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 GIFT OF 
 DR. JOHN B.WALKER 
 
Digitized by the Internet Archive 
 
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 Open Knowledge Commons (for the Medical Heritage Library project) 
 
 http://www.archive.org/details/textbookofoperat1908bick 
 
A TEXT-BOOK 
 
 OF 
 
 Operative Surgery 
 
 COVERING THE SURGICAL ANATOMY AND 
 OPERATIVE TECHNIC INVOLVED IN THE 
 OPERATIONS OF GENERAL SURGERY 
 
 DESIGNED FOR PRACTITIONERS AND STUDENTS 
 
 BY 
 
 WARREN STONE BICKHAM, M. D., Phar. M. 
 
 Junior Surgeon, Touro Hospital. New Orleans ; late Surgeon to Manhattan State Hospital, New 
 
 York; late Assistant Instructor in Operative Surgery, College of Physicians and Surgeons 
 
 (Columbia University), New York ; late Instructor in Surgery, New York Post-Graduate 
 
 Medical School and Hospital; late Instructor in Surgery, New York Polyclinic 
 
 Medical School and Hospital ; late Yisiting Surgeon to Charity Hospital, 
 
 New Orleans ; late Demonstrator of Operative Surgery, Medical 
 
 Department, Tulane University of Louisiana, New Orleans ; 
 
 Fellow of the New York Academy of Medicine, etc. 
 
 THIRD EDITION, GREATLY ENLARGED 
 CONTAINING 854 ILLUSTRATIONS 
 
 PHILADELPHIA AND LONDON 
 
 W. B. SAUNDERS COMPANY 
 
 1 908 
 
Set up, electrotyped, printed, and copyrighted August, 1903 Revised, reprinted, and recopyrighted 
 
 April, 1904. Reprinted February, 1905, February, 1906, and September, 1906. 
 
 Revised, reprinted, and recopyrighted September, 1908. 
 
 Copyright, 1908, by W. B. Saunders Company. 
 
 !ESS O F 
 
 M O E RS COMP* 
 
IN REVERED MEMORY OF MY FATHER 
 
 Cbarles Jasper 36icfebam 
 
 WHOSE DAILY LIFE EMBODIED THE HIGHEST IDEALS OF CHRISTIAN 
 PHYSICIAN, I LOVINGLY DEDICATE THIS WORK 
 
PREFACE TO THIRD EDITION. 
 
 The scope of the alterations in this edition of the present work is suffi- 
 ciently shown by the additions and omissions here indicated. 
 
 The last edition of this work contained 984 pages, including 559 illustra- 
 tions. 
 
 The present edition contains 1204 pages, including 854 illustrations. 
 
 In the new edition the following changes have been made from the old: 
 29 pages of text, covering 25 operations, have been dropped; 123 pages of 
 text, descriptive of 106 operations, have been added; 42 old pictures have 
 been omitted; 45 old pictures have been redrawn; and 331 new pictures 
 have been added. 
 
 The Author especially desires to express his appreciation of the kindly 
 reception of his efforts by the Profession — Surgical and Medical — as evi- 
 denced by the demand for additional editions, and trusts that the recent 
 changes and additions in the writings and illustrations will materially add 
 to the general usefulness of the work. 
 
 Deep gratitude is due the author's Wife for her constant aid throughout 
 the work, and for her unfaltering encouragement during the many days of 
 its preparation. 
 
 The writer wishes to testify his sincere appreciation of the continuous 
 and substantial aid given him by Mrs. Farnsworth, his Assistant, in the 
 general work of revision, and especially in the drawing of considerably the 
 larger number of the new pictures. 
 
 Thanks are again extended to Miss Fry for those illustrations made by 
 her. 
 
 The liberality of the Publishers in arranging the details of the revision 
 and the excellence of its execution are fully acknowledged. 
 
 Finally, the writer desires to express his earnest esteem of the many 
 valuable intellectual opportunities, and of the large practical contact with 
 surgical work, resulting from the close professional and friendlv associate- 
 ship with Professor Rudolph Matas, whose general surgical knowledge, 
 marvelous in its extent and detail, is most probably not exceeded by that of 
 any Surgeon living. 
 
 W. S. B. 
 
 New Orleans, September, 1908. 
 3521 Prytania Street. 
 
PREFACE TO THE FIRST EDITION. 
 
 The sub-title of the present volume sufficiently designates its intended 
 scope — "The Surgical Anatomy and Operative Technic involved in the 
 Operations of General Surgery." The work is planned to be a presentation 
 to the Student and Practitioner of the best technic of modern Surgeons in 
 the operations mentioned — accompanied by a brief summary of the descrip- 
 tive and surgical anatomy of the structures involved. 
 
 The clinical aspect of Operative Surgery has been less fully dealt with — 
 and in generalizations in connection with groups of operations, rather than 
 specifically in connection with individual operations. 
 
 An apology for the amount of Anatomy given may seem, to some, neces- 
 sary. From the standpoint of the pure technician, Operative Surgery is, 
 largely, Applied Anatomy — the application of the facts of Surgical Anatomy 
 during the progress of Surgical Manipulations — the resulting Operative 
 Technic being more or less perfect as the knowledge of the Surgical Anatomy 
 and the conduction of the Surgical Manipulations are more or less perfect. 
 Theoretically, it is proper to expect fourth-year Students to come into the 
 Operating Room with their Anatomy in an available form for surgical work 
 — practically, this is rarely found — and is often absent in seasoned Operators. 
 
 In the arrangement of this work the subjects have been grouped under, 
 The Operations of General Surgery (Part I), and, The Operations of Special 
 Surgery (Part II) — as further detailed in the especially full Contents. In 
 dealing with each group of tissues, or class of operations (in Part I), or with 
 each organ (in Part II), the following divisions of the subjects are taken up, 
 in order:— (i) Surgical Anatomy (of the region or organ); (2) Surface Form 
 and Landmarks; (3) General Surgical Considerations (in operating upon 
 that region or organ) ; (4) Instruments (used in such operations) — all being 
 introductory to the specific operations, — after which each operation is taken 
 up in turn, under the following headings: — (1) Title of Operation; (2) De- 
 scription of Operation (including its general indications); (3) Preparation 
 of Patient; (4) Position of Patient, Surgeon, and Assistant; (5) Landmarks 
 of Operation; (6) Incision for Operation; (7) Steps of Operation; (8) Com- 
 ments. 
 
 In the description of the technic of the operations the "Incision" is given 
 a heading to itself — to emphasize the importance of this step of the operation 
 — recognizing that the Operator who starts out aright is a long way ahead 
 of the man who takes his initial step erroneously. Under "Operation" the 
 various steps are given in numbered paragraphs — the different paragraphs 
 usually indicating, in a general way, some change in the technic or in the 
 stage of the operation. 
 
 The Principles of Operative Surgery, and Anesthesia, as well as the 
 Operations of Plastic Surgery, many of the operations more properly classed 
 as the operations of Special Branches of Surgery, and some of the many 
 variations of the operations of General Surgery, have been omitted. 
 
2 PREFACE. 
 
 In the preparation of these pages, obligations are hereby gratefully and 
 fully acknowledged to the writings of many well-known Surgeons in the 
 standard works of the day upon Operative Surgery, and in the current surgical 
 literature, whose pages have been freely consulted — and to the work of many 
 Surgeons, here and abroad, whose operative technic it has been the privilege 
 of the author to witness — and to writings upon Anatomy. 
 
 The name of the deviser of an operation is given, in brackets, after the 
 title of the operation, wherever known to the author. Where slight de- 
 partures from the manner of doing the operation as performed by its originator 
 occur, such omission is accidental — or, where the original description is 
 ambiguous, the operation is given as it seems to be interpreted by the majority 
 of Surgeons. 
 
 Appreciation of encouragement shown during the preparation of the 
 manuscript is gratefully acknowledged to Professors Bull, Dennis, Hal- 
 sted, Hartley, Matas, Richardson, Senn, Weir, and Wyeth — and to my 
 co-workers, Doctors Peck, Schmitt, and Taylor, in the Department of Op- 
 erative Surgery at the College of Physicians and Surgeons — and to Doctor 
 Gessner, my former co-worker in the Laboratory of Operative Surgery 
 of Tulane University — and to Doctors Armstrong and LeBeuf — and to 
 other friends whose kindly words have aided and lightened the work of 
 preparation. 
 
 The author feels deeply indebted to Miss Eleanora Fry, who has drawn, 
 under his close directions, all the illustrations for the book, during many 
 weeks of conscientious work and unflagging interest — the large majority of 
 the five-hundred and fifty-nine illustrations being original, and the remainder 
 so largely modified as to be, in many instances, practically new pictures. 
 
 I wish to thank the Publishers for the courteous consideration they have 
 shown my every expression of wish throughout — for their interest in the 
 manuscript — and for the quality of their finished work. 
 
 I desire to express my high valuation of my Wife's ever-ready and untiring 
 aid in all the proof-readings of the manuscript during the many months 
 of its preparation. 
 
 The imperfections of the present work are very fully realized — and the 
 author will be glad to receive all criticisms which may tend to the bettering 
 of the text and illustrations. 
 
 WARREN STONE BICKHAM. 
 
 10 East 58TH Street, 
 New York City. 
 
CONTENTS. 
 
 PART I. 
 THE OPERATIONS OF GENERAL SURGERY. 
 
 CHAPTER I. 
 OPERATIONS UPON ARTERIES. 
 
 I. Ligation of arteries — General considerations, 17. 
 
 II. Surgical Anatomy and Ligation of following Arteries of Head and Neck:— Innominate, 
 by angular incision (Mott's operation), 27 — By oblique incision, 30 — By partial bony resection 
 (Bardenheuer's operation), 31 — By splitting of manubrium sterni, 31 — Common carotid, above 
 omohyoid, 34 — Below omohyoid, 35 — External carotid, below digastric, 37 — Above digastric, 
 behind ramus of jaw, 38 — Lingual, near origin, 39 — Beneath hyoglossus, 39 — Facial, near 
 origin, 41 — Over inferior maxilla, 41 — Occipital, near origin, 42 — Behind mastoid process, 
 42 — Temporal, just above zygoma, 43 — Internal maxillary (surgical anatomy), 44 — Trunk 
 of middle meningeal, in cranium, through trephine-opening exposed by curved oblique incision, 
 47 — Anterior branch of middle meningeal, through trephine-opening exposed by horseshoe 
 incision, 48 — Posterior branch of middle meningeal, through trephine-opening exposed by 
 horseshoe incision, 49 — Internal carotid, near origin, 50 — First part of right subclavian, by 
 angular incision, 52 — First part of left subclavian, by angular incision, 52 — Second part of 
 subclavian, 53 — Third part of subclavian, 53 — Vertebral, near origin, 55 — Inferior thyroid, 57. 
 
 III. Surgical Anatomy and Ligation of following Arteries of Upper Extremity and Thorax: 
 — Internal mammary, in second intercostal space, 58 — First part of axillary, by curved trans- 
 verse incision below clavicle, 60 — Third part of axillary, 62 — Brachial, in mid-arm, 64 — At 
 bend of elbow, 65 — Radial, in upper third, 69 — In lower third, 70 — Deep palmar arch, 72 — 
 Ulnar, in middle third, 74 — In lower third, 76 — Intercostal, by intercostal incision, 76 — Inter- 
 costal, by partial subperiosteal excision of rib (Hartley's method), 78. 
 
 IV. Surgical Anatomy and Ligation of following Arteries of Trunk: — Abdominal aorta, 
 by transperitoneal method, 79 — By retroperitoneal method, 80 — Common iliac, by retroperitoneal 
 method, Si — By transperitoneal method, 83 — Internal iliac, by retroperitoneal method, 84 — 
 By transperitoneal method, 84 — Sciatic, upon buttock, 84 — Internal pudic, upon buttock, 87 — 
 In perineum, 87 — Gluteal, on buttock, 87 — External iliac, by retroperitoneal method, 89 — By 
 transperitoneal method, 91. 
 
 V. Surgical Anatomy and Ligation of following Arteries of Lower Extremity: — Common 
 femoral, at base of Scarpa's triangle, 93 — Profunda femoris, near origin, 95 — Superficial femoral, 
 at apex of Scarpa's triangle, 96 — In Hunter's canal, 98 — Popliteal, in upper part of popliteal 
 space, from behind, 100 — In upper part of popliteal space, from inner side of thigh, Jobert's 
 operation, 100 — In lower part of popliteal space, 10 1 — Anterior tibial, in upper third, 104 — 
 In middle third, 105 — In lower third, 105 — Dorsalis pedis, just below ankle-joint, 107 — Pos- 
 terior tibial, in upper third, above peroneal branch, 109 — In middle third, no — In lower third, 
 112 — Behind internal malleolus, 112 — Peroneal, in middle of leg, 114 — External plantar in 
 sole of foot, 116 — Internal plantar, at origin, 117 — In sole of foot, 117. 
 
 VI. Temporary ligation, 118 — Intermediate ligation, 118 — Arteriorrhaphy, 118 — Closure 
 of wounds of larger arteries by special rubber plaster (Brewer's method), 124 — Aneurismor- 
 rhaphy (Matas' method), 125 — Operation for the radical cure of anteriovenous aneurisms, with 
 preservation of circulation in artery and vein (Matas-Bickham operation), 133 — Ligation for 
 radical cure of aneurism, 139 — Other operations for radical cure of aneurism, 139 — Arterial 
 forcipressure, 140 — Arteriostrepsis, 140 — YVyeth's treatment of vascular neoplasms, 14 r. 
 
 3 
 
4 CONTENTS. 
 
 CHAPTER IE 
 OPERATIONS UPON VEINS. 
 
 Phlebotomy, 142 — Phleborrhaphy, 142 — Lateral ligation of veins, 143 — Transverse liga- 
 tion of veins, 144 -Temporary ligation of veins, 144 — Venous ligation en masse, 145 — Venous 
 forcipressure, 145 — Phlebostrepsis, 145 — Acupressure of veins, 145 — Phlebectomy, 145 — - 
 Intravenous infusion of normal salt solution, 140. 
 
 CHAPTER III. 
 
 OPERATIONS UPON LYMPHATIC GLANDS AND VESSELS. 
 
 Surgical anatomy of thoracic duct, 148 — Suture of thoracic duct, 148 — Ligation of thoracic 
 duct, 149 — Surgical anatomy of antero-lateral aspect of neck, 149 — Removal of lymphatic 
 glands of neck, 151 — Surgical anatomy of axillary region, 154 — Removal of axillary lymphatic 
 glands, 155 — Surgical anatomy of Scarpa's triangle, 155 — Removal of inguinal lymphatic 
 glands, 156. 
 
 CHAPTER IV. 
 OPERATIONS UPON NERVES, PLEXUSES, AND GANGLIA. 
 
 I. Neurotomy, 157 — Neurectomy, 158 — Neurectasy, 158 — Nerve-avulsion, 159— 
 Neurorrhaphy, 160 — Neuroplasty, 163 — Nerve-grafting, 165 — Neurolysis, or an operation for 
 relief of nerve-compression, 169 — Intraneural infiltration for regional anesthesia (operation 
 of Matas and Crile), 169 — Paraneural infiltration for regional anesthesia (Matas' method), 
 171 — Massive infiltration anesthesia with weak analgesic solutions (Matas' modification of 
 Schleich's method), 172. 
 
 II. Surgical Anatomy and Exposure of following Nerves and Ganglia of Head and Neck: — 
 Gasserian ganglion and three divisions of fifth, by direct infra-arterial (Cushing's method), 175 — 
 Same, by intracranial exposure (Hartley-Krause method), 177 — Same, by trephining through 
 pterygomaxillary fossa (Rose's method), 181 — Supraorbital, at supraorbital foramen, 182 — 
 Exposure of superior maxillary nerve at foramen rotundum by osteoplasic resection of malar 
 and adjacent bones (Kocher's operation), 183 — Meckel's ganglion and superior maxillary, 
 by antral route (Carnochan's operation), 185 — Same, by orbital route, 186 — Same, by pterygo- 
 maxillary route (Braun-Loessen operation), 1S6 — Exposure of inferior maxillary nerve at foramen 
 ovale by osteoplastic resection of malozygomatic arch (Kocher's operation), 188 — Inferior maxill- 
 ary, at foramen ovale, 190; or superior maxillary, at foramen rotundum (Mixter's operation), 190 
 — Inferior dental, in mouth (Paravicini's intrabuccal method), 191 — Through ascending ramus 
 of inferior maxilla, 192 — At mental foramen, from within mouth, 193 — Lingual (gustatory) of 
 inferior maxillary, in mouth, 194 — Facial, in front of mastoid process (Baum's operation), 195 — 
 Spinal accessory, at anterior border of sternomastoid, 195 — Facio-accessory or facio-hypoglossal 
 anastomosis for peripheral facial paralysis, 196 — Posterior divisions of first, second, and third 
 cervical nerves (Keen's operation), 197 — Brachial plexus, in neck, 198 — Operation for brachial 
 birth palsy, 199. 
 
 III. Surgical Anatomy and Exposure of following Nerves of Upper Extremity and Thorax: 
 — Median, in middle of arm, 201 — At bend of elbow, 202 — Ulnar, above middle of arm : 202 — 
 Just above internal condyle of humerus, 203 — Musculospiral, below middle of arm, 203 — 
 Intercostal, between angle and middle of rib, 204. 
 
 IV. Surgical Anatomy and Exposure of following Nerves of Lower Extremity: — Anterior 
 crural, below Poupart's ligament, 205 — Obturator, at thyroid foramen, 205 — Superior gluteal, 
 upon buttock, 205 — Pudic, upon buttock, 205 — Great sciatic, at lower border of gluteus maximus, 
 206 — Internal popliteal, at lower part of popliteal space, 206 — Posterior tibial, between origin 
 and ankle, 207 — Behind internal malleolus, 207 — External popliteal (peroneal), behind tendon 
 of biceps, 207 — Anterior tibial, near origin, 208. 
 
 V. Surgical Anatomy of Cervical Sympathetic Ganglia and Cord, 208 — Total excision 
 of cervical sympathetic ganglia and cord (Jonnesco's operation), 209. 
 
 CHAPTER V. 
 OPERATIONS UPON BONES. 
 
 Osteotomy in general, 210— Linear osteotomy, by subcutaneous method, 211— Linear 
 osteotomy, by open method, 213 — Cuneiform osteotomy, 214— The operative treatment of 
 fractures in general, 214— Operations for recent or ununited fractures, by resection of ends 
 
CONTENTS. 5 
 
 of bones, with retention of coaptated ends by immobilizing splints, 215 — Same, by suturing 
 of ends of bones, with or without resection, 217 — Other operative methods of approximating 
 and fixing ends of fractured bones, 221 — Operative treatment of simple fractures, 225 — Bone- 
 grafting or bone-implantation, 227 — Operations for delayed union, non-union, and mal-union 
 of fractures, 228 — Operative treatment of compound, comminuted, and complicated fractures, 
 230 — Operative treatment of fractures involving joints and of fracture dislocations, 231 — 
 Operative treatment of separated epiphyses, 232 — Operation for recent or ununited fracture 
 of patella, by suturing soft parts (Stimson's method), 233 — Same, by wiring or suturing of bone 
 and soft parts, 234 — Same, by an encircling suture of soft parts, 236 — Operation for recent 
 or ununited fracture of olecranon, by wiring or suturing of bone and soft parts, 238 — Seques- 
 trotomy, 239 — Osteoplasty, 240 — Excision, 240. 
 
 CHAPTER VI. 
 OPERATIONS UPON JOINTS. 
 
 Exploratory puncture of joints, 241 — Arthrotomy, 241 — Arthroplasty, 241 — Arthrodesis, 
 242 — Erasion, or arthrectomy, 242 — Operation for dislocated semilunar cartilages, 244 — 
 Excision, 244. 
 
 CHAPTER VII. 
 
 OPERATIONS UPON MUSCLES. 
 
 Myotomy, 245 — Myorrhaphy, 245 — Muscle-lengthening, 246. 
 
 CHAPTER VIII. 
 OPERATIONS UPON TENDONS AND TENDON-SHEATHS. 
 
 Tenotomy, 249 — Tenorrhaphy, 251 — Tendon-lengthening, 254 — Tendon-shortening, 259 — 
 Tendon-grafting, 261 — Operation for uniting tendon to periosteum (Lange's method), 263 — ■ 
 Operation for uniting tendon to bone (Wolff's method), 264 — Transplantation of tendon with 
 its osseous insertion, 265 — Repair of ruptured or divided tendon-sheaths, 265 — Excision of 
 tendon-sheaths, 267. 
 
 CHAPTER IX. 
 
 OPERATIONS UPON LIGAMENTS. 
 
 Syndesmotomy, 267 — Suturing of ligaments, 267 — Lengthening of ligaments, 267 — Shorten- 
 ing of ligaments, 267. 
 
 CHAPTER X. 
 
 OPERATIONS UPON FASCIAE. 
 
 Fasciotomy or aponeurotomy, 269 
 
 CHAPTER XI. 
 OPERATIONS UPON BURS^E. 
 
 Puncture of bursas, 270 — Incision of bursa?, 270 — Excision of bursa?, 270. 
 
 CHAPTER XII. 
 AMPUTATIONS AND DISARTICULATIONS. 
 
 I. General considerations, 271 — The general technic in amputating, 274 — Location of 
 line of bone-section, or disarticulation, 274 — Location of limits of skin incisions, 275 — Incision 
 of skin and fascia, 276 — Freeing of skin and fascia, 279 — Retraction of skin and fascia, 2S0 — 
 Division of muscles in circular methods of amputation, 2S1 — Division of muscles in flap methods 
 of amputation, 284 — Freeing and retracting of muscles, 2S8 — Making musculo-periostcal, or 
 
6 CONTENTS. 
 
 periosteo-capsular, covering for end of bone, 289 — Retraction of soft parts preparatory to sawing 
 bone, 292 — Sawing bone or bones, 292 — Removing splintered bone, 294 — Ligating arteries and 
 veins, 295 — Treatment of nerves, tendons, and tags of muscle, fascia, and skin, 297 — Trimming 
 of flaps, 297 — Re-amputation for improperly made flaps, 297 — Adjustment and suturing of 
 musculo-periosteal, or periosteo-capsular, covering, 297 — Quilting of muscles, 298 — Drainage, 
 300 — Suturing of stump, 300 — Dressing of wound, 301 — Removal of dressings, 301. 
 
 II. The methods of amputation, 301 — The evolution of amputation methods, 301 — Sum- 
 mary of amputation methods, 303 — Circular methods of amputation, 303 — Ordinary circular 
 amputation (Amputation circulaire infundibuliforme), 303 — Cuff method of circular amputation 
 (Circular amputation a la manchette), 305 — Modified circular amputation (mixed method), 
 306 — Oval method, 307 — Racket method, 308 — Flap methods of amputation, 309 — Amputating 
 by single flap of skin and muscle, 309 — By single flap of skin, 311 — By equal flaps of skin and 
 muscle, 311— By equal flaps of skin, 311 — By unequal flaps of skin and muscle, 313 — By unequal 
 flaps of skin, 314 — By unequal rectangular flaps of skin and muscle (Teale's method), 314 — 
 Elliptical method, 315 — Osteoplastic amputations, 317 — Irregular methods of amputation, 
 3*7 — Selection of amputation method, 317 — Primary, intermediate, and secondary amputa- 
 tions, 319. 
 
 III. The amputation stump, 319 — Qualities of a good stump, 319 — Characteristics of 
 a bad stump, 320 — Conditions influencing vitality of stump, 320 — Contractility of tissues of 
 stump, 321 — Position of stump cicatrices, 321 — Function of amputation-stumps, 321 — Site 
 of amputation in connection with the resulting stump and its adaptability to an artificial limb, 
 322. 
 
 IV. Surgical Anatomy, Surface Form and Landmarks, General Surgical Considerations 
 and Methods in Amputations and Disarticulations about the Fingers: — Amputation through 
 last phalanx, by palmar flap, 327 — At second phalangeal joint, by palmar flap, 329 — Same, 
 by short dorsal and long palmar flaps, 329 — Through second phalanx, by palmar flap, 330 — 
 Same, by short dorsal and long palmar flaps, 330 — At first phalangeal joint, by palmar flap, 
 331 — Same, by short dorsal and long palmar flaps, 331 — Through first phalanx, by palmar 
 flap, 331 — Same, by short dorsal and long palmar flaps, 332 — At metacarpophalangeal joints 
 of fingers in general, by oval method, 332 — Same of thumb, by oval method, 334 — Same of thumb, 
 by oblique palmar flap (Farabeuf), 335 — Same of index, by externo-palmar flap (Farabeuf), 
 335 — Same of little finger, by interno-palmar flap (Farabeuf), 336. 
 
 V. Same, in Amputations and Disarticulations about the Hand: — Amputation of finger, 
 in general, with part of its metacarpals, by racket method, 341 — Of thumb, with part of its 
 metacarpal, by racket, 342 — Of little finger, with part of its metacarpal, by racket, 342 — Of two 
 contiguous inside fingers, with part of their metacarpals, by racket, 342 — Of three innermost 
 fingers, with parts of their metacarpals, by racket, 342 — Same, by equal dorsal and palmar 
 flaps, 343 — Of all fingers (except thumb), with parts of their metacarpals, by anterior ellipse, 
 343 — Of an inner finger, with its metacarpal, by racket, 344 — Of index, with its metacarpal, by 
 racket, 344 — Of little finger, with its metacarpal, by racket, 344 — Of thumb, with its metacarpal, 
 by racket, 345 — Of two continuous inside fingers, with their metacarpals, by racket, 346 — 
 Of three inside fingers, with their metacarpals, by rackets, 346 — Of three inner fingers, with their 
 metacarpals, by equal dorsal and palmar flaps, 346 — Of all fingers (except thumb), with their 
 metacarpals, by anterior ellipse, 348 — Of fingers and thumb, at carpo-metacarpal articulation, 
 by palmar flap, 348. 
 
 VI. Same, in Disarticulations about the Wrist-joint: — Disarticulation at wrist-joint by 
 anterior ellipse, 351 — By palmar flap, 352 — By external lateral, or radial, flap (Dubrueil's method), 
 353- 
 
 VII. Same, in Amputations about the Forearm: — Through lower third, by modified cir- 
 cular, 356 — By circular (cuff variety), 357 — Through upper two-thirds, by equal anterior and 
 posterior flaps, 358. 
 
 VIII. Same, in Disarticulations about Elbow-joint: — Disarticulation of elbow-joint, by 
 anterior ellipse (Farabeuf), 362 — By posterior ellipse, 363 — By long antero-internal and short 
 postero-external flaps, 364. 
 
 IX. Same, in Amputations about the Arm: — Amputation through lower third, by modified 
 circular, 368 — Through upper two-thirds, by long anterior and short posterior flaps, 370 — 
 Through surgical neck, by single external flap, 370. 
 
 X. Same, in Disarticulations about the Shoulder-joint: — Disarticulation at shoulder-joint 
 by anterior racket (Spence's operation), 378— By external racket (Larrey's operation), 381— 
 By external or deltoid flap, 382. 
 
 XI. Amputation of Upper Limb, together with Scapula and part of Clavicle, by antero- 
 inferior (or pectoro-axillary) and postero-superior (or cervico-scapular) flaps (Berger's opera- 
 tion), 383. 
 
 XII. Surgical Anatomy, Surface Form and Landmarks, General Surgical Considerations, 
 and Methods in Amputations and Disarticulations about the Toes: — Amputation through 
 last phalanx, by plantar flap, 388— At second phalangeal joint, by plantar flap, 389— Through 
 
CONTENTS. 7 
 
 second' phalanx, by plantar flap, 390 — At first phalangeal joint, by oval, 390 — Through first 
 phalanx, by oval, 392 — Same, by circular, 392 — At metatarso-phalangeal joints of toes in general, 
 by oval method, 392 — At' same of great toe, by interno-plantar flap (Farabeuf), 393 — At same 
 of little toe, by externo-dorsal flap (Farabeuf), 394 — Disarticulation of two adjoining toes at 
 metatarso-phalangeal joints, by oval method, 395 — Of toes en masse, at metatarso-phalangeal 
 joint, by equal short dorsal and plantar flaps, 395. 
 
 XIII. Same, in Amputations and Disarticulations about Foot: — Amputation of all toes 
 through the metatarsus, by short dorsal and long plantar flaps (Metatarsal amputation), 402 — 
 Disarticulation of toe, with its entire metatarsal, by racket method, 404 — Of great toe and its 
 metatarsal, by racket, 404 — Of little toe and its metatarsal, by racket, 406 — Of two or three 
 contiguous toes with their entire metatarsals, by oval or racket, 407 — Of all toes, at tarso- 
 metatarsal joints, by short dorsal and long plantar flaps (Lisfranc's operation), 407 — Of all 
 toes, at tarso-metatarsal joints, with sawing off of end of internal cuneiform, by short dorsal 
 and long plantar flaps (Hey's operation), 408 — Of anterior part of foot at medio-tarsal joint, 
 by short dorsal and long plantar flaps (Chopart's operation), 409 — Of foot at astragalo-scaphoid 
 and astragalo-calcaneal joints, subastragaloid disarticulation, by large interno-plantar flap 
 (Farabeuf), 410 — Of foot at astragalo-scaphoid and astragalo-calcaneal joints, subastragaloid 
 disarticulation, by heel-flap, 412. 
 
 XIY. Same, in Disarticulations about Ankle-joint: — Disarticulation of foot at ankle- 
 joint, with removal of malleoli and articular surface of tibia, by heel-flap (Syme's operation), 
 414 — Disarticulation of foot at ankle-joint, with removal of malleoli, articular surface of tibia, 
 and anterior part of os calcis, by heel-flap (Pirogoff's operation), 415. 
 
 XV. Same, in Amputation about the Leg: — Through supramalleolar region, by oblique 
 elliptical incision (Guyon's supramalleolar operation), 419 — Through lower third, by large 
 posterior and small anterior flaps (Farabeuf), 420 — Osteoplastic amputation, by long posterior 
 and short anterior flaps, 422 — Through middle third, by long posterior and short anterior flaps 
 (Hey's operation), 424 — Through upper third, by large external flap (Farabeuf), 425 — Same, 
 by bilateral hooded flaps (Stephen Smith's method), 427 — Osteoplastic amputation, through 
 upper third, by antero-internal flap (Bier's method), 429. 
 
 XVI. Same, in Disarticulations about the Knee-joint: — Disarticulation at knee-joint 
 by bilateral hooded flaps (Stephen Smith), 434 — By an oblique curved incision, 435. 
 
 XVII. Same, in Amputations about the Thigh: — Through condyles of femur, transcondyloid 
 amputation, by shorter anterior and longer posterior flaps (Lister's modification of Carden's 
 transcondyloid operation), 440 — Just above condyles of femur, with splitting of patella (supra- 
 condyloid osteoplastic amputation of Gritti-Stokes) by longer anterior and shorter posterior 
 flaps, 441 — Femorotibial osteoplastic amputation of lower limb, by longer anterior and shorter 
 posterior flaps (Ssabanajeff's operation), 443 — Through lower third of thigh by oblique circular 
 method, 444 — Through thigh in general, by long anterior and short posterior flaps, 446 — Same, 
 by equal anterior and posterior flaps, 448 — Through thigh just below trochanters, by external 
 oval method, 449. 
 
 XVIII. Same, in Excisions about the Hip-joint: — Disarticulation at hip-joint by Wyeth's 
 method, 456 — By external racket, 458 — By anterior racket, 459 — Interilio-abdominal amputa- 
 tion (Keen's method), 460. 
 
 CHAPTER XIII. 
 EXCISIONS AND OSTEOPLASTIC RESECTIONS OF BONES AND JOINTS. 
 
 I. General Considerations, 463 — Excision by subperiosteal method, 463 — Excision by 
 open method, 467 — Excision of coccyx, by posterior median incision, 468 — Surgical anatomy 
 in excisions about superior maxilla, excision of superior maxilla, by median incision (Fergusson's 
 operation), 471 — Osteoplastic resection of superior maxilla, by vertical and horizontal incisions, 
 473 — Chondroplastic resection of nasal cartilages, to expose nose and anterior nasopharynx 
 by nasal route, by transverse incision (Rouge's operation), 473 — Osteoplastic resection of superior 
 maxilla, to expose nasopharynx by palatine route, by transverse and median incisions (Annan- 
 dale's operation), 474 — Osteoplastic resection of superior maxilla, to expose nasopharynx by 
 maxillary route, by two semilunar incisions (Langenbeck's operation), 474 — Surgical anatomy 
 in excisions about inferior maxilla, excision of temporomaxillary articulation, by angular incision, 
 476 — Excision of inferior maxilla, by single incision along inferior and posterior borders, 477 — 
 Osteoplastic resection of lower jaw, to expose structures in pharynx and upon floor of mouth, 
 479 — Excision of ribs, in general, 479 — Excision of entire rib and costal cartilage by parallel 
 incision over center of rib, 480 — Excision of clavicle, in general, 480 — Total excision of clavicle 
 by long axial incision, 481 — Total excision of scapula, by straight incisions along spine and 
 vertebral border, forming superior and inferior flaps, 482. 
 
8 CONTENTS. 
 
 II. Surgical Anatomy, Surface Form and Landmarks, General Surgical Considerations 
 and Methods in Excisions about the Fingers: — Excision of terminal phalanges, by U-shaped 
 incision, 484 — Of second phalangeal joints, by two lateral incisions, 484 — Of second phalangeal 
 joint of index, by dorso external incision, 486 — Of second phalangeal joint of little finger, by 
 dorso-internal incision, 486 — Of second phalanges of fingers in general, by dorso-lateral incision, 
 486 — Of second phalanx, by dorso-external incision, for index-finger, 486 — Of second phalanx 
 of little finger, by dorso-internal incision, 487 — Of first phalangeal joints, by same methods 
 as for second phalangeal joints, 487 — Of first phalanges of fingers in general, 487. 
 
 III. Same, in Excisions about Hand: — Excision of metacarpophalangeal joints of fingers, 
 in general, by dorso lateral incision, 487 — Of metacarpals, in general, by dorsal incision, 488 — 
 Of metacarpal of thumb, by dorso-external incision, 489 — Of metacarpal of little finger, by 
 dorso-internal incision, 489. 
 
 IV. Same, in Excisions about Wrist-joint: — Excision of wrist by radial and ulnar dorsal 
 incisions (Oilier), 490 — Same, by single dorso-radial incision (Boeckel-Langenbeck), 491 — 
 Excision of wrist-joint, by single dorso-ulnar incision (Kocher's method), 492. 
 
 V. Same, in Excisions about Bones of Forearm: — Total excision of ulna, by long posterior 
 incision, 493 — Same, of radius, by long externo-dorsal incision, 494. ■ 
 
 VI. Same, in Excision about Elbow-joint: — Excision of elbow -joint, by posterior median 
 incision (Langenbeck), 495 — Same, by posterior bayonet-shaped incision, with or without an 
 additional short vertical ulnar incision (Oilier), 497 — Excision of elbow-joint, by vertically 
 curved dorso-external incision (Kocher's method), 498 — Excision of superior radio-ulnar articu- 
 lation, by posterior vertical incision, 500. 
 
 VII. Same, in Excisions about Humerus: — Excision of humerus, by long external incision, 
 501. 
 
 VIII. Same, in Excisions about Shoulder-joint and vicinity: — Excision of shoulder-joint, 
 by anterior oblique incision, 502 — Osteoplastic resection of shoulder-joint, by posterior curved 
 incision (Kocher's method), 503. 
 
 IX. Same, in Excisions about the Toes: — Excision of terminal phalanges, 423 — Of second 
 phalangeal joints, 506 — Of second phalanges, 506 — Of first phalangeal joint, 506 — Of first 
 phalanges, 507. 
 
 X. Same, in Excisions about Foot: — Excision of metatarso-phalangeal joints, 507 — Of 
 metatarsals, 507 — Of astragalus, by external curved incision, 507 — Same, by external angular 
 and internal curved incisions, 508 — Of os calcis, by horizontal curved and vertical incisions, 510. 
 
 XI. Same, in Excisions about Ankle-joint: — Excision of ankle-joint, by transversely curved 
 external incision (Lauenstcin), 511 — Same, by external curved and internal angular incisions, 
 512 — Osteoplastic resection of anterior tarsus and tarsometatarsus, by internal and external 
 dorsolateral incisions, 513 — Osteoplastic resection of mid-tarsus, by external transverse curved 
 incision, 514 — Osteoplastic resection of posterior tarsus, by external curved incision, 515 — 
 Osteoplastic resection of foot, by transverse upper and lower and oblique lateral incisions (Wladi- 
 miroff-Mikulicz operation), 516 — Total excision of tarsus, by externo-lateral curved incision 
 (modification of Wladimiroff-Mikulicz operation), 518. 
 
 XII. Same, in Excisions about Bones of Leg:— Total excision of tibia, by internal vertical 
 incision, 519 — Total excision of fibula, by posterior vertical incision, 520 — Total excision of 
 patella, by vertical incision, 520. 
 
 XIII. Same, in Excisions about the Knee-joint: — Excision of knee-joint, by curved trans- 
 verse anterior incision, 522 — Excision of knee-joint, by vertically curved external incision 
 (Kocher's method), 523. 
 
 XIV. Same, in Excisions about Femur: — Excision of parts of diaphysis, by external vertical 
 incision, 526. 
 
 XV. Same, in Excisions about Hip-joint: — Excision of hip-joint, by external straight incision 
 (Langenbeck), 528— Same, by anterior straight incision (Barker), 529— Same, by posterior 
 angular incision (Kocher), 530— Excision of the innominate bone (Kocher), 531. 
 
CONTENTS. 
 PART II. 
 
 THE OPERATIONS OF SPECIAL SURGERY. 
 
 CHAPTER I. 
 OPERATIONS UPON THE HEAD. 
 
 I. Crano-cerebral Region: — Surgical anatomy of scalp, skull, and brain, 533 — Chief 
 cranial landmarks, 537 — Cranio-cerebral topography, 538 — Localization of brain areas, 543 — 
 Chipault's method of cranio-cerebral localization, 540 — Bell's cyrtometer in Chipault's method 
 of cranio-cerebral localization, 550 — Reid's method of same, 551 — Kroenlein's method of same, 
 553 — Chiene's method of determining Rolandic fissure, 554 — General surgical considerations 
 in cranio-cerebral operations, 554 — Instruments, 557 — Craniotomy, in general, 557 — Trephining, 
 or circular craniotomy, 55S — Osteoplastic resection of skull, 565 — Linear craniotomy, 580 — 
 Partial craniectomy, 581 — Exploratory puncture of brain, 5S4 — Operation for intracranial 
 hemorrhage, 585 — Ligation of middle meningeal artery and its anterior and posterior branches, 
 586 — Ligation of longitudinal or lateral sinuses, 586 — Operation for thrombosis of lateral sinus, 
 588 — Trephining for fracture of skull, 590 — Operation for bullet-wound of brain, 591 — Opera- 
 tion for exposure of a motor center, 593 — Puncture and drainage of lateral ventricles, 594 — 
 Incision of cerebellar subarachnoid space for drainage (Parkin), 595 — Operation for cerebral 
 abscess, 595 — For cerebellar abscess, 596 — For cerebral tumor, 597 — For cerebellar tumor, 599 
 — Operations upon mastoid antrum and cells, 599 — Operations upon Gasserian ganglion, 599. 
 
 II. Bony (Air) Sinuses of Head and Face: — Operations upon mastoid antrum and cells, 
 600 — Surgical anatomy, 600 — Surface form and landmarks, 602 — General surgical considera- 
 tions, 603 — Operation for exposure of mastoid antrum and cells (Antrum operation of Schwartze), 
 604 — Operation for exposing mastoid antrum and cells, together with interior of tympanun 
 and meatus, and the exenteration of middle-ear cavities (the tympano-mastoid exenteration, 
 or radical operation, of Schwartze-Stacke, or Schwartze-Zaufal), 606 — Operations upon frontal 
 sinuses, 608 — Surgical anatomy, surface form and landmarks, and general surgical considera- 
 tions, 608, 609 — Instruments, 610 — Exposure and drainage of frontal sinuses, 610 — Operations 
 upon maxillary sinuses, 611 — Surgical anatomy, surface form and landmarks, and general surgical 
 considerations, 611, 612 — Instruments, 613 — Opening of maxillary sinus through its facial 
 aspect, above alveolar margin, 613 — Opening through socket of second molar tooth, 614. 
 
 III. Eyeball and Orbit: — Operations upon the eyeball, 614 — Surgical anatomy of orbit, 
 614 — Enucleation of eyeball, 615 — Evisceration of eyeball, 616 — Exenteration of orbit, 616 — 
 Exposure of entra-orbital and retrobulbar structures (Kroenlein's operation), 617. 
 
 IV. Ear and Eustachian Tube: — Surgical anatomy of membrana tympani, 61 8 — Intro- 
 duction of ear speculum for examination of membrana tympani, 618 — Paracentesis tympani, 
 619 — Introduction of Eustachian catheter, 619. 
 
 Y. Xose and Nasal Cavities, 619. 
 
 VI. Tongue: — Surgical anatomy, 619 — General surgical considerations, 620 — Instruments, 
 621 — Excision of limited portion of tongue, 622 — Excision through mouth, without preliminary 
 ligation of lingual arteries (Whitehead), 622 — Excision through mouth, after preliminary ligation 
 of Unguals in neck, 624 — Excision of tongue by median incision through lower lip, chin, and 
 neck, with osteoplastic division of inferior maxilla (Kocher), 624 — Excision of tongue, together 
 with cervical and submaxillary glands, by an incision in neck, after preliminary tracheotomy 
 and ligation of lingual and facial ateries (Kocher), 627. 
 
 CHAPTER II. 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 Surgical anatomy, 629 — Surface form and landmarks, 632 — General surgical considerations, 
 642 — Osteoplastic resection of spine, 648 — Laminectomy, 661 — Subarachnoid puncture for 
 spinal anesthesia, 666 — Lumbar puncture for diagnosis and therapeusis, 669 — Spinal puncture 
 for drainage of subarachnoid space, 670 — Operative treatment of fractures of spine, 670 — 
 Operative treatment of dislocations of spine, 672 — Operative treatment of fracture-dislocations 
 of spine, 673 — Operative treatment of incised and penetrating wounds of cord, 674 — Operative 
 treatment of gunshot wounds of cord, 675 — Intraspinal partial neurectomy of posterior nerve- 
 
IO CONTENTS. 
 
 roots, 679 — Spina bifida, 679 — Operative treatment of posterior vertebral tubercular osteitis 
 of spine, 685 — Operative treatment of anterior vertebral osteitis, Pott's disease, 685. 
 
 CHAPTER III. 
 OPERATIONS UPON THE NECK. 
 
 I. Larynx: — Surgical anatomy of neck, 695 — Surgical anatomy of larynx, 695 — Surface 
 form and landmarks, 695 — Instruments, 696 — Laryngotomy, 697 — Thyrotomy, 698 — Com- 
 plete laryngectomy, 699 — Partial laryngectomy, 700 — Intubation of larynx (O'Dwyer), 701 — 
 Other operations, 702. 
 
 II. Trachea: — Surgical anatomy, 702 — Surface form and landmarks, 703 — General sur- 
 gical considerations, 703 — Instruments, 703 — High tracheotomy, 704 — Low tracheotomy, 
 706 — Other operations, 706. 
 
 III. Pharynx: — Surgical anatomy, 707 — Instruments, 707 — Median pharyngotomy, by 
 median vertical incision through mouth, 708 — Lateral pharyngotomy, by curved lateral incision 
 through neck (Kocher), 708 — Subhyoid pharyngotomy, by transverse curved incision through 
 neck, 709 — Exposure of retro-pharyngeal space, by lateral cervical incision along posterior 
 border of sternomastoid (Chiene), 710. 
 
 IY. Esophagus: — Surgical anatomy, 711 — General surgical considerations, 712 — Instru- 
 ments, 712 — External cervical esophagotomy, 712 — Cervical esophagostomy, 714 — Partial 
 cervical esophagectomy, 714 — Introduction of esophageal bougie, 715 — Other operations, 715. 
 
 V. Tonsils: — Surgical anatomy, 717 — General surgical considerations, 717 — Instruments, 
 717 — Tonsillotomy, 717 — Partial tonsillectomy through mouth, 718 — Complete tonsillectomy 
 through mouth, 718 — Complete tonsillectomy through neck (Cheever), 719. 
 
 VI. Parotid Gland and Stenson's: — Surgical anatomy, 721 — Instruments, 722 — Excision, 
 722. 
 
 VII. Submaxillary Gland and Wharton's Duct: — Surgical anatomy, 724 — Instruments, 
 724 — Excision, 725. 
 
 VIII. Sublingual Gland and Duct of Bartholin: — Surgical anatomy, 726 — Instruments, 
 725 — Excision, through floor of mouth, 726. 
 
 IX. Thyroid Gland: — Surgical anatomy, 727 — Instruments, 727 — Partial thyroidectomy, 
 by angular incision (Kocher), 727 — Complete thyroidectomy, by transverse curved incision 
 (Kocher), 729. 
 
 CHAPTER IV. 
 
 OPERATIONS UPON THE THORAX. 
 
 I. Thoracic Wall and Contents: — Surgical anatomy, 731 — Surface form and landmarks, 
 733 — Instruments, 734 — Chrondroplastic resection of chest-wall, by subcostal incision and 
 temporary division of seventh, eighth, ninth, and tenth costal cartilages, 734. 
 
 II. Female Mammary Gland: — Surgical anatomy, 736 — Surface form and landmarks, 
 736 — General surgical considerations, 736 — Incision of breast, 737 — Partial excision of breast 
 by elliptical incision, 737 — Radical excision, by Meyer's method, 738 — Radical excision, by Hal- 
 sted's method, 741 — Radical excision, by Warren's method, 744 — Ordinary excision, by elliptcal 
 incision, 745 — Subcutaneous excision, by inferior curved incision, 746. 
 
 III. Superior Mediastinum: — Surgical anatomy, 747 — Surface form and landmarks, 
 747 — General surgical considerations, 747. 
 
 IV. Anterior Mediastinum: — Surgical anatomy, 748 — Anterior mediastinal thoracotomy, 
 by long median incision (Milton's anterior mediastinotomy), 748 — Anterior mediastinal thora- 
 cotomy, by osteoplasic resection of part of sternum corresponding with third, fourth, and fifth 
 costal cartilages, 750 — Other operations, 752. 
 
 V. Middle Mediastinum: — Surgical anatomy, 752 — Operations upon middle medias- 
 tinum, 752. 
 
 VI. Posterior Mediastinum: — Surgical anatomy, 752 — Posterior mediastinal thoracotomy, 
 by thoracoplastic flap (Bryant), 752. 
 
 VII. Diaphragm: — Surgical anatomy, 755 — Transthoracic exposure of diaphragm, by 
 partial excision of two or three ribs, 756. 
 
 VIII. Pleura;: — Surgical anatomy, 759 — Surface form and landmarks, 760 — Paracentesis 
 thoracis, 761 — Intercostal thoracotomy, 761 — Thoracotomy, by partial excision of one or 
 more ribs, 763 — Partial pleurectomy (Estlander's thoracoplastic operation), 765 — Partial 
 pleurectomy (Schede's thoracoplastic operation), 768 — Total pleurectomy (Fowler's thoraco- 
 plastic operation), 770 — Discission of pleura in chronic empyema (Ransohoff's operation), 
 771 — Other operations, 771. 
 
CONTENTS. II 
 
 IX. Lungs: — Surgical anatomy, 772 — General surgical considerations, 773 — Pneumotomy, 
 through a cutaneo-muscular thoracoplastic flap, 774 — Partial pneumectomy, through cutaneo- 
 musculo-osseous thoracoplastic flap, 776. 
 
 X. Pericardium: — Surgical anatomy, 7S0 — Surface form and landmarks, 780 — Pericardio- 
 centesis, 7S1 — Pericardiotomy, through intercostal incision, 7S2 — Exposure of pericardium 
 and heart, by excision of left fifth costal cartilage, 7S4 — Pericardiorrhaphy, 7S5. 
 
 XL Heart; — Surgical anatomy, 785 — Paracentesis of right auricle, 787 — Paracentesis of 
 right ventricle, 787 — Exposure of heart and pericardium, by a thoracoplastic flap (Rotter's 
 operation), 788 — Cardiorrhaphy, 790. 
 
 XII. Thoracic Trachea: — Surgical anatomy, 791 — Thoracic tracheotomy, 791. 
 
 XIII. Bronchi: — Surgical anatomy, 791 — Bronchotomy, 791. 
 
 XIV. Thoracic Esophagus, 792 — Surgical anatomy, 792 — Thoracic esophagotomy, by 
 posterior mediastinal osteoplastic flap operation, 792. 
 
 CHAPTER V. 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 I. Abdomino- pelvic Wall: — Surgical anatomy, 793 — Surface form and landmarks, 797 — 
 General surgical considerations, 799 — Instruments, 801 — Median abdominal section, 801 — 
 Anterolateral abdominal section, by McBurney's intramuscular "gridiron" incision, S07 — 
 Anterolateral abdominal section, by the Harrington-Weir prolongation of the anterolateral 
 intra-muscular incision through rectal sheath, with temporary displacement of rectus, 810 — 
 Anterior abdominal section through rectal sheath, with temporary- displacement of rectus, by 
 the Battle-Jalaguier-Kammerer method, 811 — Median inferior abdominal section by Pfannen- 
 stiel's superficial transverse curved, and deep vertical incisions, 815 — Inferior anterolateral 
 abdominal section, by Meyer's "hockey stick" incision, 817 — Inferior anterolateral abdominal 
 section, by Fowler's angular incision, 818 — Superior anterolateral abdominal section, by oblique- 
 subcostal incision, 818 — Exposure of hypochondriac regions by chondroplastic resection of 
 chest-wall, by subcostal incision and temporary division of seventh, eighth, ninth, and tenth 
 costal cartilages, S19 — Lateral abdominal section by Vischer's lumbo-iliac incision, S19. 
 
 II. Peritoneum: — Surgical anatomy, 820 — General surgical considerations, 822 — Opera- 
 tions for separation, division, or ligation of peritoneal adhesions, 822 — Paracentesis 
 abdominis, 824 — Operative treatment of diffuse septic peritonitis (Murphy's method), 825 — 
 Same (Blake's method), 826 — Operative treatment of intra-abdominal abscess, 829. 
 
 III. Omentum: — Surgical anatomy, 830 — General surgical considerations, 831 — Ligation 
 of omentum, 831 — Omental grafting, 832. 
 
 IV. Mesentery: — Surgical anatomy, 833 — General surgical considerations, 833 — Partial 
 excision, 833 — Suturing, 833. 
 
 V. Intestines: — Surgical anatomy of small intestines, 833 — Surface form and landmarks 
 of small intestines, 836 — Surgical anatomy of large intestines, 836 — Surface form and landmarks 
 of large intestines, 839 — General surgical considerations in operations upon the intestines, S40 — 
 Instruments, 840 — Enterotomy, 841 — Enterorrhaphy, in general, 841 — By Lembert's interrupted 
 suture, S43 — By Czerny-Lembert interrupted suture, 844 — By Halsted's interrupted quilt or 
 mattress suture, 845 — By Lembert's continuous suture, 846 — By Cushing's right-angled con- 
 tinuous suture, 846 — By combined overhand continuous suture of all coats, followed by inter- 
 rupted Lembert suturing of outer coats, 848 — Enterorrhaphy for wounds of intestine, 848 — ■ 
 Partial enterectomy, 850 — Entero-enterostomy (intestinal anastomosis, approximation, and 
 implantation) in general, 854 — (A) Entero-enterostomy by methods of simple suturing, in 
 general, 855 — By simple continuous overhand suture of all coats, followed by interrupted or 
 continuous Lembert sutures of outer coats, by author's method, 856 — By perforating mattress 
 sutures knotted in lumen (Connell's method), 864 — By Czerny-Lembert interrupted suture, 
 867 — By Halsted's method of interrupted mattress or quilt sutures, 868 — By Maunsell's invagina- 
 tion method, 870 — (B) Entero-enterostomy by means of absorbable mechanical devices left 
 within the intestines, in general, 878 — By means of absorbable bobbins, 879 — By absorbable 
 buttons, 880 — By Ullmann's modification of Maunsell's method, 881 — By Coffey's method, 
 883 — (C) Entero-enterostomy by means of non-absorbable mechanical devices left within the 
 intestinal canal, in general, 883 — By means of the Murphy button, 885 — Lateral intestinal 
 anastomosis by the Jaboulay button, 892 — Entero-enterostomy by Harrington's segmented 
 rings, 893 — (D) Entero-enterostomy by mechanical means temporarily used for approxima- 
 ting the intestinal edges during suturing, in general, 895 — By means of Lee's intestinal holder, 
 895 — Excision of ilio-caecum, 899 — Appendicectomy, by McBurney's intramuscular operation, 
 900 — Appendicectomy through the rectal sheath, 911 — Appendicectomy, by the non-intramus- 
 cular method, 911 — Appendicectomy, by Weir's operation, 912 — Enterostomy, in general, 
 913 — Right inguinal enterostomy (or ileostomy) for establishment of temporary fecal fistula 
 
12 CONTENTS. 
 
 of a permanent artificial anus, 914 — Colostomy, in general, 916 — Left inguinal colostomy, 
 917 — Anterior intramuscular colostomy (Mixter's operation), 921 — Left lumbar colostomy, 
 924 — Operation for closure of fecal fistula and artificial anus, 927 — Enteroplasty, 930 — Opera- 
 tion for intussusception (Jessett- Barker method), 930 — Colopexy, by Bryant's method, 
 932 — Rectopexy, by Verneuil's method, 933 — Internal rectotomy, 934 — External rectotomy, 
 934 — Excision of rectum, in general, 935 — Excision by sacral route by partial excision of sacrum 
 (Kraske's operation), 935 — Excision by sacral route, by the Rehn-Rydygier osteoplastic flap 
 method, 940 — Excision of lower part of rectum by perineal route, 942 — Operation for cure of 
 hemorrhoids by ligation and excision (Allingham's method), 944 — Operation for cure of hemor- 
 rhoids by excision (Whitehead's method), 945 — Operation for cure of hemorrhoids by clamp 
 and cautery, 946 — Operation for cure of fistula-in-ano by incision, 947. 
 
 VI. Stomach: — Surgical anatomy, 950 — Surface form and landmarks, 951 — General surgi- 
 cal considerations, 951 — Instruments, 952 — Introduction of stomach-tube, 952 — Gastrotomy, 
 by' median incision, 952 — Gastrotomy by oblique subcostal incision, 954 — Gastrorrhaphy, 
 955 — Gastrostomy, in general, 956 — Gastrostomy, by Ssabanajew-Franck's method, 957 — 
 Same, by Witzel's method, 959 — Same, by Marwedel's method, 962 — Same, by Kader's method, 
 964 — Gastro-enterostomy, in general, 967 — Anterior gastro-enterostomy, by simple suturing 
 (Wolfler's method), 968 — Same, by the Murphy button, followed by single or multiple intestinal 
 anastomosis by the Jaboulay-Braun method, 971 — Posterior gastro-enterostomy, by von Hacker's 
 method, 974 — Same, by the Murphy button, 978 — Gastrogastrostomy by Wolfler's method, 
 979 — Gastroplication, by Weir's modification of Bircher's method, 981 — Same, Moynihan's 
 modification of Bircher's operation, 983 — Gastropexy, 983 — Gastrolysis, 983 — Gastroplasty, 
 9S4 — Pyloroplasty, by Heineke-Mikulicz method, 984 — Divulsion of pyloric orifice of stomach, 
 by Loreta's method, 986 — Dilatation of cardiac orifice of stomach, 987 — Gastro-duodenostomy 
 (Finney's operation), 987 — Pylorectomy, in general, 991 — Pylorectomy, followed by independent 
 gastrojejunostomy (Mayo's operation), 991 — Pylorectomy, followed by end-in-side posterior 
 gastro-duodenostomy, by Kocher's method, 994 — Pylorectomy followed by end-to-end gastro- 
 enterostomy, by Billroth's method, 997 — Partial gastrectomy, of median portion, 999 — Total 
 gastrectomy, 1001 — Operation for gastric ulcer, 1002. 
 
 VII. Liver: — Surgical anatomy, 1004 — Surface form and landmarks, 1006 — General 
 surgical considerations, 1006 — Instruments, 100S — Exploratory puncture of liver, 1008 — 
 Hepatotomy, in general, 1009 — Anterior subcostal transperitoneal hepatotomy, by anterior 
 oblique incision parallel with costal arch, 1010 — Exposure of liver by anterior subcostal trans- 
 peritoneal route, by anterior vertical incision through right linca semilunaris, 10 12 — Exposure 
 of liver by lateral subcostal transperitoneal route, by lateral horizontally curved incision below 
 right twelfth rib, 1013 — Exposure of liver by intercostal subpleural route, by intercostal incision 
 below level of pleura, 10 13 — Exposure of liver by subpleural route, by partial excision of one or 
 more ribs below level of the pleura, 1014 — Exposure of liver by subpleural route, by partial 
 excision of one or more ribs opposite the pleura, 10 14 — Exposure of liver by transpleural route, 
 by partial excision of one or more ribs opposite the pleura, 1016 — Exposure of liver by chon- 
 droplastic resection of right costal arch, by anterior oblique subcostal incision, 1017 — Hepator- 
 rhaphy, 1019 — Hepatopexy, 1019 — Partial hepatectomy, 1019 — Operation for cirrhosis of liver, 
 epiplorrhaphy, or epiplopexy (Talma-Drummond operation), 1021. 
 
 VIII. Gall-bladder: — Surgical anatomy, 102 1 — Surface form and landmarks, 1022 — 
 General surgical considerations, 1022 — Instruments, 1022 — Cholecystotomy, by vertical sub- 
 costal incision, 1022 — Cholecystostomy, by oblique or vertical subcostal incision, 1024 — Cho- 
 lecystenterostomy, by Murphy button, 1026 — Cholecystenterostomy by simple suturing, 1028 — 
 Cholecystolithotrity, 1028 — Cholecystectomy, 1029. 
 
 IX. Gall-ducts: — Surgical anatomy, 1030 — Surface form and landmarks, 1031 — Instru- 
 ments, 1031 — General surgical considerations, 1031 — Supraduodenal choledochotomy, 1031 — 
 Retroduodenal choledochotomy (Haaslers operation), 1034 — Transduodenal choledochostcmy 
 (Kocher's operation), 1034 — Cysticotomy, 1035 — Hepaticotomy, 1036. 
 
 X. Spleen: — Surgical anatomy, 1036 — Surface form and landmarks, 1037 — General 
 surgical considerations, 1037 — Instruments, 1038 — Exploratory puncture, 1038 — Splenotomy, 
 by oblique subcostal incision, 1038 — Exposure of spleen by subpleural route, by partial excision 
 of one or two ribs, 1039 — Splenorrhaphy, 1039 — Splenopexy, 1039 — Partial splenectomy, by 
 subcostal incision parallel with ribs, 1040 — Total splenectomy, by vertical incision in left inea 
 semilunaris, 1041. 
 
 XI. Pancreas: — Surgical anatomy, 1043 — Surface form and landmarks, 1044 — General 
 surgical considerations, 1044 — Instruments, 1046 — Pancreatotomy, by gastrocolic route, 1046 — 
 Partial pancreatectomy, by gastrocolic route, 1047. 
 
 XII. Kidneys: — Surgical anatomy, 104S — Surface form and landmarks, 105 1 — General 
 surgical considerations, 1052 — Instruments, 1053 — Retroperitoneal exposure of kidney by 
 oblique lumbar incision, 1053 — Retroperitoneal exposure of kidney, by Koenig's augular lumbo- 
 abdominal incision, 1056 — Retroperitoneal exposure of kidney, by lumbar intramuscular method, 
 1057 — Transperitoneal exposure of kidney, by vertical incision in linea semilunaris (Langenbuch's 
 
CONTEXTS. 13 
 
 operation), 1057 — Transperitoneal exposure of kidney by median abdominal section, 1059 — 
 Exposure of kidney by combined abdominolumbar operation, by anterior transperitoneal and 
 posterior retroperitoneal incisions, 1059 — Exploratory puncture of kidney, 1060 — Nephrotomy, 
 1061 — Pyelotomy, 1062 — Nephrolithotomy, 1062 — Nephrorrhaphy, 1063 — Nephropexy, by 
 suturing split and everted proper capsule of kidney to lumbar wall, Edebohls's operation, 
 1064 — Nephropexy, by suturing split proper capsule and parenchyma of kidney to lumbar wall, 
 by oblique lumbar incision, Tuffier's operation, 1068 — Nephropexy, by simple suturing, 1069 — 
 Total nephrectomy, by oblique lumbar incision, 1070 — Partial nephrectomy, by oblique lumbar 
 incision, 1072 — Subcapsular nephrectomy, 1072 — Total nephrectomy by anterior transperitoneal 
 method, 1072. 
 
 XIII. Ureters: — Surgical anatomy, 1073 — Surface form and landmarks, 1074 — General 
 surgical considerations, 1075 — Instruments, 1076 — Exposure of ureters, in general, 1076 — 
 Extraperitoneal exposure of the kidney and the entire ureter, by oblique lumbo-iliac incision, 
 1076 — Ureterotomy, 1078 — Ureterorrhaphy, 1079 — Ureteroplasty, 10S0 — Uretero-ureteral anas- 
 tomosis (uretero-uret'-rostomy), 1080 — Implantation of ureters, in general, 1084 — Implantation 
 of ureters into bladder (ureterocystostomy), 10S5 — Implantation of ureters into large intestine 
 (ureterorectostomy) by Fowler's method, 1086 — Implantation of ureters upon skin, 1089 — ■ 
 Ureterectomy, in general, 1089 — Partial ureterectomy, by oblique lumbar incision, 1090 — 
 Total ureterectomy, together with removal of kidney, by anterior median abdominal section, 
 1090. 
 
 XIY. Bladder: — Surgical anatomy, 1091 — Surface form and landmarks, 1092 — General 
 surgical considerations, 1093 — Instruments, 1094 — Introduction of sound or catheter, 1094 — 
 Paracentesis vesica 1 , 1095 — Cystotomy, in general, 1096 — Suprapubic cystotomy, 1096 — Lateral 
 perineal cystotomy, for removal of vesical calculus, 1099 — Median perineal cystotomy, for 
 removal of vesical calculus, 1102 — Cystorrhaphy, 1103 — Lithotrity, 1104 — Litholapaxy, 1104 — 
 Vesical drainage, 110S — Partial cystectomy, 1109 — Total cystectomy, by suprapubic median 
 vertical and transverse incisions, 11 10. 
 
 CHAPTER VI. 
 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 I. Penis: — Surgical anatomy, 11 n — Instruments, n n — Circumcision, n 12 — Partial 
 amputation of penis, by flap method, 11 14 — Total amputation, n 16. 
 
 II. Urethra: — Surgical anatomy of male urethra, 111S — Surgical anatomy of female 
 urethra, n 19 — Surface form and landmarks, n 19 — General surgical considerations, n 19 — 
 Instruments, 11 20 — Introduction of sound or catheter, n 20 — Meatotomy, 11 20 — Urethrotomy, 
 in general, 1120 — Internal urethrotomy, by dilating urethrotome, 1121 — External perineal 
 urethrotomy, upon grooved staff (Syme's operation), 1123 — External perineal urethrotomy, 
 upon filiform guide (Gouley's operation), n 24 — External perineal urethrotomy upon grooved 
 staff passed down to stricture (Wheelhouse's operation), n 25 — Perineal section, or external 
 perineal urethrotomy without a guide (Cock's operation), 1126 — Urethrorrhaphy, 1127 — 
 Urethrostomy, n 27. 
 
 III. Scrotum and Testes: — Surgical anatomy, 1128 — Paracentesis tunica vaginalis, 1129 — 
 Partial excision of scrotum, n 29 — Operation for hydrocele, by incision of tunica vaginalis, 
 Volkmann's operation, 1131 — Operation for hydrocele, by eversion and suturing of tunica 
 vaginalis (Jaboulay's operat'on), 1132 — Operation for hydrocele, by incision, with partial 
 excision of tunica vaginalis, von Bergmann's operation, 1133 — Orchidectomy, 1 134. 
 
 IV. Spermatic Cord: — Surgical anatomy, 113^ — Instruments, 1136 — Partial vasectomy, 
 1 136 — Operation for radical cure of varicocele, Bennett's modification of Howse's operation, 
 
 II37- 
 
 V. Vesiculae Seminales and Ejaculatory Ducts: — Surgical anatomy, 1138 — Instruments, 
 1 139 — Total excision of vesiculae seminales and part of ejaculatory ducts, by suprapubic retro- 
 cystic extraperitoneal route, Young's operation, 1139- 
 
 VI. Prostate Gland: — Surgical anatomy, 1140 — Instruments, 1141 — Prostatotomv — 
 Prostatectomy, in general, 1141 — Suprapubic prostatectomy, by median vertical incision, 
 1 142 — Perineal prostatectomy, by transverse curved incision, 1143 — Prostatectomy by the 
 combined median suprapubic and median perineal incisions, Alexander's operation, 1144 — 
 Note, 1 146. 
 
 CHAPTER VII. 
 
 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 I. Uterus: — Surgical anatomy of uterus, broad ligaments, round ligaments, and vagina, 
 1147— Surface form and landmarks, 1 1 50 —Instruments, 1150 — Partial abdominal hysterectomy, 
 together with removal of ovaries and tubes (partial abdominal hysterosalpingo-oophorectomy), 
 
14 CONTENTS. 
 
 1 151 — Total abdominal hysterectomy, together with removal of ovaries and tubes (total abdomi- 
 nal hysterosalpingo-oophorectomy), 11 53 — Total vaginal hysterectomy, 1153. 
 
 II. Ovaries: — Surgical anatomy of ovaries, Fallopian tubes, 1150 — Ovariectomy, or oopho- 
 rectomy, with removal of Fallopian tube (salpingo-ovariectomy, or salpingo-oophorectomy), 
 1 1 60— Note, 1 1 62 . 
 
 CHAPTER VIII. 
 OPERATIONS FOR HERNIJE. 
 
 I. Inguinal Hernia, 1163 — Surgical anatomy, 1163 — General surgical considerations, 
 1164 — Instruments, 1166 — Operation for radical cure of oblique inguinal hernia (Bassini's 
 method), 1166 — Operation for radical cure of same (Halsted's method), 1171. 
 
 II. Femoral Hernia, 1174 — Surgical anatomy, 1174 — General surgical considerations, 
 1 1 76 — Operation for radical cure of femoral hernia (Bassini's method), 11 76. 
 
 III. Umbilical Hernia, n 78 — Surgical anatomy, n 78 — Operation for radical cure of 
 umbilical hernia by excision of sac and suturing of freshened edges of ring, n 79 — Operation 
 for radical cure of umbilical hernia (Mayo's overlapping method), n 81. 
 
 Index 1185 
 
A TEXT-BOOK 
 
 OPERATIVE SURGERY 
 
 BICKHAM 
 
PART I. 
 THE OPERATIONS OF GENERAL SURGERY. 
 
 CHAPTER I. 
 
 OPERATIONS UPON THE ARTERIES. 
 LIGATION OF ARTERIES. 
 
 GENERAL CONSIDERATIONS. 
 
 Description. — The ligation of an artery signifies the constriction of the 
 artery by means of a ligature, for the purpose of controlling the circulation in 
 that vessel. 
 
 Varieties of Ligation. — A ligation may be "terminal," where the cut 
 end of an artery is tied; — " in continuity," where tied in its unbroken course; 
 — "single," where but one ligation is used; — "double," where two are applied 
 (as in dividing a vessel between ligatures); — "immediate," where applied 
 directly to the artery proper; — "intermediate," where the ligature passes 
 around more or less connective or other tissue surrounding the artery (as 
 in ligation for parenchymatous hemorrhage); — "permanent," where applied 
 to remain; — or "temporary," where applied for arrest of circulation for a brief 
 period. 
 
 Indications for Ligation of Arteries. — Wounds; aneurisms; hemor- 
 rhage, from main trunk near site of ligation, or from either main trunk or 
 one of its branches at a distance from site of ligation; rupture of vessels; 
 angiomata; to control hemorrhage in operations distal to site of ligation; 
 to lessen nutrition of inoperable tumors; to cause atrophy of an organ by 
 diminishing its blood-supply. 
 
 Preparation. — (i) General; — -none is necessary for the smaller ligations. 
 In the case of the ligation of the larger arteries, the constitutional state of the 
 patient should be looked after as in other major operations. (2) Local; — 
 the usual antiseptic preparation of the part — the patient coming to the table 
 with the site of operation in an aseptic dressing. 
 
 Position. — Patient upon table of proper height, and so placed as to 
 bring the involved artery most conveniently and advantageously before the 
 surgeon. Surgeon stands where he can best manipulate, which is generally 
 on the side of the operation, and usually cuts downward on the right, and 
 upward on the left. Assistant generally stands opposite the surgeon, and 
 exposes the field of operation by retraction, or assists in the steps of the 
 ligation. The position of patient, surgeon, and assistant will vary according 
 to the artery operated upon, and will be given in the individual operations. 
 
 Instruments. — Esmarch bandage and tourniquet; scalpels, heavy and 
 2 17 
 
18 OPERATIONS UPON THE ARTERIES. 
 
 light; scissors, straight and curved, sharp-pointed and blunt; forceps, dis- 
 secting and toothed; hemostatic forceps; grooved director; tenacula; re- 
 tractors, various sizes and shapes; aneurism-needles, large and small, straight 
 and laterally curved; ligature-carrier; ligaturing and suturing material (v. i.); 
 needles, straight and curved, surgeon's and Hagedorn; needle-holder; wound- 
 hooks; drainage materials (for special emergencies); special small needles, fine 
 silk, and needle-holder for repairing wounds of vessels; means of illuminating 
 deep wounds. 
 
 Ligature Materials. — Plain catgut; chromicized catgut; kangaroo 
 tendon; ox aorta: silk, plain and floss. For the closure of skin-wounds, 
 silkworm-gut or silk sutures. 
 
 (i) For the ligation of smaller arteries — plain catgut. (2) For medium 
 arteries — chromicized catgut. (3) For largest arteries — kangaroo tendon 
 (flat); ox aorta (flat); chromicized catgut; soft floss-silk. 
 
 Steps of the Operation of Ligation. — For the satisfactory carrying 
 out of a ligation, a systematic course should be followed in all cases, the 
 proper steps of which are given below, in order. 
 
 (a) Control of Circulation Preliminary to Operation. — In ligating 
 the arteries of the head, neck, and trunk, no attempt is usually made to 
 control the circulation by any means of pressure. In the limbs, also, it is 
 rarely absolutely necessary. But where its use is preferred, — and the satis- 
 faction of operating in a dry field is unquestionable, — the limb is first elevated, 
 the soft parts massaged toward the trunk, and the tourniquet of Esmarch 
 (without the previous use of the Esmarch rubber bandage) is applied around 
 the limb, as high up as indicated. The sacrifice of the guiding pulsation 
 (necessitated by the use of any form of constrictor) is counterbalanced by 
 the dryness of the field, especially in prolonged and difficult operations. 
 
 (b) Line of Artery. — This is determined in advance of any operative 
 step, and is based upon a knowledge of the anatomy of the part. A knowledge 
 of the chief variations in the course of the arteries should also be possessed. 
 Acquaintance with the line of the special artery is an absolute pre-requisite — 
 a correct line, properly followed, leading directly and expeditiously to the goal 
 of the operation; — an incorrect line, once taken, often plunging the operator 
 into unnecessary difficulties from the start, frequently requiring loss of time, 
 retracing of steps, unnecessary injury to structures, and the regaining of the 
 right path finally after considerable and humiliating bungling. This line 
 of the artery may be previously marked out upon the body with a sterilized 
 dermographic pencil (or nitrate of silver stain) — but such marking is generally 
 unnecessary. ( 1) The line of the artery is frequently modified by the position of 
 the limb, and, in such cases, a constant position should be understood to apply 
 in speaking of such arteries (for instance, the line of the brachial artery is one 
 thing, if the arm be lying out supine at a right angle to the body, and another, 
 if resting on its inner border parallel with the thorax. (Fig. 23.) On the 
 other hand, no change in the position of the foot causes a change in the line 
 of the dorsalis pedis (Fig. 54.) (2) The line of an artery often coincides so 
 nearly with muscular or tendinous landmarks that these landmarks are often 
 given instead of the line itself (for instance, one may speak of ligating the 
 brachial artery by incising along a line extending from the junction of the 
 anterior and middle thirds of the outer axillary boundary, to the middle of 
 the bend of the elbow, the arm being at a right angle to the body and on its 
 extensor surface; or one may also speak of ligating this artery by incising 
 along the inner border of the coracobrachialis muscle above, and the biceps 
 below, Fig. 23). It is well to know both the commonly accepted "line" 
 and the natural muscular or other markings — the former is usually the more 
 
LIGATION OF ARTERIES. 19 
 
 accurate guide to the vessel, especially in the early stage of the operation (for 
 instance, in the above case, the brachial artery is often considerably overlapped 
 by the biceps in a well-developed subject), though the latter are the natural 
 boundaries, which generally have to be encountered and manipulated before 
 finally reaching the artery. (3) In other cases the line bears no relation what- 
 ever to external muscular or tendinous elevations or furrows, and, in such 
 cases, the line alone has to be blindly followed, in the early part of the opera- 
 tion, as a guide to the course of the artery (as in the case of the upper portion 
 of the ulnar artery, Fig. 30). 
 
 (c) Incision. — (I) Position and Direction of Incision: — In the great major- 
 ity of cases the line of incision coincides with the line of the artery, from begin- 
 ning to end of operation, superficially and in the deeper layers (as in ligation 
 of the popliteal artery in the middle of the popliteal space), and should be so 
 placed as to have its center over the site of ligation. In other cases the line 
 of incision will follow a muscular marking, even if at a slight variance with 
 the recognized "line of artery" (e. gr, in ligating the common carotid above 
 the omohyoid, the incision is made parallel with the inner margin of the 
 stern omastoid, which, in muscular and well-developed necks, is known to 
 overlap and lie slightly to the inner side of the artery, Fig. 10, F). In other 
 cases the incision follows neither line of artery nor muscular marking, but lies 
 in a course parallel with both line of artery and muscular fibers, and is so placed 
 as to reach the vessel most advantageously and with least damage to neighbor- 
 ing structures (e. g., ligation of posterior tibial artery in middle of leg, Fig. 51, 
 I). In other cases the incision may coincide with the line of artery but cross an 
 overlying muscle at a right angle (e. g., ligation of lingual artery beneath the 
 hyoglossus muscle, Fig. 10, L). In still other cases the incision may cross the 
 course of the artery at a right angle (e. g., ligation of external iliac extraperi- 
 toneally, by an incision parallel with Poupart's ligament, Fig. 39). (2) Super- 
 ficial Incision : — Having chosen the line of incision as free from superficial vessels 
 and nerves as circumstances permit, steady the area of incision by means of the 
 left thumb and forefinger, which, by their separation, put the parts under 
 slight tension and give room for the knife-cut between them. Grasp the scalpel 
 in the "pen-position" for finer, more limited cuts, and in the "dinner-knife 
 position" for heavier, longer cuts. Enter the point of the scalpel at a right 
 angle to the skin surface — traverse the line of incision with the knife-handle at 
 about 45 degrees — and withdraw the knife with the point of blade again at a 
 right angle to the surface, thereby cutting to equal depth throughout. This 
 incision should pass through skin and superficial fascia, and, while not unnec- 
 essarily long, should be amply long enough to enable subsequent manipulations 
 to be carried on without injury to the structures. The length of the incision 
 should rather be determined by the depth of the artery and the nature of 
 the parts to be encountered, than by any attempt to remember an arbitrary 
 length of incision for each artery. The deep fascia is similarly divided in 
 the original line — avoiding, where possible, superficial vessels, and, especially, 
 nerves. (3) Deep Incision: — Having passed through all overlying fascia in 
 the superficial incision, the muscle and tendinous landmarks now come to both 
 sight and touch. Generally no further cutting is necessary — the rest of the 
 approach "and exposure of the artery being accomplished by blunt dissection. 
 In by far the majority of cases arteries are henceforth reached by following 
 down between muscular planes, it being very rare that muscle-fibers are 
 separated, and rarer still that muscles are cut transversely. At this stage of 
 the operation the muscular or tendinous boundaries are recognized and followed 
 to the known position of the artery, the intermuscular planes being separated 
 
20 OPERATIONS UPON THE ARTERIES. 
 
 by the handle of the scalpel rather than by the blade, and this separation 
 being carried out t<> correspond with the length of the superficial wound. 
 The three best means of recognizing intermuscular planes, in the order of 
 their reliability, are: — sense of touch of tip of left index-finger (which flexion 
 of the limb may assist); — following down of intermuscular branches of the 
 artery; — the white fascial, or yellow fatty, so-called ''line' ' in the intermuscular 
 spaces. It is of great importance to recognize the proper intermuscular 
 spa< e at the start, as, once in a wrong intermuscular interval, one may wander 
 on indefinitely, completely off the track, missing the artery and doing much 
 damage to the parts (and injury to one's own feelings). Good retraction 
 should be freely used at this stage, and muscles and tendons should be drawn to 
 their proper sides (flexing the limb often aiding considerably in this retraction). 
 Important vessels, nerves, and other structures should be guarded during this 
 separation of the parts, and, when in the way, should be displaced to the more 
 convenient side of the operation-field — always remembering that nerves are 
 the most important structures to be safeguarded, in the great majority of cases. 
 If an Esmarch have not been used, the wound is kept comparatively dry by 
 frequent sponging of the field with dry gauze-wipes. 
 
 (d) Exposure of Artery. — Having gotten down into the region of muscles 
 and tendons, these should be clearly identified, and the artery sought by its 
 known relation to these structures. The muscles and tendons are the rallying- 
 points in the depth of the wound. Three structures, outwardly more or less 
 similar in appearance, and often in sensation, are to be distinguished: — (I) 
 Arteries are recognized by their known course; their pulsation, when no 
 proximal constriction is used (and by the hard, unyielding plaster or starch 
 injection in the cadaver) ; their swelling proximally when compressed distaily 
 (where no constrictor is used); their firm, round, resisting, elastic, cord-like 
 feeling; their peculiar sensation when compressed between the fingers, present- 
 ing a central depression and two lateral, elevated ridges; their thicker walls; 
 their rubber-tube-like feeling when touched and tendency to glide from 
 beneath the fingers; the force required to compress them; their regular outline; 
 their pinkish or pinkish-yellow color. Of these means of recognition, pulsa- 
 tion is the conclusive test, provided there can be eliminated all possibility 
 of error caused by pulsation transmitted through contact (as a vein or a nerve 
 made to rise and fall by an artery beating beneath or to one side of it). 
 
 (2) Veins are recognized by not pulsating (where no Esmarch is used); by 
 having thinner coats; by swelling toward the periphery when compressed cen- 
 trally (no constrictor being used); by being softer and less resisting to touch; 
 by the flat, ribbon-like feeling throughout their whole width when compressed 
 between the fingers; by their purplish color; by their wavy, irregular contour; 
 by their accompanying the arteries, in many regions, in pairs or companion 
 veins; by their larger size than the corresponding arteries; by the ease with 
 which they are compressed. It may be mentioned here, in connection with 
 the companion veins, that two vena? comites are to be found accompanying 
 all arteries below the axilla; all arteries below the knee; most of the small 
 and medium-sized arteries of the trunk; and that the arteries of the head 
 and neck are accompanied by single veins. These veins generally run on 
 either side of the artery, communicating across the artery at frequent intervals, 
 — generally lying in front of and behind the artery when the intermuscular 
 plane enclosing the artery lies anteroposteriorly, — and usually lying to the 
 right and left of the artery when the intermuscular plane runs transversely. 
 
 (3) Nerves are distinguished by their known position; their white color; 
 their round contour, unyielding consistency, and non-compressibility; their 
 
LIGATION OF ARTERIES. 21 
 
 appearance of being made up of parallel bundles; their swelling neither 
 proximally, like arteries, nor peripherally, like veins, when compressed (no 
 constrictor being used). 
 
 (e) Opening the Sheath. — Having identified this structure and brought 
 it well within the field, its wall is to be opened and the contained artery ex- 
 posed — for the purpose of clearing a path for the aneurism-needle (Fig. i). 
 Only the main vessels have a distinct sheath of connective tissue, and the 
 larger the artery, the more distinct the sheath. In some cases the accom- 
 panying vein and nerve are included in a common sheath, together with 
 the artery — the sheath being composed of more or less condensed connective 
 tissue. The smaller arteries are surrounded by a less distinct layer of areolar 
 tissue, generally not demonstrable as a sheath. The sheath should be opened 
 at least 1.3 cm. (h inch) from any branch. With a pair of finely pointed 
 forceps, pick up the sheath where it is desired to pass the ligature, and in 
 such a way as to raise the sheath in a fold parallel with the long axis of the 
 
 Fig. 1. — Ligation of an Artery. Opening the sheath. A, Retraction of adjacent muscles; 
 B, Toothed forceps raising sheath of artery in a longitudinal fold ; C, Incising sheath in long axis of 
 artery ; D, Artery visible through incised sheath. 
 
 vessel (Fig. 1, B). Let the forceps pick up the sheath upon its anterior 
 aspect, but slightly to one side of the median longitudinal line, thereby leav- 
 ing space to incise the sheath exactly in the middle line. After grasping the 
 sheath, shift the forceps gently up and down to see that the sheath, held in 
 the bight of the forceps, glides over the contained vessel, proving, thereby, 
 that no part of the artery itself is picked up. This longitudinal fold of the 
 sheath, while held by the forceps and lifted up from the artery, is incised in 
 the long axis of the artery, for a distance of about 6 to 8 mm. (j to § 
 inch) (the shorter the distance of separation of the sheath the better, to pre- 
 serve the vasa vasorum), the flat surface of the knife being turned to the 
 artery (Fig. 1, C). As soon as the incision is made in the sheath, a gap 
 appears between the wall of the artery and the wall of the sheath (Fig. 1 . D). 
 The hold of the forceps upon the wall of the sheath should be retained, not 
 being relaxed after once grasping the fold of sheath. In ligating smaller 
 
22 OPERATIONS UPON THE ARTERIES. 
 
 arteries, which have no well-defined sheath, the vessel is simply freed of all 
 visible connective tissue. (This axial division of the sheath of the artery is 
 preferable to the transverse division so often advised.) 
 
 (f) Clearing the Artery. — A path for the passing of the ligature between 
 the outer wall of the artery and the inner wall of the sheath is now to be 
 made, and the best instrument with which to make it is the dull, flat end of 
 a curved aneurism-needle (Fig. 2). Having retained the original hold of 
 the forceps upon the sheath (Fig. 2, B), insinuate the end of the needle between 
 this wall of the sheath and the artery, and while drawing this lip of the sheath 
 gently away from the artery, carefully work the point of the needle around 
 one-half of the circumference of the artery, in the connective-tissue plane 
 between artery and sheath, by a combination of forward movement, on the 
 part of the tip of the needle, with a side to side movement, on the part of the 
 lateral margins of the curved tip, over a distance of from 6 to 8 mm. (\ to | inch) 
 (Fig. 2, C). Having thus cleared a path around half the vessel, and still 
 
 Fig. 2. — Ligation of an Artery. Clearing the artery. A, A, Retraction of adjacent muscles; 
 B, Forceps grasping nearer lip of sheath ; C, Aneurism-needle clearing artery in its passage between 
 sheath and vessel ; D, Forceps grasping further lip of sheath ; F, Aneurism-needle emerging between 
 artery and further lip of sheath. 
 
 holding the tip of the needle in the path already cleared, the forceps for the 
 first time relinquishes its hold on the lip of the sheath originally grasped, and 
 grasps the opposite lip of the sheath and similarly draws this part of the sheath 
 away from the artery (Fig. 2, D), at the same time also similarly working 
 the point of the needle onward and from side to side, until it clears a way com- 
 pletely around the artery and appears between the vessel and the further lip 
 of the sheath (Fig. 2, E). Throughout this entire manoeuvre the handle of 
 the needle is held approximately at a right angle to the vessel, and the tip of 
 the needle hugs the wall of the artery, especially while working under its deepest 
 part, particularly where a common sheath contains other structures, and 
 thereby is prevented from penetrating the sheath and injuring the vessels, 
 nerves, or viscera beyond. 
 
 (g) Passing the Ligature. — Once a passage has been cleared between 
 
LIGATION OF ARTERIES. 
 
 23 
 
 artery and sheath, the aneurism-needle readily traverses it — so that as soon as 
 the needle has appeared on the further side of the artery, it is withdrawn. 
 The needle is now threaded and carefully passed between vessel and sheath, 
 through the previously cleared way, following precisely the same course and 
 carrying out the same steps— first opening the entrance to the passage by 
 drawing the sheath away with forceps — then hugging the vessel in making 
 the circuit — and finally emerging on the opposite side between the vessel and 
 the further lip of the sheath, which the forceps have now grasped and drawn 
 away (Fig. 3, F, B, C). An aneurism-needle may be passed with a fine silk 
 ligature-loop as a carrier, and through this "carrier" the proper ligature may 
 be threaded and drawn back. There is no fixed rule for the direction in which 
 
 Fig. 3.— Ligation of an Artery. Passing the ligature and tying the knot. A, A, Retraction 
 of neighboring parts; B, Aneurism-needle carrying ligature beneath artery; C, Tenaculum drawing 
 one end of ligature under artery, while aneurism-needle is being withdrawn ; D, Tying the knot; 
 F, Retracting lip of sheath. 
 
 Fig. 4. — Knot Used in Ligating Medium and Large Arteries. E, Two turns of a fric- 
 tion-knot followed by a reef-knot, constituting a surgeon's knot. 
 
 the needle should be passed in each case; the rule should be that the 
 needle is to be passed from the more important structures toward the least im- 
 portant, or from the structures more difficult to avoid toward those more easily 
 avoided. Therefore the needle may enter the sheath in the reverse order 
 to that in which it has been freed from the artery, or vice versa, as seems 
 safest and easiest. Having passed the needle completely around the vessel, 
 until its threaded eye protrudes on the opposite side, grasp one of the 
 threads of the looped ligature with forceps or tenaculum, and, while thus 
 held, carefully withdraw the needle, following the curve of the artery 
 (Fig. 3, B, C). Thus a single thread is left beneath the vessel — an end 
 coming out between the artery and sheath on either side. Some surgeons pass 
 
24 
 
 OPERATIONS UPON THE ARTERIES. 
 
 the needle unthreaded, and thread the eye on the opposite side, then, holding 
 one arm of the ligature with forceps, withdraw the needle — with the same 
 result. There is no objection to this method in simple cases where the artery 
 is accessible and the threading easily done with the needle in situ (as in the 
 lower third of the radial), but it should not be attempted in a region where 
 the exposure is difficult (as in the retroperitoneal ligation of the common 
 iliac). Such an instrument as the Cleaveland needle (ligature-carrier) is 
 preferred to the common aneurism-needle by some — the instrument, being 
 passed under the artery empty, grasps the ligature on the opposite side, and 
 draws back one end under the vessel. In arteries too small to have sheaths 
 the ligature is simply carried under and around the artery, which has been 
 freed of all connective tissue, the general method being the same as just 
 described. 
 
 (h) Tying the Knot. — The largest arteries are most safely and satis- 
 factorily tied with the "stay-knot" of 
 Ballance and Edmunds. The stay- 
 knot of these surgeons is made by con- 
 ducting two or more bundles of soft 
 floss-silk — or two or more pieces of 
 kangaroo-tendon, catgut, silk-worm 
 gut, or plain silk around the artery, 
 parallel with each other and side by 
 side; — the first hitch of a reef-knot 
 is then tied in each bundle, so that 
 two or more knots lie side by side, 
 the force to tie them having been 
 sufficient to closely approximate the 
 inner and middle coats of the artery 
 and completely stop the flow, but 
 •r^s^Ol \ "HA % without rupturing these coats (Fig. 
 
 5, A, and Fig. 7). A friction knot 
 is even safer than the first hitch of a 
 reef-knot, as the preliminary step — 
 especially in tying the larger vessels. 
 After tying these at first lightly, they 
 are both taken up together and gently 
 tightened simultaneously. The two 
 or more ends of the bundles are then 
 taken up on the one side, and the two 
 or more ends of the other bundles on the opposite side, — the several 
 bundles on each side now being regarded as one.- — and these two bundles 
 are tied in a single knot, after the manner of the second step of a reef-knot 
 (Fig. 6, B). Thus a knot is formed the first part of which will not slip while 
 the second is being tied (which is apt to be the case in large arteries, especially 
 if they be pulsating at the time, thus allowing the establishment of a small 
 stream of blood). By this method a broad compression and approximation 
 of the arterial coats will be accomplished, which will add strength to the site 
 of ligation against secondary hemorrhage. This simple approximation is 
 sufficient to excite endothelial proliferation and union of the opposed surfaces. 
 It is hard to draw such a ligature tight enough to rupture the inner coats. An 
 artery with its two inner coats ruptured by ligation has only the strength of 
 its outer coat to withstand the strain of the circulation until the secondary 
 phenomena take place, which permanently strengthen the site — prior to which 
 
 Figs. 5 and 6.— Floss-silk Stay-knot of 
 Ballance and Edmunds. A, First stage; B, 
 Second stage. 
 
LIGATION OF ARTERIES. 
 
 25 
 
 secondary hemorrhage may occur. Several parallel strands of smaller-sized 
 chromic catgut, led under the artery by a carrier, are sometimes used, thus 
 securing width for the ligature and the consequent distribution of pressure. 
 All medium-sized arteries should be tied with a surgeon's knot (a friction-knot 
 followed by the second step of a reef-knot) (Fig. 4, E). All small arteries 
 
 ^ 
 
 Fig. 7. — The Stay-knot 
 of Ballance and Edmunds. 
 
 Showing the first step of tying 
 three kangaroo-tendon liga- 
 tures. 
 
 Fig. 8. — Showing the Pleating 
 or the Coats or a Ligated Artery 
 in Cross-section. (Modified from 
 Ballance and Edmunds.) 
 
 Fig. o. — Illustrating the Manner 
 of Suturing the Wound, the Edges of 
 which are put upon the Stretch by 
 YYurND-HOOKS at Either End. Interrupted 
 sutures are shown at one end and continuous 
 suturing at the other end. 
 
 are safely tied with tne reef-knot alone. In making tension upon the ends 
 of the ligature, special care should be taken not to lift the artery out of its 
 sheath. To avoid this, the tips of the right and left forefingers should come 
 together, end to end, directly upon the knot in the act of being tied, and the 
 tightening should be done by putting the terminal and middle knuckles of 
 the index-fingers in apposition, back to back, and using them as fulcra (Fig. 
 
2 6 OPERATIONS UPON THE ARTERIES. 
 
 3, D). The thumbs may be similarly used instead of the forefingers. It is 
 a disputed point as to how much tension should be used in tightening a ligature. 
 It may be said that it is best to tighten the ligature upon all large vessels suffi- 
 ciently to thoroughly approximate their inner wall in pleats, thereby com- 
 pletely closing the lumen, without rupturing their two inner coats (Fig. 
 8). The same holds true of all diseased vessels, independently of their size. 
 All medium vessels may be similarly ligated. The smaller arteries generally 
 have their ligatures tightened sufficiently to rupture their inner and middle 
 coats. A tightening almost sufficient to sever all coats, especially when using 
 silk, is distinctly to be avoided. Secondary hemorrhage seems less frequent, 
 and the strength of the vessel greater, where the vessels are only constricted 
 enough to closely approximate the two inner coats, without causing their 
 rupture. All knots should be cut comparatively short. A round ligature 
 tightly drawn will rupture the inner coats; a broad ligature will do so far less 
 readily. 
 
 (i) Closure of Wound. — Where a large, well-marked sheath has been 
 opened in exposing the artery, although not absolutely necessary, it is well 
 to unite the edges of the sheath by one or two fine catgut sutures. Where 
 anv muscle tissue has been incised in order to reach the artery, it is usually 
 best to repair the divided muscle tissue by catgut sutures passed through 
 the lips of the muscle wound — which suture becomes buried in the final 
 steps of the operation. Where deep intermuscular planes have been opened 
 up, and dead spaces are apt to be left, it is advisable to put in a few buried 
 catgut sutures through the muscle tissue, drawing together the muscles into 
 their normal intermuscular cleavage line. Where no muscle has been wounded, 
 — and in the final step of those cases where muscle has been incised and 
 sutured, — complete closure of the wound is accomplished by a line of inter- 
 rupted silkworm-gut or silk sutures, or by a continuous silk suture — the 
 suturing, in either case, being materially aided by putting the wound on 
 the stretch by a wound-hook in either end (Fig. 9). No form of drainage 
 is used in clean cases. A simple gauze and cotton dressing, held in place 
 by a bandage, completes the dressing. 
 
 (j) After-treatment. — Very little after-treatment is indicated in the 
 ligation of the smaller arteries. Where a large artery is ligated, a splint 
 should be incorporated in the dressing where feasible, in order to control 
 all movement of the part. In the case of the main artery of a limb, the . 
 limb should be encased in cotton, and artificial warmth applied in addition, 
 until the new circulation is established. The limb is elevated in bed to 
 favor venous return. The skin sutures are removed on the seventh or eighth 
 day. A rest in bed of from two to four weeks is required in the ligation 
 of the larger arteries. 
 
 Local Results of Ligation. — Obliteration of artery at site of ligation. 
 Establishment of a new (collateral) circulation. 
 
 Chief Dangers in Ligation of Arteries. — Secondary hemorrhage. 
 Gangrene. 
 
 Comment. — (1) Where it is difficult or impossible to separate one or 
 more veins from the artery, the artery and vein, or veins, may be included 
 in the one ligature. (2) Especial care should be taken to avoid the inclusion 
 of the smallest nerve in the ligature. (3) When a large vein is wounded, 
 the wound should be at once closed by lateral ligature (Fig. 99), or by sutur- 
 ing (Fig. 98), preferably the former. If this be not feasible, the vein should 
 be ligated. All medium and small veins should be ligated if wounded. If 
 the ligation of the artery can be accomplished without the likelihood of 
 
LIGATION OF INNOMINATE ARTERY. 
 
 27 
 
 again wounding the vein, it should be completed at the original site. If 
 there be danger of further complication, a new site should be chosen just 
 above or below the one originally selected. (4) It is held by some that 
 secondary hemorrhage is less likely if an artery be ligated in two places, 
 from 2.5 to 5 cm. (1 to 2 inches) apart, and then divided between these two 
 ligatures, allowing each end to retract — upon the principle that the arteries 
 of the body are constantly under longitudinal tension, and, when ligated in 
 continuity (especially where the inner coats are severed), there are present 
 the conditions calculated to predispose to secondary hemorrhage. Practical 
 experience seems to have borne out the claim of the double ligature with 
 division, but the operation is not always feasible, especially in the deeper, 
 larger vessels. (5) All ligature material should be thoroughly pliable before 
 being used. 
 
 SURGICAL ANATOMY OF INNOMINATE ARTERY. 
 
 Description. — Largest branch of arch of aorta. From 3.8 to 5 cm. 
 (lh to 2 inches) in length. Arises from beginning of arch of aorta, opposite 
 fourth dorsal vertebra; runs upward, forward, and to right, to upper border 
 of right sternoclavicular articulation, where it divides into right common 
 carotid and right subclavian. 
 
 Relations. — Anteriorly: manubrium; origin sternohyoid; origin sterno- 
 thyroid; right sternoclavicular joint; remains of thymus gland; left innominate 
 vein; right inferior thyroid vein; inferior cervical cardiac branches of right 
 pneumogastric. Posteriorly: trachea; right pleura. To right: right in- 
 nominate vein; right pneumogastric nerve; right pleura. To left : left common 
 carotid; remains of thymus gland; left inferior thyroid vein; trachea. 
 
 Branches. — Thyroidea ima (sometimes) ; thymic branch (sometimes) ; 
 bronchial branch (sometimes). 
 
 Line of Artery. — From center of manubrium, to center of right sterno- 
 clavicular joint. 
 
 Indications for Ligation. — Aneurism of right carotid, subclavian, and 
 of innominate itself. 
 
 Sites of Ligation. — From 1.3 to 2 cm. (h to f inch) below bifurcation 
 (Fig. 10, A, B, C, D, E). 
 
 Comparison of Methods of Exposure of the Innominate. — Choice 
 would be given to. methods of non-division of muscles, with retraction — 
 the oblique incision thus being preferable to the angular one — where these 
 incisions promise sufficient room for manipulation. Where more room is 
 necessary, especially from abnormal displacement of the parts (as from 
 aneurism), the angular incision, or the methods of partial resection, give more 
 space for the safe carrying-out of the necessary steps; and of these latter, 
 the method of partial resection upon the right aspect of the manubrio-clavicular 
 region is applicable to cases where a more limited sacrifice of bone will suffice; 
 and Bardenheuer's operation — or the splitting of the manubrium — where the 
 maximum space is required. The innominate has also been ligated through 
 a trephine-opening made through the manubrium sterni, after turning back 
 a flap of soft parts. 
 
 LIGATION OF INNOMINATE ARTERY 
 
 BY ANGULAR INCISION (MOTT'S OPERATION i. 
 
 Position. — Patient supine, chest raised, head backward and to opposite 
 side. Surgeon to outer side of shoulder. Assistant opposite surgeon. 
 Landmarks. — Clavicle; sternomastoid muscle; sternoclavicular joint. 
 
28 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Incision. — A-shaped (on right). Horizontal portion of incision is 
 made along upper margin of inner third of clavicle, for a distance of about 
 7.5 cm. (3 inches). Oblique portion (meeting horizontal at an acute angle) 
 is made along anterior margin of sternomastoid, for about 7.5 cm. (3 inches) 
 (Fig. 10, A). 
 
 Fig. 10. — Incisions for Ligation of Chief Arteries of Head and Neck :— A, A, Innom- 
 inate, by angular incision; B, B, Same, by oblique incision; C, C, Same, by partial bony resection, 
 through an oblique incision; D, O, Same, by partial buns resection ( Bardenheuer's operation); E, 
 Same, by splitting manubrium; F, Common carotid, above omohyoid; G, Same, below omohyoid; 
 H, External carotid, below digastric ; I, Same, above digastric ; J, Thyroid, at origin ; K. Lingual, at 
 origin; L, Lingual, beneath hyoglossus ; M, Facial, over inferior maxilla; N, Occipital, behind mas- 
 toid process; O, Temporal, just above zygoma ; P, Trunk of middle meningeal, by trephine-opening 
 exposed by curved oblique incision (lower of two trephine-openings); Q, Anterior branch of middle 
 meningeal, by trephine-opening exposed by horseshoe incision (higher of two trephine-openings |; R, 
 Posterior branch of middle meningeal, by trephine-opening exposed by horseshoe incision; S, Internal 
 carotid, near origin ; T, Third part of subclavian ; U, Transversalis colli and suprascapular, at outer 
 margin of sternomastoid ; V, Internal mammary, in second intercostal space ; W, First part of axil- 
 lary, by curved transverse incision below clavicle. 
 
LIGATION OF INNOMINATE ARTERY. 2 g 
 
 Operation. — -Having incised skin and superficial fascia, this triangular 
 flap is dissected upward. Cut the sternal and clavicular attachments of 
 the sternomastoid, as far as exposed. The sternohyoid and sternothvroid 
 muscles are also cut, or are nicked and drawn well inward. Expose, ligate 
 doubly, and cut the anterior jugular vein between its two ligatures, lying 
 beneath the sternomastoid; and also the right inferior thyroid vein. Divide 
 the deep cervical fascia along the original lines of incision, thus exposing 
 the common carotid. Open its sheath and follow to its origin, avoiding 
 the recurrent laryngeal nerve. Thus guided to the innominate, clear its 
 trunk — with especial care on the outer side, of the pneumogastric nerve, 
 right innominate vein, and pleura — and pass the needle from these structures. 
 
 Fig. ii. — Ligation of the Innominate Artery by an Angular Incision; Also of the 
 Right Common Carotid below the Omohyoid, and of the Vertebral Near its Origin': — 
 A, A, Platysma; B, B, B, B, Sternomastoid; C, C, Sternohyoid; D, D, Sternothyroid; E, Innomin- 
 ate artery bifurcating into subclavian and common carotid; F, Internal jugular vein; G, Pneumo- 
 gastric nerve; H, Vertebral artery; I, Trachea; J, Thyroid gland; K, Right sternoclavicular 
 articulation. 
 
 Comment. — (I) As the chief source of failure is secondary hemorrhage, 
 the common carotid and vertebral arteries are also tied — being the chief 
 sources through which the recurrent flow occurs. (2) This free section of 
 muscles leaves, by their retraction, a deep gap at the root of the neck for 
 infection and slow filling-up. As much repairing of cut muscle tissue as 
 possible, by suturing, should, therefore, be done in completing the operation. 
 (3) Artificial illumination is desirable in this operation. 
 
 Collateral Circulation. — First aortic intercostal, with superior inter- 
 costal of subclavian. Upper aortic intercostals, with thoracic branches of 
 axillary and intercostals of internal mammary. Phrenic, with musculo- 
 phrenic of internal mammary. Deep epigastric, with superior epigastric 
 of internal mammary. Free communication of vertebrals and interna] 
 carotids of opposite side, inside of skull. Communication of branches of 
 opposite external carotids in middle line of face and neck. (MacCormac). 
 
3° 
 
 OPERATIONS UPON THE ARTERIES 
 
 LIGATION OF INNOMINATE ARTERY 
 
 BY OBLIQUE INCISION. 
 
 Position — Landmarks. — As for Mott's operation (page 27). 
 
 Incision. — Begin at junction of middle and lower thirds of anterior 
 border of right sternomastoid muscle — pass down along the lower third of 
 its anterior margin — thence sweep over upper edge of the episternal notch 
 onto the manubrium sterni (Fig. 10, B, B). 
 
 Operation. — Incise skin, superficial fascia, platysma, and deep fascia 
 (Fig. 12). Tie anterior jugular vein between two ligatures — also ligate the 
 
 N 
 
 Fig. 12. — Ligation of Innominate by Oblique Incision; Also of Right Common 
 Carotid below Omohyoid; Vertebral Near Origin; and Inferior Thyroid Near Origin: 
 — A, Platysma; B, Sternomastoid retracted outward and downward; C, Right sternoclavicular 
 articulation; E, Manubrium sterni; F, Omohyoid; G, Sternohyoid; H, Sternothyroid; I, Thyroid 
 gland; J, Innominate artery dividing into common carotid and subclavian; L, Inferior thyroid; 
 M, Vertebral; N, Right innominate vein, with subclavian and internal jugular; O, Pneumo- 
 gastric; P, Recurrent laryngeal; R, Nerves from loop between communicans and descendens 
 hypoglossi; S, Superficial cervical nerves. 
 
 transverse branch between the two anterior jugulars, if in the way. Draw 
 the sternomastoid outward — and, if necessary, its inner, sternal portion may 
 be divided. Draw inward the sternohyoid and sternothyroid muscles — and, 
 if necessary, their sternal attachments may be partly or entirely cut. Incise 
 the deep cervical fascia over the carotid sheath. Open the sheath and follow 
 the common carotid behind the sternoclavicular articulation to the subclavian 
 and to the innominate, guarding the recurrent laryngeal nerve behind the 
 common carotid sheath. Ligate the right inferior thyroid vein. Clear the 
 
LIGATION OF INNOMINATE ARTERY. 
 
 3 1 
 
 innominate, avoiding the left innominate vein in front — the right pleura 
 behind — and the right pneumogastric nerve, right innominate vein, and right 
 pleura to the right. 
 
 Comment. — (i) As above mentioned, under Mott's operation, the 
 common carotid and vertebral arteries should also be tied — which can be 
 done through this incision (2) By this separation and retraction of muscles 
 (or partial division) less damage is done to the parts and less of a cavity 
 is left. 
 
 LIGATION OF INNOMINATE ARTERY 
 
 BY PARTIAL BONY RESECTION— THROUGH TRANSVERSE AND VERTICAL 
 INCISIONS— (BARDENHEUER'S OPERATION |. 
 
 Description. — The following parts are excised through a combined 
 transverse and vertical incision: — the right and left sternoclavicular articula- 
 tions, sternal ends of right and left first ribs, sternal end of right second rib, 
 and upper 2.5 cm. (1 inch) of manubrium — thus exposing the innominate. 
 
 Position. — As in Mott's operation (page 27). 
 
 Landmarks. — Suprasternal notch and manubrium; sternal ends of 
 clavicles; inferior margin of thyroid cartilage. 
 
 Incisions. — (1) Transverse incision — along upper border of sternum and 
 over the surfaces of the inner thirds of both clavicles. (2) Vertical incision 
 — from lower border of larynx, down the median line, and well onto the 
 manubrium sterni (Fig. 10, D, D). 
 
 Operation. — Carry both incisions through skin, superficial and deep 
 fasciae. In the transverse incision, divide sternomastoids, sternohyoids, 
 and sternothyroids. Subperiosteally resect (with Gigli saw, rongeur, bone- 
 cutting forceps, or chisel) the inner extremities of the left clavicle and left 
 first rib — for about 1.3 cm. (^ inch) of their extent. Having made this 
 exposure of the upper and outer portion of the manubrium upon its left 
 aspect, free, through this approach, the posterior surface of the manubrium 
 subperiosteally. The manubrium is then cut transversely through at a level 
 about 2.5 cm. (1 inch) below its upper border — the division being accom- 
 plished, preferably, by a Gigli saw conducted beneath the bone, between it 
 and the periosteum. The sternal ends of the right clavicle and the right 
 first and second ribs, after having been well cleared, are divided close to the 
 outer margin of the sternum, in the same manner as the manubrium was 
 divided. The mass of bone detached by the above cuts is now removed. 
 The periosteum is then incised in the median line — the inferior thyroid 
 veins ligated — the left innominate vein depressed — the right innominate vein 
 retracted — the right pneumogastric nerve and pleura guarded on the outer 
 side and behind — the innominate artery cleared — and the ligature passed 
 from the pleura and pneumogastric. 
 
 LIGATION OF INNOMINATE ARTERY 
 
 BY SPLITTING OF MANUBRIUM STERNI. 
 
 Description. — The manubrium is exposed by a transverse incision — 
 divided transversely at its junction with the gladiolus — then split vertically 
 at its center — followed by the separation of the two halves of the manubrium 
 
32 OPERATIONS UPON THE ARTERIES. 
 
 and the exposure of the innominate. Upon completing the operation, the 
 bony parts are returned to their normal positions — with or without suturing 
 of the edges of the vertically divided manubrium into apposition. 
 
 Position. — Patient supine; shoulders raised; neck prominent. Surgeon 
 to right side. Assistant opposite. 
 
 Landmarks. — Sternoclavicular articulations; lower border of manubrium 
 (marked by line extending transversely across between the articulations of 
 the second ribs). 
 
 Incision. — Curved transverse incision — passing from inner third of 
 anterior surface of one clavicle to the inner third of the anterior surface of 
 the opposite clavicle, and passing down over the manubrium to the junction 
 of its upper and middle thirds (Fig. 10, E). 
 
 Operation. — Having incised skin, fascia, and anterior borders of the 
 platysma down to the bone, clamp and tie all bleeding vessels. Free the 
 manubrium subperiosteally over its anterior surface, downward to the junc- 
 tion of the manubrium and gladiolus, and upward to its superior border. 
 Follow the superior border backward and downward along its posterior 
 aspect — also freeing this surface subperiosteally as far as the junction of manu- 
 brium and gladiolus. Retract the overlying soft parts on the anterior aspect 
 of the manubrium and divide the sternum along the manubrio-gladiolar 
 junction — accomplishing the division with a Gigli saw, if one can be conducted 
 across beneath the bone, or by bone-cutting forceps. Through the opening 
 thus made by the transverse division, carry a Gigli saw from the center of 
 the lower border of the divided manubrium to the center of the suprasternal 
 notch — and divide the manubrium vertically in its center, cutting from the 
 manubrio-gladiolar junction upward toward the free superior border — the 
 Gigli saw traveling between the posterior surface of the manubrium in front, 
 and its periosteum posteriorly. After the completion of the vertical section, 
 retract the two halves of the manubrium laterally — incise the posterior perios- 
 teum — ligate the inferior thyroid veins — depress the left innominate vein, 
 retract the right innominate vein — guard the right pneumogastric and pleura 
 externally and posteriorly — clear the innominate — and pass the ligature from 
 the pleura and pneumogastric. 
 
 Comment. — Where it is wished to suture together the vertical borders 
 of the split manubrium, two or three holes should be drilled on each side 
 as soon as the manubrium has been exposed anteriorly and posteriorly, and 
 before its division — the soft parts below being protected by some thin, flat 
 metallic instrument during the drilling. 
 
 SURGICAL ANATOMY OF COMMON CAROTID ARTERIES. 
 
 Description.— (a) Right Common Carotid : About 9.5 cm. (3I inches) 
 in length. Arises from bifurcation of innominate, behind right sternoclavicular 
 articulation — passes upward and outward and slightly backward to upper 
 border of thyroid cartilage (opposite fourth cervical vertebra, according to 
 Morris; — third cervical vertebra, according to Gray) — there dividing into ex- 
 ternal and internal carotids. In its course it is contained within a common 
 sheath of connective tissue, which also includes internal jugular vein and 
 pneumogastric nerve, each separated by a fibrous septum — the vein lying to 
 outer side and slightly overlapping artery, and the pneumogastric lying 
 between and posterior to both. The omohyoid muscle crosses common 
 
SURGICAL ANATOMY OF COMMON CAROTID ARTERIES. 3$ 
 
 carotid opposite lower border of cricoid cartilage, and divides the artery, 
 surgically, into a lower part, deeply placed^and an upper part, superfici- 
 ally placed, (b) Left Common Carotid: About n. 5 cm. (4^ inches) in 
 length. Arises from middle of transverse portion of arch of aorta — ascends 
 upward and outward behind, but at some distance from, manubrium sterni, 
 overlapped by left lung and pleura, and in front of trachea, to left sterno- 
 clavicular articulation — whence its course, relations, and terminations are 
 same as for right common carotid. The crossing and relations of the omo- 
 hyoid muscle are also similar. 
 
 Relations. — (a) Left Common Carotid in Thorax : Anteriorly — 
 manubrium sterni; origin sternohyoid; origin sternothyroid (above three 
 structures being at some distance); remains of thymus; fatty areolar tissue 
 of superior mediastinum; left innominate vein. Posteriorly (from below 
 upward) — trachea; esophagus; thoracic duct; recurrent laryngeal nerve. 
 External (to left) — left pleura and lung (slightly overlapping); left pneumo- 
 gastric; left subclavian (both of latter being somewhat posterior). Internally 
 (to right) — innominate artery; trachea; remains of thymus gland; left 
 inferior thyroid vein, (b) Both Common Carotids in Neck: Anteriorly 
 — skin; superficial fascia; platysma; deep fascia; sternomastoid; sternohyoid; 
 sternothyroid; omohyoid; anterior jugular vein; thyroid body (often overlaps); 
 middle thyroid vein; superior thyroid vein; lingual vein; facial vein; middle 
 sternomastoid artery; descendens hypoglossi nerve (generally upon, some- 
 times within, sheath); communicantes hypoglossi; lymphatic glands. Poste- 
 riorly — pneumogastric nerve; sympathetic nerve; cervical cardiac branches 
 of sympathetic and pneumogastric nerves; recurrent laryngeal nerve; inferior 
 thyroid artery; longus colli; rectus capitis anticus major. Externally — 
 internal jugular vein; pneumogastric nerve. (On right side a space is left 
 at root of neck by divergence of vein, in which pneumogastric nerve and 
 vertebral artery are found; on left side the internal jugular vein overlaps 
 this space). Internally (from below upward) — trachea; esophagus; re- 
 current laryngeal nerve; branches of inferior thyroid artery; lateral lobe of 
 thyroid body; cricoid cartilage; thyroid cartilage; lower part of pharynx; 
 carotid glands. 
 
 Branches. — None, ordinarily. 
 
 Line. — (With head turned moderately to opposite side and upward) — 
 from sternoclavicular articulation to a point midway between angle of jaw 
 and tip of mastoid process — that portion of this line between the sterno- 
 clavicular articulation and the level of the upper border of the thyroid cartilage 
 representing the common carotid. From the clavicle a little external to the 
 sternoclavicular articulation would more accurately represent the line. The 
 anterior margin of the sternomastoid muscle overlaps the carotid throughout. 
 The omohyoid muscle crosses the carotid opposite and directly over Chas- 
 saignac's "carotid tubercle" (costal process of sixth cervical vertebra) — 
 which is about 6.3 cm. (2^ inches) above the clavicle. 
 
 Indications for Ligation. — Wounds of itself and branches of external 
 and internal carotid; distal and proximal aneurism; distal angiomata; as a 
 temporary ligature; to limit growth of inoperable tumors; hemorrhage from 
 areas supplied by distal branches. 
 
 Sites of Ligation. — Above the omohyoid muscle — place of election. 
 Below the omohyoid — depth of artery and nature of relations make the 
 operation more difficult and more fatal (Fig. 10, F and G). 
 3 
 
34 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Fig. 13. — Ligation of Right Common Carotid above Omohyoid: — A, A Platysma ; B, Ster- 
 nomastoid (retracted outward I ; C, Omohyoid 1 retracted downward I ; D, Sternothyroid; E, Common 
 carotid (its sheath incised above omohyoid); F, Sternomastoid artery; G, Internal jugular vein; 
 H, Superior thyroid vein; I, Inferior thyroid vein; J, Communicating vein between anterior and 
 external jugular ; K, One of transversalis colli nerves ; L, Nerves from loop between descendens and 
 communicans hypoglossi. 
 
 LIGATION OF COMMON CAROTID ARTERY 
 
 ABOVE THE OMOHYOID MUSCLE. 
 
 Position.— Patient supine; shoulders elevated; neck prominent; chin 
 upward and to opposite side. Surgeon on side of operation, or on the right 
 for both sides. 
 
 Landmarks. — Line of artery; anterior border of sternomastoid; cricoid 
 cartilage. 
 
 Incision. — About 7.5 cm. (3 inches) in length, with center at level of 
 cricoid cartilage — the incision lying in the line of the artery (Fig. 10, F). 
 
 Operation. — Incise skin, superficial fascia, and platysma. Superficial 
 veins connecting anterior and external jugulars, and sometimes intercom- 
 municating veins between facial and anterior jugular, as well as cutaneous 
 nerves, are encountered (Fig. 13). Divide the deep fascia along the anterior 
 border of the sternomastoid and open up the cellular tissue. The upper 
 border of the omohyoid is here exposed, either by direct incision or by follow- 
 ing up the anterior border of the sternomastoid. Having identified the 
 intersection of sternomastoid and omohyoid, the omohyoid is retracted 
 downward (or may be divided if in the way) — and the sternomastoid outward. 
 Flexing the chin aids during these manipulations, by relaxing the parts. 
 The common carotid is now located as it crosses the "carotid tubercle" (see 
 Anatomy, "Line," page 33). Clear its sheath, avoiding or tying the 
 sternomastoid artery and the superior and middle thyroid veins. Carefully 
 incise the sheath, approaching from the inner side, to avoid the descendens 
 
LIGATION OF COMMON CAROTID ARTERY. 
 
 35 
 
 hypoglossi nerve (generally on the antero-external side of the sheath) and 
 the internal jugular vein, and see that artery is freed from its sheath in its 
 entire circumference. Pass the needle from the internal jugular and pneu- 
 mogastric nerve. 
 
 Collateral Circulation. — Inferior thyroid, with superior thyroid. Deep 
 cervical, with occipital. Transversalis colli, with occipital. Branches of 
 two vertebrals, with branches of two external carotids. Circle of Willis. 
 
 LIGATION OF COMMON CAROTID ARTERY 
 
 BELOW THE OMOHVOID MUSCLE. 
 
 Position — Landmarks. — As in the ligation above the omohyoid. 
 
 Incision. —About 7.5 cm. (3 inches) in length, in line of artery — from 
 just below cricoid cartilage to just above sternoclavicular articulation 
 (Fig. 10, G). 
 
 Fig. 14. — Cross-section of the Neck at the Level of the Seventh Cervical Ver- 
 tebra: — A, A, Scaleni muscles; B, B, Sternocleidomastoid muscles; C, C, Sternohyoid and 
 sternothyroid muscles; D, D, Common carotid arteries and internal jugular veins; E, E, Vertebral 
 arteries and veins; F, F, Inferior thyroid arteries and veins. (Modified from Braune.) 
 
 Operation. — Incise skin, superficial fascia, and platysma. Here are 
 encountered the superficial veins between the facial, anterior and external 
 jugular veins, and the cutaneous cervical nerves. Divide the deep fascia 
 along the anterior border of the sternomastoid. Expose the inner border 
 of this muscle, flexing the head to relax the parts. The sternohyoid is then 
 exposed, and sometimes the underlying sternothyroid. The omohyoid is, 
 
36 OPERATIONS UPON THE ARTERIES. 
 
 ordinarily, not brought into the field of operation. These muscles, if en- 
 countered, are retracted in their respective directions, or may be divided 
 as far as necessary. Tie the inferior thyroid veins. The sheath is to be 
 exposed as, and with the precautions, mentioned in the above operation. 
 The recurrent laryngeal nerve and the inferior thyroid artery are to be espe- 
 cially guarded in operating at this site. 
 
 Comment. — The ligation of the common carotid is more difficult on 
 the left side, owing to the nearness of the internal jugular vein (see Anatomy, 
 "Relations," page 32), and the operation is less frequently done than on 
 the right side. 
 
 SURGICAL ANATOMY OF EXTERNAL CAROTID ARTERY. 
 
 Description.— The smaller of the two divisions of the common carotid. 
 About 6.3 cm. {t.\ inches) in length. Begins opposite upper border of thyroid 
 cartilage; passes upward, forward, and then backward, under the stylohyoid 
 and posterior belly of the digastric, to the interval between neck of condyle 
 of inferior maxilla and the external auditory meatus, where it divides, in 
 the substance of the parotid gland, into the internal maxillary and temporal 
 arteries. 
 
 Relations. — Anteriorly: skin; superficial fascia; platysma; deep fascia; 
 anterior border of sternomastoid; hypoglossal nerve; lingual vein, facial vein; 
 posterior belly of digastric; stylohyoid; temporomaxillary vein; superior 
 cervical lymphatic glands; branches of facial nerve; parotid gland. Poste- 
 riorly: internal carotid artery; styloglossus; stylopharyngeus; glossopharyn- 
 geal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament; parotid 
 gland; superior laryngeal nerve. Externally: internal carotid artery. In- 
 ternally: hyoid bone; pharynx; ramus of inferior maxilla; stylomaxillary 
 ligament; submaxillary gland; parotid gland. 
 
 Branches (from below). — Ascending pharyngeal; superior thyroid; 
 lingual; facial; occipital; posterior auricular; temporal; internal maxillary. 
 
 Line. — Upper part of line of common carotid artery (page 33). 
 
 Indications for Ligation. — Wounds and aneurism of trunk and branches; 
 hemorrhage from areas of branches; palliative in malignant growths; pre- 
 liminary to operations; aneurism by anastomosis in the regions of the 
 trunks. 
 
 Sites of Ligation. — Below the digastric (between the superior thyroid 
 and lingual branches) — place of election — the operation is easier and more 
 branches are thus controlled. Above the digastric — the operation is more 
 difficult and more apt to involve branches of the facial nerve. Note: — The 
 digastric muscle crosses the artery about 3.2 cm. (\\ inches) above its origin, 
 opposite the upper border of the thyroid cartilage. The lingual arises oppo- 
 site the great cornu of the hyoid bone. (Fig. 10, H and I.) 
 
 Comment. — (1) The external carotid may be distinguished from the in- 
 ternal carotid by the presence of its branches and by being to the inner side 
 of the external carotid. (2) The ligation of the external carotid is now 
 generally done where formerly the common carotid was ligated for 
 conditions of the former vessel and its branches — the practicability and 
 desirability of the operation having been demonstrated by the work of 
 Wyeth. 
 
LIGATION OF EXTERNAL CAROTID ARTERY. 37 
 
 LIGATION OF EXTERNAL CAROTID ARTERY 
 
 BELOW THE DIGASTRIC MUSCLE. 
 
 Position. — As for the common carotid (page 34). 
 
 Landmarks. — Sternomastoid; thyroid cartilage; angle of jaw. 
 
 Incision. — About 7.5 cm. (3 inches) — along the anterior border of the 
 sternomastoid, or slightly in front of border — from level of middle of thyroid 
 cartilage, to near angle of jaw (Fig. 10, H). 
 
 Operation. — Incise skin, superficial fascia, and platysma (Fig. 15). Tie 
 any veins which may lie in the line of incision. Divide the deep fascia and 
 expose the anterior border of the sternomastoid and draw it outward. Find 
 
 Fig. 15.— Ligation of Right External Carotid below Digastric ; and also of Internal 
 Carotid, Superior Thyroid, Lingual, Facial and Occipital, near Origin:— A, Superficial 
 fascia; B, B, Platysma ; C, Cervical fascia ; D, Sternomastoid (retracted outward); E, Posterior belly 
 of digastric; F, Hyoglossus, with lingual artery disappearing beneath it; G, Thyrohyoid M. ; H, 
 Middle constrictor M. ; I, Inferior constrictor M. ; J, Tip of great cornu of hyoid bone ; K External 
 carotid A.; L, Internal carotid; M, Superior thyroid; X, Facial; O, Occipital; P. Internal jugular 
 V. ; Q, Lingual and facial veins emptying into internal jugular; R. Superior thyroid V.; S, Hypo- 
 glossal N. ; T, Descendens noni N. 
 
 the posterior belly of the digastric at the upper angle of the wound. Next, 
 locate the hypoglossal nerve crossing the external carotid below the origin 
 of the occipital artery. Locate the tip of the great cornu of the hyoid bone, 
 opposite which the lingual artery arises. Having fixed the location of these 
 three structures, and avoiding the superior thyroid, facial, and lingual veins; 
 expose the artery opposite the tip of the great cornu of the hyoid. Clear 
 the sheath and pass the ligature between the superior thyroid and lingual 
 branches — guarding the descendens hypoglossi nerve in front, and the supe- 
 rior laryngeal nerve passing behind the artery — directing the needle from 
 the internal carotid. 
 
38 OPERATIONS UPON THE ARTERIES. 
 
 Comment. — (1) The operation is not an easy one, and it is often difficult 
 to recognize the branches. (2) Jacobson advises simultaneous ligation of 
 the superior thyroid, the lingual, and, if possible, the ascending pharyngeal 
 branches — on account of secondary hemorrhage. (3) Through this same 
 incision the superior thyroid, lingual, facial, occipital, and ascending pharyn- 
 geal may be ligated. 
 
 Collateral Circulation. — Same as for the ligation of the common carotid 
 above the omohyoid (page 34). 
 
 LIGATION OF EXTERNAL CAROTID ARTERY 
 
 ABOVE DIGASTRIC MUSCLE AND BEHIND RAMI'S OF JAW. 
 
 Position. — As for the common carotid. 
 
 Landmarks. — Line of artery; ramus of inferior maxilla. 
 
 Incision. — From tragus of ear, to below angle of inferior maxilla, and 
 placed just behind the ramus of the jaw, in the line of the artery (Fig. 10, I). 
 
 Operation. — Incise skin and superficial fascia. Avoid, or doubly ligate 
 and incise, the tributaries of the external jugular and facial veins. Divide 
 the deep fascia. Expose the anterior border of the sternomastoid and retract 
 outward. Expose the posterior belly of the digastric and stylohyoid and 
 draw downward — partially or entirely dividing them if necessary. Avoid 
 the branches of the facial nerve. Expose the parotid gland and draw upward 
 and forward — thus exposing the vessel. Clear the artery and open its sheath 
 — and pass the ligature around the artery prior to its entrance into the sub- 
 stance of the parotid gland. Repair, by suturing, whatever muscles may 
 have been incised. 
 
 SURGICAL ANATOMY OF LINGUAL BRANCH OF EXTERNAL CAROTID. 
 
 Description. — The third in order, and an anterior branch of the external 
 carotid. Arises opposite, or a little below, the great cornu of the hyoid bone, 
 about 2 cm. (| inch) above the bifurcation of the common carotid, (a) First 
 or Oblique Portion: — lies in superior carotid triangle, extending obliquely 
 upward to the external border of the hyoglossus, — being covered by skin, 
 superficial fascia, piatysma, deep fascia, and hypoglossal nerve, — and resting 
 on the middle constrictor and laryngeal nerve, (b) Second or Horizontal 
 Portion: — lies in the digastric triangle, running horizontally beneath the hyo- 
 glossus muscle, along the superior border of the hyoid bone, — being covered 
 by the hyoglossus muscle (which separates the artery from the hypoglossal 
 nerve, posterior belly of the digastric, stylohyoid muscle, and lingual vein), 
 — and resting upon the middle constrictor of the pharynx and geniohyo- 
 glossus. (c) Third or Ascending Portion: — ascends between the hyoglossus 
 and geniohyoglossus to the inferior surface of the tongue, (d) Fourth or 
 Terminal Portion: — runs forward to tip of tongue, lying between the lingualis 
 and geniohyoglossus, and covered only by mucous membrane. Two venae 
 comites accompany the lingual artery beneath the hyoglossus. The ranine 
 vein runs on the superficial surface of the hyoglossus, below the hypoglossal 
 nerve. Several veins follow the dorsalis linguae artery. 
 
 Sites of Ligature. — Its first or second portions are the parts usually 
 tied — and of these, the second is preferable (Fig. 10, K and L). 
 
LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID. 
 
 39 
 
 LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID 
 
 NEAR ITS ORIGIN. 
 
 Position — Landmarks. — As for ligation of external carotid below the 
 digastric (page 35). 
 
 Incision. — In line of external carotid, with its center opposite the body 
 of the hyoid bone (Fig. 10, K). 
 
 Operation. — Same, practically, as for ligation of external carotid below 
 the digastric, the main vessel being first exposed and the origin of the lingual 
 then located. 
 
 Comment. — The first part of the lingual may also be tied, though less 
 readily, by a transverse incision extending from the level of the body of the 
 hyoid bone to the anterior border of the sternomastoid, the artery being 
 exposed and tied just before passing under the hyoglossus muscle. 
 
 LIGATION OF LINGUAL BRANCH OF EXTERNAL CAROTID 
 
 BENEATH THE HVOGLOSSUS. 
 
 Position. — Patient supine; shoulders raised; neck prominent; head to 
 opposite side and chin upward. Surgeon on side of operation, cutting from 
 before backward on the right, and vice versa. 
 
 _ M 
 
 E 
 
 Fig. 16. — Ligation of Right Lingual Artery beneath Hyoglossus: — A, A, Platysma; 
 B, Transverse cervical fascia over submaxillary gland; C, Deep transverse cervical fascia under 
 submaxillary gland; D, Submaxillary gland; E, Hyoid bone; F, Anterior belly of digastric; 
 G, Posterior belly of digastric; H, Stylohyoid; I, Mylohyoid; J, Hyoglossus; K, Omohyoid; 
 L, Thyrohyoid; M, Lingual artery see'n through incision in hyoglossus; N, Submental A.; O, 
 Tributary of temporomaxillary V.; P, Tributary of anterior jugular V.; Q, Ranine V. (below); 
 R, Transverse cervical nerve;' S, Superior laryngeal nerve and vessels; T, Hypoglossal N. 
 
40 OPERATIONS UPON THE ARTERIES. 
 
 Landmarks. — Lower border of inferior maxilla; facial artery crossing 
 inferior maxilla; hyoid bone. 
 
 Incision. — Curved incision — beginning just below and external to sym- 
 physis menti — and ending just below and internal to crossing of facial artery 
 over inferior maxilla — its center being just above the greater cornu of the 
 hyoid bone (Fig. 10, L). 
 
 Operation. — Incise skin, superficial fascia, platysma, and deep fascia. 
 Avoid or ligate tributaries of facial, anterior jugular, or temporomaxillary 
 veins. Incise the transverse cervical fascia over the submaxillary gland — 
 exposing the gland and retracting it upward, out of its bed, over the margin 
 of the lower jaw (Fig. 16). Incise transversely the deep cervical fascia 
 exposed by lifting out the submaxillary gland — and identify the mylohyoid 
 muscle in the anterior aspect of the wound. Expose the two bellies of the 
 digastric and firmly retract them downward at their point of attachment to 
 the hyoid bone — which steadies the parts and renders the hyoglossus more 
 prominent. Clear the surface of the hyoglossus and identify the hypoglossal 
 nerve crossing its anterior aspect. The ranine vein crosses the same surface 
 just below and parallel with the nerve and at about the same level as the 
 artery lies on the opposite side of the muscle. Retract both hypoglossal 
 nerve and ranine vein upward. Divide the hyoglossus transversely for 
 about 1.3 cm. (| inch) just above and parallel with the hyoid bone. This 
 incision falls just over the artery, which generally bulges into the opening 
 as soon as it is made, or through which it is easily reached. Having 
 isolated the artery, trace it backward until the dorsalis linguae branch 
 is reached, so that the ligature may be placed upon its proximal side. 
 Having passed the ligature, replace the submaxillary gland and close the 
 wound. 
 
 Comment. — The fascia of the submaxillary gland may be sutured over 
 it, and the incision in the hyoglossus may be repaired by suturing, if either 
 be considered indicated. 
 
 SURGICAL ANATOMY OF FACIAL BRANCH OF EXTERNAL CAROTID. 
 
 Description. — The fourth in order, and an anterior branch of the ex- 
 ternal carotid. The Cervical Portion passes upward and forward in the 
 posterior part of submaxillary triangle, under the digastric, stylohyoid, 
 submaxillary gland, and horizontal ramus of inferior maxilla. The Facial 
 Portion curves over lower border of inferior maxilla at the anterior border 
 of masseter muscle — and, running forward and upward, crosses the cheek 
 to the angle of mouth — thence upward along side of nose to end at internal 
 canthus of eye. 
 
 Relations. — Cervical portion rests on (from below upward) stylo- 
 glossus; mylohyoid; submaxillary gland (in or under it); — and is covered by 
 (from below upward) posterior belly of digastric; stylohyoid; hypoglossal 
 nerve (generally); submaxillary gland (beneath or in its substance); inferior 
 maxilla; lymphatic glands; fascia; platysma; skin. Facial portion rests on 
 (from below upward) inferior maxilla; buccinator; levator anguli oris; levator 
 labii superioris (sometimes); infraorbital branches of fifth nerve; — and is 
 covered by (from below upward) risorius; zygomatici major and minor; 
 supramaxillary and buccal branches of facial nerve; levator labii superioris; 
 levator labii superioris alaeque nasi; infraorbital branches of facial- The 
 cervical portion of the facial vein is more direct than the artery, and separated 
 
LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID. 
 
 41 
 
 from it by submaxillary gland, posterior belly of digastric, stylohyoid muscle, 
 and hypoglossal nerve. The facial portion of the facial vein is also more 
 direct than the facial portion of the facial artery, and is separated from its 
 arterv by the zygomatic] major and minor. 
 
 Sites of Ligation. — Near origin (less frequently), — over lower jaw (the 
 usual selection) (Fig. 10, M). 
 
 LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID 
 
 NEAR ORIGIN. 
 
 Position — Landmarks — Incision — Operation. — Practically the same as 
 for ligation of the external carotid below the digastric. 
 
 LIGATION OF FACIAL BRANCH OF EXTERNAL CAROTID 
 
 OVER INFERIOR MAXILLA. 
 
 Position. — Patient supine; shoulders raised; head thrown back and to 
 opposite side. Surgeon on side of operation, or on right for both sides. 
 
 Landmarks. — Anterior margin of masseter muscle; horizontal portion 
 of inferior maxilla. 
 
 Fig. 17. — Ligation of Right Facial over Border of Inferior Maxilla: — A, Cervical 
 fascia; B, Platysma ; C, Deep cervical fascia; D, Submaxillary gland; E, Mylohyoid muscle; F. 
 Inferior maxilla ; G, Masseter M. ; H, Depressor anguli oris ; I, Facial A.; J, Facial V. ; K, Submen- 
 tal A. ; L, Supramaxillai y N. 
 
 Incision. — About 2.5 cm. (1 inch) in length — placed along and under 
 cover of lower border of lower jaw, with its center over the course of the 
 artery (at the anterior margin of the masseter muscle) (Fig. 10, M). 
 
 Operation. — Incise skin, superficial fascia, platysma, and deep fascia, 
 when the artery should come into view — with the facial vein just posterior 
 to it. Avoid branches of the facial nerve (Fig. 17). 
 
42 OPERATIONS UPON THE ARTERIES. 
 
 SURGICAL ANATOMY OF OCCIPITAL BRANCH OF EXTERNAL 
 
 CAROTID. 
 
 Description. — The fifth in order, and a posterior branch of the external 
 carotid — passing upward and backward to the interval between mastoid 
 process of temporal and transverse process of atlas — thence horizontally 
 backward in the occipital groove — thence upward onto the scalp. 
 
 Relations. — First Part (internal to sternomastoid) — covered by skin, 
 fascia, posterior belly of digastric; parotid gland; temporomaxillary vein; 
 hypoglossal nerve; — and rests on internal carotid artery; hypoglossal nerve; 
 pneumogastric nerve; internal jugular vein, and spinal accessory nerve. 
 Second Part (beneath sternomastoid) — covered by sternomastoid; splenius 
 capitis; trachelomastoid; origin of digastric; — and rests on capitis lateralis, in 
 occipital groove of mastoid process of temporal, and on the insertion of 
 superior oblique muscle. Third Part (external to sternomastoid) — covered 
 by skin, aponeurosis uniting occipital attachments of sternomastoid and 
 trapezius — and resting upon the complexus. It perforates this aponeurosis 
 just mentioned, or the posterior belly itself of the occipitofrontalis, together 
 with the great occipital nerve — and follows, roughly, the line of the lambdoid 
 suture, between the integument and the cranial aponeurosis. Two venae 
 comites accompany the occipital artery. 
 
 Sites of Ligation. — Near its origin — and behind the mastoid process 
 of the temporal — according to site of lesion requiring ligature (Fig. 10, N). 
 
 LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID 
 
 NEAR ORIGIN. 
 
 Position — Landmarks — Incision — Operation. — As for ligation of the 
 external carotid below the digastric (page 35). 
 
 LIGATION OF OCCIPITAL BRANCH OF EXTERNAL CAROTID 
 
 BEHIND MASTOID PROCESS. 
 
 Position. — Patient supine; shoulders and head elevated; head turned 
 well to opposite side (or patient resting slightly to one side). Surgeon stands 
 behind, on side of operation. 
 
 Landmarks. — Mastoid process; external occipital protuberance. 
 
 Incision. — About 5 cm. (2 inches) in length — beginning from tip of 
 mastoid process and extending toward the external occipital protuberance 
 (Fig. 10, N). 
 
 Operation. — Having incised skin and fascia, divide the posterior half 
 of the sternomastoid and its strong aponeurosis — then the splenius capitis — 
 then as many fibers of the trachelomastoid as are in the way (Fig. 18). Relax 
 and retract the muscles by turning the head to the side of the operation. 
 Expose the artery deep down between the mastoid process of the temporal 
 and the transverse process of the atlas, resting upon the superior oblique 
 and complexus muscles. Having separated from it the accompanying veins, 
 and having guarded the veins from the mastoid foramen, the ligature is 
 passed. The lesser occipital nerve runs on the posterior surface of the sterno- 
 
LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID. 43 
 
 Fig. 18. — Ligation of Left Occipital Artery behind Mastoid Process: — \, Posterior 
 cervical fascia; B, Trapezius muscle; C, Sternomastoid; D, Splenius capitis; E, Trachelomastoid; 
 F, Occipital artery and vena comites, lying upon complexus muscle; G, Great occipital nerve; 
 H, Lesser occipital nerve; I, Posterior external jugular vein. 
 
 mastoid, near its posterior border, and the great occipital nerve pierces the 
 trapezius muscle near its outer border. 
 
 SURGICAL ANATOMY OF TEMPORAL BRANCH OF EXTERNAL 
 
 CAROTID. 
 
 Description. — The seventh in order and the smaller but more direct 
 of the two terminal branches of the external carotid. Arises in substance 
 of parotid gland, opposite neck of inferior maxilla — and runs upward, beneath 
 parotid gland, between condyle and external auditory meatus — thence upward, 
 crossing the posterior root of the zygoma — and continuing upward under the 
 attrahens aurem muscle and temporal aponeurosis for 3.8 cm. to 5 cm. (1^ 
 to 2 inches), where it divides into anterior and posterior branches. A plexus 
 of sympathetic nerves surrounds the vessel — -it is crossed by the temporofacial 
 division of the facial nerve — and is accompanied by the auriculotemporal 
 nerve. 
 
 Sites of Ligation. — The main trunk may be ligated just above root of 
 zygoma. The anterior and posterior branches may be ligated at their bifurca- 
 tion, about 3.8 to 5 cm. (1^ to 2 inches) above the zygoma . 
 
 LIGATION OF TEMPORAL BRANCH OF EXTERNAL CAROTID 
 
 JUST ABOVE ZYGOMA. 
 
 Position. — Patient supine; shoulders raised; head to opposite side. 
 Surgeon on side of operation, cutting from above downward on right, and 
 vice versa (or on right for both operations, cutting from above downward). 
 
 Landmarks. — Tragus of ear; condyle of jaw; zygoma. 
 
44 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Incision. — Vertical, about 2.5 to 3.8 cm. (1 to i\ inches) in length, over 
 line of artery, with center over zygoma, and extending downward in the 
 interval between the tragus of the ear and the condyle of the lower jaw 
 (Fig. 10, O). 
 
 Operation. — Incise skin and dense subcutaneous tissue and parotid 
 fascia — when the artery will be exposed lying quite superficial as it crosses 
 the zygoma. Avoid the accompanying vein posteriorly — also avoid the 
 branches of the temporofacial division of the facial nerve and the auriculo- 
 temporal nerve (Fig. 19). 
 
 Fig. 19. — Ligation ok Right Temporal Just above Zygoma :— A, Temporal artery, with its 
 anterior and posterior bifurcations, and its transverse facial, middle temporal, and anterior auricular 
 branches; B, Temporal vein, with branches corresponding to those of artery ; C, Temporal branches 
 of auriculotemporal nerve ; D, Branch of temporofacial division of facial nerve ; E, Temporal fascia. 
 
 SURGICAL ANATOMY OF MIDDLE MENINGEAL BRANCH OF INTERNAL 
 MAXILLARY BRANCH OF EXTERNAL CAROTID. 
 
 Description. — The largest branch of the first or Maxillary Portion of 
 the internal maxillary. Arises between internal lateral ligament and neck 
 of inferior maxilla — and, under cover of external pterygoid, passes upward 
 between the two roots of the auriculotemporal nerve to the foramen spinosum, 
 being crossed by the chorda tympani nerve. It enters the skull through 
 this foramen and ascends in the groove on the great wing of the sphenoid, 
 where it divides into anterior and posterior branches which ramify between 
 the bone and the dura. The point of bifurcation is generally given by anato- 
 mists as corresponding, on the exterior of the skull, with a point 3.8 cm. (1^ 
 inches) behind the external angular process of the frontal bone, and 3.8 to 
 4.5 cm. (1^ to if inches) above the zygoma. The Anterior Branch runs in 
 a groove on the great ala of the sphenoid and the anterior inferior angle of 
 the parietal. The Posterior Branch crosses the squamous portion of the 
 temporal and then enters the groove on the posterior inferior angle of the 
 parietal bone. In the young these measurements are less. 
 
 Indications for Ligation. — Intracranial hemorrhage. 
 
 Sites of Ligation. — The common trunk, or the anterior or posterior 
 branch, as indicated (Fig. 10, P, Q, R). 
 
 Note. — Because of the practical surgical bearing of the middle meningeal 
 artery and its branches, and because of the wide variations from each other 
 
SURGICAL ANATOMY OF MIDDLE MENINGEAL ARTERY. 45 
 
 in the descriptions of the intracranial portion of the middle meningeal artery 
 and its branches in various anatomies, and because of the equally wide 
 variations of the artery and its branches, as actually found in the skull, 
 from the text-book descriptions, — the following summary is given of the out- 
 come of special research upon the subject made upon fifty dried skulls and 
 thirty cadavera (representing 160, upon the two sides) by S. C. Plummer. 
 In the following data it is to be remembered that, owing to beveling, the 
 lower part of the coronal suture is 5 mm. to 1 cm. (y 3 ^- to f inch) more pos- 
 terior on the inner than outer side of skull, and that the squamoparietal 
 suture is from 1 to 1.5 cm. (f to § inch) lower on the inner than the outer 
 side. 
 
 Covering of Artery. — Instead of lying between dura and bone (as 
 generally understood) the artery is really covered by a thin process of dura 
 on its outer surface; hence its adherence to the dura in separation of the 
 latter from the bone. 
 
 Trunk of Middle Meningeal Artery, — (1) Present in 95 per cent. In 
 50 per cent., anterior and posterior branches entered separately, or the trunk 
 divided at the foramen spinosum. (2) Point of Division into Anterior and 
 Posterior Branches: — 2 mm. to 5.5 cm. (little more than y 1 ^ to 2^ inches) from 
 foramen spinosum in a direct line — (less than 1 cm. or T 7 g- inch) in 16 cases — 
 between 1 and 3 cm. (y 7 ^ and iy\ inches) in 60 cases — over 3 cm. (iy\ ; - inches) 
 in 19 cases. Bifurcation was 58 times upon squamous part of temporal — 21 
 upon sphenoid — 15 upon squamosphenoidal suture — once on sphenoparietal 
 suture. (Steiner, another investigator, found a common trunk present in 
 only 43 per cent. — and found that bifurcation occurred in 57 per cent, at the 
 foramen spinosum.) (3) Length: — corresponds with point of bifurcation, 
 when point of bifurcation is not more than 2 cm. (f inch) above the foramen 
 spinosum, — and from 1 mm. to 1.2 cm. (-^ to ^ inch) greater when the point 
 of bifurcation is more than 2 cm. (f inch) above the foramen spinosum (due 
 to curve in artery). (In Steiner's cases the length was from 1 to 3.5 cm., or 
 § to if inches, in 43 cases — and from 3.5 to 5 cm., or if to 2 inches, in 8 cases.) 
 (4) Direction: — almost invariably outward — and more frequently outward 
 and forward than outward and backward. Generallv runs outward for 2 mm. 
 to 1.7 cm. (little more than T X g- to J inch) and thence outward and forward — 
 running in a gentle curve. (5) Location: — almost always runs from foramen 
 spinosum onto the temporal (sometimes first runs onto the sphenoid, or 
 squamosphenoidal suture) — generally running from 5 mm. to 1 cm. ( T 3 g- to § 
 inch) posterior to the squamosphenoidal suture; thence a long trunk generally 
 runs onto the squamosphenoidal suture — and then onto the great wing of the 
 sphenoid. 
 
 Anterior Branch of Middle Meningeal Artery. — (1) Relative Size: — 
 Generally the main branch and larger than the posterior. (2) Direction 
 and Location: — Beginning at point at which lowest bifurcation occurs (v. s.), 
 the anterior branch, after bifurcating on the squamous, squamosphenoidal 
 suture, sphenoid, or on the sphenoparietal suture, as the case may be, passes 
 forward and upward across the anterior and lower part of the squamous; — 
 thence almost invariably crosses the upper part of the great wing of the 
 sphenoid; — thence passes backward across the sphenoparietal suture onto the 
 parietal — and runs thence generally upward and backward about parallel 
 with the coronal suture, and generally within 2 mm. to 3 cm. (little 
 more than y 1 ^ to iy 3 ^ inches) of it. Practically, the most constant position 
 of the anterior branch is where it crosses the sphenoparietal suture — the cross- 
 
46 OPERATIONS UPON THE ARTERIES. 
 
 ing may be at any part of its 1.5 cm. (nearly § inch) length, but is usually 
 on its anterior half. (3) As to Branches of Anterior Branch: — The anterior 
 branch did not divide in 44 per cent. In the 56 per cent, in which it did 
 divide, it divided 25 times on the right and 31 on the left. There were 2 
 branches in 49 cases — 3 branches in 5 cases — 4 branches in 2 cases; — and these 
 divisions occurred 51 times on the parietal, 3 times on the sphenoparietal 
 suture, and 2 times on the sphenoid. Kroenlein considers that the anterior 
 branch, in the average case, divides into two branches, one of which runs 
 up in front and one behind the rolandic fissure. Where the anterior branch 
 divides into branches, one branch generally runs parallel with and within 
 2 cm. (f inch) of the coronal suture. (4) Bony Canal: — In from 38 per cent. 
 (Steiner) to 60 per cent. (Plummer), the anterior branch was found to run 
 through a bony canal upon the anterior inferior angle of the parietal bone — 
 the canal sometimes beginning upon the sphenoid — being from 3 mm. to 
 2.S cm. (| to i£ incr.es) Ions;. 
 
 Posterior Branch of Middle Meningeal Artery. — (1) Much less con- 
 stant in size and position than anterior branch. Generally smaller — often 
 appearing as, and mistaken for, a branch of the anterior branch. Some- 
 times appears to be a continuation of the trunk and larger than the anterior — 
 and sometimes is larger without appearing to be main trunk. (2) Direction: — 
 At first outward and backward, or upward and backward — rarely directly 
 backward. Subsequently, in majority of cases, it passes horizontally backward 
 — exceptionally, downward and backward. (3) Location: — (a) In Majority 
 of Cases: — it runs approximately parallel with squamoparietal suture, gener- 
 ally within 1 cm. (f inch), never more than 2 cm. (f inch) from it — gradually 
 approaching it — crossing it (unless its terminal branches are given off on the 
 temporal bone) generally within 2 cm. (f inch) of its posterior end, passing 
 thence onto the parietal bone — its small branches running onto the occipital, 
 (It may at first run parallel with the squamosphenoidal suture. It may 
 cross the squamoparietal suture onto the parietal bone at any point.) (b) 
 In Other Cases: — sometimes it runs outward and backward over the squamo- 
 petrosal suture, or upon the squamous parallel with and generally within 
 1 cm. of the squamopetrosal suture — passing back over the base of the petrous 
 bone, crossing the squamoparietal suture near its posterior end — thence back 
 onto the parietal bone, superiorly to and parallel with the mastoparietal 
 suture. (4) Branches of Posterior Branch : — In majority of cases the posterior 
 branch divides into two branches — on the temporal bone, most frequently 
 — on the parietal bone, next most frequently — and on the squamoparietal 
 suture, least frequently. 
 
 Summary. — (1) That no parts of the middle meningeal artery or its 
 anterior or posterior branches have fixed relations, except the main trunk 
 at its exit from the foramen spinosum, and the anterior branch where it 
 crosses the sphenoparietal suture to reach anterior inferior angle of parietal. 
 (2) That the common trunk is generally present. (3) That the anterior branch 
 may be given off from the orbital branch of the lachrymal branch of the 
 ophthalmic. (4) That a tendency to symmetry exists upon the two sides 
 of the skull, but is not constant. (5) That the anterior branch runs through 
 a bony canal in the anterior inferior angle of the parietal bone in the majority 
 of cases. 
 
LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY. 
 
 47 
 
 LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY IN THE 
 
 CRANIUM 
 
 THROUGH TREPHINE-OPENING EXPOSED BY CURVED OBLIQUE INCISION. 
 
 Position. — Patient supine; head supported, shaved and turned to oppo- 
 site side; surgeon on side of operation. 
 
 Landmarks. — A point is selected as the center of the trephine-opening 
 which will fall over the trunk of the artery proximal to its bifurcation, — and 
 which is taken to be about 3.8 cm. (i4 inches) behind the external angular 
 process of the frontal bone and 2.5 cm. (1 inch) above the zygoma. 
 
 Incision. — Begins at external angular process of frontal bone — passes 
 obliquely downward and backward to the posterior end of the zygoma — and 
 from this point upward and backward above the auricle (Fig. 10, P). 
 
 Fig. 20. — Ligation of Trunk of Right Middle Meningeal through Trephine- 
 opening in Temporal Fossa by Curved Oblique Incision: — A, Temporal muscle (iis 
 posterior border retracted upward and forward); B, Zygomatic arch, and temporal fossa 'ust 
 above; C, Main trunk and anterior and posterior branches of midd'e meningeal, exposed through 
 trephine-open ng 1 which is here shown somewhat too high); D, Deep temporal artery; E, Super- 
 ficial temporal artery and vein; F, Auriculotemporal nerve (retracted backward); G, Branches 
 of facial nerve (retracted downward and backward). 
 
 Operation. — (1) Having incised skin and temporal fascia, ligate the 
 superficial temporal artery and vein, guarding the auriculotemporal nerve 
 and branches of the facial (Fig. 20). Then carry the incision along the 
 posterior border of the temporal muscle through the periosteum to the bone. 
 Detach the temporal muscle forward subperiosteal!}', baring parts of the 
 squamous, parietal, and sphenoid bones — guarding the deep temporal arteries. 
 Firmly retract the soft parts thus freed upward and forward. (2) Using a 
 trephine about 3.8 cm. (ih inches) in diameter, place its center over a point 
 about 3.8 cm. (i^ inches) behind the external angular process and 2.5 cm. 
 (1 inch) above the zygoma. Having removed the disc of bone (which is 
 here thin), expose the artery — and pass the needle carefully, to avoid wounding 
 the brain. (3) In completing the operation, the disc of bone may be replaced, 
 
48 OPERATIONS UPON THE ARTERIES. 
 
 or not, according to the individual ideas of the surgeon. Allow the perios- 
 teum and soft parts to re-occupy their normal positions. Suture the margins 
 of severed periosteum with buried catgut. Repair by gut-suturing any 
 muscle tissue which may have been cut and close the skin incision. 
 
 Comment. — (i) This incision of Kocher, together with the subsequent 
 retraction of the soft parts, involves less injury to the parts than the turning 
 downward or upward of a semilunar or horseshoe flap, which is the method 
 of approach most frequently adopted. (2) According to the researches of 
 Plummer (v. s.), the osteoplastic flap operation of Hartley-Krause furnishes 
 the best method of exposing the main trunk of the middle meningeal artery 
 and its branches. (3) If the above trephine-opening expose the artery 
 inconveniently near its circumference, the opening may be enlarged in the 
 direction of the artery with rongeur forceps. 
 
 LIGATION OF ANTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY 
 
 IN THE CRANIUM 
 
 THROUGH TREPHINE-OPENING EXPOSED. BV A HORSESHOE INCISION. 
 
 Position. — As for ligation of main trunk. 
 
 Landmarks. — A point is selected as the center of the trephine-opening 
 which will fall over the anterior branch just beyond its bifurcation — and is 
 taken to be about 3.8 cm. (ih inches) behind the external angular process 
 of the frontal bone, and from 3.8 to 4.5 cm. (1^ to if inches) above the zygoma. 
 
 Incision. — A horseshoe incision with its center over the above point 
 and its convexity upward is outlined — its anterior limb being just behind 
 the external angular process, and the posterior limb corresponding with a 
 line extending vertically upward from the auditory meatus (Fig. 10, Q). 
 
 Operation. — The incision is carried, throughout, through skin, temporal 
 fascia, temporal muscle, and periosteum to bone. These soft parts are 
 raised subperiosteally and turned downward. A trephine of about 3.8 cm. 
 (1^ inches) diameter is applied with its center over the above point. The 
 steps of the operation are, henceforth, the same, practically, as those for 
 the main trunk (page 47). 
 
 Comment. — (1) See the surgical anatomy of the middle meningeal 
 artery and its branches for variations in the course of the anterior branch. 
 (2) According to Chipault's method of cranio-cerebral localization (page 546), 
 the anterior branch of the middle meningeal crosses the second tenths of the 
 three primary lines. In following which method, therefore, the trephine 
 should have its center placed over a line which will cross these tenths at 
 about their middle. (3) According to the researches of Plummer (page 45), 
 who recommends Kroenlein's method of locating the anterior branch as the 
 best of several, the following points are of practical value: — (A) That site 
 should be chosen — (a) Which is high enough to avoid missing the anterior 
 branch in case it originates from the orbital branch; — (b) which is high enough 
 to be above the orbital branch when that branch is only a communicating 
 branch; — (c) which is least apt to fall over the bony canal in the anterior inferior 
 angle of the parietal, and over the bony ridge along the lower portion of the 
 coronal suture: — (B) That a 2.5 cm. (1 inch) trephine-opening placed just 
 behind any portion of the coronal suture will almost certainly strike the ante- 
 rior branch, or a branch of the anterior branch. (4) According to Kroenlein's 
 method, Reid's base line (page 551) is first drawn — then a higher line is drawn 
 parallel with it and on a level with the supraorbital border. On the latter 
 line a point is taken 3 or 4 cm. (iy F to i T 9 g- inches) behind the external angular 
 
SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. 49 
 
 process. The center of the trephine will rest on the sphenoid in the majority 
 of cases. (This corresponds, practically, with the data often given, of fixing 
 upon a point from 3.2 to 3.8 cm. (i| to 1^ inches), according to the size of 
 the head, behind the external angular process — and from 3.8 to 4.5 cm. (i£ 
 to if inches) above the zygoma. 
 
 LIGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY 
 
 IN THE CRANIUM 
 
 THROUGH TREPHINE-OPENING EXPOSED BY A HORSESHOE INCISION. 
 
 Position. — As in ligating the main trunk. 
 
 Landmarks. — A point is selected as the center of the trephine-opening 
 which will fall over the posterior branch in the groove of the parietal bone — 
 and is taken to be at the intersection of a line drawn horizontally backward 
 on a level with the roof of the orbit, and one drawn vertically upward from 
 directly behind the mastoid process — which point of intersection lies just 
 below the parietal eminence (Jacobson). 
 
 Incision. — A horseshoe incision with its center over the above point, 
 its convexity upward, and its limbs being from 5 to 5.7 cm. (2 to i\ inches) 
 apart (Fig. 10, R). 
 
 Operation. — Performed in the same general manner as for ligation of 
 the anterior branch (page 48). 
 
 Comment. — (i) According to the researches of Plummer (page 45), 
 who recommends Steiner's method as the best of several for locating the 
 posterior branch, the following points are of practical value : — (A) The posterior 
 branch is incapable of being located with as much certainty as the anterior 
 branch: — (B) The lateral sinus is to be guarded in exposing the posterior 
 branch. (2) According to Steiner's method, Reid's base-line is first drawn — 
 then a second higher line is drawn parallel with it and on a level with the 
 supraorbital border. A third line is drawn vertically upward along the 
 anterior border of the mastoid (drawing the ear forward). The intersection 
 of the third with the second line marks a convenient site for reaching the 
 posterior branch. The trephine-pin rests on the squamoparietal suture. 
 When the posterior branch itself is not encountered, its two branches usu- 
 ally are. 
 
 SURGICAL ANATOMY OF INTERNAL CAROTID ARTERY. 
 
 Description. — The larger of the two branches of the common carotid. 
 Arises opposite upper border of thyroid cartilage (on level with fourth cervical 
 vertebra) — at first comparatively superficial, and lies slightly external to 
 external carotid, then sinks more deeply in neck and passes posteriorly to 
 that vessel — ascending neck in front of transverse processes of upper cervical 
 vertebra.' to enter the carotid canal. The relations of its different portions 
 are as follows: 
 
 Relations. — (i) First or Cervical Portion :— Anteriorly (from below 
 upward) — skin; superficial fascia; platysma; deep fascia; sternomastoid; 
 posterior belly of digastric; stylohyoid; hypoglossal; occipital artery; posterior 
 auricular artery; external carotid; styloglossus; stylopharyngeus; glosso- 
 pharyngeal nerve; pharyngeal branch of pneumogastric; stylohyoid ligament. 
 Posteriorly — rectus capitis anticus major; transverse processes of three 
 
5° 
 
 OPERATIONS UPON THE ARTERIES. 
 
 upper cervical vertebra-; superior cervical ganglion; pneumogastric nerve; 
 hypoglossal nerve; glossopharyngeal nerve; spinal accessory nerve; internal 
 jugular vein. Externally— internal jugular vein; pneumogastric nerve. 
 Internally— pharynx; superior constrictor; tonsil; ascending pharyngeal 
 artery; ascending palatine artery; eustachian tube; levator palati. (2) 
 Second or Petrous Portion :— Within carotid canal in petrous portion of 
 temporal bone. (3) Third or Cavernous Portion :— Between layers of dura 
 mater, forming cavernous sinus. (4) Fourth or Cerebral Portion : — Enters 
 inner extremity of fissure of Sylvius and gives off its branches. 
 
 Branches.'— From cervical portion— none. From petrous portion— 
 tympanic; vidian. From cavernous portion — arteria receptaculi; pituitary; 
 gasserian; anterior meningeal; ophthalmic. From cerebral portion— anterior 
 cerebral; middle cerebral; posterior communicating; anterior choroid. 
 
 Line.— Same, practically, as for the external carotid.,— or possibly a little 
 to the outer side of that line at its lower part. 
 
 Indications for Ligation. — Wounds; aneurism. 
 
 Site of Ligation. — Near origin (Fig. 10, S). 
 
 LIGATION OF INTERNAL CAROTID ARTERY 
 
 NEAR ORIGIN. 
 
 Position— Landmarks. — As for ligation of external carotid below the 
 digastric (page 37). 
 
 Incision.— Slightly posterior to the incision lor the external carotid 
 artery— that is, along' the anterior border of the sternomastoid. instead of 
 just in front of it — with the center of the incision about 1.3 cm. (h inch) above 
 the upper border of the thyroid cartilage (Fig. 10, S). 
 
 Operation. — The steps are, at first, the same as those for exposing the 
 external carotid below the digastric. This artery (external carotid) is first 
 sought (all the structures mentioned in that operation being encountered) 
 and traced to its bifurcation, and thus the internal carotid is exposed — the 
 external carotid being drawn inward and the digastric upward. In opening 
 the sheath special care must be taken to guard the internal jugular vein, 
 pneumogastric nerve, cervical sympathetic, ascending pharyngeal artery — ■ 
 the needle being passed from the vagus and internal jugular vein (Fig. 15). 
 
 Collateral Circulation. — Circle of Willis. 
 
 SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. 
 
 Description. — Subclavian artery on right side, about 7.5 cm. (3 inches) 
 in length, arises from the innominate; and, on the left, about 10 cm. (4 inches) 
 in length, arises from arch of aorta — arching, in both cases, across the root 
 of neck, over the dome of the lung and pleura, to the lower border of the 
 first rib, where it becomes the axillary artery. That portion of the subclavian 
 internal to inner border of scalenus anticus being the first part — that portion 
 behind this muscle being the second part — and that portion external to the 
 outer border of scalenus anticus being the third part. The subclavian vein 
 lies below and anterior to artery, the scalenus anticus intervening. The 
 posterior border of the sternomastoid corresponds with the external border 
 of the scalenus anticus. 
 
 Relations.— (a) First Portion of Right Subclavian: — About 3 cm. 
 
SURGICAL ANATOMY OF SUBCLAVIAN ARTERY. 5 1 
 
 (i\ inches) in length' — arises from bifurcation of innominate, behind upper 
 border of right sternoclavicular articulation — curves upward and outward 
 (with convexity upward) at a variable distance above clavicle, over apex 
 of right lung and pleura, to inner border of right scalenus anticus, hav- 
 ing following relations: — Anteriorly — skin; superficial fascia; platysma; an- 
 terior laver of deep fascia; clavicular origin of sternomastoid; sternohyoid; 
 sternothvroid; deep cervical fascia; right innominate vein; internal 
 jugular vein; vertebral vein; pneumogastric nerve; phrenic nerve; superior 
 cardiac branches of sympathetic nerve: — Posteriorly — areolar tissue; longus 
 colli; transverse process of seventh cervical and first dorsal vertebra; sym- 
 pathetic nerve; inferior cardiac nerves; recurrent laryngeal nerve; apex of 
 right lung and pleura; neck of first rib: — Inferiorly — pleura and lung; 
 recurrent laryngeal nerve; subclavian vein, (b) First Portion of Left 
 Subclavian: — Much longer than that of right — arises from distal end of 
 transverse part of arch of aorta, opposite fourth dorsal vertebra, to left and 
 slightly posterior to left common carotid — ascending, at first, almost vertically 
 — then arching further upward and outward over apex of left lung and pleura 
 to inner border of left scalenus anticus — having following relations: — Ante- 
 riorly — left pleura and lung; sternothyroid; sternohyoid; sternomastoid; left 
 innominate vein; internal jugular vein; vertebral vein; subclavian vein; phrenic 
 nerve; pneumogastric nerve; left cervical cardiac nerves of sympathetic; 
 left common carotid; thoracic duct: — Posteriorly — esophagus; thoracic duct; 
 inferior cervical sympathetic ganglion; longus colli; vertebral column; left 
 pleura and lung: — Externally — left pleura and lung: — Internally— trachea; 
 recurrent laryngeal nerve; esophagus; thoracic duct, (c) Second Portions 
 of Both Subclavian Arteries : — Highest part of the vessel — about 2 cm. 
 (f inch) in length — lies behind scalenus anticus, which separates the artery 
 from the subclavian vein — and has following relations: — Anteriorly — skin; 
 superficial fascia; platysma; anterior layer of deep fascia; clavicular origin 
 of sternomastoid; deep layer of deep fascia; phrenic nerve; subclavian vein; 
 scalenus anticus: — Posteriorly — apex of lung and pleura; scalenus medius: — 
 Superiorly— brachial plexus: — Inferiorly— lung and pleura, (d) Third 
 Portions of Both Subclavians : — Lie in subclavian triangle (of sternomastoid, 
 omohvoid, and clavicle). Extend from outer border of scalenus anticus 
 downward and outward to lower border of first rib, and have following rela- 
 tions: — Anteriorly — skin; superficial fascia; platysma; clavicular branches 
 of descending portion of cervical plexus; anterior layer of deep fascia (from 
 omohyoid to clavicle) ; posterior layer of deep fascia (from omohyoid to first 
 rib); fatty areolar tissue between layers of deep cervical fascia; suprascapular 
 artery; external jugular vein; suprascapular vein; transversalis colli vein; 
 other tributary veins to external jugular; nerve to subclavius muscle; sterno- 
 mastoid (sometimes); clavicle; subclavius muscle: — Posteriorly— scalenus 
 medius; cord of brachial plexus formed by eighth cervical and first dorsal: 
 — Superiorly— brachial plexus; posterior belly of omohyoid: — Inferiorly 
 — first rib. 
 
 Branches.— From First Portion : — vertebral, thyroid axis (inferior thyroid, 
 transversalis colli, suprascapular), internal mammary. From Second Portion: 
 — superior intercostal. From Third Portion: — no branches, ordinarily. 
 
 Line.— A curve, with convexity upward, at base of posterior triangle- 
 beginning at sternoclavicular articulation and ending at center of inferior 
 border of clavicle— its mid-point being about 1.3 cm. (h inch) above the 
 superior border of clavicle. 
 
 Indications for Ligation.— Wounds; aneurism; preliminary to extensive 
 operations about the shoulder and upper extremity. 
 
52 OPERATIONS UPON THE ARTERIES. 
 
 Sites of Ligation.— But few successful cases of ligation of the first portion 
 of the right subclavian are recorded and fewer of the left — the ligation being 
 particularly hazardous, especially upon the latter side. Nor is ligature of the 
 second portion to be recommended, owing to the depth and relations of the 
 artery. The third portion is the part of the artery usually selected for ligation 
 (Fig. 10, T). Ligation of the first portion of the subclavian differs slightly 
 upon the two sides, owing to anatomical relations. 
 
 LIGATION OF FIRST PORTION OF RIGHT SUBCLAVIAN 
 
 BY ANGULAR INCISION. 
 
 Position — Landmarks — Incision. — As for ligation of innominate by 
 angular incision (page 27). 
 
 Operation. — Having incised skin and superficial fascia, this triangular 
 flap is dissected up, as in ligation of the innominate. The anterior jugular 
 vein is doubly ligated and divided, and the external jugular similarly treated, 
 if in the way. Divide the deep fascia. Expose and sever the sternal and 
 clavicular heads of the sternomastoid. Divide the sternohyoid and sterno- 
 thyroid either in whole or in part. Expose the common carotid, carefully 
 retracting the internal jugular vein and pneumogastric nerve outward and 
 displacing or doubly ligating any overlying veins. Identify the subclavian 
 vein by following down the common carotid on its postero-external aspect 
 to the bifurcation. Clear the subclavian artery, carefully guarding the 
 recurrent laryngeal and phrenic nerves and vertebral artery. Displace the 
 pleura downward and outward with tip of finger, and pass. the needle from 
 below (from the pleura). The vertebral should also be secured at the same 
 time and through the same incision — to accomplish which, the internal 
 jugular and pneumogastric nerve are now retracted inward and the vertebral 
 exposed by a few strokes of the knife as it lies between the longus colli and 
 scalenus, guarding the phrenic and recurrent laryngeal nerves and the inferior 
 thyroid artery. (Also see Fig. 12.) 
 
 Comment. — Excision of the right sternoclavicular articulation may be 
 done when necessary, as in the ligation of the innominate by partial bony 
 resection. 
 
 Collateral Circulation. — Superior thyroid, with inferior thyroid; one 
 vertebral, with opposite vertebral. Internal mammary, with deep epigastric 
 and aortic intercostals. Superior intercostal, with aortic intercostals. Pro- 
 funda cervicis, with princeps cervicis. Scapular branches of thyroid axis, 
 with branches of axillary. Thoracic branches of axillary, with aortic inter- 
 costals. 
 
 LIGATION OF FIRST PORTION OF LEFT SUBCLAVIAN 
 
 BY ANGULAR INCISION. 
 
 Position — Landmarks — Incision. — As for ligation of innominate by 
 angular incision, except that the operation is placed upon the left side. 
 
 Operation. — The steps of the operation are similar to those for ligation 
 of the first portion of the right subclavian — up to the exposure of the common 
 carotid and internal jugular. Here the common carotid and pneumogastric 
 are retracted inward, the internal jugular is drawn outward and downward, 
 and, with it, the left innominate vein. At this stage the head is bent forward 
 
LIGATION OF THIRD PORTION OF THE SUBCLAVIAN. 53 
 
 to relax the parts. Special care is here given to identifying the thoracic 
 duct before proceeding — the duct arching from the seventh cervical vertebra 
 forward and downward over the subclavian artery in front of the scalenus 
 anticus, and emptying into the left subclavian vein at the junction with it 
 of the left internal jugular, being embedded in the loose areolar tissue of the 
 part, making it often difficult to find, and sometimes dividing into several 
 branches. Having safeguarded the important neighboring structures, follow 
 down the common carotid with the finger until the subclavian is identified, 
 on a plane posterior and external to that of the former vessel. The artery 
 is then to be freed, carefully guarding the pleura; the sheath is opened and 
 the needle passed from the pleura. 
 
 Comment. — If more room be required than given by the above incision, 
 or if it be required to ligate the vessel nearer the arch, an excision of the 
 sternoclavicular articulation can be done. 
 
 Collateral Circulation. — See Ligation of First Part of Right Subclavian. 
 
 LIGATION OF SECOND PORTION OF SUBCLAVIAN ARTERY. 
 
 Position — Landmarks — Incision. — As for ligation of third portion of 
 subclavian. 
 
 Operation. — The steps of this operation, up to the division of the deep 
 cervical fascia and the recognition of the outer border of the scalenus anticus 
 (which lies directly under the outer border of the sternomastoid), are identical 
 with those for the exposure of the third part of the subclavian. The further 
 steps consist in the inward retraction of the scalenus anticus (and overlying 
 sternomastoid), with the division of as many of their fibers as necessary, when 
 the artery will be exposed and may be ligated. Especial care is taken to 
 guard the phrenic nerve, which crosses obliquely the lower anterior surface 
 of the scalenus anticus, — as well as the transversalis colli and suprascapular 
 arteries, which cross the scalenus anticus transversely, — and the external 
 jugular vein, running parallel with the anterior scalene muscle. 
 
 Comment. — This operation is often merely a proximal continuation of 
 the operation for the exposure of the third part of the subclavian, when the 
 application of a ligature to the third part is impracticable. 
 
 LIGATION OF THIRD PORTION OF THE SUBCLAVIAN. 
 
 Position. — Patient supine; shoulders raised; head thrown back and to 
 opposite side; operated shoulder depressed by arm drawn downward and 
 placed under the back (to open out the posterior cervical triangle). Surgeon 
 in front of shoulder. 
 
 Landmarks. — Posterior border of sternomastoid (which corresponds 
 with the outer border of the scalenus anticus); anterior border of trapezius; 
 middle of clavicle. 
 
 Incision. — With the skin of the posterior cervical triangle drawn down 
 over the clavicle by the left hand, an incision about 7.5 cm. (3 inches) is 
 made transversely over the clavicle down to the bone, from the posterior 
 border of the sternomastoid to the anterior border of the trapezius, and with 
 its center about 2.5 cm. (1 inch) internal to the center of the superior border 
 of the clavicle (Fig. 10, T). 
 
 Operation. — (i) This incision will divide the skin, fascia, platysma, 
 
54 
 
 OPERATIONS UPON THE ARTERIES. 
 
 some supraclavicular nerves, and maybe a connecting vein between the 
 cephalic and internal jugular— but will avoid the external jugular, which 
 passes through the deep fascia above the clavicle. The incision will lie 
 about 2.5 cm. (£ inch) above the clavicle when the tension upon the skin is 
 relaxed (Fig. 21). (2) The margins of the sternomastoid and trapezius will 
 be exposed, & and, if more room be needed, may be divided along the clavicle 
 as far as necessary. (3) The deep cervical fascia is next incised, the external 
 jugular vein being carefully exposed and retracted, or divided between double 
 ligatures. Tributary vein's of the external jugular are to be similarly treated, 
 especially the transv'ersalis colli and suprascapular. (4) Generally the trans- 
 versaiis colli artery lies transversely above the incision, and the suprascap- 
 ular transversely below it, under the clavicle and out of the way; but one or 
 
 Fig. 21. — Ligation of Third Part of Right Subclavian: — A, Platysma; B, Trapezius; C 
 Sternomastoid (posterior border incised); D, Scalenus amicus; E, Posterior belly of omohyoid (re- 
 tracted upward); F, Clavicle ; G, Third part of subclavian ; H, Transversalis colli A.; I, Suprascapu- 
 lar A.; J, Subclavian vein; K, Upper end of external jugular V. (divided and retracted), with 
 transversalis colli V. and communicating branch to anterior jugular ; L, Lower end of external jugu- 
 lar (divided and retracted), with suprascapular branch ; M, Brachial plexus; N, N, N, Supraclavicu- 
 lar nerves ; O, Deep cervical fascia. 
 
 both may present in the field, and are to be carefully preserved for collateral 
 circulation. Retract the posterior belly of the omohyoid upward if in the 
 way. Identify the outer margin of the scalenus (just under the outer margin 
 of the sternomastoid) as a guide to the artery, and follow its outer border 
 downward until the finger reaches the tubercle on the upper border of the 
 first rib, which lies between the subclavian vein in front, and the subclavian 
 artery behind — when the artery will be recognized and may be traced upward. 
 (5) Expose the lowest cord of the brachial plexus — for the purpose of hence- 
 forth avoiding it (as it has been mistaken and ligated for the artery). The 
 subclavian vein will lie anteriorly and inferiorly to the artery. (6) Open 
 the sheath — clear the artery — and pass the needle from the brachial plexus, 
 guarding the subclavian vein and the pleura. 
 
LIGATION OF VERTEBRAL BRANCH OF SUBCLAVIAN. 55 
 
 Collateral Circulation. — (When the second or third part is tied) : — Supra- 
 scapular and posterior scapular above, with acromiothoracic, infrascapular, 
 subscapular, and dorsalis scapuke below; internal mammary, superior inter- 
 costals, aortic intercostals above, with long thoracic and scapular arteries 
 below; plexiform vessels from branches of subclavian above, with branches 
 of axillary below. 
 
 SURGICAL ANATOMY OF VERTEBRAL ARTERY. 
 
 Description. — Largest and generally first branch of subclavian. Arises 
 from upper and posterior portion of first part of subclavian, near inner border 
 of scalenus anticus — ascends upward, backward, and outward, in interval 
 between scalenus anticus and longus colli, to foramen in transverse process 
 of sixth cervical vertebra — passes through foramina in all vertebrae above 
 this — emerging from foramen in transverse process of atlas, it runs in groove 
 on posterior arch of atlas, lying in the suboccipital triangle, and pierces the 
 occipito-atloid ligament and dura mater — and passes into cranium through 
 foramen magnum — upward upon lateral aspect of medulla to its anterior 
 aspect, where it unites with its fellow to form the basilar. 
 
 Relations. — (a) First or Cervical Part : — from origin to transverse 
 process of sixth cervical vertebra, lying between scalenus anticus and longus 
 colli. Anteriorly — vertebral vein; internal jugular vein; inferior thyroid 
 artery; thoracic duct (left side). Posteriorly — transverse process of seventh 
 cervical vertebra; sympathetic nerve. Externally — scalenus anticus. In- 
 ternally — longus colli, (b) Second or Vertebral Portion : — runs in osseo- 
 muscular canal formed by intervertebral foramina and intertransverse muscles, 
 surrounded by plexus of veins and branches of sympathetic nerve, (c) 
 Third or Occipital Portion : — lies in suboccipital triangle, which is formed, 
 superiorly and internally, by rectus capitis posticus major; superiorly and 
 externally, by obliquus capitis superior; inferiorly and externally, by obliquus 
 capitis inferior; covered by complexus muscle; and floor formed by posterior 
 occipito-atlantal ligament, posterior arch of atlas and posterior atlanto- 
 axial ligament; — the triangle containing the vertebral artery and suboccipital 
 nerve, the latter passing between the artery and arch of the atlas. Ante- 
 riorly — rectus capitis lateralis; articular process of atlas; occipito-atloid 
 ligament. Posteriorly — superior oblique; rectus capitis posticus major; 
 complexus. (d) Fourth or Intracranial Portion: — from opening in dura 
 to lower border of pons, where it unites with its fellow to form basilar 
 artery. 
 
 Indications for Ligation. — Wounds; traumatic aneurism; in connection 
 with ligation of innominate (to prevent secondary hemorrhage). 
 
 Sites of Ligation. — In the first or cervical portion (usual site); in third 
 or occipital portion (rarely). 
 
 LIGATION OF VERTEBRAL BRANCH OF SUBCLAVIAN 
 
 NEAR ITS ORIGIN. 
 
 Position. — Patient supine; shoulders raised; neck prominent; head to 
 opposite side; surgeon on right, in operating on either vertebral. 
 Landmarks. — Anterior border of sternomastoid. 
 
56 OPERATIONS UPON THE ARTERIES. 
 
 Incision.- — About 7.5 cm. (3 inches) in length, extending along the ante- 
 rior border of the sternomastoid, ending below at the clavicle. (As for ligation 
 of the common carotid below the omohyoid.) 
 
 Operation. — (1) Having divided skin, superficial fascia, and the anterior 
 portion of the platysma, branches of the superficial cervical nerve, and com- 
 municating veins between the anterior and external jugular veins, are en- 
 countered and are treated as indicated. (2) Incise the deep cervical fascia, 
 exposing the anterior border of the sternomastoid, which is to be drawn 
 outward; and the omohyoid, which is to be retracted downward and inward; 
 and also the sternohyoid, which is drawn inward. (3) Having freed the 
 attachment of the inner aspect of the common sheath, the carotid, internal 
 jugular, and pneumogastric are drawn outward from over the vertebral 
 artery. The prevertebral fascia is then incised vertically between the carotid 
 tubercle (transverse process of sixth cervical vertebra) and the arch of the 
 inferior thyroid artery (where it turns inward to the posterior surface of the 
 thyroid gland) — where the vertebral artery will be found ascending, partly 
 covered by the longus colli, to the foramen in the transverse process of the 
 sixth cervical vertebra, having the anterior scalenus muscle and phrenic 
 nerve to its outer side, and the longus colli muscle and recurrent laryngeal 
 nerve to its inner side, and the inferior thyroid artery and vein and the vertebral 
 vein lying over it. All these structures, therefore, are to be displaced in the 
 most convenient directions, as the finger seeks the vertebral artery in the 
 above triangular space. The pleura lies below and internally. The thoracic 
 duct, on the left, crosses the artery from within outward. (4) The artery is 
 to be exposed, and the ligature passed with especial care, in order to avoid, 
 as far as possible, the fibers of the sympathetic, some of which are apt to be 
 included in the ligature. (Also see Fig. 12, M.) 
 
 Comment. — The vertebral artery may also be ligated bv an incision 
 made along the posterior border of the sternomastoid, followed by the inward 
 retraction of that muscle (with or without a partial division of its clavicular 
 attachment), but is less simple than the above. The artery may also be 
 ligated in the suboccipital triangle. 
 
 SURGICAL ANATOMY OF INFERIOR THYROID BRANCH OF THYROID 
 AXIS OF SUBCLAVIAN ARTERY. 
 
 Description and Relations. — Largest branch of thyroid axis (which 
 latter arises from first part of subclavian). Ascends upward and inward 
 to posterior surface of thyroid gland — passing behind common carotid, internal 
 jugular, pneumogastric nerve, and sympathetic nerve (middle cervical gan- 
 glion usually resting upon it) — and in front of vertebral artery, recurrent 
 laryngeal nerve (sometimes posterior to it), longus colli muscle. The thoracic 
 duct passes in front of commencement of left vertebral artery. 
 
 Indications for Ligation. — Preliminary to thyreoidectomy; and to 
 diminish goiter. 
 
 Sites of Ligation. — Just beyond the ascending cervical branch (which 
 arises shortly before the vertebral passes behind the carotid). 
 
SURGICAL ANATOMY OF INTERNAL MAMMARY. 57 
 
 LIGATION OF INFERIOR THYROID BRANCH OF THYROID AXIS OF 
 
 SUBCLAVIAN. 
 
 Position. — Patient supine; shoulders elevated; neck prominent; head to 
 opposite side. Surgeon to right side, in either case. 
 
 Landmarks. — Anterior border of sternomastoid. 
 
 Incision. — About 7.5 cm. (3 inches) in length, along the anterior margin 
 of the sternomastoid (as for the common carotid). 
 
 Operation. — Divide skin, superficial fascia, and the platysma, when 
 branches of the superficiaiis colli nerve and tributaries between the anterior 
 and external jugular veins are met, and are to be dealt with as indicated. 
 Incise the deep cervical fascia and define the anterior border of the sterno- 
 mastoid, and retract that muscle outward — the omohyoid is drawn downward 
 and inward, and the sternohyoid inward. After freeing the inner attachment 
 of the common sheath, the carotid, internal jugular, and pneumogastric are 
 drawn outward from over the inferior thyroid artery. The artery is then 
 sought by continuing the dissection toward the .vertebra?, lying a little way 
 below the carotid tubercle, in the interval covered by the sternothyroid muscle, 
 between the inner border of the retracted carotid sheath and the outer border 
 of the thyroid gland. The gland is raised and displaced inward. The 
 artery is exposed where it arches inward, and where the ascending cervical 
 branch arises. The ligature is applied just beyond this branch — thus avoid- 
 ing the recurrent laryngeal nerve, which runs along the trachea and behind 
 the thyroid gland; and the vertebral artery, nearly parallel with it below 
 and passing behind the inferior thyroid as the latter bends inward. The 
 sympathetic nerve, which sometimes embraces the artery, and the phrenic, 
 which lies to its outer side, are to be guarded against injury. 
 
 SURGICAL ANATOMY OF INTERNAL MAMMARY BRANCH OF SUB- 
 CLAVIAN. 
 
 Description. — Arises from lower aspect of first part of subclavian, near 
 to inner margin of scalenus anticus — descends forward and inward, passing 
 behind clavicle to enter thorax posterior to cartilage of first rib — thence 
 runs downward parallel with and about 1.3 cm. (h inch) external to margin 
 of sternum, to interspace between sixth and seventh costal cartilages, where 
 it divides into superior epigastric and musculophrenic. Its two vena? comites 
 unite to form one trunk in first intercostal space and empty into the innominate 
 vein. The internal mammary artery, above, is 0.5 to 1.5 cm. (i- to f inch) 
 from border of sternum — and, below, from 1 to 2 cm. (f- to A inch) from the 
 sternal margin. In its upper part it lies between the internal intercostal 
 muscle and costal cartilages, in front; and pleura behind. In its lower part 
 it lies between the costal cartilages in front; and triangularis sterni behind 
 (the latter structure intervening between it and the pleura). 
 
 Relations. — (a) Cervical Part : — Covered by sternomastoid, subclavian 
 vein, internal jugular vein, phrenic nerve. Rests on pleura, innominate 
 vein, (b) Thoracic Part : — Covered by cartilages of first to sixth ribs, pecto- 
 ralis major, internal intercostal muscles, anterior intercostal membrane. 
 Rests on pleura (above), and triangularis sterni (below). 
 
 Arterial Supply of the Antero-lateral Thoracic Wall. — (a) As the 
 internal mammary artery crosses the upper intercostal spaces two branches 
 (superior and inferior anterior intercostal arteries, or superior and inferior 
 branches of the anterior intercostal arteries, where they arise from a common 
 trunk) are given off in each of the five or six upper interspaces — which pass 
 outward between the pleura and the internal intercostal muscles, and then 
 
58 
 
 OPERATIONS UPON THE ARTERIES. 
 
 between the internal and external intercostal muscles, running along the 
 lower border of the superior, and the upper border of the inferior rib — to 
 anastomose with the superior and inferior branches of the aortic intercostals. 
 (b) In each of the same upper five or six spaces a single branch, the perforating, 
 or the anterior perforating, is given off between the upper and lower anterior 
 intercostal arteries — which pierce the internal intercostal muscles, between 
 the costal cartilages, and supply the pectoralis major, mammary gland (sec- 
 ond, third, and fourth branches), and skin, (c) The anterior intercostal 
 branches for the five or six lower interspaces are given off by the mus- 
 culophrenic branch, which passes down behind the costal cartilages, pierc- 
 ing the diaphragm opposite the ninth rib, and ending at the tenth or eleventh 
 interspace by anastomosing with the ascending branch of the deep circumflex 
 iliac. The anterior intercostals anastomose with the lower aortic intercostals. 
 (See Surgical Anatomy of Aortic Intercostal Arteries, page 76.) 
 
 Indications for Ligation. — Rare, except for wound, when it is usually 
 ligated at the site of injury. If the artery have retracted out of reach, it is 
 ligated in the interspace above or below. 
 
 Sites of Ligations. — Reached most readily in first, second, or third 
 interspaces — especially in the second. 
 
 A CFG 
 
 Fig. 22.— Ligation of Right Internal Mammary in Second Intercostal Space:— A, Pec- 
 toralis major; B, External intercostal muscle, continued to sternum by anterior intercostal mem- 
 brane; C, Internal intercostal muscle; D, Margin of sternum; E, Endothoracic fascia; F, Pleura; 
 G, Internal mammary artery and venae comites. 
 
 LIGATION OF INTERNAL MAMMARY BRANCH OF SUBCLAVIAN 
 
 IN SECOND INTERCOSTAL SPACE. 
 
 Position. — Patient supine; chest supported from behind (to increase 
 width of intercostal spaces). Surgeon on side of operation. 
 
 Landmarks. — Outer border of sternum; lower border of second and 
 upper border of third costal cartilages. 
 
SURGICAL ANATOMY OF AXILLARY ARTERY. 
 
 59 
 
 Incision. — Transverse in direction and about 6.3 cm. (2J inches) in 
 length — beginning over center of sternum and passing outward over center 
 of interspace between second and third costal cartilages (Fig. 10, V). 
 
 Operation. — Divide skin, fascia, pectoralis major, anterior intercostal 
 membrane (running downward and inward), internal intercostal muscle 
 (running downward and outward), and endothoracic fascia — when the artery 
 is found lying upon the pleura, with the venae comites to either side. Separate 
 the artery and pass the needle with especial care, to avoid the pleura (Fig. 58). 
 
 W « 
 
 Fig. 23. — Incisions for Ligating Right Axillary and Brachial Arteries: — A, Junction 
 of anterior and middle thirds of outer axillary wall ; B, Center of bend of elbow ; C, Ligation of third 
 part of axillary ; D, Of brachial in middle of arm ; E, Of brachial at bend of elbow. 
 
 SURGICAL ANATOMY OF AXILLARY ARTERY. 
 
 Description and Relations. — Continuation of subclavian — extending 
 through axilla, from lower border of first rib, on to the arm, at the lower 
 border of the tendon of teres major muscle, where it becomes the brachial. 
 It is divided into three parts: (a) First Part : — About 2.5 cm. (1 inch) in length 
 — extending from lower border of first rib to upper border of pectoralis 
 minor, having following relations: Anteriorly — skin; superficial fascia; 
 origin of platysma; deep fascia; pectoralis major; clavicle (when shoulder is 
 depressed) ; subclavius muscle (when shoulder is depressed) ; costocoracoid 
 membrane; layer of areolar fatty tissue; cephalic vein; acromiothoracic vein; 
 anterior external thoracic nerve; axillary lymphatic trunk. Posteriorly — 
 first intercostal space; first intercostal muscle; second (and sometimes third) 
 serrations of serratus magnus; part of second rib; posterior thoracic nerve. 
 Externally — brachial plexus. Internally — axillary vein; anterior internal 
 thoracic nerve, (b) Second Part : — about 3 cm. (i| inches) in length — 
 lying behind pectoralis minor muscle, and having following relations: Ante- 
 
60 OPERATIONS UPON THE ARTERIES. 
 
 riorly — integuments; superficial fascia; pectoralis major; pectoralis minor. 
 Posteriorly — posterior cord of brachial plexus; areolar tissue and fat; sub- 
 scapularis. Externally — external cord of brachial plexus; coracoid process 
 (somewhat removed). Internally — internal cord of brachial plexus; axillary 
 vein, (c) Third Part: — about 7.5 cm. (3 inches) in length — extending from 
 lower border of pectoralis minor to lower border of tendon of teres major 
 (the upper half being in axilla, the lower half on arm), and having following 
 relations: Anteriorly — integument; superficial fascia; pectoralis major; deep 
 fascia of arm; internal root of median nerve; external brachial vena comes. 
 Posteriorly — musculospiral nerve; circumflex nerve; fatty areolar tissue; 
 subscapulars ; latissimus dorsi; teres major. Externally — external root of 
 median nerve; musculocutaneous nerve; coracobrachialis. Internally — in- 
 ternal root of median nerve; ulnar nerve; internal cutaneous nerve; lesser 
 internal cutaneous nerve; axillary vein. 
 
 Branches. — From first part — superior thoracic, acromial thoracic. 
 From second part — long thoracic, alar thoracic. From third part — sub- 
 scapular, anterior circumflex, posterior circumflex. 
 
 Line of Artery. — (With arm at right angle to trunk and hand supine) — 
 from middle of clavicle to junction of anterior and middle thirds of the 
 outer axillary wall, between the anterior and posterior folds of the axilla. 
 
 Sites of Ligation. — Third part, by preference; — first part, if third part 
 not available. Ligation of third portion of subclavian is usually considered 
 preferable to that of first part of axillary (Figs. 23, C, and 10, W). 
 
 Comment. — (1) When the arm is at a right angle to the body, the axillary 
 vein is drawn across the first part of the artery. (2) The upper and lower 
 borders of the pectoralis minor correspond, respectively, with lines drawn 
 from the junction of the third rib and its cartilage to the coracoid process; 
 and from the junction of the fifth rib and its cartilage to the coracoid process. 
 (3) Two brachial venae comites are generally found at the lower part of the 
 artery — and also the basilic vein, unless it have already joined the internal 
 vena comes. 
 
 LIGATION OF FIRST PART OF AXILLARY ARTERY 
 
 PA' CURVED TRANSVERSE INCISION BELOW CLAVICLE. 
 
 Position. — Patient on back, at edge of table; upper thorax raised; shoulder 
 backward. Surgeon near thorax on left, for left operation; near head on 
 right, for right operation — (or between abducted limb and body on each 
 side). 
 
 Landmarks. — Clavicle; sternoclavicular articulation; coracoid process. 
 
 Incision. — Curved incision in infraclavicular fossa — beginning just ex- 
 ternal to the sternoclavicular joint — dipping, at lowest point, about 1.3 cm. 
 (^inch) below clavicle — and ending at the coracoid process (Fig. 10, W). 
 
 Operation. — Incise skin, platysma, supraclavicular nerves, and fascia. 
 Carefully guard the cephalic vein and branches of acromial thoracic artery 
 at outer part of wound, on account of collateral circulation. Divide the clavic- 
 ular origin of the pectoralis major throughout the wound. Clear the areolar 
 tissue beneath the pectoralis major. Expose the upper border of the pectoralis 
 minor and draw it downward. Divide obliquely downward and outward, near 
 the coracoid process, the costocoracoid membrane — through which pass the 
 cephalic vein, branches of the acromiothoracic artery, and the anterior thoracic 
 nerves — and displace it upward and outward. The cephalic vein, indicating 
 the position of the axillary vein, is generally closely adherent to the costocora- 
 
LIGATION OF FIRST PART OF AXILLARY ARTERY. 
 
 6l 
 
 coid membrane. Expose the sheath and clear the artery — which lies between 
 the axillary vein on the inner side and the brachial plexus on the outer, aided 
 in the exposure by bringing the arm nearer the body, when the axillary vein 
 will be carried from over the artery to its inner side. The ligature is placed 
 above the acromiothoracic branch. The incised pectoralis major muscle 
 is repaired by gut suturing. 
 
 Comment. — This is the easiest and most frequent ligation of the first part 
 in the rare cases in which a ligation at this site is done — a ligation of the third 
 portion of the subclavian being considered preferable. The first part may also 
 be exposed by an oblique incision in the groove between the pectoralis major 
 and deltoid. 
 
 Collateral Circulation. — When ligated between the superior thoracic 
 and acromial thoracic: — Suprascapular and posterior scapular; with acromial 
 thoracic and subscapular. Internal mammary, aortic intercostals, superior 
 intercostal; with long thoracic and subscapular. Plexiform vessels from 
 subclavian; with plexiform vessels from axillary. 
 
 Fig. 24. — Ligation of Third Part of Right Axillary: — A, Coracobrachial (retracted 
 outward); B, Pectoralis major; C, Teres major; D, Triceps; E, Axillary artery; F, Basilic vein, 
 becoming axillarv vein after receiving two brachial venae comites; G, Right brachial vena 
 comes; H, Musculocutaneous nerve; 1, Median X.; S, Internal cutaneous X.; K, K, Ulnar N. 
 
62 
 
 OPERATIONS UPON THE ARTERIES. 
 
 LIGATION OF THIRD PART OF AXILLARY ARTERY. 
 
 Position. — Patient supine at edge of table; shoulders raised; arm at 
 right angle to body, and slightly rotated outward. Surgeon between arm 
 and chest, on either side. Axilla to be shaved. 
 
 Landmarks. — Junction of anterior and middle thirds of external axillary 
 wall; coracobrachialis. 
 
 Incision. — About 7.5 cm. (3 inches) in length — beginning at the middle 
 of the outlet of the axilla, at the junction of the anterior and middle thirds 
 of its outer wall, and passing downward along the inner border of the coraco- 
 brachialis (Fig. 23, C). 
 
 Fig. 25. — Cross-section of the Right Arm at the Axillary Level: — A, Axillary 
 artery and vein; B, Ulnar nerve; C, Musculospiral nerve; D, Median nerve; E, Internal cutaneous 
 nerve; F, Musculocutaneous nerve; G, Coracobrachialis muscle; H, Biceps; I, Pectoralis major 
 muscle and biceps tendon; J, Deltoid; K, Triceps; L, L, Latissimus dorsi. (The cross-section 
 modified from Esmarch.) 
 
 Operation. — Having incised integument and fascia, expose the inner 
 border of the coracobrachialis (Fig. 24). Draw this muscle and the musculo- 
 cutaneous nerve outward. The median nerve is exposed and also drawn 
 outward. The internal cutaneous and ulnar nerves are drawn inward. Venae 
 comites are generally present at the lower part of the axilla and sometimes 
 the basilic vein, which have to be guarded. Again, the axillary vein alone 
 may be present to the inner side of the artery. Pass the needle from the vein, 
 ligating the artery as far from a large branch as possible (Fig. 25). 
 
SURGICAL ANATOMY OF BRACHIAL ARTERY. 
 
 63 
 
 Collateral Circulation. — (a) If tied below the circumflex arteries: — the 
 posterior circumflex above, with the superior profunda below, (b) If tied 
 between subscapular above and two circumflex branches below: — the supra- 
 scapular and acromial thoracic above, with posterior circumflex below. 
 
 SURGICAL ANATOMY OF BRACHIAL ARTERY. 
 
 Description. — Continuation of axillary artery. Extends down inner 
 and anterior aspect of arm, from lower border of tendon of teres major to 
 about 1.3 cm. (^ inch) below center of crease at bend of elbow, and divides, 
 opposite junction of head with neck of radius, into radial and ulnar arteries. 
 The artery lies in the depression at the inner borders of the coracobrachialis 
 and biceps, and then in the groove between the supinator longus and pronator 
 radii teres, passing under the bicipital fascia below. It lies to the inner side 
 of humerus above, and in front of it below. 
 
 Fig. 26.— Ligation of Right Brachial at Middle of Arm :— A, Biceps; B, Coracobrachi- 
 alis (retracted outward) : C, Triceps; D, Brachial artery and branches; E, Brachial venae comites 
 and communicating branches ; F, Basilic vein ; G. Branch from basilic to cephalic vein ; H, Median 
 nerve; I, Ulnar X. ; J, Internal cutaneous N. 
 
 Relations. — Anteriorly: integument; superficial and deep fascia; 
 median nerve (in middle); median basilic vein and bicipital fascia (at elbow). 
 Posteriorly : lies, in order, upon — long head of triceps (musculospiral nerve 
 and superior profunda artery intervening); inner head of triceps; insertion 
 of coracobrachialis; brachialis anticus. Externally: in order — coraco- 
 brachialis; belly of biceps (both slightly overlapping the artery); tendon of 
 
6 4 
 
 OPKRATIONS UPON THE ARTERIES. 
 
 biceps; median nerve, above (crossing artery at middle); external vena comes. 
 Internally: internal cutaneous and ulnar nerves (above); median nerve 
 (below); internal vena comes; basilic vein. 
 
 Branches. — Superior profunda; inferior profunda; anastomotica magna; 
 nutrient; muscular. 
 
 Line of Artery. — (Arm extended and abducted, hand supine.) From 
 junction of anterior and middle thirds of outer wall of axilla to center of 
 bend of elbow (Fig. 23, A and B). 
 
 Sites of Ligation. — Middle of arm (preferably); bend of elbow. 
 
 Fig. 27. — Cross-section of the Middle of the Right Arm: — A, Brachial artery and 
 veins and inferior profunda artery and median and ulnar nerves; B, Musculospiral nerve and 
 superior profunda artery; C, Nutrient vessels; D, Biceps muscle; E, Triceps; F, Brachialis anticus 
 muscle. (Cross-section modified from Braune.) 
 
 LIGATION OF BRACHIAL ARTERY 
 
 IN MIDDLE OF ARM. 
 
 Position. — Limb extended, abducted, and hand supine. Surgeon to 
 outer side of limb, cutting from above downward on right, and from below 
 upward on left. 
 
 Landmarks. — Inner border of coracobrachialis and biceps; line of 
 artery. 
 
 Incision. — About 5 to 7.5 cm. (2 to 3 inches) in length, extending along 
 inner border of biceps, in line of artery, opposite middle of arm (Fig. 23, D). 
 
 Operation. — The skin and fascia having been divided, the inner border 
 of the biceps must be clearly recognized and retracted outward — when the 
 arterv is generally found under its inner margin — the median nerve usually 
 crossing the front of the arterv at its middle — the internal cutaneous nerve 
 
LIGATION OF BRACHIAL ARTERY. 
 
 65 
 
 lying to the inner side (Fig. 26). The venae comites and basilic vein are to 
 be separated from the artery. The needle is passed from the nerve (Fig. 27). 
 Comment. — (1) The artery is not as easily found in this situation as 
 the superficial position would suggest. Its exposure is made easier by an 
 assistant's holding the limb by the wrist, so that it cannot rest on the table, 
 where the triceps is apt to be pushed upward and may protrude the inferior 
 profunda artery and ulnar nerve, instead of the brachial artery and median 
 nerve (Heath). (2) In ligating higher than the middle third, the artery 
 lies to the inner side of the coracobrachialis, the median nerve to the outer 
 side, and the ulnar nerve to the inner. 
 
 Fig. 28. — Ligation of the Right Brachial at the Bend of the Elbow: — A, A, Median 
 basilic vein; B, Median cephalic vein; C, Internal cutaneous nerve and branches; D, Biceps; 
 E, E, Bicipital fascia; F, Brachial artery; G, Brachial venae comites and communicating branch; 
 H, Median nerve; I, Brachialis anticus muscle. 
 
 LIGATION OF BRACHIAL ARTERY 
 
 AT BEND OF ELBOW. 
 
 Position. — Limb extended (not overextended) and abducted. Surgeon 
 to outer side of limb, cutting from above on right, and from below on left. 
 
 Landmarks. — Inner border of biceps tendon. 
 
 Incision. — About 5 cm. (2 inches) in length — in the internal bicipital 
 fossa, along the inner border of the biceps tendon — its center corresponding 
 to the " fold of the elbow." This incision will be oblique and its upper end 
 will commence opposite the tip of the internal condyle of the humerus. It is 
 well to compress the veins above, to get an idea of their position at the elbow, 
 
66 
 
 OPERATIONS UPON THE ARTERIES. 
 
 and thus avoid them, if possible. Ordinarily the incision will lie above and 
 to the outer side of the median basilic (Fig. 23, E). 
 
 Operation. — Having incised skin and superficial fascia, isolate the median 
 basilic vein and accompanying internal cutaneous nerve and retract them 
 inward (Fig. 28). Incise, in the direction of the original wound, the deep 
 fascia and the bicipital fascia — the latter (passing inward and downward) 
 is to be incised to as limited an extent as possible. Beneath the bicipital fascia 
 lies the artery, with its vense comites — the median nerve generally lying out 
 of the way and to the inner side, nearer the upper than the lower part of the 
 
 Fig. 20 — Cross-section of Right Arm just below the Elbow-joint : — A, Brachial 
 artery dividing into radial and ulnar, with vena; comites; B, Median basilic vein; C, Radial 
 recurrent artery and radial and interosseous nerves; D, Ulnar nerve and posterior ulnar recurrent 
 artery; E, Median nerve and anterior ulnar recurrent artery; F, Biceps tendon; G, Supinator 
 longus muscle; H, Extensor carpi radialis longior; I, Extensor carpi radialis brevior; J, Extensor 
 carpi ulnaris; K, Anconeus; L, Pronator radii teres; M, Flexor sublimis digitorum; N, Flexor 
 carpi ulnaris (a fascial line is seen between its two parts). The brachialis anticus muscle lies 
 just below the brachial artery. The flexor carpi radialis lies just to the right of the pronator 
 radii teres. (The cross-section modified from Braune.) 
 
 wound. Pass the needle from the side of the ulnar nerve, 
 bicipital fascia with gut (Fig. 29). 
 
 Resuture the 
 
 SURGICAL ANATOMY OF RADIAL ARTERY. 
 
 Description. — Smaller but more direct of two divisions of brachial. 
 Begins at bifurcation of brachial, about 1.3 cm. (J inch) below bend of elbow 
 — runs outward and downward along radial side of forearm to styloid process 
 of radius — thence passes around outer side of carpus over external lateral 
 ligament and beneath extensor tendons of thumb, to back of wrist — and 
 enters palm between first and second metacarpal bones, passing between 
 the two heads of first dorsal interosseous muscle — thence crosses metacarpal 
 
SURGICAL ANATOMY OF RADIAL ARTERY. 67 
 
 bones and interossei muscles, anastomosing at ulnar side of hand with deep 
 branch of ulnar, to form deep palmar arch. The artery is accompanied by 
 two vena? comites. 
 
 Relations. — (a) In Forearm : — The artery runs in outermost intermuscu- 
 lar space, lying between supinator longus and pronator radii teres above, and 
 between supinator longus and tendon of flexor carpi radialis below. Ante- 
 riorly — skin; fascia; supinator longus (above). Skin; fascia; cutaneous 
 vessels and nerves (below). Posteriorly — (from above downward) tendon 
 of biceps; supinator brevis; insertion of pronator radii teres; radial origin 
 of flexor sublimis digitorum; flexor longus pollicis; pronator quadratus; 
 anterior surface of lower end of radius. Externally — supinator longus 
 (guide to arterv) and external vena comes (throughout) ; radial nerve (middle 
 third). Internally — pronator radii teres (upper third); tendon flexor carpi 
 radialis (lower third); internal vena comes (throughout), (b) At Wrist: — 
 The artery winds over outer side of carpus, from a point just below and 
 internal to stvloid process of radius, to base of first interosseous space, entering 
 the palm between the two heads of the first dorsal interosseous muscle (ab- 
 ductor indicis) to form the deep palmar arch. It is covered, successively, 
 by extensor ossis metacarpi pollicis; extensor brevis pollicis; branches of 
 radial nerve; superficial radial veins; extensor longus pollicis; — and rests, in 
 order, upon external lateral ligament; scaphoid; trapezium; base of first 
 metacarpal; dorsal carpal ligaments. It is accompanied by two vena? comites 
 and branches of musculocutaneous nerve, (c) In the Palm : — Enters palm 
 in upper part of interval between first and second metacarpals, passing 
 between two heads of first dorsal interosseous muscle (abductor indicis) — 
 runs inward between adductor obliquus pollicis and adductor transversus 
 pollicis — crossing the palm transversely, with slight downward curve, to 
 base of metacarpal of little finger, and there anastomoses with deep branch 
 of ulnar, forming the deep palmar arch. The deep palmar arch, therefore, 
 extends from base of first interosseous space to base of metacarpal of little 
 finger, and is about 2 cm. (f inch) nearer the wrist than is the superficial 
 palmar arch. It is covered by the superficial and deep flexor tendons; ad- 
 ductor obliquus pollicis; part of flexor brevis minimi digiti; part of opponens 
 minimi digiti; lumbricales. It rests upon adductor transversus pollicis; 
 carpal extremities of metacarpal bones; interossei muscles. It is accom- 
 panied by two vena? comites and the deep branch of the ulnar nerve (running 
 in opposite direction). 
 
 Branches. — (a) In Forearm — radial recurrent; muscular; anterior radial 
 carpal; superficialis vola?. (b) At Wrist — posterior radial carpal; metacarpal 
 (first dorsal interosseous); dorsalis pollicis; dorsalis indicis. (c) In Palm 
 — princeps pollicis; radialis indicis; palmar interosseous; recurrent; per- 
 forating. 
 
 Line of Artery. — (a) In Forearm (with hand supine) — from center of 
 bend of elbow, to inner side of forepart of stvloid process of radius (Fig. 
 30, H and I), (b) At Wrist — from inner side of forepart of styloid process 
 to base of first interosseous space, (c) In Palm — runs about 2 cm. (f 
 inch) nearer wrist than does superficial palmar arch (which corresponds 
 with a line continued across on level with lower border of outstretched 
 thumb). 
 
 Sites for Ligature. — Upper forearm (rarely); middle forearm; lower 
 forearm (preferably); back of hand (rarely). In palm — the arch may be 
 tied in case of wounds, under which circumstances it may be ligated at any 
 site (Fig. 30, A, B, C, D). 
 
 Anatomy of the " Tabatiere," or " Snuff-box." — The triangular 
 
68 
 
 OPERATIONS UPON THE ARTERIES. 
 
 space on back of hand — bounded, on radial side, by extensor ossis metacarpi 
 pollicis, and extensor brevis pollicis; — on ulnar side, by extensor longus polli- 
 cis; — above, by lower edge of posterior annular ligament. Its floor is 
 formed by trapezium, part of scaphoid, base of first metacarpal. It con- 
 tains radial artery, cephalic vein of thumb, branch of internal division of 
 radial nerve, branch of musculocutaneous nerve. 
 
 Fig. 30.— Incisions for Ligating Right Radial and Ulnar Arteries, and Superficial 
 and Deep Palmar Arches :— A, Ligation of radial in upper third of forearm ; B, of radial in middle 
 third; C, of radial in lower third; D, of deep palmar arch ; E, Ligation of ulnar in middle third of 
 forearm; F, of ulnar in lower third ; G, of superficial palmar arch; H, Center of bend of elbow ; I, 
 Antero-internal aspect of styloid process of radius; J, Radial sideof pisiform bone; K, Anterior aspect 
 of inner condyle of humerus; L, Point on inner aspect of forearm at junction of upper and middle, 
 thirds. 
 
LIGATION OF RADIAL ARTERY. 
 
 69 
 
 Fig. 31. — Ligation of the Right Radial Artery in the Upper Part of the Forearm: 
 — A, Radial artery; B, Radial vena? comites; C, Radial nerve; D, Supinator longus muscle; 
 E, Pronator radii teres muscle; F, Flexor carpi radialis muscle. (Modified from Deaver.) 
 
 LIGATION OF RADIAL ARTERY 
 
 IN UPPER THIRD OP" FOREARM. 
 
 Position. — Hand supine; wrist extended. Surgeon stands outside of 
 limb, cutting downward on right and upward on left. Assistant holds fingers 
 with one hand and grasps forearm with other. 
 
 Landmarks. — Line of artery; inner border of supinator longus. 
 
 Incision. — From 5 to 7.5 cm. (2 to 3 inches), in line of artery — with 
 center over the point to be tied (Fig. 30, A). 
 
 Operation. — Having incised skin and superficial fascia, the radial or 
 median vein may be met. Divide the deep fascia and open up the space 
 between the supinator longus (fibers running directly downward) and the 
 pronator radii teres (fibers running downward and outward) (Fig. 31). The 
 artery lies under the edge of the supinator longus and upon the inser- 
 tion of the pronator radii teres. The radial nerve lies well to the outer 
 side. 
 
 Comment. — Unless one recognize the inner margin of the supinator 
 longus, there is possibility of hitting off the wrong intermuscular septum and 
 getting too near the middle of the forearm. The anterior surface of the 
 supinator longus (and not its. inner border) appears at first, in operating upon 
 
7o 
 
 OPERATIONS UPON THE ARTERIES. 
 
 the muscular — and this must be well retracted outward. Note. — Ligation 
 of the middle third of the radial amounts to a downward extension of the follow- 
 ing operation {v. s.), or an upward extension of the following operation 
 (v. i.). The vessel is found at the inner margin of the supinator longus, 
 resting upon the flexor sublimis digitorum and tlexor longus pollicis. 
 
 Fig. 32. — Cross-section of the Upper Third of the Right Forearm: — A, Radial 
 artery and branches, veins, and nerve; B, Ulnar and interosseous arteries, veins, and median 
 nerve; C, Ulnar nerve; D, Pronator radii teres muscle; E, Flexor carpi radialis; F, Subcutaneous 
 vein and nerve, G, Flexor profundus digitorum; H, Flexor carpi ulnaris; I, Anconeus; J, Supinator 
 longus; K, Extensor carpi radialis longior; L, Supinator brevis; M, Extensor carpi radialis 
 brevior; N, Extensor communis digitorum; O, Extensor carpi ulnaris. (Cross-section modified 
 from Braune.) 
 
 LIGATION OF RADIAL ARTERY 
 
 IN LOWER THIRD OF FOREARM. 
 
 Position. — As for upper third. 
 
 Landmarks. — Tendons of supinator longus and flexor carpi radialis. 
 
 Incision. — From 2.5 to 5 cm. (1 to 2 inches), vertically, in center of interval 
 between tendons of supinator longus and flexor carpi radialis (Fig. 30, C). 
 
 Operation. — Having incised skin and superficial fascia, the radial vein, 
 or a large branch, and often the superficialis volse artery, are met and are 
 displaced to one side (Fig. 33). The deep fascia is divided, and the interval 
 between the tendon of the supinator longus, externally, and the tendon of the 
 flexor carpi radialis, internally, is opened up and the artery and its venae 
 comites are found between them, accompanied by the anterior branch of 
 the musculocutaneous nerve. 
 
LIGATION OF RADIAL ARTERY. 
 
 71 
 
 Fig. 33.— Ligation ok Lower Third of Right Radial (Jtst above Wrist) :— A, Radial 
 vein; B, Anterior branch of musculocutaneous nerve; C, Supinator longus tendon ; D, Flexor carpi 
 radialis tendon ; E, Pronator quadratus ; F, Radial artery ; G, Superficialis volae artery ; H, H, Radial 
 venae comites. 
 
 Fig. 34. — Cross-section of the Lower Third of the Right Forearm: — A, Radial 
 artery and veins; B, Ulnar artery, veins, and nerve; C, Anterior interosseous artery; D, Posterior 
 interosseous artery; E, Median nerve; F, Flexor sublimis digitorum muscle; H, Flexor digitorum 
 profundus; I, Flexor longus pollicis; J, Pronator quadratus; K, Extensor indicis pollicis; L, 
 Extensor proprius pollicis; M, Extensor indicis; X, Extensor communis digitorum; O, Supinator 
 longus tendon; P, Flexor carpi radialis. (The cross-section modified from Braune.) 
 
7 2 
 
 OPERATIONS UPON THE ARTERIES. 
 
 r 
 
 F'g- 35- — Ligation of Left Superficial and Deep Palmar Arches: — A, Annular liga- 
 ment; B, Flexor brevis pollicis (part of its origin from annular ligament incised) ; C, Tendons of 
 flexor sublimis digitorum and outer lumbrical (drawn inward); 1), Adductor obliquus pollicis; E, 
 Adductor transversus pollicis; F, F, Branches of median nerve ; H, H, Superficial palmar arch ; G, 
 Deep palmar arch and its vena; comites ; I, I, Superficial vein. 
 
 LIGATION OF DEEP PALMAR ARCH OF RADIAL ARTERY. 
 
 Position. — Limb supine; hand extended. Assistant steadying fingers 
 and wrist. Surgeon cuts from above downward on both sides. 
 
 Landmarks. — Oblique crease running downward and outward from 
 junction of thenar and hypothenar eminences and partially circumscribing 
 the thenar eminence. 
 
 Incision. — From junction of the thenar and hypothenar eminences — and 
 running along the thenar crease toward the metacarpo-phalangeal joint of 
 the index-finger — with the center of the incision opposite the center of the 
 ball of the thumb (Fig. 30, D). 
 
SURGICAL ANATOMY OF ULNAR ARTERY. 73 
 
 Operation. — Having incised skin and superficial fascia, expose and 
 ligate the superficial palmar arch (crossing the palm on a level with the lower 
 border of the outstretched thumb) (Fig. 35). The muscles of the thenar 
 eminence are now exposed, and these, with the annular ligament, are incised 
 at the upper part of the wound to as limited an extent as possible. The 
 interval between the flexor tendon of the index-finger and its accompanying 
 lumbrical muscle, on the one hand, and the muscles of the thumb, on the 
 other, is made out and opened up by deep retraction, guarding the branches 
 of the median nerve. In the interval thus exposed by retraction is seen 
 the adductor obliquus pollicis, which is to be divided vertically, w hen the 
 arch will be found under it, running transversely from between the adductor 
 obliquus pollicis and adductor transversus pollicis onto the deep fascia covering 
 the interossei, and about 2 cm. (f inch) nearer the wrist than does the super- 
 ficial arch. The needle is to be carefully passed in the deep wound, to avoid 
 the nerves and veins. 
 
 Comment. — The position for ligating can be located by feeling for the 
 apex of the first interosseous space on the back of the hand. 
 
 SURGICAL ANATOMY OF ULNAR ARTERY. 
 
 Description. — Larger of two divisions of brachial artery. Begins at 
 bifurcation of brachial, about 1.3 cm. (J inch) below bend of elbow, and in 
 middle of forearm — runs through upper half of forearm, with slight curve 
 (convexity to ulnar side), to ulnar aspect of limb, passing beneath the pronator 
 radii teres and superficial flexors — thence vertically down the lower half 
 of the forearm, along its ulnar border to the wrist, being slightly overlapped 
 by the flexor carpi ulnaris. It crosses the annular ligament immediately 
 to the radial side of the pisiform bone, and, entering the palm, divides into 
 superficial and deep palmar branches, to help form superficial and deep 
 palmar arches. It is accompanied by two vena? comites. The ulnar 
 nerve comes into contact with the artery at the junction of its upper and 
 middle thirds, and remains in relation with it to the palm, being upon its 
 ulnar side. 
 
 Relations. — (A) In Forearm: — Anteriorly — (a) Above — skin; fascia; 
 superficial flexors (pronator radii teres, flexor carpi radialis, palmaris longus, 
 flexor sublimis digitorum) ; median nerve (separated from artery by deep 
 head of pronator radii teres), (b) Upper part of lower half — skin; fascia; 
 and overlapped by tendon of flexor carpi ulnaris. (c) Lower part of lower 
 half — skin; superficial fascia; deep fascia; palmar cutaneous branch of ulnar 
 nerve. Posteriorly — brachialis anticus; flexor profundus digitorum. Ex- 
 ternally — flexor sublimis digitorum (in lower two-thirds of artery's course). 
 Internally — flexor carpi ulnaris (in lower two-thirds) ; ulnar nerve (in lower 
 two-thirds). (B) At Wrist : — This part of the artery extends from the upper 
 to the lower part of the annular ligament, running in a channel formed by 
 the pisiform and unciform process of unciform bone and by expansion of 
 flexor carpi ulnaris extending from pisiform to unciform process. Ante- 
 riorly — skin; fascia; expansion of flexor carpi ulnaris from pisiform to unci- 
 form process of unciform. Posteriorly — anterior annular ligament. Ex- 
 ternally — unciform process of unciform bone. Internally — pisiform bone; 
 ulnar nerve. (C) In Palm : — On entering the palm, the ulnar divides into 
 superficial branch and deep branch: — (1) Superficial branch of ulnar — 
 direct continuation of ulnar artery — descends short distance toward gap 
 
74 OPERATIONS UPON THE ARTERIES. 
 
 between fourth and fifth fingers, thence curves outward (with convexity 
 toward fingers) and anastomoses opposite gap between index and middle 
 finger, and at junction of upper and middle thirds of hand, with superficialis 
 vola? of radial (sometimes with branch from radialis indicis of radial) to 
 form superficial palmar arch — having following relations: Anteriorly — 
 skin; fascia; and, from ulnar to radial side, by palmaris brevis, palmar branch 
 of ulnar nerve, palmar fascia, palmar branch of median nerve. Posteriorly 
 — in order, from ulnar to radial side — annular ligament; short muscles of 
 little finger; digital branches of ulnar nerve; superficial flexor tendons; digital 
 branches of median nerve. (2) Deep (communicating) branch of ulnar 
 artery — runs deeply inward, between abductor minimi digiti and flexor 
 brevis minimi digiti — anastomosing with termination of radial to form deep 
 palmar arch. 
 
 Branches. — (a) In Forearm — anterior ulnar recurrent; posterior ulnar 
 recurrent; common interosseous (anterior and posterior interosseous); mus- 
 cular, (b) At Wrist — anterior ulnar carpal; posterior ulnar carpal, (c) 
 In Palm — superficial palmar arch; deep (communicating) palmar. 
 
 Line of Artery. — Upper third of artery corresponds with line from a 
 point about 1.3 cm. (h inch) below center of bend of elbow, passing to inner 
 side with gentle curve (convexity to ulnar side), to a point at junction of 
 upper and middle thirds of following line. Lower two-thirds corresponds 
 with line from anterior surface of internal condyle of humerus to radial 
 side of pisiform bone (Fig. 30, H, L, and K, J). 
 
 Sites for Ligation. — Upper third of forearm (rarely) ; middle third; lower 
 third (commonly); superficial palmar arch (for wounds at that site). (Fig. 
 3°-) 
 
 LIGATION OF ULNAR ARTERY 
 
 IN MIDDLE THIRD OF FOREARM. 
 
 Position. — As for the radial artery. 
 
 Landmarks. — Line of artery. The muscular landmarks at the middle 
 of the forearm are generally difficult to recognize. 
 
 Incision. — About 7.5 cm. (3 inches), in line of artery, with its center 
 corresponding with the center of the forearm (Fig. 30, E). 
 
 Operation. — Incise skin and superficial fascia. The anterior ulnar vein 
 and anterior branch of internal cutaneous nerve are likely to be encountered 
 (Fig. 36). Divide the deep fascia somewhat to the outer side of the skin 
 incision, as the flexor sublimis digitorum is generally slightly overlapped by 
 the flexor carpi ulnaris. In this deep fascia the intermuscular plane between 
 the flexor carpi ulnaris and flexor sublimis digitorum is sought by exposure 
 and by the sense of touch. A muscular branch will often lead to it. These 
 muscles are retracted well apart, when the ulnar nerve is first encountered 
 between them — and, following inward on the same plane, the artery will be 
 found upon the flexor profundus, surrounded by the venae comites, and with 
 the ulnar nerve to the ulnar side. 
 
 Comment. — It is sometimes exceedingly difficult to hit off the intermuscular 
 space, and even to find the artery when once in it. Remember that the anterior 
 margin of the flexor carpi ulnaris slightly overlaps the flexor sublimis digitorum 
 at this level. Also remember, when once in the intermuscular space, not to 
 pass below the ulnar nerve, and thus go too deeply on the ulnar side of the 
 forearm, but rather work inward from the level of the nerve. 
 
LIGATION OF ULNAR ARTERY. 
 
 75 
 
 Fig. 36. — Ligation of Right Ulnar in Upper Part of Middle Third: — A, Anterior 
 ulnar vein; B, Anterior branch of internal cutaneous nerve; C, Flexor carpi ulnaris; D, Flexor 
 sublimis digitorum; E, Flexor profundus digitorum; F, Ulnar nerve; G, Ulnar artery; H, Vena? 
 comites. 
 
 Fig- 37- — Ligation of Lower Third of Right Ulnar (Just above the Wrist): — A, 
 Anterior ulnar vein; C, Tendon of flexor carpi ulnaris; D, Tendon of flexor sublimis digitorum: 
 E, Ulnar artery; G, Ulnar vena; comites; H, Ulnar nerve. 
 
76 OPERATIONS UPON THE ARTERIES. 
 
 LIGATION OF ULNAR ARTERY 
 
 IN LOWER THIRD OF FOREARM. 
 
 Position. — As for radial. 
 
 Landmarks. — Outer border of flexor carpi ulnaris. 
 
 Incision. — About 5 cm. (2 inches) in length— ending about 2.5 cm. 
 (1 inch) above the pisiform bone — and placed between the tendon of the 
 flexor carpi ulnaris and the innermost tendon of the flexor sublimis digitorum. 
 (As the innermost tendon of the flexor sublimis digitorum is not always 
 recognizable, the incision is generally placed to the outer side of the tendon 
 of the flexor carpi ulnaris.) (Fig. 30, F.) 
 
 Operation. — Having incised skin and superficial fascia, avoid the anterior 
 ulnar vein or its branches (Fig. 37). Divide the deep fascia. Partly flex 
 the wrist to relax the structures, and retract the flexor carpi ulnaris to the ulnar 
 side. The artery will be found upon the flexor profoundus digitorum, with 
 the venae comites closely surrounding it, and the ulnar nerve lying closely to 
 the ulnar side. 
 
 SURGICAL ANATOMY OF INTERCOSTAL BRANCHES OF THORACIC 
 
 AORTA. 
 
 Description. — The ten aortic intercostals generally supply from the 
 third to eleventh intercostal spaces inclusive— the first space being supplied 
 by superior intercostal alone — and the second space also by superior inter- 
 costal alone, or conjointly by it and the first aortic intercostal. The tenth 
 aortic intercostal runs below the twelfth rib (subcostal artery), (a) The Ver- 
 tebral Portions of the Intercostal Arteries, arising in pairs from the posterior 
 part of the thoracic aorta, pass around the vertebne — the right being covered 
 by thoracic duct, vena azygos major, pleura, lung, esophagus— the left, 
 by vena azygos minor, left superior intercostal vein, third vena azygos 
 pleura, lung. The arteries here divide into posterior or dorsal, and anterior 
 or intercostal branches, (b) The Intercostal Portions run forward and 
 obliquely upward in the intercostal space to the lower border of the superior 
 rib, and divide near the angle of the rib into upper (larger) and lower (smaller) 
 branches — the former, to run in the groove along the lower border of the 
 upper rib and anastomose with the superior intercostal branch of the internal 
 mammary in the upper spaces, and of the musculophrenic in the lower — the 
 latter, to run along the upper border of the lower rib and anastomose with 
 the inferior branch of the internal mammary in the upper spaces, and of the 
 musculophrenic in the lower. At first these arteries lie between pleurae, 
 lungs, endothoracic fascia, and infracostals internally — and external inter- 
 costal muscles externally — then (from the angles of the ribs) between the 
 external and internal intercostal muscles. The sympathetic nerve crosses 
 them opposite the head of the ribs. The intercostal vein lies above and 
 the intercostal nerve below the intercostal arteries — except in the upper 
 spaces. The arteries of the tenth and eleventh spaces run outward between 
 the abdominal muscles. 
 
 LIGATION OF AN INTERCOSTAL ARTERY 
 
 BY AN INTERCOSTAL INCISION. 
 
 Position. — Patient supine, and so turned as to render site of operation 
 prominent, and chest supported below, so as to increase width of intercostal 
 spaces. Surgeon stands on side of operation. Assistant opposite. 
 
LIGATION OF AN INTERCOSTAL ARTERY. 
 
 77 
 
 Landmarks. — Lower border of rib in the groove of which the special 
 artery runs; or the upper border, in case it be the lower branch of the inter- 
 costal artery. 
 
 Incision. — About 5 cm. (2 inches), parallel with and just below the 
 lower border of the indicated rib; or just above the upper border, as the 
 case may be. 
 
 Operation. — Incise skin and superficial fascia. As to what muscle, and 
 as to what amount of muscle tissue, as well as fascia, will have to be further 
 incised in the line of the original incision, before the intercostal muscles are 
 reached, will depend upon the site at which the artery is to be exposed. Having 
 passed through the overlying muscle-covering of the thoracic wall, the inter- 
 costal fascia is met and incised, then the external intercostal muscle (if operat- 
 ing anywhere between the tubercles of the ribs behind, and the costal car- 
 tilages in front). The two cut margins of the external intercostals are then 
 drawn upward and downward and the artery sought as it lies partially or 
 entirely concealed in the inferior intercostal groove, with intercostal nerve 
 below and vein above. The artery may be drawn out of its groove and down 
 into view by the curved tip of the aneurism-needle. The vessel should be 
 doubly ligated (its supply coming from both directions). The incised inter- 
 costal muscle and fascia may be sutured with gut in closing the wound. 
 
 Comment. — (1) If difficulty in exposing the artery be experienced, the rib 
 may be exposed subperiosteally, as in the following operation. (2) It is to be 
 remembered, in operating posterior to the angle of the rib, that the intercostal 
 artery has not yet reached the inferior groove of the upper rib, but lies between 
 the two ribs, and has not divided into its upper and lower branches. (3) If it 
 be desired to ligate the upper and lower branches of the intercostal (anywhere 
 between the angle and costal cartilages), the incision is made midway between 
 the ribs, and, after retracting the cut external intercostal muscle, the upper 
 branch is sought as above, and the lower branch is found along the upper 
 border of the lower rib. Both are doubly ligated. The upper intercostal 
 artery is often so small as to be difficult or impossible to find. 
 
 Fig. 38. — Ligation of Left Intercostal Artery, in Lower Anterior Thoracic Region, 
 by Partial Excision of a Rib: — A, Thoracic muscles; B, External intercostal muscle; C, Rib, 
 with half-button of bone bitten out with rongeur forceps; D, Periosteum, incised over center of 
 rib; E, Lower half of anterior layer of periosteum retracted downward ; F, F, Posterior layer oi peri- 
 osteum incised and retracted upward and downward, showing intercostal vessels beneath; G, Inter- 
 costal artery ; H, Intercostal vein ; I, Intercostal nerve. (Hartley's method.) 
 
78 OPERATIONS UPON THE ARTERIES. 
 
 LIGATION OF AN INTERCOSTAL ARTERY 
 
 BY PARTIAL, SUBPERIOSTEAL EXCISION OF RIB (HARTLEY'S METHOD.) 
 
 Position — Landmarks. — As in the preceding operation. 
 
 Incision.- — About 6 cm. (2^ inches), parallel with and directly over 
 center of rib. 
 
 Operation. — The above incision passes through skin, superficial fascia, 
 any overlying thoracic muscles (according to site of operation), deep fascia and 
 periosteum (Fig. 38). With periosteal elevator, free the lower half of the 
 anterior surface, the inferior groove, and the lower half of the posterior sur- 
 face of the rib, all subperiosteally. Then, with rongeur bone-forceps, bite 
 out a "half -button" of bone from the bared lower half of the rib, being 
 careful to insert the lower blade of the rongeur between the detached peri- 
 osteum and the rib. After the half-button of bone is removed, the position 
 of the artery is plainly evident— and the vessel is exposed by incising 
 through the periosteal membrane, directly over it. 
 
 Comment. — The artery may also be exposed by the ordinary method of 
 subperiosteal excision of about 4 cm. (ij inches) of rib throughout its entire 
 thickness. 
 
 SURGICAL ANATOMY OF ABDOMINAL AORTA. 
 
 Description. — Continuation of thoracic aorta. Commences at aortic 
 opening of diaphragm, opposite lower border of twelfth dorsal vertebra — and 
 passes down between pillars of diaphragm, in front of lumbar vertebrae, at 
 first in median line, but deviating to left as it descends, until it lies a little 
 to left of spine at its point of bifurcation, opposite lower border of fourth 
 lumbar vertebra, where it divides into right and left common iliac arteries. 
 Its point of bifurcation is represented externally, roughly, by a point about 
 1.3 cm. (^ inch) below and a little to left of umbilicus — and, more accurately, 
 by a line crossing the abdomen on a level with the highest points of the iliac 
 crests. The accompanying vena cava is separated from the aorta above 
 by the right crus of the diaphragm, and is on a plane anterior to it. Below, 
 the vein lies in contact with the artery, and on a somewhat posterior plane. 
 The artery is covered only by peritoneum at the site indicated for ligation, 
 but between the serous covering and the artery lie important sympathetic 
 nerve-cords from the aortic plexus (lying along the aorta between the superior 
 and inferior mesenteric arteries) to the hypogastric plexus (lying between 
 the common iliacs). 
 
 Relations. — Anteriorly (from above downward, in order) : right lobe 
 of liver; solar plexus; lesser omentum; termination of esophagus in stomach; 
 ascending layer of transverse mesocolon; splenic vein (or beginning of vena 
 portae); pancreas; left renal vein; third part of duodenum; mesentery; aortic 
 plexus of sympathetic; spermatic (or ovarian) arteries; inferior mesenteric 
 artery; median lumbar lymphatic glands and vessels; small intestines. Pos- 
 teriorly: bodies of lumbar vertebrae; intervening intervertebral cartilages; 
 anterior common ligament; left crus of diaphragm; left lumbar veins. To 
 right: right crus of diaphragm; great splanchnic nerve; spigelian lobe of 
 liver; receptaculum chyli (on a posterior plane); thoracic duct (on a posterior 
 plane); right semilunar ganglion; inferior vena cava; vena azygos major. 
 To left: left crus of diaphragm; left splanchnic nerve; left semilunar gan- 
 glion; tail of pancreas; small intestines. 
 
LIGATION OF ABDOMINAL AORTA. 
 
 79 
 
 Branches. — (From above downward.) Phrenic, coeliac axis (gastric, 
 hepatic, splenic); suprarenals; first lumbars, superior mesenteric; renals; 
 spermatics (ovarians) ; second lumbars; inferior mesenteric; third lumbars; 
 fourth lumbars; common iliacs; middle sacral. 
 
 Line of Artery. — From a point in the anterior median line, on a level 
 with the lower border of twelfth dorsal vertebra, to a point a little to left of 
 umbilicus, on a level with the highest points of the iliac crests. 
 
 Indications for Ligation. — Iliac and inguinal aneurisms and primary 
 and secondary hemorrhage — in cases where no other means are possible. 
 More than a dozen cases have been reported — one case living ten days. 
 
 Sites for Ligation. — Between the origin of the inferior mesenteric (be- 
 tween 2.5 and 5 cm., or 1 and 2 inches, above the bifurcation) and the bifurca- 
 tion (Fig. 39). 
 
 Fig- 39- — Incisions for Ligations in the Abdomino-pelvic Region:— A, Exposure of 
 abdominal aorta by transperitoneal route, through median incision over umbilicus; B, Exposure of 
 internal iliac, common iliac, and abdominal aorta by retroperitoneal route, through oblique incision 
 parallel with Poupart's ligament ; C, Exposure of external, internal, and common iliacs by transperi- 
 toneal route, through median incision below umbilicus ; D, of external and deep epigastric, retro- 
 peritoneally, through oblique incision parallel with Poupart's ligament ; E, of common, internal, and 
 external iliacs, transperitoneally, through vertical incision in linea semilunaris; F, of external iliac, 
 transperitoneally, through intramuscular incision ; G, G, Anterior superior iliac spines; H, Symphysis 
 pubis. 
 
 LIGATION OF ABDOMINAL AORTA 
 
 BV TRANSPERITONEAL .METHOD. 
 
 Description. — The abdomen is opened in the median line, the intestines 
 displaced, and the posterior parietal peritoneum opened over the artery. 
 
 Position. — Patient supine; shoulders raised; knees slightly flexed. Surgeon 
 on right. Assistant opposite. 
 
80 OPERATIONS UPON THE ARTERIES. 
 
 Landmarks. — Median, vertical abdominal line; transverse line on level 
 with highest points of iliac crests. 
 
 Incision. — About 10 cm. (4 inches) in length, in linca alba, with its 
 center corresponding with the umbilicus — the incision passing slightly to 
 left of the navel, to avoid the round ligament of the liver and the urachus 
 
 (Fig. 39, A). 
 
 Operation. — The peritoneal cavity having been opened in the usual 
 manner, the small intestines and. mesentery are well retracted upward and 
 to the sides. Guided to the artery by its known position and by its pulsation, 
 the peritoneum covering the vessel is carefully divided between the inferior 
 mesenteric and its bifurcation in the iliacs. The clearing of the artery should 
 be done with especial care, as inclusion of the sympathetic nerve-fibers (see 
 Surgical Anatomy) is otherwise apt to take place — and is supposed to have 
 been done in one case, which quickly ended fatally. A flat ligature should 
 be used (kangaroo tendon, chromicized gut and silk, flat and round, have 
 been used). The needle should be of special make and shape, and should 
 be passed from the inferior vena cava. 
 
 Comment. — This is the more desirable form of operation, though the 
 case which survived longest was done through a posterior retroperitoneal 
 incision. 
 
 Collateral Circulation. — Internal mammary, above; with deep epi- 
 gastric, below. Inferior mesenteric, above; with internal pudic, below. 
 Possibly by lumbar arteries, above; with branches of internal iliac, below. 
 And, if above the inferior mesenteric, by superior mesenteric, above; with 
 inferior mesenteric, below. 
 
 LIGATION OF ABDOMINAL AORTA 
 
 BY RETROPERITONEAL OPERATION. 
 
 Description. — The artery is here approached from the anterolateral 
 abdominal region, the peritoneum being pushed back from the iliac vessels 
 until the aorta is reached and exposed. 
 
 Position — Landmarks — Incision — Operation. — The operation is prac- 
 tically similar to that for the exposure and ligation of the common iliac extra- 
 peritoneally, the site being reached by an extension of those steps (Fig. 39, B, 
 except on left side, and Fig. 40). The patient is placed so as to be tilted toward 
 the right side, the surgeon standing behind the patient, upon the side of the 
 operation (the left). An extension of the incision employed for the common 
 iliac is carried further upward to give the necessary room; and, if still required, 
 additional room may be gotten by a second incision running parallel with the 
 ribs, at a right angle to the main incision. The incision is made upon the 
 left side — its general direction being from just within the anterior superior 
 iliac spine toward the tip of the tenth rib — and the aorta is reached by following 
 up the common iliac in the peeling back of the peritoneum from the iliac fascia 
 The separation of the parts and exposure of the common iliac are, otherwise, 
 the same as for the ligation of that vessel. The vessel is thus less satis- 
 factorily exposed than by the intra-abdominal operation, and there is greater 
 difficulty in avoiding the sympathetic nerve-cords that surround the vessel. 
 The ligature is placed upon the same site as in the intra-abdominal operation, 
 and the inferior vena cava is guarded in passing the needle. 
 
LIGATION OF COMMON ILIAC ARTERY. 8 1 
 
 SURGICAL ANATOMY OF COMMON ILIAC ARTERIES. 
 
 Description. — Arise from bifurcation of the abdominal aorta, opposite 
 lower border of left side of body of fourth lumbar vertebra (corresponding, 
 approximately, to a point about 1.3 cm. [h inch] below and a little to left of 
 umbilicus — or, more accurately, on a level with a line passing transversely 
 through the highest points of the iliac crests) — and pass thence downward 
 and outward over the body of the fifth lumbar vertebra to margin of pelvis, 
 bifurcating opposite upper border of sacro-iliac synchondrosis, into external 
 and internal iliac arteries. The relations of right and left common iliacs 
 differ slightly. 
 
 Relations of Right Common Iliac Artery. — Anteriorly: peritoneum; 
 right ureter (a little above its bifurcation) ; ovaries (in female) ; termination of 
 ileum; terminal branches of superior mesenteric; branches of sympathetic 
 to hypogastric plexus. Posteriorly: right common iliac vein; end of left 
 common iliac vein; beginning of inferior vena cava; and, in less immediate 
 relationship, the following — psoas magnus; sympathetic nerve; lumbosacral 
 cord; obturator nerve; iliolumbar artery. Externally: beginning of inferior 
 vena cava; end of right common iliac vein; psoas magnus. Internally: 
 right common iliac vein; end of left common iliac vein; hypogastric plexus. 
 
 Relations of Left Common Iliac Artery.— Anteriorly : peritoneum; 
 small intestines; ureter; ovarian artery (in female); branches of sympathetic 
 to hypogastric plexus; termination of inferior mesenteric artery; sigmoid 
 flexure; sigmoid mesocolon; superior hemorrhoidal artery. Posteriorly: 
 lower part of body of fourth lumbar vertebra; fifth lumbar vertebra; inter- 
 vertebral discs; left common iliac vein; and, in less immediate relationship, 
 the following — psoas muscle; obturator nerve; lumbosacral cord; iliolumbar 
 artery. Externally: psoas muscle. Internally: left common iliac vein; 
 hypogastric plexus; middle sacral artery. 
 
 Branches. — Peritoneal; subperitoneal; ureteric; internal iliac; external 
 iliac. 
 
 Line of Artery. — Draw a line transversely across the abdomen, on 
 level with highest points of iliac crests, which will cross the abdominal aorta 
 at its bifurcation — draw a second line transversely across the abdomen on a 
 level with the anterior superior iliac spines, which will cross the common 
 iliacs at their bifurcation — draw a third line from a point on the first line about 
 1.3 cm. (h inch) to the left of its center (which is the linea alba), to a point 
 midway between the anttrior superior iliac spine and symphysis pubis. 
 That portion of the third line between the two zones represents the common 
 iliac— and that portion below the lower zone, the external iliac. The right 
 common iliac is about 5 cm. (2 inches) in length; and the left, about 4.5 cm. 
 (if inches). 
 
 Site for Ligation. — As nearly midway of its length as possible. 
 
 LIGATION OF COMMON ILIAC ARTERY 
 
 BV RETROPERITONEAL OPERATION. 
 
 Position. — Patient supine, or slightly turned to one side. The intes- 
 tines are more easily displaced from the field of operation if the patient be 
 in the Trendelenburg position. Surgeon stands upon side of operation. 
 Assistant opposite. 
 
 Landmarks. — Line of external iliac (v. s.); Poupart's ligament; anterior 
 superior spine of ilium; eleventh rib. 
 6 
 
82 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Incision. — Begun as for exposure of external iliac (page 89) and con- 
 tinued in the cleavage line of the external oblique as far upward toward 
 the eleventh rib as necessary to furnish sufficient room (Fig. 39, B). 
 
 Operation. — The steps of the operation are identical with those for 
 exposure of the external iliac (page 89), with an extension upward, in the 
 present operation, of the separation of the fibers of the external oblique 
 and a division of the fibers of the internal oblique and transversalis as far 
 
 Fig. 40. — Ligation of Right Common and Internal Iliacs, Retroperitoneally : — A, A, 
 External oblique muscle and aponeurosis; B, Internal oblique; C, Transversalis; D, Conjoint ten- 
 don ; E, E, Peritoneum retracted ; F, Ureter, retracted. ; G. Common iliac artery (sheath incised) ; H, 
 Internal iliac artery (sheath incised) ; I, External iliac artery ; J, External and internal iliac veins; 
 K, K, Deep epigastric artery ; L, Deep circumflex iliac artery; M, Lumbar artery ; N, Iliolumbar 
 artery; O, Spermatic artery; P, Anterior crural nerve; Q, Ilio-inguinal nerve; R, Genitocrural 
 nerve; S, External cutaneous nerve; T, Iliac fascia; M, Lumbar artery and iliohypogastric (or 
 dorsal) nerve. 
 
 up toward the eleventh rib as necessary — the incision of the two latter muscles 
 corresponding in direction with the separation of the fibers of the external 
 oblique (Fig. 40). In this higher part of the wound the last dorsal and 
 other dorsal nerves are apt to be encountered between the internal oblique 
 and transversalis, and are to be carefully preserved. The deep circumflex 
 iliac artery and the lumbar arteries are apt to be met here above the crest 
 of the ilium. Having divided the transversalis fascia and separated the 
 peritoneum from the iliac fascia (which overlies the iliacus muscle), detaching 
 it downward and backward to the psoas muscle and then upward to the 
 
SURGICAL ANATOMY OF INTERNAL ILIAC ARTERY. 83 
 
 sacral promontory, the structures in the floor of the iliac fossa are exposed. 
 The external iliac artery is first found, and this is followed up to the common 
 iliac, guarding the deep epigastric. The genitocrural, external cutaneous, 
 and anterior crural nerves, branch of the iliolumbar, and the spermatic 
 arteries cross this area. The ureter crosses either the common iliac, or the 
 external iliac, obliquely, opposite the first piece of the sacrum, having the 
 ileum in front of it on the right, and the sigmoid flexure of the colon in front 
 of it on the left; but in the peeling back of the peritoneum the ureter usually 
 adheres to the peritoneum, and is thus removed from the area of operation 
 without trouble. The artery having been reached and bared of peritoneum, 
 the needle is passed from the iliac vein. 
 
 Comment. — The line of incision may begin further to the outer side 
 of the external iliac than for the typical operation upon that artery, though 
 that vessel is then a little less easily encountered. As to a choice between 
 the extraperitoneal and intraperitoneal operations, the former is to be pre- 
 ferred wherever the relations of the parts are not too much disturbed by 
 disease or injury. 
 
 Collateral Circulation. — Internal mammary and lower intercostals 
 above, with deep epigastric below. Lumbar above, with deep circumflex 
 iliac and iliolumbar below. Superior hemorrhoidal above, with middle and 
 inferior hemorrhoidal below. Aliddle sacral above, with lateral sacral below. 
 Pudic, epigastric, obturator and epigastric branches of one side, with corre- 
 sponding arteries of other side. 
 
 LIGATION OF COMMON ILIAC ARTERY 
 
 BY TRANSPERITONEAL OPERATION. 
 
 Position — Landmarks — Incision — Operation. — The steps are prac- 
 tically the same as for the transperitoneal ligation of the abdominal aorta, 
 though somewhat less extensive, and with the slight modifications necessitated 
 by the anatomy of the parts (Fig. 39, C). Especial care is taken to recognize 
 the position of the ureter before incising the peritoneum. 
 
 SURGICAL ANATOMY OF INTERNAL ILIAC ARTERY. 
 
 Description. — About 4 cm. (1^ inches) in length — arising from bifurca- 
 tion of common iliac, opposite upper border of sacro iliac synchondrosis. 
 Descends in pelvis to upper margin of great sacrosciatic foramen, where it 
 divides into anterior and posterior branches. 
 
 Relations. — Anteriorly: peritoneum; ureter. Posteriorly: termina- 
 tion of external iliac vein; internal iliac vein; inner border of psoas; lumbo- 
 sacral cord; obturator nerve; sacrum. Externally: psoas. Internally: 
 internal iliac vein; peritoneum. 
 
 Branches. — From Anterior Trunk: — Hypogastric; superior, middle, and 
 inferior vesical; middle hemorrhoidal; obturator; sciatic; internal pudic; 
 uterine; vaginal. From Posterior Trunk: — Iliolumbar; lateral sacral; glu- 
 teal. 
 
 Line of Artery. — See under Line of Common Iliac. 
 
 Indications for Ligation. — Gluteal and sciatic aneurism; hemorrhage; 
 to cause atrophy of prostate gland. 
 
 Sites for Ligation. — Midway between its origin and its bifurcation. 
 
84 OPERATIONS UPON THE ARTERIES. 
 
 LIGATION OF INTERNAL ILIAC ARTERY 
 
 BY RETROPERITONEAL OPERATION. 
 
 Position — Landmarks — Incision — Operation. — Same as for the retro- 
 peritoneal ligation of the external iliac— which, having been exposed, is 
 followed up to the bifurcation of the common iliac (Fig. 39, B, and Fig. 
 
 44)- 
 
 Collateral Circulation. — Sciatic above, with superior branch of profunda 
 below. Inferior mesenteric above, with hemorrhoidal arteries below. Pubic 
 branch of obturator of one side, with same of opposite. Branches of pudic 
 of one side, with same of opposite. Circumflex and perforating of profunda 
 above, with sciatic and gluteal below. Middle sacral above, with lateral 
 sacral below. Circumflex iliac above, with iliolumbar and gluteal below. 
 
 LIGATION OF INTERNAL ILIAC ARTERY 
 
 BY TRANSPERITONEAL OPERATION. 
 
 Position— Landmarks— Incision— Operation. Same as for the trans- 
 peritoneal ligation of the abdominal aorta, with the modifications necessitated 
 by the anatomy of the parts (Fig. 39, C, and page 80). Recognize the 
 position of the ureter before incising the peritoneum. 
 
 SURGICAL ANATOMY OF SCIATIC BRANCH OF ANTERIOR DIVISION 
 OF INTERNAL ILIAC. 
 
 Description and Relations. — Larger of two terminal branches of 
 anterior trunk. Descends over sacral plexus and pyriformis muscle to lower 
 part of great sacrosciatic foramen, whence it passes out of pelvis between 
 pyriformis and coccygeus muscles, with pudic artery anterior and internal 
 to it. Emerging through great sciatic foramen upon buttock, beneath the 
 gluteus maximus, it descends the thigh midway between trochanter major 
 and tuberosity of ischium, resting upon gemellus superior, obturator internus, 
 gemellus inferior, quadratus femoris and adductor magnus — being to inner 
 side of great sciatic nerve and accompanied by small sciatic nerve. 
 
 Line of Artery. — Having rotated the thigh inward and slightly flexed 
 it, draw a line from the posterior superior iliac spine to the outer border 
 of the tuberosity of the ischium. A point on this line, at the junction of its 
 middle and lower thirds, will represent the site at which the sciatic and pudic 
 arteries emerge from the lower part of the sciatic foramen upon the gluteal 
 region (Fig. 41, A, C, E). 
 
 Indications for Ligation. — Wounds. 
 
 Site for Ligation. — At its emergence onto the gluteal region, just below 
 the pyriformis muscle (Fig. 41). 
 
 LIGATION OF SCIATIC BRANCH OF INTERNAL ILIAC 
 
 UPON THE BUTTOCK. 
 
 Position. — Patient upon uninvolved side, rolled nearly onto chest, with 
 knee flexed and thigh rotated in. Surgeon on side of operation; assistant 
 opposite. 
 
SURGICAL ANATOMY OF INTERNAL PUDIC ARTERY. 
 
 85 
 
 Landmarks. — Posterior superior iliac spine; tuberosity of ischium. 
 
 Incision. — Having drawn the line given under Anatomy, make an in- 
 cision about 10 cm. (4 inches) in length, obliquely across this line, in the 
 direction of the fibers of the gluteus maximus (which run from above and 
 behind, downward and forward) — with its center corresponding to the junc- 
 tion of the middle and lower thirds of the line (Fig. 41, E). 
 
 Operation. — Having incised skin and thick fatty areolar tissue, divide 
 
 9^\ 
 
 y 
 m 
 
 , 
 
 
 
 Fig. 41. — Incisions for Ligations about the Buttock : — A, Posterior superior iliac spine ; B, 
 Great trochanter; C, Tuberosity of ischium; D, Incision for exposure of gluteal branch of internal 
 iliac at its emergence from upper part of great sacrosciatic notch ; E, For exposure of sciatic and 
 internal pudic branches of internal iliac at their emergence from lower part of great sacrosciatic notch. 
 
 the fibers of the gluteus maximus in their cleavage line (Fig. 42, F). Retract 
 the separated margins of this muscle upward and downward, respectively. 
 Expose the lower margin of the pyriformis muscle. Follow the lesser sacro- 
 sciatic ligament to the spine of the ischium — when the sciatic artery will be 
 found emerging from beneath the pyriformis muscle — passing out of the 
 pelvis above the spine of the ischium, and the lesser sacrosciatic ligament 
 attached to it — and lying posterior and external to the pudic artery. 
 
 SURGICAL ANATOMY OF INTERNAL PUDIC BRANCH OF ANTERIOR 
 DIVISION OF INTERNAL ILIAC. 
 
 Description. — Smaller of two terminal branches of anterior trunk of 
 internal iliac. Descends over pyriformis and sacral plexus to lower border 
 of great sacrosciatic foramen, lying in front and to inner side of sciatic artery — ■ 
 passes thence out of pelvis between pyriformis and coccygeus — crosses over 
 
86 OPERATIONS UPON THE ARTERIES. 
 
 outer surface of spine of ischium, under gluteus . maximus, and re-enters 
 pelvis through lesser sciatic notch — passing, thence, forward over obturator 
 interims muscle, along outer wall of ischiorectal fossa, about 4 cm. (i£ inches) 
 above the lower margin of the tuberosity of ischium, and contained in a canal 
 of the obturator fascia. Gradually approaching the border of the ischial 
 ramus, it runs forward and upward — pierces posterior layer of deep perineal 
 fascia, runs forward along inner margin of ramus of pubis, giving off artery 
 of cms penis and artery of bulb between layers of triangular ligament — piercing 
 anterior layer of deep perineal fascia as the dorsal arterv of penis. 
 
 Relations. — (a) Within Pelvis: — descends over pyriformis muscle and 
 sacral plexus to lower border of great sacrosciatic notch, whence it emerges 
 between pyriformis and coccygeus muscles, together with sciatic artery, 
 pudic nerve, greater and lesser sciatic nerves, and nerve to obturator internus 
 
 Fig. 42. — Ligation of Right Internal Pudic and Sciatic Arteriks upon the Buttock, be- 
 low the Pyriformis: — A, A, Gluteus maximus (incised and retracted); P>, Pyriformis (lower 
 border retracted upward); C, Obturator internus, with gemellus superior and inferior, above and 
 beli iw ; D, Pudic artery and venae comites ; E, Internal pudic nerve ; F, Sciatic artery and venae com- 
 ites ; G, Small sciatic nerve ; H, Great sciatic nerve. 
 
 muscle, (b) Crossing Spine of Ischium: — is covered by gluteus maximus and 
 edge of great sacrosciatic ligament. A vena comes is on either side, and the 
 nerve to the obturator internus to the outer side and the pudic nerve to the 
 inner side, (c) On Obturator Internus Muscle: — bound to muscle by sheath 
 of obturator layer of pelvic fascia (Alcock's canal), with dorsal nerve of penis 
 above and superficial perineal nerve below, (d) Between Two Layers of 
 Triangular Ligament: — runs near to ramus of pubis, in substance of com- 
 pressor urethra? muscle. 
 
 Line of Artery. — See Surgical Anatomy of Sciatic Artery. 
 
 Indications for Ligation. — Wounds. 
 
 Sites for Ligation. — Over the spine of the ischium, or in the perineum. 
 (Fig 41, E.) 
 
 Comment. — The main trunk of the arterv is the same in both sexes. 
 
LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY. 87 
 LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC 
 
 UPOX THE BUTTOCK. 
 
 Position — Landmarks — Incision — Operation. — Same as for Ligation 
 of Sciatic Branch of Internal Iliac upon the Buttock — the arteries lying side 
 by side at their exit from the pelvis, below the lower border of the pyriformis 
 (Fig. 41, E, and Fig. 42, D). 
 
 LIGATION OF INTERNAL PUDIC BRANCH OF INTERNAL ILIAC 
 
 IN THE PERINEUM. 
 
 Position. — Patient in lithotomy position. Surgeon sits facing buttock. 
 
 Landmarks. — Tuberosity and ascending ramus of ischium. 
 
 Incision. — Begins about 7.5 cm. (3 inches) above inner border of tuber- 
 osity of ischium and passes downward along the margin of the ascending 
 ramus of the ischium. 
 
 Operation. — Divide skin and fascia, avoiding inferior pudendal nerve 
 beneath the superficial fascia. The erector penis muscle is exposed (in the 
 male). The transversus perinan is either cut or drawn downward and in- 
 ward. Divide the base of the triangular ligament and adjacent parietal 
 pelvic fascia — when the artery will be found running forward above the 
 pudic nerve, upon the inner surface of the obturator internus muscle, and 
 above the attachment of the great sacrosciatic ligament. 
 
 SURGICAL ANATOMY OF GLUTEAL BRANCH OF POSTERIOR DIVI- 
 SION OF INTERNAL ILIAC. 
 
 Description and Relations. — Largest branch of posterior division, of 
 which it is the continuation. Passes backward and downward between 
 first sacral nerve and lumbosacral cord — leaving pelvis through upper part 
 of sacrosciatic notch, above pyriformis, in osseotendinous groove formed by 
 margin of bone and pelvic fascia, accompanied by gluteal vein and superior 
 gluteal nerve, — emerging from the pelvis under the gluteus maximus, where 
 it divides into its branches just above the upper border of the pyriformis 
 muscle. 
 
 Line of Artery. — Having rotated inward and slightly flexed the thigh, 
 draw a line from the posterior superior iliac spine to the top of the great 
 trochanter. A point on this line at the junction of the upper and middle 
 thirds will correspond with the emergence of the gluteal artery from the 
 sciatic notch (Fig. 41, A, B, D). 
 
 Indications for Ligation. — Wounds; aneurism. 
 
 Site for Ligation. — At emergence from sciatic notch, at upper border 
 of pyriformis muscle (Fig. 41). 
 
 LIGATION OF GLUTEAL BRANCH OF INTERNAL ILIAC ARTERY 
 
 ON THE BUTTOCK. 
 
 Position. — Patient on involved side, rolled nearly onto chest; knee flexed; 
 thigh rotated inward. Surgeon on side of operation. 
 
 Landmarks. — Posterior superior iliac spine; top of great trochanter. 
 
88 OPERATIONS UPON THE ARTERIES. 
 
 Incision. — Having drawn the line given under Surgical Anatomy, an 
 incision about to cm. (4 inches) in length is drawn along this line, with its 
 center corresponding with the junction of its upper and middle thirds, which 
 will be over the site at which the gluteal artery leaves the sciatic notch 
 (Fig. 41, D). 
 
 Operation. — After dividing skin, superficial fascia, some superficial 
 nerves, and the fascia of the gluteus maximus, the muscle itself is met, its 
 fibers running parallel with the skin incision (Fig. 43). Incise the muscle- 
 fibers of the gluteus maximus along their cleavage line. Having passed 
 through the thickness of the gluteus maximus, a branch of the gluteal artery 
 will generally lead to the interval between the gluteus medius and pyriformis 
 (which otherwise is sought without this guide). Having divided the fascia 
 over the lower border of the gluteus medius, separate these muscles by re- 
 tractors and expose the upper margin of the sciatic notch by passing the 
 
 Fig. 43.— Ligation of Right Gluteal Artery upon the Buttock, above the Pyriformis: — 
 A, Deep fascia over gluteus maximus; B, B, Gluteus maximus, incised and retracted; C, Gluteus 
 medius (retracted upward) ; D, Pyriformis (retracted downward i ; E, Fascia between gluteus max- 
 imus and gluteus medius and pyriformis; F, Gluteal artery and vena; comites ; G, Superior gluteal 
 nerve and branches; H, Gluteus minimus. 
 
 finger under the lower border of the gluteus medius — and through the upper 
 portion of the sciatic notch, between the lower border of the gluteus medius 
 and upper border of the pyriformis, emerge the gluteal artery, vein, and 
 superior gluteal nerve. 
 
 SURGICAL ANATOMY OF EXTERNAL ILIAC ARTERY. 
 
 Description. — The larger (in the adult) branch of common iliac. About 
 9 to 10 cm. (3^ to 4 inches) in length. Arises at bifurcation of common 
 iliac at sacro-iliac synchondrosis — running thence obliquely downward and 
 outward along brim of pelvis, upon inner border of psoas muscle — passing 
 under lower border of Poupart's ligament, midway between anterior superior 
 iliac spine and symphysis pubis, to become femoral. The external iliac vein 
 lies to inner side of artery below, and to inner and posterior aspect above. 
 
LIGATION OF EXTERNAL ILIAC. 89 
 
 The deep epigastric artery arises about 6 mm. (\ inch) above Poupart's 
 ligament, and runs between transversalis fascia and peritoneum toward the 
 umbilicus. The deep circumflex iliac arises below the deep epigastric, and 
 passes behind Poupart's ligament upon the iliacus muscle. The internal 
 abdominal ring is situated about 1.3 cm. (% inch) above Poupart's ligament, 
 and midway between anterior superior iliac spine and spine of os pubis, 
 and hence just external to course of artery. 
 
 Relations. — Anteriorly: Parietal peritoneum; subperitoneal fascia; end 
 of ileum, on right; sigmoid flexure of colon, on left; genital branch of genito- 
 crural nerve (over its lower third); circumflex iliac vein; spermatic artery 
 and vein; ovarian vessels (in female); vas deferens; ureter (sometimes); ex- 
 ternal iliac lymphatic vessels and glands. Posteriorly : External iliac vein ; 
 inner border of psoas magnus and its tendon; iliac fascia. Internally: 
 External iliac vein; peritoneum; vas deferens; ovarian vessels, in female. 
 Externally: Psoas magnus; iliac fascia. 
 
 Branches. — Deep epigastric; deep circumflex iliac; several branches to 
 psoas magnus and lymphatic glands. 
 
 Line of Artery. — See Surgical Anatomy of Common Iliac. 
 
 Indications for Ligation. — Wounds; secondary hemorrhage; femoral 
 or iliofemoral aneurisms; to arrest malignant growths; in elephantiasis arabum; 
 as a distal ligation in aneurism of common iliac. 
 
 Sites of Ligation. — Proximal to deep epigastric and deep circumflex iliac 
 branches (Fig. 39, D). 
 
 LIGATION OF EXTERNAL ILIAC 
 
 BY RETROPERITONEAL ROUTE. 
 
 Position. — Patient supine, near edge of table. Surgeon on side of 
 operation.' 
 
 Landmarks. — Poupart's ligament; anterior superior iliac spine; line of 
 artery. 
 
 Incision. — Begins over external iliac artery, about 1.3 cm. (h inch) 
 above Poupart's ligament, and passes upward and outward parallel with 
 the ligament, to the anterior superior iliac spine — and is prolonged upward as 
 far as necessary, in the cleavage line of the external oblique (Fig. 39, D). 
 
 Operation. — (1) Having incised skin, superficial fascia — together with, 
 possibly, the superficial epigastric, branches of superficial circumflex iliac, 
 with their veins, ligating where necessary, expose the aponeurosis of the 
 external oblique (Fig. 44). (2) Divide this aponeurosis in its cleavage line, 
 without cutting its fibers — and continue this division, or separation, in the 
 cleavage line as far toward or beyond the anterior superior iliac spine as 
 indicated to give free room for manipulation. (3) Having retracted the cut 
 edges of the external oblique well apart, separate from the outer half of 
 Poupart's ligament the attachment of the internal oblique. Carefully retract 
 the cut edges of the internal oblique, being on the watch for branches of the 
 iliohvpogastric and ilio-inguinal nerves between the internal oblique and 
 transversalis, and, if encountered, carefully displace them above or below, 
 but avoid cutting them. If necessary to gain more room, the internal oblique 
 is to be incised in the line of the separation of the external oblique as far as 
 the upper limit of the separation of the fibers of the latter muscle. (4) Having 
 incised the internal oblique and protected the nerves encountered, detach 
 the transversalis from the outer third of Poupart's ligament, and as far beyond 
 
9° 
 
 OPERATIONS UPON THE ARTERIES. 
 
 as necessary, incising its fibers transversely to their direction, but in the 
 direction of the division of the internal oblique. After dividing the trans- 
 versalis, guard the deep circumflex iliac artery and vein and the genitocrural 
 nerve, both lying between the transversalis fascia and peritoneum. (5) 
 Having now separated the fibers of the aponeurosis of the external oblique, 
 and divided the fibers of the internal oblique and transversalis in the same 
 line as the separation of the external oblique aponeurosis, and having safe- 
 guarded the important nerves encountered, the fascia transversalis is then 
 exposed and is divided over the artery in a transverse direction, corresponding 
 
 Fig. 44— Ligation of Right External Iliac, Retroperitoneally— through Oblique In- 
 cision Parallel with Poupart's Ligament: — A, A, Superficial epigastric artery; B, External 
 oblique muscle ; C, C, G, External oblique aponeurosis ; D, Internal oblique; E, Ilioinguinal nerve ; 
 F, Transversalis muscle; H, Deep circumflex iliac artery and accompanying vein; I, Deep epigas- 
 tric artery and venae comites ; J, Genitocrural nerve ; K, Peritoneum (peeled back and retracted up- 
 ward) ; L, Iliac fascia ; M, External iliac artery (its sheath incisedj ; N, External iliac vein ; O, An- 
 terior crural nerve (seen through fascial ; P, Poupart's ligament. 
 
 with the preceding separation and incision lines. The artery is here clearly 
 defined, and the deep epigastric, the main source of collateral circulation, 
 is carefully guarded. (6) As soon as the artery is clearly located, the sub- 
 peritoneal tissue about the vessel is carefully opened up and the artery well 
 exposed — as well as the deep epigastric, for the purpose of guarding it. The 
 peritoneum is then pushed and rolled backward and upward from the vessel 
 with the fingers and held out of the way by retractors. (7) When sufficiently 
 exposed, the sheath of the artery is opened and the needle passed from the 
 vein on its inner side guarding the anterior crural nerve on its outer side. 
 The ligature should be about 3 cm. (i\ inches) above Poupart's ligament. 
 (8) In concluding the operation, the cut edges of the transversalis are united 
 by buried catgut sutures to their line of severance from Poupart's ligament, 
 and as far beyond as they may have been divided. The cut edges of the 
 internal oblique are similarly sutured to their former attachment to Poupart's 
 ligament, and to their opposite cut margin as far beyond as divided. And, 
 
SURGICAL ANATOMY OF FEMORAL ARTERY. QI 
 
 finally, the separated margins of the external oblique are united by a buried 
 gut suture. The skin wound is then closed. 
 
 Comment. — The incision for exposure may, if thought necessary, begin 
 about 3 cm. (i| inches) to the outer side of the spine of the os pubis — being 
 thus begun well to the inner side of the artery, as in the modified Astley 
 Cooper operation. 
 
 Collateral Circulation. — Internal mammary, lumbar, lower intercostals, 
 above; with deep epigastric, below. Iliolumbar, lumbar, gluteal, above; 
 with deep circumflex iliac, below. Obturator and sciatic, above; with internal 
 circumflex below. Sciatic, above; with superior perforating, below. Gluteal, 
 above; with external and internal circumflex and first perforating, below. 
 Internal pudic, above; with external pudic, below. 
 
 LIGATION OF EXTERNAL ILIAC 
 
 BV TRANSPERITONEAL ROUTE. 
 
 Position. — As in the extraperitoneal operation. Or in the Trendelen- 
 burg position. 
 
 Landmarks. — As for the extraperitoneal exposure. 
 
 Incision. — The incision may be in one of three sites: (a) As an intra- 
 muscular incision, placed over the site of the artery to be tied (Fig. 39, F); 
 (b) vertical, in the linea semilunaris (Fig. 39, E); or (c) vertical, in the linea 
 alba (Fig 39 , C). 
 
 Operation. — The steps of the operation and the manipulation to expose 
 the site of ligation are, practically, similar to those in the transperitoneal 
 exposure of the common iliac, or the internal iliac. 
 
 SURGICAL ANATOMY OF FEMORAL ARTERY. 
 
 Description. — Continuation of external iliac. Begins at lower border 
 of Poupart's ligament, midway between anterior superior iliac spine and 
 symphysis pubis — passes down anterior and inner side of thigh to opening 
 in adductor magnus, at junction of middle and lower thirds of thigh, through 
 which it passes into popliteal space, becoming popliteal artery. Above, the 
 artery lies near the antero-internal aspect of head of femur. Below, it is 
 close to inner side of bone. Between, it is some distance from bone. In 
 its upper third the artery passes from the center of base to apex of Scarpa's 
 triangle. [Scarpa's triangle is bounded, externally, by sartorius; internally, 
 by adductor iongus; its base, above, being formed by Poupart's ligament; 
 its apex, below, at junction of sartorius and adductor Iongus. Its floor 
 (from without inward) is formed by iliacus, psoas, pectineus, small part of 
 adductor brevis, and small part of adductor Iongus. It contains femoral 
 artery (in its center), with its cutaneous and profunda branches; femoral vein 
 (toward inner side), with deep femoral vein and internal saphenous branches, 
 passing from middle of base to apex; anterior crural nerve (to outer side): 
 lymphatic glands.] In its lower third the artery passes through Hunter's 
 canal. [Hunter's canal is an aponeurotic canal extending from apex of 
 Scarpa's triangle to femoral opening in adductor magnus, and formed, ex- 
 ternally, by vastus internus; postero-internaily, by adductor Iongus and 
 magnus; antero-internally, by aponeurosis stretching from vastus internus 
 over femoral vessels to adductor Iongus and magnus, the sartorius passing 
 over top of this aponeurosis. It contains femoral artery, femoral vein (each 
 
92 
 
 OPERATIONS UPON THE ARTERIES. 
 
 in its own sheath, the vein being behind and external to artery), and long 
 saphenous nerve (external to vessels).] 
 
 Divisions of Artery.— Common Femoral— first 4 cm. (i 1 inches). 
 Superficial Femoral— made up by remainder (about 9 cm.— 3$ inches). Deep 
 Femoral — profunda femoris branch. 
 
 Relations.— (a) Common Femoral :— Anteriorly— skin; superficial 
 fascia; superficial inguinal glands; iliac portion of fascia lata; continuation 
 of transversalis fascia into femoral sheath; crural branch of genitocrural 
 nerve; superficial circumflex iliac vein; superficial epigastric vein (sometimes). 
 Posteriorly — continuation of iliac fascia into femoral sheath; pubic portion 
 of fascia lata; nerve to pectineus; psoas muscle; pectineus muscle; capsule 
 of hip-joint. Externally— anterior crural nerves. Internally— femoral 
 vein, (b) Superficial Femoral Artery in Scarpa's Triangle :— Anteriorly 
 —skin; superficial fascia; crural branch of genitocrural nerve; deep fascia; 
 
 Fig. 45. —Incisions for Ligation of Chief Arteries of Thigh :— A. Anterior superior iliac 
 spine ; B, Symphysis pubis ; C, Adductor tubercle ; D, Mid-point between anterior superior iliac spine 
 and symphysis pubis ; E, Ligation of common femoral at baseof Scarpa's triangle, by incision parallel 
 with artery; F, Same, by incision parallel with and just below Poupart's ligament; G, Of profunda 
 femoris, near origin ; H, Of superficial femoral at apex of Scarpa's triangle ; I, Of superficial femoral 
 in Hunter's canal ; J, Of popliteal in upper part of popliteal space, from inner side of thigh. 
 
 internal cutaneous nerve. Posteriorly — femoral vein; profunda vein; pro- 
 funda artery; pectineus muscle; adductor longus. Externally — long saphe- 
 nous nerve; nerve to vastus internus. Internally — femoral vein (getting 
 behind artery at apex of Scarpa's triangle), (c) Superficial Femoral 
 Artery in Hunter's Canal: — Anteriorly — skin; superficial fascia; deep 
 fascia; sartorius; aponeurotic roof of Hunter's canal; internal saphenous 
 nerve. Posteriorly — angle of junction of vastus internus and adductors; 
 femoral vein (lying, in middle of Hunter's canal, behind and becoming 
 slightly external and closely adherent to artery). Externally— vastus internus, 
 femoral vein (at lower part of Hunter's canal). Internally— adductor longus 
 (above) ; adductor magnus (below) . 
 
 Branches. — From Common Femoral — superficial epigastric, superficial 
 circumflex iliac, superficial external pudic, deep external pudic, profunda. 
 From Superficial Femoral in Scarpa's Triangle— muscular, saphenous. 
 
LIGATION OF COMMON FEMORAL. 93 
 
 From Superficial Femoral in Hunter's Canal— muscular, anastomotica 
 magna. 
 
 Line of Artery. — (With hip slightly flexed, thigh abducted and rotated 
 outward.) From a point midway between anterior superior iliac spine 
 and symphysis pubis, to adductor tubercle of internal femoral condyle 
 (Fig. 45, D, C). (When thigh in normal position and parallel with its 
 fellow — from midway between anterior superior iliac spine and symphysis 
 pubis, to inner border of patella.) 
 
 Sites for Ligation. — Common femoral at base of Scarpa's triangle — 
 rare (on account of proximity of large vessels). Superficial femoral at apex 
 of Scarpa's triangle — operation of election. Superficial femoral in Hunter's 
 canal — not common (Fig. 45). 
 
 Indications for Ligation.— As for ligation of External Iliac (page 89). 
 
 Comment. — (i) A short common femoral is more frequent than a long 
 one. (2) Apex of Scarpa's triangle is from 7.5 to 9 cm. (3 to 3$ inches) 
 below Poupart's ligament. (3) Profunda femoris arises about 4 cm. (i£ 
 inches) below Poupart's ligament. (4) At groin, femoral artery and vein 
 are on same plane — at apex of Scarpa's triangle, vein is posterior — in middle 
 of Hunter's canal, vein is posterior and slightly external — at lower part of 
 Hunter's canal, vein is external. (5) Order of vessels at apex of Scarpa's 
 triangle, from before backward, is femoral artery, femoral vein, profunda 
 vein, profunda artery. (6) Line approximately representing course of long 
 saphenous vein is one running from a point about 2 cm. (f inch) internal to 
 mid-point between anterior superior iliac spine and symphysis pubis, to 
 posterior border of sartorius muscle at femoral condyle. 
 
 LIGATION OF COMMON FEMORAL 
 
 AT BASE OF SCARPA'S TRIANGLE— BY INCISION PARALLEL WITH ARTERY. 
 
 Position. — Patient supine; hip slightly flexed; thigh abducted and rotated 
 outward; knee bent and lying upon its outer aspect. Surgeon stands on 
 side of operated limb, cutting from above downward on the right, and vice 
 versa. 
 
 Landmarks. — Line of artery (page 93) . 
 
 Incision. — About 5 cm. (2 inches), beginning just a little above Poupart's 
 ligament and extending downward in line of artery (Fig. 45, E). 
 
 Operation. — Incise skin and superficial fascia. Avoid lymphatic glands 
 — also the superficial circumflex iliac, superficial epigastric, and superficial 
 external pudic arteries and veins. Divide the iliac portion of the fascia lata 
 (Fig. 46). Avoid the crural branch of the genitocrural nerve on the femoral 
 sheath, a little external to the artery. Expose and open the sheath, guarding 
 the femoral vein, which lies immediately to the inner side of the artery and 
 within the sheath — and the anterior crural nerve lying further to the outer 
 side of the artery and outside of the sheath. Pass the needle from the vein 
 
 (Fig. 47)- 
 
 Comment. — (I) Ligation at the base of Scarpa's triangle is rarely done, 
 owing to the nearness and number of the branches — except in such cases 
 as wounds, and to control hemorrhage at the hip-joint, or for temporary 
 control in operating about the thigh. Where not otherwise indicated, ligation 
 of the external iliac is the better operation. (2) The artery may also be 
 exposed, at this site, by an incision parallel with and about 6 mm. (^ inch) 
 below the middle third of Poupart's ligament (Fig. 45, F). 
 
 Collateral Circulation. — Internal pudic of internal iliac; with pudic 
 
94 
 
 OPERATIONS UPON THE ARTERIES. 
 
 of femoral. Gluteal; with external and internal circumflex and superior 
 perforating. Superficial circumflex iliac; with external circumflex. Ob- 
 turator; with internal circumflex. Sciatic; with superior perforating and 
 
 Fig. 46. — Ligation of Right Common Femoral at Base of Scarpa's Triangle: — A, A> 
 Superficial fascia; B, B, Fascia lata; D, Pectineus; E, Psoas; G, G, Poupart's ligament and external 
 oblique; H, Common femoral artery, with superficial epigastric, external pudic, and circumflex 
 iliac branches; I, I, Femoral vein; J, Internal saphenous, with superficial epigastric, external 
 pudic, and circumflex iliac veins; K, Anterior crural nerve; L, Crural branch of genitocrural. 
 
 internal circumflex. Comes nervi ischiadici; with all the perforating branches 
 of profunda and articular of popliteal. 
 
 SURGICAL ANATOMY OF PROFUNDA FEMORIS BRANCH OF COMMON 
 
 FEMORAL ARTERY. 
 
 Description. — Largest branch of femoral, nearly equaling main trunk. 
 Arises from externo-posterior aspect of common femoral, about 4 cm. (ih 
 inches) below Poupart's ligament — passing down thigh, at first external to 
 
LIGATION OF PROFUNDA FEMORIS. 
 
 95 
 
 superficial femoral — thence posterior to femoral artery and vein to inner 
 side of femur — thence leaves femur and runs beneath adductor longus and 
 adductor magnus. 
 
 Relations. — Anteriorly: (near origin) skin; superficial fascia; deep 
 fascia; branches of anterior crural nerve; (lower down) femoral vein; pro- 
 funda vein; (still lower) adductor longus. Posteriorly: (in order) iliacus; 
 pectineus; adductor brevis; adductor magnus. Externally : vastus internus. 
 Internally: pectineus; angle of junction of adductor brevis and adductor 
 magnus. 
 
 Branches. — External circumflex; internal circumflex; three perforating. 
 
 Site of Ligation. — At origin. 
 
 Indications for Ligation. — Wounds of itself and branches. Aneurisms. 
 
 
 
 Fig. 47. — Cross-section of the Left Thigh, through the Head of the Femur (The 
 skin relations of this section erroneously represent a lower level.): — A, Iliacus; B, Sartorius; 
 C, Femoral artery, vein, and crural nerve; D, Pectineus; E, Psoas; F, Tensor vaginas femoris; 
 G, Gluteus minimus; H, Gluteus medius; I, Great sciatic artery, vein, and nerve; J, Gluteus 
 maximus; K, Obturator internus; L, Obturator externus; M, Adductor brevis; N, Adductor 
 longus. (The cross-section from Braune.j 
 
 LIGATION OF PROFUNDA FEMORIS 
 
 NEAR ORIGIN. 
 
 Position. — Patient supine; limb extended and parallel with fellow. 
 Surgeon on outer side of operated limb, cutting from above downward on 
 the right, and vice versa. 
 
 Landmarks. — Line of artery (with extended limb — see page 93) ; Pou- 
 part's ligament. 
 
9 6 
 
 OPERATION'S UPON THE ARTERIES. 
 
 Incision. — About 5 or 6 cm. (2 or 2^ inches) in length, in line of artery 
 — calculating to fall over its outer border, with the center of incision over a 
 point in the course of the artery about 4 cm. (ij inches) below Poupart's 
 ligament (Fig. 45, G). 
 
 Operation. — Incise skin, superficial fascia, and fascia lata. Expose the 
 inner edge of the sartorius and retract it outward. Beneath this muscle 
 lies the rectus, with branches of the anterior crural nerve in close relation — 
 these are to be drawn outward. The trunk of the common femoral will 
 then be exposed, with the profunda coming off from its postero-external 
 aspect, and running outward and downward, with the external circumflex 
 arising from it and passing under the rectus. The artery is then freed and 
 the ligature passed. 
 
 Fig. 48. —Ligation of Right Femoral at Apex of Scarpa's Triangle :— A, Sartorius; B, 
 Adductor longus ; C, Femoral artery and muscular branches, with its sheath incised and retracted; 
 D, Femoral vein ; E, Branch of internal saphenous vein ; F, Long saphenous nerve ; G, Internal cuta- 
 neous nerve. 
 
 LIGATION OF SUPERFICIAL FEMORAL 
 
 AT APEX OF SCARPA'S TRIANGLE. 
 
 Position. — Same as for ligation of common femoral at base of Scarpa's 
 triangle. 
 
 Landmarks. — Line of artery. 
 
 Incision. — About 7.5 cm. (3 inches) in length, in line of artery — with its 
 
LIGATION OF SUPERFICIAL FEMORAL ARTERY. 
 
 97 
 
 center over apex of Scarpa's triangle, that is, about 7.5 cm. (3 inches) below 
 Poupart's ligament (Fig. 45, H). 
 
 Operation. — Incise skin and superficial fascia. Draw aside, or ligate, 
 branches of internal saphenous vein (Fig. 48). Divide fascia lata. Identify 
 inner margin of sartorius (fibers running downward and inward) and retract 
 outward. Open up the groove between the sartorius and adductor longus 
 (fibers of latter running directly downward, or downward and outward) and 
 retract the adductor longus internally, if necessary. The internal cutaneous 
 nerve and long saphenous nerve are encountered anterior to the artery, and 
 are to be displaced to one side. Clearly identify the femoral sheath and 
 incise — guarding the femoral vein, which lies posteriorly and internally to 
 the artery. Pass the needle from the vein. 
 
 Collateral Circulation. — External circumflex; with lower muscular 
 branches of femoral, anastomotica magna, superior articular of popliteal, 
 and anterior tibial recurrent. Perforating and terminating of profunda, 
 with muscular branches of femoral and muscular and superior articular 
 branches of popliteal. Comes nervi ischiadici; with perforating of profunda 
 and articular of popliteal. 
 
 Fig 49. — Ligation of the Right Femoral Artery in Hunter's Canal: — A, Internal 
 cutaneous nerve; B, Sartorius; C, Hunter's canal, the roof incised; D, Femoral artery; E, Femoral 
 vein: F, Internal saphenous nerve. 
 7 
 
9 8 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Fitr. 50. — Cross-section through the Middle of the Left Thigh: — A Rectus muscle; 
 B, Vastus interims; C, Sartorius; D, Superficial femoral artery, vein, and saphenous nerve; 
 E, Adductor longus; F, Adductor magnus; G, Gracilis; H, Semimembranosus; I, Vastus externus; 
 J, Descending branch of external circumflex; K, Terminal branch of profunda femoris; L, 
 Crureus; M, Great sciatic nerve and arteria comes nervi ischiadici; N, Biceps; O, Semitendinosus. 
 (The cross section modified from Braune.) 
 
 LIGATION OF SUPERFICIAL FEMORAL 
 
 IN HUNTER'S CANAL. 
 
 Position. — Same as for common femoral at base of triangle. 
 
 Landmarks. — Line of artery. 
 
 Incision. — From 7.5 to 9 cm. (3 to 3^ inches), in line of artery — over 
 middle third of thigh (Fig. 45, I). 
 
 Operation. — Incise skin and superficial fascia. The anterior branch of 
 the internal cutaneous nerve, to the outer side, and the long saphenous vein, 
 to the inner side, are likely to be encountered. Divide the fascia lata. Ex- 
 pose the outer edge of the sartorius (its fibers running downward and inward) 
 and retract inward from its position over the roof of Hunter's canal. Hunter's 
 canal is thereby exposed in the interval between the vastus internus and the 
 adductor magnus (the fibers of the latter running obliquely downward and 
 outward). The nerve to the vastus internus may be here exposed. Incise 
 the roof of the canal, when the internal saphenous nerve is found between 
 the aponeurotic roof and the sheath of the vessels, running from without 
 inward. Open the sheath and pass the needle from the vein (Fig. 50). 
 
SURGICAL ANATOMY OF POPLITEAL ARTERY. 
 
 99 
 
 Comment. — Guard against taking 
 the vastus internus for the sartorius — 
 the fibers of the former running down- 
 ward and outward. 
 
 Collateral Circulation. — Same as 
 for the superficial femoral at the apex of 
 Scarpa's triangle. 
 
 SURGICAL ANATOMY OF POPLITEAL 
 ARTERY. 
 
 Description. — Continuation of fem- 
 oral. Extends from aponeurotic open- 
 ing in adductor magnus, at junction of 
 middle and lower thirds of thigh, down- 
 ward and outward through the popliteal 
 space to its center behind the knee-joint 
 — thence vertically downward to the in- 
 ferior border of the popliteus muscle, op- 
 posite the lower border of the tubercle of 
 the tibia, where it divides into anterior 
 and posterior tibial arteries. 
 
 Relations. — Anteriorly : (from above 
 downward) popliteal surface of femur; 
 posterior ligament of knee; posterior 
 articular surface of tibia; popliteus mus- 
 cle. Posteriorly : (above) semimem- 
 branosus; (center) skin, superficial fascia, 
 deep fascia; (below) internal head of gas- 
 trocnemius, aponeurotic arch of soleus. 
 Popliteal vein lies behind artery through- 
 out its course, crossing obliquely from 
 outer to inner side, and may be double 
 below. Internal popliteal nerve lies be- 
 hind artery and vein (immediately pos- 
 terior to latter), crossing the vessels ob- 
 liquely at their center, from outer to 
 inner side. Externally : (above) ex- 
 ternal condyle, biceps, internal popliteal 
 nerve; (below) outer head of gastroc- 
 nemius, plantaris. Internally : (above) 
 semimembranosus; (below) inner head 
 of gastrocnemius, internal popliteal nerve. 
 
 Branches. — Cutaneous; muscular 
 (superior muscular, inferior muscular or 
 sural) ; articular (superior external artic- 
 ular, superior internal articular, inferior 
 external articular, inferior internal artic- 
 ular, azygos articular); terminal (poste- 
 rior tibial, anterior tibial). 
 
 Fig. 51. — Ligation of Popliteal, 
 Posterior Tibial, and Peroneal Ar- 
 teries: — A, Outer border of semimem- 
 branosus (at junction of middle and lower 
 thirds of thigh) ; B, Middle of popliteal 
 space ; C, Center of posterior aspect of leg 
 on level with tibial tubercle; D, Point 
 midway between convexity of heel and tip 
 of internal malleolus; E, Mid-point between 
 outer border of tendo Achillis and tip of 
 external malleolus ; F, Incision for popliteal 
 
 artery in upper part of popliteal space, from behind; G, Same, in lower part of popliteal space; 
 
 H, Of posterior tibial in its upper third ; I, Same, in its middle third; J, Same, in its lower third ; 
 
 K, Same, behind internal malleolus ; L, Incision for peroneal in middle of leg. 
 
IOO OPERATIONS UPON THE ARTERIES. 
 
 Line of Artery. — From outer border of semimembranosus (at junction 
 of middle and lower thirds of thigh) obliquely down to middle of popliteal 
 space, directly posterior to the knee-joint (for upper part of artery); and 
 from mid-point of popliteal space vertically down to level of lower border 
 of tubercle of tibia (for lower part of artery). (Fig. 51, A, B, C.) 
 
 Sites of Ligation. — May be ligated either in its upper part or lower 
 part — the artery being tied with difficulty in its middle, owing to its depth 
 and relations (Figs. 45, J, and 51, F and G). 
 
 Indications for Ligation. — Rare, other than wounds and aneurism — 
 the superficial femoral usually being ligated instead. 
 
 LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL 
 
 SPACE 
 
 FROM BEHIND. 
 
 Position. — Patient as nearly prone as feasible, resting on side of shoulder 
 and chest, with limb extended. Surgeon to outer side of left limb, cutting 
 downward; and to outer side of right limb, cutting upward (or inside of 
 right limb, cutting downward). 
 
 Landmarks. — Line of artery and upper boundaries of popliteal space. 
 
 Incision. — About 9 cm. (3^ inches) in length, in line of artery, beginning 
 at outer border of semimembranosus, at junction of middle and lower thirds 
 of thigh, and passing obliquely downward to the middle of the popliteal 
 space (Fig. 51, F). 
 
 Operation. — Incise skin and superficial fascia. Avoid the small sciatic 
 nerve. Open up the deep fascia. Retract the hamstring muscles to the 
 outer and inner sides. The popliteal nerve is first encountered crossing from 
 the outer to the inner side — the popliteal vein crossing similarly. Displace 
 these structures laterally — when the artery is found, generally lying in fatty 
 areolar tissue. 
 
 Collateral Circulation. — Where the ligation is between the superior 
 and inferior articular arteries; — anastomotic^ magna, superior external and 
 internal articular, descending branch of external circumflex, above; with in- 
 ferior external and internal articular and anterior tibial recurrent (also, possibly, 
 posterior tibial recurrent and superior fibular of anterior recurrent), below. 
 
 Comment. — The upper part of the popliteal artery may also be tied 
 from the inner side of the leg (v. i.) — but the above operation is simpler, unless 
 the popliteal region be encroached upon by some pathological condition. 
 
 LIGATION OF POPLITEAL ARTERY IN UPPER PART OF POPLITEAL 
 
 SPACE 
 
 FROM INNER SIDE OF THIGH— JOBERT'S OPERATION. 
 
 Position. — Patient supine; thigh slightly flexed; fully abducted and 
 rotated outward; knee at a right angle and resting on external aspect. Surgeon 
 on outside, cutting downward on right, upward on left (or may stand on 
 inner side of left and cut downward) . 
 
 Landmarks. — Tendon of adductor magnus. 
 
 Incision. — About 7.5 cm. (3 inches) in length, beginning opposite the 
 junction of middle and lower thirds of thigh, and running parallel with and 
 immediately posterior to the tendon of the adductor magnus (which is inserted 
 into the adductor tubercle on the internal condyle of the femur). (Fig. 45, J.) 
 
 Operation. — Incise skin and superficial fascia. Avoid anterior branch 
 of internal cutaneous nerve (Fig. 52). Divide deep fascia. Expose the 
 
LIGATION OF POPLITEAL ARTERY. 
 
 IOI 
 
 anterior edge of the sartorius and retract it backward, together with the 
 internal saphenous vein, if in view (the internal saphenous nerve being beneath 
 the sartorius, out of view). Having thoroughly divided the deep fascia, the 
 adductor magnus tendon is identified and drawn forward — then the semi- 
 
 Fig. 52.— Ligation of Upper Part of Right Popliteal from Inner Side of Thigh : — A, 
 Anterior branch of internal cutaneous nerve; B, Internal saphenous vein ; C, Sartorius (its anterior 
 border retracted posteriorly I ; D, Internal saphenous nerve (mainly under sartorius, out of sight) ; E, 
 Adductor magnus (drawn anteriorly); F, Semimembranosus (drawn posteriorly); G, Popliteal 
 artery ; H, Popliteal vein (below and external to artery). • 
 
 membranosus is identified and drawn backward — and the artery is then 
 sought between these two structures, near the bone and in considerable 
 fatty areolar tissue. Both popliteal vein and nerve lie on a plane posterior 
 to the artery, and are generally not brought to view. 
 
 LIGATION OF POPLITEAL ARTERY IN LOWER PART OF POPLITEAL 
 
 SPACE 
 
 P.V POSTERIOR MEDIAN INCISION. 
 
 Position. — As for ligation in the upper part of the space. 
 
 Landmarks. — Boundaries of the popliteal space (the biceps above, and 
 the plantaris and outer head of gastrocnemius below, forming the outer 
 boundary; — and the semimembranosus and semitendinosus above, and the 
 inner head of the gastrocnemius below, forming the inner boundary). 
 
102 OPERATIONS UPON THE ARTERIES. 
 
 Incision. — About 9 cm. (3? inches) in length, beginning at the middle 
 of the popliteal space (on a level with the knee-joint) and passing downward 
 between the two heads of the gastrocnemius (Fig. 51, G). 
 
 Operation. — Incise skin and superficial fascia. Avoid the external 
 saphenous vein and external saphenous nerve in the outer aspect of the 
 wound, or the communicans poplitei nerve which helps form the external 
 saphenous nerve (Fig. 53). Divide the deep fascia. Expose the inner and 
 outer heads of the gastrocnemius, with the sural arteries going to them — 
 and retract these and the plantaris muscle to their respective sides. Muscular 
 branches of the internal popliteal nerve may be met with here, and maybe 
 
 Fig- 53- — Ligation of Right Popliteal at Lower Part of Popliteal Space: — A, Inner 
 head of gastrocnemius (retracted inward l; B, Outer head of gastrocnemius (drawn outward); C, 
 Plantaris; D, External saphenous vein ; E, Communicans poplitei nerve; F, Internal popliteal nerve 
 (drawn inward) ; G, Popliteal vein (drawn inward] ; H, Popliteal artery and muscular branches; I, 
 Popliteus muscle. 
 
 the posterior tibial nerve. The external saphenous vein is the guide to the 
 popliteal vessels. The internal popliteal nerve is found most superficial of 
 the three important structures — the popliteal vein next (both crossing to the 
 inner side, toward which side they are further retracted) — and the artery 
 deepest of all, near the bone and in much fatty areolar tissue. The needle 
 is passed from the side of the vein, flexure of the knee aiding during this 
 stage. 
 
 Comment. — A continuation upward of the above incision would amount 
 to ligation of the popliteal artery in the middle of the popliteal space. 
 
SURGICAL ANATOMY OF ANTERIOR TIBIAL ARTERY 
 
 103 
 
 Collateral Circulation. — If the artery be ligated between the superior 
 and inferior articular branches, the 
 collateral anastomosis would be the 
 same as after the above operation. 
 
 SURGICAL ANATOMY OF ANTERIOR 
 TIBIAL ARTERY. 
 
 Description. — The smaller bifur- 
 cation of popliteal artery, at lower 
 border of popliteus muscle, passing 
 thence forward between the two heads 
 of tibialis posticus, through aperture 
 in upper part of interosseous mem- 
 brane, between tibia and fibula, to 
 deep part of front of leg — descending, 
 at first, on anterior surface of interos- 
 seous membrane, then on the tibia, 
 and finally onto front of ankle-joint, 
 beneath anterior annular ligament, 
 where it becomes dorsalis pedis. It 
 is accompanied by two vena? comites. 
 The anterior tibial nerve accompanies 
 its lower three-fourths, lying upon its 
 fibular side, though partly overlapping 
 it in middle of leg. 
 
 Relations. — Anteriorly : skin, 
 superficial fascia; deep fascia; anterior 
 tibial nerve (at middle) ; tibialis an- 
 ticus (above) ; extensor longus digi- 
 torum (above) ; extensor proprius poi- 
 nds (below) ; anterior annular ligament 
 (below). Posteriorly: interosseous 
 membrane (upper two-thirds) ; tibia 
 and ankle-joint (lower one-third). Ex- 
 ternally : anterior tibial nerve (above 
 and below) ; extensor longus digitorum 
 (upper third) ; extensor proprius poi- 
 nds (middle third). Internally : tibi- 
 alis anticus (upper two-thirds) ; ex- 
 tensor proprius pollicis (crosses lower 
 part of arterv). 
 
 Branches. — Posterior tibial recur- 
 rent, superior fibular (sometimes), an- 
 terior tibial recurrent, muscular, in- 
 ternal malleolar, external malleolar. 
 
 Line of Artery. — From inner side 
 of head of fibula, to center of line be- 
 tween the malleoli — (according to 
 Kocher, from midway between ex- 
 ternal surface of head of fibula and 
 center of tubercle of tibia, to the 
 
 Fig. 54. — Incisions for Ligation of 
 Anterior Tibial and Dorsalis Pedis Ar- 
 teries : — A, Incision for upper third of anterii >r 
 tibial ; B, For middle third of anterior tibial ; 
 C, For lower third of anterior tibial ; D, For 
 dorsalis pedis just below ankle-joint; E, For 
 dorsalis pedis in first interosseous space; F, 
 Inner side of head of fibula ; G, Mid-point be- 
 tween two malleoli. 
 
 same point below). The artery passes 
 
io4 
 
 OPERATIONS UPON THE ARTERIES. 
 
 through the interosseous membrane about 3 cm. (1} inches) below the level 
 of the head of the fibula. 
 
 Indications for Ligation.— Wounds (of anterior tibial or in foot); 
 aneurism. 
 
 Sites of Ligation.— Upper and middle thirds— rarely, except in wounds. 
 Lower third — most frequent site. (Fig. 54). 
 
 LIGATION OF ANTERIOR TIBIAL 
 
 IN ITS UPPER THIRD. 
 
 Position. — Patient supine; leg extended and rotated inward. Surgeon 
 on outer side (cutting from above downward, on the right — and vice versa). 
 
 Landmarks. — Line of artery. 
 
 Incision. — About 7.5 cm. (3 inches) in length, in line of artery — beginning 
 about 2.5 cm. (1 inch) below head of fibula (Fig. 54, A). 
 
 Fig. 55. — Ligation of the Upper Third of the Right Anterior Tibial Artery: — 
 A, Anterior tibial artery; B, Vena; comites; C, Anterior tibial nerve; D, Extensor communis 
 digitorum; E, Branch of internal saphenous vein; F, Tibialis anticus muscle. 
 
 Operation. — Incise skin, superficial fascia, and deep fascia. Define the 
 gap between tibialis anticus, internally, and extensor longus digitorum, 
 externally, and retract these structures to their respective sides (Fig. 55). 
 Open up this interval — flexing the foot to relax the parts. Aim to reach the 
 external aspect of the tibia, covered by the tibialis anticus, and, when reached, 
 
LIGATION OF ANTERIOR TIBIAL. 
 
 I°5 
 
 follow down to the interosseous membrane, upon which the artery will be 
 found. Two venae comites lie in very close contact, in front of and behind the 
 artery. The anterior tibial nerve may not yet have reached the outer side 
 of the artery. If the vena; comites be not separable, include them in the 
 ligature. 
 
 Comment. — The interval between the tibialis anticus and extensor 
 longus digitorum is the key to the situation, and is rather hard to find. The 
 outer edge of the tibialis anticus. often overlaps the extensor longus digitorum. 
 And also one may get into the septum between the extensor longus digitorum 
 and peroneus longus and work down toward the fibula. Guides to the 
 proper intermuscular gap, accessory to the sensation of touch, are the " white 
 line" (sometimes visible) and a small artery leading to the anterior tibial. 
 
 Fig. 56. — Cross-section through the Upper Third of the Right Leg: — A, Tibialis 
 anticus; B, Extensor longus digitorum; C, Anterior tibial vessels and nerve; D, Musculocutaneous 
 nerve; E, Peroneus longus; F, F, F, F, Gastrocnemius; H, Posterior tibial vessels and nerve; 
 I, Soleus; J, Internal saphenous vein and nerve; K, Popliteus. (The cross-section modified 
 from Braune.) 
 
 LIGATION OF ANTERIOR TIBIAL 
 
 IN ITS MIDDLE THIRD. 
 
 Position — Landmarks. — As for ligation of the upper third. 
 
 Incision. — About 7.5 cm. (3 inches) in length, in line of artery, with its 
 center over the center of the leg (Fig. 54, B). 
 
 Operation. — Incise skin, superficial and deep fascia. Recognize the 
 interval between the tibialis anticus (its outer edge still muscular) internally — 
 and the extensor longus digitorum (its inner edge tendinous) externally. A 
 
io6 
 
 OPERATIONS UPON THE ARTERIES. 
 
 yellow fatty line may sometimes indicate the interval. Open up this interval, 
 flexing the foot. Retract these muscles to their own sides — and, deeper in 
 the wound, also retract the extensor proprius pollicis to the outer side. Follow 
 down the gap toward the tibia (and not the gap between the extensor longus 
 digitorum and extensor proprius pollicis). The anterior tibial nerve will be 
 found slightly overlapping the artery — draw it outward. The artery will be 
 found on the interosseous membrane, under cover of the muscular fibers 
 of the tibialis anticus, with the extensor proprius pollicis on its outer side. 
 The venae comites are separated with difficulty, and, if so, may be included 
 in the ligature. 
 
 Fig. 57. — 'Ligation of Lower Third of Right Anterior Tibial :— A, Tendon of tibialis 
 anticus, retracted inward ; B. Extensor proprius hallucis, retracted outward ; C, Extensor longus 
 digitorum ; U, Annular ligament ; E, Anterior tibial artery and branches ; F, F, Anterior tibial venae 
 comites; G, Anterior tibial nerve; H, Inner branch of musculocutaneous nerve; I, Branch of 
 internal saphenous vein. 
 
 LIGATION OF ANTERIOR TIBIAL 
 
 IX ITS LOWER THIRD. 
 
 Position. — As for ligation of the upper third — without the inward rota- 
 tion of the foot. 
 
 Landmarks. — Line of artery. 
 
 Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with center over 
 center of lower third of leg (Fig. 54, C). 
 
 Operation. — Incise skin and fascia. Clearly identify tendon of tibialis 
 anticus. Divide the upper part of the superior band of the anterior annular 
 ligament in the line of the wound (Fig. 57). Demonstrate the interval be- 
 
LIGATION OF DORSALIS PEDIS. 107 
 
 tween the tendon of the tibialis anticus and tendon of the extensor proprius 
 pollicis — flexing the foot and retracting these tendons to their own sides. 
 The anterior tibial artery will be found between them, lying upon the anterior 
 aspect of the tibia and held down by fatty areolar tissue — accompanied by 
 two venae comites, and with the anterior tibial nerve on the outer side. Pass 
 the needle from the nerve. In closing the wound, suture the anterior annular 
 ligament. 
 
 Comment. — If the artery were ligated after passing beneath the obliquely 
 crossing extensor proprius pollicis, it would then have the tendon of the 
 extensor proprius pollicis to its inner side and the innermost tendon of the 
 extensor longus digitorum to its outer side. 
 
 Collateral Circulation. — (When ligated below the malleolar branches.) 
 External malleolar of anterior tibial, with anterior peroneal of peroneal and 
 with calcaneal of posterior peroneal. Internal malleolar of anterior tibial, 
 with internal malleolar of posterior tibial. Dorsalis pedis and branches, 
 with internal plantar of posterior tibial, with external plantar of posterior 
 tibial, with anterior peroneal of peroneal, and with calcaneal of posterior 
 peroneal. Muscular branches of anterior tibial anastomosing through the 
 interosseous membrane with muscular branches of posterior tibial. 
 
 SURGICAL ANATOMY OF DORSALIS PEDIS (OF ANTERIOR TIBIAL). 
 
 Description. — Continuation of anterior tibial — extending from bend of 
 ankle along tibial side of foot to apex of first intermetatarsal space — passing 
 into sole (as communicating artery) between two heads of first dorsal inter- 
 osseous. The anterior tibial nerve lies upon its outer side. The artery is 
 accompanied by two venae comites. 
 
 Relations. — Anteriorly: Skin, superficial fascia; deep fascia; anterior 
 annular ligament; extensor longus pollicis; innermost tendon of extensor 
 brevis digitorum. Posteriorly: (from above downward) Astragalus; scaph- 
 oid; internal cuneiform; ligament of first and second metacarpals. Ex- 
 ternally : Innermost tendon of extensor longus digitorum (above) ; innermost 
 tendon of extensor brevis digitorum (below) ; anterior tibial nerve. In- 
 ternally : Extensor longus pollicis. 
 
 Branches. — Tarsal; metatarsal; dorsalis hallucis; communicating (plantar 
 digital). 
 
 Line of Artery. — From center of line connecting two malleoli, to proximal 
 end of first metatarsal space. 
 
 Indications for Ligation. — Rare — wounds, aneurism. 
 
 Sites of Ligation. — At ankle-joint (involves cutting anterior annular 
 ligament); below ankle-joint (general site); at first interosseous space (Fig. 
 54, D and E). 
 
 LIGATION OF DORSALIS PEDIS 
 
 JUST BELOW ANKLE-JOINT. 
 
 Position. — Patient supine; foot resting on heel and extended. Surgeon 
 below foot, on either side, cutting downward (or on outer side of both limbs, 
 cutting downward on right, and upward on left). Assistant steadies foot. 
 
 Landmarks. — Line of artery. 
 
io8 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Incision. — From 2.5 to 5 cm. (1 to 2 in.), in line of artery, passing from 
 lower border of anterior annular ligament — between tendon of extensor 
 pollicis and inner tendon of extensor longus digitorum (Fig. 54, D). 
 
 Fig. 58. — Ligation of Right Dorsalis Pedis Just below Ankle-joint: — A, A, Branches of 
 internal saphenous vein ; B, Internal branch of musculocutaneous nerve and its divisions ; C, Tendon 
 of extensor proprius hallucis ; D, Inner tendon of riexor longus digitorum ; E. Inner tendon of exten- 
 sor brevis digitorum ; F, Dorsalis pedis artery ; G, Venae comites of dorsalis pedis artery ; H, Ante- 
 rior tibial nerve; I, Annular ligament. 
 
 Operation. — Incise skin and superficial fascia. Tributaries of internal 
 saphenous vein and the internal branch of the musculocutaneous nerve lie 
 in the line of incision (Fig. 58). Open up the deep fascia between the tendon 
 of the extensor proprius pollicis and innermost tendon of flexor longus digitorum 
 — when the artery will be found upon the tarsal ligaments. The anterior 
 tibial nerve lies upon its fibular side — two vena? comites accompanying the 
 artery. Avoid opening the tendon sheaths. 
 
 Comment. — When the artery is tied at the base of the first interosseous 
 space, an incision is made from the apex of the first interosseous space, passing 
 down between the first and second metatarsals. The artery is found emerging 
 from under the innermost tendon of the extensor brevis digitorum, which 
 is retracted inward. 
 
 SURGICAL ANATOMY OF POSTERIOR TIBIAL ARTERY. 
 
 Description. — Larger and more direct division of popliteal artery — ■ 
 extending from lower border of popliteus muscle (on level with lower border 
 of tubercle of tibia), down tibial side of back of leg, between superficial and 
 deep muscles, to middle of fossa between tip of internal malleolus and os 
 calcis — and dividing, under abductor hallucis, into internal and external 
 
LIGATION OF POSTERIOR TIBIAL. 109 
 
 plantar branches. It arises midway between tibia and fibula, covered by 
 the superficial muscles — lower down it lies behind the tibia — and at its lower 
 third it is covered by only skin and fascia, and then passes beneath the internal 
 annular ligament. It is accompanied by two vena? comites. The posterior 
 tibial nerve crosses the artery, from the inner to outer side, about 2.5 to 4 
 cm. (1 to 1 J inches) below inferior border of popliteus, and runs thence along 
 its fibular aspect. 
 
 Relations. — Anteriorly: (From above downward) tibialis posticus; 
 flexor longus digitorum; tibia; internal lateral ligament of ankle-joint. Pos- 
 teriorly: Skin; superficial fascia; gastrocnemius; soleus; deep intermuscular 
 (transverse) fascia binding artery to underlying muscles; posterior tibial 
 nerve (crossing from inner to outer side above, and then running along fibular 
 side). In lower third, covered only by skin and fascia. Externally : Poste- 
 rior tibial nerve (lower three-fourths) ; vena comes. Internally : Posterior 
 tibial nerve (upper one-fourth); vena comes. At Ankle-joint: Posterior 
 tibial artery lies under internal annular ligament and abductor hallucis — 
 resting upon internal lateral ligament of ankle — having tibialis posticus and 
 flexor longus digitorum in front — and posterior tibial nerve and flexor longus 
 hallucis behind and externally. 
 
 Branches. — Peroneal, muscular, medullary, cutaneous, communicating, 
 internal malleolar, internal calcaneal, external plantar, internal plantar. 
 
 Line of Artery. — Lower half — line from a point 5 cm. (2 inches) below 
 center of popliteal space, to midway between tip of internal malleolus and 
 center of convexity of heel. Upper half — forms a slight curve inward from 
 this line. 
 
 Indications for Ligation. — Wounds; aneurisms. 
 
 Sites of Ligation. — Upper third — not frequent — difficult because of 
 depth. Middle third — same. Lower third — most usual site. Behind ankle 
 — also common. (Fig. 51, H, I, J, K.) 
 
 LIGATION OF POSTERIOR TIBIAL 
 
 IN ITS UPPER THIRD— ABOVE ORIGIN' OF PERONEAL BRANCH. 
 
 Position. — As for ligation of lower part of popliteal artery (page 101). 
 
 Landmarks. — Popliteal boundaries (page 101); head of fibula. 
 
 Incision. — Begins in popliteal space, on level with head of fibula, and 
 passes directly down the middle line for about 7.5 cm. (3 inches) (Fig. 51, H). 
 
 Operation. — Incise skin, superficial fascia, avoiding external saphenous 
 vein and nerve. Divide deep fascia, exposing two heads of gastrocnemius. 
 Incise their connecting raphe freely and separate them fully, avoiding their 
 nerves and vessels as much as possible. Expose the upper border of the 
 soleus beneath the external head of the gastrocnemius. Retract the plantaris 
 (found between the outer head of the gastrocnemius and soleus). The 
 lower border of the popliteus, opposite which the posterior tibial nerve begins, 
 about corresponds with the upper border of the soleus — so that after re- 
 tracting the internal popliteal nerve and vein to the inner side, draw the 
 upper border of the soleus downward (or nick its upper border) and thus 
 expose the bifurcation of the popliteal artery into anterior tibial (passing 
 through the interosseous membrane) and posterior tibial (descending on 
 the deep muscles). Pass the needle between the anterior tibial and peroneal 
 branches. 
 
 Collateral Circulation. — (When ligated between the bifurcation and 
 
no 
 
 OPERATIONS UPON THE ARTERIES. 
 
 origin of the peroneal.) Peroneal of posterior tibial, with communicating 
 and muscular branches of the posterior tibial; external calcaneal of peroneal, 
 with internal calcaneal of external plantar; external malleolar of anterior 
 tibial, with external plantar; internal malleolar of anterior tibial, with internal 
 malleolar of posterior tibial; dorsalis pedis and branches, with internal and 
 external plantar. 
 
 F'g- 59- — Ligation of Middle Third of Right Posterior Tibial: — A, Internal saphenous 
 vein; B, Internal saphenous nerve; C, Soleus, incised vertically, and margins of incision well 
 retracted; D, Inner border of gastrocnemius strongly retracted outward ; E, Transverse intermuscu- 
 lar fascia ; F, Flexor longus digitorum ; G, Tibialis posticus ; H, Posterior tibial artery ; I, I, Poste- 
 rior tibial venae comites ; J, Posterior tibial nerve. 
 
 LIGATION OF POSTERIOR TIBIAL 
 
 IN ITS MIDDLE THIRD. 
 
 Position. — Patient supine; knee flexed; leg on outer side. Surgeon to 
 outer side, cutting downward on right, and upward on left. 
 
 Landmarks. — Inner margin of tibia. 
 
 Incision. — From 7.5 cm. to 10 cm. (3 to 4 inches) in length, placed 
 parallel with and 2 cm. (f inch) behind the inner margin of the tibia, along 
 its middle third (Fig. 51, I). 
 
 Operation. — Incise skin and superficial fascia. Avoid internal saphenous 
 vein and internal saphenous nerve (Fig. 59). Divide the deep fascia. The 
 inner edge of the gastrocnemius should be identified here — and retracted 
 outward. Having gone through the deep fascia, the soleus is exposed, and 
 is to be divided along its attachment to the tibia, and its outer part retracted. 
 
LIGATION OF POSTERIOR TIBIAL. 
 
 The transverse intermuscular fascia (between superficial and deep muscles 
 of back of leg) is now in view, and is incised in the axis of the limb, whereby 
 the flexor longus digitorum is reached — and, by following along the surface 
 of this muscle until nearly opposite the outer border of the tibia, the vena 
 comes interna, posterior tibial artery, vena comes externa, and posterior 
 tibial nerve are met in order, lying upon the tibialis posticus, or between it 
 and the flexor longus digitorum. Pass the needle from the nerve, including 
 the vena? comites if unavoidable — flexing the knee and foot to relax the 
 structures. (Fig. 60.) 
 
 Fig. 60. — Cross-section of the Middle of the Right Leg: — A, Tibialis amicus; B, 
 Extensor longus digitorum; C, Extensor pollicis; D, Anterior tibial artery, vein, and nerve; 
 E, Peronei; F, Tibialis posticus; G, Long saphenous vein and nerve; H, Flexor longus digitorum; 
 I, Posterior tibial artery, veins, and nerve; J, Soleus; K, Gastrocnemius; L, Peroneal artery 
 and veins. (The cross-section modified from Braune.) 
 
 Comment. — The knife should be held at a right angle to the surface 
 of the muscle, in cutting through the soleus, pointing toward the tibia until 
 the transverse fascia is reached — and thereby wandering too deeply, or in 
 the wrong direction, is less likely. If one incise too near the tibia, the flexor 
 longus digitorum may be divided and the interosseous membrane reached. 
 While incising the soleus, do not mistake its central membranous tendon 
 for the transverse intermuscular fascia. The artery lies about 3 cm. (i| 
 inches) external to the inner border of the tibia. 
 
112 OPERATIONS UPON THE ARTERIES. 
 
 LIGATION OF POSTERIOR TIBIAL 
 
 IN ITS LOWER THIRD. 
 
 Position. — As for the middle third. 
 Landmarks. — Line of artery. 
 
 Incision. — About 5 cm. (2 inches) in length, in line of artery, with its 
 center over the lower third of the leg — which should fall midway between 
 the inner border of the tendo Achillis and the inner border of the tibia 
 (Fig- 51, re- 
 operation. — Incite skin and superficial fascia. Divide the deep fascia 
 binding down the flexor tendons — when the artery will be found lying be- 
 tween the flexor longus digitorum and flexor longus pollicis — the posterior 
 tibial nerve lying to its fibular side, with the venae comites surrounding the 
 artery. 
 
 Comment. — If the incision be at the upper part of the lower third of 
 the artery, the vessel will be found upon the flexor longus digitorum. If 
 the incision be at the lower part of the lower third, the upper part of the 
 internal annular ligament must be cut. 
 
 G 
 
 — 1 
 
 "1 
 
 Fig. 61. — Ligation of Right Posterior Tibial behind Internal Malleolus: — A, Branch 
 of internal saphenous vein; B, Branch of internal saphenous nerve; C, Internal annular ligament 
 (incised); D, Tendon of flexor longus hallucis; E, Tendon of flexor longus digitorum; F, Tendon 
 of tibialis posticus ; G, Posterior tibial artery ; H, H, Posterior tibial vense comites ; I, Posterior tibial 
 nerve. 
 
 LIGATION OF POSTERIOR TIBIAL 
 
 BEHIND INTERNAL MALLEOLUS. 
 
 Position. — As for ligation of the lower third. 
 Landmarks. — Internal malleolus. 
 
 Incision. — About 5 cm. (2 inches) in length, placed about 1.3 cm. (\ 
 inch) posterior to and parallel with the inner malleolus (Fig. 51, K). 
 
LIGATION OF POSTERIOR TIBIAL. 
 
 Operation. — Incise skin and superficial fascia — during which branches 
 of the internal saphenous vein are encountered (Fig. 61). Expose the in- 
 ternal annular ligament and divide it over the vessels — the artery being found 
 in the interval between the flexor longus digitorum and flexor longus hallucis, 
 surrounded by its vena; comites and with the nerve upon its fibular side (Fig. 
 62). 
 
 Fig. 62. — Cross-section of the Right Leg just Above the Ankle: — A, Extensor 
 proprius pollicis; B, Anterior tibial vessels and nerve; C, Peroneus brevis; D, Peroneus longus; 
 E, Flexor longus pollicis; F, Tibialis anticus; G, Extensor proprius pollicis; H, Tibialis posticus; 
 I, Flexor longus digitorum; J, Posterior tibial artery, veins, and nerve; K, Tendo Achillis. (The 
 cross-section modified from Braune.) 
 
 Comment. — Keep the knife pointed toward the tibia, in making the 
 incision. Avoid opening the sheaths of the tendons. Behind the internal 
 malleolus and posterior surface of the tibia are four compartments, which, 
 passing from tip of malleolus toward heel, are — first, a canal in the annular 
 ligament for the posterior tibial muscle tendon — a second canal for the flexor 
 longus digitorum tendon — a third space occupied bv the posterior tibial 
 artery, its venae comites, and the posterior tibial nerve — and a fourth canal 
 for the flexor longus hallucis. 
 
114 OPERATIONS UPON THE ARTERIES. 
 
 SURGICAL ANATOMY OF PERONEAL BRANCH OF POSTERIOR 
 TIBIAL ARTERY. 
 
 Description. — Arises from posterior tibial about 2.5 cm. (1 inch) below 
 inferior border of popliteus — and curves (with convexity outward and upward) 
 obliquely outward and downward to fibula — descending thence close to inner 
 border of fibula, to lower third of leg, where the anterior peroneal is given off 
 (which pierces the interosseous membrane to front of leg) — thence passes, 
 as posterior peroneal, to inferior tibiofibular joint and external malleolus. 
 It is accompanied by two venae comites. 
 
 Relations. — (From origin to bifurcation.) Anteriorly : (from above 
 downward) Tibialis posticus; fibrous bed between origins of tibialis posticus 
 and flexor longus hallucis. Posteriorly: (from above downward) Soleus; 
 flexor longus hallucis (completing fibrous canal of artery). 
 
 Branches. — Muscular, nutrient, anterior peroneal, communicating, 
 posterior peroneal, external calcanean. 
 
 Line of Artery. — From middle of popliteal space, on level of lower 
 border of tubercle of tibia, arching slightly outward and then downward 
 along inner border of posterior surface of fibula. For purposes of ligation, 
 the artery is represented by a line from posterior border of head of fibula 
 to point midway between external malleolus and outer margin of tendo 
 Achillis. 
 
 Indications for Ligation. — Rare — except for wounds, when the vessel 
 is cut down upon at the point wounded. 
 
 Sites of Ligation. — Upper part — rare, owing to depth. Middle — usual 
 site (Fig. 51, L). 
 
 LIGATION OF PERONEAL BRANCH OF POSTERIOR TIBIAL 
 
 IN MIDDLE OF LEG. 
 
 Position. — Patient rests on shoulder and chest of opposite side; knee 
 flexed; leg on antero-internal surface. Surgeon on outer side, cutting from 
 below on right, and from above on left. 
 
 Landmarks. — External border of fibula. 
 
 Incision. — About 7.5 cm. (3 inches) in length — parallel with and just 
 behind external border of fibula, with its center over the middle of the leg— 
 which falls behind the peronei muscles (Fig. 51, L). 
 
 Operation. — Incise skin and superficial fascia. Branches of the external 
 saphenous nerve and external saphenous vein are apt to be encountered here 
 (Fig. 63). Expose the soleus (which, at this site, no longer arises from the 
 fibula) and retract it upward and inward (incising its lower fibers if any be 
 found attached to the fibula at this height). Divide the deep fascia behind 
 the peronei. Expose the flexor longus hallucis and incise through its thick- 
 ness, close to the fibula — until the fibrous canal of which it forms the roof 
 is reached. Divide the aponeurotic canal and expose the artery lying near 
 the fibula, with its venae comites 
 
SURGICAL ANATOMY OF THE EXTERNAL PLANTAR ARTERY. 1 15 
 
 Fig. 63. — Ligation of Right Peroneal in Middle of Leg: — A, Branch of external saph- 
 enous nerve; B, Branch of external saphenous vein; C, Gastrocnemius, retracted inward; D, 
 Soleus, retracted' upward and inward ; E, Peroneus longus ; F, Peroneus brevis ; G, Tibialis posticus; 
 H, Flexor longus hallucis, incised, showing roof of aponeurotic canal enclosing vessels ; I, Peroneal 
 artery ; J, Peroneal venae comites. 
 
 SURGICAL ANATOMY OF EXTERNAL PLANTAR BRANCH OF POS- 
 TERIOR TIBIAL. 
 
 Description. — Larger of two terminal branches given off by posterior 
 tibial at inner ankle. Passes from beneath internal annular ligament, obliquely 
 forward and outward across sole of foot to base of fifth metatarsal — thence 
 curves forward and inward to base of first interosseous space — where it 
 anastomoses with communicating branch of dorsalis pedis, to form plantar 
 arch. Two venae comites accompany the artery. 
 
 Relations. — First part (from inner ankle-joint to base of fifth meta- 
 tarsal): Rests on os calcis; flexor accessorius; flexor minimi digiti. Covered 
 by — skin; superficial fascia; plantar fascia; abductor hallucis; flexor brevis 
 digitorum and abductor minimi digiti. Lies between — flexor brevis digi- 
 torum and abductor minimi digiti. Accompanied by — external plantar 
 nerve and two venae comites. Second part: (Plantar arch; from base of 
 fifth metatarsal to proximal end of first interosseous space.) Rests on — - 
 proximal ends, and corresponding interosseous muscles, of second, third, 
 and fourth metatarsals. Covered by — skin; superficial fascia; plantar fascia; 
 flexor brevis digitorum; tendon of flexor longus digitorum; lumbricales; 
 branches of internal plantar nerve; adductor hallucis. 
 
n6 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Branches. — Muscular, calcaneal, cutaneous, anastomotic, articular, pos- 
 terior perforating, digital. 
 
 Line of Artery. — First Part: from point midway between tip of internal 
 malleolus and great tubercle of os calcis, to base of fifth metatarsal. Second 
 Part: — from base of fifth metatarsal, to posterior part of ball of great toe. 
 
 Fig. 64. — Incisions for Liga- 
 tion of Plantar Arteries: — A, 
 Incision for external plantar in sole of 
 foot; B, For internal plantar in sole of 
 foot; C, For external plantar arch at 
 base of first interosseous space; D, Ball 
 of heel; E, Base of fourth toe; F, Base 
 of first toe. 
 
 Fig. 65. — Ligation of Right External Plan- 
 tar in Sole of Foot: — A, Superficial fascia; B, 
 Abductor minimi digiti; C, Flexor brevis digitorum; 
 D, Deep plantar fascia; E, External plantar artery; 
 F, F, External plantar venae comites; G, External 
 plantar nerve. 
 
 Indications for Ligation. — Wounds and aneurisms. 
 Sites of Ligation. — At origin — more frequent site. In the sole. Plantar 
 arch — rare. (Fig. 64, A, C.) 
 
 LIGATION OF EXTERNAL PLANTAR 
 
 IN SOLE OF FOOT. 
 
 Position. — Patient supine; foot resting upon heel, steadied upon a sup- 
 port. Surgeon at foot of table. 
 
 Landmarks. — Ball of heel; fourth toe. 
 
 Incision. — Along arch of foot, in a line from ball of heel to fourth toe 
 — about 6 cm. (2 J inches) in length (Fig. 64, A). 
 
 Operation. — Divide skin, superficial fascia, fatty areolar tissue, and 
 plantar fascia. Expose the gap between the flexor brevis digitorum and 
 abductor minimi digiti — in which the artery is found, with accompanying 
 nerve and veins (Fig. 65). 
 
LIGATION OF INTERNAL PLANTAR. 
 
 117 
 
 SURGICAL ANATOMY OF INTERNAL PLANTAR BRANCH OF POSTE- 
 RIOR TIBIAL. 
 
 Description. — Smaller of two terminal branches given off by posterior 
 tibial at inner ankle — passing forward along inner side of sole, generally 
 to first interosseous space, to anastomose with fifth plantar digital of com- 
 municating branch of dorsalis pedis. 
 
 Relations. — First covered by abductor hallucis — then lies between 
 abductor hallucis and flexor brevis digitorum — and, toward distal end, is 
 covered by skin and fascia. 
 
 Branches. — Muscular, cutaneous, articular, anastomotica, superficial 
 digital. 
 
 Sites of Ligation. — At origin — more frequent. In sole. (Fig. 64, B.) 
 
 LIGATION OF INTERNAL PLANTAR 
 
 AT ORIGIN". 
 
 Position — Landmarks — Incision — Operation. — As for ligation of ex- 
 ternal plantar at origin. 
 
 A 
 
 Fig. 66. — Ligation or Right Internal Plantar Artery in Sole of Foot: — A, Super- 
 ficial fascia; B, Abductor hallucis; C, Flexor brevis digitorum; D, Internal plantar artery; E, E, 
 Internal plantar venae comites; F, Internal plantar nerve. 
 
 LIGATION OF INTERNAL PLANTAR 
 
 IN SOLE OF FOOT. 
 
 Position. — As for external plantar. 
 
 Landmarks. — Heel; great toe. 
 
 Incision. — Along arch of foot, in line from point of heel to great toe — 
 about 6 cm. (2^ inches) in length (Fig. 64, B). 
 
 Operation. —Divide skin, superficial fascia, and fattv areolar tissue. 
 Expose the gap between the abductor hallucis and flexor brevis digitorum — 
 in which interval the artery is found (Fig. 66). 
 
Il8 OPERATIONS UPON THE ARTERIES. 
 
 TEMPORARY OR PROVISIONAL LIGATION OF ARTERIES. 
 
 Definition. — The temporary arrest of circulation in an artery by means 
 of a ligature carried beneath the vessel — whereby the artery is drawn upon 
 until the flow ceases, but is not tied. 
 
 Indications. — Where it is desired to control for a time the arterial circu- 
 lation during the steps of an operation — or where a ligature is placed about 
 an artery in advance of, or preparatory for, any emergency which may arise 
 — (e. g., temporary ligature of common carotid in the removal of a tumor 
 of the neck, or of the femoral in popliteal aneurism). 
 
 Operation. — All the steps, up to the exposure of the sheath of the artery, 
 are similar to those for an ordinary ligation. At this point, instead of opening 
 the sheath, the sheath itself is isolated (unless a common sheath contain 
 other important structures). A stout ligature (preferably broad) that will 
 not cut is passed beneath the sheath. The two ends of the ligature are not 
 tied upon the artery, but are simply grasped by clamp-forceps in the hands 
 of an assistant (or knotted into a loop). When it is desired to control all 
 flow through the vessel, the assistant simply lifts the artery slightly from 
 its position — the under wall of the artery is thereby pressed into contact 
 with the upper wall by the loop of the ligature, over which the artery makes 
 an angle, and the flow ceases. On relaxing tension, the artery falls back 
 into its normal position and the flow continues. Where no further need 
 exists for this control, one end of the loop is drawn upon and the ligature 
 slips out from under the artery. Where the temporary is converted into a 
 permanent ligature, the ligature is tightened in the ordinary manner — although, 
 were this likelihood foreseen, it would be better to open the sheath of the 
 artery at first and place the temporary ligature directly around the artery 
 proper. Floss silk is especially useful for provisional ligatures. 
 
 Comment. — As this subsidiary operation is generally resorted to in 
 advance or in the course of some more major operation, the steps of the 
 temporary ligation are modified by those of the main operation. 
 
 INTERMEDIATE LIGATION, OR LIGATURE EN MASSE. 
 
 Definition. — Ligature en masse for parenchymatous hemorrhage is a 
 method of controlling hemorrhage which comes from no definite vessels, or 
 from inaccessible sources, or as a capillary oozing. 
 
 Description. — A fully curved needle, armed with catgut, is made to 
 enter the tissue to one side of the site from which the flow comes — passes 
 deeply into the parts, and, in emerging, more or less completely surrounds 
 the area of hemorrhage — which is controlled by the tightening of the ligature. 
 Or, in hemorrhage from a larger area, a curved needle, held in a holder, 
 may be made to surround the area from which parenchymatous bleeding 
 comes by circumventing that area with a purse-string ligature introduced 
 by several consecutive insertions of the needle — at, for instance, four points 
 of a circle. The ends of beginning and ending of this catgut ligature are 
 then drawn and knotted — only tightly enough to control hemorrhage, and 
 not tightly enough to strangulate the parts. 
 
 ARTERIORRHAPHY. 
 
 Definition. — Suture of an artery. 
 
 Indications. — Arteriorrhaphy may be required in longitudinal wounds 
 of an artery; in limited transverse or oblique wounds; in transverse wounds 
 
ARTERIORRHAPHY. 
 
 II 9 
 
 of more than half the circumference; in complete division, or in division 
 with partial resection (the resected portion not exceeding more than about 
 2 cm. — I inch). 
 
 Exposure of the Vessel and Repair of a Longitudinal or Partial 
 Transverse Wound of an Artery by Suture of the Outer Coats. — (i) 
 With aseptic precautions, the sheath of the artery is exposed and opened with 
 minimum injury to vessel and surroundings. If the circulation have not 
 been temporarily controlled by a constrictor, or some form of pressure, the 
 artery is clamped above and below the injury with special forceps (e. g., 
 Billroth's, with broad blades protected by pieces of rubber drainage-tubes 
 drawn over them; or probably better, by means of floss silk lightly tied or 
 looped). (2) Seize, in turn, the lips of the wounded artery with a pair of 
 oculist's rat-tooth fixation-forceps. Using a fully curved and round con- 
 junctival needle (or straight floss-needle, or cambric needle) threaded with 
 
 Fig. 67. — ARTERIORRHAPHY IN COMPLETE CIRCULAR DIVISION OF AN ARTERY (MURPHY'S 
 
 Method) : — A, Intussusceptum, with sutures passing through outer and middle coats; B, Intus- 
 suscipiens (split to aid invagination) with sutures passing through all coats. 
 Fig 68. — C, Same showing all sutures tied. 
 
 twisted silk of exact size as eye of needle (that hemorrhage may not occur 
 through the needle-hole which the silk has not fully filled), penetrate the 
 tunica adventitia and muscularis, down to (but not through) the intima. 
 The lips of the wound are pierced immediately opposite each other. The 
 knots are interrupted — are from 1 to 2 mm. (about -^ to TTr inch) apart — 
 enter artery about 1.5 mm. (y 1 ^ inch) from edge of wound — and are lightly 
 tied with a reef-knot, avoiding inversion of the lips of the artery. The sheath 
 of the artery is separately sutured over the vessel, if possible. The skin 
 wound is closed as usual. A wound in the long axis of the artery tends to 
 gape least, and a transverse wound most. If the artery be divided through 
 one-half of its circumference, it should be entirely divided and re-united by 
 some method of suture, preferably by invagination. 
 
 Repair of Complete Transverse Division of an Artery by Invagina- 
 tion. — Murphy's Method: The artery is united end-to-end by invagination. 
 
120 OPERATIONS UPON THE ARTERIES. 
 
 A piece of finely twisted silk is threaded upon two needles — one of which 
 is passed through the outer and middle coats of the proximal end (intussus- 
 ceptum), in the transverse axis — then both needles, held side by side, are 
 simultaneously passed through all coats of the distal end (intussuscipiens) 
 about 7 to 12 mm. (J to J inch) from its free end, passing from within outward. 
 Two or three of these sutures are applied equidistantly. The distal end is 
 then slit a short distance (the slit not extending as low as the sutures) to aid 
 in invagination — which is then accomplished by traction upon the sutures — 
 which are, after invagination is complete, tied lightly with reef-knot. Rein- 
 forcing sutures are placed at the line of junction, and uniting the lips of the 
 slit — but do not pass through the intima of the intussusceptum. (See Figs. 
 67 and 68.) 
 
 Repair of Longitudinal or Oblique Wounds of the Larger Vessels, 
 or of Complete Transverse Division, by Combination Cobbler's Stitch 
 through all the Coats, and Interrupted Sutures through the Outer Coats. 
 — Based upon the fact that union between approximated endothelial coats 
 of the blood-vessels -rapidly occurs — and realizing the advantages of a suture 
 which, while applied through very limited available extent of tissue, must 
 bring together relatively broad surfaces of vessel-wall closely and strongly, 
 in order to withstand the constant hammering and distention of the arterial 
 and distention of the venous flow, the author suggests a method (original 
 as far as he knows) of tightly and firmly approximating relatively broad sur- 
 faces of the tunica intima of the larger vessels, especially arteries, by means 
 of the cobbler's stitch through all the coats, followed by reinforcing the margins 
 of the wound by interrupted sutures through the tunica adventitia and tunica 
 muscularis. 
 
 Irrespectively of the theoretical consideration it has been found, practically, 
 that through-and-through suturing of all the coats of a vessel is not followed 
 by harmful consequences. Therefore, although the necessity for guarding 
 against this complete penetration of all coats now no longer exists, yet in the 
 present method, notwithstanding all coats are actually pierced, the effect of 
 the suture is most probably not that of a through-and-through suture — since 
 the method of its application makes it likely that little, if any, portion of the 
 stitch itself comes into contact with the blood-current, owing to the recession 
 upon the inner aspect of the vessel and protection of the stitches by consequent 
 contact with and union of adjacent intimre, corresponding to and caused by 
 the external ridging produced by this particular form of suturing. 
 
 The materials used for the continuous through-and-through suture are the 
 finest chromic gut, having sufficient tensile strength — and, for the interrupted 
 sutures of the outer coats, fine silk. Fine silk or fine Pagenstecher thread 
 may be used in the primary as well as in the secondary suturing. The finest 
 possible special round needles which will carry the suture should be used — 
 with eyes nearly as large as the diameter of the head of the needle as mechani- 
 cally possible, that the thread following the needle-puncture may completely 
 fill the puncture in the vessel-wall. Where feasible, a straight needle long 
 enough to be held in the fingers should be used — or, where necessary, shorter, 
 straight needles or curved ones may be employed in a convenient form of 
 needle-holder. During the placing of the sutures the opposite edges of the 
 artery are held in contact and ready to receive the suture by two delicate dis- 
 secting (ribbed, but not toothed) forceps in the fingers of an assistant, who 
 so approximates the lips of the vessel- wound as to aid the operator materially 
 in the process of suturing (Fig. 69, F, F). Prior to closing the main (skin) 
 wound, in all methods of vessel-suturing, the newlv sutured vessel-wall should 
 
ARTERIORRHAPHY. 
 
 121 
 
 be supported, where possible, by suturing muscle, or other resistant neighboring 
 tissue, in such a way as to protect the vessel at this site. 
 
 While necessarily the caliber of a vessel thus sutured is encroached upon, 
 in the case of the larger vessels this encroachment is not sufficient to be of 
 practical importance — and, in the case of smaller vessels, the remaining lessened 
 channel is better than no channel at 
 all, which was the case in formerly 
 ligating all wounded vessels. 
 
 (A) Suture of a Longitudinal 
 Vessel-wound. — The opposite lips of 
 the wound are each grasped with for- 
 ceps and held in contact (Fig. 69, 
 F, F). The needles (one held be- 
 tween the operator's thumb and first 
 finger of each hand) are made to 
 enter the lips of the wound on oppo- 
 site sides and pass in opposite direc- 
 tions (Fig. 69, B, B), beginning just 
 above one of the limits of the wound, 
 at a distance of about 1.5 mm. ( T *g- 
 inch) from a line that would represent 
 a continuation of the vessel-wound 
 (Fig. 69, A). The needles now 
 change hands, and are made to pass 
 through all the coats in an opposite 
 direction, about 3 mm. (| inch) fur- 
 ther along the wound. This char- 
 acteristic cobbler's stitch is continued 
 as indicated in the figure — the thread 
 being drawn tightly at the end of each 
 stitch. Finally, the two ends of the 
 thread are tied in a reef knot at the 
 far end of the wound. This method 
 of suturing will ridge up the vessel 
 at the site of its application — approxi- 
 mating two surfaces of intima slightly 
 more than 1.5 mm. (y 1 ^- inch) in 
 width, and a little longer than the 
 length of the wound — and causing the 
 two free margins of the lips of the 
 wound to lie parallel, presenting them- 
 selves prominently forward in lateral, 
 but not edge-to-edge, contact, as 
 shown in Fig. 69. This lateral con- 
 tact is now converted at the margins 
 
 into a partial, if not complete, edge-to-edge contact by the reinforcing 
 interrupted silk sutures — which enter the tunica adventitia about 1 mm. 
 (less than y 1 ^ inch) from the free margin (Fig. 69, D, D) — pass through 
 the tunica adventitia, and all or a greater part of the tunica muscularis — 
 to emerge just between the tunica muscularis and tunica intima — thence, 
 crossing the inner aspects of the vessel-wall wound, enter between the 
 tunica intima and tunica muscularis of the opposite lip — to emerge 
 through the tunica adventitia at a distance corresponding with the point 
 
 Fig. 69. — Repair of Longitudinal 
 Wound of Artery by Combination Cob- 
 bler's Stitch through all Coats, and 
 Interrupted Sutures through Outer 
 Coats, as suggested by the Author: — A, 
 Beginning of cobbler's stitch through all coats; 
 B, B, Needles in act of passing through same 
 opening in opposite directions, in characteristic 
 cobbler fashion; C, C, Three interrupted 
 sutures through outer coats, ready to be tied; 
 D, D, Two interrupted sutures tied, passing 
 through outer coats. 
 
122 
 
 OPERATIONS UPON THE ARTERIES. 
 
 of entrance — after which the opposite ends of the interrupted sutures are 
 tied (Fig. 69, C, C) — thus practically bringing the margins of the opposite 
 lips into close contact — and thereby affording opportunity of union not only 
 between the relatively broad surfaces of endothelial coats, but also between 
 the free edges of the corresponding coats at their margins. While this 
 method is of application to vessel-wounds in general, it is particularly applicable 
 to brittle, atheromatous vessels, in which it is difficult to make the ordinary 
 form of suture hold. 
 
 (B) Suture of an Oblique Vessel-wound. — There is no special principle 
 involved in suturing wounds which cross the long axis of a vessel obliquely 
 
 ' 
 
 « 
 
 "•:-. 
 
 Fig. 70. — Repair of Oblique Wound 
 of Artery by Combination Cobbler's 
 Stitch through all Coats, and Inter- 
 rupted Stitches through Outer Coats, 
 as suggested by the Author: — A, A, 
 Cobbler's stitch being completed by needles 
 passing through all coats in opposite direc- 
 tions; B, B, Interrupted sutures passing 
 through outer coats. 
 
 Fig. 7 1 . — Repair of Complete Trans- 
 verse Division of Artery by Combina- 
 tion Cobbler's Stitch through all 
 Coats, followed by Interrupted Su- 
 tures through Outer Coats, as sug- 
 gested by the Author: — A, A, Needles 
 passing in opposite directions through all 
 coats, in act of placing cobbler's stitch; 
 B, Superficial tier of interrupted stitches 
 through outer coats, showing three untied 
 and two tied. 
 
 not already brought out in the longitudinal suturing. In proportion as such 
 wounds correspond with the long axis of the vessel does the technic corre- 
 spond with that of the longitudinal wounds — and in proportion as the wound 
 approaches complete encircling of the vessel, though in an oblique direction, 
 is the technic equivalent to that employed in complete transverse division of 
 the vessel (Fig. 70). 
 
 (C) Suture of Complete Transverse Division of a Vessel. — The above 
 principles are here applied to a circumferential wound of a vessel — the edges 
 of the wounded vessel-wall representing a transverse section rather than a 
 longitudinal or an oblique one. In carrying the cobbler's stitch around the 
 vessel it is well to calculate that corresponding extents of the circumference 
 
ARTERIORRHAPHY. 
 
 123 
 
 are being taken up, so that no redundancy of any one aspect will be left in 
 terminating the line of suture (Fig. 71, A, A). The tier of reinforcing 
 interrupted sutures is applied in the manner described for longitudinal wounds 
 (Fig. 71, B). 
 
 Fig. 72. — Circular Arteriorrhaphy in Complete Division of an Artery: — A, Method of 
 
 Salomoni and Tomaselli — interrupted sutures through all coats. 
 
 ■fig- 73- — B, Same, method of Gliick — interrupted sutures through outer coats, protected by 
 
 cylinder of decalcihed bone, ivory, or rubber. 
 
 Other Methods of Suturing Arteries. — Besides the methods above 
 described, end-to-end union may be accomplished by suturing through all 
 
 Figs. 74, 75, 76. — Circular Arteriorrhaphy, after Complete Division of an Artery:— 
 
 The methods of Bougie. 
 
 the coats of both ends, after the manner of Salomoni and Tomaselli (Fig. 72., 
 or by the method of Gliick (Fig. 73), or by one of the methods of Bougie 
 (Figs. 74, 75, 76). 
 
124 
 
 OPERATIONS UPON THE ARTERIES. 
 
 CLOSURE OF WOUNDS OF LARGER ARTERIES BY SPECIAL RUBBER 
 
 PLASTER. 
 
 BREWER'S METHOD. 
 
 Description. — The portion of the vessel involved in the wound is encircled 
 by several turns of elastic plaster. This plaster is made by coating long, 
 narrow, ribbon-like sheets of thin, pure rubber with the material of which 
 zinc oxid plaster is coated, and is sterilized by formaldehyd vapor. Following 
 the application of the plaster, the wounded vessel is further reinforced, where 
 possible, by bringing neighboring muscle or connective tissue into contact 
 with it in the process of suturing the wound. 
 
 Position; — Landmarks; — Incision. — Determined by the special oper- 
 ation. 
 
 Operation. — Having exposed the wounded vessel, the artery is isolated 
 
 Fig. 77. — Brewer's Method of Closing Arterial Wounds by Special Rubber 
 Plaster: — The femoral artery is exposed at the apex of Scarpa's triangle. The circulation is 
 temporarily controlled by special artery clamps applied above and below the wound (here 
 represented by a longitudinal slit in the vessel-wall). The adhesive rubber ribbon has been 
 drawn under the vessel and is held taut by forceps. 
 
 sufficiently for manipulation, is brought out of its sheath, and is gently com- 
 pressed above and below the wounded site by the fingers, or by some special 
 clamps which compress just enough to control the circulation without injuring 
 the vessel. By means of pledgets of gauze wet with ether the wall of the 
 artery is cleaned of blood and made dry, so that the rubber plaster will adhere. 
 A strip of the rubber ribbon is now carried under the artery, with its adhesive 
 surface next the vessel, the two corners of its end grasped by forceps, preferably 
 of the artery -clamp kind (Fig. 77). The shorter end of the adhesive strip 
 which has been carried beneath the artery is now brought up over and into 
 contact with the vessel, and the longer end of the plaster carried over the shorter 
 end by reversing the position of the ends of the plaster, so that they will now 
 
ANEURISMORRHAPHY. 
 
 be in the position shown in Fig. 78. During this manoeuver the plaster is 
 kept gently on the stretch, so as to subject the vessel to slight pressure and 
 compression in the act of rolling the plaster around it. Two or more encirclings 
 are made, as deemed necessary — after which the plaster is cut transversely 
 and the artery allowed to drop back into its original position (Fig. 79). The 
 
 Fig. 70. — Same : — The vessel has been sur- 
 rounded by several turns of the rubber plaster, 
 which is then cut transversely. 
 
 Fig. 78. — Brewer's Method of Clos- 
 ing Arterial Wounds by Special Rubber 
 Plaster: — The end of the rubber plaster be 
 neath the vessel is brought into contact with 
 the vessel by carrying the forceps grasping 
 this encl to the left — after which the longer 
 end is carried over to the right. 
 
 neighboring parts, where possible, are so sutured as further to support the 
 wounded vessel. The main wound is sutured without drainage. 
 
 ANEURISMORRHAPHY 
 
 OPERATION FOR RADICAL CURE OF ANEURISM BASED UPON 
 
 ARTERIORRHAPHY. 
 
 MATAS'S OPERATION. 
 
 Description. — The objects sought in this plastic procedure are the restor- 
 ation of the blood-current and the obliteration of the aneurismal sac. The 
 accomplishment of these objects is dependent for its success upon the readily 
 occurring union of the general endothelial lining, which, continuous with that 
 of the vessel, not only covers the common arterio-aneurismal orifice between 
 vessel and aneurismal sac, but the interior of the sac as well. In operat- 
 ing upon the saccular form of aneurism (Fig. 81) the aneurismal sac is laid 
 
126 
 
 OPERATIONS UPON THE ARTERIES. 
 
 open; — the aneurismal orifice is exposed and closed by suture in such a way 
 as not to interfere with the circulation through the main vessel — and the cavity 
 of the sac is completely obliterated by suturing its walls and overlying integu- 
 mentary parts to its floor. In operating upon the fusiform variety (Fig. 89) 
 in those cases where the walls are pliable and available, the circulation through 
 the part is restored by forming a new blood-channel by suturing the adjacent 
 floor of the sac over a temporarily placed rubber tube — which is withdrawn 
 just before tightening the final sutures — after which the aneurismal sac is 
 obliterated. In the fusiform variety, where the aneurismal walls are so bound 
 down or are of such consistency as to make it impossible to bring them together 
 to form a new channel; the two orifices are closed by suture and the restoration 
 
 of the blood-current is permanently aband- 
 oned (Fig. 91) — the sac, however, being ob- 
 literated in the usual manner. 
 
 Indications. — The method of restoration 
 of current is applicable in all cases where — 
 (a) a distinct sac exists (whether fusiform 
 or saccular); (b) where the proximal circula- 
 tion can be temporarily controlled; and (c) 
 where the sac-wall is sufficiently free and 
 pliable to be manipulated in the necessary 
 manner. Where the aneurismal sac is not 
 sufficiently free and pliable, the obliteration 
 of the current, as well as the sac, is necessary. 
 In the fusiform type of aneurism two open- 
 ings of the main vessel exist — one at either 
 end, generally with a groove connecting them. 
 Here a new blood-channel is built over a 
 rubber tube temporarily inserted into the 
 openings of the aneurism and lying in the 
 groove, or along the bed between the open- 
 ings — thus restoring the circulation. In the 
 saccular type of aneurism a single opening of 
 the main vessel exists. Here the margins of 
 the opening are brought together by suture, 
 leaving the artery intact and capable of carry- 
 ing on circulation. The operation differs 
 slightly in the different types. The opera- 
 tion, in general, will be described in the 
 case of saccular aneurisms — after which the 
 special features of the other types will be 
 pointed out. 
 The advantages of this method of operating are the following: — Restoration 
 of blood-current through the main vessel in favorable cases; — simpler tech- 
 nic; — less traumatism; — elimination of any ligaturing; — no disturbance of 
 structures in vicinity of aneurismal sac; — preservation of collateral circula- 
 tion; — usual prompt healing by the approximation of the integumentary 
 coverings to the floor of the sac. 
 
 Position; — Landmarks; — Incision. — Will be determined by the special 
 aneurism. 
 
 Operation. — (A) For the closure of the arterio-aneurismal opening 
 and the restoration of the blood-current in the artery, in saccular aneu- 
 risms : — (1) Where the position of the aneurism permits, the entire circulation 
 
 Fig. 80. — Aneurismorrhaphy: 
 ■ — First stage of operation. Ex- 
 posure of popliteal aneurism — a 
 fusiform aneurism laid open, show- 
 ing two openings and an intervening 
 groove. (Modified from Matas.) 
 
ANEURISMORRHAPHY. 
 
 127 
 
 through the limb is controlled by a rubber constrictor. Otherwise the aneu- 
 rism is exposed and the artery is controlled proximally by Matas's special 
 curved aneurism clamp-forceps, Crile's clamps, by a traction-loop around the 
 vessel, or by some other device. In cases where the entire circulation of the 
 limb cannot be preliminarily controlled, profuse bleeding may occur, on laying 
 open the aneurism, from the collaterals opening into the sac. (2) A free 
 median incision of the overlying parts is made — after which the adjacent 
 structures are retracted away from the presenting aspect of the aneurismal sac 
 (Fig. 80). (3) The sac is now incised from end to end — guarding against 
 sudden hemorrhage from one or more unknown collaterals, which may be 
 temporarily controlled by thrusting a gauze pack tightly into the aneurismal 
 sac. (4) All laminated fibrin is rubbed off the walls of the aneurism with gauze 
 — and the walls themselves are also briskly rubbed with gauze to promote 
 endothelial proliferation. (5) The main arterio-aneurismal opening is now 
 closed by two tiers of interrupted chromic gut sutures. The sutures of the 
 first tier pass through the margins of the orifice without entering the lumen of 
 the artery and without piercing the entire thickness of the aneurismal wall- 
 extending somewhat beyond both poles of the opening. They are planned 
 so as to afford broad serous surfaces for union (Fig. 81). A rubber tube, 
 
 Fig. 81. — Aneurismorehaphy: — Operation to restore current in saccular aneurism — 
 first stage. Placing of interrupted sutures through borders of arterial opening into aneurism — 
 leaving channel of vessel intact. (Modified from Matas.) 
 
 temporarily inserted within the lumen of the vessel, may be used to aid suturing, 
 if necessary — as in fusiform aneurisms. The lumen of the artery is thus not 
 interfered with, and the circulation is 'preserved. The sutures of the first tier 
 are now tied (Fig. 82), the knots being to one side of the median line — thus 
 approximating the two sides of an ellipse (Fig. 81) into a median straight 
 line (Fig. 82). A second or reinforcing tier of interrupted sutures is now 
 placed — not only strengthening the primary line of sutures against leakage, 
 but also ridging up the floor of the aneurismal sac and helping, thereby, to 
 obliterate it (Fig. 82). The details of the two tiers of suturing are better 
 
128 
 
 OPERATIONS UPON THE ARTERIES. 
 
 seen in Fig. 87. Both of these tiers of suture may be continuous (Fig. 86). 
 (6) The mouth of any collateral vessel opening into the sac is closed by two 
 
 Fig. 82. — Aneurismorrhaphy: — Operation to restore current in saccular aneurism — 
 second stage. The interrupted sutures through the borders of the arterial opening have been 
 tied. A second tier of interrupted sutures, overlying and outlying the first, is being placed 
 through the inner coats of the aneurismal sac — which, upon being tied, will bury the first tier 
 and ridge up the floor of the aneurism in the median line. (Modified from Matas.) 
 
 or more interrupted sutures placed as shown in Fig. 91, and tied as shown 
 in Fig. 92. (7) The tourniquet around the limb, or the special clamps upon 
 the vessel, is now removed and the efficiency of the suturing tested. All hemor- 
 
 
 
 ___>c> 
 
 i 
 
 
 
 /*t 
 
 
 
 F- 
 
 Fig. 83. — Aneurismorrhaphy: — Cross-sec^on of the parts involved in the operation where 
 the current is restored, together with the complete obliteration of the sac of the aneurism: — A 
 Integuments; B, Aneurismal sac; C, Walls of blood-channel; D, First tier of sutures, approxi- 
 mating walls of blood-channel; E, Second tier of sutures, approximating floor of sac over first 
 tier; F, F, Sutures through walls and into floor of aneurism, approximating former to latter; 
 G, Suture through margin of integuments and into floor of sac, over second tier; H, Restored 
 blood-channel. (Modified from Matas.) 
 
