicatri- zation. In such cases Dicffenbach formed a new prepuce by a plastic opera- tion (Posthioplasty). 794 SURGICAL TECHNIC He removed the proboscis-like anterior margin of the prepuce and sepa- rated the external layer, which had been forcibly retracted from the internal layer by superficial incisions, as far as i centimeter behind the corona glan- dis ; next, he carefully dissected off the whole internal lamella from the glans, and cut it off all around along the corona glandis. Then he inverted the free margin of the external layer as far as the sul- cus coronarius, and fastened the thus doubled external layer in this position by a few sutures. A reunion by adhesion could not occur after that, and the surface of the glans became cicatrized after a short time. Probably it is better not to remove the firmly adherent internal layer, but to graft the wound surface of the internal lamella at once with epidermis. The cedcvm of the prepuce and skin of the penis frequently occurring after all these operations should be prevented by immediately dressing the whole penis with fine gauze or rubber bandages. (Dressing the wound with carbolated vaseline, elastic compression from the tip of the glans to the root of the penis, rest in bed, and elevation of the penis are the most efficient means in preventing oedema and in expediting the healing of the wound.) OPERATION FOR PARAPHIMOSIS If the glans is strangulated by a retraetcd tight pj'epnce, oedema and gan- grene of the prepuce and glans soon occur, unless the strangulation is removed. Since the chief obstacle to reduction consists in adevia, which quickly develops, its removal must always be first attempted. This is accom- plished in most cases by wrapping a small elastic rubber bandage around the whole penis. Commencing at the tip of the glans, slowly envelop the whole penis as far as its root under moderate traction of the bandage. The com- pression should be strongest over the glans and diminish gradually in the direction of the root of the penis. After a few minutes the bandage is removed; then the reduction of the prepuce (taxis) can generally be made without difficulty. 1. The penis is held with the left hand so as to be encircled by the fore- finger and the thumb behind the incarcerated swelling, while with the first three fingers of the right hand pressure is made against the glans in the direction of the constricting ring {Desruelles, Fig. 1450), or 2. While the forefinger and the middle finger of each hand encircle the penis behind the swelling, and push the prepuce over the glans anteriorly. OPERATIONS ON THE PENIS AND THE SCROTUM 795 the two thumbs lying together upon the glans, press the same through the incarcerating ring [Coster, Fig. 145 1). Fig. 1450 Fig. 145 1 Reduction of Prepuce (Taxis) in Paraphimosis If these attempts do not succeed, or if gangrene of the prepuce has already set in, it is preferable to incise the strangulating ring (Fig. 1452;. Into the middle of the dorsum of the penis a pointed grooved director is pressed from behind beneath the strangulating ring (groove due to compression between the two swelHngs corresponding to the anterior margin of the pre- puce), and the same is divided with the knife. If the strangulating ring can be exposed by drawing apart the two ridge-like swellings (oedematous internal and external layer of the prepuce), it is completely divided in layers from without inward. Fig. 1452. Incising Strangulating Ring After a subsequent reposition of the prepuce, it is sometimes desirable to remove the existing phimosis a few days later. 796 SURGICAL TECHNIC AMPUTATION OF THE PENIS The penis must be aniputalid for malignant disease involving the glans, prepuce, and the penis. The operation is made by the "bloodless method " by elastic constriction, either in front of the scrotum or behind it, according to the seat of the tumor. I. While an assistant securely holds the root of the penis, the portion to be detached, which is covered with gauze, is grasped with the left hand; the penis is drawn away from the body under moderate traction of the skin, and amputated in the healthy part with one sweep of a medium-sized amputation knife (Fig. 1453). Fig. 1454. Wound Surface Fig. 1453. Amputation of Penis Fig. 1455. ^i-TURE 2. Next, on the surface of the wound (Fig. 1454), the dorsal arteries of the penis, the artery of the corpus cavernosum, and the artery of the bulb are sought for, ligated, or twisted. The hemorrhage from the corpora caver- nosa is arrested by ligatures ''en masse,'' or by closing the surface of inci- sion by drawing over it the albuginea, which is sutured over it. 3. After the constrictor has been removed, and any secondary hemor- rhage has been arrested, the mucous membrane of the urethra is drawn forward (if necessary it is nicked somewhat at its lower margin), and its OPERATIONS ON THE PENIS AND THE SCROTUM 797 margin is united with the external skin by four interrupted sutures (Fig. 1455) to guard against stenosis of the new opening. Between the deep sutures a few superficial sutures may be added, according to necessity. In a very high amputation the stump, before its complete division, must be grasped with a hook or with tenac- ulum forceps, so that the corpora cav- ernosa cannot retract underneath the skin in case the elastic constriction should not prevent this. If the amputation must be made as far as and into the scrotum, the latter is divided in the median line into two halves, and the carefully dissected-out urethral stump is sutured downward into the slit of the skin (Fig. 1456), or the urethral stump is drawn out through a wound made on the peri- neum (perineal urethrostomy ; see also page 763). By this operation the constant wetting of the scrotum with urine is prevented. For dressing, a small piece of iodoform gauze is used. This is applied on the surface of the wound, removed in urinating, and at once renewed. It is not necessary to introduce a catheter permanently, but sometimes during the first days the evacuation of urine by means of a catheter may be necessary. Fig. 1456. High Amputation of Penis Division of Scrotum OPERATIONS FOR HYDROCELE TESTIS The simplest procedure for removing an ordinary Jiydrocele is : — I. Puncture and injection of solution of iodine. After the position of the testicle, which in most cases lies at the posterior side of the swelling, has been ascertained, the operator with his left hand grasps the scrotum from behind, and stretches it. With his right hand he inserts a moderately strong trocar through the anterior wall in an upward direction at a point where there are no visible veins ; the depth to which the instrument is to be inserted is fixed by applying the point of the forefinger upon the canula(Fig. 1457). Puncturing the testicle should be avoided. In extracting the stylet, the canula is inserted at the same time as far as its shield, and the contents are then allowed to flow out ; during this pro- 798 SURGICAL TECHNIC cedure the internal opening of the canula must be prevented by skilful manipulations from coming in contact with the opposite wall. After all of the fluid has been drained off, the point of the syringe, fitting exactly into the opening of the canula and filled with 5 to 10 grams tincture of iodine or LugoFs solution (iodine, i ; kali jodat. 2 ; aq. 24), are injected into the canula, and its con- tents are slowly emptied into the cavity. While the syringe remains inserted in the canula, the assistant, by kneading massage movements, tries to bring the iodine solution in contact with the whole wall of the sac. Then, by drawing the piston of the syringe, the larger portion of the fluid is removed by aspiration. After removal of the canula, the puncture is sealed with iodoform col- lodion, adhesive plaster, etc. The patient remains in bed for eight days with his scrotum slightly elevated ; he then receives a suspensory, and is dismissed with a request to report Fig. 1457. Puncture for Hydrocele Testis about the success of the operation after six months ; for it frequently takes this length of time for the interior of the sac to become obliterated by the irritation of the iodine after a renewed (inflammatory) extravasation. Recurrence occurs after this operation only in rare cases. Hence, in its simplicity, it can be considered the normal procedure, especially in children that do not keep themselves clean. (In this country iodine is seldom used in the radical treatment of hydro- cele, owing to the uncertainty of the results and the violent inflammation which occasionally follows this procedure. The favorite treatment consists in injecting carbolic acid (pure) after puncture and evacuation of the sac {Levis). The amount of carbolic acid injected varies, according to circum- stances, from a few drops to half a drachm.) Incision with suturing of the tunica vaginalis to skin {von Volkvinnii). This operation is indicated in Jicpmatocelc, pyoccle, and Jiydrocclc, when the puncturing, with iodine injection, has proved unsuccessful. OPERATIONS ON THE PENIS AND THE SCROTUM 799 After a careful disinfection, the scrotum is held tense with the left hand from behind, as for puncture, and is incised at its anterior external side by an incision 5 to lO centimeters long down to the tunica vaginalis. After the hemorrhage has been arrested, the exposed tnnica vaginalis propria is punctured with the knife, and the opening is enlarged to corre- spond with the external incision, while the contents escape. Next, the margins of the tunica vaginalis are grasped with forceps, some- what drawn forward, and stitcJied to the margins of the skin by a few inter- rupted sutures (Fig. 1458). (The tunica vagi- nalis should be united with the skin by a continuous fine catgut suture.) If the testicle has prolapsed, it is replaced into the sac ; and beside it, a short drainage tube is introduced, and the sutured margin of the wound is in- verted and held in place by a few deep sutures. The rest of the wound is tamponed with iodoform gauze, and finally a typical pelvic dressing or a pair of bathing drawers are applied. Konig incises the tunica vaginalis to the extent of the external incision, inspects the cavity, irrigates it thoroughly, and sutures the wound by a continuous suture, with the exception of a small opening into which a strip of iodoform gauze is introduced. (The editor has always placed great stress on the importance of bringing in contact with every part of the parietal and visceral tunica vaginalis iodo- form gauze (one strip), which is allowed to remain for at least six to seven days in order to transform the endothelial into a granulating surface.) Sometimes, especially in thickened walls of hasmatoceles of long stand- ing {vaginalitis proliferans^, it is necessary to resect corresponding portions of the parietal tunica vaginalis, and to line the remainder with skin. But, since the healing always occupies some time, the total extirpation of the in- ternal tunica vaginalis {iwn Bejgmann) is a method that effects a thorough healing in a shorter time. From a skin incision sufficiently large, the whole tunica vaginalis propria is enucleated bluntly as far as and close to the testicle and the spermatic cord, and detached near the testicle with the scis- sors, leaving in position only a small portion ; the wound of the skin is sutured in its whole extent ; an introduced drainage tube is removed after Fig. 1458. Von Volkmann's Incision for Hydrocele 8oo SURGICAL TECHNIC two days. In a similar manner, the sac is excised in hydrocele of the spermatic cord. The folding together of the divided tunica vaginalis, which Storp places around the testicle (as a soldier folds his cloak around his knapsack), can be employed only for milder cases, and can probably be dispensed with. OPERATIONS FOR VARICOCELE The largely distended veins of the panipiniforui plexus are extirpated if they cause symptoms which cannot be removed by wearing a siispensory. After the scrotum of the patient, while standing, has been constricted by a rubber tube in such a manner that the veins greatly swell from stasis by the first (gentle) constriction, while the next tour effects a complete arrest of the circu- lation, after anaesthesia has taken effect, a correspondingly long incision exposing the bundles of the veins is made through the skin of the scrotum. Any incised lumina or veins are closed at once by hemostatic forceps. The dilated veins are then dis- sected off from the surrounding loose con- nective tissue for a distance of a few centi- meters ; and after double ligation they are divided near the testicle, dissected off in an upward direction, and also cut off centrally after another double ligation (Fig. 1459). The extremities of the resected veins can be tied together by means of the ligature threads, also a piece can be cut off from the skin of the scrotum, if the same is much elongated ; or, still better (according to Kohler, Parker, Senji), the longi- tudinal wound of the scrotum can be sutured transversely, whereby the scrotal half becomes considerably shortened. (Elastic constriction at the base of the scrotum is of no special value in the enucleation of varicose spermatic veins. The operation is performed almost blcodlessly by careful dissection. The vein stump should be sutured together with a fine catgut suture enforced by tying the ligature ends together. Excision of the scrotum is superfluous if the scrotal wound is sutured transversely.) 1459. Oi'ER.vno.\ FOR Varicxicele OPERATIONS ON THE PENIS AND THE SCROTUM 80I One or two veins, however, must remain uninjured; likewise an injury to the arteries must be avoided, else atrophy or necrosis of the testicle easily ensues. The wound of the skin is closed by suture as far as the lower angle, and finally an antiseptic dressing is applied. After the heahng of the wound, the patient must wear a suspensory. Ricord's sitbcutaneozis ligation is less safe, and has probably been dis- placed completely by the aseptic extirpation. But the double ligation and subsequent division of the exposed veins may be attempted. CASTRATION The removal of the testicle is indicated in the treatment of malignant tJimors and tuberculosis of an advanced degree. I. After the application of the elastic constriction tube around penis and scrotum, the scrotum is seized with the left hand and drawn tense ; external incision over the most prominent part of the tumor or swelling by dividing Vd ^ Fig. 1460 Fig. 1461 Castration, a, external incision; h, ligating spermatic cord; Vd, vas deferens the different layers separately down to the tunica vaginalis. In existing fistulous openings, and in very large tumors, it is desirable to cut away a corresponding (elliptical) portion of the diseased or superfluous skin (Fig. 1460). 2. Incision of the tunica vaginalis, rendering the diagnosis certain by a careful inspection of the testicle. Next, the testicle is enucleated as bluntly 3F 8o2 SURGICAL TECHNIC as possible from its envelopes, until it is connected only with the spermatic cord. If, in firmer adhesions, the knife must be used, the operator should always cut toward the tumor of the testicle, and guard against opening the scrotal cavity on the other side by an injury to the septum scroti. 3. The vas deferens, which can easily be felt, is sought for, isolated from the loose connective tissue, and divided. 4. The spermatic cord is pierced through in its middle portion with a pair of forceps or a similar instrument ; a double strong catgut thread is passed through the opening, and each half is very firmly ligated and eut off about I centimeter below the ligature (Fig. 1461). To prevent the stump from sUpping back into the abdominal cavity, the threads of these hgatures " en masse'" are allowed to remain about the length of a finger in the upper angle of the wound, where they serve at the same time for drainage. 5. The large wound is kept patent by retractors, and each bleeding vessel is grasped and ligated; next, after any superfluous skin has been removed with scissors or knife, the surfaces of the wound are sutured by buried sutures, and its margins by interrupted sutures. Drainage in most cases is superfluous. To avoid suturing of the rugous scrotal skin, which is difficult to disinfect, the spermatic cord can also be exposed first beneath the inguinal canal by a longer oblique incision, and then the testicle can be luxated out from this opening (as in post mortems). In a double castration, a curved - — ^ external incision is made across the raphe, and the greater part of the scrotum is extirpated. Recently, in old men, the double castration has been made {Ranini, White), to relieve the obstructive symptoms incident to hypertrophy of the prostate gland; it is claimed that this operation results in progressive diminution in the size of the prostate gland, and thus relieves the symptoms caused by it. Since, however^ serious psychical disturbances are not rarely resulting from this operation, it is advisable to make instead resection of the vas deferens, vasectomy (Jl/ears, HclfericJi), a simple and harmless operation, which, in case of necessity, can be made without narcosis under ScJileicJis anaesthesia. From an external incision 3 to 4 centimeters in length across the round cord of the vas deferens, which can be distinctly felt between two fingers in the region of the inguinal opening, or deeper, the vas deferens is liberated from the other spermatic strictures, drawn forward somewhat, cut off cen- trally, and torn from the epididymis. The removed portion often measures from 8 to 10 centimeters. Von Biingner recommended evulsion^ whereby, through a gradually increased traction on the exposed vas deferens, a large portion of it in the abdominal cavity is also torn out. OPERATIONS ON THE RECTUM AND THE ANUS 803 OPERATIONS ON THE RECTUM AND THE ANUS EXAMINATION OF THE RECTUM For an external examination, the patient is requested to stoop over a table or a bed, while the coccygeal region is turned toward the light; still better is the knee-elbow position. Next, the buttocks are drawn apart, and the patient is told to strain so that the anus is made more prominent. Fig. 1462. Anatomy of Pelvic Organs. .5", symphysis; j?, rectum; ^, bladder; f/, ureter; P, peritoneum; Vd, vas deferens; Z, levator ani; Sp, sphincter For internal examination, the forefinger, well lubricated with antiseptic salve (boric vaseline), is introduced into the rectum, previously cleansed by an enema. By slow and gentle turnings, the finger is advanced far enough to palpate the internal surfaces of the rectum. In order to palpate also the higher sections of the rectum with the tip of the finger, the patient is requested to force or to press, or the surgeon himself presses with his other hand upon the abdomen of the patient in a backward and downward direction. 8o4 SURCxICAL TECHNIC But, if it is necessary to inspect the internal surface of the rectum, the resistance of the sphincters must be overcome; for this purpose a rectal speculum {speculum ani) is used. Fergiissons speculum (Fig. 1463) consists of a tube closed anteriorly, whose internal surface is coated with mirror glass. The portion of the rec- tum to be inspected is placed in the longitudinal opening of the tube. Of similar construction is Goivllaud's speculum. Allinghavis speculum (Fig. 1464) consists of four blades ; its arms can be separated by compressing the handles, and can be held in position for any width by means of the screw in the middle. With this instrument, the entire lower section of the rectum can be satisfactorily inspected. Fig. 1463. Feigusson's Fig. 1464. AUingham's Rectal Specula In great irritability of the sphincter, and in all serious cases, however, it is advisable to make the exaviination undei' ancBst/iesia. After the sphincter has become relaxed from the effects of the anaesthetic, Simss (Fig. 1465) or Swwns (Fig. \A^(i6) groove-shaped vagmal specula can be introduced without any trouble ; with this, the whole internal surface of the rectum can be in- spected. In the knee-elbow position, after the introduction of these specula, the rectum becomes inflated with air, and can be well inspected. The for- cible dilatation of the anus according to Recamier, made by stretching the sphincter during deep anaesthesia, likewise greatly facilitates the inspection of the lower section of the rectum ; it is made, also, as a preliminary proced- ure for removing diseases of the rectum. First, both thumbs are introduced into the anus, while the four fingers rest on the buttocks (Fig. 1467). Next, OPERATIONS ON THE RECTUM AND THE ANUS 805 the thumbs are slowly removed from each other until the stretching of the anal ring becomes very extensive. The same procedure is then repeated in various directions until the whole anal ring is sufficiently stretched. The sphincter becomes lacerated subcutaneously during this procedure, and finally feels like a well-beaten steak. After the operation very little blood flows from the anus. In difficult cases (in high carcinoma, foreign bodies, ileus) it may become necessary to introduce the whole hand (and the forearm) into the rectum under anaesthesia {Simon). Into the anus, previously dilated, the operator introduces first one fin- ger, then several fingers, then half the hand, and finally the whole hand into the rectal cav- FiG. 1465 SiMs's Speculum Fig. 1466 Simon's Speculum Fig. 1467 Forcible Dilatation of Anus ity, with careful turning movements and a pressure gradually becoming more effective. If the folded hand is not more than 25 centimeters in circumference, it can generally be forced through the anus of an adult with- out lacerating the mucous membrane. (Manual explorations should be undertaken only by surgeons with small, delicate hands.) Posterior sphincterotomy, the posterior raphe incision, is rarely necessary for the purpose of an examination, but it facilitates many operations on the posterior wall of the rectum. With a probe-pointed knife introduced upon the finger as a guide, the whole sphincter is divided in the raphe in a posterior direction as far as the tip of the coccyx. The latter may be displaced down- ward and outward, or be extirpated completely {Verneiiil). Fecal incontinence, caused by this operation, disappears, as a rule, after eight to fourteen days. 8o6 SURGICAL TECHNIC PROCTOPLASTY TJie formation of an openiiig of the anus is required in the various forms of congenital imperforate anus {atresia ani), to create a sufficient exit for the collected intestinal contents, and to establish thereby the natural condi tions as far as possible. The child is placed in a dorsal sacral position, and is but slightly anaes- thetized, since the pressing forward of the perineal region, caused by its crying, essentially facilitates performing the operation. The bladder must be previously evacuated. 