 Fig. 84. — Aneurismorrhaphy : — Cross-section of the parts involved in the operation where 
 the blood-channel, together with the aneurismal sac, are completely obliterated. The figures 
 are the same as in the above, except that H here represents the obliterated blood-channel. (Mod- 
 ified from Matas.) 
 
ANEURISMORRHAPHV. 
 
 129 
 
 rhage in the general wound is controlled by ligature. (8) The empty aneu- 
 rismal sac is next obliterated. This is accomplished by means of four sutures 
 placed in the manner shown in Fig. 88. Four interrupted sutures of chromic 
 gut, kangaroo-tendon, or silkworm gut are placed, as indicated in the 
 illustration, in the floor of the aneurism by means of an ordinary curved needle 
 or Reverdin needle, passing deeply into but not through the walls of the sac 
 (Fig. 88, A, A). Each one of the free ends of these four loops is now brought 
 out through the corresponding aspect of the outer wall (or roof) of the aneurism 
 and overlying integumentary parts, by means of a Reverdin needle (Fig. 88, 
 B, B), which is passed through the skin on into the aneurism through all the 
 
 Fig. 85. — Aneurismorrhaphy: 
 — Final stage of operation. The 
 walls of the aneurism-sac and the 
 integuments are sutured to the floor 
 of the sac over gauze rollers, thus 
 firmly approximating the former to 
 the latter. (Modified from Matas.) 
 
 Fig. 86. — Aneurismorrhaphy : — Operation to 
 restore current in saccular aneurism. In the present 
 instance both tiers of sutures are continuous — the first 
 has been placed and is being tightened — and the second 
 is being placed. The principles of the operation, other- 
 wise, are the same as in the corresponding operation 
 by interrupted sutures (Figs. Si and 82). (Modified 
 from Matas.) 
 
 intervening structures. These sutures are tightly tied over small gauze rolls — 
 thereby firmly infolding and compressing the roof of the aneurismal sac and 
 all overlying structures, to the floor of the sac and the central elevation, or 
 ridging, formed by the two tiers of suturing. The result of the tying of these 
 sutures and the consequent relation of the parts are shown in the diagrammatic 
 cross-section (Fig. 83). The two flaps thus inturned consist of aneurism-wall 
 and integumentary coverings — the approximation obliterating all dead space 
 between the wall of the sac and the integuments, on the one side, and the floor 
 of the sac, on the other. (9) The main wound is now closed by a median 
 line of interrupted sutures (Fig. 85). 
 
l 3° 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Fig. 87. — Aneurismorrhaphy: — Showing in greater detail the steps of the last two illus- 
 trations (Figs. 81 and 82). All but two of the first tier of interrupted sutures have been placed 
 and tied. The second tier is being placed and is in the act of burying under the first tier and 
 ridging up the floor of the aneurism. (Modified from Matas.) 
 
 (B) For the closure of the arterio-aneurismal opening and the resto- 
 ration of the blood-current in the artery, in fusiform aneurisms : — The 
 
 preliminary and final steps are the same as just described. Owing to the 
 distance between the orifices which usually exists in fusiform aneurisms, and 
 
 Fig. 88. — Aneurismorrhaphy: — Operation to restore current in saccular aneurism — 
 third stage. The second tier of interrupted sutures is here shown tied. A, A, Placing interrupted 
 sutures, with curved needle, in floor of aneurism, preparatory to approximating the aneurism- 
 wall to the floor of the aneurism; B, B, Reverdin needle in act of drawing the sutures (just placed) 
 through the aneurism wall. (The final tying of these four sutures is shown in Fig. 83, F, F, 
 and Fig. 85.) (Modified from Matas.) 
 
ANEURISMORRHAPHY. 
 
 131 
 
 Fig. S9. — Aneurismorrhaphy : — Operation to restore current in fusiform aneurism. 
 Suturing borders of opening and of connecting groove over a temporary rubber tube — the ends 
 of which are seen projecting into the lumen of the vessel, at either end. The interrupted form 
 of suture is here shown. (Modified from Matas.) 
 
 the inability to form a channel along this intervening distance without some 
 form of support, a rubber tube (the end of a catheter, for instance) is inserted 
 into these openings and made to occupy the groove which generally exists 
 between the two openings (Fig. 89). Over this tube the sac is sutured, as 
 
 Fig. 90. — Aneurismorrhaphy: — Operation to restore current in fusiform aneurism. 
 The interrupted sutures placed in the preceding figure have been tied at the two ends — 
 while those in the center are being held apart during the withdrawal of the rubber tube, 
 after which these also are tied. Some of the second tier of sutures are shown in place, ready 
 to be tied. (Modified from Matas.) 
 
132 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Fig. 91. — Aneurismorrhaphy: — Operation to obliterate openings and channel in fusiform 
 aneurism. All of the first tier of sutures is placed, and the lower half tied, obliterating the lower 
 opening and half of the channel. The lower half of the second tier is placed, but not tied. 
 Sutures are seen in the mouth of a collateral, opening upon the wall of the sac. (Modified 
 from Matas.) 
 
 in Witzel's gastrostomy (page 959). All the sutures are placed before any 
 are tied. The end sutures are then tied over the tube — when the tube is with- 
 
 Fig. 92. — Aneurismorrhaphy: — Operation to obliterate openings and channel in fusiform 
 aneurism — second stage. The second tier of suturing (which is here a continuous suture) is 
 shown, entirely concealing the first tier and all evidence of openings and channel. A, A, Placing 
 interrupted sutures, with curved needle, in floor of aneurism, preparatory to approximating the 
 aneurism wall to the floor of the aneurism; B, B, Reverdin needle in act of drawing the sutures 
 (just placed) through the aneurism wall. (The final tying of these four sutures is shown in 
 Fig. 83, F, F, and Fig. 85.) The closure of the mouth of a collateral vessel is shown in the wall 
 of the aneurism-sac. (Modified from Matas.) 
 
OPERATION FOR RADICAL CURE OF ARTERIOVENOUS ANEURISMS. 133 
 
 drawn through the separated middle sutures, which are then tied (Fig. 87). 
 The operation is completed in the general manner — a second tier of sutures 
 being used here as elsewhere. 
 
 (C) For the obliteration of both blood-channel and aneurismal sac, 
 in fusiform aneurisms : — In cases of fusiform aneurism where it is found that, 
 owing to such circumstances as the adhesion of the floor of the aneurismal sac 
 to some unyielding structure, or owing to some pathologic change preventing 
 the necessary manipulation of the sac-wall, a new blood-channel cannot be 
 made, nothing remains but to close both arterio-aneurismal orifices and the 
 intervening groove without attempting to bring about the restoration of 
 circulation. In these cases both the orifices and intervening groove are closed 
 by a double tier of sutures, placed in the ordinary manner (Figs. 91 and 92), 
 after which the sac is treated in the usual way. The cross-section of an 
 obliterating operation of this nature is shown in Fig. 84. 
 
 Comment. — (I) Union takes place between the serous surfaces lining 
 the sac (the arteries being mesoblastic in origin). (2) The sutures should 
 take strong hold in the walls of the sac. (3) Superfluous sac-wall is to be 
 excised. (4) The perisaccular structures should not be disturbed more than 
 absolutely necessary, as most of the nourishment of the sac comes to it through 
 these structures. (5) Firm pressure should be applied in the outer dressing 
 over the aneurism site, to aid in keeping in contact the parts held by the 
 transfixion sutures. (6) In the case of the limbs, the part is to be elevated 
 and kept swathed in cotton-batting to maintain the temperature of the part, 
 applying artificial heat if necessary. 
 
 OPERATION FOR THE RADICAL CURE OF ARTERIOVENOUS ANEU- 
 RISMS, WITH PRESERVATION OF CIRCULATION IN ARTERY AND 
 VEIN. 
 
 MATAS-BICKHAM OPERATION. 
 
 Description. — This technic consists, as suggested by the author, in the 
 application to the arteriovenous type of aneurisms of the method of radical 
 cure which Matas applies to ordinary arterial aneurisms- — with the modifications 
 necessitated by the special forms of arteriovenous aneurisms, thus preserving 
 the integritv of both artery and vein and sparing the patient the great risk 
 attendant upon the loss of circulation through one or both of these vessels. 
 Where this form of operation can be carried out, the composite aneurismal sac 
 is exposed — its double blood-supply controlled — the sac incised — the openings 
 of artery and vein sutured- — and the common sac either obliterated by approxi- 
 mation of its walls, as carried out in the operation of aneurismorrhaphy — or 
 the sac is excised in whole or in part and the orifices closed by suturing. 
 
 Indications. — In all cases — (a) where a distinct sac exists;- — (b) where 
 the arteriovenous circulation through the aneurism can be controlled prior 
 to incising the sac; — and (c) where the structure and surroundings of the sac 
 will admit of the necessary manipulations. It is a known fact that the nature 
 of arteriovenous aneurisms cannot always be determined clinically, and are 
 often only discovered when the site has been exposed by operation. But it 
 would be warrantable to expose the aneurism in every appropriate case and, 
 where feasible, make an attempt to preserve the circulation through both 
 vessels. 
 
 Position; — Landmarks; — Incision. — Determined by the special opera- 
 tion. 
 
134 
 
 OPERATIONS UPON THE ARTERIES. 
 
 Operation. — (A) Upon the Varicose-aneurism Type of Arterio- 
 venous Aneurisms, with Preservation of the Sac— In these cases an 
 aneurismal sac intervenes between artery and vein, communicating with 
 both vessels by separate mouths (Fig. 93). After temporarily controlling 
 
 Fig. 93. — Varicose-aneurism Type of Arteriovenous Aneurism of Left Common 
 Femoral Artery and Vein — showing the Application to this Class of Aneurisms of the 
 Matas Method of Operating upon Ordinary Aneurisms: — The opening of the femoral 
 artery into the common aneurismal sac is shown on the right, with interrupted Lembert gut 
 sutures in position, ready to be tied. The opening of the femoral vein is seen on the left, with 
 similar Lembert sutures in position. On the left of the sac two gut sutures are in the act of 
 being placed, which, when tied, will approximate the roof of the sac (including skin and inter- 
 vening tissues, which are not here shown) to the floor of the sac. Similar sutures will approxi- 
 mate the roof and floor of the sac upon the right. (From Bickham, "Annals of Surgery," 
 May, 1904.) 
 
 the circulation through the involved vessels, lay open the intervening aneuris- 
 mal sac, locate both the arterial and venous openings into it, and close them 
 off by fine chromic gut Lembert sutures applied interruptedly, followed 
 by obliteration of the sac by suturing its roof, including the overlying parts, 
 to its floor. It is to be remembered that an endothelial layer usually lines 
 the cavity of an arteriovenous aneurism, and is especially apt to be present 
 near the openings into the sac; although the absence of an endothelial lining 
 
OPERATION FOR RADICAL CURE OF ARTERIOVENOUS ANEURISMS. 135 
 
 would not seem to be a contraindication to the application of this method, 
 as the surfaces of even a pure connective-tissue sac could be roughened by 
 curettement or friction to promote adhesion of its walls. This lechnic is 
 shown in Fig. 93. 
 
 (B) Operation upon the Aneurismal-varix Type of Arteriovenous 
 
 Fig. 94. — Aneurismal-varix Type of Arteriovenous Aneurism of Left Common 
 Femoral Artery and Vein: — The opening of the femoral artery into the varicosed vein is 
 shown, with interrupted Lembert gut sutures in position, ready to be tied. The longitudinal 
 incision in the vein, for approaching the arteriovenous opening (and which is here made somewhat 
 unnecessarily long) is shown in the act of being closed by two methods of suturing — above, by 
 the continuous Lembert of the outer coats — below, by interrupted ordinary sutures of the outer 
 coats. (From Bickham, "Annals of Surgery," May, 1904.) 
 
 Aneurisms, with Preservation of the Sac. — In these cases there is a vari- 
 cosed dilatation of a vein, caused by the force of the arterial circulation poured 
 into it through a direct communication from an artery, without an intervening 
 aneurismal sac (Fig. 94). After temporarily controlling the circulation 
 through the involved vessels, make a longitudinal incision through the enlarged 
 and varicosed vein for as limited an extent as would seem to afford approach 
 
i3 6 
 
 OPERATIONS UPON THE ARTERIES. 
 
 to the opening into the vein, and so placed as to lie directly opposite this 
 communicating opening from the artery, retract the lips of this wound in the 
 vein, thus exposing the interior of the vein and the arterial communication, 
 suture up the opening of the artery into the vein in the usual Matas manner, 
 and then close the incised vein by a continuous lateral suture of, approxi- 
 mately, the Lembert type. Fig. 94 illustrates tin's technic. Owing to the 
 fact, in aneurismal-varix cases, that foreign material will be left in contact 
 with the venous current by this manner of suturing (which does not apply in 
 the varicose-aneurism cases), with the consequent theoretical possibility of 
 
 U^" 
 
 Fig. 95. — Same as Fig. 94, showing a continuous Lembert gut suture, which, having been 
 passed through the outer coats of the thickened vein at the angle of junction of vein and artery, 
 and knotted, is passed on between the coats of the vein until its varicosed cavity is entered very 
 near one end of, and immediately above, the first tier of interrupted sutures — and is then made 
 to bury i 1 this first tier and itself in continuous Lembert fashion — and, emerging at the opposite 
 angle of junction of vein and artery, is tied in the same manner as at its entrance. (This suture 
 is not yet tightened throughout.) (From Bickham, "Annals of Surgery," May, 1904.) 
 
 pieces of the suture forming emboli, it would be well to use very fine gut for 
 this suture, and to tie very small, closely cut knots. Or it would be better 
 still to bury-in the row of interrupted Lembert sutures, closing off the arterial 
 opening, by means of a continuous buried suture introduced from without 
 entirely through the vein, at one of the angles of junction of artery and vein, 
 passing in continuous Lembert fashion above the interrupted sutures, through 
 part of the thickness of the wall of the vein, and out through the entire thickness 
 of the vein at the opposite angle of junction of artery and vein, in very much 
 the same manner as a subcuticular suture is passed, and so placed that the 
 suture throughout its entire length and its points of entrance and exit to and 
 
OPERATION FOR RADICAL CURE OF ARTERIOVENOUS ANEURISMS. 137 
 
 from the vein is also buried, which, in the case of a thickened, varicosed vein 
 would be easier of accomplishment than in a normal vein. This second tier 
 of suturing is shown in Fig. 95. 
 
 (C) Operation upon the Varicose-aneurism Type of Arteriovenous 
 Aneurisms, with Excision of the Sac. — More recently, successful artery- 
 suturing and vein-suturing have been demonstrated, and these principles may 
 be applied to arteriovenous aneurisms. In those cases of the varicose- 
 aneurism type where both arterial and venous circulation can be controlled 
 proximally to the sac, and the sac exposed by dissection, the aneurismal sac 
 
 Fig. 96. — Varicose-aneurism of Left Common Femoral Artery and Vein, treated 
 by Excision of the Sac, followed by Suturing of the Openings in the Vessels: — Upon 
 the right, a small elliptical piece of the sac is shown connected with the arterial opening, with 
 the first tier of interrupted Lembert gut sutures in position, ready to be tied. Upon the left, 
 a similar elliptical piece of sac has been left connected with the venous opening. The first 
 row of Lembert sutures has been tied, and a second tier of ordinary sutures through all the coats 
 is being applied, burying in the first tier. Fig. 96 is the same as Fig. 93, with the sac excised. 
 (From Eickham, "Annals of Surgery," May, 1904.) 
 
 may, in appropriate cases, be excised up to very near the arterial and venous 
 openings into it, and these openings then closed by a row of interrupted 
 Lembert gut sutures, followed by a second burying-in row through the free 
 margins of the small portion of the sac left around the jug-like opening into 
 the artery and vein, as shown in Fig. q6. 
 
 (D) Operation upon the Aneurismal-varix Type of Arteriovenous 
 Aneurisms, with Excision of the Sac. — In those cases of the aneurismal- 
 varix type, where, similarly, both the arterial and venous circulation may be 
 arrested proximally to the arteriovenous communication, and this site of 
 
138 
 
 OPERATIONS UPON THE ARTERIES. 
 
 communication be exposed by dissection, the artery and enlarged vein may, 
 in appropriate cases, be severed from each other by an incision through the 
 connecting opening, made parallel with artery and vein, and these openings 
 closed by lateral suture with fine gut or silk, the openings left by the incision 
 of the connection between artery and vein being, in the aneurismal-varix, less 
 jug-like and with less free margin than in the varicose aneurism. This technic 
 
 Fig. 97. — Aneurismal-varix of Left Common Femoral Artery and Vein, treated 
 by Severance of Vessels from each other, followed by Suturing of their Openings: — 
 On the right, interrupted gut sutures are shown passing through the outer coats of the artery, 
 ready to be tied. On the left, a continuous Lembert gut suture through the outer coats is shown 
 closing the venous opening. Fig. 97 is the same as Fig. 94, with the vessels cut apart. (From 
 Bickham, "Annals of Surgery," May, 1904.) 
 
 is shown in Fig. 97. If necessary, these openings left by the liberating 
 incision could be trimmed into elliptical shapes. 
 
 Comment. — While recognizing that it is ideal to excise the aneurismal 
 sac of a varicose aneurism and suture up the openings in the artery and vein, 
 and to cut apart artery and vein in an aneurismal-varix and somewhat similarly 
 suture up the openings in the vessels which the severing of the common con- 
 nection between them has left, leaving the circulation intact in both class of 
 cases — yet there must occur cases in which there is difficulty of satisfactorily 
 exposing the parts, or where there is difficulty in, and contraindication to, 
 the removal of the sac of a varicose aneurism, or the cutting apart of artery 
 and vein in an aneurismal varix- — and in such cases the Matas method would 
 
OTHER OPERATIONS FOR RADICAL CURE OF ANEURISM. 139 
 
 seem to be a desirable technic. And while one feature is common to all of 
 these more modern methods, and that is, the retention of the circulation through 
 artery and vein, yet it may be questioned where, from the circumstances of 
 the case, it is optional, whether the Matas method would not really be preferable 
 in dealing with the varicose aneurism type of cases; for it would seem the 
 suturing together of the roof and floor of the sac would strengthen the suturing 
 of the arterial and venous openings into the sac and make secondary hemor- 
 rhage less likely, and also accomplish the end with less traumatism. 
 
 LIGATION FOR RADICAL CURE OF ANEURISM. 
 
 Description. — Several methods of applying ligatures for the radical cure 
 of aneurism have been adopted — either as a means alone or in conjunction 
 with other steps. 
 
 Methods. — (I) Antyllus's Method ("Old Method"): — The sac is incised 
 — the clots are turned out — and the involved artery ligated above and below 
 the sac. (2) Anel's Method: — Ligature of the involved artery just above 
 (proximal to) the sac. (3) Hunter's Method: — Ligature of the main vessel in- 
 volved at some distance above (proximal to) the sac, so that one branch, at 
 least, intervenes between sac and ligature, thereby only partly cutting off the 
 circulation through the sac. (4) Brasdor's Method: — Ligature of the main 
 artery involved beyond (distal to) the sac, entirely cutting off the circulation 
 through the sac. (5) YVardrop's Method: — Ligature of one or more of the 
 distal branches. (6) Extirpation: — Ligature of the main vessel (and collateral 
 branches) above and below the sac, with extirpation of the aneurism — with 
 or without opening the sac. 
 
 OTHER OPERATIONS FOR RADICAL CURE OF ANEURISM. 
 
 Acupuncture. — A method of treating aneurisms by the introduction of 
 long needles into their sacs. Several long, fine needles are simultaneously 
 introduced, by the safest route, through overlying integuments, into and 
 through the wall of the aneurism — and on beyond, until in contact with the 
 opposite wall. Here they are allowed to quietly rest for several hours, and 
 are then withdrawn. Repetition of this process may be resorted to upon 
 successive occasions. Coagulation is thus favored. 
 
 Needling (Macewen's Operation). — The introduction of one or two 
 long needles into the sac, with irritation of its wall. A long, fine needle is 
 introduced, by the safest route, through skin and connective tissue, into and 
 through the wall of the aneurism — and is pushed on until in contact with 
 the inner surface of the opposite wall. The wall of the aneurism is then 
 gently irritated by a process of scratching, by means of the point of the needle 
 — which is then withdrawn. The interior of the sac should be evenly irritated 
 throughout, or at different sites consecutively. This direct irritation of the 
 wall should be only great enough to produce a reparative exudation together 
 with a deposit of fibrin — and thus white thrombi are formed upon the surface 
 of the sac. Two or more needles may be used simultaneously in a large sac, 
 and several hours may be consumed in the process — and their use repeated 
 upon successive occasions. 
 
 Introduction of Wire. — A fine cannula is introduced, by the safest route, 
 through skin, fascia, and wall of aneurism, into the cavity of the sac. Through 
 this cannula several vards of fine wire (according to size of aneurism) are 
 
140 OPERATIONS UPON THE ARTERIES. 
 
 introduced and left, the cannula being withdrawn. Cure is effected by the 
 clotting of blood upon this wire meshwork. Catgut, silk, horsehair, and the 
 like have been used — but silvered copper wire has proved the most satis- 
 factory. 
 
 Comment. — The method of aneurismorrhaphy is preferable to all others 
 in those cases where the circulation can be controlled prior to opening the 
 sac. Second to this, or where this method cannot be applied, one of the 
 methods of ligation, with or without extirpation of the sac, should be used. 
 
 ARTERIAL FORCIPRESSURE. 
 
 Definition. — Pressure of artery by artery-clamp forceps. 
 
 Description. — This is the ordinary method of controlling hemorrhage 
 by seizing arteries in a wound, upon an amputation stump or in the course 
 of any operation — by means of clamp or hemostatic forceps. The forceps 
 are allowed to remain in situ for a period of time after their application, but 
 are not twisted upon their axis (as in the following operation). The hemostat 
 should grasp the bleeding end of the artery, and as little else as possible. 
 Where circumstances allow, the artery to be subjected to forcipressure should 
 be cleared of surrounding connective tissue by a stroke or two of the knife, 
 especially in the case of the larger vessels. In the case of the smaller arteries, 
 the forceps may be removed and nothing further done, with fair certainty 
 that no further bleeding will occur from the crushed vessels. In the case 
 of the larger arteries, a catgut ligature should be applied over the point of the 
 forceps, just prior to their removal (Fig. 293, B). 
 
 Comment. — In some operations, as in vaginal hysterectomy by the 
 clamp method, the forceps are left in the wound for twenty-four or forty- 
 eight hours or longer. 
 
 ARTERIOSTREPSIS. 
 
 Definition. — Torsion of an artery by means of artery-clamp forceps. 
 
 Description. — The operation consists in the seizing of the divided end 
 of an artery with forreps and twisting it through two or three revolutions, in 
 the direction of its long axis — causing a rupture and retraction of its inner 
 and middle coats wdthin the outer coat. A clot forms and organizes upon 
 and in the roughened inner coats and is protected by the outer coat. The 
 twisting should cease short of causing a complete severance of the end of the 
 artery. This is the common method of arresting hemorrhage from the 
 smaller vessels bleeding in a wound or upon the surface of an amputation 
 stump, and its use should be confined to such vessels, although the femoral 
 artery has been successfully controlled by torsion (occurring in accidents). 
 The technic differs slightly in the application of arteriostrepsis to small and 
 medium vessels: (a) Upon Smaller Arteries: — seize the extremity of the bleed- 
 ing vessel with catch-forceps, including as little tissue, other than the sheath 
 of the artery, as possible — draw it out from its connections and twist it around 
 two or three times and release the hold, (b) Upon Medium Arteries: — seize 
 the extremity of the severed artery, in its long axis, with catch-forceps, and 
 draw the vessel out of its sheath for about 1.3 to 2 cm. (J to f inch). With 
 a second pair of catch-forceps, grasp the bared artery about 1.3 cm. (^ inch) 
 from its extremity, at a right angle to its long axis, and hold steadily. Then 
 
TREATMENT OF VASCULAR NEOPLASMS. 141 
 
 rotate the vessel two or three times by means of the terminal forceps, and 
 let go. Thus the proximal forceps prevent the artery from being twisted in 
 its sheath, which would sever its vasa vasorum in their passage from the 
 sheath to the arterv. Only that portion of the artery, therefore, between the 
 clamps is twisted. Ligation is generally to be preferred to arteriostrepsis. 
 
 THE TREATMENT OF VASCULAR NEOPLASMS BY INJECTION OF 
 WATER AT HIGH TEMPERATURE. 
 
 WYETH'S OPERATION. 
 
 Description. — This method of treatment consists in the injection into 
 the substance of vascular neoplasms (angeiomata) of water at a temperature 
 of from 190° to 212 F. and over — the object being immediately to coagulate 
 the blood and albuminoids of the tissues. The vascular tumors thus far 
 treated by the author of the operation have been arterial angeiomata (cirsoid 
 aneurisms), capillary angeiomata ('' mother's marks"), and venous angeiomata 
 (cavernous nawi). 
 
 Instruments. — Syringe with metallic cylinder and an adjustable piston, 
 and needles of various sizes. The water is usually gotten from some im- 
 mediately adjacent vessel in which it has come to a boil, and under all aseptic 
 precautions. In cirsoid aneurisms and in the larger cavernous narvi, where 
 the water should be kept at the boiling-point during the use of the needle 
 and syringe, the author of the operation has devised a long metallic instru- 
 ment under the cylinder of which a Bunsen burner is held during operation. 
 
 Operation. — (1) The region of the injection is rendered aseptic in the 
 usual manner. The operation is done under complete narcosis. The quan- 
 titv and temperature of the water will vary according to the size and nature 
 of the growth. (2) In arterial and venous angeiomata the needle is carried 
 deeply into the substance of the growth and from 30 to 60 minims of water 
 are thrown out in one site — the needle is then withdrawn from 1.3 to 2.5 
 cm. (J to 1 inch) and about the same amount injected — and the same steps 
 repeated in different sites until the whole tumor is solidified. While using 
 water of a temperature sufficiently high to coagulate the blood and albu- 
 minoids of the neighboring tissues, it should not be delivered into the part 
 so exceedingly hot nor with such pressure as to cause subsequent sloughing 
 of the overlying parts. Evidence of sufficient distention of the part to dis- 
 continue the injection in that particular site is given by slight bleaching 
 of the skin. (3) In capillary angeiomata, especially upon delicate parts, 
 water a little loelow boiling (about 190 F.) should be used — and only about 
 two to six minims thrown in at a single puncture — beginning at the periphery 
 of the growth. Sloughing is more apt to occur in the capillary angeiomata. 
 The injection may be repeated in from seven to ten days, if necessary. (4) 
 A surgical dressing is then applied and the part kept at rest. 
 
 Comment. — (i) Especial care is advised in the cases of angeiomata of the 
 neck and scalp, because of oedema. (2) No more than from five to six 
 ounces should be injected at one sitting in the largest growths and very much 
 less in most cases. (3) Sloughing of the tissues from the action of the boiling 
 water deposited in their midst is possible, and is an important consideration 
 in localities when this occurrence would be functionally or cosmetically serious. 
 
CHAPTER II. 
 
 OPERATIONS UPON THE VEINS. 
 
 PHLEBOTOMY. 
 
 Definition. — Incision of a vein, or venesection. A method, now rarely 
 practised, of depletion by bleeding, for its effect upon the system. One of 
 the veins of the elbow is usually selected. 
 
 Indications. — Pulmonary engorgement; engorgement of the right heart; 
 many inflammatory states in sthenic persons. 
 
 Preparation. — Bend of elbow shaved. 
 
 Position. — Patient, holding arm extended and abducted, sits upright, 
 that warning by approaching syncope may be given. Surgeon stands in 
 front and to right of either arm. 
 
 Instruments and Accessories. — Lancet or bistoury; fillet or constrictor; 
 round object to grasp (roller bandage); a graduated "bleeding-bowl" or 
 measure; gauze compress; bandage. 
 
 Operation. — Apply the constrictor around the lower third of the arm, 
 that the return venous flow may be obstructed and veins about the elbow 
 made prominent, while not firmly enough to obstruct the arterial flow. The 
 grasping and manipulating of the fingers about some object will aid the 
 distention of the veins. The most prominent vein at the bend of the elbow 
 is now selected. The median basilic vein (which is crossed by the internal 
 cutaneous nerve and is parallel with and separated from the brachial artery 
 by the bicipital fascia) is generally chosen — because of its greater prominence, 
 and because of being steadied by the underlying bicipital fascia. The median 
 cephalic vein (which is covered by skin and fascia alone and rests upon the 
 external cutaneous nerve) is often chosen — and is also sometimes the more 
 prominent. The vein is steadied by pressure of the left thumb just below 
 the intended incision. The lancet or bistoury, with its back to the arm, is 
 thrust through the skin over the vessel, and into the distended vein beneath 
 — and is made to cut its way upward and outward at a single stroke — cal- 
 culating to sever, in an oblique direction, about two-thirds of the vein. Upon 
 removing the thumb, the bleeding is allowed to continue until approaching 
 faintness indicates a sufficient loss — when the constrictor is removed, the 
 gauze pad placed over the wound, and a figure-of-eight bandage applied 
 to the elbow. 
 
 Comment. — (i) If bleeding continue, the vein is to be entirely severed 
 — and the wound may even be enlarged and the vessel doubly ligated. (2) 
 The internal saphenous vein may also be used. 
 
 PHLEBORRHAPHY. 
 
 Definition. — The suture of a wound in a vein, without occluding the 
 caliber of the vessel. 
 
 142 
 
LATERAL LIGATION OF VEINS. 
 
 143 
 
 Indications. — Where, in the case of a limited wound to one of the larger 
 veins, it is desired to control hemorrhage without permanently destroying 
 the function of the vein by transverse ligation — and where the wound is too 
 long for lateral ligation. 
 
 Operation. — Having well exposed the vein and controlled the hemorrhage 
 from the vessel by distal compression (by constrictor, digital compression, 
 or temporary ligature), one of the lips of the wounded vein is steadied with 
 fine forceps,' while a fine needle, armed with finest catgut, pierces this lip, 
 including, if possible, only the external and part of the middle coat. The 
 opposite lip is similarly steadied and similarly pierced, in the opposite direction 
 
 Fig. 98.— Phlebokrhaphy:— Forceps are seen everting lip of wound for passaj 
 
 interrupted sutures. 
 
 of needle and 
 
 (penetrating part of the middle and the entire thickness of the outer coat). 
 By tying the ligatures carefully, the two lips are brought into even apposition. 
 Interrupted sutures, closely applied, will more safely repair the wound than 
 continuous suture (Fig. 98). 
 
 Comment. — This method is especially applicable where (a) the wound 
 is longitudinal (and therefore the lips tend to lie parallel), and (b) where 
 the wound extends in any one direction a distance greater than equivalent 
 to the diameter of the lumen. Sometimes instead of approximating lip to 
 lip, the edges of the wound are sutured upon themselves. 
 
 LATERAL LIGATION OF VEINS. 
 
 Description. — The application of a ligature to the wall of a vein for 
 the purpose of closing a wound in the vein without obliterating its lumen. 
 Indications. — Wound of one of the larger veins, where it is desired to 
 
144 OPERATIONS UPON THE VEINS. 
 
 control hemorrhage without destroying the function of the vein by transverse 
 ligation. 
 
 Operation. — Having controlled hemorrhage and brought the vein well 
 into the field of operation, seize the two lips of the wounded vein in a single 
 bite of a pair of dissecting forceps — draw them outward from the wall of 
 the vein in the form of a small cone (whose apex is formed by the forceps) — and, 
 around the base of the cone, tie, with a reef-knot, a ligature of fine chromicized 
 catgut, relaxing the tension upon the cone at the moment of tightening the 
 
 F'&- 99- — Lateral Ligation of a Vein : — Forceps are shown drawing outward and puckering 
 together the wounded lateral wall of a vein, around which a ligature is being tied. 
 
 knot — and thus throwing into folds the walls of the rent in the vessel very 
 much as one puckers together the mouth of a sac with a draw-string. The 
 ligature is cut short and the temporary compression relaxed — and the wound 
 closed as in an ordinary ligation (Fig. 99). 
 
 Comment. — This method is applicable where the wound does not extend 
 in any one direction a distance equivalent to the diameter of the lumen. 
 Transverse wounds gape more than longitudinal ones and are thus especially 
 suitable for this form of ligature. 
 
 TRANSVERSE LIGATION OF VEINS. 
 
 Description. — The ordinary ligation of a vein (in contradistinction to 
 lateral ligation). 
 
 Indications. — Wounds; arteriovenous aneurism; simple and suppurative 
 phlebitis; thrombosis; angeiomata. 
 
 Operation. — As for ligation of arteries, in general principle. 
 
 TEMPORARY LIGATION OF VEINS. 
 
 Description. — As for same operation upon arteries (page 118). 
 Indications. — As in temporary ligation of an artery (e. g., temporary 
 
PHLEBECTOMY. 145 
 
 ligation of internal jugular vein in removal of tumor of neck — or while ligating 
 or suturing a wound of the vein). 
 
 Operation.— Same, practically, as for the corresponding operation upon 
 the arteries (page 118). 
 
 VENOUS LIGATION EN MASSE. 
 
 Description. — For parenchymatous hemorrhage. 
 
 Operation. — Practically identical with intermediate ligation, or ligation 
 en masse, described under Arteries (page 118). 
 
 VENOUS FORCIPRESSURE. 
 
 Description. — A method of control of venous hemorrhage, corresponding 
 with arterial forcipressure (page 140) — though of more limited application. 
 
 PHLEBOSTREPSIS. 
 Description. — Corresponding with arteriostrepsis (page 140). 
 
 ACUPRESSURE OF VEINS. 
 
 Description. — Pressure of vein by needle — the pressure being applied 
 directly or indirectly. Rarely resorted to at present. Formerly much used 
 for varicose veins, nasvi, and venous hemorrhage. 
 
 Operation. — Several methods of acupressure exist, differing in but minor 
 details. The following is the most generally applicable method : The needle 
 (or pin) enters the skin near the involved vein — passes under the vein as closely 
 as possible — and emerges from the skin on the opposite side. Over this 
 needle, in a figure-of-eight fashion, a silk ligature is wound — thus compressing 
 the vein between needle and ligature. 
 
 PHLEBECTOMY. 
 
 Description. — Excision of a vein, in whole or in part. 
 
 Indications. — The usual causes for which veins are removed are vari 
 cosity (e. g., excision of varicosed veins of leg, or of a varicocele) and throm- 
 bosis, especially suppurative (e. g., excision of internal jugular for suppurative 
 thrombosis following middle-ear disease). 
 
 Operation. — As illustrative of the technic of phlebectomy in general, 
 partial excision of the internal saphenous will be described for varicosity 
 of that vein and its branches — the operation consisting in the total removal 
 of sections of the vein and its branches at intervals along its course. (1) 
 The site and course of the varicose veins are previously marked with nitrate 
 of silver stain (on the preceding day, to allow of darkening), that the land- 
 marks may not be lost during operation. The limb is shaved. An Esmarch 
 is generally used to control hemorrhage. (2) Over the course of the vein 
 (or slightly to one side, or obliquely crossing it) incisions of from 8 to 15 cm. 
 
146 OPERATIONS UPON THE VEINS. 
 
 (3 to 6 inches) are made at intervals — extending, if necessary, from the inner 
 side of the foot to the saphenous opening in the thigh. These incisions are 
 especially placed over the most marked groups of veins — and those nearer 
 the saphenous opening are usually the first attacked. The skin and bands 
 of fibrous tissue binding down the vein are divided and the involved veins 
 exposed. The vein and its branches are entirely isolated to the extent of 
 the incision, by blunt and sharp dissection. The vein is then gently drawn 
 upon, so as to bring into the open wound as much of itself and branches as 
 possible — when it is gut-ligatured at both ends, each branch being also liga- 
 tured — after which the main vein and its branches are cut away. This site 
 of operation is then packed with gauze, until removal at all indicated sites is 
 accomplished — to allow of cessation of all bleeding before suturing. (3) 
 The edges of the skin wound are then sutured with silk, or silkworm-gut — 
 after which the limb is dressed, immobilized, and slightly elevated. 
 
 Comment. — (1) The removal of the vein in sections appears to give as 
 good, or better, results as the attempt to remove the entire vein. (2) Avoid 
 wounding the veins in operation, which increases the difficulties. (3) Avoid 
 including a nerve filament in the ligature, which has caused much subsequent 
 pain. 
 
 INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. 
 
 Description. — Injection of normal salt solution into the venous circula- 
 tion. 
 
 Indications. — Hemorrhage; shock; sepsis; suppression of urine; and other 
 conditions. 
 
 Preparation of Normal Salt Solution. — The physiological salt solution 
 for man is a mixture of 0.6 of 1 per cent, of sodium chlorid in water (approx- 
 imately, one dram of sodium chlorid to one pint of water). This mixture is 
 to be sterilized and used at a temperature of 115 to 120 F. — being allowed 
 to pass from an elevated funnel or jar through a rubber tube and special 
 cannula into the vein. The salt may be sterilized first — or the solution may 
 be sterilized after preparation. The operation is conducted aseptically 
 throughout. 
 
 Preparation. — Patient's elbow is shaved and protected by aseptic dressing 
 (if occasion allow). 
 
 Position. — Patient recumbent; arm extended, abducted and supine. 
 Surgeon on right side of both arms — or on right side of right, cutting from 
 above; and on left side of left, cutting from below. 
 
 Instruments and Accessories. — Scalpel; dissecting forceps; artery- 
 clamp forceps; funnel; rubber tube; bulbous-pointed cannula; aneurism- 
 needle; ligature; suture; needle and holder; constrictor for arm; gauze com- 
 press, cotton and bandage. 
 
 Operation. — The most prominent vein at the bend of the elbow is chosen 
 (see Phlebotomy, page 126). If the vein be prominently marked, incise 
 directly over and parallel with it. If not marked, incise obliquely across 
 the known course of the- median basilic vein, the incision running parallel 
 with the direction of the bicipital fascia. Proceed carefully until the vein is 
 located. Expose from 2.5 to 4 cm. (1 to i| inches) of the vein. Pass two 
 catgut ligatures beneath the vein, about 2.5 cm. (1 inch) apart — and tie the 
 distal one permanently (Fig. 100). With a pair of sharp-pointed scissors, 
 curved on the flat, an oblique incision is made through one-half of the vein, 
 between the two ligatures, the apex of the "V" pointing distally. Into this 
 
INTRAVENOUS INFUSION OF NORMAL SALT SOLUTION. 
 
 147 
 
 oblique opening into the vein, the cannula (after seeing that no air is in the 
 instrument) is introduced — and the proximal ligature is tightened about it 
 with a friction-knot. Through this is allowed to flow, by static pressure, as 
 much fluid as is indicated (generally from one to six pints). The cannula 
 is then withdrawn — the proximal ligature is tightened and tied permanently 
 
 C- -n— U- 
 
 Fig. 100. — Intravenous Infusion of Normal Salt Solution : — A, Bandage tourniquet ; E, 
 Median basilic vein; C, Distal (to heart) ligature tied about vein; D, Proximal (to heart) ligature 
 loosely placed and ready to be tied about vein ; E, Forceps grasping tongue of wound in vein just 
 made by curved scissors ; F, tip of cannula about to enter vein and around which ligature will be tied ; 
 G, Stop-cock. 
 
 — and the vein completely severed. The wound is sutured and the dressing 
 applied. 
 
 Comment. — The fluid may be thrown into an open vein in a stump — 
 or any convenient vein in a wound may be opened. The basilic vein itself 
 may be used — or the internal saphenous. Szumann's infusion solution con- 
 sists of six parts of sodium chlorid, one part of carbonate of soda, and one 
 thousand parts of sterilized water, heated to a temperature of no° to 112 F. 
 Szumann's formula may be expressed as follows: 
 
 R. Sterilized water 32 oz. 
 
 Sodium chlorid 1 ^2 dr. 
 
 Sodium carbonate 15 gr. 
 
 Mix and heat to 1 io° or 1 1 2° F. 
 
CHAPTER III. 
 
 OPERATIONS UPON THE LYMPHATIC GLANDS 
 
 AND VESSELS. 
 
 SURGICAL ANATOMY OF THORACIC DUCT. 
 
 Course and Relations. — (i) Abdominal portion: — (from origin to dia- 
 phragm); — Begins in abdomen at receptaculum chyli, on anterior surface 
 of second lumbar vertebra, lying behind and to right side of aorta and between 
 aorta and right crus of diaphragm. At aortic opening in diaphragm (in 
 front of twelfth dorsal vertebra) it still lies to right of aorta and has vena 
 azygos major to its right. (2) Thoracic portion : — (from diaphragm to 
 superior thoracic opening) ; — Runs up posterior mediastinum between aorta 
 and vena azygos major, in front of sixth to twelfth dorsal vertebr&\ Opposite 
 to fifth dorsal vertebra it passes to left behind esophagus and aortic arch 
 to enter superior mediastinum, whence it emerges through superior thoracic 
 opening into root of neck, (a) In Posterior Mediastinum (from below 
 upward) — Anteriorly ; pericardium; esophagus; arch of aorta. Posteriorly ; 
 sixth to twelfth dorsal vertebras; anterior common ligament; right inferior 
 intercostal arteries; vena azygos minor (sometimes one of left middle inter- 
 costal veins and vena azygos tertia). Left; thoracic aorta. Right; vena 
 azygos major; right pleura, (b) In Superior Mediastinum; — anteriorly; 
 first part of left subclavian artery. Posteriorly ; upper dorsal vertebra? 
 (first to fifth.) Left ; left pleura. Right ; esophagus. (3) Cervical por- 
 tion : — (from superior thoracic opening to termination) ; — From superior 
 thoracic opening it ascends on left side of neck to level of seventh cervical 
 vertebra — curves thence downward, forward, and outward, arching over 
 apex of left pleura — passing in front of subclavian artery, scalenus anticus 
 muscle, vertebral vein — and behind left internal jugular vein, and behind 
 and then externally to left common carotid artery — and, receiving left jugular 
 lymphatic trunk, empties into left innominate vein at junction of left internal 
 jugular and left subclavian veins. 
 
 Course and Relations of Right Lymphatic Duct. — About 1.3 to 2 
 cm. (^ to f inch) in length — formed by union of subclavian and jugular 
 lymphatic ducts — passes downward and inward — and empties into venous 
 circulation at junction of right internal jugular and subclavian veins. 
 
 SUTURE OF THORACIC DUCT. 
 
 Description. — Suture of the thoracic duct is indicated in wounds of 
 the duct occurring from external injury, or in the course of an operation. 
 
 Operation. — The method of suturing the thoracic duct is similar to 
 that employed in suturing a vein (see Phleborrhaphy, page 142). Having 
 completed the technic of suturing the duct itself, the neighboring tissues 
 should be drawn over and sutured about the wound in the duct, to aid in 
 closing and reinforcing the sutured site — and the overlying skin should be 
 
SURGICAL ANATOMY OF AXTERO-LATERAL ASPECT OF NECK. 149 
 
 sutured throughout and pressure applied. Minimum nourishment should 
 be administered to the patient, to keep the duct as empty as possible until 
 union of the wound has occurred. 
 
 Comment. — If possible, the right duct should be similarly dealt with. 
 
 LIGATION OF THORACIC DUCT. 
 
 Description. — The thoracic duct, where completely severed by accident, 
 has been ligated, and recovery lias followed — although there has been a 
 question as to whether, in such cases, a branch of the main duct has not 
 existed and maintained the circulation. Suturing, however, is always prefer- 
 able to ligation, where possible. Where ligation is performed, the technic 
 is the same as that for ligating a vein (pages 143 and 144). 
 
 Comment. — The right lymphatic duct may also require ligation if its 
 divided ends be discovered in a wound. 
 
 SURGICAL ANATOMY OF ANTERO-LATERAL ASPECT OF NECK. 
 
 Boundaries of Antero-lateral Aspect of Neck. — Superiorly : lower 
 border of body of inferior maxilla, and imaginary line from angle of inferior 
 maxilla to mastoid process. Inferiorly : upper border of clavicle. Ante- 
 riorly : median line of neck. Posteriorly : anterior border of trapezius. 
 
 Subdivisions of Quadrilateral Surface of Neck. — (a) Anterior Triangle 
 — divided, by digastric muscle above and anterior belly of omohyoid below, 
 into submaxillary, superior carotid, and inferior carotid triangles, (b) 
 Posterior Triangle — divided, by posterior belly of omohyoid, into occipital 
 and subclavian triangles. 
 
 Anterior Triangle. — Boundaries, anteriorly: median line of neck, 
 from chin to sternum. Posteriorly : anterior margin of sternomastoid 
 muscle. Superiorly : lower border of body of inferior maxilla, and line 
 from angle of inferior maxilla to mastoid process (base). Inferiorly: at 
 sternum (apex). This triangle is subdivided into submaxillary, superior 
 carotid, and inferior carotid triangles. 
 
 Submaxillary Triangle. — Boundaries : Superiorly — lower border of 
 inferior maxilla, and line from angle of inferior maxilla to mastoid process. 
 Inferiorly — posterior belly of digastric and stylohyoid. Anteriorly — anterior 
 belly of digastric (or middle line of neck). Coverings: integument; super- 
 ficial fascia; platysma; deep fascia; branches of facial nerve; branches of 
 superficialis colli nerve. Floor: anterior belly of digastric; mylohyoid; 
 hyoglossus. Contents : Muscles — styloglossus, stylopharyngeus. Ligaments 
 — stylomaxillary (separating anterior from posterior part of triangle). Ar- 
 teries — external carotid, posterior auricular, temporal, internal maxillary, 
 mylohyoid branch of inferior dental, facial with submaxillary and submental 
 branches, internal carotid. Veins — internal jugular, facial, submaxillary. 
 Nerves — facial, pneumogastric, glossopharyngeal, mylohyoid branch of in- 
 ferior dental. Other Structures— parotid gland, submaxillary gland, lymph- 
 atic glands. 
 
 Superior Carotid Triangle. — Boundaries : Superiorly — posterior belly 
 of digastric. Inferiorly — anterior belly of omohyoid. Posteriorly — anterior 
 border of sternomastoid. Coverings: integument; superficial fascia; pla- 
 tysma; deep fascia; branches of facial nerve; branches of superficialis colli 
 
150 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 
 
 nerve. Floor: parts of thyrohyoid; hyoglossus; inferior constrictor of 
 pharynx; middle constrictor of pharynx. Contents: Arteries — common 
 carotid; internal carotid; external carotid; superior thyroid; lingual; facial; 
 occipital; ascending pharyngeal. Veins — internal jugular; superior thyroid; 
 lingual; facial; occipital (sometimes); ascending pharyngeal. Nerves — 
 descendens hypoglossi; hypoglossal; pneumogastric; sympathetic; spinal 
 accessory; superior laryngeal; external laryngeal. Other Structures — larynx; 
 pharynx; lymphatic glands. 
 
 Inferior Carotid Triangle. — Boundaries: Superiorly — anterior belly 
 of omohyoid. Anteriorly — middle line of neck. Posteriorly — anterior margin 
 of sternomastoid. Coverings: integument; superficial fascia; platysma; 
 deep fascia; descending branch of superficialis colli nerve. Floor: scalenus 
 anticus (superiorly and externally); longus colli (inferiorly and internally); 
 rectus capitis anticus major (between and superiorly); vertebral artery and 
 vein (between and inferiorly). Contents: Muscles — sternohyoid; sterno- 
 thyroid. Arteries — common carotid (not strictly); inferior thyroid; vertebral. 
 Veins — internal jugular. Nerves — pneumogastric; descending filaments from 
 loop between descendens and communicans hypoglossi; recurrent laryngeal; 
 sympathetic. Other Structures — larynx; trachea; thyroid gland; lymphatic 
 glands. 
 
 Posterior Triangle. — Boundaries : Anteriorly — posterior border of 
 sternomastoid. Posteriorly — anterior border of trapezius. Superiorly — ■ 
 occiput (apex). Inferiorly — superior border of clavicle (base). This triangle 
 is subdivided into the occipital and subclavian triangles. 
 
 Occipital Triangle. — Boundaries: Anteriorly — posterior border of 
 sternomastoid. Posteriorly — anterior border of trapezius. Inferiorly — 
 posterior belly of omohyoid. Coverings: integument; superficial fascia; 
 platysma; deep fascia. Floor: splenius capitis; levator anguli scapulas; 
 middle scalenus; posterior scalenus. Contents : Arteries — transversalis colli. 
 Veins — transversalis colli. Nerves — spinal accessory; descending branches 
 of cervical plexus. Other Structures — lymphatic glands. 
 
 Subclavian Triangle. — Boundaries: — Posteriorly — posterior belly of 
 omohyoid. Inferiorly — upper border of clavicle. Anteriorly — posterior 
 border of sternomastoid (base). Coverings : — integument; superficial fascia; 
 platysma; deep fascia; descending branches of cervical plexus. Floor :— 
 first rib, first serration of serratus magnus. Contents : — Arteries — subclavian 
 (third part); suprascapular; transversalis colli. Veins — subclavian (some- 
 times); suprascapular; transversalis colli; external jugular; small vein from 
 cephalic to external jugular. Nerves — brachial plexus, small nerve to sub- 
 clavius. Other Structures — lymphatic glands. 
 
 Lymphatic Glands of Head and Neck. — Consist of superficial and 
 deep glands. (A) Superficial glands of head and neck : — Consist of 
 transverse and vertical sets. (1) Transverse set of superficial glands: — 
 Extend transversely from occiput along mastoid process, zygoma, and lower 
 border of jaw, to symphysis menti, and comprise following groups; — (a) Oc- 
 cipital or Suboccipital — below superior curved line of occipital bone, between 
 skin and insertion of complexus muscle, (b) Posterior Auricular, or Sterno- 
 mastoid — behind ear, between skin and insertion of sternomastoid. (c) 
 Parotid — in front of ear, between skin and parotid gland, some being embedded 
 within parotid gland, (d) Buccal — on surface of buccinator, between it 
 and skin, (e) Submaxillary — in digastric triangle, between skin and mylo- 
 hyoid and hyoglossus. (f) Suprahyoid — in middle line, between anterior 
 bellies of digastric, between skin and mylohyoid. (2) Vertical set of super- 
 
REMOVAL OF LYMPHATIC GLANDS OF NECK. 151 
 
 ficial glands (superficial cervical chain) : — (a) Anterior — in front of neck, 
 between hyoid bone and sternum, and between skin and superficial muscles. 
 (b) Middle (superficial cervical chain) — chiefly along external jugular vein, 
 mainly in posterior triangle of neck, between platysma and deep cervical 
 fascia, (c) Posterior — over trapezius, between it and skin. (B) Deep glands 
 of head and neck : — Comprising those of head and neck. (1) Those of 
 head : — Consisting of following groups: — (a) Lingual — on external surface of 
 hvoglossus and geniohyoglossus. (b) Internal Maxillary — on lateral aspect 
 of pharynx, behind buccinator muscle, (c) Posterior Pharyngeal — between 
 posterior surface of pharynx and rectus capitis anticus major, near base of 
 skull. (2) Those of neck : — Consisting of following sets; — (a) Superior set — 
 along internal jugular vein, from base of skull to level of thyroid cartilage, 
 (b) Inferior set — along internal jugular vein, from thyroid cartilage to near 
 clavicle. 
 
 REMOVAL OF LYMPHATIC GLANDS OF NECK. 
 
 General Considerations. — In the case of diseased cervical glands, an 
 operation may be undertaken — (1) for the removal of one or a few defined 
 glands, in one or more of the regions of the neck, in which case a single or 
 several incisions, more or less limited, are so placed as most readily and 
 safely to expose the involved glands; — or (2) for the removal of glands widely, 
 deeply, and indistinctly disseminated throughout the antero-lateral aspect 
 of the neck, in which case one or more extensive incisions are necessary, 
 both for the removal of the glands and in order to give room in which to 
 safeguard important structures during their removal. Removal of dis- 
 seminated cervical glands will be first described — and removal of isolated 
 glands will be referred to under Comment. 
 
 Indications for Removal of Cervical Lymphatic Glands. — Chronic 
 tubercular adenitis (most frequently) ; acute non-tubercular suppurative 
 adenitis; enlargement secondarily from neighboring malignant growths. 
 
 Preparation. — Shaving of all hairy parts at site of and bordering upon 
 field of operation. 
 
 Position. — Patient supine; shoulders raised; neck resting over a support, 
 to render it prominent; head so turned as to increase prominence, length, 
 and width of neck, and in order to drag glands out from under protecting 
 tissues. Surgeon on side of operation; assistant opposite. 
 
 Landmarks. — The triangles of the neck. 
 
 Instruments. — Scalpels; scissors, straight, curved, blunt and sharp; 
 dissecting forceps; toothed forceps; artery-clamp forceps; blunt dissector; 
 retractors; tenacula; grooved director; aneurism-needle; needles; needle- 
 holder; sutures; ligatures; sterilized water on hand to flood neck in case of 
 opening large vein in an inaccessible localitv. 
 
 Incision. — Various forms of incision have been used, singly or combined. 
 Where the entire antero-lateral aspect of the neck is to be exposed, a X-shaped 
 incision (Fig. 101) may be used — BC extending from over the mastoid process 
 to the interval between the sternal and clavicular attachment of the sterno- 
 mastoid, passing down the middle of the sternomastoid or along its anterior 
 border — BA extending transversely forward from the upper end of the oblique 
 incision to the angle of the jaw, and thence along the lower border of the 
 jaw to the symphysis — CD extending transversely outward along the upper 
 border of the clavicle, as far toward the acromioclavicular articulation as 
 necessarv. If only the anterior triangle of the neck be involved, the por- 
 
152 
 
 OPERATIOXS UPON THE LYMPHATIC GLANDS AND VESSELS. 
 
 tion ABC of the incision is alone used — if the posterior triangle, the portion 
 BCD. 
 
 Operation. — (i) Incise directly through skin, superficial fascia, platysma, 
 and deep fascia — the diagonal portion of the X-shaped incision being first 
 made; that is, the portion over the anterior border of the sternomastoid. 
 Sever the external jugular vein between two ligatures. Branches of the 
 superficialis colli nerve will be cut, but the auricularis magnus and occipitalis 
 minor should be retracted backward, if exposed. This incision is carried 
 down to and exposes the whole length of the sternomastoid muscle. (2) 
 Carry the upper incision transverselv downward to the angle of the jaw, 
 
 N, 
 
 Fig. 1 01. —Incisions for Exposing Lymphatic Glands of Cervical Rf.c.ion :—BC, Line over 
 anterior border of sternomastoid, from mastoid process to interval between sternal and clavicular 
 origins of sternomastoid ; BA, Line from mastoid process to angle of jaw, and thence forward along 
 its lower border; CD, Line from sternoclavicular articulation outward along upper border of clavicle. 
 Anterior triangle of neck is exposed by raising flap ABC; Posterior triangle, by raising flap BCD ; 
 Entire antero-lateral aspect of neck, by raising both flaps. Following incisions may be used for 
 removing isolated groups of glands ; EF, Incision parallel with anterior border of sternomastoid ; 
 GH, parallel with posterior border ; IJ, Transverse oblique in upper part of neck ; KL, Transverse 
 oblique in lower part of neck. 
 
 and then forward along the lower border of the inferior maxilla toward the 
 symphysis, passing through the skin, superficial fascia, platysma, and deep 
 fascia — and exposing, without injury, the parotid gland, facial nerve, tribu- 
 taries of temporomaxillary vein, facial artery and vein, submaxillary and 
 submental glands. The facial artery and vein may be divided between two 
 ligatures, if necessary. (3) The lower incision is now carried transversely 
 along the upper border of the clavicle, as far toward its outer end as necessary 
 — passing through skin, superficial fascia, platysma, and deep fascia — 
 dividing some of the descending superficial branches of the cervical plexus 
 and a few minor vessels. (4) Having now completed these three incisions, 
 
REMOVAL OF LYMPHATIC GLANDS OF NECK. 153 
 
 two triangular flaps are carefully dissected up and turned aside — an anterior 
 flap (ABC), having the same boundaries as the anterior triangle of the neck, 
 is turned forward, hinging on the anterior median line of the neck — and a 
 posterior flap (BCD), having the same boundaries as the posterior triangle 
 of the neck, is turned backward, hinging on the anterior margin of the tra- 
 pezius (or on a line posterior to that, if the lower transverse incision have 
 been extended posteriorly to the acromioclavicular articulation). Thus, 
 the superficial parts having been turned aside, the entire antero-lateral quadri- 
 lateral surface of the neck is exposed on a plane with the important structures 
 and in easy access to those structures. (5) All glands are now dissected out, 
 together with their surrounding connective tissue — being sought in the locali- 
 ties indicated in the above summary (see Lymphatic Glands of Head and 
 Neck, page 150) — guarding, at the same time, the important anatomical 
 structures enumerated under Surgical Anatomy of the Triangles of the Xeck. 
 (6) If avoidable, the sternomastoid should not be cut — it generallv being 
 possible, in such a free exposure, to retract it alternately well forward and 
 backward in order to remove the glands partly or entirely covered In - it, 
 slightly flexing the chin on the sternum to lessen tension. Where, however, 
 it proves a barrier to thorough and safe work, it should be unhesitatingly 
 severed — the emergence of the spinal accessory nerve from its posterior 
 border being exposed, and the muscle divided transversely below the nerve 
 The upper end of the muscle is then turned upward and backward with 
 the uninjured nerve, and the lower end downward and forward — and the 
 important structures beneath it thus easily brought to view. (7) In com- 
 pleting the operation, the cut ends of the sternomastoid should be carefully 
 sutured with interrupted buried catgut sutures. The flaps are now turned 
 back into place and sutured throughout — the flaps being sutured to each 
 other first, then along the superior transverse line, and, last, along the inferior 
 transverse line — the wound being closed throughout with silkworm-gut or 
 silk — and firm pressure, to occlude dead spaces, made in the dressing. The 
 neck and head are steadied in some form of retentive apparatus until union 
 has occurred. 
 
 Removal of Isolated Lymphatic Glands of the Neck. — These isolated 
 glands will belong to one of the groups of superficial or deep glands given, 
 with their relations, upon a preceding page. The position, direction, and 
 extent of the incision for their exposure will be determined by the special 
 group of glands involved and the extent of the involvement — the general 
 rule being that the incision is so placed as to reach the site most readily and 
 with greatest safety to neighboring structures — and mav be a single vertical, 
 transverse, or oblique straight incision, making an opening whose lips have 
 to be retracted to expose the parts; — or a combination of these; — or a curved 
 incision, thereby forming a flap, which is temporarily turned back. The 
 two most generally used forms of incision, however, are those which are 
 more or less parallel with one of the borders of the sternomastoid (Fig. 101, 
 EF or GH) — or more or less parallel with the natural obliquely transverse 
 crease crossing the neck about on a level with the hyoid bone, in the cleavage 
 line of the skin (Fig. 101, IJ or KL). The incision may be placed over the 
 submaxillary, superior carotid, or inferior carotid triangle, of the anterior 
 triangle of the neck, or over the occipital or subclavian triangle, of the posterior 
 triangle — or over the posterior aspect of the neck, between the anterior border 
 of the trapezius and the posterior median line, and between the superior 
 border of the scapula — or may involve several triangles. 
 
 Comment. — (i) Great care is necessary in removing glands from thin- 
 
154 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 
 
 walled veins. Should a vein be wounded, the opening should be caught up 
 instantly and laterally ligated, if the wound be appropriate, or sutured, or 
 even transversely ligated. If so situated that closure cannot be immediately 
 made, the part should be flooded with water, so that water stands over the 
 open vein, to prevent the drawing-in of air until the vein can be secured. 
 (2) The important nerves are to be particularly guarded. (3) The arteries 
 and arterial hemorrhage give far less concern than the veins and venous 
 hemorrhage. (4) It is better to dissect the glands out in masses or chains, 
 together with their adherent connective tissue — invisible, impalpable glands 
 being thus more thoroughly removed. (5) Glands should be removed with 
 their capsules intact. (6) The sternohyoid and omohyoid may also be divided 
 and subsequently sutured. (7) All bleeding should be immediately con- 
 trolled as encountered, and ligated as soon as convenient. 
 
 SURGICAL ANATOMY OF AXILLARY REGION. 
 
 Description. — The axilla is a pyramidal space between the upper lateral 
 wall of thorax and inner wall of arm — its apex corresponding with interval 
 between first rib on inner side, clavicle in front, and upper edge of scapula 
 behind; — its base, broad at chest and narrow at arm, is composed of skin 
 and dense fascia, extending between inferior border of pectoralis major in 
 front, and inferior border of latissimus dorsi behind. 
 
 Boundaries. — Anteriorly — pectoralis major (throughout) ; pectoralis 
 minor (its center). Posteriorly — subscapulars (above); teres major and 
 latissimus dorsi (below). Internally — first to fourth ribs; first to third 
 intercostal muscles; serratus magnus. Externally — humerus; coracobrachi- 
 al ; biceps. 
 
 Contents. — Arteries : — axillary (along external wall, nearer anterior than 
 posterior boundary); superior thoracic; acromial thoracic; long thoracic; 
 alar thoracic; subscapular; anterior circumflex; posterior circumflex. Veins : 
 — axillary (to inner side of axillary artery) ; receiving venae comites of brachial 
 artery and tributaries of branches of axillary artery. Nerves: — brachial 
 plexus lies to outer side of first part of axillary artery; — the second part of 
 axillary artery has the outer, inner, and posterior cords of plexus in the rela- 
 tions expressed by their names; — the third part of the artery has, anteriorly, 
 inner head of median nerve; posteriorly, musculospiral and circumflex; 
 externally, median, musculo-cutaneous; internally, ulnar, internal cutaneous, 
 lesser internal cutaneous. Posterior thoracic (on serratus magnus). In- 
 tercosto-humeral. External and internal anterior thoracic, crossing in front 
 and behind axillary artery respectively. Glands : — see below. 
 
 Axillary Lymphatic Glands.— Are arranged in four groups: (a) Axillary 
 glands proper — median set; three or four in number; along axillary artery 
 and vein, (b) Pectoral glands; inner or anterior set; four or five in number; 
 along long thoracic artery, below great pectoral muscles and on serratus 
 magnus. (c) Subscapular glands — external or posterior set; two in number; 
 along subscapular artery, under latissimus dorsi. (d) Subclavian or infra- 
 clavicular — superior set; two in number; near cephalic vein; just below clavicle 
 in fossa under pectoralis major and deltoid, upon costocoracoid membrane. 
 
 Axillary Lymphatic Trunk. — Efferent trunk from above sets of glands 
 — runs upward along subclavian vein — emptying into thoracic duct on left, 
 and into right lymphatic duct on right. 
 
REMOVAL OF AXILLARY LYMPHATIC GLANDS. 
 
 155 
 
 REMOVAL OF AXILLARY LYMPHATIC GLANDS. 
 
 Description. — The removal of the axillary glands is done, in the majority 
 of cases, in connection with the removal of neighboring malignant growths, 
 especially those involving the breast — and, in such cases, the incision for 
 exposing the axillary region is merely a prolongation into the axilla of the 
 incision for the original operation. The steps, therefore, of the operation 
 for the removal of these glands will be found sufficiently described under 
 the operations for the radical removal of the breast (pages 738 to 744). Where 
 it is planned to remove enlarged ax- 
 illary glands alone and as a distinct 
 operation, the incision is placed 
 over the involved glands (Fig. 102). 
 
 SURGICAL ANATOMY OF 
 SCARPA'S TRIANGLE. 
 
 Description. — A triangular 
 area just below fold of groin. 
 
 Boundaries. — Base (above) ; 
 Poupart's ligament. Externally; 
 sartorius. Internally; adductor 
 longus. Apex (below) ; junction of 
 sartorius and adductor longus. 
 
 Roof. — Skin; superficial fascia; 
 fascia lata. 
 
 Floor. — (From without in- 
 ward.) Iliacus; psoas; pectineus; 
 adductor brevis; adductor longus. 
 
 Contents. — Arteries; common 
 femoral (from middle of base to 
 apex); superior epigastric; superfi- 
 cial circumflex iliac; superficial ex- 
 ternal pudic; deep external pudic; 
 profunda femoris. Veins; femoral 
 (to inner side of artery) ; profunda 
 femoris; tributaries of branches of 
 
 femoral; internal saphenous. Fig. io 2 .-Incision for Exposing Axillary 
 
 Nerves; anterior crural (to outer Lymphatic Glands:— Passing between biceps 
 
 Side of arterv) ; crural branch of and pectoral muscles, in front, and the scapular 
 
 , ' ' . muscles, posteriorly; to which may be added one 
 
 gemtocrural; external cutaneous. or more modifying incisions, as necessitated by 
 
 Lymphatics; superficial and deep the special case, 
 glands. 
 
 Inguinal Lymphatic Glands. — Consist of two following sets; (1) Super- 
 ficial Glands ; Oblique or Inguinal Set — along Poupart's ligament, upon 
 fascia lata. Vertical or Saphenous Set — around saphenous opening and upon 
 fascia lata. (2) Deep Glands ; along upper part of femoral vessels, one or 
 more being within femoral canal. 
 
156 OPERATIONS UPON THE LYMPHATIC GLANDS AND VESSELS. 
 
 REMOVAL OF INGUINAL LYMPHATIC GLANDS. 
 
 Description. — The operation will differ according to site and amount 
 of glandular involvement — and the lines of incision are given accordingly. 
 Indications. — Glands enlarged or broken down as a result of venereal 
 disease; tubercular glands; simple, chronic, and suppurative adenitis; malig- 
 nant involvement. 
 
 Preparation. — Groin shaved. 
 
 Position. — As for ligation of femoral artery at base of Scarpa's triangle 
 
 (page 95). 
 
 Landmarks. — Given under Sur- 
 gical Anatomy of Scarpa's Triangle. 
 Instruments. — As for removal 
 of cervical glands (page 151). 
 
 Incisions.— (1) Where the ob- 
 lique (superficial) set of glands are 
 involved — an incision may be made 
 parallel with and just below Pou- 
 part's ligament, with its center over 
 the enlarged glands (Fig. 103, B); 
 or just above Poupart's ligament 
 (Fig. 103, A). (2) Where the 
 vertical (superficial and deep) sets 
 are involved — the incision is made 
 along the course of the femoral 
 artery, with its center over the 
 enlarged glands (Fig. 103, B). (See 
 ligation of common femoral at base 
 of Scarpa's triangle, page 93.) (3) 
 Where all three sets are involved — 
 the incision may be a combination of 
 the above two, being somewhat 
 T->haped. 
 
 Operation. — Divide skin and 
 superficial fascia in the direction or 
 directions indicated above. The 
 superficial vessels encountered are 
 ligated. The superficial glands 
 (oblique and vertical sets) will be 
 found upon the fascia lata, in the positions indicated. To reach the deep 
 glands (lying along the great vessels) the fascia lata is incised in the line of the 
 femoral artery (as for ligation of that artery). Important structures are to be 
 avoided and the glands sought along the course of the artery and vein. The 
 general principles mentioned under the removal of cervical lymphatic glands 
 are applicable here — and elsewhere, wherever glandular tissue is removed. 
 
 Fig. 103. — Incisions for Exposing 
 Inguinal Lymphatic Glands: — A, Oblique 
 incisions just below and parallel with Pou- 
 part's ligament, for oblique superficial set 
 of glands; B, Vertical incision over femoral 
 artery, for vertical superficial and deep sets. 
 A T-shaped incision may be made by uniting 
 these, where all three sets are involved. 
 
CHAPTER IV. 
 
 OPERATIONS UPON THE NERVES, PLEXUSES, 
 AND GANGLIA. 
 
 Note. — The operations which may be performed upon Nerves, Plexuses, 
 and Ganglia will be first described — and then the operations for the exposure 
 of the more important nerves, plexuses, and ganglia will be given. Having 
 exposed a nerve, any of the operations about to be described may be applied 
 to it, as indicated. 
 
 NEUROTOMY. 
 
 Description. — Section of a nerve. Neurotomy may be transverse (e. g., 
 as when performed for neuralgia of a sensory nerve, or spasm of a motor 
 nerve) ;— or longitudinal (e.g., as done in some cases of neurorrhaphy and 
 neuroplasty). 
 
 Indications. — Neuralgia of sensory nerves; spasm of motor nerves; 
 preliminary to neurorrhaphy or neuroplasty. 
 
 Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
 — Determined by the special nerve involved. 
 
 Fig. 104. — Neurotomy of Supraorbital Nerve. 
 
 Operation. — Having exposed and isolated the individual nerve, it is 
 lifted from its bed by forceps and divided with a scalpel or scissors. The 
 cut ends are allowed to fall back into place — or, better, should be so dropped 
 back into the wound as to make re-union unlikely. The wound is closed as 
 usual. No special after-treatment is carried out (Fig. 104). 
 
 Comment. — Chiefly applicable to smaller sensory nerves — and, rarely, 
 smaller motor nerves. Not generally successful in neuralgias. 
 
 i57 
 
158 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 NEURECTOMY. 
 
 Description. — Excision of a nerve. Neurectomy may be partial or com- 
 plete. As ordinarily performed, only a small part of the length of the nerve 
 is removed. 
 
 Preparation— Position — Landmarks — Surgical Anatomy— Incision. 
 — Determined by the special nerve. 
 
 Indications. — Neuralgia of sensory nerves; spasm of motor nerves. 
 
 Fig. 105. — Neurectomy of Supraorbital Nerve. 
 
 Operation. — The nerve having been exposed and brought well into 
 the field, is lifted out of its bed with forceps — and from 2 to 3 cm. (1 to 1^ 
 inches) of its trunk is excised with scalpel (preferable to scissors, which partly 
 crush). The ends are then allowed to drop back into position — and the 
 wound is closed (Fig. 105). 
 
 Comment. — Total excision is most frequently done by avulsion (page 159). 
 
 NEURECTASY. 
 
 Description. — Nerve-stretching. 
 
 Indications. — Neuralgia of sensory and spasm of motor nerves. 
 
 Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
 
 - — Determined by the nerve operated upon. 
 
 Operation. — The nerve is freely exposed and separated by blunt dis- 
 section sufficiently for manipulation. Small nerves are stretched by means 
 of a nerve-hook inserted beneath them. Large nerves are stretched by being 
 grasped between thumb and finger — the nerve is steadily and evenly pulled 
 from its center for about five minutes — then from its periphery for about 
 five minutes. The extremes of force employed may be represented by a 
 pull of a half-pound for the supraorbital — and from thirty to sixty pounds 
 (according to the judgment of the operator) for the sciatic. The manipu- 
 lation is done with as limited disturbance to the surrounding structures as 
 possible. After the stretching, the nerve is dropped back into place and the 
 incision closed. In the after-treatment, the part should be immobilized until 
 union of the wound occurs. Temporary paralyses of motion and sensation 
 
NERVE-AVULSION. 
 
 J 59 
 
 are to be expected (Fig. 106). The breaking strain of the principal nerves 
 of the body has been given by Nombetta as the following: — 
 
 Great sciatic 183 pounds 
 
 Internal popliteal 114 
 
 Anterior crural 83 
 
 Median crural 83 
 
 Ulnar and radial 59 
 
 Brachial plexus in the neck 48-63 
 
 Brachial plexus in the axilla 35~8i 
 
 
 Fig. 106. — Neurectasy of Infraorbital Nerve. 
 
 Comment. — Sensory nerves seem more dulled by traction in a direction 
 away from the cord — motor nerves more dulled by traction toward the cord. 
 
 • 
 
 Fig. 107.— Nerve-avulsion of Infraorbital. 
 
 NERVE-AVULSION. 
 
 Description. — The tearing away of a nerve from its central and peripheral 
 connections. 
 
 Indications. — Neuralgia. Chiefly used upon branches of the fifth nerve. 
 
 Preparation— Position— Landmarks— Surgical Anatomy— Incision. 
 — Determined by the special nerve. 
 
160 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 Operation. — Having exposed the nerve involved, it is grasped by catch- 
 forceps (firmly, but not strong enough to crush and break it) — and then 
 slowly wound around the forceps (by twisting the latter between the fingers) 
 — until the nerve is torn away from its connections, both proximally and 
 distallv. Branches of the nerve are also sometimes avulsed, to a greater or 
 less extent along with the main trunk — as well as a part or the whole of a 
 ganglion. The nerve may, also, be partly cut — either distallv (generally) 
 or peripherally. The wound is closed throughout, in the usual manner 
 (Fig. 107). 
 
 NEURORRHAPHY. 
 
 Description. — Suturing of nerve which has been partially or entirely 
 divided. Neurorrhaphy may be primary, or immediate, where the nerve 
 is sutured at once, — or secondary, where the suturing is done subsequent 
 to repair of injury. 
 
 Indications. — Repair of injury to nerve. Neuroplasty. 
 
 Preparation — Position — Landmarks — Surgical Anatomy — Incision. 
 — Determined by the nerve involved. 
 
 Operation of Primary, or Immediate, Neurorrhaphy. — The severed 
 nerve-ends are exposed in the wound and brought well within reach. See 
 if they be cleanly cut. If not, gently grasp them with forceps and cut them 
 cleanlv, and preferably transversely, with a sharp knife, with a minimum 
 sacrifice of nerve-tissue. The ends are brought and held in apposition, in 
 their normal relations, anterior aspect to anterior aspect, and the like. If 
 
 Figs. 108-112. — Methods of Nerve-suturing: — I. — A B, C, Sutures passing through entire 
 thickness of nerve and sheath; D, E, Sutures passing through nerve-sheath only. 
 
 the ends cannot be approximated, flex or extend the limb to increase the 
 length, or stretch both ends gently (preferably grasping them with the fingers). 
 It is desirable that there should be no tension upon the sutures. The junction 
 is made with a fine cambric needle threaded with fine chromic catgut and 
 held in a needle-holder. One of several methods of suturing may be adopted; 
 — (a) The sutures may be passed entirely through the sheath and nerve, in 
 two or more directions, and about 3 mm. (i inch) from the ends. The 
 needle passes from before backward through the entire thickness of the 
 proximal end — then similarly through the distal end, from behind forward— 
 
NEURORRHAPHY. 
 
 161 
 
 and the suture is tied lightly, so as not to have tension. A second suture may 
 be applied antero-posteriorly, or laterally — and as many as seem needed 
 accurately to coapt the ends. This is the most general method of nerve- 
 suturing (Figs. 108-112, A, B, C). (b) Sutures may be passed through the 
 
 Figs. 113-117. — Methods or Nerve-suturing: — II. — A, B, Sutures passing through 
 sheath and part of nerve; C, Sutures through sheath, reinforced by relaxation-suture through 
 entire nerve; D, Nerve cut obliquely and united by suture through sheath and part of nerve; 
 E, Same with relaxation-suture. 
 
 nerve-sheath alone, encircling the nerve proper. This is the preferable 
 operation — but is possible only in. large nerves (Figs, in, 112, D, E). (c) 
 Part of the sutures may pass through the nerve and sheath (as in a) — and 
 part through the sheath only (as in b) (Figs. 113, 114, 115, A, B, C). (d) 
 
 Figs. 118-121. — Methods of Nerve-suturixg : — III. — A, Reinforcing through-and- 
 through suture by lateral suture through loops of first suture; B, C, D, Various methods of 
 union by approximation of lateral aspects of nerve, after freshening. 
 
 After paring the larger end, it may be split down its center for about 1.3 cm. 
 {\ inch) — the smaller end may be beveled on two sides and sutured between 
 the lips of the split end (Fig." 122, A), (e) One end may be beveled on its 
 upper surface, the other on its lower surface — the two freshened surfaces 
 are then placed in contact and sutured through and through (Figs. 116 and 
 
162 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 117, D, E). This requires a greater length of nerve than some of the other 
 methods. Other methods are shown in Figs. 118 to 121 and 123, B, and 124, 
 C. Having completed the union of the nerve-ends, the wound is sutured and 
 the limb immobilized so as to minimize tension for about ten days — the part 
 is then gently massaged daily and the splint reapplied between times and not 
 removed for about six weeks. Primary union is particularly to be sought. The 
 restraining splint should be such as will hold the part so that the nerve will be 
 relaxed. 
 
 Operation of Secondary Neurorrhaphy. — Having applied Esmarch's 
 bandage, one may cut directly down upon the supposed site of the nerve ends. 
 It is better, however, deliberately to incise for and expose both proximal 
 and distal nerve-trunks, above and below the involvement, on anatomical 
 grounds. Much difficulty may be experienced in finding the nerve-ends, 
 unless traced down and upward, as the case may be, from the nerve-trunks. 
 The proximal end is easier to find, and apt to be bulbous and sensitive. The 
 distal end is apt to be atrophied. Sufficient freeing of the nerve-ends to 
 enable them to meet is necessary. While in primary suturing the severed 
 
 ends may or may not 
 require trimming before 
 suturing, in secondary 
 suturing they are, in ad- 
 dition to being freed 
 from connective tissue, 
 always to be excised. 
 Having identified the 
 nerve-ends, dissect away 
 all intervening fibrous 
 tissue. With a sharp 
 knife cut away trans- 
 versely the proximal 
 end until healthy nerve 
 tissue is reached. In 
 the case of the distal 
 end, simply cut away 
 enough of the upper 
 end to afford good ap- 
 proximation (for degen- 
 erative processes will 
 have extended far down 
 this end under any cir- 
 cumstances). If the ends can now be made to meet without too much ten- 
 sion, they are sutured together by one of the methods described under primary 
 neurorrhaphy. If greater length be necessary, as is almost invariably the 
 case, it may generally be gotten by first carefully stretching the ends — after 
 which they are united by suture. If sufficient length cannot be thus secured, 
 neuroplasty must be done (page 163). Following secondary neurorrhaphy 
 the wound is closed, the limb splinted, and the same after-treatment carried 
 on as after the primary operation — although results are not to be expected 
 so soon. Restoration of function may require from one to two years. 
 
 Comment. — Where stretching is resorted to to gain length in secondary 
 suturing, it should be applied before excising the nerve-ends — traction being 
 made upon the nerve-ends themselves, which are afterward removed. And 
 if tension be too great upon the sutured ends, relaxation-sutures may be 
 applied above and below the line of finer approximation sutures. 
 
 «f 
 
 Figs. 122-124. — Less Usual Methods of Nerve- 
 suturing: — IV. — A, Suturing of beveled end between lips of 
 split end; B, C, Method of uniting sound upper and lower 
 portions of nerve by splitting and suturing contracted portion. 
 
NEUROPLASTY. 
 
 163 
 
 NEUROPLASTY. 
 
 Description. — The union of severed nerve-ends by processes of plastic 
 elongation of the nerve itself, — or by the interposition of nerve or other 
 
 Figs. 125-128. — Neuroplasty : — I. — A, B, Union by splitting both ends of nerve and uniting 
 split ends end-to-end; C, D, Same, with split ends united laterally. 
 
 material — in cases where the loss of nerve-substance is so great that the 
 severed ends cannot be brought and held together by the ordinary methods 
 
 Figs. 129-132. — Neuroplasty: — II. — A, Splitting one end, with union of lateral aspect 
 of split end to lateral aspect of opposite entire end freshened laterally; B, Same, with union 
 end-to-end; C, D, Same as in B, in case of bulbous ends. 
 
164 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 — Neitroplasty: — III. — A, B, 
 Doubly splitting both ends, with union of split ends 
 end-to-end; C, Interpolation of section of nerve. 
 
 of suturing. The object sought in the latter cases is the supplying of a sub- 
 stance between the cut ends along which the nerve-fibers may grow from 
 
 the proximal to the distal end 
 (as the tendrils of a vine grow 
 along a trellis). The operations 
 of nerve-anastomosis, nerve- 
 grafting, and nerve-implanta- 
 tion are also instances of neuro- 
 plasty. 
 
 Indications.— Where, in 
 primary operations, consider- 
 able nerve-substance has been 
 destroyed by the cause of the 
 injury — or, in secondary oper- 
 ations, the retraction of the 
 severed ends has been very 
 great — so that by no other 
 means can the ends of the 
 nerves be brought and kept 
 together. 
 
 Preparation — Position — 
 Landmarks — Surgical Anat- 
 omy — Incision. — Determined 
 by the special operation. 
 
 Operation. — Having exposed 
 and isolated the severed ends, 
 
 and, in the case of secondary operations, freed them from connective tissue 
 
 and freshened them by partial excision, one of the following means of bringing 
 
 and holding the ends in contact is 
 
 resorted to: — (a) At points as far from 
 
 the ends of the nerves as indicated by 
 
 the length of the intervening space to be 
 
 filled, divide each nerve half-way, trans- 
 versely — split each end back to within 
 
 about 6 mm. (| inch) of its end — 
 
 bend the two cut portions toward each 
 
 other — and suture them end to end, or 
 
 laterally (Figs. 125-128, A, B, C, D). 
 
 In filling smaller gaps, one trunk only 
 
 may be split — bent back to the other 
 
 end — and both freshened and sutured 
 
 (Figs. 129 and 130, A, B). (b) Sec- 
 tions of nerves from a freshly amputated 
 
 human limb, or from the lower animals, 
 
 may be interposed in the gap and 
 
 sutured at both ends by one of the 
 
 methods given under neurorrhaphy. 
 
 This interposed part does not grow, 
 
 but only serves the role of a trellis 
 
 (Fig. 135, C). (c) A solid cylinder 
 
 of decalcified bone may be interposed 
 
 and sutured to the ends of the nerves, (d) Strands of fine catgut may be 
 
 made to bridge the interval, as a guide to the new nerve-fibers (Fig. 136, A). 
 
 C2E^ 
 
 ) 
 
 Figs. 136-138. — Neuroplasty : — IV. 
 — A, Union by strands of gut alone; B, C, 
 Same, reinforced with decalcified bone 
 cylinder. 
 
NERVE-ANASTOMOSIS; NERVE-GRAFTING; NERVE-IMPLANTATION. 165 
 
 (e) The proximal and distal ends of the nerve may be enclosed in a hollow 
 cylinder of decalcified bone (Figs. 137 and 138, B, C). (f) Proceed as in 
 Fig. 133, A — then shift the cut ends laterally, and approximate as shown in 
 Fig. 134, B. (g) Combine methods (d) and (e) — the combined method of 
 bridging with catgut and enclosure in decalcified bone tube. One end of the 
 catgut bridge is slipped through the tube, sutured to the other end, and drawn 
 back within the tube (Figs. 136 and 138, B, C). (h) Shortening of the limb, 
 by resection of its bone or bones, to allow of approximation of the ends of 
 the nerve. (The musculospiral has been thus successfully treated.) Of 
 the above methods, method (a) is the one most generally used. Having 
 completed the neuroplastic operation, the wound is closed and the part immo- 
 bilized in a position to relax the nerve. 
 
 NERVE- ANASTOMOSIS; NERVE-GRAFTING; NERVE-IMPLANTATION. 
 
 Description. — The grafting of any portion of an injured nerve into the 
 trunk of a neighboring nerve. In the case of a divided and retracted nerve, the 
 severed upper end is grafted into the intact nerve at a point opposite its level, 
 
 <3S23| 
 
 D 
 
 Figs. 139-142. — Nerve-grafting: — I. — A, B, Engrafting of freshened lower end of 
 divided median nerve (for instance) upon intact ulnar nerve; C, D, Engrafting of freshened 
 upper and lower ends of divided median nerve upon intact ulnar nerve. 
 
 above — and the severed lower end grafted into the intact trunk opposite its 
 level, below — that is, at points where they can be conveniently brought into 
 contact with the sound nerve. The object sought is to switch the interrupted 
 nerve-stream, or nerve-impulse, from the proximal end of the cut nerve into 
 the neighboring sound nerve — thence to have it conveyed along this used 
 nerve down to the point where the distal end of the cut nerve is sutured to the 
 utilized nerve — and thence returned to the original nerve and transmitted 
 along the distal portion of the cut nerve to its final distribution, as though no 
 interruption to its normal course and transmission had occurred. An illus- 
 tration would be a divided median nerve and an intact ulnar nerve — where 
 the upper end of the median nerve is sutured to the upper part of the ulnar — 
 
166 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 and the lower end of the median to the lower part of the ulnar (Figs. 141 
 and 142, C, D). The object finally sought is to have nerve-fibrils grow 
 down this nerve from the proximal cut end to the distal cut end. The method 
 is of limited application, because of the necessity of finding large nerves in 
 close proximity — the upper extremity being about the only locality in which 
 the method can be utilized (Figs. 143 and 144), or the lower end only may be 
 grafted upon the sound nerve — the impulse from the latter passing into the 
 impaired nerve and going on to its distribution (Fig. 143, A and B). 
 
 Preparation— Position — Landmarks — Surgical Anatomy — Incision. 
 — Determined by the individual operation. 
 
 Operation. — Expose, isolate, and excise the proximal and distal ends 
 of the severed nerve, supposing it to be a secondary case. Also through 
 
 Figs. 143 and 144. — Nerve-grafting: — II. — A (to left), Showing ulnar and median 
 nerves divided at different heights; B (to right), Union of upper end of median to lower end of 
 ulnar; — followed by engrafting of upper end of ulnar and lower end of median into this new 
 trunk. 
 
 the original incision, expose the neighboring nerve upon which the grafting 
 or implantation is to be made. By means of curved scissors, remove a limited 
 portion of its sheath, on the lateral aspect of the nerve, at the sites where 
 the upper and lower severed nerve-ends are to be grafted. The obliquely 
 
NERVE- ANASTOMOSIS; NERVE-GRAFTING; NERVE-IMPLANTATION. 167 
 
 or transversely divided ends of the involved nerve are to be sutured to the 
 denuded lateral aspect of the intact nerve, above and below, by fine chromic 
 
 B C D 
 
 Figs. 145, 146, 147, and 148. — Nerve-graftixg: — III. — A, The darker, smaller nerve 
 has lost all function, — B, Is divided transversely and its distal end sutured into the sound nerve. 
 G, The darker nerve has lost all function, — D, Is divided and sutured to the split portion of the 
 sound nerve. 
 
 sutures passing through the sheath of the nerve-ends, on the one hand, 
 and through the sheath and part of the thickness of the intact nerve at the 
 
 Figs. 149, 150, 151, and 152. — Nerve-graftixg: — IV. — E, The darker, smaller nerve has 
 retained part of its function, — F, Is split and its split end sutured to the split end of the sound 
 nerve. G, The darker nerve has retained part of its function, — H, Is divided transversely, and 
 its proximal end sutured to the distal split portion of the sound nerve, while its distal end is 
 sutured to the proximal split portion of the sound nerve. 
 
 bared sites, on the other hand. Having completed the nerve-suturing, if 
 the neighboring parts have been disarranged, these should be rearranged — 
 by buried catgut sutures, if necessary. The wound is then closed throughout. 
 
168 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 The part should be immobilized in a position of relaxation of nerve-tension 
 until union has occurred — and subsequently treated as described under 
 neurorrhaphy. It sometimes happens that an adjacent nerve has, through 
 degenerative changes, sustained a total or partial loss of function. Where 
 the loss is complete (Fig. 145, A), the involved nerve is divided transversely 
 and its distal end sutured laterally to the adjacent sound nerve (Fig. 146, B); — 
 or the distal end may be sutured end-to-end to split portion of the sound nerve 
 (Figs. 147 and 148, C and D). Where the loss of function in the involved 
 nerve is not complete, a cross-anastomosis may be done, thus preserving all 
 of each nerve, — that is, both nerves may be split, and the split portions sutured, 
 leaving the main trunks continuous (Figs. 149 and 150, E and F); — or the 
 involved nerve may be divided transversely and the sound nerve split longi- 
 tudinally in both directions, after which the proximal end of the impaired nerve 
 is sutured to the distal split portion of the sound nerve, and the distal end of 
 the impaired nerve is sutured to the proximal split portion of the sound nerve 
 (Figs. 151 and 152, G and H). 
 
 Comment. — (i) The severed distal end of the involved nerve is sometimes 
 bevelled and implanted within the incised substance of the sound nerve 
 (Fig. 153). It may happen, in extensive injuries, that the lower portion of 
 one nerve is destroyed, and -the upper end, or ends, of one or two adjacent 
 
 Fig. 153. — Implantation of Bevelled End of Divided Nerve into Longitudinal 
 Slit in Sound Nerve. 
 
 Fig. 154. — Anastomosis of Divided Distal Ends of Two Nerves whose Proximal 
 Portions have been Destroyed, into Proximal Trunk of Adjacent Nerve whose Distal 
 Portion has been Destroyed. 
 
 nerves. In such unusual cases, and in the rare localities where such a pro- 
 cedure is possible, the divided distal ends of the latter may be sutured into 
 the transversely divided proximal end of the former (Fig. 154). (2) It 
 seems to make no difference whether a sensory nerve be grafted to a motor 
 or to a mixed nerve— or vice versa. 
 
INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 169 
 
 NEUROLYSIS, OR AN OPERATION FOR RELIEF OF NERVE COM- 
 PRESSED BY BONY OR FIBROUS CICATRICIAL TISSUE OR BY 
 ADHESIONS. 
 
 Description. — Nerves are sometimes involved and pressed upon in the 
 processes of repair following injury of bones and soft parts, or in the processes 
 of disease, or by adhesions, and eventually become so firmly compressed as 
 to have their function impaired — in which case an operation to free them for 
 pressure is indicated. 
 
 Position — Landmarks — Incision. — Dependent upon nerve involved. 
 
 Operation. — The steps of the operation will be determined by the position 
 and nature of the compression. Where fibrous cicatricial tissue surrounds 
 the nerve, the mass is to be exposed by dissection — the nerve is to be isolated 
 either above or below the mass and is to be followed through it and dissected 
 out from it. The cause of compression, as far as possible, is to be removed, 
 so as to avoid a recurrence. Where a bony callus surrounds the nerve, this 
 is to be reached by the safest route through the muscular planes — the nerve 
 being similarly isolated above and below the mass — and freed through it. 
 It is often necessary to chisel away as much of the callus as imprisons the 
 nerve — and in order to render a recurrence of compression unlikely. The 
 wound is closed as usual. Cargile membrane has been used to prevent 
 re-adhesion. 
 
 Comment. — Nerves may be compressed by growing tumors — their relief 
 being determined by the treatment adopted for the tumor, or nerves may be 
 compressed by their thickened sheaths, which require longitudinal incision. 
 
 INTRANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 
 
 OPERATION OF MAT AS AND CRILE. 
 
 Description. — -The injection of a sterilized anesthetic solution directly 
 into a nerve-trunk. The injection may be made at the site of the proposed 
 operation, or above the site. 
 
 Indications. — To produce anesthesia in the region supplied by the nerve, 
 for the purpose of major or minor operations. Especially indicated in those 
 portions of the body in which nerve-trunks may be isolated, — and in those 
 cases in which general anesthesia is contraindicated. 
 
 Position — Landmarks— Incision. — Determined by the special operation. 
 
 Nature of the Anesthetic Solutions. — These have been of various con- 
 stitutions and percentages — there being no recognized standard solution 
 universally employed in this comparatively new field of surgery. Sterilized 
 solutions of cocain, of eucain B, of nirvanin, of Schleich's solution, and others, 
 have been used. Almost any suitable syringe may be employed, though a 
 special instrument is more appropriate. Matas (whose writing upon local 
 anesthesia this article largely follows) uses from 5 to 40 min. (according 
 to the size of the nerve) of Schleich's solution No. 1. (One tablet of Schleich 
 No. 1 dissolved in 100 minims of water, represents -5^ part of cocain hydro- 
 chlorid, 4 0V0 P art of morphin hydrochlorid, and -5-^-,- part of sodium chlorid.) 
 
 Operation. — The anesthetic fluid may be injected at the site of operation 
 or above it; — (a) Where the Injection is made into the Nerve-trunk above 
 the site of Operation — the anesthesia being produced in the region supplied 
 by the nerve: — (Suppose the injection be made into the sciatic nerve, .for 
 amputation of the leg); To prepare the way for the incision, anesthetize the 
 skin by intradermal infiltration — and the connective tissue by subdermal 
 
170 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 (subcutaneous) infiltration — both with the Schleich solution. Expose the 
 sciatic nerve above the bifurcation into internal and external popliteal and 
 isolate it sufficiently for manipulation. Insert the needle of the syringe 
 through the sheath of the nerve and into and among its fibers — and slowly 
 inject the anesthetizing fluid (the amount determined by the nature of the 
 solution and size of the nerve) until the entire extent of a transverse section 
 of the nerve has been infiltrated or "blocked" (Fig. 155). If this single 
 injection be considered sufficient to last throughout the operation, the wound 
 may be at once closed — otherwise it is temporarily packed with gauze. The 
 limb is elevated and exsanguinated by gravity. A circular constrictor is 
 applied above the site at which the nerve was infiltrated. Within a few 
 minutes of the infiltration, the distal regions supplied by the nerve will be 
 
 Fig. 155. — Intraneural Infiltration for Regional Anesthesia: — The great sciatic nerve 
 
 being here infiltrated. 
 
 completely anesthetic, and any operation may be performed thereon, as long 
 as the constrictor remains in situ, (b) Where Infiltration is made into 
 Nerve-trunks as exposed in the course of an Operation: — Anesthetize the skin 
 by intradermal infiltration, and the connective tissue by subdermal infiltration. 
 As each nerve is exposed it is isolated, taken up, and infiltrated, as in the 
 above method. Where the case is a limb, a circular constrictor is used as 
 above. Where the region is such an one as is involved in the radical operation 
 for inguinal hernia, no arrest of circulation is attempted. In this method 
 the anesthesia is complete not only at the site infiltrated, but in the regions 
 supplied by the infiltrated nerves — but lasts a shorter time, unless the infiltra- 
 tion be repeated, than where a constrictor can be applied. 
 
 Comment. — If the site of operation be supplied entirely by one nerve, 
 that nerve alone need be infiltrated, at some convenient point proximal to the 
 site of intended operation. If the site of operation, however, be supplied by 
 
PARANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 171 
 
 several nerves, each has to be separately infiltrated; — for example, in the 
 operation of amputation of the leg described above, if the operation is to be 
 above the level of the tuberosity of the tibia, the anterior crural nerve is to be 
 also injected, — if below that level, the long saphenous nerve is to be injected 
 instead of the anterior crural — the sciatic being, of course, infiltrated in both 
 instances. The entire upper limb can be anesthetized by infiltrating the 
 brachial plexus above the clavicle. 
 
 PARANEURAL INFILTRATION FOR REGIONAL ANESTHESIA. 
 
 MATAS' METHOD. 
 
 Description. — The injection of a sterilized anesthetic solution into the 
 tissues immediately surrounding a nerve-trunk, so planned as to envelop the 
 nerve as closely as possible in an anesthetic atmosphere, as it were. 
 
 Indications. — To produce anesthesia in the region of the infiltration and 
 as far beyond as the solution is diffused. 
 
 Position — Landmarks. — Determined by the special operation. 
 
 Operation. — Without making any incision for the exposure of the nerve, 
 the anesthetic solution is injected first intra dermally, to deaden the site super- 
 ficiallv, and then into the tissues immediately in the neighborhood of the 
 nerve', and as near to the nerve as possible. This infiltration of the tissues 
 alongside of the nerve is done upon a knowledge of the anatomy of the nerve 
 and its relation — and is meant to "envelop the nerve in an anesthetic atmos- 
 phere." In the case of dealing with an extremity, a few minutes after the 
 infiltration the part is elevated, exsanguinated by gravity, and a circular con- 
 strictor applied above the region of infiltration — subsequently to which the 
 parts below the infiltration will be anesthetized by the diffusion of the anesthetic 
 solution (Fig. 158). In other localities no attempt to control the circulation 
 is made. The anesthetic solutions and the special syringe for injection are 
 mentioned under Intraneural Infiltration. Matas uses the Schleich's solution 
 No. 1, calculating in this, as in other forms of regional anesthesia, not to 
 leave more than 1 gr. of cocain in the tissues. To illustrate the paraneural 
 method (copying from Matas' writing upon the subject) let the anesthetization 
 of the finger, for the removal of a nail or the opening of a felon, be taken. 
 "The skin at the root of the finger, on its dorsal aspect, is infiltrated over 
 two spots on each side of the phalanx nearest the carpometacarpal joint, 
 and on a level with the web of the hand. The needle is then thrust into each 
 spot and directed toward the known situation of the digital nerves, which are 
 deeply situated in the lateral aspect of the digits. From 10 to 15 minims of 
 the anesthetizing solution are diffused in the region of each nerve, with the view 
 of creating a cocain atmosphere around it. After a few minutes' delay to allow 
 the capillary circulation to diffuse the fluid, the hand is exsanguinated by 
 elevation, and an elastic constrictor is carried around the root of the finger 
 below the seat of the infiltration. The finger will then become numb and 
 dead to all painful impressions, and it will be possible to perform any operation 
 upon the digit, at any point beyond the line of constriction." 
 
 Comment. — This method is more applicable to smaller extremities and 
 parts — while the intraneural method to the larger. The paraneural infiltration 
 for regional anesthesia differs from local infiltration for regional anesthesia 
 (which may be represented by the common use of cocain hypodermatically) 
 in that in the latter no attempt is made to infiltrate along the anatomical 
 course of the nerves, but the injection is made almost at random into the 
 cutaneous and subcutaneous tissue. 
 
172 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 MASSIVE INFILTRATION ANESTHESIA WITH WEAK ANALGESIC 
 
 SOLUTIONS. 
 
 MATAS' MODIFICATION" OF SCHLEICH'S METHOD. 
 
 Description. — By infiltration anesthesia is meant ihe production of 
 diminished or suppressed sensibility of a part by means of edematization of 
 the tissues through the injection of weak analgesic solutions. The fluid 
 (from one to thirty ounces) is thrown into the tissues without reference to the 
 nerves of the part — the needle avoiding important structures. (The author, 
 however, has seen a quantity of the solution thrown into the internal jugular 
 vein, toward the heart, in operating upon the neck, without appreciable 
 result.) The analgesia thus produced is accomplished partly, and chiefly, 
 by the physical effect of the pressure exercised upon the conductivity of the 
 sensory nerves by the infiltrated fluid, and partly by the paralyzation of the 
 sensitive structures by the chemical action of the agents used. Several 
 analgesic solutions are in use, and almost any syringe may be employed for 
 their introduction. Matas, whose writings on this subject have been largely 
 followed, uses a special form of instrument and a special solution. 
 
 Fig. 156. — The Latest Model of Matas' Infiltrator :- 
 
 thesia. 
 
 -Used In massive infiltration anes- 
 
 Apparatus. — The infiltrator devised by Matas (Fig. 156) ''consists of 
 a glass receptacle with space for 7 oz. of fluid and 2 oz. of air. The fluid is 
 introduced through the bottom (or the part which becomes the bottom when 
 the apparatus is inverted and ready for use) which is closed by screw-cap 
 over a rubber washer which makes an air-tight joint. The bottle is graduated, 
 which enables the operator to see the amount of fluid that is being used during 
 an operation. The top is provided with a T-tube, with two stop-cocks, one 
 for the introduction of air, and the other for the egress of the fluid. A rubber 
 bulb for compressing the air is attached to the bottle by means of rubber 
 tubing and suitable connections (Fig. 156). Eight needles, straight and 
 
MASSIVE INFILTRATION ANESTHESIA. 
 
 173 
 
 curved, are provided with the outfit, varying in size from a fine hypodermic 
 needle to a large aspirating needle. The needles are connected to reservoir 
 by rubber tubing of sufficient length to give the operator freedom of movement 
 iii handling the needle. After the sterilized solution has been placed in the 
 receptacle this is charged with air until marked resistance is felt in compressing 
 the bulb, when the bulb and its tubing are detached from their special stop-cock. 
 The apparatus is now ready for infiltration. The chief advantages of this 
 apparatus over the ordinary syringes used for infiltration anesthesia are: — 
 (a ) That it allows the operator to infiltrate and edematize large areas rapidly, 
 continuously, or interruptedly without the delay caused by recharging or 
 exchanging svringes; — (b) That by the use of long needles it tends to diminish 
 the traumatism caused by frequent punctures made necessary by shorter 
 needles used with the ordinary quickly exhausted syringes." 
 
 Solutions. — The solution used by Matas for routine work is a sterilized 
 j^j- of 1 per cent, eucain B solution in normal salt solution ( T 8 o- of 1 per 
 cent.) — with 10 to 15 minims of 1 : 1000 adrenalin chlorid solution added 
 to the total amount injected. This solution is used in bulk, up to 5 or 6 
 ounces for injection into the tissues where the bulk of it will flow out — and 
 
 Fig. 157. — The Original Type of Matas' Infiltrator: — Shown here to illustrate the 
 manner of charging the receptacle with compressed air, which is done on the same general 
 principle in the latest instrument. 
 
 up to 2 ounces where this amount will be retained. The adrenalin is added 
 for the purpose of producing ischaemia of the parts, especially where no form 
 of constrictor can be used, and may be of benefit additionally because of its 
 action upon the circulation. For preliminary intradermal injection i of 1 per 
 cent, eucain B solution is used. 
 
 Indications. — "In a general way, this method of infiltration is indicated 
 in all operations in which the circulation cannot be controlled, and in which 
 the major part of the infiltrating solution must remain in the tissues. By this 
 method extensive extirpation of tumors, excision of malignant growths, ligation 
 of all the important vessels of the neck and extremities, resection of nerves 
 for neuralgia, excision of tongue, extirpation of thyroid gland, amputations, 
 operations for hernia and other abdominal operations on debilitated patients, 
 thoracotomy with resection of ribs, and other operations have been successfully 
 performed in the clinics of the author of this method by combining the intra- 
 neural method with local infiltration." 
 
 Preparation; — Position; — Landmarks. — Dependent upon the special 
 operation. 
 
 Operation. — "In this, as in all other methods of local anesthesia, it is 
 
174 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 most important to remember that the derm proper, and especially its papillary 
 layer, must be first edematized by intraarticular infiltration before beginning 
 the infiltration of the deeper planes; the same rule applies to mucous surfaces." 
 For this purpose the weaker solution above mentioned is used, carried through 
 a fine needle. "The field of the operation can then be edematized, (I) in toto; 
 i. e., by infiltration en bloc without reference to nerves or other anatomical 
 elements (as in the extirpation of a benign tumor of the breast); or (2) by 
 circumferential infiltration; i. e., by enclosing the field of operation within a 
 wall of anesthetizing edema, thus cutting off the enclosed space from all nerve 
 communication with the surrounding parts (e. g., the extirpation of a pedicu- 
 
 Fig. 158. — Matas' Older Form of Infiltrator: — Shown here to illustrate the manner 
 of accomplishing massive infiltration, after filling the space in the bottle with compressed air — 
 the same general technic being used with the latest instrument. 
 
 lated tumor, or sebaceous cyst)," or the amputation of a limb. Where it is 
 possible to control the circulation by a constrictor, and where exsanguination 
 can be practised, these should be done. "The solutions are injected tepid 
 or cold into the tissues; after the infiltration is completed the entire field is 
 covered with a sterilized ice-bag for three to five minutes, which by refrigera- 
 ting the solution, greatly intensifies the anesthetic action." Having obtained 
 loss of sensation, the operation is proceeded with as indicated in the special 
 instance. During the course of an operation begun by infiltration, individual 
 nerves may be taken up and injected intraneurally — or the infiltrating solu- 
 tion may be deposited among the deeper tissues (Fig. 158). 
 
EXPOSURE OF GASSERIAN GANGLION. 1 75 
 
 SURGICAL ANATOMY OF GASSERIAN GANGLION OF TRIFACIAL 
 
 NERVE. 
 
 Description and Relations. — (a) Both sensory and motor root of the 
 trifacial pass downward and forward through an aperture in dura mater, 
 which lies under cover of tentorium cerebelli and a little to outer side of apex 
 of petrous portion of temporal bone, to enter Meckel's space, between the 
 supporting and periosteal layers of dura mater, in which space the sensory 
 portion enlarges into the gasserian ganglion, (b) The gasserian ganglion, of 
 somewhat semilunar form, with convexity forward, rests in depression upon 
 upper surface of petrous portion of temporal bone, near its apex — and also to a 
 slight extent upon cartilage which occupies foramen lacerum medium. Its 
 upper surface is firmly attached to dura mater (roof of Meckel's space) — its 
 lower surface, less firmly (to floor of Meckel's space). Its inner part lies 
 near posterior extremity of cavernous sinus and internal carotid artery. 
 The motor root and the large superficial petrosal nerve lie beneath the ganglion. 
 From its convex antero-external border are given off the following main 
 divisions; — Ophthalmic, passing out through sphenoidal fissure; Superior 
 Maxillary, passing through foramen rotundum; Inferior Maxillary, passing 
 through foramen ovale and being joined immediately after its exit by the 
 motor root, which also passes through foramen ovale separately. 
 
 EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF 
 FIFTH NERVE BY THE DIRECT INFRA- ARTERIAL ROUTE. 
 
 cushing's method. 
 
 Description. — A flap of soft parts, including the temporarily resected 
 zygoma, is turned down, thus exposing the zygomatic and pterygomaxillary 
 fossae. An opening is then made, with trephine or special instrument, through 
 the most prominent portion of the great wing of the sphenoid, near, or including, 
 the zygomatic ridge (infratemporal crest). The dura is thus reached below 
 the middle meningeal artery and the ganglion exposed extra-durallv, in 
 Meckel's space. The route of approach is more direct, the hemorrhage less, 
 and the amount of handling of the brain less than in most of the methods of 
 reaching the ganglion. 
 
 Preparation. — Head shaved. 
 
 Position. — Patient on back, head on one side and supported by firm 
 pillow. Surgeon at side of head, either in front of or behind patient. Assis- 
 tant opposite. 
 
 Landmarks. — Outline of zygomatic arch. 
 
 Incision. — Horse-shoe in shape, the ends of the two limbs being upon 
 the outer and inner ends of the zygomatic arch, about 4 cm. (ij inches) apart, 
 and the upper part of the convexity extending about 5 cm. (4 inches) above 
 the zygoma. 
 
 Operation. — (1) A skin-flap of the parts overlying the temporal fascia 
 is turned down to a level just below the zygoma. The temporal vessels are 
 secured. (2) A second horse-shoe incision, like the first but slightly smaller, 
 is made through the temporal fascia, the base of the incision passing through 
 the periosteum along the middle of the outer aspect of the zygoma. Through 
 this periosteal incision free the zygoma of its periosteum except along the 
 attachment of the masseter muscle. Divide the zygomatic arch at its inner 
 
176 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 and outer ends with a Gigli saw conducted beneath it — having first drilled on 
 each side of each saw-cut, for future ligaturing. (3) Along the line of the 
 limbs and convexity of the preceding horse-shoe incision divide the temporal 
 muscle down to the bone. Turn the flap of soft parts, with zygoma adherent, 
 downward, firmly retracting it — so as to expose the zygomatic crest (infra- 
 temporal ridge), the lower part of the temporal fossa and the beginning of the 
 pterygomaxillary fossa. (4) An opening is now made through the prominent 
 part of the wing of the sphenoid, either by a trephine of about 3 cm. (i\ inches), 
 or by means of some special instrument, with or without previous burr-openings. 
 The dura in the middle fossa of the base of the skull is thus exposed at a point 
 to the outer side of and about midway between the foramina ovale and rotun- 
 dum — very near the foramina and below and to the outer side of the middle 
 meningeal artery emerging from the foramen spinosum. (5) The Gasserian 
 ganglion and its three branches are thus exposed, after gently separating the 
 dura from the bony wall of the middle fossa — these structures being still 
 covered by their special investment of the dura, constituting Meckel's cavity 
 or space (Fig. 159). This cavity of Meckel, which it is very important to 
 
 S BC D 
 
 Fir. 159. — Cushing's Operation for Exposure of Gasserian Ganglion and Three 
 Branches of Trifacial Nerve: — A, Gasserian ganglion; B, Ophthalmic division of fifth nerve; 
 C, Superior maxillary division; D, Inferior maxillary division; E, Floor of Meckel's space; F, 
 Dural arch and roof of Meckel's space; G, Middle meningeal artery. (Modified from Cushing.) 
 
 recognize, and which it is necessary to open before coming into direct contact 
 with the structures sought, is incised along its outer aspect, between the second 
 and third nerves, at their entrance into their foramina. By careful blunt 
 dissection the superior portion of the roof of Meckel',s space is further opened 
 up, leaving the ganglion and the second and third branches exposed upon the 
 floor, or lower aspect, of Meckel's space. The floor of Meckel's space is now 
 separated from these structures by blunt dissection, until the ganglion is 
 
EXPOSURE OF GASSERIAX GAXGLIOX. 177 
 
 raised from it. The dura is then separated on the inner side, where it lies 
 in contact with the sixth nerve and cavernous sinus, the separation being 
 accomplished toward the first division. The second and third divisions 
 are put on the stretch gently by means of blunt hooks and divided close to their 
 foramina. The body of the ganglion is seized with forceps and torn out, 
 together with the origins of the second and third divisions and the first division. 
 (6) Wounding of the middle meningeal artery is generally avoided. Hemor- 
 rhage from small arteries and veins, and the cavernous sinus, if wounded, is 
 controlled by packing temporarily. Where continuous packing is not neces- 
 sitated, the wound is closed throughout, without drainage — suturing back 
 the structures, including the zygoma, into normal position. The eye is covered 
 with rubber protective — avoiding all pressure. 
 
 Comment. — (1) Hemorrhage from the middle meningeal artery, the 
 chief source of serious hemorrhage, is avoided by approaching the ganglion 
 from below the artery. (2) The small size and protected locality of the 
 opening through the skull makes the necessity of a bone-covering less than 
 in the operations which reach the ganglion through the temporal fossa. (3) 
 No attempt should be made to remove the ganglion until it has been freed 
 from its special envelope of reflected dura — which should be accomplished 
 from above first, thus lessening the hemorrhage which often accompanies the 
 freeing of the ganglion from its bed. (4) The sixth nerve is often injured 
 in freeing the ophthalmic division of the nerve — and the sympathetic always 
 is, because of its intimate relation — but these occurrences are generallv not 
 permanently serious. (5) The zygoma is sometimes not sutured back into 
 position — but is allowed to sink into a less prominent position as the muscles 
 of mastication atrophy. (6) It may be necessary to ligate the middle menin- 
 geal artery. 
 
 EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF 
 FIFTH NERVE THROUGH TEMPORAL FOSSA BY OSTEOPLASTIC 
 FLAP. 
 
 HARTLEY-KRAUSE OPERATION. 
 
 Description. — Osteoplastic resection of temporal region with temporary 
 turning down of flap of bone and soft parts and separation of dura mater 
 from middle fossa of skull — the three divisions of the fifth nerve being exposed 
 and traced to the Gasserian ganglion, in Meckel's space, outside of the dura 
 proper. 
 
 Preparation. — Head shaved. 
 
 Position. — Patient on back; head to one side and supported by firm 
 pillow. Surgeon at side of head, either in front of or behind patient. Assist- 
 ant opposite. 
 
 Landmarks. — External angular process of frontal; tragus of ear; supra- 
 temporal ridge. 
 
 Incision. — A horseshoe-shaped incision is made over the temporal 
 region, its anterior extremity being near the external angular process of the 
 frontal bone, its posterior extremity near the tragus of the ear, and the highest 
 part of the curve reaching the supratemporal ridge (Fig. 160). 
 
 Operation. — (1) The above incision passes through all the soft tissues 
 and periosteum directly to the bone, along the entire line. (2) With periosteal 
 elevator, the soft parts of *' flap are freed from the bone to a slight extent 
 only, around the entire i . n line — the freeing at the two ends of the base- 
 
178 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 line being a little more extensive. Throughout the rest of its extent, the 
 flap remains adherent to the underlying bone. (3) With a trephine of about 
 1.3 cm. (J inch) diameter, two discs of bone are removed, the anterior with 
 its center over the tip of the sphenoid wing, the posterior having its center 
 over a point 2.5 cm. (1 inch) vertically above the external auditory meatus. 
 From these trephine openings the dura is separated as far as possible, both 
 
 Fig. 160.— Exposure of Gasserian Ganglion by Osteoplastic Flai — Preparatory to the 
 Hartley-Krause Operation: — I. — A, Periosteum; B, Horseshoe flap broken back and turned 
 down ; C, Dura mater, with anterior and posterior branches of middle meningeal artery. 
 
 along the straight basal line connecting the two openings, and in the direction 
 in which the convex bone-section is to be made. (4) A section of bone similar 
 in shape to the skin incision, but smaller in size, is now made. This section 
 is made from the squamous portion of the temporal and greater wing of the 
 sphenoid — the basal attachment being somewhat narrower than the greatest 
 
EXPOSURE OF GASSERIAN GANGLION. 
 
 179 
 
 transverse measurement of the convex portion. This bone-section was 
 formerly made by a special chisel cutting a triangular groove- — but is now 
 made by a motor or other saw — the section beginning at one trephine-opening 
 and ending at the other, care being taken to do no damage to the dura. (5) 
 The bone being thus cut through everywhere except across its basal line, 
 some stout instrument (such as an osteotome or elevator) is inserted into the 
 groove at its greatest convexity, resting against the parietal bone as a fulcrum 
 — then, with a sharp, sudden movement, this flap of skin, muscle, periosteum, 
 
 Fig. 161. — Exposure of Gasserian Ganglion" and Roots of Trifacial Nerve by 
 Osteoplastic Flap, by the Hartley-Krause Method: — II. — A, Retractor elevating brain 
 and exposing middle fossa of skull; B, Gasserian ganglion, with first division of trifacial nerve 
 passing through sphenoidal fissure, second division through foramen rotundum, and third 
 division through foramen ovale; C, Middle meningeal artery entering through foramen spinosum; 
 D, Position of cavernous sinus and internal carotid artery; the third, fourth, and sixth nerves 
 are seen between the cavernous sinus and the first division of the fifth nerve. The lamina of 
 dura forming Meckel's space has been incised over the ganglion and the third division, but is 
 not accurately shown in its reflection forming the roof of Meckel's cavity. Note: — the ganglion 
 and branches are represented somewhat disproportionately large and prominent, as well as 
 upon too high a plane. 
 
 and bone is prized outward and downward, generally snapping directlv and 
 evenly across the basal line just above the zygomatic arch, and remaining 
 hinged by the soft parts — and exposing an area of brain (covered by dura 
 mater) of about 5 to 7.5 cm. (2 to 3 inches) in diameter (Fig. 161). (6) If 
 
180 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 the middle meningeal artery is found injured, it is tied as near the foramen 
 spinosum as possible. (7) The dura mater and temporosphenoidal lobe of 
 the brain are now separated from the middle fossa of the skull. This is done 
 in the direction toward the apex of the petrous portion of the temporal bone, 
 and is accomplished by the fingers or a piece of gauze, or by a curved, blunt 
 elevator. Sometimes the dura is considerably torn, and sometimes the 
 artery is torn whether the dura is or not, requiring temporary packing of 
 the bony groove to control the hemorrhage, where ligature is impossible. 
 Injured dura should be sutured wherever possible. (8) The three divisions 
 of the nerve are now seen and are traced back from their foramina. The 
 positions of the carotid artery and cavernous sinus are located as nearly as 
 possible, for the purpose of guarding them. (9) Isolate and cut the first, 
 second, and third divisions close to the sphenoidal fissure, foramen rotundum, 
 and foramen ovale, respectively. Secure the proximal ends of the severed 
 nerves with forceps or silk, and, practising traction upon them, trace them 
 back to the gasserian ganglion — after incising the dura mater over them. 
 Then, raising the ganglion from its bed, sever its connections with the brain 
 close to the dura mater, and, if possible, without including or injuring the 
 motor root. (10) At the end of the operation the dura and unexposed cerebral 
 convolutions are allowed to fall into place — the flap of bone and soft parts is 
 turned up — and sutures applied to skin and muscles. 
 
 Comment. — (1) The width of the basal line of bone may be decreased 
 by rongeur forceps, thus increasing the likelihood of a clean, transverse 
 breakage — or a Gigli saw may be conducted under the bone at its base and 
 made partly to divide it. (2) In the use of either chisel or saw, the inner 
 tablet of the skull may be left uncut in two or three places, over a limited 
 extent, so that when the flap is broken back, these parts of the vitreous are 
 left as shelves for the flap to rest upon when turned back into place. (3) 
 Bleeding may be so great as compel one to pack and finish the operation in 
 two stages. (4) The advisability of removing the first division is doubtful, 
 because of the trophic changes which follow in the eye. The first division 
 is never involved alone. (5) The motor root should always be left undisturbed, 
 if possible — to avoid paralysis of the muscles of mastication. It is more apt to 
 be injured if the dura of Meckel's space be opened over the ganglion and the 
 sensory root be cut between the ganglion and the pons. When possible it is 
 best to cut the second and third divisions close to the foramen rotundum and 
 foramen ovale respectively — dissect them back to the ganglion, and remove the 
 parts of the ganglion corresponding to these divisions, leaving untouched the 
 first division, with its corresponding ganglion and the motor root. (6) If the 
 first division be removed, with the corresponding part of the ganglion, especial 
 care is needed not to harm the cavernous sinus and the nerves to the eye — 
 to aid in avoiding which, the second and third divisions should be removed 
 first to give more room. If the first division be accidentally severed, leave 
 the lacerated end as near the remains of the ganglion as possible. (7) If 
 much oozing follows packing, wick or gauze drainage is indicated for twenty- 
 four or forty-eight hours. (8) The chief dangers of the operations are — ■ 
 injury to internal carotid and cavernous sinus; laceration of brain; injury 
 to nerves of eye (third, fourth, and ophthalmic division) ; hemorrhage from 
 middle meningeal artery. (9) In Horsley's method of intracranial exposure 
 of the gasserian ganglion a large soft flap is turned down from the temporal 
 region, the underlying bone is removed by trephine and bone forceps (not 
 to be returned), the temporosphenoidal lobe exposed, the dura incised, the 
 ganglion exposed, and the root cut on the proximal side of the ganglion. 
 
EXPOSURE OF GASSERIAN GANGLION. 181 
 
 EXPOSURE OF GASSERIAN GANGLION AND THREE DIVISIONS OF 
 FIFTH NERVE BY TREPHINING THROUGH PTERYGOMAXILLARY 
 FOSSA. 
 
 rose's method. 
 
 Description. — The ganglion is approached through the pterygomaxillary 
 fossa, the zygoma being temporarily and the coronoid process of the inferior 
 maxilla permanently resected, and the trephine applied to include the anterior 
 and outer portion of the foramen ovale. The dura proper is not opened. 
 
 Preparation. — Head shaved; eyelids stitched together with temporary 
 sutures. 
 
 Position. — As in preceding operation. 
 
 Landmarks. — ( >uter canthus of eye; zygomatic arch; meatus auditorius 
 externus; angle and horizontal ramus of lower jaw. 
 
 Incision. — Begins near outer canthus of eye, about 1.3 cm. (h inch) 
 below the external angular process of the frontal — passes backward along 
 the upper border of the zygoma to its posterior extremity — thence downward 
 just in front of ear to the angle of the jaw — thence forward along the horizontal 
 ramus of the jaw to the facial vessels. 
 
 Operation. — (1) Reflection of the Skin Flap; — Incise through skin and 
 fascia only, along the above line. Raise this semicircular skin flap without 
 harming the facial nerve or Stenson's duct. (2) Exposure of the Pterygoid 
 Space; — Incise down through the periosteum for the entire length of the 
 zygoma, and detach the periosteum. Drill (for later wiring of the bones) 
 two holes through the zygomatic process of the malar, and two through the 
 root of the zygoma. Divide the bone (downward and forward) between the 
 two anterior holes — and also between the two posterior holes. Displace the 
 zygoma downward and backward, bringing the masseter with it (dividing 
 the necessary muscle-fibers). The coronoid process is exposed and cut 
 obliquely downward and forward, as low as possible, then turned upward, 
 and, together with tendon, cut away (there being no object in retaining it, 
 as it would waste with the other muscles of mastication supplied by the 
 motor fibers of the third division). (3) Exposure of the Foramen Ovale; — 
 Expose the internal pterygoid by removing the overlying fat and connective 
 tissue. The internal maxillary artery, which is generally found upon the 
 muscle, is divided between two ligatures. The inferior dental and lingual 
 gustatory nerves are sought at the lower border of the external pterygoid, 
 cut, and their proximal ends tied with silk, to serve as guides. Expose the 
 foramen ovale on the under surface of the great wing of the sphenoid, by 
 partly cutting away and partly retracting away (by scraping) the external 
 pterygoid — thus exposing both the great wing of the sphenoid and the external 
 pterygoid plate. The foramen ovale is sought by following up the silk liga- 
 ture, drawing the nerves of the third division taut, and also by the finger 
 feeling in its known position, a little behind and external to the external 
 pterygoid plate, remembering that just to the inner side and behind the 
 foramen ovale lie the eustachian tube and the middle meningeal artery about 
 to enter the foramen ovale. Bleeding is apt to be considerable here, espe- 
 cially from the veins of the pterygoid plexus and from veins passing through 
 the foramen ovale between the pterygoid plexus and the cavernous sinus. 
 This hemorrhage is controlled by gauze packing. (4) Opening the Base 
 of the Skull; — A small, long-handled trephine is placed just in front and 
 to the outer side of the foramen ovale, so that the margin of the foramen is 
 included in the disc of the bone to be removed. (5) Division of Nerve- 
 trunks and Partial Removal of the Ganglion; — The trephine-opening having 
 
182 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 been cleared and sufficiently enlarged by chisel or forceps, the surgeon follows, 
 by means of the silk ligature, the third division up to the ganglion, which is 
 Loosened from its bed and its second and third divisions freely resected — 
 the first being left undisturbed. (6) Closure of the Wound;— The wound 
 having been irrigated with i : 4000 bichlorid, dried and dusted with iodoform, 
 the previously drilled zygoma is wired, the temporal fascia sutured to the cut 
 margin of the fascia over the zygoma, and the wound closed without drainage. 
 The eyelid stitches are removed in three or four days. 
 
 Comment. — (1) The operation may be performed in two stages. (2) 
 The coronoid process may be drilled (for wiring) before cutting. 
 
 SURGICAL ANATOMY OF SUPRAORBITAL BRANCH OF FRONTAL 
 
 NERVE. 
 
 Description. — Passes forward from bifurcation of frontal nerve and 
 leaves orbit through supraorbital notch (or foramen) — and, giving off palpebral 
 branches, ascends vertically upward close to bone, beneath orbicularis pal- 
 pebrarum and occipitofrontalis to forehead, where it divides into cutaneous 
 and pericranial branches. The supraorbital vessels lie on its outer side. 
 
 EXPOSURE OF SUPRAORBITAL BRANCH OF FRONTAL AT 
 SUPRAORBITAL FORAMEN. 
 
 Position. — Patient supine; head slightly elevated. Surgeon on side of 
 operation, or above head. 
 
 Landmarks. — Supraorbital notch (or foramen) — which, if not easily 
 felt, lies at junction of inner and middle thirds of supraorbital margin. 
 
 Incision. — Transverse, about 2.5 cm. (1 inch) in length, along supra- 
 orbital margin, with center over position of supraorbital notch (or foramen) 
 — the evebrow having been previously shaved. 
 
 Operation. — Having steadied the brow by the first finger of left hand 
 (which also draws up the soft parts so as to hide subsequent scar) and de- 
 pressed lid with left thumb, carry the above incision through skin, fascia, 
 and orbicularis palpebrarum — when the nerve will be found upon the peri- 
 osteum, accompanied by its vessels. (Fig. 104). 
 
 SURGICAL ANATOMY OF SUPERIOR MAXILLARY BRANCH OF TRI- 
 FACIAL AND MECKEL'S GANGLION. 
 
 Description. — Arises from center of gasserian ganglion — runs forward 
 through foramen rotund urn — traverses upper part of sphenomaxillary fossa 
 — enters orbit through sphenomaxillary fissure — thence courses forward along 
 infraorbital groove, accompanied by infraorbital artery, to infraorbital canal 
 — along which it passes to emerge upon face through infraorbital foramen, 
 as the infraorbital nerve, terminating beneath levator labii superioris muscle 
 in a leash of branches. The distance of infraorbital foramen from foramen 
 rotundum is about 5 cm. (2 inches). 
 
 Sphenopalatine or Meckel's Ganglion. — Placed deeply in spheno- 
 maxillary fossa, beneath superior maxillary nerve, near sphenopalatine 
 foramen. Its relations are: — Superiorly, superior maxillary nerve; Poste- 
 
EXPOSURE OF SURERIOR MAXILLARY XERVE. 
 
 I8 3 
 
 riorly, sphenoid bone and Vidian canal; Externally, internal maxillary artery 
 and external pterygoid muscle; Internally, vertical plate of palate and spheno- 
 palatine foramen. 
 
 Comment. — The posterior superior dental is given off from the superior 
 maxillary just before the nerve enters the infraorbital canal — the middle 
 superior dental, at the back part of the canal — and the anterior superior 
 dental just before its exit upon the face. To insure, therefore, the removal 
 of the origin of the posterior superior dental nerve, the trunk has to be 
 removed as far back as Meckel's ganglion. . 
 
 EXPOSURE OF SUPERIOR MAXILLARY NERVE AT FORAMEN RO- 
 TUNDUM BY OSTEOPLASTIC RESECTION OF MALAR AND ADJA- 
 CENT BONES. 
 
 kocher's operation. 
 
 Description. — Having temporarily raised a bony flap (composed of the 
 parts mentioned below), the infraorbital nerve is liberated and traced back to 
 the superior maxillary nerve and Meckel's ganglion, at the foramen rotundum 
 in the sphenomaxillary fossa. 
 
 Fig. 162. — Skin* Incisions for Exposure of Superior and Inferior M\xillary 
 Nerves: — A, Kocher's incision for osteoplastic exposure of superior maxillary nerve at foramen 
 rotundum; B, Kocher's incision for osteoplastic exposure of inferior nerve at foramen ovale. 
 
 Position. — Patient supine; head elevated and turned to opposite side. 
 Surgeon on side of operation. 
 
 Landmarks. — Infraorbital foramen; infraorbital margin of orbit; malar 
 bone. 
 
 Incision. — Begins 1 cm. (nearly h inch) internal to the infraorbital 
 foramen, and \ cm. (about \ inch) below the inner end of the infraorbital 
 margin — -and runs almost horizontally outward, with slight downward inclina- 
 tion, over the inferior aspect of the malar, to end over the zygoma (Fig. 162, A). 
 
 Operation. — This incision exposes the angular artery at it- inner end, 
 enabling the vessel to be displaced further inward or ligated. Steno's duct 
 lies below the incision. The inner end of the incision passes down to the bone 
 
184 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 between the fibers of the orbicularis palpebrarum and the levator labii 
 superioris. The orbicularis, together with the periosteum, is raised from the 
 bone as far upward as the orbit. The levator labii superioris is dissected 
 subperiosteal! v down to the infraorbital foramen, where the infraorbital 
 nerve is secured with a tenaculum or ligature. The outer portion of the 
 incision runs above the origins of the zygomatici — these are detached down- 
 ward — and the anterior fibers of the masseter are separated from the inferior 
 and internal aspects of the malar. The external and internal surfaces of the 
 malar are thus bared. The malar process of the superior maxilla is bared, 
 upon its anterior surface, up to the infraorbital foramen — and, upon its 
 superior surface, as far posteriorly as the sphenomaxillary fissure. Retract 
 the upper edge of the wound upward sufficiently to expose the frontomalar 
 suture, which is so chiseled through toward the posterior part of the spheno- 
 maxillary fissure that its superior border, the orbital process of the malar, 
 part of the orbital plate of the sphenoid, and part of the zygomatic process 
 can be raised (Fig. 163). Anteriorly, the bone is chiseled through from 
 
 Fig. 163. 
 
 -Bone Sections in Kocher's Osteoplastic Exposure of Superior Maxillary 
 Nerve at Foramen Rotundum. 
 
 above the infraorbital nerve (in such a manner that the roof of the infraorbital 
 canal is carried away) downward and outward, to below the anterior border 
 of the origin of the masseter — and then upw 7 ard through the external wall of 
 the antrum until it meets, posteriorly, the section through the orbital structures. 
 Thus the external part of the orbital plate and the supero-external wall of the 
 antrum, along with its posterior angle, remain connected with the malar bone, 
 when the latter is levered out. Having raised the orbital fat with a special 
 elevator and protected the globe of the eye, the mass of bone is dislodged 
 upward and outward from the wound by means of a stout hook or periosteal 
 
EXPOSURE OF SUPERIOR MAXILLARY NERVE. 185 
 
 elevator. The infraorbital nerve, which is kept taut by the ligature attached 
 to it, is now traced through the upper part of the opened antrum to the foramen 
 rotundum. A small, blunt hook is carried behind the descending spheno- 
 palatine nerves and made to grasp the main trunk, which is then divided or 
 wrenched out. The accompanying infraorbital artery is either retracted or 
 ligated. The malar bone, with its attached bony fragments, is now put back 
 into its normal position — where it will generally remain without sutures, 
 although fixation sutures may be used if desired. The soft parts are closed 
 without drainage. No harm is ordinarily done by opening the antrum — 
 and verv little disfigurement results. 
 
 EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
 GANGLION BY THE ANTRAL ROUTE. 
 
 CARXOCHAN'S OPERATION. 
 
 Description. — The superior maxillary nerve is removed from the infra- 
 orbital foramen to the foramen rotundum, together with Meckel's ganglion— 
 by following the course of the infraorbital canal, and removing parts of the 
 anterior wall, roof, and posterior wall of the antrum of Highmore. 
 
 Position. — Patient supine; head elevated and turned slightly to one side. 
 Surgeon on side of operation. 
 
 Landmarks. — Infraorbital foramen (which is about S mm. — J inch — 
 below the infraorbital margin, and on a line drawn from the supraorbital 
 foramen to a point between the two bicuspids of both jaws). 
 
 Incision. — -V-shaped (two sides of an equilateral triangle, each side 
 being about 2.5 cm. — 1 inch — long), placed with its center over the infraorbital 
 foramen and its two limbs upward. 
 
 Operation. — (1) This incision is carried to the bone. The flap is then 
 turned up over the closed eye and its apex stitched to the forehead. (2) 
 The infraorbital nerve is isolated at the foramen, cut as long as possible, 
 and tied with silk — to serve as a guide and means of traction. (3) A trephine 
 of about 1.3 to 2 cm. (§ to f inch) in diameter, or a chisel, is now applied to 
 the cleared bone, and a portion of bone removed including the foramen in its 
 upper half — and the mucous membrane of the antrum is incised. (4) The 
 upper portion of the posterior wall of the antrum is similarly removed over 
 an area of about 6 mm. (\ inch), either by trephine or chisel. (5) The mucous 
 membrane covering the roof of the antrum is now divided in the direction 
 of the infraorbital canal, followed by breaking away the bony floor of the 
 canal, which may be done by chisel or stout scissors, while practising traction 
 upon the nerve as a guide. (6) By this means, and by the use of long slender 
 scissors and dissecting forceps, the nerve is freed back across the spheno- 
 maxillary fossa to the foramen rotundum, until it hangs freely exposed. 
 
 (7) Effort should be made to recognize Meckel's ganglion at this stage, locating 
 it as definitely as possible. Considerable bleeding may be expected at this 
 period of the operation — hemorrhage being controlled chiefly by pressure. 
 Artificial illumination should be used. The nerve, while slight traction is 
 being applied, should be divided at the foramen rotundum and from its 
 sphenopalatine branches. The nerve and ganglion are then withdrawn. 
 
 (8) The soft parts are now sutured — and, if much oozing occur, temporary 
 drainage is to be provided for through the lower angle of the wound, or tem- 
 porary packing may be necessary, with subsequent suturing of the lower 
 part of the wound. 
 
186 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 Comment. — (i) A T-shaped incision may be used — the horizontal 
 portion being placed under the lower margin of the orbit, and the vertical 
 portion running down on the cheek to near the mouth. Or a r -shaped 
 incision may be used — the horizontal portion along the orbit, and the vertical 
 portion in the nasolabial groove. Probably the best incision is a long trans- 
 verse one below the orbital margin, with strong retraction. (2) When 
 Meckel's ganglion is removed, the vidian nerve is paralyzed and therefore 
 the motor branches to the palate muscles. 
 
 EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
 GANGLION BY THE ORBITAL ROUTE. 
 
 Description. — After subperiosteally displacing the contents of the orbit 
 from the infraorbital canal and removing the roof of the canal, the nerve 
 is followed back to and beyond Meckel's ganglion and cut at the foramen 
 rotundum. 
 
 Position. — As in the above operation. 
 
 Landmarks. — Infraorbital margin and infraorbital foramen. 
 
 Incision. — Curved incision along lower margin of orbit over infraorbital 
 foramen — extending from near internal angular process to external angular 
 process of frontal. 
 
 Operation. — Carry the incision to the bone throughout. Isolate the 
 nerve — cut as long as possible — and attach a stout piece of silk to the proximal 
 end as a guide and means of traction. The bone between the infraorbital 
 foramen and infraorbital margin is removed by trephine or chisel, exposing 
 the anterior portion of the infraorbital canal. The periosteum of the floor 
 of the orbit is raised along the orbital margin with a periosteal elevator — 
 a spatula or retractor is placed beneath this and the tissues of the orbit are 
 held out of the way. The roof of the canal is next broken down with a fine 
 chisel, or other instrument — bleeding being controlled by pressure— and the 
 nerve lifted out of its bed by traction on the ligature — and is then traced 
 back with delicate instruments to the foramen rotundum and removed, 
 together with Meckel's ganglion and its terminal filaments. The orbital 
 contents are then allowed to fall back into place and the skin incision sutured. 
 
 Comment. — It is exceedingly difficult, and probably impossible, actually 
 to leach the ganglion by this method, especially without wounding the eye- 
 structures. It is also difficult to make the section far enough back to include 
 all the dental nerves. 
 
 EXPOSURE OF SUPERIOR MAXILLARY NERVE AND MECKEL'S 
 GANGLION BY THE PTERYGOMAXILLARY ROUTE. 
 
 BRAUN-LOESSEN OPERATION. 
 
 Description. — The nerve and ganglion are reached in the pterygo- 
 maxillary fossa by temporarily resecting the zygoma, turning it and the 
 masseter muscle downward, firmly retracting the temporal muscle backward, 
 and following the posterior surface of the superior maxillary bone into the 
 pterygomaxillary fossa. 
 
 Position. — Patient supine; head on one side and elevated; surgeon to 
 right for both sides. 
 
EXPOSURE OF SUPERIOR MAXILLARY NERVE. 187 
 
 Landmarks. — External angular process of frontal; zygoma; posterior 
 border of ascending ramus of lower jaw. 
 
 Incision. — Begins at external angular process of frontal, passes downward 
 and backward along upper border of zygoma to tragus of ear, thence down- 
 ward in front of ear along posterior margin of inferior maxilla to angle of 
 lower jaw. 
 
 Operation. — (1) This incision (the region having been shaved) passes 
 only through skin and superficial fascia — and the flap of integumentary 
 tissues thus raised by dissection is turned forward and temporarily attached 
 to the nose by suture. (2) An incision is made along the zygoma, passing 
 to the bone, which is then exposed subperiosteally. Two holes are drilled 
 (for wiring the bone later) through the malar bone on a line with a continua- 
 tion of the upper part of its posterior border, and two through the zygoma 
 near its root. The zygomatic arch is then sawed through between the two 
 anterior drill-holes and between the two posterior drill-holes, directing the 
 saw from without inward at the two ends (forming a beveled shelf for the 
 arch to rest upon when replaced). The temporal fascia has been freed 
 along its upper border in exposing the arch — and now the entire arch is 
 turned down, with its attached masseter, cutting whatever fibers of that 
 muscle are still holding the arch in place. (3) At this stage the mouth is 
 opened with a gag and the lower jaw depressed, to carry downward and 
 backward the coronoid process, with its temporal attachment — at the same 
 time drawing backward with retractors the temporal muscle and tendon 
 from the anterior portion of the temporal fossa. If this do not give sufficient 
 exposure, the anterior part of the muscle and tendon is divided transversely. 
 (4) The pterygomaxillary fissure is thereby exposed — and the internal maxil- 
 lary artery and vein are seen entering and leaving the pterygomaxillary 
 fossa through this fissure and are both ligated. The superior maxillary 
 nerve is found leaving the foramen rotundum and is brought forward by 
 means of a nerve-hook. The nerve and Meckel's ganglion can be more 
 thoroughly exposed, at this stage of the operation, by chiseling away the 
 spur of bone at the base of the external pterygoid plate, projecting outward 
 and forward across the pterygomaxillary fissure and partially blocking the 
 entrance to the pterygomaxillary fossa — and then both nerve and ganglion 
 can be hooked forward. (5) In concluding the operation, the temporarily 
 removed zygomatic arch is wired at both ends where previously drilled. If 
 the temporal muscle have been partly severed, this is sutured. The temporal 
 fascia is sutured to the cut margin of fascia over the zygoma. The skin 
 incision is closed as usual. 
 
 Comment. — (i) If the infraorbital nerve be exposed at its emergence 
 upon the face from the infraorbital foramen and be severed, then by traction 
 upon the nerve hooked up in the sphenomaxillary fossa the entire length 
 of the infraorbital nerve may be drawn out of the canal backward and all its 
 dental branches torn across in their bony canals. (2) This operation is 
 similar, in principle, to Rose's method of exposing the gasserian ganglion— 
 and the chief indication for its use is where it is found desirable to expose 
 the inferior maxillary at the foramen ovale, as well as the superior maxillary, 
 with Meckel's ganglion, at the foramen rotundum. To expose the superior 
 maxillary and Meckel's ganglion alone, the antral or the orbital route would 
 be preferable; — and to expose all three roots, or the second and third, the 
 Hartley-Krause or the Rose operation, especially the former, would be better. 
 
1 88 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 EXPOSURE OF INFRAORBITAL NERVE AT INFRAORBITAL 
 
 FORAMEN. 
 
 Position. — Patient's head slightly elevated. Surgeon to side of operation. 
 
 Landmarks. —Infraorbital foramen — which, if not palpable, lies about 8 
 mm. (J inch) below infraorbital margin, and on line from supraorbital foramen 
 to a point between the two bicuspids in both jaws. 
 
 Incision. — About 2 cm. (f inch) in length, over the infraorbital foramen, 
 parallel with the margin of the orbit. 
 
 Operation. — Skin, fat, and orbicularis palpebrarum are incised. The 
 levator labii superioris is exposed and also incised. The nerve is found at 
 its emergence from the foramen. (Fig. 106). 
 
 Comment. — The infraorbital nerve may be exposed through the mouth, 
 without scarring. Having made the gingivolabial fold tense, an incision is 
 made through the mucous membrane and periosteum along the line of reflec- 
 tion from the upper lip to the superior maxilla. The soft parts are then 
 dissected away from the bone along the canine fossa, subperiosteally, and 
 firmly retracted upward — until the infraorbital foramen is reached. 
 
 Note. — For the Anatomy of the Infraorbital, see the Superior Maxillary 
 nerve. 
 
 SURGICAL ANATOMY OF INFERIOR MAXILLARY BRANCH OF TRI- 
 FACIAL AND THE OTIC AND SUBMAXILLARY GANGLIA. 
 
 Description of Inferior Maxillary. — Formed of two roots — a large 
 sensory root from the inferior angle of gasserian ganglion — and a small 
 motor root which passes under the ganglion and unites with the sensory root 
 just after it has passed through the foramen ovale — both roots passing through 
 the foramen separately. The nerve divides into anterior and posterior divi- 
 sions 3 to 4 mm. Q inch, about) beneath the base of skull and under cover 
 of the external pterygoid — the former receiving the greater part of the motor 
 root and the latter the greater part of the sensory root. 
 
 Ganglia. — (1) Otic (Arnold's) Ganglion; — situated immediately beneath 
 foramen ovale, having inferior maxillary nerve on its outer side, the eustachian 
 tube on its inner side, and the middle meningeal artery on its posterior side. 
 (2) Submaxillary Ganglion; — placed between mylohyoid and hyoglossus 
 muscles, above deep portion of submaxillary gland, and at outer side of 
 Wharton's duct. 
 
 Note. — Foramen ovale lies on a line connecting the eminentia articularis, 
 at root of zygoma, of one side, with that of the other, and about 3 cm. (if 
 inches) from the eminentia — and is directly posterior and a little external 
 to the external pterygoid plate. The middle meningeal artery enters the 
 foramen spinosum just behind the foramen ovale. (3) The internal maxillary 
 artery, in its second part, runs forward and upward on outer surface of external 
 pterygoid muscle. (4) The pterygoid plexus of veins lies on the external 
 pterygoid muscle. 
 
 EXPOSURE OF INFERIOR MAXILLARY NERVE AT FORAMEN OVALE 
 BY OSTEOPLASTIC RESECTION OF MALOZYGOMATIC ARCH. 
 
 kocher's operation. 
 
 Description.— Having temporarily resected the malozygomatic arch, 
 the pterygomaxillary fossa is exposed, and the third division of the fifth nerve 
 traced to its exit from the foramen ovale. 
 
EXPOSURE OF INFERIOR MAXILLARY NERVE. 
 
 189 
 
 Position. — Patient supine; head elevated and turned to opposite side. 
 Surgeon on side of operation. 
 
 Landmarks. — Frontal process of malar; posterior extremity of zygoma; 
 pinna of ear. 
 
 Incision. — Begins just posterior to the frontal process of the malar — 
 passes thence obliquely downward and backward to the posterior end of the 
 zygoma — and is carried thence upward and backward, in front of the ear, 
 at right angles to the first portion of the incision (Fig. 162, B). 
 
 Operation. — The first part of this incision is superficial — the latter 
 portion, passing upward in front of the ear, is carried down to the bone, 
 and the temporal vessels ligated. More anteriorly the incision divides the 
 skin, superficial fascia, dense temporal fascia, and some fibers of the orbicularis 
 palpebrarum — all of which are displaced downward, together with branches 
 of the facial nerve going to the orbicularis and frontal muscles. The malar 
 bone is exposed just behind its frontal process and divided vertically with a 
 
 Fig. 164. — Bone Sections for Kocher's Osteoplastic Exposure of Inferior Maxillary 
 Nerve at Foramen Ovale, at Malar and Zygoma. 
 
 saw (Fig. 164). The zygoma is similarly divided transversely near its 
 posterior root. The malozygomatic arch is then displaced downward with a 
 strong hook. The external aspect of the temporal muscle is thus exposed — 
 and its posterior and inferior borders are separated from the skull and retracted 
 firmly forward. If necessary to afford freer access — which is rarely the 
 case — the temporal insertion into the coronoid may be divided, or the coronoid 
 itself be removed. Forward retraction of the temporal, however, is usually 
 sufficient — together with the forward displacement, by retraction, of the 
 structures of the retromaxillary fossa. All the soft parts, together with the 
 periosteum, are thus liberated and retracted forward and inward — thereby 
 exposing the external aspect of the pterygoid process — just posterior to the 
 sharp edge of which the foramen is readily palpable, lying about 3 cm. (ij 
 inches) internal to the zygomatic process. The middle meningeal artery, 
 entering the foramen spinosum, lies just behind. The branches of the max- 
 illary lie in the parts already retracted downward. The sometimes severe 
 hemorrhage can be controlled by packing temporarily. The inferior maxillary 
 
190 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 nerve is seized near its exit with a small, blunt hook and drawn forward — and 
 is then grasped with forceps and removed entire. If the hemorrhage have 
 ceased, and it is certain all the nerve has been removed, the malozygomatic 
 arch is replaced and sutured into position and the wound closed throughout. 
 If, on the other hand, hemorrhage persist, and there is uncertainty as to the 
 nerve, the wound is packed for a time — and reopened in one or two days — 
 and then secondarily sutured. The scar following the operation is not promi- 
 nent. 
 
 EXPOSURE OF INFERIOR MAXILLARY NERVE AT FORAMEN OVALE 
 —OR OF SUPERIOR MAXILLARY NERVE AT FORAMEN ROTUNDUM. 
 
 MIXTER'S OPERATION. 
 
 Description. — Mixter's operation consists in a temporary excision and 
 downward displacement of the zygomatic arch, with the attached masseter 
 — followed bv a backward displacement of the temporal muscle, to reach 
 the superior maxillary nerve and foramen rotundum — and a forward dis- 
 placement of the muscle to reach the inferior maxillary and foramen ovale. 
 The inferior maxillary nerve may be exposed at its origin by any of the opera- 
 tions exposing the gasserian ganglion, either intracranially or extracranially. 
 
 Position. — Patient on back; head elevated and turned to one side. Surgeon 
 on side of operation, or to right for both operations. 
 
 Landmarks. — Zygoma; temporal ridge. 
 
 Incision. — Curved, with convexity upward — beginning about 1.3 cm. 
 {\ inch) below malar portion of zygomatic arch and passing upward along 
 posterior margin of malar bone and external angular process of frontal bone, 
 to commencement of temporal ridge — thence follows lower temporal ridge 
 to opposite anterior margin of ear — and then curves downward to pass in 
 front of ear and ends about 1.3 cm. (J inch) below root of zygoma. 
 
 Operation. — The above incision is made through the shaved skin and 
 through the fascia — and this flap is turned downward, guarding Steno's duct. 
 The temporal artery is ligated, unless it can be displaced backward. The 
 zygomatic arch is exposed subperiosteal!}- and sawed through in front and 
 behind, beveling from without inward — and guarding against opening the 
 inferior maxillary articulation behind. The zygoma, attached masseter, and 
 fatty connective tissue are now well retracted downward. The temporal 
 muscle and its attachment to the coronoid process become thereby well exposed 
 — and are manipulated in accordance with the structure sought: — (a) To 
 Expose the Superior Maxillary Nerve and the Foramen Rotundum: — The 
 temporal muscle and tendon are firmly retracted posteriorly, by a broad, 
 smooth retractor, aided by an assistant's depressing the jaw — the surgeon 
 being guided by the posterior wall of the superior maxillary bone and the 
 spur of bone projecting forward and outward from the base of the external 
 pterygoid plate. This spur is chiseled away to better expose the foramen 
 rotundum, if necessary — the chiseling being done in a forward and slightly 
 inward direction, to avoid going into the middle fossa of the skull. Having 
 removed this spur, the superior maxillary nerve is to be found crossing the 
 pterygomaxillary fossa from the foramen rotundum to the infraorbital foramen, 
 with Meckel's ganglion beneath it, and near the sphenopalatine foramen, 
 (b) To Expose the Inferior Maxillary Nerve and Foramen Ovale: — The 
 temporal muscle and tendon are now firmly retracted forward (the jaw 
 being now closed to carry the coronoid process forward) — the surgeon being 
 
EXPOSURE OF INFERIOR DENTAL NERVE IN MOUTH. 191 
 
 guided to the foramen ovale by its position just posterior and external to the 
 base of the external pterygoid plate, at a distance of about 3 cm. (1^ inches) 
 internal to the anterior margin of the posterior attachment of the zygoma 
 and slightly posterior to this line drawn directly inward. On the way inward 
 the internal maxillary artery is met on the external pterygoid muscle and 
 ligated. The pterygoid plexus of veins also lies upon this muscle. The 
 external and internal pterygoid muscles can generally be displaced by retrac- 
 tion without necessitating their incision. The foramen ovale is usually 
 recognized by the tip of the finger and the nerve is exposed emerging from 
 it and drawn forward by a hook. Free hemorrhage may necessitate packing 
 one part of the wound while working in another. In concluding the operation 
 for exposure of either structure, the zygoma is replaced and the flap turned 
 back into position. 
 
 Comment. — (I) If the zygoma be drilled anteriorly and posteriorly 
 and then sawed between each pair of drill-holes, it may be subsequently 
 wired. (2) If sufficient room cannot be gotten by retraction of the temporal 
 muscle and tendon, it may be divided in part, transversely — the anterior 
 portion being cut to reach the foramen rotundum — and the posterior portion 
 in order to reach the foramen ovale. The muscle should be sutured on 
 completing the operation. (3) The coronoid process could be drilled, sawed 
 between the drill-holes, and the coronoid tip and temporal attachment turned 
 upward — to be afterward sutured back in place. (4) As much of the pterygoid 
 muscles (especially the external) may be divided, or drawn away from its 
 origin at the sphenoid, as needed. But the less the detachment of the tem- 
 poral and pterygoid muscles, the less the involvement of the jaw articulation 
 subsequently — except that caused by paralytic atrophy if the motor part of 
 the third division be cut. (5) The motor part of the inferior maxillary is 
 to be avoided if possible — but is generally unavoidably included in the destruc- 
 tion of the sensory portion. 
 
 SURGICAL ANATOMY OF INFERIOR DENTAL NERVE. 
 
 Description and Relations. — A sensory nerve — a branch of inferior 
 maxillary nerve, passing down under cover of external pterygoid muscle, it 
 descends to outer side of internal pterygoid, to interval between ramus of 
 inferior maxilla and internal lateral ligament, to dental foramen — accom- 
 panied by inferior dental artery and having lingual nerve in front and internal 
 to it. The mylohyoid branch is given off just before the nerve enters the 
 dental canal, and the mental branch at its exit at the mental foramen. The 
 dental foramen is surrounded by the lingula of Spix, to which is attached 
 the internal lateral ligament, the groove for the mylohyoid nerve being just 
 behind it and the attachment of the internal pterygoid muscle reaching to 
 its base. The inferior dental vessels pass along behind and outside the 
 nerve. The internal maxillary artery passes safely above the dental foramen. 
 
 EXPOSURE OF INFERIOR DENTAL NERVE IN MOUTH 
 
 PARAVICINI'S INTRABUCCAL METHOD. 
 
 Position. — Patient supine; head slightly raised; gag in opposite side of 
 mouth; cheek of operated side held open by retractors and commissure of 
 mouth drawn backward. Surgeon faces patient and stands on his right for 
 both operations. A head-mirror should be used. 
 
192 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 Landmarks. — Ascending ramus of jaw; spine of Spix; internal pterygoid 
 muscle. 
 
 Incision. — About 2.5 cm. (1 inch) in length — along anterior border of 
 ascending ramus of inferior maxilla, about 7 mm. (^ inch) to inner side 
 of sharp anterior border of coronoid process, and ending over the spine of 
 Spix. 
 
 Operation. — Having incised and detached the mucous membrane and 
 periosteum, feel for the spine of Spix — cutting the internal lateral ligament 
 with scissors if necessary in order to expose the nerve entering the foramen — 
 which is then isolated and drawn forward. The inferior dental artery lies 
 in close contact and should be avoided. In completing the operation, it is 
 better to close the incision with sutures — though these are often omitted. 
 
 Comment. — Expose the dental foramen that the lingual may not be 
 taken for the inferior dental nerve. If possible, avoid injuring the internal 
 lateral ligament, which is attached to the spine of Spix. 
 
 EXPOSURE OF INFERIOR DENTAL THROUGH ASCENDING RAMUS 
 OF INFERIOR MAXILLA. 
 
 Description. — The outer aspect of the lower jaw is exposed and the 
 nerve reached by trephining the bone. 
 
 Position. — Patient's head turned to one side and slightly elevated. 
 Surgeon on side of operation. 
 
 Landmarks. — The four borders of the ascending ramus of the inferior 
 maxilla. 
 
 Incision. — Curved, circumscribing the angle and lower half of ascending 
 ramus of lower jaw — the transverse curve being just above the lower margin 
 — and the vertical limbs corresponding with the anterior and posterior borders. 
 Thus Stenson's duct escapes and but few branches of the facial nerve are 
 injured. 
 
 Operation. — This incision is first carried through skin and superficial 
 fascia, when whatever nerves are in line of incision are retracted (especially 
 the buccal and supramaxillary) — then through masseter and periosteum to 
 bone. The soft parts are now freed from bone subperiosteally and retracted 
 strongly upward, gaining room by this upward retraction without harm to 
 the facial nerve or Stenson's duct. A window of bone, having its center 
 corresponding with this quadrilateral surface of bone, is then removed with 
 the trephine or chisel (a disc about 1.3 to 2 cm. — h to f inch — in diameter), 
 remembering that the lower and anterior part of the ascending ramus is 
 much thicker than the upper and posterior. Approach the nerve and accom- 
 panying artery with care, elevating, rather than chiseling or trephining, the 
 last thickness of bone. The nerve is then isolated in its canal. 
 
 Comment. — (1) The nerve can be reached at its entrance into the dental 
 canal and traced up to the foramen ovale by an extension of this operation, 
 by widening the sigmoid notch. The incision passes through skin and 
 superficial fascia only — beginning at the middle of the zygoma, passing 
 backward and downward in front of the tragus to the angle of the jaw, and 
 thence forward to a point just posterior to the facial artery. Raise this flap 
 of skin and superficial fascia as far as the anterior border of the masseter 
 and turn it forward. Expose Stenson's duct and edge of the parotid gland 
 (sufficiently to guard them). Divide the masseter and overlying deep fascia 
 down to the bone in a transverse direction, and between Stenson's duct above 
 and the highest branch of the facial nerve below. Free the muscle from 
 
SURGICAL ANATOMY OF LINGUAL NERVE. 193 
 
 the bone at the sigmoid notch and just below. Apply the trephine so as 
 to leave a slight bridge of bone between the sigmoid notch and the trephine- 
 opening — and subsequently cut this bridge away with bone-forceps. Expose 
 the inferior dental nerve and artery — ligate the artery and also the internal 
 maxillary artery (upon the external pterygoid muscle) if necessary. Secure 
 the nerve with silk ligature, and, by traction on silk, follow the nerve to the 
 foramen ovale, retracting the external pterygoid upward (or divide it). Sever 
 the nerve as high and as low as possible. The lingual nerve, lying further 
 forward and inward, may be also reached at the same time. (2) The entrance 
 to the inferior dental canal may also be reached from the inner aspect of the 
 inferior maxilla — by making an incision around the angle of the jaw, corre- 
 sponding with the insertion of the masseter, and raising the soft parts from 
 the inner surface of the bones subperiosteally to the dental foramen — the 
 mouth cavity not being opened (Liicke-Sonnenburg operation). (3) The 
 operation of exposing the inferior dental nerve through the mouth is to be 
 preferred, as being less disfiguring — although probably more difficult. 
 
 EXPOSURE OF INFERIOR DENTAL NERVE AT MENTAL FORAMEN, 
 FROM WITHIN MOUTH. 
 
 Description. — The lower lip is everted and an incision made over the 
 site of the mental foramen. 
 
 Position. — Patient supine; head supported and to one side. Surgeon 
 on side of operation, or on right for both operations. Assistant draws lower 
 lip well downward. 
 
 Landmarks. — A line drawn over the supraorbital foramen and between 
 the two bicuspids of both jaws will cross the infraorbital and mental foramina 
 — the mental foramen, in the adult, generally lying midway between the upper 
 and lower borders of the jaw proper (exclusive of teeth). 
 
 Incision. — Transverse, through mucous membrane along line of its 
 reflection from lower lip to inferior maxilla, with its center between the two 
 bicuspids, the lower lip being firmly drawn downward. A vertical incision 
 may be made instead of the transverse. 
 
 Operation. — This incision passes through periosteum to bone, upon 
 slight downward freeing of which the nerve is found emerging from the 
 mental foramen. 
 
 Comment. — An incision could be made from without, through the 
 tissues of the chin, over the position of the foramen, in the direction of the 
 fibers of the facial nerve, if the matter of scarring be not taken into account. 
 
 SURGICAL ANATOMY OF LINGUAL (GUSTATORY) NERVE. 
 
 Description and Relations. — A nerve of common sensation — branch 
 of posterior division of inferior maxillary nerve. Descends under external 
 pterygoid, to inner side and anterior to dental nerve, a cord generally con- 
 necting the two, and being joined near origin by chorda tympani. The 
 nerve then passes between internal pterygoid muscle and ramus of lower 
 jaw — inclining inward to side of tongue, and, passing over attachment of 
 superior constrictor of pharynx to the lower jaw and the styloglossus muscle, 
 above the deep part of submaxillary gland, is continued forward between 
 mucous membrane of mouth and mvlohvoid muscle and lies on its origin 
 13 
 
194 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 close to bone — then runs between mylohyoid and hyoglossus — crosses below 
 Wharton's duct, and passes along side of tongue, under mucous membrane, 
 to apex. 
 
 Comment. — On widely opening the mouth, one can feel the pterygo- 
 maxillarv ligament, as a prominent ridge behind the last molar. The nerve 
 is generally to be felt behind the ptervgomaxillary ligament, about 1.3 cm. 
 (\ inch) posterior and inferior to the last molar, lying just beneath the mucous 
 membrane. 
 
 EXPOSURE OF LINGUAL (GUSTATORY) NERVE IN THE MOUTH. 
 
 Position. — Patient on back; head slightly raised; gag in opposite side 
 of mouth; cheek of operated side held open by retractors; tongue of patient 
 drawn out and to opposite side by assistant. Surgeon stands on patient's 
 right for both operations, and uses a head-mirror. 
 
 Landmarks. — Ramus of jaw; pterygomaxillary ligament; last molar 
 tooth. 
 
 Incision. — Vertical, about 2.5 cm. (1 inch) in length, placed in fold of 
 mucous membrane midway between tongue and gum, with center on level 
 with last molar. The nerve lies about at the junction of the upper and 
 middle thirds of a line from the crown of the last molar to the angle of the 
 jaw. 
 
 Operation. — Having incised in the above line, the nerve is found just 
 beneath the mucous membrane, prior to dipping under the mylohyoid muscle 
 — and is isolated and drawn forward by a hook. 
 
 Comment. — The lingual nerve may be reached from outside the mouth 
 by excising a part of the inferior maxilla, at the junction of the alveolar process 
 and the ascending ramus (Loebker). Or it may be reached by dissecting 
 up under the internal surface of the inferior maxilla, displacing the sub- 
 maxillary gland, dividing the posterior portion of the mylohyoid and finding 
 the nerve under the posterior portion of the sublingual gland (Luschka). 
 
 SURGICAL ANATOMY OF FACIAL NERVE. 
 
 Description. — Arises, superficially, at upper end of medulla oblongata, 
 in groove between olivary and restiform bodies — passes, in company with 
 auditory nerve-, forward and outward to internal auditory meatus, which it 
 enters with auditory nerve, the pars intermedia intervening between the 
 nerves. At the bottom of meatus, the facial nerve enters aqueductus Fallopii, 
 which it follows to its emergence at the stylomastoid foramen — thence passes 
 downward and forward through substance of parotid gland — crosses external 
 carotid artery and divides behind ramus of inferior maxilla, opposite upper 
 margin of digastric muscle, into two chief branches: — (1) Temporofacial, 
 running upward and forward through parotid gland, crossing external carotid 
 artery and temporomaxillary vein and passing over neck of condyle of jaw, 
 and dividing into temporal, malar, and infraorbital branches, — and (2) 
 Cervicofacial, running downward and forward, through parotid gland, 
 crossing external carotid artery, and dividing, opposite angle of jaw, into 
 buccal, supramaxillary, and inframaxillary branches. 
 
EXPOSURE OF SPINAL ACCESSORY NERVE. 1 95 
 
 EXPOSURE OF FACIAL NERVE IN FRONT OF MASTOID PROCESS. 
 
 BAUM'S OPERATION'. 
 
 Position. — Patient supine; head elevated and to one side. Surgeon to 
 right for both operations. 
 
 Landmarks. — Anterior border of mastoid process; posterior border of 
 ascending ramus of inferior maxilla. The point at which the nerve is sought 
 being from 6 mm. to 1.3 cm. (J to \ inch) in front of center of anterior border 
 of mastoid process. 
 
 Incision. — Begins close behind pinna of ear, opposite meatus — passes 
 downward to opposite lobule of ear, and then downward and forward almost 
 to angle of inferior maxilla. 
 
 Operation. — This incision is deepened through skin and fascia, with 
 care. The parotid fascia is incised and the parotid gland is retracted forward. 
 The anterior edge of the sternomastoid is exposed and drawn backward. 
 The posterior belly of the digastric is exposed and the nerve is sought on a 
 line with the upper border of the posterior belly of this muscle and at the 
 point above mentioned — coming from the stylomastoid foramen toward the 
 surface. The posterior auricular artery and vein will probably need ligating, 
 and some fibers of the great auricular nerve will be cut. The internal jugular 
 vein is near the deep part of the wound, but there are no other important vessels 
 anterior to the plane of the digastric (behind which is the external carotid). 
 If necessary, especially in stout subjects, a small transverse incision, passing 
 forward from below the pinna, may be added. 
 
 SURGICAL ANATOMY OF SPINAL ACCESSORY NERVE. 
 
 Description and Relations. — (i) Accessory portion passes outward to 
 jugular foramen, where it unites with spinal portion, and is joined to upper 
 ganglion of the vagus and sends fibers into its pharyngeal and superior laryn- 
 geal branches and into the trunk of that nerve below the ganglion. (2) 
 Spinal portion, after issuing from jugular foramen (where it unites with 
 accessorv portion), passes backward, crossing in front of (sometimes behind) 
 the internal jugular vein, descends obliquely behind digastric and stylo- 
 hyoid muscles and occipital artery to enter upper third of sternomastoid 
 about 5 cm. (2 inches) below tip of mastoid process — perforates this muscle 
 in its second fourth and emerges on level with center of its posterior border 
 — and runs thence obliquely across the occipital triangle, and, entering 
 upper part of lower third of its anterior border, terminates in the deep surface 
 of the trapezius. 
 
 EXPOSURE OF SPINAL ACCESSORY NERVE AT ANTERIOR BORDER 
 OF STERNOMASTOID MUSCLE. 
 
 Position.— Patient supine; shoulders slightly elevated; head to opposite 
 side; neck supported. Surgeon on right, for either operation. 
 
 Landmarks. — Anterior border of upper portion of sternomastoid. 
 
 Incision. — About 7.5 cm. (3 inches) in length, following the anterior 
 border of the sternomastoid, with its center opposite a point about 5 cm. 
 (2 inches) below the tip of the mastoid process. 
 
 Operation. — Having cut through skin and superficial fascia, and opened 
 
196 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 up the cervical fascia, avoiding the external jugular vein and great auricular 
 nerve, expose the anterior border of the sternomastoid and draw the muscle 
 firmly backward. Recognize the inferior border of the posterior belly of 
 
 the digastric — the nerve will be found pass- 
 ing from beneath it to the sternomastoid, 
 crossing the transverse process of the atlas. 
 Avoid branches of the facial nerve (at the 
 upper edge of the wound) and the occipital 
 artery (lying over the nerve). 
 
 Comment. — If only that portion of the 
 spinal accessory be involved which is distal 
 to the sternomastoid, the nerve may be ex- 
 posed by an incision placed along the poste- 
 rior border of the sternomastoid, with its 
 center opposite the center of the posterior 
 border of the muscle. 
 
 FACIO-ACCESSORY OR FACIO-HYPOGLOS- 
 
 SAL ANASTOMOSIS FOR PERIPHERAL 
 
 FACIAL PARALYSIS. 
 
 Description. — The operation consists in 
 anastomosing the paralyzed facial nerve with 
 some neighboring intact nerve. The anasto- 
 mosis is usually made with either spinal ac- 
 cessory or the hypoglossal. While each 
 method has its advantages and disadvant- 
 ages — and each method its adherents — it 
 would seem that the greater advantages lie 
 in favor of severing the spinal accessory 
 nerve, and uniting its central end to the 
 impaired peripheral end of the facial. The 
 glossopharyngeal has also been used. 
 
 Position. — Patient supine; shoulders 
 slightly elevated; head to opposite side; 
 neck supported. Surgeon on side of oper- 
 ation. 
 
 Landmarks. — Anterior border of sterno- 
 mastoid muscle; mastoid process; upper bor- 
 der of thyroid cartilage. 
 
 Incision. — Along the anterior border 
 of the sternomastoid — beginning 2 cm. 
 (about I inch) above the tip of the mastoid process — and ending opposite 
 the upper border of the thyroid cartilage. 
 
 Operation. — (1) To Expose the Facial Nerve; — Having incised through 
 skin and fascia, the sternomastoid is exposed and retracted posteriorly, and 
 the parotid gland exposed and displaced anteriorly. The nerve is sought 
 as it emerges from the gland at a point approximately 1 cm. (about J inch) 
 above, and 1 cm. (about J inch) internal to the tip of the mastoid process. 
 Just distal to the point selected for division, which should be as near the 
 stylomastoid foramen as possible, two fine silk sutures should be carried through 
 the sheath of the nerve, after which the nerve is divided (Fig. 165). (2) 
 
 Fig. 165. — F acid-accessory An- 
 astomosis: — A, Mastoid process; B, 
 Parotid gland; C, Sternomastoid 
 muscle; D, Stylohyoid and posterior 
 belly of digastric muscles; E, E, Di- 
 vided ends of facial nerve; F, Spinal 
 portion of spinal accessory nerve; G, 
 Divided end of spinal accessory anasto- 
 mosed with distal end of facial nerve. 
 (Modified from Berger and Hart- 
 mann.) 
 
EXPOSURE OF POSTERIOR DIVISIONS OF CERVICAL NERVES. 197 
 
 To Expose the Spinal Accessory Nerve; — The nerve enters the deep surface 
 of the sternomastoid about 5 cm. (2 inches) below the mastoid process. It is 
 covered by the posterior belly of the digastric and the deep fascia, and lies 
 just below the transverse process of the atlas. Here also two fine silk sutures 
 are passed through the sheath of the nerve just proximal, in this case, to the 
 line where the nerve is to be divided. The nerve is then divided transversely, 
 with a sharp knife (and not with scissors, which also crush) — and is dissected 
 up sufficiently to enable it to reach the severed distal end of the facial without 
 tension — and here the facial and spinal accessory stumps are united end-to- 
 end by means of fine silk interrupted sutures passing through their sheaths 
 only. The spinal accessory may be used in three ways — the entire nerve 
 may be taken; the branch to the trapezius may be used; or the trunk may be 
 split and one of the split portions be employed. (3) To Expose the Hypo- 
 glossal Nerve; — This is accomplished through the same incision. The pos- 
 terior belly of the digastric lies just above the nerve, which is isolated as it runs 
 forward from under the occipital artery to cross the external carotid. The 
 technic of anastomosis is carried out as in the above instance. 
 
 EXPOSURE OF POSTERIOR DIVISIONS OF FIRST, SECOND, AND 
 THIRD CERVICAL NERVES. 
 
 KEEN'S OPERATION. 
 
 Description. — The posterior divisions of the first, second, and third 
 cervical nerves have been exposed and excised in spasmodic torticollis- 
 supplying, as they do, the posterior rotator muscles of the neck. 
 
 Position. — Patient turned to one side; neck made prominent. Surgeon 
 at patient's back. 
 
 Landmarks. — Middle line of neck; external occipital protuberance. 
 
 Incision. — From 6 to 7.5 cm. (2^ to 3 inches) in length and transverse 
 in direction — passing outward from the middle line of the neck, at a point 
 about 4 cm. (1^ inches) below the external occipital protuberance. 
 
 Operation. — Divide, in the line of incision, the skin, fascia, trapezius, 
 and posterior border of the splenitis capitis, until the complexus is reached, 
 after which the nerves are separately isolated: — (1) Find the occipitalis major 
 nerve (internal branch of posterior division of second cervical nerve) emerging 
 from the complexus and about to enter the trapezius. Divide the complexus 
 transversely, on a level with the nerve. Follow the nerve to the common 
 trunk of the posterior division (before the external and internal branches 
 are given off). Thus the second cervical nerve is exposed. (2) Recognize 
 the suboccipital triangle, — bounded, above and internally, by the rectus 
 capitis posticus major (from spinous process of axis to superior curved line 
 of occiput), — above and externally, by obliquus capitis superior (from upper 
 surface of transverse process of atlas to occipital bone, between curved lines, 
 and external to complexus), — below and externally, bv obliquus capitis 
 inferior (from apex of spinous process of axis to lower and back part of trans- 
 verse process of atlas). Within this triangle lies the suboccipital nerve 
 (posterior division of first cervical nerve), which does not divide into internal 
 and external branches — lying close to the occiput and behind the vertebral 
 artery. Trace it as near to the spine as possible. Thus the first cervical 
 nerve is exposed. (3) The external branch of the posterior division of 
 the third cervical nerve is found about 2.5 cm. (1 inch) lower down than 
 the occipitalis major and upder the complexus. It is to be followed 
 
198 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 to the common trunk of the posterior division. And thus the third cervical 
 nerve is exposed. 
 
 Comment. — This operation has been modified by making a vertical 
 incision from the occiput downward, about 4 cm. (1^ inches) outside of 
 the median line — passing through the trapezius, edge of the splenius, and 
 then through the complexus. Also, the second and third divisions may be 
 divided without the first. 
 
 SURGICAL ANATOMY OF BRACHIAL PLEXUS OF NERVES. 
 
 Formed by. — Fasciculus from anterior branch of fourth cervical, anterior 
 branches of fifth, sixth, seventh, and eighth cervical, and greater part of 
 anterior branch of first dorsal. 
 
 Extent and Position. — From lower part of side of neck to lower part 
 of axillary space, dividing, opposite the coracoid process, into numerous 
 trunks, and giving off its terminal nerves at the lower axillary boundary, 
 
 Relations. — (1) In neck : — First, lies between anterior and middle 
 scaleni and at outer border of former muscle; — then parti}- behind and partly 
 above and external to third part of subclavian artery, in the posterior triangle 
 of neck, crossed by posterior belly of omohyoid; — then behind clavicle and 
 subclavius muscle, upon first serration of serratus magnus and subscapularis 
 muscles. (2) In axilla : — Lies to outer side of first portion of axillary artery, 
 being covered by pectoralis major — then surrounds second portion of artery, 
 covered by the pectoralis minor and resting upon subscapularis muscle, one 
 cord lying to inner side, one behind, and one to outer side of vessel. The 
 third part of the artery has the internal cutaneous and inner head of median 
 nerve in front; circumflex and musculospiral behind; ulnar and lesser internal 
 cutaneous on inner side; and trunk of median and musculocutaneous on 
 outer side. 
 
 EXPOSURE OF BRACHIAL PLEXUS IN NECK. 
 
 Position. — Patient upon back, near edge of table; thorax raised; head 
 extended and turned to opposite side; arm drawn downward and behind 
 back. Surgeon stands in front of right shoulder, in operating upon either 
 side. 
 
 Landmarks. — Sternomastoid ; trapezius. 
 
 Incision. — Vertical, in posterior triangle of neck — beginning about 9 
 cm. (3^ inches) above clavicle and passing downward to within about 1.3 
 cm. (J inch) of middle of clavicle, parallel with anterior border of trapezius, 
 but nearer posterior border of sternomastoid. 
 
 Operation. — Having divided skin and platysma, the external jugular 
 vein is either ligated and cut between two ligatures, or retracted. Some of 
 the descending branches of the cervical plexus are apt to be incised, generally 
 the supraclavicular. Incise the deep cervical fascia. Recognize the outer 
 border of the anterior scalenus and retract inward. Retract the posterior 
 belly of the omohyoid downward and expose the brachial plexus by dissection. 
 Avoid the transversalis colli artery and vein crossing the middle of the plexus. 
 Identify the cords of the plexus by following with finger to the interval between 
 the anterior and middle scalenus muscles. 
 
OPERATION FOR BRACHIAL BIRTH PALSY. 
 
 199 
 
 OPERATION FOR BRACHIAL BIRTH PALSY. 
 
 Description. — The brachial plexus as a whole, or its constituent roots 
 individually, is subject to the injuries which may involve nerve structures in 
 general, resulting in a partial or general paralysis. A special form of paralysis, 
 termed brachial birth palsy, is especially apt to occur at birth in those cases 
 where the head and neck have been forced away from the shoulder, thus 
 overstretching or lacerating nerve-roots of the brachial plexus, especially the 
 upper roots. This subject has been extensively and creditably worked up 
 by Clark, Taylor, and Prout, through whose courtesy the following writing is 
 taken from Keen's " Surgery," Vol. II. 
 
 "One of the most common and interesting forms of brachial palsy are 
 the brachial birth palsies, usually of the upper arm type, very rarely the total 
 
 Fig. 166. — Dissection* of the Operative Field in Brachial Birth Palsy (Clark, 
 Taylor, and Prout): — A, Scalenus amicus muscle; B, Phrenic nerve; C, Internal jugular vein; 
 D, Transversalis colli artery, divided; E, \'II Cervical root; F, Omohyoid muscle; G, V Cervical 
 root; H, Scalenus medius muscle; I, VI Cervical root; J, Transversalis colli artery; K, Supra- 
 scapular nerve; L, Nerve to subclavian muscle; M, Clavicle; N, Nerve to scalenus anticus muscle. 
 
 arm palsy. They may occur in either vertex or breech presentation, when 
 traction is exerted and the head pulled away from the shoulder. The attitude 
 is very characteristic in severe cases; the arm hangs limp by the side, as it 
 cannot be abducted at the shoulder or flexed at the elbow, and, as it cannot be 
 rotated out at the shoulder or supinated in the forearm, the whole arm is 
 rotated in and the hand is pronated so that it looks backward and sometimes 
 even outward. They should be operated on as described below. Kennedv 
 and Taylor have reported several operations with good results, and among 
 them were cases ten and eleven years old. In mild cases nothing is required 
 except massage, passive motion, electricity, and apparatus — and in all cases, 
 unless there is neuritis, these measures should be faithfully employed until 
 recovery results or it becomes necessary to operate. When there is neuritis, 
 complete rest in the normal position is demanded until inflammation has 
 subsided. The only treatment for cases of permanent paralysis is the excision 
 
200 OPERATIONS UPON THE XERXES, PLEXUSES, AND GANGLIA. 
 
 of the scar tissue replacing and surrounding the injured nerve and suture of 
 the freshened nerve-ends. The time at which to undertake this treatment 
 is still a matter of dispute. Kennedy advises early operation — in two or three 
 months if the muscles give no response to the faradic current. If the muscles 
 re-pond and continue to improve in response to the faradic current, he does 
 not operate but expects spontaneous recovery. Taylor advises delay for 
 a year in most cases of brachial birth palsies. The advantages of this delay 
 are a more definite localization of the lesion, larger size of the field of operation, 
 and diminished danger from shock and hemorrhage. 
 
 Fig. 167. — Dissection of the Operative Field in Brachial Birth Palsy (Clark, 
 Taylor, and Prout): — A, Phrenic nerve; B, Scalenus anticus muscle; C, Internal jugular vein; 
 D, Transversalis colli artery; E, Omohyoid muscle, divided; F, Suprascapular artery, divided; 
 (j, YIII Cervical and I dorsal roots; H, External anterior thoracic nerve; I, Subclavian artery; 
 J, V Cervical root; K, VI Cervical root; L, Scalenus medius muscle; M, Nerve to scalenus anticus 
 muscle; X, Suprascapular nerve; O, Transversalis colli artery; P, VII Cervical root; Q, Omo- 
 hyoid muscle, divided; R, Suprascapular artery; S, Clavicle and subclavius muscle, divided and 
 retracted; T, Deltoid, pectoralis minor, pectoralis major (muscles); U, Nerve to subclavius 
 muscle. 
 
 " The incision extends from the posterior border of the sternomastoid at 
 the junction of its middle and lower third, to the junction of the middle and 
 outer thirds of the clavicle through the skin, platysma, and deep fascia. The 
 omohyoid muscle, exposed near the clavicle, with the suprascapular vessels 
 beneath it, is retracted downward, or, if necessary, divided. Beneath the 
 layer of fat at this level the deep fascia, usually thickened, covering the plexus 
 is divided and dissected away from it. The injured portion of the nerve or 
 nerves, determined beforehand from the paralysis, is felt to be thickened or 
 
EXPOSURE OF MEDIAN NERVE IN MIDDLE OF ARM. 201 
 
 indurated. This area is excised by a sharp scalpel through healthy nerve- 
 tissue and the ends sutured (Figs. 166 and 167). 
 
 " This incision suffices for the common type where the lesion is confined 
 to the fifth or fifth and sixth nerve-roots and their junction. When, however, 
 the lesion extends to the lower roots of the plexus, or lies in the lower part of 
 the plexus, the incision should be extended downward and the clavicle, sub- 
 clavius muscle, and, if necessary, the pectoral muscles divided to give a 
 better exposure. If thought best, the operation may be done in two stages 
 to avoid too long an operation and too much shock. The clavicle is afterward 
 sutured periosteally. An immobolizing dressing approximating the head 
 and shoulder to relieve any tension on the plexus should be applied and this 
 position maintained for two or three weeks. After-treatment by massage, 
 electricity, and the use and education of the muscles is very important. The 
 results of these operations have been very encouraging. The improvement 
 is slow and continuous through a number of vears." 
 
 SURGICAL ANATOMY OF MEDIAN NERVE. 
 
 Description. — (a) In Arm; Arises by a root from inner and one from 
 outer cords of brachial plexus, which embrace axillary artery, uniting either 
 in front or to outer side of the vessel. Descends arm on outer side of brachial 
 artery at first — then crosses in front of the middle of artery (though some- 
 times passing behind) — thence downward on inner side of artery to elbow — 
 where it is separated from elbow-joint by brachialis anticus muscle and is 
 covered by bicipital fascia, (b) In Forearm; Passes between two heads of 
 pronator radii teres and descends between flexor sublimis and profundus 
 digitorum to about 5 cm. (2 inches) above the annular ligament of wrist, 
 where it lies beneath the fascia, between the tendons of the flexor sublimis 
 digitorum below, the palmaris longus internally, and the flexor carpi radialis 
 externally (or rather more under the palmaris longus). (c) In Hand; It 
 enters palm beneath the annular ligament and rests upon flexor tendons, 
 covered by fascia and superficial palmar arch. 
 
 EXPOSURE OF MEDIAN NERVE IN MIDDLE OF ARM. 
 
 Position. — Patient's arm is extended and abducted, with hand supine. 
 Surgeon stands on outer side of right limb, cutting from above downward; 
 and between body and left limb, cutting from above downward (or on outside 
 of left limb, cutting from below upward). 
 
 Landmarks. — Inner edge of bicipital muscle. 
 
 Incision. — Along inner edge of biceps, in middle of arm — about 4 cm. 
 (2^ inches) in length. 
 
 Operation. — Divide skin and connective tissue. Avoid internal cutaneous 
 nerve and basilic vein. Clearly expose inner edge of biceps muscle and 
 draw the muscle to the outer side, when the median nerve is found crossing 
 the brachial artery from the outer toward the inner side (or sometimes passing 
 beneath the artery). 
 
202 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 EXPOSURE OF MEDIAN NERVE AT BEND OF ELBOW. 
 
 Position. — As above. 
 
 Landmarks. — Groove between biceps and pronator radii teres muscles. 
 
 Incision. — Between inner margin of biceps and outer margin of pronator 
 radii teres, somewhat nearer the former, with center of incision opposite 
 the fold of the elbow, and being about 5 cm. (2 inches) in length. 
 
 Operation. — This incision will, in the usual disposition of the veins 
 at the elbow, pass to the outer side and nearly parallel with the median basilic 
 vein, which should be retracted inward. Incise the bicipital fascia in a line 
 with the skin-cut. The median nerve lies just to the inner side of the brachial 
 artery and its vena? comites — all lying upon the brachialis anticus. Gut- 
 suture the bicipital fascia in closing the wound. 
 
 SURGICAL ANATOMY OF ULNAR NERVE. 
 
 Description. — (a) In Arm; Arises from inner cord of brachial plexus, 
 between axillary artery and vein, and passes down arm on inner side of 
 axillary and brachial arteries to middle of arm, covered only by skin and 
 fascia — thence diverges to cross inner head of triceps obliquely — pierces 
 interna] intermuscular septum and descends posterior to that structure, 
 together with inferior profunda artery, which is upon its outer side, (b) 
 At Elbow; Occupies groove between olecranon and internal condyle, resting 
 upon posterior surface of latter (rarely upon anterior surface), and enters 
 forearm between two heads of flexor carpi ulnaris. (c) In Forearm; Passes 
 vertically down ulnar side, upon. flexor profundus digitorum, its upper half 
 covered by flexor carpi ulnaris, its lower half by skin and fascia (the nerve 
 here lying external to flexor carpi ulnaris). The ulnar nerve lies, throughout, 
 to the ulnar side of the ulnar artery — the upper third lying considerably to 
 the inner side, and the lower two-thirds near to the inner side. The dorsal 
 cutaneous branch passes posteriorly between 5 and 7.5 cm. (2 and 3 inches) 
 above the wrist, (d) At Wrist; Crosses front of annular ligament between 
 ulnar artery and pisiform bone, a little internal and posterior to the artery, 
 and immediately divides into superficial and deep palmar branches. 
 
 EXPOSURE OF ULNAR NERVE ABOVE MIDDLE OF ARM. 
 
 Position. — As for median nerve in middle of arm (page 201). 
 
 Landmarks. — Brachial artery, which is parallel with and to outer side 
 of the nerve for the upper half of the arm. 
 
 Incision. — From 5 to 7.5 cm. (2 to 3 inches) in length, with its center 
 just above the middle of the arm — running parallel with and about 1.3 cm. 
 (^ inch) to inner side of line of brachial artery (the line for the ligation of 
 the middle third of the brachial artery passing along the inner margin of the 
 biceps muscle). 
 
 Operation. — Incise skin and fascia, which here alone cover the nerve. 
 Avoid the basilic vein and the vena? comites of the brachial artery — also the 
 internal cutaneous nerve to the outer, and the lesser internal cutaneous nerve 
 to the inner side. The ulnar nerve is found diverging from its course parallel 
 with the inner side of the brachial artery to pass obliquely across the inner 
 head of the triceps to pierce the internal intermuscular septum. 
 
EXPOSURE OF MUSCULOSPIRAL NERVE. 203 
 
 EXPOSURE OF ULNAR NERVE JUST ABOVE INTERNAL CONDYLE OF 
 
 HUMERUS. 
 
 Position. — Patient upon back at edge of table. Assistant stands on 
 side opposite one to be operated, and, grasping patient's wrist, with patient's 
 hand prone, draws his (patient's) arm and forearm across the chest, thus 
 exposing its posterior surface to the operator — who stands upon the side to 
 be operated, cutting from elbow toward shoulder on both sides. 
 
 Landmarks. — Olecranon; internal condyle of humerus. 
 
 Incision. — About 5 cm. (2 inches) in length, extending from a point 
 about 1.3 cm. (h inch) above (to proximal side of) internal condyle and midway 
 between internal condyle and olecranon, upward toward a point at inner 
 side of brachial artery opposite the insertion of the coracobrachialis muscle 
 (about center of arm). 
 
 Operation. — Incise skin and fascia in above line — when the nerve will 
 be found upon the posterior surface of the internal intermuscular septum, 
 with the inferior profunda artery upon its outer side. 
 
 Comment. — If the incision were to extend over the internal condyle, 
 the nerve would be found lying upon the posterior surface of the base of the 
 inner condyle of the humerus, close to the bone and along the inner edge 
 of the triceps. 
 
 SURGICAL ANATOMY OF MUSCULOSPIRAL NERVE. 
 
 Description. — Arises, in common with circumflex nerve, from posterior 
 cord of brachial plexus — descends arm behind axillary and brachial arteries 
 and in front of tendons of latissimus dorsi and teres major, and winds around 
 humerus in musculospiral groove, from inner to outer side, with superior 
 profunda artery, lying between the internal and external heads of the triceps. 
 Arriving at outer side of arm, it pierces the external intermuscular septum 
 about midway between insertion of deltoid and tip of external condyle (namely, 
 at lower third) and descends between supinator longus and brachialis anticus 
 to front of external condyle, where it divides into radial and posterior inter- 
 osseous nerves. 
 
 EXPOSURE OF MUSCULOSPIRAL NERVE BELOW MIDDLE OF ARM. 
 
 Description. — The exposure is here made upon the external aspect of 
 the arm and the nerve is reached anterior to the external intermuscular 
 septum. 
 
 Position. — Same as for ulnar nerve just above internal condyle (page 
 203). The surgeon may also stand so as to cut from shoulder toward elbow. 
 
 Landmarks. — Insertion of deltoid (about middle of arm); external 
 condyle of humerus; upper border of supinator longus. 
 
 Incision. — About 6 to 7.5 cm. (2% to 3 inches) in length — crossing obliquely 
 the outer surface of the lower third of the arm — so placed that its center 
 will be midway between the deltoid and the external condyle — and so that 
 its obliquity will follow the line of the upper border of the supinator longus. 
 
 Operation. — Having incised skin and fascia, avoiding cephalic and 
 median cephalic veins, identify the internal border of the supinator longus. 
 Draw this muscle to the outer side, so as to expose the interval between it 
 
204 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 and the brachialis anticus — where the nerve will be found close to the bone, 
 accompanied by a branch of the superior profunda artery. 
 
 Comment. — Exposure of the nerve at its bifurcation into radial and 
 posterior interosseous may be accomplished (if not performed as a separate 
 operation) by continuing the above incision downward. 
 
 SURGICAL ANATOMY OF THE INTERCOSTAL NERVES. 
 
 Description. — (a) Pectoral Intercostal Nerves : — Pass outward, as 
 the anterior divisions of the dorsal nerves, in front of superior costotransverse 
 ligaments, levatores costarum, external intercostal muscles, covered (to angle 
 of ribs) by pleura and endothoracic fascia. They then approach upper 
 part of each intercostal space to accompany intercostal vessels, in groove of 
 rib above, to front of chest — the nerve lying below the vessels. Between 
 angle of rib and middle of rib they lie between internal and external inter- 
 costal muscles, giving off, a little posterior to middle of the ribs, the lateral 
 cutaneous branches — which latter branches pass through external intercostal 
 and serratus magnus muscles about center of ribs and divide into anterior 
 and posterior branches. The main trunk of the intercostal nerve continues 
 forward among fibers of internal intercostal muscles to costal cartilages — ■ 
 thence passes between internal intercostal muscles and pleura, crossing in 
 front of internal mammary artery and triangularis sterni muscle — to pierce 
 internal intercostal muscles and pectoralis major and end in the anterior 
 cutaneous branches, (b) Abdominal Intercostal Nerves : — Take the same 
 course (as the anterior divisions of the dorsal nerves) as the pectoral inter- 
 costals, from their origin to ends of intercostal spaces in which they lie — 
 thence they run between the slips of origin of diaphragm to enter the abdominal 
 wall, each nerve (from seventh to ninth, inclusive) crossing behind cartilage 
 of rib below. In the abdominal wall they pass between internal oblique 
 and transversalis, diverging from each other as they go forward, to outer 
 edge of the rectus — and, piercing posterior layer of rectal sheath, rectus itself, 
 and anterior layer of sheath, they supply rectus and sheath and end in the 
 anterior cutaneous nerves near the linea alba. 
 
 Comment. — (i) The exceptions in the distribution of the anterior divi- 
 sions of the first, second, and twelfth nerves are not mentioned in the above 
 descriptions. (2) The upper six dorsal nerves form the pectoral intercostal 
 nerves — the lower six, the abdominal intercostals. (3) The final distribution 
 of the lower dorsal nerves is as follows; — sixth, to pit of stomach; seventh, to 
 lower end of ensiform cartilage; eighth, over the middle linea transversa; 
 tenth, to the umbilicus; twelfth, midway between umbilicus and pubis. 
 
 EXPOSURE OF INTERCOSTAL NERVE BETWEEN ANGLE AND MIDDLE 
 
 OF RIB. 
 
 Position. — Patient on side. Surgeon either in front or at back of patient. 
 
 Landmarks. — Angle and lower border of rib. 
 
 Incision. — Parallel with and just below lower border of rib, and lying 
 between the angle and middle of rib. 
 
 Operation. — Having incised skin, fascia, and external intercostal muscle, 
 separate the cut edges of the external intercostal muscle and seek for nerve 
 in the intermuscular plane between external and internal intercostals, near 
 the lower border of the rib above. The nerve may be drawn down into view 
 from the groove in the lower border of the rib by means of a nerve-hook. If 
 
SURGICAL ANATOMY OF GREAT SCIATIC NERVE. 205 
 
 necessary, bite out a half-button of rib subperiosteally with rongeur forceps, 
 fully exposing the nerve and intercostal vessels, when the latter may be 
 divided between ligatures, if necessary. 
 
 SURGICAL ANATOMY OF ANTERIOR CRURAL NERVE. 
 
 Arises from second, third, and fourth lumbar nerves and descends through 
 fibers of psoas muscle — emerging from lower part of its outer border, and 
 descending beneath Poupart's ligament into thigh, beneath the iliac fascia, 
 in groove between psoas and iliacus, being separated from femoral artery 
 on its inner side by the psoas. It divides below Poupart's ligament into an 
 anterior division, passing in front of the external circumflex vessels — and a 
 posterior division, passing behind these vessels. 
 
 EXPOSURE OF ANTERIOR CRURAL NERVE, BELOW POUPART'S 
 
 LIGAMENT. 
 
 Position. — Patient on back; limb extended and rotated slightly outward. 
 Surgeon to outer side of right limb, and to inner side of left or on right, 
 leaning over body; or on outer side of left limb, cutting from below up- 
 ward). 
 
 Landmarks. — Middle of Poupart's ligament. 
 
 Incision. — Vertical, about 5 cm. (2 inches) in length, carried downward 
 from a point about 1.3 cm. (h inch) external to center of Poupart's ligament. 
 
 Operation. — Incise skin and superficial fascia. Crural branch of genito- 
 crural nerve may be met running down the thigh. The superficial circumflex 
 iliac vessels will lie across the incision. Flex the thigh to relax the muscles. 
 The nerve will be found lying to the outer side of the femoral artery, in the 
 groove between the iliacus and psoas muscle-. 
 
 EXPOSURE OF OBTURATOR, SUPERIOR GLUTEAL. AND PUDIC 
 
 NERVES. 
 
 The operations for the exposure of the obturator nerve at the thyroid 
 foramen, the superior gluteal nerve upon the buttock, the pudic nerve upon 
 the buttock, and the pudic nerve in the perineum, are. practically, the same 
 as the operations for the ligation of the obturator artery at the thyroid foramen, 
 the gluteal artery upon the buttock (page 87), the internal pudic artery upon 
 the buttock (page 87), and the internal pudic artery in the perineum (page 
 87), respectively. 
 
 SURGICAL ANATOMY OF GREAT SCIATIC NERVE. 
 
 Description. — Continuation of lower cord of sacral plexus — leaves pelvis 
 by great sacrosciatic foramen, below pyriformis — descends from hollow 
 between great trochanter and tuberosity of ischium down back of thigh, to 
 about its lower third, where it divides into external and internal popliteal 
 nerves (the division often occurring higher). The great sciatic nerve rests, 
 from above downward, upon the ischium, gemellus superior, obturator 
 internus, gemellus inferior, quadratus femoris and adductor magnus, — and 
 is covered by, from above downward, the skin, fascia, gluteus maximus, 
 biceps, and small sciatic nerve. It has the sciatic artery to its inner side, 
 and small sciatic nerve superficial to it above, and to its inner side as it (the 
 small sciatic nerve) descends the thigh. 
 
2o6 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 EXPOSURE OF GREAT SCIATIC NERVE AT LOWER BORDER OF 
 GLUTEUS MAXIMUS. 
 
 Position. — Patient turned upon side sufficiently to expose field of opera- 
 tion. Surgeon on side of operation, cutting downward on left side, and 
 upward on right. 
 
 Landmarks. — Lower margin of gluteus, which is below fold of buttock; 
 tuberosity of ischium; great trochanter. 
 
 Incision. — Begins over gluteal fold and passes vertically downward for 
 a distance of 7.5 to 10 cm. (3 to 4 inches), with center of incision over lower 
 margin of gluteus maximus and placed midway between tuberosity of ischium 
 and great trochanter — although the nerve lies a' little nearer the former than 
 the latter, for by this incision the hamstring muscles are more easily retracted. 
 
 Operation. — Having incised skin and fatty areolar tissue, the small 
 sciatic nerve and cutaneous vessels are encountered. Expose the lower edge 
 of the gluteus maximus, running downward and outward, and retract upward. 
 Find and retract the hamstring muscles inward, bending the knee to aid the 
 retraction. The nerve is found a little nearer the tuberosity of the ischium 
 than the great trochanter and under the outer edge of the biceps muscle. 
 
 SURGICAL ANATOMY OF INTERNAL POPLITEAL BRANCH OF GREAT 
 
 SCIATIC NERVE. 
 
 Description. — The larger branch of the great sciatic. Extends from 
 bifurcation, at lower third of thigh, through middle of popliteal space to 
 lower border of popliteus muscle, where it becomes the posterior tibial nerve. 
 It is covered, above, by hamstring muscles; in the middle, by skin and fascia; 
 and below, by heads of gastrocnemii. The popliteal vein intervenes between 
 the nerve superficially, and the artery deeply. In the upper popliteal space 
 the nerve lies external to the popliteal artery and vein; at the level of the 
 knee, the nerve crosses these vessels; and in the lower popliteal space the 
 nerve lies to the inner side of the vessels. 
 
 EXPOSURE OF INTERNAL POPLITEAL NERVE AT LOWER PART OF 
 
 POPLITEAL SPACE. 
 
 Position. — Patient rests on shoulder and side of chest, as nearly prone 
 as anesthesia will allow; limb extended. Surgeon to outer side of left, cutting 
 downward; and to inner side of right, cutting downward (or to outer side, 
 cutting upward). 
 
 Landmarks. — Heads of gastrocnemii muscles. 
 
 Incision. — Begins opposite the center of the popliteal space and passes 
 vertically downward for about 9 cm. (3^ inches), between the two heads of 
 the gastrocnemii. 
 
 Operation. — Having divided skin and superficial fascia, avoid external 
 saphenous vein and nerve at the outer and lower part of the wound. Expose 
 the heads of the gastrocnemii and open up, by blunt dissection, the interval 
 between them, retracting the heads of the muscle to their respective sides. 
 The nerve will be found the most superficial of the important structures in 
 the popliteal space. 
 
EXPOSURE OF EXTERNAL POPLITEAL NERVE. 207 
 
 SURGICAL ANATOMY OF POSTERIOR TIBIAL NERVE. 
 
 Description. — The direct continuation of internal popliteal nerve. 
 Extends from lower border of popliteus muscle to interval between internal 
 malleolus and heel, where it divides into internal and external plantar nerves. 
 It is covered, above, by gastrocnemius, plantaris, soleus, and intermuscular 
 deep fascia; and, below, by only skin and fascia. It rests upon (its anterior 
 relations are), above, tibialis posticus; and, below, flexor longus digitorum. 
 It lies to inner side of posterior tibial artery above, but soon crosses it and 
 runs on its fibular side to ankle. 
 
 EXPOSURE OF POSTERIOR TIBIAL BETWEEN ORIGIN AND ANKLE. 
 
 The operation for the exposure of the posterior tibial nerve at its origin 
 is, practically, the same as that for the exposure of the internal popliteal at 
 the lower part of the popliteal space (page 206). The posterior tibial nerve 
 in the leg may be exposed by the same operation as would expose the poste- 
 rior tibial artery at the same level (pages 109 and no). 
 
 EXPOSURE OF POSTERIOR TIBIAL NERVE BEHIND INTERNAL 
 
 MALLEOLUS. 
 
 Position. — Patient on back; knee flexed; leg resting on outer side. Sur- 
 geon stands facing either foot, cutting from above downward. 
 
 Landmarks. — Internal malleolus; tendo Achillis. 
 
 Incision. — Curved, about 5 cm. (2 inches) in length, made about 1.3 
 cm. (^ inch) behind and parallel with the internal malleolus, beginning just 
 in front of tip of malleolus and extending upward in a line midway between 
 internal malleolus and tendo Achillis. 
 
 Operation. — Directing the knife toward the tibia, divide skin, superficial 
 fascia, and annular ligament. The order of the structures met behind the 
 internal malleolus, from within outward, is, tibialis posticus; flexor longus 
 digitorum; posterior tibial artery, vein and nerve; flexor longus hallucis. 
 The nerve is therefore sought between the tendons of the flexor longus digi- 
 torum and flexor longus hallucis. 
 
 SURGICAL ANATOMY OF EXTERNAL POPLITEAL (PERONEAL) 
 BRANCH OF GREAT SCIATIC. 
 
 Description. — Smaller branch of great sciatic. Enters superior angle 
 of popliteal space and passes obliquely along outer side of this space to head 
 of fibula, lying near inner border of biceps (lying beneath skin and fascia, 
 behind head of fibula, to inner side of biceps tendon). The nerve leaves 
 the popliteal space in interval between biceps tendon and outer head of 
 gastrocnemius — winds around neck of fibula between bone and peroneus 
 longus muscle — and, piercing origin of latter muscle, divides into anterior 
 tibial, musculocutaneous, and recurrent articular nerves. 
 
 EXPOSURE OF EXTERNAL POPLITEAL BEHIND TENDON OF BICEPS. 
 
 Position. — Patient on uninvolved side, rolled into slightly prone position; 
 leg extended. Surgeon stands facing back of patient's knee. 
 Landmarks. — Tendon of biceps; head of fibula. 
 
208 OPERATIONS UPON THE NERVES, PLEXUSES, AND GANGLIA. 
 
 Incision. — About 4 to 5 cm. (i£ to 2 inches), along posterior edge of 
 tendon of biceps, extending from over the prominence of the external condyle 
 of the femur toward the posterior border of the head of the fibula. 
 
 Operation. — Divide skin and deep fascia. Expose the biceps tendon. 
 Flex the knee to relax the tendon and search for the nerve near the attachment 
 of the biceps tendon to the head of the fibula, near the outer edge of the 
 gastrocnemius. 
 
 SURGICAL ANATOMY OF ANTERIOR TIBIAL BRANCH OF EXTERNAL 
 
 POPLITEAL. 
 
 Description. — One of the terminal branches of the external popliteal. 
 Commences between fibula and peroneus longus — pierces septum between 
 peronei and extensors — passing obliquely beneath extensor longus digitorum 
 to forepart of interosseous membrane. Runs forward on interosseous mem- 
 brane between extensor longus digitorum and tibialis anticus, in upper part 
 of leg — and between tibialis anticus and extensor longus hallucis, lower 
 down. Passes under anterior annular ligament and ends in front of bend 
 of ankle in external and internal branches. The anterior tibial nerve reaches 
 the fibular side of the tibial artery at the junction of the upper and second 
 fourths of the leg, thence lies in front of the artery to the ankle, and thence 
 generally lies to its outer side. 
 
 EXPOSURE OF ANTERIOR TIBIAL NERVE NEAR ORIGIN. 
 
 Position. — Patient supine and inclined to uninvolved side; hip slightly 
 flexed and rotated inward, so that knee rests upon inner aspect. Surgeon 
 stands behind either limb, cutting from above on the right, and from below 
 on the left. 
 
 Landmarks. — Outer tuberosity of tibia; head of fibula. 
 
 Incision. — Begins opposite the most external part of the tibial tuberosity, 
 and about 1.3 cm. (| inch) anterior to the head of the fibula, and passes 
 downward for 5 to 7.5 cm. (2 to 3 inches). 
 
 Operation. — Having incised skin and fascia, the intermuscular septum 
 between peroneus longus and extensor longus digitorum is sought, running 
 obliquely downward and forward, and is opened up by blunt dissection. 
 The anterior tibial nerve (and also the musculocutaneous nerve) is found 
 deep in this intermuscular interval, running downward and inward, below 
 the fibular head and covered by the extensor longus digitorum (the musculo- 
 cutaneous running vertically downward). 
 
 Comment. — The anterior tibial nerve may be exposed at any point on 
 the leg below its upper fourth, by the same operation as would expose the 
 anterior tibial artery at the corresponding level (pages 104, 105, and 106). 
 
 SURGICAL ANATOMY OF THE CERVICAL SYMPATHETIC GANGLIA 
 
 AND CORD. 
 
 Description. — The cervical portion of the gangliated cord lies deeply 
 in the neck, embedded in the fascia between the muscles covering the front 
 of the vertebral column behind, and the carotid sheath in front — and consists 
 of three ganglia, together with the connecting cord: — (a) Superior Cervical 
 
TOTAL EXCISION OF CERVICAL SYMPATHETIC. 209 
 
 Ganglion (largest) — lies opposite second and third cervical vertebrae (some- 
 times, fourth and fifth) — rests upon rectus capitis anticus major, posteriorly, 
 — has internal carotid artery and internal jugular vein, anteriorly, — and 
 pneumogastric nerve, externally, (b) Middle Cervical Ganglion (sometimes 
 wanting) — opposite sixth (or seventh) cervical vertebra — upon, or close to, 
 where the cord crosses the inferior thyroid artery, (c) Inferior Cervical 
 Ganglion — between base of transverse process of seventh cervical vertebra 
 and neck of first rib, lying between subclavian and vertebral arteries. 
 
 TOTAL EXCISION OF CERVICAL SYMPATHETIC GANGLIA AND CORD. 
 
 JONNESCO'S OPERATION. 
 
 Description. — -The cervical sympathetic ganglia and cord have been 
 incised, partially excised, and totally excised — chiefly for exophthalmic goiter 
 and epilepsy — and also in hysteria, chorea, tumors of the brain, and glau- 
 coma. The cord and one or both upper ganglia of one or both sides have 
 been removed, — or both upper ganglia of both sides, with intervening cords, 
 — or both cords with all the ganglia of one or both sides. The removal of 
 the cord and ganglia of one side will be described below. 
 
 Position. — Patient supine; shoulders and head raised and latter turned 
 to opposite side; neck, shaved, rests upon a narrow support (to render promi- 
 nent). Surgeon to right, for both sides. 
 
 Landmarks. — Mastoid process; posterior border of sternomastoid; 
 clavicle. 
 
 Incision. — Beginning opposite the posterior margin of the mastoid pro- 
 cess, passes downward along the posterior border of the sternomastoid to 
 just below the clavicle. 
 
 Operation. — Incise skin, superficial fascia, and platysma. Divide the 
 external jugular vein between two ligatures. Displace the sternomastoid 
 inward (or it may be split longitudinally near its posterior border and the 
 parts retracted laterally). Expose the common sheath of the vessels by blunt 
 dissection. Lift the carotid sheath, unopened, upward and retract it inward 
 — when the cervical cord and superior and middle cervical ganglia will be 
 exposed, lying upon the prevertebral muscles. Having well retracted the 
 structures to that side toward which most easily displaced, isolate the trunk 
 of the cervical sympathetic near the center of the incision. Follow it up to 
 the superior ganglion, divide the communicating branches of the ganglion 
 with delicate scissors, and remove the ganglion with fine forceps. Practising 
 slight traction upon the distal end of the trunk, trace the cord down to the 
 middle ganglion, which is similarly removed — carefully guarding, throughout, 
 all important adjacent structures. Continuing gentle traction upon the cord, 
 just sufficient to follow it, trace the main trunk down behind the clavicle to 
 the inferior ganglion. Guard the spinal accessory nerve in the upper part 
 of the neck — the nerves of the cervical plexus in the middle of the neck — 
 the thyroid and vertebral vessels, recurrent laryngeal and phrenic nerves 
 and pleura in the lower part of the neck — and the thoracic duct on the lower 
 left side. In closing the operation, approximate the separated muscles with 
 buried gut sutures — and close the superficial wound in the usual manner, 
 unless temporary drainage be indicated. 
 
CHAPTER V. 
 
 OPERATIONS UPON THE BONES. 
 
 OSTEOTOMY IN GENERAL. 
 
 Definition. — Any division of bone by cutting instrument. 
 
 Indications. — Deformities of bones and joints (such as result from 
 congenital conditions) ; diseases of bones and joints, followed by weakening 
 of bone and subsequent curvature or angularity; malunion following fracture; 
 ankylosis. 
 
 Varieties. — (a) Linear Osteotomy; Simple division of bone in its con- 
 tinuity, by simple transverse, oblique or vertical section-line (e. g., linear 
 osteotomy of neck or shaft of femur for faulty ankylosis), (b) Cuneiform 
 Osteotomy; Removal of a wedge-shaped piece of bone in its continuity (e. g., 
 cuneiform osteotomy for bent tibia), — or from, or including, one of its ends 
 (e. g., cuneiform osteotomy of a joint for ankylosis), (c) Osteo-arthrotomy; 
 Though not a distinct variety of osteotomy, may be considered as an inter- 
 articular osteotomy, linear or cuneiform. 
 
 General Manner of Performing Osteotomy as to the Instrument. 
 —Osteotomy, in general, may be performed with an osteotome, an instrument 
 ground evenly from both sides, and graded upon its blade to indicate depth 
 of section, — with a chisel, an instrument beveled from one side only, and 
 similarly graded upon handle, — or with a special saw. 
 
 General Manner of Performing Osteotomy as to Method of Opera- 
 tion. — (a) Open Method; in which the site of the bone-section is exposed 
 to view by a preliminary operation, (b) Subcutaneous or Submuscular 
 Method; in which the site of bone-section is reached through the smallest, 
 simplest incision and the bone divided out of sight and by the sense of touch. 
 Cuneiform osteotomy is nearly always done by the open method. Linear 
 osteotomy may be done by the subcutaneous or by the open method — the 
 former being more frequently done — the latter being preferable where the 
 safety of the parts can be better preserved by first exposing them. Cuneiform 
 osteotomy should be done subperiosteally where possible, and when not 
 contraindicated (as by disease). Linear osteotomy should be done sub- 
 periosteally when performed by the open method, if possible and not contra- 
 indicated. Linear osteotomy is usually performed with an osteotome or a 
 saw. Cuneiform osteotomy is generally done with a chisel (sometimes with 
 a saw). 
 
 Instruments Used in Osteotomy. — Rubber tourniquet; scalpels; 
 tenotomy knives; hemostatic forceps; dissecting and toothed forceps; scissors, 
 curved and straight, sharp and blunt; retractors; chisels, various sizes and 
 widths; osteotomes, various sizes and widths; mallets, preferably of wood; 
 saws, especially of the osteotomy type (with narrow blade and with cutting 
 part only at end, and with blunt point and large handle), and also chain- 
 saws, Gigli saws, and butcher saw; periosteal elevators, curved and straight; 
 rugines; raspatories; blunt dissector; bone-holding forceps; bone-cutting 
 
 2IO 
 
LIXEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. 211 
 
 forceps; needles, straight and curved; needle-holder; chromic and plain 
 gut; silkworm-gut and kangaroo tendon; bone-drills; silver wire; pegs and 
 nails, ivory and metallic; sand-bag (for part to rest upon and dissipate the 
 jar). 
 
 Preparation of Patient. — The part shaved. 
 
 Position. — The position of patient, surgeon, and assistant will be deter- 
 mined by the special operation. 
 
 LINEAR OSTEOTOMY BY THE SUBCUTANEOUS METHOD. 
 
 Steps of Operation Preparatory to Division of Bone.— Having ex- 
 sanguinated the limb by elevation, followed by the application of a rubber 
 tourniquet (which may generally be dispensed with), the portion of the limb 
 involved is placed 
 upon a sand-bag 
 (previously damp- 
 ened and covered 
 with several layers 
 of wet. sterilized tow- 
 els, to prevent the fly- 
 ing of dust), which 
 forms a yielding bed 
 into which the part 
 may be moulded and 
 in which it may re- 
 ceive the jar of the 
 blows from the mal- 
 let. An incision, just 
 long enough to ad- 
 mit the osteotome or 
 saw, is made over 
 the site of the bone- 
 section. The incision 
 is as limited as pos- 
 sible, and so placed 
 as to reach the bone 
 by the most direct 
 and safest route, and 
 with the least danger 
 to important struc- 
 tures. It should be, 
 where possible, in a 
 line with the over- 
 lying muscle-fibers— 
 
 should avoid vessels and nerves — and is generally parallel with the bone. 
 This incision is usually made directly to the bone with one stroke — it being 
 impossible, from the small size of the wound, to recognize the intermuscular 
 planes, or the bone's exact level, if at any depth from the surface. Hav- 
 ing made a path to the bone, the remaining steps of the operation will de- 
 pend upon the instrument with which the division of the bone is to be made. 
 
 Division of Bone with Osteotome. — Having made the incision through 
 
 Fig. 1 6S.— Linear Osteotomy by the Sibcutaneois Method: 
 — A. Linear osteotomy of anatomical neck of femur with saw; B, 
 Linear osteotomy of surgical neck of femur with osteotome. 
 
212 OPERATIONS UPON THE BONES. 
 
 the soft parts with a knife, the knife is not withdrawn but allowed to remain 
 in situ as a guide — upon this an osteotome (somewhat narrower than the 
 bone to be divided) is introduced, entering the wound with the length of its 
 cutting edge corresponding to the length of the wound. It is carefully passed 
 down, in contact with the knife, to the bone, and the knife withdrawn. The 
 osteotome, constantly held in contact with the bone, is now turned with its 
 cutting-edge in the direction of the desired bone-section (which is generally 
 at a right angle to the incision of the soft parts). In the act of turning the 
 osteotome into position, the soft parts are levered away by the blunt sides 
 of the instrument, and the bone is hugged, but care is used not to detach 
 the periosteum (which the knife-incision may have cut) (Fig. 168, B). The 
 osteotome is held in the surgeon's left hand near its cutting end — being grasped 
 in his full hand, the ulnar margin of his hand resting on the patient's limb 
 to steady the instrument. The instrument should cut away from important 
 structures, and preferably toward the surgeon. After each stroke of the 
 mallet, the osteotome should be shifted, traveling back and forth in the line 
 of section, that it may not bind in any one place. In section of thick bones, 
 if the instrument bind, it is withdrawn and a thinner (not narrower) one is 
 introduced — and subsequently a still thinner, if necessary. Progress through 
 the bone is determined by the skilled sense of touch. The section should be 
 evenly made, as to depth, completely across the width of bone, traveling 
 back and forth, no two blows being made in one site. Never remove the 
 instrument from the groove in the bone when once the section has been 
 commenced (unless a larger instrument catches in the section and has to 
 be replaced by a thinner one), for it is often hard to regain the groove. The 
 last portion of bone on the far side of the section, when important structures 
 are just beyond, need not be cut with the osteotome, but may be bent or 
 broken subsequently by manipulation of the limb. 
 
 Division of Bone with Saw. — A special osteotomy saw, generally of 
 the Adams type, is used. The operation is very similar to that just described, 
 except in the substitution of the saw for the osteotome. The skin incision 
 is placed as in the above operation, but is made with a tenotome instead 
 of an ordinary knife — usually cutting in the line of the muscle-fibers and in 
 the axis of the limb. When the bone is reached, the blade of the tenotome 
 is turned so as to cross the bone transversely and is made to cut a path for 
 the saw across the bone — the non-cutting part of the handle of the tenotome 
 doing no harm to the soft parts between the bone and wound of entrance. 
 When the way for the saw has been prepared, the tenotome is left in situ 
 as a guide. Upon this the blade of the saw is introduced down to the bone 
 and its cutting part pushed on across the portion of bone to be divided (Fig. 
 1 68, A). The bone is to be sawed with short strokes, guarding against 
 thrusting the point of the saw into the soft parts, especially at the beginning 
 and ending of the section. The section may be nearly made with the saw 
 and completed by manual bending or breaking. 
 
 After-treatment. — Following osteotomy, the limb, or part, is in a con- 
 dition of compound fracture made under the most favorable circumstances. 
 Some form of splint, or a plaster-dressing, must immobilize the limb and 
 keep the ends of the bones in apposition. The wound is closed by suture 
 — no drainage being used in clean cases. 
 
 Comment. — (i) In division by an osteotome, the osteotome itself is 
 sometimes used to cut its way through the soft parts, instead of knife. (2) 
 When the bone-section is nearly complete, bending is especially applicable 
 
LINEAR OSTEOTOMY BY THE OPEN METHOD. 
 
 213 
 
 in young tender bones. (3) The section of the bone should generally be 
 completed by instrument, and not by breaking, as a splinter of bone may 
 do damage to adjacent parts. 
 
 LINEAR OSTEOTOMY BY THE OPEN METHOD. 
 
 Steps of Operation Preparatory to Division of Bone. — The site of 
 the bone-section is exposed by an incision so placed as to reach the bone 
 most readily and safely, seeking an intermuscular plane where possible. 
 Having passed through skin, fascia — and through or between muscles — ■ 
 the soft parts are opened up and retracted to either side — and the region 
 of bone fully exposed to view. Where it is possible to do so, and where 
 it is not contraindicated, the periosteum is incised in the long axis of the 
 bone, freed from its circumference, and retracted with the soft parts. The 
 bone-section may then be made with an osteotome or with a saw: — ■ 
 
 Division of Bone with Osteotome. — The osteotome is introduced at 
 once upon the bone, in the direction the section is to be made — after which it 
 is manipulated as in the 
 subcutaneous method — 
 much greater control 
 of the instrument being 
 possible. 
 
 Division of Bone 
 with Saw. — -The saw- 
 is similarly introduced 
 at once upon the bone, 
 in the direction the sec- 
 tion is to be made. 
 The section is then 
 made by short strokes, 
 while the parts are well 
 retracted and the entire 
 operation exposed to 
 view. 
 
 After - treatment. 
 — U n 1 e s s contraindi- 
 cated, the periosteum 
 should be sutured with 
 gut — the sutures at the 
 same time passing 
 through the muscles and 
 quilting them together. 
 The wound is then 
 
 closed in the usual way — and a retentive apparatus applied, as described 
 in the last operation. 
 
 Comparison. — In subcutaneous osteotomy the use of the osteotome is 
 safer, less damaging, and the section is cleaner than by the saw. In open 
 osteotomy the saw is preferable, especially the chain or Gigli saw. In the 
 open method, while a larger wound of entrance is made, the bone-section 
 is more accuratelv made and less damage is done to the neighboring tissues. 
 
 Fig. 169, 
 
 -Cuneiform Osteotomy: — Chisel is shown removing 
 wedge-shaped piece of bone from bent tibia. 
 
214 OPERATIONS UPON THE BONES. 
 
 CUNEIFORM OSTEOTOMY. 
 
 Description. — A wedge-shaped piece of bone is removed, the size of 
 which is determined by the needs of the case — the general rule being that 
 the sides of the wedge should be at right angles to the axis of the bone just 
 above and below the section — ordinarily, however, a smaller wedge suffices. 
 The wedge usually extends entirely through the bone, its base being upon 
 one surface and the apex upon the opposite — but it may extend only two- 
 thirds or three-fourths of the way through, the balance being bent or broken. 
 The operation is nearly always done by the open method. 
 
 Operation. — Having exsanguinated the limb by elevation, followed by 
 the application of a rubber tourniquet (which is much more frequently used 
 than in the linear form of osteotomy) the limb is placed upon a sand-bag. 
 The incision is placed over the site of the base of the wedge to be removed 
 and is considerably longer than the base of the wedge — and is so planned 
 as to enable the bone to be reached through the most direct and safest route, 
 and to enable the muscles to be separated rather than cut. The skin and 
 fascia are first incised — the muscles separated in their intermuscular cleavage 
 line and retracted — and the periosteum incised in the axis of the bone, down 
 to the bone, and retracted with, and adherent to, the soft parts. This clearing 
 of the bone subperiosteally is accomplished with a curved periosteal elevator, 
 the clearing being done more extensively at the site corresponding with the 
 base of the wedge. The chisel is the best instrument with which to perform 
 cuneiform osteotomy — though a chain or Gigli saw may sometimes be used 
 advantageously, and even an ordinarv saw may be conveniently used in 
 some cases of angular ankylosis (Fig. 169). The chisel is held like an osteo- 
 tome, for the sake of steadiness. The beveled edge of the chisel is directed 
 toward the wedge of bone to be removed. If the wedge be of considerable 
 size, it cannot be removed with accuracy in one piece — a small wedge, narrow 
 at its base, must be first removed — and then slices may be chiseled from the 
 sides of this until a cuneiform space representing a wedge of the requisite 
 size is removed. Having removed the wedge of bone, the ends of the bone 
 are put into position — the periosteum is sutured with gut — the wound closed 
 — and the limb put up in an immovable splint. 
 
 Comment. — In this, as in the other forms of osteotomy, additional 
 means may be used for holding the divided ends of the bone in place, besides 
 the special form of splint — such as wiring, pegging, suturing, and other 
 devices mentioned under operations for ununited fractures. 
 
 THE OPERATIVE TREATMENT OF FRACTURES IN GENERAL. 1 
 
 Operations for ununited fractures resolve themselves, as far as the forms 
 of the bones are concerned, into three classes — those for fractures of the long 
 bones — of the short bones — and of the mixed bones. The general principles 
 involved are the same in all classes. Fractures of some special bones require 
 special treatment. 
 
 1 Much of what follows upon this subject is taken from a paper read by the author upon 
 "The Operative Treatment of Fractures in General,'' before the surgeons of the Chicago, 
 Hamilton, and Dayton Railway, at Dayton, Ohio; and before the New York Post-Graduate 
 Clinical Society, and is here reproduced or modified by their courtesy. 
 
RESECTION FOR FRACTURED BONES. 215 
 
 The principles involved: — the placing of freshened ends of bones in good 
 position, without too great tension, and without intervening soft parts — and 
 the maintaining of these ends strictly in position by competent immobilizing 
 splint. 
 
 Following is a brief summary of the technic employed in the majority of 
 cases; — exposure of ends of bones as nearly subperiosteally as possible — 
 resection of the ends as nearly transversely as the nature of the fracture will 
 permit — if the ends of the bones can be easily approximated and easily retained 
 in position, place them in apposition, suture the periosteum, approximate 
 the muscles by buried sutures, close the wound, and apply an immobilizing 
 splint. If the ends are not likely to be easily kept in approximation (especiallv 
 as the result of an oblique section), one of the methods of holding them in 
 apposition (to be described below) may be resorted to — in addition to placing 
 the ends in contact and applying a retentive form of apparatus. 
 
 In operating, some form of tourniquet is usually applied. The site of 
 operation is to be shaved. The position of patient, surgeon, and assistant 
 will be determined by the special operation. 
 
 The instruments used are those employed for Osteotomy (page 210). 
 
 The subject of the Operative Treatment of Fractures may be considered 
 under several headings: — (I) Operative Methods of Approximating and 
 Fixing Ends of Fractured Bones — (2) Operative Treatment of Simple Frac- 
 tures — (3) Bone Grafting, or Implantation — (4) Operative Treatment of 
 Delayed Union, Non-union and Mal-union — (5) Operative Treatment of 
 Compound, Comminuted, and Complicated Fractures — (6) Operative Treat- 
 ment of Fractures Involving Joints, and of Fracture-dislocations — and (7) 
 Operative Treatment of Separated Epiphyses. 
 
 The results to be aimed at in fracture-treatment are — union without 
 deformity — without impairment of function of limb — and with as limited 
 loss of time and usefulness as possible. 
 
 To summarize the status of fracture-treatment, it may be said that the 
 present treatment of fractures is in a transitional stage — and is now in the act 
 of passing from the routine, hard-and-fast, prolonged splinting, which was 
 in common use until a very short time ago — to the more rational methods 
 of the present time, which include the use of early passive movements and 
 massage in conjunction with removable splints, and the practice of open 
 incision in appropriate cases. 
 
 Various methods are in use for bringing the ends of fractured bones into 
 apposition and holding them in place until bony union has occurred. The 
 best form of internal fixation for the special case cannot be known in advance 
 of the actual exposure of the parts involved. The technic of exposing the 
 ends of the bones, however, does not materially differ, no matter what form 
 of internal fixation be employed — and this technic, therefore, will be first 
 briefly described — and then will be enumerated the most generally used 
 methods resorted to for holding the broken bones together. 
 
 OPERATION FOR RECENT OR UNUNITED FRACTURE BY RESECTION 
 
 OF ENDS OF BONES, WITH RETENTION OF COAPTATED ENDS BY 
 
 IMMOBILIZING SPLINTS. 
 
 Description. — The ends of the bones are exposed and excised, and the 
 freshened ends are then brought into contact and held in apposition by a 
 splint or a plaster cast. 
 
2l6 
 
 OPERATIONS UPON THE BONES. 
 
 Take, fur an example of the technic, the operation for the repair of a 
 simple recent fracture by resection of the ends of the bones, with retention of 
 the coaptated ends by immobilizing splints — where no form of mechanical 
 fixation is used other than that secured by placing the ends of the sawn bones in 
 proper relation and holding them in such relation by splints. (And what is 
 here said of recent fractures applies also to ununited fractures.) In many cases 
 of recent fracture the nature of the broken ends might be such as not to require 
 their resection prior to the application of the special form of internal fixation. 
 
 Operation. — Hav- 
 ing exsanguinated the 
 limb and applied a 
 tourniquet, an inci- 
 sion, sufficiently free 
 to allow of protrusion 
 of the ends of the 
 bones, is made in the 
 long axis of the limb, 
 directly over the ends 
 of the bones — and 
 placed so as to give 
 free access by the most 
 direct and safest route 
 to the involved site. 
 The skin and fascia 
 are divided — the mus- 
 cles are separated in 
 their intermuscular 
 planes and retracted 
 — or, if separation of 
 the muscles in their 
 planes be impossible, 
 they are divided as nearly in the direction of their fibers as possible. Important 
 vessels and nerves are carefully avoided, being retracted to one side. The wound 
 is made fully large and the lateral retraction of the soft parts sufficient to make 
 the necessary manipulations possible without adding to the traumatism. 
 The ends of the bones are fully exposed and entirely freed of all tissue which 
 may intervene between the fragments, whether normal or cicatricial. As 
 the ends of the bones are approached, care is taken to avoid injuring the 
 periosteum — which should be split longitudinally and freed circumferentially 
 from the ends of the bones, without otherwise severing its connection, and 
 should be raised without separation of overlying muscle, that is, as a musculo- 
 periosteal covering. The end of each bone is dealt with in turn, and, after 
 being thoroughly freed, is, where possible, protruded through the wound, 
 the limb being bent at an angle for this purpose and the soft parts well retracted, 
 the periosteum being carefully peeled back during this step. A minimum 
 slice of bone is now removed from the end of each bone, simply enough to 
 insure a fresh, raw surface upon each. If the bones have been protruded, 
 this section is generally best made with a butcher's saw. If the ends have 
 not been protruded through the wound, after they have been well freed, it is 
 best to slip a chain or Gigli saw between the bone and the periosteum and thus 
 make the section. The section may also be made, though generally less 
 satisfactorily, with a chisel. The direction of the section will depend largely 
 upon the nature of the ends of the bone; — if a rather transverse fracture, the 
 
 C D 
 
 -I. — Operations for Ununited Frac- 
 tures by Simple Section: — A, B, Simple transverse fracture, 
 followed by transverse section of bones; C, D, Irregularly trans- 
 verse fracture, followed by section of bone parallel with fractures. 
 
SUTURING FOR FRACTURED BONES. 
 
 217 
 
 section is made transversely; — if a very oblique fracture, the section is made 
 obliquely (Figs. 170-173, A, B, C, D; and Figs. 174-177, A, B, C, D). 
 Whether the section be made transversely or obliquely, the section is so planned 
 as to leave a limb in correct position, as to its axis and as to its rotation, and 
 is so made as to secure 
 two parallel surfaces for 
 contact. An exception 
 to this is where some 
 special form of section is 
 made, as when the bones 
 are so sawed as to have 
 an angularity of one fit 
 into a depression of 
 another, producing the 
 mortising effect — the 
 
 great principle being that 
 the ends of the bones 
 should be cut so as to fit 
 each other. A transverse 
 section of the bones is 
 always preferable, unless 
 involving too great a sac- 
 rifice of length. The 
 ends are now approx- 
 imated in the position in 
 which the bones will re- 
 main, and are held in this 
 position during the re- 
 mainder of the operation and until the permanent splint be applied. The 
 periosteum is sutured with gut. The muscles are brought together with buried 
 gut sutures. The outer wound is closed in the usual way. The limb is then 
 placed in a permanent splint, or in a plaster cast, with extreme care, so steady- 
 ing the parts during the dressing that the ends of the bones remain undisturbed. 
 Where the case is one of mal-union, either the ends of the mal-united bones 
 are excised, or the badly united ends are sawn or chiseled apart, after which, 
 in either case, the ends are treated as in cases of non-union. 
 
 Comment. — (i) The operation is, practically, that of osteotomy by the 
 open method. (2) In a recent case, the after-treatment is that of a compound 
 fracture, with the limb put up in a position to relax the pull on the fractured 
 ends. (3) In old cases where bands of fascia, or tendons, are apt to draw 
 the ends out of place, these should be divided. (4) Where it seems likely 
 that the ends of the bones will tend to displacement, especially in such cases 
 as the femur, a process of mortising may be carried out in fashioning the 
 ends of the bones for approximation. 
 
 -II. — Operations for Ununited 
 Fractures by Simple Section: — A, B, Wedge-shaped and 
 C, D, rectangular fracture, followed by section of bone par- 
 allel with fracture. 
 
 OPERATION FOR RECENT OR UNUNITED FRACTURE BY SUTURING 
 OF ENDS OF BONES, WITH OR WITHOUT RESECTION. 
 
 Description. — Instead of simple approximation of the broken ends and 
 their retention by splints applied to the outer surfaces of the limb, some form 
 of mechanical device may be also used to hold together the ends of the bones 
 themselves. In such cases, having exposed the site of fracture by, approx- 
 
2l8 OPERATIONS UPON THE BONES. 
 
 imately, such steps as those just described, the broken ends of the bone are 
 now to be brought into apposition and fixed by some special method selected 
 by the surgeon — of which the following are the chief procedures in use — it 
 being understood that these methods apply equally, whether the case be a 
 recent fracture, an old fracture with pseudarthrosis, a non-union, a mal-union, 
 a simple fracture, or a compound fracture — and whether the form of 
 fixation be employed after the ends of the bone have been resected, or 
 without resection. In the method about to be described, in addition to 
 the retention of the coaptated ends of the bones by splints, the ends 
 are previously drilled and held in contact by some form of suturing. In 
 the case of new fractures, where the ends are left so shaped as likely to remain 
 in position when sutured, resection of the ends of the bones need not be done 
 — otherwise the ends should be resected. In all cases of old fracture the 
 ends of the bones are always resected, so as to present freshened surfaces. As 
 
 Fig. 178. — Method of Drilling Bone for Wiring: — A, Bone-holding forceps; B, hand-drill. 
 
 the chief dependence is in the ultimate bony union between the fractured 
 or resected ends, and as the chief function of the retaining substance is tem- 
 porarily to hold the ends in position until union is sufficiently advanced to fix 
 the ends of the bones firmly and permanently, it is unquestionably best to use 
 the material which, while fulfilling that temporary office, will then disappear 
 of its own accord and give no future trouble — and, therefore, kangaroo tendon, 
 or heavy, 30-40-day chromic gut, is the ideal material for this purpose. Of 
 the soft materials, silk and silkworm gut are also used. Of the non-absorbable 
 metallic substances used, silver wire is the most frequently employed. The 
 wire should be of different sizes for different bones. It should be of pure 
 silver, or it will not stand as much strain on twisting. It should be cut into 
 lengths and straightened. Each piece should be heated to a dull red heat in 
 the flame just before using (in order to make it much more pliable and less apt 
 to break) — then cooled and dropped into sterile solution ready for use. Some- 
 times wire is used with the intention that it should only remain in temporarily 
 and be removed when its usefulness is at an end — -but generally it is hoped 
 
SUTURING FOR FRACTURED BONES. 
 
 219 
 
 that it will remain in permanently — the ends of the wire, therefore, are treated 
 according to the views entertained. The general method of applying the 
 suture, no matter what the material, is the same. 
 
 Operation. — The steps of the operation are the same, in all respects, as 
 for resection with retention by splints — up to the exposure and clearing of 
 the ends of the bones — after which the technic will differ, dependent upon 
 whether the bones are resected or not; — (a) Suturing of the bones without 
 resection: — The ends of the bones are grasped and steadied by some special 
 foim of bone-holding forceps, while holes for the passage of wire are drilled 
 — sufficient in number to furnish the desired strength and so planned in 
 position as to retain the normal axis of the bone (Fig. 178). The holes may 
 be drilled and the suture passed in several ways. Where the fracture is 
 practically a transverse division of the bone, the drill-holes are usually made 
 to pass through one wall of the upper and the corresponding wall of the lower 
 fragment, the suture thus passing through but a small portion of the medulla 
 of the bone (Figs. 179-181, A, B, C). In the case of an oblique fracture, 
 
 Figs. 179-181. — Operations for Un- 
 united Fractures by Section \nd Sutur- 
 ing : — I. — In transverse fractures; — A, Single 
 suture through both walls of each bone; B, 
 Double suture through both walls of each 
 bone; C, Sutures passed through single wall 
 of each end. These forms may be used 
 without section of bone. 
 
 C 1 m 
 
 Figs. 1S2-1S4. — Operations for Un- 
 united Fractures by Section and Suturing: 
 — II. — In oblique fractures; — A, Double sutures 
 through both walls of each end, in axis of bone 
 (not advisable); B, Same, crossing fracture at 
 right angle (advisable); C, Loop of suture 
 carried through drill-hole, and free ends brought 
 around bone and through loop and twisted. 
 These forms may be used without section of 
 bone. 
 
 the holes may be drilled and the suture passed in the same way — or the 
 fragments may be held in position and the holes drilled through opposite 
 walls and the intervening medullary substance (Figs. 182-184). In the 
 case of wire, the ends, in either of the methods above mentioned, may then 
 be twisted, cut short, and pressed into the periosteum and bone — or may 
 be twisted long and brought out of the wound (Figs. 185-187 and 188-190). 
 In both methods the periosteum is pierced by the suture, though elsewhere it is 
 preserved as intact as possible upon the bones. In previously drilling the 
 holes for the passage of the suture, the most useful instrument to have at hand, 
 
220 
 
 OPERATIONS UPON THE BONES. 
 
 next to one of the many forms of bone-drill, is a pair of stout bone-holding 
 forceps with fenestrated blades — by which the bone is firmly held and through 
 the fenestrated openings of which the drill is applied, thus steadying both the 
 bone and the drill-point (Fig. 178). (b) Wiring of the bones after resection: — 
 The resection of the ends of the bones is accomplished just as in the operation 
 for ununited fracture by resection of the ends of the bones, with retention of 
 the coaptated ends by immobilizing splints (page 215). The ends of the bones 
 are then drawn back into their musculo-periosteal sheaths — and the ends are 
 then sutured as in (a) above. Following the approximation of the ends 
 of the bones, the periosteum is sutured with gut — the muscles are brought 
 together with buried gut sutures — the outside wound closed as usual — and 
 
 Figs. 185-187. — Operations for Un- 
 united Fractures by Section and Wir- 
 ing: — III. — By simple loop-ligatures: — A, 
 By double loops around bone at right angle 
 to axis of bone; B, Double loops at right 
 angle to line of oblique fracture; C, Double 
 loops, as in A, reinforced by lateral wire- 
 loops. These forms may be adopted without 
 section of bone. 
 
 Figs. 188-190. — Operations for Ununited 
 Fractures by Section and Wiring: — IV. — By 
 frame-ligature; A, B, C, First, second, and third 
 stages of the frame-ligature. 
 
 an immobilizing splint applied. The wire is not expected to be removed 
 when buried, — when left long, it is subsequently (after firm union) untwisted 
 and drawn out, to accomplish which it is sometimes necessary to expose the 
 parts by incision down to the bone. 
 
 Comment. — The drill-holes should be a little larger than the silver wire 
 used. The wire should be fairly heavy. The holes are drilled from 8 mm. 
 to 1.3 cm. (I to \ inch) from the ends of the bones, penetrating obliquely 
 if but one wall of the upper and one wall of the lower fragment be drilled — 
 and penetrating at a right angle to the surface, if the drilling pass transversely 
 through opposite walls. In drilling for oblique fracture, the suture should 
 pass at a right angle to the line of fracture. 
 
METHODS OF FIXING ENDS OF FRACTURED BONES. 221 
 
 OTHER OPERATIVE METHODS OF APPROXIMATING AND FIXING 
 ENDS OF FRACTURED BONES. 
 
 In the various forms of mechanically uniting ununited bones, about to be 
 described, the preliminary steps of exposing and preparing the ends of the 
 bones for coaptation, whether resection has been done or not, are the same 
 as those given in the preceding operations. 
 
 Union of Fractured Bone by Metallic Nails or Ivory Pegs. — While 
 the ends of the bones are held in firm contact in the grip of strong, fenestrated, 
 bone-holding forceps, plated nails are so driven as to bind both ends — or 
 ivory pegs are inserted through previously drilled holes. The nails usually 
 protrude through the skin and are subsequently withdrawn (in about two 
 weeks) — whereas ivory pegs are generally cut flush with the bone and are 
 left, in the hope that they will become incorporated with the osseous tissue 
 (or they, too, may be left long and be withdrawn). If the fracture or section 
 be transverse, the nails or pegs are put in obliquely, passing from without 
 through the proximal wall of the upper fragment, through the medullary 
 
 Fig. 
 
 191. — Uniting Fractured or Re- 
 sected Bone by Nailing. 
 
 Fig. 192. — Uniting Fractured or Re- 
 sected Bone by Pegging. 
 
 substance, and into the wall of the lower fragment, from within outward. 
 Two or more nails or pegs are generally inserted, passing in different direc- 
 tions (Figs. 191 and 192). If the section, or fracture, be oblique, the nails 
 are put in at a right angle to the surface of bone and pass transversely through. 
 As little damage as possible is done to the periosteum. The muscles are 
 brought together by buried gut sutures — the wound closed — and the limb 
 immobilized. 
 
2 22 
 
 OPERATIONS UPON THE BONES. 
 
 Union of Fractured Bone by Metallic Screws. — The technic is here 
 very similar to that in the lust proceeding, except that plated screws replace 
 the nails. The holes for the screws which bind the two fragments are first 
 drilled of a slightly smaller size than the diameter of the screws — which are 
 driven home with a screw-driver until their heads are flush with the periosteum. 
 It is necessary to have a large variety of screws on hand, especially as to 
 length. They may remain permanently in situ — or may be cut down upon 
 and unscrewed. 
 
 Union of Fractured Bone by Metallic Plates and Screws. — Following 
 the technic of Steinbach, silver plates of various sizes and shapes are used, 
 secured in position by small galvanized steel screws — those, for example, for 
 the tibia, their most useful field of application, are 6 mm. (\ inch) thick, 
 g cm. (T>h inches) long, and 8 cm. (j| inches) wide, and with screw-holes 1.2 cm. 
 (| inch) apart. Having retracted the soft parts without disturbing the 
 periosteum, the screw-holes are first drilled a size slightly smaller than the 
 screws, some into the upper fragment, some into the lower, and the drilling 
 is continued until loss of substance shows that the medullary cavity has been 
 entered, when the screws are driven firmly into place by means of a screw- 
 driver. When bony union is solid, the plate is generally cut down upon and 
 
 Figs. 193 and 194. — Uniting Fractured or Resected Bone by Screwing: — Screws may 
 be used alone — or in metallic plates, as shown in diagram to left. 
 
 the screws unscrewed, and all removed. The plate is sometimes left per- 
 manently in situ (Figs. 193 and 194). 
 
 Union of Fractured Bone with Metallic or Bone Ferrules. — Rings of 
 thin metal, of some width, or of bone, are slipped over the ends of the broken 
 bone — especiallv in the case of oblique fractures. The metallic ferrule is 
 difficult to remove, should it become necessary, even if split on one side. The 
 bone ferrule becomes absorbed. 
 
METHODS OF FIXING ENDS OF FRACTURED BONES. 
 
 223 
 
 Union of Ununited Fracture by Parkhill's Clamp. — The fragments 
 of bone are here held together by means of a special form of clamp consisting 
 of four long steel screw-pins and an interlocking mechanism. The ends of 
 the bones are exposed and freed in the ordinary manner — and resected, if 
 necessary. Two holes are drilled in the long axis of each fragment, in direct 
 line with each other. Four long steel screw-pins are then screwed into these 
 holes by means of a clock-key attachment — after which the "wings" of the 
 instrument are adjusted. While the ends of the bones are held in accurate 
 apposition and care taken that the proper axis of the bone is secured, the 
 two fragments are clamped together in the special manner of the instrument. 
 The muscles and other soft parts are then adjusted about the screws of the 
 clamp, which projects without the wound. The dressing is then applied — 
 
 Fig. 195. — Operation for Fractured 
 or Resected Bone by Parkhill's Bone- 
 clamp: — Surface view of clamp in position. 
 
 Fig. 196. — Operation for Fractured 
 or Resected Bone by Parkhill's Bone- 
 clamp: — Side view of clamp in position. 
 
 and the pins of the clamp not removed for from four to six weeks (Figs. 195 
 and 196). 
 
 Ligation of Bone. — One or more pieces of wire are passed around the 
 fractured portion of bone, either at a right angle to the axis of the bone or 
 at a right angle to the line of fracture. These are twisted, cut short, and 
 
224 
 
 OPERATIONS UPON THE BONES. 
 
 buried. The bone may be notched to aid in holding the wire in place. Longi- 
 tudinal Loops may unite the circumferential wire bands (Figs. 185-187 ). 
 
 Combined Ligature and Suture. — A hole is drilled through the frag- 
 ments at a right angle to their line of fracture — a loop of wire is passed through, 
 given a half-turn in the center, and the two ends passed around the sides of 
 the bone and through the loop and twisted (Fig. 184, C). 
 
 Frame Ligature of Bone.— Drill two holes through the fragments, 
 in the long axis of the bone — pass the free ends of a wire loop through the 
 holes — pass the loop over the free ends and draw tight — then bring the -free 
 ends around to the holes through which the looped end originally passed and 
 carry them under the wires emerging from those holes and twist them together 
 in the long axis of the bone (Figs. 188-190). 
 
 Intramedullary Pegging. — Pegs of ivory, or of fresh or decalcified 
 bone, are lightly driven into the medullary canal of one bone, and the ends 
 of the fractured bone so displaced, temporarily, as to enable the medullary 
 cavity of the opposite fragment to be slipped over the opposite end of the 
 peg (Figs. 197 and 198). Where there has been a loss of substance of bone 
 
 Figs. 197 and 198. — Operation for 
 Fractured or Resected Bone by Intra- 
 medullary Pegging: — A, Peg is seen in 
 medullary cavity of lower bone, and about to 
 be introduced into that of upper; B, Peri- 
 osteum is being sutured along margins of bone. 
 
 Fig. 199. — Operation jor Fractured 
 or Resected Bone by Intramedullary 
 Pegging : — Where part of one bone has been 
 excised and periosteum is being sutured 
 around peg. 
 
 and the periosteum corresponding to the absent bone is preserved, this has 
 
 been sutured over the bone peg with success, especially in the young (Fig. 199). 
 
 Summary. — In summing up the subject of the mechanical fastening of 
 
 the ends of broken bones, it will be seen that the uniting substance may be 
 
OPERATIVE TREATMENT OF SIMPLE FRACTURES. 225 
 
 buried in tissues with the hope that it will remain quiescent — or, if suitable 
 for absorption, that it will be absorbed — while, on the other hand, substances 
 are sometimes put in temporarily, with the purpose of removing them when 
 they have accomplished their object and the parts have become solidly united. 
 The best method can only be determined when the parts are exposed — and the 
 best method of internal fixation is that method which immobilizes most 
 efficiently. The guide for the selection of the special form of this internal 
 fixation will depend, in part, upon the special bone involved and the nature 
 of the fracture — and, in part, upon the views and habits of the surgeon as to 
 retentive appliances. The judgment of the writer would be distinctly in 
 favor of kangaroo tendon, or 30-40-day chromic gut — as being an absorbable 
 substance, and as being a method of wider range of applicability to the various 
 fractures of the body than any other. The strength of either of these sub- 
 stances is sufficient to retain the ends of fractured bones in contact the necessary 
 length of time, if properly handled— at the end of which time absorption usually 
 renders any further dealing with the wound unnecessary. If the limb be 
 carefully held by an assistant assigned to that duty alone, so that the tendon or 
 gut is not put upon the stretch before the limb is secured in its splint, these 
 substances would probably never. stretch to an extent harmful to the interests 
 of the fracture, as claimed — and which has been an objection raised by some. 
 
 OPERATIVE TREATMENT OF SIMPLE FRACTURES. 
 
 Of the various applications of operative treatment to fractures, the question 
 of the operative treatment of simple fractures is probably the most interesting 
 at the present time, for not only is the field for the application of operative 
 interference greater in simple fractures than in any other form of fracture, 
 or in any result of fracture, but the practice itself is comparatively new, and 
 the opinion of the profession at large has not yet been definitely formulated 
 as to the full scope of the technic and the variety of cases to which it should 
 be applied. 
 
 As matters stand at present, the number of surgeons who are operating 
 in cases of simple fracture seems to be steadily increasing. 
 
 Compound or open fractures have always received some form of operative 
 treatment, if only to the extent of cleaning the site and putting the parts into 
 favorable position for repair, and comminuted and complicated fractures 
 have frequently received such treatment, so that the application of a somewhat 
 more radical operative treatment than heretofore to these classes of cases is 
 not so distinctly new — but the treatment of simple or closed fractures is a 
 new field brought up in surgery during comparatively recent years. 
 
 The argument that the operative treatment of simple fractures converts 
 every simple fracture into a compound fracture does not carry with it the same 
 gravity as formerly, for in the vast majority of cases such a procedure carried 
 out with thorough asepsis is accompanied by comparatively little risk. It may 
 be said that the way to the operative treatment of simple fractures was paved 
 by the operations of osteotomy, by the subcutaneous and open methods, for 
 all such operations made compound fractures of the cases, and results in such 
 instances nearly invariably come to a satisfactory conclusion without untoward 
 complications. 
 
 *The special objects accomplished by the open operation in fractures, in 
 those cases where it is indicated, are the following: — ends of bones may be 
 accurately approximated by fingers and instruments while in view and acces- 
 l 5 ' 
 
226 OPERATIONS UPON THE BONES. 
 
 sible in the field; — these ends may be permanently fixed in normal position by 
 whatever means are chosen; — some fractures which cannot be reduced at all 
 by the ordinary methods can be reduced by open operation; — many fractures 
 which are reducible by the ordinary methods only with difficulty and uncer- 
 tainty can be reduced with ease and accuracy; — the ends of many fractured 
 bones not capable of being retained in position by postural treatment are 
 easily retained by internal fixation; — ankylosis is often avoided in fractures 
 near to and involving joints; — partially separated and detached periosteum 
 may be replaced, and sutured if necessary; — a correct diagnosis is possible; — 
 all tissues intervening between the ends of the bones can be removed and 
 placed in normal positions; — clots of blood may be gotten rid of; — injury done 
 to the neighboring structures may be repaired; especially torn nerves may be 
 sutured; compressed nerves freed of their pressure; divided vessels ligated; 
 lacerated muscles repaired; and spiculae of detached bone removed; — inflamed 
 processes are often reduced; — the amount of callus is generally lessened; — 
 shortening is prevented; — deformity is less frequent; — the period of disability 
 is considered by some surgeons to be lessened by one-third; — and a gain in 
 the range of function is often secured. The open method of treatment is 
 especially applicable to many compound fractures, comminuted and com- 
 plicated fractures, old fractures with deformity, cases of non-union, and 
 fracture-dislocations. These results, it must be admitted, are weighty con- 
 siderations, and it must also be admitted that some of these objects cannot be 
 accomplished at all by the ordinary methods of treatment, and that many of 
 those which are accomplished by the usual methods are accomplished more 
 by accident than by intelligent design, for the ordinary method of treating 
 most fractures is, both figuratively and literally, by working very much in 
 the dark, as to both sight and touch. 
 
 Briefly, the object of operative treatment of fractures is, in the language 
 of Van Werden, "to bring into apposition, and hold in contact by direct 
 temporary mechanical measures, the different anatomical constituents of the 
 wound until the process of repair throughout is complete." 
 
 Operative treatment is fully warranted, therefore, and should be unhes- 
 itatingly undertaken where the complete reduction of the fracture and the 
 retention of the ends of the bone in good apposition by simpler means are 
 impossible; where complications otherwise irremediable exist; and is further 
 warranted whenever it is considered that a distinct gain in time to the patient 
 and increase in function of the part can be expected from open operation. 
 
 The compound fracture is here made through a region aseptically ready 
 for it and but slightly apt to resent it. In operating upon fractures immediately 
 after the accident, the soft parts offer no great opposition to extension and 
 replacement, but after a few days have elapsed, physiological shrinkage may 
 offer so much opposition to extension and replacement as to be relieved only 
 by flexing the contiguous joints or by division of tendons and fascia. 
 
 Having determined upon operation, the general manner of exposing 
 the parts is similar in technic to that already described under Operative 
 Methods of Approximating and Fixing Ends of Fractured Bones, and will 
 not be given in further detail here. 
 
 After having exposed the ends, the interlockable nature of the fragments 
 may be such as to make any other form of fixation other than simply causing 
 the ends to interlock, unnecessary. Some form of mechanical fixation, 
 however, is generally done; the writer would prefer, as indicated above, kan- 
 garoo tendon or chromic gut in the great majority of cases. 
 
 The operative treatment of simple fractures should be carried out imme- 
 
BONE-GRAFTING OR BONE-IMPLANTATION. 227 
 
 diately after injury, and if this cannot be done, some surgeons wait until a 
 week has elapsed. 
 
 Where irregularly fractured ends can be interlocked in their normal relation- 
 ship before being sutured, their holding together is more firm than if they had 
 been sawed, and the full length of the limb is maintained. 
 
 It has only been since the introduction of the open method of treating 
 simple fractures that the difficulties in their reduction, up to that time con- 
 cealed by unbroken skin, have been so clearly demonstrated. Of these several 
 difficulties the greatest is caused by the shortening of all the soft parts in the 
 region near the break, which, in turn, is caused by inflammatory action, 
 hemorrhage into the tissues, and by contraction of the tissues themselves — 
 for after the fracture there is no resistance to the contraction of the soft parts, 
 as compared to their normal stretched condition. The bones are thus pulled 
 together, and, where the nature of the fracture makes it possible, causes an 
 overriding of the ends. This condition of contraction is prevented when 
 internal fixation of the fragments has been satisfactorily accomplished. 
 
 BONE-GRAFTING OR BONE-IMPLANTATION. 
 
 Bone-grafting consists of the transplantation of living bone, or periosteum, 
 from the same or different individual, or from an animal, into the defect to be 
 repaired. 
 
 There is another group of substances which cannot be strictly called 
 bone-grafts, but which are rather to be regarded — either as "scaffoldings," 
 or "trellis-works," along which bone-material may grow in the process of 
 repair — or as irritants which serve to provoke this osteoplastic process. Such 
 are: dead bone, variously prepared and rendered aseptic — bone-plates — bone- 
 ferrules — calcined bone — decalcified bone — and even fresh bone with its 
 periosteum and endosteum scraped off — and bone-chips. 
 
 It has not been absolutely decided whether the living graft ever remains 
 as such and grows — or whether it does not always disappear after exciting 
 new bone-formation. It is held by some that the implanted bone lives — by 
 others, and this is more probable, that it does not live as normal bone. Valan 
 holds that the center of the graft dies, but that the periphery becomes fused 
 with the living bone and lives. In still other cases it neither grows itself nor 
 excites new bone-formation — but, in such cases, and where the operation and 
 its subsequent course are aseptic, it may cause the formation of firm fibrous 
 tissue which is almost as serviceable as bone. 
 
 The return to its site of the button of bone temporarily removed by tre- 
 phining is one form of bone-implantation, where the trephining may be 
 regarded as a deliberate fracture or solution of bony continuity made by the 
 surgeon for some specific object. An osteoplastic amputation, such, for 
 example, as those about the lower extremity, is an illustration of bone-trans- 
 plantation designedly made in the course of an operation. Of the artificially 
 prepared substitutes for bone, calcined bone, either in the form of coarse 
 granular powder or in the form of plates, would seem to be an approximate 
 physiological substitute for bone, supplying, as it does, the lime salts. It is 
 easily prepared — easily sterilized — readily fills the cavities — and is so porous 
 that it is gradually replaced by bone which grows over it and through its 
 interstices as over an arbor. The calcined bone-plates are made from the 
 cancellated bone of the scapula of calves. It is held by Valan that calcined 
 bone is better to use than decalcified bone — because the resulting bone-tissue 
 is stronger. 
 
228 OPERATIONS UPON THE BONES. 
 
 The chief indication for hone-grafting, or bone-implantation, is to fill 
 in the interval left by lost bone in such conditions as compound or comminuted 
 fractures, where the bone is very much fragmented and the pieces are nearly 
 or entirely detached, or seem unlikely to live; in mal-union, necessitating opera- 
 tion, with loss of bone; to restore the continuity of long bones where all or a 
 considerable portion of the shaft is lost; and in deformities, to replace destroyed 
 bone. 
 
 There are several varieties of bone-grafts: (I) Detached portions of 
 human bone (from the same or another individual), living at the time of 
 detachment from the donor, and implantation into defect of recipient. (2) 
 Detached portions of animal bone, living at the time of detachment from donor 
 and implantation into defect of recipient. (3) Portions of human bone 
 adherent by periosteum, soft parts, and vascular supply to an adjacent part 
 of the donor's body (as in fractures and deformities about the face). (4) 
 Portions of animal bone adherent by periosteum, soft parts, and vascular supply 
 tn an adjacent part of the donor's body. 
 
 There are now a sufficient number of authentic cases of extensive successful 
 bone-grafting from the lower animals to man to warrant the expectation that 
 the technic of this operation will be rapidly elaborated, and the field of its 
 usefulness greatly expanded. 
 
 The manner of exposing the site to be grafted is the same as that described 
 under the operations for exposing the ends of fractured bones for the purpose 
 of applying internal fixation; or a preexisting wound, or other circumstances, 
 may determine the method of exposure. Where the bony defect is of a 
 limited nature, this defect may often be repaired from the adjacent bone of the 
 individual himself — by clipping off portions of the bone and periosteum and 
 wedging them in between the ends of the bone by means of an osteotome or 
 chisel. If small pieces of bone can be chipped off from the ends of the broken 
 bone and packed into a tube of periosteum connecting these ends, there is 
 an especially favorable outlook for bone-formation. If a periosteal tube be 
 absent, the soft parts may be brought around the grafts and held in place by 
 catgut sutures. Some surgeons prefer human and some animal grafts. 
 The latter must, of course, be much more generally available. The animal 
 graft may be implanted as a solid piece of the required length, or a piece of 
 the proper length may be split longitudinally into several small pieces and 
 these inserted into the gap, with their periosteum adherent. Where a graft 
 fails to take in the gap between the ends of one of the bones in a double-bone 
 limb, a portion of the second bone should, in appropriate cases, be excised to 
 correspond with the opposite gap, thus making both bones of the same length. 
 This, however, should only be done as a last resort. 
 
 OPERATIONS FOR DELAYED UNION, NON-UNION, AND MAL-UNION 
 
 OF FRACTURES. 
 
 Delayed Union. — Fractures which have resisted the ordinary attempt to 
 bring about union by the usual form of procedure — as carried out by those 
 who are in the habit of submitting the great majority of fractures to splinting 
 and. its accessories — are usually, and generally rightly, subjected to a second 
 treatment by the same means, with especial attention to constitutional indica 
 tions, and possibly more active out-of-door life. Where, on the other hand, de- 
 layed unions are treated by those who more frequently adopt the open operation 
 in even simple fractures, they will probably be subjected to operative treatment 
 upon their first failure to unite — in which cases they will come, as far as 
 
OPERATIONS FOR DELAYED UNION OF FRACTURES. 229 
 
 operative technic is concerned, within the following category, which they 
 resemble in all but their duration. 
 
 Non-union. — The two most usual methods of treating non-union, after 
 having exposed the parts, are, first, to resect the ends, bring the bones into 
 apposition, and hold them in this position by plaster or other splinting, or, 
 secondly, after having resected the ends, to bring and hold the bones together 
 by some form of internal fixation, if possible, preferably by kangaroo-tendon 
 or chromic gut, or by silver wire; or, where the resulting gap is too great in 
 the involved bone of a double-bone limb, by bone-grafting. The technic of 
 exposure is the same as that given under the operative method of approxi- 
 mating and fixing the ends of fractured bones. In addition to the technic 
 there given, the callus and all inter-fragmentary tissues are to be removed 
 by knife, scissors, and bone gouge. Where a condition of pseudarthrosis 
 exists, the structures entering into the formation of the false joint are all 
 thoroughly cleared away. The ends of the bone are then sawed off squarely 
 or shaped so as to hold more firmly when brought into apposition, orotherwi>e 
 resected, as indicated by the special form of fracture, or, in some cases, may be 
 simply scraped with bone gouge. The ends are then brought together by 
 the form of internal fixation selected, or the intervening gap filled with a bone- 
 graft, as just indicated. The periosteum, if preserved, is sutured with catgut, 
 the muscles separated in the approach are brought together by buried gut 
 sutures, if need be, the wound is closed without drainage, and the limb put up 
 in its splint. 
 
 Mal-union. — -Occurs most usually in the upper third of the femur 
 or middle of the humerus. The deformity may be simply a shortening of the 
 limb from overlapping of the fragments, the limb remaining in its normal 
 axis; or an angularity may exist, which is more serious when near a joint. 
 The treatment for mal-union should invariably be by open osteotomy; where 
 a simple transverse, linear osteotomy, or cuneiform osteotomy, as indicated, 
 should be done; or, if marked, the deformed site of fracture may be excised. 
 Where it is possible to do so, the bone section should be made as subperios- 
 teally as the condition of the original torn periosteum permits, that is, a 
 longitudinal incision should be made through the periosteum over the bone, 
 during the latter steps of the approach to the bone; beginning well over the 
 sound periosteum of the upper bone, and extending well over that of the lower 
 bone, and the two lips of periosteum peeled back from the bone, at the site 
 where the section is to be made, until the entire circumference of the bone is 
 exposed, and then the bone, bared of periosteum, is to be divided by linear or 
 cuneiform osteotomy. In this way the periosteum is left intact to materially 
 aid in the regenerative process of callus formation. If the bone of a single- 
 bone limb, or appropriate bones of head or trunk, have been thus divided, the 
 ends should be drilled and brought together with kangaroo tendon, or chromic 
 gut, which, when the periosteum has been first temporarily removed from the 
 bone at the site, is inserted through the bone, but not through the periosteum, 
 so that the periosteum is allowed to fall back in place, and overlie the suture 
 knots. If, on the other hand, the bone is one of the bones in a double-bone 
 limb, if a tangible piece with parallel ends be removed, the ends left after 
 the incision cannot, of course, be approximated and sutured (owing to the 
 fact that the length of the limb or part is maintained by the other bone), and, 
 in these cases, the site has either to be put up with the ends of the involved 
 bone apart, or, which is probably better, the empty casing of periosteum can 
 be filled with either a single bone-graft or bone-grafts, and its lips sutured 
 over such graft or grafts. Even the empty casing of the periosteum, although 
 
230 OPERATIONS UPON THE BONES. 
 
 partly collapsed by the pressure of soft parts, would probably produce bone 
 which would fill in the gap between the ends. Excision of a corresponding 
 length of the opposite bone in the double-bone limbs is sometimes done, but 
 is not so desirable. In any of these cases the limb is subsequently treated 
 as one with a compound fracture made under favorable circumstances. 
 Under no circumstances should the deformity of a badly united fracture be 
 corrected by osteoclasis, for all methods of bone-breaking are crude, uncertain, 
 dangerous to neighboring parts, and are distinctly unsurgical — nor is the 
 subcutaneous division by saw, or osteotome, of the bone or bones involved 
 in the mal-union warrantable. 
 
 OPERATIVE TREATMENT OF COMPOUND, COMMINUTED, AND COM- 
 PLICATED FRACTURES. 
 
 Compound Fractures. — The progressive advance in the treatment of 
 compound fractures is one of the most marked illustrations of the evolution of 
 conservative surgery. At one period a very large percentage of compound 
 fractures came to amputation — and in many hospitals it was the accepted rule 
 to amputate all limbs above the site of a compound fracture involving a large 
 joint. Then followed a period when conservatism was shown by saving the 
 limb at the expense of shortening it, by making an excision at the site of com- 
 pound fracture, including a joint, if necessary. At the present time still 
 further conservatism is accomplished in many cases by neither amputation nor 
 excision, but by freely exposing the parts by operation, correcting the damage 
 done to neighboring soft structures, thoroughly disinfecting the part with 
 antiseptic irrigation, followed by aseptic douching, treating the ends of the 
 bone as indicated by the conditions found, carrying out some method of internal 
 fixation of broken ends, and putting the limb in an open or fenestrated splint. 
 Owing to the uncertainty of asepsis, drainage should generally be instituted 
 at first. It should be maintained as long as the necessity for it exists, but can 
 frequently be dispensed with in two or three days. The technic applies almost 
 as forcibly to compound fractures with the smallest puncture, as to those with 
 larger external wounds. The temptation may be very great to disinfect exter- 
 nally, and to try to disinfect internally, an insignificant-looking puncture of a 
 compound fracture and hermetically seal it with collodion, but subsequent 
 septic developments will often cause regret. When the parts are exposed, the 
 extent and nature of the damage may indicate the advisability of excision. 
 
 Comminuted Fractures. — Comminution in a fracture may not be recog- 
 nized by ordinary manipulation, and may only be demonstrated by .v-raying. 
 Even when present, especially where simple and not extensive, it may not par- 
 ticularly complicate the fracture. In such cases ordinary, non-operative treat- 
 ment of the fracture may be carried out. But where the comminution is more 
 extensive or more complicated, or even where, when simple, comminution 
 prevents the exact approximation and retention of the bone-ends in position, 
 the involved site should be unhesitatingly cut down upon and dealt with as the 
 needs of the special case require. The fragments can often be tied together 
 or sutured to one end of the main bone with chromic gut. Large fragments 
 whose periosteum has been entirely torn off are not so likely to unite, but small 
 chips of bone will. A bond of union by periosteum with the main bone, or 
 with a larger fragment, is very useful in bringing about bony connection. 
 Pieces of bone will frequently live even when taken out of the wound, disin- 
 fected and replaced, and often even if they have been reversed in position and 
 order. Entirely detached bone can, therefore, be removed temporarily, disin- 
 
OPERATIVE TREATMENT OF FRACTURE DISLOCATIONS. 23 1 
 
 fected in 2\ per cent, carbolic solution, or 1-1000 bichloride; rinsed in warm, 
 sterile, normal salt solution, in which they should stay until needed, and 
 returned to their normal position, where, if possible, they should be secured to 
 a neighboring bone by gut suture. If much periosteum has been lost, the bone 
 should be covered with soft connective tissue and muscles (which may be held 
 about the bone with buried gut sutures). In cases of extensive comminution, 
 excision of the bone-ends may be called for, followed by internal fixation of the 
 ends -r by bone-grafting. 
 
 Complicated Fractures. — One of the strongest arguments in favor of the 
 more general treatment of fractures by operative measures followed by internal 
 fixation is that open incision, which gives free access to the fracture, also gives 
 full opportunity to rectify, or treat as indicated, the special complication of the 
 case, which complication may be more important than the fracture itself. So 
 that, apart from the general operative technic of exposing, approximating, and 
 fixing the bone fragments, already described, the special treatment of the case 
 becomes the treatment of the predominating complications, whatever they may 
 be, whether involving arteries, veins, nerves, viscera, or other soft structures, 
 and their line of treatment will be determined by the structure involved and 
 the nature of its injury. 
 
 OPERATIVE TREATMENT OF FRACTURES INVOLVING JOINTS AND 
 OF FRACTURE DISLOCATIONS. 
 
 Fractures Involving Joints. — The difficulties in fractures involving 
 joints treated by non-operative methods are, first, the almost impossibility of 
 getting the fragments into normal position; secondly, the keeping of them in 
 place; and, thirdly, the prevention of deformity and limited movement. While 
 the certainty of accomplishing these desirable ends does not by any means 
 necessarily follow operative treatment, yet the chance of accomplishing them 
 by open incision is much greater than without. 
 
 When, therefore, examination under anesthesia and with the x-ray (which 
 should always be used in these cases, and are very serviceable in all cases) show 
 that the broken bones will not stay in very accurate apposition when once 
 reduced, the fractured ends should be cut down upon and united by internal 
 fixation (especially here by some absorbable suture) ; the joint cleared of effused 
 blood and inflammatory products; the wound temporarily drained, and the 
 limb put up in a splint. It must be remembered that union has to be unusually 
 accurate in these cases, as the slightest irregularity upon the articular surface 
 of a bone is apt to lead to impaired joint movement. By this course of treat- 
 ment passive movement and massage are also made possible earlier, with the 
 consequent likelihood of the prevention of both extra- and intra-articular 
 adhesions, and, therefore, an increased range of functioning. 
 
 Much of what was said under extra-articular compound fractures also 
 applies to intra-articular compound fractures. Formerly, many compound 
 fractures involving joints cost individuals the amputation of the limb above 
 or at the site of fracture. Then, as a great advance upon this destructive sur- 
 gery, immediate excision of the joint was generally done, in order to get a mov- 
 able joint and avoid sepsis. Now, one asepticizes the involved regions, and is 
 thoroughly conservative, and though he may have to excise later, generally a 
 shorter excision (less loss of bone) can usually be accomplished secondarily 
 than primarily. 
 
 It is to be remembered that while the skin wound of a compound fracture 
 
232 OPERATIONS UPON THE BONES. 
 
 may extend into the joint, the fracture itself may not do so, which somewhat 
 simplifies matters. 
 
 Dislocations Complicating Fractures. — When a fracture is not imme- 
 diately near a dislocated joint, and where operative treatment is not indicated, 
 reduce the dislocation first (putting up the broken limb in temporary splints, 
 so as to be able to manipulate it somewhat more freely), then reduce the fracture 
 and so splint the limb, incasing it as a whole, that passive movements of the 
 joint may be begun early. 
 
 When the fracture is near the joint, the distal bone was formerly put up in 
 line with the proximal one, and when the fracture was well, the dislocation was 
 reduced, but now the more rational technic is to expose the parts by operation, 
 and first to reduce the dislocation and suture up the capsule, and then approxi- 
 mate the ends of the broken bone by internal fixation. The limb is then put 
 up in a splint and massage begun early. 
 
 OPERATIVE TREATMENT OF SEPARATED EPIPHYSES.. 
 
 In attempting to reduce fractures of the epiphyses, wherever it is found 
 that an exact alignment of the epiphysis with the shaft can not be obtained, or 
 where obtained, it can not be maintained, some form of operation is indicated. 
 
 It has been found that it is best, in operating upon separated epiphyses, to 
 avoid the use of any mechanical means which penetrates the epiphyses and 
 remains any length of time as an irritant (as, for example, a nail), for while an 
 uninjured though detached epiphysis may retain its integrity for some weeks 
 and then grow to the main bone when replaced, yet if, on the other hand, con- 
 stantly irritated by this foreign body, it may either suppurate or undergo hyper- 
 trophic overgrowth. 
 
 The treatment of epiphyseal separation differs in many instances materially 
 from the treatment of a fracture in the same locality, and especially is an accu- 
 rate knowledge of the contiguous anatomy necessary in dealing with such cases. 
 
 If operative treatment were done as a more systematic procedure in the 
 treatment of such injuries, there would not be so many deformed limbs and 
 joints. 
 
 When deformity occurs from arrest of growth in one of the parallel bones of 
 the double-bone limbs, conjugal chondrectomy (that is, excision of the con- 
 jugal cartilage of the corresponding normal bone) should be done, if the age 
 of the normal bone is not too great, namely, beyond its period of active growth. 
 
 Epiphyseal separation occurs in a vastly larger number of cases among males 
 than among females, and the separation of the epiphyses of the upper extremity 
 is more frequent than of the lower. 
 
 Separation of epiphyses occurs in the following order of frequency: Upper 
 epiphysis of humerus, lower of radius, lower of femur, lower of tibia. 
 
 ^c-Raying is of little or no assistance in the diagnosis of epiphyseal separation, 
 as the epiphyses are transparent to these rays. The greatest diagnostic aid is 
 gotten by manipulation under anesthesia. 
 
 Operation, where the epiphysis cannot be certainly and satisfactorily manip- 
 ulated into place, consists of exposure, followed by suturing the epiphyses to 
 the shaft with tendon or gut, and, where the epiphysis is entirely or partially 
 intra-capsular, of closure of the capsule. 
 
STIMSON'S OPERATION FOR FRACTURED PATELLA. 233 
 
 Fig. 200.— Operation for Fractured Patella by Stimson's Method of Mediate Suture : 
 — A, Heavy silk suture (of mattress variety) passing through greater thickness of quadriceps extensor 
 tendon, above, and ligamentum patellae, below; B, Chromic gut suture of torn capsule and fibro- 
 periosteum. 
 
 OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 
 
 BY SUTURING OF SOFT PARTS. 
 
 stimson's METHOD. 
 
 Description. — The margins of bone, after being cleared, and, if necessary, 
 freshened, are held in position by a heavy silk suture-loop passed trans- 
 versely through the quadriceps extensor tendon above, and the ligamentum 
 patella. 1 below. 
 
 Position. — Patient supine; limb fully extended. Surgeon on side of 
 operation. Assistant opposite. 
 
 Landmarks. — Contour of patella. 
 
 Incision. — Median, in long axis of limb, with its center over center of 
 patella and extending considerably above and below the patella but not 
 passing into muscular tissue. 
 
 Operation. — The incision extends through skin, fascia, prepatellar bursa, 
 expansion of quadriceps extensor tendon, and periosteum directly to the 
 patella bone. The soft parts are well retracted, so as to expose the entire 
 extent of the transverse fracture (which is possible because of the length 
 of the incision) (Fig. 200). The joint is irrigated to remove the clots. If 
 the fracture be recent, no removal of fibrous tissue or bone is necessary. If 
 old, each fragment is carefully seized with bone-holding forceps and steadied 
 
234 OPERATIONS UPON THE BONES. 
 
 in such a position as to render it accessible to the saw, and a thin slice of 
 bone is then removed. A heavy silk ligature, threaded upon a curved needle, 
 is now carried transversely through the ligamentum patella? near its apex, 
 passing through about two-thirds of its width and thickness — then trans- 
 versely through the quadriceps extensor tendon, near the upper border of 
 the patella, also passing through about two-thirds of its width and thickness. 
 While the fragments are held in close contact this ligature is tightly tied. 
 The torn capsule on either side of the patella and the fibro-periosteum are 
 sutured with chromic gut. The fibrous tissues overlying the patella, and 
 divided in the median incision, may then be sutured with buried gut suture. 
 The skin wound is closed. No drainage is used. The limb is put up in 
 full extension. 
 
 Comment. — In some old cases the quadriceps extensor tendon has con- 
 tracted to such an extent that it is necessary to lengthen the common quad- 
 riceps extensor (see operation for muscle-lengthening, page 246). 
 
 OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 
 
 BY WIRING OR SUTURING OF BONE AND SOFT PARTS. 
 
 Description. — The ends of the bones, after being cleared, and, if neces- 
 sary, freshened, are drilled and wired together, the wire being buried and 
 left — or they may be sutured with an absorbable material. The joint may 
 be exposed by a median vertical, transverse, or by Cheyne's oval incision — 
 the last being here described. 
 
 Position — Landmarks. — As in the above operation. 
 
 Incision. — Oval, outlining a flap with upward convexity, which is raised 
 from over the patella and temporarily turned downward. The incision 
 begins 2.5 cm. (1 inch) to one side of the patella, on a level a little below 
 the fracture — extends vertically upward and then curves across the front of 
 the thigh about 2.5 cm. (1 inch) above the upper border of the patella, and 
 descends on the opposite side to a point corresponding with its commence- 
 ment. This flap-incision gives a full field and places the scar above the 
 patella. 
 
 Operation. — The fractured ends of the bones are exposed, the joint 
 irrigated, and the fragments slightly everted and examined. All interposed 
 periosteum, fibrous and other tissue are removed. In recent cases no removal 
 of bone is ordinarily indicated. In old cases a thin slice of bone is removed 
 from each fragment. Each fragment is now grasped in turn by means of 
 stout bone-forceps, injuring the bone as little as possible while firmly steadying 
 it (Fig. 201). One, two, or three wire sutures, as seem indicated, are now 
 introduced in the following manner; — Two holes are drilled directly opposite 
 each other in a vertical line, in the upper and lower fragments, a short incision 
 being made for the drill through the fibrous covering of the patella, within 
 8 mm. to 1.3 cm. (^ to \ inch) of the fractured edges — the margins of the 
 incision through the fibrous tissue being drawn aside and the drill (hand or 
 motor) directed obliquely, so as to come out at the fractured margin after 
 having passed through about two-thirds of the thickness of the bone. All 
 the drill-holes are first made, and are made from without inward. Care is 
 taken that each pair of holes is drilled immediately opposite and that their 
 points of emergence on the fractured surfaces are on the same level. The 
 wires are now passed, are grasped with strong forceps, and, while an assistant 
 firmly approximates the margins of the fragments, these wires are tightly 
 
OPERATION FOR FRACTURED PATELLA BY WIRING. 
 
 235 
 
 twisted for three or four turns, cut off about 6 mm. (J inch) long, bent upon 
 the bone, and slightly buried by one or two blows of the mallet. The peri- 
 osteum which has been drawn out from between the fragments of bones 
 is stitched together with chromic gut to the opposite lip of the torn periosteum. 
 
 Fig. 201.— Operation for Fractured Patella by Wiring:— a. Lower fragment of patella 
 steadied with hone-holding forceps ; B, Drill in act of making holes for passage of silver wire, one 
 piece of which is seen in position ; C, Chromic gut suture of torn capsule and fibro-periosteum. 
 
 The rent in the capsule generally found on each side of the fractured patella is 
 similarly sutured with gut. The fibrous covering of the patella, incised in 
 raising the oval flap, is sutured with buried gut. The wound is closed through- 
 out — no drainage being used. The limb is put up in full extension. 
 
 Comment. — Chromic gut, kangaroo tendon, and silk are also used in 
 the same manner as wire. 
 
236 
 
 OPERATIONS UPON THE BONES. 
 
 OPERATION FOR RECENT OR UNUNITED FRACTURE OF PATELLA 
 
 BY AN ENCIRCLING SUTURE OF THE SOFT PARTS. 
 
 Description. — Having exposed the fracture, an encircling suture of kanga- 
 roo-tendon, chromic gut, or silver wire is carried through the soft parts border- 
 ing upon the patella, including the quadriceps extensor tendon, the ligamentum 
 patellae, and the capsule — which is then tightened and tied or twisted, while 
 the fragments are held in close apposition. 
 
 Position;— Landmarks.— As in the preceding operations. 
 
 Fig. 202. — Encircling Suture used in Fracture of Patella: — The suture passes 
 through the quadriceps extensor tendon above, through the ligamentum patellas below, and 
 through the capsule and lateral ligaments at the sides. The transverse rent in the capsule is 
 then sutured separately. 
 
 Incision. — The patella may be exposed by either of the incisions just 
 described — or a flap with downward convexity may be raised. In the latter 
 instance a flap with downward convexity is outlined, which will be the reverse 
 of the one in the preceding operation. It begins 2.5 cm. (1 inch) to one side 
 of the patella, on a level a little above the fracture — extends vertically down- 
 ward and then curves across the front of the leg about 2.5 cm. (1 inch) below 
 the lower border of the patella, and ascends on the opposite side to a point cor- 
 responding with its commencement. This flap-incision gives a full field and 
 places the scar below the patella. 
 
OPERATION FOR RECENT FRACTURE OF OLECRANON. 
 
 237 
 
 Operation. — As to the exposure of the fractured parts, the steps of the oper- 
 ation are in every respect similar to those in the operation described at page 233, 
 the manner in which the patella is surrounded with the ligature alone differing. 
 By means of a Reverdin needle heavy kangaroo-tendon is carried in and out 
 through the soft parts bordering upon the patella, including the extensor quadri- 
 ceps tendon, the ligamentum patellae, and the lateral aspects of the capsular 
 ligament, in the manner shown in Fig. 202. Chromic gut or silver wire may 
 be used. In the case of using the last, it is drawn into position by means of a 
 silk carrier. After the suture has been placed, the fragments of the patella 
 are drawn into very close apposition by pointed retractors pulled in opposite 
 directions — during which close contact of the margins the suture is drawn 
 tight and tied, or, in the case of wire, twisted. The rent in the capsule and 
 lateral ligaments is then closed, from one extreme lateral aspect to the opposite 
 and across the front of the patella, as in all operations upon the patella. The 
 flap is now brought down and sutured along its margin — without drainage. 
 
 Comment. — The circular suture may be carried continuously through the 
 substance of the quadriceps extensor tendon and the ligamentum patellae. 
 
 Fig. 203.— Operation for Fractured Olecranon by Wiring : — A, Drilling holes for pas- 
 sage of silver wire, one suture being seen in position, and one being drawn through ; B, Chromic gut 
 suturing of torn capsule and nbro-periosteuni. 
 
238 OPERATIONS UPON THE BONES. 
 
 OPERATION FOR RECENT OR UNUNITED FRACTURE OF OLECRANON 
 
 BY WIRING OR SUTURING OF BONE AND SOFT PARTS. 
 
 Description. — The olecranon is quite frequently fractured at its junction 
 with the shaft of the ulna — and is repaired by wiring or suturing in the same 
 general manner as in the case of fracture of the patella. 
 
 Position. — Patient supine; forearm drawn across chest, by an assistant 
 on the opposite side, presenting to the surgeon the semiflexed elbow, while 
 exposing the fragments; and fully extended by the side while suturing. Surgeon 
 stands opposite the elbow. 
 
 Landmarks. — Contour of olecranon; shaft of ulna; condyles of humerus. 
 
 Incision. — The site of fracture may be exposed — (1) By an oval incision; — 
 beginning to one side of lateral border of olecranon, just below the fracture 
 — passes upward in axis of limb for about 2.5 cm. (1 inch) above the olecra- 
 non — thence curves across arm and descends to a corresponding point on the 
 opposite side — thus furnishing a free exposure of the fracture and providing 
 a scar which falls out of the way of pressure. (2) By a median longitudinal 
 
 
 Fig. 204. — Encircling Suture used in Fracture of Olecranon: — The upper limb 
 of the suture is shown passing through the olecranon; and the lower limb through the shaft of 
 the ulna. 
 
 incision; — beginning and ending considerably above and below the line of 
 fracture, but not involving the muscles above or below — and having its center 
 over the fracture. The length of this incision allows of sufficient lateral 
 retraction to well expose the parts (though less perfectly than the incision 
 just described). 
 
 Operation. — The incision passes through skin, fascia, bursa, fibrous 
 expansion of the triceps tendon, and periosteum directly onto the bone 
 (Fig. 203). The manner of exposing the fractured ends, irrigating the 
 joint, removing a slice of bone from each fragment in old cases, drilling the 
 fragments, passing and tightening the wire, suturing the torn periosteum and 
 fascia, and closure of wound are similar, in all practical essentials, to the 
 corresponding steps in the operations just described upon the patella (page 
 234). The limb is put up in full extension. 
 
 Comment. — (1) Chromic gut, kangaroo tendon, and silk may be used 
 
SEQUESTROTOMY. 
 
 2 39 
 
 instead of wire. (2) In some old cases, where much retraction of the triceps 
 has occurred, that muscle should be lengthened, as described under muscle- 
 lengthening (page 246). (3) Instead of passing the sutures in the way indi- 
 cated above, an encircling suture may be carried in such a manner as to pass 
 through the shaft of the ulna below, and through the triceps tendon above and 
 be tied on one side, as shown in Fig. 204. The capsule and lateral ligaments 
 are closed by sutures. 
 
 SEQUESTROTOMY. 
 
 Description. — An operation for the removal or excision of a sequestrum 
 (dead bone) en masse. The operation might be more properly termed 
 sequestrectomy. The site of the sequestrum is generally determined by the 
 presence of one or more sinuses, together with the history of the case. 
 
 Position and Preparation. — Patient is so placed as to expose the in- 
 
 Fig. 205.— Cross-section of Leg, Showing a Sequestrum-cavity. 
 
 volved site most conveniently. A constrictor is usually applied, where 
 possible, to control hemorrhage. 
 
 Landmarks. — Generally the existence of one or more sinuses; the known 
 anatomy of the part. 
 
 Incision. — Generally placed in the long axis of the limb, or in such a 
 position as to fall in with the intermuscular cleavage line and so as to lead 
 to the site by the safest route — with its center over the sinus, or extending 
 between the two chief sinuses (Fig. 205). 
 
 Operation. — The incision passes down to and through the periosteum. 
 The soft parts, including periosteum, are then retracted laterally, fully exposing 
 the bone in the neighborhood of the sinus, or between two or more sinuses. 
 It may be at once possible to grasp the sequestrum with strong forceps 
 introduced through the sinus-opening and draw it out — or the sinus-opening 
 may be sufficiently enlarged for this purpose by rongeur forceps. If neither 
 of these can be clone, the sinus may be enlarged with the curved chisel — 
 or the bone between two sinuses may be chiseled away — or the bone may 
 be chiseled away in the long axis of the sequestrum, even where but one 
 opening exists — or a trephine-opening (one or more) may be made instead 
 of using the chisel. Following the removal of the sequestrum, the cavity 
 of the bone should be well scraped. The periosteum and muscles are then 
 united by buried gut sutures, and the skin closed with sutures of silkworm - 
 gut or silk — drainage being established to the bottom of the bone cavity 
 in the most favorable position. If the limb be weakened by the operation, 
 it should be put up in a splint. 
 
240 OPERATIONS UPON THE BONES. 
 
 Comment. — Bone-chips may be used in the cavity — or the entire thick- 
 ness of the soft parts, including periosteum, may be inverted into the bottom 
 of the bone cavity from each side and held in place by a nail or peg (Fig. 
 206). Or the cavity may be packed throughout with gauze. 
 
 Fig.206— Sequestrotomy:— Neuber's Operation. The antero-internal aspect of the tibia is 
 removed— sequestrum cavity scraped— the integumentary tissues nailed to its floor— and relaxation 
 sutures placed. 
 
 OSTEOPLASTY. 
 
 Description. — Transplantation of bone — in the form of bone-chips or 
 decalcified bone-fragments — which are placed in the desired site and among 
 which organization of the blood-clot takes place. The transplantation of 
 a larger section of bone, entirely detached, has not yet been commonly done — 
 though the success of reinserting the trephine-buttons suggests the practi- 
 cability of such a course. This principle will be further mentioned under 
 osteoplastic amputations. 
 
 Operation. — The site of operation having been rendered bloodless by 
 a proximal constrictor, and having provided the bone-chips in advance 
 (which come specially prepared by decalcification), the locality is exposed. 
 If the chips are to be used within a bone cavity, such as a scraped medullary 
 cavity, it is seen that this is thoroughly aseptic before their introduction. 
 If they are to be used within a periosteal cavity (as after the partial resection 
 of a bone), this periosteal cavity should be kept as nearly like the special 
 form of the original bone as possible. In the case of the bone cavity, the 
 bone-chips are dropped into the cavity and the soft parts sutured as just 
 described in the above operation. In the case of a periosteal cavity, sutures 
 of gut are made to approximate the periosteal margins over the included bone- 
 chips — and the muscles over the periosteum — and finally the skin, in the usual 
 manner. The tourniquet is then removed and the blood allowed to flow 
 into the part and fill the interstices between the bone-chips. The part is 
 usually put up in an immobilizing splint. 
 
 Comment. — If the neighboring parts do not cover the site in which the 
 bone-chips have been deposited, they may be covered by sterilized rubber 
 tissue. Other applications of osteoplasty are mentioned under Bone-grafting 
 (page 227). 
 
 EXCISION. 
 
 Excision of the bones is described under the general head of Excisions 
 and Osteoplastic Resection of Bones and Joints (pages 463 to 531). 
 
CHAPTER VI. 
 
 OPERATIONS UPON THE JOINTS. 
 
 EXPLORATORY PUNCTURE OF JOINTS. 
 
 Description. — The exploration of the fluid contents of a joint by means 
 of the needle of a suction-syringe — for the purpose of ascertaining the nature 
 of those contents — or for the evacuation of the fluid found. 
 
 Indications. — Collection of pus, or other fluid, within a joint. 
 
 Preparation — Position. — As for arthrotomy. 
 
 Special Instruments. — Exploratory or aspirating syringe. 
 
 Operation. — The same preliminaries having been observed as in ar- 
 throtomy, the needle of the exploratory syringe is thrust, by the safest and 
 shortest route, into the joint — the cylinder withdrawn and the contents 
 aspirated. Following the withdrawal of the needle, the punctured wound 
 is hermetically closed with sterilized collodion. 
 
 ARTHROTOMY. 
 
 Description. — A simple incision into a joint. 
 
 Indications. — Exploration; removal of foreign body; evacuation of pus, 
 or other fluid; irrigation; drainage. 
 
 Preparation. — As for a major operation of the same joint. 
 
 Position. — Determined by the special operation — and such as to render 
 the site of incision prominent and convenient. 
 
 Special Instruments. — Scalpel; dissecting forceps; artery-clamp forceps; 
 retractors; tourniquet (sometimes). 
 
 Operation. — The patient having been placed in a position to render 
 the joint most accessible — and the overlying tissues in the best position with 
 reference to the joint — an incision, of the simplest form and shortest extent 
 compatible with the object in view, is made over that aspect of the joint 
 which will lead into the interior of the joint-structures by the route which is 
 shortest and safest, both in regard to the joint-structures and the tissues 
 intervening between skin and joint. Having opened up the joint, the sub- 
 sequent steps will depend upon the special object of the operation; — (a) 
 Where exploration is the object; its interior is examined by some form of 
 probe or sound, or, preferably, by the gloved finger-tip; — (b) Where the 
 removal of a foreign body is sought; suitable forceps are introduced, with 
 which it is grasped and withdrawn; — (c) Where drainage is indicated; a 
 tube, or other drain, is inserted through the incision, with or without a counter- 
 opening. In the first two cases, the wound is entirely closed. In all cases 
 the joint is immobilized. 
 
 ARTHROPLASTY. 
 
 Description. — The formation of a movable joint, by the interposition 
 between the loosened ends of the bones of some of the neighboring soft tissues 
 or of some foreign material. 
 
 Indications. — Ankylosis of the joints. 
 16 241 
 
242 OPERATIONS UPON THE JOINTS. 
 
 Preparation; — Position; — Incision. — Determined by the special oper- 
 ation. 
 
 Operation. — The site of the former normal joint is exposed in the usual 
 manner. At the original joint-line the ankylosed bones are divided by means 
 of a chisel or saw. All bone interfering with joint-movement is cut away. 
 Synovial membrane and capsule are excised and any other structures apt to 
 prevent movement of the new joint. Muscular and tendinous attachments 
 are preserved. Shortened muscles are lengthened. All cicatricial tissue 
 is removed. The preparation for the interposition of the neighboring soft 
 parts must be thorough. A musculo-aponeurotic flap, covered by fat, and 
 large enough to cover the ends of the divided bones, is raised from the neighbor- 
 hood of the special joint and turned in between the sawn ends of the bones, 
 and is sutured to the margin of the capsule which has been left in situ. Where 
 the aponeurosis is insufficient, a muscle-flap, with as much adherent fat as 
 possible, is used. The part is immobolized for a week or more — after which 
 passive motion is begun (with anesthesia if necessary), followed my massage — 
 irrespective of the suffering caused, as the production of a joint will depend 
 upon the transformation of the interposed tissue to a bursa. 
 
 Comment. — Animal membrane, such as a piece of bladder, has been used. 
 Foreign substances have also been employed, such as silver, tin, rubber, cellu- 
 loid, silver foil, and the like, in the form of plates — but the interposition of 
 the neighboring soft parts, especially fat (which, under pressure, readily 
 develops connective tissue and forms a bursa), produces the best results. 
 
 ARTHRODESIS. 
 
 Description. — The production of an artificial ankylosis in a joint by the 
 removal of a part or all of the articular cartilage. 
 
 Indications. — Sometimes resorted to in order to produce a rigid joint in 
 certain muscular paralyses and flail-like joints. 
 
 Preparation; — Position; — Incision. — Dependent upon the individual 
 joint. 
 
 Operation. — The special joint is exposed by a convenient incision. The 
 articular cartilage entering into the formation of the joint is removed by means 
 of a knife or chisel, in a thin layer, from the surfaces of the bones forming the 
 joint. The denuded bones are then placed in apposition, and either held 
 there by subsequent plaster dressing or splints, or by means of nailing or sutur- 
 ing the parts together. The site is thus immobilized until ankylosis has 
 occurred. 
 
 Comment. — In some situations, the ankle-joint, for instance, the operation 
 may be reinforced by the transplantation of tendons. 
 
 ERASION OR ARTHRECTOMY. 
 
 Description. — Etymologically, erasion signifies the scraping or curetting 
 of a joint — and arthrectomy, the cutting out of a joint. Practically, both 
 expressions are used synonymously — and are taken to signify the exposure 
 of a joint with the removal of the diseased tissue alone. While arthrectomv 
 signifies, literally, the cutting out of a joint, it is- not here used as the word ex- 
 cision commonly signifies. In excision, the articular ends of the bones are 
 invariably removed — in erasion or arthrectomy, while a certain amount of 
 
ERASION OR ARTHRECTOMV. 243 
 
 bone may be incidentally removed (and always as much as is diseased is 
 removed) in the gouging, only the articular cartilages and synovial membrane 
 are supposed to be scraped or curetted. When bone is removed at all, the 
 least possible is removed, and that is generally done with a gouge — and the 
 whole operation conducted with as little injury as possible to the neighboring 
 structures. In extreme cases all the articular cartilage is gouged away, all 
 the synovial membrane is dissected out, and some of the bone is removed. 
 An erasion or arthrectomy is, therefore, commonly understood as the applica- 
 tion of scraping to the interior of a joint — the laying open of a joint and the 
 removal of as many and as much of the tissues forming the joint as are dis- 
 eased — synovial membrane, capsular ligaments, cartilage, and bone — the 
 removal generally being accomplished by some form of gouge for cartilage 
 and bone, and scissors and knife for soft parts. An arthrectomy, finally, 
 may be regarded as a procedure the same in general purpose, though less 
 
 Fig. 207.— Erasion of the Knee-joint: — A, Removal oi cartilage of condyle of lemur wilh 
 raspatory ; B, Removal of cartilage of tibia with curette. The joint is exposed by a transversely 
 curved incision and the patella turned backward. 
 
 severe in degree, as an excision — and is distinctly a conservative measure espe- 
 cially applicable to early cases. An arthrectomy is a part of every excision. 
 Arthrectomy has its greatest application in joints of simple structure and easy 
 approach — the knee being its most frequent site of application. A movable 
 joint is always to be sought after erasion, even in the case of the knee 
 (although in the latter case some surgeons prefer to secure ankylosis in 
 preference to a probable weak joint). Arthrectomy is always preferable tc 
 excision in children, owing to its non-interference with the growth of bone. 
 
 Indications. — Disease of the articular structures, especially tubercular. 
 
 Preparation — Position. — As for excisions (page 397). 
 
 Special Instruments. — Besides those used for excisions, the following 
 are specially required; — Gouges, curettes; spoons — of many sizes and shapes, 
 dull and sharp. Flushing-gouges. 
 
 Operation. — No form of constrictor is ordinarily used — though may be 
 used, as in excisions. The incision is generally the same as that for the 
 excision of the corresponding joint. Having exposed the interior of the joint, 
 the following structures are closely examined, and, if necessary, removed 
 — the guide being that all diseased tissue should be removed; — (a) Synovial 
 
244 OPERATIONS UPON THE JOINTS. 
 
 membrane; where but slightly involved, is curetted, — where extensively, it is 
 grasped with toothed forceps and dissected out, in as continuous a layer as 
 possible, with scissors or scalpel. Every recess is sought and, if diseased, 
 thoroughly curetted or removed, (b) Bursa* communicating with joint; are 
 subjected to the same treatment as the synovial membrane — opened up 
 and followed to their furthest extent, (c) Ligamentous tissue; to be scraped 
 and cut away, (d) Articular cartilage; all involved or suspicious areas are 
 gouged out with a sharp spoon, (e) Articular ends of bones; if actually 
 diseased, or suspicious, to be removed with gouge, (f) Extra-synovial and 
 extra-articular tissues; to be dissected out and removed, if involved. Finally, 
 where much debris results, it is well to use a flushing-gouge and clean out 
 the area of operation. Drainage is usually not necessary — but may be 
 temporarily used where thought best. The capsular ligament, if not dis- 
 sected away in removing disease, is closed by buried gut sutures. Muscles 
 separated in reaching the joint are similarly brought together with buried 
 gut sutures. The limb is put up upon an immobilizing splint. The after- 
 treatment is practically the same as after excisions — and a more satisfactorily 
 functioning joint is to be expected. (Fig. 207.) 
 
 OPERATION FOR DISLOCATED SEMILUNAR CARTILAGES. 
 
 Description. — A dislocated semilunar cartilage of the knee may be exposed 
 and sutured back into position — or may be removed in part or in its entirety. 
 
 Indications. — Those cases in which postural and mechanical treatment 
 have failed. 
 
 Preparation; — Position; — Landmarks. — As in the operation of excision 
 of the knee-joint (page 521). 
 
 Incision. — A vertical incision may be made to either side of the patella, 
 dependent upon the particular semilunar involved. Or the entire joint may 
 be exposed by means of a transverse curved incision, as for excision (page 522). 
 
 Operation. — A sufficiently free exposure of the joint is made to enable 
 manipulation of the involved structure. If the cartilage be only slightly sepa- 
 rated from its peripheral attachment, or be torn to a limited extent radially, 
 it may be sutured into its normal position with catgut sutures and the joint 
 closed. If this technic does not promise to suffice, a portion of the cartilage 
 may be excised. If a greater degree of separation or damage be found, the 
 entire cartilage may be excised. The joint is closed without drainage, unless 
 hemorrhage into the joint indicate the need for temporary drainage. The 
 joint is immobolized for six to eight weeks — the muscles being kept up by 
 massage in the mean time. The functional result of the joint is usually satis- 
 factory. 
 
 EXCISION. 
 
 Excision of the joints is described under the general head of Excisions and 
 Osteoplastic Resections of Bones and Joints (pages 463 to 531). 
 
CHAPTER VII. 
 
 OPERATIONS UPON THE MUSCLES. 
 
 MYOTOMY. 
 
 Description. — Division of muscle — generally done as a preliminary to 
 muscle-lengthening, or in the exposure of underlying parts, or in deformities. 
 
 Operation. — The muscle is fully exposed by an appropriate incision — 
 or is exposed in the course of some 
 operation. Having been isolated 
 from neighboring structures, the 
 muscle is cleanly divided with a 
 scalpel, cutting transversely, or 
 very slightly obliquely, to the di- 
 rection of its fibers. A grooved 
 director may first be passed beneath 
 the muscle, but is rarely necessary. 
 Myotomy should be done by the 
 open method. Muscles are some- 
 times divided subcutaneously (as 
 the sternomastoid, for torticollis), 
 but this is even less advisable 
 (owing to their greater size and 
 less accurately defined contour) 
 than the subcutaneous division of 
 tendons. 
 
 MYORRHAPHY. 
 
 Description. — -Suturing of 
 muscle which has been either pur- 
 posely and cleanly divided (as in 
 an operation) — or accidentally and 
 unevenly divided or ruptured (as 
 from injun- or from excessive 
 action). 
 
 Operation. — (a) Where mus- 
 cle has been deliberately cut in the 
 course of an operation, to expose 
 underlying parts (as in dividing 
 the sternomastoid in removing the 
 cervical glands); — The muscle is 
 here cleanly and evenly divided, 
 
 preferably in a transverse or very slightly oblique direction. At the 
 time of suturing, the parts are put into a position to relax the muscle as 
 much as possible. While the two opposing ends of the muscle are carefully 
 held in easy contact, as many muscle-sutures are inserted and tied as the 
 
 2 45 
 
 Fig.208.— Myorrhaphy : — The divided biceps 
 is here shown sutured in several ways ; A, Mat- 
 tress suture; B, Lateral knotted suture; C, 
 Peripheral suture ; D, Lateral through-and- 
 through suture; E, Antero-posterior through-and- 
 through suture. The last two are here shown as 
 relaxation — or reinforcing — sutures. 
 
246 OPERATIONS UPON THE MUSCLES. 
 
 size and form of the muscle require. Chromic gut or kangaroo tendon is 
 used for suturing — and the sutures are all buried. One of several forms of 
 stitch may be applied. As the muscle-sutures are practically the same as 
 tendon-sutures, and applied in the same manner, they will only be briefly 
 mentioned here and their fuller description given under tendons, (i) Inter- 
 rupted mattress sutures (Fig. 208, A). This is probably the best form of 
 muscle-suturing. (The manner of its insertion is given at page 252.) (2) 
 Interrupted sutures passing transversely through the upper and lower ends 
 uf the cut muscle (page 252). (3) Lateral knotted sutures (Fig. 208, B) 
 (page 253). (4) Simple, peripheral longitudinal coaptation sutures (Fig. 208, 
 C) (page 252). (5) Relaxation sutures for reinforcement; — In any of the 
 above forms of primary or coaptation sutures, one or more relaxation sutures 
 of heavy catgut may be applied, passing transversely through the entire thick- 
 ness of the muscle considerably above and below the primary sutures, and tied 
 tightly enough to take the chief tension — and thus free the primary sutures 
 from strain (Fig. 208, D, E). (6) Binnie's form of suture is particularly 
 good — it is a continuous suture, passing well into the substance of the muscle 
 and reinforced at intervals by transverse passage of the needle, (b) Where 
 the muscle has been accidentally and unevenly ruptured; — The ruptured 
 muscle is exposed by the safest, most direct, and least damaging route — remem- 
 bering that the ends of the muscles may have retracted far away from their 
 normal position. If the ends of the muscle have been left very irregular, they 
 are carefully trimmed, and are then sutured in one of the above manners. If 
 they be torn almost transversely, they are approximated and sutured 
 without trimming. If much muscle tissue have been lost, or be sacrificed in 
 trimming, some process of lengthening may have to be resorted to before the 
 ends can be made to meet without too great tension (see muscle-lengthening, 
 below). In order that the skin-incision, used in reaching the part, may not 
 lie over the muscle wound, bringing two cicatrices directly opposite, a curved 
 incision may be used — or an oval flap of overlying parts may be raised. In 
 completing the operation, the part should be so immobilized in the dressing 
 as to relax the muscle as completely as possible. 
 
 MUSCLE-LENGTHENING. 
 
 Description. — In old cases in which muscle tissue has contracted con- 
 siderably (as in long-standing cases of fractured patella or olecranon) — or 
 in cases in which much muscle tissue has been lost in injury, or has been 
 sacrificed in trimming muscles for suturing — it is impossible to approximate 
 the separated ends without too great tension, unless the muscle be lengthened. 
 Muscle-lengthening, therefore, is resorted to in two sets of cases, — those in 
 which muscle must be lengthened to enable parts below, other than the 
 muscle, to be approximated without too great tension (as in the case of the 
 triceps or the common quadriceps extensor, in fractures of olecranon and 
 patella), — and those in which lengthening is necessary after an old transverse 
 rupture of a muscle in which the ends are separated too far to allow of ap- 
 proximation without too great tension (as in transverse rupture of the biceps 
 muscle). In either category of cases the operation is the same. 
 
 Operation. — The patient having been placed so as to relax the part 
 completely, the site of lengthening is exposed by a longitudinal incision of 
 about 7.5 to 10 cm. (3 to 4 inches) in length, placed over the involved muscle. 
 The incision should be sufficiently long to afford free access and manipulation 
 and planned to reach the parts by the safest, most direct, and least damaging 
 route. Retract the overlying soft parts and isolate the muscle. Divide the 
 
MUSCLE-LENGTHENING. 
 
 247 
 
 muscle in a zig-zag line running transversely, and about 7.5 to 10 cm. 
 (3 to 4 inches) above the ruptured part. This is a series of bluntly rounded 
 serrations or V's — the incision passing upward about 5 cm. (2 inches) and 
 downward the same distance, until the width and entire thickness of the 
 muscle is traversed (Fig. 209, A). The muscle on either side of the zig-zag 
 incision is now drawn apart until the apices of the V's touch. If the teeth 
 or serrations are 5 cm. (2 inches) in length, when the suturing is done, 
 nearly 5 cm. (2 inches) in length 
 will be gained. The adjacent late- 
 ral margins of the t.vo muscle-ends 
 are now sutured by the knotted 
 sutures described above (Fig. 210, 
 E, E) (page 253). A V from above 
 is now sutured, by the same knotted 
 suture, or other form of suture, to 
 
 Fig. 20Q.— Muscle-lengthening:— I.— Fig. 210.— Muscle-lengthening:— II. 
 
 A, By means of a series of U-shaped incisions; — Manner of suturing the muscle-sections 
 
 B, by a single long V-shaped incision. A case shown in the last illustration: A, Needle carrv- 
 of ruptured patella is here represented. (The ing one part of a lateral knotted suture through 
 manner of uniting these sections is shown in one of the tongues of the split muscle; B, 
 the following diagram.) Opposite part placed; C, Each half tied and 
 
 the free ends being knotted; D, A completed 
 lateral knotted suture; E, E, Lateral knotted 
 sutures approximating the bases of the tongues 
 and also serving as relaxation-sutures; F, 
 Suture of the tongue-and-groove suture. 
 
 the A below, so that their blunted tips are held in contact by the sutures 
 passed through above and below their tips (unless some such form of 
 suture be used, as shown in Fig. 208, A, B, C, D). Theoretically, the apex 
 of a V above will correspond with the base of a V below, but, practically, 
 the apices are so disposed in the suturing as to bring them in contact. Suffi- 
 cient length having been gained, the lower operation, for which the lengthening 
 was primarily done, is now performed (an ununited fracture of patella or 
 
24S OPERATIONS UPON THE MUSCLES. 
 
 olecranon, or ruptured biceps) — and unless this site has been exposed in 
 the original incision, a separate incision is made for that purpose. Both 
 wounds are then closed and the limb placed in a splint that will cause full 
 relaxation of the parts during healing. Lengthening may also be accom- 
 plished by a long V-shaped incision, as in Fig. 209, B, which is then sutured 
 as shown in Fig. 210, F. Some of the methods of tendon-lengthening 
 described on pages 254 to 259 are also applicable to muscles. 
 
CHAPTER VIII. 
 
 OPERATIONS UPON THE TENDONS AND 
 TENDON-SHEATHS. 
 
 TENOTOMY. 
 
 Description. — Division of tendons. 
 
 Varieties. — Open Tenotomy, where the tendon is freely exposed before 
 
 Fig- 2 1 1.— Open Tenotomy : — Of the tendo Achillis. 
 
 being cut. Subcutaneous Tenotomy, where the division is made beneath 
 the skin, by the sense of touch. Complete Tenotomy, where the entire thick- 
 
 249 
 
250 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 ness of the tendon is divided. Partial Tenotomy, where a part only of the 
 thickness of the tendon is divided, the remaining fibers being stretched. 
 
 Indications. — Shortening of tendons. To prevent action of muscles. 
 
 Special Instruments. — For open tenotomy; — scalpel; artery-clamps; dis- 
 secting forceps; retractors. For subcutaneous tenotomy; — tenotomes, straight, 
 curved, sharp and blunt. 
 
 Open Tenotomy. — The tendon is here divided in an open wound. The 
 incision for its exposure is generally made parallel with and directly over 
 the tendon. The overlying soft parts are retracted — the tendon is exposed 
 and isolated — and its sheath, if any, is opened. The tendon is then grasped 
 with forceps and divided with a scalpel. The ends retract in both directions. 
 
 Fig. 2 1 2. —Subcutaneous Tenotomy : — Of the tendo Achillis. 
 
 The wound is entirely closed and the limb dressed upon a splint, or the part 
 immobilized (Fig. 211). 
 
 Subcutaneous Tenotomy. — The tendon is here divided subcutaneously, 
 through the smallest possible wound. Having put the tendon upon the 
 stretch, to render prominent, an incision is made parallel with and just to 
 one side of the tendon to be cut, and so placed as to do the least damage 
 to other structures in the neighborhood. The incision is first made with a 
 sharp tenotome, through skin and fascia down to the tendon — upon this as 
 a guide the blunt tenotome is passed sidewise (the sharp one being withdrawn). 
 The tenotome is then insinuated beneath the tendon, which it closely hugs 
 throughout. Sometimes temporary relaxation of the tendon will aid the 
 passage of the knife beneath it. The cutting-edge of the tenotome is then 
 turned outward — the tendon put upon the stretch — the forefinger of the 
 
TENORRHAPHY. 
 
 251 
 
 left hand being placed over the site of section as a guard and guide — and the 
 tendon cut by a short sawing movement, the last fibers being cut carefully 
 as the tendon is felt to yield. The knife is finally withdrawn upon its side. 
 The wound is sutured and the limb dressed upon a splint '(Fig. 212). 
 
 Comment. — (1) In simple sections where the tendons are easily accessible 
 and the neighboring parts are not important, subcutaneous tenotomy may 
 be done. Where the opposite conditions exist, open tenotomy should always 
 be practised. (2) In doing subcutaneous tenotomy, the tenotome is some- 
 times inserted between skin and tendon and the section made inward upon 
 the tendon — which is more dangerous than cutting from beneath the tendon 
 outward. 
 
 TENORRHAPHY. 
 
 Description. — Suturing of tendon. In recent cases the ends of the 
 tendons can ordinarily be approximated without great difficulty. In old cases 
 if the ends cannot be approximated and sutured after freshening them by 
 
 Figs.2 13-2 16.— Tenorrhaphy : — A, Single suture through entire thickness of tendon; E, Two 
 sutures entirely through tendon, in opposite directions; C, Peripheral sutures; D, Woelfler's quilt 
 sutures. 
 
 trimming, some method of lengthening must be used — and if their union 
 cannot be accomplished by lengthening, transplantation to adjacent tendons 
 may be resorted to. 
 
 Varieties. — Primary, when the tenorrhaphy is done near the time of 
 injury. Secondary, when done after healing. 
 
 Operation. — In recent cases an already existing wound may be present 
 (except in such cases as subcutaneous rupture of a tendon) — and where a wound 
 is present, this is simply enlarged and the tendon more fully exposed and the 
 ends isolated. Where no wound exists at the time of the tenorrhaphy, the 
 main tendon and its ends are exposed by an incision which reaches the site 
 by the safest and simplest route. In primary tenorrhaphy the ends may 
 require no trimming, especially in clean cuts, — or but slight trimming. In 
 secondary tenorrhaphy, a transverse or oblique section of the tendon ends 
 is always necessary, prior to suturing. In either case, the opposite ends of 
 
25 : 
 
 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 the tendons are brought well into the wound and approximated. Chromic 
 catgut and kangaroo tendon are the best materials for uniting the ends. 
 Several methods of suturing are used — the chief of which will be here de- 
 scribed: (a) Interrupted sutures passing transversely through upper and 
 lower ends of divided tendon (Figs. 213 and 214, letters A, B) ; — A straight 
 needle enters the proximal surface of the upper portion and passes transversely 
 through its thickness, about 8 mm. or 1.3 cm. (from ^ to ^ inch) from the 
 cut margin — emerges at same level upon distal surface — crosses the gap- 
 enters the distal surface of the lower portion, from 8 mm. to 1.3 cm. ($ to \ 
 inch) from the cut end — passes transversely through — emerges at same level 
 on proximal surface. The two ends of the suture are drawn upon until the 
 tendon ends are approximated, and are then tied. When the tendon-ends 
 have been cut obliquely, the sutures are so passed as to cross the line of 
 division at a right angle (Fig. 222, B). (b) Interrupted mattress sutures; — ■ 
 A curved needle enters the proximal surface of the lower portion, about 8 
 mm. (3 inch) from its end — passes axially through two-thirds of the thickness 
 
 Figs. 217-220. 
 
 -Tenorrhaphy: — A, Mattress sutures; B, Same, tied; C, Lateral; knotted 
 sutures (a less usual form of tenorrhaphy); D, Same, tied. 
 
 of the tendon — emerges on the cut margin — crosses the gap to the upper 
 portion — enters the cut margin about two-thirds its thickness from the prox- 
 imal surface — emerges about 8 mm. (J inch) above the end — passes over 
 the outer surface of the upper portion of the tendon for from 8 mm. to 1.3 
 cm. (3 to ^ inch) — again enters the upper portion on a level with the point 
 at which it has just emerged from the upper portion — passes through about 
 two-thirds its thickness — emerges on the cut margin — crosses the gap to the 
 lower portion — enters its cut margin about two-thirds its thickness from 
 the proximal surface — and emerges on the proximal surface on a level with 
 the original entrance — when the two ends of the tendon are drawn upon 
 until the cut surfaces come well into contact and are then tied (Figs. 217 and 
 218, A and B; and Fig. 216, D). (c) Peripheral longitudinal coaptation 
 sutures; — A curved needle enters the lateral surface of the upper portion, 
 about 8 mm. or 1.3 cm. Q to \ inch) from the cut edge — passes longitudinally 
 through the tendon and emerges on the cut margin about 6 to 8 mm. {\ to \ 
 
TENORRHAPHY 
 
 253 
 
 inch) from the lateral surface — crosses the gap — enters the cut margin of the 
 lower portion, from 6 to 8 mm. (j to ^ inch) from the lateral surface — passes 
 longitudinally through the muscle and emerges on the lateral surface, about 
 8 mm. to 1.3 cm. (^ to ^ inch) from the cut margin. The upper and lower 
 ends of the sutures are now tied, approximating the tendons. These sutures 
 are repeated at intervals of about 8 mm. to 1.3 cm. (J to \ inch) around the 
 entire circumference of the tendon (Fig. 215, C). (d) Lateral knotted sutures; 
 — A curved needle enters the lateral surface of the upper portion about 8 
 mm. to 1.3 cm. (£ to \ inch) from the cut margin — passes transversely through 
 the tendon tissue for about 8 mm. to 1.3 cm. (£ to \ inch) in width, and 8 mm. 
 (| inch) in depth — and emerges on the level of entrance. The two ends 
 of the suture are now tied, care being taken to but slightly, if at all, pucker 
 the tendon — and one end of the suture is then cut short The same kind of 
 suture is applied immediately below, in the lower portion of the tendon, and 
 one end of the suture similarly cut short. The two long ends of the sutures 
 are then tied together, thus approximating the two ends of the tendon. As 
 
 Figs. 221-223. — Tenorrhaphy: — A, Reinforcing or relaxation suture, applicable to any 
 form of suturing (shown with first turn of knot); B, Suturing of obliquely divided ends; C, 
 Reinforcing through-and-through suture by lateral suture through loops of first suture (a less 
 usual form of suturing). 
 
 many of these pairs of sutures are introduced as necessary (Figs. 210 and 
 220, C and D). The extreme margins of the tendon-ends may be further 
 sutured, between these sutures, by method "c." (e) Relaxation sutures; — 
 In any of the above forms of primary or coaptation sutures, one or more 
 relaxation sutures of heavy catgut may be applied, passing transversely 
 through the entire thickness of the tendon considerably above and below the 
 primary sutures — and tied tightly enough to take the chief tension, and thus 
 free the primary sutures from strain (Fig. 221, A), (f) Combination of the 
 interrupted mattress (method "b"), or lateral knotted sutures (method "d"), 
 with relaxation sutures (method "e"). Of these various methods, either 
 method "a" or "b" is probably most generally applicable — the former 
 especially in smaller tendons and the latter in larger. Having united the 
 tendon-ends, the wound is closed and the limb put up upon an immobilizing 
 splint. 
 
254 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 Comment. — (i) While a constrictor is not generally necessary, its use is 
 ordinarily advisable. (2) Some surgeons prefer to expose the parts by a 
 curved incision, beginning and ending over the tendon, above and below 
 the rupture, but not over the rupture — so that there may be no possibility 
 of adhesion between the tendon cicatrix and the skin cicatrix. (3) The 
 ends of the tendons often form adhesions to their sheaths, and must be freed 
 before they can be brought together. (4) All tendon-sheaths opened to expose 
 tendons must be repaired with catgut. (5) The upper end of the divided 
 tendon retracts further, and is harder to find, than the lower. The upper 
 end retracts more because of the more active shortening of the proximal end 
 of the muscle. It may be found, in hard cases, by "milking" the tendon- 
 sheath downward — or by incising over the tendon higher up and tracing 
 downward — or by incising the sheath in the lower part of the wound and 
 tracing upward. The upper end of the tendon may sometimes be brought 
 into view by extending the fingers or toes, the fibro-serous vincula pulling 
 down the adjacent tendons. The lower end is generally not hard to be 
 found — when hard, incise over the sheath lower down and trace upward — 
 or pass a probe into its sheath from below and protrude it upward. (6) 
 If the two ends cannot be found, one end must be transplanted into a neigh- 
 boring tendon of the same group or function (see transplantation and grafting 
 of tendons, pages 261 to 265). (7) The limb is put up so as to relax the 
 tendon and muscle fully, and held so in a splint during union. After union 
 has occurred, passive and active movements are begun early and persisted 
 in — in order to prevent adhesion of tendon to sheath, and to get full range 
 of movement. (8) It will be seen by comparing the illustrations of Neuror- 
 rhaphy (pages 160 to 162) that many of the methods used in uniting nerves 
 are applicable to the union of tendons, and vice versa. 
 
 TENDON-LENGTHENING. 
 
 Description. — Tendon-lengthening, sometimes called tendoplasty, is ap- 
 plied to the lengthening of shortened tendons, or to the union of severed 
 tendons, by processes of plastic elongation. 
 
 Varieties. — Tendon-lengthening may be required in two classes of cases; 
 — (1) Where the tendon is intact but shortened; — (2) Where the tendon has 
 been severed and the divided ends have retracted. As to the time of per- 
 forming the operation, tendon-lengthening may be either primary (done near 
 the time of injury), or secondary (when done after retraction and healing). 
 
 Operation. — Much that has been said under Tenorrhaphy, as to the 
 exposure of the tendon, is equally applicable here — (see Operation, page 251, 
 and Comment, page 254). Having exposed the shortened tendon, or the 
 retracted tendon-ends, in the wound, one of several methods of lengthening 
 may be applied — the chief of which will be here described: — (a) Operations 
 for lengthening shortened intact tendons: — (1) By long oblique division 
 of tendon, with gliding of beveled ends; — The obliquity of the division will 
 determine the amount of lengthening — the ends being slid past each other far 
 enough to still leave sufficient substance for union — and then the ends are 
 sutured by several transverse sutures of chromic gut or kangaroo tendon. 
 An oblique incision of 5 cm. (2 inches) will furnish a lengthening of from 
 2.5 to 4 cm. (1 to ij inches) (Fig. 225, B). (2) By central longitudinal 
 splitting of tendon with transverse division of the split ends and their 
 approximation, surface to surface; — Having split the shortened tendon 
 
TENDON-LENGTHENING. 
 
 2 55 
 
 Figs. 224— 227.— Tendon-lengthening : — A, Splitting tendon transversely and longitudinally and 
 suturing ends laterally ; B, Splitting and suturing tendon obliquely ; C, Splitting tendon obliquely and 
 longitudinally and suturing split portions end-to-end ; D, Splitting one end obliquely and longitudi- 
 nally and suturing the split end laterally to opposite unsplit end. 
 
 Figs. 228-231. — Less Usual Forms of Tendon-lengthening: — A, Splitting one end 
 longitudinally and transversely, reinforcing where bent, and suturing split end into opposite 
 unsplit end; B, Splitting both ends longitudinally and transversely, reinforcing where bent, and 
 suturing split portions end to end; C, Same, with suturing of split portions laterally; D, Same 
 as last, with different sutures (lateral knotted and ordinary). 
 
256 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 Fig. 232. — Bayer's Method of Tendon-lengthening: — A, The lines of through-and-through 
 
 division of one-half the width of the tendon are shown. 
 Fig. 233. — B, The appearance of the tendon after traction and the gliding of the longitudinal 
 
 fibers past each other. 
 
 down its center, as far as necessary to furnish the needed length, the ends of the 
 split portion are divided transversely, or slightly obliquely, in opposite direc- 
 
 Fig. 234. — A less Common Form of Tendon-lengthening: — A, The preliminary rectangular 
 
 incisions. 
 Fig. 235. — B, The subsequent appearance of the tendon after traction upon its ends. 
 
 tions. They are then glided past each other and fastened laterally near their 
 ends by two or more sutures passing through their combined thickness (Fig. 
 
TENDON-LEXGTHENIXG. 
 
 257 
 
 224, A). (3) By central longitudinal splitting of tendon with transverse 
 division of the split ends and their approximation, end to end; — Somewhat 
 similar to the method just described, except that the extreme ends of the split 
 portions are sutured end-to-end, rather than surface-to-surface (Fig. 226, C). 
 
 (4) Bv zig-zag incisions; — Incisions, transverse to the length of the tendon, 
 are made on opposite sides of the tendon, passing half-way across, and not 
 placed directly opposite each other. As many as are deemed necessary are 
 thus placed, and the tendon lengthened by traction (Figs. 241 and 242, A, B). 
 
 (5) A tendon may be lengthened by Bayer's method of partial division, followed 
 by gliding the uncut fibers; — one-half of the width of the tendon is divided 
 from its lateral (right) margin transversely to its center — and the opposite 
 half of the width is similarly divided from its lateral (left) margin transversely 
 to its center, but at a distance of 2.5 cm. (1 inch) or more from the first trans- 
 
 Figs. 236-239. — Less Common" Forms of Tendon-lengthening : — A, Double splitting 
 of both ends, reinforcing where bent, and suturing split portions end-to-end; B, Bridging with 
 gut, or reinforcing or relaxing with lateral knotted sutures; C, Bridging with twisted gut; D, 
 Interpolation with another piece of tendon. 
 
 verse division. By putting the tendon under tension, the margins of the trans- 
 versely cut portions separate, and the fibers of the portions between the cuts 
 may be made to glide past each other as far as desired. The parts which are 
 about to glide entirely out of contact may be reinforced by a double suture. 
 (Figs. 232 and 233.) (6) A tendon may be lengthened by being incised as 
 shown in Fig. 234, A — followed by traction and the production of the effect 
 shown in Fig. 235, B. (b) Operations for lengthening shortened severed 
 tendons: — (I) By partially splitting one end, twisting the split half, and 
 suturing it to itself and to the end of the opposite end. Calculating the required 
 amount of tendon needed, the upper end of the tendon is partially split, twisted 
 upon itself, and sutured to itself — and its free end sutured to the opposite lower 
 end of the unsplit tendon (Fig. 227, D; and Fig. 228, A). (2) By partially 
 .splitting both ends, twisting the split portions and suturing them to themselves 
 17 
 
258 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 and to the end of the opposite end. This is the application to both ends of 
 the principle applied in "1" to one end (Fig. 229, B). (3) By partially split- 
 ting both ends, twisting the split portions and suturing them to themselves 
 and laterally to the opposite end (Fig. 230, C). (4) By distance suturing, 
 or bridging, with catgut; — The ends are approximated by lateral knotted 
 sutures, as far as possible, then a continuous catgut suture is run back and 
 forth between the ends and between the lateral knotted sutures, partially filling 
 in the gap by catgut strands, upon which lymph and blood are poured, and, 
 together with the catgut, organized (Figs. 237 and 238, B and C; and Fig. 
 243, C). (5) Tendon lengthening by means of interposed silk sutures (Lange's 
 method); — If the end of a severed tendon is not long enough to reach to the 
 opposite end of the tendon, or to the site cf its periosteal insertion, it may be 
 attached to this opposite end, or periosteum, by means of one or more stout silk 
 sutures introduced in the fashion of a mattress suture. Experience has shown 
 that tendon will form along this intervening silk and thus continue the con- 
 tinuity of the tendon. Especially careful technic has to be employed, as septic 
 infection is likely to invalidate the result. Four strands are used in ordinary 
 tendons — and eight to twelve in tendons the size of the quadriceps extensor. 
 The silk, which is stout, is boiled in 1-1000 bichloride of mercury solution. 
 With a long, straight needle, the silk is introduced in the manner illustrated 
 in Fig. 240. When the knot is tied tightly, the pull comes squarely from the 
 
 Fig. 240. — Lange's Method of Tendon-lengthexing by Means of. Interposed 
 Silk Sutures: — The method of introducing the suture is here shown in the case of a small 
 tendon. Several sutures are used in larger tendons, evenly distributed throughout the substance 
 of the tendon. 
 
 points of emergence of the silk from one end of the tendon, to the points of 
 entrance into the opposite end, directly in the long axis of the tendon. A drain 
 for forty-eight hours is used, to carry off the fluids of the wound. Following the 
 union of the tendon-ends, the tendon-sheath, if it have been incised or other- 
 wise injured, is repaired with catgut sutures, as far as possible. In exposing 
 the tendon, the sheath should not have been needlessly freed, for the vessels 
 of the tendon reach it through the sheath. The overlying muscles are brought 
 together with buried catgut sutures. The skin-wound is then closed — and the 
 limb immobilized upon a splint, which will insure relaxation of the part. Pas- 
 sive and active motion should be begun as soon as sound healing has occurred. 
 
 Comment. — Many of the methods of nerve-lengthening are equally 
 applicable to tendon-lengthening (pages 163 to 165). Not only may 
 tendon-lengthening be accomplished by processes of plastic elongation in the 
 sense of bringing into position undetached portions of tendon — but elongation 
 may be also accomplished by the interposition of tendon substance, in those 
 cases where the gap is too long to be bridged by other means, as in the similar 
 operation for nerve-lengthening. The two most ordinary ways are the 
 following; — (a) A piece of tendon of the required length and as nearly the 
 desired size as possible, taken from a human being just operated upon, or 
 
TEXDOX-LEXGTHEMXG. 
 
 259 
 
 from a lower animal, is inserted into the interval between the severed ends, 
 which have been freshened, and is sutured to both ends of the main tendon 
 by longitudinal peripheral sutures, or other method (Fig. 239, D). (b) Half 
 the thickness, and as much of the length as required, of part of the same or 
 of one of the neighboring tendons of the patient is taken, and sutured, as 
 
 Figs. 241-243. — Tendon-lengthening: — A, Poncet's accordion method (in case of tendo 
 Achillis) — incisions partly across tendon; B, Same, showing amount of lengthening by traction 
 upon tendon; C, Bridging with gut, reinforced with decalcified bone-cylinder. 
 
 above, into the gap. The wound is treated as after other forms of tendon- 
 lengthening. The interpolated tendon probably disappears, as such, after 
 serving as a framework. 
 
 TENDON-SHORTENING. 
 
 Description. — The shortening of a tendon for the purpose of increasing 
 the action of a muscle which has become impaired by the elongation of its 
 tendon, — or for the purpose of improving a deformity (as the shortening of 
 the tendo Achillis for talipes calcaneus). 
 
 Operation. — Having exposed the involved tendon, its shortening may be 
 accomplished in one of several ways; — (r) By excision of a piece of the tendon, 
 with the union of the resulting ends by one of the methods of tenorrhaphy. 
 (2) By oblique- division of the tendon, followed by gliding of the ends in such 
 a way as to lessen the length of the tendon, and the suturing of the ends as 
 in Fig. 244, A. (3) By division and shortening of the tendon, followed by 
 the beveling of one end into a wedge, and the splitting of the other end — and 
 the suturing of the wedge into the split portion, thus using up the excess of 
 length (Fig. 246, C). (4) By the figure of Z method (Fig. 245, B); — make 
 a vertical incision down the center of the tendon from F to K, and transverse 
 
20O OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 ones along E F and K L. Having drawn the cut portions apart, shorten each 
 piece by removing the ends at G H and I J. E F and G H are then sutured 
 
 Figs. 244-247. — Tendon-shortening: — A, Portion of tendon excised obliquely and sev- 
 ered portions sutured end-to-end, in direct contact or overlapping (reverse of Fig. 225, B); B, 
 Z-shaped incision is made, followed by excision of E F G H and I J K L, after which E F is 
 sutured to K L: C, Following excision, ends of tendon are sutured in form of mortise; D, Ex- 
 cision of portion of tendon by transverse incision, followed bv mattress-suturing of opposite 
 ends (portion between circular transverse incisions is here excised). 
 
 together, and I J and K L — as well as the vertical line of division. The wound, 
 following the operations for tendon-shortening, is closed and treated as after 
 
 Fig. 248. — Hoffa's Method of Tendon-shortening: — A, The manner of inserting the 
 
 through-and-through suture. 
 Fig. 249. — B, The appearance of the tendon after the tightening and knotting of the suture. 
 
TENDON-GRAFTING. 
 
 261 
 
 tendon-lengthening. Another form of tendon-shortening is shown in Fig. 247, 
 D, where a portion of tendon is removed. (5) A tendon may be shortened 
 by passing through its substance, lengthwise, two stout silk sutures after the 
 fashion of the cords in Venetian blinds (Fig. 248, A) — traction upon which, 
 and knotting will produce the shortening shown in Fig. 249, B, Hofta's method. 
 
 TENDON-GRAFTING. 
 
 Description. — Tendon-grafting, tendon-transplantation, or tendon-im- 
 plantation, as the operation is variously termed, is the attachment of the 
 distal end of a divided tendon into a neighboring sound tendon of the same 
 general group or function. The attachment is sometimes made laterally, 
 without the division of the involved tendon. A limb may be tunnelled and a 
 tendon of one group drawn entirely through the limb and sutured to a tendon 
 of another group on the opposite aspect. 
 
 Indications. — (1) Those cases in which so much of the tendon has been 
 destroved that its reconstruction is impossible — and the damaged tendon 
 
 Fig. 250.— Tendon-grafting :— Of sound extensor of great toe into impaired anterior tibial ; A, 
 Tendon of tibialis amicus; B. Proximal end of extensor proprius hallucis, which has been severed 
 from lower end, C, and engrafted upon anterior tibial tendon; D, Innermost tendon of extensor 
 brevis digitorum. 
 
 is therefore grafted to a neighboring tendon (for instance, should one of the 
 four tendons of the flexor sublimis or profundus digitorum be too extensively 
 damaged for union of the proximal and distal ends, its distal end may be 
 
262 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 attached to one of the neighboring sound tendons of the same muscle). (2) 
 Those cases in which a group of muscles, or a single muscle, has been para- 
 lyzed — and one or more of the tendons of the paralyzed group is therefore 
 grafted to a tendon of an unparalyzed group (for instance, if the tibialis 
 anticus were paralyzed and the extensor propius hallucis intact, the tendon 
 of the latter may be grafted upon the tibialis anticus) (Fig. 250). Where the 
 tendon of the muscle from which the power is to be derived is of comparatively 
 
 Figs. 251-254. — Tendon-grafting : — I. — Where the tendon of the muscle supplying the 
 power is of comparatively little importance (shown on the right, in light), the entire sound 
 tendon is grafted upon the impaired tendon (shown on the left, in dark). (Modified from 
 
 Vulpius.) 
 
 Figs. 255-259 — Tendon-grafting: — II — Where the tendon of the muscle supplying the 
 power is of greater importance (shown on the right, in light), only a portion of the sound 
 tendon is grafted upon the impaired tendon (shown on the left, in dark). (Modified from Vulpius.) 
 
 little importance functionally, and the paralyzed muscle is of more importance, 
 the entire sound tendon may be diverted into the paralyzed muscle (Figs. 
 251-254). But where the tendon of the muscle which is to supply the power 
 is more important than the paralyzed tendon, then but a portion of the sound 
 tendon should be diverted into the paralyzed one (Figs. 255-259). 
 
OPERATION FOR UNITING TENDON TO PERIOSTEUM. 
 
 263 
 
 Operation. — Having exposed the field of operation by an incision harming 
 the adjacent structures as little as possible, and having isolated the involved 
 and the sound tendons, the technic of grafting may be accomplished in one 
 of several ways — the chief of which will be here mentioned; — (a) Tendon- 
 grafting by lateral attachment : — In the case of a divided tendon, the 
 distal end is freshened by an oblique paring (Fig. 260, A). In the case of a 
 paralyzed (undivided) tendon, it is divided obliquely (also A, Fig. 260). 
 That portion of the sound tendon to which the involved tendon is to be at- 
 tached is freshened upon its lateral aspect — to which the obliquely divided 
 distal end of the injured, or paralyzed, tendon is now sutured with gut by 
 peripheral coaptation sutures, or other form of suturing. Sometimes the 
 paralyzed tendon is not divided, but its lateral aspect freshened, just as in 
 the case of the sound tendon — these aspects being then brought together 
 and sutured (Fig. 261, 
 B). Especially would 
 this be indicated where it 
 is possible for the struc- 
 ture of the paralyzed 
 muscle eventually to re- 
 gain its functioning, (b) 
 Tendon - grafting by 
 implantation : — The 
 sound tendon is split en- 
 tirely through its center, 
 over an area sufficiently 
 long to accommodate the 
 tendon to be grafted. 
 Freshen the distal end 
 of the involved tendon 
 (injured or paralyzed) 
 by paring both sides in 
 a beveling or wedge- 
 shaped fashion. The 
 wedge-shaped piece of 
 tendon is then inserted 
 
 between the lips of the 
 split tendon and held in 
 place by two or more 
 
 Figs.260-262.— Tendon-grafting :— A, Grafting end of di- 
 vided tendon into lateral aspect of undivided tendon ; B, Grafting 
 undivided tendons laterally; C, Implantation of beveled end of 
 tendon between the split portions of sound tendon. 
 
 gut sutures passed trans- 
 versely through both tendons (Fig. 262, C). The wound is finally closed 
 in the usual way — and the limb put up upon a splint in such a position as to 
 secure relaxation of the parts. 
 
 OPERATION FOR UNITING TENDON TO PERIOSTEUM. 
 
 lange's method. 
 
 Description. — It sometimes happens that the end of a divided tendon can 
 not be made to reach its normal site — it is then to be sutured either to a neigh- 
 boring tendon or into adjacent periosteum or bone, as near to its original 
 insertion as possible. In the case of uniting it to the periosteum, the technic 
 is as follows: — a flap of periosteum, from 1 to 2 cm. ({ to f inch) in length 
 is detached with periosteal elevator, in convenient relationship to the tendon. 
 
264 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 The end of the tendon is then cut obliquely in such a way as to present a favor- 
 able surface, and this freshened surface is sutured with fine chromic gut to the 
 
 Fig. 263. — Lange's Method of Uniting Tendon to Periosteal Flap. 
 
 outer surface of the periosteal flap. The neighboring soft parts are brought 
 normally about the site of operation, buried sutures being used where indicated 
 — and the wound closed. (See Fig. 263.) 
 
 Fig. 264. — Wolff's Method of Implanting Tendon into Bone. 
 
 OPERATION FOR UNITING TENDON TO BONE. 
 wolff's method. 
 
 Description. — Instead of uniting the end of the tendon to periosteum as' 
 in the operation just given, the tendon may be implanted within the bone and 
 
REPAIR OF RUPTURED OR DIVIDED TENDON-SHEATHS. 
 
 *5 
 
 surrounded by the periosteum. The periosteum is incised over the site where 
 the end of the tendon is to be implanted. After having retracted the two lips 
 of the incised periosteum, a groove is chiselled in the exposed bone. The 
 bevelled end of the tendon is buried in this groove — and the margins of the 
 periosteum are sutured to the implanted tendon and to each other. The 
 wound is closed without drainage, unless otherwise indicated. (Fig. 264.) 
 
 TRANSPLANTATION OF TENDON WITH ITS OSSEOUS INSERTION. 
 Description. — It occasionally happens, after fracture of the patella 
 (especially when repair is not undertaken until after contracture has taken 
 place) and after rupture of the tendon of the quadriceps extensor or the tendo 
 Achillis, that it is impossible to approximate the fragments of bone, or ends of 
 the tendons, without the transplantation proximally of the osseous prominences 
 into which the tendons are inserted. Let it be supposed that the quadriceps 
 extensor tendon has been ruptured a short distance above the patella; — 
 When the site of rupture is exposed, it is found impossible to bring the ends of 
 the tendon together. The vertical incision for its exposure is continued down- 
 ward. The patella, ligamentum patella?, and tibial tubercle are exposed. The 
 tibial tubercle is now chiselled from the tibia — and any adhesions which bind 
 the parts down are freed. The ruptured extensor tendon is now sutured — 
 during which the separated tibial tubercle has glided upward upon the tibia 
 into a new position. In this higher position upon the anterior aspect of the 
 tibia, sufficiently far below the upper margin of the tibia not to interfere with 
 the joint-movement, a steel nail is driven through the tibial tubercle — a nail 
 sufficiently long to be left protruding through the skin to be removed after union 
 is complete. The soft parts are then closed about the nail — as well as over 
 
 Fig. 265. — Transplantation of Tendon with its Osseous Insertion. 
 
 the site of the ruptured tendon. This same technic may be applied to the 
 tendon of the triceps. (Fig. 265.) 
 
 REPAIR OF RUPTURED OR DIVIDED TENDON-SHEATHS. 
 
 Description. — A tendon-sheath may be accidentally ruptured by violent 
 action or injury, as in the case of the long head of the biceps, or may be pur- 
 posely divided in an operation temporarily to expose the tendon within, or 
 
266 OPERATIONS UPON THE TENDONS AND TENDON-SHEATHS. 
 
 the underlying parts beyond (as the division of the sheath of the tendo Achillis 
 for tenorrhaphy, or the division of the common sheath of the peroneus longus 
 and brevis tendons temporarily to retract the contained tendons in the excision 
 of the ankle-joint). 
 
 Operation. When the object is to expose the tendon and sheath alone, 
 a slightly curved incision is made, coming over the sheath above and below 
 but somewhat to one side at the site of rupture (so that the cicatrices of skin 
 and sheath will not fall directly over each other). Or a straight incision 
 may be made directly over the tendon-sheath. When the sheath is divided 
 in the course of some other operation, the position of the incision will have 
 been determined by the special operation. The part is then put into that 
 
 Fit 
 
 266. — Excision of Tkndon-sheath : — Sheath is seized with forceps and divided circularly 
 around the tendon at both ends of the involved area. 
 
 position which will relax the tendon to the greatest extent — the tendon and 
 sheath are then clearly located, and the former placed within the latter, 
 while the edges of the sheath are held aside. The sheath is then carefully 
 dropped together over the tendon and the sheath-margins sutured with a 
 fine continuous gut suture. The wound is now closed and the limb put up 
 so as completely to relax the tendon. In about ten days the limb is taken out 
 of the splint at intervals and passively moved, to prevent adhesion of tendon 
 to sheath — while the surgeon's left thumb placed over the tendon during 
 manipulation holds it in place within the sheath and relieves part of the 
 strain upon the recently sutured sheath. 
 
 Comment. — In cases of paralysis, the peroneus longus has been grafted 
 
EXCISION OF TEXDOX-SHEATHS. 267 
 
 into the tendo Achillis, into the tibialis posticus, and even into the tibialis 
 anticus; — the tibialis anticus into the extensor proprius haUucis; — the sartorius 
 into the rectus femoris, and the like. Tendons are sometimes approximated 
 by tunneling under other structures. 
 
 EXCISION OF TENDON-SHEATHS. 
 
 Description. — The removal of more or less of the sheath of a tendon. 
 Generally resorted to in cases of obstinate tenosvnovitis. 
 
 Operation. — The special tendon-sheath involved is exposed by an incision 
 directly over it, — or by an incision beginning and ending over the sheath but 
 passing to one side of the sheath throughout the rest of its course, thus en- 
 abling a skin-flap to be turned to one side, so that when replaced its scar 
 will not fall directly over the tendon. Having retracted the soft parts, the 
 tendon-sheath is entirely isolated, with care, from the neighboring structures — 
 especially from those forming its bed. The sheath of the tendon is now 
 divided circularly around the tendon, above and below the diseased portion 
 — but without cutting the tendon itself. Having completed the two circular 
 incisions at either end, the sheath is split in the long axis of the tendon— 
 and thus laid completely open — and may be removed in one piece (Fig. 266). 
 Any diseased portions of the contained tendon found, should be scraped. 
 The skin-flap is then united — and the limb put up so as to immobilize the 
 tendon. 
 
CHAPTER IX. 
 
 OPERATIONS UPON THE LIGAMENTS. 
 
 SYNDESMOTOMY. 
 
 Description. — Division of ligaments. Generally performed for the con- 
 traction of ligaments occurring as the cause, in whole or in part, of some 
 of the deformities. 
 
 Operations. — The ligament, or ligaments, at fault may be divided by 
 the subcutaneous or open method — the latter being preferable. In the open 
 method the involved ligaments are exposed by the simplest and safest route 
 — and divided in the same general manner as the division of tendons by the 
 open method — and the wound similarly treated. 
 
 SUTURING OF LIGAMENTS. 
 
 The suturing of ligaments is performed upon the same general principles 
 as is tendon-suturing (see page 251). 
 
 LENGTHENING OF LIGAMENTS. 
 
 Description. — Lengthening of ligaments which have become shortened 
 through disease or injury — especially in cases of deformity. 
 
 Operation. — Many of the same methods involved in tendon-lengthening 
 are applicable to the lengthening of ligaments. Where a ligament is attached 
 to a bony prominence, this has been chiseled off and displaced to a neigh- 
 boring site and there nailed (as in the case of the ligamentum patella?, where 
 the tubercle of the tibia has been displaced to the upper portion of the tibia 
 — but with uncertain success). (See Tendon-lengthening, page 254.) 
 
 SHORTENING OF LIGAMENTS. 
 
 Description. — Shortening of ligaments which may have become lengthened 
 through disease or injury. 
 
 Operation. — Many of the tendon-shortening methods may also be ap 
 plied to elongated ligaments. As in the above operation, where a ligament 
 is attached to a prominence of bone, this may be chiseled from its normal 
 site and nailed to an adjacent site (as in the case of the ligamentum patellae, 
 where the tibial tubercle has been displaced lower down the tibia). 
 
 Note. — Most of the work done upon Ligaments will be found described 
 in special writings upon orthopedic surgery. (Also see Tendon-shortening, 
 page 259.) 
 
 268 
 
CHAPTER X. 
 
 OPERATIONS UPON THE FASCIA. 
 
 FASCIOTOMY OR APONEUROTOMY. 
 
 Description. — Fasciotomy or aponeurotomy signifies the division of 
 bands or planes of contracted fascia. The term is used with especial reference 
 to operations upon contracted palmar and plantar fascia, in the deformities 
 of those parts — and in connection with the contracted fascia lata, and the 
 contracted fascia following burns, and the like. 
 
 Operation. — The division is usually accomplished by the subcutaneous 
 or open method. The general principles of the operations will be here de- 
 scribed — the steps of the special operation will be determined by the anatomy 
 and contraction of the part involved, (a) Fasciotomy by the Subcutaneous 
 Method : — Where the contracted fascia is in the form of narrow bands, a 
 sharp-pointed tenotome with a narrow cutting-edge (of about 6 mm., or J 
 inch) is best. Where the fascia is contracted in the form of planes, a sharp- 
 pointed tenotome with a longer cutting-edge is to be preferred. The short- 
 bladed fasciatome, however, is the safer form of tenotome, as far as damaging 
 the neighboring structures is concerned. The instrument is inserted flatwise 
 beneath the fascia — the cutting-edge is then turned toward the contracted 
 fascia, which is rendered further prominent by extending the part, and the 
 special band of fascia is divided against which the knife-edge presses — then 
 another band is sought — new bands appearing to spring into existence as 
 others are cut — the tenotome being carefully pushed in different directions 
 until all the bands are cut. Just before each band is cut, the tip of the surgeon's 
 left forefinger should be placed over the tense band of fascia and make counter- 
 pressure, and thereby serve as a guide of the progress of the knife toward the 
 skin. Sometimes all the bands can be divided through one introduction 
 of the tenotome — in other cases the tenotome is introduced at several sites. 
 The tenotome is sometimes introduced between the skin and the fascia and 
 divides the latter by cutting downward, which is somewhat more risky. 
 When all or nearly all of the ligaments have been divided which the tenotome 
 can detect and reach, the part is fully extended, breaking down the remaining 
 ones if any. The tenotome wound or wounds are then closed by a suture 
 or two and the limb immobilized in a splint, which is worn for a long period. 
 (b) Fasciotomy by the Open Method : — A number of limited incisions 
 may be made from without inward, through the skin and fascial bands, — 
 or the involved fascial bands may be exposed through a skin-flap which is 
 raised and retracted to one side, or through a long straight incision whose 
 margins are retracted laterally. Following the thorough exposure of the 
 parts, in the last method, the contracted fascia is dissected out wherever 
 present. In either one of the open methods, the part is fully extended after 
 the operation, the skin-wound closed and the part immobilized. 
 
 Note. — Much of the work done upon the Fascia will be found described 
 in special writings upon orthopedic surgery. 
 
 269 
 
CHAPTER XI. 
 
 OPERATIONS UPON THE BURSAE. 
 
 PUNCTURE OF BURSAE. 
 
 Description. — Generally resorted to for exploring the nature of the 
 bursal contents, or for injecting fluid for destroying its secreting surface, or 
 simply for the evacuation of its contents. 
 
 Operation. — The needle of the syringe is introduced, with the usual 
 precautions, into the interior of the enlarged bursa — piercing the skin as 
 directly over the. cyst as possible and passing by the safest route through, or 
 preferably between, the overlying tissues. The site of the introduction will 
 depend upon the special bursa. 
 
 INCISION OF BURSAE. 
 
 Description. — Usually resorted to for the evacuation of pus, or other 
 fluid; or to expose the interior for curettage. 
 
 Operation. — An incision is made down to the bursal sac — selecting a 
 site where the least important structures will be encountered and the sac 
 most readily reached. The intervening parts having been retracted to one 
 or both sides and the bursa steadied by the surgeon's left forefinger and 
 thumb, its wall is incised with a scalpel — after which the special object of 
 the operation is accomplished. The steps of the operation will depend upon 
 the special bursa. In some cases the incision will pass from the skin directly 
 into the bursal cavity, without any intervening dissection. 
 
 EXCISION OF BURSAE. 
 
 Description. — Generallv done for the removal of chronically inflamed 
 or diseased bursa? — the majority of the latter cases being tubercular. 
 
 Operation. — The exposure of the enlarged bursa is accomplished as 
 described under the operation for incision. The surrounding parts having 
 been then drawn well aside, the entire bursal sac is dissected from its bed, 
 partly by blunt and partly by sharp dissection — carefully guarding the neigh- 
 boring structures, and especially those joints with which the bursa may 
 communicate. Whenever possible, the communication with a joint should 
 be closed by suturing together the edges of the neck of the excised bursa. 
 The wound is then closed, or drained, as indicated. 
 
 270 
 
CHAPTER XII. 
 
 AMPUTATIONS, 
 
 GENERAL CONSIDERATIONS. 
 
 Definition. — Amputation — the removal of a limb through its continuity. 
 Disarticulation — the removal of a limb at a joint. 
 
 Indications. — Any injury, disease, or malformation rendering retention 
 of the limb incompatible with life or comfort; — avulsion of limb; compound 
 fracture; compound dislocation; fracture with great comminution of bone; 
 laceration of important vessels; extensive contusion; extensive laceration; gun- 
 shot injuries; aneurism; effects of heat and cold; gangrene; extensive bone 
 disease; tumors; elephantiasis; tetanus; snake-bite; deformities. Amputa- 
 tions are far less frequent in modern conservative surgery than formerly — 
 limbs now being often saved by excision, and other operations, which were 
 at one time sacrificed. 
 
 Preparation of Patient. — The constitutional preparation of the patient 
 — and the previous and immediate local antiseptic preparation of the part — ■ 
 are the same as for any major operation. The part should be shaved, where 
 its condition admits of this preparation — and should come to the table with 
 the preliminary dressing in position. 
 
 Position of Patient, Surgeon, and Assistant. — (i) Patient rests upon 
 back, lying near side of table, and nearer the upper end for amputations of 
 the upper extremity, that the limb may be held out from the table at a right 
 angle; — and nearer the lower end for amputations of the lower extremity, 
 that the limb may be held both out from the table, and also over the end of 
 the table. (2) Surgeon so places himself as to enable him to grasp with 
 his left hand the patient's limb between the saw-line and the trunk — which 
 will place him upon the outer side of the right limbs, and on the inner side 
 of the left limbs (between the table and the left limbs) (Fig. 267). This is 
 the general rule, of almost universal application (and will not be repeated 
 with each operation) — where exceptions occur they will be mentioned with 
 the special amputations. In amputations of the upper part of the left arm 
 and upper part of the left thigh, especially the latter, it may be more con- 
 venient to stand to the outer side of the limb, in which case the left hand 
 grasps the limb below the saw-line. This avoids wedging one's self between 
 the table and the upper part of the limb, which, in the case of the lower limb 
 particularly, cannot be stretched out at a right angle from the table. (3) As- 
 sistant : — grasps the part of the limb, wrapped in an aseptic towel, that is 
 to be removed, standing facing the surgeon, so that he can better steady the 
 limb against the movements of the saw than if he stood at the end of the 
 limb — his arms being thus parallel rather than at a right angle to the working 
 of the saw. 
 
 Instruments. — Esmarch's rubber bandage and tourniquet; amputating 
 knives, long and short; scalpels, various; cartilage knives; Catlin knives; 
 saws, ordinary amputating, bow, and butcher; small thin saw, for spicule 
 of bones; periosteal elevators; metallic retractors (for flaps); linen retractors 
 
 271 
 
2 7 2 
 
 AMPUTATIl >\S. 
 
 (for flaps); broad metallic or ivory spatula? and retractors to hold soft parts 
 out of way; dissecting and toothed forceps; artery-clamp forceps, numerous; 
 rongeur forceps; scissors, straight and curved, sharp and blunt; tenacula; 
 probes; grooved directors; ligatures and sutures, silk, catgut, plain, chro- 
 mic, silk-worm gut, tendon; needles, straight and curved; needle-holder; 
 
 Fig. 267. — Illustrating Position of Surgeon in Amputating: — Standing to outer side 
 of right and to inner side of left limbs — manipulating knife with right hand, and steadying limb 
 (also retracting soft parts) with left hand placed between saw-line and trunk. — Hands of assistant 
 are shown in various positions, grasping and supporting part to come away. This may be taken 
 as a bird's-eye view of patient in dorsal decubitus. 
 
 drainage-tubes; irrigator and irrigation fluid; normal salt solution and instru- 
 ments for intravenous infusion; dressings for stump; splint. Special instru- 
 ments will be mentioned under special amputations. 
 