1 . External incision exactly in the median line from the scrotum ( posterior commissure of the labia) as far as the tip of the coccyx. 2. With careful sweeps of the knife, the operator gradually advances deeper as far as the prominence of the blind sac, through the wall of which the shining meconium can be distinctly seen. The connective tissue around the same is detached bluntly so far that the blind sac sinks down somewhat, and fills the gaping wound in the form of a dark blue bladder. 3. By two fine silk threads applied at the two angles of the wound (the ends of which have been introduced into fine needles), the blind sac is fixed in the wound (Fig. 1468) and then incised between these traction ligatures. While the contents of the rectum escape by means of a douche, the warm boric solution is allowed to enter until it flows out clear. 4. Now, with a little hook, the loops of the two threads previously inserted are drawn from the cleft, divided in the middle (Fig. 1469, E\ and employed for four interrupted sutures, by which, anteriorly and posteriorly, the divided blind sac is stitched to the external skin (Fig. 1469). 5. Next, the remaining portion of the margins of the incision of the rectum is sutured to the external skin all around with interrupted sutures {DiejfenbacJi s labial suture, similar as in Fig. 999), whereby an anal stenosis, which otherwise might occur, is permanently prevented. Even if the atresia extends very high, the attempt should always be made to reach the blind sac by a courageous deepening of the perineal incision if necessary, by opening the perineal sac and by extirpating the coccyx, to gain better access to the deeper layers. In case of necessity, a loop of the large intestine hanging down low may also be drawn forward and sutured to the margins of the wound and opened. Macleod recommends, in difficult cases, even opening the abdominal cavity anteriorly in the median line, searching for the blind sac, detaching it from its connections, and forcing it from above toward the perineal incision. To prevent the escape of meconium, the same OPERATIONS ON THE RECTUM AND THE ANUS 807 is stroked from the lower extremity toward the colon while the child is in Trendelenburg's position. If the rectum terminates in the bladder, urethra, or vagina, the rectum is likewise exposed by a perineal incision ; next, the cellular tissue around the place of inosculation is detached bluntly, and the intestine is cut off Fig. 1468. Fixing blind sac in the wound Proctoplasty Fig. 1469. Opening blind sac Tying sutures transversely with the scissors. The opening thereby produced in the wall of the vagina or the bladder is sutured immediately; the portion of the rectum, however, is drawn downward into the perineal wound, and fastened there {Rizzoli). If the anus cannot, in any manner, be formed in its natural place, an inguinal anus must be established (see page 700) in order to preserve the life of the child. STRICTURES OF THE RECTUM Strictures of the rectum are recognized most readily by digital examina- tion ; if they are located very high, bougies (similar to those described on page 756) must be introduced. If any pass through the stricture, the operator, on withdrawing them, feels their points arrested. Still better are the ivory-olive points fastened to a whalebone rod (Fig. 1470, see also Fig. 12 19), in the employment of which the operator has distinctly the sensation of a resistance suddenly overcome, when they have passed through the stricture. Moreover, they do not relax the sphincter so much, when left in position for some time. 8o8 SURGICAL TECHNIC 1470. Bl'she's Olive-pointed Bougie During these examinations, the patient is best placed in the knee-elbow position or Trendelenburg's position, in order to displace the intestines as much as possible from the true pelvis ; else the operator is very easily deceived by the for- mation of folds, etc. The slozv dilatation ivitJi bou- gies is best made with olive- tipped bougies or glass-tipped bougies (Figs. 1470, 1471), ac- cording to the principles laid down for urethral strictures. The bougies are passed not too often (every two to four days), and all violence must be avoided, since a slight movieiitary press- lire influences the firmer tissue of the stricture most effectively. The forcible dilatation must be made only with the tip of the forefinger, which has been introduced slowly and carefully ; if the tissue prove to be very firm, its margin can be nicked very superficially and in several places with a herniotome (as hernial ring in herniotomy, rectotomia interna). After deeper incisions, — which might divide the entire wall of the rectum thereby opening the cavity, — ■ progressive phlegmon with fatal termination easily ensues. In strictures seated very high, the external rectotomy ( 5(w//£';z- bnrg) is to be recommended. After the posterior surface of the rectum has been exposed by resection of the coccyx and sacrum fig. 1471 (see page 819), the stricture is divided from without inward; tJie Glass spJiincter remains intact. The wound is tamponed, and heals very slowly (after the manner of external urethrotomy); the cicatricial contrac- tion gradually draws all healthy intestinal portions downward. In very serious cases, colostomy, or if there is no hope whatever of im- proving the stricture, an artificial aju/s must be made. OPERATIONS ON THE RECTUM AND THE ANUS 809 STRICTURES OF THE ANUS can be removed permanently only in rare cases, by a tedious bougie treatment. It is better, in milder cases, to divide the anus longitudinally, and suture the wound ti-ansverscly. In very narrow strictures, it is better to divide the anus longitiLdinally in front and behind /// the median line, to detach the mucous membrane of the rectum all around so far that it can be drawn down to the external wound when it is sutured to the skin, especially at the angles of the wound (as described on page 526 in the discussion of stoniato- plasty). If the cicatricial tissue extends far into the rectum, while the external skin is in a normal condition, two tongue-shaped Jlaps, after a median divi- sion, are formed from the latter ; their point is turned toward the anus. These flaps are detached, drawn across the gaping clefts into the rectum, and fastened here with fine sutures {Dieffenbach). OPERATION FOR RECTAL FISTULA consists in division of the wall of the entire fistulous canal from one end to the other ; this is the simplest, most rapid, and safest method of curing a fistula radically. Fig. 1472. Fistula Ani. a, externa incompleta; b, interna incompleta; c, completa After the patient has been subjected to a thorough evacuation for several days, he is anaesthetized and placed in a lateral or lithotomy position. I. The internal orifice of the fistula must be searched for. 8io SURGICAL TECHNIC The latter is often located near the sphincter, as a small, hard swelling, toward which a probe can be pushed through the external opening (Fig. 1473)- ^ ^=^— - o Fig. 1473. Probe for Rectal Fistula Very small internal openings, located very high, are found in the most satisfactory manner by injecting milky solutions (milk, creoline); while a rectal speculum {eg: Fig. 1463) is introduced, the solution is injected under moderate pressure with a small syringe, through the external fistulous open- ing ; generally the fluid escapes in a fine spray from the wall of the rectum ; in this manner also the existence of several internal openings is ascertained. (The most reliable diagnosis of the resources in determining the existence of a complete fistula is to inject through the external opening peroxide of hydrogen. If the fistula is incomplete, tension and pain will follow. If it is complete, foam will escape from the anus.) 2. Next, a flexible metal probe-pointed sound, with grooved shaft, is carefully introduced, without great violence, toward the rectal cavity through the external opening; the narrow internal opening, if necessary, is Fig. 1475. Operation for Rectal Fistula enlarged by pressing the probe-pointed sound forward, so that it becomes visible in the rectum. While the point of the probe is bent downward (Fig. 1474), and forced out of the anus with the introduced forefinger, the probe is pushed through farther. All soft parts lying between the two open- ings are nozv lying as a thick fold upon the probe in front of the amcs, and OPERATIONS ON THE RECTUM AND THE ANUS 8ll may easily be divided \\\t\\ a pointed knife pushed along the groove of the probe (Fig. 1475); or they are incised with the thermo-cautery, or with the galvano-caustic loop. 3. The walls of the divided fistulous canal are thoroughly scraped with the sharp spoon ; for a dressing, a thick tube wrapped with iodoform gauze (Fig. 1476) is introduced ; this, by means of its pressure, arrests the hemor- rhage, in most cases inconsiderable ; likewise it forces apart the margins of the wound and prevents their premature union ; for it is desirable that the wound sJioiild heal from its bottom by gra^inlation. Fig. 1476. Tube for Dressing in Rect.'u. Fistula If the internal opening is located very high, and surrounded bv indu- rated tissue in such a manner that the probe point cannot be brought out of the anus, either a wooden gorget (Fig. 1478) may be introduced into the rec- tum for protecting the wall lying opposite to the same, when the operator is cutting with a long-pointed knife along a grooved director ; else Allijigliam" s scissors may be used, one blade of which, provided with a probe-point, glides along a deeply grooved director (Fig. 1477). If there are several external or several internal openings, they must all be divided, and again united with one another ; undermined livid skin-bridges are cut away. Fig. 1477. Allingham's Probe and Scissors for dividing Rectal Fistula Incomplete fist2ilce (Fig. 1472, a, b) must be transformed into complete fistulas. If no internal opening can be found, the wall of the rectum is pierced with the point of the probe at its thinnest place, and the probe is caught 8l2 SURGICAL TECHNIC with the introduced finger or in the groove of a gorget (Fig. 1478); all the portions lying between are divided. If the external opening is absent, and if only a hard place, sensitive to pressure and slightly prominent, indicates that the abscess will break through at this place, it is often possible to push the point of a hook-shaped probe through the internal opening as far as the skin, and to make an incision upon the same ; else a sharp-pointed knife is pushed into the hard place until pus is reached; then, from the cavity of the abscess, the internal opening is searched for, and all the tissue intervening is divided. The division of the fistula by silk or elastic ligatures is tedious and not without danger. But after laying open the fistula, the indu- rated tissue of the fistulous canal can be extir- pated completely, and the surfaces of the wound can be at once united completely by sntiire {Step/ian, Smith, Lange). Fig. 1478. Dividing Incomplete Rectal Fistula PROLAPSUS RECTI is often permanently reduced i>i children, if they are prevented from violent straining and if the prolapsed rectum is carefully pushed back into position with the lubricated fingers after each evacuation. The inflammatory condition of the mucous membrane and the relaxation of the tissues are removed by brushing the prolapsed mucous membrane with the solid stick of nitrate of sil- ver or the thenno-cantcjy in radiating lines. If this procedure does not pro- duce the desired object, an energetic cauterization of the whole mucous mem- brane luith fuming nitric acid is made under anaesthesia. With this (with- out touching the skin of the anus) the carefully dried mucous membrane is touched, until a dry green eschar has been formed ; next, the prolapse is reduced with a tampon, and the buttocks are drawn together over the same by a broad strip of adhesive plaster. Fig. 1479. Rectal Siti'orter OPERATIONS ON THE RECTUM AND THE ANUS 813 Adults may use a rectal supporter {Y'lg. 1479), that is, an elastic rubber ball which is pressed against the opening of the anus by belts. By a thorough cauterization or the excision of a large viyrtle-leaf-shapcd portion with sub- sequent suture {Dieffenbacli), sometimes a not too large prolapse can be removed permanently. The anal orifice can also be diminished by a purse- string suture or by a ring of thick silver wire applied subcutaneously, which has often yielded good results {Thiersch). Gei'suuy detached the lower part of the rectum, turned it around its longitudinal axis until the lumen was just passable for a finger, and sutured it in this position. In obstinate cases, however, resection of the entire prolapse is the best and safest procedure, especially when reduction is impossible or dangerous on account of incipient or existing gangrene. Into the intestine, pressed forward as much as possible, a wooden cyHnder provided at its superior extremity with a shalloAv transverse groove, a rectal bougie, or something else, is introduced so far that the prolapse can be constricted with a thin rubber tube around the groove closely in front of the anus {vou Esmarch). Any intestinal loops present in the prolapse must first be reduced. Next, under the bloodless method, the whole intestinal wall is carefully divided, cutting through the several layers separately, 2 centimeters in front of the elastic constrictor ; and, after ligation of all visible blood vessels, first the serous coats and, then (after removal of the tube), the muscular and the mucous coats are sutured together. Instead of the bougie, a tampon tube is introduced, and thereby the sutured intestine is returned. In obstinate cases, however, the resection of the whole prolapse is the best and safest procedure. Mieulicz proceeded in a similar manner as follows : — 1. After two deep ligature loops have been inserted through the summit of the prolapse, to hold the intestine in position, first the anterior circum- ference of the external visceral canal is divided transversely in la}"ers about I to 2 centimeters in front of the anal fold until the serous surface of the internal intestinal is exposed. If any intestines are found in the opened peritoneal pouch, they must be returned, if necessary, after dilatation of the anus. 2. By interrupted sutures, two intestinal sutures with their peritoneal surfaces facing each other are united on the peritojieal side as carefully as possible, until the peritoneal cavity at this place has been closed completely. 3. Next, the anterior circumference of the internal intestinal tube is divided in layers, and the two visceral canals are united in the entire line 8 14 SURGICAL TECHNIC of incision by deep interrupted sutures, including all layers ; the ends of the ligature remain long. Finally, the posterior circumference of both intestinal tubes is divided in layers, the vessels of the mesocolon lying between them are ligated, and following the hne of division the margins of the incision are united step by step by deep interrupted sutures (see also page 702, enterorrhaphy). 5. After all threads have been cut off short to the knot, the stump, lightly dusted with iodoform, is pushed back carefully into the anus. Tubu- lar tampon and dressing are not required. If the external intestinal tube has a much longer circumference than the inner, a wedge-shaped cleft is left open in the most posterior portion, into which a strip of iodoform gauze is inserted. Hclferich makes this resection more rapidly and more easily by longitu- dinally dividing the entire anterior and the posterior wall of the prolapse ; at the ends of these incisions a suture is applied through all layers ; the base of the formed flaps is pierced with quilt sutures, and cut off transversely before them. In prolapse which cannot be returned, Bogdanik and others obviate resec- tion by drawing back the invaginated intestinal portion after having opened the abdominal cavity, and by fastening it in its normal position to the parie- tal peritoneum with a few sutures, which do not pierce the mucous membrane (colopexy, Bogdanik). The inferior portion of the rectum can be sutured to the coccyx with a few silk sutures after a longitudinal division of the skin from the anus to the coccyx (rectopexy, Vcrncuil). In the knee-and-elbow position Lange exposed the posterior surface of the rectum by a longitudinal incision of the anal depression and resection of the coccyx, and by buried quilt sutures he formed a deep lo7igit2idinal fold of the rectum projecting inwardly (rectoplicatio). After the divided fibres of the levator and sphincter ani have been sutured, the wound of the skin is likewise closed, and the cavity formed by excision of the coccyx is tamponed. For narroiving the dilated anus cauterization with a cautery iron and the radiate excision of several folds {Dupuytren) are successful only in rare cases. More effective is tJie excision of a large luedge from the prolapsed mucous membrane, the anus, and the external skin, with subsequent suture {Dieffenbacli). OPERATION FOR HEMORRHOIDS When the phlebectases (varicosities) of the /leinorrlioidal plex?is, as well by their size and number as by their tendency to hemorrhages, have become OPERATIONS ON THE RECTUM AND THE ANUS 815 troublesome, it is advisable to remove them ; this is best and most thoroughly effected by extirpating the hemorrhoidal swellings in the following manner : — After the bowels have been evacuated thoroughly for several days, directly before the operation an enema of very warm water is given, which, by straining, is evacuated into a chamber filled with hot water, whereby all varicosities (intermediary and internal) usually appear to view. The patient is then deeply anaesthetized and placed in the lithotomy position. Milder cases may also be operated upon under ScJileicJi s anaes- thesia. be d Fig. 1480. Clamp Forceps, a, Smith's; b, Curling's; c, Hahn's; d, Luer's 1. The anal ring is forcibly dilated {st& Fig. 1467), and a large sponge, fastened with a strong silk thread, is introduced high into the rectum ; the latter is thoroughly irrigated with a warm antiseptic solution (boric or salicylic). 2. Next, all the large external swellings, as well as the internal, are grasped with clamp forceps (Fig. 1480) and drawn forward; by the weight of the hanging forceps they are prevented from slipping back. 3. One after the other the base of each hemorrhoid is detached on its internal side, first from the sphincter muscle by a deep incision with a pair of good cutting scissors {Allinghani' s hemorrhoidal scissors, Fig. 148 1), or with the knife. It is then drawn forcibly forward, and the mucous membrane 8i6 SURGICAL TECH NIC above the base is drawn to the external skin with a quilt suture (Fig. 1482). Next, the mass is cut off in front of the suture, all spurting vessels are ligated, and the wound is closed by tying the quilt suture. The margins Fig. 1481. Allingham's Hemorrhoidal Scissors of the wound still gaping are carefully united by superficial catgut sutures, after they have been sponged wuth a sublimate solution. In the same man- ner all internal and external hemorrhoids are removed. Under some circumstances the entire degenerated mucous membrane of the anus can thus be extirpated in several sections, and the mucous mem- brane of the rectum can be sutured closely all around to the external skin. The threads of the suture remain long for better manipulation, and are Fig. 1482. Extirpating He.mhrrhoidal Swellings spread in a radiate manner around the anus. For preventing, however, cicatricial contractions occurring subsequently, it is advisable to leave a few small mucous membrane bridges uninjured between the extirpated nodules. After the operation, the sponge introduced into the rectum is removed, and a thick rubber Uibe wrapped with iodoform gauze (Fig. 611) is intro- duced. This remains in position until the ne.xt evacuation, which is post- poned to the sixth or eighth day by opiates. OPERATIONS OX THE RECTUM AND THE ANT'S 817 The spasmodic retention of urine occurring mostly during the first days after the operation {spasvuis ta'ethr(z) is removed by opium and warm com- presses over the pubic region, or more quickly by a careful introduction of a catheter, which must not be too small. The removal of hemorrhoids by ligation, a favorite method in England, and their destruction by the actual cautery after grasping them with von Langenbeck' s clamp forceps (Fig. 1483), have indeed met with just as good success, but they bring about the de- sired end considerably more slowly, since the hgated or cauterized nodules must slough off before healing can take place by granulation, while by extirpation the wound generally heals by primary intention. Also cajiterizations with nitric acid {Houstori) and pure carboHc acid are used. Recently Pooley, Langc, and others have favorably men- tioned the parejichymatous injection of carbolic acid glyce- rine (aa) with a Pravaz syringe — a convenient procedure by which one to two drops can be injected with a fine syringe into the nodules protected by some lubricating substance. Xo carbolic acid should come in contact with the mucous membrane, else it becomes necrotic. (The old-fashioned hemorrhoidal clamps are all too heavy and cumbersome. The delicate curved clamp devised by Dr. Charles Adams of Chicago is very useful and can be manipulated with the greatest ease.) Hemorrhoidal nodules that are not too large not rarely disappear after a forcible dilatation of the anus ( Vernenil ). Fig. 1483 Vox Laxgenbeck's Clamp Forceps OPERATION FOR CANCER OF THE RECTUM is made variously, according to the seat and the extent of the disease. Smaller or well-defined pedunculated tumors of the rectal wall are removed by simple excision. If they occupy tJie anal portion, they are drawn forward with tenaculum forceps ; after a forcible dilatation of the anus, the operator circumscribes them with the knife in the healthy parts, and sutures the surface of the wound completely ; after the hemorrhage has been arrested, if possible,, the wound is closed in a transverse direction, in order that no harmful constriction may follow the operation. If, however, the tumor is located so high above the anal portion that it cannot be drawn outside of the anus, the latter is incised through the pos- 3G 8l8 SURGICAL TECHNIC terior raphe as far as the tip of the coccyx {DieffenbacJi). The margins of the deep wound are now drawn apart with sharp hooks, and the tumor drawn downward is circumscribed with the knife by two semikmar incisions. If the tumor occupies tJie anterior rectal wall, the anus is divided in the median hne toward the perineum {anterior spJiincterotoviy), and the anterior wall of the rectum is carefully dissected off from the prostate and the bladder. After the removal of the tumor, the wound is reduced in size by a few sutures, and the remainder is drained. If tJie anus is the starting point of the trouble, and if the entire anal ring is included in the carcinoma, the anus is circumscribed by two semilunar incisions through healthy tissue ; next, with rapid sweeps of the knife, the operator penetrates into the cellular tissue surrounding the rectum as far as and beyond the limit of the disease, which is determined with the left fore- finger introduced into the rectum. The detached portion of the rectum is now forcibly drawn forward with tenaculum forceps, and the intestine is transversely divided above the limit of the disease. After the hemorrhage has been arrested, the rectum, which has been drawn down, is sutured to the margins of the skin (extirpatio ani, according to Lisfranc). In the course of time the ivonnd lieals by granulation and cicatrization ; the contraction following the operation is sufficient to prevent total rectal incontinence. With a view of preventing rectal prolapse, which frequently follows, it is advisable to make use of pressure by a ball of common cotton applied over the new anal opening, and to hold it in place by a suitable bandage. If the tumor occupies the larger portion of the circuvference or even the whole circumferejice of the rectal wall (annuld.r), the whole rectum must be removed as far as and beyond the upper limit of the disease (resectio recti). If the tumor, springing from the anal portion, has not yet invaded the sphincters, the anus, according to DieffenbacJi, is divided first anteriorly in the raphe as far as the bulb of the urethra, and then posteriorly as far as the tip of the coccyx ; but the mucous membrane is divided transversely on both sides at the junction with the anal integument ; it is then detached from the internal sphincter. After the two halves of the anus have been drawn apart with large sharp retractors {Si7non) by an assistant, the rectum is divided below the tumor transversely on both sides, and detached from its surrounding tissues as far as, and at least 4 centimeters above, the upper limit of the tumor. First, the anterior wall is dissected off carefully from the prostate and the bladder ; next, all around and close to the external wall, the operator OPERATIONS ON THE RECTUM AND THE ANUS 819 penetrates carefully upward, pressing more with the fingers and blunt instru- ments than cutting with the knife, and thus dividing the tense bands of con- nective tissue, and securely ligating every vessel, if possible, before its division. Farther upward, and within reach of the tumor, the operator avoids the rectal wall as much as possible. If the upper limit of the tumor, palpable through the intestinal wall, is situated so high that the lozver duplicatnre of tJie peritonewn must necessarily be opened, the peritoneum is incised transversely ; it is then easy to draw the rectum downward. Sometimes the surgeon also succeeds by blunt dis- section in pushing the peritoneum carefully upward ; at each inspiration, it bulges like a fish bladder in the large wound cavity ; after a thorough dis- infection, smaller rents are closed immediately by the suture. As soon as the surgeon has reached a part of the bowel at a safe distance above the tumor, he penetrates with his forefinger through the loose cellular tissue to the other side, and now tries, by curving the finger like a hook, and by grasping the tumor with the whole hand, to draw the intestine forcibly downward, and to detach it on all sides until it has been made freely mov- able, when it hangs down in front of the gaping wound. Next, the intestine is divided transversely at least 4 centimeters above the demonstrable proximal limits of the tumor ; all bleeding vessels are ligated. Then the margin of the resected intestine is united with the anal integu- ment by sutures, at least at its anterior surface, for it is better to tampon the posterior surface for effective drainage for the secretions and the faeces. The wounds in the perineum and in the gluteal furrow are somewhat reduced by suturing, and drained. In very high carcinoma, if the coccyx is in the way, it is detached from the sacrum (Kocher). The largest space for the removal of tumors seated very high in the rectum is obtained by RESECTION OF THE SACRUM {Kraske) in the following manner : — I. While the anaesthetized patient lies on his right side, a skin incision from the posterior margin of the anus is made in the median line as far as the middle of the sacj'uni. (The patient should always be placed in the ventral position, the pelvis well elevated for the purpose of facilitating the technical part of an operation, 820 SURGICAL TECHNIC and to minimize the hemorrhage. A cot is preferable to an operating table) (Fig. 1485). 2. Penetrating layer by layer, the operator detaches the insertion of the gluteus viaxinius from the left side of the sacrum and disarticulates the coccyx. 3. Next, the lowest portion of the great sacro-sciatic and of the lesser sacro-sciatic ligament is detached from the sacrum ; by this means the superior portion of the posterior wall of the rectum becomes much more accessible. 4. With strong bone-cutting forceps, the lower portion of the left border of the sacrum is excised in a line beginning from the left margin at a level with Fig. 1484. Resection of Sacri-m. a, according to Kraske; a-a', ac- cording to Bardenheuer ; b, according to von Volkmann and Rose Fig. 1485. Position of Patient for Operations of THE Sacrum the third posterior foramen of the sacrum, and extending in a curve inward and downward around the fourth sacral foramen as far as the left inferior sacral cornu (Fig. 1484, a). The spinal canal is not injured ; the sacral nerves, however, are divided as far as the third. 5. The patient is then placed in the lithotomy position wdth his pelvis elevated ; first, the whole rectum is detached from its adjacent tissues in the manner described before, beyond the limits of the tumor, to such an extent that the diseased portion can be drawn down as far as the anal margin, without great tension. If the operator finds any diseased lymphatic glands OPERATIONS ON THE RECTUM AND THE ANUS 821 in the pelvic connective tissue of the sacral cavity, he enucleates them as bluntly as possible. 6. At the posterior wall of the rectum, always advancing as closely to the same as possible, it is comparatively easy to detach the rectum all around, — in part, bluntly; in part, with scissors (see page 819). 7. If the anal portion is not invaded by the disease, it can be preserved uninjured by excising the diseased intestinal portion by two transverse in- cisions in the healthy parts, and by suturing the upper end, after it has been drawn down to the posterior vertical incision of the anal portion. For this purpose, it is best to suture only the anterior half of the intestinal circum- ference, and to leave the posterior half open. 8. The whole wound and the posterior raphe incision are tamponed ; subsequently the latter can be closed by suturing the two lateral flaps of skin ; a tampon tube is introduced high up into the rectum. It is just as good to draw the rectal portion, temporarily closed by a rubber ligature or completely closed by a silk ligature, through the anal portion stripped of its mucous membrane, and to fasten it in this invaginated position {Kocher, Hochenegg). Nicoladoni sutured the proximal end drawn downward to a ring 3 to 4 centimeters wide, wrapped with iodoform gauze to prevent it from slipping back. Rehn proceeds according to Kraske s method in two sittings, by amputat- ing first the diseased rectum ; after about ten days he sutures the stumps. (The editor has had a somewhat extensive experience with Kraske's method of rectal extirpations, and he has come to the conclusion that the additional space secured is but an inadequate compensation for the increased risks incurred to life by the operations. For a number of years he has limited pelvic resection to excision of the coccyx as a preliminary step to excision of the rectum for malignant disease.) If the anal portion has also to be removed, a narrowing to the requisite extent of the rectum, which has been drawn down, is effected by rotating it around its longitudinal axis {Gersuny). A still more convenient access to the true pelvis from behind than by Kraske's method is obtained by the transverse resection of the sacrum according to Bardenhener. He removes the whole lower portion of the bone as far as the third sacral foramen (Fig. 1484, a-d), advances then toward the rectal wall, and detaches the same as bluntly as possible from the surround- ing tissue. Without any evil consequences, the bone may be chiselled off transversely even as far as the second sacral foramen {von Volkmann, Rose, posterior coeliectomy) . 822 SURGICAL TECHNIC Von Heineke makes the resection of the sacrum ostcoplastically. The posterior sphincter incision is extended in the median Hne as far as the fourth sacral foramen, the coccyx and the sacrum are divided longitudi- nally in the median line with the broad amputating saw, and the sacrum is then chiselled off transversely and a little obliquely downward along the lower border of the fourth sacral foramen (protection of the fourth sacral nerve). The flaps of bone and soft parts are turned over laterally. Fig. 1489). By a somewhat similar procedure, W. Levy protects the levator ani and its sympathetic nerve originating from the fourth sacral nerve, by dividing the sacrum transversely below the fourth sacral foramen, a finger's breadth above the cornua of the coccyx. From the extremities of this incision, two longitudinal incisions are made 8 centimeters downward, and the skin-bone flap is forcibly drawn downward (Fig. 1490). ScJihmge proceeded in a similar manner — only the extremities of the lateral incisions divide below the skin alone (protection of the inferior hemorrhoidal nerves), but above they detach the gluteus maximus and the Hgaments from the border of the sacrum. Hcgar turned the sacrum over in an upward direction, after he had circumscribed it by two incisions extending from the inferior posterior spine of the ilium to the tip of the coccyx ; below the second sacral foramen, he divided it transversely (Fig. 1491). Rydygier makes the incision through the soft parts obliquely, a little distant from the border of the sacrum, from the superior posterior spine of the ilium as far as the tip of the coccyx, and then in the median line toward the anus. Having detached the soft parts from the sacrum, he chisels through the latter transversely below the third sacral foramen and turns it over to the right, so that the sacral nerves of the right side remain uninjured (Fig. 1493)- O. Ziickerkaiidl created a passage to the pelvic organs according to Hiieters method, on the anteiior side of the rectum, by a large horseshoe- shaped incisio7i (Fig. 1494), from which he penetrated between the prostate and the bladder on one side and the rectum on the other as far as the peritoneal reflection. The retraction of the divided levator ani facilitates the operation considerably. After the diseased intestine had been resected, he united the sigmoid flexure with the anal portion by circular enterorrhaphy. It is still better to incise the anus in front and to tampon the wound temporarily. Similar is //z/r/rr'i- operation by a horseshoe incision (Fig. 1495), in which a musculo-cutaneous flap is turned downward, exposing the anterior rectal wall. OPERATIONS ON THE RECTUM AND THE ANUS 823 E. Zuckcrkandl suggested, from an anatomical point of view, the parasa- cral incision, for the exposure of the pelvic organs. w c a I The patient is placed in a right lateral position ; the mcision extends from the left tuberosity of the ischium in a slight curve close to the sacral border as far as the ischiorectal fossa in the middle between the tuberosity of the coccyx and the rectum. 124 SURGICAL TECHNIC 2. The gluteus maximus, the great sacrosciatic and the lesser sacrosciatic ligament, the coccygeal muscle, and, if necessary, also a portion of the levator ani, are cut off close to the sacrum and the coccyx, whereby the extraperitoneal rectal portion is exposed in its whole length (Fig. 1496). Fig. 1494 Fig. 1495 Perineal Extirpation of Rectum, a, Zuckerkandl's; d, Hueter's 3. If the operator now advances toward Douglas's fossa, he can reach also, after opening the peritoneum, the superior part of the rectum and the sigmoid flexure. Wblfler proceeded in a similar manner, but operated on the rig]it side. If the tumor, on account of extensive adhesions with the surrounding parts, can not be excised, or if the patient is so feeble that he would not Fig. 1496 Fig. 1497 Zuckerkandl's Parasacral Incision survive a major surgical operation, at least a passage must be created for the faeces accumulating above the stricture. This is effected either by removing as much as possible from the tumor mass with the sharp spoon and the thermo-cautery, or by incising the entire posterior wall of the OPERATIONS OX THE RECTUM AND THE AXUS 825 rectum as far as and beyond the superior limit of the tumor, with the thermo-cautery (linear rectotomy, according to Verneiiil). In most cases, however, it is advisable to form an artificial anus, for the escape of the faeces, and by doing so any irritation of the ulcerated surfaces by faeces is prevented (see also page 700). To provide this anus with some tiling like a sphincter, the central extremity maybe sutured into the sacral incision (sacral anus, HocJienegg); and the peripheral rectal end, containing the carcinoma, can be sutured ; or the intestinal end, cut off in healthy tissue, is pushed through a transverse opening, made four to five fingers' breadth at the side of the sacral incision between the fibres of the glutei (gluteal rectotomy, Witzel). But if the disease extends so far in an upward direction that the sigmoid flexure or the colon must be used for the new anus, an inguinal anus is estab- lished, as described on page 700. Witzel obtains with this a better closure, by drawing the upper end of the intestine through an incision along the left crest of the ilium under the skin as far as the superior later?! gluteal region (colostomia glutealis;. Here, by the fibres of the gluteus maximus, a sphincter is formed ; the portion of the intestine in the extrapelvic tissues can easily be made to serve as a sphincter by making pressure against the ilium. INDEX OF NAMES A Adams, Charles, Curved Clamp Forceps, 817. Adams, Metacarpal Saw, 307. Rhinoplastos, 580. Adelmami, Hyperflexion of Limbs, 241. Strips of Plaster of Paris Bandage, 113. Aiyrdpaa, Protheses for Collapsed Noses, 543. Albert, Duodenostomy, 695. Meloplasty, 527. Allessandri, Intestinal Suture, 704. Allingham, Hemorrhoidal Scissors, 815. Rectal Speculum, 804. Scissors for Dividing Rectal Fistula, 811. Von Ammon, Blepharoplasty, 515. Rhinoplasty, 531. Amussat, Clamp Forceps, 246. Colostomy, 699. Intestinal Suture, 704. Andrews, E., Intraparietal Oblique Fistula, 683. Andrews, W., Gastrotomy, 679. Anel, Ligation of Arteries, 285. Angerer, Sublimate Tablets, 27. Anschutz, Plastic Plaster of Paris Splints, 120. Antal, Cystorrhaphy, 775. Antyllus, Ligation of Arteries, 285, 286. Assaky, Neuroplasty, 29B. B Baracz, Dividing Nose in the Median Line, 572. Intestinal Suture, 705. Von Bardeleben, Amputation of Leg, 373. Chloride of Zinc Jute, 28. Osteoclasis, 305. Pelvic Support, 123. Premaxillary Bone, 549. Wire Suspension Apparatus for Fractured 167. Bardetiheuer, Cholecystotomy, 735. Cystotomy, 772. Extirpation of Larynx, 623, 625. Extraperitoneal Explorative Incision, 676. Ligation of Innominate Artery, 651, 652, 654, Renal Incision, 742. Replacing Metacarpal Bone, 394. Resection of Elbow Joint, 410. Resection of the Lower Jaw, 490. Resection of the Sacrum, 821. Splenopexy, 739. Tarsectomy, 430. Tendinoplasty, 296. Bartsch, Metal Strips for the Resected Maxillary Arch, 490. Bartscher, Open Treatment of Wounds, 66. Barwell, Lateral Extension for Scoliotic Spine, 152. Bassini, Operation for Hernia, 723, 726. Operation for Femoral Hernia, 730. Battle, Cystoplasty, 786. Baum, Ankylosis, 492. Oil of Turpentine, 243. Banvtann, Thyroidin, 626. Bayer, Extension of Tendon of Achilles, 292. Meloplasty, 528. Becker, Acetonuria from Ether, 190. Beck's Portable Compact Sterilizer, 17. VoJi Beck, Straw Splints, 162. Bellocq, Canula for Tamponing Nostrils, 477, 536. Bell, Splints, 99, 150. Beefy, Plaster of Paris Bandage Machine, 115. Plaster of Paris Hemp Splint, 128. Plaster of Paris Splints, 120. Bengue, Ethyl Chloride, 193. Bennet, Ascertaining Location of Central Fissure, 465. Berger, Disarticulation of Shoulder Girdle, 353. Von Bergmann, Bullets in Human Body, 221. Cerebral Hemorrhage, 461. Closure in Anus praeternaturalis, 713. Enterorrhaphy, 708. Innominate Artery, 652. Nephrectomy, 741, 744. Leg, Oesophageal Diverticula, 644. Operating Table, 16. Operation for Hydrocele Testis, 799. Spindle for Ligations, 744. Sublimate, 25, 26. Trephining the Skull at the Base of the Squamous Portion of the Temporal Bone, 468. Bernays, Cholecystotomy, 734. Berndt, Regionary Analgesia, 194. 827 828 INDEX OF NAMES Beyeile, Phonetic Canula, 624. Bier, Cocainizing Spinal Cord, 195. Ligation of Hypogastric Arteries, 782. Local Exclusion of Diseased Intestines, 711. Osteoplastic Amputation to produce Stumps that bear well, 334. Osteoplastic Necrotomy, 315. Resection of Ilium, 454. Biermer, Thoracocentesis, 658. Bigelow, Litholapaxy, 784. Lithotriptor, 783. BiUioth, Adhesive Iodoform Gauze, 33. Batiste, Oil Cloth, 44. Enteroanastomosis, 70B. Extirpation of Goitre, 626. Extirpation of Larynx, 623. Extiipation of Patella in Disarticulation of Knee Joint, 377. Extirpation of the Tongue, 602. Intestinal Clamps, 686. Margins of Plaster of Paris Bandage, 117, 118. Mixture of Chloroform, 181, 192. CEsophagotomy, 643. Oil of Turpentine as a Styptic, 243. Resection of the Pylorus, 685, 686, 689. Thoracocentesis, 657. Bircher, Direct Fixation of Bones, 310. Gastroplication, 679. Blaiidin, Deviation of Septum, 580. Excision of Cuneiform Portion from the Vomer, 550- Uranoplasty, 590. Bockel, Division of the Palate, 576. Ligation of Superficial Palmar Arch, 267. Backer, Galvanocaustic Handle, 206. Bogdariik, Colopexy, 814. Biihm, Potash Silicate Dressing, 112. Bona, Intertarsal Disarticulation, 359. Bonnecken , Aluminum Bronze Wire, 490. Bonnet, Wire Breeches, 139, 140. Borchardt, Operation for Hernia, 730. Bose, Elastic Retractor, 616, 620. Retrofascial Separation of the Thyroid Gland in Tracheotomy, 617. Bosworth, Antipyrine, 243. Botlini, Amputation of the Tongue, 600. Ankylosis, 492. Galvanocaustic Excision of the Prostate Gland, 781. Operation for Hernia, 728. Zinc Sulphocarbolate, 31. Bouisson, Rhinoplasty, 534. Bourgery, Resection of Wrist, 395. Braatz, Spiral Splint for Radius Fracture, 120. Brainard, Extirpation of the Parotid Gland, 605, Posterior Catheterism, 769. Brandts, Aorta Tourniquet, 240. Cautery Iron, 204. Brandt, Gastroplication, 679. Obturator, 560. Uranoplasty, 556. Brasdor, Ligation of Arteries, 286. Bratcn, Resection of Malar Bone, 498, 504. Nephrectomy, 741. Breiger, Plaster of Paris Cotton, 114, 115, 120. Broka, Instruments for Measuring the Skull, 466. Brokaw, Intestinal Suture, 705, 709. Brophy, Cleft Palate, 551. Brown, Pliaryngeal Syringe, 579. Von Bruns, Anatomy of the Parotid Gland, 606. Carbolized Gauze, 24. Cheiloplasty, 520, 522, 525. Galvanocaustic Handle, 206. Glue Dressing, 112. Modification of Pirogoff, 371. Needle provided with Handle, 555. Neurectomy of Inframaxillary Nerve, 501. Omphalectomy, 732. Oral Speculum, 582. Phonetic Canula, 624. Plastic Felt, no. Plastic Pasteboard, no. 1 urning Nose upward, 574. Wound Cotton, 4-1. Brya:it, Gum Arabic Chalk Dressing, 112. Buclianan , Amputation in Line of Epiphyses, 379. Biilau, Aspiration Drainage, 660. VoH Biliigner, Evulsion of the Vas Deferens, 802. Burggriive, Cotton, Pasteboard Dressing, in. Biirkkardt. Retropharyngeal Abscesses, 611. Btirow, Aluminum Acetate, 28. Cheiloplasty, 522, 523. Open Treatment of Wounds, 66. Skingrafting, 302. Busch, Restoring Tip of the Nose, 540. Buslie, Rectal Bougie, 808. Butclier, Disarticulation of Knee Joint, 379. Riitschik, Trichloi phenol, 30. C Callisen, Colostomy, 699. Canquoin, Paste of Chloride of Zinc, 208. Cantani, Hypodermoclysma, 280. Garden, Intracondylic Amputation, 379. Carr, Radius Splint, 98. Cathart, Location of Sulcus Centralis, 466. Catterina, Resection of Wrist, 402. Cclsiis, Circular Amputation by One Incision, 318 INDEX OF NAMES 829 Rubbing in Pseudoarthroses, 312. Skingrafting,-302, 303. Chalot, Resection of Hard Palate, 576. Champ lonniere, Hooked Tongue Holding Forceps, 184. Chassaignac, Drainage, 38. Drainage Trocar, 39, 476. Ecrasement, 225. Ligation of Vertebral Artery, 262. Resection of Coronoidal Process, 489. Resection of Septum, 580. Turning Nose upward, 574. Chelius, Operation for Struma, 626. Cheselden, Circular Amputation by Two Incisions 322. Ckeyne, Healing under the Scab, 38. Chopart, Disarticulation at the Tarsus, 359. Ciaiiiiciati, lodol, 35. Civiale, Lithotriptor, 782. Urethrotome, 759. Cline, Splints, 99. Clover, Radius Splints, 98, 99. Collin, Adjustable CEsophagus Hook, 638. Catheter Catcher, 766. Intestinal Clamps, 712. OEsophagotome, 641. Condamin, Omphalectomy, 732. Cooper, Aneurism Needle, 253. Ligation of the Aorta, 270. Scissors, 201, 298. Cosine, Frere, Arsenic Paste, 208. Costa, Cocaine Anaesthesia, 194. Coster, Paraphimosis, 795. Courvoisier, Cholecystendysis, 734. Gastro-enterostomy, 692. Hepatic Border Incision, 734. Cramer, Wire Splint, 103. Crosby, Adhesive Plaster Loop, 147. Cubasch, Suspension Apparatus, 167. Cnrlit7g, Hemorrhoidal Forceps, 815. Cush'mg, Intestinal Suture, 703. Czei-ny, Carbolized Silk, 210. Cystoplasty, 786. Extirpation of Larynx, 621. Galvanocaustic Excision of the Prostate Gland, 781. Intestinal Suture, 702. Nephrectomy, 741. Operation for Hernia, 722. Resection of the CEsophagus, 643. Subperiosteal Cuneiform Excision of the Vomer, 55°- D Davidsolm, Sterilization of Instruments, 7. Daiy, Direct Fixation ot Bones, 310. Delpech, Resection of the Lower Jaw, 491. Demme, Cystoplasty, 787. Scabbard-shaped Compressed Trachea, 634. De Quervain, Tobacco Pouch Suture, 215. Desault, Amputation by Three Circular Incisions, 323- Bandage for the Clavicle, 78, 122, 155. Extension Splint, 146. Operation for Salivary Fistula, 608. Desmarres, Clamp for Eyelids, 234. Dieffenbach, Anal Stenosis, 806, 809. Blepharoplasty, 514, 516, 517. Cheiloplasty, 520, 525. Cuneiform Excision of the Anus, 814. Cuneiform Excision of the Tongue, 579. Disarticulation of the Thigh, 388. Division of Nose, 571. Labial Suture, 806. Lace Suture, 215. Needle Holder, 209. Phanmgeal Tumors, 576. Plastic Operation for Contraction of Nostrils, 579. Posthioplasty, 793. Prolapsus Recti, 813. Prothesis for the Tongue, 604. Raphe Incision, 818. Resection of Septum, 580. Resection of Upper Jaw, 478. Resectio Recti, 818. Restoring Ala of the Nose, 540. Restoring Septum of Nose, 541. Rhinoplasty, 531, 540. Ring Forceps, 234. Sinuous Incision of Upper Lip, 478, 481. Staphylorrhaphy, 553. Stomatoplasty, 526. Tenotome, 290. Tonsillotomy, 591. Urethroplasty, 765. Dieulafoy, Aspirator, 659. Von Dittel, Lateral Prostatectomy, 781. Position for Pelvic Dressing, 125. Retention Cntheter, 753. DJelitzyn, Osteoplastic Amputation, 380. Dobson, Wooden Frame, 141. Danders, Epidermic Suture, 78. Doyen, Angiotripsy, 246, 247. Gastro-enterostomy, 694. Resection of Ganglion Gasseri, 509. Tobacco Pouch Suture, 215. Drencke, Anaesthesia, 179. Drescher, Ether AnEESthesia, 190. Dreser, Ether Anaesthesia, 189. Duchenne, Phrenic Faradization, 186. 