 Anesthesia in Amputations. — While general anesthesia (preferably nitrous 
 oxid and ether) is ordinarily used in amputations, spinal analgesia and neural 
 infiltration may be used where especially indicated (where, for instance, 
 general anesthesia is contraindicated) . 
 
 Control of Hemorrhage in Amputations. — Hemorrhage may be con- 
 trolled in one of two general ways — by some form of tourniquet or constrictor 
 or by digital compression. (A) Control of hemorrhage by tourniquet 
 
GENERAL CONSIDERATIONS. 
 
 273 
 
 or constrictor: — Several forms of tourniquet control are in use; — (1) 
 Esmarch's Broad Rubber Bandage, and Tourniquet of Rubber Tubing or 
 Narrow Band; — These constrictors may be used in two ways; — (a) Use of 
 Bandage and Tourniquet (Esmarch Method) ; — The bandage is applied 
 from the fingers or toes upward, for example, nearly to the shoulder or hip 
 — the tourniquet is then applied above the bandage — and the bandage re- 
 moved. This saving to the patient of the blood in the limb is more particu- 
 larlv indicated when the limb is healthy and the patient anemic — otherwise a 
 patient who loses a limb can also generally afford to lose its proportional amount 
 
 Fij;- 268.— Illustrating Methods of Hemorrhage Control:— Wyeth's method by rubber 
 tourniquet and needles, at right shoulder-joint.— Same at left hip-joint.— Ordinary rubber tourniquet 
 and pad at left shoulder-joint, reinforced (kept from slipping) by strips of roller-bandage. — Same, at 
 right hip-joint.— Use of Esmarch rubber tourniquet above left elbow.— Exsanguination of limb by 
 Esmarch rubber bandage, followed by application of rubber tubing 1 or Esmarch rubber tourniquet) 
 above left knee. — Compression of right femoral by Petit type of tourniquet.— Preliminary ligation 
 of left femoral. — Digital compression of main arteries at right wrist. 
 
 of blood. (Fig. 268, left leg.) (b) Use of Esmarch's Tourniquet Alone;— The 
 limb is held elevated for about three minutes (this empties the veins mechani- 
 cally and causes the arteries to contract reflexly, thus lessening the blood to the 
 limb; but if the elevation be too long, the arteries recover, dilate, and let in 
 
 18 
 
274 AMPUTATIONS. 
 
 more blood) — and, during the time of this elevation, a healthy limb may be 
 massaged downward to aid exsanguination — the tourniquet alone is then 
 applied as high up the limb as indicated for the special operation, no form of 
 bandage having been previously applied (Fig. 268, left arm). In operating any- 
 where below the elbow or knee, the constriction should be applied just above the 
 elbow or knee, — and in amputating anywhere above the elbow or knee, the con- 
 striction should be applied as near the trunk as possible. This is the general 
 method of hemorrhage control in the majority of cases. The objections 
 which have been urged against the Esmarch bandage and tourniquet, or 
 tourniquet alone, are — the increased bleeding following the operation, from 
 temporary vasomotor paralysis; the possible lowered vitality of the com- 
 pressed parts; occasional temporary paralysis of nerve-trunks from pressure; 
 and the possibility of forcing pathological products into the body. The 
 great advantage over these disadvantages, however, is that it controls all 
 bleeding — and its use, therefore, is advisable in spite of the disadvantages. 
 (2) Tourniquet of the Petit Type; — The entire limb is compressed, with 
 special pressure over the main artery (Fig. 268, right thigh). (3) Tourniquet 
 of the Signorini Type; — No circular constriction is used — a pad on one arm 
 of the tourniquet compresses the artery against a counter-pad on the other 
 arm of the tourniquet opposite or beneath the limb or body. (B) Digital 
 compression of the main artery : — Compression is generally made through 
 the skin — but may be made directly upon the main vessel through an incision 
 made immediately over it. (Fig. 268, right hand.) The office of hemorrhage- 
 control by digital compression is sometimes delegated to a single individual 
 in a hospital. Note : — Special methods of controlling the circulation will be 
 mentioned in connection with special amputations, especially those about 
 the shoulder- and hip-joints (Fig. 268, shoulders and hips). Also see dis- 
 articulations at shoulder and knee (pages 374 and 433). 
 
 THE GENERAL TECHNIC IN AMPUTATING. 
 LOCATION OF LINE OF BONE-SECTION, OR DISARTICULATION. 
 
 The determination of the saw-line in an amputation, or the disarticula- 
 tion-line in a disarticulation, is the first step — generally marking the upper 
 limit of the operation — and is the necessary guide to the subsequent steps. 
 
 Level at Which the Bone, or Bones, are to be Sawed. — Is to be deter- 
 mined by the individual case — and its position should be such that enough 
 healthy tissue will be provided for, between the saw-line and the upper limit 
 of the diseased or injured tissues to be removed, to furnish ample covering 
 of soft parts to protect the stump without undue tension. 
 
 Level of Joint-line at which Disarticulation is to be Done. — The 
 position of the articulation-line is, of course, fixed — it is only necessary to 
 recognize it anatomically — and to determine whether sufficient sound tissue 
 intervenes between joint-line and upper limit of the parts to be removed to 
 afford covering satisfactory in quantity and quality to protect the stump. 
 Otherwise the disarticulation will have to be converted into an amputation 
 at a higher level. 
 
 Relation of Saw-line to Length of Flap, and Vice Versa. — While 
 the position of the saw-line determines the amount of tissue (and, conse- 
 quently, length of flap or flaps or of circular covering) which will be required 
 to cover the sawed bone — so also does the choice of the method of amputation 
 to be used largely determine the amount of bone to be sacrificed (and, con- 
 sequently, the length of the resulting limb) — for (a), In circular amputations 
 
LOCATK >N < >F LIMITS OF SKIN INCISIONS. 
 
 275 
 
 and amputations by equal flaps, the minimum amount of bone is sacrificed; 
 and (b), In amputations by a single flap, the maximum amount of bone is 
 sacrificed. 
 
 LOCATION OF LIMITS OF SKIN INCISIONS. 
 
 A total covering of soft parts equivalent to ih diameters of the limb at 
 the saw-line is the general rule of allowance. It is necessary, therefore, to 
 determine the lower limit of the skin incision, as this forms the lower limit 
 of the total covering. This limit may be determined accurately or approx- 
 imately. 
 
 In Circular Amputations. — (a) Accurately; — Find the circumference of 
 the limb at the saw-line by means of a metallic tape-line (say, 15 cm., or 6 
 inches) — one-third of the circumference will give the diameter (say, 5 cm., 
 or 2 inches). Therefore, to furnish ih diameters (say, 7.5 cm., or 3 inches) 
 the lower limit of the skin incision would have to be 3.8 cm., or 1^ inches, 
 below the saw-line, (b) Approximately; — Place the thumb at the saw-line 
 on the anterior aspect of the limb (the nail facing the junction of the limb 
 with the trunk) and the tip of the index-finger immediately opposite on the 
 posterior aspect of the limb (without compressing the soft parts). Xow, 
 keeping the thumb where first placed, and keeping the distance between 
 the tip of the thumb and tip of the index unchanged, rotate the hand around 
 (making these two fingers act as the two arms of callipers) until the tip of 
 
 Fig. 269.— Relation of Skin Incision to Saw-line: — Methods of amputation by equal 
 flaps, circular covering, and unequal flaps are shown each to furnish a covering of \ l ,' 2 diameters of 
 limb at saw-line. 
 
 the index rests upon the anterior aspect of the limb in a vertical line below 
 the tip of the thumb. The distance between the thumb-tip and the finger-tip 
 will be the diameter of the limb at the saw-line — and three-fourths of this 
 measurement will insure a covering of the requisite \\ diameters of the limb. 
 In calculating the covering in the circular method of amputating, it is to be 
 remembered that as the circular covering will be sutured in a straight line. 
 either from before backward or from side to side, practically the covering 
 may be regarded as being furnished by two aspects of the limb, either the 
 front and back or the two sides — that is, as though furnished by two equal 
 flaps (Fig. 269). 
 
 In Equal Flap Amputations. — Same as for the circular method, whether 
 calculated accurately or approximately (Fig. 269). 
 
 In Unequal Flap Amputations. — (say the anterior twice as long as 
 the posterior flap) ; — (a) Accurately; — Finding the circumference and diameter 
 in the above manner (the measurements being as there given) — the lower 
 limit of the anterior flap would be 5 cm. (2 inches) below the saw-line, and 
 the lower limit of the posterior, 2.5 cm (1 inch) below, (b) Approximately; — 
 Having gotten the measurement of the full diameter marked out on the 
 
276 
 
 AMPUTATIONS. 
 
 anterior aspect, as explained above, this will represent the length of the 
 anterior flap — and one-half of this measurement will give the length of the 
 posterior flap (Fig. 269). 
 
 INCISION OF SKIN AND FASCIA. 
 
 In general terms, it is considered that the aspects of the limb furnish an 
 average covering of 1^ diameters of the limb at the saw-line — whether this 
 covering consist of skin alone, or of skin and muscle combined — and whether 
 furnished by one or more aspects of the limb. In the circular method of 
 amputating, the covering is furnished equally from all aspects of the limb. 
 In the method by equal flaps, it is furnished equally by two aspects of the 
 limb. And in the method by unequal flaps, the inequality of length may 
 be parceled out in any way indicated, just so the total covering is equivalent 
 to ih diameters at the saw-line. If the covering be from one aspect alone, 
 as in the single flap or in the elliptical methods, the total diameter and a half 
 comes from that one aspect. Where the amputation is done through a site 
 of maximum contractility of skin and muscles (as through the lower half of 
 
 Fig. 
 
 :7c— Incising Skin and Fascia in Circular Amputation: — I, Position of long knife in 
 incising upper, further and part of lower aspects of limb. 
 
 the arm, or the lower half of the thigh), a somewhat greater allowance may 
 become necessary (even to the extent of two diameters). Where the ampu- 
 tation is done through a site of minimum contractility of skin and muscles 
 (as through the dense tissues of the palm of hand and sole of foot), a somewhat 
 less allowance than the average may be provided. 
 
 Manner of Incising Skin and Fascia in Circular Amputations. — 
 Whether a stump is going to be covered by skin alone, or by skin and muscle, 
 the skin is invariably cut first and cut separately. Standing to the outer 
 side of the right and inner side of the left limbs, grasp the part above the level 
 of the skin incision with the left hand and retract the skin upward, either 
 entirely alone or aided by an assistant (the assistant's aid being more necessary 
 in large limbs) — the retraction being evenly maintained throughout. This 
 is done to provide as ample a skin covering for the muscles as possible, for, 
 as the average contractility of the skin involved in an amputation is greater 
 
INCISION OF SKIN AND FASCIA. 
 
 277 
 
 than the average contractility of the muscles involved, if the skin and muscles 
 were divided on the same level it would subsequently be found difficult, or 
 impossible to make the skin meet over the cut muscles. Therefore this 
 circular division of skin, which has been well drawn up under the knife-cut 
 prior to incising, means an actual division of the skin a little lower than the 
 position of the knife on the limb indicates — but insures having a somewhat 
 fuller measure of skin than if it were cut without retraction. Having thus 
 retracted the skin, take a long knife with a blade one-and-a-half times the 
 diameter of the limb to be removed — and, holding it in a full hand, like a 
 pruning-knife, pass the arm under the patient's limb and bring the cutting- 
 edge into contact with the upper surface of the limb, the back of the knife 
 being horizontal and pointing upward, the heel of the knife being over the 
 center of the limb, and the point projecting beyond the limb toward the 
 surgeon. Beginning the incision with the heel of the knife, steadily and 
 evenly draw the knife from heel to point, passing with one sweep of the knife 
 
 Fig. 271— Incising Skin and Fascia in Circular Amputation : — II — Position of I01 
 incising nearer and remainder of lower aspect of limb. 
 
 through three-fourths of the circumference (Fig. 270). The knife is then with- 
 drawn and reinserted with its heel at the place of beginning of the incision 
 on the supero-external surface (in operating on the right limbs), and, with 
 one sweep, passes through the remaining fourth of the circumference 
 (Fig. 271). The attempt to make the complete circuit with one sweep is 
 not to be recommended, as the ends of the resulting wound are not apt to 
 be in line, and the wound, generally, imperfectly made. This circular skin 
 incision is sometimes made with a small knife. The assistant can aid the 
 surgeon by rotating the limb to meet the knife. The blade is held perpen- 
 dicular to the skin throughout. The incision passes through skin and fas- 
 cia, but not into muscles. Owing to the unequal retraction which some- 
 times takes place upon the different aspects of a limb, it may be necessary 
 
278 
 
 AMPUTATIONS. 
 
 to plan one portion of the circular incision upon a lower level than the rest 
 of the incision — this greater allowance of skin at this site will, however, be 
 drawn up on a level with the rest of the circular incision, owing to the 
 greater retraction there. So that what may appear as an oblique incision, 
 will become circular and upon the same level after the division. 
 
 Manner of Incising Skin and Fascia in Flap Amputations. — As in 
 
 Fig. 272.— Incising Skin and Fascia in Flap Amputation: — I — In cutting rounded flaps. 
 
 Fig. 273.— Incising Skin and Fascia in Flap Amputation :— II — In cutting rectangular flaps. 
 
 the circular method, whether the covering is to be of skin alone, or of skin 
 and muscles, the skin is invariably cut first and separately — and whether 
 the flap be cut from without inward, or from within outward (by transfixion). 
 The preliminary steps, as to position, retraction of skin, and general prin- 
 
FREEING SKIN AND FASCIA. 279 
 
 ciples involved, are the same as in making the skin incision in the circular 
 amputation. When all is ready, the surgeon takes an ordinary scalpel of 
 medium size, and, holding it as a violin-bow, enters its point into the skin 
 vertically, at the upper limit of the base of the flap. The knife passes through 
 skin and connective tissue, and as it travels vertically down one limb of the 
 flap the cutting-edge is lowered until it forms less than a right angle with 
 the surface being cut — when nearly the lower limit of the flap is reached, 
 the knife rounds the corner of the flap — thence passes transversely across 
 that aspect of the limb from which the flap is being taken — then similarly 
 rounds the opposite corner — and thence travels vertically upward to a point cor- 
 responding with the point of beginning (Fig. 272). Care should be exercised 
 that each flap should measure one-half the circumference of the limb at its base, 
 and one-half of the circumference at that part of its free end just above the 
 rounded corners — and that these corners should be very bluntly, and not 
 sharply, rounded (that they should be squarely rounded, as it were), for if 
 they be too much tapered at their free ends, the}' will cover the stumps with 
 difficulty and unsatisfactorily. Instead of cutting the entire flap with one 
 sweep of the knife, each vertical limb and one corner of the flap should be 
 made with one downward cut of the knife. While all flaps should be prac- 
 tically square, with merely the corners rounded, an exception is made in the 
 method of unequal rectangular flaps of skin and fascia (Teale's method) — 
 the corners of the flaps being here right-angled, instead of rounded (Fig. 
 273). This is also the case in the conversion of a circular method of 
 amputation into a flap method by two vertical incisions placed laterally — 
 and even here the corners mav be rounded. 
 
 FREEING SKIN AND FASCIA. 
 
 Having incised skin and fascia, for either a circular or a flap amputation, 
 the manner and extent of further freeing skin and fascia will depend upon 
 whether the method is to be one of simply skin and fascial covering, or of 
 skin, fascial, and muscular covering for the stump. 
 
 Freeing Skin and Fascia in Simple Skin and Fascial Covering for 
 Stump. — The skin and fascia, after having been divided, are partlv retracted 
 and partly dissected back to the line of future division of muscles. The edges 
 of skin and fascia (avoiding the separation of the one from the other, as the 
 vessels reach the skin through the fascia) are grasped by the fingers of the 
 left hand, lifted from the muscles, and drawn upward — and, while held in 
 this position, and while under slight tension, the fascia is touched here and 
 there at points where it especially binds along the line of its junction with 
 the muscles and deep fascial planes, by a scalpel held at a right angle to the 
 surface of the muscles and with its cutting-edge toward the part to be removed 
 — and thus scoring of the skin and consequent damage to its blood-supply are 
 avoided. The skin and fascia are, by this means, raised in one layer from 
 the muscles — and the skin should be raised with all the underlying fascia 
 possible — and the combined skin and fascia should be raised evenly up tc 
 the future line of muscle division (Fig. 274). 
 
 Freeing Skin and Fascia in Skin, Fascial, and Muscular Covering 
 for Stump. — Special care is here taken not to separate skin and fascia from 
 underlying muscles, any further than simply in the immediate line of original 
 skin incision, and simply for the purpose of allowing of full retraction. The 
 skin and fascia are here not picked up and separated from the muscles — ■ 
 
2 8o 
 
 AMPUTATIONS. 
 
 the only knife-touches necessary being a few where the fascia has not been 
 thoroughly divided and where it is necessary further to divide a fascial attach- 
 ment here and there in order that the skin and fascia may retract as far as 
 
 Fig. 274.— Freeing Skin and Fascia from Underlying Muscles. 
 
 they naturally will unaided by manual retraction — and this is done by touching 
 the points of binding at the bottom of the original incision, by the point of a 
 knife held vertically. 
 
 Fig. 275. — Retraction of Skin and Fascia. 
 
 RETRACTION OF SKIN AND FASCIA. 
 
 Where Stump-coverings are to be of Skin and Fascia Alone. — Having 
 freed skin and fascia from the underlying parts, as above described, partly 
 by retraction and partly by dissection, until the line is reached at which the 
 muscles are to be divided, the skin and fascia are further retracted above 
 
DIVISION OF MUSI l.KS IN CIRCULAR METHODS OF AMPUTATION. 281 
 
 this line and are held out of the way by the hands of an assistant, or by re- 
 tractors (Fig. 275). 
 
 Where the Stump-coverings are to be of Skin, Fascia, and Muscles. 
 — Retraction of skin and fascia from the underlying muscles, other than that 
 which occurs unaided, is not practised. It is sought, on the other hand, to 
 keep in contact, as one layer, skin, fascia, and muscles. 
 
 DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. 
 
 In the Ordinary, or Infundibuliform, Variety of Circular Amputa- 
 tion. — (For description, see page 303.) — (a) Division of More Superficial 
 Muscles; — The position of surgeon, manner of holding limb, kind of knife 
 and manner of manipulating it, are all the same as in making the skin incision. 
 
 Fig. 276.— Division of Muscles in Infundibular Variety of Circular Amputation: — I — Di- 
 viding more superficial muscles on level with retracted skin and fascia. 
 
 The skin and fascia having been circularly incised and allowed to retract, 
 the surgeon grasps the limb above the naturally retracted skin, and further 
 retracts skin and fascia, putting, at the same time, the muscles upon the 
 stretch by this upward retraction of the overlying parts, aided by an assistant 
 in the case of larger limbs. The more superficial muscles are now divided 
 circularly on an exact level with the retracted skin, by one sweep of a long 
 knife passing, first, through three-fourths of a circle, followed by a second sweep 
 through the remaining fourth (Fig. 276). It is not always possible to divide 
 only and wholly what are generally understood as the superficial layers of 
 muscles — it is only meant that one divides, in this first circular division, about 
 one-half of the muscular covering of the limb, the knife sometimes dividing 
 a group of muscles completely and sometimes only partially. To allow for 
 unequal retraction, the muscles may sometimes have to be divided lower 
 on one aspect of the limb than on another, (b) Retraction of More Super- 
 
>S2 
 
 AMPUTATIONS. 
 
 ficial Muscles; — This layer of muscle tissue is now retracted as the skin was 
 above it. It is not expected that the first muscle layer includes all and only 
 the superficial muscles, and the deep layer all and only the deep muscles — 
 
 Fig- 2/7- 
 
 -Division of Muscles in Infundibular Variety of Circular Amputation :— II— 
 Dividing deeper muscles on level with retracted superficial muscles. 
 
 the former includes simply the more superficially placed, and the latter the more 
 deeply placed muscles. There is no general use made of the scalpel in freeing 
 the superficial muscle layer, as in the case of separating the fascia and skin 
 from the muscles, but, where indicated, a touch of the knife may be used to 
 
 Fig. 278— Division of Muscles in Cuff Variety of Circular Amputation— on a level with 
 the turned-back cuff and fascia. 
 
 enable the more superficial muscles to be evenly retracted, (c) Division of 
 Deeper Muscles; — Having retracted the divided muscles more superficially 
 placed, the more deeply situated muscles are now circularly divided on a 
 
DIVISION OF MUSCLES IN CIRCULAR METHODS OF AMPUTATION. 283 
 level with the retracted superficial muscles, and in a manner similar to the divi 
 
 Fig. 279.— Division of Muscles in Modified Circular Amputation— showing flaps of skin 
 and fascia turned back, the more superficial muscles divided, and the knife in the act of dividing the 
 deeper muscles in the infundibular fashion. 
 
 sion of the first layer (Fig. 277) . It is to be planned that this circular division 
 of the deep muscles will come down 
 upon the bone sufficiently far below the 
 saw-line to provide for a periosteal flap, 
 (d) Retraction of Deeper Muscles;— 
 This is done preparatory to forming 
 the periosteal covering. Note — it will 
 thus be seen that, having divided skin 
 and fascia lowest of all, the superficial 
 muscles have been divided upon a higher 
 level, and the deep muscles upon a still 
 higher level — forming, thereby, when the 
 bone is sawed, a hollow cone, whose apex 
 will be formed by the sawed bone, whose 
 base will be the margin of skin and 
 fascia, and whose sides will be com- 
 posed of the cut muscles (Fig. 302). 
 
 In the Circular Amputation "a 
 la Manchette," or Cuff Variety of 
 Circular Amputation. — (For descrip- 
 tion, see page 305.) — In this method, 
 all the muscles are divided circularly 
 down to the bone at one level, which 
 is that of the reflected cuff of skin — cal- 
 culating to come down upon the bone 
 sufficiently far below the saw-line to 
 form a musculo-periosteal covering (Fig. w n 
 
 „ r o \ o pjg -2 8o. — Division of Muscles in Oval 
 
 2 7"y- Method of Amputation. 
 
284 AMPUTATIONS. 
 
 In the Modified Circular Amputation. — (For description, see page 
 306.) — After the flaps of skin and fascia have been retracted, the more super- 
 ficial muscles are divided on a level with the retracted flaps — this layer of 
 muscle tissue is retracted — and the deeper layer is divided upon a level with 
 the retracted superficial layer — calculating to come down upon the bone far 
 enough below the saw-line to allow for a musculo-periosteal covering (Fig. 279). 
 The division of muscles being, in other words, just as in the ordinary circular 
 amputation. This is the better way of dividing the muscles in the modified 
 circular operation. Where, in the modified circular amputation, the muscles 
 are all divided at one level (that of the retracted flaps), the muscles are di- 
 vided as in the circular amputation a la manchette. 
 
 In the Oval Method of Amputating. — (For description, see page 307.) 
 -After having made the oval incision through skin and fascia, the muscles 
 are divided directly to the bone — the knife entering the muscle tissue upon 
 the line of the retracted skin and fascia. Along the queue, or vertical portion 
 of the oval, which begins at, or just above, the saw-line, or disarticulation- 
 line, the two lines of incision will coincide — parting below to follow the 
 outlines of the oval — and meeting at the mid-point behind (Fig. 280). 
 
 In the Racket Method of Amputating. — (For description, see page 
 308). — The principle here is the same as in the oval method. 
 
 DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 
 
 In Amputating by Single Flap of Skin and Muscle. — (For description, 
 see page 309.) — The skin-and-fascia flap having been outlined and incised, 
 the muscles are cut, preferably from without inward (or may be cut from 
 within outward, by transfixion), beveling inward, on a line with the retracted 
 skin-and-fascia flap — the incision coming down upon the bone sufficiently 
 far below the saw-line to provide for a musculo-periosteal covering (Fig. 281). 
 
 In Amputating by a Single Skin-flap. — (For description, see page 
 311). — Having retracted skin-and-fascia flap, the muscles are divided cir- 
 cularly at the saw-line, or disarticulation-line. 
 
 In Amputating by Equal Flaps of Skin and Muscle. — (For description, 
 see page 311.) —Same as by single flap of skin and muscle (Fig. 282). 
 
 In Amputating by Equal Flaps of Skin. — (For description, see page 
 311.) — Same as by single skin flap. 
 
 In Amputating by Unequal Flaps of Skin and Muscle. — (For de- 
 scription, see page 313.) — Same as by single flap of skin and muscle. 
 
 In Amputating by Unequal Flaps of Skin. — (For description, see 
 page 314.) — Same as by single flap of skin. 
 
 In Amputating by the Elliptical Method. — (For description, see page 
 315.) — As this may be considered a variety of single flap amputation (of 
 either skin alone, or of skin and muscle combined), the manner of dealing 
 with the muscle is here the same as in that operation. 
 
 In Amputating by Teale's Method of Unequal Rectangular Flaps 
 of Skin and Muscle. — (For description, see page 314.) — Upon the line 
 of the retracted skin and fascia, the muscles are cut through the periosteum 
 along the two vertical lines. The muscles are then cut through the periosteum 
 transversely along the free margin of the retracted skin and fascia representing 
 the end of the longer flap — all of the soft parts are then dissected up above 
 the lower limit of the shorter flap, when the muscles opposite its lower limit 
 are transversely divided through periosteum to bone. 
 
 Method of Cutting Flaps from Without Inward. — In this method 
 the flaps are cut by dissection, as it is sometimes called. The incision out- 
 
DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 285 
 
 lining the flap having been made through skin and fascia, the surgeon, standing 
 to the outer side of right limbs and inner side of left limbs, and grasping the 
 limbs between saw-line and trunk, proceeds to cut the muscle portion of 
 the flap. A scalpel is made to cut the muscles along the line of retracted 
 skin-and-fascia flap, the point 
 of the knife entering the 
 muscles at the upper limit of 
 one of the limbs of the skin- 
 and-fascia flaps — follows this 
 margin vertically downward, 
 passing deeply through the 
 muscles — as the free border 
 is approached, the knife is 
 given a direction obliquely 
 inward, so as to broadly and 
 thickly bevel the muscles 
 here, leaving them thinnest 
 (though not thin) along this 
 aspect of the flap — continu- 
 ing the beveling process 
 across the entire transverse 
 width of the free end of the 
 flap and well around its 
 bluntly rounded corner — 
 thence the knife passes ver- 
 tically up the opposite limb 
 of the flap, sinking deeply 
 into the muscles, though the 
 bone need not be fully 
 reached in the vertical cuts at 
 the first stroke (Fig. 283). 
 As in cutting skin-flaps, the 
 entire incision need not be 
 made at one stroke of the 
 knife — but is better made 
 in two strokes from above 
 downward. The surgeon 
 now grasps the partly cut 
 flap with the fingers of his 
 left hand, and, while draw- 
 ing it away from the bone, proceeds to fashion the rest of it along the same 
 lines upon which it was begun, beveling it toward the bone by successive cuts 
 of the knife — planning that the base of the flap will contain the full thickness 
 of the soft parts covering the bone — and calculating that the knife will come 
 down upon the bone (or bones) far enough below the saw-line (or disarticula- 
 tion-line) to provide a musculo-periosteal (or capsulo-periosteal) covering. 
 Where two flaps are cut, the second is cut in the same general manner. Care 
 should be taken that the muscles are thickly and bluntly beveled, else a thin, 
 ill-nourished ending to the flap is apt to be left. No attempt is made to 
 bevel the upper part of the sides of the flap (the vertical portions) — the beveling 
 beginning only just above the rounded corners. By cutting on a line with 
 the retracted skin, ample covering of the muscle-portion of the flap by the 
 skin-and-fascia portion is provided (Fig. 282). 
 
 Method of Cutting Flaps from Within Outward. — In this method 
 
 Fig. 281.— Division of Muscles in Amputation by Single 
 Flap Method. 
 
286 
 
 AMPUTATIONS. 
 
 the flaps are cut by transfixion. The skin and fascia should always be cut 
 first and from without inward, as the first step of every flap (as well as of 
 every other kind of) amputation — no matter what the method of doing the 
 
 Fig. 282.— Division of Muscles in Amputation by Double Flap Method. 
 
 other steps of the operation. If this be not done, the muscles and skin will 
 necessarily be cut upon the same, or nearly the same, level — with the inevitable 
 result that there will be a deficiency of skin to cover the muscles, owing to 
 the greater retraction of the former. Having, therefore, cut the skin and 
 fascia flap from without, the surgeon proceeds to cut the muscles by trans- 
 fixion. A long knife is taken, having a length equal to at least one-and-a-half 
 diameters of the limb at the site in question. Marking the saw-line with 
 
 Fig. 283.— Method of Raising Flaps of Skin and Muscle by Cutting from Without 
 
 Inward. 
 
 the thumb of the left hand, the point of the long knife (whose sides look 
 upward and downward and whose edge points toward the extremity to be 
 removed) is entered directly in the center of the lateral aspect of the limb 
 (where the flaps are to be taken from the anterior and posterior aspects of 
 the limb) and opposite the saw-line. The knife-point should be so placed 
 and pointed as to avoid important vessels. The knife is then carefully 
 pushed directly forward, until its point strikes the center of the lateral aspect 
 of the bone (or, if two bones, of that one nearer the operator) — the handle is 
 then lowered while the forward progress of the knife continues, so that its 
 point is made to hug the bone closely until its upper margin is reached — 
 the handle is then raised so as to cause the point to sink and follow, as nearly 
 as possible, the surface of the bone (or bones) on the opposite side (which, 
 
DIVISION OF MUSCLES IN FLAP METHODS OF AMPUTATION. 287 
 
 naturally, can be less closely followed than the nearer quadrant of the bone's 
 circumference). When the knife's point is felt to have reached a point on 
 the far side of the limb corresponding with the center of the bone, the handle 
 is then lowered to a horizontal position and the knife thrust on forward until 
 it protrudes through the skin on the far side of the limb. The surgeon stops 
 here a moment to calculate the line along which the cutting-edge of the knife 
 is to emerge — the guide to which being the line of the retracted skin flap. 
 With a slow back-and-forth sawing movement, the knife is made to cut 
 its way forward — hugging the bone (or bones) closely throughout the greater 
 portion of its way — until near the free end of the flap, when it is made to 
 round its way out in such a manner as to cut a thickly beveled edge of muscle on 
 
 Fig. 284.T-METHOD of Raising Flaps of Skin and Muscle by Cutting from Within 
 Outward (by Transfixion) — cutting upon the line of retracted skin and fascia, which have been 
 previously divided. 
 
 a line with the retracted free edge of skin (Fig. 284). In cutting a second flap 
 from the opposite aspect of the limb, the first flap is retracted out of the way — 
 the knife then passes over the cut surface of the muscle along exactly the 
 same course as in beginning the transfixion of the first flap — until its point 
 strikes the center of the lateral aspect nearer the surgeon (at exactly the same 
 point as in the first manoeuvre). The handle is now raised, to cause the point 
 to follow down the lower quarter of the circumference of bone nearer the 
 operator — when its lower margin is reached, the handle of the knife is lowered 
 and the knife pushed forward, until the inferior surface of the bone (or bones) 
 is passed. The handle is now still further lowered and the knife pushed 
 forward, so as to cause the point to follow the further inferior quarter of the 
 bone and emerge opposite the center of its lateral aspect. But as this manoeuvre 
 is difficult to accomplish, the surgeon generally aids the knife with his left 
 hand, by partly guiding it and partly depressing the remaining soft parts on 
 far side below the point of the knife so that its edge escapes them. Then 
 with a similar back-and-forth movement, at first hugging the bone, the knife 
 is made to cut its way out on a line with the retracted skin-flap. In order to 
 avoid cutting the muscle-flaps too narrow and too thin, it is necessary to hug 
 the bone (or bones) until about three-fourths of the flap is cut and then 
 abruptly round out to the line of the retracted skin-flap. Great care is also 
 necessary to avoid piercing the main vessels in making the transfixion — 
 and to avoid splitting them (whether at first transfixed or not) in cutting 
 
288 AMPUTATIONS. 
 
 forward to form the flap. Therefore, it is sometimes necessary, when forming 
 flaps by transfixion, to so plan them that they will not be precisely antero- 
 posterior, or lateral — but will be so formed as to be least likely to contain 
 split vessels. Considerable tissue at the base of the Hap often escapes division 
 in cutting by transfixion and has to be cut subsequently. The method of 
 transfixion may be varied by not passing the knife so closely to the bone- 
 that is, by transfixing the more superficial muscles only, retracting these, 
 and then cutting the deeper muscles circularly at the saw-line. A further 
 modification of the transfixion method consists in cutting through skin-and- 
 fascia flap from without — then transfixing the apex of the muscle-flap — 
 and dissecting up the remaining soft parts. 
 
 Comparison of Methods of Cutting Flaps. — (a) The method of cutting 
 from without inward enables a flap to be cut with greater precision — makes 
 the wounding and splitting of the main vessels unlikely — and provides for a 
 more accurate calculation of covering for the stump, especially as to the 
 relation between the amount of skin and muscle covering. It is the method 
 to be chosen in the great majority of cases, (b) The method of cutting flaps 
 from within outward (transfixion) is a convenient method in very large 
 limbs, and in some special amputations, and where speed is necessary. Flaps 
 thus cut are apt to have their arteries injured — are apt to be too thinly beveled 
 at their free ends — are apt to be too narrow throughout, and too pointed 
 at their ends — and, generally, less judgment can be exercised in their fashion- 
 ing. Even in the larger limbs a flap can be more satisfactorily cut from 
 without inward than by transfixion. Even where transfixion is used, how- 
 ever, the skin and fascia should invariably be cut from without — and the 
 knife should come out on a line with this retracted skin. 
 
 FREEING AND RETRACTING OF MUSCLES. 
 
 In Ordinary Circular Method. — After the division of the more super- 
 ficial muscles by the circular sweep of the knife, it may be found that here 
 and there these muscles are not divided to an equal depth. Such unequal 
 division, wherever found, is completed by a few strokes of the edge of a 
 small knife. This layer of muscles is then retracted upward until the level 
 is reached for the circular division of the deeper muscles. 
 
 In Circular Amputation a la Manchette. — Here the muscles are 
 divided directly to the bone, on the line of the reflected cuff, and no special 
 freeing or retraction of the muscles is done, until ready to make the musculo- 
 periosteal covering. 
 
 In Modified Circular Amputation. — The muscles are here freed and 
 retracted as in the ordinary circular amputation. 
 
 In Oval Method of Amputation.— Here the muscles are divided on the 
 line of the oval — no freeing or retraction being necessary until ready to make 
 the musculo-periosteal flap. 
 
 In Racket Method of Amputation. — Same as in the oval method. 
 
 In Single, or Equal, or Unequal Flaps of Skin and Muscle. — (A) 
 When Cut from Without; — The fingers of the left hand raise the flap away 
 from the bone, while the surgeon cuts the vertical limbs of the flap to the 
 bone, and gradually bevels the terminal portion of the flap obliquely upward 
 tow T ard the bone. (B) When Cut from Within by Transfixion; — No freeing 
 or retraction is necessary, until ready to make the musculo-periosteal covering. 
 (The fingers of the left hand may grasp up the soft parts of the limb and 
 lift them away from the bone as the knife cuts its way out.) 
 
 In Single, or Equal, or Unequal Flaps of Skin.— The muscles are 
 
MAKING MUSCULO-PERIOSTEAL COVERING. 289 
 
 here divided on one level — no freeing or retraction being necessary, until 
 ready to make the musculo-periosteal covering. 
 
 In Elliptical Method. — The muscles are handled as in an amputation 
 by a single flap of skin and muscles. 
 
 In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). 
 —The muscles are here handled as in amputation by unequal flaps of skin 
 and muscle. 
 
 MAKING MUSCULO-PERIOSTEAL, OR PERIOSTEO-CAPSULAR, COVER- 
 ING FOR END OF BONE. 
 
 Description. — A covering should be provided for the end of the ampu- 
 tated or disarticulated bone, or bones, which will consist of periosteum and 
 overlying muscle, raised as a single musculo-periosteal or periosteo-capsular 
 flap or covering. Care should be exercised in raising this covering, that 
 muscle is not first raised from periosteum and periosteum from bone, but 
 that muscle and periosteum should be raised in one adherent layer. Peri- 
 osteum is absent over cartilaginous surfaces, hence a pure musculo-periosteal 
 covering is not to be gotten in a disarticulation — but as much of the capsule 
 of the joint, which is practically a continuation of the periosteum, should 
 be preserved as possible, and treated in the same way as the periosteum, 
 that the articular end of the proximal bone may be covered. The distinct 
 advantages of a musculo-periosteal covering for the end of the bone are the 
 following; — (1) The muscles being adherent to the periosteum, when a 
 covering of the latter is stitched over the bone, a thicker and more fixed 
 covering to the end of the bone is secured than could be otherwise attained: 
 — (2) The end of the bone being covered by periosteum, adhesion of the 
 soft parts to the end of the bone is far less likely, the parts covering the bone 
 generally remaining freely movable, and are, therefore, both better nourished 
 and are less likely to become painful; — (3) The medullary cavity of the bone 
 being shut off by the musculo-periosteal covering, is much less apt to become 
 involved in any septic process which may arise in the stump. The only 
 objections which can be raised to a musculo-periosteal covering are the 
 time and trouble involved — which should not be allowed to weigh against 
 the practical advantages — nor should the possible formation of osteophytes and 
 proliferation of bone from the turned-over periosteum be seriously regarded. 
 
 Manner of Providing Musculo-periosteal Covering in all Forms 
 of Circular Amputation, and in all Double-flap Amputations Cut from 
 Without Inward. — The surgeon should plan to have his knife pass through 
 the deep layer of muscles surrounding the bone in such a way as to come 
 down through these muscles and upon the periosteum without separating 
 muscles from periosteum (which would also detach the vascular supply 
 of the periosteum), and at such a level on the bone below the saw-line as to 
 equal a full half-diameter of the bone at the saw-line. In circular amputa- 
 tions this final cut will pass transversely through the muscles, — in flap ampu- 
 tations, obliquely through, in the process of beveling. As soon as the peri- 
 osteum is reached in this final incision, all the soft parts are carefully retracted 
 around the whole circumference of bone at this level, especial care being 
 taken not to use force in the retraction, thereby separating muscle from 
 periosteum by dragging the former off of the latter. A circular incision 
 is now made through the periosteum around the entire circumference of 
 bone, at the level of the lightly retracted muscles — cutting the periosteum 
 with especial firmness where closely bound to the lineae aspera?. The peri- 
 
 !9 
 
290 
 
 AMPUTATIONS. 
 
 osteum is then detached back to the line of the future saw-cut, by means of 
 a periosteal elevator — care being exercised not to push the muscles off the 
 periosteum, but to push the periosteum back from the bone with the muscles 
 attached (Fig. 285). 
 
 In Flap Amputations by Transfixion. — The knife should be entered just 
 far enough below the saw-line to equal a full half-diameter, or more, of bone at 
 the sawdine. When the flaps are cut, the periosteum is divided circularly 
 at this level — and then the periosteum and muscles are detached back to 
 
 Fig. 285.— Raising a Musculo-periosteal Covering — in the circular method of amputation. 
 
 the sawdine — or the periosteum may be raised as two small flaps, their 
 incision beginning at the sawdine (Fig. 286). 
 
 In Oval and Racket Modifications of the Circular Amputation. — 
 The freeing back of the muscles should be stopped at a level equal to a full 
 half-diameter, or more, of the bone below the saw-line — the periosteum is 
 here circularly divided — and the periosteum and muscles detached thence 
 back to the saw-line. 
 
 In Single-flap Amputations of Skin and Muscle. — The knife comes 
 down upon the bone one full diameter, or more, of bone below the saw-line. As 
 the two vertical limbs of the flap have been cut down to the periosteum in the 
 earlier part of the operation, a musculo-periosteal flap is now marked out, 
 having a base equal to half the circumference of the bone at the saw-line 
 and a length equal to one full diameter, or more, of the bone at the saw-line. 
 The periosteum and muscles are now detached back to the line of bone-section 
 — all the hitherto undisturbed parts on the opposite side of the limb are 
 now divided transversely to the bone — and the bone sawed. 
 
 In Flap Amputations of Skin Only. — As the muscles are here divided 
 circularly, the musculo-periosteal flap is provided for just as in the ordinary 
 circular amputation. 
 
 In the Elliptical Modification of the Single-flap Method. — The 
 musculo-periosteal covering is handled as in the single flap of skin and muscle. 
 
 In Unequal Rectangular Flaps of Skin and Muscle (Teale's Method). 
 — The musculo-periosteal covering is secured as in amputation by unequal 
 flaps of skin and muscle. 
 
 In Amputating Limbs with Two Bones. — The musculo-periosteal 
 covering for the larger bone is provided as described in the single-bone limbs. 
 
MAKING MUSCULO-PERIOSTEAL COVERING. 291 
 
 The musculo-periosteal covering for the smaller bone is provided in the 
 same manner, but will be cut at a higher level (as it is circularly divided, or 
 a flap is cut, which will be equivalent to the smaller diameter of the smaller 
 bone). Where the bones are of the same size, the periosteum is divided 
 at the same level in each case — which may also be done when the bones 
 are of unequal size, the redundancy of periosteum in the case of the smaller 
 bone being subsequently removed with scissors, if necessary. 
 
 Fig. 286.— Raising a Musculo-periosteal Covering— in the flap method of amputating. 
 
 Note. — The final treatment of the periosteal covering cannot be carried 
 out until after the division of bone. 
 
 Comment. — (1) It will be seen that in circular amputations and in ampu- 
 tations by double flaps, the musculo-periosteal covering is furnished from 
 the entire circumference of the bone — while in amputations by single flaps, 
 a single flap of musculo-periosteal tissue is raised, the width of which is 
 equal to a half-circumference of bone and a length equal to a diameter of 
 bone. (2) As there is comparatively little retraction of fibrous periosteal 
 tissue, the chief retraction taking place in the attached and overlying muscles, 
 a length for the musculo-periosteal covering of one full diameter of the bone 
 (each side of the bone hereby furnishing one-half diameter) will, therefore, 
 cover the end of the bone, but none too fully — so that this measurement 
 should be made very full. (3) Where it is difficult to detach the musculo- 
 periosteal covering backward after simply a circular division of the periosteum, 
 two vertical incisions may be made upon the lateral aspects of the bone, 
 from the site of the saw-line to join the circular cut — which will make the 
 detachment easier. These vertical incisions may, indeed, be made in aD 
 cases. Even where the vertical incisions are not made in detaching the 
 periosteum, they may be subsequently made before adjusting the periosteal 
 flaps or covering. In the pure flap amputations the muscles have already 
 been divided to the periosteum, so that the knife easily makes the two vertical 
 incisions in the periosteum. In the circular amputation where it is necessary 
 to add the vertical cuts before sawing the bone (that is, in order to reach the 
 saw line), the point of the knife may be pushed into the transversely divided 
 muscles, in the long axis of the limb, up to the saw-line (which will lie only 
 a half-diameter of the bone above) and cut downward thence to join the 
 circular cut. (4) In the case of the two-bone limbs, the interosseous mem- 
 brane is also freed back in the act of detaching the periosteum. (5) Some 
 hold that the periosteal covering is without value in the adult and actually 
 harmful in the young, owing to the possibility of reproduction of bone render- 
 
292 
 
 AMPUTATIONS. 
 
 ing the stump conical. The former is an error of observation. The latter 
 must be very rare, the epiphysis being responsible for the chief increase of 
 length of bone. 
 
 Fig. 287.— Retraction of Soft Parts Preparatory to Sawing of Bone— in the case of a 
 single-bone limb. A single-tail retractor is shown above. 
 
 RETRACTION OF SOFT PARTS PREPARATORY TO SAWING THE 
 
 BONE. 
 
 All the soft parts overlying the bone having now been divided, from skin 
 to periosteum, these soft parts are to be retracted above and out of 
 
 the way of the saw- 
 line, which should be 
 seen to be clear in its 
 entire circumference 
 before making the 
 bone-section. 
 
 In Si ngle-bone 
 Limbs. — A double- 
 tailed linen retractor 
 is generally used to 
 hold the soft parts 
 back — the two tails 
 of the retractor pass- 
 ing around the bone, 
 thus supporting the 
 soft parts and drawing 
 them upward and out 
 of the way (Fig. 287). 
 In Double -bone 
 Limbs. — A three-tailed linen retractor is usually used — the central tail pass- 
 ing between the bones — the outer of the other two tails on the outer side of 
 the outer bone, and the inner on the inner side of the inner bone (Fig. 288). 
 Comment.- — The parts may also be retracted by the hands, or by various 
 forms of metallic or other retractors, such as Cooper's retractors (Fig. 289). 
 
 SAWING THE BONE, OR BONES. 
 
 General Considerations. — The surgeon, standing to the outer side 
 of right limbs and to the inner side of left limbs, grasps the limb firmly with 
 
 Fig. 288.— Retraction of Soft Parts Preparatory to 
 Sawing of Bone — in the case of a double-bone limb. A double- 
 tail retractor is shown above. 
 
SAWING THE BONE, OR BONES. 
 
 2 93 
 
 his left hand just above the saw-line. An assistant supports the distal portion 
 of the limb, holding it out over the side of the table, and on an exact line 
 with the level at which the limb leaves the trunk, in the case of the arm and 
 thigh; and on a level with the surgeon's left hand in the case of the forearm 
 
 Fig. 28q. — Cooper's Metallic Amputation Retractors. 
 
 and leg. If he elevates it above the common level, he will bind the surgeon's 
 saw throughout the entire transverse section (because the parallel walls of 
 the section will tend to approximate), — and if he depresses it below the common 
 level, while he makes it easier for the surgeon to saw, he is apt to splinter 
 the bone just before the section is completed (because the parallel walls of 
 the section will tend to diverge). 
 
 Fig. 290.— Manner of Sawing the Bone — in the case of a single-bone limb. 
 
 In Single-bone Limbs. — The surgeon places the edge of his thumb- 
 nail down upon the bone immediately above the saw-line, as a guide to the 
 saw, temporarily loosening but not entirely relaxing his steadying hold with 
 the other fingers and palm upon the limb. Holding an ordinary amputating 
 saw in his right hand, he deliberately places its heel against his thumb and 
 knuckles, and directly over the saw-line — and, with a fairly slow but firm 
 and steadv movement, he draws the saw backward from heel to point, thus 
 grooving the bone transversely. If this groove be not distinct or deep enough, 
 
294 
 
 AMPUTATIONS. 
 
 the first movement (from heel to point) may be repeated. The surgeon 
 now resumes his steadying grasp of the limb with his left hand and proceeds 
 to saw the bone by slow, even, steady, back-and-forth strokes of the saw, 
 traveling the entire length of the saw-blade at each stroke — and avoiding 
 uneven and too rapid sawing, the latter sometimes generating a harmful 
 degree of heat. It is during the section of the latter part of the bone that 
 the assistant is most careful in his manner of holding the limb and the surgeon 
 in his use of the saw. Toward the last the strokes of the saw should be 
 slower, shorter, and lighter, and the limb so balanced that there will be no 
 cross-strain anywhere throughout its length — and thus are the chances of 
 splintering minimized. If indicated, the larger saw may be removed toward 
 the last and the section be completed with a lighter, finer saw, but this is 
 ordinarily unnecessary. As the bones of both single-bone limbs are nearly 
 circular, no beveling of the edges is needed (Fig. 290) . 
 
 In Double-bone Limbs. — The general manipulative method is here 
 the same as in the single-bone limbs. The saw first engages the heavier 
 bone, and, having passed partly through this, is dropped upon the lighter 
 or more movable bone — the section of which latter bone should be first com- 
 pleted, the saw all the while cutting the heavier bone also, which it finally 
 completes alone. Where both bones are of the same size (as the middle 
 of the forearm), the saw grooves the one nearer the operator and is then 
 
 dropped upon the farther one. 
 Where a bone presents a promi- 
 nent ridge, almost or quite sub- 
 cutaneous (as the anterior border 
 of the tibia), this would become 
 an angular projection after sec- 
 tion of the bone and would be 
 apt to become a prominent point 
 of pressure. To avoid this, this 
 edge of bone should be beveled — 
 which is best done by making an 
 oblique saw-cut from above down- 
 ward, beginning about 1.3 cm. (£ 
 inch) above the saw-line and pass- 
 ing obliquely into the bone at such 
 an angle as to be about 6 or 8 mm. (j or ^ inch) below the level of the bone by the 
 time it has reached the saw-line. Having made this 1.3 cm. (^ inch) oblique 
 saw-cut into the bone, the saw is then withdrawn and is made to traverse 
 the bone transversely along the line of bone-section in the ordinary manner. 
 When the saw, traveling transversely, reaches the short oblique section, 
 the small triangle of bone will drop out — and when the section is completed, 
 the prominent edge of the bone will be found beveled (Fig. 291). 
 
 Comment. — In the very young, and especially in amputating those bones 
 which grow chiefly from an upper epiphysis, it is well to saw the bone as high 
 as possible — as subsequent growth from such bones may require reamputation. 
 
 Fig. 291. — Manner of Sawing the Bones — 
 in the case of a double-bone limb. The method of 
 beveling a prominent margin of bone is also here 
 shown. 
 
 REMOVING SPLINTERED BONE. 
 
 If, in the final saw-section, whether by splintering or a transverse snapping 
 of the frail bridge of bone, a fragment of bone is left projecting from the 
 stump, or any other projecting irregularity should appear upon the trans- 
 versely divided bone, this should be removed down to a level with the face 
 of the bone. This is accomplished by grasping the spicula of bone with 
 
LIGATIXG ARTERIES AXD VEINS. 295 
 
 bone-holding forceps (such as the lion-jaw type) and steadying it, while the 
 surgeon removes the spicula with a small, fine saw (Fig. 292). 
 
 Comment. — (1) Bony projections are often crudely crushed off with 
 bone-cutting forceps — this is quickly done and is a temptation — but is not 
 to be recommended, as necrosis of the margin of the bone is more apt to 
 follow crushing than sawing. (2) The splinter of bone may be upon the 
 
 292.-MANXER of Removing a Piece of Splintered Bone. 
 
 portion of bone removed — there will then be a corresponding depression, 
 with probably a tearing of periosteum and muscles, upon the bone in the 
 stump — which may require to be evened off. 
 
 LIGATING ARTERIES AND VEINS. 
 
 As soon as the bone has been sawed, all the chief arteries and the larger 
 veins should be tied. The arteries are tied in the order of their importance 
 and are sought in their known positions. They have frequently retracted 
 somewhat, so as to be out of sight, and are to be traced by their known rela- 
 tions. The stump should be held in a good position and light — and, if 
 necessary, dried of blood. The cut ends of the arteries are caught by catch- 
 forceps and drawn out of their beds by the surgeon — while an assistant 
 ligates the larger vessels with chromic catgut, tying them with a surgeon's 
 knot. The larger arteries may be tied with the stay-knot of Edmunds and 
 Ballance (page 24). All the vessels should be clamped before any are tied. 
 The larger arteries should be drawn out of their sheath before being tied. 
 The smaller arteries with their sheaths may be included in the ligature. 
 Arteries which are caught with difficulty with catch-forceps may be taken 
 up with a tenaculum. Very small vessels may be compressed or twisted 
 without ligaturing. The chief veins should be tied — as well as any others 
 which are seen gaping. All vessels should be tied as long as possible — and 
 should be disturbed in their sheath as little as possible. Arteries bleeding 
 from their osseous canals in the end of the bone cannot be tied, but may be 
 controlled by plugging the vascular canal with a piece of catgut, a piece of 
 sterilized wood, or with Horsley's antiseptic wax, or Halsted's gut-wool — 
 
296 
 
 AMPUTATIONS. 
 
 or a limited portion of the canal may be crushed in upon itself. After all 
 known vessels are tied, the Esmarch, or other constrictor, should be relaxed 
 and all hitherto untied vessels which now bleed are to be ligated (Fig. 293, A, 
 B, and C). 
 
 Comment. — (1) See that the first knot (friction-knot) does not loosen 
 before the second knot (surgeon's knot) is complete — and that the knot is 
 far enough from the end of the vessel not to slip off. (2) Where hemorrhage 
 
 Fig. 293.— Stump after Amputating through Lower Part of Right Leg: — A, Ligation of 
 anterior tibial artery; B, Clamping of posterior tibial artery; C, Plugging vascular canal of bone 
 with piece of catgut ; D, Cutting off tag of peroneus longus ; E, Cutting anterior tibial nerve short. 
 
 is apprehended, vessels may be taken up immediately after dividing the 
 soft parts, and before even severing the bone. Instead of taking up and 
 tying the vessels seriatim, they may be immediately clamped, one after another, 
 and, if not tied at once, the catch-forceps may be retracted with the flaps, 
 or with the circular division of soft parts, and the bone sawed, after which the 
 vessels are tied — relaxing the original hold where vessel and sheath are in- 
 cluded and taking up vessel alone. (3) Obstinate oozing may generally be 
 
SUTURING OF MUSCULO-PERIOSTEAL COVERING. 297 
 
 controlled by ligating en masse — or by douching with hot saline solution, or 
 by pressure. This is the form of hemorrhage which is more apt to occur 
 after the removal of the constrictor. 
 
 TREATMENT OF NERVES, TENDONS, AND TAGS OF MUSCLE, FASCIA, 
 
 AND SKIN. 
 
 (1) All nerves should be cut as short as possible, to avoid entanglement 
 and pressure in the process of cicatrization — to accomplish which they should 
 be caught bv forceps and drawn well out and then cut with scissors and 
 allowed to retract out of sight. Where the flap method has been done and 
 it is likely that an important nerve may be subjected to pressure when the 
 flaps are bent and sutured over the end of the bone, the nerve should be dis- 
 sected out. This is especially the case in the method of single-flap ampu- 
 tation. Nerve ends are apt to become bulbous in any event, but will not 
 be troublesome unless subjected to pressure. (2) All tendons should be 
 caught with forceps, steadied, and cut short under slight tension. They are 
 difficult to cut unless steadily held and slightly stretched — when they may 
 be cut with scissors or a very sharp knife. Tendon-ends possess low vitality, 
 are apt to slough, fulfil no useful purpose in the stump, and make but poor 
 covering. (3) All tags and irregularities of muscle, fascia, and skin should 
 be evenlv trimmed, so as to conform with the general contour. (Fig. 293, 
 E and D.) 
 
 TRIMMING OF FLAPS. 
 
 It is undesirable, and somewhat unsurgical, to make a miscalculation in 
 the length or contour of a flap, which will require any subsequent trimming 
 ■ — but where a flap is distinctly too long, or too large, or misshapen, it is 
 better to do the trimming necessary to make a good fit than to suture it in 
 place as it is. It is held in the left hand, or caught with forceps, and trimmed 
 as one would trim a piece of paper. A flap may be trimmed as a whole — or 
 some individual tissue composing it may be trimmed. 
 
 RE-AMPUTATION FOR IMPROPERLY MADE FLAPS. 
 It is even more unsurgical, and much more difficult to rectify, to find 
 that so little allowance of covering has been made that the end of the bone 
 either cannot be covered at all, or cannot be covered without a degree of 
 tension calculated to endanger the flaps. In such a case all that one can 
 do is to amputate at a higher level. If only a slight deficiency of covering 
 exist, the end of the bone may be freed of its soft parts by retraction and 
 made to project and then be removed by the saw. Where the deficiency is 
 greater, from one to several inches of the soft parts may also have to be re- 
 moved, as well as the bone. In such a case one proceeds very much as in 
 the original operation, modified by the needs. 
 
 ADJUSTMENT AND SUTURING OF MUSCULO-PERIOSTEAL OR 
 PERIOSTEO-CAPSULAR COVERING. 
 
 The first step in the closure of the stump-tissues is the adjustment of the 
 musculo-periosteal covering. It will be remembered that in all circular 
 amputations, and in all double-flap amputations of skin and muscle, the 
 
298 AMPUTATIONS. 
 
 musculo-periosteal covering was made by a circular division of the periosteum 
 around the bone one-half of a full diameter of the bone below the saw-line 
 (thus furnishing a full diameter), and that the periosteum, with adherent 
 muscles, was then detached in one layer up to the saw-line. Therefore, 
 after the bone is sawed and the soft parts drop down around its cut end, 
 the musculo-periosteal covering will form a hollow cylinder projecting from 
 the lower surface of the transversely sawed bone — the periosteum hanging 
 down around the bone for a depth, approximately, of a half diameter of the 
 bone, the muscles being adherent to its outer side. This cuff of musculo- 
 periosteal covering may be converted into two small flaps by cutting along 
 its lateral aspects with straight-pointed scissors, from its lower free margins 
 up to the bone. The corners of these little flaps may then be slightly rounded, 
 though this is not necessary. These two flaps are then dropped over the 
 end of the bone and their edges are sutured together with catgut, the sutures 
 passing through periosteum and muscles. While the above method makes 
 a neater fit, it is not really necessary that the musculo-periosteal covering 
 
 should be slit up at all on the 
 sides — it suffices simply to ap- 
 proximate the edges over the 
 bone by a suture running either 
 antero-posteriorly or trans- 
 versely. Where the musculo- 
 periosteal covering has been 
 raised in the form of a single 
 flap (as in the amputation by a 
 single flap), this single flap of 
 musculo-periosteal covering is 
 dropped over the end of the 
 bone and its margins sutured 
 to the cut margins of the peri- 
 osteum around the rest of the 
 ering. circumference of bone, including 
 
 the muscle overlying the perios- 
 teum. Where the bone-section is very small, it is often difficult to adopt 
 any definite plan of making and suturing a musculo-periosteal flap, the per- 
 iosteum being torn in shreds in the process of detachment. In such cases 
 the mass of musculo-periosteal tissue is simply gathered together and sutured 
 over the end of the bone. (Figs. 294 and 302.) 
 
 QUILTING OF MUSCLES. 
 
 The muscle tissue which enters into the covering of the bone should, 
 where possible, be approximated and sutured into apposition by buried 
 chromic gut sutures, placed in one or more tiers, by means of either buried 
 simple sutures, or buried quilt- or mattress-sutures. Thus the cut aspects 
 of the muscles are brought into contact, — less tendency for them to retract 
 away from the end of the bone occurs, — in the process of cicatrization they 
 become incorporated in the general pad of covering which forms the stump 
 (even though the muscle tissue itself may be subsequently replaced by fibrous 
 tissue), — there is less chance of adhesions forming between bone and skin, — 
 and, altogether, a fuller, softer, better-formed pad of covering is provided. 
 These advantages more than counterbalance the only two disadvantages — 
 namely, of time and trouble involved. By the process of quilting, muscles 
 
QUILTING OF MUSCLES. 
 
 299 
 
 Fig.295.-Qu11.TiNG of Muscles in Circular 
 Method of Amputation: — First tier of sutures 
 has been placed — and is being buried by the second 
 tier. 
 
 are brought and held in contact until united, which, in the ordinary method 
 of simply dropping muscles over the ends of the bones and depending upon 
 the single line of marginal skin-sutures to approximate, either could not be 
 made to come into contact even temporarily, or, if so, would generally retract 
 apart before union. 
 
 In Circular (Infundibuliform Variety), Modified Circular, Oval, 
 and Racket Methods. — After su- 
 turing the musculo-periosteal cover- 
 ing the muscle surfaces are brought 
 into contact immediately over the 
 musculo-periosteally covered end of 
 bone. The approximation of mus- 
 cle tissue over the bone may be 
 made in the way in which the mus- 
 cles most naturally fall. Other 
 things being equal, the approxima- 
 tion should be made so as to cause 
 the suture line to be parallel with 
 the future suture line of the integu- 
 mentary coverings. The first tier 
 of sutures is placed nearer the bone, 
 entering and leaving the muscle tis- 
 sue at such a distance from the 
 bone as to secure an easy ap- 
 proximation of the muscle substance 
 
 over the end of bone. This first row of sutures, which, if of the simple 
 form, may be either interrupted or continuous, will conceal the end of the 
 bone. A second tier, especially in heavily muscled limbs, or in thin 
 
 limbs with large muscle 
 flaps, should be applied 
 —being inserted nearer 
 the edge of the muscle 
 tissue than the first — 
 and, when tied, will hide 
 the first row (Fig. 295). 
 In Circular 
 Method a La Man- 
 chette. — As the mus- 
 cles are here all divided 
 on one level, and that 
 '\ level is that of the re- 
 
 tracted skin, skin and 
 fascia alone cover the 
 end of the bone, and 
 no approximation and 
 quilting of the muscles 
 are possible. 
 In All Double-flap Amputations of Skin and Muscle. — The muscles 
 are quilted in the same manner as in the ordinary circular (infundibuli- 
 form), the process of muscle-quilting being easier in the double-flap 
 method than in the ordinary circular, as the muscles are adherent to the 
 flaps on either side and are more readily held in approximation while being 
 quilted (Fig. 296). 
 
 Fig. 296.— Quilting of Muscles in Flap Method of Ampu- 
 tation : — First tier of buried sutures has been placed and tied — 
 and second tier is being placed. 
 
300 AMPUTATIONS. 
 
 In All Double Flaps of Skin. — No quilting of muscles is here possible 
 — as the muscles are transversely divided on a level with the retracted skin- 
 flaps. 
 
 In All Single Flaps of Skin and Muscle, Including the Elliptical 
 Method. — As the muscles are here divided obliquely on the side of the flap, 
 and transversely on the opposite side, the quilting of muscles is not done 
 as in the above-described methods (where the lateral aspects of the muscles 
 are sutured to lateral aspect, or ends to ends). The lateral aspect of the 
 muscles in the present instance, some of which aspect is made up by the 
 obliquely beveled muscles, is sutured to the transversely divided muscles 
 on the side of the limb opposite to the flap — and the ends of the muscles in 
 the flap are sutured to the circumferential margin of the transversely divided 
 muscles in the stump. As the base of the flap comes from a full half-cir- 
 cumference of the limb, the bent-over flap is only approximated to the opposite 
 half of the face of the stump. Where the elliptical method is used in the 
 neighborhood of an articulation (that is, in a disarticulation) where only 
 tendons pass over and cover the joint, no quilting is possible. It is, therefore, 
 applicable only where muscles cover bones, which, in the case of the joints, is 
 only at the shoulder and hip. 
 
 DRAINAGE. 
 
 No drainage is necessary in amputating through sound tissue in the 
 continuity of a limb. Temporary drainage (for two or three days) may be 
 instituted in disarticulating through the larger joints — to provide for the 
 escape of the synovial fluid which the remaining synovial surfaces will go 
 on secreting for a time. Where drainage is indicated, it is sometimes better 
 to make a counter-opening than to attempt to drain through a non-dependent 
 suture-line. Drainage may be temporarily used where bleeding in the 
 stump-tissues is feared after prolonged use of an Esmarch, or for other reason. 
 Drains of rubber-tubing, glass, gauze, or bone-tube may be used. 
 
 SUTURING OF THE STUMP. 
 
 The suturing of the edges of the wound should be done with silk and by 
 means of interrupted sutures. Where no great tension is likely to occur, 
 silkworm-gut may be used. Catgut is also employed. The parts should 
 come together without tension. The interrupted is to be preferred to the 
 continuous form of suturing, for the parts may be thereby more accurately 
 adjusted — and if it become necessary to open any part of the wound for 
 drainage, or other cause, only the few indicated sutures need be cut. 
 
 In Circular Amputations. — It is optional with the operator as to whether 
 the soft parts are so approximated as to result in a line of sutures running 
 from before backward, or from side to side. The former is to be preferred, 
 as the lower end of the suture-line (in the recumbent position of the patient) 
 drains the wound by gravity, in case drainage be necessary. Where skin 
 and muscle come evenly to the edge of the wound, both are included in the 
 sutures. Where skin is longer than muscle, the sutures which close the 
 wound pass through skin only — the muscles having been approximated by 
 their own buried sutures. 
 
 In Flap Amputations. — Here the direction of the line of sutures will be 
 determined by the position of the flaps. Where double flaps are taken 
 from the anterior and posterior aspects of a limb, the suture-line will run 
 
THE EVOLUTION OF AMPUTATION METHODS. 301 
 
 from side to side. Where double flaps are taken from the lateral aspects 
 the suture-line will be antero-posterior. Where a single flap is approximated 
 to the opposite side of the limb, its margin is sutured to the opposite half- 
 circumference. Where the margin of the flaps is composed of skin and 
 muscle, both are included in the sutures. Where the skin is longer than the 
 muscle, the skin alone is included in the suturing. In all cases the muscle 
 surfaces are supposed to have been quilted together prior to the final closure 
 of the wound. 
 
 Comment. — (1) Owing to the difficulty of equally dividing out the posi- 
 tions for sutures where a large wound is to be brought together, it is well 
 to begin by putting in a central suture and then divide each remaining half 
 of the space into quarters by two other sutures — then these smaller lengths 
 can be sutured with interrupted or continuous suture — the former being 
 better, as, in case it be necessary to loosen any suture for suppuration, or 
 otherwise, the entire line need not be loosened. (2) If tension upon the 
 edges be great, a few tension-sutures mav be used. 
 
 DRESSING OF THE WOUND. 
 
 The wound and stump should be covered with absorbent gauze — the 
 entire stump enveloped in absorbent cotton — which should be snugly bandaged 
 to the end of the stump and the circumference of the limb. A padded poste- 
 rior splint should be incorporated in the outer layers of the dressing, pro- 
 jecting beyond the stump slightly — both to support the part; protect it from 
 injury; and control, or lessen, the muscular startings which are apt to occur. 
 The stump should rest upon an inclined plane, outside of bed-covering. 
 
 REMOVAL OF DRESSINGS. 
 
 If all goes well, the dressings are not removed until about the tenth day 
 (or from the tenth to the fourteenth). If a drainage-tube be used, the dress- 
 ings are often changed when that is withdrawn — although it is sometimes 
 withdrawn at the end of the second or third day — and the dressings not 
 removed until the usual time. 
 
 THE METHODS OF AMPUTATION. 
 THE EVOLUTION OF AMPUTATION METHODS. 
 
 The methods of amputation have undergone a slow process of evolution 
 — which may be briefly stated in the following tabular form (modified from 
 Kocher). 
 
 Circular Incision. — The fundamental type of amputation. Of which 
 there are two varieties, and from which all other methods of amputation 
 may be derived; — (a) Transverse circular incision (Fig. 297, A); (b) Oblique 
 circular incision (Fig. 297, B). 
 
 Racket Incision. — Formed by the addition of a longitudinal incision 
 to the circular incision, (a) If the longitudinal incision be added to the 
 transverse circular incision, the transverse racket incision results (Fig. 297, 
 C); (b) If the longitudinal incision be added to the oblique circular incision, 
 the oblique racket incision results (Fig. 297, D). Xote — The corners of the 
 
302 AMPUTATIONS. 
 
 racket incision are now generally rounded off, as in the oval method, the 
 
 Fig.297.— The Evolution of Amputation Methods: — I — A, Transverse circular incision; B, 
 Oblique circular incision; C, Transverse racket incision; D, Oblique racket incision. (Modified 
 from Kocher.) 
 
 only practical difference between the two, as now usually employed, being 
 that the queue is made longer in the racket method. 
 
 Oval Incision. — Formed by the shortening of the queue and the rounding- 
 
 Fig. 298.— The Evolution of Amputation Methods : — II— A, Transverse oval incision ; 
 B, Oblique oval incision; C, Equal rectangular flaps; D, Unequal rectangular flaps. (Modified 
 from Kocher.) 
 
 off of the angles of the racket incision, (a) If the angles of the transverse 
 racket incision be rounded, the transverse oval incision results (Fig. 298, A); 
 
 Fig. 299.— The Evolution of Amputation Methods: — III — A, Equal rounded flaps ; B, Unequal 
 rounded flaps. (Modified from Kocher.) 
 
 (b) If the angles of the oblique racket incision be rounded off, the oblique oval 
 incision results (Fig. 298, B). 
 
ORDINARY CIRCULAR AMPUTATION. 303 
 
 Rectangular Flaps. — Formed by adding two longitudinal incisions to the 
 circular incision, (a) If the two longitudinal incisions be added to the circular 
 incision, equal rectangular flaps result (Fig. 298, C) ; (b) If they be added to 
 the oblique circular incision, unequal rectangular flaps result (Fig. 298, D). 
 
 Rounded Flaps. — Formed by rounding the angles of the rectangular 
 flaps, (a) If the angles of equal rectangular flaps be rounded, equal rounded 
 flaps result (Fig. 299, A) ; (b) If the angles of unequal rectangular flaps be 
 rounded, unequal rounded flaps result (Fig. 299, B). 
 
 Elliptical Method. — The position of this method, in the process of evo 
 lution, will be described further on (page 315). 
 
 SUMMARY OF AMPUTATION METHODS. 
 
 Fundamental Types. — Circular Method; Flap Method. 
 
 Modern Types. — (a) Circular and its modifications; (b) Flap and its 
 modifications; (c) Irregular methods of amputation. 
 
 As to Nature of Covering of Stump. — All methods of amputation 
 are either — (a) Skin Coverings — that is, skin and fascia alone cover the 
 divided muscles and bone, as in the cuff method of the circular amputation, 
 and in the simple skin-flap in the flap method of amputation; — or (b) Skin- 
 and-muscle Coverings — where skin, fascia, and muscles, combined and un- 
 separated, including the periosteum, cover the end of the bone, as in the 
 ordinary (infundibuliform) circular amputation, and in flaps of skin and 
 muscle in the flap method of amputation. 
 
 CIRCULAR METHODS OF AMPUTATING. 
 
 (a) Ordinary Circular Method — (amputation circulaire infundibuli- 
 forme); — (b) Cuff Method of Circular Amputation — (amputation a la nian- 
 chette); — (c) Modified Circular Method of Amputation — (mixed method); — 
 (d) Oval (or Lanceolate) Method;— (e) Racket Method. 
 
 ORDINARY CIRCULAR AMPUTATION. 
 
 (AMPUTATION CIRCULAIRE INFUNDIBULIFORME). 
 
 General Description. — The soft parts are divided by a series of circular 
 cuts, retraction of the parts taking place between each circular sweep of the 
 knife, so that they are cut partly through at different levels — the sawed bone 
 forming the apex of the funnel left upon the proximal end of the limb, and 
 the skin margin the base — the distal part removed being cone-shaped. 
 
 Technic. — Stand to outer side of right and inner side of left limbs, so 
 as to grasp limb between trunk and amputation-site. Determine the saw- 
 line. Fix the skin incision at a level below the saw-line equal to \ of ih 
 times the diameter of the limb (or three-fourths of that diameter) at the 
 saw-line (that is, at 11.5 cm., or 4J inches, below the saw-line, if the diam- 
 eter of the limb at the saw-line be 15.3 cm., or 6 inches) (Fig. 300, A). 
 Grasp the limb just above the line of the skin incision with the left 
 hand and retract the skin upward, aided, if the limb be large, by an 
 assistant. With a long knife, make a circular incision, at the skin-incision 
 line, through skin and superficial fascia, entirely around the limb. Free 
 skin with its superficial fascia from the muscles with their deep fascia, aiding 
 
3°4 
 
 AMPUTATIONS. 
 
 the separation in the interfascial line by touches with a scalpel, where neces- 
 sary. Retract the skin and fascia evenly around the circumference of the 
 limb. Divide the more superficial layer of muscles circularly, on a level 
 with the retracted skin. Retract this more superficial layer of muscles. 
 Divide the remaining deeper muscles circularly on a level with the retracted 
 outer layer of muscles — and planning to come down upon the bone, or 
 bones, far enough below the saw-line to allow of making a musculo-periosteal 
 covering for the bone or bones. Retract the deeper muscles thus cut. Divide 
 with a stout knife, the periosteum circularly around the bone, or bones, at a 
 distance below the saw-line equal to a good one-half diameter of the bone 
 
 Figs. 300 and 301.— Ordinary (Infundibular) Form of Circular Amputation : — A, Position 
 of incision and bone-section ; B, Resulting suture-line. The skin-incision and suture-line here are 
 also applicable to the cuff variety of the circular method. 
 
 at the saw-line. Push up the periosteum from the bone with periosteal 
 elevator — keeping the muscles adherent to the periosteum. Apply linen 
 (or other) retractors to the soft parts and draw them above the saw-line. 
 Saw the bone, or bones. If splintering occur, grasp the spicula with forceps 
 and remove with finer saw. Allow the soft parts to drop over the end of 
 bone, or bones, the sawed ends of which will form the apex of a funnel — 
 the bone being covered by periosteum — periosteum by muscle — and muscle 
 by fascia and skin (Fig. 302). Tie the vessels — cut the nerves and ten- 
 dons short — and remove any tags of connective tissue or skin. Suture 
 the musculo-periosteal covering over the end of bone, or bones. Quilt the 
 
CUFF METHOD OF CIRCULAR AMPUTATION. 
 
 3°5 
 
 muscles together in one or two layers. Suture the skin and fascia antero- 
 posterior!}' (Fig. 301, B) — and apply the dressing and supporting splint. 
 
 Resulting Stump. — Evenly covered on all sides by muscle and skin 
 — the bone being particularly well protected and on a higher level above the 
 surface of the stump than in any other 
 form of amputation. The scar is ter- 
 minal — antero-posterior, if the wound be 
 sutured from before backward, — lateral, 
 if sutured from side to side (Fig. 301, B). 
 
 Indications. — In limbs more or less 
 evenly surrounded by muscles: — lower 
 part of forearm (sometimes), arm, and 
 thigh. 
 
 Comment. — (1) Owing to unequal 
 skin retraction in some localities (as the 
 antero-internal aspect of the arm and 
 thigh) the circular incision may have to 
 be planned obliquely and only become 
 circular after the incision — and may also 
 have to be planned lower. (2) A pure 
 ordinary circular (infundibuliform) am- 
 putation is impossible in a limb of rap- 
 idly increasing girth, as it is impossible 
 to retract the soft parts. A single lateral 
 vertical incision through skin and fascia, 
 or double lateral incisions, may become 
 necessary in order to free the parts — 
 when it ceases to be a typical infundi- 
 buliform amputation. 
 
 Fig. 302.— Appearance of the Parts 
 Following the Infundibular Form of 
 Circular Amputation :— A funnel-shaped 
 cavity left proximally, and a cone-shaped 
 mass distallv. 
 
 CUFF METHOD OF CIRCULAR AMPUTATION 
 
 (CIRCULAR AMPUTATION A LA MANCHETTE). 
 
 General Description. — A circular division of the skin is made, which 
 is turned over and upward upon itself as a cuff — and, upon a level with this 
 retracted cuff of skin and fascia, the muscles are divided to the bone, generally 
 with one circular sweep of a long knife. 
 
 Technic. — The steps of the operation are similar to those of the ordinary 
 circular amputation (page 303) up to the completion of the circular incision 
 through the skin and superficial fascia. The skin and subcutaneous tissue 
 are then turned back upon themselves as a cuff — the freeing being done 
 by means of the fingers of the left hand, aided by touches of a scalpel, until 
 evenly retracted all around. On a level with the retracted cuff, the muscles 
 are circularly divided down to the bone — the site at which this division takes 
 place being such as will allow of ample and easy covering of the transversely 
 divided muscle by the skin and fascia — an average calculation being that 
 about one-third of the total distance from saw-line to line of skin incision 
 should be given to skin and fascia alone. The subsequent steps of the opera- 
 tion, including the musculo-periosteal covering for the bone, being the same 
 as for the ordinary, or infundibuliform, circular amputation. 
 
 Resulting Stump. — Apt to be more or less irregular in contour and not 
 so well padded, owing to the nature of the parts used for covering. The 
 scar lies as in the ordinary circular amputation (Fig. 301). 
 
306 
 
 AMPUTATIONS. 
 
 Indications. — Most frequently used where the soft coverings are more 
 tendinous than muscular: — wrist, lower part of forearm, ankle, and lower 
 part of leg (in thin subjects). 
 
 Comment. — (i) and (2) The same comments made under (1) and (2) 
 of the last operation apply equally here (page 305). (3) Owing to the greater 
 proportion of skin in this covering and the division of muscles in one layer, 
 as well as the number of tendons present in the sites where this method is 
 generally used, the covering of the bones is not so satisfactory as in the ordinary 
 circular method. 
 
 MODIFIED CIRCULAR AMPUTATION 
 
 (MIXED METHOD). 
 
 General Description. — Two equal flaps, composed of skin and fascia, 
 
 Figs. 303 and 304.— Modified Circular Method of Amputation: — A, Position of incision and 
 bone-section ; B, Resulting suture-line. 
 
 of varying length, and having bases equal to one-half of the circumference 
 of the limb at their upper ends, are cut and dissected up a short distance — 
 followed by a circular sweep of the knife through the retracted superficial 
 muscles — and by a second circular sweep at a higher level, through the re- 
 tracted deeper muscles — and completion of the operation as in the ordinary 
 circular amputation. 
 
 Technic. — Having fixed upon the saw-line, and having marked a point 
 below the saw-line equal to \ of ih diameters of the limb at the saw-line (that 
 
OVAL METHOD OF AMPUTATION. 307 
 
 is, three-fourths of the diameter at the saw-line), two equal flaps of skin and 
 fascia (of this length) are planned. These flaps have bases equal to 
 one-half the circumference of the limb at the level of their upper limit 
 — and their length will be equal to one-third or one-half of the total distance 
 between saw-line and lowest limit of skin-covering (generally one-third in 
 slender, ill-formed limbs, and often one-half in large, tapering limbs). The 
 flaps are usually lateral ones, but may be anterior or posterior (Fig. 303, A). 
 Retracting the skin with the left hand, begin the incision at one mid-lateral 
 aspect of the limb, at a level above the lowest limit of the skin incision equal to 
 one-third or one-half (as the case may be) of the distance between the saw-line 
 and the lowest limit of the skin incision — pass vertically downward, through 
 skin and fascia, until nearly at the level of the lowest skin incision — thence 
 round forward into the line of lowest skin incision, in a bluntly rounding 
 manner — and complete the opposite end of the same flap in the same manner. 
 Then make the opposite flap in the same way as the first one, corresponding 
 in shape and size. Dissect these flaps of skin and fascia back to just beyond 
 their bases. While the flaps, and the muscles also, are retracted, divide the 
 more superficial muscles circularly — retract these, and divide the deeper 
 muscles similarly — making the usual provision for the musculo-periosteal 
 covering. The operation is completed as in the ordinary circular ampu- 
 tation — the skin and fascial flaps being sewed over the quilted muscles — 
 the bone being at the apex of a funnel which is somewhat shallower than 
 in the infundibuliform variety of circular amputation (owing to the muscles 
 having been divided at a higher level). 
 
 Resulting Stump. — While not covering the end of the bone with quite 
 as thick a padding of soft parts, its general features are the same as those 
 following the ordinary circular method. The main part of the scar is terminal, 
 but its ends are apt to be partly lateral (Fig. 304, B). 
 
 Indications. — This is the form of circular amputation most generally 
 used and is adapted to a greater number of sites than the ordinary circular, 
 or the cuff modification of the ordinary method. 
 
 Comment. — (1) The skin-flaps may be cut of unequal lengths. (2) 
 The muscles may be divided at one level. (3) This form of circular ampu- 
 tation has largely replaced either of the other forms. 
 
 OVAL METHOD OF AMPUTATION. 
 
 General Description. — A modification of the circular method. The 
 skin incision is in the form of an oval, with one of its ends more prolonged 
 and pointed — the soft parts between skin and bone being divided by cutting 
 from without inward — and the lips of the wound being sutured in a single 
 line parallel with the long axis of the wound. 
 
 Technic. — This amputation being generally used in disarticulations, the 
 upper or pointed end of the oval usually begins just above a joint-line and 
 upon its outer or anterior aspect — the limbs of the oval parting at an angle 
 sufficient to include the head of the distal bone — and sweeping thence in 
 a curve down the lateral aspects of the limb — passing, finally, transversely 
 toward each other — to meet upon the inner or under surface of the distal 
 limb and at a distance beneath the line of articulation calculated to furnish 
 sufficient covering for the head of the proximal one of the bones making up the 
 joint (Fig. 305, A). Having completed the incision through skin and fascia, one 
 of two courses may then be adopted ; — (a) The incision may then be deepened 
 
308 
 
 AMPUTATIONS. 
 
 throughout direct to the bone, by cutting from without — the deep incision, 
 from the point where the arms or limbs of the oval begin to diverge, following 
 the line of the retracted skin. This is the general method in all of the smaller 
 
 disarticulations and in most of the larger, 
 (b) Or the joint may be opened by the 
 more vertical part of the incision and, after 
 disarticulation, the muscles may be cut 
 from within outward, on a line with the re- 
 tracted skin. Having tied the vessels and 
 cut the nerves and tendons short, the wound 
 is sutured in its long axis (Fig. 307, B). 
 
 Resulting Stump.— The end of the 
 bone is very fully covered except where 
 the head or articular end of the proximal 
 bone is disproportionately large. The scar 
 is termino-lateral (Fig. 307, B). 
 
 Indications. — A form of amputation 
 generally used for disarticulating a limb 
 from the trunk, or a smaller limb from 
 a larger limb. The method admits of 
 first opening the joint for investigation 
 before finally deciding upon amputation — 
 and it also admits of securing the vessels 
 before removing the limb. 
 
 Comment. — The suture-line may run 
 antero-posteriorly in one straight line — 
 or the free, lower convex border of the 
 flap may be turned over and sutured 
 to the upper angular concavity of the wound. 
 
 Fig. 305.— Oval Mkthod of Ampi 
 TATion : — A, Form and position of oval 
 B, Resulting suture-line. 
 
 RACKET METHOD OF 
 AMPUTATION. 
 
 General Description. — 
 A modification of the cir- 
 cular method. The same, 
 in principle, as the oval am- 
 putation — with the addition 
 of a longitudinal vertical cut 
 prolonged from the apex of 
 the oval forming the " han- 
 dle of a racket" — thus 
 giving a better exposure of 
 joints without sacrifice of 
 tissue and securing a better 
 covering for the bone in the 
 upper part of the wound. 
 
 Technic. — Practically 
 similar to the oval amputa- 
 tion, except that the queue 
 of the racket begins con- 
 siderably farther back over 
 
 Figs. 306 and 307.— Racket Method of Amputation: — A 
 Form and position of incision ; B, Resulting suture-line. 
 
AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. 309 
 
 the head of the proximal bone forming the joint — and along this single 
 straight line the knife travels some distance before the arms of the racket 
 begin to diverge. After the beginning of the divergence of the limbs of the 
 racket, the operation is completed as in the oval operation (Fig. 306, A). 
 
 Resulting Stump. — More satisfactory covering is secured by the racket 
 than by the oval method of amputating. The scar is termino-lateral (Fig. 
 307, B). 
 
 Indications. — Disarticulations of the shoulder- and hip-joints, and of 
 the digits from the hand and foot (especially, in the latter instances, where 
 a metatarsal or metacarpal bone is removed with the digit). As in the oval 
 method, but to a much greater extent, does the racket method admit of a pre- 
 liminary examination of the joint through the vertical portion of the incision, 
 before deciding upon amputation. The vessels may also be secured before 
 entirely separating the limb. The muscles in the stump are better preserved. 
 
 Comment. — (1) The queue of the racket should be placed, if possible, 
 over an intermuscular septum and be deepened in the septum. (2) Ampu- 
 tation by a T-shaped incision is, practically, a form of racket incision. (3) 
 The suture line may run antero-posteriorly (or from the outer to the inner 
 aspect of the part), which is to be preferred. Or the upper portion of the 
 queue may be sutured in this manner and the lower convex portion of the 
 flap brought up and sutured to the angular concavity formed by the di- 
 vergence of the lateral limbs of the racket. 
 
 FLAP METHODS OF AMPUTATING. 
 
 (a) Single Flap of Skin and Muscles; — (b) Single Flap of Skin; — (c) 
 Equal Flaps of Skin and Muscles; — (d) Equal Flaps of Skin; — (e) Unequal 
 Flaps of Skin and Muscles; — (f) Unequal Flaps of Skin; — (g) Elliptical 
 Method; — (h) Unequal Rectangular Flaps of Skin and Muscle. 
 
 AMPUTATION BY SINGLE FLAP OF SKIN AND MUSCLES. 
 
 General Description. — A method of amputating whereby the stump 
 is covered with a single flap derived from one aspect of a limb — and consists 
 of skin, fascia, and muscles. Such an amputation involves the maximum 
 sacrifice of bone. 
 
 Technic. — Having fixed upon the saw-line (or line of disarticulation), 
 a point is determined upon below this line, and on that aspect of the limb 
 which is to furnish the flap, which will represent a distance below the saw- 
 line equivalent to i| diameters of the limb at the saw-line. A flap is then 
 marked out with a base equal in width to a half-circumference of the limb 
 at the saw-line, and a length equal to i| diameters of the limb at that line. 
 (Fig. 308, A). Grasping the limb as in the ordinary circular amputation, the 
 knife is entered at the far upper end of the base of the flap, at a right angle to 
 the skin — and passes vertically down the mid-axis of the limb to near the lower 
 limit of the flap — where it forms a squarely or bluntly rounded corner to the flap 
 — thence passes transversely along the lower limit of the flap — and completes 
 the opposite limb of the flap symmetrically with the first limb. This incision 
 passes through skin and fascia. When this integumentary flap has retracted, 
 the muscles are cut obliquely on a line with its retracted edges, so directing 
 the knife as to bluntly bevel the muscular portion as the knife cuts its way 
 
3io 
 
 AMPUTATIONS. 
 
 from without inward and upward. This incision passes obliquely through all 
 the muscles and is planned to come down upon the bone at a distance beneath 
 the saw dine equivalent to a good diameter of the bone at the saw-line, thus 
 providing for a musculo-periosteal covering. The knife is then carried through 
 the periosteum so as to form a musculo-periosteal flap with a base of half 
 the bone at the sawdine and a length of once the diameter. The musculo- 
 periosteal covering is then detached back to the saw-line. Divide the hitherto 
 undisturbed soft parts on the opposite side of the limb by a circular sweep 
 of the knife — passing through the skin and fascia of the half-circumference 
 
 Figs. 308 and 309— Amputation by Single Flap of Skin and Muscle : — A, Form and position of 
 incisions ; B, Resulting suture-line. 
 
 a little below the level of the base of the single flap — and through the muscles 
 on a level with the base of that flap, including the periosteum. Retract all 
 the soft parts on the proximal side of the saw-line and divide the bone. Suture 
 the musculo-periosteal flap over the bone, the free edge of the periosteal 
 flap being sutured to the half-circumference of the opposite aspect of the 
 periosteum. Quilt the lateral and terminal aspects of the cut muscles in the 
 flap with the transversely cut ends of the muscles on the opposite side of the 
 limb. Suture the terminal and lateral aspects of the skin of the flap tc the 
 transversely divided skin of the opposite side. 
 
 Resulting Stump. — The stump is at first well covered with muscle — 
 and, when this atrophies, by the replacing fibrous tissue. The scar is lateral 
 (Fig. 309, B). 
 
AMPUTATION BY EQUAL FLAPS OF SKIN AND MUSCLE. 311 
 
 Indications. — Cases of injury so destroying the soft parts as to leave 
 those of but one aspect available. Also in such cases as Farabeuf's amputa- 
 tion of the upper third of the leg by a single external flap of skin and muscles, 
 or Dubreuil's disarticulation at the wrist by a single external flap of skin 
 and muscles. 
 
 Comment. — (1) In all flaps, skin must be longer than muscle. (2) 
 There is sometimes an excess of muscle in a flap, part of which should be 
 removed in the process of beveling — but a fully muscled flap is generally 
 desirable. (3) A flap of skin and muscle is more apt to live and makes a 
 better covering than one of skin alone. (4) While the muscle tissue as such 
 may not remain in the tissues of a stump, the muscle-fibers undergoing 
 atrophy, yet the fibrous tissue matting and padding together of the parts 
 is left in its place. (5) A single flap requires the maximum sacrifice of limb, 
 one side of the limb furnishing the entire covering and the bone being con- 
 sequently divided at a higher level. 
 
 AMPUTATION BY SINGLE FLAP OF SKIN. 
 
 General Description. — The features of this operation are practically 
 the same as those of the amputation by a single flap of skin and muscles, 
 except that the covering here consists entirely of skin. 
 
 Technic. — Having incised through skin and fascia, this integumentary 
 flap is dissected up from the muscles throughout, including all overlving 
 fascia, and is retracted above the saw-line (or disarticulation-line) — when 
 the bone is sawed or disarticulated, and the flap dropped over the end of 
 the limb — its terminal aspect being sutured to the transversely divided skin 
 of the opposite side. 
 
 Resulting Stump. — -Very thinly covered, but as the skin so utilized is 
 generally accustomed to pressure, the result is usually satisfactory. 
 
 Indications. — Such localities as the knee-joint (disarticulation by a 
 single anterior flap), or the elbow-joint (disarticulation by a single posterior 
 flap). 
 
 Comment. — (1) As this method is generally used in a disarticulation, a 
 capsulo-periosteal covering may sometimes be provided. (2) Nutrition of 
 a single flap of skin and muscle is more difficult to maintain than in the more 
 ordinary methods — and the nutrition of a flap of skin alone is even harder. 
 (3) Skin-flaps are more used now than formerly because, owing to rarer 
 suppuration, their vitality can be more counted upon. 
 
 AMPUTATION BY EQUAL FLAPS OF SKIN AND MUSCLE. 
 
 General Description. — Coverings for the stump are gotten from two 
 opposite aspects of the limb in the form of two flaps composed of all the 
 soft parts covering the limb — having equal bases and lengths — and the 
 allowance of skin being sufficiently in excess to well cover the muscles. 
 
 Technic. — The preliminaries being the same as in the ordinary circular 
 amputation, two flaps are marked out, each having a width of base equal 
 to the half-circumference at the saw-line and a length equal to three-fourths 
 of the diameter of the limb at that same line (Fig. 310, A). With a large scal- 
 pel, incise along the outlined flaps, passing through skin and connective tissue. 
 When these integumentary flaps have retracted, proceed to form the remainder 
 of the flaps — cutting obliquely along the margin of the retracted skin, in such 
 
312 
 
 AMPUTATIONS. 
 
 a manner that the flaps will be bluntly (not thinly) beveled, directing the 
 knife so that the beveling will be greatest (though not thin even here) at the 
 tip, and thickest toward the base — and coming down upon the bone, or bones, 
 a distance below the saw-line equal to a full diameter of the bone (or of the 
 bigger bone) to allow for musculo-periosteal covering. At this level make 
 a circular cut around the bone through the periosteum with a heavy knife 
 — detach the musculo-periosteal covering of the bone upward to the saw-line 
 — retract the soft parts — divide the bone — suture the musculo-periosteal 
 covering— quilt the muscles — and suture the skin. 
 
 Resulting Stump. — As a rule, excellently covered by substantial tissues. 
 The scar is termino-lateral (Fig. 311, B). 
 
 Figs. 310 and 31 1.— Amputation by Equal Mixed Flaps: — A, Form and position of incisions; B 
 
 Resulting suture-line. 
 
 Indications. — In the continuity of limbs (between joints) where the 
 bone or bones are equally covered with soft parts. 
 
 Comment. — (1) The simplest form of making double flaps is by two 
 vertical incisions down the opposite sides of what has been begun as a circular 
 method. (2) One flap may be cut from without inward, and the other by 
 transfixion. (3) In very muscular limbs it makes the meeting of skin over 
 muscles easier if about 2.5 cm. (1 inch) of skin and fascia are dissected up 
 from the muscle, after marking out and dividing the skin and fascia, and 
 then cutting the muscles to the bone in a beveling fashion. 
 
 AMPUTATION BY EQUAL FLAPS OF SKIN. 
 
 This operation is the same, in general contour and dimensions of the 
 flaps, as the last — except that the covering here consists of skin only. 
 
AMPUTATION BY UNEQUAL FLAPS OF SKIN AND MUSCLES. 313 
 
 Technic. — Having incised through skin and fascia, upon the same lines 
 as in the last form of amputation, the two equal flaps of integumentary tissues 
 are dissected up to a level below the saw-line which will allow of providing 
 a musculo-periosteal covering — at this level the muscles, after retracting the 
 skin, are circularly divided down to the bone — this circular incision is con- 
 tinued, on the same level (one-half diameter of the bone below the saw-line) 
 around and through the periosteum — the periosteum is then retracted, with 
 the overlying muscles, to the saw-line— and the bone divided. The musculo- 
 periosteal covering is then sutured over the bone — and the skin margins 
 sutured together. 
 
 Resulting Stump. — Thinly covered, no muscle being present — but is 
 generally satisfactory in the localities where adopted. The scar is termino- 
 lateral. 
 
 Indications. — Where a satisfactory muscle covering is hard to secure — 
 as in the lower third of the forearm and leg and in the ringers — the tendons 
 predominating in these localities. 
 
 Figs. 312 and 313.— Amputation by Unequal Mixed Flaps:— A, Form and position of incisions, 
 and line of bone-section ; B, Resulting suture-line. 
 
 AMPUTATION BY UNEQUAL FLAPS OF SKIN AND MUSCLES. 
 
 General Description. — Coverings are furnished by two flaps taken 
 from opposite aspects of the limb — each flap having a base equal to one- 
 half circumference of the limb at the saw-line — and one flap having a length 
 greater than the other. One flap usually furnishes one-third or two-thirds 
 of the covering, and the opposite flap two-thirds or one-third — the longer 
 
314 AMPUTATIONS. 
 
 flap generally coming from that aspect of the limb most thickly muscled. 
 The flaps may bear any relation to each other in relative length — but the 
 two flaps combined furnish a covering equivalent to i| diameters of the 
 limb at the saw-line. 
 
 Technic. — This amputation is identical, except as to the length of the 
 flaps, with the amputation by equal flaps of skin and muscle (Fig. 312, A). 
 
 Resulting Stump. — Generally well covered. With scar either entirely 
 lateral or partlv lateral and partly terminal, dependent upon the preponderance 
 of one flap over the other (Fig. 313, B). 
 
 Indications. — Thigh and arm throughout, and upper parts of forearm 
 and leg. 
 
 AMPUTATION BY UNEQUAL FLAPS OF SKIN. 
 
 General Description. — Coverings are of skin and fascia alone and 
 are furnished by the two opposite aspects of the limb, in the form of two 
 flaps having equal bases and unequal lengths. This amputation is identical 
 throughout with the amputation by equal flaps of skin, except as to the 
 length of the flaps. 
 
 AMPUTATION BY UNEQUAL RECTANGULAR FLAPS OF SKIN AND 
 
 MUSCLES. 
 
 TEALE'S METHOD. 
 
 General Description. — The general method of performing this operation 
 is similar, in principle, to that for amputation by unequal flaps of skin and 
 muscles — with the exception that the flaps are rectangular (instead of rounded) 
 and of special dimensions. 
 
 Technic. — Having fixed upon the saw-line, two flaps are marked out, 
 having their bases at that line and extending downward as described below. 
 Find the circumference of the limb at the saw-line. The longer flap is to 
 have its length and its breadth equal to a half-circumference at the saw-line. 
 The shorter flap is to be one-fourth of the length of the longer, and its breadth 
 equal to the remaining half-circumference at the saw-line. The longer flap 
 should be of the same width all the way down. The shorter flap will have 
 a width at its free end equal to very nearly a half-circumference of the limb 
 at the level where it terminates (as that level, in the case of the shorter flap, 
 is so short a distance beneath the saw-line) (Fig. 314, A). Having marked out 
 these flaps, which should be accurately measured, the vertical parts of the inci- 
 sion should be made from above downward, connected at their lower ends by 
 the transverse incision which marks the limit of the longer flap, and by another 
 transverse incision across the opposite half-circumference of the limb, at the 
 proper level, marking off the lower limit of the shorter flap. These incisions 
 at first involve skin and fascia only. When retraction has occurred (making 
 a difference in the transverse incisions only), they are deepened throughout 
 to the periosteum. The vertical limbs of the flaps are first cut to the peri- 
 osteum — then the lower transverse limit of the longer flap, which is dissected 
 up above the lower limit of the shorter flap — which in turn is cut transversely 
 to the periosteum and dissected up. When a level below the saw-line is 
 reached equal to a half-diameter of the bone at the saw-line, a circular incision 
 is made through the periosteum and a musculo-periosteal covering raised. 
 All the soft parts are now retracted above the saw-line and the bone divided. 
 The musculo-periosteal covering is sutured. The longer flap is bent over 
 
ELLIPTICAL METHOD OF AMPUTATION. 
 
 315 
 
 the end of the bone — its end being sutured to the end of the shorter flap — 
 the lateral aspects of the shorter flap are sutured to the lateral aspects of the 
 longer — and the lateral aspects of the bent-over portion of the long flap are 
 sutured to the contiguous lateral aspects of the unbent portion of the long 
 flap. The muscles are quilted prior to suturing the skin. The part is well 
 supported by splint, with only light pressure over the bent longer flap. 
 
 Resulting Stump. — An H -shaped cicatrix is formed upon the aspect 
 of the limb furnishing the shorter flap. The end of the bone is well covered 
 when the long flap contains a preponderance of muscle — less well covered 
 when containing a preponderance of tendons (Fig. 315, B). 
 
 Figs. 314 and 315.— Amputation by Unequal Mixed Rectangular Flaps :— A, Form and position 
 of incisions, and line of bone-section ; B, Resulting suture-line. 
 
 Indications. — In the lower part of the leg (where the longer flap is taken 
 from the anterior aspect) — and sometimes in the lower forearm (where the 
 longer flap comes from the posterior aspect). 
 
 ELLIPTICAL METHOD OF AMPUTATION. 
 
 General Description. — This is not a distinct form of amputation. It 
 may be considered a variety of the circular method (an oblique circular), 
 or, equally, a variety of single-flap amputation — and may be held in an 
 intermediate position. It is circular, as to skin incision; and flap, as to its 
 manner of covering the stump and in the suturing. The skin incision is in 
 the form of an ellipse, or a lozenge, the upper part of the ellipse being upon 
 one aspect of the limb and the lower part upon the opposite — the lateral 
 limbs of the figure crossing the lateral aspects of the limb to be amputated. 
 
316 
 
 AMPUTATIONS. 
 
 The idea of the ellipse is brought out by imagining the outline projected upon 
 a fiat surface. 
 
 Technic. — Having fixed upon the saw-line (or line of disarticulation), 
 a point is determined above this, on, say, the posterior aspect of the limb, 
 which is just above the saw-line — this becomes the highest point of the ellipse. 
 The point marking the lowest point of the ellipse is placed upon the opposite 
 side of the limb, at a distance below the saw-line equal, approximately, to 
 i£ diameters of the limb at the saw-line (as there is but this one source of 
 covering). Between these two points the lateral limbs of the ellipse pass, 
 crossing the lateral aspects of the limb to be operated obliquely, from above 
 downward, and so planned as to give a well-rounded convex termination of the 
 ellipse below to be brought up and fitted into a corresponding concavity above 
 (Fig. 316, A). The incision first passes around the outline of the ellipse, 
 
 through skin and fascia only. 
 Around the lower three- 
 fourths of the line of this 
 retracted skin and fascia a 
 second incision passes through 
 the muscles to the bone. The 
 soft parts (skin and muscles) 
 forming the lower part of the 
 ellipse (the part that is to 
 remain attached to the limb 
 which is to be retained) are 
 now dissected up from the 
 bone to a point sufficiently 
 below the upper limit of the 
 ellipse to allow a musculo- 
 periosteal or capsulo-perios- 
 teal covering to be raised, and 
 then on up to just below the 
 upper limit of the ellipse (that 
 is, to the saw-line or line of 
 disarticulation). This large 
 single mass of soft parts is 
 well retracted — and the mus- 
 cles on that aspect of the limb 
 opposite to the one furnishing 
 the muscles in the elliptical 
 covering are circularly divided — and the limb sawed, or disarticulated, pre- 
 serving the periosteum in the usual way. The lower convexity of the ellip- 
 tical flap is now sutured into the upper concavity left by the part of the limb 
 removed — the musculo-periosteal, or capsulo-periosteal, covering and the 
 muscles being treated in the general manner by buried gut sutures — and the 
 skin wound closed. 
 
 Resulting Stump. — The ellipse is generally taken from a locality which 
 affords a plentiful covering for the extremity, which is thus well provided for. 
 The scar is lateral (Fig. 317, B). 
 
 Indications. — Chiefly used for disarticulations — especially at the elbow 
 and wrist, and in the supramalleolar amputation. 
 
 Comment. — The muscle portion of the ellipse may be cut also by trans- 
 fixion, although, as usual, less satisfactorily. 
 
 B 
 
 Figs. 316 and 317.— Amputation by the Ellipticai 
 Method : — A, Form and position of incision ; B, Re- 
 sulting suture-line. 
 
SELECTION OF AMPUTATION METHOD. 317 
 
 OSTEOPLASTIC AMPUTATIONS. 
 
 Description. — An osteoplastic operation, in general, consists in the approx- 
 imation of fresh sections of bone to each other, for the purpose of bringing 
 about union between their opposed surfaces. In an osteoplastic amputation, 
 some portion of a distal bone is raised in the form of an osseoperiosteal flap, 
 adherent to its neighboring soft parts, and applied to the sawed aspect of the 
 proximal bone. In performing osteoplastic amputations a special saw should 
 be provided — a bow-saw with a scroll-blade of strong, narrow, thin metal, 
 which can be turned in any direction while in the act of making bone-sections, 
 such as the Helferich pattern of saw. (A saw for osteoplastic work is now 
 on trial which is, practically, a Gigli saw held in a bow-handle.) The freshened 
 surfaces of bone are variously held in contact — the edges of the surrounding 
 periosteum may be sutured together — the bone surfaces may be wired, pegged, 
 or nailed — or the bone aspects may be held in apposition (especially where 
 there is no strong counter-pull) by the simple suturing of the surrounding 
 soft parts together. 
 
 Objects of the Osteoplastic Method of Amputation. — (i) Closure 
 and protection of the medullary canal; — (2) Securing of a solid end of bone 
 to meet pressure — brought about by the rounding off of the section of bone 
 whose surface becomes united with the end of the main bone; — (3) Avoidance 
 of adhesions between sawed bone and soft coverings — and, by retaining the 
 mobility of these parts, thereby lessening the chance of neuralgia and ulcera- 
 tion in the stump. 
 
 Application of the Osteoplastic Method of Amputation. — Up to the 
 present time the chief sites at which this method of amputation has been 
 used have been in the lower extremity — that is, where pressure-bearing stumps 
 are sought. The following are examples of the osteoplastic method of ampu- 
 tation; — Pirogoff's osteoplastic amputation of the foot (page 415) — Lister's 
 modification of Carden's transcondyloid amputation of the thigh (page 440) — 
 Gritti-Stokes's supracondyloid amputation of the thigh (page 441) — Sabane- 
 jeff's amputation of the thigh (Figs. 367, 368, 369) — Bier's amputation of the 
 leg (Figs. 360, 361, and 362). 
 
 IRREGULAR METHODS OF AMPUTATION. 
 
 This is a special feature of modern-day surgery. Formerly amputations 
 were done upon hard and fast lines. Now there is a marked tendency to 
 allow the method of amputation to be determined by the special features 
 and need of the individual case — and, as a result, irregular amputations 
 are more commonly done, which, while accomplishing the general indica- 
 tions, are not bound by any set rule, shape, or measurement. The practical 
 surgeon, therefore, should, on common-sense ground, adapt his method of 
 amputation to the case in point, rather than be bound by any fixed form of 
 amputation. The greatest field for irregular forms of amputation is in 
 cases of injury and deformity, rather than in disease. 
 
 SELECTION OF AMPUTATION METHOD. 
 
 Many considerations enter into the determination of the best method 
 of amputation in a particular case — and the choice should be given to that 
 method which promises to fulfil the greatest number of the following features; — 
 
 Characteristics of Good Amputation Methods. — (1) Minimum sacri- 
 
318 AMPUTATIONS. 
 
 fice of healthy tissue — (2) Best permanent bone-covering — (3) Small wound 
 area — (4) Good blood-supply to stump — (5) Favorably placed cicatrix — (6) 
 Efficient drainage — (7) Simplicity of method — (8) Vessels and muscles cut 
 transversely — (9) Possibility of getting satisfactory musculo-periosteal covering 
 — (10) Ease of exposing bone at saw-line — (n) Ease of bringing soft parts 
 together over bone without tension — (12) Adjustability of artificial limb— 
 (13) Largest range of adaptability — (14) Shapeliness of resulting stump— 
 (15) Rapidity of method. 
 
 Comment. — Circumstances may determine the selection of an ampu- 
 tation method known in advance not to be the best — for instance, owing 
 to the increased mortality in approaching the trunk, a limb may be removed, 
 in a case where the vitality of the patient demands that every chance be 
 given him, at a level which, while increasing his chances for life, may not 
 furnish the best covering. Again, in amputating about the hand, it may 
 conserve the interest of the patient better to be satisfied with even a partial 
 flap and allow the remainder to heal by granulation, rather than remove 
 an additional \ cm. (\ inch) of an important finger. Rapidity of method 
 used to be the chief consideration, but is now the last in importance, except 
 in special instances — other considerations taking precedence — the operation 
 being done with deliberation and precision. 
 
 Features of the Circular Method of Amputating. — (1) Minimum 
 sacrifice of bone and soft parts of any method. — (2) Bone especially well 
 covered in the infundibuliform variety. Conical stump sometimes follows 
 retraction, especially in the cuff and modified varieties of the circular. — (3) 
 Smallest wound area of any method. — (4) Tissues of stump well supplied 
 with blood. — (5) Cicatrix terminal. — (6) Efficient drainage when sutured 
 antero-posteriorly. — (7) Most simple of any method. — (8) Main vessels and 
 muscles cut transversely. — (9) Musculo-periosteal covering well provided. 
 — (10) Exposure of bone at saw-line not always easy. — (n) Not always 
 easy to bring soft parts together over bone. — (12) Terminal cicatrix favorable 
 for hollow artificial limbs; unfavorable for solid limbs of lower extremity. — 
 (13) Unfavorable for amputation following injury involving the aspects of 
 the limb to unequal heights. — (14) Somewhat greater tendency to become 
 conical. — (15) Most rapid of any method. 
 
 Features of the Flap Method of Amputating. — (1) Greater sacrifice 
 of bone and soft tissues (especially in unequal flaps). — (2) Coverings of bone 
 can be more largely regulated to suit demand. Conical stumps less apt to 
 follow than after the cuff and modified forms of the circular. — (3) Greater 
 wound area. — (4) In long flaps the blood-supply may not be so satisfactory. — 
 (5) Terminal or termino-lateral cicatrix — can be planned as desired. — (6) 
 Drainage as efficient as in the circular if the flaps be lateral. Not so efficient 
 if the flaps be antero-posterior. — (7) Not so simple as the circular. — (8) 
 Muscles divided obliquely; vessels also, and latter may be split up. — (9) 
 Musculo-periosteal covering well provided. — (10) Bone easily exposed at 
 the saw-line. — (n) Flaps easily brought together over bone. — (12) Terminal 
 cicatrix favorable for any hollow artificial limb. Terminal portion of termino- 
 lateral cicatrix pressed upon by solid lower limb, and lateral portion pressed 
 upon by any hollow artificial limb. — (13) Favorable for amputations following 
 injury involving the aspects of the limbs unequally. Adaptable to any part 
 of any limb. — (14) Stump apt to be more shapely than that of the circular. — 
 (15) Less rapid than the circular. 
 
 Circumstances Influencing Death-rate After Amputation. — The 
 death-rate is greater; — (1) The nearer the amputation is to the trunk — (2) 
 
QUALITIES OF A GOOD STUMP. 319 
 
 In the lower than in the upper limbs — (3) Fur injury than for disease — (4) 
 In men than in women — (5) Between the ages of five to fifteen than before 
 or after. In a tabulation of 3600 amputations performed by himself, Estes 
 has found that, as far as the upper extremity is concerned, there is no appreci- 
 able difference in fatality following amputations through the various parts of 
 the hand, forearm, and arm, until the shoulder-joint is reached, where, naturally, 
 the maximum mortality for the upper extremity occurs. In the case of the 
 lower extremity, on the other hand, there is an increase in mortality from ampu- 
 tations from the foot upward, as the lower limb is ascended, reaching the 
 maximum for the whole body at the hip-joint. 
 
 Influence of Age upon Amputations. — The young and old, especially 
 if feeble, stand the actual operation less well than those in the reverse condi- 
 tions — and also tolerate the subsequent confinement and apparatus less well. 
 
 PRIMARY, INTERMEDIATE, AND SECONDARY AMPUTATIONS. 
 
 In amputations done for disease the time for operation may be selected 
 which will coincide with the patient's best condition to meet the procedure. 
 Amputations done for injury are either Primary (performed immediately after 
 the reception of the injury) — Intermediate (in the course of wound-repair) 
 and Secondary (after healing). In primary amputations the operation should 
 be done at once, if the general condition of the patient permit. If the con- 
 dition of shock (from psychical effect and blood loss) contraindicate imme- 
 diate interference, stimulation, intravenous infusion, the application of heat, 
 and the like, should be resorted to, and the limb removed during the reaction- 
 ary period (generally within thirty-six hours). If the condition of shock is 
 thought to be kept up by the damaged limb, amputation should be done at 
 once, the above measures of revival being maintained the while. 
 
 THE AMPUTATION STUMP. 
 QUALITIES OF A GOOD STUMP. 
 
 Firm in consistency — well covered — insensitive — of regular and symmetrical 
 contour. The death-rate and the quality of the stump determine the success 
 of any form of amputation. The following features are characteristic of a 
 good stump — and also indicate the changes which follow successful ampu- 
 tation: — 
 
 Skin. — Not adherent, except at cicatrix. Capable of withstanding (and, 
 preferably, accustomed to withstand) pressure. Plentifully supplied with 
 blood. 
 
 Muscles. — The muscles of a stump are not retained as such — the muscle 
 tissue disappears in greater part and is replaced by fibrous tissue. Ex- 
 ceptionally some muscle tissue remains and continues to function. The 
 mass of fibrous tissue which replaces it, however, serves a useful purpose 
 in padding over the end of the bone. In brief, muscle tissue tends to de- 
 crease — and fibrous tissue to increase. Muscles and tendons either become 
 incorporated in the cicatrix, form new attachments to bone, or retract out 
 of the way. 
 
 Bone. — The ends of the bones become rounded and the medullary 
 canals closed bv fibrous tissue. The end of the bone may either dwindle 
 
320 AMPUTATIONS. 
 
 and atrophy, or the periosteum may, exceptionally, deposit an excess of bone. 
 The shaft of the bone in an amputated limb also atrophies somewhat. 
 
 Cartilage. — Following a disarticulation, the articular cartilage left 
 atrophies and sometimes entirely disappears. 
 
 Nerves. — Also atrophy to a greater or less extent. The ends generally 
 become bulbous, but give no trouble unless they become adherent to bone 
 or cicatrix. 
 
 Vessels. — Share in the general atrophy, and dwindle to a size com- 
 mensurate with the parts to be supplied. Ligated trunks become obliterated 
 to their nearest branch. Collateral circulation is established. 
 
 CHARACTERISTICS OF A BAD STUMP. 
 
 In contradistinction to the general qualities of a good stump, a bad stump 
 may be flaccid, scantily covered, sensitive, of irregular contour — and may 
 be further characterized by the following conditions: — 
 
 Skin. — Thin, scanty, tightly drawn, adherent, puckered — cold or purple 
 from improper circulation— ulcerated from the same cause, or from trophic 
 changes — involved with corns — and may become malignant. 
 
 Muscles. — See the changes mentioned in the last section. 
 
 Connective Tissue. — Bursae may form. 
 
 Bone. — Osteitis, periosteitis, and necrosis may occur. 
 
 Two special forms of bad stump are met: — 
 
 Painful Stump. — May be due to osteitis or periosteitis— but is generally 
 due to compression of the nerve. The nerve may be directly pressed upon 
 by new bone or fibrous tissue — may be stretched over the stump — or may 
 be the seat of neuritis. The end of a painful nerve is generally bulbous — 
 but not necessarily — for often normal-looking nerve-ends are sensitive, and 
 bulbous ones non-sensitive. 
 
 Conical Stump. — The end of the bone forms the apex of a cone which 
 may be the result of one or more of the following causes — (i) Flaps cut too 
 short — or bone too long. — (2) Sloughing or suppuration of the soft parts. — 
 (3) Post-operative contraction of muscles. — (4) Growth of the bone from 
 an active epiphysis in the young. 
 
 Comment. — Unfavorable changes are less apt to occur in case of primary 
 union than in the reverse. 
 
 CONDITIONS INFLUENCING VITALITY OF STUMP. 
 
 (1) Blood-supply — full or scant, impeded or unobstructed by position 
 of stump-covering. — (2) Compression by bandage, dressing or splint. — (3) 
 Tightness and unnatural position of flaps, as compared with easy and natural 
 position. — (4) Full allowance of skin and non-separation of skin from muscle, 
 as compared with the reverse. — (5) Long and loose tendons and aponeuroses. 
 (6) Too rapid sawing of bone. — (7) Finally, site of amputation, manner of 
 performing the operation, prior local condition, prior constitutional con- 
 dition, and after-treatment — all influence the vitality of the stump. 
 
 Comment.— The chief dangers to be avoided, are — over-tension in the 
 skin and muscle covering — insufficient blood-supply — rough projections of 
 bone and laceration of the parts — and inclusion of nerves in the cicatrization. 
 
 Immediate Complications of Amputations. — Spasm of muscles; hemor- 
 rhage from nutrient artery of bone, and general post-operative hemorrhage. 
 
FUNCTION OF AMPUTATION STUMPS. 32 1 
 
 CONTRACTILITY OF THE TISSUES OF THE STUMP. 
 
 Skin. — The average contractility of the skin is equivalent to about one- 
 third of its length. It is most contractile where thinnest — where the sub- 
 cutaneous tissue is least — where its attachment to underlving parts is least 
 — where it is least stretched by movements — and where the process of healing 
 has been longest. It is least contractile where the opposite conditions exist. 
 
 Muscles. — The extremes of muscular contractility vary from a slight 
 separation of divided parts up to a retraction of four-fifths of their length. 
 Contractility is primary, where it occurs at the time of the operation — and 
 secondary, where it occurs subsequent to the operation. Muscles contract 
 most — which are freest between origin and insertion — which have long 
 fibers — and where the process of healing has been longest. The larger the 
 muscle, the greater the amount left in the flap, and the younger and healthier 
 the subject, the greater the contraction. Muscles contract least where the 
 conditions are the reverse of those just mentioned. 
 
 Skin, Fascia, and Muscles. — The average contractility of the mixed 
 tissues of a flap, or covering, is generally equivalent to about one-third of 
 the length of the flap, or covering. Additional length, however, should be 
 allowed, in calculating the length of coverings — (1) When the transverse 
 section of the bone is large as compared with the transverse section of the 
 soft parts — (2) When the amputation is considerably below the origin of the 
 muscle involved — (3) When secondary retraction is expected. 
 
 POSITION OF STUMP-CICATRICES. 
 
 The cicatrix should be so placed as to be the least exposed to pressure 
 after the healing of the wound. 
 
 With Reference to Their Position. — Scars may be Terminal — at the 
 end of the stump; — Lateral — on one or more sides of the stump; — Termino- 
 lateral — occupying the end and side of the stump. 
 
 With Reference to Their Production. — The following methods of 
 amputation produce the following kinds of scars; — Circular is followed by 
 terminal scar; — Elliptical, by lateral scar, if the ellipse be oblique, and terminal 
 if the ellipse be nearly horizontal; — Oval, by termino-lateral; — Racket, by 
 termino-lateral; — Single flap, by lateral scar; — Double flap, by terminal scar, 
 if the flaps be equal, and lateral if the flaps be unequal. 
 
 Comment. — (1) Other things being equal, that method of amputation 
 should be chosen which will bring the scar in the most favorable position 
 for that particular case — and especially with reference to the subsequent 
 functioning of the stump and its adaptability to an artificial limb. (2) In 
 amputating in some situations the muscles of one group being so much stronger 
 than those of another, will often draw a scar, terminal at the time of opera- 
 tion, much higher up upon one aspect than it will be drawn on the opposite 
 aspect. Calculations for such an occurrence have, therefore, to be made. 
 
 FUNCTION OF AMPUTATION STUMPS. 
 
 In the Upper Extremity. — The chief function of the stump in the upper 
 extremity is range of movement and power to wield an artificial limb, rather 
 than to bear pressure and weight. As the chief pressure of an artificial limb 
 
322 AMPUTATIONS. 
 
 comes upon the lateral aspects of the stump, the scar of the stump in the 
 upper extremity is best when terminally placed. 
 
 In the Lower Extremity. — The chief function of the stump in the lower 
 extemity is to bear pressure and weight. As the chief pressure of a solid 
 artificial limb comes upon the end of the stump, the scar of the stump in the 
 lower extremity is best when laterally placed — in those cases in which 
 a solid artificial limb is to be worn. As, however, most modern artificial 
 limbs for the lower extremity, for the better classes, are hollow, there is not 
 now made the same difference as formerly. 
 
 The Modern Type of Artificial Limb. — While the above was particu- 
 larly true of the older, cruder forms of artificial limbs (and is still true of the 
 peg-leg), the modern forms of artificial limbs are nearly always made upon 
 the basis of a light, hollow cone, and are so adjusted as to largely adapt 
 themselves to the conditions found — and, generally speaking, most of the 
 pressure is of the lateral aspects of the stump and living limb against the 
 sides of the hollow cone of the artificial limb — so that pressure is exercised 
 upon the lateral aspects of the living stump and limb rather than upon the 
 end — and in the lower as well as in the upper extremity. 
 
 Comment. — A function of the stump of the upper extremity, especially 
 about the hand, and more particularly of a woman, is to be as symmetrical 
 and shapely as possible, in the case of partial sacrifice of that member. While 
 in the case of a laborer it would certainly be better to sacrifice appearance 
 to strength and utility, one might be urged to sacrifice strength for appearance 
 in the case of a woman of the non-working class. 
 
 SITE OF AMPUTATION IN CONNECTION WITH THE RESULTING 
 STUMP AND ITS ADAPTABILITY TO AN ARTIFICIAL LIMB. 
 
 The choice of the site of amputation is determined by the resulting mortality 
 and the fitness of the stump for an artificial limb. Concerning the effect of 
 the amputation site upon mortality, see Circumstances Influencing the Death- 
 rate after Amputation (page 318). 
 
 In general, the longer the stump, the more useful the limb. 
 
 Considerable responsibility rests with the surgeon in choosing the site and 
 technic of operation, which will leave the patient the best stump, circumstances 
 considered, adaptable to an artificial limb. 
 
 While formerly it was taught to save every fraction of limb possible, it is 
 now regarded as better for the patient's interest to select that site and form of 
 amputation furnishing a stump best suited to take an artificial limb of the 
 widest range of function. 
 
 In planning the form of skin covering, it is to be remembered that if the 
 scar be not terminal, it should be somewhat posterior or lateral, rather than 
 anterior, as the movement to force an artificial limb forward causes the appa- 
 ratus to press upon an anterior scar. For the same reasons the ends of divided 
 bones which lie near the skin, which is generally their anterior aspect, should 
 be rounded, so as not to be pressed by the false limb. 
 
 In calculating an efficient stump distal to a joint, sufficient length below 
 the joint must be provided to bear upon and wield or swing the artificial limb. 
 Every additional inch is here a matter of importance. 
 
 The primary function of the upper artificial limb is for prehension — of the 
 lower, to bear weight and admit of locomotion. 
 
SURGICAL ANATOMY OF THE FINGERS. 323 
 
 As the main growth in the length of the humerus and femur is from the 
 upper epiphysis, amputation through the shaft of these bones, in the young, 
 will almost certainly be followed by a conical stump, which will often require 
 re-amputation. 
 
 In the lower extremity an osteoplastic amputation is preferable, where 
 feasible — especially in operating for disease, where a deliberate calculation 
 can be made. 
 
 The general tendency of the day, in operating about the foot, is to regard the 
 foot as a whole, irrespective of joint-lines, and to amputate along improvised 
 lines adapted to the special case. 
 
 Classical and irregular amputations through the tarsus, though condemned 
 by artificial-limb makers, and though supposed by some to yield too large a 
 proportion of sensitive stumps, should be performed in preference to ampu- 
 tations above the ankle. 
 
 The lower third of the leg is the place of election in amputating through the 
 leg — rather than the formerly given "hand's breadth" below the knee-joint. 
 In the latter case too limited a length of bone is left for good leverage in adapt- 
 ing a false limb. The site of choice is at the junction of the middle and lower 
 thirds of the leg — thus leaving room for an artificial ankle-joint. 
 
 Under no circumstances amputate through the tibia higher than 8 cm. 
 (3 inches) below its superior articular surface. 
 
 In amputating in the neighborhood of the knee-joint, one of the osteoplastic 
 operations by which a piece of bone from the tibia is approximated to the sawn 
 end of the femur in the condyloid region serves an useful purpose, furnishes 
 a stump that will bear pressure well, and generally leaves room for the artificial 
 knee-joint in approximately a normal position. 
 
 Amputation through the thigh 8 cm. (3 inches) above the knee-joint gives 
 ample room for an artificial joint in a normal position. 
 
 Amputations through the thigh higher than its middle do not furnish as 
 satisfactory stumps as those at and below this level. 
 
 In operating above the knee, however, it is to be borne in mind that the 
 weight is also borne by the ischio-perineal region. 
 
 AMPUTATIONS AND DISARTICULATIONS OF THE UPPER 
 
 EXTREMITY. 
 
 SURGICAL ANATOMY OF THE FINGERS. 
 
 Bones. — Third, second, and first phalanges of the fingers; — and second 
 and first phalanges of the thumb. 
 
 Articulations and Ligaments. — (a) Second Interphalangeal Articula- 
 tions; anterior; two lateral; capsule. Posterior ligament not present — place 
 supplied by united tendons of extensor communis digitorum and extensor 
 indicis, for index; — extensor communis digitorum for middle and ring; — 
 united tendons of extensor communis digitorum and extensor minimi digiti, 
 for little finger, (b) First Interphalangeal Articulations; — anterior (glenoid); 
 two lateral; capsule. Posterior ligament not present — place supplied by 
 extensor longus pollicis (extensor secundi internodii pollicis) for thumb; — 
 united tendons of extensor communis digitorum and extensor indicis, for 
 index; — extensor communis digitorum, for middle and ring; — united tendons 
 of extensor communis digitorum and extensor minimi digiti, for little finger, 
 (c) Metacarpo-phalangeal Articulations; — anterior; two lateral; capsule. 
 
324 AMPUTATIONS. 
 
 Posterior ligament — not present as distinct ligament — place supplied by 
 scattered fibers from one lateral ligament to opposite lateral ligament; ex- 
 tensor brevis pollicis (extensor primi internodii pollicis) ; extensor longus 
 pollkis (extensor secundi internodii pollicis), for thumb; — and the same 
 ligaments for the other fingers as those for the first interphalangeal joints. 
 
 Sesamoid Bones. — Two on palmar surface of metacarpophalangeal 
 joint of thumb, developed in inner and outer heads of flexor brevis pollicis, 
 which here replace the anterior ligament. One or two on palmar surface 
 of metacarpophalangeal joint of index and little fingers. Rarely one on 
 palmar surface of metacarpophalangeal of middle and ring fingers. Rarely 
 one on palmar surface of interphalangeal joint of thumb. 
 
 Muscles and Tendons. — (A) Of Fingers in General; — (a) On palmar 
 aspect; — flexor sublimis digitorum; flexor profundis digitorum. (b) On 
 dorsal aspect of index; — united tendons of extensor communis digitorum 
 and extensor indicis; first dorsal interosseous (abductor indicis). On dorsal 
 aspect of middle finger; — extensor communis digitorum; second dorsal 
 interosseous; third dorsal interosseous. On dorsal aspect of ring finger; — 
 extensor communis digitorum; fourth dorsal interosseous; second palmar 
 interosseous. On dorsal aspect of little finger; — united tendons of extensor 
 communis digitorum and extensor minimi digiti; fourth lumbrical; third 
 palmar interosseous, (c) On ulnar aspect of little finger; — abductor minimi 
 digiti; flexor brevis minimi digiti. (B) Of Thumb; — (a) On palmar aspect; 
 — flexor longus pollicis. (b) On dorsal aspect; — extensor brevis pollicis 
 (extensor primi internodii pollicis) ; extensor longus pollicis (extensor secundi 
 internodii pollicis). (c) On radial aspect; — abductor pollicis; outer head of 
 flexor brevis pollicis. (d) On ulnar aspect; — inner head of flexor brevis 
 pollicis; adductor obliquus pollicis; adductor transversus pollicis. 
 
 Sheaths (Thecae). — Processes of palmar fascia extending down fingers 
 from palm of hand to bases of last phalanges, being attached to lateral margins 
 of first phalanges, and forming sheaths for flexor tendons. 
 
 Synovial Membranes. — (a) Of index, middle, and ring fingers; — extend 
 from base of last phalanges up to bifurcation of palmar fascia, namely, about 
 opposite necks of metacarpals (corresponding, approximately, to middle 
 crease on palm of hand, for index, and to lowest crease for middle and ring), 
 (b) Of thumb and little finger; — extend from base of last phalanges to and 
 into great synovial sac of hand. 
 
 Nails. — Overlie the soft parts covering the distal two-thirds of the last 
 phalanges on their dorsal aspect. 
 
 Arteries. — (a) Palmar Supply; — Four palmar digital branches of super- 
 ficial arch; radialis indicis of deep arch; princeps pollicis of deep arch, (b) 
 Dorsal Supply; — Second and third dorsal interosseous branches of posterior 
 radial carpal branch of radial; first dorsal interosseous (metacarpal) branch 
 of radial; dorsalis indicis branch of radial; dorsalis pollicis branch of radial. 
 
 Veins. — (a) Superficial; — digital (one on each side), (b) Deep; — venae 
 comites. 
 
 Lymphatics. — One lymphatic vessel on dorsal and one on palmar aspect 
 of each side of each finger. 
 
 Nerves. — (a) Median supplies — thumb, index, middle, and ring fingers, 
 (b) Ulnar supplies — ring, little, and middle (sometimes), (c) Radial supplies 
 — thumb, index, middle, and ring. 
 
GENERAL CONSIDERATIONS IN FINGER AMPUTATIONS. 325 
 
 SURFACE FORM AND LANDMARKS OF THE FINGERS. 
 
 The proximal ends of the phalanges form the knuckles — and therefore 
 the joint-line is beyond the knuckle. The interphalangeal joint-lines are 
 found, with approximate accuracy, by flexing the distal phalanges at a right 
 angle with the proximal phalanges (or metacarpals) — and then prolonging 
 the mid-lateral axis of the proximal bone forward — this line will pass through 
 the center of the joints. More accurately, the last interphalangeal joint is 
 2 mm. (yV inch), the first interphalangeal joint 4 mm. (^ inch), and the meta- 
 carpophalangeal joint 8 mm. (J inch) beyond the prominence of the knuckle. 
 
 The sesamoid bones can be felt in front of the metacarpo-phalangeal 
 joint of the thumb. 
 
 The palmar aspects of the fingers are crossed by three series of transverse 
 folds; — the highest are single for the index and little fingers, double for the 
 middle and ring — and are nearly 2 cm. (f inch) below the metacarpo-phalan- 
 geal joints; — the middle are double for all the fingers — and are directly 
 opposite the first interphalangeal joints; — the lowest are single for all the 
 fingers — and are a little above the second interphalangeal joints. The 
 thumb has two folds — the higher, single, crosses the metacarpo-phalangeal 
 joint obliquelv; — the lower, single, directly opposite the first interphalangeal 
 joint. 
 
 The free margin of the webs of the fingers is about 2 cm. (f inch) below 
 the metacarpo-phalangeal joints. 
 
 The lateral ligaments of the joints are nearer the palm than the dorsum. 
 
 The sheaths of the flexor tendons extend from the metacarpo-phalangeal 
 joints to the proximal ends of the third phalanges — are least distinct opposite 
 the joints — gape when cut — and lead into the palm of the hand. 
 
 The digital arteries bifurcate about 8 mm. (J inch) above the free margin 
 of the webs of the fingers. 
 
 The epiphyses form the heads of the four inner metacarpals, the base 
 of the first, and the bases of all the phalanges — all joining the shaft about 
 the twentieth year. 
 
 The skin of the palm is thick, dense, and adherent — that of the dorsum, 
 thin and loosely connected to the fascia. 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS OF THE 
 
 FINGERS. 
 
 Minimum sacrifice of tissue is the rule in all amputations about the fingers 
 — especially in thumb, index, and little fingers — so that there may be left 
 some length of digit, no matter how short, to approximate to other digits 
 and objects grasped. The basal principle here is — (a) Save a stump, no 
 matter how imperfect — (b) provided tendons remain connected to it, or can 
 be sutured to it — (c) and sound skin can be found to cover it. Indeed, the 
 last may be dispensed with, if there seem fair chance that granulation will 
 cover over the part. Amputations here, especially in cases of injury, are 
 often irregular operations, and amount to little more than trimming of mangled 
 parts — as a bony stump of irregular form, provided flexion and extension 
 exist, is better than a shorter stump of more symmetrical contour. 
 
 Since the bones of the fingers are large, as compared with the surrounding 
 soft parts, an ample allowance of covering should be made. 
 
326 AMPUTATIONS. 
 
 In the interphalangeal region the joints are concave from side to side, 
 with the concavity toward the finger-tips. In the metacarpo-phalangeal 
 region the convexity is toward the tips. 
 
 Owing to the function of the fingers, cicatrices should be planned to fall 
 out of the way of pressure — should not be terminal or palmar — and are best 
 placed on the dorsum. 
 
 The stump of a phalanx is often considerably in the way unless the flexor 
 and extensor tendons can act upon it. Formerly all of a finger below the 
 center of the middle phalanx (where the superficial flexor is attached) was 
 sacrificed. Now, however, the flexor tendon is sutured into the mouth of 
 the cut theca and periosteum, or even the flap, thereby securing control 
 of the phalangeal stump. 
 
 The fibrous sheaths of the flexor tendons gape open when cut across 
 and their channels lead directly into the palm of the hand, and those of the 
 thumb and little finger into the great synovial sac beneath the annular ligament 
 of the wrist, furnishing a ready avenue for possible infection. They should, 
 therefore, be closed by two or three catgut sutures, passed from the palmar 
 to the dorsal aspect of the sheath with a curved needle, whenever cut in the 
 course of an amputation about the fingers. But when cut, especially when 
 the finger is extended, the flexor tendons draw up into the sheath out of 
 sight, and if the sheaths were then sutured the action of the flexor tendons 
 upon the phalangeal stump would be lost. Therefore, to give the flexor 
 tendons a firm hold upon the part, the sutures should include flexor tendon, 
 theca, and periosteum — passing, in order, from before backward, through 
 anterior wall of theca, flexor tendon (if distal to center of middle phalanx), 
 or tendons (if proximal to center of middle phalanx), and posterior wall of 
 theca, which is blended with the periosteum. Where the theca is imperfect, 
 the tendons should be sutured to neighboring periosteum, glenoid ligament, 
 adjacent fibrous tissue, or into the tissues of the flap. Thus the mouth of 
 the sheath is closed by the tendon while anchoring the latter to the part. 
 This sheath is absent over the terminal phalanx and over the distal inter- 
 phalangeal joint — and is indistinct over the metacarpo-phalangeal joint. 
 Where absent, the flexor tendons should be sutured into the neighboring 
 structures, as just described. Where the periosteum is to be included in the 
 suture, it should be stripped back before dividing the bone. 
 
 If the base of the terminal phalanx be saved, the attachment of the deep 
 flexor is preserved. If the upper third of the second phalanx be saved, the 
 attachment of the superficial flexor is preserved. If the amputation be 
 through the first interphalangeal joint, or proximal to it, both flexor tendons 
 will be lost — unless they are sutured into the neighboring structures as just 
 described (into theca, periosteum, or flaps). 
 
 The best form of amputation for all parts below the metacarpo-phalangeal 
 joint is one in which a palmar flap predominates — furnishing a covering 
 of thick, sensitive skin accustomed to pressure — and a cicatrix on the dorsum. 
 
 In disarticulations by the palmar flap method, a slight downward con- 
 vexity given to the transverse dorsal incision gives a better apposition with 
 the palmar flap than would a straight transverse incision over the dorsum 
 of the joint. 
 
 Disarticulation is best accomplished from the dorsum, after flexing the 
 joint — cutting, in order, through the following structures — skin; fascia; 
 extensor tendons (attached to the bases in the interphalangeal joints, and 
 forming the posterior ligaments of the joints); dorsal portion of the capsule; 
 the knife passing thence behind the base of the distal bone and cutting the 
 
AMPUTATION THROUGH LAST PHALANX OF FINGERS. 327 
 
 lateral ligaments from within outward; anterior portion of capsule, from 
 within; and anterior ligament, also from within. 
 
 The glenoid ligament, the fibro-cartilaginous plate which is mainly attached 
 to the base of the distal bone, should be left in the stump. 
 
 A longitudinal cut made in the mid-lateral aspect of the finger will have 
 the digital arteries on the palmar side. 
 
 All flaps should be cut from without inward — none by transfixion. 
 
 The heads of the metacarpals should be preserved, especially in those 
 who require strength in their hands. Their removal weakens the hand. If left 
 in, they and their soft overlying parts eventually atrophy to some extent and 
 the gap is not so apparent. If removed, somewhat greater symmetry is 
 acquired at the cost of strength. 
 
 Musculo-periosteal coverings in these small amputations through the 
 phalanges are often difficult to provide, but should be provided where possible 
 — even a periosteo-capsular covering in disarticulating. 
 
 In making all palmar incisions, the part should be extended — and flexed 
 while making dorsal incisions. The fullest coverings will be thus secured. 
 
 Guard against making flaps too narrow and pointed — the heads of the 
 bones to be covered are all large, following disarticulation. 
 
 All incisions outlining the different amputations pass through only skin 
 and fascia at first. 
 
 All ligatures should be catgut — and the skin sutures either silk or silkworm- 
 gut. 
 
 In all amputations about the fingers the stump should be snugly dressed 
 and bandaged, and an anterior splint should be included in the dressing. 
 
 AMPUTATION THROUGH LAST PHALANX OF FINGERS, IN GENERAL. 
 
 Best Form. — Palmar Flap. 
 
 Comment. — The palmar flap method furnishes the best form of covering 
 — and, owing to the presence of the nail, is about the only available form 
 of amputation in this locality. 
 
 AMPUTATION THROUGH LAST PHALANX OF FINGERS 
 
 BY PALMAR FLAP. 
 
 Description. — Single palmar flap of all tissues down to bone. 
 
 Position (for all Amputations about the Fingers). — Patient on back; 
 upper extremity held out from body, or, better, supported on a small table; 
 hand pronated and fingers flexed while dorsal incisions are made, and hand 
 supinated and fingers extended during palmar incisions. Assistant stands 
 in front of surgeon, between him and shoulder of patient — steadying the hand 
 with both of his own and holding the adjacent fingers out of the way. Surgeon 
 holds digit to be removed with thumb and forefinger of left hand — with 
 back of thumb downward and his hand pronated during palmar incisions — ■ 
 and with his thumb upward and his hand supinated during dorsal incisions. 
 
 Landmarks. — The space is so limited that the saw-line can only be 
 placed between the matrix of nail and proximal end of second phalanx. 
 
 Incision. — (1) Palmar incision — from saw-line downward along lateral 
 aspect of phalanx, midway between dorsal and palmar surfaces, around the 
 center of the pulp, and back to the saw-line on the opposite side. (2) Dorsal 
 
328 
 
 AMPUTATIONS. 
 
 incision — connects upper ends of palmar incision, passing transversely over 
 the dorsum with slight downward convexity. (For principle, see Fig. 318, C, 
 and 319, B, where disarticulation at the last interphalangeal joint is shown.) 
 
 Fig. 318.— Amputations about the Finger :— A, Through first phalanx, by equal palmar and 
 dorsal flaps ; B, At first interphalangeal joint, by long palmar and short dorsal flaps ; C, At second 
 interphalangeal joint, by palmar flap. 
 
 Operation. — Having outlined these incisions, carry the palmar incision 
 to the bone — dissect up all palmar tissues down to the bone — deepen the 
 dorsal incision to the bone — retract the soft parts, in the entire circumference 
 - — and saw the phalanx with a light saw, while holding the tip of the phalanx 
 
 Fig. 319. — Amputations about the Thumb: — A, Disarticulation of thumb at carpo- 
 metacarpal joint by oval incision; B, Disarticulation at metacarpophalangeal joint by oblique 
 palmar flap; C, Disarticulation at interphalangeal joint by palmar flap. 
 
 with bone-holding forceps (as there is generally too little room for the fingers 
 of the operator to grasp). Ligate the palmar digital artery on each side. 
 Suture the deep flexor tendon to the periosteum or flap. Suture the palmar 
 flap to the transverse dorsal line. 
 
DISARTICULATION THROUGH SECOND JOINT OF FINGERS. 329 
 
 DISARTICULATION AT SECOND INTERPHALANGEAL JOINT OF 
 FINGERS, IN GENERAL. 
 
 Best Method. — Palmar Flap. 
 
 Other Methods. — Short Dorsal and Long Palmar Flaps. 
 Comment. — Even where the double flap method is adopted, the covering 
 must be almost entirely palmar, owing to the position of the nail. 
 
 DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 
 
 OF FINGERS 
 
 BV PALMAR FLAP 
 
 Position. — As for amputation through last phalanx (page 327). 
 
 Landmarks. — Second interphalangeal joint-line. 
 
 Incisions. — (1) Palmar incision — begins opposite the joint-line, midway 
 between dorsal and palmar surfaces — passes down lateral aspect for a distance 
 equal to i| diameters of the finger at the disarticulation-line — crosses palmar 
 aspect with bluntly rounded corners — and passes upward to the corresponding 
 point on the opposite side of the finger. (2) Dorsal incision — connects upper 
 end of palmar incision by a transverse incision made over dorsum of joint, 
 with slight downward convexity (Fig. 318, C). 
 
 Operation. — Having outlined these incisions through skin and fascia, 
 carry the palmar incision to the bone on a line with the retracted skin — and 
 dissect the soft parts up from the bone. Deepen the dorsal incision to 
 the bone, along the line of retracted skin — open the joint from the dorsum 
 and disarticulate from within outward. There is no theca here to close. 
 Suture the deep flexor tendons into the neighboring tissues. Ligate the two 
 digital arteries. Suture the palmar flap to the dorsal line. 
 
 Comment. — The joint is sometimes first disarticulated by a transverse 
 dorsal incision — and the palmar flap then cut from within outward — but 
 with less satisfactorv result. 
 
 DISARTICULATION THROUGH SECOND INTERPHALANGEAL JOINT 
 
 OF FINGERS 
 
 BY SHORT DORSAL AND LONG PALMAR FLAPS. 
 
 Position — Landmarks. — As in the last operation. 
 
 Incisions. — (1) Palmar flap — little more than length of diameter of 
 finger at disarticulation-line — begins at disarticulation-line, in mid-lateral 
 aspect of finger — passes directly down the finger for the above distance — 
 crosses the palm with bluntly rounded corners— and passes up the finger to 
 the corresponding site upon the opposite side. (2) Dorsal flap — one-third 
 the length of the palmar — beginning and ending at the same points as the 
 palmar — and crossing the dorsum with bluntly rounded corners at the above 
 distance below the upper limit. (For principle, see Fig. 318, B.) 
 
 Operation. — Carry these incisions to the bone on the lines of retracted 
 skin, completing the palmar incision first — dissect the soft parts from the 
 bone up to the joint-line — open the dorsal aspect of the joint and disarticulate 
 — completing the operation as in the above method. 
 
330 AMPUTATIONS. 
 
 AMPUTATION THROUGH SECOND PHALANX OF FINGERS, IN 
 
 GENERAL. 
 
 Best Methods. — Palmar Flap; Short Dorsal and Long Palmar Flaps. 
 
 Other Methods. — Equal Dorsal and Palmar Flaps; Equal Lateral 
 Flaps; Single External Flap (for index); Single Internal Flap (for little finger); 
 Circular; Oblique Circular; Dorsal Flap. 
 
 Comment. — Any single flap, unless taken from the palm, brings part of 
 the scar into the palm. A dorsal flap gives a palmar scar. All equal flap 
 methods and circular methods give terminal scars. 
 
 AMPUTATION THROUGH SECOND PHALANX OF FINGERS 
 
 BY PALMAR FLAP. 
 
 Position. — As for amputation through last phalanx (page 327). 
 
 Landmarks. — Lines of proximal and distal joints. 
 
 Incisions. — (1) Palmar incision — begins opposite saw-line in mid-lateral 
 aspect of finger — passes vertically downward a distance equivalent to ij 
 diameters of the finger at the saw-line — crosses the palmar aspect with bluntly 
 rounded corners — passes vertically upward in the mid-lateral aspect of the 
 opposite side to a point corresponding with the one of beginning. (2) Dorsal 
 incision — connects the upper limits of the limbs of the palmar incision, 
 passing transversely across the dorsum with slight downward convexity. 
 (For principle, see Fig. 318, C.) 
 
 Operation. —The above incisions are now deepened to the bone, the 
 palmar first and then the dorsal, on a line with the retracted skin. The 
 soft parts are dissected off the bone back to the saw-line and are retracted 
 while the bone is being sawed. Ligate the digital arteries. In amputating 
 distally to the upper third of the second phalanx, the superficial flexor tendon 
 will retain its attachment. The deep flexor tendon will, however, be 
 severed and should be sutured into the mouth of the fibrous sheath (which 
 ends at the middle of the second phalanx) and into neighboring periosteum 
 and soft parts, if necessary — the closure of the sheath being accomplished 
 in the process of anchoring the deep flexor tendon. The flap is then 
 sutured in the usual way. 
 
 AMPUTATION THROUGH SECOND PHALANX OF FINGERS 
 
 BY SHORT DORSAL AND LONG PALMAR FLAPS. 
 
 Position — Landmarks. — As in the last operation. 
 
 Incisions. — (1) Palmar Flap — (2) Dorsal Flap — both outlined exactly 
 as in the disarticulation through the second interphalangeal joint by short 
 dorsal and long palmar flaps — with the necessary calculations for the change 
 in position (page 327). (For principle, see Fig. 318, B.) 
 
 Operation. — For the technic of the operation, see the disarticulation 
 just mentioned. For the manner of dealing with the structures encountered, 
 see the operation last described. 
 
AMPUTATION THROUGH FIRST PHALANX OF FINGERS. 33 1 
 
 DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF 
 FINGERS, IN GENERAL. 
 
 Best Methods. — Same as mentioned under amputation through second 
 phalanx (page 330). 
 
 Other Methods. — Same (page 330). 
 Comment. — Same (page 330). 
 
 DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF FINGERS 
 
 BY PALMAR FLAP. 
 
 Position. — As in amputation through last phalanx (page 327). 
 
 Landmarks. — First interphalangeal joint-line. 
 
 Incisions. — As for disarticulation at second interphalangeal joint by 
 palmar flap (page 329). (For principle, see Fig. 318, C.) 
 
 Operation. — Same, in principle, as the disarticulation at the second 
 joint of the fingers. Both flexor tendons are here severed below their inser- 
 tions, and the use of the proximal phalanx would be much interfered 
 with unless these tendons were securely attached to the sheath, periosteum, 
 or glenoid ligament of the stump. 
 
 DISARTICULATION AT FIRST INTERPHALANGEAL JOINT OF 
 
 FINGERS 
 
 BY SHORT DORSAL AND LONG PALMAR FLAPS. 
 
 Position — Landmarks. — As in the last operation. 
 
 Incision. — Same as in disarticulation at the second interphalangeal joint 
 (page 329). (For principle, see Fig. 318, B.) 
 
 Operation. — Same as in the operation just referred to (page 329). For 
 treatment of the flexor tendons, see disarticulation at first interphalangeal 
 joint by a palmar flap (page $^, 1) . 
 
 AMPUTATION THROUGH FIRST PHALANX OF FINGERS , IN GENERAL. 
 
 Best Methods. — Palmar Flap; Short Dorsal and Long Palmar Flaps. 
 
 Other Methods. — Same as mentioned under amputation through second 
 phalanx (page 330). To which list may be added the oval method. 
 
 Comment. — Same as made under the operation just referred to (page 
 33o)- 
 
 AMPUTATION THROUGH FIRST PHALANX OF FINGERS 
 
 BY PALMAR FLAP. 
 
 Position. — As for amputation through last phalanx (page 327). 
 
 Landmarks. — Lines of metacarpophalangeal and first interphalangeal 
 joints. 
 
 Incisions — Operation. — Same as for amputation through second phalanx 
 (page 330). For reference to flexor tendons, see under disarticulation at 
 first interphalangeal joint by palmar flap (page 331). 
 
332 AMPUTATIONS. 
 
 AMPUTATION THROUGH FIRST PHALANX OF FINGERS 
 
 BY SHORT DORSAL AND PALMAR FLAPS. 
 
 Position — Landmarks. — As in the above operation. 
 
 Incision — Operation. — As for amputation through the second phalanx 
 by the same method (page 330). For reference to treatment of the flexor 
 tendons and sheaths, see under disarticulation at first interphalangeal joint 
 by palmar flap (page 331). 
 
 DISARTICULATION OF FINGERS AT METACARPO-PHALANGEAL 
 JOINTS, IN GENERAL. 
 
 Best Methods. — Oval Method (for fingers in general and for thumb); 
 Externo-palmar Flap of Farabeuf (for index) ; Interno-palmar Flap of Fara- 
 beuf (for little finger); Oblique Palmar Flap (for thumb). 
 
 Other Methods. — Equal Lateral Flaps; Circular Incision, joined by 
 vertical dorsal queue; Palmar Plap; Large External and Small Internal 
 Flaps (for index); Large Internal and Small External Flaps (for little finger). 
 
 Comment. — The first four are the best in the sites indicated and are 
 superior to the others mentioned. The oblique palmar flap for the thumb 
 gives the best covering where sufficient tissue exists. 
 
 DISARTICULATION OF FINGERS, IN GENERAL, AT METACARPO- 
 PHALANGEAL JOINT. 
 
 BY OVAL METHOD. 
 
 Description. — The queue is placed over the dorsum of the joint and 
 the center of the oval passes across the palmar aspect at the web-line. 
 
 Position. — As for amputation through the last phalanx (page 327). 
 
 Landmarks. — Head of metacarpal; metacarpo-phalangeal joint-line; 
 web of finger. 
 
 Incision. — Begins just above head of metacarpal, on its dorsal aspect 
 (in the position corresponding with its neck) — passes down the median dorsal 
 aspect over the prominence of the knuckle, to just beyond the base 
 of the first phalanx (which is about midway between the metacarpo- 
 phalangeal joint-line and the free edge of the web) — at this point the hitherto 
 median incision diverges into two symmetrical limbs — each sweeping across 
 the dorso-lateral aspect of the finger to just below the junction of the finger 
 with the web — and thence transversely across the palmar surface in the 
 line of the crease, on a level with the free border of the web, coming to the 
 opposite side just below the junction of the web with the finger. This rather 
 extensive incision is best made with three strokes — from commencement to 
 web of one side — from point of divergence of median line to web of opposite 
 side — and across palmar surface connecting the two limbs (Fig. 320, H, and 
 321, E). 
 
 Operation. — The above incision through skin and fascia is now deepened. 
 The palmar portion is cut to the bone while the finger is forcibly extended. 
 The lateral portions are carried to the bone, cutting the lumbricales and 
 interossei. The soft parts are retracted to the joint-line. The extensor 
 tendons are then cut and the joint thus entered from the dorsum — the lateral 
 
METACARPO-PHALANGEAL DISARTICULATION OF THUMB. 333 
 
 ligaments and glenoid ligament being cut from within and the disarticulation 
 
 Fig. 320.— Amputations about the Fingers, Hand, and Wrist : — A, Through second phalanx 
 of little finger, by single internal flap ; B, At first interphalangeal joint, by oval method ; C, Through 
 second phalanx, by equal lateral flaps; D, Through second phalanx of index, by single external flap ; 
 E, Through first phalanx, by oblique circular; F, Through first phalanx, by ordinary circular ; G, 
 At metacarpophalangeal joint of little finger, by interno-palmar flap; H, At metacarpophalangeal 
 joint, by oval method ; I, At metacarpophalangeal joint of index, by externo-palmar flap ; J, Of little 
 finger at carpo-metacarpal joint, by racket method ; K, Same of ring finger; L, Of middle finger and 
 part of metacarpal, by racket method ; M, Of two inner fingers at carpo-metacarpal joints, by racket 
 method ; N, Of thumb at carpo-metacarpal joint, by racket method ; O, Through metacarpophalan- 
 geal joint of thumb, by oblique palmar flap ; P, P, At wrist-joint, by external flap. 
 
 completed. The two digital arteries are tied and the synovial sheath closed. 
 The edges of the sides of the oval are sutured in one vertical, antero-posterior 
 
,334 AMPUTATIONS. 
 
 line, in continuation with the queue of the incision. The splint applied 
 should include the wrist-joint. 
 
 Comment. — (i) The joint may be opened from the palmar surface, by 
 cutting the glenoid ligament transversely against the base of the metacarpal. 
 In either case, the glenoid ligament is retained. (2) No attempt is made to 
 attach the flexor tendons, as the entire finger is removed and there would 
 be nothing for them to flex. (3) The lower end of the vertical cicatrix is 
 eventually drawn up out of the way of palmar pressure. (4) If it be desired 
 to remove the head of the metacarpal, prolong the queue of the incision 
 upward — free the neck of the bone of soft parts, hugging the bone in the 
 process — retract the soft parts — and, while partly lifting the metacarpal 
 from its bed by traction upon the finger, if still attached, or by grasping the 
 head of the bone with bone-forceps, if disarticulation have occurred, pass 
 a chain or Gigli saw beneath the bone and make a section, so as to bevel the 
 bone obliquely from behind downward and forward, and from the inner- 
 or outer aspect toward the median aspect (Fig. 321, C and D). (5) Where 
 the skin of the palm is very dense and hard, as in laborers, an awkward pro- 
 jection of skin may be left on the palmar surface of the convexity of the oval, 
 which can be removed and make the suturing more satisfactory by cutting 
 out a V-shaped portion from the palmar aspect. This, however, amounts, 
 practically, to lateral flaps, and brings part of the scar into the palm. (6) 
 Avoid cutting into the web. 
 
 DISARTICULATION OF THUMB AT METACARPO-PHALANGEAL JOINT 
 
 BV OVAL METHOD. 
 
 Position. — As in amputation through last phalanx (page 327). 
 
 Landmarks. — Neck of first metacarpal; metacarpo-phalangeal joint. 
 
 Incision. — Begins on dorsal aspect of neck of metacarpal, to ulnar side 
 of median line — passes directly down over head of bone and along median 
 aspect of extensor tendons, or slightly to ulnar side, to just beyond the base 
 of the metacarpal — thence the median incision diverges — each limb passing 
 obliquely across the dorso-lateral borders of the thumb, so as to cross and 
 meet upon the palmar aspect opposite the center of the first phalanx (Fig. 
 3i9, A). 
 
 Operation. — Deepen this incision to the bone along the line of the re- 
 tracted skin — dividing the extensor brevis pollicis and extensor longus pollicis 
 opposite the metacarpo-phalangeal joint, and the flexor longus pollicis 
 opposite the middle of the first phalanx. The sesamoid bones are to be 
 detached from the base of the first phalanx and left in the stump. As far 
 as possible the muscles which are attached to the base of the first phalanx 
 (extensor brevis pollicis, adductor obliquus pollicis, adductor transversus 
 pollicis, abductor pollicis, flexor brevis pollicis), as well as the long flexors 
 and extensors, should be sutured into the tissues of the stump — as considerable 
 range of movement is thereby secured for the metacarpal bone, whereby 
 it may offer counterpressure to the fingers. Close the synovial sheath. Tie 
 the dorsalis pollicis and two branches of the princeps pollicis. Suture the 
 oval in a single straight line in continuation of the queue. 
 
 Comment. — The head of the metacarpal is large and requires ample 
 covering. 
 
METACARPOPHALANGEAL DISARTICULATION OF INDEX-FINGER. 335 
 DISARTICULATION OF THUMB AT METACARPO-PHALANGEAL JOINT 
 
 BY OBLIQUE PALMAR FLAP — (FARABEUF). 
 
 Description. — This method consists of two U-shaped incisions, the 
 dorsal having its convexity upward, the palmar having its convexity down- 
 ward — the limhs of each U passing, and obliquely meeting, on the lateral 
 aspects of the thumb. 
 
 Position. — As for amputation through the last phalanx (page 327). 
 
 Landmarks. — Lines of the metacarpophalangeal and interphalangeal 
 joints. 
 
 Incision. — The convexity of the dorsal U is upward and corresponds 
 with the dorsal aspect of the metacarpophalangeal joint. The convexity 
 of the palmar U is downward and is placed just above the interphalangeal 
 joint-line. Between these two rounded extremities the lateral limbs pass 
 in an oblique direction along the lateral borders of the thumb, becoming 
 continuous with each other (Fig. 320, O, and 319. B). 
 
 Operation. — This incision is deepened throughout to the bone, along 
 the line of the retracted skin — the extensor brevis pollicis and extensor longus 
 pollicis are divided over the metacarpophalangeal joint, and the flexor 
 longus pollicis about the center of the first phalanx — the soft parts are freed 
 back to the joint-line — the sesamoid bones are detached from the base of 
 the first phalanx and left in the Map — the joint is entered from above and 
 disarticulation completed. The dorsalis pollicis and the two branches of 
 the princeps pollicis are to be tied. The synovial sheath is closed. The 
 convexity of the palmar flap is sutured into the concavity of the dorsal wound 
 — bringing the cicatrix well on to the dorsum and out of the way of pressure 
 
 Comment. — As the head of the metacarpal is disproportionately large, 
 an additional allowance of covering must be made. 
 
 DISARTICULATION OF INDEX-FINGER AT METACARPO-PHALANGEAL 
 
 JOINT 
 
 P.V EXTERNO-PALMAR FLAP— (FARABEUF). 
 
 Description. — This is really an oval method, so modified as to bring 
 the cicatrix upon the interno-dorsal aspect of the metacarpophalangeal 
 region — so that fingers and objects opposed to that aspect may not come 
 into contact with the scar. 
 
 Position. — As for amputation through last phalanx of finger (page 327). 
 
 Landmarks. — Metacarpophalangeal joint-line; middle of first phalanx; 
 web. 
 
 Incision. — Begins at metacarpophalangeal joint-line, immediately over 
 the median aspect of the extensor tendon — passes vertically down the median 
 dorsal aspect of the finger, in the above relation to the extensor tendon, to 
 the center of the first phalanx — thence sweeps across the lateral and palmar 
 aspects to the web — and thence passes in a straight line, by the shortest 
 route, up the inner side of the finger to the place of beginning (Fig. 320, I). 
 
 Operation. — This superficial incision is deepened to the bone — the soft 
 parts retracted to the joint-line — disarticulation effected — and the operation 
 completed as in the simple oval method. The digital, dorsalis indicis, and 
 radialis indicis arteries are to be tied. The flexor sheath is to be closed — 
 and the parts so sutured as to cause the cicatrix to occupy the position of the 
 straight portion of the incision, upon the interno-dorsal aspect. 
 
336 AMPUTATIONS. 
 
 Comment. — (i) The placing of the incision over the median, or even 
 slightly to the ulnar, rather than the radial aspect of the extensor tendon 
 (as recommended by Farabeuf), gives ampler covering, and a greater cer- 
 tainty of the scar falling well to the ulnar side. (2) If the head of the meta- 
 carpal be removed, it is exposed as mentioned under the oval method (page 
 334, Comment). 
 
 DISARTICULATION OF LITTLE FINGER AT METACARPOPHALANGEAL 
 
 JOINT 
 
 BV INTERNO-PALMAR FLAP— (FARABEUF). 
 
 Description. — This, also, is a modification of the oval method, so cal- 
 culated as to bring the cicatrix upon the externo-dorsal aspect of the meta- 
 carpophalangeal region — that non-scar tissue may come into contact with 
 objects which press the stump. 
 
 Position — Landmarks. — As in the last operation. 
 
 Incision. — Begins at the metacarpo-phalangeal joint-line, immediately 
 over the median aspect of the extensor tendon — passes vertically down the 
 dorsal aspect of the finger, in the above relation to the extensor tendon, to 
 the center of the first phalanx — thence sweeps across the lateral and palmar 
 aspects of the finger to the web — and thence passes in a straight line, by the 
 shortest route, up the radial side of the finger to place of beginning (Fig. 
 320, G). 
 
 Operation. — The steps of the disarticulation are completed as in the 
 corresponding operation just described upon the thumb, the reverse of which 
 this is, in every respect. Two digital arteries are to be tied. The parts 
 are to be so sutured as to cause the cicatrix to occupy the position of the 
 straight portion of the incision, upon the externo-dorsal aspect of the region, 
 buried in the groove formed by the adjacent finger. 
 
 Comment. — (1) Carrying the incision over the median aspect of the 
 extensor tendon insures more covering than if the incision passed down the 
 ulnar aspect, as recommended by Farabeuf — and also makes it more certain 
 that the scar will fall well to the radial side of the stump, out of the way of 
 pressure. (2) If it be desired to remove the head of the metacarpal, it is 
 exposed as described under the oval method of disarticulating the fingers in 
 general — the bone being here beveled from ulnar to radial aspect, and from 
 dorsum to palm. 
 
 SURGICAL ANATOMY OF THE HAND. 
 
 Bones. — (a) Metacarpals, of thumb and fingers; — (b) Carpals; — First 
 Row; scaphoid, semilunar, cuneiform, pisiform; — Second Row; trapezium, 
 trapezoid, os magnum, unciform. 
 
 Articulations and Ligaments. — (A) Metacarpophalangeal Articula- 
 tions; — See description under Surgical Anatomy of Fingers. (B) Meta- 
 carpals with each other (Intermetacarpal) ; — (a) Carpal ends of four inner 
 metacarpals; — dorsal, palmar, and interosseous ligaments, and synovial 
 membrane; — (b) Digital ends of four inner metacarpals; — transverse meta- 
 carpal ligaments (on palmar aspect). (C) Inner Metacarpals with the 
 carpus; — dorsal, palmar, and interosseous ligaments, and synovial membrane. 
 (D) Metacarpal of thumb with trapezium; — capsular ligament. (E) Articu- 
 lations of second row of carpals with each other; — three dorsal, three palmar, 
 and three interosseous ligaments, between trapezium and trapezoid, between 
 
SURGICAL ANATOMY OF THE HAND. 337 
 
 trapezoid and os magnum, and between os magnum and unciform; and 
 synovial membrane between each. (F) Articulations of carpals of first row 
 with each other; — two dorsal ligaments between scaphoid and semilunar, 
 and between semilunar and cuneiform; two palmar ligaments between scaphoid 
 and semilunar, and between semilunar and cuneiform; two interosseous 
 ligaments between scaphoid and semilunar, and between semilunar and 
 cuneiform; capsular ligament between cuneiform and pisiform; two palmar 
 ligaments between pisiform and unciform process of unciform, and between 
 pisiform and fifth metacarpal; and synovial membrane between each bone. 
 (G) Articulations of two rows of carpals with each other (medio-carpal) ; — 
 palmar, dorsal, external lateral and internal lateral ligaments, and synovial 
 membrane (between each row). 
 
 Anterior Annular Ligament. — (a) Attachments; — Internally; pisiform 
 and unciform process of unciform bone. Externally; tuberosity of scaphoid 
 inner part of anterior surface, and ridge on trapezium. Superiorly; con 
 tinuous with deep fascia of forearm. Inferiorly; continuous with palmar 
 fascia, and furnishing attachment to some of muscles of thumb and little 
 finger, (b) Structures passing superficial to anterior annular ligament (from 
 without inward) ; radial vessels and nerve, flexor carpi radialis, palmaris 
 longus, ulnar vessels and nerve, flexor carpi ulnaris. (c) Structures passing 
 beneath anterior annular ligament (from above downward) ; flexor sublimis 
 digitorum, median nerve, flexor profundus digitorum, flexor longus pollicis. 
 
 Posterior Annular Ligament. — (a) Attachments; — Internally; styloid 
 process of ulna, cuneiform and pisiform bones. Externally; outer margin 
 of radius and elevated ridge on its posterior surface. Superiorly; continuous 
 with deep fascia of forearm, (b) Tendons passing beneath posterior annular 
 ligament (in six compartments, from without inward) ; — (1) extensor ossis 
 metacarpi pollicis and extensor brevis pollicis; (2) extensor carpi radialis 
 longior and brevior; (3) extensor longus pollicis; (4) extensor communis 
 digitorum and extensor indicis; (5) extensor minimi digiti; (6) extensor 
 carpi ulnaris. 
 
 Synovial Sacs. — Two synovial sacs lie beneath the anterior annular 
 ligament, one for the flexor sublimis digitorum and flexor profundus digitorum, 
 and one for the flexor longus pollicis. Both extend upward for 3 to 4 cm. 
 (ij to ij inches) above the anterior annular ligament. That for the flexor 
 longus pollicis extends downward to last phalanx of thumb. That for the 
 flexor tendons of fingers divides into four processes; the one for the little 
 finger generally extending to base of last phalanx; — those for index, middle, 
 and ring fingers ending about middle of the metacarpals — and are thus 
 separated by about 1.3 cm. (J inch) from the great synovial sac. Thus there 
 is an open channel from the ends of the thumb and little fingers to a point 
 3 or 4 cm. (1 J to 1 ^ inches) above the anterior annular ligament. 
 
 Muscles and Tendons. — (i) Of palmar aspect : — (a) Superficial 
 Muscles from Forearm; — Flexor carpi radialis; palmaris longus; flexor carpi 
 ulnaris; flexor sublimis digitorum. (b) Deep Muscles from Forearm; — 
 Flexor profundus digitorum; flexor longus pollicis. (c) Short, small Muscles 
 of Thumb; — Abductor pollicis; opponens pollicis (flexor ossis metacarpi 
 pollicis); flexor brevis pollicis; adductor obliquus pollicis; adductor trans- 
 versa pollicis. (d) Short, small Muscles of Little Finger; — palmaris brevis; 
 abductor minimi digiti; flexor brevis minimi digiti; opponens minimi digiti 
 (flexor ossis metacarpi minimi digiti). (e) Short Central Muscles of Hand; 
 — four lumbricals; three palmar interossei. (2) Of dorsal aspect :— (a) 
 Superficial Muscles from Forearm; — Extensor communis digitorum; extensor 
 
33% AMPUTATIONS. 
 
 minimi digiti; extensor carpi ulnaris. (b) Deep Muscles from Forearm;— 
 Extensor ossis metacarpi pollicis; extensor brevis pollicis (extensor primi 
 internodii pollicis); extensor longus pollicis (extensor secundi internodii 
 pollicis); extensor indicis; extensor carpi radialis longior; extensor carpi 
 radialis brevior. (c) Small Muscles of Dorsal Aspect of Hand; — four dorsal 
 interossei. 
 
 Attachment of Muscles to Bases of Metacarpals. — To first; extensor 
 ossis metacarpi pollicis. To second; extensor carpi radialis longior; flexor 
 carpi radialis. To third; extensor carpi radialis brevior. To fifth; extensor 
 carpi ulnaris; some fibers of flexor carpi ulnaris. 
 
 Arteries. — (a) Palmar supply: — (i) From Radial; — anterior radial 
 carpal; superficialis yoke; deep arch; princeps pollicis; radialis indicis; three 
 palmar interossei; three superior (posterior) communicating (perforating); 
 three inferior (anterior) communicating (perforating); palmar carpal re- 
 current. (2) From Ulnar; — anterior interosseous; anterior ulnar carpal; 
 superficial palmar arch; four palmar digital; deep palmar (communicating); 
 three palmar interossei (from deep arch, common to radial and ulnar) ; three 
 superior (posterior) communicating (perforating) (also common to radial); 
 three inferior (anterior) communicating (perforating) (also common to 
 radial); palmar carpal recurrent (also common to radial), (b) Dorsal 
 supply : — (i) From Radial; — radial; posterior radial carpal; dorsalis pollicis; 
 dorsalis indicis; metacarpal (first dorsal interosseous); second and third 
 dorsal interosseous; three superior (posterior) communicating (perforating); 
 three inferior (anterior) communicating (perforating). (2) From Ulnar; — 
 posterior ulnar carpal; metacarpal. 
 
 Veins. — (a) Superficial; — Dorsal Venous Plexus — from which arise super- 
 ficial radial vein, and anterior and posterior superficial ulnar veins; — Anterior 
 Median Plexus — from which arise superficial median vein, (b) Deep; Two 
 venae comites for each artery. 
 
 Lymphatics. — Pass up the forearm from the lymphatic palmar arch, 
 and from the dorsal plexus of lymphatics. 
 
 Nerves. — (a) From Median; — Median and following branches; outer 
 and inner palmar cutaneous; muscular branches; five digital branches; (b) 
 From Ulnar; — Ulnar and following branches; palmar cutaneous; dorsal 
 cutaneous; superficial palmar branch; deep palmar branch, (c) From 
 Radial; — external branch; internal branch. 
 
 SURFACE FORM AND LANDMARKS OF THE HAND. 
 
 Carpal bones — two subcutaneous eminences may be felt upon the palmar 
 aspect of the hand just below the wrist — the outer (just beneath the radial 
 styloid process) due to the tuberosity of the scaphoid and ridge on the trape- 
 zium (the ridge being just beneath the former) — the inner, due to the pisiform 
 bone The unciform process of the unciform lies below and slightly internal 
 to the pisiform. No other carpal bones are recognizable on the palmar 
 surface — and only the cuneiform on the dorsum. 
 
 Metacarpal bones — The heads of the metacarpals form the knuckles. 
 The dorsal surface of the fifth, and the heads of all, are subcutaneous — all the 
 other aspects of the remainder are covered by muscles or tendons. The base 
 of the metacarpal of the thumb can be felt — and the sesamoid bones opposite 
 the metacarpo-phalangeal joint. 
 
 Skin-folds (creases) of the hand — (a) Superior fold — begins at wrist, 
 between thenar and hypothenar eminences, and runs to the outer border 
 
SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT HANDS. 339 
 
 of the hand at the base of the index-finger — and is formed by the adduction 
 of the thumb, (b) Middle fold — begins at outer border of hand where supe- 
 rior fold ends, and runs inward and slightly upward and ends at outer limit 
 of hypothenar eminence — and is formed by the simultaneous flexion of the 
 metacarpophalangeal joints of the first and second fingers — and about 
 corresponds, opposite the third metacarpal, to the lower portion of the super- 
 ficial palmar arch, (c) Inferior fold — begins opposite the cleft between 
 the index and middle fingers and runs almost transversely to the ulnar margin 
 of the hand, crossing the lower part of the hypothenar eminence — and is 
 formed by the flexion of the middle, ring, and little fingers. It crosses the 
 necks of the three inner metacarpals, and approximately indicates the upper 
 limit of the synovial sheaths of the flexor tendons of the three outer fingers. 
 Midway between this fold and the free margins of the webs are the meta- 
 carpophalangeal joints. 
 
 Line of carpo-meta carpal joints — from base of fifth metacarpal, to carpo- 
 metacarpal joint-line of thumb (both of which may be recognized). The 
 inner portion of this line is regular, the outer portion irregular. 
 
 Line of metacarpophalangeal joint-line — found by flexing the first 
 phalanges at a right angle with the metacarpals — and then prolonging the 
 mid-lateral axis of the metacarpals forward — which lines will pass through 
 the center of the joints. 
 
 Free edges of webs of fingers, on palmar aspect, are about 2 cm. (f inch) 
 below the metacarpophalangeal joints. 
 
 Muscles — The muscles of the thenar (thumb) eminence — and .those of 
 the hypothenar (little finger) eminence are recognizable, and also the ad- 
 ductor transversus pollicis. The lumbricals form soft eminences behind the 
 clefts of the fingers — and the dorsal interossei form similar soft eminences 
 between the metacarpals. The position of many of the extensor tendons 
 can be recognized by both sight and. touch — and some of the flexor tendons 
 can be detected by touch while in the act of movement. 
 
 Vessels — the superficial palmar arch is on a level with the lower border 
 of the outstretched thumb, passing down from the wrist on the outer side 
 of the pisiform. The deep palmar arch lies about 1.3 cm. (h inch) nearer 
 the wrist, crossing the shafts of the second, third, and fourth metacarpals 
 near their bases. 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 
 
 THE HANDS. 
 
 A finger may be removed with a part, or the whole, of its metacarpal. 
 In the middle metacarpals, the removal of a part, where possible, is better 
 than a disarticulation at the carpo-metacarpal joint — as the end of the bone 
 is not apt to get into the way, and the strength of the hand is greater. In 
 the case of the thumb and little finger, however (which are the fingers most 
 frequently removed, because most exposed to injury), it is best to remove the 
 entire metacarpal — the retention of a part of the outer metacarpals being 
 of little value, and often in the way — and its removal not weakening the hand 
 as much as the loss of an inner one. 
 
 If but a part of the metacarpal of the thumb or little finger be removed, 
 however, the remaining portion should be beveled obliquely away from the 
 position of most pressure. 
 
 The metacarpals should be divided in their continuity by a Gigli saw 
 It is easier, but less surgical, to divide them with bone-cutting pliers. 
 
34° 
 
 AMPUTATIONS. 
 
 Fig. 321. — Amputations about Hand and Wrist: — A, Disarticulation of two inner fingers, 
 together with their metacarpals, by curved racket incision; B, Disarticulation at wrist by equal 
 anterior and posterior flaps; C, D, Oblique section of second and fifth metacarpals as sometimes 
 practised in disarticulation at metacarpo-phalangeal joints of first and fourth fingers; E, Amputa- 
 tion of part of metacarpal by oval method as sometimes performed in disarticulation at the 
 metacarpo-phalangeal joints of the innermost and outermost fingers. 
 
 Additional advantages in amputating a finger and part of its metacarpal, 
 over disarticulating a finger and all of its metacarpal, are the following; — 
 deep palmar arch is not exposed; synovial sacs of flexor tendons may escape, 
 
AMPUTATION OF FINGER WITH PART OF ITS METACARPAL. 341 
 
 if the bone be divided above its center; carpo-metacarpal synovial sacs are 
 not opened; and tendons attached to bases of metacarpals are not lost. 
 
 Where, in disarticulating at the carpo-metacarpal articulation, the joint- 
 line is not easily located before incising, begin the incision as high as thought 
 to be the articular line, and then verify the line by inserting the tip of the 
 index-finger into the wound, while the opposite hand manipulates the special 
 finger whose metacarpal forms part of the articulation. 
 
 As the metacarpal of the thumb and, according to some, of the little finger 
 do not communicate with the large synovial sac of the carpal bones, they 
 can be removed in their entirety with little danger of infection — but, in un- 
 clean cases, the removal of the second, third, and fourth metacarpals in their 
 continuity is preferable to a disarticulation at the carpo-metacarpal line, 
 with the likelihood of general infection. 
 
 The synovial sheaths should be closed with gut-suture when cut. But 
 where large synovial sheaths and extensive articular surfaces are opened up, 
 drainage for twenty-four or forty-eight hours is indicated. 
 
 In partial amputations of the hand, the flexor and extensor tendons should 
 be cut long enough to be sutured into the wound, so as to retain flexion and 
 extension of the stump. 
 
 The main dangers in amputating and disarticulating about the hand 
 are wounding of the deep palmar arch or termination of the radial, and in 
 opening the synovial sheath of the palm or fingers. 
 
 The stump should be dressed upon a splint which will immobilize the 
 wrist. 
 
 AMPUTATION OF FINGERS, IN GENERAL, WITH PARTS OF THEIR 
 
 METACARPALS. 
 
 Methods. — Racket Method — best for single fingers, in general, as well as 
 for thumb and little finger; and also for two or three continguous inside 
 fingers. Equal Dorsal and Palmar Flaps — best for the three inner fingers. 
 Anterior Ellipse (sometimes called a Short Palmar Flap) — best for all the 
 fingers, not including the thumb. 
 
 General Indications. — Traumatism and infection. 
 
 AMPUTATION OF A FINGER. IN GENERAL, WITH PART OF ITS 
 
 METACARPAL, 
 
 BY RACKET METHOD. 
 
 Description. — The finger is removed as one continuous whole at the 
 line of section of the metacarpal. 
 
 Position. — Same as for amputation through last phalanx (page 327). 
 
 Landmarks. — Outline of dorsal aspect of metacarpal; carpo-metacarpal 
 joint; webs of fingers. 
 
 Incision. — Begins over dorsum of metacarpal, a short distance above 
 the point at which the bone is to be sawed — passes thence downward over 
 the middle of the dorsal aspect until the neck of the metacarpal is reached 
 — whence the median line diverges into two limbs, each limb passing down 
 the dorso-lateral aspect of the finger to just below the junction of the web and 
 finger — whence each limb crosses immediately in front of the digito-palmar 
 crease to meet in the center of the palmar aspect of the finger (Fig. 320, L). 
 
342 AMPUTATIONS. 
 
 Operation.— This incision is rleepened to the bone on the line of the 
 retracted skin. The extensor tendons are divided near the upper end of 
 the vertical incision. The sides of the shaft of the metacarpal are carefully 
 cleared, hugging the bone in the process. The region of the metacarpo- 
 phalangeal joint is also freed and the flexor tendons divided near the neck 
 of the metacarpal, while the finger is forcibly extended. The shaft of the 
 metacarpal is further cleared up to the saw-line, the finger being held in 
 extreme extension. The Gigli or chain saw is now passed beneath the meta- 
 carpal, while the soft parts are held out of the way, and the bone sawed so 
 as to bevel it from below upward and toward the dorsum. The digital 
 arteries are divided and are to be tied. The synovial sheath of the flexor 
 tendons should be closed with gut sutures. The wound is sutured in a single 
 median line upon the dorsal aspect. 
 
 AMPUTATION OF THUMB WITH PART OF ITS METACARPAL 
 
 BY RACKET METHOD. 
 
 Description — Position — Landmarks. — As for amputation of a finger 
 with part of its metacarpal (page 341). 
 
 Incision. — As in disarticulation of thumb with its entire metacarpal, by 
 the racket method (page 345) — except that the queue of the incision only 
 extends up to a little above the sawdine. 
 
 Operation. — As for amputation of a finger with part of its metacarpal 
 (page 341). The metacarpal should be beveled from above downward and 
 inward. 
 
 AMPUTATION OF LITTLE FINGER WITH PART OF ITS METACARPAL 
 
 BY RACKET METHOD. 
 
 Description — Position — Landmarks. — As for amputation of a finger 
 with part of its metacarpal (page 341). 
 
 Incision. — As in disarticulation of little finger with its entire metacarpal, 
 by the racket method (page 344) — except that the queue of incision begins 
 just above sectiondine of bone. 
 
 Operation. — As for amputation of a finger with part of its metacarpal, 
 by the racket method. The metacarpal should be beveled from above 
 downward and toward the radial side. 
 
 AMPUTATION OF TWO CONTIGUOUS INSIDE FINGERS WITH PART 
 OF THEIR METACARPALS 
 
 BY RACKET METHOD. 
 
 Similar, practically, to the disarticulation of two contiguous inside fingers 
 with their entire metacarpals, by the racket method (page 346). 
 
 AMPUTATION OF THREE INSIDE FINGERS WITH PARTS OF 
 THEIR METACARPALS 
 
 BY RACKET METHOD. 
 
 See the disarticulation of the three innermost fingers with their entire 
 metacarpals by the racket method (page 346). 
 
DISARTICULATION OF FINGERS WITH ENTIRE METACARPALS. 343 
 
 AMPUTATION OF THREE INNERMOST FINGERS WITH PARTS OF 
 THEIR METACARPALS 
 
 BY EQUAL DORSAL AND PALMAR FLAPS. 
 
 See the disarticulation of the three innermost fingers with their entire 
 metacarpals, by the method of equal dorsal and palmar flaps (page 346) . 
 
 AMPUTATION OF ALL THE FINGERS (EXCLUDING THE THUMB), 
 WITH PARTS OF THEIR METACARPALS, 
 
 BY ANTERIOR ELLIPSE. 
 
 See the corresponding disarticulation of all the fingers, exclusive of the 
 thumb, with their entire metacarpals, bv an anterior ellipse (or short palmar 
 flap, as it is sometimes called) (page 348). 
 
 Fig. 322. — Showing the Relations or the Various Metacarpal to the Correspond" 
 tng Carpal Bones, as Guides in Disarticulating the Metacarpals from the Carpals 
 and the Adjacent Metacarpals. 
 
 DISARTICULATION OF FINGERS, IN GENERAL, WITH THEIR ENTIRE 
 
 METACARPALS. 
 
 Methods. — Racket Method — best for the fingers in general, including 
 thumb, index, and little fingers — and also used for the two or three inside 
 fingers. Equal Dorsal and Palmar Flaps — best for three innermost fingers. 
 Anterior Ellipse (Short Palmar Flap) — best for all the fingers, exclusive of 
 thumb — and also best for all the fingers including thumb. Palmar Flaps — ■ 
 sometimes used for the thumb, but inferior to the racket. Circular Method 
 — sometimes used for all the fingers, with or without the thumb. 
 
 Comment. — Preservation of the carpus is desirable, especially if the 
 flexor and extensor tendons are so sutured into the wound that considerable 
 range of movement may be secured for the stump wielding the artificial 
 limb. Fig. 322 shows the intercarpal and carpo-metacarpal joints. 
 
344 
 
 AMPUTATIONS. 
 
 DISARTICULATION OF AN INNER FINGER WITH ITS METACARPAL 
 
 BY RACKET INCISION. 
 
 Description. — The finger is removed as one continuous whole at the 
 carpometacarpal articulation. 
 
 Position. — As for amputation through the last phalanx (page 327). 
 
 Landmarks. — Outline of dorsal aspect of carpo-metacarpal articulation, 
 and metacarpal bone. 
 
 Incision — Begins just above the carpo-metacarpal joint — passes down 
 the median dorsal aspect of the metacarpal until its neck is reached — thence 
 diverges into two limbs, each limb running over the dorso-lateral aspect of 
 the finger to just below the junction of the web and finger — whence each 
 limb crosses the digito-palmar crease to meet in the center of the palmar 
 aspect of the finger. If necessary for the purpose of aiding disarticulation 
 at the carpo-metacarpal joint, a short transverse incision may be made at a 
 right angle to the upper end of the queue (Fig. 320, K). 
 
 Operation. — This incision is now deepened on a line of the retracted 
 skin and fascia. The shaft of the metacarpal and the metacarpophalangeal 
 joint are carefully cleared, hugging the bones as closely as possible, while 
 an assistant keeps the finger in the position of extreme extension. The extensor 
 tendons are divided as near the upper limit of the queue as possible — the 
 flexor tendons near the neck of the metacarpal. The sides of the metacarpal 
 are now bared up toward the carpo-metacarpal articulation, using especial 
 care in the palmar region. The ligaments of the intermetacarpal joints 
 and carpo-metacarpal joints are divided by carefully thrusting a knife between 
 the sides of the bases of the metacarpals and between the metacarpals and 
 the carpal bones, working from the dorsum of the hand. The disarticulation 
 is completed by forcibly turning back the finger upon the dorsum of the 
 hand, completing, with the knife, the division of any undivided ligaments, 
 insertions of tendons, or palmar structures. The synovial sheaths of the 
 flexor tendons should be sutured with catgut, if possible. Tie the two digital 
 arteries — and suture the wound in a single median line upon its dorsal aspect. 
 
 DISARTICULATION OF INDEX-FINGER WITH ITS METACARPAL 
 
 BY RACKET INCISION. 
 
 Description. — The steps of this operation are practically the same as 
 for the corresponding operation upon an inner finger. The incision is in 
 the mid-dorsal line. The addition of a short transverse incision at a right 
 angle to the upper end of the queue is especially advisable here, owing to 
 the width of the base of the second metacarpal. The outer (radial) of the 
 diverging limbs below should follow the dorsal aspect a little further down 
 before sweeping over the lateral aspect than does the inner (ulnar) limb, in 
 order to bring the scar more out of the way of pressure. The index should 
 be extended and abducted in clearing and disarticulating. Tie the digital, 
 radialis indicis, and dorsalis indicis arteries — and suture the wound in a ver- 
 tical dorsal line. 
 
 DISARTICULATION OF LITTLE FINGER WITH ITS METACARPAL 
 
 BY RACKET INCISION. 
 
 Description. — The steps of the operation are essentially similar to those 
 for the removal of an inner finger with its metacarpal by the racket incision. 
 It is better to place the incision in the mid-dorsal aspect than toward the 
 
DISARTICULATION OF THUMB WITH ITS METACARPAL. 345 
 
 inner (ulnar) side of the metacarpal, as objects less easily press such a scar. 
 At the upper extremity of the queue a short transverse incision may be added, 
 not crossing the upper end of the queue (as in the case of the inner fingers), 
 but running from the upper end of the queue at a right angle toward the 
 ulnar aspect of the hand, over the carpo-metacarpal joint — to allow of readier 
 disarticulation. The inner (ulnar) of the diverging limbs below should 
 follow the dorsal aspect a little further down before sweeping over the lateral 
 border than does the outer (radial) limb — in order to bring the scar more 
 out of the way of pressure. The little finger should be extended and ab- 
 ducted (from the median line of the hand) in clearing and disarticulation. 
 Carefully close the large synovial sac of the little finger, if opened. Preserve 
 the hypothenar muscles as far as possible and suture into the wound. Suture 
 the wound in a single dorsal line (Fig. 320, J). 
 
 DISARTICULATION OF THUMB WITH ITS METACARPAL 
 
 BY RACKET INCISIOX. 
 
 Description. — Removal of the thumb, together with its metacarpal, at 
 the carpo-metacarpal joint. 
 
 Position. — Same as for the fingers, except that the hand is held midway 
 between pronation and supination. 
 
 Landmarks. — Outline of the dorsal aspect of the metacarpal, and the 
 carpo-metacarpal joint. 
 
 Incision. — Begins just above the carpo-metacarpal joint-line, in the 
 mid-dorsal aspect of the metacarpal — passing into the "snuff-box," if at all, 
 with great care and, at first, very superficially, on account of the radial artery. 
 The incision then passes down the center of the dorsum of the thumb to the 
 neck of the metacarpal — and here divides into the two limbs of an oval, 
 which part to encircle the head of the metacarpal, crossing the palmar aspect 
 of the thumb on a level with the free edge of the web — the outer (radial) of the 
 diverging limbs following the dorsal aspect a little further down before sweep- 
 ing over the lateral aspect than does the inner (ulnar) limb (Fig. 320, N). 
 
 Operation. — This incision is deepened on the line of the retracted skin 
 and fascia. The extensor tendons of the first and second phalanges are 
 cut as long as possible, so as to be sutured into the wound. The dorsum 
 and sides of the metacarpal are cleared of soft parts, hugging the bone. The 
 thumb is extended and abducted and the muscles attached to the base of 
 the first phalanx are divided near the sesamoid bones, preserving the thenar 
 muscles as far as possible. The palmar aspect of the metacarpal is cleared 
 while an assistant rotates the thumb from side to side, working as near the 
 bone as possible. The flexor longus pollicis tendon is divided low down, so 
 that it may be sutured into the wound. Disarticulation is accomplished 
 by severing the binding ligaments and the extensor ossis metacarpi pollicis, 
 while the thumb is flexed into the palm — opening the joint from the dorsum, 
 the thumb being then rotated in different directions to complete the dis- 
 articulation. Suture the sheath of the flexor tendon. Tie the arteria princeps 
 pollicis, or its two branches, and the dorsalis pollicis. Quilt the muscles, 
 suturing the flexor, extensor, and thenar tendons and muscles into the wound. 
 The cicatrix will run in a dorsal median line. 
 
346 AMPUTATIONS. 
 
 DISARTICULATION OF TWO CONTIGUOUS INSIDE FINGERS WITH 
 THEIR METACARPALS 
 
 BY RACKET INCISION. 
 
 Description. — The operation is the same, in principle, as that for the 
 removal of a single finger and its metacarpal. A vertical incision begins 
 just above the carpo-metacarpal joint-line and between the bases of the two 
 contiguous metacarpals — passes down the back of the hand midway between 
 the two metacarpals for about one-half of their length — then divides into 
 the two limbs of an oval, or racket — the radial limb passing to the radial side 
 of the outer of the two fingers to be removed — the ulnar limb to the ulnar 
 side of the inner of the two fingers to be removed — to the junction of the 
 fingers and webs — thence both limbs cross and meet beneath the fingers 
 in the digito-palmar crease. The incision is deepened — the metacarpals 
 cleared — the tendons cut long — disarticulation accomplished — and the opera- 
 tion completed just as in the disarticulation of a single finger and its meta- 
 carpal. The flexor and extensor tendons are to be sutured into the wound. 
 (Fig. 320, M.) 
 
 DISARTICULATION OF THREE INSIDE FINGERS WITH THEIR META- 
 CARPALS 
 
 BY RACKET INCISION. 
 
 Description. — Same, in the main, as the disarticulation of any two 
 contiguous inside fingers with their metacarpals — except that the vertical 
 incision begins just above the carpo-metacarpal joint line, over the center 
 of the base of the central one of the three metacarpals — passes down this 
 metacarpal for about one-third of its length — and thence diverges, the radial 
 limb to the radial side of the outer finger, and the ulnar limb to the ulnar 
 side of the inner finger — both limbs passing to the junction of the fingers 
 with the webs — and thence crossing and meeting in the digito-palmar crease 
 beneath the central finger. The operation is completed as in the last — three 
 fingers and their metacarpals being removed instead of two. 
 
 DISARTICULATION OF THREE INNERMOST FINGERS WITH THEIR 
 
 METACARPALS 
 
 BY EQUAL DORSAL AND PALMAR FLAPS. 
 
 Description. — Corresponding incisions are made upon palmar and 
 dorsal aspects of the hand, furnishing symmetrical flaps. 
 
 Position. — As in operations upon the fingers (page 327). 
 
 Landmarks. — Carpo-metacarpal articulations of third, fourth, and fifth 
 metacarpals; middle palmar crease. 
 
 Incision. — (1) Palmar incision — begins just below the base of the fifth 
 metacarpal — passes downward and outward across the palm, parallel with 
 but just below the middle palmar crease, until opposite the center of the 
 ring-finger or just beyond — and is thence directed to the junction of the 
 outer side of the middle finger and web. (2) Dorsal incision — corre- 
 sponds with the palmar incision (Fig. 323, A). 
 
 Operation. — The above incisions are deepened on the line of the retracted 
 skin and fascia. The metacarpal bones are bared to their joint-lines, which 
 is more easilv done in the case of the fourth and fifth, the third being exposed 
 
DISARTICULATIONS OF FINGERS WITH THEIR METACARPALS. 
 
 347 
 
 by upward and outward retraction of the soft parts. The nerves are cut 
 as near the line of disarticulation as possible. The flexor and extensor 
 tendons are cut long, so as to be sutured into the wound. Care is taken 
 not to wound the deep arch. Tie the interosseous branches of the deep arch, 
 and the palmar digital branches of the superficial arch, or the arch itself, if 
 wounded. Suture the synovial sheaths where opened. The muscles of the 
 hypothenar eminence are left in the palmar flap as far as possible and are 
 quilted to the fascia of the dorsal region, where there are no muscles. The 
 
 
 
 Fig. 323.— Amputations about the Hand : — A, Disarticulation of three inner fingers, with their 
 metacarpals, by equal dorsal and palmar flaps; B. Disarticulation of all the fingers, except thumb, 
 with their metacarpals, by anterior ellipse; C, Disarticulation at wrist-joint, by circular method. 
 (Dorsal view.) 
 
 flexor and extensor tendons are also sutured into the wound. The dorsal and 
 palmar flaps are united by suture extending along the ulnar side of the hand. 
 Comment. — In the unusual cases where this operation is done, injury 
 has generally been the cause, and its extent upon the dorsum and palm will 
 determine the outline of the coverings. Where both are equally involved 
 the above coverings will have to be taken — but if the predominant covering 
 could be gotten from the palm, so as to make a larger palmar and smaller 
 dorsal flap, the scar would lie on the dorsal aspect and be out of the way of 
 pressure, which would be preferable. 
 
348 AMPUTATIONS. 
 
 DISARTICULATION OF ALL FINGERS, EXCLUDING THUMB, WITH 
 THEIR METACARPALS 
 
 PA' ANTERIOR ELLIPSE. 
 
 Description. — This is, practically, a palmar covering, whose convex 
 anterior border fits into the concave wound on the dorsum of the hand. It 
 is sometimes called the short palmar flap method. 
 
 Position. — As in the amputations upon the fingers in general (page 327). 
 
 Landmarks. — Base of fifth metacarpal (marking the point at which the 
 ellipse crosses the ulnar border of the hand); point midway between the 
 central crease of the hand and the level of the outstretched thumb (marking 
 the point at which the ellipse crosses the radial border of the hand); the 
 carpometacarpal joint-line. 
 
 Incisions. — Palmar incision — passes between the two above points, with 
 a downward convexity, whose lowest part reaches below the middle of the 
 metacarpals. Dorsal incision — also passes between the same two points, 
 with an upward convexity, whose highest part corresponds with the bases 
 of the two inner metacarpals (Fig. 323, B). 
 
 Operation. — These incisions are deepened to the bone. The flexor 
 and extensor tendons are cut long. The soft parts are cleared up to the 
 carpo-metacarpal joint-line — the metacarpals are disarticulated from the 
 carpals, and the second metacarpal from the first metacarpal, cutting the 
 dorsal ligaments by flexing and the palmar ligaments by extending the hand. 
 Tie the palmar digital, palmar interosseous, dorsalis indicis, radialis indicis, 
 and palmar arches, if severed. Close the flexor sheaths — suture the flexor 
 and extensor tendons into the wound — and suture the convex palmar flap 
 to the concave dorsal wound. 
 
 DISARTICULATION OF FINGERS AND THUMB AT CARPO-META- 
 CARPAL ARTICULATION 
 
 BY PALMAR FLAP. 
 
 Description. — Same, in principle, as the disarticulation of the hand at 
 the wrist-joint (page 352) — except that the upper limits of the flap extend 
 only to the ulnar margin of the unciform-metacarpal articulation, on the 
 one side, and the radial margin of the trapezio-metacarpal articulation, on 
 the other side — the lower limit crossing the necks of the metacarpals. 
 
 SURGICAL ANATOMY OF THE WRIST- JOINT. 
 
 Bones. — Radius; ulna; first row of carpal bones (scaphoid, semilunar, 
 cuneiform, pisiform). 
 
 Ligaments. — Anterior radiocarpal; posterior radio-carpal; external 
 lateral; internal lateral; and synovial membrane. 
 
 Movements. — Flexion; — accomplished by flexor carpi radialis; flexor 
 carpi ulnaris; palmaris longus. Extension; — by extensor carpi radialis 
 longior; extensor carpi radialis brevior; extensor carpi ulnaris. Adduction; — 
 by flexor carpi ulnaris; extensor carpi ulnaris. Abduction; — by extensor ossis 
 metacarpi pollicis; extensores brevior et longior pollicis; extensores carpi 
 radialis longior et brevior; flexor carpi radialis. 
 
 Muscles and Tendons in Neighborhood of Wrist-joint.— (a) Ante- 
 riorly; — flexor carpi radialis; palmaris longus; flexor carpi ulnaris; flexor 
 
SURFACE FORM AND LANDMARKS OF THE WRIST-JOINT. 349 
 
 sublimis digitorum; tlcxor profundus digitorum; flexor longus pollicis. (b) 
 Posteriorly; — extensores carpi radialis longior et brevior; extensor communis 
 digitorum; extensor indicis; extensor minimi digiti; extensor carpi ulnaris. (c) 
 Radial Aspect; — supinator longus; extensor ossis metacarpi pollicis; extensor 
 brevis (primi internodii) pollicis; extensor longus (secundi internodii) pollicis. 
 
 Arteries in Neighborhood of Wrist-joint. — Radial, with its anterior 
 carpal, superficialis volae, posterior carpal and metacarpal (first dorsal inter- 
 osseous). Ulnar, with its anterior carpal, posterior carpal, carpal branch 
 of anterior interosseous, posterior termination of anterior interosseous. Carpal 
 recurrent branch from deep arch. 
 
 Veins in Neighborhood of Wrist-joint. — Superficial — anterior ulnar; 
 posterior ulnar; radial; median. Deep — two vena 1 comites accompany each 
 of the above arteries. 
 
 Nerves in Neighborhood of Wrist-joint. — Superficial — anterior and 
 posterior branches of musculocutaneous; anterior and posterior branches 
 of internal cutaneous; palmar cutaneous branch of median; palmar cutaneous 
 branch of ulnar; cutaneous branch of ulnar communicating with anterior 
 branch of internal cutaneous (frequently absent) ; dorsal cutaneous branch 
 of ulnar; palmar cutaneous branch of radial; dorsal division of radial. 
 Deep; — median; ulnar; termination of interosseous. 
 
 SURFACE FORM AND LANDMARKS OF THE WRIST-JOINT. 
 
 Articulation of the wrist-joint is on a level with the apex of the styloid 
 process of the ulna, which is the key to the joint. To find the joint-line of 
 the wrist, draw a straight line connecting the radial and ulnar styloid processes 
 — then draw a curved line between the same points, with the highest part of 
 the convexity 1.3 cm. (J inch) above the straight line — this curved line will 
 represent the dome-shaped articular line. The ulnar styloid process is more 
 distinct in pronation — that of radial in supination. 
 
 Two or three skin-folds generally cross the palmar surface of the wrist 
 transversely — the lowest fairly represents the upper border of the anterior 
 annular ligament — and is about 1.3 to 2 cm. (^ to f inch) below the arch 
 of the wrist-joint. 
 
 All the muscles mentioned above under Surgical Anatomy can generally 
 be felt and recognized about the wrist-joint — except the flexor profundus 
 digitorum and flexor longus pollicis, of the anterior group; the extensor 
 carpi ulnaris, of the posterior group; and the supinator longus, of the radial 
 group. 
 
 Bony prominences of the tubercle of the scaphoid and ridge of the trape- 
 zium are generally to be felt on the anterior aspect of the radial side of the 
 wrist — and those of the pisiform and unciform process of the unciform, on 
 the ulnar side. 
 
 The lower end of the diaphysis of the ulna just comes to the radio-ulnar 
 joint. The lower end of the diaphysis of the radius comes within the synovial 
 membrane. 
 
 The tendon of the extensor longus (secundi internodii) pollicis marks 
 the center of the lower end of the radius — and indicates the interval between 
 the scaphoid and semilunar. 
 
 The ulnar artery, with the ulnar nerve to the ulnar side, lies on the anterior 
 annular ligament, to the radial side of the pisiform and to the ulnar side of 
 the hook of the unciform (in the groove between them). The deep branch 
 of the ulnar artery arises directly below the pisiform. 
 
350 AMPUTATIONS. 
 
 The radial artery passes under the extensor tendons of the thumb, upon 
 the external lateral ligament, winding over the outer side of the carpus from 
 a point just below and internal to the styloid process of the radius to the 
 base of the first interosseous space. 
 
 The superficial palmar arch is on a line with the lower border of the 
 outstretched thumb — and the deep arch is 1.3 cm. (h inch) higher. 
 
 GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT THE 
 
 WRIST-JOINT. 
 
 Disarticulation at the wrist-joint is preferable to amputation through 
 the forearm, as pronation and supination are usually retained, and the stump 
 is better adapted to an artificial limb. 
 
 Avoid injuring the radio-ulnar articulation — which is adjacent to, but 
 not a part of, the wrist-joint. 
 
 The styloid processes of the radius and ulna should not be removed, 
 especially that of the radius, owing to the attachment of the supinator longus. 
 
 Disarticulation of the joint is more easily done from the dorsum. 
 
 The pisiform bone is often unconsciously removed with the flap, and it 
 is convenient to so remove it and subsequently to dissect it out. 
 
 The best covering for the joint is from the palm, but the nature of the 
 condition for which the operation is done will generally determine from 
 which aspect the covering can be gotten. Care must be exercised to cover 
 the prominent radial styloid process. In approximating the thick palmar 
 to the thin dorsal skin, the sutures are to be securely tied and left amply long. 
 Drainage is indicated for twenty-four or thirty-six hours. The stump should 
 be placed upon a splint which will steady the part and prevent pronation 
 and supination, in a position midway between pronation and supination. 
 
 The lower epiphyses of the radius and ulna join the bones about the 
 twentieth year. 
 
 DISARTICULATION AT THE WRIST- JOINT, IN GENERAL. 
 
 Best Methods. — Anterior Ellipse; Palmar Flap; External lateral, or 
 radial, Flap (Dubrueil's Method). 
 
 Other Methods. — Modified Circular; Circular; Equal Palmar and 
 Dorsal Flaps; Dorsal Flap. 
 
 Comment. — Anterior ellipse method forms the best covering, and amounts 
 to a palmar flap. Palmar flap — rather bulky and unyielding and less ad- 
 justable. External flap — a good substantial covering, and especially adapted 
 to cases in which the palmar covering is not available. Circular method — 
 forms a scanty covering. Dorsal flap — warrantable when the palmar and 
 external coverings are unavailable, but consists only of skin and tendons. 
 
 General Indications. — Bad crushes of hand; malignant disease; chronic 
 disease of bones or joints of hand 
 
DISARTICULATION AT THE WRIST-JOINT. 
 
 DISARTICULATION AT THE WRIST- JOINT 
 
 BY ANTERIOR ELLIPSE. 
 
 Description. — The covering raised is, practically, an anterior flap. The 
 idea of the ellipse is appreciated after marking the outline, as given below, 
 and then viewing it from the radial or ulnar aspect of the hand. 
 
 Fig. 324. — Disarticulation ai the Wrist-joint by the Anterior Elliptical Method. 
 
 (Palmar view.) 
 Fig. 325.— Disarticulation at the Wrist-joint by the Palmar Flap Method. (Palmar 
 
 view.) 
 
 Position. — Patient on back, forearm abducted horizontally; hand pro- 
 nated or supinated, as indicated by the stage of the operation. Surgeon sits 
 or stands, facing the patient's hand. An assistant steadies the limb from 
 above, and holds the parts out of the way. 
 
 Landmarks. — Line of the wrist- joint; pisiform; base of fifth metacarpal; 
 carpo-metacarpal joint of the thumb. 
 
 Incision. — Highest point of the ellipse is upon the dorsum, 1.3 cm. (| 
 inch) below the line of the wrist-joint, and on a line with the middle finger. 
 Lowest point of the ellipse is upon the palm, 6.3 cm. {t\ inches) below the 
 line of the wrist-joint, and on a line with the middle finger. The inner 
 portion of the ellipse crosses the ulnar border of the hand between the pisiform 
 bone and base of the fifth metacarpal. The outer portion of the ellipse 
 
352 AMPUTATIONS. 
 
 crosses the radial border of the hand at the carpo-metacarpal joint-line of 
 the thumb. The entire incision has, therefore, a downward convexity upon 
 the palm and an upward convexity upon the dorsum, and passes through 
 the four above-mentioned points (Fig. 324, A). 
 
 Operation. — Supinating the hand while incising the palm, and pronating 
 it while making the dorsal incisions, this entire ellipse, which has been made 
 through the skin and fascia at first, is now deepened throughout. The 
 dorsal integuments are first dissected to the joint-line. The hand is flexed 
 and the extensor tendons, posterior ligament, and lateral ligaments are cut 
 and the joint opened — and then the anterior ligaments. First one and then 
 the other lateral border of the hand is made to present and the lateral parts 
 of the ellipse carried to the bones. The knife is then carried between the 
 flexor tendons and the carpus, from above and within, and made to clear 
 out the hollow of the carpus in the act of cutting its way obliquely from within 
 downward and outward, to the margin of the palmar incision through the 
 skin — and the hand thus severed from the arm. All loose tendons and 
 nerves are to be cut. The following arteries are to be tied; radial, ulnar 
 (below the deep branch), deep branch of the ulnar, superficialis volae. The 
 deep palmar arch and part of the superficial palmar arch are removed with 
 the hand. The convex palmar flap is sutured into the concave wound at 
 the back of the wrist. 
 
 Comment. — The palmar covering can be entirely freed up to the joint- 
 line before disarticulating. 
 
 DISARTICULATION AT THE WRIST 
 
 BY PALMAR FLAP. 
 
 Description. — The flap is U-shaped, and raised entirely from the palm. 
 
 Position. — As in the disarticulation by an anterior ellipse (page 304). 
 
 Landmarks. — Styloid process of radius; styloid process of ulna; middle 
 of metacarpus. 
 
 Incision. — Palmar incision — radial limb of the U begins 1.3 cm. (^ inch) 
 below the radial styloid process and is directed downward along the radial 
 border of the index. Ulnar limb of the U begins 1.3 cm. (J? inch) below the 
 ulnar styloid process and is directed downward along the ulnar border of 
 the little finger. These limbs are bluntly rounded at their lower ends and 
 pass transversely toward each other so as to meet just above the center of 
 the metacarpus. Dorsal incision — crosses the carpus in a straight line, or, 
 better, with slightly downward convexity, between the two upper ends of the 
 palmar incision (Fig. 325). 
 
 Operation. — With the hand in supination and extension, the palmar 
 incision is deepened to the flexor tendons, the thenar and hypothenar muscles 
 being cut through to that extent — and the palmar flap then dissected up to 
 the joint-line, raising the flap from the bony prominences in the palm. With 
 the hand now in pronation and the skin of the wrist drawn upward, the dorsal 
 incision is deepened and the integuments dissected up to the joint-line, when 
 the extensor tendons, posterior ligament, and lateral ligaments are severed 
 and disarticulation accomplished. The flexor tendons and surrounding tis- 
 sues on the palmar surface are now severed, while on the stretch, by dividing 
 the anterior ligament from within the disarticulated joint and then cutting 
 the flexor tendons from the dorsal toward the palmar aspect, on a line with 
 
SURGICAL ANATOMY OF THE FOREARM. 353 
 
 the retracted palmar (lap. The same arteries are to be tied as in the ellip- 
 tical method, the deep arch and loops of the superficial arch coming away 
 with the hand. 
 
 DISARTICULATION AT THE WRIST- JOINT 
 
 BY EXTERNAL LATERAL, OR RADIAL FLAP — DUBRUEIL'S METHOD. 
 
 Description. — A saddle-shaped flap of skin and muscles is raised from 
 the metacarpal region of the thumb, and approximated to the disarticulated 
 ends of the radius and ulna. 
 
 Position. — As in disarticulation by the elliptical method (page 351). 
 
 Landmarks. — Wrist-joint; first metacarpal. 
 
 Incision. — Flap-incision — begins on back of wrist, about 6 mm. (j inch) 
 below the wrist-joint line, and at the junction of the outer and middle thirds 
 of that line — passes thence downward upon the dorsal aspect of the thumb — 
 thence rounds outward to cross the first metacarpal transversely about its 
 middle (remaining, up to the point of rounding outward, as far from the 
 outer border of the hand as at the beginning). The incision now passes 
 upward correspondingly on the inner aspect of the thumb, following the 
 inner part of the thenar eminence to a point about 6 mm. (| inch) below the 
 wrist-joint line, at the junction of the outer and middle thirds of that line 
 on the palmar surface. Disarticulating-incision — the two upper ends of this 
 flap are connected by a transverse incision passing directly around the inner 
 aspect of the wrist-joint (Fig, 320, P, P). 
 
 Operation. — The thenar incision, forming the flap, is deepened — the 
 soft parts are dissected from the metacarpal, and as much of the thenar 
 muscles as possible is taken. The soft parts upon the inner aspect of the 
 wrist are divided to the bone by the circular incision on a level with the base 
 of the flap. Disarticulation is accomplished from the dorsal and inner 
 aspect, toward the palmar and outer. The following arteries are to be tied: 
 superficial and deep palmar arches, dorsalis and radialis indicis and ulnar. 
 The tendons and nerves are treated as in the preceding operations upon the 
 wrist. The external or thenar flap is now brought transversely across the 
 articular ends of the radius and ulna, and sutured to the circularly divided 
 parts. 
 
 SURGICAL ANATOMY OF THE FOREARM. 
 
 Bones. — Radius; ulna. 
 
 Articulations and Ligaments. — (a) Superior Radio-ulnar Articulation; 
 — orbicular ligament; synovial membrane, (b) Middle Radio-ulnar Articu- 
 lation; — oblique (round) ligament; interosseous membrane. (c) Inferior 
 Radio-ulnar Articulation; — anterior radio-ulnar ligament; posterior radio- 
 ulnar ligament; interarticular (triangular) fibro-cartilage; synovial mem- 
 brane, (d) Elbow-joint (page 359). (e) Wrist-joint (page 348). 
 
 Muscles of the Forearm. — (a) Anterior radio-ulnar region : — (i) 
 More Superficial Muscles; — pronator radii teres; flexor carpi radialis; palmaris 
 longus; flexor carpi ulnaris; flexor sublimis digitorum. (2) Deeper Muscles; 
 — flexor profundus digitorum; flexor longus pollicis; pronator quadratus. 
 (b) Radial region: — supinator longus; extensor carpi radialis longior; ex- 
 tensor carpi radialis brevior. (c) Posterior radio-ulnar region:— (1) 
 
 2 3 
 
354 AMPUTATIONS. 
 
 More Superficial Muscles; — extensor communis digitorum; extensor minimi 
 digiti; extensor carpi ulnaris; anconeus. (2) Deeper Muscles; — supinator 
 brevis; extensor ossis metacarpi pollicis; extensor brevis (primi internodii) 
 pollicis; extensor longus (secundi internodii) pollicis; extensor indicis. 
 
 Arteries of the Forearm. — Radial, with radial recurrent; muscular; 
 anterior carpal; superficialis volar, posterior carpal branches. Ulnar, with 
 anterior ulnar recurrent; posterior ulnar recurrent; common interosseous; 
 anterior interosseous; posterior interosseous; muscular; anterior carpal; 
 posterior carpal branches. 
 
 Veins of Forearm. — Superficial — median; median cephalic; median 
 basilic; deep median; radial cephalic; cephalic; anterior ulnar; posterior 
 ulnar; common ulnar; basilic. Deep — two venae comites accompanying each 
 of above arteries. 
 
 Nerves of Forearm. — Superficial; — musculocutaneous; internal cutane- 
 ous; external cutaneous branch of musculospiral; cutaneous branch of ulnar; 
 dorsal cutaneous branch of ulnar; cutaneous branches of radial. Deep; — 
 ulnar and its muscular branches; median and its muscular branches; muscular 
 branches of musculospiral; radial branch of musculospiral; posterior inter- 
 osseous branch of musculospiral. The cross-sections of the forearm are shown 
 in Figs. 32, 34, and 327. 
 
 SURFACE FORM AND LANDMARKS OF THE FOREARM. 
 
 Olecranon and posterior border of upper part of ulna are subcutaneous 
 — and the entire shaft is to be felt down to the styloid process, passing from 
 the center of the forearm above to the ulnar side of the wrist below, and lying 
 between the flexor and extensor carpi ulnaris. The ulnar styloid process is 
 best felt with the forearm midway between flexion and extension, being con- 
 tinuous with the posterior subcutaneous border of the bone. 
 
 Head of the radius is felt just below and a little in front of the posterior 
 surface of the external condyle, revolving in the orbicular ligament and lesser 
 sigmoid cavity — marked by a dimple in the skin posteriorly, best seen when 
 the arm is extended. The lower half of the radius can be outlined, though 
 not subcutaneous — the outer aspect of the lower part alone being subcutaneous, 
 and ending in the radial styloid process. The radius is deeply covered above 
 and superficially covered below. Opposite a point in the forearm where 
 one bone is most slender, the opposite bone is most substantial — both being 
 about equal in the middle. The radius and ulna are everywhere nearer the 
 posterior than anterior aspect of the forearm, and increasingly so above. 
 They are nearest each other in complete pronation and furthest in complete 
 supination. 
 
 Flexor and pronator muscles form the muscular elevation upon the inner 
 side of the elbow and forearm — the extensor and supinator muscles forming 
 a corresponding elevation upon the outer and posterior side of the elbow 
 and forearm. These two groups diverge above toward the condyles of the 
 humerus and converge below toward the center of the forearm — the supinator 
 longus forming the outer boundary and the pronator radii teres the inner 
 boundary of the triangular space at the bend of the elbow. Of the muscles 
 of the internal group, the pronator radii teres, flexor carpi radialis, palmaris 
 longus, flexor carpi ulnaris, alone influence surface form, the remainder being 
 unrecognizable. The external group of muscles divides into two longitudinal 
 
SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT FOREARM. 355 
 
 eminences, diverging from each other, with a triangular interval between 
 them: — the outer, consisting of the supinator longus, extensor carpi radialis 
 longior and brevis, descending from the outer condyloid ridge toward the 
 radial styloid process; — the other, more posterior, consisting of the extensor 
 communis digitorum, extensor minimi digiti, extensor carpi ulnaris, descend- 
 ing from the external condyle, separated above from the anconeus by a furrow, 
 and below from the pronator-flexor mass by the ulnar furrow. In the tri- 
 angular interval between these two groups the extensor ossis metacarpi 
 pollicis, extensor brevis pollicis, extensor longus pollicis, and extensor indicis 
 pass downward. The anconeus forms a slight prominence external to the 
 subcutaneous posterior surface of the olecranon. 
 
 In the muscular, the transverse is much greater than the antero-posterior 
 diameter of the forearm — and the downward tapering is marked. In the 
 non-muscular, the forearm is more rounded and the tapering is less. Above, 
 the muscles are found chiefly at the sides and in front; — below, more equally 
 along the anterior and posterior aspects — hence flap amputations are 
 more adapted to the upper and circular amputations to the lower part of 
 the forearm. 
 
 The three chief pronators of the forearm are, the pronator radii teres, 
 pronator quadratus, and flexor carpi radialis. The three chief supinators 
 are, the supinator longus, supinator brevis, and biceps. 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 
 
 THE FOREARM. 
 
 For the purposes of amputation, the forearm may be divided into two 
 natural regions, a lower one-third and an upper two-thirds — the former 
 being characterized by an almost even contour of similar dimensions through- 
 out — the latter, especially in the muscular, by its rapidly increasing measure- 
 ments up to from 2.5 to 5 cm. (1 to 2 inches) below the elbow, and with a 
 slight decrease thence to the elbow-joint. Therefore, on this account, and 
 because of the grouping of the muscles, amputation-methods are described 
 as applicable to "the lower third" and "the upper two-thirds." (In this 
 connection, see the last paragraph from the bottom, in the above section.) 
 
 The general type of amputation most suitable for the lower third of the 
 forearm is the circular method — and the general type most suitable for the 
 upper two-thirds is the flap method. 
 
 Saving of the smallest part of the forearm, with its movement, is preferable 
 to disarticulation at the elbow. 
 
 If possible, the bones should be sawed below the insertion of the pronator 
 radii teres, otherwise the radius will become supinated and rotatory move- 
 ments lost. 
 
 Owing to the tendency of the bones to project through the angles of the 
 flaps, the flaps at their bases and their lower ends should be made fully long. 
 
 In cutting by transfixion the interosseous membrane is apt to be pierced. 
 
 A terminal cicatrix is here desirable, as best adapted to an artificial limb. 
 
 The stump should be dressed with the forearm midway between pronation 
 and supination, and the elbow steadied by a right-angled splint. 
 
356 
 
 AMPUTATIONS. 
 
 AMPUTATION OF THE FOREARM, IN GENERAL. 
 
 Best Methods. — Modified Circular — 
 for the lower third. Equal Anterior and 
 Posterior Flaps— for the upper two-thirds 
 
 Other Methods. — Long Anterior Flap 
 — where the posterior tissues are defi- 
 cient. Long Posterior Flap — where the 
 anterior tissues are deficient. Long An- 
 terior and Short Posterior Flap. Rec- 
 tangular Flaps (Teale's method). Ex- 
 ternal Lateral Flap — where the internal 
 tissues are deficient. Equilateral Skin- 
 flaps. Circular Skin-flap. Circular. 
 
 General Indications. — Injury; tuber- 
 cular disease of wrist; malignancy. 
 
 AMPUTATION OF LOWER THIRD OF 
 FOREARM 
 
 BY MODIFIED CIRCULAR METHOD. 
 
 Description. — Two short flaps of 
 skin and fascia are turned back and 
 the muscles are then circularly divided at 
 the level of the retracted skin-and-fascia 
 flaps. 
 
 Position. — Patient supine, near edge 
 of table, with upper limb abducted to a 
 right angle — and held by an assistant in 
 supination during anterior incisions, and 
 in pronation, or vertically, during pos- 
 terior incisions. Surgeon to outer side of 
 right limbs and inner side of left. 
 Landmarks. — Saw-line. 
 Incision. — The total covering is to be 
 i^ diameters of the forearm at the saw- 
 line. The anterior and posterior aspects will each furnish three-fourths 
 of a diameter. One-half of this three-fourths diameter length will be of 
 skin and fascia alone, on each side — the remaining half of skin, fascia, 
 and muscle. Therefore a point below the saw-line equal to three-fourths 
 of a diameter at the saw-line will mark the lowest limit from which the covering 
 is to be provided. Two small flaps are incised, each having a base equal 
 to a half-circumference, and a length equal to half (the lower half) of the 
 distance between the saw-line and the lowest limit of the skin incision. These 
 flaps will be bluntly rounded at their lower ends (Fig. 326, A). 
 
 Operation. — Dissect up the integumentary flaps half-way to the saw- 
 line — retract them, and, on a level with the retracted flaps, circularly divide 
 the muscles to the bone. This circular incision also divides the periosteum 
 and interosseous membrane. The muscles and periosteum are then retracted 
 to the saw-line — and the bones divided, completing the section of the more 
 movable radius first. Tie the radial, ulnar, anterior and posterior inter- 
 osseous arteries. Stitch the musculo-periosteal covering over the bones. 
 
 Fig. 326. — Amputations through 
 the Forearm and at the Elbow: — ■ 
 A, Through lower part of forearm by 
 modified circular; B, Through upper 
 forearm by equal anterior and posterior 
 flaps; C, Disarticulation at elbow-joint 
 by oblique circular method. 
 
AMPUTATION OF LOWER THIRD OF FOREARM. 357 
 
 Quilt the muscles or tendons of the anterior to those of the posterior aspect 
 of the forearm if possible. Suture the integumentary coverings in a straight 
 line antero-posteriorly. 
 
 Comment. — The preponderance of tendinous over muscular tissues here 
 makes the infundibular variety of the modified circular difficult or impossible. 
 
 Fig. 327. — Cross-section of the Middle of the Right Forearm: — A, Flexor carpi 
 radialis; B, Median nerve; C, Supinator longus; D, Radial artery, veins, and nerve; E, Flexor 
 longus pollicis; F, Extensor carpi radialis; G, Extensor ossis metacarpi pollicis; H, Flexor sub- 
 limis digitorum; I, Flexor carpi ulnaris; J, Ulnar artery, veins, and nerve; K, Flexor profundus 
 digitorum; L, Anterior interosseous vessels; M, Extensor indicis; X, Extensor carpi ulnaris; 
 O, Extensor minimi digiti; P, Extensor communis digitorum. (The crods-section modified 
 from Braune.) 
 
 AMPUTATION OF LOWER THIRD OF FOREARM 
 
 BY CIRCULAR METHOD (CUFF VARIETY). 
 
 Description. — The cuff variety of the circular amputation is here done 
 (see under Comment). A cuff of skin, circularly cut, is turned back — and 
 the muscles circularly divided on a level with the reflected skin — the ends 
 of the bones being covered by skin and fascia alone. 
 
 Position. — As in the last operation. 
 
 Landmarks. — Saw- line. 
 
 Incision. — Circular cut, placed three-fourths of a diameter (at the saw- 
 line) below the line of bone-section — thus making a total covering of i 1 
 diameters, as each side may be regarded as furnishing one-half of the cover- 
 ing. (For principle, see Fig. 328, A.) 
 
 Operation. — This circular incision divides the skin and fascia, which 
 are then dissected up, the forearm being vertical while the posterior dissection 
 is done. This dissection and turning back of the flap is continued up to a 
 distance below the saw-line which will leave space to provide a musculo- 
 periosteal covering. Here, after well retracting the integumentary coverings, 
 the muscles are divided circularlv to the bone, — extending the hand while 
 
35» 
 
 AMPUTATIONS. 
 
 c 
 
 B 
 
 the flexors are cut and flexing it while the extensors are being severed. A 
 circular cut is made through the periosteum, around each bone, on a level 
 with the cut muscles — the interosseous membrane is divided transversely — 
 
 and a musculo-periosteal covering is freed 
 up to the saw-line, with a periosteal 
 elevator, from each bone. All soft parts 
 are now retracted and the bones sawed, 
 completing the section of the more mov- 
 able radius first. Tie the radial, ulnar, 
 anterior and posterior interosseous arter- 
 ies. Cut the tendons (which are here 
 especially numerous) and the nerves 
 short. Suture the musculo-periosteal 
 covering over the bones — and stitch the 
 skin and fascia in a vertical antero-pos- 
 terior or lateral direction. 
 
 Comment. — (i) Owing to the pre- 
 dominance of tendons in this locality, the 
 infundibuliform variety of the circular 
 method is impracticable. (2) The above 
 operation is very similar to the modified 
 circular method just described, which is 
 generally considered better than the pres- 
 ent form, in this locality. The cuff 
 method, indeed, is not possible if the 
 limb tapers very decidedly at the site in- 
 volved. (3) A musculo-periosteal cover- 
 ing is specially indicated here, as being 
 the best means of guarding against a 
 fusion of the cut edges of the bones and 
 consequent loss of pronation and supina- 
 tion. (4) As the large mass of tendons 
 is difficult to cut squarely by a circular 
 incision, a long, narrow knife may be 
 slipped under them, and they may then 
 be cut directly upward from within — or they may be divided with strong, 
 sharp scissors. 
 
 P'ig.328.— Amutations about Fore- 
 arm and Elbow : — A, Through middled 
 forearm, by circular method ; B, At elbow- 
 joint, by single external flap ; C, At elbow, 
 by oblique circular method. 
 
 AMPUTATION OF UPPER TWO-THIRDS OF FOREARM 
 
 BV EQUAL ANTERIOR AND POSTERIOR FLAPS. 
 
 Description. — The anterior and posterior aspects of the forearm furnish 
 equal U-shaped flaps of skin and muscle — the anteriorly largely composed 
 of supinator longus and flexors, — the posterior largely made up of extensors. 
 
 Position. — As in the modified circular method (page 356). 
 
 Landmarks. — Saw-line. 
 
 Incisions. — An anterior and a posterior U-shaped flap are incised on 
 the respective aspects of the forearm, the base of each flap at the saw-line 
 being equal to a half-circumference of the limb at that line, and the length 
 of each equal to three-fourths of the diameter — the hand being supinated 
 in making the anterior flap, and the forearm vertical in making the posterior 
 flap (Fig. 326, B). 
 
SURGICAL ANATOMY OF THE ELBOW-JOINT. 359 
 
 Operation. — Having cut through skin and fascia in outlining the flaps, 
 these incisions are now deepened upon the line of the retracted skin, beginning 
 at the ulnar side of the anterior flap, in case of the right arm (and on the 
 radial side upon the opposite arm). The vertical ulnar incision will involve 
 the flexor carpi ulnaris and flexor profundus — the vertical radial incision 
 will involve the two radial carpal extensors — both vertical incisions passing 
 directly to the bones. The muscles on the anterior and posterior aspects 
 of the forearm, at the lower rounded extremities of the flaps, are cut from 
 without inward in such a manner as to bevel them, slightly. The entire flaps 
 are now raised from the bones up to a point sufficiently below the saw-line 
 to furnish a musculo-periosteal covering — at which level the periosteum is 
 circularly divided around the bones — the interosseous membrane cut trans- 
 versely — and the musculo-periosteal covering freed to the saw-line. The 
 soft parts are then retracted and the bones sawed. The radial, ulnar, anterior 
 and posterior interosseous arteries are tied. The median, radial, and ulnar 
 nerves should be cut short, or even dissected from the flap. The musculo- 
 periosteal covering is sutured and the muscles quilted — and the integuments 
 sutured in a lateral line. 
 
 Comment. — These flaps may be less satisfactorily cut by transfixion— 
 in which method, also, the interosseous membrane is apt to be pierced. 
 
 SURGICAL ANATOMY OF THE ELBOW-JOINT. 
 
 Bones. — Humerus, radius, and ulna. 
 
 Articulations and Ligaments. — (a) Of the Elbow-joint; — anterior, 
 posterior, internal lateral and external lateral ligaments, and synovial mem- 
 brane, (b) Of the Superior Radio-ulnar Joint; — orbicular ligament, and 
 synovial membrane. 
 
 Muscles in Neighborhood of Elbow. — (A) Muscles arising a greater 
 or lesser distance above elbow and inserted below elbow: — (a) On anterior 
 aspect; — biceps and brachialis anticus. (b) On posterior aspect; — triceps 
 and subanconeus. (c) On radial aspect; — supinator longus and extensor 
 carpi radialis longior. (B) Muscles arising from inner condyle of humerus 
 and inserted into forearm and hand; — pronator radii teres, flexor carpi 
 radialis, palmaris longus, flexor carpi ulnaris, flexor sublimis digitorum. 
 (C) Muscles arising from outer condyle of humerus and inserted into forearm 
 and hand; — extensor carpi radialis brevior, extensor communis digitorum, 
 extensor minimi digiti, extensor carpi ulnaris, anconeus and supinator brevis. 
 
 Muscles in Direct Relation with Elbow-joint. — Anteriorly; brachialis 
 anticus. Posteriorly; triceps and anconeus. Externally; supinator brevis 
 and common tendon of origin of extensor muscles. Internally; common 
 tendon of origin of flexor muscles. 
 
 Arteries in Neighborhood of Elbow. — Brachial, with superior profunda, 
 inferior profunda, and anastomotica magna branches. Radial, with radial 
 recurrent branch. Ulnar, with anterior ulnar recurrent and posterior ulnar 
 recurrent branches. 
 
 Veins in Neighborhood of Elbow. — Superficial; — median, median 
 basilic, median cephalic, deep median, radial, cephalic, anterior ulnar, poste- 
 rior ulnar, and common ulnar. Deep; — Two venae comites accompanying 
 each of above arteries. 
 
 Nerves in Neighborhood of Elbow. — Superficial; — musculocutaneous, 
 internal cutaneous, lesser internal cutaneous, external cutaneous, and branches 
 
360 AMPUTATIONS. 
 
 of triusculospiral. Deep; — ulnar, median, radial and posterior interosseous 
 branches of rnusculospiral. 
 
 Bicipital Fascia. — A broad aponeurosis given off from inner side of 
 tendon of biceps, opposite bend of elbow — and passing between the brachial 
 artery and superficial veins and nerves of elbow obliquely downward and 
 inward to become continuous with the deep fascia of forearm, fastening 
 down the flexor muscles. 
 
 Bursae in Neighborhood of Elbow. — Between olecranon and skin, and 
 between olecranon and triceps. 
 
 Epiphyses. — Portion of epiphysis forming radial condyle and trochlea 
 is within the capsule of the joint — that forming the two condyles is without. 
 The epiphyses for the trochlea and external condyle blend and join shaft 
 about sixteenth or seventeenth year — that for internal condyle, about eighteenth 
 year. The upper epiphysis of radius forms the head — is within the joint — 
 and joins shaft about sixteenth or seventeenth year. The olecranon is chiefly 
 formed by diaphysis — an epiphysis occurs in its summit from the tenth to 
 twelfth year— joins shaft about sixteenth or seventeenth year — anteriorly 
 the epiphysis being intersynovial, and posteriorly subperiosteal. 
 
 Movements of Elbow- joint. — (1) Flexion — by biceps, brachialis anticus, 
 aided by muscles having origin from internal condyle of humerus and by 
 supinator longus. (2) Extension — by triceps, anconeus, aided by extensors 
 of wrist and by extensor communis digitorum and extensor minimi digiti. 
 The cross-sections at and just below the elbow-joint are shown in Figs. 329 
 and 29. 
 
 SURFACE FORM AND LANDMARKS OF THE ELBOW. 
 
 Position of radio-humeral line, and hence the joint-line of the elbow, may 
 be found by feeling for the depression between the head of the radius and 
 capitellum of the humerus at the back of the elbow, marked by a dimple in 
 the integument in the interval between the anconeus to the ulnar side, and 
 the muscular mass of supinator longus and two carpal radial extensors to 
 the radial side. 
 
 The humero-radial articulation is horizontal — the humero-ulnar articu- 
 lation slopes slightly downward. 
 
 The fold of the elbow, more prominent when the forearm is semi-flexed, 
 is a little above the level of the joint, and forms the base of the triangular 
 fossa below the elbow, whose sides are formed by the supinator longus and 
 pronator radii teres. 
 
 The inner condyle of the humerus is the more prominent and is a little 
 more than 2.5 cm. (1 inch) above the elbow-joint. The outer condyle is 2 
 cm. (f inch) above. 
 
 When the forearm is fully extended, the inner condyle, tip of olecranon, 
 and external condyle are all on the same transverse line (in extreme extension, 
 the tip of the olecranon is slightly above); — when the forearm is flexed to a 
 right angle, the tip of the olecranon is directly below the condyles; — when 
 the forearm is completely flexed, the tip of the olecranon is below and in 
 front of the condyles. 
 
 A line connecting the two condyles forms a right angle with the axis of 
 the arm — and an angle with that of the forearm. 
 
SURGICAL CONSIDERATIONS IN DISARTICULATING ELBOW-JOINT. 361 
 
 The upper part of the olecranon is covered by the triceps — the lower 
 part is subcutaneous, and separated from the skin by a bursa. 
 
 Three eminences are present upon the anterior aspect of the elbow region; 
 — the biceps above and in the center — the supinator longus and common 
 extensor group on the outer — and the pronator radii teres and common 
 flexor group upon the inner side. 
 
 The ulnar nerve and posterior ulnar recurrent artery lie in a deep groove 
 between the olecranon and inner condyle of the humerus. 
 
 The anterior integument of the elbow is thin and retractile — the posterior 
 integument loose and but little retractile. 
 
 GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT 
 
 THE ELBOW- JOINT. 
 
 The stump after disarticulating at the elbow-joint is better for the adapta- 
 tion of an artificial limb than after amputation through the arm. 
 
 To find the elbow-joint — place the thumb just beneath the external 
 condyle of the humerus and, grasping the wrist with the right hand, pronate 
 and supinate the forearm — when the upper limit of the radial head will be 
 found about 1.3 cm. (4 inch) below the external condyle. 
 
 The joint is entered and disarticulated more easily from the outer side. 
 
 Fig. 329. — Transverse Section through the Condyloid Expansion of the Right 
 Arm: — A, Biceps tendon; B, Supinator longus; C, Musculospiral nerve and superior profundus 
 artery; D, Brachialis anticus; E, Extensor carpi radialis longior; F, Olecranon; G, Anconeus; 
 H, Triceps; I, Brachial artery, vena; comites, and median basilic vein; J, Pronator radii teres; 
 K, Median nerve; L, Flexor carpi radialis; M, Condyloid expansion of humerus; N, Ulnar 
 nerve; O, Olecranon bursa. (Cross-section modified from Braune.) 
 
 The muscles on the outer side of the elbow retract more powerfully than 
 those upon the inner side, chiefly owing to the presence of the supinator 
 longus. 
 
3^2 AMPUTATIONS. 
 
 The lower end of the humerus is so large that a liberal allowance of covering 
 is necessary. And a more liberal covering has to be provided for the inner 
 than for the outer condyle of the humerus — incisions, therefore, are longer 
 on the inner aspect. 
 
 The skin posteriorly is used to pressure — but the muscles here are not 
 so available for padding as in front. 
 
 Temporary drainage should be used after disarticulation. The stump 
 should be elevated upon a splint. 
 
 DISARTICULATIONS AT THE ELBOW, IN GENERAL. 
 
 Best Methods. — Anterior Ellipse — best, where ample sound tissue exists; 
 well nourished and thick enough to cover bones well; cicatrix well placed; 
 but requires considerable tissue; skin-pouch over the olecranon is apt to be 
 left. Posterior Ellipse — best where anterior tissue is unavailable; covering 
 thin and uneven, though used to pressure. Long Antero-internal and Short 
 Postero-external Flaps — cover disarticulated end of humerus well; especially 
 indicated where both lateral aspects of forearm can furnish covering and 
 neither anterior nor posterior can supply the large amounts of tissue neces- 
 sary for the elliptical methods. 
 
 Other Methods. — Circular. Modified Circular. Anterior Flap. Poste- 
 rior Flap. Long Anterior and Short Posterior Flaps. Short Anterior and 
 Long Posterior Flaps. Single External Flap. Equal Lateral Flaps. Un- 
 equal Lateral Flaps. Lateral Skin Flap. Racket Method. Of these 
 methods, the circular requires the least sacrifice of parts, but the resulting 
 covering is not so satisfactory. 
 
 General Indications. — Tubercular disease; injury or disease of forearm. 
 
 DISARTICULATION OF ELBOW- JOINT 
 
 BY ANTERIOR ELLIPSE — FARABEUF. 
 
 Description. — The covering is, essentially, an anterior flap — the idea 
 of the ellipse being gotten in viewing the outlined incision laterally. The 
 lower anterior convexity of the covering is sutured into the upper posterior 
 concavity. 
 
 Position. — Given in the course of the operation. 
 
 Landmarks. — Joint-line; prominence of olecranon; eminence of supinator 
 longus on anterior aspect of forearm. 
 
 Incision. — The highest point of the ellipse is posterior, over the prominence 
 of the olecranon. The lowest point of the ellipse is anterior, over the eminence 
 of the supinator longus, just above the middle of the forearm. Midway 
 between the upper and lower rounded ends of the ellipse the lateral borders 
 of the ellipse pass along the mid-lateral aspects of the forearm (Fig. 330, A). 
 
 Operation. — The surgeon stands on the left of either right or left elbow 
 (which will place the patient's elbow on his right) — grasping his wrist with 
 his left hand, and flexing the elbow, so rotates the limb as to make the entire 
 elliptical incision without relaxing his hold of the wrist, or removing the 
 knife, which passes from olecranon to olecranon. Taking the right limb, 
 for instance, turn the slightly flexed elbow so as to present the radial aspect— 
 
DISARTICULATION OF ELBOW-JOINT. 
 
 363 
 
 enter the knife at the apex of the olecranon — pass down the radial lateral 
 aspect — across the lower end of the ellipse, on the anterior aspect of the 
 forearm (with the forearm extended and supine) — then along the inner 
 aspect (with elbow again flexed and the inner aspect of the forearm thereby 
 made to present) and upward to the olecranon. The skin and fascia 
 upon the proximal side of the lower end of this incision are now further 
 retracted by hand. On the line of the retracted integuments the muscles are 
 then cut obliquely from without inward and upward toward the joint, in such 
 a manner as to bevel the anterior covering which is being raised — and, at the 
 same time, raise as much of a capsulo-periosteal covering as possible. This 
 anterior flap is dissected and retracted upward to the joint-line. The anterior 
 lateral and posterior ligaments of the joint are now cut in order. The triceps 
 and any remaining posterior tissues are sev- 
 ered. The radial, ulnar, interosseous, mus- 
 cular branches, and, possibly, the posterior 
 ulnar recurrent and terminations of the su- 
 perior and inferior profunda are ligated. 
 Quilt the muscles in the anterior flap to the 
 fascia along the margins of the upper half of 
 the ellipse. Suture the integumentary tis- 
 sues of the convex lower end of the flap into 
 those of the upper concavity. Temporary 
 drainage is indicated. 
 
 Comment. — After the integuments are 
 incised, the muscles are sometimes, though 
 less satisfactorily, cut by thrusting a long 
 knife through the limb opposite the anterior g 
 aspect of the joint and cutting from within 
 outward on a line with the retracted skin. 
 
 DISARTICULATION OF ELBOW- JOINT 
 
 BV POSTERIOR ELLIPSE. 
 
 A 
 
 Fig. 330. — Disarticulations at 
 the Elbow-joint: — A, By anterior 
 ellipse; B, By long antero-internal 
 and short postero-external flaps. 
 
 Description. — The covering is, practi- 
 cally, a posterior flap — the idea of the ellipse 
 being seen in a lateral view of the incision. 
 
 Position. — Given in the course of the 
 operation. 
 
 Landmarks. — Joint-line; tip of olecranon. 
 
 Incision. — The highest point of the 
 ellipse is anterior, opposite the lower 
 margin of the joint-line. The lowest 
 part is posterior, between 8 and 10 cm. 
 
 (3 and 4 inches) below the joint-line. Midway between the upper and lower 
 rounded ends of the ellipse, the lateral borders of the ellipse pass along the 
 mid-lateral aspects of the forearm. \\ ith the elbow flexed to an angle of 
 135 degrees, the lateral parts of the incision will be parallel with the prolonged 
 anterior aspect of the arm (Fig. 331). 
 
 Operation. — The surgeon stands on the right of either elbow, grasping 
 the patient's wrist with his left hand (the back of his hand uppermost and 
 his thumb toward the patient's fingers), and manipulates the elbow so as 
 to complete the incision at one sweep — beginning the incision at the anterior 
 joint-line with the elbow flexed at the above angle — passing down the inner 
 
3°4 
 
 AMPUTATIONS. 
 
 aspect (while that part is manipulated so as to render it prominent) — crossing 
 the dorsal aspect (while the forearm is held vertical) — ascending the outer 
 aspect (while that aspect is made prominent) — to the place of beginning. 
 Upon the line of the retracted integuments, the deeper parts are now cut. 
 Those along the posterior aspect of the ellipse are divided, together with 
 the periosteum, and including the anconeus, and insertion of the triceps when 
 reached, and are dissected up to just above the tip of the olecranon. The 
 deeper parts along the anterior portion of the ellipse are then divided, corre- 
 sponding with the joint-line, and the capsule of the joint divided transversely, 
 lollowed by division of the lateral ligaments and posterior portion of the 
 capsule (unless a capsulo-periosteal covering can be raised). Tie the brachial, 
 posterior interosseous, muscular branches and terminations of the superior 
 
 and inferior profunda. Cut the ulnar nerve 
 especially short. Quilt the muscles in the 
 posterior flap to the fascia along the mar- 
 gins of the upper half of the ellipse. Drain 
 temporarily. Suture the integuments of the 
 lower portion of the ellipse (the convexity) of 
 the posterior flap, to the upper concavity of 
 the incision. 
 
 Comment. — Transfixion of the lower 
 part of the posterior flap is even less advisable 
 than transfixion in the anterior ellipse — as, in 
 the former case, the bone is almost subcu- 
 taneous. 
 
 DISARTICULATION OF ELBOW- JOINT 
 
 BY LONG ANTERO-INTERNAL AND SHORT POS- 
 TERO-EXTERNAL FLAPS. 
 
 Description. — A method of unequal lat- 
 eral flaps of skin and muscles — the incisions 
 themselves are lateral, the bulk of the mus- 
 cles being antero-internal and postero-ex- 
 ternal. 
 
 Position. — The forearm is held in supi- 
 nation during anterior incisions — and verti- 
 cal during posterior incisions, or partly flexed. 
 Landmarks. — Elbow joint-line; tip and 
 base of olecranon. 
 Incisions. — Antero-internal incision — begins at center of anterior aspect 
 of the joint-line — passes obliquely downward and inward over the forearm, 
 in such a way as to meet the mid-lateral aspect of the forearm, on the ulnar 
 side, at a distance of about 7.5 cm. (3 inches) below the joint-line — thence 
 passes upward and backward along a corresponding line to the base of the 
 olecranon. Postero-external incision — a shorter incision but very similar to 
 the longer, passes between the same points, crossing the mid-lateral aspect 
 of the forearm, on the radial side, about 2.5 cm. (1 inch) below the joint- 
 line (Fig. 330, B). This is practically an internal and external flap. 
 
 Operation. — Along the line of these retracted integuments the muscles 
 are cut obliquely down to the bone — when they, and as much of the periosteum 
 
 Fig. 331. — Disarticulation of 
 Elbow by Posterior Ellipse? 
 
SURGICAL ANATOMY OF THE ARM. 
 
 365 
 
 as possible, are dissected up to the joint-line in front, and to the tip of the 
 olecranon behind. The elbow is then flexed — the triceps is divided at its 
 attachment to the olecranon — and disarticulation completed by dividing the 
 posterior, lateral and anterior ligaments, in order. Tie the brachial, termina- 
 tions of the superior and inferior profunda, and, possibly, some small muscular 
 and articular branches. The large antero-internal flap folds over the articular 
 end of the humerus— its muscles are to be quilted to those of the smaller flap 
 — and the integuments of the two flaps sutured — placing the cicatrix upon 
 the externo-terminal aspect of the joint. 
 
 Fig. 332. — Disarticulation at 
 Elbow : — By long anterior and short 
 posterior flaps. 
 
 Fig. 333. — Disarticulation at 
 Elbow : — By long posterior and short 
 anterior flaps. 
 
 SURGICAL ANATOMY OF THE ARM. 
 
 Bones. — Humerus. 
 
 Muscles of the Arm. — (A) Anterior Humeral Region: — coracobrachial, 
 biceps, brachialis anticus. (B) Posterior Humeral Region: — triceps, sub- 
 anconeus. (C) Muscles having their insertions in upper portion of humerus: 
 — supraspinatus, infraspinatus, teres minor, subscapularis, pectoralis major, 
 latissimus dorsi, deltoid, teres major. (D) Muscles having their origin 
 from lower portion of humerus: — (a) From internal condyle and ridge: — 
 pronator radii teres, flexor carpi radialis, palmaris longus, flexor carpi ulnaris, 
 flexor sublimis digitorum — (b) From external condyle and ridge: — supinator 
 longus, extensor carpi radialis longior, extensor carpi radialis brevior, ex- 
 tensor communis digitorum, extensor minimi digiti, extensor carpi ulnaris, 
 anconeus, supinator brevis. 
 
 Arteries of Humeral Region. — From Axillary: — acromial and humeral 
 branches of acromial thoracic, subscapular, anterior circumflex, posterior 
 circumflex, and axillary itself. From Brachial: — superior profunda, nutrient, 
 
366 AMPUTATIONS. 
 
 inferior profunda, anastomotica magna, muscular, and brachial itself. From 
 Radial: — radial recurrent. From Ulnar: — anterior ulnar recurrent, posterior 
 ulnar recurrent. 
 
 Veins of Humeral Region. — Superficial: — cephalic, basilic, Deep: — 
 two vente comites accompany each of above branches of main arteries, and 
 also brachial artery. Axillary vein is formed by two brachial venae comites 
 and basilic vein. 
 
 Nerves of Humeral Region. — Anteriorly: — musculocutaneous, median, 
 internal cutaneous, ulnar, lesser internal cutaneous, intercosto-humeral. 
 Posteriorly: — circumflex, musculospiral. The cross-sections of the arm are 
 shown in Figs. 25, 27, and 335. 
 
 SURFACE FORM AND LANDMARKS OF THE ARM. 
 
 The humerus is almost entirely covered by muscles, being subcutaneous 
 only at the internal and external condyles. The greater and lesser tuber- 
 osities and the head may be defined. The greater tuberosity lies just below 
 the antero-external aspect of the acromion. The lesser tuberosity lies to the 
 inner side of and below the greater, the bicipital groove intervening. To 
 feel the head of the bone, abduct the arm, when the head will project promi- 
 nently into the axilla. 
 
 The internal condyle and internal condyloid ridge, and external condyle 
 and external condyloid ridge, can be felt just above the elbow-joint. The 
 latter are more easily felt during semiflexion, as a depression between adjacent 
 muscles. 
 
 The greater tuberosity and external condyle are in the same straight line 
 and face in the same direction. The head of the humerus and the internal 
 condyle are also in the same straight line and likewise face in the same direc- 
 tion. 
 
 When the arm hangs by the side, the bicipital groove looks directly for- 
 ward. 
 
 The rough prominence upon the outer aspect of the middle of the humerus, 
 into which the deltoid is inserted, also marks the level of the insertion of the 
 coracobrachialis and the origin of the brachialis anticus — and also the 
 entrance of the nutrient artery into the bone, and the level at which the 
 musculospiral nerve and superior profunda artery cross the back of the bone. 
 
 The upper epiphysis is horizontal and placed just above the surgical 
 neck, joining the shaft at the twentieth year. 
 
 The coracobrachialis and biceps above, and the biceps below, form the 
 prominent muscular mass of the front of the arm. The brachialis anticus is 
 discernible at the lower part of the arm, on each side of the biceps. 
 
 The triceps determines the form of the back of the arm. The inner head 
 is least distinct. The outer head forms the large prominence just below the 
 posterior border of the deltoid. The long head emerges from between the 
 teres major and minor and descends along the back of the arm. 
 
 The supinator longus and extensor carpi radialis longior form a prom- 
 inence on the outer side of the lower portion of the arm. 
 
 Above the middle of the arm, the biceps, deltoid, coracobrachialis, and 
 long head of triceps are more or less free and capable of retraction. Below 
 the middle of the arm, the biceps is the only free muscle. It is for this reason 
 that the circular method of amputation is suitable only to the lower half of 
 the arm. 
 
 In women and in fat persons the contour of the arm is more rounded 
 
SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT ARM. 367 
 
 and more nearly of one size throughout. In the muscular, it is less regular 
 and more flattened laterally. 
 
 On the inner and outer sides of the biceps are found the inner and outer 
 bicipital furrow,— the cephalic vein occupying the latter — and the brachial 
 artery and basi'ic vein the former. 
 
 The superior profunda artery arises just below the outlet of the axilla — 
 the inferior profunda opposite the center of the shaft — and the anastomotica 
 magna about 5 cm. (2 inches) above the bend of the elbow. 
 
 The skin is most retractile over the inner aspect of the arm. 
 
 Fig. 334. — Transverse Section through the Lower Third of the Right Arm: — 
 A, Biceps; B, Brachialis anticus; C, Musculospiral nerve and superior profunda artery; G, 
 Supinator longus; D, Brachial artery, vena; comites, basilic vein, and median nerve; E, Ulnar 
 nerve and superior profunda artery; F, Triceps. (The cross-section modified from Braune.) 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 
 
 THE ARM. 
 
 The shortest stump of an arm, even an amputation at the surgical neck, 
 is better than a shoulder-joint disarticulation — as such a stump will ordinarily 
 be able to move an artificial limb. It is, therefore, desirable to retain as 
 much of the humerus as possible, as leverage for the artificial limb. 
 
 From the standpoint of the amputator, the arm may be divided into two 
 natural regions — a lower third, more or less cylindrical, and where the muscles 
 are largely attached to bone — and an upper two-thirds, more or less conical, 
 flattened or irregular, and where the muscles are largelv free and capable 
 of retraction. Therefore a circular method of amputation is preferable for 
 the lower third, and a flap method for the upper two-thirds. 
 
 The surgical neck of the humerus marks the height at which a useful 
 stump can be obtained, as the capsule extends down to its level internally. 
 
368 AMPUTATIONS. 
 
 In amputating at the surgical neck, the bone is sawed between the tuber- 
 osities, and insertions of the pectoralis major and teres major. The supra- 
 spinatus, infraspinatus, teres minor, and subscapularis are left attached to 
 the head of the humerus. The bone is sawed below the epiphyseal line. 
 The synovial membrane of the joint (accompanying the biceps tendon) is apt 
 to be opened on the inner aspect, where it is lowest. The bursa under the 
 subscapularis tendon generally communicates with the joint and may be 
 opened during the operation. As much of the attachment of the pectoralis 
 major, teres major, and latissimus dorsi as possible is raised with the peri- 
 osteum, so as to be included in the musculo-periosteal covering of the end 
 of the bone and in the quilting of the muscles, in order to retain the attach- 
 ments of these muscles upon the stump and, therefore, their action upon 
 the artificial limb. 
 
 In an amputation through the upper two-thirds by an anterior flap twice 
 as long as the posterior, the scar will eventually be terminal, owing to the 
 much greater retraction of the anterior parts — the biceps contracting most of 
 any muscle. A terminal cicatrix is sought in the stumps of the arm. 
 
 The stump should be dressed upon a splint. 
 
 For control of hemorrhage in amputating at the shoulder joint, see page 374. 
 
 AMPUTATION OF THE ARM, IN GENERAL. 
 
 Best Methods. — Modified Circular — best for the lower third. Long 
 Anterior and Short Posterior Flaps — best for the upper two-thirds. Single 
 Externa] Flap — best at the surgical neck. 
 
 Other Methods. — Simple Circular (infundibular form). Single Anterior 
 Flap (Malgaigne's method). Anterior Ellipse (practically an anterior flap). 
 Posterior Ellipse (practically a posterior flap). Lateral Flaps (of skin and 
 muscles). Rectangular Flap (Teale's method). Oval Method (at the surgi- 
 cal neck). 
 
 General Indications. — Extensive crushes of upper extremity; tubercular 
 osteo-arthritis; sarcoma; tumors of elbow. 
 
 AMPUTATION THROUGH THE LOWER THIRD OF THE ARM 
 
 BY MODIFIED CIRCULAR METHOD. 
 
 Description. — Two short skin-flaps are cut and turned back, and the 
 muscles divided circularly in the infundibular manner. 
 
 Position. — Patient supine, at edge of table; limb horizontally abducted 
 over the edge of table during anterior incisions, and held vertically, with 
 bent elbow, or drawn over the chest, in dorsal incisions. Surgeon on outer 
 side of right and inner side of left limbs. Assistants steady the limb above 
 and below the site of amputation. 
 
 Landmarks. — Saw-line. 
 
 Incision. — The lowest limit of the skin incision is placed at a distance 
 below the saw-line equal to three-fourths of the diameter of the limb at 
 the saw-line (thus securing a covering of ij diameters). Of this total dis- 
 tance the small flaps will occupy, approximately, the lower one-third. These 
 flaps are generally anterior and posterior (but may be lateral, or in any 
 intermediate position, as the local conditions may demand). Their base is 
 one-half the circumference of the limb — they pass down the lateral aspects 
 of the limb to nearly their lower limit, when the}- bluntly round transversely 
 
AMPUTATION THROUGH THE LOWER THIRD OF THE ARM. 369 
 
 across the limb to a corresponding point on the opposite side. The anterior 
 and posterior daps are similar (Fig. 335, A). 
 
 Operation. — These flaps of skin and fascia are freed up to their base 
 and turned back as cuffs. Here the more superficial muscles are circularly 
 divided, and retracted in turn. Upon the line of these retracted superficial 
 muscles, the deeper muscles are cut to the bone — at a level still beneath the 
 saw-line. This last circular division also divides the periosteum around 
 
 Fig.335.— Amputations through Arm and at Shoulder :— A, Through lower part of arm, 
 by modified circular ; B, Through upper part of arm, by long anterior and short posterior flaps ; C, 
 At shoulder-joint, by external racket method (Larrey's operation) ; D, D, At shoulder, by external, or 
 deltoid, flap (Dupuytren's operation). 
 
 the entire bone. All the soft parts, including the periosteum, are now freed 
 up to the saw-line and the bone divided. Tie the brachial, superior pro- 
 funda, inferior profunda, muscular, and possibly the anastomotica magna, 
 branches. See that the musculospiral nerve is cleanly divided, and excise 
 any portion of it apt to be pressed upon in bending the flap over the end of 
 bone. Suture the musculo-periosteal covering. Quilt the muscles. Suture 
 the flaps in a lateral line. 
 
37° AMPUTATIONS. 
 
 Comment. — (i) The modified circular method makes it easier to free 
 the bone of soft parts up to the saw-line, and also furnishes a more sym- 
 metrical terminal covering. If necessary, the skin-flaps may represent one- 
 half of the distance between the saw-line and the lowest limit of the skin- 
 incision. (2) The simple circular method (the infundibular form) mav be 
 done here in small limbs with flabby coverings — but would be difficult in 
 large limbs with firm coverings. When the infundibular circular method is 
 used, it should be an oblique circular, the circle dipping lower on the antero- 
 internal aspect of the arm, where, owing to greater retraction, it will be sub- 
 sequently drawn up to the level with the outer part. 
 
 AMPUTATION OF THE UPPER TWO-THIRDS OF THE ARM 
 
 BY LONG ANTERIOR AND SHORT POSTERIOR FLAPS. 
 
 Description. — Two U-shaped flaps of skin and muscle are raised, the 
 posterior being one-half the length of the anterior. 
 
 Position. — As in the last operation. 
 
 Landmarks. — Saw-line. 
 
 Incisions. — The base of each flap equals one-half circumference at the 
 saw-line. The length of the anterior flap is equivalent to one diameter at 
 the saw-line. And the length of the posterior flap is one-half the diameter. 
 Both are U -shaped flaps. Care is taken to place these flaps so that the brachial 
 artery will not be apt to be split — the vessel should be in the posterior flap — 
 and the points of junction of the two flaps on the inner and outer aspect of 
 the arm should be so shifted toward the outer side as to make this certain. 
 The arm is raised vertically while the posterior flap is being marked out 
 and incised (Fig. 335, B). 
 
 Operation.- — Having incised skin and fascia along the above lines, the 
 muscles are divided along the retracted integumentary coverings — cutting 
 to the bone along the vertical limbs of the flaps, and cutting obliquely inward 
 and upward along the rounded transverse endings of the flaps, in a bluntly 
 beveled fashion — coming down upon the bone sufficiently far below the saw- 
 line to provide a periosteal covering, which, with the muscles, is freed up to 
 the saw line — and the bone divided. Care is taken to divide the musculo- 
 spiral nerve evenly and short — as well as the nerves in the anterior flap which 
 bend over the end of the bone, partially excising them if necessary. Tie the 
 brachial, superior profunda, and inferior profunda, and muscular branches. 
 Quilt the muscles of the anterior to those of the posterior flap — the former 
 chieflv covering the end of the bone. Suture the skin margins of the flaps. 
 The limbs should be steadied by a splint which also includes the shoulder. 
 
 AMPUTATION OF ARM AT SURGICAL NECK 
 
 BY SINGLE EXTERNAL FLAP. 
 
 Description. — A U-shaped flap, composed chiefly of deltoid, is raised 
 from the outer aspect of the arm, while the parts on the inner aspect are 
 divided transversely, or with slight downward convexity, on a level with the 
 upper limit of the limbs of the flap. 
 
 Position. — As in the above operations — the limb being drawn well away 
 from the body, which will give access to both outer and inner aspects. 
 
 Landmarks. — Surgical neck of humerus (just below the tuberosities). 
 
AMPUTATION OF ARM AT SURGICAL NECK. 
 
 371 
 
 Incisions. — Flap incision — the base of the flap, which is U-shaped, is 
 placed about 2.5 cm. (1 inch) below the saw-line through the surgical neck — 
 its width being equal to half the circumference of the limb at the flap's upper 
 limit — its length being that of the diameter at the saw-line. The anterior 
 limb of the flap passes down the mid-anterior aspect of the arm, and the 
 
 Fig. 336.— Amputations about Arm and at Shoulder: — A, Through lower part of arm, by 
 equal lateral flaps; B, Through surgical neck of humerus, by single external flap; C, At shoulder- 
 joint, by Furneaux Jordan's method. 
 
 posterior limb down the mid-posterior aspect. Inner incision — crosses the 
 inner aspect of the arm, with a slight downward convexity, connecting the 
 upper limits of the vertical limbs of the flap (Fig. 336, B). 
 
 Operation. — The above incisions pass, at first, through skin and fascia 
 only. After the integuments have retracted, the external flap is cut from 
 without inward, upon the line of the retracted tissues, beveling obliquely 
 upward and inward toward the upper limit of the flap. The bleeding vessels 
 in this external wound are clamped as met. The inner incision is now deep- 
 ened — and the axillary vessels tied as encountered and before being cut — 
 
37 2 AMPUTATIONS. 
 
 and the nerves cut short. The tendon of the pectoralis major is preserved, 
 the periosteum being divided below the bicipital groove and stripped up, 
 including this tendon. Avoid opening the synovial sheath of the biceps 
 tendon, dividing it low down, together with the coracobrachialis. Detach 
 the tendons of the latissimus dorsi and teres major as subperiosteal^ as 
 possible. Retract the outer flap and the parts on the inner aspect of the arm 
 up to the saw-line — and divide the bone through the lowest part of the surgical 
 neck possible. Avoid the circumflex nerve and the posterior circumflex 
 artery. The brachial artery will have been tied in the course of operation — 
 branches of the anterior and posterior circumflex and muscular branches 
 which have not been previously tied are now taken up. Bring the outer 
 flap across the end of the bone — quilt the muscles of the flap to those divided 
 in the inner incision — and suture the integumentary portion of the flap trans- 
 versely to corresponding tissues of the inner wound. Dress the arm against 
 a full pad in the axilla. 
 
 Comment. — ( i) The chief advantages of amputation through the surgical 
 neck, over disarticulation at the shoulder, are, that the mortality is less; 
 that a stump for an artificial limb is secured; and that there is not so much 
 muscular atrophy. The chief disadvantages are, that the remaining epiph- 
 ysis is apt to produce bone; and that the stump may be strongly abducted. 
 (2) The outer flap may be less satisfactorily cut by transfixion. 
 
 SURGICAL ANATOMY OF SHOULDER- JOINT. 
 
 Bones. — Scapula; clavicle; humerus. 
 
 Articulations and Ligaments. — (a) Acromio-clavicular Articulation: — 
 superior acromio-clavicular, inferior acromio-clavicular ligaments; inter- 
 articular fibro-cartilage; synovial membrane, (b) Coraco-clavicular Union: — 
 trapezoid and conoid ligaments, (c) Shoulder-joint: — capsular, gleno- 
 humeral bands of capsular, coraco-humeral, glenoid and transverse humeral 
 ligaments, and synovial membrane. 
 
 Muscles Reinforcing Shoulder-joint. — Above: — supraspinatus. Be- 
 low: — long head of triceps; an upward extension of pectoralis major. In- 
 ternally: — subscapularis. Externally: — infraspinatus; teres minor. Within 
 Joint: — long head of biceps. Surrounding Joint: — deltoid. 
 
 Muscles in More or Less Direct Relation with Shoulder-joint. — (a) 
 Anterior Thoracic Region: — pectoralis major, pectoralis minor, subclavius. 
 (b) Lateral Thoracic Region: — serratus magnus. (c) Acromial Region: — 
 deltoid, (d) Anterior Scapular Region: — subscapularis. (e) Posterior Scapu- 
 lar Region: — supraspinatus, infraspinatus, teres minor, teres major, (f) 
 Muscles Passing from Shoulder to Arm Anteriorly: — biceps, coracobrachialis. 
 (g) Muscles Passing from Shoulder to Arm Posteriorly: — triceps. 
 
 Movements of Shoulder-joint. — Forward: — pectoralis major, anterior 
 fibers of deltoid, coracobrachialis, biceps (when elbow is flexed). Backward: 
 — latissimus dorsi, teres major, posterior fibers of deltoid, triceps (when 
 elbow is extended). Abduction: — deltoid, supraspinatus. Adduction: — 
 subscapularis, pectoralis major, latissimus dorsi, teres major. Outward 
 Rotation: — infraspinatus, teres minor. Inward Rotation: — subscapularis, 
 latissimus dorsi, teres major, pectoralis major. 
 
 Bursa? in Neighborhood of Joint. — Beneath tendon of subscapularis 
 — communicating with joint by opening on anterior side of capsule. Beneath 
 tendon of infraspinatus (sometimes present) — communicating with joint by 
 
SURFACE FORM AND LANDMARKS OF SHOULDER- JOINT. 373 
 
 opening on posterior aspect of capsule. Between under surface of deltoid 
 and outer surface of capsule — not communicating with joint. Biceps tendon 
 passes through the joint and is surrounded by tubular sheath continuous 
 with synovial membrane. 
 
 Arteries in Neighborhood of Shoulder-joint. — Suprascapular, trans- 
 versalis colli, superior thoracic, acromial thoracic, long thoracic, alar thoracic. 
 subscapular, anterior circumflex, posterior circumflex. 
 
 Veins in Neighborhood of Shoulder-joint. — Two suprascapular, two 
 transversalis colli, superior thoracic, acromial thoracic, long thoracic, alar 
 thoracic, subscapular, anterior circumflex, posterior circumflex, cephalic 
 
 Nerves in Neighborhood of Shoulder-joint. — Acromial branch of 
 cervical plexus, posterior thoracic, suprascapular, external anterior thoracic, 
 internal anterior thoracic, upper subscapular, lower subscapular, middle 
 subscapular, circumflex, — and following passing through axilla to arm and 
 forearm; musculocutaneous, internal cutaneous, lesser internal cutaneous, 
 median, ulnar, musculospiral. 
 
 SURFACE FORM AND LANDMARKS OF SHOULDER- JOINT. 
 
 To find the direction and position of the shoulder-joint — having fully 
 abducted the arm, draw a slightly curved line from the middle of the coraco- 
 acromial ligament, with convexity inward, to the innermost part of the head 
 of the humerus felt in the axilla. 
 
 The coracoid process is not actually within the infraclavicular fossa, but 
 lies near the pectoro-deltoid groove, covered by the anterior fibers of the 
 deltoid, and a little below the clavicle. 
 
 The center of the coraco-acromial ligament lies over the superior aspect 
 of the shoulder-joint. 
 
 The greater tuberosity of the humerus is felt externally — the lesser ante- 
 riorly. To the former are attached the supraspinatus, infraspinatus, and 
 teres minor, in order, from above downward. To the lesser — the subscapularis. 
 
 With the arm by the side and the hand supine, the bicipital groove looks 
 directly forward — the head of the humerus lying entirely to the outer side 
 of the vertical line from the coracoid process. The head of the humerus 
 faces, practicallv, in the direction of the inner condyle — and the greater 
 tuberosity in the direction of the outer condyle. 
 
 The upper epiphysis of the humerus unites with the bone about the 
 twentieth year — the inner part of the cartilage is within the capsule of the 
 joint — the outer, anterior and posterior parts are subperiosteal. 
 
 The surgical neck lies between the bases of the tuberosities and the inser- 
 tions of the latissimus dorsi, teres major, and pectoralis major. 
 
 The deltoid gives the rounded outline to the shoulder — and its insertion 
 is marked by a depression on the outer aspect of the middle of the arm. 
 
 The groove between the pectoralis major and deltoid contains the cephalic 
 vein and the humeral branch of the acromio-thoracic artery. 
 
 The acromio-thoracic artery emerges from the upper border of the pec- 
 toralis minor in the course of the brachial artery, where a line from near the 
 junction of the third rib and its cartilage to the coracoid process crosses that 
 vessel. 
 
 The posterior circumflex artery and circumflex nerve cross the surgical 
 neck of the humerus transversely about 1.3 cm. (h inch) above the center 
 of the vertical axis of the deltoid. 
 
374 
 
 AMPUTATIONS. 
 
 The skin over the deltoid is thick, adherent, and little retractile — that 
 over the pectoralis major is fine and retractile. 
 
 The dorsalis scapulae artery crosses the axillary border of the scapula 
 opposite the center of the vertical axis of the deltoid. 
 
 GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATING AT 
 
 SHOULDER- JOINT. 
 
 Methods of Hemorrhage-control during operations near the Shoulder- 
 joint — (a) Wyeth's Shoulder Transfixion Pins, with tubular rubber Tourni- 
 quet placed above them; — The anterior pin (Fig. 337, A) enters the middle 
 of the anterior axillary fold, slightly to the inner side of the center of the fold — 
 
 D A 
 
 u A 
 
 tig. 337. — Wyeth's Pins Controlling Hemorrhage in Disarticulation at the 
 Shoulder-joint: — A Anterior pin; B, Posterior pin. The rubber tubing is then wound about 
 the limb proximally to the pins and knotted. 
 
 Fig. 337- 
 
 and emerges 2.5 cm. (1 inch) within the tip of the acromion process. The 
 posterior pin (Fig. 337, B) enters the posterior axillary fold, at a point corre- 
 sponding with the entrance of the anterior pin — and similarly emerges poster- 
 iorly 2.5 cm. (1 inch) within the tip of the acromial process. Care is neces- 
 sary to avoid striking the spine of the scapula with the posterior pin. Rubber 
 tubing of 1.3 cm. (£ inch) diameter is wound several times around the axilla, 
 above the pins, and tied (Fig. 268, right shoulder), (b) Where the special 
 pins are not at hand, the tube has been held in place by several sutures passed 
 through the true skin and temporarily tied over the tubing, after it has been 
 knotted. The tubing is thus prevented from slipping when the soft parts 
 recede, or sink in, after the head of the humerus is removed. The method, 
 however, is less satisfactory than the use of the pins (Fig. 338). (c) J. Lynn 
 Cardiff has devised a clever forceps-tourniquet for controlling hemorrhage 
 during operations upon the extremities. It consists of a clamp, one blade of 
 
SURGICAL CONSIDERATIONS IN SHOULDER DISARTICULATIONS. 375 
 
 which is probe-pointed, the other serrated. In the interscapulo-thoracic 
 amputation a limited incision is made, exposing the lower edge of the pectoral 
 muscle in the mid-axilla — through this the probe-pointed blade of the clamp 
 is thrust and carried onward and upward beneath the pectoral muscles and 
 the axillary vessels and nerves — to emerge through the wound previously made 
 for the purpose of dividing the clavicle (Fig. 339). The instrument is then 
 
 Fig. 338.— Illustrating the Use of Sutures Passed through the True Skin and 
 Temporarily tied over Rubber Tubing to hold it in Place: — Used in order to control 
 the vessels in disarticulating at the shoulder-joint in the absence of the Wyeth pins. 
 
 clamped — thus compressing the muscles and axillary structures between the 
 probe-pointed and serrated blades. The soft parts are then divided distally 
 to the clamp — the vessels are brought within easy reach — and the ligatures 
 are placed (Fig. 340). The points of entrance and exit of the probe-pointed 
 blade are made to correspond with some part of the incision for the interscapulo- 
 thoracic amputation, (d) Preliminary exposure and double ligation of the 
 axillary artery, with division between the two ligatures (as in Larrey's oper- 
 ation, page 381). (e) Digital compression of the main artery in the flap by 
 an assistant, who grasps the part just prior to division of the artery (as in 
 Spence's operation, page 378). (f) By Tourniquet and Pad; — A firm pad 
 is placed in the axilla — over tins are placed several turns of rubber tubing 
 passing around the axilla — the ends are then carried in a single figure-of-eight 
 fashion over the clavicle of the same side, and thence across the chest and are 
 tied beneath the opposite axilla. Two strips of sterile gauze run beneath 
 the tubing anteriorly and posteriorly (or placed in position prior to applying 
 the tubing) will enable the tubing to be further and more securely drawn 
 inward and thus make less the chances of slipping when the head of the humerus 
 is removed (Fig. 268, left shoulder), (g) Compression (digital or instru- 
 mental) of subclavian artery against the first rib, either with or without pre- 
 liminary incision over the third part of the artery, through the superficial 
 tissues, (h) Securing of the main vessels at the lower end of the incision, as 
 
376 
 
 AMPUTATIONS. 
 
 met in the course of the operation — an ordinary tourniquet having been first 
 applied — (as in the Fourneaux Jordan method) . 
 
 Comparison of methods of hemorrhage-control:— The control of hemor- 
 rhage in disarticulating at the shoulder-joint, or in amputating very near 
 the shoulder articulation, is the most serious consideration connected with 
 these operations. Wyeth's method, where the pins do not interfere with the 
 operation as planned, may be regarded as the best means against hemorrhage. 
 Preliminary exposure and ligation of the artery — and compression of the 
 artery in the flap— may be regarded as the next best methods. 
 
 Fig. 339. — Thomas' Forceps-tourniquet for Controlling Hemorrhage during 
 Operations itpon the Extremities: — The probe- pointed blade passes under the pectoral 
 muscles and axillary vessels and nerves, and the serrated blade over these structures — the former 
 coming out above the region of the previously divided clavicle. (Modified from Thomas.) 
 
 The axillary vessels should be as cleanly cut as possible — and so approached 
 as to be secured before being cut, where the method of preliminary ligation 
 is adopted. 
 
 The branches of the brachial plexus are to be divided high up. 
 
 The acromial process should always be preserved — as it furnishes a 
 support for the artificial limb. 
 
 A capsulo-periosteally covered stump should be sought — as furnishing 
 the best support for an artificial limb — therefore one should endeavor to 
 
DISARTICULATION AT SHOULDER-JOINT, IN GENERAL. 
 
 377 
 
 detach the insertions of the pectoralis major, latissimus dorsi, teres major, 
 subscapularis, supraspinatus, infraspinatus, and teres minor along with the 
 periosteum and capsule, in so far as this is possible. 
 
 A vertical wound, in closing the site of operation, affords the best drainage. 
 Sometimes drainage is made through a secondary opening. Temporary 
 drainage is always indicated — owing to the extensive synovial surfaces. 
 
 The stump should be dressed so as to compress dead spaces — and steadied 
 against the thorax as a splint by the surrounding bandaging. 
 
 Fig. 340. — Thomas' Forceps-tourniquet: — The pectoral muscles and axillary structures 
 have been divided distally to the clamp and turned forward. Note: — the probe-pointed blade 
 is here erroneously shown to be where the serrated blade should be, and vice versa. The correct 
 position of the blades is shown in the preceding illustration. (Modified from Thomas.) 
 
 DISARTICULATION AT SHOULDER- JOINT, IN GENERAL. 
 
 Best Methods. — Anterior Racket Method (Spence's operation). Ex- 
 ternal Racket Method (Larrey's operation). External or Deltoid Flap 
 (Dupuytren's operation). 
 
 Other Methods. — Anterior and Posterior Flaps. Circular. Elliptical. 
 Lateral Flaps. Fourneaux Jordan's Method. 
 
 Comparison of Methods. — The racket methods are the best. The 
 features of the anterior racket method are: — excision of the shoulder-joint 
 
378 AMPUTATIONS. 
 
 may be done, instead of an amputation, through the vertical portion of the 
 incision, which may be alone made at first, until it be found whether ampu- 
 tation be necessary; there is the smallest division of muscle; the posterior 
 circumflex artery and circumflex nerve are not cut; the main vessels are 
 easily controlled. The features of the external racket method are: — the 
 vertical portion of the incision also allows of an excision, the incision at first 
 being exploratory, through which an excision of the joint may be made, or 
 the operation may be converted into an amputation; there is considerable 
 division of muscle and the joint is more deeply placed than in the anterior 
 racket; the posterior circumflex artery and circumflex nerve are apt to be cut. 
 The disadvantages of the external or deltoid flap, which may be regarded 
 as probably the third best form of disarticulation, are, that the circumflex 
 nerve and posterior circumflex artery are cut — and that preliminary exami- 
 nation of the joint is impossible. 
 
 General Indications. — Tumors of arm; extensive injury of arm; com- 
 pound comminuted fractures; gunshot injuries; chronic disease of shoulder- 
 joint; gangrene of upper limb; extensive osteomyelitis; extensive tumor masses 
 of shoulder and scapula. 
 
 DISARTICULATION AT SHOULDER- JOINT 
 
 BV ANTERIOR RACKET METHOD — SPENCE'S OPERATION. 
 
 Description. — The queue of the incision is placed over the anterior 
 aspect of the upper end of the humerus — the diverging limbs of the racket, 
 or oval, encircling the inner and outer aspects of the arm and meeting behind. 
 
 Position. — Patient near edge of table; shoulders elevated; head to oppo- 
 site side; limb partly abducted. Surgeon on outer side of both shoulders, 
 or may stand on inner side of left. First assistant stands between shoulder 
 and patient's head, controls hemorrhage and retracts flaps. Second assistant 
 stands near elbow and manipulates limb. 
 
 Landmarks. — Coracoid process; pectoro-deltoid groove. 
 
 Incision. — Abduct the arm and rotate the head of the humerus outward. 
 Begin the incision just to the outer side of the coracoid process — pass down 
 through the clavicular fibers of the deltoid and pectoralis major, until the 
 humeral attachment of the pectoralis major is reached, which is divided. 
 From this point, the outer limb of the racket curves gently outward through 
 the lowest part of the deltoid to the posterior border of the axilla. From 
 the point of division of the humeral attachment* of the pectoralis major, the 
 inner limb of the racket curves downward across the inner aspect of the arm — 
 until it coincides with the opposite limb of the racket (Fig. 341, B). 
 
 Operation. — (I) The vertical portion of the incision is carried directly 
 to the bone. The outer limb of the racket at first passes through skin and 
 fascia, and is then deepened to the bone and through the periosteum, along 
 the line of the incised integuments. The inner limb of the racket merely 
 passes through skin and fascia, and especial care is taken that it goes no 
 deeper at this stage. (2) Returning to the outer lip of the wound, the anterior 
 fibers of the deltoid will be found divided, and this lip of the wound is now 
 freed from the bone and joint, as nearly subperiosteally as possible, thereby 
 securing the retention of some of the attachments of the pectoralis major, * 
 latissimus dorsi, and teres major to the fibrous tissue — the freeing being 
 accomplished by means of the thumb, periosteal elevator and knife, and 
 continuing up to the great tuberosity — carefully avoiding (by hugging the 
 
DISARTICULATION AT SHOULDER-JOINT. 
 
 379 
 
 bone) injury to the circumflex nerve and posterior circumflex artery, which 
 are raised from the bone in this outer flap. (3) The inner lip is similarly, 
 though less extensively, freed up to the lesser tuberosity, carefully guarding 
 
 Fig. 341.— Amputations through Arm and at Shoulder :— A, Through lower arm, by oblique 
 circular method ; B, At shoulder, by anterior racket method (Spence's operation) ; C, Of upper limb, 
 together with scapula and part of clavicle, by antero-inferior (pectoro-axillary) and postero-superior 
 (cervico-scapular) flaps (Berger's operation). 
 
 the axillary vessels. (4) By manipulating the limb from the elbow, flexed 
 at a right angle, the head of the bone and its tuberosities are made to present 
 themselves in the wound. By rotating inward, the great tuberosity presents, 
 and the supraspinatus, infraspinatus, and teres minor are severed very close 
 
380 AMPUTATIONS. 
 
 to the bone. By rotating outward, the lesser tuberosity presents, and the 
 subscapularis is severed. (5) The long head of the biceps is next cut, and 
 the capsule opened by dividing it transversely against the head of the bone. 
 The capsule being cut and the muscles attached to the tuberosities severed, 
 the head of the bone is now disarticulated and thrust upward above the 
 glenoid cavity, by abducting and rotating the head of the humerus outward — 
 the connection of the limb being maintained by the still unsevered tissues 
 upon the inner aspect. (6) The surgeon grasps the disarticulated head with 
 the left hand and draws it outward from the trunk. As he does so, the first 
 assistant, standing behind the shoulder, places the palm of the fingers of 
 both hands against the axillary aspect of the still uncut inner tissues, and his 
 thumbs, one from each side, between the neck of the bone and the tissues 
 of the inner side, compressing the axillary vessels between the thumbs in the 
 wound and the outspread fingers in the axilla — until he feels all circulation 
 controlled. The surgeon now passes a long knife between the neck of the 
 bone and the thumb-nails of his assistant, and, by a steady, sawing move- 
 ment, cuts his way from within downward and outward, aiming to come out 
 on a line with the retracted integuments along the original incision, along 
 me inner limb of the racket. As the knife cuts its way out, the fingers of 
 the assistant follow the blade closely, with the artery under his grasp. Just 
 prior to the final passage of the knife, the tissues are tightly grasped and 
 steadilv held, until the knife emerges — when he presents to the surgeon the 
 cut margin of the inner flap, with the vessels in easy evidence. (7) Tie the 
 brachial artery at once, and the two brachial venae comites and the basilic 
 vein. In the vertical and external limb of the racket, in incising and deepen- 
 ing the wound, branches of the acromial thoracic, the anterior circumflex, 
 and muscular branches are at first clamped and subsequently tied. (8) The 
 posterior circumflex nerve should not be injured. The nerves which are 
 severed are cut short. (9) The margins of the capsulo-periosteal wound, 
 where any appreciable periosteum has been saved, are sutured. The muscles 
 are quilted by deep and superficial tiers of buried catgut (chromic) sutures. 
 Temporary drainage is provided. The integumentary edges of the wound 
 are sutured in one vertical line. The stump should be snugly compressed 
 against the thorax by the bandage. 
 
 Comment. — (1) This operation is an illustration of the control of hemor- 
 rhage by digital compression in the flap. (2) By saving as much of the 
 attachment of the pectoralis major, latissimus dorsi and teres major, in the 
 subperiosteal freeing of the humerus, connections in the stump are formed 
 by these tendons and considerable range of movement is thereby added to 
 an artificial limb. (3) The axillary vessels have been exposed where the 
 inner limb of the racket crosses their course and ligated prior to disarticula- 
 tion. (4) Where the deltoid tissues are very thick, this flap may be ad- 
 vantageously thinned a little by making the incision of the outer limb of the 
 racket in a beveling manner. (5) The more nearly the operation is done 
 subperiosteallv, where no contraindication to the preservation of the peri- 
 osteum exists, the greater the safety to the important tissues, especially the 
 circumflex nerve and posterior circumflex artery. 
 
DISARTICULATION AT SHOULDER-JOINT. 381 
 
 DISARTICULATION AT SHOULDER- JOINT 
 
 BY EXTERNAL RACKET METHOD — LARREY'S OPERATION. 
 
 Description. — The queue of the incision is placed oYer the external 
 aspect of the upper end of the humerus — from the center of this incision 
 (which may first haYe been made for exploration of the joint alone) the two 
 limbs of the racket diverge — encircling the anterior and posterior aspects 
 of the arm and meeting on the inner side. 
 
 Position. — As in Spence's operation (page 378). 
 
 Landmarks. — Prominence of acromion. 
 
 Incisions. — d) Vertical incision — (arm being slightly abducted) begins 
 immediately below the anterior aspect of the prominence of the acromion 
 and passes thence vertically down the external aspect of the arm for 10 cm. 
 (4 inches). (2) Oval incision — from the center of the vertical incision the 
 two limbs of the oval, or racket, begin and pass obliquely downward over 
 the anterior and posterior aspects of the limb, meeting upon its inner border 
 on a level with the lowest part of the vertical incision (Fig. 335, C). 
 
 Operation. — (i) The vertical incision passes at once through the deltoid 
 directly to the bone and into the joint. The operation, which may have 
 been begun as an exploratory one, may end with an investigation of the joint 
 — or may proceed to an excision of the joint structures — or may end as an 
 amputation. If the latter, the oval, or racket, incision, as above described, 
 is added to the vertical incision. (2) The limbs of the racket are at first 
 incised through skin and fascia only, and may be made at one stroke, or, 
 better, by two. (3) The anterior limb of the racket is now deepened, while 
 the arm is rotated outward — the incision passing through the anterior portion 
 of the deltoid — the tendon of the pectoralis major is severed as near the 
 bone as possible — the coracobrachialis and biceps are divided — and, next to 
 these, the axillary vessels are encountered, carefully exposed and doubly 
 ligated, beyond the posterior circumflex branch. This flap is then freed 
 up to the joint. For the same reasons mentioned under the last operation, 
 the freeing of these flaps should be done as subperiosteally as possible. (4) 
 The posterior limb of the racket is similarly deepened, the arm being rotated 
 inward — the incision passing through the posterior portion of the deltoid — 
 and meeting the anterior limb upon the inner side of the arm. This flap 
 is then also freed up to the joint as subperiosteally as possible. (5) Dis- 
 articulation is accomplished (after severing close to the bone in the above 
 freeing of the anterior and posterior flaps, the attachments of the supra- 
 spinatus, infraspinatus, and teres minor to the great tuberosity, and the 
 subscapularis to the lesser) by cutting the capsule and the long head of the 
 biceps against the head of the bone transversely. The head of the bone is 
 now disarticulated and thrust upward. (6) To sever the remaining soft 
 parts, the surgeon grasps the disarticulated head of the humerus with his 
 left hand and draws it outward — then inserts a long knife between the neck 
 of the bone and the remaining undivided parts, and, by a sawing movement, 
 cuts his way downward and outward between the severed axillary vessels 
 and the bone, coming out on a line with the retracted inner limb of the racket 
 incision (just as in the disarticulation by the anterior racket). (7) Besides 
 the above-named vessels, the anterior and posterior circumflex are both apt 
 to be divided, as well as some muscular branches. The circumflex nerve is 
 likely to be severed. All nerves are cut short. (8) The capsule is to be 
 trimmed, if hanging in tags. Temporary drainage is used. The capsulo- 
 
382 AMPUTATIONS. 
 
 periosteal, or capsulo-muscular covering is sutured — the muscles quilted 
 deeply and superficially — and the skin sutured in a vertical line. 
 
 Comment. — This operation is an illustration of the control of hemor- 
 rhage by the ligation of the main vessels in the line of incision, prior to dis- 
 articulation. 
 
 DISARTICULATION AT SHOULDER- JOINT 
 
 PA' EXTERNAL OR DELTOID FLAP. 
 
 Description. — A U-shaped flap, consisting practically of the deltoid 
 muscle, is raised from the outer side of the shoulder — its upper limits being 
 connected by a transversely curved incision across the inner aspect of the 
 arm. 
 
 Position.— As in Spence's operation (page 378). 
 
 Landmarks. — Coracoid process of scapula; spine of scapula. 
 
 Incision. — The base of this U-shaped flap extends from the coracoid 
 process, anteriorly, to the spine of the scapula at the root of the acromion 
 posteriorly. In length, the flap extends nearly to the insertion of the deltoid. 
 The upper extremities of the limbs of the flap are joined by a transversely 
 curved incision (with slight downward convexity) crossing the inner side 
 of the arm about 5 cm. (2 inches) below the lower limit of the axilla. On 
 the right side, the incision begins at the root of the acromion and ends at the 
 coracoid, the arm having been placed across the chest. On the left side, 
 the incision begins at the coracoid, with the arm abducted — and ends at the 
 root of the acromion, with the arm across the chest. In both, the surgeon 
 manipulates the limb with his left hand. This flap consists of the entire 
 thickness of the deltoid at the base, while its margins are beveled. (Fig. 335, 
 D, D.) 
 
 Operation. — The entire length of the superficial incision outlining the 
 flap is now deepened to the bone along the line of the retracted skin — cutting 
 in a beveling fashion obliquely from without inward and from below upward. 
 This mass of soft tissues is then raised from the bone, severing the attach- 
 ments of the muscles of the great and less tuberosities. The joint is now 
 opened by cutting directly down upon the capsule and long head of the biceps 
 transversely against the head of the bone. The head of the bone is dis- 
 articulated and thrust upward, and the operation completed as in Spence's 
 method of disarticulating — that is, the head of the bone is grasped and drawn 
 outward — an assistant guarding the tissues of the inner flap as in the opera- 
 tion just mentioned, a long knife is inserted between the neck of the bone 
 and the still undivided tissues upon the inner aspect and made to cut its way 
 downward and outward on a line with the transversely curved portion of the 
 incision connecting the upper limbs of the flap, thus severing the pectoralis 
 major, latissimus dorsi, and teres major. Having ligated the vessels and 
 cut the nerves short — the muscles are quilted — and the integumentary margin 
 of the deltoid flap is sutured to the border of the short internal flap. 
 
 Comment. — (1) This is the least desirable of the three methods of dis- 
 articulation described. (2) Hemorrhage may be controlled by some form 
 of tourniquet, or by the early ligation of the artery in the axilla. (3) An 
 attempt may be made to save the circumflex nerve and the posterior circumflex 
 artery — either by isolating and retracting them while incising from the skin 
 downward in the posterior limb of the flap — or by approaching them from 
 the anterior portion of the flap, working under the periosteum and then 
 retracting them. 
 
INTERSCAPULO-THORACIC AMPUTATION. 383 
 
 AMPUTATION OF UPPER LIMB, TOGETHER WITH SCAPULA AND 
 PART OF CLAVICLE, 
 
 BY ANTEROINFERIOR (OR PECTORO-AXILLARY) AND POSTERO-SITERIOR (OR 
 CERVICO-SCAPULAR) FLAPS— BERGER'S OPERATION. 
 
 Description. — Consists in the removal of the upper limb, together with 
 the scapula and the outer two-thirds of the clavicle, en masse, without dis- 
 articulation at the shoulder-joint. 
 
 Position. — Given in the steps of the operation. 
 
 Landmarks. — Outline of clavicle; outline of scapula; line of shoulder- 
 joint articulation. 
 
 Operation.— (1) Subperiosteal Excision of middle third of Clavicle and 
 double ligature and division of Subclavian Artery and Vein: — Patient on 
 back, at edge of table; shoulders raised; arm by side. Make an incision 
 through the periosteum to bone, over the upper surface of the clavicle, from 
 outer border of sternomastoid to just beyond the acromioclavicular articu- 
 lation (Fig. 341, C, C, C). The vein from the cephalic to the external jugular 
 is hereby cut and is doubly ligated. The periosteum is raised, with curved 
 periosteal elevator, from around the entire circumference of the middle third 
 of the clavicle. A chain or Gigli saw is passed between bone and periosteum 
 and the clavicle is divided at the junction of its inner and middle thirds. 
 The outer two-thirds of the clavicle is now grasped with lion-jaw forceps 
 and drawn outward, during which outward traction whatever periosteum 
 may remain is now detached from its middle third. The clavicle is then 
 sawed at the junction of the middle and outer thirds, by a chain, Gigli, or 
 small saw. The middle third of the clavicle is thereby removed. The 
 periosteum over the subclavius muscle and the subclavius muscle are 
 now divided transversely, opposite the inner section of the clavicle, and 
 are dissected up and turned outward, thereby exposing the subclavian 
 vessels, surrounded by more or less fascia. Having divided the over- 
 lying fascia, the subclavian vein and then the artery are exposed. Both 
 artery and vein are doubly ligated and divided opposite the lower 
 border of the first rib — the former being secured first (to lessen the 
 amount of blood left in the limb). (2) Formation of Anteroinferior (or 
 Pectoro-axillary) Flap: — Patient on back, with shoulder over edge of table; 
 arm abducted; head to opposite side. Surgeon between arm and trunk. 
 The incision begins at the middle of the clavicular incision — curves down- 
 ward and outward, passing close to the outer side of the coracoid process — 
 thence along the anterior portion of the deltoid, just external to the pectoro- 
 deltoid groove, to the junction of the anterior axillary wall with the arm — 
 thence across the lower border of the pectoralis major — thence transversely 
 across the inner or axillary surface of the arm — to the lower borders of the 
 tendons of the latissimus dorsi and teres major. Here the limb is elevated — 
 and the incision is earned downward and inward in the groove between 
 the vertical border of the scapula and the muscular elevation formed by 
 the teres major and latissimus dorsi, to end over the posterior surface of the 
 inferior angle of the scapula. This incision passes, at first, through skin 
 and fascia, and is then deepened through the pectoral and axillary tissues 
 — the pectoralis major being cut where its tendinous portion commences — 
 the pectoralis minor near the coracoid process — the brachial plexus near the 
 first rib — the latissimus dorsi in the more posterior part of the line of incision 
 — and whatever remaining axillary tissues bind the limb are cut as encoun- 
 tered. The shoulder is thus freed from the trunk anteriorly — and tends to 
 
384 AMPUTATIONS. 
 
 fall outward and backward. (3) Formation of the Postero-superior (or 
 Cervico-scapular) Flap: — The patient is still supine, with shoulder over 
 edge of table; the arm is now drawn across the chest to emphasize the scapular 
 region. The surgeon stands to the outer side. The incision begins at the 
 outer end of the clavicular incision, just external to the acromio-clavicular 
 joint — passing thence backward over the spine of the scapula by the shortest 
 route, to join the lower end of the antero-inferior flap incision over the inferior 
 angle of the scapula. This incision at first involves only the skin and fascia, 
 which are then well retracted along their upper part, thus exposing the trape- 
 zius, which is now divided near its attachment to the clavicle and scapula, 
 and thus severed from the whole limb. (4) Severing of Connections of 
 Scapula to Trunk: — The patient lies as in the last step — and the surgeon 
 stands to the inner side of the right and outer side of left limb. The anterior 
 and posterior flaps are well retracted and the limb permitted to hang away 
 from the side. The superior and vertical borders of the scapula are rendered 
 prominent and are now freed by cutting the following muscles close to the 
 bone, in order from above downward: omohyoid, levator anguli scapula 1 , 
 rhomboideus minor, rhomboideus major, and serratus magnus. The upper 
 extremity is now free from the trunk — the muscles arising from the scapula 
 and inserted into the humerus (teres major and minor, subscapulars, supra- 
 spinatus, and infraspinatus) are removed untouched with the limb. (5) Con- 
 trol of Hemorrhage: — Preliminary ligation of the subclavian artery and vein 
 control the chief hemorrhage. In forming the anterior flap, branches of 
 the acromio-thoracic, long thoracic and subscapular are encountered. In 
 forming the posterior flap, the muscular branches in the trapezius are met. 
 In severing the scapula the chief bleeding occurs — the suprascapular artery 
 is to be tied near the omohyoid as it is about to enter the supraspinous fossa 
 — and the posterior scapular is to be tied near the upper angle of the scapula 
 just after dividing the levator anguli scapulae. (6) Closure of the Wound: — 
 All the nerves are divided short. Generally no sufficient redundancy of mus- 
 cles is present to admit of quilting, it usually being difficult to approximate 
 the edges of the wound — but, if it be possible, quilting of the muscles together 
 with buried gut sutures should be done — to make a thicker stump-padding 
 and to take the strain off the cutaneous sutures. The anterior and posterior 
 flaps are brought together and sutured in one oblique line, extending from 
 above, downward, outward, and backward. To obliterate the dead spaces 
 which tend to form in so extensive a wound, considerable even pressure is 
 applied in the dressings which bind the parts to the thorax. No drainage 
 is indicated in simple cases. 
 
 Comment. — (1) Sometimes the outer two-thirds of the clavicle is drawn 
 outward and disarticulated at the acromion. (2) If the suprascapular and 
 posterior scapular arteries are ligated through such a wound as is made 
 in exposing the clavicle, at this stage, the chief bleeding of the whole operation 
 will be avoided. The former is easily found. (3) One is apt to find too 
 scanty an allowance of flap covering, which is caused by not extending the 
 oval parts of the incisions far enough out over the shoulder. 
 
SURFACE FORM AND LANDMARKS OF TOES. 385 
 
 AMPUTATIONS AND DISARTICULATIONS OF THE LOWER 
 
 EXTREMITY. 
 
 SURGICAL ANATOMY OF THE TOES. 
 
 Bones. — Third, second, and first Phalanges. 
 
 Articulations and Ligaments. — (a) Second and Third Interphalangeal 
 Joint: — Plantar; dorsal and two lateral ligaments. Extensor tendon rein- 
 forces dorsal aspect of joint, (b) First and Second Interphalangeal Joint: — 
 Same as last, (c) Metatarsophalangeal Joints: — Plantar (glenoid), dorsal, 
 and two lateral ligaments. Extensor tendon reinforces dorsal aspect. 
 
 Muscles. — See under Foot (page 397). 
 
 Sheaths of Flexor Tendons. — Tendons of flexor longus digitorum and 
 flexor brevis digitorum, in their passage along the phalanges, are bound 
 against the bones by fibrous sheaths attached to margins of phalanges and 
 forming osseo-aponeurotic canals lined by synovial membrane. They are 
 strongest opposite the first and second phalanges, and weakest opposite 
 the interphalangeal joints. 
 
 Arteries. — Two dorsal digital, from dorsal interosseous and from dorsalis 
 hallucis; two plantar from plantar digital and from princeps hallucis. 
 
 Veins. — Superficial: — branches from the superficies of each toe. Deep: 
 — accompany the digital arteries. Note — From the foot to the knee, two 
 veins accompany each artery; from knee upward, one vein accompanies 
 each artery, except at back of thigh and gluteal region, where there are gener- 
 ally two. 
 
 Nerves. — External saphenous; internal and external branches of musculo- 
 cutaneous; internal branch of anterior tibial; digital branches of internal 
 plantar; digital branches of external plantar. 
 
 SURFACE FORM AND LANDMARKS OF TOES. 
 
 Extensor tendons of four outer toes — the four tendons of the extensor 
 longus digitorum, having been joined by the tendons of the extensor brevis 
 digitorum (except that the latter muscle furnishes no tendon to the little 
 toe) and by fibrous expansions from the interossei and lumbricales — all 
 spread out into a broad aponeurosis, which covers the dorsum of the first 
 phalanx and divides into three slips — the middle slip being inserted into 
 the bases of the second phalanges of the four lesser toes — the two lateral 
 slips, having united on the dorsum of the second phalanx, are inserted into 
 the bases of the third phalanges of the four lesser toes. 
 
 Extensor tendon of great toe — the innermost tendon of the extensor 
 brevis digitorum is inserted into the dorsal surface of the base of the first 
 phalanx — blending with the tendon of the extensor proprius hallucis, which 
 is inserted into the dorsal surface of the base of the last phalanx. 
 
 Flexor tendons of four outer toes — the four tendons of the flexor brevis 
 digitorum divide opposite the base of the first phalanges (for the passage of 
 the tendon of the flexor longus digitorum) and then unite opposite the first 
 phalanges to form a channel for the flexor longus digitorum — then divide — 
 and are finally inserted into the sides of the middle of the second phalanges. 
 The four tendons of the flexor longus digitorum are inserted into the bases 
 of the plantar surfaces of the last phalanges of the four lesser toes. 
 
 2 5 
 
386 AMPUTATIONS. 
 
 Flexor tendons of great toe — the flexor brevis hallucis is inserted into 
 the inner and outer sides of the plantar surface of the base of the first phalanx, 
 a sesamoid bone being present in each of its two heads of insertion. The 
 tendon of the flexor longus hallucis is inserted into the plantar surface of the 
 base of the last phalanx. 
 
 The flexor sheaths, which are not so distinct as in the fingers, have been 
 given under Surgical Anatomy (page 385). 
 
 The first interphalangeal joint of each toe is about opposite its middle. 
 
 The knuckle of each phalangeal joint is formed by the head of the proximal 
 bone — as in the hand. 
 
 The joint-line of the interphalangeal and metatarso-phalangeal articula- 
 tions is found by flexing the distal bone at a right angle to the proximal and 
 extending the mid-lateral axis of the proximal bone — which will pass over 
 the joint-line. 
 
 The metatarso-phalangeal joints follow, approximately, the curve of the 
 toes and are about 2.5 cm. (1 inch) behind the webs. The metatarso-phalangeal 
 articulation of the first and fifth toes is detectable by manipulation, and the 
 line of the other joints then found by making a curve between them about 
 parallel with the interdigital webs. 
 
 The anterior, or glenoid, ligament occupies the plantar surface of the 
 metatarso-phalangeal and the interphalangeal joints and is more firmly 
 adherent to the base of the distal than to the head of the proximal bone. 
 It is cut against the base of the former. 
 
 The nail largely overlies the last phalanx. 
 
 Each metatarsal has one epiphysis at its head, uniting from the eighteenth 
 to twentieth year — that of the great toe having it at its base, and uniting 
 at the same time. Each phalanx has one epiphysis at its base — uniting 
 from the seventeenth to eighteenth year. 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS AND 
 DISARTICULATIONS ABOUT THE TOES. 
 
 Many of the observations made concerning amputations and disarticula- 
 tions about the fingers apply to corresponding regions of the toes. But 
 operations here, except about the great toe, are apt to be very irregular pro- 
 ceedings, largely determined by circumstances. 
 
 Minimum sacrifice of parts is indicated, often amounting to mere trim- 
 mings — but this principle is not as absolutely necessary as in the fingers. 
 
 Preservation of the heads of the metatarsals increases the strength of 
 the foot. 
 
 If the base of the last phalanx be saved, all of the extensor and the deep 
 flexor tendon (flexor longus digitorum) will be preserved. If the proximal 
 half of the second phalanx be saved, part of the extensor and the superficial 
 flexor (flexor brevis digitorum) tendon will be saved. 
 
 Preservation of parts of the great toe is much more important than preser- 
 vation of the four lesser toes. 
 
 As the foot rests on the heel, heads of the metatarsals and inner margin 
 of the sole, as much as possible of the anterior part of the foot and phalanges 
 of the great toe is to be saved. 
 
 It is important to save the base of the first phalanx of the great toe, owing 
 to the number of muscles which are there inserted. If the base of the first 
 phalanx cannot be saved, its many attached tendons should be removed as 
 nearly subperiosteally as possible and be sutured into the tissues of the stump. 
 
SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT TOES. 387 
 
 Except in the case of the great toe, a portion of a toe is of little or no use; 
 and, in the case of the four outer toes, a retained portion of a toe may be 
 drawn permanently upward and thus be pressed against. Therefore some 
 surgeons remove the four outer toes at the metatarso-phalangeal joint, if 
 removed at all. 
 
 The flexor sheaths should be closed as in the finger operations (page 339). 
 
 The flexor tendons should be so sutured as to secure their union to the 
 stump, if it be wished to retain their action. But, except in the case of the 
 great toe, this is much less important than in the fingers. 
 
 Musculo-periosteal coverings and capsulo-periosteal coverings in these 
 small amputations and disarticulations are, theoretically, desirable, but, 
 practically, difficult or impossible. 
 
 Cicatrices should be planned not to fall in the sole, where they would 
 be constantly exposed to pressure. The plantar flap, therefore, is the best 
 general type of amputation or disarticulation for the toes, bringing, as it 
 does, the cicatrix upon the dorsum. 
 
 In amputating by the plantar flap a slight downward convexity given to 
 the transverse dorsal incision makes a better fit. 
 
 In making all plantar incisions the part should be extended — and flexed 
 while making dorsal incisions — whereby a fuller covering will be obtained. 
 
 Flaps are generally formed (in the palmar flap method) by cutting directly 
 downward in the mid-lateral aspects of the toes, but if the vertical limbs of 
 the incisions be a little nearer the dorsal than the plantar surface, a more 
 liberal covering will be secured. 
 
 All flaps should be cut from without inward. 
 
 Bones should be divided by a fine, rigid saw, or a chain or Gigli saw — 
 and never by bone-cutting forceps. 
 
 Disarticulation of the interphalangeal joints may be made from the 
 dorsal or plantar aspect. In the former, the extensor tendon is cut from 
 without, and then the lateral and glenoid ligaments are cut from within 
 outward. In the latter, the glenoid ligament is cut against the base of the 
 distal bone, and the joint opened, and then the lateral ligaments and the 
 extensor tendon are cut from within outward. The dorsal disarticulation 
 is preferable. 
 
 In disarticulating at the metatarso-phalangeal joints, the following points 
 are to be observed: — The joint is to be disarticulated from the dorsum. 
 The sesamoid bones are to be left in with the head of the metatarsal. Ample 
 covering is necessary for the disproportionately large head of the metatarsal. 
 The cicatrix should be away from the plantar surface (where it would be 
 exposed to pressure). Owing to the distance of the joint-line above the 
 web, it would be difficult to disarticulate from the plantar aspect. The 
 heads of the metatarsals should not be removed. 
 
 Great care is necessary to hug the bone in freeing up flaps, in order to 
 avoid the digital arteries, which run near the bone and are the sole supply 
 to the coverings. These vessels should run to the end of the flaps. 
 
 Ligatures should be catgut — and sutures silk, or silkworm-gut for the 
 skin. Sutures for quilting muscles or tendons, or for closing sheaths, should 
 be of catgut. 
 
 Drainage is generally unnecessary. 
 
 In all amputations or disarticulations, the stump should be snugly dressed 
 and bandaged against an adjoining toe as a splint. 
 
 The stump should be kept out from under the bed-clothes while healing 
 
388 AMPUTATIONS. 
 
 —and the patient frequently lie upon the side to favor drainage, where in- 
 dicated. 
 
 Note. — The indications for amputations through the various parts of the 
 lower extremity correspond, in a general way, with those for amputating 
 through the corresponding parts of the upper extremity. 
 
 AMPUTATION THROUGH LAST PHALANX OF TOES, IN GENERAL. 
 
 Best Method. ■■ -Plantar Flap. 
 Other Method.— Oblique Circular. 
 
 V jtO 
 
 Fig. 342. — Dorsal View of the Bones or the Foot, Showing the Intertarsal, Tarso- 
 metatarsal, AND INTERMETATARSAL ARTICULATIONS. 
 Fig- 343- — Plantar View of the Bones of the Foot, Showing the Intertarsal, Tarso- 
 metatarsal, AND INTERMETATARSAL ARTICULATIONS. 
 
 AMPUTATION THROUGH LAST PHALANX OF TOES 
 
 BV PLANTAR FLAP. 
 
 Description. — Hardly feasible as a definite operation — amounting, 
 generallv, to trimming of the parts — except in the case of the great toe, which 
 is the operation here described. 
 
 Position.— (For all amputations about the toes) : —Patient supine, 
 
DISARTICULATION AT SECOND INTERPHALAXGEAL JOINT. 389 
 
 with foot bevond end of table; toes extended during plantar incisions, and 
 flexed during dorsal incisions. Assistant stands in front of surgeon, steadying 
 foot with both hands, the fingers of which, at the same time, draw aside 
 and out of the way, the adjacent toes. Surgeon grasps toe to be removed 
 with thumb and forefinger of left hand — with his thumb on the dorsum 
 of the toe during dorsal incisions; and on the plantar surface of toe during 
 plantar incisions — the index-finger occupying the opposite aspect in each 
 case. His hand will be supinated during dorsal, and pronated during plantar 
 incisions. 
 
 Landmarks. — Saw-line, which will lie between base of nail and inter- 
 phalangeal joint above. 
 
 Incision. — The vertical portion begins opposite the saw-line, in the 
 mid-lateral aspect of the toe, or a little nearer the dorsum (which furnishes 
 a fuller plantar flap) — passes straight down that aspect and around the 
 pulp of the toe to the corresponding point on the opposite side. The trans- 
 verse dorsal incision connects the upper ends of the limbs, with slight down- 
 ward convexity (Fig. 349, A, for principle). 
 
 Operation. — Having incised skin and fascia, these incisions are deepened 
 to the bone — the soft parts are separated up to the saw-line and retracted. 
 The tip of the phalanx is grasped with bone-holding forceps and steadied, 
 while the bone is sawed. If the base of the last phalanges be left, the inser- 
 tion of the flexor and extensor tendons will be preserved. Arteries rarely 
 have to be tied — except in the case of the great toe. 
 
 DISARTICULATION AT SECOND INTERPHALANGEAL JOINT, IN 
 
 GENERAL. 
 
 Best Method.— Plantar Flap. 
 Other Method. — Oblique Circular. 
 
 DISARTICULATION AT SECOND INTERPHALANGEAL JOINT OF TOES 
 
 BV PLANTAR FLAP. 
 
 Description. — A U-shaped flap is raised from the plantar aspect of the 
 toe and approximated to the dorsal wound. 
 
 Position. — As for the last phalanx (page 388). 
 
 Landmarks. — Second interphalangeal joint-line. 
 
 Incisions. — The vertical portion of the incision begins opposite the 
 joint-line, in the mid-lateral aspect, or a little nearer the dorsum — passes 
 directly down this aspect of the toe a distance sufficient to furnish a covering 
 of ii diameters of the toe at the saw-line — then rounds bluntly across the 
 plantar surface and is continued up to a corresponding point on the opposite 
 side. The transverse incision connects the upper limbs of the flap by a 
 slight! v rounded convex line (Fig. 349, A). 
 
 Operation. — Deepen the vertical portion and the rounded end of the 
 flap to the bone — dissect up the soft parts to the joint-line, cutting the glenoid 
 ligament and flexor tendon against the base of the last phalanx, thus opening 
 the joint. Forcibly hex the joint and deepen the transverse incision to and 
 into the joint, entering from the dorsum and cutting the lateral ligaments 
 
39° AMPUTATIONS. 
 
 from within outward. Two dorsal and two plantar digital arteries may 
 require ligation. Close the flexor sheath with catgut — and, in the great 
 toe, include the flexor tendon. Suture the plantar flap to the transverse 
 dorsal wound. 
 
 AMPUTATION THROUGH SECOND PHALANX OF TOES, IN GENERAL. 
 
 Best Method.— Plantar Flap. 
 Other Method. — Oblique Circular. 
 
 AMPUTATION THROUGH SECOND PHALANX OF TOES 
 
 BY PLANTAR FLAP. 
 
 Description. — The manner of performing this operation is sufficiently 
 described in the amputation through the last phalanx (page 388), and the 
 dimensions of the flap, under the disarticulation at the second interphalangeal 
 joint (page 389). 
 
 DISARTICULATION AT FIRST INTERPHALANGEAL JOINTS OF TOES, 
 
 IN GENERAL. 
 Best Method.— Oval Method. 
 Other Methods. — Oblique Circular. Plantar Flap. 
 
 DISARTICULATION AT FIRST INTERPHALANGEAL JOINTS OF TOES 
 
 BY OVAL METHOD. 
 
 Description. — Queue of incision over dorsal aspect of joint — the limbs 
 of the oval encircling the toe beyond the first interphalangeal jointdine. 
 
 Position. — As in amputating through the last phalanx. 
 
 Landmarks. — First Interphalangeal joint. 
 
 Incision. — The queue of the oval begins just above the head of the 
 first phalanx, on its mid-dorsal aspect — passes vertically downward over 
 the head of the phalanx, and continues down to near the middle of the first 
 phalanx — where the two corresponding limbs diverge to encircle the second 
 phalanx and meet in the middle of its plantar aspect (Fig. 344, C). 
 
 Operation. — Deepen the dorsal incision to the extensor tendon. Extend 
 the toe and deepen the oval to the bone, cutting the flexor tendons trans- 
 versely. Dissect up the soft parts upon the plantar and lateral aspects. 
 Divide the glenoid (anterior) ligament by cutting against the base of the 
 second phalanx and opening the joint. Divide the lateral ligaments from 
 wdthin outward. Draw upon the toe and cut the extensor tendon high up. 
 Two plantar and two dorsal digital arteries are cut — the former may require 
 ligation. Close the flexor sheath. Suture the wound vertically. The 
 cicatrix will be vertical and dorso-terminal. 
 
 Comment. — The head of the first phalanx may be removed, especially 
 of the second and third toes — as it is large and mav be in the way. 
 
AMPUTATION THROUGH FIRST PHALANGES OF TOES. 
 
 39 1 
 
 Fig. 344.— Amputations about the Toes and Foot :— A. At interphalangeal joint of great toe, 
 by a single internal flap: B, At first phalangeal joint, by equal lateral flaps ; C, At first phalangeal 
 joint, by oval method ; D, Through second phalanx, by oblique circular ; E, At first phalangeal joint 
 of little toe, by single external flap ; F, At metatarso-phalangeal joint of little toe, by externo-dorsal 
 flap; G, At metatarso-phalangeal joint, by oval method ; H. At metatarso-phalangeal joint of great 
 toe, by interno-plantar flap ; I, Of two inner toes at tarso-metatarsal joints, by racket method ; J, Of 
 toe, with its entire metatarsal at tarso-metatarsal joint, by racket method. 
 
 AMPUTATION THROUGH FIRST PHALANGES OF TOES, IN GENERAL. 
 
 Best Methods. — Oval Method. Circular Method. 
 
 Other Methods. — Oblique Circular. Equal Lateral. Single External 
 Flap. 
 
 Comparison. — The oval method allows readier access to the saw-line 
 and the freeing of the soft parts to that line. The scar is dorso-terminal. 
 
392 AMPUTATIONS. 
 
 The circular furnishes less easy approach, but leaves a smaller cicatrix, 
 which, however, is terminal. 
 
 AMPUTATION THROUGH FIRST PHALANX OF TOES 
 
 BY OVAL METHOD. 
 
 Description. — The operation is exactly similar to that for disarticulation 
 at the first interphalangeal joint just described — except that the queue 
 begins just above the future saw-line, and the oval extends down the toe 
 a distance that will make the covering furnished by the two lateral aspects 
 of the oval about equal to i^ diameters of the toe at the saw-line. 
 
 AMPUTATION THROUGH FIRST PHALANX OF TOES 
 
 BY CIRCULAR METHOD. 
 
 Description. — The covering is furnished by a circular division of all 
 the soft parts down to the bone, with a vertical suturing of the covering. 
 
 Position — Landmarks. — As for the toes in general. 
 
 Incision. — A circular incision is made through skin and fascia around 
 the toe at a distance below the saw-line equal to three-fourths of the diameter 
 of the toe at the saw-line (to furnish a covering of i| diameters) (Fig. 350, A, 
 for principle, disregarding obliquity of incision). 
 
 Operation. — Upon the level of the retracted integuments, the remaining 
 soft parts are circularly divided to the bone — flexing the toe while cutting 
 the dorsal, and extending it while cutting the plantar aspect. These are now 
 retracted to the saw-line and the bone severed. The arteries divided are the 
 same as in the last operation — and the flexor sheath is treated in the same 
 manner. The cicatrix will be vertical and terminal. 
 
 DISARTICULATION AT METATARSO-PHALANGEAL JOINTS OF TOES. 
 
 IN GENERAL. 
 
 Best Methods. — Oval Method — best for the inside toes (second, third, 
 and fourth). Interno-Plantar Flap — best for great toe. Externo-Dorsal 
 Flap — best for little toe. Short Dorsal and Plantar Flaps — best for toes 
 en masse at the metatarso-phalangeal joints. 
 
 Other Methods. — Lateral Flaps. Internal Flap — for great toe. Ex- 
 ternal Flap — for little toe. Oval Flap — for great or little toe. Irregular 
 Circular, with U-shaped flap for Great Toe (Dubrueil's method) — for toes 
 en masse at the metatarso-phalangeal joints. 
 
 DISARTICULATION OF SECOND, THIRD, OR FOURTH TOES AT META- 
 TARSO-PHALANGEAL JOINT 
 
 BY OVAL METHOD. 
 
 Description. — Same, in principle, as disarticulation at first interphalangeal 
 joint by the oval method. 
 
 Position. — As for the toes in general (page 388). 
 
METATARSOPHALANGEAL DISARTICULATION OF GREAT TOE. 393 
 
 Landmarks. — Metatarsophalangeal joint. 
 
 Incision. — The queue of the incision begins just above the head of the 
 metatarsal, over its mid-dorsal aspect — passes downward in the median 
 line until past the base of the first phalanx — the limbs of the oval now gradu- 
 ally diverge to pass obliquely downward over the lateral aspects of the toes 
 and cross the plantar surface transversely, meeting just in front of the line 
 of the webs (Fig. 344, G). 
 
 Operation. — The vertical portion of the incision is deepened to the 
 extensor tendon — the lateral portions are cut to the bone — the toe is extended 
 and the plantar aspect cut transversely to the bone, thereby severing the 
 flexor tendons high up. The soft parts are freed, partly by retraction and 
 partly by disseccion, from the upper portion of the first phalanx to the joint- 
 line, which lies about 2.5 cm. (1 inch) above the web. The glenoid ligament 
 is cut transversely against the base of the first phalanx and the joint opened. 
 Disarticulation may be completed from below, but more conveniently by 
 severing the extensor tendon and disarticulating from the dorsum, cutting 
 the lateral ligaments from within outward, as the toe is rotated from side 
 to side and disarticulation completed. Two dorsal and two plantar digital 
 arteries are cut. The flexor sheath should be closed. The wound is sutured 
 vertically — the scar becoming dorso-terminal. 
 
 DISARTICULATION OF GREAT TOE AT METATARSOPHALANGEAL 
 
 JOINT 
 
 BY IXTERXO-FLAXTAR FLAP — FARABEUF. 
 
 Description. — A modification of the oval method, whereby the covering 
 is gotten from the internal and plantar aspects of the great toe, and the cica- 
 trix is brought well over to lie obliquely from the upper angle of the inter- 
 digital web to the head of the metatarsal, and thus well removed from internal 
 and terminal pressure. 
 
 Position. — As for the toes in general (page 388). 
 
 Landmarks. — Metatarso-phalangeal joint-line; interdigital web. 
 
 Incision. — Begins over the metatarso-phalangeal joint, at the junction 
 of the dorsal and internal surfaces — passes vertically down the toe, in the 
 line represented by the junction of these two surfaces (parallel with the 
 extensor tendon), nearly to the head of the first phalanx — curves thence 
 downward over the inner surface to the junction of the internal and plantar 
 surfaces — passes thence obliquely across the plantar surface to the angle of 
 the interdigital web — thence runs directly over the external and dorsal surfaces 
 of the toe to the point of beginning, by the shortest route (Fig. 344, H). 
 
 Operation. — This incision is now deepened to the bone in the same 
 order as made, extending the toe while cutting the plantar and flexing while 
 cutting the dorsal tissues. Free the soft parts up to the joint-line. Sever 
 the glenoid ligament against the base of the first phalanx, thus opening the 
 joint, and leaving the glenoid ligament and sesamoid bones in the stump. 
 Divide the lateral ligaments and the extensor tendon. Two plantar and 
 two dorsal digital arteries are cut and will probably require ligation. Close 
 the flexor sheath. Include the cut flexor and extensor tendons in the tissues 
 of the stump. Suture the internal and plantar portions of the oval to the 
 straight incision from the interdigital web to the head of the metatarsal, 
 which will represent the line of the cicatrix. 
 
394 
 
 AMPUTATIONS. 
 
 Comment. — If the vertical portion of the oval be placed directly over 
 the mid-dorsal aspect (as in the corresponding operation upon the index- 
 finger, page 336) a fuller covering will be gotten and the cicatrix will be 
 more certainly protected. 
 
 DISARTICULATION OF LITTLE TOE AT METATARSOPHALANGEAL 
 
 JOINT 
 
 BV EXTERNO-DORSAL FLAP— FARABEUF. 
 
 Description. — This is the reverse of the last operation — a modification 
 of the oval method, whereby the covering is gotten from the external and 
 dorsal aspects of the little toe — and the cicatrix brought well over to lie obliquely 
 
 Fig- 345- — Amputations about the Foot: — A, Disarticulation of the great toe at the 
 tarsometatarsal joint by a curvilinear racket incision; B, Disarticulation of the little toe at the 
 tarsometatarsal joint by a curvilinear racket incision; C, Amputation of a toe with part of its 
 metatarsal by a racket incision. 
 
 from the upper angle of the interdigital web to the head of the metatarsal — 
 and thus well removed from external and terminal pressure. 
 
 Position — Landmarks. — As in the last operation. 
 
 Incision. — Begins over dorsal aspect of metatarso-phalangeal joint, just 
 
METATARSOPHALANGEAL DISARTICULATION EN MASSE. 395 
 
 to inner side of extensor tendon — passes vertically down the inner margin 
 of the tendon to the end of the first phalanx — curves thence downward and 
 outward over the external aspect of the toe — thence obliquely across the 
 plantar surface to the angle of the interdigital web — thence along the internal 
 aspect of the toe to the point of beginning, by the shortest route (Fig. 344, F). 
 Operation. — The steps of the operation are exactly similar to those of 
 the disarticulation of the metatarso-phalangeal joint of the great toe. The 
 dorsal, external and part of the plantar portion of the oval are sutured to the 
 straight incision from the metatarso-phalangeal joint to the interdigital web, 
 which will represent the line of cicatrix and be out of the way of pressure. 
 
 DISARTICULATION OF TWO ADJOINING TOES AT METATARSO- 
 PHALANGEAL JOINT 
 
 BV OVAL METHOD. 
 
 Description. — Same as the disarticulation of a single toe at the meta- 
 tarso-phalangeal joint (page 392) — except that the queue of the oval is placed 
 between the two toes, beginning a little higher above the metatarso-phalangeal 
 joint-line — the two limbs of the oval diverging to encircle the outer and 
 inner toes and meet at the margin of the web between the toes. Each toe 
 is then freed up to the metatarso-phalangeal joint and disarticulated. The 
 wound is sutured as a vertical cicatrix. 
 
 DISARTICULATION OF ALL TOES EN MASSE AT METATARSO- 
 PHALANGEAL JOINT 
 
 BY EQUAL SHORT DORSAL AND PLANTAR FLAPS. 
 
 Description. — The covering is gotten equally from the dorsal and plantar 
 surfaces and the scar is terminal. 
 
 Position. — Patient supine; foot over edge of table. Surgeon grasps 
 toes with left hand, with thumb on dorsum and fingers on plantar surface 
 for dorsal incisions — and thumb on plantar and fingers on dorsum for plantar 
 incisions — manipulating the foot as indicated. After the incisions are made, 
 an assistant takes the toes and the surgeon manipulates the flaps. The 
 surgeon stands for the dorsal and sits for the plantar incisions. 
 
 Incisions. — (Supposing the left foot to be operated upon) — the dorsal 
 incision (with foot extended and toes flexed) begins at the mid-lateral aspect 
 of the metatarso-phalangeal joint of the great toe — passes vertically down 
 the inner margin of the foot to the middle of the first phalanx — thence rounds 
 broadly on to the dorsum of the foot and follows the line of the web, dipping 
 in between the toes as they are separated, until the little toe is reached, when 
 the incision again rounds broadly into the outer aspect of the foot and passes 
 vertically up in the mid-lateral aspect to the metatarso-phalangeal joint. 
 The plantar incision (with foot flexed and toes extended) passes transversely 
 across the plantar surface of the foot, connecting the distal ends of the vertical 
 limbs of the dorsal incision — beginning at a point where the vertical limb 
 begins to round onto the dorsum, the plantar incision rounds onto the plantar 
 surface at the middle of the first phalanx of the great toe, and thence follows 
 the line of the web and creases of the toes, dipping in between the toes as they 
 
396 
 
 AMPUTATIONS. 
 
 are separated, until the little toe is reached, when the incision rounds into 
 the outer aspect and joins the dorsal incision at a point where the outer 
 vertical limb began to round onto the dorsum (Fig. 346, A, A). 
 
 Operation. — The dorsal incision is deepened to the extensor tendons 
 
 Fig. 346.— Disarticulations about the Foot:— A, A. Of all the toes at metatarsophalangeal 
 joints, by equal short dorsal and plantar flaps : B. B, Of all the toes at tarso-metatarsal joints, by 
 short dorsal and long plantar flaps (Lisfranc"s operation). 
 
 and freed half-way back to the joint-line, when the extensor tendons are cut 
 transversely, each toe being previously forcibly flexed in turn. The flap of 
 entire soft parts is then dissected back to the metatarso-phalangeal joint-line. 
 The plantar incision is now deepened to the flexor tendons and freed half-way 
 back to the joint-line, when the flexor tendons are cut transversely, each 
 toe being previously forcibly extended in turn. The flap of entire soft parts 
 is then dissected back to the metatarso-phalangeal joint-line. Both flaps 
 are well retracted to the general joint-line — the toes are flexed and the joints 
 are opened from the dorsum and the lateral ligaments cut from within out- 
 ward. The toes are then extended and the plantar ligaments are cut from 
 the plantar surface, preserving the glenoid ligaments. The disarticulation 
 
SURGICAL ANATOMY OF THE FOOT. 397 
 
 of each toe is thus completed in turn. The flexor sheaths are closed. Two 
 plantar and two dorsal digital arteries for each toe are cut — the latter may 
 not require ligature. The dorsal and plantar flaps are sutured in one lateral, 
 terminal line. 
 
 Comment. — It is difficult to get covering for the large head of the first 
 metatarsal — special care is, therefore, given to procuring this covering by 
 keeping well in the mid-lateral aspect of the inner surface of the great toe 
 until quite to, or beyond, the middle of the first phalanx, before rounding 
 into the dorsal and plantar surfaces. 
 
 SURGICAL ANATOMY OF THE FOOT. 
 
 Bones. — Five metatarsals; seven tarsals (astragalus; os calcis; scaphoid; 
 internal cuneiform; middle cuneiform; external cuneiform; cuboid). 
 
 Articulations and Ligaments. — (A) Metatarsophalangeal Articula- 
 tions: — See Surgical Anatomy of Toes, page 333. (B) Articulation of Meta- 
 tarsals with each other: — Dorsal, plantar, transverse metatarsal, interosseous 
 ligaments, and synovial membrane. (C) Articulations of Metatarsals with 
 Tarsals: — dorsal, plantar, and interosseous ligaments, and synovial mem- 
 brane. (D) Articulation of External Cuneiform and Cuboid: — dorsal, 
 plantar, and interosseous ligaments, and synovial membrane. (E) Articu- 
 lations of Internal, Middle, External Cuneiform bones with each other: — 
 dorsal, plantar, and interosseous ligaments, and synovial membrane. (F) 
 Articulation of Scaphoid and Cuboid: — dorsal, plantar, and interosseous 
 ligaments, and synovial membrane. (G) Articulation of Scaphoid and 
 three Cuneiform Bones: — dorsal and plantar ligaments, and synovial mem- 
 brane. (H) Articulation of Astragalus and Scaphoid: — Superior astragalo- 
 scaphoid ligament, and synovial membrane. (I) Articulation of Os Calcis 
 and Scaphoid: — superior (or external) and inferior (or internal) calcaneo- 
 scaphoid ligaments, and synovial membrane. (J) Articulation of Os Calcis 
 and Cuboid: — (a) Dorsal — superior and internal (interosseous) ligaments; 
 (b) Palmar — long calcaneocuboid (long plantar) and short calcaneocuboid 
 (short plantar) ligaments. And synovial membrane. (K) Articulation ot 
 Os Calcis and Astragalus : — external, internal, and posterior calcaneo-astraga- 
 loid, and interosseous ligaments, and synovial membrane. (L) Articulation 
 of Tarsus with Bones of Leg: — See Surgical Anatomy of the Ankle, page 358. 
 
 Anterior Annular Ligament. — Consists of two portions: — (a) Vertical 
 (Superior) Portion: — Binds down extensor tendons to tibia and fibula. Con- 
 tinuous with fascia of leg above, and extending from anterior border of tibia 
 to anterior border of subcutaneous surface of fibula. Contains synovial 
 sheath for tendon of tibialis anticus. Following structures pass under it- 
 extensor proprius hallucis, extensor longus digitorum, peroneus tertius, 
 anterior tibial vessels and nerve, (b) Horizontal (Inferior, or Y-shaped) 
 Portion: — Binds down extensor tendons to tarsus. Is connected with vertical 
 portion. Attached, externally, to superior surface of os calcis, — anteriorly, 
 to depression for interosseous ligament. It passes upward and inward in a 
 superficial band (which runs in front of the peroneus tertius. extensor longus 
 digitorum, and part of origin of extensor brevis digitorum), and a deep band 
 (which runs behind these muscles). Having formed this loop containing 
 the above muscles, surrounded by synovial membrane, these two bands 
 
398 AMPUTATIONS. 
 
 unite and redivide into two limbs. The Upper Limb passes upward and 
 inward tu the internal malleolus — containing tibialis amicus muscle and its 
 synovial sheath in its structure, but passing over extensor proprius hallucis 
 and anterior tibial vessels and nerve. The Lower Limb passes downward 
 and inward to the scaphoid and internal cuneiform — running over extensor 
 proprius pollicis, tibialis anticus, and anterior tibial vessels and nerve. 
 
 Internal Annular Ligament. — Extends from inner malleolus above, 
 to internal border of os calcis below, converting the grooves of this region 
 into four canals, each lined by separated synovial membrane. The canals 
 transmit, from within outward — tibialis posticus — flexor longus digitorum — 
 posterior tibial vessels and nerve — flexor longus hallucis. It is continuous, 
 above, with deep fascia of leg, and, below, with plantar fascia and origin of 
 abductor hallucis. 
 
 External Annular Ligament. — Extends from extremity of external 
 malleolus to outer surface of os calcis. Binds down and transmits tendons 
 of peroneus longus and brevis beneath the outer ankle, in one synovial sheath. 
 
 Plantar Fascia. — (a) Central Portion: — Arises from internal tubercle 
 of os calcis, posterior to origin of flexor brevis digitorum — divides, near 
 heads of metatarsals, into processes for each of five toes — which again sub- 
 divide, opposite metatarso-phalangeal joints, into superficial and deep por- 
 tions. The superficial part is inserted into the transverse sulcus between 
 sole and toes. The deep part redivides into two slips — which blend with 
 flexor tendons and sheaths and transverse metatarsal ligament. Two vertical 
 intermuscular septa are sent up by central portion — separating middle from 
 external and from internal plantar groups of muscles, (b) Outer Lateral 
 Portion : — From os calcis to base of fifth metatarsal — covering inferior surface 
 of abductor minimi digiti — and continuous with central and dorsal fascia, 
 (c) Inner Lateral Portion: — From internal annular ligament — covering 
 abductor hallucis — and continuous with central and dorsal fascia. 
 
 Muscles. — (a) Dorsal Region: — Extensor brevis digitorum; and muscles 
 from leg (page 416). (b) Plantar Region: — First Layer — abductor hallucis, 
 flexor brevis digitorum, abductor minimi digiti; — Second Layer — flexor ac- 
 cessorius, four lumbricales; — Third Layer — flexor brevis hallucis, abductor 
 obliquus hallucis, abductor transversus hallucis, flexor brevis minimi digiti; — 
 Fourth Layer — four dorsal interossei, three plantar interossei. And muscles 
 from leg (page 416). 
 
 Synovial Membranes of Tarsal and Metatarsal Joints. — Synovial 
 membranes exist for following joints; — posterior calcaneo-astragaloid joint; — 
 anterior calcaneo-astragaloid and astragalo-navicular joints; — calcaneo- 
 cuboid joint; — articulation of navicular with three cuneiforms, three cunei- 
 forms with each other, external cuneiform with cuboid, middle and external 
 cuneiform with bases of second and third metatarsals, lateral surfaces of 
 second, third, and fourth metatarsals with each other; — internal cuneiform 
 with metatarsal of great toe; — articulation of cuboid with fourth and fifth 
 metatarsals; — (and sometimes the articulation of navicular with cuboid). 
 
 Arteries. — Dorsalis pedis branch of anterior tibial, and following branches 
 — external tarsal; internal tarsal; metatarsal and its three dorsal interosseous 
 branches, with the latter's three posterior and three anterior perforating 
 branches; dorsalis hallucis (or first dorsal interosseous); communicating (or 
 plantar digital). Posterior tibial and following branches — anterior peroneal, 
 posterior peroneal and external calcaneal branches of peroneal; internal 
 calcaneal branch of posterior tibial; internal plantar branch of posterioi 
 
SURGICAL ANATOMY OF THE FOOT. 399 
 
 tibial; external plantar branch of posterior tibial and following branches, 
 three posterior perforating (between plantar arch and interosseous), four 
 plantar digital, three anterior perforating (between digital and interosseous), 
 princeps hallucis (fifth plantar digital). 
 
 Veins. — Superficial — tributaries of internal (long) saphenous; tributaries 
 of external (short) saphenous. Deep — two venae comites for each artery. 
 
 Nerves. — (a) From Lumbar Plexus — internal saphenous, (b) From 
 Sacral Plexus — following from great sciatic; — external (short) saphenous — 
 posterior tibial and plantar cutaneous branch — internal plantar with cutane- 
 ous, muscular, articular, and four digital branches — external plantar, with 
 superficial and deep (or muscular) branches — anterior tibial, with external 
 (or tarsal) branch and its three interosseous; internal branch (continuation 
 of anterior tibial) and its interosseous branch ;— and internal and external 
 branches of musculocutaneous. 
 
 Bursae About Foot. — These are variable — the following are generally 
 present — (a) Above, or beneath, tendon of extensor proprius hallucis, over 
 instep, — (b) Between tendon of extensor longus digitorum and projecting 
 end of astragalus (sometimes communicating with joint of head of astragalus), 
 — (c) Between tendo Achillis and calcaneum, — And others may occur over 
 any bony prominence. 
 
 SURFACE FORM AND LANDMARKS OF FOOT. 
 
 Bony landmarks of dorsum — head of astragalus is felt on extension of 
 foot, in front of ankle-joint. 
 
 Bony landmarks of inner aspect of foot — internal tuberosity of os calcis; 
 sustentaculum tali (lesser process of os calcis), 2.5 cm., or 1 inch, below 
 internal malleolus; tuberosity of scaphoid (2.5 to 3 cm., or 1 to i| inches, in 
 front of internal malleolus) ; internal cuneiform (but slightly) ; base of first 
 metatarsal (obscurely); shaft of first metatarsal; head of first metatarsal; 
 base of first phalanx of great toe; internal sesamoid bone. 
 
 Bony landmarks of outer aspect of foot — outer tuberosity of os calcis; 
 greater part of outer surface and anterior end of os calcis; peroneal tubercle 
 (when present) 2.5 cm., or 1 inch, below external malleolus; base of fifth 
 metatarsal; shaft of fifth metatarsal; head of fifth metatarsal; base of first 
 phalanx of little toe. 
 
 Bony landmarks of plantar aspect of foot — inferior surface of os calcis; 
 heads of metatarsals. 
 
 Landmarks of medio-tarsal articulation — the joint-line runs transversely 
 across the foot from the astragalo-scaphoid articulation on the inner side, 
 to the calcaneo-cuboid articulation on the outer side. The astragalo-scaphoid 
 joint lies just posterior to the prominent tuberosity of the scaphoid (forcibly 
 extend the foot, when the interval between the tuberosity of the scaphoid 
 and head of the astragalus will be evident). The calcaneo-cuboid joint lies 
 midway between the external malleolus and the prominent base of the fifth 
 metatarsal. 
 
 Landmarks of the tarso-metatarsal articulation — the cubo-metatarsal 
 joint (on the outer side) is found on a line with the base of the prominent 
 fifth metatarsal, and this serves as a guide to the remaining joints — the line 
 of which runs obliquely forward toward the inner side of the foot, to a point 
 about 2.5 cm., or 1 inch (extremes 3.8 to 4.5 cm., or 1^ to if inches), below 
 
400 
 
 AMPUTATIONS. 
 
 the posterior margin of the tuberosity of the scaphoid. Practically, the 
 articulations of the fifth, fourth, third, and first metatarsals are in one line, 
 while the line of the articulation of the second metatarsal with the middle 
 
 Fig. 347. — Lines of Disarticulations about the Foot: — A, A, Metatarsophalangeal 
 disarticulation; B, B, Tarsometatarsal disarticulation (Lisfranc's operation); C, C, Anterior 
 intertarsal amputation (between the cuneiforms and scaphoid, with transverse section of the 
 cuboid — the Jaeger-Bona, or Forbes' operation); D, D, Posterior intertarsal or mediotarsal 
 disarticulation (Chopart's operation); E, E, Disarticulation at the ankle-joint. Note: — Pirogoff's 
 intercalcaneal osteoplastic amputation, with section of the tibia and fibula, and also the sub- 
 astragaloid disarticulation are not shown here. 
 
 cuneiform is from 7 mm. to 1.3 cm. (J to ^ inch) above this oblique line. 
 The tarso-metatarsal articulation of the great toe can sometimes be felt as a 
 
SURGICAL CONSIDERATIONS IN FOOT AMPUTATIONS. 401 
 
 depression 3.8 to 4.5 cm. (i£ to if inches) anterior to the posterior margin 
 of the tuberosity of the scaphoid, by pressure here while manipulating the 
 toe — which would give an inner landmark to be used with the base of the 
 fifth metatarsal on the outer aspect. 
 
 Landmarks of the metatarso-phalangeal articulations — about 2.5 cm. (1 
 inch) behind the webs of the corresponding toes. 
 
 Muscles and tendons more or less influencing surface form upon the 
 dorsum of the foot, from within outward — tibialis anticus, extensor proprius 
 hallucis, extensor longus digitorum, peroneus tertius — and, beneath these, 
 extensor brevis digitorum and dorsal interossei. 
 
 Muscles on sole of foot influencing surface form — abductor minimi digiti, 
 abductor hallucis, flexor brevis digitorum. 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 
 
 THE FOOT. 
 
 Remove as little as possible of the metatarsals of the great and little toes 
 as they largely support the weight of the body. 
 
 Amputation of the toe, except the great toe, with part or all of its meta- 
 tarsal, is of very little practical applicability. 
 
 ' Scars should be kept from the plantar, internal, and external aspects of 
 the foot. They should be at the end of the stump or dorsal. 
 
 Plantar covering is the best form to provide. 
 
 In removing the metatarsal bones entirely, or in part, it is well to adopt 
 the subperiosteal method as far as possible. 
 
 There is an increasing tendency to regard the foot as a whole and to 
 amputate regardless of joints. 
 
 Sutures should remain in the thick, hard skin of the sole extra long. 
 
 Temporary drainage is indicated when large joint-surfaces are opened up. 
 
 Stumps should remain out from under the bed-covering when dressed. 
 
 Patients should lie part of the time on their side, or flex the knee, to allow 
 of drainage from the angles of wounds, if any fluid accumulate. 
 
 If drainage be necessary, drain with two short tubes in either end of the 
 wound. 
 
 Amputation through the metatarsus is preferable to tarso-metatarsal 
 disarticulation, for, in the former, attachment of all the important muscles 
 of the foot and all its movements are retained. 
 
 Disarticulation at the tarso-metatarsal joints (Lisfranc's operation) gives 
 an excellent stump. Disarticulation at the medio-tarsal joints (Chopart's 
 operation) gives a not altogether satisfactory result. 
 
 Subastragaloid disarticulation gives a very good result, furnishing a 
 long limb with ankle-movement. 
 
 Syme's amputation (disarticulation at the ankle-joint) is generally con- 
 sidered preferable to either Chopart's or Pirogoff's operation. 
 
 In Lisfranc's and Chopart's operations the unopposed action of the calf 
 muscles may permanently raise the heel. 
 
 AMPUTATION OF TOES WITH PART OF THEIR METATARSALS. 
 
 The amputation of the toes with part of their metatarsals is so similar, 
 in all essential details, to disarticulation of the toes with their entire meta- 
 26 
 
402 AMPUTATIONS. 
 
 tarsals that the former will not be separately given (as was done in the case 
 of the fingers). The best method of removing any of the toes with part of 
 their metatarsal, whether an inside toe or the great or little toe, is by the 
 racket method (see pages 404-406). The best method for the removal of 
 two or three contiguous toes with parts of their metatarsals is by the oval 
 operation (see page 407). The best methods, as well as other methods 
 for these partial operations, are the same as for the entire operations — and 
 will be given at the above references. 
 
 The practical differences between the partial and complete operations 
 are — that the incision begins, in the former, just above the saw-line, instead 
 of just above the tarso-metatarsal joint-line — and, instead of disarticulating 
 the proximal end of the bone, it is sawed with a Gigli or chain saw. 
 
 The amputation of all the toes with parts of their metatarsals will be 
 given. 
 
 AMPUTATION OF ALL THE TOES THROUGH THE METATARSUS 
 
 BY SHORT DORSAL AND LONG PLANTAR FLAPS (METATARSAL AMPUTATION). 
 
 Description. — The height at which the amputation will be done will 
 depend upon the nature of the cause and condition of the parts. The opera- 
 tion resembles Lisfranc's disarticulation at the tarso-metatarsal joint. 
 
 Position. — Patient supine; foot over edge of table. Surgeon opposite 
 foot, standing while operating on dorsum, sitting while working upon plantar 
 aspect — steadying the toes with his left fingers during the incisions, while 
 assistant holds ankle; — and, as soon as incisions are made, assistant takes 
 the toes, while the surgeon grasps the flaps with his left hand. 
 
 Landmarks. — Saw-line (which is oblique, to be parallel with the ends 
 of the metatarsals — its inner end being more anteriorly placed than its outer 
 — the line running about parallel with the webs) ; interdigital webs. 
 
 Incisions. — Plantar incision (supposing the metatarsals to be divided 
 at their middle, in the case of the left foot) begins at the mid-lateral aspect 
 of the inner side of the foot and just behind the saw-line — passes vertically 
 down this side of the foot to the level of the crease between the sole and 
 plantar surface of the great toe — thence rounds broadly into the sole and 
 sweeps across the plantar aspect just behind and parallel with the web, to 
 the crease between the sole and little toe — whence it rounds broadly into the 
 mid-lateral aspect of the outer side of the foot and passes straight upward 
 to just beyond the saw line. Dorsal incision is made parallel with the plantar 
 incision, and joins the vertical portion of that incision about 2.5 cm. (1 inch) 
 from their upper ends, rounding onto the dorsum (that is, the dorsal flap is 
 about 2.5 cm., 1 inch long). The foot is flexed on the leg while the plantar 
 incision is made and extended while the dorsal incision is made (Fig. 348, 
 A, A). 
 
 Operation. — The plantar incision is first deepened to the flexor tendons, 
 is then dissected up a short distance and the flexor tendons divided trans- 
 verselv while the foot is forcibly flexed on the leg and toes extended on foot — 
 thence upward to the saw-line, all soft parts down to the bone being raised 
 in the plantar flap. The dorsal incision is now deepened to the extensor 
 tendons, and dissected up a short way, when these tendons are divided trans- 
 verselv while the foot is forcibly extended on the leg and the toes flexed on 
 the foot — thence upward to saw-line, all soft parts down to the bone being 
 raised in the dorsal flap. Both flaps are now retracted — the bones freed 
 
TARSOMETATARSAL DISARTICULATIONS. 
 
 403 
 
 of their interossei muscles — and each bone separately sawed with a fine saw. 
 The following arteries are tied — six plantar digital (upon contiguous sides 
 of the toes, and outer side of the little and inner side of the great toes), second, 
 third, and fourth dorsal interossei, and first dorsal interosseous, or its three 
 dorsal digital branches. The muscles are quilted, those of the dorsal to 
 those of the plantar aspect — and the integumentary margins of the dorsal 
 
 Fig. 348.— Amputations about the Foot : — A, A. Amputation of all the toes through the meta- 
 tarsus, by short dorsal and long plantar flaps (metatarsal amputation) ; B, B, Disarticulation of an- 
 terior part of foot at medio-tarsal joints, by short dorsal and long plantar flaps (Chopart's operation). 
 
 and plantar flaps united in a transverse line. The stump is supported upon 
 a splint. 
 
 Comment. — If the division of the metatarsus is made nearer its base, 
 the flaps will be proportionately shorter. The flaps may also be made of 
 equal length, or otherwise planned — according to available tissue. 
 
 DISARTICULATION OF TOES WITH THEIR ENTIRE METATARSALS. 
 
 Best Methods. — Racket — toes in general. Racket, with or without an 
 additional transverse incision at upper end of queue — for great or little toe. 
 
4 04 AMPUTATIONS. 
 
 Short Dorsal and Long Plantar Flaps (Lisfranc's Operation) — for the toes 
 en masse. Short Dorsal and Long Plantar Flaps, with sawing off the end 
 of the internal cuneiform (Hey's Operation) — for the toes en masse. 
 
 Other Methods. — Internal Flap — for great toe. External Flap — for 
 little toe. Equal Plantar and Dorsal Flaps — for the toes en masse. Long 
 Plantar Flap — for the toes en masse. 
 
 DISARTICULATION OF TOE WITH ITS ENTIRE METATARSAL 
 
 BY RACKET METHOD. 
 
 Description. — The coverings are gotten from the lateral and plantar 
 aspects, and the cicatrix is vertical and dorso-terminal. 
 
 Position. — As in the metatarsal amputation, page 402. 
 
 Landmarks. — Tarso-metatarsal joint; interdigital web. 
 
 Incision. — Begins just above the tarso-metatarsal joint, in the mid- 
 dorsal aspect — passes vertically down in the median line to the head of the 
 metatarsal — thence the two limbs of the oval diverge — the outer limb running 
 downward across the outer aspect of the toe to the web — the inner limb 
 across the inner aspect to the web — the two meeting in the digito-plantar 
 crease (which about corresponds to the center of the first phalanx) (Fig. 
 
 344, J)- 
 
 Operation. — Deepen the vertical incision, dividing the extensor tendons 
 as high up as encountered, while the toe is flexed. Deepen the oval incision 
 to the bone, upon the lateral and plantar aspects, extending the toe while 
 severing the flexor tendons transversely. Free the soft parts along the dorsum 
 and lateral surfaces, with a periosteal elevator, hugging the bone closely. 
 Forcibly extend the toe and its metatarsal and free the plantar surface as 
 far as possible. Sever, from the dorsum, the ligaments binding the metatarsal 
 to the tarsus and to the adjacent metatarsals, while the toe is being manipu- 
 lated and the ligaments are put upon the stretch — thus completing the dis- 
 articulation. Divide the flexor tendons high up and close the sheaths. Two 
 dorsal and two plantar digital arteries are cut and are to be tied. Suture 
 the wound in one vertical line. 
 
 Comment. — (1) By hugging the bone very closely and guarding the point 
 of the knife while disarticulating, minimum damage is done to the tissues 
 of the sole of the foot. (2) Disarticulation of the second toe from the tarsus 
 and adjacent metatarsals is somewhat difficult (see Lisfranc's operation). 
 
 DISARTICULATION OF GREAT TOE WITH ITS ENTIRE METATARSAL 
 
 BY RACKET METHOD. 
 
 Description — Landmarks. — As in the last operation. 
 
 Incision. — Begins just above the tarso-metatarsal joint, at its dorso- 
 internal aspect — passes vertically downward along the outer margin of the 
 extensor tendon to just beyond the center of the metatarsal — thence the two 
 limbs of the oval diverge — the outer limb passing across the dorso-external 
 aspect of the toe to the web — the inner limb passing across the dorso-internal 
 aspect to the plantar surface at a point opposite the web — the two limbs 
 meeting in the digito-plantar crease. If needed for purpose of exposing the 
 joint more readily, an additional transverse incision may be added to the 
 upper end of the vertical incision, running as far as thought necessary directly 
 inward parallel to the tarso-metatarsal joint (Fig. 349, B). 
 
 Operation. — Deepen the vertical incision, exposing and dividing the 
 
TARSOMETATARSAL DISARTICULATION OF GREAT TOE. 
 
 405 
 
 tendons of the extensor proprius and brevis hallucis near the tarso-metatarsal 
 joint. Deepen the limbs of the oval, cutting to the bone along the lateral 
 and plantar surfaces. Free, up to the tarso-metatarsal joint, the soft parts 
 from the external, internal, and plantar surfaces of the metatarsal and phalanx 
 by closely hugging the bones with periosteal elevator, rotating the toe as 
 indicated. The sesamoid bones are left behind, and the structures about 
 the metatarso-phalangeal joint are removed as nearly subcapsulo-periosteally 
 as possible, in order to retain the attachment of the severed tendons there 
 inserted. Open the tarso-metatarsal joint from the dorsum, completing the 
 disarticulation by severing the remaining ligaments while under tension 
 
 Fig. 349.— Amputations about the Toes and Foot — Inner view : — A, At interphalangeal joint 
 of great toe, by plantar flap ; B. Of great toe and its metatarsal, at tarso-metatarsal joint, by racket 
 method, with transverse incision added to upper end ; C. Inner aspect of plantar and dorsal incisions 
 in Syme's disarticulation of foot at ankle, by heel-flap ; C, Line of tibial and fibular section ; D. Inner 
 aspect of plantar and dorsal incisions, in PirogofT s disarticulation at ankle, by heel-flap ; D', Line of 
 section of bones of leg, in same ; I )". Line of section of os calcis. in same ; E, Inner aspect of plantar 
 and dorsal incisions in subastragaloid disarticulation of foot, by heel-flap. 
 
 during the manipulation of the toe. Divide the tendons of the peroneus 
 longus and tibialis anticus. Cut the flexor tendons short and close their 
 sheaths. The following arteries are divided — two dorsal digital, two plantar 
 digital, and termination of internal plantar. Guard against wounding the 
 communicating branch of the dorsalis pedis in the first interosseous space. 
 The suture line will be vertical and fall over the dorso-external aspect of the 
 toe, out of the way of pressure. 
 
 Comment. — When the upper transverse incision is added, the vertical 
 incision generallv begins just below the tarso-metatarsal joint and the trans- 
 verse incision is then parallel with the tarso-metatarsal joint. When the 
 vertical incision alone is used, it begins over the internal cuneiform. 
 
406 
 
 AMPUTATIONS. 
 
 DISARTICULATION OF LITTLE TOE WITH ITS ENTIRE METATARSAL 
 
 PA' RACKET METHOD. 
 
 Description — Landmarks. — As in the last operation. 
 
 Incision. — Begins just above the tarsometatarsal joint at its dorso- 
 external aspect — passes vertically downward along the outer margin of the 
 extensor tendon to just beyond the center of the metatarsal — thence the two 
 limbs of the oval diverge — the inner limb passing across the dorso-internal 
 aspect of the toe to the web — the outer limb passing across the dorso-external 
 aspect of the plantar surface at a point opposite the web — the two limbs 
 
 Fig. 350. — Amputations about the Toes and Foot — Outer view: — A, Through first interpha- 
 langeal joint of little toe, by oblique circular method ; B, Of little toe and its metatarsal, by racket 
 method, with added curved incision at upper end ; C, Outer aspect of plantar and dorsal incisions, in 
 Syme's disarticulation of foot at ankle, by a heel-flap ; C, Line of section through tibia and fibula, in 
 same ; D, Outer aspect of plantar and dorsal incisions, in Pirogoff's disarticulation'at ankle ; D', Line 
 of section of tibia and fibula in same ; D", Line of section of os calcis, in same; E, Supramalleolar 
 amputation of leg, by oblique elliptical incision; E', Tibial and fibular section in same; F, Outer 
 aspect of dorsal and plantar incisions in Subastragaloid Disarticulation of foot by heel-flap. 
 
 meeting in the digito-plantar groove. If needed for purpose of more readily 
 exposing the joint, an additional transverse, or oblique, incision may be 
 added to the upper end of the vertical incision, by prolonging the latter a 
 short wav directly outward parallel with the tarso-metatarsal joint (Fig. 
 35o, B). ' 
 
 Operation. — The steps of the operation are practically the same as in 
 the corresponding operation upon the great toe (page 404). The metatarsal 
 is disarticulated from the cuboid and from the fourth metatarsal. Two 
 dorsal and two plantar digital arteries are cut. 
 
TARSOMETATARSAL DISARTICULATION OF THE TOES. 407 
 
 DISARTICULATION OF TWO OR THREE CONTIGUOUS TOES WITH 
 THEIR ENTIRE METATARSALS 
 
 BY OVAL OR RACKET METHOD. 
 