830 INDEX OF NAMES Diihrssen, Dressing Box, 47. Von Dumreicher, Alar Splint, 107. Hyperasmia for Forming Solid Callous, 312. Operation for Necrosis of Lower Jaw, 492. Operation for. Necrosis of Upper Jaw, 481. Railway Apparatus, 150. Duplay, Oisophagotomy, 643. Wire Snare, 570. Dupuytren, Contraction of Fingers, 292. Intestinal Clamps, 712. Narrowing Dilated Anus, 814. Splint for Fracture of the Ankle, 146. O' Duyer, Intubation, 619. Von Eisehberg , Local Exclusion of Diseased Intes- tine, 711. Englisch, Rhineurynter, 566. Erb's Paralysis, 179. Vo7i Esniarch, Adjustable Oblique Board, 61. Akidopeirastik, 202. Ankylosis, 492. Antiseptic Dressing Package, 171. Aorta Tourniquet, 238. Arsenic Caustic Powder, 208. Bloodless Method, 225. Brass Spiral Bandage, 230. Chloride of Sodium, 31. Chloroform Apparatus, 174. Clamp Buckle, 226, 228. Cold Coil, 64. Cooling Box, 64. Cooling Cover, 65. Double Inclined Plane, 140. Double Splint, 136. Von Esmarch, E., Cleaning \\'alls of Room, 3. Elastic Constriction, 226. Glass Bougie, 808. Heel Support, 124. Hj'drochloric Acid, 31. Inguinal Colostomy in Tumors of the Rectum, 701. Iron Arch Splint, 136. Iron Suspension Splint, 136. Meloplasty, 527, 530. Modification of Pirogoff's Operation, 370. Needle Case for Intestinal Sutures, 702. Operation for Harelip, 547, 549. Operation for Phimosis, 792. Osteoclast, 306. Plaster of Paris Suspension Splint, 133. Pole Pressure for Aneurism, 284. Principle of Economy, 547. Prolapsus Recti, 813. Reflection of Periosteum in Amputations, 323. Resection of Articular Surface and Neck of Scapula, 417. Separable Wooden Splint, 95, 154. Splint Material, 97. Stretcher Extension Dressing, 153. Tongue-holding Forceps, 184. Tourniquet Suspender, 231. Triangular Cloth, 84. Urethroplasty, 765. Wire Breeches, 140. W'ire Cloth, 103. Estlander, Cheiloplasty, 520. Thoracoplasty, 662. Ewald, Meloplasty, 527. Fabricius, Operation for Femoral Hernia, 731. Fabricius ab Aquapendente, Taxis, 717. Fahnestock, Tonsillotome, 592. Farabceuf, Forceps, 391, 412. Fearti, Ligation of Arteries, 286. Fehleisen, Tamponing Recium in Sectio Alta, 770. Fenger, Gastrostomy, 680. Nephrectomy, 740. Fergusson, Lion Forceps, 391. Rectal Speculum, 804. Resection of Upper Jaw, 478. Staphylorrhaphy, 553. Fialla, Rod Splint, 143. Fickert, Plaster of Paris Plate Dressing, 114. Filekne, Injury to the Brain by Hammering, 460. Fine, Colostomy, 700. Fischer, E., Naphthalin, 34. Sugar as Antiseptic, 35. Fischer, R. de. Plastic Cellulose Sheets, no. Gastrostomy, 680. Oi^sophagotomy, 643. Flashar, Artificial Respiration. 186. Fleurant, Trocar for Bladder, 768. Fowler, Bullet Probe, 223. Frdnckel, Nasal Speculum, 565. Uvula Forceps, 566. Frank, Intestinal Button, 706. Local Exclusion of Diseased Hernia, 711. Oblique Fistula. 682, 684. Operation for Hernia, 728. Frantzel, Trocar, 659. Freudenberg, Galvanocaustic Excision of the Prostate Gland, 781. Fricke, Blepharoplasty, 515, 516. Fritsch, Water Sterilizer, 21. Frohlich, Hooked Forceps, 552, 591. Fiirbringer, Sterilization of Hands, 4. INDEX OF XA-MES 831 Apparatus for Infusion, 281. Aspirator, 660. G Gar son, Cystotomy, 770- Gensoul, Resection of Upper Jaw, 478. Gerdy, Cloth Bandages, 84. Gerstem, Osteoplastic Resection of the Skull, 463. Gersier, Epityphlitis, 711. Gersuny, Compress of Loose Gauze, 13. Craniectomy, 462. Operation for Umbilical Hernia, 731. Pedunculated Flaps, 528. Prolapsus of Rectum, 813. Rotation of Rectum, 821. Transverse Thyrotomy, 614. Gigli, \\'ire Saw, 480. Gipp, Ligation of the Isthmus in Goitre, 633. Giraldis, Operation for Harelip, 546. Girard, Gastrostomy, 682. Resection of Ankle Joint, 427. Glisson's Sling, 151, 152. Gluck, Costal Scissors, 655. Xeuroplasty, 298. Tendinop'.asty, 295. Gooch, Flexible Wooden Splint, 95, 96, 160. Gosselin, Nasopharyngeal PohT^i, 577. Gottsiein, Circular Knife, 579. Goursaiid, External CEsophagotomy, 640. Goyrand, Ligation of Internal Mammary Artery, 653 Graf, Borogiycerine Lanolin, 28. Tannin, 243. Von Grafe, Coin Catcher, 638. Exenteration of the Bulb, 563. Ligature, 225. Loop Tightener, 599. Rhinoplasty, 537. Staphylorrhaphy, 551. Gritti, Resection of Wrist, 402. Supracondylic Osteoplastic Amputation, 380. Grossmann, Ether Mask, 189. Gross, S. IV., Prothesis for the Nose, 538. Giierin, Ansesthesia, 180. Resection of Os Calcis, 430. De Guise, Salivary Fistula, 608. Gurlt, Statistics of Chloroform Ansesthesia, 181. Statistics of Ether Anaesthesia, 188. Gussenbauer, Ankylosis, 492. Bone Clamps, 310. Chiselling open the Hard Palate, 576. Combined CEsophagotomy, 643. Parallel Forceps, 686, 690. Phonetic Canula, 624. Resection of Nose, 575. Gutsch, Lower Maxilla Holder, 183. H Hobs, Chiselling Hard Palate, 576. Von Hacker, Endless Probing, 640. Gastro-enterostomy, 692. Gastroiysis, 679. Gastrostomy, 680, 682. Oesophageal Fistula, 643. CEsophdgop'.asty, 644. Retrograde Dilation, 682. Rhinoplasty, 534. Hagedorn, Gastrostomy, 681. Glass Box for Catgut Ligatures, 10. Needle Holder, 210, 554, 555. Needles, 210, 294, 296. Operating Table, 16. Operation for Harelip, 546, 548. Sphagnum Pasteboard, 42. Tracheal Canula, 61&, 701. Hageler, Skingrafting , 304. Hahn, Colostomy, 701. Compressed Sponge Canula, 477, 621, 622. Curved Incision in Disarticulation of Knee Joim 439- Gastrostomy, 682. Hemorrhoidal Forceps, 815. Intestinal Clamps, 686. Meloplasty, 528. Nailing Resected Knee, 437. , Nephropexy, 745. I Haidenhehi, Amputation of Breast, 668. Halsfead, Amputation of the Breast, 668. Serous Suture, 702. Hammer, Solveal, 25. Hancock, Osteoplastic Disarticulation of Foot, 364- Hannsmann, Victoria Metal Strips, 490. Harrison, Cystoplasty, 788. Hartmann, Tamponing Nares, 569. Hasnervon Artha, Blepharoplasty, 516. Hausmann, Aluminum Bone Splints, 310. Hegar, Needle Holder, 209. Resection of Sacrum, 822. Von Heineke, Intestinal Clamps, 686, 707. Pyloroplasty, 696. Resection of Sacrum, 822. Heine, Tirefond, 459. Heister, Fracture Box, 143. Gag, 183, 581. Helferich, Amputation of Leg, 373. Amputation Saw, 392. Ankylosis, 492. Disarticulation of Thigh, 384. Epispadias, 790. Hyperemia in Forming Osseous Callus, 312. INDEX OF NAMES Intestinal Anastomosis in Gangrenous Hernia, 721. Resection of Acromion in Disarticulation of Shoulder Joint, 352. Resection of Os Calcis in Disarticulation at the Tarsus, 361. Resection of Prolapsus Recti, 814. Sawing Out Curve-shaped Wedge in Resection of Knee Joint, 437. Sectio Alta, 776. Vasectomy, 802. Henle, Anatomy of the Antrum of Highmore, 485. Henneberg, Sterilizer, 16. Hepp, Odor Test, 173. Herinant, 1 in Splints, 102. Hessing, Healing in Pseudoarthrosis, 312. Hcyfelder, Needle for Resection of Upper Jaw, 479. Resection of Both Upper Jaws, 481. Hippocrates, Thoracotomy, 662. Hirsch, Stump to bear pressure, 334. Hirscliberg, Cystoplasty, 785. Hochenegg, Local Exclusion of Diseased Intestine, 711. CEsophagoplasty, 644. Resection of Sacrum, 821. Sacral Anus, 825. P'on Hoeter, Splints of Sheet Zinc, 102. Hoffa, Amputation of the Breast, 670. Arthrotomy for Congenital Dislocation of Hip Joint, 453. Hoffman, Longitudinal Division of Tonsils, 593. Rongeur Forceps, 455. Holscher, Ether Ansesthesia, 190. Holt, Divulsor, 758. Home, Wax Cast of the Urethra, 747. Hotnen, Thoracoplasty, 662. Hoppe-Seyler, Carbol Test, 25. Horsley, Cyrtometer, 466. Flexible Knife, 461. Instrument for Measuring Skull, 466. Houston, Cauterization of Hemorrhoids, 817. Stretching Facial Nerve, 509. Howard, Artificial Respiration, 186. H'libscher, Glued Cellulose Sheets, no. Skingrafting, 300. Hueter, Amputation of Leg, 373. Artificial Mouth, 527. Ligation of Lingual Artery, 259. Naso-pharyngeal Polypi, 577. Neuroplasty, 297. Paratendinous Suture, 293. Plastic Surgen,' for Restoring Tip of the Nose, 540. Prostatic Catheter, 753. Resection of Ankle Joint, 428. Resection of Elbow Joint, 406. Resection of Hip, 451. Resection of Knee Joint, 442. Resection of Rectum, 822. Restoring Septum of Nose, 541. Rhinoplasty, 534. Tendinoplasty, 295. Hulke, Operation for Ileus, 676. Hunter, Indirect Ligation of Arteries, 251. Ligation in Aneurism, 285. I Israel, Correcting Collapsed Noses, 542. Meloplasty, 528. Purulent Peritonitis, 675. Rhinoplasty, 538, 543. Ureterotomy, 746. J yaboulay, Exothyreopexia, 633. Jackson, Ether, 188. Jager, Metatarsal Disarticulation, 359. jfaenicke, Tetraboric Sodium, 28. Jaesche, Cheiloplasty, 521, 535. yassimowsky. Suture of Arteries, 290. Jobert, Invagination, 705. Joes, Finger Pressure during Vomiting in Anaes- thesia, 180. Jones, Ligation of the Isthmus in Goitre, 633. Jordan, Division of the Nose, 572. Juilhird, Ether Mask, 188. Operating Table, 16. Junker, Chloroform Apparatus, 176. Juracz, Nasal Speculum, 565. Septum Forceps, 580. K Kader, Gastrostomy, 684. Kappeler, Asphyxia in Anaesthesia, 183, 184. Chloroform Apparatus, 176. Cholecysto-enterostomy, 737. Kaufmann, Stretching Facial Nerve, 510. Keen, Omphalectomy, 732. Kelen, Ethylene Chloride, 192. Keller, Sterilization of Sponges, 12. Kingsley, Obturator, 559. Klein, Bullet Probe, 223. Kleinmann, Prothesis for the Nose, 538. Knapper, Intrabuccal Incision for Resection of the Upper Jaw, 477. Kny-Sprague, Perfection Sterilizer, 17. Koch, Cystoplasty, 787. Injury to the Brain by Hammering, 460. Resection of Symphysis, 776. INDEX OF NAMES 833 Steam Cooking Apparatus, 17. Sublimate, 25, 26. Syringe, 202. Kocher, Arthrectomy of Knee Joint, 389, 443. Bismuth, 34. Cachexia thyropriva, 626. Colostomy, 700. Division of Septum, 566. Drainage Tubes with Threads, 331. Enucleation Resection of Goitre, 631. Ethelyne-Bromide-Ether Anaesthesia, 192. Ether Spray, 193. Evacuation of Goitre, 630. Extirpation of Coccyx, 819. Extirpation of Palmar Fascia, 292. Extirpation of Tongue, 602. Exposing Antrum of Highmore, 486. Gastroduodenostomy, 689. Gastro-enterostomy, 694. Goitre Probe, 627. Instruments for Measuring Skull, 466. Invagination Displacement, 730. Juniper Catgut, 11. Ligation of Carotids, 258. Ligation of Inferior Thyroid Artery, 633. Ligation of Superficial Palmar Arch, 267. Ligation of Superior Thyroid Artery, 631. Ligation of Vertebral Artery, 262. Middle Meningeal Artery, 471. Nephrectomy, 740, 741. CEsophageal Diverticula, 644. Osteoplastic Resection of Both Upper Jaws, 483, 486. Oval Incision in Disarticulation of Shoulder Joint, 353. Prerectal Pointed Arch Incision, 780. Quilt Suture in Tendinorrhaphy, 293. Resection of Ankle Joint, 426. Resection of Elbow Joint, 408. Resection of Hip Joint, 449. Resection of Knee Joint, 435, 443. Resection of Lower Jaw, 488. Resection of Malar Bone, 498, 504, Resection of Pelvis, 454. Resection of Sacrum, 821. Resection of Shoulder Joint, 415. Resection of the Intestine, 707. Resection of Upper Jaw, 477, 478. Scabbard-shaped Trachea, 634. Strumectomy, 627. Temporal Incision, 475, 504. Transposing Hernial Sac, 729. Koeberle, Clamp Forceps, 246. Ferrum sesquichloratum (Ferric Chloride), 31. K'dhler, Anus Praeternaturalis, 713. Ferment Intoxication, 278. Operation for Varicocele, 800. Stirrup of Iron for Locating Central Sulcus, 466, 468. Transfusion of Blood, 218. Konig, Ankylosis, 492. Arthrectomy, 453. Chloride of Zinc Solution, 28. Colostomy, 701. Cystoplasty, 787. Ether-Chloroform Ansesthesia, 191. Flexible Canula for Tracheotomy in Struma, 635. Gliding Stirrup for Extension, 150. Longitudinal Division of Nose, 571. Magnesite Dressing, 112. Massage in Syncope, 187. Mouth Gag, 581. Operation for Harelip, 546. Operatioii for Hernia, 723. Plastic Splint for Club Foot, 433. Plastic Operation for Collapsed Noses, 542. Resection of Ankle Joint, 425. Resection of Hip Joint, 448. Resection of Skull, 464. Retroperitoneal Laparotomy, 742. Rhinoplasty, 535. Urethrostomy, 763. Korte, Operation for Hernia, 730. Kraske, Benzoic Acid, 30. Meloplasty, 528. Operation for Hernia, 723. Resection of Sacrum, 819. Retrograde Dilatation, 640. Krause, Resection of Ganglion Gasseri, 507. Skingrafting, 299. Kronecker, Infusion of Sodium Chloride, 278. Kronlein, Hasmatoma posticum, 470, Middle Meningeal Artery, 472. Resection of II and III Ramus of the Trigemi- nus, 505. Retrobuccai Method, 562, 505. Kucheni7jeister, Rhineurynter, 566. Kuhn, Neurectomy of the Inframaxillary Nerve, 501. Kilimnel, Galvanocaustic Excision of the Prostate Gland, 781. Operation for Ileus, 677. Kussmaul, Trocar, 657. Kuster, Amputation of the Breast, 670, 671. Ankylosis, 492. Atypical Amputation, 358. Cleft Palate, 558. Covering Orbit, 562. Epispadias, 790. 834 LNDEX OF NAMES Extirpation of Bladder, 776. Iodoform Collodion Dressing, 33. Modification of Pirogoff, 372. Nephrectomy, 741. Parallel Forceps, 686. Resection of Pharjnx, 610. Staphyloplasty, 557. Swan (Needle Holder), 209. Kitttner, Extiipation of Tongue, 604. Labor de. Artificial Respiration, 186. Gelatine Solution, 287. Lancereaux. Gelatine Solution for Aneurism, 287. Landau. Echinococcus of the Liver, 733. Landerer, Adhesive Piaster Dressing, 155. Extension Dressing for the Genu Valgum, 156. Hypospadias, 791. Infusion of Sodium Chloride Sugar, 278. Intestinal Suture, 705. Prostatic Forceps, 779. Resection of Os Calcis, 430. Varix Bandage, 287. Lane, Craniectomy, 461. Lange, Carbolic Acid Injection for Hemonhoids, 817. Circular Knife, 578. Exposing Kidney, 742. Extirpation of Fistula, 812. Forceps for Ligations, 744. Injection of Claret into the Rectum, 685. Knife Blade for Retrograde Dilatation, 640. Nephrolithotomy, 743. Rectoplication, 814. Von Langenbeck, A., Ligation of Inferior Thyroid Artery, 632. Von Langenbeck, Amputation of the Tongue, 600. Blepharoplasty, 515. Blunt Retractors, 57, 200. Bullet Forceps, 222. Cheiloplasty, 520, 523. Clamp Forceps, 817. Correcting Collapsed Noses, 542. Disarticulation of Thigh, 388. Distortion of Margins of Lips, 545. Double Hook, 617. Elevator, 391. Extirpation of Tonsils with Extirpation of the Jaw, 594. Extirpation of Varices, 288. Flap Knife, 324. Forceps, 391. Hemorrhage in Tonsillotomy, 593. Instruments for Staphylorrhaphy, 551. Lateral Pharyngectomy, 610. Ligation of Inferior Thyroid Artery, 632. Ligation of Innominate Artery, 651. Metacarpal Saw, 307, 392. Method of Restoring Alee of Nose, 539. Needle Holder, 554. Osteoplastic Resection of the Upper Jaw, 482. Oval Incision, 326. Operation for Harelip, 545, 548. Removing Nasal Pol>-pi by Ligation, 570. Resection of Ankle Joint, 424. Resection of Elbow Joint, 403, 405. Resection of Knee Joint, 437, 440. Resection of Leg with Lateral Skin Flap, 372. Resection of Nasal Process, 572. Resection of Olecranon, 409. Resection of Scapula, 418. Resection of Shoulder, 411. Resection of Upper Jaw, 478, 481. Resection of Wrist, 399. Retromaxillary Tumors, 577. Rhinoplasty, 531, 534, 539. Semilunar Flaps of Skin in Amputations, 324. Sharp Hook, 392. Staphyloplasty, 590. Staphylorrhaphy, 552, 553. Subhyoid Pharyngotomy, 608. Subperiosteal Resection, 390, 440. Suture Bearer, 551, 555. Temporary Resection of Lower Jaw, 600. Tripolith Dressing, 112. Uranoplasty, 555, 557, 590. Langenbuch, Constriction of Tongue, 599. Langeiibucli, Trichloride of Iodine, 30. Applying Indirect Ligature, 518. Cholecystectomy, 735. Cystotomy, 776. Resection of the Liver, 733. Subhyoid Laryngotomy, 615. Supramaxillary Nerve, 497. Lannelongue, Craniectomy, 461. Solution of Chloride of Zinc in Pseudoarthroses, 312. Uranoplasty, 556. Laplace, Sublimate Gauze, 27. Lassar, Paste for Eczema, 49. Laitb, Hip Rest, 55. Lanenstein, Closure in Anus Praeternaturalis, 713. Resection of Foot, 428. Resection of Pylorus, 686. Sectio Mediana, 778. Tliumbless Hand, 340. Larrey, Disarticulation of Shoulder Joint 353. Disarticulation of Thigh, 386. INDEX OF NAMES 835 Lawrefice, Turning Xose upward, 574. Lawson Tait, Paraffin Dressing, 112. Cholecystectomy, 735. Cholecystostomy, 734. Lazarsky, Sublimate Gauze, 26. Lecluse, Elevator, 585. Lecomte-Luer, Exploring Instrument for Bullets, 223. Ledderhose, Splenectomy, 739. Le Dentil, Ankylosis, 491. Lee^ Metal Splints, 102. Le Ford, Electropuncture in Pseudoarthroses, 312. Modification of Pirogoff, 372. Leisriiik, Echinococcus of the Liver, 733. Sphagnum Pasteboard, 42. Lembert, Serous Suture, 679, 702. Leroy d' Etiolles, Adjustable Curette, 564, 766. Catgut Strings, 797. Letievant, Neuroplasty, 297. Levis, Operation for Hydrocele Testis, 798. Levy, Resection of Sacrum, 822. Levain, Cloth Saturated with Vinegar, 178. Von Leyden, Permanent Tube for CEsophagus, 640, 641. Liebreick, Electric Bullet Probe, 223. Li?idemann, Echinococcus of the Liver, 733. Linhart, Xeurectomy of Inframaxillary Xerve, 501. Link, Preserving Toes, Chopart Disarticulation, 361. Suture, 214. Lisfranc, Disarticulation of Foot, 357. Extirpatio Ani, 818. Tarso-Metatarsal Disarticulation, 364. Lister, Antiseptic Treatment, 23. Boric Acid, 28. Boric Salve, 28. Button Suture, 216. Carbolic Acid, 23. Carbolized Oil, 11. Chloride of Zinc, 27, 28. Chromic Acid, 29. Compress, 41. Drainage Forceps, 28. Eucalyptol, 32. Healing under the Scab, 38. Protective Silk, 44. Splint for Resection of Wrist, 145. Spray, 2. Sublimate Gauze, 26. Liston, Bone Cutting Forceps, 330, 480, 613. Listofi, Maclntyre's Splint, 143. Extension Splint, 146. Resection of Elbow Joint, 403. Little, Plastic Splint for Clubfoot, 433. Littre, Colostomy, 700. Lobker, Exposing Facial Xerve, 509. Resection in Tendinorrhaphy, 295. Spoon Elevator, 451. Longmore, Bullet Probe, 224. Lorenz, Congenital Dislocation of Hip Joint, 453. Osteoclast, 306. Loret, Wire Snare, 570. Loreta, Pyloroplasty, 696. Resection of the Liver, 733. Lorinser, Phlebotome, 283. Lassen, Resection of Malar Bone, 498, 504. Lotheisen, Ethylene Chloride Anaesthesia, 192. Louis, Circular Amputation by Two Incisions, 322. Lowdham, Amputation by Skin Flap Incision, 324. Liicke, Gastro-enterostomy, 693. Lingual Xerve, 506. Neurectomy of Inframaxillary Xerve, 500. Osteoplastic Xecrotomy, 315. Parallel Forceps, 686, 707. Resection of Malar Bone, 498, 504. Resection of Spleen, 739. Sugar, 35- Lud-wig, Infusion of Sodium Chloride, 278. Liier, Gouge Forceps, 330, 455. Hemorrhoidal Forceps, 815. Lip Holder, 581. Lithoclast, 778. Tracheal Canula, 618. M Alaas, Amputation of the Breast, 670. Extirpation of Larynx, 623. Ligation of Aorta, 269. Operation for Harelip, 546, 548. Sublimate Gauze, 27, 31. McBurney, Epityphlitis, 711. Mac Ewen, Acupuncture in Aneurism, 287. Operation for Hernia, 723. Osteotome, 307. Resection of Skull, 463. Supracondylic Osteotomy, 308. Mac Gill, Prostatectomy, 780. Machityre, Splint, 143. Macleod, Atresia Ani, 806. Macnamara, Tamponing Xose, 568. McBurney, Adjustable Telescopic Hip Rest, 50. Madelung, Cartilaginous Plate Suture, 705. Colostomy, 701. Ether-Chloroform Anaesthesia, igi. Extirpation of Varices, 288. Inguinal Anus, 701. Resection of Intestine, 707, Tendinorrhaphy, 293. 