 Description. — Same, in principle, as the operation for the removal of 
 a single toe and its metatarsal (page 402). Where two contiguous toes are 
 removed, the vertical portion of the incision is placed between the two toes, 
 beginning just above the saw-line and diverging to include both toes — meeting 
 on the plantar surface of the web between them. Where three contiguous 
 toes are removed, the vertical portion of the incision is placed over the middle 
 metatarsal, beginning at the disarticulation line, or just above, and diverging 
 to include all three toes, meeting at the center of the plantar surface of the 
 middle toe, in the digito-plantar crease (Fig. 344, I) . 
 
 DISARTICULATION OF ALL THE TOES AT TARSO-METATARSAL 
 
 JOINTS 
 
 BY SHORT DORSAL AND LONG PLANTAR FLAPS — LISFRANC'S OPERATION. 
 
 Description. — Disarticulation of the anterior portion of the foot at the 
 tarso-metatarsal line — the stump being formed of plantar and dorsal tissues. 
 
 Position. — As for the metatarsal amputation (page 402). 
 
 Landmarks. — Tarso-metatarsal joint-line; heads of metatarsals. 
 
 Incision. — (Supposing the foot of the right side to be operated upon) 
 — (1) Dorsal Flap — The surgeon's left hand grasps the foot with his thumb 
 on the base of the fifth metatarsal and forefinger on the base of the first, 
 his palm to the sole — the foot being extended. The incision begins just 
 behind the base of the fifth metatarsal, nearer the plantar than dorsal surface 
 — passes straight down the outer aspect of the foot for 2.5 cm. (1 inch) — 
 thence rounds onto the dorsum and crosses the foot with slight downward 
 convexity, parallel with and about 1.3 cm. (J inch) below the tarso-metatarsal 
 joints, reaching the inner border of the foot 1.3 cm. (J inch) below the tarso- 
 metatarsal joint — thence rounds into the inner aspect of the foot and passes 
 straight upward and ends 2 cm. (f inch) above the cuneiform-metatarsal articu- 
 lation of the great toe, somewhat nearer the plantar than the dorsal aspect. (2) 
 Plantar Flap — the surgeon holds the toes between the fingers on the dorsum 
 and thumb on the plantar surfaces — the foot being flexed. The incision is con- 
 tinuous with the horizontal portion of the dorsal incision, passing down the 
 outer lateral aspect of the foot along the plantar edge of the fifth metatarsal 
 to just below its middle — then gradually rounds into the sole and sweeps 
 obliquely across the plantar surface in such a way as to cross the fifth meta- 
 tarsal just above its neck, the fourth metatarsal at its neck, the third and 
 second opposite their heads, and then the first metatarsal at the metatarso- 
 phalangeal joint — thence rounds into the inner mid-lateral aspect of the foot 
 and passes straight up its border, along the plantar edge of the first meta- 
 tarsal, to become continuous with the vertical portion of the dorsal incision 
 (Fig. 346, B, B). 
 
 Operation. — Deepen the dorsal line to the extensor tendons and free 
 back the superficial tissues for about 6 mm. (\ inch) — and then divide all 
 the soft parts down to the bones, while the foot is fully extended on the leg 
 and the toes flexed on the foot — and free the flap to, and very slightly above, the 
 joint-line, hugging the bone to save the interosseous vessels and portions of in- 
 
4o8 
 
 AMPUTATIONS. 
 
 terosseous muscles. Deepen the plantar incision to the flexor tendons and free 
 back the flap of superficial tissues to the hollow behind the heads of the meta- 
 tarsals — and then divide all the soft parts down to the bones, while the foot is 
 fully Hexed on the leg and the toes extended on the foot — and free the flap to, 
 and very slightly above, the tarso-metatarsal joint-line. Both flaps contain all 
 the soft parts to the bones. Disarticulation is now accomplished from the dor- 
 sum. Retract the flaps — extend the foot — and begin the disarticulation by 
 entering the knife behind the prominent base of the fifth metatarsal, at the outer 
 side of the foot — and then, passing obliquely forward and inward, cut the 
 peroneus brevis and tertius tendons and disarticulate the fifth, fourth, and third 
 metatarsals. Then turn to the inner side of the foot, and sever the ligaments of 
 the first tarso-metatarsal joint, and divide the expansion of the tibialis anticus. 
 There remains the freeing of the second metatarsal, which is somewhat diffi- 
 cult, unless undertaken in a definite manner. Hold the knife like a dagger, 
 with the cutting-edge toward the ankle, the blade pointing forward at an angle 
 with the dorsum of the foot — enter the point deeply between the bases of 
 first and second metatarsals, where they begin to bind — elevate the handle 
 until perpendicular to the dorsum, cutting, at the same time, forward — and 
 thus the ligaments binding the base of the second metatarsal to the base of 
 the first metatarsal and internal cuneiform are severed (the manceuvre being 
 called the "coup de maitre"). Repeat this manoeuvre between the bases 
 of the second and third metatarsals. Complete the disarticulation of the 
 second metatarsal by severing, from the dorsum, the ligaments between 
 the middle cuneiform and base of the metatarsal. Divide any connecting 
 bands upon the plantar aspect of the joints. The peroneus longus tendon 
 now alone holds the metatarsal — put this upon the stretch, dividing it high 
 up. The following arteries are to be tied — in the dorsal flap; four dorsal 
 interosseous, communicating branch of dorsalis pedis; — in plantar flap; five 
 plantar digital branches of external plantar (and possibly the external plantar 
 itself) and the termination of the internal plantar. Suture any open sheaths. 
 Quilt the muscles. Suture the plantar and dorsal flaps in one transverse 
 line. Support the stump upon a splint. 
 
 Comment. — (i) The plantar flap may be cut first. (2) The dorsal flap 
 may be made and disarticulation accomplished, and then the plantar flap 
 cut from within outward — which is not so satisfactory as the above. (3) 
 Freer allowance should be made to cover the thicker inner than the thinner 
 outer side of the foot — which is the reason for cutting the inner aspect of the 
 flap longer. (4) Guard against making the dorsal flap (00 short and too 
 scant on the dorsal aspects — and also against making either flap too pointed. 
 (5) Guard against mistaking the scapho-cuneiform joint for the metatarso- 
 cuneiform joint. (6) Guard the plantar tissues while disarticulating the 
 second metatarsal. (7) The dorsal flap should include most of the tissues 
 upon the outer and inner aspect of the foot. (8) This method makes an 
 excellent and useful stump. 
 
 DISARTICULATION OF ALL THE TOES AT THE TARSO-METATARSAL 
 
 JOINTS, WITH SAWING OFF OF END OF 
 
 INTERNAL CUNEIFORM, 
 
 EY SHORT DORSAL AND LONG PLANTAR FLAPS — HEV'S OPERATION. 
 
 Description. — This operation is similar to Lisfranc's as to incisions, 
 freeing of flaps, ligation of vessels and suturing of wound — differing only 
 in one respect — namely, after disarticulating the four outer metatarsals, 
 
MEDIO-TARSAL DISARTICULATION OF FOOT. 409 
 
 the .protruding end of the innermost cuneiform is sawed off on a line with 
 the others, and removed together with the first metatarsal still articulated. 
 
 DISARTICULATION OF ANTERIOR PART OF FOOT AT MEDIO-TARSAL 
 JOINT, IN GENERAL. 
 
 Best Methods. — Short Dorsal and Long Plantar Flaps — Chopart's 
 Operation. 
 
 Other Methods. — Modified Oval (Tripier's Operation) — medio-tarsal 
 disarticulation, with horizontal sawing of os calcis. 
 
 DISARTICULATION OF ANTERIOR PART OF FOOT AT MEDIO-TARSAL 
 
 JOINT 
 
 BY SHORT DORSAL AND LONG PLANTAR FLAPS — CHOPART'S OPERATION. 
 
 Description. — Disarticulation of anterior portion of foot at astragalo- 
 scaphoid and calcaneo-cuboid joints, by means of a short dorsal and long 
 plantar flap — the operation being somewhat similar to Lisfranc's tarso- 
 metatarsal disarticulation. 
 
 Position. — As for Lisfranc's operation. 
 
 Landmarks. — Astragalo-scaphoid joint (just behind the tuberosity of 
 the scaphoid) ; calcaneo-cuboid joint (midway between the external malleolus 
 and tubercle of fifth metatarsal); tarso-metatarsal joint-line; middle of meta- 
 tarsus. 
 
 Incisions. — (Right foot) — Plantar incision — begins on outer aspect of 
 foot, little -nearer plantar than dorsal surface, and at a point opposite the 
 calcaneo-cuboid joint (see Landmarks) — passes straight down the outer side 
 of foot to near middle of fifth metatarsal — thence rounds inward and crosses 
 sole of foot, opposite the middle of the metatarsals, to the inner side of the 
 foot — rounds into the inner border of the foot and passes straight up that 
 border, little nearer the plantar than dorsal surface, to a point opposite the 
 astragalo-scaphoid joint (see Landmarks). Dorsal incision — begins by 
 curving from the outer limb of the plantar incision, just posterior to the fifth 
 tarso-metatarsal joint — and ends by curving into the inner limb of the plantar 
 incision just posterior to the first tarso-metatarsal joint — crossing the dorsum 
 opposite the bases of the metatarsals (Fig. 348, B, B). 
 
 Operation. — Deepen the plantar incision, the foot flexed on the leg 
 and the toes extended on the foot, to the flexor tendons. Free the skin and 
 fascia a short distance — divide all soft parts to the bones — and dissect up 
 the flap of the entire soft parts to the medio-tarsal joint. Deepen the dorsal 
 incision, the foot extended on the leg and the toes flexed on the foot, to the 
 extensor tendons. Free the skin and fascia a short distance — divide all 
 the soft parts to the bones — and dissect up the flap of the entire soft tissues 
 to the medio-tarsal joint. Disarticulate from the dorsum while the foot 
 is forcibly extended — rotating the forepart of the foot outward while severing 
 the ligaments of the astragalo-scaphoid joint, and inward while dividing 
 those of the calcaneo-cuboid articulation. The tendons of the tibialis anticus 
 and posticus, and peroneus tertius, brevis, and longus, are cut among the 
 deeper structures. Quilt the muscular and tendinous tissues of the two 
 flaps, especially suturing the extensor tendons and tibialis anticus of the 
 dorsal flap, to the tissues of the plantar flap — in order to counteract the 
 
41 o AMPUTATIONS. 
 
 tendency of the tendo Achillis to permanently extend the foot. In the dorsal 
 flap, the dorsalis pedis and its tarsal and metatarsal branches are cut — and 
 in the plantar flap, the terminations of external and internal plantar arteries, 
 and plantar digital branches. 
 
 Comment. — (i) Considerable tendency exists for displacement of the 
 bones of the stump subsequent to healing — either the posterior portion of 
 the os calcis being drawn up by the tendo Achillis, thus throwing the head 
 of the os calcis downward to be pressed upon in walking — or the stump is 
 turned into the varus position and the patient walks upon the outer border 
 of the os calcis. (2) The proportionate lengths of the flaps and the manner 
 of their making may be varied, as described in Lisfranc's operation. The 
 total covering required is about 1^ diameters at the saw-line. 
 
 DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- 
 
 TRAGALO-CALCANEAL ARTICULATIONS— SUBASTRAGALOID 
 
 DISARTICULATION— IN GENERAL. 
 
 Best Methods. — Large Interno-plantar Flap (Farabeuf). Heel-flap. 
 
 Other Methods. — Oval, or Racket Method (Maurice Perrin). Oval 
 Method (Verneuil). 
 
 Comparison. — The interno-plantar flap furnishes the best blood-supply 
 — the cicatrix is well placed and the stump is broad. But the method requires 
 considerable healthy, available tissue — the operation is somewhat difficult 
 to perform — and the flap is somewhat unwieldy. The heel-flap method is 
 a simpler operation and requires minimum tissue — but gives a narrower 
 stump. 
 
 DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- 
 TRAGALO-CALCANEAL JOINTS— SUBASTRAGALOID DIS- 
 ARTICULATION 
 
 BY LARGE INTERNO-PLANTAR FLAP — FARABEUF. 
 
 Description. — A modified oval method. The structures below the 
 astragalus are removed — the stump being covered by a large flap gotten 
 from the sole and inner border of the foot — the scar being horizontal and 
 upon the outer and anterior aspects of the foot. 
 
 Position. — As in the preceding operations, in general — the surgeon so 
 manipulating the foot with his left hand as to turn it from side to side in 
 following the complicated incision. 
 
 Landmarks. — Tendo Achillis; external malleolus; base of fifth meta- 
 tarsal; joint between scaphoid and cuneiforms; joi<nt-line between scaphoid 
 and internal and middle cuneiforms; tendon of extensor longus hallucis, 
 cuneo-metatarsal joint of big toe; external tuberosity of os calcis. 
 
 Incision. — Begins at outer margin of insertion of tendo Achillis — curves 
 upward to a point 2.5 cm. (1 inch) below the external malleolus — passes 
 horizontally forward at this level, parallel with the border of the foot, until 
 a point is reached on a line connecting the base of the fifth metatarsal with 
 the joints between the scaphoid and cuneiform bones — thence curves sharply 
 across the dorsum, just anterior to the joint-fine between the scaphoid with the 
 internal and middle cuneiforms, until the tendon of the extensor longus hallucis 
 is reached — thence curves slightly forward to cross the inner border of the 
 
SUBASTRAGALOID DISARTICULATION OF FOOT. 411 
 
 foot in the line of the cuneo-metatarsal joint of great toe — thence sweeps 
 across the center of the sole — and, curving into the outer border of the foot, 
 follows that border to the external tuberosity of the os calcis — thence upward 
 to end at the insertion of the tendo Achillis, at the point of beginning (Fig. 351). 
 Operation. — The above incision is now everywhere deepened to the bone 
 along the line of retracted skin and fascia, using a stout knife and cutting 
 with force as the parts are put upon the stretch — cutting all tendons cleanly 
 — and opening no joints. Now flex the leg upon the thigh, turn the knee 
 inward, and press the inner side of the leg on the table, so that the outer 
 side of the leg presents and the foot is beyond the edge and kept upon the 
 stretch. Dissect up, cleanly from the bones, the outer dorsal portion of the 
 flap, until the head of the astragalus is exposed in front and the tendo Achillis 
 
 
 *f 
 
 
 Fig. 351.— SUBASTRAGALOID DISARTICULATION OF FOOT BY LARGE INTERNO-PLANTAR FLAP 
 
 (Farabeuf): — A. Outline of incision upon outer aspect of foot; B, Outline of incision upon inner 
 aspect. 
 
 behind — divide the tendo Achillis — enter the astragalo-scaphoid joint on its 
 dorsal aspect — keep the knife in the interarticular line and cut backward 
 between the astragalus and os calcis, passing beneath the tip of the external 
 malleolus to the already cut tendo Achillis, severing all ligaments and everting 
 the os calcis as the ligaments are cut — until the under surface of the astragalus 
 is free. The foot is further twisted into extreme varus, and the inner and 
 under surfaces of the os calcis are bared, working from the inner toward 
 the under and outer surfaces of the os calcis, by cutting with short strokes 
 of a strong knife, and closely hugging the bone to avoid damaging important 
 structures on the inner aspect, especially the vessels which supply the flap. 
 Bv the time the externo-plantar border of the os calcis is reached, the dorsum 
 of the foot will be looking downward. Free the skin from the posterior 
 surface of the os calcis carefully so as not to score the integumentary parts. 
 Sever any remaining connections. Cut the anterior and posterior tibial 
 
4 12 AMPUTATIONS. 
 
 nerves high up. The following arteries are encountered, in the direction of 
 the incision, and will require ligation — posterior peroneal, anterior peroneal, 
 dorsalis pedis, internal plantar and external plantar. Provide temporary 
 drainage, by puncturing the heel portion of the flap. Quilt the muscles 
 and tendons. Suture the flap in an external and anterior horizontal line. 
 Dress the stump upon a posterior splint. 
 
 DISARTICULATION OF FOOT AT ASTRAGALO-SCAPHOID AND AS- 
 TRAGALO-CALCANEAL JOINTS— SUBASTRAGALOID DIS- 
 ARTICULATION 
 
 BV HEEL FLAP. 
 
 Description. — The structures removed are the same as in the above 
 operation. In the present instance the coverings are furnished from the heel 
 and sole tissues. The steps of the operation are very similar to those of 
 Syme's disarticulation of the foot at the ankle-joint. 
 
 Position. — See Syme's operation (page 414). 
 
 Landmarks. — External and internal malleoli. 
 
 Incisions. — Plantar incision — begins 1.3 cm. (\ inch) below the tip of 
 the external malleolus — passes directly across the sole of the foot — and ends 
 2.5 cm. (1 inch) below the posterior border of the internal malleolus. Dorsal 
 incision — is U-shaped, connecting the upper ends of the plantar incision- 
 curving across the dorsum on a level with the astragalo-scaphoid joint (Fig. 
 349, E, and Fig. 350, F). 
 
 Operation. — For the general steps of the operation, see Syme's dis- 
 articulation at the ankle-joint (page 414), which is similar in general prin- 
 ciple, though different in detail. Deepen the incisions to the bones — dissect 
 the heel-flap backward and the dorsal flap upward — open the astragalo- 
 scaphoid joint from the dorsum and cut backward, disarticulating the astraga- 
 lus from the os calcis. The extreme head of the astragalus may be sawed 
 off. The operation is concluded as in Syme's — the same vessels being also 
 ligated. 
 
 Other Amputations About the Foot. — (1) Anterior Intertarsal Dis- 
 articulation (Jaeger's Operation) — consists of a disarticulation between the 
 three cuneiforms anteriorly, and the scaphoid posteriori}- — the cuboid being 
 sawed across in a line with the disarticulation. This would occupy a position 
 between Lisfranc's tarso-metatarsal disarticulation and Chopart's medio- 
 tarsal disarticulation. (2) Amputation Through the Posterior Tarsus — if 
 soft parts cannot be gotten to cover Chopart's stump, the articular surfaces 
 of the astragalus and os calcis are sawed off. (3) Subastragaloid Osteoplastic 
 Amputation (Hancock's Operation) — the tuberosity of the os calcis is sawed 
 off and applied to the lower surface of the astragalus, from which the articular 
 cartilage has been removed. 
 
 SURGICAL ANATOMY OF ANKLE-JOINT. 
 
 Bones. — Tibia; fibula; astragalus. 
 
 Articulations and Ligaments. — Anterior tibio-tarsal, posterior tibio- 
 tarsal, external lateral (consisting of anterior astragalo-fibular, posterior 
 astragalo-fibular, and middle calcaneo-fibular fasciculi), internal lateral (or 
 deltoid) ligaments, and synovial membrane. 
 
SURGICAL CONSIDERATIONS IN ANKLE DISARTICULATIONS. 413 
 
 Muscles. — See under Foot (page 398) and Leg (page 416). 
 
 Movements of Ankle-joint. — Extension — by gastrocnemius, soleus, 
 plantaris, tibialis posticus, peroneus longus, peroneus brevis, flexor longus 
 digitorum, flexor longus hallucis. Flexion — by tibialis anticus, peroneus ter- 
 tius, extensor longus digitorum, extensor proprius hallucis. Adduction — tibialis 
 anticus, tibialis posticus. Abduction — Peroneus longus, peroneus brevis. 
 
 Arteries. — Following branches of anterior tibial — internal and external 
 malleolar and dorsalis pedis. Following branch of posterior tibial — internal 
 calcaneal branch of posterior tibial: — and following branches of peroneal 
 branch of posterior tibial; anterior peroneal, posterior peroneal, and external 
 calcaneal. 
 
 Veins. — Superficial — internal saphenous and tributaries; external saphen- 
 ous and tributaries. Deep — Two venae comites accompany each artery. 
 
 Nerves. — From lumbar plexus — internal saphenous from anterior crural. 
 From sacral plexus — following from great sciatic — external saphenous (from 
 communicans poplitei and communicans peronei) ; plantar cutaneous, articu- 
 lar, internal plantar and external plantar (from posterior tibial); articular, 
 muscular and external (or tarsal) (from anterior tibial); and internal and 
 external branches of musculocutaneous. 
 
 Annular Ligaments. — See under Foot (page 397). 
 
 SURFACE FORM AND LANDMARKS OF ANKLE-JOINT. 
 
 The general feature of the ankle-joint is that of the prominently rounded 
 superior surface of the astragalus received into the dome of the tibia, and 
 bounded laterally by the descending malleoli. 
 
 The line of the joint is transverse — crossing the front of the leg about 
 1.3 cm. (J inch) above the tip of the internal malleolus. 
 
 The external malleolus extends from 1.3 to 2 cm. (J to f inch) lower than 
 the internal — and is placed upon a plane about 1.3 cm. (£ inch) posterior 
 to the internal malleolus. The external malleolus is opposite the center 
 of the joint — the internal is in front of the center of the joint. The tip of the 
 external malleolus is nearer the posterior border of the fibula, and the tip 
 of the internal malleolus nearer the anterior border of the tibia. 
 
 Chief structures about the ankle-joint — Anteriorly — (from within outward) 
 tibialis anticus, extensor proprius hallucis, anterior tibial artery, anterior 
 tibial nerve, extensor longus digitorum, peroneus tertius. Posteriorly — tendo 
 Achillis. Internally — (from before backward) tibialis posticus, flexor longus 
 digitorum, companion vein, posterior tibial artery, companion vein, posterior 
 tibial nerve, flexor longus hallucis. Externally — (from before backward) 
 peroneus brevis, peroneus longus, external calcaneal and termination of 
 peroneal artery. 
 
 The lower epiphysis of the tibia includes the articular surface and internal 
 malleolus, and unites about the eighteenth year. The lower epiphvsis of the 
 fibula includes the articular surface and outer malleolus, and unites about 
 the twentv-first vear. 
 
 GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATIONS AT 
 
 ANKLE-JOINT. 
 
 Great care should be taken of the blood -supply to the heel tissues forming 
 the stump — the chief vessels being the external calcaneal of the posterior 
 
41 4 AMPUTATIONS. 
 
 peroneal, externally; and the internal calcaneal of the external plantar, 
 internally. 
 
 In section of the lower ends of the tibia and fibula most of the anterior 
 and posterior tibio-libular and interosseous ligaments are saved. 
 
 A posterior splint is used in the dressing following disarticulation. 
 
 DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF 
 
 MALLEOLI AND ARTICULAR SURFACE OF 
 
 TIBIA, IN GENERAL. 
 
 Best Method. — Heel-flap — Syme's operation. 
 
 Other Methods. — Modified Oval Method — Roux's operation. Large 
 Interno-plantar Flap — Farabeuf's operation. Internal Lateral Flap. Modi- 
 fied External Racket. Dorsal Flap. 
 
 DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF 
 MALLEOLI AND ARTICULAR SURFACE OF TIBIA, 
 
 BY HEEL FLAP — SYME'S OPERATION. 
 
 Description. — As described in the title. 
 
 Position. — Patient supine; foot elevated and over edge of table. As- 
 sistant steadies leg with one hand and holds foot at right angle to leg by 
 grasping toes with other hand. Surgeon sits for plantar and stands for 
 dorsal incisions. 
 
 Landmarks. — Outline of ankle-joint; malleoli. 
 
 Incisions. — Plantar incision — begins at tip of external malleolus, on the 
 right side (the surgeon's left palm resting on the instep, with forefinger and 
 thumb upon the malleoli) — passes vertically down the outer side of the foot, 
 across the sole and vertically up the inner side of the foot to a point 1.3 cm. 
 (J inch) below the tip of the internal malleolus. This incision passes exactly 
 at a right angle to the long axis of the foot, in a straight line between these 
 two points — if inclined forward, the flap is very difficult to dissect from the 
 os calcis — if inclined backward, it is easier to separate but apt to form a 
 scanty covering, with imperfect vascular supply. If the inner limb of the 
 vertical incision passes up to the posterior border of the inner malleolus, 
 the posterior tibial artery is more in danger of being divided before its bifurca- 
 tion and the main branch of the flap, the internal calcaneal of the external 
 plantar, lost. The above incision is made in two cuts, each from a malleolus 
 to the center of the sole. Dorsal incision — (surgeon's left palm to sole, with 
 thumb and first finger grasping the margins of the foot and extending it) — 
 connects the upper ends of the plantar incision by an incision sweeping 
 straight across the front of the ankle. The dorsal and plantar incisions are 
 approximately at a right angle to each other (Fig. 349, C, C, and Fig. 350, 
 C, CO- 
 
 Operation. — The plantar incision, made with a strong knife, passes 
 directly and cleanly to the bone. The large heel-flap is freed from the os 
 calcis as far as its tuberosities, partly by the use of the left thumb, partly 
 by a stout knife cutting close to the bone. It is possible, but difficult and 
 unadvisable, to entirely dissect and retract the heel-flap from the tuberosities 
 and posterior surface of the os calcis, from the plantar wound. With the 
 
PIROGOFFS OPERATION. 415 
 
 foot fully extended the dorsal incision is now made directly to the bone, 
 cutting the tendons and ligaments cleanly. This incision cuts directly through 
 the anterior ligament of the ankle-joint and opens the articulation. The 
 disarticulation is continued by cutting the lateral ligaments from within 
 outward, and completed by similarly cutting the posterior ligament. The 
 tendo Achillis is now cut. The foot is then drawn downward and forward 
 and the posterior and lateral surfaces of the os calcis dissected free of the 
 heel covering by working from behind downward and forward with short, 
 close strokes of the knife while the parts are under tension. The malleoli 
 are now closely cleared of their soft parts, hugging the bones and guarding 
 the flaps. The soft parts are well retracted — and the tibia and fibula are 
 sawed transversely at about 6 mm. (J inch) above the inferior border of the 
 tibia (which will remove the articular surface of the dome) — the malleoli 
 being steadied by forceps during the sawing. Ligate the anterior tibial, 
 external and internal plantar, and probably the external and internal malleolar 
 of the anterior tibial, the anterior peroneal, internal malleolar of posterior 
 tibial, and internal and external saphenous veins. Cut all nerves short, 
 especially those of the heel-flap, which is bent over the ends of the sawed 
 bones. Suture the heel-flap to the dorsal incision— using tension-sutures 
 in addition to coaptation-sutures, if there be much strain upon the suture-line. 
 Institute drainage through a counter-opening in the heel-flap, if indicated. 
 So dress the part, with a posterior splint included, as to draw the heel-flap 
 forward and upward. 
 
 Comment. — (1) This is probably the best form of disarticulation about 
 the ankle and usually furnishes a very satisfactory result. (2) It is advisable 
 to free the os calcis subperiosteals, if possible — and also to leave the posterior 
 epiphysis, in the young, in the flap. 
 
 DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF 
 
 MALLEOLI, ARTICULAR SURFACE OF TIBIA, AND ANTERIOR 
 
 PART OF OS CALCIS,— IN GENERAL. 
 
 Best Method. — Heel-flap — Pirogoff's operation. 
 
 Other Methods.— Racket Method (Pasquier-LeFort) — racket from inner 
 side, with horizontal division of calcaneum. Watson's modification of Piro- 
 goff's Heel-flap Method — sawing calcaneum from plantar surface immediately 
 after plantar incision. Sedilot's modification of Pirogoff's operation — middle 
 (internal) oval method, with oblique sawing of calcaneum. Others have 
 sawed the os calcis in angular and curved directions. 
 
 DISARTICULATION OF FOOT AT ANKLE-JOINT, WITH REMOVAL OF 
 
 MALLEOLI. ARTICULAR SURFACE OF TIBIA, AND ANTERIOR 
 
 PART OF OS CALCIS, 
 
 BV HEEL-FLAP — PIROGOFF'S OPERATION. 
 
 Description. — An intra-calcaneal osteoplastic amputation of the foot. 
 The operation is very similar to Syme's, except that the anterior and major 
 portion of the os calcis is sawed off and the remaining posterior portion, 
 which is left in the heel-flap, is adjusted to the transversely sawed tibia and 
 fibula. 
 
 Position — Landmarks. — As in Syme's operation (page 414). 
 
416 AMPUTATIONS. 
 
 Incisions. — Plantar incision (right foot) — begins just anterior to the 
 tip of the external malleolus — passes vertically down the outer side of the 
 foot, across the sole, and vertically up the inner side of the foot to a point 
 1.3 cm. (^ inch) below and a short distance anterior to the tip of the internal 
 malleolus (which points are a little anterior to those of Syme's operation). 
 Dorsal incision — is somewhat more convex; that is, passes further down on 
 the dorsum of the foot than does Syme's (Fig. 349, D, D', D", and Fig. 
 350, D, D', D"). 
 
 Operation. — These incisions are made and deepened in the same manner 
 as in Syme's operation. The heel-flap is not freed back from the plantar 
 surface of the os calcis quite to its tuberosities. The disarticulation is accom- 
 plished as in Syme's. The foot is placed in extreme extension and the upper 
 surface of the os calcis exposed, but the tendo Achillis not cut. The whole 
 of the os calcis having been freed except its posterior third, the saw is applied 
 (with the foot in extension) to the upper surface of the os calcis, 1.3 to 2 cm. 
 (£ to f inch) behind the astragalus, and made to saw its way obliquely down- 
 ward and forward (or more nearly vertically, in the extended position of the 
 foot) in a line about parallel with the now distorted heel incision — all the 
 soft parts being carefully retracted the while, especially the inner arteries. 
 The lower ends of the tibia and fibula are then freed as in Syme's and are 
 sawed off in the same manner, except that, after entering the anterior surface 
 of the bone about 6 mm. (\ inch) above the inferior border of the tibia, the 
 section is so made that the saw emerges posteriorly about 1.3 cm. (J inch) 
 higher than on the anterior surface (to be parallel with the section of the 
 calcaneum). Ligate the same vessels as encountered in Syme's operation. 
 Cut the nerves short and the loose tendons. Approximate the sawed cal- 
 caneum to the sawed tibia — and suture the plantar flap to the dorsal incision. 
 
 Comment. — (1) If the sawed ends of the bone do not lie in good apposi- 
 tion, a thin slice of bone may be further removed with the saw where indicated 
 — or the surfaces of bone may be nailed or pegged together. But when 
 the proper calculations are made the surfaces can generally be held in contact 
 by the suturing together of the fibrous tissues surrounding the sawed ends, 
 with buried chromic gut. (2) The stump thus gained is a little longer than 
 in Syme's operation — the flap is better .nourished, is firmer, contains bone 
 and tendo Achillis, and the movement is greater. But the bone is apt to 
 necrose, or become displaced, or may not unite. The operation is more 
 suitable to traumatic cases. An artificial limb is harder to fit. The method 
 is, altogether, not superior to Syme's. 
 
 SURGICAL ANATOMY OF LEG. 
 
 Bones. — Tibia; fibula. 
 
 Articulations and Ligaments. — (a) Superior Tibiofibular Articula- 
 tion — anterior and posterior superior tibio-fibular ligaments, and synovial 
 membrane, (b) Middle Tibio-fibular Articulation — interosseous membrane, 
 (c) Inferior Tibio-fibular Articulation — anterior and posterior inferior tibio- 
 fibular and transverse ligaments, inferior interosseous membrane, and synovial 
 membrane. 
 
 Muscles. — (a) Anterior Tibio-fibular Region: — tibialis anticus; extensor 
 proprius hallucis; extensor longus digitorum; peroneus tertius. (b) Posterior 
 Tibio-fibular Region: — (1) Superficial Muscles; — gastrocnemius, soleus, 
 plantaris. (2) Deep Muscles: — popliteus, flexor longus hallucis, flexor 
 
SURFACE FORM AND LANDMARKS OF LEG. 417 
 
 longus digitorum, tibialis posticus, (c) Outer, or Fibular, Region : — peroneus 
 longus, peroneus brevis. 
 
 Arteries. — Following branches of popliteal — inferior muscular, inferior 
 external articular, inferior internal articular. Anterior tibial and following 
 branches — posterior recurrent tibial, superior fibular, anterior recurrent 
 tibial, muscular, internal malleolar, external malleolar. Posterior tibial 
 and following branches: — peroneal (with its muscular, nutrient, anterior 
 peroneal, and communicating branches), muscular, nutrient, and communi- 
 cating branches. 
 
 Veins. — Superficial — internal saphenous and tributaries — external saphe- 
 nous and tributaries. Deep — Two vena? comites for each artery. 
 
 Nerves. — (a) From lumbar plexus — (1) From anterior crural; posterior 
 branch of internal cutaneous; long saphenous branch and its branches, (b) 
 From sacral plexus — (1) From great sciatic — anterior popliteal and muscular 
 branches; communicans poplitei. Posterior tibial and muscular branches. 
 External popliteal (or peroneal) and cutaneous branches. Anterior tibial 
 and muscular branches. Musculocutaneous and muscular and cutaneous 
 branches. The cross-sections of the leg are shown in Figs. 56, 60, 352, and 62. 
 
 SURFACE FORM AND LANDMARKS OF LEG. 
 
 Following parts of the tibia are palpable — external tuberosity (more 
 prominent); internal tuberosity (broader); tubercle; anterior border, or 
 crest (for upper two-thirds); internal border; internal surface (from tuberosity 
 to malleolus) ; internal malleolus. 
 
 Following parts of fibula are palpable — head ; lower part of external surface 
 of shaft (between peroneus tertius, and peronei longus and brevis) ; external 
 malleolus. 
 
 The fibula is on a plane considerably posterior to the tibia. 
 
 No muscular fibers are attached to the lower third of the tibia. 
 
 The sharp crest of the tibia has become rounded in its lower third. 
 
 The interosseous space is widest at the center of the leg, decreasing in 
 width toward both ends. 
 
 The tibialis anticus forms a muscular prominence running down the leg 
 external to the tibia. The extensor longus digitorum, a smaller prominence, 
 fills the rest of the interval between the fibula and the tibialis anticus muscle — 
 a groove intervening between these two muscles above, and the extensor 
 proprius hallucis coming to the front between them below. 
 
 Externally, the peroneus longus, brevis, and tertius form a muscular 
 prominence. 
 
 The internal aspect of the leg is formed- -anteriorly, by the subcutaneous 
 tibia — posteriorly, by the projecting border of the soleus and tendon of the 
 tibialis posticus. 
 
 The fleshy mass of the calf is formed by the gastrocnemius and soleus, 
 tapering to the tendo Achillis — and beneath them the popliteus, flexor longus 
 hallucis, flexor longus digitorum, and tibialis posticus. 
 
 A groove exists between either malleolus and the extended tendo Achillis. 
 
 The interosseous membrane separates the anterior from the posterior 
 tibio-fibular muscles. 
 
 Tendons predominate over muscles in the lower third of the leg. 
 
 The gastrocnemius and soleus have joined by the time the lower third 
 of the leg is reached. 
 
 The greatest girth of the leg is at about the junction of the upper and 
 27 
 
418 AMPUTATIONS. 
 
 middle thirds — tapering gradually above to the knee-joint — and rapidly 
 decreasing in size below toward the ankle. 
 
 The popliteal artery bifurcates about 5 cm. (2 inches) below the knee- 
 joint — on a level with the lower part of the tubercle of the tibia. In ampu- 
 tating 2.5 cm. (1 inch) below the head of the fibula, one main artery, the' 
 popliteal, is cut — at 5 cm. (2 inches), two main arteries, the anterior and 
 posterior tibials — and at 7.5 cm. (3 inches), three main arteries, the anterior 
 and posterior tibials and the peroneal (Holden). 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 
 
 THE LEG. 
 
 In the lower and middle thirds of the leg, the bulk of the muscles are 
 posterior — hence a posterior flap forms the best covering. 
 
 In the upper third of the leg the bulk of the muscles are postero-external 
 —hence a flap chiefly external furnishes the best covering. 
 
 In all amputations through the upper third of the leg, it is well to cut 
 the fibula at a higher level than the tibia, as it is apt to be drawn out of posi- 
 tion and be exposed to pressure. 
 
 The "place of election," especially referred to in older writings, was 
 understood to be a hand's-breadth (or an average of 9 cm., or 3^ inches) 
 below the knee-joint. 
 
 The termination of the stump, in amputations about the leg, does not 
 directly meet pressure (except in the peg-leg) — the pressure being borne by 
 the lateral aspects of the hollow modern limb — so that a terminal scar (except 
 where a peg-leg is contemplated) is not objectionable. 
 
 It is especially necessary, in amputating in the lower extremity, to dissect 
 out all nerves which may be pressed upon — especially in the flap forms of 
 operation. 
 
 In sawing the bones of the leg, the prominent border (shin) of the tibia 
 should be beveled, as described in the General Principles (page 294) . 
 
 The stump should be dressed upon a splint — and be kept out from under 
 the bedclothes. 
 
 AMPUTATIONS ABOUT THE LEG, IN GENERAL. 
 
 Best Methods. — Oblique Elliptical (Guyon's Supramalleolar Ampu- 
 tation) — for the supramalleolar region. Large Anterior and Small Posterior 
 Flaps (Farabeuf) — for lower third, between supramalleolar region and lower 
 limit of middle third. Large Posterior and Short Anterior Flaps (Hey's 
 Operation) — for middle third. Large External Flap (Farabeuf) — for upper 
 third. Bilateral Hooded Flap (Stephen Smith's Operation) — for "place of 
 election," or upper part of upper third. 
 
 Other Methods. — Modified Circular — for supramalleolar region. Oblique 
 Elliptical (Duval) — for lower third. Rectangular Flaps (Teale) — for lower 
 third. Large Posterior and Small Anterior Flaps (Henry Lee) — for middle 
 third. Circular Method. Equal Lateral Flaps. Large Posterior Flap. 
 Large Anterior Flap. Long Anterior and Short Posterior Flaps. Oblique 
 Circular, forming an anterior flap — for upper and lower thirds. Oblique 
 Circular, forming an antero-external flap — for middle thirds. Oblique 
 Circular — forming a dorsal flap — for supramalleolar region. Long anterior 
 
AMPUTATION THROUGH LOWER THIRD OF LEG. 
 
 419 
 
 Curved Flap. Long Anterior Rectangular Flap. Large Anterior Semilunar 
 and Small Posterior Semilunar Flaps. 
 
 Fig. 352. — Cross-section through the Lower Third of the Right Leg: — A, Tibialis 
 anticus; B, Extensor proprius pollicis; C, Extensor longus digitorum; D, Anterior tibial artery, 
 veins, and nerve; E, Tibialis posticus; F, Peroneal artery and veins; G, Peroneus brevis; H, 
 Peroneus longus; I, Flexor longus pollicis; J, J, Gastrocnemius and soleus; L, Posterior tibial 
 artery, veins, and nerve. (The cross-section modified from Rraune.) 
 
 AMPUTATION OF LEG THROUGH SUPRAMALLEOLAR REGION 
 
 BY OBLIQUE ELLIPTICAL INCISION — GUYON'S SUPRAMALLEOLAR OPERATION. 
 
 Description. — An operation somewhat resembling Syme's — the tibia 
 and fibula being divided below the medullary canal, and the ends of the 
 bones covered by a heel-flap of skin and muscles. 
 
 Position. — In operating upon the leg, in general, the limb projects over 
 the edge of the table — the patient being supine — the surgeon standing to 
 the outer side of the right, and inner side of the left — the assistant steadving 
 the part to come away. In the present operation, the surgeon grasps' the 
 foot in his left hand and manipulates it so as to readily expose the line 
 of incision. On the right, the foot is turned inward and the incision begins 
 at the outer side of the heel — crosses the outer aspect of the foot, which is 
 then turned upon its outer side, and the incision carried to the heel along the 
 inner aspect. On the left, the incision may begin in front, with the foot 
 upon its inner side. 
 
 Landmarks. — Ankle-joint; malleoli; greatest prominence of the heel. 
 
 Incision. — Begins, say, on the anterior aspect of the ankle, opposite the 
 
420 AMPUTATIONS. 
 
 center of the ankle-joint — curves obliquely downward and backward over 
 the lateral aspects of the foot, just skirting the inner malleolus, and passing 
 slightly in front of the external malleolus — ending over the summit of the 
 curve of the heel. The incision may be made from the instep to the heel, 
 or vice versa (Fig. 350, E, E'). 
 
 Operation. — The above incision is made through skin and fascia, and 
 is then everywhere deepened to the bone — except that the ankle-joint is not 
 opened, and the peronei tendons behind the external malleolus are not cut, 
 until the soft parts have been cleared above the ankle-joint. The soft tissues 
 are now carefully freed up about 5 cm. (2 inches) above the tips of the malleoli, 
 providing a musculo-periosteal covering — using great care to preserve the 
 vessels on the inner aspect — the surgeon standing for the anterior dealing, 
 and sitting (or elevating the limb) for the posterior clearing. The tendo 
 Achillis is divided. The peronei tendons are cut at about the level of the 
 ankle. The ankle-joint is not opened. The anterior tibial, posterior tibial, 
 termination of the peroneal, and anterior peroneal vessels are ligated. The 
 nerves and tendons are cut especially short. It is probably better to dissect 
 out the posterior tibial nerve. The convex heel-flap is then sutured to the 
 upper concave incision, and the stump dressed as in Syme's operation. 
 
 AMPUTATION THROUGH LOWER THIRD OF LEG 
 
 EV LARGE POSTERIOR AND SMALL ANTERIOR FLAPS— FARABEUF. 
 
 Description. — The operation is usually known as a large posterior flap 
 method, the anterior flap supplying so small a part of the covering. Both 
 flaps are of skin and muscle. The posterior flap, which forms the bulk of 
 the covering, is derived really more from the postero-internal aspect, and the 
 anterior or smaller flap, which is about one-fourth the length of the larger, 
 from the antero-external aspect. 
 
 Position. — See Guyon's operation (page 419) — and under Incision, below. 
 
 Landmarks. — Saw-line. 
 
 Incisions. — Posterior flap — begins (on the right side) with the leg turned 
 to present the inner side, at the saw-line, on the inner side of the leg — and 
 passes vertically down in front of the inner border of the tibia for a distance 
 equal to about 1^ diameters of the limb at the saw-line — then rounds across 
 the posterior aspect of the leg. The outer limb of the incision begins, with 
 the leg turned to present the outer side, at the saw-line, on the outer side 
 of the leg — and passes vertically down just behind the fibula, for a distance 
 equal to about i| diameters of the leg at the saw-line — then rounds across 
 the posterior aspect of the leg to meet the inner incision. The anterior flap 
 is made by a transverse incision, slightly convex downward, passing between 
 the two vertical incisions, at a distance below their upper ends equal to about 
 one-fourth of the length of the posterior flap (Fig. 352, A). 
 
 Operation. — These incisions having been made through skin and fascia, 
 the tendo Achillis is divided on a line with the retracted skin and the leg 
 is turned to present its inner side — and the upper part of the inner incision 
 is deepened for a length of about 5 cm. (2 inches), by freeing the muscles 
 from the tibia. The leg is now turned to present the outer side and the 
 upper end of the outer incision is similarly deepened for a distance of about 
 5 cm. (2 inches), by freeing the muscles from the fibula. The leg is flexed 
 during these incisions. Through these two opposite openings, the left thumb 
 and index are thrust, meeting in the center, and thus the soft parts are picked 
 
AMPUTATION THROUGH LOWER THIRD OF LEG. 
 
 421 
 
 up and drawn from the bones, the limb still being flexed. A long knife is 
 passed through this opening and made to cut its way out on a line with the 
 retracted skin, bluntly beveling the flap. The anterior incision is now deepened 
 to the bones on a line with the retracted skin. The soft parts are then freed 
 back to the saw-line — the interosseous membrane being divided transversely, 
 and the periosteum having been circularly divided a distance below the 
 saw-line sufficient to furnish a covering of one diameter of each bone at the 
 
 ■ 
 
 Fig. 353.— Amputations about the Lkg : — A, Through lower third of leg, by large posterior 
 and small anterior flap ; B, Through middle third, by long posterior and short anterior (Hey's opera- 
 tion); C, Through upper third, by bilateral hooded flaps (Stephen Smith's operation). 
 
 saw line. The soft parts are retracted and the bones are sawed — beveling 
 the prominent anterior border of the tibia as described at page 294. Ligate 
 the anterior tibial, posterior tibial, peroneal arteries, and internal and ex- 
 ternal saphenous veins. Suture the periosteo-muscular coverings over the 
 ends of the bones. Quilting of the muscles is particularly indicated, as the 
 heavy posterior muscles are apt to sag backward. Dissect out the posterior 
 tibial nerve. Dress the stump on a posterior splint. 
 
422 
 
 AMPUTATIONS. 
 
 OSTEOPLASTIC AMPUTATION OF THE LEG 
 
 BY LONG POSTERIOR AND SHORT ANTERIOR FLAPS. 
 
 Description. — Having amputated the leg by a long posterior and short 
 anterior flap, a vertical section is made from the anterior surface of the tibia, 
 forming an adherent bone-flap — which is broken backward, and subsequently 
 applied to the transversely divided portions of the tibia and fibula. 
 
 Position. — As in amputating the leg in antero-posterior flap methods 
 (v. page 420). 
 
 Fig. 354. — Amputations about the Knee and Leg: — A, Disarticulation at the knee- 
 joint by an oblique incision; P>, Osteoplastic amputation of the leg by long posterior and short 
 anterior flap. 
 
 Landmarks. — The saw-line. 
 
 Incisions. — The posterior flap, having a base equal to one-half the cir- 
 cumference of the limb at the line of bone-section, is made by an incision begin- 
 ning just below the line of the division of the bone and passing down behind 
 the posterior border of the tibia and fibula, rounding out into the posterior 
 aspect of the limb at a distance below the saw-level equivalent to about one 
 diameter of the limb at the level of the bone-section. The anterior flap is 
 
OSTEOPLASTIC AMPUTATION OF THE LEG. 
 
 423 
 
 one-third the length of the posterior, beginning and ending in the same lines 
 laterally. (Fig. 354, B.j 
 
 Operation. — Having outlined both flaps through skin and fascia, the soft 
 parts of the posterior flap are divided to the bones, cutting obliquely from the 
 line of the retracted skin. This flap is then retracted, en masse, up to the 
 saw-line. The anterior flap is dealt with in the same way — both flaps con- 
 
 Fig. 355. — Lines of Section of Bones in the Osteoplastic Amputation of the Leg : — 
 Having completed the division and retraction of the soft parts, the tibia and fibula are sawn 
 transversely at H and F; — The tibia is sawn longitudinally from H to G, along AC and BD; — 
 The fibula' is then sawn through completely at E, and the tibia is divided at CD, nearly to but 
 not through the periosteum toward G; — The portion of the tibia between the lines AHB and 
 CGD represents the osteoplastic flap. 
 
 sisting of all the soft parts down to but not including the periosteum. Having 
 retracted the soft flaps well out of the way, thus exposing the tibia and fibula 
 with their undisturbed periosteum, the bone-flap to be taken from the tibia 
 is planned. A sufficient length of bone-flap is calculated to cover the trans- 
 versely divided ends of tibia and fibula — the bone-flap coming from the antero- 
 internal aspect of the tibia. The making of this flap is somewhat complicated 
 — but is well shown in the diagrammatic Figs. 355, 356, 357, and 358. Having 
 
 
 I 
 
 Fig. 356. — Removing Sections of Tibia and Fibula to enable the Tibial Bone-flap 
 to be Hinged over upon the Sawn Fibula: — A, A third transverse section of both bones is 
 here made for this purpose, at a height above the preceding section equivalent to the thickness 
 of the bone-flap. 
 
 completed the division and retraction of the soft parts, the tibia and fibula 
 are sawn transversely at H and F, Fig. 355. The tibia is sawn longitudinally 
 from H to G, along A C and B D. The fibula is then sawn through com- 
 pletely at E, and the tibia is divided at C D, nearly to but not through the 
 periosteum toward G. The portion of the tibia between the lines AHB 
 and CGD represents the osteoplastic flap. The periosteal flap is now 
 
424 
 
 AMPUTATIONS. 
 
 broken back through the limited portion of bone still holding it — by means 
 of a chisel inserted in the saw-section and given a slight tap. Having hinged 
 back the bone-flap, room has now to be provided for its bending forward over 
 the transversely divided tibia and fibula. This is accomplished by making 
 another transverse division of both bones at a height above the preceding sec- 
 
 9 M 
 
 r* ~vw 
 
 j 
 
 Fig- 357- — -The Osteoplastic Amputation of the Leg: — The bone-flap, AB, with its 
 periosteal hinge, K, is here shown ready to be applied to the transversely divided ends of the 
 tibia and fibula, L, M. Owing to the removal of the piece of tibia and fibula accomplished by 
 the last section (Fig. 356) this hinging is made possible. 
 
 tion equivalent to the thickness of the bone-flap — Fig. 356. The completed 
 bone-sections are shown in Fig. 357, where the redundancy of periosteum is 
 shown, furnishing the hinge. The bone-flap is now dropped over the ends of 
 the bones and is held in place either by suturing its periosteum to that of the 
 tibia and fibula, or by carrying an absorbable suture through a hole previously 
 
 Fig. 358. — The Osteoplastic Amputation of the Leg : — The tibial flap, with its adherent 
 and continuous periosteum, is here shown applied to itself and fibula — a suture, passed through 
 drilled holes, holding the parts in contact. 
 
 drilled through both bones, as shown in Fig. 358. Having united the bone- 
 flap to the tibia and fibula, the larger posterior flap of soft parts is brought 
 over the bone-flap and sutured to the contour of the smaller anterior flap — 
 the muscle structures in the two flaps being supported by buried absorbable 
 sutures. 
 
 AMPUTATION THROUGH MIDDLE THIRD OF LEG 
 
 BY LONG POSTERIOR AND SHORT ANTERIOR FLAPS — BY HEY'S OPERATION. 
 
 Description. — The covering is by skin and muscle flaps, furnished 
 almost entirely from the posterior aspect of the leg. The method is fre- 
 
AMPUTATION THROUGH UPPER THIRD OF LEG. 425 
 
 quently termed simply a long posterior flap operation — and differs but little 
 from the preceding operation. 
 
 Position. — As in Guyon's operation (page 419) — and as given under 
 Incision, below. 
 
 Landmarks. — Saw-line. 
 
 Incisions. — The posterior flap is U-shaped — its breadth is equal to half 
 the circumference of the limb at the saw-line, and its length is equivalent 
 to one diameter of the limb at that line. It begins 2.5 cm. (1 inch) below 
 the saw-line (instead of at that line). The inner limb passes vertically down 
 the leg just behind the internal border of the tibia, rounding broadly into 
 the posterior aspect of the limb — the outer limb passing vertically downward 
 just behind the fibula, posterior to the peronei muscles, and rounding broadly 
 into the posterior aspect of the leg to unite with the opposite limb of the 
 incision. The anterior flap is about one-third the length of the posterior, 
 and is made by joining the vertical limbs of the posterior flap, at their upper 
 thirds, by a transverse incision, with slight downward convexity, across the 
 front of the leg. In these incisions the knee is flexed and the leg is laid on 
 its outer side while the inner incision is being made from above downward, 
 and vice versa (Fig. 353, B). 
 
 Operation. — The above incisions pass through the skin and fascia onlv. 
 With the leg flexed on the thigh and the knee everted, the gastrocnemius is 
 held up by thumb and first finger and cut from without, on a line with the 
 retracted skin and fascia. The upper parts of both vertical incisions are now 
 deepened — the inner to the tibia, the outer to the fibula, behind the peronei 
 muscles. The left thumb and index are inserted into these slits and the 
 muscles drawn outward. The muscles having been detached from the 
 bones and interosseous membrane above, a long knife is passed between the 
 bones and separated muscles and is made to cut its way outward along the 
 fine of the retracted skin. The interosseous membrane is divided transversely 
 and the periosteum of the tibia and fibula circularly — and all the soft parts 
 retracted upward for the 2.5 cm. (1 inch) between the saw-line and the begin- 
 ning of the flaps. The flaps are now retracted — the bones divided, and the 
 prominent crest of the tibia beveled. The anterior tibial, posterior tibial, 
 and peroneal arteries are ligated. The musculo-periosteal coverings are 
 sutured over the ends of the bones. The muscles are quilted with special 
 care, owing to the tendency of the posterior flap to sag backward. The 
 large posterior and short anterior flaps are then sutured together — and the 
 stump supported upon a posterior splint. 
 
 AMPUTATION THROUGH UPPER THIRD OF LEG 
 
 BY LARGE EXTERNAL FLAP — FARABEUF. 
 
 Description. — The stump is covered by a large U-shaped flap of skin 
 and muscles raised from the external aspect of the leg. 
 
 Position. — Patient supine; leg projecting over side of table, with knee 
 flexed and leg lying on inner side for the incision of the external flap, and 
 on the outer side for the transverse incision. Surgeon to outer side of right 
 and inner side of left leg. 
 
 Landmarks. — Saw-line. 
 
 Incision. — External flap — U-shaped, equivalent in length to one diameter 
 of limb at saw-line — begins opposite the saw-line anteriorly — passes vertically 
 downward parallel with and just internal to the anterior border of the tibia 
 
426 
 
 AMPUTATIONS. 
 
 — rounds across the external aspect of the leg and passes vertically upward 
 directly opposite the anterior incision — but ends about 4 cm. (ij inches) 
 below the saw-line. Transverse incision — passes transversely across the 
 inner aspect of the limb, with slight downward convexity, connecting the 
 upper end of the posterior incision with a point on the anterior incision 4 cm. 
 (i^ inches) below its beginning. The external flap may be cut, or outlined, 
 
 1 c 
 
 Fig- 359.— Amputations about the Leg: — A, Through lower third of leg, by oblique circular 
 method; B, Through middle third, by modified circular method ; C, Through upper third, by large 
 external flap. 
 
 with one sweep of the knife — but it is better to complete it in two strokes 
 (Fig. 359, C). 
 
 Operation. — Beginning with the external flap, the above incision is 
 deepened along the line of the retracted skin — and the large flap, of all 
 the soft parts to the bones, raised. To accomplish this, the incision is first 
 deepened along the anterior limb by cutting down upon the anterior border 
 
AMPUTATION THROUGH UPPER THIRD OF LEG. 427 
 
 of the tibia, from above downward. The tibialis anticus is thus freed from 
 the bone. The left fingers of the operator, slipped between muscle and 
 bones, draw it outward, while the short knife continues its downward inci- 
 sions, beveling obliquely the lower portion of the muscular mass toward the 
 extremitv of the flap. Thus the entire muscle-mass is separated from the 
 tibia, interosseous membrane, and fibula, by the use of the knife, fingers, 
 and elevator. Care is taken that the anterior tibial artery is not divided 
 before the free end of the flap is reached, the integrity of which so largely 
 depends upon this vessel. If the parts are freed up too high, especially 
 posteriorlv, where the vertical incision is shorter than the anterior, the anterior 
 tibial artery may be severed before traversing the interosseous membrane. 
 The transverse incision crossing the inner aspect of the limb is now deepened 
 by cutting from without inward on the line of retracted skin and fascia. 
 The interosseous membrane is divided transversely. The periosteum is 
 circularlv divided around the tibia and fibula. The periosteum and soft 
 parts are then freed up to the saw-line and retracted while the bones are 
 divided — the prominent margin of the tibia being beveled from above down- 
 ward, and from before backward. The fibula is sawed a little higher than 
 the tibia, and beveled from above downward, and from without inward. 
 The anterior tibial, posterior tibial, peroneal, muscular branches to the 
 gastrocnemius and soleus, and nutrient arteries are ligated. All nerve-trunks 
 which are apt to be pressed upon are dissected out. The muscles are quilted. 
 The margins of the external flap are sutured to the inner transverse incision 
 — and the limb dressed upon a posterior splint. 
 
 AMPUTATION THROUGH UPPER THIRD OF LEG 
 
 PA' BILATERAL HOODED FLAPS — STEPHEN SMITH. 
 
 Description. — Two lateral flaps of skin and fascia are raised from the 
 outer sides of the leg, by an incision extending much higher behind than in 
 front— these are retracted about 2.5 cm. (1 inch)— the muscles circularly 
 divided and retracted to the saw-line and the bones sawed— forming a bilateral 
 hood over the ends of the bones, which is sutured vertically— the scar being 
 eventually drawn up behind the bones. 
 
 Position. — Patient supine; leg over edge of table, held horizontal for 
 skin incisions and vertical when freeing back the soft parts. The surgeon, 
 to outer side of right and inner side of left limbs, places the right thumb 
 upon the crest of the tibia, to mark the upper limit of the anterior incision, 
 and the index posteriorly, to mark the upper limit of the posterior incision- 
 leaning over patient and cutting from behind forward on both sides, the 
 incisions meeting at the highest point of the anterior incision. 
 
 Landmarks.— Saw-line, marking the upper limit of the posterior incision 
 —and the point on the crest of the tibia marking the upper limit of the anterior 
 incision, and placed about three-fourths of a diameter of the limb at the 
 saw-line below the upper limit of the posterior incision (Fig. 353, C). 
 
 Incisions. — The surgeon, having grasped the limb in such a manner 
 as to mark the upper limit of the anterior incision by his left thumb upon the 
 crest of the tibia, and of the posterior incision by his left index in the mid- 
 posterior aspect of the leg at the saw-line— bends over the patient's leg (his 
 arm being above and to the far side of the limb) and inserts the point of a 
 stout knife, held at a right angle to the skin, into the posterior tissues opposite 
 the tip of the index— cuts thence downward, through skin and fascia— 
 verticallv downward, at first— and then soon begins gradually to sweep to 
 
428 
 
 AMPUTATIONS. 
 
 the side of the limb opposite to that on which he is standing — and continues 
 to pass in this curvilinear manner until a little below the level marked by his 
 left thumb — then curves transversely across the far side of the limb and 
 slightly ascends to the point marked by the tip of the thumb. The knife 
 is now removed and this incision is repeated upon the near side of the limb, 
 the knife entering at the highest point posteriorly, sweeping with the same 
 curve (except that the flap may be advantageously made a little larger on 
 the inner side, to cover the larger tibia) to the highest point anteriorly. 
 
 , 
 
 
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 1 * " 
 
 1 jl 
 
 1 j 1 
 
 | 
 
 
 1 
 
 Jr 
 
 1 
 1 
 
 
 Fig. 360. — Bier's Osteoplastic Amputation of the Upper Third of the Leg: — Lines 
 for" the incision of the soft parts, forming the antero-internal cellulocutaneous flap. 
 
 Operation. — Having incised the skin and fascia, these flaps are raised 
 from their lower ends for about 2.5 cm. (1 inch) and are retracted, when 
 the muscles are circularly divided to the bone — and are retracted from the 
 tibia and fibula up to a level far enough below the saw-line to furnish a perios- 
 teal covering. Here the interosseous membrane is divided transversely — 
 and the periosteum circularly around the tibia. All the soft parts, including 
 periosteum, are then retracted above the saw-line and the bone divided, 
 beveling the tibia and sawing the fibula shorter than the tibia. The short 
 piece of the fibula may then be disarticulated and excised. The anterior and 
 posterior tibial, peroneal, and muscular arteries are tied. The musculo- 
 periosteal covering is sutured over the tibia — the muscles quilted— and the 
 flaps sutured in a vertical line— the redundancy of soft parts being eventually 
 drawn up behind the stump. The hood of skin and muscle falls over the 
 ends of the bones and the stump is freely movable. 
 
OSTEOPLASTIC AMPUTATION THROUGH UPPER THIRD OF LEG. 429 
 
 OSTEOPLASTIC AMPUTATION THROUGH THE UPPER THIRD OF 
 
 THE LEG 
 
 BY ANTERO-INTERNAL FLAP BIER'S METHOD. 
 
 Description. — An osteoplastic flap is taken from the antero-internal 
 aspect of the tibia, in the upper third of the leg, and applied to the trans- 
 versely divided tibia and fibula. 
 
 Position. — As for amputations through the upper part of the leg (v. 
 page 425 and 427, in part). 
 
 Landmarks. — The saw-line, which may be at any height of the leg, but 
 is usually in the neighborhood of the junction of the upper and middle thirds. 
 
 Incisions. — An antero-internal skin-and-connective-tissue flap is out- 
 lined, having a base equal to half the circumference of the limb at the saw- 
 line, and whose length is somewhat greater than the diameter at that line. 
 The upper limits of this flap are connected by a semi-circular incision with 
 slight downward dip at its center and passing posteriorly (Fig. 360). 
 
 Operation. — Having carried these incisions through skin and fascia, the 
 large antero-internal flap is dissected back and turned upward upon the limb. 
 The periosteum is incised upon the subcutaneous aspect of the tibia — trans- 
 versely at the lower limit of the flap, and vertically along the borders of the 
 tibia, sufficiently to plan for the formation of the periosteally covered bone-flap. 
 
 Figs. 361 and 362. — Bier's Osteoplastic Amputation of the Leg: — A, Showing manner 
 of raising an osseo- periosteal flap from tibia; B, showing bone-flap brought over sawed ends of 
 tibia and fibula, and its periosteal margins sutured to the margins of periosteum around tibia 
 and fibula. The osseo-periosteal flap is here shown separated from its soft parts, to which it 
 should be adherent. (Modified from Bier.) 
 
 A bone-flap, with periosteum attached, is now raised from this aspect of the 
 tibia by means of a Gigli-Haertel saw — calculated to cover the transversely 
 divided tibia and fibula. The bone-flap is broken back at its base, the perios- 
 teum maintaining a hinge connection with the upper part of the bone (Fig. 
 361, A). This bone-flap is turned upward and backward — and the limb is 
 amputated at the level of the upper limit of the limbs of the antero-internal 
 flap by a transverse incision. The vessels are secured and the nerves and 
 tendons cut short. Enough of the upper end of the bone-flap is removed 
 with a saw to enable the intervening hinge of periosteum to bend over the end 
 
430 AMPUTATIONS. 
 
 of the bone without too great stretching. Having approximated the sawn 
 bone-flap to the sawn ends of tibia and fibula, it is held in place by suturing 
 the adjacents margins of periosteum with absorbable sutures, as indicated 
 in Fig. 362, B. The skin-flap is finally turned down and sutured to the 
 transversely divided skin posteriorly. 
 
 SURGICAL ANATOMY OF THE KNEE-JOINT. 
 
 Bones. — Conchies of lemur; tuberosities of tibia; head of fibula; patella. 
 
 Articulations and Ligaments. — (a) External Ligaments — anterior, or 
 ligamentum patellae; fibrous expansion of extensor tendons (central and two 
 lateral portions); posterior, or ligamentum posticum Winslowii; internal 
 lateral; anterior external lateral; posterior external lateral; capsular, (b) 
 Internal Ligaments — anterior, or external crucial; posterior, or internal 
 crucial; internal semilunar fibro-cartilage; external semilunar fibro- cartilage; 
 transverse; coronary ligaments; and synovial membrane (with the prolonga- 
 tions, ligamentum mucosum and ligamenta alaria). 
 
 Muscles. — See under Muscles of Leg (page 416) and those of Thigh 
 (page 436) • 
 
 Arteries. — Following branches from femoral — anastomotica magna; 
 terminal branch of profunda; descending branch of external circumflex. 
 Popliteal and following branches — superior and inferior muscular; cutaneous; 
 superior external articular; superior internal articular; azygos articular; 
 inferior external articular; inferior internal articular. Following branches 
 from anterior tibial — anterior tibial recurrent. 
 
 Veins. — Superficial: — internal saphenous and tributaries; external saphe- 
 nous and tributaries. Deep: — popliteal; two venae comites to each artery 
 below the knee; one vena comes to each artery above the knee. 
 
 Nerves. — (a) From nerves of lumbar plexus: — From external cutaneous: 
 — anterior branch. From anterior crural: — middle cutaneous; anterior and 
 posterior branches of internal cutaneous branch; internal saphenous; nervus 
 cutaneus patellae branch of internal saphenous; muscular branches; articular 
 branches, (b) From Sacral Plexus: — Small sciatic branches. From great 
 sciatic; — internal popliteal, and its articular, muscular, and communicans 
 poplitei branches; external popliteal (peroneal) and its articular branches. 
 
 Synovial Membrane of Knee-joint. — Beginning at the upper border 
 of the patella and following the capsule of the joint upward, it forms a large 
 cul-de-sac beneath the quadriceps extensor tendon, on the anterior aspect 
 of the thigh, for a distance of 5 to 6.5 cm. (2 to 2^ inches) above the articular 
 surface of the femur, which generally communicates with a synovial bursa 
 between the tendon and front of the femur above the level of the attachment 
 of the capsular ligament. Having invested the circumference of the lower 
 end of the femur, it is reflected upon the fibrous covering of the joint formed 
 by the capsular, posterior, and lateral ligaments, extending on each side 
 of the patella beneath the aponeurosis of the vastus internus and externus 
 (especially the former). Below the patella the synovial membrane is separated 
 from the anterior ligament by the capsular ligament and adipose tissue. 
 From the capsule, the synovial membrane extends down to the semilunar 
 cartilages, covering their upper surface, free border, and inner surface, and 
 forming a cul-de-sac between the groove on the back part of the external 
 semilunar cartilage and the popliteus muscle, extending down to the tibio- 
 fibular ligament, constituting a bursa for the play of the popliteus tendon. 
 
SURFACE FORM AND LANDMARKS OF KNEE-JOINT. 431 
 
 It is reflected from the under surface of the semilunar cartilages onto the 
 coronary ligaments, thence to the head of the tibia and a short way around 
 its circumference. The inner surface of the ligaments enclosing the joint 
 is covered by synovial membrane, and the crucial ligaments are surrounded 
 by it, except where in contact with other structures (and hence excluded 
 from the synovial cavity). Posteriorly a pouch is prolonged between the 
 outer head of the gastrocnemius and the external condyle of the femur, and 
 one between the internal head of the gastrocnemius and the internal condyle 
 of the femur. For prolongations of the mucous membrane as ligamentum 
 mucosum and ligamentaria alaria, see under Ligaments. 
 
 Bursae About the Joint.— (a) In Front:— (1) Between patella and skin, 
 
 (2) Between upper part of tuberosity of tibia and ligamentum patella\ (3) 
 Between lower part of tuberosity of tibia and skin, (b) On Outer Side: — 
 (1) Beneath outer head of gastrocnemius (sometimes communicating with 
 joint). (2) i\bove external lateral ligament, between it and tendon of biceps. 
 
 (3) Beneath external lateral ligament, between it and tendon of popliteus 
 (sometimes only an expansion from following bursa). (4) Beneath tendon 
 of popliteus, between it and condyle of femur (generally an extension from 
 synovial membrane), (c) On Inner Side: — (1) Beneath inner head of gastroc- 
 nemius, with prolongations between tendons of gastrocnemius and semi- 
 membranosus (often communicating with joint). (2) Above internal lateral 
 ligament, between it and tendons of sartorius, gracilis, and semitendinosus. 
 (3) Beneath internal lateral ligament, between it and tendon of semimem- 
 branosus (sometimes only an expansion from following). (4) Beneath the 
 tendon of semimembranosus, between it and head of tibia. (5) Between 
 tendons of semimembranosus and semitendinosus (sometimes). 
 
 Structures in Relation with Knee-joint. — (a) Anteriorly: — quadriceps 
 extensor, (b) Posteriorly: — expansion from tendon of semimembranosus; 
 popliteal vessels; internal popliteal nerve; popliteus; plantaris; inner and 
 outer heads of gastrocnemius; lymphatic glands, (c) Externally: — quadriceps 
 extensor; tendon of biceps; tendon of popliteus; external popliteal nerve, 
 (d) Internally: — quadriceps extensor; sartorius; gracilis; semitendinosus; 
 semimembranosus. 
 
 Movements of Joint. — Flexion — by biceps, semitendinosus, semi- 
 membranosus — assisted by gracilis; sartorius; gastrocnemius; popliteus; 
 plantaris. Extension — by quadriceps extensor. Inward Rotation — by pop- 
 liteus; semitendinosus — assisted by semimembranosus; sartorius; gracilis. 
 Outward Rotation — by biceps. The cross-section of the knee is shown 
 in Fig. 362. 
 
 SURFACE FORM AND LANDMARKS OF KNEE-JOINT. 
 
 Bony landmarks — patella; condyles of femur; tuberosities of tibia; tubercle 
 of tibia; head of fibula. 
 
 To find the articular line of the knee-joint — cross the leg on the knee, 
 when the inner tuberosity of the tibia will project beyond the inner condyle 
 of the femur and make the articulation-line evident. The depression between 
 the outer tuberosity of the tibia and outer condyle of the femur may also 
 be made out. 
 
 The upper margin of the external tuberosity of the tibia, when the joint 
 is semiflexed, not only represents the articular line — but also the lower limit 
 of the synovial membrane of the knee-joint. 
 
43 2 
 
 AMPUTATIONS. 
 
 The knee-joint lies, about 2 cm. (f inch) above the prominence of the 
 tubercle of the tibia — and about opposite the transverse crease of skin in the 
 popliteal space. 
 
 When the limb is extended, the joint-line lies slightly above the apex of 
 the patella. When the limb is slightly flexed, an instrument passed hori- 
 zontally backward just below the apex of the patella will enter the joint. 
 
 In full extension the lower third of the patella rests upon the condyles 
 of the femur; — in full flexion, its upper third is in contact with the condyles; 
 —in semiflexion, the middle third of the patella rests upon the greatest prom- 
 inence of the femoral condyles. The apex of the patella, in extension, corre- 
 sponds with the upper margin of the tibia. 
 
 The axis of the femur inclines inward from the pelvis. The axis of the 
 tibia is vertical. 
 
 The inner aspect of the inner condyle faces, practically, in the same 
 direction as the head of the femur. 
 
 Internally, the inner condyle of the femur is more marked, and the inner 
 tuberosity of the tibia less. Externally, the outer tuberosity of the femur 
 is less marked, and the outer tuberosity of the tibia more. 
 
 The adductor tubercle of the femur is to be felt at the upper part of the 
 inner condyle — and marks the lower epiphysis. 
 
 The upper border of the tubercle of the tibia is on a level with the upper 
 aspect of the head of the fibula. 
 
 The head of the fibula may be felt at the outer and back part, in the 
 depression between the tendon of the biceps above, and the peroneus longus 
 below. 
 
 The hollow of the popliteal space exists only upon flexion — disappearing 
 upon extension. 
 
 The synovial membrane of the knee-joint separates the upper part of 
 the ligamentum patellae (quadriceps extensor tendon) from the knee-joint — 
 a bursa separates it from the tubercle of the tibia — and another bursa lies 
 between the patella and the skin. 
 
 The synovial membrane extends anteriorly for 5 to 6.5 cm. (2 to 2\ inches) 
 above the joint — and, internally, for about 7.5 cm. (3 inches) above the 
 joint (about 2.5 cm., or 1 inch, above the patella). 
 
 Popliteal structures detectable by palpation — (a) Outer side: — ilio-tibial 
 band, tendon of biceps, external popliteal nerve (close to preceding), (b) 
 Inner side: — tendon of semitendinosus (slender), tendon of semimembranosus 
 (thicker), gracilis (appearing as one tendon with preceding, unless manipu- 
 lated), sartorius (at extreme inner side, detectable by putting into action). 
 
 The lower epiphysis of the femur unites about the twentieth year, and 
 the epiphyseal line is intracapsular. The upper epiphysis of the tibia unites 
 about the twentieth year — and the epiphyseal line is extracapsular, and 
 includes the tuberosities and tubercle of the tibia. The epiphysis of the 
 upper end of the fibula unites about the twenty-fifth year. 
 
 GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATION AT 
 
 THE KNEE-JOINT. 
 
 Following disarticulation through the knee-joint, a stump usually results 
 which is capable of bearing direct pressure (which, as a rule, stumps of the 
 femur above the condyles cannot do), and which takes an artificial limb better 
 — the disarticulation being preferable to an amputation through the femoral 
 condyles, or higher. 
 
DISARTICULATION AT KNEE-JOINT, IN GENERAL. 
 
 433 
 
 Instrument-makers generally object to a limb disarticulated at the knee, 
 as the artificial knee then comes in the upper part of the leg. In spite of 
 this, however, and because of the reasons above given, disarticulation should 
 be done in preference to amputation through the thigh. 
 
 It is not necessarv to remove the remains of the synovial membrane, 
 or the articular cartilages — but the knee-joint should be free of disease. 
 
 The semilunar cartilages should not be removed — as they give a square, 
 or flat, surface to rest upon, and help hold down the synovial capsule. 
 
 The patella should not be removed — as it affords rotundity and firmness, 
 and the attachment of the quadriceps extensor tendon is thereby retained. 
 
 Fig- 363.— Cross-section of the Right Thigh through the Condyles and Patella: — 
 A, Biceps; B, Popliteal artery, vein, and internal popliteal nerve; C, Outer head of the gastroc- 
 nemius; D, External popliteal nerve; E, Sartorius; F, Inner head of the gastrocnemius; G, 
 Semimembranosus; H, Tendon of semitendinosus; I, Tendon of gracilis. (The cross-section 
 modified from Braune.) 
 
 DISARTICULATION AT KNEE-JOINT, IN GENERAL. 
 Best Methods.— Bilateral Hooded Flaps — Stephen Smith's Method. 
 Other Methods. — Elliptical Method (Bauden's) — forming an anterior 
 flap. Oblique Circular — forming an anterior flap. Long Anterior Flap. 
 Long Posterior Flap. Bilateral Skin-flaps (Pick's operation). Equal 
 Anterior and Posterior Flaps. Lateral Flaps. Long Anterior and Short 
 Posterior Flaps. 
 28 
 
434 AMPUTATIONS. 
 
 DISARTICULATION AT KNEE-JOINT 
 
 BY BILATERAL HOODED FLAPS — STEPHEN SMITH. 
 
 Description. — The same, in principle, as the amputation through the 
 upper part of the leg by the same method — except, as originally planned, 
 the present operation furnishes a covering of skin and fascia only. For its 
 modification, see Comment. 
 
 Position. — As in the operation through the leg (page 427) — with the 
 minor changes suggested by the higher elevation. 
 
 Landmarks. — Knee-joint articulation; tubercle of tibia. 
 
 Incision. — The highest point of the posterior incision is opposite the 
 joint-line; — and the highest point of the anterior incision is 2.5 cm. (1 inch) 
 below the tuberosity of the tibia. The surgeon's left thumb marks the 
 anterior, and his index the posterior points, as in the last operation. The 
 incision begins posteriorly (the surgeon wielding his knife as in the above 
 operation) in the mid-popliteal space, opposite the interarticular line, as 
 defined by the tip of his left index — passes thence vertically down the mid- 
 posterior aspect for a short distance (about 5 cm., or 2 inches) — thence 
 gradually diverges from the median line as it sweeps downward and outward 
 over that side of the limb further from the surgeon (and over which he is 
 leaning) until about 5 cm. (2 inches) below the tubercle of the tibia, cutting 
 a flap with convexity downward — thence curves forward and slightly upward 
 to a point in the median line 2.5 cm. (1 inch) below the tibial tubercle, thus 
 ending the outline of the further flap. The knife again enters posteriorly 
 at the same point, and makes a similar incision upon that side of the limb 
 nearer the operator — calculating that the internal flap is slightly larger, to 
 cover the larger internal femoral condyle — and meeting the first incision at 
 the median line in front. The limb is rotated outward while the inner incision 
 is being made — and vice versa. The knee is extended throughout (Fig. 
 364, B). 
 
 Operation. — The skin and fascia are now freed all around and dissected 
 up from the muscles and tendons. The ligamentum patellae is cut trans- 
 versely against the tuberosity of the tibia as soon as reached. The skin and 
 fascia flaps are retracted up to the joint-line. Incise, transversely, the struc- 
 tures along the upper margin of the tibia, on the anterior and lateral aspects 
 — ilio-tibial band, tendons of sartorius, gracilis, semitendinosus, biceps, the 
 lateral ligaments — and, lastly, cut the coronary ligaments, binding down the 
 semilunar cartilages, attacking them upon the sides of the joint — entering 
 the joint between the head of the tibia and the semilunar cartilages, thus 
 leaving these cartilages in the stump, and completing their separation by 
 flexing the knee. Flex the knee and cut the crucial ligaments. Extend 
 the knee and divide transversely, with one sweep of a long knife, all the soft 
 parts opposite the posterior aspect of the joint — the gastrocnemius, popliteus, 
 hamstring tendons, popliteal vessels and nerves, and posterior ligament. 
 Ligate the popliteal artery and vein, sural, superior articular, and anastomotica 
 magna branches. Suture the lateral flaps in a vertical line — the scar being 
 eventually drawn into the intercondyloid notch. Drain temporarily through 
 the upper end of the posterior incision. 
 
 Comment. — The original technic may be advantageously modified by 
 dissecting up the lower ends of the flaps for about 2.5 cm. (1 inch) — then 
 dividing all the soft parts circularly and retracting these to the joint-line, 
 
DISARTICULATION AT KNEE-JOINT. 
 
 435 
 
 including their fibrous attachments as far as possible — and then disarticulate. 
 A much more substantial covering is thus gotten for the femoral condyles. 
 Wherever it is possible to quilt muscle tissue into apposition, this should 
 be done. 
 
 Fig. 364.— Amputations apout the Leg and Thigh : — A. Through upper third of leg, by equal 
 lateral flaps; B, Disarticulation at knee, by bilateral hooded flaps (Stephen Smith's operation 1; C, 
 Through lower part of thigh, by oval method. 
 
 DISARTICULATION AT THE KNEE-JOINT BY AN OBLIQUE CURVED 
 
 INCISION. 
 
 Description. — An anterior covering of soft parts, including the patella, 
 is here furnished. 
 
 Position.— As in the disarticulation of Stephen Smith, page 434. 
 
 Landmarks. — Knee-joint line; tibial tubercle. 
 
 Incision. — Begins posteriorly opposite the level of the joint and ends 
 anteriorly about 8 cm. (3 inches) below the tubercle of the tibia — the line 
 curving between these two elevations. If the limb be held in such a way as 
 to cause the leg to make an angle of 135 ° with the thigh, the continuation of 
 the posterior aspect of the long axis of the thigh will represent the line of the 
 incision. 
 
436 AMPUTATIONS. 
 
 Operation. — Divide skin and fascia along the above line and dissect 
 these soft parts up to the level of the joint anteriorly. Incise the capsular 
 ligament, after having divided the ligamentum patellae. Cut through the 
 lateral ligaments and semilunar cartilages, leaving the latter upon the stump. 
 Divide the crucial ligaments at their attachment to the spine of the tibia. 
 Divide the soft parts posteriorly and the posterior part of the capsule along 
 the upper border of the tibia, including the vessels, thus completing the 
 disarticulation. The popliteal artery and vein and articular and muscular 
 branches are here ligated — and the nerves drawn down and cut short. Tem- 
 porary drainage of the portion of the joint and bursal surfaces left upon the 
 thigh is necessary. 
 
 SURGICAL ANATOMY OF THIGH. 
 
 Bones. — Femur. 
 
 Muscles of Thigh and Hip-joint. — (a) Muscles of Iliac Region: — 
 psoas magnus; psoas parvus; iliacus. (b) Of Anterior Femoral Region: — 
 tensor vaginae femoris; sartorius; rectus femoris; vastus externus; vastus 
 internus and crureus; subcrureus. (c) Of Internal Femoral Region: — 
 gracilis; pectineus; adductor longus; adductor brevis; adductor magnus. (d) 
 Of Gluteal Region: — gluteus maximus; gluteus medius; gluteus minimus; 
 pyriformis; obturator internus; gemellus superior; gemellus inferior; quadratus 
 femoris; obturator externus. (e) Of Posterior Femoral Region: — biceps; 
 semitendinosus ; semimembranosus. 
 
 Arteries of Thigh. — Femoral and following branches: — superficial epi- 
 gastric; superficial circumflex iliac; superficial external pudic; deep external 
 pudic; profunda (with external circumflex, internal circumflex, and three 
 perforating branches); muscular; anastomotica magna. And also arteries 
 given under the supply to the hip-joint (page 450). 
 
 Veins of the Thigh. — Superficial — internal saphenous and tributaries 
 (especially external and internal femoral cutaneous). Deep — one vena comes 
 to each artery on anterior, internal, and external aspects; two venae comites 
 to each artery on posterior aspect and gluteal region. 
 
 Nerves of Thigh. — (a) From Dorsal Nerves: — lateral cutaneous branch 
 of last dorsal, (b) From Posterior Divisions of Lumbar Nerves: — cutaneous 
 nerves from external branches of three upper posterior divisions, (c) From 
 Lumbar Plexus: — ilio-hypogastric ; ilio-inguinal; genito-crural; external cu- 
 taneous; anterior crural; obturator; accessory obturator. (d) From Sacral 
 Plexus: — muscular; superior gluteal; inferior gluteal; perforating cutaneous; 
 pudic; small sciatic; great sciatic (with internal and external popliteal 
 branches). The cross-sections of the thigh are shown in Figs. 365, 50, 371, 
 
 373, 47- 
 
 SURFACE FORM AND LANDMARKS OF THIGH. 
 
 The only portions of the femur which can be felt are the outer surface 
 of the great trochanter; internal and external condyles, with the tuberosities 
 upon each; and the adductor tubercle at the upper part of the inner condyle. 
 
 The rami of the pubes and ischia, from the pubic spines to the ischial 
 tuberosities, mark the boundary between the thigh and perineum. 
 
 The head of the femur lies close below Poupart's ligament, just to the 
 outer side of its center. 
 
SURFACE FORM AXD LANDMARKS OF THIGH. 437 
 
 The.femur is nearest the external aspect of the thigh in its upper third— 
 about the center in the middle third — and nearest the anterior, or antero- 
 external, aspect in the lower third. 
 
 The shaft of the femur is nearest the surface and is most easily reached 
 in its lowest third, in the interval between the vastus externus and biceps. 
 
 The articular surface extends higher on the anterior aspect of the external 
 than on the internal condyle of the femur. 
 
 A transverse section of the femur at the level of the adductor tubercle 
 touches the upper limit of the articular cartilage and corresponds with the 
 epiphyseal line. 
 
 The medullary canal is only present distinctly in the middle two-fourths 
 of the shaft of the femur. 
 
 The thigh is separated from the abdomen by the inguinal furrow, the 
 bottom of which furrow is formed by Poupart's ligament, at the meeting 
 of the aponeurosis of the external oblique and fascia lata. 
 
 The skin is coarse and thick on the external aspect of the thigh — fine and 
 thin on the inner aspect — and loosely adherent throughout, though more 
 adherent at the intermuscular septa. 
 
 Dense fascia underlies the skin throughout. 
 
 The outline of a transverse section of the thigh is irregular in the muscular 
 — and more or less rounded in the stout, non-muscular, and in children. 
 
 Most of the muscles of the femoral region are attached to the femur — 
 but the semitendinosus, semimembranosus, sartorius, and gracilis are entirely 
 free, and the biceps nearly so — therefore very unequal retraction follows their 
 section, especially on the posterior and internal aspects. 
 
 The rectus femoris forms a prominence below the anterior superior iliac 
 spine, in the angle of divergence between the sartorius and the tensor vaginae 
 femoris — and largely forms the convex front of the thigh as it descends down- 
 ward. A furrow on either side separates it from the vasti. 
 
 The vastus externus forms a flattened plane on the outer aspect of the 
 thigh, traversed by a vertical groove formed by the ilio-tibial band. 
 
 The vastus internus forms an eminence on the inner side of the lower 
 half of the thigh. 
 
 When the sartorius is relaxed, a depression exists between the extensor 
 quadriceps and the adductor muscles, running downward and inward, from 
 the apex of Scarpa's triangle to the inner side of the knee — which corresponds 
 with this muscle. 
 
 The adductor muscles, together with the gracilis, form the fullness of the 
 inner aspect of the upper part of the thigh and are not to be separately identi- 
 fied—except the upper tendon of the adductor longus (near the pubic spine), 
 and the lower tendon of the adductor magnus (near the adductor tubercle, 
 between the vastus internus and sartorius). 
 
 The muscles on the inner aspect of the thigh are not distinctlv marked 
 off from those on the posterior femoral aspect. But the muscles on the 
 antero-external aspect are more distinctly marked off from the posterior 
 femoral muscles by the external intermuscular septum. 
 
 The tensor vaginae femoris extends downward and slightly backward 
 from the upper part of the outer side of the thigh — and is continued down 
 the thigh as the ilio-tibial band — which forms a furrow to the outer side 
 of the knee. 
 
 The hamstring muscles descend from beneath the fold of the buttock, 
 diverging as thev pass downward to form the boundaries of the popliteal 
 space — the biceps forming the outer hamstring — and the semitendinosus, 
 
43 8 AMPUTATIONS. 
 
 semimembranosus, and gracilis (in order, from within outward) forming the 
 inner hamstring. 
 
 For the landmarks of Scarpa's triangle and the femoral artery, see pages 
 92 and 93, respectively. 
 
 The head of the femur joins the shaft at the eighteenth year; — the great 
 trochanter, the same; — the lesser trochanter, at the thirteenth or fourteenth 
 year; — and the lower extremity joins the shaft at the twentieth year. 
 
 The growth, in length, of the lower extremity is chiefly from the lower 
 epiphysis of the femur and the upper epiphysis of the tibia and fibula. 
 
 GENERAL SURGICAL CONSIDERATIONS IN AMPUTATIONS ABOUT 
 
 THE THIGH. 
 
 The thigh is usually amputated at or below its middle. 
 
 In the young, the preservation of whose epiphysis is important, division 
 of the bone should be below the lower epiphyseal line (transcondyloid) if 
 possible — and the covering gotten by a circular method of amputation. 
 
 Any length of stump left is better than a hip joint disarticulation — for 
 the function of the thigh-stump is partly to bear weight, but also to form a 
 lever to move an artificial limb — and the longer the lever, the better. 
 
 In amputating through the thigh, the chief weight of the body, as sup- 
 ported by an artificial limb, is borne against the tuberosity of the ischium — and 
 the chief pressure of the artificial apparatus is against the sides of the limb by 
 the sides of the hollow cone of the apparatus. A terminal scar is, therefore, 
 not contraindicated where a hollow form of artificial limb is intended. 
 
 Subtrochanteric amputation is preferable to disarticulation at the hip. 
 If it be found necessary in the course of such an operation, the amputation 
 could be converted into a disarticulation. 
 
 In amputating through the condyles (transcondyloid), the section is made 
 through the condyles on a level with the adductor tubercle of the femur. 
 
 In amputating just above the condyles (supracondyloid), the section is 
 made from 1.3 to 2 cm. (h to f inch) above the condyles. 
 
 Thigh amputations through the condyles can generally bear the pressure 
 of the body — while one through the shaft usually cannot. 
 
 The patella is removed in amputating through the condyles. 
 
 The general type of amputation through the thigh is by a longer anterior 
 and shorter posterior flap — at any level, but especially throughout the upper 
 two-thirds. 
 
 Greater retraction occurs upon the posterior and inner aspects of the 
 thigh, where additional allowances should be made. The lower the ampu- 
 tation through the thigh, the greater will be the retraction. 
 
 In planning a method which will give a terminal scar, dissect out any 
 nerves which might be pressed over the end of the bone. 
 
 In antero-posterior flaps cut above the center of the thigh, the femoral 
 and profunda arteries will be cut in the anterior flap; — in similar flaps below 
 the center of the thigh, the femoral artery will be cut in the posterior flap 
 and is in danger of being split; — and in amputations through the middle of 
 the thigh, the antero-posterior flaps should be shifted so as to become antero- 
 external and postero-internal, in order to avoid the risk of splitting the main 
 artery. 
 
 In longer anterior and shorter posterior flaps, as compared with equal 
 anterior and posterior flaps, the longer anterior flap drops over the end of 
 
SURGICAL CONSIDERATION'S IN AMPUTATIONS ABOUT THIGH. 439 
 
 the bone, and the shorter posterior flap is not heavy enough to sag backward — 
 as is apt to be the case in equal flaps (and especially in predominating posterior 
 flaps) . 
 
 Flaps are much more accurately fashioned if cut from without — and the 
 anterior one always should be. If the posterior one must be cut by trans- 
 fixion, first outline it through skin and fascia with a small knife, and then, 
 transfixing, cut outward on a line with the retracted skin and fascia. 
 
 Where speed is requisite (as in the very old, or in emergencv), the quickest 
 methods of amputating through the thigh, are, by the circular method through 
 
 Fig- 3 6 5- — Transverse Section through the Lower Third of the Right Thigh: — 
 A, Y;istus externus; B, D, Biceps; C, Great sciatic nerve and vessels; E, Semitendinosus; F, 
 Rectus; G, I, Vastus internus; H, Crureus; J, Femoral vessels and long saphenous nerve; K, 
 Sartorius; L, Adductor magnus; M, Semimembranosus; N, Gracilis. (The cross-section modi- 
 fied from Braune ) 
 
 the lower third; and antero-posterior flap cut by transfixion through the 
 upper two-thirds. 
 
 Owing to the extent and inequality of retraction of muscles in amputating 
 through all parts of the thigh, a conical stump is not uncommon. 
 
 Hemorrhage is controlled, in operating through the middle and lower 
 
440 AMPUTATIONS. 
 
 thirds, by a rubber tourniquet ordinarily applied, just below the hip-joint. 
 In amputating higher, the tourniquet should be applied as high as possible 
 in the form of a spica, passing around the groin and pelvis. In both cases, 
 especially the latter, the tubing should be held in place by a loop of bandage 
 previously laid under the tubing or tourniquet, anteriorly and posteriorly, 
 to be subsequently drawn upward. 
 
 The femur is to be carefully sawed at a right angle to its length — sawing 
 carefully near the linea' asperse, to avoid splintering. 
 
 The stump should be dressed with a posterior splint included and placed 
 upon an inclined plane, to relax the quadriceps extensor pull. 
 
 AMPUTATIONS THROUGH THE THIGH, IN GENERAL. 
 
 Best Methods. — Shorter Anterior and Longer Posterior Flaps (Lister's 
 Modification of Carden's operation) — for transcondyloid region. Longer 
 Anterior and Shorter Posterior Flaps (Gritti-Stokes's Method) — for supra- 
 condvloid osteoplastic operation. Long Anterior and Short Posterior Flaps 
 — for thigh throughout. Equal Anterior and Posterior Flaps — for thigh 
 throughout, where the tissue is limited. Oblique Circular, or Elliptical, 
 Method — for lower third. External Oval Method — for subtrochanteric 
 region. 
 
 Other Methods. — Long x\nterior Flap — Carden's transcondyloid opera- 
 tion. Long Anterior and Short Posterior Flaps — Farabeuf's Modification 
 of Carden's transcondyloid operation. Osteoplastic Transcondyloid Method 
 of Sabanajeff. Long Anterior Rectangular Flap — Gritti's osteoplastic supra- 
 condyloid operation. Circular. Modified Circular. Long Anterior Flap. 
 Oval Method — throughout. Bilateral Hooded Flaps of Stephen Smith — for 
 lower half. Rectangular Flaps of Teale — for lower half. 
 
 AMPUTATION THROUGH CONDYLES OF FEMUR— TRANSCONDYLOID 
 
 AMPUTATION 
 
 BY SHORTER ANTERIOR AND LONGER POSTERIOR FLAPS — LISTER'S MODIFICATION 
 OF CARDEN'S TRANSCONDYLOID OPERATION. 
 
 Description. — Carden's operation consists in a division of the femur on 
 a level with the adductor tubercle, together with the removal of the patella 
 — the covering being gotten from a single anterior flap. Lister's modification 
 consists in adding a posterior flap to the anterior flap, and then freeing the 
 soft parts considerably above the base of the flaps. 
 
 Position. — Patient on back; drawn down on table so that buttocks are 
 near, or are on, the edge of the table. Surgeon on outer side of right and 
 inner side of left limbs. One assistant steadies and supports the part below 
 the site of operation— and another holds the limb, or retracts the parts, above 
 the site of amputation. 
 
 Landmarks. — Adductor magnus tubercle; knee-joint; tubercle of tibia. 
 
 Incisions. — Anterior incision — crosses the front of the knee with slight 
 downward convexity — beginning on the horizontal line of the knee-joint and 
 in a vertical line with the prominences of the tuberosities of the femoral 
 condyles, and crossing the ligamentum patellae just above its center. The 
 left thumb and index mark the two ends of this incision, and the knee is 
 slightly flexed and rotated from side to side during its making. Posterior 
 
AMPUTATION ABOVE CONDYLES OF FEMUR. 441 
 
 incision— joins the posterior extremities of the anterior incision at an angle 
 of 45 degrees to the axis of the leg (Fig. 366, A, A'). 
 
 Operation.— These incisions pass through skin and fascia, and the flaps 
 outlined by them are then dissected upward as in a circular amputation. The 
 dissection is carried on close to muscles, tendons, and patella. The hamstring 
 muscles are cut as soon as encountered, dividing them transversely. The 
 quadriceps extensor tendon is similarly cut transversely as soon as the upper 
 border of the patella is reached. The soft parts, including as much of a 
 capsulo-periosteal covering as possible, are then retracted to the level of the 
 adductor tubercle. The condyles of the femur are then sawed through at 
 that level, transversely to the axis of the limb (not of the bone). Ligate the 
 popliteal, or its anterior and posterior tibial divisions, and muscular, articular, 
 and anastomotica magna branches. Suture the capsulo-periosteal covering 
 over the end of the bone. Suture the anterior and posterior flap margins 
 together. Dress the stump upon a posterior splint and place upon an inclined 
 plane. 
 
 Comment. — (i) The scar is drawn posteriorly, out of the way of pressure. 
 (2) The patella may be raised in the anterior flap and subsequently dissected 
 out, especially if the parts be thick and unyielding. 
 
 AMPUTATION JUST ABOVE CONDYLES OF FEMUR, WITH SPLITTING 
 
 OF PATELLA, 
 
 BY LONGER ANTERIOR AND SHORTER POSTERIOR FLAPS — GRITTI-STOKES'S SUPRA- 
 CONDVLOID OSTEOPLASTIC AMPUTATION. 
 
 Description. — Gritti's operation consists in the division of the femoral 
 condyles at the level of the adductor magnus tubercles; the removal of the 
 articular surface from the patella; the application of the sawed patella into 
 contact with the sawed femur; and the covering of the stump with a long 
 rectangular anterior flap. Stokes's modification consists in dividing the 
 femur 2 to 2.5 cm. (f to 1 inch) above the adductor tubercle (where the trans- 
 verse section of the femur more nearly corresponds with the size of the split 
 patella) — the stump being then covered by an anterior longer and posterior 
 shorter flap. The object being, in the latter case, to approximate bone- 
 sections of nearer similar size, and to bring them into contact with less tension. 
 
 Position — Landmarks. — As in the above operation. 
 
 Incisions. — Anterior longer flap — begins 2.5 cm. (1 inch) directly above 
 the prominence of one condyle and ends the same distance directly above the 
 prominence of the opposite condyle — crossing the front of the knee, with 
 broad curve, just below the tubercle of the tibia. Posterior shorter flap — 
 passes, in a broad curve, between the points of beginning and ending of the 
 anterior flap — being one-third the length of the anterior flap (Fig. 366, B, 
 B', B"). 
 
 Operation. — These flaps, having been outlined through skin and fascia, 
 are now dissected upward. The skin and fascia of the anterior flap is raised 
 from its lower edge until the ligamentum patelke is reached — which is cut 
 transversely — and the flap further freed and turned up with the patella in it. 
 The posterior flap of skin and fascia is then freed upward from the muscle 
 structures. These flaps are now retracted to the saw-line (2 to 2.5 cm., or 
 f to 1 inch, above the adductor magnus tubercle) and all the soft parts, in- 
 
44: 
 
 AMPUTATIONS. 
 
 eluding periosteum, are circularly divided to the bone, after which the bone 
 is sawed. The main vessels may be now tied before the section of the patella, 
 which is the most difficult part of the operation, is done. These vessels are 
 
 Fig. 366.— Amputations about Knee and Thigh : — A, Lister's modification of Garden's trans- 
 condyloid amputation of thigh; A'. Division ol femur in Lister's operation, on level with adductor 
 tubercle; B, Gritti-Stokcs's supracondyloid amputation of thigh ; with dotted lines, B' and B", show- 
 ing division of femur above level of adductor tubercle, and splitting of patella; C, Through lower 
 part of thigh, by long anterior and short posterior flaps. 
 
 the popliteal, muscular, articular, anastomotic^ magna. The patella is 
 grasped firmly by lion-jaw forceps, and held in such a way as to present its 
 articular surface horizontally. A section of the bone is made in such a 
 manner as to remove the articular surface of the patella. This is best accom- 
 plished with a narrow, thin saw. It may also be done with a broad chisel, 
 and, less satisfactorily, with cutting pliers. The cut surface of the patella 
 is then approximated to the sawed end of the femur. It may be held in 
 place by inserting two or three ivory or steel pegs through previously drilled 
 holes in the patella — or by wire or chromic gut suturing through drill-holes 
 near the margins of patella and femur — or by closely suturing fibrous parts 
 about the patella to the fibrous or periosteal parts about the lower end of the 
 femur. The anterior and posterior flaps are then sutured together. Firm 
 
FEMOROTIBIAL OSTEOPLASTIC AMPUTATION OF LOWER LIMB. 443 
 
 pressure is used against the stump, in the dressing, to aid in steadying the 
 patella against the femur. 
 
 Comment. — The scar is drawn up posteriorly out of the way of pressure. 
 This operation is comparable with Pirogoff's osteoplastic amputation of 
 the leg. 
 
 FEMOROTIBIAL OSTEOPLASTIC AMPUTATION OF THE LOWER LIMB 
 
 BY LONGER ANTERIOR AND SHORTER POSTERIOR FLAPS. 
 SSABANAJEFF'S OPERATION. 
 
 Description. — The limb is amputated through the condyles of the femur- 
 To this sawn surface a bone-flap, with adherent soft parts, is applied. The 
 osteoplastic flap is derived from the upper anterior aspect of the tibia. 
 
 Position. — As for disarticulation at the knee-joint (p. 434, in part). 
 
 Landmarks. — Head of fibula; internal lateral ligament; tubercle of tibia; 
 tibio-fibular articulation; knee-joint. 
 
 Fig. 367. — Ssabanajeff's Femorotibial 
 Osteoplastic Amputation of the Lower 
 Limb: — Lines of incision of the soft parts 
 outlining long anterior and short posterior 
 flaps. 
 
 Fig. 368. — Ssabanajeff's Femorotibial 
 Osteoplastic Amputation of the Lower 
 Limb: — Lines of bone-sections; — A, Portion of 
 femoral condyles removed; B, Rectangular 
 piece of tibia, with attached patellar tendon, 
 removed from tibia. (Modified from Ssaban- 
 ajeff.) 
 
 Incisions. — Anterior flap, — the vertical limbs pass down the mid-lateral 
 aspects of the leg, from the head of the fibula on one side, and the internal 
 lateral ligament on the other, to near the junction of the middle and upper 
 thirds of the limb, where they round out and meet in the anterior aspect of the 
 part. Posterior flap is similar in form and about half the length of the anterior 
 
 (Fig- 367)- , . , , . 
 
 Operation. — Having outlined both flaps through skin and fascia, the 
 
 posterior flap of skin and fascia alone is dissected up to the articulations 
 
444 AMPUTATIONS. 
 
 between tibia and fibula and between tibia and femur. The knee-joint and 
 the tibiofibular joint are now opened from behind. Divide the lateral, 
 posterior, and crucial ligaments, after having severed the overlying soft struc- 
 tures. The leg is now bent forward, so that the anterior surface of leg and 
 thigh lie in contact — thus exposing the ends of the bones for sawing. The 
 lower end of the femur is divided transversely through the expansion of the 
 condyles (Fig. 368, A). Finally, a bone-flap is made from the upper and 
 anterior aspect of the tibia as indicated in Fig. 368, B, with the attachment 
 
 Fig. 369. — Ssabanajeff's Femorotibial Osteoplastic Amputation or the Lower 
 Limb: — The rectangular portion of the excised tibia, with its attached tendon, is here shown 
 held in contact with the sawn femoral condyles by a kangaroo tendon or wire suture, passed 
 through the drilled bone. (Modified from Ssabanajeff.) 
 
 of the ligamentum patellae preserved, the saw travelling first down the long 
 axis of the tibia to below the attachment of the patellar ligament, thence 
 transversely outward to its anterior surface. The sawn surface of the tibial 
 bone-flap is then applied to the transversely sawn femoral condyles, the patellar 
 ligament hinging around the anterior aspect of the bone sections. The 
 femoral condyles and the tibial bone-flaps may be drilled and sutured with 
 kangaroo tendon, as indicated in Fig. 369, or the bony surfaces may be held 
 in contact simply by the peripheral suturing of the soft parts. The longer 
 anterior flap is now carried backward and sutured to the posterior flap, by 
 deep and superficial sutures. 
 
 AMPUTATION THROUGH LOWER THIRD OF THIGH 
 
 BY OBLIQUE CIRCULAR METHOD. 
 
 Description. — Owing to greater retraction upon the posterior and inner 
 aspects of the thigh, and in order, therefore, that the incision may eventually 
 occupy the same height around the entire circumference of the limb, the 
 circular incision is placed obliquely — so that it is lowest where the muscular 
 retraction is greatest, namely, at the postero-internal aspect of the thigh. 
 
 Position. — As in the transcondyloid operation. 
 
 Landmarks. — Saw-line. 
 
 Incision. — The highest part of the circular incision is antero-external 
 and is a little more than half the diameter of the limb (at the saw-line) below 
 the bone-section. The lowest part of the circular incision is postero-internal 
 and is little less than one diameter of the limb (at the saw-line) below the 
 
AMPUTATION THROUGH LOWER THIRD OF THIGH. 
 
 445 
 
 bone-section — the two calculations of covering thus providing i^ diameters 
 of covering in the aggregate. Such an incision is hard to follow unless pre- 
 viously marked (Fig. 370, A). 
 
 Operation.— The above incision through skin and fascia is made with 
 
 Fig.370— Amputations about Thigh and Hip-joint :— A, Through lower part of thigh, by oblique 
 circular method ; B, Disarticulation at hip-joint, by anterior racket. 
 
 two strokes of a long knife — the limb being conveniently rotated during the 
 manoeuvre, as described under the " Circular Method of Amputation," page 
 303. The skin and fascia are then obliquely retracted a short way, parallel 
 with the original incision — and the more superficial muscles circularly, or 
 
446 AMPUTATIONS. 
 
 slightly obliquely, divided. These are further retracted and the deeper mus- 
 cles circularly, or slightly obliquely, divided to and including the periosteum, to 
 the bone — cutting each time parallel with the skin incision. The skin, mus- 
 cles, and periosteum are freed up to just above the saw-line, and retracted— as 
 in the ordinary infundibular form of circular amputation — and the bone sawed. 
 The femoral, anastomotiea magna, descending branches of the external cir- 
 cumflex, perforating and muscular branches will be cut and require ligature. 
 The muscles are quilted in two tiers. The skin is sutured so as to make an 
 antero-posterior scar. 
 
 Comment. — (i) This may be called an elliptical method, as well as an 
 oblique circular. It is not appropriate except at the lower third of the thigh 
 — where it is excellent. (2) Where great difficulty is experienced in freeing 
 back the soft parts, the circular operation may be modified by adding one or 
 two short lateral vertical incisions, thus forming two antero-posterior in- 
 tegumentary flaps — and dividing the muscles circularly after retracting the 
 skin. This, however, constitutes the modified form of circular amputation. 
 
 AMPUTATION THROUGH LOWER, MIDDLE, OR UPPER THIRD OF 
 
 THIGH 
 
 BY LONG ANTERIOR AND SHORT POSTERIOR FLAPS. 
 
 Description. — Two U-shaped flaps of skin and muscle are raised, ante- 
 riorly and posteriorly — the latter being one-fourth the length of the anterior 
 and a little narrower at the base. 
 
 Position — Landmarks. — As in the above operation. 
 
 Incisions. — Anterior flap — is equal, in length, to i^ diameters of the 
 thigh at the saw-line, and, in width, a little more than ^ circumference. It 
 begins (on right side) (with thigh rotated outward) opposite the saw-line, 
 at about the middle of its inner aspect, or a fraction behind — passes vertically 
 down the inner side of thigh — rounds broadly across the anterior surface, 
 at a distance below the saw-line equal to 1^ diameters, and into the outer 
 aspect — and passes vertically upward (the thigh now rotated inward) to a 
 corresponding point on the opposite side. Posterior flap — begins and ends 
 at the upper limits of the anterior flap — rounding across the posterior surface 
 at a distance below the saw-line equal to a half-diameter — the surgeon's 
 hand passing beneath the thigh. In the above calculations, extra length is 
 allowed, because of the extra retraction (Fig. 366, C). 
 
 Operation. — The tissues outlined in the anterior flap are now picked up 
 by the surgeon's left hand, and, along the line of the retracted flap, the muscles 
 are divided obliquely from without inward and upward — so beveling the flap 
 that its extremity will consist of skin and fascia alone. The muscle tissue will 
 begin to enter into the formation of the flap just above the extremity, and in- 
 creases in thickness to the bone — into contact with which the incision will come 
 at about one-half to three-fourths the diameter of the femur below the saw-line, 
 at which level the whole thickness of the muscle will be represented. The 
 thigh is then elevated and the posterior flap similarly cut, being obliquely 
 beveled from without inward and from below upward, leaving skin and 
 fascia at the lower end of the 'flap and full thickness of the muscles at the 
 upper end, where the bone is reached the same distance below the saw-line 
 as in the anterior flap. At the level at which the bone has been reached in 
 the upward cutting of the flaps, a circular sweep of the knife around the 
 femur frees the periosteum. The soft parts, including the periosteum, are 
 
FLAP AMPUTATIONS OF THIGH. 
 
 447 
 
 then freed upward to just above the saw-line (which is everywhere easily 
 accomplished except at the linea aspera posteriorly) and the bone sawed'. 
 If the flaps have been made above the middle of the thigh, the femoral, pro- 
 funda, descending branches of the external circumflex, and muscular branches 
 will be cut in the anterior flap — and branches of the perforating arteries in 
 the posterior flap. If the flaps have been made below the middle of the 
 thigh, the descending branches of the external circumflex and muscular 
 branches will be cut in the anterior flan — and the femoral, anastomotica 
 
 Fig. 371. — Transverse Section through the Upper Third of the Left Thigh :— 
 P, Adductor longus; A, Gracilis; B, Obturator nerve and vessels; C, Deep femoral vessels; D, 
 Adductor magnus; E, Semimembranosus; F, G, Semitendinosus; H, Biceps; I, Sartorius; J, 
 Rectus; K, Superficial femoral artery, vein, and saphenous nerve; L, Vastus internus; M, Crureus; 
 N, Vastus externus; O, Gluteus maximus. (The cross-section modified from Braune.) 
 
 magna, and branches of the perforating in the posterior flap. Suture the 
 musculo-periosteal covering over the end of the bone. Quilt the heavy 
 muscles of the flaps in at least two tiers, with buried chromic gut sutures. 
 The anterior flap will drop over the end of the bone and be sutured to the 
 posterior flap. The flaps are well supported by the pressure of the dressing, 
 in which a posterior splint has been included — and the limb placed upon 
 an inclined plane. 
 
 Comment. — The flaps may be cut by transfixion, after outlining through 
 skin and fascia — but less satisfactorilv. 
 
44 8 
 
 AMPUTATIONS. 
 
 AMPUTATION THROUGH LOWER, MIDDLE, OR UPPER THIRD OF 
 
 THIGH 
 
 BY EQUAL ANTERIOR AND POSTERIOR FLAPS. 
 
 Description. — Same in all essential respects, except as to difference in 
 length of flaps, as amputation by long anterior and short posterior flaps. 
 
 Fig. 372. — Amputations about Thigh and at Hip-joint: — A, Through middle of thigh, by 
 equal anterior and posterior flaps ; B, Disarticulation at hip-joint, by external racket method ; C, At 
 hip-joint, by long anterior and short posterior flaps. 
 
 Position — Landmarks. — As in the last operation. 
 
 Incisions. — Anterior flap — is, in length, three-fourths the diameter of 
 the limb at the saw-line. Posterior flap — is, in length, one diameter of the 
 
AMPUTATION OF THIGH JUST BELOW THE TROCHANTERS. 449 
 
 limb — its greater retraction eventually reducing its length to that of the 
 anterior flap. The width of both is equivalent to half the circumference of 
 the limb at the saw-line (Fig. 372, A). 
 
 Operation. — As in the preceding. The vessels severed are also the same. 
 
 Comment. — (i) The method by equal flaps is indicated only where the 
 anterior tissues are limited. (2) Less sacrifice of length of limb is involved. 
 (3) These flaps are frequently cut by transfixion, without even outlining 
 through the integumentary tissues in advance — but such technic is not ad- 
 visable. 
 
 Fig- 373- — Cross-section through the Left Thigh at the Level of the Lesser 
 Trochanter: — A, Sartorius; B, Rectus; C, Superficial femoral artery, vein, and anterior crural 
 nerve; D, Profunda femoral artery and vein; E, Crureus; F, Iliacus; G, Tensor vagina? femoris; 
 H, Pectineus; I, Vastus externus; J, Sciatic nerve and artery; K, Semimembranosus; L, Biceps 
 and semitendinosus; M, Gluteus maximus; N, Adductor magnus; O, adductor brevis; P, Adduc- 
 tor longus; R, Gracilis. (The cross-section modified from Braune.) 
 
 AMPUTATION OF THIGH JUST BELOW THE TROCHANTERS 
 
 BY EXTERNAL OVAL METHOD. 
 
 Description.— Similar in principle to disarticulation of the hip-joint by 
 the external racket method (page 458) — except that the vertical incision 
 begins lower, and the bone is divided below the lesser trochanter. 
 
 Position. — As in disarticulation of the hip-joint by the external racket 
 method (page 458). 
 
 Landmarks. — Great trochanter; lesser trochanter. 
 29 
 
450 AMPUTATIONS. 
 
 Incision. — With the limb adducted, rotated in and slightly flexed, the 
 vertical portion of the incision begins over the prominence of the great tro- 
 chanter, in the mid-outer aspect of the limb — passes vertically down the outer 
 side of the thigh for about 10 cm. (4 inches) — thence the limbs of the oval 
 diverge to pass over the anterior and posterior aspects of the thigh and meet 
 in the center of its inner side, at a point about 5 cm. (2 inches) lower than the 
 lower end of the vertical incision. Thus an inverted Y is formed upon the 
 outer side of the thigh. 
 
 Operation. — The skin and fascia are dissected up along the oval portion 
 of the incision for about 5 cm. (2 inches). The vertical incision is then 
 deepened to the bone. Through the vertical incision the shaft is freed as 
 extensively as possible. The muscles are now circularly divided on a line 
 with the retracted skin and fascia. The soft parts are entirely freed from 
 the bone up to the saw-line — providing a musculo-periosteal covering when 
 near that line. The soft tissues are retracted and the femur sawed. Ligate 
 the femoral artery and vein, profunda artery and vein, internal circumflex, 
 descending (and possibly transverse) branch of external circumflex, comes 
 nervi ischiadici, and many muscular branches. Suture the musculo-periosteal 
 flap. Quilt the muscles with two tiers of gut sutures, along both vertical 
 and oval portions of incision. Suture skin in a horizontal line, forming 
 externo-terminal scar. Include splint in dressing and place on an inclined 
 plane. 
 
 SURGICAL ANATOMY OF HIP- JOINT. 
 
 Bones. — Os innominatum; femur. 
 
 Articulations and Ligaments. — Capsular (with following auxiliary 
 bands — pectineo-capsular, ilio-trochanteric, and ischio-capsular) ; ilio-femoral 
 (also an auxiliary portion of capsular ligament); ligamentum teres; cotyloid; 
 transverse; and synovial membrane. 
 
 Synovial Membrane of Hip-joint. — Beginning at border of carti- 
 laginous surface of head of femur — covers neck of femur within joint — is 
 reflected to inner surface of capsular ligament — covers both surfaces of 
 cotyloid ligament and fat at bottom of acetabulum — and is prolonged around 
 ligamentum teres to head of femur. 
 
 Muscles of Region of Hip-joint. — Mentioned in connection with the 
 Thigh (page 436). 
 
 Muscles in Relation with Hip-joint. — Anteriorly: — psoas and iliacus 
 Posteriorlv: — pyriformis; gemellus superior; obturator internus; gemellus in- 
 ferior; obturator externus; quadratus femoris. Superiorly: — straight and 
 reflected tendons of rectus; and gluteus minimus. Internally: — obturator 
 externus and pectineus. 
 
 Bursae in Relation with Hip-joint. — Between great trochanter and 
 gluteus maximus. Between vastus externus and gluteus maximus. Between 
 front of joint, and psoas and iliacus (often communicating with joint). 
 
 Movements of Hip-joint. — Flexion: — by psoas, iliacus, rectus, sar- 
 torius, pectineus, adductor longus, adductor brevis, anterior fibers of gluteus 
 medius, and minimus. Extension: — by gluteus maximus, biceps, semi- 
 tendinosus, semimembranosus, gracilis. Adduction: — by adductor magnus, 
 longus and brevis, pectineus, gracilis. Abduction: — by gluteus maximus, 
 medius and minimus. Inward Rotation: — anterior fibers of gluteus medius, 
 gluteus minimus, and tensor vaginae femoris. Outward Rotation: — posterior 
 fibers of gluteus medius, pyriformis, obturator externus, obturator internus, 
 
SURFACE FORM AND LANDMARKS OF HIP-JOINT. 451 
 
 gemellus superior and inferior, quadratus femoris, psoas, iliacus, gluteus 
 maximus, adductor magnus, longus and brevis, pectineus, sartorius. 
 
 Arteries of Region of Hip-joint.— (a) From Internal Iliac— obturator; 
 internal pudic; sciatic: ilio-lumbar; lateral sacral; gluteal, (b) From External 
 Iliac — deep circumflex iliac, (c) From Femoral — see Arteries of Thigh, 
 page 436- 
 
 Veins of Region of Hip-joint.— Superficial:— tributaries of internal 
 saphenous. Deep: — accompany corresponding arteries. See Veins of Thigh, 
 page 436. 
 
 Nerves of Region of Hip-joint.— (a) From Dorsal Nerves:— lateral 
 cutaneous branch of last dorsal, (b) From Posterior Divisions of Lumbar 
 Nerves: — cutaneous nerves from external branches of three upper posterior 
 divisions, (c) From Lumbar Plexus: — ilio-hypogastric, ilio-inguinal, genito- 
 crural, external cutaneous, anterior crural, obturator, accessory obturator, 
 (d) From Posterior Divisions of the Five Sacral and First Coccygeal Nerves: 
 — external branches, (e) From the Sacral Plexus: — muscular, superior 
 gluteal, inferior gluteal, perforating cutaneous, pudic, small sciatic, great 
 sciatic. The cross-section of the hip-joint is shown in Fig. 47. 
 
 SURFACE FORM AND LANDMARKS OF HIP-JOINT AND VICINITY. 
 
 Spine of the os pubis is palpable, and is nearly on a level with the upper 
 border of the great trochanter — and the upper border of the great trochanter 
 is on a level with the center of the hip-joint. 
 
 Top of the great trochanter is about 2 cm. (f inch) below the level of the 
 head of the femur. 
 
 Great trochanter is from 7.5 to 10 cm. (3 to 4 inches) below the iliac 
 crest, and a little in front of its center. 
 
 Head of the femur lies just below Poupart's ligament — and just external 
 to its center. 
 
 Nelaton's line runs from the anterior superior iliac spine to the most 
 prominent part of the tuberosity of the ischium. It runs through the center 
 of the acetabulum and indicates the level of the hip-joint. 
 
 Bryant's line — (with patient flat on back) — first line is dropped vertically 
 to the table, from the anterior superior iliac spine; — second line passes, in a 
 straight direction, in a line with the long axis of the thigh, from the top of 
 the great trochanter to meet first line; — third line runs from the anterior 
 superior iliac spine to the top of the great trochanter. On the damaged or 
 diseased side, the second line will be shortened. 
 
 Anterior superior iliac spine and the crest of the ilium are palpable. 
 
 Posterior superior iliac spine is marked by a depression on each side of, 
 and on a level with, the spinous process of the second sacral vertebra — and 
 is just behind the center of the sacro-iliac articulation. 
 
 The anterior inferior iliac spine is about 2 cm. (f inch) above the upper 
 border of the acetabulum: 
 
 Line from the posterior superior iliac spine to the outer part of the tuber- 
 osity of the ischium will cross the posterior inferior iliac spine nearly 5 cm. 
 (2 inches) below the posterior superior iliac spine — and the ischial spine 
 about 10 cm. (4 inches) below the posterior superior iliac spine. 
 
 Tuberosities of the ischia are palpable on either side of the anus, beneath 
 the lower border of the glutei maximi, especially when the hip is flexed. 
 They are covered, in standing, by the lower margin of the glutei maximi — 
 and, when sitting, by the dense skin and fascia alone. 
 
45 2 AMPUTATIONS. 
 
 Third sacral spine is on a level with the lowest limit of the spinal mem- 
 branes and the cerebrospinal fluid, and is opposite the upper border of the 
 great sacro-sciatic notch. 
 
 First piece of the sacrum is on a level with the spine of the ischium. 
 
 Apex of the coccyx is just behind the last piece of the rectum. 
 
 Gluteus maximus forms the rounded outline of the buttock — its lower 
 border being more oblique and higher than the fold of the buttock. A line 
 from the side of the coccyx to the lower border of the great trochanter corre- 
 sponds with the lower border of the gluteus maximus. 
 
 Fold of the buttock is caused by the creasing of the skin in flexion and 
 extension, and does not correspond with the lower margin of the gluteus 
 maximus but is lower and less oblique. 
 
 The antero-internal margin of the acetabulum is about 5 cm. (2 inches) 
 external to the pubic spine. 
 
 Edge of the great sacro-sciatic ligament can be felt by pressing deeply 
 under the lower edge of the gluteus maximus. 
 
 Femoral artery is separated from the capsule of the hip-joint by the psoas 
 magnus, upon which it rests. 
 
 For the landmarks of the gluteal, sciatic, and pudic arteries, see under 
 the Ligations of those arteries (pages 87, 84, and 85). 
 
 Ossification in the head of the femur begins at the end of the first year, 
 uniting with the shaft at the eighteenth year; — that in the great trochanter 
 begins in the fourth year, and that in the lesser trochanter at the thirteenth 
 to fourteenth year, uniting, in both cases, about the eighteenth year. The 
 epiphyseal line of the head of the femur is entirely within the capsular ligament. 
 
 GENERAL SURGICAL CONSIDERATIONS IN DISARTICULATION AT 
 
 THE HIP- JOINT. 
 
 The question of control of hemorrhage is the most serious problem in 
 hip-joint disarticulations. 
 
 The methods of hemorrhage-control are the following; — Wyeth's mattress- 
 neeclles and tourniquet; elastic tourniquet; preliminary ligation of femoral; 
 Senn's method; ligation of femoral during amputation; digital compression 
 of the femoral, or of the external iliac, above the amputation-site; digital 
 compression of the femoral in the flap, as cut; Trendelenburg's rod beneath 
 the femoral vessels, with rubber tubing wound in figure-of-eight fashion over 
 it; Thomas' Forceps Tourniquet. The first three of the above methods are 
 the best. Such methods as pressure of the abdominal aorta, either extra- 
 or intra-abdominally, or through the rectum, are now not usually resorted to. 
 
 Only some form of circularly surrounding tourniquet controls hemorrhage 
 from branches of the internal iliac, as well as from the femoral. When 
 hemorrhage is once controlled, any form of disarticulation may be adopted. 
 
 Manner of applying Wyeth's mattress-needles and tourniquet: — Two 
 steel needles from 3 to 5 mm. ( T 2 g to T 3 ? inch) in diameter and 25.5 cm. (10 
 inches) in length are inserted and capped with corks (to prevent their points 
 from injuring operator and assistants). The outer needle enters the tissues 
 of the outer aspect of the thigh 6 mm. Q inch) below and just to the inner 
 side of the anterior superior iliac spine — traverses the superficial muscles 
 and fascia upon the outer side of the hip, and emerges on a level with, and 
 about 7.5 cm. (3 inches) external to, the entrance. The inner needle enters 
 
GENERAL CONSIDERATIONS IN HIP-JOINT DISARTICULATION. 453 
 
 the tissues of the inner aspect of the thigh internal to the saphenous opening, 
 and about 1.3 cm. (£ inch) below the crotch — traverses the adductors — and 
 emerges 2.5 cm. (1 inch) below the tuberosity of the ischium. White rubber 
 
 Fig. 374. — Manner of Inserting the Wyeth Pins: — The outer pin. 
 
 tubing, about 7 mm. (J inch) in diameter, is wound tightly four or five times 
 around the thigh above the fixation-needles, and clamped. This rubber 
 
 -^^^ 
 
 
 /^ --c 
 
 \x 
 
 
 i mm 
 
 
 
 
 0% 
 
 * \ u C^j^ 
 
 
 »-. 
 
 
 
 
 Fig- 375- — Manner of Inserting the Wyeth Pins: — The inner pin. After both pins have been 
 inserted, the rubber tubing is applied above them, as shown in their use at the shoulder-joint. 
 
 band compresses the common femoral against the rim of the pelvis, anteriorly 
 — and the gluteal, sciatic, and internal pudic against the margin of the great 
 sacro-sciatic notch, posteriorly (Fig. 268, left hip). 
 
454 AMPUTATIONS. 
 
 Manner of applying the ordinary rubber tourniquet (Jordan Lloyd's 
 method) — First elevate the limb to a vertical position, and hold thus for a 
 few minutes, further aiding the emptying of blood from the limb by down- 
 ward massage. A strip of sterilized roller bandage is laid down the outer, 
 and one down the inner aspect of the thigh. A sterilized pad is placed over 
 the external iliac artery. Rubber tubing, about 1.8 m. (6 feet) long, is 
 passed around the thigh in several tight turns, over the pad and pieces of 
 roller bandage. The center of these turns is placed between the tuberosity 
 of the ischium and the anus (of the operated side) — the tubing being brought 
 up so as to pass over the center of the iliac crest. The two ends of the tubing 
 are finally grasped firmly in either hand and tightly drawn upward and 
 forward and made to cross each other above the center of the iliac crest. 
 At the point of crossing, an assistant, with the back of the hand (the right 
 hand for the left side, and vice versa) to the patient's body, grasps and holds 
 the crossed rubber band. Or the two ends may be carried around the trunk, 
 brought back again, and make a second similar traversing as the first spica 
 — the two ends being then tied, or clamped, above the center of the iliac 
 crest (of the same or opposite side). The two roller bandages forming the 
 two loops are now drawn upward to hold the tourniquet in place and lift it 
 further from the field of operation — one coming up from in front of the anterior 
 superior iliac spine, and the other from opposite the ischial tuberosity. The 
 anterior part of the tourniquet, running above and parallel with Poupart's 
 ligament, compresses the external iliac under the pad — the posterior part, 
 running across the great sacro-sciatic notch, compresses the gluteal, sciatic, 
 and internal pudic (Fig. 268, right hip). 
 
 Manner of preliminary ligation of femoral: — see under Ligations, page 
 93, and Figs. 268 (left thigh) and 46. 
 
 Manner of applving Senn's method of hemorrhage-control in disarticula- 
 tion at the hip-joint— A straight incision of about 20 cm. (8 inches) is made 
 over the central aspect of the great trochanter, in the long axis of the limb, 
 and commencing about 7.5 cm. (3 inches) above the superior border of the 
 great trochanter. As soon as the femur has been exposed and the head of 
 the bone disarticulated, a pair of hemostatic forceps is introduced closed 
 behind the femur, and on a level which would correspond with that of the 
 trochanter minor when in normal position (that is, prior to disarticulation) — 
 and is pushed inward and downward below the ramus of the ischium and 
 just posterior to the adductor muscles — until felt through the skin on the 
 inner aspect of the thigh, when an incision is made over its tip and the instru- 
 ment oressed on through. By opening the blades, the tunnel through the 
 soft parts is enlarged — and the forceps are then made to seize a piece of 
 rubber tubing at its center and draw the doubled portion backward through 
 the wound at the outer aspect of the thigh, leaving the free ends protruding 
 through the inner opening. The portion of the tube grasped by forceps is 
 then cut in two. The limb is now held elevated a few moments, during 
 which the return of blood to the trunk is further aided by downward massage. 
 The anterior half of the tube is then carried firmly around the anterior portion 
 of the soft parts and tied or clamped — and the posterior around the posterior 
 portion, and similarly tied or clamped — thus controlling all circulation prox- 
 imal to the tubing — the tubing being prevented from slipping by the tun- 
 neling of the soft parts. The operation is then completed. 
 
 The method by Trendelenburg's rod (Fig. 376) and Thomas' Forceps 
 Tourniquet (Fig. 377) are sufficiently described by their illustrations and 
 legends. 
 
GENERAL CONSIDERATIONS IN HIP-JOINT DISARTICULATION. 455 
 
 I 
 
 fig. 376. — Manner of Using Trendelenburg's Rod for the Control of Hemorrhage 
 in Amputations near the Hip-joint: — The rod is thrust through the limb beneath the femoral 
 vessels, which are then constricted by a rubber band wound in figure-of-eight fashion about the 
 rod. (The cross-section adapted from Braune.) 
 
 Where the disarticulation has been done by a method allowing of free 
 exposure of the femur in advance of disarticulation, the shaft can be largely 
 
 Fig. 377. — Thomas' Forceps Tourniquet for Controlling Hemorrhage During 
 Operations upon the Extremities: — The probe-pointed blade passes under the femoral 
 vessels, and the serrated blade over these structures — the former coming out through a pre- 
 viously cut exit, after which the blades are clamped. 
 
 freed subperiosteally — with the result that a sufficient growth of bone usually 
 occurs to enable the stump to be freely moved in all directions. 
 
456 AMPUTATIONS. 
 
 Temporary drainage is indicated — and should be provided through an 
 opening made posteriorly, if no dependent opening exist as a result of the 
 operation. 
 
 Sutures are left in an extra length of time — and the flaps are subsequently 
 temporarily supported by strapping. 
 
 The stump should be rather firmly bandaged and supported upon a 
 pillow. 
 
 DISARTICULATION AT HIP- JOINT, IN GENERAL. 
 
 Best Methods.— Wyeth's Method. External Racket Method. Anterior 
 Racket Method. 
 
 Other Methods. — Furneaux Jordan's Method (external vertical incision, 
 with circular division of muscles). Long Anterior and Short Posterior Flaps. 
 Equal Anterior and Posterior Flaps. Equal Lateral Flaps. Antero-internal 
 and Postero-external Flaps. Modified Circular Method. Single Internal 
 Flap. Esmarch's Method (circular division of muscles and bone, with 
 dissection out of the bone through an external vertical incision). 
 
 DISARTICULATION AT HIP- JOINT 
 
 BY WYETH'S METHOD. 
 
 Description. — Having controlled hemorrhage by means of rubber-tubing 
 wound around the thigh at its junction with the pelvis, above two large pins 
 introduced in a special manner, a circular incision is made around the thigh, 
 followed by a vertical external incision, and disarticulation at the hip-joint 
 accomplished. 
 
 Position. — Patient supine, drawn to foot of table until the sacrum rests 
 upon the corner, with hip projecting beyond, and kept from slipping from 
 table by being steadily held. Surgeon generally stands upon the outer side 
 of both, thighs, although it is more convenient to be upon the inner side of the 
 left limb. An assistant holds and manipulates the limb projecting over the 
 table. Another assistant steadies the pelvis and guards the method of hemor- 
 rhage-control. 
 
 Control of Hemorrhage. — Special pins are introduced in the manner 
 described under General Surgical Considerations (page 45 2). Previous to 
 the application of the pins, the limb should be constricted by an Esmarch 
 rubber bandage, from the toes to the hip-joint — unless contraindicated. 
 
 Landmarks. — Great trochanter; points for the passage of the pins (page 
 
 389)- 
 
 Incisions. — A circular incision is made around the thigh about 15.3 cm. 
 (6 inches) below the center of the anterior aspect of the rubber tourniquet. 
 The vertical incision passes vertically down the external aspect of the thigh, 
 directly over the great trochanter — passing in a straight line from the tourni- 
 quet to the circular incision (Fig. 378, B). 
 
 Operation. — The circular incision passes through skin and fascia alone. 
 These are dissected up to the level of the lesser trochanter— that is, for about 
 5 cm. (2 inches). At this level the muscles are circularly divided to the bone, 
 on a line with the retracted skin and fascia. The vertical incision is now 
 made from the tourniquet down to the circular division, passing directly 
 over the great trochanter. The larger vessels are at once tied— the femoral 
 and profunda arteries and veins, and any other prominent vessel. Through 
 
DISARTICULATION AT HIP-TOIXT. 
 
 457 
 
 the vertical incision, which has extended, at one sweep, directly through 
 skin, fascia, muscles, and periosteum to the bone, the soft parts are all cleared, 
 as subperiosteal!}- as possible, from the shaft and tuberosities of the femur. 
 Retract the soft parts and divide the capsular ligament transversely over its 
 
 Fig. 378.— Amputations through Thigh and at Hip-joint: — A, Through lower part of thigh, by 
 modified circular; B, Disarticulation at hip-joint, by Wyeth's method. 
 
 outer aspect. Manipulate the limb as a lever, nicking the cotyloid ligament 
 to let in air — cut the ligamentum teres — and disarticulate by thrusting the 
 head of the femur upward and outward. If not already severed, divide the 
 posterior aspect of the capsule, and any retaining structures — and remove 
 the limb. If the enucleation be difficult, which is rarelv the case in this 
 
458 AMPUTATIONS. 
 
 extensive exposure, the margin of the acetabulum can be chipped away 
 with a chisel sufficiently to let in air — or, if all the vessels be ligatured, 
 the tourniquet may be removed carefully and slowly and the disarticula- 
 tion completed. The remaining vessels in the posterior aspect of the wound 
 are now ligated — these are chiefly the branches of the sciatic, obturator, ex- 
 ternal and internal circumflex, and perforating. Having trimmed away all 
 tags of tissue, the heavy muscles are to be quilted together with especial 
 care, by means of two or three tiers of chromic gut sutures. Drainage is 
 to be established — the margins of the wound united in one continuous 
 termino-external suture-line — firm compression made in dressing the wound 
 — and the stump supported upon a pillow. 
 
 Comment. — This method probably represents the safest, simplest, and 
 best manner of disarticulating at the hip-joint. 
 
 DISARTICULATION AT HIP- JOINT 
 
 BY EXTERNAL RACKET METHOD. 
 
 Description. — The queue of the incision is placed over the external 
 aspect of the joint — the limbs of the incision encircling the anterior, internal, 
 and posterior aspects of the thigh. Hemorrhage is controlled by an ordinary 
 rubber tourniquet. 
 
 Position. — Patient is sufficiently turned to the opposite side to expose 
 the area, and is drawn to the end of the table so that the pelvis rests upon 
 the edge of the table and the hips project beyond — the limb is adducted, 
 rotated inward, and slightly flexed. Surgeon and 'assistants stand as in the 
 last operation. 
 
 Control of Hemorrhage. — For the description of the application of the 
 rubber tourniquet, see General Surgical Considerations, page 452. Also see 
 Hemorrhage-control, under the last operation, for reference to the Esmarch 
 bandage. 
 
 Landmarks. — Great trochanter. 
 
 Incision. — The queue begins about 5 cm. (2 inches) above the upper 
 border of the great trochanter — passes vertically down the limb, along the 
 posterior border of the great trochanter, for about 17 cm. (7 inches) — the 
 two limbs of the racket here diverge to encircle anteriorly and posteriorly, 
 meeting upon the center of the inner aspect of the thigh, about 5 cm. (2 inches) 
 lower down than the termination of the vertical portion of the incision — 
 forming an inverted Y on the outer aspect of the thigh. The limb is rotated 
 as the incision is made (Fig. 372, B). 
 
 Operation. — These incisions pass, at first, through skin and fascia only. 
 The skin and fascia of the oval portion of the incision are then dissected up 
 for about 5 cm. (2 inches). The vertical portion of the incision is now deep- 
 ened to the bone — with the limb in the original position. The anterior, 
 superior, and posterior borders of the great trochanter are cleared of muscles 
 in the order named — as subperiosteal^ as circumstances allow. The shaft 
 of the femur is cleared, as far as possible, to the extent of the vertical incision. 
 Adduct the limb strongly and divide the superior and posterior parts of the 
 capsule transversely — flex the limb and divide the anterior part of the capsule 
 — rotate outward and cut the round ligament — and then disarticulate. Having 
 ascertained that the tourniquet is compressing the parts well, after the dis- 
 articulation of the head of the femur, the muscles are circularly divided on 
 a level with the retracted skin and fascia of the oval incision. The important 
 
DISARTICULATION AT HIP-JOINT. 459 
 
 vessels are at once ligated — consisting of the femoral and profunda arteries 
 and veins, the internal circumflex (and possibly the transverse branch of the 
 external circumflex), comes nervi ischiadici, and muscular branches. The 
 muscles are quilted in two or three tiers, with buried chromic gut sutures, 
 along both the vertical and oval portions of the wound. The suture-line of 
 the skin margins will be termino-external, in one straight line. 
 
 Comment. — The approach to the bone is through a region less vascular 
 than by the anterior racket method. The hip-joint can be preliminarily 
 examined, in case disarticulation prove unnecessary. Disarticulation can 
 be effected before severing the vessels. The subperiosteal method can be 
 more easily carried out than by an anterior approach. The branches of the 
 internal pudic are comparatively little involved — there is a low transverse 
 division of the muscles — and good drainage is secured. The method is 
 probably better than disarticulation by the anterior racket method. 
 
 DISARTICULATION AT HIP- JOINT 
 
 BY ANTERIOR RACKET METHOD. 
 
 Description. — The queue of the racket, or oval, is placed anteriorly — 
 the limbs of the oval encircling the external, internal, and posterior surfaces. 
 No tourniquet is used. The femoral is ligated during operation, and the 
 remaining vessels as encountered. 
 
 Control of Hemorrhage. — Utilizing the queue of the incision, the common 
 femoral artery and vein are exposed and ligated — during the progress of 
 the operation. Other vessels are secured as exposed. 
 
 Position. — Patient supine — otherwise as in the external racket method 
 (page 458). 
 
 Landmarks. — Center of Poupart's ligament; course of femoral artery. 
 
 Incision. — The queue begins at the center of Poupart's ligament — 
 passes down along the femoral artery for about 7.5 cm. (3 inches) — thence 
 curves inward and crosses the inner aspect of the thigh about 10 cm. (4 inches) 
 below the genito-crural fold — continues across the posterior aspect of the 
 thigh — crosses the outer side of the limb a short distance below the base of 
 the great trochanter — and thence ascends upward and inward obliquely 
 across the anterior aspect to join the vertical incision about 5 cm. (2 inches) 
 below its commencement at Poupart's ligament (Fig. 370, B). 
 
 Operation. — This incision passes well through skin and fascia only, 
 which are allowed to fully retract — and is made with several sweeps of the 
 knife, while the limb is manipulated as indicated. Through the vertical 
 portion of the racket incision, the common femoral artery and vein are early 
 exposed and each ligated in two places and severed between the ligatures. 
 The skin and fascia are fully freed around the entire incision, without any 
 special dissection. The muscles on the outer side (sartorius, rectus, tensor 
 vagina? femoris) are divided and the external circumflex artery doubly ligated 
 and severed. Passing backward, rotate the thigh inward and cut the insertion 
 of the gluteus maximus. Passing forward, rotate the thigh outward and 
 cut the psoas — and retract the parts and doubly ligate and divide the internal 
 circumflex artery. Divide the muscles of the internal flap on a level with 
 the retracted skin (pectineus, gracilis, and adductors), ligating the muscular 
 branches. Adduct and rotate the thigh inward — severing the muscles attached 
 to the great trochanter. Abduct and rotate the thigh outward — cut the 
 capsule transverselv — disarticulate — sever the round ligament — and the 
 
460 AMPUTATIONS. 
 
 obturator externus tendon, if still undivided. The head of the bone is now 
 drawn forward and outward — a long knife is carried behind the bone, passing 
 downward and backward and dividing the remaining parts at the posterior 
 aspect, on a level with the retracted skin (hamstrings, parts of the adductors 
 and sciatic nerve) — ligating the perforating and muscular branches. The 
 muscles are quilted in two or three tiers — after having severed all tags of 
 tissue and instituted drainage. The margins of skin are sutured in a single 
 vertical line. The stump is dressed as in the preceding operations. 
 
 Comment. — While possessing many good points in common with the 
 method by external racket incision, the anterior racket method possesses the 
 further advantage that the hip-joint is more easily and directly reached, and 
 disarticulation more readily accomplished. No special form of tourniquet 
 control is necessary. There is, however, not so good an opportunity afforded 
 for a preliminary examination of the hip-joint, with possible excision sub- 
 stituted for amputation. The operation is longer, owing to the slower hemor- 
 rhage-control. 
 
 INTERILIO-ABDOMINAL AMPUTATION 
 
 BY AX INTERNAL FLAP KEEN'S OPERATION. 
 
 Description. — Consists of the removal of the entire lower extremity, 
 with a portion or all of the ilium. Indicated in extensive growths in the 
 region of the hip-joint. 
 
 Position. — The patient is supine, with the hip-joint projecting over the 
 end of the table, during the outlining and making of the internal flap — and 
 is then turned toward the opposite side during the exposure of the iliac portion 
 of the wound. 
 
 Landmarks. — Spine of pubis; Poupart's ligament; crest of the ilium; 
 posterior superior iliac spine. 
 
 Incision. — Iliac incision extends from the spine of the pubis, 2 cm. (f in.) 
 above and parallel with Poupart's ligament and the crest of the ilium to about 
 its middle. Subsequently, after ligating the internal iliac artery, this incision 
 is continued around nearly to the posterior superior iliac spine. Thigh incision 
 begins just external to the middle of Poupart's ligament and passes downward 
 to a point a little below the middle of the thigh — then horizontally to the 
 median line of the thigh posteriorly — and then upward to the posterior end of 
 the first incision, i. e., slightly external to the posterior superior iliac spine 
 
 (Fig- 379)- 
 
 Operation. — (1) Having divided skin, fascia, and muscles in the incision 
 extending from the pubic spine, just above and parallel with Poupart's liga- 
 ment and the iliac crest to about its middle, the internal iliac artery is exposed 
 extra-peritoneally and ligated. (2) The long internal flap is now made. 
 The incision is made just external to the center of Poupart's ligament, in order 
 to preserve the femoral vessels — passing thence vertically down the anterior 
 aspect of the thigh to just below its middle — where it rounds horizontally 
 outward to the mid -posterior aspect — and thence vertically upward to the 
 posterior end of the horizontal incision. Having outlined this incision through 
 skin and fascia, it is deepened to the bone. At the transversely divided mus- 
 cles, the femoral vessels are tied. This long internal flap, when turned upward 
 and outward, will form the outer wall of the pelvis and will be the barrier 
 against intestinal hernia. (3) Division of the muscles inserted into the crest 
 of the Ilium;— Having continued the first part of the iliac incision nearly to 
 the posterior superior iliac spine, all of the muscles of the anterior, lateral, 
 
INTERILIO-ABDOMINAL AMPUTATION. 
 
 461 
 
 and posterior abdominal wall lying beneath this incision are divided down 
 to the peritoneum, the opening of which is carefully avoided. (4) The 
 psoas magnus and iliacus internus are now separated from the internal aspect 
 of the ilium, to be left with the trunk. If they be involved in the tumor-mass, 
 they are to be sacrificed. (5) Removal of the bone; — The horizontal and 
 descending rami of the pubic bone are divided — instead of disarticulating at 
 
 Pig. 379 . — Lines of Incision for Keen's Interilio-abdominal Amputation. 
 
 the symphysis. The attachment of the rectus abdominis is thus preserved, 
 and consequently the firmness of support given thereby to the abdominal 
 viscera. In order to preserve the sexual power in the male, the descending 
 pubic ramus should be divided below the attachment of the corpus cavernosum 
 of that side. Much time, difficulty, and hemorrhage are also saved in thus 
 avoiding the separation of the rectus muscle and corpus cavernosum, and the 
 disarticulation at the symphysis pubis. The ilium is now divided posteriorly 
 by sawing from the crest of the ilium, near its junction with the sacrum, down 
 
462 AMPUTATIONS. 
 
 into the sacrosciatic notch. This avoids the difficulty and time involved in 
 disarticulating at the sacro-iliac joint. If indicated, however, the small remain- 
 ing portion of ilium thus left attached could be removed after the removal of 
 the main portion of bone — and this would also apply to the small part of the 
 pubic bone at first left. The entire lower extremity now comes away, with 
 the detached ilium and the undisarticulated hip-joint. (6) The long internal 
 flap is now brought upward and sutured so that its transversely divided end is 
 applied to the iliac incision. The muscles are approximated by buried 
 sutures — drainage is provided — and the skin closed. Pressure is made in the 
 voluminous dressings, so as to sustain the weight of the heavy flap and exercise 
 a supporting influence against the weakened pelvic wall. 
 
 Comments. — Varying portions of the iliac bone have been removed — or 
 the entire bone has been disarticulated. Where the bone is divided, this is 
 best accomplished by the Gigli saw. Provision for infusion should be made 
 in advance. 
 
CHAPTER XIII. 
 
 EXCISIONS AND OSTEOPLASTIC RESECTIONS 
 OF BONES AND JOINTS. 
 
 GENERAL CONSIDERATIONS. 
 
 Definitions. — Excision signifies a cutting-out. By Excision of Joints, 
 is meant the removal of the articular ends (including cartilage and synovial 
 membrane) of the bones entering into the formation of the joint, with a 
 minimum injury to the neighboring parts. The articular extremities of the 
 proximal and distal bones are removed, except in the cases of the shoulder- 
 and hip-joints, where the articular ends of the humerus and femur, respec- 
 tivelv. are alone removed, the articular cavities of the scapula and os in- 
 nominatum being gouged or scraped. In Excision of Bones, the removal of 
 a bone is, signified, with minimum injur}' to neighboring structures. In the 
 Total Excision of a bone, the entire bone is removed, including its articular 
 ends. In the Partial Excision of a bone, a part, only, of the bone is removed. 
 By Resection, is meant the removal of the entire thickness of a bone (thus, a 
 joint is said to be excised by the resection of the ends of its constituent bones) 
 — but the terms excision and resection are generally used synonymously. 
 Osteoplastic Resection signifies the temporary removal of a bone, or part 
 of a bone, covered by its soft parts still attached, for the purpose of exposing 
 more deeply seated structures — the cutaneo-muscular-osseous flap being re- 
 placed later. 
 
 Object of Excisions. — By the operation of Excision, in the case of the 
 extremities, limbs are often now saved in a state of usefulness which formerly 
 were entirely lost by amputation — thus marking one of the greatest advances 
 of modern conservative surgery. 
 
 General Features of Excisions. — (i) Total removal of all diseased 
 tissue. (2) Preservation of a useful limb. The excessive removal of bone, 
 or faulty repair of a wound, or improper after-treatment may result in a flail 
 limb. A movable joint is to be expected everywhere, except in the case of 
 the knee, where ankylosis is sought. (3) The removal of bare bone, free 
 of its periosteum — with minimum disturbance to surrounding soft parts 
 and neighboring bony parts. (4) Division of bones in such a manner, and 
 at such an angle and height, as to place them in a position favorable to the 
 formation of a new joint — or favorable to ankylosis in the most desirable 
 position. The operation is rarely undertaken in the very young or in the 
 very old. 
 
 Indications for Excision. — Joint disease (generally tuberculosis); dis- 
 ease of shaft or articular ends of bones; extensive injury to bone or joint; 
 unreduced dislocation; ankylosis; deformity; compound dislocation or frac- 
 ture; fracture-dislocation; ununited fracture. 
 
 Preparation. — Locally, the part should be prepared as for any extensive 
 operation — the part should be shaved, and should come upon the table in 
 an aseptic dressing. Constitutionally, the patient should be gotten into a 
 condition to stand a long operation — and, subsequently, to meet the demands 
 of a prolonged convalescence. Previous to the operation, an apparatus 
 
 463 
 
464 EXCISIONS. 
 
 should be provided suitable for the double purpose of retaining the part 
 immovable, and, when desired, of enabling passive movement to be accom- 
 plished. In no other class of operations does the final result so largely depend 
 upon the mechanical contrivance in which the part is to be subsequently held 
 and passively exercised. 
 
 Instruments. — Scalpels, light and heavy; bistouries, sharp and blunt; 
 excision-knives (strong instruments, with good grasping handles and stout 
 blades); scissors, straight and curved, sharp and blunt; saws, large and small, 
 solid-bladed and open-bladed, broad and narrow, especially saws with ad- 
 justable and revolvable blades, chain and Gigli saws, key-hole saw, Adam's 
 pattern, Hey's pattern; forceps, dissecting, toothed, and artery-clamp; bone- 
 holding forceps, of various sizes and curves; periosteal elevators, an especially 
 large variety of straight, curved and angular, light and heavy; rugines and 
 raspatories; retractors, angular and curved, toothed and smooth; spatula?, 
 metal or ivory; directors, ordinary grooved and saw-directors; probes; chisels, 
 narrow and broad, straight and curved; osteotomes, various; bone-gouges 
 and curettes, of various shapes and sizes; drills; flushing-gouge; pins, pegs, 
 and needles; wire; suture and ligature material of silk, gut, chromic gut, 
 silkworm-gut, and wire; needles; needle-holders; Esmarch rubber bandage 
 and tourniquet. 
 
 Varieties of Excision. — A joint or a bone may be excised by either 
 the subperiosteal or the open method. 
 
 EXCISION BY THE SUBPERIOSTEAL METHOD. 
 
 Description. — In this method it is sought to preserve the entire periosteum 
 — from the site at which it is first reached in the operation — on upward or 
 downward to the opposite limit of the wound. In the case of excising a 
 joint, no periosteum covers the articular ends of the bones — the periosteum 
 becoming merged into the fibrous tissue of the capsular ligament — and here 
 a periosteo-capsular covering is separated continuously. The advantages 
 of the subperiosteal method are: — (a) Production of new bone from the 
 preserved periosteum; (b) Preservation of the capsule of the joint, with the 
 ligaments attached to it — and hence a stronger and more useful joint; (c) 
 Preservation of the attachment of tendons to neighboring periosteum — and 
 hence additional strength and movement; (d) Less hemorrhage, and less 
 damage to surrounding tissues, as, when the bone is once reached, the opera- 
 tion is henceforth conducted in a comparatively safe area, between bone and 
 periosteum (or between bone and periosteo-capsular covering); (e) The 
 neighboring intermuscular planes (except to reach the bone) are not opened 
 up — the operation-site being circumscribed by the periosteal or capsulo- 
 periosteal sheath raised. The disadvantages of the subperiosteal method 
 are the following: — (a) Possibility of retaining diseased periosteum; (b) 
 Difficulty of the operation, and the likelihood of detaching the periosteum 
 in shreds; (c) Time necessary for its performance. To summarize — the 
 subperiosteal method is excellent in theory, but is often difficult, and some- 
 times contraindicated, in practice. The subperiosteal method should be 
 adopted whenever possible — and carried out as far as possible — where the 
 periosteum is healthy. Always aim for the subperiosteal method, where the 
 periosteum is healthy and there is no contraindication — and, if only partly 
 successful, less damage will have been done to the neighboring tissues, and 
 the result will be more satisfactory, than if the open method had been 
 
EXCISION BY THE SUBPERIOSTEAL METHOD. 465 
 
 undertaken from the start. As a result of a successful subperiosteal excision, 
 bone is reproduced, refilling the periosteal cavity to a greater or lesser extent, 
 and assuming a form largely determined by the limiting periosteum — being 
 poured out, so to speak, into a mould of periosteum or capsulo-periosteum. 
 Sometimes no new bone forms — sometimes an excess. Some reabsorption 
 of the new bone occurs. Exceptionally, reproduction of shafts and joint 
 surfaces of bones is remarkable — and the functioning almost normal. As 
 to the peculiarities of the periosteum, — in the young, it is thick and easily 
 detachable (and also more valuable); — in the old (and in cadavera) it is 
 thinner and more adherent; — in chronic inflammation, it is easily detachable 
 (but often less valuable here). 
 
 Preparation. — (liven under General Considerations. 
 
 Position. — Patient's limb is placed in such a position as to be most 
 accessible to the surgeon, and, at the same time, most relax the overlying 
 parts. Surgeon stands in the same general relation to the limb as in ampu- 
 tating — to the outer side of right and inner side of left limbs. Assistant so 
 stands as to steady the part or retract the lips of the wound. Special positions 
 will be mentioned under special operations. 
 
 Landmarks. — Will be mentioned under each operation. 
 
 Preliminary Control of Hemorrhage. — While the same need for the 
 control of hemorrhage does not exist as in the case of amputations, as no 
 important vessels are ordinarily cut, yet, to avoid what hemorrhage would 
 otherwise occur, and for the sake of having a clean, dry field, it is best to 
 apply a rubber constrictor above the site of operation. If its application be 
 preceded by elevation and proximal massage of the limb, less regurgitant 
 bleeding will occur. Though oozing may be greater after the removal of 
 an Esmarch than might be the case had it not been used, yet the advantages 
 more than conterbalance the disadvantages. The constrictor should always 
 be removed before suturing the wound, that all vessels which still bleed may 
 be taken up. 
 
 Incision. — An incision should be chosen which is simple — which passes 
 to the joint or bone, by the most direct and safest route — which will do the 
 minimum injury to the neighboring structures on its way to the site — which 
 will fall in with the intermuscular planes — and, if possible, with the cleavage 
 line of the skin. The incision should be fully long enough to admit of easy 
 manipulation in the depth of the wound, upon which the subperiosteal method 
 so largely depends. Generally a single straight cut is used. The incision 
 usually passes at first through only skin and fascia — but, in some cases, 
 passes directly to bone. 
 
 Operation. — (1) If the primary incision have passed only through skin 
 and fascia, an intermuscular plane is now sought, and, by lateral retraction 
 of the lips of the wound and the underlying muscles, the bone is reached — 
 with the least possible damage to the soft parts and without any further 
 cutting, but simply by separation of fascial planes. In other instances, the 
 way may be partly opened up by separation and retraction, and parti}' by 
 cutting muscular tissue and less important vessels and nerves. In still other 
 cases, the original incision passes directly to the joint or bone. In any event, 
 the final incision passes down through the periosteum of the lower end of 
 the proximal bone — through the capsule of the joint — and through the perios- 
 teum of the upper end of the distal bone — all in one continuous sweep of a 
 stout excision knife. (2) Having once gotten within the periosteum and 
 capsule, the knife is laid aside and this capsulo-periosteal covering of the 
 joint and articular ends of the bones — or the periosteum alone where only 
 3° 
 
466 EXCISIONS. 
 
 the interarticular portion of the bone is involved — is separated by means of 
 periostea] elevators, which work constantly toward the bone, hugging it 
 always. Where the tendons and muscles are inserted into the periosteum, 
 these are levered off the bone by means of periosteal elevators and rugines — 
 retaining their attachments continuous with the periosteum. In other words, 
 in an ideal case, the osseous tissue is decorticated, or shelled out of its capsulo- 
 periosteal sheath, leaving the periosteum and capsule intact and continuous, 
 as well as the ligaments of the joint and the tendons in the neighborhood. 
 (3) As soon as the articular ends have been sufficiently freed and bared in 
 their capsulo-periosteal sheath, disarticulation is accomplished and the ends 
 of the bones, in turn or together, are protruded through the incision, or in- 
 cisions, and are excised just above their articular cartilages — the soft parts 
 being protected during the sawing. (4) The sawed ends of the bones are 
 now drawn back within their capsulo-periosteal covering. The tourniquet 
 is then loosened and the vessels not tied during the steps of the operation 
 which bleed are now tied. The edges of the capsulo-periosteal sheath are 
 sutured together with catgut. But where muscles have been cut along the 
 original incision, these are quilted with catgut. Even where no muscle- 
 fibers are laid bare, but only the rounded borders uncut, it is well to quilt 
 together such separated muscles, as the fascia covering them unites and fills 
 the dead spaces and hastens repair of the wound as a whole. Temporary 
 drainage is indicated in the larger excisions. The suturing of the skin should 
 be done with silk or silkworm-gut — which is usually removed about the tenth 
 day. 
 
 Application of Retentive Apparatus, and After-treatment. — The 
 future usefulness of the limb depends almost more upon the after-treatment 
 than upon the manner of operation. There is hardly any set of operations 
 in which the ultimate outcome is more dependent upon the care and manage- 
 ment subsequent to operation. The usefulness of the limb also largely 
 depends upon non-suppuration, or but limited and brief suppuration. While 
 temporary drainage is at first indicated, the dressings should be dry and 
 infrequent. In applying the first dressing, the limb may be immobilized 
 upon almost any splint — often the permanent position, or method of treatment, 
 cannot be adopted immediately. Or the limb, on the other hand, may be 
 put up in its permanent and special splint from the first. This latter course 
 is preferable when possible. In still another class of cases, as in operating 
 for deformity, it may take some time to bring the limb into its permanent 
 position. The kind of splint or retentive apparatus adopted is extremely 
 important. It should be selected to do the special work in hand — and be 
 very precisely applied. Its features are, — (a) that it should firmly grasp 
 the limb above and below the excised joint — and (b) that it should be hinged, 
 the hinge corresponding with the joint, so that from time to time the angle 
 of the joint can be changed, while still retaining the relative relations of the 
 ends of the bones. If mobility is to be expected, the ends of the bones should 
 not be put up in direct contact — the amount of separation varying with 
 circumstances — the separation being less in adults, and where much perios- 
 teum has been saved, than in the reverse conditions. If ankylosis be desired, 
 the ends of the bones should be put up in close contact in the position desired 
 — and should be kept rigidly in contact until union is solid. As to passive 
 movement, there is no fixed time at which it should begin. It should com- 
 mence just as soon as acute inflammation and sensitiveness subside (generally 
 in from one to three weeks). General good health, massage, and electricity 
 all aid the favorable course of the traumatism and the final functioning. 
 
EXCISION BY THE OPEX METHOD. 467 
 
 What has been said of apparatus and after-treatment in connection with 
 the subperiosteal method of excision, also applies equally to the open method. 
 Comment. — (I) No vessels of importance are ordinarily injured in the 
 operations of excision — but, if injured, should be ligated. (2) All synovial 
 membrane, and even extra-articular tissue, must be removed if diseased. 
 (3) Where muscles or tendons must be divided, their oblique division is 
 preferable. In any event, they should be sutured with gut. (4) Extensive 
 gouging, or curettage, is a legitimate substitute for typical excision, where 
 the latter is impracticable — as where an epiphyseal cartilage might be de- 
 stroyed. (5) Where ankylosis is sought, the synovial membrane should be 
 thoroughly dissected away. (6) Retention of the periosteum gives firmness 
 to the cicatrix, even where the amount of bone deposited is little or none — 
 lessens the shortening of the limb — and helps retain the proper relational 
 attachment of the muscles. A periosteo-capsular covering favors the repro- 
 duction of a joint with articular cartilages, and gives support to ligaments. 
 (7) Tendons often have to be removed with knife, cutting close to the bone — 
 or may be chiseled away with a thin shell of bone. (8) The removal of 
 tissue must not, ordinarily, be stopped short of the removal of the entire 
 diseased structures. (9) The destruction of the epiphyses in young children 
 should be avoided. (10) When the saw-section does not remove all of the 
 involved bone, it is better to remove the balance with a gouge than to saw 
 another section, (n) The gap of an excised bone may be filled by bone- 
 grafting. (12) The periosteum is easily removable in chronic osteitis and 
 synovitis — and hard to remove in acute periosteitis. 
 
 EXCISION BY THE OPEN METHOD. 
 
 Description. — No attempt is here made to preserve the periosteum. The 
 continuous attachment, therefore, of periosteum and capsule is sacrificed — 
 though the capsule is preserved. The tendons are peeled from their attach- 
 ment to the periosteum — and some of the ligaments of the joints are sacrificed. 
 The open method is more rapid, but more damage is done to the neighboring 
 structures, and less satisfactory functioning of the joint is apt to follow. 
 The chief indication for adopting the open method is found in those cases 
 where, from disease, or other cause, the preservation of the periosteum is 
 contraindicated. For further comparison, see under Description of the 
 Subperiosteal Method, page 464. A reckless and careless sacrifice of capsule, 
 tendons, and ligaments in the open method is distinctly unjustifiable. In 
 undertaking the open method, even in disease, the operation should be carried 
 out with the underlying idea of a "modified subperiosteal method as far as 
 consistent." 
 
 Preparation — Position — Landmarks. — As in the subperiosteal method. 
 
 Preliminary Control of Hemorrhage. — The use of a constrictor is here 
 indicated even more than in the subperiosteal method — as hemorrhage will, 
 usually, be greater, from the greater damage to the involved parts. 
 
 Incision. — The line of incision for the open method is generally the 
 same as that for the subperiosteal method. Sometimes, however, the sub- 
 periosteal excision of a joint is done through one incision — and the open 
 excision through another. Whether the position of the line of incision be 
 the same or not, the manner of making it and of reaching the level of the 
 bone, or joint, are the same. 
 
 Operation.— Up to the point of reaching the level of the joint, or bone, 
 
468 EXCISIONS. 
 
 there is no difference between the open and subperiosteal methods of excision. 
 Once the bone is reached in the open method, however, no attempt is made 
 to preserve the periosteum — although the soft parts are disturbed as little 
 as possible. The periosteum is not cut through over the bones above and 
 below the joint. The muscles and tendons are detached — not cut, but 
 peeled — from the bones as closely as possible. While some of the ligaments 
 of the joint are saved, some are unavoidably lost. This separation is accom- 
 plished by rugines, raspatories, and by stout excision knives, rather than by 
 periosteal elevators. The capsule of the joint is cut into as soon as the 
 articular region is sufficiently exposed and cleared. The bones are then 
 disarticulated and their ends protruded and sawed off, during which the soft 
 parts are well protected. The ends of the bones are now drawn back into 
 their musculo-capsular (rather than periosteo-capsular) sheath — the con- 
 strictor relaxed — the vessels ligated — the cut or separated muscles quilted — 
 and the limb put up and subsequently treated as in the subperiosteal method. 
 Application of Retentive Apparatus, and After-treatment — Com- 
 ment. — As in Excision by the Subperiosteal Method (page 464). 
 
 EXCISION OF COCCYX 
 
 BY POSTERIOR MEDIAN INCISION. 
 
 Description. — Separation of coccyx at sacrococcygeal articulation and 
 removal from its bed of soft parts. 
 
 Position. — Patient on side at edge of table; thigh flexed; buttocks sepa- 
 rated. 
 
 Landmarks. — Tip and outline of coccyx, and position of sacrococcygeal 
 articulation. If necessary, this articulation may be determined by means 
 of a gloved finger introduced within the rectum and the coccyx palpated 
 between this finger within and the thumb without. 
 
 Incision. — Begins in middle line, just above sacrococcygeal articulation 
 — passes vertically downward — and ends just below the tip of the coccyx. 
 
 Operation. — Incise through skin and fascia to the bone. Separate the 
 gluteus maximus from the posterior surface — the coccygeus from the anterior 
 surface — the sphincter ani from its tip in front and the levator ani from its 
 tip behind — and the sacrococcygeal ligaments from its upper aspect — hugging 
 the bone closely and putting the parts upon the stretch after freeing the tip 
 — thus completing the disarticulation. Sometimes the bone may be more 
 easily removed by freeing its posterior aspect and lateral borders — then dis- 
 articulating and levering out its upper end — and, while this is being drawn 
 backward, its anterior surface is freed from above downward. The incised 
 muscles are sutured together deeply with buried gut — and the superficial 
 wound closed. 
 
 OSTEOPLASTIC RESECTIONS OF BONES AND JOINTS. 
 
 Description. — An osteoplastic operation, in general, consists in the ap- 
 proximation of fresh sections of bone to each other, for the purpose of bringing 
 about union between their opposed aspects. The surfaces brought thus 
 into contact may have been originally in contact, as the margin of an oval 
 of bone turned back from the skull and afterward dropped into its old place, 
 — or some new bony contact may be brought about, as when, after total 
 excision of the tarsus, the sawed ends of the metatarsals are approximated 
 
EXCISIONS ABOUT THE SUPERIOR MAXILLA. 469 
 
 to the sawed ends of the tibia and fibula. Osteoplastic Resection of a Bone 
 consists in the resection, or cutting through, of a bone in such a way as to 
 leave its soft coverings attached, and, in addition, a hinge-like connection 
 of soft parts connecting it with the neighboring bone from which cut — and 
 in then turning, that is, breaking, back the portion of bone, with its soft cover- 
 ings adherent and soft hinge intact, in some convenient direction, thus ad- 
 mitting of free access to the underlying structures sought in the special opera- 
 tion — and of subsequently, upon completion of the object sought, turning the 
 bone-flap, or bone part, with its connected soft parts, back into its original 
 place — union of the bony surfaces being expected and a reproduction of the 
 status ante quo — as in the osteoplastic exposure of the brain. Osteoplastic 
 Resection of a Joint is an operation in which, after the ordinary excision of 
 the joint, the sawed bony surfaces immediately beyond the joint are brought 
 into contact for permanent union — and, therefore, implies that no motion is 
 to be expected in that region. The excision of the knee-joint, or of any other 
 joint, where ankylosis is expected, or results, whether expected or not, is, 
 consequently, not, properly speaking, a simple excision, but an osteoplastic 
 excision or resection. In another sense an osteoplastic resection of a joint 
 may consist of a technic some part of which involves the temporary severing 
 of a neighboring part of bone to reach the joint, after accomplishing which 
 the severed bone is sutured back into place — as the temporary removal of the 
 acromion to reach the shoulder-joint by Kocher's method (page 503). 
 
 General Surgical Considerations. — (i) The osteoplastic resection of a 
 bone, as to the manner of its performance, is done, in all practical respects, 
 in the same way as an excision of a bone — except that the soft parts are not 
 cleared from the surface of the bone entering into the osteoplastic flap, and 
 that the hinge-like connection of soft parts between the bone-flap and the 
 main bone, or bony surroundings, is disturbed as little as possible. (2) The 
 osteoplastic resection of a joint is performed, as far as the excision itself is 
 concerned, in precisely the same manner as an ordinary excision of a joint — 
 except that after the removal, or excision of the joint surfaces, the cut surfaces 
 of the bones beyond are brought into permanent contact — and solid bony 
 union sought, or a neighboring process of bone may be temporarily removed 
 to reach the joint, as described above. 
 
 SURGICAL ANATOMY INVOLVED IN EXCISIONS ABOUT THE 
 SUPERIOR MAXILLA. 
 
 Articulations of Superior Maxilla. — With frontal; ethmoid; nasal; 
 lachrymal; malar; inferior turbinated; palate; vomer; and its fellow. 
 
 Muscles Attached to Superior Maxilla. — Orbicularis palpebrarum; 
 inferior oblique; levator labii superioris akeque nasi; levator labii superioris; 
 levator anguli oris; compressor nasi; depressor alae nasi; dilator naris poste- 
 rior; masseter; buccinator; internal pterygoid; orbicularis oris. 
 
 Arteries in Neighborhood of Superior Maxilla. — Facial and its follow- 
 ing branches: — superior coronary, arteria septi nasi, lateralis nasi, angular, 
 muscular (masseter and buccinator). From temporal: — transverse facial. 
 From internal maxillary: — anterior dental, alveolar or posterior dental, 
 descending or posterior palatine, pterygopalatine, sphenopalatine, infra- 
 orbital. From ophthalmic: — inferior palpebral. 
 
 Veins in Neighborhood of Superior Maxilla. — (1) Superficial:— Facial, 
 with its following tributaries,— angular, superior and inferior lateral nasal, 
 inferior palpebral, infraorbital, anterior internal maxillary (deep facial, 
 
47° 
 
 EXCISIONS. 
 
 between buccinator and masseter muscles), superior coronary, transverse 
 facial, and muscular branches (masseter and buccinator). (2) Deep: — 
 veins corresponding to branches of internal maxillary artery, forming the 
 pterygoid plexus (situated on the inner surface of the internal pterygoid and 
 partly around the external pterygoid) — ending, anteriorly, in the anterior 
 internal maxillary (or deep facial), joining the facial vein — and ending, 
 posteriorly, in the internal maxillary vein, which unites with the common 
 temporal vein to form the temporomaxillary vein 
 
 Chief Nerves in Neighborhood of Superior Maxilla. — (1) From facial: 
 — malar; supraorbital branches of temporofacial division; and buccal branch 
 of cervicofacial division. (2) From superior maxillary division of fifth nerve: 
 — malar; posterior superior, middle superior, and anterior superior dental; 
 
 Fig. 380. — Skin Incisions in Excisions about the Maxill.k: — A, Excision of superior max- 
 illa, by median incision (Fergusson's operation); B, Excision of inferior maxilla. 
 
 palpebral; nasal; labial. (3) From sphenopalatine ganglion — anterior (large) 
 palatine; middle (external) palatine; posterior (small) palatine; superior 
 nasal branches; nasopalatine; upper posterior nasal. 
 
 Other Structures in Neighborhood of Superior Maxilla. — Eye; 
 nasal duct; antrum of Highmore. 
 
 Surface Form and Landmarks of Superior Maxilla. — The superior 
 maxilla forms the largest part of the face — the outer wall and larger part of 
 floor of nose — the larger part of roof and part of outer wall of mouth — and 
 part of floor of orbit. 
 
 General Surgical Considerations in Operations upon Superior 
 Maxilla. — See under Description and Comment, in Excision of the upper 
 jaw, pages 471 and 473. 
 
EXCISION OF SUPERIOR MAXILLA. 47 1 
 
 EXCISION OF SUPERIOR MAXILLA 
 
 BY MEDIAN INCISION — FERGUSSON'S OPERATION. 
 
 Description. — Ordinarily refers to removal of superior maxilla of one 
 side, as herein described — more rarely, to the removal of both superior maxilla-. 
 The entire bone is removed — except the upper part of the nasal process. In 
 addition to the removal of the entire bone, the following additional bones 
 are removed, in whole or in part: — lower part of malar; part or whole of 
 palate bone; whole inferior turbinated. 
 
 Preliminary Steps to Excision. — Preliminary tracheotomy is often per 
 formed, with plugging of the larynx, or the use of a tampon-cannula. Pre- 
 liminary exposure of the external carotid, with temporary ligation of 
 the vessel during the operation, is also often performed. Both of these 
 steps are indicated in difficult cases where especial trouble is antici- 
 pated. 
 
 Position. — Patient supine; head and shoulders well elevated; face 
 turned to sound side; region shaved; posterior nares plugged (for earlier 
 part of operation). Surgeon to right side in either case. Assistant oppo- 
 site surgeon. 
 
 Landmarks. — General contour and boundaries of superior maxilla. 
 
 Incisions. — Median Incision — begins about 1.3 cm. (\ inch) below 
 the inner canthus — passes down in the naso-facial groove- — curves around 
 convexity of ala nasi — passes along margin of nostril, in naso-labial 
 groove, to mid-line of lip — and thence downward through the center 
 of the upper lip. Horizontal Incision — passes from the beginning of the 
 median incision along the lower border of the orbit, to end over the malar 
 bone beyond the outer canthus (Figs. 380, A, and 381, A, B, C). 
 
 Operation. — (1) The above incision passes everywhere to the bone. 
 While incising from the inner canthus to the septum nasi, and from the inner 
 canthus to the malar, the facial artery is compressed over the inferior maxilla. 
 Just before dividing the upper lip, the lip is compressed on either side of the 
 median line, between thumb and finger, and, when severed, the superior 
 coronary arteries are tied while still compressed. In this median incision 
 are cut the following arteries and corresponding veins — angular, lateralis 
 nasi, superior coronary, arteria septi nasi, and branches of the infraorbital. 
 In the horizontal incision, branches of the infraorbital and transverse facial 
 are cut. (2) Dissect up the flap included in the above incisions — clearing 
 the surface of the superior maxilla as completely as possible, though not 
 subperiosteal!}'. The infraorbital artery is divided during this stage. (3) 
 Detach the nasal cartilages from the bone. Divide the nasal process of the 
 superior maxilla with a fine saw, from the junction of the nasal process with 
 the lower border of the nasal bone, to the margin of the orbit just below the 
 canal for the nasal duct. (4) Raise the periosteum from the floor of the 
 orbit, including the origin of the inferior oblique, and retract them upward, 
 carefully protecting the eye-structures. With a fine, narrow chisel, chisel 
 obliquely across the orbital plate, from the end of the saw-cut dividing the 
 nasal process, to the anterior end of the sphenomaxillary fissure. (5) The 
 orbital and external surfaces of the malar bone are now cleared, the former 
 subperiosteallv, preparatory to sawing. A chain or Gigli saw is then guided 
 
472 
 
 EXCISIONS. 
 
 into position through the sphenomaxillary fissure and zygomatic fossa, upon 
 
 a curved carrier, or aneurism- 
 needle, closely hugging the bone 
 — and the malar bone divided ob- 
 liquely through its middle, from the 
 anterior end of the sphenomaxil- 
 lary fissure downward and out- 
 ward to the center of its lower 
 free border. (6) Extract the cen- 
 tral incisor tooth of the involved 
 side. Divide the muco-periosteal 
 covering of the hard palate in the 
 median line along the intermax- 
 illary and interpalatal sutures, 
 from the alveolar process to the 
 posterior nasal spine. Similarly 
 divide the muco-periosteal cover- 
 ing of the floor of the nose, with 
 a long knife, cutting as near the 
 septum as possible, from the pos- 
 terior nasal spine to the anterior 
 nasal spine. Make a transverse 
 incision across the roof of the 
 mouth, at the junction of the hard 
 and soft palates, and separate the 
 latter from the former. Pass a 
 long, narrow saw in through the 
 nose, seeing that its tip passes 
 through the interval between the 
 separated hard and soft palates (not 
 injuring the latter), and divide the 
 horizontal plate of the palate and palatal and alveolar portions of the superior 
 maxillary bone as nearly in the central line as the septum nasi will allow. The 
 descending palatine and nasopalatine arteries are cut here and bleed freely. 
 (7) Grasp the superior maxilla with large bone-forceps, catching the orbital 
 and alveolar aspects of the bone, and gently wrench it from side to side to 
 determine the position and extent of the remaining connections which still 
 hold it in place. The two remaining bony connections are, part of the orbital 
 plate, and the union between the pterygoid processes and superior maxilla. 
 These are generally severed with cutting forceps. The former is more 
 accessible. The latter, after depressing the inferior maxilla, and freeing the 
 outer and posterior surfaces of the superior maxilla, is separated by means of 
 angular bone-cutting forceps introduced within the mouth and passed up 
 behind the maxillary tuberosity — being sure that the soft palate has been 
 entirely separated and held out of the way. Or, after depressing the inferior 
 maxilla, a chisel may be used between the superior maxilla and pterygoid 
 process. The superior maxilla is thus drawn away in the hold of the large 
 forceps, after all bony connections have been divided. The posterior dental, 
 pterygopalatine, and infraorbital arteries are here severed. (8) All bleeding 
 vessels are now secured, and remaining hemorrhage controlled by temporary 
 gauze packing. The wound is sutured throughout — and with especial care* 
 through the upper lip, to avoid disfigurement. Drainage is established 
 through the mouth. Feeding is done by a tube for a time. An artificial 
 palate is generally worn after the operation. 
 
 Fig. 381. — Bone Sections in Excisions 
 about the Maxill/E: — A, B, C, Lines of 
 bone-division in excision of right superior 
 maxilla, by Fergusson's method; D, Line of 
 division of inferior maxilla, in excision of left 
 inferior maxilla, or in the osteoplastic resec- 
 tion of the lower jaw, by median section. 
 
CHOXDROPLASTIC RESECTION OF NASAL CARTILAGES. 473 
 
 Comment. — (I) No attempt is made to remove the superior maxilla 
 subperiosteal!}' in 'the above operation. (2) Preservation of branches of the 
 facial nerve is important. (3) While the above method of freeing the bone 
 from its final attachments is to be preferred, yet if difficulty be experienced 
 in severing the ptervgomaxillary connections by cutting forceps, the superior 
 maxilla may be separated from the pterygoid processes by a quick downward 
 wrench, tearing it away from its bony attachments. (4) The upper jaw may 
 also be excised by the methods of Velpeau, Langenbeck, Liston, Gensoul, 
 Nelaton, Boeckel, Oilier, and others. 
 
 Partial Excisions of the Superior Maxilla. — The following parts of 
 the upper jaw may be done through special incisions, — (a) Alveolar and 
 palate processes, — (b) Orbital and nasal portions, — (c) All the superior 
 maxilla below the infraorbital foramen, — (d) All the superior maxilla except 
 the orbital plate. 
 
 OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA 
 
 BY VERTICAL AND HORIZONTAL INCISIONS. 
 
 Description. — Having made the same incisions, preceded by the same 
 preliminaries, as in the ordinary excision of the upper jaw by Fergusson's 
 method (page 471), and carried them everywhere to the bone — the soft parts 
 are carefully guarded, and are nowhere freed from the bones, except in so 
 far as necessary to reach the bones in making the original incisions. The 
 bones are now divided just as in that operation, everywhere along the line 
 of skin incision — except that no division of the bone is made from the anterior 
 end of the sphenomaxillary fissure through the malar — this portion of bone 
 being preserved for the "hinge." When all other connections have been 
 divided, the bone, with its soft parts adherent, is broken outward and back- 
 ward through the above indicated undivided portion as a hinge — by putting 
 pressure from without over the region where the bone is to be broken back, 
 and then prizing it outward and backward in that direction. At the end 
 r>f the operation, the flap of bone and soft parts is turned back into place — 
 and, if necessary, the bone wired. 
 
 Comment. — It is better to previously divide the frontal process of the 
 malar, making a limited incision for that purpose, prior to turning back the 
 bone — thus avoiding the uncertainty of the line of breakage and possible 
 harm that might result to neighboring structures through the rougher 
 manoeuvre. 
 
 CHONDROPLASTIC RESECTION OF NASAL CARTILAGES 
 
 TO EXPOSE NOSE AND ANTERIOR NASOPHARYNX PA* NASAL ROUTE, BY TRANS- 
 VERSE INCISION — ROUGE'S OPERATION. 
 
 Description. — The cartilaginous portion of the nose is temporarily 
 separated from the bony nares and turned upward. 
 
 Position. — Patient supine, with head elevated and thrown back. 
 
 Landmarks. — Line of reflection of mucous membrane of upper lip. 
 
 Incision and Operation. — An assistant stands behind the head and 
 draws the upper lip well upward, holding it opposite the angles of the mouth. 
 The surgeon, standing in front, with scissors curved on the flat, cuts the 
 mucous membrane in the line of its reflection from the superior maxilla, from 
 one bicuspid tooth to the opposite one, hugging the bone throughout. Simi- 
 larly separate the cartilaginous septum from the anterior nasal spine, and 
 alar cartilages from the lateral borders of the maxilla. Having retracted 
 
474 EXCISIONS. 
 
 the cheeks well, the anterior naris is now turned upward and backward 
 toward the forehead. At the end of the operation, the nose is dropped back 
 into place and the cut edges of the mucous membrane sutured, if sufficient 
 free margin exist — but suturing is not necessary. 
 
 Comment. — This operation gives imperfect access to the nasopharynx — ■ 
 but satisfactory access to the nose. The cheeks must be sufficiently separated 
 from the underlying bones to enable the nose to be turned back. 
 
 OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA 
 
 TO EXPOSE NASOPHARYNX BY PALATINE ROUTE, BY TRANSVERSE AND 
 Ml MIAN INCISIONS — ANN ANDALE'S OPERATION. 
 
 Description. — After having exposed the bony anterior nares as in Rouge's 
 operation, the alveolar and palatal processes of the superior maxilla are 
 divided in the median line, and the septum nasi also divided. The two 
 halves of the superior maxilla can then be separated from 1.3 to 2.5 cm. 
 (J to 1 inch). 
 
 Position. — Patient supine, head elevated and thrown back. Surgeon 
 faces patient. 
 
 Landmarks. — Anterior and posterior nasal spines; septum nasi; two 
 central incisors. 
 
 Incisions. — Transverse Incision — through mucous membrane of upper 
 lip (this portion of the operation being similar to Rouge's). Median Incision 
 — follows the base of the septum nasi, as near to the middle line as possible, 
 and extending along the floor of the nose from the margin of the posterior 
 bonv nares to the anterior bony nares, and along the alveolar process of the 
 superior maxilla between the two central incisors, possibly extracting one. 
 
 Operation. — Expose the bony anterior nares as in Rouge's operation 
 (page 473). Divide the septum nasi just above the maxillary attachment, 
 from before backward, with a fine narrow saw, or with cutting pliers. Having 
 gagged the mouth open, separate the soft from the hard palate by a short 
 transverse incision crossing the median line. If necessary, the soft palate 
 may be divided. Drill holes in the alveolar process for future wiring. 
 By means of a fine, narrow saw, introduced through the nose, divide the entire 
 length of hard palate and alveolar process of superior maxilla, in the median 
 line. The two halves of the superior maxillae are now prized apart and the 
 nasopharynx reached with instruments. Upon the completion of the opera- 
 tion, the alveolar process is wired and the soft palate sutured back to the 
 soft tissues of the hard palate (and together, if divided). The nose-flap of 
 Rouge's operation is dropped back into place and the mucous lips of the 
 wound closed. 
 
 Comment. — The room thus furnished is not great. The above operation 
 may be considered the first step of an osteoplastic resection of the entire 
 superior maxilla. 
 
 OSTEOPLASTIC RESECTION OF SUPERIOR MAXILLA 
 
 TO EXPOSE NASOPHARYNX BY MAXILLARY ROUTE, BY TWO SEMILUNAR 
 INCISIONS — LANGENBECK'S OPERATION. 
 
 Description. — A tongue-shaped flap, having its base over the nose and 
 its apex over the malar bone is turned forward and inward upon the nasal 
 bone and nasal process of superior maxilla as a hinge. 
 
 Position. — Patient supine; head elevated and turned to opposite side 
 Surgeon on side of operation. 
 
EXCISIONS ABOUT THE INFERIOR MAXILLA. 475 
 
 Landmarks. — Naso-frontal suture; ala nasi; malo-zygomatic arch. 
 
 Incisions. — Upper Incision — begins at root of nose and passes down- 
 ward and outward just below the lower border of the orbit, ending a short 
 distance posterior to the center of the malar. Lower Incision — begins at 
 ala nasi and passes upward and outward across the cheek, joining the outer 
 end of the upper incision. These united incisions may extend further out- 
 ward as a single incision along the zygoma, if necessary. 
 
 Operation. — (1) Incise everywhere through skin, fascia, and muscles, 
 and through periosteum to bone. Separate the periosteum for only a wide 
 enough interval along the lines of incision for a saw to travel — except along 
 the floor of the orbit, where it is stripped to the anterior end of the spheno- 
 maxillary fissure. The masseter is detached from the malar where exposed. 
 The soft parts are not otherwise raised from the bone. (2) Depress the 
 inferior maxilla and pass a sharp periosteal elevator, or pointed director, 
 below the inferior border of the zygoma, opposite its junction with the malar, 
 and thrust it horizontally through the pterygomaxillary fissure to the outer 
 wall of the nasal cavity, which is recognized by a finger in the mouth. Upon 
 this guide, introduce a fine key-hole saw and divide the zygomatic arch 
 upward — continuing the section so as to enter the sphenomaxillary fissure, 
 cutting the posterior wall of the superior maxilla and following the floor of 
 the orbit nearly to the lachrymal bone. If possible, however, it is better to 
 make the saw section follow the line of the upper semilunar incision, thus 
 avoiding the orbital plate. (3) The saw is again passed into the pterygo- 
 maxillary fissure and made to cut forward and downward, passing through 
 the walls of the antrum and into the anterior nasal cavity near its floor — 
 following, approximately, the line of the inferior semilunar incision. (4) Pass 
 the periosteal elevator into the pterygomaxillary fissure and prize the severed 
 portion of the superior maxilla upward and inward — bending it over the nasal 
 bone and nasal process of the superior maxilla (which fracture in the act) 
 as a hinge. (5) At the end of the operation, turn the displaced bone, with 
 its soft coverings attached, back into place — and suture the wound. 
 
 Comment. — Next to the osteoplastic resection of the entire bone, the 
 above operation gives freer access to the nasopharynx than does any of the 
 other partial osteoplastic resections mentioned. 
 
 SURGICAL ANATOMY INVOLVED IN EXCISIONS ABOUT THE 
 INFERIOR MAXILLA. 
 
 Ligaments of Temporomaxillary Articulation. — External lateral; 
 internal lateral; stylomaxillary; capsular; interarticular fibrocartilage. Two 
 svnovial membranes. 
 
 Muscles Attached to Inferior Maxilla.— To Outer Aspect; — levator 
 labii inferioris; orbicularis oris; depressor labii inferioris; depressor anguli 
 oris; platvsma myoides; buccinator; masseter. To Inner Aspect; — Genio- 
 hyoglossus; geniohyoid; mylohyoid; digastric; superior constrictor of pharynx; 
 temporal; internal pterygoid; external pterygoid. 
 
 Arteries in Neighborhood of Inferior Maxilla. — Facial and following 
 branches: — submaxillary, submental, muscular (pterygoid, masseter, buc- 
 cinator), inferior labial, inferior coronary. Internal maxillary and following 
 branches: — tympanitic, middle meningeal, inferior dental, pterygoid, masse- 
 teric, buccal. From temporal: — transverse facial. (The internal carotid 
 lies considerablv to the inner side of the lower jaw.) 
 
 Veins in Neighborhood of Inferior Maxilla. — Superficial; — facial, 
 
476 EXCISIONS. 
 
 with its following tributaries; transverse facial, inferior coronary, inferior 
 labial, submental, submaxillary, muscular (pterygoid, masseter, buccinator). 
 Superficial and Deep; — external jugular and its tributaries; common tem- 
 poral, internal maxillary, communicating branch from the facial to external 
 jugular. Deep; — veins corresponding to the above branches of the internal 
 maxillary artery. (The internal jugular vein lies considerably to the inner 
 side of the lower jaw.) 
 
 Chief Nerves in Neighborhood of Inferior Maxilla. — From facial; — 
 buccal, supramaxillary and inframaxillary branches of cervicofacial division. 
 From inferior maxillary division of fifth nerve; — internal pterygoid, masse- 
 teric, temporal, buccal, external pterygoid, auriculotemporal, lingual, inferior 
 dental. (The glossopharyngeal and hypoglossal are considerably to the 
 inner side of the inferior maxilla.) 
 
 Other Structures in Neighborhood of Inferior Maxilla. — Parotid 
 gland; submaxillary gland; sublingual gland. 
 
 Surface Form and Landmarks of Inferior Maxillary Region. — (i) 
 Steno's duct of the parotid gland crosses the ascending ramus of the inferior 
 maxilla horizontally, about 2 cm. (f inch) below and parallel with the zygo- 
 matic arch — the transverse facial artery lying above and the facial nerve 
 below it. (2) The facial nerve crosses the parotid gland forward and slightly 
 downward, from the junction of the anterior border of the mastoid process 
 and the ear. (3) The facial artery crosses the inferior maxilla at the anterior 
 border of the masseter muscle — the facial vein lying just behind. 
 
 EXCISION OF TEMPOROMAXILLARY ARTICULATION 
 
 BY ANGULAR INCISION. 
 
 Description. — Consists in removal of condyle of inferior maxilla. The 
 interarticular fibro-cartilage of the joint and the glenoid cavity are, ordinarily, 
 not disturbed. 
 
 Position. — Patient's head and shoulders elevated; faced turned to oppo- 
 site side. Surgeon on side of operation. Assistant opposite. 
 
 Landmarks. — Ascending ramus and condyle of inferior maxilla. 
 
 Incision. — Vertical portion — begins at lower border of zygoma and 
 passes vertically downward anterior to the temporal artery (which is about 
 2 cm., f inch, in front of the tragus), ending just above the transverse facial 
 artery (which is from 1.3 to 2 cm., ^ to -| inch, below the zygoma). Horizontal 
 portion — passes forward along the lower border of the zygoma for about 
 4 cm. (i£ inches). (Fig. 382.) 
 
 Operation. — Incise through skin and fascia and turn the triangular flap 
 thus raised downward and forward. Be on the lookout for the transverse 
 facial artery, Steno's duct, and facial nerve, all crossing parallel with the 
 zygoma from behind forward, and in the above order from above downward. 
 Retract the lower border of the wound downward to avoid these — and the 
 vertical border backward, with the anterior margin of the parotid gland. 
 Incise whatever portion of the masseter fibers are encountered along the 
 lower border of the zygoma — and along the ascending ramus, if any extend 
 into the field. Incise the capsule of the joint vertically and expose the condyle. 
 Clear the circumference of the neck of the condyle, as near the condyle itself 
 as possible, closely hugging the bone — leaving some of the lower fibers of 
 the external pterygoid, if feasible. Conduct a Gigli saw around the neck 
 of the bone and divide it just below the condyle. This is better than dividing 
 it by chisel or pliers. Seize the condyle with bone-forceps and divide any 
 
EXCISION OF INFERIOR MAXILLA. 
 
 477 
 
 remaining connections, while putting traction upon the end of the bone — 
 preserving the capsule as intact as possible. Suture the capsule with buried 
 gut. If the masseter have been extensively removed from the zygoma, suture 
 it back to the periosteum. Establish temporary drainage. Close the angular 
 wound — and dress the jaw closed. 
 
 Comment. — (I) Both temporomaxillary articulations may require simul- 
 taneous excision. (2) The joint may be less satisfactorily excised from within 
 the mouth. 
 
 Fig. 382. — Incisions about the Inferior Maxilla: — A, Skin incision in excision of 
 temporomaxillary articulation by angular incision; B, Bone section in osteoplastic resection of 
 lower jaw by lateral section. 
 
 EXCISION OF INFERIOR MAXILLA 
 
 BY SINGLE INCISION ALONG INFERIOR AND POSTERIOR BORDERS. 
 
 Description. — Ordinarily refers to the removal of the inferior maxilla of 
 one side. Both sides may be removed. The bone is removed subperiosteally, 
 when the preservation of the periosteum is not contraindicated. 
 
 Position. — Patient supine; head and shoulders elevated; head to opposite 
 side; face shaved. Surgeon on side of operation. Assistant stands opposite. 
 
 Landmarks. — General contour of bone, especially its inferior and poste- 
 rior borders. 
 
 Incision. — Begins in the midline of the chin, just below the free portion 
 of the lip — passes down the front of the chin well around its prominent border 
 — thence follows the lower border of the inferior maxilla, passing a little 
 nearer the posterior than the anterior aspect of the border (in order to hide 
 the scar) to the angle — thence upward along the posterior border of the 
 ascending ramus — ending about opposite the center of the ascending ramus 
 (about opposite the lobule of the ear). (Fig. 380, B, and 381, D.) 
 
 Operation. — (1) This incision is everywhere carried through skin, fascia, 
 platysma, and periosteum to bone — except over the facial artery, where the 
 
478 EXCISIONS. 
 
 skin alone is incised. The facial artery is then regularly exposed, doubly 
 ligated and cut between the ligatures. (2) All the structures (see Surgical 
 Anatomy, page 475) covering the outer surface of the inferior maxilla are now 
 raised subperiosteally, working from the free border of the bone toward the 
 alveolar margin, and from the symphysis toward the angle and upward along 
 the ascending ramus. The mental vessels and nerve are divided at the 
 mental foramen. The strong attachment of the masseter muscle is difficult 
 to free from the margin of the angle, except with a sharp rugine, after having 
 cut through the periosteum to the bone. The bone is closely hugged every- 
 where. The clearing is continued as high up the ascending ramus as can be 
 reached with the bone in situ. (3) The structures along the inner aspect 
 of the horizontal ramus of the jaw are now similarly separated subperiosteally, 
 in the same order as upon the outer surface, as far as they can be reached. 
 Guard against injuring the submaxillary and sublingual glands. (4) The 
 mucous membrane is then divided along the alveolar margin, on the outer 
 and inner sides — all the muscles having been freed from both aspects of the 
 bone. The lower lateral incisor tooth is extracted and a chain or Gigli saw 
 conducted around the bone at the site of the empty socket. As much of 
 the attachments of the digastric, geniohyoid, and geniohyoglossus of the 
 involved side as possible are saved (for their future action). (5) Seizing 
 the anterior end of the severed jaw, and drawing it outward, the remaining 
 structures are detached from the inner aspect — internal pterygoid muscle, 
 inferior dental artery and nerve at the inferior dental foramen, superior con- 
 strictor of the pharynx, internal lateral ligament, stylomaxillary ligament. 
 If not already divided, the mylohyoid and posterior part of the mucous mem- 
 brane of the mouth are now separated. (6) Firmly depress the anterior 
 portion of the inferior maxilla, thereby bringing the coronoid process further 
 forward and downward — and then cut from it the temporal muscle with 
 blunt curved scissors, following the anterior border of the coronoid process 
 upward. (7) Still further depress the inferior maxilla, until the coronoid 
 process is more accessible. This is especially necessary, as the original in- 
 cision ceases about the center of the posterior border of the ascending ramus, 
 in order to avoid the danger of cutting the important structures near the 
 upper half of the posterior border of the ascending ramus (parotid gland, 
 facial nerve, transverse facial and internal maxillary arteries, Steno's duct, 
 and temporomaxillary vein) — hence the coronoid process is thus approached 
 from before rather than from behind. The inferior maxilla should be de- 
 pressed only, and not rotated outward — in doing the latter, the internal 
 maxillary artery is apt to be hooked around the inner portion of the condyloid 
 process and dragged out into the wound, and even ruptured. (8) Following 
 the upper inner aspect of the condyloid process, free the insertion of the 
 external pterygoid with elevator, or cut with blunt curved scissors. Divide 
 the capsule and disarticulate the head of the bone forward. If not already 
 divided, sever the internal lateral, stylomaxillary, and pterygomaxillary 
 ligaments, and any binding bands of fascia, or fibers of the external pterygoid 
 muscle. (9) The wound is temporarily drained through the posterior portion 
 of the incision. The skin wound is carefully sutured to avoid scar. 
 
 Comment— (1) Excision, where large growths complicate, may require 
 a preliminary ligation of the external carotid — and a preliminary tracheotomy, 
 with tamponing of the larynx — as well as division of the entire thickness of 
 the lower lip. (2) If the median portion of the inferior maxilla, and therefore 
 the genial tubercles, be removed, the tongue must be stitched forward to 
 keep it from falling backward. (3) The coronoid and condyloid processes 
 
EXCISION OF RIBS, IN GENERAL. 479 
 
 may require to be first divided with forceps or chisel, and then withdrawn. 
 (4) Only healthy periosteum is to be saved — otherwise an open operation is 
 indicated. (5) Any portion of the alveolar process, or of the body, may be 
 removed. (6) Both inferior maxillae may be simultaneously removed, by 
 a repetition of the above procedure. (7) Feeding through a tube is, at first, 
 indicated after the operation. 
 
 OSTEOPLASTIC RESECTION OF THE LOWER JAW 
 
 TO EXPOSE STRUCTURES IN PHARYNX AND UPON FLOOR OF MOUTH. 
 
 Description. — The inferior maxilla is divided either in the middle line, 
 or just in front of its ascending ramus — the former, for the exposure of the 
 structures in the floor of the mouth, the fauces, and the anterior pharyngeal 
 structures — the latter, for the exposure of the fauces and the posterior pharyn- 
 geal structures. At the completion of the operation, the severed bone is 
 brought together with silk or metallic suture. 
 
 Preparation ; — Position. — As in the simple excision of the lower jaw 
 (page 477)- 
 
 Landmarks. — The median line, for the anterior operation, — and the angle 
 of the jaw and the attachment of the masseter, for the lateral operation. 
 
 Incisions. — (A) For the division in the middle line; — the incision is made 
 in the median line, through the lower lip, extending thence down to the hyoid 
 bone (Fig. 381, D). (B) For the division in front of the ascending ramus 
 of the jaw, at the anterior margin of the masseter; — an incision passing from 
 the tip of the mastoid process toward the hyoid bone (Fig. 380, B). 
 
 Operation. — (A) In the middle line; — The upper part of the median 
 incision is carried directly to the bone — the lower part is carefully deepened 
 and extended as far as the hyoid bone. The arteries in the lips are 
 clamped. The entire circumference of the jaw is cleared subperiosteally — a 
 central incisor tooth is drawn — a Gigli saw is conducted beneath that site of 
 the bone — and the jaw divided so as to be bevelled at the expense of its inner 
 surface and lower border, and so as to spare the genial tubercles (thus prevent- 
 ing over-riding of the bone, and keeping the genio-hyo-glossi and genio-hyoids 
 intact). The two sides of the jaw are now widely drawn apart by hooks — 
 and the tongue forward by a silk ligature passed through its substance. The 
 special object of the operation is now accomplished. Holes should have been 
 drilled on each side of the site to be divided — through which kangaroo-tendon 
 is now carried and tied. The skin wound is then closed — and the vermillion 
 border of the lip carefully sutured. (B) In front of the ascending ramus of 
 the jaw; — Ligate the facial artery and expose the inferior border of the lower 
 jaw at the anterior border of the masseter muscle — raising the periosteum and 
 inching the mucous membrane upon both aspects of the jaw. Having drilled 
 holes for future suturing, at the site of intended division, a Gigli saw is con- 
 ducted around the bone behind the molar teeth, and the section made obliquely 
 — the limit of section being farther forward upon the external and inferior 
 than upon the internal and superior aspect. The ascending ramus is drawn 
 upward and the body of the jaw forward — thus securing the requisite exposure. 
 At the completion of the operation, the parts of the bone are sutured and the 
 wound closed. 
 
 EXCISION OF RIBS, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 the Thorax, pages 733, 734. 
 
480 EXCISIONS. 
 
 General Surgical Considerations. — (1) The following extents of rib 
 may be removed; — (a) An entire rib, from and including its chondrosternal 
 articulation, to and including its costovertebral articulation; — (b) Part of a 
 rib (the rib proper), from and including the chondrocostal, to and including 
 the costovertebral articulation; — (c) Part of a rib, from and including the 
 chondrocostal, up to the costotransverse articulation; — (d) Any limited por- 
 tion of a rib; — (e) Two or more adjacent ribs, in whole or in part. (2) 
 Unless contraindicated, the portion of rib covered by periosteum should be 
 removed subperiosteal!}' (that is, the rib proper). 
 
 Best Methods of Excision. — By parallel incision over center of rib — 
 for one rib, or part of a rib. Parallel incision midway between ribs — for 
 two adjacent ribs. 
 
 EXCISION OF ENTIRE RIB AND COSTAL CARTILAGE 
 
 BV PARALLEL INCISION OVER CENTER OF RIB. 
 
 Position. — Patient near edge of table, in such a position as to render 
 site of operation accessible, and resting upon pad so as to render the part 
 prominent. Surgeon on side of operation, or behind, if patient be upon 
 side. Assistant stands opposite. 
 
 Landmarks. — Tipper and lower border of rib; chondrosternal articula- 
 tion; costovertebral articulation. 
 
 Incision. — The long parallel incision begins over the center of the chondro- 
 sternal articulation — passes directly over center of costal cartilage and rib — 
 ending over costovertebral articulation. The posterior end of this incision 
 will be over the center of the vertebral ends of the ribs, in the case of the lower 
 ribs — but will run along their upper border, just above the transverse pro- 
 cesses of the vertebra?, in the case of the upper ribs. 
 
 Operation. — Incise directly through skin, fascia, overlying muscle, and 
 periosteum, down to bone. Over the costal cartilages there is no periosteum, 
 as such. The treatment of the overlying muscles will be modified by the 
 part of the chest involved — where unimportant, they are cut through — where 
 important and capable of retraction after being cut, they are divided in their 
 cleavage line as far as this is possible — otherwise their fibers must be cut. 
 Important vessels, and especially important nerves, coursing downward 
 from the axillary region, are to be avoided, if possible. The rib is freed 
 subperiosteally — and with especial care along the groove upon the lower, 
 inner aspect, where the intercostal vessels and nerve run — using fully curved 
 periosteal elevator and rugine. Guard the pleura behind the posterior 
 surfaces of the ribs — intrathoracic fascia alone here intervening. Having 
 freed the center of the rib around its entire circumference, a chain or Gigli 
 saw is carried between bone and periosteum and the rib divided. First one 
 and then the other cut end of the rib is seized with bone-forceps and drawn 
 outward — and, while held in this position, is freed toward either end and 
 disarticulated. The musculo-periosteal sheath is sutured with gut — and the 
 wound closed. 
 
 Comment. — For excision of two or more consecutive ribs, in whole or 
 in part, see Estlaender's and Schede's operations, pages 765 and 768. 
 
 EXCISION OF CLAVICLE, IN GENERAL. 
 
 Surgical Anatomy. — Anteriorly; — supraclavicular nerves and vein con- 
 necting cephalic and external jugular veins cross the antero-superior surface 
 of the clavicle. Interiorly; — axillary vessels and brachial plexus rest upon 
 
EXCISION OF SCAPULA, IN GENERAL. 481 
 
 the first rib, under the clavicle, the subclavius muscle and dense fascia inter- 
 vening Posteriorlv; — omohyoid, scalenus anticus, scalenus medius, scalenus 
 posticus, sternohyoid, and sternothyroid muscles; subclavian, suprascapular, 
 and internal mammary arteries; innominate, subclavian, and external jugular 
 veins; brachial plexus, phrenic and posterior thoracic nerves; pleura, apex 
 of lung, and thoracic duct. 
 
 General Surgical Considerations. — The clavicle may be removed in 
 whole or in part — or the sternoclavicular or acromioclavicular joints may be 
 separately excised. 
 
 TOTAL EXCISION OF CLAVICLE 
 
 BY LONG AXIAL INCISION. 
 
 Position. — As for ligation of third part of subclavian artery, page 53. 
 
 Landmarks. — Clavicle; acromioclavicular joint; sternoclavicular joint. 
 
 Incision. — Along the antero-superior surface, following the curve of the 
 bone and extending beyond both sternoclavicular and acromioclavicular 
 joints (Fig. 383, C). 
 
 Operation. — The incision passes directly through skin, platysma, supra- 
 clavicular nerves, fascia, and periosteum to bone. Once within the perios- 
 teum, this membrane is completely detached with a fairly sharp, curved 
 periosteal elevator, together with the attached muscles and coracoclavicular 
 ligament. The clearing is first completed entirely around the center of the 
 bone, and at this point the bone is divided with a chain or Gigli saw conducted 
 between bone and periosteum. Each end is then grasped in turn with bone- 
 forceps and drawn outward — the remaining portions of periosteum being 
 freed to the articular ends while the bone is thus held. The outer end is 
 first removed and then the inner — especially guarding the important struc- 
 tures near the latter. The knife and periosteal elevator, or rugine, hug the 
 bone throughout the entire operation, the soft and important parts being 
 protected by spatula'. The musculo-periosteal sheath is closed as usual, and 
 the wound closed. The arm is put up as in the case of fractured clavicle. 
 
 Comment. — The safety of the operation and the freedom from hemor- 
 rhage will depend upon the nearness with which the subperiosteal method is 
 followed out. The chief dangers are the wounding of the structures beneath 
 and behind the clavicle (v. Surgical Anatomy, page 480). Any portion of the 
 clavicle may be removed through a corresponding part of this incision. 
 
 Excision of Sternoclavicular or Acromioclavicular Joints. — In ex- 
 cising the sternoclavicular or acromioclavicular articulations, disarticulation 
 is first accomplished — the inner or outer end of the clavicle, as may be, is 
 then elevated sufficiently to slip the Gigli saw beneath — it is then removed, 
 and the sternum or acromion gouged. The bone is closely hugged in these 
 operations, especially when working near its inner end. 
 
 EXCISION OF SCAPULA, IN GENERAL. 
 
 Surgical Anatomy. — The chief arteries in the neighborhood of the 
 scapula are the following: — suprascapular, crossing the ligament of the 
 suprascapular notch; posterior scapular, along the vertebral border; sub- 
 scapular branch of axillary, along the inferior border of the subscapularis; 
 dorsalis scapulae branch of subscapular, crossing the axillary border; acromial 
 branches of acromial thoracic, about the acromial process. The surgical neck 
 of the bone is marked off by a line from the suprascapular notch through 
 the great scapular notch. 
 31 
 
482 
 
 EXCISIONS. 
 
 General Surgical Considerations. — (1) The scapula may be removed 
 in whole or in part. The parts usually separately removed are, the acromion, 
 part of the spine, and part of the lower angle. (2) The glenoid, acromion 
 and coracoid processes are to be saved when possible. (3) The chief danger 
 is from hemorrhage. The chief difficulty is in the detachment of the muscles. 
 (4) Temporary drainage is indicated. (5) The excision is generally by the 
 open method. The subperiosteal method is scarcely practicable, and is 
 generally not indicated, as well. 
 
 After-treatment. — A pad is placed in the axilla to keep the head of the 
 humerus out. The arm is pushed up so that the head is in its natural position 
 and steadied against the chest — and held there by a sling for three or four 
 months. Passive movement is used in about three weeks. 
 
 Results. — A very useful limb often results — capable of all underhand, 
 but no overhand, movements, and of lifting weights. 
 
 TOTAL EXCISION OF SCAPULA 
 
 BY STRAIGHT INCISIONS ALONG SPINE AND VERTEBRAL BORDER, FORMING 
 SUPERIOR AND INFERIOR FLAPS. 
 
 Position. — Patient on sound side, near edge of table, with back to opera- 
 tor. Surgeon behind both scap- 
 ula?. One assistant compresses 
 subclavian artery. Another as- 
 sistant retracts flaps. 
 
 Landmarks. — Bony promi- 
 nences and outlines of scapula. 
 
 Incisions. — Vertebral Inci- 
 sion — passes parallel with and 
 just to outer side of vertebral 
 border, from superior to interior 
 angle. Spinal Incision — begins 
 over acromioclavicular joint and 
 passes thence along acromion 
 and spine to junction with ver- 
 tebral incision, meeting it at 
 almost a right angle. (Fig. 383, 
 C, C, and B, B'.) 
 
 Operation. — (1) These in 
 cisions pass through skin and 
 fascia. Raise the superior flap, 
 dividing the trapezius along the 
 upper border of the spine. (2) 
 Raise the inferior flap, divid- 
 ing the deltoid along the lower 
 border of the spine. (3) Render 
 the vertebral border prominent 
 by drawing the patient's arm 
 across his chest and divide the 
 muscles along that border (leva- 
 tor anguli scapulae, rhomboidei minor and major) — then further drawing 
 the vertebral border outward, divide the serratus magnus. Ligate the pos- 
 terior scapular artery near the superior angle. (4) Clear the superior border, 
 severing the omohyoid and ligating the suprascapular artery near the supra- 
 
 Fig. 383.— Excisions about the Shoulder and 
 Scapula : — A, Excision of shoulder-joint, by posterior 
 vertical incision ; B, B', Vertebral incision, in total 
 excision of scapula by vertebral and spinal incisions ; 
 C, C'i Spinal incision, in total excision of scapula by 
 vertebral and spinal incisions ; D, V-shaped incision, 
 for excision of superior angle of scapula ; E, V-shaped 
 incision, for excision of inferior angle of scapula. 
 
EXCISIONS ABOUT THE FINGERS. 483 
 
 scapular notch — the arm still being held across the chest. (5) Render the 
 angle of the shoulder prominent by drawing the arm downward — open the 
 acromioclavicular joint — sever any remaining portions of the deltoid and 
 trapezius — and cut the conoid and trapezoid ligaments as near the clavicle 
 as possible. (6) Manipulate the arm so as to bring the coracoid process 
 as far as possible into the wound made by separating the acromion from 
 the clavicle, and sever the insertion of the biceps, coracobrachialis and pec- 
 toralis minor. (7) Divide the capsule and the muscles surrounding it (supra- 
 spinatus, infraspinatus, and subscapularis) — and also the scapular head of the 
 biceps at the upper part of the glenoid fossa, and the scapular head of the 
 triceps at the lower part of the glenoid fossa. (8) Divide the remaining 
 muscles connecting the axillary border of the scapula to the arm, the teres 
 major and minor, cutting these muscles from in front — seizing and tying the 
 subscapular artery proximal to the origin of the dorsalis scapula?. (9) The 
 deeper muscles, the supraspinatus, infraspinatus, and subscapularis, are re- 
 moved with the bone — except that their tendons of insertion into the humerus 
 are left. Drop the flaps into place and suture their margins. Temporary 
 drainage should be used, as oozing is apt to be marked. 
 
 Comment. — If necessary, the subclavian may be compressed through an 
 incision. The chief vessels, however, may be ligated in advance of incisions 
 for the flaps, that is, before the beginning of the operation proper — but can 
 generally be taken up during the operation, before actually cutting them. 
 
 Partial Excisions of the Scapula. — The acromion process may be 
 excised through an incision placed centrally over its prominent contour (Fig. 
 383, B). The angles of the bone may be removed by V-shaped incisions 
 (Fig. 383, D and E). The body of the scapula is excised through practically 
 the same incisions as are used for the total excision. 
 
 EXCISIONS ABOUT THE FINGERS. 
 
 Surgical Anatomy — Surface Form and Landmarks. — See under Am- 
 putations of the Fingers, pages 323 and 324. 
 
 General Surgical Considerations. — (i) Typical excisions about the 
 
 Fig.384 —Excisions about the Fingers :— A, Excision of terminal phalanx, by U-shaped pal- 
 mar incision ; B, Excision of second phalanx of index, by dorso-external incision ; C, Excision of first 
 interphalangeal joint, by two lateral incisions. 
 
 fingers are unusual. Incomplete excisions for dead bone are more common. 
 (2) Excision of the terminal phalanx is better than disarticulation at the 
 last interphalangeal joint. (3) Excision of the interphalangeal joints is very 
 satisfactory. (4) Excision of the metacarpo-phalangeal joints often leaves a 
 
484 EXCISIONS. 
 
 useless joint — except in the case of the thumb. It should n< t be clone in the 
 young, as it destroys the epiphyses of the metacarpal and phalanx. It is 
 satisfactory in the case of the thumb, especially if the phalangeal epiphysis 
 be left (there is no lower metacarpal epiphysis). (5) In excisions of the 
 phalanges and metacarpals, the subperiosteal method is particularly indicated, 
 although its execution is not very satisfactory. (6) Partial excision of the 
 phalanges and metacarpals is more satisfactory than total excision. (7) 
 About the only phalanges one usually attempts to excise are the last of all 
 the fingers, the second of the index, and the first of the thumb. 
 
 Methods of Excision about the Fingers. — (a) For Terminal Phalanx 
 of Finger or Thumb: — Best Method; U-shaped Palmar Incision, (b) For 
 Second Interphalangeal Joint: — Be>t Methods; Two Lateral Incisions (for 
 lingers in general); Dorso-external Incision (for index); Dorso-internal Inci- 
 sion (for little finger) ; — Other Methods; Dorsolateral Incision; Single Lateral 
 Incision, (c) For Second Phalanx: — Dorso-lateral Incision (for ringers in 
 general — if done at all); U-shaped Palmar Incision (for thumb); Dorso- 
 external Incision (for index) ; Dorso-internal Incision (for little finger — if 
 done at all); — Other Methods; Two Lateral Incision-, (d) For First Inter- 
 phalangeal Joints: — Two Lateral Incisions (for fingers in general); Dorso- 
 external Incision (for index and thumb); Dorso-internal Incision (for little 
 finger); — Other Methods; Single Lateral Incision, (e) For First Phalanx: — 
 Dorso-lateral Incision (for fingers in general — if done at all); Dorso-internal 
 Incision (for thumb — and for index, if done in the latter case at all) ; Dorso- 
 internal (for little finger — if done at all; ; — Other Method; Two Lateral 
 Incisions. 
 
 EXCISION OF TERMINAL PHALANGES OF FINGERS 
 
 BY I'-SHAPED PALMAR.' IXCISIOX. 
 
 Position. — As for Amputations about the Fingers (page 327). 
 
 Landmarks. — Terminal interphalangeal joint. 
 
 Incision. — U -shaped incision — beginning opposite the terminal inter- 
 phalangeal joint-line, with the two limbs about three-fourths of the width 
 of the linger apart, and with the convexity extending downward nearly to 
 the nail-tip (Fig. 384, A). 
 
 Operation. — The incision passes directly to the bone — the soft parts are 
 dissected up in the form of a palmar flap — and the terminal phalanx grasped 
 with forceps, disarticulated, and enucleated. The palmar flap is then sutured 
 back into position and the digit dressed upon a palmar splint. 
 
 Comment. — Is is better to make a partial excision, if possible, leaving 
 the base of the phalanx — which insures the retention of the epiphvsis and 
 the attachment of the flexor profundus digitorum. If a total excision be 
 done, suture the flexor tendon into the stump and close the beginning of the 
 flexor sheath, if demonstrable. 
 
 EXCISION OF SECOND INTERPHALANGEAL JOINTS OF FINGERS 
 
 BY TWO LATERAL [NCISK INS. 
 
 Position. — As for Amputations about the fingers (page 327). 
 
 Landmarks. — Second Interphalangeal joint-line. 
 
 Incisions. — Two straight incisions in the mid-lateral aspects of the 
 fingers, with their center over the joint-line (Fig. 385 A. A'). 
 
 Operation. — The incisions pass directly through skin, fascia, lateral 
 ligaments, periosteum, and capsule into joint. By hugging the bones and 
 
EXCISION OF SECOND 1XTERPHALAXGEAL JOINTS OF FIXGERS. 485 
 
 working between them and the soft parts with a sharp, fully curved small 
 periosteal elevator, the bones are everywhere freed. The articular ends are 
 then disarticulated — thrust out of the wounds — cut off with saw — and the 
 
 Fig.385.— Excisions about the Hand and Wrist :— A. A'. Excision of second interphalangeal 
 joint by two lateral incisions : B. Of second interphalangeal joint of index, by dorso-external incision ; 
 C. Of second interphalangeal joint of little ringer, by dorso-internal incision : D. Of second phalanx of 
 finger, by dorso-lateral incision : E. E'. Of first interphalangeal joint, by two lateral incisions ; F. Of 
 first phalanx of thumb, by dorso-external incision : G. Ofmetacarpo-phalangeal joint, by dorso-latera) 
 (dorso-external' incision: H. Of metacarpophalangeal joint, by dorso-lateral .dorso-internal) inci- 
 sion ; I. Of metacarpal, by dorsal incision ; J. Of metacarpal, by dorsal incision, with added angular 
 incision : K. Of metacarpal of little finger, by dorso-internal incision; L. Of metacarpal of thumb, by 
 dorso-extenial incision: M, M', Of wrist-joint, by radial incision, and N, ulnar incision lOllier's 
 operation); O, O, Of wrist joint, by dorso-radial incision (Boeckel-Langenbeck operation); P, P, 
 of wrist-joint, by dorso-ulnar incision (.Kocher's method). 
 
 sawed ends drawn back. The musculo-periosteo-capstilar sheath is then 
 closed on either side with buried gut sutures. The skin wounds are sutured 
 and the parts dressed on a palmar splint. 
 
4 86 EXCISIONS. 
 
 EXCISION OF SECOND INTERPHALANGEAL JOINT OF INDEX 
 
 BY DORSO-EXTERNAL INCISION. 
 
 Position — Landmarks. — As in the above operation. 
 
 Incision. — A straight incision placed over the dorsal aspect of the second 
 interphalangeal joint, just to the outer side of the extensor tendon — with its 
 center over the joint-line. 
 
 Operation. — The incision passes directly through skin, fascia, capsule, 
 and periosteum — going through the last over the ends of the phalanges just 
 above and below the joint. The soft parts are subperiosteally elevated from 
 the joint and ends of the bones. The bones are then disarticulated — pro- 
 truded — and their ends sawed off just beyond their articular surfaces. The 
 sawed ends are now drawn back into position — the musculo-periosteo- 
 capsular sheath is closed, on either side, with buried gut sutures — the lips 
 of the skin wounds sutured — and the digit dressed upon a palmar splint. 
 (For principle, see Fig. 384, C, and Fig. 385, B.) 
 
 EXCISION OF SECOND INTERPHALANGEAL JOINT OF LITTLE FINGER 
 
 BY DORSO-INTERNAL INCISION. 
 
 Description. — The operation is, in every respect, similar to the above 
 — except that the incision is placed over the dorsal aspect of the second inter- 
 phalangeal joint of the little finger, just to the inner side of the extensor 
 tendon, with its center over the joint-line (Fig. 385, C). 
 
 EXCISION OF SECOND PHALANGES OF FINGERS 
 
 BY DORSO-LATERAL INCISION. 
 
 Position. — As for Amputations (page 327). 
 
 Landmarks. — Second phalanx, and first and second interphalangeal 
 joints. 
 
 Incision. — Straight incision placed over the dorsal aspect of the second 
 phalanx, just to the outer or inner side of the extensor tendon — beginning 
 just above the first interphalangeal joint and ending just below the second 
 interphalangeal joint. In the index-finger the incision would be dorso- 
 external (that is, to the outer side of the extensor tendon). In the little 
 finger, if performed at all, it would be dorso-internal. In the thumb, it 
 would be by a U-shaped palmar incision (Fig. 384, B, and Fig. 385, D). 
 
 Operation. — The incision passes directly through skin, fascia, perios- 
 teum, and capsules of the first and second interphalangeal joints. The soft 
 parts are subperiosteally elevated from the bone and the bone isolated and 
 disarticulated. The lips of the periosteo-capsular sheath are carefully sutured 
 with buried gut sutures. The margins of the skin wound are closed in the 
 usual manner. The finger is dressed upon a palmar splint until new bone 
 has been thrown out. 
 
 Comment. — In the case of the thumb, the operation is the same as for 
 the terminal phalanx of the fingers in general. 
 
 EXCISION OF SECOND PHALANX OF INDEX 
 
 P.Y DORSO-EXTERNAL INCISION. 
 
 Position. — As for Amputations of Fingers (page 327). 
 
 Landmarks. — Second phalanx. 
 
 Incision. — Straight incision over dorsal aspect of index, placed just to 
 the outer side of the extensor tendon — beginning just above the first inter- 
 phalangeal joint and ending just below the second interphalangeal joint 
 (Fig. 384, B). 
 
EXCISION OF METACARPOPHALANGEAL JOINTS OF FINGERS. 487 
 
 Operation. — As for excision of the second phalanges of the fingers in 
 general. 
 
 EXCISION OF SECOND PHALANX OF LITTLE FINGER 
 
 BY DORSO-INTERNAL INCISION". 
 
 Position — Landmarks. — As in the last operation. 
 
 Incision. — Straight incision over dorsal aspect of little finger, just to the 
 inner side of the extensor tendon — beginning just above the first and ending 
 just below the second interphalangeal joint. 
 
 Operation. — As for excision of the second phalanges in general. 
 
 EXCISION OF FIRST INTERPHALANGEAL JOINTS OF FINGERS. 
 
 Description. — The best method of excising the first interphalangeal 
 joints is the same as adopted in the case of the second interphalangeal joints 
 — namely, by two lateral incisions for the fingers in general (Fig. 385, E, E'), 
 ■ — dorso-external incision, for the index or thumb, — and dorso-internal in- 
 cision, for the little finger. (For principle, see Fig. 385, G and C.) These 
 operations are described at pages 4S4 and 486. 
 
 EXCISION OF FIRST PHALANGES OF FINGERS. 
 
 Description. — The excision of the first phalanx of a finger is, ordinarily, 
 not admissible — except in the case of the thumb. If performed at all, the 
 best methods would be the same as those adopted in the case of excision 
 of the second phalanges — namely, by the dorsodateral incision, for the fingers 
 in general (on either inner or outer side of the extensor tendon), — dorso- 
 external for thumb or index, — and dorso-internal for little finger. 
 
 EXCISIONS ABOUT THE HAND. 
 
 Surgical Anatomy — Surface Form and Landmarks. — See under Am- 
 putations about the Hand, pages 323, 324, and 325. 
 
 General Surgical Considerations. — (i) Partial excisions about the hand 
 are successful operations. (2) Total excisions, if subperiosteal, will some- 
 times yield a firm cicatrix that will render the finger useful. But sometimes 
 the finger is drawn up and useless. (3) Operations for the partial excision 
 of the metacarpals are the same in principle as those for the excision of the 
 entire bone, except more limited — and hence will not be given separately. 
 If a chain or Gigli saw can be passed around the bone in these operations 
 of partial excision, this is preferable to cutting the metacarpal with pliers. 
 If this cannot be done, one can cut through the center of that part which is 
 to be removed with pliers, and then slip a chain or Gigli saw under either 
 end and remove the requisite amount, thus avoiding the crushing effect of 
 the bone pliers. (4) Operations for the removal of individual carpal bones 
 are uncommon. Their removal in the course of excision of the wrist is dealt 
 with under that operation. 
 
 EXCISION OF METACARPOPHALANGEAL JOINTS OF FINGERS 
 
 BY DORS' )-LATERAL INCISION. 
 
 Position. — As for Disarticulations at the Metacarpophalangeal joints 
 (page 332). 
 
488 EXCISIONS. 
 
 Landmarks. — Metacarpophalangeal joints. 
 
 Incision. — Straight incision over the dorsal aspect of the joint, just 
 to the outer or inner side of the extensor tendon, with its center over the 
 joint-line (Fig. 385, H and G). 
 
 Operation. — The incision passes through skin, fascia, capsule of the 
 joint, and the periosteum of the ends of the metacarpal and phalangeal 
 bones. The bones are closely hugged and the soft parts are freed from the 
 articular ends and shafts. The articular ends of the bones are disarticulated 
 and the base of the phalanx first protruded and sawed off. The parts are 
 then retracted from about the head of the metacarpal, which is thus made 
 prominent and removed with a small saw, or chain or Gigli saw, while steady- 
 ing the end of the bone with bone-forceps. The bones are then drawn back 
 in place — the periosteo-capsular sheath sutured with buried gut stitches — 
 the skin wound closed — and the part dressed upon a palmar splint. 
 
 Comment. — In excising the metacarpophalangeal joint of the thumb or 
 index, a dorso-external incision is used — and, in the case of the little finger, 
 a dorso-internal incision. Otherwise the operations at these sites are similar 
 to the one just described. 
 
 EXCISION OF THE METACARPALS 
 
 BY DORSAL INCISION. 
 
 Position. — As for Disarticulation of the Metacarpals, page 332. 
 
 Landmarks. — Carpo-metacarpal and metacarpophalangeal joints. 
 
 Incision. — Straight incision over the dorsal aspect, immediately to the 
 outer or inner side of the extensor tendon, beginning just above the carpo- 
 metacarpal and ending just below the metacarpo-phalangeal joint. If neces- 
 sary, the upper and lower ends of the incision may have two short diverging 
 arms continuing from them, to better expose the joints. The incision may 
 be placed directly in the mid-dorsal line, the extensor tendon being carefully 
 drawn to one side, out of harm's way, as soon as the skin is incised (Fig. ^85, 
 I and J). 
 
 Operation. — After guarding the extensor tendon, the incision passes 
 through periosteum of the metacarpal and the capsules of the two joints 
 directly to the bone. The central portion of the metacarpal is first cleared 
 subperiosteal]} 7 - around its entire circumference by a fully curved periosteal 
 elevator, the interossei being separated with the periosteum. Unless a Gigli 
 saw can be conducted around the shaft of the metacarpal, the center of the 
 bone is divided with cutting pliers (for although they crush the bone, no part 
 of it is to be saved). Each end of the divided bone is then seized in turn 
 with bone-forceps and forcibly drawn backward and manipulated from side 
 to side — during which manipulation the lateral and palmar surfaces are freed 
 and the ligaments at the carpo-metacarpal and metacarpo-phalangeal joints 
 are put upon the stretch and divided. The musculo-periosteal sheath is 
 then sutured with buried catgut stitches and the skin wound closed. 
 
 Comment. — (1) The metacarpal may be first disarticulated at the meta- 
 carpo-phalangeal joint and then drawn backward — but the above method is 
 easier. (2) The extensor tendons and the structures in the palm of the 
 hand are always especially guarded. 
 
EXCISION OF THE WRIST-JOINT, IN GENERAL. 489 
 
 EXCISION OF METACARPAL OF THUMB 
 
 BY DORSO-EXTERNAL INCISION. 
 
 Position. — The ulnar side of the hand is held against the table, the radial 
 side presenting. 
 
 Landmarks. — The metacarpal bone and carpometacarpal and meta- 
 carpophalangeal joints. 
 
 Incision. — Straight incision over the dorso-external aspect of the meta- 
 carpal, just to the outer side of the extensor brevis pollicis tendon — beginning 
 above the trapezio-metacarpal and ending just below the metacarpo-phalan- 
 geal joints. If necessary an angular incision may be added to the ends of 
 the straight incision (Fig. 385, L). 
 
 Operation. — Having incised skin, avoid the external branch of the radial 
 nerve — and then cut directly through periosteum and capsules onto bone and 
 into joints. The operation is then completed as in the case of an ordinary 
 finger. The extensor ossis metacarpi pollicis is separated from the base of 
 the metacarpal. The subperiosteal method is here especially to be carried 
 out, if possible. 
 
 EXCISION OF METACARPAL OF LITTLE FINGER 
 
 BY DORSO-INTERNAL INCISION. 
 
 Description. — The operation is the same as that for the fingers in general, 
 except that the incision is placed upon the inner side of the extensor tendon 
 (Fig. 385, K). 
 
 EXCISION OF THE WRIST- JOINT, IN GENERAL. 
 
 Surgical Anatomy — Surface Forms and Landmarks. — Given under 
 Disarticulation at the Wrist, page 348. 
 
 Position. — See each operation. 
 
 General Surgical Considerations.— In complete excision of the wrist- 
 joint, all of the carpals, the lower ends of the radius and ulna, and the articular 
 ends of the metacarpals are removed. When not diseased, it is well, however, 
 to leave the pisiform, unciform process of the unciform and trapezium, as the 
 two former give attachment to man}- muscles and the latter forms part of the 
 important thumb-joint. 
 
 After-treatment. — A splint is indicated which will support the palm; 
 keep the wrist slightlv extended; the fingers slightly flexed and the thumb 
 slightly separated from the hand. The fingers should be passively moved 
 within three or four days. The wrist should be kept still until fairly solid 
 and then passively moved, still being held upon a splint, which is generally 
 retained for from three to six months. 
 
 Results. — Usually not altogether satisfactory. The hand may become 
 rigid, adducted, and useless. Speedy healing without suppuration, a good 
 splint, and faithful passive movement aid largely in the production of a 
 satisfactory result. 
 
 Best Methods.— Radial and Ulnar Dorsal Incisions (Ollier's operation). 
 Single Dorso-radial Incision (Boeckei-Langenbeck operation) . Single Dorso- 
 ulnar Incision (Kocher's method). 
 
 Other Methods. — Bilateral Incisions (Lister's method). Dorso-ulnar 
 Incision. Median Dorsal Incision (Mayo Robson's method). Single Ulnar 
 Lateral Incision (Heron Watson's method). 
 
49© EXCISIONS. 
 
 Comparison. — The carpal bones are removed with greater ease, and less 
 damage is done to the tendons, bv the method of the radial and ulnar dorsal 
 
 EXCISION OF WRIST 
 
 BV RADIAL AND ULNAR DORSAL INCISION — OLLIKR'S OPERATION. 
 
 Description. — The articular ends of the radius and ulnar are removed. 
 The articular ends of the metacarpal bono are gouged only, unless exten- 
 sivelv diseased, and, if so, are removed. The pisiform bone, the unciform 
 processes of the unciform bone, and the trapezium are preserved, if possible — 
 for the reasons given below. 
 
 Position. — Patient's hand, prone, rests by his side, or, preferably, upon 
 a small table at the patient's side, supported upon a firm cushion. Surgeon 
 sits in front of the hand. Assistant steadies patient's forearm and fingers. 
 
 Landmarks. — See Incision. 
 
 Incisions. — (i) Radial Incision — begins opposite the center of the dorsal 
 surface of the second metacarpal — passes obliqued}' upward, just to the outer 
 border of the extensor indicis tendon, to the center of a line connecting the 
 two stvloid processes — thence changes its course slightly and passes vertically 
 upward in the long axis of the limn for about 7.5 cm. (3 inches) above the 
 radial styloid process. (2) Ulnar Incision — begins opposite the center of the 
 dorsal surface of the fifth metacarpal — and passes upward $.2 cm. (i\ inches) 
 above the tip of the ulnar styloid process, lying to the inner side of the extensor 
 carpi ulnaris (Fig. 385, MM' and X). 
 
 Operation. — (1) The radial incision is at first superficial. The internal 
 branch of the dorsal division of the radial nerve is avoided, if possible. The 
 extensor indicis tendon is exposed and is retracted outward, with its sheath. 
 The tendon of the extensor carpi radialis brevior is crossed by the incision — 
 is followed down to the insertion into the base of the third metacarpal and 
 is drawn outward, but not cut. The upper part of the incision passes down 
 between the extensor indicis (which, with the extensor communis digitorum, 
 is drawn inward) and the extensor longus pollicis (which is drawn outward). 
 This incision is now, after retraction of the muscles and tendons, carried 
 through the posterior annular ligament, capsule of the joint, and periosteum 
 of the carpal, radial, and metacarpal bones. (2) The ulnar incision is also 
 at first superficial. The dorsal cutaneous branch of the ulnar nerve is avoided, 
 if possible. The incision is carried down along the inner border of the ex- 
 tensor carpi ulnaris — upon the ulna, cuneiform, unciform, and fifth meta- 
 carpal — going through the posterior annular ligament, capsule, and peri- 
 osteum of the ulna, carpal and metacarpal bones. (3) Decortication is 
 begun upon the radial side. The periosteum and ligaments are stripped up 
 from the dorsal surface of the carpal bones as far as can be done through 
 the radial incision. All the tendons are raised with their periosteum bodily 
 from their grooves, with their sheaths unopened. The same steps are re- 
 peated through the ulnar incision — hugging the bones closely and elevating 
 off all the overlying tissues, working entirely between these tissues and the 
 bones. (4) Removal of the carpal bones. As each carpal bone is outlined 
 and partially separated, it is seized from the dorsum of the hand with strong 
 bone-forceps, and, while being twisted from side to side, its lateral attach- 
 ments are severed as close to the bone as possible, and its palmar attachments 
 as subperiosteal!}' as possible, and removed. The most convenient order in 
 
EXCISION OF THE WRIST- JOINT. 49 1 
 
 which to remove the carpal bones is, scaphoid, semilunar, cuneiform, os 
 magnum, trapezoid, and body of unciform. All are thus freed and removed 
 — except that the pisiform (which is deeply seated and has the attachments 
 of the flexor carpi ulnaris and abductor minimi digiti) is left; — and the unci- 
 form process of the unciform bone (which is also deeply seated and has the 
 attachments of the flexor brevis minimi digiti, flexor ossis metacarpi minimi 
 digiti, and anterior annular ligament) should be cut through with bone-pliers 
 and left — and the trapezium (which is rarely diseased and which enters into 
 the important metacarpo-trapezial joint of the thumb, and has the attach- 
 ments of the abductor pollicis, flexor ossis metacarpi pollicis, flexor brevis 
 pollicis, and anterior annular ligament) should also be left. If any of these 
 be diseased, however, they should be removed. (5) The lower ends of the 
 radius and ulna are now freed of periosteum, by following them around from 
 the upper part of the vertical incisions. The soft parts are all then retracted 
 and the ends of the bones protruded through the wound and removed just 
 above the articular cartilages — or, if but little diseased, may be simply gouged 
 without being extensively freed. (6) The articular ends of the metacarpals 
 should be gouged, if not much involved — or. if extensively diseased, removed, 
 by being protruded into the wound and a thin slice of bone taken off with a 
 narrow saw. (7) Temporary drainage is used — the wound sutured and 
 dressed — and a special splint applied. 
 
 Comment. — (1) The subperiosteal method is difficult, but if carefully 
 carried out, no tendons are cut. In the open method the tendons of the 
 extensores carpi radialis longior et brevior are cut — and tendons of the flexor 
 carpi radialis, flexor carpi ulnaris, and extensor carpi ulnaris are in danger 
 of being cut. (2) The ends of the radius and ulna may be first disarticulated 
 and sawed, and then the carpal bones removed, if such a course seem more 
 convenient. (3) The radial artery and the palmar structures are to be 
 specially guarded. 
 
 EXCISION OF THE WRIST- JOINT 
 
 BY SINGLE DORSO-RADIAL INCISION — BOECKEL-LANGENBECK OPERATION. 
 
 Description. — Same as for the last operation, as to the bones removed — 
 but different in incision of approach. 
 
 Position. — As in preceding operation. 
 
 Landmarks. — See Incision. 
 
 Incision. — Straight incision, between the extensor communis digitorum 
 and extensor indicis, on the inner side, and extensor longus pollicis (extensor 
 secundi internodii pollicis) on the outer side, running close to the outer border 
 of the former — extending from the ulnar border of the dorsal surface of the 
 lower third (or half) of the second metacarpal up over the radius for about 
 5 cm. (2 inches) above the joint-line (Fig. 385, O, O'). 
 
 Operation. — The incision is made carefully, and branches of the radial 
 nerve to the middle finger avoided, if possible. The incision is now deepened 
 toward the second metacarpal, trapezoid, scaphoid, capsule, posterior annular 
 ligament, and radius. In this deeper incision, however, the tendons of the 
 extensor indicis and extensor communis digitorum are retracted when exposed 
 — and the tendons of the extensor radialis longior and extensor radialis brevior 
 are not cut. These latter tendons are isolated and are then freed down to 
 their attachment into the bases of the second and third metacarpals respec- 
 tively. If the trapezium is to be left, together with the pisiform and unciform 
 
492 
 
 EXCISIONS. 
 
 process of the unciform, it is possible, though difficult, to complete the exci- 
 sion without severing these tendons. Otherwise, however, and where the 
 tissues are much infiltrated and bound down especially, these two tendons 
 are detached subperiosteal!;/ at their insertion. If not divided, these tendons 
 are shifted from side to side in the subsequent manipulations. If divided, 
 they are sutured back as nearly in their normal positions as possible, at the 
 end of the operation. The remaining steps of the operation — decortication — • 
 
 freeing and excising of the ends of the radius 
 and ulna — removal of the carpal bones — 
 freeing and excising, or gouging, of the 
 ends of the metacarpals — together with the 
 closure of the wound — are all carried out 
 through this single opening, aided by good 
 lateral retraction, just as in Ollier's opera- 
 tion by the double dorsal incisions. 
 
 Comment. — The chief objections to the 
 operation are the difficulty of dealing with 
 the bones to lie excised without division of 
 the extensores carpi radialis longior et bre- 
 vior — and damage done to the extensor 
 muscles of the hand, dorsifiexion some- 
 times being seriously impaired subsequently. 
 
 EXCISION OF THE WRIST- JOINT 
 
 BY SINGLE DORSO-ULNAR INCISION 
 
 kocher's METHOD. 
 
 Description. — The joint is approached 
 from its ulnar aspect — the important radial 
 extensor tendons are not severed- — and by 
 completely dislocating the joint, it is pos- 
 sible to inspect it in its entirety. 
 
 Position. — As in Ollier's method (page 
 490). 
 
 Landmarks. — Fifth metacarpal bone; 
 wrist-joint. 
 
 Incision.— Is from 7 to 8 cm. (about 3 
 inches) in length — -extending from the cen- 
 ter of the wrist-joint — and thence upward 
 along the middle of the back of the fore- 
 arm (Fig. 385, P, P). 
 
 Operation. — Deepen this incision — 
 avoiding dorsal branch of the ulnar nerve 
 and the posterior ulnar vein in the lower part 
 of the incision. Divide the fascia and the pos- 
 terior annular ligament and open the sheaths 
 of the extensor minimi digiti and extensor communis tendons and draw them to 
 the radial side. Under the retracted tendons the ligaments connecting the fifth 
 metacarpal, the unciform, cuneiform, and ulna are divided. The capsule 
 together with the tendon of the extensor carpi ulnaris is separated and retracted 
 toward the ulnar aspect. (The separation of the extensor carpi ulnaris in 
 this operation is not as serious as the separation of the two radial extensors 
 in the Dorso-radial operation.) The tendon of the extensor carpi ulnaris is 
 
 Fig. 386. — Excisions about the 
 Long Bones of the Upper Extrem- 
 ity: — A, Excision of ulna, by long pos- 
 terior incision ; B, Excision of radius, 
 by long externo-dorsal incision ; C, Ex- 
 cision of part of diaphysis of humerus, 
 by external vertical incision. 
 
TOTAL EXCISION OF THE ULNA 
 
 493 
 
 removed from its osseous groove on the dorsal surface of the ulna. The cap- 
 sule is incised and removed from around the lower end of the ulna. The 
 meniscus is to be removed if the inferior radio-ulnar articulation is involved. 
 The joint between the cuneiform and pisiform is opened up — leaving the 
 tendon of the flexor carpi ulnaris attached to the pisiform. The unciform 
 process of the unciform is exposed and cut off with bone-cutting pliers. The 
 mass of common flexor tendons is lifted out of their groove. The ligamentous 
 connections between the three innermost metacarpals are separated upon 
 the palmar aspect of the hand — preserving the insertion of the flexor carpi 
 radialis into the second metacarpal. Detach the anterior ligament of the 
 wrist from anterior aspect of the lower end of the radius. Dorsally, the 
 posterior ligament is detached from the inferior end of the radius as far as the 
 extensors of the radius and thumb, and the tendons are elevated from their 
 grooves — the insertions of the radial extensor tendons into the third and 
 second metacarpals being preserved. The hand is now forcibly flexed toward 
 the forearm and completely dislocated toward the radio-flexor aspect — bringing 
 the thumb into touch with the radial border of the forearm, and displacing 
 the extensor tendons to the radial side of the radius. If necessary, further 
 detach the capsule from the outer aspect of the radius up to the insertion of 
 the supinator longus. The carpal bones are now dissected out in turn — the 
 trapezium and trapezoid being the most difficult to remove. A thin slice of 
 the articular aspect of the bones of the forearm and the heads of the metacarpals 
 is removed with an appropriate saw. These bones should be sawn so as to 
 give surfaces curved on a transverse axis — to aid in subsequent dorsal and 
 palmar flexion and extension. The hand is brought back into line with the 
 forearm — and the limb put up in a splint which will secure dorsi-flexion of 
 the hand, while leaving the fingers free for passive movement. 
 
 Comment. — (i) Apart from the advantages mentioned under Description, 
 this form of approach is especially indicated where the involvement is chiefly 
 of the ulnar aspect of the hand. (2) Avoid the radial artery in its course 
 upon the dorsum between the trapezium and trapezoid and passing to the 
 palm between the first and second metacarpals. 
 
 EXCISION OF THE ULNA, IN GENERAL. 
 
 Surgical Anatomy Surface Form and Landmarks. — Given under 
 Amputations about the Forearm, pages 353 and 354. 
 
 General Surgical Considerations. — The entire ulna, or any portion of 
 its diaphysis, may be removed. 
 
 After-treatment. — A long supporting splint for the forearm, with pas- 
 sive movement at the elbow and wrist. 
 
 Results. — Satisfactory results have followed the subperiosteal method. 
 
 TOTAL EXCISION OF ULNA 
 
 BY LONG POSTERIOR INCISION. 
 
 Position. — Patient's forearm is pronated and outstretched upon a small 
 table. 
 
 Landmarks. — Ulna; elbow- and wrist-joints. 
 
 Incision. — In the long axis of the ulna, and placed so as to fall upon its 
 posterior border in the interval between the anconeus and flexor carpi ulnaris 
 above, and between the flexor carpi ulnaris and extensor carpi ulnaris below 
 (Fig. 386, A). 
 
 Operation. — Having incised the skin and fascia, the above intermuscular 
 
494 EXCISIONS. 
 
 spaces are recognized and followed to the bone — after having sought the 
 dorsal branch of the ulnar nerve beneath the flexor carpi ulnaris, about 5 
 cm. (2 inches) above the wrist-joint, and henceforth guarded it. The perios- 
 teum is incised to the bone throughout along the line of incision. The center 
 of bone is then freed of periosteum entirely around its circumference, using 
 a well-curved periosteal elevator. A chain or Gigli saw is now carried between 
 bone and periosteum and the former divided at its center. Each end of the 
 bone is then seized with bone-forceps and, while manipulated, is further 
 freed of periosteum up to and into the capsules of the elbow- and wrist-joints 
 — thus raising a periosteo-capsular covering. Both articular ends are dis- 
 articulated — the periosteo-capsular sheath sutured with buried gut stitches — 
 the muscles quilted — the skin-wound closed, except for temporary drainage 
 of the elbow and wrist articulations — and the limb put up upon a long splint. 
 Comment. — If it be possible to leave one or both articular ends of the 
 bone, it is desirable. 
 
 EXCISION OF THE RADIUS, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks General Sur- 
 gical Considerations — After-treatment — Results. — As in the case of the 
 Ulna, page 493- 
 
 TOTAL EXCISION OF RADIUS 
 
 BY LONG EXTERXO-DORSAL INCISION. 
 
 Position. — Patient's forearm lies outstretched and upon its ulnar border, 
 resting on a small table. 
 
 Landmarks. — Radius; elbow- and wrist-joints. 
 
 Incision. — In long axis of radius, and placed so as to fall upon its ex- 
 terno-dorsal aspect, in the groove between the supinator longus and extensor 
 carpi radialis longior (Fig. 386, B). 
 
 Operation. — Having incised the skin and fascia, this intermuscular space 
 is identified and followed to the bone — after having sought the radial nerve 
 beneath the supinator longus and henceforth guarded it. The periosteum 
 is incised to the bone throughout. The insertion of the pronator radii teres 
 is raised from the bone with the periosteum and turned forward. The 
 supinator brevis is bisected vertically, the anterior half being displaced forward 
 with the radial nerve, the posterior half backward with the posterior inter- 
 osseous nerve. The bone is now freed of its periosteum entirely around its 
 circumference at its center, using a fully curved periosteal elevator. A chain 
 or Gigli saw is passed between bone and periosteum and the former divided. 
 Each end of the bone is then seized with bone-forceps — and the operation 
 completed as in the corresponding operation upon the ulna (page 49 2 )- 
 
 Comment. — Same as for the Ulna (page 494) • 
 
 EXCISION OF ELBOW- JOINT, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Disarticulation at the Elbow, pages 359 and 360. 
 
 General Surgical Considerations. — (1) Excision of the elbow-joint 
 consists in the removal of the lower end of the humerus and the upper ends 
 of the radius and ulna. (2) It is difficult, if not impossible, to save the peri- 
 osteo-capsular sheath intact. (3) Partial excisions may be done — of the 
 articular ends of either humerus, radius, or ulna. (4) The brachialis anticus 
 
EXCISION OF ELBOW- JOINT. 495 
 
 is inserted into the ulna beyond the coronoid process, — and the triceps into 
 the sides as well as the tip of the olecranon, and thence into the deep fascia 
 of both sides of the forearm, especially on the inner side. Therefore as little 
 of these parts is to be sacrificed as possible. The preservation of the bands 
 of fibers continued from the triceps to the fascia of the forearm is important 
 in excising the elbow, as the power to extend the limb is thereby preserved 
 in part. For the relation of the triceps and brachialis anticus to the move- 
 ments of the forearm, see Movements of the Elbow-joint, page 360. (5) 
 The ulnar and posterior interosseous nerves are to be especially guarded 
 in these operations. 
 
 After-treatment. — A special jointed splint is indicated that will hold the 
 forearm and arm at any angle to each other, with the power to change the angle 
 without removing the splint. The limb is at first put up at an angle of 135 
 degrees, with the forearm midway between pronation and supination, the 
 ends of the bones being about 1.3 cm. (h inch) apart, and the fingers free. 
 Where ankylosis is feared (as in children and after the subperiosteal method), 
 or where much bone has been removed, the limb may be put up at a right 
 angle from the start. 
 
 Results. — Satisfactory, as a rule. Ankylosis is likely to follow if the 
 sawed ends are kept in contact — and a flail limb, if kept too far apart. There 
 is generally a tendency to the posterior displacement of the bones of the 
 forearm. 
 
 Best Methods. — Posterior Median Incision (Langenbeck). Posterior 
 Bayonet-shaped Incision, with or without an additional Ulnar Incision 
 (Oilier). Vertically Curved Dorso-external Incision (Kocher). The Radio- 
 ulnar Articulation may be excised by a Posterior Vertical Incision. 
 
 Other Methods. — Dorso-radial Angular Incision (Kocher). Lateral 
 Radial and Ulnar Incisions (Hueter). H -shaped Incision (Moreau). Pos- 
 terior Angular Incision (Nelaton). 
 
 EXCISION OF ELBOW- JOINT 
 
 BV POSTERIOR MEDIAN INCISION — LAN GENBECK'S OPERATION. 
 
 Position. — Patient supine, near edge of table. Assistant on side of 
 table opposite to surgeon, holding the operated limb by the wrist and forearm, 
 with patient's forearm across his (the patient's) chest, so that the arm is 
 vertical and the forearm horizontal (nearly at a right angle to the arm) — 
 thus throwing the flexed elbow prominently out toward the surgeon, with the 
 ulna and olecranon uppermost. Surgeon stands to outer side of elbow, on 
 the involved side, and cuts from the forearm toward the arm. 
 
 Landmarks. — Lower end of humerus; elbow-joint; upper ends of radius 
 and ulna. 
 
 Incision. — About 10 cm. (4 inches) in length, in the long axis of the 
 limb, passing directly over the center of the humerus, olecranon fossa, olec- 
 ranon process, and posterior crest of ulna — half of the incision being above 
 the tip of the olecranon and half below (Fig. 387, A). 
 
 Operation. — (i) This incision is made at once directly through soft 
 parts, periosteum, and capsule to the bone — and, in the above position, will 
 pass from above downward, from the forearm over the olecranon and onto 
 the arm — bisecting the triceps tendon, incising the capsule and passing 
 through the muscular portion of the triceps onto the humerus. (2) The 
 incision is at once deepened to the bone throughout — efficient retraction of 
 
49 6 
 
 EXCISIONS. 
 
 the lips of the wound being very important for the ease of the subsequent 
 steps. The periosteal elevator, of various curves, and the rugine, should 
 closely hug the many irregularities about the joint-structure — raising up 
 the periosteum and the periosteo-capsular sheath with the attachments of 
 the ligaments undisturbed. The surgeon's left thumb aids in the separation, 
 while the knife is used as sparingly as possible — the object being to peel 
 the bones bare of all soft parts, including periosteum. (3) The inner aspect 
 of the wound is first freed. The inner half of the triceps tendon is freed 
 from the olecranon — especial care being observed and the bone being very 
 closely hugged in freeing the groove between the olecranon and internal 
 
 condyle, that the ulnar nerve may not 
 be wounded. The internal lateral liga- 
 ment is freed from the humerus and ulna, 
 and, with it, the common origin of the 
 flexor muscles, together with the perios- 
 teum. (4) The outer aspect of the wound 
 is next freed. The outer half of the tri- 
 ceps tendon is separated from the olecra- 
 non, with especial care that its expansion 
 into the deep fascia of the forearm be not 
 severed. The anconeus, the continua- 
 tion of the outer portion of the triceps, is 
 similarly separated. The external . lat- 
 eral ligament, and, with it, the common 
 origin of the extensor muscles, are sepa- 
 rated from the external condyle, together 
 with the periosteum. The supinator 
 brevis is freed from the external condyle 
 and ulna and turned forward, especially 
 guarding the interosseous nerve between 
 its superficial and deep portions. (5) 
 The bones are now everywhere free ex- 
 cept upon their anterior surfaces (Fig. 
 388). The articular end of the humerus 
 is generally first removed. The patient's 
 hand, of the involved side, is placed prone 
 upon the table near his head, and firmly 
 held there, while steadying the forearm in 
 an upright position — while an assistant 
 steadies the arm midway between a ver- 
 tical and horizontal. By firmly drawing the soft parts downward (toward the 
 shoulder) the assistant protrudes the lower end of the humerus upward. Its 
 anterior surface is now sufficiently cleared— and, while the articular end is 
 steadied with lion-jaw forceps, 'and the soft parts retracted with spatula? 
 or retractors, the bone is sawed at a right angle to its axis and generally on 
 a level just below the tips of the condyles, or at whatever height may be in- 
 dicated. (6) The articular ends of the radius and ulna are now removed. 
 By drawing down (toward the wrist) the soft parts from the radius and 
 ulna, while held in the above almost vertical position, their articular ends 
 are made to protrude, and are freed as far as necessary on their anterior 
 surfaces, care being taken that the attachment of the brachials anticus is 
 not entirely freed from the coronoid process. The olecranon is seized and 
 
 Fig. 3S7.— Excisions about Elbow : 
 — A, Excision of elbo\v-joint,by posterior 
 median incision (Langenbeck's operation); 
 B, B', Excision of elbow-joint, by radial 
 and ulnar lateral incisions ; C, Excision of 
 superior radio-ulnar articulation, by pos- 
 terior vertical incision. 
 
EXCISION OF ELBOW-JOINT. 
 
 497 
 
 steadied with forceps, the soft parts well re- 
 tracted, and the articular end of the olecra- 
 non sawed off horizontally to its base, the 
 section including a thin slice from the articu- 
 lar end of the radius. (7) The wound in 
 the periosteo-capsule is sutured with buried 
 gut stitches. The muscles are quilted, also 
 by buried gut sutures. The wound is closed, 
 with temporary drainage provided — and 
 dressed upon a special splint previously pro- 
 vided. (See After-treatment, page 495 . ) 
 
 Comment. — (1) Avoid injury to the ul- 
 nar and posterior interosseous nerves. (2) 
 Do not completely detach the insertions of 
 the brachialis anticus and triceps from all 
 their neighboring attachments, as such at- 
 tachments preserved greatly aid flexion and 
 extension. (3) The biceps insertion is also 
 to be strictly guarded, but is not so much in 
 danger as the others mentioned. (4) Freer 
 access may be given to the articulation by 
 an earlier division of the olecranon. (5) Par- 
 tial excision of the articular end of the ulna 
 may he readily done through the posterior 
 median incision. 
 
 Fig. 388.— Te 
 of the Elbow-, 
 terior Aspect. 
 
 Articul 
 ixt CPOX 
 
 ar Line 
 its Ax- 
 
 Fig. 389. — Excisions about El- 
 bow: — A, Excision of elbow -joint, 
 by bayonet-shaped incision (Ot- 
 her's operation); B, Ulnar incision, 
 added to bayonet-shaped incision, 
 if needed. 
 
 3 2 
 
 EXCISION OF ELBOW- JOINT 
 
 BY POSTERIOR BAYONET-SHAPED INCISION, 
 
 WITH OR WITHOUT AN ADDITIONAL 
 
 SHORT VERTICAL ULNAR INCISION 
 
 — OLLIER'S OPERATION. 
 
 Description. — The operation can usually 
 be completed through the bayonet-shaped in- 
 cision alone. Where insufficient access is 
 thereby given, a short vertical ulnar incision 
 may be added. 
 
 Position — Landmarks. — As in the above 
 operation. 
 
 Incisions. — (1) Bayonet-shaped incision 
 — the upper part of the incision is vertical, 
 practically parallel with the axis of the hu- 
 merus, placed in the groove between the tri- 
 ceps and supinator longus, and extends from 
 about 5 cm. (2^ inches) above the joint-line 
 to the tip of the outer condyle, — the middle 
 portion is oblique, placed between the outer 
 head of the triceps and anconeus, and ex- 
 tends from the tip of the outer condyle 
 obliquely downward and inward to the base 
 of the olecranon, — the lower portion is again 
 vertical, placed over the posterior border of the 
 olecranon and extends from the base of the 
 
498 EXCISIONS. 
 
 olecranon down the forearm for about 4 to 5 cm. (i£ to 2 inches). (2) Ulnar 
 incision (when used) — is a vertical incision of about 5 cm. (2 inches) and is 
 placed over the lateral aspect of the internal condyle. It is resorted to in 
 order to secure more working-room, especially in cases of disease (Fig. 389, 
 A and B). 
 
 Operation. — (1) The above incision is at first only superficial. The 
 intermuscular planes above indicated are identified and in these planes the 
 incision is carried to the bones, through the periosteum and periosteo-capsulai 
 sheath. (2) Through this wound, by means of rugine and periosteal elevator, 
 are detached, subperiosteal^, the triceps insertion, external lateral ligament, 
 common origin of extensor muscles and insertion of brachialis anticus, and 
 the olecranon and border of the sigmoid cavity are decorticated and the head 
 of the radius exposed. (3) Through the same wound — or through the addi- 
 tional ulnar incision, if necessary — the internal lateral ligament and common 
 origin of flexor tendons are freed, and the internal condyle decorticated, 
 special care being taken of the ulnar nerve in the groove between the olecranon 
 and internal condyle. (4) Disarticulation is now accomplished. The 
 articular ends of ulna and radius are thrust outward, freed to the desired 
 extent, if not already so (being careful to preserve the greater part of the 
 attachment of the brachialis anticus), steadied with forceps and sawed hori- 
 zontally through at the base of the olecranon, including a slice of the radius. 
 The articular end of the humerus is similarly treated. (5) The periosteo- 
 capsular sheath is sutured — the muscles quilted— temporary drainage estab- 
 lished — the wound closed — and the part dressed upon a special splint. 
 
 Comment. — (1) The disadvantages of this method are, that the external 
 expansion of the triceps tendon is cut; the anconeus atrophies (for the nerve 
 to it comes from that branch of the musculospiral which supplies the outer 
 head of the triceps and is cut in the oblique portion of the incision); and 
 the ulnar nerve is less easily kept from harm. (2) Partial excision (of the 
 articular ends of humerus, ulna, or radius) may be done through part of 
 Ollier's incision. 
 
 EXCISION OF THE ELBOW- JOINT 
 
 BY VERTICALLY CURVED DORSO-EXTERNAL INCISION KOCHER'S METHOD. 
 
 Description. — The special object of the present operation is to preserve 
 all the muscles and their attachments, of the region involved, as well as the 
 nerves which supply them. The nerve which supplies the anconeus (descend- 
 ing from the branch of the musculo-spiral which supplies the outer head of 
 the triceps) is here preserved — while it is divided (with consequent atrophy 
 of the anconeus) in the excision of the elbow by Ollier's bayonet-shaped 
 incision) . 
 
 Position. — As in excision of the elbow by Langenbeck's method (page 495) . 
 
 Landmarks. — Supracondyloid ridge; — line of elbow-joint; head of radius; 
 — anconeus; — posterior border of ulna; — olecranon. 
 
 Incision. — Having flexed the elbow to an angle of 150 degrees, the incision 
 begins from 3 to 5 cm. (i| to 2 inches) above the line of the elbow-joint, at 
 the supracondyloid ridge — passes thence downward vertically in the axis of 
 the limb to the head of the radius — thence along the external border of the 
 anconeus to the posterior border of the ulna, to a point about 7.5 cm. (3 inches) 
 below the tip of olecranon — and then, curving slightly inward, ends over the 
 inner surface of the ulna (Fig. 390) . 
 
 Operation. — Passing from above downward, this incision is deepened 
 
EXCISION OF ELBOW-JOINT. 
 
 499 
 
 to the external border and outer condyle of the humerus, having the radial 
 extensors and supinator longus in front, and the margin of the triceps pos- 
 teriorly — and, in the forearm, it passes to the bone between the extensor carpi 
 ulnaris and the external border of the anconeus — dividing the capsule over 
 the radial head and the annular ligament at its attachment to the ulna. The 
 lowermost end of the incision severs the lower fibers of the anconeus nearly 
 transversely at their ulnar attachment — these fibers extending quite far down 
 the forearm. It will be seen that this incision passes along the interval between 
 
 Fig. 390. — Excisions about Elbow and Shoulder: — Excision of elbow by vertically 
 curved dorso-external incision (Kocher); osteoplastic exckion of shoulder by posterior curved 
 incision (Kocher). 
 
 the muscles supplied by the musculo-spiral and those supplied by the posterior 
 interosseous, thereby avoiding atrophy of the anconeus, which tenses and fixes 
 the capsule of the joint. Having exposed the bones of the region and incised 
 the capsule, detach the external head of the triceps subperiosteally, and the 
 capsule subcapsularis- from the humerus — and the triceps and anconeus 
 subperiosteally from the ulna. The flap thus formed of the triceps and 
 anconeus is now retracted from the olecranon and displaced to the ulnar side. 
 
500 EXCISIONS. 
 
 The external lateral ligament and the attachment of extensor tendons are 
 chiselled from the external condyle subcortically and displaced forward. 
 The forearm can now be readily and completely dislocated inward, which 
 is done. The extensor structures and their nerves are thus preserved. If 
 the object of the operation is to gain free access to the interior of the joint, 
 this is now readily accomplished. If it be desired to make a complete excision, 
 the internal lateral ligament and adjacent muscles are separated subperios- 
 teal^ from the internal humeral condyle and the inner border of the ulna — 
 accomplishing the separation subcortically, as in the case of the external 
 condyle. The sawing off of the articular ends of the bones is next accom- 
 plished — and this should be done in such a way as to leave surfaces of humerus 
 above, and radius and ulna below, curved on a transverse axis, in order to 
 aid in subsequent flexion and extension, and also to prevent displacement. 
 This method of sawing reproduces the curve of the olecranon. The capsule 
 is now closed — the musculo-aponeurotic tissue brought together with buried 
 sutures — and the wound closed with or without drainage, as indicated — and 
 the limb immobilized. 
 
 EXCISION OF SUPERIOR RADIO-ULNAR ARTICULATION 
 
 BY POSTERIOR VERTICAL INCISION. 
 
 Description. — An operation sometimes done for unreduced dislocation 
 of the head of the radius. 
 
 Position. — As in excision of the elbow-joint by the posterior median 
 incision. 
 
 Landmarks. — Elbow and radio-ulnar articulations. 
 
 Incision. — Vertical, about 5 cm. (2 inches) in length, with its center 
 over the radio-ulnar articulation, and placed behind and over the posterior 
 part of the supinator longus (Fig. 387, C). 
 
 Operation. — Incision passes through skin and fascia. The supinator 
 longus is recognized and is either slightly displaced, the incision passing 
 along its posterior border — or the incision passes directly through its posterior 
 fibers and upon the supinator brevis. This latter muscle is then carefully 
 divided over the head of the radius, preferably in the direction of its fibers 
 (guarding the posterior interosseous nerve between its two layers, and also 
 the musculospiral nerve and the biceps tendon). The orbicular ligament 
 is now severed — the parts well retracted — the head exposed and removed 
 with a Gigli or other saw. The musculo-periosteo-capsular structures are 
 sutured with buried gut stitches — the muscles quilted — the wound closed — 
 and the elbow dressed upon a special splint. 
 
 EXCISION OF HUMERUS, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Amputations about the Arm, pages 365 and 366. 
 
 General Surgical Considerations. — The entire humerus has been ex- 
 cised subperiosteallv, followed by a useful arm. Generally, however, only 
 portions of the shaft are excised. The operation for its entire removal will 
 be described — any portion of the incision being available for the removal of 
 special portions of the bone. The result of the operation, even of a portion 
 of the bone, is often a tlail and useless limb. 
 
EXCISION OF SHOULDER-JOINT, IN GENERAL. 501 
 
 EXCISION OF HUMERUS 
 
 BY LONG EXTERNAL INCISION. 
 
 Position. — Patient is turned partly upon his side and the arm sc placed 
 as to expose its external aspect. 
 
 Landmarks. — Pectoro-deltoid groove; external bicipital sulcus. 
 
 Incision. — So placed as to lie between the deltoid and pectoralis major 
 above — and along the external bicipital sulcus below (Fig. 386, C, where 
 incision for partial excision is given). 
 
 Operation. — The incision is carried through skin and superficial fascia, 
 and is then carefully deepened between the soft parts, through the periosteum, 
 to the bone throughout. The deltoid fascia is incised and the groove between 
 the deltoid and pectoralis major opened up by retraction — the bicipital fascia 
 incised — and the humerus reached along the outer border of the coraco- 
 brachialis and brachialis anticus. Avoid, by retraction, the acromial thoracic 
 and cephalic vessels in the pectoro-deltoid groove — the circumflex vessels 
 and nerve at the surgical neck — the musculospiral nerve and superior pro- 
 funda artery to the outer side of the middle of the shaft — and the musculo- 
 cutaneous nerve between the biceps and brachialis anticus in the lower third 
 of the arm. The bone is freed subperiosteally, the insertions of the tendons 
 being raised with the periosteum. The entire circumference of the bone 
 is freed at its center. A chain or Gigli saw is then passed between periosteum 
 and center of humerus and the bone divided — after which either end is grasped 
 by bone-forceps and cleared toward either articulation. The articular ends 
 are disarticulated in a manner similar to the disarticulation in the excision 
 of a joint — except that the ends of the bones are approached from the shaft. 
 The long musculo-periosteal sheath of the diaphysis, and the musculo- 
 periosteo-capsular sheaths of the articular ends, are united with buried gut 
 sutures — the muscles quilted — temporary drainage established at the joint- 
 ends — and the wound closed. The limb is dressed in a long rigid splint, 
 which includes both shoulder and elbow. (See end of preceding page.) 
 
 EXCISION OF SHOULDER- JOINT, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Disarticulation at the Shoulder-joint, pages 372 and 373. 
 
 General Surgical Considerations. — Excision of the shoulder-joint con- 
 sists in the removal of the articular end of the humerus, with gouging, only, 
 of the glenoid fossa — no part of the scapula being removed with a saw. The 
 subperiosteal method is especially desirable, the best results attained having 
 followed this method. 
 
 After-treatment. — The sawed end of the humerus is held in contact with 
 the glenoid fossa, the arm being bound to the side, an axillary pad inter- 
 vening, and the weight of the extremity being supported by a sling. The 
 axillary pad is important in keeping the head of the bone from being drawn 
 under the coracoid process, which is more likely when the external rotators 
 have been cut and the pectoralis major and latissimus dorsi act unopposedly. 
 Passive movements should begin as soon as acute inflammation subsides — 
 abduction being the last movement, as it displaces the head inward. 
 
 Results. — All movements are to be expected, except abduction beyond 
 a right angle. Weights may also be lifted. 
 
502 EXCISIONS. 
 
 Best Methods. — Anterior Oblique Incision (Baudens, Hueter, and 
 Oilier). Posterior Curved Incision (Kocher's Osteoplastic Method). 
 
 Other Methods. — Anterior Vertical Incision (Langenbeck) . Posterior 
 Vertical Incision. Deltoid Flap. Anterior Curved Incision. Posterior 
 Curved Incision. External Curved Incision (Senn's Osteoplastic Method) . 
 
 Comparison of Methods. — The anterior oblique method involves the 
 minimum damage to the deltoid muscle, the chief muscle of the shoulder- 
 joint. 
 
 Fig. 39 1. —Excisions about the Shoulder : — A, Excision of shoulder-joint, by anterior oblique 
 incision ; B, Excision of shoulder-joint, by anterior vertical incision ; C, Excision of clavicle, by long 
 axial incision. 
 
 EXCISION OF SHOULDER- JOINT 
 
 BY ANTERIOR OBLIQUE INCISION. 
 
 Position. — Patient supine, near edge of table, shoulders raised, arm 
 slightly abducted. Surgeon to outer side of both shoulders. Assistant 
 supports limb. 
 
 Landmarks. — Coracoid process; pectoro-deltoid groove; shoulder-joint. 
 
 Incision. — Begins just to outer side of tip of coracoid process and passes 
 obliquely downward and outward along the anterior border of the deltoid 
 for 9 to 10 cm. (3J to 4 inches) (Fig. 391, A). 
 
OSTEOPLASTIC RESECTION OF THE SHOULDER- JOINT. 503 
 
 Operation. — (I) This incision passes, at first through skin and fascia, 
 from the coraco-acromial arch to its lower end. The pectoro-deltoid groove 
 is then demonstrated. The cephalic vein and pectoral muscle are drawn 
 inward — the deltoid outward. The biceps tendon is identified, its sheath 
 opened, and the contained tendon drawn inward. The incision is continued 
 in the original line through the capsule into the joint just to the outer side of 
 this tendon, and through the periosteum onto the humerus. (2) The outer 
 lip of the wound is now cleared. The periosteum, capsule, muscular and 
 tendinous insertions are separated by rugine and periosteal elevator as one 
 continuous layer. An assistant depressing the elbow and rotating the humerus 
 inward, brings the greater tuberosity into the wound, and the insertions of 
 the supraspinatus, infraspinatus, and teres minor are cleared. (3) The 
 inner lip of the wound is similarly cleared. By depressing the elbow and 
 rotating the humerus outward, the lesser tuberosity is brought into the wound. 
 The biceps tendon is now drawn out and the insertion of the subscapularis is 
 separated. (4) The head of the humerus is then disarticulated by depressing 
 the elbow and thrusting the head forward through the retracted wound, while 
 the biceps tendon is drawn inward. The neck of the bone is now cleared 
 posteriorly, hugging the bone carefully to avoid damage to the circumflex 
 vessels and nerve. After disarticulation, the head of the humerus is steadied 
 by lion-jaw forceps and sawed, the section passing from without and slightly 
 downward and inward, the surgeon so standing, on both sides, as to grasp 
 the limb with his left hand distally to the saw-cut, while the soft parts are well 
 retracted by an assistant. Following the section, the margins of the sawed 
 bone may be rounded slightly. The humerus is sawed between the attach- 
 ments of the pectoralis major, latissimus dorsi and teres major below, and 
 the muscles of the tuberosities above — the section being as high as possible. 
 (5) The glenoid cavity is gouged thoroughly with a sharp spoon, and the 
 capsule of the joint is scraped, if indicated. (6) Temporary drainage is 
 provided through a posterior opening. The head of the bone is drawn into 
 place — the periosteo-capsular wound is sutured with buried gut stitches — the 
 muscles quilted — and the wound closed. 
 
 Comment. — (1) The capsule should not be cut transversely, if avoidable. 
 (2) All the muscles, tendons, and ligaments should be raised attached to the 
 periosteo-capsular covering. (3) The head of the bone may be, less advis- 
 ably, divided in situ by means of a chain or Gigli saw. 
 
 OSTEOPLASTIC RESECTION OF THE SHOULDER- JOINT 
 
 BY POSTERIOR CURVED INCISION KOCHER'S METHOD. 
 
 Description. — The essential features of this operation are that the posterior 
 joint structures are more fully exposed — while no serious damage is done 
 to muscle or nerve structure. The acromion process is temporarily displaced. 
 
 Position. — The patient lies partly upon the opposite chest, rendering the 
 externo-posterior aspect of the shoulder region prominent. 
 
 Landmarks. — Acromio-clavicular articulation; — acromion; — spine of the 
 scapula; — posterior fold of axilla. 
 
 Incision. — Begins at the acromio-clavicular articulation — passes over 
 the upper part of the shoulder, along the superior border of the acromion to 
 the outer aspect of the spine of the scapula — thence curves downward to end 
 about 3 cm. (i| inches) above the posterior fold of the axilla (Fig. 392). 
 
5°4 
 
 EXCISIONS. 
 
 Operation. — This incision is carried directly into the acromio-clavicular 
 joint — and separates the attachment of the trapezius from the superior border 
 of the spine of the scapula — the lower portion of the incision exposing the 
 posterior border of the deltoid. By a finger inserted beneath it the deltoid 
 is separated from the posterior scapular muscles up to its insertion into the 
 acromion. Its posterior fibers are incised. The upper border of the infra- 
 spinatus muscle is similarly freed with a finger opposite the outer border of the 
 spine and the root of the acromion. The supraspinatus is similarly detached 
 with a blunt dissector from the superior border of the scapular spine — so that 
 a passage may be made beneath the root of the acromion, which is chiselled 
 off obliquely — and, together with the deltoid, is retracted over the head of 
 the humerus. Prior to this chiselling, holes should be drilled for subsequent 
 
 
 Fig. 392. — Osteoplastic Resection of the Shoulder joint by Curved External Inci- 
 sion (Senn's Method). 
 
 suturing of the acromion. The suprascapular nerve is guarded at this stage 
 of the operation. With the reflection of the acromio-deltoid flap, the head of 
 the humerus is freely exposed superiorly, externally, and posteriorly, together 
 with the attachments of the supraspinatus, infraspinatus, and teres minor 
 muscles, as well as the posterior aspect of these muscles. The capsule is now 
 incised. Having rotated the arm outward, the capsular incision begins at 
 the upper part of the posterior lip of the bicipital groove — extends thence 
 upward through the thickness of the capsule along the anterior border of the 
 insertions of the external rotator muscles^to the highest part of the humeral 
 head — thus exposing the tendon of the biceps up to its attachment to the 
 glenoid cavity. Detach the supraspinatus, infraspinatus, and teres minor 
 
EXCISIONS OF BONES AND JOINTS ABOUT TOES. 505 
 
 muscles from the great tuberosity and retract them backward. Lift the 
 biceps tendon from its groove and displace it forward, exposing its sheath. 
 Thus the whole head of the humerus and the entire glenoid fossa are freely 
 accessible. If a complete exposure of the joint be sought, this is now accom- 
 plished, allowing the preservation of the anterior portion of the capsule and 
 the anterior muscles. If, however, an excision be intended, the subscapularis 
 is detached from the lesser tuberosity — the cora-humeral head of the biceps 
 displaced — and the head of the humerus thrown outward. The division of 
 the bone is accomplished as in the preceding operation. The capsule is 
 sutured. The repair of the neighboring soft parts is carried out as far as 
 indicated. The chiselled acromion is sutured back into position through 
 the previously drilled holes — and the skin incision closed, with temporary 
 drainage. The shoulder and arm are immobilized. 
 
 Fig. 393. — Excisions about Shoulder and Scapula: — A, Excision of shoulder-joint, 
 by deltoid flap (or less desirable form of exposure); B, Incision for excision of acromion and 
 spinous process of scapula. 
 
 Comment. — (i) Instead of chiselling off the acromion, the posterior flap 
 may be formed by detaching the scapular origin of the deltoid subcortically, 
 which subsequently unites firmly. (2) The circumflex vessels and nerves, 
 coming out from under the teres minor, can be preserved from injur}'. 
 
 EXCISIONS OF BONES AND JOINTS ABOUT THE TOES. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Amputations about the Toes, pages 385 and 386. 
 
506 
 
 EXCISIONS. 
 
 General Surgical Considerations. — The same general principles apply 
 in excisions about the toes as in excisions about the fingers. The details 
 
 of the various excisions about the 
 toes will, therefore, not be separately 
 given. Besides, excision of the 
 parts of the toes is quite rare — am- 
 putations generally being done in- 
 stead. This applies to all the toes 
 except the great toe — with reference 
 to which it may be understood that 
 most of the following operations 
 apply. 
 
 EXCISION OF TERMINAL PHA- 
 LANGES OF TOES. 
 
 Best Method. — U-Shaped 
 
 Plantar Incision. 
 
 Description. — As for the termi- 
 nal phalanx of finger, page 484. 
 
 EXCISION OF SECOND INTER- 
 PHALANGEAL JOINTS OF TOES. 
 
 Best Method. — Two Dorso-lat- 
 eral Incisions. 
 
 Description. — As for the second 
 interphalangeal joint of the fingers 
 (page 484) — except that the inci- 
 sions are here more dorsal than lat- 
 eral. (Fig. 394, A, A'.) 
 
 EXCISION OF SECOND PHA- 
 LANGES OF TOES. 
 
 Best Methods. — Two Dorso- 
 lateral Incisions — for toes in general. 
 U-shaped Palmar Incision — • for 
 great toe. 
 
 Description. — As for the sec- 
 ond phalanx of the fingers (page 
 486) — or of the thumb (page 484). 
 (Fig. 394, B, B'.) 
 
 Fig-. 394. — Excisions about the Foot : — A, 
 A', Excision of second phalangeal joint by two dor- 
 sal incisions ; B, B', Excision of second phalanx, 
 by two dorsal incisions; C, C, Excision of first 
 phalang :al joint, by two dorsal incisions ; D, Exci- 
 sion of first phalangeal joint of great toe by dorso- 
 internal incision ; E, E', Excision of metatarso- 
 phalangeal joint by two dorso-lateral incisions ; F, 
 
 Excision of metatarsal, by dorsal incision; G, Ex- _, vr , TCT __ T ~_ _ TT;)CT T __ ^^ 
 cisionof metatarsal bv dorsal incision, with addi- r-AClblUlN Ur riK.^1 liNinxmA- 
 tional angular incision; H, H', Osteoplastic resec- LANGEAL JOINTS OF TOES. 
 
 tion of anterior tarsus and tarso-metatarsus, by in- 
 
 ternal and external dorso-lateral incisions. Best Method. — T WO, Dorsolat- 
 
 eral Incisions — for toes in general. 
 Dorso-internal Incision — for great toe. 
 
 Description. — As for the first interphalangeal joint of the fingers (page 
 487) — or of the thumb (also page 487). (Fig. 394, C, C.) 
 
EXCISION OF ASTRAGALUS. 507 
 
 EXCISION OF FIRST PHALANGES OF TOES. 
 
 Best Methods. — Dorso-internal Incision — for great toe. Two Dorso- 
 lateral Incisions — for toes in general, if done at all. 
 
 Description. — As for the first phalanx of the fingers in general, if done 
 at all (page 487) — or for the thumb (also page 487). 
 
 EXCISIONS OF BONES AND JOINTS ABOUT THE FOOT. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Amputations and Disarticulations about the Foot (pages 385 and 386). 
 
 General Surgical Considerations. — (i) The general features of ex- 
 cisions of the metatarsals are the same as of excisions of the metacarpals. 
 (2) Individual metatarsal bones are not frequently excised. That of the 
 great toe is the one most often excised. (3) The sesamoid bones are left 
 in situ, as in the hand. (4) The chief tarsal bones systematically excised 
 are the os calcis and astragalus. Other portions of the tarsus are excised 
 as indicated. And other tarsal bones are wholly or partially excised in such 
 operations as those for the deformities about the foot. 
 
 EXCISION OF METATARSO-PHALANGEAL JOINTS. 
 
 Best Methods. — Two Dorso-lateral Incisions — for the toes in general. 
 Dorso-internal Incision — for the great toe. 
 
 Description. — As for the metacarpophalangeal joint of the fingers, in 
 general (page 487) — or of the thumb. (Fig. 394, E, E'.) 
 
 EXCISION OF THE METATARSAL BONES. 
 
 Best Methods. — Dorsal Incision — for toes in general. Dorso-internal 
 Incision — for great toe. 
 
 Other Methods. — Interno-plantar Flap — for great toe. 
 
 Description. — As for the metacarpal bones by dorsal incision (page 488) 
 — or of the metacarpal of the thumb by dorso-external incision (page 489). 
 (Fig. 394.) 
 
 EXCISION OF ASTRAGALUS 
 
 BY EXTERNAL CURVED INCISION. 
 
 Position. — Patient supine, foot resting on inner side. Surgeon on side 
 of operation. Assistant steadies foot and leg. 
 
 Landmarks. — Fibula; astragalus; base of fifth metatarsal. 
 
 Incision. — Begins about 7.5 cm. (3 inches) above ankle, at anterior 
 border of fibula — passes vertically downward external to peroneus tertius 
 and musculocutaneous nerve — and curves thence forward over outer surface 
 of astragalus to base of fifth metatarsal (Fig. 395, A). 
 
 Operation. — Having incised skin and fascia, retract the peroneus tertius 
 inward and extensor brevis digitorum outward. In the interval thus left, 
 incise the capsule of the ankle-joint and open the medio-tarsal joint. Free 
 the neck of the astragalus and the lower ends of the tibia and fibula. Divide 
 
508 EXCISIONS. 
 
 the calcaneo-astragaloid ligament and anterior and posterior bands .of the 
 externa] lateral ligament. Run along the outline of the astragalus at its 
 junction with the os calcis and scaphoid with a stout knife. Invert the foot 
 forcibly and, while in this semidislocated position, free the inner surface of 
 the astragalus, using special care near the posterior tibial vessels and nerve. 
 The astragalus is now grasped with bone-forceps and removed — severing any 
 further binding ligaments which may hold it, while under tension. The leg 
 then drops down upon the upper surface of the os calcis. The soft parts are 
 brought together with deep and superficial sutures — the deep sutures being 
 of chromic gut and including as much fibrous tissue as possible. Temporary 
 drainage is used — and the foot is put up at a right angle to the leg. 
 
 Comment. — Excision of the astragalus by the external curved incision 
 is preferable where the unyielding condition of the tissues does not require 
 two lateral incisions, as in the following operation. 
 
 EXCISION OF ASTRAGALUS 
 
 BV EXTERNAL ANGULAR AND INTERNAL CURVED INCISION. 
 
 Description. — The bone is most easily removed from the outer aspect — 
 the bone being approached between the tendons of the tibialis anticus and 
 tibialis posticus, on the inner side — and, on the outer side, between the tendons 
 of the peroneus tertius and peroneus brevis. The operation is done by the 
 open method. 
 
 Position. — Patient supine, foot extending over edge of table and turned 
 to face inward and upward for inner incision and outward and upward for 
 outer incision. The surgeon stands facing the foot. The assistant steadies 
 leg and toes. 
 
 Landmarks. — Inner and outer malleoli; articular border of tibia; as- 
 tragalo-scaphoid joint; astragalo-calcaneal joint. 
 
 Incisions. — (i) External Angular Incision; — The Vertical portion begins 
 just above the level of the articular border of the tibia, on its antero-external 
 aspect, and passes downward between the tendons of the peroneus tertius 
 and peroneus brevis, parallel with and just behind the former tendon, for 
 about 6 cm. (2 \ inches), and ends over the cuboid bone; — the Horizontal 
 portion, shorter, is at a right angle to the vertical portion, beginning about 
 its center and passing backward and slightly downward, ending just below 
 the tip of the external malleolus. (2) Internal Curved Incision; — begins just 
 above the level of the articular surface of the tibia, on its antero-internal 
 aspect, and passes down immediately in front of the anterior margin of the 
 tibia to slightly below the tip of the internal malleolus, whence it curves 
 backward and ends just below the center of the internal malleolus. (Fig. 
 395, B, and Fig. 396, C.) 
 
 Operation. — (1) These incisions first pass through skin and fascia only. 
 
 (2) The outer incision is then deepened first, and the two rectangular flaps 
 turned back and the antero-external aspect of the astragalus exposed between 
 the tendons of the peroneus tertius and peroneus brevis. Forcibly extend 
 and invert the foot, retracting the tendons, and divide the ligaments between 
 the astragalus, on the one hand, and the fibula, os caicis, scaphoid, and 
 tibia, on the other — as far as can be accomplished from the outer wound. 
 
 (3) The inner incision is now deepened and the curved flap turned back and 
 the antero-internal aspect of the astragalus exposed between the tendons of 
 the tibialis anticus and posticus. Forcibly extend and evert the foot, re- 
 
EXCISION OF ASTRAGALUS. 
 
 5°9 
 
 tracting the tendons out of the way, and complete the division of the ligaments 
 binding the astragalus to the tibia, os calcis, and scaphoid — as far as can be 
 
 Fig. 395.— Excisions about thk Foot : — A, Excision of astragalus, by external curved incision ; B, 
 External angular incision, in excision of astragalus by external angular and internal curved incisions ; 
 C, Excision of os calcis, by horizontal curved and vertical incisions. 
 
 Fig. 396.— Excisions about the Foot: — A, Excision of terminal phalanx by U-shaped palmar 
 incision; B, Excision of metatarsal of great toe, by dorse-internal incision, with or without one or 
 more additional incisions at one or both ends; C, Internal curved incision, in excision of astragalus 
 by external angular and internal curved incisions ; D, Internal angular incision, in excision of ankle- 
 joint by external curved and internal angular incisions. 
 
 further accomplished from the inner wound. (4) The foot being again 
 firmly extended and inverted, the astragalus is seized with lion-jaw forceps 
 
510 EXCISIONS. 
 
 and strongly whipped out through the outer wound — any remaining connec- 
 tions being severed while on the stretch. (5) Suture the flaps into place — 
 institute temporary drainage — and put up the foot at a right angle to the 
 leg. Prior to suturing the skin-flaps, it is well to apply several buried chromic 
 gut sutures wherever loose portions of fibrous tissue may be brought into 
 contact to strengthen the parts. 
 
 Comment. — (1) This excision may be made through simply the vertical 
 portions of these two incisions — by retracting the lips of the wounds and 
 thus reaching the bones. (2) Movement of the ankle-joint is not expected. 
 
 Other Methods of Excision. — External Angular Incision. Transverse 
 Incision. Internal and External Vertical Incisions. 
 
 EXCISION OF OS CALCIS 
 
 BY HORIZONTAL CURVED AND VERTICAL INCISIONS. 
 
 Description. — The bone is removed from the postero-external aspect. 
 The operation should be done as subperiosteally as possible. 
 
 Position. — Patient lies on sound side with foot supported on inner side 
 and free. Surgeon faces foot. Assistant steadies leg. 
 
 Landmarks. — Base of fifth metatarsal; position of posterior tibial vessels; 
 tendo Achillis; calcaneo-cuboid joint. 
 
 Incisions. — Horizontal Incision — begins at base of fifth metatarsal — 
 passes horizontally backward, well above the margin of the sole, around the 
 convexity of the heel to its inner side, to a point about 3.2 cm. (1^ inches) 
 internal to the median line of the heel — stopping well posterior to the posterior 
 tibial vessels and nerve. Vertical Incision — begins about 5 cm. (2 inches) 
 above the horizontal incision, on the outer side of the foot — and passes ver- 
 tically downward just anterior to the tendo Achillis, and between it and the 
 tendons of the peroneus longus and brevis, and meets the horizontal incision 
 at a right angle. (Fig. 305, C.) 
 
 Operation. — (1) These incisions are now deepened and the two small 
 flaps made by them are turned forward and upward, and backward and 
 upward, respectively. (2) The os calcis : s exposed behind the peronei tendons 
 and the periosteum incised in the lines of the incisions. By means of a rugine 
 everything is raised from the bone as subperiosteally as possible — on its 
 outer, under, posterior, inner, and upper surfaces, in order. The tendo 
 Achillis is severed and the soft parts and tendons are well retracted during 
 this decortication. (3) The head of the bone is grasped with lion-jaw forceps 
 and is drawn outward — the remaining connections being severed while on 
 the stretch. (4) The flaps are dropped into place and sutured — temporary 
 drainage being established. The foot is put up at a right angle, upon an 
 anterior splint (so as not to exert any undue pressure upon the wound). 
 
 EXCISION OF ANKLE-JOINT, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Disarticulation at the Ankle, pages 412, 413. 
 
 General Surgical Considerations. — The operation is not frequently 
 performed. Ankylosis results in the majority of cases. The medio-tarsal 
 joint, however, generally takes on considerable compensatory action. Some 
 
EXCISION OF ANKLE-JOINT. 511 
 
 shortening results. Sometimes the entire astragalus is removed at the same 
 time. 
 
 After-treatment. — The foot is kept at a right angle to the leg in a fixed 
 splint — and in the same straight line with the leg. Although ankylosis is 
 sought by some surgeons, movement is aimed at by the majority — and passive 
 movements are begun early. 
 
 Best Methods. — Transversely curved external incision (Lauenstein) ; 
 external curved and internal angular incisions. 
 
 EXCISION OF ANKLE-JOINT 
 
 BY TRANSVERSELY CURVED EXTERNAL INCISION — LAUENSTEIN'S OPERATION. 
 
 Description. — The joint is exposed through a single external incision, 
 and the articular surfaces of the bones brought into the field by disarticula- 
 tion accomplished by forcible temporary inversion of the foot. 
 
 Position. — Patient midway between supine and lateral positions; foot 
 resting upon inner side. Surgeon stands behind heel to make incision, and 
 faces foot to complete operation. Assistant steadies leg. 
 
 Landmarks. — Ankle and astragalo-scaphoid joints; peroneus tertius 
 tendon; external malleolus; tendons of peroneus longus, brevis. and Achillis. 
 
 Incision. — Begins on dorsum of foot, midway between ankle-joint and 
 astragalo-scaphoid articulation, and over peroneus tertius tendon — passes 
 nearly horizontally backward below and beyond the outer malleolus — and 
 thence upward between the tendo Achillis, on the one hand, and the tendons 
 of the peroneus longus and brevis, until from 5 to 7.5 cm. (2 to 3 inches) 
 above the joint (Fig. 397, A). 
 
 Operation. — (1) The skin and fascia are at first carefully divided. The 
 musculocutaneous nerve is identified and drawn inward. The peroneus ter- 
 tius tendon and extensor tendons are also displaced inward. The external 
 saphenous vein and nerve are not disturbed posteriorly. (2) The incision 
 is deepened between the retracted extensor tendons and fibula down to the as- 
 tragalus, dividing the capsule cf the ankle-joint back to the external malleolus. 
 The three bands of the external lateral ligament are separated from the 
 outer malleolus. The sheath of the peroneus longus and brevis is carefully 
 incised upward posteriorly to the fibula so that it may be subsequently sutured 
 (the sheaths being separate below the tip of the external malleolus and common 
 above the tip). The tendons are then removed from their sheath and re- 
 tracted backward. By dividing the peroneal sheath high up the leg and 
 freeing of the tendons, sufficient room may often be gotten for disarticulation 
 without severing the tendons — otherwise these tendons must be cut and 
 subsequently sutured with catgut. (3) The periosteum is now divided over 
 the fibula, and it, together with the peroneal sheath, are separated posteriorly, 
 with as much as possible of the periosteum, from the posterior surface of 
 the fibula and tibia. (4) The periosteum is similarly separated from the 
 anterior part of the fibula and anterior surface of the tibia, carrying with it 
 the attachment of the anterior portion of the capsule. The foot is thus freed 
 from its attachments to the outer aspect of the fibula and to the anterior 
 and posterior aspects of the tibia. (5) Forcibly bend the foot inward until 
 disarticulation is so completely accomplished that the inner aspect of the 
 foot rests against the leg and the sole looks upward (toward the crotch), 
 turning upon the internal lateral ligament as a hinge — the ligament being 
 preserved, if possible. All the joint surfaces are thus brought well to view — 
 and no tendons are severed, except as mentioned above. (6) As much of 
 the bones is now removed as indicated. It is especially sought to avoid 
 
5i2 
 
 KXCISIONS. 
 
 sawing off more than the articular surface of the astragalus — and the gouging 
 of the articular surfaces of the tibia and fibula, leaving the malleoli to prevent 
 lateral displacement of the foot. If necessary, however, as much may be 
 removed of the osseous tissues as in the following operation. (7) If the 
 peroneal tendons have been severed, these are now sutured with chromic gut 
 — replaced in their sheath — and the sheath, in any event (whether the tendons 
 have been divided or not), is repaired by chromic gut suturing. Temporary 
 drainage is used — the wound closed — and the foot put up at a right angle. 
 
 EXCISION OF ANKLE-JOINT 
 
 BY EXTERNAL CURVED AND INTERNAL ANGULAR INCISIONS. 
 
 Position. — Patient rests midway between side and back, so as to bring 
 
 Fig.397.— Excisions about the Foot: — A, Excision of ankle-joint by transverse curved exter- 
 nal incision ; B, External curved incision, in excision of ankle-joint by external curved and internal 
 angular incisions. 
 
 inner aspect of foot uppermost during the inner incision, and vice versa; 
 with foot supported. Surgeon faces foot. Assistant steadies limb. 
 
 Landmarks. — The lower part of tibia and inner malleolus; lower part 
 of fibula and outer malleolus; tibio-astragaloid joint. 
 
 Incisions. — (1) External Incision — (with foot resting on inner aspect) 
 — about 7.5 cm. (3 inches) in length — extends down the antero-lateral aspect 
 of fibula to just below the tip of the outer malleolus — thence curves backward 
 around the external malleolus and passes upward along the posterior border 
 of the fibula for about 2.5 cm. (1 inch) (Fig. 397, B). (2) Internal Incision— 
 (with foot resting upon outer aspect) — about 7.5 cm. (3 inches) in length — 
 extends down inner aspect of tibia to tip of internal malleolus. A second 
 incision may then be added — either a transverse incision meeting the first 
 almost at a right angle, and extending about 1.3 cm. (5 inch) on either side 
 (Fig. 396, D) — or a curved incision passing forward. 
 
 Operation. — (1) The outer incision passes down through skin, fascia, 
 and periosteum as far as it lies over the fibula — that portion below the external 
 
OSTEOPLASTIC RESECTIONS ABOUT FOOT. 513 
 
 malleolus at first passes through skin and fascia alone. The periosteum is 
 now turned forward and backward over the fibula — the external lateral 
 ligament and capsule are split in line with the vertical incision and turned 
 backward and forward with the periosteum. The peroneus longus and 
 brevis tendons are retracted backward. The anterior surface of the fibula, 
 and as much as possible of the anterior surface of the tibia and astragalus, 
 are freed subperiosteally through the outer wound, as well as the posterior 
 surface of the fibula, and as much as possible of the posterior surface of the 
 tibia. (2) The lower end of the fibula is now divided with a chain or Gigli 
 saw, or with a chisel, about 2.5 cm. (1 inch) above its tip — and is grasped 
 bv bone-forceps and removed, aided by a touch of the rugine where necessary. 
 (3) The internal incision is made through skin, fascia, and periosteum to 
 bone, where it lies over the tibia — and through skin and fascia; below the 
 tip of the malleolus. The periosteum is similarly freed forward and back- 
 ward, with the overlying and connected ligaments — freeing, through the inner 
 wound, the outer and remaining portions of the anterior and posterior sur- 
 faces of the tibia, and the anterior surface of the astragalus. The internal 
 lateral ligament and capsule are similarly divided vertically and turned for- 
 ward and backward as part of the periosteo-capsular covering. (4) The 
 anterior and posterior tibial tendons are well retracted while working through 
 the inner incision — and if a lower crosscut be added to the inner vertical 
 incision, care is taken that it does not extend far enough anteriorly or pos- 
 teriorly to injure these tendons. (5) The lower end of the tibia is now either 
 divided in situ with a chain-saw, or protruded through the inner wound, 
 grasped with forceps, and sawed just above its articular surface. (6) The 
 upper portion of the astragalus is then sawed off with a thin, narrow saw, 
 through the outer wound — or entirely disarticulated and removed, as indi- 
 cated. (7) The inner and outer wounds are sutured — temporary drainage 
 established — and the foot dressed at a right angle to the leg. 
 
 OSTEOPLASTIC RESECTION OF ANTERIOR TARSUS AND TARSO- 
 
 METATARSUS 
 
 BV INTERNAL AND EXTERNAL DORSOLATERAL INCISIONS. 
 
 Description. — Consists in the removal of the tarso-metatarsal joints; the 
 entire tarsal bones distal to the astragalo-scaphoid and calcaneo-cuboid, or 
 medio-tarsal. joint (namely, the scaphoid, cuboid, internal, middle and ex- 
 ternal cuneiform); and the articular surfaces of the astragalus and os calcis; 
 followed by the approximation of the sawed proximal and distal bones. 
 The operation is resorted to in disease, especially tubercle, of the anterior tarsal 
 joints. Where the disease is limited to the bases of the metatarsals, a tarso- 
 metatarsal excision is done — the bases of the metatarsals and adjacent articular 
 surfaces of the cuboid, internal, middle and external cuneiforms are alone 
 removed. Where the disease is more general, in addition to the tarso-meta- 
 tarsal excision, the anterior tarsus (scaphoid, cuboid, and three cuneiforms) 
 is also excised. And where the disease is still more extensive, the articular 
 surfaces of the posterior tarsus (astragalus and os calcis) are additionally 
 removed 
 
 Position. — Patient supine, with foot over edge of table and so manipulated 
 as to bring the site of operation into prominence during the various steps. 
 Surgeon faces foot. Assistant steadies and manipulates foot and leg. 
 
 Landmarks. — First metatarsal, internal cuneiform, scaphoid, and head 
 
514 EXCISIONS. 
 
 of astragalus, on inner aspect of foot, — and fifth metatarsal, cuboid, head of 
 os calcis, and external malleolus, on outer aspect. 
 
 Incisions. — Internal Incision — from the posterior third of the dorsal 
 aspect of the first metatarsal backward over the internal cuneiform and 
 scaphoid to just above the dorso-lateral aspect of the head of the astragalus. 
 External Incision — from the posterior third of the dorso-lateral aspect of the 
 fifth metatarsal (external to the extensor tendons) backward over the cuboid 
 to the dorso-lateral aspect of the os calcis, between the calcaneo-cuboid 
 articulation and external malleolus. (Fig. 394, H, H'.) 
 
 Operation. — (1) The internal incision first passes through skin and 
 fascia. Then working upward and toward the middle line of the dorsum, 
 the attachment of the tibialis anticus is separated from the first metatarsal 
 and the internal cuneiform — and the dorsal aspect of the first metatarsal, 
 internal cuneiform, scaphoid, and part of astragalus are bared, as far toward 
 the middle of the dorsum as possible. Then working downward and toward 
 the middle line of the sole, the attachment of the posterior tibial to the tuber- 
 osity of the scaphoid and internal cuneiform is separated — and the plantar 
 surfaces of the first metatarsal, internal cuneiform, scaphoid, and part of 
 astragalus are cleared, as far toward the center of the sole as possible. (2) 
 The external incision also, at first, involves skin and fascia. First working 
 toward the dorsum, the tendon of the peroneus tertius is then separated from 
 its attachment to the base of the fifth metatarsal — and the dorsal aspect of 
 the outer metatarsals, cuboid, and part of os calcis, and as far toward the 
 center of the dorsum as possible, are cleared. Then working toward the sole, 
 from the outer aspect, the attachment of the peroneus brevis is separated 
 from the base of the fifth metatarsal and the tendon of the peroneus longus 
 is detached from the groove under the cuboid and drawn backward — and the 
 under surface of the other metatarsals, cuboid, and part of os calcis are 
 cleared as far toward the center of the sole as possible. (3) The cuboid, 
 three cuneiforms, and scaphoid are removed by being grasped by bone-forceps 
 and dissected out from the lateral wounds. The articular surfaces of the 
 metatarsals below, and astragalus and os calcis above, are then sawed or 
 gouged. (4) The sawed ends of the metatarsals are approximated to the 
 sawed ends of the astragalus and os calcis — the dorsal and plantar redundancy 
 of tissue being eventually taken up. (5) Temporary drainage is established — 
 the two lateral wounds sutured — and the foot put up upon a splint, at a right 
 angle to the leg. Buried chromic gut sutures between the deeper fibrous 
 margins of the wound should be placed wherever indicated. 
 
 Comment. — The anterior tarsus alone may be removed, by limiting the 
 incision accordintrlv. 
 
 OSTEOPLASTIC RESECTION OF MID-TARSUS 
 
 BY EXTERNAL TRANSVERSE CURVED INCISION. 
 
 Description. — Removal of anterior part of astragalus and os calcis, and 
 the posterior part of the scaphoid and cuboid — followed by the approximation 
 of the sawed distal and proximal bones. 
 
 Position. — As in the above operation. 
 
 Landmarks. — Medio-tarsal joint line (astragalo-scaphoid and calcaneo- 
 cuboid articulations) ; external malleolus. 
 
 Incision. — Begins over dorsal aspect of astragalo-scaphoid joint — curves 
 obliquely downward and outward over upper part of calcaneo-cuboid joint, 
 and passes thence backward to a point on a line with and about 1.3 cm. (^ 
 inch) below the external malleolus (Fig. 398, A). 
 
OSTEOPLASTIC RESECTION OF POSTERIOR TARSUS. 515 
 
 Operation. — (i) Incise skin and fascia. The musculocutaneous nerve 
 is encountered and retracted at the upper angle of the wound, and the external 
 saphenous nerve and vein at the lower. The tendons of the peroneus tertius 
 and extensor longus digitorum appear at the upper part of the wound and are 
 retracted. The tendons of the peroneus longus and brevis appear at the lower 
 part of the wound — their sheaths are slit and the tendons retracted. (2) The 
 medio-tarsal region is approached in the interval thus made. The capsule is 
 incised over the head of the astragalus — the astragalo-scaphoid joint opened 
 — and the capsule separated from the articular ends of both bones. (3) 
 Retract downward the upper border of the extensor brevis digitorum and 
 
 Fig. 398.— Osteoplastic Resections about the Foot : — A, Osteoplastic resection of mid-tarsus 
 by external transverse curved incision ; B, B', Osteoplastic resection of posterior tarsus by external 
 curved incision; B, C, Incision in osteoplastic resection of foot by externo-lateral curved incision 
 (modification of Wladimiroff-Mikulicz operation 1. 
 
 open the calcaneo-cuboid joint, and free the capsule from the articular ends 
 of both bones. (4) Sever the greater process of the os calcis and neck of 
 astragalus with chisel and remove with bone-forceps, cutting the binding 
 ligaments under traction. With chisel or gouge, remove as much of the 
 cuboid as indicated — and the whole or as much as necessary of the scaphoid. 
 (5) The sawed scaphoid and cuboid are approximated to the sawed astragalus 
 and os calcis. The slit sheaths are sutured over the peronei tendons — the 
 deep parts brought together with buried chromic gut sutures — the wound 
 sutured — and the foot put up at a right angle to the leg, with the leg flexed. 
 No drainage is established unless articular surfaces are left. 
 
 OSTEOPLASTIC RESECTION OF POSTERIOR TARSUS 
 
 BV EXTERNAL CURVED INCISION. 
 
 Description. — Removal of astragalus and anterior half of os calcis; 
 together with the articular surfaces of the tibia and fibula, and of the scaphoid 
 and cuboid; after which, the anterior sawed surface of the posterior half of 
 the os calcis is approximated to the sawed surfaces of the tarsal bones (scaphoid 
 
516 EXCISIONS. 
 
 and cuboid) ; and the upper sawed surface of the posterior half of the os calcis 
 is approximated to the sawed tibia and fibula. 
 
 Position. — Patient supine, with foot resting upon its inner side. Surgeon 
 stands upon the outer side — and an assistant steadies the leg and foot. 
 
 Landmarks. — Tendo Achillis; external malleolus; base of fifth meta- 
 tarsal. 
 
 Incision. — Begins upon external border of tendo Achillis, about 7.5 cm. 
 (3 inches) above the ankle-joint — passes down behind the tendons of the pero- 
 neus longus and brevis and external malleolus — thence forward, nearer the 
 sole than the external malleolus, to the base of the fifth metatarsal (Fig. 
 398, BB'). 
 
 Operation. — (1) Incise skin and fascia. Slit sheaths of peroneus longus 
 and brevis and retract the tendons forward. Separating the margins of the 
 wound as far as possible, open the capsule of the ankle-joint and, working 
 beneath this with rugine and periosteal elevator, free the surfaces of the 
 astragalus and os calcis, and their articulations with the scaphoid and cuboid, 
 as far as possible in all directions, and working as subperiosteally as possible. 
 The origin of the extensor brevis digitorum is separated from the antero- 
 external aspect of the os calcis. The articular line of the astragalus is freed 
 as fully as possible. (2) The foot is then forcibly inverted and, while in this 
 position, the astragalus is strongly prized and drawn out by bone-forceps, the 
 binding ligaments being cut under tension. The peronei and tibial tendons 
 are carefully preserved. (3) The calcaneo-cuboid articular surfaces are 
 then separated. The lower ends of the tibia and fibula are projected into 
 the wound (by complete inversion of the foot) and sawed off just above the 
 articular lines, leaving enough of the external malleolus for the peronei tendons 
 to hook behind, if possible. The anterior half of the os calcis is then removed 
 by vertical section with saw or chisel. The posterior half of the os calcis is 
 now depressed forward, so as to render its upper surface accessible, and a 
 horizontal slice of bone is removed from its upper surface, but not involving 
 the tendo Achillis. The posterior articular surfaces of the scaphoid and 
 cuboid are thrust into the wound (by twisting the anterior portion of the foot 
 inward) and a vertical section made just posterior to their articular surfaces. 
 
 (4) The vertical section of the posterior half of the os calcis and vertical sec- 
 tions of the scaphoid and cuboid are now approximated — and the horizontal 
 sections of the tibia and fibula are dropped down upon and approximated to 
 the horizontal section of the upper aspect of the posterior part of the os calcis. 
 
 (5) Repair the incised sheaths of the peroneus tendons by suturing them 
 over the tendons with buried gut. The wound is sutured and the foot put up 
 at a right angle to the leg. 
 
 Comment. — (1) The tendons of the peroneus longus, brevis, and tertius, 
 and of the tibialis anticus and posticus, and their attachments, are especially 
 preserved intact. (2) The excision of the calcaneo-astragaloid joint alone 
 may be done through this incision. 
 
 OSTEOPLASTIC RESECTION OF FOOT 
 
 BY TRANSVERSE UPPER AND LOWER AND OBLIQUE LATERAL INCISIONS — 
 WLADIMIROFF-MIKULICZ OPERATION. 
 
 Description. — Removal of soft parts of heel, together with astragalus 
 and os calcis, and approximation of sawed tibia and fibula to sawed scaphoid 
 and cuboid. A foot in the permanent position of extreme talipes equinus 
 results, the patent walking upon the balls and phalanges of the toes. 
 
OSTEOPLASTIC RESECTION OF FOOT. 
 
 5*7 
 
 Position. — Patient supine, with knee flexed to enable inner or outer 
 side of foot to be turned uppermost at end of table. Surgeon's position 
 will vary with the varied steps of the operation. 
 
 Landmarks. — Tuberosity of scaphoid; base of fifth metatarsal; external 
 and internal malleoli; ankle-joint. 
 
 Incisions. — Transverse Plantar Incision — from tuberosity of scaphoid 
 across sole of foot to a point slightly behind the base of the fifth metatarsal. 
 Internal and External Oblique Incisions — pass from the upper extremities 
 of the plantar incisions obliquely upward and backward over the inner and 
 outer aspects of the foot to the bases of the internal and external malleoli. 
 Posterior Horizontal Incision — passes transversely backward around the 
 posterior aspect of the leg, connecting the upper extremities of the inner and 
 outer oblique incisions. (Fig. 399, C, C, C", D, and E.) 
 
 Operation. — (1) The above incisions are everywhere carried to the bone 
 — the plantar vessels and posterior tibial nerve being divided in the transverse 
 plantar incision. (2) Flex the foot forcibly — divide the tendo Achillis and 
 the posterior ligaments — opening the articulation from behind. Further 
 flex the foot on the leg and complete the disarticulation of the ankle-joint. 
 
 Fig.399.— Excisions about the Foot :— A, Excision of first phalanx of great toe, by dorso- 
 internal incision ; B, Excision of metatarsophalangeal joint of great toe by dorso-internal incision ; 
 C, C, C", Skin incisions in Wladimiroff-Mikulicz's osteoplastic resection of foot ; D, Bone-section of 
 scaphoid and cuboid, in same ; E, Bone-section of tibia and fibula, in same. 
 
 (3) By means of rugine and periosteal elevator, and approaching from the 
 lateral incisions, detach the soft parts from the dorsum of the foot as sub- 
 periosteally as possible, thus guarding the anterior tibial vessels and extensor 
 tendons. (4) Disarticulate anteriorly at the astragalo-scaphoid and calcaneo- 
 cuboid joints, and remove the astragalus and os calcis with the adherent soft 
 coverings. (5) Divide the tibia and fibula horizontally just above the articular 
 surfaces. Divide the scaphoid and cuboid vertically at about the center of 
 each bone. Approximate the sawed surfaces of the tibia and fibula above, 
 to the scaphoid and cuboid below, in the vertical or extreme talipes equinus 
 position — holding them in place by kangaroo tendon, silver wire, or pegs. 
 (6) Having tied all vessels, approximate and suture the cut ends of the 
 
518 EXCISIONS. 
 
 posterior tibial nerve. Establish temporary drainage. Suture the trans- 
 verse plantar incision and the lower half of the oblique lateral incision, to 
 the upper half of the oblique lateral incision and posterior horizontal incision. 
 The limb is then put up in a plaster cast. 
 
 Comment. — (i) The redundancy of tissue is soon taken up. (2) The 
 limb is generally permanently a little lengthened, and a special boot is always 
 to be worn. (3) Nourishment of the part occurs through the dorsalis pedis 
 artery and its anastomoses with the plantar. (4) The section of bone below 
 may be made through the three cuneiforms and cuboid. 
 
 TOTAL EXCISION OF TARSUS — OR OSTEOPLASTIC RESECTION OF 
 
 FOOT 
 
 BY EXTERNO-LATERAL CURVED INCISION — MODIFICATION OF WLADIMIROFF- 
 MIKULICZ OPERATION. 
 
 Description. — Removal of all the tarsal bones, and sawing off of distal 
 articular surfaces of tibia and fibula and proximal articular surfaces of meta- 
 tarsals — with approximation of sawed tibia and fibula to sawed metatarsals — 
 the foot being brought into a vertical line with the leg. This is a modification 
 of the Wladimiroff-Mikulicz osteoplastic resection of the foot, and is prefer- 
 able to that operation where the soft tissues of the heel do not have to be 
 sacrificed. The patient walks on the balls of the toes and the phalanges. 
 
 Position — Landmarks. — As for osteoplastic resection of posterior tarsus, 
 page 516. 
 
 Incision. — As for osteoplastic resection of posterior tarsus — except that 
 the incision extends to near the end of the fifth metatarsal (Fig. 398, BC). 
 
 Operation. — The exposure and freeing of the surfaces of the tarsal 
 bones, lower end of the tibia and fibula, and bases of the metatarsals are 
 accomplished in the same manner as described in freeing the bones involved 
 in osteoplastic resection of the posterior tarsus, except that the clearing is 
 more extensive. The origins and insertions of all the muscles and tendons 
 into the bones to be removed are to be separated as encountered. All vessels 
 and nerves are carefully guarded by working close to the bones. The tendons 
 of the peroneus longus and brevis are freed from their sheath and drawn 
 forward. The tendo Achillis is subperiosteally separated from the os calcis. 
 The long dorsal, plantar, external and internal tendons are separated — and 
 the short muscles as well. The tarsal bones are to be removed one by one 
 while the foot is forcibly inverted, access being gained to the region, if neces- 
 sary, by chiseling off the external malleolus. The articular ends of the 
 tibia and fibula and of the metatarsals are exposed by thrusting them through 
 the external wound and are sawed off. Their sawed surfaces are then 
 placed in contact in a vertical line — the fibrous tissues brought together with 
 chromic sutures, where indicated — the superficial wound closed — and the 
 limb put up in a splint, or plaster, in such a manner as to retain this position. 
 
 EXCISION OF TIBIA. IN GENERAL. 
 
 Surgical Anatomy— Surface Form and Landmarks.— Given under 
 Amputations about the Leg. 
 
 General Surgical Considerations. — Where a subperiosteal excision is 
 done, a very useful limb often results, even after the entire removal of the 
 bone. The' articular ends should be left if possible. Any portion of the 
 tibia may be removed through the corresponding part of the following in- 
 cision. 
 
EXCISION OF FIBULA, IN GENERAL. 
 
 519 
 
 TOTAL EXCISION OF TIBIA 
 
 BY INTERNAL VERTICAL IN'CISION. 
 
 Position. — Patient supine; leg turned outward. Surgeon to outer side 
 of right limb, cutting downward, and vice versa on left. 
 
 Landmarks. — Inner aspect of tibia, which is practically everywhere 
 subcutaneous. 
 
 Incision. — Passes just in front of the inner border of the entire length 
 of the tibia, from the knee-joint to the ankle-joint (Fig. 400, A). 
 
 Operation. — The incision passes directly through periosteum to bone — 
 running behind the tendons of the sartorius, gracilis, and semitendinosus 
 above — and the internal saphenous nerve being recognized and retracted 
 below. Once beneath the periosteum, the shaft of the bone is entirely freed 
 subperiosteal!}' by means of a well-curved perios- 
 teal elevator. The periosteum, together with all the 
 muscles and tendons attached, is freed to near 
 the articular ends. A chain or Gigli saw is then 
 passed between the bone and periosteum and the 
 bone divided at its center. Each end of the tibia is 
 grasped in turn, with strong bone-forceps, and drawn 
 outward — during which manoeuvre the articular 
 end is freed up to the joint subperiosteo-capsularly 
 — and disarticulated. The edges of the incision in 
 the periosteum of the shaft, and in the capsules 
 of either end, are now sutured with buried gut 
 stitches. Temporary drainage is instituted at 
 either joint end — the muscles and deep connective 
 tissue quilted together, wherever indicated — the skin 
 wound closed — and the limb put up on a straight 
 splint. 
 
 EXCISION OF FIBULA. IN GENERAL. 
 
 Surgical Anatomy — Surface Form and 
 Landmarks. — Given under Amputations about 
 the Leg, pages 417 and 418. 
 
 General Surgical Considerations. — (1) The 
 fibula may be removed in whole or in part. (2) 
 Removal of the outer malleolus is apt to be fol- 
 lowed by eversion of the foot. A very useful limb, 
 however, generally follows the subperiosteal exci- 
 sion of the bone. (3) The superior tibio-fibular ar- 
 ticulation often communicates with the knee-joint 
 — it is, therefore, desirable to leave, if possible, 
 the head of the fibula entirely, or, after cutting it 
 off, gouge out the head, leaving a protective barrier 
 of bone to intervene between the knee-joint. (4) 
 In excising the upper half of the bone alone, a 
 posterior vertical incision (part of the following 
 incision) is used, passing behind the peronei mus- 
 cles. (5) In excising the lower half alone, an 
 antero-external vertical incision is used, passing in 
 front of the peronei muscles. 
 
 Fig. 400.— Excisions about 
 Long Bones of Lower Ex- 
 tremity: — A, Excision of tibia 
 by internal vertical incision ; B, 
 Excision of fibula by posterior 
 vertical incision ; C, D, Exci- 
 sion of portions of femur by ex- 
 ternal vertical incision. 
 
520 EXCISIONS. 
 
 EXCISION OF FIBULA 
 
 BY POSTERIOR VERTICAL INCISION. 
 
 Position. — Patient supine; leg turned well to inner side. Surgeon and 
 assistant stand as in excising the tibia (page 519). 
 
 Landmarks. — Outline of fibula; articulations of superior tibio-fibular 
 joint and ankle-joint. 
 
 Incision. — Passes the entire length of the bone, from the tibio-fibul ir 
 articulation to the ankle-joint — running down behind the peroneus longus 
 and brevis muscles, along the posterior aspect of the bone (Fig. 400, B). 
 
 Operation. — The above incision is first made through skin and fascia — 
 and then deepened through periosteum to bone— guarding the external 
 popliteal nerve above, where it winds around the neck of the bone, and the 
 peroneal artery behind the lower half of the bone. The bone is reached, 
 above, between the peroneus longus in front, and soleus, behind — and, 
 below, between the peroneus longus and brevis, in front, and flexor longus 
 hallucis, behind. Once beneath the periosteum, this membrane is raised 
 from the bone in as nearly one layer as possible, and to as near the articular 
 ends of the bone as possible, together with the overlying muscles and tendons 
 still attached. A chain or Gigli saw is then slipped between bone and perios- 
 teum and the bone divided in its middle. Each end is then grasped by bone- 
 forceps and drawn outward — and, while so held, is further freed of its perios- 
 teum, and, at its articular ends, of its periosteo-capsular covering. The 
 articular ends are then disarticulated at the ankle-joint and at the superior 
 tibio-fibular articulation (see General Surgical Considerations, page 519). 
 Avoid opening into the knee-joint, if possible, and injury to the anterior 
 tibial and musculocutaneous nerves. It is preferable to preserve the upper 
 and lower articular ends in situ — making the section just beyond the articu- 
 lation, unless contraindicated. The long periosteal and peristeo-capsular 
 wound is now sutured with catgut — muscles quilted — temporary drainage 
 instituted, if the articulations have been opened up — the wound closed— 
 and the limb put up on a long splint. 
 
 EXCISION OF PATELLA 
 
 BY VERTICAL INCISION. 
 
 Description. — The patella, which may be considered a sesamoid bone 
 developed in the quadriceps extensor tendon, is simply shelled out of that 
 structure, through a single anterior longitudinal incision, with • minimum 
 damage to the surrounding structures, and especially the knee-joint. 
 
 Position. — Patient supine; limb extended. Surgeon cuts from above 
 downward on right, and vice versa on left. 
 
 Landmarks. — Contour of patella. 
 
 Incision.— The incision passes through skin, fascia, prepatellar bursa, 
 quadriceps aponeurotic expansion, and periosteum to bone. Working be- 
 neath the periosteum with rugine and curved periosteal elevator, the bone 
 is freed from its soft parts and from the anterior surface of the capsule and 
 thus enucleated. The cut margins of the capsule are now sutured with 
 buried gut stitches— the split quadriceps expansion similarly sutured— the 
 wound closed — and the limb put up in extension. 
 
EXCISION OF KNEE-JOINT, IN GENERAL. 
 
 521 
 
 EXCISION OF KNEE-JOINT, IN GENERAL. 
 
 Surgical Anatomy— Surface Form and Landmarks.— Given under dis 
 articulation at the knee-joint, pages 430 and 431. 
 
 General Surgical Considerations. — (1) In excision of the knee-joint, the 
 articular ends of the femur and tibia are removed — the sawed ends of the 
 bones are approximated — and firm ankylosis in full extension is sought. (2) 
 The lower epiphysis of the femur is to be saved in the young, if possible. 
 (3) The patella may be left, if healthy — but should be removed, in whole or 
 in part, if diseased. (4) The subperiosteal method of excision is almost 
 impracticable. 
 
 After-treatment. — The limb is put up fully extended, and so kept for 
 
 Fig. 401. — Showing Relations of Femur, Tibia, and Fibula at the Knee-joint. 
 
 one and a half to three months — followed by other support for several months 
 longer. An extra-soled shoe is used for the unavoidable shortening. 
 
 Results. — The result is satisfactory where ankylosis in a good position 
 is secured. Flail and useless limbs sometimes occur. There is a tendency 
 of the femur to glide forward. If the whole of the trochlear surface be re- 
 moved, the epiphysis (the chief source of growth of the lower extremity) will 
 be lost. 
 
 Best Method. — Curved Transverse Anterior Incision; Vertically Curved 
 External Incision (Kocher). 
 
522 
 
 EXCISIONS. 
 
 Other Methods. — Anterior U-shaped Flap; Anterior Vertical Incision, 
 with temporary splitting or retraction of patella. Transverse Incision (through 
 patella, or removing patella). Crucial Incisions. H -shaped Incision. 
 
 EXCISION OF KNEE-JOINT 
 
 BV CURVED TRANSVERSE ANTERIOR INCISION. 
 
 Position. — Patient supine, near edge of table, with leg half over end of 
 
 table. Surgeon on side of operation, or on 
 outer side of right and inner side of left knee. 
 One assistant steadies the thigh — another ma- 
 nipulates the leg. At the beginning of the 
 operation, the knee is slightly flexed, and subse- 
 quently bent at a right angle. 
 
 Landmarks. — Posterior margins of the 
 femoral condyles; tubercle of tibia. 
 
 Incision. — Begins at posterior margin of 
 one femoral condyle (which is about 1.3 
 cm. — \ inch — above the lowest articular sur- 
 face) and ends at the posterior margin of the 
 opposite condyle — curving downward in front 
 to midway between the lower margin of the 
 patella and insertion of the ligamentum pa- 
 tella? (Fig. 402). 
 
 Operation. — (1) The above incision, made 
 while the knee is slightly flexed, passes through 
 skin and fascia — and is then deepened, cutting 
 through anterior capsule and ligamentum pa- 
 tella;, thus opening the knee-joint. The divi- 
 sion of the ligamentum patella? at its center 
 will permit of the subsequent suturing of its 
 ends. (2) Turn the patella and its apo- 
 neurosis upward — further Ilex the joint and di- 
 vide both lateral ligaments and both crucial 
 ligaments. (3) Bend the joint to a right angle, 
 with sole of foot on table and leg support- 
 ing thigh. Now clear the femur to the saw- 
 line, retracting the soft parts and guarding the 
 popliteal region. The femur is then sawed 
 (holding the saw vertically) just above the 
 articular line — the antero-posterior section 
 being at a right angle to the shaft of the 
 femur — and the transverse section parallel to 
 the articular surfaces of the condyles (Fig. 401). (4) The upper end of the 
 tibia is now freed while in the vertical position, down to the saw-line — the soft 
 parts retracted — the popliteal region guarded — and the articular end of the 
 tibia sawed off, holding the saw horizontal and parallel with the articular 
 surface. (5) If healthy, the patella may be left. If the articular surface be 
 slightly diseased, the bone is steadied with bone-holding forceps while the 
 articular surface is removed with a saw or chisel, or the diseased bone is 
 gouged away. If badly diseased, it is entirely dissected out. It is often 
 removed, whether healthy or not — but it is better to leave it, if uninvolved. 
 
 Fig. 402.— Excision of Knee- 
 joint : — By curved transverse ante- 
 rior incision. 
 
EXCISION OF THE KNEE-JOINT. 523 
 
 (6) The pouch beneath the quadriceps extensor tendon is opened up and 
 curetted out — and all other synovial recesses similarly treated. (7) The end 
 of the bones are now approximated with extreme care, and retained in position 
 according to the individual ideas of the surgeon (by pegging, wiring, simple 
 suturing of periosteo-capsular sheath and fibrous tissues around the margins 
 of the two ends ; or simply by apposition of the ends and the use of a plaster 
 or other splint). (8) If the curved incision have severed the ligamentum 
 patelke a short distance above the tubercle of the tibia, which is desirable, 
 the cut ends of the ligament are now sutured with chromic gut. (9) Tempo- 
 rary drainage is established from either angle of the wound — the subcutaneous 
 soft parts brought together with buried gut sutures — the skin-wound closed — 
 and the limb put up upon a posterior splint in full extension. 
 
 Comment.— (1) Only branches of the articular, anastomotica magna, and 
 anterior tibial recurrent are cut, and rarely require ligature. (2) Much of the 
 ease of the efficient exposure of the joint structures will depend on carrying the 
 limbs of the incision to the posterior margin of the femoral condyles. (3) The 
 posterior ligament is separated from the femur and tibia, in preparing them 
 for the saw — and carefully kept intact throughout the operation, as a barrier 
 to the important popliteal region. (4) The retention of the patella is of no 
 special service, as ankylosis of the joint is sought. If removed, it should 
 be done as subperiosteal^ as possible, from the articular aspects, to preserve 
 all the overlying tissues, if these be healthy. (5) As little of the femur should 
 be removed as possible, especially in the young. (6) Be on guard for the 
 internal saphenous vein and nerve at the back part of the inner portion of 
 the incision. (7) If the bone sections be not made in the proper planes, the 
 limb may be knock-kneed or bow-legged, accordingly. In such an event, 
 another section of bone should be made, of tibia or femur, or both. The 
 limb should be absolutely straight. 
 
 EXCISION A OF THE KNEE-JOINT 
 
 BY VERTICALLY CURVED EXTERNAL INCISION KOCHER'S METHOD. 
 
 Description. — The joint is exposed by a curved external incision, having 
 a general longitudinal direction. The tibial tubercle is chiselled off, retaining 
 its periosteal attachment. The soft parts, including the quadriceps apparatus, 
 are displaced to the inner side — the crucial ligaments severed, and the artic- 
 ular ends of the bones thrown out. The femur is sawn convexly and the 
 tibia concavely, so that the sawn surfaces will fit each other reciprocally. 
 
 Position. — For the making of the incision, the knee is placed somewhat 
 upon its inner aspect, to render the outer aspect prominent. 
 
 Landmarks. — Vastus externus; patella; tibial tuberosity; anterior border 
 of tibia. 
 
 Incision. — Begins over the vastus externus, about 8 cm. (3 inches) above 
 the upper border of the patella — extends vertically downward 1.5 cm. (J inch) 
 external to it — thence curves slightly inward, ending at the anterior border 
 of tibia just below the tibial tuberosity (Fig. 403, A). 
 
 Operation. — Divide the skin and the dense fascia lata in the line of the 
 incision. The outer margin of the vastus externus is exposed and divided in 
 the upper aspect of the wound. The external surface of the capsular ligament, 
 fatty tissue, and the external margin of the ligamentum patella? are exposed. 
 The ligament of the patella is freed down to the tubercle of the tibia. The 
 tibial tubercle, together with the patellar ligament and periosteum, are chiselled 
 
524 
 
 EXCISIONS. 
 
 off subcortically and retracted inward — the soft attachments being carefully 
 maintained. The capsular ligament is incised over the outer part of the 
 external condyle and the great synovial sac beneath the quadriceps opened up. 
 The anterior end of the external semilunar cartilage is cut away from the tibia 
 
 Fig. 403. — Excisions about the Lower Extremity: — A, Excision of knee-joint by 
 vertically curved external incision (Kocher); B, Excision of hip-joint by external straight incision 
 (Langenbeck); C, Excision of innominate bone (Kocher). 
 
 and drawn aside without separating it from the capsule. The patellar ligament 
 is retracted inward, and, after severing the anterior end of the internal semilunar 
 cartilage from the head of the tibia, the cartilage, together with the capsule 
 and periosteum, is detached from the margin of the internal condyle. The 
 
EXCISION OF THE KXEE-JOIXT. 
 
 525 
 
 patella is now dislocated to the inner side of the limb. The capsular ligament 
 is detached from both sides of the tibia — until the leg can be flexed completely. 
 The attachments of the crucial ligaments and the posterior attachments of the 
 semilunar cartilages are separated from the head of the tibia back to its poste- 
 rior surface. If it is intended to remove the articular ends of the bones, the 
 upper ends of the crucial ligaments are detached from the intercondyloid fossa 
 in such a manner that, together with the semilunar cartilages, they remain 
 attached to the posterior aspect of the capsule and the periosteum. The 
 capsule of the joint is now divided on a level with the condyloid cartilages of 
 the femur — and (provided it is not to be removed) it is separated backward 
 subperiosteally to the superior attachments of the lateral ligaments. The 
 
 Fig. 404. — -Excision 7 of Knee-joint: — By anterior U-shaped incision. 
 
 capsule and periosteum are separated from the posterior aspect of the tibia. 
 The femur is then sawn below the level of the separated lateral ligaments in 
 such a manner as to leave a convex surface from before backward — and the 
 tibia is sawn so as to leave a concave surface from before backward — thus 
 forming reciprocally fitting surfaces of bone. Where the capsule has been 
 preserved, it is sutured together along the line of original incision, making 
 provision for drainage — after which the skin and superficial parts are united 
 by suture, up to the exit of the drains. The limb is then dressed in an immo- 
 bilizing splint. 
 
 Comment. — Where the disease extends upward, the lateral ligaments are 
 detached higher, chiselling off the epicondyles. All involved tissue is removed, 
 even exceeding the above limits if indicated. 
 
526 EXCISIONS. 
 
 EXCISION OF FEMUR, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Amputations about the Thigh. 
 
 General Surgical Considerations. — (1) Excision is generally confined 
 to the removal of limited portions of the diaphvsis of the femur. But the 
 removal of the entire shaft, subperiosteally, especially in the young, has been 
 followed bv the reproduction of bone and a very useful limb. 
 
 After-treatment. — In the young, the limb should be under traction to the 
 same length as the other, and held rigidly in a splint. In the old, where only 
 a limited amount of bone is removed and satisfactory reproduction of bone 
 is not likely, the sawed ends are to be approximated, and the shorter limb 
 built up by a shoe on that side, as a solid shorter limb is better than a flail 
 longer one. 
 
 EXCISION OF PARTS OF DIAPHYSIS OF FEMUR 
 
 BY EXTERNAL VERTICAL INCISION. 
 
 Description. — Portions of the entire thickness of the femur, between the 
 articular ends, have been removed with successful result. Also see General 
 Surgical Considerations, page 526. 
 
 Position. — Patient on back, turned slightly to one side, to expose outer 
 aspect of thigh. Surgeon stands behind limb, cutting from above downward 
 on right, and vice versa. Assistant opposite surgeon. 
 
 Incision.— Down outer side of thigh, in groove between posterior border 
 of vastus externus and biceps — and extending from base of great trochanter 
 to base of external condyle — or part of the way, as indicated — (Fig. 400, C 
 and D). 
 
 Operation. — The incision first passes through skin, fascia, and fascia 
 lata. The intermuscular plane just mentioned is identified in the upper 
 portion of the wound and followed to the bone. The transverse terminal 
 branch of the external circumflex artery is encountered above, passing beneath 
 the vastus externus muscle — and the superior external articular artery below, 
 winding around the bone. The incision is carried directly through perios- 
 teum to bone. The periosteum is then freed, together with attached muscles 
 and tendons, from the entire circumference of the femur, by means of fully 
 curved rugine and periosteal elevators, especially along the inner and outer 
 lips of the linea aspera. Having freed the center of the shaft, pass a chain 
 or Gigli saw between bone and periosteum — divide the bone — grasp either 
 end with bone-forceps and draw outward — and further free the bone while 
 thus held, as far upward and downward as indicated. Then again pass the 
 chain saw subperiosteally at either end and divide. If feasible, the femur 
 may be freed over the entire length and circumference of the part to be re- 
 moved, and then a chain saw passed at the upper and lower limits and the 
 bone thus divided but twice. Suture periosteal sheath — quilt the muscles 
 with buried sutures — close the wound — and put the limb up in a rigid, straight 
 splint (v. After-treatment, page 526). 
 
 EXCISION OF HIP- JOINT, IN GENERAL. 
 
 Surgical Anatomy — Surface Form and Landmarks. — Given under 
 Disarticulation of Hip-joint, pages 450 and 451. 
 
EXCISION OF HIP-JOINT, IN GENERAL. 
 
 527 
 
 General Surgical Considerations. — (1) Excision of the hip-joint con- 
 sists in the removal of the upper end of the femur and scraping of the acetabu- 
 lum. (2) No tourniquet is necessary — the slight hemorrhage encountered 
 is from small vessels which are controlled as divided. (3) According to some, 
 the section of the bone should, as a rule, be made below the great trochanter, 
 for even where less of the bone is involved, retention of the great trochanter 
 is apt to be followed by harmful pressure (Fig. 405, B). According to other 
 surgeons, as little of the bone should be removed as possible, together with the 
 minimum disturbance of the muscles of the trochanters (Fig. 405, A) . 
 
 After-treatment. — The limb is kept at absolute rest- — in full extension 
 — with the sawed end of the femur slightly separated from the acetabular 
 cavity. 
 
 Results. — A movable and useful joint generallv follows. Ankvlosis or 
 a flail limb is exceptional. Some atrophy generally occurs — and there is 
 always some shortening. 
 
 Fig. 405. — Lines of Section of Head of Femur in Excision of the Hii'-joint: — A, 
 Transcervical section; B, Subtrochanteric section. (Modified from Gray. J 
 
 Best Methods. — Anterior Straight Incision (Barker). External Straight 
 Incision (Langenbeck). Posterior Angular Incision (Kocher). 
 
 Other Methods. — Curved Retro-trochanteric Incision. 
 
 Comparison of Methods. — Each method has its own special indication. 
 The method by external incision is, on the whole, probably the best. The 
 anterior incision does least harm to neighboring structures, dividing no 
 muscles (which the external and posterior incisions do). The posterior 
 incision gives the freest access to the joint and the best drainage. 
 
528 EXCISIONS. 
 
 EXCISION OF HIP- JOINT 
 
 BY EXTERNAL STRAIGHT INCISION — LANGENBECK'S OPERATION. 
 
 Position. — Patient on sound side; thigh flexed at an angle of 45 degrees 
 and rotated inward. Surgeon to outer side of hip. Assistant, grasping knee 
 and foot, rotates and manipulates the limb as indicated. 
 
 Landmarks. — Great trochanter. 
 
 Incision. — Begins over the ilium, about 7.5 cm. (3 inches) above the 
 upper border of the great trochanter (which is about opposite the upper 
 margin of the great sacrosciatic notch) — passes downward for 11.5 to 12.5 
 cm. (4 \ to 5 inches) in the long axis of the limb, lying just behind the center 
 of the outer surface of the great trochanter, and ends just below the base 
 of the great trochanter. (In the above position of the limb, the direction 
 of the incision will be represented by a straight line from the posterior superior 
 iliac spine, passing down the center of the long axis of the limb.) (Fig. 403,6.) 
 
 Operation. — (1) This incision passes, at first, through skin and fascia — 
 then through the gluteus maximus, dividing it, approximately, in the line of 
 its fibers. (2) The gap between the gluteus medius in front, and pyriformis 
 behind, is sought and widened to the joint by retraction — and the capsule 
 of the joint and periosteum of the great trochanter are divided to the bone 
 in the line of the original incision. If necessary, the capsule of the joint is 
 further divided transversely. By means of curved rugine and periosteal 
 elevator, the anterior and posterior capsulo-periosteal flaps are raised, sub- 
 periosieally, if possible — or by the open method. (3) The cotyloid ligament 
 is cut by thrusting a stout knife between the head of the bone and the cotyloid 
 ligament and cutting the ligament toward the rim of the acetabulum, and air 
 thus allowed to enter and separate the articular surfaces. In those cases where 
 difficulty is experienced in admitting air to the joint cavity, a small portion of 
 the rim of the acetabulum, with its cotyloid cartilage, may be chiseled away 
 'over about 1.3 cm. (J inch) of the circumference. (4) The muscles attached 
 to the outer and posterior surfaces of the great trochanter are now raised sub- 
 periosteally, or severed, while an assistant, grasping the knee and foot, rotates 
 the thigh inward, — and those attached to the anterior surface and lesser tro- 
 chanter while the thigh is rotated outward. (5) The ligamentum teres is 
 now divided and the head of the bone dislocated backward and outward bv 
 depressing the limb (if the thigh partly rests over the end of the table as a 
 fulcrum) and rotating outward. (6) The soft parts are further cleared from 
 the upper end of the femur and retracted. While steadied with bone-holding 
 forceps, the head of the femur is sawed below the great trochanter, with slight 
 obliquity, from above downward, and from without inward. (7) The ace- 
 tabular cavity is scraped or cleared with a gouge. All synovial recesses are 
 curetted. (8) Temporary drainage is instituted — the capsule sutured — the 
 muscles quilted — the wound sutured — and the limb put up in extension (see 
 After-treatment, page 527). 
 
 Comment. — (1) Only minor hemorrhage occurs, seldom necessitating 
 ligature. (2) The strength of the capsule is increased if its transverse division 
 be avoided. (3) Some surgeons remove as little of the head of the femur as 
 possible, sawing through the neck — but it is generally better *to saw below 
 the great trochanter, as this mass of bone, if left, is apt to be drawn up and 
 constantly press the cicatrix. (4) Considerable division of muscle is made. 
 
EXCISION OF HIP-JOINT. 
 
 529 
 
 EXCISION OF HIP- JOINT 
 
 BY ANTERIOR STRAIGHT INCISION — BARKER'S OPERATION. 
 
 Position. — Patient supine; limb extended. Surgeon on side of operation. 
 Assistant steadies limb. 
 
 Landmarks. — Anterior superior iliac spine; groove between tensor vagi- 
 na? femoris and glutei on outer 
 side, and sartorius and rectus on 
 inner side. 
 
 Incision. — Begins on front 
 of thigh, about 1.3 cm. (h inch) 
 below the anterior superior iliac 
 spine — passing downward and 
 slightly inward for 7.5 to 10 cm. 
 (3 to 4 inches), in groove formed, 
 on inner side, by sartorius and 
 rectus, and, on outer side, by ten- 
 sor vaginae femoris and glutei 
 (Fig. 406). 
 
 Operation. — (1) This incision 
 passes through skin and fascia, 
 at first. The external cutaneous 
 nerve is avoided, being retracted 
 outward, if in the way. The 
 above intermuscular groove is rec- 
 ognized and the muscles forming 
 it retracted inward and outward. 
 (2) The terminal branch of the 
 transverse division of the external 
 circumflex artery is encountered 
 and generally requires ligation. 
 The parts are further drawn aside 
 and the joint reached without any 
 division of muscles whatever, or 
 of any vessels or nerves of im 
 portance. (3) An incision is now 
 made over the anterior aspect of 
 
 the joint, in line with the original incision, passing through the capsule into 
 the joint and on to the head of the femur. (4) The cotyloid ligament is in- 
 cised to admit air into the joint and enable the head of the femur to be drawn 
 down lower. The neck of the bone is exposed and divided in situ with a nar- 
 row saw, or with a chain or Gigli saw — the soft parts being as much retracted 
 as possible. The severed head is then seized with strong bone-forceps and 
 removed, the ligamentum teres having been cut. (5) The acetabular cavity 
 and recesses of synovial membrane are curetted with Barker's flushing-gouge 
 — and the operation completed as in the excision by external incision. Tem- 
 porary drainage is used and is best accomplished through a counter-opening 
 made posteriorly. 
 
 Comment. — Disarticulation may be accomplished as in the external 
 incision and the head excised outside of the wound. 
 
 Fig. 406. 
 
 -hxcisioN of Hip-joint : — By anterior 
 straight incision. 
 
53° 
 
 EXCISIONS. 
 
 EXCISION OF HIP-JOINT 
 
 BY POSTERIOR ANGULAR OR CURVED INCISION — KOCHER'S OPERATION. 
 
 Position. — Patient on sound side; hip prominent; knee semiflexed and 
 rotated inward. Surgeon stands behind hip. Assistant steadies the part. 
 
 Landmarks. — Great trochanter; 
 direction of fibers of gluteus maximus. 
 Incision. — Begins at base of exter- 
 nal aspect of great trochanter — passes 
 thence upward and forward to its an- 
 terior superior angle — and then runs 
 obliquely upward and inward in the 
 line of the filters of the gluteus maxi- 
 mus (Fig. 407). 
 
 Operation. — (1) Theincision passes 
 through skin and fascia, at first. Di- 
 vide the aponeurosis of the gluteus 
 maximus over the external aspect of 
 the great trochanter — and ligate the cut 
 branches of the external circumflex ar- 
 tery. (2) Divide the fibers of the mus- 
 cular portion of the gluteus maximus in 
 the upper part of the wound, and ligate 
 the cut branches of the gluteal artery. 
 (3) Dissect through the intermuscular 
 fat and fascia and expose the interval 
 between the gluteus medius and mini- 
 mus above and pyriformis below — 
 drawing the two former upward and 
 the latter downward. Thus the pos- 
 terior part of the capsule and acetabu- 
 lum are approached and exposed. (4) 
 Divide the capsule along the superior 
 border of the pyriformis. Rotate the 
 thigh outward and subperiosteally sep- 
 arate the gluteus medius from the outer 
 surface and the gluteus minimus from the anterior border of the great 
 trochanter, raising a thin layer of bone, with rugine or chisel, if necessary. 
 Then subperiosteally detach the pyriformis, obturator interims, and gemelli 
 from the inner aspect of the great trochanter, and the obturator externus from 
 the digital fossa. (5) Rotate the thigh inward and free the inner and posterior 
 aspects of the great trochanter. The head, neck, and great trochanter are 
 thus cleared. Some branches of the internal circumflex may require ligation 
 near the capsule of the joint, and branches of the external circumflex near 
 the base of the great trochanter. (6) Cut the internal cotyloid ligament to 
 admit air — divide the ligamentum teres from behind, on the head of the 
 femur while the limb is adducted, flexed, and rotated inward. The head is 
 now dislocated through the wound by outward rotation, and removed. (7) 
 The periosteo-muscular wound is sutured with buried chromic gut stitches 
 — the muscles quilted — temporary drainage established — the wound closed — 
 and the limb put up upon a splint in extension. 
 
 Comment. — The above operation is really a development of Langenbeck's 
 external incision, but admits of freer access to the joint and gives better 
 drainage. 
 
 Fig. 407. — Excision of Hip- joint: — 
 By posterior angular incision. The 
 angularity of this incision may be changed to 
 a curve. 
 
EXCISION OF THE INNOMINATE BONE. 53 1 
 
 EXCISION OF THE INNOMINATE BONE 
 kocher's operation. 
 
 Description. — The entire removal of one of the innominate bones may 
 be required by extensive growths of the bony pelvis. 
 
 Position. — The patient rests upon the uninvolved side, and is turned 
 toward his face or his back during the progress of the operation. 
 
 Landmarks. — Sacro-iliac joint; crest of ilium; Poupart's ligament. 
 
 Incision. — Begins at the sacro-iliac joint — passes along the crest of the 
 ilium — and thence along Poupart's ligament (Fig. 403, C). 
 
 Operation. — Divide the abdominal muscles from their attachment to 
 Poupart's ligament and the crest of the ilium. Separate the transversalis 
 fascia and the peritoneum from the pelvic floor as far inward as the iliac 
 vessels and retract them further inward. The smaller nerves are cut — and 
 the smaller arteries clamped and tied. The muscles posterior to Poupart's 
 ligament and external to the iliac vessels are isolated and divided. Separate 
 and detach as far back as the sacro-iliac joint the rectus femoris, sartorius, 
 tensor vaginae femoris, and the iliac attachments of the gluteus medius and 
 minimus. Divide the ilio-psoas muscle and the capsule of the joint. Sub- 
 periosteally expose the pubis and ischium and divide them with Gigli saw, 
 chisel, or bone-cutting forceps. The innominate bone can now be displaced 
 downward. The remainder of the posterior aspect of the pelvis is exposed 
 and the attachments of the flexor muscles severed. The great sacro-sciatic 
 ligament is cut from the tuber ischii, and the lesser sacro-sciatic ligament from 
 the ischial spine. While there is considerable bleeding from smaller vessels, 
 no artery had to be ligated in Kocher's case. The wound healed by primary 
 union. Kocher suggests, however, that the internal iliac vessels be ligated 
 when exposed in the wound. The lower limb is immobilized in line with the 
 trunk. 
 
PART II. 
 THE OPERATIONS OF SPECIAL SURGERY. 
 
 CHAPTER I. 
 
 OPERATIONS UPON THE HEAD. 
 I. THE CRANIO-CEREBRAL REGION. 
 
 SURGICAL ANATOMY OF SCALP, SKULL, AND BRAIN. 
 
 Muscles in Relation with Outer Surface of Skull.— Anteriorly; 
 
 frontal portion of occipitofrontalis; corrugator supercilii; orbicularis pal- 
 pebrarum. Posteriorly; occipital portion of occipitofrontalis; trapezius; 
 sternomastoid ; complexus; splenius capitis; rectus capitis posticus minor and 
 major; obliquus capitis superior; trachelomastoid; digastric; rectus capitis 
 lateralis. Laterally; aponeurosis of occipitofrontalis; temporal; attrahens 
 aurem; attolens aurem; retrahens aurem; external pterygoid. Superiorly; 
 aponeurosis of occipitofrontalis. 
 
 Arteries of Scalp. — Anteriorly; frontal and supraorbital branches of 
 ophthalmic. Posteriorly; occipital and posterior auricular branches of 
 external carotid. Laterally ; superficial temporal branch of external carotid, 
 with its anterior and posterior branches; posterior auricular branch of ex- 
 ternal carotid. 
 
 Veins of Scalp. — Anteriorly; frontal, emptying into angular vein; 
 supraorbital, emptying into frontal and ophthalmic veins. Posteriorly; 
 occipital, emptying into deep cervical vein; posterior auricular, emptying 
 into temporomaxillary vein. Laterally; anterior, middle, and posterior 
 temporal veins; forming common temporal, which empties into temporo- 
 maxillary vein; posterior auricular, emptying into external jugular. 
 
 Nerves of Scalp. — Anteriorly; supraorbital branch of ophthalmic. 
 Posteriorly; occipitalis major, from cervical plexus. Laterally; temporal 
 branches of facial; auriculotemporal branch of inferior maxillary; occipitalis 
 minor, from cervical plexus; auricularis magnus, from cervical plexus. 
 
 Parts of Brain. — Medulla oblongata; pons varolii; cerebellum; crura 
 cerebri (mid-brain) ; cerebrum. The only parts of the brain at present 
 accessible to operation are the cerebrum and cerebellum. 
 
 Chief Fissures upon Surface of Cerebrum. — Great Longitudinal 
 Fissure ; extending antero-posteriorly in the median line and separating the 
 hemispheres of the cerebrum. Sylvian fissure; most important of the in- 
 complete fissures of the brain. Forms boundary between frontal and tem- 
 poro-sphenoidal lobes. Contains middle cerebral artery. Begins at anterior 
 perforated space, upon base of brain, and, running outward, divides into an 
 anterior limb (passing forward into inferior frontal convolution), an ascending 
 
 533 
 
534 OPERATIONS UPON THE HEAD. 
 
 limb (passing upward also into inferior frontal convolution), and a horizontal 
 or posterior limb (representing the continuation of sylvian fissure, passing 
 backward and upward). Rolandic fissure; second most important incom- 
 plete fissure of brain. Forms boundary between frontal and parietal lobes. 
 Extends from great longitudinal fissure, at a point about 55 per cent, of the 
 distance from the nasion to the inion, to or nearly to horizontal limb of fissure 
 of Sylvius. Parieto-occipital fissure ; forms boundary between parietal and 
 occipital lobes. Begins about half-way between rolandic fissure and posterior 
 extremity of brain — its outer portion extending downward and forward upon 
 external aspect of brain for about one inch — its inner portion extending upon 
 internal aspect of hemisphere. These four fissures just mentioned divide 
 the surface of the cerebrum into the five following lobes. 
 
 Chief Lobes of Cerebrum. — Frontal lobe; forms forepart of hemi- 
 sphere — rests upon orbital plate of frontal bone — presents three surfaces. 
 Boundaries; Posteriorly, rolandic fissure, — Inferiorly, orbital plate of frontal 
 bone and horizontal limb of sylvian fissure, — Internally, calloso-marginal 
 fissure. Frontal (supero-external) surface, presents precentral, superior 
 frontal, and inferior frontal sulci, — and ascending frontal, superior frontal, 
 middle frontal, and inferior frontal convolutions. Orbital (inferior) surface, 
 presents triradiate (or orbital) and olfactory sulci, — and internal orbital, 
 anterior orbital, and posterior orbital convolutions. Mesial (internal) sur- 
 face, is given below. Parietal lobe ; that portion of convexity of brain 
 lying between frontal and occipital and above temporal lobes. Boundaries; 
 Anteriorly, rolandic fissure, — Posteriorly, external parieto-occipital fissure 
 and a line continuing its course, — Inferiorly, horizontal limb of sylvian 
 fissure and a line connecting this fissure with inferior end of superior occipital 
 sulcus, — Internally, it is continued into the mesial surface of the hemisphere. 
 Sulcus; intraparietal (consisting of superior and inferior vertical and horizontal 
 parts). Convolutions; ascending parietal; superior parietal; supramarginal 
 and angular gyrus. Occipital lobe ; posterior extremity of hemisphere — 
 rests upon tentorium — continuous with parietal lobe above and temporal 
 lobe below. Boundaries; Anteriorly; external parieto-occipital fissure and 
 a line continuing its course, — Posteriorly; superior fossa of occipital bone, — 
 Inferiorly; tentorium, — Internally; it is continued into the mesial surface of 
 hemisphere. Sulci; superior, middle (often but faintly marked) and inferior 
 occipital. Convolutions; superior, middle, and inferior occipital. Temporal 
 or temporo-sphenoidal lobe ; that portion of hemisphere within middle 
 fossa of skull — continuous with parietal and occipital lobes behind. Boun- 
 daries; Anteriorly and Superiorly; sylvian fissure, — Inferiorly, middle fossa of 
 skull, — Posteriorly; continuous with parietal and occipital lobes. Sulci; 
 superior (first temporal or parallel), middle (second temporal), inferior 
 temporal (on under surface). Convolutions; superior, middle, inferior (or 
 first, second, third) temporal, — and an external occipitotemporal (or fourth 
 temporal) on the under surface. Central lobe, or island of Reil; corre- 
 sponds to floor of embryonic fossa of Sylvius — is situated at base of brain, 
 in fissure of Sylvius — and is composed of five to seven gyri operti divided by 
 the sulci of Reil. Boundaries; separated by anterior sulcus Reilii from poste- 
 rior orbital convolution; by external sulcus Reilii from inferior frontal, ascend- 
 ing frontal, and ascending parietal convolutions; by posterior sulcus Reilii 
 from temporal lobe. 
 
 Mesial Fissures and Lobes of Cerebrum. — Fissures; calloso-marginal; 
 parieto-occipital; calcarine; collateral; dentate. Lobes; gyrus fornicatus, 
 
SURGICAL ANATOMY OF SCALP, SKULL, AND BRAIX. 535 
 
 marginal, paracentral, quadrate (precuneus); cuneate; infracalcarine (fifth 
 temporal); hippocampal; uncinate; fourth temporal. 
 
 Cerebellum. — Occupies inferior occipital fossae of skull, separated from 
 occipital lobes of brain by tentorium — and is divided into a central lobe (or 
 worm) and two lateral lobes (or hemispheres). Fissures upon superior 
 surface of central and lateral lobes; precentral, post-central, preclival, post- 
 clival. Lobules upon superior surface of central and lateral lobes; lingula; 
 lobulus centralis; culmen; clivus; folium cacuminis, lobules of the central 
 lobe; — and frenulum ; ala; anterior crescentic, posterior crescentic and 
 posterior superior, lobules of the lateral lobes. Fissures upon the inferior 
 surface of central and lateral lobes; post-nodular; prepyramidal; post-pyr- 
 amidal. Lobules upon inferior surface of central and lateral lobes; tuber 
 valvulae; pyramid; uvula and nodulus, lobules of central lobe; — and postero- 
 inferior; digastric; amygdala and flocculus; lobules of lateral lobes. 
 