836 INDEX OF NAMES Maisoniieiive, Enteroanastomosis, 708. Pharyngeal Tumors, 576. Urethrotome, 759. Major, Triangular Cloth, 170. Ma/gaigne,. Disarticulation of Foot, 371. Operation for Harelip, 545. Resection of Upper Jaw, 478. Subhyoid Pharyngotomy, 608. Manec, Disarticulation of the Thigh, Puncture Method, 383. Mamie, Pharyngeal Tumors, 576. Alariz, Regionary Analgesia, 194. Marshall, Osteotribe, 312. Marshall Hall, Artificial Respiration, 186. Manvedel, Oblique Fistula, 683. Matthieu, Laryngeal Forceps, 637. TonsiHotome, 592. Urethra! Forceps, 766. Mathysen, Plaster of Paris Dressing, 113. Maunouiy, Lower Oral Route, 603. Maydl, Colostomy, 700. Doudenostomy, 695. Extirpation of the Bladder in Ectopia, 788. Mayor, Cloth Bandages, 84. Cloth Bandage for Fracture of the Patella, 94. Mears, Ankylosis, 492. Vasectomy, 802. Merchie, Moulded Pasteboard Splints, 108. Mercier, Prostatic Catheter, 753. Menvel-Schneider' s Extension Apparatus, 305. Meusel, Urethroplasty, 766. Meyer, Amputation of the Breast, 668. Adenoid Vegetation, 577. Circular Knife, 578. Michael, Compressed Sponge Canula, 621, Naso-Pharyngeal Forceps, 579. MUulicz, Compressory Instrument for the Tonsils, 594- Correcting Collapsed Noses, 543. Cystoplasty, 786. Extension Dressing for the Genu Valgum, 157. Extirpation of the Sternocleidomastoid, 646. Extirpation of Tonsils, 595. Nephropexy, 746. Oil of Turpentine in Pseudoarthroses, 312. Operation for Aneurism, 286. Operation for Ileus, 677. Pyloroplasty, 696. Resection of Goitre, 630. Resection of Prolapsus of the Rectum, 813. Stylet for Antrum of Highmore, 486. Tamponing Dead Spaces, 40, 675, 739. Tarsectomy, 431. Temporary Resection of Lower Jaw, 502. Middeldorpf, Akidopeirastik, 202. Galvanocautery, 206. Triangle, 145. Millon, Reagent, 25. Alirault, Operation for Harelip, 545. Mitscherlich, Cement Dressing, 112. Morgan, Cheiloplasty, 523, 524. Morton, Ether, 188. Von Mosetig, Fistulous Forination in Cleft Palate, 558. Iodoform, 32. Lactic Acid, 208. Motais, Pointed Instrument for Supplying Finger Nail, 578. Mott, Ligation of Innominate Artery, 654. Midler, Plastic Operations on Bones, 310. Resection of Skull, 464. Struma Cystica, 626. Murphy, Intestinal Button, 695, 705. Intestinal Button in Gastro-enterostomy, 695. Murray, Ligation of Aona, 269. Muzeiix, Tenaculum Forceps^ 591, 687. N Nebhiger, Tendinorrliaphy, 294. Nelaton, Abduction Splint, 97. Catheter, 752. Cystoplasty, 785. Inversion in Syncope, 187. I ithotrite, 766. Operation for Harelip, 544. Probe, 223. Resection of Elbow Joint, 408. Resection of Hard Palate, 576. Resection of Upper Jaw, 478. Rhinoplasty, 536. Transverse Perineal Incision, 778. Urethroplasty, 765. Neither, Cystorrhaphy, 775. Intestinal Suture, 704. Inversion Suture, 315. Glass Splint, 105. Peat Mull, 42. Neudorfer, Apolysis, 393. Shoemaker Shavings, 121. Nicaise, Elastic Band, 227. Nicoladoni, Resection of Rectum, 821. Nikolaysen, Acupuncture in Pseudoarthroses, 312. Nothnagel, Sodium Chloride to produce Antiperi- staltic Motion, 694. Von Nussbaum, Adhesive Plaster, 217. Ligation of Aorta, 270. Protective Silk, 39. INDEX OF NA.AIES 837 Peroxyde of Hydrogen, 243. Suturing Sigmoid Fiexure, 677. O Obalmski, Tarsectomy, 431. Oder lander. Dilatator, 758. Oberst, Meloplasty, 527. Regionary Analgesia, 194. Oesterlein, Dysmorphosteopalinclast, 306. Ogsto/i, Arthrodeses of Astragalo-Navicular Articu- lation, 434. Oilier, Correcting Collapsed Noses, 543. Ether, 188. Resection of Elbow Joint, 407. Resection of Hip, 452. Resection of Os Calcis, 429. Resection of Scapula, 418. Resection of Shoulder Joint, 415. Subperiosteal Enucleation of Os Calcis, 366. Subperiosteal Resection, 390. Turning Nose upward, 574. Olshausen, Splenectomy, 739. Oppler, Pulverized Coffee, 35. Otis, Arresting Hemorrhage in Urethrotomy, 761. Endoscope, 757. Litholapax-y, 784. Urethrometer, 754. Urethrotome, 759. Overlach, Injection Syringe, 202. Pagenstecher, Celluloid Flax Thread, 210. Paget, Thoracotomy, 661. Pancoast, Aorta Tourniquet, 238. Paquelin, Thermocautery, 204. Paravicini, Exposing Lingual Nerve, 506. Parker, Operation for Varicocele, 800. Partsch, Resection of Lower Jaw, 490. Resection of Palate, 576. Passavant, Cystoplasty, 787. Palato-pharyngeal Suture, 558. Suturing Device for Staphylorrhaphy, 555. Paul von Aegina, Detaching Cartilaginous Meatus, 564- Pean, Clamp Forceps, 246. Splenectomy, 739. Peter Franco, Cystotomy, 770. Petersen, Circular Incision for Varices, 228. Cystotomy, 772. Hallux Valgus, 420. Oxide of Zinc, 34. Resection of Septum, 580. Overcorrection, 153. Petit, Boot, loi. Circular Amputation by Two Incisions, 320, 322. Fracture Box, 62, 140, 143. Screw Tourniquet, 238. Phelps, Operation for Clubfoot, 292, 433. Pictet, Ether, 188. Pinner, Arrest for Propagation of Schizomycetes, 29. Pirogoff, Bridge Plaster of Paris Dressing, 128. Disarticulation of Foot, 36. Etherization per Rectum, 190. Nasal Bridge, 569. Strips of Plaster of Paris Bandage, 114. Transcondylary Amputation, 348. Pitha, Oral Wedge, 581. Plessing, Blepharoplasty, 515. Pollard, Enucleation of Tonsils, 593. Poncet, Cystostomy, 769. Gastropexy, 679. Urethrostomy, 763. Ponfick, Regeneration of the Liver, 733. Pooley, Carbolic Acid Injection for Hemorrhoids, 817. Popperf, Cystoplasty, 786. Port, Splints of Sheet Zinc, 102. Porta, Enucleation of Goitre,- 630. Porter, Sawdust, 42. Telegraph Wire Splints, 103, 162, 164. Potai?i, Aspiration, 659. Pott, Side Position, 139. Splints, 99. Pozzi, Cystoplasty, 786. Pravaz, Syringe, 202. Priessnitz, Compresses, Cataplasms, 44, 63. Prince, Cuneiform Tarsectomy, 433. Q Quimby, Modification of PirogofTs Amputation, 372. Quincke, Aspiration Drainage, 660. Lumbar Puncture, 195, 470. Pneumotomy, 664, 665. R Ramm, Hypertrophy of the Prostate Gland, 802. Ranke, Thymol, 30. Rawa, Paraneurotic Suture, 297. Recainier, Cheiloplast}', 524. Rectus, Cocaine Analgesia, 194. Regnier, Cheiloplasty, 524. Regnoli, Extirpation of Tongue, 602. Rehn, Irrigating Stomach in Ileus Operation, 677. Resection of Rectum, 821. Suturing Wound of the Heart, 666. Reid, Arresting Circulation in Aneurism, 285. Reiner, Amputation Saw, 327. 838 INDEX OF NAMES Keismann, Stretching Margins of Tracheal Wound, 658. Von Rem, Abduction Box, 141, 142. Reverdin, Skingrafting, 298, 299. Reybard, Thoracocentesis, 658. Richardson, Ether Spray, 192, 193. Ricord, Forceps for Phimosis, 235. Operation for Varicocele, 801. Removing Polj-pi by Ligation, 57a Ried, Hanging Head, 584. Riedel, Cholecystostomy, 735. Morphine Ether Anaesthesia, 191. Xephropex}', 745. Ries, Margins of Plaster of Paris Dressing, 117, 118. Rietschel and Henneberg, Sterilizer, 16. Rizzoli, Ankylosis, 492. Osteoclast, 306. Proctoplasty in Atresia Ani, 807. Roberts, Pericardial Puncture, 665. Trephining, 457. Robin, Osteoclast, 306. Rolando, Location of Central Fissure, 465. Rontgen, Ray, 219, 223, 767. Rose, Enucleation of Goitre, 631. Extirpation of Thigh, 386. Hanging Head, 477, 500, 584. Posterior CcEliectomy, 821. Strumectomy, 626. Uranoplasty, 590. Rose, W., Resection of Ganglion Gasseri, 507. Rosenberg, Anaesthesia, 180. Roser, Apron Bandage, 89, 92. Apron Bandage for the Hip, 93, 94. Bone Cutting Forceps, 459, 589. Bone Screw with Hook, 459. Deviation of Septum, 579. Dilating Forceps in CEsophagotomy, 643. Diiator, 57. Dorsal Splint, 98. Empyema, 663. External Urethrotomy, 764. Gag. 183. Incision for Phimosis, 792. Iron Wire Splints, 103. Mouth Gag, 581. Needle Holder for Staphylorrhaphy, 555. Resection of Elbow Joint after Treatment, 410. Stomatoplasty, 527. Three Handed Chiselling, 487. Transverse Division of Cheek, 506. Uranoplasty', 590. Rotgans, Intrabuccal Incision in Resection of the Upper Jaw, 477. [ Rotter, Abscesses of Tonsils, 594. Extirpation of Larjnx, 625. Pastils, 32. Rouge, Temporal Detachment of Nose, 573. Roux, Needle Holder, 209, 555. Rupprecht, Deviation of Septum, 580. Rush Medical College, Sublimate Tablets, 27. Ruysch, Disarticulation of Wrist, 343. De Ruyter, Iodoform Ether Alcohol, 33. Rydygier, Amputation of the Breast, 671. Cystoplasty, 786. Excision of Gastric Ulcers, 678. Inferior Thyroid Artery, 632. Intestinal Clamps, 686, 707. ' PirogofFs Disarticulation, 368. Plastic Ofjeration on Bones, 310. Resection of Sacrum, 822. Resection of the Pylorus, 685, 689. Splenopexy, 739. Superior Thyroid Arten.-, 631. Sabanejeff, Intracondylic Osteoplastic Amputation, 364, 380. Saenger, Transperitoneal Nephrectomy, 745. Sahli, Infusion, 280. Salmon, English Truss, 714. Salomon, Tin Splints, loi. Salter, Local Exclusion of Diseased Intestinal Part, 710. Operation for Femoral Hernia, 731. Resection of Malar Bone, 504. Samter, Removing Projecting Premaxiliary Bone, 551. Sauer, Nasal Prothesis, 538. Sayre, Adhesive Piaster Bandage for Fracture of Clavicle, 155. Elevator, 391. Extension Dressing for Knee Joint, 157. Extension for Scoliotic Spine, 152. Jury Mast, 158. Plaster of Paris Corset, 119. Taylor's Extension Apparatus, 158. Scarpa, Herniotomy, 720. Schaffer, Taylor's Extension Apparatus, 158. Schede, Congenital Dislocation of Hip, 453. Healing under the Scab, 38. Ligature of Veins, 289, 290. Moist Blood Clot after Necrotomy, 315. Operation for Hernia, 723. Radius Splint, no. Resection of Hip Joint, 450. Resection of the Pylorus, 686. Silver Wire, 674. Spun Glass Wool, 44. INDEX OF XA.MES 839 Sublimate Gauze, 26. Thoracoplasty, 662. Varices, 288. Vertical Extension, 150. Scheuer, Fracture Box, 143, 144. Schiltsky, Obturator for Palate, 559. Schlinmelbusch, Mask, 175. Rhinoplasty, 535, 536, 543. Sterilization of Instruments, 7. Sterilization of Sponges, 12. Tin Box for Sterilized Silk, 10. Schlange, Cystoplasty, 786. Resection of Sacrum, 822. Sckleich, Infiltration Ansesthesia, 195, 588, 6S5. Solutions, 196. Schmidt, Exploratory Perforation of the Skull, 469. Longitudinal Division of the Tonsils, 593. Schmucker, Refrigerating Mixture, 63. Schneider-Mennel, Extension Apparatus, 305. Schnyder, Cloth Splints, 96. Sckoeh, Circular Knife, 579. Sckoen, Splints of Sheet Zinc, 102. Sckonborn, Colostomy, 701. Staphyloplasty, 558. Schuh, Extirpation of Ranula, 604. Schulten, Amputation of the Tongue, 604. Sck'dller, Artificial Respiration, 185. Extirpation of the Parotid Gland, 606. Neurorrhaphy, 297. Schulze, Eucalyptus Gauze, 32. Schwab, Gaslrotomy, 678. Scultet, Bandage, 73, iii, 113, 157. Sedillot, Cheiloplasty, 525, 526. Gastrostomy, 680. Resection of Lower Jaw, 602. Tendinorrhaphy, 293. Semmelweiss, Chloride of Lime, 31. Senn, Boric and Salicylic Acid, 35. Decalcified Chips of Bone, 315. Direct Fixation of Bones, 310. Disarticulation of Thigh, 386, 388. Entero-anastomosis, 709. Hydrogen Gas for Intestinal Wounds, 706. Intestinal Suture, 705. Operation for Varicocele, 800. Osteoplastic Resection of Skull, 463. Shortening Mesentery by Folding, 677. Senn, E. y.. Gastrostomy, 684. Incision for Amputation of the Breast, 668. Seiitin, Starch Dressing, iii. Von Siebold, Suspension Apparatus, 55. Silvester, Anificial Aspiration, 185. Simon, Dilatation of Anus, 805. Dilatation of Female Urethra, 778. Nephrectomy, 740. Operation for Cleft Palate, 550. Operation for Echinococcus of the Liver, 732. Rectal Speculum, 804. Operation for Empyema, 662. Simpson, Chloroform, 172. Sims, Vaginal Speculum, 804. Skinner, Chloroform Apparatus, 175. Smith, Extirpation of Rectal Fistula, 812. Hemorrhoidal Forceps, 815. Pasteboard Splints in Urethrotomy, 761. Socin, Enucleation of Goitre, 630. Gastro-enterostomy, 692. Oxide of Zinc Paste, 35. Retrograde Dilatation, 640. Skingrafting, 301. Supporting Apparatus for Loose Freely Movable Joint, 410. Sonnenbiirg, External Rectotomy, 808. Extirpation of the Bladder in Ek:topia, 788. Lingual Nen^e, 506. Neurectomy of the Inframaxillary Ner\-e, 500. Treatment of Cavities, 665. Soulier, Ethylene Chloride Anesthesia, 192. Spencer- Wells, Artery Forceps, '>\ \ . Spitzka, Exploratory Puncture of the Brain, 470. Sporon, Tendinoplasty, 296. Stacke, Exposing Lateral Chambers of Antrum, 474- Stapler, Suture, 214. Starke, Etherization per Rectum, 190. Permanent Irrigation, 60. Steiner, Middle Meningeal Arten-, 472. Stephan, Extirpation of Rectal Fistula, 812. Stille, Bone Nipping Forceps, 459. Operating Table, 771. Stilling, Pyoctanin, 32. Storp, Operation for Hydrocele, 800. Strong, Cystotomy, 770. Strotneyer, Arm Pillow, 144. Arresting Hemorrhage in Struma, 626. Needle Holder in Staphylorrhaphy, 555. Oblique Bed for Caput Obstipum, 645. Padded Strips of Wood for Splints, 97, 98. Phlebostatic Hemorrhage, 247. Tenotomy, 290. Tenotomy of the Stemo Cleido Mastoid, 644. Suersen, Obturator for Palate, 559. Syme, Aneurism Needle, 253. Disarticulation of Foot, 364. Grooved Sound, 763. Intracondylic Amputation, 379. Resection of Upper Jaw, 478. 840 INDEX OF NAMES Szy m allows ky. Cloth Bandage for Fracture of Clavicle, 89,91, 119. T Tagliacozza, Rhinoplasty, 537. Tdit, Cholecystotomy, 734. Paraffin Dressing, 112. Tauber, Modification of Pirogoff, 371. Tavel, Solution, 673. Taylor, Extension Apparatus, 158. Textor, Resection of Knee Joint, 435. Thane, Ascertaining Location of Central Fissure, 465. Thiersch, Blepharoplasty, 515. Butterfly, 549. Cystoplasty, 785. Epispadias, 788. Extraction of Nerves, 493. Forceps, 494, 500. Improvised \\'ound Douche, 20. Meloplasty, 527, 528. Pearl Suture, 216. Rhinoplasty, 532, 534, 536, 539. Salicylic Acid, 28, 29. Silver Ring in Prolapse, 813. Skingrafting, 299, 300, 302, 304. Sodium Chloride Solution, 301. Spindle for Ligations, 744. Uranoplasty, 590. Thompson, Digital Palpation of the Bladder, jjj. Dilator, 758. Prostatic Forceps, -jyj. Suture of Bladder, 775. Urethral Forceps, 766. Thornton, Nephrectomy, 740. Tichow, Suture of Veins, 289. Tiemann, Flexible Laryngeal Forceps, 637. Tillaux, Tendinoplasty, 295. Tillmanns, Chloroform, Ether, 192. Ignipuncture, 288. Oral Speculum, 582. Tiling, Resection of Hip, 452. Nasal Protheses, 538. Tomasi, Carbol Test, 25. Tonnasko, Suture, 214. Trager, Exploratory Puncture of the Brain, 470. Trelat, CEsophagotome, 641. Trendelenburg, Cheiloplasty, 521, 522, 524. Cystoplasty, 787. Disarticulation of Thigh, 386. Drainage of the Bladder, 776. Gastrostomy, 681. Ligation of the Long Saphenous Vein, 288. Operation for Hydronephrosis, 745. Pelvic High Position, 771. Position in Resection of the Intestine, 714. Resection of Olecranon, 409. Staphyloplasty, 558. Supramalleolar Osteotomy, 309, 434. Tampon Canula, 477, 621. Tricomi, Gastrostenoplasty, 679. Tripier, Blepharoplasty, 516, 517. Trommsdorff, Hydrogen Peroxide, 32. Sozoiodol, 35. Trousseau, Probe, 639. Trnka, Tendinorrhaphy, 294. Tuffier, Extrapleural Palpation, 664. Turk, Tongue Depressor, 565, 582. Turner, Instrument for Measuring the Skull, 466. Plaited Silk, 210. U Unna, Gauze Sash, 89, 93. V Vanlair, Neuroplasty, 298. Veiel, Glue Dressing, 112. Velpeau, Bandage for Fracture of the Clavicle, 80. Neurectomy of Inframaxillary Ner\'e, 501. Resection of Both Upper Jaws, 481. Verduin, Forming Flaps by Transfixion, 325. Verneuil, Chlorinated Soda, 31. Dilatation of the Anus, 817. Extirpation of Coccyx, 805. Linear Rectotomy, 825. Lower Oral Route, 603. Rectopexy, 814. Rhinoplasty, 534. Vetsch, Disarticulation of Thigh, 386. Viborg, Ligation of Salivary Duct, 608. Vidal, Cystotomy in Two Stages, 773. Herniotomy, 720. Vogt, Ligation of Superficial Palmar Arch, 268. Middle Meningeal Artery, 471. Resection of Astragalus, 428. Resection of Wrist, 398. Resection Splint (Watson's), 100, loi. Volcker's Cooling Experiments, 66. Stick Tourniquet, 241. "Tapetenspan " for Plaster of Paris Dressing, 121. Von V^olkmann, Arthrectomy, 389. Dorsal Splint, 134. Dressing after Amputation of the Thigh, 382. Drop Canula, 60. Echinococcus of the Liver, 732. Extension Apparatus for the Cervical Portion of the Spine, 151. Ischemic Paralysis of Muscles, 68. Knee Splint, loi. INDEX OF XA.MES 841 " Kriill " Gauze, 41. Operation for Hydrocele Testis, 798. Resection of Knee Joint, 440. Resection of Sacrum, 821. Sharp Retractor, 200. Sharp Spoon, 203. Sleigh Apparatus, 148. Subtrochanteric Osteotomy, 308. Supination Splint, 100, loi. Suspension Apparatus for Injured Arm, 167. Suspension Frame, 55. Suspension Splint, 61, 151. T Splint, 100, loi, 165. Tenotomy of the Sternocleidomastoid, 644. Tin Splints, 149. Wire Sling, 60. Voltolini, Immersion Batten,', 206. Uvula Forceps, 566. W Wagner, Hollow Elevator, 479. Resection of Skull, 463, 507. Von Walther, Lateral Flap Incision, 341. Ligation of Arteries in Enucleation of Goitre, 631. Radial Flap Incision (Wrist), 344. Walton, Haynes, Extension Dressing, 146. Wardrop, Ligation of Arteries, 286. Warren, Uranoplasty, 556. Watson, Drainage Tube for the Prostate Gland, 779. Resection Splint, 100, loi. Suspension Splint, 133. Weber, Osteoplastic Resection of the Upper Jaw, 483. Resection of Upper Jaw, 478. Rhinoplasty, 540. Wehr, Intestinal Clamp, 686. Weinlechner , Mouth Gag, 581. Weir, Gastroplication, 679. Weiss, Fishbone Catcher, 638. WAite, Hj^pertrophy of the Prostate Gland, 802. Resection of Hip Joint, 445. Whitehead, Amputation of the Tongue, 600. Oral Speculum, 551, 582, 600. Taylor's Extension Apparatus, 158. Wilde, Wire Snare, 57c. Wille, Bone Suture, 310. Willemer, Arthrectomy, 389. Wilson, Instrument for Measuring the Skull, 466. Von Winiwarter, Cholecysto-enterostomy, 737. Witzel, Colostomy, 701. Gluteal Colostomy, 825. Gluteal Rectostomy, 825. Oblique Fistula, 682, 769. Preserving Toes in Chopart's Disarticulation, 561, 362. Tendinorrhaphy, 294. Wladimiroff, Tarsectomy, 431. Wolberg, Needles, 294. Wol/e, Blepharoplasty, 515. Skin Grafting, 299, 531. Wolff, Distortion of the Margins of the Lips, 545. Cleft Palate, 551. Extirpation of Larynx, 625. Obturator for Palate, 559. Operation for Harelip, 545. Phonetic Canula, 624. Strictures of the CEsophagus, 640. Wolfier, Anatomy of the Xeck, 629. Blepharoplasty, 517. Cheiloplasty, 524. Dislocation of Goitre, 633. Gastro-anastomosis, 697. Gastro-enterostomy, 689, 690. Gastroplasty, 696. Gum Arabic Chalk Dressing, 112. Inferior Thyroid i\rtery, 632. Internal Intestinal Suture, 704. Ligation of Arteries in Enucleation of Goitre, 631. Operation for Hernia, 728. Parasacral Incision, 824. Resection of the Pylorus, 685, 689. Tendinorrhaphy, 294. Wright, Fibrin Ferment as Styptic, 243. Wyeth, Disarticulation of Thigh, 386. Wyzuodzoff, Plaster of Paris Bandage Machine, 115. Zaufal, Nose Funnel, 565. Zeis, Rhinoplasty, 531. Zerssen, Cooling Experiments, 66. Von Ziemssen, Phrenic Faradization, 186. Zuckerhandl, Parasacial Incision, 823. Perineal Prerectal Incision, 779. Resection of the Rectum, 822. INDEX OF SUBJECT-MATTER Abdomen, Opening the, 673. Operation on the, 672. Puncture of the, 672. Abdominal Cavity, Opening of the, 673. Abduction Box, 141. Splint, 97. Ablatio Mammae, 667. UvuIk, 595- Accidents, Unpleasant, during Anaesthesia, 179. Acid, aseptinic, 31. Acupuncture in Aneurism, 287. for forming Osseous Callus, 312. Adetioid Vegetations in the Naso-pharyngeal Cavity, 577. Adhesive Iodoform Gauze, 33. Adhesive Plaster for Wounds, 217. Adhesive Plaster Loop, 147. Dressing for Fracture of the Clavicle, 155. Aditus ad Antrum, Opening of the, 474. Agaric, 243. Agglutinative Bandages, 45. Air Cushion, 51. Air Embolism in Operations on the Xeck, 649. Air Infection, 2. Air Passages, Opening of the, 612. Akidopeirastik, 202. Alabaster Gypsum, 1 13. Alar Splint, 107. Alcohol, 32. Alligator forceps for the Urethra, 766. Alum, 31. as an Escharctic, 207. Aluminum Acetate, 28, 59. Acetico-tartaricum, 29. Splints, 102. Alveolar Process of the Upper Jaw, Resection of the, 476. of the Lower Jaw, Resection of the, 487. Amputation, 316. of the Arm, 348. of the Forearm, 344. of the Leg, 372. of Limbs, 316. of the Scapula, 419. of the Thigh, 383. of the Tongue, 599. of the Tonsils, 590. of the Penis, 796. of the Uvula, 595. Indication for, 316. Intracondylic, 379. Knives, 319. Malleolar, 364. Metatarsal, 355. Osteoplastic, 374, 380. Saw, 327. Supracondylic Osteoplastic, 379. Tibiocalcanea Osteoplastica, 367. Transcondylar of the Arm, 348. Anasthesia, Action of the Surgeon during Serious Accidents, 182. Awakening from an, 178, 189. Bromoform, 192. By Means of Cocaine, 194. Chloroform, 172. Chloroform-ether, 191. Chloroform Mixture, 191. Combined, 191. Course of Chloroform, 176. Dangers in Ether, 189. Ether, 188. Ethylene Bromide, 192. Ethylene Chloride, 192. General, 172. Infiltration, 195. Pental, 192. Preparations for, 173. Unpleasant Accidents in, 179. Analgesia, Local, 192. Regionary, 194. Anal Perineal Incision, 764. Anastomosis of Xers'es, 298. of Tendons, 296. Anatomy of the Axilla, 669. of Centres of the Brain, 465. 843 844 INDEX OF SUBJECT-MATTER of the Head and Neck, 647, 648. of the Inguinal Region, 716. of the Parotid Gland, 606. of Lower Surface of the Liver, 736. of the Pelvic Organs, 803. of the Perineal Region, 763." of the Recurrent Nerve, 629. of the Rectal Fistula, 810. of the Region of the Larynx, 622. of the Renal Region, 743. of the Soft Palate, 553. of the Thorax, 656. of the Trigeminus, 495. of the Urethra, 748, 749. of the Veins of the Head, 628. Crural Arch, 717. Mastoid Process, 474. Temporo-maxillary Articulation, 491. Topographical, of the Innominate Artery, 651. Aneurism, Extirpation of, 286. Ligation of, 285. Needle, 253. Operation for, 283. Angiotripsy, 247. Angular Incision for Resection of Elbow Joint, 407. Angular Scissors, 201. Spatula, 582. Ankle, Splint for Fracture of the (L)upuytren's), 146. Ankle-joint, Resection of, 421. Iron Arch Splint for Resection of (von Es- march's), 136. Plaster of Paris Suspension Splint for Resec- tion of, 133. Ankylosis, Operation for, 491. Antiphlogistic Treatment, 61. Antipyrine as an Analgetic, 195. Antiseptics, 22. Antisepsis, 2, 22. in War, 168. Primary, 36. Secondary, 57. Antrum, Opening Lateral Chambers of the, 474. Antrum of Higkmore, Opening of the, 485. Tympanicum Opening of the, 474. Anus Arlihcial, Formation of an, 699. Dilatation of, 804, 805. Extirpation of, 817, 818. Formation of an Opening of the, S06. Inguinal (Littre), 700. Operations on the, 803. Narrowing Dilated, 814. Praeternaturalis, 712. Strictures of the, 809. Aorta, Abdominal, Ligation of, 269. Tourniquet, 238. Apolysis after Resection, 393. Appendicitis, Operation for, 71 1. Applying of Bandage, 69. Apron Bandage. 89, 94. Aqua, Binelli, 30. Chlori, 30. Goulardi, 29. Arch Splint, Iron, 136. Divided Iron, 136. Arches of Sheet Iron, 127. Argenlum Xitricutn as a Caustic, 207. Aristol, 35. Arm, Amputation of, 348. Bandaging of the Whole, 77. Bath, 14. Pillow, 144. Splint, 105. Splint for the (at an oblique angle), 98. Tub, 14. Arsenic, Caustic Powder, 208. Paste, 208. Arteries, Aneurism, 2S5. Anterior Tibial, 275. Axillary, 264. at the Bend of the Ell^ow (Arteria ajicojiea'), 265. at the Place of Selection, 251, Brachial, 265. Common Carotid, 256. Common Iliac, 270. Compression of, 235. External Carotid, 257. External Iliac, 272. External Maxillary, 258. Femoral, 272. Internal Carotid, 258. Internal Iliac, 271. Ligation of, 251. Ligation of Abdominal Aorta, 269. Ligation of Po]iliteal, 275. Ligation of Ulnar, 266. Lingual, 258. Occijiital, 259. Opening Sheath of, 252. Posterior Tibial, 276. Radial, 266. Subclavian, 259. Superior (Jluteai, 271. INDEX OF SUBJFXT-MATTER 845 Sciatic, 271. Superficial Palmar Arch, 267. Suture of, 289. Temporal, 258. Topography of, 248-250. Torsion of, 246. Vertebral, 262. Artery Compressor (Tourniquet), 236. Improved, 240. Artery, Dorsal, of the Foot, 276. Forceps, 244. Hypogastric, Ligation of, 782. Inferior Thyroid, Ligation of, 632. Innominate, Ligation of the, 651. Mammary Internal, Ligation of, 652. Middle Meningeal, Ligation of, 470, 507 Superior Thyroid, Ligation of, 631. Arthrectomy, 389. of the Knee Joint, 443. Arthrodesis, 389. in Flat Foot, 434. Artindations, Resection of, 389. Dividing of, 358. Artificial Anus, 806. Larynx, 624. Limb (Prothesis), 334. Mouth, 527. Nose, 538. Oedematization, 195. Respiration, 185. Tongue, 604. Asepsis, 2. Ideal, 22. of Surgeon, 3, 4. Aseptic Operation, 18. Aseptin, 31. Aseptinic Acid, 31. Aseptol, 31. Ashes, 42. Asphyxia, Paralytic, 180. Spastic, 180. Aspiration of the Lungs, 665, with Aspirator, 658. Aspirator, 659. Astragalonavicidar Articulation, Arthrod the, 434. Astragalus, Disarticulation below the, 362. Resection of the, 428. Atheromatous Cysts, 646. Atmokausis, 243. Atresia Ani, 806. Auditory Meatus, Foreign Bodies in the nal, 563. Auricle, Detaching of the, 564. Autoplasty on the Skull, 463. Autotransfusion, 281. Awakening from an Anesthesia, 1 78. Axilla, Clearing out of the, 667. B Back Bandage, 89. Back Rest, Adjustable, 51. Baiid, Elastic, 225. Bandage, Applying of, 69, 70. Bilateral Compressive, for the Breast, 81. Binoculus, 75. Compressive, for the Breast, 81. Cross Turn, 72. Elastic, for Bloodless Method, 225. Elastic, for Dressing, 44. Fastening of, 70. Figure-of-8 Turn of, 72. for the Breast, 81. for the Whole Breast, 89, 90. Gaping, 69. Halter, 74. for the Leg, 82. Linen for Bloodless Method, 232. Material, 45. Roller, 70. Scultet's Many-tailed, 73. Turns of, 71. Unwrapping of, 70. Bandages, 44, 68. for the Arm, 76. Cambric, 45. Caoutchouc, 45. Cotton, 45. Flannel, 45. Gauze, 45. for the Head, 74. for the Leg, 82. Linen, 45. Shirting or Stouts, 45. Thorax, for the, 80, 89. Tricot, 45. Bandaging, 67. esis of the Arm, 77. the Leg, 82, 83. Bath for the Arm, 14- Portable Hospital, 14. Permanent Antiseptic, 59> 65. Batiste (Billroth), 44. Bayonet Incision for Resection of the Elbow Exter- I Joint, 407. 1 Bayonets used for Splint, 166. 