 Meningeal Arteries. — Chief meningeal arteries; Middle Meningeal 
 branch of internal maxillary, entering skull through foramen spinosum in 
 middle fossa, ascends a short distance in groove on great wing of sphenoid, 
 dividing into anterior and posterior branches. Anterior Branch of middle 
 meningeal ascends in groove upon great wing of sphenoid, up to and upon 
 anterior inferior angle of parietal bone (corresponding to a point on exterior 
 of skull approximately 3.8 cm. [1^ inches] behind and 2.5 cm. [1 inch] above 
 external angular process of frontal bone), and is continued thence upward 
 and backward, more or less parallel with anterior border of parietal bone, 
 nearly to superior longitudinal sinus, giving off branches running backward. 
 Corresponds, approximately, with points respectively 2.5, 3.8, and 5 cm. (1, 
 ii, and 2 inches) both above zygoma and behind external angular process. 
 Posterior Branch of middle meningeal runs backward and upward over 
 squamous portion of temporal bone — less regular in its course than anterior 
 branch — gives off branches which pass upward to superior longitudinal sinus 
 and backward to lateral sinus. (For anatomy of these important arteries 
 in greater detail, see Ligations, pages 44-46.) Other meningeal arteries; 
 In Anterior Cranial Fossa ; anterior meningeal branches of anterior and pos- 
 terior ethmoidal (through anterior and posterior internal orbital canals) ; twigs 
 of middle meningeal (through great wing of sphenoid) ; — In Middle Cranial 
 Fossa ; branch of ascending pharyngeal (through cartilage of foramen lacerum 
 medium) ; meningea parva (through foramen ovale) ; meningeal branch of 
 internal carotid; twigs of middle meningeal, — In Posterior Cranial Fossa; 
 meningeal branch of occipital (through posterior compartment of jugular 
 foramen) ; another meningeal branch of occipital (through mastoid foramen) ; 
 meningeal branch of ascending pharyngeal (through posterior compartment 
 of jugular foramen) ; another meningeal branch of ascending pharyngeal 
 (through anterior condyloid foramen) ; meningeal branch of vertebral (through 
 foramen magnum). Another meningeal branch of occipital sometimes enters 
 through parietal foramen. 
 
 Chief Cerebral Arteries. — Anterior Cerebral; — Middle Cerebral, larger 
 terminal division of internal carotid and most important, surgically, of the 
 intracerebral vessels, supplying the motor convolutions of the brain — runs 
 upward and outward in fissure of Sylvius, dividing opposite island of Reil 
 into, (1) Ganglionic or Central Branches (caudate branches; antero-lateral 
 branches): Lenticulo-striate branch, or "artery of cerebral hemorrhage," 
 a larger branch of antero-lateral set, enters outer part of anterior perforated 
 space, passes upward between lenticular nucleus and external capsule, 
 pierces internal capsule and ends in caudate nucleus: (2) Hemispheral or 
 
536 OPERATIONS UPON THE HEAD. 
 
 Cortical Brandies (inferior or orbitofrontal; ascending frontal; parietal; 
 parieto-temporal) ; — Posterior Cerebral: — Anterior Communicating; — Poste- 
 rior Communicating; — Basilar. 
 
 Chief Cerebellar Arteries. — Superior cerebellar; anterior cerebellar; 
 inferior cerebellar. 
 
 Venous Sinuses of Dura Mater. — (i) More superficial sinuses; — 
 Superior longitudinal sinus; extends from foramen caecum, at lower part 
 of frontal bone, along median line, in attached margin of falx cerebri, to 
 torcular Herophili in depression of internal occipital protuberance. Generally 
 deviates slightly to right in the back part of the skull. Posteriorly, the 
 longitudinal sinus extends 6 mm. (j inch) to left, and 15 mm. (f inch) to 
 right of external occipital protuberance, which measurement of 2 cm. (f 
 inch) represents width of longitudinal sinus, at this site, and attachment 
 of falx cerebri. Lateral sinus; extends outward, forward, and downward, 
 passing from internal occipital protuberance along lateral sinus groove of 
 occipital, posterior inferior angle of parietal, mastoid process of temporal 
 and jugular process of occipital, to end in posterior compartment of jugular 
 fossa. From the internal occipital protuberance the lateral sinus forms a 
 slight curve, with upward convexity, to back of ear, on level with upper 
 border of meatus auditorius externus, constituting the transverse portion of 
 the lateral sinus, — and thence passes in a curved line, convexity forward, over 
 prominence of mastoid process to its apex, as far as a point 5 mm. ( T 3 g- inch) 
 below lower border of external auditory meatus, thus forming the sigmoid 
 portion of the lateral sinus. The Transverse portion of the Longitudinal 
 Sinus lies above a straight line drawn from the external occipital protuberance 
 to the center of the external auditory canal — its highest portion (which is 
 opposite the posterior inferior angle of the parietal, at masto-parietal suture) 
 lying from 15 to 25 mm. (f to 1 inch), generally averaging from 15 to 20 mm. 
 (I to if inch), above this line, and somewhat external to its center. The 
 Sigmoid portion of the Longitudinal Sinus generally lies from 10 to 12 mm., 
 or -j- 7 ^ to h inch (extremes 2 to 12 mm., or nearly § to ^ inch), from the poste- 
 rior wall of meatus auditorius externus (corresponding, approximately, to 
 posterior reflection of skin from pinna of ear to head). Distance of sinus 
 from surface of mastoid process varies from 1 to 15 mm., or from nearly 
 y 1 ^ to f inch (average distance being about 7 mm., or f inch). Width of sig- 
 moid portion of sinus (which is larger than transverse portion) is from 5 to 
 15 mm. (j to f inch). Right lateral sinus is generally larger, more forward, 
 and more superficial than left. Junction of transverse and sigmoid portions 
 lies directly below anterior part of parieto-mastoid suture. Inferior longi- 
 tudinal sinus; situated in free margin of falx cerebri. Straight sinus; 
 extends along line of junction of falx cerebri and tentorium. Occipital 
 sinus; contained within attached border of falx cerebelli. (2) Sinuses at 
 base of skull; — circular, transverse, cavernous, superior petrosal, inferior 
 petrosal. 
 
 Chief Veins of Cerebrum. — Cortical (Hemispheral or Superficial), 
 consisting of superior and inferior cortical veins, which empty chiefly into 
 the more superficial venous sinuses of the dura mater; — Central (Ganglionic 
 or Deep), collect into two venae Galeni, which unite to form the vena magna 
 Galeni, which empties into the straight sinus; — Basilar, which enters vein 
 of Galen. 
 
 Chief Veins of Cerebellum. — Superior and Inferior veins. 
 
CHIEF CRANIAL LANDMARKS. 
 
 CHIEF CRANIAL LANDMARKS. 
 
 537 
 
 Nasion: mid-point of naso-frontal suture; most important anterior median 
 landmark. 
 
 Glabella: point in median line between superciliary arches; unreliable, 
 may be an elevation or a depression. 
 
 Bregma (anterior fontanelle) : point where coronal, sagittal, and frontal 
 sutures meet; just in front of center of line between the two auditory meatuses. 
 
 Coronal Suture: on line from bregma to middle of zygomatic arch, running 
 2.5 to 3.8 cm. (1 to ij inches) anterior to rolandic fissure. 
 
 Obelion: point on sagittal suture on a line running between the two 
 parietal foramina. 
 
 Lambda (posterior fontanelle): junction of lambdoid and sagittal sutures; 
 8 to 10 cm. (3y\ to 4 inches) behind superior rolandic point (a point 55 per 
 cent, of distance from nasion to inion, on median line), or 6 to 7 cm. 
 (2§ to 2| inches) above external occipital protuberance. 
 
 Lambdoid (or parieto-occipital) Suture: sometimes an elevation of superior 
 border of occipital bone marks this suture, which is roughlv represented by 
 a line from the external occipital protuberance to the lower part of the tip 
 of the mastoid process. 
 
 Inion (or external occipital protuberance) : most important posterior 
 median landmark. 
 
 Superior Occipital Curved Lines (nuchal line) : running from the external 
 occipital protuberance outward toward mastoid process, marking the posterior 
 junction of the head and neck. 
 
 External Occipital Crest: from external occipital protuberance to center 
 of posterior border of foramen magnum; sometimes palpable. 
 
 Nuchal Furrow: depression in median vertical line between posterior 
 muscles of neck, having in its center, above, the external occipital protuberance; 
 its upper end corresponding with inner ends of superior curved occipital 
 lines. 
 
 Orbit: margin everywhere palpable. 
 
 Supraorbital Arch: palpable throughout. 
 
 Internal Angular process: inner end of supraorbital arch. 
 
 External Angular Process: outer end of supraorbital arch. 
 
 Superciliary Ridge: first prominence above supraorbital arch. 
 
 Frontal Eminence: second prominence above supraorbital arch. 
 
 Superior Temporal Ridge: especially marked at forepart of lateral aspect, 
 leading downward and forward to external angular process; gives attachment 
 to temporal fascia. 
 
 Superior Stephanion: where coronal suture crosses superior temporal 
 ridge. 
 
 Inferior Temporal Ridge: indicates upper boundary and attachment o c 
 temporal muscle, the contraction of which muscle will aid in determining 
 site of ridge. 
 
 Inferior Stephanion: where coronal suture crosses inferior temporal ridge. 
 
 Pterion: point in zygomatic fossa, from 3.8 to 5 cm. ( t+ to 2 inches) behind 
 external angular process and same distance above zygoma, where parietal, 
 temporal, frontal, and sphenoid bones meet. 
 
 Sylvian Point: where sylvian fissure reaches the convexity of the hemi- 
 sphere, at a point from 2.9 to 3.2 cm. (ij to i^ inches) directly behind external 
 angular process. 
 
53 8 OPERATIONS UPON THE HEAD. 
 
 Parietal Eminence: most prominent postero-lateral eminence. 
 
 Malar Bone: palpable throughout. 
 
 Retro-orbital Tubercle : apophysis upon posterior border of upper part of 
 frontal process of malar bone, a short distance below malo-frontal suture; 
 the most important anterior lateral landmark. 
 
 Zygomatic Arch: palpable throughout; its upper border may be taken as 
 a practically horizontal measurement, in the upright position of the body. 
 
 Auricular Point: center of external auditory meatus; most reliable middle 
 lateral landmark. 
 
 Preauricular Point: point on Reid's base-line (v. i.) in depression between 
 tragus of the ear and condyle of inferior maxilla. 
 
 Supra-auricular Point: point vertically above auricular point, at root of 
 zygomatic process. 
 
 Squamous Suture: summit of which is 4.4 cm. (if inches) above zygoma. 
 
 Mastoid Process of Temporal: palpable throughout. 
 
 Asterion: point behind ear where parietal, temporal, and occipital bones 
 and lambdoid and squamous sutures meet; about 1.8 cm. (f inch) behind 
 and 1.2 cm. (^ inch) above upper part of posterior border of mastoid process. 
 
 Note: — For other landmarks of the cranio-cerebral region, see the methods 
 of Chipault (page 546), Kroenlein (page 553), Reid (page 551), and Chiene 
 (page 554) for localizing the brain areas, and also the data under the following 
 division of the subject. 
 
 CRANIO-CEREBRAL TOPOGRAPHY. 
 
 Description. — Relation of areas and structures of brain to the cranial 
 bones. While discrepancies are found in the statements of the highest 
 authorities in this department of surgical work, and differences actually exist 
 in different heads, the following may be considered the most generally accepted 
 data, for the average head. 
 
 Extent of Cerebral Hemispheres. — (1) Superior or mesial border; 
 extends from mid-point of naso-frontal suture to a point averaging 1 cm., 
 or y 7 ^ inch (extremes, 5 to 15 mm., or \ to f inch), above the external occipital 
 protuberance, and 5 mm. (\ inch) to its left and 15 mm. (f inch) to its right 
 (representing the width of the superior longitudinal sinus and attachment of 
 the dural walls). It is separated from the opposite hemisphere by the superior 
 longitudinal sinus above, which deviates slightly to right, and by falx cerebri 
 below. (2) Inferior or lateral border; (a) Frontal Portion; — begins in 
 median line, opposite floor of naso-frontal groove — arches upward and out- 
 ward 8 mm. (f inch) above center of supraorbital margin of frontal bone — 
 crosses temporal crest just above external angular process — thence descends 
 slightly to a point in temporal fossa about 30 mm., or iy^g- inches (extremes, 
 29 to 32 mm., or iy 2 ^ to iy 4 ^ inches), directly behind external angular process, 
 where it coincides with margin of temporal lobe at a point where the sylvian 
 fissure reaches the convexity of the hemisphere (the sylvian point) — the 
 frontal lobe in front and above and the temporal lobe behind and below 
 forming a receding angle here. (More roughly outlined, the frontal portion 
 lies just above the eyebrow in front, and just above the upper margin of the 
 zygoma laterally.) (b) Temporo-occipital Portion; — -continuing the line of 
 lower margin of frontal portion from the sylvian point, at receding angle 
 formed by svlvian fissure, it curves slightly downward and forward from the 
 lower margin of frontal lobe to a point 20 mm. (yf inch) above the zygoma, 
 and 15 mm. (f inch) behind external angular process (which marks the 
 
CRANIOCEREBRAL TOPOGRAPHY. 539 
 
 anterior pole of the temporal lobe) — thence passes backward on level with 
 upper border of posterior half of zygomatic arch — thence still backward at 
 an average distance of 6 mm., or £ inch (extremes, 3 to 9 mm., or ^ to | 
 inch), above the roof of meatus auditorius externus — continuing horizontally 
 backward it crosses the supramastoid crest — and runs thence to a point 
 5 to 15 mm. (j to f inch) above the external occipital protuberance, 5 mm. (j 
 inch) external to the protuberance on the left, and 18 mm. (f inch) external 
 to it on the right. (More roughly outlined, the temporo-occipital portion co- 
 incides with the upper margin of the zygoma laterally, and the superior 
 curved line of the occipital posteriorly.) 
 
 Extent of Cerebellum.— Occupies inferior cerebellar fossae and is in 
 contact with cranial wall, extending upward to lower margin of transverse 
 portion of lateral sinus above, and forward to posterior margin of sigmoid 
 portion of lateral sinus in front. 
 
 Great Longitudinal Fissure. — Straight median line from mid-point of 
 naso-frontal suture to center of external occipital protuberance — with a 
 slight tendency to the left, especially posteriorly. 
 
 Great Transverse Fissure. — (Between cerebrum and cerebellum.) 
 Represented, approximately, by a line between external occipital protuberance 
 and center of external auditory meatus. 
 
 Sylvian Fissure. — The parts of the sylvian fissure may be traced out by 
 measurement, or by means of the sutures of the skull, (a) Location of 
 parts of Sylvian Fissure by Measurement; Sylvian Point — found by carrying 
 straight line from posterior margin of fronto-malar junction directly horizon- 
 tally backward for 3.1 to 3.5 cm., or i\ to if inches (average, ^.^ cm., or i T 5 g 
 inches), thence vertically upward for 6 to 12 mm., or J to \ inch (average 9 
 mm., or § inch), the termination of which latter line marks the sylvian point, 
 where the anterior branches of the sylvian fissure are given off. Sylvian Line 
 — found by carrying a straight line from the sylvian point backward and 
 upward to a point from 1.2 to 1.8 cm. (^ to £ inch) below the most prominent 
 part of the parietal eminence. Horizontal or Posterior Limb of Sylvian 
 Fissure — that portion just mentioned (from sylvian point to lower part of 
 parietal eminence) having a length of 7.5 to 10 cm. (3 to 4 inches). Ascending 
 Limb of Sylvian Fissure — a line 3 cm. (i T 3 g- inches) long, drawn upward and 
 forward from the sylvian point, at right angle to sylvian line. Anterior 
 Limb of Sylvian Fissure — a line 2 cm. (yf inch) long, drawn horizontally 
 forward from the sylvian point, (b) Location of Parts of Sylvian Fissure 
 by means of Sutures of Skull; Point of Division of Sylvian Fissure — in the 
 pterion, under or very near the spheno-parietal suture, near its posterior end. 
 Horizontal or Posterior Limb of Sylvian Fissure — runs from the point of 
 division backward and slightly upward, following the squamous suture at 
 first, and then crossing the temporal portion of the parietal bone to the inferior 
 temporal line, and thence ascending beneath the parietal eminence. Ascending 
 Limb of Sylvian Fissure — runs from the point of division obliquely upward 
 and forward, crossing the lower end of the coronal suture. Anterior Limb 
 of Sylvian Fissure — runs from point of division forward in the direction of 
 the spheno-parietal suture. 
 
 The horizontal limb of the sylvian fissure is more oblique, and further 
 above the squamous suture, up to the third or fourth year than subsequently. 
 
 Rolandic Fissure. — The parts of the Rolandic Fissure may also be 
 traced out bv measurement, or by means of the sutures and bony landmarks, 
 in the exposed skull; (a) Location of position and direction of Rolandic 
 Fissure by Measurement; Superior Rolandic Point— variously estimated at 
 
540 OPERATIONS UPON THE HEAD. 
 
 from 55 to 57 per cent, (average being between 55 and' 56 per cent., probably 
 about 55.7 per cent.) of distance from mid-point of naso-frontal suture to 
 external occipital protuberance. Quain, upon another basis, gives the point 
 at 1 cm. (j\ inch) behind the center of the naso-inial line, and Poirier as 2 cm. 
 ( T f inch) behind that center. Where the inion is indistinct, the superior ro- 
 landic point may be considered as 18 cm., or 7^ inches, in large (and 17 cm., 
 or6yi inches, in small) heads posterior to the nasion, in the median line. Direc- 
 tion of Rolandic Line — forms an angle generally averaging about 70 degrees 
 (extremes 64 degrees to 75 degrees) with the median line. (Formerly the angle 
 was generally considered 67 ^ degrees. Different writers have given the wide 
 variations covered in the above extremes.) The rolandic line coincides with the 
 rolandic fissure more accurately in its upper part — the inferior genu of the 
 rolandic fissure projecting slightly in front of the rolandic line below its cen- 
 ter, corresponding to a point 5 to 15 mm. (j to f inch) above the lower tem- 
 poral line. Inferior Rolandic Point — lies on the rolandic line generally 1 cm. 
 (-j\ inch) above the sylvian line (v. s.). Length of Rolandic Fissure— gen- 
 erally from 8.5 to 9.5 cm. (3! to 3! inches). (b) Location of Rolandic Fis- 
 sure by Bony Landmarks; lies entirely under the parietal bone, the superior 
 rolandic point being from 4 to 5 cm. (iyV to 2 inches) and the inferior rolandic 
 point about 3 cm. (iy 3 g- inches) posterior to the coronal suture. 
 
 The rolandic fissure is somewhat further forward and more obliquely 
 placed in children under nine years. 
 
 Parieto-occipital Fissure. — A line about 2 cm. ( T f- inch) long running 
 transversely outward, at right angle to naso-inial line, from a point averaging 
 about 6 mm., or \ inch (extremes, from lambda itself to a point 15 mm., or 
 f inch), in front of lambda. Where the lambda is not distinct, its position 
 lies from 6 to 7 cm. (2§ to 2f inches) above the external occipital protuberance, 
 or 8 to 10 cm. (3J to 4 inches) behind the superior rolandic point. The 
 above line represents the external portion of the fissure, the internal portion 
 lying upon the mesial aspect of the hemisphere. (If the horizontal limb of 
 the sylvian fissure be continued backward to the median line, its last 2 cm. 
 — yf inch — would represent, approximately, the external portion of the 
 parieto-occipito fissure.) In children this fissure lies somewhat further 
 forward. 
 
 Precentral Fissure. — Runs downward and forward about 15 mm. (f 
 inch) anterior to and nearly parallel with the rolandic fissure. Its upper 
 portion lies from 2 to 3 cm. ( T f to i T 3 ¥ inches) behind the upper part, and 
 its lower portion from 1 to 2 cm. (f to T f inch) behind the lower part of the 
 coronal suture. Its lower end terminates about 1 cm. (§ inch) above the 
 sylvian fissure. 
 
 Postcentral Fissure. — Runs downward and forward about 15 mm. (f 
 inch) posterior to and nearly parallel with the rolandic fissure. 
 
 Superior Frontal Fissure. — Line running forward, approximately 
 parallel with the naso-inial line, from the precentral fissure, just internal to 
 mid-distance between temporal crest and median line, to the supraorbital 
 notch. 
 
 Inferior Frontal Fissure. — Line running forward and slightly down- 
 ward from the precentral fissure to just above the superior stephanion (inter- 
 section of superior temporal ridge and coronal suture), and thence forward, 
 nearly coinciding with the anterior portion of the temporal ridge. 
 
 Intraparietal Fissure. — The ascending portion runs upward for about 
 1.8 cm. (f inch) nearly parallel with and about 1.5 cm. (f inch) posterior to 
 the rolandic fissure. The longitudinal portion runs thence backward and 
 
CRANIO-CEREBRAL TOPOGRAPHY. 541 
 
 slightly inward just above the parietal eminence, being about 4.5 cm. (i|f 
 inches) from the median line anteriorly, and about 3.5 cm. (if inches) poste- 
 riorly, at a point opposite the lambda. 
 
 Superior Temporo-sphenoidal (Parallel) Fissure. — General direction 
 of this fissure is represented by a straight line passing from the retro-orbital 
 tubercle to the lambda, which line coincides more accurately with the tem- 
 poral part of the fissure. This fissure lies beneath the superior part of the 
 squamous portion of the temporal, and posterior part of temporal portion of 
 parietal, and thence turns upward across the temporal lines and passes under 
 the upper division of the parietal bone. Placed somewhat higher in children. 
 
 Ascending Frontal Convolution. — Lies beneath the anterior third of 
 the parietal bone. 
 
 Superior Frontal Convolution. — Its base lies under the anterior third 
 of the parietal, and its main part corresponds to somewhat less than the inner 
 half of the frontal region of the frontal bone. 
 
 Middle Frontal Convolution, — Its base lies under the anterior third 
 of the parietal; its main part corresponds to somewhat more than the outer 
 half of the frontal region of the frontal bone, and its anterior portion lies 
 under the frontal eminence. 
 
 Inferior Frontal Convolution. — Its base lies under the anterior third 
 of the parietal; the apex of its triangular part lies under the anterior inferior 
 angle of the parietal; and its orbital part lies beneath the temporal division 
 of the frontal and superoir end of great wing of sphenoid. 
 
 Island of Reil. — Pole of the triangular island of Reil corresponds with 
 the sylvian point. Posterior Angle corresponds with a point on the sylvian 
 line 3.5 cm. (if inches) behind the sylvian point. Superior Boundary is 
 indicated by an evenly curved line, with upward convexity, extending from 
 the posterior angle to the upper extremity of the ascending limb of the sylvian 
 fissure, and thence forward in the same curve 1.5 cm. (f inch) beyond a 
 vertical line passing upward from the sylvian point. Postero-inferior Boun- 
 dary extends from the posterior angle downward and forward to a point on 
 the superior temporo-sphenoidal line directly below the sylvian point. 
 
 Parietal Lobe. — Lies beneath the parietal bone, the parietal eminence 
 overlying some part of the supramarginal convolution. 
 
 Ascending Parietal Convolution. — Lies between the rolandic fissure 
 and the ascending portion of the intraparietal fissure. 
 
 Angular Gyrus. — At the intersection of Reid's posterior perpendicular 
 line (v. i.) and the direct continuation of the sylvian line. 
 
 Temporal Lobe. — Lies chiefly beneath the squamous part of the temporal 
 and the posterior and inferior fourth of the parietal — its anterior end lying 
 under the great wing of the sphenoid — its posterior part (inferior temporal 
 convolution) lying beneath the occipital lobe. 
 
 Occipital Lobe. — Lies in the cerebral portion of the occipital bone, and 
 sometimes slightly beneath the adjoining parietal. 
 
 Basal Ganglia. — Consist of the following; nucleus caudatus and nu- 
 cleus lenticularis, forming the corpus striatum; claustra; amygdaloid nuclei. 
 The optic thalami lie near the corpora striata, but belong to the thalamen- 
 cephalon or interbrain. The above ganglia, except the amygdaloid nucleus, 
 lie subjacent to the island of Reil — they extend slightly beyond the limits 
 of the island — and are circumscribed by the curved line limiting the main 
 part of the lateral ventricle (v. i.). The following important white fasciculi 
 are closely related to the corpora striata; inner capsule; outer capsule: anterior 
 commissure; taenia semicircularis. 
 
542 OPERATIONS UPON THE HEAD. 
 
 Lateral Ventricle. — Commencing at the anterior extremity of the Ante- 
 rior Horn, i cm. (f inch) in front of the most anterior point of the outline 
 of the island of Reil (v. s.), pass backward along the Body of the Lateral 
 Ventricle in a curve following parallel with and i cm. (f inch) above the 
 superior boundary of the island of Reil, to a point 2 cm. (|f inch) behind its 
 posterior limit — thence the Descending Horn curves forward and downward 
 to terminate 1 cm. (§ inch) below the level of the superior temporo-sphenoidal 
 (parallel) fissure and slightly anterior to a line from the lower rolandic point 
 to the preauricular point — while the Posterior Horn passes backward from 
 this curve, a variable distance, toward the back part of the hemisphere, 
 which is somewhat higher than the occipital pole. Another method of locating 
 the lateral ventricle is to take a point 3.1 cm. (i| inches) above and the same 
 distance behind the external auditory meatus (Keen). Ordinarily the lateral 
 ventricle lies at a distance of 5.7 to 6.3 cm. (2^ to 2+ inches) from the surface. 
 
 Naso-lambdoidal Line. — Begins at naso-frontal groove — passes directly 
 backward 6 mm. (j inch) above the external auditory meatus to end 1 cm. 
 (f inch) above the lambda (or, if that is not recognizable, about 7 cm., or 2§ 
 inches, above the external occipital protuberance). It passes through the 
 lower part of Broca's (inferior frontal) convolution — runs along the posterior 
 limb of the sylvian fissure for 4 to 6 cm. (i T ! V to 2| inches) — touches the 
 lower part of the supramarginal convolution — passes through the base of the 
 angular gyrus — and ends in the parietooccipital fissure. 
 
 Superior Longitudinal Sinus. — Is represented by two straight lines, 
 both beginning together from the mid-point of the naso-frontal suture (foramen 
 caecum) and slightly diverging as they pass posteriorly, one going to a point 
 opposite the external occipital protuberance and 5 mm. (y\ inch) to its left, 
 the other to a corresponding point 15 mm. (§ inch) to the right of the external 
 occipital protuberance. This divergence represents the attachment of the 
 laminae of the falx cerebri forming the sinus, which increases in width poste- 
 riorly. 
 
 Lateral Sinuses. — Transverse Portion forms a slight curve, with upward 
 convexitv, from external occipital protuberance to back of ear, on level with 
 upper border of external auditory meatus. The highest part of the sinus 
 (opposite masto-parietal suture) lies from 1.5 to 2.5 cm. (f to 1 inch) above a 
 straight line drawn from the external occipital protuberance to the center of the 
 external auditory meatus and a little external to its center. Sigmoid Portion 
 passes from back of ear, on level with upper border of external auditory mea- 
 tus, in a sigmoidally curved direction (convexity forward) over the prominence 
 of the mastoid process to its apex, lying generally from 10 to 12 mm., or y^ to 
 \ inch (extremes, 2 to 12 mm., or nearly \ to \ inch), behind the posterioi 
 wall of the external auditory meatus, and extending downward about 5 mm. 
 (-£r inch) below the lower border of the external auditory meatus. Distance 
 of sigmoid portion from outer surface of mastoid process is about 7 mm., 
 or f inch (extremes, 1 to 15 mm., or T V to f- inch). Width of sigmoid portion 
 is about 10 mm., or § inch (extremes, 5 to 15 mm., or T : V to f inch). (For 
 other data concerning the Lateral Sinuses, see Surgical Anatomy of Brain 
 [page 532], and Relations of Mastoid Antrum, [page 602].) 
 
 Middle Meningeal Artery and Its Branches. — For course and rela- 
 tions, see under Surgical Anatomy of the Brain (page 535), and under 
 the Surgical Anatomy in connection with the ligation of those vessels 
 
 (pages 47-49)- 
 
 Facial Nerve. — Descends in fallopian canal through the mastoid pro- 
 cess, lying between the sigmoid portion of the lateral sinus and the external 
 
LOCALIZATION OF BRAIN AREAS. 
 
 543 
 
 auditory meatus (very near the latter). For fuller description of its relations, 
 see under Surgical Anatomy of the Mastoid region (pages 602 and 603). 
 
 LOCALIZATION OF BRAIN AREAS. 
 
 Description. — The determination of the situation of those areas of the 
 Brain which are concerned with certain functions. These centers do not 
 
 
 fra<*c 
 
 
 
 \_... 
 
 o$S\lv'iu.s 
 
 >*^ 
 
 EcfyuiLtn 
 
 uA 
 
 - r M 
 
 5^ 
 
 2 
 5 ? 
 
 .it 
 
 £ o • 
 
 Fig. 40S. — Craniocerebral Topography: — Cortical areas of the right outer surface of the 
 brain. (Modified from Dalton.) 
 
 necessarily coincide with fixed convolutions — are not limited in extent by 
 hard and fast lines — often overlap each other — and their position and dimen- 
 sions are not, in all cases, invariably fixed, nor absolutely ascertained. Each 
 functional center most probably has a wider general representation over the 
 adjacent areas and a more limited special representation, whereby a small 
 area may be removed without total paralysis of that part of the limb specially 
 represented by that area. The following summary may be taken as repre- 
 senting the present state of knowledge of the best authorities, and was kindly 
 prepared by Dr. Roy M. Van Wart, who has done creditable work in this field. 
 What slight discrepancies between the plates, Figs. 40S, 409, 410, and the 
 text appear, the text, being later, should be followed, especially as to the non- 
 saddling of the Rolandic fissure by the motor and sensory centers, which are, 
 in fact, divided from each other by this fissure. 
 
 " The localization of brain areas is the determination of those areas of the 
 
544 
 
 OPERATIONS UPON THE HEAD. 
 
 brain which are concerned with certain functions. These centers do not 
 necessarily coincide with the convolutions. They are, however, as far as 
 certain areas are concerned, fairly definitely determined. 
 
 "Histological studies have shown that various areas are sharply marked off 
 from the surrounding parts by some peculiarity in structure, and this has been 
 shown to correspond in the motor area with the physiological delineation with 
 the ampolar electrode. As this peculiarity in structure is found to correspond 
 to certain areas whose function is more or less definitely known, it is probable 
 that the future will enable us to mark off sharply the functions of the various 
 parts. 
 
 "Motor Areas. — The area controlling the movements of the various parts 
 
 ~Rul 
 
 cr-*? 
 
 ffj( s*f 
 
 -/"-SSUreof ^ oJan£ y 
 
 T°«5 
 
 Fissure. F SUvius 
 
 Fig. 409. 
 
 -Cranio cerebral Topography: — Cortical areas of the left outer surface of the 
 brain. (Modified from Dalton.) 
 
 of the body is now definitely known, and is found to be separate and distinct 
 from that of sensation. The posterior limitation is the fissure of Rolando, 
 and anteriorly it is bounded by a line cutting off a small part of the horizontal 
 frontal convolutions. The movements are distributed on the convolutions 
 from below upward as follows; — Tongue, face, head, and neck; — Thumb, 
 fingers, forearm, arm, and shoulder; — Trunk, thigh, leg, foot, and toes. 
 Some of the movements of the lower extremity are situated on the median 
 surface. 
 
 "Sensory Areas. — These are limited anteriorly by the fissure of Rolando. 
 The posterior boundary is not yet definitely known. They are arranged in 
 the same order from below upward as those of motion. It is probable that 
 
LOCALIZATION OF BRAIN AREAS. 
 
 545 
 
 areas exist for the different forms of sensation, and some writers show areas 
 for the stereognostic sense, cutaneous sensation, and muscular sensation. 
 
 "Speech Areas. — Most of the older works give complicated diagrams 
 showing the various speech centers and their connections, but recently con- 
 siderable doubt has been thrown on their actual existence by the studies of 
 Marie. The following, however, may be stated — centers for the sending out 
 of speech and writing impulses exist, but probably in conjunction with those 
 for other movements of the parts used in speaking and writing. 
 
 "Auditory and Visual Word Memories. — What has just been said of 
 the Speech Areas may also be said of these areas. 
 
 "Area of Sight Sensation. — This area occupies a site in the cortex 
 around the calcarine fissure. It may be divided into two parts — that for the 
 reception of sight sensations, visuo-sensory — and that for their interpretation, 
 visuo-psychic. 
 
 Motor 
 
 Fig. 410. 
 
 -Craniocerebral Topography: — Areas of the median aspect of the brain. 1 Mod- 
 ified from Dalton.) 
 
 "Area of Sound Sensation. — The center for the reception of auditory 
 sensations, audito-sensory, is in the first temporal convolution — that for their 
 elaboration, visuo-psychic, in the second temporal convolution. 
 
 "Areas of Smell and Taste Sensations. — These probably lie, respec- 
 tively, in the cortex of the uncus hippocampi and the fusiform gyrus (Mills). 
 
 "Higher Psychical Centers. — Large areas of the brain are without 
 projection fibers, and it is probable that they have to do with the higher 
 psychical functions. The anterior part of the frontal lobe is the most import- 
 ant of these areas. 
 
 "Crura Cerebri — Pons — Medulla. — Embrace the centers of cranial 
 nerve nuclei and contain the motor and sensory fibers passing to and from 
 the spinal cord. 
 
 "Cerebellum. — Regulates the equilibrium of the body." 
 
 35 
 
546 OPERATIONS UPON THE HEAD. 
 
 CHIPAULT'S METHOD OF CRANIO-CEREBRAL LOCALIZATION. 
 
 Description. — This method of cranio-cerebral localization is based 
 upon the relations of the parts of the brain to the skull, as determined by 
 the percentage measurements of the skull made in the metric system. It 
 is, therefore, equally applicable to skulls of different sizes, shapes, and 
 ages. 
 
 Following Fixed Bony Landmarks of Measurement are taken: — 
 Nasion — mid-point of naso-frontal suture (avoid confusing this with the 
 glabella). Inion — external occipital protuberance. Retro-orbital Tubercle 
 — the apophysis upon the posterior border of the upper part of the frontal 
 process of the malar bone, a short distance below the fronto-malar suture. 
 The most prominent part of this apophysis forms the lower limit of the three 
 primary lines of Chipault's method (avoid confusing this with the external 
 angular process of the frontal bone). (Fig. 411.) 
 
 Following Percentage Points are Marked upon the Median Naso- 
 inial Line (a line extending in the median line of the head, from nasion to 
 inion) — which percentage points are to become the median or upper limits 
 of lines to be subsequently drawn: — Precentral Point is marked at 45 per 
 cent, of the distance from nasion to inion. Rolandic Point is marked at 55 
 per cent, of the distance from nasion to inion. Sylvian Point is marked at 
 70 per cent, of the distance from nasion to inion. Lambdoidal, or Superior 
 Te-mporo-sphenoidal Point, is marked at 80 per cent, of the distance from 
 nasion to inion. Lateral Sinus Point is marked at 95 per cent, of the 
 distance from nasion to inion. (Fig. 412.) 
 
 (Illustration — suppose distance from nasion to inion to be 30 centimeters 
 — then t 4 q% of that distance, or the Precentral point, will be 13.5 cm. from 
 the nasion; — -f$\, or the Rolandic point, 16.5 cm.; — T W, or the Sylvian point, 
 21 cm.; — j 8 ^, or the Superior Temporo-sphenoidal point, 24 cm.; — y%\, 
 or the Lateral Sinus point, 28.5 cm. If measured in inches, and the naso- 
 inial line measured 12 inches, t 4 q% of 12 inches, or the Precentral point, would 
 lie 5.4 inches from the nasion, etc.) 
 
 Three Primary Lines are Drawn. — Sylvian Line — from retro-orbital 
 tubercle to sylvian point (70 per cent.) — its anterior portion marking the 
 sylvian fissure. Superior Temporo-sphenoidal Line — from retro-orbital 
 tubercle to lambdoidal or superior temporo-sphenoidal point (80 per cent.) 
 — its anterior part marking the superior temporo-sphenoidal fissure. Lateral 
 Sinus Line — from retro-orbital tubercle to lateral sinus point (95 per cent.) 
 —its anterior part crossing the lower portion of the temporal lobe — its poste- 
 rior portion marking the upper part of the transverse portion of the lateral 
 sinus, the tentorium cerebelli, and the great transverse fissure of the brain. 
 (Fig- 413O 
 
 These three primary lines are now marked off into tenths of their lengths. 
 (For instance, if the sylvian line measures 21 cm., this line is divided off into 
 ten parts of 2.1 cm. each.) 
 
 Two Secondary Lines are Drawn. — Precentral Line — from junction of 
 second and third tenths of sylvian line, to precentral point (45 per cent.) — 
 commencing at the bifurcation of the sylvian fissure, it at first follows the 
 ascending limb of the sylvian fissure, and then corresponds in its two upper 
 thirds to the precentral fissure. Rolandic Line — from junction of third and 
 fourth tenths of sylvian line, to rolandic point (55 per cent.) — beginning at 
 lower extremity of rolandic fissure and following its entire length. 
 
CHIPAULTS METHOD OF CRAXIO-CEREBRAL LOCALIZATION. 547 
 
 These two secondary lines are now divided and marked off into tenths. 
 Thus, with the tenths marked on the three primary lines, sufficient data are 
 furnished for all practical purposes of localization." 
 
 Other Points and Lines. — Inferior Frontal Fissure— begins at junction 
 of third and fourth tenths of precentral line— Anterior Branch of Middle 
 
 H5% 
 
 Fig.41 1.— Chipault's Method of Cranio-cerebral Localization— Scalp View :— A, Nasion ; 
 B, Inion ; C, Retro-orbital tubercle ; 45^, or Precentral point ; 55^, or Rolandic point ; 70^, or Sylvian 
 point; 80^, or Superior temporo-sphenoidal uoint ; 95^, or Lateral sinus point; D, Sylvian line; E, 
 Superior temporo-sphenoidal line; F, Lateral sinus line; G, Precentral line; H Rolandic line ; I, 
 Junction of second and third tenths of sylvian line; J, Junction of third and fourth tenths of sylvian 
 line. 
 
 Meningeal Artery — crosses the second tenths of the three primary lines. 
 Lateral Ventricle — lies directly opposite the junction of the third and fourth 
 tenths of the superior temporo-sphenoidal line. This point strikes the Body 
 of the lateral ventricle at its posterior part. Hartley has determined that 
 the cavity of the ventricle is reached at a distance from the surface of the 
 brain equal to one-third of the transverse diameter of the brain itself opposite 
 
54« 
 
 OPERATIONS UPON THE HEAD. 
 
 this point. (For example, take the full diameter of the skull and scalp with 
 calipers, say 15 cm. — take thickness of skull and scalp of the side opened, 
 say 1 cm. — double this for the opposite side — take result of this doubling, 
 say 2 cm., from the total transverse diameter, which will give the diameter 
 of the brain alone, say 13 cm. — take one-third of this, say 4.3 cm.- — and 
 enter the brain to that depth upon a direct horizontal line.) To puncture 
 the Descending Horn of the lateral ventricle, Hartley passes through the 
 
 Fig. 412.— Chipault's Method oh Craniocerebral Localization — Skull View :— A, Nasion; 
 B, Inion ; C, Retro-orbital tubercle ; 45;*, or Precentral point ; 554, or Rolandic point ; 70$, or Sylvian 
 point; 80$, or Superior temporo-sphenoidal point; 95$, or Lateral sinus point; D, Sylvian line; E, 
 Superior temporo-sphenoidal line ; F, Lateral sinus line; G, Precentral line; H, Rolandic line; I, 
 Junction of second and third tenths of sylvian line ; J, Junction of third and fourth tenths of sylvian 
 line ; K, Lateral sinus. 
 
 middle temporo-sphenoidal convolution in a line directly above the external 
 auditory meatus. To puncture the Posterior Horn of the lateral ventricle, 
 he passes through the middle temporo-sphenoidal convolution in a line with 
 the posterior border of the mastoid process. 
 
 Summary. — Having determined the position of the chief fissures of the 
 
CHIPAULT'S METHOD OF CRANIOCEREBRAL LOCALIZATION. 549 
 
 brain in the above manner, and knowing the general relations of the convo- 
 lutions, structures, and functional areas to these fissures, any desired area 
 may be exposed. Preference is given to the method of Chipault over the 
 several others in use, for while none are perfect, or absolutely simple, this 
 method has proved itself quite accurate and fairly easy of application, and 
 furnishes sufficient data from which to locate any desired area of cerebrum 
 or cerebellum. 
 
 %7> 
 
 Fig.41,3 — Chipaui.t's Method of Cranio-cerebral Localization— Brain View :— A, Nasion ; 
 B, Inion ; C, Retro-orbital tubercle ; 45:;, or Precentral point; 55$, or Rolandic point ; 7u.n1 Sylvian 
 point ; hov. ur Superior temporo-sphenoidal point ; 95^, or Lateral sinus point ; L). Sylvian line, over- 
 lying sylvian fissure ; E, Superior temporo-sphenoidal line, overlying superior temporo-sphenoidal 
 fissure; F, Lateral sinus line; G, Precentral line, overlying precentral fissure; H, Rolandic line, 
 overlying Rolandic fissure ; I, Junction of second and third tenths of sylvian line ; J, Junction of third 
 and fourth tenths of sylvian line ; K, Lateral sinus ; L. Cerebellum. 
 
 The manner of applying these (or any other) measurements is to shave 
 the head and mark out the landmarks and the desired areas upon the scalp, 
 by means of a solution of nitrate of silver or a dermographic pencil — then, 
 with a sharp-pointed instrument of small circumference inserted through the 
 scalp to the bone, a slight blow or two is given with a mallet just sufficiently 
 
550 OPERATIONS UPON THE HEAD. 
 
 to mark the bone — the soft parts are then turned back and the bone removed 
 by the method elected, preferably some form of motor saw, with or without 
 the aid of previous small trephine-openings outlining the area to be removed. 
 Where a trephine-opening is used as the entire means of exposure, an instru- 
 ment of sufficiently large diameter should be used to allow of the possibility 
 of a smaller opening not fully covering the area sought. Of course, it is 
 only necessary, in operating in life, to mark out upon the scalp the particular 
 area desired, and then to mark, in the above manner, the corresponding site 
 on the skull — for instance, if one sought a motor center lying along the rolandic 
 fissure, only the sylvian and rolandic points and the sylvian and rolandic 
 lines of the above system need be marked out on the scalp — and only the center 
 of the motor area itself on the bone. For the technique of the operations 
 whereby this method of localization may be applied, see the operations of 
 craniotomy (page 558) and osteoplastic resection of the skull (page 565). 
 
 THE USE OF BELL'S GEOMETRICAL CYRTOMETER FOR THE EASY 
 
 APPLICATION OF CHIPAULT'S METHOD OF CRANIO-CEREBRAL 
 
 LOCALIZATION. 
 
 William H. Bell has worked out, geometrically, a device for use in connec- 
 tion with Chipault's method, whereby is avoided the necessity of calculating 
 each time the percentage distances from nasion to inion and dividing the pri- 
 mary and secondary lines into tenths. His description of its application is 
 here given. 
 
 The device is based upon the maximum and minimum measurements 
 between the bony landmarks concerned. "These are three in number: — 
 First, The greatest distance from Nasion to Inion over the cranial vault along 
 the median longitudinal line; — second, The shortest distance from Nasion to 
 Inion over the cranial vault along the median longitudinal line; — and third, 
 The shortest distance from a point dividing the third and fourth tenths on 
 the Sylvian line to the 55 per cent, point on the above line from Nasion to 
 Inion. (See Fig. 411.) 
 
 Fig. 414. — The Geometrical Cyrtometer of Bell: — B C, Least distance from 
 Nasion to Inion; A C, Greatest distance from Nasion to Inion; also greatest distance in 
 tenths; A B, The shortest distance from a point dividing the third and fourth tenths on the 
 Sylvian line to the 55 per cent, point on the line from the Nasion to Inion. (Modified from 
 Bell.) 
 
 " The accompanying diagram (Fig. 414) illustrates the idea and, indeed, 
 is the cyrtometer itself. It is to be printed on some soft, tough paper and used 
 in that way, or blue prints can be made from a tracing. Either can be sterilized 
 in lots if desired. The edge A C (40.5 m., or 16 inches) represents the first 
 dimension (v. s.) ; B C (30.5 m., or 12 inches) the second dimension; A B 
 (12.5 cm., or 5 inches) the third dimension. The per cents., 45, 55, 70, 80, 
 and Q5 are pointed off on the line A C, and, from these, lines are drawn across 
 the diagram parallel with dimensions A B. The dimension A B is divided 
 
REID'S METHOD OF CRANIO-CEREBRAL LOCALIZATION. 551 
 
 into tenths and from each point a line is drawn across the diagram parallel to 
 the dimension B C. 
 
 " The employment of this simple paper triangular chart is easy, and the 
 manner of applying it is as with any other system of surgical craniometry: 
 by shaving the head and marking the craniometric points and desired areas 
 upon the scalp by means of a solution of nitrate of silver, or a dermographic 
 pencil, etc. 
 
 " To find the desired per cent, distance, or distances, along the median longi- 
 tudinal line, place the apex C on the inion and swing the base A B across the 
 forehead until some point on this base corresponds to the nasion (e. g., a, 
 Fig. 414) . Mark and fold, or cut off in a straight line from a to C, and replace 
 along the longitudinal line from Nasion to Inion, when you immediately and 
 automatically obtain the per cent, distances desired and can point them off 
 on the scalp in the usual way. 
 
 " If the paper has been folded it can be used for the other measurements. 
 If it has been cut (and this seems the better plan) take a new diagram and 
 proceed as follows: Place the apex A at the Retro-orbital Tubercle and swing 
 the base B C across the cranium until some point (for example, b, Fig. 414) 
 on this base corresponds with the per cent, mark, say, 70 per cent., obtained 
 by the previous proceeding. Mark and fold, or cut off in a straight line, from 
 b to a and replace, when you immediately and automatically divide the dis- 
 tance into tenths, by which to locate the area desired. 
 
 " These two lines involve the cranial landmarks and may be regarded as the 
 guides in Chipault's method, and they also demonstrate the use of the Geomet- 
 rical Cyrtometer. All other lines and areas are located by a similar proceed- 
 ing." 
 
 REID'S METHOD OF CRANIO-CEREBRAL LOCALIZATION. 
 
 Description. — A method of determining the relations of the principal 
 parts of the brain to the skull, by means of certain lines drawn upon the 
 scalp between known landmarks. (See Fig. 415.) 
 
 Fundamental Lines. — Base Line: — a horizontal line from the lowest 
 part of the infraorbital border, through center of external auditory meatus, 
 thence directly backward (Fig. 415, A B). Anterior Perpendicular Line: — 
 from preauricular point (a depression upon the base-line, between tragus 
 and condyle of jaw) to longitudinal fissure (E D). Posterior Perpendicular 
 Line: — along posterior border of mastoid process, from base-line to longi- 
 tudinal fissure (G F). Some of the structures are located in connection with 
 these lines, and others are located upon other data. An average adult head 
 is supposed. 
 
 Longitudinal Fissure. — From mid-point of the naso-frontal suture to 
 external occipital protuberance. 
 
 Sylvian Fissure. — Extends from a point 3.1 cm. (i| inches) horizontally 
 behind the external angular process to a point 1.8 cm. (f inch) below the 
 most prominent part of the parietal eminence (Fig. 415, H J). Main 
 part of the sylvian fissure is represented by the anterior 1.8 cm. (f inch) of 
 the above line (HI). Horizontal Limb of the fissure is represented by the 
 remainder of the line (I J). Ascending Limb of the fissure extends from the 
 posterior end of the main fissure vertically upward for 2.5 cm. (1 inch) (IK). 
 Bifurcation of the sylvian fissure, therefore, lies 5 cm. (2 inches) posteriorly 
 
55- 
 
 OPERATIONS UPON THE HEAD, 
 
 to the external angular process, and about 6 mm. (| inch) above the level 
 of the external angular process (I). 
 
 Rolandic Fissure. — Represented by a diagonal line from upper end of 
 posterior perpendicular line to junction of anterior perpendicular line with 
 the sylvian fissure (L F). 
 
 Sigmoid Portion of the Lateral Sinus. Point on the baseline 1.8 
 cm. (f inch) behind the center of the external auditory meatus (M). 
 
 Transverse Portion of the Lateral Sinus. — Point 2.5 cm. (1 inch) 
 behind the center of the external auditory meatus, and 6 mm. (| inch) above 
 the base-line (N). 
 
 Mastoid Antrum. — Intersection of line drawn along the superior wall 
 
 Fig. 415. — Reid's Method of Cranio-cerebral Localization: — A B, Base-line; E, 
 Preauricular point; E D, Anterior perpendicular line; G F, Posterior perpendicular line; H I, 
 Main part of Sylvian fissure; I J, Horizontal limb of Sylvian fissure; I K, Ascending limb of 
 Sylvian fissure; L F, Rolandic fissure; M, Sigmoid portion of lateral sinus; N, Transverse portion 
 of lateral sinus; O, Mastoid antrum; P, Lateral ventricle; R, Main trunk of middle meningeal 
 artery; S, Cerebral abscess; T, Cerebellar abscess. (For explanations, see text.) 
 
 of the auditory meatus parallel with the basedine, with line drawn along the 
 posterior wall of the auditory meatus perpendicular to the basedine (( >). 
 
 Lateral Ventricle. — Lies 3.8 cm. (i| inches) directly above the center 
 of the external auditory meatus (P). 
 
 Anterior Branch of the Middle Meningeal Artery. —Encountered 
 at a point 3.8 cm. (ij inches) behind external angular process, and 3.8 cm. 
 (1^ inches) above zygomatic arch (Q). 
 
 Posterior Branch of Middle Meningeal Artery. — Encountered at a 
 point 4.4 cm. (if inches) behind external angular process, and 6 mm. (j 
 inch) above zvgomatic arch (R). 
 
 Usual Site of Cerebral Abscess. — In the temporo-sphenoidal lobe at 
 
KROENLEIN'S METHOD OF CRANIO-CEREBRAL LOCALIZATION. 553 
 
 a point 1.8 cm. (f inch) above the base-line, on a line drawn along the pos- 
 terior wall of the auditory meatus perpendicular to the base-line (S). 
 
 Usual Site of Cerebellar Abscess. — Opposite a point 3.8 cm. (i| inches) 
 behind center of external auditory meatus, and 6 mm. (\ inch) below the 
 base-line (T). 
 
 KROENLEIN'S METHOD OF CRANIO-CEREBRAL LOCALIZATION. 
 
 Kroenlein's construction is formed by two parallel horizontal, two parallel 
 vertical, and two oblique lines. 
 
 (A) Horizontal Lines; — (1) The Inferior, or fundamental line, passes 
 through the inferior border of the orbit and the superior border of the auditory 
 
 Fig. 416. — Kroenlein's Method of Craniocerebral Localization: — A, The German, 
 or lower, horizontal line; B, Superior horizontal; C, Anterior vertical; D, Middle vertical; E, 
 Posterior vertical; F, Rolandic line and fissure; L, Lower end of Rolandic fissure; G, Sylvian 
 line; I, O, Sylvian fissure; H, I, J, Main trunk and anterior and posterior branches of middle 
 meningeal artery; H, I, J, K, Square within which von Bergmann recommends opening the 
 skull for otitic abscess in the temporal lobe. 
 
 meatus (Fig. 416, A). (2) The Superior Horizontal, parallel with the pre- 
 ceding, passes through the upper border of the orbit (Fig. 416, B). 
 
 (B) Vertical Lines; — (1) The Anterior Vertical, perpendicular to the 
 Inferior Horizontal, passes through the middle of the zygoma (Fig. 416, C). 
 (2) The Middle Vertical, perpendicular to the Inferior Horizontal, passes 
 through the temporo-maxillary joint (Fig. 416, D). (3) The Posterior Ver- 
 tical, perpendicular to the Inferior Horizontal, passes through the most poste- 
 rior border of the mastoid process (Fig. 416, E). 
 
554 
 
 OPERATIONS UPON THE HEAD. 
 
 E 
 
 (C) Oblique Lines; — (i) The Rolandic Line passes from the point of 
 intersection of the Superior Horizontal and Anterior Vertical, to the point 
 where the Posterior Vertical crosses the sagittal suture (Fig. 416, I, F). The 
 inferior extremity of the Rolandic Fissure is found at the point where the 
 Rolandic Line crosses the Middle Vertical (Fig. 416, L). (2) The Sylvian 
 Line is found in the following way: — Bisect the angle formed by the inter- 
 section of the Rolandic Line with the Superior Horizontal (Fig. 416, I, G) — 
 the Sylvian fissure will be represented by that portion of the bisector which 
 extends from this intersection to the Posterior Vertical (Fig. 416, I, O). 
 
 The main trunk and the anterior and posterior branches of the middle 
 meningeal artery are to be sought, respectively, at the points H, I, and J. 
 
 Von Bergmann recommends exploring for otitic abscess of the temporal 
 lobe within the square M, J, N, K. 
 
 CHIENE'S METHOD OF DETERMINING THE ROLANDIC FISSURE. 
 
 Take a piece of paper about three inches square — crease it diagonally 
 
 from A to D, so that A B D 
 coincides with A E D. A E D 
 will then represent an angle of 
 45 degrees. Then, after open- 
 ing out the square, crease A 
 BD along A C, so that A B 
 C coincides with A C D, and 
 allow the last folding to re- 
 main creased. A C D (half of 
 an angle of 45 degrees) will 
 represent 22 \ degrees. There- 
 fore E A C will be equal to 
 an angle of 67^ degrees. Apply 
 figure A EDC to the head 
 so that A E falls upon the 
 median line, with A 1.2 cm. 
 (h inch) posterior to the mid- 
 point of the line from nasion 
 to inion, with E forward — 
 when the line A C will repre- 
 sent an angle of 67J degrees 
 with the median line, and, 
 therefore, approximately, the 
 rolandic fissure. (See Fig. 
 
 4I7-) 
 
 As the angle, however, 
 
 which the rolandic fissure makes with the median line is now generally 
 
 regarded as somewhat greater than 6jh degrees (see Fissure of Rolando, 
 
 Cranio-cerebral Topography, page 539)", a somewhat greater allowance, say 
 
 about 70 degrees, should be made. 
 
 [ 
 
 D 
 
 Fig.417.— Chiene's Method of Determining the 
 Rolandic Fissure:— A B D E, a square; A E D (one- 
 half of A B D E, creased diagonally), an angle of 45 de- 
 grees : A B C (one-half of A B D), an angle of 22^ degrees. 
 Therefore E A C represents an angle of 67^ degrees. 
 
 GENERAL SURGICAL CONSIDERATIONS IN CRANIO-CEREBRAL 
 
 OPERATIONS. 
 
 Relations of Cranial Contents to Cranial Bones.— It has been noted 
 that irregularities of relationships do sometimes occur, and that discrepancies 
 sometimes exist in the statements of the different methods of localizing, as 
 
SURGICAL CONSIDERATIONS IN CRANTO-CEREBRAL OPERATIONS. 555 
 
 given by different men of extended experience— but these irregularities and 
 discrepancies are generally so slight that the structures or areas sought are 
 readily accessible through the data given— and if not found directly in the 
 center of the site exposed by operation, are usually within reach of the opening 
 made. As a rule, apparent discrepancies are generally the result of an error 
 in applying the special method of localizing. 
 
 Fig. 418. — Rubber Tourniquet for Control of Hemorrhage from the Scalp in Opera- 
 ting ABOUT THE HEAD. 
 
 Preparation. — Head shaved. Ears cleansed and packed with sterile 
 cotton. 
 
 Position. — Patient supine, head elevated upon a firm support, at end of 
 table, and turned so as to give freest access to site of operation. Surgeon on 
 side of operation, or directly behind patient's head. Assistant opposite 
 surgeon, or at his side. 
 
 Fig. 419. — Doyen's Saw: — The guard set at 10 mm. (i in.). 
 
 Control of Hemorrhage. — Hemorrhage from the scalp is generally con- 
 trolled by clamp-forceps, applied immediately upon the completion of the 
 incision, followed by ligation with gut of the clamped vessels. Where ex- 
 tensive bleeding from the scalp is anticipated, especially in removing growths 
 of that structure, a circular constrictor around the lower part of the skull 
 (passing just above the nose and ears and just below the external occipital 
 protuberance) may sometimes be advantageously used — such as the narrow 
 
556 
 
 OPERATIONS UPON THE HEAD. 
 
 flat band of the Esmarch set, or a rubber tube which flattens as it is applied 
 (Fig. 418). To aid in its effectiveness, small compresses may be first placed 
 over the temporal, posterior auricular, and occipital arteries, upon one or, 
 preferably, both sides, and held in place by rubber plaster — and the con- 
 strictor applied over these. Intracranial hemorrhage (from middle meningeal 
 arteries, venous sinuses, and the intracerebral vessels) will be specially men- 
 tioned among the operations upon the cerebral contents. 
 
 Figs. 420 and 421. 
 
 -A, MacEwen's Trephining-brace, with Various Sizes of Conical 
 Trephines; B, An Interchangeable Trephine. 
 
 Manner of Making the Cranial Section. — The use of a saw (motor 
 or hand, including the trephine, which is practically a circular saw) is prefer- 
 able for all forms of cranial section. MacEwen's trephine-brace is a valuable 
 modification of the trephine (Figs. 420, 421). In this category the chain 
 and Gigli saws are also included. Next to the saw, the bone-cutting forceps 
 are to be chosen. And last to be recommended are the various forms of 
 chisels, used with mallets. The only field for these last-mentioned instruments 
 
CRANIOTOMY IN GENERAL. 557 
 
 (owing to the concussion caused) is where a moderate blow or two will accom- 
 plish the object. Doyen's hand-saw is an excellent instrument (Fig. 419) . 
 
 Thickness of Skull. — Average thickness is about 5 mm. (A inch). In 
 early life and in oid age the skull is thinnest, and at these ages the diploe is 
 absent from the squamous bone, the parietal in the neighborhood of the 
 squamous, and in the fossae of the occipital. Thinnest parts of the cranial 
 bones— squamous part of temporal; inferior occipital fossae; over venous 
 sinuses; over frontal sinuses; over grooves for meningeal vessels. Thickest 
 parts of cranial bones — occipital protuberance of occipital; mastiod portion 
 of temporal; lower part of frontal (except over frontal sinuses). 
 
 Use of Electrode in Corroborating Motor Centers. — First try to get 
 reaction through dura, without opening this membrane. In applying to 
 brain itself, guard against burning by too strong a current. 
 
 Where part of dura is permanently removed, gold-foil, or some similar 
 substance may be advantageously used to prevent cortical adhesions. 
 
 Where much brain tissue is removed, as in operations for tumors, etc., 
 temporary packing should be used, to equalize brain pressure. 
 
 Cranio-cerebral Operations in Two Stages. — Some surgeons open the 
 cranium, down to the dura, at the first operation — and open the dura and 
 complete the operation several days later — upon the ground of less shi ck, 
 less hemorrhage, and a better protection of surrounding parts by adhesions. 
 The majority of operators, however, complete the operation at one sitting, 
 unless specially contraindicated. 
 
 INSTRUMENTS USED IN CRANIO-CEREBRAL OPERATIONS. 
 
 Scalpels, light and heavy; dissecting forceps; toothed forceps; fine forceps 
 for holding dura, various shapes; artery-clamp forceps; sinus forceps; scissors, 
 sharp and blunt, curved, straight and angular; trephines (of Gait pattern, 
 or with guard), various sizes; trephine brushes; saws, motor and hand; Doyen's 
 saw; chain saw; Gigli saw and carrier; bone-cutting forceps, various sizes 
 and shapes; bone-holding forceps, various; rongeur forceps; periosteal elevator; 
 bone elevator; gouges; curettes; retractors; spatulae; dural separator; grooved 
 director; probe, with one flat end, to detect depth of trephine cut; tenacula; 
 chisels, various sizes and shapes; mallets; aneurism-needles, various; brad 
 awl; Fluhrer's probe; metal meter measure, in millimeters and centimeters; 
 electrode for diagnosis; measurer of skull-thickness; surgeon's wax for plugging 
 bony canals of vessels; needles, various, especially fine curved; needle-holders; 
 sutures and ligatures, of silk, plain and chromic gut, and silkworm-gut; 
 drains; gauze; rubber-band tourniquet; gold foil; rubber tissue. 
 
 CRANIOTOMY IN GENERAL. 
 
 Description. — Section of cranial bones. Operations upon the cranio- 
 cerebral region resolve themselves, as far as the operation upon the cranium 
 is concerned, into the making of an opening in the bony vault for the pur- 
 pose of reaching the object itself of the special operation — and these openings 
 are either simple trephinings, irregular cranial sections, or some form of 
 osteoplastic resection. The operation of cutting through the bones of the 
 skull is, after shaving the head, preceded by either the turning back of a 
 flap composed of the soft tissues of the scalp, or the flap turned back consists 
 of combined soft parts and bone undetached from each other. The flap, in 
 
558 OPERATIONS UPON THE HEAD. 
 
 either case, is so planned as to have its pedicle below, that the arteries supplying 
 its nutriment may not be severed. At the end of the operation the flap is 
 dropped back into place and sutured. One or the other of these is the common 
 method of approach, no matter what the subsequent steps may be. When 
 the portion of bone is not returned, the operation becomes, strictly speaking, 
 a partial craniectomy. 
 
 Varieties. — (I) Circular Craniotomv, or Trephining; generally per- 
 formed with the conical (Gait's) trephine. The diameter of the opening 
 thus made may be from 1.2 to 6.3 cm. (| to 2+ inches). Generally resorted 
 to where a more limited opening will suffice. (2) Linear Craniotomy; division 
 of cranial bones in straight lines — preferably by means of a motor saw, gener- 
 ally preceded by a small trephine-opening through which to begin the section. 
 Generally used as a simple section in the course of some operation. (3) 
 Irregular Craniotomy; openings of irregular outline and varying size, such 
 as may be unexpectedly indicated in the course of some operation. For 
 example, original openings, when found inadequate, may be increased to the 
 desired extent and form by the further application of trephine, saw, chisel, 
 or bone-cutting forceps. (4) Osteoplastic Resection; a form of irregular 
 craniotomy in which an area of scalp and cranium are cut through throughout 
 the greater portion of their extent, but not separated from each other — and 
 are then temporarily turned back, partly by breaking, partly by bending the 
 unsevered portion — and subsequently replaced. Generally resorted to where 
 the largest openings are required. 
 
 TREPHINING, OR CIRCULAR CRANIOTOMY. 
 
 Description. — The division of the cranial bones by means of a trephine, 
 preferably of the conical or Gait tvpe (Fig. 423) — preceded by the temporary 
 turning back of a flap composed of the soft parts. Indications: intracranial 
 hemorrhage; abscess; fracture; foreign body; evacuation of cerebrospinal 
 fluid through the lateral ventricle; as a preliminary step to osteoplastic resec- 
 tion and to linear craniectomy; epilepsy; bullet and other wounds; small 
 tumors; drainage of frontal sinus; drainage of mastoid antrum and cells; 
 thrombosis of venous sinuses. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations. 
 
 Landmarks. — Determined by bony landmarks of skull, or calculated by 
 some method of cranio-cerebral localization, according to special operation. 
 
 Control of Hemorrhage. — Ordinarily the hemorrhage is controlled by 
 clamping the arteries in the margin of wound as cut. Excess of bleeding 
 can be temporarily controlled, until arteries are clamped, by digital com- 
 pression of temporal, occipital, or posterior auricular vessels against the 
 skull. Where much bleeding is anticipated, the arteries may be compressed 
 against the skull by circular constriction, as explained under General Surgical 
 Considerations in Cranio-cerebral Operations (page 555). See also under 
 Comment at end of this operation, and under Operations for Intracranial 
 Hemorrhage (page 586). 
 
 Incision. — An incision is made outlining an oval or U-shaped flap, with 
 its convexity toward the crown of the head and its pedicle toward the base, 
 its sides corresponding with the general direction of the vessels and nerves, 
 thus providing for free ingress of arteries into the flap. Where possible, so 
 place the flap as to avoid the main arteries. Size of flap should be consider- 
 ably greater (at least 1.2 cm., or \ inch, all around) than the disc of bone 
 
TREPHINING, OR CIRCULAR CRANIOTOMY 
 
 559 
 
 to be removed, so that the cicatrix of the soft parts should not overlie the 
 margin of the bone-opening. The center of the soft flap should about corre- 
 spond with the center of the bone-disc to be removed. (The oval-flap incision 
 is distinctly superior to the crucial or other form of incision.) (Fig. 422.) 
 
 Operation. — (1) The original incision passes directly through skin, 
 fascia, muscle (or aponeurosis), and periosteum to the bone throughout. 
 Clamp arteries as cut, followed by ligation of main vessels with gut and removal 
 of clamp forceps, so as to avoid encumbering the site of operation with instru- 
 ments. (2) The periosteum, together with the overlying parts adherent to 
 
 422. — Trephining, or Circular Craniotomy: — I. 
 
 of soft parts. 
 
 -Subperiosteal elevation of the flap 
 
 it, is then detached from the bone, en masse, with periosteal elevator (its 
 adherence being firmest along the suture lines), and the entire flap turned 
 down (Fig. 422) — and either held out of the way by a metallic or thread 
 "retractor, or stitched to the neighboring soft parts. (3) When all bleeding 
 has been controlled, apply trephine to desired site, with its pin slightly pro- 
 jecting, withdrawing pin as soon as teeth of instrument have cut a groove in 
 the bone. By repeated right to left pronations and supinations of wrist, con- 
 tinue the half-circular movements of the trephine until the section is made 
 through the bone, to but not into the dura (Fig. 423). The progress of the 
 trephine is best determined at intervals by withdrawing the instrument and 
 
560 
 
 OPERATIONS UPON THE HEAD. 
 
 ascertaining the depth of the groove by the tip of the flat end of the ordinary 
 probe, which readily detects the yielding dura. Additional pressure should 
 be made upon that aspect of the incision which is thickest or is least cut, while 
 the trephine is tilted away from the part completely divided. If the teeth of 
 the trephine become blocked with bone-dust, remove such dust with trephine- 
 brush or gauze. Pressure upon the instrument should decrease as the brain 
 is approached. At first, greater resistance in going through the outer table 
 of the skull is offered — then less resistance as the instrument passes through 
 the diploe, and the bone-dust of the diploetic region is usually more blood- 
 
 Fig. 423. — Trephining: — II. — Application of the Gait conical trephine to the skul 
 
 stained — then finally greater resistance is experienced again in passing through 
 the inner table. When section of bone has been almost or quite completed, 
 the button of bone may generally be lifted out by means of an elevator (Fig. 
 424) or in the grasp of special curved, thin-bladed trephine-forceps. (4) If 
 more space be required than afforded by the removal of the button, it may be 
 gotten by biting out pieces of bone from the circumference of the opening by 
 means of suitably curved rongeur forceps — or by making an additional con- 
 tiguous trephine-opening of the same or smaller size, followed by biting out of 
 
TREPHINING, OR CIRCULAR CRANIOTOMY. 
 
 56l 
 
 the intervening bridge-work of bone. (5) The dura mater is now exposed, and 
 should be opened by marking out, on a very small scale, a flap very similar 
 to the scalp-flap — its pedicle should be placed so as to best preserve its blood- 
 supply (without reference to coinciding with the pedicle of the scalp-flap)— 
 its convexity should lie in the opposite direction and be everywhere sufficiently 
 far from the edge of the bone (at least 6 mm., or \ inch) to enable the cut 
 margins of dura to be sutured at the end of the operation (Fig. 425, D). If 
 arteries of fair size cross the dura, they should be ligated, where possible, prior 
 to incising the dura, by passing a small, fully curved needle, armed with fine 
 
 Fig. 424. — Trephining:— III. — Levering out the excised button of bone. 
 
 gut, beneath them, including the dura. Arteries should be tied along the line 
 which will form the convexity of the flap, rather than where they enter its 
 pedicle. If not possible to tie them in advance, they should be caught as soon 
 as cut and tied or twisted. The dura should be carefully incised with a light 
 touch of the point of a fine, sharp knife, or cut with fine curved scissors, aided 
 by grasping the small dural flap with delicate forceps as soon as a margin of it 
 is free, and taking care not to wound the surface of the brain or the vessels 
 coursing over it. (6) The special object of the operation, whatever it may be, 
 is now carried out. (7) Having accomplished the particular object ot the 
 operation, the dural flap is dropped into place and sutured with two or three 
 36 
 
562 
 
 OPERATIONS UPON THE HEAD. 
 
 or more, fine gut sutures, by means of a small, fully curved needle held by 
 needle-forceps, while the dura is steadied by fine forceps (Fig. 425, E). (8) 
 The opening in the bone may now be treated in one of several ways: (a) 
 Left without replacement of any bone-tissue, which is especially done in the 
 making of small trephine-openings; — (b) The button of bone may be replaced 
 intact upon the dura, and the soft flap of periosteum and other tissues brought 
 over the button — a method which may be pursued in dealing with buttons of 
 larger size; — (c) The button may be divided into parts by fragmentation and 
 sprinkled over the dura, where they form the nucleus of new bone growth ; — 
 
 Fig.425.— Trephining, or Circular Craniotomy : — A, Circle left by removed disc of bone ; B, 
 Incised dura mater; C, Surface of brain; D, Dural flap, with meningeal vessels, turned back ; E, 
 Gut-sutures through margins of incised dura and dural flap ; F, Scalp-flap, with branches of occipital 
 vessels, turned down. 
 
 (d) A celluloid, metallic, or gutta-percha plate may be placed in the opening. 
 In trephinings of small diameter the button is not generally replaced. 
 In large openings some surgeons do, and some do not, replace the button, whole 
 or fragmented, or some artificial covering. Where the button, either intact 
 or fragmented, is used, it is dropped into warm normal salt solution as soon 
 as removed. (9) The flap of scalp tissues is now brought back into its original 
 position — the edges of the periosteum are sutured with catgut — and the edges 
 of the overlying soft parts are sutured interruptedly with silkworm-gut, silk, 
 
TREPHINING, OR CIRCULAR CRANIOTOMY. 
 
 563 
 
 Fig. 426. — deVilbiss' Cranial Bone-gouging Forceps: — The biting-blade is shown in 
 detail. Also known as Dalgrene's bone forceps. 
 
 or catgut, passing through all the soft tissues down to the periosteum. (10) 
 No drainage is ordinarily used unless specially indicated — and, if indicated, 
 
 ■ i^gflHH" 1 ""■■if 
 
 Fig. 427. — Doyen's Cranial Chisel. 
 
 a few strands of catgut, horsehair, silk, or gauze suffice. A full dressing is 
 applied. 
 
 p 
 
 Fig. 428.— Osteoplastic Repair of a Trephine or other Opening:— I.— A, Flap 
 raised in exposing site for trephining; B, Flap to be raised, including a portion of bone (the 
 outer tablet of the skull) and to be shifted to cover the trephine-opening. 
 
 Comment.— Bleeding from the diploe may be stopped by compressing 
 a small part of the bone upon the vessel with bone-forceps, or by plugging 
 
564 
 
 OPERATIONS UPON THE HEAD. 
 
 with catgut or surgeon's wax. Bleeding from the dura may be checked by 
 fine catgut ligature. For bleeding from venous sinuses, see Ligation of Longi- 
 tudinal and Lateral Sinuses (page 586). 
 
 It is probably always best to open the dura in all cases of trephining. 
 
 If more room be required than is furnished by the trephine-opening, 
 additional bone may be bitten away by some special instrument, such as de 
 Vilbiss' bone-gouging forceps (Fig. 426), or less desirably may be chiselled 
 away by such an instrument as Doyen's cranial chisel (Fig. 427), using in 
 either case the margin of the trephine-opening as a starting point. 
 
 Though not frequently resorted to, or indicated, it may be possible to make 
 an osteoplastic closure of a trephine opening. In order to accomplish this, 
 
 Fig. 429. — Osteoplastic Repair of a Trephine or other Opening: — II. — A, Flap 
 raised in exposing site for trephining and about to be shifted to cover site of Flap B, and the 
 shallow bony opening left by removing the outer tablet of the skull under and along with Flap B; 
 B, Hap, including attached bone-graft, shifted so as to bring the autoplastic bone-graft over the 
 trephine or other opening. 
 
 an adjacent flap may be raised, corresponding somewhat with the flap raised 
 for the original exposure, but with its base lying in the opposite direction. In 
 the act of raising this secondary flap a portion of the outer layer of the skull 
 is chiselled off, retaining its connection with the secondary flap and so planned 
 as to approximately fit the defect which it is intended to cover. Each flap is 
 then so shifted as to lie in the position formerly occupied by its neighbor — the 
 bone-bearing flap covering the exposed brain, and the boneless flap covering 
 the site furnishing the bone-flap. These steps are shown in Figs. 428 and 
 429. 
 
OSTEOPLASTIC RESECTION OF SKULL. 
 
 565 
 
 OSTEOPLASTIC RESECTION OF THE SKULL. 
 
 Description. — Temporary partial displacement of a section of the skull, 
 together with its overlying soft parts unseparated — accomplished by partly 
 bending, partly breaking backward, the base of the bony section from the 
 dura, upon a hinge, as it were, of the soft parts, without complete severance 
 
 Fig. 430— Osteoplastic Resection of thk Skill:— A. Cutaiieo-musculo-osseous flap tempo- 
 rarily turned back ; the component parts adherent, and with scalp vessels cut along the margin ; B, B. B, 
 B, Four trephine-openings made preceding the sawing of the bon~ ; C, Line along which the bone was 
 cracked back; D, Incised dura, with divided vessels ligated ; E, Dural flap turned back; F, Gut- 
 sutures through margins of incised dura and dural flap ; G, Periosteum retracted from line of saw- 
 cut; H, Margin of skull left by temporary removal of osteoplastic flap ; I, Surface of brain. 
 
 of the vascular supply — followed by the replacement of the flap of bony 
 and soft parts into apposition. (See Fig. 430.) 
 
 (The replacement of a trephined button of bone is, strictly, an instance 
 of osteoplastic resection with temporary complete displacement of the excised 
 piece of bone.) 
 
 Indications. -For exploration; tumors; intracranial abscess; intracranial 
 
5 66 
 
 OPERATIONS UPON THE HEAD, 
 
 hemorrhage; exposure of Gasserian ganglion; wounds. In general, where 
 the freest access to brain is required. 
 
 Fig. 431. — Osteoplastic Exposure of the Brain: — A horseshoe flap has been incised 
 to the bone. Burr-openings are being made by a Doyen hand-drill, to which a fraise (burr) 
 i-. attached. The commencement of an opening, made by the perforator, is also shown. 
 
 Preparation and Position. — See under General Surgical Considerations 
 in Cranio-cerebral Operations (page 554) • 
 
 Figs. 432-436. — Doyen's Brace, with several sizes of Burr-drills (Fraises) and a 
 
 Perforator. 
 
 Landmarks. — Same as for trephining (q. v.). 
 
 Control of Hemorrhage from Scalp. — Hemorrhages ordinarily con- 
 trolled as in trephining (q. v.). Where extensive hemorrhage is anticipated 
 
OSTEOPLASTIC RESECTION OF SKULL. 
 
 567 
 
 the vessels may be controlled by circular constriction, as explained under 
 General Surgical Considerations in Cranio-cerebral Operations. 
 
 Form of Cranial Opening.— (1) The best and general form is that of a 
 
 Fig. 437. — Perforator: — A, Fraise or burr; B, in section of the skull. 
 
 horseshoe, with its broader convexity upward and its more contracted base 
 downward (Fig. 430) — or an i-'-shaped flap, the horizontal cuts at base (which 
 may or may not be made) serving as liberating incisions. (2) A square, or a 
 
 Fig. 438. — Osteoplastic Exposure of the Braix: — Application of the mensurator 
 through a cranial drill-opening, in order to ascertain the thickness of the skull at the different 
 openings, as a guide to the setting of the guard in the Doyen or other form of saw. 
 
 rectangular piece, longer than broad, may be used — though the process oi 
 bending backward is always aided if the base be somewhat narrower thai* 
 the free portion (Fig. 468). (3) A second horseshoe, or square of bone, may 
 
5 68 
 
 OPERATIONS UPON THE HEAD. 
 
 Fig. 439. — Showing the method of application of the mensurator, between dura and skull, 
 demonstrating, at this particular site, a skull 5 mm. ( T 3 B inch) thick. 
 
 be turned back, if the original flap do not furnish sufficient room — the second 
 being either turned back in an opposite direction from the first but in the same 
 line, or from one side of the original opening (Fig. 469) . 
 
 Fig. 440.— Osteoplastic Exposure of the Brain:— Doyen hand-saw, set to cut, say, 
 through 7 mm. ($ inch) thickness of skull, in the act of making a bevelled bone-section between 
 two drill-openings — bevelling at the expense of the inner surface. 
 
 Incision of Scalp. — The form of scalp incision will be regulated by the 
 previously determined form of bone section. Having decided this, the incision 
 
OSTEOPLASTIC RESECTION OF SKILL. 
 
 5 6 9 
 
 through the soft parts should conform, in general outline, with the bone section 
 to be made, but should extend at least 1.2 cm. {h inch) beyond the line of 
 bone section, so that the cicatrix of soft parts will not fall directly over the line 
 of bony union or repair. The incision should be so placed, where possible, 
 
 Fig. 441. — Osteoplastic Exposure of the Brain: — The starting outward (by means of 
 an osteotome carefully introduced down to the dura) of the composite flap — the bone of which 
 is to be snapped back and broken at its base on a transverse line with the two lowermost drill- 
 holes. 
 
 as to give free ingress of the neighboring arteries into its substance, especially 
 the chief artery of the region. The removal of an area of bone greater than 
 7.5 cm. (3 inches) square is rarely called for — and this would require a skin- 
 flap at least 10 cm. (4 inches) broad. 
 
 Fig. 442. — Marion's Gigli-saw Conductor. 
 
 Operation. — (1) The incision passes everywhere through skin, fascia, 
 muscle, aponeurosis, and periosteum directly to the bone (Fig. 431). Or 
 the incision may pass down to the periosteum — these allowed to retract, and 
 periosteum cut on line of retracted soft parts, midway between the line of the 
 skin incision and the line of the bone incision, so that periosteal and skin cica- 
 
57° 
 
 OPERATIONS UPON THE HEAD. 
 
 trices do not fall together, nor periosteal and bony cicatrices coincide. (2) A 
 rim of periosteum, without separating the overlying soft parts, is carefully 
 detached to the extent of about 1.2 cm. (^ inch) around the horseshoe flap, 
 separating it chiefly toward center of flap, and but slightly upon the outer edge 
 of the incision. (3) Having exposed the entire area for the bone section, the 
 bone is divided about 6 mm. (| inch) inside of the division of the periosteum 
 in one of several ways: — (a) By means of Doyen's Hand-drill and Hand-saw; 
 — Doyen's special brace, with perforators and burr-drills, is used (Figs. 432- 
 436) . The beginning of the opening is made by means of the perforator (Fig. 
 437, A), which cuts into the bone in such fashion as to enable the burr to keep 
 its hold and not slip over the convex surface of the skull. The burr is then 
 
 Fig. 443. — Osteoplastic Exposure of the Brain: — Gigli saw being carried beneath the 
 skull, between the burr-openings, by means of the Marion conductor. 
 
 applied and cuts its way through the entire thickness of the skull down to the 
 dura mater — its form being such as to make it impossible to crush into the 
 brain, except through carelessness — and its cutting surface so modelled as to 
 revolve upon the dura without cutting it, unless driven too far through the 
 skull (Fig. 437, B). During the use of the burr the instrument should be 
 removed and the depth of the opening sounded. The position of the brace, 
 during these manoeuvres, is shown in Fig. 431. Having made these openings 
 at sufficiently close intervals in the outline of the intended bone-flap, the thick- 
 ness of the skull is ascertained by means of the mensurator (Figs. 438 and 
 439). These soundings (made in millimeters) through any two contiguous 
 openings will usually give the thickness of the skull for that special interval 
 with sufficient accuracy (barring such accidental occurrence as the presence 
 
OSTEOPLASTIC RESECTION OF SKULL. 
 
 571 
 
 of a depression in the skull for a Pacchionian body). Having set the guard 
 of the Doyen saw (Fig. 419) at the number of millimeters indicated by the 
 mensurator, the skull is cut through between each pair of drill-openings — ■ 
 changing the guard to correspond with the thickness of the skull in each region. 
 The saw sections are always made on the bevel — in such a manner as to cut 
 at the expense of the inner surface of the bone-flap — so that when it is replaced 
 the flap of bone will rest upon a ledge of bone furnished by the margin of the 
 opening and thus not be depressed upon the brain (Fig. 440). It is better 
 to saw nearly through rather than .entirely through the skull — leaving the 
 limited bony attachments which may still exist to be broken by the slight, 
 light tap of a wooden mallet upon an osteotome (not a chisel) (Fig. 441), 
 
 Fig. 444. — Osteoplastic Exposure of the Brain: — Gigli saw making a bevelled section 
 between two drill-openings. The bevelling is made at the expense of the inner surface of the 
 bone-flap, so that, when replaced, the bone-flap will rest upon the skull and not be pressed against 
 the brain. 
 
 preparatory to breaking back (hinging back) the bone-flap, (b) By means 
 of a Gigli saw conducted between burr-openings or small trephine openings, 
 between skull and dura ; — The burr openings may be made as in the preceding 
 technic, by the Doyen hand-drill — or small trephine openings may be made 
 along the line of the intended flap. A pliable dural separator is then passed 
 from hole to hole, detaching and depressing the dura from the skull. A 
 Gigli saw is now conducted beneath the bone by a special carrier (such as 
 Marion's Gigli-saw conductor (Fig. 442) between two contiguous holes (Fig. 
 443) and the bone divided — and this repeated until the section is completed — 
 the saw bevelling the bone as described in the last method (Fig. 444). (c) 
 By means of Doyen's Flectric-Motor Drills and Saws; — This instrument is 
 
572 
 
 OPERATIONS UPON THE HEAD. 
 
 driven by electric power and is a combination of drill and saw (Figs. 445- 
 447). The drill-* tpenings in the line of the flap are made in the same manner 
 as are the drill- or burr-openings made by Doyen's hand-drill and saw (Fig. 
 448) . As soon as the burr-openings have been made and their depth measured, 
 an appropriate saw, with its proper guard, is chosen (Figs. 449-452 — a guard 
 which will enable the saw to cut nearly through (as previously determined by 
 the mensurator), but not entirely through, the skull — leaving a thin portion of 
 the inner plate to be divided by a stroke or two of mallet against osteotome. 
 The section between burr-holes is then made in the same general way as by 
 the hand saw — and bevelled in the same fashion. Another form of the Doyen 
 Electric-Motor Saw is provided with a dural guard and separator, which 
 
 D 
 
 Figs. 445-447. — Doyen's Electric-motor Drill and Saw: — A, Metallic cylinder for 
 reception of special instrument; B, Rubber tube enclosing metallic core connected with motor; 
 C, C, C, Handle, in various positions, to accommodate application of instrument to different 
 aspects of skull; D, Fraise; E, Saw, with guard-disc limiting depth of section. (Modified from 
 Marion.) 
 
 travels between skull and bone and ahead of the saw (Fig. 453) — and is 
 applied as shown in Fig. 454. (d) By means of Hartley's Electric Motor; — 
 The source of electric power is, in this case, contained within the instrument 
 itself — consisting of a motor furnishing about one-eighth horsepower — yielding 
 2100 revolutions per minute — the entire instrument weighing 8J pounds. 
 The outer casing is sterilized before the motor is placed within it (Fig. 455). 
 The cutting instruments used with this motor are shown in Figs. 456-459, — 
 the saws being of the same general type as the Doyen saws (Figs. 449-452). 
 (e) By means of Hartley's Compressed-air Motor; — This instrument is 
 pictured in Fig. 460 — the same cutting instruments being adjustable to both 
 it and the Electric Motor, (f) By means of Sudeck's Fraise; — The fraise 
 is shown in Fig. 461. The instrument is attached to some form of motor — 
 
OSTEOPLASTIC RESECTION OF SKULL, 
 
 573 
 
 Fig. 44S. — Osteoplastic Exposure of the Braix: — Same as preceding figure — except 
 Doyen's electric motor drill, with fraise attachment, is here shown. 
 
 and used as pictured in Fig. 462. (4) When the bone has been divided 
 throughout down to the base of the bone-flap, provision must be made for the 
 
 
 
 'A 
 
 Figs. 449-452. — A, A, Doyen's circular saws of various sizes, adjustable to the common 
 handle of his motor saw. B, B, Doyen's safety-discs of various sizes, adjustable to various 
 sizes of saws in order to limit the depth of their cutting-edge. (The saws and discs are shown 
 in groups and separately.) 
 
 bending and breaking back of the bone at the site which will form the hinge 
 of the osteoplastic flap — this hinging of the flap may be accomplished in one 
 
574 
 
 OPERATIONS UPON THE HEAD. 
 
 Fig. 453. — Another form of Doyen saw, driven by electric motor — with attached guard and 
 dural separator passing between skull and dura. 
 
 of several ways; — (a) When all is in readiness, and without having previously 
 partly divided the bridge of bone at the base of the flap, a stout steel elevator 
 
 ■ 
 
 Fig. 454. — Osteoplastic Exposure of the Brain: — The Doyen electric motor, with 
 combined saw attachment and dural separator — the latter being inserted through one cranial 
 opening, while the saw is cutting its way to the next. 
 
 may be inserted under the edge of the convexity of the bone-flap (that part 
 opposite the narrow base of the flap) so as to rest upon the intact portion of 
 
OSTEOPLASTIC RESECTION OE SKULL. 
 
 575 
 
 Fig. 455. — The Hartley Electric Motor with Sterilizable Casing: — The various 
 cutting instruments are attached directly to the armature by means of an adjustable chuck. 
 (Modified from Hartley and Kenyon.) 
 
 the skull {Fig. 463) — the fingers of the surgeon's left hand pressing upon the 
 
 "i 
 
 Figs. 456-459. — Skull-cutting Instruments Adjustable to the Hartley Motor: — 
 A, B, Conical cutters; C, Cutting ball mounted upon cutting cone; D, Composite cutter, com- 
 bining the features of B and C. (Modified from Hartley and Kenyon.) The saws and guards 
 are of the same general type as Doyen's, shown in Pigs. 449-452. 
 
 skull immediately below the line where it is sought to bend and break the bone 
 — and then with' a sudden sharp (not slow and deliberate) movement of the 
 
576 
 
 OPERATIONS UPON THE HEAD. 
 
 lever the bone is sprung hack — and generally breaks accurately enough for 
 all practical purposes, and drops outward and downward still clinging to its 
 hinge of soft parts (Fig. 464) . (b) To insure a more accurate line of break- 
 age, as well as against splintering of the bone and wounding of the brain, 
 two small trephine-openings may be made immediately opposite each other, 
 at the base of the bone-flap and on the line to be broken, provided it be not too 
 long — a pliable dural separator is now passed between the openings — a Gigli 
 
 Fig. 460. — Hartley's Sterilizable Compressed-air Motor: — Driven by compressed 
 air, at a pressure of 75 to 90 pounds; the bone-cutting instruments pictured in Figs. 456-459 
 are adjustable to it. (Modified from Hartley and Kenyon.) 
 
 saw is conducted beneath the bone — and the bone is sawed sufficiently far 
 through, especially at its edges, to insure an accurate breakage and freedom 
 from splintering when the elevator is used as a lever as just described. (5) 
 As the bone is broken back, it is separated from the dura, where not already 
 detached by dural separator or otherwise. The osteoplastic flap of bone and 
 soft parts is allowed to fall back upon its hinge out of the way. (6) Before 
 proceeding, all bleeding from the diploe is controlled by pressure, plugging 
 the openings with catgut or sterilized wax, or by gently crushing the bony 
 
 Fig. 461. — Sudeck's Fraise. 
 
 opening together with bone forceps. (7) The dura is now opened in the form 
 of a flap (Fig. 464), by picking it up with two forceps, incising with knife, and 
 further cutting with curved, blunt scissors (just as described in trephining, 
 q. v.), the division being made sufficiently far from the margin of the bone 
 (at least 6 mm., or I inch) to allow the suturing — and this little flap should 
 be so planned as to preserve the arteries intact which enter its base, ligating 
 them with fine catgut only where they cross the line of incised dura (they are 
 
OSTEOPLASTIC RESECTION OF SKULL. 
 
 577 
 
 Fig. 462. — Osteoplastic Exposure of the Brain: — Manner of using Sudeck's fraise- 
 motor attachment not being here shown. 
 
 -the 
 
 Pi„ 4 6 3 — Osteoplastic Exposure of the Brain: — The final loosening of parts of the 
 inner tablet of the bone-flap in places where the saw-section may not have passed entirely through 
 the skull, by a few light taps with a wooden mallet upon a chisel carefully held so as not to pene- 
 trate the brain. 
 37 
 
578 
 
 OPERATIONS UPON THE HEAD. 
 
 best taken up in advance by passing a small, fully curved needle beneath 
 them). The position of the base of the small dural flap will be determined 
 by the position of the dural vessels, and while it need not necessarily corre- 
 spond with that of the osteoplastic flap, yet it usually does so in a general way. 
 (8) The dural flap having been turned back out of the way, the surface of 
 the brain is exposed and the special object of the operation accomplished (Fig. 
 4°5) • (9) Upon the completion of the operation the dural flap is sutured 
 
 Pig. 464. — Osteoplastic Exposure of the Brain: — I. — A composite flap of soft parts 
 and skull has been turned down. The vessels which will be cut in incising the membranes along 
 the dotted line are ligatured in advance by passing a threaded needle beneath them. Scissors 
 are about to divide the membranes which have been lifted away from the brain between two 
 forceps, throwing them into a ridge. 
 
 back with fine gut to the margin from which cut. (10) The question of intra - 
 or extra-dural drainage, if any, will be determined by the special operation. 
 Strands of silk, silkworm-gut, or fine twists of gauze are usually employed. 
 When used, provision must be made for their passage through the membranes 
 and through the bone-flap — as shown in Figs. 466 and 467. (n) The osseo- 
 cutaneous flap is now turned back into place. The previously freed margin 
 of periosteum clinging to the bone-flap is sutured with interrupted catgut 
 sutures to the margin of the main periosteum from which cut. If muscles 
 
OSTEOPLASTIC RESECTION OF SKULL. 
 
 579 
 
 of any thickness have been involved, these are united by buried catgut sutures. 
 Finally, the skin wound is closed with silk, silkworm-gut, catgut, or silk, by 
 means of interrupted sutures (Fig. 467). If drainage of the extra-cranial 
 wound be indicated, it is accomplished by gauze or fine drainage-tubing, 
 brought out through an opening made by biting a half-button of bone from 
 the edge of the bone-flap with rongeur forceps or through a drill-opening, Fig. 
 466. If intracranial drainage be used, it is brought out through this half- 
 button opening or drill-opening — and then serves as an extra-dural and extra- 
 cranial drain as well. 
 
 Fig. 465. — Osteoplastic Exposure of the Brain: — II. — The dural flap is turned down, 
 
 exposing the brain. 
 
 Comment. — The narrower the pedicle of the horseshoe flap of bone, the 
 easier it is to crack it across at its base, but it should be broad enough to insure 
 nutrition of the osteoplastic flap. 
 
 The edges of the bone of the osteoplastic flap and the margin of the cranium 
 may be drilled and the borders of bone united (if thought necessary) by 
 chromic gut sutures. If the osteoplastic flap be beveled, as always should 
 be, if possible, suturing is not necessary — and is not generally necessary any- 
 how, as the adherent scalp usually holds the bone up in place. 
 
5 8o 
 
 OPERATIONS UPON THE HEAD. 
 
 It is best to open the dura in all cases calling for osteoplastic resection 
 of the skull. 
 
 The application of the osteoplastic method of exposure to some of the 
 sites i if the brain is shown in Figs. 468, 469, 470. 
 
 Fig. 466. — Ixtra-dural axd Extra-dcral Draixage: — I. — The membranes are shown 
 sutured, and through the lower angles of the dural flap a cerebral drain of catgut strands, or 
 silkworm gut, is making its exit from the brain and escaping onto the surface of the scalp, through 
 the drill-holes at the lower angles of the bone-flap, for intra-dural drainage. A bone-drill is 
 seen, the burr in the act of making an opening through the skull, for extra-dural drainage. 
 
 LINEAR CRANIOTOMY. 
 
 Description. — The division of the cranial bones in one or more straight 
 lines variously placed — an operation sometimes resorted to in microcephalus 
 for the purpose of giving increased room to the brain. No portion of the 
 bone is removed except the buttons of bone from the trephine-openings made 
 preliminary to the use of the saw. (While craniotomy is performed in micro- 
 cephalus, partial craniectomy, or the removal of a definite piece of bone, is 
 probably a preferable operation for this purpose, if any at all be justifiable.) 
 
 The operation of craniotomy is included under that of craniectomy (q. v.). 
 
PARTIAL CRANIECTOMY. 
 
 58l 
 
 PARTIAL CRANIECTOMY. 
 
 Description. — Removal of a section of the cranial bones from one or 
 both sides of the head, — an operation sometimes done in microcephalus for 
 the purpose of increasing room for the growth of the brain. 
 
 (Strictly, in trephining and other cranial operations where the button or 
 part of bone is not returned, the operation becomes a Partial Craniectomy 
 though the term is not here used in that sense.) 
 
 Preparation and Position. — See under General Surgical Considerations 
 in Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Nasion and inion, and the general bony landmarks of 
 the skull. 
 
 Fig. 467. — Intra-dural and Extra-dural Drainage: — II. — The strands of the intra- 
 dural drain are seen at their exit through the drill-holes of the osteoplastic flap; — and the rubber- 
 tube of the extra-dural drain at its exit through the burr-opening in the center of the flap. The 
 soft parts are in the act of being sutured, after turning back the composite flap. 
 
 Control of Hemorrhage. — By means of a flat rubber tourniquet wound 
 several times around base of skull, small compresses having been placed 
 over the main arteries of the scalp and held in place by the tourniquet — as 
 described under General Surgical Considerations in Cranio-cerebral Opera- 
 tions. This method of control is generally indicated, as hemorrhage is apt 
 to be marked. 
 
 Incision. — From the junction of the skin of the forehead with the hair, 
 to the inion — passing slightly external to the median line. 
 
 Operation. — (1) The incision of the soft parts passes through the skin, 
 
5 82 
 
 OPERATIONS UPON THE HEAD. 
 
 fascia, muscle, aponeurosis, and periosteum to bone. Clamp all bleeding 
 vessels uncontrolled by constrictor and ligate the chief ones with gut. (2) 
 The soft parts are raised from the bone by periosteal elevator and turned 
 downward, being held out of the way by retractor, or a stitch or two. The 
 flap thus turned back will be represented by practically the soft parts of one 
 entire side of the skull. (3) Having exposed a large area upon one side of 
 the skull, and having controlled all further hemorrhage, the amount, posi- 
 tion, and shape of bone section are determined. An area of bone in the form 
 of a narrow parallelogram represents the section of bone most usually removed, 
 
 Fig. 468. — Exposure of the Cerebellum through an Osteoplastic Flap: — A correspond 
 ing dural flap, together with double ligature of the occipital sinus, is shown. 
 
 though other forms of bone-section are used. Supposing the parallel lines 
 representing this figure to be 1.2 cm. (\ inch) or 1.9 cm. (f inch) apart, a 
 trephine-opening is made at either end of this figure with a diameter of 1.2 
 cm. or 1.9 cm. (\ or § inch) accordingly. If the distance between the trephine- 
 openings be too long for a dural separator and guide to travel, one or more 
 
PARTIAL CRANIECTOMY. 583 
 
 intermediate trephine-openings should be made. A pliable dural separator 
 is then passed from opening to opening between bone and dura and traveling 
 in two parallel lines corresponding with the upper and lower margins of the 
 circumference of the trephine-openings. A grooved guide is then passed in 
 the tracks cleared by the dural separator to protect the brain, and the bone 
 then divided in two parallel lines with an electric motor saw (the Powell 
 electric saw answering the purpose well)— first in a line with the upper mar- 
 gins of the trephine-openings and then in a line with the lower margins 
 of these openings. By properly directing the saw both ends of the section 
 may be pointed, going beyond the trephine-openings at both ends. The 
 bone section is best made with a motor saw— it may be made with rongeur 
 forceps — but preferably not with chisel, as chiseling causes too much jarring. 
 In using an ordinary motor saw a trephine-opening is necessary wherever 
 the direction is changed. A Gigli saw passed between the openings also 
 
 Fig. 469. — Hartley's Double Osteoplastic Flaps for Exposing the Frontal Con- 
 volutions: — Having their bases over the temporal regions. (Modified from Hartley and Ken- 
 yon.) 
 
 answers well. (4) If there be no special indication for exploration, the dura 
 is not opened. If opened, it is so incised as to admit of subsequent suturing. 
 (5) The bone, of course, is not replaced. The soft parts are sutured into 
 position. No drainage is ordinarily used. 
 
 Comment. — (1) Hemorrhage from the diploe is apt to be great and may 
 have to be controlled by plugging with catgut or aseptic wax, by crushing 
 together the walls of the bony canals, or by gauze pressure. (2) Probably 
 it is best to operate upon the second side of the head at a subsequent date. 
 (3) A grooved director for the saw can be used — or the dural separator may 
 be grooved. (4) Where craniotomy is done instead of craniectomy the saw- 
 travels only once between the trephine-openings, which are merely large 
 enough to allow of separation of dura and passage of a guide — and no bone 
 (other than the trephine-buttons) is removed. A crescent-shaped piece of 
 bone may be removed, instead of a piece of the above-described shape. 
 
5§4 
 
 OPERATIONS UPON THE HEAD. 
 
 EXPLORATORY PUNCTURE OF THE BRAIN. 
 
 Description. — For the purposes of exploration, the needle of an aspira- 
 torv syringe may be thrust into the brain substance, especially where pus 
 and fluid tumors or hemorrhage are suspected — the brain having been ex^ 
 posed through a small trephine-opening. A solid needle, or special probe, 
 may be used for the detection of solid bodies. 
 
 Fig. 470. — Osteoplastic Exposure of the Antero-superior Aspect of the Frontal 
 Lobes of the Brain: — The superior longitudinal sinus is doubly ligated. (Modified from 
 Kiliani.) 
 
 Preparations and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 454). 
 
 Landmarks. — Position of some lesion and localization symptoms, taken 
 in connection with the special structures to be avoided. 
 
 Incision. — That for ordinary trephining. 
 
 Operation. — (1) Is the same as that for trephining, up to the raising of 
 the dural flap and the exposure of the brain. (2) The needle is then steadily 
 thrust into the brain in a straight line in any direction indicated by the phe- 
 
OPERATION FOR INTRACRANIAL HEMORRHAGE IN GENERAL. 585 
 
 nomena present, avoiding the venous sinuses, large vessels, basal ganglia), 
 and ventricles (unless puncture of the latter be indicated). The needle 
 should be withdrawn after each puncture. Whenever it is desired to explore 
 in another direction, the needle is reinserted and always carried in a straight 
 line, without side to side movement. (3) Having accomplished the obi'ect 
 of the operation, or after meeting with a negative result, the wound is closed 
 as after trephining. 
 
 Comment. — For further data as to exploratory puncture of the intra- 
 cerebral structures, see Operations for Cerebral and Cerebellar Abscess 
 (pages 595 and 596), Tumor (pages 597-599), and Hemorrhage (page 585). 
 
 OPERATION FOR INTRACRANIAL HEMORRHAGE IN GENERAL. 
 
 Varieties of Intracranial Hemorrhage. — (i) Epidural (Extra-dural) ; 
 between cranial bones and dura — may be arterial or venous. If arterial — 
 generallv from middle meningeal or its branches. If venous — generally from 
 the superior longitudinal, lateral, or occipital sinus. (2) Intrameningeal; if 
 arterial, generallv from middle meningeal or branches. If venous, fre- 
 quentlv from veins connected with longitudinal or other sinus. If capillary, 
 generallv due to traumatism, and site dependent upon trauma. If subdural 
 (into subdural space), it may be caused either by rupture of dura, and is 
 then generallv from the middle meningeal vessels; or by a vessel of the pia 
 rupturing through the arachnoid. If subarachnoidean (between arachnoid 
 and pia mater), it is due either to rupture of vessels of pia into the pia-arach- 
 noid, or to rupture of middle meningeal through dura and arachnoid. (3) 
 Intracerebral: generally from middle cerebral or one of its branches, 
 especially the lenticulo-striate. 
 
 Onlv the general features of intracranial hemorrhage will be here con- 
 sidered. For specific operations for hemorrhage from the middle meningeal 
 arterv and its anterior and posterior branches, and from longitudinal and 
 lateral venous sinuses, see ligations of those structures (pages 47, 48, 49 
 and 586). 
 
 Preparation and Position. — See General Surgical Considerations in 
 Craniocerebral Operations (page 554). 
 
 Landmarks. — Determined by circumstances of particular case and by 
 general cranio-cerebral topography. Site of hemorrhage may be determined 
 by external injury or by localization symptoms. 
 
 Incision. — As for trephining or osteoplastic resection (according to size 
 of opening required), and placed in accordance with nature of case. 
 
 Operation. — (I) Having exposed the area involved, either by a trephine- 
 opening or osteoplastic section (the steps of the operation up to this point 
 1 icing, in all essential features, those of one or the other of these procedures), 
 the site of the blood-clot, if any, is located and the source of the hemorrhage 
 traced. (2) The clot is carefully turned out with such an instrument a- the 
 handle of a thin silver spoon — the bleeding vessel is sought and doubly ligated 
 with gut. The dura must, of course, be opened if hemorrhage be subdural 
 — and it is even best to open it though hemorrhage appear to be only epidural, 
 for the sake of verification. Where the hemorrhage comes from the middle 
 cerebral an attempt should be cautiously made, when possible, to reach the 
 site of hemorrhage, by carefully separating the lips of the sylvian fissure 
 and doubly tying the artery with gut. If site of hemorrhage cannot be 
 accuratelv ascertained and still continues, all that can be done is to carefully 
 pack the region with gauze. (3) Finally, carefully irrigate with warm normal 
 
5^6 OPERATIONS UPON THE HEAD. 
 
 salt solution (except where packing is used) — drain if necessary — closing 
 wound as after simple trephining or osteoplastic resection. 
 
 Comment. — If no accurate data lead to source of hemorrhage, it is best 
 to seek first in the position of the anterior branch of middle meningeal artery 
 - — then in the position of the posterior branch. 
 
 LIGATION OF TRUNK OF MIDDLE MENINGEAL ARTERY. 
 See under Ligation of Arteries (page 47). 
 
 LIGATION OF ANTERIOR BRANCH OF MIDDLE MENINGEAL ARTERY. 
 See under Ligation of Arteries (page 48). 
 
 LIGATION OF POSTERIOR BRANCH OF MIDDLE MENINGEAL 
 
 ARTERY. 
 
 See under Ligation of Arteries (page 49). 
 
 LIGATION OF LONGITUDINAL OR LATERAL SINUS. 
 
 Description. — The longitudinal and lateral sinuses are sometimes 
 accidentally injured in operation, or otherwise, or lie directly in the course 
 of some operation — under which circumstances it becomes necessary to 
 control hemorrhage from them, which, when possible, should be done by 
 ligation. (See Figs. 471 and 472.) 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Determined by site of sinus involved. 
 
 Incision. — Often determined by a preceding injury or local condition 
 — or circumstances calling for ligation may accidentally arise during the 
 course of some other cranio-cerebral operation. If deliberately planned to 
 tie the longitudinal or lateral sinus in the path of an operation (as, for example, 
 preliminarily to exposing a surface of brain more or less covered by a sinus), 
 two small trephine-openings are made on either side and very near the borders 
 of the sinus, after having exposed the site of both trephine-openings by turning 
 back a single oval flap. For course and deviations of the sinuses, see Surgical 
 Anatomy of the Cranio-cerebral Region (page 536). 
 
 Operation. — (1) Complete the operation, up to the removal of the two 
 buttons of bone, as an ordinary trephining. (2) The dura and, with it, the 
 sinus are detached from the cranium by passing a dural separator between 
 the bone and dura, from one to the other of these two small trephine-openings 
 immediately adjacent to the outer borders of the sinus. The bridge-work 
 of bone between the two openings is then cut away, preferably with Gigli saw 
 (cutting pliers or rongeur forceps). A limited longitudinal incision of the 
 dura is made safely to the outer aspect of each side of the sinus, which enables 
 a more intelligent and safer passage of the ligature than if it were simply 
 carried blindly beneath the supposed lower limit of the sinus. The sinus is 
 thereby fully exposed and is doubly ligated transversely with chromic gut, by 
 passing a fully curved needle beneath the sinus and through the falx cerebri, 
 and divided between the ligatures. If the sinus be wounded to a limited 
 degree, it is often possible to either laterally ligate the rent, or suture \t — as 
 described under the ligation of veins. (3) The operation is completed as 
 indicated by the special circumstances attending it — the button of bone 
 
LIGATION OF LONGITUDINAL OR LATERAL SINUS. 
 
 53; 
 
 being replaced, or nut, according to the judgment of the operator. Drain- 
 age would be used or not, as indicated (generally not, if all bleeding be con- 
 trolled and wound be clean). The flap of soft parts is sutured into place. 
 
 litis. 471 and 472.— Ligation of the Longitudinal Sinus : — A, Exposure of longitudinal sinus 
 by means of two trephine-openings on either side, followed by cutting away the intervening bridge of 
 bone; B. Scalp-flap turned back; C, Two trephine-openings made near the outer borders of the 
 longitudinal sinus, with intervening bone cut away; D, Incisions through dura, on either side of 
 sinus, for passage of needle and ligature ; E, Longitudinal sinus ; F, Cross-section of head, showing 
 position of sinuses. 
 
588 OPERATIONS UPON THE HEAD. 
 
 OPERATION FOR THROMBOSIS OF LATERAL SINUS. 
 
 Description. — As a result of otitis media, the adjacent sigmoid and 
 transverse portions of the lateral sinus frequently become infected and undergo 
 sinus phlebitis and thrombosis, requiring their exposure, the removal of 
 thrombosed contents and their obliteration by ligature or otherwise. The 
 operation is intimately connected with that for the exposure of the mastoid 
 
 Fig. 473. — Operation for Infection and Thrombosis of the Lateral Sinus and 
 Internal Jugular Vein: — I. — The lateral sinus and membranes of the brain exposed through 
 a chiselled opening in the skull. The internal jugular vein exposed in the neck and doubly 
 ligated. 
 
 antrum and cells, which should be reviewed in this connection (pages 600- 
 608). The internal jugular vein may also be involved and require exposing. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Lines for sigmoid and transverse portions of the lateral 
 sinus. (See Surgical Anatomy, pages 536 and 542, and also Fig. 479, L M.) 
 
OPERATION FOR THROMBOSIS OF LATERAL SINUS. 
 
 589 
 
 Incision. — Where this sinus, at junction of transverse and sigmoid 
 portions, is independently exposed, a horseshoe flap is turned down, with 
 pedicle below, so planned as to expose an area with its center about 2.5 cm. 
 (1 inch) behind and 6 mm. (\ inch) above the center of the external auditory 
 meatus. Where the opening-up of the neighboring sinus is simply a con- 
 tinuation of the mastoid operation (which is usually the case) the incision 
 for the exposure of the sinus is prolonged from the original incision. 
 
 Fig. 474. — Operation* for Infection and Thrombosis of the Lateral Sinus and 
 Internal Jugular Vein: — II. — The lateral sinus has been incised, the clot removed, its cere- 
 bral end packed with gauze, and its cervical end left open for irrigation. The internal jugular 
 vein has been ligated below the thrombosis and its upper end opened and brought out for drainage 
 through the otherwise closed wound in the neck. 
 
 Operation. — (1) Proceeding as in the operation of trephining, a trephine 
 having a diameter of about 2.5 cm. (1 inch) is applied over this center and a 
 button of bone carefully removed, without injury to dura and without pre- 
 mature opening of sinus (Figs. 415 and 473). Whatever additional room 
 
590 OPERATIONS UPON THE HEAD. 
 
 may be required can be gotten by biting out the circumference of the trephine- 
 opening by means of rongeur forceps. (2) Thrombosis having been deter- 
 mined by palpation and exploratory needle, the thrombosed sinus is now laid 
 open longitudinally and the contents carefully turned out with a special scoop, 
 as far as accessible in both directions, or until a patulous condition is reached, 
 when the flow is controlled by gut ligature of the sinus, if possible, or by gauze 
 packing. (3) The mastoid antrum and cells, the usual source of the original 
 infection, are generally opened up into continuity with the sinus by means of 
 a gouge, sharp spoon, or chisel. (4) The internal jugular vein is often exposed 
 in the neck (page 474), when found in a condition of thrombosis, and ligated. 
 The thrombosed vein may then be opened above the ligature and the vein 
 irrigated from the lateral sinus, and vice versa. (5) The wound is packed, 
 and closed only in part, room being left for drainage. 
 
 Comment. — If contents of lateral sinus be fluid, the sinus, if possible, 
 should be ligated prior to opening the thrombosed part. A firm, healthy 
 clot, about to undergo organization, may sometimes be left on the distal side 
 of a ligature. 
 
 TREPHINING FOR FRACTURE OF SKULL. 
 
 Description. — The seat of fracture is exposed, the depressed pieces of 
 bone are elevated to the common level, and any spicuke of bone which may 
 be exercising pressure upon the brain are removed. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Determined by the nature and site of the fracture ami 
 general cranio-cerebral topography. 
 
 Incision. — Where a skin wound exists, this is usually enlarged, or used 
 as a part of the incision for the exposure. Where the skin is unbroken, the 
 site of fracture is best exposed through a U-shaped flap, as in trephining. 
 
 Operation. — (1) The soft parts, including the periosteum, are turned 
 back, in the same manner as in trephining, and site of fracture thus exposed 
 — hemorrhage being controlled as in that operation. Even where the bones 
 of a depressed fracture can be raised by being levered back into position 
 without exposing the brain (which often can be done), it is always best to 
 expose the dura at least — and safer still to open the dura and examine the 
 surface of the underlying brain. (2) The following steps of the operation are 
 conducted very much as in ordinary trephining. The point of the trephine 
 is placed upon sound bone that will resist pressure, avoiding the site of vessels 
 and sinuses, and in a position from which the fractured bone can be best 
 raised — with the major portion of the circle (which should be from 1.2 to 
 1.8 cm., or \ to f inch) generally lying over sound bone, and the inner portion 
 overlapping or coming in line with the fractured margin. When the button 
 of bone is removed, if more room be needed, it can be gotten by biting out 
 portions of bone with rongeur forceps. (3) A blunt elevator (an osteotome 
 answers well) is now carefully inserted beneath the fractured bone, resting 
 upon the sound margin of bone, or upon an instrument or a finger stretched 
 across the area as a fulcrum, and the fractured bone levered back into place, 
 without disconnecting it from its natural attachments (Fig. 475). (4) Some- 
 times judicious use of chisel or saw will aid in freeing the fragments. All 
 sharp edges are rounded off. All pieces likely to become detached are removed. 
 (5) The dura, if deliberately opened by the operator, is repaired as after 
 
OPERATION FOR BULLET WOUND OF BRAIN. 
 
 591 
 
 trephining — if wounded by fragments, is repaired by catgut suturing as fully 
 as possible. (6) The manner of treating bone space left by trephining for 
 fracture is the same as after simple trephining. Drainage is used, if indicated 
 — and the wound entirely or partially closed in accordance. 
 
 Fig. 475. — Operations for Fractures of the Skull: — A, A loosened fragment of bone 
 being pried out by an instrument introduced beneath its border through a trephine-opening made 
 immediately adjacent to and continuous with one of the lines of fracture. B, Levering out a 
 bony fragment from an adjacent margin of sound bone as a fulcrum. C, The removal of a 
 fragment by means of bone-holding forceps. 
 
 OPERATION FOR BULLET WOUND OF BRAIN. 
 
 Description. — For the purpose of seeking the bullet, removing spiculas 
 of bone and foreign material, and for providing drainage. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Determined by position of wound and position of im- 
 portant underlying structures and areas. 
 
 Incision. — An oval (or reversed U-shaped) flap, with pedicle downward, 
 and center corresponding with wound. 
 
 Operation. — (1) The soft parts are incised to the bone, the vessels clamped 
 and tied, and the flap raised and turned back. If trephining were not con- 
 templated, the periosteum need not be raised with the flap — but as the use 
 
592 
 
 OPERATIONS UPON THE HEAD. 
 
 of the trephine or that of the rongeur is practically always indicated, the 
 bone should be completely bared. (2) Access to the brain may be gotten 
 by biting out the circumference of the wound-opening with rongeur forceps, 
 or, better, by trephining with a trephine whose diameter is sufficiently large 
 to make a cut extending around the wound 1.2 to 1.8 cm. (h to f inches), 
 according to accompanying circumstances, and with the precautions observed 
 in trephining for fracture (q. v.). All fragments of bone are removed or 
 elevated into position — and all foreign material is picked out with forceps 
 as encountered. (3) Having thus enlarged the bullet wound, the bullet is 
 sought along its track with such instruments as a long, delicate needle, Fluhrer's 
 
 Fig. 476. — Operations for Bullet-wounds of Skull and Brain : — Above, the bullet- 
 wound in the skull has been trephined and a button of bone, whose center is the bullet-hole, 
 is being removed. Below, the bullet-hole in the bone is being enlarged by biting out its mar- 
 gin with special rongeur forceps. 
 
 aluminium probe, or Girdner's telephone probe. If the bullet can be reached 
 with special forceps, it may be withdrawn by that means through the original 
 wound, especially if near it. If the bullet be near the far end of the wound- 
 track, it is generally more readily and safely removed through a counter- 
 opening. Such a counter-opening may be made at a point determined by 
 thrusting a probe along the track of the wound, directly in the line of the 
 bullet-track, to the inner wall of the opposite side of the skull — passing the 
 bullet if it lie on the way — followed by tying a piece of silk to the outer end 
 of the probe and carrying the silk across the shaved scalp at different points 
 
OPERATION FOR EXPOSURE OF A MOTOR CENTER. 593 
 
 upon its contour — the common point at which these lines all intersect will 
 indicate the point on the exterior of the skull opposite which the inner end 
 of the probe has come into contact with the inner wall of the skull. At this 
 point a trephine-opening is made. The counter-opening is made with a 
 trephine of 3.8 to 5 cm. (i^ to 2 inches) in diameter, as the bullet is apt to 
 lie an inch or more below the point of striking the inner wall, and room is 
 often necessary for manipulation and exploration. Upon a probe, a grooved 
 director is carried down to the bullet, and upon the director a pair of bullet- 
 forceps, with which the bullet is grasped and removed. When the region 
 does not admit of a counter-opening, as toward the base of the brain, the 
 bullet must be removed through a single opening. (4) Thorough drainage 
 may be instituted by drawing, upon a long probe, a few strands of silk, silk- 
 worm-gut, or rubber drainage-tube. (5) The wound is carefully irrigated, 
 and then closed up to the points of drainage. 
 
 Comment. — The bullet may sometimes be located by placing the patient 
 so that the bullet-track is vertical, and then letting the probe drop into the 
 wound as far as possible. It may also sometimes be located by means of 
 x-ray shadows taken in two directions. 
 
 OPERATION FOR EXPOSURE OF A MOTOR CENTER. 
 
 (ILLUSTRATED BY OPERATION FOR FOCAL EPILEPSY.) 
 
 Description. — The operation performed for Focal Epilepsy consists in 
 the exposure of an area to which attention has been called by convulsive 
 movements beginning in those parts controlled by that area — or in connection 
 with which some. injury has been received — the object being to remove the 
 source of irritation, which may be some form of pressure or an adhesion, or 
 a part of the motor center itself may be removed to a limited extent — the area 
 usually being exposed by trephining. It will be supposed, in the present 
 case, that the epileptic seizures are preceded by muscular twitchings of the 
 muscles of the right fingers, hand and forearm. The exposure of the cortical 
 center presiding over these structures will be indicated, namely, the lower 
 posterior part of the middle third of the sensori-motor area of the left side. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554 1. 
 
 Landmarks. — Site of the motor center (here, for example, the center 
 for the right fingers, hand and forearm) is determined by some form of local- 
 ization method (in this instance, by Chipault's method, page 546). 
 
 Incision. — An oval flap (U-shaped), with convexity above and base 
 below, is outlined, having its center about 1 cm. (f inch) posterior to the 
 junction of the lower third and fourth tenths of Chipault's rolandic line 
 (see Chipault's method). For the bone-section, a trephine of at least 3.8, 
 cm. (ij inches) should be used. 
 
 Operation. — (1) The steps of the operation, up to the removal of the 
 button of bone, are the same as for trephining. (2) Open the aura in the 
 form of a small flap, as heretofore described. As soon as the brain is exposed 
 carefully examine for abnormal adhesions between dura and brain, and, if 
 detected, free by cautiously sweeping a bent probe between these structures. 
 If bony growths be found pressing upon brain, remove them by bone-section. 
 (3) If part of a motor center is to be removed, incise the brain substance 
 38 
 
594 OPERATIONS UPON THE HEAD. 
 
 in the direction of the commissural fibers, making the incision carefully with 
 delicate knife or scissors. (4) Tie all bleeding meningeal and cerebral vessels 
 with fine gut — dividing them in advance, where possible, between double 
 ligatures. Harm pia mater as little as possible, and replace if pushed aside. 
 (5) To avoid readhesion, if previous adhesion existed, or to avoid new adhe- 
 sion, plates of very thin celluloid, gold leaf, gutta-percha, decalcified bone- 
 plate, india-rubber, etc., are sometimes placed over the pia mater. (6) The 
 dura is carefully sutured with fine gut. The button of bone is replaced or 
 not, according to the surgeon's judgment. The scalp-flap is sutured, without 
 drainage, and speedy union especially sought. 
 
 PUNCTURE AND DRAINAGE OF LATERAL VENTRICLES. 
 
 Description. — Puncture of the lateral ventricle and withdrawal of cerebro- 
 spinal fluid by aspiration, simple drainage by cannula, or by capillary drainage. 
 Indications; acute hydrocephalus (to withdraw excess of fluid and relieve 
 tension) ; chronic hydrocephalus (to withdraw excess of fluid and relieve 
 tension, or to inject medicated fluid); meningitis (for drainage). 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Junction of the third and fourth tenths of Chipault's 
 temporo-sphenoidal line represents the posterior part of the body of the 
 lateral ventricle. (For this, as well as for the descending and posterior 
 horns, see Chipault's Cranio-cerebral Localization Method, page 548.) 
 
 Incision. — An oval or inverted U-shaped flap with its center at the above 
 point is outlined. The bone-section should be made by a trephine of at 
 least 2.5 cm. (1 inch) in diameter. 
 
 Operation. — (1) Having made and turned down the flap of soft parts — 
 controlled hemorrhage by clamps and ligature — applied trephine and removed 
 disc of bone — the dura is exposed and a small dural flap turned down. (2) 
 The needle of the aspiratory syringe, or trocar and cannula, is then thrust 
 directly into the substance of the brain, opposite the point indicated above, 
 avoiding all visible vessels — and is made to penetrate horizontally inward for 
 one-third of the transverse diameter of the brain itself (as determined after 
 subtracting the thickness of the scalp and skull of both sides from the total 
 thickness of the head on the line of puncture). (See Chipault's Method, Other 
 Points and Lines, page 547 .) Through the needle (or cannula) introduced fluid 
 is withdrawn. (3) Subsequently, before withdrawal of instrument, medicated 
 fluid may be injected, if indicated. Where it is desired to introduce drain- 
 age, silk, silkworm-gut, wick, gauze, or a drainage-tube may be introduced 
 through the cannula, if a trocar and cannula have been used — or by means of 
 special forceps alongside an ordinary aspiratory needle before its withdrawal. 
 (4) If no drainage be instituted, the wound is closed as after simple 
 trephining. If drainage be used, the dura and soft parts are only partially 
 sutured, and the button of bone is either not returned, or only a part of it 
 is returned. 
 
 Comment. — While it is more satisfactory to open the dura, thus exposing 
 the condition of the brain and the position of the vessels, yet where drainage 
 is not indicated, the lateral ventricles may be aspirated through the unopened 
 dura. 
 
OPERATION FOR CEREBRAL ABSCESS. 595 
 
 INCISION OF THE CEREBELLAR SUBARACHNOID SPACE FOR 
 
 DRAINAGE. 
 
 PARKINS OPERATION. 
 
 Description. — The exposure, by trephine, of the membranes in the 
 cerebellar fossa, followed by the incision of the subarachnoid space below 
 the tentorium cerebelli. Sometimes performed for the relief of intracranial 
 pressure by dependent drainage of the cerebrospinal fluid in acute and chronic 
 meningitis and in hydrocephalus. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — Lines of lateral and occipital sinuses. 
 
 Incision. — An oval (or reversed U-shaped) flap is outlined, with con- 
 vexity upward and base downward toward the neck, and its center over the 
 center of the right or left cerebellar fossa. 
 
 Operation. — (I) The incision outlining the above flap is carried to the 
 bone, the vertical portions of the incision passing, at this site, through con- 
 siderable thickness of muscular tissue, and rather free bleeding may occur. 
 All vessels are clamped and tied with catgut. The flap is retracted down- 
 ward and the occipital bone exposed. (2) A trephine of about 1.2 cm. (1 
 inch) diameter is so applied as to be safely below the lateral sinus, and safely 
 to the outer side of the occipital sinus, and away from the thickness of the 
 external occipital protuberance. The button of bone thus defined is removed, 
 and the dura exposed. (3) The dura is seized with delicate forceps and 
 incised with knife or scissors sufficiently to make a satisfactory opening for 
 drainage — and the subarachnoid space thus entered. (4) Drainage is accom- 
 plished by strands of silk, silkworm-gut, wick, gauze, or tubing. (5) The 
 button of bone is not returned. The wound is sutured in part, leaving open 
 only enough space for drainage. 
 
 OPERATION FOR CEREBRAL ABSCESS. 
 
 Description. — Intracranial abscess may be extradural or intracerebral. 
 The site of abscess (when not directly traceable to an evident cause) is deter- 
 mined, in conjunction with constitutional symptoms, by local compression 
 symptoms referable to the part of the brain pressed upon by the collection 
 of pus — and the operation is done over that area determined by these symp- 
 toms. 
 
 The most frequent causes of cerebral abscess are otitis media, first of 
 all, and conditions of suppuration in the orbital and nasal cavities. Abscess 
 occurs more frequently on the right side. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — The site of abscess, if not otherwise fixed, is determined 
 by pressure symptoms, and localized by known position of center pressed 
 upon. 
 
 Incision. — An oval (or reversed U-shaped) flap is outlined for the appli- 
 cation of a trephine of about 3.8 cm. (1^ inches) diameter — the center of 
 the trephine to be placed over the site determined as above described. A 
 
596 OPERATIONS UPON THE HEAD. 
 
 trephine-opening will generally suffice, though an osteoplastic (lap is some- 
 times raised. (See Comment.) 
 
 Operation. — (1) The ordinary steps of a trephining (or the raising of 
 an osteoplastic flap) are carried out, up to the exposure of the dura. (2) 
 If an abscess be found between the cranium and dura, it is evacuated (pro- 
 tecting the diploe as much as possible), irrigated, and loosely packed with 
 gauze, a portion of the gauze serving as a drain. The scalp-flap is sutured 
 back in place throughout its greater part, room being left for drain. The but- 
 ton of bone is usually not replaced — if used at all, only a part of the button 
 is returned, the rest being bitten off for drain-opening. (3) If pus be not 
 thus found outside of dura, a flap of dura is raised, as in trephining, and the 
 brain exposed and explored in various directions with a needle (see Exploratory 
 Puncture of the Brain, page 584). Wherever found, especially if deep, the 
 needle is left in situ and serves as a guide. The dura over the site is divided 
 by a crucial incision (to provide free exit), a linear incision tending to close. 
 If dura be divided before the presence of abscess is assured, a straight inci- 
 sion of the membrane is made, admitting of subsequent suture if indicated. 
 Before freeing the pus, the cut diploe should be protected from infection as 
 well as possible, by a strip of thin rubber tissue, or by smearing the bone- 
 section with sterile vaseline. The abscess cavity may be cut into by a punc- 
 ture-like thrust of a knife — or, probably better, a pair of special forceps 
 (or ordinary dressing forceps) may be inserted closed, guided by the needle 
 left in situ, and then opened to a limited extent, allowing the pus to drain 
 along the handles, or a grooved director may be used. Two parallel pieces 
 of small-calibered rubber drainage-tubes are then inserted, one serving for 
 inflow of irrigant, the other for the outflow of pus — the tubes being held 
 in place by transfixing them with a safety-pin resting upon the gauze which 
 has been packed around them. (4) The dural and scalp flaps are partly 
 sutured into place, leaving room for drainage. 
 
 Comment. — As the most general cause of cerebral abscess is otitis media, 
 the most usual site for the abscess is in the temporo-sphenoidal lobe, in the 
 middle fossa of the skull, adjacent to the antero-superior aspect of the petrous 
 portion of the temporal bone — and the landmark for the operation is, there- 
 fore, generally taken as a point 1.8 to 2.5 cm. (f to 1 inch) above Reid's 
 base-line (see Reid's Method of Cranio-cerebral Localization, page 551, 
 also Fig. 415, S), on a line drawn vertically upward along the posterior border 
 of the external auditory meatus, at right angle to the base-line — and this 
 point is used as the point at which first to explore, where uncertainty exists. 
 This site having been exposed, if evidence of pus be not found, explore with 
 needle, of fair calibre, and preferably first through the unopened dura — 
 first inward, forward, and downward toward the apex of the petrous por- 
 tion of the temporal — then upward and forward, and backward and inward, 
 and in other directions — but guarding the basal ganglia and the petrosal 
 sinuses. When pus is located, the dura is always incised. 
 
 OPERATION FOR CEREBELLAR ABSCESS. 
 
 Description. — Like cerebral abscess, cerebellar abscess may be extra- 
 dural or intracerebellar. As the cause of abscess is generally, as in the case 
 of the cerebrum, otitis media, the abscess is usually found in the vicinity 
 
OPERATION FOR CEREBRAL TUMOR. 592 
 
 of the posterior or postero-superior aspect of the petrous portion of the 
 temporal bone. The site is usually exposed by a trephine-opening. 
 
 Preparation and Position. — See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks. — The external auditory meatus and the lines of the sigmoid 
 and transverse portions of the lateral sinus. 
 
 Incision. — Draw a line from the external occipital protuberance to the 
 center of the external auditory meatus. To allow for an unusually low trans- 
 verse portion of lateral sinus, trephine 1 cm. (fy- inch) below this line. And 
 to avoid the sigmoid portion of the lateral sinus, and also the occipital artery 
 trephine posterior to a vertical line placed 3.5 cm. (if inches) behind the 
 center of the external auditory meatus. Outline an oval (or reversed U- 
 shaped) flap with its center calculated to be over the center of the above 
 indicated area — the limbs of the incision running well into the neck, as 
 the occipital fossa is to be opened below the nuchal furrow. 
 
 Operation. — (1) Carry the incision outlining the flap to the bone — 
 control hemorrhage, which is apt to be marked, by clamp and ligature. 
 Retract this thick muscular flap downward, exposing the occipital bone 
 below the superior curved line. (2) Apply, in the site indicated under 
 Incision, a trephine of at least 2.5 cm. (1 inch) diameter and remove the 
 button of bone, exposing the cerebellar dura. (3) The abscess is now sought 
 in a direction forward, upward, and outward; or forward, upward, and 
 inward, in the same general manner as in cerebral abscess — and, if found, 
 dealt with in the same fashion — and the wound finally similarly treated. 
 
 Comment. — Cerebellar abscess is often encountered, when it exists, in 
 the course of an operation upon the mastoid region — during an operation 
 where the inner wall of the mastoid process has been exposed and removed, 
 laving bare the lateral sinus and the dura anterior and posterior to it. Where 
 the abscess follows disease of the inner mastoid wall, it generally lies behind 
 the lateral sinus and in contact with the involved bone. Where the abscess 
 is connected with involvement of the labyrinth, it lies in front of the lateral 
 sinus and in connection with the internal meatus or vestibular aqueduct. 
 A fistula generally leads from the diseased bone to the abscess. 
 
 OPERATION FOR CEREBRAL TUMOR. 
 
 Description. — Removal, en masse, of growths from surface or interior 
 of brain. Those involving the basal ganglia, internal capsule, and base of 
 brain generallv, are inoperable. 
 
 Preparation and Position.— See General Surgical Considerations in 
 Cranio-cerebral Operations (page 554). 
 
 Landmarks.— Site of tumor will have been determined by localization 
 symptoms — and site of operation determined accordingly. 
 
 Incision. — Amount of room required for recognition and removal of 
 tumor generallv necessitates an osteoplastic resection of the skull, which 
 should be planned with reference to the particular case. Or the overlying 
 bone may be totally and permanently removed by making several small 
 trephine-openings and connecting these — or a large trephine may be first 
 used and the margins of the resulting opening bitten out with rongeurs as 
 far as necessarv— in either of which cases a horseshoe flap of soft parts is 
 temporarily turned down and then replaced. 
 
59§ 
 
 OPERATIONS UPON THE HEAD. 
 
 Operation. — (i) The steps of the operation, up to the exposure of the 
 dura, are the same as for osteoplastic resection of the skull, hemorrhage 
 being controlled as during that operation. (2) The dural flap is turned 
 back as in osteoplastic resection. The pia mater is divided in the direction 
 of the length of the tumor — hemorrhage from the pia being controlled by 
 slight tension upon it or by ligature en masse. (3) The situation and extent 
 
 Fig. 477. — Removal of a Cerebral Tumor through an Osteoplastic Exposure: — 
 The outlying area has been previously ligatured off by the needle and ligature seen dipping deeply 
 beneath a cerebral vessel into the brain substance. The tumor is shown partly separated by a 
 special spoon. 
 
 of the tumor are now determined by palpation and exploration. (4) Having 
 reasonably settled both of these questions, the tumor is to be excised. The 
 incision into the brain substance is begun, where possible, at the apex of a 
 convolution and is made in the direction of its commissural fibers — and 
 rather over a convolution than over a sulcus, as there is less hemorrhage. 
 A special spoon may also be used (Fig. 477). If the tumor be encapsulated, 
 
OPERATIONS UPON THE GASSERIAN GANGLION. 599 
 
 divide the overlying brain and gently retract the cerebral substance, cutting 
 from above downward, and enucleate with a spoon. If the tumor lie beneath 
 the surface but not encapsulated, isolate by carefully incising its connections 
 and enucleating with such an instrument as the curved handle of a thin silver 
 spoon. Cystic tumors sometimes only admit of draining, cauterizing, and 
 packing. (5) The cavity left is lightly packed with gauze if bleeding occurs. 
 Where possible, the brain incision is closed with catgut, with or without drain- 
 age, as indicated. The dura is sutured. Celluloid or metallic plates are some- 
 times used to reinforce the opening. The osteoplastic flap or flap of soft 
 parts, according to method of exposure used, is sutured into place, as in the 
 osteoplastic resection or trephining operation respectively. 
 
 Comment. — If working in the motor area, use of the faradic electrode 
 mav corroborate diagnosis. 
 
 OPERATION FOR CEREBELLAR TUMOR. 
 
 Description. — The operation is similar to that for cerebral tumor, in 
 essential details — with the following modifications (chiefly from the greater 
 inaccessibility of the cerebellum) : — (a) A horseshoe flap of soft parts alone 
 may be used, with its base toward the neck — or an osteoplastic flap may be 
 raised: — (b) In the former case, the opening in the bone is made with a 
 trephine of as large a diameter as feasible, and is enlarged, if necessary, by 
 biting out its circumference with rongeurs. Thinness of the occipital fossa^; 
 nearness of the sinuses of the occipital bone and proximity of the foramen 
 magnum require especial care, and make the osteoplastic method especially 
 difficult. 
 
 OPERATIONS UPON THE MASTOID ANTRUM AND CELLS. 
 
 See under Operations upon the Bony (Air) Sinuses of Head and Face 
 (page 600). 
 
 OPERATIONS UPON THE GASSERIAN GANGLION. 
 
 See under Operations upon the Nerves, Plexuses, and Ganglia (pages 
 175 and 181). 
 
6oo 
 
 OPERATIONS UPON THE HEAD. 
 
 II. THE BONY (AIR) SINUSES OF THE HEAD AND FACE.* 
 
 OPERATIONS UPON THE MASTOID ANTRUM AND CELLS. 
 
 SURGICAL ANATOMY OF MASTOID ANTRUM AND CELLS. 
 
 Muscles of the Mastoid Region. — Retrahens aurem; occipitofrontalis; 
 sternomastoid; splenius capitis; trachelomastoid ; digastric. 
 
 Fig. 478.— Surgical Anatomy of Middle Ear and Mastoid Region :— With membrana tym- 
 pani removed and four windows chiseled into mastoid process : A, Pinna of ear stitched to cheek ; B, 
 Curved incision of exposure, back of ear ; C, Soft external auditory canal; D, Temporal fascia ; E, 
 Mastoid cells ; F, Mastoid antrum ; G, Lateral sinus ; H, Suprameatal spine ; I, Bony plate covering 
 facial nerve ; J, Promontory and fenestrum rotundum ; K, Malleus ; L, Incus ; M, Stapedius muscle ; 
 N, Tensor tympani muscle ; O, Chorda tympani nerve. (From drawing made from cadaver, in De- 
 partment of Operative Surgery, College of Physicians and Surgeons, by Dr. A. E. Schmitt.) 
 
 Arteries of the Mastoid Region. — Posterior auricular and occipital 
 branches of external carotid. 
 
 Veins of the Mastoid Region. — Posterior auricular (emptying into 
 temporomaxillary vein); occipital (emptying into internal jugular). 
 
 * Among the Bony (Air) Sinuses of the Head and Face, will be considered the Mastoid 
 Antrum and Cells, the Frontal Sinus and the Maxillary Sinus — the Ethmoidal and Sphe- 
 noidal Sinuses more properly belonging to the special surgery of the Nose. 
 
SURGICAL ANATOMY OF MASTOID ANTRUM AND CELLS. 
 
 601 
 
 Nerves of the Mastoid Region. — Posterior auricular branch of facial; 
 auricularis magnus from cervical plexus; occipitalis minor from cervical 
 plexus; auricular branch of occipitalis major; external branch of posterior 
 division of second cervical nerve. 
 
 Mastoid Antrum. — A retort-shaped cavity situated in mastoid portion 
 of temporal bone, communicating with mastoid cells posteriorlv, and opening, 
 anteriorly, through aditus ad antrum, into highest part of tvmpanic cavity, 
 the epitympanic recess (attic of tympanum), thereby communicating with 
 eustachian tube. The epitympanic recess lies above the anterior three- 
 fourths of the orifice of the opening of the antrum into tvmpanic cavity. 
 The floor of antrum lies below the level of the entrance into antrum, generally 
 
 Fig. 479— Surgical Anatomy of Mastoid Region and Middle Ear :— With membrana tym- 
 pani removed ; mastoid cells, mastoid antrum, and lateral sinus exposed ; and trephine disc removed 
 just above temporal crest and ear ; A, Soft auditory canal in turned-back ear ; B, Temporal muscle; 
 C, Temporal crest ; D, Horizontal semicircular canal ; E, Promontory ; F, Fenestrum rotundum ; G, 
 Stapes; H, Facial nerve; I, Mastoid cells ; J, Arrow passing from attic to antrum, along aditus ad 
 antrum; K, Trephine-opening exposing posterior branch of middle meningeal artery; L, Horizontal 
 limb of lateral sinus ; M, Descending limb of lateral sinus ; N, Beginning of internal limb of lateral 
 sinus ; O, Opening of opposite lateral siuns ; P, Opening of longitudinal sinus ; Q, Opening of superior 
 petrosal sinus ; R. Mastoid foramen. ( From drawing made from cadaver, in Department of Operative 
 Surgery. College oi Physicians and Surgeons, by Dr. A. E. Schmitt.) 
 
 corresponding with level of center of auditory meatus, or even higher. The 
 communication between antrum and epitympanic recess is triangular in 
 shape, with base upward and rounded angle below; its lower portion being 
 on level with superior wall of external auditory meatus; its measurement 
 being about 4 mm. ( T \ inch) both transversely and vertically. The antrum 
 lies from 7 to 14 mm. (y\- to ^g- inch) from surface of mastoid bone; and 
 from 7 to 12 mm. ( T \ to T 8 g inch) behind superior posterior margin of tympanic 
 ring — the outer portion of overlying bone being hard, the inner portion more 
 spongy. The antrum measures, longitudinally, 10 to 15 mm. ( T 6 g to T f inch) ; 
 vertically, 10 mm. (y 6 ^ inch); transversely, 4 to 6 mm. (f\ to T \ inch). In 
 infancy and childhood the antrum is nearly full size, but the mastoid cells 
 rarely develop before twelve years of age. The overlying bone is relatively 
 thin in the young. 
 
602 
 
 OPERATIONS UPON THE HEAD. 
 
 Mastoid Cells. — Situated within mastoid process of temporal bone; 
 opening, anteriorly, into mastoid antrum; and extending, postero-inferiorly, 
 sometimes to tip of mastoid process. 
 
 Relations of Mastoid Antrum. — (I) Superiorly; antrum is separated 
 from middle cranial fossa of skull by a thin, bony plate, the tegmen tympani, 
 sometimes partially deficient, a fibrous membrane and vascular tissue then 
 intervening. Roof of antrum generally corresponds to supramastoid crest, 
 though sometimes being upon a higher level than crest, in which latter cases 
 the inferior temporal convolution of the cerebral hemisphere may overlap 
 upper part of antrum. (2) Inferiorly; floor of antrum is formed by mastoid 
 portion of petrosal bone. (3) Anteriorly; a thin wall of bone comes between 
 antrum and deep portion of auditory meatus. (4) Posteriorly, extends 
 backward and outward, lying nearer surface posteriorly than anteriorly, 
 approaching sigmoid portion of lateral sinus, sometimes but a thin bony 
 lamina intervening, though distance between the two generally averaging 
 5 to 10 mm. ( T 3 g- to j's inch) and usually consisting of mastoid cells; the lateral 
 sinus ordinarily lying nearer the surface than the antrum. (5) Externally; 
 outer wall is formed by squamous portion of temporal below supramastoid 
 crest. (Figs. 478 and 479.) 
 
 Fig. 480. — Incision for Exposing the Antrum and Mastoid Cells and the Neighbor- 
 ing Intracranial Structures: — B D, Incision for exposing mastoid antrum and cells (antrum 
 operation of Schwartze); B A and B E, Incisions for exposing brain abscess; C F, Incisions for 
 exposing lateral sinus; G H, Incision for tympano-mastoid exenteration (radical operation of 
 Schvvartze-Stacke); L, Auricle drawn forward; I, Suprameatal crest; J, Suprameatal spine; 
 K, Position of mastoid antrum; M, Lateral sinus; N, Occipital artery. 
 
 SURFACE FORM AND LANDMARKS OF MASTOID ANTRUM AND 
 
 CELLS. 
 
 External auditory meatus — varying in shape, size, and in the direction 
 of its longest diameter. Separated from mastoid process by the concha 
 of the ear. 
 
 External auditory canal — corresponds with general direction of approach 
 to antrum through mastoid process. 
 
 Mastoid process of temporal bone — contour generally capable of being 
 outlined through the skin. 
 
SURGICAL CONSIDERATIONS IN MASTOID OPERATIONS. 603 
 
 Supramastoid crest (linea temporalis) — continuation of zygomatic ridge 
 backward. 
 
 Suprameatal triangle — site of approach to mastoid antrum; having follow- 
 ing boundaries; Superiorly, supramastoid crest; Inferiorly and Anteriorly, 
 outer margin of posterior superior quadrant of bony external auditory meatus; 
 Posteriorly, vertical line drawn upward along most posterior margin of bony 
 external auditory meatus. (Fig. 480.) 
 
 Suprameatal fossa (fossa mastoidea) — depression in upper posterior angle 
 of suprameatal triangle. 
 
 Suprameatal spine — crest of bone separating suprameatal fossa from 
 external auditory meatus. 
 
 Suprameatal line — line continuing level of suprameatal spine backward. 
 
 Remains of masto-squamosal suture — sometimes exists, with small canals 
 occupied by connective tissue and veins. 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON MAS- 
 TOID ANTRUM AND CELLS. 
 
 Site and Direction of Operation for Opening Antrum. — (i) Site lies 
 in suprameatal fossa, directly within suprameatal triangle, or immediately 
 behind it. This generally brings upper edge of opening about 3 mm. (y% 
 inch) below suprameatal line, and about 5 mm. ( T 3 g- inch) behind bony external 
 auditory meatus. (2) Direction of opening passes inward and slightly upward 
 and forward, following general direction of bony external auditory canal. 
 This will open into anterior part of antrum, at distance of from 7 to 14 mm. 
 (tV t° tV inch) (extremes, especially in disease, from 3 to 18 mm., or -f^ to Cl- 
 inch) from surface of mastoid process. 
 
 General Precautions in Operating. — (i) Keep below supramastoid 
 crest — to avoid middle cerebral fossa of skull. Middle cranial fossa some- 
 times dips down to quite a low level between petrous and squamous portions 
 of temporal bone, and the roof of antrum and tympanum form part of floor 
 of this fossa. The level of floor of fossa may vary as much as 2 cm. (-^-f inch) 
 but is never as much as 1 cm. (f^ inch) below supramastoid crest. Where 
 supramastoid crest cannot be felt, keep 3 mm. ( T 2 g- inch) below horizontal 
 line running backward from upper edge of bony external auditory meatus, 
 in order to avoid middle fossa. To further avoid the possibility of entering 
 middle cranial fossa, make opening at first directly inward, penetrating from 
 5 to 8 mm. (y 3 g- to j\ inch) before taking an upward direction. (2) Do not 
 go more than 2 mm. (between T V and T 2 g- inch) behind posterior limit of 
 suprameatal triangle — to avoid lateral sinus. (3) Check instrument as soon 
 as antrum is entered — to avoid external semicircular canal and facial nerve. 
 
 Special Structures to be Avoided. — (i) At inferior aspect of entrance 
 into antrum, inner wall of antrum bulges slightly over external semicircular 
 canal, which lies on median side of aditus, superior to and separated from 
 fallopian canal by thin lamina of bone. It may form the antero-median 
 wall of antrum, if it project backward. To avoid injury to external semi- 
 circular canal, check instrument as soon as cavity of antrum is reached. 
 The inner wall of antrum lies about 17 to 20 mm. (y^- to T § inch) from surface 
 of mastoid. (2) On inner side of epitympanic recess, inferiorly and anteriorly 
 to the bulging marking external semicircular canal, is the arching osseous 
 
604 OPERATIONS UPON THE HEAD. 
 
 canal of the facial nerve. The wall toward antrum is thin and partly wanting. 
 Avoid facial nerve by not directing the opening too far forward. The per- 
 pendicular portion of fallopian canal, with contained nerve, may be 3 mm. 
 (A- inch) internal to posterior periphery of ear-drum, or its position may be 
 almost immediately opposite this posterior periphery. (3) Between external 
 semicircular canal anteriorly, and lateral sinus posteriorly, the air-cells are 
 separated from posterior fossa of skull by bony wall from 1 to 9 mm. (from 
 less than yg- to T 6 g- inch) thick. (4) Extreme curvature of sigmoid portion 
 of lateral sinus may occur. 'Where this exists, the sigmoid sinus may be in 
 almost direct contact with outer cortex of mastoid, and it may come to within 
 3 mm. (3% inch) of posterior wall of bony auditory meatus. As its course 
 cannot be known in advance, it is best avoided by careful use of gouge or 
 chisel (which are preferable to all instruments which approach by boring 
 their way). 
 
 Manner of Making Bone-section. — Bone is divided either by chisels 
 and mallet, aided by hand gouges and curettes; or by a burr driven by an 
 engine or worked by hand, followed by use of gouges and curettes. 
 
 INSTRUMENTS. 
 
 (i) For incision and repair of soft parts, see instruments used in cranio- 
 cerebral operations (page 557). (2) Special instruments used upon mastoid 
 process, auditory canal, and tympanic cavity, are the following: small mallet; 
 chisels; gouges; guard for gouge; scoops; curettes; elevators; small trephine; 
 forceps; burr driven by hand or by engine; bradawl; two or three centi- 
 meters of a metallic millimeter measure. (3) Special instruments for intra- 
 tympanic work; straight and angled knives; tenotomy knives; synechia knives; 
 ear-drum knives; incus hooks; fine forceps. 
 
 OPERATION FOR EXPOSING MASTOID ANTRUM AND CELLS. 
 
 ANTRUM OPERATION OF SCHWARTZE. 
 
 Description. — In this operation only the antrum and cells of the mastoid 
 process are opened up, without invading the cavity of the tympanum. Indi- 
 cated in such conditions as empyema, osteitis, or osteomyelitis occurring in 
 the mastoid process alone. In the following account the description of J. 
 Orne Green is largely followed. (See Fig. 481.) 
 
 Preparation. — The ear is irrigated with antiseptic solution and packed 
 with sterile cotton. The hair of the neighborhood is shaved, and the head 
 and neck enveloped in sterile dressings. 
 
 Position. — Patient rests upon side, with head elevated and so placed 
 upon its opposite side as to make mastoid region prominent, resting upon a 
 firm cushion to prevent jarring. Surgeon stands behind patient. Assistant 
 stands opposite and to one side of surgeon. 
 
 Landmarks. — External auditory meatus; supramastoid crest; mastoid 
 process. 
 
 Incision. — Slightly curvilinear, placed behind ear — beginning 1 cm. 
 ( T fi g- inch) above level of upper edge of auditory meatus and passing down- 
 ward at a distance of 0.5 to 1 cm. (yg- to T 6 T inch) behind insertion of auricle, 
 and ending at tip of mastoid process. (See Fig. 480, B, D.j 
 
ANTRIM OPERATION OF SCHWARTZE. 
 
 6o = 
 
 Operation. — (1) Incision passes through skin, overlying muscles, and peri- 
 osteum directly to bone (Fig. 481). (2) The soft parts are elevated from the 
 bone with periosteal elevator — anteriorly, until the supra meatal spine is ex- 
 posed — posteriorly, until the mastoid process is bared. (3) From the supra- 
 meatal spine, draw a line horizontally backward. Make an opening with its 
 upper edge 3 mm. (y 2 ^ inch) below this suprameatal line, and its anterior edge 
 5 mm. (y 3 ^ inch) behind the auditory meatus — which position will correspond 
 with the suprameatal fossa (fossa mastoidea) when that depression is suffi- 
 ciently marked for recognition. The area of operation, bounded as above, 
 will extend over a surface 7 to 10 mm. ( T 4 (T to T 6 -g inch) in diameter. (4) By 
 
 Fig. 48 1.— Exposure of Mastoid Antrum and Cells (Operation of Schwaktze j:— A, Auricle 
 drawn forward ; B, Mastoid antrum; C, Mastoid Cells ; D, Periosteum drawn aside; E, Sternomas- 
 toid muscle ; F, Temporal muscle ; G, Posterior branch of posterior auricular artery. 
 
 means of gouge and mallet the bone is removed in thin chips, always keeping 
 the process of excavation in a line parallel with the auditory canal. The 
 amount of bone to be removed varies from a thin lamina up to 1 cm. (j^ inch) 
 before the mastoid cells are reached. (5) As soon as the air-cells are opened, 
 explore with probe — upward, to locate the roof of the mastoid — inward and 
 backward, to locate the posterior fossa of the skull. (6) Break down the 
 intervening wall between the cells, working directly inward for 5 to 8 mm. 
 (f (T to y% inch). Thence work in a slightly upward and forward direction, 
 with curette, until the antrum is reached, at a distance from the surface of 
 7 to 14 mm. (y 4 ^- to y 9 ^- inch). The excavation should not extend beyond 14 
 or 15 mm. (y 9 -^ or T¥ inch) from the surface, which is as far as it is safe to 
 go. (7) Carious bone should be removed wherever found, even if it be neces- 
 sary to expose the dura — and whether the roof of the mastoid lie imme- 
 diately beneath the cerebrum; or the inner wall, with the lateral sinus and 
 cerebellum, lie just to the inner side. The dura is displaced with a dural 
 
606 OPERATIONS UPON THE HEAD. 
 
 separator and the bone is removed with a curette. (8) The interior of the 
 mastoid process must be dealt with according to indications. Pus should 
 be evacuated — granulations removed and cell-walls broken down. In in- 
 flamed diploe, the cancellated structure should be curetted away. In osteitis, 
 curette away softened bone short of harming the labyrinth and facial nerve. 
 The entire external aspect of the mastoid process may be removed to the tip 
 of the process. (9) In completing the operation, pack the cavity left in the 
 mastoid with gauze. Suture the periosteum partially, and the soft parts also 
 in part, leaving room for drainage. 
 
 Comment. — (i) Where the interior of the mastoid is partly or wholly 
 diploetic, proceed with greater care, using curette or hand gouge. Pass 
 directly inward parallel with auditory canal, for 5 to 8 mm. ( T \ to ^g- inch) — 
 if no air-cells are reached by this time, pass slightly forward, upward and 
 inward to the antrum — but do not go beyond 15 mm. ( T \- inch) from the 
 external surface of the anterior edge of the osseous opening, lest the facial 
 nerve or horizontal semicircular canal be injured. (2) In a mastoid affected 
 with osteosclerosis (from long suppuration or previous disease) the usual 
 landmarks, gotten with a probe as one advances, are not so available. Proceed 
 carefully in the same directions and for the same distances as in the diploetic 
 tissue just mentioned, but working with a chisel and mallet, instead of a 
 hand gouge. Diploetic bone may be met after passing through 7 to 10 mm. 
 (tit t0 tt m ch) of sclerosed bone. Sometimes, though rarely, the antrum may 
 be obliterated by osteosclerosis. (3) Where fistula? exist, these should be 
 exposed and followed up, rather than to make another opening through 
 healthy bone; or the fistulous tracks may be used in conjunction with the 
 ordinary opening. An externally placed fistula is exposed by reflecting the 
 periosteum from the external surface of the mastoid process. An anteriorly 
 placed fistula is exposed by reflecting the periosteum from the posterior wall 
 of the auditory canal. An inferiorly placed fistula is exposed by reflecting 
 the periosteum from the tip of the mastoid process, toward the digastric 
 groove. 
 
 OPERATION FOR EXPOSING MASTOID ANTRUM AND CELLS, TO- 
 GETHER WITH INTERIOR OF TYMPANUM AND MEATUS, 
 AND THE EXENTERATION OF THE MIDDLE- 
 EAR CAVITIES. 
 
 THE TYMPANOMASTOID EXENTERATION, OR RADICAL OPERATION, OF 
 SCHWARTZE-STACKE (OR SCHWARTZE-ZAUFAL). 
 
 Description. — This operation, much more extensive than the last, con- 
 sists in the opening up of the mastoid antrum, mastoid cells, tympanum, and 
 meatus, and of the complete exenteration (evisceration) of the middle-ear 
 cavities. The whole interior of the mastoid antrum, aditus, epitympanum, 
 tympanum, and meatus are thereby converted into a single large and continu- 
 ous cavity — the smooth walls of which are made to heal throughout by epider- 
 mization — the epidermis growing in from the meatus and the edges of the 
 wound. Indicated in empyema, osteitis or osteomyelitis of mastoid process 
 occurring in connection with osteitis of the aditus, epitympanum, tympanum, 
 and meatus; and also in cholesteatomatous collections in those parts. In 
 the following account the description of J. Orne Green is largely followed. 
 
 Preparation — Position — Landmarks. — Same as in the Antrum Opera- 
 tion (page 604). 
 
TYMPANO-MASTOID EXENTERATION. 607 
 
 Incisions and Operation. — 
 
 A. Formation of Skin-flap and Periosteal Flap, and exposure of Operation 
 Site: — -(i) Skin-flap — incision begins 3 mm. ( T 2 g- inch) above the anterior 
 superior insertion of the auricle — passes downward about 3 mm. (y\ inch), 
 posterior to and parallel with the auricle, to the tip of the mastoid process — 
 thence about 12 mm. (yg- inch) backward — thence upward and slightly 
 backward over the posterior aspect of the mastoid to its upper part. (See 
 Fig. 480, B.) The skin over this triangle is dissected off from the remaining 
 soft parts and displaced upward. (2) Partial separation of auricle — dissect 
 off the auricle, without the periosteum, up to the postero-superior margin of 
 the meatus and displace it forward. (3) Periosteal Flap — incise horizontally- 
 backward through the periosteum to bone along the supramastoid crest, from 
 near the meatus to the upper end of the posterior skin incision — and also 
 perpendicularly downward near to meatus. Displace downward the triangular 
 flap of periosteum thus made. 
 
 Sometimes this order of raising the flaps is reversed, the skin-flap being 
 turned downward and the periosteal flap upward. Hemorrhage is controlled 
 as encountered. 
 
 B. Extirpation of lining of Superior and Posterior aspects of Osseous 
 Auditorv Meatus — (1) Detach the cartilaginous meatus from the osseous 
 meatus, with periosteal elevator, along its superior and posterior aspects and 
 displace it forward and downward with the auricle. (2) Incise the lining 
 of the meatus along the antero-superior and postero-inferior walls, beginning 
 at the drum-membrane and ending at the free margin — dicsarding the excised 
 triangular portion of periosteum. 
 
 C. Exposure of Antrum, with Removal of posterior wall of Osseous audi- 
 tory canal, together with Membrana and Malleus — (1) Expose the antrum as 
 in the ordinary antrum operation (q. v.). (2) Chisel out a wedge of bone be- 
 tween the anterior edge of the mastoid opening and the posterior edge of the 
 meatus. As the lower chisel-cuts approach the floor of the meatus and 
 grow deeper, they are directed somewhat upward, finally opening into the 
 osseous auditory canal. (3) Dissect out the fibrous tympanic ring by means 
 of a special knife, and remove the membrana tympani and the malleus, if 
 still present. (4) Pass a bent probe, or special guide, by the tympanic route, 
 through the aditus into the antrum, and, upon this as a guide, chisel away 
 the remaining wedge of bone between the antrum and aditus — making as 
 wide an opening as the position of the facial nerve will allow. 
 
 D. Extirpation of Epitympanum and Removal of Incus: — (1) Chisel away 
 the outer wall of the epitympanum with a specially curved chisel, exposing 
 the entire epitympanum. (2) Disarticulate the incus from the stapes with a 
 special knife, and remove the incus with forceps. 
 
 E. Exenteration of entire Mastoid Antrum, Aditus, and Epitympanum: 
 — (1) Chisel away most of the outer cortex of the mastoid and its cancellated 
 portion. (2) So chisel away the posterior wall of the osseous auditory meatus 
 as to leave a ridge of firm bone between mastoid and meatus, sloping outward 
 and downward from the floor of the aditus. The fallopian canal lies inside 
 this ridge, none of which is to be removed on the median side of the tympanic 
 ring. (3) Smooth, by curette or surgical engine, all bony irregularities in the 
 walls of the mastoid, antrum, epitympanum, and roof of tympanum. Espe- 
 ciallv search for caries upon the posterior and interno-inferior aspects of 
 antrum, lateral sinus, and roof of tympanum — exposing the dura if required. 
 (4) Guard the horizontal part of the fallopian canal through the tympanum, 
 
608 OPERATIONS UPON THE HEAD. 
 
 and the perpendicular part running down from the aditus — also the horizontal 
 semicircular canal in the inner wall of the aditus. 
 
 F. Splitting of Membranous Meatus and Suturing: — (i) Slit the car- 
 tilaginous meatus throughout its posterior wall, from near the concha out- 
 ward. Two triangular flaps are thus formed, whose corners are to be sutured 
 with catgut to the external tissues, one being stretched upward, the other 
 downward. (2) Suture the auricle back into its former position as far down 
 as the supramastoid crest. (3) Turn the skin-flap and periosteal flap into 
 the cavity made, after cleansing and draining it — and tampon them with 
 gauze. (4) Suture the skin over the lower part of the mastoid. (5) Apply 
 a voluminous protective dressing. 
 
 G. After-treatment: — Keep evefy crevice of cavity well packed with 
 gauze, until the cavity fills with granulations, and until granulations are 
 covered with epidermis — which epidermis is gotten partly from epidermization 
 of granulations, partly from the skin-flap turned in — and may also be gotten 
 from grafts. 
 
 Comment. — The middle ear is sometimes first exposed by removing the 
 upper and posterior wall of the osseous canal, and then, by means of a probe 
 in the aditus ad antrum, the aditus and antrum are expcsed. Thus antra 
 lying further forward than usual would be exposed with less danger to the 
 cranial cavity (Stacke). 
 
 OPERATIONS UPON THE FRONTAL SINUSES. 
 SURGICAL ANATOMY OF THE FRONTAL SINUSES. 
 
 Description. — Two more or less triangular air-spaces of variable size, 
 with bases anteriorly and apices posteriorly, situated chiefly in antero-inferior 
 portions of frontal bones, on either side of median line, anterior to ethmoidal 
 notches, and separated from each other by an intervening bony septum. 
 They lie at the antero-internal junction of horizontal and vertical portions 
 of frontal bones, immediately internal to internal angular processes, lying 
 above root of nose and more or less beneath inner portions of superciliary 
 ridges. The sinuses begin to develop at two years, but are insignificant in 
 size until after seven years. 
 
 Muscles in Relation with Frontal Sinuses. — Frontal portion of occipito- 
 frontalis; orbicularis palpebrarum; corrugator supercilii; sometimes the an- 
 terior part of temporal. 
 
 Arteries in Neighborhood of Frontal Sinuses. — Angular; termination 
 of facial; frontal branch of ophthalmic; supraorbital branch of ophthalmic. 
 
 Veins in Neighborhood of Frontal Sinuses. — Frontal (emptying into 
 nasal arch and supraorbital); supraorbital (forming, with frontal, the angular 
 vein); angular (becoming the facial); anterior temporal (emptying into 
 common temporal). 
 
 Nerves in Neighborhood of Frontal Sinuses. — Supraorbital and 
 supratrochlear branches of frontal division of ophthalmic; sometimes the 
 lachrymal branch of ophthalmic. 
 
 Walls and Their Relations. — (1) Anterior Wall: formed by vertical 
 portion of frontal; extends from supraorbital arch below, a variable distance 
 upward (v. i.); contains diploe; thickness of wall varies from 1 to 6 mm. 
 (from less than Jg- to yV inch) in different places, average being from 2 to 
 3 mm. (from about yg- to T 2 ¥ inch) ; has, in relation, the soft parts mentioned 
 above (see muscles, arteries, veins, and nerves). (2) Postero-superior Wall 
 
GENERAL SURGICAL CONSIDERATIONS. 609 
 
 (or roof): forms part of anterior boundary wall of anterior cranial fossa; 
 dense and brittle; has, in relation, the frontal lcbe of brain and the olfactory 
 lobe. (3) Inferior Wall (or floor): (a) Orbital Portion: forms part of roof 
 of orbit; of variable extent; marked by depression for pullev of superior 
 oblique muscle of eye; (b) Nasal Portion: (the part of greater surgical im- 
 portance) ; articulates with anterior ethmoidal cells, nasal process of superior 
 maxillary and nasal bones; infundibulum opens through this portion of 
 inferior surface from frontal sinus into middle meatus of nose. (4) Internal 
 Wall: formed by the antero-posterior septum between the sinuses, which 
 generally deviates from median line. 
 
 Extent. — (1) Laterally; Average of two hundred cases gave an extension 
 outward from median line of from 2 to 2.8 cm. (};: to i T 2 y inches) — Extremes, 
 from mere slits in nasal part of frontal, to cavities extending from median 
 septum into external angular process of frontal. (2) Vertically; averages, 
 from base to apex above, along its inner border (its highest part), from 1.8 
 to 2.5 cm. (f-f to 1 inch) — extremes, from nasofrontal suture to frontal eminence. 
 (3) Floor, frequently extends back as far as anterior ethmoidal foramen — 
 rarely back to lesser wing of sphenoid. 
 
 The size of the frontal sinuses is not determined by neighboring bony 
 prominences and depressions, as they may be largely formed at the expense 
 of the inner table of the skull. It is also often said that one sinus may be 
 absent or rudimentary, the opposite one extending across the median line, but 
 in Lothrop's examination of two hundred and fifty sinuses the orbital portion 
 of the sinus was not once missing. 
 
 Septum. — A thin bony septum separates the two sinuses, which may 
 deviate slightly or considerably to one side. Septum generally does deviate 
 to one side, and this deviation may amount to 5 mm. (j^ inch) or more. 
 When deviation is very marked, one sinus partly overlaps the other, an im- 
 portant surgical fact. The septum is rarely absent. Perforation of septum 
 is very exceptionally found (once in one hundred and eighty cases). 
 
 Communication with Nose. — By infundibulum, which passes downward 
 and backward behind the nasal process of superior maxillary bone, through 
 anterior portion of lateral mass of ethmoid, and opens into middle meatus 
 of nose, under anterior end of middle turbinated bone, and on a level with 
 the palpebral fissure. 
 
 SURFACE FORM AND LANDMARKS. 
 
 No external guide exists as to the extent of the frontal sinuses — though, 
 generally, the more prominent and larger the supraorbital area, inclusive of 
 the superciliary ridges and nasal eminences, the greater the extent of the 
 sinuses. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 It is not safe to make an opening for the exposure of the frontal sinus 
 at any point external to the supraorbital notch — the site at which the sinus 
 is most surely encountered being just above the antero-inferior aspect of the 
 internal angular process of the frontal bone, at a position to one side of the 
 median line sufficiently far to miss the average position of the septum. 
 
 39 
 
6io OPERATIONS UPON THE HEAD. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE FRONTAL SINUSES. 
 
 See those mentioned under the Cranio-cerebral and Mastoid regions 
 (pages 557 and 604). 
 
 EXPOSURE AND DRAINAGE OF THE FRONTAL SINUSES. 
 
 Description. — The frontal sinus is exposed through its anterior wall — 
 and subsequently drained either through the original wound — or, where 
 possible, through the infundibulum into the middle meatus of the nose, after 
 closing the original wound — or through both routes. 
 
 Preparation. — Shave eyebrow. Close eyelid and place a sterile pad 
 over it. 
 
 Position. — Patient supine; shoulders elevated; head extended. Surgeon 
 on side of operation, or behind head. Assistant opposite. 
 
 Landmarks. — Supraorbital ridge; supraorbital notch (generally detectable 
 through the skin, at the junction of the inner and middle thirds of the supra- 
 orbital ridge) ; sagittal suture (middle line of head) ; nasofrontal suture (de- 
 tectable when soft parts are retracted). 
 
 Incision. — A horizontal incision is made, beginning to the outer side of 
 the center of the supraorbital ridge, and continued inward to the median line, 
 just above the supraorbital margin (Fig. 482). If more room be needed, 
 this incision may cross the median line, or be curved upward or downward at 
 the median line. (Instead of the horizontal, a vertical incision is some- 
 times made in the median line, between the superciliary ridges — but leaves 
 more of a scar than an incision through the eyebrow. 
 
 Operation. — (1) The incision passes directly to the bone, through the 
 skin, the fascia, transversely through the frontal portion of the occipito- 
 frontalis, longitudinally between some fibers of the orbicularis palpebrarum 
 and through periosteum to bone. The supraorbital vessels and the supra- 
 orbital and supratrochlear nerves are cut — but the more important branches 
 of the facial nerve to the occipitofrontalis, corrugator supercilii, and orbicu- 
 laris palpebrarum are not cut. (2) The periosteum is elevated and, together 
 with the soft parts, is displaced upward and downward by retractors. (3) 
 The bone having been well exposed, and bleeding controlled, an opening is 
 made with a small trephine or burr (or, less desirably, with chisel and mallet). 
 The opening is placed just above the antero-inferior aspect of the internal 
 angular process of the frontal bone — the inner margin of the opening should 
 be external to the median line, to allow for deviation of the septum — the 
 outer margin should never extend beyond the supraorbital foramen — and 
 the lower margin should be above the nasofrontal suture. (4) After pene- 
 trating the anterior bony wall, with its diploe, the mucous membrane of the 
 frontal sinus is encountered and divided. (5) Pass a probe through the 
 trephine-opening into the sinus — thence through the infundibulum (which 
 first runs downward and backward a short way, then sharply forward and 
 downward) into the middle meatus of the nose, which it enters under the 
 anterior end of the middle turbinated bone. (6) The interior of the cavity, 
 if necessary, may be curetted. The infundibulum may be forcibly dilated. 
 Drainage, at least temporary, is generally indicated — and may be accomplished 
 in one of the following ways — (a) by drawing a rubber tube through the 
 infundibulum into the middle meatus of the nose, with entire closure of the 
 
SURGICAL ANATOMY OF THE MAXILLARY SINUSES. 611 
 
 external wound — or (b) by combined external drainage through the lower 
 part of the external wound (the upper part of the wound being sutured) and 
 drainage into the middle meatus of the nose by rubber tube or strands of 
 silkworm-gut or silk. It is better to adopt the latter method at first — and 
 the former may be adopted later, when external drainage can be abandoned. 
 The first method alone is preferable if the matter of scarring from a granu- 
 lating wound be of importance. Suture all of the external wound except 
 that portion required for drainage. The transversely divided muscle tissue 
 should be repaired with catgut. 
 
 Comment. — (') Avoid passing the probe through the ethmoidal cells 
 into the brain. (2) It is well to remove the anterior end of the middle tui- 
 
 Fig.482.— Exposure of Frontal Sinus by Transverse Supraorbi iai. Incision : — A, Remains 
 of frontal suture ; B, Nasofrontal suture; C, Supraorbital foramen, artery, and nerve; D, Trephine- 
 opening through internal angular process of frontal bone ; E, Orbicularis palpebrarum divided longi- 
 tudinally ; F, Occipitofrontalis divided transversely ; G, Supratrochlear nerve ; H, Periosteum drawn 
 aside ; I, Nasal suture. 
 
 binated bone, as freer access to and from the infundibulum is thereby given. 
 (3) Where possible, the lips of the wound through the eyebrow should be 
 very carefully approximated and sutured, that the eyebrows may grow out 
 in their proper axes. 
 
 OPERATIONS UPON THE MAXILLARY SINUSES. 
 
 SURGICAL ANATOMY OF THE MAXILLARY SINUSES. 
 
 Description. — A somewhat pyramidal air-cavity generally occupying 
 chief portion of body of superior maxillary bones. Dimensions variable — 
 may be contracted — may extend into malar bone. Small with thick walls 
 in young — larger with thinner walls in old. Communicates by an irregular 
 opening with middle meatus of nose — sometimes more than one communi- 
 cating opening may exist. Infraorbital canal, for infraorbital nerve, pene- 
 trates its superior and anterior walls. Posterior dental canals groove its 
 posterior wall. Bony septa may divide interior of cavity. Floor of antrum 
 uneven from upward projection of roots of teeth. Teeth in contact with 
 
612 OPERATIONS UPON THE HEAD 
 
 the antrum are the molars, and especially the first and second molars — 
 sometimes the roots of all the teeth of one side may be in contact with floor 
 of antrum of that side. 
 
 Muscles in Relation. — (i) In Relation with Anterior or Facial Wall; 
 levator labii superioris alaeque nasi; levator labii superioris; levator anguli 
 oris; zygomaticus major; zygomaticus minor; orbicularis oris; buccinator; 
 risorius. (2) In Relation with Posterior or Zygomatic Wall; masseter; 
 temporal; external pterygoid. 
 
 Arteries in Relation. — (1) In Relation with Anterior Wall; facial of 
 external carotid; transverse facial branch of temporal branch of external 
 carotid. (2) With Posterior Wall; internal maxillary of external carotid; 
 posterior dental (alveolar) of internal maxillary; descending palatine of 
 internal maxillary. (3) With Internal Wall; sphenopalatine of internal 
 maxillary. (4) With Superior Wall; infraorbital of internal maxillary. 
 
 Veins in Relation. — Correspond with arteries. 
 
 Nerves in Relation. — (1) In Relation with Anterior Wall; middle supe- 
 rior dental branch of superior maxillary; anterior superior dental branch of 
 superior maxillary; malar branches of facial; infraorbital branches of facial; 
 buccal branches of facial. (2) With Posterior Wall; posterior superior dental 
 branches of superior maxillary; anterior or large palatine nerve from Meckel's 
 ganglion; posterior or small palatine nerve from Meckel's ganglion. (3) 
 With Superior Wall; infraorbital division of superior maxillary (emerges on 
 anterior wall). (4) With Internal Wall; nasopalatine nerve of Meckel's 
 ganglion. 
 
 Walls and Their Relations. — (1) Base or Internal (Nasal) Wall; pre- 
 sents the very irregular opening of antrum of Highmore, at its posterior part, 
 communicating with middle meatus of nose — and is partly filled in by vertical 
 plate of palate, unciform process of ethmoid, maxillary process of inferior 
 turbinated, part of lachrymal and by mucous membrane. (2) Apex; formed 
 by malar process of superior maxillary. (3) Superior Wall; orbital plate of 
 superior maxillary. (4) Inferior Wall; alveolar ridge. (5) Anterior Wall; 
 facial surface of superior maxillary. (6) Posterior Wall; zygomatic surface 
 of superior maxillary. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The antero-external and postero-external walls of the sinus, together with 
 the alveolar ridge, which are the aspects where openings are usually made, 
 are best exposed by upward and backward traction of the upper lip and 
 cheek of that side, sufficiently to obliterate the fold of mucous membrane 
 reflected from cheek to gums. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The maxillary sinus may be approached by enlarging its natural opening 
 into the middle meatus of the nose; by making an opening through its ex- 
 ternal wall; or by going through a socket of one of the molar teeth. The 
 best site for the opening, upon the facial aspect of the bone, is in the interval 
 between the first and second molar teeth, upon the posterior aspect of the 
 malar ridge of the superior maxillary bone, sufficiently high to avoid the 
 roots of the teeth. Above the second molar might be better, but the malar 
 ridge makes it difficult to get high enough up to avoid the root of the tooth 
 
OPENING OF MAXILLARY SINUS THROUGH THE FACE. 
 
 613 
 
 — but this site would be better if the tooth were absent. Where the opening 
 is made through the alveolar ridge the second molar tooth is drawn and the 
 socket penetrated by a burr or drill. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE MAXILLARY 
 
 SINUSES. 
 
 See those mentioned under the Cranio-cerebral and Mastoid regions 
 (pages 557 and 604). 
 
 OPENING OF MAXILLARY SINUS (ANTRUM OF HIGHMORE) THROUGH 
 ITS FACIAL ASPECT, ABOVE THE ALVEOLAR MARGIN. 
 
 Description. — The upper lip and cheek are displaced upward and back- 
 ward, and the antrum entered above the fangs of the molar teeth, preferably 
 
 Fig. 483.— Exposure; of Maxillary Antri m : — Through the malar ridge of the superior maxilla, 
 above the interval between fust and second molar teeth fangs. 
 
 in the interval between the first and second molars, upon the postero-external 
 aspect of the malar ridge of the superior maxilla. (See Fig. 483.) 
 
 Preparation. — Mouth cleansed; sponge so placed as to absorb blood and 
 prevent its reaching throat. 
 
 Position. — Patient supine; head elevated, resting upon sound side. 
 Surgeon on side of operation. Assistant opposite. 
 
 Landmarks. — Alveolar margin; first and second molars; malar ridge of 
 superior maxilla. 
 
6l4 OPERATIONS UPON THE HEAD. 
 
 Incision. — Having retracted upward and backward the upper lip and 
 cheek, a vertical incision is made above the roots of the first and second molars 
 and as nearly over the interspace between them as is accessible, being guided 
 in the placing of the incision by the prominent ridge of the superior maxilla 
 leading up to the malar process. 
 
 Operation. — (I) Carry the incision through mucous membrane and 
 periosteum to the bone — free the periosteum from the bone by periosteal 
 elevator — retract soft parts anteriorly and posteriorly. (2) Apply a small 
 trephine just above the back part of the root of the first molar and high 
 enough to avoid its fangs, directing it upward, inward, and backward — 
 until it is felt to have entered the cavity. (3) Remove diseased tissue of 
 antrum with scoop or curette. By tilting head forward, irrigation may be 
 made from artificial opening through middle meatus of nose. The opening 
 should be plugged during meals, or a tube with an adjustable plug should 
 be worn. 
 
 Comment. — (1) Avoid injury to infraorbital vessels and nerves by keeping 
 below and to outer side of infraorbital foramen. (2) Avoid entering the 
 orbit. (3) This operation is probably better than entering through the 
 socket of a tooth — while the latter gives better drainage, the former better 
 protects from entrance of food into the sinus from the mouth. 
 
 OPENING OF MAXILLARY SINUS (ANTRUM OF HIGHMORE) THROUGH 
 THE SOCKET OF THE SECOND MOLAR TOOTH. 
 
 Description. — The removal of the tooth alone may accomplish sufficient 
 drainage, as the fangs may open directly into the antrum, save for their 
 thin bony covering, which is easily broken down. If the opening made by 
 the simple withdrawal of the tooth be insufficient (which is usually the case) 
 it may be deepened and enlarged. 
 
 Preparation and Position. — Same as in last operation. 
 
 Landmarks. — Second molar tooth. 
 
 Operation. — Draw second molar tooth. If fangs leave opening com- 
 municating with the antrum, deepen and enlarge it with a bone-drill. If no 
 opening be found, drill through the intervening bone. Drain and treat as in 
 the above operation. 
 
 Comment. — This operation gives better drainage than the preceding, 
 but is more apt to be contaminated from the mouth, unless the opening be 
 closed artificially by some form of plug, except during irrigation. The loss 
 of the tooth is entailed. The operation is especially indicated when the 
 tooth is already absent. 
 
 III. THE EYEBALL AND THE ORBIT.* 
 
 OPERATIONS UPON THE EYEBALL. 
 
 SURGICAL ANATOMY OF THE ORBIT. 
 
 Fibrous Tissues of the Orbit. — (1) Orbital periosteum. (2) Fascia 
 ensheathing muscles, vessels, optic and other nerves, and enclosing lobules 
 of fat. Posteriorly, it blends with periosteum (where the fascia is thinner 
 
 * Only the removal of the eye will be here considered, most of the operations upon the 
 contents of the orbit belonging to the special field of ophthalmology. 
 
ENUCLEATION OF THE EYEBALL. 615 
 
 and looser). Anteriorly, it is thicker and firmer, accompanying the muscles 
 nearly to the equator of eyeball, where it divides into an anterior lamina, 
 forming a complete investment and passing forward to eyelids, — and a poste- 
 rior lamina, turning backward and covering the hinder third of the globe. 
 (3) Tenon's capsule, a serous membrane (whose layers are separated by 
 Tenon's lymph-space) — surrounding the hinder two-thirds of the eyeball. 
 The visceral layer follows the convexity of the sclerotic, from the ciliary 
 margin of the cornea to entrance of optic nerve, where it is reflected from the 
 eyeball and, becoming the parietal layer, blends with the posterior lamina of 
 the muscle-fascia (v. s.). Anteriorly, Tenon's capsule is continued into the 
 conjunctiva. Posteriorly, it is continued with the subarachnoid space through 
 the sheath of the optic nerve. Tenon's capsule is pierced by the ocular 
 muscles, which are surrounded by sheaths from Tenon's capsule. 
 
 Muscles of the Orbit. — Recti superior, inferior, external and internal; 
 obliquus oculi superior and inferior; levator palpebral superioris. 
 
 Arteries of the Orbit. — Ophthalmic and its branches — lachrymal; 
 supraorbital; posterior ethmoidal; anterior ethmoidal; palpebral; frontal; 
 nasal; muscular; anterior ciliary, short ciliary; long ciliary; arteria centralis 
 retinas. 
 
 Veins of the Orbit. — Superior muscular; anterior and posterior ciliary; 
 anterior and posterior ethmoidal; lachrymal; central vein of retina; — all form 
 superior ophthalmic vein. Inferior muscular and lower posterior ciliary 
 form inferior ophthalmic. Superior and inferior ophthalmic veins unite to 
 form the common ophthalmic vein. 
 
 Nerves of the Orbit. — Optic; motor oculi; trochlear; lachrymal, frontal 
 and nasal branches of the ophthalmic division of the fifth; ophthalmic (ciliary; 
 ganglion. 
 
 ENUCLEATION OF THE EYEBALL. 
 
 Description. — Consists of the removal of the eyeball intact, after incising 
 the conjunctiva, severing the attachment of the ocular muscles to the globe 
 and dividing the optic nerve at its entrance into the eyeball. Indicated 
 chiefly in malignant disease and in extensive injury. 
 
 Special Instruments Required. — Eye-speculum; toothed fixation for- 
 ceps; strabismus hook; blunt-pointed scissors curved on the flat. 
 
 Position. — Patient supine; head elevated. Surgeon on side of operation. 
 Assistant opposite. 
 
 Landmarks. — Reflection of the conjunctiva on to the globe. 
 
 Operation. — (1) Insert a spring eye-speculum, an arm passing between 
 the globe and each lid, holding the latter out of the way. (2) Catch up the 
 ocular conjunctiva with toothed forceps and snip it with blunt-pointed scissors 
 all around, near to the cornea. (3) Having opened Tenon's capsule, catch 
 up each rectus tendon — generally beginning with the external, then the 
 superior and inferior, ending with the internal — with a strabismus-hook, 
 drawing them forward and dividing them with scissors close to their sclerotic 
 attachment. (4) Press upon the speculum slightly so as to push it behind 
 the equator of the eye, which will cause the ball to start forward. Pass 
 curved scissors backward, on the outer side of and behind the globe, and 
 divide the optic nerve close to the eyeball. Draw the eyeball forward and 
 tut the superior and inferior oblique muscles near the sclerotic — and remove 
 the eye. (5) The ophthalmic artery is immediately clamped and tied. Other 
 
616 OPERATIONS UPON THE HEAD. 
 
 bleeding vessels are controlled by ligature or by pressure maintained by 
 dressing. 
 
 Comment. — (I) Where the globe has collapsed, or collapses during the 
 operation, seize it with forceps and dissect it out. (2) In disease it is often 
 indicated to remove all the soft tissues of the orbit, as well as the eye proper. 
 
 EVISCERATION OF THE EYEBALL. 
 
 Description. — Consists in the removal of the contents of the eyeball, 
 leaving a stump composed of the tissues of the globe for the better reception 
 of an artificial eye within the original sclerotic. Indicated chiefly in suppura- 
 tion of the eyes and in limited lesions. 
 
 Special Instruments. — Those given under Enucleation, together with 
 the following in addition — Beer knife; sharp scoop; needle-holder; curved 
 needles; silk; glass globes of various sizes, with globe-introducers. 
 
 Position and Landmarks. — Same as for Enucleation. 
 
 Operation. — (1) Introduce eye-speculum as for Enucleation. (2) Steady 
 eye by grasping conjunctiva with fixation forceps. Remove cornea by 
 incising sclerotic with a Beer knife a little outside of the sclero-corneal junction 
 — continuing the incision a short distance into the sclerotic on each side, at 
 the mid-lateral aspects of the opening — to provide for the insertion of the 
 artificial eye and an easy coming together of the wound. Remove from 
 the sclerotic the entire contents of the globe with a scoop, especially from the 
 uveal tract. (3) Control hemorrhage by hot or cold irrigation. Insert a 
 glass eye of appropriate size and appearance — suturing the edges of the 
 wound over it, the sutures passing through the conjunctiva and sclerotic, 
 around the circumference and uniting the lips of the two lateral incisions. 
 
 EXENTERATION OF THE ORBIT. 
 
 Description. — Removal of the entire contents of the orbit— indicated 
 chiefly in malignant disease. 
 
 Position. — As in the preceding operations. 
 
 Landmarks. — Margin of the orbit; external tarsal ligament. 
 
 Incision. — An incision is made from the external canthus outward through 
 the external tarsal ligament — to allow the lids to be fully separated. The 
 conjunctiva is cut through down to the bone, around the entire circumference 
 of the bony orbit — to subperiosteal^ expose the cavity of the orbit. 
 
 Operation. — The soft parts having been thus freed, the periosteum of the 
 orbit is raised by means of an appropriate, curved periosteal elevator. The 
 structures within the orbit are not disturbed separately — but are freed, en 
 masse, within the surrounding periosteum, toward the apex of the orbit. The 
 mass of soft parts is then drawn forward and divided close to the apex of the 
 orbital cavity by means of a pair of curved scissors inserted deeply behind the 
 mass of tissues. The orbital cavity, and especially its apex, is then tamponed 
 firmly. This tamponade may be allowed to remain — or it may be withdrawn 
 and the ophthalmic artery clamped and ligated. 
 
 The manner of completing the operation will be determined by the special 
 object for which it was performed. Grafting by means of the lids may be 
 at once resorted to — or may be subsequently done from adjacent tissues. The 
 incision through the outer canthus is sutured. 
 
EXPOSURE OF IXTRA-ORBITAL AND RETRO-BULBAR STRUCTURES. 617 
 EXPOSURE OF INTRA-ORBITAL AND RETRO-BULBAR STRUCTURES. 
 
 KROENLEIN'S OPERATION. 
 
 Description. —The outer wall of the orbit, consisting of bony and soft 
 parts, is osteoplastically turned outward — and subsequently replaced. The 
 procedure is indicated in retro-bulbar diseases and intra-orbital injuries. 
 
 Position. — The patient's head, resting upon its back, is turned slightly 
 toward the operator. 
 
 Landmarks. — External angular process of the frontal bone; margin of 
 the orbit; outline of the malar and zygoma. 
 
 Fig. 484. — Kroenlein's Operation for the Exposure of the Intra-orbital Structures: — 
 A B, Skin-incision; C and D, Bone sections. 
 
 Incision. — The skin-incision begins in the temporal region, about 1 cm. 
 (about J inch) above the supra-orbital margin — runs thence downward and 
 forward, with anterior convexity, along the external orbital margin, to the 
 upper edge of the zygoma — where it turns backward and ends over the center 
 of the zygomatic arch. 
 
 Operation. — Incise through skin, superficial fascia, aponeuroses, muscles, 
 and periosteum to the bone throughout. By means of a curved periosteal 
 elevator the periosteum is then raised from the outer wall of the orbit, carrying 
 with it the intra-orbital structures as far as the spheno-maxillary fissure. The 
 external angular process of the frontal bone is then sawn or chiselled through 
 in the direction indicated by the line A, Fig. 484, the section beginning just 
 above the fronto-malar suture-line. The malar is then divided, from its 
 outer margin into the anterior end of the spheno-maxillary fissure, as indicated 
 
618 OPERATIONS UPON THE HEAD. 
 
 by the line B, Fig. 484. The bony outer wall of the orbit is now turned out- 
 ward, with the adherent and undisturbed overlying soft parts — thus exposing 
 the structures within the orbit. When the object of the exposure has been 
 accomplished, the composite flap is turned back into position — the bone, if 
 indicated, being sutured through previously drilled holes. 
 
 Comment. — Eventration may also be performed after exposing the orbital 
 cavity by means of Kroenlein's operation. 
 
 IV. THE EAR AND EUSTACHIAN TUBE.* 
 
 SURGICAL ANATOMY OF THE MEMBRANA TYMPANI. 
 
 Description. — The membrana tympani is an ellipsoidal disc (with slight 
 central depression) about 10 mm. (between y%- and y 7 ^ inch) in length, 9 mm. 
 (between f 5 ^ and y\ inch) in width, and about 0.1 mm. in thickness. It 
 extends obliquely from above downward, its circumference being lodged in 
 the groove of the tympanic ring, at the inner end of the external auditory 
 meatus — forming the boundary between external and middle ear. It con- 
 sists of three layers — the cuticular covering without, the fibrous layer, and 
 the mucous lining within. The handle of the malleus descends downward 
 and backward between its two inner layers and is attached to the membrana 
 tympani a little below its center, at the umbo. The short process of the mal- 
 leus and long process of the incus are visible through the membrana tympani 
 at its upper part. A cone of light is generally visible extending from the 
 umbo (end of manubrium or handle of malleus) downward and forward 
 toward the circumference. 
 
 INTRODUCTION OF EAR SPECULUM FOR EXAMINATION OF MEM- 
 BRANA TYMPANI. 
 
 Seat patient upright in chair, with a good natural light (other than sun- 
 light) or artificial illumination available — the patient occupying such a position 
 as to enable the light to be reflected by a head-mirror, worn by the operator, 
 into the auditory canal. Warm and moisten a speculum (Gruber's silver 
 speculum, or other) — grasp the upper free portion of the auricle between the 
 bent knuckles of the index and middle fingers of the left hand — draw the 
 ear upward, backward, and outward (suggested by the letters u, b, o), to 
 straighten the canal — insert the speculum, held lightly between right index 
 and thumb, by twirling it forward and backward in a small arc until it has 
 sunk to the right depth in the proper axis of the external auditory canal, 
 when it is steadied by the left thumb placed upon its rim. It may then 
 be manipulated in different directions to expose all portions of the depth of 
 the auditory canal and the surface of the membrana tympani — noticing par- 
 ticularly the color and position of the drum as to whether normally re- 
 tracted, or abnormally bulging from a collection of fluid in the tympanum. 
 
 *Only the introduction of the ear-speculum and the eustachian catheter and the punc- 
 ture of the ear-drum will be here considered, most of the operations upon the ear belonging 
 to the special field of Otology. 
 
SURGICAL AX ATOMY. 619 
 
 PARACENTESIS TYMPANI. 
 
 Description. — Incision of tympanic membrane for the purpose of drainage 
 of the tympanic cavity and for irrigation. Indicated chiefly in otitis media. 
 
 Instruments Required. — Ear-speculum; double-edged paracentesis 
 needle. 
 
 Preparation. — Cleansing of auditory canal by antiseptic irrigation. 
 
 Position. — Patient sits upright. Surgeon sits opposite the involved ear. 
 
 Landmarks. — Handle of malleus showing through the membrana tym- 
 pani. 
 
 Operation. — (1) Insert the ear-speculum — expose the membrana tympani 
 in the field of the speculum — and recognize the handle of the malleus. (2) 
 Incise the ear-drum, making the incision in the posterior half of the mem- 
 brane, between the handle of the malleus and the posterior border of the 
 membrana tympani, and enlarge the opening vertically — taking care not to 
 wound the middle ear. 
 
 INTRODUCTION OF THE EUSTACHIAN CATHETER. 
 
 Place the patient in a chair opposite the operator, with head thrown back 
 and supported upon the back of the chair or upon a rest. The surgeon, 
 standing or sitting, places the fingers of his left hand upon the patient's fore- 
 head, while his left thumb pushes the tip of the patient's nose upward (to 
 bring the nostril on a level with the floor of the nose). Warm and lubricate 
 the eustachian catheter, having atomized the nasal cavity with a local anes- 
 thetic, if necessary — push the tip of the catheter, pointing downward, along 
 the floor of the nose, until it touches the posterior wall of the pharynx — turn 
 the point obliquely outward but not quite horizontal — withdraw the instru- 
 ment until the point is felt to glide over the projecting posterior border of 
 the eustachian tube — now turn the tip further outward, until the guide-ring 
 at the posterior end of the catheter points to the outer canthus of the eye of 
 the same side — when the direction of the beak will generally coincide with 
 the axis of the eustachian tube. 
 
 V. THE NOSE AND NASAL CAVITIES. 
 
 For operations exposing the Nasal Cavities, see Excisions and Osteoplastic 
 Resections (pages 473, 474). Most of the other operations upon the Nose 
 and Nasal Cavities belong to the special field of Rhinology. 
 
 VI. THE TONGUE. 
 
 SURGICAL ANATOMY. 
 
 Connections of the Tongue. — (1) With Os Hyoides; by hyoglossi and 
 geniohvoglossi muscles, and hyoglossal membrane. (2) With Styloid Process; 
 by styloglossi muscles. (3) With Inferior Maxilla ; by geniohvoglossi muscles. 
 (4) With Pharvnx; by superior constrictors and mucous membrane. (5) 
 With Epiglottis; by median and two lateral glosso-epiglottic folds of mucous 
 membrane. (6) With Soft Palate; by anterior pillars of the fauces {i.e., 
 
620 OPERATIONS UPON THE HEAD. 
 
 the palatoglossi muscles covered by mucous membrane). (7) With Gums 
 and Floor of Mouth; by mucous membrane and fraenum linguae. 
 
 Muscles Entering into Formation of Tongue. — (1) Extrinsic Muscles 
 
 (arising externally and terminating in tongue); styloglossi, hyoglossi, genio- 
 hyoglossi, palatoglossi, pharyngeoglossal portion of superior constrictors, 
 chondroglossi. (2) Intrinsic Muscles (entirely within tongue and forming 
 its chief bulk); superior, transverse, vertical and inferior linguales. 
 
 Arteries of Tongue. — (1) Lingual (for its surgical anatomy, see Liga- 
 tions) ; dorsalis lingiue branch of Lingual (arises beneath hyoglossus and 
 passes to dorsum of tongue) ; sublingual branch of lingual (arises at anterior 
 border of hyoglossus and passes forward between geniohyoglossus and sub- 
 lingual gland); ranine branch of lingual (arises at anterior border of hvo- 
 glossus and passes forward beneath under surface of tongue). (2) Tonsillar 
 branch of facial; muscular branch of facial to styloglossus. (3) Branches of 
 ascending pharyngeal branch of external carotid. 
 
 Veins of Tongue. — Correspond with arteries. 
 
 Nerves of Tongue. — Lingual branch of trifacial (to papilla? of front and 
 sides of tongue) ; lingual branch of glossopharyngeal (to mucous membrane 
 of base and sides and to papilla? circumvallata?) ; hypoglossal (to muscular 
 substance of tongue) ; chorda tympani (to lingualis) ; sympathetic filaments. 
 
 GENERAL SURGICAL CONSIDERATIONS IN THE REMOVAL OF PART 
 OR THE WHOLE OF THE TONGUE. 
 
 Indications. — Chiefly removed for malignant growth. 
 
 Varieties of Operation and Manners of Operating. — (1) Small por- 
 tions of tongue may be excised by a V-shaped, or other, incision. One half 
 of tongue, transversely or longitudinally, may be removed. The entire 
 organ may be excised. (2) The tongue may be removed through the un- 
 altered mouth; through an incision in the neck; through the mouth after 
 splitting the cheek, or temporarily dividing the inferior maxilla; or after 
 excision of the inferior maxilla. (3) It may be removed with or without 
 previous ligation of the lingual arteries, either beneath the hyoglossi or at 
 their origin — and with or without previous tracheotomy — dependent upon the 
 difficulties and circumstances of the case. (4) It may be removed by scissors; 
 by knife; by some form of ecraseur, applied through mouth or neck; by 
 ligature; or by galvano-cautery. 
 
 General Observations. — Where the involvement is strictly limited to 
 the tongue alone, it should be removed through the mouth. Where the floor 
 of the mouth or the cervical glands, and especially both are involved, the 
 tongue should be removed through the neck, together with the simultaneous 
 removal of all the diseased tissues. Where but a limited portion of the 
 tongue is involved, especially where the involvement is at or toward the 
 anterior end of the organ, a limited portion of tissue, or a transverse or longi- 
 tudinal half may be removed. The natural separation of the two halves of 
 the tongue by a fibrous septum makes it possible to remove one half alone 
 comparatively easy. The tongue is readily split by placing a stout silk 
 retractor in each half, about 2.5 cm. (1 inch) behind the tip and about 1.2 
 cm. (\ inch) from the median line — while these are drawn in different direc- 
 tions, the tongus is split down the median fibrous raphe with blunt-pointed 
 scalpel or scissors. In removing one half or the entire tongue, it is readily 
 drawn out of the mouth after dividing; the frcenum and mucous membrane 
 
EXCISION OF LIMITED PORTIONS OF THE TONGUE. 621 
 
 of the floor of the mouth in front, and the anterior pillars of the fauces laterally. 
 The chief difficulties of operating are the narrow working-room and hemor- 
 rhage. A good light is necessary in all cases. In exceptional cases the 
 extraction of two or three of the lower teeth to give fuller working-room is 
 indicated — the teeth being subsequently replaced upon a dental splint. 
 
 Control of Hemorrhage in Operations upon the Tongue. — The chief 
 hemorrhage is from the lingual arteries, divided in the floor of the mouth, 
 anterior to the hyoglossi (where they are called the ranine) — the position of 
 the cut vessels being the chief difficulty encountered — the hemorrhage being 
 apt to flood the field of operation and get into the air-passages. The head 
 is to be held so as to direct the flow of blood away from the back of the throat. 
 If the mouth be kept well open, the cut arteries are inclined to spurt out of 
 the mouth. By firm pressure applied without upon the neck, between the 
 inferior maxilla and hyoid bone, the stump of the tongue can be brought 
 into view, and the hemorrhage also temporarily arrested by that pressure. 
 The same thing may also be accomplished by hooking a finger or an instru- 
 ment around the base of the stump and drawing it forward. Hemorrhage 
 can be thus temporarily controlled until the vessels can be clamped and tied. 
 If only the anterior half or two-thirds of the tongue is to be removed, a double 
 ligature may be passed through the center of the organ, well behind the 
 growth and temporarily tied on either lateral aspect of the tongue, thereby 
 controlling hemorrhage. Preliminary ligation of the lingual arteries in the 
 neck insures a comparatively dry field, and therefore more thorough work. 
 
 INSTRUMENTS USED IN REMOVAL OF THE TONGUE. 
 
 Special mouth-gags; cheek retractors; blunt hooks; tongue depressors; 
 tenacula; tongue forceps; sponges in holders; scalpels, various; dissecting 
 forceps; toothed forceps; artery clamp forceps, long and short; scissors, 
 straight and curved, long and short; aneurism-needles, various; ligature 
 carriers; needles, various; ligatures, silk and chromic gut; sutures, silk and 
 gut; needle-holder; silk-retractors for tongue; curved needle in handle to 
 carry silk-retractors through tongue; volsella; tracheotomy tubes; tampon 
 cannula; thermocautery; Gigli or chain saw; bone-holding forceps; bone- 
 cutting forceps; drill; wire; wire-cutters (in case lower maxilla is to be divided) ; 
 hare-lip pins, sometimes used if cheek be split. 
 
 EXCISION OF LIMITED PORTIONS OF THE TONGUE. 
 
 Description. — Limited portions of the tongue are best excised, where 
 possible, by a V-shaped incision. Where it is possible to do so, the resulting 
 edges of the wound are brought together and sutured with silk — otherwise 
 the margins must heal by granulation. This method is generally applicable 
 to limited involvement of the free portion of the tongue. 
 
 Preparation and Position. — As in the removal of the entire organ. 
 (See the following operation.) 
 
 Landmarks. — The known attachments of the tongue to the structures 
 of the mouth, and the position of its vessels. 
 
 Operation. — Gag the mouth open, as in the complete operation. Place 
 a thread retractor on each side of the area to be removed. An assistant, with 
 a retractor in each hand, draws the tongue forward out of the mouth. The 
 
622 OPERATION'S UPON THE HEAD. 
 
 operator seizes the part to come away with toothed forceps held in his left 
 hand — and taking a knife in his right hand, he enters it behind the center 
 of the growth to be removed, allowing a fairly wide area, and cuts forward 
 on one side of the area. The knife is then entered at the same spot and 
 made to cut its way out on the opposite side of the area, thus removing a 
 V-shaped piece. The bleeding vessels are ligatured with gut, or twisted — 
 and the lips of the incision, if practicable, are sutured, otherwise they are left 
 to granulate. 
 
 Comment. — For removal of one half of the tongue longitudinally, see the 
 following operation. For removal of one half of the tongue transversely, 
 hemorrhage may be controlled as mentioned under General Surgical Con- 
 siderations — the tongue is then drawn out of the mouth by thread retractors 
 and the anterior portion removed by curved scissors, cutting transversely 
 just anterior to the temporary ligatures. The lingual arteries are then 
 clamped and tied with chromic gut or silk, the smaller ones being twisted, 
 and the stump left to heal by granulation. 
 
 EXCISION OF THE TONGUE THROUGH THE MOUTH, WITHOUT PRE- 
 LIMINARY LIGATION OF THE LINGUAL ARTERIES. 
 
 WHITEHEAD'S OPERATION. 
 
 Description. — The tongue is drawn forward with a double silk retractor 
 — its connections with the floor of the mouth and the anterior pillars of the 
 fauces are divided with scissors — its base is similarly divided transversely — 
 the lingual arteries being seized just before division, divided, clamped, and 
 then twisted. 
 
 Preparation. — Thorough cleansing of the mouth and teeth. 
 
 Position. — Patient lies near right edge of table, shoulders and head 
 raised almost to the sitting position (preferably until his head is nearly on a 
 level with the surgeon's axilla) — his head being turned to the right side and 
 slightly forward, so that blood gravitates out of the mouth. A gag is placed 
 in position upon the left side of the mouth and held firmly pressed to the left 
 side of the face. Surgeon stands to the right. Assistant opposite. 
 
 Landmarks. — The known attachments of the tongue, and the position 
 of its vessels. 
 
 Operation. — (i) Having gagged the mouth wide open, pass a heavy 
 double ligature through the anterior portion of the tongue, in the median 
 line, and, by means of this retractor, draw the tongue out of the mouth. 
 (See Fig. 485.) (2) Separate the tongue from the floor of the mouth and 
 the anterior pillars of the fauces by cutting boldly through the fraenum linguae, 
 connective tissues and the anterior pillars, while the tongue is drawn well 
 forward by the thread retractors, freeing the tongue first horizontally to a point 
 behind the focus of disease (or as far as practicable) and then dividing it trans- 
 versely across its base — cutting not in little snips, but in decided cuts carried 
 boldly on until near the known position of the lingual arteries upon the lingualis, 
 just to the outer side of the geniohyoglossi — sponging away all blood promptly 
 as the division progresses. (3) Just prior to dividing the Unguals, they are 
 seized, together with the tissue immediately surrounding, by artery forceps 
 and clamped — the tissues including the arteries are then cut — after which 
 the arteries are caught by a second pair of clamp forceps, twisted, and let go. 
 (4) Before finally severing the last attachments of the tongue, pass a stout 
 
EXCISION OF THE TONGUE THROUGH THE MOUTH. 
 
 623 
 
 silk retractor through the glosso-epiglottidean fold, to enable the base of 
 the tongue-stump to be drawn forward in case of hemorrhage or difficulty of 
 respiration. Allow this ligature to remain attached for about twenty-four 
 hours, in case of need. (5) The stum]) receives, at the hands of the author 
 of the operation, an immediate coating of a special antiseptic, styptic varnish. 
 Other surgeons merely dust the stump with some form of powder. Others 
 make no special form of application, merely frequently washing the mouth 
 with an antiseptic solution. 
 
 Fig.485.— Whitehead's Excision of the Tongue through the Mouth :— A, Tongue partly 
 split in the median raphe and draw n out of the gagged mouth by thread retractors; B, Scissors free- 
 ing the attachments of the tongue from the floor of the mouth ; C, Scissors dividing the anterior pillar 
 of the fauces and base of the tongue ; D, Catch-forceps clamping the lingual artery in situ prior to its 
 division by scissors ; E, Suture through the glosso-epiglottidean fold, placed before its division, for 
 drawing the base of the tongue forward. 
 
 Comment. — (1) The operation is rapidly and boldly done, until the 
 tongue is removed and the arteries and the stump are in view and in control. 
 
 (2) The thread retractor in the glosso-epiglottidean fold may be omitted, as 
 the tongue may be hooked forward with a finger or an instrument if necessary. 
 
 (3) Jacobson first splits the tongue in the middle line and removes each half 
 separately. He also cuts a transverse groove through the side and dorsum 
 of the tongue nearly to the artery, and then tears through with the finger and 
 closed scissors until the artery is reached and clamped. (4) If necessary to 
 remove but one half of the tongue, a thread retractor is placed through the 
 
624 OPERATIONS UPON THE HEAD. 
 
 tip of the sound side — the tongue is then split through the median fibrous 
 raphe (while the opposite side is held by forceps or another thread retractor) 
 — the connections with the floor of the mouth and the anterior pillars of the 
 fauces are separated on that side alone — and the operation completed as 
 above. (5) Preliminary tracheotomy is not generally done, but may be done 
 if indicated. (6) The lingual arteries may be tied, when exposed in the 
 above way, instead of being merely twisted. 
 
 EXCISION OF THE TONGUE THROUGH THE MOUTH, AFTER PRE- 
 LIMINARY LIGATION OF THE LINGUAL ARTERIES IN 
 THE NECK. 
 
 Description. — The two Unguals are first tied in the neck, and the tongue 
 is then removed through the mouth by means of scissors. 
 
 Preparation, Position, and Landmarks. — As in the preceding opera- 
 tion. 
 
 Operation. — The two lingual arteries are first tied in the neck, beneath 
 the hyoglossi — precisely as in the simple ligation of those vessels (see Liga- 
 tions, page 38) — and the wounds closed and dressed. The tongue is then 
 removed through the gagged mouth by means of scissors, just as in the White- 
 head operation previously described. Thus comparatively slight hemorrhage 
 occurs — from the dorsalis linguae branch of the lingual and from branches of 
 the facial and ascending pharyngeal of the external carotid. 
 
 EXCISION OF THE TONGUE BY MEDIAN INCISION THROUGH LOWER 
 
 LIP, CHIN, AND NECK, WITH OSTEOPLASTIC DIVISION OF 
 
 INFERIOR MAXILLA. 
 
 kocher's operation. 
 
 Description. — This, the more modern form of Kocher's operations for 
 the removal of the tongue, is especially indicated where the growth involves 
 the adjacent intra-oral structures, particularly those rather posteriorly placed, 
 and hence difficult to reach, and where, at the same time, the glandular 
 structures lying along the large cervical vessels are not involved (unless these 
 latter be removed by separate operation) . 
 
 Preparation. — The teeth, mouth, and pharynx are to be thoroughly 
 cleansed to guard against aspiration pneumonia. 
 
 Position. — The patient is in the half-sitting position — no preliminary 
 tracheotomy is done — and complete anaesthesia is used. 
 
 Landmarks. — Median line of lower lip, inferior maxilla, and hyoid bone. 
 
 Incision. — Carry a median incision through the structures of the lower 
 lip and the structures of the chin down to the bone — thence the incision is 
 prolonged in the median line through the soft structures of the neck to the 
 center of the hyoid bone (Fig. 486, A) . 
 
 Operation. — Having carried the incision through the soft parts, the vessels 
 are clamped or tied. The inferior maxilla is now sawn through in the middle 
 line by means of a Gigli saw conducted around and behind it, coming out 
 above between two teeth, or through the space made by extracting a central 
 incisor (Fig. 487). It is rather better to divide the jaw obliquely backward 
 in the direction of the involved side, thus keeping the insertions of the genio- 
 hyo-glossi and genio-hyoids of both sides attached to the healthy side — the 
 
EXCISION OF TONGUE THROUGH LOWER LIP. 
 
 625 
 
 bevelling also making subsequent displacement less likely. Previous to 
 division of the bone, drill-holes may be made for subsequent sutures. Whether 
 the muscles attached to the tubercles near the symphysis menu' be exposed so 
 as to leave half of them or all of them attached to one side of the divided bone 
 or not, the two sides of the divided jaw are now firmly retracted to opposite 
 sides by means of toothed retractors. The tongue is drawm well out of the 
 mouth by a thread or special retractor — and displaced to the side opposite 
 to that involved. The mucous membrane of the floor of the mouth is divided 
 posteriorly — under which is exposed the lingual vein, which is ligated as it 
 crosses the side of the hyo-glossus muscle. The lingual nerve, coming forward 
 just under the mucous membrane, is also divided. The hypoglossal nerve is 
 found crossing the outer surface of the genio-glossus. The lingual artery is 
 well in the field, between the hyo-glossus and the genio-hyo-glossus, and can be 
 
 V 
 
 Fig. 486. — Lines of Incision for Kocher's Excisions of the Tongue: — A, By median 
 straight incision through lower lip, chin, and neck, with osteoplastic division of inferior maxilla; 
 B, By lateral angular, or curved, incision raising a flap upon the side of the neck. 
 
 ligated at once or later. The hyo-glossus is divided outside the growth and 
 cauterized. The tongue is drawn forcibly forward and its mucous membrane 
 is divided far back with the actual cautery, away from the growth. The 
 stylo-glossus muscle and the glosso-pharyngeal nerve lying near it are also 
 divided. 
 
 If the mucous membrane is divided in front of the tonsil, the tonsil, if 
 involved, can be separated by passing a curved, blunt dissector around its 
 outer aspect — thus baring the internal pterygoid muscle. Divide with the 
 cautery as much of the soft palate as is involved. The tensor and levator 
 palati are divided, and the posterior pharyngeal mucous membrane down to 
 the longus colli and in front of the root of the tongue. 
 
 The tongue is now divided with the cautery where it is normal in structure — 
 
 and the muscles, nerves, and vessels (previously tied) are divided on the under 
 
 40 
 
626 
 
 OPERATIONS UPON THE HEAD. 
 
 surface before entering the new growth — the nerves and muscles of deglutition 
 being left as long as possible. 
 
 The two halves of the lower jaw are then united by wire sutures introduced 
 through the previously drilled holes. Gauze drainage is established through 
 the posterior end of the opening, just above the hyoid bone. Kocher rubs 
 xeroform into the cut surfaces and, after suturing the median wound, smears 
 the suture line with bismuth paste. 
 
 Comment. — (i) Damage as little as possible the muscles and nerves of 
 the mouth, tongue, and pharynx. (2) Provide ample escape of wound fluids. 
 (3) Let the patient occupy a half-sitting posture in bed from the time of the 
 operation, during convalescence. (4) Division of the muscles by the actual 
 cautery limits the initial infection of the soft parts at the time of operation. 
 (5) No preliminary tracheotomy is done. (6) If the cervical glands are 
 
 Fig. 487. — Kocher's Excision of the Tongue by Median Incision through Lower 
 Lip, Chin, and Neck, with Osteoplastic Resection of Inferior .Maxilla: — A, K, Two 
 halves of jaw drawn apart by retractors; C, Divided mucous membrane of mouth; D, Lingual 
 nerve; E, Lingual vein; F, Lingual artery; G, Hypoglossal nerve; H, Hyoglossus muscle; B, 
 Tongue, retracted to non-diseased side; I, Right genio-hyoglossus muscle; J, Left genio-hyo- 
 glossus muscle; L, Genio-hyoid muscle. (Redrawn from Kocher.) 
 
 involved, they are removed by a subsequent separate operation. (7) Very little 
 hemorrhage should occur — and but limited functional disability, movements 
 usually being possible at once without pain, and swallowing the following dav. 
 The lip wound leaves but little scarring if properly sutured. (8) Non-inter- 
 ference with deglutition is usually accomplished in this operation and is the 
 chief safeguard against deglutition pneumonia. (9) The operation may be 
 done with the patient in Trendelenburg's position. (10) The access to the 
 involved structures is especially full, as far back as the isthmus of the fauces. 
 (ii) In passing in between the genio-hyo-glossi the room given is not so free 
 as in making the bone-section to one side of their attachment. The genio-hyo- 
 glossus, however, is only detached from the jaw (as pictured in the illustration) 
 if adherent upon the involved side, thereby preventing the separation of the 
 two halves of the jaw. The mylo-hyoid is stretched to its limit. 
 
EXCISION OF THE TONGUE THROUGH THE NECK. 627 
 
 EXCISION OF THE TONGUE, TOGETHER WITH THE CERVICAL AND 
 
 SUBMAXILLARY GLANDS, BY AN INCISION IN THE NECK, 
 
 AFTER PRELIMINARY TRACHEOTOMY AND LIGATION 
 
 OF THE LINGUAL AND FACIAL ARTERIES. 
 
 KOCHER'S OPERATK >N. 
 
 Description. — After a preliminary tracheotomy and the ligation of the 
 lingual and facial arteries in the neck, upon both sides, followed by the removal 
 of the cervical and submaxillary glands (and the sublingual, if necessary) 
 of both sides, the tongue is drawn through an incision made through one 
 side of the floor of the mouth, from the wound in the neck, and removed 
 bv division transversely at its base. The preliminary tracheotomy is prefer- 
 ablv done a few days in advance, that the patient may have become accustomed 
 to breathe through the tube at the time of the operation. Thus several 
 distinct operations are done — tracheotomy; ligation of both lingual and 
 both facial arteries at their origin; excision of the cervical and submaxillary, 
 and probablv sublingual, glands; and the removal of the tongue. 
 
 Preparation. — Thorough cleansing of mouth and teeth. A preliminary 
 tracheotomv done several days in advance of the main operation. 
 
 Position. — Patient supine, at right edge of table; shoulders elevated; 
 head thrown back and turned to one side; neck prominent. Surgeon on side 
 of operation. Assistant opposite. (The positions of the principals will differ 
 somewhat with the various steps of the complex operation.) 
 
 Landmarks. — Those of the following operations (q. v.), tracheotomy, 
 ligation of lingual and facial arteries in the neck, excision of submaxillary, 
 sublingual, and cervical glands, together with the following; — the anterior 
 border of the sternomastoid, the hyoid bone, and the anterior belly of the 
 digastric muscle. 
 
 Incision. — See step No. 3 of the Operation. 
 
 Operation. — (1) A tracheotomy is first performed in the usual way — 
 and, where possible, several days in advance. (See page 704.) (2) The 
 pharynx is plugged with a sterile sponge attached to a piece of silk — to prevent 
 the ingress of blood into the trachea or esophagus. (3) The incision is now 
 made along the anterior border of the sternomastoid, from the mastoid process 
 to about the center of the muscle — thence transversely forward in the crease 
 between the floor of the mouth and the neck, to the hyoid bone — thence along 
 the anterior belly of the digastric to the symphysis menti. (See Fig. 486.) 
 (4) Having divided skin and subcutaneous fascia, and ligated the subcu- 
 taneous veins, turn back, by dissection, the flap thus marked out, and, dis- 
 placing it upward, suture it to the cheek. (See Fig. 488.) (5) Expose the 
 anterior border of the sternomastoid, as far down as the great cornu of the 
 hyoid bone, also the anterior belly of the digastric muscle — and remove, en 
 masse, all enlarged glands from the upper end of the sternomastoid and from 
 beneath the angle and body of the inferior maxilla (see page 150). The veins 
 are ligated as encountered and the mass of involved glands and connective tissue 
 are raised together, exposing the posterior belly of the digastric and stylohyoid 
 muscles posteriorly. (6) The submaxillary gland is dissected up, working 
 from behind, and removed simultaneously with the cervical glands. (See 
 page 725.) The sublingual gland is similarly removed, if involved. (See 
 page 726.) (7) The facial artery is tied near its origin from the external 
 carotid, as soon as exposed in the process of raising the submaxillary gland 
 (see page 41). The lingual artery is also tied near its origin, before passing 
 under the hyoglossus (see page 39). All veins encountered are ligated. (8) 
 
6a8 
 
 OPERATIONS UPON THE HEAD. 
 
 Steps (3), (4), (5), and (7) are repeated on the opposite side, if the entire 
 tongue is to be removed — and also (6) if the submaxillary and sublingual, 
 as well as the lymphatic glands, be involved. (9) The mylohyoid muscle is 
 now exposed and divided as far as necessary. The mucous membrane is 
 then cut close to and parallel with the inferior maxilla — and the mouth thus 
 
 Fig. 48S. — Kocher's Excision of Tongue, together with the Cervical and Sub- 
 maxillary. Glands, by a Curved or Angular Lateral Cervical Incision, after Pre- 
 liminary Tracheotomy and Ligation of Lingual and Facial Arteries: — B, Flap raised 
 from neck and stitched to cheek: A, Submaxillary gland being dissected out; C, External jugular 
 vein ligated; D, Internal jugular vein; E, Facial artery ligated near origin from external carotid: 
 H, Hypoglossal nerve crossing hyoglossus muscle; F, External carotid artery; G, Lingual artery, 
 ligated near origin; I, N, Retractors retracting digastric and stylohyoid muscles; O, Ranine 
 vein; J, Scissors, introduced through mouth, cutting base of tongue away from hyoid bone and 
 its remaining attachments; K, Flap of skin, fascia, and platysma; L, Incision in mylohyoid 
 muscle; M, Tongue being drawn through incision in mylo-hyoid muscle. 
 
 entered. (10) The tongue is seized and drawn through the floor of the mouth 
 and the wound in the neck. While under tension it is cut away from the hyoid 
 bone, by means of blunt scissors introduced through the mouth. The stump 
 is then drawn forward in the mouth and a few remaining arterial twigs 
 
EXCISION OF THE TONGUE THROUGH THE NECK. 629 
 
 which bleed are twisted. (11) The wound is not sutured — but is allowed to 
 close by granulation, with the freest possible drainage. (12) The tracheot- 
 omy tube remains in until the wound is granulating well — the entrance to the 
 larynx being, in the mean time, plugged to prevent lung infection. Feeding 
 is carried on by the introduction of fluids through an esophageal tube. The 
 mouth is frequently washed with an antiseptic solution. 
 
 Comment. — If but one half of the tongue is to be removed, an incision 
 is made only upon the corresponding side of the neck — the tongue is then 
 split down its center, from within the mouth, and the diseased half drawn 
 through the wound in the neck and divided at its base by blunt, curved 
 scissors introduced through the mouth. 
 
 NOTE. 
 
 Operations upon the Teeth; Hard Palate; Lips; Gums; Soft Palate; and 
 Uvula, will not be separately considered. 
 
 Operations upon the following structures of the Head will be found under 
 those structures among the Operations of General Surgery, namely, Bones; 
 Joints; Ligaments; Fasciae; Muscles; Arteries; Veins; Lymphatics; Nerves, 
 Plexuses, and Ganglia. 
 
CHAPTER II. 
 
 OPERATIONS UPON THE SPINE AND SPINAL 
 
 CORD. 
 
 SURGICAL ANATOMY OF THE SPINE AND SPINAL CORD. 
 
 Muscles in Relation with the Spine. — (i) Cervical Region: Ante- 
 riorly; rectus capitis amicus major; rectus capitis anticus minor; rectus 
 lateralis; longus colli. Laterally; scalenus anticus, medius and posticus. 
 Posteriorly; trapezius; levator anguli scapula?; rhomboideus minor; serratus 
 posticus superior; splenius capitis; splenius colli; cervicalis ascendens; trans 
 versalis colli; trachelomastoid ; spinalis colli; complexus; biventer cervicis; 
 semispinalis dorsi; semispinalis colli; multifidus spinse; supraspinales; inter- 
 spinales; intertransversales; rectus capitis posticus major; rectus capitis 
 posticus minor; obliquus capitis inferior; obliquus capitis superior. (2) 
 Thoracic Region: Antero-laterally; psoas minor. Postero-laterally; trape- 
 zius; latissimus dorsi; rhomboideus minor; rhomboideus major; serratus 
 posticus superior; serratus posticus inferior; splenius capitis; splenius colli; 
 longissimus dorsi; transversalis colli; trachelomastoid; spinalis dorsi; com- 
 plexus; biventer cervicis; semispinalis dorsi; semispinalis colli; multifidus 
 spinae; rotatores spinas; interspinales; intertransversales; levatores costarum. 
 (3) Lumbar Region: Antero-laterally; crura of diaphragm; psoas magnus; 
 psoas minor. Postero-laterally; latissimus dorsi; serratus posticus inferior; 
 erector spinae; longissimus dorsi; spinalis dorsi; multifidus spina?; inter- 
 spinales; intertransversales; transversalis abdominis; quadratus lumborum. 
 Note — The ligamentum nuchas extends from external occipital protuberance 
 to spinous process of seventh cervical vertebra. The supraspinous ligament 
 is a continuation downward of the ligamentum nuchas, stretching between 
 the spinous processes. 
 
 Arteries of the Spinal Region. — (I) Arteries in the Neighborhood of 
 the Spine; muscular branches and arteria princeps cervicis of occipital; pre- 
 vertebral branches of ascending pharyngeal; lateral spinal, muscular, anterior 
 spinal, and posterior spinal branches of vertebral; ascending cervical of 
 inferior thyroid; superficial cervical of transversalis colli; muscular, anterior 
 spinal, and profunda cervicis of superior intercostal; muscular and spinal 
 branches from the posterior branches of the intercostals; muscular and spinal 
 branches from the dorsal branches of the lumbar; middle sacral artery from 
 abdominal aorta; lumbar branch from ileo-lumbar; superior and inferior 
 branches from the lateral sacral arteries. (2) Arteries of the Spinal Cord; 
 anterior spinal — from vertebrals, intercostals, lumbar and other arteries 
 (passing to cord along anterior roots); posterior spinal — from vertebrals, 
 intercostals, and other arteries (running just in front of line of attachment 
 of posterior nerve-roots) ; anastomotic chain — formed by branches of posterior 
 spinal running behind line of posterior nerve-roots. 
 
 Veins of the Spinal Region. — (i) Extra-spinal; anterior spinal plexus 
 (in front of bodies of vertebras, emptying into neighboring veins) ; dorsal 
 spinal plexus (around spinous, articular, transverse, and laminar Drocesses, 
 
 630 
 
SURGICAL ANATOMY OF THE SPINE AND SPINAL CORD. 
 
 6 3 I 
 
 emptying into vertebral, dorsal branch of intercostal, lumbar and lateral 
 sacral). (2) Intra -spinal; (a) Meningeal Veins; two anterior longitudinal 
 
 X. to rectus lateralis 
 '_to rectus antic, minor 
 Anastomosis with hypoglossal 
 
 Anastomosis with pncumogastrio 
 
 ,A r . to rectus antic.major. 
 
 N. to mastoid region. 
 
 .Qreat auricular n. 
 
 ■Transverse cervical n. 
 
 N. to Trapezius, Ang. Scop, and Rhomboid- 
 
 Supra clavicular n. 
 Supra-acromial n. 
 Phrenic n. 
 N. to levator ang. scap* 
 
 N. to rhomboid 
 
 Subscapular n. 
 
 Subclavicular n. 
 
 JV. topectoraliQ major. 
 
 Circumflex n. 
 
 ^Musculocutaneous n. 
 
 Internal cutaneous n. 
 Small internal cutaneous fU 
 
 
 
 J>~-z-ii 
 
 
 0L.I 
 
 
 ilJjA 
 
 >— . rtio-nypogastrfc rt. 
 
 t 3 T^, 
 
 ^\..Ilic-lngutnal n. 
 
 ^^si/A 
 
 V^V_. External cutaneou9 
 
 4 T^^V 
 
 X. Qen ito-cru rain. 
 
 
 
 \v / \f 
 
 ^L— Anterior crural n. 
 
 
 Obturator n. 
 
 jr. to levator ani. r^v." 
 
 -V. to obturator int ^ 
 
 N. to sphincter ant. 
 
 Coccygeal n. 
 
 Co.I 
 
 Superior gluteal n. 
 
 A*, to pyriformla 
 
 N. to gemellus super. 
 
 ,N. lo gemellus Infer. 
 
 N. to quadratus 
 
 Small sciatic n. 
 Static n. 
 
 Fig. 489. — The Relations of the Segments of the Spinal Cord and Their Nerve- 
 roots to the Bodies and Splnes of the Yertebr.e. (Dejerine and Thomas, modified by 
 Starr.) 
 
 spinal (on each side of posterior surfaces of bodies of vertebrae) connected 
 by transverse branches, into which the venae basis vertebrae open (emptying 
 
632 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 into posterior longitudinal veins, the vertebral, intercostal, lumbar, and 
 sacral veins); two posterior longitudinal spinal (between posterior wall of 
 spinal canal and dura mater), emptying into anterior longitudinal, dorsal, 
 and spinal veins, (b) Medullary Veins; coming from substance of cord, 
 empty into the venous ring of each vertebra. 
 
 Nerves of the Spinal Region. — Spinal nerves (emerging through the 
 intervertebral foramina at a considerably lower level than their origin from 
 the cord) ; posterior divisions of the cervical, dorsal, and lumbar nerves ; 
 sympathetic ganglia and nerves. 
 
 Membranes of the Cord. — (1) Dura Mater; loose, strong, fibrous sheath 
 surrounding the cord — prolonged in tubular form around spinal nerves and 
 cauda equina — separated from spinal canal by lax areolar tissue and plexus 
 of veins which connect its rough external surface to periosteum and liga- 
 ments — extends from dura of brain to second or third sacral vertebra, and 
 thence to base of coccyx as sheath of filum terminale — its smooth inner surface 
 is separated by subdural space from arachnoid and is connected to cord by 
 ligamentum denticulatum (a special development of pia mater) — it sends 
 tubular prolongations around spinal nerves, which merge into their epineurium, 
 each tube being divided into an anterior compartment for anterior nerve-root 
 and posterior compartment for posterior nerve-root. (2) Arachnoid; con- 
 tinuous with cerebral arachnoid, surrounding cord down to second or third 
 sacral vertebra — separated from dura by subdural space — separated from 
 pia mater by subarachnoid tissue (subarachnoidean space, for cerebrospinal 
 fluid) — sends tubular prolongations along nerve-roots — connected to pia by 
 incomplete septum posticum. (3) Pia Mater; formed by two layers, only the 
 outer, stronger layer being continuous with cerebral pia mater — outer and 
 inner layers pass into anterior fissure of cord — only inner layer dips into 
 posterior fissure. Ligamenta denticulata — fibrous bands continuous with 
 pia, attached on either side of cord and externally to dura — not piercing 
 arachnoid but its denticulations receiving tubular sheaths from it — extending 
 from foramen magnum above and continuous with filum terminale below. 
 Linea splendens — a linear thickening on anterior surface of cord. Filum 
 terminale — prolongation of pia-matral covering of cord — attached to lower 
 end of sacrum or first piece of coccyx. 
 
 Spinal Localization. — The relation of the segments of the spinal cord 
 and their nerve-roots to the bodies and spines of the vertebrae is shown in 
 Fig. 489 — the distribution of the sensory nerves in the skin in Figs. 490, 491 — 
 and the symptoms in cross-lesions of the spinal cord in Figs. 492 to 508. 
 
 SURFACE FORM AND LANDMARKS OF SPINE AND SPINAL CORD. 
 
 The spinal cord extends from the upper border of the atlas to the lower 
 part of the body of the first lumbar vertebra, and is thence continued as the 
 ilium terminale to the lower end of the sacrum or the first piece of the coccyx. 
 At birth the cord extends to the third lumbar vertebra. 
 
 The cervical enlargement of the spinal cord extends from the third cervical 
 to the second dorsal vertebra, and the lumbar enlargement from the ninth 
 to the twelfth dorsal. 
 
 The anterior nerve-roots emerge from the cord along the antero-lateral 
 fissure, and the posterior nerve-roots along the postero-lateral fissure — and 
 unite near the outer part of the intervertebral foramina. The intrathecal 
 nerve-roots increase in length as they descend. 
 
SURGICAL ANATOMY OF THE SPINE AND SPINAL CORD. 
 
 6 33 
 
 Auriculotemporal 3 V, 
 
 Great oceipita 
 
 Lacrimal 1 V 
 
 Temporomalar 2 V 
 
 Small occipital C. P 
 
 Great auricular C. P. 
 
 Supraclavicular 
 * C. P. 
 Acromial branch 
 Middle branch 
 
 Circumflex E. P. 
 Interoostohumeral 
 
 Nerve of Wrisberg 
 
 B. P. 
 Exterual cutaneous 
 of musculospiial 
 B. P. 
 
 Internal cutaneous 
 B. P. 
 
 Musculocutaneous 
 B. P. 
 
 Median 
 B. P. 
 
 Ulnar B. P 
 Exterual cutaneous L. P 
 
 Branches from external 
 popliteal S. P. 
 
 Musculocutaneous S. P. 
 
 External saphenous S. P. 
 Anterior tibial S. P. 
 
 Supra-orbital 1 V. 
 
 Supratrochlear 1 V. 
 Intratrochlear 1 V. 
 Nasal 1 V. 
 
 Infra-orbital 2 V. 
 Buccal 3 V. 
 Mental 3 V. 
 
 Superficial cervical C. P. 
 
 Sternal branch 
 
 Anterior branches of intercostal 
 nerves 
 
 Lateral branches <>f intercostal 
 nerves 
 
 Iliohypogastric L. P. 
 Porsalis penis of pudic S. P. 
 Ilioinguinal L. P. 
 
 Genitocrural L. P. 
 Middle cutaneous L. P. 
 Internal cutaneous L. P. 
 
 Internal saphenous L. P. 
 
 Fig. 490.— Cutaneous distribution of nerves (after Flower). 
 
634 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 Great occipital, posterior branch or 
 second cervical 
 
 Third cervical 
 
 Posterior branches of spinal nerves 
 
 Lateral branches of intercostal nerves 
 
 Iliac branch of ilio-inguinal L. P. 
 Second lumbar 
 
 Inferior hemorrhoidal of pudic S. P. 
 
 Superficial perineal of pudic and 
 inferior pudendal of small 
 sciatic S. P. 
 
 Interior gluteal of small sciatic S. P. 
 
 Internal cutaneous L. P. 
 
 Internal saphenous L. P. 
 
 Auriculotemporal 3 V. 
 Small occipital C. P. 
 
 Great auricular C. P. 
 
 Supraclavicular 
 C. P., acromial 
 branch 
 
 Second dorsal 
 Circumflex B. P. 
 
 Intercostohumeral 
 
 Internal cutaneous 
 
 of niusculospiral 
 
 B. P. 
 Nerves of Wrisberg 
 
 B. P. 
 External cutaneous 
 
 of musculospiral 
 
 B. P. 
 Internal cutaneous 
 
 B. P. 
 Musculocutaneous 
 
 B. P. 
 
 Radial B. P. 
 Ulnar B. P. 
 
 External cutaneous L. P. 
 
 Branches from external 
 popliteal S. P. 
 
 External saphenous S. P. 
 
 Posterior tibial S. P. 
 
 Fi<r. 491.— Cutaneous distribution of nerves (after Flower). 
 

 
 
 
 
 
 
 
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642 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 The spinous processes of the vertebrae are found in the nuchal, dorso- 
 lumbar, and sacral furrows. The spines of the more central dorsal region 
 overlap each other considerably — those of the lower cervical and upper 
 dorsal but slightly — those of the lower dorsal slightly or not at all — and those 
 of the upper cervical and entire lumbar not at all. 
 
 The spinous process of the seventh cervical vertebra (vertebra prominens) 
 is generally easily located, and from this the spines of the vertebras above 
 and below are readily found by counting — all the spinous processes being 
 more prominent when the vertebral column is bent forward. Other less 
 accurate methods of locating the spines are sometimes used. When the arms 
 are at the side, the superior angle of the scapula corresponds, generally, to 
 the interval between the first and second dorsal spines (and the upper border 
 of the second rib) ; — the root of the spine of the scapula with the third dorsal 
 spine, or with the interspace between the third and fourth dorsal spines; — 
 and the inferior angle of the scapula with the seventh dorsal spine, or with the 
 interspace between the seventh and eighth (and sometimes with the eighth 
 rib). The twelfth dorsal spine corresponds with the head of the twelfth rib. 
 The third lumbar spine is generally slightly above the umbilicus, — and the 
 fourth lumbar spine is on a level with the highest part of the iliac crests. 
 
 The approximate relations of the origins of the roots of the spinal nerves 
 to the spinous processes of the vertebrae are, according to R. W. Reid, as 
 follows; — (a) Second Cervical arises opposite the arch of the atlas, — third, 
 from opposite the spine of the axis, — fourth, from opposite the interspace 
 between second and third spines, — fifth, sixth, seventh, and eighth arise 
 opposite the spine of the second cervical vertebra above the intervertebra' 
 foramen of exit of each nerve, (b) First, second, third, fourth, fifth, and 
 sixth Dorsal Nerves arise opposite the spinous processes of the third vertebra 
 above their respective foramina of exit, — seventh, eighth, ninth, tenth, eleventh, 
 and twelfth arise opposite the spines of the fourth vertebra above their respec- 
 tive foramina of exit, (c) Lumbar Nerves arise near the spines of the tenth 
 and eleventh dorsal vertebra?, (d) Sacral Nerves arise between the eleventh 
 dorsal and first lumbar spines. 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE 
 SPINE AND SPINAL CORD. 
 
 I. The General Considerations of the Osteoplastic Resection of the 
 Spine and of Laminectomy, and their Relative Values. — In an osteo- 
 plastic resection of the spine, a composite flap, consisting of skin, fascia, one 
 or more spinous processes, a set or more of corresponding laminae, and con- 
 necting ligaments, is partially excised en masse, with the constituent parts 
 adherent, and temporarily turned backward and upward, hinging upon its 
 own ligaments, thus exposing the portion of cord or spine involved, and is 
 finally dropped back into its normal place at the conclusion of the operation, 
 with practically all of its structures present and in natural relation. The 
 soft parts are at no time detached from the spines, and only partly and tem- 
 porarily detached from the laminae. 
 
 In the operation of laminectomy, or lamnectomy, as it is variously called, 
 the spinous processes and lamina?, with connecting ligaments, of two or more 
 vertebrae, are completely freed from surrounding structures, excised, and per- 
 manently discarded. Where, as has occasionally been done, the spinous 
 processes and laminae are temporarily preserved in warm normal salt solution 
 
SURGICAL CONSIDERATIONS IN OPERATIONS UPON SPINE. 643 
 
 and replaced in situ at the end of the operation, the procedure is not, strictly, 
 a laminectomy, but becomes a form of osteoplastic resection without all the 
 good points of the latter done in a typical manner. 
 
 In performing laminectomy an attempt, at least, should always be made 
 to do the operation subperiosteally, unless there be some pathological con- 
 traindication. Many surgeons, however, never attempt to free the spines 
 and laminae of their periosteum before their excision, and in the majority of 
 cases where it is undertaken it may be safely said that the subperiosteal feature 
 of the operation is carried out so imperfectly as to scarcely amount to a sub- 
 periosteal method at all, so great are the difficulties of preserving that mem- 
 brane in clearing these small and irregular bones. In the osteoplastic resection 
 there is no indication to work along subperiosteal lines. 
 
 The actual opening in the spine may be of practically the same size and 
 shape in both operations; but the tendency is to form a narrower bony opening 
 in laminectomy, and, of necessity, the field for manipulation is more contracted 
 than in osteoplastic resection, owing to the much nearer approximation of 
 the walls of the wound in the soft parts. 
 
 As to difficulty of execution, when one has practised both operations 
 equally, no appreciable difference in the difficulty of technique, worthy of a 
 determining consideration, is experienced. 
 
 It is not open to question that the laminectomy leaves a weaker spine than 
 does an osteoplastic resection, for the latter leaves, practically, an intact spine, 
 while the former leaves a spine minus as many spinous processes and laminae, 
 with their connecting ligaments, as have been cut out. Just how much weaker 
 laminectomy leaves the spine it would be hard to calculate; but it is self-evident 
 that a whole spine is better than part of a spine, even if only one-quarter or one- 
 third of two or three vertebrae have been permanently removed, and although 
 the bone thus represented be replaced by fibrous tissue, or partly fibrous and 
 partly bony. It is known that patients have sometimes not been able to sit 
 upright, or to hold their heads up, after laminectomy, necessitating the wearing 
 of a spinal support for some time. 
 
 Weighing all considerations involved in the selection of one or the other 
 method of approach, the choice of operation should, in the opinion of the writer, 
 be unquestionably given to the osteoplastic resection, as an altogether more 
 surgical procedure, — saving to the individual, as it does, practically all of his 
 structures, all save one spinous process, — leaving, after union, an almost 
 intact and necessarily stronger spinal column; affording a freer and fuller 
 field for inspection and manipulation at the time of operation; furnishing 
 greater subsequent protection to the spinal cord, and most probably furnishing 
 also greater immediate protection to the cord by reducing, in shutting off the 
 spinal canal, the chances of intraspinal infection in the event of non-primary 
 healing. 
 
 To summarize, it is safe to say that no operator who is equally skilful 
 in performing an osteoplastic resection and a laminectomy will hesitate in 
 choosing the former as the best procedure in the vast majority of cases; and 
 that if, on the other hand, he does, it is likely he is only familiar with the older, 
 cruder form of exposure with crushing and chiselling instruments and un- 
 familiar with, or unskilled in, the more modern technics. Whenever laminec- 
 tomy is elected in preference to osteoplastic resection, there being no special 
 indication for the former, the only partial justification there would seem to 
 be for the performing of laminectomy would be that it be done subperiosteally, 
 and, as already mentioned, there are those who feel that a subperiosteal laminec- 
 tomy is very rarely accomplished, even when definitelv undertaken by the 
 skilful. 
 
644 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 Before considering and illustrating the operations of osteoplastic resection 
 and laminectomy in detail, there are aspects of the technique which are common 
 to both operations and of a fundamental importance to their performance, 
 and which will, therefore, be first mentioned and pictured as briefly as con- 
 sistent with their understanding. 
 
 II. The Features Common to both Operations. — (i) Preparation of 
 Operation-site. — The region is shaved, whether visible hair be present or not, 
 and is made aseptic by the special antiseptic measures of the individual oper- 
 ator, the patient coming to the table with the part protected by dressings 
 applied after the preliminary preparation, the final preparation being made 
 at the time of operation. 
 
 (2) Position of Patient, Surgeon, and Assistants. — The patient lies upon a 
 specially narrow table, in the semiprone position, as nearly upon the front of 
 the chest as the conditions of anesthesia will allow, being supported by 
 cushions. The surgeon stands at the patient's back throughout most of the 
 operation, passing to the opposite side of the table and leaning over the chest 
 whenever it is more convenient to manipulate from that side. Two assistants 
 are useful — one at the surgeon's side, and another opposite him, on the other 
 side of the table, bending over the patient. 
 
 (S) Anesthesia. — Nitrous oxide and ether, unless contraindicated for special 
 reasons. 
 
 (4) Instruments and Accessories. — Heavy cartilage knife and medium 
 knife; artery-clamp forceps; dissecting forceps; two pairs of special retractors 
 with teeth blunt and long enough to reach the bottom of the wound; chisel 
 about two centimeters (about three-quarters of an inch) wide; Doyen saw; 
 Gigli saw; probe with thin, flat end; curved, heavy scissors for interspinous 
 and interlaminous ligaments; small angular scissors for incising membranes 
 of the cord; two small, toothed forceps for membranes; large and small needle- 
 holders; fine, fully curved needles for membranes; heavy curved needles for 
 buried muscle sutures; straight needles for skin; plain fine catgut for mem- 
 branes; twenty-day chromic gut for buried muscle sutures; silkworm gut, or 
 silk, for skin sutures; horse-hair or catgut for intradural drainage; tubing or 
 gauze for extraspinal drainage; gauze for packing wound; hot normal salt 
 solution for hemorrhage. 
 
 (5) Landmarks of Operation. — The spinous processes corresponding with 
 the lamina? to be removed should, if possible, be very clearly located before 
 beginning the incision. This can always be done in backs of medium thick- 
 ness, and generally in moderately thick backs upon deep pressure. The trans- 
 verse processes in the dorsal and lumbar regions and the articular processes 
 in the cervical region should also be located, in the case of the osteoplastic 
 resection, if it be possible; but often cannot be determined until after the skin 
 and fascia have been incised in the operation last mentioned. 
 
 (6) Manner of Incising Muscles and Aponeuroses. — While this is not a 
 major point, attention to the principle involved will insure a more cleanly 
 cut section in the case of osteoplastic resection, and a more complete clearing 
 of soft parts from the spines in laminectomy than if the principle were not 
 observed. One is familiar with the fact that the spines of a feather may be 
 more readily and cleanly stripped from the quill by cutting from tip to base 
 than by cutting in the opposite direction. Therefore, will the section of 
 muscles and aponeuroses be more cleanly and evenly made if made by a stout 
 knife wielded in such a manner as to cut into, or toward, the more acute 
 angle formed by the attachment of the muscular or aponeurotic fibers to the 
 parts of the vertebral column, rather than toward the more obtuse angle; 
 
SURGICAL CONSIDERATIONS IN OPERATIONS UPON SPINE. 
 
 645 
 
 and especially is this the case the nearer the spinous processes one approaches. 
 This will sometimes necessitate cutting toward the head, sometimes toward 
 the sacrum, according to the direction of the fibers at the site of operation, 
 and may require stepping to the opposite side of the table. Practically, two 
 
 \ 
 
 m 
 
 -■ 
 
 Fig. 509. — Muscles of Dorsal Region of Back, showing that Muscular axd 
 Aponeurotic Fibers are more Cleanly Divided by Cutting t< ward the more Acute 
 Angle formed by their Attachment to Bony Structures. (Modified from Gray's "Anat- 
 omy.") 
 
 changes in the direction of the incision on either side of the median line will 
 fulfil these indications. It will, therefore, be seen that it is not advised to cut 
 from skin to bone or even from fascia to bone, at one stroke, but rather with 
 three,— one through skin and fascia and two through the musculo-aponeurotic 
 
6 4 6 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 structures, — retracting between each incision, such a procedure furnishing a 
 wound with less raggedly cut walls (Fig. 509). 
 
 (7) Manner of Clearing Soft Parts from Spines and Lamina;. — This, as 
 usually done, is accomplished by the combined use of cartilage knife, perios- 
 teal elevator, and raspatory, with more or less satisfactory result. The clean- 
 ing of the bones may, however, be much more thoroughly done, and by a 
 single instrument, by using an ordinary chisel. When the incisions have been 
 carried fully to the bones, a knife is no longer necessary. Through the incision 
 made by the knife, a chisel (about two centimeters, or about three-quarters 
 of an inch, wide) is carried directly to the depth of the wound, guided, if 
 necessary, by the surgeon's left index-finger, and so directed that its bevelled 
 edge will be turned away from the soft parts to be pried from the bones. In 
 osteoplastic resections the blade of the chisel rests against the transverse proc- 
 esses in the dorsal and lumbar regions, and against the articular processes, 
 
 Fig. 510. — Dorsal Vertebra, showing results of Incisions begun at Relatively 
 Corresponding Sites and passing through Lamina in Different Directions: — A, Proper 
 section, cutting lamina at right angle to its surface and entering spinal canal; B, Improper section 
 passing through lamina parallel with general direction of spinous process and entering pedicle 
 of vertebra and passing on into body. (Modified from Quain's "Anatomy."; 
 
 partly covered by muscles, in the cervical region, and, from these as fulcra, 
 the soft parts are levered off toward the spines (Fig. 515, D). In a laminec- 
 tomy the chisel-blade rests against the spinous processes, and from these as 
 fulcra the soft parts are pried out of the bony groove toward the transverse 
 processes in the dorsal and lumbar regions, and articular processes in the 
 cervical (Fig. 519, C). This use of the chisel is exceedingly satisfactory, 
 its sharp edge easily and thoroughly removing all the soft parts, and probably 
 leaving a cleaner bony bed for the saw than is accomplished in any other way. 
 This result is not so well secured if the bevel of the chisel is turned toward the 
 parts to be removed. 
 
 (8) Manner of Dividing the Lamina?. — This step, in either operation, is of 
 paramount importance, and the manner of its performance, as far as the actual 
 making of the saw-cut is concerned, is the same, whether the operation be 
 
SURGICAL CONSIDERATIONS IN OPERATIONS UPON SPINE. 647 
 
 osteoplastic resection or laminectomy. And the principle is also the same, 
 as far as the direction of the section is concerned, no matter with what form 
 of instrument the division of bone be made. This important principle is that 
 the instrument should have its edge placed upon the lamina? at or a little to 
 the outer side of their center, and be made to cut its way through the laminae 
 strictly at a right angle to the general direction of their surfaces (Fig. 510, A). 
 Even if the edge of the bone-cutting instrument enter in about the same site 
 as just described, and the section be made, as so often done by beginners, 
 parallel with the general direction of the spinous processes, the chances are 
 that the section wall pass on into the solid articular processes and pedicles, 
 and, if continued, on into the bodies of the vertebrae (Fig. 510, B). The 
 writer has observed the marked tendency to this serious error upon the part 
 of students, who really often do not appreciate their difficulty until it is pointed 
 out to them upon the skeleton. The error, once made, is hard to correct; 
 it. is absolutely impossible to go ahead upon that straight line; it is hard to 
 start a new saw-cut, and often, much chagrined, one is at a loss to know what 
 to do and is tempted to chisel his way through. It is better, however, to perse- 
 vere with the saw until the groove of a new cut is made in the right direction. 
 
 (9) Instrument for Making the Bone-sections. — Doyen's saw, in the judg- 
 ment of the writer, is the instrument, par excellence, for all bone-sections which 
 are necessary in exposing the spinal cord and canal. It is useless to more than 
 mention the many means that have been resorted, to to divide the parts of the 
 vertebrae, such as excision of the spines with bone-pliers, followed by cutting 
 away the laminae with bone-cutting forceps, or sawing them off with Gigli or 
 chain saw; dividing the laminae directly by bone-cutting forceps, one blade 
 of which has been thrust through an interlaminous ligament; chiselling through 
 the laminae in parallel lines (at the cost of much jarring and irregular division) ; 
 the use of small trephine-openings, the intervening laminae being cut away, 
 and the use of the Hey saw. Doyen's saw is, practically, a Hey's saw with 
 an adjustable guard (Fig. 419). 
 
 (10) Hartley's Preliminary Excision of the Spinous Process immediately 
 above the Flap in Osteoplastic Resection of the Spine. — While this procedure 
 is not common to both osteoplastic resection and laminectomy, and conse- 
 quently does not strictly come under this division of the subject, yet it is a fun- 
 damental feature of the osteoplastic resection, and its general principles will, 
 therefore, be briefly described here. It is difficult to see how an osteoplastic 
 resection is possible without first removing the spine immediately above the 
 flap to be turned back. Most markedly in the dorsal region, and even in the 
 cervical and lumbar regions, will any lower spine quickly become interlocked 
 with the one just above if an attempt be made to turn it backward and upward. 
 So that without the preliminary excision of the spine above, the flap below 
 can only be turned backward and upward by main force, and often a con- 
 siderable degree of force is necessary, during the exercise of which bony por- 
 tions of contiguous vertebrae may be broken, or other damage done. This 
 preliminary step to the main operation may, therefore, be regarded not only 
 as a most useful feature, but almost as a sine qua non of the operation as a 
 whole. The manner of its execution will be described more in detail under 
 the osteoplastic resection. 
 
 (11) Control of Hemorrhage. — The three stages at which hemorrhage is 
 apt to be encountered are: After making the skin and fascial wound; during 
 the incision of the muscles of the back; and after opening the spinal canal, 
 in removing or incising the vascular fatty areolar tissue from around the mem- 
 branes. Hemorrhage from visible vessels encountered prior to reaching the 
 
6 4 8 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 spine should be controlled by artery-clamp forceps, followed by ligature 
 or torsion. General oozing and hemorrhage from undetectable sources 
 (which form the chief bleeding) should be arrested by gauze packing, or by 
 flushing with hot normal salt solution, and by alternately working upon the 
 two sides of the wound. Intradural bleeding from the vascular fatty areolar 
 tissue surrounding the cord, and which is chiefly venous, should be stopped 
 by pressure with gauze held in forceps. 
 
 Fig. 511. — Lines of Skin Incisions in Relation to Underlying Bones in Osteo- 
 plastic Resection* and in Laminectomy : — A, Line to remove seventh dorsal spine in Hartley's 
 preliminary operation of excising the spinous process of the vertebra immediately above those 
 forming part of the osteoplastic flap; B, modified U-shaped incision outlining the osteoplastic 
 flap for turning back the eighth and ninth dorsal spines and lamina;; C, line of incision for 
 laminectomy of third, fourth, and fifth dorsal spines and lamina;. (Drawn from the skeleton.) 
 
 OSTEOPLASTIC RESECTION OF THE SPINE. 
 
 Description. — See page 642, above. 
 Preparation. — See page 644, above. 
 Position. — See page 644, above. 
 Landmarks. — See page 644, above. 
 Incision. — See page 652, below. 
 
 Operation. — Two distinct operative steps are here undertaken, — the pre- 
 liminary excision of the spinous process above the flap, and the formation 
 
OSTEOPLASTIC RESECTION OF THE SPINE. 
 
 649 
 
 and turning-back of the osteoplastic flap. The nature of the operation has 
 been briefly described under General Considerations. 
 
 (A) Preliminary Excision of the Spinous Process Immediately Above the 
 Osteoplastic Flap (Hartley's Operation). — This preliminary operation may be 
 considered under the following headings: Incision; Exposure of Spinous 
 Process; Severing of Supra- and Inter-spinous Ligaments; Excision of Spine; 
 Temporary Packing of Preliminary Wound; Final Suturing of Preliminary 
 Wound. 
 
 Fig. 512. — Osteoplastic Resection or the Spine; Hartley's Preliminary Operation 
 for Excising the Spine of the Vertebra Immediately above the Flap: — A, A, Retractors 
 in the wound, also serving as protectors of soft parts; B, H, Gigli saw in position for excising the 
 entire spinous process. (Drawn from cadaveric operation.) Note: — The subperiosteal method 
 is not shown here. 
 
 (1) Incision. — A vertical incision is made directly in the median line; its 
 center over the spinous process to be excised, and extending in length from 
 the tip, or near the tip, of the spine above to the tip, or near the tip, of the 
 spine below (Fig. 511, A, and Fig. 514, B). 
 
 (2) Exposure of the Spinous Process. — The above incision is carried through 
 skin and fascia directly onto the spinous process mentioned. The lips of the 
 wound are then well retracted, and the spine in question is exposed fully to 
 its base by prying away the overlying and closely attached soft parts by means 
 of a chisel used against the spine as a fulcrum, in the special manner described 
 
650 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 under General Considerations. This freeing having been accomplished, 
 the soft parts are strongly drawn aside by means of retractors, which also 
 serve the part of protectors of the soft parts during the use of the saw (Fig. 
 512, A, A). A subperiosteal exposure of the spine should be attempted. 
 
 (3) Severing of Supra- and fiiler-spiiious Ligaments. — These ligaments 
 are now to be divided, both in order to sever this spine from the one below 
 and to prepare a passage for the Gigli saw. This division of ligaments may 
 be made with a knife, but can be better and more readily accomplished by 
 means of curved scissors whose concavity is held upward. Having passed 
 through the supraspinous ligament, the inter-spinous ligament is divided down 
 to the ligamenta subflava. The spinal canal should not be opened in this 
 procedure. 
 
 (4) Excision of the Spinous Process. — A passageway having been thus 
 
 Fig. 513. — Hartley's Method or Preliminarily Excising the Spinous Process Imme- 
 diately ABOVE THE LAMIN/E TO BE TEMPORARILY TURNED BACK IN OSTEOPLASTIC RESECTION 
 
 OF the Spinal Column. The use of bone-cutting pliers is here shown. 
 
 provided, a Gigli saw is carried deeply down to the very base of this spinous 
 process and the entire process removed (Fig. 512, B, B). Care is exercised 
 to avoid making but a partial excision, as the remaining stump may interfere 
 with the turning back of the flap almost as much as though the entire spine 
 were in situ. Some operators cut the spine off with bone-cutting forceps 
 (Fig. 513); but the use of bone-cutting pliers here, as in many other instances, 
 is unsurgical, removing, as they do, by a crude process of crushing, a part of 
 bone which is much more cleanly and less traumatically cut away by a Gigli 
 or other form of saw. 
 
 (5) Temporary Packing of the Preliminary Wound. — The spine of bone 
 having been removed, the preliminary operation is for the time being ended. 
 The further use of this wound will be described in connection with the turning 
 back of the osteoplastic flap. Some operators here permanently suture up 
 
OSTEOPLASTIC RESECTION OF THE SPINE. 
 
 651 
 
 the wound left by the excision of the spinous process; but it is distinctly best 
 not to do so, as will be evident farther on. This wound should be tightly 
 packed with gauze and temporarily left alone. 
 
 (6) Final Suturing of the Preliminary Wound. — At the conclusion of the 
 entire operation the preliminary wound is sutured upon the same general 
 
 Fig. 514. — Region of the Spinal Column and Cord: — A, Position for incision in lami- 
 nectomy of fourth, fifth, and sixth cervical vertebras; B, Position for incision in Hartley's pre- 
 liminary excision of a spinous process (of sixth dorsal vertebra) preceding osteoplastic resection; 
 
 C, Position of incision in an osteoplastic resection of seventh, eighth, and ninth dorsal vertebras; 
 
 D, Lumbar puncture between the fourth and fifth lumbar laminas, for spinal analgesia. 
 
 principles to be described for the main wound, namely, buried chromic gut 
 sutures to bring the muscle and aponeurotic structures together in the space 
 formerly occupied by the now excised spinous process, and silkworm-gut, or 
 silk, for the skin wound, no drainage being used (Fig. 518, A, A). 
 
 (B) The Formation and Turning Back of the Osteoplastic Flap. — This, the 
 
652 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 main operation, will be considered under the following divisions: Incision; 
 Division of Muscles and Aponeurosis; Freeing of Laminae Preparatory to 
 their Division; Division of Laminae and Ligamenta Subflava; Division of 
 Supraspinous, Interspinous, and Interlaminous Ligaments; Separation and 
 Turning Back of Osteoplastic Flap; Freeing of Spinal Cord from Extradural 
 Fatty Areolar Tissue and Control of Intraspinal Hemorrhage; Opening of 
 Membranes of Cord; Manner of Dealing with Incised Membranes; Reposition 
 of Cutaneomusculo-osseous Flap; Deep Buried Suturing of Muscles and 
 Aponeurosis; Skin and Fascial Suturing; Provision for Drainage when Indi- 
 cated; After-treatment; Comment. 
 
 (i) Incision. — A modified U-shaped incision is used. This incision out- 
 lines the two sides and lower limit of the composite flap of skin-muscle-aponeu- 
 rosis-bone-and-ligament to be temporarily turned back (Fig. 514, C). Its 
 two strictly vertical limbs. begin over the lamina' of the vertebra whose spine 
 is to be excised, commencing to the outer side of its vertical center, near the 
 root of the transverse process in the dorsal and lumbar regions, and near the 
 base of the articular process in the cervical vertebras, and extend, on both sides, 
 downward in straight lines, parallel with the tips of the spinous processes, 
 until opposite the tip of the last spine to be included in the resection; here 
 the incisions broadly curve toward the median line, meeting midway between 
 the tip of the spinous process just mentioned and the tip of the spinous process 
 next below. It is very essential that this broad curve should be given to the 
 lower end of the incision rather than that a narrow contracted curve be made, 
 much of the ease of subsequent manipulations depending thereon. For the 
 purpose, solely, of providing a greater influx of blood into the base of the semi- 
 detached flap of skin-muscle-and-bone, a slightly outward curve may be 
 given to the upper ends of the vertical portions of the U-shaped incision (Fig. 
 511, B). These curves, however, are awkward if the limbs of the incision 
 have to be extended upward. It might be asked how the bases of the trans- 
 verse processes of the dorsal and lumbar vertebra; and the bases of the cervical 
 articular processes may be recognized prior to the skin-incision; in reply to 
 which it may be said that the tips of these processes themselves (transverse 
 and articular) may generally be felt upon firm pressure made upon backs of 
 medium thickness, and, having recognized the tips of these processes, their 
 corresponding bases lie approximately midway between their tips and the 
 median line formed by the apices of the spinous processes. Where the tips 
 of the transverse processes of the dorsal and lumbar vertebrae and tips of the 
 articular processes of the cervical vertebrae cannot be recognized by palpation 
 at all, it may be stated that the tips of the transverse processes of the dorsal 
 vertebrae lie, in the average skeleton, about 3 to 3.5 centimeters (one and 
 one-fourth to one and three-eighth inches) from the tips of the dorsal spines, 
 the tips of the lumbar transverse processes about four to five centimeters 
 (one and five-eighth to two inches) from the tips of the lumbar spines, and 
 the tips of the cervical articular processes about three centimeters (one and 
 one-fourth inches) from the centers of the cervical bifid spines. 
 
 (2) Division of the Muscles and Aponeuroses. — The direction of the incision 
 through the layers of muscles and aponeuroses at the different layers, and the 
 reasons therefor, have been given above under General Considerations (page 
 644). The incision through skin and fascia will, upon retraction, have exposed 
 muscle or aponeurosis, according to the site of operation. The margins of 
 the skin and fascial wound having been retracted and hemorrhage controlled, 
 the muscular and aponeurotic layers in view are incised in a general direction 
 which will correspond with the acuter of the two angles which their component 
 
OSTEOPLASTIC RESECTION OF THE SPINE. 
 
 653 
 
 fibers make with the spine, and the layers below similarly incised. Imme- 
 diately prior to deepening the muscle incision down to the bone, it is advisable 
 to satisfy one's self, by means of a finger introduced into the wound, that the 
 vertical limbs of the U-shaped incision are falling well within the bases of the 
 transverse processes in the dorsal and lumbar regions and within the tips of the 
 articular processes in the cervical region. This precaution will insure the 
 coming of the incision down upon the spinal column over the laminae, which 
 will make the clearing of the laminae correspondingly easy. 
 
 Fig. 515. — Osteoplastic Resection of the Spine: — A, Position of dorsal spines; B, 
 Wound of Hartley's preliminary excision of spinous process immediately above flap; C, C, C, C, 
 Retractors of main wound; D, Chisel, against transverse processes as fulcra, in act of prying 
 soft parts from laminar, E, Lamina; F, Interlaminous ligament (ligamentum subflavum); G, 
 Doyen's saw in act of completing section through lamina? and interlaminous ligaments. (Drawn 
 from cadaveric operation.) 
 
 (3) JPreeing the Lamina Preparatory to their Division. — The gauze packing 
 is now removed from that side of the U which was first incised and packed, 
 by which time the hemorrhage, which is usually rather free, has ceased. While 
 instrumental retraction should be practised during the latter stage of the 
 freeing of the laminae, it is not necessary, and is certainly better omitted 
 during the beginning of the freeing, owing to the small amount of room in 
 the wound for finger and chisel. At the stage when retractors are used, they 
 should have blunt hooks, to avoid wounding the fingers of operator and assist- 
 ants, which are also in the wound; and they should be long enough to reach 
 to the bottom of the incision. Proceeding, therefore, at first without retractors, 
 
654 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 the left index is introduced into the wound until its tip is in contact with the 
 laminae. An ordinary chisel, as mentioned in the Introduction, is now inserted 
 alongside of the already introduced finger, with its edge parallel with the 
 direction of the spines and with the bevel turned away from the parts to be 
 pried from the laminae, in the manner already described. A path for the 
 Doyen saw is thus made over those laminae which are to be temporarily turned 
 back, — the chisel being used as a lever, — braced against the transverse proc- 
 esses in the dorsal region, against the articular and transverse processes in 
 the lumbar region, and against the articular processes in the cervical region, 
 and, with these as fulcra, is made to pry the overlying soft parts from the bony 
 groove formed by the laminae and interlaminous ligaments (Fig. 515, D). 
 While the major portion of this clearing of the saw-bed can be accomplished 
 by manipulating the chisel from the aspect of the transverse and articular 
 processes toward the base of the spines, a still more thorough completion of 
 the clearing can be secured by withdrawing the chisel, turning it around (so 
 that the bevel is toward the transverse processes), and also using it against 
 the spines, covered by their soft parts, as fulcra, while prying away from the 
 laminae those soft parts lying nearer the transverse and articular processes. 
 This manipulation is shown in Fig. 519, C, where the principle is used in 
 the laminectomy operation. Not only should the special laminae and inter- 
 laminous ligaments involved in the resection be completely cleared of oyerlying 
 soft parts, but the lower half of the laminae above and the upper half of the 
 laminae below these should also be freed, as it will be necessary for them to 
 accommodate the end of the saw in its excursions. This additional clearing 
 is shown in Fig. 515. When the saw-bed upon one side has been thus pre- 
 pared, it is firmly packed with gauze, to control bleeding, while the opposite 
 side is being similarly prepared and packed. 
 
 (4) Division of Lamina: and Ligamenta Subflava. — The edges of each of 
 the vertical limbs of the wound should be retracted, one at a time, by four 
 special retractors with extra-long blunt teeth, the wound presenting a rec- 
 tangular shape (Fig. 515, C, C, C, and a small unlettered retractor). The 
 guard of the Doyen saw is set at ten millimeters (about seven-sixteenths of 
 an inch), which will give a sufficient cutting-edge to pass completely through 
 the laminae at any portion of the spine, provided the section be made well 
 within the laminae proper, and at a right angle to their surface. With the 
 guard thus set it is simply impossible to wound the cord (the cord and spine 
 being normal), not that the bone is here ten millimeters thick, but because the 
 saw will bind after traversing the bone part of the way. As a matter of fact, the 
 guard may be entirely dispensed with ; though under such circumstances care 
 is necessary, and the saw must be checked immediately upon the sense of 
 lost, or lessening, resistance, as the last thickness of the laminae is encountered. 
 ( )ne has frequently thus used the saw upon the cadaver without other than 
 the most ordinary precautions, and has never seen injury done in such cases; 
 nor has he but once ever seen the cord injured by a student during the roughest 
 manipulation, independently of the form of instrument used for the bone 
 division, so securely is the cord ordinarily protected by its position. The 
 saw, protected by the guard at ten millimeters, should be used until it has cut 
 its way completely through and is stopped by the shoulder of the guard. The 
 sweep of the saw at each stroke should be as full as the length of the wound 
 will allow; and the general cutting-edge of the saw should be held as level as 
 circumstances will permit, that the bone-section may be made of equal depth 
 throughout as great a length of the wound as can be reached in one position 
 of the saw. It is usually impossible to complete the section of one side with 
 
OSTEOPLASTIC RESECTION OF THE SPINE. 
 
 655 
 
 the saw in one position, owing to the shape and position of the handle of the 
 saw, as the end of the saw nearer the handle will not travel the full length of 
 the wound quite as satisfactorily as the distal end. Fig. 515, G, illustrates 
 this principle. The surgeon, therefore, standing at the patient's back, intro- 
 duces the saw first into one side and then into the other, using the instrument 
 from below upward and sawing through the lower half of the laminae above 
 those to be turned back, as well as through as many of the laminae to be resected 
 as the teeth of the saw will engage themselves in. When division of the upper 
 
 Fig. 516. — Osteoplastic Resection of Spine: — A, A, A, A, Retractors in main wound; 
 
 B, Surgeon's left index-finger introduced into preliminary wound to aid in bending back of flap; 
 
 C, Curved scissors cutting interspinous and interlaminous ligaments; D, Chisel introduced 
 into saw-cut and supported against transverse processes as fulcra, prying out osteoplastic flap; 
 E, Opposite saw-cut, the flap being levered out. (Drawn from cadaveric operation.) 
 
 parts of both sides has been made, the surgeon, unless ambidextrous, must 
 walk around the table, lean over the thorax of the patient (in his semiprone 
 position), and, sawing now from above downward, complete the section of 
 those laminae to be temporarily turned back, as well as of one-half of the laminae 
 next below. The depth of the bony section may be tested from time to time 
 by means of the flat end of a specially thin probe. This division of one-half 
 of both the laminae above and below those to be temporarily displaced is only 
 
656 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 necessary because unavoidable, as the saw-blade cannot be carried abruptly 
 up to the limit of one lamina and completely divide it without also at least 
 partly dividing a portion of the contiguous lamina (Fig. 515, E). But no 
 practical harm is done thereby, as only a very small proportion of these two 
 sets of laminae is divided by the very fine blade of the saw, and must soon 
 solidify. The ligamenta subflava are also divided by the saw (Fig. 515, F). 
 
 (5) Division of the Supraspinous, Inter spinous, and Interlaminous Liga- 
 ments. — The lowest one of the spines in the osteoplastic flap, with its corre- 
 sponding laminae, is now to be severed from the corresponding intact structures 
 next below, involving the division of the above-mentioned ligaments. These 
 ligaments may be divided with a knife held sidewise, but are more satisfactorily 
 divided by a pair of curved scissors held with their concavity backward (Fig. 
 516, C). The process of division is aided by grasping the composite flap to 
 be displaced and lifting the lowest spine away from its neighbor next below, 
 thus giving the scissors more room for dividing the V-shaped ligamentous 
 structure formed by the supraspinous and interspinous ligaments posteriorly 
 and the ligamenta subflava to either side. 
 
 (6) Separation and Turning Back of the Osteoplastic Flap. — The detach- 
 ment or loosening of the resected portion of the spinal column is best accom- 
 plished by means of the same chisel used in clearing the soft parts from the 
 bones, and held in the same way, that is, with the non-bevelled edge toward 
 the part to be pried out. Preparatory to thus using the chisel as a lever, the 
 edges of one of the vertical limbs of the wound are retracted by the four special 
 retractors mentioned above (Fig. 516, A, A, A, and a small unlettered 
 retractor), the parts sponged dry with gauze, and the saw-cut brought well 
 into view. The surgeon's left index-finger should be introduced into the pre- 
 liminary wound through which the spinous process has been removed (Fig. 
 516, B), carried down to its sawn-off end and adjacent interlaminous ligaments, 
 and held there until the composite flap has been pried out of its site, the tip 
 of the finger greatly aiding in this manoeuvre and in determining the progress 
 of the elevation. The chisel is placed in position, with its bevelled side against 
 a transverse process (in the dorsal or lumbar region) or against an articular 
 process in the cervical region, and its edge, with non-bevelled surface toward 
 the spines, engaged in the saw-cut (Fig. 516, D). The composite mass is 
 seized between the surgeon's left thumb and index and steadied and gently 
 drawn away during the prying-out process. Ordinarily, a single, light, down- 
 ward pressure of the handle of the chisel will suffice to start the composite 
 flap from its normal site, after which the entire flap can be readily turned back. 
 This is always so if the section of bones and ligaments haye been previously 
 made complete, which should invariably be the case, and verified by sounding 
 along the entire line of section with the flat end of a thin probe. Should the 
 flap not readily, and without force, start backward, it argues that the section 
 has not been fully made; and there is no alternative but to lay down the chisel 
 and complete the division of bone with the Doyen saw, or of the ligaments 
 holding the last spine and laminae with scissors, as may be indicated, before 
 going on with the levering-out process. As soon as the section is felt to be 
 started from its bed sufficiently to get the end of the finger under the tip of the 
 lowest one of the spinous processes, all instruments may be laid aside. With 
 the left index-finger still in the preliminary wound through which the spine 
 has been removed, pressing down between the stump of the excised end and 
 the upper margin of the laminae below, and with the right index under the last 
 spine of the flap, the entire mass is turned backward and upward onto the 
 patient's back (Fig. 517, A). The backward displacement of this flap is 
 
OSTEOPLASTIC RESECTION OF THE SPINE. 
 
 657 
 
 accomplished in the following way: The mass hinges over the stump of the 
 excised spinous process, the interlaminous ligaments serving as the hinge; 
 
 Fig. 517. — Osteoplastic Resection of the Spine: — A, Tenaculum-forceps holding back 
 composite flap; B, B, Delicate forceps grasping and elevating membranes and forming a trans- 
 verse ridge; C, C, Tenacula holding apart edges of incised membranes; D, Angular scissors 
 used in incising membranes; E, Half-button of bone bitten out of lower margin of last lamina 
 in flap by rongeur forceps; F, Similar half-button bitten out of upper margin of next stationary 
 lamina below, the two half-buttons forming a circular opening, when in contact, for drainage; 
 G, Vascular fatty areolar tissue covering membranes. The stump of the excised spine is shown, 
 in impression, through the turned-back flap. (Drawn from cadaveric operation.) 
 
 at the maximum of tension of the parts the upper border of the detached 
 laminae below is pried downward and outward from under the lower border 
 of the intact laminae above, and then slightly rides up over the latter in the 
 
658 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 turning-back process. This manoeuvre does not so fully occur in the lumbar 
 region, and but slightly, if at all, in the cervical region, owing to the different 
 deposition of these lamime and their wider separation from each other. If 
 the line of bone-section have fallen well within the articular processes, the 
 joints of the articular processes will not be opened. This manipulation, though 
 exercising some violence upon the structures entering into the make-up of the 
 interlaminous relations at the hinge, does no permanent harm, as the parts 
 readily drop back into their normal relationship at the end of the operation 
 and undoubtedly soon solidify. The composite flap, once turned back, will 
 generally lie in situ without restraint, or may be held so with a light retractor 
 or tenaculum-forceps (Fig. 517, A). 
 
 (7) Freeing of the Spinal Cord from the Extra-dural Fatty Areolar Tissue, 
 and Control of Intraspinal Hemorrhage. — Having turned back the osteoplastic 
 flap, the window in the spinal column is shown, corresponding in length with 
 the number of lamina? resected, and in width with the distance apart of the 
 saw-cuts (Fig. 517). In some cases the membranes of the cord lie readily 
 within view and touch through the window thus formed, surrounded by a 
 minimum of connective tissue. In other cases a more or less thick layer of 
 vascular fatty areolar tissue may intervene between the bone and the cord 
 (Fig. 517, G). To reach the membranes, this layer must be removed, which 
 is best accomplished by grasping it with delicate forceps and cutting it with 
 fine angular scissors. The hemorrhage which results from this manoeuvre, 
 and which may be somewhat marked, is usually readily controlled by the 
 pressure of gauze held in small forceps. The hemorrhage will be less if this 
 vascular tissue, chiefly venous, be cut accurately in the median line. Upon 
 the removal of this fatty connective tissue the white, glistening membranes of 
 the cord are brought into the field. If the object of the operation have been 
 only to expose the membranes, that object is now accomplished. If the cord 
 itself is to be exposed, other steps are necessary. 
 
 (8) Opening of the Membranes of the Cord. — The most satisfactory manner 
 of incising the membranes which the writer has found is the following: Two 
 pairs of delicate, toothed forceps are taken, one held in the surgeon's left hand 
 and one in an assistant's right hand (Fig. 517, B, B) ; each of these, on the 
 same level, takes a light hold upon the membranes of the cord about three 
 millimeters (approximately one-eighth of an inch) from the median line of 
 the membranes (making the forceps six millimeters, or one-fourth of an inch, 
 apart), care being taken that the membranes alone are grasped. The tips 
 of the forceps are now drawn gently outward and upward, away from the under- 
 lying cord, whereby a marked transverse ridging of the membranes is produced 
 at a right angle to the length of the cord. While thus held, this ridge is cut 
 with the points of a pair of small, angular scissors held in the right hand of 
 the operator (Fig. 517, D). Having made an opening in the membranes, 
 the lower blade of the scissors is passed along between the cord and theca, 
 and the incision extended to the desired length, the holds of the forceps being 
 shifted as the incision advances, and being subsequently maintained to retract 
 the incised membranes, or the edges of the cut theca may be held apart with 
 fine tenacula (Fig. 517, C, C). Upon the wide retraction of the cut mem- 
 branes the spinal cord and the exit of the nerve-roots from the cord are brought 
 well into view. The special object of the operation, if it involve the cord, 
 is now carried out. The present chapter deals solely with the manner of exposing 
 the cord and canal, the various special conditions for which this exposure 
 may have been made not being taken up. 
 
 (9) Manner of Dealing with the Incised Membranes. — This will pre- 
 
OSTEOPLASTIC RESECTION OF THE SPINE. 659 
 
 eminently depend upon the nature of the special operation. All bearings of 
 the operation being favorable, it is best to close the membranes after the carry- 
 ing out of the special object in view. This is done with fine, plain catgut 
 threaded upon a specially adapted, fully curved needle held in an appropriate 
 needle-holder. The margin of each lip of the cut theca is brought into proper 
 relationship for suturing by being held by the delicate toothed forceps used 
 in steadying the membranes during the incision of its structures. A continuous 
 suture completely closing the incision is preferable. 
 
 (10) Reposition of the Ciiianeoniusculo-osseous Flap. — The object of the 
 operation, as a whole, having been fulfilled, the composite flap will often fall 
 back into accurate apposition without any effort to make it do so. It is, how- 
 ever, better for the surgeon to reinsert his left index into the preliminary wound 
 through which the spinous process has been excised, and carry this finger down 
 to the stump of the excised spine (Fig. 516, B), while with his right hand he 
 replaces the flap, thus having a better opportunity to verify the accurate fitting 
 of the parts. This fitting of the structures back into their original relationship 
 should be absolute; and, fortunately, it is easy to determine whether or not 
 it is so, and equally easy to make it so if there seems to be difficulty. This 
 replacement is brought about by manual manipulation alone, the left index 
 in the small wound guiding the parts at their hinge-junction. The accuracy 
 of the apposition is verified by exposing the saw-cuts, and seeing that the parts 
 of the laminae on either side of the section line are on an exact level; and, when 
 this is the case, it will be found that the shelving surfaces of the contiguous 
 laminae, where the interspinous and interlaminous ligaments were cut, are in 
 accurate apposition, that the spines are in line and on a level, and that the 
 skin margins come easily and evenly together. 
 
 (11) Buried Suturing of Muscles and Aponeuroses. — Having readjusted 
 the composite flap, the soft parts intervening between skin and bone should 
 be brought together by deeply buried sutures (Fig. 518, C). One would 
 give the preference to twenty-day chromic gut, fairly stout, carried upon a 
 fully curved needle. The cut muscles and aponeuroses are brought together 
 in their proper layers and relations in the bite of heavy forceps, and are thus 
 held while being penetrated by needle and suture. Two continuous sutures 
 may be used, each passing from the upper end of one of the limbs of the U- 
 shaped incision above to the center of the incision below, or interrupted sutures 
 may be applied. It is not practicable to suture together the cut edges of the 
 interspinous and interlaminous ligaments, nor is it necessary, so closely do 
 the parts come together, but the cut ends of the supraspinous ligament may 
 be sutured. 
 
 (12) Skin and Fascial Suturing. — The skin and fascia should have their 
 edges united with interrupted sutures of silkworm-gut or silk. A continuous 
 suture of a wound of this shape and extent is not apt to bring the margins 
 so accurately together (Fig. 518, D). 
 
 (13) Provision for Drainage, When Indicated. — Opinions differ upon the 
 subject of drainage, — some advising its use both within the membranes and 
 in the extraspinal wound, and some its non-use. Unless there were some 
 special contraindications, the preference of the writer would be to completely 
 and accurately suture the incised membranes; to shut off infection from with- 
 out, and the escape of cerebrospinal fluid from within; to introduce, for from 
 twenty-four to forty-eight hours, an intraspinal but extradural drain of a few 
 strands of horsehair or catgut, bringing these out between a couple of omitted 
 >u]ierficial sutures (Fig. 518, E), incorporating them with a strip of gauze 
 placed in the deep muscle wound and leading down to the spine (Fig. 518, F), 
 
66o 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 both emerging together from the skin wound. Where intraspinal drainage 
 is used, whether it be intra- or extra-dural, special provision must be made for 
 it. This is best secured by biting out, with rongeur forceps, a half-button of 
 bone from the lower margin of the lowermost lamina in the flap (Fig. 517, E), 
 and a corresponding half-button of bone from the upper margin of the upper- 
 most one of the intact lamina? below (Fig. 517, F), so that when the osteo- 
 plastic flap is turned back into place, the two half-buttons will afford a circular 
 bone-opening for drainage, the drains being conducted thence out through 
 muscles and skin, as just mentioned. 
 
 Fig. 518. — Osteoplastic Resection of the Spine: — A, A, Retractors in preliminary 
 wound, showing buried sutures of muscles and superficial sutures of skin; B, B, Large retractors 
 drawing back skin of main wound; C, Line of continuous buried sutures of deeper parts; D, 
 Line of interrupted superficial sutures; E, Intradural horsehair or catgut drains; F, Extraspinal 
 gauze drain. (Drawn from cadaveric operation.) 
 
 (14) After-treatment. — It is conceivable, though the writer knows of no 
 such recorded case, that, through the excision of a large number of laminae in 
 the operation of laminectomy, a patient might be broken into two by subsequent 
 rough or imprudent handling, so that it might be well, in even osteoplastic 
 resection, where the operation has been extensive, to include some form of 
 spinal splint in the final dressing immediately after operation, which could be 
 worn until solidification of the parts had taken place through union, as after 
 any other fracture, the patient meanwhile maintaining a strictly horizontal 
 posture. In ordinary osteoplastic resection of average extent, and with the 
 spine normal as to strength, the use of a splint would seem superfluous. The 
 writer has never used any form of spinal support following laminectomy, 
 
LAMINECTOMY. 66l 
 
 where the spine is left even weaker than after an osteoplastic resection. If the 
 need of it were felt, following the convalescence of the patient, some form of 
 leather, or leather and metal, support could be worn as long as indicated. 
 Reference has been made to the occasional need of such a support under 
 General Considerations. 
 
 (15) Comment. — Both during and immediately following all operations 
 in which the membranes of the cord are opened, the patient's head should be 
 kept lower than the body and the spine absolutely horizontal, in order to 
 lessen the loss of cerebrospinal fluid. 
 
 Where the window in the spine has been made too narrow, through the 
 placing of the bone-sections too near together, if more space for manipulation 
 be absolutely demanded, there is no alternative but to bite out a portion of the 
 margin of the opening into the spine, by means of rongeur forceps or bone- 
 cutting pliers. If this be done to a limited extent, although there will be a 
 corresponding gap when the osteoplastic flap is turned back into place, the 
 flap will, nevertheless, be held in position and kept from pressing against the 
 spine by resting upon the margins of the bone-section which have not been 
 thus additionally cut away. 
 
 While the normal cord, in a normal canal, is not apt to be injured by any 
 method of ordinarily careful approach, in pathological cases the need of 
 additional care is always present. 
 
 When it is necessary to reach the anterior aspect of the spinal canal, the 
 cord must be displaced temporarily to one side by means of gentle retraction. 
 If such retraction should not give sufficient room for manipulation, one or 
 two nerve-roots have been severed to afford the required additional room, and, 
 at the end of the operation, sutured with fine plain catgut. 
 
 LAMINECTOMY. 
 
 Description. — See page 642, above. 
 
 Preparation. — See page 644, above. 
 
 Position. — See page 644, above. 
 
 Landmarks. — See page 644, above. 
 
 Incision. — See page 661, below. 
 
 Operation. — The nature of this operation has been briefly described 
 under General Considerations (page 642). So many of the features of the 
 operation of laminectomy are in principle common to the operation of osteo- 
 plastic resection, which has just been detailed at length, that only the salient 
 and distinguishing points of laminectomy will be here mentioned. 
 
 (1) Incision. — A median incision is made directly over the centers of the 
 apices, which are, together with their corresponding laminae, to be removed. 
 In order to give greater room for the exposure of these spines and lamina-, 
 the incision should begin over the spine next above and end over the spine 
 next below those to be removed (Fig. 511, C, also Fig. 514, A). It is a bad 
 practice to place the vertical incision immediately to one side of the spines, in a 
 line along which the muscles and aponeuroses are to be subsequently separated 
 from the bone in the subperiosteal operation (or incised in the open, or non- 
 subperiosteal, method) ; for if this be done, the median lip of this wound will 
 have to be retracted to and beyond the line of the apices of the spines when 
 the soft parts are freed from the side of the spine opposite to the one first 
 attacked. 
 
 (2) Division of Muscles and Aponeuroses. — These structures are divided 
 
662 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 in the same general way, in so far as the direction of incising their structures 
 is concerned, as described under Osteoplastic Resection, paragraph 2, and as 
 indicated in Fig. 509, A and B. But as soon as the spines are reached, the 
 knife should be wielded firmly and made to cut its way through the periosteum 
 to the bone, in a straight median line over their posterior aspects, from the 
 apex of each up to a point where the apex of the spine above prevents further 
 incision of the periosteum. The subperiosteal method should always be 
 undertaken unless specially contraindicated; but if it be elected not to attempt 
 the subperiosteal operation, the knife should hug the spines so closely, in deep- 
 ening the incision through the soft parts, that a minimum of muscle and apo- 
 neurotic tissue be left adherent to the bones. 
 
 Fig. 519. — Dorsal or Lumbar Laminectomy: — A, A, A, Retractors withdrawing edges of 
 wound; B, Clamp-forceps controlling hemorrhage; C, Chisel, against spinous processes as fulcra, 
 levering soft part away from laminae; D, Spine of vertebra; E, Lamina; F, Interlaminous ligament; 
 G, Doyen saw completing section of lamina and interlaminous ligaments. (Drawn from ca- 
 daveric operation.) Note: — The feature of the subperiosteal operation is not shown here. 
 
 (3) Subperiosteal Freeing of Spines and Lamince Preparatory to their Divi- 
 sion. — Having started up the edge of the incised periosteum from the apices and 
 posterior aspects of the spines by means of a raspatory or periosteal elevator, 
 this process of separation may be continued; or, better, a chisel, with its non- 
 bevelled edge toward the parts to be removed and its blade braced against 
 the spinous processes (articular processes in the neck) as fulcra, is made to 
 clear the soft parts from the spines and laminae. The edge of the chisel is 
 carefully inserted beneath the freed margin of the periosteum, and is made 
 
LAMINECTOMY. 
 
 663 
 
 to remove the periosteum first from the spines and then from the laminae, in 
 the form of as intact a layer as possible, and as adherent as possible to the over- 
 lying soft parts. As it is impracticable, in advance of clearing each spine and 
 its set of lamina?, to incise through the periosteum along the upper and lower 
 borders of the spine and lamina?, the layer of periosteum on each side, corre- 
 sponding with each spine and the lamina of that side, must be more or less 
 shredded and imperfect, especially where it merges into ligamentous tissue; 
 
 Fig. 520. — Cervical Laminectomy: — A, A, Saw-cuts through the lamina?, just within 
 their junction with the articular processes; B, Doyen saw in act of dividing the lamina; at a right 
 angle to their surface, its guard (determining the depth of section) being entirely raised at the 
 beginning of the division; C, Knife dividing the ligamenta subflava; D, Osteotome levering away 
 the muscles of the vertebral grooves, using the spinous processes as fulcra. 
 
 but an attempt, nevertheless, should be made to preserve, even if in strips, 
 enough periosteum from each spine and lamina to make the deposition of 
 bone therefrom fairly likely. As mentioned under General Considerations, 
 practically the only practical justification for performing laminectomy, ordi- 
 narily recognized by the writer, is the doing of the operation subperiosteally. 
 (If the subperiosteal method be not elected, the freeing of spines and lamina? is 
 done in the same general way as in osteoplastic resection, except, in the present 
 instance, that the chisel, with bevel toward the spines, is braced against the 
 
664 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 spinous processes as fulcra, and the soft parts are pried away from the spines 
 and lamime toward the transverse processes (or articular processes in the 
 neck). The method of manipulating the chisel is shown at Fig. 519, C, 
 but the special feature of removing the periosteum, together with the soft parts, 
 is not shown in this illustration. As a result of the procedures just described, 
 a path is cleared for the saw, extending onto the lamina next above and the 
 one just below those to be removed. 
 
 Fig. 521. — Laminectomy: — A, A, A, A, Retractors separating edges of wound; B, Curved 
 scissors dividing interspinous and interlaminous ligaments; C, Bone-holding forceps grasping 
 spines and supraspinous ligaments, to aid in lifting out the excised area of bone; D, Chisel, against 
 transverse processes as fulcra, with edge in saw-cut, prying out the excised part. (Drawn from 
 cadaveric operation.) Note: — The interlaminous ligament at the upper part of the wound should 
 also be represented cut. 
 
 (4) Division of Lamina: and Ligamenta Subflava. — Having removed the 
 packing from the wound upon one side of the spines, its lip farther from the 
 spinous processes is firmly retracted by two special retractors, thus exposing 
 bared lamina? (Fig. 519, A, A). The saw, held with its edge at a right angle 
 to the surface of the laminae and somewhat nearer the bases of the transverse 
 processes (bases of the cervical articular processes) than the bases of the 
 
LAMINECTOMY. 
 
 66 5 
 
 spines, is made to cut through the indicated laminae, as well as through one- 
 half of the lamina next above and next below those to be removed (Fig. 519, 
 G, also Fig. 520, B) . The course of the saw and the completion of the section 
 should be determined as in the osteoplastic resection. 
 
 (5) Division of Supraspinous, Interspinous, and Intcrlaininous Ligaments. — 
 The above ligaments between the spines and laminae at the lower end of the 
 section are divided with curved scissors, just as described in Osteoplastic 
 Resection, and as illustrated in Fig. 521, B — or less safely with a knife (Fig. 
 520, C). In addition, the same ligaments are divided in the same manner 
 
 Fig. 522. — Laminectomy: — A, A, A, A, Retractors holding apart margins of the wound: B, 
 spinous process of vertebra above segment of spinal column removed; C, Shelving laminae of 
 intact vertebra below; D, Cut surface of laminae; E, E, Delicate forceps grasping membranes 
 so as to form a transverse ridge; F, Scissors in act of incising transverse ridge and continuation 
 of membranes. (Drawn from cadaveric operation.) 
 
 at the upper end of the section. The segment of spines, laminae, and ligaments 
 is thus entirely isolated by the saw-cuts on either side and the division of the 
 ligaments above and below. In Fig. 520 the saw cuts and the division below 
 are alone shown. 
 
 (6) Separation and Removal of Ligamento-osseous Section. — Having well 
 retracted the margins of the wound (Fig. 521, A, A, A, A), and determined 
 that the sections through bone and ligaments are complete, the segment thus 
 limited is ready to be pried from its bed. While the spines and connecting 
 ligaments are grasped by bone-holding forceps (Fig. 521, C), a chisel, with 
 
666 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 its bevelled edge away from the parts to be removed, and its blade braced 
 against the transverse processes (or cervical articular processes) as fulcra, is 
 made by depressing its handle, to lever out the mass from its bed, aided by 
 moderate traction upon the forceps grasping the spines. In the act of its 
 removal the mass is given a downward direction, so as to dislodge the upper- 
 most laminae of the section from the laminae and spinous process of the last 
 intact vertebra above (Fig. 522, B). 
 
 (7) Freeing of the Cord from Extradural Areolar Tissue, and Control of 
 Intraspinal Hemorrhage. — These are accomplished exactly as in the Osteo- 
 plastic Operation described above, and partially illustrated in Fig. 517, G. 
 
 (8) Opening of the Membrane of the Cord. — This portion of the present 
 operation is also accomplished in a manner similar to that mentioned under 
 the Osteoplastic Resection, and is pictured in Fig. 522, E, E, and F. 
 
 (9) Manner of Dealing with the Incised Membranes. — As in the Osteoplastic 
 Operation. 
 
 (10) Deep Suturing of Muscles and Aponeuroses. — More care is here neces- 
 sary than even in the osteoplastic resection. A large mass of tissue has been 
 permanently removed, and the soft parts which were formerly in contact with 
 the bones and ligaments which have just been removed are now to be brought 
 into contact with each other and sutured together by deeply buried stout 
 twenty-day chromic gut. In the apposition of these soft parts, whatever 
 periosteum has been saved should be so manipulated as to be made to lie in 
 as normal a relation as possible, so that whatever bony deposit occurs, should 
 take place as nearly as may be in the site of the missing laminae and spines, 
 and thus strengthen the spinal column. Interrupted sutures probably accom- 
 plish this object better than a continuous form of suturing. 
 
 (11) Skin and Fascial Suturing. — A median continuous or interrupted 
 suture of silkworm-gut or silk should be placed through skin and fascia. 
 
 (12) Provision for Drainage, When Indicated. — What applies in principle 
 in osteoplastic resection also applies here. When temporary intraspinal 
 drainage, whether intra- or extra-dural, is indicated, drains are readily con- 
 ducted from within outward to the skin surface, through openings left in the 
 soft parts between omitted sutures. 
 
 (13) After-treatment. — Here, much more than in Osteoplastic Resection, 
 may it be indicated not only to include some form of splint in the dressing 
 immediately following the operation, but also the wearing of some form of 
 spinal support for several weeks or months following the operation, until the 
 spinal column has solidified through the deposit of bone by the periosteum, 
 or otherwise. 
 
 (14) Comment. — The observations made under the Osteoplastic Operation 
 also apply here (page 661). 
 
 SUBARACHNOID PUNCTURE FOR SPINAL ANALGESIA. 
 
 Description. — The injection into the subarachnoid space of the spinal 
 cord of an anesthetic solution for the purpose of producing regional surgical 
 anesthesia or analgesia. 
 
 Spinal analgesia, recently somewhat extensively and enthusiastically used, 
 has now been largely abandoned, as being more unsafe than general anesthesia, 
 more unpleasant in many instances, and as a retainer of consciousness during 
 operation, an undesirable thing in itself, without in exchange offering greater 
 safety to the patient. 
 
SUBARACHNOID PUNCTURE FOR SPINAL ANALGESIA. 
 
 667 
 
 Injections for this purpose have been made into various portions of the 
 entire cerebrospinal tract — but the operation as practised for surgical pur- 
 poses is practically limited to the lumbar region of the spine. As the cord 
 ends at the lower border of the first lumbar vertebra, any intervertebral space 
 below that may be used, namely, between the second and third — between 
 the third and fourth — between the fourth and fifth — or between the fifth 
 lumbar and sacrum. The space usually chosen is that between the fourth 
 and fifth lumbar vertebrae — next, the lumbosacral space, or the space between 
 the third and fourth lumbar. 
 
 Fig. 523. — Subarachnoid Lumbar Puncture (Between Fourth and Fifth Verte- 
 br.e): — Showing position of needle among nerves of Cauda equina in vertical section of the 
 spinal region. (Modified from Stewart.) 
 
 Various anesthetic solutions have been used — chiefly cocain or eucain B, 
 used alone or combined with morphin. The cocain-morphin-saline solution 
 originally used by Matas (from whose writings the accompanying description 
 is largely taken) consisted of cocain hydrochlorate gr. j, morphin hydrochlorate 
 gr. 7 ' n , sodium chlorid gr. i, dissolved in 20 minims of water, the water first 
 sterilized and the mixture subsequently resterilized by the fractional method, 
 and injected warm by means of a special syringe. 
 
 More recently stovain has been found safer, and Matas now uses § of a 
 grain dissolved in from 30 to 60 minims of the spinal fluid withdrawn. 
 
 Preparation. — Thorough sterilization of the field of operation. 
 
 Position. — Where possible, the patient sits upright upon the edge of the 
 table, with feet upon a chair, and leaning forward, supporting himself by 
 hands upon knees, so as to round out the back convexly and increase the 
 
668 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 transverse width of the intervertebral spaces by 1.5 cm. (§ inch) — and also to 
 cause the cerebrospinal fluid to gravitate. Where the patient cannot sit up, 
 he may lie upon his side in Sims's position with back similarly arched. 
 
 Landmarks. — The spinous processes of the fourth and fifth lumbar ver- 
 tebrae should be identified, which is not always easy in thickly covered backs. 
 A straight line drawn transversely between the highest points of the iliac crests 
 posteriorly, while the patient is as erect as possible, will cross the tip of the 
 spinous process of the fourth lumbar vertebra. The point of injection lies 
 just below and slightly to the outer side of the junction of this line with the 
 tip of the spinous process of the fourth lumbar vertebra. The spinous proc- 
 esses may be also identified by counting downward from the seventh cervical 
 spine (the vertebra prominens) . (See Fig. 523, D.) 
 
 Operation. — (1) The skin having been thoroughly prepared — the imme- 
 diate area infiltrated with a few drops of Schleich's cocain solution — the back 
 
 Fig. 524. — Subarachnoid Lumbar Puncture (Between Fourth and Fifth Verte- 
 brae): — Showing position of needlt-point among nerves of cauda equina, in the subarachnoid 
 space, in transverse section of the spinal region. 
 
 rounded out by the patient's leaning forward — the tip of the spinous process 
 of the fourth lumbar vertebra is marked by the left index-finger. The needle 
 of an empty syringe (preferably a special syringe and one made without screw 
 attachment for the junction with the needle) is entered at a point about 1 cm. 
 (nearly \ inch) to the right and just below the tip of this spinous process — 
 and is made to penetrate slowly in a direction forward, inward (toward the 
 median line), and slightly upward into the interspinous space between the 
 fourth and fifth lumbar vertebrae (Fig. 523), recognizing, if possible, the 
 entrance of the needle into the subarachnoid space by the lessened resistance 
 as the needle passes through a tense structure into a freer cavity. The distance 
 thus penetrated is generally between 6.5 and 7.5 cm. (about 2% to 3 inches) 
 (Fig. 524). (2) The piston of the syringe is now drawn and, if the needle 
 be in the subarachnoid space, the clear cerebrospinal fluid will appear (if 
 the needle be of fair size and not occluded). As soon as a few drops have 
 
LUMBAR PUNCTURE FOR DIAGNOSIS AND THERAPEUSIS. 669 
 
 flowed, the cylinder of the syringe is detached from the needle (which is left 
 in situ), with the least possible loss of cerebrospinal fluid — and the cylinder 
 of the syringe, now charged with the anesthetic solution, is reattached to the 
 needle and the fluid carefully injected. The needle is allowed to remain in 
 situ a few moments and is then withdrawn — and the needle wound sealed 
 with sterilized cotton and flexible collodion. Anesthesia should follow in 
 from ten to fifteen minutes. 
 
 Comment. — Where the space originally sought cannot be found or satis- 
 factorily entered, resort to any available interlumbar space below that between 
 the first and second. Sometimes an incision, under local anesthesia, has been 
 made down to tiie ligamenta subflava. A laminectomy has sometimes been 
 first performed. But these steps are unnecessary in the vast majority of cases. 
 
 LUMBAR PUNCTURE FOR DIAGNOSIS AND FOR THERAPEUSIS. 
 
 This comparatively recent aspect of lumbar puncture is an important 
 application of the operation — and is based upon the examination and inter- 
 pretation of the fluids, and especially the suspended solids, physiological and 
 pathological, withdrawn from the subarachnoidean space by puncture with 
 needle or fine trocar. 
 
 These examinations embrace several fields of inquiry; — 
 
 (1) Physically; — For characters presented in such conditions as meningitis, 
 jaundice, and hemorrhage (either intra-cranial or intra-spinal) . Cryoscopy 
 of the cerebrospinal fluid has been practised, especially in meningitis, where 
 the freezing-point has been reported as lowered. 
 
 (2) Chemically; — For characters presented in such conditions as menin- 
 gitis, general paralysis of the insane, and some degenerative lesions of the 
 brain and cord. 
 
 (3) Bacteriologically; — Chiefly for the purpose, at present, of determining 
 the variety of micro-organisms in a special case of meningitis. 
 
 (4) Microscopically ;— Not only is the centrifuged fluid examined for 
 bacteria, but also an especially important bearing of the microscopic exami- 
 nation is the determination of the type of leukocytes (cytodiagnosis proper), 
 particularly under such circumstances as in the differentiation of acute and 
 chronic meningitis, and in syphilitic and post-syphilitic involvements of the 
 central nervous system. 
 
 A particularly valuable bearing of the diagnostic possibility of lumbar 
 puncture for the surgeon is in intra-cranial and intra-spinal hemorrhage from 
 no matter what source. For instance, in a suspected fracture of the spine 
 with wounding of the cord, bloody cerebrospinal fluid would be rather corrobo- 
 ratory. Again, in a case of unconsciousness, bloody fluid drawn by lumbar 
 puncture would argue more strongly for intra-cranial hemorrhage than for 
 thrombosis — and such a case of hemorrhage is recorded as diagnosed by this 
 method, operated, and saved. 
 
 In making the puncture for diagnosis, it should be made as low as possible, 
 between the fifth lumbar and first sacral, in order to get fluid rich in sediment. 
 
 The chief application of lumbar puncture as a means of therapeusis is 
 illustrated in injecting antitetanic serum into the subarachnoidean space. 
 
 The technic of puncturing the lumbar subarachnoidean space, whether 
 for cytodiagnosis or therapeusis, is practically the same as described under 
 Lumbar Puncture for Spinal Analgesia. 
 
670 OPERATIONS UPON THE SPINE AND SPINAL CORD 
 
 SPINAL PUNCTURE FOR DRAINAGE OF THE SUBARACHNOID 
 
 SPACE. 
 
 Description. — Excess of cerebrospinal fluid is sometimes removed for 
 the relief of pressure in the cerebrospinal tract. This may be done through 
 any of the interspinous spaces — but is usually done in the lumbar region, in 
 the same space and in the same general manner as Subarachnoid Puncture 
 for Spinal Analgesia. For the same purpose the occipital bone has been 
 trephined and the basal subarachnoid space beneath the cerebellum entered 
 and drained — see Incision of the Cerebellar Subarachnoid Space for Drainage, 
 page 595. Drainage of the cerebrospinal fluid is chiefly indicated in menin- 
 gitis and hydrocephalus, cerebral abscess, intra-cranial tumors, uremic 
 coma and convulsions, syphilitic headache, and in some auditory troubles of 
 labyrinthian origin. 
 
 The chief applications of lumbar puncture therapeutically, through drain- 
 age, are either as a cerebrospinal "decompressive agent" alone, as where 
 the accumulated fluid is harmful only because of the pressure exercised, as 
 in hydrocephalus, or as a combined decompressive and evacuant agent, as 
 where the fluid is also harmful because of its quality, as in suppurative menin- 
 gitis. 
 
 Preparation — Position— Landmarks. — As in Subarachnoid Puncture 
 for Spinal Analgesia. 
 
 Operation. — The steps of the operation are, in all practical respects, the 
 same as in the preceding one. The cerebrospinal fluid may be withdrawn 
 by trocar and cannula — or, better, by aspiratory syringe — preceded by infil- 
 tration anesthesia. 
 
 OPERATIVE TREATMENT OF FRACTURES OF THE SPINE. 
 
 All cases of spinal fracture may be divided into three categories, in so far 
 as the question of cord involvement is concerned: — cases in which it is reason- 
 ably certain the cord is crushed; — cases in which it is fair to assume the cord 
 is compressed or otherwise involved; — and cases in which it is fair to assume 
 the cord is not involved by the fracture or its consequences. 
 
 It is often impossible to tell whether the cord is injured until the cord is 
 exposed, unless one waits a length of time which will often make the correction 
 of the damage impossible. 
 
 Only three general methods of treatment are open to the surgeon: — the 
 expectant; reduction by bloodless methods and fixation; and operation. 
 
 The non-operative methods are usually continuous extension, traction in 
 the horizontal position, or vertical suspension. 
 
 One would advise waiting a reasonable length of time, to exclude shock and 
 a certain degree of anesthesia often caused by shock; then, if not otherwise 
 contraindicated, to operate on the second day, as only exposure will reveal 
 the exact condition, and if a harmful condition be allowed to exist for many 
 hours, irremediable damage may be done. If, on the other hand, there be 
 no doubt, and the general condition permit, operation should be done imme- 
 diately. 
 
 One should also exercise judgment in being deterred by the general con- 
 dition, for that is known to be often kept up until the local condition is relieved. 
 
 It may be impossible to distinguish compression, concussion, and rupture 
 of the cord, and while it would be, of course, desirable to recognize compression 
 
OPERATIVE TREATMENT OF FRACTURES OF THE SPIXE. 
 
 671 
 
 before operation, valuable time may be lost in waiting for the diagnosis to be 
 made clear. 
 
 Compression, or even destruction of the cord and nerves, may occur from 
 hematoma, extra- or intra-dural, or even hematomyelia, resulting from the 
 fracture, or by exudate, and not directly from the fracture itself. 
 
 In cases of fracture where the cord is not injured at the time of the fracture, 
 or immediately after, it may be subsequently compressed by callus thrown out 
 in repair, necessitating operation. 
 
 There is no recognized technic in operating upon fractured spine. The 
 conditions found in each case must guide the operator, the underlying principles 
 being to remove completely detached pieces of bone which are exercising 
 
 Fig. 
 
 525. — Wire-ligaturing in Fractures of the Spine: — A, Interspinal ligature of Hadra; 
 B, Intertransverse ligature of Hadra; C, Interlaminar ligature of Chipault. 
 
 pressure, and, where possible, to bring into alignment and retain partially 
 detached bone. The latter is accomplished by simple reposition alone, or 
 reposition followed by wiring of sound bone (Figs. 525 and 526). In either 
 case an immobilizing dressing is applied, the wound being closed with or 
 without drainage, as indicated. 
 
 The site of fracture is best approached along the lines of an ordinary lami- 
 nectomy. This gives full exposure to the posterior arches of the vertebrae. 
 The transverse processes and pedicles may be exposed by continuing the freeing 
 of these structures of their soft parts through the laminectomy incision widely 
 retracted. In the case of fractures of the bodies, all that can be done is to 
 pry them back into line by levering them into place by using the neighboring 
 
672 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 bony firm parts as fulcra, by means of some appropriate metallic instrument, 
 or by means of manual manipulation. Whether the fracture be of the bodies 
 or the arches, the method of using wire is to carry it from some sound part of 
 the arch above the fracture to a corresponding sound part below the involve- 
 ment. 
 
 Fig. 526. — Wire-suturing in Fractures of the Spine: — A, Interspinous suture through 
 drilled spines above and below fracture; B, Intertransverse suture through drilled transverse 
 processes above and below fractured vertebra. 
 
 OPERATIVE TREATMENT OF DISLOCATIONS OF THE SPINE. 
 
 Dislocation of the spinal vertebrae is caused by the articular process of the 
 higher vertebra gliding downward and forward over the lower. If the gliding 
 has gone far enough to cause the posterior margin of the upper articular process 
 to pass beyond the articular margin of the lower articular process, where it 
 becomes interlocked, dislocation is said to have occurred, the body of the 
 upper vertebra having glided to some extent over the body of the vertebra 
 below. If the gliding has been less extensive, so that these margins have not 
 passed each other, and interlocking, therefore, has not occurred, subluxation is 
 said to have taken place. 
 
 The dislocation may be unilateral or bilateral, the latter always causing 
 cord pressure. 
 
OPERATIVE TREATMENT OF FRACTURE-DISLOCATIONS OF SPINE. 673 
 
 Dislocation in the dorsal and lumbar regions always involves fracture of 
 the articular processes, and generally also of the laminae, owing to the more 
 nearly vertical position of the articular processes. 
 
 Dislocation is most common in the cervical region (owing to the play of 
 the vertebra?), usually between the fifth and sixth vertebra?; next, between 
 atlas and axis. It is rare in the lumbar region, and rarest in the dorsal. 
 
 Dislocations should be reduced by non-operative measures if possible. If 
 they cannot be so reduced, there are those w T ho make no further effort at 
 rectifying the lesion, provided no nervous symptoms be present. If, however, 
 nervous symptoms be present in a case which has withstood non-operative 
 efforts at reduction, operation is then indicated. What has been here said 
 applies to recent dislocations. 
 
 If the case be an old one, and there are no nervous symptoms and no 
 great deformity, it may be let alone. If there be nervous symptoms, or great 
 deformity or discomfort, operation should be undertaken — understanding 
 the increased difficulties in the way of reduction and the likelihood of finding 
 a partially degenerated cord, and the possibility of inflicting additional damage 
 in the operation. These, however, should not deter one from a radical pro- 
 cedure. 
 
 The non-operative technic consists in first practising firm traction upon 
 the column, manual or instrumental, and then, by manipulation, to disengage 
 the interlocked vertebra? and push the dislocated one back into place. 
 
 In operating, especially in bilateral dislocation, it is to be remembered that 
 one may expect to find the intervertebral articulation torn, the supraspinous and 
 interspinous ligaments, ligamenta subflava, and the anterior and posterior 
 common ligaments lacerated, and the intervertebral substance damaged. The 
 soft parts should be well retracted from the bones, so as to expose the latter 
 thoroughly. By manual or instrumental manipulations, while the spinal 
 column is kept under traction, an effort should be made to return the parts to 
 their normal positions. Failing in this, excision of part of one or both articular 
 processes should be done — after which reduction can usually be accomplished. 
 In completing the operation, the ligaments and other soft parts injured by 
 the original traumatism and by the operation should be repaired by kangaroo- 
 tendon suture — the spinous processes may be wired with silver wire — and 
 the back should be supported by a metallic or plaster brace. 
 
 OPERATIVE TREATMENT OF FRACTURE-DISLOCATIONS OF THE 
 
 SPINE. 
 
 Two forms of fracture-dislocation are recognized: 
 
 (A) One or both inter-articular joints are dislocated, and there is pres- 
 
 sure-fracture of the body of the vertebra. 
 
 (B) Both inter-articular joints are dislocated, and the body of the ver- 
 
 tebra is both dislocated and fractured. 
 
 The indications for operation may be gleaned from what has been said 
 under this head in the Sections upon Fractures and upon Dislocations, — the 
 methods of procedure being practically the same. 
 
 The injury done the cord in these cases is, naturally, generally greater than 
 in either fracture or dislocation alone — and, unless the case be absolutely hope- 
 less, the indication for surgical interference is also usually greater, and should 
 be prompt and radical. 
 
 Chipault advises, following the rectification of the injury, to drill the spi- 
 nous processes, and even the transverse processes and lamina?, and wire them. 
 
 43 
 
674 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 OPERATIVE TREATMENT OF INCISED AND PENETRATING WOUNDS 
 
 OF THE CORD. 
 
 Classification of Wounds as to Penetration — (penetration meaning either 
 penetration of both membranes and cord, or membranes alone), 
 (i) Wounds where penetration is doubtful. 
 
 (2) Penetrating wounds without injury to cord. 
 
 (3) Penetrating wounds involving the cord. 
 
 It is evident that one of these conditions must exist — but it is evident that 
 it may often be impossible to tell which. Berger and Hartmann summarize 
 the indications for operation as follows: — 
 
 Indications for surgical measures, dependent upon the period of the wound, 
 taken in conjunction with penetration or non-penetration: — 
 
 (A) /;/ the Immediate Period: — 
 
 (i) Where penetration is doubtful — One may intervene at once — or 
 await the development of the case. 
 
 (2) Where penetration is supposed to have occurred, but no nervous 
 symptoms have developed; — Intervene. 
 
 (3) Where penetration is supposed to have occurred, and nervous symp- 
 toms have developed; — two possibilities arise: — 
 
 If incomplete section of the cord is supposed — Operate. 
 
 If section of the cord is supposed to be complete — the usual advice 
 is not to operate. The writer would advise operation on the 
 ground, first, that such cannot be known without operation, and, 
 secondly, that it is better to attempt to repair the damage than not 
 to attempt to do so. 
 
 (B) In the Secondary Period: — 
 
 If continuous suppuration occurs or pressure symptoms— Operate. 
 If foreign body be present — 
 
 If it be a determining factor — Operate. 
 
 If an unimportant factor — Remove if accessible. 
 
 Some generalizations may be made in connection with Incised and Penetrat- 
 ing Wounds. 
 
 An escape of cerebrospinal fluid argues a penetrating wound. 
 
 A suspicious wound accompanied or followed by cord- or nerve-phenomena 
 is more apt to be penetrating than otherwise. 
 
 Lumbar puncture made for diagnosis, in which bloody fluid is withdrawn, 
 is sufficient warranty for accepting penetration, provided it is not likely the 
 blood comes from the needle-wound. Failure to withdraw blood, while pre- 
 sumptive, is not such positive proof in the opposite direction. 
 
 If one be in doubt, the wound can be enlarged, stopping short of exposing 
 the cord if there be reasonable evidences against penetration. 
 
 It is safer to drain all doubtful wounds — reference being here made to 
 wounds of the overlying soft parts. 
 
 If the membranes have been opened by the wound, the membranes should 
 not be sutured where infection is likely to have occurred. If infection be 
 unlikely, suturing of the membranes will make subsequent outside infection 
 less likely to occur, and will prevent the escape of cerebrospinal fluid. 
 
 If the membranes be drained, keep the head low. 
 
 Symptoms may be caused by no actual wound of the cord, but indirectly by 
 a hematoma resulting from the wound and pressing the cord intraspinally. 
 
 Intraspinal hemorrhage may be extradural or intradural, or within the 
 cord — hematomyelia. 
 
OPERATIVE TREATMENT OF GUNSHOT WOUNDS OF THE CORD. 675 
 
 One should guard against considering every nervous phenomenon as evi- 
 dence of penetration. 
 
 Undoubtedly the most difficult cases in which to reach a decision will be 
 those in which it seems certain that penetration has occurred, and yet in which 
 there are no nervous symptoms. Undoubtedly the safest plan in such 
 cases would be to operate, yet it is probable that many surgeons would await 
 evidences of infection or pressure. The method of dealing with a cord com- 
 pletely divided is given under the Operative Treatment of Gunshot Wounds 
 of the Cord (page 675). 
 
 OPERATIVE TREATMENT OF GUNSHCT WOUNDS OF THE CORD. 
 
 Gunshot wounds, owing to the nature and size of the projectile, form, with 
 fractures, a class of injuries in connection with which complete transverse 
 destruction of the cord is most apt to occur. 
 
 They more nearly resemble fractures in the amount of damage they are apt 
 to do the cord, both by their own trauma and that of bone-splinters — while 
 they more nearly resemble penetrating wounds in other respects. 
 
 The indications for surgical interference are, practically, the same as those 
 just given for incised and penetrating wounds, with even more emphasis upon 
 prompt operative treatment — and the generalizations there given also apply 
 here. 
 
 A paper upon Gunshot Wounds of the Spinal Cord, read before the Xew 
 York Academy of Medicine by Haynes, gives strong argument for early and 
 more general operation — where it was conclusively shown that cases so treated 
 stood a better chance of recovery than the non-operated cases. His researches 
 covered the ten years from 1896 to 1906. During this time he could find only 
 43 cases recorded, to which were added 3 cases (with 1 recovery and 2 deaths) 
 operated by the writer in the Charity Hospital of Xew Orleans. Of this total 
 of 46, 7,t, were operated, 19 recovering and 14 dying — giving a mortality of 
 operated cases of 42^ per cent. Of the 13 non-operated cases, 4 recovered and 
 9 died — giving a mortality of 69J per cent. There is thus, in this collection, a 
 percentage of 26I per cent, in favor of operation. 
 
 The following conditions were found in the above cases: — Bullet in spinal 
 canal, n times; — cord severed, 10 times; — cord crushed, 4 times; — cord 
 pierced by bullet or bone, 5 times; — cord compressed, n times; — not desig- 
 nated, 5 cases; — total, 46. 
 
 The questions of greatest practical importance in gunshot wounds of the 
 spine are as to the extent of injury done the cord — and the best method of 
 treating the condition. It is exceedingly interesting, as well as remarkable, 
 to know that among the above 46 cases there were three cases reported (by the 
 late Dr. Fowler, of Brooklyn; by Estes, of Bethlehem, Pa., and one conjointly 
 by Stewart and Hart, of Philadelphia) in which there was total transverse 
 destruction of the cord, with loss of substance — in which the ends of the cord 
 were united by suture — and in which not only was life saved, but also some 
 degree of functioning regained. 
 
 The manner of dealing with the cord in these three successful cases is here 
 given: — 
 
 In the case of Stewart and Hart, operated three hours after injury, f inch of 
 the cord, opposite the seventh dorsal vertebra, was destroyed by the bullet. 
 The ends of the cord were approximated by one anteroposterior and two 
 transverse chromic-gut sutures, passing through the entire thickness of the 
 cord. 
 
676 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 Estes, operating on the tenth day, writes: "I made a complete section of a 
 disintegrated cord at the first lumbar vertebra — removed about f inch — squared 
 off the ends, and brought them together with catgut sutures, and sutured the 
 dura over the united cord." 
 
 Fowler, also operating on the tenth day, found a .38 caliber bullet lying 
 between the ends of a completely divided cord, between the tenth and eleventh 
 dorsal vertebrae. He wrote: "The ends of the cord were then sutured with three 
 fine chromic catgut sutures. No special difficulty was experienced in drawing 
 together the ends of the cord and closing the defect, the latter representing the 
 width of the diameter of a .38 caliber bullet. The dura was further secured 
 with a number of sutures of fine catgut, and a drain, consisting of a half-dozen 
 narrow strips of oiled-silk protective, introduced." 
 
 In all three cases a meningomyelorrhaphy was done (Fig. 527) — and 
 Estes preceded his suturing by the excision of the ends of the cord. 
 
 Fig. 527. — Meningomyelorrhaphy: — Sutures passing through both cord and membranes. 
 
 Instead of passing the sutures through both membranes and cord, Chipault 
 advises passing them through membranes alone (meningeorrhaphy), thus 
 avoiding further damage to the cord proper. In the writer's case, where the 
 cord was completely severed and an amount corresponding with the diameter 
 of the ball gone, the sutures were passed through the membranes and cord — 
 but it was impossible to approximate the ends of the cord. In the future, one 
 would temporarily divide two or three sets of nerves, if necessary, and loosen up 
 the dura from the canal, and then do a simple circular meningorrhaphy (Fig. 
 528), by interrupted fine chromic-gut sutures passed through the membranes 
 only — suturing the divided nerves at the end of the operation — for while there is 
 no full consensus of opinion upon the efficacy of cord-suturing, and while the 
 preponderance of experience does not justify the belief that there is cord- 
 
OPERATIONS FOR REMOVAL OF TUMORS OF SPINAL CORD. 677 
 
 regeneration, yet in those cases in which, at operation, the cord is found severed, 
 it is better to make an attempt to suture it rather than to make none. 
 
 Hart and Stewart and Haynes have made satisfactory union of the cord in 
 experimental work upon the cadaver, after excising up to one inch — aided by the 
 posture of the subject and by the temporary division of nerve-roots. 
 
 Fig. 528. — Mexixgeorrhaphv: — Sutures passing through membranes alone. 
 
 OPERATIONS FOR THE REMOVAL OF TUMORS OF THE SPINAL 
 
 CORD. 
 
 Indications for Removal of Tumors Involving the Spinal Cord as 
 Determined by their Anatomical Origin. — The classification of William- 
 son may be here used: — 
 
 (1) Vertebral — originating within the vertebrae and secondarily compressing 
 the cord — the most favorable for removal. 
 
 (2) Extra-dural Meningeal — originating within the meninges and extending 
 between meninges and spinal canal — favorable for removal. 
 
 (3) Intra-dural Meningeal — originating within the meninges and extending 
 between meninges and cord — generally removable. 
 
 (4) Intra-medullary — originating within the cord substance — least favor- 
 able — inoperable in proportion to degree of involvement and infiltration of the 
 cord. 
 
 Tumors within the spinal canal are generally best removed through an 
 osteoplastic flap exposure. Those involving the posterior arches of the spinal 
 column are usually removed by laminectomy. 
 
678 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 Preparation ;— Position ; — Landmarks.— As in Osteoplastic Resection 
 of the Spine (page 648) or as in Laminectomy (page 661). 
 
 Operation. — The general principles involved in the removal of cerebral 
 and cerebellar tumors also apply to tumors of the cord (pages 597 and 599). 
 
 If the tumor be of the posterior arches of the spine, it is exposed by incising 
 
 Fig. 529. — Exposure or Intra-dural Spinal Tumor by Osteoplastic Resection: — 
 A, Composite flap of soft parts, lamina;, spinous processes, and ligamenta subflava turned back- 
 ward; B, Spinal canal exposed by the temporarily severed and displaced lamina;; C, Intra-dural 
 meningeal tumor, displacing and pressing upon cord and nerves of left side. 
 
 and retracting the overlying soft parts. If it be intra-spinal, it is preferably 
 exposed by an osteoplastic flap. 
 
 Vertebral and extra-dural meningeal tumors are removed without opening 
 the membranes, as a rule. The membranes are incised in exposing intra-dural 
 meningeal and intra-medullary tumors. 
 
SPIXA BIFIDA. 679 
 
 After exposure the tumor may be found non-removable, and nothing 
 remains but to close the wound. This, however, is the exception, unless the 
 tumor be intra-medullary. 
 
 When the growth is exposed it is sometimes impossible to tell whether the 
 tumor originated from the cord, from the meninges, or from the vertebrae. 
 
 The tumor is best removed with a sharp spoon or curette, enucleating it 
 where possible. The majority of strictly intra-spinal tumors are connected 
 with the meninges, and their removal, mechanically, is usually not difficult. 
 
 Intra-dural meningeal tumors generally involve the cord only by pressure 
 (Fig. 529). Intra-medullary tumors which only involve a part of the cord 
 should be dissected away from the substance of the cord with the minimum 
 damage — hoping not to totally impair the functions of the cord by too extensive 
 transverse destruction. Should the tumor prove inoperable the pain, which 
 may have been severe, may at least be relieved by the intra-spinal section of the 
 nerve-roots involved in the pressure, and it is necessary to cut at least three 
 roots, owing to the association of the sensory fibers. 
 
 It has been suggested, in operating upon tumors of the anterior aspect of the 
 cord, to temporarily divide the necessary nerve-roots intraspinally — displace 
 the cord laterally and posteriorly— attack the growth — and resuture the nerves 
 at the end of the operation. 
 
 The cerebrospinal fluid should be allowed to escape slowly — if too freely or 
 rapidly, surround the upper end of the cord by temporary ligature of floss-silk 
 (Schede) — or lightly pack the upper end of the canal (Pearson or Woolsey). 
 
 Suture the dura lightly with fine catgut — although its non-suture is advised 
 by some surgeons. Temporarily drain down to the dura in any case. 
 
 In spinal tumors, resection of the vertebral arches may be indicated. 
 
 INTRASPINAL PARTIAL NEURECTOMY OF THE POSTERIOR NERVE- 
 ROOTS. 
 
 Description. — In cases of inveterate neuralgia sections of the posterior 
 nerve-roots, representing the nerves involved, have been removed after opening 
 the spinal membranes. In the cases operated upon the results have not been 
 altogether satisfactory. If, as in one of Abbe's cases, the limb has been ampu- 
 tated and spasms still continue in the stump, as well as the manifestation of 
 pain, the motor roots may also be cut (neurotomy), besides the partial excision 
 (neurectomy) of the posterior roots. In addition to the excision, Keen has 
 suggested the breaking up of the ganglia upon the posterior nerve-roots, for 
 fear of reestablishment of connection. The technique of the operation is 
 simply that of a laminectomy or, preferably, an osteoplastic spinal resection, 
 as far as the exposure of the membranes and cord is concerned. Care is 
 exercised in choosing the site of the exposure that the roots of the nerves 
 involved may be accurately located. After the canal is exposed the membranes 
 are opened as described under Laminectomy — the particular nerves are recog- 
 nized — and as much of the posterior roots as can be resected within the dura is 
 excised — and the membranes and the wound dealt with as in laminectomy 
 or osteoplastic spinal resection. 
 
 SPINA BIFIDA. 
 
 Description. — This condition consists of an abnormal congenital opening, 
 due to error in development, situated in some part of the spinal column, 
 generally in the median line of the posterior arches of one or more vertebrae, 
 
680 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 rarely in the bodies— through which cerebrospinal fluid and a part or all of 
 the structures of the cord protrude, or with which they are in contact. 
 
 Varieties. — (i) Spina Bifida Occulta— a vertebral cleft existing without 
 the protrusion of cord or membranes. (2) Meningocele — the membranes 
 alone protruding through the vertebral cleft, the cord proper remaining within 
 the spinal canal— furnishing about 8 per cent, of all cases. (3) Meningo- 
 myelocele — both cord and membranes protrude through the cleft, the wall of 
 the sac consisting of skin and dura mater, lined by arachnoid membrane, its 
 cavity being continuous with the subarachnoid space. The cord is generally 
 in contact with the posterior wail of the sac, the nerves traversing its lateral 
 walls to the intervertebral foramina (though sometimes running directly through 
 its cavity). In the lower part of the column the nerves forming the cauda 
 equina are usually found spread over and adherent to the wall of the sac. 
 This, the meningomyelocele, is the commonest form of spina bifida, forming 
 about 62 per cent, of the cases. (4) Syringomyelocele — the cavity of the tumor 
 is here formed by the dilated central canal of the cord, its membranes, and the 
 integumentary coverings — constituting a rare form of the disease. (5) In the 
 fifth form of spina bifida the central canal of the cord communicates with the 
 surface of the body, no skin covering the bony defect and no barrier existing 
 to the free escape of cerebrospinal fluid. This is another very rare form of 
 the lesion. 
 
 Rarely is the bony defect in the body of the vertebrae, but when it is, the 
 hernia protrudes anteriorly into the pelvis, abdomen, thorax, or neck. 
 
 The order of frequency in which spina? bifida? occur is lumbar, lumbo- 
 sacral, sacral, cervical, dorsal. 
 
 Operation for spina bifida was considered impossible a few years ago. 
 Indications for Operation. — In the ordinary course of events, death 
 usually occurs in about six months after birth in unoperated cases. 
 
 As to the question of advisability of operation, two classes of cases occur: 
 In the first category, the tumor, following birth, grows rapidly, the covering 
 becomes thin, and rupture seems imminent. In these cases the general 
 opinion is to operate — and prompt operatio: l is, undoubtedly, the better course. 
 Others, Broca among them, on the other hand, hold that it is in just such cases 
 that operation most frequently fails, and that it is best to do nothing. While 
 it is true that it is in just such cases that the chances are most desperate, and 
 hydrocephalus is most apt to follow, if parents understand and accept these 
 conditions, operations should be done in the great majority of cases. 
 
 In the second category of cases the tumor exists, but not menacingly, and 
 parents ask for its removal for appearance's sake only. In such cases, other 
 conditions being favorable, one should operate. 
 
 If the child be in a bad general condition, the longer the delay, the better 
 the chances to obtain a good immediate operative result and a satisfactory 
 general result. The condition, rather than the age, should determine the time 
 of operation — other things being equal. The best age is between three and 
 four years, where, as mentioned above, death is not threatened earlier. The 
 outlook is not so good when other deformities or involvements coexist. 
 
 To summarize the indications for operation, spina bifida is preeminently 
 a condition in which the patient has nothing to lose and everything to gain by 
 operation — in spite of the fact that many cases of successful operation for 
 spina bifida die subsequently of hydrocephalus. 
 
 Preparation; — Position; — Landmarks. — Determined by the position 
 and nature of the tumor. 
 
 Operation. — The only operation to be seriously considered for this con- 
 
SPIXA BIFIDA. 
 
 68l 
 
 dition is excision, with closure of the cleft by means of flaps of the soft parts, or 
 by one of the osteoplastic methods, as indicated — the steps and modifications of 
 which are the following: — An elliptical incision, generally in the long axis of the 
 spine, is so planned that, beginning and ending a sufficient distance above and 
 below the base of the tumor, its limbs are so placed upon or near the base of 
 the tumor laterally as to enable two flaps of proper size and shape to be raised 
 to cover the bony defect. Or a single median skin incision may be made, with 
 elliptical muscle incisions (Fig. 530). These two flaps, consisting of all the 
 
 Fig. 530. — Operation for Spina Bifida by Mcsculo-aponeurotic Flaps: — I. — 
 A, A, Retractors exposing dorsal structures; B, B, Spines of vertebrae above and below bony 
 defect; C, Remnant of sac of spina bifida after excision of its redundancy; D, D, Lines of relaxing 
 incisions through outlying muscles and aponeuroses. 
 
 soft parts down to the membranes, are dissected back, on each side, to a little 
 beyond the margins of the bony cleft. Having exposed the sac proper, and 
 having placed the head of the child low, so as to avoid loss of cerebrospinal 
 fluid, select some part of the sac, preferably its lateral aspect, where it is not 
 likely to encounter cord and nerves and where the cicatrices of the median 
 skin and lateral sac incisions will not coincide. Incise the sac carefully and 
 enlarge the opening gradually, both to better safeguard the nerve structures 
 and to decrease the rapidity of outflow of cerebrospinal fluid. Having opened 
 
682 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 the sac, one of three conditions may be found: — (A) Where the sac contains 
 neither cord nor nerves, the sac, if its neck be small, may either be ligated at its 
 emergence from the spinal cleft, and excised — or, if its neck be large, it may be 
 excised just distal to the cleft and its cut margins sutured; the former probably 
 the better plan. (B) Where the sac contains unimportant nerve elements 
 ending in its walls, one may ligate or suture as just described, as such nerves 
 may be harmlessly sacrificed: (C) Where the sac contains the cord and 
 important nerves, or even important nerves alone, running through the sac, 
 
 Fig. 531. — Operation tor Spina Bifida by Musculo-aponeurotic Flaps: — II. — 
 A, A, B, B, As in above figure; C, C, Relaxing incisions showing depth and extent of inward retrac- 
 tion of musculo-aponeurotic flaps; D, Line of suture of inner margins of musculo-aponeurotic 
 flaps over center of remnant of sutured sac of spina bifida. 
 
 or adherent to its walls, one should first carefully dissect out all such structures 
 from the sac and return them to the spinal canal, after which the sac should be 
 excised and the deep edges of the sac, including the membranes, should be 
 sutured over these structures. 
 
 The bony cleft may be closed by the already overlying or adjacent soft 
 structures (myoplasty) or by adjacent or distant bony structures (osteoplasty). 
 
 I. Myoplastic Methods. — (A) Where the case is simple, the bony opening 
 small, and the overlying skin, connective tissues, and adjacent muscles and 
 aponeuroses thick, these overlying structures may simply be brought together 
 
SPINA BIFIDA. 
 
 683 
 
 in the median line and sutured — with or without lateral liberating incisions 
 
 ( Fi g- S3 1 )- , e 
 
 (B) In larger openings, Bayer, using the myoplastic method, after under- 
 cutting and retracting the skin, cuts out two semilunar flaps of dorsolumbar 
 aponeuroses and muscles from the spinal furrows, one on either side of the spine, 
 which he then displaces inward and sutures in the middle line, so twisting them 
 that their deeper surfaces become more superficial. 
 
 II. Osteoplastic Methods. — Where large, extensive openings exist, some 
 form of the osteoplastic method secures a better closure — and of these there 
 are several: 
 
 (1) The osseous flap may be borrowed from the vertebral column: — 
 (a) Dolinger, retracting the muscles covering the rudimentary lamina? 
 which form the boundaries of the osseous defect, cuts through their bases, in 
 whole or in part, freeing them as limitedly as possible from their soft parts, 
 bends them toward the median line over the defect, and sutures them there 
 (Figs. 532, 533). 
 
 Figs. 532 and 533. — Dollinger's Osteoplastic Method in Operating for Spina 
 Bifida: — In A, a small bony opening is seen — which is shown repaired in B, by partially splitting 
 the rudimentary laminas, turning them backward, and suturing them together — thus restoring 
 the spinal canal by aid of the laminae. 
 
 (b) Zenenko and Broca, splitting the bounding transverse processes of the 
 two sides parallel with their faces, so as to form anterior and posterior halves, 
 and bending their posterior halves backward, sutures them in the median line 
 over the cleft (Figs. 534, 535). 
 
 (2) The osseous flap may be borrowed from neighboring or distant bones 
 other than the vertebral column: — 
 
 (a) Chipault, by a semi-circular incision, convexity outward, detached a 
 periosteal or osseo-periosteal flap, on each side, which he turned toward the 
 median line and sutured. 
 
 (b) Bobroff made a semi-circular incision, with outward convexity, along 
 one iliac crest and detached a small osseo-periosteal flap from the postero- 
 superior crest of the ilium. The flap is then turned backward upon the defect, 
 its periosteal face inward, and sutured to the revivified borders of the opening. 
 
 (c) Bobroff, by another method, raises an osseo-periosteal flap from the 
 ribs, which he turns backward to cover the cleft. 
 
68 4 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 (d) A bony flap may be raised from the scapula in the cervico-dorsal spina 
 bifida. 
 
 Finally, osseous grafts have been taken from the scapula of dog or rabbit. 
 
 Closure of the Wound. — Having provided for the closure of the bony 
 cleft in one of the manners above mentioned, the adjacent soft parts are care- 
 fully sutured in the median line without drainage. A gauze and cotton dress- 
 ing is applied with moderately firm pressure, in which may be included some 
 form of mechanical dressing to protect the parts from pressure if the dorsal 
 decubitus is to be employed — it is better, however, to fix the child face down- 
 ward in a special or plaster appliance. 
 
 Comments. — (i) Escape of cerebrospinal fluid during operation, if excess- 
 ive, may be prevented by lightly packing the upper end of the spinal canal with 
 gauze. (2) In Spina Bifida Occulta no operation should be done, as no 
 tumor protrudes — but if symptoms occur from mechanical pressure or other- 
 wise, an attempt may be made to close the cleft by a myoplastic or an osteo- 
 plastic operation. (3) Experience has shown that even large bony defects 
 
 Figs. 534 and 535. — Zknenko's Osteoplastic Method in Operating for Spina' Bifida: 
 — In A, a large bony opening is seen — which is shown repaired in B, by partially splitting the 
 transverse processes, turning them backward and suturing them together, thus restoring the 
 spinal canal by aid of the transverse processes. 
 
 have been effectively closed by the displacement of muscle-flaps alone to cover 
 them. (4) It has been suggested to spring a celluloid plate into the gap. 
 (5) If the skin covering the tumor be inappropriate for covering, it should be 
 gotten from the neighboring region by displacement. (6) Seek primary 
 union — to prevent leakage of the cerebrospinal fluid and infection. Avoid 
 drainage. (7) Bayer's method is probably the most generally applicable 
 and most frequently used of any. (8) It is best not to sacrifice even apparently 
 unimportant nerves, as their relative importance often cannot be determined at 
 the operation. (9) In syringomyelocele (or, synonymously, myelocystocele), 
 where the tumor is composed of the dilated cord itself, operation is more 
 difficult and unsatisfactory, especially where marked paralysis has been caused 
 by the condition. Some surgeons do not consider operation under these cir- 
 cumstances justifiable. The dorsal part of the cord makes up a portion of the 
 sac-wall and may have to be injured or partially destroyed during operation. 
 
TREATMENT OF ANTERIOR VERTEBRAL TUBERCULAR OSTEITIS. 685 
 
 Often, however, in such cases the amount of paralysis already present is not 
 at all increased by section of the cord. An attempt, nevertheless, should be 
 made to dissect the skin away from the meninges, then empty the sac, and 
 finally cover the defect with skin, or preferably with muscle and skin — or, if 
 feasible, by one of the osteoplastic methods. 
 
 OPERATIVE TREATMENT OF POSTERIOR VERTEBRAL TUBERCULAR 
 OSTEITIS OF THE SPINE. 
 
 The posterior arches and transverse processes of the vertebra? are much less 
 frequently the site of tuberculosis than are the bodies of the vertebrae. 
 
 When so involved, the same general principle as employed in treating the 
 more frequently invaded bodies is carried out here. The posterior structures, 
 being much more superficially situated, the problem is a correspondingly 
 simpler one. 
 
 The disease is exposed by the safest and most direct route, differing with the 
 part diseased or the presence of an abscess — the general features being the 
 opening of abscesses, removal of sequestra, and the scraping away of diseased 
 bone. 
 
 The spines and lamellae are exposed as in a laminectomy — the transverse 
 processes are less accessible — but may be reached by making a somewhat 
 longer vertical incision, so as to allow of more extensive lateral retraction of the 
 overlying soft parts. 
 
 It may be necessary to remove lamina? in order to expose the site of disease — 
 or in order to remove pus which may be compressing the cord. 
 
 All pus-tracts should be enlarged and curetted. 
 
 The costo-transverse articulations and even the heads of the ribs may be 
 involved, requiring a considerable exposure. 
 
 The methods of approaching the deeper parts are more fully given under 
 Tubercular Osteitis of the Bodv. 
 
 OPERATIVE TREATMENT OF ANTERIOR VERTEBRAL TUBERCULAR 
 
 OSTEITIS. 
 
 pott's disease. 
 
 Description. — Pott's disease, originating in the bodies, may extend to 
 adjacent bony processes and articulations — and is most common in the dorso- 
 lumbar, dorsal, or cervical regions. The cord may be pressed upon by tuber- 
 cular deposit within the canal — pachymeningitis, with thickening of the 
 membranes — pus-formation — bony deposits, narrowing the canal — and by 
 bony angulation of the canal. The most usual causes of pressure of the cord 
 are tubercular deposits or pachymeningitis, rather than bony — often the greatest 
 paralysis occurring with the least bony deformity. 
 
 Indications for treatment will differ with the stage of the disease: — 
 
 (I) In the early stages — General constitutional treatment and local treat- 
 ment, especially immobilization. 
 
 (H) In Pott's disease with angular curvature — of which there are two 
 classes — ■ 
 
 (1) Old cases of angularity — in which the least can be done. 
 
 (2) .Angularities in the act of evolution; — of which there are three — 
 (A) Large angularities, or angularities which may be classed as old, accom- 
 panied by abscess, or occurring in cachectic subjects already involved in other 
 
686 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 tubercular lesions — immobilization. (B) Small, recent angularity, existing 
 without abscess and occurring in otherwise satisfactory persons — extension 
 and immobilization. Here ligation of the spines has also been done. (C) 
 Deviations which accompany suboccipital disease — continuous extension. 
 
 (III) In Pott's disease with paraplegia; — compression is not caused by the 
 vertebrae alone, if at all, but by the tubercular deposits, thickened membranes, 
 chronic abscesses, sequestra, and the like. Myelitis and neuritis are often so 
 extensively present that nothing is accomplished by the operation. The para- 
 plegia is frequently cured when the disease itself is cured. Treatment may be 
 as in more recent angularities — by simple immobilization. If angularity co- 
 exist, an attempt may be made to reduce it. As a last resort, more active inter- 
 vention may be used, such as an attempt to liberate the cord and nerves com- 
 pressed by the tubercular deposits, chronic abscess, or by bony deformity — the 
 outcome of which is doubtful, but the attempt is frequently better than non- 
 action. 
 
 (IV) In Pott's disease with chronic abscess; — (i) Immobilization may be 
 used alone or in conjunction with other methods. (2) If the abscess accompany 
 angular deformity, it is wiser not to try to reduce the deformity while the pus- 
 sac exists, as rupture of the sac is apt to be followed by mixed infection, exten- 
 sive suppuration, and amyloid degeneration. (3) If the abscess be deeply 
 placed and show no tendency to increase or give trouble — one may temporize 
 without operation, as the abscess is often cured by the cure of the disease. (4) 
 If the abscess tend to be large, or to give trouble otherwise, it may be punctured, 
 evacuated, and injected — or operated upon as described elsewhere. (5) If the 
 abscess be about to rupture — it should be incised and drained, without curet- 
 tage, which would likely lead to neighboring infection. (6) If the abscess 
 have already ruptured and fistula? be present, with or without mixed infection, 
 — the openings should be enlarged, curetted, and the pockets connected — 
 drainage being used. (7) If an open abscess exist and have withstood immo- 
 bilization, curettement, injection, drainage, and general treatment, showing no 
 tendency to heal — the site of lesion should be operated upon as described below. 
 (8) Closed abscesses may also be operated upon radically, without being first 
 subjected to less radical measures, according to the judgment of the individual 
 surgeon. 
 
 The more chronic manifestations of cord pressure may be due, as men- 
 tioned by Lloyd, "to a pachymeningitis; to a tubercular deposit in the canal; to 
 a gradual increase in the kyphosis, causing bony pressure; to an inflammatory 
 thickening along the ligamentum subflavum; to caseous deposit around the 
 tubercular focus; to rupture of an anterior abscess into the canal, or from pres- 
 sure of such an abscess; or to debris from a tuberculosis of the body or other 
 portion of the vertebras being forced into the canal; or to sequestra." 
 
 The length of time of paralysis does not contraindicate operations — it is 
 rather the kind than the length of pressure that modifies the outlook. 
 
 There is a marked tendency for paralysis, even after long duration, to recov- 
 ery. 
 
 The condition of the cord is rather one of slowly developed pressure 
 atrophy than a myelitis. 
 
 Schmaus and others have shown, by postmortem work, that angularity of 
 the column is the cause of pressure from the cord in only about two per cent, 
 of the cases, but that it is nearly always due to an invasion of the spinal canal 
 by the tubercular process, a tubercular peri-pachymeningitis, or tubercular 
 abscess in the canal generally being the immediate cause. 
 
 The greatest relief from operation comes when the paralysis is caused by 
 
TREATMENT OF ANTERIOR VERTEBRAL TUBERCULAR OSTEITIS 687 
 
 an intraspinal abscess or tubercular granulation tissue — and least when due to 
 an extensive peri-pachymeningitis. 
 
 It would be ideal to remove the focus of disease before time for pus-for- 
 mation, although the technical difficulty and the danger are great. 
 
 There is greater mortality in operating in the cervical region than in the 
 dorsal. Two causes of death are peculiar to this region — wounding verte- 
 bral arteries and phrenic nerves. 
 
 The supposition of the past, of recovery following forcible straightening 
 followed by prolonged extension, has not been verified of late years. 
 
 Reinert reports a mortality of 60 per cent, from the Tubingen Clinic, of 
 23 out of 33 cases treated by extension alone — with 54 per cent, of recoveries 
 and 26 per cent, improved of the 10 treated by laminectomy. 
 
 Operations — are indicated — where constitutional and mechanical treat- 
 ment have failed — where bony pressure from dislocation, sequestra, or angu- 
 larity is present — where pressure myelitis is threatened, or peri-pachymenin- 
 gitis is present. 
 
 Operations are contraindicated — during active tuberculosis — where other 
 complicating tubercular lesions exist — and where mechanical treatment has 
 not been applied. 
 
 The site of disease is exposed by one of the methods already described for 
 approaching disease of the posterior arches, or by one of those about to be 
 given for reaching disease of the more anterior aspect of the spine. 
 
 The Puncture of Cold Abscesses; — The skin should be punctured obliquely 
 so that the superficial and deep wounds are not in line. After evacuation the 
 injection of one of the solutions usually used may be carried out (iodoform 
 and ether; iodoform and glycerin; camphorated naphthol; 5 per cent, carbolic 
 acid solution; and other agents). 
 
 The Incision of Cold Abscesses; — this varies with the region and promi- 
 nence of the abscess. 
 
 (A) Lumbar abscess, tending to descend, should be incised in the inguinal 
 region, in the position as for ligation of the iliac artery — or extra-peritoneally 
 in the iliac fossa or pelvis, as indicated. 
 
 (B) Lumbo-dorsal; — these should be incised either in the iliac fossa — or 
 along the spine, in the lumbar region, as in Treves' operation. 
 
 (C) Dorsal Abscess; — is best reached by the operation of costo-trans- 
 versectomy, as described below. 
 
 (D) Cervical Abscess; — is best opened by an incision posterior to the sterno- 
 mastoid. The skin, connective tissue, and sterno-mastoid are drawn forward — 
 the cervical plexus is guarded — the transverse process is sought and followed 
 down posterior to the sheath of the vessel — until the bodies are met — where the 
 abscess is encountered. 
 
 Methods of Approaching the Vertebras : — The exposure of the site and treat- 
 ment of the lesion are here given for the different regions. 
 
 (I) In The Lumbar Region. 
 
 The technic of Treves is the most satisfactory — the details of which 
 are given below : 
 
 Description. — The abscess is opened through an incision in the loin — the 
 pus-sac irrigated — all caseous material curetted out — dead bone scraped away, 
 and the sac and the wound sutured without drainage. 
 
 Preparation and Position. — As for osteoplastic resection of the spine 
 (page 648). 
 
 Landmarks. — Last rib; crest of ilium; outer border of erector spinae 
 muscle (generally from 2\ to 3 inches — 6 to 8 cm. — from spinous processes of 
 lumbar vertebrae). 
 
688 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 Incision. — Vertical, 2-3 inches long (5 to 8 cm.), with its center midway 
 between last rib and iliac crest, passing parallel with outer border of erector 
 spina? (Fig. 536, B). 
 
 Operation. — (1) Having incised skin and superficial fascia, the super- 
 ficial layer of lumbar fascia (which is the posterior aponeurosis of the erector 
 spinae) comes into view — the lower part tendinous, the upper part giving 
 origin to fibers of the latissimus dorsi. (2) Divide this superficial layer of 
 lumbar fascia the length of the incision and expose the erector spinse muscle, 
 with its fibers running vertically. (3) Recognize the outer border of erector 
 spinae and retract toward spine, thus exposing the middle layer of the fascia 
 lumborum (which is the anterior aponeurosis of the erector spinae muscle) — 
 its glistening fibers tending transversely. The erector spinas is, at this site, 
 
 Fig. 536. — Incisions for Exposing the Bodies of the Vertebr.-e in Tubercular 
 Osteitis: — A, Angular incision for exposing the dorsal vertebrae (costo-transversectomy); 
 B, Vertical incision for exposing the lumbar vertebrae (Treves' operation). 
 
 now adherent to its aponeurosis anteriorly and posteriorly. (4) Feel for the 
 transverse processes of the lumbar vertebra? through this aponeurosis, the 
 third usually being the most prominent. Draw the erector spinae well toward 
 the middle line and divide its anterior aponeurosis vertically, near to the trans- 
 verse processes, thus exposing the quadratus lumborum muscle, with its fibers 
 and tendon bundles running obliquely outward and downward. (6) Carefully 
 incise the quadratus lumborum near the transverse processes and enlarge to 
 the full extent of the wound, guarding abdominal branches of lumbar arteries. 
 The psoas muscle (with its fibers running outward and downward) is thus 
 exposed, overlapping the inner edge of the quadratus lumborum and running 
 about parallel with its posterior fibers. The anterior lamella of the lumbar 
 fascia occupies the interval between these two muscles. (7) Having divided 
 some of the fibers of the psoas close to a transverse process, pass a finger under- 
 
TREATMENT OF ANTERIOR VERTEBRAL TUBERCULAR OSTEITIS. 689 
 
 neath the muscle and cautiously advance along the transverse processes until 
 in contact with the anterior aspect of the vertebral bodies, enlarging the incision 
 in the psoas as far as necessary. (8) The abscess cavity is encountered in the 
 passage of the finger around the body of the vertebra and is incised. A finger is 
 then introduced into the abscess cavity and the anterior aspect of the vertebral 
 column is carefully examined where disease of the lumbar or dorso-lumbar 
 regions is suspected — care being taken to make provision for the escape of 
 pus directly outward, the pus-sac itself and the lips of the sac after incision 
 being drawn well into the wound. P'ree irrigation with normal salt or anti- 
 septic fluid of the emptied pus-sac is carried out by means of a tube conducted 
 to its bottom, the emptying of the sac being made more thorough by an assis- 
 tant's compression of the abdomen from in front and by change in the position 
 of the patient, thus alternately filling and emptying the sac. (9) Following 
 the irrigation of the abscess cavity, a finger is introduced into the sac and as 
 much of its lining membrane as possible is removed. Diverticula are opened 
 up and caseous masses are thus removed by the finger-nail, or by a semi- 
 sharpened spoon used with care, especially upon the thinner anterior wall of 
 the cavity — or a flushing gouge may be used. The sac wall should finally be 
 scrubbed' with gauze carried in upon a sponge-holder. The cavity is then 
 once more flushed out, to free it of the debris of these last manoeuvres, and once 
 more wiped out so as to be left dry. (10) The lips of the incisions are now 
 brought together by buried chromic-gut suture — no drainage being used. The 
 cut edges of muscles and aponeuroses are also sutured with buried chromic gut 
 — and the skin and fascia with silkworm gut. 
 
 After-treatment. — As these abscesses are nearly always of tubercular 
 origin, an indefinite recumbent posture should be observed subsequently to 
 operation, for usually a period of about six months, in either bed or spinal 
 carriage. The abscess may refill with purely tubercular products and require 
 to be again treated in the same way as before. On the other hand, the 
 originally tubercular involvement may become the site of a mixed infection 
 and require open treatment, an unfortunate sequence to be especially guarded 
 against. 
 
 Comment. — (1) The abscess may be approached almost equally well from 
 an incision on either side of the spine, though somewhat more conveniently 
 from the right side — while the peritoneum is somewhat less exposed on the 
 left. (2) The difficulty of the operation is much increased by thickness of 
 the patient's back. The length of the incision may need to be much increased, 
 or a transverse cut added to it. (3) Great care is necessary to avoid wounding 
 the lumbar arteries, the abdominal branches of which generally run behind 
 the quadratus lumborum — except that from the first (and sometimes those of 
 one or two others) which runs in front. Avoid them, and the trunks from 
 which the)' arise, by keeping close to the transverse processes. The main 
 vessels pass between the transverse processes, for which reason the spine is 
 more safely reached following along a transverse process. (4) While special 
 care should be taken to avoid doing so, there should not be much danger of 
 wounding the peritoneum — or even opening up the subperitoneal connective 
 tissue, both risks being less by incising close to the transverse processes. (5) If 
 carious and necrosed bone be encountered, such destroyed bone should be 
 curetted away, or removed as sequestra with properly shaped instruments, 
 and the debris irrigated out. (6) If much angular deformity of the spine 
 exist, the last rib and iliac crest may be so near each other, or actually overlap, 
 as to make the operation very difficult or impossible, though in such extreme 
 cases operation is generally contraindicated. (7) Iodoform emulsion thrown 
 
690 
 
 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 into the sac, and the excess squeezed out, after rubbing its walls, is sometimes 
 used before suturing. 
 
 (II) In the Dorsal Region. 
 
 (A) The operation of costo-transversectomy best exposes the vertebra; 
 in this region and is performed in the following manner: — A vertical incision, 
 3 to 4 inches (8 to 10 cm.) in length, is made about one-half inch (1 cm.) from 
 
 Fig- 537-— Costo-transversectomy for Exposing the Bodies of the Dorsal Ver- 
 tebra: — I. — Exposing thr Rib and Transverse Process: — A, A, The dorsal muscles 
 displaced toward the median line; B, C, The flaps of soft parts retracted respectively upward 
 and outward, and downward and outward; D, Subperiosteal exposure of rib and transverse 
 process; E, Excision of vertebral end of rib with Gigli saw; F, Line of similar excision of trans- 
 verse process of vertebra. 
 
 the median line, its center being opposite the center of involvement. A second 
 incision is made from the first (beginning at the center of involvement) and 
 is carried over the rib to be partially excised (Fig. 536, A) . The incisions are 
 carried through skin, fasciae, and muscles. The two flaps made by these inci- 
 sions are turned aside (Fig. 537). The muscles and aponeuroses are levered 
 from the spinal groove (made by the transverse processes and laminae — and 
 
TREATMENT OF ANTERIOR VERTEBRAL TUBERCULAR OSTEITIS. 691 
 
 corresponding with the vertical incision) ; — and from the transverse processes 
 and ribs (corresponding with the oblique incision). The transverse process 
 is excised at its base with Gigli saw or bone-pliers and torn away. The rib 
 is exposed subperiosteally, most carefully, with curved periosteal elevator — and 
 is then resected about 2 \ inches (6 cm.) from its extremity and removed — the 
 head remaining attached to the vertebrae if its removal be unnecessary or 
 difficult — thus giving access to the vertebrae for curettage and drainage (Fig. 
 538). 
 
 Fig. 538. — COSTO-TRANSVERSECTOMY FOR EXPOSING THE BODIES OF THE DORSAL VER- 
 
 TEBR.+;: — II. — Exposing the Body of the Vertebra: — A, A, B, C, D, As in above figure; 
 G, right side of body of vertebra; H, Vena cava; I, Pleura; the sawn ends of rib and transverse 
 process are seen in section. The incised periosteal membrane is shown drawn apart by three 
 small retractors. 
 
 (B) Lambotti's operation is an osteoplastic method and is performed as 
 follows: — (1) Elevation of Osseo-musculo-cutaneous flap; — the patient lies 
 upon his left side — a vertical incision is made on the right, opposite the angles 
 of the ribs, and two horizontal incisions are made from the ends of this, extend- 
 ing toward the spine, making a rectangular flap. The flap is then raised — 
 the spines are cut at their bases — and the detachment of the flap is continued 
 as far as the left transverse processes. A flap is thus raised, consisting of skin, 
 fascia, aponeuroses, muscle, spines, and periosteum of the laminae. The bottom 
 
692 
 
 OPERATION'S UPON THE SPINE AND SPINAL CORD. 
 
 of thi wound is formed by lamina' and the right ribs and transverse processes. 
 (2) Laminectomy; — Resect the lamina? with a Doyen saw — and thus one 
 reaches the transverse process. (3) Resection of Extremities of Right Ribs; — - 
 
 Fig. 539. — Displacement of the Cord to Expose its Anterior Aspect or the Spinal 
 Canal; also showing Intraspinal Section of Nerves and Repair of Severed Nerves: — 
 A, Tenaculum forceps holding back composite flap; B, B, Retraction hooks lifting cord from 
 spinal canal and displacing it laterally; C, C, Sutures placed ready to repair severed nerve-roots; 
 D, Half-button of bone bitten from lower margin of last lamina in flap by rongeur forceps; E, 
 Similar half-button bitten from upper margin of next stationary lamina below, the two half- 
 buttons forming a circular opening, when in contact, for drainage; F, Vascular fatty areolar 
 tissue covering membranes. 
 
 this is done subperiosteally, guarding the pleura and cutting them 1^ inches 
 (4 cm.) from the spine and tearing them away from their articulation by torsion. 
 According to the extent of the caries, one resects from one to four ribs. The 
 
TREATMENT OF ANTERIOR VERTEBRAL TUBERCULAR OSTEITIS. 693 
 
 removal of two ribs gives quite a large space — in which the pleura is pushed 
 back and the lateral aspect of the vertebras reached. (4) Resection of the 
 Vertebral Bodies; — In order to expose the intraspinal aspect of the Vertebral 
 bodies, two or three nerves on the right are temporarily resected, which easily 
 exposes the meningo-medullary furrow upon the retraction of the cord. The 
 vertebral bodies are thus exposed — and may be attacked with gouge or curette, 
 without danger to the mediastinal organs. (5) Closure of the Wound; — the 
 cord is replaced — the cut nerves are resutured with catgut — and the composite 
 flap is replaced and sutured — temporary drainage being used or not, according 
 to indication. 
 
 (Ill) In the Cervical Region. 
 
 The operation is here performed as for cold abscess of that region, which 
 has been just described. Incision is carried along the posterior border of the 
 
 Fig. 540.— Spinal Angularity Resulting from Pott's Disease:— A, Disintegrated and 
 solidified vertebrae, causing angularity; B, Compressed and atrophied cord; C, Line of section of 
 bone (which is made by chisel or gouge after exposure and retraction of cord) so planned as to 
 make spinal canal straighter and larger. (Modified from Urban.) 
 
 sterno-mastoid, opening its sheath. The muscle is retracted anteriorly. 
 Opening up the space behind the sterno-mastoid, one works toward the trans- 
 verse processes as rallying points, and then works further inward upon the 
 vertebral bodies, behind the prevertebral muscles — and, therefore, behind the 
 sympathetic. 
 
 The general method of treating the seat of disease is by curettage, removal 
 of sequestra, and the ablation of fungosities — followed or not by drainage. 
 
 The drainage is either prevertebral — trans-somatic (that is, through the 
 bodies of the vertebra?) — or pre-medullary (in those case- in which the bodies 
 have been destroyed). 
 
694 OPERATIONS UPON THE SPINE AND SPINAL CORD. 
 
 In all cases in which the spinal column may have been weakened by the 
 combined disease and operation, some form of metallic or plaster brace should 
 re-inforce the dressing. 
 
 Generalizations of Treatment. — General Comment. — (1) Where bony 
 angularity compresses the curd in front, as is usually the case, if re- 
 traction laterally of the cord does not expose the site of pressure, tem- 
 porarily resect the necessary nerves and resuture them at the end of 
 the operation (Fig. 539). (2) The angularity of bone may be erased 
 or chiselled after retracting the cord (Fig. 540). (3) Do not open the 
 dura in operating for Pott's disease, if avoidable, as the tubercular infection 
 may be spread to an otherwise uninvolved structure. (4) If the cord be 
 pressed upon by scar or granulation tissue, or tubercular or carious masses, 
 these are to be scraped or cut away until the cord is made comparatively smooth 
 and pulsation in it is detected, or at least until it is evident that the constriction 
 has been removed. To accomplish this, the cord is displaced to first one side 
 and then the other by a blunt hook. (5) While opening the dura is to be 
 avoided, as mentioned above, if cause of constriction cannot be otherwise 
 located and appears to be intra-thecal, it is best to open the membranes rather 
 than close the wound in doubt. (6) Especially in angulation of the spine, 
 or adhesions between dura and bone, the close proximity of the cord to the 
 laminae is to be expected in opening the canal. (7) The extra-dural plexus 
 is generally obliterated in Pott's disease — hence hemorrhage is less apt to occur 
 from this source. (8) All drainage is to be avoided in tubercular diseases if 
 at all possible — as mixed infection is so apt to occur before the long course of 
 the tubercular trouble is at an end — and it is for this reason that the dissection 
 out of abscess and diseased bones and the closure of the wound (or even the 
 closure of a curetted abscess sac) are so desirable. (9) In operating by the 
 costo-transversectomy method it would be better, unless the lesion were not 
 accessible from this side, to go in on the left, as it would probably be easier to 
 recognize the aorta from the abscess than the vena cava from the abscess. 
 (10) In closing off the neck of a chronic abscess sac the sutures should be 
 placed deeply just within the neck. (n) The osteoplastic method of resec- 
 tion is pre-eminently to be used in exposing the cord in Pott's disease, as it 
 does not, like laminectomy, remove any portion of the already weakened 
 spinal column. (12) The spinous processes have been drilled and wired, as 
 well as the laminae and transverse processes. (13) One may often learn much 
 of the nature of the deformity by means of the x-ray plates — and thus be 
 guided in the steps of the operation. 
 
 NOTE. 
 
 For operations upon Bones, Muscles, Joints, Ligaments, Arteries, Veins, 
 and Nerves of the Spinal Region, see General Surgery. 
 
CHAPTER III. 
 
 OPERATIONS UPON THE NECK. 
 I. THE LARYNX. 
 
 SURGICAL ANATOMY OF THE NECK. 
 
 For Surgical Anatomy of the antero-lateral region of the Neck, see under 
 ''Lymphatic Glands and Vessels," page 149. For Surgical Anatomy of the 
 posterior region of the Neck, see under "Spine and Spinal Cord," page 630. 
 
 SURGICAL ANATOMY OF THE LARYNX. 
 
 Situation. — Lies in upper forepart of median aspect of neck — below 
 tongue and hyoid bone — in front of pharynx — and between large vessels of 
 neck. 
 
 Relations. — Anteriorly, skin and cervical fascia; — Posteriorly, sepa- 
 rated from fourth, fifth, and sixth cervical vertebrae and prevertebral muscles 
 by laryngeal portion of pharynx; — Laterally, sternohyoid; sternothyroid; 
 thyrohvoid; superior end of lateral lobe of thyroid; portion of inferior con- 
 strictor; — Superiorly, opens into pharynx; — Inferiorly, opens into trachea. 
 
 Arteries. — Superior laryngeal branch of superior thyroid; inferior laryn- 
 geal branch of inferior thyroid; dorsalis linguae of lingual. 
 
 Veins. — Empty into superior, middle, and inferior thyroid veins. 
 
 Lymphatics. — Drain into carotid glands and into glands in front of 
 cricothyroid membrane, or into inferior laryngeal glands. 
 
 Nerves. — From superior laryngeal and recurrent laryngeal branches of 
 the pneumogastric, and from the sympathetic. 
 
 SURFACE LANDMARKS AND GENERAL SURGICAL CONSIDERATIONS. 
 
 The contour of the thyroid and cricoid cartilages, with the intervening 
 cricothvroid membrane, can generally be outlined in the average neck — with 
 the thyrohyoid membrane extending upward from the upper border of the 
 thyroid cartilages, and the rings of the trachea extending downward from the 
 cricoid cartilage. The height of the cricothyroid space is about 1 cm. 
 (nearly \ inch) in the average adult. 
 
 The internal (sensory) branch of the superior laryngeal nerve pierces the 
 thyrohyoid membrane above the superior laryngeal artery. The external 
 branch (principally motor) of the superior laryngeal is distributed to the 
 cricothyroid muscle and to the mucous membrane. The inferior or recurrent 
 laryngeal (motor) runs up in the groove between the trachea and esophagus, 
 and reaches the larynx below the inferior constrictor and just behind the 
 cricothvroid articulation, where it divides into anterior and posterior branches. 
 
 The cricothyroid artery (branch of superior thyroid) crosses transversely 
 
 6 95 
 
696 
 
 OPERATIONS I PON THE NECK. 
 
 over the upper part of the cricothyroid membrane, and is the chief artery 
 complicating laryngotomy. 
 
 Small venous trunks cross the laryngeal region irregularly, chiefly emptying 
 into the superior thyroid vein. 
 
 INSTRUMENTS. 
 
 Scalpels; scissors, sharp and blunt, curved and straight; forceps; dis- 
 secting, toothed, and artery-clamp; tenacula; wound hooks; laryngotomy 
 
 Fig. 541. — Positions of Incisions for Opening the Laryngotracheal Tract:— 
 A, Hyoid bone; B, Thyroid cartilage; C, Cricoid cartilage; D, Isthmus of thyroid gland; E, 
 Anterior belly of digastric; F, Mylohyoid muscle; G, Sternohyoid muscle; H, Sternothyroid 
 muscle; I, Sternocleidomastoid muscle; J, Omohyoid muscle; K, Thyrohyoid membrane; 
 L, Cricothyroid artery upon cricothyroid membrane; M, N, Branches of superior and inferior 
 thyroid arteries (the lower arteries are not lettered); O, Inferior thyroid veins; P, Pneumogastric 
 nerve; Q, Suprathyroid laryngotomy (subhyoid pharyngotomy) ; R, Median thyrotomy; S, 
 Laryngotomy; T, High tracheotomy; Y, Low tracheotomy. 
 
 tubes; tampon cannula?; artificial larynx; laryngeal forceps; artificial feather 
 for cleansing tube; grooved director; mouth-gag; tongue forceps; tongue 
 depressor; wound retractors; dilator for laryngeal wound; laryngeal aspirator; 
 spatulae; needles, curved and straight - needle-holder; sutures and ligatures, 
 
LARYNGOTOMY. 697 
 
 silk and gut; traction-ligatures; O'Dwyer's intubation set; shield for mouth 
 and eyes of operator; tracheotomy tubes. 
 
 LARYNGOTOMY. 
 
 Description. — Laryngotomy, or Infrathyroid Laryngotomy, consists in 
 the opening of the larynx through the cricothyroid membrane. The super- 
 ficial incision is made in the median line of the neck, and the opening into the 
 larynx is made transversely through the cricothyroid membrane, followed 
 by the introduction of a special laryngotomy tube flattened from above down- 
 ward so as to present an oval opening. 
 
 Preparation. — The neck is shaved, if covered by hair. 
 
 Fig. 542. — Laryxgotoity : — A, Tenaculum steadying thyroid cartilage; B, Cricoid cartilage; 
 C, Cricothyroid muscle; D, Sternothyroid muscle; E, Sternohyoid muscle; F, Knife in act of 
 increasing opening in cricothyroid membrane after stab-incision; G, Forceps grasping margin 
 of incised cricothyroid membrane; H, H, Retractors retracting sternohyoid and sternothyroid 
 muscles. 
 
 Position. — Patient supine, shoulders supported and head thrown back, 
 so as to round out and tense the laryngeal region. 
 
 Landmarks. — Thyroid and cricoid cartilages and cricothyroid space. 
 
 Incision. — A vertical incision is made exactly in the median line, from 
 3 to 4 cm. (about i^ to 1^ inches) long — beginning over the lower part of 
 the thvroid cartilage, passing over the cricothyroid membrane, and ending 
 at the lower border or just below the cricoid cartilage — while the larynx is 
 steadied in the middle line between the left thumb and forefinger. (See 
 Fig. 541, C.) 
 
 Operation. — (1) Incise the skin, superficial fascia, platysma, and cervical 
 fascia — dividing between ligatures any veins encountered. (2) Recognize the 
 interval between the sternothyroid and cricothyroid muscles and open up 
 this interval bv blunt dissection, thus exposing the cricothyroid membrane 
 (see Fig. 542). Retract the tissues laterally. Divide the cricothyroid artery 
 
698 OPERATIONS UPON THE NECK. 
 
 between two ligatures. (3) Steady the larynx by means of left thumb and 
 forefinger and incise the cricothyroid membrane laterally, carefully stabbing, 
 with a narrow, sharp knife, into the lumen at one side and incising trans- 
 versely just above the cricoid cartilage in the act of withdrawing the knife. 
 (4) Seize and evert one lip of the laryngeal wound with toothed forceps, and, 
 parting the lips of the wound by a special laryngeal dilator, insert the oval 
 laryngeal tube into the larynx, so that its greatest width corresponds with 
 the length of the wound. Attach tube to the neck by means of a band. (5) 
 If the superficial wound be long, its ends may be sutured, leaving less of an 
 area for granulation. (6) A dressing should be applied between the flange 
 of the tube and the neck. 
 
 Comment. — Stab well into the lumen of the larynx (while guarding 
 against stabbing too far), so as to avoid pushing the mucous lining of the 
 larynx ahead of the knife and really not entering the lumen at all. Cut 
 very near the cricoid cartilage, especially if compelled to operate hastily — 
 as the cricothyroid artery runs nearer the lower border of the thyroid cartilage. 
 
 Sometimes the cricothyroid membrane is incised vertically, just as the 
 superficial wound — additional room being gotten by dividing the cricoid 
 cartilage in the same line. The above is, however, preferable. 
 
 Laryngotomy and Tracheotomy compared; — Laryngotomy is rapidly and 
 easily performed — it is the operation where great haste is necessary and few 
 instruments and limited assistance are at hand. It is inapplicable under 
 thirteen years (the space being too narrow). It is more difficult to insert a 
 proper laryngotomy tube than a tracheotomy tube. The vocal cords are 
 nearer and are more apt to be injured by wearing a laryngotomy tube. Laryn- 
 gotomy is not applicable where a tube must be worn for some time. In 
 Laryngotomy the cricothyroid artery must be avoided or tied. 
 
 THYROTOMY. 
 
 Description. — Division of the thyroid cartilage, partially or completely, 
 in the median line, in order to expose the cavity of the larynx. Resorted to 
 for the removal of foreign bodies and growths. Vocalization is apt to be 
 permanently involved. The operation is very similar to Laryngotomy. 
 
 Preparation. — As in Laryngotomv. In addition, a preliminary Trache- 
 otomy is done (preferably several days in advance). (A preliminary laryngo- 
 tomy may be done, but is less satisfactory.) The trachea should be plugged, 
 or a tampon cannula used after the tracheotomy. 
 
 Position. — As in Laryngotomy. 
 
 Landmarks. — Hyoid bone, thyrohyoid membrane, thyroid cartilage, 
 cricothyroid membrane and cricoid cartilage. 
 
 Incision. — A vertical incision is made exactly in the median line, begin- 
 ning at the lower border of the hyoid bone and ending over the cricoid cartilage 
 — steadying the larynx between the left thumb and forefinger (see Fig. 541, B). 
 
 Operation. — (1) Incise skin, superficial fascia, platysma, and cervical 
 fascia — encountering the terminal branches of the superficial cervical and 
 inframaxillary nerves, the communicating branches between the anterior 
 jugular veins, and some small superficial arterial and venous branches. (2) 
 Open up the connective-tissue interval between the sternothyroid and crico- 
 thyroid muscles by blunt dissection, exposing the thyroid cartilage and thyro- 
 hyoid and cricothyroid membranes. (3) Divide the thyroid cartilage care- 
 fully and exactly in the median line, by cutting from above downward and 
 from without inward, with a sharp, fairly heavy, rounded knife. If the upper 
 
COMPLETE LARYNGECTOMY. 699 
 
 margin of the thyroid cartilage can be left uncut, better subsequent adjust- 
 ment is obtained — but if necessary, not only the entire thyroid may be divided 
 but as much of the thyrohyoid and cricothyroid membranes as indicated. 
 This manner of division is safer than inserting the point of a knife below the 
 thyroid and cutting upward from within. In calcined cartilages a small saw 
 may be necessary. (4) The two aire of the thyroid cartilage are now drawn 
 aside with small, blunt hooks, exposing the interior of the larynx and enabling 
 the special object of the operation to be carried out. If the alae cannot be 
 separated sufficiently for the object sought, divide the thyrohyoid or crico- 
 thyroid membranes, or both, transversely near their cartilages. (5) Having 
 accomplished the object of the operation, the severed borders of the thyroid 
 are united by chromic catgut — (and the margins of membranes if cut). The 
 external wound is left open in the center, having been closed at the ends. 
 Temporary drainage is used. The tracheotomy tube is retained for several 
 days. 
 
 COMPLETE LARYNGECTOMY. 
 
 Description. — Excision of the entire larynx. Its removal may or may 
 not be followed by the substitution of an artificial larynx. Generally resorted 
 to for malignant disease. 
 
 Preparation. — As for Laryngotomy. In addition, a preliminary low 
 tracheotomy should be done ten days or one week in advance. Some form of 
 tampon cannula should be inserted into the tracheotomy wound just before 
 the major operation. 
 
 Position. — Patient supine, shoulders elevated, head thrown back, neck 
 prominent over a cushion or sand-bag. Surgeon to patient's right. Assistant 
 opposite surgeon. 
 
 Landmarks. — Hyoid bone, thyrohyoid space, larynx, cricoid cartilage 
 and upper tracheal rings, sternomastoid muscles. 
 
 Incision. — (1) Vertical incision, exactly in the median line, extending 
 from the center of the thyrohyoid membrane to the second or third tracheal 
 rings; — (2) Transverse incision, carried across at upper limit of vertical 
 incision, passing from one sternomastoid muscle to the opposite one. (See 
 Fig. 548, B.) 
 
 Operation. — (1) Having carried the above incisions through skin, superfi- 
 cial fascia, platysma, and cervical fascia; ligated the superficial vessels; and 
 encountered branches of the superficial cervical and inframaxillary nerves, 
 the two rectangular flaps thus outlined are turned outward and downward, 
 exposing the anterior margins of the sternomastoids, thyroid and cricoid 
 cartilages, and trachea. (2) Divide, between double ligatures, the superior 
 thyroid arteries, as they lie at the posterior border of the thyrohyoid muscles, 
 near the superior margin of the thyroid cartilage. Similarly ligate and divide 
 the inferior thyroid arteries at the posterior border of the sternothvroids. at 
 the lower edge of the larynx. The thyroid veins encountered are similarly 
 dealt with. (3) The cricothyroid, sternothyroid, and thyrohyoid of one side, 
 together with the adjacent soft parts, are retracted outward, while the larynx 
 is retracted to the opposite side. (4) The inferior constrictor muscle of that 
 side is now severed from the thyroid cartilage bv a curved blunt dissector 
 and scissors — the larynx is drawn forward and the tissues between the cut 
 inferior constrictor and the ends of the superior thyroid arteries are divided 
 • — the superior laryngeal nerve is cut — and the thyroid gland is retracted out 
 of the way. (5) The larynx is now drawn to the opposite (freed) side and 
 
700 OPERATIONS UPON THE NECK. 
 
 the same process of separation is repeated upon the second side. (6) Sever 
 the thyrohyoid membrane and the thyrohyoid ligaments — divide the extra- 
 laryngeal attachments of the epiglottis while putting the parts on the stretch 
 (thyro-epiglottic ligament, hyo-epiglottic ligament, glosso-epiglottic folds, and 
 aryteno-epiglottic folds). (7) Draw the larynx forward and complete the 
 division of the connections of the larynx to the pharynx and esophagus, from 
 side to side and from above downward, guarding the esophagus from injury. 
 (8) If the trachea be bound in situ by the preliminary tracheotomy, it will 
 retain its position when cut — if not, it is to be steadied by two silk sutures — 
 and then divided transversely between the cricoid cartilage and the first ring 
 of the trachea, from behind forward. (9) Secure the upper end of the trachea 
 to the surrounding integument by a few interrupted silk sutures. A deeper 
 layer of silver wire or silk sutures may be put in to secure the deeper part of 
 the trachea to the deeper surrounding parts — and another layer uniting the 
 mucous membrane of the trachea to the skin. (io) Suture the transverse 
 part of the wound, packing the rest. The tampon cannula is to be left in 
 situ for one or two days, then replaced by the ordinary tracheotomy tube. 
 The patient is fed through a stomach-tube at first. An artificial larynx is to 
 be inserted in from four to six weeks, if one be used. 
 
 Comment. — (a) Some surgeons do the tracheotomv only at the time of 
 the main operation, (b) All bleeding vessels are ligated or clamped as en- 
 countered, (c) It may be necessary to divide the isthmus of the thyroid 
 gland between ligatures, (d) All enlarged glands encountered are to be 
 removed, (e) Hug the cartilages throughout the entire operation, (f) The 
 larynx may be detached from below upward, dividing transversely below the 
 cricoid cartilage, (g) If in doubt as to the needs of removing the entire 
 larynx, split the larynx and thoroughly examine, (h) The epiglottis is best 
 removed — some leave it — it may interfere with the artificial larynx — or 
 become the seat of returning disease, (i) The cricoid cartilage is best away. 
 Some prefer to leave it as a support to an artificial larynx. Others think its 
 retention interferes with swallowing. 
 
 PARTIAL LARYNGECTOMY. 
 
 Description. — Excision of one-half (in the middle line) of the larynx. 
 Indicated in the partial involvement of the organ. 
 
 Preparation. — Same as for Complete Laryngectomy, including the pre- 
 liminarv tracheotomv. 
 
 Position — Landmarks. — Same as in the complete operation. 
 
 Incision. — Same as for total Laryngectomy, except that the transverse 
 portion of the incision is made only upon one side. (See Fig. 548, B.) 
 
 Operation. — Same, practically, as for the total excision, except that the 
 thyroid cartilage is divided dowm its center and the involved half removed 
 after being separated from its soft parts by carefully hugging the cartilage 
 during the freeing. The superior cornu of the thyroid cartilage is divided 
 at its base by forceps. The epiglottis is left, the aryteno-epiglottic fold of 
 the involved side being severed near WrrSberg's cartilage — though one-half 
 of the epiglottis may be left and one-half removed. The cricoid cartilage 
 may be left. The after-treatment is practically the same as for the total 
 removal, except briefer. 
 
INTUBATION OF THE LARYNX. 701 
 
 INTUBATION OF THE LARYNX. 
 
 O'DWYER'S OPERATION. 
 
 Description. — The introduction, by a special instrument (introductor), into 
 the larynx of a special metallic tube — which, upon the accomplishment of the 
 object, after a shorter or longer time, is removed by another form of special 
 instrument (extractor). Intubation is used in cases of impeded breathing 
 arising in the larynx or upper trachea from causes other than foreign body. 
 
 Operation. — (1) Supposing the case to be a child — the nurse sits upright 
 in a straight-back chair — the child, enveloped in a sheet or large bath-towel, 
 thus pinioning its arms, is held upright in the nurse's right lap, her right 
 arm passing forward around the child's shoulders and chest, her left forward 
 around its hands and abdomen — its legs are placed between her knees — its 
 head is thrown slightly backward over the nurse's right shoulder, and is 
 steadied by an assistant standing behind the nurse — the child's mouth is 
 gagged on the left side and the gag held by the assistant's left hand. (2) 
 The surgeon, standing in front of the child (his mouth, eyes, and nose pro- 
 tected from the cough, etc., of the patient, in contagious cases) — inserts his 
 left index into the throat until in contact with the epiglottis, which he elevates 
 by hooking forward and presses against the root of the tongue with the tip 
 of this finger, at the same time also drawing the base of the tongue slightly 
 forward. The tube, with its contained obturator attached to the introductor, 
 is passed into the mouth parallel with the left index as a guide (the handle 
 of the instrument, at this stage, being about parallel with the chest-wall) and 
 is directed in the necessary curve by elevating the handle of the introductor 
 — and is guided through the rima glottidis by the tip of the finger which has 
 drawn the epiglottis forward. As soon as the instrument is felt to be engaged 
 within the larynx, the left index-finger is shifted to the shoulder of the tube 
 and aids in gently pushing it down into place between the cords. The obtu- 
 rator is then detached from the tube by a special mechanical movement, 
 controlled within the handle of the instrument, and is withdrawn together 
 with the introductor. If the safety-thread (which has been previouslv intro- 
 duced through the eye of the laryngeal tube) be removed, the left index 
 remains in contact with the tube until the thread is withdrawn. The thread 
 is often retained as a means of hasty and easy withdrawal in case of need, 
 and is tied about a tooth or the ear. (3) To withdraw the tube, let the same 
 position of patient, surgeon, assistant, and nurse be assumed as before — 
 similarly draw the epiglottis forward with the left index — and, having similarly 
 guided the beak of the extractor into the lumen of the laryngeal tube, expand 
 the blades of the beak and withdraw the tube. If the thread have been left 
 in situ, the tube may be withdrawn by it. 
 
 Comment. — Always be ready, in advance, to do an immediate trache- 
 otomy — in the event that intubation cannot be performed, or that tube get 
 into trachea, or that membrane be protruded ahead of the tube and impede 
 trachea and tube. 
 
 To feed the child while the tube is in the larynx — place it upon its back 
 in the nurse's lap — let its head bend over her knee, lower than its shoulders — 
 feed it fluid food from a bottle on to the roof of its mouth (which is now lower 
 than the floor) — the liquid will then flow over the soft palate on to the posterior 
 pharyngeal wall, and thus nothing pass over the laryngeal tube. Some 
 children, however, feed naturally without trouble. 
 
 The shoulders of the laryngeal tube are grasped by the superior or false 
 vocal cords. 
 
7°2 OPERATK >NS UPON THE NECK. 
 
 OTHER OPERATIONS UPON THE LARYNX. 
 
 Suprathyroid Laryngotomy. — 
 
 Same as Subhyoid Pharyngotomy (page 709). Sometimes employed to 
 expose the upper part of the larynx and the region of the epiglottis. 
 
 Laryngo-tracheotomy. — 
 
 Larynx and trachea are both opened in one continuous median line — 
 where more room is required than furnished by either laryngotomy or trache- 
 otomy alone. 
 
 Tamponing of Larynx. — 
 
 The placing of gauze or sponge packing over the entrance of the larynx 
 in order to prevent the entrance of fluids or blood into the air-passages during 
 operations about the oral, pharyngeal, and nasal cavities — a preliminary 
 tracheotomy having been done. 
 
 Introduction of Artificial Larynx. — 
 
 After the parts have healed, following a total laryngectomy, an artificial 
 larynx is sometimes inserted through the wound in the neck — a mechanical 
 contrivance having a longer tracheal tube which fits into the trachea, a shorter 
 pharyngeal tube passing up toward the site formerly occupied by the larynx, 
 and an external protected opening occupying the cervical wound, and a vibrat- 
 ing apparatus for speech. 
 
 Operation for the Removal of Foreign Bodies. — 
 
 Foreign bodies are removed either by means of instruments introduced 
 into the larynx through the rima glottidis by way of the mouth — or by opening 
 the cavity of the larynx from without by means of one of the operations above 
 described. 
 
 Laryngoscopy. — 
 
 Examination of the larynx by means of a laryngoscopic mirror introduced 
 through the mouth. 
 
 II. THE TRACHEA. 
 SURGICAL ANATOMY. 
 
 Situation. — The trachea extends from lower border of fifth cervical 
 vertebra above, where it is continuous with the larynx, to fourth or fifth 
 dorsal vertebra below, where it bifurcates into right and left bronchi. Its 
 length is from 10 to 13 cm. (4 to 5 inches) — its width from about 2 to 2.5 cm. 
 (f to 1 inch). It lies in a bed of lax connective tissue. 
 
 Relations. — (a) Cervical portion, — anteriorly ; skin; superficial cervical 
 fascia; anterior jugular veins; communicating branch between anterior 
 jugular veins; inferior thyroid veins; thyroidea ima artery (when present); 
 sternohyoid and sternothyroid muscles, separated by deep cervical fascia, 
 and partly overlapping sides of trachea; isthmus of thyroid gland; thymus 
 gland (or its remains). Posteriorly; esophagus. Laterally; lateral lobes 
 of thyroid gland (especially on left); inferior thyroid arteries; recurrent 
 laryngeal nerves; sheath of common carotid, internal jugular and pneumo- 
 gastric. (b) Thoracic portion, — anteriorly; sternum; remains of thymus; 
 origins of sternohyoid and sternothyroid muscles; left innominate vein; 
 transverse arch of aorta; innominate artery; left common carotid artery; 
 deep cardiac plexus; left recurrent laryngeal nerve. Posteriorly; esophagus. 
 Laterally; lies between the pleural sacs; pneumogastrics. 
 
 Arteries. — From inferior thyroid branch of thyroid axis. 
 
 Veins. — End in thyroid plexus. 
 
INSTRUMENTS USED IN OPERATIONS UPON THE TRACHEA. 703 
 
 Nerves. — From trunk of pneumogastric; recurrent laryngeal branch of 
 pneumogastric; sympathetic. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The isthmus of the thyroid gland crosses the second and third tracheal 
 rings in the adult. It is generally higher in the child. 
 
 In an average adult, about 2 cm. (f inch) of additional trachea is drawn 
 up into the neck in full extension of the cervical region. 
 
 In infants under two years, the thymus gland extends upward nearlv or 
 quite to the lower border of the thyroid gland. 
 
 Small venous trunks cross the tracheal region irregularly, chiefly emptying 
 into the superior thyroid veins. 
 
 A communicating vein between the superior thyroid veins crosses the 
 trachea above the isthmus of the thyroid gland. 
 
 Arteria thyroidea ima, when present, passes up from the innominate 
 along the anterior surface of the trachea. 
 
 The upper portion of the trachea is comparatively superficial. The 
 lower portion is comparatively deep and the vascular relations more com- 
 plicated. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Tracheotomy may be done in three sites — (1) Above the isthmus of the 
 thyroid gland, or High Tracheotomy (the operation of election, because the 
 trachea is here more accessible), — (2) Below the isthmus, or Low Trache- 
 otomy, — and (3) Behind the isthmus (by its ligature and removal of the 
 isthmus — hardly a separate operation, but generally added to one of the 
 others where more room is required). 
 
 Structures of the anterior aspect of the neck more or less involved in 
 tracheotomy above the isthmus of the thyroid, — skin; superficial cervical 
 fascia; superficial cervical nerves; inframaxillary nerves; cutaneous arteries; 
 anterior jugulars and communicating vein; deep cervical fascia; superior 
 thyroid arteries and veins; tracheal layer of deep cervical fascia. 
 
 Structures of the anterior aspect of the neck more or less involved in 
 tracheotomy below the thyroid isthmus, — the superficial structures men- 
 tioned above; communicating branch between the anterior jugular veins 
 larger; sternothyroids closer; inferior thyroid veins larger; arteria thyroidea 
 ima possibly present; innominate artery may cross seventh tracheal ring; 
 trachea deeper and more movable; thymus gland present up to second year. 
 The innominate and common carotid arteries may be in the way of a low 
 tracheotomy. 
 
 The thymus gland or the isthmus of the thyroid gland is to be incised, 
 between ligatures, if in the way. 
 
 If the tracheal fascia be not well incised, there is a liability of working 
 between the fascia and trachea rather than in the latter. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE TRACHEA. 
 
 Scalpels: scissors, sharp and blunt, curved and straight; forceps, dis- 
 secting, toothed, and artery-clamp; tenacula; wound hooks; tracheotomy 
 tubes; tampon cannula?; tracheal forceps; artificial feather for cleansing 
 tube; grooved director; wound retractors; dilator for tracheal wound; tracheal 
 
7°4 
 
 OPERATIONS UPON THE NECK. 
 
 aspirator; needles, curved and straight; needle-holder; sutures and ligatures; 
 silk and gut; traction ligatures; Langenbeck's double tracheotomy hook, 
 shield for mouth, nose, and eyes of operator. 
 
 HIGH TRACHEOTOMY. 
 
 Description. — The opening of the trachea above the isthmus of the 
 thyroid gland. This is the operation (if choice, because of the greater acces- 
 sibility of the trachea here, and because of the fewer important relations. 
 
 Preparation. — The neck is to be shaved, if necessary. 
 
 Position.— Patient supine, at edge of table, shoulders elevated, head 
 thrown back, neck made prominent by being bent well backward over a 
 
 Fig. 543. — High Tracheotomy: — A, Tenaculum steadying cricoid cartilage; B, Retractor 
 drawing down thyroid isthmus from tracheal rings; C, Sternohyoid muscle; D, Sternothyroid 
 muscle; E, E, Sternohyoid and sternothyroid muscles retracted from median line; F, Forceps 
 drawing outward one lip of incised trachea; G, Knife in act of increasing tracheal opening after 
 stab-incision. 
 
 cushion or sand-bag, chin kept rigidly in median line. Surgeon to the right 
 of patient. Assistant opposite surgeon. 
 
 Landmarks. — Median line of neck; cricoid cartilage; upper rings of 
 trachea. 
 
 Incision. — Vertical incision made exactly in the median line of the neck, 
 extending from the upper border of the cricoid cartilage downward for 2.5 
 to 4 cm. (about 1 to ij inches) — the skin and trachea being steadied between 
 the left forefinger and thumb on either side. (See Fig. 541, D.) 
 
 Operation. — (1) Divide skin, subcutaneous fatty areolar tissue, possibly 
 the platysma, and the anterior layer of the cervical fascia, cutting between 
 double ligatures any communicating branches between the anterior jugular 
 veins. (2) Recognize and open up the cellular interval between the sterno- 
 
HIGH TRACHEOTOMY. 705 
 
 hyoid and sternothyroid muscles by clean, full-length cuts — the inner border 
 of these muscles being separated by blunt dissection. All separated tissues 
 are retracted laterally. (See Fig. 543.) (3) Divide the deeper cervical fascia 
 overlying the trachea, cutting between double ligatures any veins crossing 
 the line of incision — a small venous plexus lies over the isthmus, and a trans- 
 verse branch between the superior thyroids, crossing above the isthmus, 
 sometimes occurs — also abnormal branches of the superior thyroid arteries 
 may cross the upper part of the trachea. The isthmus of the thyroid gland 
 is exposed, and, if in the way, drawn down by a hook. The tracheal rings 
 are felt for by the finger-tip and exposed to view. The parts are still steadied 
 laterally by the left thumb and forefinger, until the tracheal rings are well in 
 the field. (4) All bleeding having been controlled and the white rings of the 
 trachea being clearly defined, the trachea is to be steadied preparatorv to 
 opening. For this purpose, a tenaculum, or, preferably, Langenbeck's 
 double tenaculum hook, is fastened by its point into the anteroinferior aspect 
 of the cricoid cartilage and given to an assistant, who draws the cricoid 
 cartilage upward and forward directly in the median line, gently following 
 the play of the larynx, thus steadying the trachea by making it tense. The 
 tip of the surgeon's left forefinger feels for the upper border of the isthmus 
 of the thyroid gland — and, with a sharp, slender knife, held with its cutting- 
 edge upward, a quick, limited stab is made into the median line of the trachea, 
 just above the thyroid isthmus, and the trachea divided upward toward 
 the chin, to but not into the cricoid cartilage, in the act of withdrawing the 
 knife. (5) Gently seize the right lip of the tracheal wound with toothed 
 forceps held in the left hand, and evert it just sufficiently to cause a slight 
 gap between the cut margins — into which gap gently, quickly, but steadily 
 insert the tracheotomy tube — still steadying the cricoid with the tenaculum 
 until the tube is in place. (6) Having seen that all hemorrhage is controlled, 
 the tube is tied in place by bands passing around the neck, a dressing being 
 applied between skin and instrument. The upper and lower ends of a long 
 wound may be united by suture, to lessen the area to be closed bv granulation. 
 
 Comment. —Observe the following, — Incise only in the median line; See 
 and feel bare tracheal rings before opening trachea; Be sure the opening is 
 made into the trachea, and not into the surrounding areolar tissue. If 
 possible, control all bleeding before incising the trachea — although often 
 venous hemorrhage, otherwise difficult to stop, will cease as soon as air enters 
 the lungs freely through ihe tracheal wound. 
 
 Where the thyroid isthmus encroaches upon the field, draw it down with 
 a hook or special retractor. 
 
 Where the tissues of the neck are very thick, outward retraction bv thread 
 or instrument retractors aids in exposing the trachea and keeping the bottom 
 of the wound freer from blood. 
 
 It is easier to insert the tube if the neck be straightened just before everting 
 the lip of the tracheal wound, to relax the tension of the structures. The lips 
 of the tracheal wound may be held apart by a tracheal dilator while the tube 
 is being inserted, or by two tenacula. 
 
 Modification. — Where it is found that the isthmus of the thyroid gland 
 encroaches too much upon the site of operation to avoid it — or in those cases 
 in which it is elected to perform tracheotomy beneath the isthmus — having 
 incised and separated the tissues down to the isthmus in the usual way, cut 
 vertically directly through the center of the isthmus — immediately seize each 
 cut half with clamp-forceps and allow the clamped ends to drop away from 
 the trachea without any special effort to further dissect or retract them from 
 
 45 
 
706 OPERATIONS UPON THE NECK. 
 
 the trachea unless the opening be encroached upon. These cut portions 
 are subsequently gut ligatured. If time allow, the isthmus may be doubly 
 ligated in situ and divided between these ligatures. 
 
 Modification. — Hose's Bloodless Method of Tracheotomy. — Make a 
 median vertical incision from the middle of the thyroid cartilage downward 
 for 4 to 5 cm. (about ij to 2 inches) — the soft parts are retracted laterally — 
 incision is made through the deep layer of the cervical fascia along the upper 
 border of the cricoid cartilage, covering the trachea and binding down the 
 thyroid isthmus — this fascia is detached by blunt dissection and retracted 
 downward bv a special hook, carrying the isthmus and vascular supply 
 covering the front of the trachea. The trachea being thus bared, the opera- 
 tion is completed as above. 
 
 LOW TRACHEOTOMY. 
 
 Description. — Inferior or Low Tracheotomy consists in the opening of 
 the trachea below the thyroid isthmus. The trachea is much deeper here 
 and its relations much more important — and subsequent wound complications 
 more serious. 
 
 Preparation — Position. — As in High Tracheotomy. 
 
 Landmarks. — Median line of neck; cricoid cartilage; rings of the trachea, 
 recognizing the upper ones, if possible, so as to determine the site of the 
 thyroid isthmus over the second and third tracheal rings. 
 
 Incision. — Vertical incision is made exactly in the middle line of the 
 neck, extending from the lower border of the cricoid cartilage downward to 
 within 2 cm. (about \ inch) of the sternal notch — while the trachea is steadied 
 by the left forefinger and thumb on either side. (See Fig. 541, V.) 
 
 Operation. — (1) Divide skin, subcutaneous fatty areolar tissue, anterior 
 layer of the cervical fascia, cutting between double ligatures communicating 
 veins crossing between the anterior jugulars. (2) Having incised the connec- 
 tive tissue, thicker here than in the high operation, expose and separate the 
 inner borders of the sternothyroids and sternohyoids. (3) Incise the deeper 
 cervical fascia, also thicker here than in the high operation, and divide between 
 double ligatures the communicating veins between the inferior thyroids, and 
 whatever other vessels may be encountered, including the thyroidea ima 
 artery, if present — retracting all tissues laterally. (4) The trachea is brought 
 within sight and touch — hemorrhage is controlled by pressure forceps — the 
 trachea is caught by Langenbeck's double tenaculum hook, or an ordinary 
 tenaculum, and lifted upward and forward — the thyroid isthmus being re- 
 tracted upward if necessary — and a sharp, slender knife is thrust with a con- 
 trolled stab-movement into the trachea and made to cut through three or four 
 rings in an upward direction as it is withdrawn. (5) The tracheotomy tube 
 (which must have a deeper curve than for the high operation) is inserted as 
 in the higher operation. (6) The treatment of the tube and wound are the 
 same as in the high operation. 
 
 OTHER OPERATIONS UPON THE TRACHEA. 
 
 Tracheo-laryngotomy. — 
 
 An opening, by median incision, involving both the upper rings of the 
 trachea and the cricothyroid membrane of the larynx — performed where 
 more room is required than furnished by either operation alone. 
 
INSTRUMENTS USED IN OPERATIONS UPON THE PHARYNX. 707 
 
 Tamponing of Trachea. — 
 
 The use of some form of packing, or some form of inflation, applied around 
 the stem of an ordinary tracheotomy tube, or a special form of tampon cannula, 
 whereby fluids and blood are prevented from entering the lungs during 
 operations upon the oral, nasal, and pharyngeal cavities. 
 
 Operation for the Removal of Foreign Bodies. — 
 
 Foreign bodies may be removed by means of special forceps introduced 
 through one of the tracheotomy wounds above described. 
 
 Tracheoscopy. — 
 
 Examination of the upper part of the trachea by means of the laryngo- 
 scopy mirror. 
 
 Thoracic Tracheotomy. — 
 
 Opening of the trachea in the posterior mediastinum (see page 752). 
 
 III. THE PHARYNX. 
 SURGICAL ANATOMY OF THE PHARYNX. 
 
 Situation, Extent, and Structure. — A conical, musculo-membranous 
 sac (consisting of nasal and buccal portions) placed base upward, apex down- 
 ward, behind the nose, mouth, and larynx. It extends downward from base 
 of skull to lower border of cricoid cartilage in front, and fifth (or between 
 fifth and sixth) cervical vertebra behind. It is composed of three coats — 
 Inner Coat, of mucous membrane: — Middle Coat, of pharyngeal aponeurosis 
 (thickest above, where muscles are thinnest; and thinnest below, where 
 muscles are thickest): — Outer Coat, of muscles (inferior, middle, and superior 
 constrictors, reinforced by stylopharyngeus, palatopharyngeus and salpingo- 
 pharyngeus). 
 
 Relations and Boundaries. — Superiorly, body of sphenoid; basilar 
 process of occipital: — Inferiorly, continuous with esophagus opposite fifth 
 (or between fifth and sixth) cervical vertebra: — Anteriorly (incomplete), 
 attached, from above downward, to internal pterygoid plate, pterygomaxillary 
 ligament, inferior maxilla, tongue, hyoid bone, thyroid cartilage, cricoid 
 cartilage: — Posteriorly, attached, by lax connective tissue, to prevertebral 
 fascia, longi colli, and recti capitis antici majores muscles, and to cervical 
 vertebral column: — Laterally, attached to styloid process and its muscles 
 (styloglossus, stylohyoid, and stylopharyngeus) ; and in relation with common 
 carotid, internal carotid, and ascending pharyngeal arteries, internal jugular 
 vein, glossopharyngeal, pneumogastric, hypoglossal, and sympathetic nerves, 
 internal pterygoid muscle (above) and lateral lobes of thyroid gland. 
 
 Openings Into. — Two posterior nares; two eustachian tubes; mouth; 
 larynx; esophagus. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE PHARYNX. 
 
 Scalpels; scissors; forceps, dissecting, toothed and artery-clamp; re- 
 tractors; probe; grooved director; tenacula; wound hooks; mouth-gag; tongue 
 forceps; tongue depressor; needles; needle-holder; ligatures and sutures; 
 aneurism-needle. 
 
708 OPERATIONS UPON THE NECK. 
 
 MEDIAN PHARYNGOTOMY 
 
 BY MEDIAN* VERTICAL INCISION THROUGH THE MOUTH. 
 
 Description. — Incision of the posterior pharyngeal wall in the median 
 line, through the mouth. Applicable to cases of retropharyngeal abscess of 
 small size and due to temporary cause (e. g., an acute abscess). 
 
 Preparation. — Mouth cleansed by frequent antiseptic washings. 
 
 Position. — Patient on side, head elevated and turned to one side, with 
 mouth dependent. Surgeon in front of patient. 
 
 Landmarks. — Median line of the prevertebral region; contour of involved 
 region. 
 
 Operation. — The mouth is gagged and so directed that pus or other 
 fluid will flow out. A straight, sharp bistoury, protected by wrapping except 
 for about i cm. (about \ inch) at its point, is directed in toward the center 
 of the posterior pharyngeal wall, or toward the most fluctuating point, guided 
 by the left forefinger, which marks the site — an incision about i cm. (about 
 \ inch) long is then made vertically in the median line, either upward or 
 downward. The incised wound is not closed by suture, but allowed to 
 drain. 
 
 LATERAL PHARYNGOTOMY 
 
 BY CURVED LATERAL INCISION THROUGH THE NECK — KOCHER'S OPERATION. 
 
 Description. — Incision of the pharynx through the lateral wall of the 
 neck — for the exposure of the lateral wall of the pharynx, together with the 
 tonsil, base of tongue, and retropharyngeal space. Applicable to cases 
 requiring the fullest exposure of the pharynx. 
 
 Preparation. — Shaving of the neck, if necessary. Cleansing of the throat 
 with antiseptic washes. 
 
 Position. — Patient supine, shoulders elevated, neck prominent, head to 
 opposite side. Surgeon either in front of, or behind, the neck. Assistant 
 opposite surgeon. 
 
 Landmarks. — Apex of mastoid process; anterior border of sternomastoid 
 muscle; hyoid bone. 
 
 Incision. — Begins at the anterior border of the apex of the mastoid 
 process — runs in a slight downward curve, with posterior convexity, crossing 
 the anterior border of the sternomastoid about 2 cm. (about J inch) behind 
 the angle of the jaw — ending at the middle of the hyoid bone. (See Fig. 
 544, A.) 
 
 Operation. — (1) Divide the skin, superficial fascia, and platysma along 
 the above line — cutting between double ligatures the external jugular, facial, 
 and temporofacial veins. (2) Expose the submaxillary region — dissect out 
 the submaxillary gland and either throw it upward over the border of the 
 inferior maxilla, or extirpate it — dividing the facial artery between two liga- 
 tures — and preserving, if possible, the auricularis magnus and cervicofacial 
 nerves. (3) The lingual, ascending pharyngeal, and ascending palatine 
 arteries are tied, if necessary, close to their origin — or the external carotid 
 itself. (4) Retract backward the great cervical vessels, with the pneumo- 
 gastric and spinal accessory nerves — draw the hypoglossal nerve upward — 
 the superior laryngeal nerve and superior thyroid artery remaining under the 
 lower margin of the wound. (5) Work up along the internal surface of the 
 inferior maxilla and of the internal pterygoid in the direction of the mucous 
 membrane of the pharynx, in order to preserve the muscles lying anteriorly 
 
SUBHYOID PHARVXGOTOMV 
 
 709 
 
 and connected with the act of swallowing. If the muscles must be sacrificed, 
 so cut them that their innervated ends will be as long as possible — dividing 
 the posterior belly of the digastric and stylohyoid near the hyoid (their supply 
 from the facial entering posteriorly) — the styloglossus near the tongue, avoiding 
 the lingual and glossopharyngeal nerves (unless involved, when they must 
 be divided) lying upon it — the stylopharyngeus near the pharyngeal insertion 
 — and the hyoglossus and mylohyoid, to the extent indicated, near their 
 insertion into the hyoid. (6) The wall of the pharynx will now be exposed, 
 the superior constrictor lying above and the inferior constrictor below. Having 
 well retracted the sur- 
 rounding parts and 
 having incised the con- 
 strictors, forming the 
 lateral boundary of the 
 pharynx, its interior is 
 exposed. (7) Having 
 accomplished the object 
 of the operation, in clos- 
 ing the wound suture 
 up the pharyngeal wall 
 as completely as pos- 
 sible, in so far as the 
 mucous membrane is 
 concerned — leaving the 
 center of the outer 
 wound unsutured and 
 packed down to the mu- 
 cous membrane with 
 gauze, to provide for 
 drainage both from pos- 
 sible leakage from the 
 mouth and from the 
 fluids of the wound — 
 the ends only of the 
 outer wound being 
 closed by suture. 
 
 Comment. — If a part of the wall of the pharynx be removed, the operation 
 becomes a partial pharyngectomy. 
 
 Compare this operation with that for exposure of the tonsils through the 
 neck, page 719. 
 
 Fig. 544.— Incisions Exposing Pharyngo-esophageal Re- 
 gion: — A, Curved lateral incision for lateral pharyngotomy, and 
 for exposure of tonsil, base of tongue, and retropharyngeal space 
 (Kocher's operation); B, Lateral cervical incision for exposing the 
 retropharyngeal space (Chiene's operation); C Incision for cer- 
 vical esophagotomy. 
 
 SUBHYOID PHARYNGOTOMY 
 
 BV TRANSVERSE CURVED INCISION THROUGH THE NECK. 
 
 Description. — Subhyoid Pharyngotomy, or Suprathyroid Laryngotomy, 
 consists in opening the pharynx through the thyrohyoid membrane, just 
 below the hyoid bone. Chiefly done to expose the entrance of the larynx 
 for the purpose of removing foreign bodies or growths from the upper air- 
 passages, or for abscesses at base of epiglottis. 
 
 Preparation. — As for Lateral Pharyngotomy. 
 
 Position. — Patient supine, shoulders elevated, head thrown back, neck 
 prominent, resting upon a cushion or sand-bag. Surgeon on patient's right 
 or left. Assistant opposite. 
 
710 OPERATIONS UPON THE NECK. 
 
 Landmarks. — Hyoid bone, upper border of thyroid cartilage. 
 
 Incision. — Transverse curved incision along the lower border of the 
 body and greater cornua of the hyoid bone. In very thick necks a vertical 
 incision may have to be added to this. 
 
 Operation. — (i) Having incised the skin, superficial cervical fascia, and 
 platysma, divide between double ligatures the anterior jugular veins and 
 their branches. Some branches of the superficial cervical and cervicofacial 
 nerves are encountered. The hyoid arteries and veins along the hyoid bone 
 are generally not injured — and the superior thyroid artery is generally avoided, 
 running parallel with the incision. (2) Divide most of the muscles attached 
 to the lower border of the hyoid bone (sternohyoids, omohyoids, and most 
 but not all of the thyrohyoids). (3) The thyrohyoid membrane (its middle 
 and lateral portions) is now exposed — and, together with the subjacent 
 mucous membrane lying between the base of the tongue and the superior 
 border of the epiglottis, is incised along the inferior border of the hyoid bone, 
 while a finger in the mouth guides the knife — keeping rather near the hyoid 
 bone to avoid the superior laryngeal nerves piercing the lateral parts of the 
 thyrohyoid membrane (because of the importance of preserving the sensi- 
 tiveness, and thereby the expulsive power, of the larynx). (4) Seize the 
 epiglottis, which projects into the wound, with toothed forceps and draw it 
 forward, when the interior of the larynx and the lowest part of the pharynx 
 will be exposed to view. (5) Having accomplished the object of the operation, 
 suture the mucous membrane throughout — suture the ends of the external 
 wound — and pack with gauze the central portion of the wound down to the 
 sutured mucous membrane. 
 
 EXPOSURE OF THE RETROPHARYNGEAL SPACE 
 
 BV LATERAL CERVICAL INCISION ALONG POSTERIOR BORDER OK STERNO- 
 MASTOID MUSCLE — CHIENE'S OPERATION. 
 
 Description. — The retropharyngeal, or retro-esophageal, prevertebral 
 areolar tissue is opened up — without incising the pharyngeal or esophageal 
 wall. Indicated in cases of retropharyngeal abscesses due to protracted 
 cause (e. g., chronic abscess, generally from tubercular disease of the cervical 
 vertebra?) where drainage is apt to be prolonged; — also in large, acute retro- 
 pharyngeal abscesses, especially where jaws can no longer be widely opened. 
 
 Preparation. — Shave neck, if necessary. 
 
 Position. — Patient supine, or turned slightly to one side, shoulders 
 elevated, neck prominent, resting upon cushion or sand-bag and turned to 
 one side. Surgeon on side of operation. Assistant opposite. 
 
 Landmarks. — Posterior border of the sternomastoid. 
 
 Incision. — Along the posterior border of the sternomastoid, beginning 
 at the mastoid process and descending as far downward as necessary, de- 
 pendent upon the thickness of the structures of the neck. (See Fig. 544, B.) 
 
 Operation. — (1) Incise skin and fascia in the above line — ligate super- 
 ficial vessels encountered — avoid the transverse and the descending superficial 
 cervical nerves. (2) Recognize the posterior border of the sternomastoid 
 (which overlaps the scalenus anticus somewhat) and draw it forward — the 
 intermuscular groove between the sternomastoid and the scalenus anticus, 
 in the deep cervical fascia, is thus made evident. (3) Follow with a blunt 
 dissector, closely along the anterior surface of the scalenus anticus and in the 
 connective-tissue plane between the scalenus behind and the common sheath 
 
SURGICAL ANATOMY OF THE ESOPHAGUS. 711 
 
 of the great vessels in front, guarding the spinal accessory nerve beneath the 
 sternomastoid as the dissection passes behind its posterior border. (4) 
 Recognize the outer border of the longus colli muscle as soon as reached, 
 and keep behind this, as well as behind the great vessels — and having passed 
 beneath the longus colli the prevertebral areolar tissue of the retropharyngeal 
 space is reached — and the pus thus evacuated through a route behind and 
 comparatively free of important structures. (5) Free drainage is established 
 from the bottom of the wound — only the ends of the original incision being 
 sutured. 
 
 Comment. — The retropharyngeal space may be also approached by in- 
 cising along the anterior border of the sternomastoid, on the level of the 
 larynx (Buckhardt's operation) — passing in front of the common sheath of 
 the great vessels — retracting these and the sternomastoid backward, and the 
 thyroid, larynx, trachea, and anterior cervical muscles forward — opening the 
 fascia covering the longus colli and passing, anteriorly to it, transversely 
 across to its inner side into the retropharyngeal or retro-esophageal pre- 
 vertebral areolar tissue. 
 
 IV. THE ESOPHAGUS. 
 SURGICAL ANATOMY OF THE ESOPHAGUS. 
 
 Situation and Extent. — A muco-areolar muscular canal, from 23 to 26 
 cm. (about 9 to 10 inches) long — beginning at lower boundary of pharynx, at 
 upper border of cricoid cartilage, opposite fifth cervical vertebra (or between 
 fifth and sixth), passes down through superior and posterior mediastina along 
 front of spine, lying at first behind left part of the aortic arch, then descending 
 along right side of aorta until it curves forward anterior to and somewhat 
 to left of aorta — to descend through esophageal opening in diaphragm into 
 abdomen, ending in cardiac orifice of stomach, opposite tenth dorsal vertebra 
 (or between tenth and eleventh). 
 
 Curves of the Esophagus. — The antero-posterior curves of the esophagus 
 follow those of the vertebral column. Laterally, it curves to the left at the 
 root of neck, and at esophageal opening of diaphragm — and is in the middle 
 line at fifth cervical and fifth dorsal vertebra\ 
 
 Relations. — (a) In the neck : anteriorly, trachea, posterior part of left 
 lateral lobe of thyroid, left recurrent laryngeal nerve. Posteriorly, spinal 
 column, left longus colli muscle, prevertebral fascia. Right, right common 
 carotid, right recurrent laryngeal nerve. Left, left carotid, left inferior 
 thyroid artery and vein, left subclavian artery, thoracic duct. (The relation- 
 ships are more marked on the left.) (b) In the thorax : anteriorly, lower 
 part of trachea, beginning of left bronchus, transverse arch of aorta, 
 left common carotid, left subclavian, posterior surface of pericardium. 
 Posteriorly, spinal column, longi colli muscles, thoracic duct, right inter- 
 costal arteries and veins, left inferior azygos vein, inferior part of thoracic 
 aorta. Laterally, pleurae, pneumogastrics (forming plexus gulae below root 
 of lungs, thence left pneumogastric passes to anterior surface and right pneu- 
 mogastric to posterior surface of esophagus). Vena azygos major lies on the 
 right, and descending aorta on left. 
 
 Arteries. — From inferior thyroid branch of thyroid axis; descending 
 thoracic aorta; gastric branch of cceliac axis; left inferior phrenic. 
 
 Veins. — Empty into inferior thyroid, azygos, and gastric veins. 
 
 Lymphatics. — Empty into inferior cervical and posterior mediastinal 
 trlands. 
 
712 OPERATIONS UPON THE NECK. 
 
 Nerves.- From recurrent laryngeals, pneumogastrics, and sympathetic. 
 (The recurrent laryngeal branches of the pneumogastric run upward on both 
 sides to the interval between trachea and esophagus — the left nerve lying 
 somewhat anterior to the esophagus — the right nerve at some distance from it.) 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The narrowest parts of the esophagus are — at its beginning (narrowest) 
 ■ — opposite the fourth dorsal vertebra — at the diaphragm. 
 
 Distances (in the average adult) — from upper incisor teeth to diaphrag- 
 matic opening, about 37 cm. (about 14^ inches) — from same point to aorta, 
 about 23 cm. (about 9 inches) — from same point to upper end of esophagus, 
 about 14 cm. (about 5^ inches). 
 
 The deviation from the median line toward the left, in the cervical portion 
 of the esophagus, amounts to about 1 cm. (about h inch). 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE ESOPHAGUS. 
 
 Scalpels; scissors, blunt, sharp, straight, curved; forceps, dissecting, 
 toothed, artery-clamp; retractors; probe; grooved director; tenacula; ligature- 
 retractors; needles, straight and curved; needle-holder; ligatures and sutures, 
 silk and gut; mouth-gag; tongue-forceps; esophageal forceps, various; com- 
 bined mouth-gag and tongue depressor; esophageal bougies; blunt bistoury; 
 drainage tubing and material; blunt dissector; wound-hooks; elevators; 
 bristle probang; special foreign-body forceps and devices; stomach-tube; 
 dilating bougies; esophagotomes; bougie with string attachment; tubage set. 
 
 EXTERNAL CERVICAL ESOPHAGOTOMY. 
 
 Description. — Incision of the esophagus in the neck — the opening 
 ordinarilv being made on the left side, opposite the natural curve of the 
 esophagus, except when the object is more prominent and more easily reached 
 on the right. Generally indicated for the removal of foreign body, and 
 sometimes for tumor and for dilatation of the esophagus. 
 
 Preparation. — The neck is shaved if necessary. Where the operation 
 is for foreign body, the position of the body is sought by instruments before 
 incision, and the position of the incision regulated, as far as possible, by its 
 situation. 
 
 Position. — Patient supine, shoulders elevated, neck prominent, upon 
 cushion or sand-bag, head thrown back and turned to opposite side (generally 
 to the right). Surgeon on side of operation — Assistant opposite. 
 
 Landmarks. — Thyroid and cricoid cartilages; trachea; anterior border 
 of sternomastoid muscle 
 
 Incision. — Straight incision, generally made on the left side, 8 to 10 cm. 
 (about 3 to 4 inches) in length, beginning opposite the upper border of the 
 thyroid cartilage and continuing downward along the anterior border of the 
 sternomastoid, toward the clavicle, as far as necessary. (See Fig. 544, C.) 
 
 Operation. — (1) Incise skin, superficial fascia, and platysma. Ligate, 
 between double ligatures, the communicating veins between the anterior and 
 external jugular veins, and between the anterior jugular and facial, and 
 possibly also the anterior jugular vein. Some branches of the superficial 
 
EXTERNAL CERVICAL ESOPHAGOTOMY. 
 
 713 
 
 cervical nerve will also be cut. (2) Expose the anterior border of the sterno- 
 mastoid and draw it outward — also the sternohyoid and sternothyroid and 
 draw them inward — divide the omohyoid (unless it can be displaced down- 
 ward). (See Fig. 545.) (3) Divide the thyroid fascia — which is deep cervical 
 fascia forming the capsule of the thyroid gland — which is blended externally 
 with the sheath of the large vessels — and which must be divided before the 
 esophagus can be reached. After dividing this fascia, draw the thyroid 
 gland, larynx, and trachea inward and forward — and the common sheath of 
 the large vessels and pneumogastric, together with the descendens noni 
 nerve, outward. (4) Ligate and divide between two ligatures the inferior 
 thyroid artery as it crosses the longus colli transversely, lying behind the 
 common carotid — also the middle and superior thyroid veins if necessary. 
 Carefully avoid the recurrent laryngeal nerve, ascending in the groove between 
 
 Fig. 545.— Cervical Esophagotomy : — A, Sternomastoid muscle; P., Sternohyoid muscle; C, 
 Sternothyroid muscle; D, Omohyoid muscle; E, Trachea; F, Esophagus, showing incision, with 
 lips of esophageal wall retracted; G, Recurrent laryngeal nerve; H, Common carotid; I, Inferior 
 thyroid artery, ligated ; J. Communicating vein between anterior and external jugular; k", Thyroid 
 gland, showing superior and inferior thyroid arteries, and superior, middle, and inferior thyroid veins. 
 
 the trachea and esophagus, drawing it downward and inward if necessary. 
 (5) The esophagus, in the form of a red tube, will now appear in the bottom 
 of the wound. Pass a sound or esophageal bougie into the esophagus through 
 the mouth, so as to protrude the esophageal wall prominently into the wound. 
 A vertical incision is now made through the lateral or postero-lateral aspect 
 of the wall of the esophagus, while steadied with toothed forceps, carefully 
 avoiding the recurrent laryngeal nerve. (6) The lips of the wound in the 
 tube are grasped in turn with toothed forceps and a thread-retractor carried 
 through each lip upon a fully curved needle — thus enabling the wound to 
 be held widely open and the interior brought to view for the purpose of in- 
 spection, removal of foreign body, or operation. (7) At the conclusion of 
 the operation, unless contraindicated by nature of operation (generally after 
 the simple removal of foreign bodies), the lips of the esophageal wound should 
 
714 OPERATIONS UPON THE NECK. 
 
 be sutured with gut. The outside wound is sutured at its ends, leaving the 
 portion opposite the wound in the tube open and lightly packed with gauze, 
 until the tube has healed and no longer danger of leakage exists from the 
 esophagus. Where indicated, the wounds in the esophagus and in the neck 
 are both left open until the esophageal wall has healed, when the outer wound 
 is aided to granulate as rapidly as possible, or granulating surfaces may be 
 brought together by suture and the process of union hastened. (8) The 
 patient is temporarily fed by bowel at first — then by stomach-tube carefully 
 introduced. 
 
 Comment. — The wound in the esophageal wall is best closed by two 
 rows of fine catgut sutures — one whipping together the edges of the mucous 
 coat — the other passed a short distance from the margins of the wound, 
 after the manner of a Lembert suture, approximating the connective-tissue 
 coats. 
 
 CERVICAL ESOPHAGOSTOMY. 
 
 Description. — The making of an artificial opening in the esophagus 
 through the neck. Generally resorted to below the site of an inoperable 
 stricture, or during the treatment of an operable one, for the purpose, in the 
 former case, of introducing food into the stomach, and, in the latter, of prac- 
 tising mechanical dilatation. 
 
 Preparation — Position — Landmarks — Incision. — As for Esophago- 
 tomy. 
 
 Operation. — All the steps in the operation are the same as for Cervical 
 Esophagotomy, up to the opening of the esophagus. This having been 
 accomplished, the edges of the esophageal wound (the walls of the esophagus) 
 are sutured to or as near to the skin of the external wound as possible — the 
 external incision being then closed up to the margin of the funnel-shaped 
 wound leading into the esophagus. After healing, the patient is fed by an 
 esophageal tube introduced through the cervical wound — or his stricture 
 is svstematically dilated through the same channel. (See Figs. 544 and 545.) 
 
 Comment. — YYheie it is found that a single seance of dilatation, in the 
 case of esophageal stricture, accomplishes the object, the esophageal wound 
 is closed at once — and the operation-wound becomes in name, and in all other 
 respects, an Esophagotomy. 
 
 PARTIAL CERVICAL ESOPHAGECTOMY. 
 
 Description. — The excision of a portion of the cervical esophagus through- 
 out its entire circumference — with the restoration of the severed ends by 
 suturing, if possible — or as a preliminary to a Cervical Esophagostomy. 
 Generally done for malignant growth of the esophagus. 
 
 Preparation Position — Landmarks — Incision. — As for Cervical 
 Esophagotomy. 
 
 Operation. — (1) Having exposed the esophagus as in the above opera- 
 tions, this tube is isolated, being separated by blunt dissection upward and 
 downward — from the trachea in front — from the prevertebral areolar tissue 
 behind— from the connective tissue, lateral lobes of the thyroid, recurrent 
 laryngeal nerves, and the great vessels laterally. (2) The involved portion 
 of the esophagus is then excised by transverse division with scissors above 
 and below. (3) If the gap be not too great, and it be otherwise possible, 
 the proximal and distal ends are now sutured by two tiers of chromic gut — 
 
OTHER OPERATIONS UPON THE ESOPHAGUS. 715 
 
 the first whipping the edges of all the coats of the esophagus together — the 
 second being interrupted Lembert sutures passing through the outer walls 
 of the esophagus a short distance from the lips of the wound in the tube — 
 the suturing being done over an esophageal bougie passed through the mouth 
 and distending the esophagus opposite the site of suturing. (4) If the ends 
 of the esophagus cannot be made to meet, the proximal end is closed, first by 
 whipping, then by suturing the outer coats in the Lembert fashion — and the 
 distal end is sutured into the wound in the neck permanently, as for esopha- 
 gectomy, the entire circumference of the distal portion being sutured into the 
 cervical wound (differing in this respect from the Cervical Esophagostomy 
 above described, where only the lips of the lateral wound in the esophagus 
 care stitched into the cervical wound). (5) The external wound is left open 
 in either case — temporarily in the first instance — permanently in the second. 
 Figs. 544, C and 545 illustrate some common features.) 
 
 INTRODUCTION OF ESOPHAGEAL BOUGIE. 
 
 Description. — (1) Seat the patient upright, preferably in a chair — head 
 thrown back and slightly to side away from surgeon, and steadied in this 
 position by the individual or by an assistant. Gag the mouth, the handle 
 of the gag being upon the patient's left. Place a small, thin napkin upon the 
 tongue, extending well back. Insert the left index-finger to the base of the 
 tongue, both depressing it and simultaneously drawing it forward, the napkin 
 giving a firmer hold. (2) Upon this left finger as a guide, introduce the 
 lubricated bougie, held between the right index and thumb, straight into the 
 mouth, until its tip reaches the posterior pharyngeal wall — then direct it 
 downward and backward along the esophagus — causing the patient to swallow 
 it as he gags — being guided as to the depth of introduction by the circum- 
 stances of the case and the known distances of the structures from the upper 
 incisor teeth. (See General Surgical Considerations.) 
 
 OTHER OPERATIONS UPON THE ESOPHAGUS. 
 
 Esophagoscopy. — 
 
 The introduction into the esophagus of a special instrument, elec- 
 trically illuminated, and with or without mirrors (an esophagoscope) — wherebv 
 the lumen of the canal may be examined as it is withdrawn from the stomach 
 to the mouth (after the manner of an urethroscope). 
 
 Internal Esophagotomy. — 
 
 The division of the strictured esophagus upon the principle of the 
 stnetured urethra — by means of a cutting instrument passed through the 
 narrowed portion upon a guide — or by some special form of esophagotome. 
 
 Operation for Foreign Bodies in the Esophagus. — 
 
 Foreign bodies high up in the esophagus can often be seen or felt, and 
 removed with special pharyngeal forceps. Those lower down, out of sight 
 and reach, may still often be removed by special instruments for that purpose, 
 introduced through the mouth. Impacted bodies not removable by instru- 
 ments alone, are removed by instruments introduced, in the majority of cases, 
 through an esophageal wound — generally a cervical esophagotomy. Foreign 
 bodies very low down may be reached by forceps or the fingers through the 
 cardiac orifice of the stomach, introduced through a gastrotomy wound. 
 
716 OPERATIONS UPON THE NECK. 
 
 Direct Dilatation of the Esophagus for Stricture. — 
 
 The dilating bougies or instruments of increasing sizes, are passed directly 
 from the mouth through the narrowed esophagus, in the same manner as de- 
 scribed under the Introduction of the Esophageal Bougie, the stricture being 
 gradually distended. 
 
 Direct Divulsion of Esophageal Stricture. — 
 
 The passage, from the mouth, in quick succession, of increasing sizes 
 of dilators — thus rupturing, in a minor degree, the surrounding contracted 
 tissues. 
 
 Retrograde Dilatation of the Esophagus for Stricture.— 
 
 Here the dilating instrument is passed from below — through a gastrotomy 
 wound, in cases where but one sitting of the retrograde method is necessary, 
 followed by the immediate closure of the stomach wound, — or through a gas- 
 trostomy wound, where frequent resorts to the method are necessary. Dila- 
 tation may be begun by passage of the instrument from the stomach through 
 the strictured esophagus (as the title indicates) — but is often commenced by 
 causing the patient to swallow, prior to anesthesia, a thread with a split 
 shot attached — this is found in the stomach, and upon it the dilating rubber 
 tubes, or other instruments, are drawn from the mouth, through the esophagus, 
 out of the stomach wound — or vice versa. 
 
 Retrograde Divulsion of Esophageal Stricture. — 
 
 The same as Direct Divulsion — except performed in the reverse direction, 
 through a gastrotomy or gastrostomy wound. 
 
 Division of Esophageal Stricture by String Friction (Abbe's Opera- 
 tion). — 
 
 A preliminary gastrostomy is done — after recovery from which a small 
 bougie, with attached silk thread, is passed from the mouth into the stom- 
 ach — the ends of the thread are grasped by fingers at the mouth and 
 stomach — the small bougie is then withdrawn — another large enough to 
 gently engage the stricture is introduced — the thread is then drawn back 
 and forth, and the frictioning process, as it passes between the engaged bougie 
 and the esophageal wall, soon causes the engaged bougie to become loose — 
 and it is then similarly replaced by a larger size, until the desired caliber is 
 reached. Sometimes the thread is passed through a cervical esophagostomy 
 wound, instead of through the mouth, and then out of the stomach. When 
 sufficient dilatation has been secured, the gastrostomy wound is closed (and 
 also the esophagostomy wound, if one have been made). 
 
 Division of Esophageal Stricture by String Friction (Bryant's 
 Operation). — 
 
 A special form of bougie, carrying a thread passed through an opening 
 near its tip and running over a concealed pulley, is passed through the mouth 
 and down the esophagus, until well engaged in the stricture — when by the 
 sawing motion of the thread the stricture is worn down as in the above 
 operation. By this method, gastrostomy may often be dispensed with. 
 
 Treatment of Esophageal Stricture by Permanent Tubage. — 
 
 Consists in the passage through the stricture of a funnel-shaped rubber 
 tube, by means of a guide, until the funnel portion of the tube rests above the 
 stricture — a piece of silk attached to a hole in the tube being also tied to 
 the ear of the patient. The tube remains in situ for ten days at a time, and 
 is then cleansed and replaced — fluid food being taken through it. Applic- 
 able to some otherwise inoperable cases of malignant disease. 
 
TONSILLOTOMY. 717 
 
 V. THE TONSILS. 
 SURGICAL ANATOMY OF THE TONSILS. 
 
 Situation. — In the recesses between the anterior pillars of the fauces 
 (the palatoglossi muscles) and the posterior pillars of the fauces (the palato- 
 pharvngei muscles) — corresponding, externally, to the angle of the inferior 
 maxilla. 
 
 Relations. — Externally, inner surface of superior constrictor — which, 
 together with the pharyngeal aponeurosis, separates the tonsil from the 
 internal carotid and ascending pharyngeal arteries. Internally, free. 
 Anteriorly, palatoglossi muscles. Posteriorly, palatopharyngei muscles. 
 
 Arteries. — Dorsalis linguae of lingual; ascending palatine of facial; 
 ascending pharyngeal from external carotid; tonsillar of facial; descending 
 palatine of internal maxillary; branch from small meningeal of internal 
 maxillary (or from middle meningeal). 
 
 Veins. — End in the tonsillar plexus, outside of the tonsil. 
 
 Nerves. — From Meckel's ganglion, and from the glossopharyngeal. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The internal carotid artery lies about 2 cm. (about f inch) to the postero- 
 external aspect of the tonsil — and nearer when tortuous — separated from it 
 by the superior constrictor, styloglossus, and stylopharyngeus. The facial 
 artery, when tortuous, may approach the anterior border of the tonsil. The 
 ascending pharyngeal artery and the glossopharyngeal nerve lie to its outer 
 side. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE TONSILS. 
 
 (1) For Operations through the Mouth: — bistouries, straight and curved, 
 sharp-pointed; Whitehead's combined tongue-depressor and mouth-gag; 
 head-mirror; tonsillotomes; scissors, long-handled, sharp and blunt, straight 
 and curved; forceps, long-handled; artery-clamp forceps, long-handled; 
 tenacula, long-handled; aneurism-needles, long-handled, straight and laterally 
 curved; sponge-holders; needle-holder, long-handled; curved needles; liga- 
 tures; sutures. (2) For Operations through the Neck: — Same as those used 
 for approaching the esophagus, omitting those for use within the esophagus. 
 
 TONSILLOTOMY. 
 
 Description. — Incision of the tonsil by means of a knife introduced 
 through the mouth. Indicated in abscess. 
 
 Preparation. — Mouth is washed frequently with antiseptic solutions. 
 
 Position. — Patient sits upright in a chair, in a good light — mouth gagged 
 on the opposite side — head thrown back and steadied. Surgeon sits in front 
 — assistant stands behind patient's head, steadying it and gag, and pressing 
 tonsil into the field by fingers in the neck. 
 
 Operation. — A straight or slightly curved sharp-pointed bistoury, wrapped 
 with plaster or silk to within a little more than 1 cm. (about h inch) of its 
 point, is made to enter the mouth flatwise (its surfaces looking upward and 
 downward), with the back of the blade toward the cheek — it passes backward 
 horizontally and is made to enter the protruding anterior border of the tonsil 
 
718 OPERATIONS UPON THE NECK. 
 
 (which border generally extends out beyond the anterior pillar of the fauces) 
 in this position — passes into the gland parallel with its free inner surface — 
 and cuts its way from within outward on to its free aspect, in the act of with- 
 drawal. 
 
 PARTIAL TONSILLECTOMY THROUGH THE MOUTH. 
 
 Description. — Excision of the free portion of the tonsil (generally hyper- 
 trophied) — by means of a special instrument (tonsillotome) — or by means 
 of scissors or knife, aided by forceps. 
 
 Preparation — Position. — As for Tonsillotomy. 
 
 Operation. — (a) With the Tonsillotome; Having applied a combined 
 mouth-gag and tongue-depressor, introduce the tonsillotome flatwise, with 
 blade drawn back, until the pharynx is reached — then rotate it through a 
 quarter circle, holding its handle parallel with the median line — engage the 
 tonsil in the ring of the instrument, encircling it everywhere to an equal depth, 
 drawing the tonsil out with a tenaculum if necessary — push the blade home 
 firmly and steadily — and withdraw the instrument with the attached portion 
 of the tonsil, (b) With long, curved, blunt scissors; Having similarly applied 
 a combined mouth-gag and tongue-depressor, and supposing the tonsil to 
 be the left one, this tonsil is grasped with long forceps held in the operator's 
 left hand — the scissors, held in the right hand, are introduced closed — and are 
 then opened and made to seize the portion of the tonsil protruding beyond 
 the pillars of the fauces, between the grasp of the forceps and the pillars, 
 and to sever the tonsil with one stroke — which is withdrawn in the hold of 
 the forceps. In operating on the right side, hold the- instruments in the 
 opposite hands, (c) With long straight, blunt bistoury; The operation is done 
 as with scissors. 
 
 COMPLETE TONSILLECTOMY THROUGH THE MOUTH. 
 
 Description. — The entire tonsil is excised through the mouth — preceded, 
 where difficulty i- anticipated, by a preliminary tracheotomy, a temporary 
 ligation of the common carotid, and, if necessary, by a temporary splitting 
 of the cheek. Indicated in those cases where the growth is limited to the 
 tonsil, or but slightly involves the adjacent portion of the base of the tongue 
 or pillars of the fauces, but in which the tissues of the neck are not infiltrated. 
 
 Preparation. — As for Tonsillotomy. 
 
 Position. — Patient supine, shoulders and head raised, and head turned 
 so as best to expose and illuminate field — Surgeon n side opposite operation 
 = — Assistant opposite surgeon. Positions for the preliminary operations will 
 be determined by those operations. 
 
 Landmarks. — Anatomical boundaries (see Surgical Anatomy, page 717). 
 
 Preliminary Operations.— (a) Preliminary tracheotomy, with plugging 
 of the larynx, or the use of a tampon-cannula — performed several days in 
 advance of the operation, preferably (or may be done at the time of the opera- 
 tion), (b) Preliminary temporary ligation of the common carotid — performed 
 at the time of the operation, (c) Preliminary splitting of the cheek, if con- 
 sidered necessary — from the angle of the mouth backward to the masseter, 
 with twisting or gut-ligaturing of both ends of the facial artery — performed 
 at the time of the main operation. 
 
 Operation. — (1) Having completed the preliminary tracheotomy and the 
 temporary ligation of the common carotid, expose the region of the tonsil 
 
COMPLETE TONSILLECTOMY THROUGH THE NECK. 719 
 
 bv means of a gag on the opposite side, and by splitting of the cheek on the 
 same side, and by drawing the tongue well out of the mouth. The tumor 
 is now dealt with as indicated. (2) Where a movable, encapsulated tumor is 
 encountered, the overlying mucous membrane is incised and the tumor 
 shelled out by means of blunt dissection and the fingers. These simple cases 
 hardly call for such extensive preliminary operations. (3) Where the tumor 
 is immovable, and involves to some extent the fauces and the base of the 
 tongue, — the soft palate is divided in the middle line and thence outward, 
 with scissors — the growth is seized with forceps or tenaculum and drawn 
 toward the median line — while its boundaries are attacked with long, blunt, 
 curved scissors, removing the pillars and tonsillar tumor en masse — together 
 with the entire gland and growth, and as much of the fauces and tongue as 
 necessary, all being deliberately dissected out of their bed — controlling 
 hemorrhage by pressure-forceps, or by twisting or traction upon the tem- 
 porary ligature around the common carotid until the vessels can be controlled. 
 
 (4) No suturing of the parts about the bed of the tonsil is done. If necessary, 
 the region is packed with gauze, and pressure kept up without and within. 
 
 (5) The wound of the cheek is neatly repaired by interrupted external and 
 internal sutures, the latter being applied first. The wound of the common 
 carotid is closed. The tracheotomy tube is retained in situ for a few days. 
 The mouth is frequently rinsed with antiseptic washes. 
 
 COMPLETE TONSILLECTOMY THROUGH THE NECK. 
 
 CHEEVER'S OPERATION. 
 
 Description. — The lateral pharyngeal wall is exposed by means of a 
 careful dissection through the neck, and removed to the indicated extent, 
 together with the tumor, tonsil, and all lymphatic glands and involved tissues 
 adjacent. The operation is at first a cervical pharyngotomy, and becomes 
 a partial pharyngectomy, in proportion to the amount of pharyngeal wall 
 removed. Indicated in large, adherent diffused tumors of the tonsillar 
 region, with lymphatic involvement of the neck. 
 
 Preparation. — Mouth frequently cleansed with antiseptic washes. Xeck 
 and side of face shaved, if necessary. 
 
 Position. — Patient supine, shoulders elevated, head thrown back and to 
 opposite side, over a cushion or sand-bag, rendering neck prominent — 
 Surgeon on side of operation (or on opposite side leaning over) — Assistant 
 opposite surgeon. 
 
 Landmarks. — Lobule of ear; anterior border of sternomastoid ; hyoid 
 bone; lower border of inferior maxilla and its angle; known anatomical 
 relations of the tonsil. 
 
 Incision. — (1) Oblique incision begins opposite lobule of ear — passes 
 down anterior border of sternomastoid as far as the level of the hyoid bone, 
 or to below the level of the lower border of the tumor. (2) A second nearly 
 horizontal incision begins from the oblique one. opposite the angle of the 
 jaw, and is continued transversely forward along the lower border of the 
 inferior maxilla. (See Fig. 546, A.) 
 
 Operation. — (1) These incisions are carried through skin, platysma, 
 and superficial fascia — the external jugular and temporofacial veins are 
 divided between two ligatures — branches of the cervicofacial nerve encoun- 
 tered are guarded as far as possible. (2) The flaps thus marked out are 
 drawn, the one upward and forward, the other downward and forward, and 
 
720 OPERATIONS UPON THE NECK. 
 
 the dissection carried on deeply in the submaxillary and superior carotid 
 triangles (see Surgical Anatomy of the neck, page 149) — dividing the stylo- 
 hyoid, styloglossus, stylopharyngeus, and probably the digastric — dividing 
 the facial artery and vein between double ligatures — and guarding the hypo- 
 glossal and glossopharyngeal nerves. (3) The parotid gland is displaced 
 upward — the submaxillary gland forward — and the internal carotid artery 
 and internal jugular vein outward — these structures being held out of the 
 way by retraction. (4) The pharyngeal wall is now exposed and opened — 
 and the tonsil removed, together with as much of the pharyngeal wall and 
 adjacent tissues, including cervical glands, as are involved, by scissors or 
 knife. (5) The pharyngeal wall, upon completion of the operation, is sutured 
 as well as possible, and a temporary drain is placed from the pharyngeal wall 
 
 Fig. 546.— Incisions for Excision of Tonsil and Parotid Gland :— A, Incision for complete ton- 
 sillectomy through the neck (Cheever's operation) ; B, Incision for excision of the parotid gland. 
 
 through the lower part of the cervical wound, the remainder of the outer 
 wound being sutured. 
 
 Comment. — The operation may be aided by a finger in the mouth, out- 
 lining the growth and pressing it outward. The cheek may also be split 
 and the tonsil attacked from both sides. 
 
 Other Methods of Pharyngotomy for Exposure of the Tonsil. — 
 
 Czerny's Method — a preliminary tracheotomy is performed, a tampon- 
 cannula being used — the inferior maxilla is then divided and its parts tem- 
 porarily turned aside. 
 
 Mikulicz's Method — a preliminary tracheotomy, with a tampon-cannula, 
 is performed — and a part or all of the ascending ramus of the inferior maxilla 
 is excised. 
 
SURGICAL ANATOMY OF THE PAROTID GLAND. 721 
 
 VI. THE PAROTID GLAND AND STENSON'S DUCT. 
 SURGICAL ANATOMY. 
 
 Situation. — The parotid gland lies upon the side of the face just below 
 and in front of the ear, overlapping the angle of the ramus of the inferior 
 maxilla anteriorly, and extending behind it posteriorly. 
 
 Boundaries. — Superiorly; root of zygoma. Inferiorly; angle of in- 
 ferior maxilla, and line drawn thence to mastoid process. Anteriorly ; 
 overlaps masseter muscle to a variable extent. Posteriorly ; external auditory 
 meatus; mastoid process; sternomastoid; posterior belly of digastric (some- 
 what overlapping it). 
 
 Relations of Surfaces. — Anterior surface; grooved by posterior 
 border of ascending ramus of inferior maxilla — lying, in front of ramus, 
 over masseter muscle — and passing, behind ramus, between external and 
 internal pterygoid muscles. External surface ; lobulated and covered by 
 parotid fascia, platysma, and skin, with several lymphatic glands resting 
 upon it, as well as facial branches of auricularis magnus nerve. Internal 
 surface ; in relation with styloid process and its muscles, and with internal 
 carotid arterv and internal jugular vein — and passes deeply into neck by 
 three large processes — (1) Pterygoid process, running forward under ramus 
 of inferior maxilla, between external and internal pterygoids — (2) Glenoid 
 process, running inward under temporomaxillary articulation into back of 
 glenoid cavitv — (3) Carotid process, running inward to surround styloid 
 process and pass between carotid vessels. Separated from submaxillary 
 gland by stylomaxillary ligament. 
 
 Arteries. — From the external carotid and from its branches. 
 
 Veins. — Empty into the external jugular. 
 
 Lymphatics. — Empty into the superficial and deep cervical glands. 
 
 Nerves. — From carotid plexus; facial; auriculotemporal; auricularis 
 magnus. 
 
 Structures Passing through the Parotid Gland. — Arteries; external 
 carotid passes deeplv into gland from below and posteriorly, and gives off 
 within the gland — transverse facial, emerging from front of gland — temporal, 
 emerging from above — posterior auricular, emerging from behind — and 
 internal maxillary, passing inward between neck of jaw and internal lateral 
 ligament. Veins; temporomaxillary; connecting vein from temporomaxillary 
 to internal jugular. Nerves; facial, entering gland at its posterior border, 
 crossing external carotid in its passage forward, and dividing in the gland 
 into — temporofacial division, emerging upward and forward from anterior 
 border of gland — and cervicofacial division, emerging downward and forward 
 from anterior border of gland; branches of auricularis magnus, entering from 
 below to join facial; auriculotemporal branch of inferior maxillary, emerging 
 from upper part of gland. 
 
 Structures in Proximity to Bed of Parotid Gland. — Internal carotid 
 arterv; internal jugular vein; spinal accessory, glossopharyngeal, and pneu- 
 mogastric nerves. 
 
 Stenson's Duct. — Formed by branches converging from anterior part 
 of gland — runs transversely forward, crossing masseter muscle, piercing 
 buccinator muscle, and passing obliquely forward between this muscle and 
 the mucous membrane of the mouth, to open upon the inner aspect of cheek 
 opposite the crown of the second upper molar tooth. Its general course is 
 about a finger's-breadth below the zygoma. The transverse facial artery 
 passes above it, and branches of the facial nerve below it. 
 46 
 
722 OPERATIONS UPON THE NECK. 
 
 Socia Parotidis. — Sometimes exists as a separate gland, lying upon the 
 masseter between the zygoma and Stenson's duct. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE PAROTID GLANDS. 
 
 See those mentioned under the Esophagus (page 712) and Tonsils (page 
 717) — especially those used in exposing these structures. 
 
 EXCISION OF THE PAROTID GLAND. 
 
 Description. — The total removal of even the normal parotid gland is 
 very difficult — and when involved by a large, adherent tumor, it is practically 
 impossible to remove the entire gland. When the tumor is small and the 
 combined mass of tumor and gland is movable, the excision is somewhat 
 less difficult. 
 
 Preparation. — Neck and side of face are shaved, if necessary. 
 
 Position. — Patient supine, shoulders elevated, neck prominent, head 
 turned to opposite side. Surgeon on side of operation. Assistant opposite 
 surgeon. 
 
 Landmarks. — Anatomical boundaries of the parotid, and the contour 
 of the tumor. 
 
 Incision. — Vertical incision beginning midway between mastoid process 
 and condyle of jaw — extending downward parallel with the ascending ramus 
 of the jaw to just below its angle — rounding thence forward just beneath 
 the lower border of the inferior maxilla to the anterior border of the masseter 
 muscle. Additional room may be gotten by adding a posterior incision to 
 the vertical one opposite the forward curve just described. Also the vertical 
 incision may be continued on downward along the anterior border of the 
 sternomastoid below the point at which the anterior or posterior addition to 
 the vertical incision comes off, as determined by the size and nature of the 
 tumor. (See Fig. 546, B.) 
 
 Operation. — (1) The flap of integuments marked out by the vertical 
 incision with the forward curve beneath the inferior maxilla, should be raised 
 and turned upward upon the face and stitched to the cheek — and the posterior 
 margin of the wound drawn well backward. Doubly iigate the superficial 
 veins as encountered, and divide them between the ligatures. (See Fig. 547.) 
 (2) The chief hemorrhage may be controlled in one of three ways, dependent 
 upon the nature and extent of the operation and the judgment of the operator 
 — (a) By the ligation of the vessels as encountered in the steps of the operation 
 — (b) By the early exposure and double ligation of the external carotid with 
 its division between the ligatures — (c) By the early exposure and temporary 
 ligation of the common carotid. The first method may be resorted to in the 
 simplest cases — the third in the most difficult. (3) The gland and tumor 
 are approached from the inferior and posterior aspect — dissected from their 
 bed and drawn upward and forward and held under traction of vulsella. 
 During this step the external carotid will be brought into view and should 
 be doubly ligated and divided between the ligatures (unless done as a pre- 
 liminary operation — and should be done even if the common carotid have 
 had a temporary ligature thrown around it, as the branches of the external 
 carotid help to hold the gland in its bed). And all arterial and venous branches 
 subsequently encountered entering or leaving the gland, as it is raised from 
 its bed, are to be similarly divided between double ligatures. (4) The treat- 
 
EXCISION OF THE PAROTID GLAND. 
 
 7 2 3 
 
 ment of the facial nerve is difficult. If the nerve be involved in large, ad- 
 herent tumor-growth, its sacrifice is almost certain — and, under these circum- 
 stances, it is often deliberately divided. If the tumor be more friable, and 
 danger of leaving infecting material not thereby materially increased, one 
 should endeavor, by means of a blunt dissector and the fingers, to break 
 away overlying and encompassing gland and free the main divisions (temporo- 
 facial and cervicofacial) of the nerve and preserve them intact. In any 
 event, where possible and not contraindicated, an attempt should be made 
 to save the branches of the nerve as long as possible — and, where they have 
 been divided, after the removal of the gland, to gut-suture the proximal and 
 distal ends of those severed (neurorrhaphy). (5) The deeper portions of the 
 gland (pterygoid, glenoid, and carotid lobes) are to be now dissected from 
 
 Fig.547.— Excision of Parotid Gland: — A. Parotid gland; B, Stc-nson's duct; C, Masseter 
 muscle; D, Stylohyoid muscle; E, Sternomastoid muscle; F, External carotid artery; G, Jugular 
 vein ; H, Hypoglossal nerve ; I, Posterior auricular artery and vein ; J, Temporal artery and vein and 
 auriculotemporal nerve; K. Transverse facial artery and vein. Temporofacial branches of facial 
 nerve are seen emerging upward and forward from the gland — and cervicofacial branches downward 
 and forward. The pterygoid, glenoid, and carotid processes of the gland are hidden from view. L 
 The flap stitched back to the cheek. 
 
 their beds chiefly by means of a blunt dissector and curved scissors, with 
 extreme care — remembering that these processes of the gland rest upon the 
 internal carotid artery and internal jugular vein — and that the pneumo- 
 gastric, glossopharyngeal, spinal accessory, and hypoglossal nerves lie in 
 comparatively close proximity. Injury to the internal jugular vein is the 
 chief danger here. Slight additional room is gained at this difficult stage, 
 in the deep wound between the jaw and the mastoid process, by pushing the 
 jaw well forward and to the opposite side. Where difficulties appear in- 
 surmountable, the deeper lobes, or parts of them, must be cut off and left 
 behind. (6) The tumor is now drawn upward and the facial portion dissected 
 out. (7) Stenson's duct is ligated with chromic gut and severed a short 
 
724 OPERATIONS UPON THE NECK. 
 
 distance from the gland — its distal end being touched with the actual cautery, 
 or carbolic acid, and left in situ. (8) All hemorrhage having been controlled, 
 a dependent drainage is temporarily introduced and the remainder of the 
 wound sutured and a firm compress applied. 
 
 Comment. — The vessels from which hemorrhage is to be expected are 
 the superficial temporal, transverse facial, occipital, posterior auricular, 
 internal maxillary, and external carotid arteries; the external jugular and 
 temporomaxillary veins, and branches between the external and internal 
 jugular veins; and numerous unnamed and enlarged anastomoses. 
 
 The ramus of the lower jaw may be turned aside in an osteoplastic flap 
 to give more room. 
 
 Where the tumor of the parotid is encapsulated, the tumor alone may be 
 removed and the gland left intact, except for the incision into the gland for 
 the enucleation of the growth. 
 
 VII. THE SUBMAXILLARY GLAND AND WHARTON'S DUCT. 
 SURGICAL ANATOMY. 
 
 Situation. — The submaxillary gland lies below the base and internal 
 surface of the inferior maxilla and above the digastric muscle — occupying 
 the anterior part of the submaxillary triangle. 
 
 Relations. — Covered by; skin; platysma; superficial cervical fascia, 
 facial vein, inframaxillary branches of facial nerve; deep cervical fascia; 
 submaxillary fossa of body of inferior maxilla; lymphatic glands. Rests 
 upon; mylohyoid in front; hyoglossus behind; styloglossus above; and also 
 upon facial artery, mylohyoid branch of inferior dental artery, and mylohyoid 
 branch of inferior dental nerve. Anteriorly ; anterior belly of digastric. 
 Posteriorly ; stylomaxillary ligament, which separates it from parotid gland. 
 
 Other Relations. — (a) Bulk of submaxillary gland is separated from 
 sublingual gland by mylohyoid muscle, (b) Facial artery grooves posterior 
 and superior aspects of the gland, (c) Lingual branch of fifth and hypo- 
 glossal nerves lie between the gland and hyoglossus muscle. The glosso- 
 pharyngeal nerve lies beneath the hyoglossus muscle, (d) Deep portion of 
 submaxillary gland passes around posterior free border of mylohyoid muscle 
 on to the hyoglossus muscle. 
 
 Arteries. — Submaxillary and submental branches of facial, and branches 
 of lingual. 
 
 Veins. — Branches corresponding with arteries. 
 
 Nerves. — From submaxillary ganglion; mylohyoid branch of inferior 
 dental; sympathetic. 
 
 Wharton's Duct. — Runs inward between mylohyoid and hyoglossus — 
 then between mylohyoid and geniohyoglossus — and finally under mucous 
 membrane of mouth, between geniohyoglossus and sublingual gland — to 
 empty at side of fraenum linguae. It runs between the lingual of fifth and 
 hypoglossal nerves on hyoglossus muscle — passing under lingual nerve at 
 anterior border of hyoglossus, and then lying above it. 
 
 INSTRUMENTS. 
 See those used in exposing Esophagus and Tonsils. 
 
EXCISION OF SUBMAXILLARY GLAND. 
 
 7^5 
 
 
 Fig. 548. — Incisions for Operations upon Larynx, Submaxillary Gland, and Thyroid 
 Gland: — A, Curved submaxillary incision for excision of submaxillary gland; B, T-shaped 
 incision for total laryngectomy; F, E, Kocher's curved transverse incision for total thyroidectomy; 
 D, H, G, Kocher's triangular incision for partial thyroidectomy; F, E, H, G, Author's combined 
 transverse curved and median vertical incision for total thvroidectomv. 
 
 EXCISION OF SUBMAXILLARY GLAND. 
 
 Description. — The submaxillary gland is frequently removed for tumor 
 
 Preparation — Position. — As for the Parotid Gland (page 722). 
 
 Landmarks. — Anatomical boundaries of the gland, and the contour of 
 the tumor. 
 
 Incision. — Curved incision, with downward convexity, extending from 
 just below median line of inferior maxilla to just below angle of inferior 
 maxilla — reaching below to hyoid bone. (See Fig. 548, A.) 
 
 Operation. — (1) Incise skin, platysma, superficial fascia along above 
 line — dividing, between double ligatures, the superficial veins encountered 
 (tributaries of facial, anterior jugular, external jugular). The inframaxillary 
 branches of the facial nerve are encountered crossing the line of incision 
 and are safeguarded as far as possible by retraction. (2) The flap of super- 
 ficial structures thus formed is dissected back — retracted upward toward the 
 face — and either held out of the way, or stitched to the cheek. (3) The 
 special compartment of deep cervical fascia enclosing the submaxillary gland 
 is now incised transversely at its lower part and the gland exposed. The 
 connective tissue attachments of the gland to the hyoid bone and digastric 
 tendon are divided. (4) The gland is now raised from the mylohyoid and 
 hyoglossus and retracted upward over the lower border of the jaw. (5) 
 The facial artery is tied and cut between two ligatures as soon as it presents 
 in the field. The hypoglossal nerve is guarded as it lies between the sub- 
 maxillary gland and the lower part of the hyoglossus; and the lingual of the 
 fifth as it lies between the gland and the upper part of the hyoglossus and 
 styloglossus; (the glossopharyngeal lying beneath the hyoglossus and out of 
 the way)- (6) The gland is now drawn downward and outward and separated 
 from the submaxillary fossa of the inferior maxilla by blunt dissection — and 
 
726 OPERATIONS UPON THE NECK. 
 
 its deep portion drawn and dissected out from behind the mylohyoid muscle. 
 (7) Wharton's duct is ligated a short distance from the gland and divided — 
 and its distal end touched with the actual cautery or carbolic acid. (8) 
 Temporary drainage may be used at the dependent angle of the wound — which 
 is elsewhere closed — and a firm compress applied. 
 
 VIII. THE SUBLINGUAL GLAND AND DUCT OF BAR- 
 THOLIN. 
 
 SURGICAL ANATOMY. 
 
 Situation. — The sublingual gland lies beneath mucous membrane of 
 forepart of mouth, near to fraenum linguae, in contact with sublingual fossa 
 of inferior maxilla, and rests upon mylohyoid and geniohyoglossus muscles. 
 
 Relations. — Superiorly; mucous membrane of mouth. Inferiorly; 
 mylohyoid muscle. Anteriorly; sublingual fossa of inferior maxilla; its 
 opposite fellow. Posteriorly; deep part of submaxillary gland (mylohyoid 
 separating it from bulk of submaxillary gland) . Internally ; geniohyoglossus, 
 from which lingual nerve and Wharton's duct separate it. 
 
 Arteries. — Sublingual and submental. 
 
 Veins. — Correspond with arteries. 
 
 Nerves. — From gustatory and sympathetic. 
 
 Duct of Bartholin. — The main duct of the gland — running along with, 
 and opening in common with, Wharton's duct. 
 
 Ducts of Rivinus. — Eight to twenty secondary ducts — opening on floor 
 of mouth. 
 
 INSTRUMENTS. 
 
 See those used in exposing the Esophagus (page 712) and Tonsils (page 
 7i7)- 
 
 EXCISION OF SUBLINGUAL GLAND 
 
 THROUGH FLOOR OF MOUTH. 
 
 Description. — The sublingual gland may require removal for tumor, 
 or for embedded calculus. 
 
 Preparation. — Frequent antiseptic rinsings of mouth. 
 
 Position. — Patient supine, shoulders and head elevated, mouth gagged 
 open and tongue held to opposite side — Surgeon on side of operation— 
 Assistant opposite. 
 
 Landmarks. — Anatomical relations of gland, and outline of tumor. 
 
 Incision. — A straight incision made in floor of mouth, beginning at the 
 median line, a short distance back of the alveolar margin, and carried obliquely 
 backward and outward, parallel with the alveolar margin, for about 4 cm. 
 (about ij inches). 
 
 Operation. — (1) Having incised mucous membrane of mouth and re- 
 tracted margins of wound, the upper aspect of the gland is exposed imme- 
 diately beneath it. (2) Having well exposed the upper portion of the gland 
 by retraction of the margins of the wound, the gland is seized with toothed 
 forceps and drawn upward, while being separated by means of a blunt dis- 
 sector — from the mylohyoid muscle below — from the geniohyoglossus muscle, 
 lingual nerve, and Wharton's duct internally — from its opposite fellow in 
 front and on the opposite side — and from the deep part of the submaxillary 
 gland behind. (3) Having raised it from its bed, its ducts are divided. (4) 
 The mucous membrane is sutured over its site — one end being left open for 
 temporary drainage, if thought necessary. 
 
PARTIAL THYROIDECTOMY. 727 
 
 Comment. — The gland may be partially excised (in cystic enlargements) 
 by picking up its upper wall with toothed forceps and cutting out a large 
 piece of the wall and gland with curved scissors. 
 
 IX. THE THYROID GLAND. 
 SURGICAL ANATOMY. 
 
 Situation. — The thyroid gland is situated at the upper part of the trachea 
 — consisting of two lateral lobes, which extend from nearly as high as the 
 oblique line on the ala of thyroid cartilage, down to fifth or sixth tracheal 
 ring — and of an isthmus from 0.5 to 2 cm. (about j to f inch) broad, which 
 generally covers the second and third (and sometimes fourth) tracheal rings. 
 
 Relations. — Anteriorly; covered by sternohyoid; sternothyroid; omo- 
 hyoid; and slightly overlapped by anterior border of sternomastoid. Later- 
 ally ; sheath of great vessels. Upper part of lateral lobe lies between the 
 sternothyroid and inferior constrictor, the latter separating it from the ala 
 of thyroid cartilage. Posteriorly; embraces trachea and larynx, reaching 
 backward to lower part of pharynx, and, especially on left, to esophagus; 
 recurrent laryngeal nerves; branches of inferior thyroid artery. 
 
 Middle or Pyramidal Process. — May be developed in connection with 
 the thyroglossal duct — extending upward from the isthmus or left lobe — 
 and connected to the thyrohyoid membrane or body of the hyoid bone. 
 
 Suspensory Ligaments of the Thyreoid Gland. — Two ligaments pass 
 from inner and posterior aspect of lobes upward to sides of cricoid cartilage. 
 Recurrent laryngeal nerves lie in contact with their outer surface. 
 
 Arteries. — Two superior thyroid arteries from external carotid to superior, 
 internal and anterior parts of lateral lobes; two inferior thyroids from thyroid 
 axis to external and posterior parts of lateral lobes; and sometimes thyroidea 
 ima from innominate or aorta. 
 
 Veins. — Two superior and two middle thyroid emptying into internal 
 jugular; two inferior thyroid, emptying into innominate. These veins form 
 a plexus upon the surface of the gland and trachea. 
 
 Lymphatics. — Empty into thoracic duct and right lymphatic duct. 
 
 Nerves. — From inferior and middle cervical ganglion. 
 
 Other Relations. — Recurrent laryngeal nerves ascend obliquely to side 
 of trachea, running eitner behind or in front of inferior thyroid arteries — 
 requiring, therefore, special care to avoid them. 
 
 Middle cervical ganglion — lies opposite sixth cervical vertebra — generally 
 lying upon or near the inferior thyroid artery. 
 
 It is necessary to distinguish the deep cervical fascia surrounding the 
 thyroid gland from the capsule of the gland itself. 
 
 INSTRUMENTS. 
 See those used in exposing the Esophagus (page 712) and Tonsils (page 
 717). 
 
 PARTIAL THYROIDECTOMY 
 
 BY ANGULAR INCISION — KOCHER'S OPERATIOX. 
 
 Description. — Consists in the removal of one lobe of the thyroid gland. 
 The features of the removal of a larsje goitrous thyroid can be but very 
 
728 OPERATIONS UPON THE NECK. 
 
 imperfectly illustrated upon a normal thyroid gland — but the steps of the 
 operation for the former condition will be given. 
 
 Preparation. — Neck shaved. 
 
 Position. — Patient supine, shoulders elevated, neck prominent, head at 
 first slightly to opposite side and then held in median line. Surgeon in front 
 of neck, on side of lobe to be removed (or on opposite side leaning over). 
 Assistant opposite surgeon. 
 
 Landmarks. — Outline of sternomastoid muscle; upper border of thyroid 
 cartilage; anatomical position of thyroid gland; contour of tumor. 
 
 Incision. — Begins over the prominence of the sternomastoid muscle, on 
 a level with the thyroid cartilage — runs forward nearly transversely, to 
 median line, inclining slightly downward in the crease of the neck — thence 
 passes vertically downward to the suprasternal notch, or, in large tumors, 
 on to the manubrium. (See Fig. 548. D, H, C.) 
 
 Operation. — (1) The above incision passes through skin, superficial 
 fascia, and platysma. (2) In the Horizontal Portion of the Wound; — the 
 anterior jugular and connecting branch between it and the external jugular 
 are divided between double ligatures. (The external jugular lies behind 
 the posterior end of this incision.) Branches of the superficial cervical and 
 inframaxillary nerves are encountered and are guarded as well as possible 
 by retraction. Externally, the anterior edge of the sternomastoid is exposed, 
 freed, and drawn backward. Internally, the sternohyoid and sternothyroid 
 are exposed, the overlying fascia being displaced upward. (3) In the Vertical 
 Portion of the Wound; — the cervical fascia between the sternohyoid and 
 sternothyroid is divided. The transverse vein above the suprasternal notch 
 is divided between double ligatures. The inner margins of the two above 
 muscles are freed and partly divided toward their upper ends, with double 
 ligature and division of the vessels encountered. (4) The Outer Capsule of 
 the Goitre now alone intervenes between the Gland ; — divide this and separate 
 it from the lateral aspects of the goitre with blunt dissector — dividing between 
 double ligature the superior and inferior accessory veins which may pass 
 from the capsule to the goitre. Displace the outer capsule of the goitre, 
 with the overlying muscles, by passing a finger beneath the goitre from the 
 outer side. (5) Dislocation of the Goitre is now done; which is accomplished, 
 after inserting a finger beneath the goitre, by lifting it forward out of its bed 
 and turning it toward the opposite side — exercising care that the vessels, 
 especially the inferior thyroids, are not stretched sufficiently to give way. 
 (6) The Chief Vessels are now Ligated between Double Ligatures; — these are 
 brought into the field in proportion to the dislocation of the tumor from its 
 bed. The inferior thyroid artery and vein are first sought by drawing the 
 tumor upward and forward — the artery is isolated with especial care, as the 
 recurrent laryngeal nerve is in very near relation, either anteriorly or poste- 
 riorly to it — and if any doubt exist, it should be left until the last. The supe- 
 rior thyroid artery and vein are sought above the isthmus, being freed with 
 blunt dissector while the tumor is drawn downward and forward. The middle 
 thyroid vein and the branches of unnamed enlarged vessels are similarly tied 
 and divided. (7) Isolation of the Isthmus; — expose if possible, and divide 
 between double ligatures, a superior and inferior communicating vein, and 
 probably some arteries, at the upper and lower borders of the isthmus. By 
 means of a director, or blunt dissector, the isthmus is separated from the 
 trachea — a stout double ligature is passed beneath, tied on either side, and 
 the isthmus divided between them — while the tumor is further lifted out of 
 its bed and away from the trachea by fingers passed beneath the growth. 
 
COMPLETE THYROIDECTOMY 
 
 729 
 
 Be especially careful of the recurrent laryngeal nerve in the separation of the 
 posterior portion of the gland from the trachea — for which reason it is well 
 to cut through the posterior portion of the capsule of the gland in order to 
 protect the recurrent laryngeal nerve. (8) The depth of the wound is tem- 
 porarily drained — the major portion of the wound being sutured — and a firm, 
 compressing dressing applied. 
 
 Comment. — Many additional unnamed vessels are present in large 
 goitres. 
 
 Fig. 549. — Total Thyroidectomy by Combined Transverse Curved and Median 
 Vertical Incision: — A, Retracting tissues from trachea; B, Retracting left margin of wound 
 and sternohyoid muscle; C, Retracting right lobe of thyroid gland, which is in the >>.ct of being 
 freed from its bed; D, D, Transversely divided sternohyoid muscles; E, E, E, E, Ligated ends 
 of anterior jugular veins; F, F, Superior thyroid arteries; G, G, Thyroid veins ramifying on 
 surface of thyroid gland. 
 
 COMPLETE THYROIDECTOMY 
 
 BY TRAXSYKRSF. CURVED INCISION — KOCHKR'S OPERATION. 
 
 Description. — Where both lobes of the thyroid gland are involved, both 
 lobes of the gland are removed — except that a small portion of the healthy 
 gland tissue is left, if possible, in order to maintain the special function of the 
 gland and thus prevent the cachexia strumipriva which is apt to supervene 
 when the entire thyreoid gland tissue is removed. The full difficulties of the 
 operation are very imperfectly appreciated in the excision of a normal gland, 
 as compared with those encountered in a large goitrous tumor. 
 
730 OPERATIONS UPON THE NECK. 
 
 Preparation. — Neck shaved. 
 
 Position. — As for Partial Thyreoidectomy, except that the position of 
 the head is changed from time to time to meet the indications of the steps of 
 the operation. 
 
 Landmarks. — Those of the partial operation. 
 
 Incision. — Transverse curved incision, with slight downward convexity, 
 is made across the prominence of the tumor, so as to subsequently fall along 
 the cleavage line of the neck — extending laterally over the sternomastoids — 
 and extending further upward and backward on the side of greater enlarge- 
 ment. (See Fig. 548, F, E.) 
 
 Operation. — In all essential features the operation is similar to the one 
 just described, with such modifications as the larger size of the tumor suggests. 
 (I) After having cut through skin, superficial fascia, and platysma, and 
 ligated the superficial vessels, the sternohyoid, sternothyroid, and omohyoid 
 muscles (which are often thinned over the tumor by pressure) are divided 
 transverselv over the tumor, internally, and their ends drawn upward and 
 downward, — and the sternomastoids are partly cut through (entirely if neces- 
 sary) from their anterior border and the uncut portions retracted outward. (2) 
 The tumor is thus completely exposed, covered by its outer capsule — and its 
 further removal is accomplished practically as in the partial thyroidectomy. 
 First one lateral lobe and then the other is attacked — dislocated — and its 
 vessels tied — the isthmus isolated and divided between ligatures — the details 
 of the steps and the termination of the operation being similar to the unilateral 
 operation. 
 
 Comment. — The least amount of transverse division of muscles done 
 the better, as marked retraction and deformity are apt to follow if the muscles 
 do not reunite. All muscles severed, whether wholly or in part, should be 
 repaired with catgut suture at the end of the operation. 
 
 The transverse curved incision, where the muscles do not have to be 
 divided, makes a better skin scar — and the angular incision leaves a more 
 marked skin scar but does not divide the muscies. 
 
 Goitres are also treated by Enucleation-resection — by Enucleation — by 
 Exothyropexv (freeing the gland from the capsule and fixing superficially in 
 the wound to granulate and shrink) — by injection — etc. 
 
 An excellent exposure is secured by turning down two triangular flaps 
 raised by means of a combined transverse curved and a median vertical incision 
 (Figs. 548, F, E, H, G, and 549). 
 
CHAPTER IV. 
 
 OPERATIONS UPON THE THORAX. 
 
 I. THE THORACIC WALL AND CONTENTS. 
 
 SURGICAL ANATOMY. 
 
 Boundaries of Thorax. — Anteriorly; manubrium, gladiolus, and ensi- 
 form portions of sternum; costal cartilages; muscles of anterior thoracic 
 region; vessels and nerves. Posteriorly; dorsal vertebra 1 ; ribs, from vertebral 
 extremities to angles; muscles of posterior thoracic and spinal regions; vessels 
 and nerves. Laterally; ribs, from costal cartilages to angles; muscles of 
 lateral thoracic regions; clavicles and their muscles; scapulae and their muscles; 
 vessels and nerves. Superiorly, upper opening of thorax. Interiorly, lower 
 opening of thorax, closed by diaphragm. 
 
 Contents of Thorax. — Heart and pericardium; lungs and pleurae; trachea 
 and bronchi; esophagus; thoracic vessels and nerves; thoracic duct; superior, 
 anterior, middle, and posterior mediastina; thoracic aspect of diaphragm. 
 (For contents of mediastina, see each mediastinum, pages 747, 748, and 752.) 
 
 Boundaries of Upper Opening of Thorax. — Anteriorly; upper border 
 of manubrium sterni. Posteriorly; body of first dorsal vertebra. Laterally; 
 first rib. Dimensions; averages 12.7 cm. (5 inches) transversely, and 6.3 
 cm. (2j inches) antero-posteriorly. 
 
 Structures Passing through Upper Thoracic Opening. — (1) Centrally; 
 sternohyoid and sternothyroid muscles; thin layer of deep cervical fascia; 
 thymus gland (in infants) or its remains; middle thyroid artery (sometimes); 
 trachea; esophagus; prevertebral fascia; longi colli muscles. (2) Laterally; 
 innominate artery (on right side) ; common carotid and left subclavian arteries 
 (on left); internal mammary and superior intercostal (on both sides); in- 
 nominate and inferior thyroid veins; pneumogastric, cardiac, phrenic, sympa- 
 thetic, left recurrent laryngeal, and anterior branches of first dorsal nerves; 
 apices of lungs and their pleurae; thoracic duct (on left); right lymphatic duct 
 (on right). 
 
 Boundaries of Lower Thoracic Opening. — Anteriorly; ensiform car- 
 tilage; cartilages of seventh, eighth, ninth, tenth, and eleventh ribs. Poste- 
 riorly; body of twelfth dorsal vertebra. Laterally; twelfth ribs. Floor; 
 formed by diaphragm, varying in elevation with respiration. 
 
 Structures Passing through Floor of Thorax: (Diaphragm). - 
 Through Aortic Opening of Diaphragm; aorta; vena azygos major; thoracic 
 duct; left sympathetic nerve (occasionally). Through Esophageal Opening; 
 esophagus; pneumogastric nerves; esophageal branches of thoracic aorta. 
 Through ('aval Opening; vena cava inferior; branches of phrenic nerve. 
 Through Right Crural Opening; greater and lesser right splanchnic nerves; 
 right svmpathetic nerve. Through Left Crural Opening; greater and lesser 
 left splanchnic nerves; vena azygos minor; left sympathetic nerve (generally). 
 (For attachments, relations, and position of diaphragm, see that structure.) 
 
 Structures of Thoracic Wall Opposite an Intercostal Space (between 
 costal cartilages and angles of ribs). — Integument; superficial fascia, with 
 
 73i 
 
732 OPERATIONS UPON THE THORAX. 
 
 superficial arteries, veins, lymphatics, and nerves; special thoracic muscles 
 overlying ribs (dependent upon site); dec]) fascia; external intercostal muscles; 
 intermuscular areolar tissue between intercostal muscles, with intercostal 
 arteries, veins, lymphatics, and nerves; internal intercostal muscles; endo- 
 thoracic fascia; subpleural areolar tissue; parietal pleura. (The external 
 intercostal muscles extend from tubercles of ribs, posteriorly, to costal car- 
 tilages, anteriorly, and from the anterior ends of the external intercostals 
 the external intercostal fascia is continued to the sternum. And beneath this 
 fascia, the internal intercostal muscles intervening, lies the triangularis sterni 
 muscle, extending from second or third costal cartilage above, to seventh 
 costal cartilage below, and to outer end of costal cartilages externally. The 
 internal intercostal muscles extend from the sternum, anteriorly, to the angles 
 of the ribs, posteriorly, and from the posterior ends of the internal intercostals 
 the internal intercostal fascia is continued to the vertebral column. And 
 beneath this fascia, the external intercostal muscles intervening, lie the infra- 
 costales muscles, extending from the angles of the ribs toward the vertebral 
 column.) 
 
 Structure of Thoracic Wall Opposite a Rib (between costal cartilages 
 and angles of ribs). — Integument; superficial fascia, with superficial arteries, 
 veins, lymphatics, and nerves; special thoracic muscles overlying ribs (de- 
 pendent upon site); deep fascia; external layer of costal periosteum; rib; 
 internal layer of costal periosteum; endothoracic fascia; subpleural areolar 
 tissue; parietal pleura. 
 
 Relations of Overlying Bones to Chest-wall. — Clavicle; its inner end 
 articulates with supero-external aspect of manubrium (forming the lateral 
 boundaries of suprasternal notch) . The inner third of clavicle passes obliquely 
 over the manubrium, costal cartilage, and inner end of first rib, lying 0.6 to 
 1.2 cm. (| to \ inch) above rib, and passes thence outward to its articulation 
 with acromion, crossing about the center of second rib, from 3.2 to 3.8 cm. 
 (ij to i| inches) above the rib. Scapula; rests upon postero-external aspect 
 of thorax, from second to eighth ribs. When arms are by side, superior 
 angle is on level with upper border of second rib (opposite interval between 
 first and second dorsal spines), inferior angle being on level with seventh 
 intercostal interval, or sometimes upper border of eighth rib (between seventh 
 and eighth dorsal spines), and root of spine on level with interval between 
 third and fourth dorsal spines. 
 
 Muscles Covering and Forming Thoracic Wall (extracostal, inter- 
 costal, and infracostal muscles). — Anteriorly; pectoralis major; subclavius, 
 internal intercostals; triangularis sterni (and attachments of sternomastoid, 
 sternohyoid, and sternothyroid to manubrium; and attachments of aponeuroses 
 of external oblique, internal oblique, and transversalis abdominis and dia- 
 phragm to ensiform cartilage). Laterally; platysma myoides; pectoralis 
 major; pectoralis minor; latissimus dorsi; serratus magnus; external inter- 
 costals; internal intercostals; diaphragm (and parts or all of some of the 
 more particularly clavicular and scapular muscles — subclavius; deltoid; omo- 
 hyoid; supraspinatus; infraspinatus; subscapularis; teres minor; teres major; 
 trapezius, — and parts of some of the muscles attached to the upper ribs — 
 scalenus anticus and medius, — and parts of some of those attached to the 
 lower ribs — external oblique; internal oblique; transversalis abdominis). 
 Posteriorly; trapezius; latissimus dorsi; quadratus lumborum; serratus 
 magnus; levator anguli scapuli; rhomboideus major and minor; scalenus 
 posticus; serratus posticus superior and inferior; splenius capitis and colli; 
 ilio-costalis; musculus accessorius ad ilio-costalem; cervicalis ascendens; 
 
SURFACE FORM AND LANDMARKS. 733 
 
 longissimus dorsi; transversalis colli; trachelomastoid ; spinalis dorsi; corn- 
 plexus; biventer cervicis; semispinalis dorsi and colli; multindus spinae; 
 rotatores spinae; supraspinales; interspinales; intertransversales; levatores 
 costarum; internal intercostals; infra costales; diaphragm. 
 
 Chief Arteries of Thoracic Wall. — Internal Mammary of thyroid axis, 
 giving off following branches — sternal; anterior intercostal (two in each of 
 five or six upper spaces); perforating (five or six branches to the 
 five or six upper spaces) ; musculophrenic (furnishing anterior intercostal 
 branches for five or six lower spaces). Superior Intercostal of thyroid axis, 
 to first intercostal space. Suprascapular of thyroid axis. From Trans- 
 versa lis Colli of thyroid axis — posterior scapular. From Axillary — superior 
 thoracic; acromial thoracic; long thoracic; alar thoracic; subscapular. From 
 Thoracic Aorta — ten or eleven aortic intercostals, giving off anterior and 
 posterior branches — the anterior, or true intercostal arteries, dividing into 
 superior and inferior, supplying each intercostal space from the second to 
 the space below twelfth rib, and anastomosing with anterior intercostals of 
 internal mammary and musculophrenic. From Abdominal Aorta — phrenic 
 arteries. 
 
 Chief Veins of Thoracic Wall. — Correspond with arteries. 
 
 Chief Nerves of Thoracic Wall. — From Posterior Divisions of Cervical 
 Nerves — branches from third, fourth, fifth, sixth, seventh, and eighth nerves. 
 From Cervical Plexus — supraclavicular branches; deep muscular branches. 
 From Brachial Plexus — muscular branches; posterior thoracic; suprascapular; 
 anterior thoracic; subscapular. From Dorsal Nerves — anterior branches of 
 upper eleven nerves (the intercostal nerves) ; posterior branches of upper 
 eleven nerves. 
 
 SURFACE FORM AND LANDMARKS. 
 
 Suprasternal Notch is formed by upper border of manubrium and inner 
 aspects of non-articular portions of inner ends of clavicles. 
 
 Superior border of sternum (during inspiration) is on level with carti- 
 laginous disc between second and third dorsal vertebrae. 
 
 Transverse ridge at junction of manubrium and gladiolus corresponds 
 with costal cartilage of second rib, and is opposite fifth dorsal vertebra. 
 
 Lower end of gladiolus is opposite ninth dorsal vertebra, and corresponds 
 with termination of seventh costal cartilages. 
 
 Infrasternal depression lies between seventh costal cartilages, and corre- 
 sponds with ensiform cartilage. 
 
 Structures behind manubrium sterni — Left innominate vein lies slightly 
 below superior border; Innominate, common carotid, and subclavian arteries 
 come off from aortic arch about 2.5 cm. (one inch) below upper border; 
 Trachea bifurcates opposite manubrio-gladiolar junction; Esophagus. 
 
 Pectoral furrow (sternal furrow) is the median vertical furrow between 
 pectoral muscles, its bottom corresponding with center of sternum. 
 
 Subcostal (abdominothoracic) arch is formed by ensiform cartilage and 
 cartilages of seventh, eighth, ninth, and tenth ribs and extremities of eleventh 
 and twelfth ribs. The subcostal angle varies from 60 degrees to 80 degrees, 
 averaging about 70 degrees in male and 75 degrees in female. 
 
 Apices of lungs, with their pleurae, rise from 1.2 to 4.4 cm. (h to if inches) 
 above clavicle. 
 
 Right sterno-clavicular articulation is in relation with innominate artery, 
 right innominate vein, and pleura. 
 
734 OPERATIONS UPON THE THORAX. 
 
 Left sterno-clavicular articulation is in relation with left innominate vein, 
 left carotid and pleura. 
 
 First rib is almost covered by clavicle and scapula. 
 
 Infraclavicular fossa is the space, or hollow, between lower border of 
 clavicle and upper border of second rib. 
 
 Coracoid process lies about i inch below junction of outer and middle 
 thirds of clavicle. 
 
 Nipple, in male, lies over infero-external part of pectoralis major, gener- 
 ally between fourth and fifth ribs, about -f inch to outer side of junction of 
 ribs and costal cartilages, and a little more than 4 inches from median line. 
 
 Inferior border of pectoralis major corresponds with fifth rib. 
 
 Internal mammary artery is 0.5 to 1.5 cm. (\ to f inch) from outer border 
 of sternum, above — and 1 to 2 cm. ( T 7 g- to -ff inch) from it below. 
 
 Costo-vertebral groove is occupied by the erector spina.' and multifidus 
 spina?, and their subdivisions. 
 
 Tips of the spinous processes at the upper and lower parts of thorax- 
 correspond, approximately, with the neck of the rib below the particular 
 spine, but the tips of those spines near the center of the series about correspond 
 with the neck of the second rib below. 
 
 Distance from upper central incisor teeth to bodies of first, second, third, 
 fourth, fifth, and tenth dorsal vertebras is, approximately, 20.3, 21.8, 23.8, 
 25.7, 28, and 38 cm. (8, 8f, 9!, io|, n, and 15 inches) respectively, in the 
 average person of 5 feet 8 inches, as measured by esophageal route (which 
 data are of use in locating obstructions of the esophagus). 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE THORAX. 
 
 Exploratory syringe; cannula and trocar; scalpels; cartilage knives; probe- 
 pointed bistoury; dissecting forceps; toothed forceps; artery-clamp forceps; 
 tracheal and esophageal forceps; scissors, curved and straight; retractors, 
 various; saws, Gigli's, chain, Doyen's; probe; large sound; grooved director; 
 tenacula; periosteal elevators, straight and curved; costotome; bone-cutting 
 forceps; rongeur forceps; bone-holding forceps; bone-drill; wire; aneurism- 
 needles, straight and curved; needles, various; needle-holder; sutures and 
 ligatures of silk, plain and chromic gut, and silkworm-gut; drainage-tubes; 
 gauze. 
 
 CHONDROPLASTIC RESECTION OF CHEST-WALL 
 
 BY SUBCOSTAL INCISION AND TEMPORARY DIVISION OF SEVENTH, EIGHTH, 
 NINTH, AND TENTH COSTAL CARTILAGES. 
 
 Description. — Owing to the rigidity of the chest-wall it is difficult to satis- 
 factorily expose the dome of the diaphragm, the upper surface of the liver, the 
 lower end of the esophagus, and the cardiac end of the stomach. By the tem- 
 porary resection of the costal arch of either the left or right side, as indicated, 
 these structures are much more readily brought into the operative field. 
 
 While this operation* is generally resorted to in connection with structures 
 within the abdominal cavity, yet as it involves the chest-wall, it is here described 
 among the thoracic operations. 
 
 Preparation. — As for an intra-abdominal operation. 
 
 Position. — The reversed Trendelenburg position causes the abdominal 
 
CHONDROPLASTIC RESECTION OF CHEST-WALL. 
 
 735 
 
 viscera to gravitate away from the dome of the diaphragm — and hence render 
 the operation site more accessible. 
 
 Landmarks. — The costal arch of the side involved and the position of the 
 seventh, eighth, ninth, and tenth ribs. 
 
 Incision. — In the case, for instance, of operating upon the upper surface of 
 the liver, the incision is a curved one placed just below the right costal arch and 
 extending from the ensiform cartilage to the tenth rib (Fig. 550). 
 
 Fig. 550. — Chondroplastic Resection of Chest-wall: — Subcostal incision of soft parts 
 seen just below costal arch, from ensiform cartilage to tenth rib. Costal cartilages of seventh, 
 eighth, ninth, and tenth ribs are divided at each end of darkened part — which latter represents 
 the portion of costal arch temporarily turned back. (Thorax modified from Bock.) 
 
 Operation. — In the upper aspect of this wound the rectus and external 
 oblique muscles are separated from the internal oblique and transversalis — 
 thus exposing the lower margin of the costal arch, represented by the cartilages 
 of the seventh, eighth, ninth, and tenth costal cartilages. The cartilage of the 
 seventh rib is divided near its junction with the sternum. Carrying the blunt 
 dissection downward and outward, the junction of the seventh, eighth, ninth, 
 and tenth ribs with their cartilages are exposed — and the cartilages divided just 
 internal to their junctions with the corresponding ribs (Fig. 550, the darkened 
 area) . The flap thus composed of these cartilages and their overlying soft parts 
 is retracted upward and outward — giving free access to the hypochondrium. 
 At the end of the operation the cartilages are dropped back into place — where 
 their divided ends may be sutured with catgut through holes previously pierced 
 — and the wound sutured. 
 
736 OPERATIONS UPON THE THORAX. 
 
 OPERATIONS UPON THE THORACIC WALL AND CONTENTS. 
 
 For operations upon the Thoracic Viscera, Mediastina, Diaphragm, and 
 Mammary Gland, see those structures in the following sections. For opera- 
 tions upon the Bones, Joints, Arteries, and Nerves of the Thorax, see those 
 structures in Part I, General Surgery. 
 
 II. THE FEMALE MAMMARY GLAND. 
 SURGICAL ANATOMY. 
 
 Description and Position. — A hemispherical eminence consisting of 
 glandular, fatty, and areolar tissue, lying between the two layers of the super- 
 ficial pectoral fascia, the lower layer resting upon the sheaths of the pectoralis 
 major and serratus magnus muscles, and the upper layer being covered by 
 the skin. The superficial pectoral fascia (continuous above with the super- 
 ficial cervical fascia) divides, opposite the upper border of the mamma, into 
 anterior and posterior layers, passing, respectively, in front and behind the 
 gland, and holding it, as it were, in a sling. From the anterior layer of this 
 superficial pectoral fascia numerous processes pass into the gland and support 
 its parenchyma. The posterior layer of this fascia is separated from the 
 deep thoracic fascia by a loose, easily separable layer of areolar tissue. 
 
 Arteries of Mammary Gland. — Anterior intercostals of internal mam- 
 mary, of second, third, fourth, and fifth spaces; perforating branches of 
 internal mammary, of second, third, fourth, and fifth spaces; intercostals 
 of thoracic aorta, of second, third, fourth, and fifth spaces; long thoracic of 
 axillary; external mammary, of axillary (if present). 
 
 Veins of Mammary Gland. — Form circulus venosus around base of 
 gland and empty into branches corresponding with arteries. 
 
 Lymphatics of Mammary Gland. — Empty into axillary and anterior 
 mediastinal glands. (For position of axillary glands, see Axilla, under 
 Lymphatic Glands and Vessels, page 154.) 
 
 Nerves of Mammary Gland. — Anterior and lateral cutaneous branches 
 of second, third, fourth, and fifth intercostal nerves; supraclavicular branches 
 of cervical plexus. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The female mammary gland extends vertically generally over the third, 
 fourth, fifth, and sixth (and sometimes seventh) ribs, and transversely from 
 the border of the sternum to the anterior axillarv margin. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Three grades of excision for the removal of the female breast may be 
 done; — (1) Radical excision of the entire breast, with the removal of the 
 entire lymphatic and areolar tissue of the axillary region, and of the thoracic 
 wall between the breast and axilla (whether visibly or palpably diseased or 
 not), with or without removal of parts of the pectoral muscles. Indicated 
 in cases of malignant disease of mammary gland. (2) Ordinary or non- 
 radical excision of entire breast, either without opening of axilla, or with 
 limited opening of axilla for the removal of only the palpably enlarged glands. 
 Indicated in non-malignant growth of the mammary gland, and also used by 
 
PARTIAL EXCISION OF MAMMARY GLAND. 737 
 
 some operators for malignancy of the gland. (3) Partial excision of the breast. 
 Indicated where a benign growth is limited to a comparatively small portion 
 of the breast. 
 
 For instruments used in operating upon the breast, see those mentioned 
 under "The Thoracic Wall and Contents" (page 734). 
 
 INCISION OF BREAST. 
 
 Description. — Division of mammary gland tissue. Most frequently in- 
 dicated in abscesses which may be antemammary (in areolar tissue between 
 skin and gland), intramammary (within the glandular tissue), or postmam- 
 mary (in areolar tissue between gland and pectoral muscle). In the first and 
 third varieties the abscess should be opened by a route not involving the 
 gland. In the second variety (which is here considered) the gland substance 
 itself is incised. 
 
 Preparation. — Site of incision and irregularities of nipple are scrubbed. 
 Axilla is shielded from operation-site. 
 
 Position. — Patient supine, at edge of table. Surgeon on side of operation. 
 
 Landmarks. — Contour of breast, together with situation of abscess. 
 
 Incision. — All incisions into gland substance should be straight, and 
 made somewhere in a straight line radiating from nipple to circumference 
 of gland, so as to damage lactiferous ducts as little as possible. Incision 
 should not extend too near nipple. 
 
 Operation. — Incise skin, superficial fascia, and the gland substance 
 intervening between fascia and outer wall of abscess, generally with one cut 
 of knife. Having laid open cavity of abscess, and controlled hemorrhage 
 with clamp-forceps, if necessary, its walls are well curetted, so as to leave 
 clean, raw surfaces. The resulting walls of cavity may then be approximated 
 by deeply buried gut sutures, followed by closure of more superficial wound. 
 Or cavity may be temporarily packed with gauze, after curettage and irriga- 
 tion, and the superficial wound closed up to the exit of gauze drainage. The 
 latter course is better in acute and the former in chronic abscesses. 
 
 Comment. — It is sometimes possible to excise the entire abscess, without 
 opening its cavity, and close the entire wound at once by deeply buried and 
 superficial cutaneous sutures. 
 
 PARTIAL EXCISION OF MAMMARY GLAND 
 
 BV ELLIPTICAL INCISION. 
 
 Description. — Removal of a limited portion of the breast. 
 
 Preparation. — Breast and nipple scoured; breast shaved, if necessary; 
 axilla protected from field of operation. 
 
 Position. — Patient supine, at edge of table. Surgeon on side of operation. 
 Assistant opposite Surgeon. 
 
 Landmarks. — Contour of breast, together with position of growth; plane 
 of pectoral muscle. 
 
 Incision. — An ellipse is outlined so as to include the growth by a wide 
 margin, with the two arms of the incision meeting between the inner aspect 
 of the growth and the nipple, and between the outer aspect of the growth 
 and the periphery of the gland, the general direction of the ellipse radiating 
 from nipple to circumference. When indicated, the nipple is also included 
 in the ellipse and removed (Fig. 551, B). 
 47 
 
738 OPERATIONS UPON THE THORAX. 
 
 Operation. — Incise skin and superficial fascia, first along one side of 
 ellipse, then along opposite side, controlling bleeding with clamp-forceps. 
 Slightly retracting tissues in a direction away from the ellipse, incise through 
 the glandular tissue along the lines of the original incision, passing downward 
 toward the base <>f the gland, with a tendency for the incisions to approach 
 as they deepen. The part to he removed is thus entirely surrounded and it:; 
 depth finally reached, either before the entire thickness of the mammary gland 
 has been traversed, or at the pectoral muscle, after traversing its entire thick- 
 ness, and is removed en masse. All bleeding vessels are tied with gut. The 
 depths of the wound are approximated by buried gut sutures, and the margins 
 of the wound united with silk or silkworm-gut. 
 
 Comment. — When the part removed is considerable, it may be necessary 
 to undercut the tissues laterally to enable the walls and surface of the wound 
 to be approximated without too great tension. The principle of the subcu- 
 taneous excision of the mammary gland (7. v.) may also be applied to the 
 excision of a part of the gland (page 746). 
 
 RADICAL EXCISION OF MAMMARY GLAND, TOGETHER WITH ENTIRE 
 BELLY OF PECTORALIS MAJOR AND PECTORALIS MINOR 
 MUSCLES, AND AXILLARY GLANDULAR AND CON- 
 NECTIVE TISSUES, IN ONE MASS. 
 
 willy meyer's operation. 
 
 Description. — The entire breast and the pectoralis major and pectoralis 
 minor muscles are removed, together with the lymphatic glandular and the 
 connective tissues of the axilla. The special feature of the operation is that, 
 after division of the tendons of the two pectoral muscles, the structures of 
 the axilla are first exposed and the necessary vessels ligated — in the act of 
 dissecting out the glandular and areolar tissues — after which the axillary 
 mass and the breast, with the two muscles, are removed en masse in a 
 direction from the axilla toward the sternum — thus minimizing the pressure 
 of infectious material from the site of malignancy toward the axilla and 
 thence into the general system, and also materially lessening hemorrhage by 
 the early clamping and dividing of vessels near their origin. 
 
 Preparation. — The entire anterior aspect of the thorax, axilla, arm, and 
 lateral and part of posterior aspects of thorax are shaven. The anterior sur- 
 faces of both thighs are also shaven (to provide surfaces from which grafts 
 may be needed). 
 
 Position. — The patient rests upon two horsehair pillows placed parallel 
 to the spine under the back — thus rendering the sides of the thorax more 
 accessible by elevation. The involved arm is held slightly above a right angle 
 with the longitudinal axis of the body, with the elbow flexed at an angle of 90 
 degrees. 
 
 Landmarks. — Humeral attachment of pectoralis major muscle; lower 
 border of pectoralis major; border of latissimus dorsi, sternal and thoracic 
 origins of pectoral muscles; sternum; contour of breast; cephalic vein; clavicle. 
 
 Incision. — An incision is so planned as to allow two flaps to be raised:- — 
 (1) The lower flap is formed by an incision that begins at the humeral attach- 
 ment of the pectoralis major — the incision passing downward and inward, 
 parallel with and about 2.5 cm. (1 inch) above the lower border of the pectoral 
 muscle, to the base of the breast — thence is continued along the lower margin 
 of the breast, to end over the sternum slightly beyond the median line. (2) The 
 
RADICAL EXCISION OF MAMMARY GLAXD. 
 
 739 
 
 upper flap is formed by an incision which simply follows the upper contour 
 of the breast, joining the upper and lower ends of the preceding incision 
 (Fig. SSi, A). 
 
 Operation. — (i) Freeing the flaps; — The lower flap is loosened and 
 retracted downward, until the border of the latissimus dorsi and the chest-wall 
 are exposed in the axilla — freeing the fat by incision and blunt dissection in 
 such a way as to leave as much of it as possible adherent to the breast. The 
 border of the latissimus dorsi is freed down to the serratus anticus major and 
 up to the bicipital sulcus of the arm. In freeing and retracting the upper flap 
 as much fat is here, too, left adherent to the breast as possible, guarding against 
 endangering the nutrition of the skin. Care is taken not to include the pectoral 
 fascia. The breast and pectoralis major are now retracted downward and the 
 upper flap upward — and the cephalic vein, lower border of the clavicle, and 
 sternoclavicular articulation exposed; (2) Division of tendons of pectoral 
 muscles and exposure of axilla and subclavian vein (Fig. 552). The cephalic 
 
 -eSc i 
 
 /7f 
 
 Fig. 551. — Incisions for the Removal of the Breast, in Whole or in Part: — A, 
 Incision for Meyer's radical excision of the breast; B, Elliptical incision for excision of small 
 benign tumor. 
 
 vein, running in the groove between the pectoralis major and minor, is followed 
 up to the humeral attachment of the pectoral muscle. The tendon of the 
 muscle is then freed and divided close to the humerus. The pectoral muscle 
 is retracted downward and inward with a sharp retractor and is severed from 
 the lower border of the clavicle and the sternoclavicular articulation. The 
 vessels in the lines of incision are doubly clamped and divided and the nerves 
 to the pectoral muscle cut. The thoracic wall and the pectoralis minor are 
 thus exposed. The pectoralis minor is traced up to the coracoid process, 
 encircled by the finger (to guard the subclavian vein) and divided, and also 
 retracted downward and inward. The axillary fascia is divided in a line with 
 the vessels and the axillary artery and vein exposed by blunt dissection. (3) 
 Extirpation of axillary glands and fatty areolar tissue. The gauze packing 
 that had been placed under the lower flap earlier in the operation is removed. 
 The axillary connective tissue and fat over the upper part of the latissimus 
 dorsi is divided up to the axillary vein, the left forefinger surrounding it, its 
 
74o 
 
 OPERATIONS UPON THE THORAX. 
 
 tip resting on the vein, thus severing it from the fatty areolar tissue in the sulcus 
 bicipitalis brachii, and is then also drawn downward. The lower part of the 
 axillary artery and vein are exposed and cleared up to the site where the sub- 
 clavian vein disappears beneath the clavicle — doubly ligating and dividing 
 vascular branches as encountered. Preserve the two superior subscapular 
 nerves — sacrificing the third (to the latissimus dorsi) in order to expose all 
 infected tissue. (4) The formation of a pedicle of the entire mass over the 
 sternum and removal of the breast, muscles, glands, and fat. The mass of 
 loosened tissues is carefully lifted away from the axilla and thoracic wall, 
 avoiding the tearing away of periosteum and perichondrium. Returning to 
 the already exposed subscapular space, the knife is made to cut perpendicularly 
 down to the thoracic wall, avoiding the fibers of the serratus anticus major 
 muscle. The pectoralis major is cut close to the chest-wall by incisions 
 
 Fig. 552. — Radical Excision of the Breast, showing Features of the Meyer Opera- 
 tion: — The general method of removal is the primary freeing and division of the origins of the 
 pectoral muscles and dissection of the axilla and subsequent freeing of the mass toward the 
 thoracic wall. The severed muscles are the pectoralis major and minor. The clavicular portion 
 of the former muscle is not here divided. The axillary vein and branches are seen. The proper 
 incision for this exposure is shown at A, Fig. 551. 
 
 underneath its belly and parallel with and almost on a level with the ribs 
 and intercostal muscles. All vessels encountered are clamped and ligated. 
 The last remaining connection of the tumor mass with the chest wall is now 
 divided close to the sternum, clamping and tying the perforating arteries. 
 (5) Ligation, drainage, and suturing. Throughout the operation vessels are 
 preferably clamped by two hemostats and divided between them. At the end 
 of the operation the clamped vessels are taken up and ligated. The axillary 
 space is drained through a separate opening at its bottom, made in the final 
 steps of the operation — through which two halves of a divided large rubber 
 drainage-tube are put. A small gutter drain is placed in the upper angle of 
 the wound down to the severed tendon of the pectoralis major, the end of 
 which has been whipped over with a suture. The upper and lower angles of 
 the wound are now sutured, continuously or interruptedly, as far toward the 
 
RADICAL EXCISION OF MAMMARY GLAND. 741 
 
 site of the former breast as possible. An uncovered area of varying size 
 remains, representing the base of the breast. If the thoracic stump of the 
 pectoralis minor (about \ cm. — \ inch long) be left (and this portion of that 
 muscle is very rarely involved) part of the lower flap can often be stitched to 
 this stump and thus the area is prepared for grafting. (6) The raw area left 
 by the unapproximated edges is immediately grafted by long, thin, wide grafts 
 taken from the previously prepared thighs. These are placed longitudinally 
 with the axis of the body, the ends of the grafts resting upon the skin surfaces 
 and the thin margins overlapping each other. (7) Dressing of the wound. 
 The grafted area is covered by long strips of sterilized rubber tissue placed 
 horizontally. Gauze fluffs and compresses are put over this. The exits of 
 drains are protected by split gauze compresses. The entire wound is now 
 covered by abundant gauze fluffs and compresses — the arm is carried across 
 the chest, the axilla having been filled with sterile cotton — the whole dressing 
 being held in place by a Desault bandage. The patient is put in bed, with the 
 elbow supported upon a small pillow. 
 
 After-treatment. — The patient is kept upon her back for twenty-four 
 hours, after which she is raised by one or more pillows. The elbow remains 
 supported. The dressing is removed on the sixth day. One of the split 
 drainage-tubes is then removed. The other split tube and the smaller tube 
 at the upper angle of the wound are shortened — and a wet dressing with 
 Thiersch's solution is applied. The second dressing is changed two days 
 later, when all drains are removed. Beginning with the tenth to twelfth day, 
 the patient is later taught how to exercise the arm. The patient is expected 
 to have perfect use of the arm, including perpendicular erection. In this 
 operation the supraclavicular space is invaded only when glands are palpable. 
 
 RADICAL EXCISION OF MAMMARY GLAND, THE AXILLARY, GLANDU- 
 LAR, AND CONNECTIVE TISSUES, AND PARTS OF THE 
 PECTORAL MUSCLES. 
 
 HALSTED'S OPERATION. 
 
 Description. — Consists in complete excision of breast, together with 
 removal of the entire pectoralis major (or all save its clavicular portion), as 
 well as a transverse division of the pectoralis minor, with the turning outward 
 of its outer part, and clearing, en masse, of fatty-areolar-glandular tissue 
 from axilla. The substance of the operation, as described by Halsted, is 
 given in the following account. The removal is made from the chest toward 
 the axilla. 
 
 Preparation. — Breast, nipple, and axilla scrubbed; chest-wall and axilla 
 shaved. 
 
 Position. — Patient supine, at edge of table, with head and shoulders 
 elevated and arm held at right angle to side. Surgeon on side of operation. 
 Assistant opposite. 
 
 Landmarks. — Contour of breast and growth; landmarks of axilla and 
 pectoral muscles. 
 
 Incision. — Begins directly above the upper circumference of mammary 
 gland, well beyond all detectable involvement, and passes outward and down- 
 ward along outer border of gland; curves below around breast and ascends 
 upon inner side upward in a curve to point of beginning, thus entirely en- 
 circling gland; and thence, without stopping, is continued in a curved direction 
 along anterior surface of pectoralis major, to and slightly down upon the 
 anterior fold of the axilla (Fig. 553, M N L). 
 
742 
 
 OPERATIONS UPON THE THORAX. 
 
 Operation. — (I) Incise, throughout, through skin and fatty areolar 
 tissue, clamping or tying all bleeding vessels. (2) Reflect the triangular flap 
 of skin only (L M N) outward to base-line (L N). Dissect back, as a 
 separate flap, the fattv areolar tissue (corresponding to this triangle of skin) 
 to inferior border of pectoralis major, where it becomes a part of the axillary 
 areolar-fattv tissue. (3) Divide costal insertions of pectoralis major, and 
 split the muscle itself in the groove between costal and clavicular portions 
 outward to about opposite scalenus anticus tubercle on first rib (which lies 
 nearly opposite junction of inner and middle thirds of clavicle). (4) Cut 
 through (opposite scalenus tubercle on first rib) the clavicular portion of 
 pectoralis major, directly to clavicle, cutting at right angle to fibers of clavicular 
 portion, thus exposing apex of axillary space. (5) Retract pectoralis major 
 upward and dissect out areolar tissue from under its clavicular portion. (6) 
 
 Fig. 553. — Operations upon the Mammary Gland:— R, Radical excision of the breast, Hal- 
 sted's operation; S, Incision for radical excision of the breast, Warren's operation. 
 
 Continue splitting of pectoralis major, in original line, out to humerus and 
 sever the humeral attachment of the costal (sternal) portion. (7) Raise the 
 entire mass of integument, mamma, and fatty-areolar tissue upward and 
 outward, and while the submuscular fascia is thus put upon the stretch, this 
 mass is stripped from the chest-wall and pectoralis minor, closely hugging 
 the ribs and removing, if possible, the fascial sheath of the pectoralis minor, 
 beginning above at the upper and inner part of the wound and proceeding 
 downward and outward. (8) Having reached in this clearing, and well 
 exposed, the lower (outer) margin of pectoralis minor, divide that muscle 
 just below its center, at right angle to its fibers. (9) Divide fascia and areolar 
 tissue over coracoid attachment of pectoralis minor and turn them inward, 
 preparatory to the upward reflection of outer part of pectoralis minor. (10) 
 Retract upward and outward the severed outer part of pectoralis minor with 
 the retractor that had heretofore retracted pectoralis major alone, (n) 
 
RADICAL EXCISION OF MAMMARY GLAND. 
 
 743 
 
 Dissect out the loose fatty-areolar tissue beneath pectoralis minor near its 
 insertion, carefully clearing the small vessels (mainly veins) and ligating 
 them off close to axillary vein. (12) Expose subclavian vein at its highest 
 subclavicular point and dissect away the entire contents (fat, areolar tissue, 
 glands, and many small vessels) of the axilla, with extremest care and thor- 
 oughness and with a sharp knife, aided by forceps. Expose and strip axillary 
 vein absolutely clean of all extraneous tissue, ligating its branches close to 
 main trunk, holding the tissues and pushing the vein from them, rather than 
 the reverse. Expose axillary artery, in the majority of cases, and remove 
 all loose tissue above the axillary vessels and axillary plexus of nerves. (13) 
 Having cleared axillary region, grasp mass of tissues to be removed, drawing 
 ; t outward and somewhat upward with left hand, to put upon slight stretch, 
 
 Fig. 554. — Halsted's Radical Excision of the Breast: — Showing the primary detach- 
 ment of the breast and pectoral muscles from the thoracic wall and subsequent freeing of the 
 mass toward the axillary structures. The thoracic end of the severed pectoralis minor is shown. 
 The separated pectoralis major and proximal end of the pectoralis minor have retracted toward 
 their origins. The breast retains its connection to these and to the axillary connective tissue. 
 
 and cut away the mass of fascia from the lateral thoracic wall (inner axillary 
 wall), closely hugging ribs and serratus magnus. (14) Just prior to reaching 
 junction of posterior and lateral axillary walls, the original triangle of skin 
 (freed early in the operation) (R) is drawn outward by an assistant, to aid 
 in exposing the tissues lying upon the subscapularis, teres major, and 
 latissimus dorsi. The surgeon, taking a new hold upon the mass to be 
 removed, now cleans out the posterior axillary wall, from within outward. 
 Thus the subscapular vessels are conveniently exposed, and are tied or clamped 
 before being cut. The subscapular nerves are exposed, and may or may not 
 be removed, their retention being preferable. (15) Turn the mass of tissues 
 back into their original position and divide their connection with the thorax 
 by a single stroke of the knife passing along the first incision made, namely, 
 
744 OPERATIONS UPON THE THORAX. 
 
 from L to N, removing everything in one piece. (16) Approximate circum- 
 ference of wound by a buried purse-string suture of strong silk. Only 
 the base, L N, of the triangular skin-flap (L M N) is included in the 
 purse-string. The apex and rest of the triangular flap are shifted 
 to a new and lower position so as to form a lining for the fornix of the 
 axilla. (17) No drainage is established. Uncovered portion of wound 
 frequently heals by organization of the blood-clot and should be covered 
 with rubber tissue. 
 
 Comment. — Every bleeding point in this extensive field of operation is 
 immediately clamped. The divided pectoralis minor should be sutured with 
 chromic gut. 
 
 RADICAL EXCISION OF MAMMARY GLAND. 
 
 WARREN'S OPERATION. 
 
 Description. — Consists in complete excision of breast, together with 
 removal of sternal part of pectoralis major entirely; and also in removal of 
 entire pectoralis minor, or a simple turning back of its divided ends; with 
 clearing out, en masse, of fatty-areolar-glandular tissues of axilla, aided by 
 a transverse division of clavicular portion of pectoralis major; and the forma- 
 tion of one or two cutaneo-areolar flaps from the lateral thoracic wall to cover 
 over the main wound, in conjunction with its own margins. 
 
 Preparation — Position — Landmarks. — Same as in the Radical Excision 
 of the Breast by Halsted's method (page 741). 
 
 Incisions. — (1) Outer Primary Incision (Fig. 553, S) begins at anterior 
 margin of axilla, at its junction with the arm, and passes along just above 
 anterior border of axilla and the lower margin of pectoralis major, encircling 
 the lower circumference of the breast to its inner and lower quadrant. (2j 
 Inner Primary Incision (D C) begins at center of anterior axillary border 
 (D) and, passing inward and downward, diverges from first incision to 
 encircle upper and inner part of circumference of breast and meet first 
 incision at point of its ending (C). (3) Upper Secondary Incision (E F) is 
 made later, passing from point E, on upper primary incision, to clavicle (F), 
 dividing the clavicular portion of pectoralis major at right angle to its fibers. 
 (4) Lower Secondary Incisions (H and I) are made at end of operation, for 
 the purpose of raising flaps to cover the main wound, the incisions (one, or 
 both if necessary) begin from lower primary incision at point G (not shown 
 in figure), and pass upward (I) and downward (H). 
 
 Operation. — (1) Incise through skin and fatty-areolar tissue along above 
 primary lines, clamping all bleeding vessels. (2) Dissect back margins of 
 wound so as to expose base of gland in its entire circumference, carrying 
 incision to pectoralis major, which is freely exposed along entire upper inci- 
 sion. (3) Divide sternal portion of pectoralis major from thorax, and throw 
 entire mass outward and downward. (4) Sever humeral insertion of pectoralis 
 major, exposing pectoralis minor and axilla. (5) Upper secondary incision 
 is now made, to expose axillary vessels up to where they pass beneath the 
 clavicle. (6) Divide the pectoralis minor transversely and reflect halves 
 outward and inward, or entirely remove them. (7) Clear, by careful dis- 
 section, axilla of all extraneous tissues and unimportant vessels, from clavicle 
 to lower part of axilla, including all fatty, glandular, and areolar tissue lying 
 in front and behind the vessels, as well as the areolar tissue between serratus 
 magnus and subscapularis. Branches of axillary vein and artery are tied 
 close to their vessels, and any thoracic or scapular nerves which are in the 
 way of thorough clearing of the axilla are sacrificed, unless they can be tern- 
 
ORDINARY EXCISION OF MAMMARY GLAND. 
 
 745 
 
 porarily displaced. (8) Reflect mamma, with pectoral muscles and adherent 
 axillary contents, outward and sever them from thorax in one continuous mass 
 by a few sweeps of the knife along the outer primary incision. (9) Lower 
 secondary incisions are now made, and the cutaneo-areolar flaps represented 
 by them are raised by undercutting, and are ready to be shifted inward, (io) 
 Margins of original primary incisions, together with the margins of the flaps 
 raised for that purpose, are approximated by suture, so as to entirely, if 
 possible, cover in the whole wound and secure primary union, (n) Tem- 
 porary horsehair or gauze drainage is used for twenty-four hours. (12) 
 Voluminous dressings, including binding of arm to chest, are used. 
 
 Comment. — Whatever muscle tissue has been divided and not subse- 
 quently removed, should be repaired by chromic catgut suturing at the end 
 of the operation. If indicated, the upper secondary incision may be con- 
 tinued above the clavicle and the supraclavicular glands removed from the 
 posterior cervical triangle. 
 
 ORDINARY EXCISION OF MAMMARY GLAND 
 
 BY ELLIPTICAL INCISION. 
 
 Description. — Breast is circumscribed by an elliptical incision, with a 
 straight continuation outward to the center of the axilla, and another straight 
 
 Fig. 555. — Excisions of the Mammary Gland:— A, Excision of the breast by the ordinary 
 elliptical incision, the upper end of the ellipse being extended into the axilla; B, Excision of the 
 breast subcutaneously, by an inferior curved incision. 
 
 incision continued downward toward the sternum. Mamma is simply dis- 
 sected from pectoralis major muscle. Axilla is not invaded unless glands are 
 felt through upper end of wound, and, if so, these glands are removed by 
 blunt dissection through a limited exposure of axilla. 
 
 Preparation. — Same as for Radical Excision (page 741); 
 
746 OPERATIONS UPON THE THORAX. 
 
 Position. — Same as for Radical Excision (q. v.). Or patient's hand may 
 be placed behind nape of neck. Surgeon may stand on side of operation, 
 cutting from above downward on right, and from below upward on left; or 
 may stand on right side for either breast, leaning over thorax and cutting 
 from above downward when operating on left side. 
 
 Landmarks. — Same as for Radical Excision (q. v.). 
 
 Incision. — An elliptical incision is made, with its long axis parallel with 
 anterior axillary fold (with arm in above position) ; its center corresponding 
 with nipple; its width regulated by size of breast (or tumor); its upper and 
 lower angles being just beyond the mamma. The ellipse itself does not 
 extend the full length of the incision. From the upper angle of the ellipse 
 a straight incision is carried up to opposite the center of the axilla. From 
 the lower angle of the ellipse another straight incision is also carried down- 
 ward a short distance below the breast. (See Fig. 555, A.) 
 
 Operation. — (1) Keeping parts tense by left hand, the full length of the 
 incision, including upper curve of ellipse, is completed at one stroke. The 
 lower curve of the ellipse is made with a second stroke of the knife, joining 
 the straight portions of the first incision at upper and outer and at lower and 
 inner circumference of breast, respectively. Incise through skin and super- 
 ficial connective tissue throughout. (2) Having clamped bleeding vessels, 
 the incision is carried down to pectoral muscle along upper line of ellipse, 
 while skin above is drawn upward by assistant and breast downward by 
 surgeon's left hand, the incision passing well above the upper limit of the 
 breast. (3) Drawing breast away from thoracic wall, surgeon frees it from 
 pectoralis major, beginning along the upper line. (4) Assistant now draws 
 breast upward, and surgeon, retracting skin downward with left hand, cuts 
 down to thoracic muscles along lower line of ellipse, the incision passing 
 well below the lower limit of the breast. (5) While under traction, the con- 
 nective tissue of breast to thorax is now severed toward its axillary aspect, 
 together with the vascular connections, which are the last cut, and the breast 
 thus freed from chest. All vessels cut are at once clamped, and clamped in 
 advance of section, where possible. The pectoralis major is left bare. (6) 
 Right index-finger is inserted into axilla through upper end of wound and 
 enlarged glands felt for. If none be found, axilla is not opened up further. 
 (7) If enlarged axillary glands be felt, the incision is continued upward into 
 armpit, the axillary space exposed, and the glands removed with as little 
 disturbance and damage to neighboring tissues as possible, and generally by 
 blunt dissection. (8) Margins of wound, even the elliptical portion, are 
 generally capable of being brought into apposition, and are sutured 
 throughout. (9) If temporary drainage be indicated, it is provided for 
 at the lower angle of wound. Abundant dressing is applied and arm 
 bound to side. 
 
 Comment. — Where breast is involved by small innocent tumor, merely 
 the elliptical portion of the above incision is used, the straight portions ex- 
 tending above into axilla and below toward sternum being omitted. 
 
 SUBCUTANEOUS EXCISION OF MAMMARY GLAND 
 
 BY INFERIOR CURVED INCISION. 
 
 Description. — Through a curved incision made in the inferior mammary 
 fold, the breast is turned upward and dissected (enucleated) in whole or in 
 part from out of its overlying capsule of skin and fascia, generally leaving 
 the nipple intact. Indicated in non-malignant conditions for partial or com- 
 plete removal of the mamma. 
 
GENERAL SURGICAL CONSIDERATIONS. 747 
 
 Preparation — Position. — Same as for Radical Excision. 
 
 Landmarks. — Inferior mammary fold (at junction of lower circumference 
 of breast with chest-wall). 
 
 Incision. — -Curved incision passing around beneath the lower margin of 
 breast in the mammary fold, extending sufficiently far up on either side to 
 enable breast to be turned upward and backward. (See Fig. 555, B.) 
 
 Operation. — Incise through skin and fascia down to pectoral fascia. 
 Having gotten between the deep layer of the superficial pectoral fascia and 
 the sheath of the pectoralis major, the breast is readily detached by blunt 
 dissection and turned upward and outward — and then freed from its cutaneo- 
 areolar covering from behind forward. The nipple is left, if possible, to 
 lessen disfigurement. All bleeding vessels are ligated with gut. The remain- 
 ing portion of the breast, if any, is returned to its normal site (otherwise the 
 cutaneo-areolar capsule of the enucleated breast is turned back into place) 
 and the margins of the wound are carefully sutured to avoid scarring. No 
 drainage is used. A snug dressing is applied, to obliterate dead spaces. 
 
 III. THE SUPERIOR MEDIASTINUM. 
 SURGICAL ANATOMY. 
 
 Description. — The mediastinum is the region of the thoracic cavity be- 
 tween the pleura? laterally, and the thoracic walls anteriorly and posteriorly. 
 That portion above the upper level of the heart is the superior mediastinum. 
 That portion below the upper level of the heart is divided into anterior, 
 middle, and posterior mediastina, the anterior being in front of the heart, the 
 posterior behind the heart, and the middle enclosing the heart. 
 
 Boundaries of Superior Mediastinum. — Anteriorly, manubrium sterni. 
 Posteriorlv; bodies of first, second, third, and fourth dorsal vertebrae. Later- 
 allv; pleura\ Superiorly; upper opening of thorax. Interiorly; plane passing 
 horizontally backward from manubrio-gladiolar junction to lower portion of 
 body of fourth dorsal vertebra — nearly coinciding with upper portion of 
 pericardium. 
 
 Contents of Superior Mediastinum. — Origins of sternohyoid and 
 sternothyroid, and lower ends of longi colli muscles; transverse arch of aorta; 
 innominate, thyroidea ima, left carotid, and left subclavian arteries; in- 
 nominate, superior vena cava, and left superior intercostal veins; pneumo- 
 gastric, left recurrent laryngeal, phrenic, and cardiac nerves; trachea; esopha- 
 gus; thoracic duct; thymus gland, or its remains; bronchial lymphatic glands; 
 superior sterno-pericardiac ligaments. 
 
 SURFACE FORM AND LANDMARKS. 
 The planes limiting the upper and lower boundaries of the superior 
 mediastinum are, respectively, those corresponding with the upper opening 
 of the thorax above, and the junction of the manubrium and gladiolus below. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The superior mediastinum (as well as the anterior and middle mediastina) 
 is exposed in the operation of anterior mediastinal thoracotomy (page 748). 
 It is also exposed in the operations upon the innominate artery, in excisions 
 of the sterno-clavicular articulation and of the manubrium. 
 
748 OPERATIONS UPON THE THORAX. 
 
 IV. THE ANTERIOR MEDIASTINUM. 
 SURGICAL ANATOMY. 
 
 Boundaries. — Anteriorly; all of gladiolus sterni, with parts of left 
 fourth, fifth, sixth, and seventh costal cartilages. Posteriorly; pericardium. 
 Laterally; pleurae. 
 
 Contents. — Origin of triangularis sterni muscle; areolar tissue; lymphatic 
 vessels and glands (anterior mediastinal glands) ; thymus gland (or its remains) ; 
 inferior sterno-pericardiac ligaments. 
 
 ANTERIOR MEDIASTINAL THORACOTOMY 
 
 BY LONG MEDIAN INCISION — MILTON'S OSTEOPLASTIC ANTERIOR 
 MEDIASTINOTOMY. 
 
 Description. — Exposure of the superior, anterior, and middle mediastina 
 through a temporary longitudinal division of the sternum in the median 
 line. (The posterior mediastinum may also be reached, in part, by this 
 incision, but is better approached by a separate operation.) Resorted to for 
 gaining very free access to the entire contents of the mediastina mentioned, 
 especially for the removal of anterior mediastinal growths and pus, — the 
 esophagus, trachea, and bronchi being more readily reached and treated from 
 behind (Posterior Mediastinotomy). 
 
 Preparation. — Beard and presternal hair shaved, if necessary. 
 
 Position. — Patient supine, shoulders elevated, head supported, neck 
 prominent — Surgeon to right — Assistant opposite. 
 
 Landmarks. — Median line of neck and sternum; thyroid cartilage; 
 ensiform cartilage. 
 
 Incision. — From lower part of thyroid cartilage to base of ensiform 
 cartilage, made in median line of neck and sternum. (The cervical portion 
 of the incision is to give room for the lateral retraction of the split sternum.) 
 (See Fig. 556, A.) 
 
 Operation. — (1) Incise through the skin and superficial connective tis- 
 sue along the neck — and down to the bone over the full length of the sternum. 
 Clamp or ligate superficial vessels. (2) Deepen the cervical incision by re- 
 tracting the sternohyoid and sternothyroid muscles and dividing the deep 
 cervical fascia, controlling all vessels encountered. The trachea is thus 
 exposed from the thyroid cartilage to the episternal notch, except that the 
 isthmus of the thyroid gland is not divided. If necessary, it may be divided 
 between two ligatures. Expose the episternal notch by separating the fascia 
 from it outward on either side to the origins of the sternomastoids. (3) Free 
 the posterior surface of the manubrium sterni downward as far as possible, 
 by means of curved periosteal elevator and finger, depressing the important 
 structures downward. The more nearly this is done subperiosteally, the 
 greater the protection to the soft parts adjacent. (4) By means of a thin, 
 special saw, divide the sternum longitudinally in the median line, from above 
 downward — dividing it through its entire thickness above, where the saw- 
 teeth can be protected by a thin metallic guide or spatula slipped behind the 
 upper portion of the sternum — but dividing it elsewhere, at first, very nearly 
 but not quite through, and not extending the division below the base of the 
 ensiform cartilage. (5) Detach the ensiform cartilage from the gladiolus by 
 stout, curved, blunt scissors or bone-forceps, avoiding the neighboring struc- 
 tures of importance, especially the peritoneum. (6) Grasp the margins of 
 the sawed sternum on both sides by means of broad retractors with teeth— 
 and steadily and carefully draw the divided bones apart by outward and 
 
ANTERIOR MEDIASTINAL THORACOTOMY. 
 
 749 
 
 slight upward traction. Draw the ensiform cartilage downward. Pass a 
 director or thin spatula upward, inserting it between the lower end of the 
 gladiolus and the disconnected ensiform cartilage, hugging the posterior 
 surface of the lower portion of the gladiolus — and, upon this protector, com- 
 plete the division of the lower part of the gladiolus by means of the special 
 saw or bone-cutting forceps, working from below upward. (7) The bony- 
 division having been completed, additional traction is made upon the divided 
 edges of the sternum, the separation being started by prizing the split sides 
 of the sternum asunder with some stout, blunt instrument — detaching by 
 
 Fit;. 556. — Incisions for Exposing the Mediastina: — A, A, Milton's anterior mediastinal 
 thoracotomy for exposing superior, anterior, and middle mediastina; B, Incision for thoraco- 
 plasty flap exposing anterior and middle mediastina (corresponding with sternum and third, 
 fourth, and fifth costal cartilages); C, C, Incision for vertical thoracoplastic flap exposing superior 
 mediastinum (corresponding with manubrium and first and second costal cartilages); D, D, 
 Incision for horizontal thoracoplastic flap exposing superior mediastinum (corresponding with 
 manubrium and first and second costal cartilages). (Thorax modified from Spalteholz.) 
 
 blunt dissection all binding tissues, or dividing them with scissors, as soon 
 as revealed by the gradual separation of the parts, and, where necessary, 
 taking renewed holds upon the edges of bone with the retractors, as the gap 
 increases. (8) An interval of between 5 and 8 cm. (about 2 to 3 inches) is 
 thus ordinarily attainable. Through this opening the contents of the superior, 
 anterior, and middle mediastina are readily reached — and even the posterior 
 mediastinum may also, though of course less easily, be thus reached on the 
 right side, after separating the pericardium and pleura. The further steps 
 of the operation will depend upon the object for which performed — but, in 
 any case, should be carried on with exceptional care, owing to the unusually 
 important nature of the parts involved, and should be done chiefly by means 
 
75° OPERATIONS UPON THE THORAX. 
 
 of blunt dissection. (9) At the close of the operation, the edges of the sternum 
 are approximated by four to six silver-wire sutures passed through drill-holes 
 ■ — gauze or other drainage having been temporarily introduced behind the 
 sternal notch and below the lower end of the gladiolus — and the skin wound 
 closed except opposite the drainages. 
 
 Comment. — The pleura and peritoneum are both in great danger of 
 injury — wounds of these should be immediately closed by circular ligation 
 of their mouth, if small; and by suture, if large. 
 
 The principal tissues which interfere with the separation of the parts are 
 those about the left innominate vein, crossing behind the manubrium sterni, 
 in the line of the division, above; and about the ensiform cartilage below. 
 
 Especial care is necessary as to respiration, due to collapse of lungs, and 
 a Fell-O'Dwyer instrument should have been provided previously for main- 
 taining artificial respiration. Costal breathing ceases with division and 
 separation of the sternum, though the lungs may not collapse on that account 
 alone. In special cases where dyspnoea may be anticipated, a preliminary 
 tracheotomy is sometimes done. 
 
 ANTERIOR MEDIASTINAL THORACOTOMY 
 
 BY OSTEOPLASTIC RESECTION OF PART OF STERNUM CORRESPONDING WITH 
 THIRD, FOURTH, AND FIFTH COSTAL CARTILAGES. 
 
 Description. — The anterior mediastinum, and also the middle medias- 
 tinum, may be exposed by the osteoplastic resection of that portion of the 
 sternum corresponding with the third, fourth, and fifth costal cartilages — 
 which portion is temporarily turned back, exposing a large part of the anterior 
 and middle mediastina and their contents. This operation is less extensive 
 and severe than Milton's, and is indicated where a more limited exposure 
 will suffice — especially for the removal of glands, small growths, evacuation 
 of pus; and for the exposure of the heart and pericardium in the treatment 
 of wounds and evacuation of pus. 
 
 Preparation. — Chest-wall shaved, if necessary. 
 
 Position. — Patient supine, chest elevated and resting upon some object 
 which will render the anterior thoracic aspect prominent. Surgeon on left. 
 Assistant opposite. 
 
 Landmarks. — Gladiolus sterni, between chondro-sternal articulations of 
 third, fourth, and fifth costal cartilages; line of internal mammary artery 
 (see page 57). 
 
 Incision. — (1) Upper transverse incision passes on a level with the upper 
 border of third costal cartilages, not extending more than 1.2 cm. (about 
 \ inch) beyond either sternal border (to avoid the internal mammary artery). 
 (2) The lower transverse incision passes similarly on a level with the lower 
 border of the fifth costal cartilages, between points about 1.2 cm. (about 
 \ inch) beyond the sternal borders. (3) The vertical incision joins the left 
 ends of the two transverse incisions, passing flown between the left internal 
 mammary artery and the left margin of the sternum. These incisions outline 
 three sides of a square, having the hinge of the flap at the right margin of the 
 sternum. (See Fig. 556, B.) 
 
 Operation. — (1) Incise through skin, fascia, and fibers of the pectoralis 
 major, down to the sternum and intercostal membranes, using care over the 
 intercostal spaces that the knife does not penetrate the thorax. Clamp and 
 ligate the superficial vessels cut along the lines of incision — but do not separate 
 the skin and fascia from the sternum. (See Fig. 557.) (2) The costal 
 cartilages are well exposed where the vertical incision crosses them and are 
 divided with blunt-pointed cartilage-pliers with great care, to avoid injury 
 
ANTERIOR MEDIASTINAL THORACOTOMY 
 
 751 
 
 to pleura and pericardium. This having been dune, the left margin of the 
 sternum, thus freed of its third, fourth, and fifth cartilages, is now drawn 
 slightly forward with toothed retractor, and, while held in this position, the 
 posterior surface of that portion of the sternum is freed of triangularis sterni 
 muscle and connective tissue by means of a slightly curved periosteal elevator. 
 (3) The sternum is now divided where the upper and lower transverse inci- 
 sions cross it — and this is best accomplished, in those cases where it has been 
 possible to clear the posterior surface of the sternum entirely across to the 
 opposite border, by means of a Gigli saw conducted beneath the sternum, 
 with which the section is readily made. In other cases the section may be 
 made (though with less neatness and precision and more danger) by means 
 of stout, curved, blunt-pointed, bone-cutting pliers, the lower blade hugging 
 the sternum closely. (4) This section of the sternum having been freed upon 
 
 Fig. 557.— Anterior Mediastinal Thoracotomy, by an Osteoplastic Flap Consisting of 
 Soft Parts and Sternum Corresponding with Third, Fourth, and Fifth Costal Carti- 
 lages :— A, Osteoplastic flap turned to left : B. Pectoralis major muscle ; C, C, Intercostal arteries ; D, 
 Costal cartilage divided by instrument; I£. Costal cartilage partly broken in hinging back the flap; 
 F, F, Drill-holes; ("». Triangularis sterni muscle; H. H. Lungs and pleura;, the latter extending 
 further toward the middle line; I, Heart and pericardium. 
 
 three of its sides, its posterior surface having been cleared, and with the soft 
 parts still adherent to its anterior surface, it is now to be partly turned, parti} 
 broken back upon the structures along its right margin, as upon a hinge, the 
 costal cartilages generally snapping in part or entirely, though sometimes 
 bending. (5) The anterior mediastinum, and also the middle mediastinum 
 (although of course less fully), are now exposed — and their contained struc- 
 tures may be reached by gentle manipulation and blunt dissection — and the 
 special object of the operation accomplished. (6) At the close of the opera- 
 tion, the osteoplastic flap is turned back into place. It is well to drill holes 
 (two above and two below) for chromic gut ligatures, or silver wire, along 
 the upper and lower transverse divisions of the sternum, before replacing the 
 flap (holding the detached piece of sternum with strong bone forceps while 
 drilling; and protecting the inferior surfaces of the margins of the upper and 
 lower intact pieces) — and tightening the sutures when the piece is in place. 
 If thought necessary, the costal cartilages may be similarly drilled and tied 
 on either side of the line of section. (7) Temporary drainage should be pro 
 vided — which may be done by excising a small portion of one of the costal 
 
752 OPERATIONS UPON THE THORAX. 
 
 cartilages at its articulation with the sternum, as well as a limited portion 
 of the margin of the sternum at that point, in the form of a semicircle. The 
 skin-portion of the osteoplastic flap is sutured throughout most of its extent, 
 leaving an opening for drainage. 
 
 Comment. — Instead of the above window opening laterally upon a 
 vertical hinge, one may be (though less easily) formed opening upward or 
 downward upon a transverse hinge across the sternum, by making two vertical 
 incisions just outside of the borders of the sternum and the transverse incision 
 on a level with the lower border of the fifth costal cartilage (where the hinge 
 is to be above). 
 
 The window may be placed higher or lower than indicated in the above 
 operation. 
 
 OTHER OPERATIONS UPON THE ANTERIOR MEDIASTINUM. 
 
 See all operations upon the Heart and Pericardium — which, lying in the 
 middle mediastinum, are reached through the anterior mediastinum, 
 
 V. THE MIDDLE MEDIASTINUM. 
 SURGICAL ANATOMY. 
 Boundaries. — Anteriorly; limits of anterior mediastinum. Poste- 
 riorly; limits of posterior mediastinum. Laterally; pleura'. 
 
 Contents. — Heart and pericardium; ascending aorta; pulmonary artery 
 and its two branches; arteries of the phrenic nerves; superior vena cava; 
 right and left pulmonary veins; vena azygos major; phrenic nerves; roots of 
 lungs; bifurcation of trachea; two bronchi; bronchial lymphatic glands. 
 
 OPERATIONS UPON THE MIDDLE MEDIASTINUM. 
 
 For operations upon the Middle Mediastinum, see operations upon the 
 Pericardium and Heart (pages 780 and 785). 
 
 For other operations exposing the Middle Mediastinum, see operations 
 upon the Anterior Mediastinum (pages 748 to 752). 
 
 For operations upon the thoracic esophagus and trachea and upon the 
 bronchi, see Posterior Mediastinal Thoracotomy (page 752) — the first being 
 in the Posterior Mediastinum — the last two in the Middle Mediastinum, 
 but best reached through the Posterior Mediastinum. 
 
 VI. THE POSTERIOR MEDIASTINUM. 
 SURGICAL ANATOMY. 
 
 Boundaries. — Anteriorly; pericardium; roots of lungs. Posteriorly; 
 vertebral column (below inferior border of fourth dorsal vertebra) . Laterally ; 
 pleura?. 
 
 Contents. — Descending aorta; greater and lesser azygos veins; pneumo- 
 gastric nerves; splanchnic nerves; esophagus; thoracic duct; posterior medias- 
 tinal lymphatic glands. 
 
 POSTERIOR MEDIASTINAL THORACOTOMY 
 
 BV THORACOPLASTY FLAP — BRYANT'S OPERATION. 
 
 Description. — Exposure of the posterior mediastinum by means of an 
 osteoplastic flap about 8 to 10 cm. (about 3 to 4 inches) square, and generally 
 including the width of three ribs raised over the site of the operation — part 
 of the central rib being permanently sacrificed from angle to outer end of 
 
POSTERIOR MEDIASTINAL THORACOTOMY. 753 
 
 transverse process, and similar parts of the other two returned. Usually 
 performed for the removal of foreign bodies in the esophagus, trachea, and 
 bronchi, and for the evacuation of pus. Some of the more posterior contents 
 of the middle mediastinum are thus also accessible from this opening. 
 
 Position. — Patient partially upon side and chest, with the side of opera- 
 tion uppermost, and resting upon some object in order to increase the width 
 of the intercostal intervals at the site of operation. The scapula is drawn 
 forward to increase the interval between the vertebrae and the vertebral bor- 
 der of the scapula. Surgeon on side of operation. Assistant opposite. 
 
 Landmarks. — Position of upper ribs; spinous processes of upper dorsal 
 vertebra^ with corresponding ribs; vertebral border of scapula; root of spine 
 of scapula (which generally corresponds to the interspace between third and 
 
 Fig. 558. — Operations upon the Thoracic Cavity: — A, Posterior mediastinal thora- 
 cotomy, by thoracoplastic flap; B, Position for paracentesis thoracis in the eighth intercostal 
 space in the line of the inferior angle of the scapula. (Thorax modified from Bardeleben, 
 Haeckel, and Frohse.) 
 
 fourth dorsal spines). The site of the operation is determined by the posi- 
 tion of the foreign body to be removed. Parts of three ribs are generally in- 
 cluded in the operation, the central one being at the center of the field. Some- 
 what readier access is gotten to the esophagus from the left side, though at the 
 level of the usual operation the esophagus is practically in the middle line. The 
 trachea usually bifurcates opposite the fourth dorsal vertebra (sometimes the 
 fifth). Where the site of the operation cannot be previously determined, the 
 left fourth, fifth, and sixth ribs are generally chosen. 
 
 Incision. — In the form of three sides of approximately a three-inch 
 square — the fourth side being represented by the spinous processes of the 
 vertebrae. This area is so placed as to have its center over the central one 
 of the three ribs to be removed — the upper and lower parallel incisions passing 
 above and below the other two ribs respectively. (See Fig. 558, A.) 
 
 Operation. — (i) Incise the three sides of the outline indicated above, 
 through skin, fascia, and muscles down to the ribs, carefully avoiding pene- 
 48 
 
754 
 
 OPERATIONS UPON THE THORAX. 
 
 trating the intercostal spaces. Clamp all cut vessels. Free up the thick 
 flap of soft parts from the ribs and turn it over the spinous processes to the 
 opposite side. Ligate the previously clamped vessels, and others as exposed. 
 (See Fig. 559.) (2) Make a longitudinal incision over the center of the outer 
 aspect of the central one of the three ribs, through the periosteum, from the 
 outer end of the transverse process of the vertebra to the angle of the rib — 
 free it subperiosteal!}- with curved periosteotome (or by a piece of silk con- 
 ducted between bone and periosteum) — pass a Gigli saw between rib and 
 periosteum, guarding the pleura, and remove the portion of rib above indi- 
 cated, and discard. (3) The inner and outer ends of the exposed portions 
 of the upper and lower ribs are now similarly exposed subperiosteallv, without 
 
 Fig. 559.— Posterior Mediastinal Thoracotomy, by Thoracoplasty Flap: — A, Skin and 
 muscle flap turned horizontally backward ; B. Flap of part of fourth rib and intercostal muscles 
 turned upward ; C, Flap of part of sixth rib and intercostal muscles turned downward ; D, D, Verte- 
 bral ends of fourth and sixth ribs, drilled forwiring ; E, Intercostal artery, vein, and nerve ; F, F, F 
 Fourth, fifth, and sixth dorsal nerves exposed and retracted ; G, Pleura and lung ; H, Broad retractor 
 displacing pleura and lung; I, Thoracic aorta; J, Left bronchus; K, Esophagus protruded into 
 wound by sound introduced through mouth. The operations of Bronchotomy and Thoracic Esopha- 
 gotomy are shown at J and K, respectively. The pulmonary and bronchial vessels are omitted, for 
 clearness. 
 
 freeing the intervening portions more than can be helped, and especially 
 without isolating the upper rib from its upper attachment and the lower rib 
 from its lower attachment. Two holes are drilled at either end of the yet 
 undivided ribs for future wiring. Both ribs are then divided between the 
 pairs of drilled holes, by means of a Gigli saw. (4) The intercostal arteries 
 in the field are now ligated at the inner and outer side of the wound. The 
 intercostal nerves are carefully retracted throughout the operation, it being 
 
SURGICAL ANATOMY OF THE DIAPHRAGM. 755 
 
 unnecessary to divide them. The periosteum forming the bed of the central 
 rib is now very carefully divided lengthwise of its course. Through this 
 opening the pleura is carefully detached and is further separated by the 
 finger from the muscular and bony wall of the thorax corresponding to the 
 extent of the wound, the separation being accomplished during expiration. 
 At either side of the wound, in line with the divided ribs, the remaining 
 chest-wall is divided while the pleura beneath is carefully guarded by an 
 instrument or the finger. These two vertical incisions last made, crossing 
 the transverse one through the bed of the middle rib's periosteum, make, 
 by an H-shaped incision, two small flaps — the upper one, containing the 
 upper rib as extensively adherent as possible (for nutrition), is now turned 
 upward upon its hinge of soft parts — and the lower one, with the lower rib 
 similarly attached, is turned downward in like fashion — care being taken not 
 to injure the intercostal vessels and soft tissues above the upper rib, nor below 
 the lower rib. (5) The posterior mediastinum is thus exposed — and its 
 contents, as well as some of the more posteriorly situated contents of the 
 middle mediastinum, are accessible after careful separation of important 
 structures by means of blunt dissection, instrumental retraction, and the use 
 of the fingers. The pleura, especially, is carefully pushed externally out of 
 the way and so guarded as to avoid opening it. The trachea, bronchi, and 
 esophagus may be both felt and seen. The important vessels of the posterior 
 and middle mediastinum (see Surgical Anatomy) are to be carefully guarded. 
 When trachea, bronchi, or esophagus are to be opened, thev are incised, 
 after being steadied with toothed forceps, in their longitudinal axis — and 
 subsequently not sutured — but the wound packed down to the incised tube, 
 for the escape of all drainage through a drainage-tube placed in the center 
 of the gauze packing. (6) In completing the operation, the middle one of 
 the three ribs is not replaced — the upper and lower ribs are turned back into 
 place and wired (or sutured with chromic gut) through the previouslv drilled 
 holes. The drainage will pass out of chest through the incision in the bed 
 of the middle rib — and will escape externally through a convenient opening 
 left beneath the skin and muscle flap which is only partially stitched into 
 place. 
 
 Comment. — (1) The scapula should be displaced forward out of the way, 
 and so held by an assistant. (2) It might be better to plan the skin incision 
 on a somewhat larger scale (say 2.5 cm., or about 1 inch, larger) so that the 
 skin suture-line would not directly coincide with the bone-sections. (3) All 
 bleeding should be controlled as encountered — first by clamp, then by liga- 
 ture. (4) The pleura is to be widely separated around the margin of the 
 opening by the finger — to enable freer displacement of the mediastinal con- 
 tents. (5) Below the arch of the aorta the esophagus is more readily reached 
 from the right — above the arch, it may be reached from either side, although 
 somewhat better from the left. (6) Removal of a body from the esophagus 
 below the body of the ninth dorsal vertebra is very difficult and hardly justi- 
 fiable. (7) The left bronchus is reached with greater difficulty and risk of 
 hemorrhage. 
 
 VII. THE DIAPHRAGM. 
 SURGICAL ANATOMY. 
 
 Attachments of Diaphragm. — Anterior (sternal) part; inferior and 
 posterior border of ensiform cartilage; neighboring posterior surface of ante- 
 rior aponeurosis of transversalis muscle. Lateral (costal) part; inferior 
 border and inferior surface of the cartilages and bony parts of the sixth or 
 
756 OPERATIONS UPON THE THORAX. 
 
 seventh inferior ribs. Posterior (vertebral) part; (a) ligamentum arcuatum 
 externum (the thickened anterior layer of lumbar fascia extending from tip 
 of transverse process of second lumbar vertebra to tip of twelfth rib); (b) 
 ligamentum arcuatum internum (the thickened iliac fascia arching over the 
 psoas, from the side of body of second lumbar vertebra to tip of transverse 
 process of same vertebra ) . (c) right crus of diaphragm (arising from anterior 
 surface of bodies of first to third, or fourth, lumbar vertebra; from inter- 
 vening fibro-cartilages; from anterior common ligament); (d) left crus of 
 diaphragm (arising from anterior surface of bodies of first to second, or 
 third, lumbar vertebra; from intervening fibro-cartilages; from anterior 
 common ligament). The insertion of these various origins is into the ante- 
 rior, posterior, and lateral aspects of the central tendon of the diaphragm. 
 
 Structures in Relation with Diaphragm. — Superiorly (thoracic 
 cavity); pleura and lungs; pericardium and heart. Inferiorly (abdominal 
 cavity); peritoneum; liver; stomach; spleen; pancreas; kidneys; suprarenal 
 capsules. 
 
 Upper Limits of the Diaphragm. — Right Leaflet, on level with junction 
 of fifth costal cartilage with sternum (about 2.5 cm., or 1 inch, below the 
 nipple). Left Leaflet, on level with junction of sixth costal cartilage with 
 sternum. Central Tendon, about on level with end of sternum, or seventh 
 ch< >ndro-sternal articulation. 
 
 Boundaries of Lower Thoracic Opening. — See Thoracic Wall, page 731. 
 
 Structures Passing through Floor of Thorax (Diaphragm). — See 
 Thoracic Wall, page 731. 
 
 Other Relations of Diaphragm. — (a) The fibers of diaphragm are 
 absent or deficient in the interval between the sides of the muscular strip 
 from ensiform cartilage to cartilages of neighboring ribs — areolar tissue 
 occupies this position, covered above by pleura, and below by peritoneum. 
 
 (b) The central tendon of the diaphragm is blended with the pericardium. 
 
 (c) After forced expiration, the right diaphragmatic arch is on a level, ante- 
 riorly with fourth costal cartilage; laterally, with fifth, sixth, and seventh 
 ribs; posteriorly, with eighth rib; similar measurements on left generally 
 being from one to two ribs' width lower. In forced inspiration, there is a 
 descent of from 2.5 to 5 cm. (about 1 to 2 inches), (d) Circumferentially, 
 the diaphragm is higher in the median line, and lower at the sides — but the 
 central tendon supporting the heart is lower than the sides, (e) For a narrow 
 interval around the lower and posterior circumference, the diaphragm is not 
 covered by pleura, but is in immediate contact with the chest-wall, (f) 
 The costo-phrenic sinus is that area over which the parietal and visceral 
 layers of the pleura are in constant contact, whether in inspiration or ex- 
 piration — and is represented by the line of reflection of the diaphragmatic 
 pleura onto the intrathoracic wall. 
 
 TRANSTHORACIC EXPOSURE OF DIAPHRAGM 
 
 BY PARTIAL EXCISION OF TWO OR THREE RIBS. 
 
 Description. — The upper (thoracic) surface of the diaphragm is exposed 
 (at the site of the diaphragmatic lesion) by means of the partial excision of 
 two or three ribs performed subperiosteally, through a single incision between 
 them. Or the site may be exposed by turning back a flap of overlying soft 
 parts and then excising the indicated parts of the ribs, — or an osteo-thoraco- 
 plastic flap may be temporarily turned aside and replaced at the end of the 
 
TRANSTHORACIC EXPOSURE OF DIAPHRAGM. 757 
 
 operation. (See operations upon the pleura and heart.) Having opened the 
 chest-wall over the area, the diaphragm may be approached in one of several 
 ways — below the reflection of the pleura, — subpleurally (after detaching and 
 pressing back the unopened pleura), — transpleural!}- (the pleura; being non- 
 adherent), — or through adherent pleural surfaces. Indicated for the evacua- 
 tion of pus in subphrenic abscess; for the repair of wounds of the diaphragm; 
 for hernia through the diaphragm. In subphrenic abscess, the approach is 
 usually made by the lumbar, iliac, or lateral thoracic routes, in order of 
 preference — parts of the ninth and tenth ribs being incised in simple sub- 
 phrenic abscess — and part of the eighth if the pleura be involved. The site 
 of the operation may be on either side and will be determined by the lesion 
 and the physical signs. Generally from 7.5 to 10 cm. (about 3 to 4 inches) 
 of the ninth and tenth ribs, between the anterior axillary and scapular lines, 
 
 Fig. 560.— Transthoracic Exposure of Diaphragm through the Right Ninth Inter- 
 costal Space : — A, Latissimus dorsi muscle ; B, Serratus magnus muscle ; C, Obliquus externus ab- 
 dominis muscle; D, D, Resected ends of ninth and tenth ribs, the periosteal bed extending between 
 the exposed ends, the intercostal vessels and nerves showing through the periosteum ; E, Anterior 
 layer of periosteum retracted and everted ; F, Posterior layer of periosteum, together with externa] 
 and internal intercostal muscles, retracted ; G, Pleura displaced upward ; H, Diaphragm. 
 
 as indicated, are excised through a single incision made between them, in the 
 case of an abscess between the liver and diaphragm, which is usually ap- 
 proached subpleurally. Where the abscess is near the dome of the diaphragm, 
 the transpleural approach at a higher level generally must be used. The 
 excision of one or more costal cartilages in the mammary line may suffice. 
 
 For operations for hepatic abscess and empyema, see Operations upon 
 the Liver and Pleura. 
 
 Position. — Determined by the lesion — and will be such as to conve- 
 nientlv expose the area — in this case in the semi-prone position. 
 
 Landmarks. — Site of lesion; line of pleura; line of diaphragm. 
 
 Incision. — In the center of the interspace between the ninth and tenth 
 ribs — the center of the incision being midway between the anterior axillary 
 and scapular lines — and about 13 cm. (about 5 inches) in length, so as to 
 provide for the removal of about 9 cm. (about 3^ inches) of each rib. 
 
758 OPERATIONS UPON THE THORAX. 
 
 Operation. — (i) Incise through skin, fascia, and overlying thoracic 
 muscles, down to the plane of intercostal muscles, clamping all bleeding 
 vessels. Free back the upper and lower lips of the wound upon this same 
 plane, until the ninth and tenth ribs are reached and exposed in their entire 
 width — the soft parts being retracted well above and below their limits. (2) 
 Subperiosteally excise about 9 cm. (about 3^ inches) of each rib, in the usual 
 manner (see the Subperiosteal Excision of the Ribs, page 447) — carefully 
 guarding the parietal pleura from the slightest nicking or injury (Fig. 350). 
 (3) Incise the intercostal tissues longitudinally in the center of the interspace 
 between the two excised ribs. If necessary, the intercostal arteries of the 
 excised ribs may be ligated at both ends, though this may be omitted generally, 
 as they are usually not in the way unless it be indicated to carry an incision 
 across their course. Preserve the intercostal nerves by retraction. The re- 
 moval of these two ribs generally gives ample room for exposure when the 
 upper and lower limits of the wound are well retracted. (4) Five methods 
 of reaching the diaphragm are now open to the operator; (a) If the site of 
 operation be below the level of the reflected pleura, where the diaphragm 
 and chest-wall are in contact, the diaphragm may be approached at once, — 
 (b) If the pleura be encountered as soon as the chest-cavity is opened, its 
 parietal layer should be most carefully detached with the fingers and by 
 means of blunt dissection and peeled back from its connection with the endo- 
 thoracic fascia and surface of the diaphragm — peeling it backward with the 
 tips of the fingers and constantly pushing it from the freed area with the 
 back of the fingers — continue this freeing back of the unopened pleura until 
 the site of the diaphragmatic operation is reached — and then hold the pleura 
 in place by gauze packing (Fig. 560). (c) If both surfaces of the pleura are 
 found adherent, thus shutting off the general pleural cavity, the incision may 
 be carried directly down to the diaphragmatic site without danger of entering 
 the pleural cavity (unless the adhesions be pulled apart in the manipulations), 
 — (d) If the two pleural surfaces are not adherent, and it be impracticable 
 to detach the pleura as described under (1)), the two pleurae may be united 
 by suture around an area sufficiently large to admit of operating within and 
 thus reaching the diaphragm at once, (e) If the two pleural layers be found 
 not in contact by adhesion, and cannot be separated and displaced upward as 
 mentioned under (b), and if time be to spare, adhesion between the two 
 surfaces may be brought about by gauze packing, with the accomplishment 
 of the rest of the operation two or three days later, when the cavity will have 
 been closed off by adhesions. Where it is possible to choose the route, it 
 is better to approach the diaphragm either below the level of the pleural 
 reflection — or to detach the unopened pleura and reach the diaphragm 
 beneath the pleural cavity. (5) The surface of the diaphragm having been 
 exposed, the special object of the operation is now accomplished — the abscess 
 incised — the wounded diaphragm sutured — or the hernial opening closed — 
 upon the same principles practised elsewhere. Owing to the constant move- 
 ment of the diaphragm, it is somewhat more difficult to deal with its struc- 
 ture. An abscess cavity should be evacuated by the most direct route, 
 especially guarding the pleural cavity from infection. If a newly made 
 wound exist, it is sutured at once. If the wound be old, or the opening be 
 a hernia, the edges are seized with toothed forceps to steady them and then 
 freshened with curved blunt scissors — the moving lung being held out of the 
 way, if necessary, by gauze packing — and with a fully curved needle, held 
 in special needle-holder, the margins of the wound or opening are brought 
 together with chromic gut sutures. (6) The pleural sac, previously held 
 
SURGICAL ANATOMY OF THE PLEUR.l.. 759 
 
 out of the way by packing, is now allowed to fall into place. Temporary 
 drainage is established, if indicated, through an unsutured part of the ex- 
 ternal wound — the remaining portion of the outer wound being closed. 
 
 Comment. — (a) If the pleura be nicked, ligate or suture it at once, (b) 
 If necessary to gain more room, free back the soft parts and excise the same 
 amount of the rib above or below — especially is this the case when it is needed 
 to reach the diaphragm nearer its dome, (c) A U-shaped flap, with base 
 forward or backward, may be used to expose the ribs, (d) On the left side 
 all calculations are made somewhat lower. 
 
 VIII. THE PLEURA. 
 SURGICAL ANATOMY. 
 
 Relations. — (1) Pleura costalic (Parietal Layer of Pleura); beginning 
 at sternum, pleura lines thoracic cavity, covering inner aspect of costal car- 
 tilages, ribs, intercostal muscles — passing, posteriorly, over heads of ribs, 
 thoracic ganglia and branches, lateral surfaces of bodies of dorsal vertebra? — 
 thence to side of pericardium, which it partially covers — thence to root of 
 lung, where it becomes pleura pulmonis. (2) Pleura pulmonis (Visceral 
 Layer of Pleura); beginning at root of lung, pleura passes around posterior 
 border, over convex outer aspect, from base to summit — over sides of fissures 
 between lobes — around its anterior border — on to anterior aspect of root — 
 thence upon pericardium to inner aspect of sternum. (3) Pleura cervicalis; 
 apex of pleura closely covers apex of lung, projecting, with it, from 1.3 to 
 4.5 cm. (about h to if inches) above the first rib — but not above level of 
 neck of first rib. Subclavian artery arches over it, grooving its internal and 
 anterior aspect just below its apex. Scalenus anticus and medius muscles 
 are in contact with it externally. (4) Pleura diaphragmatis ; covers superior 
 surface of diaphragm, except narrow interval along its circumference, which 
 is in contact with costal parietes. (5) Pleura mediastinalis ; forms lateral 
 boundaries of mediastina. 
 
 Relations of Margins of Pleura? to Chest-wall. — (1) Anterior mar- 
 gin ; extending from apex of lung, passes from sterno-clavicular articulation 
 downward and inward, meeting opposite pleura at upper border of sternum 
 — thence both pleura? descend in contact to upper margin of fifth costal 
 cartilages, whence they diverge. Right Pleura continues nearly vertically 
 downward to lower end of gladiolus, thence turns outward. Left Pleura 
 diverges from median line at upper margin of fifth costal cartilage, so as to 
 be 1.5 cm. (about § inch) to outer side of left border of sternum at level of 
 sternal end of fifth costal cartilage — 2 cm. (about |f inch) at level of sternal 
 end of sixth — 3.5 cm. (about if inches) at level of sternal end of seventh 
 (Luschka). In many cases this deviation of left pleura is not so marked, 
 the margin lying much nearer the median line. (2) Lower margin; reflected 
 on to diaphragm along line extending from lower end of sternum outward 
 behind seventh costal cartilage nearly to sternal end of rib. (Melsome says 
 this margin follows lower border of sixth costal cartilage on left side.) The 
 lower border of the pleura corresponds in height with the following structures 
 at the following points: — In the Nipple line, with eighth rib, — In Mid-axillary 
 line, with tenth rib on left, and ninth rib on right, — In Posterior Scapular 
 line (vertical line from tip of inferior angle of scapula), with twelfth rib, — 
 At Spine, with vertebral end of twelfth rib; sometimes with transverse process 
 of first lumbar vertebra. The lower margin of the lung will correspond with 
 a point two ribs higher in each case. 
 
760 OPERATIONS UPON THE THORAX. 
 
 Attachments of Pleurae. — (i) Ligamentum latum pulmonis, passes 
 from lower portion of posterior part of root of lung to diaphragm — formed 
 by two layers of pleura? continuous above with the layers in front and behind 
 root of lung. (2) Expansion of fascia covering and strengthening apex, and 
 extending across from posterior border of first rib to anterior border of trans- 
 verse process of seventh cervical vertebra — and further strengthened by 
 few fibers of scalenus anticus. (3) Interpleural Ligament, passing between 
 two pleura? behind esophagus and in front of aorta. 
 
 Supplemental or Complemental Pleural Spaces. — These spaces are 
 situations where two portions of parietal pleura? are in contact, even during 
 forcible inspiration — (1) Between Chest-wall and Diaphragm (Costo-phrenic 
 sinus), where costal pleura is reflected on to diaphragm, best marked poste- 
 riorly, where costal and diaphragmatic parts of pleura? are in contact from 
 about tenth to twelfth ribs, — (2) Between Chest-wall and Pericardium on 
 left, opposite lower portion of gladiolus. 
 
 Arteries. — From intercostal, internal mammary, musculophrenic, thymic, 
 pericardiac, bronchial. 
 
 Veins. — Correspond with arteries. 
 
 Nerves. — From phrenic and sympathetic. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The interval between the two pleura? is considerable above and below, 
 but opposite the gladiolus (second, third, and fourth costal cartilages) they 
 are more nearly approximated, or are in contact. 
 
 The anterior margins of the two pleura? are more nearly parallel and in 
 a vertical line than the corresponding margins of the lungs, that is, the left 
 anterior pleural margin extends further over the pericardium than does the 
 lung. 
 
 The right pleura is shorter and wider than the left (owing to the liver), 
 though it reaches slightly higher in the neck. 
 
 There is a tendency for the left pleura to extend lower down than the 
 right — most markedly upon the lateral aspect of the chest-wall — somewhat 
 so upon the anterior aspect — and even slightly so behind. 
 
 In some cases the pleura has extended into the abdomen, beneath the 
 ligamentum arcuatum externum, and uncovered by diaphragm at this site. 
 
 The outer surface of the pleura is firmly adherent to the surface of the 
 lung, to the pulmonary vessels emerging from the pericardium, to the upper 
 surface of the diaphragm, and to the triangularis sterni — elsewhere it is less 
 firmly adherent. 
 
 If the twelfth rib be well developed and full length, the pleura is generally 
 in contact with only its inner half. If the twelfth rib be very short, the pleura 
 may be in contact with all of its anterior surface — and the pleura may extend 
 to the transverse process of the first lumbar vertebra. 
 
 The outer margin of the erector spina? muscle cuts the twelfth rib about 
 its middle. Where the twelfth rib is present and extends beyond the outer 
 border of the erector spina?, the lower border of that portion of the rib ex- 
 ternal to the border of the muscle can be cut upon with reasonable certainty 
 of not opening the pleura. Where the twelfth rib is absent or short, the 
 above is not available. 
 
 Never take for granted that the last rib is the twelfth rib — always count 
 from the first rib. If the twelfth were absent and one were to cut down 
 
INTERCOSTAL THORACOTOMY. 761 
 
 upon the eleventh (mistaking it for the twelfth), the pleura would almost 
 certainly be opened. 
 
 Where the twelfth rib is absent or short, one may cut to within 2.5 cm. 
 (about 1 inch) of the apex of the angle formed by the outer margin of the 
 erector spinas and the lower border of that portion of the eleventh rib pro- 
 jecting to the outer side of the muscle — that is, one should not cut higher 
 than the position the twelfth rib would occupy if present (Melsome). 
 
 PARACENTESIS THORACIS. 
 
 Description. — Paracentesis thoracis (thoracentesis, or pleuracentesis) 
 consists in the penetration of the pleural cavity by means of a hollow needle 
 or cannula, for the purpose of exploratory aspiration or the evacuation of 
 fluid. 
 
 Sites usually Selected for Thoracentesis. — Sixth (or seventh) inter- 
 costal space in the mid-axillary line; eighth (or ninth, especially on left) 
 intercostal space in the posterior scapular line. 
 
 Position. — Patient supine at edge of table for lateral punctures — and 
 rolled slightly forward for posterior punctures — with arm of affected side 
 elevated above head (to widen intercostal spaces, and draw skin upward, 
 which will subsequently come back into place valve-like over the opening). 
 For simple puncture, if patient can sit upright in a chair, this position will 
 better enable fluid to gravitate downward. 
 
 Landmarks. — Sixth (or seventh) intercostal space in the mid-axillary 
 line — or the eighth (or ninth) space in the line of the inferior angle of the 
 scapula. The posterior puncture secures better drainage. (See Figs. 563, 
 C, and 558, B.) 
 
 Operation. — Having cocainized the part, grasp a needle, or cannula 
 and trocar, so as to control its progress and limit the depth of the puncture 
 — and having displaced the skin upward with the left thumb and forefinger, 
 so as subsequently to form a valve — the point is entered nearer the upper 
 than the lower border of the ribs limiting the special interspace (in order 
 to escape the more important lower intercostal artery, while also missing the 
 upper one) — and is made to pass inward and upward (so as to avoid wound- 
 ing the lung and diaphragm) — passing through skin, fascia, thoracic muscles, 
 intercostal muscles, endothoracic fascia, and parietal layer of pleura — its 
 entrance into the free pleural cavity being recognized by the sensation imparted 
 to the finger guarding its onward progress. When the needle, or cannula 
 point, is felt to be within the pleural cavity, the contents are slowly withdrawn, 
 the opening being subsequently sealed with sterilized cotton and collodion. 
 
 Comment. — Puncture may be made wherever physical signs indicate 
 fluid within the area of the pleura — but the above sites are the most usual. 
 The puncture may be preceded by a limited incision of the skin alone — or, if 
 difficulty occur, the incision may extend down to the intercostal muscles. 
 To avoid the intercostal arteries, the puncture should not be made posteriorly 
 to the angle of the ribs. 
 
 INTERCOSTAL THORACOTOMY. 
 
 Description. — Intercostal thoracotomy, or pleurotomy, consists in the 
 exposure and incision of the pleura in an intercostal space for the evacuation 
 of fluid. A simpler though generally less satisfactory operation than thora- 
 
762 
 
 OPERATIONS UPON THE THORAX. 
 
 cotomy through the partial excision of a rib, though often sufficient in minor 
 cases. 
 
 Sites Usually Selected for Intercostal Thoracotomy. — In the sixth 
 (or seventh) intercostal space in the mid-axillary line; in the eighth (or ninth, 
 especially on the left) intercostal space in the posterior scapular line — i. e., 
 in the same sites as for paracentesis, avoiding a position in which the dia- 
 phragm or scapula would interfere with free drainage. 
 
 Position. — As for paracentesis thoracis — except that here the opening 
 must not be valulvar, but, on the contrary, it is planned that the cutaneous 
 and pleural openings are opposite. 
 
 Fig. 561. — Operations for the Exposure of the Pleura: — A, Incision for intercostal 
 pleurotomv; B, Intercostal incision for the partial excision of two adjacent ribs; C, Incision over 
 a rib for either the partial excision of one rib or of three ribs (the one beneath the incision and 
 those immediately above and below). (Thorax modified from Spalteholz.) 
 
 Landmarks. — As for paracentesis thoracis. 
 
 Incision. — Midway between the two ribs, in the long axis of the inter- 
 costal space — extending about 5 cm. (about 2 inches) in a thin chest-wall, 
 and about 7.5 cm. (about 3 inches) in a thick chest-wall — the center of the 
 incision being, as above indicated, generally in the mid-axillary line for the 
 sixth intercostal space, and in the posterior scapular line for the eighth inter- 
 space. (Fig. 561, A.) 
 
 Operation. — (1) Incise through skin, fascia, external thoracic muscles 
 (serratus magnus in sixth space; chiefly the latissimus dorsi in eighth space), 
 
THORACOTOMY BY PARTIAL EXCISION OF RIBS. 763 
 
 and intercostal muscles down to the endothoracic fascia. Clamp and ligate 
 all bleeding vessels encountered — the incision lying between the upper and 
 lower intercostal arteries and not generally involving them. Retract the soft 
 parts upward and downward, including the ribs bounding the space — and 
 the parietal pleura is exposed. (2) The tense pleura is then deliberately 
 incised in the axis of the intercostal space (not by stabbing) — preceded, if 
 necessary, by an exploratory puncture — the opening being increased, if 
 indicated, upon a grooved director, or with blunt scissors or blunt bistoury 
 — and the fluid evacuated. (3) Drainage is then established by some form 
 of not easily collapsible drain (to withstand the tendency of the adjacent 
 ribs to narrow the opening). The ends of the external wound are sutured, 
 leaving room for the exit of the drain. 
 
 Comment. — Where the incision can be made to the outer margin of the 
 latissimus dorsi, lesser thickness of muscle presents. 
 
 THORACOTOMY BY PARTIAL EXCISION OF ONE OR MORE RIBS. 
 
 Description. — Exposure and incision of pleura through a thoracic open- 
 ing made by the excision of parts of one or two (or more) ribs. Generally 
 resorted to for the evacuation of intrapleural fluids where a larger opening 
 is required than furnished by an intercostal thoracotomv. Part of one rib 
 alone is generally excised — where more room is required part of the rib above 
 or below, or both, may be excised. From 2.5 to 5 cm. (about 1 to 2 inches) 
 of bone are ordinarily removed — and more if necessary. 
 
 Sites usually Selected for the Excision of Ribs. — Wherever a collec- 
 tion of fluid is indicated by physical signs (that is, determined by the physical 
 signs of localized collection) — where the collection is a localized one. Where 
 the fluid is in the free pleural cavity, the site generally chosen is the sixth 
 or seventh rib in the mid-axillary line — or the eighth or ninth rib just external 
 to the posterior scapular line — the latter situation usually being preferable. 
 (Kocher gives the sixth rib in the mammary line — the ninth rib on the right, 
 and the tenth on the left, in the lateral line — and the twelfth on both sides 
 posteriorly in the scapular line.) But the position should be so chosen that 
 the drainage will not be interfered with by either diaphragm or scapula in the 
 functioning of these structures. 
 
 Position. — As for Intercostal Thoracotomv (page 761). 
 
 Operation by Partial Excision of One Rib. — (1) An incision of about 
 8 cm. (about 3 inches) is made directly over the center of the chosen rib, 
 passing through skin, fascia, overlying muscles, and periosteum. (See Fig. 
 561, C, and 562.) (2) The rib is then freed subperiosteal^ for nearly 5 cm. 
 (about 2 inches), carefully avoiding injury to the intercostal vessels and pleura 
 — which are in safety as long as the operation is subperiosteal. About 2.5 to 
 4 cm. (about 1 to 1 \ inches) is now removed with a Gigli saw, as in the ordinary 
 partial excision of a rib. (3) The intercostal vessels are then easily isolated 
 in the bed of the rib, and are treated according to circumstances — they may 
 be tied at both ends of the wound and divided, where they are likely to be 
 injured — or they may be left intact, the incision into the pleura being made 
 between and parallel with the upper and lower intercostal vessels. (4) An 
 incision of about 2.5 to 4 cm. (about 1 to ij inches) is now carefully made 
 through the center of the periosteal bed and in the axis of the former rib, 
 passing through the costal periosteum, endothoracic fascia, and parietal 
 pleura into the pleural cavity — and drainage thus established — the drain 
 
764 
 
 OPERATIONS UPON THE THORAX. 
 
 used being so placed and of such a nature as not to impinge upon the lungs 
 during respiration. 
 
 Operation by Partial Excision of Two or More Ribs. — (1) If it be 
 found, after excising part of one rib, that it is desirable to excise part of the 
 rib above or below, or both, add two vertical incisions to the horizontal one, 
 extending from the ends of the former horizontal incision upward to the 
 upper border of the rib above — or two vertical incisions extending downward 
 
 Fig. 562. — Thoracotomy by Partial Excision of a Rib: — A, Thoracic muscles divided down 
 to rib, directly over its center; B, Periosteum raised and turned back, in the subperiosteal exposure 
 of the rib ; C, Transverse section of rib, indicating; portion of rib removed by means of a Gigli or chain 
 saw conducted between rib and periosteum ; D, Knife incising through periosteal bed and endotho- 
 racic fascia into pleural cavity. 
 
 to the lower border of the rib below — or both. A flap of overlying soft 
 parts may thus be turned upward or downward, or in both directions, 
 exposing the two or three ribs — which are then partially excised just as a 
 single rib in the above operation. (2) Where it is wished, from the first, to 
 excise parts of two ribs — make an incision of about 10 cm. (about 4 inches) 
 midway between the two ribs — passing through skin, fascia, and overlying 
 muscles, down to the level of the outer surface of the ribs and intercostal 
 muscles — then retract the upper lip of the wound upward until the upper 
 rib is well exposed — and the lower lip downward until the lower rib is similarly 
 exposed — incising muscle tissue, or separating by blunt dissection, in the 
 approach toward the upper border of the rib below and the lower border of 
 the rib above, maintaining an even thickness of soft covering everywhere. 
 The ribs thus exposed are partially resected as in the single rib operation. 
 (See Figs. 561, B, 560, and 562.) (3) Where it is wished to excise parts of 
 three ribs from the first, make an incision in the long axis of the middle one of 
 the three ribs — join this by a vertical incision at either end of the transverse 
 incision, from the upper border of the rib above to the lower border of the rib 
 below (making an H -shaped incision) — and turn one flap upward and the 
 other downward (as explained in (1) above). Parts of three ribs are then 
 
PARTIAL PLEURECTOMY ESTLANDER'S OPERATION. 765 
 
 excised — the intercostal arteries are ligated at both ends — the nerves are 
 retracted — and an incision made vertically in the center of the area. At 
 the end of the operation, the external wound is clcsed along the lines of 
 incision, except that drainage is provided for through an unsutured part 
 of the wound. (4) Where more than part of a single rib is excised, the 
 soft parts which intervene between the beds of the excised ribs, and includ- 
 ing the beds, are carefully incised in a vertical direction, down to the 
 endothoracic fascia — and the pleura is then incised in the same direction. 
 Prior to this, the intercostal vessels corresponding to each rib are ligated at 
 either end of the original wound, so that when divided in their center no 
 bleeding of any consequence occurs. The nerves are drawn out of their beds 
 and retracted upward and downward, out of the way, if possible. 
 
 Comment. — Parts of three ribs may be excised by a single incision (about 
 15 cm., or 6 inches, long), made over the central rib, followed by good retraction. 
 
 After making a thoracic opening at the chosen site, lower openings, or 
 counter-openings, for better drainage, can be made by cutting down upon 
 a curved sound introduced through the original opening and directed to a 
 lower part of the cavity 
 
 PARTIAL PLEURECTOMY. 
 
 ESTLANDER'S THORACOPLASTIC OPERATION. 
 
 Description — This operation, suggested by Warren Stone, and estab- 
 lished by Estlaender, consists, as now practised, in the subperiosteal excision 
 of parts of several contiguous ribs over a pleural cavity, together with the 
 removal of their periosteum, the intercostal tissues, endothoracic fascia, and 
 the parietal pleura — thereby allowing the corresponding soft thoracic wall to 
 sink in and obliterate the abnormal cavity by the approximation and union 
 of this thoracic wall of integumentary and muscular tissues to the visceral 
 pleura, which has been freshened by curettage. The number of ribs which 
 are partially excised, and the amount of each rib removed, will depend upon 
 the position and extent of the involved area, as determined by the physical 
 signs before operation; or by probing, or by the amount of fluid contained, 
 after opening the cavity — and usually corresponds with that area. From 
 the second to the ninth ribs, inclusive, have been excised — but generally 
 from the second to the seventh, inclusive, are the ones taken. From the 
 costal cartilages to the tubercles, in amount, has been resected — but the 
 average is from about 13 to 15 cm. (about 5 to 6 inches)— the amount being 
 greatest where the cavity is widest, and vice versa. The operation is appli- 
 cable to long-standing cases of empyaema which have resisted drainage, and 
 in which the lung no longer expands and the pleura is much thickened. 
 Originally Estlaender did not remove the costal periosteum and intercostal 
 tissues, nor the parietal pleura. The pleural surfaces were allowed to fall 
 into contact if possible. The pleura was not opened, other than for the 
 drainage which may have been previously resorted to — but the external wall, 
 with its parietal pleura, minus ribs, was merely allowed to come into contact 
 with the visceral pleura. Now both the costal periosteum is excised (to pre- 
 vent regrowth of bone), together with the intercostal muscles and fascia, and 
 the parietal pleura and endothoracic fascia removed, and even the visceral 
 pleura scraped (to destroy pyogenic membrane and to approximate fresh sur- 
 faces for union) — and the outer wall held in contact with the visceral pleura 
 by dressings, as far as possible. 
 
766 
 
 OPERATIONS UPON THE THORAX. 
 
 Preparation. — The thoracic wall is shaved, where necessary. 
 
 Position. — Patient is so placed as to best expose the special site involved, 
 generally resting upon one side — surgeon usually stands in front in operating 
 upon the left side, and behind in operating upon the right side — assistant 
 stands opposite surgeon. 
 
 Landmarks. — Outline of the empya'mic cavity to be obliterated, as 
 determined by physical signs; normal limits of lung and pleura; relation of 
 important adjacent organs. 
 
 Incision. — Supposing that parts of the second to seventh ribs, inclusive, 
 are to be removed, from the right antero-lateral aspect of the chest-wall — say 
 8 cm. (about 3 inches) of second rib — 10 cm. (about 4 inches) of third — 13 
 
 Fig. 563. — Operations upon the Pleural Cavity: — C, Incision for Estlander's thor- 
 acoplasty (removing, in this case, parts of third to eighth ribs, inclusive, through three in- 
 tercostal incisions); A, Schede's thoracoplasty (removing nearly all of the second to ninth 
 ribs, inclusive); D, Position for paracentesis thoracis in the sixth intercostal space, in the mid- 
 axillary line. (Thorax modified from Spalteholz.) 
 
 cm. (about 5 inches) of fourth — 15 cm. (about 6 inches) of fifth — 18 cm. 
 (about 7 inches) of sixth, and 20 cm. (about 8 inches) of seventh — then 
 transverse incisions somewhat longer than the length of the part of the rib to 
 be removed (to allow for sufficient retraction of soft parts to get at the required 
 length of rib) are made in the center of the long axis of each alternate inter- 
 space, as follows — between the second and third ribs, for removal of those 
 ribs — between the fourth and fifth ribs, for the removal of those ribs — between 
 the sixth and seventh ribs, for the removal of those. If an uneven number 
 of ribs were to be removed, three of them could be removed through an 
 
PARTIAL PLEURECTOMY — ESTLANDER'S OPERATION. 767 
 
 incision placed over the central one of the three. The greatest length will 
 be removed from that rib which spans the greatest width of cavity, whether 
 at the middle or either end — and narrower lengths toward the tapering or 
 narrowing aspects of the cavity. An equal length of each rib is sometimes 
 removed. (See Fig. 563, A, where a kite-shaped excision is shown.) 
 
 Operation. — (i) Incise through skin, fascia, and overlving thoracic 
 muscles, until down to the external intercostal muscles (on a level with the 
 ribs). Tie all bleeding vessels. Retract upper lip of wound, in its full 
 thickness, upward, exposing the rib above — cutting, where necessary, muscular 
 fibers close to the level of the external intercostal muscles and external aspect 
 of the rib (so as to keep as thick a flap of soft parts as possible). The lower 
 lip of the wound is similarly retracted, exposing the lower rib. (2) The 
 upper and lower ribs are now excised subperiosteally to the requisite extent. 
 (3) The above steps are repeated for the second and third pairs of ribs. (4) 
 The intercostal vessels are now tied at both ends of each intercostal bed. 
 (5) There are now three long incisions, and two bridge-like strips of external 
 soft parts, composed of skin, fascia, and outer thoracic muscles. These 
 bridgedike parts are carefully preserved. Beneath these lie a deeper con- 
 tinuous layer of soft parts composed of costal periosteum (beds of ribs), 
 external and internal intercostal muscles, endothoracic fascia, and parietal 
 pleura (the last often very much thickened) — all forming the outer wall of 
 the empyaemic cavity. Having retracted upward (/". e., outward), out of the 
 way, the above-described bridge-like strips of soft parts, this deeper layer of 
 soft parts just mentioned is all cut away with scissors — well within the ligated 
 intercostal arteries, on either side — and along the highest and lowest inter- 
 costal space of the involved and freed area. (6) The visceral pleura, espe- 
 cially if much thickened, is advantageously curetted. (7) The three original 
 incisions are now sutured throughout, except a part of the lowest is left open 
 for drainage, where drainage is instituted. The new outer wall of soft thoracic 
 tissues is now allowed to come into contact with the freshened visceral pleura 
 — and is held in contact by dressings as far as possible, to promote union 
 and obliteration of the cavity. 
 
 Comment. — Considerable hemorrhage occurs throughout the operation. 
 which is controlled by clamp, ligature, pressure, and hot solution. 
 
 There is not, as now practised, as distinct a difference between Est- 
 laender's and Schede's operations of Thoracoplasty as formerly — modern 
 operators using the good features of both in each. 
 
 The second rib is left where possible. 
 
 The external soft parts may be raised as one flap (as Schede does) — or 
 as several smaller flaps (as Tacobson advises) — or the necessary amount of 
 ribs over a small cavity may be exposed by a vertical incision over the desig- 
 nated ribs, followed by firm retraction (as Pearce Gould suggests). 
 
 A cavity wider than long requires the excision of more of fewer ribs — 
 a cavity longer than wide requiring the excision of less of more ribs. 
 
 Where the cavity involves the posterior part of the upper ribs (those 
 behind the scapula), their anterior ends may be severed in the usual way — 
 the posterior ends being severed from the interior of the chest with stout, 
 curved cutting-pliers — after freeing the rib of soft parts. 
 
768 OPERATIONS UPON THE THORAX. 
 
 PARTIAL PLEURECTOMY. 
 schede's tiioracoplastic operation. 
 
 Description. — This operation, more extensive than Estlaender's, differs 
 in detail from the latter, while being conducted upon the same general prin- 
 ciple, and in the same general type of cases. A large U-shaped flap is raised, 
 corresponding in extent to the underlying cavity (sometimes to nearly the 
 entire pleural cavity) and consisting of all the soft parts overlying the ribs. 
 The ribs, intercostal tissues, endothoracic fascia, and parietal pleura outlined 
 by this incision are then excised en masse — the visceral pleura scraped — and 
 the external flap allowed to fall into contact with the freshened pleura, being 
 sutured back in place and held in contact with the visceral pleura by the 
 dressings — opening for drainage being left. Generally resorted to in old 
 empyasmic cases of the worst type, especially where the pleura' are very much 
 thickened, and which have resisted all other measures, and represents the 
 most radical operation of its kind available, consisting, practically, of the 
 removal of nearly the entire chest-wall of one side beneath the plane of the 
 thoracic muscles. The number of ribs removed is determined by the vertical 
 extent of the cavity, but is generally from the second to the ninth inclusive. 
 The amount of each rib removed is likewise determined by the width of the 
 cavity, but is often from the costal cartilages to the tubercles of the ribs. 
 
 Preparation — Position. — As for Estlaender's Thoracoplasty (page 765). 
 
 Landmarks. — Where adapted to a localized cavity, the outline of that 
 cavity and the position of important adjacent structures will determine the 
 landmarks. Where the maximum removal of the thoracic wall is indicated, 
 that amount of each rib (from and including the second downward) which 
 is in contact with the pleural cavity — in the average case, from the second to 
 the ninth, inclusive, and from the costal cartilage to the tubercle. This latter 
 extent will be understood in the following operation. 
 
 Incision. — Begins anteriorly at the upper border of the second costo- 
 chondral articulation (about 2.5 cm., or 1 inch, from the sternal border) — 
 passes downward following the curve of the ehondro-costal articulations 
 slightly outward (the cartilages increasing in length as they descend) to the 
 eighth rib in the nipple-line — to the ninth rib in the mid-axillary line on the 
 right side (the tenth on the left) — thence transversely backward to the poste- 
 rior scapular line — thence upward along a line midway between the vertebral 
 border of the scapula and the spinous processes of the vertebrae, to the second 
 rib. (Some surgeons begin the incision at the outer border of the pectoralis 
 major, above the level of the fourth rib — and retract from this point upward 
 to expose the third and second ribs.) (See Fig. 563, A.) 
 
 Operation. — (1) Incise down to and upon the ribs and intercostal muscles 
 throughout the line of incision — bearing lightly over the intercostal spaces 
 to avoid penetrating the thorax. (2) This entire flap of overlying soft parts 
 is dissected en masse from the bony and intercostal muscular wall of the 
 thorax, hugging the ribs and intercostal muscles closely (so that the extensive 
 flap may be as thick and well nourished as possible). The scapula, with the 
 subscapularis muscle, are drawn upward and away from the trunk so as to 
 give access to the upper ribs and to enable the anterior part of the upper 
 ribs, especially where the incision only extends upward anteriorly to the 
 fourth, to be freed. (3) The ribs are now to be divided in front and behind, 
 about 1.5 cm. (about ^ inch) within the line of division of the soft parts (so 
 that the cicatrix will not fall directly over the line of the ends of the divided 
 ribs). This division is best accomplished in the following way, devised by 
 
PARTIAL PLEURECTOMY SCHEDE'S OPERATION. 769 
 
 Hartley, — Where each rib is to be divided, anteriorly and posteriorly, the 
 periosteum is divided over the center of the rib, midway between upper and 
 lower borders, by an incision about 4 cm. (about 1^ inches) long, with the 
 center of the incision at the point where each section of rib is to be made. 
 To this more or less horizontal incision, at the two ends of the ribs, add a 
 vertical incision through the periosteum, beginning at the center of the hori- 
 zontal incision, or at both of its ends, and ending at the lower border of 
 the rib. \Yith a curved periosteal elevator, free the lower half of anterior 
 and posterior ends of the ribs where the sections are to be made, for the 
 extent of about 1.5 cm. (about \ inch) — especially freeing the intercostal 
 groove with the intercostal vessels. Complete this process of freeing at each 
 end of each rib before proceeding to the next step. Now grasp the lower 
 half of each rib, where cleared of periosteum, with rongeur forceps, inserting 
 the lower lip of the rongeur forceps, between bone and periosteum, and 
 bite out a half-button of bone (Oi), which will include the subcostal groove, 
 and the removal of which will well expose the intercostal vessels. Complete 
 this half-button excision at the inner and outer ends of each rib before 
 proceeding further in the operation. (4) The intercostal vessels are all 
 now ligated at both ends of the exposed part of each rib, being easily 
 accomplished by passing a curved needle armed with chromic catgut, 
 beneath them as they lie fully exposed — plainly in view, or very accessible 
 in their beds, or are made accessible by a very little dissection. The 
 arteries and veins should be picked up separately or together — but especial 
 care should be exercised not to include the intercostal nerves. The vessels 
 thus tied are the inferior intercostal vessels. The upper intercostal vessels 
 are generally much smaller and may usually be taken up with clamp 
 forceps and tied as divided in the osseo-periosteo-muscular nap. If con- 
 sidered necessary, the superior intercostal vessels may be exposed in the 
 same manner as the lower ones, by biting out part of the upper border of the 
 rib with rongeur forceps. (5) The ribs may now be freely divided at both 
 ends by passing a Gigli saw between periosteum and bone — the saw-carrier 
 easily passing between the rib and the separated part of the pericsteum which 
 had been freed in excising the half-buttons of bone, and for the balance of 
 the way from the end of the separated area up to the upper border of the 
 bone, hugging the rib closely on its inner aspect and emerging between the 
 upper border of the rib and the position of the superior intercostal vessels. 
 Both ends of all the ribs are thus divided. (6) Nothing now remains but to 
 divide with blunt-pointed scissors the intercostal tissues in the line of the 
 severed ribs on both sides, along the upper border of the second rib above, 
 and along the lower border of the ninth rib below — thus removing the entire 
 lot of ribs, intercostal tissues, endothoracic fascia, and parietal pleura en masse 
 in a single sheet. (7) The thickened visceral pleura covering the remnant 
 of contracted lung is thoroughly scraped and as much adventitious tissue 
 removed as possible. (8) The flap of skin, fascia, and muscles is now allowed 
 to fall into contact with the freshened visceral pleura — its margin being 
 sutured to the margin of the thoracic opening, except a dependent opening 
 left for drainage. The region is so dressed as to keep the flap in contact 
 with the freshened visceral pleura and aid in early union of the surfaces and 
 obliteration of the cavity — the arm being bound to the side. In this step 
 of closing the wound, all divided thoracic muscles along the line of incision 
 are quilted together by means of a buried row of chromic gut sutures, before 
 placing the final tier of sutures. 
 
 Comment. — (1) After the flap of soft parts has been turned back each 
 
 49 
 
770 OPERATIONS UPON THE THORAX. 
 
 rib may be excised subperiosteally and then the intercostal tissues cut away, 
 as in Estlaender's operation — but much more time is consumed. (2) While 
 removing the deeper flap composed of ribs, intercostal muscles, endothoracic 
 fascia, and parietal pleura, a sound or a finger within the cavity should guide 
 the scissors along the contour of the portion being excised. (3) The second 
 rib is left where possible. (4) The scapula is displaced forward during the 
 posterior incision. (5) The upper ribs may be removed from within the 
 cavity, after division at both ends, as explained in Estlander's operation. 
 
 TOTAL PLEURECTOMY. 
 
 fowler's thoracoplastic operation. 
 
 Description. — The operation consists in the removal of the entire pleura 
 of one side. It is indicated in those cases where the lung does not expand but 
 is bound down by firm, dense adhesions — and where Estlander's operation has 
 
 Fig. 564. — Operations upon the Pleura: — A, Incision for Fowler's total pleurectomy; 
 B, Incisions for one of the methods of exposure in Ransohoff 's discission of the pleura. (Tho- 
 rax modified from Bardeleben, Haeckel, and Frohse.) 
 
 failed to accomplish relief. There is less destruction of rib structure than in 
 Schede's operation. The operation is sometimes called decortication of the 
 lung. 
 
 Preparation — Position. — As in Estlander's operation, page 765. 
 
 Landmarks. — A pre-existing sinus, or the recognized site of a pyothorax. 
 
 Incision. — In those cases where a previous sinus exists, this is incised along 
 
OTHER OPERATIONS UPON THE PLEUR.E. 77 1 
 
 the intercostal space corresponding with its position, anteriorly and posteriorly, 
 to the extent of about 20 to 22.5 cm. (8 to 9 inches) . At the posterior extremity 
 of this incision another incision is made vertically downward to the extent of 
 two ribs — and similarly at the anterior extremity of the horizontal incision 
 another incision is made vertically upward to the extent of two ribs (Fig. 
 564, A). Where no sinus exists, the horizontal incision is made in an inter- 
 costal space with its center over the center of the pyothorax. 
 
 Operation. — Two triangular flaps are outlined by the above incisions. 
 The anterior flap (consisting of all the soft parts down to the ribs) is reflected 
 upward and forward. The posterior flap is reflected downward and back- 
 ward. In this way four ribs are exposed. About 20 cm. (8 inches) of each of 
 these ribs is excised. The cavity is then entered — and by blunt dissection and 
 "peeling" the entire pleura is removed — beginning with the parietal and end- 
 ing with the visceral layer. By carefully incising across the visceral pleura 
 that layer may be removed with les>& danger to the lung — which partially 
 expands as it is released. At the end of the operation the flaps of soft part> arc 
 turned into position and sutured. Provision is made for drainage, if indicated 
 — otherwise, not. 
 
 DISCISSION OF PLEURA IN CHRONIC EMPYEMA. 
 ransohoff's operation. 
 
 Description. — Having exposed the contracted and bound-down lung, the 
 thickened overlying visceral pleura is "gridironed with many parallel incisions 
 removed from each other about 6 mm. (j inch), and by others crossing these 
 obliquely or at right angles. Little islands of thickened pleura are thus left 
 on the surface of the expanding lung. But if the cuts have been made deep 
 enough they shrivel in size, while the discission is still in process of being com- 
 pleted." This technic is a modification of the operation of decortication. 
 
 Preparation; — Position; — Landmarks. — As in the preceding operations 
 upon the pleura. 
 
 Incision. — An incision is made over the sinus, or cavity, with the partial 
 excision of one or two ribs. Through this opening the extent of the involve- 
 ment is determined. 
 
 Operation. — As determined by the nature of the process and its extent, 
 multiple subperiosteal rib excisions are made — either through several parallel 
 incisions — (Fig. 564, B); through a Schede incision (Fig. 563, A); or through 
 a trap-door incision (Fig. 565). Having gotten ample exposure, decortica- 
 tion should be first tried, which is to be preferred if easily and satisfactorily 
 accomplishable. If this is not readily accomplished, gridironing incisions, as 
 described above, are made over the visceral pleura. If the lung does not 
 satisfactorily expand following these incisions, an incision is carefully carried 
 along the groove of reflexion of visceral and parietal pleura — the danger being 
 less if this liberating incision is carried toward the chest-wall. Drainage is 
 instituted where indicated — and the wound otherwise closed. Often several 
 consecutive operations are necessary. 
 
 OTHER OPERATIONS UPON THE PLEURA. 
 
 See Operations upon the Lungs (pages 772 to 780) — and Operations 
 upon the Liver (pages 1004 to 1021). 
 
772 OPERATIONS UPON THE THORAX. 
 
 IX. THE LUNGS. 
 SURGICAL ANATOMY. 
 
 Relations. — Apex; extends from 1.2 to 4.5 cm., averaging 2.5 (from \ to 
 if inches, averaging 1), above level of first rib into the neck (but not extending 
 higher than the neck of the first rib) — lying beneath subclavian artery, and 
 behind interval between two heads of sternomastoid and inner end of clavicle 
 — and covered by subclavian artery and scalenus anticus. Right apex may 
 project slightly higher than left. Base; rests- upon convexity of diaphragm. 
 External surface; chiefly corresponds to cavity of thoracic wall. Internal 
 surface ; in contact with pericardium and lateral pleural wall of mediastina. 
 Anterior border; overlaps anterior surface of pericardium on right, and 
 partially so on left. Posterior border; fits into concavity on either side of 
 vertebral column. Inferior border; fits into space between inferior ribs 
 and costal attachment of diaphragm. 
 
 Relations of Margins of Lungs to Chest-wall. — Anterior margins; 
 extend from their apices (at an average point of 2.5 cm., or 1 inch, above 
 the first rib, and nearer posterior than anterior border of sternomastoid) 
 downward and inward across sternoclavicular articulation and manubrium 
 sterni to near center of articulation of manubrium and gladiolus, where the 
 two margins meet, or verv nearlv meet — thence both borders descend parallel 
 to each other and just bevond the middle line (the right sometimes slightly 
 overlapping it) to midway between the level of the articulations of the fourth 
 costal cartilages with the sternum — from which point they diverge unequally. 
 Right margin continues to descend almost vertically downward to sixth 
 chondro-sternal articulation (sometimes to lower end of gladiolus), whence 
 it curves downward and outward along that cartilage to sixth costo-chondral 
 articulation. Left margin, from point of divergence, passes along lower 
 border of fourth rib outward with a downward inclination, and then down- 
 ward across fourth interspace and fifth rib with an outward inclination to 
 apex of heart (a point 3.8 cm., or 1^ inches, below, and 2.5 cm., or 1 inch, to 
 inner side of left male nipple in fifth interspace) — thence to sixth costo- 
 chondral articulation. Lower margins; marked by a slightly curved line. 
 with downward convexity, extending from sixth costo-chondral articulation 
 to spinous process of tenth dorsal vertebra — crossing (while arms are elevated 
 at right angle) the nipple-line at sixth rib — mid-axillary line (arms still raised) 
 at eighth rib — scapular line (arms now lowered) at tenth rib. Lower margin 
 of left lung starts on level with sixth costo-chondral joint, but much further 
 out than right — about 7.5 cm. (3 inches) to left of median line in fifth inter- 
 space. Sometimes lower margin of left lung may be one rib lower than right. 
 Posterior margins ; marked by line from level of spinous process of seventh 
 cervical vertebra, passing vertically downward on either side of spine, over 
 the costo-vertebral articulations, to spinous process of tenth dorsal vertebra. 
 
 Excursion of Lower Borders of Lungs in Forced Respiration. — 
 Extend about 3.8 cm. (ij inches) below the line given above for the rela- 
 tion of the lower margin, in deep inspiration — and rise above it in forced 
 expiration. 
 
 Relations of Fissures of Lungs to Chest-wall. — (1) Great or Lower 
 Fissure of Right Lung: — draw line from fourth dorsal vertebra forward and 
 downward around chest to intersection of anterior margin of lung and seventh 
 rib. (2) Lesser or Upper Fissure of Right Lung: — draw line from point of 
 intersection of preceding line with mid-axillary line, to fourth chondro- 
 
GENERAL SURGICAL CONSIDERATIONS. 773 
 
 sternal articulation. (3) Fissure of Left Lung: — draw line from third dorsal 
 vertebra forward and downward around chest to intersection of anterior 
 margin of lung with sixth costal cartilage. 
 
 Structures of Roots of Lungs, and their Relations. — Structures 
 of each root ; bronchial tube, pulmonary artery, pulmonary veins, bronchial 
 artery (generally one on right and two on left), two bronchial veins, anterior 
 pulmonary plexus of nerves, posterior pulmonary plexus of nerves, bronchial 
 lymphatic glands, areolar tissue — all being enclosed within pleura. Rela- 
 tions of right root : Anteriorly; right auricle, superior vena cava, ascending 
 aorta, phrenic nerve, anterior pulmonary plexus. Superiorly; vena azygos 
 major arching to join superior vena cava. Posteriorly; pneumogastric 
 nerve, posterior pulmonary plexus. Inferiorly; ligamentum latum pulmonis. 
 Relations of left root: Anteriorly; phrenic nerve, anterior pulmonary 
 plexus. Superiorly; arch of aorta. Posteriorly; descending aorta, pneumo- 
 gastric nerve, posterior pulmonary plexus. Inferiorly; ligamentum latum 
 pulmonis. Order of structures of right root: From Before Backward; 
 pulmonary veins, pulmonary artery, bronchus, and bronchial vessels. From 
 Above Downward; bronchus, pulmonary artery, pulmonary veins. Order 
 of structures of left root: From Before Backward; pulmonary veins, 
 pulmonary artery, bronchus, and bronchial vessels. From Above Downward ; 
 pulmonary artery, bronchus, pulmonary veins. 
 
 Position of Hilum of Lung. — Upon inner aspect, slightly above middle, 
 and much nearer posterior than anterior border — on level with bodies of 
 fifth, sixth, seventh, and sometimes eighth dorsal vertebra?. 
 
 Bifurcation of Trachea and Bronchi. — Trachea bifurcates opposite 
 the spinous process of fourth dorsal vertebra — right bronchus passing nearlv 
 horizontally outward and dividing into three chief bronchial tubes — left 
 bronchus passing more directly downward and dividing into two chief bron- 
 chial tubes. 
 
 Arteries. — Pulmonary; bronchial. 
 
 Veins. — Pulmonary; bronchial. 
 
 Nerves. — From anterior and posterior pulmonary plexus, formed mainly 
 by sympathetic and pneumogastric. 
 
 Lymphatics. — End in bronchial glands. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Collapse of the lung is one of the chief and most serious of the possible 
 dangers in intra-pleural surgery. This possibility should be guarded against 
 in all intra-thoracic operations in one of the following ways; — by the accurate 
 suturing of parietal and visceral layers of the pleura together prior to incising 
 the membrane, — the maintenance of artificial respiration by some such device 
 as Matas' modification of the Fell-O'Dwyer instrument,— performance of the 
 operation under negative atmospheric pressure (Sauerbruch's box),— or the 
 carrying out of the operation under increased atmospheric pressure (Bauer's 
 apparatus). 
 
 The lung tissue is best divided by the thermocautery at red heat, especially 
 vascular and comparatively normal portions. The tip of the finger may also 
 be used. Indurated areas are best divided with a knife. 
 
774 
 
 OPERATIONS UPON THE THORAX. 
 
 PNEUMOTOMY 
 
 THROUGH A CUTANEOMUSCULAR THORACOPLASTY FLAP. 
 
 Description. — Incision of lung tissue through a temporary opening mad e 
 in the chest-wall. This opening may be made in the form of an intercostal 
 
 thoracotomy, — through the partial re- 
 section of one or more ribs, — or through 
 an osteothoracoplastic flap. In the 
 present instance, a partial resection 
 of three ribs will be made, after raising 
 a thoracoplasty flap. Generally re- 
 sorted to in cases of abscess, gangrene, 
 hydatid cyst, and sometimes for bron- 
 chial dilatation and tuberculous cavi- 
 ties. The flap consists of soft parts 
 only. 
 
 Preparation. — Chest-wall is shaved 
 where hairy growth exists. 
 
 Position. — Patient so placed as to 
 render site of operation accessible 
 during exposure of lung — but placed 
 so as to render site dependent before 
 cutting into lung tissue (that fluid may 
 not flow into bronchial tubes opened 
 by incision, in addition to that which 
 may be drawn into them). Surgeon 
 on side of operation — assistant on same 
 side, or opposite. 
 
 Landmarks. — Determined by phy- 
 sical signs locating disease, and gener- 
 ally verified by preliminary explora- 
 tion; known position of important 
 structures. 
 
 Incision. — A U-shaped flap is out- 
 lined, with base upward and convexity 
 downward, or vice versa — usually ex- 
 tending over two or three ribs, and 
 of sufficient size to well include the 
 incision into the lung with room for 
 manipulation (Fig. 565, A and C). 
 (Vitality of flap would be better assured 
 if base were forward or backward and 
 Fig. 565.— Incisions for Pneumotomy convexity in opposite direction. (Fig. 
 or Pneumectomy, by means of Cutaneo- $6"] , A and C.) 
 
 Operation. — (1) This U-shaped 
 flap of all the soft parts down to the 
 ribs and intercostal muscles is raised. 
 (2) Having controlled hemorrhage, the 
 necessary parts of the indicated ribs are 
 excised subperiosteally — calculating 
 that the line of division of the ribs will fall about 1 cm. (nearly \ inch) within 
 the line of flap-incision (that cicatrix of latter may not fall over ends of ribs). 
 (3) An exploratory needle may now be introduced through the periosteal 
 
 MUSCULAR OR CUTANEO-MUSCULO-OSSEOUS 
 
 Flaps: — A, Trap-door flap involving two ribs, 
 hinging upward; C, One involving three ribs, 
 hinging downward. The continuous line re- 
 presents the skin incision — the broken lines, 
 the rib sections. (Figure redrawn from 
 Deaver.) 
 
PXKUMOTOMV. 
 
 775 
 
 bed of a rib, thus avoiding the intercostal vessels— and the needle may be 
 left in situ as a guide. (4) An incision is now carefulh made in the long 
 axis of a space, or, preferably, in the bed of a rib, avoiding intercostal vessels, 
 —if in a space, passing through intercostal muscles and endothoracic fascia. 
 In the transverse incisions sufficient room can usually be gotten by upward 
 and downward retraction of the soft parts, without requiring the division of 
 the vessels. If it be elected to make a vertical opening, after removing the 
 ribs, then the intercostal vessels are ligated at both ends of the exposed beds 
 of the excised ribs— so that when the vertical incision is made in the center 
 of the exposed area, little or no hemorrhage will occur. This vertical incision 
 is in the center of the area from which the ribs have been partially excised, 
 
 Fig. 566. — Exposure of Pleura and Lung by means of a Cutaxeo-muscular Flap: — 
 A flap of skin, fascia, and muscles has been turned back. The sites of excised portions of 
 ribs are shown. The parietal and visceral pleura? are stitched together by a continuous suture 
 ellipticallv around the position of the future incision into the lung. An incision has been 
 carried into the lung substance. 
 
 and extends between the intact ribs above and below. In any event, the 
 incision should be made, if possible, down to, but not directly through, the 
 parietal pleura, at this stage. (5) Here one of two conditions will be found: — 
 (A) The parietal and visceral pleurae may be adherent — the general pleural 
 cavity will then be walled off, and the incision may be made directly into the 
 lung tissue — having determined its depth by exploratory puncture. (B) 
 Parietal and visceral pleura? may be non-adherent; (a) If it be necessary 
 to proceed with the operation at once, suture the two surfaces of the pleurae 
 together with catgut, in a sufficiently large circle — thus closing off the general 
 pleural cavity by suture and by packing the outer circumference of the circle 
 with gauze (Fig. 566) . The incision may be then made at once into the lung 
 through the above circle, (b) If no need of haste exist, pack the wound with 
 
776 OPERATIONS UPON THE THORAX. 
 
 gauze a little firmly, so that the pleural surfaces are held in contact — and in two 
 or three days the surfaces will be united for some distance around, and incision 
 into lung tissue may be made through the united surfaces, without fear of 
 invading the general pleural cavity. This adhesion is made more certain 
 and firmer by also suturing the pleura? in a circular manner at the time of 
 the exposure. (6) Incision into the lung is usually made in the direction of 
 the original incision by which it has been approached — the incision extending 
 through the full thickness of the variously thick layer of lung tissue overlying 
 the cavity. (7) Drainage is provided for — the drain coming out through 
 an unsutured lower part of the flap, the remainder of the flap being sutured 
 back into place — or the drain may come out through a convenient opening 
 in the flap, the circumference of the flap being sutured throughout. 
 
 Comment. — (i) Usually the removal of parts of one or two ribs suffices 
 to expose the site. (2) The distance of the cavity from the surface should 
 be determined by needle before incising. (3) The following methods of 
 incising the lung tissue are used; — actual cautery — best for soft lung tissue; 
 incision by knife — safe in hardened lung tissue; exploratory needle and small 
 grooved director introduced simultaneously — the needle is withdrawn and 
 director left in situ — upon which dilators of increasing size are slipped into 
 cavity, which is then dilated; blunt dissection; trocar and cannula. (4) If 
 hemorrhage occurs from lung tissue, pack with gauze. (5) Collapse of lung 
 is very apt to follow going through the opened pleural cavity (where the two 
 surfaces are not united by adhesion) — requiring the use of a Fell-O'Dwyer 
 instrument. (6) Pneumotomy may be performed by means of an osteo- 
 thoracoplastic flap, as described under Pneumectomy — or by any method 
 which satisfactorily exposes the lung. 
 
 PARTIAL PNEUMECTOMY 
 
 THROUGH CUTANEOMUSCULO-OSSEOUS THORACOPLASTIC FLAP. 
 
 Description. — The excision of part of a lung involved in some lesion — 
 an uncommon though possible operation. Access may be obtained by the 
 permanent excision of parts of several ribs, after raising a thoracoplasty flap, 
 as described under Pneumotomy — or, better still, by the turning back tem- 
 porarily of a window consisting of the entire thickness of the soft and bony 
 parts of the chest- wall (thoracoplasty). The operation has generally been 
 resorted to for the removal of malignant and hydatid tumors of the lungs — and 
 also for localized tuberculosis. In the latter cases the part excised has usually 
 been the apex. The trap-door flap may hinge in any direction. 
 
 Preparation — Position — Landmarks. — As in Pneumotomy. 
 
 Incision. — (1) Supposing the tumor to be of the middle lobe of the right 
 lung — an incision is to be planned outlining an upper, a lower, and an anterior 
 side of a square or rectangle, the fourth or posterior side forming the hinge 
 —the square including the antero-lateral aspect of the fourth, fifth, and sixth 
 ribs. The upper line will lie in the middle of the third interspace, in its 
 long axis — the lower line will be similarly placed in the center of the sixth 
 interspace — the anterior line will run vertically about 2.5 cm. (1 inch) outside 
 of the costal cartilages — and the posterior side will be parallel with the anterior 
 and from 10 to 13 cm. (about 4 to 5 inches) behind it. (2) Supposing the 
 case to be one of localized tuberculosis of the apex of the left lung — a U- 
 shaped flap is planned, with its convexity over the middle of the sternum; its 
 
PARTIAL PXEU.MECTOMY. 
 
 777 
 
 base reaching nearly to the anterior axillary line; its upper horizontal limb 
 in the middle of the first intercostal space; its lower horizontal limb in the 
 middle of the third intercostal space. The general forms of" flap are shown in 
 Fig. 567, A and C. 
 
 Operation. — Carrying out the steps of the operation indicated in the first 
 incision given above — (1) Incise through 
 skin, fascia, and overlying thoracic 
 muscles, down to the ribs and intercos- 
 tal muscles, along the upper, lower, and 
 curved sides only (Fig. 567, C). (2) 
 Along the anterior line, where the ribs 
 are intersected by the vertical portion of 
 the incision, retract the soft parts a lim- 
 ited distance on each side over the ribs 
 — and make a short incision directly 1 wer 
 the center of their long axes, passing 
 through the periosteum (not through the 
 skin) — free the circumference of the ribs 
 here subperiosteally with a curved peri- 
 osteal elevator over the least width of 
 rib possible to accomplish its freeing. 
 Do not yet divide the rib (Fig. 569). 
 (3) A short incision is now made 
 directly over the center of the long axis 
 of the ribs posteriorly, through all the 
 overlying soft parts down to and through 
 the periosteum — the center of each in- 
 cision being an imaginary line connect- 
 ing the posterior ends of the upper and 
 lower lines (just as the center of the 
 transperiosteal incisions anteriorly was 
 the real line connecting the anterior ends 
 of the horizontal lines of incision). 
 The ribs are here freed subperiosteally 
 as in front — their circumference being 
 bared over the smallest space practic- 
 able (Fig. 569, D, D). (4) A Gigli saw 
 is now carried beneath the freed por- 
 tions of the ribs in front and behind — 
 thus entirely freeing the bony connec- 
 tions of the flap. (5) The upper, lower, 
 and anterior sides of the square, or 
 rectangle, are now carefully incised 
 through their soft structures not already muscular 
 divided, down to the endothoracic fascia, 
 carefully avoiding penetration of the 
 parietal pleura. (6) This large cutaneo- 
 musculo-osseous flap is now carefully 
 elevated and turned backward upon its 
 posterior hinge (which hinge, as far as the soft parts and the integrity of their 
 blood-supply go, has been very little injured by the longitudinal cuts 
 over the ribs) — carefully separating it from the parietal pleura as it is turned 
 backward. (7) If it be found that the two surfaces of pleura? are not ad- 
 
 Fig. 567. — Incisions for Pxeumotomy 
 or Pneumectomy, by means of Cutaneo- 
 or cutaneomusculo-osseous 
 Flaps: — A, Trap-door flap involving three 
 ribs, hinging forward; C, One involving three 
 ribs, hinging backward. The continuous line 
 represents the skin incision — the broken lines, 
 the rib sections. If base of flap A be poste- 
 rior, the blood supply is better. 
 
778 OPERATIONS UPON THE THORAX. 
 
 herent, the wound is rather snugly packed with gauze — the flap turned as 
 far back into place as the gauze will allow — and adhesion is awaited for three 
 or four days. Or the vitality of the flap and the firmness of adhesion would 
 probably be more safely and thoroughly secured if the parietal and visceral 
 pleura? were sutured around the extreme margin of the wound with catgut 
 — allowing the flap to fall fully into place, where it could either rest, or be 
 sutured, the necessary time for adhesions to form — and subsequently raised 
 for the excision of the growth. Or the pleura may be incised and the opera- 
 tion completed immediately, after the suturing together of the pleural sur- 
 faces. (8) At the time of the removal of the tumor, the method of the removal 
 will be somewhat determined by the character of the tumor. Whether fluid 
 (e.g., hydatid cyst) or solid (e.g., primary malignant tumor), if its accessi- 
 bility will allow, it is best to ligate off the surrounding lung tissue by carrying 
 
 Fig. 568. — Exposure of Pleura and Lung by means of a Cutaneomusculo-osseous 
 Flap: — A flap of skin, fascia, muscles, and temporarily excised ribs is turned back. The 
 parietal pleura has been incised and turned back separately upon the composite flap. The 
 lung, with an interlobular sulcus, is seen in the field. 
 
 chromic gut in a large, fully-curved needle around the growth in segments — 
 and then excise by actual cautery, knife, or blunt dissection, where possible. 
 (See Pneumotomy, page 774.) Sometimes previous ligation is impossible — 
 the tumor is then removed without it. and hemorrhage controlled by packing 
 the cavity with gauze. It sometimes happens in hydatid cysts that the tumors 
 have to be incised, their contents evacuated and their walls curetted, the 
 remainder being allowed to slough out — although complete removal of their 
 walls is much preferable. (9) The cavity left by the removal of a tumor 
 should be temporarily packed with gauze — which is brought out for drainage 
 through a convenient opening made at a margin of the flap — the flap being 
 elsewhere sutured back into its normal position. As the ribs are adherent 
 to the soft part of the flap, which will be sutured to the thorax around its 
 margin, the ribs will thereby be held in place and prevented from being 
 materially displaced. If, when the section of the ribs is made, it be done in 
 
PARTIAL PXEUMECTOMY. 
 
 779 
 
 a beveling fashion (at the expense of the inner aspect of the parts of the ribs 
 in the flap), when the flap is turned back into place this beveling will addi- 
 tionally steady the rib ends in place. If desired, the contiguous ends of the 
 severed ribs, in front and behind, can be united by chromic gut or silver wire, 
 after having been previously drilled. 
 
 Comment. — (i) In carrying out the steps of the operation indicated in 
 the second incision given above, the description given under Pneumotomy 
 by a Thoracoplasty Flap will sufficiently cover, being practically similar. 
 The indurated apex of the lung, when exposed, is seized with forceps — de- 
 
 D 
 
 Fig. 569. — Manner of Raising a Cctaneomusculo-osseous Thoracoplastic "Trap- 
 door" Flap: — A, A, A, Line of incision of soft parts outlining flap; K, K, Retracting convex 
 portion of flap, snowing position of rib-sections at distal end of flap; C, C, Lines of incisions 
 through all overlying soft parts, including periosteum, down to ribs at base of flap; D, D, Details 
 of wounds made through incisions C, C, showing site of section of rib; E, E, Position of rib- 
 sections at base of flap. 
 
 taching it, if necessary, from its adhesions — and withdrawn through the 
 thoracic opening — a chromic gut ligature is then carried below the involved 
 portion — or a double ligature is passed through upon a needle and each side 
 tied separately — the apex is now excised — the lung replaced, after bringing 
 together the raw surfaces of the lung by gut suture, if possible — and the edges 
 of the parietal pleura? sutured with catgut. The operation is completed as in 
 Pneumotomy by Thoracoplastic Flap. (2) Turner has removed portions of 
 tubercular lung through a simple intercostal thoracotomy in the second 
 interspace — opening the pleura and delivering and excising the involved 
 
780 OPERATIONS UPON THE THORAX. 
 
 portion of lung. (3) Where the ligature is not used, the actual cautery is 
 the safest means with which to excise lung tissue. (4) The operation is 
 simplified if the neighboring healthy lung is adherent to the parietal pleura. 
 Collapse is also much less likely. (5) The lower two-thirds of the first rib 
 are sometimes alone excised. 
 
 X. THE PERICARDIUM. 
 SURGICAL ANATOMY. 
 
 Position. — Occupies middle mediastinum of thorax, lying Detween 
 anterior mediastinum, in front (opposite sternum and third, fourth, fifth, 
 sixth, and seventh costal cartilages) — posterior mediastinum, behind — and 
 pleura?, laterally. Consists of visceral and parietal layers. Has general 
 outline of heart, except where reflected on to great vessels at base of heart. 
 
 Attachments. — Apex; covers great vessels for about 5 cm. (2 inches) 
 and is held in position by them. Base; attached to central tendon of dia- 
 phragm and adjacent surface. Anterior surface of pericardium; attached 
 to posterior surface of manubrium and ensiform process by superior and 
 inferior sterno-pericardial ligaments. 
 
 Relations. — Superiorly ; great vessels of heart. Inferiorly ; diaphragm. 
 Anteriorly; thymus gland (or remains); areolar tissue; margins of lungs 
 (especially left); sterno-pericardial ligaments; triangularis sterni muscle; 
 internal mammary vessels; anterior mediastinum; sternum. Posteriorly; 
 bronchi; esophagus; descending aorta; pneumogastric nerves; posterior medi- 
 astinum. Laterally; pleurae; anterior margins of lungs (especially left); 
 phrenic nerves; accompanying phrenic vessels. 
 
 Structures Covered by Pericardium. — Aorta; superior vena cava; pul- 
 monary artery and bifurcations; ductus arteriosus; four pulmonary veins. 
 
 Arteries. — Pericardiac and musculophrenic from internal mammary; 
 pericardiac, esophageal, and bronchial from descending aorta; coronary from 
 ascending aorta; phrenic from abdominal aorta. 
 
 Veins. — Pass to azygos, internal mammary and phrenic trunks, cardiac 
 veins emptying into right auricle. 
 
 Nerves. — Branches from pneumogastric, phrenic, and sympathetic. 
 
 Lymphatics. — Empty into mediastinal glands. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The anterior surface of the upper portion of the pericardium is from 3 
 to 5 cm. (about i\ to 2 inches) posterior to the sternum — and the anterior 
 surface of the lower portion is about 1 cm. (about f inch) posterior to the 
 sternum. 
 
 Normally there is a collapsed cul-de-sac at the base of the anterior portion 
 of the pericardium, which is much distended in effusion. This is the site 
 sought in drainage. 
 
 According to Yoinitch-Sianojentsky, the interpleural pericardial area 
 extends vertically from the lower border of the left fifth chondro-sternal 
 articulation to the left seventh chondro-sternal articulation — lying mainly 
 behind the sternum but also corresponding to the sternal end of the sixth 
 intercostal space — wherefore, puncture of the pericardium in the sixth space 
 
PERICARDIOCENTESIS. 781 
 
 may be made directly inward — whereas it should be directed very obliquely 
 downward if made in the fifth interspace, to avoid the heart (that is, it runs 
 parallel with the heart after entering the pericardium). 
 
 A cartilaginous bridge unites the sixth and seventh costal cartilages — 
 and sometimes also the fifth and sixth — and thereby the intercostal area for 
 puncture, between the inner border of the cartilaginous bridge and the left 
 border of the sternum, may be considerably encroached upon. 
 
 The internal mammary artery runs down at an average distance of about 
 1.2 cm. (about \ inch) to the outer side of the sternal border— to the sixth 
 interspace, where it divides into the superior epigastric and the musculo- 
 phrenic. 
 
 For outline of Pleura, see Anatomy of Pleura. 
 
 PERICARDIOCENTESIS. 
 
 Description. — -Pericardiocentesis, or paracentesis pericardii, consists in 
 the penetration of the pericardium by a hollow needle attached to a vacuum 
 syringe for the purpose of withdrawing pericardial contents. It is chiefly used 
 for diagnosis — sometimes for the withdrawal, in bulk, of the fluid in hemo- 
 pericardium and hydropericardium. In pyopericardium pericardiotomy 
 should be performed, rather than pericardiocentesis. 
 
 Preparation. — Region shaved, if necessary. 
 
 Position. — Patient supine, preferably resting upon some object which 
 will render chest prominent and increase the width of the intercostal spaces. 
 Surgeon on left of patient. 
 
 Sites of Puncture. — Puncture may be made in either the fifth or sixth 
 interspace — and either internal to or external to the internal mammary artery 
 (Fig. 570) . In the fifth interspace, the width is greater near the sternal border, 
 and is the space usually chosen. In the sixth interspace, the internal mammary 
 artery and the pleura are both further from the left sternal border, and puncture 
 may be made more directly inward. Where sufficient width of space exists, 
 the sixth interspace should be chosen. Puncture should, by preference, be 
 made internal to the internal mammary artery, as the pleura is in less danger 
 of injury, especially in the fifth space---and even in the sixth space, the punc- 
 ture would have to be about 2.5 cm. (about 1 inch) outside of the border of 
 the sternum to be sure of being external to the internal mammary artery, and 
 then it is apt to strike the pleura. (See Fig. 570.) 
 
 Landmarks. — Fifth left intercostal space (or sixth) ; left margin of sternum; 
 course of internal mammary artery; anterior border of left lung and pleura; 
 right border of heart. See the Surgical Anatomy of these structures. 
 
 Operation.— (1) An incision should be made in the long axis of the sternal 
 end of the fifth intercostal space, through skin, fascia, pectoralis major, down 
 to the intercostal membrane, clamping all bleeding vessels. (2) Expose the in- 
 tercostal membrane by retraction of the edges of the wound. Grasping the 
 needle with right forefinger and thumb, so placed as to prevent its suddenly 
 entering too far, pierce the fifth intercostal space near the left border of the 
 sternum, and near the upper border of the sixth costal cartilage — penetrate 
 straight backward about 0.8 cm. (about j\ inch), which is, approximately, the 
 thickness of the sternum — then penetrate inward toward the posterior surface 
 of the sternum for 1 to 2 cm. (f to if inch), to avoid the possible forward 
 extension of the pleura — thence penetrate downward and inward through the 
 pericardium — the sensation generally indicating when the pericardium is 
 
782 
 
 OPERATIONS UPON THE THORAX. 
 
 entered. Briefly stated — pass backward, inward, and downward (Delorme 
 and Mignon). Where the sixth intercostal space is used, the needle is passed 
 directly inward and backward, close to the sternum and in the middle of the 
 interspace (Voinitch-Sianojentsky) . 
 
 Comment. — Puncture may be made without previous incision, but pre- 
 liminary incision is better, as the intercostal space and border of the sternum 
 are exposed, and the course and depth of the needle and entrance into the 
 pericardium are better appreciated. Also the bridge of cartilage across the 
 intercostal space, when present, may be avoided. There is less danger of 
 wounding the heart in the sixth interspace. 
 
 Fig. 570. — Sites for Pericardiocentesis: — The uncovered area of the heart and the 
 course of the internal mammary artery are shown. Paracentesis is preferably made to the inner 
 side of the internal mammary artery, in the sixth (by choice) or fifth intercostal space, close to 
 the margin of the sternum, — or to the outer side of the artery, in the fifth or iourth interspace, 
 from 2.5 to 5 cm. (1 to 2 inches) outside of the sternal border. (Thorax modified from Deaver.) 
 
 PERICARDIOTOMY 
 
 THROUGH AN INTERCOSTAL INCISION. 
 
 Description. — Incision of the pericardium through the fifth intercostal 
 space — generally resorted to for purposes of drainage. The method here 
 described will be the simpler one of exposing and incising the pericardium 
 through an intercostal incision. The more extensive exposures involve the 
 
PERICARDIOTOMY. 
 
 783 
 
 removal of part of the cartilaginous or bony wall of the thorax. The inter- 
 space where the operation of intercostal pericardiotomy is usually done is 
 so narrow that the operation by excision of the fifth costal cartilage is much 
 preferable. 
 
 Preparation and Position. — As for Paracentesis Pericardii. 
 
 Landmarks. — Sternal end of left fifth intercostal space (between fifth 
 and sixth rib-cartilages) ; and other landmarks mentioned under Paracentesis 
 Pericardii. 
 
 Incision. — Incision in center of fifth intercostal space, parallel with its 
 long axis — beginning at the left sternal border and extending 5 to 7.5 cm. 
 (about 2 or 3 inches) in length. (See Fig. 571, A.) 
 
 Fi,c 571. — Sites of. Incisions for Pericardiotomy: — A, Intercostal incision in fifth 
 left interspace; B, Incision for excision of fifth left costal cartilage: C, C, Kocher"s sternocostal 
 incision for excision of sixth and sometimes of fifth and fourth costal cartilages. (Thorax modified 
 from Gray.) 
 
 Operation. — (1) Incise skin, fascia, pectoralis major, external intercostal 
 membrane, internal intercostal muscles — ligating all bleeding vessels. (2) 
 Internal mammary artery is either divided between two ligatures, or, prefer- 
 ablv, drawn outward. (3) Triangularis sterni muscle is divided, or its fibers 
 separated by blunt dissection. If the pleura be in the field, it will lie exposed 
 after passing through the triangularis sterni, and should be carefully dis- 
 placed outward. (4) The pericardium is now within sight and touch — and 
 is carefully seized and steadied by two toothed forceps and incised for 1 to 
 2.5 cm. (about ^ to 1 inch) between them, in a direction downward and out- 
 ward from the border of the sternum. (5) The edges of the pericardium 
 are sutured into the deeper plane of the thoracic wound — that is, at the opening 
 through the internal intercostal muscle. Drainage is established from the 
 interior of the pericardium through the lowest part of the outer wound, the 
 upper portion of which may be closed. 
 
 Comment. — (a) The pericardium should be opened with scissors, and 
 the opening increased by blunt-pointed scissors or probe-pointed knife, 
 (b) Pericardiotomy may also be performed, but less safely, through the 
 costo-xiphoid angle (Larrey's space). 
 
784 OPERATIONS UPON THE THORAX. 
 
 EXPOSURE OF PERICARDIUM AND HEART 
 
 FA' EXCISION OF LEFT FIFTH COSTAL CARTILAGE. 
 
 Description. — Exposure of pericardium and heart after excision of the 
 left fifth costal cartilage — and, where more room is required, also of the 
 fourth and sixth costal cartilages. Generally resorted to for suturing wounds 
 of the heart and pericardium and for drainage of the latter — especially in 
 those cases where more space is required than attainable by the intercostal 
 operation. 
 
 Preparation — Position. — As for Paracentesis Pericardii. 
 
 Landmarks. — Left fifth costal cartilage; and other landmarks men- 
 tioned under Paracentesis Pericardii. 
 
 Incision. — Directlv over center of fifth costal cartilage — beginning over 
 center of sternum and ending just beyond chondrocostal articulations. (See 
 Fig. 571, B.) 
 
 Operation. — (1) Incise skin, superficial fascia, pectoralis major, and 
 deep fascia directly down upon the full length of the fifth costal cartilage, 
 ligating all vessels severed. (2) Isolate the fifth costal cartilage from its 
 neighboring structures (external intercostal membrane, internal intercostal 
 muscle, and triangularis sterni, if any of the last be attached) as completely 
 
 I- if;. 5 72— Exposlrk of Pkricardhm and Hkart by Partial Excision of Left Fifth 
 Costal Cartilage :— A, Pectoralis major muscle retracted, overlying the retracted intercostal 
 muscles and membrane; B, Internal mammary vessels; C, Intercostal vessels; D, Sternum and 
 part of fifth costal cartilage; E. Pleura and lung retracted; F, Pericardium, incised and margins 
 retracted ; G, Heart, showing incised wound being sutured. 
 
 as possible, by hugging and clearing the cartilage closely. Divide its sternal 
 and costal ends with blunt-pointed pliers — or, preferably, with Gigli saw. 
 (3) Ligate the intercostal vessels at both ends of the wound and divide them 
 between the ligatures. Divide tissues which intervene between bed of carti- 
 lage and internal mammary artery. Cut the internal mammary artery be- 
 tween two ligatures, or draw it outward. Incise the triangularis sterni if 
 necessary, or separate it from the sternum and push it to the right. Displace 
 the pleura outward, after careful separation from the pericardium and sternal 
 structures. (4) The pericardium is now in the field, and is treated as indi- 
 cated by the object of the operation; — In Pericardiotomy (for drainage) the 
 
SURGICAL ANATOMY OF THE HEART. 785 
 
 pericardium is steadied between two toothed forceps and carefully incised 
 obliquely downward and outward from close to the border of the sternum; — 
 In Pericardiorrhaphy (for incised wounds of the pericardium) the lips of the 
 pericardial wound are approximated and so sutured with catgut as to bring 
 the serous surfaces together. (5) Where the pericardium has been incised 
 for drainage, it is sutured into the lower plane of the outer wound — that is, 
 the triangularis sterni and internal intercostal muscles. The external wound 
 is closed in greater part, and drainage provided from the interior of the peri- 
 cardium through the part of the thoracic wound left open. Where the peri- 
 cardium has been sutured, temporary drainage of the external wound only 
 is instituted, through a limited opening — the remainder of the thoracic wound 
 being closed. (See Fig. 572.) 
 
 Comment. — (a) This may be considered the best manner of exposing 
 the pericardium and heart — and the opening of the pericardium after free 
 exposure may, ordinarily, be considered safer than puncture or aspiration 
 through an unopened thorax, (b) Having excised the fifth costal cartilage 
 by the above incision, if more room be required, or it be desired also to remove 
 the fourth and sixth costal cartilages in addition, the object may be accom- 
 plished by making a vertical incision at the inner end of the original incision, 
 down the center of the sternum, and another vertical incision at the outer end 
 of the original incision. Where both the fourth and sixth costal cartilages 
 are to be removed, these two vertical incisions will extend from above the 
 fourth to just below the sixth cartilages, thus making an M-shaped incision, 
 and enabling two flaps of soft parts down to the cartilages to be turned, the 
 one upward, and the other downward. If it be desired to remove only the 
 fourth cartilage in addition, then only the upper parts of the vertical incisions 
 are added. If only the sixth cartilage must be additionally removed, then 
 only the lower parts of the vertical incisions are used. If it be known from 
 the start that two or more costal cartilages must be removed, an oval or modi- 
 fied horseshoe flap of soft parts with its base over the sternum and its con- 
 vexity extending beyond the outer limit of the excision, may be used, — or an 
 I-shaped incision, the vertical portion being from 1 to 2 cm. (about h to f inch) 
 from the sternum, the transverse parts corresponding with the uppermost 
 and lowermost ribs to be removed, may be used, the two flaps thus outlined 
 being turned inward and outward. Additional room may always be gotten 
 by resecting, with rongeur forceps, the left border of the sternum. 
 
 Comment. — Where a greater exposure is necessary, Kocher's sternocostal 
 incision may be made — through which not only the sixth, but the fifth and 
 fourth, costal cartilages may be excised (Fig. 571, C, C). 
 
 PERICARDIORRHAPHY. 
 
 Consists in the suturing of wounds of the pericardium. The operation 
 is sufficiently described under Exposure of the Pericardium and Heart by 
 Excision of the Left Fifth Costal Cartilage (page 784). 
 
 XL THE HEART. 
 SURGICAL ANATOMY. 
 
 Position of the Heart and Its Various Parts. — Occupies greater por- 
 tion of middle mediastinum — lying obliquely behind lower two-thirds of 
 sternum — and projecting about 7.5 cm. (about 3 inches) to left of median line, 
 
 5° 
 
786 OPERATIONS UPON THE THORAX. 
 
 and about 4 cm. (about 1^ inches) to right of median line — extending from 
 above to the right, to below and to the left. Base ; directed upward, back- 
 ward, and to the right, corresponding to interval between fifth and ninth dorsal 
 vertebra?. Apex; directed downward, forward, and to left, corresponding 
 to chest-wall between fifth and sixth costal cartilages — at a point about 2 cm. 
 (about I inch) to inner side, and about 4 cm. (about ij inches) below left 
 male nipple. Inferior border; corresponds to right ventricle and rests on 
 central tendon of diaphragm. Anterior border ; corresponds to right auricle. 
 Left border; corresponds to left ventricle. Anterior surface; formed 
 mainly by right ventricle and part of left. Posterior surface; formed 
 mainly by left ventricle. 
 
 Relations of Heart to Chest-wall. — Base; corresponds to line from 
 point on lower border of second left costal cartilage 2.5 cm. (1 inch) from 
 sternum, to upper border of third right costal cartilage 1.2 cm. (about J inch) 
 from sternum. Apex; corresponds to point 3.8 cm. (about 1^ inches) below, 
 and 2 cm. (f inch) internal to left male nipple — which is about 9 cm. (about 
 3^ inches) to left of median line, and between fifth and sixth costal cartilages, 
 and just internal to end of fifth rib. Lower border ; corresponds to line from 
 apex, with slight downward convexity, to seventh right chondro- sternal 
 articulation. Right border; represented by line joining right extremity 
 of base-line with right extremity of lower border-line (seventh right chondro- 
 sternal articulation), with a slight outward convexity projecting about 3.8 
 cm. (about 1^ inches) from median line. Left border; represented by line 
 joining left extremity of base-line with apex-point, with slight convexity to 
 left — extending about 7.6 cm. (about 3 inches) to left of median line of sternum. 
 
 Relations of Parts of Heart to Chest-wall. — Right auricle ; behind 
 sternal ends of third, fourth, fifth, and sixth costal cartilages of right side; 
 corresponding intervening spaces; right border of sternum. Right auricular 
 appendix; behind or to left of median line, on level with third costal 
 cartilages. Left auricle ; extends vertically from level of lower border of 
 second left costal cartilage to upper border of fourth — and corresponds, hori- 
 zontally, with body of seventh dorsal vertebra and heads of adjoining left 
 ribs. Apex of left auricular appendix; behind third costal cartilage, 
 about 3.2 cm. (ij inches) to left of sternum. Right ventricle; extends 
 from third costal cartilage above, to seventh costal cartilage below, on left 
 side. Right auriculo-ventricular sulcus; line obliquely upward, from 
 sternal end of sixth right costal cartilage, to third left costal cartilage. Left 
 ventricle ; not in contact with chest-wall, except small part of apex of left 
 ventricle during expiration. 
 
 Relations of Orifices of Heart to Chest-wall. — Pulmonary orifice 
 (Pulmonary Semilunar Valves) ; behind junction of upper border of left third 
 costal cartilage with sternum. Aortic orifice (Aortic Semilunar Valves); 
 behind left half of sternum, opposite lower border of third costal cartilage. 
 Left auriculo-ventricular opening (Mitral Valves) ; behind sternum, to 
 left of median line, opposite fourth costal cartilage. Right auriculo-ven- 
 tricular opening (Tricuspid Valves); behind center of sternum, opposite 
 fourth intercostal space. 
 
 Relations of Uncovered Area of Heart to Chest-wall. — The triangular 
 area of the heart uncovered by pleura is represented within the three following 
 lines; — (a) Draw line downward and to left from middle of sternum, between 
 fourth costal cartilages, to apex of heart; (b) Draw line from starting-point 
 of first line down the lower third of the central line of the sternum; — (c) Draw 
 line from sternal end of sixth right costal cartilage through seventh left costal 
 cartilage. 
 
PARACENTESIS OF RIGHT VENTRICLE OF HEART. 787 
 
 Arteries. — Anterior and posterior coronary. 
 Veins. — Correspond with arteries, emptying into right auricle. 
 Lymphatics. — End in thoracic and right lymphatic ducts. 
 Nerves. — From cardiac plexus. 
 
 PARACENTESIS OF RIGHT AURICLE OF HEART. 
 
 Description. — Puncture of right auricle of heart by needle of aspiratory 
 syringe — for the purpose of withdrawing a portion of the blood in cases where 
 the right side of the heart is engorged from obstruction to the circulation 
 through the lungs. 
 
 Preparation — Position. — As for Paracentesis Pericardii. 
 
 Landmarks. — Position of right auricle. 
 
 Operation. — An aspiratory needle, so held as to control the depth of 
 puncture, is entered in the right third intercostal space, close to the margin 
 of the sternum — and thrust directly backward through skin, fascia, pectoralis 
 major, external intercostal membrane, internal intercostal muscle, probably 
 through fibers of triangularis sterni, through areolar tissue of anterior medi- 
 astinum, both layers of pleura, periphery of right lung, into the right auricle — 
 its entrance generally being recognized by the sensation, and verified by the 
 free flow of blood into the syringe. The requisite amount of blood is with- 
 drawn — and the wound is sealed with sterile cotton and collodion. (See 
 
 Fig- 573, D.) 
 
 Comment. — (a) A preliminary incision may be made in the intercostal 
 space, down to the intercostal membrane — whereby the entrance of the 
 needle into the auricle, especially in thick thoracic walls, is more readily 
 recognized. However, in using a vacuum syringe, this is not generally neces- 
 sary, (b) It is necessary to withdraw blood by suction, as the blood-pressure 
 in the right auricle is not sufficient to cause spontaneous flow, (c) The right 
 auricle is preferable to the right ventricle for operation, because its position 
 is not apt to be altered and its internal antero-posterior diameter is greater 
 than that of the richt ventricle. 
 
 PARACENTESIS OF RIGHT VENTRICLE OF HEART. 
 
 Description. — Puncture of right ventricle of heart by needle of aspiratory 
 syringe, or by fine trocar and cannula — in the same cases as mentioned under 
 Paracentesis of Right Auricle (q. v.). 
 
 Preparation — Position. — As in Paracentesis of Right Auricle. 
 
 Landmarks. — Position of Right Ventricle. 
 
 Operation. — The cannula and trocar, or needle, are entered in the fourth 
 right intercostal space, 2.5 cm. (about 1 inch) from the right sternal border. 
 It is manipulated as in Paracentesis Auriculi — and passes through practically 
 the same structures — but is directed inward as well as backward, in order to 
 strike the right ventricle, which, normally, might not be certainly reached, 
 but which is reached with greater certainty when thus engorged. The 
 requisite amount of blood is allowed to flow spontaneously — and the wound 
 is then sealed with sterile cotton and collodion. (See Fig. 573, E.) 
 
 Comment. — Blood-pressure in the right ventricle is sufficient to cause 
 spontaneous flow through the cannula. See Comment under Paracentesis 
 Auriculi. 
 
788 OPERATIONS UPON THE THORAX 
 
 EXPOSURE OF THE HEART AND PERICARDIUM 
 
 BY A THORACOPLASTIC FLAP — ROTTER'S OPERATION. 
 
 Description. — The heart is exposed through a thoracoplasty flap con- 
 sisting of the fourth and fifth costal cartilages and parts of the corresponding 
 ribs. No attempt to preserve the pleura intact is made — as that membrane 
 is almost always involved in the injury and it is generally indicated to remove 
 blood from its cavity. 
 
 Preparation. — As pneumothorax may have occurred prior to operation, 
 
 Fig- 573- — Sites for Paracenteses and Lines for Exposures of the Heart: — D, 
 Paracentesis of right auricle; E, Paracentesis of right ventricle; A, Rotter's thoracoplastic flap; 
 B, Fontan's thoracoplastic flap; C, Kocher's thoracoplastic flap. (Thorax modified from 
 Deaver.) 
 
 or may take place in the course of the operation, the operation may be per- 
 formed in Sauerbruch's chamber (negative atmospheric pressure) or in Bauer's 
 apparatus (increased pressure). In this way the collapse of the lungs and, 
 therefore, of the heart is avoided. 
 
 Position. — Patient supine, preferably resting upon some object which 
 will elevate the chest and render it prominent and thus increase the width of 
 the intercostal spaces. 
 
 Landmarks. — Left border of sternum; third, fourth, and fifth ribs and 
 their cartilages; mammary line. 
 
EXPOSURE OF THE HEART AND PERICARDIUM. 
 
 789 
 
 Incision. — A flap is outlined with its hinge near the left border of the 
 sternum — beginning about 2 cm. (f inch) from the left margin of the sternum. 
 These incisions are continued along the lower borders of the third and fifth 
 ribs — and may extend outward in the interspaces as far as the mammary line. 
 Their outer ends are connected by a vertical incision (Fig. 573, A). 
 
 Operation. — (1) In the horizontal incisions are divided the skin, fascia, 
 
 Fig. S74- — Rotter's Osteoplastic Exposure of Heart and Pericardium: — A, Fifth rib; 
 B, Fourth rib; C, Intercostal muscles; D, Pectoralis major; E, Costochondral junction (frac- 
 tured); F, Internal mammary vessels; G, Parietal pleura; H, Fatty tissue over pericardium; 
 I, Visceral pleura, with lung showing through; J, J, Incised pericardium retracted; K, Traction- 
 suture in apex of heart. (Modified from Rockenheimer and Frohse.) 
 
 pectoralis major and minor, intercostals, and generally the parietal layer of the 
 pleura (Fig. 574). The vertical incision does not at first go deeper than the 
 pectoral muscles. The intercostal vessels are ligated and the fourth and fifth 
 ribs divided — and the incision is then carried to the pleura. (2) The entire 
 cutaneomusculo-periosteo-osseous flap is now turned upward and inward. 
 Even if the pleura have previously escaped, it may be torn in the process of 
 
790 OPERATIONS UPON THE THORAX. 
 
 exposure and turning back of the flap. Pneumothorax should be prevented 
 by drawing the lung forward and suturing it to the intercostal muscles — or the 
 opening in the pleura may be covered by gauze tampons, the lung being pushed 
 backward and outward. When the flap is turned upward and inward, the 
 triangularis sterni muscle is torn. The costal cartilages are apt to break near 
 their articulations — disarticulation should, however, be carried out. The 
 internal mammary artery is generally left intact. (3) The fatty areolar tissue 
 over the pericardium is retracted and the pericardium incised in its longitudinal 
 axis, from its infero-external aspect. Fixation sutures are introduced into the 
 muscular tissue of the apex of the heart if necessary to steady it in the indicated 
 manipulations. All accumulated blood in the pericardium is removed. (4) 
 The special object of the operation is now accomplished. Unless specially 
 indicated, the pericardium is sutured without drainage (as the constant impact 
 of the heart against the drain is apt to produce pericarditis). Drainage may 
 be used down to the pericardium, in closing the wound. 
 
 CARDIORRHAPHY. 
 
 Description. — Suturing of wounds of the heart-muscle — after having 
 freely exposed the organ by the operation just described or by one of those 
 mentioned in the preceding pages. 
 
 Preparation — Position. — As for Paracentesis Auriculi. 
 
 Landmarks. — The landmarks will be those of the operation by which the 
 heart is exposed. For the fullest exposure, the osteoplastic resection for 
 exposure of the anterior and middle mediastina is probably best — see page 
 750. For a less extensive exposure, the resection of the fifth costal cartilage 
 may be used — see page 784. Additionally, the landmarks of the parts of the 
 heart should be noted. 
 
 Operation. — (1) The pericardium having been exposed and the wound 
 in it enlarged, if necessary, the heart is brought into the held. (2) Silk, upon 
 a fully curved needle, held in a good needle-holder, is used. The needle 
 is quickly, but gently and steadily, inserted during diastole only, and 
 no attempt is made to proceed with the operation except during diastole. 
 The needle enters about 4 to 5 mm. (about f,; to yV, inch) from one edge — 
 penetrates moderately deeply only (never entering the endocardium) — 
 crosses the gap between the walls of the wound (or may dip beneath the 
 bottom of the wound, if the wound does not entirely penetrate the wall of the 
 heart and there is room beneath it for suture to pass without entering the 
 endocardium) — and makes its exit at a corresponding point on the opposite 
 side. During a subsequent diastole the thread is drawn through the lips of 
 the wound — and, during still another, knotted. After the first suture has 
 been placed, gentle traction upon it steadies the heart while placing the others. 
 (3) The pericardial wound might also be sutured in a perfectly clean case — 
 but, practically, it is better to temporarily leave it open, lightly packing the 
 mouth of the pericardial wound and carrying drainage through that part of 
 the external wound not closed. (See Fig. 572.) 
 
 Comment. — When the needle enters the heart, there is a momentary 
 stoppage, followed by brief tumultuous action. 
 
BRONCHOTOMY. 79 1 
 
 XII. THE THORACIC TRACHEA. 
 SURGICAL ANATOMY. 
 See Trachea under Operations upon the Xeck (page 702). 
 
 THORACIC TRACHEOTOMY 
 
 BY POSTERIOR MEDIASTINAL THORACOPLASTIC FLAP OPERATION. 
 
 See Posterior Mediastinal Thoracotomy (page 752). The exposure and 
 incision of the trachea in the posterior mediastinum is resorted to for the 
 removal of foreign bodies situated too low in the trachea to be accessible and 
 removable from a cervical tracheotomv wound. 
 
 XIII. THE BRONCHI. 
 SURGICAL ANATOMY. 
 
 Relations. — (1) Right bronchus; vena azygos major passes above bron- 
 chus from behind forward, on its way to superior vena cava ; right pulmonary 
 arteryliesat first below and then in front of bronchus. (2) Left bronchus; 
 passes beneath arch of aorta, resting upon esophagus, thoracic duct, and de- 
 scending aorta; left pulmonary artery lies at first above and then in front of it. 
 
 Differences in the Bronchi. — (1) Right bronchus; about 2.5 cm. 
 (about 1 inch) long; wider, shorter, and more horizontal than left; enters 
 right lung opposite fifth dorsal vertebra. About 2 cm. (about f inch) from 
 origin, the upper or eparterial branch of bronchus is given off above right 
 pulmonary artery to upper lobe of lung: the main bronchus, or hyparterial 
 branch, passes below and behind right pulmonary artery and divides into 
 two branches, for middle and lower lobes. 2 Left bronchus; about 5 
 cm. (about 2 inches) long; smaller, longer, and more oblique than right: 
 enters left lung opposite sixth dorsal vertebra (about 2.5 cm., or 1 inch, lower 
 than right). Left bronchus is entirely below left pulmonary artery (hypar- 
 terial), and divides into two branches, for upper and lower lobes. Note. — In 
 majoritv of cases, right bronchus seems a more direct continuation of trachea 
 than left (that is, the dividing ridge between the two bronchi lies more to the 
 left) — although the left is the more oblique in direction — wherefore, foreign 
 bodies are more frequently lodged in the right bronchus. 
 
 Arteries. — Bronchial branches of thoracic aorta. 
 
 Veins. — Bronchial — emptying into vena azygos major on right side — and 
 into superior intercostal vein on left. 
 
 BRONCHOTOMY. 
 
 Description. — Exposure and incision of the bronchial tubes. Generally 
 resorted to for the removal of foreign bodies — and sometimes for the drainage 
 of bronchiectatic cavities. The manner and site of the operation will depend 
 upon the circumstances of the individual case — the manner of approach being 
 by one of the procedures already described. 
 
 Where Bronchotomy is done for the removal of foreign bodies, the main 
 bronchi are the ones usually opened — and are exposed through a Posterior 
 Mediastinal Thoracotomy, by means of the osteoplastic flap operation de- 
 scribed at page 752. The bronchi are opened as the trachea is opened in that 
 operation — either directly over the foreign body — or at the site most accessible 
 
792 OPERATIONS UPON THE THORAX. 
 
 to the object — the object being sought, in the latter case, by slender, curved 
 forceps introduced through the opening in the bronchus. Both the bronchial 
 wound and the outer wound are treated as in the operation to which reference 
 has been made. 
 
 Where Bronchotomy is performed to afford drainage in a case of dilated 
 bronchial tube, in Bronchiectasis, the operation is practically the same as 
 Pneumotomy for abscess, etc. The operation is rarely of much avail, unless 
 it be practically a single, defined cavity in an accessible site, previously well 
 located. (See Fig. 559, J.) 
 
 XIV. THE THORACIC ESOPHAGUS. 
 
 SURGICAL ANATOMY. 
 See Esophagus under Operations upon the Neck (page 711). 
 
 THORACIC ESOPHAGOTOMY 
 
 BY POSTERIOR MEDIASTINAL OSTEOPLASTIC ELAP OPERATION. 
 
 See Posterior Mediastinal Thoracotomy (page 752). 
 
 Exposure and incision of the esophagus in the posterior mediastinum are 
 resorted to for the removal of foreign bodies situated too low in the esophagus 
 to be accessible and removable from a cervical esophagectomy. 
 
 Having isolated the esophagus, as described in the operation mentioned, 
 and having located the foreign body, the esophagus is steadied with toothed 
 forecps, if necessary — an incision in its longitudinal axis is made — the lips 
 of the wound are held apart by two pairs of toothed forceps, and the foreign 
 body removed with appropriate forceps. The opening into the esophagus 
 should be made upon its lateral aspect (generally the left aspect). The 
 wound in the esophagus, in favorable cases, may be sutured with catgut — 
 for drainage may take place into the stomach (where in a corresponding 
 operation upon the trachea, or bronchi, drainage is by means of the external 
 wound, and suturing of the trachea or bronchus is not indicated). Drainage 
 is instituted from the wall of the esophagus through the outer wound. (See 
 Fig- 559, K 
 
CHAPTER V. 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC 
 
 REGION. 
 
 L THE ABDOMINO-PELVIC WALL. 
 SURGICAL ANATOMY OF THE ABDOMINO-PELVIC WALL. 
 
 Boundaries of the Abdomino-pelvic Cavity. — Above ; concave dome 
 of diaphragm. Below; levatores ani and coccygei muscles ("diaphragm 
 of pelvis"). Laterally; lower thoracic, and abdominal and pelvic walls. 
 
 Boundaries of Abdominal Cavity. — Superiorly; central tendon of dia- 
 phragm (rising to about inferior end of sternum, or seventh chondro-sternal 
 joint); right half of diaphragm (to about level of fifth rib, or about 2.5 cm., or 
 1 inch, below right male nipple) ; left half of diaphragm (rising not quite so 
 high as right) ; costal arches and ensiform process of sternum. Inferiorly ; 
 ileo-pectineal lines, laterally; crest of pubic bones, anteriorly; base of sacrum 
 and sacro-vertebral angle, posteriorly; Poupart's ligaments, superficiallv. 
 
 Boundaries of Pelvic Cavity. — Superiorly; ileo pectineal lines, later- 
 ally; crest of pubic bones, anteriorly; base of sacrum and sacro-vertebral 
 angle, posteriorly. Inferiorly; Anteriorly; pubic arch and subpubic liga- 
 ment; rami of os pubis and ischium; — Posteriorly; great sacro-sciatic liga- 
 ments and tip of coccyx; — Laterally; tuberosities of ischia. 
 
 Regions of the Abdomino-pelvic Cavity and Their Contents. — Basis of 
 divisions ; Two horizontal lines are drawn — one corresponding with the 
 lowest part of the tenth costal arch — the other with the most prominent lateral 
 points of the iliac crests; — and two vertical lines are made to intersect these 
 passing upward from the center of Poupart's ligaments — thus forming the 
 nine following regions (Quain) ; — Epigastric ; most or all of left lobe of liver; 
 part of right lobe of liver; gall-bladder; part of body and cardiac and pyloric 
 orifices of stomach; first and second parts of duodenum; duodeno-jejunal 
 flexure; pancreas; supero-internal part of spleen; parts of both kidneys; 
 suprarenal bodies. Right hypochondriac; most of right lobe of liver; 
 hepatic flexure of colon; part of right kidney. Left hypochondriac; por- 
 tion of stomach; greater part of spleen; tail of pancreas; splenic flexure of 
 colon; part of left kidney; part of left lobe of liver (sometimes). Umbilical; 
 most of transverse colon; third part of duodenum; some convolutions of 
 jejunum and ileum; part of mesentery; part of great omentum; part of 
 right kidney (sometimes parts of both). Right lumbar; ascending colon; 
 portion of right kidney; part of ileum (sometimes). Left lumbar; de- 
 scending colon; part of jejunum; small part of left kidney (sometimes). 
 Hypogastric ; convolutions of ileum; bladder in children (and in adults when 
 distended); gravid uterus; sigmoid loop; upper portion of rectum. Right 
 iliac; caecum, with vermiform appendix; end of ileum. Left iliac; sig 
 moid colon; convolutions of jejunum and ileum. 
 
 793 
 
794 OPERATION'S UPON THE ABDOMINO-PELVIC REGION. 
 
 Apertures in the Abdominal Wall. — Above; those through the dia- 
 phragm (see that structure, page 756). Below; for femoral vessels ; for sper- 
 matic curd. Anteriorly; umbilicus. 
 
 Fig. 575- — Distribution of Nerves to Antero-lateral Abdominal Wall:— The 
 Intercostal' (upper six) nerves are distributed to the chest proper; — The lower abdominal inter- 
 costal (lower six) nerves pass forward from the intercostal spaces, between the internal oblique 
 and transversalis muscles, to the sheath of the rectus. (Modified from an unplaced source.) 
 
 Structures of Antero-lateral Abdominal Wall. — (From without in- 
 ward) — skin; superficial fascia, superficial and deep layers; general areolar 
 tissue overlying external oblique muscle, and special intercolumnar fascia 
 of external abdominal ring; external oblique and its aponeurosis; internal 
 oblique and its aponeurosis; transversalis and its aponeurosis; rectus; 
 pyramidalis; fascia transversalis; subperitoneal areolar tissue; peritoneum. 
 
 Structures of Posterior Abdominal Wall.— (J) Osseous Portion — five 
 
SURGICAL ANATOMY OF THE ABDOMINO-PELVIC WALL. 795 
 
 lumbar vertebrae and interarticular fibro-cartilages; posterolateral portions 
 of ilia; — (2) Soft Portion (from without inward) — skin; subcutaneous areolar 
 tissue ; lumbar aponeurosis (posterior layer) ; erector spina? ; lumbar aponeu- 
 rosis (middle layer) attached to transverse processes of lumbar vertebrae; 
 quadratus lumborum; lumbar aponeurosis (anterior layer); psoas; crura of 
 diaphragm; kidney, areolar tissue, and colon; subperitoneal areolar tissue; 
 peritoneum. 
 
 Arteries of Antero-lateral Abdominal Wall. — Superficial epigastric, 
 superficial circumflex iliac, and superficial external pudic from femoral; 
 lowest two intercostals from thoracic aorta; abdominal branches of lumbar 
 arteries from abdominal aorta; ilio-lumbar from internal iliac; deep circum- 
 flex iliac and deep epigastric from external iliac; superior epigastric and 
 musculophrenic from internal mammary. 
 
 Arteries of Posterior Abdominal Wall. — Lumbar branches of abdom- 
 inal aorta. 
 
 Veins of Antero-lateral Abdominal Wall. — Correspond, chiefly, with 
 the arteries. 
 
 Veins of Posterior Abdominal Wall. — Correspond, chiefly, with the 
 arteries. 
 
 Lymphatics of Antero-lateral Abdominal Wall. — Superficial vessels 
 above umbilicus empty into axillary glands: — superficial vessels below um- 
 bilicus empty into inguinal glands: — deep vessels above umbilicus empty into 
 sternal glands (probably) : — deep vessels below umbilicus empty into iliac 
 glands. 
 
 Lymphatics of Posterior Abdominal Wall. — Median (aortic) lumbar 
 glands: — lateral (psoas) lumbar glands. 
 
 Distribution of Nerves to Antero-lateral Abdominal Wall (Fig. 575). — 
 Lower intercostal nerves; emerging from intercostal spaces behind costal 
 cartilages (except twelfth, which is subcostal), they pass forward between inter- 
 nal oblique and transversalis (generally intercommunicating here) — penetrate 
 outer edge of sheath of rectus — supply rectus — pass through its substance — 
 penetrate anterior layer of rectal sheath — and are distributed to skin. Lateral 
 cutaneous branches of lower intercostal nerves; divide into Anterior 
 Branches (to skin up to outer border of rectus, and superficial part of external 
 oblique) and Posterior Branches (to skin of outer part of back). Sixth 
 intercostal; supplies region between lower end of sternum and tip of end- 
 form cartilage. Seventh intercostal; distributed to region near lower end 
 of ensiform cartilage. Eighth intercostal; runs up under cover of costal 
 arch and supplies area of middle linea transversa, between tip of ensiform 
 cartilage and umbilicus. Ninth intercostal; runs directly forward on level 
 with ninth costal cartilage and supplies region just above umbilicus. Tenth 
 intercostal; runs directly forward on level with tenth costal cartilage and sup- 
 plies skin about umbilicus. Eleventh intercostal; runs forward and down- 
 ward, supplying the region a little below the umbilicus. Twelfth intercostal ; 
 passes in front of quadratus lumborum, along lower border of twelfth rib — 
 pierces transversalis and runs forward between transversalis and internal 
 oblique — (a) Anterior Branch of Twelfth Intercostal, penetrates rectus and 
 is distributed below a point midway between umbilicus and pubis — (b) 
 Lateral Cutaneous Branch of Twelfth Intercostal, penetrates internal oblique, 
 then emerges from external oblique from 2.5 to 8 cm. (about 1 to 3 inches) 
 above the iliac crest, and is distributed to skin over front of hip. Ilio-hypo- 
 gastric branch of first lumbar ; emerges from upper outer border of psoas 
 
796 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 — runs in front of quadratus lumborum to iliac crest — piercing transversalis 
 posteriorly, and divides between transversalis and internal oblique, about 
 6.5 cm. (about 2 \ inches) posterior to anterior superior iliac spine into: — (a) 
 Hypogastric Branch, passing forward between transversalis and internal 
 oblique, pierces internal oblique, then pierces aponeurosis of external oblique 
 about 2.5 cm. (about 1 inch) above and just to outer side of external abdominal 
 • ring, and supplies skin of hypogastric and external ring region, — (b) Iliac 
 Branch, piercing internal oblique and external oblique directly above crest of 
 ilium, and supplying skin of gluteal region posterior to lateral cutaneous 
 branch of twelfth dorsal nerve. Ilio-inguinal branch of first lumbar; 
 passes from outer border of psoas just inferior to ilio-hypogastric — runs 
 obliquely across quadratus lumborum and iliacus — penetrates transversalis 
 near anterior part of iliac crest (communicating here with ilio-hypogastric) 
 —runs forward between internal oblique and transversalis, piercing internal 
 oblique a little in front of anterior superior iliac spine — passes forward beneath 
 aponeurosis of external oblique, accompanying cord through inguinal canal 
 and emerging at external abdominal ring — supplying skin of upper and inner 
 aspects of thigh — and scrotum in male, and labium in female. 
 
 Distribution of Nerves to Posterior Abdominal Wall. — Posterior 
 divisions of lumbar nerves; dividing into internal and external branches. 
 Genitocrural nerve ; arising from first and second lumbar nerves, passes 
 obliquely through psoas, emerging from its inner border opposite disc between 
 third and fourth lumbar vertebrae — passing downward upon anterior surface 
 of psoas and dividing, at outer side of external iliac artery, into — (a) Genital 
 Branch, piercing fascia transversalis and descending on posterior part of 
 spermatic cord through inguinal canal — emerging at external abdominal ring 
 and supplying cremaster muscle in male, and round ligament in female. — (b) 
 Crural Branch, descending on external iliac artery and piercing femoral 
 sheath about 5 cm. (about 2 inches) below Poupart's ligament, to be dis- 
 tributed to skin of upper central part of thigh. External cutaneous ; arising 
 from second and third lumbar nerves, emerges from center of outer border 
 of psoas and runs obliquely over iliacus muscle to notch just below anterior 
 superior iliac spine, where it escapes beneath Poupart's ligament on to thigh. 
 Anterior crural ; obturator ; accessory obturator nerves — descend to 
 their distributions through the postero-lateral aspect of the abdomino-pelvic 
 wall. 
 
 Summary of Distribution of Anterior Abdominal Nerves. — Seventh 
 and eighth run upward and inward and supply upper third of abdominal 
 wall; — ninth and tenth run nearly transversely inward and supply middle 
 third; — eleventh and twelfth, and Ilio-hypogastric and Ilio-inguinal, run 
 downward and inward and supply lower third of abdominal wall. 
 
 Anterior Sheath of Rectus. — Formed, above, by blending of aponeu- 
 roses of external oblique and outer lamella of internal oblique — below, by 
 blending of aponeuroses of external oblique, internal oblique, and trans- 
 versalis. 
 
 Posterior Sheath of Rectus. — Formed, above, by blending of aponeu- 
 roses of inner lamella of internal oblique and transversalis; next to which 
 come, in order, transversalis fascia, subperitoneal areolar tissue, and parietal 
 peritoneum, — below semilunar fold of Douglas, by transversalis fascia alone; 
 next to which come, in order, subperitoneal areolar tissue and parietal peri- 
 toneum. 
 
 Linea Alba. — A tendinous raphe, extending from ensiform cartilage to 
 
SURFACE FORM AND LANDMARKS OF ABDOMINO-PELVIC WALL. 797 
 
 symphysis pubis, down median line of abdominal wall, and formed by the 
 union of the aponeuroses of the obliquus externus and interims and the trans- 
 versalis, between the inner margins of the rectus muscles. Most distinct 
 just above the umbilicus. Practically absent below semilunar fold of Douglas 
 — because from that line downward the aponeuroses of external oblique, 
 internal oblique, and transversalis all pass in front of rectus (the linea alba 
 being formed by the junction of the anterior and posterior aponeuroses which 
 form the sheath of the rectus). 
 
 SURFACE FORM AND LANDMARKS OF THE ABDOMINO-PELVIC 
 
 WALL. 
 
 Linea alba — extending from apex of ensiform cartilage to symphysis pubis 
 — broader above, narrower below the umbilicus — incomplete posteriorly 
 (only) in its lower fourth, where the transversalis fascia replaces it. One or 
 both borders of the recti are apt to be incised in operating below the umbilicus. 
 Represents junction of inner borders of aponeuroses of the flat abdominal 
 muscles. 
 
 Linear semilunares — represent the line of division of the aponeuroses of 
 the abdomen — correspond with the outer borders of the recti muscles — extend 
 from lowest part of seventh costal cartilages to spines of os pubis, so curved 
 that opposite the umbilicus they are 6 to 7.5 cm. (2^ to 3 inches) from the 
 median line. 
 
 Linea? transversa? — three tendinous intersections in the substance of the 
 recti muscles, forming transverse furrows upon their surface — the upper one, 
 opposite, or just below, the tip of the ensiform cartilage, — the middle one, 
 between the tip of the ensiform cartilage and the umbilicus (about opposite 
 the tenth costal cartilage), — the lower one, opposite the umbilicus, — (and 
 sometimes a fourth one, below the umbilicus). 
 
 Semilunar fold of Douglas — below which the posterior sheath of the recti 
 is formed by transversalis fascia alone — about opposite the junction of the 
 upper three-fourths and the lower fourth of the recti muscles — about 3 cm. 
 (1 j inches) below the umbilicus. 
 
 Abdominal furrow — extends from infrasternal fossa to, or a little below, 
 the umbilicus, where it becomes lost. Its bottom is formed by the linea alba. 
 
 Umbilicus — situated in the linea alba — always above the level of the highest 
 points of the crests of the ilia (generally from 2 to 2.5 cm., f to 1 inch, above) 
 — from 2 to 2.5 cm. (f to 1 inch) above and to the inner side of the bifurcation 
 of the abdominal aorta — opposite the tip of the third lumbar spine, or the 
 intervertebral disc between the third and fourth lumbar vertebrae. 
 
 Spine of the os pubis — found by following up the tendon of the abductor 
 longus — nearly on the same horizontal line as the upper edge of the great 
 trochanter — gives attachment to the outer pillar of the external abdominal 
 ring. 
 
 Anterior superior iliac spine — the most prominent landmark of the lower 
 antero-lateral abdominal wall. 
 
 Crests of the iliac bones — continuations backward of the anterior superior 
 iliac spines — found at the bottom of the iliac furrows, in the fleshy. 
 
 Poupart's ligament — represented by a line curved slightly downward, be- 
 tween the anterior superior iliac spine and the pubic spine. 
 
 Iliac furrow — corresponds to the iliac crests — and formed by the attach- 
 ment of the external oblique muscles to these crests. 
 
798 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Sacral promontory — represented by a transverse line between the two an- 
 terior superior iliac spines. 
 
 Internal abdominal ring — situated about 1.3 cm. (\ inch) above the center 
 of Poupart's ligament. 
 
 External abdominal ring — situated just superior and external to the crest 
 of the os pubis. 
 
 Aponeuro-muscular limits of external oblique — the line representing the 
 junction of the aponeurotic and muscular portions anteriorly, is one passing 
 from the anterior superior iliac spine to the ninth costal cartilage (or one 
 slightly anterior to these points) ; — The lower limit of the fleshy part of the 
 external oblique is represented by a transverse line from a point on the iliac 
 crest 2.5 to 5 cm. (1 to 2 inches) posterior to the anterior superior iliac spine, 
 to a corresponding point on the opposite side. The fibers of the muscle and 
 aponeurosis run about at a right angle with a line from the anterior superior 
 iliac spine to the umbilicus. 
 
 Aponeuro-muscular limit of the internal oblique — Above, by an oblique 
 line from a point below the anterior end of the twelfth rib extending upward 
 parallel with the costal arch, — Internally, by a line extending from the middle 
 of Poupart's ligament upward and slightly outward. The upper line marks 
 the upper limit of the muscular part. 
 
 Aponeuro-muscular limit of the transversalis — the median limit of the 
 fleshy part of the transversalis is nearer the middle line of the body above 
 and below than at the center. 
 
 Deep epigastric artery — runs from a point just internal to the middle of 
 Poupart's ligament upward and inward to the inner aspect of the internal 
 abdominal ring — thence still upward and inward to about midway between 
 the pubes and umbilicus — and, passing beneath the semilunar fold of Douglas, 
 runs between the sheath of the rectus and the muscle, finally piercing the 
 muscle. 
 
 Abdominal aorta — bifurcates about 2 cm. (f inch) below and to left of 
 the umbilicus. 
 
 Cceliac axis — situated from 10 to 12.5 cm. (about 4 to 5 inches) above 
 the umbilicus. 
 
 Superior mesenteric and suprarenal arteries — arise just below the cceliac 
 axis. 
 
 Renal arteries — arise about 1.2 cm. (J inch) below the superior mesenteric. 
 
 Inferior mesenteric — arises about 2.5 cm. (1 inch) above the umbilicus. 
 
 Peritoneal reflection from bladder on to lower abdominal wall — see under 
 the Bladder, page 1093. 
 
 Posterior superior spinous process of ilium — generally marked by a de- 
 pression on a level with, and on either side of, the spinous process of second 
 sacral vertebra. 
 
 Spinous process of third sacral vertebra — generally to be felt below the 
 second sacral vertebra, which last is nearly always detectable. 
 
 Outer border of erector spinae — generally felt by deep palpation made to 
 the outer side of and parallel with the vertebral column. See Surgical Land- 
 marks of the Kidney, page 105 1. 
 
GENERAL SURGICAL CONSIDERATIONS. 799 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE 
 ABDOMINO-PELVIC CAVITY. 
 
 Guide to the choice of special abdominal incisions — that incision should 
 be chosen which most satisfactorily accomplishes the following (in order of 
 importance) : — free access — avoidance of nerves — separation of muscular 
 and aponeurotic fibers rather than their division — avoidance of vessels. 
 
 Separation of the fibers of muscles and aponeuroses in their cleavage line 
 should always be done in preference to a division of those fibers transversely 
 or even obliquely. 
 
 Blood-vessels, as compared with nerves, are of secondary importance — 
 though the deep epigastric artery (the most important of the abdominal 
 wall), and its anastomosis with the superior epigastric of the internal mam- 
 mary, should be spared when possible. (See Fig. 575.) 
 
 Better to cut through muscle than through aponeurosis (where cleavage 
 separation is not possible) — as the former is more resistant to hernia (Hyrtl). 
 
 Median Incisions — available for parts most accessible thereby. Through 
 a median incision above the umbilicus; the stomach, liver, pancreas, and 
 intestines may be reached. Through a median incision below the umbilicus; 
 the intestines, bladder, ureters, uterus, and ovaries may be reached. 
 
 Lateral Vertical Incisions — (along the outer border of the rectus) — not ad- 
 visable ordinarily, as they divide the motor nerves to the rectus muscle, and 
 thereby predispose to hernia. When done, generally done for the gall-bladder 
 and ducts, duodenum, ascending and descending colons, spleen, and kidneys. 
 
 Transverse or slightly Oblique Incisions — preferable for reaching those 
 sites laterally placed. The incisions are more or less parallel with the nerves — 
 the muscles are separated in their cleavage lines, where possible, and re- 
 tracted — the nerves are recognized in the intermuscular planes (especially 
 between internal oblique and transversalis) and held to one side. This 
 incision may be used for the appendix, ascending and descending colons, 
 kidneys, stomach, liver, gall-ducts, intestines, and ureters. 
 
 Special Abdominal Incisions — see the different methods of abdominal 
 section following. 
 
 In the above summary of abdominal incisions no hard-and-fast rule exists 
 as to their application — it merely being meant to mention some cases in 
 which each category of incisions may be used — more specific data being given 
 under the different viscera. 
 
 All abdominal incisions should avoid, where possible, the anterior branches 
 of the dorsal and lumbar nerves — which run obliquely from behind downward 
 and forward between the muscular abdominal planes. The lower abdominal 
 nerves run inwardly somewhat more transversely than do the fibers of the 
 external oblique muscle and aponeurosis — so that in an oblique incision 
 parallel with the fibers, one or more nerves may be encountered — but should 
 be recognized, and can generally be spared. 
 
 All vertical incisions of the abdominal wall, of any length, except those 
 in the median line, cut one or more nerves. 
 
 Vertical incisions over the center of the rectus divide the motor nerves 
 to the inner half of the rectus muscle. 
 
 Long cutaneous and fascial incisions are harmless — and are desirable if 
 thereby free access to the site be gained. 
 
 Longer incisions are necessary in the intramuscular separation than where 
 the muscle-fibers are cut. 
 
 Longer incisions are necessary in verv fat and thick abdominal walls. 
 
800 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Hernia is more apt to follow incisions in the lower than in the upper 
 part of the abdomen — and in the anterior rather than in the lateral and 
 posterior portions. 
 
 Linea alba is broader above than below the umbilicus, hence both inner 
 rectal borders are more likely to be exposed by a median incision below 
 than above the navel. If it be desired to identify the linea alba, after cutting 
 through the superficial fascia, make a slightly oblique superficial incision over 
 the median line — until the linea alba is recognized as a white fascial line 
 or as a cord extending between the inner borders of the recti. 
 
 Pyramidales (one or both) may overlap the median line and their fibers 
 may be divided in a median abdominal section performed low down. 
 
 Linea? transversa. 1 do not extend all the way through the rectus to its 
 posterior aspect. 
 
 Avoid cutting through the umbilicus, ordinarily. Also pass slightly to its 
 left to avoid the round ligament. Incision may be made directly through 
 the center of the umbilicus itself — inclining slightly to the left just above it, 
 to avoid the round ligament. Kelly mentions, after cutting through the um- 
 bilicus, that it is well, in closing the wound, to " split it on each side before 
 putting in sutures, to convert the naturally thin surface between skin and 
 peritoneum into a broader area for better approximation. " 
 
 If the round ligament of the liver be cut during operation, no harm of 
 consequence is done. It should be repaired with chromic gut suture. 
 
 Peritoneum is more loosely connected with the linea alba above and below 
 the umbilicus — and more closely in the neighborhood of the umbilicus. 
 
 A transverse vessel in the subcutaneous fat, about 2 cm. (f inch) above 
 the symphysis pubis, is mentioned by Kelly, which spouts arterial blood from 
 one side and venous blood from the other when cut. He also mentions one 
 or more veins ("celiotomy veins") lying just over the peritoneum in the lower 
 third of the linea alba, running very nearly parallel with the linea alba and 
 ending in the vesical plexus at the neck of the bladder. 
 
 Empty the bladder before operating — and, if necessary, outline the bladder 
 with a sound during operation. 
 
 In all operations involving the pelvic and lower abdominal regions, the 
 Trendelenburg position is desirable — causing a displacement of the intestines 
 and viscera above away from the field of operation. It should be assumed 
 just before the operation and continued during it — at an angle of from 18 
 to 45 degrees, the average being about 30 degrees. 
 
 Intestines and viscera are best held out of the way by means of flat pads 
 of sterilized non-absorbable cotton covered with non-absorbable gauze. 
 
 As soon as the peritoneum is incised, and in order to make less likely 
 the stripping of the peritoneum from the muscular wall, a silk ligature may 
 be passed into either lip of the peritoneum, including the muscular wall, 
 and used as a retractor, after being knotted. 
 
 In incising the abdominal wall the peritoneum is at first only opened to 
 a limited extent — the opening being increased after intra-abdominal examina- 
 tion by means of a finger introduced. 
 
 Avoid mistaking the transversalis fascia for subserous areolar tissue — and 
 subserous areolar tissue for omentum — and especially intestine for peritoneum. 
 
 In cleansing the abdomino-pelvic cavity, the natural fossae should receive 
 especial attention — especially Douglas's cul-de-sac, rectal, duodenal, jejunal, 
 renal, and caecal. 
 
 Part or all of the omentum may be ligated off and removed. 
 
 Suture-materials — For peritoneum; fine, plain catgut. For fascial and 
 
MEDIAN ABDOMINAL SECTION. 801 
 
 aponeurotic planes; chromic gut, kangaroo tendon, silk, silver wire. For 
 muscles; chromic gut, plain gut, silk, kangaroo tendon. For subcutaneous 
 tissue; plain or chromic gut, silk. For skin; silkworm-gut, silk (gut). 
 
 Avoid including omentum and intestinal walls in the tightening of sutures. 
 
 Just before tightening the last suture or two, press upon the abdominal 
 wall to expel air or fluids. 
 
 Quilt sutures may be used for the fascial planes of suturing. 
 
 Relaxation sutures may be used — about 2.5 cm. (1 inch) apart, and from 
 about 1.2 to 2 cm. (J to f inch) from the edges of the wound. 
 
 In all kinds of suturing the process is aided by the use of wound -hooks, 
 which render the edges straight, parallel, and tense, and lift away the abdomi- 
 nal wall from the underlying intestines and viscera. 
 
 Sutures are removed from the tenth to the fifteenth day. 
 
 INSTRUMENTS USED IN OPERATIONS UPON THE ABDOMINO-PELVIC 
 
 WALL. 
 
 Scalpels; probe-pointed bistoury; scissors, pointed and blunt, straight and 
 curved; forceps, dissecting and toothed; artery-clamp forceps; retractors, 
 various; probe; grooved director; tenaculum; wound-hooks; sponge-holders; 
 aneurism-needle ; needles, curved and straight ; needle-holder; ligature-car- 
 riers; ligatures and sutures, plain and chromic gut, silk, silkworm-gut; gauze 
 pads; drainage-tubes. 
 
 MEDIAN ABDOMINAL SECTION. 
 
 Description. — The opening of the abdominal or abdomino-pelvic cavity 
 through an incision in the median line of the abdomino-pelvic wall. The 
 site of this incision may be anywhere between the tip of the ensiform cartilage 
 and the svmphysis pubis — dependent upon the object of the operation. Ab- 
 dominal section, except in cases where done for exploration, is generally but 
 the preliminary step preceding some special operation. 
 
 Preparation. — Anterior abdominal wall shaved, especially along site of 
 linea alba. Recesses of navel thoroughly cleansed. Bladder is emptied, 
 especially if incision is to extend very low. 
 
 Position. — Patient supine, at edge of table, with arm beneath back. 
 Operation-site is walled off with sterilized towels. Surgeon on right, cutting 
 from above downward. Assistant opposite. 
 
 Landmarks. — Median line (linea alba). The center of the lower portion 
 of the sternum, the umbilicus, and the suprapubic notch all are in the median 
 straight line of the body in the normal abdomen. 
 
 Incision. — Is placed directly in the median line — above, below, or in- 
 cluding the umbilicus, as indicated. If more room be needed than planned 
 in the original incision, it may be gotten by continuing the incision upward 
 or downward. After incising to within 5 cm. (2 inches) of the bladder, great 
 care should be exercised and the bladder protruded away from the line of 
 incision by the fingers of the left hand — for, although empty, if adherent 
 unusually high, it may be wounded. In passing the site of the umbilicus 
 the incision may be carried directly through its center, with a slight tendency 
 to the left just above the umbilicus, to avoid the suspensory ligament of the 
 liver — or may pass, when quite near the upper or lower aspects of the um- 
 bilicus, in a curved direction around it — the curve passing to the left, thereby 
 51 
 
802 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 avoiding the round or suspensory ligament (the remains of the fetal umbilical 
 vein) between the umbilical fissure of the liver and the umbilicus — which is, 
 in consequence, left adherent to the right lip of the wound. (See Fig. 576 
 A and B.) 
 
 I 
 
 Fig- 5 76-— Incisions for Abdominal Sections: — A, Median Abdominal Section, supra-umbil- 
 ical; B, Median Abdominal Section, infra-umbilical; C, Imaginary line from umbilicus to anterior 
 superior iliac spine; D, Anterior superior iliac spine; E, Incision for McBurney's Intramuscular 
 Abdominal Section ; F, Incision (skin portion) for Weir's prolongation of the antero-lateral Intra- 
 muscular Abdominal Section; G, The Battle-Jalaguier-Kammerer Incision; H, Superficial trans- 
 versely curved incision of Pfannenstiel's Median Inferior Abdominal Section ; I, Deep vertical inci- 
 sion of Pfannenstiel's Median Inferior Abdominal Section ; J, Meyer's " Hockey-stick " Incision ; K, 
 Fowler's Angular Incision; L, Oblique Subcostal Incision; M, Vischer's Lumbo-iliac Incision; N, 
 Position of deep epigastric vessels. 
 
 Operation. — (1) Having steadied and rendered tense the abdominal wall 
 by left thumb and forefinger (or middle finger) on either side of the median 
 line, the incision is made the full length of the predetermined distance, at 
 one clean sweep of the knife, passing through skin and connective tissue. 
 
MEDIAN ABDOMINAL SECTION. 
 
 803 
 
 In very fat subjects the skin and thick fatty areolar tissue may be divided 
 by two or three successive sweeps of the knife. Throughout the passage 
 through the abdominal wall, all incisions should be made the full length of 
 the original skin incision. (See Fig. 577.) (2) Clamp all bleeding vessels 
 upon the lips of the wound, and subsequently tie with gut those likely to 
 bleed. (3) Continuing to retract the lips of the wound with left thumb and 
 
 Fig. 577- — Median Abdominal Section: — A, Skin; B, Fascia; C, C, Inner borders of the 
 recti and pyramidales muscles; D, Transversalis fascia and subperitoneal areolar tissue; E, 
 Peritoneum; F, F, Forceps grasping and lifting up the peritoneum; G, Knife cutting through the 
 fold of peritoneum made prominent by traction. 
 
 forefinger, incise the aponeurosis of the recti directly to the median line. 
 While aiming to cut between the inner margins of the recti muscles, along 
 their line of junction, without dividing their muscular fibers, it is found, 
 especially when operating below the umbilicus, that frequently one or both 
 recti, together with their sheaths, are cut, or the pyramidales, where the 
 latter overlap inwardly. The linea alba is not as distinct below the umbilicus 
 as above it. In the upper three-fourths of the anterior abdominal wall, 
 
804 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 directly in the median line, after passing through the skin and fascia, one 
 divides the aponeurosis between the inner borders of the recti; and just to 
 one side of the median line, one divides the outer layer of the rectal sheath, 
 the rectus muscle, the inner layer of the rectal sheath (which inner layer is 
 formed by the aponeurosis of the transversalis and inner lamella of the internal 
 oblique). In the lower one-fourth of the anterior abdominal wall, directly 
 in the median line, after passing through skin and fascia, one divides the 
 aponeurosis between the inner borders of the recti; and just to one side of 
 the median line, one divides the outer layer of the rectal sheath, the pyrami- 
 dalis, the rectus muscle, and comes directly down upon the transversalis fascia, 
 which here alone forms the posterior layer of the rectal sheath. All bleeding 
 vessels encountered in passing through the aponeurotic and muscular planes 
 of the abdominal wall are clamped or tied. (4) The fascia transversalis is 
 now exposed in the whole length of the wound, lying beneath the posterior 
 layer of the rectal sheath in the upper three-fourths of the linea alba — and 
 forming the posterior layer in the lower fourth — and is similarly incised. (5) 
 The subperitoneal areolar tissue lies between the transversalis fascia and the 
 peritoneum, and is generally divided together with the transversalis fascia. 
 It may be quite thick in the very fatty. All clamped vessels are now tied 
 before opening the peritoneum. (6) The peritoneum is now encountered 
 lying directly beneath the subperitoneal areolar tissue — its position being 
 anticipated by a recognition of the structures and layers through which the 
 incisions have passed — and its actual presence is further recognized by its 
 commoner characteristics, available in the majority of cases — its glistening, 
 bluish, arborescent surface, and tough nature (which are less available iii 
 adhesions and other abnormalities). Having controlled all bleeding, the peri- 
 toneum, the final barrier to the peritoneal cavity, is now to be opened. L 
 is important that the peritoneum should be isolated from all underlying 
 structures, and especially the intestines, before being incised. This is best 
 done by picking it up lightly with a pair of toothed forceps, in the form of 
 a small fold. Thus grasping the peritoneum, the forceps should be shifted 
 laterally and vertically to determine that they hold nothing in their teeth 
 but peritoneum alone. Should intestines, omentum, or other structures have 
 been grasped, in addition to the peritoneum, a new and lighter hold should 
 be taken. While thus held in the grasp of the forceps — or, better still, between 
 the grasps of two pairs of forceps, one held by the surgeon and the other 
 by the assistant — the peritoneum is at first opened to a very limited extent, 
 by making a carefully guarded scissors-cut or knife-incision, in the median 
 line, near the tip of the single pair of forceps — or between the tips of the 
 double pair. One limb of a pair of straight, blunt scissors, or a probe-pointed 
 bistoury, is now introduced into this small opening, and the incision enlarged 
 by cutting in the median line — introducing the left first and second fingers 
 as a guide (formed by their palmar surface) as soon as sufficient opening 
 has been made — after which the peritoneal opening is enlarged to correspond 
 with the length of the rest of the wound, which should nowhere be funnel- 
 shaped, but of equal depth throughout. (7) Having opened the peritoneum 
 and widely retracted the lips of the abdominal wound, the special object 
 for which the abdominal section was made is now carried out. (8) Having 
 completed the object of the operation, and prior to closing the abdominal 
 wound, the abdominal cavity should be cleansed of all fluid, by means of 
 gauze mops or sponges — especially in the regions of Douglas's pouch, in the 
 female, the iliac fossae, the renal and hepatic regions, and among the intestinal 
 coils and recesses. Where the abdominal cavity has been extensivelv soiled, 
 
MEDIAN ABDOMINAL SECTION. 
 
 8o 5 
 
 especially bv tenacious fluids, a general flushing of the cavity may be indicated, 
 until the irrigating fluid comes away clear, followed by light sponging with 
 gauze mops. Having cleansed the cavity, stopped all bleeding by ligature, 
 and counted all instruments and 
 sponges, or pads, used in the oper- 
 ation, the abdomen is ready for 
 closure. (9) Several methods of su- 
 turing the lips of the wound are in 
 use. Preceding the adoption of any 
 particular method, the underlying in- 
 testines and viscera are protected and 
 held out of the way by a broad pad 
 of absorbable gauze. This pad also 
 absorbs any suture-bleeding which 
 may occur, and remains in situ until 
 nearly the entire length of the deepest 
 layer (or nearly all of the single layer, 
 where but one layer of sutures is used) 
 is placed and tied (if interrupted), or 
 tightened (if continuous) — and is then 
 withdrawn through one end. (a) In- 
 terrupted sutures of all layers in a 
 single tier: — Having armed a fully 
 curved needle, held in a needle- 
 holder, with fairly stout silk, the su- 
 tures are passed from without into the 
 abdominal cavity through one wound- 
 lip, and thence outward through the 
 opposite, passing through all of the 
 constituents of each lip, in the follow- 
 ing manner: While the lips of the 
 wound are held under slight tension 
 by wound-hooks at either end, the sur- 
 geon grasps the entire thickness of one 
 lip between his left thumb and finger 
 and sees that all of the component 
 structures of that lip are brought into 
 line at the margin of the wound, so 
 as to be within bite of the point of 
 the needle. This is particularly neces- 
 sary in the case of the peritoneum, 
 which is often partially separated 
 from the rest of the abdominal wall 
 in the subperitoneal areolar plane 
 and is thus apt not to be included 
 in the suture. While thus holding 
 the lip of one side, the needle is 
 passed from without inward, passing 
 through all the structures of the lip at 
 the same distance from their free edge 
 and entering the abdominal cavity. The opposite lip is similarly grasped 
 and the needle similarly passed — but from within outward, emerging at a 
 corresponding point on the side opposite to that entered. Each of the in- 
 
 Fig. 578. — Tier-suturing of the 
 Wound following Median Abdominal 
 Section: — Continuous suture approxima- 
 ting edges of peritoneum; — Interrupted 
 sutures bringing together subserous areolar 
 tissue, transversalis fascia, borders of 
 recti muscles, and aponeuroses of the 
 recti; — Continuous suture of superficial 
 fascia, especially where this is thick; — 
 Interrupted sutures of the skin. 
 
806 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 terrupted sutures will penetrate the lips of the wound at about 0.5 cm. ( T \ 
 inch) from their edge, and will be about 1 cm. (f inch) apart. When all 
 are placed, the free ends of the sutures on either side should be grasped 
 and drawn upon, to see if the lips come well and evenly together. While the 
 lips are still under tension the sutures are tied, generally beginning at one 
 or the other end. Just prior to completing the tying, the gauze pad over 
 the intestines must be withdrawn. Superficial sutures may be put through 
 the skin and connective tissue between the others, if necessary. Where much 
 tension exists, deep relaxation sutures, placed about 1.2 cm. (^ inch) from 
 the lips of the wound, and about 2 cm. (f inch) apart, may be placed. Chro- 
 mic gut may be similarly used. Silkworm-gut may be used, but requires 
 especial care in tying the knot, (b) Tier-suturing: — First Tier — peritoneum. 
 (To shut off the abdominal cavity.) A buried, continuous (may be inter- 
 rupted), fine, chromic catgut suture, passed upon a straight needle, at a 
 distance of about 0.3 cm. (£ inch) from the edge. Second Tier — aponeuroses 
 of rectal sheath, including transversalis fascia and subperitoneal areolar 
 tissue, and margins of recti where they have been cut. (Chief suture of 
 strength.) Interrupted, buried, chromic catgut suture, introduced upon a 
 curved needle, about 0.5 cm. (f^- inch) from the edge and about 1 cm. (f 
 inch) apart. Third Tier — subcutaneous areolar tissue, that is, all tissues 
 between the outer layer of the rectal sheath and the skin. (To obliterate 
 dead spaces.) A continuous, buried, chromic catgut suture, introduced upon 
 a straight needle. Fourth Tier — skin. (To shut off outside contamination.) 
 A continuous, subcuticular silk suture passing through the tough corion, intro- 
 duced upon Keith's long, straight abdominal needle. (See Fig. 578.) Inter- 
 rupted silkworm-gut maybe used for the fourth tier (though stitch-abscesses are 
 more frequent) . Or strong, fine catgut may be used — and need not be removed. 
 Interrupted silk sutures are often used. The tier method of suturing is prefer- 
 able to the single- layer suture. Often but three tiers are used — Continuous 
 chromic suture of peritoneum; — Interrupted chromic gut suture of subperi- 
 toneal and transversalis fascial, rectal aponeuroses (or recti themselves) en 
 masse; — Interrupted silkworm-gut, or silk suture, of skin and subcutaneous 
 fascia. Sometimes only two tiers are used — Continuous chromic gut of peri- 
 toneum; — and Interrupted silk or chromic gut of the remaining tissues. (10) 
 No drainage is ordinarily used. Several layers of gauze and cotton are 
 placed over the wound — and one of the various forms of abdominal binders 
 applied. 
 
 Complications Occurring during Abdominal Section. — (a) Adhe- 
 sions; — (1) Adhesions of the intestines, viscera, or omentum with each 
 other, or with the parietal wall, may be encountered. (2) When, in the 
 presence of adhesions, there is doubt as to whether the peritoneal cavity has 
 been reached, pick up and roll the tissues between the finger-tips, thus judging 
 of their nature. (3) The general principle to be adopted in the management 
 of adhesions is to find the plane of cleavage in the abnormal union — and, 
 following it up, separate it as carefully as possible by fingers or blunt dissection. 
 Where this is impossible, areas, dependent upon their nature, have to be 
 ligated or clamped and cut, with the sacrifice of some portion of the least 
 important structure. Ligatures are best made with plain gut for small adhe- 
 sions, and chromic gut for large adhesions. While slighter adhesions may be 
 mechanically separated, denser ones are to be clamped or ligated, en masse 
 or piecemeal, and cut. (4) Intestinal Adhesions. Thin membranous adhe- 
 sions may be stripped apart. Dense, organized adhesions must be separated 
 by careful dissection, requiring especial care, as no part of the entire thickness 
 
ANTEROLATERAL ABDOMINAL SECTION. 807 
 
 of the adhesion can be taken from the one and left as a patch on the other, 
 as may be done in some adhesions in other localities. (5) Omental Adhesions. 
 These must be stripped off, or ligated and excised. The entire omentum 
 may be ligated and excised, if necessary. Omental adhesions are ligated 
 on their proximal side — by pushing forceps through the free spaces and 
 drawing back the gut ligature and tying — and repeating the step, always 
 tying over the free edge left by the preceding ligature. See Omentum, page 
 830. (6) Visceral Adhesions: — Where separation cannot be accomplished — - 
 and where the step is possible, a layer, or the entire thickness, of the less 
 important structure is left attached to the more important one — after ligaturing 
 and blunt dissection or incision. The serous covering of the viscera should 
 be preserved wherever possible — thereby aiding in the preservation of nutrition 
 and the avoidance of adhesions and sloughing. Such denuded surfaces may 
 have omental grafts applied. See Omentum, page 830. In the median ab- 
 dominal section it is to be remembered that an adherent bladder, though 
 empty, may not be able to descend out of the way of the incision, — and thereby 
 may not escape injury unless specially guarded. For further consideration 
 of adhesions, see the Peritoneum, page 820. Also see Fig. 586. (B) Hemor- 
 rhage : — Tie, where possible, all vessels prior to their division, or immediately 
 afterward — as encountered in the steps of the operation after entering the 
 abdominal cavity. Vessels which have been cut without recognition, should be 
 immediately clamped and then tied. In the abdominal incision, prior to enter- 
 ing the cavity, the vessels are clamped as cut and tied before opening the peri- 
 toneal cavity. Gauze pressure and hot douching often control bleeding from 
 indefinite sources. (C) Irrigation : — Unless the abdominal cavity be contami- 
 nated or soiled, or unless much hemorrhage have occurred, irrigation is gen- 
 erally not indicated. If indicated, hot normal salt solution is used. Localized 
 infection can often be treated by localized flushing and wiping — general 
 infection by general flushing and drying with gauze mops. (D) Drainage : — 
 Not indicated in uncomplicated cases. Indicated in (a) Localized and 
 general infection (in the former, generally — in the latter always), — (b) After 
 intestinal or hollow-visceral suturing, where there is uncertainty of efficiency 
 of the suturing or integrity of the intestine or viscus, — (c) In persistent hemor- 
 rhage. Nature of drainage materials, — gauze, rubber tubing, glass tubing, 
 strands of gut, silk, or horsehair. Where drainage is used, the wound should 
 have the suturing placed throughout, and just as though the entire wound 
 were to be closed — and those at first left untied for the passage of the drain, 
 should be tightened and tied when all occasion for drainage has ceased. 
 Comment. — See under General Surgical Considerations, page 799. 
 
 ANTERO-LATERAL ABDOMINAL SECTION 
 
 BY McBURNEY'S INTRAMUSCULAR ("GRIDIRON") INCISION. 
 
 Description. — Having divided skin and fascia, the various musculo- 
 aponeurotic planes of the abdominal wall are divided in the order encountered 
 and in a line with the muscular and tendinous fibers composing those planes — ■ 
 thus avoiding the division of any important nerves; the transverse division of 
 any of the component muscular fibers; the retraction of transversely cut mus- 
 cular and tendinous fibers — and, therefore, avoiding the consequent paralysis 
 of parts supplied by severed nerves, and weakening of cut muscles. 
 
 While McBurney's operation is chiefly applicable to the antero-lateral 
 abdominal region (where the external and internal oblique and the transver- 
 
8o8 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 salis muscles are all present), the principle of intramuscular separation should 
 be applied to all sites of the abdominal wall where it is possible to do so. 
 The operation is principally resorted to for the removal of the appendix 
 vermiformis, especially in the quiescent stage of appendicitis 
 
 Preparation.— Site of incision to be shaved. 
 
 Position.— As in Median Abdominal Section. 
 
 Landmarks. — Where the operation is done in connection with Appendic- 
 
 i 
 
 Fig. 579. — Anterolateral Abdominal Section by McBurney's Intramuscular 
 ("Gridiron") Incision: — A, A, Retracting external oblique, the fibers of which have been 
 separated in the line of their cleavage; B, B, Retracting internal oblique and transversalis, 
 split in the lines of their cleavage. Beneath these an incised wound in the peritoneum is seen, 
 through which appear coils of intestine. 
 
 ectomy, McBurney's point is located, which is a point on an imaginary 
 line extending from the anterior superior iliac spine to the umbilicus, at a 
 distance of 3.8 cm. (ij inches) internal to the anterior superior iliac spine. 
 
 Incision. — In cases of Appendicectomy, the incision commences about 
 2.5 cm. (1 inch) above the imaginary line just mentioned, and passes obliquelv 
 downward and inward in the direction of the fibers of the external oblique 
 muscle and aponeurosis — crossing the above line at McBurney's point — and 
 ending about the same distance below as above it. The length of the incision 
 
AXTERO-LATERAL ABDOMINAL SECTION. 809 
 
 may be greater or less than the above, according to the space required. A 
 free skin incision greatly aids the muscular retraction. (See Fig. 576, E.) 
 
 Operation. — (I) Having incised the skin and fascia in the above line 
 (which will correspond with the cleavage line of the skin), and having con- 
 trolled hemorrhage and retracted the lips of the wound, the muscular and 
 tendinous fibers of the external oblique will be exposed. (See Fig. 579.) (2) 
 Incise the external oblique, with a sharp scalpel, directly in a line with its 
 muscular fibers above, and their tendinous continuation in the aponeurosis 
 below — continuing the separation with scalpel or scissors, incising between 
 the fibers without severing them. The two lips of the incised external oblique 
 are drawn respectively upward and inward, and downward and outward — 
 thus exposing the intermuscular fascia between external and internal oblique. 
 (3) The sheath and fibers of the internal oblique (the muscle being here quite 
 thick) are now similarly separated by scalpel, scissors, or blunt dissection, 
 in the line of their cleavage (which is nearly at a right angle to the cleavage 
 line of the fibers of the external oblique), the center of the separation of the 
 fibers being about opposite the anterior superior iliac spine. The lips of the 
 internal oblique are now retracted respectively upward and outward, and 
 downward and inward — thus exposing the intermuscular fascia between in- 
 ternal oblique and transversalis. Guard with especial care all nerves lying 
 in this intermuscular plane. (4) The fibers of the transversalis, which, for 
 practical purposes, run very nearly in the same direction as those of the 
 internal oblique, are now similarly separated in their cleavage line. The lips 
 of the transversalis may be separately retracted upward and downward, 
 but are generally included in the grasp of the same retractors which retract 
 the internal oblique. The transversalis fascia at the bottom of the wound 
 is thus exposed for an inch or more. (5) The transversalis fascia is grasped 
 with forceps and divided in the line of the transversalis muscle (transversely) — 
 when the subserous areolar tissue and peritoneum will be exposed. (6) The 
 peritoneum is grasped with two delicate-toothed forceps, manipulated as in 
 the median abdominal section, and divided with scissors to a limited and 
 guarded extent. One blade of the scissors is then carefully introduced within 
 the abdominal cavity and the opening enlarged toward the median line and 
 the anterior superior iliac spine. The subperitoneal areolar' tissue, trans- 
 versalis fascia, and peritoneum may be simultaneously incised — but it is better 
 to incise down to and recognize the peritoneum, and then incise the peritoneum 
 separately and alone. (7) The special object of the operation is now accom- 
 plished. The wound is then ready for closure. (8) Separate continuous 
 suturing of the following layers with catgut is made ; — (a) peritoneum, sub- 
 serous areolar tissue, and transversalis fascia — (b) transversalis — (c) internal 
 oblique — (d) external oblique — (e) subcutaneous fascia, especially where 
 thick — (f) and the skin is closed by subcuticular silk suture, or interrupted 
 silkworm-gut. The subcutaneous areolar tissue and skin are often included 
 in one tier, where interrupted suturing of these two structures is done. All 
 parts are thus brought together along their original cleavage lines and accu- 
 rately approximated. 
 
 Comment. — (I) But small part of the muscular portion of the external 
 oblique is exposed. (2) The twelfth intercostal nerve, and, when the incision 
 is long, the iliohypogastric nerve are in danger (as they run somewhat more 
 transversely than the fibers of the external oblique) and should be retracted 
 out of danger. (3) This is the best method of entering the abdominal cavity, 
 where applicable. 
 
8io 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 ANTERO-LATERAL ABDOMINAL SECTION 
 
 BY THE HARRINGTON-WEIR PROLONGATION OF THE ANTERO-LATERAL INTRA- 
 MUSCULAR INCISION THROUGH THE RECTAL SHEATH, WITH TEMPORARY 
 DISPLACEMENT OF THE RECTUS. 
 
 Description. — Having entered the abdominal cavity by the intramuscular 
 operation just described, an extension or enlargement of that incision, with 
 a fuller exposure of the abdominal, pelvic and iliac cavities, may be obtained 
 by continuing that incision to the outer border of the rectal sheath, tearing 
 off the " denuded fascia of the external oblique muscle," incising transversely 
 the remaining structures forming the anterior layer of the rectal sheath and 
 displacing the rectus muscle toward the median line, followed by the transverse 
 division of the posterior rectal sheath. While the operation is chiefly appli- 
 cable to the region of the appendix, it may be used on either side of the 
 abdomino-pelvic region, and also in the region of the liver and gall -bladder 
 where additional room is necessary. It will be here described in connection 
 with appendicectomy. 
 
 Preparation — Position. — As in McBurney's Intramuscular Operation 
 (page 808). 
 
 Landmarks. — McBurney's point (see McBurney's Operation, Landmarks, 
 page 808) ; linea alba; semilunar line. 
 
 Incision. — Begins as an ordinary McBurney intramuscular incision — and, 
 after prolonging the incision to the outer border of the rectus, and after 
 
 Fig.580.— Antero-lateral Abdominal Section by Weir's Method :— A, External oblique 
 muscle; B, External oblique being separated from the anterior layer of the rectal sheath ; C, Internal 
 oblique muscle ; D, Transversalis muscle; E, Transversalis fascia, subperitoneal areolar tissue, and 
 peritoneum; F, Anterior layer of rectal sheath; G, Posterior layer of rectal sheath; H, Rectus 
 muscle ; I, Deep epigastric vessels ; J, Branch of deep circumflex iliac, or of one of lumbar arteries; 
 K, Twelfth intercostal, or iliohypogastric nerve ; L, A superficial vessel ; M, Coils of small intestine. 
 
 tearing off and retracting inward the fascia of the external oblique from the 
 sheath of the rectus, the incision is continued across the anterior layer of 
 the sheath of the rectus in a prolongation of the same line with the intra- 
 
ANTERIOR ABDOMINAL SECTION THROUGH RECTAL SHEATH. 8ll 
 
 muscular opening into the peritoneum (or may be continued transversely 
 across) — followed by the inward retraction of the rectus muscle and trans- 
 verse division of the posterior rectal sheath. (See Fig. 576, F.) 
 
 Operation. — (1) Proceed exactly as in the McBurney operation, up to 
 the point of entering the abdominal cavity — whether operating upon the right 
 or left side. (2) Continue the separation of the fibers of the external oblique 
 muscle and aponeurosis, in the line of their cleavage, right up to the linea 
 semilunaris (outer border of the rectal sheath). Also continue the separation 
 of the fibers of the internal oblique and transversalis until the inner aspect 
 of the common opening is brought up to the outer margin of the rectal sheath. 
 (See Fig. 580.) (3) The already denuded fascia of the external oblique is 
 now separated by blunt dissection from the anterior layer of the sheath of 
 the rectus, from the linea semilunaris inward to the median line — retracting 
 or dividing the overlying structures where necessary. (4) While the denuded 
 and displaced fascia of the external oblique is held retracted, the remaining 
 structures forming the anterior layer of the rectal sheath (aponeuroses of in- 
 ternal oblique and transversalis) are divided transversely, or slightly obliquelv, 
 inward, in a line continuing the external oblique intramuscular incision — or, if 
 the abdominal cavity have been already opened and more room be needed, in a 
 line with the intramuscular opening into the peritoneum. (5) Separate the 
 outer border of the rectus from its sheath and retract the muscle inward as far 
 as necessary, lifting it away from the posterior layer of the sheath. (6) Doublv 
 ligate and divide the deep epigastric artery and veins lying upon the transver- 
 salis fascia — unless they may be temporarily displaced by retraction. (7) 
 Incise transversely the posterior layer of the sheath of the rectus (which, in 
 the lower part of the abdomen, consists of transversalis fascia alone) and 
 peritoneum, both in the same line as the incision through the anterior laver — 
 thus opening up the abdomino-pelvic cavity toward the median line. (8) 
 The abdominal, pelvic, and iliac cavities are thus exposed and the object 
 of the operation accomplished. (9) The suturing of the general wound is 
 done as in the McBurney operation (page 809, paragraph 8). In closing the 
 portion involving the rectal sheath, the posterior layer of the sheath is sutured 
 with continued catgut — the rectus muscle is then allowed to fall back into 
 place — and the anterior layer of the sheath is similarly closed. 
 
 Comment. — Additional exposure is secured by the Trendelenburg posi- 
 tion, or by sand-bags under the hips. This is the best one of the modifications 
 of the intramuscular operation, for giving increased room. 
 
 ANTERIOR ABDOMINAL SECTION THROUGH THE RECTAL SHEATH, 
 WITH TEMPORARY DISPLACEMENT OF THE RECTUS, 
 
 BV THE BATTLE-JALAGUIER-KAMMERER METHOD. 
 
 Description . — Consists, after a vertical incision of skin and fascia, in 
 the vertical division of the anterior layer of the sheath of the rectus, with 
 the retraction of the entire rectus inward — followed by the vertical division 
 of the posterior layer of the rectal sheath, somewhat nearer the median line, 
 together with the subserous areolar tissue and peritoneum. At the end of 
 the operation the rectus is allowed to resume its normal position, and the 
 divided rectal sheath is repaired. Chiefly used in the quiescent stage of appen- 
 dicitis — and also applicable in some operations upon the stomach, liver, and 
 gall-bladder. 
 
 Preparation— Position.— As in Median Abdominal Section. 
 
8l2 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Landmarks. — Linea alba and linea semilunaris, forming, respectively, 
 the inner and outer boundaries of the rectal sheath. 
 
 Incision. — Vertical incision about 7.5 cm. (3 inches) long, and calculated, 
 as nearly as possible, to fall from 1 to 2.5 cm. (f to 1 inch) internal to the 
 outer border of the rectus. (See Fig. 576, G.) 
 
 Operation. — (1) Incise skin and fascia in the above line — clamp vessels — 
 retract overlying tissues — and expose the rectal sheath. (2) Incise the ante- 
 rior layer of the sheath of the rectus vertically, at a distance of from 1 to 2.5 
 cm. (f to 1 inch) internal to its outer border. (See Fig. 581.) (3) Retract 
 outward the outer portion of the divided rectal sheath, so as to expose the 
 
 Fig. 5S1. — Abdominal Section by the Battle-Jalaguier-Kammerer Incision: — A, A, 
 Anterior layer of rectal sheath; B, Posterior layer of rectal sheath; C, Incision through anterior 
 layer of rectal sheath; D, Left rectus muscle displaced toward median line; E, Incision through 
 posterior layer of rectal sheath (further toward median line than incision through outer rectal 
 sheath) exposing coils of intestine; F, Transverse fascia, subperitoneal areolar tissue, and peri- 
 toneum; G, A superficial vessel. The operation is here shown on the left side. 
 
 outer border of the rectus muscle — and then retract the intact rectus muscle in- 
 ward (Fig. 582). (4) Incise the posterior layer of the rectal sheath somewhat 
 nearer the median line than in the case of the anterior layer. Or, in operating in 
 the neighborhood of the deep epigastric artery, in order to avoid this vessel, 
 the incision in the posterior layer may be made somewhat further outward 
 than the incision through the anterior layer. The artery may, however, be 
 readily ligated if in the way. (5) In the same line as the division of the 
 posterior layer of the rectal sheath, incise vertically the subjacent tissues — 
 which will consist of transversalis fascia, subperitoneal areolar tissue, and 
 peritoneum, except below the semilunar fold of Douglas, below which line 
 
ANTERIOR ABDOMINAL SECTION THROUGH RECTAL SHEATH. 813 
 
 the posterior layer of the sheath itself consists of transversalis fascia alone, 
 and the subjacent tissues consist of subperitoneal areolar tissue and perito- 
 neum. (6) Having accomplished the object of the operation, the structures 
 are to be sutured in the following layers, — peritoneum, subserous areolar 
 tissue, and posterior layer of the rectal sheath, with interrupted or continuous 
 catgut suture; — anterior layer of rectal sheath with interrupted gut sutures, 
 which also pass partly through the rectus muscle (the displaced border of the 
 rectus should also be sutured to the outer margin of the rectal sheath) ; — 
 the fascia, with gut — and the skin with subcuticular silk, or interrupted silk- 
 worm-gut sutures (or skin and fascia may be sutured together). 
 
 Fig. 582. — " Overlapping " Closure of Exposltre of Abdominal Cavity through 
 the Rectal Sheath: — Line of continuous sutures through peritoneum, subserous areolar 
 tissue, and transversalis fascia; Interrupted mattress sutures passing through posterior layer of 
 outer portion of rectal sheath, on the left, and posterior layer of rectal sheath and outer aspect of 
 rectus, on the right; Mattress suture passing through inner aspect of anterior layer of rectal 
 sheath, on the right, and the outer aspect of the anterior layer, on the left; Interrupted skin 
 sutures. 
 
 Comment. — The chief objection to the operation is the division of the 
 nerves corresponding with the incision, and consequent atrophy and paresis 
 of the rectus. The nerves severed in the site where the operation is usually 
 
814 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 performed (for appendicitis) being generally the tenth, eleventh, and twelfth 
 dorsal, with or without the iliohypogastric. The deep epigastric artery is 
 usually divided, although this is of no great consequence. 
 
 A lateral exposure of the abdominal contents may be secured by adding to 
 the regular Battle-Jalaguier-Kammerer form of exposure the features common 
 to the Fowler operation and to the Weir modification of the McBurney oper- 
 ation. The sheath of the rectus is exposed in the usual manner (Fig. 583). 
 
 Fig. 583. — Fowler's Method of Intramuscular Transverse Exposure of the 
 Abdominal Cavity: — A, Retracting skin and fatty areolar tissue from external oblique; B, 
 Retracting inner lip of incision through outer aspect of rectal sheath. (Modified from Fowler.) 
 
 The rectus is then retracted inward (Fig. 584) — after which the fibers of the 
 external oblique are separated in their cleavage line (Fig. 584) — the internal 
 oblique is retracted or divided — the transversalis fibers are separated in the 
 line of their cleavage — and the transversalis fascia, subserous areolar tissue, and 
 peritoneum are incised at a right angle to the line of the rectus — and the poste- 
 rior layer of the rectal sheath is incised transversely, after careful retraction of 
 the rectus muscle and epigastric vessels. At the close of the operation the 
 aponeurotic lines of division are closed in the lines of their separation. 
 
MEDIAN INFERIOR ABDOMINAL SECTION. 
 
 >I5 
 
 Fig. 584. — Same as Above: — A, Inward retraction of rectal sheath; B, Inward retraction 
 of rectus; C, Separation of fibers of external oblique in cleavage line. The internal oblique is 
 shown beneath the fibers of the external oblique — as is also the transverse incision through the 
 peritoneum and posterior layer of the rectal sheath. (Modified from Fowler.) 
 
 MEDIAN INFERIOR ABDOMINAL SECTION 
 
 BY PFANNENSTIEL'S SUPERFICIAL TRANSVERSELY CURVED AND DEEP VERTICAL 
 
 INCISIONS. 
 
 Description . — A method of entering the peritoneal cavity in the lower 
 median abdominal region — by means of a superficial curved incision, with 
 downward convexity, just above the inner halves of Poupart's ligaments and 
 the symphysis., with an upward retraction of the outlined flap of skin, fascia, 
 and anterior rectal sheath — followed by a deep vertical division in the median 
 line. A median scar is avoided, and the transverse scar lies partly hidden 
 by the hair-line. Hernia is supposed to be less apt to follow. Chiefly used 
 for limited operations upon the tubes, ovaries, uterus, bladder, and pelvic 
 cavity. 
 
 Preparation — Position. — As for Median Abdominal Section. 
 
 Landmarks. — Linea alba; position of deep epigastric arteries; Poupart's 
 ligaments; symphysis pubis. 
 
 Incision. — (1) Superficial transversely curved incision, with downward 
 convexity, beginning and ending over the deep epigastric arteries, passing 
 just above the inner halves of Poupart's ligaments and the symphysis pubis, 
 
8i6 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 in the hair-line; — (2) Deep vertical incision, after the anterior layer of the 
 rectal sheath has been retracted, passes between the inner borders of the 
 recti muscles, in the median line, from just above the symphysis pubis upward. 
 (See Fig. 576, I and H.) 
 