846 INDEX OF SUBJECT-MATTER Benzoic Acid, 30. Benzosol, 30. Biliary Fistula, Establishing, 734. Binoculus Bandage, 75. Bismuth, 34. Bismuthuin Snbnitricuiii, 34. Bistoury, 8. Bladder, Puncture of the, 768. Washing out the, 753. Foreign Bodies in the, 766. Bleeding, 282. Blepharoplasty, 514. Blood, Saving of, 224. Bloodless Method, 225. Apparatus for, 228. in Aneurism, 225, 285. Secondary Hemorrhage, 233. in Operation on the Lips, 518. in Operation on the Tongue, 598. Blood Vessels, Ligation of, in the Wound, 245. Ligation of, by Indirect Ligature, 245. Injury to Walls of the, 2S9. Blotting Paper, 42. Bone Cavity, Opening of, 312. Bone Chips, Decalcified, 463. Decalcified for filling Gap after Necrotomy, 315- Bone Clamps, 310. Cover for Amputation Stump, 374. Cutting Forceps for Roots of Teeth, 589. Drill, 309, 475. P^orceps, 330. Implantation of, 310. Nipping Forceps, 459. Plates, Decalcified for Enterorrhaphy, 704. Section, 307. Screw, 459. Sawing of the, 326. " Skelettierung " of, 390. Suture, 310. Tube, Decalcified, 704. Union, 31 1. Union, Aluminum Splints for, 31 1. Bones, Operation on, 305. Boot used as Foot Splint, 165. Petit's, loi. Boric Acid, 28, 35, 59. Lint, 28. Salve, 28. Boring Chisel, 485. Bougie for the CEsophagus, 640. for the Rectum, 807. for the Urethra, 756. '■'■ Boutonni}rc,^^ 761. Palatine, 576. Brain, Injury to the, by Hammering, 460. Protruding Portions of the, 457. Brass Spiral Bandage, 230. Breast, Compressive Bandage for the, 81. Operations on the, 651. Suspensory Bandage for the, 81. Bridge Plaster of Paris Dressing, 128. Bromoform Anasthesia, 192. Bronchoioiity, 612. Buccal Bandage, 87. Bulbus, Enucleation of the, 561. Exenteration of the, 563. Extirpation of the, 562. Bullet Screw, 222. Forceps, 222.. Probe, 223. Probe, Electric, 223. Bullets, Extraction of. 219. Buried 'ivXyxxt, 214. Sutures, 37. Butterfly in Maxillary Fissure, 549. Buttocks, Cloth for the, 89. Button Suture, 216. Cachexia thyreopriva, 626. Canifie Fossa, Opening of the, 4S6. Canula, Bellocq's, 567. for Hypertrophy of the Prostate Gland, 779- for Puncture of the Bladder, 769. for Tracheotomy, 618. for Tracheotomy in Goitre, 635. Phonetic, 624. Caoutchouc Bandage, 45. Pure Materials of, 44, 45. Capistruin Bandage, 74. Caput obstipum. Operation for, 644. Carbolic Acid, Injection of, into Hemorrhoidal Swellings, 817. as an Escharotic, 208. Symptoms of Poisoning of, 24. Test, 25. Carholized Gauze, 24. Glycerine, 24. Silk, 210. Solution, Strong, 23. Solution, Weak, 23. Carbonic Acid, Liquid, as an Analgetic, 193. Cardiac Region, Massage of, in Chloroform Anaes- thesia, 187. INDEX OF SUBJECT-MATTER 847 Carpejiter^s Chisel iot Necrotomy, 312. Cartilage Plate Suture for Enterorrhaphy, 705. Castration, 801. Catgut^ 210. Aseptic, 10. Glass Box for Catgut Ligatures, il. Ring for Enterorrhaphy, 704. Strings as Bougie, 757. Catheter Catcher, 767. Introduction of, 749. with Double Canula, 753. Catheterism, 747. in the Female, 752. in Hypertrophy of the Prostate, 752. Posterior, 764, 769. Catliiie, 329. Caustic Pastes, 2.Q']. Cauteriiim Acttiale, 204. Cauteriitm Potentiate, 207. Cautery Iron, 204, 243. Cavities, Tubercular Treatment of, 664. Cavity, Shallow, after Necrotomy, 314. Celluloid Thread, 210. Plates in Resection of the Skull, 463. Cellulose Cotton, 42. Sheets, no. Central Fissure, Locating, 464. Centres of the Surface of the Brain, 465. Cerebral Abscess in the Temporal Lobe, 468. Topography, 465. Cerumen, Hardened, 564. Cervical Portion of the Spine, Extension Appa- ratus for, 151. Tumors, Operation for, 646, 647. Chaff Pillows, 51. Chai7i Saw, 392. Changing the Dressings, 47. Charcoal, 35. Char pie Cotton, 41. Cheek, Transverse Division of the, 506, 600. Cheiloplasty, 517. Chin, Bandage for the, 87. Chirotheka, 76. Chisel for Necrotomy, 314. Chloral Hydrate, 31. Chloride of Lime, 31. Chloride of Sodium, 31. Infusion of, 242. Infusion of, in Chloroform Anaesthesia, 187. Chloride of Zinc, 27, 243. Jute, 28. Paste of, 208. Chlorinated Soda, 31. Chlorine, 30. Water, 30. Chloroform Anaesthesia, 172. Apparatus, 174, 175, 176. -ether i\ntesthesia, 191. English Mixture, 192. Mixtures, 191. Mortality from, 181. Odor Test in, 173. Syncope from, 187. Cholecystectomy, 735. Cholecystendysis, 734. Cholecysto-enter ostomy , 737. Cholecystopexia, 734. Cholecystotomy, 733, 734. Ideal, 734. Choledocho-lithecto77iy, 737. Choledocho-lithotripsy, 736. Chromic Acid, 29. as an Escharotic, 208. Catgut, II. ■Cingtdu7ji Pectoris, 89. Circular A77Zputatio7t, 323. by one Incision, 318. by two Incisions, 320. by three Incisions, 318. for Varices, 288. Stump after, 320, 323. Circular Ba7idage, Danger from, in Fracture of Forearm, 108. Circular E/iterorrhaphy, 704. Circular K7iife for Adenoid Vegetations, 578. for Tonsillotomy, 592. Circular Suture, 688. Circular Turn, 71. Circu7)icisio7t, 793. Cla77ip for Fastening Elastic Tube, 228. Forceps (Amussat's), 246. Forceps for Hemorrhoids, 8x6, 817. Forceps for Operations on the Eyelids, using the " Bloodless Method," 234. Cla77ip Buckle, 226. Clavicle, Cloth Bandage for Fractured, 89. Resection of the, 419. Temporary Division by sawing off the, 670. Claw Foot, 589. Claw Ha7id, 334. Cleari7ig out of the Axilla, 667. of the Floor of the Mouth, 604. of the Orbit, 561. Cleft Palate, 551. Clefts of the Hard Palate, 555. 848 INDEX OF SUBJECT-MATTER Cloth Bandages, 84. Bandage for Fracture of the Clavicle, 89. Dressing for Fracture of the Patella, 94. for Pelvic Region, 89. Large Square for the Head, 86. Splints, 96. Triangular, for the Head, 85. Clothing, Articles of, used for Splints, 162. Clove-hitch, 753. Clubfoot, Operation for, 433. Clubfoot Shoe with Elastic Extension, 157. Coagulation of the Blood in Aneurism, 283. Cocaine Anaesthesia, 193. Spray of, in Anaesthesia, iSo. Toxic Symptoms of, 195. Cocainizing Spinal Cord, 195. Coccyx, Extirpation of, 806, 819. Ccecal Incision, 711. Cceliectomy, Posterior, 821. Cceliotoviy, 673. Coffee as an Antiseptic, 35. Coin-catcher, 638. Cold Coil, 64. Collodion, 37. Colopexy in Prolapse, 814. Colostomy, 697. Gluteal, 825. Colpeurynter, 243, 770, Combined Anesthesias, 191. Compressed Sponge Canula, 621. Compresses, Antiseptic, 59. Cold, 62. Divided, 328. Compression for the Tonsils, 594. Instrument for Resection of the Pylorus, 686. of Main Trunk of the Artery, 235. of the Aorta, 240. of the Subclavian Artery in Disarticulation of the Shoulder Joint, 351. of the Wound, 242. Compressive Bandage for Female Breast, 81. Compressorium Mamma, 81. Conical Stump, it^t^. Constriction caused by Bandage, 68. Temporary, of the Tongue, 598. Tube, 226. Constricto'-, Elastic, 226. Contact-infection, 2. Co?itinued Suture, 214. Tying of a, 214. Cooling Box (used instead of Ice-bag), 64. Cover, 65. Copper Sulphate as an Escharotic, 207. Cornea, Reflex, in Anaesthesia, 177. Cortical Epilepsy, 461. Costal Scissors, 656. Costotome, 655. Cotton, 41. Bandage, 41. Common, 41. Pasteboard Dressing, ill. Counter Extension, 150. Cover Dressings, 40. Coxitis Extension, Apparatus for, 158. Cracks in Plaster of Paris Dressing, 1 18. Craniectomy, 461. Cranio-cephalometer for locating Central Sulcus (Kohler), 466. Creolin, 25, 59. Creosote, 30. Cricectomy, 615. Cricotomy, 615. Cricotracheotomy, 618. Cross Bandage, 74. for the Hand, 87. Cross Turn of Bandage, 72. Croivtt Saw (Trephine), 457. Crural Arch, Anatomy of the, 717. Cuneiform Excision from the Alveolar Process, 476. from the Angle of the Jaw, 492. from the Anus, 814. from the Lower Lip, 519. from the Mesentery, 70S. from the Tongue, 597. from the Vomer, 550. Cuneiform Tarsectomy, 433. Cuprum Siilphuricum, 31. Curette, 485. Adjustable, 564. Cushioned Dressing, 41. Cystopexy, 775. Cystoplasty, 785. Cystorrhaphy, 775. Cystostomy, 769. Perineal, 777. Subpubic, 776. Suprapubic, 770. Cystotomy, 'J'jo. D Death from Chloroform Anaesthesia, 181, Decalcified Bone Drainage Tube, 38. Decapitation of the Head of the Humerus, 415- Deep Sutures, 214. INDEX OF SUBIECT-.MATTER 849 Defect, Congenital, of the Abdominal Wall and Bladder, 784. Dental Bur for Bone Suture, 310. Dependant Head, 551, 5S4. Dermatol, 35. Detachment, Temporar)", of Mammary Gland, 668. Transverse of the Mesentery, 707. Deziation (Scoliosis) of the Septum, 580. Diadem, 551. Digital Compression, 235. for arresting Hemorrhage, 235. in Aneurism, 284. Digital Palpation of the Bladder, 777. Dilatation of the Anus, 805, 817. of the Female Urethra, 778. of the Mouth, 526. of the CEsophagus, 639. Dilatation, Retrograde, of Strictures of the CEsophagus, 640. Dilator, 57. for the Urethra, 758. for the Female Urethra, 778. Diodothioresorcin, 35. Disarticulation below the Astragalus, 362. of the Elbow Joint, 346. of the Fingers, 336. of all Fingers, 339. of the Foot, 364. of the Foot (Pirogoff's Method), 367. General Rules for, 332. Intertarsal, 359. of the Knee Joint, 377. of Limbs, 316. Mediotarsal, 359. of the last four Metacarpal Bones, 341. at the Metacarpo-phalangeal Joint, 337. of the Shoulder Girdle, 353. at the Shoulder Joint, 350. Subperiosteal, 334. Tarso-metatarsal, 357. at the Tarsus (Chopart), 359. of the Thigh, 383. of the Thumb, 340. of the Toes, 355. of the Wrist, 342. Disinfection of the Patient, 13. Diverticula, CEsophageal, 644. Diviilsion of Strictures, 758. Divulsor, 758. Dolabra Reversa, 71. Dorsal Splint for Leg, 1 34. for Radius, 98. Double Canula for Tracheotomy, 616. Double-headed Bandage, 72. Union Bandage, 74. Double Hook for Tonsillotomy, 591. for Tracheotomy, 616. Double Inclined Plane, 62. 140. Double-rowed Ifitestinal Suture, 702. Drainage Forceps, 38. of the Frontal Sinus, 476. of the Knee Joint, 444. of the Maxillary Sinus, 486. of Wound, 38. Openings in the Skin, 39. Trocar, 39, 476. Tube provided with Threads, 331. Tube of Rubber, 38. Dressing vnt\L Adhesive Plaster, 155. Basin, 22. Boxes, 47. Forceps, 218. for Dr\-ing the Wound, 40. for Fracture of the Clancle. 78. Glue for, 112. Material for, 40, 41. Package, Soldier's, Antiseptic, 1 70. Pad, 43. Scissors, 48. Dressings, Antiseptic Cushion for Stump after Amputation, 46. Antiseptic for Large Wounds on the Xeck, 46. Changing the, 47. Cover, 40. Extension, 146. for Cervical Spondylitis, 158. for Hip (Taylor's), 158. for the Wrist, 151, 154. Permanent, 47. Plastic, 1 10. Drill, 475. Drop Anasthesia, 176. Z)rj'2»§- of the Wound, 37. Duodenostamy, 695. Dysmorpliosteopalinclast, 306. Ear Speculum, 563. Echitiococcus of tlie Liter, Operation for, 732. Ecrasetnetit, 225. Ecraseur, 225. Ectopia Vesical, 784. Ectropium, Operation for, 514. " Ectropcesophag^'' 641. Elastic Bandage for Dressing, 44. Elastic Constriction for Bloodless Method, 226. 850 INDEX OF SUBJECT-MATTER for rendering Limbs Bloodless, 225. in Disarticulation of the Thigh, 383. in Regionary Analgesia, 194. Elastic Extension, 153. Elastic Reti- actor, 616, 620. Elastic Stocking for Varices, 287. Elaitic Support Flap for Rhinoplasty, 534. Elbow Cloth, 88. Elbow Joint, Disarticulation of, 346. Double Splint for Resection of the (von Esmarch's), 137. Plaster of Paris Suspension Splint for Resec- tion of the, 130. Resection of, 403. Stirrup Plaster of Paris Dressing for the, 128. Electrolysis, 207. Electromotor, 31 1. with Rotating Circular Saw, 460. Electropuncture in Aneurism, 287. in Chloroform Anesthesia, 187. for forming Osseous Callus, 312. Elevation of Limbs, 61. Elevator, 391. for Extracting Roots of the Teeth, 5S5, 5S9. Ernpveiiia, After treatment of, 663. Drainage of, by Aspiration, 660. Resection of Rib, 661. Endoscope for the Urethra, 757. Enteroanastoiiiosis, 708. Enterocele, Treatment of, 714. Enter or rhaphy, 702, 703. Circular, 704. Internal, 704. Enterostomy, 676, 679. Temporary, 697. Enterotomy, 697. Enucleation of the Eyeball, 562, of a Goitre, 630, 631. of the Bulb, 561. of the Tonsils, 593. Resection of Goitre, 631. Epicystotomy, 770. Epidural Htcmatoma, 470. Epispadias, 788. Epityphlitis, Operation for, 71 1. Epulis, 476. Escharotics, 207. Etage Suture, 214. for the Intestine, 702. in Amputations, 331. Ether Ancrsthesia, 188. Dangers from, 189. Ether-chloroform Anasthesia, 191, Ether, Clonic Contractions from, 189. Mask, 188. Spray for Local Anesthesia, 193. Etherization per Rectum, 190. Ethylene Bromide Aneesthesia, 192. Bromide Ether Anesthesia, 192. Chloride Anaesthesia, 192. Chloride, Flask containing, 193. Eucaine, 195. Eucalyptol, 31. Eucalyptus Gattze, 32. Evacuation of the Orbit, 561. of Struma, 631. Evulsion of the Vas Deferens, 802. Excision of Cancer, of the Rectum, Si 7. of the Lower Lip, 519. of the Tongue, 597. Excitation Stage in Chloroform Anaesthesia, 177. Exenteration of the Bulb, 563. Exothyropexia, 633. Explorative Incision, Extraperitoneal, 676. Exploratory Perforatioti of the Skull, 469. Exposing h.cc&'s&oxy Nerve, 510. Brachial Plexus, 511. Crural Nerve, 51 1. Facial Nerve, 509. Foramen Ovale, 502. Foramen Rotundum, 499. Inframaxillary Nerve, 499. Lingual Nerve, 506. Mental Nerve, 506. Popliteal Nerve, 513. Supramaxillary Nerve, 496. Supraorbital Nerve, 494. Extension Apparatus for Osteoclasis, 305. Extension Dressings, 146, 147. of the Arm, 150. with Adhesive Plaster, 155, for Femoral Fracture, 146. for the Hip (Taylor's), 158. for the Knee Joint (Sayre's), 157. Separable for the Thigh, 154. of the Trunk, 151. by Weight, 147. Extirpation of Aneurism, 286. of the Anus, 818. of the Cervical Glands, 646. of the Coccyx, 806, 819. of the Eyeball, 562. of the Gall Bladder, 735. of Hemorrhoids, 814. INDEX OF SUBJECT-MATTER 851 of Intraglandular Struma, 630. of the Kidney, 740. of the Larynx, 621. of the Lungs, 665. of the Mammary Gland, 666. of Naso-pharyngeal Polypi, 577- of the Parotid Gland, 605. of the Pharynx, 610. of Ranula, 604. of Rectal Fistula, 812. of the Sternocleidomastoid, 621. of Struma, 626. Subcutaneous, of Cervical Glands, 651. of Submaxillary Gland, 607. of Testicle, 800. of the Tonsils, 594- of the Urinary Bladder, 776. of Varicocele, 800. Extraction of Teeth, 584, 586. of Roots of Teeth, 589. Extraperitoneal Explorative Incision, 676. Eye, Artificial, 562. Bandage, 75, 87. Enucleation of the, 562. Operations on the, 561. Eyelid, Plastic Surgery of the, 514. F False Passage in Catheterism, 756. Fan Turn, 72. Faradization of Phrenic Nerve, 186. Fascia circularis, 71. nodosa, 74. sagittahs, 74. stellata, 80. uniens, 74. Fasciotomy, 292. Felt, Plastic, no. Femoral Hernia, Truss for, 715. Radical Operation for, 730. Fenestrated Plaster of Paris Dressing, 126. Ferric Chloride, 243. Ferripyrine, 243. Ferruni Sesquichloratum, 31. Figure-of-8 Turn of Bandage, 72. Fil de Florence, 210. Filiform Bougies, 756. Finger, Metal Sheath for Protecting, 566. Fi7iger Nail, Pointed Instrument for Supplyi 578. Fingers, Bandaging the, 76. Contraction of, 292. Disarticulation of, 336. Disarticulation of all, 340. Resection of Fingers, 394. Fish-bone Catcher, 638. Fissure, Congenital, of Anterior Pelvic Region, Plastic Operation for, 784. of Sylvius, Location of, 464. Fistula Ani, Operation for, 809. Fistulous formation on the Foramen Incis.vum, 558. Flannel Bandage, 45. Flap Knife, 324. Flask containing Ethylene Chloride, 193- Flat foot, Arthrodesis in, 434. Operation for, 434. Flax, 42. Thread for Suturing Material, 210. Floating Spleen, Stitching of, 739- Flower Trellis as a Splint after Resection of Knee Joint, 847. Folding Suture, 215. Foot, Bandaging of, 82. Board (Crosby), 147- Cloth, 95. Disarticulation of, 364. Osteoplastic Amputation, of the, 367. Resection of the Tarsal Bones of, 430, Skeleton of, 357. Tub, 14. Foramen Ovale, Exposing, 502. Kotundum, Exposing, 499. Forceps, Anatomical, for Ligatures, 244. for Calculi, 744. 777- for Extraction of Nerves, 493. for extracting teeth, 586. for the Urethra, 767. for Nasal Polypi, 568. for Prostatotomy, 779- with Removable Lock, 9. for the Septum, 580. for Hemorrhoids, 816. Hemostatic, 244. Splinter, 218. Surgical, 8. Forcipressure, 246. Forearm, Amputation of, 344. Resection of its Lower Extremity, 394. Splint, 97. . Wood-shaving Plaster of Paris Dressing for, 1 22. Foreign Bodies in the Bladder, 766. in the External Auditory Meatus, 563. in the (Esophagus, 636. in the Urethra, 766. Removal of, 218. 852 INDEX OF SUBJECT-MATTER " Four Masters;' Suture of the, 704. Fracture Box, Heister's, 143. Petit's, 62, 140, 143. Scheuer's, 143, 144. French Rhinoplasty, 537. Frontal Bandage, 87. Frontal Sinus, Opening of, 475. Full Bath, 13. Funda Bandage, 73. Capitis. 86. Maxillae, 75, 87, 91. Gall Bladder, Anatomy of, 736. Extirpation of the, 735. Incision of the, 734. Operations on the, 732. Galvanocautery, 206. G alvanopuncture, 207. Ganglion Gasseri, Resection of, 507. Gaping Bandage, 69. Gastric Ulcers, Castrotomy, 678. Gastroanastomosrs, 697. Gastroduodenostomy, 689. Gastroenterostomy, 690. Gastrolysis, 679. Gastropexy, 679. Gastroplasty, 679. Gastroplication, 6yg. Gastroptosis, 679. Gastrorrhagia, Castrotomy for, 678. Gastrorrhaphy, b-jc). Gastrostenoplasty, 679. Gastrostomy, 680. Gastrotomy, 678. Gauntlet, 87. Gauze Bandage, 45. Sash, 89. Gauze Sponges, Sterilization of, 13. for Sterilization of, 16. for Tampon, 13. Gelatine, 243. Solution of, in Aneurism, 287. Genu Valgum,- Extension Dressing for, 156, 157- Glass Bottle for Dry Cold, 63. Box for Catgut Ligatures, II. Instrument Tray Stand, 9. ■ Irrigator, 20. Splints, 105. Wool, 44. Glass Bougie for Rectum, 808. Glazed Paper, 44. Gliding Stirrup (Konig's), 150. Glover's Suture, 214. Glue Dressing, 1 1 2. Glycerine Pad for Trusses, 715. Goitre, Dislocation of, 633. Ligation of the Isthmus of the Thyroid Gland in, 633. Operations for, 625. Probe, 627. Resection of, 630. Tracheotomy for, 635. Gorget, 812. Gouge Chisel, Spoon-shaped, 550. Gouge Forceps, 330. Gown, Surgeon's, 5, 7. Grafting of Portions of Skin, 298. Granny's Knot, 85, 211. Granulation after Tracheotomy, 619. Grooved Director, 199. Guajacol as an Analgetic, 197. Guide-staff, 761. Guillotine (Tonsillotome), 592. Gum Arabic Chalk Dressing, 112. Gunshot Wounds, Hemorrhage from, 247. Gutta Percha Sheets, no. H Hcematoma, Eiiidural, 470. Hallux, Arthrectomy of the, 420. Halter Bandage, 74. Hamt>ter for Removing Plaster of Paris Dress- ing, 1 18. Hammering, Injury to the Brain by, 460. Hand Cloth, 87. Cross Bandage for the, 77, 87. Trephine, 457. Hands, Boards for the, 97. Sterilization of the, 4. Harelip, Double, 548. Operations for, 544. and Maxillary Fissure, 544. Head, Anatomy of the, 647. Bandages for the, 74. Cloth, Square, 86. Cloth, Triangular, 85. Hanging Downward, Operations on the, 584. Healing under the Scab, 38. Heart, Paralysis of, in Anaesthesia, 1 81. Paralysis of, in Chloroform Anaesthesia, 187. Heel, Support for the, 50, 124. Plemorrhage, Arrest of, 224. Arresting by Compression, 242. Arresting during Operation, 19. INDEX OF SUBJECT-MATTER 853 Arresting by Raising Limb vertically, 242. Arresting by Tamponade, 242. Death from Excessive, 277. Phlebostatic, 247. from Puncture and Gunshot Wounds, 247. after Removing Constriction Bandage, 232. Hemorrhoidal Clamp Forceps, 816. Scissors, 816. Hemorrhoids, Operation for, 814. Hemostatic Forceps, 244. Hepatic Border Incision, 733. Hernia, Operation for, 714. Radical Operation for, 722. Hernial Sac, Transposing of the, 729. Herniotome, 719. Herniotomy, 716, 7 1 8. Heteroplasty on the Skull, 463. Highmore, Anatomy of the Antrum of, 485. Opening of the, 485. Hindoo Method, Rhinoplasty, 530. Hip Cloth, 93. Dislocation of. Operation for, 453. Joint, Resection of, 445. Joint, Subperiosteal Resection of, 446. Spica Coxse for the, 83. Rest, Telescopic, 49, 123. Hollow-moulded Splint, 99. Holloiv Reflector, 497. Hook for Separable Wooden Splint, 154. Hook-shaped Incision for Resection of Elbow Joint, 408. Incision for Resection of Knee Joint, 443. Horse-hair for Suturing Material, 211. Hospital Bath, Portable, 13. Hourglass Contractions of the Stomach, 696. Humerus, Wood-shaving Plaster of Paris Dressing for the, 121. Hydrocele, Operation for, 797. Radical Operation for, 798. Hydrochloric Acid, 31. Hydrogen Dioxide, 59. Hydrogen Gas for Intestinal Wounds, 706. Hydrogen Superoxide, 32. Hydronephrosis, Operation for, 745. Hydropneumothorax, 657. HypercEmia for Osseous Callus Formation, 312. Hyperflexion for Arresting Hemorrhage, 241. Hypnotism for bringing on Ansesthesia, 197. Hypodermoclysma, 280. Hypospadias, 791. I Ice Bag, 63. Idiocy (Craniectomy), 461. Ileostomy, 697. Ileus, Laparatomy for, 676. Ilium, Resection of the, 454. Immersion, Permanent Antiseptic, 59, 65. Improvising Artery Compressors, 240. Bullet Probe, 224. Stick Tournicjuet, 241. Inactivity, Paralysis from, after Resection, 393. Incision, 197. of the Mammary Gland, 666. Incisor Prostatic, 781. India Rubber Hose, with Hooks for Extension Dressing, 153. Indirect Ligature for Cheiloplasty, 518. Infiltration AncEsthesia, 195. Infusion, 277. Apparatus for, 281. Canula for, 279. Graduated Glass Cylinder for, 279. Ingrown Nail, 302. Inguitial Anus, Forming of, 700. Hernia, Radical Operation for, 722. Hernia, Radical Operation for, in the Female, 730. Hernia, Truss for, 715. Region, Anatomy of the, 716. Injection in Hemorrhoidal Swellings, 815. Intramuscular, 203. Intravenous, 279. Parenchymatous, 204. Parenchymatous in Goitre, 625. Subcutaneous, 202, 203. Syringe for, 202. Insects in the Auditory Meatus, 564. Inspection of the Nares, 565. of the Oral Cavity, 581. of the Rectum, 804. Interosseous Space, Knives for dividing Soft Parts in the, 329. Interrupted Plaster of Paris Dressing, 127. Interrupted Suture, 211. Intestinal {qx Anus Praeternaturalis, 712. Button (Murphy's), 705, 706. Clamps, 687. Scissors, 712. Suture, Needles for, 702. Intestine, Forming a Fistulous Opening in the In- testine and the Abdominal Wall, 697. Local Exclusion of a Diseased Part of the, 710. Opening the, 697. Resection of the, 706. Resection of the, in Anus praeternaturalis, 713. Resection of the, in Grangrenous Hernia, 706. 854 INDEX OF SUBJECT-MATTER Instrument Sterilizer, 9. Instruments, Sterilization of, 7. Intrabiucal Incision for Resection of the Maxilla, 477- Intracranial Ixesection of the Ganglion Gasseri, 508. Introducing Catheter, 750. Oesophageal Tube, 635. Intubation of the Larynx, 619. Invagination Displacement (Hernial Sac), 730. for Enterorrhaphy, 705. Invalid Lift, 52, 53, 54. Siebold's, 55, 56. Inversion in Chloroform Anaesthesia, 187. Suture, 38. Suture after Necrotomy, 315. Involutio Brachii, 77. Pedis, 82. Thedenii, 83. Iodine, Trichloride of, 30. Iodoform, 32, 35. Adhesive (Billroth), 33. Collodion, 2,t„ 37. Ether, n. Ether-alcohol, 33. Gauze, n, 40, 58. Glycerine, 33. Pencils, 33. Poisoning, Symptoms of, 34. Powder, T^'i)- Silk, 210. Test of, 34. lodol, 35. Iron Wire Splints, 103. for Suture, 21 1. Irrigateur, " a vide Bouteille," 21. Irrigation, 65. Permanent Antiseptic, 59. Permanent Apparatus for, 60. Irrigator, Improved, 20. Improvised, 21, 159. Tube, 60. Irritants for forming Osseous Callus, 310. Ischemia, Temporary, 225. Italian Rhinoplasty, 537. Ivory Pegs for Bone Cavity, 310. Pins for Bone Union, 310. Jejtmostomy, 695. Juniper Catgut, II. Oil of, 32. Jury Alast, 158. fute, 48. K A'ali Causticwn, 207. Kangaroo Teiidons, 210. Kelen AncEsthesia, 192. Kerchief for Bandage, 87. Kidney, Fixation of the, by Sutures, 745. Operations on the, 740. Kionotoiiiy, 595. Ktiee Cloth, 93. Splint, loi. Stirrup, Plaster of Paris Dressing for the, 127. Joint, Drainage of, 444. Disarticulation of the Leg at the, 377. Extension Dressing for the, 157. Plaster of Paris Suspension Splint for the, 132. Puncture of the, 444. Resection of the, 435. Knife, Aseptic, 8. Holding it like a \'io]in Bow in making In- cisions, 198. Methods of holding the, 197. Blades, Shape of, 198. Knives, Three-edged, for Retrograde Dilatation, 641. ^^ Kruell" Gauze, 41, 43. Labial Suture in Atresia Ani, 806. Margins, Sliding of, in Cheiloplasty, 520. Method of Distortion in Harelip, 545. Lace Suture, 215. Lactic Acid &% an Escharotic, 208. Lancet for Venesection, 283. Languette Suture, 214. Laparotomy, 673. After treatment, 675. Abdominal Supporter after, 676. for Ileus, 676. Laryngeal Forceps, 637. Lary ugofiss ure, 615. Diagnostic, 622. Laryngotomy, 612. Infrathyroid, 614. Subhyoid, 615. Larynx, Artificial, 624. Extirpation of the, 621. Intubation of the, 619. Region of the. Anatomy of the, 622, Lateral Extension in Scoliosis, 153. Flap Incision for the Thumb, 341. Fla]) Incision for the Wrist, 344. Position, 139. INDEX OF SUBJECT-MATTER 855 Lead Acetate, 29. Leg, Bandages of the, 82. Bandaging the Whole, 83. splints for the, loi, 105. Wood-shaving Plaster of Paris Dressing for the, 123. Lifting Loicer Jaw, 182. Ligation of Afferent Arteries in Vascular Goitre, 631. of Blood Vessels by Indirect Ligature, 245, 246. Direct, 247. of the Hemorrhoids, 816. of the Hj'pogastric Artery in Hypertrophy of the Prostate, 782. of the Inferior Thyroid, 632. of the Innominate Artery, 651. of the Internal Mammary Artery, 652. of Lateral of Veins, 287, 289. en masse, 246. of the Middle Meningeal Artery, 507. of Nasal Polypi, 570. for Operating in a Bloodless Manner, 225. at the Place of Selection, 251. Removing Nasal Poh^us by, 571. of Saphenous Vein, 288. of Subcutaneous vein, for Varicocele, 801. of the Superior Thyroid, 631. of Varices, 288. of Veins, Lateral, 649. of Vessels in Aneurism, 285. in the Wound, 243. Ligature Loop as Retractor, 200. Ligature A'eedle, 253. Ligatures, Sterilization of, 10. Limb, Raising vertically after Bloodless Method, 232. Linen Bandages, 45. Lining for Rhinoplasty, 534. for Urethroplasty, 765. Lint, 41. Lion Forceps, 391. Lips, Plastic Surgery of the, 517. Lit hoc last, jjS. Manipulation of, 782. Litholapaxy, 784. Lithotomy, 770. Forceps, 774, 777. Position, 761. Lithotripsy, 782. Lithotriptor, Adjustable, 767. for the Urethra, 767. Manipulation of the, 782. Lithotrite, 777. Liver, Abscesses of the, 733. Anatomy of the, 736. Operations on the, 732. Resection of the, 733. Local AncESthesia, 192. Longitudinal Division of Anal Fistula, 810. Loop Tightener, 599. Loose Gauze (" Kruell "), 41, 43. Freely Movable Joint after Resection, 393. Lower Jaw, Resection of the, 487. Subperiosteal Resection of the, 493. Temporar}' Resection in the Median Line, 602. Temporary Resection of the, 502, 600. Lower Lip, Restoration of the, 517. Restoration of the Whole Lip, 520. Lower Maxilla Holder, 1S3. Lifting of. 182. Lumbar, Incision for the Kidney, 741. Incision for Laparotomy, 676. Puncture, 470. Lunar Caustic, 207. Lung, Extirpation of the, 665. Incision of the, 664. Resection of the, 665. Lysol, 25. Gauze, 61. M Macaroni, Pieces of, for Enterorrhaphv, 704. Mackintosh, 44. Malar Bone, Temporary Resection of, 498. Mammary Gland, Ablation of the, with Clearing out of the Axilla, 667. Extirpation of the, 666. Incision of the, 666. Operations on the, 666. Temporary Detachment of the, 667. Mamibrium Sterni, Resection of, 653, 654. Many-headed Bandage, 73. Marginal Sutures for Tendons, 294. Margins in Plaster of Paris Dressing, 1 1 7. ALask for Chloroform Anaesthesia, 174. for Ether An;£sthesia, 188. Masse, Ligatures eti, 246. "Masters, Four^''' Suture of the, 704. Mastoid Process, Anatomy of, 474. Opening of the, 473. Maxilla, Osteoplastic Resection of, 482. Osteoplastic Resection of Both, 483. Resection of the, 476. Resection of Both, 481. Resection of the (Intrabuccal Incision), 477. Resectionof the Nasal Processof the Upper, 572. 856 INDEX OF SUBJECT-MATTER Maxillary Arch, Resection of the, 489. Maxillary Fissure, Double, 548. Operation for, 544. Meatotomy, 760. Meatus, Foreign Bodies in the External Auditory, 563- Meloplasty, 527. Meningeal Artery, Ligation of the, 470. Metacarpal Bone, Resection of a, 394. Bones, Disarticulation of, 341. Saw, 392, 655. Saw for Osteotomy, 307. Saw for Resection of Ribs, 655. Metacarpophalangeal Joint, Disarticulation of, 337- Metal Catheter, 750. Rings, Removing of, 219. Ring for Enterorrhaphy, 704. Splints, 102. Strips as Protheses after Resection of Maxil- lary Arch, 490. Wire, 211. Metatarsal Bones, Amputation of, 355. Resection of the, 421. Methyl Chloride, 193. Microcephalus (Craniectomy), 461. Military Model Operating Table, 165. Minerva, 158. Mitella, Improvised, 159. Large Square, 89. (Sling), 88. Mitra Hippocratis, 74. Model lox Rhinoplasty, 531. Monoctilus, 75. Morphium-ether Ancesthesia, 191. Morphiwn-chloroforin Amesthesia, 191. Motor y Centres of the Brain, 465. Mouth, Artificial, 527. Clearing floor of the, 604. Gag, 581, 582, 583. Inspection of the Cavity of the, 581. Plastic Surgery of the, 526. Mucoid Polypi, Removal of, 568. Muscular Cone in Circular Amputation, 323. Flaps, 325. Suture, 332. Musket used as Splint, 166. N Avails, Operations on, 302. Naphthalin, 34. Nares, Inspection of the, 565. Tamponade of the, 566. Nasal Polypi, Removing, 568, 569 Nasal Process, Resection of, 572. N^asal Protheses, 53S, 543. Speculum, 565. A'aso-pharyngeal Polypi, Removing, 571. Cavity, Adenoid Vegetations in the, 577. Extirpation of, 577. Forceps, 578. Osteoplastic Resection of Both Upper Jaws, 483- A^atriuni Chloroboricum, 31. Chloroborosum, 31. Tetraborjcum, 28. Neck, Antiseptic Dressing for the, 46. Topography of the, 647. N^ecrotomy, 312. Hammer for, 313. in Gunshot Wounds, 224. Osteoplastic, 315. 1 A^eedle for applying Suture, 209. Holder, 209. Holder for Staphylorrhaphy, 554. Needles provided with Handle, 554. Nephrectomy, 740. Transperitoneal, 745. Nephrolithotomy, 743. Nephropexy, 745. Nephrotomy^ 740. N^erve, Accessory, Exposing of, 510. Crural, Exposing of, 511. Extraction of Nerve, 493. Facial, Exposing of, 509. Inframaxillary, Exposing of, 499. Lingual, Exposing of, 506. Mental, Exposing of, 506. Popliteal, Exposing of, 513. Recurrent, Course of the, 629. Resection of, 493. Sciatic, Exposing of, 512. Stretching, 493. Supramaxillary, Exposing of, 496. Supraorbital, Exposing of, 494. Trigeminus, Topography of, 495. Phrenic, Faradization of, 186. Nerves, Anastomosis of, 298. Operations on, 296. Neurectomy, 493. A^eurexairesis, 493. Neuroplasty, 297. Neurorrhaphy, 2Qi(i, Neurotomy, 493. Nitric Acid as an Escharotic, 208. A'ose, Bandage for the, 75. INDEX OF SUBJECT-.MATTER 857 Deviation of the Septum of the, 580. Division of the, in the Median Line, 571. Framework of the, 535. Funnel, 565. Plastic Surgery for Restoring Tip of the, 540. Plastic Surgery of the, 530. Plastic Surgery for Restoring Ala of, 539. Restoring Septum of the, 541. Temporary- Detachment of, 573. Turning up the Whole, 574. Nostrils, Contraction of, 579. O Oakum, 42. Oblique Bed for Torticollis, 645. Board, Adjustable, 61. Fistula, Formation of, on the Exposed Vesical Wall, 769. Fistula in Gastrostomy, 683. Obliteration of Varices, 288. Obturators for Palatal Clefts, 559, 560. Occlusion Suttire, 687. CEdematization, Artificial, 195. CEsophageal Diverticula, 644. Fistula, Lip-shaped, 643. Forceps, 637. Probang, 638. Tube, Introducing, 635. QLsophagoplasty, 644. CEsophagotome, 640. CEsophagostomy, 643. CEsophagotomy, Combined, 643. External, 641. Internal, 640. (Esophagus, Diverticula of the, 644. Hook, Adjustable, 638. Operations on the, 635. Resection of the, 643. Strictures of the, 639. Oil Cloth, 44. Olecranon, Resection of, 409. Olive for Retrograde Dilatation, 640. Pointed Bougie, for the CEsophagus, 640. for the Rectum, 808. for the Urethra, 755. Opening of the Air Passages, 612. of the Antrum of Highmore, 4S5. of the Canine Fossa, 486. Echinococcus of the Liver, 732. Frontal Sinus, 475. of the Gall Bladder, 732. of the Mastoid Process, 473. of the Skull, 457. of the Stomach, 678. of the Thoracic Cavity, 657. the Trachea, 617. Operating Table, 3. Military Model, 165. Operation, Aseptic, 18. Preparation for an, 2. Oral Retractor, 552. Oral Route, Lower, for Extirpating Tumors of the Tongue, 603. Oral Specula, 581. Orbit, Evacuation of the, 561. Operations on the, 561. Organtine Bandage, 45. Orthofortn, 197. Os Calcis, Resection of, 429. Osteoclasis, 305. Osteoclast, 306. Osteoplastic, Amputation, 374. Amputation of the Foot, 367. Amputation of the Knee Joint, 380. Detachment of the Trochanter, 452. Necrotomy, 315. Operation on the Skull, 464. Resection, see Temporary Resection. Resection of Both Jaws, 483. Resection of the Lower Jaw, 490. Resection of the Manubrium Sterni, 655. Resection of the Maxilla, 482. Resection of the Skull, 463. Osteotojne, 307. Osteotomy, 306. for Clubfoot, 433. Subtrochanteric, 308. Supracondylic, 308. Supramalleolar, 309. Osteotribe, 312. P Padded Strips of Wood, 97. Padding iox Plaster of Paris Dressing, 1 16. Palatal Protheses, 558. Palate, Cleft, 551. Defects of the, Acquired, 590. Defects of the. Congenital, 556. Muscles of the, 553. Resection of the, in Pharyngeal Tumors, 577. Falato-Pharytigeal Suture, 558. Pabnar Arch, Superficial Ligation of, 267. Paper, Strips of, for Starch Dressing, ill. Parajffine Dressing, 112. Parallel Clamp Forceps for Intestinal Resection, 688. for the Lower Lip, 518. 8;8 INDEX OF SUBJECT-MATTER Paraneurotic Suture, 296. Paraphimosis, 794. Parasacral Incision, 823, 824. Paratendinous Suture, 293. Parenchymatous Injection, 204. Parotid Gland, Anatomy of, 606. Extirpation of the, 605. Pasteboard Model for Arm Splint, 106, loS. Splint for the Arm, 106. Splints for Temporary- Dressing, 162. Patella, Cloth Bandage for Fracture of the, 94. Patient, Disinfection of the, 1 3. Pearl Needles for Enterorrhaphy, 702. for Suture, 216. Peat, 42. Moss (Sphagnum), 42. Peg Leg, 335- for Amputated Leg, 335. Pelvic, High Position, 771. in Resections of the Intestine, 714. in Taxis, 717. Organs, Topography of the, 804. Pelvis, Operations on the, 747. Pen, Holding Knife like a, in making Incisions, 198. Penghawar Yanibi, 243. Penis, Amputation of the, 796. Circumference of the, 754. Operations on the, 792. Pental Anasthesia, 192. Perforation, Exploratory, of the Skull, 469. Pericardiotomy, 665. Pericardium, Puncture of the, 665. Perineal Cystotomy, 777. Resection of the Rectum, 824. Section, Median, 777. Transverse, 778. Perineurotic Suture, 296. Periosteal Suture, 309. in Amputations, 332. Periosteum, Reflection of, in Amputations, 320. Perityphlitis, Operation for, 711. Phalanx, Disarticulation of, 336. Resection of the entire, 394. Pharyngeal Granulations, 577. Syringe, 579. Pharyngectomy, Lateral, 610. Pharyngotomy, Subhyoid, 608. Pharynx, Extirpation of, 610. Phenylic Acid, 23. Phimosis, Operation for, 792. Phlebotome, 283. Phlebotomy, 282. Phlegmonous Inflammation, Acute Septic, 59. Phosphorous Necrosis, 481, 492. Photoxyline, 37. Pine Wool, 42. Plane, Double Inclined, 140. Plaster of Pans Bandage, 115. Bandage Machine, 115. Bandage, Strips of, 113. Boots, 120. Box, 116. Corset, 119. Cotton, 115, 120. Cream, Preparing of, 113. Compresses, 114. Dressing, 1 1 3. Application of, 1 13, 1 17. Cracks in, 118. Drying of, 1 18. for Forearm, 122. Fenestrated, 126. Spiral Splint, 120. Interrupted, 127. Making of, 1 15. Removable, 119. Removing of, 118. Strengthening of, 121. Hemp Splint, 128. Knife, 118. Plate Dressing, 114. Plastic Hemp Splints, 120, 128. Saw, 119. Scissors, 118. Suspension Splints, 138. for Ankle Joint, 133. for Elbow, 130. for Knee Joint, 132. Made of Telegraph Wires, 134. for Wrist. 1 31. Tutor, 120. Plastic Felt, no. Plaster of Paris Splints, 120. Splints, no. Pleura, Puncture of the, 657. Plexus Brachialis, Exposing of, 511. Plug, Grooved Wooden, 153. Plumbum Aceticum, 29. Pnetimotomy, 664. Pole Pressure in Aneurism, 284. Polypi, Nasal, Removing of, 568. Polypus Forceps, 568. Porte-Causttques, 207. Position of Apparatus, 50, I of Dressings, 138. INDEX OF SUBJECT-MATTER 859 Elevated, 61. of the Patient, 49. of the Patient in Bed^ 51. of the Patient for Cystostomy, 769. of the Patient for Operations on the Sacrum, 819. Posthioplasty, 793. Potash Silicate, 112. Dressing, 113. Potassitvn Permanganate, 30, 59. Potato Plates for Enterorrhaphy, 705. Precautionary Measures for Anaesthesia, 173. Premaxilla7-y Bone in Maxillary Fissure, 548. Forcing back of, 549. Preparations for Anaesthesia, 173. Prepuce, Longitudinal Division of, 791. Removing, 793. Taxis of, 794. Prerectal Incision, 780. Pointed Arch Incision, 781. Principle of Fconomy, 547. Probe, Curved, for Ligations, 253. Olive-pointed, for the Urethra, 755. for Rectal Fistula, 810. Probes, Olive-pointed, for the Urethra, 755. Probi7igs, Endless (CEsophagus), 640. Process, Mastoid, Opening of the, 473. Proctoplasty, 806. Prolapsus Recti, 812. Prostate Catheters, 750. Galvanocaustic Excision of the, 781. Catheterism in Hypertrophy of the, S02. Ligation of the Hypogastric Arteries, 782. Vasectomy of the, 802. Prostatectomy, Lateral, 78 1. Suprapubic, 780. Prostatotomy, 778. Protecting Basket, 52. Protective Dressing, 40. Silk, 44. Taffeta, 44. Protheses, 334. after Amputation of the Tongue, 604. for Cleft Palate, 558. for the Hand (Claw Hand), 334. for the Nose, 538. Protruding Portions of the Brain, 457. Pruning Shears, American, 656. Pseudoarthroses, Treatment of, 309. Puncture, 201. of the Abdomen, 672. of the Bladder, 768. Exploratory, of the Brain, 469. for Goitre, 625. of Hydrocele, 798. of Knee Joint, 444. of the Pericardium, 665. with Permanent Aspirations, 659, 660. of the Thoracic Cavity, 657. Pupil, the, during Ansesthesia, 177. Purifying Operating Room, 2, 3. Sea and Gauze Sponges, 11. Pus Basin, 20, 21. Pyloroplasty, 696. Pylorits, Dilatation of the, 696. Intussusception of the, 696. Resection of the, 685. Pyoctanine, 32. Quadriga, 80. Qtdlled Suture, 216. Quilt Suture, 216. for Tendons, 294. R Radial Flap, Incision for Disarticulation of Thumb, 340. for the ^Yrist, 344. Radical Operation of Antrum of Highmore, 4S6. for Femoral Hernia, 730. for Hernia, 722. for Hydrocele, 798. for L'mbilical Hernia, 731. for Varices, 288. Radioscppy for Bullets, 221. Radius Splint, 98, 99, no. Raikvay Apparatus, 1 50. Ranula, Operation for, 604. Raphe Incision, Posterior, 805, 817. Raspatory, 314, 390. Ray Turn, 72. Reamputation, 333. Rectal Fistula, Operation for, 809. Probe for, 810. Scissors for, 811. Tube for Dressing in, 81 1. Rectal Specida, 804. Rectal Supporter, 812. Rectangular Intestinal Suture, 703. Rectopexia in Prolapse, 814. Rectoplication, 814. Rectostomy, Gluteal, 825. Rectotomy, External, 80S. Internal, 808. Linear, 825. 86o INDEX OF SUBJECT-MATTER Rectum, Cancer of the, Operation for, 817. Operations on the, 803. Perineal Extirpation of the, S24. Prolapse of the, 812. Resection of the, 818. Strictures of the, 807. Reducing to Fragments a Calculus in the Blad- der, 782. Reef Knot, 211. Refrigerating Mixture, 63. Refrigeration as an Anaesthetic, 192. Regionary Analgesia, 194. Reimplantation of the Teeth, 589. Reindeer Tendons, 210. Relaxation Suture, 213. Releveur, 51. Renal Resection, 744. Region, Anatomy of the, 743. Renverse, 71. Replacing Resected Metacarpal Bone, 394. Resection of the Alveolar Process, 476. of Aneurism, 286. of the Ankle Joint, 421. for Anus Praeternaturalis, 713. of the Artificial Surface and Xeck of the Scapula, 417. of the Astragalus, 428. of the Bones of the Forearm, 395. of the Bone Stump, Subperiosteal, t^t^t^. of Both Jaws, 481. of the Clavicle, 419. of the Coccyx, 806. of the Elbow Joint, 403. of the Fingers, 394. of Ganglion Gasseri, 507. of Gangrenous Hernia, 721. of Goitre, 630. of Hip Joint, 445. of the Ilium, 454. Indications for, 389. of the Intestine, 706. of Joints, 3S9. of the Kidney, 744. of the Knee Joint, 435. of the Knee Joint Subperiosteal, 440. Knife, 391. of the Liver, 733. of the Lower Jaw, 487. of the Lung, 665. of the Manubrium Sterni, 653. for Prolapsus Recti, 813. for Urethra Strictures, 763. for \"aricocele, 800. of Xasal Process, 572. of Ribs, in Empyema, 662. of Shoulder Joint, 411. of the Maxilla, 476. of the Maxillary Arch, 489. of the (lEsophagus, 643. of the Olecranon, 409. of the Os Calcis, 429. of the Pharynx, 611. of the Pylorus, 685. of the Rectum, 818. of the Ribs, 655. of the Sacrum, 454, 819. of the Scapula, 418. of the Septum of the Nose, 580. of the Spleen, 739. of the Stricture of the Urethra, 763. of the Symphysis, 776. of the Toes, 420. of the Tunica Vaginalis, Soo. of the Vas deferens, 802. of the Vault of the Cranium, 455. of the Vermiform Appendix, 711. of the Wrist, 399. Osteoplastic, of the Skull, 463. Osteoplastic, of the Sacrum, 823. Splints, loi, 133. Subperiosteal, 390. of the Elbow Joint, 405. of the Shoulder Joint, 413. of the Hip Joint, 446. of the Lower Jaw, 492. Temporary, of the Lower Jaw, 502. Lateral, of the Lower Jaw, 600. of the Malar Bone, 498. of the Xose, 575. of the Zygomatic Arch, 504. Resorcin, 30. Respiration, Artificial, 184, 185. Unobstructed, 182. Rest, 61. Restoration of the Lost Eyelid, 514. of the Lips, 517. of the Xose, 530. of the Upper Lip, 525. of the Whole Lower Lip, 520. Retention, Bougie, 758. Catheter, 753. Retractor, 200. Improvised, 200. von Langenbeck's, 57. Retrobuccal Xeurectomy of the Infra-maxillary Xerve, 502. INDEX OF SUBJECT-MATTER 86i Ret7-ograde Dilatation (CEsophagusj, 640. Relroviaxillary Tumors, 4S2, 577. Retropharyngeal Abscesses, 610. Retropharyngeal Tumors, Osteoplastic Resection of Both Upper Jaws, 483. Reversion, Antiseptic, 59, 62. Tour, 71. (Turn of Bandage), 71. Rhiiieurynter, 243. R/iinoplastos, 580. Rhinoplasty for Saddle Noses, 541. French Method, 530, 537. Italian, 537. Models for, 531. Partial, 539. Rhinoscopy, Posterior, 565. Rib, Resection of a, 655. Ribs, Resection of, in Empyema, 662. Ring Forceps for the Bloodless Method, 234. Rod Splint, 143. Rolling up Bajidage, 69. Rongeur Forceps, 455. Root Forceps, 589. Screw, 589. Roots of Teeth; Extraction of, 588. Rotating Circular Saw, 460. Rotter ine, 32. Rubber Ball, Double for Anus PrKternaturalis, 713- Bandages, 69. Blanket, 16. Constrictor for Bloodless Method, 227, 228. Constrictor for Disarticulalon of the Thigh, Drainage Tube, 38. Ring for Resection of the Intestine, 704. S ^rtc;-c7/ Anus, 821, 825. Methods, 823. Sacrum, Resection of the, 454, 819. Saddle Noses, Correction of, 541. Protheses, 543. Sagittal Bandage, 74. Sailor Knot, 85. Salicylic Acid, 29. Salivary Fistula, Operation for, 607. Salol, 35. Sand, 42. Saphenous Vein, Long, Ligation of, 288. Saw for Amputation, 327. Sa-ivdust, 42. Sawing off the Bones, 326. Scabbard natd as a Splint, 166. Scabbard-shaped Trachea, 634. Scale for Urethral Instruments, 754. Scalpel, 198. Scapula, Partial Resection of the, 419. Resection of the, 417. Scissors, Angular, 201. Straight, 201. Scoliotic Curvature, Extension for, 152. Screw Bandage, 71. or Spiral Course, Zt,. Splints, 157. Tourniquet, 238. Wedge, 581. Scrotum, Division of the, after Amputation of the Penis, 797. Sea Sponges, Sterilization of, 11, 12, 13. Sectio Alta, 770. Media, 777. Subpubica, 776. Section, Anatomical. of the Arm in front of Axilla, 349. at its Lower Third, 348. at its Middle Third, 348. of the Elbow Joint in the Line of the Con- dyles, 347. of the Forearm at its Lower Third, 344. at its Middle Part, 345. at its Upper Third, 345. of the Leg at its Lower Third, 375. at its Middle Third, 375. at its Upper Third, 376. Median, for the Bladder, 769. of the Thigh, in the Line of the Condyles, 376. at its Lower Third, 380. at its Middle Third, 381. at its Upper Third, 382. Secondary Antisepsis, 57. Suture, 40. Seegrass, 210. Septum, Longitudinal Division of the, 566. Resection of the, 580. Sequestrum Forceps, 313. Serous Suture for the Intestine, 702. Serpentine Tour, 71. Sharp Spoon, 203. Sheet Zinc, Sheets of, I02. Shirting Bandages, 45. Shock in Anaesthesia, 181. from Trephining, 461. Shot SzUure, 216. 