 Operation. — (1) Incise skin, fascia, and anterior layer of rectal sheath 
 in the superficial transversely curved incision. Clamp vessels. Dissect and 
 retract the curved flap thus formed upward, including the anterior rectal 
 
 Fig.jS^. — Abdominal Section by Pfannenstiel's Superficial Transversely Curved and 
 Deep Vertical Incisions : — A, Flap, with anterior layer of rectal sheath adherent, turned upward ; 
 B, Linea semilunaris; C, Rectus muscle; D, Pyramidalis muscle; E, Transversalis fascia, subperi- 
 toneal areolar tissue, and peritoneum; F, Coils of small intestine; G, Uterus; H, Bladder; I, A 
 superficial vessel. 
 
 sheath, thereby exposing the bared recti muscles. (See Fig. 585.) (2) Incise 
 between the inner borders of the recti and pyramidales muscles, just as in 
 median abdominal section, until the peritoneal cavity is reached, which is 
 entered just as in that operation. (3) Having accomplished the object of 
 the operation, the wound is sutured in the following manner; — the posterior 
 laver of the rectal sheath is closed with continued catsrut suture, including 
 
INFERIOR ANTEROLATERAL ABDOMINAL SECTION. 817 
 
 the edges of the peritoneum and subserous areolar tissue — the inner margins 
 of the recti are next sutured with gut — the cut edge of the transversely divided 
 anterior rectal sheath is similarly sutured with gut — and the skin wound is 
 closed with silk, or silkworm-gut. 
 
 Comment. — Care is necessary to avoid wounding the bladder, which 
 should be empty at the time of operation. 
 
 INFERIOR ANTERO-LATERAL ABDOMINAL SECTION 
 
 BY MEYER'S " HOCKEV-STICK " IN'CISION. 
 
 Description. — A method of entering the lower antero -lateral abdominal 
 cavity, partly by intramuscular separation, partly by transverse division of 
 muscle, by means of an incision shaped somewhat like a "hockey-stick." 
 Resorted to for the purpose of gaining a greater degree of exposure of the 
 abdomino pelvic cavity than afforded by the simple McBurney incision. 
 Used by its originator for some complicated cases of appendicitis. 
 
 Preparation — Position. — As in McBurney's Operation. 
 
 Landmarks. — Imaginary line from umbilicus to anterior superior iliac 
 spine, with the location of McBurney's point (see McBurney's operation. 
 Landmarks, page 808); Poupart's ligament; outer border of the rectus; deep 
 epigastric artery. 
 
 Incision. — (1) Primary Incision, — begins about 1.3 cm. (\ inch) above 
 an imaginary line from the umbilicus to the anterior spine of the ilium, at 
 a point 2 cm. (J inch) to the inner side of the anterior superior iliac spine 
 (that is, midway between McBurney's point and the anterior superior iliac 
 spine), and passes thence in a direct line toward the point where the femoral 
 artery runs under Poupart's ligament, ending about 1.3 to 2 cm. (h to f inch) 
 above Poupart's ligament. (2) Secondary incision, which is only made sub- 
 sequently, for the purpose of gaining more room, passes upward and inward, 
 or curves directly inward, from the lower end of the primary incision toward 
 the outer border of the rectus. (See Fig. 576, J.) 
 
 Operation. — (1) Incise skin and fascia in the line of the primary inci- 
 sion — clamp vessels — and retract margins of wound. (2) Split the fibers of 
 the external oblique muscle and its aponeurosis in their cleavage line. (3) 
 Divide the internal oblique and transversalis in the same line as made by 
 the separation of the fibers of the external oblique — which will cut the fibers 
 of the internal oblique transversely and those of the transversalis obliquely. 
 (4) Incise the transversalis fascia, subserous areolar tissue, and peritoneum 
 transversely. (5) If more room be now necessary, the left index is passed 
 into the abdominal cavity to the deep epigastric artery, as a guide and pro- 
 tector, and the lower end of the incision is extended upward and inward, 
 or directly inward, to the outer border of the rectus muscle. (6) If still more 
 room be needed, the rectus muscle itself can be displaced inward and the 
 peritoneum incised beneath it. (7) The object of the operation is now accom- 
 plished. The wound is then closed by tier-suturing. 
 
 Comment. — The deep epigastric vessels are doubly ligated and divided, 
 if necessary. 
 52 
 
OPERATIONS UPON THE ABDOMINO-PELVTC REGION. 
 
 INFERIOR ANTERO-LATERAL ABDOMINAL SECTION 
 
 PA' FOWLER'S ANGULAR INCISION. 
 
 Description. — Founded, in part of its application, upon the same principle 
 as McBurney's intramuscular operation — and planned to give freer access to 
 the contents of the ileo-caecal region, and especially to the base of the appendix. 
 Especially intended by its author for cases of appendicitis in which the process 
 is still limited to the appendix. 
 
 Preparation — Position. — As in McBurney's operation. 
 
 Landmarks. — Anterior superior iliac spine; outer border of the rectus. 
 
 Incision. — Begins at the upper border of the anterior superior iliac 
 spine — runs horizontally inward to the outer border of the rectus muscle — 
 curves thence downward and runs parallel with the outer border of the rectus 
 for 5 to 7.5 cm. (2 to 3I inches). (See Fig. 576, K.) 
 
 Operation. — (1) Incise skin and fascia in the above line — clamp vessels — 
 and turn downward and outward this triangular flap of skin and fascia, 
 exposing the aponeurosis of the external oblique beneath. Place retractors at 
 the center of the transverse incision and at the lower angle of the wound, 
 and retract in the cleavage line of the external oblique. (2) Incise the ex- 
 ternal oblique muscle and aponeurosis in the cleavage line of their fibers, 
 and retract in the direction opposite to their cleavage line. (3) Expose and 
 open the sheath of the rectus and retract the rectus muscle, with the deep 
 epigastric vessels, strongly toward the linea alba — while retracting the aponeu- 
 rosis to the outer side. (4) Incise transversely, in line with the horizontal 
 part of the skin incision, the internal oblique and transversalis muscles, 
 transversalis fascia, subserous areolar tissue and peritoneum, all as one 
 structure — beginning at the outer margin of the retracted rectus. And retract 
 the deep lips of the wound, exposing the abdominal cavity. (5) The special 
 object of the operation is now accomplished. (6) At the completion of the 
 operation, the structures are sutured in the following order; — peritoneum, 
 subserous areolar tissue, transversalis fascia, transversalis and internal oblique 
 muscles are all sutured in one layer, with continuous chromic gut; — the rectus 
 is allowed to fall back into place; — the external oblique aponeurosis and 
 muscle are sutured with continuous kangaroo tendon, in which layer the 
 rectal sheath is also included ; — and the skin is closed by a subcuticular silk 
 suture (and the fascia separately with gut, if it be very thick). 
 
 Comment. — In applying the above operation to cases of appendicitis, 
 Fowler considers the base of the appendix to be most generally found at 
 the intersection of a transverse line between the anterior superior iliac spines 
 with a vertical line running midway between the median line of the body 
 and the anterior superior iliac spine. 
 
 This operation gives no more room than Weir's — and the latter operation 
 does not divide muscle-fibers transversely. 
 
 SUPERIOR ANTERO-LATERAL ABDOMINAL SECTION 
 
 BY OBLIQUE SUBCOSTAL IN'CISION. 
 
 Description. — A method of entering the abdominal cavity parallel with 
 and a short distance below the costo-chondral arches. Generally resorted 
 to for the exposure of the subhepatic, gastric, and splenic regions. 
 
LATERAL ABDOMINAL SECTION. 819 
 
 Preparation — Position. — As in Median Abdominal Section. 
 
 Landmarks. — Costo-chondral arches. 
 
 Incision. — Generally parallel with and about 2.5 cm. (1 inch) below the 
 costo-chondral arch of one or the other side — with the center of the incision 
 over the object sought. (See Fig. 576, L.) 
 
 Operation. — (I) Incise skin, and fascia — clamp vessels — retract lips of 
 wound. (2) Incise external oblique, which will be aponeurotic above and 
 muscular below — the incision crossing its fibers about at a right angle. (3) 
 Separate the fibers of the internal oblique in their cleavage line — which may 
 be done external to the outer border of the rectal sheath. (4) Incise the 
 transversalis parallel with the costo-chondral border, which will be perpen- 
 dicular to their fibers. (5) Incise the transversalis fascia, subserous areolar 
 tissue, and peritoneum in the same line with the preceding incision — and thus 
 enter the peritoneal cavity. (6) Having completed the object of the opera- 
 tion — suture the structures in the following layers, with buried catgut; — peri- 
 toneum, subserous areolar tissue, transversalis fascia; — transversalis and in- 
 ternal oblique muscles; — external oblique ; — and fascia and skin with silk 
 or silkworm-gut. 
 
 Comment. — This incision corresponds with the cleavage line of the skin — 
 and especially corresponds with the course of the seventh and eighth inter- 
 costal nerves, which run upward and are thereby uninjured. The incision 
 can be prolonged up to the rectus muscle followed by a transverse incision 
 of its anterior sheath, with inward retraction of the intact muscle — and a 
 similar transverse division of its posterior sheath — the sheath being sutured 
 at the end of the operation. For the application of this incision, see operations 
 upon the stomach. 
 
 EXPOSURE OF HYPOCHONDRIAC REGIONS BY CHONDROPLASTIC 
 RESECTION OF CHEST-WALL 
 
 BY SUBCOSTAL INCISION AXD TEMPORARY DIVISION OF SEVENTH, EIGHTH, 
 NINTH, AND TENTH COSTAL CARTILAGES. 
 
 Owing to the rigidity of the chest-wall it is difficult to satisfactorily expose 
 the dome of the diaphragm, the upper surface of the liver, the lower end of the 
 esophagus, and the cardiac end of the stomach and the spleen. By the tem- 
 porary resection of the costal arch of either the right or left side, as indicated, 
 these structures are much more readily brought into the operative field. 
 
 The details of this operation have been given under Thoracic Operations, 
 page 734- 
 
 LATERAL ABDOMINAL SECTION 
 
 BY YISCHER/S LLMBO-ILIAC INCISION. 
 
 Description. — Consists in the separation of the muscular and tendinous 
 fibers of the abdominal muscles of the lumbo-iliac region, just above the 
 center of the iliac crest, in their cleavage lines, without transverse division 
 of muscle-fibers, or harm to abdominal nerves — and exposing the operation- 
 site by retraction of the separated muscles. Applicable to exposure of struc- 
 tures in the above region, and especially for suppurating cases of appendi- 
 citis — being advantageous because of the ability to extend the opening from 
 either end of the original incision. 
 
820 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Preparation. — As in McBurney's operation. 
 
 Position. — Patient partly turned toward opposite side, with pad placed 
 beneath involved side, to render site of operation prominent. Surgeon on 
 side of operation. Assistant opposite to surgeon. 
 
 Landmarks. — Crest of ilium; anterior superior iliac spine; Poupart's 
 ligament. 
 
 Incision. — Runs 2.5 cm. (1 inch) above and parallel with the crest of 
 the ilium, beginning at the outer border of the external oblique (which corre- 
 sponds with about the center of the iliac crest) and ending opposite the anterior 
 superior iliac spine — or may extend forward parallel with the outer part of 
 Poupart's ligament. (See Fig. 576, M.) 
 
 Operation. — (1) Incise skin and fascia in the above line — clamp vessels — 
 retract lips of wound, exposing the external oblique. (2) The fibers of the 
 external oblique are now separated in their cleavage line. As the fibers of 
 the muscular portion run somewhat more vertically here than the line of 
 the skin incision, a good, free length of separation is necessary, with firm 
 retraction inward and upward, and outward and downward, respectively, in 
 order to expose the internal oblique. (3) The fibers of the internal oblique, 
 which run upward and inward, are similarly separated in their cleavage 
 line, and retracted upward and backward, and downward and forward; — care- 
 fully guarding all important nerve structures between the internal oblique 
 and transversalis, which latter muscle is now exposed. (4) The fibers of the 
 transversalis, running transversely inward, practically in the same line with 
 the internal oblique, are now separated in like manner in their cleavage line, 
 and retracted upward and downward, exposing the transversalis fascia. (5) 
 The transversalis fascia, subserous areolar tissue, and peritoneum are divided 
 vertically — and the peritoneal cavity entered. (6) Upon completion of the 
 operation, the structures are sutured as in McBurney's operation (page 809). 
 
 Comment. — More room may be gotten anteriorly, by continuing the 
 separation of the aponeurotic fibers of the external oblique parallel with 
 Poupart's ligament, in the line of the original incision, — and posteriorly and 
 superiorly, by continuing the separation of the muscular fibers and lumbar 
 aponeurosis. A branch of the deep circumflex iliac artery, between trans- 
 versalis and internal oblique, is clamped and divided. 
 
 Note. — Other incisions are given under the different abdomino-peivic 
 viscera. Closure of the abdominal wall by " overlapping " methods is espe- 
 cially shown under Operations for Hernia, pages 1163 to 1183. 
 
 II. THE PERITONEUM. 
 
 SURGICAL ANATOMY. 
 
 Course of the Peritoneum Forming the Greater Sac — In Longitudinal 
 Section. — Passing down from the umbilicus, the peritoneum lines the anterior 
 abdominal wall — covers the urachus and obliterated hypogastric arteries — 
 passes onto the bladder, from its upper aspect to the trigone — is reflected 
 onto the anterior and upper part of the lateral aspects of the rectum, in the 
 male, forming the recto-vesical pouch. In the female, the reflection is from 
 the bladder onto the uterus (utero-vesical fold) — extending thence over the 
 upper portion of the posterior vaginal wall — and thence to the rectum (recto- 
 vaginal pouch). From the rectum, the sigmoid flexure of the colon is entirely 
 covered (sigmoid mesocolon) — the ascending and descending colons being 
 
SURGICAL ANATOMY OF THE PERITONEUM. 821 
 
 covered, generally, only anteriorly and laterally — and passing from the spine 
 downward, the peritoneum covers the small intestines, forming the lower 
 leaf of the mesentery — and thence back again, completing the investment 
 of the small bowel, forming the upper leaf of the mesentery — and passes 
 backward over the transverse portion of the duodenum to the pancreas — 
 thence forward to form the inferior layer of the transverse mesocolon — covers 
 the inferior and part of the anterior aspect of the transverse colon — thence 
 runs downward to form the posterior layer of the great omentum — returning 
 to form the anterior layer of the great omentum — thence to the stomach, 
 covering its antero-superior aspect — thence to the under surface of the liver, 
 forming the anterior layer of the lesser or gastro-hepatic omentum — thence 
 covers the inferior surface of the liver, from the transverse fissure to its anterior 
 border — whence it is reflected over the anterior border to cover the superior 
 surface of the liver to the posterior peritoneal limit — thence it passes to the 
 inferior concave surface of the diaphragm (superior layer of the coronary 
 ligament) — thence over the anterior portion of the concavity of the diaphragm 
 to the anterior abdominal wall — whence it passes down the anterior abdominal 
 parietes to the umbilicus, to the place of beginning. 
 
 Course of the Peritoneum Forming the Lesser Sac — In Longitudinal 
 Section. — Beginning at the posterior aspect of the stomach, which it covers, 
 the peritoneum of the lesser sac passes upward to the inferior surface of the 
 liver, behind the transverse fissure, forming the posterior layer of the lesser 
 or gastro-hepatic omentum — and having covered the postero-inferior aspect of 
 the liver, it passes on to the under surface of the diaphragm (inferior layer 
 of the coronary ligament) — thence passes downward over the posterior portion 
 of the concavity of the diaphragm to the spine, covering the great vessels — 
 thence to the pancreas — thence forward, forming the upper layer of the 
 transverse mesocolon — covers the supero-anterior aspect of the transverse 
 colon — descends, forming the innermost layer of the great omentum — then 
 ascends to the greater curvature of the stomach — and covers its posterior wall, 
 to the place of beginning. The lesser sac is in relation with the inner aspect 
 of the spleen, forming the inner layer of the gastro-splenic omentum — and 
 also in relation with the superior portion of the left kidnev. 
 
 Layers and Folds of Peritoneum. — (i) Parietal Layer — connected by 
 subperitoneal areolar tissue with the walls of the abdomino-pelvic cavity. 
 (2) Visceral Layer — covers some part, or the entire surface, of all the viscera 
 of the abdomino-pelvic cavity. (3) Mesenteries — folds of peritoneum con- 
 necting parts of the intestinal tract with the posterior abdomino-pelvic wall. 
 See page 833. (4) Omenta — folds of peritoneum connecting the stomach 
 with other viscera. See page 830. (5) Ligaments — reflections of peritoneum 
 from parts of the abdomino-pelvic walls and diaphragm to the various 
 abdomino-pelvic viscera other than the intestines — for example, those of the 
 liver, spleen, uterus, etc. For these ligaments, see the various viscera of the 
 abdomino-pelvic region. 
 
 Foramen of Winslow. — Communication between the greater and lesser 
 peritoneal sacs — revealed by lifting the liver upward and to the right, and 
 depressing the first part of the duodenum and intestines downward and to 
 the left. Bounded: — Superiorly; by caudate lobule of liver; — Inferiorly; by 
 first part of duodenum and first part of hepatic artery; — Anteriorly; by liga- 
 mentum hepato-duodenale (right free edge of lesser omentum), with its con- 
 tained ductus communis choledochus, vena portae, and hepatic artery, in order 
 from right to left — the vena porta? lying somewhat posterior to artery and duct. 
 
 Viscera Almost Entirely Covered by Peritoneum. — Liver; stomach; 
 
822 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 spleen; first portion of duodenum; jejunum; ileum; transverse colon; caecum; 
 sigmoid flexure of colon; upper half of rectum; uterus; ovaries. 
 
 Viscera Partly Covered by Peritoneum. — Descending and transverse 
 parts of duodenum; ascending and descending colons; mid-portion of rec- 
 tum; upper part of vagina; posterior wall of bladder. 
 
 Viscera in Contact with Peritoneum without Being Especially Cov- 
 ered by It. — Kidneys; suprarenal capsules; pancreas. 
 
 Viscera Uncovered by Peritoneum. — Lower end of rectum; neck, base 
 and anterior aspect of bladder; anterior and inferior portion of posterior 
 wall of vagina. 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE 
 
 PERITONEUM. 
 
 Where the peritoneum is attacked surgically it is generally dealt with 
 incidentally, as a part of some special operation. The technic, therefore, 
 of dealing with the peritoneum is described in those special operations. In 
 some cases, however, the peritoneum is the structure primarily dealt with — 
 and will be so considered in the present section. 
 
 The surface form and landmarks of the peritoneum, as well as the instru- 
 ments used, are sufficiently given under the operations upon the viscera of 
 the abdomino-pelvic cavity. 
 
 OPERATIONS FOR THE SEPARATION, DIVISION, OR LIGATION OF 
 PERITONEAL ADHESIONS. 
 
 Description. — Adhesions, resulting from the union of the serous surfaces 
 of the peritoneum, may occur in the form of thin, thick, narrow or broad 
 sheets or membranes; — in the form of fragile, dense, short or long bands; — 
 or as limited or extensive surfaces loosely or intimately united. Adhesions 
 may be vascular or comparatively non-vascular. Adhesions may be en- 
 countered in any operation involving any serous cavity — therefore, the special 
 features, anatomical relations, and all steps preliminary to the discovery of 
 the adhesions, will depend upon the operation in question. 
 
 Two general methods of dealing with adhesions are available; (i) By 
 blunt dissection, with or without ligature, — more applicable in non-vascular, 
 loose and limited adhesions; — (2) By division between ligatures, — more appli- 
 cable to vascular, firmer and more extensive adhesions. 
 
 Separation of Adhesions by Blunt Dissection, with or without Liga- 
 tion. — The underlying principle in this method of dealing with adhesions 
 is to find the plane of cleavage in the abnormal union and follow it up, sepa- 
 rating the adherent surfaces as carefully as possible. This separation is best 
 accomplished by means of a blunt dissector, the handle of a knife, the closed 
 ends of a pair of blunt scissors, or the tip of the finger. If the last be used, 
 a better hold may be gotten upon the parts by stretching a single thickness 
 of gauze over the finger-tip. The adhesions are gently torn apart, always 
 endeavoring to adhere strictly to the cleavage line, especially where important 
 structures are involved, as in the serous coverings of viscera. If the adhesions 
 be limited and but little vascular, ligation is generally unnecessary. If they 
 be vascular, and especially if somewhat extensive and dense, they should be 
 ligated in two places from 1.3 to 2.5 cm. (J to 1 inch) apart, according to 
 circumstances, and then divided between the ligatures. The preferable liga- 
 
OPERATIONS FOR PERITONEAL ADHESIONS. 
 
 ^3 
 
 ture is plain gut for small adhesions — and chromic gut for larger ones. Ad- 
 hesions are often first divided and then ligated. (See Fig. 586, D.) 
 
 Division of Adhesions between Ligatures. — The adhesions are first 
 carefully isolated — and then treated according to their nature. If they be in 
 the form of bands, double ligatures of chromic gut are thrown around them 
 
 Fig.586.— OPERATIONS FOR THE SEPARATION OF PERITONEAL ADHESIONS AND THE LIGATION 
 
 ok Omentum : — A, A, Dividing-, in sections, thick layers of intestino-abdominal adhesions between 
 double ligatures ; B, Incising thin layers of inter-intestinal adhesions ; C, Ligating isolated bands of 
 intestino-abdominal adhesions ; D, Separation of membranous inter-intestinal adhesions by blunt dis- 
 section ; E, F, F, Tying off. in sections, adherent omentum, preparatory to excision of distal portion 
 — E, by means of individual ligature carried by aneurism-needle — F, F, by means of continuous liga- 
 ture applied to the posterior and drawn through the anterior aspect of the omentum in sections, by 
 catch-forceps. 
 
 and tied, and the bands are then divided between them. If the adhesions 
 be in the form of broad surfaces, they are ligated in sections and divided 
 upon the distal side of the ligatures — or between two ligatures, if indicated. 
 (See Fig. 586, A.) 
 
 Visceral Adhesions to the Abdomino-pelvic Wall. — \\ hen entering 
 the abdominal cavity where adhesions may be suspected, or where, in the 
 
824 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 neighborhood of known adhesions, it is uncertain as to whether the peritoneal 
 cavity have been entered, the underlying tissues should be picked up and 
 rolled between the fingers, to enable a judgment to be formed by the sensation 
 imparted. If the peritoneal cavity be entered in the immediate vicinity of 
 an adhesion, this should be at once recognized by sweeping the finger around 
 the vicinity of the opening — and the adhesion separated by blunt dissection, 
 or divided between double ligatures if necessary. Where the opening made 
 comes directly down upon adhesions, these should be recognized as soon 
 as possible, that the progress toward the peritoneal cavity may be known — 
 and then an endeavor be made to reach a free margin of the adhesion, from 
 which the remainder of the separation, or division, may be made on the 
 general principles mentioned. (See Fig. 586, A, C.) 
 
 Intestinal Adhesions. — The thin, membranous or velamentous adhesions 
 may generally be separated by blunt dissection with the fingers — by putting 
 the parts gently upon the stretch and keeping the adhesion in a broad, thin 
 layer, rather than in a thick, twisted cord. Dense, organized adhesions 
 require careful dissection — that no part of either wall raav be dangerouslv 
 thinned. (See Fig. 586, B, D.) 
 
 Inter-visceral Adhesions. — Or adhesions between growths and viscera — 
 should be dealt with by putting the adhesion upon moderate stretch — by 
 traction upon one or both viscera, until the bond of adhesion is demonstrated — 
 then first ligate or clamp on each side, safely to the outer side of the viscus, 
 and divide the adhesion between the ligatures or clamps. 
 
 Omental Adhesions. — Adherent omentum may often be stripped off 
 with the fingers. If too dense, or too firmly united for this, it should be 
 ligated with a single ligature, or in sections, and divided. Large portions 
 of the omentum — and even the entire omentum — may be amputated. The 
 omentum may require onlv a proximal, or mav require double ligaturing. 
 (See Fig. 586, E, F, F.) 
 
 Comment. — (1) While the separation in the plane of the abnormal adhe- 
 sion should always be the course attempted, where this is impossible it often 
 happens that areas, dependent upon their nature, have to be ligated, or 
 clamped, and cut, with the sacrifice of some portion of the least important 
 structure. (2) Where the separation of an adhesion between viscera and 
 neighboring structures (visceral or otherwise) is impossible, and where the 
 step is permissible, one or more layers, or even the entire thickness, of the 
 less important structure is left attached to the more important one — after 
 ligating and blunt dissection, or incision, of the adhesion — thus leaving a 
 limited area of adherent tissue attached to an organ, rather than risk injuring 
 the organ by further attempt at removal. In such cases the portion left is 
 reduced to its smallest and thinnest size. (3) It is always desirable to preserve 
 the serous covering of a viscus (to aid nutrition and avoid adhesions and 
 sloughing) — and sometimes surfaces left raw by separating adhesions may be 
 covered, and hemorrhage also controlled, by suturing adjacent serous surfaces 
 over them — or by attaching omental grafts. (See page 832.) 
 
 Xote. — For further consideration of this subject, see Complications of 
 Median Abdominal Section, page 806. 
 
 PARACENTESIS ABDOMINIS. 
 
 Description. — Puncture of the peritoneal cavity for diagnostic purposes, 
 or for evacuation of fluid. 
 
OPERATIVE TREATMENT OF DIFFUSE SEPTIC PERITONITIS. 825 
 
 Preparation. — Shave abdominal wall. Empty bladder and bowels. 
 Area of dulness verified by percussion immediately before paracentesis. 
 Cocainization of the area of puncture. 
 
 Position. — Patient, where possible, sits upright in chair — where impossi- 
 ble, lies upon edge of bed. A many-tailed, sterilized bandage, or ordinary 
 towel, with a central opening corresponding to the site of paracentesis, is 
 placed around the patient, and tightened posteriorly by an assistant as the 
 abdominal enlargement decreases with the evacuation of fluid. Surgeon sits 
 immediately in front of patient. 
 
 Landmarks. — Linea alba; umbilicus; limit of upper aspect of bladder 
 (see that structure, page 796). 
 
 Special Instruments. — For exploratory punctures, aspiratorv svringes 
 with needles of small caliber. For evacuation of considerable quantity of 
 fluid, a straight cannula and trocar of fairly large size is used. Aspirators 
 of the Dieulafoy and Potain type may be employed. Where the skin is to 
 be preliminarily incised, a knife is necessary — and a needle and thread, 
 where the incision, or trocar-wound, is to be closed bv suture. 
 
 Site of Paracentesis. — Generally in the linea alba, midway between 
 umbilicus and symphysis pubis. Sometimes the puncture is made in the 
 lower half of either semilunar line. 
 
 Operation. — (1) Having so placed the broad bandage that the opening is 
 opposite the site of paracentesis, and having grasped the exploratorv or aspira- 
 torv needle, or trocar, in such a way as to predetermine, by means of the right 
 index, the depth to which it is to enter, which will be decided bv the estimated 
 thickness of the abdominal wall, the instrument is quickly but guardedly 
 thrust through the abdominal wall into the free peritoneal cavity, in a single 
 movement. In the case of the exploratory syringe, sufficient fluid is with- 
 drawn for examination — the needle withdrawn, and the wound closed with 
 collodion and cotton. (2) In the case of the evacuation of large amounts 
 of fluids by means of cannula and trocar (or aspirator) the trocar is with- 
 drawn and the cannula left in situ — the fluid is then allowed to flow, the 
 bandage being tightened pari passu. At the end of the operation, the can- 
 nula is withdrawn — and, if it have been of large size, an interrupted gut 
 suture is made to close the opening by being passed on a curved needle, 
 from side to side, through a part of the thickness of the abdominal wall. 
 The outer aspect of the opening is then closed with collodion and gauze, or 
 cotton. 
 
 Comment. — (i) Where a large size instrument is used, it is best to make 
 a small preliminary incision through the tough skin. (2) A cannula should 
 preferably be used the end of which is not pointed or sharp. (3) If the 
 cannula be obstructed during the flow, it may generally be freed by the 
 passage of a sterile probe down its length. (4) As the fluid escapes, the 
 inner end of the cannula (especially if dull) may be shifted so as to furnish 
 the best evacuation. (5) The fluid should be made to escape slowly — and 
 may be retarded by a compress over the outer end of the cannula — tc avoid 
 syncope. 
 
 OPERATIVE TREATMENT OF DIFFUSE SEPTIC PERITONITIS. 
 murphy's method. 
 
 A great variety of methods of operating for diffuse septic peritonitis, 
 variously combined, have been resorted to by various surgeons — the chief 
 among which have been: Local dry sponging of the involved area, with or 
 
826 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 without evisceration; Extensive saline irrigation of the entire peritoneal cavity 
 during the operation; Local irrigation of the involved area; Simple evacu- 
 ation of septic fluid, with no other procedure; Cigarette, cigar and Mikulicz 
 drains; Glass-tube drainage, with or without gauze; Rubber-tube drainage, 
 with or without gauze; Drainage through unsutured wound, or through 
 wound but partly sutured, with or without gauze or other drains; Drainage 
 through counter-openings (as through the pelvis, loin, perineum, or vagina) ; 
 Closure without irrigation; Irrigation followed by closure; Elevation of 
 head of bed (Fowler's position), with one or more of the above measures. 
 
 Two methods will be here described; Murphy's method, illustrating 
 drainage; — and Blake's method, illustrating irrigation with closure. 
 
 It can not be said that any radically new ideas are used in either method — 
 but each, by grouping various measures, has evolved a technic. 
 
 The features of the Murphy method are the following: 
 
 (1) The rapid removal of the cause of infection, as far as possible, and with 
 the minimum handling of the intestines. No attempt is made to sponge the 
 peritoneal surfaces, or to remove lymph exudate, which would tend to open 
 up channels for toxic absorption. 
 
 (2) The drainage of the floor of the pelvis through a suprapubic incision 
 as well as through the operative incision. The combined post-operative pos- 
 ture and the action of the diaphragm thereby aid in the expulsion Of accumu- 
 lated fluid. 
 
 (3) The foregoing of all lengthy procedure and secondary objects accom- 
 plishing satisfactory drainage and minimizing manipulation and length of 
 anesthesia. 
 
 (4) The semi-sitting post-operative posture (Fowler's position), — for the 
 purpose of causing the fluids to gravitate toward the drains and away from 
 the channels of greatest absorption into the system. 
 
 (5) The post-operative absorption of large quantities of saline solution 
 through the rectum, thus reversing the lymphatic current and converting the 
 peritoneal surface into a secreting rather than an absorbing membrane — and 
 also largely increasing the urine. This is accomplished in the following way; — 
 a nozzle with several openings is inserted into the rectum — to which is attached 
 a rubber tubing leading to a reservoir bag — the bag hanging only a few inches 
 above the level of the rectum — so that the fluid simply trickles into the rectum 
 at but slightly faster rate than absorption occurs. From one to two quarts flows 
 in continuously in about an hour. Through the extra holes in the nozzle 
 flatus is expelled and the intestine thus kept deflated, especially as the nozzle 
 may remain in situ after the tube is disconnected. The peritoneum thus 
 discharges fluid freely — whicn, by diaphragmatic action and the special pos- 
 ture, is carried downward toward the dependent drains — thereby washing 
 the peritoneum in its passage over its surface and escaping through the exits 
 provided. The heart's action is increased and larger quantities of urine are 
 voided, thus increasing the elimination of septic material. 
 
 (6) Intestinal peristalsis is prevented by abstinence from mouth-feeding 
 and drinking — thereby lessening the chance of disseminating septic matter. 
 Opium may possibly be given to aid to this end. 
 
 OPERATIVE TREATMENT OF DIFFUSE SEPTIC PERITONITIS. 
 
 blake's method. 
 
 The features of this technic are, in the words of its author, — "Early oper- 
 ation — lavage of the peritoneum with large quantities of saline solution — 
 
OPERATIVE TREATMENT OF DIFFUSE SEPTIC PERITONITIS. 827 
 
 closure of the peritoneal cavity without drainage, unless the latter is absolutely 
 indicated by the presence of non-absorbable amounts of necrotic material." 
 
 Three categories of cases are recognized — Localized collections of pus, 
 with limiting adhesions — cases of spreading peritonitis with no limitations of 
 
 Fig. 587. — Sites and Forms of Intra-abdominal Drainage and Irrigation: — (1) 
 Cigarette drainage in the appendical region; (2) Mikulicz bag and pack in the left hypochondriac 
 region; (3) Gauze drain from the pelvic peritoneum through the posterior vaginal pouch and 
 vagina; (4) Intra-peritoneal irrigation by Blake's irrigator through median incision (the filling 
 funnel and exit tube are not attached); (5) Drainage of the pelvic peritoneum may also be 
 accomplished through this wound, especially if made somewhat lower; (6) Intra-peritoneal 
 irrigation by Kelly's irrigator (the water returning through open wound, along tube, after dis- 
 tending abdomen); (7) Drainage of the right hypochondrium may also be secured through this 
 wound. 
 
 the process by adhesions or gravitation, but in which the limits, nevertheless, 
 are ascertainable — and cases of general peritonitis in which apparently the 
 entire peritoneal cavity, with possibly the exception of the lesser cavity, is 
 involved. The last two categories constitute general diffuse peritonitis. 
 
8 2 8 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 The two essential features of the technic are — The removal, as early as 
 possible, of the cause of infection, or the limitation of the results of infection, 
 thereby minimizing additional peritoneal and general infection; the placing 
 of the peritoneum in the best condition to combat and eliminate generalized 
 infection. 
 
 The peritoneum is cleansed by abundant irrigation with decinormal saline 
 solution of no° F. This solution may be delivered into the cavity of the 
 peritoneum from the mouth of a pitcher — or, more recently, is carried 
 throughout the indicated portions of the peritoneal cavity by means of a 
 special irrigator (Fig. 587). As much of the fluid as does not readily flow 
 
 Fig. 588. — Approaching an Appendical Abscess by an Extra-peritoneal Route: — 
 A, A, Retracting abdominal wound; B, Reflection of peritoneum detached from iliac fossa and 
 pushed inward; C, Cecum; D, Ileum; E, Appendix; F, Iliac muscle; G, Psoas muscle; H, Iliac 
 vessels; I, Appendical abscess; J, Course of approach and drainage of abscess. (Modified 
 from Kelly and Hurdon.) 
 
 out is left in the cavity — and handling of the intestines, other than done by 
 the irrigator and fluid, is avoided. The peritoneal endothelium is thus less 
 damaged and the detachable products of infection are diluted and removed. 
 
 In those cases in which the focal cause of infection can be removed, drainage 
 may or may not be used. In other cases drainage has been generally used by 
 the majority of operators. More latterly the author of the technic has omitted 
 drainage almost entirely — only using it in cases where the existence of necrotic 
 tissue or hemorrhage necessitated it. 
 
 When indicated, the parietal wound can be drained down to the peritoneum. 
 Other forms of intra-abdominal irrigation and drainage are shown in Fig. 587. 
 
OPERATIVE TREATMENT OF DIFFUSE SEPTIC PERITONITIS. 829 
 OPERATIVE TREATMENT OF INTRA-ABDOMINAL ABSCESSES. 
 
 Only generalizations of technic can be here mentioned — the indications 
 differing in abscesses of different origins and sites. In the present instance an 
 abscess of appendical origin will be taken as a type. 
 
 The site of evacuation of such an abscess, as of any other, will often be 
 determined by the local phenomena of tenderness and swelling — and the 
 incision to the focus of suppuration should generally be over these. As a 
 
 Fig. 589. — Localization of an Adherent Appendicular Abscess through a Primary 
 Incision in the Outer part of the Right Rectus, opening up the General Peritoneal 
 Cavity — and its Evacuation and Drainage through a Secondary Incision near the 
 Iliac Crest, through Adhesions Walling it off from the General Cavity — the Main 
 Wound being Closed. (Modified from Kelly and Hurdon.) 
 
 usual thing, the incision will lie rather to the outer side, between the position 
 of the appendix and the iliac crest, or Poupart's ligament. Where it is possible, 
 the fibers of the external oblique should be separated rather than cut. The 
 internal oblique and transversalis should be injured as little as possible, but 
 the fibers of one or both must generally be divided — or may be penetrated by 
 
830 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 blunt dissection. Sometimes it is necessary to make a free incision, largely 
 dividing the muscles from the last rib to the iliac crest. 
 
 When it is possible to do so, the abscess should be opened retroperitoneally 
 — which is usually accomplished by following down closely to the iliac fossa, 
 detaching and pushing the peritoneum inward — until the abscess can be reached 
 behind the peritoneum (Fig. 588). 
 
 If, on approaching the abscess, the peritoneum be found free and movable 
 over the abscess, one of several courses may be pursued — By displacement of 
 the peritoneum, or the mass, an attempt may be made to reach the site of pus 
 outside of the peritoneum, as just described — The general relations and extent 
 of the abscess may be discovered by one hand introduced into the general 
 peritoneal cavity through a median, or other, incision, and, while this is open, 
 or after its closure, the abscess may be approached and evacuated through a 
 second incision extraperitoneally (Fig. 589) — Or the abscess may be deliber- 
 ately incised transversely, after packing off the field with gauze and guarding 
 the general cavity from infection. 
 
 Whether the pus-sac be reached retroperitoneally, or through adherent peri- 
 toneum, or be free in the peritoneal cavity, it is best opened by carrying a pair 
 of closed artery or dressing forceps into its cavity — and opening its blades in 
 the act of withdrawal (Fig. 589). The neighboring structures should be 
 protected from soiling by gauze packing and the abscess be brought as near 
 to the surface before emptying as possible, that its contents may be poured 
 directly outward. Part of its fluid, especially if the cavity be distended, may 
 be first aspirated, that the remainder may be more fully controllable during 
 evacuation. Following penetration of its wall, a finger should be introduced 
 for exploration. 
 
 After evacuation and cleansing of the abscess cavity free drainage should 
 be established by means of cigarette drains, Mikulicz pack, or rubber tubes. 
 
 III. THE OMENTUM. 
 SURGICAL ANATOMY. 
 
 Description. — The omenta are folds of peritoneum connecting the stom- 
 ach with other viscera. They consist of the great or gastro-colic, small or 
 gastro-hepatic, and gastro-splenic omenta. 
 
 Great or Gastro-colic Omentum. — Passes down from the greater curva- 
 ture of the stomach as an apron in front of the small intestine, thence upward 
 to be fused with the transverse colon, being connected with the gastro-splenic 
 omentum on the left, and with the hepatic flexure of the colon and descend- 
 ing colon on the right; — consisting of four layers, two descending and two 
 ascending; the two middle layers belonging to the lesser sac and the two 
 superficial layers to the greater sac; — its vessels coming chiefly from the 
 gastro-epiploica sinistra of the splenic artery, and to a less extent from the 
 gastro-epiploica dextra of the gastro-duodenal branch of the hepatic artery. 
 
 Small or Gastro-hepatic Omentum. — Extends from transverse fis>ure 
 of liver to lesser curvature of stomach, being continuous on the right with 
 the first part of the duodenum (there forming the ligamentum hepato-duo- 
 denale), and, on the left, with the gastro-splenic omentum; — formed of two 
 la vers, one from the lesser and one from the greater sac; — and having the 
 following relation of vessels between the layers of the hepato-duodenal portion 
 of the gastro-hepatic omentum: ductus communis choledochus, on the right: 
 hepatic arterv, on the left: vena porta\ between the two and somewhat pos- 
 terior to them. 
 
LIGATION OF THE OMENTUM. 
 
 831 
 
 Gastro-splenic Omentum. — Extends from the fundus of the stomach 
 to the gastric surface of the spleen; — and transmits the vasa brevia of the 
 splenic artery to the stomach. 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE 
 
 OMENTUM. 
 
 The remarks made under this head in connection with the Peritoneum 
 are applicable to this section. See page 649. 
 
 Fig. 590. — LlGATIXG THE OMENTUM THROUGH AREAS PREVIOUSLY CRUSHED BY AN ANGIO- 
 
 TRIBE. 
 
 LIGATION OF THE OMENTUM. 
 
 Description. — In the course of intra-abdominal operations, it is often 
 necessary to ligate portions of the omentum, either for the purpose of freeing 
 adhesions, or as a preliminary step to the removal of a part, or even the 
 whole, of the great omentum. 
 
 Ligation of Omental Adhesions. — The general principle of dealing 
 with adhesions by separation by blunt dissection, or by ligature and division, 
 described under the operations for peritoneal adhesions (see page 649), 
 applies equally to those of the omentum. \Yhere the separation can be 
 accomplished by blunt dissection, this should be done. Where division by 
 knife or scissors is necessary, this should generally be preceded by ligation 
 with chromic gut. The ligature may be conveniently passed by means of 
 an aneurism-needle — either around a single band of adhesion, or in sections 
 through broader extents of adhesion. The omentum is then divided distally 
 to the ligature — or, where indicated, as is generally the case in dense adhe- 
 sions, between double ligatures. (See Fig. 586, E, F, F.) 
 
 Ligation of the Omentum Preparatory to Removal of Larger Por- 
 tions. — The omentum may be so irregularly and completely bound down 
 as to require ligature and division in piecemeal, as in tying off adhesions, 
 
8 3 2 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 as just described. Where, however, it is largely or entirely free, a tier of 
 ligatures may be quickly run across the free portion just above the line of 
 subsequent division. This tier may be applied in sections by means of an 
 aneurism-needle. (See Fig. 586, E.) Or it may be more quickly placed by 
 holding the ligature in contact with the back or opposite side of the omen- 
 tum, and then, at proper intervals, piercing the omentum from the front with 
 a pair of catch-forceps, or a Cleveland ligature-carrier, grasping the ligature 
 and drawing it through — it is then cut at each opening through which drawn, 
 interlocked with its neighbor by a half-turn, and tied — as shown in Fig. 586, 
 F, F. Heavy, thick portions of omentum are best crushed with an angiotribe 
 and ligated through the crushed area (Fig. 590). 
 
 OMENTAL GRAFTING. 
 
 Description. — Consists in the using of isolated pieces of omentum to 
 repair peritoneal defects. These pieces of omentum are excised from the 
 great omentum and sutured to wounded or denuded surfaces, or suture- 
 lines, of the abdomino-pelvic viscera normally covered by peritoneum. They 
 are especially used to reinforce suspicious intestinal sites — but may be applied 
 to any of the serous surfaces of other viscera. They become adherent within 
 a few hours — and thus strengthen weakened sites. 
 
 Operation. — The application of omental grafts is called for during the 
 course of intra-abdominal operations — and the technic of the operation is 
 simple. A small piece of the great omentum, preferably its free aspect, 
 
 Fig-. 591.— Omental Grafting :— Graft of omentum reinforcing circular enterorrhaphy, sutured to 
 the mesentery and partly sutured to the intestine. 
 
 calculated in shape and size to cover the defect by a good margin, is cut 
 away with scissors, distally to previously placed ligatures of gut — and this 
 graft is placed in contact with the area to be reinforced, preceded or not 
 by slight scarification of the site with a needle-point — and is held in contact 
 by means of a few loosely applied, interrupted, fine gut-sutures. If the 
 grafts cannot be used immediately after being cut, they are placed in warm 
 normal salt solution until required, when they are partially dried between 
 gauze. The grafts used to reinforce circular enterorrhaphy generally average 
 from 4 to 5 cm. (1^ to 2 inches) in width, and should be long enough to 
 completely surround the site in question. (See Fig. 591.) 
 
SURGICAL ANATOMY OF THE SMALL INTESTINES. 833 
 
 IV. THE MESENTERY. 
 
 SURGICAL ANATOMY. 
 
 Description. — The mesenteries are peritoneal folds connecting any por- 
 tion of the gastro-intestinal tract to the posterior abdomino-pelvic wall. 
 
 Divisions. — Mesogastrium; mesoduodenum; mesentery proper; mesen- 
 teriolum (mesentery of the vermiform appendix) ; ascending mesocolon (some- 
 times present); transverse mesocolon; descending mesocolon (sometimes 
 present); sigmoid mesocolon; mesorectum. 
 
 Mesentery (proper). — A fan-shaped fold of peritoneum beginning at 
 the spinal column and following and covering the anterior aspect of the 
 superior mesenteric vessels to the loops of the small intestine, enveloping 
 all the coils of the jejunum and ileum (but not those of the duodenum) — 
 returning thence along the posterior aspect of the superior mesenteric vessels 
 to the vertebral column. The root of the mesentery extends from the left 
 lateral aspect of the body of the second lumbar vertebra downward — crossing 
 obliquely the spinal column, aorta,- vena cava inferior, and third portion 
 of the duodenum, ending at the right sacro-iliac synchondrosis, or in the 
 right iliac fossa. It contains, between its right upper and left lower layers, 
 the mesenteric arteries and veins, lacteals, lymphatics and nerves, all held 
 together by fatty areolar tissue. The right upper layer of the mesentery 
 passes from the root of the mesentery to the lower layer of the transverse 
 mesocolon. Laterally the layers are continuous with the inner lamellae of 
 the right and left colons. Below, the left layer is continuous with the peri- 
 toneum covering the lumbar vertebra?, and passing thence over the pelvic 
 organs. In dimensions, its length (convex intestinal border) is about 6.45 
 m. (21 feet) — its width averages 20.5 to 23 cm. (8 to 9 inches), its greatest 
 width (opposite the central and lower loops of the intestine) being from 20 
 to 25 cm. (8 to 10 inches). 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON THE 
 
 MESENTERY. 
 
 The mesentery is involved surgically chiefly in the operation of partial 
 enterectomy. 
 
 PARTIAL EXCISION OF THE MESENTERY. 
 See under Partial Enterectomy, page 850. 
 
 SUTURING OF THE MESENTERY. 
 
 See under Partial Enterectomy, page 850. 
 
 V. THE INTESTINES. 
 SURGICAL ANATOMY OF THE SMALL INTESTINES. 
 
 Description. — Extend from pylorus of stomach to ileo-caecal valve. 
 About 7.6 meters (25 feet) long. 
 
 Divisions. — Duodenum (from 25.5 to 30.5 cm., or 10 to 12 inches) — con- 
 sists of First or Superior Curved Portion (Superior Hepatic Curve) (not 
 quite 5 cm., or 2 inches); — Second or Descending (Vertical) Portion (not 
 quite 7.5 cm., or 3 inches); — Third or Transverse (Preaortic) Portion (about 
 12.5 cm., or 5 inches); — Fourth or Ascending Portion (about 2.5 to 5 cm., 
 or 1 to 2 inches): — Fifth or Duodenojejunal angle. Jejunum — about upper 
 two-fifths of remaining small intestines (about 2.9 meters, or 9 feet 7 inches). 
 
834 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Ileum — about lower three-fifths of remaining portion (about 4.3 meters, or 
 14 feet 5 inches). 
 
 General Form of Duodenum. — Usually has the form of a U, with which 
 the above description corresponds — but is sometimes V-shaped. 
 
 Course and Relations of First or Superior Curved Portion (Superior 
 Hepatic Curve) of Duodenum. — Course ; from pylorus, passes upward and 
 backward to right, ending at neck of gall-bladder. Superiorly and ante- 
 riorly; quadrate lobe of liver; neck of gall-bladder; foramen of Winslow 
 (duodenum forming its lower boundary); hepatic artery. Inferiorly; head 
 and neck of pancreas. Posteriorly; common bile-duct; venaportae; gastro- 
 duodenal artery; vena cava inferior; first lumbar vertebra. 
 
 Course and Relations of Second or Descending (Vertical) Portion 
 of Duodenum. — Course; descends from neck of gall-bladder down right 
 side of vertebral column, from first to body of third or fourth lumbar vertebra 
 — transverse colon crossing its middle third. Anteriorly; right lobe of liver 
 (duodenal impression); right end of transverse colon; transverse mesocolon; 
 small intestine; mesentery (right leaf). Posteriorly; right kidney, and 
 suprarenal capsule (sometimes); renal vessels; common bile and pancreatic 
 ducts; inferior vena cava; spermatic vessels. Internally (to left); head of 
 pancreas; common bile and pancreatic ducts; pancreatico-duodenal vessels; 
 first to fourth lumbar vertebra? and intervertebral discs. 
 
 Course and Relations of Third or Transverse (Preaortic) Portion of 
 Duodenum. — Course; from right side of body of third or fourth lumbar 
 vertebra, crosses vertebral column in horizontal or slightly ascending manner, 
 in front of great vessels and crura of diaphragm, moulding itself over these 
 structures. Superiorly; head of pancreas; superior mesenteric vessels; in- 
 ferior pancreatico-duodenal artery. Anteriorly; root and right and left 
 layers of mesentery; lower layer of transverse mesocolon; superior mesenteric 
 vessels; small intestines. Posteriorly; inferior vena cava; aorta; dia- 
 phragmatic crura; third and fourth lumbar vertebra. 
 
 Course and Relations of Fourth or Ascending Portion of Duodenum. 
 — Course ; ascends vertically along left side of spine, from third or fourth 
 lumbar vertebra to side of second or first lumbar vertebra. Anteriorly; 
 transverse colon; transverse mesocolon (lower layer); small intestine; mesen- 
 tery (left layer); antrum pylori (sometimes). Posteriorly; left diaphrag- 
 matic crus; left psoas; left renal vessels; spermatic vessels; kidney (interno- 
 inferior part). Internally (to right); head and neck of pancreas; aorta; 
 fourth or third and second lumbar vertebra?. 
 
 Course and Relations of Fifth Part, or Duodenojejunal Angle : 
 Position; at left side of second or first lumbar vertebra. Superiorly; body 
 of pancreas. Anteriorly; mesentery (left layer). Externally; left kidney 
 (inner border). 
 
 Peritoneal Covering of Duodenum. — First part; covered by perito- 
 neum, except parts of posterior surface near vena cava and neck of gall- 
 bladder. Second part; covered in front only (except that no peritoneum 
 covers the front opposite the divergence of two layers of transverse mesocolon). 
 Third part ; covered in front only (except that there is no peritoneum in 
 front opposite root of mesentery). Fourth part; covered entirely in front, 
 and partly at sides. Fifth part; entirely covered by peritoneum where it 
 becomes jejunum. 
 
 Ligaments of Duodenum. — Ligamentum Hepato-duodenale (suspensory 
 ligament of duodenum) — right edge of lesser omentum — from hilus of liver 
 to first part of duodenum. Ligamentum Cystico-duodenale — from neck of 
 gall-bladder to first part of duodenum. Ligamentum Duodeno-renale — 
 
SURGICAL ANATOMY OF THE SMALL INTESTINES. 835 
 
 from summit of right kidney to outer aspect of first part. Ligamentum 
 Duodeno-mesocolica — from junction of left layer of mesentery with lower 
 layer of transverse mesocolon, to outer aspect of fourth part of duodenum. 
 
 Other Fixation-points of Duodenum. — Common bile-duct and pan- 
 creatic duct; cceliac axis and superior mesenteric artery; fibro-nervous struc- 
 tures; muscle of Treitz (passing from duodeno-jejunal angle upward beneath 
 pancreas to left crus of diaphragm). 
 
 Fossae in Neighborhood of Ascending Duodenum and Duodeno- 
 jejunal Angle. — Inferior duodenal fossa; superior duodenal fossa (these 
 two may coexist) ; duodeno-jejunal (mesocolic) fossa (non-coexistent with 
 above two) . 
 
 Position of Jejunum. — Extends from duodeno-jejunal angle to beginning 
 of ileum. Position not fixed — coils of jejunum generally to be found upon 
 left side of abdominal cavity, in left lumbar, left inguinal, and left half of 
 umbilical regions. The upper loops are apt to be more transverse than the 
 lower. 
 
 Characteristics of Middle Portion of Jejunum (as Compared with 
 Middle Portion of Ileum). — Diameter about 4 cm. (i£ inch). Walls 
 thicker, more vascular, and mucous membrane more complex. Weight of 
 given length greater. No valvular conniventes (or poorly marked). Its 
 position. 
 
 Mesentery of Jejunum and Ileum (Attachment of Jejunum and Ileum) 
 — (1) Passes obliquely from left side of body of second lumbar vertebra 
 downward and to right, crossing spinal column, aorta, inferior vena cava, 
 and third part of duodenum, to right sacro-iliac synchondrosis (or to right iliac 
 fossa). (2) Middle and inferior loops of small intestine have longest mesen- 
 tery — and are, therefore, generally found in pelvis. Duodenum has no 
 mesentery. Lower part of Ileum has shortest mesentery (opposite right 
 psoas muscle). (3) Mesentery extends from distal end of duodenum to 
 ileo-caecal junction. Its upper (right) layer is continuous with inferior layer 
 of transverse mesocolon and with peritoneum of ascending colon. Its lower 
 (left) layer joins peritoneum enclosing descending colon and forming sigmoid 
 mesentery. (4) Average length of mesentery (from spine to intestines) 
 from 20 to 25 cm. (8 to 10 inches). 
 
 Position of Ileum. — Extends from lower end of jejunum to ileo-ca?cal 
 valve. Position not fixed — coils of ileum generally to be found on right side 
 of abdomen and pelvis, in right lumbar, right inguinal and in right half of 
 umbilical and hvpogastric regions. The lower loops are apt to be more 
 vertical than the upper. 
 
 Characteristics of Middle Portion of Ileum (as compared with 
 Middle Portion of Jejunum). — Diameter about 3 cm. (i\ inch). Walls 
 thinner, less vascular, and mucous membrane simpler. Weight of given 
 length less. Valvular conniventes. Its position. 
 
 Meckel's Diverticulum of Ileum (remains of vitelline duct). — Blind 
 diverticulum of ileum and directly continuous with its lumen. Length, from 
 5 to 7.5 cm. (2 to 3 inches) — extremes, from 1 to 18 cm. (^ to 7 inches). 
 Arises about 109 cm. (43 inches) — extremes, from 30.5 to 305 cm. (1 to 10 
 feet) — above ileo-caxal junction. Generally lies free in abdominal cavity 
 (instead of passing to umbilicus, as in fetus). But distal end may be con- 
 nected with umbilicus, or other site, by strong band (remains of enlarged 
 omphalo-mesenteric vessels). Its presence occurs in about 50 per cent. 
 
 Arteries of Small Intestines. — (1) Duodenum; pyloric of hepatic; supe- 
 rior pancreatico-duodenal branch of gastro-duodenal branch of hepatic; 
 
836 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 inferior pancreaticoduodenal of superior mesenteric. (2) Jejunum and 
 Ileum; superior mesenteric. 
 
 Veins of Small Intestines. — Correspond with arteries — a single vein 
 accompanying each artery. 
 
 Lymphatics of Small Intestines. — End in mesenteric lacteals. 
 
 Nerves of Small Intestines. — From superior mesenteric plexus, formed 
 by nerves from cceliac plexus, semilunar ganglion, and right vagus. 
 
 SURFACE FORM AND LANDMARKS OF THE SMALL INTESTINES. 
 
 Upper limit of attachment of mesentery (duodenojejunal angle) generally 
 lies from 8 to 10 cm. (3 to 4 inches) above the umbilicus, slightly to left of 
 median line. Lower limit is about 10 cm. (4 inches) from middle of right 
 Poupart's ligament, on a line directed upward and inward in the course 
 of psoas muscle. 
 
 SURGICAL ANATOMY OF THE LARGE INTESTINES. 
 
 Description. — Extend from lower end of ileum to anus. About 1.5 to 
 1.8 meters (5 to 6 feet) long. 
 
 Divisions. — Cfficum; Ascending Colon; Hepatic Flexure; Transverse 
 Colon; Splenic Flexure; Descending Colon; Sigmoid Flexure (Sigmoid Colon) ; 
 Rectum. 
 
 General Characteristics of Large Intestines (as compared with small 
 intestines). — Greater size; greater fixity of position; sacculations; longitu- 
 dinal bands; appendices epiploicae. (Last three characteristics not present 
 in rectum). 
 
 Caecum. — (About 7.5 cm., or 3 inches, broad, and 6.3 cm., or 2\ inches, 
 long.) Position; lies in right iliac fossa, above outer half of Poupart's 
 ligament, generally resting upon psoas muscle — sometimes upon iliacus only — 
 sometimes bulk of caecum rests on iliacus and apex on psoas — sometimes 
 free of both, being entirely in pelvic cavity, or even projecting beyond median 
 line. Its apex, or lower point, lies slightly to inner side of middle of Poupart's 
 ligament, just behind anterior abdominal wall and opposite inner portion 
 of psoas. The caecum is entirely covered by peritoneum and lies free in 
 abdominal cavity. There is no mesocaecum. Several forms or types of 
 caecum occur (see Appendix). Anteriorly; abdominal parietes above outer 
 half of Poupart's ligament. Posteriorly; ilio-psoas; appendix (origin). 
 Superiorly; ileo-caecal valve. Internally; ileum (termination). 
 
 Ileo-ceecal Fossae. — Superior Ileo-caecal Fossa, an anterior pouch be- 
 tween end of ileum and ascending colon. Inferior Ueo-Caecal Fossa, an 
 inferior pouch under ileum, between it and caecum. 
 
 Appendix Caeci. — Description; small blind tube, generally hollow to 
 tip, its lumen continuous with that of caecum and sometimes guarded by valve. 
 Average length, 9.2 cm., or 3! inches (extremes, from 3.1 to 23 cm., or from 
 \\ to 9 inches). Diameter, about 6 mm. {\ inch) at base — 5 mm.(f\ inch) 
 at apex. Origin, generally arises 1.7 cm. {\\ inch) below ileo-caecal 
 valve, upon its inner and posterior aspect — but sometimes forms the true 
 apex of caecum. Course; variable — (1) According to Treves, the appendix 
 generally passes upward from behind caecum toward spleen, lying behind 
 lower end of ileum and its mesentery. (2) According to Berry, the order 
 of frequency of position is, " (a) pelvic; (b) retrocaecal; (c) internal to caecum, 
 i. e., Treves's position; (d) variable." (3) According to Bryant, in order of 
 
SURGICAL ANATOMY OF THE LARGE INTESTINES. 837 
 
 frequency, "(a) inward; (b) behind caecum; (c) downward and inward; (d) 
 into true pelvis. " Relations to peritoneum ; Mesentery always present 
 but not extending to tip — about distal third being entirely enveloped in peri- 
 toneum and free. Meso-appendix, of triangular form — derived from left 
 leaf of mesentery — containing, in its free margin, posterior branch of ileo- 
 cecal artery (from ileo-colic). Relations to caecum; four types of caecum 
 occur (Treves) — (a) appendix arising from apex of caecum; (b) appendix 
 arising between two sacculi of equal size; (c) appendix arising between two 
 sacculi of unequal size (about 90 per cent, of cases) ; (d) appendix appearing 
 to arise from ileo-colic junction. Relations to anterior abdominal wall; 
 
 (1) According to McBurney, — draw straight line from anterior superior iliac 
 spine to umbilicus, and beneath this line, from 4 to 5 cm. (ih to 2 inches) 
 internal to the spine, the base of the appendix is found (in right iliac fossa). 
 
 (2) According to Clado, — draw a line along outer edge of rectus — another 
 between anterior superior iliac spines — opposite the junction of these the 
 base of the appendix is found (in hypogastric region). 
 
 Ileo-caecal Valve. — Opens upon postero-internal aspect, at upper border 
 of caecum. 
 
 Ascending Colon. — Description; About 20 cm. (8 inches) in length. 
 Extends vertically upward from caecum to inferior surface of right lobe of 
 liver, at right of gall-bladder (hepatic flexure). Covered by peritoneum 
 anteriorly and laterally, which binds it to posterior abdominal wall. Its 
 posterior surface (where peritoneum is absent) is bound by areolar tissue to 
 quadratus lumborum, transversalis, and right kidney (antero-external part). 
 Mesentery (ascending mesocolon) present in 26 per cent. (Treves). Rela- 
 tions; Anteriorly; ileum; abdominal wall. Posteriorly; quadratus lum- 
 borum; transversalis; kidney (antero-external part). Superiorly; liver (right 
 lobe). 
 
 Hepatic Flexure of Colon. — Upon under surface of liver, near gall- 
 bladder, the ascending colon bends from posterior abdominal wall sharply 
 to front and left, to become transverse colon. 
 
 Transverse Colon. — Description; About 51 cm., or 20 inches (ex- 
 tremes, from 30 to 84 cm., or 12 to ^t, inches), in length. Extends from 
 inferior surface of liver, in right hypochondrium (hepatic flexure), trans- 
 versely across anterior abdominal wall, with slight downward and forward 
 convexity at its center, to the spleen in left hypochondrium (splenic flexure). 
 Transverse mesocolon is long, and connects transverse colon to posterior 
 abdominal wall — most movable part of large intestine. Transverse colon lies 
 above the umbilicus four times out of five — and below it one time out of five 
 (usually on a line connecting lowest parts of costal arches). Peritoneum 
 entirely surrounds transverse colon. Relations; Anteriorly; abdominal 
 wall; great omentum. Posteriorly; transverse mesocolon; descending duo- 
 denum; small intestines; superior curvature of stomach (at times). Supe- 
 riorly ; liver and gall-bladder (inferior surfaces) ; great curvature of stomach ; 
 spleen (inferior end); pancreas (tail). Inferiorly; small intestines. 
 
 Splenic Flexure of Colon. — Situated beneath lower end of spleen — 
 further back in abdomen than hepatic flexure. Connected by phreno-colic 
 ligament (a fold of peritoneum) passing between splenic flexure to diaphragm, 
 between tenth and eleventh ribs. 
 
 Descending Colon. — Description; About 21.5 cm. (8| inches) long. 
 Extends from spienic flexure vertically through left hypochondrium and 
 lumbar regions to sigmoid flexure. Peritoneum covers it similarly to ascend- 
 ing colon (q. v.). Mesenterv (descending mesocolon) present in 36 per cent. 
 
838 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 (Treves). Relations: — Anteriorly; abdominal wall; jejunum. Poste- 
 riorly; diaphragm; left kidney (infero-external part); quadratus lumborum; 
 transversalis. Superiorly; spleen; phreno-colic ligament. 
 
 Sigmoid Flexure of Colon (Sigmoid Colon). — Description; An S- 
 
 shaped curve, about 31 cm. (13 inches) long, lying in left iliac fossa, beginning 
 at iliac crest and ending at brim of true pelvis, opposite left sacroiliac syn- 
 chondrosis (or opposite upper edge of sacrum). Divisions; First Portion, 
 of Colic Limb, tends downward, inward, and slightly forward toward outer 
 aspect of Poupart's ligament and abdominal wall — generally has a short 
 mesocolon (though sometimes peritoneum only anteriorly and laterally). 
 Second or Rectal Part, tends to hang into true pelvis — mesentery about 
 7.5 cm. (3 inches) — very movable. Insertion of Sigmoid Mesocolon; in 
 line extending obliquely from left iliac crest across psoas and left iliac vessels 
 (at about their bifurcation) to join mesorectum at sacral promontory. Note ; 
 More properly the sigmoid colon, or flexure, should include that portion 
 of large intestine usually described as the first part of the rectum — and then 
 would end where the mesorectum ceases, opposite the third piece of the 
 sacrum, thus having more of an omega than a sigmoid appearance. Rela- 
 tions ; Anteriorly; abdominal wall; small intestines. Posteriorly; left 
 ilio-psoas; posterior pelvic wall; rectum. 
 
 Intersigmoid Fossa. — In the layers of the mesocolon, generally over 
 bifurcation of iliac vessels — looks downward to left. Sometimes found in 
 children — rarely in adults. 
 
 Rectum. — (Length, about 20 to 23 cm., or 8 to 9 inches.) Divisions: 
 First or Superior Part; Second or Middle Part; Third Part, or Anal Canal. 
 Note ; The rectum will be here described as consisting of three parts, as 
 mentioned. More properly it consists of but two parts, corresponding with 
 the second and third parts just mentioned — the first part above mentioned 
 being, strictly, a portion of the Sigmoid Colon (see "note" under Sigmoid 
 Flexure of Colon). First or Superior Part; 8 to 9 cm. (3 \ to 3^ inches) 
 long. Corresponds with lower part of Sigmoid Colon, as sometimes de- 
 scribed. Runs obliquely from left pelvic brim (beginning opposite either 
 sacro-iliac synchondrosis, or sacral promontory, or even right side of base 
 of sacrum) downward, backward, and to right to third sacral vertebra in the 
 median line. Almost entirely enveloped in peritoneum, except posteriorly. 
 Mesorectum connects its posterior aspect to anterior surface of sacrum. Mes- 
 entery continuous with sigmoid mesocolon and terminates at third sacral ver- 
 tebra. Relations of first part; Anteriorly; small intestine; sigmoid colon; 
 bladder (posterior surface) in male; uterus (posterior surface) in female. Pos- 
 teriorly; mesorectum; left pyriformis muscle; left sacral plexus; left internal 
 iliac artery and veins; first, second, and one-half of third sacral vertebra?. Ex- 
 ternally ; left ureter; left internal iliac artery and veins. Description of sec- 
 ond or middle part ; 10 to 1 1 cm. (3 to 4 inches) long. Extends in a curve from 
 middle of third sacral vertebra to opposite apex of prostate gland — running 
 at first along right aspect of fourth sacral vertebra — thence back to median 
 line about the sacro-coccygeal articulation — and passes thence downward and 
 forward to opposite a line connecting the anterior aspects of the two ischial 
 tuberosities, which is opposite the apex of prostate gland, and about 2.5 
 cm. (1 inch) below tip of coccyx. Partially covered by peritoneum— covered 
 above, anteriorly and laterally — then only anteriorly — and about 2.5 cm. 
 (1 inch) above prostate gland (never more than 8 cm., or 3I inch) it is re- 
 flected from anterior surface of rectum to posterior surface of bladder, in 
 male, or to posterior surface of upper one-fifth of vagina, in female (forming 
 
SURFACE FORM AND LANDMARKS OF LARGE INTESTINES. 839 
 
 rectovesical or recto-vaginal pouch). No mesorectum exists. On posterior 
 surface of rectum there is no peritoneum below a point 12.5 cm. (5 inches) 
 above anus. Relations of second or middle part of rectum; Anteriorly; 
 (a) In Male; recto-vesical pouch; small intestines; bladder (trigone); vesicular 
 seminales; vasa deferentia; prostate gland (inferior aspect); (b) In Female; 
 vagina (posterior surface); recto-vaginal pouch; recto-uterine pouch; small 
 intestines. Posteriorly; sacrum (lower portion); coccyx; ano-coccygeal 
 body; middle sacral vessels; pyriformis muscles. Description of third 
 part, or anal canal; About 2 to 3 cm. (f to i£ inch) — little less in female. 
 Passes downward and backward, from a point opposite apex of prostate 
 gland (about 2.5 cm., or 1 inch, below tip of coccyx) to end in anus. No 
 peritoneal covering. Surrounded by sphincter muscles. Relations of third 
 part, or anal canal ; Anteriorly ; bulb and membranous part of urethra 
 (male); perineal body (female). Posteriorly; ano-coccygeal body; coccygei 
 muscles. Laterally; fatty areolar tissue of ischio-rectal fossae; levatores ani 
 muscles. 
 
 Anus. — Surrounded by internal sphincter, levatores ani, and external 
 sphincter. (See Perineum.) 
 
 Arteries of Caecum and Colon. — Ileo-colic, colica dextra, and colica 
 media, from superior mesenteric; colica sinistra and sigmoid, from inferior 
 mesenteric. 
 
 Veins of Caecum and Colon. — Superior and inferior mesenteric, emptying 
 into portal system. 
 
 Lymphatics of Caecum and Colon. — Those of ascending, transverse, 
 and descending colon empty into mesenteric glands. Those of sigmoid colon 
 empty into lumbar glands. 
 
 Nerves of Caecum and Colon. — Caecum, ascending and proximal half 
 of transverse colon are supplied by superior mesenteric plexus, from cceliac 
 plexus. Distal half of transverse colon, descending and sigmoid colon are 
 supplied by inferior mesenteric plexus, from aortic plexus. 
 
 Arteries of Rectum. — Superior hemorrhoidal (of inferior mesenteric); 
 middle hemorrhoidal (of internal iliac); inferior hemorrhoidal (of internal 
 pudic) ; branches from sacra media (of abdominal aorta) ; branches from 
 sciatic (of internal iliac); branches from vaginal,' in female (of internal 
 iliac). 
 
 Veins of Rectum. — Chiefly from superior hemorrhoidal to inferior mesen- 
 teric, and thence to portal system. Some blood passes back by systemic 
 system to inferior vena cava. Anastomosis between systemic and portal 
 systems occurs in rectum. 
 
 Lymphatics of Rectum. — Empty into anterior sacral and inguinal 
 glands. 
 
 Nerves of Rectum. — From cerebrospinal system (sacral plexus) — and 
 from sympathetic system (hypogastric and inferior mesenteric plexuses). 
 
 SURFACE FORM AND LANDMARKS OF THE LARGE INTESTINES. 
 
 Caecum lies in right inguinal region, its lower border corresponding, at 
 its center, with the center of a line drawn from anterior superior iliac spine 
 to symphysis pubis. 
 
 Ascending Colon ascends through right lumbar and hypochondriac regions 
 to hepatic flexure. 
 
 Hepatic Flexure lies beneath the liver in the right hypochondrium. 
 
840 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Transverse Colon crosses the abdomen transversely at about the junction 
 of the umbilical and epigastric regions — its superior border lying just below 
 the greater curvature of the stomach — its inferior border just above the 
 umbilicus. 
 
 Splenic Flexure is posterior to the stomach in the left hypochondrium. 
 
 Descending Colon descends through the left hypochondriac and lumbar 
 regions to the sigmoid flexure. 
 
 Sigmoid Colon lies in the left inguinal region. 
 
 Note. — For the more detailed description of the relations of the parts of 
 the large intestines, see Surgical Anatomy of the special parts. 
 
 GENERAL CONSIDERATIONS IN OPERATIONS UPON THE 
 INTESTINES. 
 
 Preparation of Patient. — Bowels are to be emptied. Abdomen should 
 be shaved. 
 
 Position. — Patient lies supine, usually in a horizontal position, near the 
 edge of the table. Surgeon may stand on either side of patient, but usually 
 stands on the patient's right, incising from above downward. Assistant 
 stands opposite surgeon. 
 
 Portion of the Intestinal Wall where the Lamina? of the Mesentery 
 Separate to Enclose the Intestines. — In the case of those portions of the 
 intestines which have a mesentery, the lamina? of the mesentery begin to 
 separate (in order to surround the wall of the gut) about 1.5 to 2 cm. (§ to 
 f inch) from the intestine, leaving, upon these viscera, a triangular interval 
 with a base of about 8 mm. (fV inch) where the muscular coat is uncovered 
 by peritoneum — this triangular space being occupied by fatty areolar tissue, 
 vessels, and nerves. The practical bearings of the above fact being; — (1) The 
 necessity of being particularly careful in ordinary suturing, or the adoption 
 of some special form ot suturing, in operations upon the intestines, in order 
 to bring the peritoneum of the cut margins into contact with the wall of 
 the intestines at the mesenteric border, thus securing the covering of the 
 denuded tract with peritoneum and also securing apposition of serous surfaces 
 when two ends of intestine are brought together; — (2) The guarding of the 
 blood-supply to the intestines transmitted through this triangular space. 
 Note— the method of dealing with this area of the intestine will be mentioned 
 under special operations. 
 
 Note. — For other general considerations bearing upon operations upon 
 the intestines, see the introductions to the special classes of intestinal opera- 
 tions. 
 
 INSTRUMENTS USED IN OPERATIONS UFON THE INTESTINES. 
 
 I. Instruments used in entering the peritoneal cavity — see the instru- 
 ments for performing Abdominal Section (page 801). 
 
 II. Instruments used in general intestinal operations; — intestinal clamps; 
 artery-clamp forceps; dissecting and toothed forceps; scissors; bistouries; 
 aneurism-needles; probe; grooved director; tenaculum; needles, ordinary 
 straight cambric, curved, calyx-eyed, Keith's abdominal; needle-holder; fine 
 silk; catgut; gauze pads; gauze sponges; sponge-holders; drains of gauze, 
 wick, rubber tubing, glass tubing. Special instruments and mechanical 
 contrivances required in special operations upon the intestines in general, 
 particularly in the operations of entero-enterostomy. 
 
ENTERORRHAPHY IN GENERAL. 
 
 III. Instruments used in operations upon the rectum and anus — see the 
 operations upon those structures. 
 
 ENTEROTOMY. 
 
 Description. — Incision of intestine, with closure of wound at the same 
 sitting. Generally resorted to for the removal of foreign bodies from the 
 intestinal canal, or as a step in some operation. Formerly used in the same 
 sense as enterostomy. 
 
 Preparation — Position — Landmarks — Incision. — As in Median Ab- 
 dominal Section (page 801). 
 
 Operation. — (I) Having exposed that portion of the intestine which is 
 to become the site of the operation, the coil involved is lifted out of the ab- 
 dominal cavity and placed upon a warm, wet, sterile towel — the rest of the 
 abdominal cavity and the other coils of intestine being protected by gauze 
 packing. (2) The intestinal contents are pressed away from the site to be 
 opened and the intestine is clamped proximally and distally to the operation- 
 site. (3) Incision into the intestine is made upon its anti-mesenteric border, 
 in the long axis of the gut — exercising care that the opposite intestinal walls 
 be not injured. If the canal contain a foreign body, this may usually be 
 cut down upon directly, its presence protecting the other coats. Otherwise 
 the assistant should so hold the gut that its walls are separated while the 
 surgeon makes a rapid, controlled stab into the lumen with a sharp, narrow 
 bistoury, in order that the mucous membrane may not be simply protruded 
 ahead of the incision. The keeping of the opposite walls apart during incision is 
 best accomplished by gently grasping the lateral aspects of the intestine (a little 
 nearer the anti-mesenteric than the mesenteric border) with forceps (or with the 
 fingers, or thread retractors passing only through the outer coats) and drawing 
 them apart laterally, while the mesenteric border is simultaneously drawn 
 downward, thus forming a hollow triangle within the lumen of the gut. The 
 wound in the intestine may be enlarged in the act of withdrawing the original 
 bistoury — or by means of a blunt-pointed bistoury separately inserted — or one 
 blade of blunt-pointed scissors may be introduced and the opening thus 
 enlarged. (4) Care is used in preventing any unnecessary escape of in- 
 testinal contents — and all sites of possible infection are packed off. (5) The 
 object of the operation having been accomplished, the wound in the intestine 
 is closed by one of the methods of intestinal suturing described under Enteror- 
 rhaphy (usually with Lembert sutures). The abdominal wound is closed in 
 the ordinarv manner. 
 
 ENTERORRHAPHY IN GENERAL. 
 
 Description. — Union of intestinal tissue by suturing. Sutures are of 
 two kinds — Interrupted, each suture being formed of a separate thread; — 
 Continuous, the entire line of suturing being formed of one thread. The 
 features in favor of interrupted sutures are: — the strain is upon many rather 
 than upon one thread, and is more evenly distributed; the blood-supply of 
 the edges of the intestine is less interfered with; the giving-way of one thread 
 is not so serious. The feature in favor of the continuous suture is its rapidity 
 of application. Linear Enterorrhaphy is generally used of suturing limited 
 wounds or incisions of the intestine, whether in the long axis or transversely. 
 
842 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Circular Enterorrhaphy is usually used of suturing the entire circumference 
 of intestine after complete transverse or oblique division of the gut. 
 
 Characteristics of a Satisfactory Intestinal Suture. — The following, 
 modified from Treves, are the features possessed by the best forms of suture; — 
 (a) Two broad peritoneal surfaces should be brought into contact, (b) 
 Closure should be tight enough to hold water, (c) The mucous membrane, 
 if included, should not be penetrated by the same suture which passes through 
 the serous coat (which might enable the intestinal contents to escape by 
 capillarity). If only one tier of suturing be used, the mucous membrane 
 should not be included, (d) Suturing should not be sufficiently tight to 
 strangulate the edges of the intestine compressed by the sutures, (e) The 
 method should be simple enough to be easily and rapidly carried out. (f) 
 The suture should take a sufficiently firm hold of the intestine to run no 
 chance of tearing out when put to a fair test, (g) The suture should pass 
 through the serous, muscular, and part of (into) the relatively strong and 
 thick submucous coat, (h) The material of suture must be sufficiently dura- 
 ble and of non-irritating quality. 
 
 Suture Materials. — Silk, fine, strong and preferably colored black (for 
 more easy detection). Catgut, fine, plain, or chromic, may also be used, 
 though less trustworthy and not capable of making so neat a suture knot 
 line. All suture-materials should be tested before being used. 
 
 General Considerations in Intestinal Suturing. — (1) The intestine in- 
 volved is exposed through the simplest incision, generally by median abdomi- 
 nal section, or by enlargement of a previous wound. The portion of intes- 
 tine to be operated upon is drawn out of the abdomen and laid upon 
 a warm towel wrung out of sterile normal salt solution, and steadied 
 by an assistant. (2) Some form of intestinal clamping should be used to 
 prevent the escape of the contents of the gut. One clamp should be placed 
 upon the proximal and one upon the distal side of the site operated upon. 
 The index-finger and thumb of each hand may be used in place of an instru- 
 mental clamp, though generally less satisfactorily. Before the application of 
 any manner of clamping, the contents of the intestine should be pressed 
 away from either side of the site of operation by a process of manipulation 
 resembling that of milking — so that the tract included within the clamps 
 may be as free of intestinal contents as possible. (3) Avoid, as completely 
 as possible, the escape of intestinal contents — and if the escape be inevitable, 
 provide for the catching of the escaping fluid upon abundant gauze packing, 
 which is immediately removed and other put in its place. (4) Control all 
 unnecessary hemorrhage by making incisions in as non-vascular regions of 
 the site to be operated upon as possible. All bleeding vessels are caught 
 with artery forceps and tied with fine silk or catgut, preferably the latter, 
 in the case of smaller vessels. (5) The general feature of intestinal suturing 
 is to bring surfaces of serous membrane into contact for union — preceded or 
 not by a primary tier of suturing which approximates the mucous coats 
 alone,' or all the coats. (6) Theoretically, it is well to aim at including part 
 of the submucous coat, but, practically, what is generally done is to include 
 all of the serous and most of the muscular coats. The submucous coat 
 of the intestine is tough and strong, and it should be the aim to include it 
 in all intestinal suturing — though it is sometimes difficult to include the sub- 
 mucous without also including the mucous coat. (7) While theoretically it 
 is well not to have the same suture which passes through the serous also 
 pass through the mucous coat, yet practical experience has shown that in 
 manv instances where this is done no harm has resulted — and some surgeons 
 
ENTERORRHAPHY BY LEMBERT'S INTERRUPTED SUTURE. 843 
 
 do not attempt to avoid it — though it should, however, be avoided if possible. 
 (8) All sutures should be tied with a surgeon's knot. In intestinal suturing 
 it would seem that the use of two tiers of different kinds of suture makes 
 a better juncture than the two tiers of one kind — thus a continued and in- 
 terrupted combined may be considered better than two continued or two inter- 
 rupted. (9) Interrupted sutures have a tendency to permit lateral expansion 
 at the site of suturing — continuous have the opposite tendency — and therefore, 
 theoretically at least, the latter encroach more upon the lumen of the gut. 
 The interrupted form of suturing may generally be considered the better 
 form of intestinal suturing in the majority of cases. (10) Often the suturing 
 can be expedited by placing two or four temporary silk traction sutures 
 through the serous and muscular coats in sue!" a position as to draw into two 
 parallel folds or ridges the two edges to be apposed when the traction sutures 
 are held by an assistant who draws upon them. (11) Needles should be used 
 which displace rather than cut the tissues through which they pass on their 
 way through the intestinal coats. The straight domestic needle or the instru- 
 ment-makers' round straight or curved needle is the best. The curved 
 needle always, and the straight needle sometimes, require a needle holder. 
 
 (12) The abdominal cavity should be cleansed, if soiled, at the end of the 
 operation — by means of gauze mops, with or without irrigation, as indicated. 
 
 (13) Whether or not the abdomen will be closed without drainage will depend 
 upon the nature of the case. In simple, clean suturing, the abdomen is 
 closed without drainage. (14) Very many forms of intestinal suture are 
 used — only those most generally employed will be here given. 
 
 Fig. 592.— ENTERORRHAPHY BY THE LEMBERT INTERRUPTED SUTURE. 
 
 ENTERORRHAPHY BY LEMBERT'S INTERRUPTED SUTURE. 
 
 Description. — (i) The suture is carried across at a right angle to the line 
 of intestinal wound to be closed — the needle picking up a fold on one side 
 of the wound — and a similar fold on the directly opposite side — whereby, 
 when the knot is tied, the serous surfaces of the two lips of the wound are 
 approximated and the edges of the wound are invaginated into the lumen 
 of the gut. (2) The fold of serous, muscular, and part of submucous coats 
 
844 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 picked up will be about 2 to 2.5 mm. ( T V to y 1 ^ inch in width) — the needle 
 emerging about 2.5 to 3 mm. (^ to J inch) from the edge of the wound — enter- 
 ing the opposite lip of the wound at the same distance from its edge and travers- 
 ing the same amount of tissue as on the first side. The sutures will be about 
 2.5 to 3 mm. ( T L to I inch^) apart. (3) All sutures are placed before any 
 are tied— except that where the line to be sutured is somewhat long, a few 
 sutures may be applied at intervals and at once tied, so as to evenly divide 
 and fix the parts. The knots are not to be tied too tightly (for fear of cutting 
 through or strangulating the parts) — and are cut quite short (so as not to 
 interfere with the process of invagination of the edges). (4) The sutures are 
 generally applied with one long thread and a single needle, cutting the thread 
 at the end of each completed suture. Or numerous needles may be threaded 
 with short lengths of thread. (5) Four temporary traction-sutures, passed 
 through the outer coats of the intestine, placed on the opposite sides of the 
 wound and at each of its ends, if drawn upon in a line with the suturing, 
 will raise two parallel folds which will make the insertion of sutures easier, 
 more rapid, and more regular. They should be placed just to the outer 
 side of the lips of the wound so that the folds caused by their traction will 
 represent the surfaces which are to be approximated by the permanent 
 sutures. (6) For manner of application, see Fig. 592, and also Fig. 593, A. 
 Comment. — The best all around suture. 
 
 Fig. 593. — Enterorrhaphy by the Czerny-Lembert Interrupted Suture: — A, Interrupted 
 Lembert suture through serous, muscular, and part of submucous coats — applied from without ; B, 
 Interrupted Czerny suture through mucous and part of submucous coats — applied from within. 
 The latter is applied first. (Modified from Esmarch.) 
 
 ENTERORRHAPHY BY THE CZERNY-LEMBERT INTERRUPTED 
 
 SUTURE. 
 
 Description. — (1) By this method the mucous membrane is first sepa- 
 rately sutured with the Czerny suture, the sutures being so introduced as 
 to bring the knots within the lumen — and then the serous, muscular, and 
 part of the submucous coats are united by the ordinary Lembert method. 
 (2) The passage of the Czerny suture is a little difficult if it be desired to 
 have all the knots fall within. The mucous membrane of one side of the 
 wound is caught with delicate forceps and steadied, and, at the same time, 
 drawn forward into view and slightly everted — a curved needle, held in a 
 holder, is then passed from the mucous surface of the mucous membrane 
 outward entirely through that membrane and part of the submucous coat — 
 then the mucous membrane of the opposite edge of the wound is similarly 
 
ENTERORRHAPHY BY HALSTED'S SUTURE. 
 
 845 
 
 seized with forceps, and, while similarly held, except without eversion, the 
 needle is now passed in the reverse direction, from without inward, through 
 part of the submucous coat and the mucous membrane. The two ends of 
 the thread are therefore toward the lumen and, when tied, the knot will 
 be within. When tying the last one or two knots, it will be necessary to 
 protrude them within the lumen with the blunt end of a probe. The above 
 method of applying the sutures is especially necessary in suturing short 
 wounds and in completing the line of circular suturing after resection of the 
 intestine. For two-thirds of the distance in circular enterorrhaphy, following 
 intestinal resection, the Czerny sutures can be readily applied — it is only 
 toward the latter part, when the lumen is almost excluded, that their applica- 
 tion becomes more difficult. If there be any likelihood of the first part of 
 the last one or two knots slipping, make that part a friction-knot. (3) The 
 passage of the Lembert sutures is accomplished in the usual fashion — and, 
 when tied, completely covers in the Czerny sutures. (4) Some surgeons apply 
 the sutures through the mucous membrane in the ordinary manner, tying 
 the knots toward the surface, depending upon the Lembert row to bury 
 them. (5) For the manner of applying the suture, see Fig. 593; also see 
 Fig. 618 (Czerny-Lembert Entero-enterostomy). 
 
 Comment. — Confusion often exists between the Czerny-Lembert and the 
 YYolfler sutures. They are practically the same. 
 
 Fig. 594. — Enterorrhaphy by Halsted's Interrupted Quilt (or Mattress) Suture. 
 
 ENTERORRHAPHY BY HALSTED'S INTERRUPTED QUILT- OR MAT- 
 TRESS-SUTURE. 
 
 Description. — (1) This is a modification of the Lembert principle — and 
 consists in an ordinary quilt- or mattress-suture (the terms being used synony- 
 mously) so applied that the looped end is upon one side of the wound and 
 the two free ends upon the opposite side — the thread passing through the 
 serous, muscular, and especially a part of the tough submucous coats. (2) 
 As to the manner of their application, each quilt-suture may be regarded 
 as composed of two parallel Lembert sutures, united by the loop. When 
 the knot is tightened, folds of serous surfaces from the two sides are brought 
 
846 OPERATIONS UPON THE AI5DOMINO-PELVIC REGION. 
 
 into contact— the fold on one side being held by the loops — on the other, 
 by the knots. (3) For manner of application, see Fig. 594. 
 
 Comment. — It is claimed that these sutures compress the tissues less, 
 take a stronger hold, and approximate the parts more accurately. It is 
 probably the next best interrupted suture to Lembert's. 
 
 ENTERORRHAPHY BY LEMBERT'S CONTINUOUS SUTURE. 
 
 Description. — (1) This suture passes diagonally back and forth from side 
 to side, between the lips of the intestinal wound, passing through serous, 
 muscular, and part of submucous coats. When the suture is drawn tight, 
 two folds of serous surfaces, parallel with the edge of the wound, and parallel 
 with each other, are brought into contact. (2) The general principle of the 
 introduction of the continuous Lembert suture follows that of the interrupted 
 Lembert suture — except that the former is applied continuously, and the 
 needle-punctures are made in a direction slightly obliquely to the cut margins 
 
 Fig. 595. —ENTERORRHAPHY BY THE LEMBERT CONTINUOUS SUTURE. 
 
 of the intestinal wound — the general rule as to the distances being about 
 the same in both methods. (3) For the manner of application, see Fig. 
 
 595- 
 
 Comment. — The most quickly applied of the regular continuous intestinal 
 
 sutures (those approximating serous surfaces). 
 
 ENTERORRHAPHY BY CUSHING'S RIGHT-ANGLED CONTINUOUS 
 
 SUTURE. 
 
 Description. — (1) In this suture the thread is carried along in its onward 
 progress exactly parallel with the edge of the wound in the intestine — and 
 when the wound is crossed, the crossing is always directly at right angles 
 to the course of the wound. The suture is everywhere buried except where 
 it crosses the wound, and even this part of the suture is buried by the invagina- 
 tion of the lips of the wound when the thread is drawn tight. (2) Having 
 begun the suture by passing through the serous, muscular, and into the 
 submucous coats, a short distance from and directly opposite one end of 
 
ENTERORRHAPHY BY CUSHING'S SUTURE. 
 
 847 
 
 the wound, the thread is knotted in the ordinary manner — the needle is then 
 carried outside of the intestinal wall onward to a point a short distance to one 
 
 Fig. 596. — Enterorrhaphy by Cushing's Right-angled Continuous Suture. 
 
 side of the edge of the wound — passes beneath the serous, muscular, and into 
 the submucous coat, parallel with the edges of the wound — emerges a short 
 distance beyond — crosses, outside, at a right angle to the wound — to a point 
 
 Fig. 597.— Enterorrhaphy by Combined Overhand Continuous Suture of all the 
 Coats, Followed by Interrupted Lemberts of the Outer Coats : — A, Continuous overhand 
 suture ; B, Interrupted Lemberts. 
 
 on the other side directly opposite its last emergence — travels similarly for- 
 ward beneath the serous, muscular, and part of the submucous coat for a 
 
848 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 short distance — thence back across the wound at a right angle, to the original 
 side — and thus on to the opposite end of the wound, beyond which it is 
 carried a short distance and then knotted. Before the final knotting the 
 thread is drawn tight, thus infolding the margins of the wound and approxi- 
 mating the serous surfaces. (3) For manner of application, see Fig. 596. 
 
 Comment. — Cushing's method of knotting, at either end, is unnecessarily 
 complicated. 
 
 ENTERORRHAPHY BY COMBINED OVERHAND CONTINUOUS SUTURE 
 
 OF ALL COATS, FOLLOWED BY INTERRUPTED LEMBERT 
 
 SUTURING OF OUTER COATS. 
 
 Description.— (i"i This method consists, first, in whipping together the 
 edges of the wound by a simple, running, continuous, overhand suture, 
 passing through all the coats of each margin of the wound, as a preliminary 
 suture of approximation and strength — which is then followed by a secondary 
 tier of generally either the interrupted or continuous Lembert sutures passing 
 through the serous, muscular, and part of the submucous coats. (2) For 
 manner of application, see Entero-enterostomy by simple suturing (page 855), 
 for the general description of the method, — and Fig. 597, for its application 
 to a limited wound. 
 
 ENTERORRHAPHY FOR WOUNDS OF THE INTESTINE. 
 
 Description. — Wounds of the intestines may be divided into five classes; 
 (a) Longitudinal wounds, incised or lacerated; (b) Transverse wounds, in- 
 cised or lacerated ; (c) Irregular wounds, incised or lacerated; (d) Complete 
 transverse division of the intestine; (e) Contused wounds. 
 
 Preparation — Position — Landmarks. — As for median abdominal sec- 
 tion. 
 
 Incision. — In the majority of cases the incision will be in the median 
 line, as for median abdominal section. If the abdominal wound, which may 
 already exist, lie outside of either rectus, and especially if it be indicated 
 that the wound has not ranged toward the median line, the incision is fre- 
 quently made vertical over the external abdominal wound. 
 
 Operation. — (1) Having entered the abdominal cavity, the edges of 
 the wound should be well retracted in order to expose the involved coils of 
 intestine. (2) All bleeding vessels should be controlled by clamp and gut- 
 ligature before proceeding to the intestinal operation. (3) If the omentum 
 be found wounded, the lips of the wound should be approximated by gut- 
 suture. (4) Unless the wounded coil of intestine be readily detected, it is 
 best to systematically examine the intestines, beginning at the stomach — 
 lifting the stomach and transverse colon to trace the duodenum — and then, 
 catching up the beginning of the jejunum beneath the ligament of Treitz, 
 follow down the rest of the small and large intestines. (5) Some surgeons 
 clamp each wound, in the case of gunshot wounds, as found — and suture 
 none until all are clamped — in order to control intestinal contents. (6) 
 Coils of intestine temporarily removed from the abdominal cavity should 
 be surrounded with warm, wet, sterilized gauze or towels, with or without 
 a preliminary enveloping with sterile rubber tissue. (7) All escaped intes- 
 tinal contents should be wiped away with gauze, or, if excessive, by irrigation. 
 (8) If the mesentery be wounded, the edges of the wound should be sutured 
 
ENTERORRHAPIIY FOR WOUNDS OF THE INTESTINE. 849 
 
 with gut sutures. (9) Having brought the involved portion of intestine into 
 the field of operation, the wound is repaired as indicated by the special case. 
 (10) Simple longitudinal wounds are closed by a line of interrupted Lembert 
 sutures. (11) Simple transverse wounds are closed in the same manner as 
 longitudinal ones. (12) In irregular wounds, if consisting of a transverse and 
 longitudinal wound (the two arms crossing each other at a right angle or 
 diagonally) and not too extensive, the part of the transverse wound on one 
 side of the longitudinal wound should be first closed with interrupted Lembert 
 sutures — then similarly the part of the transverse wound on the other side- 
 then the entire length of the longitudinal wound by interrupted Lemberts 
 placed transversely to its length. (See Fig. 598.) Sometimes the two parts 
 of the transverse wound and the ends of the longitudinal are closed as just 
 described — and then the remaining portions of the sides of the longitudinal 
 are sutured after the fashion of suturing the intestine in Enteroplasty for 
 stricture. (See Comment.) Such an irregular wound as that made by a bullet, 
 if not too large, may be treated as an ordinary wound, being sutured with 
 Lembert sutures in such a way as to infold its margins. Sometimes the 
 
 fc^A 
 
 Fig. 598.— Enterorrhaphy in Irregular Wounds of the Intestines: — The two limbs of 
 the transverse wound being first sutured with interrupted Lemberts, and then the two limbs of the 
 longitudinal wound. 
 
 ragged edge of a bullet wound may be advantageously trimmed with curved 
 scissors before suturing. Where destruction has been great, resection of a 
 portion of the intestine, followed by some form of intestinal anastomosis, 
 is generally safer. (13) Complete transverse division of the intestine will 
 necessitate an end-to-end anastomosis, by means of a simple suturing or 
 some mechanical device. (14) Contused wounds, if at all bad, should be 
 treated as lacerated wounds, as the walls of such wounds are rendered of 
 lowered vitality by the traumatism. The contused surface is thus turned 
 into the lumen of the gut by Lembert sutures, where, if sloughing of the 
 portion within the line of sutures occurs, no harm is done. (15) The injury 
 to the intestine having been repaired, the abdomen is closed as in median 
 abdominal section, with or without drainage, as indicated by circumstances. 
 Comment, — (0 Lembert or Halsted interrupted sutures are generally 
 best in suturing intestinal wounds. (2) If any doubt exist as to the efficiency 
 of the first row of sutures, a second tier, generally continued Lembert, may 
 be put in, burying the first. (3) Areas of suspicious suturing may be strength- 
 ened bv suturing over them omental grafts (elliptical pieces taken from the 
 omentum followed by suturing up the lips of the wound thus made in the 
 54 
 
850 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 omentum) — these are applied over the intestinal suturing and held in place 
 by two or three gut sutures. (4) Resection, followed by an entero-enteros- 
 tomy, is preferable to any form of suturing, if by such form of simple suturing 
 the lumen of the gut will be reduced to less than half its diameter. (5) Trans- 
 verse suturing interferes less with the vascular supply than the longitudinal — 
 especially when the longitudinal is near the mesenteric border. (6) A longi- 
 tudinal wound of considerable length, and more or less breadth, the ordinary 
 suturing of which might reduce its calibre too greatly, may be repaired by 
 what is termed "elbowing" (such as is seen in the joining of segments of 
 stove pipes). The intestine is bent somewhat upon itself, the center of the 
 bending being the center of the wound — then one half of one side of the 
 wound is joined, by interrupted Lembert sutures, to the other half of the 
 same side — and the same steps are carried out on the opposite side. - This 
 is applicable only to wounds on or toward the antimesenteric border. The 
 edges of the wound may be sometimes trimmed prior to suturing. Too 
 great narrowing, as might result from simple suturing, or even resection, is 
 hereby avoided. 
 
 PARTIAL ENTERECTOMY. 
 
 Description. — By partial enterectomy is meant the excision, or resection, 
 of a part of the intestinal canal, with or without the excision of the corre- 
 sponding portion of the mesentery. By prefixing the name of the part of 
 the canal, the site of the partial excision is designated — Partial Duodenectomy, 
 Jejunectomy, Ileectomy, Caecectomy, Colectomy (ascending, transverse, or 
 descending), Sigmoidectomy, Rectectomy. By the term Enterectomy alone 
 is usually understood an excision of some part of the small intestine. As, 
 of course, excision of the whole intestine is never considered, Enterectomy 
 is generally used in the sense of a partial excision, without the preceding 
 word "partial." Enterectomy carries with it the idea of three operations — 
 partial excision of the intestine — partial excision, or incision, of the mesentery 
 — intestinal junction. The operation is generally resorted to where the disease 
 or injury to a part of the intestine, or its mesentery, is so extensive that a 
 portion of the intestine must be cut out and sacrificed. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab 
 dominal section (page 631). 
 
 Operation, — (1) Having opened the abdomen, the portion of intestine 
 involved is brought out into the field of operation. (2) Before excising any 
 portion of the intestinal tract, the contents of that part should be removed 
 from it as much as possible — which is best accomplished by " milking" the 
 intestines in opposite directions from a central point, the center of the part 
 to be excised — and then clamping the intestines, proximally and distally, 
 beyond the site to be removed. Various forms of clamps are used for this 
 purpose, which may be divided into three categories; — (A) Special intestinal 
 clamps, which are generally best (Figs. 600, C, and 599) ; — (B) Improvised 
 clamps may be used, such as: (a) Pierce the mesentery near the intestinal 
 border with the closed ends of a pair of forceps — grasp a small rubber tube in 
 the bite of the forceps and draw it through the mesentery — and tie the two ends 
 over the intestine (Fig. 600, E) ; (b) Pass a sterilized wooden toothpick 
 through the mesentery, near the intestine, and make a figure-of-8 with a rubber 
 band over it, compressing the intestine between toothpick and rubber band 
 (Fig. 600, D) ; (c) Pass the pin of a safety-pin through the mesentery, near 
 
PARTIAL ENTERECTOMY. 
 
 851 
 
 the intestine — and fasten, in the act of closing the pin, a small piece of flat 
 sponge over the intestine (Fig. 600, A) ; (d) Pass a piece of gauze through the 
 mesentery, near the bowel, and tie over the intestine after the fashion of the 
 rubber tube in (e) above: — (C) The thumb and index of each hand of an 
 assistant may be used to compress the intestine in the position a pair of clamps 
 would occupy — after having pressed away the intestinal contents (Fig. 600, B) . 
 (3) The indicated portion of the intestine is now excised — by dividing the gut 
 on either side of the segment to be removed, with scissors or knife, exactly at a 
 right angle to the length of the intestine at the part divided — so that the cut ends 
 may be afterward approximated without any tension at either mesenteric or 
 
 Fig. 599. — Partial Enterectomy: — The excision of a part of the small intestine is shown, 
 with the excision of a corresponding V-shaped portion of mesentery. The intestine is divided 
 at a right angle to its length, between two clamps at either end of the excised area. The main 
 mesenteric vessels are ligated prior to section. 
 
 antimesenteric aspect (Fig. 599) . (There is somewhat greater retraction of the 
 antimesenteric border naturally.) Division of the intestine with a knife is better 
 than by means of scissors, which latter compress the edges somewhat. It is 
 well to have, if possible, a good artery left just to the proximal side of the proxi- 
 mal intestinal incision, and one on the distal side of the distal intestinal incision 
 — to furnish nourishment to the uniting edges. The triangular space, at the 
 
8 5 2 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 separation of the leaves of the mesentery, will be opened up — and care should 
 be exercised not to bare the intestinal tube further than necessary. (4) The 
 treatment of the mesentery corresponding with the excised portion of the 
 intestine differs — one of the following methods may be used: — (a) Probably 
 the best plan, after having excised the portion of intestine, is to remove a 
 triangular or V-shaped piece of the mesentery — whose base will be a little 
 narrower than the section of the intestine removed — whose sides will pass 
 down obliquely toward each other in the direction of the root of the mesentery, 
 but meeting midway between the two free ends of the intestine and before 
 
 Fig. 600.— Methods of Controlling the Intestinal Contents di-ring Partial En- 
 terectomy :— A, Maunsell's method by means of sponge and safety-pin ; B, Digital compression ; C, 
 Special intestinal clamps ; D, Toothpick, or similar object, piercing the mesentery, with an ordinary 
 rubber-band passed over it in figure-of-eight fashion ; E, Rubber tube passed through mesentery and 
 tied over the intestine. (Whichever method of control be used, the same method is generally applied 
 on each side of the area to be excised.) 
 
 reaching the root of the mesentery. The division is made with a knife or 
 scissors, from a line with the free ends of the divided intestines at their mesen- 
 teric borders — taking care to preserve the artery supplying the free end of 
 the intestine, proximally and distally. In suturing, the edges of the cut 
 mesentery are approximated with gut by continuous or interrupted suture 
 (Fig. 601, A and B). Or the edges may be slightly overlapped and 
 then sutured, uniting laterally (Fig. 601, C). All vessels which fall along 
 the line of division of the mesentery, whose position is shown through the 
 thin mesentery, should be ligated, proximally in advance of the division— by 
 passing a curved needle armed with gut, beneath them, — or the vessels may 
 
PARTIAL ENTERECTOMY. 
 
 853 
 
 be clamped immediately after division and then ligated (see Fig. 372). 
 This method is especially advisable in malignant disease where the mesenteric 
 glands may be involved, (b) Another method is, after dividing the intestine 
 at both ends, simply to cut away the excised portion close along the mesenteric 
 attachment, after having ligated its vessels as in the above method. In 
 suturing, the redundant mesentery is simply folded upon itself and a few 
 gut sutures passed from side to side, along the angle of junction with the 
 rest of the mesentery — and by whipping the free margins with a gut suture, 
 to prevent a hernia occurring through the opening. This method probably 
 insures a better blood-supply to the intestine (Fig. 601, D). (c) In addition 
 to the steps mentioned in the last method, the entire triangular fold may 
 
 Fig. 001.— Methods of Suturing the Mesentery in Partial Enterectomy : — A, A 
 V-shaped portion of mesentery excised, with suturing of edge to edge by continuous suture ; B, Same 
 with suturing of edge to edge by interrupted sutures; C, Same, with edges overlapped by running 
 suture; D, Mesentery left intact, with free edges sutured together by continuous overhand stitch ; E, 
 Same, with suturing of both free border and free fold of redundant mesentery to main mesentery, 
 together with closure by continuous suture of entrance to mesenteric pocket. Note — Several mesen- 
 teric vessels are shown ligated, by the passage of needle and gut-ligature beneath them. 
 
 be sutured back to the general mesentery by sutures along its folded border, 
 as well as along its free border (Fig. 601, E). 
 
 Comment. — Partial Enterectomy is an incomplete operation in itself — 
 and naturally carries with it the idea of suturing together the two free ends 
 of the intestinal canal left open after the excision, and thus repairing the 
 intestinal tract — but since the junction of these two ends is accomplished 
 by a separate and distinct operation, it will be treated of separately. (See 
 Entero-enterostomy.) 
 
854 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 ENTERO-ENTEROSTOMY. 
 
 INTESTINAL ANASTOMOSIS, APPROXIMATION, AND IMPLANTATION, IN 
 
 GENERAL. 
 
 Intestinal Anastomosis was originally applied to the operation of estab- 
 lishing a communication between the intestine above and the intestine below 
 the seat of obstruction, without the removal of the portion of intestine in 
 which the obstruction was situated. As a result, the larger part of intestinal 
 contents would tlow by the new route, thus "short-circuiting" the obstruction, 
 while the smaller portion would flow through the partially obstructed canal, 
 until the obstruction was relieved or became complete. As, in such cases, 
 no portion of the intestine was removed, the Anastomosis was always a 
 Lateral Anastomosis, that is, the joining of the lateral aspect of one coil 
 with the lateral aspect of another coil. Subsequently, however, Intestinal 
 Anastomosis came to be used, by many surgeons, in the same sense as Intes- 
 tinal Approximation, and applied to both end-to-end and to lateral joinings. 
 
 Intestinal Approximation was originally used to signify the union of 
 the portions of the intestinal tract following the excision of a part of the 
 canal — the approximation being either end-to-end or lateral. In End-to-end 
 Intestinal Approximation, after the excision of a part of the intestine has 
 been accomplished, the free ends of the intestine above and below are ap- 
 proximated and united. In Lateral Intestinal Approximation, after the partial 
 enterectomy has been performed, the free ends of the intestine above and 
 below are closed by suture, and then the lateral aspect of the closed upper 
 end is approximated and united to the lateral aspect of the closed lower 
 end. 
 
 Intestinal Implantation has generally been used to signify the implanta- 
 tion, or union, of the end of one piece of intestine into an opening in the 
 lateral, antimesenteric aspect of another coil — following the excision of a seg- 
 ment of intestine. This process of union imitates the union of the ileum with 
 the colon (caecum). 
 
 Entero-enterostomy signifies the junction of the lumen of some part of 
 one intestinal coil with the lumen of some part of another. Strictly speaking, 
 therefore, Entero-enterostomy is a term of broader significance than those above 
 used, and includes Anastomosis, Approximation, and Implantation. No hard- 
 and-fast rule, however, exists as to the use of the terms designating the union 
 of coils of intestine, but the shades of difference expressed in the terms 
 Intestinal Anastomosis, Approximation, and Implantation might probably be 
 more accurately expressed by the terms Entero-enterostomy by Lateral An- 
 astomosis — Entero-enterostomy by End-to-end Approximation —Entero-en- 
 terostomy by Lateral Approximation —Entero-enterostomy by End-in-side 
 Implantation. While, therefore, Entero-enterostomy expresses the junction of 
 lumina of segments of intestine, the method of that junction is best expressed 
 by following the term with some qualifying words. 
 
 The Scope of the Methods of Intestinal-joining.— Many of the methods 
 used for variously uniting segments of the intestines to each other are also used 
 to unite portions of the intestines with different parts of the stomach — and also 
 with the gall-bladder. The range of usefulness of any method of intestinal 
 joining, therefore, is measured by the ability of that special method to meet the 
 requirements of the following operations involving the intestines:— Entero- 
 enterostomy by Lateral Anastomosis; Entero-enterostomy by End-to-end 
 Approximation; Entero-enterostomy by Lateral Approximation; Entero-en- 
 
EXTERO-ENTEROSTOMV BY SIMPLE SUTURING. 855 
 
 terostomy by End-in-side Implantation; Simple Gastro -enterostomy (by 
 lateral anastomosis, or end-in-side implantation); Gastro-enterostomy fol- 
 lowing pylorectomy; Cholecystenterostomv. 
 
 The Methods of Accomplishing Intestinal Joinings. — (1) Union of 
 portions of Intestinal, Gastro-intestinal, and Cholecyst-intestinal tracts by 
 simple suturing; — (2) Union of portions of Intestinal, Gastro-intestinal, and 
 Cholecyst-intestinal tracts by absorbable mechanical devices; — (3) Union of 
 portions of Intestinal, Gastro-intestinal, and Cholecyst-intestinal tracts by 
 non-absorbable devices; — (4) Union of portions of Intestinal, Gastro-intes- 
 tinal, and Cholecyst-intestinal tracts by mechanical means temporarily used 
 during suturing. 
 
 Note. — In the various operations of Entero-enterostomy it is not necessary 
 that any previous excision (partial enterectomy) must have been done — though 
 such an excision may have been done. In the following operations of Entero- 
 enterostomy the joining of the portions of intestine will (to make the operation 
 more complete) be supposed to follow, in the majority of cases, excision of 
 some part of the gut. Of course, the same operations which are applicable 
 after the excision of a part of the intestine are also applicable after a circular 
 division (circular enterotomy) of the gut without any excision of a part of 
 the canal. 
 
 (A) ENTERO-ENTEROSTOMY BY METHODS OF SIMPLE 
 
 SUTURING 
 
 IX GENERAL. 
 
 Union is here accomplished by the ordinary methods of suturing, unaided 
 by mechanical devices other than sutures. 
 
 (1) For the general principles of intestinal suturing, see Enterorrhaphy in 
 General. (2) Fine silk or fine chromic gut may be used throughout. Or silk 
 may be used for the first tier and chromic gut for the second. This applies 
 whether the first tier includes all the coats or only the mucous membrane. (3) 
 Some surgeons prefer to use only interrupted sutures throughout in intestinal 
 suturing— upon the ground that in continuous suturing (especially when of 
 silk) the size of the opening becomes more or less fixed and less capable of the 
 distention which, on the other hand, may readily occur in all forms of inter- 
 rupted sutures. (4) It is well to bear in mind that sometimes Lembert inter- 
 rupted sutures which may appear to be near enough in the undisturbed condi- 
 tion of the gut become too far apart when it is distended. (5) No matter what 
 form of suturing be used for the first tier, the second tier should include only 
 the serous, muscular, and, if possible, part of the submucous coats — and should 
 bury in the first tier. (6) Difficulties encountered in placing sutures may be 
 largely overcome by seizing the site to be sutured with delicate forceps and thus 
 causing that part to meet the needle with its proper aspect rendered prominent 
 by eversion, inversion, traction, etc. (7) When segments of unequal size are to 
 be approximated end-to-end, the only way this can be done by simple suturing 
 is either, (a) to partially close the opening of the larger gut down to the size of 
 the smaller, which maybe accomplished by taking a V-shaped piece out of the 
 antimesenteric aspect of the larger gut and then suturing together the edges of 
 the V before making the junction,— or (b) by cutting the opening of the smaller 
 gut obliquely (Wehr's method) instead of transversely, at the expense of the 
 
856 OPERATIONS UPON THE ABDOM1NO-PELVIC REGION. 
 
 free border, and thus increasing its size to match the larger gut. The best 
 methods, however, of uniting segments of unequal size are probably either by 
 the Murphy button or the Maunsell method. 
 
 ENTERO-ENTEROSTOMY BY SIMPLE CONTINUOUS OVERHAND 
 SUTURE OF ALL COATS, FOLLOWED BY INTERRUPTED OR 
 CONTINUOUS LEMBERT SUTURES OF OUTER COATS. 
 
 Description. — The first tier of suturing is for approximation and strength 
 — the second, for union of the serous surfaces and occlusion of the intestinal 
 lumen. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 Fig.602.— Entero-enterostomy by Simple Continuous Overhand Suturing of All Coats, 
 
 FOLLOWED BY INTERRUPTED OR (CONTINUOUS) L.EMBERT SUTURES OK OUTER COATS : — A method 
 
 of holding the intestine and introducing the first tier of simple continuous overhand suturing of all 
 coats. Author's method. 
 
 End-to-end Approximation — Author's Method. — (1) Open the ab- 
 domen — isolate and bring forward the indicated coil of intestine — press 
 away the intestinal contents — apply intestinal clamps, proximally and dis- 
 tally, to the site to be excised — and excise the portion of intestine, with 
 or without the corresponding portion of mesentery (see Enterectomy). 
 The two ends of the intestine are now brought into convenient apposition 
 
EXTERO-EXTEROSTOMY BY SIMPLE SUTURING 
 
 857 
 
 for suturing, and are held in apposition during the placing of the first 
 tier of sutures. (2) The first row of continuous suturing passes through 
 all the coats of proximal and distal segments of intestine, and consists 
 of a continuous silk or gut suture carried upon a straight needle held in the 
 fingers. The surgeon holds the approximated borders of the two coils of 
 intestine over the radial aspect of his left first finger, approximating the op- 
 posite borders with the left second finger and thumb (or holds them over his 
 
 Figs. 603-605. — Details of Simple Continuous Overhand Suturing of All Coats, shown 
 in Fig. 602: — A, Manner of knotting and beginning suture, at a — traversing posterior edges of 
 intestines — and including lamina? of mesentery at b, whence the suture starts to return ; P.. Manner 
 of traversing anterior edges of intestines— and ending the suture at a, preparatory to knotting ; 
 C. Manner of tying final knot of first tier of sutures at a, and appearance of suture-line and 
 approximated leaves of mesentery. Author's method. 
 
 left second finger, approximating with his left index and thumb). (See Fig. 
 602.) Four thicknesses of gut are thus brought together, two from the prox- 
 imal and two from the distal end of the divided intestine. The adjacent 
 aspects of the apposed edges should be first sutured. (See Fig. 603, A.) The 
 needle should first enter at the antimesenteric borders, the first stitch being so 
 placed as to leave the free end of the suture, after knotting, on the outside, 
 which is done by beginning the stitch from without and then passing the needle 
 back into the lumen after tying the first knot. After the needle has passed 
 back into the lumen it should always, in going toward the mesenteric attach- 
 ment, travel from within outward through the wall of the intestine on the right 
 (nearer the operator)— then from without inward through the wall of the intes- 
 tine on the left (further from the operator) — and so on, descending toward the 
 mesenteric aspect. The last stitch, before beginning the return, includes, besides 
 the two thicknesses of the gut, also the two laminae which are adjacent (one 
 
858 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 from the proximal and one from the distal portion of gut) . And the first stitch, 
 after beginning the return, includes, besides the two thicknesses of gut, also the 
 two laminae of mesentery (one from the proximal and one from the distal por- 
 tion of gut) which are furthest from each other at the taking of the stitch, but 
 which will be brought into contact by the stitch. (See Fig. 604, B.) The 
 suturing is then continued back to the antimesenteric aspect in an overhand 
 stitch, as before — passing, now, from without inward through the wall of the 
 intestine nearer the operator, and from within outward through the wall of the 
 intestine further from the operator. When the last stitch is reached, its free 
 end on the outer side is knotted to the free end left on the outer side at the start. 
 
 Fig.606.— Entero-enterostomy by Simple Continuous Overhand Suturing of All Coats, 
 
 FOLLOWED BY INTERRUPTED (OR CONTINUOUS) LEMBERT SUTURES OF OUTER C OATS :— A method 
 
 of holding the intestine and introducing the second tier of interrupted Lembert sutures, which is seen 
 burying in the first tier of continuous overhand suturing. The assistant's hands are held in pronation 
 while suturing the anterior, and in supination while suturing the posterior aspect. 
 
 (See Fig. 605, C.) During the return-row of suturing care is taken that the 
 stitches do not penetrate the coats already whipped together by the first row — 
 which is easily avoided, as the edges are all in plain view as each needle-punc- 
 ture is made. (3) The second row of suturing consists of interrupted Lembert 
 sutures passing through the serous and muscular, and probably also the sub- 
 mucous, coats. The sutures are silk or chromic gut, carried upon a straight 
 needle held in the fingers. The barrel of intestine is now held out straight by 
 an assistant, who grasps it about 10 cm. (4 inches) on either side of the suture 
 line — while the operator picks up a transverse fold of the gut wall near the origi- 
 nal suture line by means of delicate forceps held in his left hand — and a similar 
 fold just beyond the suture-line — passing the needle through both folds in the 
 ordinary Lembert fashion. (See Fig. 606.) One half of the circumference of 
 the gut is sutured from one side, after which the intestine is turned over and 
 the other half sutured from the opposite side. The sutures are inserted in the 
 
EXTERO-ENTEROSTOMY BY SIMPLE SUTURING. 
 
 859 
 
 usual manner of the Lembert method — the forceps picking up the tissue in 
 transverse folds and thus drawing it away from the opposite wall, thereby mak- 
 ing the passage of the suture easier, and the penetration of the opposite wall 
 impossible. Especial care is necessary as the diverging lamina 1 of the mesentery 
 are encountered, in order that each lamina may be closely approximated to the 
 barrel of its own segment of intestine and to the opposite lamina on the same 
 side of the intestine. The Lembert sutures should, therefore, be continued on 
 
 Figs. 607 and 60S. — Entkroenterostomy by Simple Continuous Overhand Suturing of 
 All Coats, followed by Interrupted (or Continuous) Lembert Sutures of Outer Coats: — 
 A. Another method of holding the intestines and introducing the first tier of simple continuous 
 suturing of all coats; B. Diagram showing manner of introducing the three preliminary traction- 
 sutures. Author's method. 
 
 down to the very junction of the mesentery with the intestine and slightly 
 beyond. 
 
 Note. — Instead of holding the intestines as above described during the 
 placing of the first tier of sutures. >everal methods of holding them in apposition 
 may be employed. Three interrupted sutures may be placed and knotted in 
 loops as temporary traction-sutures — each including all the coats of the two 
 adjacent walls of the proximal and distal segments of intestine — one placed at 
 the mesenteric aspect — and the other two dividing the circumference of the 
 severed ends into three equal parts. An assistant now draws these three loops 
 in different directions (which a single assistant can do by hooking them over his 
 fingers, if the loops are not too long) — whereby two objects are accomplished; 
 — one-third of the margins of each gut are brought into contact, — and the mar- 
 gins of the other two-thirds are held out of the way (and thus the penetration of 
 their wall by the needle rendered impossible). While held in this manner, the 
 adjacent margins of each third are whipped together by a continuous overhand 
 
S6o 
 
 OPERATIONS UPON THE ABDOMINO-PELYIC REGION. 
 
 suture — after which the temporary traction-loops are cut and withdrawn (or 
 may he tied and cut short, as permanent interrupted sutures reinforcing the 
 continuous ones). (See Figs. 607 and 608.) The second tier of interrupted 
 
 Fig. 609. — Lateral Intestinal Approximation by Simple Continuol t s Overhand 
 Suturing of all Coats, followed by Interrupted (or Continuous) Lembert Sutures 
 of Outer Coats: — I. — Manner of placing posterior sutures: A, Showing manner of placing 
 sutures along posterior aspect and at ends of incisions; R, Manner of holding end of intestine 
 between thumb and index while placing sutures; C, Manner of holding the ends with temporary 
 traction-sutures passed through outer coats, while invaginating. 
 
 Lembert sutures is applied as just described. Or' the traction sutures may be 
 retained until the Lemberts are placed, to draw the edges parallel. 
 
 Lateral Approximation. — (1) Excise the indicated portion of intestine, 
 with or without the corresponding piece of mesentery, as described under 
 Enterectomy. (2) The proximal and distal free ends of the intestine are now 
 each closed by one of the following methods; — (a) Hold the free end of the in- 
 testine between the left thumb and index, and whip together the parallel walls 
 by an overhand continuous suture of all the coats — followed by an invagination 
 of this line of suturing by means of a line of interrupted or continuous Lemberts 
 (see Fig. 609, B). — (b) Pass a traction-suture at the mesenteric aspect, and 
 another at the antimesenteric aspect, near to but not quite at the free margins — 
 and, while these are drawn upon by an assistant, whip the free edges together as 
 above — and, while further drawing upon them, invert the first suture-line with 
 a probe, and place a row of Lemberts so as to permanently invaginate the first 
 tier (see Fig. 609, C). — (C) The free ends of the intestine may be closed by a 
 
ENTERO-EXTEROSTOMY BY SIMPLE SUTURING. 
 
 86l 
 
 continuous overhand suture of all the coats, while the walls of the intestine are 
 still held in contact by the special forceps grasping the whole width of intestine, 
 and along which they have been divided in the operation of enterectomy — fol- 
 lowed by an invaginating Lembert tier, as above (see Fig. 610, B). — (d) The 
 free end of each piece of intestine may be gathered together by an ordinary 
 purse-string suture — and this first tier then further invaginated by a second 
 tier of Lemberts, as above described (see Fig. 610, C). (3) Having closed the 
 open ends of the gut, approximate these ends so that they overlap about 5 to 
 7.5 cm. (2 to 3 inches), with their antimesenteric aspects in contact — and have 
 an assistant hold them in this position. The lateral aspects of the coils of intes- 
 tine may be held in approximation by the hands of an assistant during the sutur- 
 ing; — but the contact can be made more satisfactory, and the likelihood of leakage 
 
 Fig. 610. — Lateral Intestinal Approximation by Simple Continuous Overhand 
 Suturing of all Coats, followed by Interrupted (or Continuous) Lembert Sutures of 
 Outer Coats: — II. — Manner of placing anterior sutures. A, Showing manner of carrying 
 suture around ends and along anterior aspect of incisions; B, Manner of holding end of intestine 
 with clamp-forceps while suturing; C, Manner of closing end of intestine with purse-string suture 
 preparatory to placing final tier of end-sutures. 
 
 less, by the use of special intestinal clamps (Fig. 611). (4) Place a tier of con- 
 tinuous Lembert suturing of gut, carried upon a curved needle held in a needle- 
 holder, along what will be the posterior line of union between the serous sur- 
 faces — extending the line of suturing out at either end, in a somewhat elliptical 
 form, beyond the limits of the future incision — leaving one end of the suture, 
 after knotting, long and free — and the other end, also after half knotting, long 
 and threaded upon the needle. (See Fig. 609.) (5) Incisions in the long axis 
 of both pieces of intestine are now made opposite each other in the correspond- 
 ing aspects of the guts — and sufficiently far from the posterior suture-line to 
 leave two free edges for suturing — and equidistant from what will form the 
 anterior suture-line of the serous surfaces. These incisions will begin and stop 
 short of reaching the outer limits of the surrounding Lembert suture-line which 
 will enclose them. (6) The corresponding free margins of the wounds are now 
 
862 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 sutured with continuous overhand silk suture, carried in a curved needle held in 
 a needle-holder. Begin the suturing at the right end of the posterior aspect 
 (furthest from operator) — knot the suture and leave one end of the thread free — 
 and continue the suturing toward the operator, until the posterior lips are 
 united. Having reached the limit of the posterior aspect of the opening, the 
 direction of the suturing now changes and is made to traverse the anterior aspect 
 of the wound, similarly whipping together the anterior lips of the intestinal 
 incisions from left to right, away from the operator — until the point of begin- 
 ning is reached, when the end from which the needle lias just been withdrawn is 
 knotted to the end previously left free — thus completely approximating the lips 
 of the openings throughout. (7) The threaded needle of the original serous 
 
 Fig. 6n. — Lateral Intestinal Anastomosis by Simple Continuous Overhand 
 Suture of all Coats, followed by Interrupted (or Continuous) Lembert Suturing of 
 Outer Coats, Aided by Intestinal Clamps: — The posterior seromuscular suture is shown 
 with knot at its right end and needle on its left end; — The inner through-and-through suture is 
 seen, with its right end knotted and its left end free. 
 
 suture, which had been temporarily dropped, is now taken up — and this line of 
 continuous Lemberts is carried on around the outside of the line uniting the 
 edges, at the same distance from their edge as the posterior serous line passed — 
 until the free end of line of serous suture, left at starting, is reached, when they 
 are knotted together, — which completes the union between the intestines. 
 (See Fig. 610.) (8) The mesentery is now sutured as indicated. 
 
 Lateral Anastomosis. — The operation is here performed in a precisely 
 similar manner to the last (Lateral Approximation) — omitting the excision of 
 any portion of the intestinal canal— the antimesenteric aspects of the gut being 
 brought into apposition. Care is taken that the intestinal coils are not twisted 
 out of their natural relations. (See Fig. 612.) 
 
ENTERO-ENTEROSTOMY BY SIMPLE SUTURING. 
 
 86 3 
 
 Note. — In Lateral Approximation and Lateral Anastomosis, in order to 
 prevent bagging, and sagging away of the intestines near the site of union, it is 
 well to slightly scarify and suture (or suture alone) the free portions of the in- 
 testine together for about 2.5 cm. (1 inch) on either side of the union. 
 
 End-in-side Implantation.— (1) Following excision (for example, of the 
 caecum) the free end of the intestine, the lateral aspect of which is to receive the 
 implanted gut, is closed by a double line of suturing in precisely the same man- 
 ner as described under Lateral Intestinal Approximation. (2) An incision is 
 
 Fig.612 — Lateral Intestinal Anastomosis by Simple Continuous Overhand Suturing 
 of All Coats, followed by Interrupted (or Continuous) Lemberi Sutures of Cuter 
 Coats : — A, Simple continuous overhand suture of all coats; B, Continuous Lembert suture of outer 
 coats. The intestinal current passes as indicated by arrows, "short-circuiting" the cancerous 
 growth. 
 
 made near the end of the invaginated gut corresponding with the end of gut to 
 be implanted. (3) The open end of the gut which is to be implanted (usually 
 of smaller calibre) is now brought into apposition with the incision upon the 
 antimesenteric aspect of the gut which is to receive the implantation, at about 
 5 cm. (2 inches) from its sutured end — and held in contact by an assistant 
 throughout the operation. A line of continuous overhand silk sutures, carried 
 upon a curved needle held in a needle-holder, is placed through all the coats 
 of both pieces of the intestine, in exactly the same manner as described under 
 the Lateral Approximation operation, the difference in the direction of apposi- 
 tion of the two pieces of gut in the end-in-side implantation making no differ- 
 ence in the manner of application of the sutures. Interrupted sutures may 
 be used instead of the continuous. The margins of the end-opening in one 
 piece of intestine and the lateral openings in the other are thus brought together 
 throughout. (4) A continuous or interrupted Lembert suture is now carried 
 through the serous and muscular (and probably into the submucous) coats of 
 the two pieces of intestine, in such a manner as to surround the first line of 
 through-and-through suture in a somewhat elliptical fashion. (5) The mesen- 
 teric borders are sutured in such a manner as to leave no opening through which 
 coils of intestine may pass. (See Fig. 613.) 
 
86 4 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Note. — (i) The same ultimate method of union may be accomplished in a 
 somewhat different order. The serous surface near the free margins of the 
 smaller gut may be attached, by Lembert sutures, to the serous surface of the 
 invaginated gut, in such a position as to correspond with the future opening — 
 the attachment being first along the posterior aspect, as in Lateral Approxima- 
 tion. An opening is then made by incision into the invaginated end corre- 
 sponding with the partly attached free end of intestine. The free edges of the 
 opening are then united throughout by continuous silk suture — after which 
 the continuous or interrupted Lembert suture of the serous surfaces is carried 
 around the anterior aspect of the opening — thus completing the union. (2) 
 The process of union may be mechanically aided by using Senn's rubber band 
 as a temporary ring within the segment of intestine to be implanted — where it 
 is held for a time by gut sutures — and is afterward liberated and passed down 
 the canal. 
 
 Fig. 613.— End-in-side Intestinal Implantation by Simple Continuous (or Interrupted) 
 Overhand Suturing of All Coats, followed by Interrupted (or Continuous) Lembert 
 Sutures of Outer Coats :— A, Ileum ; B, Ascending colon ; C, C, Interrupted sutures of all coats 
 of both intestines; D, Continuous suture of outer coats. 
 
 END-TO-END ENTERO-ENTEROSTOMY BY PERFORATING MATTRESS 
 
 SUTURES KNOTTED IN THE LUMEN. 
 
 connell's method. 
 
 Description. — Interrupted mattress sutures are so carried through all the 
 coats of the intestine and tied as to bring all the knots within the intestinal 
 lumen. 
 
END-TO-END ENTERO-ENTEROSTOMY. 
 
 86 5 
 
 Preparation— Position— Landmarks— Incision.— As for median abdom- 
 inal section. 
 
 Operation. — (1) The mesenteric, the most important, suture is placed in 
 the following manner (Fig. 614, A) ; — The needle (calculating that the stitches 
 are 3 mm. (^ inch) apart and the same distance from the free edge of the 
 intestine) passes through all the coats of one end of the intestine, from within 
 outward — into the free space between intestine and leaf of the mesentery — 
 through this left from within outward — over to the opposite leaf of the mesen- 
 tery — through this from without inward — through the free space between 
 mesenteric leaf to the intestine — through all the coats of the other end of the 
 intestine, from without inward — thence, returning, the needle and thread take 
 a corresponding course — to emerge parallel with the thread of entrance, within 
 the lumen of the original end of the intestine — ready to be tied. This stitch 
 approximates the leaves of the mesentery to the barrel of the intestine, and the 
 two ends of the intestine to each other. (2) Four traction-sutures are inserted, 
 dividing the intestinal circumferences into thirds, for the purpose of aiding in 
 the mechanical insertion of the remaining mattress sutures. Two are placed 
 
 Fig. 614. — End-to-end Entero-enterostomy by Connell's Method: — I. — A, Mes- 
 enteric stitch; B, B, Interrupted mattress sutures through all coats of both ends of intestine, 
 knotted within the lumen. 
 
 as indicated at A and B, Fig. 615. These pass through all the coats of both 
 ends of the intestine, and are separated from each other one-third of the cir- 
 cumference of the intestine. By traction upon them the walls of the intervening 
 third of the end of each piece of intestine are put upon the stretch and made 
 parallel, thus rendering them easy of access for the placing of the sutures for 
 that third. Upon the completion of this third, traction-suture B is carried 
 toward the position formerly occupied by traction-suture A, and traction-sutures 
 C and D are brought together and drawn in the opposite direction— which will 
 make the second third of the intestinal margins occupy the position originally 
 occupied by the first third. The last third is brought into line and sutured in 
 the same way, with the modification to be mentioned. (3) The sutures pass 
 through all the coats of both of the intestinal ends, as shown in Fig. 614, B, B, 
 and in Fig. 615, E, and are knotted as soon as placed. (4) The suturing is 
 thus rendered very easy until the circumference has been nearly traversed. 
 In the suturing of the last third there is greater mechanical difficulty, owing to 
 the lessened working-room. It is best to place the sutures of this third before 
 tying them. When this is done,— all are tied except the last one. The closure 
 
 55 
 
866 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 A- 
 
 A- 
 
 ^ 
 
 Fig. 615. — End-to-end Entero-enterostomy by Connell's Method: — II. — A, B, 
 Traction-sutures drawing margins of first thirds of intestines parallel; C, D, Traction-sutures 
 to be used in parallelling remaining thirds of intestinal margins; E, One of the interrupted mattress 
 sutures placed, ready to be tied. 
 
 Fig. 616. — End-to-end Entero-enterostomy by Connell's Method: — III. — Insertion 
 of needle, eye-end first, through interval between sutures — projecting through interval left by 
 yet untied last mattress suture — the threads of which are within loop made by needle and its 
 thread, ready to be drawn out through place of entrance of eye-end of needle. 
 
ENTERO-ENTEROSTOMY BY CZERNY-LEMBERT SUTURE. 
 
 867 
 
 represented by the last stitch is accomplished in one of two ways: — (a) The 
 author of the technic completes the tying of the last mattress stitch by insert- 
 ing a threaded needle, eye first, between two sutures of an opposite aspect of 
 the circumference (Fig. 616) — the eye-end of the needle is protruded through 
 the opening left by the last stitch — the two threads composing this last stitch 
 are then carried through the noose made by the shaft of the needle and its 
 double thread — after which the needle is withdrawn, carrying the two threads 
 of the last stitch with it — which are then knotted and cut short — during which 
 process the walls of the lumen are approximated — and regain their normal 
 relation upon the cutting of the knot — the serosae separated by the entrance 
 of the eye-end of the needle also coming together, (b) The opening repre- 
 sented by the last suture can, however, be more simply closed by a sero-mus- 
 cular mattress suture, as suggested by Gould, Fig. 617. 
 
 Fig. 617. — End-to-end Entero-enterostomy by Connell's Method: — IV. — Gould's 
 method of closing interval left by last mattress suture in Connell's operation, by means of a sero- 
 muscular mattress suture. (Redrawn from Gould.) 
 
 ENTERO-ENTEROSTOMY BY THE CZERNY-LEMBERT INTERRUPTED 
 
 SUTURE. 
 
 Description. — The edges of the mucous coat are brought together by the 
 interrupted Czerny suture, which passes through this coat alone — followed 
 by the ordinary interrupted Lembert suture through the serous, muscular, and 
 part of the submucous coats. The method of application is the same as that 
 described under " Enterorrhaphy by the Czerny-Lembert interrupted suture" 
 page 844). 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — (1) The ends of the intestines are held in 
 convenient apposition — as described in the same operation by the last method. 
 The suture consists of silk or gut, carried upon a curved needle held in a needle- 
 holder. The manner of manipulating is described under Enterorrhaphy by 
 this method. The sutures are interrupted and are introduced and knotted 
 from within, in the Czerny fashion. When the circular enterorrhaphy is 
 almost completed, the last suture or two are somewhat more difficult to place, 
 owing to the tendency of the knot to remain upon the outer aspect — which may 
 be allowed, as this tier will be subsequently buried in — or, better, maybe in- 
 
868 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 vaginated within the lumen of the gut by a probe. (See Fig. 618, B.) (2) 
 Having completed the first or mucous tier of sutures, the second or outer tier 
 of interrupted Lemberts is carried through the serous, muscular, and part of 
 the submucous coats — and consists of silk or gut carried upon a straight needle 
 held in the fingers — and is introduced in every respect as the interrupted 
 Lemberts are introduced in the method just described. (See Fig. 618, A.) 
 
 Lateral Approximation —Lateral Anastomosis — End-in-side Implan- 
 tation. — The methods of holding the segments of intestines in contact and the 
 general principles of completing the entero-enterostomy are the same as in the 
 corresponding operations by the overhand continuous suture of all the coats, 
 followed by the interrupted or continuous Lembert suturing of the outer coats 
 
 Fig. 618 — Entero-enterostomy by the Czerny-Lembert Interrupted Siture: — B, 
 Czerny interrupted suture passing through mucous and part of submucous coats — applied from 
 within ; A, Lembert interrupted suture passing through serous, muscular, and part of submucous 
 coats — applied from without. 
 
 — with the exception that the first tier of suturing, in the present method, is of 
 the mucous coat alone, and the second tier of the outer coats. 
 
 Note. — The Czerny suture should include some of the submucous coat, to 
 hold well. 
 
 ENTERO-ENTEROSTOMY BY HALSTED'S METHOD OF INTERRUPTED 
 
 MATTRESS SUTURES. 
 
 Description. — The opposite intestinal walls are brought and held in con- 
 tact by a single tier of the characteristic Halsted mattress or quilt interrupted 
 suture, passing through the serous, muscular, and part of the submucous coats. 
 The general method of application of this form of suturing to circular enteror- 
 rhaphy is identical with the method described under "Enterorrhaphy by 
 Halsted's interrupted mattress suture" (page 845). In the end-to-end ap- 
 proximation, six " presection sutures " are used additionally. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — The details of the application of the 
 Halsted sutures in performing entero-enterostomy without artificial aids are 
 precisely the same as employed in the Halsted operation of entero-enteros- 
 tomy by means of an inflatable rubber cylinder. The technic of the opera- 
 tion, therefore, will be found under the latter head — and may be used here, 
 
ENTERO-ENTEROSTOMY BY HALSTED SUTURE. 869 
 
 omitting the use of the cylinder, and accomplishing the junction of the seg- 
 ments of intestine by end-to-end approximation by means of simple suturing. 
 The ends of intestine to be approximated are, in this case, simply held in con- 
 venient contact by an assistant — the steps are otherwise the same as in the 
 more elaborate operation. 
 
 Lateral Approximation. — (1) Having excised the required portion of in- 
 testine, the free ends of both pieces of gut are closed by a single row of the Hal- 
 sted interrupted mattress sutures, introduced in the Halsted manner (see Fig. 
 619). (2) The antimesenteric aspects of the two pieces of intestine are then 
 held in contact at about 5 cm. (2 inches) from their free ends. A posterior row 
 of interrupted Halsted sutures is now placed along the line which is to form the 
 posterior boundary of the intestinal junction, generally being about eight in 
 number. At either end of this line two additional sutures are placed, coming 
 slightly more forward, in continuation of the posterior longitudinal line in a for- 
 ward curve. All of these sutures are first placed before any are tied — and then 
 all are tied before placing the final ones. (See Fig. 619.) The anterior row of 
 interrupted sutures is now similarly placed before any are tied — and so planned 
 as to form an elliptical figure surrounded by sutures. (3) The sutures forming 
 the anterior row are now drawn apart in the center (without drawing any of 
 them entirely out), and a longitudinal opening is made in each gut, midway 
 between the two lines of sutures and not extending quite to the ends (so as to be 
 
 - c 
 
 Fig. 619.— Lateral Intestinal Approximation by Halsted's Quilt Sutures: — A, Show- 
 ing posterior line of sutures, and end sutures beginning to outline an ellipse; B, Line of future in- 
 cision into intestine, corresponding to similar line on opposite intestine ; C, C, Ends of intestines 
 closed by same kind of sutures. t. Modified from Halsted.) 
 
 well included within the enveloping line of sutures). (See Fig. 620.) (4) The 
 sutures forming the anterior line are now knotted — thus completely apposing 
 the site of union and enclosing the common opening between proximal and 
 distal segments. (5) The edges of the mesentery are treated as indicated. 
 
 Lateral Anastomosis. — The operation is here performed in every respect 
 exactly as in Lateral Approximation, except that no excision of intestinal tract 
 is done — and, consequently, no invagination of free ends of intestine is re- 
 
870 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 quired. Two convenient antimesenteric aspects of intestine are brought to- 
 gether and the union made at once by the method of suturing just described. 
 End-in-side Implantation. — If this somewhat unusual operation be called 
 for, it is accomplished in the following manner; — the free end of the bowel to be 
 implanted is brought into contact with the antimesenteric aspect of the portion 
 of bowel to receive the implantation (the free end of which has been closed as 
 in Lateral Approximation) — while held in this relation, the interrupted Hal- 
 sted sutures are placed, passing from just beyond the edge of the opening in the 
 latter piece of bowel, to just beyond the free edge of the former piece, and back 
 to the latter piece — thus drawing, by means of the loop, the inverted edge of the 
 
 Fig. 620— Lateral Intesi inal Approximation by Halsted's Interrupted Quilt Sutures: 
 — Showing all the posterior and half the end sutures tied — and the anterior sutures in position to be 
 tied. The two corresponding intestinal incisions are seen. (Modified from Halsted.) 
 
 free end of the bowel above, down upon the inverted edge forming the incised 
 opening in the bowel below — approximating serous surfaces entirely around 
 the opening by the tying of the knots. 
 
 ENTERO-ENTEROSTOMY BY MAUNSELL'S INVAGINATION METHOD. 
 
 Description. — In intestinal joinings made by this special method of simple 
 suturing a temporary window is cut in the intestinal tract, near one of the two 
 sites to be united (always in the larger piece of gut) — and through this opening 
 the two ends of intestine are temporarily invaginated by means of traction- 
 sutures. The free edges of gut, brought concentrically through the window, 
 are now united by interrupted sutures — after which they are drawn back into 
 their normal position and the window is closed by suturing — thus completing 
 the operation. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — (1) Having brought the coil of intestine 
 into the field of operation, excise the indicated portion, together with the cor- 
 
ENTERO-ENTEROSTOMY BY MAUNSELLS METHOD. 87 1 
 
 responding V-shaped part of the mesentery — and bring together the edges of 
 the mesentery with gut sutures. (2) Two horse-hair sutures (or silk) are now 
 introduced, which are temporarily left long and serve, primarily, as traction- 
 sutures — after which they are cut short and serve as two of the permanent 
 sutures. The first is placed at the antimesenteric aspect — the needle being 
 made to penetrate all the coats of the proximal intestine, near its free border, 
 from within outward — then all the coats of the distal segment of gut at a cor- 
 responding point, but now from without inward. (See Fig. 621.) This suture 
 is then knotted upon the inner side, one thread being cut short, the other left 
 temporarily long as a traction-suture. The second suture, somewhat more 
 complicated, is placed at the mesenteric aspect — beginning with that segment 
 of gut of larger calibre (which becomes the intussuscipiens), the needle passes 
 from within the lumen of intestine outward, penetrating the intestine near its 
 free border and entering the triangular space where the two laminae of the 
 mesentery separate to embrace the barrel of the intestine — then going through 
 the corresponding lamina of that side of the intestine, is carried across to the 
 opposite segment of gut (which is to become the intussusceptum), there pene- 
 trating, from without inward, the lamina of the mesentery of the same side — 
 and, passing onward, pierces the corresponding wall of intestine, emerging 
 upon its inner aspect — crosses thence to the opposite side of the same segment 
 of gut — pierces its wall from within outward, passing through the correspond- 
 
 Fig.62I.— ENTERO-ENTEROSTOMY BY MAUNSELL'S INVAGINATION' METHOD— PREPARATORY TO 
 
 Invagination :— A, Window in antimesenteric aspect of intussuscipiens; B, Manner of placing the 
 antimesenteric traction-suture ; C, Manner of placing the mesenteric traction-suture. 
 
 ing lamina of mesentery of that side — thence across to the opposite segment of 
 gut — where it pierces, from without inward, the lamina of the mesentery of the 
 same side — passing thence onward and emerging in the lumen of that segment 
 of gut at which the suture was started. This important suture is now drawn 
 tight, thus approximating, by the peculiar manner of its passage, the laminae 
 of the mesentery closely to the barrel of the two segments of intestine at their 
 most unprotected sites. Its knot having been tied on the inner side, one thread 
 is cut short and one left temporarily long as a traction-suture. (3) A tempo- 
 rarv window is now made in the segment of intestine of larger calibre, inde- 
 pendently of its being proximal or distal. If both pieces are of the same size, 
 the window is generally made in the proximal portion. The opening is made 
 upon the antimesenteric aspect of the intestine, in the form of a longitudinal 
 slit of about 4 cm. (1$ inches) in length, beginning about 2.5 cm. (1 inch) 
 from the divided end of the gut and extending in the opposite direction. This 
 slit is often made by pinching up a fold of intestine longitudinally, between the 
 
872 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 left thumb and index, passing a knife through it and cutting upward — but as 
 this is very uncertain and inaccurate, it is best to have an assistant so hold the 
 intestine as to separate its walls and then make the slit by a controlled stab-like 
 incision with a sharp, narrow bistoury, increasing its dimensions with the same 
 instrument or with a pair of scissors — or, even better still, carefully catch 
 the antimesenteric aspect of the intestine with two forceps, about 1.3 cm. 
 (J inch) apart, raising a transverse ridge, which is cut with scissors in the 
 long axis of the bowel, after which one blade of the scissors is intro- 
 duced and the opening enlarged. (4) A pair of forceps is introduced 
 through the window and grasps first one and then the other of the traction- 
 sutures, drawing them out through the opening. While the intestines are 
 steadied in the left hand, the traction-sutures are drawn upon, until the free end 
 of the segment of gut further from the window is drawn into the lumen of the 
 gut containing the window — the free edge of the latter being turned inward and 
 invaginated by the opposite segment as it enters — the process of invagination 
 continuing until the free ends of both emerge at the window as two concentric 
 
 #0 
 TV I 
 
 ■ y 
 
 Fig. 622.— Entero-enterostomy by Maunsell's Invagination Method— the Invagina- 
 tion Accomplished : — A, Window in intussuscipiens ; B, Concentric ends of two pieces of intestine 
 of equal size; C, Antimesenteric traction-suture ; D, Mesenteric traction-suture; E, Edges of mesen- 
 tery sutured. 
 
 circles, which are drawn sufficiently far out through the window for subsequent 
 manipulations. Both peritoneal surfaces will thus be in contact. (See Fig. 
 622. j (5) While the ends of the intestines are held upward and away from the 
 opening by the traction-sutures in the hands of an assistant, a long needle 
 threaded with horsehair (or silk) is passed straight across the concentric circles 
 about midway between the two traction-sutures, passing through all the coats 
 of the four thicknesses of intestines at about 5 mm. (fV inch) from the free 
 borders. After the passage of the needle, leaving a long piece of suture at 
 either side, the suture is caught with forceps at the center of the opening of the 
 concentric guts and drawn upward and outward a short distance and cut. 
 Each suture is then tied over the free borders of the two thicknesses of gut 
 embraced by it. Thus about twenty (or more if needed) sutures are placed at 
 equidistant sites by the passage of ten lengths of horsehair (or silk) — and are 
 tied and cut. The two long ends of the traction-sutures are now cut short. 
 
ENTERO-ENTEROSTOMY BY MAUNSELL'S METHOD. 873 
 
 (If they have been placed at inconvenient sites, in relation with the other 
 sutures, they may be cut out and removed.) (6) By gentle traction in the 
 reverse direction the invagination is reduced — the intestines now forming one 
 continuous length. (7) The window is then closed by continuous (or inter- 
 rupted) Lembert sutures (see Fig. 623), thus completing the operation. 
 
 Comment. — (1) The above method is an imitation of nature's successful 
 manner of performing enterorrhaphy, namely, by invagination and sloughing. 
 (2) Maunsell used horsehair — others have used silk and silkworm-gut. (3) 
 By suturing the edges of the excised mesentery before rather than after uniting 
 the intestines there is less danger of further separating the laminae of the mesen- 
 tery. (4) At the end of the operation the serous surfaces should be in contact 
 — and all of the knots at the end of the intestines should be within the gut. In 
 thin-walled guts there is a tendency for the knots and threads not to be so well 
 buried as in the thicker walls. (5) The sutures may be passed through the 
 walls of the concentric guts in the ordinary manner and tied one by one, in- 
 stead of in the above manner. (6) The sutures should not be tied too tightly. 
 
 
 
 Fig. 623, — Entero-enterostomy by Maunsell's Invagination Method — the Invagi- 
 nation Reduced:— A, External view of suture-line; B, Closing the window with interrupted 
 Lemberts. 
 
 (7) This is an instance of using a single layer of through-and-through sutures 
 in intestinal work — but practical experience has proved the method a good one. 
 To avoid the possibility of drainage-infection of the peritoneum by the sutures 
 which pass through all the coats, some surgeons place additional interrupted 
 Lembert sutures outside of the regular row. Fine gut may be thus used. 
 
 Where Segments of Intestines of Unequal Size are to be United End- 
 to-end. — (1) The traction-suture through the mesenteric borders is introduced 
 in the above manner. A second traction-suture is introduced in precisely the 
 same manner as the antimesenteric traction-suture above, but so placed as to 
 pass through the edge of the upper part of the smaller gut and through the 
 edge of the larger gut on its side, at a distance from its mesenteric attachment 
 about equal to the diameter of the smaller gut. A third traction-suture is 
 passed through the antimesenteric border of the larger gut alone (see Fig. 624). 
 (2) The window is now made in the larger gut — and the invagination accom- 
 plished as in the above case. The two free ends of the gut will not now be con- 
 centric, as in the above instance, owing to the difference in size and to the fact 
 
874 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 that the circumference of the smaller gut is fixed to the circumference of the 
 larger in two places by suture. (3) The suturing of the borders of these two 
 non-concentric circles can be best accomplished by the passage of a needle 
 through only the two walls in contact at a time — instead, of simultaneously 
 through these two and the opposite two, as in suturing coils of similar calibre. 
 Each suture is at once tied. The first and second traction-sutures become per- 
 manent — the third (through the larger gut alone) is removed. It is well to put 
 the sutures in alternately on the two sides, proceeding from the mesenteric to- 
 ward the antimesenteric border, until the edges of the small intestine have been 
 sutured to those of the larger. When near the antimesenteric aspect of the 
 smaller gut, the redundancy of the larger gut will be apparent. This redun- 
 dancy, if at all marked, is best disposed of by cutting, with scissors, a V-shaped 
 piece out of the antimesenteric aspect of the larger gut, of a size calculated for 
 the individual case. This V is now carefully sutured by approximation of its 
 margins by an overhand stitch, from its apex toward the antimesenteric aspect 
 
 Fig. 624. — Entero-enterostomy by Maunsell's Invagination Method in Intestinal 
 Coils of Unequal Size — Preparatory to Invagination: — A, Window in intussuscipiens ; B, 
 Mesenteric traction-suture ; C, Traction-suture which is antimesenteric for the smaller and lateral for 
 the larger gut ; D, Traction-suture which is antimesenteric for the larger gut. 
 
 of the smaller gut, being especially careful to approximate the edges of the 
 larger intestine, at the base of the V, with the edges of the antimesenteric border 
 of the smaller gut. (See Fig. 625.) (4) The invagination is reduced by gently 
 drawing upon the intestines — and the window is closed as in the regular ope- 
 ration. While an elbow, marking the excess of the larger over the smaller 
 intestine, will be present, the union will be secure. (See Fig. 626.) 
 
 Lateral Approximation. — (1) Excision of the intestine and corresponding 
 mesentery is done, the clamps having been placed especially well away from 
 the site of operation. (2) The two ends of intestine are overlapped upon their 
 free, antimesenteric borders, and a continuous Lembert suture (leaving the end 
 of beginning long, after knotting) is run along what will be the posterior aspect 
 of the junction, extending at either end slightly beyond the line of future union 
 around the common opening — and left long and threaded. (See Fig. 627.) 
 (3) Two corresponding incisions in the long axis of both guts are made. (4) 
 The posterior edges of the wounds are sutured together by an overhand, con- 
 tinuous suture of all the coats, leaving the end of beginning long, after knotting, 
 
ENTERO-ENTEROSTOMY BY MAUNSELL'S METHOD. 
 
 §7: 
 
 and also the end of ending long and threaded. (5) Forceps are protruded 
 through the opening and out either free end of the intestine, catching up the 
 
 Fig. 625.— Entero-enterostomy by Maunsell's Invagination Method in Intestinal Coils 
 of Unequal Size — the Invagination Accomplished : — A, Window in intussuscipiens ; B, Non-con- 
 centric ends of two pieces of intestine of unequal size ; C, Mesenteric traction-suture; D, Traction- 
 suture which is antimesenteric for the small and lateral for the large gut ; E, Traction-suture which 
 is antimesenteric for the large gut ; F, One of the sutures uniting the opposite edges of the redundant 
 portion of the large gut. 
 
 Fig. 626. — Entero-enterostomy by Maunsell's Invagination Method in Intestinal 
 Coils of Unequal Size — the Invagination Reduced : — A, External view of portion of suture-line 
 representing the end of the small intestine; B. External view of portion of suture-line represented by 
 the redundancy of the large intestine; C, Closing the window with interrupted Lemberts ; D, In- 
 terrupted sutures approximating the edges of the cut mesentery. 
 
 free end in their grasp and drawing (invaginating) it into the lumen and 
 through the opening. A circular silk ligature is then tied around either free 
 
Fig. 627.— Lateral Intestinal Approximation by Maunsell's Invagination Method:-- 
 A, End of intestine invaginated through window and circular ligature placed around it ; B, Traction- 
 ligatures grasped by forceps in act of invaginating opposite end of intestine; C, Continuous overhand 
 suture of all coats ; D, Continuous Lembert suture of outer coats. 
 
 Figs. 628 and 629. — Lateral Intestinal Anastomosis by Maunsell's Invagination Method : 
 — A, Intussusceptum drawn through window ; P>, Intussuscipiens, with window in its antimesenteric 
 aspect; C, Diagram showing manner of placing traction-sutures. 
 
 '876 
 
EXTERO-ENTEROSTOMV BY MAUNSELL'S METHOD. 
 
 877 
 
 end and they are dropped into their respective lumina. (6) The needle at- 
 tached to one end of the "whipping over" suture then continues the process 
 until the corresponding edges of the entire circumference are brought together 
 and the long ends tied. (7) Then the needle upon the serous suture is taken up 
 and the continuous Lemberts through the serous and muscular coats are con- 
 tinued around the anterior aspect of the wound, burying in the first layer. The 
 edges of the mesenterv are sutured as indicated. 
 
 Figs. 630 and 631. -End-in-side Intestinal Implantation by Maunsell's Invagination 
 Method :— A, Colon ; B, Ileum ; C, Free edge of lateral window in colon ; D, Free edge of end of 
 ileum; E, Free, open end of colon; F, Traction-sutures invaginating free end of ileum and lateral 
 opening of colon through open end of colon ; G, Diagram shoving manner of placing traction-sutures. 
 
 Comment.— The circularly ligated ends of intestine may be reinforced 
 with interrupted or continuous Lemberts. 
 
 Lateral Anastomosis.— Two knuckles of intestine are apposed along 
 their antimesenteric borders — two corresponding axial incisions are made — a 
 window is then cut about 2.5 cm. (1 inch) above — four traction-sutures are 
 applied to the cut margins and knotted within — a pair of forceps, passed 
 through the window, catches the four traction-sutures and draws them back 
 through the opening — by means of these traction-sutures the lateral aspects of 
 the two pieces of intestine are invaginated through the window — sutures are 
 applied to their margins, as in the end-to-end approximation — the invagination 
 
878 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 is reduced — and the window closed by interrupted or continuous Lembert 
 sutures. The line of anastomosis may be reinforced by Lemberts, if con- 
 sidered necessary. (See Figs. 628 and 629.) 
 
 End-in-side Implantation. — Excise the portion of intestine, with the 
 corresponding part of mesentery — bring the free end of the smaller gut to 
 the antimesenteric aspect of the larger gut, near its end — about 2.5 cm. 
 (1 inch) from the free margin of the latter, upon its antimesenteric aspect, 
 make an axial incision, corresponding in length to the diameter of the free 
 end to be implanted — place four traction-sutures, knotting them within — 
 draw these traction-sutures out through the free end of the gut in which 
 the lateral opening was made, by means of forceps — suture together the 
 margins of the free end and the lateral opening of the larger gut, as in end- 
 to-end approximation — reduce the invagination — close the free end of the 
 gut with the lateral opening first by continuous, overhand silk sutures, which 
 are then buried by interrupted gut sutures of the Lembert type — thus com- 
 pleting the operation. The edges of the mesentery are so sutured as to 
 close all openings. The site of implantation may be reinforced by Lembert 
 suturing, if considered necessary. (See Figs. 630 and 631.) 
 
 Note. — In all the operations by the Maunsell method, the traction-sutures 
 may be dispensed with — the invagination being accomplished by forceps 
 introduced through the windows, as in Ullmann's modification of Maunsell's 
 operation (page 881). 
 
 (B) ENTERO-ENTEROSTOMY BY MEANS OF ABSORBALE ME- 
 CHANICAL DEVICES LEFT WITHIN THE INTESTINE. 
 
 IN GENERAL. 
 
 Description. — (1) The mechanical devices, which are made of some 
 absorbable material and are inserted into the intestinal tract to serve as 
 distending frameworks over which the suturing may be conveniently applied, 
 are bobbins, buttons, cylinders, plates, etc. They are left within the lumen 
 of the intestinal tract, either to be entirely absorbed, or to be partially ab- 
 sorbed and the residue passed by nature. While possessing, in common 
 with non-absorbable devices, the property of aiding in the approximation 
 of the parts, they possess the additional advantage of becoming absorbed 
 after having accomplished their purpose — with the concomitant disadvantage 
 of possibly sometimes becoming absorbed before having done their work 
 completely. (2) The bobbins are in the form of two cones united at their 
 apices, which is their smallest part. Their shape has a greater tendency 
 to approximate the intestinal surfaces than has the button, or reel. The 
 buttons are very much like ordinary buttons, or possibly more like reels. 
 The size of the barrel is everywhere equal between the flanges. Various 
 forms of plates are used, of which the best known are probably Senn's bone- 
 plates. Some forms of cylinders are used. The terms designating these 
 devices are sometimes used interchangeably. (3) These devices are made of 
 various materials — the most usual being decalcified bone, or some form of 
 vegetable (such as potato, carrot, turnip, etc.). In some, the bulk of the 
 device is made of entirely absorbable material, and a small part of the center, 
 where the pressure is to be borne, is made of more imperfectly absorbable 
 or of non-absorbable material. (4) These devices are always used in con- 
 nection with some form of suturing — never alone. (5) As to their range of 
 applicability — their chief field of usefulness is in end-to-end approximation — 
 
EXTERO-EXTEROSTOMY BY ABSORBABLE BOBBINS. 
 
 8 79 
 
 and only to a limited extent in lateral approximation, lateral anastomosis, 
 end-in-side implantation, gastroenterostomy, and cholecystenterostomy. 
 Some are used only in lateral methods of entero-enterostomy (as the Senn 
 bone-plates). 
 
 ENTERO-ENTEROSTOMY BY MEANS OF ABSORBABLE BOBBINS. 
 
 Description. — The Allingham partially decalcified bone bobbin will be 
 taken as representing this type — the steps of the operations being the same 
 whether the bobbin be of this or vegetable material. In Allingham's 
 bobbin the bone is decalcified to within 3 mm. (fV inch) of its very center, 
 which is left firm to resist pressure made by the suture. The two portions 
 of the intestinal tract are approximated over the center of the bobbin by 
 running sutures inserted, in purse-string fashion, in the free end of each 
 piece of intestine. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 Fig. 632.— End-to-end Intestinal Approximation by an Absorbable Bobbin :— Position of 
 bobbin is shown partly in outline; A, Purse-string suture in position ready to be tightened ; B, Purse- 
 string suture tightened and tied ; C, Interrupted Lembert suture in position to be tied. 
 
 End-to-end Approximation. — (1) Having completed the steps of a 
 preliminary enterectomy, place a running, overhand purse-string suture of 
 silk in the ends of each piece of intestine, passing through all their coats, 
 the thread entering and coming out at the antimesenteric borders — leaving 
 both free ends long. (See Fig. 632.) While less simple, a more satisfactory 
 form of purse-string suture (owing to the manner in which it approximates 
 the laminae of the mesentery) is the one used in connection with the operation 
 of entero-enterostomy by means of the Murphy button (page 885) — and this 
 suture is equallv applicable here. (2) Insert one end of the bobbin into 
 the proximal, or distal, end of the intestine — and, having made the double 
 turn of the friction-knot, draw the purse-string rather tightly down upon 
 the intestine over the center of the bobbin — but do not tie the final knot. 
 Insert the opposite end of the bobbin into the end of the opposite piece of 
 
88o 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 intestine and similarly tie it. (3) When both segments of intestine are 
 moulded well into position, so that the serous surfaces are well approximated, 
 each suture is tightened with moderate firmness and the final knot in each 
 tied — thus securely bringing and fastening the ends of the intestines at the 
 center of the bobbin, and holding in contact rather extensive serous surfaces 
 for union. (4) The serous surfaces may be scarified with a needle for about 
 1 cm. (f inch) around the line of suture, to cause exudation of lymph and 
 firmer union. (5) A few interrupted Lemberts of fine gut may be applied 
 around the line of union, further approximating the serous surfaces, if thought 
 necessary. (6) The mesentery is treated as in other operations of entero- 
 enterostomy. 
 
 Comment. — While especially applicable to end-to-end approximation, 
 the method may also be used for lateral approximation, lateral anastomosis 
 and end-in-side implantation — applying the same general principles men- 
 tioned in the preceding descriptions of those operations. As the junction 
 in the last three operations mentioned is not so perfect as in end-to-end 
 approximation, additional Lembert sutures should always be used to rein- 
 force the line of union. 
 
 ENTERO-ENTEROSTOMY BY MEANS OF ABSORBABLE BUTTONS. 
 
 Description. — The Landerer potato button will be taken as representa- 
 tive of this type of mechanical device. A purse-string suture is inserted 
 into each end of the intestinal opening — these are tightened over the barrel 
 of the button, or reel, thus relatively approximating the ends of the intestine. 
 
 Fig.633.— End-to-end Intestinal Approximation by an Absorbable Button: — Position of 
 button is shown in outline ; A, Forceps everting lips of intestine to aid suturing; B, Continuous suture 
 of mucous coat; C, Interrupted Lembert sutures of serous and muscular coats. 
 
 But as the barrel of the button or reel is of the same dimension for some 
 distance, there is not the same tendency for the approximated ends of the 
 intestine to be held in close contact as is the case in the bobbin, where there 
 is the narrowest part of the barrel at the center, into which the segments 
 
ULLMANN'S MODIFICATION OF MAUNSELL'S OPERATION. 88 1 
 
 may be readily tied. An overlying line of interrupted or continuous Lembert 
 sutures is, therefore, placed over the ends approximated by the purse-strings — 
 and thus securely apposes serous surfaces. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — (i) Having completed the steps of a 
 preliminary enterectomy, a purse-string suture of silk or of chromic gut is 
 inserted into the end of each piece of intestine — in the same manner, prefer- 
 ably, as in Murphy's button-operation (page 885). (2) Each end of the 
 intestine is drawn over the flange of the button on to the barrel — the purse- 
 string is then moderately tightened and cut short, thus bringing the two 
 ends of the intestine into contact. (The narrower the barrel of the button, 
 the closer will be the contact at this stage.) (3) The circumferential margins 
 of the intestines are united with a line of interrupted or continuous Lembert 
 sutures of the serous and muscular coats. (4) The mesentery is repaired as 
 in other operations of entero-enterostomy. 
 
 Comment. — The comment made under " Entero-enterostomv by means of 
 Absorbable Bobbins" is equally applicable here. Union may also be accom- 
 plished by an inner tier of continuous suture of the mucous coat, and an 
 outer interrupted tier of Lemberts through serous and muscular coats. (See 
 Fig- 633-) 
 
 ENTERO-ENTEROSTOMY BY MEANS OF ULLMANN'S MODIFICATION 
 OF MAUNSELL'S OPERATION. 
 
 Description. — Up to the application of the Ullmann modification, which 
 is applied after the invagination of the ends of the intestines through the 
 window iri one of the pieces of gut, the steps of the operation are identical 
 with those described under the Maunsell method (page 870). The two 
 ends of intestine having been brought through the window, a carrot (or 
 other vegetable, or decalcified bone) bobbin is inserted within their con- 
 centric lumina, so that its groove is grasped by their walls, which are then 
 tied over the groove in a circular manner, with gut or silk. The invagina- 
 tion is then reduced — and the longitudinal wound, forming the window, closed. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — (1) The operation, up to the point of 
 invagination, is precisely the same as in Maunsell's operation (page 870). 
 (2) The invagination is now accomplished by passing two catch-forceps 
 through the window — one catching the mesenteric and the other the anti- 
 mesenteric aspects of the end of the proximal gut (the gut in which the window 
 usually is) — and draws these out simultaneously through the window. The 
 mesenteric and antimesenteric aspects of the edges of the distal gut are similarly 
 caught by two catch-forceps introduced through the window — which are also 
 drawn out simultaneously through the opening. These last two forceps are 
 removed from the distal gut and made to grasp the edges of both guts at 
 their sides. The first two are then also removed from the first gut and made 
 to grasp the edges of both guts at the same site each was grasped by a single 
 forceps. Thus the concentric ends of the two intestines are readilv held 
 open by the four pairs of forceps equidistantly placed. These forceps are 
 given to an assistant, who holds them with one hand, while holding the 
 bobbin with the other. (See Fig. 634.) (3) The bobbin is now introduced 
 into the concentric openings of the intestines — the walls of the two guts are 
 56 
 
882 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 then tied down into the groove of the bobbin with thick catgut or silk (which 
 will not likely cut through). (4) The forceps are relaxed — the invaginated 
 intestines are reduced — the window is closed by interrupted or continuous 
 
 Fig. 634.— Entero-enterostomy by Ullmann's Modification of Maunsell's Invagi- 
 nation Method : — A, Window in intussuscipiens ; B. Concentric ends of intestines drawn through 
 window; C, C. Traction-forceps drawing ends of intestines through window ; D. Absorbable bobbin 
 within concentric ends of intestines; E, Ligature binding ends of both pieces of intestine to groove 
 of bobbin. 
 
 Wtfi& v iiffi* 
 
 Fig.635. — Entero-enterostomy by Ullmann's Modification of Maunsell's Invagi- 
 nation Method : — Showing the reduction of the invagination and closure of the window — bobbin 
 and ends of intestine being shown in outline. 
 
 Lembert sutures — the mesentery is repaired — and the operation concluded. 
 (See Fig. 635.) 
 
 Comment. — Although more applicable to end-to-end approximation, the 
 
ENTERO-ENTEROSTUMY BY COFFEY'S METHOD. 883 
 
 Ullmann modification of the Maunsell method may be applied to lateral 
 approximation, lateral anastomosis, and end-in-side implantation. 
 
 ENTERO-ENTEROSTOMY BY COFFEY'S METHOD. 
 
 Description. — The free ends of intestine, after having been first united 
 at their mesenteric aspects by two or three Connell sutures, are drawn over 
 a vegetable tube (made of potato, carrot or turnip, preferably the first) and 
 made to meet and overlap at its center by means of two long needles passed 
 through tube and intestines transversely, at right angles to each other — 
 after which any form of suture desired is applied — the pins then withdrawn— 
 and the potato-tube pushed on down and crushed. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 Fig. 636. — End-to-end Entero-enterostomy by Coffey's Method: — I, Ends of intestine 
 brought together and their mesenteric aspect united by three Connell sutures — preparatory to insert- 
 ing hollow potato-tube shown above. (Modified from Coffey.) 
 
 Operation. — (1) Having completed, one may suppose, the steps of an 
 excision of a portion of the intestines, the free ends are brought into contact 
 and, while thus held by an assistant, three Connell sutures placed at the 
 mesenteric aspect, the central one embracing both lamina? of the mesentery 
 of both ends of the intestine — each suture passing from within the lumen 
 of one end outward through its own wall, and from without inward through 
 the corresponding site of the opposite end — then from within outward from 
 the lumen of the opposite end, and from without inward through the cor- 
 responding site of the original end, back into the lumen of the original end — 
 where the free ends of the suture are tied within the first piece of intestine. 
 (Fig. 636.) (2) One end of the united pieces of intestine is then drawn 
 over the potato-tube up to the center of the tube — and is held there until 
 the opposite end of the intestine is similarly drawn over the opposite end 
 
884 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 of the tube to meet it, and also held in position. (3) Two long needles (or 
 hat-pins, knitting-needles, probes, or toothpicks) are now passed transversely 
 through the potato-tube and through the ends of the intestine, at right angles 
 to each other — one entering near the mesenteric, and one at the mid-lateral 
 aspect. As these needles enter and emerge, they are made to pierce the 
 overlapped edges of intestine — and thus hold them in four places — over- 
 lapped where the needles penetrate, and overlapped or in comparatively 
 close contact throughout the rest of the quadrants (Fig. 637). (4) While 
 the ends of intestine are thus held, any form of suture desired may be placed — 
 interrupted Lemberts — continuous Lembert — the Halsted quilt suture — or a 
 double line of sutures. (5) Having completed the suturing, the pins are 
 
 Fig. 637. — End-to-end Entero-enterostomy by Coffey's Method: — II, Two ends of intes- 
 tine drawn over tube and held in relation with each other by long needles thrust through the potato- 
 tube at right angles to each other and piercing the overlapped edges of intestine. While thus held 
 interrupted Lembert (or other) sutures are applied — after which, needles are withdrawn — and potato- 
 tube may be crushed. (Modified from Coffey .) 
 
 withdrawn. In the case of interrupted sutures, those stitches which were 
 placed while the needles were in situ can now be more satisfactorily drawn 
 together after the removal of the needles. The potato-tube is carefully 
 pressed away from the site of operation, distallv to it — and is then crushed into 
 comparatively small pieces. (6) The abdomen is closed in the usual manner. 
 
 (C) ENTERO-ENTEROSTOMY BY MEANS OF NONABSORB- 
 ABLE MECHANICAL DEVICES LEFT WITHIN THE 
 INTESTINAL CANAL. 
 
 IX GENERAL. 
 
 Description.— These devices, usually made of metal, serve, as in the case 
 of absorbable devices, as frameworks over which the intestinal joinings are 
 
EXTERO-ENTEROSTOMY BY MEANS OF MURPHY BUTTON. 885 
 
 made — but are left within the intestinal tract to be passed out at the anus 
 by the efforts of nature. The Murphy button may be taken as the most 
 generally used representative of this class. 
 
 ENTERO-ENTEROSTOMY BY MEANS OF THE MURPHY BUTTON. 
 
 Description. — The junction between the intestinal coils is accomplished 
 by inserting one half of an ingenious button into the free end of each portion 
 of intestine — these half-buttons are held in place by specially applied su- 
 tures — and the two halves of the button are then approximated. The 
 opposite surfaces of the two cups of the button, aided by a spring in one 
 of the cups, keep up a constant pressure upon the opposed surfaces of intes- 
 tine, thus holding their approximated serous surfaces in contact. Union 
 
 Fig. 638.— Cross-section of Intestine, Showing Manner of Placing the Purse-string 
 Suture : — A, Serosa ; B, Muscularis ; C, Submucosa ; D, Mucosa ; E, E, Laminae of mesentery ; F, 
 Mesenteric vessel and connective tissue; G, Beginning of suture ; H, Crossing of suture, approxi- 
 mating laminae to each other and to barrel of intestine; I, End of suture, ready to be knotted with 
 opposite end. 
 
 takes place between the surfaces thus held together, especially along their 
 circumferential aspects — while the buttons are freed by pressure-necrosis and 
 are generally passed by bowel. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — (1) Having opened the abdominal cavity, 
 complete the partial enterectomy in the usual manner. (2) Preparatory to 
 the insertion of half of the button into each free end of the gut, a silk suture 
 is applied in a special manner. (See Fig. 638.) A long, straight needle is 
 
886 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 threaded upon a piece of silk about 30 cm. (12 inches) long — this suture 
 begins just to the right of the center of the antimesenteric border, entering 
 about 3 mm. (£ inch) below the free edge, and passing from without directly 
 inward — thence, following the right-hand margin, in an overhand stitch, 
 over (not through) the border of the intestine to the outer side — thence through 
 the wall from without inward — and so on, until the lamina of the mesentery 
 belonging to that side is reached. As the suture passes from within the 
 lumen, over the wall outward for the last time on that side, it also passes 
 obliquely over the lamina of the mesentery of the opposite side. The suture 
 is then carried through both laminae of the mesentery as a reversed stitch — 
 emerging at the outer aspect of the opposite lamina. It is now obliquely 
 carried over the lamina of the original side (and across the first limb of the 
 suture that was carried over the opposite lamina) into the lumen of the intes- 
 tine, toward its opposite wall — and passes through this wall of the intestine 
 from within outward. The order is now reversed, and (to get out of the 
 
 Fig. 639.— End-to-end Intestinal Approximation by Murphy's Button: — Showing manner 
 of introducing button into lumen of intestine, — male button on left, with purse-string ready to be 
 tightened ;— female button on right, with suture tightened. 
 
 lumen on the left side) the thread is always carried through the free border 
 of the intestine from within outward — thence passes over (not through) the 
 wall from without inward into the lumen — and so on, until it enters the 
 lumen for the last time, at the antimesenteric border — here, at a distance 
 of about 5 mm. (yg- inch) from its point of entrance, and on the same level, 
 the needle passes through the intestinal wall from within outward. Thus 
 a "puckering" or "draw-string" is formed, so applied that when drawn about 
 the button, it will approximate the leaves of the mesentery closely about the 
 ill-protected triangle at its base — and the two threads emerging side by side 
 upon the outer aspect are ready to be tied about the button. Although 
 these sutures pass through all the coats of the intestine, they are within the 
 spring, or pressure-cup, of the button. Similar sutures are inserted into the 
 free ends of the opposite piece of intestine. (See Fig. 639.) (3) Each cup, 
 or button, is now grasped by its stem (not, as so often shown in pictures, 
 by the cup itself) by the tip of a pair of special or pointed forceps (forceps 
 
ENTERO- ENTEROSTOMY BY MEANS OF MURPHY BUTTON. 887 
 
 with rounded or squarish points would tend to bend the perfectly circular 
 opening of the stems). Both are now ready for introduction. (4) The male 
 button (one with smaller stem) is always introduced into the end of the 
 proximal gut (because when its stem has slipped into the stem of the female 
 button, a slight elbow or projection is formed where its free margin ends — 
 which is harmless while in the direction of the intestinal current, but might 
 cause obstruction by particles of solid food lodging against it, if in the opposite 
 direction). This male half of the button is introduced into the proximal 
 gut just far enough for the free end of the gut to come well around the stem. 
 The suture is then drawn moderately tight and tied with a double knot (the 
 first being a friction-knot) around the stem — evenly distributing the puck- 
 ered gut with a probe as the thread is tightened. An assistant takes the 
 forceps and so holds them that the stem of the button does not slip 
 within the intestine. (5) The female button (one with larger stem) is simi- 
 larly introduced into the distal end of the gut. The suture is similarly placed 
 and tightened about it — and the forceps given to an assistant to hold in the 
 
 Fig. 640.— End-to-end Intestinal Approximation by Murphy's Button: — The half-buttons 
 approximated and pressed home. Two loose, interrupted Lembert sutures are shown in the position 
 which a tier of these sutures would occupy, if used. 
 
 same manner as with the male button. (6) The assistant holding the buttons, 
 so crosses the handles of the forceps as to present the buttons to the surgeon 
 in their right relation for immediate approximation. (See Fig. 639.) The 
 surgeon now grasps a button in the thumb and first two fingers of each 
 hand, with the hollows of the buttons looking toward each other. The as- 
 sistant then simultaneously releases the hold of the two forceps upon the 
 stems of each half-button. At the moment of release the surgeon guards 
 the buttons lest they slip out of reach into the intestines (by pressing them 
 against the binding sutures). The surgeon now approximates the two half- 
 buttons, one held in the fingers of each hand — calculating, in their slow and 
 deliberate approximation, that the intervening intestinal walls will be so dis- 
 posed as to make an even layer over the cups of the buttons — adjusting the 
 deficiency or excess of the puckered intestine with a probe, as indicated — and 
 finally pressing the two halves home as far as his judgment deems neces- 
 sary to secure good apposition without too great compression. (See Fig. 640.) 
 
888 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 (7) The edges of the mesentery are sutured and the intestine dropped back 
 into the abdomen. 
 
 Comment. — (i) Segments of intestine of unequal size may be thus 
 united by end-to-end approximation with the Murphy button — care being 
 exercised in tying the button into the end of the larger gut, and especially 
 in the act of approximating the two buttons, to see that the puckered excess 
 of the intestinal tissue, particularly in the case of the larger gut, is evenly 
 distributed around the stem of the buttons — and that when the halves of 
 the buttons are finally pressed home the serous surfaces everywhere come 
 together. (2) A line of interrupted or continuous Lemberts is used by some 
 surgeons to reinforce the margins where the buttons meet, after their appo- 
 sition. While not generally necessary, such a line of reinforcing sutures 
 may be used where considered indicated. (See Fig. 639.) (3) See that 
 
 Fig. 641.— Lateral Intestinal Approximation by the Murphy Button :— The manner of 
 placing the purse-string suture is shown upon the lower intestine, — and the male button introduced, 
 ■with suture tightened, is seen within the upper intestine. 
 
 the purse-string sutures are, after knotting, cut close, and that their ends 
 are not held by the cups of the buttons — thus retarding the escape of the 
 button, and possibly serving as infectors of the peritoneal cavity. (4) All 
 buttons used should be of a size that will not press upon the intestinal 
 walls, else sloughing may occur. 
 
 Lateral Approximation. — (1) Having excised the portion of intestine, 
 the free ends of the two pieces of gut are first closed by overhand, continuous 
 suture of all the coats — followed by a second tier of interrupted or continuous 
 Lemberts burying in the first row. (2) Purse-string sutures are now placed. 
 (See Fig. 641.) These consist of silk and are carried by an extra long, straight 
 needle (such as Keith's abdominal needle). The site for the insertion of 
 the half-button into each segment of gut having been chosen, which will 
 
ENTERO ENTEROSTOMY BY MEANS OE MURPHY BUTTON. 889 
 
 be upon the antimesenteric aspect of the guts, beginning about 2.5 or 5 cm. 
 (1 to 2 inches) from their ends, it is necessary to calculate the length of the 
 incision to be made, as its length will regulate the length and position of 
 the purse-string suture. If the oblong button be used, the length of the 
 incision will be a little less than the transverse diameter of the button, — 
 and if the round button, a little less than the diameter — in order that when 
 the button is insinuated through an opening requiring slight distention for 
 its entrance, it will close about it sufficiently to slightly grasp it. The sutures 
 should be put in so that their looped end is toward the free end of the gut. 
 The suturing passes through all the coats. Conceiving an imaginary straight 
 line, running longitudinally, upon the center of the antimesenteric aspect 
 of the bowel to mark the site for the future incision for the reception of the 
 button, the needle is made to enter the wall of the gut about 6 mm. (j inch) 
 above (or below, as the case may be) this imaginary line, and about 3 mm. 
 (^ inch) to one side — passing through all the coats into the lumen — again 
 passing outward (always traveling in a straight line parallel with and about 
 3 mm. [f inch] from the imaginary line) and emerging about 6 mm. (j inch) 
 from the point of entrance — and so on, until it emerges finally about 6 mm. 
 (^ inch) beyond the opposite end of the imaginary line — here the loop is 
 formed, the needle crossing over and entering the intestinal wall at a point 
 corresponding with its last emergence, but on the opposite side of the imaginary 
 line — and travels down this side in the reverse direction, but in the same 
 manner as on the opposite side — finally emerging at a point corresponding 
 with the entrance on the original side. Both ends of the suture are left 
 long and the loop loose. (3) An assistant now so holds the bowel (which 
 has been clamped at some distance from the free ends) as to separate its 
 walls — while the surgeon, by a quick, controlled stab of a narrow, sharp 
 bistoury, incises the gut midway between the two parallel lines of the purse- 
 string suture, and makes an opening a little less in length than the diameter 
 of the button to go through it — and especially considerably less in length 
 than the length of the surrounding purse-string. Care is taken that the 
 mucous membrane is not simply pushed ahead of the knife, instead of being 
 cut, and that the lumen is well opened up. (4) The button, grasped by 
 forceps, as in the ordinary end-to-end operation, is now insinuated into the 
 opening, placing the male button in the proximal gut. The purse-string 
 is drawn tightly enough to approximate the walls of the gut to the stem of 
 the button and tied — evenly distributing the puckered intestine around the 
 stem. The forceps holding the button is then given to an assistant, who 
 holds it as in the end-to-end operation. (5) The opposite end of the intestine 
 is similarly treated and the female button inserted. (6) The surgeon, grasping 
 a button in the fingers of each hand, with their stems facing (as they have 
 been directed by the crossing of the forceps), signals to the assistant to release 
 the buttons by relaxing the forceps — and then pushes home the two halves — 
 using the same precautions as in the end-to-end approximation, for the even 
 distribution of the intestinal walls. (See Fig. 642.) (7) The management of 
 the mesentery will here differ from its management in the end-to-end opera- 
 tion, as the continuity of the intestinal canal will not be continued in one 
 straight line. It is better (unless otherwise indicated) not to excise a V-shaped 
 portion of mesentery, but simply to fold over and suture in contact with 
 each other, and with neighboring mesentery, the layers of the redundant 
 fold of mesenterv. If a V-shaped portion be excised, the two free borders 
 of the mesenterv left should be so sutured down to adjacent mesentery as 
 to leave no openings for hernia. 
 
890 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Comment. — (1) See the general comments under the end-to-end ap- 
 proximation. (2) Care should be used that in approximating the two ends 
 of the intestines the direction of the intestinal flow should be maintained. 
 (3) The button used may be of the oblong type, which is better for this 
 purpose— or of the ordinary round type. (4) The operation of lateral 
 approximation after closure of the ends of the resected gut is but rarely indi- 
 cated — the usual method of junction following excision being by end-to-end 
 approximation. (5) Instead of using the purse-string suture to hold the 
 button-halves in place, Carle approximates the borders of the intestinal 
 opening by one or two interrupted Lembert sutures placed at either end 
 of the incision, thus lessening its length and grasping the button. But the 
 regular method is probably better. 
 
 Lateral Anastomosis. — In this operation the two buttons are inserted 
 
 
 Fig. 642. — Lateral Intestinal Approximation by the Murphy Button: — The two half- 
 buttons are shown approximated. Interrupted or continuous Lembert sutures may reinforce the con- 
 tiguous surfaces, if considered necessary. 
 
 into the antimesenteric aspects of the two indicated coils of intestine — the 
 method of insertion being identical with that used in Lateral Approximation 
 by the button. No excision of intestine takes place. The oblong button is 
 to be preferred. Reinforcing Lemberts may be used. The Carle method 
 of tving in the buttons, just mentioned, may be used. 
 
 Lateral Anastomosis with Weir's Modification of Murphy's Button, 
 Introduced by Gallet's Method. — The male half of the original button is 
 so modified, by being sharpened and beveled, that it can be made to penetrate 
 the walls of the intestine. Both buttons are introduced, by means of special 
 forceps, through a common opening in a knuckle of intestine — each being 
 carried down a separate limb of the gut — and are then approximated — fol- 
 lowed by the closure of the incision in the knuckle. Following are the steps 
 
ENTERO-ENTEROSTOMY 15V MEANS OF MURPHY BUTTON. S91 
 
 of the operation; (1) The sites of the anastomosis must be in such positions 
 upon the antimesenteric aspects of the intestine that, when the length of 
 the intestine is doubled upon itself, the site to be occupied by each button 
 will not be beyond the reach of the special forceps to be introduced through 
 an opening at the knuckle formed by bending the intestine upon itself. (2) 
 An incision in the longitudinal axis of the gut is now made at this knuckle. 
 A button held in the grasp of the special forceps is then introduced through 
 the opening down one limb of the gut — the male button in the proximal 
 limb. The female button, similarly held, is then introduced down the oppo- 
 site limb. (3) By pressure upon the forceps holding the male button, its 
 stem is made to pierce the walls of its own side and the opposite gut — and 
 is then directed into the stem of the female button. (4) The buttons are 
 then pressed home — the adjacent surfaces of intestine being held in contact 
 without any form of suturing. (5) The treatment of the opening in the 
 knuckle of gut is as indicated. In the cases where the operation is simply 
 a lateral anastomosis, the incision in the knuckle would be closed by inter- 
 rupted or continuous Lembert sutures of gut or silk. In the majority of 
 cases where this operation is done, however, it is performed in connection 
 with a gastrojejunostomy, for the purpose of aiding in the prevention of 
 bile and intestinal regurgitation from the duodenum into the stomach — so 
 that as soon as the intestinal anastomosis has been accomplished, the opening 
 in the knuckle of intestine is sutured to a corresponding opening in the anterior 
 wall of the stomach, thus completing the gastrojejunostomy. (See Fig. 714.) 
 
 Note. — The ordinary Murphy button may be used in practically the 
 same manner. After opening the knuckle of gut, one half of the button 
 may be dropped into each limb of the intestine — these are caught and held 
 by the fingers of an assistant at corresponding positions within the two pieces 
 of gut, with the free portion of their stems held against the antimesenteric 
 aspect of the gut. While the intestinal wall is thus drawn tightly over the 
 hollow stems, a limited crucial incision is made in the center of the stems, 
 just sufficiently large for the stems to be pressed through, with the walls 
 of the intestine clinging closely around them — immediately following which 
 the two halves are pressed together, bringing the antimesenteric aspects of 
 the two portions of gut into accurate apposition — no reinforcing suture being 
 necessary. The opening in the knuckle of gut is closed as usual. (See Figs. 
 715 and 716.) 
 
 Multiple Lateral Intestinal Anastomosis (Jaboulay-Braun's Opera- 
 tion). — In addition to the single lateral intestinal anastomosis formed after 
 gastroenterostomy, as above described (Braun's operation), sometimes a 
 second, or even a third, lateral intestinal anastomosis may be made — for 
 the purpose of further avoiding the likelihood of intestinal regurgitation by 
 furnishing as direct and easy a descent from the stomach to the anus as 
 possible. Supposing, therefore, that a gastrojejunostomy has been per- 
 formed, a lateral jejuno-jejunostomy may be done by Gallet's method of 
 using Weir's modification of the Murphy button, at the time the intestine 
 was opened to unite it to the stomach — and then another jejuno-jejunostomy, 
 or a jejuno-ileostomy, could be performed lower down by the ordinarv lateral 
 anastomosis method, thus short-circuiting by two routes the contents of the 
 intestines. 
 
 Note. — Multiple intestinal anastomosis can, of course, be performed by 
 simple suturing, as well as by other methods. 
 
 End-in-side Implantation. — Supposing the caecum to have been excised 
 and the mesentery ligated, the male Murphy button is introduced into the 
 
892 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 free end of the ileum and tied in place, as in the ordinary end-to-end ap- 
 proximation. The edges of the free end of the caecum are then united by 
 overhand continuous silk sutures through all the coats — and these are buried 
 in by the interrupted or continuous Lemberts of gut or silk. An opening 
 is then made 2.5 to 5 cm. (1 to 2 inches) from the sutured end of the caecum, 
 upon its antimesenteric aspect, and the female button tied into place, just 
 as in lateral intestinal anastomosis. The two buttons are now brought 
 together in the usual fashion. The line of union should be here reinforced 
 by a tier of interrupted Lembert sutures. The borders of the mesentery 
 should be sutured as indicated. 
 
 LATERAL INTESTINAL ANASTOMOSIS BY THE JABOULAY BUTTON. 
 
 Description. — The Jaboulay button, made in three sizes, is made up of 
 two halves — each half having an outer and an inner cylinder — the outer fenes- 
 trated cylinder having a break or slit in its continuity extending into and almost 
 half around the inner cylinder. Its form of structure is intended to enable the 
 button to be inserted upon "the screw and key-ring" principle through an 
 especially small intestinal opening, and is used without the reinforcement of 
 sutures (Figs. 643 and 644). 
 
 Figs. 643 and 644. — The Jaboulay Button; Male and Female Halves. (Redrawn 
 
 from Beer.) 
 
 Preparation— Position— Landmarks— Incision.— As in median abdom- 
 inal section. 
 
 Operation. — The coils of intestine are clamped and brought into the field 
 in the usual way, with their antimesenteric aspects presenting. In using a 
 button of 2.2 cm. (approximately f inch) diameter, a longitudinal incision in the 
 antimesenteric aspect of the bowel is made of 1 cm. (§ inch) length. The 
 inner cylinder of the button is grasped with a pair of forceps, as in the case of 
 the Murphy button — but, in the present instance, the button is insinuated into 
 the lumen of the bowel by a semi-lateral cork-screw movement — the beak of 
 the outer cylinder first entering — the screw-like movement being continued 
 until the outer cylinder has entirely entered the cavity of the intestine — the 
 inner cylinder being left protruding from the intestinal wound and snugly 
 grasped by it. The opposite half of the button is introduced into the corre- 
 sponding lateral aspect of the opposite piece of intestine. The two halves are 
 then pressed tightly home, with considerable strength (as the pressure necrosis 
 which liberates the buttons is here dependent upon the amount of pressure 
 used in approximating the buttons, and not upon a special spring or third 
 cylinder, which continues to act, as in the Murphy button). The walls of the 
 intestine are thus approximated and the lumen of each piece of intestine is 
 
ENTERO-ENTEROSTOMY BY HARRINGTON'S RINGS. 
 
 893 
 
 connected through the inner cylinder. No reinforcement by suturing is used 
 unless the intestinal wall be torn in inserting the buttons (Fig. 645). 
 
 Comment. — Theoretically the above technic seems very satisfactory — 
 but the following practical difficulties (especially demonstrated by Beer's work) 
 have arisen in the use of this form of button; — In quite a large percentage of 
 cases the button can not be introduced through an incision bearing the pro- 
 portion of the diameter of the button as indicated above (and as claimed for 
 it by its author), and, in consequence, the intestinal wall is quite frequently 
 split further than intended and has to be sutured; — The button is quite often 
 
 Fig. 645. — Lateral Intestinal Anastomosis by 
 means of the Jaboulay Button: — Male and female 
 buttons. 
 
 Figs. 646-648. — Harring- 
 ton's Segmented Ring : — Seen 
 in three positions with handle in 
 position in two. 
 
 held in situ and is not passed. The especial advantages of the button are — 
 the small incision, the rapidity of its introduction, and the absence of reinforc- 
 ing suturing — where all goes well. 
 
 ENTERO-ENTEROSTOMY 
 
 BY HARRINGTON'S SEGMENTED RINGS. 
 
 Description. — "The ring, in the language of its author, is made of hard 
 aluminum in four sections. These sections are jointed firmly together by a 
 small bar of steel, which has a shoulder and a screw thread, and which serves 
 as a handle. The outer surfaces of the ring are grooved to hold the ends of 
 
894 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 the intestines, which are tied in place by catgut purse-string sutures. The 
 segments tit together by means of sliding tongue-and-groove joints so rounded 
 that they will nut cut or catch in the tissues." The ring is a mechanical aid to 
 intestinal anastomosis, end-to-end and lateral. Subsequently to being placed 
 in situ it collapses into its component segments, which are so small that they 
 are passed without danger or discomfort. The rings are made in three sizes. 
 (Figs. 646-648.) 
 
 Preparation — Position — Landmarks — Incision. — As in median abdom- 
 inal section. 
 
 Operation. — The description of the technic given by Harrington and 
 Gould will be here largely followed. The end-to-end anastomosis is performed 
 as follows (Fig. 649) :— Clamps are applied in such a way as to exclude the 
 
 Fig. 649. — Entero-enterostomy by means of Harrington's Segmented Ring: — 
 A, Mesenteric stitch; B, Purse-string suture (the one on the opposite end being tied); C, The 
 ring and handle in position. (Redrawn from Gould.) 
 
 general intestinal tract. A sero-muscular purse-string suture of No. 2 plain 
 catgut is placed around the intestines on either side of the area to be excised, 
 and the first part of a surgeon's knot tied, without tightening the suture. The 
 intestine is excised 3 mm. (J inch) from the purse-strings. A mesenteric 
 mattress stitch, after the manner of the Maunsell mesenteric stitch, is first 
 applied. The segmented ring is then introduced into one end of the intestine, 
 guided by the handle, and the purse-string of that end is tied. The mesenteric 
 mattress suture is then tied, after which the other end of the segmented ring is 
 placed within the lumen of the opposite end of intestine and the second purse- 
 string suture tied. The intestinal margins are evenly adjusted to each other 
 at the center of the ring. A Cushing right-angle continuous sero-muscular 
 suture, beginning to one side of the steel handle, is carried around the intestine, 
 with frequent knotting, to the opposite side of the handle. The handle of the 
 instrument is then unscrewed and withdrawn — after which the Cushing suture 
 
ENTERO-ENTEROSTOMY WITH LEE'S INTESTINAL HOLDER. 895 
 
 is continued over the opening left by the withdrawal of the handle. The ring 
 is held together by the purse-strings. 
 
 Lateral intestinal and gastro-intestinal anastomoses are accomplished in 
 the same general way. The purse-string sutures here consist of two parallel 
 arms crossing at one end, only far enough from each other to leave room for the 
 incision. 
 
 Comment. — It is better to leave the ring in place after completing the 
 operation — although if it seem to exert undue pressure, it may be collapsed by 
 gently compressing it through the walls of the intestine. At the end of twenty- 
 four hours the swelling is great enough to hold the intestinal ends together 
 without the purse-string sutures. But at the end of from four to six days the 
 swelling subsides, leaving the purse-strings and the lumen of the intestine con- 
 siderably larger than the circumference of the ring — which then collapses and 
 passes on down. 
 
 (D) ENTERO-ENTEROSTOMY BY MECHANICAL MEANS 
 
 TEMPORARILY USED FOR APPROXIMATING THE 
 
 INTESTINAL EDGES DURING SUTURING. 
 
 IN GENERAL. 
 
 Description. — Various more or less ingenious forms of devices have been 
 introduced for the purpose of holding in contact the opposite margins of 
 the intestines during the act of suturing — to be withdrawn just prior to the 
 completion of the suturing. Many of these, at the same time, distend the 
 otherwise flaccid gut, and render the application of sutures easier — such as 
 the Halsted inflatable rubber cylinder, Laplace's intestinal forceps, Lee's 
 intestinal holder, and the like. The last of these will be described as repre- 
 senting this class of work. 
 
 ENTERO-ENTEROSTOMY BY MEANS OF LEE'S INTESTINAL HOLDER. 
 
 Description. — The instrument, though simple in principle and con- 
 struction, is difficult to describe clearly — but its manipulation is easy. The 
 holder is introduced into the approximated ends of the intestine closed — 
 is then opened — and serves as a framework upon which suturing is done — 
 and is then finally closed and withdrawn. A single instrument fits any part 
 of the intestinal tract — and any suture may be used in conjunction with it. 
 Lee uses a modification of the Connell stitch. The method is only applicable 
 to end-to-end approximation. 
 
 Preparation— Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 End-to-end Approximation. — (1) Open the abdomen — clamp off the 
 site — and excise a portion of the intestine, with or without a part of its mesen- 
 tery. (See Fig. 650.) (2) The mesenteric suture is passed — exactly as the 
 mesenteric traction suture is passed in Maunsell's operation (page 870). 
 Both ends of the silk are left long and are knotted within the lumen of the 
 gut — thus approximating the mesenteric aspects of both guts and both lamina? 
 of the mesentery to the barrel of the gut (Fig. 651). Each end of the threads 
 is then needled — and the needles are made to pass out of the gut near the 
 knot and the threads are drawn after. (3) The intestinal holder is now 
 
8 9 6 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 introduced and opened — distending each gut flatwise — the distal arms being 
 against the mesenteric border and the proximal arms against the antimesen- 
 teric border — the free borders of intestine lying in parallel contact — there 
 being no marked tension anywhere. (4) The half of the intestine nearer 
 
 I 
 
 Fig. 650.— End-to-end Entero-enterostomy by Lee's Intestinal Holder: — A, A. Clamps 
 upon a coil of intestine from which a portion has been excised ; B, Intestinal holder beinj, inserted 
 into the ends of intestine— its blades extended ; C, C, The two ends of the mesenteric suture. (Modi- 
 fied from Lee.) 
 
 the surgeon is now sutured with right-angled continuous suture (Fig. 652), 
 passing through all the coats, tightening the thread after each stitch. When 
 the site of the emergence of the stem of the instrument is reached, the final 
 stitch is made on the side opposite to the one on which the preceding stitch 
 was made— and this final stitch is only a half-stitch, passing from without 
 
ENTERO-ENTEROSTOMY WITH LEE'S INTESTINAL HOLDER. 897 
 
 and ending on the interior of the gut (Fig. 652). (5) The instrument is 
 now so turned as to present the opposite side (Fig. 653) — which is sutured 
 in a similar manner — the final half-stitch ending on the same end of gut 
 as the last half-stitch of the first side, and on the interior of the gut. (6) 
 
 Fig. 65 1.— Entero-enterostomy by Lee's Intestinal Holder : — A, A, Mesenteric suture tied 
 and ends passed out of intestine ; B, B, Showing, first, manner of tying mesenteric suture — and, sec- 
 ondly, manner of passing ends of suture out of intestine. (Modified from Lee.) 
 
 Fig.652. — Entero-enterostomy by Lee's Intestinal Holder : — Manner of placing and end- 
 ing the right-angled continuous sutures upon the aspect of the intestine further from surgeon. 
 (Modified from Lee.) 
 
 The instrument is now folded and withdrawn (Fig. 654) — leaving two free 
 ends of silk ready to be tied. (7) To enable the ends to be knotted on the 
 interior, a threaded needle is insinuated between the stitches of the opposite 
 
 57 
 
8o8 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 side, the eye first — and is pushed upward until the threaded eye protrudes 
 through the opening formerly occupied by the handle of the instrument. 
 
 Fig. 653.— Entero-enterostomy by Lee's Intestinal Holder :— Manner of placing and 
 ending the right-angled continuous sutures upon the aspect of the intestine nearer the surgeon. 
 (Modified from Lee. 1 
 
 Fig.654.— Entero-enterostomy by Lee's Intestinal Holder :— A, Holder closed and with- 
 drawn from intestine; B, Ends of the two sutures emerging from the same side and within the in- 
 testine ; C, Loop introduced upon head of needle through suture-line at D, under which loop the ends 
 of the main suture are caught and withdrawn at D. (Modified from Lee.) 
 
ENTERO-ENTEROSTOMY WITH LEES INTESTINAL HOLDER. 
 
 899 
 
 The thread of the needle is then loosened into a loop, under which the free 
 ends of the two sutures are passed — and by means of which these free ends 
 are drawn out when the needle is withdrawn through the line of suturing, 
 at the point where the head of the needle was pushed through. (8) These 
 sutures are then knotted, during which process the bowel is flattened and 
 its mucous membrane near the final half-knots is approximated to the site 
 where the sutures are being tied — the sutures are then cut short — and the 
 knots slip into place and the intestine regains its form by a little manipulation 
 (Fig- 655). 
 
 Comment. — Any other less intricate form of suturing may be used. Rein- 
 forcing Lemberts may be used if thought necessary. 
 
 Fig. 655.— Entero-enterostomy by Lee's Intestinal Holder: — Tying the final knot upon the 
 outside — which, upon cutting the threads, recedes within the intestine. (Modified from Lee.) 
 
 EXCISION OF THE ILEO-CECUM. 
 
 Description. — Consists in the removal of the caecum, together with more 
 or less of the adjoining portions of the ileum and ascending colon — followed 
 by some form of entero-enterostomy between the small and large intestines. 
 The operation is generally resorted to for malignant or tubercular disease 
 of this region, or for intussusception of this portion. 
 
 Preparation — Position — Landmarks. — As for Appendicectomy (page 
 900). 
 
 Incision. — About 13 cm. (5 inches) long, beginning in the. anterior 
 axillary line (a vertical line from the anterior border of the axilla), midway 
 between the lower margin of the costal cartilages and the iliac crest — passing 
 
900 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 downward to within about 4 cm. (ij inches) of the anterior superior iliac 
 spine — and thence obliquely downward and forward, parallel with the outer 
 half of Poupart's ligament, ending to the outer side of the position of the 
 external iliac artery. 
 
 Operation. — (1) Divide the skin, fascia, external oblique, internal ob- 
 lique, transversalis, transversalis fascia, subperitoneal connective tissue, and 
 peritoneum. The size and condition of the parts generally necessitates an 
 operation of a magnitude too great for the intramuscular method of opening 
 the abdomen— but in so far as this method can be adopted, it should be 
 carried out. Both the muscular and aponeurotic portions of the external 
 oblique can ordinarily be separated in the cleavage line. The abdominal 
 vessels and nerves should be preserved as far as possible. Having exposed 
 the abdominal cavity, retract the lips of the wound well and deeply. (2) 
 If adherent omentum be encountered, ligate off with gut and divide. (3) 
 Separate the caecum from the iliopsoas fascia upon which it lies. This is 
 accomplished by displacing the caecum and colon inward and cutting through 
 the peritoneum along the outer aspect of the caecum and colon where it binds 
 those structures to the posterior abdominal wall, ligating where necessary 
 with gut. These structures are then displaced outward and the peritoneum 
 divided along the inner side — but on this side the colic vessels are encountered 
 as they diverge to supply the bowel — so that this region is ligated off in sections 
 and divided. This inner line will cross the ileum where it joins the colon. 
 The mesentery of this small intestine is ligated in sections, as far as may 
 be necessary, and divided. (4) Having thus freed the caecum and several 
 inches of both colon and ileum, the contents of the bowel are pushed away, 
 the intestines clamped, the neighboring regions protected with gauze packing, 
 and the intestines divided at a right angle to their axis. (5) Having excised 
 the ileo-caecal region, an entero-enterostomy is accomplished in one of the 
 following ways (previously described in detail) : — (a) End-to-end approxima- 
 tion by simple suturing, by Murphy's button, or by Maunsell's invagination 
 method — the first or second probably being preferable; (b) Invaginate the 
 ends of both guts by overhand followed by Lembert sutures, and then make 
 a lateral anastomosis between the ileum and colon by simple suture, or by 
 a Murphy button (or by one of the other methods already described) ; (c) 
 Divide the ileum obliquely, to give a larger opening, and unite it to the trans- 
 verselv divided colon by simple suturing — (often the ileum has been dis- 
 tended so long, by obstruction below, that it has become the same size as 
 the colon) ; (d) Close the end of the colon by invagination, by a double row 
 of sutures, and then implant the end of the ileum upon the lateral aspect 
 of the colon (resembling nature's junction of the small and large intestines). 
 (6) Drop the parts back into the abdomen, and close the abdomen, with 
 or without drainage, as indicated, as in abdominal section. 
 
 Comment. — Remove all diseased glandular tissue. 
 
 APPENDICECTOMY 
 
 BY McBURNEY'S INTRAMUSCULAR OPERATION. 
 
 Description. — Appendicectomy consists in the removal of the appendix 
 vermiformis. The feature of McBurney's operation is based upon the 
 exposure of the appendix through a successive separation, in the cleavage 
 line, of the overlying abdominal muscles and aponeuroses. The fibers of 
 the muscles and aponeuroses are not cut but are separated. The appendix 
 is exposed and is treated by one of several methods. This form of the opera- 
 
APPEXDICECTOMY. 901 
 
 tion is chiefly applicable to the " interval period " of appendicitis — but is 
 sometimes used in acute cases and in pus cases. 
 
 Preparation. — Site of incision to be shaved. 
 
 Position. — As in median abdominal section. 
 
 Landmarks. — McBurney's point, which is located on an imaginary line 
 extending from the anterior superior iliac spine to the umbilicus, at a distance 
 of 3.8 cm. (1^ inches) internal to the anterior superior iliac spine. 
 
 Fig. 656. — McBurney's Intramuscular Appendicectomy : — I. — Separation of the 
 fibers of the external oblique in their cleavage line by blunt dissection with the handle of a 
 knife. 
 
 Incision. — Commences about 2.5 cm. (1 inch) above the imaginary line 
 just mentioned, and passes obliquely downward and inward in the direction 
 of the fibers of the external oblique muscle and aponeurosis — crossing the above 
 line at McBurney's point — and ending about the same distance below as above 
 it. The length of the incision may be greater or less than the above, according 
 to the space required. A free skin incision greatly aids the muscular retraction 
 (Fig. 576, E). 
 
 Operation. — (i) Having incised the skin and fascia in the above lin 
 (which will correspond with the cleavage line of the skin), and having co 
 
902 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 trolled hemorrhage and retracted the lips of the wound, the muscular and 
 tendinous fibers of the external oblique will be exposed. (2) Incise the exter- 
 nal oblique with a sharp scalpel, directly in a line with its muscular fibers 
 above, and their tendinous continuation into the aponeurosis below — con- 
 tinuing the separation with scalpel and scissors, incising between the fibers 
 without severing them (Fig. 656) . The two lips of the incised external 
 oblique are drawn respectively upward and inward, and downward and out- 
 
 Fig. 657. — McBurney's Intramuscular Appendicectomy: — II. — The separated fibers 
 of the external oblique are retracted upward and inward and downward and outward. The 
 fibers of the internal oblique are being separated in their cleavage line. The libers of the trans- 
 versalis are seen in the floor of the wound. Branches of the hypogastric and ilioinguinal nerves 
 and lumbar arteries lie between the internal oblique and transversalis. 
 
 ward — thus exposing the intermuscular fascia between the external and 
 internal oblique. (3) The sheath and fibers of the internal oblique (the muscle 
 being here quite thick) are now similarly separated by scalpel, scissors, or blunt 
 dissection, in the line of their cleavage (which is nearly at a right angle to the 
 cleavage line of the fibers of the external oblique), the center of the separation 
 of the fibers being about opposite the anterior superior iliac spine. The lips 
 of the internal oblique are now retracted respectively upward and outward, 
 
APPENDICECTOMY. 903 
 
 and downward and inward — thus exposing the intermuscular fascia between the 
 internal oblique and transversalis. Guard with special care all nerves lying 
 in this intermuscular plane (Fig. 657). (4) The fibers of the transversalis, 
 which, for practical purposes, run very nearly in the same direction as those of 
 the internal oblique, are now similarly separated in their cleavage line. The 
 lips of the transversalis may be separately retracted upward and downward, 
 but are generally included in the grasp of the same retractors which retract 
 
 Fig. 658. — McBcrxey's Intramuscular Appendicectomy : — III. — The fibers of the 
 external oblique are retracted as above. The fibers of the internal oblique are retracted upward 
 and outward and downward and inward — beneath which are seen the separated fibers of the 
 transversalis — and in the interval lie the appendix and caecum. 
 
 the internal oblique. The transversalis fascia at the bottom of the wound is 
 thus exposed for 2.5 cm. (1 inch) or more. (5) The transversalis fascia is 
 grasped with forceps and divided in the line of the transversalis muscle (trans- 
 versely) — when the subserous areolar tissue and peritoneum will be exposed. 
 (6) The peritoneum is grasped with two delicate toothed forceps, manipulated 
 as in the median abdominal section, and divided with scissors to a limited and 
 guarded extent. One blade of the scissors is then carefully introduced within 
 
904 OPERATIONS UPON THE ABDOM1NO-PELVIC REGION, 
 
 the abdominal cavity and the opening enlarged toward the median line and 
 
 ~1 
 
 Fig. 659.— Appendicectomy :— A, Caecum; B, Ileum; C, Appendix; D, D, Ligatures tying off the 
 
 mesentery of the appendix. 
 
 the anterior superior iliac spine. The subperitoneal areolar tissue, trans- 
 versalis fascia, and peritoneum may be simultaneously incised — but it is 
 
 Fig. 660— Appendicectomy:— A, Edges of the mesenteriolum sutured together; B, B, Purse-string 
 suture placed, the loop being grasped by forceps and the ends free. 
 
 better to incise down to and recognize the peritoneum, and then to incise it 
 separately and alone (Fig. 658). 
 
APPENDICECTOMY. 
 
 9°5 
 
 Operation. —The right index-finger is inserted within the abdominal 
 cavity and the appendix sought. The caput coli, or some part of the 
 ascending colon, is generally encountered at once — and may even bulge 
 into the wound. Sometimes the appendix itself presents at once— though 
 exceptionally. If the appendix is not at once manifest, its base is sought 
 in its usual position— that is, upon the internal and posterior aspect of the 
 caecum, about 1.7 cm. (ji inch) below the ileo-caecal valve. If the appendix 
 is not readily found by this manoeuvre, draw out the first part of the ascending 
 colon encountered, and then follow it down to the caput coli — the anterior 
 of the three longitudinal bands of the colon will lead to the base of the appendix. 
 
 Fig. 661. — Appendicectomy : — Dilatation of canal of thickened appendix preparatory to 
 invagination, where invagination would be otherwise difficult. 
 
 The appendix is now drawn out of the wound, and its treatment will depend 
 upon the nature of the appendix and the individual views of the operator. 
 (See Fig. 659.) (7) As soon as the appendix has been delivered without the 
 abdominal cavity, it is well to pass a silk ligature, upon an aneurism-needle, 
 around the appendix, about 2 cm. (f inch) from its base, piercing its mesentery. 
 This ligature may be tightened at once or later — it is only a temporary traction- 
 ligature or its tip may be grasped with forceps. The mesentery of the appendix 
 should be ligated off with chromic gut, carried in a laterally curved aneurism- 
 needle, proceeding from apex to base, or in the opposite direction if more con- 
 venient — and tied in sections — the mesentery being then divided between 
 
906 OPERATIONS UPON THE ARDOMINO-PELVIC REGION, 
 
 appendix and ligatures. The main artery near the base should be securely tied. 
 
 Fig.662.— Appendicectomy : — The stump of the appendix being invaginated in the grasp of forceps, 
 and the purse-string about to be tightened. 
 
 If bound down by adhesions, these should be separated by blunt dissection, 
 or ligated and cut. Often the mesentery of the appendix must be ligated off 
 
 Fig.663.— Appendicectomy :— A, The free ends, after knotting, of the purse-string which has 
 invaginated the stump of the appendix into the caecum ; B, Position which reinforcing Lemberts 
 would occupy, if used ; C, The sutured edge of the mesenteriolum. 
 
 within the wound before the appendix can be delivered. The peritoneum 
 should be sutured over the stump of the mesentery. The appendix is now 
 
APPENDICECTOMY. 
 
 907 
 
 treated in one of several ways. It is well to ascertain the patulousness of the 
 lumen of the stump in advance, by the passage of a probe through its canal 
 
 
 Fig. 664.— Appendickctomv :— A Method of Dealing with Thick Appendices, by Ligation 
 and Depression into Cecum : — A, Clamping off appendix from caecum ; B (to left), Cuff of serosa 
 turned back ; C, Stump of appendix ligated ; B (to right), Edges of meseiiteriolum sutured. 
 
 Fig. 665.— APPENDICECTOMY: — A. Stump of appendix depressed into caecum ; B, Interrupted Lembert 
 sutures closing serosa over stump ; C, Sutured edges of mesenteriolum. 
 
 into the caecum, that drainage into the main intestine may be assured. The 
 following methods of closing the appendix may be used; — (a) Dawbarn's 
 
908 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Purse-string Method; a continuous silk purse-string suture, carried upon a 
 straight needle, is passed through the serous and muscular coats of the caecum 
 
 Fig. 666.— Appendicectomy : — The depressed appendix-stump and the invaginated serosa themselves 
 invaginated into the caecum by a purse-string suture of the surrounding area. 
 
 Fig. 667. — Halsted's Three-clamp Method or Removing the Appendix: — I. — 
 Dawbarn's purse-string suture surrounds the base of the appendix. The artery of the mesentery 
 is ligated and the severed margins sutured by an overhand suture. The appendix is crushed 
 by three parallel artery-clamps. 
 
 in a circle, about 6 mm. (J inch) from the base of the appendix, but not first 
 tied. (See Fig. 660.) The loop opposite the free ends of this purse-string 
 
APEND1CECTOMY 
 
 909 
 
 suture is grasped by forceps held by an assistant, to steady the appendix against 
 the counter-pull of the operator, who holds the free ends. The appendix is then 
 divided transversely about 1.2 cm. (J inch) from its base — the canal of the 
 stump may be dilated with special fine forceps (to aid in invagination) — 
 and sometimes sterilized by the actual cautery point — the free end of the 
 stump is then seized with the same forceps and invaginated into the caecum. 
 (See Fig. 661.) While the stump of the appendix is held invaginated into 
 the caecum, the operator draws upon the free ends of the purse-string suture 
 (which have been loosely knotted with a friction-knot) until the slack of 
 the loop held by the assistant is taken up — the assistant, letting go his grip 
 
 Fig. 668. — Halsted's Three-clamp Method of Removing the Appendix: — II. — 
 The central clamp is removed and the append x severed through its crushed portion by the 
 actual cautery. 
 
 of the loop with the forceps, takes the two free ends of the suture — tightening 
 the friction-knot accurately at the very moment the operator quickly with- 
 draws the invaginating forceps. A second knot is tied and the ends cut 
 short. (See Fig. 662.) If considered necessary, two or three interrupted 
 gut Lemberts may be used to further bury in the stump. (See Fig. 663.) 
 This method of closure is especially applicable to appendices whose walls 
 are of more or less natural thickness and softness — capable, in other words, 
 of invagination, (b) Divide circularly the peritoneal coat of the appendix 
 about 6 mm. (I inch) from the caecum — peel back this serous coat toward 
 
910 
 
 OPERATIONS UPON THE ABDOM1M >-PELYIC REGION. 
 
 the caecum — and, on a level with the turned-back serosa, divide the middle 
 and internal coats of the appendix very near the caecum. (See Fig. 664.) 
 See that the lumen of the stump is patulous by means of a probe, and cauterize 
 the interior of the stump with a fine Paquelin point. The edges of the stump 
 are then brought together either by fine silk sutures or by circular ligature. 
 This short stump itself is then depressed (rather than invaginated) into the 
 caecum (see Fig. 665) — and, after suturing the serosa over the stump, the 
 surrounding area of the caecum, to the extent of 3 mm. (£ inch) from the 
 base of the appendix, is invaginated by means of a purse-string suture which 
 had been previously placed in the same manner as in the last method. (See 
 Fig. 666.) Additional interrupted gut Lemberts may bring the edges of the 
 furrow together, if considered necessary. This method is particularly appli- 
 
 Fig. 669. 
 
 -The Dissection of an Adherent, Embedded Appendix — with the Suturing 
 of the Peritoneum over its Denuded Bed. 
 
 cable to thick, hard, narrow-calibered appendices, (c) The peritoneal coat 
 may be peeled back — the middle and internal coats divided transversely — 
 and the peritoneal coat sutured over the cut middle and internal coats with 
 Lemberts. (d) The mucous coat may be excised with fine, curved, sharp- 
 pointed scissors, or burnt out with the actual cautery — and the serous and 
 muscular coats sutured over it. (e) The same steps may be carried out 
 as in "b," except that the stump may be simply depressed into the caecum 
 and the walls of the caecum brought together with Lembert sutures in a 
 straight line, (f) The Halsted "three-clamp" method of removing the 
 appendix is especially to be recommended. The appendix is clamped near 
 its base with a clamp strong enough to crush it (a large size artery-clamp) — 
 a second one is applied above this, with handle in the opposite direction— and 
 
APPENDICECTOMY. 911 
 
 a third one below the middle one, with its handle running with the uppermost 
 (Fig. 667). The middle clamp is then removed — and the crushed appendix 
 severed with the actual cautery — after which it is invaginated into the caecum 
 and the purse-string suture tightened — and the site reinforced by two or more 
 Lemberts (Fig. 668). (8) The appendix having been removed and its 
 stump sutured, the bowel is returned to the abdominal cavity — and the wound 
 closed in the usual manner. Drainage is ordinarily not employed — unless 
 specially indicated. 
 
 Comment. — (i) If at any time during the operation more room be required, 
 this may be gained by continuing the separation either upward or downward. 
 In the latter direction the separation is accomplished by the Harrington- Weir 
 method (page 810). (2) It often happens that the appendix must be dis- 
 sected from a mass of more or less dense adhesions — in which cases the 
 denuded bed should be protected by suturing peritoneum over it. 
 
 APPENDICECTOMY THROUGH THE RECTAL SHEATH. 
 
 Description. — This is, practically, the Battle- Jalaguier-Kammerer oper- 
 ation (page 811) — and is especially adapted to acute cases, or cases in which 
 complications are apt to be encountered and in which, therefore, the freest 
 possible exposure is necessary. 
 
 APPENDICECTOMY 
 
 BY THE NOX -INTRAMUSCULAR METHOD. 
 
 Description. — In this operation no attempt is made to separate the 
 muscle-fibers of the abdominal wall, which are freely cut where they cross 
 the line of incision. The method is applicable to "interval" and to pus 
 cases — but guards the abdominal wall from hernia less well than does the 
 method just described. 
 
 Preparation — Position. — As in the Intramuscular Operation (page 901). 
 
 Landmarks. — Anterior superior iliac spine; umbilicus; outer border of 
 right rectus muscle. 
 
 Incision. — Draw an imaginary line from the anterior superior iliac spine 
 to the umbilicus — the incision will begin about 2.5 cm. (1 inch) above this 
 line, and will run obliquely downward and inward, parallel with and about 
 1.2 cm. (h inch) to the outer edge of the right rectus muscle. 
 
 Operation. — (i) The incision divides skin and fascia — passes through 
 the external oblique approximately parallel with its fibers — divides the internal 
 oblique and transversalis more or less transversely, and just to the outer side 
 of the ending of their muscular fibers. (2) All bleeding vessels are seized, 
 and the wound well retracted. (3) Divide the fascia transversalis, subperi- 
 toneal areolar tissue, and peritoneum in the line of the original wound and 
 with the usual precautions — especially guarding against adhesions. (4) 
 Having opened the abdomen and retracted the lips of the wound well, the 
 isolation and treatment of the appendix are carried on just as in the Intra- 
 muscular operation of McBurney (page 901). (5) And the wound is closed 
 as in median abdominal section (page 805). 
 
912 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 APPENDICOSTOMY. 
 weir's operation. 
 
 Description. — The operation is practically an enterostomy — in which the 
 appendix is made to open upon the skin surface — and through which drainage 
 and irrigation of the intestinal tract are carried on. This measure finds its 
 chief application in intractable cases of amebic dysentery. The appendix 
 is exposed through the steps of the McBurney intramuscular exposure of the 
 organ. 
 
 I 
 
 Fig. 670. — Appendicostomy : — The appendix is seen emerging from between the separated 
 fibers of the internal oblique, below — and between the separated fibers of the external oblique, 
 above. A rubber tube is in its lumen. 
 
 Preparation — Position — Landmarks — Incision. — As in McBurney's 
 intramuscular appendicectomy (page 901). 
 
 Operation. — The steps of the operation are carried out as detailed in the 
 above operation. The appendix is isolated and delivered through the smallest 
 available intramuscular opening (Fig. 905). Whatever adhesions are encoun- 
 tered are separated. The appendix is put under gentle traction and drawn 
 
ENTEROSTOMY IN GENERAL. 913 
 
 out of the abdomen until its base is in contact with the parietal peritoneum — 
 where it is anchored to the parietal peritoneum by two catgut stitches, one 
 through the mesoappendix and one through the seromuscular coats of the 
 antimesenteric aspect of the appendix. The muscles are all allowed to fall 
 together — and are reinforced by catgut suturing if indicated. The skin and 
 fascia are sutured up to the exit of the appendix. The appendix itself, at its 
 exit from the outer surface of the abdominal wall, is anchored to the skin by 
 two seromuscular stitches of silkworm-gut. If practicable, the appendix is 
 not opened for a couple of days — delaying until the general cavity is shut off 
 by adhesions. The end of the appendix is then cut off transversely. Through 
 its lumen a rubber or silk catheter is passed on into the caecum — and through 
 this catheter the bowel is irrigated or drained. The catheter may remain 
 in situ or be introduced during irrigations. When the appendicostomy has 
 ceased to be of service, the wound sometimes closes spontaneously. At other 
 times the abdomen must be opened, by a repetition of the original steps and 
 the appendix removed in the usual manner. 
 
 Comment. — In some cases the appendix can not be brought into the wound, 
 owing to its situation or to adhesions, and in such cases, a caecostomy may 
 be done through the same wound. This latter technic, indeed, is preferred 
 by some surgeons to an appendicostomy. 
 
 ENTEROSTOMY IN GENERAL. 
 
 Description. — (1) Enterostomv consists in the making of a more or less 
 permanent opening into some part of the intestinal canal, for the purpose 
 of relieving obstruction or of furnishing nourishment — the opening thus made 
 communicating with the external abdominal surface. This opening may be 
 a Jejunostomy, Ileostomy, or Colostomy. When not specially designated. 
 Enterostomy is generally understood to mean an opening of the small intes- 
 tine, in which sense it will be here used. (Enterotomy has been incorrectly 
 used to designate this operation.) If the opening be made high up in the 
 small intestine, it may serve as an artificial mouth for nourishment (e. g., 
 jejunostomy, near the stomach). If the opening be low down in the small 
 intestine (e. g., an ileostomy, low down), or anywhere in the large intestine 
 (e. g., colostomy), it will serve the role of artificial anus. In the last category 
 of cases it is generally performed for some more or less permanent obstruction, 
 the opening being, of course, above the seat of obstruction. (2) The manner 
 of performing enterostomy will differ — as to whether a temporary opening is 
 sought, which will, of its own accord, tend to close, — namely, a fecal fistula, 
 which is generally done in some form of removable obstruction, — or whether 
 a permanent opening is desired, which will, through a spur-like formation, 
 tend to remain patulous — namely, an artificial anus, which is generally done 
 in some form of irremovable obstruction. The technic of enterostomy, 
 whether for artificial mouth, temporary fecal fistula, or permanent artificial 
 anus, is practically the same as that for colostomy performed for temporary 
 fecal fistula or permanent artificial anus — the chief difference being in the 
 site of the operation. (3) Enterostomy (of the small intestine) is generally 
 done upon the right side, and as near the caecum as possible. Where the 
 operation is done for obstruction, the site is, naturally, always above the 
 obstruction. The operation may be done in the median line or upon the 
 left side. Frequently, especially in desperate and weak cases, the first coil 
 of distended gut is opened. A permanent artificial anus is generallv made, 
 58 
 
914 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 where possible, in the course of the descending colon, a description of which 
 is given under colostomy. (4) The cause having been removed, for which 
 the fecal fistula or artificial anus has been made, it is indicated to close the. 
 opening by operation if nature does not do so. (5) The site of choice for 
 opening the intestine for temporary fecal fistula, or permanent artificial anus, 
 is in the colon. (See Colostomy, page 916.) 
 
 RIGHT INGUINAL ENTEROSTOMY (OR ILEOSTOMY) FOR THE ESTAB- 
 LISHMENT OF A TEMPORARY FECAL FISTULA OR A 
 PERMANENT ARTIFICIAL ANUS. 
 
 Description. — (A) Temporary Fecal Fistula 0} Small Intestine.- — An in- 
 cision having been made in the right inguinal region, the first distended coil 
 of intestine above the caecum is drawn out and attached to the abdominal 
 wall, on a level with, or but slightly projecting above, its surface. While the 
 operation, as originally devised by Nelaton, did not follow the intramuscular 
 lines, it should do so where possible. No attempt is ordinarily made to 
 remove the cause of the obstruction. The opening is meant to be but 
 temporary, and if it does not close spontaneously, it is closed by operation 
 subsequently. 
 
 (B) Permanent Artificial Anus of Small Intestine. — Enterostomy for the 
 establishment of a permanent artificial anus differs from enterostomy for tempo- 
 rary fecal fistula, in that the former is performed in cases where the obstruction 
 is irremovable, and also where it is sought to prevent the passage of intestinal 
 contents into the limb of the bowel below the opening. The typical operation 
 of enterostomy for the establishment of a permanent artificial anus is seen in the 
 operation of Colostomy (as performed for inoperable obstruction of the rectum, 
 q. v.) . The operation to be here considered is simply an application of those 
 principles to cases of the small intestine where, upon opening the small bowel 
 above the seat of obstruction, it is found the opening must be more or less 
 permanent. It is even of greater importance that a permanent artificial 
 anus of the small intestine should be lower down than a temporary fecal 
 fistula. It is well to follow the intramuscular manner of abdominal incision, 
 where possible — both as a guard against hernia and for gaining something 
 of a sphincteric control of the intestinal opening. The only practical differ- 
 ence between this and the preceding operation is in the manner of attaching 
 the knuckle of intestine to the abdominal wound. 
 
 Preparation. — As for median abdominal section. 
 
 Position. — Patient supine, with right side near edge of table. Surgeon 
 on side of operation — assistant opposite. 
 
 Landmarks. — Outer portion of Poupart's ligament; deep epigastric 
 artery. 
 
 Incision. — About 5 to 7.5 cm. (2 to 3 inches) (according to the thickness 
 of the abdominal wall) — placed about 4 cm. (1^ inches) above and parallel 
 with the outer part of Poupart's ligament, and external to the deep epigastric 
 artery. 
 
 Operation for Temporary Fecal Fistula of Small Intestine. — (1) 
 Having followed the steps of the intramuscular incision of the abdominal 
 wall (page 807) and retracted the lips of the wound, the caecum is sought 
 with the finger and located as a rallying-point. The site of the obstruction 
 is then located if possible, and, if so, the first distended coil of intestine above 
 the obstruction is caught and brought into the wound. Where the source of 
 
RIGHT INGUINAL ENTEROSTOMY FOR TEMPORARY FISTULA. 915 
 
 obstruction cannot be found, any distended coil of intestine is taken and brought 
 forward (which will probably be a portion of the lower ileum) . In bringing the 
 gut forward into the wound, its normal relations and direction should be main- 
 tained, as far as possible — and only its convex, antimesenteric aspect should 
 project from the wound, but this aspect should well fill the portion of the wound 
 to be left open, and any excess of intestine from above should be returned to the 
 cavity, that the upper part may not sag down upon the lower. (2) The excess 
 of length of the wound is now closed from either end, either by through-and- 
 through suturing of all layers with silkworm-gut or silk, or by layer-suturing 
 with chromic gut. When shortened to the desired extent, in cases where the 
 length has been excessive — or from and beginning with the first suture at 
 either end, where the length has only been moderate — the serous and muscular 
 coats of the intestine are included in the suture at either end of the wound, 
 thus fixing the gut to the abdominal wall at the same time the lips of the 
 ends of the wound are approximated. If necessary, two fixation-sutures may 
 be applied laterally, passing through serosa and musculosa of the intestine 
 and all the layers of the abdominal wound. (3) An elliptical area of the 
 presenting gut is now sutured to the parietal peritoneum by a continuous or 
 interrupted fine silk suture, passing through serous and muscular coats of 
 the intestine, on the one hand, and peritoneum and transversalis fascia, on 
 the other. A second row of continuous or interrupted silk or gut sutures 
 may then be placed, uniting the skin of the abdominal wound to the serous 
 and muscular coats of the intestine, including the free margin of the parietal 
 peritoneum external to the elliptical suture in the presenting gut. Or the 
 second row of sutures may simply unite the edge of the abdominal skin to 
 the free margin of the parietal peritoneum. A union considered firmer bv 
 some may be secured by first suturing the parietal peritoneum to the skin 
 all around the permanent opening — and then suturing the intestine to this. 
 (4) If haste be necessary, an opening is at once made into the lumen of the 
 gut, by a quick, controlled stab with a narrow, sharp knife and increased 
 to the desired extent with blunt scissors (having ascertained that all the 
 coats of the intestine have been pierced before inserting the blade of the scis- 
 sors). If no haste be necessary, a delay of two or three days for union of 
 the serous surfaces and exclusion of the abdominal cavity is preferable 
 ("operation in two stages"). The intestinal contents are allowed to escape 
 of their own accord. 
 
 Comment. — (i) The operation may be performed through a median or 
 other incision — or the obstruction may be located through a median incision 
 and enterostomy done through a lateral incision — thus giving greater room 
 for diagnosis and possibly for correcting the cause of trouble — the excess in 
 length being closed in at either end before attaching the intestine. Left 
 inguinal enterostomy may also be done. (2) Avoid wounding the deep epi- 
 gastric artery and twisting the gut. (3) As small an opening as consistent 
 with efficient emptying should be made, to make the subsequent closing 
 easier. 
 
 Operation for Permanent Artificial Anus of Small Intestine. — (i) The 
 early steps of the operation are the same as when a temporary fecal fistula is to 
 be made (page 914). (2) When the knuckle of bowel to be drawn into the 
 wound is isolated, it is important and necessary to determine which is the prox- 
 imal part of the coil. This having been done, and the knuckle having been 
 drawn into the wound, the excess of intestinal length which tends to sag down 
 into and out of the upper angle of the wound is taken up and passed on down 
 through the lower angle of the wound (so as to do away with the likelihood of 
 future hernia of the proximal limb of the intestine through the wound) . (3) 
 
0l6 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 The desired knuckle of intestine having been isolated and retained within 
 reach by a temporary loop of silk passing through the antimesenteric aspect of 
 its outer coats, the two ends of the wound are closed toward the center, as far as 
 thought necessary, by tier suture or by through-and-through suture. (4) The 
 parietal peritoneum is drawn out and sutured to the abdominal skin, or as 
 nearly in contact with it as possible all around the wound. (5) The knuckle of 
 intestine is now drawn entirely out of the wound, until the mesenteric attach- 
 ment is on a level with the skin. Care is taken that the intestine is not twisted 
 and that the normal relations are maintained, as nearly as possible. Care is 
 also especially taken that the proximal limb of the loop is identified and kept 
 uppermost in the wound, is given plenty of room in the opening, and that 
 it is made to compress the distal limb against the lower angle of the wound 
 (to prevent the passage of intestinal contents from the proximal into the 
 distal limb). While held in this position, the knuckle of intestine is sutured 
 into permanent position — by continuous or interrupted silk sutures passing 
 through the serous and muscular, and part of the submucous, coats of the 
 intestine, on the one hand, and the parietal peritoneum (which has been 
 already attached to the skin) on the other. (6) If no haste exist, the opening 
 of the intestine is deferred for two or three days, until serous adhesions have 
 occurred. If haste be necessary, the opening may be made at once, by cutting 
 out transversely, with scissors, a triangular piece of the whole thickness of the 
 intestine, with its base at the free border and its apex at the mesenteric attach- 
 ment. 
 
 Comment. — (1) This, as well as the operation for fecal fistula, may be 
 made in the median or left lateral regions, but it is even more important 
 than in temporary fecal fistula that the opening be as low as possible, to 
 prevent starvation. (2) A somewhat smaller opening in the peritoneum is 
 generally made than in fecal fistula. (3) A glass rod may be run through 
 the mesentery, as is sometimes done in colostomy — to hold the coil of intestine 
 in place. (4) It is well to put a few interrupted Lembert sutures along the 
 lateral aspect of the two limbs of the knuckle, where they come in contact. 
 (5) Where the intestine must be opened at once, only a limited opening is 
 then made — the permanent opening being made after adhesions form. 
 
 COLOSTOMY IN GENERAL. 
 
 Description. — Colostomy signifies the establishment of an artificial open- 
 ing, either temporary (fecal fistula), or permanent (artificial anus), in some 
 part of the Colon. While a similar opening of the caecum is termed cfficos- 
 tomy, and of the sigmoid colon, sigmoidostomy, both operations are generally, 
 though less specifically, included under the term colostomy. The descending 
 colon is the site generally chosen — the cause usually being obstruction, or some 
 condition, distal to the site of operation. 
 
 Chief Varieties of Colostomy. — (1) Inguinal Colostomy (Iliac Colos- 
 tomy, Anterior Colostomy, operation of Littre) signifies the opening of the 
 sigmoid flexure of the colon in the left iliac region, through the peritoneal 
 cavity. The ascending colon is much less frequently opened. (2) Lumbar 
 Colostomy (Posterior Colostomy, operation of Amussat) signifies the opening 
 of the ascending or descending colon, preferably the latter, through the loin, 
 extraperitoneallv. 
 
 In Favor of Inguinal Colostomy. — The artificial anus is more conve- 
 niently placed; — the operation is both easier and quicker; — the position for 
 anesthesia is better; — the wound is not so deep; — there is no chance of failing 
 because of the presence of a mesentery (which sometimes interferes, by its 
 
LEFT INGUINAL COLOSTOMY. 917 
 
 presence, with the operation posteriorly) ; — the exploration of the abdomen is 
 possible; — the shallower wound makes the formation of a spur, or any other 
 indicated step, easier. 
 
 In Favor of Lumbar Colostomy. — The peritoneum is generally not 
 opened; — where the sigmoid colon is bound down, and therefore not easily 
 accessible by the anterior operation; — prolapse (hernia) is not so likely. 
 
 Observations. — (i) Left Inguinal Colostomy is the operation of choice. 
 Lumbar colostomy is now rarely performed. (2) The ascending colon has 
 a mesentery in 26 per cent. — and the descending colon in 36 per cent, of 
 cases (Treves). This means that in those cases where a mesentery is en- 
 countered, in operating posteriorly, the operation cannot be completed extra- 
 peritoneally unless the leaves of the mesenterv can be separated and the 
 mesenteric aspect of the colon thus approached. (3) The positions of the 
 ascending and descending colons are represented, in the loins, by vertical 
 lines drawn upward from a point 1.3 cm. (^ inch) posterior to the center 
 of the crest of the ilium (that is, a point 1.3 cm., or \ inch, posterior to a 
 point midway between the anterior and posterior superior iliac spines). (4) 
 If a temporary fecal fistula be sought, no spur should be formed in suturing 
 the knuckle into position. If a permanent artificial anus be sought, a spur 
 should be made in the knuckle, to prevent the flow of contents of the proximal 
 into the distal gut. (5) By operating in the intramuscular manner, hernia 
 is less apt to follow — and, additionally, greater sphincteric control is secured. 
 (6) Where a temporary opening is sought, the bowel is opened longitudi- 
 nally — and transversely where a permanent opening is planned. 
 
 LEFT INGUINAL COLOSTOMY. 
 
 Description. — Left Inguinal (Iliac or Anterior) Colostomy consists in 
 making a more or less permanent opening in the sigmoid flexure of the colon, 
 in the left iliac region, through the peritoneal cavity. The manner of suturing 
 the intestine to the abdominal wall will differ, dependent upon whether 
 a temporary fecal fistula or a permanent artificial anus be sought. Also 
 the final steps of the operation will differ, dependent upon whether the bowel 
 is to be opened at once, or whether the operation is to be performed in two 
 stages and the bowel opened in three or four days, after adhesions have 
 formed and the peritoneal cavity is shut off — and also as to whether the 
 opening is to be temporary or permanent. The operation is generally done 
 upon the left side — though it may be done upon the right — the steps being the 
 same in either case. The operation is generally done for some obstruction 
 (usually cancer of the rectum), or other condition, distal to the site of the 
 colostomy. 
 
 Preparation — Position. — As for median abdominal section. 
 
 Landmarks. — Umbilicus; left anterior superior iliac spine; Poupart's 
 ligament. 
 
 Incision. — About 5 to 6.5 cm. (2 to 2\ inches) long — crossing, at right 
 angles, an imaginary line from the umbilicus to the left anterior superior 
 iliac spine, at a point about 4 cm. (\\ inches) internal to the iliac spine, the 
 center of incision being upon this imaginary line. The incision will, there- 
 fore, be about parallel with Poupart's ligament and with the fibers of the 
 external oblique. This incision corresponds with McBurney's incision for 
 appendicectomy, except that it is upon the left (see Fig. 576). 
 
 Operation. — Up to the opening into the peritoneal cavity, the steps are 
 practicallv the same as in McBurney's intramuscular operation for the re- 
 moval of the appendix (page 807). (•) Incise the skin and fascia in the 
 
gi8 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 above line, clamping the bleeding vessels. (2) Separate and retract the 
 fibers of the aponeurosis of the external oblique in the line of their cleavage. 
 
 (3) Separate and retract the fibers of the internal oblique in their cleavage. 
 
 (4) Similarly separate and retract, intramuscularly, the fibers of the trans- 
 versalis. (5) Divide the transversalis fascia and subperitoneal connective 
 tissue in the line of separation of the transversalis muscle, for about 4 to 
 5 cm. (ij to 2 inches). (6) While holding the parts apart, replace the re- 
 tractors which have retracted the several tissues in their cleavage line by 
 two retractors — drawing the lips of the wound asunder in the two most con- 
 venient directions. (7) Introduce the right index-finger into the peritoneal 
 cavity toward the left iliac fossa — entering at the outer angle and passing 
 downward and toward the median line, with the finger held in a hook-like 
 
 Fig. 671. —Left Inguinal Colostomy — for Temporary Fecal Fistula: — A, A, Temporary 
 ligatures drawing sigmoid flexure of colon into wound ; B, B, Sutures uniting peritoneum and 
 lower part of muscular wall of wound, to serous and muscular coats of intestine ; C, C, Sutures pass- 
 ing through peritoneum and lower part of muscular wall, on one side ; serous and muscular coats of 
 intestine, in center ; and peritoneum and lower part of muscular wall, on opposite side ; D, D, Sutures 
 passing through entire thickness of muscular wall. Position of future axial incision in colon is shown 
 by dotted lines. 
 
 fashion — hooking up the sigmoid flexure of the colon and bringing it out 
 into the wound — recognizing it by its appendices epiploicae, its sacculations, 
 and its longitudinal bands. After drawing the loop well out, return into 
 the lower angle of the wound all the excess drawn out of the upper angle, 
 until checked by the mesocolon — thus assuring that there will be no downward 
 sagging of the intestine from above, with consequent tendency to hernia of 
 the proximal gut through the artificial opening. The steps of the operation 
 from this point on will be determined by, (a) the object sought, as to per- 
 manency of opening — and, (b) as to whether the intestine must be opened 
 at once, (a) Where a temporary fecal fistula is intended : — In this case 
 the presenting convexity alone (representing from one-half to three-fourths 
 of the circumference of the intestinal tube) is sutured into the wound, the 
 
LEFT INGUINAL COLOSTOMY. 
 
 919 
 
 convexity of the gut being held, during suturing, into contact with the wound 
 by two silk traction-sutures passed through the serous and muscular coats, 
 preferably through the superior longitudinal band of the colon — (or this 
 aspect of the intestine maybe gently grasped with forceps). (See Fig. 671.) 
 Continuous or interrupted silk or chromic gut sutures are now passed through 
 the serous and muscular coats of the intestine, on the one hand, and the 
 peritoneum and muscle tissue of the abdominal wound, on the other — passing 
 sufficiently far from the free edge of the peritoneum so that some width 
 of peritoneum will be approximated to gut — thus bringing serous surfaces 
 into contact. Preferably the lower line of sutures is passed through the 
 lower longitudinal band — and the upper line, near the mesentery. Any 
 excess of abdominal wound is first closed from either end by interrupted 
 sutures passed as in abdominal section. If haste is unnecessary, the opening 
 is made in two or three days, when the serous surfaces have united. An 
 incision of about 2 cm. (f inch) is made into the long axis of the gut — and 
 
 Fig. 072. — Left Inguinal Colostomy — for Permanent Artificial Anus : — A, A, Temporary 
 traction-ligatures drawing sigmoid flexure of colon into wound ; B. B, Sutures uniting peritoneum and 
 lower part of muscular wall of wound, to serous and muscular coats of intestine ; C, C, Sutures pass- 
 ing through peritoneum and lower part of muscular wall, on one side ; serous and muscular coats of 
 intestine, in center; and peritoneum and lower part of muscular wall, on opposite side ; D, D, Sutures 
 passing through entire thickness of muscular wall. Position of future excision of triangular piece of 
 colon is shown by dotted line. 
 
 the edges of the intestinal wound (all of the coats) are sutured to the skin 
 of the abdominal wound. If haste is necessary, the above is done at once. 
 (b) Where a permanent artificial anus is intended: — The knuckle of 
 intestine is drawn well out of the wound, exposing its mesentery. Incise 
 the mesentery, in a line with its vessels, and near the bowel — and insert 
 a short glass rod, or similar object, through this opening — the ends of the 
 glass rod resting on either side of the edges of the wound. If the slit through 
 the mesenterv be excessive, the excess is gut-sutured. The two limbs of 
 the knuckle above and below the rod are sutured to each other by gut sutures 
 
920 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 passing through serous and muscular coats and approximating their mesen- 
 teric aspects, thus forming a spur of the walls so brought into apposition. 
 (See Fig. 672.) Having first closed in any excess of abdominal wound from 
 either end, by sutures applied as in abdominal section, the protruded knuckle 
 is then sutured into the wound by silk or chromic gut sutures passing through 
 serous and muscular coats of the intestine, on the one hand, and through 
 peritoneum and muscle tissue of the abdominal wound, on the other. If 
 haste be not necessary — wait two or three days until the serous surfaces 
 have united and the peritoneum has been shut off — then seize, with rat- 
 tooth forceps, the prominent knuckle of intestine and cut out transversely, 
 in a line with the rod, a V-shaped segment of gut, with scissors — excising 
 the entire, or nearly the entire, diameter of gut, with the apex of the excised 
 portion ending where the limbs have been sutured together. Let the distal 
 end of the intestine retract. Suture the margins of the proximal end to the 
 skin of the abdomen. Remove the glass rod in about seven days — and 
 the sutures in about ten. If haste be necessary — the above is done at once. 
 Comment. — (1) Slight variations occur in the operation as done by 
 Maydl; — the knuckle of intestine is drawn out — the glass rod passed through 
 the mesentery — the limbs of the loop sutured together as above, — following 
 which the steps will differ as to the object sought; — (a) If the intestine is 
 to be opened at once — it is stitched to the parietal peritoneum, as described 
 above; — (b) If the intestine is not to be opened at once — it is not stitched, 
 but simply gauze is packed around and under the glass rod; — (c) If the 
 opening is to be permanent — the bowel is to be divided transversely in from 
 four to six days, through one-third of its diameter — an irrigating tube is 
 then inserted and the intestines washed out — and in two or three weeks 
 later the transverse division is completed — the edges of the proximal gut 
 are sutured to the margins of the skin and the distal end left unsutured — 
 and the rod is then withdrawn; — (d) If the opening is to be temporary — 
 the intestine is incised in its long axis — and, when the opening is ready to 
 be dispensed with, the rod is withdrawn and the knuckle of intestine allowed 
 to retract (no suturing to the skin having taken place) — the opening often 
 closing of its own accord. (2) As small an abdominal incision as possible 
 should be made, in order to lessen the chance of hernia. The higher up 
 the abdominal wall the opening is made, the less the chance of hernia. Some 
 surgeons make the incision parallel with the outer third of Poupart's ligament. 
 (3) If the small intestine, mesentery, or omentum present during operation, 
 they are pushed back into the abdomen. (4) If the sigmoid flexure cannot 
 be located readily, it can be found by injecting water through the rectum, 
 while the finger in the wound feels for the enlarging bowel. (5) The use 
 of the rod, or other object, to pierce the mesentery is not absolutely necessary. 
 The mesocolon can be sutured to the edges of the abdominal wound instead. 
 (6) In stitching the intestine into the wound, the stitching is so done as to 
 give the proximal part of the loop ample room, and, at the same time, make 
 pressure upon the distal part, to prevent the passage of intestinal contents 
 into it. (7) Sometimes the parietal peritoneum is drawn sufficiently out to 
 be sutured to the margin of the skin around the wound, the muscle layers 
 not being included — and the intestine is then sutured to this parietal perito- 
 neum. But firmer union is probably secured by the principal method de- 
 scribed above. (8) Sometimes (though hardly to be recommended) instead 
 of making a spur, which is often inefficient, the bowel is cut through above 
 the obstruction (when performed for that purpose) and the lower end is 
 closed by inverting the edges of the distal end by a double row of sutures, 
 the outer row, an overhand, continuous suture; the second, a row of Lem- 
 
ANTERIOR INTRAMUSCULAR COLOSTOMY. 
 
 921 
 
 berts; and this end is dropped into the abdominal cavity. The edges of the 
 proximal gut are then sutured into the abdominal wound by two tiers of 
 sutures; the lower, of chromic gut, through the serous and muscular coats 
 of the gut (a short distance from the edge), and peritoneum and muscles 
 of the abdominal wound; the marginal, of silk, through all the coats of 
 the gut, and the skin. The method, however, is not indicated when it is 
 desirable to keep the upper end of the distal gut patulous, where drainage 
 below is difficult. 
 
 Note. — Right Inguinal Colostomy, or Caecostomy, is but rarely done. 
 The contents of the ascending colon (from the nearness of the small intestine) 
 are more liquid and less easily controlled through such a fistula or anus. 
 The absence, or shortness, of the mesentery also makes the attachment to 
 the abdominal wall more difficult. The operation is, practically, done only 
 when the site of the trouble is uncertain, the caecum at the same time being 
 distended, — or when, in doing a Left Inguinal Colostomy, it is impossible 
 to find the sigmoid colon. When the operation is done at all, it is generally 
 only a temporary fistula which is made, as, when this site is selected, it is 
 usually an operation of emergency only. A Transverse Colostomy is even 
 rarer. 
 
 Fig. 673.— Mixter's Anterior Colostomy:— I.— Quadrilateral flap of skin and fascia 
 turned outward, exposing rectus. Separation of libers in outer part of rectus. (Redrawn 
 from Gould.) 
 
 ANTERIOR INTRAMUSCULAR COLOSTOMY. 
 mixter's operation. 
 
 Description. — The sigmoid is broughtout through the split rightrectus mus- 
 cle, which is sutured between the limbs of the loop — after which a bridge of skin 
 
922 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 and fascia is sutured under the loop and between the distal and proximal 
 limbs. In this method some muscular control of the openings is secured, 
 and the openings of the proximal and distal ends are separated some distance 
 from each other. 
 
 Preparation — Position — Landmarks. — As in Left Inguinal Colostomy, 
 page 917. 
 
 Incision. — Commences on a level with the umbilicus, over the outer third of 
 the right rectus muscle — passes vertically downward for 5 cm. (2 inches) through 
 skin and fascia to the musculature — thence turns inward at a right angle and 
 runs in a straight line for 5 cm. (2 inches) — thence downward at a right 
 angle and runs in a straight line for 5 cm. (2 inches) — thence outward at a 
 
 V 
 
 Fig. 674. — Mixter's Anterior Colostomy: — II. — Loop of sigmoid drawn through separ- 
 ated fibers of rectus — taut mesentery incised — median portion of rectal fibers sutured together 
 between proximal and distal coils. (Redrawn from Gould. J 
 
 right angle and runs in a straight line for 5 cm. (2 inches) — and finally turns 
 again at a right angle and runs downward in a straight line for 5 cm. (2 inches) 
 — as shown in Fig. 673. 
 
 Operation. — The flap thus indicated, consisting of skin and connective 
 tissue, overlying the abdominal muscles is raised and retracted outward — as 
 shown in Fig. 673. The anterior layer of the rectal sheath is incised, and 
 the longitudinal fibers of the rectus are separated in the outer part of the 
 rectus by blunt dissection. The posterior layer of the rectal sheath, trans- 
 versalis fascia, subserous areolar tissue, and peritoneum are incised in the 
 same longitudinal line. The sigmoid is located and brought out of the 
 abdomen through this opening and the loop of intestine pulled upon until 
 both of its limbs are taut — to render prolapse less likely. The mesentery 
 
ANTERIOR INTRAMUSCULAR COLOSTOMY. 
 
 923 
 
 of the sigmoid is incised at a right angle to the long axis of the bowel for 
 about 5 cm. (2 inches). The incised edges of the mesentery are retracted — 
 while the central portion of the separated border of the split rectus are 
 sutured together with catgut sutures through the margins of the incised 
 mesentery (Fig. 674). Over the sutured portion of the rectus muscle and 
 under the coil of sigmoid the skin-flap is sutured into its original position, 
 by means of one layer of interrupted sutures through the fascia and another 
 through the skin. The two limbs of sigmoid are thus separated, over a space 
 of about 5 cm. (2 inches), by a bridge of muscle, fascia, and skin. Where 
 acute obstruction exists, a right-angled Mixter glass tube, of large size, is 
 
 Fig. 675. — Mixter's Anterior Colostomy: — III. — Skin and fascia flap sutured back into 
 place beneath arch of sigmoid. Mixter tube sutured into intestine. (Redrawn from Gould.) 
 
 introduced into the lumen of the intestine at once and held in situ by a purse- 
 string suture (Fig. 675). A rubber tube is attached to the glass tube and 
 carried to a receptacle for feces. The intestine is dusted with zinc oxid 
 powder and covered with gutta-percha tissue, in order to prevent the peritoneal 
 coats from adhering to the dressings. If no necessity exist for haste, the 
 dressing is removed in four or five days and the loop of intestine excised about 
 1.3 cm. (^ inch) above the skin surface. The mucous membrane is trimmed 
 to the level of the muscle coats, and the free margins whipped with a continuous 
 suture (Fig. 676). The upper, or proximal, and the lower, or distal, openings 
 will lie some distance from each other — thus preventing feces from the former 
 
924 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 getting into the latter — the proximal opening serving for the escape of feces 
 and the distal for irrigation of the lower bowel, where that is indicated. The 
 
 split rectus muscle furnishes some de- 
 gree of sphincteric control. 
 
 LEFT LUMBAR COLOSTOMY. 
 
 Description. — Left Lumbar (Pos- 
 terior) Colostomy consists in making 
 an opening posteriorly through the loin, 
 over the descending colon — extra-peri- 
 toneally. Rarely the opening is made 
 over the ascending colon, in the right 
 loin. 
 
 Preparation — Position. — As for 
 median abdominal section. 
 
 Position. — Patient lies upon oppo- 
 site side and near edge of table, with 
 a hard pillow, or support, under the 
 opposite loin, to render prominent the 
 site of operation, — Surgeon on side of 
 operation, — Assistant opposite. 
 
 Landmarks. — Position of descend- 
 ing colon — namely, a line extending 
 vertically upward from a point about 
 1.2 cm. {\ inch) posterior to the center 
 of the iliac crest to the twelfth rib — 
 which line will about correspond with 
 the outer border of the quadratus 
 lumborum. 
 
 Incision. — About 7.5 to 10 cm. (3 
 to 4 inches) long — placed obliquely 
 between the twelfth rib and the crest 
 of the ilium, with its center over the 
 center of the vertical line representing 
 the course of the descending colon — 
 which incision will run in the direction of a line extending from the anterior 
 superior iliac spine to the angle formed by the twelfth rib and the outer 
 border of the erector spina? muscle, the incision beginning at about the outer 
 border of this muscle. (See Fig. 677.) 
 
 Operation. — (1) Divide the skin and the thick subcutaneous fatty fascia, 
 clamping all vessels. (2) Divide the latissimus dorsi and its aponeurosis in 
 the posterior part of the wound — and the posterior part of the external oblique 
 in the anterior part. (3) Divide the internal oblique, exposing the lumbar 
 fascia posteriorlv. (4) Recognize and protect the twelfth dorsal nerve and 
 accompanying branch of the lumbar artery. (5) Divide the lumbar fascia 
 and the transversalis muscle, exposing the anterior margin of the quadratus 
 lumborum (which rarely requires division) in the posterior angle of the 
 wound, and the transversalis fascia. (6) Divide the transversalis fascia, 
 from the quadratus lumborum to the anterior angle of the wound, exposing 
 the subperitoneal tissue — avoiding the twelfth nerve on its way from the 
 quadratus lumborum to the transversalis muscle. (7) A distended colon may 
 now protrude through the subperitoneal connective tissue into the wound- 
 
 Fig. 676. — Mixter's Anterior Co- 
 lostomy: — IV. — The sigmoid loop excised 
 1.3 cm. (^ inch) from skin — and the afferent 
 and efferent ends sutured to the skin. (Re- 
 drawn from Gould.) 
 
LEFT LUMBAR COLOSTOMY 
 
 925 
 
 this areolar fatty tissue, often very thick and fatty, lying around the kidney, 
 being separated by the fingers and forceps, or by a blunt dissector. If the 
 colon does not thus protrude, insert an index-finger through this subperi- 
 toneal areolar tissue, while the parts are well retracted behind the lumbar 
 fascia — following, with the back of the finger toward the patient's back, 
 along the anterior surface of the quadratus lumborum, aiming for the angle 
 between the quadratus lumborum and the psoas, toward which angle the 
 posterior surface of the colon presents, lying anterior to the plane of the 
 kidney, the lower portion of which (kidney) is generally felt. The finger 
 which has passed through the subperitoneal areolar tissue and is carefully 
 working behind the peritoneum is aided in its search by rolling the body 
 over toward the side of operation, while the assistant presses the anterior 
 abdominal wall firmly, so as to aid the colon, by gravity and pressure, to 
 fall, as it were, into the curved index finger. The colon is generally recog- 
 nized by the thickness of its wall, by the absence of the peritoneal coat, and 
 sometimes by the posterior longitudinal band. (8) Grasp the non-mesenteric 
 aspect of the colon with the fingers, or special forceps, and bring it out to 
 a level with the surface — no loop being here drawn out of the wound as in 
 the anterior operation. The colon is held in place with forceps, or traction- 
 sutures, or temporarily allowed to fall back into place — while the excess 
 of the abdominal wound is closed from either end — by layer suturing with 
 chromic gut, or by mass-suturing with chromic gut, silk, or silkworm-gut, 
 leaving just space enough for the emergence of the gut. (9) The convex 
 dome of the gut is sutured into the lips of wound — by interrupted sutures 
 
 Fig. 677.— Left Lumbar Colostomy :— A, Twelfth rib; B, Iliac crest; C, Latissimus dorsi 
 muscle; D, External oblique muscle ; E, Left kidney; F, Descending colon; G, Line of incision for 
 left lumbar colostomy. 
 
 of silk passing through the fibrous and muscular coats of the intestine, on 
 the one hand, and the skin of the abdomen, or as near it as possible, on the 
 other. (10) If haste be unnecessary — several days are allowed to pass, for 
 
926 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 union of intestine to abdominal wound to occur, and then the intestine is 
 incised and the lips of the intestinal wound sutured to the lips of the ab- 
 dominal wound— by interrupted sutures of silk, or silkworm-gut, passing 
 through all the coats of the bowel, and through the skin of the abdomen, 
 or as near it as possible — the sutures being passed from the skin into the 
 gut (making infection less likely). (11) If haste be necessary— the above 
 incision is made at once. (12) If a temporary fecal fistula be intended — 
 the gut is incised in its longitudinal axis. (13) If a permanent artificial anus 
 be intended — the gut is drawn as far into the wound as possible (which is 
 never as far as in the anterior operation) and divided nearly through — the 
 object being to form a spur as in the anterior operation. 
 
 Comment. — (1) The outer border of the erector spinae is the superficial 
 muscular guide to the colon. The outer border of the quadratus lumborum 
 mav be cut to expose the colon if necessary. (2) The operation is difficult 
 in very thick loins — thorough retraction aids the steps. (3) It is important 
 to recognize and open up the transversalis fascia — and not mistake it for 
 the peritoneum. The bulging peritoneum has been mistaken for the colon. 
 The duodenum has been mistaken for the ascending colon in operating on 
 the right side — and the stomach for the descending colon in operating on 
 the left side. The kidneys and small intestines have been mistaken for 
 the colon. The small intestines, when encountered, lie external to the colon. 
 The colon is generally distinguished by its longitudinal bands, anterior, 
 posterior (at the mesocolon, when the mesentery is present), and one internal, — 
 by its greater fixity, — and by its sacculations (often filled with scybala). 
 The descending colon is sometimes congenitally absent. The large intestine 
 may be distended with air or water to aid its recognition. The empty colon 
 is often hard to detect. If all means of detection fail, do a median abdominal 
 
 Fig. 678.— Transverse Section of the Posterior Abdominal Wall in the Lumbar 
 Region :— A, Erector spinae muscle; B, Quadratus lumborum; C, Psoas magnus ; D, Latissimus 
 dorsi; E, External oblique ; F, Internal oblique; G, Transversalis ; H, The descending colon shown 
 in its usual position, and without a mesentery, as usual ; I, The ascending colon shown with a mes- 
 entery (an exceptional occurrence). (Modified from Gray.) 
 
 section — find the bowel — and then complete the lumbar operation. (4) If 
 the peritoneum be accidentally opened, close it by gut suture if possible. 
 If this cannot be done, no harm is generally done by accidentally opening 
 the peritoneum in this locality. Draw the intestine into the wound and 
 
OPERATION FOR FECAL FISTULA AND ARTIFICIAL ANUS. 
 
 927 
 
 fix it there. (5) If the mesocolon be present, the abdominal cavity must be 
 opened, unless the laminae of the mesentery can be split — which can generally 
 be done. (See Fig. 678) A branch of the inferior mesenteric artery may 
 guide to a separation of the laminae. (6) The non-peritoneal surface of the 
 colon is generally thickly covered with fatty areolar tissue — which also inter- 
 venes between the colon, in front, and kidney, diaphragmatic crura, and 
 quadratus lumborum, behind. (7) The empty descending colon is apt to 
 tend further toward the median line, behind the border of the quadratus 
 lumborum, than a distended one — so that, in such cases, the normal site 
 of the distended colon is more apt to be occupied by peritoneum, which 
 is consequently, under these circumstances, more apt to be opened. (8) 
 Owing to the fixity of the colon, it is often hard to get enough of it into the 
 wound to form a spur, in the operation for artificial anus — though enough 
 for a fecal fistula is generally to be gotten. If difficulty be experienced in 
 causing sufficient bowel to protrude, a Paul tube may be tied into the gut, 
 the balance of the wound being closed about it. (9) Right lumbar colostomy 
 may be, but rarely is, performed. 
 
 OPERATION FOR THE CLOSURE OF FECAL FISTULA AND 
 ARTIFICIAL ANUS. 
 
 Description. — Sometimes occurring alone, and sometimes as a result of 
 the operations just described for the formation of fecal fistula and artificial 
 anus, a more or less permanent fistulous tract between the intestinal canal 
 and the abdominal wall is left. The simplest forms of such fistulous tracts 
 tend to close of their own 
 accord, but the more com- 
 plicated generally require 
 some operation for their 
 closure. These fistula? lead- 
 ing to some part of the 
 large or small intestine 
 are generally one of three 
 kinds: — (1) The gut is not 
 bent upon itself to any 
 extent; there is no spur; 
 but little of the intestinal 
 wall is involved; the open- 
 ing is small; the skin and 
 intestinal mucous mem- 
 brane are connected by a 
 sinus-like communication 
 (see Fig. 679, A);— (2) 
 The gut is bent somewhat 
 more upon itself; an in- 
 complete spur is present; 
 more of the intestinal wall 
 has been lost; the opening 
 is larger; the intestinal 
 mucous membrane and 
 
 the abdominal skin are more nearly in contact (see Fig. 679, B); (3) The 
 gut is more acutely bent on itself; a marked spur is present, forming an 
 
 Fig. 679.— Forms of Fecal Fistula and Artificial 
 Ani : — A, First form, intestine connected with skin by sinus- 
 like communication; B, Second form, intestine and skin more 
 directly in contact and gut slightly bent on itself; C, Third 
 form, showing formation of marked spur. 
 
928 
 
 OPERATIONS UPON THE ARDOMINO-PELYIC REGION. 
 
 obstruction to the intestinal passage; the amount of intestinal wall lost may 
 be variable; the condition present generally being an exaggeration of (2) (see 
 Fig. 679, C). The procedure for the closure of the fistulous tract will be 
 modified, therefore, by the various degrees of fistula found and by the extent 
 of the adjacent adhesions. 
 
 Preparation. — Neighboring skin should be gotten as healthy as possible 
 preliminarily. Evacuation of intestinal canal; local irrigation; vicinity of 
 fistula shaved. Just preceding operation, sinus is to be gently scraped and 
 again irrigated — after which it is packed with a small sponge', or with gauze, 
 attached to a piece of silk, the end of which is left out — and the lips of 
 the fistula are then tightly and deeply sutured and the long ends of the 
 
 Fig. 680. — Operation for Cure of Fecal Fistula or Artificial Anus: — A, Skin opening 
 of fistula closed by sutures used as traction-sutures; B, Ellipse of abdominal wall to be removed, with 
 its center occupied by external opening of fistula ; C, Ellipse of intestine to be removed, including neck 
 of fistulous tract ; D, Position of some of the Lembert sutures which will close in entire elliptical 
 opening in intestine after excision of fistulous tract. 
 
 sutures, after tying, are knotted, or grasped by clamp-forceps, and drawn 
 upward. 
 
 Position. — Patient supine on edge of table nearer fistula; Surgeon on side 
 of fistula; Assistant opposite. 
 
 Landmarks. — Site of fistula and known relation of neighboring parts. 
 
 I. Cases in which the operation involves the peritoneal cavity — no 
 
 extensive adhesions existing — or where it is desired to free existing adhe- 
 sions before excising the fistula: 
 
 Incision. — An elliptical incision is made around the fistulous opening — 
 its long axis will generally be vertical in operating upon fistulae of the small 
 intestine, and will usually correspond with the long axis of the large gut 
 in operating upon parts of the colon — and the length and breadth of the 
 
OPERATION FOR FECAL FISTULA AND ARTIFICIAL ANUS. 929 
 
 ellipse will be planned, as far as possible, to extend beyond the adhesions 
 probably surrounding the sinus. 
 
 Operation. — (i) Having sutured the fistulous opening and using the 
 sutures as traction-loops, this incision is carefully deepened on each side — 
 clamping bleeding vessels — and guarding against opening the peritoneum 
 prematurely, or cutting into an adherent coil of intestine. (See Fig. 680.) 
 (2) In passing through the thickness of the abdominal wall, the course of 
 the incision is directed by the sensation and form of the distended fistula 
 and by the left index-finger within the wound. In difficult cases, and espe- 
 cially in devious fistula 1 , it may be necessary to introduce a sound, or bougie, 
 through the sinus as a palpable guide. (3) Having deepened the incision, 
 all around, down to the peritoneum, the abdominal cavity is now carefully 
 opened in the line of the original ellipse. If the ellipse lie without the site 
 of adhesions, no great difficulty will be experienced. If it lie in part over 
 adhesions, a finger introduced through the site leading into the free peritoneal 
 cavity and swept around the sinus will serve for exploration and as a guide 
 to the separation or incision of the adherent portion. If the ellipse lie wholly 
 over adhesions and come down upon these all around, great care is required 
 to recognize the plane of adhesions when reached, and greater care still 
 in separating or dividing them in the line of the ellipse. (4) Having thus 
 reached the intestines, an isolated oval island of tissues (included in the 
 original ellipse and in deepening the ellipse to the intestinal wall) will be 
 evident — free above and continuous with the intestine below — through the 
 center of which the sinus extends. The intestine is carefully freed and drawn 
 out into the abdominal wound, with the oval island of tissues still adherent — 
 and the neighboring parts packed off with gauze. (5) Having pressed away 
 the intestinal contents and clamped the gut above and below the site of the 
 sinus, a small elliptical incision is made in the gut, circumscribing the con- 
 nection of the sinus with the gut, and having its long axis coincident with 
 that of the gut — and the incision is deepened through the wall of the gut, 
 thus excising an elliptical piece of the intestinal wall, representing the intes- 
 tinal end of the sinus. The escape of intestinal contents is especially guarded 
 during this excision. (6) The wound of the intestine is at once closed by 
 a double row of sutures — a continuous overhand suture of all the coats, thus 
 bringing together the free edges — followed by interrupted Lemberts of the 
 outer coats. (7) The abdominal wound is closed in the usual manner. 
 
 II. Cases in which the operation does not involve the peritoneal cavity- 
 extensive adhesions extending around the sinus, and it being possible to 
 excise the fistula and close the intestinal wound without passing beyond 
 the adhesions: 
 
 Incision. — Same in form as above, but less extensive. 
 Operation. — (i) The operation is conducted as above, except that care 
 is exercised to avoid entering the abdominal cavity, which can be done only 
 when more or less extensive and strong adhesions exist. The sinus is fol- 
 lowed down to its intestinal end by cutting directly through all intervening 
 tissues to the intestinal wall, which is then incised in such a way as to elli] id- 
 eally excise the intestinal end of the fistula — guarding against injury to neigh- 
 boring coils of intestines and viscera. (2) Having excised the sinus without 
 entering the peritoneal cavity, the borders of the wound on a plane with 
 the upper wall of the intestine are inverted and sutured together by inter- 
 rupted chromic gut or silk sutures, applied after the manner of Lembert's 
 59 
 
930 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 approximating surfaces, which, while not peritoneal, have been left raw 
 from the excision of the sinus. The sinus is closed throughout the rest of 
 its extent by deeply buried chromic gut sutures. 
 
 III. In other cases : — 
 
 In cases where large and obstinate spurs exist, or where there has been 
 much loss of intestinal wall — which may be found to be the case after having 
 exposed the parts as in the first category of cases mentioned above, a partial 
 enterectomy may be done, followed by one of the methods of entero-enteros- 
 tomv. Or the necessary calibre of intestine may be gotten by some form 
 of " elbowing, " without excision. Or junction of the involved coil of intestine 
 with a neighboring coil may be secured by lateral anastomosis without partial 
 excision of the intestine, after having closed the wound in the intestine left 
 by excision of the intestinal end of the sinus. Or, where a moderate spur 
 exists, attempts may be made to remove the spur by means of a piece of 
 rubber tubing introduced into the lumen of the gut and held against the 
 spur. Formerly the use of an enterotome, whereby the spur was crushed, 
 was much resorted to. 
 
 ENTEROPLASTY. 
 
 Description. — By enteroplasty is generally understood a plastic operation 
 carried out for the purpose of increasing the calibre of the intestinal lumen 
 in the case of a strictured gut — without resection of the bowel. The technic 
 of the operation is exactly similar to that of pyloroplasty — an axial incision 
 is made through the strictured portion of the gut and this incision is then 
 sutured in a transverse direction. For description and illustration of the 
 principle, see Pyloroplasty, page 984, and Fig. 726. 
 
 Note. — Other methods of increasing the calibre of the narrowed portion 
 of intestine are employed in connection with operations of resection : — Jeannel, 
 after partial enterectomy, cuts the ends of both pieces of intestine obliquely 
 from above downward (the right-hand piece from right to left, and the left- 
 hand piece from left to right) — and then unites their edges by suturing — 
 forming an "elbow," as in the junction of pieces of stove-pipe. Chaput, 
 after performing partial enterectomy, united the ends of the bowels by circular 
 suturing — then made a longitudinal incision through the walls of the united 
 intestines opposite the mesentery and sutured this longitudinal division trans- 
 versely — employing, in the latter part of the operation, the principle of the 
 usual enteroplastic operation. Chaput, by another method, completely 
 divides the bowel obliquely, from above downward and from side to side — ■ 
 forming two oblique ellipses of the same size, but in opposite directions, 
 at the ends of the intestines — followed by union of the intestinal margins. 
 
 OPERATION FOR INTUSSUSCEPTION. 
 
 THE JESSETT-BARKER METHOD. 
 
 Description. — An incision is made through the intussuscipiens over the 
 base of the intussusceptum — and through this incision the intussusceptum is 
 excised, the free ends of the intestine sutured — and the window in the intussus- 
 cipiens closed. 
 
 Preparation — Position — Landmarks — Incision. — As for an abdominal 
 section performed in the special locality indicated. 
 
 Operation. — Having brought the site of intussusception into the field of 
 
OPERATION FOR INTUSSUSCEPTION. 
 
 931 
 
 Fig. 681. — The Jessett-Barker Opera- 
 tion for Intussusception: — I. — The in- 
 tussuscipiens incised, exposing the intussuscep- 
 tum. (Redrawn from unplaced source.) 
 
 Fig. 682. — The Jessett-Barker Opera- 
 tion for Intussusception: — II. — The exci- 
 sion of the intussusceptum. (Redrawn from 
 unplaced source.) 
 
 Fig. 683. — The Jessett-Barker Opera- 
 tion for Intussusception: — III. — The su- 
 turing of the two walls of the intussusceptum. 
 (Redrawn from unplaced source.) 
 
 Fig. 684. — The Jessett-Barker Opera- 
 tion for Intussusception: — IV. — The su- 
 turing of the intussusceptum to the intussus- 
 cipiens, and the closure by suture of the win- 
 dow in the intussuscipiens. (Redrawn from 
 unplaced source.) 
 
932 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 operation the intussuscipiens and intussusceptum are sutured together by a 
 continuous or interrupted seromuscular suture at their line of invagination, 
 including the mesentery (Fig. 681). Through the antimesenteric aspect of 
 the intussuscipiens a longitudinal incision, 5 cm. (2 inches) in length, is made 
 into the lumen of the intestine. Through this opening the invaginated portion 
 of the intestine is drawn out (Fig. 682). It is then divided transversely a 
 short distance above the line of invagination. The free edges of the two 
 concentric ends of intestine are now sutured together by means of an overhand 
 continuous suture — which both controls hemorrhage and unites the serosae 
 of the severed ends (Fig. 683). Sometimes it is easier to deliver the intussus- 
 ceptum if the transverse section be made first. The stump of sutured intestinal 
 ends is now dropped back into the lumen of the intussuscipiens — after which 
 the longitudinal incision in the intussuscipiens is closed by a line of continuous 
 interrupted sutures — reinforced, if necessary, by a row of Lembert stitches, 
 interrupted or continuous (Fig. 684). 
 
 Comment. — (i) As the transverse section of the invaginated portion is 
 being made, the free ends are clamped and held in the field until the sutures 
 are placed. (2) If the invaginated portion of intestine cannot be detached 
 readily, efforts should be made to free it by manipulation or by the passage of 
 a long probe or sound between the walls of the two pieces of intestine. Failing 
 in this, the transverse section may still be made, leaving the invaginated bowel 
 to be passed — or the entire involved intestinal area may be excised. 
 
 COLOPEXY. 
 
 BRYANT'S METH< )D. 
 
 Description. — In this operation some part of the colon is elevated and 
 attached to the abdominal wall by suturing. Colopexy of the transverse 
 colon to the anterior abdominal wall is done in some cases of Enteroptosis. 
 Colopexy of the sigmoid flexure of the colon to the antero-lateral abdominal 
 wall is sometimes done for Prolapsus Recti. This latter operation will be 
 here considered. 
 
 Preparation — Position. — As for median abdominal section. 
 
 Landmarks. — Outer part of Poupart's ligament. 
 
 Incision. — About 7.5 cm. (3 inches) — parallel with and about 2.5 cm. 
 (1 inch) above the outer part of Poupart's ligament — being extended upward 
 if more room be necessary. 
 
 Operation. — (1) The above incision is carried clown to and through the 
 peritoneum — clamping and tying all bleeding vessels as encountered. (2) 
 After having opened the abdominal cavity, the parietal peritoneum is separated 
 from the edges of the abdominal wound for about 2.5 cm. (1 inch) on each 
 side, the width of separation being somewhat greater above than below — 
 the separated peritoneum thus forming two flaps. (3) The rectum is now 
 pulled well upward, reducing all prolapse — and, at the same time, any adjacent 
 laxity of the colon is pulled down. While the rectum is being drawn firmly 
 upward, the parietal peritoneal flaps are sutured to the serous and muscular 
 coats of the rectum by quilting and continuous silk sutures. (4) About half 
 a dozen silk sutures are then passed in the following order — through all the 
 layers of the edges of the abdominal wound — through the peritoneal flap of 
 that side — then through the serous and muscular coats of the intestine, passing 
 
RECTOPEXY. 933 
 
 behind the longitudinal band — out through the peritoneal flap of the opposite 
 side — and then through all the tissues of the corresponding edge of the ab- 
 dominal wound. These deep sutures are then drawn tight and tied — thus 
 bringing the longitudinal band and a part of the intestinal wall into contact 
 with the abdominal wall — and approximating the borders of the wound so 
 that they grasp the longitudinal band and part of the wall of the gut — and, 
 at the same time, closing the abdominal wound. 
 
 RECTOPEXY. 
 
 VERNEUIL'S METHOD. 
 
 Description. — Rectopexy, or Proctopexy, consists in the suturing of the 
 prolapsed rectum back to its posterior bed. 
 
 Preparation. — Bowels emptied; perineum shaved; prolapse replaced. 
 
 Position. — Patient in lithotomy position; Surgeon seated in front of 
 perineum; Assistant to one side. 
 
 Landmarks. — Anus; tip of coccyx; ischial tuberosities. 
 
 Incision. — Two straight incisions of about 2.5 cm. (1 inch) in length 
 are made directly outward from the mid-lateral aspect of the anal orifice 
 (at right angles to the median perineal line). Two other incisions are, later, 
 made from the tip of the coccyx to the outer ends of the two lateral incisions. 
 
 Operation. — (1) Deepen the lateral incisions through the skin and ex- 
 ternal sphincter. (2) Deepen the posterior incisions through skin, fascia, 
 and external sphincter, raising a triangular flap attached at its base to the 
 tissues of the posterior aspect of the anal orifice — and displace this flap for- 
 ward, and hold it out of the way by retractors or skin sutures. (3) Detach 
 the posterior wall of the rectum, by blunt dissection, from the anus to the 
 tip of the coccyx, and for the width of 5 to 6.5 cm. (2 to 2 J inches). (4) 
 Pass four rather stout silk sutures transversely through the posterior wall 
 of the rectum, going through its outer coats, for as nearly the whole width 
 of the posterior aspect of the rectum as possible, leaving both ends of the 
 sutures free. These sutures are parallel, the highest being opposite the 
 tip of the coccyx, the lowest about 1.5 cm. (f inch) from the anus, and the 
 others equidistant between. (5) Pass a Reverdin needle (or other needle with 
 eye at point) from the skin without to the denuded surface within — the punc- 
 tures being made about 4 cm. (ih inches) from the median line on each side, 
 and above the particular thread to be drawn through — the uppermost sutures 
 coming out through the skin on a level with the sacro-coccygeal articulation, 
 and the lowermost opposite the tip of the coccyx. Each end of each suture is 
 then threaded through the eye of the needle, in turn, and thus drawn through 
 the thickness of the posterior pelvic wall. (6) The free ends of these sutures 
 are then tied together over a firm pad of gauze (to avoid burying into and 
 cutting the skin) — either the. opposite ends of each suture being tied trans- 
 versely together — or the ends of the first and second, and of the third and 
 fourth, tied together in a vertical line on either side. Rather strong traction 
 is made during suturing — to approximate and retain the posterior aspect of 
 the denuded rectum in contact with the anterior aspect of the denuded pelvic 
 wall. (7) Suture the triangular flap back into place— narrowing, at the same 
 time, the anus, by suturing the inner ends of the lateral incisions somewhat 
 further inward than normal — freshening the margins of the anus sufficiently 
 
934 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 for the purpose (the original incisions may be planned with reference to 
 narrowing the anus). 
 
 Comment. — The same object maybe accomplished by Tuttle's somewhat 
 similar operation; — and also by Peter's operation of opening the abdomen, 
 narrowing the barrel of the rectum by invaginating a vertical strip of its 
 anterior wall by Lemberts, and then stitching the rectum to the abdominal 
 wall; — as well as by other procedures. 
 
 INTERNAL RECTOTOMY. 
 
 Description. — Rectotomy, or Proctotomy, consists in the division of the 
 rectum for constriction, obstruction, or the removal of a foreign body. In 
 Internal Rectotomy the rectum is divided from within — and is generally done 
 for stricture of its lower part. 
 
 Preparation. — Bowels emptied; anal region shaved; and, at time of 
 operation, gauze packing of rectum above, with end of gauze, or attached 
 silk ligature, held ready for withdrawal. 
 
 Position. — Patient in lithotomy position; Surgeon sits opposite peri- 
 neum; Assistant to one side. 
 
 Landmarks. — Anus; known course of rectum. 
 
 Operation. — Insert an anal speculum, which, when opened, will expose 
 the site of stricture — introduce a straight, narrow bistoury through the specu- 
 lum and divide the strictured site in the posterior median line until healthy 
 tissue is reached, cutting backward from above downward — cutting through 
 sphincters if necessary. Any vessels which bleed markedly are tied. The 
 wound is packed — and the gauze withdrawn. Some form of dilator is worn 
 for a time after the operation. 
 
 EXTERNAL RECTOTOMY. 
 
 Description. — In the operation of External or Posterior Rectotomy, or 
 Proctotomy, the rectum is opened from without and from behind — generally 
 for the removal of foreign bodies, tumors, or the division of strictures — and 
 usually gives a fuller and higher exposure than Internal Rectotomy. 
 
 Preparation — Position. — As for Internal Rectotomy. 
 
 Landmarks. — Anus; tip of coccyx; known course of rectum. 
 
 Incision. — An external incision is made from the tip of the coccyx (or 
 from somewhat below it, according to circumstances) down the median line 
 to and through the anus. 
 
 Operation. — (i) The above incision is first made through the superficial 
 parts — and all bleeding controlled. (2) A finger is then placed in the rectum, 
 or a special guide, and upon this the whole thickness of the posterior pelvic 
 wall, from tip of coccyx to anus, is divided. (3) Having completed the 
 division of the rectum and accomplished the special object, the wound is 
 treated as indicated. In cases where the operation has been for the removal 
 of foreign body, the walls of the rectum are to be carefully brought together 
 by suture (chromic gut) — and then the tissues between the rectum and the 
 skin, including the latter, are brought together by sdk sutures. Where the 
 operation has been performed for stricture, the walls of the rectum are, of 
 
EXCISION OF THE RECTUM BY THE SACRAL ROUTE. 935 
 
 course, not reunited — a light packing is placed between these to prevent 
 their reunion — and then the tissues intervening between the intestinal wall 
 and the skin, including the latter, are sutured with silk — leaving a tem- 
 porarv opening below that no accumulation of discharge within the extra- 
 intestinal tissues may take place. 
 
 EXCISION OF THE RECTUM IN GENERAL. 
 
 Rectectomy, or Proctectomy, consists in the excision of the rectum, in 
 whole or in part. It is generally resorted to for malignant disease, in cases 
 where there is little or no involvement of neighboring viscera or lymphatic 
 glands. The operation may be done through the perineum — through the 
 sacrum — through the vagina — by the abdomen — or by the combined abdomi- 
 nal and perineal routes. Proctectomy may be partial or complete. 
 
 Partial Proctectomv by the perineal route is generally confined to cases 
 in which the malignant growth is within 10 cm. (4 inches) of the anus — and, 
 in women, in which the anterior rectal wall is not involved higher up than 
 7.5 cm. (3 inches). With some the indication for the perineal route is a 
 growth within 5 cm. (2 inches) of the anus. Moderately high growths are ap- 
 proached by the sacral route. Very high involvements may be approached 
 by the combined perineal and abdominal routes. 
 
 If uninvolved, the sphincters should be preserved — provided their nerve- 
 supplv, which reaches them from their lateral aspects, can be retained intact — ■ 
 and subsequently the proximal end of the rectum should be attached to the 
 distal end containing the sphincters. 
 
 The division of the sacrum as high as the lower border of the third sacral 
 foramen may be done without serious injury to, or serious functional impair- 
 ment of, neighboring structures. But division as high as the third sacral 
 foramen has been followed by paralysis of the bladder. 
 
 A wide removal of circumanal and circumrectal tissues is indicated in all 
 malignant involvement. If involved, the prostate gland, part of the bladder, 
 or the rectovaginal septum, should be removed. 
 
 EXCISION OF THE RECTUM BY THE SACRAL ROUTE 
 
 BV PARTIAL EXCISION OF SACRUM — KRASKE'S OPERATION. 
 
 Description. — Kraske, having incised through the soft tissues vertically 
 downward from the second sacral spine to the anus and bared the coccyx 
 and left lower part of the sacrum, excised the coccyx — entirely divided the 
 sacrosciatic ligaments and completely excised the left lower portion of the 
 sacrum along a line curving from the left margin of the sacrum (on a level 
 with the third sacral foramen) along the lower border of the third sacral 
 foramen to the left inferior corner of the sacrum — and thus exposed and 
 excised the rectum. 
 
 This operation subsequently became the basis of various modifications. 
 Hochenegg, Bardenheuer, and others have extended the line of excision trans- 
 versely across the entire sacrum on a level with the lower border of the third 
 sacral foramen. Heinecke, Rehn, Rydygier, and others converted the partial 
 excision into an osteoplastic resection of the sacrum and coccyx — by a para- 
 sacral incision just outside of, and parallel with, the left border of the sacrum 
 
936 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 and coccyx, followed by a transverse division of the sacrum just below the 
 third sacral foramen — the flap thus formed being temporarily turned aside 
 to the right, hinging upon its partly broken and partly bent tissues — and 
 being subsequently replaced in position. 
 
 Preparation. — (i) A preliminary left inguinal colostomy is done by 
 many surgeons some daws in advance — insuring greater cleanliness of the 
 part during operation and the avoidance of fecal soiling for some days after- 
 ward. It is desirable in the majority of cases. Previous purgation and 
 irrigation of the lower bowel for two or three days immediately preceding 
 operation. (2) At the time of operation, high irrigation and swabbing out 
 of the bowel — and often rectal packing placed high up, above the site of 
 disease. Bladder emptied. Perineum shaved. The sphincter ani is para- 
 lyzed by digital distention. 
 
 Position. — Patient is held in the knee-chest position by means of upright 
 
 supports at end of table, 
 being suspended from 
 these from just below 
 the hip-joints, while the 
 chest is supported by 
 a cushion. The right 
 latero-prone, or the 
 exaggerated lithotomy, 
 position may also be 
 used. 
 
 Landmarks. — Anus ; 
 coccyx; sacral spines; 
 posterior superior and 
 inferior iliac spines; 
 known course of rec- 
 tum. 
 
 Incision. — In the 
 mid-line — from the sec- 
 ond sacral spine to the 
 posterior margin of the 
 anus. (See Fig. 685.) 
 
 Operation. — (1) 
 The above incision 
 passes directly to the 
 bone over sacrum and 
 coccyx — hemorrhage 
 being controlled by 
 clamp forceps. (2) The overlying soft parts are retracted outward to the left, 
 exposing the left side of the sacrum and coccyx, and from the right side of the 
 coccyx. (3) The gluteus maximus and sacrosciatic ligaments are detached 
 from both sides of the coccyx and from the left side of the sacrum. The 
 coccygei and part of the left piriformis are also detached. If it be intended 
 to remove the anus, the external sphincter and levator ani are also removed. 
 (4) Pass a periosteal elevator beneath the sacrum (in contact with its anterior 
 surface) and detach the soft parts from the hollow of the bone, and the sacra 
 media vessels and venous plexus along with them. (5) The coccyx and as much 
 of the sacrum as considered necessary are now removed. (See Fig. 686.) To 
 accomplish this the soft parts are strongly retracted to the left and the sacrum 
 is divided with chisel and mallet, or by very strong bone-cutting pliers, or 
 
 Fig. 685. — Excision of Rectum by the Kraske Opera- 
 tion : — Subject in knee-chest position. Skin-incision shown in 
 median heavy line, from second sacral spine to posterior margin 
 of anus. Bone-section shown in dotted line crossing transversely 
 just below third sacral foramina. Position of rectum shown in 
 dotted outline. The above line is the modification of Hochenegg 
 and Bardenheuer. 
 
EXCISION OF THE RECTUM BY THE SACRAL ROUTE. 
 
 937 
 
 by Gigli saw — passing, generally, from the left edge of the sacrum on a level 
 with a point just below the left third posterior sacral foramen, curving inward 
 and downward directly through the left fourth posterior sacral foramen to 
 the left lower corner of the sacrum — thus neither harming the anterior division 
 of the third sacral nerve, nor opening the sacral canal. The hemorrhage, 
 which is chiefly from the lateral sacral, middle sacral, and hemorrhoidal 
 
 Fit;. 686. —Excision of Rectum by Sacral Route— Kraske Operation :— A, Gluteus maxi- 
 mus ; B, Great sacrosciatic ligament ; C, Lesser sacrosciatic ligament ; D, Pyriformis ; E.Coccygeus; 
 F, Levator ani ; G, External sphincter; H, Sciatic artery; 1. Internal pudic artery; J, Branches of 
 internal pudic artery and pudic nerve; K, Coccyx ; L, Fourth sacral foramen ; M, Gigli saw dividing 
 sacrum just below third sacral foramina. 
 
 arteries, and anterior and posterior venous plexus, and the bone, is controlled 
 by pressure until the bone is removed — and subsequently by catch-forceps 
 and ligature. (6) Having thus exposed the pelvic cavity, incise the tissues 
 in the middle line down to and through the levatores ani, until the rectum 
 is reached. (7) The external sphincter and anus are generally left, if the 
 
938 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 site of involvement be as much as 2.5 cm. (1 inch) above the former. (8) 
 The rectum is now "shelled out" by blunt dissection. This "shelling out" 
 can be readily carried out behind and on the sides. The size of the rectum 
 may prevent the passage of the finger completely around it — and the attach- 
 ments of the peritoneum and mesorectum will prevent its being drawn down- 
 ward very far. (See Fig. 687.) (9) Having thus isolated the rectum, it 
 should be divided transversely at least 2.5 cm. (1 inch) below the lowest 
 
 Fig. 687.— Excision of Rectum by Sacral Route (Kraske Operation) — Part of Sacrum 
 and Coccyx Removed and Divided Rectum Turned Down : — Unlettered structures are same 
 as in Fig. 439. A, Section of sacrum below third sacral foramina ; B, Peritoneum; C, Vesiculse semi- 
 nales ; D, Vasa deferentia ; E, Recto-vesical layer of pelvic fascia ; F, Upper end of severed rectum ; 
 G, Lower end of divided rectum retracted downward ; H, Cancerous growth of rectum ; 1,1. Middle 
 sacral artery and branches; J, J, Superior hemorrhoidal arteries; K, Middle hemorrhoidal artery (and 
 same on opposite side;. 
 
 margin of disease. In order to retain command of the upper end, just prior 
 to dividing the rectum a stout circular ligature may be thrown around it 
 just beneath the involved area — or, simultaneously with the division, sutures 
 may be placed through the cut walls of the upper end. (10) The separation 
 of the rectum is now continued by blunt dissection, guided, in the male, 
 by a sound in the bladder, while separating the rectum from the prostate 
 
EXCISION OF THE RECTUM BY THE SACRAL ROUTE. 939 
 
 and bladder — and, in the female, by an assistant's finger in the vagina, in 
 separating the rectum from the vagina — controlling hemorrhage by pressure. 
 (11) When the peritoneal reflection upon the anterior aspect of the rectum 
 is reached, if it do not extend too high it may be found possible to protrude 
 this reflection upward with the finger and thus not have to open the peri- 
 toneum. If the growth extend above the reflection, the peritoneum must be 
 opened, and is, accordingly, freely incised. (12) The mesorectum and pre- 
 sacral areolar tissue now alone hold the rectum — and these are separated 
 and loosened upward by blunt dissection, while the bowel is gently drawn 
 downward. (13) Having freed the rectal surfaces for about 2.5 to 5 cm. 
 (1 to 2 inches) above the growth and clamped it at this site, and having 
 packed off the neighboring regions with gauze, it is divided at least 2.5 cm. 
 (1 inch) above the disease — dividing the mesorectum and presacral areolar 
 tissues on the same level. All bleeding is now controlled by clamp forceps 
 and ligature. (14) If the peritoneum have been opened during operation, a 
 small wound of the structure is to be at once sutured, with or without drainage, 
 as indicated — a large rent may be partly sutured and partly packed with 
 gauze, or entirelv packed. (15) Having completed the excision of the dis 
 eased portion of rectum, controlled hemorrhage, and repaired any damage 
 done the peritoneum, the ends of the gut are to be treated according to the 
 circumstances of the case and the special views of the operator. Considerable 
 difference of opinion exists as to the management of the ends of the intestine — 
 some of the views being here summarized: — (A) If the Sphincters and Anus 
 Have Been Retained; — (a) Direct suturing of the divided ends may be done. 
 Kraske sutures the anterior and lateral portions by a double tier of sutures, 
 one through the mucous membrane only, and one through all the coats — 
 while he inverts the posterior portion by a single tier not passing through 
 the mucous membrane, (b) The ends may be united by a Murphy button. 
 (c) Moulouguet carefully removes the mucous membrane of the lower portion 
 of the rectum (avoiding injury to the external sphincter) — and draws through 
 this lower portion the upper end and sutures its borders to the border of 
 the anus, controlled by its sphincter. (B) If the Sphincters and Anus be 
 Sacrificed; — (a) The upper end of the divided rectum is sutured into the 
 upper posterior angle of the wound, (b) Gersuny twists the upper end 
 of the rectum upon its long axis (to give some difficult}- to the fecal passage) 
 if it be long enough, and sutures it into the skin, (c) \\itzel draws the 
 upper end of the rectum through a short incision just above the free border 
 of the gluteus maximus and sutures its edge to the skin (to gain some muscular 
 control). 
 
 Comment. — (1) The coccyx alone should be first removed — as that may 
 furnish sufficient room. (2) The superior hemorrhoidal vessels (bifurcating 
 from the inferior mesenteric artery in the median line between the layers 
 of the mesorectum) run very near the muscular layer of the intestine, and 
 by cutting in the loose areolar tissue just under the peritoneum these vessels 
 are avoided and the upper rectum easily freed from the wall of the pelvis. 
 The high division of these vessels is apt to be followed by necrosis of the 
 gut. (3) In the male, with empty bladder, the rectovesical peritoneal re- 
 flection is generally about 7.5 cm. (3 inches) above the anus. A full bladder 
 raises the reflection about 2.5 cm. (1 inch). The tip of the coccyx is below 
 the level of this reflection. (4) The peritoneum nearly entirely surrounds 
 the rectum at the level of the third sacral foramen, a distinct mesorectum 
 existing — loose areolar tissue connecting the intestine to the sacrum and 
 coccyx where the peritoneum is absent. (5) A truss and pad are worn 
 
94o 
 
 OPERATIONS UPON THE AI!I)OMIN< >-I'ELVIC REGION. 
 
 where a sacral anus is made. (6) Keen performs a preliminary inguinal 
 colostomy, which is permanent — and closes the lower opening entirely. (7) 
 Fig. 687 represents the complete transverse division of the sacrum. 
 
 EXCISION OF THE RECTUM BY THE SACRAL ROUTE. 
 
 BY THE REHN-RYDYGIER OSTEOPLASTIC FLAP METHOD. 
 
 Description. — See the description given under Kraske's excision of the 
 rectum by the sacral route. 
 
 Preparation — Position — Landmarks. — Same as in Kraske's operation, 
 above given. 
 
 Incision. — (1) An oblique parasacral incision is first made, beginning 
 opposite the center of the sacrum, passing along just to the outer side of 
 
 the left border of the sacrum 
 and coccyx to the tip of the 
 coccyx — and thence along the 
 mid-line of the perineum 
 nearly to the anus. (2) A 
 second incision is then car- 
 ried transversely across the 
 sacrum about 4 cm. (1^ 
 inches) above the sacro-coc- 
 cygeal articulation. (See Fig. 
 688.) 
 
 Operation. — (1) The ob- 
 lique incision passes down- 
 ward from the posterior supe- 
 rior iliac spine along the 
 outer border of the sacrum 
 and coccyx — the transverse 
 incision passing at once to 
 the sacral bone. All bleed- 
 ing vessels in the lines of in- 
 cision are clamped. (2) Ex- 
 pose and divide the gluteus 
 maximus and the greater and 
 lesser sacrosciatic ligaments 
 of the left side, along the 
 oblique incision. (See Fig. 689.) (3) The transverse incision is further 
 deepened until the irregular depressions and elevations of the posterior 
 aspect of the sacrum are exposed in the bed of the transverse wound. 
 (4) By means of a curved elevator and blunt dissector the soft parts in 
 the hollow of the anterior surface of the sacrum are raised from the bone, 
 clearing the anterior surface of the sacrum below the level of the third sacral 
 foramina. (5) The sacrum is now divided transversely just below the third 
 sacral' foramina by means of chisel or saw — and the osteo-cutaneous flap 
 thus freed is then prized over to the right, hinging along a line corresponding 
 with the right sacro-coccygeal border — and the posterior aspect of the rectum 
 is thus exposed. All hemorrhage is now controlled by clamp and ligature 
 before proceeding. (6) The subsequent steps of the operation are practically 
 the same as in Kraske's operation (q. v.). (7) Where union between the 
 two segments of the rectum can be accomplished at the end of the operation, 
 
 Fig. 688.— Osteoplastic Resection of Rectum by 
 the Rehn-Rydygier Operation: — Patient in knee-chest 
 position. Rectum shown in outline. Skin-incision in 
 heavy oblique and vertical line. Bone-section in trans- 
 verse dotted line. 
 
EXCISION OF THE RECTUM BY THE SACRAL ROUTE. 
 
 941 
 
 this is secured as described under Kraske's operation — followed by the re- 
 position of the bone-flap in place and the holding of it there by the passage 
 of chromic gut sutures through its periosteal and aponeurotic structures — 
 accompanied by temporary gauze drainage. If union of the ends cannot 
 be accomplished, the upper end may be brought down and anchored as 
 low in the wound as possible, by sutures, the wound cavity packed, and 
 no attempt made to suture the bone-flap in place. Granulation then occurs, 
 with some retraction of the flap, but a useful result generally follows. Or, 
 where the growth cannot be all removed, or a greater gap is left between 
 the segments than foreseen, the bone-flap may be entirely detached and 
 
 * 
 
 Fig. 689.— Osteoplastic Resection of the Rectum— Rehn-Rydygier Operation: — Show- 
 ing flap of part of sacrum, coccyx, and overlying soft parts temporarily displaced to right. Unlettered 
 structures are same as in Figs. 686 and 687. 
 
 discarded (constituting a sacral excision of the lower portion of the bone) 
 and the upper end of the gut anchored in the upper angle of the external 
 wound — which is then closed throughout the balance of its extent, except 
 at the site- where drainage is established. 
 
 Comment. — The osteoplastic method of exposing the rectum is preferable 
 where it is possible — but if the flap of bone be in the way of the operation 
 itself, or in the way of the subsequent management of the case, it should 
 be removed — and the operation converted into a partial excision. The tem- 
 porary bony resection preserves the posterior support of the levatores ani. 
 
942 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 It probably does not furnish quite as much room as the method by partial 
 excision; the bone-flap may necrose; there is no room for a sacral anus, 
 where this is indicated, except by total or partial removal of the bone-flap. 
 
 EXCISION OF THE LOWER PART OF THE RECTUM BY THE 
 PERINEAL ROUTE. 
 
 Description. — The excision of the lower portion of the rectum by the 
 perineal route is usually confined to cases in which the cause of removal is 
 within finger's reach of the anus. 
 
 Preparation.-— Purgation; irrigation of the lower bowel; rectal packing; 
 bladder emptied; perineum shaved. 
 
 Position. — Patient in exaggerated lithotomy position, or in Sims' posi- 
 tion. Surgeon standing, or sitting, in front of perineum. 
 
 Fig- 69c. —Excision of Lower Rectum by Perineal Route :— Line of incision. 
 
 Landmarks. — Anus; tip of coccyx; and, later, position of bladder, pros- 
 tate, vagina, and rectum. 
 
 Incision. — Two lateral oval incisions are made — almost, but not quite, 
 meeting in front of the anus — being continued backward around the sides 
 of the anus in the ilio-rectal fossae to meet behind the anus — and prolonged 
 thence in the mid-line to the tip of the coccyx. (See Fig. 690.) 
 
 Operation. — (1) The incision passes directly into the ilio-rectal fossae — 
 and is followed by blunt dissection (with finger and blunt dissector) of the 
 lower end of the rectum up to the levatores ani — the bleeding being controlled 
 by catch-forceps and gauze-mops upon sponge-holders pressed into the 
 wound. (See Fig. 691.) (2) In the male, guided by the sound in the bladder, 
 the rectum is carefully separated from the bladder, prostate, and urethra, 
 to which it is rather closely adherent. The index-finger of an assistant 
 in the rectum, with thumb toward bladder, aids the surgeon in this separation, 
 
EXCISION OF RECTUM BY PERINEAL ROUTE. 
 
 943 
 
 (3) In the female, an assistant's index in the vagina aids the operator in 
 separating the rectum from that organ. (4) Guard against opening the 
 reflection of peritoneum — and, if opened, suture at once, if small — and pack 
 with gauze, if the opening be large. (5) The levatores ani are now divided — - 
 and the rectum thus freed everywhere but above. All bleeding vessels are 
 clamped or ligated before beginning the freeing of the rectum. (6) During 
 gentle downward traction of the bowel it is further freed by blunt dissection 
 and scissors. Having clamped the bowel above (to retain control and also 
 
 Fig. 69 1. — Excision of Lower Rectum by Perineal Route : — A, Anus; B, Coccyx; C, 
 Margin of wound, showing transverse perineal vessels anteriorly, and infei ior hemorrhoidal vessels 
 posteriorly; D, External sphincter; E, Levator ani ; F, Rectum being treed by blunt dissector (G) 
 and by traction with ringer (H)— (cancerous growth is shown at roughened portion of rectum). 
 
 to avoid soiling), it is divided transversely about 2.5 cm. (1 inch) above and 
 below the growth. Where possible, the sphincters and anus should be pre- 
 served. (7) All hemorrhage having been controlled, the question of the 
 management of the ends of the intestine must be decided: — (a) Where the 
 Sphincters and Anus are Left; — The upper end is brought down and sutured 
 to the lower by one of the methods of entero-enterostomy; (b) Where the 
 
944 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Sphincters and Anus are Removed; — The upper end may be displaced back- 
 ward and sutured between the levatores ani in the position of a subcoccvgeal 
 anus — the wound in front being closed by deep and superficial sutures, the 
 deep sutures including the levatores ani so as to form a sphincteric anus. 
 
 OPERATION FOR THE CURE OF HEMORRHOIDS BY LIGATION 
 AND EXCISION. 
 
 ALLINGHAM'S METHOD. 
 
 Description. — Consists in the isolation and freeing of the pile by dis- 
 section, until its true pedicle is reached — around which pedicle a ligature 
 is placed and the pile cut off below it. This form of operation is especially 
 indicated in isolated piles, and particularly those of columnar outline. 
 
 Preparation. — Purgation; rectal irrigation; circumanal region shaved; 
 dilatation of anus immediately preceding excision. 
 
 Position. — Patient in lithotomy position at end of table; Surgeon seated 
 opposite perineum; Assistant to surgeon's side. Patient may lie upon side, 
 with knees drawn up. 
 
 Landmarks. — Anus; hemorrhoidal tumors. 
 
 Operation. — (i) For the purpose of dilating the anal orifice, both thumbs, 
 lubricated, are inserted into the bowel, knuckle to knuckle — and, grasping 
 the ischial tuberosities on each side with the fingers, the surgeon carefully 
 and slowly separates the thumbs to the desired extent, consuming about 
 two minutes in the process. (2) Having thoroughly dilated the anal orifice, 
 the interior of the lower rectum is examined with the index-finger, and the 
 number, nature, and position of the hemorrhoids determined. (3) Beginning 
 with those upon the lower, posterior aspect (that bleeding may not obscure 
 the operation), each pile is seized with toothed forceps and drawn downward 
 and away from its attachment, putting this attachment upon gentle stretch. 
 (4) While the pile is thus held, a pair of blunt-pointed scissors (straight or 
 curved, as more convenient) is made to dissect the pile up from the sub- 
 cutaneous tissue by limited snips, beginning below at the line of muco- 
 cutaneous junction and proceeding upward in the long axis of the bowel, 
 until a point is reached where the pile is attached by the normal mucous 
 membrane and by its blood-vessels, which now form its pedicle. Up to 
 this stage but few vessels have been encountered and but little bleeding 
 occurs. (5) While the pile is thus held by an assistant, a friction-knot of 
 chromic gut is thrown around the pedicle of the pile and pushed as high 
 up as possible — this friction-knot is drawn tight and a second knot is added. 
 (6) The hemorrhoid is then cut off, with scissors or knife, just far enough 
 below the ligature to insure its retention. This procedure is repeated upon 
 as many piles as are present. (See Fig. 692, A and B.) 
 
 Comment. — (1) Piles are classed as "External," below the pressure of 
 the external sphincter; — "Internal," above the pressure of the external 
 sphincter; — " Interno-external, " partly above and partly below the grasp 
 of the external sphincter. (2) The vessels which supply hemorrhoids come 
 from above and run just under the mucous membrane, entering the upper 
 portion of the pile — which facts have a direct bearing upon the manner of 
 partially separating hemorrhoids preparatory to ligation or excision. (3) 
 Where closelv placed piles form more or less of a circle around the anus, 
 they are separated by incisions made through the mucous membrane, and 
 then each pile is ligated separately, as above described. (4) It is par- 
 
OPERATION FOR HEMORRHOIDS BY LIGATION. 
 
 945 
 
 ticularlv important to include no part of the skin within the grasp of the 
 ligature, as much and prolonged pain, from the inclusion of nerve filaments, 
 may follow. Such inclusion is impossible if the ligature be not applied 
 until the pile is freed up to its natural pedicle (5) It is well to suture up 
 with fine catgut the furrows in the submucous tissue left by the snips of 
 the scissors in dissecting the hemorrhoid from its bed. (See Fig. 692, C.) 
 
 Fig. 692.— Operation for Hemorrhoids by Ligation and Excision :— A, Hemorrhoid ex- 
 cised from its bed and ligature thrown around its pedicle ; B, Tract left to granulate after the ordinary 
 operation of removal by ligation and excision; C, Former tract, left after ligation and excision, 
 sutured so as to approximate edges and promote primary union. 
 
 OPERATION FOR THE CURE OF HEMORRHOIDS BY EXCISION. 
 
 WHITEHEAD'S OPERATION. 
 
 Description. — Consists in the excision of the pile-bearing segment of 
 mucous membrane, together with its piles — followed by the immediate suturing 
 of the divided mucous membrane above to the skin below. This form of 
 operation is especially indicated in those cases of hemorrhoids where a circle 
 of large and irregular piles more or less completely surrounds the anal orifice. 
 
 Preparation — Position— Landmarks. — As in the operation by ligation 
 above described. 
 
 Operation. — (1) Having dilated the anal orifice, as described under the 
 ligature operation, the pile-bearing segment of mucous membrane is seized 
 with forceps and put upon gentle stretch. (See Fig. 693.) (2) While thus 
 held, and beginning at the lowest portion of the circle and proceeding, pari 
 passu, up the two sides, the mucous membrane is divided with scissors exactly 
 along the muco-cutaneous line — passing entirely around the circumference of 
 60 
 
946 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 the anal opening and accurately following in and out along every irregularity 
 of the skin. (3) Working by rapid dissection along the submucous plane 
 with the closed end of blunt scissors, the external sphincter is first exposed 
 and then the beginning of the internal sphincter — and the mucous mem- 
 brane, with the attached hemorrhoids, separated from their bed of sub- 
 mucous tissue, are drawn down below the skin margin — all restraining points 
 of connective tissue being divided. (4) The mucous membrane just above 
 the hemorrhoids is now cut transversely, a small extent at a time — and the 
 limited part of the mucous membrane thus freed above is immediately 
 stitched witli silk to the free border of skin below, which has been divided 
 along the muco-cutaneous line of the primary incision. Following this, 
 another area of mucous membrane is cut free above — and at once sutured 
 
 Fig. 693— Whitehead's Operation for Hemorrhoids: — A, Pile-bearing segment of mucous 
 membrane being dissected away with scissors, while held upon the stretch with forceps ; B, Sutures 
 approximating mucous membrane above, to skin below. 
 
 to the skin below — and thus on around the circle — until the circumference 
 of pile-bearing mucous membrane is removed. 
 
 Comment. — All bleeding vessels are controlled, by Whitehead, by torsion 
 during these steps. The chief hemorrhage tends to come from the vessels 
 divided in the transverse division of the mucous membrane and pedicle of 
 the pile above — and this bleeding is largely controlled by the immediate 
 suturing of the free border of the mucous membrane to the free margin of 
 the skin. There is no reason why fine catgut ligatures should not be used 
 where considered necessarv. 
 
 OPERATION FOR THE CURE OF HEMORRHOIDS BY THE CLAMP AND 
 
 ACTUAL CAUTERY. 
 
 Description. — Consists in the cauterizing, at red heat, of the hemor- 
 rhoidal growth — while held in the grasp of special clamp-forceps. This 
 
OPERATION FOR FISTULA-IN-ANO BY INCISION. 947 
 
 form of operation may be applied to piles in general — but is more especially 
 indicated in simple venous piles of medium size. 
 
 Preparation — Position — Landmarks. — As in the ligature method. 
 
 Operation. — (1) Having dilated the anus, each pile in turn, or a cluster 
 of piles, is seized with toothed forceps and drawn downward and away from 
 its attachment. (2) Divide the muco-cutaneous border, if there be one, with 
 blunt-pointed scissors or knife (that nerve-filaments may not be included 
 in the grasp of the clamp). (3) Apply the clamp, with the pile still under 
 gentle traction, to the base of the tumor, and in the axis of the gut — the 
 clamp resting in the cut groove at the muco-cutaneous border, if the pile 
 be one having a cutaneous part. The blades are then screwed together 
 sufficiently firmly to thoroughly compress the parts. (4) With a pair of 
 curved scissors, cut away the excess of hemorrhoid which projects above the 
 clamp. Then, with a Paquelin 01 other cautery at red heat, slowly and 
 thoroughly cauterize the stump of the pile. As the clamp is loosened, follow 
 down the escaping pile-stump with the point of the cautery — seeing that all 
 hemorrhage is controlled. If necessary to make the hemostasis complete, the 
 stump may be again clamped and again cauterized. This process is repeated 
 until all the piles or clusters have been cauterized. 
 
 Comment. — Where the piles are in the form of a more or less complete 
 circle surrounding the anus, they should be divided into segments or groups 
 by incision of the mucous membrane prior to clamping and cauterizing. 
 Avoid burning the skin — or detaching the eschars, thereby favoring hemor- 
 rhage. 
 
 OPERATION FOR THE CURE OF FISTULA-IN-ANO BY INCISION. 
 
 Description. — Consists in the laying open of the fistulous tract upon a 
 grooved director — followed by the curettage of the sinus-walls — and light 
 gauze packing of the raw bed to promote healing from the bottom and ob- 
 literation of the fistula, — or excision of tract with suture of its bed. 
 
 Preparation. — Purgation; rectal irrigation; shaving of circumanal re- 
 gion; dilatation of the sphincter just before operation, in the more compli- 
 cated cases. 
 
 Position. — Patient in the lithotomy position, with nates over the end 
 of the table; surgeon sitting opposite the perineum. 
 
 Landmarks. — Anus; rectum; course of fistula and position of openings 
 determined in advance, if possible. 
 
 Operation. — (1) A grooved director is passed through the sinus, from its 
 skin opening — made to traverse its length and emerge through its internal 
 opening within the bowel — and the end of the director is then caused to 
 project through the anus by directing its tip with the left index-finger within 
 the rectum, while its handle is depressed with the right hand. The external 
 and internal openings of the fistula are then in plain view — with the grooved 
 director passing through its entire length. (See Fig. 698, A.) (2) Upon the 
 grooved director a narrow, pointed knife is passed (or a probe-pointed bis- 
 toury may be used) with its cutting-edge directed outward — thus incising 
 the fistula throughout its entire course — freeing the grooved director and 
 allowing the parts to recede into their normal positions. (3) The lips of 
 the wound and of the sinus are then separated by the operator's left thumb 
 and index — and, while thus exposed, the entire extent of the fistula should 
 be scraped with a curette, so as to remove its old wall — and then Lightly 
 packed with gauze and allowed to heal from the bottom. A T-bandage 
 
94 8 
 
 OPERATIONS I TON THE ABDOMINO-PELVIC REGION. 
 
 keeps the dressing in place. The bowels are usually kept constipated for 
 a few days. 
 
 Comment. — (i) Fistuke-in-ano are generally one of three types; — "Com- 
 plete" — "Incomplete Internal" — "Incomplete External." In addition, fis- 
 tulas may have several openings; — and they may have irregular forms, as, 
 for example, the "horseshoe" type. (See Figs. 694 to 697.) (2) If the 
 grooved director does not pass readily, a probe may first find the way — and 
 the director passed along this — and the probe then withdrawn. (3) If the 
 grooved director, or probe, cannot be made to find an internal communication 
 with the bowel, but nevertheless comes very near the mucous membrane, 
 it may be forced the remaining distance, provided this distance be short. 
 (4) If the end of the director cannot be brought out through the anus, a 
 narrow, probe-pointed bistoury may be passed along it and the director 
 
 Figs. 694—697. — Forms of Fistul^e-in-ano : — A, Rectum in vertical section; a, Incomplete external 
 fistula ; 6, Incomplete internal fistula ; c, Complete fistula ; d. Irregular complete fistula. B, Surface 
 view of fistulous tracts, showing various irregular forms of fistula; and diverticula — their external 
 openings being marked by a star. 
 
 withdrawn — and then the end of the probe-pointed bistoury is pressed against 
 the surgeon's left index-finger (or a special piece of wood) introduced within 
 the rectum — and finger and knife simultaneously withdrawn — the knife cutting 
 the intervening soft parts through in its withdrawal. Or one blade of a 
 pair of scissors may be passed along the director and the sinus thus laid open. 
 (5) In incomplete internal fistula 1 , the internal opening is found through a 
 speculum — a bent probe passed along the sinus — and an external opening 
 made where thus indicated — after which the operation is completed as in a 
 complete fistula. (6) In incomplete external fistula, if the inner end be very 
 near the mucous membrane, a director is protruded through the sinus into 
 the bowel, forcing its way through the thin barrier — after which the operation 
 is completed as in the complete fistula. If, on the other hand, the inner 
 
OPERATION FOR FISTULA- IN- ANO BY INCISION. 
 
 949 
 
 opening be not connected with or near the bowel, the entire tract must be 
 laid open from without. (7) If the fistula extend high up along the bowel, 
 judgment must be exercised as to what extent cutting is necessary, and to 
 what extent dilatation and scraping will suffice. (8) In "horseshoe" fistuke 
 (an external opening on each side of the anus leading to a single internal 
 opening, generally upon the posterior rectal wall) the bowel function is less 
 
 Fig. 698.— Operation for Cure of Fistula-in-ano by Incision and Excision: — A, Bistoury 
 in act of dividing fistula upon grooved director; B, Fistulous tract being excised by curved scissors, 
 while steadied with forceps ; C, Suturing of bed of sinus alter its excision ; D, Ligature attached to 
 gauze tampon in rectum, t<> control contents. 
 
 apt to be interfered with if the sphincter be cut on one side only (and at 
 right angles to the anal orifice) and the opposite part of the fistula be dilated, 
 scraped, and drained from the first side. (9) Search should always be made 
 for secondary fistula? running off from the main one, and these likewise laid 
 open and curetted — or dilated and scraped. (10) The internal sphincter 
 should not be divided if it can be helped. If it be necessary to incise the 
 
95© OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 internal sphincter, the division should be at right angles to its fibers at the 
 site of section (that repair may be more complete, and subsequent functioning). 
 And it is preferable not to divide the internal sphincter in more than one 
 place at a time (for the same reasons), (n) Whatever hemorrhage occurs, 
 which is generally slight, is ordinarily controlled by gauze packing — but gut- 
 ligaturing may be used where necessary. (12) In appropriate cases the entire 
 fistulous tract may be dissected out — and the raw edges thus left be brought 
 together by superficial and deep chromic gut sutures — thus at once obliterating 
 the site of sinus and inviting primary union. This method is preferable to 
 simple incision wherever applicable. (See Fig. 698, B and C.) 
 
 VI. THE STOMACH. 
 
 SURGICAL ANATOMY. 
 
 Description. — Lies in epigastric and left hypochondriac regions — being 
 about five-sixths to left and one-sixth to right of median line; — lying under 
 the liver and diaphragm, — above the jejunum, ileum, and transverse colon 
 (also upon the transverse mesocolon, which intervenes between it and pan- 
 creas, abdominal vessels and solar plexus), — and between gall-bladder on 
 right and spleen on left. 
 
 Relations. — Anteriorly and superiorly: diaphragm; thoracic wall (an- 
 terior portions seventh, eighth, and ninth ribs); left and quadrate lobes of 
 liver; anterior abdominal wall; lesser omentum. Posteriorly and infe- 
 riorly : diaphragm; crura of diaphragm; aorta and inferior vena cava; 
 first lumbar vertebra; cceliac axis; lesser peritoneal sac; splenic flexure of 
 colon ; transverse colon ; transverse mesocolon (superior layer) ; spleen (gastric 
 surface); left kidney and suprarenal capsule; pancreas; splenic vessels; duo- 
 denum (fourth, or ascending portion) ; solar plexus. Right end : transverse 
 colon; inferior surface of liver. Left end : spleen; diaphragm. 
 
 Position of Cardiac End (Fundus). — Reaches up to the left sixth chon- 
 dro-sternal articulation, or fifth rib in mammary line, and to cupola of dia- 
 phragm; — slightly above and behind the heart apex; — and 3 to 5 cm. (ij 
 to 2 inches) higher than the cardiac orifice of the stomach. 
 
 Position of Cardiac Orifice. — Opposite left seventh chondro-sternal 
 articulation, about 2.5 cm. (1 inch) from sternum; — also on level with ninth 
 dorsal spine (left side of eleventh dorsal vertebra). Lies from 2 to 3 cm. 
 (f to 1 j inches) below the esophageal opening, and about 7.5 cm. (3 inches) 
 from the left extremity of the stomach, — and n cm. (4 J inches) from the 
 anterior abdominal wall. 
 
 Position of Pylorus. — On level with bony ends of seventh ribs (which 
 are 5 to 7.5 cm., or 2 to 3 inches, below the sterno-xiphoid joint), lying to 
 right of median line and nearer the surface than the cardiac end; — also on 
 level with twelfth dorsal spine (upper border of first lumbar vertebra). 
 
 Fixation Points and Ligaments of Stomach. — Bound to diaphragm by 
 esophagus; — bound to vertebral column by duodenum ; — ligamentum phrenico- 
 gastricum connects cardia to diaphragm; — gastro-hepatic omentum (lesser 
 omentum) connects lesser curvature to liver; — ligamentum hepato-duodenale 
 connects pylorus and duodenum to liver; — gastro-splenic omentum binds 
 greater end of stomach to spleen; — great omentum binds the stomach only 
 when itself is bound. 
 
SURGICAL CONSIDERATIONS IN STOMACH OPERATIONS. 951 
 
 Peritoneal Coverings. — Everywhere — except along the upper and lower 
 curvatures, and upon the triangular areas at either end. 
 
 Arteries. — Gastric; pyloric and right gastro-epiploic branches of hepatic; 
 left gastro-epiploic and vasa brevia of splenic. 
 
 Veins. — Coronary and pyloric, emptying into portal vein; right gastro- 
 epiploic, emptying into superior mesenteric; left gastro-epiploic, emptying 
 into splenic. 
 
 Nerves. — Right vagus (posterior surface) ; left vagus (anterior surface) ; 
 solar plexus of sympathetic system. 
 
 Lymphatic Glands.— Along greater and lesser curvatures — and at 
 pyloric and cardiac ends. 
 
 SURFACE FORM AND LANDMARKS. 
 
 Stomach when empty — lies far back in the abdominal cavity, beneath 
 left lobe of liver and in front of pancreas. 
 
 In moderate distention — Cardiac end lies beneath left seventh chondro- 
 sternal articulation, about 2.5 cm. (1 inch) beyond the sternum. Pyloric 
 end lies opposite a point near end of eighth right chondro-costal articulation. 
 
 Borders (curvatures) of stomach are represented approximately by curves 
 of the characteristic contour between the points just given — the greater 
 curvature reaching at first to the left, then downward to the infracostal line. 
 The lesser curvature crosses the vertebral column on a level with the first 
 lumbar vertebra. The greater curvature crosses the epigastrium on a line 
 connecting the ninth and tenth costal cartilages — which is about two finger- 
 breadths above the umbilicus. 
 
 Gastric fossa — a triangular area of about 40 square centimeters (15J 
 inches) of the anterior wall of the stomach where it lies in direct contact 
 with the abdominal wall — bounded, below, by the transverse colon; above 
 and to left, by seventh, eighth, and ninth costal cartilages; and above and 
 to right, by the anterior border of the liver. 
 
 GENERAL SURGICAL CONSIDERATIONS IN OPERATIONS UPON 
 THE STOMACH. 
 
 Stomach may be recognized by its relation to the inferior surface of the 
 liver — by its continuity with the anterior layer of the gastro-hepatic omentum — 
 L7 its thick and stiff wall, as detenrJned by pinching it up between the fingers — 
 by the direction of its vessels — and by its pinkish-w?.- ;e color and absolute 
 opacity. The stomach and transverse colon have been mistaken for each 
 other. The transverse colon should be displaced downward and the liver 
 upward — revealing the stomach between them. If not otherwise recognizable, 
 follow back the under surface of the liver to the portal fissure, with the index- 
 finger — thence downward along the gastro-hepatic omentum to the stomach. 
 
 Anterior gastric wall lies in the greater peritoneal cavity — and its posterior 
 wall in the lesser cavity. 
 
 Superior wall of the transverse colon lies in the lesser peritoneal cavity — ■ 
 and its inferior wall in the greater cavity. 
 
 Mesentery descends downward and forward from under the back part 
 of the transverse mesocolon. The omentum major descends from the greater 
 curvature of the stomach and inferior aspect of the transverse colon — and 
 mav contain a cavity and be continuous with the omentum minor above 
 the transverse colon — but its component layers are more generally united. 
 The omentum can be more conveniently displaced upward and to the left. 
 
952 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Note. — Other general surgical considerations will be mentioned under 
 special classes of gastric operations. 
 
 INSTRUMENTS. 
 
 Scalpels; straight and blunt-pointed bistouries; scissors, curved and 
 straight; dissecting and toothed forceps; tenacula; artery-clamp forceps; 
 various retractors; large gauze pads; broad spatula?; intestinal clamps; stomach 
 clamps; Murphy button; sponge-holders; volsella; stomach-tube; rubber 
 tubing (for gastrostomies); needles, curved and straight; needle-holders; 
 sutures, silk and gut; ligatures, silk and gut; ligature-carrier, wound-hooks. 
 
 INTRODUCTION OF STOMACH-TUBE. 
 
 Description. — The passage of a hollow tube down the esophagus and 
 into the stomach — for the purpose of removing fluid from, or injecting fluid 
 into, the stomach. 
 
 Position. — Patient sits upright in chair or in bed — head thrown backward 
 (preferably steadied by an assistant) — mouth gagged (preferably, but not 
 necessarily) — napkin placed over tongue to enable it to be more easily grasped; 
 — Surgeon stands in front. 
 
 Operation. — The surgeon depresses the base of the tongue with the left 
 index-finger, and, at the same time, draws it forward — this finger thus also 
 guarding the larynx. The tube, previously warmed and lubricated, and 
 held in the fingers of the right hand, is guided along until it impinges upon 
 the posterior wall of the pharynx, when it is directed downward. The esopha- 
 gus once entered, the tube is gently pressed further downward, aided by 
 the act of swallowing, until it has entered the stomach. 
 
 Comment. — In the average adult, the distance from the upper incisor 
 teeth to the superior end of the esophagus is given as 14 cm. (5J inches); — 
 from the same point to the arch of the aorta, as 23 cm. (9 inches) ; — and from 
 the same point to the diaphragmatic opening, as 37 cm. (14 J inches). Pouches 
 and diverticula of the esophagus are to be avoided. 
 
 GASTROTOMY 
 
 BY MEDIAN INCISION. 
 
 Description. — Consists in the temporary opening of the stomach by 
 incision, followed by its closure at the same operation. Generally resorted 
 to for removal of foreign bodies, for exploration, or for treatment of surgical 
 conditions of the stomach, pylorus, or esophagus (such as gastric ulcer, 
 dilatation of the esophageal or pyloric orifice, dilatation of the esophagus, 
 etc.). The opening may be made in the median line, or below and parallel 
 with the left costal arch. As far as possible, transverse division of muscles 
 and injury to nerves should be avoided. 
 
 Preparation. — Stomach washed out. 
 
 Position. — Patient supine; Surgeon to patient's right, cutting from above 
 downward; Assistant opposite. 
 
 Landmarks. — Linea alba; xiphoid cartilage; umbilicus. 
 
 Incision. — In the median line — its center being about opposite the space 
 between the eighth and ninth costal cartilages — and extending to or toward 
 the tip of the xiphoid cartilage above, and to or toward the umbilicus below, 
 as far as the circumstances of the case require — generally being from 5 to 10 
 cm. (2 to 4 inches) long. (Fig. 699, A.) 
 
GASTROSTOMY. 
 
 953 
 
 Operation. — (i) The steps of the operation, up to entering the peri- 
 toneal cavity, are exactly similar to those for median abdominal section (see 
 page 631). (2) The edges of the abdominal wound are now well retracted 
 and the stomach sought — the steps for its recognition being given under Gen- 
 eral Surgical Considerations. While searching for the stomach, which is 
 often not easily located, temporary silk sutures, or traction-ligatures, may be 
 
 Fig. 699. — Incisions for Exposing Stomach, Liver, Gall-bladder, and Spleen: — A, 
 Median, for stomach, liver, or spleen; B, Oblique subcostal, for stomach; C, Vertical over outer 
 third of left rectus, for stomach; D, Vertical subcostal in left linea semilunaris, for spleen; E, 
 Oblique subcostal, for spleen; F, Oblique subcostal, for liver and gall-bladder; G, Vertical 
 subcostal in right linea semilunaris, for liver and gall-bladder. (Diagram modified from Deaver.) 
 
 placed through the entire thickness of each abdominal lip — partly to serve 
 as retractors, and partly to prevent the separation of the peritoneum from 
 the abdominal wall. (3) Having located the stomach, that portion of its 
 anterior wall into which the incision is to be made must be isolated and 
 drawn out of the wound by means of the fingers or special traction-forceps, 
 the general peritoneal cavity being packed off with gauze. The site of the 
 opening into the stomach will depend largely upon the site of the foreign 
 body, or upon the special object of the operation. (4) An assistant grasps 
 the anterior stomach-wall toward either side of the retracted abdominal 
 wound, between his thumbs and fingers, steadying and spreading out that 
 surface — or temporary silk traction-sutures may be passed, with curved 
 
954 OPERATIONS UPON THE ABDOMI NO-PELVIC REGION. 
 
 needle, into the stomach-wall, without entering its cavity — thus exposing 
 an area of about 5 to 7.5 cm. (2 to 3 inches) of the anterior stomach-wall. 
 (5) This area having been put upon the stretch, an opening of about 3.7 to 
 5 cm. (i| to 2 inches) is made in the vertical axis of the stomach, parallel 
 with the blood-vessels — or it may be made parallel with the long axis, avoiding 
 large vessels. This opening may be made by a quick, controlled stab of a 
 narrow, sharp bistoury, penetrating all the coats, and then enlarging with 
 blunt-pointed bistoury — or it can be more deliberately made by a pair of 
 scissors, picking up a fold of stomach-wall and cutting through at right angles 
 to the fold. (6) Two temporary traction-sutures are at once placed in the 
 opposite lips of the stomach wound, to hold them in control, and to enable 
 the interior of the stomach to be exposed by retraction of its walls. The 
 stomach opening may be enlarged if necessary. Clamp and twist all bleeding 
 vessels, carefully isolating and ligating with gut any requiring ligature. If 
 indicated, the stomach may be washed out, thoroughly protecting the abdom- 
 inal cavity from soiling. (7) The object of the operation is now accom- 
 plished. The stomach-wall is then sutured in the manner described under 
 Gastrorrhaphy, page 955, — with a tier of sutures through the mucous coat, 
 and an overlying tier of Lemberts through the outer coats — using, preferably, 
 fine chromic gut. The stomach is then dropped back into place and the 
 abdomen closed in the usual fashion. 
 
 Comment. — Where the cardiac end of the stomach is the special site 
 sought, it is more conveniently reached by an oblique subcostal incision (q. v.). 
 The above incision is the best for the pyloric end, and for all other portions 
 of the stomach except the cardiac end — and for general exploration and most 
 foreign bodies. 
 
 GASTROTOMY 
 
 BY OBLIQUE SUBCOSTAL INCISION. 
 
 Description. — The stomach is opened by an incision parallel with and 
 below the left costal arch — which more conveniently exposes the cardiac end 
 of the stomach and the cardiac orifice of the esophagus. 
 
 Preparation — Position. — As for Median Gastrotomy. 
 
 Landmarks. — Xiphoid cartilage; left costal arch. 
 
 Incision. — Begins near the tip of the xiphoid cartilage and extends 
 thence downward and outward, parallel with and about 2,5 to 3,7 cm. (1 to 
 1 J inches) to the inner side of the left costal arch, ending about opposite the 
 anterior end of the ninth rib, — generally extending for a distance of 5 to 7.5 
 cm. (2 to 3 inches), varying with the thickness of the abdominal wall and other 
 circumstances. (Fig. 699, B.) 
 
 Operation. — (1) Incise through skin and fascia, clamping all bleeding 
 vessels. The incision will pass through the fibers of the external oblique at 
 about a right angle to its fibers, — will pass between the fibers of the internal 
 oblique, — and will divide those of the transversalis transversely to their 
 course, — but will pass more or less parallel with the seventh and eighth nerves, 
 which, if possible, should be recognized and drawn aside. (2) The peri- 
 toneum is opened in the line of the original incision — the stomach is recog- 
 nized — isolated — and drawn into the wound, the general peritoneal cavity 
 being well oacked off — and its anterior wall is opened in the same general 
 way as described in Median Gastrotomy, and in the special site selected. 
 (3) The object of the operation having been accomplished, the stomach-wall 
 and the abdominal wound are closed in the manner just described. 
 
GASTRORRHAPHY. 
 
 955 
 
 Comment. — (i) The above operation is very similar to that of Gastros- 
 tomy by the same incision. (2) Large, irregular, impacted bodies are some- 
 times removed by incisions made directly over them and giving access by the 
 nearest route. 
 
 GASTRORRHAPHY. 
 
 Description. — Suturing of the stomach-wall. Generally resorted to 
 for wounds, closure after operations, ulcers, etc. (Sometimes gastrorrhaphy 
 is unadvisedly used synonymously with gastroplication.) 
 
 Preparation — Position — Landmarks — Incision. — As for gastrotomy 
 bv median incision. 
 
 Operation. — (1) The peritoneal cavity having been opened, hemorrhage 
 controlled, and the wound retracted, the stomach is exposed and brought 
 
 Fig. 700.— Gastrorrhaphy : — A, Line of overhand continuous suturing through all coats; B, Inter- 
 rupted Lemhert sutures through outer coats. 
 
 forward. (2) The area being packed off with gauze, the site of the operation 
 is conveniently held by an assistant. (3) The mucous membrane is first 
 sutured with continuous sutures of fine silk or gut — by means of a curved 
 needle held in a holder in the right hand, while picking up the mucous mem- 
 brane with forceps in the left. (4) A second line of interrupted Lemberl 
 sutures of fine chromic gut is now applied, passing through the serous and 
 muscular coats of both lips of the wound, and thus bringing serous surfaces 
 into contact. (5) The stomach is then returned to its place — and the abdo- 
 men sutured as usual. 
 
 Comment. — (1) Chromic gut may be used throughout. (2) The first 
 
956 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 tier of sutures may consist of an overhand stitching through the entire thick- 
 ness of all the coats, applied continuously — followed by interrupted Lembert 
 sutures passing through the serous and muscular coats and burying in the 
 first tier. (Fig. 700.) (3) Sometimes three tiers are applied — a continuous 
 stitch through the mucous coat — an interrupted or continuous through 
 the muscular — and an interrupted through the serous. (4) In cases of 
 suturing for gastric ulcer — (a) the edges (in simple cases) are merely in- 
 vaginated by sutures, first of the mucous membrane, then of the serous 
 and muscular coats; — (b) Or the ulcer may be excised (in hard, thick 
 walls, or in large ulcers) elliptically, the edges of the ellipse being united 
 by the two tiers just described. (5) All lines of gastric suturing may be rein- 
 forced bv omental grafts sutured over the suture-line. 
 
 GASTROSTOMY IN GENERAL. 
 
 Description. — Bv gastrostomy is meant the establishment of a more or 
 less permanent fistulous opening in some part of the anterior wall of the 
 stomach, for the purpose of alimentation or surgical treatment — the stomach 
 generallv being attached by suture to the anterior abdominal wall just pre- 
 ceding or following the incision of its wall. The operation of Gastrostomy 
 may be done in one or in two stages. Where haste is a consideration, the 
 opening must be made into the stomach as soon as the latter is attached to 
 the abdominal wall. Where haste is unnecessary, the stomach is first attached 
 to the opening in the anterior abdominal wall — from three to five days given 
 for union to take place, shutting off the peritoneal cavity — and then the 
 stomach is opened. In such cases as those in which the operation is done 
 for inoperable cancer, the gastrostomy is meant to be permanent. Where 
 the operation is done for temporary cause, the fistula is expected to subse- 
 quentlv heal of its own accord (which is generally the case), or a special opera- 
 tion is done later for its closure. 
 
 Preparation of Patient. — The stomach is washed out; the site of opera- 
 tion is shaved; the bowels are emptied. 
 
 Position during Operation. — Supine, at the side of table, with abdominal 
 parietes relaxed by slight elevation of the shoulders and slight flexion of the 
 hips; Surgeon to right in operating in median line, and to left in the sub- 
 costal operation; Assistant opposite. 
 
 Division of Abdominal Parietes. — Muscles should be divided in their 
 cleavage line, in so far as this is possible — and the abdominal nerves should 
 be spared, as far as practicable. A disadvantage of all oblique incisions 
 parallel with and just below the left costal arch is the difficulty of making 
 an intramuscular separation of the fibers. Considerable differences of 
 statement exist among the writings of surgeons as to the placing of the skin 
 incision, and as to the manner of dividing, dealing with, and suturing the 
 subjacent structures in the descriptions of even the same operation of 
 Gastrostomy. 
 
 Form of Artificial Canal. — As to regurgitation of stomach contents, 
 the longer, more indirect, and more valvular the canal between the stomach 
 and abdominal openings, the greater the control over the gastric contents. 
 Immediatelv after operation, rubber tubes for feeding are passed down the 
 artificial fistula — but after the first few days these tubes are introduced only 
 at times of feeding — while in some cases the tubes must be constantly worn, 
 only being removed for cleansing. 
 
SSABANAJEW-FRANCK'S GASTROSTOMY. 957 
 
 Comparison of Methods. — Ssabanajew-Franck's method, performed 
 through the separated fibers of the rectus, is probably the best for a permanent 
 fistula, especially in a lax stomach. Kader's method is probably the best for 
 small or adherent stomachs. MarwedeFs method is probably the best 
 for the rapidity of healing of the fistula. And Howse's method is probably 
 the most quickly done. 
 
 GASTROSTOMY 
 
 BY SSABANAJEW-FRANCK'S METHOD. 
 
 Description. — A cone of stomach is drawn through the separated left 
 rectus muscle — carried beneath a bridge-work of skin — and its apex made to 
 open upon the cutaneous surface just above the left costal arch. The stomach 
 is exposed through an oblique skin incision approximately parallel with the 
 left costal arch — with a vertical separation of the fibers of the outer part of 
 the left rectus muscle — which, at the end of the operation, are sutured about 
 the base of the cone. 
 
 Preparation — Position. — See General Surgical Considerations. 
 
 Landmarks. — Median line; linea semilunaris; left costal arch. 
 
 Incisions. — Primary incision — oblique, about 6 to 8 cm. (2^ to 3 inches) 
 in length, is made over the outer third of the left rectus muscle, beginning 
 near the median line and 'passing downward and outward somewhat more 
 vertically than transversely, though approximately parallel with and about 
 2.5 to 4 cm. (1 to ih inches) from the left costal arch. Secondary incision 
 (made later in the operation) — about 2 cm. (f inch) in length, is made 
 through the skin and fascia about 2.5 cm. (1 inch) above the costal cartilages 
 and approximately parallel with the original incision. 
 
 Operation. — (1) Incise skin and fascia in the above line — clamping 
 bleeding vessels — and retracting the lips of the wound. (2) Expose the 
 rectus muscle — divide the anterior layer of the rectal sheath — separate the 
 fibers of the outer part of the rectus muscle vertically by blunt dissection in 
 their cleavage line — divide the posterior layer of the sheath, — and divide 
 the transversalis fascia, subperitoneal areolar tissue, and peritoneum — pre- 
 serving, throughout, the integrity of the muscles and nerves as much as possi- 
 ble, and retracting the structures as divided. (Figs. 701 and 702.) (3) Draw 
 a long cone of the anterior wall of the stomach through the abdominal wound, 
 by means of a silk traction-ligature passing through the serous and muscular 
 coats — the apex of the cone being represented by a part of the stomach-wall 
 nearer the greater than the lesser curvature, and nearer the cardiac than the 
 pyloric end — calculating that sufficient length of cone be drawn out to pass, 
 without tension, under a bridge-work of skin about 5 cm. (2 inches) wide. 
 (4) The serous coat of the stomach forming the base of the cone, is now 
 sutured to the peritoneal and fascial edges of the wound by four gut sutures. 
 The serous and muscular coats of the stomach are then attached throughout 
 to the posterior layer of the rectal sheath by interrupted or continuous gut 
 sutures (preferably chromic), avoiding the danger of constriction. (5) The 
 secondary incision is now made through the skin and fascia in the site indi- 
 cated (see Incisions) — passing only into the connective tissue plane. (6) 
 By blunt dissection from the larger to the smaller wound, the two are con- 
 nected and the intervening bridge-work of skin thus undermined along the 
 fascial plane. (7) A pair of forceps is passed through the smaller opening 
 into the larger — grasps the silk traction ligature and draws the cone of the 
 
958 
 
 OPERATIONS UPON THE AI!I)OMIX()-PKLVIC REGION. 
 
 stomach into the smaller, upper wound, over the edge of the lower costal 
 cartilages — where it is held in place by four silk sutures. These four sutures 
 are passed through all the coats of the stomach, on the one side, and through 
 the skin and fascia, on the other — if the apex of the cone is to be opened at 
 once. But if the opening is to be deferred, the sutures pass through only 
 the serous and muscular coats of the stomach. The small incision is now 
 sutured at either end, leaving a sufficient opening in the center for the passage 
 of the cone. (8) The separated edges of the rectus and its sheath are now 
 sutured with interrupted chromic gut, from either end toward the center, 
 leaving a sufficient opening to guard against dangerous constriction of the 
 base of the cone, while, at the same time, approaching the base nearly enough 
 to form a muscular circle about it. (9) The skin wound is then closed 
 throughout with subcuticular silkworm-gut sutures — or other form of suturing. 
 
 Figs. 701 and 702.— Gastrostomy, Ssabanajew-Franck's Method : — I. Cone of stomach drawn 
 out of abdominal wound, over costal arch, and through opening in skin : — A, Stomach-cone ; B, Pos- 
 terior layer of rectal sheath, together with subserous and transversalis fasciae and peritoneum sutured 
 to serous and muscular coats of stomach around base of cone; C, Sutures carried through anterior 
 rectal sheath and rectus ready to approximate rectus muscle around cone of stomach. II. Com- 
 pletion of wound-suturing : — D, Sutures through rectus and anterior rectal sheath tightened, so 
 as to embrace stomach-cone ; E, Sutures through skin and fascia ; F, Apex of cone incised and sutured 
 into skin. 
 
 (10) The apex of the cone is incised at once, in cases of emergency — otherwise 
 the opening is deferred for two or three days. 
 
 Comment. — (1) In the original Ssabanajew-Franck operation, the inci- 
 sion was carried more obliquely and more nearly parallel with the costal 
 arches — and with less regard for the preservation of muscles and nerves by 
 intramuscular separation. (2) Surgeons differ as to the direction of incising 
 the posterior layer of the rectal sheath and the subjacent structures. (3) 
 This operation requires a very lax stomach, capable of furnishing a rather 
 long cone. The resulting fistula is more apt to be difficult to close than is 
 the case in some of the other methods of Gastrostomy. (4) The efficiency 
 of the operation depends upon the valve-like nature of the opening over the 
 edge of the costal cartilages — the length of the cone — the muscular action 
 
WITZEL'S GASTROSTOMY. 959 
 
 of the rectus — the double change of direction of the gastric fistula (at first 
 passing through the rectus, and then coming out at the skin wound) — and 
 upon the obliquity of the fistulous canal. (5) The deferring of making the 
 opening into the stomach until all the cone-burying sutures are placed and 
 tied, prevents regurgitation and soiling of the wound in cases in which 
 the stomach must be opened at once. 
 
 Other Gastrostomies Resembling Ssabanajew-Franck's Method in 
 
 General Principle. — 
 
 Albert's Gastrostomy. — Similar in all important essentials to Ssabana- 
 jew-Franck's operation, with the following exceptions; — (1) The primary 
 incision begins 2.5 cm. (1 inch) below the margin of the ribs and passes 
 almost vertically downward over the outer part of the rectus muscle (tending 
 to be more vertical than oblique as in Ssabanajew-Franck's). (2) The sec- 
 ondary incision is made more directly over (than to one side of) the primary 
 incision, and is placed somewhat nearer the costal margin. (3) The stom- 
 ach is bent more nearly directly upward — rather than upward and outward. 
 
 Hahn's Modification of Ssabanajew-Franck's Gastrostomy. — Re- 
 sembles, in general principle, Ssabanajew-Franck's method — the chief differ- 
 ence being that the cone of stomach is brought directly up through the eighth 
 intercostal space. (1) The primary incision (Fenger's incision) is about 
 7.5 cm. (3 inches) long — placed to the left of the left rectus muscle — 2.5 cm. 
 (1 inch) from, and parallel with, the left costal arch. The secondary incision 
 is made later — at the anterior end of the eighth left intercostal space, parallel 
 with the ribs — and about 2.5 cm. (1 inch) long. (2) Incise skin and fascia 
 in line of primary incision — incise external oblique at right angle to fibers — 
 separate internal oblique in cleavage line — divide transversalis transversely 
 to cleavage line — and transversalis fascia, subserous areolar tissue, and 
 peritoneum in same line — draw out long cone of stomach, as in Ssabanajew- 
 Franck's operation — suture serous coat of stomach to parietal peritoneum 
 and fascial edges of abdominal wound — make secondary incision in given 
 line — closed, pointed forceps are passed through the anterior end of the left 
 eighth intercostal space and made to work their way through the intervening 
 tissues, hugging the posterior aspect of the costal cartilages and guided by 
 the finger in the abdominal wound — the silk traction-suture is grasped by the 
 forceps and the cone of stomach drawn through the eighth intercostal space — 
 the operation being completed as in the regular Ssabanajew-Franck's method. 
 The danger of injuring the pleural cavity and the costal cartilages, together 
 with the fact of there being no special advantage over the regular operation, 
 are to be considered in undertaking this modification. 
 
 GASTROSTOMY 
 
 BY WITZEL'S METHOD. 
 
 Description. — The stomach is approached by an oblique incision below 
 the left costal arch, passing through skin and fascia — with vertical separation 
 of the anterior rectal sheath and fibers in their cleavage line — division of the 
 posterior layer of the rectal sheath — and vertical division of the peritoneum. 
 A rubber tube is then buried in a long, oblique canal in the anterior stomach- 
 wall, formed by a process of suturing — following which, the stomach-wall is 
 sutured to the parietal peritoneum and edges of the posterior layer of the rectal 
 sheath — and the abdominal wound closed over all. 
 
960 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Preparation — Position. — See General Surgical Considerations. 
 
 Landmarks. — Median line; linea semilunaris; left costal arch. 
 
 Incision. — Oblique, parallel with and 2.5 to 4 cm. (1 to ij inches) from 
 the left costal arch — beginning near the median line and passing downward 
 and outward for about 7.5 cm. (3 inches). 
 
 Operation. — (i) Incise skin and fascia in above line — clamp vessels — 
 and retract lips of wound. (2) Expose the rectus muscle — divide the ante- 
 rior layer of its sheath — and separate the fibers of the rectus muscle vertically, 
 in their cleavage line, by blunt dissection. (Figs. 703-705.) (3) Divide 
 the posterior layer of the rectal sheath. (4) Divide the transversalis fascia, 
 subserous areolar tissue, and peritoneum vertically. (5) Retract the parts 
 well — -and draw the portion of the anterior stomach-wall which is to be dealt 
 with well into the wound. (6) A velvet-eyed rubber tube is now laid against 
 the anterior wall of the stomach, generally in such a position as to correspond 
 with the outer wound, with the blunt end of the tube toward the cardiac end 
 
 Fig. 703. — Gasi rostomy, Witzel's Method : — I. Cone of stomach drawn through separated 
 rectal fibers — showing Lembert sutures placed ready to bury tube, which is about to enter stomach 
 through incision in its wall. 
 
 of the stomach and the opposite end directed toward the lesser curvature. 
 About 5 to 7.5 cm. (2 to 3 inches) of this tube is now buried in the anterior 
 stomach-wall by Lembert gut sutures, placed about 5 mm. (f^ inch) apart, 
 and extending at least 1.3 cm. (£ inch) beyond the point at which the tube is 
 to enter the stomach, and so placed as to avoid the larger vessels. All the 
 sutures are now tied, thus burying i n the tube — except the three or four at 
 the lower end of the tube. (7) The stomach-wall is then held in such a way 
 as to render the site of entrance of the tube into the stomach prominent, and, 
 at the same time, so as to separate the opposite (posterior) stomach-wall — - 
 and with a narrow, sharp-pointed bistoury, a quick, controlled stab is made 
 through all the layers of the anterior stomach-wall, guarding against wounding 
 the opposite (posterior) wall — the opening being made just beneath the tip 
 of the tube, which is temporarily withdrawn about 6 mm. (J inch) for that 
 purpose and just before the stab is made. Immediately upon the completion 
 
WITZEL'S GASTROSTOMY. 
 
 961 
 
 of the stab-wound, which should be a little less in extent than the caliber of 
 the tube, the end of the tube is thrust through the opening and into the cavity 
 of the stomach — and the already placed sutures, which were temporarily 
 left untied at the lower end of the tube, are at once tied — thereby preventing 
 any regurgitation of the stomach contents. (8) The stomach is now allowed 
 to fall back into the abdominal cavity sufficiently to leave only the site of the 
 anterior stomach-wall represented by the buried tube in contact with the edges 
 of the abdominal wound — and even this area is so adjusted as to cause the 
 site of the buried tube to be surrounded by the edges of the abdominal wound 
 in the form of as narrow an ellipse as possible. (9) The serous and muscular 
 coats of the stomach are now united by interrupted gut sutures to the parietal 
 
 v 
 
 n 
 
 m 
 
 Figs. 704 and 705.— Gastrostomy, Witzel's Method :— II. Manntr of placing sutures ; A, Tube 
 buried in by two parallel folds of stomach-wall united by tying of interrupted Lemberts shown in I ; 
 B. Interrupted sutures passing through serous and muscular coats of stomach, and through parietal 
 peritoneum, posterior rectal sheath, and lower plane of rectus ; C, Interrupted sutures through skin, 
 fascia, anterior rectal sheath, and major part of rectus. III. Final position of tube— seen emerging 
 from completely sutured wound. 
 
 peritoneum and lower lip of wound along this narrow ellipse. (10) The 
 edges of the abdominal wound are then united — first with chromic gut inter- 
 rupted sutures passing through the entire thickness of the opposite lips of the 
 separated rectus muscle, together with the edges of its sheath, but not in- 
 volving the already sutured peritoneum, — followed by interrupted or con- 
 tinuous silk suturing of the skin and fascia — or subcuticular suturing. Or skin, 
 fascia, and rectus may be sutured in one tier. The rubber tube will emerge 
 between the two or three upper sutures. (11) The rubber tubing is held in 
 position by a silk suture passing through the outer part of its wall and attached 
 to the skin. The tube is left in for three or four days — and then inserted only 
 for feeding. 
 61 
 
962 
 
 OPERATIONS UPON THE ABDOMIXO-PELVIC REGION. 
 
 Comment. — (1) The site of incision sometimes differs from that above 
 given — and the fibers of the rectus are sometimes cut instead of separated — 
 but all muscular structures should be separated, and nerves retracted, as 
 far as these may be done. (2) Fenger's incision is sometimes used — about 
 7.5 cm. (3 inches) in length and placed to the left of the rectus, and 2.5 cm. 
 (1 inch) from and parallel with the left costal arch. (3) Before the stomach 
 is dropped back into the abdomen, three gut sutures may be inserted through 
 its serous and muscular coats, each threaded with a needle at either end — 
 and after the stomach has receded into its normal position, these needles 
 are made to pierce the edges of the abdominal wound, from within — and 
 the stomach thus drawn up to the edges of the abdominal opening. (4) 
 By postponing the opening into the stomach until all the sutures are placed 
 and most are tied, the leakage is minimized. (5) Regurgitation is prevented 
 by the constriction of the separated fibers of the rectus — by the long, oblique 
 canal — and by the short artificial cone created by the manner of suturing, 
 and which projects into the stomach. (6) Operators differ as to the direction 
 in which they divide the layers of the rectal sheath and subjacent structures. 
 
 GASTROSTOMY 
 
 BY MARWEDEL'S METHOD. 
 
 Description. — This operation resembles Witzel's in most of its essentials — 
 except that the tube is buried between the mucous coat, on the one hand, 
 and the serous and muscular coats, on the other — and that the parietal peri- 
 
 Fig. 706.— Gastrostomy, Marwedel's Method :— I. Anchoring of stomach and splitting of 
 stomach-wall ; A, Parietal peritoneum sutured into lower part of lips of abdominal wound ; B, 
 Stomach sutured to parietal peritoneum and lower plane of abdominal wound ; D, Sutures through 
 serous and muscular coats of stomach ; D, Tube about to be buried in stomach-wall. 
 
 toneum is sutured to the skin before the stomach-wall is attached to the 
 edges of the abdominal incision. 
 
 Preparation — Position. — See General Surgical Considerations. 
 
 Landmarks. — As in Witzel's operation. 
 
MARWEDEL'S GASTROSTOMY. 963 
 
 Incision. — Oblique incision about 6 to 7.5 cm. (2% to 3 inches) in length — 
 made over the left rectus muscle — beginning near the median line and passing 
 downward and outward somewhat more vertically than horizontally, though 
 approximately parallel with and about 2.5 cm. to 4 cm. (1 to ih inches) 
 from the left costal arch. 
 