862 INDEX OF SUBJECT-MATTER Shoulder-blade, Resection of the, 418. Shoulder Cloth, 88. Shoulder Girdle, Disarticulation of, 353. Shoulder Joint, Disarticulation of the, 350. Resection of the, 411. Silk as Suturing Material, 210. Silkworm Gut, 210. Silver Wire for Laparotomy, 674. for Suture, 211. Sinus frontales, Opening of, 475. transversus, Opening of, 469. Sinuous Incision (Dieffenbach), 478. Skelettierung of the Bone in Resection, 390. Skin, Drainage, Openings in the, 39. Grafting of, 298. Operations by forming Flaps of, 324. Operations on the, 298. Plastic Operations of, 301. Skull, Covering Defects of the, 464. Exposing Base of the. 577. Exploratory Perforation of the, 469. Instruments for measuring, 466. Opening of the, at the Place of the Squamous Portion of the Temporal Bone, 469. Sleeve, Sling made of, 159. Sleigh Apparatus, 149. Sliding Forceps, Sharp-toothed, 617. Sling, Glisson's, 151, 158. Sodium, Chloride of, 31, 42. Soft Parts, Division of, in Amputations, 318. Soldier'' s Antiseptic Dressing Package, 1 70. Solutions, Antiseptic, 23. Solveol, 25. Sozoiodol, 35. Spanish Windlass, 238, 241. Spasmus Urethrce, 748. Sphagnum Pasteboard, 42. Sphenoidal Sinuses, Exposing of, 576. Sphincterotomy, Anterior, 817. Posterior, 805. Spica Coxa for the Hip, 83. (Cross Turn), 72. for the Hand, 77, 87. Humeri, 77. Manus, 77. Pedis, 82. Tour, 72. Spinal Cord, Cocainizing the, 195. Spindle Ivory for Ligatures, 744. Spiral Bandage, 83. Spleen, Operations on the, 738. Splenectomy, 738. Splenoplexy, 739. Splint for the Arm at an Oblique Angle, 98. Bayonets used for, 166. Divided Iron Suspension, 136. Dorsal, for Leg, 134. for Radius, 98. Double, for Elbow, 136. Flat, made of Twigs arranged Side by Side, 161. Gooch's Flexible Wooden, 96. Material which can be cut, 97. Reed Mat for, 164. Tin for Temporary Dressing, 162. Trellis of Flower Pot, 161. of Small Branches Tied in Bundles, 161. Splints, 95. Plastic, no. of Tinned Wire, 103. of Tinned Sheet Iron, lOi. Wire for Temporary Dressing, 162. of Wire Cloth, 103, 104. Splinter Forceps, 218. Sponge- holder, 1 84 . Spoon-shaped Forceps for Lithotomy, 774. Spoon, Sharp, 58, 203. Spray, 2, 193. Spur in Anus Prseternaturalis, 712. Incision for Os Calcis, 430. Squamous Portion of the Temporal Bone, Open- ing Skull at, 468. Stapes, 82. Staphylopharyngorrhaphy, 557, 591. Staphyloplasty, 557, 591. Staphylorrhaphy, 551, 552. Starch Bandages, 45, 103. Dressing, Application of, in. Divided, 112. Splints, III. Steel Nails for Fixation of Bones, 310. for Fixation after Resection of the Knee Joint, 437- for Fixation of Stump (Pirogoff's Method), 371- Steel Pin for Disarticulation of the Thigh, 386. for PirogofTs Operation, 371. Stella Dorsi, 80. Stellated Bandage for Chest and Back, So. Sterilization of Dressings, 16. of Hands, 4. of Instruments, 7. of Sutures and Ligatures, lO. Sterilizer, Compact Portable (Beck's), 17. (Kny-Sprague) Perfection Surgical Dressing, 17, 18. INDEX OF SUBJECT-MATTER 863 Sterilizing Instruments by Boiling, 7, 8, 9. Sternocleidomastoid, Extirpation of the, 646. Tenotomy of the, 644. Sternum, Resection of the ^lanubrium of the, 652, 653. Stick Tourniquet, 241, 242. Stilet for opening Antrum of Highmore, 486. Stimulants in Chloroform Anesthesia, 187. Stirrup Plaster of Paris Dressing, 127. Plaster of Paris Dressing for the Elbow, 128. Stomach, Establishing Fistulous Opening in the, through the Abdominal Walls, 680. Establishing Fistulous Opening between the, and the Small Intestine, 690. Opening of the, 6S0. Operations on the, 678. Pump, 635. Stomatoplasty, 526. Strangulation of Hernia, 717. Straw Mat for Splint, 163. Straw Spli7its, 163. Strengthening Plaster of Paris Dressing, 1 1 7. Stretcher Extension Dressing, 153. Stricture of Anus, 809. of CEsophagus, 639. of Urethra, 753. Extirpation of, 764. Divulsion of, 758. of Rectum, 807. Struma, Extirpation of, 626. Operation for, 625. Stump, Conical, 333. Subperiosteal Resection of the, 333. that can bear Pressure, 334. Styptics, 234. Subctttaneous Fracturing of Bones, 305. Infusion of Sodium Chloride, 280. Injection, 203. Osteoclasis, 305. Suture, 214. Sublimate, 25, 35. Catgut, 10. as an Escharotic, 208. Gauze, 26. Silk, 210. Tablets, 27. Submaxillary Gland, Extirpation of the, 607. Subperiosteal Disarticulation, 334. of the Ankle Joint, 421. of the Elbow Joint, 405. of the Hip Joint, 446. of the Knee Joint, 435. of the Scapula, 418. Subperiosteal Resection, 390. of the Bone Stump, 333. of the Clavicle, 419. of the Shoulder Joint, 413. Sugar, 35. Suggestion as an Anaesthesia, 197. Sulcus Centralis, Uocation of, 464. Sulfaminol, 35. Sulphurous Acid, 31. as an Escharotic, 208. Supinatio7i Splint, 10 1. Supporting Apparatus after Resection of the Elbow Joint, 410. Suprasymphysis Incision, 676. Surgeon^s Gown, 5, 7. Knot, 212. Suspension Apparatus (von Bardeleben's) for Fractured Ueg, 167. Apparatus (von Volkmann's) for Injured Arm, 167. Apparatus made of Stocking, 167. of Fenestrated Plaster of Paris Dressing, 62. Splint, 61. Splint Iron, 136. Stretcher, 52, 55. Suspensorium Mammce, 81. Suture, 209. Bearer for Staphylorrhaphy, 552. Buried, 37, 214. Deep, 214. in Amputations, 331. of Arteries, 290. of Bone Surfaces, 310. of the Amputation Stump, 331. of Veins, Lateral, 289. Paratendinous, 293. Periosteal, 309. Removing a, 213. Twisted, 217. Sutures, Sterilization of, 10. Tying of, 211. Various kinds of, 209. SuturingCysi Wall to Skin in Divided Goitre, 626. Tunica Vaginalis to Skin in Hydrocele, 798. Sword, Holding the Knife hke a, in making In- cisions, 198. Removing Broken-off Point of, by ChiseUing, 456- Sylvian Fissure, Locating, 464. Syncope, 181. in Chloroform Anaesthesia, 187. Syringe for Infiltration Anaesthesia, 196, for Injection, 202. 864 INDEX OF SUBJECT-MATTER T Bandage. 73. T Splint, lOi. Table Knife, Holding the Scalpel like a, in mak ing Incisions, 198. Tamponade for arresting Hemorrhage, 242. of Dead Spaces, 674. of the Nares, 566. of the Trachea, 620. Tampon Cannla, 621. Tamponing, 58, 60. Ta7inin, 243. Tarsectomy, 430. Cuneiform, 434. Tarsus, Osteoplastic Resection at the, 431. Resection at the, 430. Tartrate Antimony, Ointment of, 208. Taxis for Paraphimosis, 794. for Strangulated Hernia, 717. Teeth, Extraction of, 584. Accidents in, 588. Hemorrhage from, 588. Reimplantation, 589. Telegraph Wire, Splints made of, 103, 164. Temperature, Reduction of, 61. Temporal Incision, 471, 503. Temporary Constriction of the Tongue, 598. Detachment, Lateral, of the Lower Jaw, 600 of the Mammary (Hand, 667. Division of the Clavicle by Sawing, 670. Dressings, 159. Enterostomy, 697. Ischsemia, 225. Resection, of the Lower Jaw, 502. of the Malar Bone, 498. of the Manubrium Sterni, 653. Nasal Process, 572. of Upper Jaw, 482. of the Zygomatic Arch, 504. Splints, 160. Temporo-maxillary Articulation, Resection of the, 491. Topography of, 491. Tendinoplasty, 295. Tendinorrhaphy, 292. Tendinous Anastomosis, 296. Tendons, Extension of Shortened, 296. Operations on the, 290. Tenototny, 290. of Tendon of Achilles, 291. of Clubfoot, 292. Open, 291. Sternocleidomastoid, 292. Test of Carbolic Acid Poisoning, 25. of Iodine, 34. of Iodoform, 34. Testicle, Extirpation of the, Soi. Testudo, 72. Cubiti, 77. Genus, 72, 83. Tetraboric Sodium, 28. Thermocautery, 205. Thigh, Amputation of the, 372, 380. Disarticulation of the, 383. Peg Leg for Amputated, 335. Thoracic Cavity, Opening of the, 657. Thoracocentesis, 657. Thoracoplasty, 663. thoracotomy^ 661. Thorax, Anatomy of the, 656. Thumb, Disarticulation of, 340. Lateral Flap Incision, 341. Thymol, 30, 59. Thyroid Arteries, Diagram of, 632. Cartilage, Division of the, 612. Transverse Division of, 613. Gland, Separation of the, in Tracheotomy, 617. Operations on the, 625. Thyrotomy, Median, 612. Partial, 613. Transverse, 614. Tin Box, 64. for Sterilized Silk (Schimmelbusch's), 10. Splints, loi, 162. Tin Plate Splints, loi. Tirefond, 459. Tissue, Destruction of, 203. Raising Fold for External Incision, 200. Tobacco Pouch Szdure, 215. Toe, Disarticulation of the Great, 355. Resection of the, 420. Toes, Disarticulation of, 354. Tolerance, Period of? in Chloroform Anaesthesia, 177. Tongue, Artificial, 604. Excision of a Wedge-shaped Portion from the, 597. Extirpation of the, 602. Spatula, 583. Temporary Constriction of the, 598. Tongue-holding Forceps, 183. Tonsillar Abscesses, 594. Tonsillothlipsis, 593. Tonsillotome, 592. Tonsillotomy, 59 1 . Compressing Instruments for, 594. INDEX OF SUBJECT-MATTER 865 Tonsils, Excision of the, 590. Extirpation of the, 594. Tootk Forceps, 586. Key, 585. Topography of Arteries, 248, 250. of Carotid Artery, 254. of Femoral Artery, 269. of the Iliac Arteries, 269. of the Popliteal Space, 274. Torsion, Qosing Arteries by, 246. of the Rectum, 813. Tourniquet Suspender, 207, 231. Trachea, Opening of the, 615. Scabbard-shaped Compressed, 634. Tamponade of the, 620. Tracheotomy, 615. Inferior, 620. in Struma, 635. Superior, 616. Transcondylary Amputation of the Arm, 348. Transfixion of the Thigh, 383. Trans/iision, 277. Transperitoneal JVephrectomy, 745. Transplantation of Bone, 311. of Skin, 298. Transposing Hernial Sac, 729. Spermatic Cord in Operation for Hernia, 729, 731- Transverse Incision for Resection of the Ankle Joint, 428. Incision for Resection of the Wrist, 402. Traumaticin, 37. Trephine, 457. Trephining, 457. by means of Chisel and Hammer, 459. Triangle, Middledorpf's, 145. Triangular Cloth, 84, 85. Trichlorphenol, 30. Tricot iQt covering Surface, 119. Trigeminus, Topography of the, 495. Tripolith Dressing, 1 12. Trocar for Puncture, 201. for Puncture of the Bladder, 495. with Stop-cock, 658. for Thoracocentesis, 658. Trochanter, Osteoplastic Detachment of the, 452. Tropacocaine, 195. Trunk, Bandages of the, 80. Extension of the, 151. Trusses, 715. Tube for Dressing in Rectal Fistula, 811. Turn, Figure-of-8, 72. Turnip Plates for Enterorrhaphy, 705. 3k: Turpentine, Oil of, 243. Tutor of Plaster of Paris, 119. Twisted Suture, 217. Umbilical Hernia, Radical Operation for, 731, Truss for, 715. Umbilical Ring, Excision of the, 732. Union Bandage, 72. of Bone Fragments by Direct Fixation, 309, of Margins of the Wound, 209. of the Wound after Amputation, 331. Universal Forceps, 586. Upper Lip, Restoring of, 525. Uranoplasty, 555. in Perforations of the Palate, 590. Ureter, Exposing the, 746. Ureterotomy, 746. Urethra, Anatomy of the, 748, 749. Dilatation of the Female, 778. Foreign Bodies in the, 766. Operations on the, 747. Strictures of the, 754. Spasms of the, 748. Urethral Canal, Operations on the, 788. Fever, 758. Forceps, 767. Urethrometer, 755. Urethroplasty, ^64. Urethrorrhaphy , 763. Urethrostomy, 763. Urethrotome, 759, 760. Dilating, 759, 760. Perineal, 797. Urethrotomy, External, 761. Internal, 759. Urinary Bladder, Extirpation of the, 776. Incision above the Symphysis, 769. Puncture of the, 768. Urine, Receptacle for, 785. Uvula, Amputation of the, 595. Uvula Forceps, 566. Varices, Operation for, 287. Varicocele, Operation for, 8cx3. Varix Bandage, 287. Vas Deferens, Resection of, 802. Vasectomy, 802. Vasotribe, 247. Vault of the Cranium, Resection of the, 455. Osteoplastic Resection, 463. Vegetations, Adenoid, 577. 866 INDEX OF SUBJECT-MATTER Veins, Lateral Ligature of, 649, Lateral Ligation of, 289. Venesection, 282. Vermiform Appendix, Resection of the, 711. Vienna Caustic, 207. Vinculum Carpi, 87. Vomer, Cuneiform, Excision of, 550. F^wZ/iw^ during Anaesthesia, 179. Von Volkmann'' s Suspension Apparatus for Injured Ann, 167. W Wandering Kidney, Fixation by Sutures, 745. War, Antisepsis in, 168. Washing out the Bladder, 753. Water Cushion, 51. Sterilizer, 21. Waterproof Materials, 44. Weapons used for Temporary Splints, 165, 166. Wedge-shaped Excision for Ingrown Nail, 302. Whalebone Tendons, 210. Wiping of the Blood, 19. Wire Breeches, 139. Cloth, 103, 162. Hook, for Tracheotomy, 618. Hook, Sharp, for Tracheotomy, 617. Loop, Galvano-caustic, 206. Saw (Gigli), 480. Sling, 167. Snare, Cold, 570. for Nasal Polypi, 570. for the Ear, 564. Splints, 162. Flexible, 103. Wood Cotton Sheets, 43. Wool, 43. Shaving Plaster of Paris Dressing, 121. Shaving Plaster of Paris Dressing for the Arm, 121. Shaving Plaster of Paris Dressing for the Forearm, 122. Shaving Plaster of Paris Dressing for the Leg, 124. Wooden Frame (Dobson's), 141. Laths Plaster of Paris Dressing, 128. Splints, 95. Flexible, 95. for Femoral P'ractures, 146. for Temporary Dressings, 1 61. for the Wrist, 145. Wounds, Drainage of, 37. Dressings of, 40. Open Treatment of, 66. Retractors, 7. Treatment of, i, 159. Wrist, Disarticulation, 342. Elastic Extension for the, 154. Iron Arch Splint for the, 135. Plaster of Paris Suspension Splints for the, 133. 135- Resection of, 394. Total Resection of, 399. Zestokauiis, 243. Zinc Chloride, Paste of, in Pneumotomy, 664. Oxide of, 34. Paste, 37. Probe, Flexible, 221. Zincum Sulphocarbolate, 31. Sulphate, 31. Zygomatic Arch, Temporary Resection of, 504. RENAL GROWTHS Their Pathology, Diagnosis, and Treatment. ByT. N. Kelynack, M.D. (Vict.), M.R.C.P. (London), Pathologist, Manchester Royal Infirmary; Demonstrator and Assistant Lec- turer in Pathology, The Owens College, Manchester. 8vo. Cloth. With 96 illustra- tions. $4.00. " Dr. Kelynack has presented us with an snteresting monograph upon a subject which, from the standpoint of the pathologist, is one of the highest interest, but of extreme difficulty. This is ^e first systematic treatise upon tumors of the kidney which has yet appeared in English, and the author's main pretension is ' to indicate the work already accomplished, and to suggest hues for further research.' This he has done exceedingly well. His interesting and suggestive book is a Tvelcome addition to our meagre knowledge. It is beautifully published, and profusely illustrated with photographic reproductions which show gross appearances unusually well. There is an exhaustive bibliography." — N. Y. i^Iedical Journal. DISEASES OF WOMEN A. text-book for students and practitioners, by J. C. Webster, B.A., M.D. (Edin.), F.R.C.P., Ed. ; Professor of Gynaecology, Rush Medical College, Chicago ; late Demonstrator of Gynaecology, McGill University, Montreal, etc. Illustrated with 241 figures. Crown 8vo. $3.50. DISEASES OF THE HEART AND AORTA By George Alexander Gibson, M.D., D.Sc, F.R.C.P. (Edin.), Senior Assistant Physi- cian to and Lecturer on Clinical Medicine at the Royal Infirmary, Edinburgh, etc. With 210 illustrations. 8vo. 952 pp. Cloth, $6.00 ; sheep, $7.00. " We have only words of praise for the admirable monograph which is destined to have a perma- nent place in medical literature. It is refreshing, in these days of ceaseless activity in the making of books, to come across one characterized by the completeness and comprehensiveness, the force- fulness of presentation, and the authoritative accuracy of this. Dr. Gibson has, besides having done a tine piece of literary and scientific work, rendered a distinct service to the profession, for which he is deserving of its gratitude and commendation." — Philadelphia Medical Journal. MANUAL OF BACTERIOLOGY By Robert Muir, M.D., F.R.C.P., Ed., University of Edinburgh; Pathologist, Edinburgh Royal Infirmary; and James Ritchie, M.D., B.Sc, Lecturer in Pathology, University of Oxford, with 108 illustrations. Crown 8vo. New edition. $3.25. "A well-digested, well-arranged, and wisely and clearly expressed epitome of the medical phases of bacteriology and of the bacteriological phases of disease. The book is altogether excel- lent, and is really a modern epitome of a difficult and complex theme, a safe and stimulating guide to the student, and a boon to the busy practitioner." — Science. THE MACMILLAN COMPANY 66 FIFTH AVENUE, NE"W YORK CITY THE PRACTITIONER'S HANDBOOK OF TREATMENT; OR, THE PRINCIPLES OF THERAPEUTICS By the late J. Milner Fothergill, IM.D., M.R.C.P., Foreign Associate Fellow of the Col- lege of Physicians of Philadelphia. Fourth edition. 8vo. Cloth. $5.00. Edited, and in great part rewritten, by William Murrell, M.D., F.R.C.P. The enormous progress in all departments of medicine during the last ten years has necessi- tated a thorough revision of the work. Considerable additions have been made, but Dr. P'othergill's original design, and, above all, his characteristic style, have as far as possible been preserved. In the Preface to the First Edition of this work. Dr. Milner Fothergill points out that it is not " an imperfect practice of physic, but an attempt of original character to explain the rationale of our therapeutic measures . . . and " is a work on medical tactics for the bedside rather than the examination table." The Lancet, in its obituary notice of Dr. Fothergill, states that " in his profession he exhibited great natural skill in uiterpreting the indications for treatment of disease, and in many cases of diffi- culty he would clear up the lines of treatment with a hand that was felt to be masterly. . . . He always wrote what was instructive in a vivacious and interesting, oftentimes original and pungent, style. " INTRODUCTION TO THE OUTLINES OF THE PRINCIPLES OF DIFFERENTIAL DIAGNOSIS With Clinical Memoranda, by Fred J. SiMITH, Senior Pathologist to the London Hospital. Ex. Cr. 8vo. $2.00. DIABETES MELITUS AND ITS TREATMENT By R. T. Williamson, M.D. (Lond.), M.R.C.P., Medical Registrar, Manchester Royal Infirmary; Hon. Med. Officer, Pendleton Dispensary (Salford Royal Hospital) ; Assist- ant to the Professor of Medicine. Owens College, Manchester. With 18 illustrations (two colored). Royal 8vo. Cloth. $4.50. " The study of diabetes, which formed the basis of the author's discovery of the discoloration of methylene blue by blood taken from a diabetic subject, has made his name well known in connection with this disease. A contribution from his pen, in the form of a monograph upon-diabetes, is bound to be interesting. In the work before us, we find a more thorough consideration of the subject than has yet appeared in the English language. The chapters devoted to symptomatology and complica- tions are particularly full and thorough. The treatment of the disease is excellently handled, and closes the work in a thoroughly practical manner. The bibliography attached to each chapter and an appendix on diabetic dietetics add value to a work which in completeness and didactic worth is unexcelled." — yV. Y. Medical Neius. THE MACMILLAN COMPANY 66 FIFTH AVENUE, NEW YORK CITY CONSTIPATION IN ADULTS AND CHILDREN With special reference to Habitual Constipation and its most Successfiil Treatment bv the Mechanical Methods, by H. Illoway, M.D., formerh- Professor of the Diseases of Children, Cincinnati College of Medicine and Surgery ; with many plates and illustrations. 8vo. $4-00; sheep, 15.00. " The work is not large, but is replete with facts which are of practical value to the practitioner of medicine." — The Canadian Journal of Medicine and Surgery. ATLAS OF EXTERNAL DISEASES OF THE EYE By A. ]\1aitlaxd Ramsay, Ophthalmic Surgeon, Glasgow Royal Infirmary: Professor of Ophthalmolog)', St. Mungo's College, Glasgow : and Lecturer on Eye Diseases. Queen Margaret College, University of Glasgow. With 30 fiill-page colored plates, and 18 fiiU- page photograviu-es. Sold only by subscription. 4to. Half morocco, gilt top. $20.00. " A work of great beauty. The illustrations are unrivalled, many of them masterpieces in their kind. The text gives connected descriptions of the diseases, supplementing the stages and phases not presented in the illustrations. It is prepared with the utmost care as to precision and compre- hensiveness of language. The book is written for the observing student, describing the etiology, symptomatology', and pathology of the diseases, but omitting the treatment. The whole work, which in care of preparation and elegance of getting up, appeals, in contrast with the book of Haab, to a select class of readers, is an ornament to Scotch ophthalmology, and in particular to Glasgow, the place from which emanated the best ' practical treatise on the diseases of the eye ' before the dis- covery of the ophthalmoscope — the classical text-book of William Mackensie." — H. K., Archives of Ophthalmology, Xew York, Dr. H. Knapp, Editor. THE FUNDUS OCULI With an ophthalmoscopic atlas illustrating its physiological and pathological conditions, by W. ADA3IS Frost, F.R.C.S.. Ophthalmic Surgeon, St. George's Hospital : Surgeon to the Royal W'estminster Ophthalmic Hospital. 4to. Half morocco. $20.00. Sold by subscription only. " A work which is a pleasure to look upon and an equally great pleasure to read. The book is a folio of 220 pages of letterpress, illustrated by 46 figures in black and white, of exquisite work- manship, representing macroscopically and microscopically those parts of the eye which we see with the ophthalmoscope. Bound up in the same volume are 47 large colored plates, containing 107 figures, beautifully drawn and colored, representing the fundus of the eye as seen with the ophthal- moscope. The discussion of the different conditions observed in the fundus bears evidence of very careful observation and research. The direct, concise, and lucid maimer in which the descriptions of the various conditions are given is truly admirable." — N. Y. Medical Record. " We venture the assertion that of aU Ophthalmoscopic Atlases which have been produced in the last fort\' years, Mr. Frost's book \s facile princeps. We wish that it might be fotmd in the library of ever>' physician and surgeon." — Professor Jaiies Moore Ball, Editor The State Medical Journal and Practitioner. THE MACMILLAX COMPANY 66 FIFTH AVENUE, NEW^ YORK CITY IMPERATIVE SURGERY For the general practitioner, the specialist, and the recent graduate. By Howard LiLiENTHAL, Attending Surgeon, Mt. Sinai Hospital, New York City, with numerous original illustrations from photographs and drawings. Cloth, Square 8vo, $4.00. net. Half morocco. Square 8vo, $5.00, net. " Dr. Lilienthal has limited his work to what are ordinarily known as emergency operations ; that is, to the description of the technics of surgical procedure in conditions which demand active and immediate surgical intervention. It is in this respect that his book is unique in surgical literature. . . . " The chapters on abdominal surgery are especially complete, and, as we shall subsequently point out, are superbly illustrated. Under the description of each operation there is a full statement in detail of the after-treatment. This includes not only the care of the patient immediately following the operation, but his subsequent treatment, covering the time for removal of sutures and for change of dressings. The importance of this feature of the book is self-evident. " The text throughout is marked by earnestness and thoroughness. There is no ambiguity of pro- cedure ; the reader is not left to choose any one of several methods. The choice is made for him, and this is done in a literary style which is exceptionally lucid and concise. The impression that is made by reading the book is one of complete subordination of the unessential to the necessary, of a mass of detail which is clearly set forth and as clearly elucidated, and, finally, of an epitome of an individual surgeon's experience in a branch of the art which, perhaps, is the widest in the saving of Ufa. " It is necessary to speak of the illustrations, which are not only numerous, but of a character rarely encountered in medical books. Many are made from photographs, others from drawings ; but the distinguishing feature which characterizes them is their remarkable clearness. . . . " It is scarcely too much to say that since Dr. Lilienthal's book fills an unoccupied place in sur- gical literature, and because it is altogether scientific and modern, it must prove one of the suc- cessful books of the year." — Extracts from an extended review in the New York Medical Journal, March 17, 1900. A MANUAL OF SURGERY By Charles Stonham, F.R.C.S., Eng., Senior Surgeon to the Westminster Hospital; also Lecturer on Surgery and Clinical Surgery, and Teacher of Operative Surgery; Surgeon to the Poplar Hospital for Accidents ; Examiner in Surgery. Society of Apothecaries, London, etc., etc. Fully illustrated. Three volumes. Cloth, i2mo, $6.00, net. Vol. I, General Surgery. Vol. II, Injuries. Vol. Ill, Regional Surgery. The work is notably modern, and as such much that is of historical interest merely has been purposely omitted, since it is undesirable to clog a work intended for immediate daily use with material which is out of date so far as actual practice is concerned and is readily accessible in printed works for those who would follow up the historic side of the subject. No better aid can be found for the student or for the general practitioner who wishes to review the very latest of the new discoveries in both the theory and method of treating surgically pathologi- cal conditions. THE MACMILLAN COMPANY 66 FIFTH AVENUE, NEW YORK CITY COLUMBIA UNIVERSITY LIBRARIES (hsi.stx) RD 32 ESS C.1 Surgical techntc: a text-book on operati 2002107368 ^^5"