 Operation. — (1) Incise skin and fascia — clamp bleeding vessels — and 
 retract the lips of the wound. (2) Expose the rectus muscle — divide the 
 anterior layer of the rectal sheath vertically, nearer its outer part — separate 
 the fibers of the rectus vertically in their line of cleavage, by blunt dissection — 
 divide the posterior layer of the rectal sheath vertically — and the transversalis 
 fascia, subserous areolar tissue, and peritoneum in the same line. (3) The 
 parietal peritoneum is now drawn out and sutured with interrupted gut to 
 the skin at the margin of the abdominal wound. (See Comment.) (4) The 
 anterior stomach-wall is then drawn out and sutured to the parietal peritoneum 
 
 Fig. 707.— Gastrostomy, Marwedel's Method: — II. Burying of tube and closure of wound; 
 A, Sutures uniting peritoneum to lower plane of abdominal wound; B, Sutures uniting stomach to 
 peritoneum and lower plane of wound; C, Sutures burying tube between mucous coat below, and 
 serous and muscular above; D, Sutures through skin, fascia, anterior rectal sheath, and upper part 
 of rectus. 
 
 at the margins of the abdominal wound, in the form of a narrow ellipse. 
 (Fig. 706.) (5) For a distance of about 5 cm. (2 inches) and about parallel 
 with the line of skin incision, the serous and muscular coats are incised, 
 carefully guarding against cutting through the mucous coat. The serous and 
 muscular coats are then dissected from the mucosa to either side for a short 
 distance. A rubber tube is now laid between the split coats of the stomach, 
 which are then sutured over it with fine gut. (Fig. 707.) The sutures at the 
 lower end extend 1.2 cm. (h inch) beyond the intended opening and are 
 placed but not tied. When all the rest are tied, an opening is made through 
 the mucous coat in the same manner as in Ssabanajew-Franck's operation — 
 immediately following which, the tube is thrust into the stomach and the 
 lower sutures at once tied. (6) The margins of the abdominal wound are 
 then sutured together with interrupted silk or silkworm-gut. 
 
964 
 
 OPERATIONS UPON THE AP.DOMIXO-PELVIC REGION. 
 
 Comment. — (1) It would seem better to attach the parietal peritoneum to 
 the lower edge of the abdominal wound (rather than to the skin) — and the 
 stomach to the peritoneum thus attached — then the edges of the split rectus 
 can be brought into direct contact, in finally closing the abdominal cavity. 
 (2) Fenger's oblique subcostal incision is often used — about 7.5 cm. (3 inches) 
 in length, placed to the left of the rectus and about 2.5 cm. (1 inch) below 
 and parallel with the left costal arch. The operation may also be done in 
 the median line. (3) The tube may be buried in the stomach-wall before 
 the latter is sutured to the edges of the abdominal wound — which is some- 
 times more convenient. (4) Surgeons differ considerably upon the incision 
 and subsequent steps of the operation. 
 
 GASTROSTOMY 
 
 PA* KADER'S METHOD. 
 
 Description. — This is a modification of Witzel's operation, and consists 
 in the insertion of a tube into the stomach at a right angle to its surface — 
 and, by means of two tiers of Lembert interrupted sutures, two parallel 
 folds are made in the anterior stomach-wall, thus invaginating the stomach- 
 wall and burying in the tube. The stomach is reached through the vertically 
 separated fibers of the rectus. 
 
 Fig. 708. — Gastrostomy, Kader's Method : — I. Burying tube perpendicularly within stomach ; 
 A, Lower tier of sutures approximating lower ridges of stomach- wall ; B, Upper tier of sutures approxi- 
 mating upper ridges of stomach-wall. Both tiers are partly tied. Note — Through error, the abdominal 
 incision is represented oblique — but should be vertical, as shown in II, Fig. 710. 
 
 Preparation — Position. — See General Surgical Considerations. 
 
 Landmarks. — Linea alba; linea semilunaris; left costal arch. 
 
 Incision. — Vertical incision over the left rectus muscle, beginning about 
 2.5 cm. (1 inch) below the costal cartilages and extending downward 6 to 
 7-5 cm - Olto 3 inches). (Fig. 699, C.) 
 
 Operation. — (i) Incise skin and fascia in the above line — clamp bleeding 
 
KADER'S GASTROSTOMY. 
 
 96S 
 
 vessels — retract margins of the wound, exposing the sheath of the rectus. 
 (2) Divide the outer sheath of the rectus vertically. Separate the fibers 
 of the rectus by blunt dissection in their cleavage line. (3) Divide vertically 
 the posterior sheath of the rectus, transversalis fascia, subserous areolar 
 tissue, and peritoneum. (4) Isolate and draw into the wound a fold of 
 the anterior stomach-wall — packing off the peritoneal cavity with gauze. 
 (Fig. 708.) (5) Having selected an appropriate site, and while the stomach is 
 properly held by an assistant so as to avoid injury to the opposite (posterior) 
 wall, an opening somewhat smaller than the caliber of the tube is made by 
 a quick, controlled stab with a narrow, sharp-pointed bistoury. Having seen 
 that no serious hemorrhage follows the stab wound, a rubber tube is imme- 
 diately inserted into the stomach cavity through this opening and sutured 
 to the edge of the stomach wound with two gut sutures passing into but not 
 through the wall of the tube. (61 While the tube is held perpendicular to 
 
 >- 
 
 A* 
 
 Fig. 709. 
 
 -Gastrostomy, Kader's Method: — Burying the tube by two or more tiers of 
 purse-string sutures. (Redrawn from Fowler.) 
 
 the stomach-wall at its point of entrance, two chromic gut Lembert sutures, 
 about 1.2 cm. (h inch) apart, are so passed through the serous and muscular 
 coats of the stomach, on either side of the tube, as to raise a fold or pleat 
 of stomach-wall about 7.5 cm. (3 inches) long and 1.2 cm. (£ inch) high. 
 These deep occlusion sutures are then tied — the included tissues infolding 
 into the stomach in the form of a funnel-shaped projection. A second tier, 
 superficial occlusion sutures, is similarly placed, at the same distances apart, 
 above the first, which are, in turn, thus buried in by the second, forming 
 
966 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 a second fold. The sutures of the second tier are temporarily left long, 
 to aid in the subsequent manipulation of the stomach. (7) The tube may be 
 buried by means of two or more tiers of purse-string sutures (Fig. 709). (8) 
 The general peritoneal cavity is shut off by stitching the serous and muscular 
 coats of the stomach, on the one hand, to the parietal peritoneum and edges of 
 the divided posterior sheath of the rectus; on the other— holding the stomach 
 by means of the temporarily left occlusion sutures. (Fig. 710.) (9) The 
 separated edges of the rectus are sutured with interrupted chromic gut sutures 
 —and the anterior sheath of the rectus with a similar separate line of sutures— 
 both being closely approximated to the tube. The skin is closed by inter- 
 rupted silkworm-gut sutures. 
 
 Comment.— (1) This operation is more generally applicable than Witzel's, 
 of which it is a modification, because of requiring less amount of movable 
 stomach-wall— and because it may be used through any kind of incision 
 
 Fig. 710— Gastrostomy, Kader's Method: — II. Anchoring of stomach and closure of wound; 
 
 A, Suture uniting serous and muscular coats of stomach to parietal peritoneum and margins of wound ; 
 
 B, Sutures passing through skin, fascia, anterior rectal sheath, and rectus ; C, Tier of sutures burying 
 in tube. 
 
 exposing the stomach. (2) The folds or pleats are made transverse when 
 the opening is to be temporary-^-and perpendicular when the opening is to 
 be permanent. (3) Where the stomach is so small, or so bound down, as 
 to make it impossible to bring it well into the wound, the pleating may be 
 made and the tube buried with the stomach in sit a. (4) The efficiency of 
 the method depends chiefly upon the valvular invagination of the stomach- 
 wall. The sides of the infolded funnel soon become adherent, leaving only 
 the tubular tract patulous. (5) As in most Gastrostomies, surgeons vary as 
 to the exact placing of the external incision and the manner of dividing, 
 dealing with, and suturing the subjacent layers. (6) A somewhat similar 
 method (Abbe and Stamm) consists in thrusting a tube, through a previously 
 made opening, perpendicularly into the anterior stomach-wall — then sur- 
 rounding it by a circular purse-string suture about 1.2 cm. (J inch) from the 
 catheter, which is then tied, gut being used — then a second purse-string 
 
GASTROENTEROSTOMY IN GENERAL. 
 
 967 
 
 suture about 2.5 cm. (1 inch) from the first, which is tied similarly — and 
 a third — the stomach being attached to the abdominal wall as above. 
 
 Note. — Other forms of Gastrostomy might be mentioned — some repre- 
 senting older, some more modern methods — such as Howse's; Greig Smith's 
 modification of Howse's; E. J. Senn's; Andrew's; Yon Hacker's; and others' 
 — but those above described in detail sufficiently cover the best modern 
 methods. 
 
 GASTROENTEROSTOMY IN GENERAL. 
 
 By Gastroenterostomy is meant the establishment of an anastomotic 
 opening between the stomach and some part of the small intestine — the 
 name of the operation being further designated by the part of the intestine 
 
 Fig. 711. — Diagram Representing Gastroenterostomies : — A, Anterior gastroenterostomy 
 — small intestine being carried over omentum and applied to anterior stomach-wall ; B, Posterior 
 gastroenterostomy— small intestine being carried through an opening made in transverse mesocolon 
 and applied to posterior stomach-wall, i Modified from Gray.) 
 
 anastomosed — for example, gastro-duodenostomy, gastrojejunostomy, gastro- 
 ileostomy. The object of the operation is generally to obtain the complete 
 emptying and rest of the stomach — or to furnish egress from it in cases of 
 obstinate obstruction at or near the pyloric end — or in cases of excision of 
 the intestine near the pylorus. 
 
 The nearer to the stomach the portion of intestine anastomosed, the 
 greater will be the length of small intestine left for absorption. That portion 
 of the stomach between the pyloric end and the site of the intestine anas- 
 tomosed with the stomach becomes partially thrown out of circuit ("short- 
 circuited") in proportion as it continues or not to transmit intestinal contents, 
 and henceforth performs more or less limited function — the bulk of the 
 stomach contents traveling by the new route, while the small amount which 
 escapes through the pylorus still goes by the old route. 
 
 The flow of the stomach contents is usually from the cardiac to the pyloric 
 and alone the greater curvature, nearer which the anastomosis is generally 
 
968 OrERATlONS UPON THE ABDOMINO-PELVIC REGION. 
 
 made — and usually from the pyloric to cardiac end along the lesser curvature. 
 It is always desirable to so approximate a coil of intestine to the stomach 
 that the flow in both viscera may be in a normal direction — which is generally 
 accomplished by giving the coil of intestine a half-turn just before making 
 the anastomosis. 
 
 In order to avoid regurgitation into the stomach of intestinal contents, 
 including bile, many surgeons, after completing the gastroenterostomy, per- 
 form a jejuno-jejunostomy (between the proximal and distal limbs of the 
 jejunum) — the Jaboulay-Braun operation (see page 971). 
 
 The intestine may be anastomosed to the anterior or to the posterior wall 
 of the stomach — constituting Anterior or Posterior Gastroenterostomy. The 
 latter operation is preferable — the reasons for which being given under Com- 
 ment upon the two operations, pages 971 and 977. (Fig. 711.) 
 
 ANTERIOR GASTRO-ENTEROSTOMY 
 
 P,V SIMPLE SUTURING — WOLFLER'S OPERATION. 
 
 Description. — In this operation some part of the small intestine is carried 
 up in front of the great omentum and transverse colon and united by some 
 method of suturing, without the aid of one of the mechanical devices, to 
 the anterior wall of the stomach, nearer its greater curvature. (Fig. 711, A.) 
 The nearest part of the small intestine to the pyloric end of the stomach 
 which is available, which will generally be the jejunum, is the portion usually 
 selected for the anastomosis — constituting gastrojejunostomy. 
 
 Preparation. — The stomach is washed out; the site of the operation is 
 shaved; the bowels are emptied by purgation. 
 
 Position. — Patient supine, at side of table, with abdominal parietes 
 relaxed by slight elevation of the shoulders and slight flexion of the hips; 
 Surgeon to the right; Assistant opposite. 
 
 Landmarks. — Lineaalba; xiphoid cartilage; umbilicus. 
 
 Incision. — In median line, from just below xiphoid cartilage to umbilicus 
 — and beyond, if necessary (Fig. 699, A). 
 
 Operation. — (1) Is conducted as a median abdominal section up to 
 the exposure of the abdominal cavity. (2) The beginning of the jejunum 
 is now sought — and is most readily found by temporarily displacing the 
 great omentum upward and to the left, and the transverse colon and meso- 
 colon upward and to the right — and by following down the under surface 
 of the mesocolon to its base, from left to right, as the finger passes, beneath 
 the ligament of Treitz, a loop of small intestine is encountered, which is the 
 commencement of the jejunum. (Fig. 712.) This is now followed down 
 several inches until a convenient distance for anastomosis, without tension, 
 to the anterior stomach-wall is secured — which is generally about 40 to 50 
 cm. (16 to 20 inches). (3) This site of jejunum being held by an assistant, 
 the transverse mesocolon and great omentum are now allowed' to drop back 
 into place — the jejunum being brought down, around and in front of them — 
 seeing that sufficient length of intestine for this course is allowed. Then to 
 cause the flow in the intestinal canal to correspond with the gastric flow 
 (from left to right) the loop of jejunum is given a half-turn (Rockwitz's 
 modification) and is thus approximated to the anterior wall of the stomach, 
 near its greater curvature. (Fig. 713.) It is important that this approxima- 
 tion should be accomplished without undue twisting and tension of the 
 intestine, or other marked disarrangement of normal relations of the parts 
 concerned. (4) When all is in readiness for suturing, the proposed site of 
 
ANTERIOR GASTROENTEROSTOMY. 
 
 969 
 
 anastomosis of the anterior stomach-wall and the corresponding portion of 
 the jejunum should be drawn somewhat out of the abdominal cavity for 
 the greater convenience of manipulation. An assistant holds the antime- 
 senteric border of the jejunum in easy contact with the lower anterior surface 
 of the stomach-wall, near the great curvature — holding the stomach so as 
 to exclude, as much as possible, an outflow of its contents when incised — 
 the intestines being squeezed empty and clamped — or each viscus may be 
 clamped, as shown in the posterior operation (Fig. 717). (5) With a long, 
 straight needle, threaded with chromic gut, or silk, a line of continuous suturing, 
 passing through serous and muscular coats of the intestine, on the one hand, 
 and the same coats of the stomach, on the other, is carried along what will 
 form the posterior line of union, the needle being inserted at close intervals — 
 the suture left hanging long at both ends, with the needle at one end, and 
 knotted at the other — and the suturing having extended in a slightly elliptical 
 
 Fig. 712. — Manner of Locating Beginning of Jejunum; Incised Mesocolon Pre- 
 paratory to Posterior Gastro-enterostomy: — A, Great omentum displaced upward and 
 to left; B, Transverse colon and mesocolon displaced upward and to right; C, Commencement 
 of jejunum emerging from beneath ligament of Treitz; D, Incision in mesocolon through which 
 jejunum is to be carried into the cavity of the lesser omentum and approximated to posterior 
 stomach-wall. 
 
 direction, beginning and ending about 1.2 cm. (^ inch) beyond the ends 
 of the future incision through the two opposed walls. (6) With a sharp- 
 pointed bistoury, a quick, controlled stab is made into the stomach, in its 
 long axis, and then into the intestine, in its long axis, in the indicated sites, 
 and so planned that the incisions will fall immediately opposite each other 
 and be of the same size — the incisions being made while both stomach and 
 intestine are so held by an assistant as to present their proper surfaces, and, 
 at the same time, the opposite wails are held apart so as not to be also pene- 
 trated by the knife stab. One blade of a pair of sharp-pointed scissors is 
 now introduced, and both incisions lengthened in the long axes of both viscera 
 to the extent of about 5 to 6.5 cm. (2 to 2 \ inches) — until within about 1.2 
 cm. (^ inch) of either end of the posterior line of suturing. These incisions 
 
97° 
 
 OPERATIONS UPON THE ABDOMIXO-PELVIC REGION. 
 
 into the stomach and intestine, made immediately opposite each other, should 
 be from 5 to 8 mm. (j to ^ inch) from the suture-line. Soiling of the adjacent 
 structures with the outflow of stomach and intestinal contents should be 
 prevented as much as possible with gauze packing. All bleeding should be 
 controlled by clamping and twisting — and is further controlled by suturing — 
 and by gut ligature if necessary. (7) Immediately following these incisions, 
 the margins of the intestinal incision are united to the margins of the stomach 
 
 Fig. 713. — Anterior Gastroenterostomy Followed by Jejuno-jejunostomy: — 
 A, Stomach; B, Duodenum; C, Jejunum, after emerging from ligament of Treitz; D, Coil of 
 jejunum given a half-turn and applied to lower aspect of anterior stomach-wall; E, E, Outer 
 tier of continuous Lembert suturing; F, F, Inner tier of continuous overhand suturing approxi- 
 mating edges of opening in stomach and intestine; G, Intestinal clamps; H, Entero-enterostomy 
 by Murphy button; I, Transverse colon; J, Omentum folded back by uplifted jejunum. 
 
 incision by continuous suturing with silk or chromic gut, passed with a curved 
 needle held in a holder, the sutures passing through all the coats of both 
 stomach and intestine, the edges of the incision being so held as to enable 
 them to be whipped together by an overhand stitch. (8) The threaded end 
 of the original continuous gut or silk suture is now taken up and the line 
 of suturing continued from the end where it was temporarily discontinued, 
 on around now in front of the line of incisions into stomach and intestine, 
 in the same slightly elliptical outline as upon the posterior aspect, and passing 
 
ANTERIOR GASTROENTEROSTOMY BY MURPHY BUTTON. 971 
 
 about S to 12 mm. (J to h inch) from the line of incision into the lumina 
 of the viscera — until the suturing reaches the opposite end, when the free 
 end of the suture is tied to the end originally left long after knotting. Thus 
 the inside line of sutures, chiefly for strength, is reinforced by -this secondary 
 line uniting the muscular and serous coats, and thus shutting off any leakage 
 which might escape through the suturing of the margins alone. The stomach 
 and intestine must be so manipulated during the various stages of the suturing 
 as to present the site to the surgeon most advantageously. (9) A third line 
 of interrupted gut Lemberts may be now applied, burying in the other two, 
 if thought necessary — but is rarely needed. (10) The viscera are now dropped 
 back into the peritoneal cavity and the abdominal wound closed as usual. 
 See, under Comment, reference to intestinal anastomosis as an accompaniment 
 of gastro-enterostomv. 
 
 Comment. — (i) The chief objections to the anterior method of gastro- 
 enterostomy are — that the transverse colon is apt to be compressed by the 
 small intestine resting and dragging upon it; — that the two intestinal arms 
 descending from the stomach are apt, by gravity and traction, to become 
 parallel, and a spur-formation thereby occur at the stomach opening, by 
 converting the original curve at their point of meeting into an angularity; — 
 and that regurgitation of intestinal contents, including bile, into the stomach 
 is more frequent after the anterior operation. Therefore various suggestions 
 have been made to overcome the above disadvantages — such as valvular 
 forms of anastomoses, — multiple intestinal anastomoses, or a single intestinal 
 anastomosis, to carry off the contents of the proximal end of the intestine, 
 including bile, — and, probably best of all, posterior gastro-enterostomv. (2) 
 In all forms of gastro-enterostomv, but especially in the anterior operations, 
 it is advisable, after completing the gastro-enterostomv proper, to form an 
 intestinal anastomosis, a jejuno-jejunostomy, at the site and in the manner 
 described in connection with the following operation (page 971). (3) In the 
 operation just described, wherever the continuous suture is used, it is well 
 to tie it at several points (without intermitting the stitch) rather than at 
 one only — to do away with any possibility of the suture acting as a "draw- 
 string" and constricting the opening. 
 
 ANTERIOR GASTROENTEROSTOMY BY THE MURPHY BUTTON; 
 
 FOLLOWED BY SINGLE OR MULTIPLE INTESTINAL ANASTOMOSIS BV THE 
 JABOULAY-BRAUN METHI >D. 
 
 Description. — Consists, first, in performing an anterior gastro-enteros- 
 tomv, by bringing the highest available part of the jejunum up in front of 
 the great omentum and transverse colon and uniting it to the anterior wall 
 of the stomach, nearer its greater curvature, by means of the Murphy button. 
 For the reasons explained under Comment in the last operation, the two 
 arms of the loop of jejunum are then anastomosed, either by the Murphy 
 button or by simple suturing — constituting single intestinal anastomosis, — 
 or, in addition to the anastomosis thus formed, one or more other anasto- 
 moses may be made between adjacent coils of intestine, if the need for these 
 be indicated. 
 
 Preparation — Position — Landmarks — Incision. — As in the operation 
 just described. "* 
 
 Operation. — (1) All the steps of the gastro-enterostomv are precisely 
 similar to those described under anterior gastro-enterostomv by simple suture, 
 
972 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 up to the point of making the anastomosis — which, in the present case, is 
 accomplished by means of the Murphy button. The male half of the button 
 is inserted into a convenient, relatively non-vascular part of the anterior wall 
 of the stomach, near the greater curvature and about at its center. The 
 insertion of the half button into the stomach is accomplished exactly as 
 described under entero-enterostomy by the Murphy button (page 885) — the 
 incision into the stomach-wall being in its long axis, and all bleeding being 
 controlled by twisting or ligature before proceeding. The female half of the 
 button is then inserted into the antimesenteric aspect of the loop of jejunum — 
 also in the same manner as described in entero-enterostomy by the Murphy 
 button. When all is in readiness, the two halves of the button are approxi- 
 mated in the usual manner. If thought necessary, the button anastomosis 
 
 Fig. 714. — Anterior Gastroenterostomy by Simple Suturing, followed by Entero- 
 enterostomy by Gallet's Method of Introducing Weir's Modification of the Murphy 
 Button: — A, Stomach opening; B, Intestinal opening; C, C, Manner of applying the buttons 
 from within parallel limbs of jejunum; D, Omentum folded back over a reversed coil of jejunum. 
 
 may be reinforced by a few interrupted Lemberts. (2) The anastomosis 
 between the antimesenteric aspect of the limbs of the jejunum, several inches 
 below the stomach, is now accomplished in one of the following ways: — 
 (a) By Gallet's method of introducing Weir's modification of the Murphy 
 button: — When the incision is made into the knuckle of jejunum to be anas- 
 tomosed to the anterior stomach-wall, and before that anastomosis is done, 
 the male half of the button, with the end of its cylinder beveled and sharpened, 
 as modified by Weir, is introduced down the proximal limb of the jejunum, 
 in the grasp of a pair of forceps, the handle of the forceps being steadied 
 by an assistant, — and the female button, similarly grasped, is introduced 
 down the distal limb of the jejunum — and while thus held, the two halves 
 of the button are approximated and pressed home, the cutting cylinder of 
 
ANTERIOR GASTROENTEROSTOMY BY MURPHY BUTTON. 973 
 
 the male button cutting its way through intervening intestinal wall of the 
 proximal and distal limbs of the gut and finding its way into the female 
 cylinder. No reinforcing suture is necessary — though may be applied if 
 desired. The forceps are now withdrawn from the opening in the knuckle 
 of intestine, and the anastomosis between stomach and intestine completed. 
 (Fig. 714.) (b) By Hartley's method: — the ordinary Murphy buttons are 
 used — the male button being dropped through the incision at the knuckle 
 of intestine into the proximal, and the female button into the distal limb. 
 The gastro-intestinal anastomosis is then completed — after which each button 
 is grasped and, while so held as to bring their cylinders into contact with 
 the antimesenteric aspect of the jejunum, at the indicated site, two small 
 incisions are made at right angles through the intestinal wall, which has been 
 stretched like a drum-head over the ends of the cylinders — the surgeon steady- 
 ing one button with the fingers of his left hand, and an assistant steadying 
 
 Fig. 715. — Anterior Gastroenterostomy by Simple Suturing, followed by Entero- 
 ENTEROSTOMY by the Mi'rphy Bctton: — By means of buttons dropped into parallel limbs 
 of jejunum, and then approximated through incisions made over their cylinders. (Hartley's 
 method.) 
 
 the other. The buttons are then pressed together in the usual fashion — no 
 reinforcing suturing being ordinarily used. (Fig. 715.) (c) The Murphy 
 buttons may be used to make the intestinal anastomosis in the ordinary 
 manner — as described in entero-enterostomy by lateral anastomosis (page 
 888). (d) The intestinal anastomosis may also be made by simple suturing. 
 (3) The stomach and intestines having been dropped back into place, the 
 abdomen is closed as in median abdominal section. 
 
 Comment. — If it be thought advisable, in addition, to anastomose adjacent 
 coils of intestine, in order to increase the freedom of passage of intestinal 
 contents, one or more anastomoses may be made where indicated — the opera- 
 tion becoming an entero-enterostomy by lateral anastomosis, and one of the 
 methods described under that head may be used — the Murphy button being 
 the means usually employed. 
 
974 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 POSTERIOR GASTROENTEROSTOMY 
 
 BY VON HACKER'S METHOD. 
 
 Description. — In this, the more commonly performed, operation some 
 part of the small intestine as near as possible to the stomach (generally the 
 upper part of the jejunum) is carried through an artificial opening made for 
 the purpose in the transverse mesocolon, and anastomosed with the posterior 
 wall of the stomach — constituting a posterior gastrojejunostomy (Fig. 711, 
 B) — after which the two limbs of the jejunal loop are united, forming a 
 jejuno-jejunostomy. 
 
 Preparation — Position — Landmarks. — As in the anterior operation. 
 
 N 
 
 •X 
 
 N 
 
 Fig. 716. — Posterior Gastro-enterostomy: — I. — The omentum and transverse colon 
 have been displaced upward and in front of the stomach; — The transverse mesocolon is incised 
 and its margins sutured to the posterior stomach-wall; — A loop of the jejunum has been brought 
 up into contact with the stomach; — The lines of incision are shown upon the stomach and 
 jejunum. (Modified from Mayo and Gould.) 
 
 Incision. — In the median line — beginning about 5 cm. (2 inches) below 
 the ensiform cartilage and extending below the umbilicus. The incision is 
 sometimes made through the right rectus. 
 
 Operation. — (1) Expose the peritoneal cavity, as in median abdominal 
 section. (2) Lift the great omentum upward and to the left, and the trans- 
 verse colon upward and to the right, displacing them over the stomach. 
 (3) Isolate and draw out the beginning of the jejunum, as described in anterior 
 gastro-enterostomy. (4) An assistant, standing above the stomach and to 
 one side, so grasps the stomach that both his thumbs press its anterior and 
 
POSTERIOR GASTROENTEROSTOMY. 
 
 975 
 
 his fingers its posterior surface — then by pronating his forearms, the posterior 
 surface is protruded downward and forward prominently toward the surgeon, 
 the transverse mesocolon intervening. (5) Separate the fibers of the trans- 
 verse mesocolon by blunt dissection in the direction of its vessels, in anon- 
 vascular region, and opposite the site of the future anastomosis — thus opening 
 into the cavity of the lesser omentum. (Fig. 716.) (6) The assistant, 
 continuing to press upon the stomach as above, causes its posterior wall to 
 bulge through the artificial slit in the transverse mesocolon — until it presents 
 in the cavity of the great omentum. The edges of this slit in the mesocolon 
 are immediately sutured to the stomach, leaving an oval area of posterior 
 stomach-wall of sufficient size, the sutures passing through the entire thickness 
 of transverse mesocolon and through serous and muscular coats of the stomach. 
 
 
 Fig. 717. — Posterior Gastroenterostomy: — II. — Folds of stomach and intestine have 
 been taken up by special clamps, approximated, incised — and are being sutured; — The outer 
 seromuscular and the inner through-and-through sutures are shown. (Modified from Mayo 
 and Gould.) 
 
 (7) A convenient coil of jejunum, so selected as to avoid tension and kinking, 
 is now approximated to the posterior gastric wall — its contents having been 
 pushed away for several inches on either side and kept away by clamping 
 the gut — the assistant holding the stomach likewise keeping its contents away 
 from the site as far as possible. The coil of jejunum should be so approximated 
 to the stomach as to make the flow of contents from the latter correspond with 
 that in the intestine (Fig. 716). While the need of giving it a half-turn is 
 not so pressingly necessary as in the anterior gastro-enterostomy, because of 
 the more favorable relations of the parts at the site of the posterior oper- 
 ation, it is, nevertheless, generally best to resort to this manoeuvre. The 
 stomach and jejunum are very satisfactorily held in contact for incision 
 and suturing by means of special clamps applied as shown in Fig. 717. (8) 
 
976 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Moynihan's line of gastric incision is oblique, passing from above and to the 
 left, downward and to the right, along an imaginary line extending between 
 two points represented by the middle of the dome and the lowest point on the 
 greater curvature of the stomach. The lowest point, which is variable, is 
 placed at from 5 to 7.5 cm. (2 to 3 inches) to the left of the sphincter of the 
 pylorus. The handles of the gastric clamp will point to the patient's right 
 shoulder. Mayo carries the incision to the lower edge of the stomach, which 
 requires the separation of the greater omentum from the posterior aspect of 
 the stomach to some extent. The incision into the jejunum is made upon 
 its antimesenteric aspect. (9) While the jejunum is held in contact with 
 the posterior stomach-wall (both being drawn as far out of the abdominal 
 
 
 . 
 
 w 
 
 r 
 
 J. - 
 
 Fig. 718. — Posterior Gastroenterostomy : — III. — The jejunum is shown sutured to 
 the wall of the stomach — the latter part of the seromuscular suture being placed. (Modified 
 from Mayo and Gould.) 
 
 cavity as feasible) the surfaces are sutured together exactly as in Wolner's 
 Anterior Gastro-enterostomy (page 968). (10) With a long, straight needle, 
 threaded with chromic gut or silk, a line of continuous suturing, passing 
 through serous and muscular coats of the intestine, on the one hand, and the 
 same coats of the stomach, on the other, is carried along what will form the 
 posterior line of union, the needle being inserted at close intervals — the suture 
 left hanging long at both ends, with the needle at one end, and knotted at the 
 other — and the suturing having extended in a slightly elliptical direction, 
 beginning and ending about 1.2 cm. {\ inch) beyond the ends of the future 
 incision through the two opposed walls (Fig. 718). (n) With a sharp-pointed 
 bistoury, a quick, controlled stab is made into the stomach, in its oblique 
 axis, and then into the intestine, in its long axis, in the indicated sites, and 
 
POSTERIOR GASTROENTEROSTOMY. 977 
 
 so planned that the incisions will fall immediately opposite each other and 
 be of the same size — the incisions being made while both stomach and intestine 
 are clamped and are so held by an assistant as to present their proper sur- 
 faces, and, at the same time, the opposite walls are held apart so as not to be 
 also penetrated by the knife stab. One blade of a pair of sharp-pointed 
 scissors is now introduced, and both incisions lengthened in both viscera 
 to the extent of about 5 to 6.5 cm. (2 to 2 J? inches) — until within about 1.2 
 cm. (i inch) of either end of the posterior line of suturing. These incisions 
 into the stomach and intestine, made immediately opposite each other, should 
 be from 5 to 8 mm. (| to J inch) from the suture-line. Soiling of the adjacent 
 structures with the outflow of stomach and intestinal contents should be 
 prevented as much as possible with gauze packing. All bleeding should be 
 controlled by clamping and twisting — and is further controlled by suturing — 
 and by gut ligature if necessary. (12) Immediately following these incisions 
 the margins of the intestinal incision are united to the margins of the stomach 
 incision by continuous suturing with silk or chromic gut, passed with a curved 
 needle held in a holder, the sutures passing through all the coats of both 
 stomach and intestine, the edges of the incision being so held as to enable 
 them to be whipped together by an overhand stitch. (13) The threaded end 
 of the original continuous gut or silk suture is now taken up and the line of 
 suturing continued from the end where it was temporarily discontinued, 
 on around now in front of the line of incisions into stomach and intestine, 
 in the same slightly elliptical outline as upon the posterior aspect, and passing 
 about 8 to 12 mm. (^ to h inch) from the line of incision into the lumina of 
 the viscera — until the suturing reaches the opposite end, when the free end 
 of the suture is tied to the end originally left long after knotting. Thus 
 the inside line of sutures, chiefly for strength, is reinforced by this secondary 
 line uniting the muscular and serous coats, and thus shutting off any leakage 
 which might escape through the suturing of the margins alone. The stomach 
 and intestine must be so manipulated during the various stages of the suturing 
 as to present the site to the surgeon most advantageously. (14) A third line 
 of interrupted gut Lemberts may be now applied, burying in the other two, 
 if thought necessary — but is rarely needed. (15) The viscera are now 
 undamped and dropped back into the peritoneal cavity. After which the 
 limbs of the jejunal loop are anastomosed by simple suturing, or by some 
 form of mechanical device. See comment following YYolfler's Anterior 
 Gastro-enterostomy, page 971, and also Figs. 713, 714, and 715. (16) The 
 abdomen is closed in the usual manner. 
 
 Comment. — (1) When adhesions make the exposure of the lesser peri- 
 toneal cavity difficult or impossible, the posterior operation should be abandoned 
 and the anterior adopted. (2) The jejunum should be suspended by a 
 stitch to the stomach on each side of the anastomosis, to prevent kinking and 
 dragging (Hadra). (3) The portion of the jejunum about 10 to 12.5 cm. 
 (4 to 5 inches) from the duodenojejunal juncture is used. About 7.5 cm. 
 (3 inches) of the viscera are taken up in the clamps. (4) In the posterior 
 operation, the opening in the stomach is made with a slight obliquity from 
 left to right and from above downward — the intestine being incised in its long 
 axis, as in the anterior operation. (5) The suturing of the split transverse 
 mesocolon to the stomach lessens the chance of the intestine slipping through 
 the opening — and also lessens traction of the transverse mesocolon on the small 
 intestine. (6) The application of the sutures is somewhat more difficult in the 
 posterior operation. In placing the continuous suture, it is well to tie it at 
 intervals, without interrupting its continuity — to prevent its acting as a draw- 
 
97 8 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 string. There is also probably greater danger of twisting of the intestines 
 subsequently — owing to the passage through the slit in the mesocolon. (7) 
 While a single intestinal anastomosis is generally advisable, some surgeons 
 perform multiple intestinal anastomoses — to further prevent regurgitation of 
 intestinal contents. Some surgeons also narrow the caliber of the proximal 
 portion of the small intestine, by Lemberts through the serous and muscular 
 coats transversely, thus infolding the walls as a rosette. (8) The various 
 disadvantages of the anterior operation are, however, largely overcome — and 
 some of them entirely overcome. The direction of the flow and the position 
 of the parts are more natural. 
 
 Fig. 719. — Posterior Gastroenterostomy by the Murphy Button, followed by 
 Entero-enterostomy : — A and B, Great omentum and transverse colon turned upward; C, 
 Transverse mesocolon with edges of its incised wall sutured to posterior stomach-wall; D, Pos- 
 terior stomach-wall with a half-button inserted; E, Coil of jejunum, with a half-button inserted; 
 F, F, Forceps holding buttons; G, Coil of jejunum, just beyond ligament of Treitz, given a 
 half-turn; H, Mesentery of jejunum; I, Entero-enterostomy by simple suturing; J, Intestinal 
 clamps. 
 
 POSTERIOR GASTROENTEROSTOMY 
 
 BY THE MURPHY BUTTON. 
 
 Description. — Consists in anastomosing the jejunum to the posterior 
 stomach-wall by means of the Murphy button — the manner of exposing the 
 
GASTROGASTROSTOMY. 979 
 
 parts being the same as in Von Hacker's Posterior Gastro-enterostomy — 
 and the manner of applying the button being identical with its application 
 in the operation of Anterior Gastro-enterostomy by the Murphy button. See 
 pages 971 and 974. (Also see Fig. 719.) 
 
 Where a single or multiple intestinal anastomosis is done in connection 
 with the operation of Gastro-enterostomy, it may be performed in one of 
 the several manners mentioned upon page 972. 
 
 Note. — There are several other methods of performing both Anterior and 
 Posterior Gastro-enterostomy — but those above described are considered 
 among the best modern methods. 
 
 GASTROGASTROSTOMY 
 
 BY W'oLFI.KR'S OPERATION. 
 
 Description. — The operation of Gastrogastrostomy consists in the anasto- 
 mosis of the two pouches of an hour-glass contraction of the stomach, for 
 the purpose of making a common cavity. Wolfler's method of operating 
 is probably more applicable to a symmetrically deformed hour-glass contrac- 
 tion, where the two pouches are approximately of the same size and the inter- 
 vening connection fairlv large. 
 
 1 
 
 Fig. 720. — The Pouches of an Hour-glass Stomach. 
 
 Preparation — Position. — Gastrostomy in General, page 956. 
 
 Landmarks. — As for median abdominal section. 
 
 Incision. — In the median line — from the tip of the xiphoid cartilage to 
 about 7.5 cm. (3 inches) below the umbilicus. 
 
 Operation. — (i) Having exposed the abdominal cavity, the deformed 
 stomach is brought as well into the wound as possible — the portion inter- 
 vening between the two pouches being apt to be bound down to the pancreas 
 and gastro-hepatic ligament. (2) Having packed off the adjacent regions 
 
980 
 
 OPERATION'S UPON THE ABDOMINO-PELVIC REGION. 
 
 with gauze, the assistant clamps and hold- first «>ne and then the other gastric 
 pouch conveniently to the surgeon — the clamps including most of the anterior 
 stomach-wall, and the greater curvature and omental attachment, so as to 
 obliterate the pouches. (3) Oval incisions (thus excising elliptical portions) 
 are made upon those aspects of the two pouches which face each other — 
 extending into their lower borders, so as to re-establish a greater curvature. 
 (Figs. 720 and 721.) It is well to use Kammerer's application of Finney's 
 gastro-duodenostomy technic here (Figs. 729-733). These openings are 
 about 7 cm. (2J inches) long and pass through all the coats of the stomach. 
 Bleeding vessels are clamped and gut-ligatured. The pouches are so held 
 as to minimize the escape of intestinal contents. (4) An assistant now 
 approximates the two openings, while a continuous seromuscular suture is 
 first applied posteriorly, followed by a through-and-through suture of the 
 margins. Then the outlying line of sutures through the serous and muscular 
 coats, which had been applied posteriorly only, is now continued on around 
 
 Fig. 721. — Gastro-gastrostomy for Hour-glass Stomach: — The two pouches have been 
 clamped and incised, and are approximated ready for suturing. ( Redrawn from Gould.) 
 
 the sides and in front — thus completing the double line of suturing. Similarly 
 and preferably the cut margins can be whipped together with a continuous 
 overhand stitch of all the coats, followed by an outlying continuous sero- 
 muscular suture. (5) The stomach is now returned to its position and the 
 abdomen closed. 
 
 Comment. — (1) The openings are so calculated that they will correspond 
 with the greater curvature of the stomach — and increase this when the two 
 halves of the stomach are united. (2) In some cases of non-symmetrical 
 hour-glass contraction of the stomach, the pyloric pouch is bent over upon 
 a vertical axis and sutured along an elliptical outline to the cardiac pouch — • 
 an opening is then made in the pyloric pouch, and through this an incision ■ 
 is made through the two walls which have been sutured together and which 
 now intervene between the two pouches — the margins of this incision through 
 the double walls is then whipped over with a button-hole stitch — and then 
 the original incision in the pyloric pouch is closed by sutures — and the abdo- 
 men, which has been opened by an incision from the tip of the xiphoid carti- 
 
GASTROPLICATION. 981 
 
 large down the median line two-thirds of the way to the umbilicus, and thence 
 rounding outward and upward to the left costal arch, is closed — constituting 
 Watson's operation. 
 
 GASTROPLICATION. 
 WEIR'S MODIFICATION OF BIRCHER'S operation. 
 
 Description. — Gastroplication consists in the reduction of the size of a 
 chronically dilated stomach bv invaeinating a fold of the stomach-wall into 
 
 Figs. 722 and 723. — Gastroplication (Weir's Modification of Bircher's Operation): — I. 
 A, Sound infolding anterior stomach-wall ; B, B, First tier of Lembert sutures burying in sound ; C, 
 Second tier of sutures ready to bury in sound for second time, when latter is placed upon first tier. 
 II. Sectional view of stomach after the two tiers have been tied. 
 
 the lumen of the stomach, with suturing together of the walls of the infolded 
 portion. 
 
 Preparation — Position — Landmarks. — As for median abdominal sec- 
 tion. 
 
 Incision. — In the median line — from below the ensiform cartilage, nearly 
 or quite to the umbilicus. 
 
 Operation. — (1) Expose the abdominal cavity by the usual steps of the 
 median abdominal section — control hemorrhage — retract the edges of the 
 wound — well expose the anterior surface of the stomach and lift it as far 
 forward into the wound as possible, separating by blunt dissection all minor 
 adhesions. (2) In a direction parallel with the long axis of the stomach, 
 
982 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 and midway between the greater and lesser curvatures, depression of the 
 anterior surface of the stomach is made with a sound, causing parallel longi- 
 tudinal ridges to form on either side of the sound. (Figs. 722 and 723.) 
 (3) These ridges of anterior stomach-wall are now united with interrupted 
 silk sutures, passing through serous and muscular coats of each ridge, and 
 extending for 15 to 20 cm. (6 to 8 inches). (4) The sound is now withdrawn 
 and reapplied over the first line of sutures, and parallel with it — similarly 
 depressing them — and similarly causing two secondary parallel longitudinal 
 folds of anterior stomach-wall to rise up on each side of the sound. These 
 secondary folds are similarly sutured. Whether a third tier is placed, will 
 depend upon the size of the stomach — the process being continued, in some 
 cases, until the greater and lesser curvatures meet. (5) The stomach is then 
 allowed to recede into position — and the abdomen is closed. 
 
 Comment.— Bircher did not suture the two walls of the fold together, 
 but left a dead space — Weir's suturing of these folds into apposition con- 
 stitutes his modification. Chromic gut may be substituted for silk. 
 
 Figs. 724 and 725.— Gastroplication (Moynihan's Modification of Bircher's 
 Operation): — I. — Interrupted plaiting sutures in anterior wall of stomach; II. — Cross-section 
 of stomach, showing the result of tightening and tying these sutures. 
 
GASTROLYSIS. 983 
 
 GASTROPLICATION. 
 moynihan's modification of bircher's operation. 
 
 Description. — The same object is here accomplished by a different 
 application of the sutures. 
 
 Preparation — Position — Landmarks — Incision. — As in the preceding 
 operation. 
 
 Operation. — Having exposed the stomach, a series of vertical interrupted 
 seromuscular sutures are placed in its anterior wall — as illustrated in Fig. 724. 
 Each stitch passes into the wall of the stomach several times — and when these 
 are drawn tight and tied, the wall of the stomach is folded into as many plaits 
 or ridges as there are bites in each suture — as shown in Fig. 725, the plaitings 
 projecting into the interior of the organ. A posterior gastroenterostomy 
 is done in completing the operation. 
 
 GASTROPEXY. 
 
 Description. — Consists in the suturing of a prolapsed or displaced stomach 
 to some fixed point of support. The condition of the stomach is termed 
 gastroptosis — and as this condition is frequently associated with a general 
 enteroptosis (Glenard's disease) of the abdominal viscera, suturing into a 
 more fixed position of other viscera than simply the stomach is generally 
 indicated. The viscera usually sutured to the anterior abdominal wall are 
 the stomach, liver, and transverse colon. 
 
 Preparation — Position — Landmarks. — As for median abdominal sec- 
 tion. 
 
 Incision. — In the median line, from just below the xiphoid cartilage to 
 or below the umbilicus. 
 
 Operation. — (1) Expose the abdominal cavity — control hemorrhage — 
 retract margins of wound — isolate the stomach and other displaced organs. 
 (2) The following steps have been resorted to: — (a) Treves, in whose case 
 the liver was also involved, passed three stout silk sutures — one through 
 the edge of the liver to the round ligament — and two from the falciform 
 ligament and round ligament to the fibrous tissue of the abdominal parietes 
 near the ensiform cartilage, (b) Duret passed a continuous suture through 
 the serous and muscular coats of the anterior wall of the stomach, on the 
 one hand, and through the undivided parietal peritoneum on a level with 
 the fold around the round ligament of the liver, on the other, (c) Rovsing 
 placed three silk ligatures between the anterior wall of the stomach and 
 the parietal peritoneum, (d) Davis, in one case, sutured, with silk, the lesser 
 curvature of the stomach to the parietal peritoneum near the xiphoid cartilage. 
 In another case, he did the same operation, together with gastroplication. 
 (e) Beyea shortened the gastro-hepatic omentum with eight or ten inter- 
 rupted sutures, (f) Depage operated by lessening the capacity of the ab- 
 dominal cavity by removing a T-shaped segment of the abdominal wall. 
 
 GASTROLYSIS. 
 
 Description. — Consists in division of gastric peritoneal adhesions from 
 neighboring structures. The adhesions are met incidentally, in the course 
 of other operations. 
 
 The region of adhesions having been well exposed in the course of some 
 
984 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 primary operation, the adhesions are dealt with according to their nature: — 
 
 (1) Slight, flat adhesions may be separated by finger or blunt dissection; — 
 
 (2) Cord-like or ribbon-like adhesions are divided between double ligatures;— 
 
 (3) Extensive, firm adhesions often require partial excision of the wall of 
 the stomach, or that of the neighboring organ — with repair of the denuded 
 surface, or excised area, by suturing, omental grafting, etc. 
 
 Note. — See the section upon Peritoneal Adhesions, page 822. 
 
 GASTROPLASTY. 
 
 Description. — An operation for widening the opening between the two 
 pouches of an hour-glass contraction of the stomach — similar in principle 
 and application to Pyloroplasty. 
 
 The stomach is exposed by median abdominal section — after which the 
 narrowed portion between the two pouches is brought into the field — and 
 the same operation is there done which will be described below under Pvloro- 
 plasty. 
 
 The contracted portion of the stomach is grasped with special clamps 
 in the long axis of the organ. An incision into the lumen is then made 
 in the long axis of the clamped portion — and the protruding mucous 
 membrane excised. While the anterior stomach-wall is being drawn forward 
 with forceps, so as to prevent leakage, the clamps are shifted — and are made 
 to grasp the opening at a right angle to their first hold. The margins 
 of the opening are then closed by a continuous overhand suture of all the 
 coats — followed by a continuous seromuscular suture after the removal of 
 the clamps. The principle is the same as that of the Heinecke-Mikulicz 
 pyloroplasty (page 984). 
 
 PYLOROPLASTY. 
 
 THE HEINEKE-MIKULICZ OPERATION. 
 
 Description. — Consists in an increasing of the caliber of the pyloric 
 orifice of the stomach, by means of a horizontal incision through its anterior 
 wall, corresponding with the site of stricture, followed by a vertical suturing 
 of the wound. Chiefly resorted to in non-malignant stricture of the pylorus. 
 
 Preparation — Position. — As for Gastrostomy. 
 
 Landmarks. — Linea alba — for median incision; — right rectus — for in- 
 cision through rectus. 
 
 Incision. — (1) Incision is generally made in the median line, beginning 
 a short distance below the xiphoid cartilage and extending nearly to, or 
 beyond, the umbilicus. (2) A better approach to the site itself, though with 
 more injury to the abdominal wall, is accomplished by a vertical incision 
 through the outer third of the right rectus muscle. The median incision will 
 be used in the operation which follows. 
 
 Operation. — (1) The abdominal cavity having been opened — hemor- 
 rhage is controlled — and the edges of the wound, especially on the right 
 side, are well retracted. (2) 'The pylorus is isolated (any slight adhesions 
 being separated by blunt dissection) and brought into the abdominal wound 
 as well as possible. Neighboring regions are well guarded by gauze packing. 
 (3) Incise longitudinally through the anterior wall of the pylorus, beginning 
 over the gastric aspect and ending over the duodenal aspect of the pylorus, 
 
PYLOROPLASTY. 
 
 985 
 
 -•/- ^H^^^ 
 
 Fig. 
 
 726. — Pyloroplasty (Heinecke-Mikulicz Operation): — I. — The stomach and duodenum 
 are clamped and the constricted gastro-duodenal junction incised. 
 
 Fig. 727. — Pyloroplasty (Heinecke-Mikulicz Operation): — II. — The incision which was 
 made in the long axis of the gastro-duodenal constriction is now retracted in the opposite direction. 
 Two rows of interrupted sutures are placed — through-and-through (the shorter) and sero- 
 muscular (the longer). 
 
 and extending along midway between the superior and inferior borders of 
 the pylorus — through all the coats. (Fig. 726.) The incision, at first, is 
 about 2 cm. (f inch) long. The right index-finger is then inserted through 
 
986 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 this opening and passed on into the pylorus, to determine the degree of con- 
 striction and the thickness of the wall, by palpation between the internal 
 finger and external thumb. The incision is now continued through the 
 strictured portion on into the healthy duodenum and stomach — and is gener- 
 ally about 5 cm. (2 inches) long. (4) By means of wound-hooks, or silk 
 retractors, inserted at the center of either side of each lip, draw upon the 
 margins until the longitudinal wound first becomes diamond-shaped, and 
 then transverse — and while held in this last position the sutures are applied. 
 (5) The mucous membrane may be first sutured with continuous silk suturing, 
 or sutures may pass through all the coats. (Figs. 727 and 728.) Interrupted 
 silk Lembert sutures are then introduced through serous and muscular coats. 
 If indicated, a third continuous Lembert suture may be applied. (6) The 
 parts are then thoroughly cleaned and dropped back into position — and the 
 abdomen closed in the usual manner. 
 
 Comment. — (I) In a very dense, thick wall, a small diamond-shaped 
 excision may be made — to aid in the approximation of the two edges. (2) 
 Suturing may be done as above, but over an absorbable tube. (3) The site 
 of operation should be clamped on both sides. 
 
 Fig. 728.— Pyloroplasty (Heinecke-Mikulicz Operation): — III. — The sutures are tied and 
 the former contracted site is now shown to be of larger caliber than normal. 
 
 DIVULSION OF PYLORIC ORIFICE OF STOMACH. 
 
 LORETA'S OPERATION. 
 
 Description. — The cavity of the stomach having been entered by gastro- 
 tomy, the constricted pyloric orifice is dilated either by finger or instrument. 
 Sometimes resorted to in non-malignant stricture. 
 
 Preparation—Position— Landmarks— Incision.— As for Gastrotomy 
 by median incision. 
 
 Operation. — (1) Median abdominal section is done — and the abdominal 
 walls retracted. (2) The pylorus is isolated and brought as well into the 
 wound as possible— exactly as in Pyloroplasty. The region is well packed 
 
GASTRO-DUODENOSTOMY. 987 
 
 off with gauze. (3) Incise the anterior stomach-wall vertically, at a distance 
 of about 5 cm. (2 inches) from the pylorus, and midway between the upper 
 and lower curvatures — at first, to an extent only sufficient to admit the index- 
 finger snugly. (4) The right index-finger is immediately inserted through 
 the opening and is made to slowly work its way through the pyloric stricture — - 
 while the region is steadied from without by the left hand. Should the 
 stricture be found too tight for the tip of the finger, a dilating instrument 
 may be used first — to be followed by the finger. When the stricture is en- 
 larged sufficiently to accommodate one finger, the stomach wound is enlarged 
 with a blunt bistoury, without withdrawing the first finger, and the middle 
 finger introduced alongside of it. The fingers in the stomach wound prevent 
 any considerable hemorrhage — the vertical direction of the gastric incision 
 also aiding in this respect. Even a third finger may be introduced. (5) 
 The object having been accomplished — the fingers are withdrawn — and the 
 hemorrhage from the stomach wound is controlled by clamping and twisting, 
 or by gut-ligaturing. (6) The wound in the stomach is then sutured in 
 the ordinary manner — or as in Pyloroplasty. (7) The abdominal wound is 
 closed in the usual fashion. 
 
 Comment. — (i) Incision into the stomach may be parallel with its length 
 and just to the left of the pylorus — as in Pyloroplasty. (2) Loreta inserted 
 both index-fingers and stretched in opposite directions. (3) In Halm's 
 operation, no opening is made into the stomach — the neighboring stomach- 
 wall is simply invaginated into the pylorus upon the end of the finger. 
 
 DILATATION OF CARDIAC ORIFICE OF STOMACH. 
 
 See under Retrograde Dilatation of Esophagus, page 716. 
 
 GASTRODUODENOSTOMY. 
 finney's operation. 
 
 Description. — The establishment of an artificial outlet from stomach to 
 duodenum. The operation consists, briefly, in the making of an extended 
 Heinecke-Alikulicz incision in the gastro-duodenum and suturing the margins 
 of the incision in a special manner — after mobilizing the upper portion of 
 the duodenum. The technic is used for the enlargement of the pyloric outlet 
 of the stomach in non-malignant cases. 
 
 Preparation — Position — Landmarks — Incision. — As for gastrotomy 
 by median incision (page 952). 
 
 Operation. — In the following description the interpretation of the opera- 
 tion as given by Gould will be largely followed. Having exposed the gastro- 
 duodenal region, mobilization of the upper portion of the duodenum is accom- 
 plished. To emote from Kocher: — "To free the duodenum in this way it is 
 necessary to divide the parietal peritoneum to the right of the descending part 
 of the duodenum. The membrane is divided vertically over the front of the 
 right kidney, a little to the left of the descending limb of the hepatic flexure 
 of the colon. We recommend that this delicate layer of the parietal peritoneum 
 be divided with the knife two finger-breadths to the right of and parallel to 
 the second part of the duodenum, so that the peritoneum covering the anterior 
 surface of the duodenum may not be injured, as would be the case were the 
 peritoneum simply torn through. If the divided peritoneum adjacent to the 
 
9 8S 
 
 OPERATIONS UPON THE ABDOM1NO-PELVIC REGION. 
 
 Fig. 729. — Gastroduodenostomy — Finney's Operation: — I. — Showing the approxima- 
 tion of stomach and duodenum by means of traction-sutures, preparatorily to the placing of 
 the sutures. 
 
 Fig. 730. — Gastroduodenostomy — Finney's Operation: — II. — The posterior layer of 
 seromuscular suturing is shown — and the dotted line indicates the position of the incision through 
 the walls of the stomach and duodenum. 
 
GASTRO-DUODENOSTOMY. 9S9 
 
 second part of the duodenum be grasped and pulled forward, the fingers can 
 be introduced behind the duodenum so as to raise it from the vertebral column, 
 the vena cava, and the aorta. By the above manipulations the second part of 
 the duodenum is rendered so movable that it can easily be brought up to the 
 anterior surface of the pyloric portion of the stomach above the greater curva- 
 ture." After this freeing, the duodenum and stomach are clamped in the 
 following manner (in Finney's original description they were held in contact 
 by traction sutures, Figs. 729 and 730); — a longitudinal fold of about 6 cm. 
 (2J inches) of the anterior aspect of the duodenum is clamped, the inner limb 
 of the clamp passing up to the pyloric sphincter; — a corresponding portion of 
 the anterior wall of the stomach at the lower portion of its pyloric aspect is 
 similarly clamped, the point of the outer limb of the stomach clamp meeting 
 
 Fig. 731. — Gastro-duodenostomy — Finney's Operation: — III. — The parts are here 
 shown held in contact by clamps, which are applied at the beginning of the operation. The 
 seromuscular line of suturing has been placed. (This is the same stage as the preceding illus- 
 tration, where, less desirably, traction sutures are used.) 
 
 the point of the inner limb of the intestinal clamp (Fig. 731). When the 
 clamps are clasped and brought together, the gastro-duodenal angle is put upon 
 the stretch — thus controlling hemorrhage and leakage from this area, otherwise 
 difficult to manage. A seromuscular continuous suture is now carried down 
 from the pyloric angle through the aspects of stomach and duodenum in 
 contact — being left long at their angle of separation (Fig. 731). A U-shaped 
 incision is next made into the lumen of stomach and intestine, directly over 
 the center of each clamp, and continuous with each other around the gastro- 
 duodenal angle (Fig. 731). The protruding mucous membrane, especially 
 that of the stomach, is trimmed off even with the seromuscular margins of the 
 openings. The incised edges of stomach and intestine are now sutured 
 
990 
 
 OPERATIONS UPOxN THE AHDOM1NO-PELVIC REGION. 
 
 Fig. 732. — Gastro-dcodenostomy — Finney's Operation: — IV. — The posterior layer of 
 the seromuscular suture is shown — and part of the posterior layer of the through-and-through 
 suturing is seen. 
 
 Fig- 733- — Gastro-duodenostomy — Finney's Operation: — V. — The operation completed. 
 
PYLORECTOMY FOLLOWED BY GASTROJEJUNOSTOMY. 991 
 
 together with an overhand running stitch of all coats — beginning with the 
 posterior lips and ending with the anterior, knotting the suture where the 
 return-stitch begins, the suture ending at the pyloric angle, where it began 
 (Fig. 732). If the parts are too tense to enable this stitch to be completed 
 otherwise, the clamps are relaxed before its last portion is completed. Finney 
 uses mattress sutures, placed prior to incising, to close in the anterior lips. 
 The clamps are now taken off and the continuous seromuscular suture, already 
 begun upon the posterior aspect, is now continued around the anterior aspect 
 of the wound (Fig. 733). 
 
 Comment. — The normal size of the pyloric outlet should be calculated 
 for, or a slight overcorrection, in planning the length of the incision — which 
 Finney makes about 10 cm. (3 inches). 
 
 PYLORECTOMY 
 
 IN GENERAL. 
 
 Pylorectomy consists in the excision of the pylorus, together with as much 
 of the stomach and duodenum as may be necessary. Generally resorted to 
 in cases of malignant growth of the pyloric end of the stomach. The operation 
 is sometimes called partial gastrectomy, especially where a considerable portion 
 of the stomach is removed. 
 
 After all pylorectomies an additional operation is always necessary, uniting 
 the lower intestinal tract with the stomach. The cut end of the duodenum 
 is the part generally united to some part of the stomach — though the cut 
 end of the duodenum may be closed by suture and the jejunum united. 
 The anastomosis may be by simple suturing or by some form of mechanical 
 device. 
 
 PYLORECTOMY FOLLOWED BY INDEPENDENT GASTRO-JE JUNOSTOMY. 
 
 MAYo'S OPERATION. 
 
 Description. — The operation consists of the excision of more or less of 
 the pyloric end of the stomach — followed by the closure of the proximal end 
 of the duodenum and the making of an independent posterior gastrojejunos- 
 tomy. The operation is, practically, a partial gastrectomy — and is resorted 
 to for malignant disease of the gastro-duodenum. The writings of William 
 J. Mayo will be here largely followed. 
 
 Preparation — Position — Landmarks. — As for gastrotomy by median 
 incision, page 952. 
 
 Incision. — Preliminarily, a limited incision is made in the median line, 
 midway between ensiform cartilage and umbilicus, for exploration — and 
 nothing more is done if the case be inoperable — the abdomen being closed with 
 some insoluble suture to expedite convalescence. Otherwise this incision 
 is enlarged to the extent of 10 to 12.5 cm. (4 to 5 inches). 
 
 Operation. — (i) Having opened the abdomen, the liver is retracted 
 upward, the stomach depressed, and the structures in the neighborhood of the 
 pylorus and duodenum exposed. (2) The four arteries which supply the 
 gastro-duodenum are controlled early in the operation, so as to minimize the 
 hemorrhage. The gastric is doubly ligated and divided about 2.5 cm. (1 inch) 
 below the cardiac orifice, where it passes to the lesser curvature. The gastro- 
 hepatic omentum is doubly ligated and divided as far as necessary (from the 
 site of ligation of the gastric artery to the structures in the free border of the 
 
992 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 omentum), the division being made close to the liver and leaving the greater 
 portion of the structure adherent to the stomach. The lesser peritoneal 
 cavity is thus opened up and the pyloric end of the stomach mobilized, together 
 with the tumor. The entire region is well protected with gauze packing. 
 The pyloric artery is now doubly tied and ligated near the pylorus — and 
 the first part of the duodenum freed for 3 or 4 cm. (i| to ij inches), prepara- 
 tory to its later resection. (3) Having entered the lesser omental cavity, 
 and guided by a finger beneath the pylorus, raise the gastro-colic omentum 
 from the transverse mesocolon and thus safely ligate the right gastro-epiploic 
 
 Fig. 734. — Pylorectomy, followed by Independent Gastrojejunostomy — Mayo's 
 Operation: — I. — The duodenum is doubly clamped and divided and the distal end sutured. 
 The lesser end of the stomach is doubly clamped, ready to be divided. The gastro- hepatic and 
 gastro-colic omenta have been tied off and divided, the division being beyond the region of the 
 lymph-nodes, which are left attached to the excised portion. The ligature of the gastro-duoden- 
 alis and gastro-epiploica sinistra arteries, along the lesser and greater curvatures of the stomach, 
 which are approached by bringing the incisions through the omenta toward the borders of the 
 stomach, are not shown here (see Fig. 735). 
 
 artery (or its parent vessel, the gastro-duodenal) . Thence doubly ligate and 
 divide progressively the gastro-colic omentum distal to the lymphatic glands 
 and vessels, up to the indicated point on the greater curvature, where the 
 left gastro-epiploic vessels are ligated. In ligating off the omenta the line of 
 ligatures should be so placed that the lymph-nodes will be left with the part 
 of the gastro-duodenum to come away. Avoid tying or cutting the middle 
 colic artery in entering the lesser omental cavity by separating it from the 
 mesocolon — as it is generally the entire supply of the transverse colon. (4) 
 The duodenum is divided by actual cautery between two clamps (Fig. 734), 
 
PYLORECTOMY FOLLOWED BY GASTROJEJUNOSTOMY. 
 
 993 
 
 leaving a stump 3 mm. (| inch) long — through the end of which a running 
 catgut suture is placed before the clamp is removed, and drawn tight as the 
 clamp comes away. This stump is then inverted by a silk or linen seromuscu- 
 lar purse-string suture placed around the duodenal stump, 2 cm. (f inch) 
 below its end. A Kocher stomach-clamp, guarded with rubber tubing, 
 clamps the stomach from the ligated gastric artery at Mikulicz's point of 
 election, obliquely to Hartmann's point of election at the greater curvature. 
 A second stomach-clamp is applied to the pyloric aspect of the first clamp, 
 to guard against leakage at the time of division. The stomach is now divided 
 through both of its walls by means of the actual cautery, 3 mm. (\ inch) from 
 the holding clamp — the severed part of the cardiac end being caught, as 
 
 Fig- 735- — PYLORECTOMY, FOLLOWED BY INDEPENDENT GASTROJEJUNOSTOMY : — MAYO'S 
 
 Operation: — II. — The excised portion has been removed, showing the corresponding portions 
 of the gastro-hepatic and gastro-colic omenta tied off. The duodenum is closed. All of the 
 through-and-through suturing of the stomach has been completed — and most of the seromus- 
 cular line of suturing. The arteries of the lesser and greater curvatures of the stomach are tied. 
 The outline of the independent posterior gastro-enterostomy is seen through the stomach. 
 
 divided, by catch forceps, to prevent retraction within the bite of the forceps. 
 The pyloric end of the stomach, with tumor, is now removed (Fig. 735). 
 The severed edges of the cardiac end of the stomach are sutured together, 
 from greater to lesser curvature, with catgut button-hole suture through all 
 the coats of both anterior and posterior walls — "and in the same manner 
 directly back, and tied at the starting-point, thus preventing hemorrhage as 
 well as leakage." On removing the clamp any bleeding point is ligated. 
 A seromuscular suture, of the right-angle Cushing type, is placed beyond the 
 preceding stitch, thus burying it in and completing the approximation. It 
 should be so placed as to avoid tension. (5) Having completely closed the 
 ends of the duodenum and of the stomach, an independent gastrojejunostomy 
 is done with a loop of the jejunum. The parts are thus brought easily into 
 
994 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 apposition and tension and handling of traumatized viscera are avoided, as 
 would be apt to be the case in the older forms of directly uniting the divided 
 end of the duodenum to the lower portion of the sutured edges of the stomach, 
 or to its anterior or posterior wall. The gastrojejunostomy is done in the 
 usual manner (page 974, and Figs. 716 and 717). Either the posterior or 
 anterior operation can be done, and the union may be by simple suturing or 
 by some mechanical device. Mayo prefers posterior gastrojejunostomy by 
 simple suturing, if the patient's condition be good and the operation a prompt 
 one — and an anterior gastrojejunostomy by the Murphy button if the condi- 
 tion be poor. (6) The abdomen is closed in the usual manner. 
 
 After-treatment. — The patient's head and shoulders are raised by four 
 or five pillows. Rectal alimentation is used. After twelve hours, hot water 
 is given by mouth in half-ounce doses, increased to an ounce every hour. 
 After thirty-six hours, careful feeding with fluid food is used. 
 
 Comment. — (1) Stress is laid upon the division of viscera and omenta 
 with the actual cautery — as means of avoiding the dissemination of cancer 
 cells throughout the abdomen. (2) Careful gauze packing is used throughout 
 — a deeper layer, which is not changed from beginning to end of operation, 
 to further aid in preventing dissemination — and a superficial layer, which is 
 being constantly changed. (3) Cigarette drains are used when much soiling 
 has occurred, the drain coming from just above the transverse colon and 
 emerging at the lower angle of the wound. 
 
 PYLORECTOMY FOLLOWED BY END-IN-SIDE POSTERIOR GASTRO- 
 
 DUODENOSTOMY. 
 
 kocher's method. 
 
 Description. — This operation consists in the excision of the pylorus, 
 with as much of the adjacent stomach and duodenum as indicated — followed 
 by a complete closure, by invaginating and suturing, of the pyloric end of 
 the stomach — and an approximation of the cut end of the duodenum to the 
 posterior aspect of the stomach near its excised end. A less desirable form 
 of pylorectomy than the Mayo technic. 
 
 Preparation — Position — Landmarks. — As for gastrotomy by median 
 incision. 
 
 Incision. — About 10 to 15 cm. (4 to 6 inches) in length — beginning a 
 short distance below the ensiform cartilage, and extending as far as necessary 
 below the umbilicus, in the median line. 
 
 Operation. — (1) Perform ordinary median abdominal section — excise the 
 umbilicus — control hemorrhage — retract lips of wound. Bring into the 
 wound the involved parts, lifting them as far out of the abdominal cavity 
 as possible. (2) Ligate off the lesser and greater omenta for an extent cor- 
 responding to the area involved and sever with scissors from the stomach 
 and duodenum, near the visceral borders. Ligate all bleeding vessels with 
 gut. Isolate the parts from which the omenta have been separated — and 
 protect, with gauze packing, the underlying and adjacent parts from the 
 stomach and intestinal contents. (Fig. 736.) (3) A clamp is placed upon the 
 duodenum just distal to the part to be removed — and a second clamp about 
 2.5 cm. (1 inch) still distal to the first, and parallel with it, the handles of the 
 clamps lying in opposite directions. Two clamps are now placed across the 
 pyloric end of the stomach, in the same line, on the cardiac side of the growth 
 — one being placed from the lesser and one from the greater curvatures, 
 
PYLORECTOMY, KOCHER'S OPERATION. 
 
 995 
 
 their ends overlapping. (4) The duodenum is now cut through between 
 its two clamp — the edges of the distal end being disinfected with 1 : 1000 
 bichloride, and turned over the right edge of the wound — and the proximal 
 end wrapped in gauze and lifted out of the wound. (5) An assistant, using 
 his forefingers and thumbs (or first and second fingers) as a second pair of 
 clamps, seizes the stomach from above and below, a short distance to 
 the cardiac side of the stomach clamps — and compresses the stomach firmly, 
 gauze being placed to catch any leakage from the stomach. The stomach 
 is now cut through between the two stomach clamps — and the growth 
 
 Fig. 736. — Pylorectomy, followed by Posterior Gastro-duodenostomy (Kocher's 
 Operation) : — Pylorus, with involved malignant growth tc be removed; Lesser omentum 
 ligated off; Greater omentum ligated off; Clamps placed on either side of line of future incision 
 through stomach; Clamps similarly placed upon duodenum. (Modified from Kocher.) 
 
 removed — and all bleeding vessels ligated with gut. (6) The cut edges of the 
 stomach are now first sutured with continuous silk suture, passing through 
 ail three coats in an overhand, or whipping fashion — approximating the 
 anterior and posterior walls. All projecting mucous membrane is disinfected 
 with bichloride. This line of primary suturing is then invaginated by a 
 second line of continuous silk Lembert sutures of serous and muscular coats 
 — thus burying in the first line and extending a short distance beyond its ends. 
 (Fig. 737.) (7) The assistant, holding the stomach in both hands, so manipu- 
 lates it as to direct its posterior wall to the front and to the right, compressing 
 
996 
 
 OPE RATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 the duodenum between the stomach and right edge of the abdominal wound 
 and thus (losing the lumen of the gut. While the stomach is thus held, the 
 posterior aspect of the duodenum (still in the grasp of the forceps) is applied 
 to the posterior wall of the stomach (the serous surfaces of both being in 
 contact). (Fig. 737.) (8) A continuous posterior serous suture of silk is 
 now placed between the serous and muscular coats of the posterior wall of 
 the stomach and the posterior aspect of the duodenum thus approximated, 
 from the upper to the lower border of the intestine — both ends of the suture 
 being left long after knotting, and the needle threaded to the lower one. 
 
 Fig- 737- — Pylorectomy, followed by Posterior Gastro-duodenostomy (Kocher's 
 Operatiom): — II. — Clamp holding stomach forward while duodenum is being sutured to its 
 posterior aspect; Line of continuous Lembert sutures uniting outer coats of stomach and duo- 
 denum; Line of continuous overhand sutures through all coats, uniting their edges. (Modified 
 from Kocher.) 
 
 These sutures in the intestine are placed sufficiently far from its extreme end 
 to leave the circumference of the extreme end of the gut free for suturing to 
 the stomach opening. The hitherto retained forceps are undamped from 
 the duodenum — (unless a pair should be kept on further down) — and what- 
 ever leakage occurs is caught upon gauze — the lumen of the gut is then disin- 
 fected—and the vessels are gut-ligatured. (9) The posterior stomach-wall 
 is now incised vertically about 1.2 cm. (\ inch) from the posterior serous 
 suture just inserted, and for a distance equal to the breadth of the duodenum. 
 Bleeding vessels are gut-ligatured. (10) A continuous silk ligature is now 
 passed, upon curved needle in holder, uniting the edges of the cut end of the 
 duodenum to the edges of the stomach opening, passing through all the coats 
 of both viscera, around the entire circumference. This line of suturing is 
 
PYLORECTOMY, BILLROTH'S OPERATION. 997 
 
 chiefly for strength. If preferred, two rows ma}" be used — one of the mucous 
 membrane — and one of the serous and muscular coats, (n) Taking up 
 now the still threaded end of the posterior serous suture, that line of con- 
 tinuous suturing is continued around the anterior aspect, forming the anterior 
 serous suture, passing through the serous and muscular coats of the intestine 
 and stomach, until the surfaces throughout the entire circumference are 
 approximated, and is then tied to the opposite free end of the suture. (12) 
 The parts are then thoroughly cleaned and disinfected and dropped back into 
 place. (13) Prior to the return of the parts to the abdomen, the free edges 
 of the lesser and greater omenta should be gut-ligatured to the upper and lower 
 margins, respectively, of stomach and intestine at the site of operation. (14) 
 The abdominal wound is then closed as in ordinary median abdominal sec- 
 tion. 
 
 Comment. — (i) The omenta can be ligated off conveniently with Cleve- 
 land's ligature-carrier, or an aneurism-needle. (2) The division of the stomach 
 and intestines is usually made with scissors. (3) A rather long abdominal 
 wound may be needed to enable sufficient lateral displacement to the right 
 to expose the gastroduodenal site sufficiently for the necessary technique, 
 upon the accuracy of the details of winch so much depends. (4) The Mur- 
 phy button may be used for the approximation, after the excision of the 
 growth by the above method. (5) A second pair of stomach clamps may 
 be used instead of the fingers of an assistant. 
 
 PYLORECTOMY FOLLOWED BY END-TO-END GASTROENTEROSTOMY. 
 
 BILLROTH'* OPERATIOX. 
 
 Description. — Following the excision of the pylorus, together with the 
 adjacent involved portions of the stomach and duodenum, the large opening 
 left in the pvloric end of the stomach having been lessened by suturing to the 
 size of the lumen of the duodenum, the two viscera are anastomosed by simple 
 suturing, end to end. This operation is not so desirable as either of the 
 preceding. 
 
 Preparation — Position. — As for Gastrotomy. 
 
 Landmarks. — Right rectus muscle. 
 
 Incision. — Vertical, in the outer third of the right rectus, beginning a 
 short distance beneath the costal arch and extending downward to or below 
 the level of the umbilicus. Various incisions have been used; — A median 
 incision, which does not so readily expose the parts; — An obliquely transverse 
 incision 10 to 12.5 cm. (4 to 5 inches) long, having one-third of its length to 
 the left, and two-thirds to the right of the linea alba, and crossing that line 
 obliquely downward from left to right, between the xiphoid cartilage and 
 umbilicus, Billroth's original line, which necessitates much transverse division 
 of muscle, though better exposing the parts. 
 
 Operation. — (1) Expose the peritoneal cavity in the usual manner of 
 abdominal section by vertical incision through the outer third of the rectus 
 muscle — control hemorrhage and retract the margins of the wound. (2) 
 The site of the operation is carefully located and packed off with gauze — 
 slight adhesions being broken down by blunt dissection — and the parts brought 
 as well forward into the wound as possible. (3) The lesser and greater omenta 
 are ligated off along the area corresponding with the parts to be removed — 
 by gut-ligature carried by an aneurism-needle, or Cleveland ligature-carrier — 
 along the upper and lower borders of the pyloric end of the stomach and duo- 
 
OOS OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 denum. (4) As soon as freed from omental attachment, the contiguous por- 
 tions of the stomach and intestine are to be packed off with especial care from 
 the general cavity and adjacent structures with gauze. Two clamps are now 
 placed upon the duodenum, parallel with and about 2 cm. (f inches) apart, on 
 
 Fig. 73S.— Pylorectomv (Billroth's Operation) : — I. A, Malignant pylorus excised; B, Free 
 end of duodenum; C, Portion of stomach-opening in excess being closed by interrupted sutures of all 
 coats, followed by interrupted Lemberts of the outer coats ; D, Remaining portion of stomach-opening 
 to be sutured to the duodenum. 
 
 either side of the line to be incised. Two are similarly placed upon the stomach 
 about 2.5 cm. (1 inch) apart. The lines of incision are so calculated that they 
 will be parallel. (5) The duodenum is first divided between the clamps, with 
 scissors. All leakage is carefully caught and the interior of the free end of the 
 gut cleaned. The stomach is then similarly dealt with. The excised portion 
 is now removed. The free ends of the stomach and intestine are brought well 
 forward and abundant packing placed posteriorly. The clamps are retained 
 as convenient means of aiding in the manipulation of the parts. (6) In order 
 to provide a lumen of stomach at the pyloric end which will correspond with 
 that of the duodenum, all that portion of the cut edges of the stomach in excess 
 of the required lumen is closed. This is done by a continuous overhand silk 
 suture including all the coats of both edges of the stomach. It begins at the 
 lesser curvature and is carried downward the required distance — leaving un- 
 sutured, next to the greater curvature, a lumen of stomach which will corre- 
 spond in size with the opposite lumen of duodenum. A line of continuous 
 or interrupted chromic gut Lembert sutures immediately buries in this first 
 line of silk suturing, passing through the serous and muscular coats of the 
 stomach, on either side of the first suture line and thus invaginating it. (Fig. 
 738.) (7) The free edges of the openings in the duodenum and stomach are 
 then approximated by an assistant who holds them in apposition by means of 
 the clamps. By means of a continuous or interrupted silk suture including all 
 the coats of intestine and stomach, the duodenum is sutured to the remaining 
 opening in the stomach — the parts being so turned, as the suturing progresses, 
 as to present the entire circumference. This line of sutures is chiefly for 
 strength. (8) The line of continuous circular suturing just applied is im- 
 
PARTIAL GASTRECTOMY. 
 
 999 
 
 mediately followed by a second tier of interrupted silk Lembert sutures passing 
 through serous and muscular coats of both viscera, thereby burying in by in- 
 vagination the first tier. This second line of suturing is chiefly for occlusion. 
 (Fig. 730.) (9) The clamps being relaxed and all parts being thoroughly 
 
 Fig. 739. — Pylorectomy (Billroth"s Operation) :— II. A, Upper portion of stomach-opening 
 sutured ; B, Interrupted sutures of all coats uniting duodenum to lower portion of stomach-opening ; 
 C, Interrupted Lemberts uniting outer coats. The greater curvature of stomach is here restored. 
 
 cleansed, the lesser and greater omenta, which had been previously ligated and 
 detached, are now resutured with gut to the upper and lower borders of the 
 attached stomach and duodenum. (10) The parts are then dropped back 
 into place and the abdomen closed. 
 
 Comment. — (1) The above is the description of Billroth's operation in the 
 main — the line of incision, the manipulation of the parts, and especially the 
 method of suturing being simplified. (2) If indicated, after excision of the 
 pyloric end of the stomach, the large opening may be closed to fit the duodenum 
 by being sutured partly from the lesser curvature downward and partly from 
 the greater curvature upward. Again, the junction may be made continuous 
 with the lesser curvature — though the stomach is better emptied when made 
 continuous with the greater curvature. (3) Murphy's button may be used in 
 accomplishing the approximation. Still other forms of operation are the 
 following; — Pylorectomy with posterior gastrojejunostomy by means of 
 Murphy's button: — Posterior gastrojejunostomy at first sitting, followed 
 by pylorectomy at second sitting (Czerny). 
 
 PARTIAL GASTRECTOMY 
 
 (OF THE MEDIAN PORTION). 
 
 Description. — The median portion of the stomach is sometimes excised 
 for stricture or malignancy. The free edges of remaining portions are then 
 united end-to-end. Any excess in size, upon the part of the cardiac end, 
 is provided for by special suturing. 
 
 Preparation — Position — Landmarks — Incision. — As for gastrotomy by 
 median incision. 
 
IOOO OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Operation. — The stomach is brought into the held as in the last operation. 
 The arteries along the upper and lower curvatures of the stomach are ligated 
 (Fig. 740) — the gastric artery along the lesser and the epiploic arteries along 
 the greater curvature — so planning the double ligatures as to leave satisfactory 
 blood supply to the severed edges. The gastro-hepatic and gastro-colic 
 omenta are ligated off in sections, corresponding with the portion of the 
 stomach to be excised, after which the lesser peritoneal cavity and the adjacent 
 parts are protected with gauze packing. Double clamps are now placed on 
 each side of the area to be excised, about 2.5 cm. (1 inch) apart, and allowing 
 ample margin of healthy tissue between the growth and themselves. The 
 involved portion of stomach is now cut away with scissors passing through 
 
 Fig. 740. — Partial Gastrectomy (of the Median Portion):— I. — The cardiac and 
 pyloric aspects of the stomach are doubly clamped, ready to be divided. The gastro-hepatic 
 and gastro-colic omenta are ligated and divided. The arteries of the lesser and greater curva- 
 tures are doubly ligated. 
 
 all the coats and travelling between each set of clamps — especial care being 
 used to guard the field from the inevitable leak which follows opening up the 
 mucous cavity of the organ. The free edges of the incised portions are now 
 approximated by means of the clamps, and held in a convenient position for 
 suturing (Fig. 741). A continuous silk or linen overhand suture of all the 
 coats is first made, and applied while the clamps are tilted away from the 
 suture-line, knotting the suture at intervals, to avoid the purse-string effect. 
 Outside of these a second row of suturing is placed, of the seromuscular type, 
 carried continuously or interruptedly, and consisting of silk or linen. Where 
 the calibers of the two portions are about alike, no great difficulty is experienced 
 in adjusting them to each other. Where a disparity exists (the cardiac end 
 
TOTAL GASTRECTOMY, 
 
 IOOI 
 
 usually being larger than the pyloric end) the edges of the excess caliber are 
 made to overlap on the line of the greater curvature of the stomach — the 
 smaller caliber being applied to and sutured into as much of the larger caliber 
 as is indicated. The omental incisions are sutured with catgut. 
 
 Comment. — The greater curvature may be restored (insuring a freer 
 emptying of the stomach, probably, by uniting the parts in the same manner 
 as in Billroth's pylorectomy (page 997, and Figs. 73S and 739). It is well 
 to leave as much of the cardiac end of the stomach as possible — to increase 
 
 Fig. 741. — Partial Gastrectomy (of the Median Portion): — II. — The median excised 
 portion of the stomach has been removed and the incised edges of the cardiac and pyloric aspects 
 are approximated by means of the clamps. The posterior layer cf the seromuscular suture has 
 been placed — its free end showing. The posterior layer of the through-and-through suture has 
 also been placed — and one end left free. The redundant portion of the cardiac aspect of the 
 stomach is sutured separately, by through-and-through and seromuscular sutures, until its 
 caliber corresponds with that of the pyloric aspect. 
 
 the ease of approximating the duodenum — excess of cardiac end being sutured 
 down to fit the duodenum, as in gastro-duodenostomy. (1) Displacement 
 of the left lobe of the liver, temporarily, aids in giving room. (2) As the 
 esophagus is more brittle than the stomach, it is well, where possible, to leave 
 enough of the latter for suturing to the duodenum. (3) Brigham, not having 
 sufficient room for simple suturing, united duodenum and esophagus with 
 No. 3 Murphy button, without any subsequent suturing. (4) Delatour used 
 temporary abdominal drainage. 
 
 TOTAL GASTRECTOMY. 
 
 Description. — Consists in the total removal of the stomach. Following 
 the removal of the stomach, anastomosis'is at once made between the esophagus 
 
1002 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 and some part of the small intestine. When circumstances permit of suffi- 
 ciently easy approximation of the cut end of the duodenum to the cut end of the 
 esophagus, esophago-duodenostomy is performed. Where this is impossible, 
 the free end of the duodenum is closed, and a loop of the jejunum is anasto- 
 mosed with the esophagus, constituting esophago-jejunostomy. 
 
 Preparation — Position — Landmarks. — As for Gastrotomy by median 
 incision. 
 
 Incision. — In the median line, from the xiphoid cartilage to or below the 
 umbilicus. 
 
 Operation. — (£) Expose the peritoneal cavity — control hemorrhage — re- 
 tract the wound. (2) The stomach and duodenum are brought to view — ad- 
 hesions, if any, being separated by blunt dissection, or divided between double 
 ligatures — and these viscera are then brought as well forward as possible. (3) 
 The lesser (gastro-hepatic) omentum is ligated off with silk near the duo- 
 denum and lesser curvature of the stomach — beginning at the duodenum and 
 extending toward the esophagus. When 8 to 10 cm. (3 or 4 inches) have been 
 thus ligated, the greater omentum is similarly ligated off, beginning at the 
 duodenum and following along the greater curvature. After 8 to 10 cm. (3 
 or 4 inches) of this omentum is ligated, the ligaturing is interrupted here and 
 resumed along the lesser omentum — and thus alternating upon the two omenta, 
 manipulating and rotating the stomach as indicated, both omenta are entirely 
 tied off. (4) The duodenum is now* clamped off with two parallel clamps and 
 divided between them — the adjacent regions having been packed off with 
 gauze. Both free ends are also well protected with gauze (the duodenum being 
 well cleansed) — the clamps being left in situ. (5) The gastro-splenic omen- 
 tum is ligated off and divided — and also the gastro-phrenic omentum. (6) 
 While some tension is being exercised upon the stomach to draw the esophagus 
 downward, a clamp is placed upon the esophagus as high up as possible. An- 
 other esophageal clamp is placed just below the site at which division is to be 
 made. The esophageal end of the stomach is then divided between the clamps, 
 the freed ends being treated as above described, the esophageal end being 
 particularly cleansed and protected. (7) An attempt is then made to ap- 
 proximate the duodenum and esophagus, and if the ends come together 
 without too much tension, they are at once united. If the esophageal end of 
 the stomach (especially when much of the cardiac end is left) be too large, it is 
 sutured down to fit the duodenum (as described under Pylorectomy). In 
 Schlatter's operation, the duodenum was sutured to the esophagus in the fol- 
 lowing manner; — the mucous membrane of the esophagus was united to that of 
 the duodenum by continuous silk suture; — the serous and muscular coats of 
 each viscus were then united by continuous suture; and both of these were 
 followed by a row of Lembert sutures. The clamps are then removed. (8) 
 If the duodenum cannot be made to easily reach the esophagus, the duodenum 
 is closed at its free end and the nearest coil of jejunum is anastomosed to the 
 esophagus (esophago-jejunostomy) — followed, if thought best, by an anasto- 
 mosis of the two coils of jejunum lower down (jejuno-jejunostomy). (9) 
 The omenta are sutured into as nearly a normal position as possible. (10) 
 The viscera are replaced and the abdomen closed. 
 
 OPERATION FOR GASTRIC ULCER. 
 
 Description. — The nature of the operation will depend upon the nature 
 and position of the ulcer. According to Welch, the most frequent sites of 
 gastric ulcers are as follows; — Upon the lesser curvature, 36 per cent.; posterior 
 wall, 29 per cent.; pylorus, 12 per cent.; anterior stomach-wall, 8 per cent.; 
 cardiac end, 6 per cent.; fundus, 3 per cent.; greater curvature, 3 per cent. 
 
OPERATION FOR GASTRIC ULCER. 
 
 1003 
 
 According to Brinton, 2 per cent, of those which occur on the posterior wall 
 perforate — 85 per cent, of those on the anterior wall — 40 per cent, of those on 
 the cardia — and 10 per cent, of those at the pylorus. 
 
 Preparation — Position — Landmarks — Incision. — As for Gastrotomy by 
 median abdominal section. 
 
 Operation for Perforated Gastric Ulcer. — Having exposed and brought 
 into the field, by median abdominal section, the stomach, and located the 
 ulcer, its treatment will depend upon the local conditions found; — (a) "Where 
 the walls are pliable and the ulcer small; — Invert the edges of the ulcer with 
 interrupted Lembert or Halsted sutures, without excision of its margins, (b) 
 "Where the gastric walls are rigid and thick: — Excise the ulcer elliptically — 
 unite the mucous membrane bv continuous silk suture — then the serous and 
 
 Fig. 742. — Excision or Gastric Ulcer: — I. — The lesser curvature of the stomach and 
 the area of the ulcer clamped off by two clamps compressing anterior and posterior stomach- 
 walls in a V-shaped fashion. 
 
 muscular coats with interrupted silk sutures, (c) "Where the edges of the 
 ulcer cannot be brought together: — One of the following methods may be used; 
 Patch with omental graft; Plug with omentum, sewing it in; Suture to a neigh- 
 boring structure; Suture to the abdominal wound and drain; Perform gastro- 
 enterostomy, uniting the incised intestine with the ulcerated stomach-opening 
 (after excising the edges of the latter) ; Drain the ulcer through the abdominal 
 wound, packing with gauze to make sinus between abdominal wound and ulcer. 
 (d) Where the question of possible malignancy may be associated with a 
 gastric ulcer, the entire suspicious area should be widely excised. In those 
 cases where the ulcer is situated upon the lesser curvature, which is their 
 most usual site, the area is excised by a V-shaped incision, with the limbs of 
 the V abutting upon the lesser curvature (Fig. 742). The gastric artery is 
 
ioo4 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 doubly ligated, and divided and the necessary extent of gastro-hepatic omentum 
 is tied off in sections. The site is controlled by two clamps placed in a V-shaped 
 fashion — their tips meeting at the apex of the V- The area is excised with 
 scissors, leaving a free margin. Owing to the inaccessibility of the posterior 
 margins these arc besl sutured with Connell stitches (page 864, Fig. 614). 
 These may be placed far enough back from the free edges as to leave room 
 
 *1 Swo' 
 
 »% 
 
 Fig. 743. — Excision of Gastric Ulcer:— II.— The margins of the stomach, left by the 
 excision, approximated by clamps — with the first tier of suturing (through-and-through) shown. 
 
 for a continuous overhand stitch of all the layers of both margins placed 
 within the outlying interrupted through-and-through Connell stitches. The 
 anterior edges of the wound are closed, first by an overhand continuous 
 stitch of all the layers (Fig. 743), followed by a continuous seromuscular 
 suture. 
 
 Comment. — Non-perforating ulcer may also be treated by excision and 
 gastrorrhaphy. Also see Enterorrhaphy for Wounds of the Intestine, page 848. 
 
 VII. THE LIVER. 
 
 SURGICAL ANATOMY. 
 
 Description. — Presents three surfaces (superior, or phrenic; — inferior, or 
 visceral; — posterior) : — two extremities (right and left) : — one border (anterior). 
 Its average measurements are transversely, 28 cm. (11 inches) — antero-pos- 
 teriorly, 20 cm. (8 inches) — vertically, 6 cm. (2^ inches). 
 
 Position. — Occupies parts of right hypochondriac, epigastric, and left 
 hypochondriac regions; — situated below diaphragm — above stomach, duo- 
 denum, transverse colon, and small intestine — and in front of right false ribs 
 (tenth, eleventh, and twelfth). 
 
SURGICAL ANATOMY. 1005 
 
 Fissures. — Left longitudinal fissure: — Anterior part forms umbilical 
 fissure (for umbilical vein in fetus, and for its remains, the round ligament, in 
 adult) ; — Posterior part forms fissure of ductus venosus. Right longitudinal 
 fissure : — Anterior part, forms fossa for gall-bladder; — Posterior part, fossa for 
 vena cava. Transverse fissure : — Transmits hepatic artery, portal vein, 
 hepatic duct, nerves, lymphatics, and connective tissue. 
 
 Lobes. — Right, Left, Quadrate, Caudate, Spigelian. 
 
 Ligaments and Fixations of Liver. — (i) Coronary: — from posterior 
 surface of liver to diaphragm. Formed of two layers of reflected parietal 
 peritoneum. (2) Right lateral ligament : — from right lobe of liver to back 
 of diaphragm. Lateral continuation of coronary ligament. (3) Left lateral 
 ligament : — from left lobe of liver to diaphragm anterior to esophagus. Lat- 
 eral continuation of coronary ligament. Note: — Middle portion of coronary 
 ligament has its anterior layer furnished by greater peritoneal sac, its posterior 
 layer by lesser sac; Right lateral ligament has both layers from greater sac; 
 Left lateral ligament has both layers from greater sac. (4) Longitudinal 
 (broad or suspensory) ligament : — Passes antero-posteriorly upon upper 
 and anterior portion of liver. Posteriorly and superiorly it is connected with 
 the coronary ligament. Anteriorly and superiorly it is connected with the 
 posterior sheath of the right rectus muscle, up to the umbilicus — and thence 
 to under surface of diaphragm, diverging to either side. Free anterior margin 
 extends from interlobular notch to transverse fissure — containing round liga- 
 ment (remains of fetal umbilical vein). Inferiorly it extends along the superior 
 surface of the liver, from before backward. Formed by portions of peritoneum 
 covering superior surface of liver — one layer passing over left lobe, the other 
 over right, and meeting at longitudinal ligament. (5) Round ligament : — 
 Remains of umbilical vein — in free margin of longitudinal ligament, extending 
 from left longitudinal fissure to umbilicus. (6) Lesser omentum (Gastro- 
 hepatic omentum) : — may be considered a ligament of liver, consisting of 
 following parts; — (a) Lig. Hepato-gastricum — from borders of transverse 
 fissure to upper curvature of stomach; — (b) Lig. Hepato-duodenale — that part 
 embracing superior curvature of duodenum, and enclosing following structures; 
 common bile-duct, portal vein, hepatic artery, lymphatics and nerves; — (c) 
 Lig. Hepato-colicum — that part passing over duodenum to transverse colon; — 
 (d) Lig. Hepato-renale — that part from inferior surface of right lobe of liver 
 (near gall-bladder and vena cava, and posterior to foramen of Winslow), to 
 upper surface of right kidney; — (e) Lig. Cystico-duodenale — that part from 
 gall-bladder to duodenum. Xotc: — Fusion of upper surface of liver to dia- 
 phragm forms a strong fixation of liver. 
 
 Peritoneal Covering. — Only portions of liver uncovered by peritoneum 
 are; transverse fissure, fossa of gall-bladder, and postero-superior aspect of 
 right lobe (where fused to diaphragm). 
 
 Relations.— (1) Antero-posteriorly: — diaphragm (whole of right arch 
 and part of left — which separates liver from right and left lungs and peri- 
 cardium) ; abdominal wall; six or seven lower right ribs (seventh to eleventh, 
 according to Morris) ; fifth to ninth right costal cartilages (sixth to ninth, ac- 
 cording to Morris). (2) Inferiorly: — stomach (cardiac and pyloric ends, 
 lesser curvature, and part of anterior surface) ; duodenum (superior curve and 
 descending parts); gall-bladder and cystic duct; portal vessels; right kidney 
 and capsule; colon (hepatic flexion). (3) Posteriorly: — diaphragm and 
 crura; tenth and eleventh dorsal vertebrae; tenth and eleventh ribs; esophagus; 
 aorta; vena cava; right suprarenal capsule; thoracic duct. 
 
 Vessels of Liver. — Hepatic artery (of cceliac axis), artery of supply; 
 
1006 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Portal vein, bringing blood from stomach, intestines, pancreas, and spleen; 
 Hepatic veins, emptying blood of liver into vena cava; Hepatic duct, formed at 
 transverse fissure. 
 
 Lymphatics. — Deep set; accompany portal vein, hepatic artery, and duct 
 and join superficial set. Superficial set; empty into (a) mediastinal glands; 
 (b) sometimes into thoracic duct; (c) glands of small omentum; (d) lumbar 
 glands; (e) glands of esophagus and lesser curvature of stomach. 
 
 Nerves. — From left pneumogastric and cceliac plexus. 
 
 Structures at Transverse Fissure. — (a) Hepatic artery, portal vein, and 
 numerous nerves enter: — (b) Hepatic duct and some lymphatics leave: — Note: 
 the hepatic veins do not emerge here, but pass backward into the vena cava. 
 
 Order of Structures at Transverse Fissure. — From before backward; 
 hepatic duct, hepatic artery, portal vein. 
 
 Order of Structures in Gastro-hepatic Omentum. — Common bile-duct, 
 to right; hepatic artery, to left; portal vein, behind and between other two. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The liver occupies parts of right hypochondriac, epigastric, and left hypo- 
 chondriac regions — filling all of right and part of left diaphragmatic arches — 
 the diaphragm forming dome of cavity in which liver rests and passing down 
 laterally between ribs and liver. 
 
 Upper limit of right lobe — is along line from right fifth chondro-sternal 
 articulation extending horizontally outward to a point about 2.5 cm. (1 inch) 
 below the right nipple — thence downward to seventh rib at lateral aspect of 
 chest. 
 
 Upper limit of left lobe — along line from right fifth chondro-sternal artic- 
 ulation extending across sternum slightly downward to a point about 5 cm. 
 (2 inches) to left of gladiolus, on a level with left sixth costal cartilage. 
 
 Lower limit of right margin — corresponds with line passing from behind 
 forward about 1.2 cm. (J inch) below the lower margin of the right thorax to 
 right ninth costal cartilage — thence obliquely across the subcostal angle to 
 left eighth costal cartilage. 
 
 Lower limit of left margin — represented by a curved line, with outward con- 
 vexity, from left eighth costal cartilage to a point 5 cm. (2 inches) to left of 
 gladiolus and on a level with left sixth costal cartilage. 
 
 Lower border of liver in middle line — about half-way between xiphoid 
 cartilage and umbilicus. 
 
 Convex surface of liver, on right side — corresponds with seventh to eleventh 
 ribs, inclusive — and, in front, with ensiform cartilage and sixth to ninth costal 
 cartilages, inclusive. 
 
 Heart descends to left fifth interspace. Right lung descends to superior 
 margin of sixth rib, in the nipple-line. 
 
 Note. — Authorities differ considerably upon the relations of the liver to the 
 thoracic wall. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The liver may be approached either through the abdominal cavity, the 
 more usual route — constituting a transperitoneal operation; — or through the 
 thoracic cavity — in which latter case the operation may be either transpleural 
 or subpleural, while, at the same time, intrathoracic. 
 
 While desirable that all incisions should be in intramuscular cleavage lines 
 
THE LIVER— GENERAL SURGICAL CONSIDERATIONS. 1007 
 
 as far as possible, yet, as hernia of the upper abdominal wall is less frequent 
 than of the lower, incisions about the liver and gall-bladder, therefore, often 
 violate this desirable rule. 
 
 The two most general methods of transperitoneal approach are the follow- 
 ing: — (a) Bv incision parallel with and about 1.2 to 2 cm. (h to f inches) below 
 the right costal arch, with its center over the indicated site; — (b) By incision 
 in the right linea semilunaris (which runs down from the ninth rib to the pubic 
 spine) — or further outward, from the tenth costal cartilage — passing from the 
 lower border of the right costal arch as far down as necessary. 
 
 Oblique subcostal incision: — gives better approach to the subhepatic space 
 — and especially to the right end of the liver. It may be extended upward or 
 downward obliquelv, parallel with the costal arch. It will cross the external 
 oblique and transversalis at a right angle, and about coincide with the fibers 
 of the internal oblique. It affords a somewhat better chance to preserve some 
 of the abdominal nerves. 
 
 Anterior vertical incision: — gives best access to gall-bladder and ducts — 
 together with a very good exposure of the liver. A vertical incision in the right 
 linea semilunaris — or more externally, from the tenth costal cartilage — can be 
 increased directlv downward to give room. Its lower end may also be ex- 
 tended transversely, or obliquely, toward the median line — giving an angular 
 flap. A continuation of the original incision gives a very extensive approach 
 to the abdominal cavity — and even the pelvis. The simple vertical incision 
 will cross the external and internal oblique muscles obliquely, and the trans- 
 versalis at a right angle — and will cross the abdominal nerves at a right angle. 
 
 In operating to expose the liver, it will often be found, when the liver is 
 reached, that its serous surface is adherent to the parietal peritoneum — and, 
 therefore, that its substance can be entered without involving the general 
 peritoneal cavity. 
 
 As adjuncts to the satisfactory exposure of these sites, the following man- 
 oeuvres are helpful: — (a) the reversed Trendelenburg position — (b) firm up- 
 ward traction upon the liver and right costal arch — (c) passage of the left index 
 through the foramen of Winslow and the left thumb over the lesser omentum, 
 thus embracing that structure between the digits. 
 
 When the round ligament is encountered descending to the umbilicus and 
 is severed, it should be sutured at the end of the operation. 
 
 Standing, the lower border of the liver is about 1.2 to 2.3 cm. (\ to \ inch) 
 below the costal cartilages; — reclining, the lower border recedes until about 
 2.5 cm. (1 inch) above the lower costal cartilages. This change in position, 
 and change during respiration, must, therefore, be allowed for in suturing the 
 liver to the parietes. 
 
 Anteriorly, the gastro-diaphragmatic sinus (between the lower edge of the 
 pleura and the diaphragm) makes it possible to reach and pierce the diaphragm 
 more easily and without involving the pleura, in operating intrathoracically, — 
 therefore the subpleural operation is more generally done anteriorly or antero- 
 laterally. This sinus is absent posteriorly, and an incision here would pass 
 through the pleura (if that structure were not raised from the course of in- 
 cision by blunt separation) — hence the posterior operation is generally trans- 
 pleural. 
 
 In the transpleural operation, where the two layers of pleura? cannot be 
 sutured /';/ situ — the parietal pleura is incised — its edges are grasped with for- 
 ceps, or traction-sutures (to keep them from receding out of the way) — then 
 the visceral peritoneum is incised — and the edges of the parietal and visceral 
 peritoneum are whipped together by an overhand stitch. 
 
iooS 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 INSTRUMENTS USED IN OPERATIONS UPON LIVER AND 
 GALL-BLADDER. 
 
 Scalpels; bistouries; scissors, curved and straight; forceps, dissecting and 
 toothed; artery-clamp forceps; clamp-forceps for adhesions; retractors, various; 
 broad spatulae; grooved director; tenaculum; costotome; blunt dissector; in- 
 testinal clamps; forceps for removing calculi; forceps for crushing calculi; 
 Halsted's hammer; lithotomy scoop (small) ; lithotomy forceps (small) ; needles 
 for needling stones; cholelithotomy forceps and scoop; sponge-holders; gauze 
 pads with tails; intestinal and other needles; silk, gut, and silkworm-gut; drain- 
 age-tubing, glass-drains, gauze-drains; exploratory cannula and trocar, or 
 exploratory needle; intestinal instruments; Murphy button (special) ; probe. 
 
 EXPLORATORY PUNCTURE OF LIVER. 
 
 Description. — Resorted to for withdrawal of fluid for diagnostic pur- 
 poses — generally pus or hydatid. An operation involving some danger. The 
 site of puncture is generally determined by some physical sign, such as tumor 
 or other indication — and the puncture is made by the safest and most direct 
 route into the site. 
 
 Preparation. — Site asepticized. 
 
 Position. — Such as to best expose the region. 
 
 Landmarks. — Anatomical outline of liver; physical signs. 
 
 Fig. 744.— Relative Relation of Abdominal Viscera on Level with Lowest Part of 
 Costal Arch (5 cm., or 2 inches, above umbilicus ; on a level with second lumbar vertebra) : — A, 
 Stomach; B, Liver; C, Spleen; D, Pancreas; E, E, Kidneys; F, Transverse colon. (Modified from 
 Riidinger.) 
 
 Operation. — The exploration is usually made with the needle of an ex- 
 ploratory syringe. The depth of puncture is to be guarded by the right index 
 on the barrel of the needle — and to be largely determined in advance by the 
 estimated thickness of the abdominal or thoracic wall and intervening liver 
 substance at the site to be punctured. If no physical sign guiding to the seat 
 of exploration exist, puncture may be made in several sites: — (i) Laterally, 
 
HEPATOTOMY IN GENERAL. ioog 
 
 in the ninth, tenth, or eleventh intercostal space, in the mid-axillary line — the 
 most general position — and the tenth space being the one most frequently 
 used; — (2) Anteriorly, in the subcostal angle, over the known region of the 
 liver (on anatomical grounds) — in the space bounded, above, by the costal 
 arches, and, below, by a line from the right ninth costal cartilage to the left 
 eighth costal cartilage. In abnormal cases, the liver may, of course, be looked 
 for considerably lower than usual; — (3) Posteriorly, in the tenth intercostal 
 space on the right. The liver is in relation, posteriorly, with the tenth and 
 eleventh ribs — and the pleura comes down to the twelfth, or lower — hence the 
 pleura would be pierced if not displaced; — (4) Transthoracic — preferably 
 subpleural — rarely transpleural. See subpleural and transpleural hepatotomy, 
 pages 1014 and 1016; — (5) Below the free border of the ribs — where the liver 
 dulness extends belov; — (6) At any point from which liver substance can be 
 reached with minimum risk and danger — the guides being anatomical and 
 physical. Upon the withdrawal of the needle the puncture-wound is generally 
 sealed with sterile gauze and collodion. (See Fig. 744.) 
 
 Comment. — (1) Wounding of the lung should be avoided — and also 
 piercing of the pleura or diaphragm, unless specially indicated. (2) The dia- 
 phragm would be penetrated by any puncture above the lower border of the 
 ribs or costal arch. The pleura would be penetrated by any puncture above 
 the eighth right rib in the nipple-line — the ninth right rib in the mid-axillary 
 line — (the tenth left rib in the same line) — and the twelfth right rib in the pos- 
 terior scapular line. The lung would be penetrated by any puncture above the 
 sixth costo-sternal articulation in front — the sixth right rib in the nipple-line — 
 the eighth right rib at the mid-axillary line — and the right twelfth rib in the 
 scapular line. 
 
 HEPATOTOMY IN GENERAL. 
 
 (1) Hepatotomy consists in an incision of the liver — and is generally re- 
 sorted to for abscess, hydatid cyst, or other tumor. The site of the incision 
 is usually determined in advance — by the presence of a tumor, or as a result of 
 an exploratory puncture. (2) The liver may be exposed by the transperito- 
 neal, subpleural, or transpleural routes — and each of these routes may be fol- 
 lowed from the anterior, lateral, or posterior aspects of the thoracico-abdom- 
 inal wall — though each method of approach usually has a site of preference. 
 (3) The selection of the site and method of operation will depend upon the 
 location of the abscess, or other condition — as to its accessibility, importance 
 of contiguous organs, and possibility of drainage. (4) The choice of incision 
 for approaching the liver transperitoneally will generally lie between the oblique 
 subcostal and vertical subcostal incisions — each having its advantages (see 
 General Surgical Considerations). It is to be remembered that abscesses, 
 hydatids, tumors, etc., often project downward considerably below the ribs. 
 It is also to be remembered that, after incision of such sacs and emptying of 
 their contents, there is a tendency for the portion of involved liver to regain its 
 normal position — and that, therefore, in calculating to suture such parts to the 
 abdominal wall for drainage, calculation must be made that the stitching will 
 not draw the part too far out of its natural position. (5) Where no guide 
 exists, the anterior or antero-lateral subcostal transperitoneal route is generally 
 chosen, as, in abscess, pus is usually in the more anterior part of the right lobe. 
 But after exposure of the liver, if, by exploratory syringe, or otherwise, pus be 
 found in a locality more conveniently reached and drained from another ex- 
 ternal incision, the first incision may be closed and a second made in the in- 
 64 
 
ioio OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 dicated position. (6) The different incisions described in the following pages 
 are given to cover the various sites in which the liver may be exposed — and 
 apply as much to the exposure of the liver for other purposes as for incision 
 of that viscus. In the case of pus or hydatids the site of operation will 
 generally have been indicated by a preliminary exploratory puncture. (7) 
 The operation of exposure of the liver may be done in one or in two stages. 
 In operating in one stage, the liver is exposed and the organ is cut into at once — 
 after safeguarding the general peritoneal cavity by suturing the parietal perito- 
 neum to the surface of the liver, or by gauze packing, — or, in transthoracic 
 operations, after protecting the pleural cavity on the same principles. In 
 operating in two stages, the liver is first exposed and the wound then packed 
 with gauze for two or three days, until the peritoneal surface of the liver adheres 
 to the wound (the union being reinforced and aided by sutures, in some cases) 
 — and then the organ is incised. (8) In operating transthoracically, if the 
 pleura be wounded, it should be immediately sutured — with a purse-string 
 suture, if possible, thus drawing the edges together. (9) The subpleural 
 method is generally impossible if adhesions exist — but then, also, the pleural 
 cavity is apt to be shut off — so that it is not opened up even if one passes 
 through its layers. (10) The posterior superior aspect of the right lobe of the 
 liver is fused to the diaphragm (there being no peritoneum here) — hence the 
 diaphragm may be immediately incised in this locality, without waiting for 
 adhesions. An abscess here would be subphrenic and extraperitoneal, (n) 
 If the transpleural method of approaching the liver be adopted, the same prin- 
 ciples should be adhered to as in operating transperitoneally — either suture the 
 two opposed pleurae together and incise through them at once — or press the 
 two pleural surfaces into contact with gauze packing for two or three days, 
 until adhesions occur — and then incise through them. (12) It is preferable 
 to pass beneath the pleura rather than through it — and if they must be incised 
 at once, it is preferable to suture the parietal and visceral layers together pre- 
 paratory to going through them. The operation of suturing the pleura?, how- 
 ever, is quite difficult — and the suturing is apt to tear away — or allow of leak- 
 age. (13) In cutting into the liver the incisions should be made in straight 
 lines radiating from the direction of the center toward the periphery. (14) 
 Bleeding from deep incisions may be controlled by ligature en masse, with in- 
 terlocked stitches — as described under partial excision of the liver. 
 
 ANTERIOR SUBCOSTAL TRANSPERITONEAL HEPATOTOMY 
 
 BY ANTERIOR OBLIQUE INCISION PARALLEL WITH COSTAL ARCH. 
 
 Description. — The liver is exposed along the right costal arch, by an in- 
 cision which parallels that arch and is placed 1.3 to 2 cm. (\ to f inch) below 
 it. Resorted to where the more central portion of the anterior aspect of the 
 liver and gall-bladder region is to be exposed. 
 
 Preparation — Position. — As for abdominal section. 
 
 Landmarks. — Right costal arch. 
 
 Incision. — Parallel with and from 1.3 to 2 cm. (\ to f inch) below the 
 right costal arch — beginning near the right linea semilunaris (which runs 
 downward from the ninth rib to the spine of the pubis) — and extends as far 
 downward and outward, below the costal arch, as considered necessary — even 
 to the extent of 12.5 to 15 cm. (5 to 6 inches). (Fig. 699, F.) 
 
 Operation. — (1) Incise skin — fascia — external oblique (transversely) — 
 internal oblique (in cleavage line). Superior epigastric artery may be cut at 
 
ANTERIOR SUBCOSTAL TRANSPERITONEAL HEPATOTOMV. ion 
 
 inner end of incision, if the inner end reaches the outer border of the rectal 
 sheath — if so, it is ligated. The abdominal nerves lie between the internal 
 oblique and transversalis, crossing the line of incision, and an attempt should 
 be made to draw them aside if encountered. The transversalis muscle is then 
 divided obliquely to its fibers. In long incisions, much division of muscles and 
 nerves must occur. In short incisions, much displacement in intramuscular 
 cleavage lines and saving of nerves may be accomplished (Fig. 745). (2) 
 Divide the transversalis fascia, subperitoneal areolar tissue, and peritoneum in 
 the original line — and retract the wound well. (3) Adhesions are looked for 
 as soon as the abdomen is opened. If encountered, intervening between the 
 seat of pus, or hydatid fluid, and the abdominal wall, they are carefully pre- 
 served — that they may serve as a protection to the general peritoneal cavity in 
 opening these collections- of fluid. If the object be the exposure of the liver 
 
 Fig. 745.— Exposure of Liver, and Hepatotomy, by Anterior Oblique Subcostal In- 
 cision : — A, External oblique ; B, Internal oblique ; C, Transversalis ; D, Outer border of right rectus 
 incised, showing superior epigastric vessels between muscle and posterior sheath; E, Transversalis 
 fascia and subserous areolar tissue; F, Peritoneum; G, Surface of liver; H, Suture through lip 
 of liver wound, peritoneum, transversalis fascia, subserous areolar tissue, and transversalis ; I, Same 
 tightened, approximating lip of liver wound to lower plane of abdominal wound. 
 
 on other grounds, the adhesions are separated by blunt dissection, or are 
 divided between ligatures. (4) The liver having been exposed, the operation 
 may be concluded in a single stage, or in two stages: — (A) In One Stage; — 
 Where (in pus and hydatid cases) adhesions of parietal peritoneum to hepatic 
 peritoneum have occurred, the incision may be made directly into the liver 
 substance. Where no such adhesions exist, one of two courses may be pur- 
 sued; — (a) The lips of the abdominal wound may be applied to and pressed 
 around the site of the liver to be opened, by the fingers of an assistant and by 
 packing — the tensity of the abscess wall is then lessened (to avoid a gush of pus) 
 by the withdrawal of some of its contents with a syringe — a narrow bistoury is 
 inserted into the abscess and its walls incised — the contents are directed out 
 without escaping into the abdomen — and as soon as the cavity is partly empty, 
 
1012 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 the edges of the abscess wall, including Glisson's capsule, are seized with 
 special forceps and drawn up into the wound and exerted, while the balance of 
 its contents is emptied — the borders of the abscess cavity are then stitched to 
 the edges of the abdominal wound at its lower plane (that is, to the parietal 
 peritoneum, subserous areolar tissue, transversalis fascia, and possibly into the 
 edge of the muscle tissue) with continuous or interrupted silk or chromic gut 
 sutures — closing in either end of the abdominal wound in the usual way— 
 leaving room for the exit of tube or gauze drain. Or, pursuing a second 
 course — (b) Before opening the peritoneum, and after recognizing that the 
 parietal and hepatic peritoneal surfaces are not adherent, the parietal peri- 
 toneum (by slight outward separation of the extraperitoneal parts of both lips 
 of the wound) may be stitched, with curved needle, to the hepatic surface over 
 an elliptical area, with continuous silk or chromic gut— surrounding and further 
 protecting the area by gauze packing — and then incision is made simultane- 
 ouslv through parietal and visceral peritoneum into the liver — drainage being 
 established and the wound treated as in (a). (B) In Two Stages; — This 
 method is practised only where no adhesions are found — and when no haste 
 exists. The parietal peritoneum is united to the serous surface of the liver in 
 one of the two above ways — the gauze packing being preferable to the stitching 
 (or both may be used together) — the wound being packed with gauze, pressing 
 the serous surfaces together for two or three days — after which the incision is 
 made and the operation completed as in (a) above. 
 
 Comment. — Where the abscess, or other cavity, is incised before the ab- 
 dominal wall is sutured to the liver, the suturing of the margin of the cavity to 
 the abdominal wound is aided by inserting the left index-finger into the cavity 
 and hooking it forward — thus holding it in contact with the abdominal wall 
 while the sutures are being placed and tied. 
 
 EXPOSURE OF LIVER BY ANTERIOR SUBCOSTAL TRANS- 
 PERITONEAL ROUTE 
 
 BV ANTERIOR VERTICAL INCISION" THROUGH RIGHT LINEA SEMILUNARIS. 
 
 Description. — A free exposure is thus given — which may be lengthened 
 so as to give access to both peritoneal and pelvic cavities. See General Sur- 
 gical Considerations. The incision may also be placed to the outer side of the 
 right semilunar line. 
 
 Preparation — Position. — As for abdominal section. 
 
 Landmarks. — Right Linea Semilunaris (which extends from the ninth 
 right costal cartilage to the pubic spine, passing within 7.5 cm. [3 inches] of the 
 umbilicus) ; right costal arch. 
 
 Incision. — Vertically downward in the right semilunar line, beginning at 
 the right ninth costal cartilage and extending as far as necessary (Fig. 699, G). 
 
 Operation. — Incise skin — fascia — external oblique (obliquely)— internal 
 oblique (obliquely) — abdominal nerves between internal oblique and trans- 
 versalis are almost necessarily divided (except in very short incisions they may 
 sometimes be displaced) — transversalis muscles (transversely) — transversalis 
 fascia, subserous areolar tissue and peritoneum — entering the abdomen in the 
 original line. All hemorrhage is controlled — the lips of the wound retracted— 
 and the liver exposed. 
 
INTERCOSTAL SUBPLEURAL EXPOSURE OF LIVER. 1013 
 
 EXPOSURE OF LIVER BY LATERAL SUBCOSTAL TRANS- 
 PERITONEAL ROUTE 
 
 BY LATERAL HORIZONTALLY CURVED INCISION BELOW RIGHT TWELFTH RIB. 
 
 Description.— The general features of the operation are the same as by 
 the anterior oblique subcostal incision — the steps of the operation differing only 
 in so far as determined by anatomical circumstances. Chiefly applicable 
 where the lower lateral aspect of the liver is to be exposed. 
 
 Preparation. — As for abdominal section. 
 
 Position. — Patient rests upon opposite side, with cushion under the sound 
 side to round out the involved side; Surgeon may stand behind or in front of 
 patient; Assistant opposite. 
 
 Landmarks. — Right twelfth rib, in the mid-axillary region. 
 
 Incision. — Parallel with and about 1.3 to 2 cm. (J to f inch) below the right 
 twelfth rib, with its center about opposite the mid-axillary line. 
 
 Operation. — Incise skin — fascia — external oblique (obliquely) — latis- 
 simus dorsi (transversely, if the incision extend that far backward) — internal 
 oblique (obliquely) — the nerves between the internal oblique and transversalis 
 being guarded as well as possible — transversalis muscle (in cleavage line) — 
 transversalis fascia, subserous areolar tissue, and peritoneum in the original 
 line. All hemorrhage is controlled — the wound retracted — and the liver 
 brought into the field. 
 
 Comment. — Unless the liver be enlarged, but small part of its lower border 
 is accessible through this incision — except by the strong upward retraction of 
 the twelfth rib, and the downward retraction of the lower lip of the wound. 
 
 EXPOSURE OF LIVER BY INTERCOSTAL SUBPLEURAL ROUTE 
 
 BY INTERCOSTAL INCISION BELOW LEVEL OF PLEURA. 
 
 Description. — This incision, which is made in an intercostal space below 
 the level of the pleura, rarely gives sufficient room — and is indicated only in 
 cases where abscess or fluid point here and adhesions have, in all probability, 
 protected surrounding regions. In the following description the operation 
 site will be supposed to be in the right tenth interspace, in the mid-axillary line. 
 
 Preparation — Position. — As for intercostal thoracotomy (see page 761). 
 
 Landmarks. — Right tenth and eleventh ribs, in the mid-axillary line. 
 
 Incision. — Midway between lower border of the right tenth and the upper 
 border of the right eleventh rib — in the mid-axillary region. 
 
 Operation. — The steps of the operation are the same, practically, as those 
 for Intercostal Thoracotomy (q. v., page 761) — with the exception that in the 
 present instance the incision is made below the level of the pleura. As an 
 operation, owing to the small amount of room which it affords, it is indicated 
 only in those cases in which the liver is supposed to be adherent to the dia- 
 phragm opposite the site of incision (either naturally or by pathological pro- 
 cess). If during operation it be found that the liver be not adherent to the 
 diaphragm, parts of one or two ribs should be excised — and the operation be 
 completed as given in the following description. 
 
 Comment. — The operation is distinctly inferior to the following method. 
 
IOI4 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 A - 
 
 Fig. 746.— Exposure of Liver by Subpleural Route, by Partial Excision of a Rib below 
 Level of Pleura : — A, A, Thoracic muscles ; B, B, Anterior and posterior layers of rib periosteum 
 retracted after excising part of rib, both divided longitudinally, and endothoracic fascia seen upon 
 under surface of latter; C, Diaphragm being sutured to convex surface of liver and incised within 
 area elliptically sutured. 
 
 EXPOSURE OF LIVER BY SUBPLEURAL ROUTE 
 
 BY PARTIAL EXCISION OF ONE OR MORE RIBS BELOW THE LEVEL OF PLEURA. 
 
 Description. — The liver is here approached transthoracically, but the 
 incision being placed below the normal level of the pleura, the pleura is not, 
 ordinarily, brought into the field of operation. In the following account, part 
 of the right eleventh rib in the mid-axillary line will be removed. 
 
 Preparation — Position. — As for Thoracotomy by the partial excision of a 
 rib. 
 
 Landmarks. — The special rib nearest the site to be exposed. 
 
 Incision — Operation. — As for the Partial Subperiosteal Excision of a 
 Rib (see page 480) — up to the point of the removal of the rib. The posterior 
 layer of periosteum, forming the bed in which the rib has lain, is then incised 
 in its center, in its long axis. If more room be required than furnished by the 
 partial excision of one rib, two or more ribs are excised in part (see page 764). 
 Having passed through the thoracic wall, the diaphragm is exposed and in- 
 cised — in a line corresponding with the direction of its muscle-fibers at the site 
 incised. The edges of the diaphragmatic wound are sutured to the convex 
 surface of the liver, if not already adherent. If adhesions be present, or if 
 haste be necessary, the liver is incised at once. If haste be unnecessary, and 
 no adhesions be present, the wound, after the above suturing, is packed with 
 gauze for two or three days, until adhesions form — and the organ then in- 
 cised (Fig. 746). 
 
 EXPOSURE OF LIVER BY SUBPLEURAL ROUTE 
 
 BY PARTIAL EXCISION OF ONE OR MORE RIBS OPPOSITE THE PLEURA. 
 
 Description. — Parts of one or more ribs are excised subperiosteally above 
 the level of the pleura — the pleura is exposed but not opened — and is carefully 
 
EXPOSURE OE LIVER BY SUBPLEURAL ROUTE. 1015 
 
 separated from the thoracic wall and diaphragm and displaced upward — the 
 diaphragm being thus exposed and the liver entered through its substance. In 
 the following account, parts of the seventh and eighth right ribs in the antero- 
 lateral aspect of die chest will be removed. 
 
 Preparation — Position. — As for Thoracotomy. 
 
 Landmarks. — The rib or ribs overlying the involved site. 
 
 Incision — Operation.— (1) The operation is conducted as a Partial Sub- 
 periosteal Excision of one or more Ribs (see page 480) — up to the removal of 
 the rib. The Subperiosteal bed of the rib is very carefully incised in the center 
 of its long axis — cautiously recognizing but not incising the costal pleura — 
 which is to be preserved with the greatest care from the smallest cut or tear (on 
 account of the respiratory complications often arising from the entrance of air 
 into the pleura, with the possible collapse of the lung, and the possible infection 
 
 Fig. 747. — Exposure of Liver by Subpleural Route, by Partial Excision of Parts of 
 Tun Ribs Opposite the Pleura : — A, A, Upper layer of periosteum and thoracic muscles retracted ; 
 B, B, Lower layer of periosteum and intercostal muscles retracted; C, Pleura detached and retracted 
 upward; D, Diaphragm incised; E, Incised margin of parietal pleura; F, Convex surface of liver; 
 G, Sutures uniting edges of diaphragm and parietal peritoneum to surface of liver. 
 
 of the pleura). (2) The costal pleura is carefully detached by blunt dissection, 
 largely aided by the back of the surgeon's fingers — first detaching it from the 
 ribs, until its lowest thin edge is reached — then from the upper surface of the 
 diaphragm — and finally displacing it upward and retaining it there by blunt, 
 rounded retractor, or gauze packing. Thus the upper surface of the diaphragm, 
 as far inward as necessary, is freely exposed — with the upper convex surface of 
 the liver immediately below it (Fig. 747). (3) The operation is now com- 
 pleted in one or in two stages: — (a) In One Stage; — The diaphragm is incised 
 over the site of fluid — the edges of the diaphragmatic wound are slightly sepa- 
 rated — and these edges are sutured with chromic gut (by means of a curved 
 needle in a holder) to the upper surface of the liver, in the form of an ellipse. 
 If adhesions be present between liver and diaphragm, this suturing is unneces- 
 sary. In addition (to either suturing or adhesions), gauze is packed around 
 
1016 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 the region, further guarding against infection. To relieve the tension part of 
 the contents of the cavity is first aspirated. The liver is then incised and 
 drained. The wound is closed up to the site of drainage — so suturing the 
 parts that the thoracic cavity is shut off and the pleura prevented from coming 
 into the region of the wound, (b) In Two Stages; — The diaphragm is 
 sutured as above to the liver and the wound packed — and, after two or three 
 days, when adhesions have occurred, the liver is incised and drained — and the 
 wound treated with the same precautions as just given. 
 
 Comment. — (i) Parts of at least two ribs should generally be excised — to 
 give the necessary room to meet the difficulties which are apt to arise in the 
 progress of the operation. (2) Where, from the position of the opening it is 
 possible to do so, it is well to unite the edges of the diaphragm to the edges of 
 the thoracic wound — thus giving freer drainage and better protection of the 
 neighboring parts from infection. 
 
 EXPOSURE OF LIVER BY TRANSPLEURAL ROUTE 
 
 BY PARTIAL EXCISION OF ONE OR MORE RIBS OPPOSITE THE PLEURA. 
 
 Description. — Following the subperiosteal excision of parts of one or 
 more ribs, no attempt is made to avoid the pleura, but care is taken not to open 
 it prematurely. After entering the thoracic cavity, in the same manner as in 
 the last operation, the costal and diaphragmatic pleurae are recognized — their 
 surfaces are then sutured together in the form of a circle or an ellipse — and an 
 opening is made through their united surfaces — at once if necessary, — after 
 two or three days if haste be unnecessary. Thus an attempt is made to pre- 
 vent the invasion and infection of their cavity. The operation is inferior to the 
 subpleural method, which should always be practised if possible — reserving the 
 method just described for those cases in which the pleura cannot be thus sepa- 
 rated and pushed above the seat of operation. In the following account parts 
 of the seventh and eighth right ribs will be excised in the antero-lateral aspect 
 of the chest. 
 
 Preparation — Position — Landmarks — Incision. — As in the operation 
 last described. 
 
 Operation. — Same as in the above operation — except that when the pleura 
 is exposed, instead of detaching and displacing it upward, the costal and dia- 
 phragmatic pleura? are sutured together in an elliptical or circular outline, 
 with continuous suture of silk or fine chromic gut carried upon a curved needle 
 in a holder — carefully guarding against opening the pleural cavity in the pro- 
 cess of manipulation — it being very difficult to prevent the tearing out of the 
 pleural stitches. The operation may now be concluded in one or in two 
 stages: — (a) In One Stage; — Through the center of the area thus sutured, the 
 two pleurae are incised — through this incision the diaphragm is exposed — the 
 margins of the pleurae are now sutured as one layer to the diaphragm, over an 
 elliptical area, with continuous suture of silk or fine chromic gut, carried upon 
 a fully curved needle in a holder — the surrounding area is packed off with 
 gauze, in addition — the diaphragm is incised — and the edges of the diaphragm 
 are stitched, in turn, to the liver with chromic gut — after which, the tension of 
 the abscess is partly relieved by aspiration — the liver then being incised — drain- 
 age established and the wound partly closed, (b) In Two Stages; — Same as 
 in the single-stage method — except that after suturing the double layer of 
 pleura together, and, at the same time, to the diaphragm, in the form of a circle 
 or ellipse — the area is packed with gauze for two or three days — after which the 
 
EXPOSURE OF LIVER BY RESECTION OF RIGHT COSTAL ARCH. 1017 
 
 operation is completed as above. In such cases, the diaphragm will usually be 
 found adherent to the liver (when the operation falls over the peritoneal aspect 
 of the liver). If, however, upon exposing the liver through the diaphragm, no 
 adhesions are found, the margins of the diaphragmatic wound can be stitched 
 to the liver surface — the wound packed and two or three days longer waited, 
 if haste be unnecessary. 
 
 Comment. — (i) If the two pleurae cannot be sutured, and time be avail- 
 able, incise the parietal pleura — pack the wound for a few days, until the two 
 pleurae have united around the margins — then incise the visceral pleura and 
 diaphragm — similarly stitching the diaphragm to the liver for a few days, if 
 desired. (2) If the situation of the wound make it possible, it is well to suture 
 the edges of the diaphragmatic and thoracic wounds together. 
 
 EXPOSURE OF LIVER BY CHONDRO-PLASTIC RESECTION OF RIGHT 
 
 COSTAL ARCH 
 
 BY ANTERIOR OBLIQUE SUBCOSTAL INCISION. 
 
 Description. — Where the operation site is encumbered by the bony or 
 cartilaginous thoracic wall, the area may be more satisfactorily exposed by 
 
 Fig. 748. — Chondroplastic Resection of the Chest-wall: — I. — The soft parts over- 
 lying the costal arch have been incised and retracted — exposing the cartilages of the seventh, 
 eighth, ninth, and tenth ribs. (Redrawn from Guibe.) 
 
 temporarily resecting the right costal cartilage forming the costo-chondral 
 arch — turning it outward — and back into place at the end of the operation. 
 By the resection of the right costal arch and, if necessary, the temporary 
 division of the suspensory ligament of the liver, the superior aspect of the 
 liver is exposed. The resection of both costal arches may be performed, 
 
I0l8 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 where the freest exposure of the liver, gall-bladder, gall-duct, and stomach 
 regions is necessary. 
 
 The chief danger is the possibility of opening the pleural cavity — to avoid 
 which it is necessary not to carry the division of the ribs too high — not higher 
 than the seventh interspace. 
 
 Preparation — Position — Landmarks. — As for exposure of the liver by 
 an anterior oblique subcostal incision. 
 
 Incision. — An oblique incision is made — commencing at the border of the 
 ensiform cartilage, a little below the last chondro-sternal articulation — 
 passing thence outward and downward, parallel with but about 2.5 cm. ( 1 inch) 
 above the border of the costal arch — generally ending at the tip of the eleventh 
 rib. 
 
 Operation. — The skin, fascia, and overlying muscle-fibers are divided — 
 
 Fig. 749. — Choxdroplastic Resection or the Chest-wall: — II. — The costal margin incised 
 and turned forward. (Redrawn from Guibe.) 
 
 until the plane of the costal cartilages is reached. The cartilaginous portion 
 of the ribs is divided with a bistoury, carefully guarding the underlying soft 
 parts. The tenth and ninth cartilages are divided just to the inner side of 
 the chondro-costal articulations. The eighth cartilage is generally divided 
 in three places — externally, just within the chondro-costal articulation — 
 internally, just without the chondro-sternal articulation — and in the middle, 
 through the band of union of the eighth to the seventh cartilage (when this 
 exists). Between the cartilages, the intercostal muscles and membranes are 
 incised (Fig. 748). The incised cartilaginous margin is then seized and 
 turned downward and inward— separating with a bistoury the muscular 
 attachments of the diaphragm and transversalis, closely hugging the cartilages 
 in the act (Fig. 749) . As soon as the chondro-plastic flap has been sufficiently 
 displaced, the muscular fibers of the diaphragm or transversalis, which form 
 the floor of the wound, are incised — thus opening the peritoneal cavity. The 
 chondro-plastic flap is then well depressed and the outer lip of the wound 
 
PARTIAL HEPATECTOMY. IO19 
 
 well elevated— when the superior surface of the liver is exposed by retracting 
 it downward and, if necessary, by temporarily dividing the suspensory liga- 
 ment — and the inferior aspect and gall-bladder region by retracting the liver 
 upward. As the end of the operation, in closing the wound, the deeper 
 portion is sutured by carrying the suture through the intercostal spaces and 
 the diaphragm, on the outer side, and through the transversalis and internal 
 oblique, on the inner side — thus bringing together the soft parts of the thorax, 
 and, with them, the incised cartilages. The overlying superficial muscles 
 are then sutured — and the skin closed as usual. If considered necessary, 
 the surfaces of the severed cartilages may be sutured through previously 
 pierced holes. Indeed, the temporarily displaced costal arch may be com- 
 pletely severed from its soft attachments and discarded — though its retention 
 is preferable. If necessary, a drain may be carried beneath the replaced 
 costal arch. 
 
 HEPATORRHAPHY. 
 
 Description. — Suturing of the liver substance. Generally done in the 
 case of wounds of the liver-^and in the approximation of the cut surfaces after 
 partial excisions. The liver may be exposed by any of the above operations, 
 according to the circumstances of the case — preference being given to the 
 simplest route. 
 
 Preparation — Position — Landmarks — Incision. — As for Hepatotomy 
 (page 10 10). 
 
 Operation. — Having exposed the liver in one of the usual methods — and 
 an assistant having brought the involved region of the organ well into the 
 field — interrupted chromic gut sutures, carried upon a large, fully-curved 
 Hagedorn, or other, needle, are carried through the opposed edges of the 
 wound. Two tiers of sutures are, ordinarily, indicated — coarser gut carried 
 more deeply and further from the edges — and finer gut more superficially and 
 nearer the edges. The deeper sutures are first tied — then the superficial, — 
 after which the liver is dropped back into place — and the abdomen closed—- 
 unless special cause for drainage exist. (See Fig. 750.) 
 
 HEPATOPEXY. 
 
 Description. — Operation of suturing the liver, in whole or in part, to the 
 abdominal wall, or neighboring structures. Resorted to for partial or com- 
 plete hepatoptosis. 
 
 Preparation — Position — Landmarks — Incision. — As for Hepatotomy 
 by anterior oblique subcostal incision. 
 
 Operation. — The prolapsed liver having been exposed, the part involved 
 in the prolapse, or the whole liver, if involved in its entirety, is brought into 
 its normal position — and is then sutured with coarse chromic gut, kangaroo- 
 tendon, or silk, to the posterior surface of the anterior abdominal wall. It 
 may also be sutured to the round ligament — to the cartilages of the ribs— or 
 to the general abdominal wall. The sutures are carried deeply into the liver 
 substance with a lanie, fullv curved needle. 
 
 PARTIAL HEPATECTOMY, 
 
 Description. — Excision of a limited portion of the liver substance. Gen- 
 erallv done in the removal of growths. 
 
1020 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Preparation —Position— Landmarks — Incision. — As for Hepatotomy 
 by one of the transperitoneal routes — and preferably by an incision parallel 
 with and just below the ribs. 
 
 Operation. — (i) The abdomen is opened — and the involved portion of 
 the liver is brought as far forward into the wound as possible. (2) Circum- 
 scribe the growth, or part to be removed, by an elliptical incision — the elliptical 
 outline representing the base of a wedge, the sides of which come together 
 within the liver beyond the part to be removed. The ellipse, where possible, is 
 made with its long .axis radiating from the center of the liver toward the per- 
 iphery, and so placed as to avoid the chief hepatic vessels. This area is ex- 
 cised by cutting down along the outline of the incision, the knife traveling at a 
 
 Fig. 750.— Partial Hepatectomy, followed by Hepatorrhaphy : — A, Incised external ob- 
 lique, internal oblique, and transversalis ; B, Incised outer border of rectal sheath; C, Costal arch 
 retracted from liver; D (lower D), Gauze pad packed under liver; E, Borders of liver-wound after 
 excision of wedge; F, Superficial sutures through liver substance; D (upper D), Deep sutures. 
 
 right angle to the surface — hemorrhage being controlled by pressure and by 
 ligature with chromic gut. (Also see Comment.) (3) The sides of the wound 
 are then brought together by deep and superficial chromic gut sutures — 
 placed and tied as described under Hepatorrhaphy (page 1019). (4) Unless 
 drainage be specially indicated, the liver is dropped back into place and the 
 abdomen closed — particularly if the surfaces of the wound be satisfactorily 
 approximated and hemorrhage be entirely controlled (Fig. 750). 
 
 Comment. — (1) If the area to be excised is first surrounded by a deeply 
 placed, interlocking chromic gut ligature, hemorrhage is more thoroughly con- 
 trolled. These ligatures are then drawn tightly enough to cut through the 
 liver substance and bind the vessels before these are cut. (2) Also a heavy 
 
SURGICAL ANATOMY OF THE GALL-BLADDER. 1021 
 
 ligature may be placed through the liver, surrounding the part to be removed, 
 which is thus tied off in sections — the ligatures being tightened and the part 
 removed with the knife or cautery. 
 
 OPERATION FOR CIRRHOSIS OF THE LIVER. 
 
 EPIPLORRHAPHY OR EPIPLOPEXY — TALMA-DRTTMMOND OPERATION. 
 
 Description. — This operation, or one of its modifications, has been 
 successfully employed in some cases of cirrhosis of the liver. It is based 
 upon the principle of forming additional venous communications between the 
 systemic and portal circulations in order to relieve obstruction in the over- 
 burdened portal circuit. 
 
 Preparation — Position — Landmarks. — As for median abdominal sec- 
 tion. 
 
 Incision. — The incision is made in or near the median line, over a length 
 equivalent to that between the ensiform cartilage and umbilicus. Local 
 anesthesia generally suffices. 
 
 Operation. — Having opened the abdominal cavity, all ascitic fluid is 
 drained or sponged away. The liver is exposed and all of the accessible upper 
 surface which comes into contact with the diaphragm is rubbed briskly with 
 gauze. The convex surface of the spleen is similarly treated. The omentum 
 is brought forward and sutured to the parietal peritoneum of the anterior 
 abdominal wall, to both sides of the median line (with or without frictioning 
 of their surfaces) — which is readily accomplished by everting the relaxed 
 abdominal wall in the average case of ascites. The greater the number of 
 adherent points between peritoneum and omentum, the better. The abdomen 
 is closed — no drainage being used in the later cases, as was formerly the habit. 
 
 VIII. THE GALL-BLADDER. 
 
 SURGICAL ANATOMY. 
 
 Description and Position. — Bound to fossa of gall-bladder, upon under 
 surface of liver, by connective tissue and vessels, lying between the right and 
 quadrate lobes — its fundus reaching the abdominal wall anteriorly — and its 
 neck extending to the transverse fissure posteriorly. Its fundus and inferior 
 and lateral aspects are covered with peritoneum reflected from the liver. It 
 sometimes has a mesentery. Its neck points backward and upward, toward 
 the transverse fissure of liver, — its fundus points downward and forward toward 
 the anterior border of liver. Its length is from 7 to 10 cm. (2| to 4 inches) — 
 the width of its fundus is from 2.5 to 3 cm. (1 to if\ inches) — and it holds 
 about 20 c.c. 
 
 Relations. — Superiorly; — fossa of gall-bladder; — Inferiorly; — duode- 
 num (first and second parts); pyloric end of stomach (sometime-); colon 
 (hepatic flexion and commencement of transverse portion); — Anteriorly; — 
 abdominal wall; ninth costal cartilage. 
 
 Arteries. — Cystic, from right branch of hepatic. 
 
 Veins. — Cystic (two) emptying into right branch of vena porta?; others 
 emptying into liver. 
 
 Lymphatics. — Run into a gland at its neck. 
 
 Nerves.— Supplied by cceliac plexus. 
 
 Fixations. — Connective tissue; vessels; peritoneum reflected over under 
 surface of liver; cvsto-duodenal ligament (a fold of peritoneum extending from 
 neck of gall-bladder to duodenum). 
 
OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The fundus of the gall-bladder projects outward beyond the anterior border 
 of the liver, in the incisura vesicalis — generally resting upon the transverse 
 colon — and coming into contact with the anterior abdominal wall close to the 
 outer border of the right rectus muscle. Authorities differ as to the exact point 
 of contact with the abdominal wall, in relation with the costochondral struc- 
 tures; — according to Morris, the fundus lies opposite the cartilage of the right 
 ninth or tenth rib; — according to Gray, opposite the inferior border of the 
 right ninth costal cartilage; — and according to Treves, below the inner end of 
 the right tenth costal cartilage. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 (i) The gall-bladder is in relation with the first and second portions of the 
 duodenum, with the hepatic flexure and commencement of the transverse colon, 
 and sometimes with the pylorus. Therefore the gall-bladder could generally 
 be united with either duodenum or colon — but if united to the colon, the func- 
 tion of the bile in the small intestines would be lost — hence the duodenum is 
 the usual site of anastomosis. (2) In examining the gall-bladder and ducts, 
 first pass the left index over these structures, to gain an idea of their size and 
 contents — then let the left index slip through the foramen of Winslow — in 
 which position the left thumb will grasp the ligamentum hepato-duodenale 
 (the right margin of the gastro-hepatic omentum) and press it against the left 
 index — and thus the ducts can be palpated between thumb and index, up- 
 ward and downward. (3) By drawing upon the gall-bladder, the gall-ducts 
 are rendered more tense and evident. (4) The pedicle of the gall-bladder 
 consists of cystic duct, artery, and veins. 
 
 INSTRUMENTS USED IN GALL-BLADDER OPERATIONS. 
 
 Mentioned under Instruments used in operations upon the Liver 
 (page 1008). 
 
 CHOLECYSTOTOMY 
 
 BY VERTICAL SUBCOSTAL INCISION. 
 
 Description. — Incision of gall-bladder for removal of its contents — 
 followed by closure at same operation. L T sually resorted to in exploratory 
 operations upon the healthy gall-bladder and with unobstructed ducts. The 
 closed gall-bladder may be dropped back into the free abdomen, but is gen- 
 erally anchored to the abdominal wall. 
 
 Preparation. — As for a median abdominal section. 
 
 Position.— The best position for gall-bladder and gall-duct work is that 
 given by Elliot, of Boston, in his own words; — "The patient is hung by straps 
 under the arms on an inclined plane at an angle of something less than 45 
 degrees. A sand-bag is placed under the back, so that the patient is bent 
 over it. In this position the intestines gravitate to the lower part of the 
 abdomen, so that when the liver is held up by a retractor, the air sucks in 
 between the liver and the intestines, much as it enters the pelvis in the Tren- 
 delenburg position." The only objection to this position (which does not 
 
CHOLECYSTOSTOMY. 
 
 1023 
 
 outweigh its advantages) is that when a simple vertical incision is used, the 
 lips of the wound tend to be approximated and tensed by the posture of the 
 body — which, however, is avoided by the adoption of the Mayo Robson inci- 
 sion. 
 
 Landmarks. — Site of fundus of gall-bladder (opposite lower border of 
 right ninth costal cartilage) ; right linea semilunaris. 
 
 Incisions. — The best incision of approach is probably that of Mayo Robson 
 — which begins as a simple vertical incision through the outer aspect of the 
 right rectus muscle, 10 or 13 cm. (4 or 5 inches) in length, from the costal 
 arch downward. If more room be needed, it may be extended upward and 
 inward below the costal arch — or downward in a straight line (Fig. 751, A). 
 The oblique subcostal incision of Kocher may be used (Fig. 751, B). 
 
 Fig. 751. — Incisions for Exposing the Gall-bladder and Ducts: — A, Mayo Robson's 
 incision; R, oblique subcostal incision. (Modified from Deaver.) 
 
 Operation. — Having opened the abdomen and examined the gall-bladder, 
 gall-ducts, and head of the pancreas, the region of the gall-bladder is packed 
 off with gauze. The fundus of the bladder is grasped with special forceps — 
 so as to draw it forward and hold it in the field during subsequent manipula- 
 tions. If at all distended, part of the contents should be withdrawn with a 
 needle — to avoid the spurt of fluid which would otherwise be likely to soil the 
 
I024 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 field when the overdistended organ is incised. The fundus is then incised 
 with a knife, or clipped with scissors — and the traction-forceps shifted to 
 grasp the lips of the bladder-wound. While the lips of the wound are held 
 apart, examination for calculi is made with a special scoop or forceps. When 
 this has been done, the gall-bladder tracts are carefully palpated. Should 
 any calculi be found, they are "milked" forward — and removed through the 
 gall-bladder wound. In completing the operation, the usual course, where 
 calculi have been found, is to establish a temporary opening and drainage of 
 the gall-bladder — a cholecystostomy (page 1024). In those cases where no 
 cause for drainage may have been found (which is rare in distinct gall-bladder 
 involvement) — in such cases, for instance, as where the bladder is opened for 
 exploration and no diseased condition be found, the organ may be sutured up 
 and the abdomen closed. The incised wound is best closed by a layer of fine 
 continuous catgut suture through all the coats of the viscus — followed by an 
 interrupted seromuscular Lembert suture, burying in the first line of suturing. 
 The gall-bladder may then be dropped back into the abdominal cavity — or be 
 anchored to the abdominal wall by a couple of catgut seromuscular sutures, 
 where, in the event that drainage become necessary, it will be easily accessible. 
 The abdomen is then closed in the usual manner. 
 
 CHOLECYSTOSTOMY 
 
 BV OBLIQUE OR VERTICAL Sl'BCOSTAL INCISION. 
 
 Description. — Incision of gall-bladder, followed by suturing of the opened 
 bladder into the abdominal wound for a shorter or longer time. Generally 
 resorted to in cases of gall-stones, or in suppuration. The operation may be 
 done in one or in two "stages — in the former case, the gall-bladder is opened at 
 once — in the latter, it is first sutured to the abdominal wall and not opened 
 until after adhesions have formed. 
 
 Preparation. — As for median abdominal section. 
 
 Fig. 752. — Cholecystostomy by Oblique Subcostal Incision: — A, External oblique; B, In- 
 ternal oblique; C, Transversalis ; D, Subserous areolar tissue and transversalis fascia; E, Peri- 
 toneum ; F, Gall-bladder, its fundus being drawn out of abdominal wound ; G, Sutures through trans- 
 versalis and subserous fasciae, and through serous and muscular coats of gall-bladder. 
 
 Position. — As for vertical subcostal cholecystotomy, page 1022. 
 Landmarks. — Lower border of tip of right ninth costal cartilage; costal 
 arch; right linea semilunaris. 
 
CHOLECYSTOSTOMV. IO25 
 
 Incision. — Oblique or vertical subcostal incision, as for exposure of the 
 liver (see page 1010 and Fig. 745, and also General Surgical Considerations 
 in Operations upon the Liver, page 1006). 
 
 Operation. — Having opened the abdomen by the chosen incision, hem- 
 orrhage is controlled, the wound is retracted, and the gall-bladder located. 
 If any adhesions are found, these are separated by blunt dissection, or tied 
 off — and the bladder brought as far out into the abdominal wound as possible 
 (Fig. 752). If much intravesical tension exist, this should be lessened pre- 
 liminarily by the aspiration of part of the fluid. The operation may now be 
 concluded in one or in two stages; — (A) In One Stage: — (a) Having partially 
 emptied the gall-bladder by aspiration, and after having packed off the vicinity 
 with gauze, the bladder is seized with special forceps, a pair in each hand of an 
 assistant — or by two traction-loops passing through the serous and muscular 
 coats — and while thus held as far out of the wound as possible, the fundus of 
 the bladder is incised vertically between the forceps or traction-loops, pro- 
 vision being made for the catching of the fluid, (b) Having opened the gall- 
 bladder, and while holding the lips of the bladder wound apart, insert a finger, 
 or special instrument, and pass it down to the cystic duct to examine the con- 
 tents — removing with special forceps or scoop any calculi found — followed by 
 irrigation or cleansing of the bladder, (c) The cystic, hepatic, and common 
 ducts are then carefully palpated, (d) In completing the operation, the pack- 
 ing is removed and the excess of abdominal wound is closed in from either end 
 toward the center, in the ordinary manner, leaving a sufficient opening mid- 
 way between the ends, or in the most convenient site for approximating the 
 bladder. The margins of the gall-bladder are now sutured into the lower 
 edge of the abdominal wound left after the partial closure of the ends of the 
 abdominal incision — in such a way that all the coats of the gall-bladder are 
 sutured to the lower layers of the abdominal wound with fine interrupted 
 chromic gut — so that serous surfaces are approximated, but so that the edges 
 of the gall-bladder wound do not reach to the skin. Or, where sufficient room 
 for manipulation exists, it is better to use two tiers of sutures — the first row of 
 fine gut sutures passing through serous and part of muscular coats of the gall- 
 bladder, on the one hand, and through the parietal peritoneum, on the other, — 
 followed by a second tier suturing all the coats of the gall-bladder to the apo- 
 neurotic layer of the abdominal wound, (e) If considered necessary, drainage 
 may be conducted through the abdominal wound down to the cystic duct. 
 The best form of bladder drainage is secured by means of a rubber tube, 
 about 6 mm. (3 inch) in diameter — 5 to 8 cm. (2 to 3 inches) of which are 
 placed within the gall-bladder — the opposite end reaching to the pelvis for 
 drainage. The tube is held in position by a catgut suture passing through 
 the rubber tube, on the one hand, and through the serous and muscular coats 
 of the gall-bladder, on the other. The serous surface of the gall-bladder 
 is made to snugly grasp the rubber tube by being drawn around it with a 
 seromuscular purse-string suture — thus avoiding leakage — as shown in 
 Fig. 753- If the incision into the fundus of the gall-bladder be too large for 
 closure by a purse-string suture, the closure may be made by a seromuscular 
 suture. The gall-bladder may be allowed to fall back into the peritoneum — 
 but it is generally better to anchor it in contact with the abdominal wall, 
 either separately by a few interrupted seromuscular sutures, or in the act of 
 suturing up the lower level of the abdominal wound. (B) In Two Stages; — 
 (a) Having closed in the excess of abdominal wound from either end, the 
 fundus of the gall-bladder is sutured into the remaining opened portion of the 
 abdominal wound by interrupted silk or fine chromic gut sutures — passing 
 
1026 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 through the serous and muscular coats of the gall-bladder, on the one hand, 
 and through the parietal peritoneum and the lower layers of the abdominal 
 wound, on the other, (b) When adhesions have formed in two or three 
 days, the fundus is incised — as in the single-stage operation. 
 
 Comment. — (A) In Operating in One Stage; — (a) The gall-bladder may 
 be tied with a purse-string around a glass flanged tube, which is then brought 
 out of the abdominal wound. Or a Murphy button-tube, with long cylinder, 
 may be used. The tube or button tied in sloughs out in a few days, by which 
 time adhesions have shut off the cavity, (b) Where the gall-bladder is small 
 and contracted, so as not to reach the abdominal wound, the parietal perito- 
 neum may be peeled back from the edges of the abdominal wound and sutured 
 around the wound in the fundus of the gall-bladder. (B) In General; — (a) 
 
 Fig. 753- — Cholecystostomy: -— A rubber drainage-tube anchored in the incised fundus of the 
 gall-bladder and about to be further buried by a purse-string suture. 
 
 It may be possible, by the oblique subcostal incision, to expose the gall-bladder 
 through an intermuscular separation of the external oblique, internal oblique, 
 and transversalis muscles, in the triangular space bounded by the eighth nerve 
 running along the costal arch, the ninth nerve running transversely inward 
 from the level of the lower border of the ninth costal cartilage, and the linea 
 semilunaris, (b) Adhesions may have to be separated before the gall-bladder 
 can be brought forward, (c) Avoid stitching the gall-bladder to the skin, as 
 such fistulae are hard to cure, (d) Sometimes stones discovered in the ducts 
 can be milked back into the gall-bladder and thence removed, (e) In the 
 two-stage operation, the examination of the interior of the bladder and of the 
 ducts is not so satisfactory as in the single-stage operation — nor the removal 
 of stones, if found, so easy. 
 
 CHOLECYSTENTEROSTOMY 
 
 BV THE MURPHY BUTTON. 
 
 Description. — By Cholecystenterostomy is meant the establishment of a 
 communication between the gall-bladder and the small or the large intestine. 
 Preferably the union is made with the duodenum (Cholecysto-duodenostomy), 
 — next, with the upper jejunum (Cholecysto-jejunostomy), — and if these be 
 not easily brought into apposition (because of adhesions, or other conditions), 
 the junction is made with the hepatic flexure of the colon (Cholecysto-col- 
 ostomy). Union may be accomplished by some mechanical device, of which 
 Murphy's special gall-bladder button is probably the best — or it may be ac- 
 complished by simple suturing. The operation is indicated in unremovable 
 obstruction of the cystic or common ducts, in chronic cholecystitis, and in 
 persistent fistulae following cholecystostomy. 
 
 Preparation — Position — Landmarks. —As for Cholecystotomy. 
 
 Incision. — A vertical subcostal incision is generally to be preferred. If a 
 
CHOLECYSTENTEROSTOMY. 
 
 1027 
 
 tumor exist, the incision is placed over it — if not, it is placed in the right semi- 
 lunar line, or just to the outer side of it. 
 
 Operation. — The steps of the operation are not essentially different from 
 Entero-enterostomy by the Murphy button. (1) The abdomen having been 
 opened, the gall-bladder and duodenum are exposed — and trial is made to as- 
 certain that both structures can be brought into the field and approximated 
 without too great tension. The field is then packed off with gauze. If the 
 bladder be very much distended, the distention is lessened by partial aspira- 
 tion, that the contents may not be thrown out over the neighboring parts on 
 incising the viscus. (2) The regular purse-string suture (see Fig. 754) is then in- 
 troduced through all the coats of the gall-bladder, calculating to so place it upon 
 the prominent fundus, or the inferior surface of the gall-bladder, as to make 
 the best approximation with the duodenum, without tension. The bladder- 
 wall is then incised between the lines of the purse-string suture for a distance 
 equal to two-thirds of the diameter of the special button. The male button, 
 grasped in the usual manner, is insinuated into the opening in the gall-bladder 
 and the walls of that viscus drawn about the cylinder of the button and tied. 
 (3) The female button is similarly introduced into the free aspect of the duo- 
 denum and tied. (4) The halves of the button are pressed together — thus 
 completing the cholecysto-duodenostomy. If reinforcing Lembert sutures are 
 considered necessary, they are applied. (5) Unless special cause for drainage 
 exists, the abdomen is closed as after ordinary abdominal section. 
 
 Fig. 754. — Cholecystenterostomy by the Murphy Button:— A, Male button within gall- 
 bladder ; B, Female button within duodenum. 
 
 Comment. — (1) Union of the gall-bladder to portions of the intestine be- 
 tween the usual site of anastomosis (duodenum, or upper part of jejunum) and 
 the hepatic flexure of the colon, is more apt to be followed by volvulus. (2) 
 
1028 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Prior to completing the anastomosis, the interior of the gall-bladder should be 
 examined for calculi, and the ducts palpated. (3) The contents of the duo- 
 denum should be pressed away from the site of anastomosis and controlled by 
 double clamps during the operation. (4) If more convenient, the smaller 
 female button may be placed in the gall-bladder. 
 
 CHOLECYSTENTEROSTOMY 
 
 BY SIMPLE SUTURING. 
 
 Description. — The operation is the same as Cholecystenterostomy by the 
 Murphy button, except that no artificial device is used in accomplishing the 
 union other than simple suturing, aided by special clamps, or small curved 
 intestinal clamps. 
 
 Preparation — Position — Landmarks — Incision — Operation. — Are, in 
 the main, the same as those just described. Having brought the gall-bladder 
 and intestine (preferably the duodenum) into convenient position for manipu- 
 lation by means of special clamps, the two viscera are united in exactly the 
 same manner as in entero-enterostomy by lateral anastomosis (see page 862). 
 A posterior row of continuous Lembert sutures is introduced through the 
 serous and muscular coats of the two viscera, along their posterior aspects, 
 leaving the threads long at both ends. The two organs are then incised — 
 and the lips of the incision whipped together by an overhand continuous 
 suture of all the coats — after which, the line of continuous Lembert suturing 
 is carried around the anterior aspect of the wound. The opening made in the 
 gall-bladder and intestine is from 1.2 to 2 cm. (£ to f inch) long. The parts 
 are returned to the abdomen, which is closed in the usual manner. 
 
 Comment. — (1) The above method of suturing is simpler than to first 
 make the incision and suture together the mucous coats alone — followed by 
 suturing of muscular and serous coats. (2) Sometimes, though rarely, union by 
 simple suturing is done in two, or even in three stages; — (a) In Two Stages; — 
 The gall-bladder and intestine are sutured together by continuous sutures of 
 serous and muscular coats, approximating an area of each equal to about 2.5 
 by 3.7 cm. (1 by i^ inches). These viscera are then sutured to the bottom of 
 the abdominal wound and the wound packed for several days. An incision is 
 then made through the intestine — and through this an incision is made through 
 the adherent walls of gall-bladder and intestine. The incised wound in the 
 intestine is then closed — and the abdominal wound also closed, (b) In Three 
 Stages ; — The gall-bladder and intestine are sutured together, as in the above. 
 The gall-bladder is then incised and its edges sutured into the abdominal 
 wound (after closing the excess of abdominal wound from the ends). After 
 several days the adherent wall between gall-bladder and intestine is incised 
 through the fistula — which fistula is then allowed to close, or is closed by a 
 plastic operation. 
 
 CHOLECYSTO-LITHOTRITY. 
 
 Description. — Consists in the exposure of the gall-bladder and crushing 
 of the calculi from the outside, as they lie within the gall-bladder — by means 
 of the fingers or special forceps with protected blades — and manipulating the 
 fragments on into the cystic duct. The operation is sometimes applicable in 
 cases of soft and friable stones. Fragments of hard stones are apt to wound the 
 gall-bladder. Small stones may sometimes be pushed or worked on out of the 
 gall-bladder into the cystic and common duct without being broken. 
 
CHOLECYSTECTOMY. 
 
 IO29 
 
 The steps of the operation are the same as those for Cholecystotomy, up 
 to the point of exposing the gall-bladder — after which it is a process of palpation 
 and manipulation with the fingers, or special protected forceps. 
 
 CHOLECYSTECTOMY. 
 
 Description.— The total excision of the gall-bladder. Indicated when 
 the gall-bladder or the cystic duct is considerably changed by disease, or where 
 contracted and deep-lying, making difficult the approximation of the gall- 
 bladder to the abdominal wall (cholecystotomy) ; and where the hepatic and 
 common bile-ducts are patulous. 
 
 Preparation — Position — Landmarks — Incision. — As for Cholecysto- 
 tomy by vertical subcostal incision. 
 
 Fig. 755.— Cholecystectomy by Vertical Subcostal Incision: — A, Liver displaced upward, 
 exposing fossa of gall-bladder; B, Gauze pad protecting neighboring structures; C, Longitudinally 
 incised peritoneum over gall-bladder being separated from the bladder by blunt dissection ; D, Liga- 
 ture placed around pedicle of gall-bladder. 
 
 Operation. — (1) Having exposed the subhepatic region by thorough re- 
 traction, aided by the reversed Trendelenburg position, and packed off the 
 neighboring vicinity with gauze, the gall-bladder is isolated (Fig. 755). (2) 
 The peritoneum binding the gall-bladder to its fossa is incised over the pro- 
 minent inferior surface of the gall-bladder — either in one straight line in the 
 long axis of the bladder, from fundus to cystic duct — or in the form of an 
 ellipse (especially where the bladder is large), the two limbs meeting at the 
 fundus and cystic duct. (3) This incision having passed simply through the 
 
1030 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 serous covering into the underlying connective tissue, the peritoneum is sepa- 
 rated from the gall-bladder by blunt dissection, from fundus to neck, and 
 throughout its width, and retracted to either side. Having dissected and 
 peeled back the peritoneal covering, the gall-bladder itself is then dissected, or 
 shelled out, by blunt dissection from its fossa and freed to its pedicle — working 
 with curved blunt scissors and a blunt dissector, and keeping strictly in the 
 connective-tissue plane. The pedicle, formed by the cystic duct and vessels, 
 is well isolated, doubly ligated with chromic gut, and divided between the 
 ligatures, the adjacent structures having been protected with gauze packing. 
 The end of the divided duct may be immediately cauterized. (4) The divided 
 peritoneum, which has been separated and retracted in the form of two flaps, 
 is now sutured with gut over the fossa of the gall-bladder. (5) The abdomen 
 is closed — generally without drainage. 
 
 Comment. — (1) It may be necessary to separate adhesions by blunt dis- 
 section, or by division between ligature. (2) If much distended, the gall- 
 bladder should be first partially emptied by aspiration through a fine needle — 
 the needle wound being subsequently puckered together with a purse-string 
 ligature before manipulating the bladder. (3) Avoid the inclusion of the 
 hepatic and common ducts. (4) The abdominal wound may be closed in 
 part only, leaving a temporary drain. (5) The cystic duct and artery may 
 be tied or clamped at the neck of the gall-bladder first and the organ removed 
 from behind forward — thus giving, possibly, a clearer, because less bloody, 
 field for the most difficult stage of the operation. The peritoneum is then 
 raised from the gall-bladder from below and the viscus enucleated in the act 
 of working forward. The incised peritoneum is sutured over the gall-bladder 
 bed. 
 
 IX. THE GALL-DUCTS. 
 
 SURGICAL ANATOMY. 
 
 Hepatic Duct. — Formed by right and left bile-ducts uniting generally at 
 their emergence from the liver. Length from 3 to 5 cm. {i\ to 2 inches). 
 Diameter, about 4 mm. (nearly f\ inch). Passes downward in right border 
 of gastro-hepatic omentum, having vena cava behind and hepatic artery to 
 left. Unites with cystic duct to form common bile-duct. 
 
 Cystic Duct. — Begins at neck of gall-bladder — is directed slightly to left — 
 and ends at its junction with hepatic duct at an acute angle, to form common 
 bile-duct. Length, 2.5 to 4 cm. (1 to 1^ inches). Passes downward, back- 
 ward, and to left in gastro-hepatic omentum — having hepatic artery to left 
 and portal vein behind. 
 
 Common Bile-duct. — Formed by union of hepatic an4 cystic ducts. 
 Length, about 7.5 cm. (3 inches), dependent upon site of union of cystic and 
 hepatic ducts. Diameter, about 6 mm. (nearly \ inch). Its course and re- 
 lations are the following; — continuing the direction of hepatic duct, it passes 
 downward and backward in hepato-duodenal portion of gastro-hepatic liga- 
 ment, having hepatic artery and its gastro-duodenal branch to left, and portal 
 vein behind and between — enters right pancreatico-gastric fold behind first 
 portion of duodenum (superior curve), then passes between second portion of 
 duodenum (descending part) and head of pancreas — and ends by entering 
 posterior and inner wall of descending portion of duodenum (being crossed on 
 the way by the pancreatico-duodenal artery), running obliquely for about 2 cm. 
 (f inch) through its walls and opening upon a papilla of mucous membrane 
 about 10 cm. (4 inches) from the pylorus. The pancreatic duct joins the com- 
 mon bile-duct just before its termination. 
 
SUPRADUODENAL CHOLEDOCHOTOMY. 
 
 1031 
 
 SURFACE FORM AND LANDMARKS. INSTRUMENTS. 
 See these headings under the Liver and Gall-bladder. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The common bile-duct lies in the hepato-duodenal ligament, near its right 
 free margin — in the free border which constitutes the fold at the entrance of 
 the foramen of Winslow — the hepatic artery lying nearby to its left — and the 
 vena porta behind and between the common duct and hepatic artery — owing 
 to which important relations, the ducts should be fully exposed before being 
 opened. (See Fig. 756.) 
 
 Where more than usual room is required, resection of the right costal arch 
 may be performed. 
 
 No suture should be used which will come within the lumen of any of the 
 ducts — for fear of forming the nucleus of calculi. 
 
 The exact nature of the operation to be done is frequently not known until 
 the gall-bladder and ducts are exposed and examined 
 
 Fig. 756.— Hepato-duodenal Ligament and Contained Structures: — A, Ligamentum 
 hepato-duodenale ; B, Common bile-duct; C, Vena porta? ; D, Hepatic artery; E, Gall-bladder; F, 
 Arrow within foramen of Winslow. 
 
 SUPRADUODENAL CHOLEDOCHOTOMY. 
 
 Description. — Incision of common bile-duct above the duodenum. Gen- 
 erally performed for the removal of calculi. 
 
 Preparation — Position — Landmarks. — As for exposure of gall-bladder 
 by vertical subcostal incision, page 1024. 
 
 Incision. — The site of operation is often reached in the course of some 
 other operation about the liver or gall-passages. Where especially planned 
 for the removal of a stone in the common duct, a vertical incision may be 
 made along the outer border of the right rectus, its upper end being extended 
 along the upper part of the subcostal border (the Robson incision, Fig. 751). 
 A curved incision may also be used — from just below the outer aspect of the 
 ensiform cartilage, thence parallel with and about 1.2 cm. (^ inch) from the 
 costal arch to a point about 1.2 cm. {\ inch) above the end of the eleventh rib. 
 In either of these incisions only the ninth nerve need be divided. Fenger 
 gives a vertical incision, combined, if necessary, with a transverse addition. 
 
I032 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Operation. — (1) The abdomen having been opened — the liver retracted 
 well upward — the intestines depressed (or having fallen away in the reversed 
 Trendelenburg position) — the gall-bladder is exposed. (2) The bladder is 
 then first palpated for calculi — and the cystic and hepatic ducts are followed 
 down until the common duct is reached — manipulating in the manner de- 
 scribed below. (3) All adhesions present should be broken down by blunt 
 dissection, or divided between chromic gut ligatures. These adhesions are apt 
 to be found between gall-bladder, stomach, transverse colon, great omentum, 
 and duodenum. The entire area should be packed off with gauze. By means 
 of a piece of gauze the liver and gall-bladder are grasped, drawn down from 
 under the costal arch, and rotated in such a way as to stretch and make promi- 
 nent the common duct and bring it nearer the surface. (4) After tracing 
 
 Fig. 757 — Choledochotomy and Choledochorrhaphy, by Vertical Subcostal Incision 
 in Right Linea Semilunaris: — A, Foramen of Winslow, leading behind hepato-duodenal liga- 
 ment ; B, Distended common bile-duct incised over a calculus. Lembert interrupted sutures are 
 shown placed ready to be tied after extraction of stone; C, Position of vena portae ; D, Position of 
 hepatic artery. 
 
 down the cystic duct, expose the anterior surface of the hepato-duodenal 
 ligament down to the duodenum — demonstrate the free border of the liga- 
 mentum hepato-duodenale to the right — insert the left index-finger into the 
 foramen of Winslow (with pulp of finger forward) and left thumb upon the 
 anterior surface of this ligament — follow its structure downward to the duo- 
 denum, having, between the fingers, the common duct to the right, the hepatic 
 artery to the left, and the vena portae on a plane posterior to and between the 
 other two. (5) Having located the stone by the above method of palpation, 
 especially guard against its slipping into the hepatic duct from between the 
 thumb and index — by pressing it forward against the anterior wall of the duct 
 and steadying it in that position. (6) Incise the duct in its long axis, directly 
 
SUPRADUODENAL CHOLEDOCHOTOM V. 
 
 1Q 33 
 
 over the stone, for a distance of from i to 3 cm. (J to i\ inches) , as indicated 
 (Fig. 757) . The escaping bile is caught in gauze — and the presenting calculus 
 removed with special forceps or scoop. Having removed the stone, the com- 
 mon duct should be examined for other stones — by means of the hnger or probe 
 — and from the duodenum to and into the cystic and hepatic ducts. (7) Hav- 
 ing extracted the stone, the wound in the duct is generally closed — either by 
 simple suturing — or by suturing aided by some such mechanical device as one 
 of Halsted's hammers ( which are of various sizes), (a) Closure Aided by 
 Halsted's Hammer; — Preliminary to the incision, two traction-sutures are 
 inserted on either side of the line of the future incision, through the outer coats 
 of the duct — for the purpose of aiding the manipulation. Having evacuated 
 the duct and examined its cavity for other calculi, Halsted's hammer is in- 
 troduced by insinuating its longer arm into the incised wound — the hammer 
 portion distending the duct and rendering it easier to suture its walls over the 
 round, firm form — which also obstructs the flow of bile during the operation. 
 (Fig. 758.) The opening is finally closed either by Halsted's mattress sutures 
 passed through the outer coats of the duct, — or two rows of ordinary sutures 
 may be used — an inner row of interrupted gut sutures through the muscular 
 and external coats, without penetrating the mucous membrane — and an outer 
 row of interrupted silk sutures through the serous surfaces. The peritoneum 
 covering the anterior aspect of the hepato-duodenal ligament is included in the 
 suturing, (b) Closure by Simple Suturing; — Having incised the duct over the 
 stone, before the stone is removed the first row of sutures, inserted upon a 
 small, fully curved needle through the muscular and external coats, is passed 
 while the stone is still in situ (using the stone as a distender of the gut) — these 
 stitches are then held apart and the stone is withdrawn between them — after 
 which the first row is tied and an outer row of interrupted silk sutures is passed 
 through the serous surfaces, as above described (Fig. 757). (8) In completing 
 the operation, a rubber drainage- 
 tube may be carried down to the 
 wound in the duct, and this sur- 
 rounded by gauze — the abdominal 
 wound being closed except where 
 the drainage comes out — consti- 
 tuting indirect drainage. Or a 
 drainage-tube may be carried into 
 the wound of the common duct, or 
 into the gall-bladder, or into the 
 cystic duct if the gall-bladder have 
 been removed (direct drainage). 
 
 Comment. — (1) If distended, 
 the gall-bladder or duct should 
 first be partly aspirated. (2) Where 
 choledochotomy with suture of the 
 duct is done, cholecystostomy is fre- 
 quently done at the same time, to 
 relieve the tension upon the stitches 
 and as a drain. (3) It is easier to 
 suture a thickened duct, and harder 
 
 to suture a thin one. If it be impossible to suture the duct, insert a small 
 rubber drainage-tube into the opened duct and pack around it with gauze. 
 (4) If the stone can be shifted, it is better to shift it nearer the duodenum before 
 incising the duct — as there is less danger of wounding the vena portae. (5) 
 
 Fig. 758.— Choledochorrhaphy, Aided by 
 Halsted's Hammer : — The hammer is shown in 
 situ during placing of sutures— and is withdrawn 
 prior to tightening last of the sutures. 
 
1034 OPERATIONS UPON THE AHDOMINO-PELVIC REGION. 
 
 After incising the duct, it may be necessary to crush the stone in situ by inserting 
 special crushing forceps through the wound in the duct and then removing 
 the debris with scoop or forceps. (6) If possible, ascertain with the probe 
 whether duct into the duodenum is patulous. 
 
 RETRODUODENAL CHOLEDOCHOTOMY. 
 
 iiaasler's operation. 
 
 Description. — Calculi have sometimes proved inaccessible by the ordinary 
 route of approach — and have been removed by exposing and incising the 
 common duct behind the duodenum. An attempt, however, should first be 
 made to dislodge such calculi upward into the more readily accessible part 
 of the duct. 
 
 Preparation — Position — Landmarks — Incision. — As in supraduodenal 
 choledochotomy. 
 
 Operation. — Having opened the abdomen and brought the field of opera- 
 tion into access, the common duct is exposed. The parietal peritoneum of 
 the posterior abdominal wall is then incised vertically, about 4 cm. (1^ inches) 
 to the right of the duodenum. The peritoneum is raised by blunt dissection 
 until the second portion of the duodenum is reached — which is then displaced 
 to the left, thus exposing its posterior surface. The second portion of the 
 common duct is located, covered by, or in a groove of, the pancreas — and is 
 exposed by blunt dissection — and incised over the calculus. The duct is 
 then explored and sutured as in the preceding operation — and drainage of its 
 bed established. 
 
 TRANSDUODENAL CHOLEDOCHOSTOMY. 
 
 kocher's operatiox. 
 
 Description.- — The second or third part of the common duct is opened to 
 remove an impacted calculus — by incising the anterior and posterior walls of 
 the second portion of the duodenum and the portion of the pancreas sur- 
 rounding the duct. 
 
 Preparation — Position — Landmarks — Incision. — As for supraduodenal 
 choledochotomy. 
 
 Operation. — The abdomen is opened — the liver elevated and retracted — 
 and the site of the common duct and duodenum exposed and packed off. 
 The duodenum is mobilized by a vertical incision about 4 cm. (ij inches) 
 to the outer aspect of the duodenum— and from this incision the peritoneum 
 is detached by blunt dissection up to the duodenum. The duodenum, 
 together with the head of the pancreas, is further freed toward the middle 
 line. A couple of fingers are then inserted behind the duodenum, or through 
 the foramen of Winslow, and the bowel elevated into the abdominal wound, 
 the hold upon the intestines being maintained throughout the operation. 
 After the stone has been steadied an incision is made through the walls of the 
 duodenum, in the long axis of the intestine, and the two edges of the intestinal 
 wound held apart by special clamps — the intestinal outflow being caught 
 upon gauze (Fig. 759). The interior of the intestine is examined — the stone 
 is felt through its posterior wall — and the opening of the ampulla is located 
 somewhat lower down. In the rare cases in which the stone can be protruded 
 through the ampulla, further incision is unnecessary. Otherwise, the incision 
 
CYSTICOTOMY, 
 
 I°3S 
 
 is made directly over the stone, in the long axis of the intestine, through its 
 posterior wall. When the knife reaches the calculus, two catgut stitches are 
 carried through the lips of the intestinal wound, one on either side — to be 
 first used as tractors and subsequently as sutures. The intestinal incision is 
 now lengthened and the stone removed with scoop or forceps. A third stitch 
 may be carried through the upper angle of the wound, including duct, pan- 
 creas, and intestinal wall. The outflow of bile is caught, and the duct is 
 explored toward the gall-bladder, by both finger and probe. Having com- 
 pleted the operation, the traction-sutures are tied as plain sutures and additional 
 ones inserted, if necessary, using catgut and carrying them through all the 
 coats. If the duct has been incised in its interstitial part, no suturing is 
 needed — but sutures should be placed if the incision has been higher. The 
 incision through the anterior wall of the duodenum is first sutured with through- 
 and-through sutures of all the coats, followed by a seromuscular suture. The 
 site of suture may be reinforced with an omental graft. The duodenum is 
 now allowed to fall back into place — and the abdomen closed — generally 
 without drainage, unless cholecystotomy or cholecystectomy have been done. 
 
 Fig. 750. — Transduodenal Choledochostomy: — The anterior wall of the duodenum 
 is incised — showing the papilla of the common duct and the incision into the duct through the 
 posterior wall of the duodenum. 
 
 Comment. — If the calculus be impacted in the interstitial portion of the 
 common duct, the incision is made into but not through the posterior wall of 
 the duodenum. If the calculus be impacted at the orifice of the ampulla, 
 and cannot be extracted from the orifice with forceps, the margin of the 
 ampulla is incised and the calculus then withdrawn (Ampullary Choledoch- 
 otomy of McBurney). 
 
 CYSTICOTOMY. 
 
 Description. — The incision of the cystic duct — an operation performed 
 for the removal of a calculus from the cystic duct — when not removable 
 through the gall-bladder or the common duct. 
 
 Preparation — Position — Landmarks — Incision. — As for Supraduodenal 
 Choledochotomy, page 1031. 
 
 Operation. — The technic here is practically the same as employed in 
 
1036 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 choledochotomy. By rotation and traction upon the liver the neck of the 
 gall-bladder and the cystic duct are exposed. The duct and its calculus are 
 steadied in the wound — and an incision made over the stone through the duct 
 wall. If further exploration of the gall-bladder tract prove it to be clear, 
 the wound in the cystic duct is closed — by a continuous fine catgut suture of 
 the outer coats (avoiding the mucosa) — followed by the suturing of the serosa 
 with fine silk or celluloid thread. The gall-bladder is drained — and the 
 abdomen otherwise drained. 
 
 HEPATICOTOMY. 
 
 Description. — The incision of the hepatic duct — an operation sometimes 
 performed for the removal of a calculus from the hepatic duct — when not 
 removable by downward displacement and incision of the common duct. 
 
 Preparation — Position — Landmarks — Incision. — As for Supraduodenal 
 Choledochotomy, page 103 1. 
 
 Operation. — The technic here employed is similar to that just given for 
 incising the cystic duct. The wound in the duct is sutured in the same 
 manner — and drainage of the gall-bladder established. 
 
 X. THE SPLEEN. 
 
 SURGICAL ANATOMY. 
 
 Description and Situation. — Situated chiefly in left hypochondriac 
 region — lying above left kidney and splenic flexure of colon — between con- 
 cavity of diaphragm to left and behind, and fundus of stomach to right and in 
 front — corresponding, in axillary line, with ninth, tenth, and eleventh left ribs. 
 It lies obliquely from above downward and from within outward. Its length 
 is about 12 cm. (4! inches) — breadth, 8 cm. (3 \ inches) — thickness, 3 cm. 
 {\\ inches). The peritoneum entirely surrounds the spleen except at its 
 hilum — which is at the center of the internal surface (between the renal and 
 gastric portions of internal surface) through which the arteries and nerves enter 
 and the veins and lymphatics emerge. Its pedicle is formed by the reflection 
 of peritoneum over the vessels at the hilum. The diaphragm separates all 
 parts of the normal spleen from the parietes. The spleen may be absent, or 
 there may be from one to twenty more or less rudimentary spleens present. 
 
 Surfaces and Borders. — Phrenic surface; lies beneath left ninth, tenth, 
 and eleventh ribs — peritoneum, diaphragm, portions of left pleura and lung, 
 the costo-phrenic sinus (and sometimes left lobe of liver) intervening. Renal 
 part of internal surface; touches superior and external part of left kidney, 
 and generally the suprarenal capsule. Gastric part of internal surface; in 
 contact with posterior wall of a filled stomach. Basal surface (lower outer 
 end) ; in contact with splenic flexure of colon and phreno-colic ligament (and 
 often with tail of pancreas). Anterior margin; situated between diaphragm 
 and stomach. Posterior border; between diaphragm and left kidney. 
 Superior end ; on level with tenth dorsal vertebra, approaching within 2 to 3 
 cm. (f to 1 \ inches) of spinal column. Reaches to level of ninth dorsal 
 spine. Inferior end; limited anteriorly by costo-clavicular line (connecting 
 left sterno-clavicular articulation with anterior end of eleventh rib). Reaches 
 to level of first lumbar spine. 
 
GENERAL SURGICAL CONSIDERATIONS. 1037 
 
 Relations. — Externally and Superiorly; peritoneum; diaphragm; left 
 ninth, tenth, and eleventh ribs; costo-phrenic sinus; left lung and pleura; pos- 
 terior thoracic muscles. Inferiorly; splenic flexure of colon; phreno-colic 
 ligament; tail of pancreas (sometimes). Internally; stomach (posterior sur- 
 face of fundus) ; left kidney and capsule; tail of pancreas; spinal column (some- 
 times). 
 
 Relations of Spleen to Thoracic Cavity. — Upper third of spleen is 
 covered by left lung, — middle third is in contact with left costo-phrenic sinus, — 
 lower third passes below lower pleural limit and costal origin of diaphragm. 
 
 Ligaments and Fixations of Spleen.— Gastro-splenic omentum — from 
 hilum to fundus of stomach. Phreno-splenic ligament— from upper end of 
 spleen to diaphragm. Spleno-renal ligament — formed partly by greater and 
 lesser peritoneal sacs — contains the splenic vessels. Phreno-colic ligament — 
 affords support, though not connected with spleen. Pancreatico-splenic liga- 
 ment — present when tail of pancreas does not reach spleen. Spleno-colic liga- 
 ment — from basal aspect of spleen to colon (sometimes present). 
 
 Arteries. — Splenic. 
 
 Veins.— Splenic. 
 
 Lymphatics. — Empty into glands at hilum. 
 
 Nerves. — From cceliac plexus and right pneumogastnc. 
 
 SURFACE FORM AND LANDMARKS. 
 
 Upper end of spleen lies opposite level of ninth dorsal spine — lower end 
 opposite level of first lumbar spine. The inner border comes within 3.8 to 
 5 cm. (ih to 2 inches) of the median plane of the body. The outer border lies 
 just posterior to the mid-axillary line — not coming further forward than a line 
 joining the left sterno-clavicular articulation and the anterior end of the 
 eleventh rib. The spleen corresponds with the ninth, tenth, and eleventh left 
 ribs — separated from them by the diaphragm and, in its upper part, also by the 
 lung. Its long axis about corresponds with the line of the left tenth rib. It 
 slightly overlaps the outer border of the left kidney below. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 The spleen may be exposed in several ways — by oblique subcostal incision 
 parallel with costal arch; by vertical incision in left linea semilunaris; by ver- 
 tical incision to left of left linea semilunaris; by median abdominal incision; by 
 intercostal incision; by partial excision of one or more ribs, followed by sub- 
 pleural or transpleural exposure of spleen. If more room be needed, any of the 
 vertical incisions may be increased by a transverse or curved incision extending 
 toward flank or median line, from the lower part of the vertical incision. 
 Where an abdominal incision is first made for pure exploratory purposes, the 
 median abdominal incision is probably best. There is general similarity in 
 the technic of hepatic and splenic operations. The freest exposure of the 
 splenic region, as of the hepatic region, is secured by the temporary resection 
 of the costal cartilage (page 1017). 
 
1038 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 INSTRUMENTS. 
 See those used in operating upon the Liver. 
 
 EXPLORATORY PUNCTURE OF SPLEEN. 
 
 Exploratory puncture of the spleen is macte in the same general manner, 
 and with the same general precautions, as is exploratory puncture of the liver 
 (see page 1008) . As in the case of the liver, exploratory puncture of the spleen 
 is rarely warrantable, owing to the risks of sepsis and hemorrhage — and should 
 not be used except in the case of tumors, which are almost certainly adherent 
 to the abdominal wall, thus shutting off the general peritoneal cavity— and 
 especially in those projecting below the ribs. The site of the tumor and the 
 general relations given under Surgical Anatomy will serve as the guide for the 
 site of puncture — the puncture itself being made exactly as it is in the case 
 of the liver. 
 
 SPLENOTOMY 
 
 BY OBLIQUE SUBCOSTAL INCISION. 
 
 Description. — Incision of the spleen — by an incision just below and paral- 
 lel with the left costal arch. The spleen may be exposed by any of the incisions 
 mentioned under General Surgical Considerations — one of the first three being 
 preferable. The operation may be done in one stage- — or in two stages (after 
 adhesions have formed) — and is generally resorted to for the liberation of pus. 
 
 Preparation — Position. — As for Median Abdominal Section. 
 
 Landmarks. — Lower border of left costal arch; left linea semilunaris; 
 position of tumor, if any. 
 
 Incision. — Oblique incision parallel with and about 1.3 cm. (\ inch) below 
 left costal arch, with its center over the site of spleen (the inner border of which 
 comes to within 4 to 5 cm. [1^ to 2 inches] of the median plane — and whose 
 outer border extends just posteriorly to the mid-axillary line). 
 
 Operation. — (1) Having opened the abdomen in the same manner as in 
 Hepatotomy by the same incision, the spleen is isolated and brought into the 
 wound as far as possible and the neighboring field packed off with gauze. In 
 dealing with fluid collections within the spleen substance, the tension should be 
 lessened by partial aspiration of the contents preliminarily to incision of the 
 viscus, after the organ is brought into the wound. (2) The operation may be 
 completed in one or in two stages; — (a) In One Stage: — Having been brought 
 as near the surface of the wound as possible, and after packing off the vicinity 
 as securely as possible, the spleen is incised in the same general manner and 
 with the same precautions as in the case of the liver (seepage 10 12). In the 
 case of a fluid collection, the edges of the pus or cyst cavity are then seized and 
 brought forward and sutured into the lower plane of the abdominal wound 
 (which is closed in from either end for a part of the distance) — the sutures 
 passing through spleen substance and capsule at some distance from the 
 wound in the viscus, on the one hand, and through parietal peritoneum and 
 part of the thickness of the lower plane of the lips of the abdominal wound, on 
 the other — thus approximating the peritoneum of the spleen and the perito- 
 
SPLENOPEXY. IO39 
 
 neum of the abdominal wall all around, (b) In Two Stages;— The spleen is 
 brought into the wound and the parietal peritoneum and edges of the abdo- 
 minal wound are stitched in an elliptical manner to the serous surface and to 
 the substance of the spleen — the wound of the abdomen, which is partly closed 
 from one or both ends, is then packed with gauze and two or three days given 
 for union — after which the spleen is incised. x\ll incisions into spleen sub- 
 stance are planned so as to avoid, as far as possible, the large vessels of the 
 viscus. (3) Where the spleen has been incised for exploration simply, and 
 nothing has been found, splenorrhaphy is done and the abdomen closed. 
 
 Comment. — When indicated, the costal cartilages may be temporarily 
 resected (page 10 17). 
 
 EXPOSURE OF SPLEEN BY SUBPLEURAL ROUTE 
 
 BY PARTIAL EXCISION OF ONE OR TWO RIBS. 
 
 Description. — For the general description, see the corresponding opera- 
 tion upon the liver. The ribs chosen are usually the tenth and eleventh 
 (and the former when only one rib is excised) — the site of excision lying mid- 
 way between a point about 4 to 5 cm. (1^ to 2 inches) from the median plane, 
 and a point just posterior to the mid-axillary line. The steps of the operation 
 are the same as those for the subpleural exposure of the liver by the partial ex- 
 cision of one or more ribs (see page 1014). 
 
 SPLENORRHAPHY. 
 
 Description. — Suturing of the spleen. Generally resorted to for incised 
 and lacerated wounds, and for approximating surfaces after partial splenec- 
 tomy. The route of approach is often determined by a pre-existing wound or 
 operation — if not, the oblique subcostal incision parallel with the left costal 
 arch gives the best exposure. For the method of approaching the spleen, 
 therefore, see Partial Splenectomy by Oblique Subcostal Incision parallel with 
 the Ribs, page 1040. For the details of the operation, after exposing the 
 organ, see Hepatorrhaphy, page 10 19, the technic being practically the same. 
 
 SPLENOPEXY. 
 
 Description. — Bv Splenopexy is meant the fixation, generally by means 
 of suturing, of a displaced spleen back to its original site, or to another site. 
 Indicated in wandering" spleen (Splenoptosis). 
 
 Preparation — Position — Landmarks. — As for Partial or Total Splen- 
 ectomy, according to the incision adopted. 
 
 Incision. — The organ may be approached by a vertical incision in the left 
 linea semilunaris; by an oblique subcostal incision; or by a median vertical 
 incision. The first incision given provides the most convenient approach to 
 the parts involved. The median incision has been used by Rydygier, who in- 
 troduced the operation. 
 
1040 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Operation. — Having opened the abdomen, isolated and exposed the dis- 
 placed spleen, its position, its environments, and the laxity of its ligaments are 
 studied, and a site for its fixation decided upon, (a) Rydygier, having opened 
 the abdomen in the median line, elevated the spleen to a proper height— then 
 detached from the parietes sufficient peritoneum to form a pocket — dividing the 
 parietal peritoneum with a transverse upward convexity, detaching it down- 
 ward from the abdominal wail. The lower half of the spleen was then placed 
 in this pocket — the parietal peritoneum was sutured to the underlying tissues 
 along the lowest line of separation (to prevent further separation) — and the 
 free border of the parietal peritoneum was attached to the gastro-splenic 
 omentum above, (b) Bardenhauer entered the abdominal cavity by a some- 
 what rectangular incision, made by a vertical incision extending from the ribs 
 to the superior iliac crest, the upper line of which was extended transversely 
 forward along the inferior border of the tenth rib. The flap thus included was 
 detached downward to but not through the peritoneum and turned inward — 
 the peritoneum was then incised sufficiently to enable the spleen to be drawn 
 through edgewise. A strong purse-string suture of silk, previously placed 
 around the margin of the peritoneal opening, was then drawn so as to pucker it 
 around the pedicle but not constrict it. A suspensory silk suture was passed 
 under the end of the spleen and over the tenth rib as a sling. Other sutures 
 were passed where indicated. The spleen was thus practically extraperito- 
 neally placed. The abdomen is closed without drainage. 
 
 PARTIAL SPLENECTOMY 
 
 BY SUBCOSTAL INCISION PARALLEL WITH RIBS. 
 
 Description. — Excision of part of spleen. Generally done for removal of 
 tumor involving a portion of the organ. 
 
 Preparation — Position. — As for median abdominal section. 
 
 Landmarks. — Lower border of left costal arch — or modified by the position 
 of a tumor, if one be present. 
 
 Incision. — Obliquely curved incision parallel with and about 1.2 cm. 
 (^ inch) below the left costal arch, with its center over the site of the spleen 
 (whose inner border extends to within 4 or 5 cm. [1^ or 2 inches] of the median 
 plane, and whose outer border extends just posteriorly to the mid-axillary line), 
 — or, if a tumor be present, directly over the tumor. 
 
 Operation. — (1) Having incised the skin and fascia; the external oblique 
 transversely; separated the internal oblique in the cleavage line; retracted 
 what nerves could be spared; divided the transversalis obliquely; and the trans- 
 versalis fascia, subserous areolar tissue, and peritoneum in the line of the 
 original wound, the abdominal cavity is opened. (2) Having retracted the 
 wound and brought the spleen as far into the opening as possible, the area of 
 the spleen to be removed, including the tumor, if any, is now to be surrounded 
 in sections by interlocking silk or chromic gut ligatures and tightened — or other 
 form of ligature which will compress the entire area to be circumscribed and 
 removed. When the entire portion to be removed has been thus circum- 
 scribed by a compressing ligature, the tied- off area is excised with curved 
 scissors, or by the actual cautery — further ligating any portions requiring lig- 
 ature. Where the area to be removed has any ligamentous attachments corre- 
 sponding to it, or adhesions connected with it, these are first tied off and divided 
 between ligatures. (3) Where possible, the surfaces left by the partial ex- 
 
TOTAL SPLENECTOMY. 
 
 IO41 
 
 cision should be approximated by deeply placed sutures. See Splenorrhaphy, 
 page 1039. The spleen is then dropped back into place — and the abdomen 
 generally closed without drainage. 
 
 Comment. — Where the tumor or tumors are small, small wedge-shaped 
 masses may be removed and the edges approximated by deeply placed sutures, 
 which both coapt the surfaces and control the hemorrhage — thus obviating 
 any previous ligation of the spleen substance. 
 
 TOTAL SPLENECTOMY 
 
 BY VERTICAL INCISION IN LEFT LINEA SEMILUNARIS. 
 
 Description. — Excisions of entire spleen. Resorted to in some cases of 
 movable spleen, injury of the organ, simple hypertrophy and in some tumors. 
 
 Preparation. — As for Median Abdominal Section. 
 
 Position. — As for Median Abdominal Section — the position of the surgeon 
 to the right of the patient giving better access to and control of the pedicle. 
 
 Landmarks.— Left linea semilunaris. 
 
 Incision. — Vertical incision in left linea semilunaris, beginning near the 
 left costal arch and extending downward as far as necessary. (Such an incision 
 
 Fig. 760. — Total Splenectomy: — The spleen is exposed by chondroplastic resection 
 of the chest-wall and drawn forward. The pedicle is clamped preparatorily to ligation in 
 sections. (Modified from Guibe.) 
 
 will divide the ninth nerve transversely on a line with the lower border of the 
 ninth rib.) The spleen may also be exposed by one of the incisions given 
 under General Surgical Considerations. 
 
 Operation. — (1) Having incised abdominal wall and opened the peritoneal 
 cavity and retracted the lips of the wound, the spleen is located and brought as 
 prominently forward as possible. If any adhesions be found between the 
 spleen and neighboring viscera, or the abdominal wall, these are separated by 
 blunt dissection, or divided between double ligatures— carefully avoiding in- 
 jurv to the spleen. (2) Freeing Splenic attachments (ligaments) and Enu- 
 cleation of the Spleen; — The phreno-splenic ligament is best reached and 
 
 66 
 
1042 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 treed, as suggested by Jonnesco, by covering the spleen with a square of gauze, 
 to avoid slipping of fingers, and then depressing the spleen downward and to 
 the right, while an assistant draws the left lower edge of the abdominal wound 
 to the left — thus exposing the bed of the spleen and vault of the diaphragm and 
 the phreno-splenic ligament, which latter is divided between double ligatures. 
 (3) Following this, the remaining ligaments and attachments of the spleen to 
 its bed are freed, commencing at its lower aspect. The spleen is then enu- 
 cleated and delivered through the abdominal wound. The gastro-splenic 
 ligament is the omentum surrounding the pedicle, and therefore a part of the 
 pedicle — and is treated in ligating the pedicle. (4) Ligation and Division of 
 the Pedicle (Fig. 760) ; — The spleen having been delivered, is then turned 
 toward its left and made to rest upon its convexity, thus exposing its pedicle. 
 The constituent vessels of the pedicle, beginning with the most important, 
 should all be separated and each doubly ligated and divided between the two 
 ligatures, which should be of strong silk. This is the most important step of the 
 operation. Separate ligation is better than ligation en masse, or in two or three 
 divisions or groups of vessels — though the latter may be done in cases of haste 
 or other need. Traction upon the constituents of the pedicle, which are easily 
 ruptured, is to be avoided. Adherence of the splenic artery and vein to the 
 tail of the pancreas often adds to the difficulty of isolation and separate liga- 
 ture of these vessels. (5) Hemostasis of the Splenic Bed; — Having removed 
 the spleen, its bed is carefully examined — and every bleeding point ligated with 
 chromic gut. Especially examine the pillar of the diaphragm, where the 
 phreno-splenic ligament has been divided — after drawing the stomach and 
 intestines to the right. Limited bleeding surfaces may be controlled by su- 
 turing peritoneum over them, where possible. (6) The abdominal wound is 
 closed — unless drainage be specially indicated, or there should be uncertainty 
 as to the hemostasis. Full elastic dressings are applied so as to compress the 
 region formerly occupied by the spleen. 
 
 Comment. — (1) It is better to ligate the pedicle at once — than to clamp 
 first and then ligate. (2) Some surgeons, especially in very large spleens, pre- 
 fer to ligate the pedicle first, with the spleen in situ — then draw the spleen 
 down and tie off the gastro-splenic omentum — then deliver the spleen. (3) 
 The vessels are often enormously enlarged — and the veins are often especially 
 thin. (4) Tie the arteries first — then the veins — as less blood is thus lost. (5) 
 See that ligatures, in tying off the pedicle, pass between rather than through 
 the vessels — passing through connective tissue between the vessels. (6) Some 
 surgeons advise first clamping and separating the gastro-splenic ligament — in 
 order to enable the spleen to be lifted up and the pedicle better exposed (J. 
 Wesley Bovee — but adds that this is often impossible in marked hypertrophy — 
 in which cases the vessels are ligated in the order encountered). (7) Some 
 surgeons, in dealing with less accessible pedicles, transfix the entire splenic 
 omentum with double ligature, tying each half separately — then subsequently 
 surround the entire pedicle with another single ligature. The pedicle may be 
 crushed with an angiotribe and then ligated in segments. (8) After exposing 
 the spleen, the hand should be passed between it and the diaphragm and its 
 surface examined — as well as its other aspects, as far as possible. Very ex- 
 tensive and firm adhesions would contraindicate the continuance of the opera- 
 tion. There may be visceral, parietal, and omental adhesions. If much 
 damage be done in separating adhesions, temporary drainage is indicated. 
 (9) Practise no traction upon the pedicle, both because of the friable vessels 
 and because of the general bad symptoms which are apt to supervene from 
 
SURGICAL ANATOMY OF THE PANCREAS. 1043 
 
 pressure upon the splenic plexus (from the solar plexus). Relax the pedicle 
 before tightening each ligature. (10) Treatment of the pedicle comes first in 
 importance and treatment of adhesion second. Hemorrhage is the chief dan- 
 ger. (11) If secondary hemorrhage be feared, suture the pedicle to the abdo- 
 minal wall. 
 
 XI. THE PANCREAS. 
 
 SURGICAL ANATOMY. 
 
 Description. — The pancreas lies transversely across the posterior abdo- 
 minal wall, the large vessels intervening between it and the wall — being on a 
 level with the second lumbar vertebra (and sometimes with the first or third) — 
 lying in the epigastric and left hypochondriac regions — having the stomach in 
 front, duodenum to the right, and spleen to the left — and the aorta, vena cava, 
 cceliac plexus, thoracic duct, and diaphragmatic crura behind. It lies behind 
 the posterior wall of the lesser omental cavity and is between the laminae of the 
 mesocolon of the transverse colon. The head of the pancreas is surrounded by 
 the loop of the duodenum. The tail of the pancreas is in contact with the 
 interno-inferior aspect of the spleen. Peritoneum covers the pancreas except 
 upon its posterior surface. The viscus is 15 to 16 cm. (about 6 inches) in 
 length — 3 to 4 cm. (1 \ to ij inches) in width — and 15 to 18 mm. (about h, inch) 
 in thickness. 
 
 Relations. — Anteriorly; Upper layer of transverse mesocolon; lesser 
 peritoneal sac; transverse colon; gastro-duodenal and pancreatico-duodenal 
 arteries; stomach (posterior surface). Posteriorly; second (sometimes third 
 or first) lumbar vertebra; crura of diaphragm; aorta and right and left renal 
 arteries and superior mesenteric artery; inferior vena cava, superior and inferior 
 mesenteric, splenic, and right and left renal veins; vena porta? ; cceliac plexus; 
 thoracic duct (origin); ductus communis choledochus and pancreatic duct; 
 left kidney (and sometimes its capsule). Superiorly; Duodenum (first part); 
 liver; hepatic and splenic arteries and cceliac axis; solar plexus. Inferiorly; 
 Duodenum, third (preaortic) and fourth (ascending) parts; duodeno-jejunal 
 angle; jejunum; transverse colon; transverse mesocolon (inferior layer); 
 superior mesenteric artery and vein; inferior mesenteric vein; mesentery. 
 Right end; Loop of duodenum. Left end; Interno-inferior aspect of spleen. 
 
 Fixations. — Held in place by its peritoneal investment and by adjacent 
 viscera and structures to which attached. 
 
 Pancreatic Duct (Canal of Wirsung). — Begins at left end, or tail, of 
 pancreas — runs thence toward the head of the organ, passing nearer its pos- 
 terior than anterior aspects — after passing the neck, it turns downward, back- 
 ward, and to right, in the head of the viscus, and runs to the left side of the 
 common bile-duct — entering the duodenal wall together and parallel with the 
 ductus communis choledochus — uniting with the latter while running ob- 
 liquely in thewallsof the duodenum — and emptying by a common opening with 
 it upon a papilla of mucous membrane about 10 cm. (4 inches) from the pylo- 
 rus — the opening being covered by a fold of mucous membrane from above. 
 The pancreatic duct is recognized by its white color and its relation to the 
 pancreatica magna artery. Its diameter, near its termination, is between 2 
 and 3 mm. (about \ inch). The Duct of the Lesser Pancreas (Duct of San- 
 
1044 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 torini) may join the Canal of Wirsung near its termination — or may empty into 
 the duodenum by a separate mouth. 
 
 Arteries. — Pancreaticae parvae and pancreatica magna from splenic artery; 
 pancreatico-duodenalis superior from gastro-duodenalis of hepatic; pancre- 
 atico-duodenalis inferior from superior mesenteric. 
 
 Veins. — Accompany the above arteries, emptying into splenic and superior 
 mesenteric veins. 
 
 Lymphatics. — End in two glands upon superior mesenteric artery. 
 
 Nerves. — From solar plexus. 
 
 SURFACE FORM AND LANDMARKS. 
 
 The pancreas lies obliquely behind the stomach — crossing the spine op- 
 posite the second (or sometimes the first or third) lumbar vertebra. Anteriorly, 
 it lies transversely about 7.5 cm. (3 inches) above the umbilicus. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 General Considerations.— (1) Surgery of the Pancreas is limited to op- 
 erations for cysts (which is the most frequent operation done upon theviscus), 
 removal of small tumors, abscess, hemorrhage, localized necrosis, calculi, 
 "annular pancreas," and for the removal of parts of the organ. (2) Anato- 
 mically, complete pancreatectomy is very difficult. (3) Surgically, complete 
 removal with subsequent life has been proved with animals — but not with man. 
 Rapidly fatal diabetes follows complete removal of the organ. (4) Cysts may 
 be incised or excised. In incision, the cyst-wall should be sutured to the abdo- 
 minal wall (marsupialization) — for drainage, and to prevent pancreatic juice 
 from getting into the abdominal cavity. (5) Pancreatic juice in the abdominal 
 cavity is apt to excite peritonitis. (6) If the pancreatic opening into the duo- 
 denum be cut off, a new route must be made, or a pancreatic fistula must be 
 established. (7) Suturing material should not be left in the pancreatic ducts, 
 as such material may form the nuclei of calculi. (8) Wounds of the pancreatic 
 canals should be closed by suture. (9) Always ligate before excising a portion 
 of the pancreas — in order to prevent the escape of pancreatic juice into the 
 peritoneal cavity. (10) Extirpation of the tail and part of the body, or of 
 limited portions of the head, may be done. The tail of the organ is the part 
 most safely operated upon. In operating upon the head, it is necessary to 
 spare the canal of Wirsung, or the duct of Santorini. In removing the whole 
 head of the pancreas, there is no way to restore the flow of pancreatic juice into 
 the intestines. 
 
 Routes of Approaching the Pancreas. — (1) Transgastrocolic ; — by 
 incising the anterior layers of the gastrocolic omentum between the greater 
 curvature of the stomach and the transverse colon, and thus entering the lesser 
 omental cavity. This is the route to be preferred — and is made by a trans- 
 peritoneal median incision above the umbilicus (Fig. 761). (2) Trans- 
 gastrohepatic ; — by cutting through the gastrohepatic omentum. This 
 approach may be used when the tumor presents above the lower curvature of 
 the stomach, as less frequently happens — and is made by transperitoneal 
 
GENERAL SURGICAL CONSIDERATIONS. 
 
 I°45 
 
 Fig. 761. — Transgastrocolic Exposure of the Pancreas: — Between the stomach 
 above and the colon below; the pancreas is seen through an incision in the gastrocolic omen- 
 tum. 
 
 median incision above the umbilicus. (3) Transmesocolic ; — by incising 
 the inferior layer of the mesocolon. This route may be used when the tumor 
 
 Fig. 762. — Transmesocolic Exposure of the Pancreas: — Having displaced the omentum 
 and colon upward, the pancreas is exposed through an incision in the mesocolon. 
 
 lies between the lamina? of the mesocolon — and is made by a transperitoneal 
 median incision above the umbilicus (Fig. 762). (4) Access to the posterior 
 
1046 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 part of the head of the pancreas may be secured by Kocher's method, of 
 "mobilizing the duodenum" described at page 987, Gastroduodenostomy. 
 (5) The pancreas has been exposed by incising anterior and posterior walls 
 of the stomach. Lumbar ; — by incising as for exposure of the kidney. Some- 
 times done for tumors of the tail of the pancreas — and is made by an extra- 
 peritoneal incision as for exposure of the left kidney — or below and along the 
 twelfth rib. (See Fig. 763.) 
 
 Methods of Drainage of Pancreatic Cavities. — (1) If pus have col- 
 lected in the bursa omentalis, incise in the median line, from the ensiform car- 
 tilage downward, and cut 
 through the gastrohepatic 
 omentum — -after, if possi- 
 ble, first suturing that 
 omentum to the abdom- 
 inal wall. (2) If pus be in 
 the bursa omentalis and 
 extend along the pancreas, 
 resort to Leith's lumbar 
 drainage mentioned below. 
 (3) Lumbar drainage is 
 sometimes necessary where 
 anterior drainage cannot 
 be secured — in such cases 
 Leith suggests a lumbar in- 
 cision made under the left 
 twelfth rib. Through this 
 the finger is inserted by 
 the upper border of the 
 quadratus lumborum, lo- 
 cating the left kidney and 
 its vessels. The tail of the 
 pancreas and the posterior 
 and external wall of the 
 bursa omentalis are placed 
 above and just internal to the renal vessels. The lesser peritoneal cavity 
 can be here entered either through the mesocolon or through the posterior 
 laver of the peritoneum. (4) If pus be retroperitoneal — make a lumbar in- 
 cision as for exposure of the left kidney and reach the site extraperitoneally. 
 
 Fig. 763. — Illustrating Routes of Approach to Pan- 
 creas:— A, Gastro-colic ; B, Trans-mesocolic ; C, Trans-gas- 
 trohepatico-omental (epigastric); D, Lumbar; E, Pancreas. 
 (Modified from Gray.) 
 
 INSTRUMENTS. 
 See those given under the Liver (page 1008). 
 
 Description 
 
 or abscess of that organ 
 
 PANCREATOTOMY 
 
 BY GASTROCOLIC ROUTE. 
 
 Incision of the pancreas. Generally resorted to for cyst 
 
 The method of approach is generally one of the 
 
PARTIAL PANCREATECTOMY. 1047 
 
 first three given under General Surgical Considerations — and is usually the 
 one above mentioned. In the case of a cyst of the pancreas, its walls may 
 be excised, or, as is more generally done, sutured to the abdominal wall and 
 drained. 
 
 Preparation — Position— Landmarks. — As for Median Abdominal Sec- 
 tion. 
 
 Incision. — In median line, with its center opposite the lower border of 
 the stomach — which is about 4 cm. (ij inches) above the umbilicus. Where 
 a tumor is evident, the incision is usually placed directly over it. 
 
 Operation. — (1) Having opened the abdomen as in median section, 
 the gastrocolic omentum is exposed. (2) Having displaced the stomach 
 upward and the transverse colon downward, the gastrocolic omentum is in- 
 cised vertically, between the lower border of the stomach and the upper 
 border of the colon — thus reaching the lesser peritoneal cavity. (3) Having 
 controlled all hemorrhage, the pancreas is reached through the opening in < 
 the omentum and drawn forward into the wound — packing off the vicinity 
 with gauze. (4) If haste be necessary, the operation is completed in one 
 stage, the cyst being incised and its edges sutured into the lower plane of the 
 abdominal wound, having been brought through the rent in the gastrocolic 
 omentum, which is sutured around the opening in the pancreas as well as 
 possible. (5) If haste be unnecessary, the operation is concluded in two 
 stages — the first step being similar to the one just described — the second step, 
 the incision of the viscus, being performed two or tHree days later, after 
 adhesions have formed and the general peritoneal cavity has been shut off. 
 (6) In any event, therefore, drainage is temporarily provided for through the 
 abdominal incision, which is usually accomplished by drainage-tube and 
 gauze packing. 
 
 Comment. — (1) Adhesions are apt to be found in such cases, and should 
 be separated by blunt dissection, or divided between chromic ligatures, 
 before attempting to expose the pancreas in the wound. (2) In distended 
 cysts or abscesses, partial aspiration should first be done to lessen tension. 
 (3) In some cases adhesions are found walling off the general peritoneal 
 cavity — so that it is possible to incise directly through the abdominal wall 
 and gastrocolic omentum into the pus or fluid cavity. (4) In exceptional 
 cases cysts may be excised in the same manner as small tumors. 
 
 PARTIAL PANCREATECTOMY 
 
 BY GASTROCOLIC ROUTE. 
 
 Description. — Excision of part of the pancreas. Generally performed 
 in connection with removal of a tumor involving a portion of the organ. 
 
 Preparation — Position — Landmarks — Incision. — As for Pancreatot- 
 omv. 
 
 Operation. — The pancreas is exposed in precisely the same manner as 
 for Pancreatotomy. The tumor in the organ is sought and brought as well 
 forward as possible. Chromic gut ligatures are then placed deeply around 
 the mass to be removed, so as to completely circumscribe it — thus preventing 
 both hemorrhage and the escape of pancreatic fluid. This having been 
 done, the tumor is excised with curved, blunt-pointed scissors, aided by blunt 
 dissection. If a marked cavitv is left, and it is possible to do so, the walls of 
 
1048 OPERATIONS UPON THE ABDOMINO-PELVIC REGION". 
 
 the cavity are approximated by dee]) chromic gut sutures. Drainage is then 
 established between the site of the operation and the abdominal wound — 
 and the remainder of the abdominal incision closed. 
 
 XII. THE KIDNEYS. 
 
 SURGICAL ANATOMY. 
 
 Description. — Each kidney lies partly in the hypochondriac, lumbar, 
 epigastric, and umbilical regions — abutting upon the confines of each — 
 resting upon the lower part of the diaphragm and areolar fatty tissue covering 
 the quadratus lumborum and psoas magnus — and placed behind the peri- 
 toneum. They lie embedded in abundant fatty areolar tissue, more abundant 
 posteriorly than anteriorly — constituting the fatty areolar capsule. The 
 right kidney generally (though not always) lies about 7 mm. to 1.3 cm. (3 to 
 \ inch) lower than the left (owing to the presence of the liver upon the right). 
 Vertically, the kidneys correspond to the space between the upper border 
 of the twelfth dorsal and the first and second (and sometimes the upper half 
 of the third) lumbar vertebras — and to the eleventh and twelfth ribs and 
 transverse processes of the first and second lumbar vertebrae — the left kidney 
 generally reaching to the upper border of the eleventh rib — and the right 
 kidney generally reaching to the lower border of the eleventh rib. Outer 
 borders of the kidneys lie from 9 to 10 cm. (3^ to 4 inches) external to the 
 lumbar spines. The superior poles of the kidneys lie about 5 cm. (2 inches), 
 and the inferior poles from 6.3 to 7.6 cm. (2% to 3 inches), from the median 
 line. Inner border of right kidney lies close to the vena cava — the inner 
 border of the left kidney lies within 2.5 cm. or more (1 inch or more) of the 
 aorta. The kidneys average 10 to 12 cm. (4 to 4! inches) in length — 2.8 cm. 
 (i£ inches) in thickness — 6.3 cm. (2^ inches) in breadth — and weigh about 
 4^ ounces. There may be an irregularity from the normal in the form, size, 
 number, position, and mobility of the kidneys. 
 
 Peritoneal Relations of the Kidneys. — 
 
 Posterior surfaces of both kidneys are uncovered by peritoneum. Upon 
 the anterior surface of the right kidney — the hepatic and mesocolic areas are 
 peritoneal — and the areas of the duodenum and transverse colon are non- 
 peritoneal. Upon the anterior surface of the left kidney — the gastric area 
 is peritoneal— the pancreatic area is non-peritoneal — the outer part of the 
 colic area is non-peritoneal, and the inner part of the colic area is peritoneal. 
 
 Fixations. — (1) Fatty areolar tissue, or capsule — in which the kidneys 
 are embedded — derived from parietal subperitoneal fascia — and separates 
 them from the diaphragm and from the anterior lamella of the lumbar fascia 
 covering the quadratus lumborum and psoas muscles. (2) Vessels, nerves, 
 and connective tissue form the pedicle. (3) Partial covering of peritoneum 
 upon their anterior surfaces and borders. 
 
 Relations. — Anterior Surface — (a) Right Kidney; — Liver (right lobe) 
 — iperitoneum intervening; ascending colon and hepatic flexure; duodenum 
 (descending part); suprarenal capsule (to slight extent), (b) Left Kidney; — ■ 
 Stomach (fundus) — peritoneum of lesser sac intervening; pancreas (tail); 
 splenic artery and vein; splenic flexure of colon and upper part of descending 
 colon; duodenum (ascending part); suprarenal capsule (to slight extent). 
 Posterior Surface — (Both Kidneys) — Areolar fatty tissue, separating the 
 
SURGICAL ANATOMY OF THE KIDNEYS. 
 
 1049 
 
 kidneys from diaphragm and quadratus lumborum and psoas muscles; pos- 
 terior abdominal wall, corresponding to eleventh and twelfth ribs and trans- 
 verse processes of first and second lumbar vertebrae; diaphragm (areolar 
 tissue intervening); anterior layer of posterior aponeurosis of transversalis 
 (/. e., anterior layer of lumbar fascia), separating kidney from quadratus 
 lumborum; psoas; diaphragmatic, transversalis and iliac fascia lining dia- 
 phragm, transversalis and iliacus; twelfth dorsal, ilio-hypogastric and ilio- 
 inguinal nerves; anterior divisions of first and second lumbar arteries and 
 veins. The nerves and vessels just mentioned all pass downward and out- 
 ward anteriorly to the quadratus lumborum and pierce the transversalis 
 beyond the external border of the quadratus. Note. — The left kidney is in 
 contact with a larger area of diaphragm than the right — and the amount of 
 diaphragm in contact may be increased on both sides when the arcuate liga- 
 ments are attached to the tips of the transverse processes of the second lumbar 
 vertebra. External border — (a) Right Kidney; liver (upper two-thirds); 
 ascending colon (lower third), (b) Left Kidney; spleen (above); descending 
 colon (below). Internal border — (a) Right Kidney; near vena cava; struc- 
 tures of hilum (q. v.). (b) Left Kidney; 2.5 cm. or more (1 inch or more) 
 from aorta; structures of hilum (q. v.). Superior extremity— (Both Kid- 
 neys) — Suprarenal capsule — which encroaches also upon the anterior and in- 
 ternal border and is bound to the kidney by the connective tissue of the sub- 
 peritoneal fascia. Inferiorly — (Both Kidneys) — come within about 5 cm. 
 (2 inches) of the crest of the ilium. 
 
 Relations of the Pleurae. — The pleurae are in proximity to, but not in 
 relation with, the kidneys. The lower limit of the pleura extends nearly 
 
 Fig. 764.— Horizontal Section through Upper Lumbar Region :— A, Pancreas; B, De- 
 scending colon; C, Spleen; D, Ascending colon; E, Small intestine; F, F, Kidneys; G, External 
 oblique; H, Internal oblique; I, Transversalis; J, Psoas magnus ; K, CJuadratus lumborum; L, 
 Erector spina; ; M, Latissimus dorsi. (Modified from Esmarch.) 
 
 horizontally outward from the lower margin of the twelfth dorsal vertebra — 
 crossing the twelfth rib close to its neck — and crossing the eleventh rib about 
 5 cm. (2 inches) beyond (external to) its neck. 
 
 Relation of Structures within the Sinus of the Kidney.— (A) Struc- 
 tures; — Branches forming renal artery; branches forming renal vein; lymph- 
 atic vessels and glands; plexus of nerves; ureter; areolar fatty tissue. (B) 
 Order of Structures from Before Backward; — (a) Right Kidney — vein, artery, 
 ureter: — (b) Left Kidney— vein, artery, ureter. (C) Order of Structures 
 from Above Downward; — (a) Right Kidney — vein, artery, ureter:— (b) 
 Left Kidney — artery, vein, ureter. 
 
1050 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Arteries. — Renal, suprarenal, spermatic, and lumbar — all from aorta. 
 
 Veins. — Renal. Right vein empties directly into vena cava. Left vein 
 receives left spermatic (or left ovarian), left inferior phrenic, and sometimes 
 left suprarenal before emptying into vena cava. 
 
 Nerves. — From solar and aortic plexuses, semilunar ganglia, splanchnics, 
 and pneumogastrics. 
 
 Lymphatics. — Superior and deep sets — emptying into lumbar glands. 
 
 Fig. 765. — Showing the General Relations of the Kidneys to the Vertebr.k and 
 Ribs. (Modilied from Deaver.) 
 
 Description of Lumbar Fascia. — Consists of three layers, which en- 
 sheathe erector spinae and quadratus lumborum muscles. (1) Posterior or 
 superficial layer : — Layer through which latissimus dorsi, and serratus pos- 
 ticus inferior beneath it, are connected to the vertebral spines (same thing as 
 aponeurosis of those muscles). Latissimus dorsi is connected with it most 
 posteriorly — serratus posticus inferior, lying beneath latissimus dorsi, is con- 
 nected with its upper part anteriorly to latissimus dorsi — and beyond the line 
 along which these two muscles are connected with it (/. e., after these two 
 muscles are free of it) it gives origin to the posterior part of the internal ob- 
 lique — and then passes on (after internal oblique is free of it) to merge with 
 middle layer — thus binding down posterior aspect of erector spinae. It is con- 
 
SURFACE FORM AND LANDMARKS. 1051 
 
 tinuous with the vertebral aponeurosis. (2) Middle layer: — Arises from 
 tips of lumbar transverse processes — runs outward between quadratus lum- 
 borum in front and erector spina? behind, to fleshy part of transversalis muscle 
 — forming posterior aponeurosis of transversalis. It is joined at outer border 
 of erector spina? by posterior layer — and at outer border of quadratus lum- 
 borum by anterior layer. It is attached, above, to lower margin of last rib — 
 and, below, to ilio-lumbar ligament and adjacent iliac crest. (3) Anterior 
 layer : — attached to front of lumbar transverse processes at inner border of 
 quadratus lumborum — covering anterior surface of quadratus lumborum to its 
 outer border, where it becomes united with middle layer and becomes the trans- 
 versalis fascia. Attached above (forming ligamentum arcuatum externum) 
 to front of transverse processes of first (or second) lumbar vertebra and apex 
 of last rib, and, below, to ilio-lumbar ligament and iliac crest (Figs. 764 and 
 765J- 
 
 SURFACE FORM AND LANDMARKS. 
 
 (1) A horizontal line through the umbilicus will be below the lower border 
 of each kidney — about 2.5 cm. (1 inch) below the right kidney, and 4 cm. 
 (1^ inches) below the left (Quain). According to Treves, such a line will in- 
 tersect the lower portion of the right kidney, and pass below the left. (2) A 
 vertical line from the middle of Poupart's ligament upward to the costal arch 
 will have one-third of the kidney to its outer, and two-thirds of the kidney to 
 its inner side. (3) Posteriorly, the kidney lies within a parallelogram in- 
 cluded within the four following lines: (a) Line parallel with and 2.5 cm. 
 (1 inch) external to the spine, from the lower border of the tip of the eleventh 
 dorsal spine to the center of the tip of the third lumbar spine, — (b) Line drawn 
 outward for 7 cm. (2% inches) at a right angle to, and from the upper end of line 
 "a," — (c) Line drawn outward for 7 cm. (2% inches) at a right angle to, and 
 from the lower end of line "a," — (d) Line parallel with line "a," between the 
 outer ends of lines "b" and "c." (4) The right kidney is generally from 1.3 
 to 2 cm. (h to f inch) lower than the left, — and will lie that far below the 
 measurements given in (3) above. (5) The upper border of the kidney lies 
 upon a level with the eleventh intercostal space and with the eleventh or twelfth 
 dorsal spine — the right kidney lying somewhat lower. (6) The twelfth ribs 
 divide the kidneys, approximately, into a superior and an inferior half. 
 (7) The lower border of the kidney about corresponds with the center of the 
 spinous process of the third lumbar vertebra. (8) The kidneys are accessible 
 to pressure in the triangle formed by the lower border of the twelfth rib above, 
 and the outer border of the erector spina? internally. (9) The axes of the kid- 
 neys are oblique — from above and within, downward and outward. (10) 
 The superior pole of the kidney is about 5 cm. (2 inches) from the median 
 plane, (n) The hilum of the kidney lies about 5 cm. (2 inches) from the 
 median plane, on a level with the first or second lumbar spine, or opposite the 
 interval between them. (12) The inferior pole of the kidney lies about 6.3 to 
 7.5 cm. (2% 10 3 inches) from the middle line. (13) The inner border of the 
 upper part of the kidney lies about 2.5 cm. (1 inch) external to the middle line 
 of the body. The inner border lies upon the external border of the psoas — the 
 rest of the kidney lying upon the lumbar fascia covering the quadratus lum- 
 borum. (14) The outer border of the lower part of the kidneys is about 9.5 
 cm. (3^ inches) from the middle line. The external border lies from 2 to 3 cm. 
 (f to 1 j inches) to the outer side of the external border of the quadratus lum- 
 
1052 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 borum muscle. (15) The ureter expands into the pelvis of the kidney op- 
 posite the lower half of the kidney. (16) Both kidneys rest upon the lower 
 portion of the arch of the diaphragm (as it comes downward between the kid- 
 neys and the twelfth ribs), quadratus lumborum, anterior layer of lumbar 
 fascia, and psoas muscle. (17) The external border of the erector spinae is the 
 superficial guide to the kidney — and the quadratus lumborum the deep guide, 
 —the former muscle marking the twelfth rib about 6.3 cm. (2^ inches) from 
 the median line — and the latter being attached to the inner half of the twelfth 
 rib (Fig. 766). 
 
 Fig.766. — Relations of Kidneys to Vertebra, Ribs, Pleur/E, and Overlying Muscles: 
 — A, A, Latissimus dorsi ; B, B, Erector spince ; C, C, Quadratus lumborum ; D, External oblique ; E, 
 Internal oblique; F, Transversalis ; G, Lower limit of pleura. Ascending colon is seen on the right, 
 the descending on the left. (Modified from Gray, and from Esmarch and Kowalzig.) 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Preparation. — -Bowels and bladder emptied — part shaved. 
 
 Position. — In operating extraperitoneally, the patient lies upon the sound 
 side, near the edge of the table, with a firm cushion or support under the op- 
 posite loin, to round out and make prominent the side of the operation and in- 
 crease the interval between the twelfth rib and the iliac crest. The surgeon 
 
RETROPERITONEAL EXPOSURE OF THE KIDNEY. 1053 
 
 stands at the patient's back, cutting from above downward on the right side, 
 and in the reverse, or in the same direction, on the left. The assistant stands 
 opposite. In operating transperitoneally, the position is the same as for 
 median abdominal section. 
 
 Approach to the kidney may be by the extraperitoneal or transperitoneal 
 route — preferably the former. 
 
 Always ascertain that the opposite kidney is present before removing a 
 kidney. 
 
 An incision to expose the kidney may go, with safety, to the lower border of 
 the twelfth rib. If the eleventh be the last rib, the pleura would be endangered 
 if that rib were taken for the twelfth. If the thirteenth rib be present, the 
 operation area would be contracted. 
 
 Do not take for granted that the last rib is the twelfth rib — else the pleura 
 may be wounded. Always count the ribs from above. 
 
 The pleurae may reach lower where the arcuate ligaments are attached to 
 the second lumbar vertebra. 
 
 If necessary to better expose the kidney, the twelfth rib may be excised 
 subperiosteal! v, in whole or in part. 
 
 Hemorrhage in kidney operations is often great. It may be controlled: — 
 by compression of the pedicle by the fingers, or a special forceps temporarily 
 applied, — by gauze-pressure of the bleeding surface, — by hot douching. Su- 
 turing of bleeding surfaces in contact also controls hemorrhage. In bisection 
 of the healthy kidney, pressure of the pedicle is necessary. Diseased kidney 
 bleeds less than healthy kidney substance. 
 
 The right renal vein is generally much shorter than the left — a fact to be 
 remembered in handling the pedicle of the right kidney. 
 
 Gut is preferable to silk throughout in kidney surgery — as being absorb- 
 able — and less apt to form the nuclei of calculi. 
 
 INSTRUMENTS. 
 
 Scalpels; bistouries; scissors, various; forceps, dissecting, toothed, and 
 dressing; blunt dissector; probe; sound; grooved director; tenacula ; exploratory 
 syringe and needle; needle in handle, for exploration; periosteotomes; costo- 
 tome; pedicle forceps; special stone scoops and forceps; stone-searcher; an- 
 eurism-needles; artery-clamp forceps; dilators; ureteral buttons; needle-holder; 
 needles, straight and curved; sutures and ligatures, of chromic and plain gut, 
 kangaroo tendon, and silk; ligature-carriers; long tenotome; drainage-tubes; 
 gauze; blunt hooks; clamps, various; retractors. 
 
 RETROPERITONEAL EXPOSURE OF THE KIDNEY 
 
 P.V OBLIQUE LUMBAR INCISION. 
 
 Description. — The most generally applicable method of exposing the 
 kidnev, for whatever purpose indicated. The incision admits of being ex- 
 tended upward over the twelfth or eleventh rib, exposing them for partial 
 excision, if necessary — as well as downward toward the anterior superior iliac 
 spine, and onward and downward just aoove and parallel with Poupart's liga- 
 
io54 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 ment, exposing, if need be, the entire length of the ureter — the parts being ex-, 
 ttosed throughout, extraperitoneaily. 
 
 Preparation — Position. — See General Surgical Considerations. 
 
 Landmarks. — Twelfth rib; outer border of erector spina*; iliac crest; 
 Poupart's ligament. 
 
 Incision. — Begins in the triangle made by the lower border of the twelfth 
 rib and the outer border of the erector spina* — at a point about 1.3 cm. (\ inch) 
 below the twelfth rib, and just to the outer border of the erector spinae (which 
 crosses the twelfth rib about 6.3 cm. \p.\ inches] from the median line) — passes 
 thence obliquely downward and forward in the direction of the anterior superior 
 
 Fig.767.— Incision for Exposure of Kidneys by the Lumbar Route:— A, Retroperitoneal 
 exposure by oblique lumbar incision ; B, Continuation of this incision where additional room is 
 required ; C, Retroperitoneal exposure by Koenig's angular lumbo-abdominal incision ; D, Incision 
 in Edebohls's operation of nephropexy. 
 
 iliac spine, generally at first for 7.5 to 10 cm. (3 to 4 inches) — and may be subse- 
 quently extended both upward and downward as mentioned. When so con- 
 tinued downward, it passes to within 2 to 2.5 cm. (f to 1 inch) of the anterior 
 superior iliac spine, and thence turns downward and inward parallel with and 
 about the same distance above Poupart's ligament (Fig. 767, A and B, and 
 Fig. 768). 
 
 Operation. — (1) Incise skin and superficial fascia, exposing the posterior 
 layer of the lumbar fascia, the anterior part of the latissimus dorsi and the 
 posterior part of the external oblique. Continuing the incision in the original 
 line, the anterior portion of the latissimus dorsi will be incised transversely to 
 its fibers. The upper part of the serratus posticus inferior will be incised 
 transversely beneath it. The posterior border of the external oblique will be 
 divided, and, if the incision be continued far toward the iliac crest, the knife 
 will pass into the intermuscular cleavage line of this muscle (Fig. 769). (2) 
 
RETROPERITONEAL EXPOSURE OF THE KIDNEY. 
 
 I055 
 
 The outer border of the erector spinas is exposed, but its sheath is not opened. 
 The internal oblique is incised nearly at a right angle to its course. The pos- 
 terior aponeurosis of the transversalis muscle (fascia lumborum) is divided 
 also to the full length of the wound. Between the internal oblique and trans- 
 versalis, branches of the last dorsal nerve and last intercostal artery may be 
 encountered passing downward and forward near the twelfth rib — and 
 branches of the first lumbar nerve and last lumbar artery near the iliac crest. 
 The nerves are retracted wherever possible. The arteries are ligated with gut. 
 All the parts are retracted as divided. (3) The outer border of the quadratus 
 lumborum muscle and the anterior layer of the fascia lumborum are now en- 
 countered. The latter is incised to the limit of the wound. The outer border 
 of the former is retracted — or may be incised if necessary. This divided layer 
 is also retracted. (4) The fas- 
 cia transversalis is thus ex- 
 posed, and is similarly divided 
 — when the entire depth of the 
 wound is well retracted on each 
 side. (5) The fatty areolar 
 capsule of the kidney is now 
 exposed, retroperitoneal!}' — and 
 is opened up, partly by careful 
 incision, and partly by blunt 
 dissection of the perirenal tis- 
 sue — while an assistant, by 
 pressure upon the abdominal 
 wall, thrusts the kidney into the 
 lumbar wound — thus exposing 
 the surface of the organ. (6) 
 The special object of the opera- 
 tion is now accomplished — and 
 the wound treated as indicated. 
 Comment. — (1) There is 
 more chance to separate, rather 
 than divide, some of the mus- 
 cle-fibers in this incision, if it 
 become necessary to extend it, 
 
 than in most of the other incisions. (2) In exploratory incisions, and in 
 limited operations upon the kidney, it is generally only necessary to divide the 
 skin, superficial fascia, lumbar fascia, latissimus dorsi, and serratus posticus 
 inferior over a distance between the anterior border of the erector spinas and the 
 posterior edges of the external and internal oblique muscles. (3) In thick loins, 
 longer incisions are necessary. (4) Where the kidney does not extend down 
 as far as usual, the incision may be extended well over the twelfth rib (but see 
 Surgical Anatomy). (5) Guard against opening the pleura, which is only 
 separated by a comparatively thin layer of fibrous tissue from the renal fatty 
 tissue at the costo-lumbar hiatus of the diaphragm. (6) Proximity of the 
 kidney is sometimes noticed, in approaching from behind, by the finer texture 
 of the fatty areolar tissue near it. (7) Avoid the colon, which sometimes 
 pushes its way into the wound. (8) If, in the course of operation, more room 
 be needed, the incision may be extended in one of three directions; — (a) back- 
 ward, dividing, if necessary, the anterior border of the erector spinas: — (b) up- 
 ward and backward over the twelfth rib, which maybe partially excised: — (c) 
 
 Fig. 768. — Oblique Lumbo-abdominal Incision : 
 exposure of kidney and ureter. 
 
ioq6 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 downward and forward toward the anterior superior iliac spine, and thence 
 parallel with and about 2.5 cm. (1 inch) above Poupart's ligament. (9) If it 
 be desired to examine the opposite kidney during operation (which should al- 
 wavs be done before removing a kidney, except where that ground has been 
 preliminarily covered by vesical catheterization of the opposite ureter), Kocher 
 resorts to the following technic; — he divides the transversalis muscle sufficiently 
 
 Fig. 76Q.— Retroperitoneal Exposure of Kidney by Oblique Lumbar Incision: — A, 
 Latissimus dorsi ; B, Serratus posticus inferior; C, Erector spinse ; D, Quadratus lumborum ; E, 
 External oblique; F, Internal oblique; G, Transversalis aponeurosis; H, Fatty areolar tissue; 
 I, Intercostal nerve and artery; J, Last dorsal nerve and lumbar artery; K, Kidney; L, Pelvis of 
 kidney. 
 
 far forward to expose the reflection of the peritoneum on to the colon, near the 
 posterior axillary line — then he opens the peritoneum and passes his hand 
 through the opening and around to the opposite kidney — the inferior surface of 
 the liver and gall-bladder being thus palpable also. After accomplishing the 
 examination, the opening in the peritoneum is sutured and the operation con- 
 tinued. (10) By keeping close to the outer edge of the quadratus lumborum 
 muscle, there is minimum danger of wounding the peritoneum. 
 
 RETROPERITONEAL EXPOSURE OF THE KIDNEY 
 
 BY KOEXIG'S ANGULAR LUMBO-ABDOMINAL IN'CISION. 
 
 Description. — A retroperitoneal exposure of the kidney where an espe- 
 cially large amount of room is required. 
 
 Preparation— Position. — See Surgical Considerations. 
 
 Landmarks. — Twelfth rib; outer border of erector spina?; iliac crest; 
 umbilicus. 
 
 Incision. — Begins about 2 cm. (f inch) below the twelfth rib, at the outer 
 border of the erector spina? — passes almost vertically downward (having slight 
 outward tendency) along the outor border of the erector spina?, to just above 
 the iliac crest — thence curves forward and upward and passes in a straight line 
 toward the umbilicus, stopping at the outer border of the rectus (Fig. 767, C). 
 
 Operation. — (1) Incise, in the vertical portion of the incision, the skin, 
 superficial fascia, posterior layer of the lumbar fascia, latissimus dorsi, serratus 
 
TRANSPERITONEAL EXPOSURE OF THE KIDNEY. 1057 
 
 posticus inferior, middle layer of lumbar fascia, quadratus lumborum, an- 
 terior layer of lumbar fascia, and subperitoneal fatty areolar tissue. The 
 vessels and nerves encountered in this portion of the incision are the same as 
 those in the oblique lumbar incision. (2) The lips of this wound are retracted 
 — the fingers are inserted and the peritoneum detached and pushed ahead in 
 advance of the oblique part of the wound, as it is being made. (3) The ob- 
 lique portion of the incision is now carried out, dividing the skin, superficial 
 fascia, latissimus dorsi, external oblique, internal oblique, transversalis, trans- 
 versalis fascia, and subperitoneal areolar tissue. All nerves encountered are 
 preserved, by retraction, as far as it is possible. The peritoneum is carefully 
 detached and held out of the way ahead of the incision until its end is reached. 
 (4) The perirenal fatty areolar tissue is now opened up and the kidney ex- 
 posed. (5) The special operation is accomplished — and the wound treated 
 accordingly. 
 
 Comment. — This operation gives abundant room, and is retroperitoneal — 
 but is very extensive, and a weakened abdominal wall is apt to follow. 
 
 RETROPERITONEAL EXPOSURE OF THE KIDNEY 
 
 PA' THE LUMBAR INTRAMUSCULAR METHOD. 
 
 Description. — A retroperitoneal exposure of the kidney in the intramus- 
 cular cleavage line and without severing important nerves and vessels. Chiefly 
 for diagnostic purposes — and such steps as can be carried out through a 
 limited space. The principle involved is the same as that in McBurney's 
 intramuscular operation. 
 
 Preparation — Position. — See General Surgical Considerations. 
 
 Landmarks. — Tip of twelfth rib; anterior superior iliac spine. 
 
 Incision. — Begins just internal to the anterior superior iliac spine — and 
 passes upward and backward, in the cleavage line of the external oblique, to 
 the tip of the twelfth rib. 
 
 Operation. — Incise skin and superficial fascia — expose external oblique 
 and separate its fibers in their cleavage line, throughout the entire length of 
 the wound, from the anterior superior iliac spine to the tip of the twelfth rib — 
 retract the separated fibers forward and upward, and backward and down- 
 ward — expose the internal oblique, running almost directly across the external 
 oblique, and separate its fibers similarly, along as much of the line as possible, 
 from the ninth costal cartilage toward the posterior superior iliac spine, and 
 retract the separated fibers forward and downward, and backward and up- 
 ward — expose the transversalis and separate its fibers similarly, and retract the 
 separated fibers upward and downward — divide the transversalis fascia — then 
 the subperitoneal connective tissue — open up the perirenal fatty areolar tissue 
 — retract the walls of the wound well — and expose the kidney. 
 
 TRANSPERITONEAL EXPOSURE OF THE KIDNEY 
 
 BY VERTICAL INCISION* IN THE LINEA SEMILUNARIS — LANGENBUCH'S 
 
 OPERATION. 
 
 Description. — An anterior transperitoneal exposure, with division of the 
 mesocolon over the kidney. Chiefly indicated in large tumors — in narrow, 
 deformed lumbar regions — in thick lumbar regions — where much room is re- 
 quired — and as furnishing an easv approach and examination of both kidnevs 
 67 
 
1058 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 and ureters. Incision over the linea semilunaris gives a more direct route 
 than incision in the median line. 
 
 Preparation — Position. — As for median abdominal section. 
 
 Landmarks. — Linea semilunaris; costal arch. 
 
 Incision. — Begins just below the border of the ribs, in the linea semilunaris 
 of the affected side, and extends vertically downward in that line for 10 or 12.5 
 cm. (4 or 5 inches) — the incision having its center about opposite the umbilicus. 
 
 Operation. — (1) The abdominal cavity is opened in the usual way and 
 the wound well retracted. The small intestines are held out of the way by 
 gauze pads and special retractors. The hand is introduced and the condition 
 of both kidneys examined. (2) The colon is displaced toward the median line 
 
 Fig. 770. — Transperitoneal Exposure of Kidney, by Vertical Incision in Linea Semi- 
 lunaris (Langenbuch's Operation): — A, Ascending colon displaced toward median line ; B, 
 Outer layer of mesocolon incised over kidney; C, Ligature around renal vein ; D, Ligature of renal 
 artery; E, Ligature of ureter. 
 
 and the outer layer of the mesocolon is incised in a vertical direction over the 
 site of the kidney — thus avoiding the vessels to the colon (Fig. 770). (3) The 
 fingers of the surgeon are passed through this incision in the mesocolon down 
 upon the kidney — the posterior surface of which is then freed and exposed, as 
 it lies in its fatty areolar bed. (4) The special steps of the operation are then 
 concluded — and the abdomen closed. For the details of total nephrectomy 
 by the abdominal route, see page 1072. 
 
 Comment. — (1) Where drainage is necessary in connection with the 
 anterior transperitoneal operation, a counter-opening is made in the loin — the 
 incision being made from without upon a sound pressing against the lumbar 
 wall from within. (2) Where it is necessary, in the anterior operation, to fix 
 
EXPOSURE OF KIDNEY BY ABDOMINO-LUMBAR ROUTES. 1059 
 
 a diseased ureter into the lumbar skin, an incision is made by cutting from 
 without upon a pair of forceps introduced from within, near the outer edge of 
 the quadratus lumborum. (3) Before closing the abdomen, the incised wound 
 in the mesocolon is sutured with gut. 
 
 TRANSPERITONEAL EXPOSURE OF THE KIDNEY 
 
 BY MEDIAN ABDOMINAL SECTION. 
 
 Description. — Exposure of the kidney by an incision in the median line. 
 Practically the same as exposure by vertical incision in the linea semilunaris, 
 except for the position of the incision — the operation last described giving the 
 most direct access to the kidney. 
 
 Preparation — Position — Landmarks — Incision. — As in median ab- 
 dominal section. 
 
 Operation. — Essentially the same as in exposure by the vertical incision 
 in the linea semilunaris. Having displaced the intestines to the opposite side, 
 the mesocolon is divided over the kidney. The lateral layer of the mesocolon 
 is preferably divided. If circumstances make this inconvenient, the median 
 layer of the mesocolon is divided. Having passed through the opening in the 
 mesocolon, the kidney is isolated and exposed — its anterior surface, lateral 
 borders, upper and lower poles, posterior surface, and pelvis being made ac- 
 cessible. Having accomplished the object of the operation, the incision in the 
 mesocolon is sutured — and the abdomen closed. 
 
 Comment. — Wherever the fatty areolar capsule has been opened up very 
 extensively in exposing the proper capsule of the kidney, at the close of the 
 operation the fatty areolar connective tissue is sutured about the kidney again 
 — and, if necessary, anchored, by a chromic gut stitch or two, to the neighbor- 
 ing structures. 
 
 EXPOSURE OF THE KIDNEY BY THE COMBINED ABDOMINO-LUMBAR 
 
 OPERATION 
 
 BY ANTERIOR TRANSPERITONEAL AND POSTERIOR RETROPERITONEAL 
 
 INCISIONS. 
 
 Description.— Consists of one of the anterior transperitoneal operations 
 combined with one of the posterior retroperitoneal operations. Generallv 
 resorted to where it is wished to make a previous examination of the abdominal 
 cavity, chiefly for diagnostic purposes connected with both kidneys and ureters 
 — or where a large tumor is to be removed. The intra-abdominal operation is 
 first performed. Guided by one hand within the peritoneal cavity, the kidnev 
 can be exposed through a smaller lumbar wound, and with greater ease, and 
 with less danger of wounding the colon and peritoneum. The great objection, 
 however, is the double operation — and the involvement of the peritoneal cavity. 
 
 Preparation. — As for both the abdominal and lumbar operations. 
 
 Position. — Patient is supine during the anterior operation, and partlv 
 upon the side during the lumbar incision. The surgeon's position changes 
 with the steps of the operation. 
 
 Landmarks. — Those of both the abdominal and lumbar operations. 
 
 Incision. — The incisions usually adopted are, for the anterior operation, 
 Langenbuch's vertical incision in the linea semilunaris — and, for the posterior 
 operation, the oblique lumbar incision. See the descriptions of these incisions, 
 pages 1053 and 1058. 
 
io6o 
 
 OPERATIONS UPON THE AP.DOMINO-l'ELVIC REGION. 
 
 Operation. — The abdominal operation is first done — the examination 
 made — and then, guided by the left hand within the abdomen, the lumbar in- 
 cision is made and the operation completed extraperitoneally, accomplishing 
 the special object sought through the posterior wound, as a rule — after which, 
 the abdomen is closed. The posterior wound is either entirely closed — or 
 partially closed and drained, as indicated. 
 
 EXPLORATORY PUNCTURE OF THE KIDNEY. 
 
 Description. — Exploration of the kidney by solid needle for calculus — or 
 by hollow needle and syringe for pus or other fluid. Two forms of puncture 
 may be made — (a) Puncture from Without ; the puncture is here made through 
 unbroken skin, or, in the case of a large needle, after incising the skin alone; — 
 the needle-puncture is made on anatomical grounds, and is made below the 
 level of the pleura (see pages 759 and 1049). (See Comment.) (b) Puncture 
 
 after exposure of the 
 Kidney — which will 
 be here described. 
 In the latter case the 
 exposure is usually 
 made through the 
 oblique lumbar in- 
 cision. 
 
 Preparation — 
 P o s i t i o n — L and- 
 marks — Incision. — 
 As for exposure of 
 the kidney by an 
 oblique lumbar in- 
 cision. 
 
 Operation.— 
 Having exposed and 
 incised the perirenal 
 fatty tissue, the kid- 
 ney surface (the 
 proper capsule) is 
 exposed over as large 
 an area as consid- 
 ered necessary, by a 
 blunt dissector and 
 the finger. The kid- 
 ney is then steadied 
 by the fingers of the 
 operator's left hand 
 — while a needle, 
 held between the right index and thumb (remembering the dimensions of the 
 kidney), is thrust into the viscus — always being introduced in a straight line, 
 and thrust from its point of entrance toward the hilum — being introduced, 
 preferably, from the convex border — next, in the sides — and, last, at the hilum. 
 A needle may be thus introduced a dozen or more times — always being with- 
 drawn and re-entered before being made to travel in a new direction. The 
 operation will be concluded according to the result of the puncture. (Fig. 771.) 
 
 Fig. 771.— Exploratory Incision and Puncture of Kidney 
 and Pelvis :— A, Nephrotomy ; B, Bisection of kidney ; C, Explora- 
 tory puncture of kidney substance with solid needle ; D, Exploratory 
 puncture with aspiratory needle ; E, Sound passed through pelvis of 
 kidney to explore ureter; F, Forceps holding apart lips of pyelotomy 
 wound. 
 
NEPHROTOMY. 1061 
 
 Comment. — Transperitoneal puncture should never be made — it is both 
 unsafe and uncertain. Extraperitoneal lumbar puncture is not so dangerous — 
 and, when made through the unbroken skin, while not so unsafe as transperi- 
 toneal puncture, it is quite uncertain. The most advisable form of puncture is 
 first to expose the kidney deliberately, and then to puncture. 
 
 NEPHROTOMY. 
 
 Description. — Incision of the kidney substance for the removal of calculi 
 or tumors, or for the evacuation of pus or other fluid from the kidney proper, 
 calices or pelvis — or for nephralgia. The kidney may be exposed by any of the 
 incisions given — the oblique lumbar incision being probably the best. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 the kidney by the oblique lumbar incision. 
 
 Operation. — (I) Having exposed the kidney and brought it into the field, 
 by counter-pressure from in front, and by drawing it down from under the rib 
 the site of the calculus or fluid is discovered by the introduction of the solid or 
 hollow needle, after the manner described under Puncture of the Kidney. (2) 
 Having located the object, an incision is made down upon it exactly as de- 
 scribed under Nephrolithotomy (page 1062), stone being the most usual in- 
 dication for Nephrotomy. (3) Following the operation for stone, the kidney 
 wound is treated as under Nephrolithotomy. (4) Following the operation for 
 pus or fluid, drainage is carried down into the cavity of pus or fluid — after, 
 where it is possible, the lips of the cavity have been brought up and sutured to 
 the deeper structures of the abdominal wound — or the cavity may be partly 
 closed around a drainage-tube going to its bottom. (5) Where the kidney has 
 been cut into and no cause for drainage is found, the kidney substance is 
 brought together by alternate deep and superficial catgut sutures. (6) The 
 fatty areolar capsule is also closed by deep buried gut sutures in all such cases. 
 (7) The lumbar wound is sutured in part, leaving room for drainage — or 
 entirely, as indicated. (Fig. 771.) 
 
 Comment. — (1) Where hemorrhage is severe on cutting into the kidney, 
 it may be controlled by compressing the pedicle (which should have been 
 demonstrated in advance) between the fingers or special clamps — or by gauze 
 packing. Hemorrhage from a healthy kidney is often enormous — while it is 
 generally much less from a diseased one. (2) Incision along the convex border 
 of the kidney is always preferable. It is better to remove a calculus in the 
 pelvis of the kidney through an incision from the convex border than by an in- 
 cision directly into the pelvis — fistula being more apt to follow incision of the 
 pelvis. (3) Where all is favorable, complete suturing of the kidney substance 
 should be done after the removal of a stone. (4) Splitting of the capsule alone 
 may be done in Nephralgia. (5) It is often hard to find the pelvis in the 
 normal kidney, even after incising from the convex border. (6) After neph- 
 rotomy for pus, always unite the margins of the cavity to the structures in 
 the lower part of the wound, if possible — to avoid, if possible, infection of the 
 perirenal tissue. (7) In unhealthy or suspicious cases, drainage is estab- 
 lished down to the kidney — or, if indicated, into not only the kidney itself, 
 but even into the pelvis — with gauze or tube, preferably gauze packed into 
 the pelvis and calices. 
 
 Bisection of Kidney. — In cases where limited incisions into the kidney 
 substance will not suffice, it is sometimes necessary to lay the kidney widely 
 open — splitting it into two halves flat-wise, or " bisecting " it. An incision is 
 
1062 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 made in the middle line of the convex border, from the upper to the lower pole 
 — passing straight into the pelvis — thus dividing the fewest vessels and urin- 
 iferous tubules. The narrow calices are dilated with the tip of the finger or a 
 pair of forceps — a probe is passed thence into the pelvis — and a bougie may be 
 passed down the ureter even into the bladder. Having accomplished the 
 object of the exploration, and, in suitable cases, having corrected the condi- 
 tion, the bisected kidney is sutured with alternate deep and superficial cat- 
 gut sutures — the deep ones passing through the entire thickness of the kidney. 
 (Fig. 772.) 
 
 PYELOTOMY. 
 
 Description. — Pyelotomy, or Pelviotomy, consists in the incision of the 
 pelvis of the kidney. Generally resorted to for calculus, or for exploration. 
 Usually done by the oblique lumbar incision. Pelvio-lithotomy, or Pyelo- 
 lithotomy, is the same operation done especially for the removal of stone from 
 the pelvis of the kidney. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 the kidney by an oblique lumbar incision. 
 
 Operation. — Having incised and freed the fatty capsule and exposed the 
 kidney by blunt dissection, the organ is brought forward and steadied — as far 
 out into the wound as possible. A longitudinal incision (in the course of the 
 pelvis) is made through the posterior wall of the pelvis. Scarcely any hem- 
 orrhage follows incision of the pelvis, as a rule — in contradistinction to the 
 rather free hemorrhage which nearly always at first follows incision of the kid- 
 ney parenchyma. Insert two temporary silk traction-sutures into the wound- 
 lips of the pelvis. Into the opening thus made and held apart by the traction- 
 sutures, a special sound, or the finger, is introduced and an examination made 
 for the object suspected — both in the calices above, and in the ureter below. 
 Having accomplished the object of the operation (which is often the removal of 
 a calculus) the wound in the pelvis, in clean cases, is closed by interrupted or 
 continuous sutures, applied like the Lembert suturing, through all the coats of 
 the pelvis except the mucous. For fear of leakage, drainage is generally es- 
 tablished down to the pelvis. In infected cases, free drainage is established 
 to and even into the pelvis — in the latter case, omitting the suturing of the en- 
 tire pelvis-wound. The lumbar wound is closed up to the exit of the drain. 
 (Fig. 771, E.) 
 
 Comment. — (1) While incision into the pelvis is followed by little or no 
 hemorrhage, and admits of probing the ureter, it gives no access to the kidney 
 parenchyma — and but imperfect access to the calices — and is more apt to be 
 followed by urinary fistula. (2) After Pyelotomy, in order to avoid urinary 
 fistula, especial care should be taken to see that the ureter is patulous — if it be 
 not patulous, the obstacle should be removed — or an ureterostomy, or other 
 operation, be done. (3) The calix, or the site of the lodged stone, may have 
 to be dilated with special forceps before it can be loosened and removed. 
 
 NEPHRO-LITHOTOMY. 
 
 Description. — Incision of the kidney for the removal of stone. The 
 operation consists, practically, of a Nephrotomy — and is generally done 
 through the oblique lumbar incision. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 kidney by oblique lumbar incision. 
 
NEPHRORRHAPIIY. 1063 
 
 Operation. — (1) Having located the kidney and pressed (by counter- 
 pressure) and drawn it into the wound, divide the fatty areolar tissue and ex- 
 pose the surface of the organ. (2) Insinuate the index-finger (of that hand 
 corresponding with the kidney involved) beneath the fatty capsule, through the 
 freeing incision, and feel the organ by palpating it between thumb and index, 
 counter-pressure being maintained the while. If the stone be palpated, steps 
 for its removal may be at once undertaken. (3) If the stone be not detected 
 by palpation, several means of investigation are available; (a) While the kidney 
 is steadied, a small, long, solid needle may be thrust in various directions, 
 entered at the external border and thrust toward the hilum — being withdrawn 
 between each thrust. This is the simplest and best instrumental exploration. 
 (b) A special sound may be passed through an incision made in one of the 
 lowest calices and the pelvis of the kidney thus examined, or a finger may be 
 introduced. Chiefly indicated when a stone is impacted there and is not re- 
 movable from the external border of the kidney, (c) An incision along the 
 convex border of the kidney, lengthwise of the kidney, may be made — pass- 
 ing as far into the substance of the organ as indicated, even into the calices. 
 Note — Methods ''a" and "c" are to be preferred to opening the pelvis of the 
 kidney, which is apt to be followed by fistula. (4) When located, the stone is 
 cut down upon by the most direct route, by a straight incision from the cortex 
 toward the hilum — and, when reached, the calculus is removed by the finger 
 alone, or aided by special scoop or forceps — or may be broken and removed in 
 pieces. (5) Having removed the calculus, and cleansed by douching or gauze- 
 sponging, as indicated, the site occupied by the stone, the wound in the kidney, 
 in clean cases, should be repaired by fine catgut (see Nephrorrhaphv), and 
 temporary drainage down to the kidney established. If purulent conditions 
 be present, the kidney wound should not be entirely sutured — and drainage to, 
 or into, the pus cavity be instituted. 
 
 Comment. — (1) Following free incision of the kidney substance, con- 
 siderable hemorrhage is apt to occur at first, but is generally capable of speedy 
 arrest by gauze pressure, or hot douching — or, these failing, by compression 
 of the pedicle. (2) Incisions into the kidney substance should be made in a 
 straight line toward the hilum (centering toward the hilum like the spokes of a 
 wheel). (3) To aid in examining the pelvis of the kidney, turn the external 
 border of the kidney upward and forward. (4) In manipulating near the 
 anterior wall of the kidney, take care lest the peritoneal cavity be entered. (5) 
 Where the kidney has been exposed by an anterior incision (transperitoneal) 
 and drainage is necessary, a posterior counter-opening should be made by 
 cutting from without down upon some instrument pressed against the lumbar 
 wall from within. The peritoneum is then closed over the anterior aspect of 
 the kidney, and the posterior wound, with drainage, is left open. These re- 
 marks just made apply to the sometimes indicated removal by a posterior in- 
 cision of a stone which has been discovered by an anterior operation. 
 
 NEPHRORRHAPHY. 
 
 Description. — Suturing of the kidney substance — here used in connection 
 with suturing kidney wounds, either accidental or those made in the course of 
 an operation. The kidney is exposed either by enlarging the original wound — 
 or, if deliberately exposed, generally by the oblique lumbar incision. Every 
 Nephropexy involves nephrorrhaphv — but not vice versa. See Nephropexy 
 page 1064. 
 
1064 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Operation. — Having exposed the kidney and brought it into convenient 
 position for manipulation, the edges of the wound are brought together and 
 
 sutured with catgut, car- 
 A ried upon a fully curved 
 needle held in a needle- 
 holder. Interrupted su- 
 tures are generally more 
 satisfactory than continu- 
 ous sutures. Where the 
 wound is superficial, a 
 single row of sutures, all 
 of the same depth, suffices. 
 Where the wound is more 
 extensive, it is well to put 
 in a double row — a deeper 
 row outlying the more 
 superficial row, — or a sin- 
 gle row may be used, 
 putting in each alternate 
 suture a deep one. Ordi- 
 nary suture may be used — 
 either interrupted or con- 
 tinuous — or the Halsted 
 quilt suture may be used, especially where much loss of kidney substance has 
 occurred. (Fig. 772.) 
 
 Fig. 772.— Nephrorrhaphv and Pyelorrhaphy : — A, 
 Small nephrotomy wound closed with superficial sutures; B, 
 Long and deep nephrotomy wound closed with alternate super- 
 ficial and deep sutures; C, Pyelotomy wound closed with 
 Lembert sutures. 
 
 NEPHROPEXY 
 
 BY SUTURING SPLIT AND EVERTED PROPER CAPSULE OF KIDNEY TO LUMBAR 
 WALL— EDEBOHLS'S OPERATION. 
 
 Description. — The fibrous capsule of the kidney is split along the con- 
 vexity of the organ and peeled back toward the pelvis, on both aspects, for 
 about half-way — after which, chromic gut sutures are passed through both the 
 detached and undetached portions of this capsule, and through the lips of the 
 lumbar wound. When these sutures are tightened and tied, they approximate 
 the partly decapsulated kidney to the raw portions of the lumbar wound. 
 
 Position. — Patient lies prone upon Edebohls's kidney air-cushion — which, 
 pressing against the abdomen, aids in bringing the kidney prominently into 
 the wound. Surgeon stands on left side in operating upon left kidney, cutting 
 from above downward — and on right side in operating upon right kidney, 
 cutting from below upward (or stands on opposite side of body, cutting from 
 above downward). Assistant stands upon the opposite side of the body. 
 
 Landmarks. — Twelfth rib; iliac crest; outer border of erector spina? 
 muscle; anatomical relations of kidnev. 
 
 Incision. — Straight incision along the external border of the erector spina? 
 muscle, passing from the inferior border of the twelfth rib to the iliac crest. 
 Where the space between rib and ilium is very narrow, this incision may begin 
 at the same point but run more obliquely and reach the ilium further to the 
 Duter side of the erector spinas. (Fig. 767, D.) 
 
 Operation. — (1) Incise skin and fascia. Recognize the latissimus dorsi 
 and separate its fibers in their cleavage line — beginning the separation over the 
 outer aspect of the erector spina? and continuing it upward and outward. The 
 sheath of the erector spina? is not opened. (2) Divide the transversalis fascia, 
 
NEPHROPEXY 
 
 106s 
 
 exposing the perirenal fatty areolar tissue. If the ilio-hypogastric nerve can- 
 not be retracted to one side, it is cut and subsequently sutured with gut, after 
 the kidney has been sutured into place. (3) The sheath of the quadratus 
 lumborum is incised from the twelfth rib to the iliac crest, along the anterior 
 surface of its lateral border — exposing, by the retraction of its incised edges, 
 considerable raw muscle. (4) The kidney is now freed by blunt dissection, 
 aided by clips of curved, blunt scissors, if necessary — and is delivered upon the 
 back, surrounded by its fatty capsule — which delivery is aided by rolling the 
 patient up and clown upon the air-pillow. The size of the opening in the 
 abdominal parietes may be increased, if need be. (5) Dissect away the entire 
 fatty capsule from the proper fibrous capsule of the kidney. (6) Any explora- 
 tion of the kidney by palpation, x-raying, or instrumental means may now be 
 done — and any measure carried out that may be indicated. (7) At this stage, 
 
 tiP 
 
 Fig. 773. — Nephropexy — Kdebohls's Operation: — I, Placing fixation or suspension sutures — the 
 kidney is shown delivered through lumbar wound — the proper capsule split and stripped back half- 
 way — and the four fixation sutures passed through reflected and attached portions of proper capsule, 
 and not penetrating kidney substance. (Modified from Edebohls.j 
 
 if the removal of the appendix vermiformis be indicated — which the author of 
 the operation considers to be so in a certain percentage of cases — the perito- 
 neum is opened external to the kidney, and to the outer side of the ascending 
 colon — part of the ascending colon is drawn out and one of its longitudinal 
 bands is followed down to the caecum and the appendix thus located at the 
 termination of the muscular band — after which the appendix is delivered into 
 the wound (the kidney having been temporarily replaced) — and is either in- 
 verted entire into the caecum, after ligating the meso-appendix, or excised and 
 the stump treated according to the operator's individual ideas. (8) Following 
 the replacing of the intestines, the author of the operation — who considers that 
 there is an association, in a certain percentage of cases, between nephroptosis 
 and disease of the bile-passages — explores, by palpation, the gall-bladder, 
 
1066 OPERATIONS UPON THE ABOOMINO-PELVIC REGION. 
 
 cystic and common ducts, inferior aspect of liver, and the pyloric end of the 
 stomach, through the lumbar wound. (9) The peritoneal wound is then 
 closed and the kidney again delivered through the lumbar wound, in prepara- 
 tion for anchorage. Where the peritoneum has not been opened, the kidney 
 remains delivered, as described under (4), from the time of its first exposure. 
 (10) Incise the proper capsule of the kidney at the center of its convex border, 
 carefully avoiding entering the kidney substance. Pass a grooved director be- 
 tween the fibrous capsule and kidney proper, first toward the upper pole, and 
 then toward the lower pole, to and half-way around both poles. The fibrous 
 capsule is then separated from the kidney by blunt dissection, from the line 
 of incision, peeling it off (as the skin from an orange) on both sides toward the 
 pelvis — until practically one-half of the kidney is denuded — the detached por- 
 
 Fig 774.— Nkphropexy — Edehohls's Operation : — II, Anchoring kidney and closing lumbarwound 
 —the skin wound is shown retracted, and the kidney has been returned within abdominal wound. 
 A, A, Two upper buried fixation sutures, untied. The two lower fixation sutures are tied. B, Untied 
 buried suture uniting lips of lumbarwound in cleavage line of latissimus dorsi. Similar sutures below 
 are tied. (Modified from Edebohls.) 
 
 tion remaining continuous with the undetached portion, and turned back upon 
 the latter as the lapel of a coat. If the proper capsule appear excessive, a por- 
 tion may be excised (Fig. 773). (") Four forty-day chromic gut fixation or 
 suspension sutures are now introduced through both that portion of the proper 
 capsule which has been detached and reflected, and through the still adherent 
 portion — the passage of the sutures occurring near the line of reflection and 
 being accomplished as shown in Fig. 773, — two being placed upon the anterior 
 and two upon the posterior aspect of the kidney, at the center of the upper and 
 lower halves on each side. A straight Hagedorn needle is used— the suture is 
 carried from within outward entirely through the reflected proper capsule, near 
 the line of reflection— travels transversely to the axis of the kidney and enters 
 the attached portion of the proper capsule (directly opposite its point of emer- 
 
NEPHROPEXY 
 
 1067 
 
 gence from the detached portion) and pierces it from without inward, just be- 
 yond the line of reflection — thence the Hagedorn needle travels, flatwise, en- 
 tirely between the proper capsule and the kidney substance, parallel with and 
 just below the line of reflection, for 2 or 3 cm. (f to i^ inches) — thence 
 emerges through the attached capsule from within outward — and, traveling 
 transversely to the axis of the kidney, passes through the reflected proper 
 capsule from without inward, parallel with the companion limb of the suture. 
 (12) Having placed all four sutures, the kidney, with the eight suture ends hang- 
 ing free, is returned within the bod}-. Each suture is now passed through 
 the entire lumbar wall, from within outward — either by threading a needle 
 upon each and penetrating the wall from within outward, or by passing a 
 Reverdin needle through the abdominal parietes from without and drawing the 
 sutures through from with- 
 in. The four inner sutures 
 will thus pierce the lumbar 
 wall on the inner side of 
 the incision, and at a dis- 
 tance from each other 
 equivalent to the distances 
 apart at which they pene- 
 trate the proper capsule — 
 and will pass through the 
 retracted sheath of the 
 quadratus lumborum near 
 its edge, through the quad- 
 ratus muscle, and through 
 the erector spinae. The 
 four outer sutures will 
 pierce the lumbar wall on 
 the outer side of the inci- 
 sion, at the same distance 
 from each other as those 
 of the opposite side, and 
 each at a distance from its 
 companion suture of the 
 opposite side equivalent to 
 the antero-posterior thick- 
 ness of the kidney — and 
 will pass through the 
 transversalis fascia and the 
 latissimus dorsi muscle. 
 
 The highest sutures pass through immediately below the last 'rib. These 
 eight sutures are, at first, left untied. (13) The incision in the lumbar wall 
 is now closed, in the cleavage line of the latissimus dorsi, by from four to six 
 deeply buried interrupted sutures of forty-day chromic gut, in such a manner 
 as to turn the raw surface of the quadratus lumborum muscle toward the 
 kidney. This is accomplished by suturing the latissimus dorsi and lumbar 
 fascia, composing the external margin of the wound — to the latissimus dorsi, 
 the sheath of the erector spinae, and the external margin of the incised sheath 
 of the quadratus lumborum, composing the inner margin of the wound (Fig. 
 774). (14) The eight free suspension or fixation sutures are now drawn taut, 
 thus snugly approximating the decapsulated convex surface of the kidney into 
 contact with the raw substance of the quadratus lumborum, from rib to ilium 
 
 Fig. 775. — Nephropexy — Edebohls's Operation: — III, 
 Cross-section of region of operation. A, Psoas magnus ; B, 
 Erector spinae ; C, Quadratus lumborum ; D, Latissimus dorsi ; 
 E, Rectus abdominis; F, External oblique; G, Internal ob- 
 lique; H, Transversalis; I, Lumbar incision exposing kid- 
 ney ; J, The decapsulated convexity of kidney is shown ap- 
 proximated to raw substance of quadratus lumborum by the 
 fixation-sutures seen passing through both the detached and 
 adherent portions of proper kidney capsule. (Modified from 
 Edebohls.) 
 
io68 
 
 OPERATIONS UPON THE ADDOMINO-PELVIC REGION. 
 
 — and are then tied (Fig. 775). (15) The skin and fascia are then closed in 
 the line of the original incision, with a subcuticular suture — and a broad lum- 
 bar dressing applied. 
 
 NEPHROPEXY 
 
 BY SUTURING SPLIT PROPER CAPSULE AND PARENCHYMA OF KIDNEY TO LUMBAR 
 WALL, BY OBLIQUE LUMBAR INCISION — TUFFIER'S OPERATION. 
 
 Description. — Anchoring of an abnormally movable kidney into its own 
 or another adjacent site — by suturing of the parenchyma and partially stripped 
 fibrous capsule to the lumbar wall or lower ribs. The kidney may be exposed 
 through any of the posterior incisions recently described — but is generally ex- 
 posed through the oblique lumbar incision. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 the kidney by an oblique lumbar incision. 
 
 Operation. — (1) Having exposed the kidney and brought it well into the 
 wound, partly by pressure from the abdomen, and partly by drawing the organ 
 
 downward and backward from under the rib 
 (or simply backward, where already much dis- 
 placed and loosened from its natural position), 
 the fatty areolar capsule is divided and partly 
 turned backward, exposing the kidney and its 
 proper fibrous capsule. (2) Trim away any 
 excess of fatty capsule. Incise the proper fi- 
 brous capsule of the kidney along its mid-pos- 
 terior aspect, in the long axis of the kidney and 
 for its entire length — adding a cross-cut, at 
 right angles, at either end of the vertical inci- 
 sion, of about 2.5 cm. (1 inch) in length, half of 
 its length being on either side of the vertical cut. 
 Peel back the fibrous capsule thus liberated for 
 about 1.3 cm. (J inch) on either side of the 
 median incision. Pass from four to six chromic 
 gut or kangaroo tendon sutures, in a curved 
 needle, held in a holder, so as to include, on one 
 side, the deeper structures in one lip of the lum- 
 bar wound (but not the entire thickness of the 
 lumbar wound), the transversalis fascia, fatty 
 capsule, reflected portion of fibrous capsule, 
 part of unreflected portion of fibrous capsule, 
 and about 1.3 cm. (£ inch) of kidney substance, 
 — emerging from the kidney substance on the 
 opposite side, it takes up, in reverse order, part of the unreflected portion of 
 the kidney capsule, reflected portion of the proper capsule, fatty capsule, 
 transversalis fascia and deeper structures in the opposite lip of the lumbar 
 wound (Fig. 776). These are tied as buried sutures, simultaneously drawing 
 the kidney up to the lumbar fascia, posterior abdominal wall, and borders of 
 the wound, and, at the same time, approximating the deeper parts of the lips 
 of the wound. Care is taken to draw the kidney up to and under the lips of 
 the wound and in contact with as much raw surface as possible — but not into 
 and between the wound. It is also essential to see that the reflected most, to 
 of the proper capsule remains spread out with its raw surface upper portion 
 add to the extent of raw surface for adhesion. (3) The upper depth and 
 
 Fig. 776.— Nephropexy by Su- 
 ture of Split Capsule and Kid- 
 ney Parenchyma : — Sutures are 
 seen penetrating kidney substance 
 and split capsule, which latter has 
 been turned back on either side. 
 The outer limbs of the sutures are 
 ready to be carried through site of 
 abdominal wall, or other site, to 
 which kidney will be approximated 
 by tightening the sutures. Tuf- 
 fier's method. 
 
NEPHROPEXY. 1069 
 
 skin margins of the wound are then closed with interrupted sutures of silk or 
 chromic gut. 
 
 Comment. — (1) This may be regarded as one of the best methods of 
 Nephropexy — granulations of the raw surface of the kidney and capsule form 
 stronger adhesions than when the kidney is not partly stripped. And stronger 
 union is formed than when the stripped capsule alone is sutured into the 
 wound (instead of the stripped capsule and kidney substance). (2) The split 
 fibrous capsule is sometimes also sutured to the periosteum of the twelfth rib. 
 (3) In some cases gauze packing is used down to the kidney in the center of the 
 wound, to strengthen adhesion by granulation. (4) Avoid including nerves 
 in suturing of the kidney to the lumbar wall. (5) Deep drainage may be 
 temporarily used — but is generally not indicated. 
 
 NEPHROPEXY 
 
 BY SIMPLE SUTURING. 
 
 Description. — Here neither the fatty nor the fibrous capsule of the kidney 
 is split — one or both of these structures being sutured to some neighboring 
 structure. See, further, "Description" of the last operation. The kidney may 
 be exposed by any of the incisions given — the oblique lumbar incision being 
 preferable 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 kidney by oblique lumbar incision. 
 
 Fig. 777— Nephropexy by Simple Suturing : — A, Sutures passing through lower portion of lips 
 of wound, perirenal fatty areolar tissue, and kidney substance, ready to bind kidney to and into lower 
 plane of wound ; B, Sutures passing through skin and upper portion of lips of wound. The structures 
 are the same as those enumerated in Fig. 769. 
 
 Operation. — Having exposed the kidney as in the last operation, the dis- 
 placed organ may be treated in one of several ways; (a) By Suturing of the 
 Unopened Fatty Capsule; — Excess of fatty areolar capsule is trimmed away, 
 and the remaining shortened capsule is stitched into the lower plane of the 
 lumbar wound by four to six interrupted chromic gut or kangaroo tendon 
 sutures — the upper layers of the lumbar wound being closed as in the last oper- 
 ation (Fig. 777). (b) By Suturing of the Parenchyma, together with the un- 
 
1070 
 
 OPERATIONS UPON THE ABDOMINO-PELV1C REGION. 
 
 stripped Fatty and Fibrous Capsules; — Having shortened the excess of fatty 
 capsule, if necessary (by excising a portion), three or four kangaroo tendon or 
 chromic gut sutures are passed, with fully curved needle, dipping about 1.3 cm. 
 (^ inch) into the kidney substance, and taking up about 2 cm. (f inch) in width 
 of the kidney, into the posterior aspect of the kidney, in a horizontal direction — 
 the sutures passing through the muscles of the wound, transversalis fascia, 
 fatty capsule, fibrous capsule, and the above amount of kidney. These are 
 buried sutures. The upper layers of the wound are separately sutured by in- 
 terrupted sutures. The fatty capsule is thus sutured between the lips of the 
 wound. 
 
 Comment. — (1) The above operation is inferior to splitting the fibrous 
 capsule. (2) Sometimes the fatty and fibrous capsules, without including the 
 kidney, are sutured to the lumbar wound. (3) Sometimes the fibrous capsule 
 is exposed and sutured to the periosteum of the twelfth rib. (4) The upper 
 kidney sutures may be carried around the twelfth rib and tied (Fig. 778). 
 
 Fig. 778. — Nephropexy: — The two uppermost kidney sutures are carried around the 
 twelfth rib, the remaining kidney sutures being carried through the lumbar aponeuroses and 
 muscles. The overlying muscles and aponeuroses are then drawn together by sutures passing 
 through their substance. (Modified from Duval.) 
 
 TOTAL NEPHRECTOMY 
 
 BY OBLIQUE LUMBAR INCISION. 
 
 Description.— Excision of one entire kidney. Generally indicated in 
 tumor, extensive suppuration, tuberculosis, fistula. No kidney should be re- 
 moved until the presence of an opposite, and, if possible, healthy one is as- 
 certained (by vesical catheterization of its ureter — or by actual palpation by 
 hand in the abdominal or lumbar wound). The kidney may be removed by 
 several routes — lumbar nephrectomy — abdominal nephrectomy. The lumbar 
 route is to be preferred — and of the lumbar incisions, the oblique lumbar is the 
 best, being especially capable of extension in either direction to give the neces- 
 sary room. 
 
NEPHROPEXY. 
 
 IO71 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 kidney by oblique lumbar incision. 
 
 Operation. — (1) The perirenal adipose tissue having been exposed and 
 separated from the kidney by blunt dissection — the kidney being enucleated, 
 as it were, by the finger — the kidney itself is brought well into the wound, 
 partly by abdominal pressure from in front, and partly by traction, while the 
 lips of the wound are drawn well apart (Fig. 779). (2) The pedicle is care- 
 fully isolated and freed by blunt dissection—and the kidney is then delivered 
 outside of the wound if possible — especially avoiding traction and twisting of 
 the structures of the pedicle during delivery. (3) The pedicle should be tied 
 with strong silk carried upon a blunt aneurism-needle. Where possible, the 
 
 Fig. 779.— Total Nephrectomy by Oblique Lumbar Incision: — A, Kidney brought out of 
 wound in grasp of vulsellum ; B, Ligature of renal artery ; C, Ligature of renal vein ; D, Ligature of 
 ureter; E, Quadratus lumborum muscle and last dorsal nerve and lumbar artery; F, Erector spinae 
 muscle ; C, Serratus posticus inferior; I, External oblique ; J, Internal oblique muscle, and intercostal 
 nerve and artery ; K, Transversalis aponeurosis. 
 
 artery and vein should be tied separately, and, preferably, prior to their division 
 into branches — the artery being tied first. If not easily differentiated and 
 isolated, the artery and vein may be tied en masse — or in several bundles, re- 
 gardless of whether arteries or veins. If possible, all the structures should be 
 doubly ligated — and the structures forming the pedicle should be relaxed dur- 
 ing the placing of ligatures. The ureter should always be tied separatelv. 
 The pedicle is then severed between the double ligatures, or between kidnev 
 and single ligatures. (4) If healthy, the proximal end of the ureter should be 
 cauterized and dropped back into the wound. If unhealthy, it should be at- 
 tached into the wound and drained. (5) In healthy, clean cases the entire 
 
1072 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 pedicle is dropped back into the abdomen and the wound closed. In sus- 
 picious cases, the pedicle is anchored into the wound and drained. 
 
 Comment. — (1) Guard the vena cava, which has been wounded in the 
 operation upon the right side. (2) Sometimes the fatty capsule as well as the 
 kidney must be removed — necessitating the removal of the entire mass from 
 the surrounding tissues. (3) The peritoneal cavity is often opened. If the 
 rent be small, it is closed with ordinary continuous or purse-string suture of gut. 
 If too large to suture, it is packed with gauze. (4) The pleural cavity may be 
 opened in working near the twelfth rib — and should be immediately sutured 
 with continuous or purse-string gut suture. (5) The colon may be wounded. 
 Treat as wounds of intestine elsewhere. (6) Nephrectomy by morcellement 
 (piecemeal) is sometimes done. (7) If the pedicle have not been doubly 
 ligated, it should be clamped near the kidney before division. 
 
 PARTIAL NEPHRECTOMY 
 
 BY OBLIQUE LUMBAR INCISION. 
 
 Description. — Removal of part of a kidney. May be done in removal of 
 growths — or in badly lacerated wounds. Generally done by the lumbar opera- 
 tion — unless occurring in the course of some other operation. 
 
 Operation. — (a) In the deliberate removal of a portion of the kidney, a 
 wedge-shaped piece should be taken out, if possible — so that the sides of the 
 kidney wound, left after the removal of the wedge, could be brought into fairly 
 accurate apposition and sutured by alternate deep and superficial sutures of 
 gut. (b) In extensive lacerations, leaving irregularities of surface, the raw 
 surfaces are to be brought into contact and sutured in the best manner pos- 
 sible — by deep and superficial gut sutures. The wound of the abdominal 
 wall is treated upon general principles. 
 
 SUBCAPSULAR NEPHRECTOMY. 
 
 Description. — Where a dense, perirenal capsular mass surrounds the 
 kidney and is firmly adherent to the peritoneum, colon, vena cava, diaphragm, 
 and other structures — so that damage to these structures would likely result in 
 attempting to separate such a capsule, this fatty areolar capsule is incised and 
 the incision carried also through the proper fibrous capsule of the kidney — 
 which is then peeled back to, and, if possible, into the pedicle — which is then 
 ligated or clamped, and the kidney removed. The cavity of the capsule is 
 then curetted (where indicated) and packed — the abdominal-wall wound being 
 closed up to the packing. The best approach in such cases is by the oblique 
 lumbar incision. 
 
 TOTAL NEPHRECTOMY 
 
 BY ANTERIOR TRANSPERITONEAL OPERATION. 
 
 Description. — Removal of an entire kidney through an anterior trans- 
 peritoneal route — the incision being made in either the median or linea semi- 
 lunaris region, the latter giving the more direct approach. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 kidney by vertical incision in linea semilunaris. 
 
SURGICAL ANATOMY OF THE URETERS. 1073 
 
 Operation. — (i) Having opened the abdomen as in the operation above 
 indicated, both kidneys and ureters are examined by the hand introduced into 
 the cavity. (2) Displace the colon toward the median line and incise the 
 outer layer of the mesocolon in a vertical direction. This division of the pos- 
 terior peritoneum will be upon either the lateral or median aspect of the meso- 
 colon, as determined by its position on the anterior surface of the kidney. The 
 vessels of the colon are less interfered with if the peritoneum be divided upon 
 the outer side of the mesocolon. (3) The fingers are now passed through this 
 incision down upon the kidney — the perirenal fat is incised and the kidney 
 enucleated by blunt dissection. The pedicle is first to be cleared — by stripping 
 off the peritoneum toward the aorta. The vessels are then ligated with silk 
 passed by means of an aneurism-needle — tying, preferably, the artery first, 
 then the veins. If room be sufficient, double ligatures should be used, pro- 
 viding for division between them, — if not, the pedicle may be clamped near the 
 kidney (instead of the second ligature). (4) The pedicle is now divided be- 
 tween the two sets of ligatures — or between the clamp and ligatures. The 
 ureter should be separately doubly ligatured and similarly divided. The liga- 
 tured stump, with or without cauterization, as indicated, is returned to the 
 abdomen. (5) The kidney is then further enucleated from its perirenal fatty 
 areolar tissue and removed. All bleeding vessels are gut-ligatured. (6) If 
 drainage be indicated, it is established through the lumbar region by a counter- 
 opening made upon some instrument thrust backward from within and cut 
 upon from without. (7) The incised mesocolon is sutured with gut. (8) 
 The abdominal wound is closed in the general manner. 
 
 Comment. — (I) The kidney should be systematically exposed, aftei in- 
 cising the fatty capsule — first the anterior surface, then the lateral borders, the 
 poles, and the posterior surface. (2) Where anterior drainage must be es- 
 tablished, the edges of the incision in the posterior peritoneum are sutured to 
 the edges of the incision in the parietal peritoneum, thus shutting off the gen- 
 eral cavity. Posterior drainage, however, is always preferable. (3) Sus- 
 picious ureters must be brought out into a posterior lumbar wound made as a 
 counter-opening. (4) Avoid injury to the nutrient arteries of the inner layer 
 of the mesocolon. (5) 'The operation is practically the same whether done 
 through a vertical incision in the linea semilunaris or through a median incision. 
 
 XIII. THE URETERS. 
 SURGICAL ANATOMY. 
 
 Description. — Fibro-elastic tubes of about 3 to 4 mm. (| to nearlv j^ inch) 
 in diameter — flattened from before backward — with walls of about 1 mm. 
 (o-g- inch) in thickness. They consist of outer, fibrous — middle, muscular — and 
 inner, mucous coats. They have an average length, in the male, of about 30.5 
 cm. (12 inches) — extremes being from 25.5 to 40.5 cm. (10 to 16 inches). 
 They are about 7.5 cm. (3 inches) apart at their beginning — about 5 cm. (2 
 inches) apart near the sacro-iliac joint — about 3.2 cm. (1 j inches) apart at en- 
 trance to bladder — and about 2 to 2.5 cm. (f to 1 inch) apart at their bladder- 
 mouths. The ureters begin in the funnel-shaped pelvis of the kidney, opposite 
 the spinous process of the first lumbar vertebra — and run downward through 
 a sort of lymph-space between the lahiina; of the subperitoneal connective tis- 
 sue, downward and inward through the lumbar and pelvic regions — ending 
 
 68 
 
1074 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 in the base of the bladder. The genitocrural nerve is in close relation with 
 the ureter. There are three sites at which the ureter is narrower than else- 
 where, — between 4 and 5 cm. (i£ and 2 inches) from the pelvis of the kidney — 
 crossing of iliac artery — ai d at junction of pelvic and vesical portions. 
 
 Course and Relations. — (1) Abdominal portion : Male and Female : — 
 (a) Right Ureter,— Runs downward and slightly inward, from pelvis of kidney 
 to promontory of sacrum, where it crosses either common or external iliac 
 artery. Rests (posteriorly) upon psoas muscle and fascia, genitocrural nerve, 
 common or external iliac artery. Covered (anteriorly) by peritoneum, sper- 
 matic and colic vessels, and ileum. Internally lies inferior vena cava, near ure- 
 ter, (b) Left Ureter, — Runs downward and slightly inward, from pelvis of 
 kidney to promontory of sacrum, where it crosses either common or external 
 iliac artery (same course as right ureter). Rests (posteriorly) upon psoas 
 muscle and fascia, genitocrural nerve, common or external iliac artery (same 
 posterior relations as right). Covered (anteriorly) by peritoneum, spermatic 
 and colic vessels, and sigmoid colon. Internally lies abdominal aorta, being 
 2.5 cm. (1 inch) from ureter above, and 1.3 cm. (|inch) below, near bifurcation. 
 (2) Pelvic portion : Both sexes : Both sides ; — Runs downward in front of 
 sacro-iliac joint — passes upon obturator internus and its fascia, lying irtferiorly 
 and internally to psoas — enters posterior false ligament of bladder (rectovesical 
 fold, in male — uterovesical fold, in female) below the obliterated hypogastric 
 artery — hence its course differs in the two sexes: — (a) Male: Both sides; — 
 It is here crossed above and to inner side by vas deferens, which intervenes be- 
 tween it and bladder — and, just before entering bladder, it passes beneath the 
 free extremity of the vesicula? seminales. The two ureters are about 5 cm. 
 (2 inches) apart at base of bladder, and about 4 cm. (ij inches) posterior to the 
 prostate gland, (b) Female : Both sides ; — It passes down parallel with the 
 cervix uteri and upper part of vagina — lying about 5 mm. (i inch) external to 
 cervix opposite os internum — running posteriorly to uterine artery, through 
 the uterine venous plexus, and below the broad ligament — crossing the vagina 
 opposite its upper third, to the vesicovaginal interspace, and entering the blad- 
 der opposite the center of the vagina, (c) Intravesical portion : Both 
 sexes : Both sides; — Entering the bladder 4 to 5 cm. (1^ to 2 inches) apart, 
 the ureters pass obliquely downward and inward through its wall, emerging 
 upon the mucous membrane about 2 cm. (f inch) apart, and about the same 
 distance posterior to the meatus urinarius internus. 
 
 Arteries. — From renal, spermatic, internal iliac, and inferior vesical. 
 Veins. — End in corresponding trunks. 
 
 Lymphatics. — Empty into pelvic and lumbar glands and into receptacu- 
 lum chyli. 
 
 Nerves. — From spermatic, renal, and hypogastric plexuses. 
 
 SURFACE FORM AND LANDMARKS. 
 
 As the ureters are about 7.5 cm. (3 inches) apart at their commencement 
 at the pelves of the kidneys, opposite the first lumbar spinous process, the be- 
 ginning of each ureter will lie about 4 cm. (i^ inches) external to the line of the 
 spinous processes, on a level with the spinous process of the first lumbar verte- 
 bra. And they lie about 5 cm. (2 inches) apart near the sacro-iliac articulation 
 — or about 2.5 cm. (1 inch) from the median line. 
 
 Anteriorly, the line of the ureters, from the kidneys to the brim of the pelvis, 
 
GENERAL SURGICAL CONSIDERATIONS. 1075 
 
 may be gotten, approximately, by drawing a line vertically upward from the 
 junction of the inner and middle thirds of Poupart's ligament. And the posi- 
 tion of the crossing of the ureters over the brim of the pelvis may be approxi- 
 mately represented by the intersection of a vertical line extending upward from 
 the spine of the pubis, with a horizontal line between the anterior superior iliac 
 spines. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 (1) The ureter is so intimately adherent to the peritoneum that when the 
 peritoneum is stript up, the ureter is almost always reflected along with that 
 membrane and adherent to it. (2) In all suturing about the ureter, an 
 attempt should be made not to include the mucous membrane — though, prac- 
 tically, this may often be done unintentionally. The fibrous and part of the 
 muscular coats should be taken up by the stitch. (3) Fine silk is the suture 
 material generally used — it being difficult to manipulate gut, or to get it fine 
 enough. (4) There is a tendency to narrowing at the site of suture, especially 
 after transverse division. (5) Extra-pelvic portions of the ureter should be 
 approached retroperitoneally — except where the cause for the operation upon 
 the ureter arises, or is discovered, during an intra-abdominal operation. (6) 
 Intra-pelvic portion of the ureter is accessible by incision through the abdom- 
 inal wall, bladder, rectum, vagina, perineum, or by sacral resection. (7) 
 Longitudinal wounds of the ureter heal better than transverse ones. (8) 
 Drainage is indicated in all cases where infection is present or suspected, or 
 where the technic is uncertain. (9) In retroperitoneal operations, suture is not 
 absolutely necessary, provided drainage be established down to the wound. 
 
 (10) Whenever the ureter is opened intraperitoneally, the peritoneum or 
 omentum should be sutured over the wound, so as to make it extraperitoneal. 
 
 (11) Where the ureter has been divided and must be transplanted, implanta- 
 tion into the bladder is the most desirable. (12) Where the ureter has been 
 completely divided transversely, it should be repaired by uretero-ureterostomy, 
 if possible. (13) Where the division is near the kidney, and uretero-ureteros- 
 tomy cannot be performed, it should be implanted into the pelvis of the kidney. 
 If the division be low down, it should be implanted into the bladder. (14) 
 If such an extent of ureter be lost that uretero-ureterostomy cannot be done — 
 or the end cannot be implanted into the pelvis of the kidney or into the bladder, 
 implantation into the bowel or skin should be done. (15) Longitudinal 
 wounds of the ureter generally heal without suture, if retroperitoneal drainage 
 be provided. (16) Where it is possible, any operation should be protected by 
 peritoneum — in one of two ways: — (a) Lift the ureter up out of its bed, at the 
 site of operation, into the peritoneal cavity — and draw the peritoneum around 
 the ureter from both sides, so stitching the serous membrane as to form a tube 
 through which the ureter runs, practically excluding it from the general peri- 
 toneal cavity. The suturing should, however, be lightly and carefully done, 
 forming a loose tube, so as to avoid subsequent contraction. This is probably 
 the better method, (b) The site of operation upon the ureter may be sur- 
 rounded by a detached piece of omentum lightly sutured to the ureter. (17) 
 The ureter has been separated for as much as 8.3 cm. (3J inches) from its at- 
 tachments without gangrene — owing to the long artery which accompanies it 
 and is intimately connected with it. (18) The ureter may be lengthened 2.5 
 cm. (1 inch) or more, by steady, gentle traction. (19) When a gap in ureter 
 at the lower end cannot be bridged by stretching, a vesical diverticulum can 
 
1076 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 sometimes be turned up to meet the end of the ureter. (20) Ureteroureteros- 
 tomy is generally practicable except in the lower 2.5 cm. (1 inch) in the male, 
 and the lower 5 cm. (2 inches) in the female. (21) In severed ureter, the best 
 course is uretero-ureterostomy by, probably, Van Hook's method — and the 
 next best, uretero-cystostomy (v. i. ). (22) Normal urine is not injurious to 
 the peritoneal cavity, but it is well not to let it come in contact if it can be 
 helped. 
 
 INSTRUMENTS. 
 
 See instruments used in operating upon the Kidneys. Also the following 
 special instruments: — Very fine needles, curved, straight, and plain cambric 
 needles; fine silk; fine catgut; fine forceps; fine scissors; small needle-holders; 
 ureteral sound; ureteral catheters; cystoscope; electric illumination; urine 
 evacuator; instruments for segregation of urines. 
 
 EXPOSURE OF THE URETER IN GENERAL. 
 
 Description. — The exposure of the ureter may be made deliberately — or 
 may be done in the course of some other operation. Most of the operations 
 for exposure of the kidney generally also admit of exposure of more or less of 
 the ureter. The ureter may be exposed extra- or intra-peritoneally. 
 
 Abdominal portion of the ureter is best exposed by the oblique lumbar 
 incision used in exposing the kidney, extending from the twelfth rib above 
 Poupart's ligament to about its center. This incision will enable the upper 
 three-fourths of the ureter to be freely exposed, and will allow of access to the 
 entire ureter, from kidney to bladder — though, of course, not so free access 
 to the lower one-fourth (Fig. 780). It is a possible thing to thus expose 
 the entire ureter extraperitoneally. This exposure should be the one of 
 preference for the upper three-fourths of the ureter (and may be resorted to 
 for even the entire ureter) — except when the ureter is exposed in the course of 
 abdominal section. 
 
 Pelvic portion of the ureter is readily accessible through the lower median 
 abdominal incision — followed by retraction of the intestines (especially aided 
 by the Trendelenburg position) — and division of the peritoneum over the 
 course of the ureter. The intrapelvic portion may also be exposed by incision 
 through the bladder, vagina, rectum, male perineum, or by sacral resection. 
 
 Intravesical portion of the ureter may be exposed through a cystotomy 
 wound (incision of the bladder) — generally by the suprapubic route. 
 
 EXTRA-PERITONEAL EXPOSURE OF THE KIDNEY AND THE ENTIRE 
 
 URETER 
 
 BY OBLIQUE LUMBO-ILIAC INCISION. 
 
 Description. — This incision will allow the kidney and the upper three- 
 fourths of the ureter to be freely exposed — and will give access to the entire 
 ureter, though, of course, not such free access to the lower one-fourth — the 
 exposure being retro-peritoneal throughout. 
 
EXTRA-PERITONEAL EXPOSURE OF THE KIDNEY AND URETER. 1077 
 
 Preparation. — As for exposure of the kidney by an oblique lumbar 
 incision. 
 
 Position. — The patient lies upon the opposite side during the work in the 
 upper part of the wound — and upon the back during the work in its lower 
 portion. 
 
 Landmarks. — Twelfth rib; outer border of erector spinae muscle; iliac 
 crest; anterior superior iliac spine; Poupart's ligament. 
 
 Incision. — Begins just below the twelfth rib, at the angle of junction of 
 the lower border of the twelfth rib and the outer border of the erector spinas 
 muscle — and passes thence obliquely downward toward, and to within 2.5 cm. 
 (1 inch) of, the anterior superior iliac spine — thence downward and parallel 
 with, and about 2 cm. (f inch) above, Poupart's ligament, to just below its 
 center (Fig. 780). 
 
 
 Fig. 780. — Incision for Exposing Kidney and Ureter Extraperitoneally. 
 
 Operation. — The first part of the operation and the exposure of the kidney 
 are conducted as in the more limited procedure of exposing the kidney alone 
 by an oblique lumbar incision (page 1053) . In the lower aspect of the wound 
 the ureter is in relation with the peritoneum and ascending colon on the right 
 side, and the peritoneum and descending colon on the left. The colon, in 
 either case, is retracted toward the median line, together with the peritoneum, 
 exposing the psoas muscle and the spermatic and colonic vessels. The ureter 
 has a tendency to cling to the peritoneum as it is displaced. A large retractor 
 draws the intestines toward the median line. The ureter is isolated at the 
 
1078 OFERATIOiNS UPON THE ABDOMINO-PELVIC REGION. 
 
 lower pole of the kidney — and is carefully traced down to the iliac vessels — 
 separating the peritoneum by blunt dissection and retracting it inward from 
 the course of the ureter — the superficial incision having been deepened through 
 skin, fascia, external, internal, and transversalis muscles and aponeuroses 
 down to the subserous areolar tissue — in which plane the separation of the 
 ureter is accomplished. In exposing the pelvic portion of the ureter the 
 patient is placed in the Trendelenburg position. The epigastric vessels are 
 doubly ligated and tied. The operator, with the pulp of his thumbs, continues 
 to free and roll the peritoneum off of the pelvic structures, still working in the 
 plane of the transversalis fascia and progressively descending toward the 
 iliac fossa — pushing the peritoneum toward the umbilicus, in the upper and 
 lower part of the pelvic wound, the parts being further retracted by a large 
 retractor. The spermatic cord and the round ligament are encountered 
 and displaced inward. The common iliac at its bifurcation into external and 
 internal branches is exposed. Thence the relations of the ureter will depend 
 upon the sex being operated upon. In the male, it is crossed above and to the 
 inner side by the vas deferens, which intervenes between it and the bladder — 
 and, just before entering the bladder, it passes beneath the free extremity of 
 the vesiculae seminales. In the female it passes down parallel with the cervix 
 uteri and upper part of the vagina — lying about 5 mm. (I inch) external to the 
 cervix, opposite the os internum — running posteriorly to the uterine artery, 
 through the uterine venous plexus, and below the broad ligament — crossing 
 the vagina opposite its upper third to the vesico-vaginal interspace, and 
 entering the bladder opposite the center of the vagina. Entering the bladder, 
 in both sexes, the ureter passes obliquely downward and inward through its 
 wall, emerging upon the mucous membrane about 2 cm. (| inch) posterior 
 to the meatus urinarius internus. 
 
 URETEROTOMY. 
 
 Description. — Incision of the ureter. Generally done for the removal of 
 calculi — in which case the operation may be called uretero-lithotomy. Calculi 
 may be lodged at either the upper or lower end of the ureter, or in the middle — 
 usually at one of the two ends. Ureterotomy may be extraperitoneal or trans- 
 peritoneal (intraperitoneal) — when the ureter is approached, respectively, 
 behind the peritoneum, or through the abdominal cavity. Extraperitoneal 
 ureterotomy is always preferable. Where the site of the ureterotomy is only 
 determined in the course of an operation performed through one of the regular 
 incisions, the ureterotomy will be extraperitoneal or intraperitoneal, according 
 to circumstances. Even when the ureterotomy is done intraperitoneally, how- 
 ever, the site of the ureterotomy, in concluding the operation, should be as 
 thoroughly shut off (walled off) by suturing of peritoneum around the site, as 
 possible. Extraperitoneal ureterotomy is usually done through the oblique 
 lumbar incision, extended as far forward and downward as necessary. Trans- 
 peritoneal ureterotomy is generally done through a median abdominal incision, 
 or one in the linea semilunaris. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 the kidney by either an oblique lumbar or an anterior abdominal incision. 
 
 Operation. — (a) In the Extraperitoneal Operation — the ureter — which 
 has generally been found by tracing downward from the pelvis of the kidney — 
 is exposed and divided longitudinally to the necessary extent — over the calculus. 
 
URETERORRHAPHY. 1079 
 
 if the operation be done for that purpose — the ureter having been steadied and 
 carefully incised with a small, sharp knife, aided by fine forceps — after which 
 the calculus is removed by scoop or forceps. The wound in the ureter, in 
 favorable cases, should be closed with fine silk sutures, passing through the 
 fibrous and muscular coats. Temporary drainage should be employed, in 
 case of leakage — the lumbar wound being closed elsewhere, (b) In the 
 Transperitoneal Operation — the ureter is exposed — the peritoneum divided 
 longitudinally over it — the ureter incised in its long axis — and the object of the 
 operation accomplished (usually the removal of a stone). The incised ureter 
 is generally sutured, as in the extraperitoneal operation — and the peritoneum 
 is then sutured about the wound in the ureter so as to render it as extraperito- 
 neal as possible. Prior to suturing the peritoneum over the ureteral wound, a 
 posterior counter-opening is made, and drainage established through this — the 
 abdominal cavity being then closed. 
 
 Comment. — Calculi lodged at the lower end of the ureter may sometimes be 
 removed through the bladder, rectum, or vagina, with or without dilating the 
 mouth of the ureter. 
 
 URETERORRHAPHY. 
 
 Description. — Suturing of the ureter. Generally done for repair of 
 wounds, or following the incision after ureterotomy for calculi. Many of the 
 wounds are accidentally made by the surgeon in the course of other operations. 
 
 Varieties of Wounds. — Longitudinal — Oblique, incomplete — Oblique, 
 complete — Transverse, incomplete — Transverse, complete. 
 
 Preparation — Position — Landmarks — Incision. — As for Exposure of 
 Ureter. 
 
 Operation. — Suturing is generally done with fine silk, or with very fine 
 catgut— carried upon a fine, curved needle, held in a needle-holder. The 
 edges of the wound are brought together by interrupted sutures, generally in- 
 troduced in the Lembert fashion — passing through the fibrous and part of the 
 muscular coats — but carefully avoiding the penetration of the mucous coat — 
 union taking place by growth of the connective tissue of the apposed surfaces, 
 which is rendered raw in exposing the ureter. The following summary sug- 
 gests the appropriate methods for dealing with the various sorts of wounds of 
 the ureter: — (1) Longitudinal wounds; (a) Close by fine silk (or fine chro- 
 mic gut) Lembert sutures. Reinforce, if possible, by folding or stitching over 
 the suture-line a fold of peritoneum, or an omental graft, (b) Or excise the 
 piece and do an end-to-end ureteral anastomosis. (2) Oblique wounds, 
 incomplete; (a) Same as above (1). (b) Or complete the oblique division 
 and treat as a complete oblique division (v. i.). (3) Transverse wounds, 
 incomplete ; (a) Lembert sutures, (b) Divide the upper lip of the wound in 
 its center longitudinally upward a short distance. Similarly divide the lower 
 lip of the wound in its center longitudinally downward a short distance. 
 Round off the four corners thus formed with scissors — and suture the borders 
 as in "elbowing" the intestines, (c) Having divided and incised as just de- 
 scribed, suture as in the operation of ureteroplasty (page 1080) (see Figs. 
 781-783). (d) Or complete the transverse division and do an end-to-end 
 anastomosis. (4) Oblique wounds, complete; (a) Oblique end-to-end 
 anastomosis. (5) Transverse wounds, complete ; (a) Transverse end- 
 to-end anastomosis. 
 
io8o 
 
 OPERATIONS UPON THE ABDOM1NO-PELVIC REGION. 
 
 URETHROPLASTY. 
 
 Description. — A congenital or acquired stricture may be encountered 
 in the course of the ureter. It is often possible to widen the caliber of such 
 a stricture by applying the method adopted in pyloroplasty (page 984). A 
 longitudinal incision through all the coats of the ureter is made through the 
 strictured portion — the lips of which are then sutured in a transverse direction 
 by means of a fine silk suture. Upon tying these sutures a distinct increase 
 of caliber is secured. (Figs. 781-783.) 
 
 *JrMU& 
 
 A B C 
 
 Figs. 781-783. — Urethroplasty: — A, Axial incision through narrowed ureter; B, Sutures 
 placed in the long axis of the ureter; C, The preceding sutures tightened, thus enlarging the 
 caliber of the ureter transversely. (Redrawn from Duval.) 
 
 URETERO-URETERAL ANASTOMOSIS (URETEROURETEROSTOMY). 
 
 Description. — Junction, or "splicing," of ends of ureter — by suturing 
 alone — or by suturing aided by supports. Indicated in wounds accompanied 
 by no loss, or very little loss, of substance. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 ureter. Or, as is usually the case, the ureter may be exposed in the course of 
 some other operation. 
 
 Operation. — Having exposed the ureter, uretero-ureterostomy may be 
 accomplished in one of several ways: — 
 
 (1) Transverse End-to-end Uretero-ureterostomy by Suturing, 
 without Support (Schopf, Cushing, and others) : — (a) The ends are brought 
 together and the walls are sutured with fine silk in small, fully curved needle, 
 held in holder — the sutures passing through the free edges of the fibrous and 
 muscular coats of the divided ends (Fig. 784). (b) Or Van Hook's method of 
 anastomosing after incomplete transverse division may be used. Make a 
 longitudinal incision extending from the center of each lip of the transverse 
 wound upward and downward, each for a distance equal to the transverse 
 
URETERO-URETERAL ANASTOMOSIS. 1081 
 
 diameter of the ureter. The sharp angles are then rounded off — and the lips 
 of the wound are then sutured longitudinally, so as to widen the site of suture 
 and avoid subsequent stricture. This is, practically, an ureteroplasty. 
 
 (2) Transverse End-to-end Uretero-ureterostomy by Suturing, 
 with Support (Tuffier) : — The divided ends are brought together over an 
 ureteral catheter or bougie — and are then sutured as in the above method — ■ 
 after which the catheter is withdrawn through an incision made in the ureter 
 opposite the distal end of the catheter — and the longitudinal wound thus made 
 for its withdrawal is sutured up as a simple longitudinal wound. (Fig. 785.) 
 
 (3) Oblique End-to-end Uretero-ureterostomy by Suturing, without 
 Support (Bovee) : — To lessen tendency to contraction, the ends are divided 
 obliquely — then dilated with special forceps for about 2.5 cm. (1 inch) — then 
 approximated — and sutured with fine silk in fully curved needle, through 
 
 Fig. 784. — Ureterorrhaphy without Support (SchofT, Cushing, and others): — The 
 obliquely divided ureter is seen sutured with interrupted Lembert sutures passed through the 
 outer coats. 
 
 fibrous and muscular coats only — the sutures used being alternating rectangu- 
 lar and interrupted. The peritoneum is then so adjusted as to exclude the 
 sutured ureter from the peritoneal cavity. 
 
 (4) Uretero-ureterostomy by End-into-end Invagination, with 
 Support, without Splitting (Markoe): — This method was resorted to in 
 division of the ureter near the bladder. Two traction-sutures, each threaded 
 upon two needles, are passed through the proximal ureter near its free end, 
 from within outward and nearly 2 mm. (about y 1 ^ inch) apart. The needles are 
 then made to draw the traction-sutures through the wall of the distal ureter, 
 entering in the same relative position and at the same distance apart, passing 
 from within outward. An ureteral catheter is then passed through the distal 
 ureter into the bladder and out of the meatus, being caught by forceps passed 
 
 
 Fig. 7S5. — Ureterorrhaphy with Sipport : — Ureteral catheter is seen within the ureter, over 
 which interrupted sutures are passed through the outer coats of the ureter. 
 
 through the female meatus (or might be passed from the urethra, by means of a 
 cystoscope, in the case of a male) — the opposite end of the catheter passing into 
 the distal ureter. Over this the proximal ureter is invaginated into the distal, 
 by the traction-sutures — which are then tied. Reinforcing circular suturing is 
 used at the line of junction, passing through all the coats of the distal and 
 through the fibrous and muscular coats of the proximal portions. 
 
 (5) Uretero-ureterostomy by End-into-end Invagination, without 
 Support, without Splitting (Poggi) : — Dilate the distal end with special for- 
 ceps — place one (or two) pair of traction-sutures through the proximal end — 
 two needles upon single thread, introduced nearly 2 mm. (about yg inch) apart, 
 
1082 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 in the same horizontal plane, and about 3 mm. (£ inch) from within the lower 
 end of the proximal portion of the ureter — brought out — and the needles passed 
 from within outward in the distal end, the same distance apart and about 7 mm. 
 to 1.3 cm. (^ to \ inch) from the free end, and opposite the points of penetra- 
 tion above. The proximal end is then invaginated into the distal by traction, 
 and the sutures tied. This invagination is then reinforced by a continuous or 
 interrupted suture applied around the line of union, including all the coats of 
 the distal and the fibrous and muscular coats of the proximal segments. 
 
 Figs. 786 and 787. — Ureteroureterostomy (Robson-Winslow Method): — A, The 
 intussusception being invaginated in the split intussuscipiens; B, the intussustipiens sutured 
 about the intussusceptum. 
 
 (6) Uretero-ureterostomy by End-into-end Invagination, without 
 Support, with Splitting (Robson, Winslow): — Slit the upper distal end 
 longitudinally — place one or two pairs of traction-sutures as above and in- 
 vaginate in the same manner — followed by suturing the slit in the distal end 
 over the proximal end. If necessary, reinforce with circular suturing, as ab< >ve. 
 (Figs. 786 and 787.) 
 
 
 Fig. 7S8. — Uretero-ureterostomy, by Van Hook's Method 
 
 Van Hook.) 
 
 -I, First step. (Modified from 
 
 (7) Uretero-ureterostomy by Lateral (End-into-side) Implantation 
 
 (Van Hook) : — Ligate the distal part of the ureter circularly, about 3 to 6 mm. 
 (| to \ inch) from its free end, with silk or gut (Fig. 788). Commencing 
 about 6 mm. (\ inch) below this ligature, make a longitudinal incision through 
 all the coats of the distal ureter for a distance equal to the diameter of the 
 ureter — with fine, narrow knife, or sharp-pointed scissors. Make a longitu- 
 dinal incision in the proximal ureter, from the margin of the free end upward 
 for about 6 mm. (\ inch). A traction suture of fine catgut, upon two needles, is 
 passed just as in the invagination method — about 3 mm. (^ inch) from the free 
 
URETERO-URETERAL ANASTOMOSIS. 1083 
 
 end, and from nearly 2 mm. to 3 mm. (y 1 ^ to £ inch) apart, and upon the lateral 
 aspect opposite to the vertical slit (Fig. 789). Pass the points of both needles 
 through the slit into the distal ureter, and thence for about 1.3 cm. (h inch) 
 below its lower end — thence penetrate the wall of the distal ureter outward, 
 upon the same aspect of the ureter as the slit, and both needles held at the 
 same horizontal level (side by side — not one over the other). Unthreading the 
 needles, draw (invaginate) the proximal into the distal ureter, until the slit in 
 the proximal is well within the slit in the distal — and then tie the sutures. 
 Complete the union by suturing the edges of the vertical incision around the 
 
 ^^SSSiPSiijjj 
 
 Fig. ;Sq. — Ureteroureterostomy, by Van Hook's Method: — II, Second step. (Modified from 
 
 Van Hook.) 
 
 proximal, the sutures passing through the fibrous and muscular coats (Fig. 
 790). Further protect the site by peritoneum folded around it, if the operation 
 be intraperitoneal. Note — Where the proximal end (from distention or other 
 cause) is too large to go into the distal, it may be narrowed by placing and tying 
 two or more sutures in its free end. Both ends of these "narrowing sutures" 
 are then threaded — and all six needles passed into the slit, in pairs, as in Van 
 Hook's operation, and the threads tied. 
 
 (8) Uretero-ureterostomy by Ligation of Severed Ends and Side- 
 to-side Anastomosis (D'Urso and Fabii's modification of Monari's method; : 
 — Monari ligated both ends of the severed ureter and then anastomosed these 
 ends side-to-side, after the corresponding manner of uniting pieces of intestine 
 laterally. D'Urso and Fabii first introduced catheters into the two ends, 
 to distend the ureters during suturing — then withdrew the catheters and 
 circularly ligated the divided ends of the ureter. (Figs. 791-793.) 
 
 Fig. 700.— Ureteroureterostomy, by Van Hook's Method: — III, Third step. (Modified from 
 
 Van Hook.) 
 
 Comment. — (') In the operations of invagination, instead of introducing 
 the traction-sutures through all the coats of the proximal end, it would be better 
 to introduce a single needle on a thread, from without through the fibrous and 
 muscular coats alone — then, keeping the needle on the original end, thread an- 
 other needle on the other end, and proceed as is ordinarily done. Thus no 
 capillary thread passes into the lumen of the proximal portion — and the ap- 
 
1084 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 proximated outer wall of the proximal portion to the inner wall of the distal 
 portion blocks off the wall of the distal ureter. (2) In some cases the kidney 
 has been lowered somewhat from its original site, in order to furnish additional 
 length for uretero-ureteral anastomosis. 
 
 .*, 
 
 Figs. 791-793. — Ureteroureterostomy — D'Urso and Fabii's Modification of 
 Monari's Side-to-side Anastomosis: — A, Closure of the ends and suturing of the ends side to 
 side, with line for incision into each ureter; B, Each ureter incised and the catheter passed into 
 the lumina; C, The openings into the ureter closed — the site of the temporary catheter being 
 shown. (Redrawn from Duval.) 
 
 Comparison of Methods of Uretero-ureterostomy. — Van Hook's 
 Lateral Implantation method is probably the best for all-around use. End- 
 to-end anastomosis is more apt to be followed by leakage. End-into-end anas- 
 tomosis is less apt to be followed by leakage and stricture. In end-into-end 
 anastomosis about 2.5 cm. (1 inch) of ureter is taken up. In end-in-side im- 
 plantation about 4 cm. (ih inches) of the ureter is consumed. 
 
 IMPLANTATION OF URETER, IN GENERAL. 
 
 After division of the ureter, or after excision of a part of the ureter (by 
 accident or other cause), the lower end of the proximal portion of the ureter 
 may be implanted, or "grafted," into the bladder, large intestine (ca?cum, 
 sigmoid, or rectum), vagina, opposite ureter, pelvis of opposite kidney, upper 
 portion of the distal end of the same side (which is really uretero-ureterostomy), 
 or into the skin. 
 
 When a simple division has taken place, without loss of substance, a simple 
 implantation, or anastomosis of the proximal into the distal end (uretero- 
 ureterostomy), is best. 
 
 Where a loss of some extent of ureter has occurred, a uretero-ureterostomy 
 is still the best course, where it is possible to approximate the ends without too 
 great tension. Where the loss is too great for this, an implantation into some 
 other structure is necessary. 
 
 The most usual sites (in order of preference) into which the proximal end 
 of the ureter is implanted are — bladder, large intestine (rectum), and skin. 
 
IMPLANTATION OF URETER INTO BLADDER. 
 
 10S5 
 
 The distal end is ligated and left in situ — some surgeons first cauterizing the 
 stump. 
 
 As many of the ureteral implantations are done for accidents to the ureter 
 occurring during other operations, the parts are usually already exposed — re- 
 quiring none or but little more dissection to fully expose them. 
 
 IMPLANTATION OF URETER INTO BLADDER 
 CYSTOSTOMY) . 
 
 (URETERO- 
 
 Description. — Implantation of ureter into male or female bladder. In 
 Uretero-cystostomy the implantation itself may be intraperitoneal or extra- 
 peritoneal. Where possible, the extraperitoneal implantation is preferable to 
 the intraperitoneal implantation — although when the latter is done, the opera- 
 tion-site should be so walled off by peritoneum as to practically amount to an 
 extraperitoneal implantation. As to the manner of exposing the ureter, this 
 is done generally by an intraperitoneal operation. It is sometimes done 
 through an extraperitoneal route, as, for example, in performing a suprapubic 
 cystotomy, followed by exposure of the ureter by cutting through the base of the 
 bladder. It may also be exposed extraperitoneal!}' through the vagina. In 
 
 in 
 
 Figs. 794-796. — Uretero-cystostomy :— I, Cut end of ureter is shown grasped in forceps and pro- 
 truded into bladder through incision in wall of latter. II, Sutures are passed through outer coats of 
 bladder and ureter. Ill, Ureter is shown sutured into bladder. The peritoneum is incised over 
 ureter in I. 
 
 the following description it will be supposed that the ureter is to be severed 
 near its vesical end. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section below the umbilicus. 
 
 Operation. — (1) Having performed a lower median abdominal section, 
 with the patient in the Trendelenburg position, displace the intestines toward 
 the diaphragm and to the opposite side — isolating the ureter and tracing it to 
 the bladder. (2) Incise the posterior peritoneum over the site of the intended 
 division of the ureter. Having freed the peritoneum and connective tissue 
 from the ureter by blunt dissection, divide the ureter transversely. Ligate the 
 distal end of the ureter and return it to its site (Figs. 794 and 796). (3) Make 
 an incision through all the walls of the bladder, as nearly the normal site as 
 
1086 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 possible, and in the long axis of the bladder, and just large enough to admit the 
 ureter. The ureter is then grasped with long, thin forceps and carried within 
 the bladder sufficiently far for its free end to project slightly within the bladder- 
 cavity. With a fine, curved needle, and with silk or gut, the edges of the blad- 
 der-wound are sutured around the ureter, passing through all the coats of both 
 bladder and ureter — except the mucous membrane. (4) The peritoneum is 
 then sutured around the site of junction, so as to practically render it extra- 
 peritoneal. (5) Where the technic has been satisfactory, the abdomen may be 
 entirely closed at once — which is always preferable. Otherwise drainage is 
 temporarily established. 
 
 Comment. — (I) Where much ureter has been lost, the bladder is some- 
 times drawn up into the pelvis and sutured to the broad ligament, in the female, 
 or other structure, before implanting. (2) In the female special forceps may 
 be introduced through the vagina, and thence through the incision made into 
 the bladder to receive the ureter — seizing the ureter and drawing it through. 
 In such cases the bladder is cut through from the outside upon a sound intro- 
 duced through the urethra. (3) In order to counteract the upward pull upon 
 the implanted end of the ureter, gut traction-sutures are sometimes placed in 
 the end of the proximal portion, in the case of the female, and carried out the 
 urethra and tied to the dressing. (4) To imitate nature, the ureter has been 
 sutured into the bladder through an oblique opening. And to give a valve 
 effect, the tip of the free end in the bladder has been split. 
 
 IMPLANTATION OF URETERS INTO THE LARGE INTESTINE — (URE- 
 
 TERO-RECTOSTOMY) 
 
 BV FOWLER'S METHOD. 
 
 Description. — Implantation and suturing of the ureters into the long axis 
 of some part of the large intestine, generally either into rectum, sigmoid flexure, 
 or caecum. Indicated especially where the bladder has been removed. The 
 difficulties of this implantation are not so great — the chief source of failure 
 and of death being infection of the ureters and kidneys from the intestinal 
 tract. In Fowler's operation, which will be here described, the implanta- 
 tion into the rectum (uretero-rectostomy) is made in such a manner as to 
 open obliquely upon an artificially formed valve of mucous membrane, which 
 valve, together with the circular action of the muscular fibers of the intestine, 
 will tend to shut off the ureters and kidneys from ascending infection from the 
 bowel, especially during defecation. 
 
 Preparation. — As for median abdominal section — with especially thor- 
 ough cleansing of the intestinal tract, and particularly the rectum. 
 
 Position. — Patient in the Trendelenburg position. Surgeon to patient's 
 left, generally. Assistant, opposite. 
 
 Landmarks — Incision. — As for median abdominal section below the 
 umbilicus. 
 
 Operation. — (1) The sphincter of the anus is first dilated. (2) The 
 abdominal cavity is opened as in ordinary abdominal section. (3) Displace 
 the intestines downward (toward the diaphragm) and laterally, exposing the 
 site of the ureters. (4) Incise the peritoneum over the ureters, from the brim 
 of the pelvis to the bladder, and free, by blunt dissection, the ureters from their 
 bed to this extent. Ligate the ureters near the bladder- wall and divide them 
 obliquely upon the side of the ligature toward the kidneys — the oblique division 
 being at the expense of the under (posterior) surface of the proximal ends of the 
 
FOWLER'S URETERORECTOSTOMY. 1087 
 
 ureters. (They may be first divided transversely and then the proximal end 
 beveled obliquely as above.) (5) Incise the anterior wall of the rectum longi- 
 tudinally in its center, for about 7 cm. (2I inches) — the incision being so placed 
 that its center will correspond with a convenient approximation of the cut ends 
 of the ureters. This incision passes through the serous and muscular coats 
 only. Dissect back, on either side, the serous and muscular coats, exposing 
 a diamond-shaped area of submucous tissue — an assistant holding aside the 
 margins with temporary traction-sutures or tenacula (Fig. 797). In the lower 
 half of the exposed area of submucous tissue cut a U-shaped flap about 2.5 cm. 
 (1 inch) long, with free end downward, incising through the mucous membrane 
 into the lumen of the rectum. Turn the free end of this flap upward and out- 
 ward upon itself, so that the apex will point to the base, and the mucous surface 
 will be uppermost — forming a flap with mucous surface upon one side, and 
 submucous upon the other — and suture the two surfaces of the reflected flap 
 together along their lateral aspect (Fig. 79S). (6) Unite the two ureters upon 
 
 Fig. 797.— Ureterorectostomy, by Fowler's Method: — I, The serous and muscular coats 
 of the rectum are incised and retracted. A U-shaped flap is outlined upon the mucous membrane. 
 (Modified from Fowler.) 
 
 their inner aspects by two or three interrupted fine gut sutures passed through 
 their fibrous and muscular coats, one placed near their free end, the second 
 about 2 to 2.5 cm. (J to 1 inch) above, and a third may be similarly placed 
 above the second, if there be room. The ureters will be thus so united as to 
 leave the obliquely beveled ends pointing posteriorly. (7) The two parallel, 
 united ureters are now so placed upon this flap of mucous and submucous tissue 
 that their obliquely beveled surfaces will lie undermost, and in contact with 
 the normal mucous surface of the reflected end of the flap — and with their tips 
 in apposition with the upper part of the reflected flap (so as to leave ample free 
 flap below to serve as a valve). Suture the free ends of both ureters to the 
 mucous flap, by fine gut sutures passing through only the fibrous and serous 
 coats of the ureters, and well into both thicknesses of the mucous flap. The 
 ureters are also sutured above to the submucous tissue of the flap. (8) The 
 suturing having been completed, carefully push the mucous flap and attached 
 ends of the ureters back into the rectum. Then suture together, with continu- 
 
io88 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 ous or interrupted catgut, the edges of the opening through the submucous and 
 mucous coats left by the flap, continuing the suturing upward a little beyond the 
 base of the flap, and beneath the ureters, until the furrow caused by approxi- 
 
 Figs. 798-800 — Uretero-rectostomy, by Fowler's Method: — II, The U-shaped flap is 
 incised and turned upward. The two beveled ureters are connected by two sutures, and then 
 sutured to the mucous flap. (Modified from Fowler.) 
 
 Fig.801. — Ureterorectostomy, by Fowler's Method: — III, The mucous flap and attached 
 ureters are then buried within the bowel by suturing the margins of the opening through the mucous 
 membrane. (Modified from Fowler.) 
 
 mating the edges has been obliterated (Fig. 800). (9) Suture together the 
 edges of the serous and muscular coats of the rectum with interrupted silk or 
 
URETERECTOMY, IN GENERAL. 
 
 1089 
 
 chromic gut, thus further burying in the tips of the ureters, and also burying in 
 that portion of the ureters lying obliquely between the submucous and serous 
 coats, insuring an oblique passage between the rectal coats of about 3 cm. (i| 
 inches). One or two of the sutures, in this line of suturing, should include 
 the outer coats of the ureters (not entering their lumen). The outer coats of 
 the rectum, in this line of suturing, should be well sutured around the ureters 
 at the site where they pass between these coats. 
 (Fig. 802.) (10) Temporary drainage may be pro- 
 vided, if deemed necessary — otherwise the abdomen 
 is closed as usual. 
 
 Comment. — (1) A permanent valve is thus 
 formed, with a mucous surface to the ureter, and a 
 mucous surface to the lumen of the gut, thus clos- 
 ing the ends of the ureters as the bowel distends 
 with combined feces and urine, aiding the control 
 and safety from infection — which the oblique pas- 
 sage of the ureters through the rectal wall further 
 aids. (2) Various other methods of intestinal im- 
 plantation have been done. Maydl transplanted 
 both ureters, including an elliptical portion of the 
 trigone of the bladder, into the rectum or sigmoid 
 flexure — thus retaining the natural functioning of 
 the ureteral openings. 
 
 IMPLANTATION OF URETER UPON THE SKIN. 
 
 Fig. 802.— Ureterorec- 
 tostomy, by Fowler's 
 Method : — IV, The ureters 
 and mucous flap are still 
 further buried by suturing 
 the edges of the incision 
 through the serous and mus- 
 cular coats. (Mollified from 
 Fovs lei . 1 
 
 Description. — Implantation of the ureter upon 
 the skin of the loin or abdomen. The implanta- 
 tion upon the former site is preferable — as extension 
 of the ureter through the abdominal cavity furnishes 
 a band for possible intestinal interference. Skin- 
 implantation, however, is the least desirable form 
 of implantation, because of the inconvenience and 
 annoyance of this exit for the urine, and because of the likelihood of infection. 
 
 Operation. — (1) If the ureter to be implanted be encountered during an 
 operation by the oblique Lumbar incision, — after ligating the distal end of the 
 severed ureter, the proximal end is loosened up by blunt dissection sufficiently 
 to free it for the requisite length — and is then sutured into the skin of the 
 lumbar wound after splitting its end — the remainder of the wound being 
 closed by suture in the ordinary fashion. (2) If the ureter be encountered 
 in the course of a median abdominal section, a counter lumbar opening is 
 made and the ureter implanted, as just described. 
 
 Comment. — The proximal end of the ureter may also be sutured to the 
 skin at the nearest point possible to the bladder, in hope of subsequently 
 doing a plastic operation for the establishment of the ureter. 
 
 URETERECTOMY. IN GENERAL. 
 
 Description. — Excision of ureter, in whole or in part. Partial ureterec- 
 tomy is the removal of a portion of the ureter, followed by either an uretero- 
 ureterostomv between the remaining ends, or an implantation of the ureter into 
 some locality. Complete ureterectomy consists in the removal of the entire 
 
 69 
 
1090 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 ureter — and implies, of course, the removal also of the corresponding kidney; 
 that is, nephro-ureterectomy. 
 
 Ureterectomy may be done extraperitoneally or intraperitoneally. Extra- 
 peritoneal ureterectomy is generally done through the oblique lumbar incision. 
 Intraperitoneal (transperitoneal) ureterectomy is usually done through an 
 anterior abdominal section. 
 
 Indicated in tuberculosis and suppuration of the ureters. Partial ureter- 
 ectomy is sometimes done accidentally in operating for other conditions. 
 
 PARTIAL URETERECTOMY 
 
 BY OBLIQUE LUMBAR INCISION. 
 
 Description. — The ureter is exposed extraperitoneally by the above in- 
 cision, and a portion of its extent removed — followed by an uretero-ureteros- 
 tomy, where the amount removed is not too great — or by an implantation, 
 where the amount removed and the site of removal indicate it. A partial 
 ureterectomy is generally accidentally done, especially in intra-abdominal 
 operations for the removal of tumor. 
 
 Preparation — Position — Landmarks — Incision. — As for exposure of 
 the ureter extraperitoneally by oblique lumbar incision, page 1076. 
 
 Operation. — If the ureterectomy be deliberately done — the kidney is ex- 
 posed — the ureter isolated by tracing downward from pelvis of kidney — and is 
 then dissected up from its bed by blunt dissection and by carefully peeling it 
 away from the peritoneum. A limited portion is now excised with scissors — 
 after ligating below the point of division — and clamping with special clamp 
 above. The proximal and distal ends are then freed up sufficiently to enable 
 the gap formed by the excision to be bridged. The ends are brought together 
 and an uretero-ureterostomy (preferably by Van Hook's method, see page 
 10S2) is done — or an ureteral implantation is performed. 
 
 TOTAL URETERECTOMY, TOGETHER WITH REMOVAL OF KIDNEY, 
 
 BY ANTERIOR MEDIAN ABDOMINAL SECTION. 
 
 Description. — Total Nephro-ureterectomy consists in the removal of the 
 kidney and of the entire ureter. Generally resorted to for tubercular or sup- 
 purative disease of kidney and ureter. The removal may be made extraperi- 
 toneally by the oblique lumbar incision, as just described in partial ureterec- 
 tomy, — or intraperitoneally, by anterior abdominal section in the median or 
 semilunar line. The exposure of the kidney and ureter extraperitoneally 
 by an oblique lumbar incision has been described and pictured at pages 1053 
 and 1055. 
 
 Preparation — Position — Landmarks — Incision. — As for median ab- 
 dominal section. 
 
 Operation. — Having opened the abdominal cavity and displaced the in- 
 testines toward the median line, divide the posterior peritoneum upon the outer 
 aspect of the colon and reflect it toward the spinal column — thus exposing the 
 kidney and ureter. The kidney is now freed and its pedicle tied off as de- 
 scribed under total nephrectomy by the abdominal route. The ureter is sim- 
 ilarly freed by blunt dissection. All vessels are ligated. Having severed the 
 pedicle of the kidney, except the ureter, the kidney is separated from its bed — ■ 
 and, by gentle traction upon it and the ureter, the ureter is traced down to the 
 bladder. The vesical end of the ureter is doubly ligated close to the bladder 
 and divided between the ligatures. The free end of the ureteral stump may be 
 
SURGICAL ANATOMY OF THE BLADDER. 1091 
 
 sterilized. The posterior peritoneum is dropped back into place over the site 
 occupied by kidney and ureter — and may be sutured here and there with in- 
 terrupted gut sutures, though it generally remains readily in place and adheres 
 to the connective tissue from which raised. Temporary drainage may be 
 established, where specially indicated — otherwise the abdomen is closed. 
 
 XIV. THE BLADDER. 
 
 SURGICAL ANATOMY. 
 
 Description. — The bladder is a musculo-membranous sac, mainly situ- 
 ated in the pelvic cavity, between pubes and rectum in male; and between 
 pubes in front, and cervix uteri and upper part of vagina behind, in female, — 
 entirely surrounded by recto-vesical fascia, and covered above by peritoneum. 
 Consists of serous (peritoneal), muscular, submucous (areolar), and mucous 
 coats. In infancy the bladder projects above the os pubis and is more of an 
 abdominal organ than in the adult. When empty — in the adult, the bladder 
 lies deeply in the pelvis, flattened antero-posteriorlv. When moderately dis- 
 tended — it is rounded and still within the pelvis. When fully distended — it is 
 ovoid and projects into the abdominal cavity. When greatly distended — it 
 may extend nearly to the umbilicus. The long axis of the bladder, which in- 
 clines to the vertical, runs from a point between the os pubis and the 
 umbilicus (dependent upon the amount of distention) downward and back- 
 ward toward the tip of the coccyx. The vertical axis is greater in the male — 
 the transverse greater in the female. 
 
 Relations. — (1) Summit : — Connected with abdominal wall by urachus 
 (remains of part of allantois), which passes from apex of bladder, between 
 transverse fascia and peritoneum, to umbilicus; obliterated hypogastric arteries, 
 passing upward from side of bladder, on each side of urachus. (2) Superior, 
 or abdominal surface : — Entirely covered by peritoneum, from summit and 
 obliterated hypogastric arteries to base of bladder; sigmoid flexure (in male); 
 part of vasa deferentia (in male) ; uterus (in female) ; small intestines (in both 
 sexes). (3) Antero-inferior, or pubic surface : — Uncovered by perito- 
 neum, and separated from the following structures by the cavum Retzii, or 
 prevesical space; triangular ligament; symphysis pubis; levatores ani and in- 
 ternal obturator muscles; abdominal wall (when distended), separated by 
 recto-vesical fascia. (4) Lateral surfaces : — Upper part covered by perito- 
 neum, above and posterior to obliterated hypogastric arteries, — lower part, 
 below and in front of obliterated hypogastric arteries, is covered by recto- 
 vesical fascia, which separates the lateral surfaces from the levatores ani and 
 surrounds the vesical vessels and nerves; obliterated hypogastric arteries, 
 which cross lateral surfaces obliquely from below upward and forward; vasa 
 deferentia, arching from before backward along subperitoneal aspect of lateral 
 surfaces toward base, crossing obliterated hypogastric arteries, and passing 
 between ureter and wall of bladder; entrance of ureter, at junction of posterior 
 and lateral surfaces, about 5 cm. (2 inches) above the prostate; levatores ani 
 and obturator internus muscles. (5) Postero-inferior surface, or base : — 
 May be subdivided into two parts; — (a) Upper, Peritoneal Portion: — Recto- 
 vesical pouch in male, generally from 1.3 to 2.5 cm. (5 to 1 inch) from pros- 
 tate, up to as much as 5 cm. (2 inches) in marked bladder distention; utero- 
 vesical cul-de-sac in female: — (b) Lower, Non-peritoneal Triangular Por- 
 tion: — In Male, rests upon anterior surface of second part of rectum, inferior 
 
1092 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 part of vasa deferentia and vesiculae seminales; — its boundaries being; Base, 
 reflected recto-vesical fold; Sides, diverging vasa deferentia and vesicuJae 
 seminales; Apex, summit of prostate; — In Female, adherent to anterior wall 
 of cervix uteri, and to upper portion of anterior vaginal wall; — Neck of Blad- 
 der, beginning of urethra. 
 
 Ligaments. — (a) Five true ligaments: — (1) Two pubo-prostatic, — 
 recto-vesical fascia and muscular tissue — from back of pubic bone to antero- 
 inferior or pubic surface of bladder, passing over superior surface of prostate 
 gland. (2) Two lateral, — recto-vesical fascia — from lateral aspects of pros- 
 tate to sides of bladder and walls of pelvis. (3) Superior ligament, or urachus, 
 — iibro-muscular structure between summit of bladder and umbilicus, (b) 
 Five false ligaments (peritoneal folds): — (1) Two posterior, or recto-vesical 
 folds of peritoneum (in male), — from side of rectum to side of bladder. (2) 
 Two posterior, or utero-vesical folds of peritoneum (in female), — from sides of 
 uterus to posterior surface and sides of bladder. (The posterior false liga- 
 ments form the lateral walls of the recto-vesical and utero-vesical cul-de-sac, 
 and transmit the ureters, obliterated hypogastric arteries, with vessels and 
 nerves.) (3) Superior ligament, — fold of peritoneum reflected over urachus 
 and obliterated hypogastric arteries, from summit of bladder to umbilicus. 
 
 Relation of Peritoneal Fold to Anterior Abdominal Wall. — The re- 
 flection of peritoneum is carried upward as the bladder is distended. The 
 maximum elevation of the peritoneal fold rarely exceeds 5 cm. (2 inches). 
 Sometimes it fails to reach the upper border of the symphysis pubis. 
 
 Space of Retzius, or Prevesical Space. — Space between the reflection of 
 peritoneum above and the symphysis pubis below, — and between the bladder 
 posteriorly and the symphysis pubis anteriorly — and occupied by connective 
 tissue. 
 
 Trigonum Vesicae. — Triangular smooth surface at base of bladder — 
 bounded at each posterior angle by the ureteral opening — and at the antero- 
 inferior angle by the urethral orifice. 
 
 Orifices of Ureters. — Situated about 3.8 cm. (1^ inches) from base of 
 prostate gland and beginning of urethra — and are a little less than 5 cm. (2 
 inches) apart, at either end of the base of the trigone. 
 
 Internal Urinary Meatus. — Lies, in the adult male, from 2 to 2.5 cm. 
 (f to 1 inch) posterior to the symphysis pubis, and from 5 to 6.3 cm. (2 to 2^ 
 inches) above the perineum. It generally lies opposite some part of the upper 
 half of the symphysis pubis. 
 
 Arteries. — Superior, middle, and inferior vesical, and branches from the 
 obturator and sciatic, in the male, — and the same, with additional branches 
 from the uterine and vaginal, in the female, — all from the anterior trunk of the 
 internal iliac. 
 
 Veins. — Form plexuses around neck, sides and base, and end in internal 
 iliac vein. 
 
 Lymphatics. — Accompany the veins and end in the pelvic glands. 
 
 Nerves. — From hypogastric plexus of sympathetic, and from third and 
 fourth sacral nerves. 
 
 SURFACE FORM AND LANDMARKS. 
 
 In young children, the apex of the empty bladder is about 25 cm. (1 inch) 
 above the level of the symphysis pubis. 
 
 In the adult, the apex of the empty bladder is about on a level with the 
 superior border of the symphysis pubis. 
 
THE BLADDER— GENERAL SURGICAL CONSIDERATIONS. 1093 
 
 In marked distention the anterior bladder-wall comes closely into contact 
 with the abdominal parietes — without the intervention of peritoneum between 
 the two. 
 
 For the normal extremes of the peritoneal reflection, see Surgical Anatomy, 
 page 1092. For the position of the peritoneal reflection under surgical dis- 
 tention, see General Surgical Considerations, below. 
 
 The neck of the bladder is on a level with a line extending horizontally 
 backward from just below the center of the symphysis pubis. Also see position 
 of internal urinary meatus, Surgical Anatomy, page 1092. 
 
 The depth from the perineal skin to the pelvic floor generally averages from 
 5 to 7.5 cm. (2 to 3 inches) in the posterior and external part of the perineum — 
 and somewhat less than 2.5 cm. (1 inch) in the anterior part. 
 
 In the lithotomy position the bladder is about 6.3 or 7.5 cm. (25 or 3 inches) 
 from the perineal surface. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 When both bladder and rectum are empty, the apex of the bladder and the 
 peritoneal reflection are slightly below the superior border of the symphysis 
 pubis. When the apex of the bladder is as much as 5 cm. (2 inches) above the 
 svmphysis and resting against the anterior abdominal wall, the peritoneal re- 
 flection is about 2 cm. (f inch) above the upper border of the symphysis. 
 
 Simple distention of the rectum alone tends to elevate the base of the blad- 
 der without correspondingly elevating the non-peritoneal prevesical space. 
 
 When the rectum is distended by a rubber bag filled with air or water, the 
 prostatic portion of the urethra is elongated, and the bladder is thereby raised 
 out of the pelvic cavity and the peritoneum pushed upward. The maximum 
 elevation of the non-peritoneal prevesical space is obtained by distending the 
 rectum first and then distending the bladder. The rectal bag is first filled with 
 about 10 or 12 ounces of fluid — and then the bladder is filled with about 8 
 ounces. Thereby an additional space free of peritoneum is secured in the 
 anterior line. The amount of space uncovered by peritoneum which is thus 
 ordinarily secured generally amounts, altogether, to about 7.5 cm. (3 inches). 
 The bladder, however, is often first filled — and up to 15 ounces may be used. 
 
 Grav states that after distending the rectum with 420 c.c. water — and then 
 filling the bladder with 500 c.c. — the bladder will be elevated by the rectum 
 sufficiently to make an interval between the lower peritoneal reflection and the 
 upper border of the symphysis equal to S.5 cm. (3yV inches). 
 
 As the point of reflection of peritoneum, therefore, is not fixed, and as it 
 sometimes comes down to a level with the upper border, or even below, the 
 symphysis pubis, it is never absolutely safe to plunge a trocar directly into the 
 bladder, even immediately above the upper border of the symphysis. It is 
 always better to expose the bladder-wall by a limited median incision before 
 using the trocar. 
 
 Though not to be recommended, the bladder may be punctured from the 
 rectum, in the lower, non-peritoneal surface at the base of the bladder. 
 
 No vessels of any size cross the median line of the abdomen or of the peri- 
 neum — the two sites through which cystotomy is generally done. 
 
 The artery of the bulb, especially when arising normally, is not generally 
 cut in perineal lithotomy. If the artery of the bulb arises from the accessory 
 pudic it will lie more anteriorly than normal — and well out of the way. If, 
 however, it arises from the pudic sooner than usual, it will cross the perineum 
 more posteriorly and will be almost certainly cut. 
 
IOQ4 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Perineal incisions made into the neck of the bladder should not exceed the 
 limits of the prostate. 
 
 The prostatic plexus of veins is likely to be wounded in lateral perineal 
 lithotomy. 
 
 The ejaculatory duct is apt to be cut in the same operation if the incision be 
 too far posterior. 
 
 INSTRUMENTS. 
 
 Scalpels; bistouries, straight and curved, sharp and blunt; lithotomy knives; 
 scissors, straight and curved, blunt and sharp; forceps, dissecting and toothed; 
 artery-clamp forceps, long and short; grooved director; special grooved 
 directors and perineal guides; grooved lithotomy staffs, median and lateral; 
 tenacula; probe; retractors, various; blunt dissector; sponge-holders; trac- 
 tion-loops; Clover's crutch; rectal bag; catheters; sounds; whalebone guides; 
 tunneled sounds; lithotomy forceps; lithotomy scoop; lithotrite; evacuator; 
 irrigating syringe; special bladder forceps; cystoscope; special electric illumi- 
 nator; trocar and cannula; exploratory syringe; needles, straight and curved; 
 needle-holder; ligatures and sutures, silk and gut; drainage-tubing; gauze. 
 
 INTRODUCTION OF SOUND OR CATHETER. 
 
 Description. — The general method of entering the male bladder by the 
 urethra is the same in all essentials — whether by metallic sounds, catheters, 
 lithotrites, or cystoscopes. Soft instruments are not subject to much guiding, 
 but generally enter the bladder by being simply protruded through the urethral 
 canal without special effort to direct them through the anatomical curves. The 
 passage of instruments in the female is simple. 
 
 Passage in the Male. — (i) The glans and the meatal opening are cleansed. 
 (2) The patient lies supine, near the edge of the table — shoulders slightly 
 elevated — thighs slightly flexed and rotated outward by bending the knees (to 
 relax the muscular tension). The surgeon stands on the left, just above the 
 hips, facing the patient's side. (3) The sound, or catheter, warmed, lubri- 
 cated, and disinfected, is held lightly in the right hand, between thumb and first 
 two fingers — the handle at first parallel with the abdominal wall. Thus held, 
 its point is introduced into the meatus, the lips of which are parted by the sur- 
 geon's left index and thumb to receive it — the glans and penis being held ver- 
 tically in the surgeon's left fingers. As the instrument is pushed onward and 
 downward, the penis is correspondingly drawn upward and over the instrument. 
 (4) As soon as the instrument is felt to have entered about io or 13 cm. (4 to 5 
 inches), and to be rounding toward the subpubic arch, the handle is gradually 
 elevated until the perpendicular is reached — allowing the instrument to gravi- 
 tate through the canal and beneath the pubic arch. (5) As this occurs, the 
 handle is continued in its sweep forward, directing the point through the tri- 
 angular ligament — onward through the membranous and prostatic urethra — 
 until the end is felt to glide into the bladder — when the handle will be found 
 pointing directly away from the bladder and slightly downward — having 
 passed through a semicircle in the vertical plane. (6) In withdrawal, the 
 above steps should be exactly reversed. 
 
 Comment. — (1) The sound should first hug the floor of the spongy ure- 
 thra, until the lacuna magna (on the roof, 2.5 cm. [1 inch] from the meatus) is 
 passed — and then gently hug the roof for the balance of the way through the 
 
PARACENTESIS YESIC.E. 1095 
 
 spongy, membranous, and prostatic urethra. (2) By carrying the handle of 
 the instrument forward and between the thighs too soon, the tip of the instru- 
 ment is made to hug the roof of the urethra too suddenly and closely, and is apt 
 to lodge against the upper part of the anterior aspect of the triangular ligament, 
 and thus fail to enter the membranous urethra. (3) On the other hand, the 
 instrument sometimes fails to pass the triangular ligament because of lodging 
 against the lower part of the anterior aspect of the triangular ligament, the 
 handle not being depressed enough — and, in such cases, is made to glide on by 
 depressing the handle more — or by lifting the lodged point upward by the left 
 index-finger in the rectum, or even by pressure against the perineum behind 
 the scrotum. (4) The instrument may be at first introduced while held about 
 parallel with the left Poupart ligament — that is, over the left groin — and then 
 swept into the median line as it descends. (5) If the beak of the instrument 
 revolves readily, the sound is in the bladder. 
 
 Passage of the Female Sound or Catheter. — (1) The patient lies supine, 
 with hips and knees semiflexed, and thighs separated. (2) Separate the labia 
 with left thumb and index. Holding the instrument between the right thumb 
 and index, the index extending beyond the end of the instrument, pass the tip 
 of the right index just within the vaginal orifice — withdraw the finger partly, 
 hugging the upper wall of the vagina — and, as the finger glides out of the 
 vagina upon the vestibule, the prominent urethral papilla is felt (about 1.3 
 cm., or h inch) above the junction of the vagina and vestibule — upon which 
 is situated the meatus — into which the instrument is then introduced and 
 protruded into the bladder. 
 
 PARACENTESIS VESIGE. 
 
 Description. — Puncture of the bladder-wall by cannula and trocar, or by 
 aspiratory syringe. Indicated in retention of urine. The bladder may be 
 punctured immediately above the pubis, just below the symphysis pubis, 
 through the rectum, or through the prostate gland. The suprapubic puncture 
 is practically the only method of puncture now resorted to — and will be here 
 described. 
 
 Preparation. — Ascertain that the bladder is well distended. Shave in 
 the region of the median line, just above the symphysis pubis. 
 
 Position. — Patient supine, — or sitting upright, supported. Surgeon on 
 patient's right, facing him. 
 
 Point of Puncture. — In median line, immediately above the upper border 
 of the symphysis pubis. 
 
 Operation. — Having outlined the distended bladder by percussion — a 
 curved cannula and trocar (which are better than the straight) are taken in the 
 operator's right hand, with the convexity upward, and so held, with the index- 
 finger upon the shaft of the instrument, that the depth to which it may enter the 
 bladder is fixed in advance. The bladder is steadied by the surgeon's left 
 thumb and index placed on each side of the median line. The instrument is 
 thrust sharply but gently into the bladder, entering in the median line just 
 above the symphysis pubis, and directed backward and downward — piercing 
 skin, superficial fascia, passing between the inner borders of the recti and 
 pyramidales (or through their muscular substance), prevesical space, anterior 
 bladder-wall, and into the bladder. The trocar is then withdrawn and the 
 cannula left in situ until the urine has come away, chiefly of its own accord, and 
 partly aided by gentle pressure. Upon withdrawal of the instrument, the 
 opening is at once closed by sterilized cotton and collodion. 
 
1096 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Comment. — (I) Local anesthesia should he first used. (2) Incision of 
 skin may be first made and then trocar introduced. This may be done either 
 to avoid the most difficult part of the puncture mechanically, namely, the 
 penetration of the tough skin with a comparatively dull instrument, — or it 
 may be done, as mentioned under Surgical Considerations, for the purpose of 
 first e.xposing the bladder before puncturing. (3) If the skin be drawn down- 
 ward over the symphysis just before puncture, a valve-like opening will be 
 formed. (4) In those rare cases in which the reflection of peritoneum comes 
 very low down, to or behind the symphysis pubis, it will almost certainly be 
 wounded — not being possible to avoid it, except, were it known in advance, by 
 exposing the area by dissection and pushing the peritoneum upward before the 
 puncture. Puncture of the peritoneum, however, is exceedingly rare provided 
 the bladder be well distended, and a curved instrument be used. 
 
 CYSTOTOMY IN GENERAL. 
 
 By Cystotomy is meant the incision of the bladder. The less correctly used 
 term " lithotomy" (or "stone-cutting," literally) is equivalent to "Cystotomy 
 for removal of calculus." 
 
 Cystotomy is indicated in calculus, foreign body in the bladder, exploration, 
 drainage, access to prostate, tumors, diseased conditions of the mucous mem- 
 brane, catheterization of the ureters intravesically, etc. 
 
 Cystotomy may be suprapubic, median perineal, lateral perineal, bilateral 
 perineal, medio-lateral perineal, medio-bilateral perineal, vaginal, and by ex- 
 ternal urethrotomy. The first three of these are, practically, all which are now 
 done — and of these three, the suprapubic is the one which is most frequently 
 performed. 
 
 For the removal of large stones, the suprapubic route should always be 
 chosen — while it is preferable for the removal of any calculus. For the pur- 
 poses of drainage alone, not weighing other considerations, the perineal route 
 is the best. 
 
 SUPRAPUBIC CYSTOTOMY. 
 
 Description. — Incision of the bladder above the symphysis pubis, through 
 the prevesical space. Indicated for calculi — especially large ones — or encysted 
 small ones; exploration; drainage; tumors; foreign bodies; access to prostate 
 gland. Much more frequently performed than median or lateral perineal 
 cystotomy. 
 
 Preparation. — Pubes shaved; rectum emptied; rectal bag in rectum, well 
 above the sphincters, in hollow of sacrum, and filled with 10 to 12 ounces of 
 water (or with air); bladder irrigated and filled with 8 to 10 ounces of water 
 (after the rectum has been distended) ; penis carefully ligated with rubber 
 band to keep water in bladder. 
 
 Position. — Patient supine. Surgeon on patient's right. Assistant oppo- 
 site. 
 
 Landmarks. — Median line; upper border of symphysis pubis. 
 
 Incision. — About 7.5 cm. (3 inches) in length — placed in the median 
 line — beginning about 6.5 cm. (2^ inches) above the symphysis pubis and ex- 
 tending to a point about 1.3 cm. {\ inch) above the symphysis. The extreme 
 upper and lower ends of this incision are not carried to the lowest depths of the 
 wound — but are only superficial and are to allow for retraction of the parts. 
 
SUPRAPUBIC CYSTOTOMY. 1097 
 
 Operation. — (1) Divide the skin and superficial fascia, clamping, if neces- 
 sary, any bleeding vessels. Sometimes abundant fatty areolar tissue must be 
 traversed. The interval between the inner borders of the recti and pyramidales 
 is sought, but is frequently not demonstrated — and, if not, the muscle tissue 
 is divided in the line of its fibers, without further needless search — the edges 
 of the wound being well retracted as they are deepened (Fig. 803). (2) The 
 transversalis fascia is encountered and similarly divided in the median line — 
 and the prevesical space reached. The areolar tissue overlying the prevesical 
 space is cautiously divided in the median line— extreme care being here used, 
 for the purpose of recognizing the lower reflection of peritoneum, especially if it 
 be prolonged unusually far down. The peritoneal fold must be sought from 
 below (near the symphysis) upward, the dissection beginning immediately 
 
 Fig. 803.— Suprapubic Cystotomy :— A, Margins of recti and pyramidales muscles ; B, B, Pre\-esi- 
 cal areolar tissue freed and retracted from bladder; C, Peritoneum retracted upward (unopened); 
 D, D, Tenacula passed through serous and muscular coats of bladder and subsequently used to re- 
 tract lips of bladder-wound. 
 
 above the upper border of the symphysis. As soon as encountered, the peri- 
 toneal fold is carefully pushed upward, with the left index, off the front of the 
 bladder, so as to be out of the way of injury. All the prevesical fatty areolar 
 tissue should be divided accurately in the middle line, until the bladder-wall is 
 well exposed — which is generally recognized by its pink muscular appearance, 
 convex contour, fluctuation, and elasticity. The lips of the wound should 
 be well retracted — and any bleeding from the prevesical veins controlled. 
 (3) The bladder is steadied by two tenacula passed transversely across the 
 median line through the outer coats, at the extreme upper and lower limits 
 of its exposed surface, and held in the two hands of the assistant. When all 
 is in readiness, the operator, with sharp, narrow knife, by a quick, controlled 
 thrust, stabs through the bladder-wall just below the upper tenaculum (in- 
 
1098 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 suring, by this method, the penetration of all coats of the bladder — and not the 
 protrusion of the muscular coat ahead of the knife-point, as sometimes happens 
 in a slowly made incision) and cuts downward in the middle line toward the 
 lower tenaculum, increasing the extent of the incision as he draws the knife out. 
 The contained fluid immediately escapes — but, owing to the holding up of the 
 bladder, but a small amount enters the prevesical wound. Two silk retraction- 
 sutures are now placed through the center of each lip of the bladder-wound — 
 and the tenacula withdrawn. Some surgeons, instead of using the tenacula 
 as above, originally place these traction-sutures, with a curved needle, passing 
 through the outer coats of the bladder, parallel with the future incision, and 
 about 1.3 cm. (h, inch) apart. Hemorrhage from the edges of the bladder- 
 wound may occur at first, but generally is easily controlled. The ligature 
 about the penis is now relaxed and the bladder emptied. (4) The assistant 
 who held the tenacula now holds the bladder-lips apart by traction-sutures. 
 The opening into the bladder is enlarged to the desired extent in the median 
 line, upward and downward — carefully guarding the peritoneum above, which 
 especially tends to prolapse when the bladder is empty. A finger is introduced 
 and the cavity of the bladder examined — and the special object of the operation 
 accomplished. If it be a calculus to be removed, special forceps, guided by the 
 introduced finger, grasps the stone and withdraws it. The rectal bag may be 
 emptied and withdrawn as soon as the bladder is entered — or, if not distended 
 before, may be then distended to bring the fundus of the bladder more into the 
 wound. (5) Where indicated — in healthy condition of the parts and where 
 no great traumatism has been done — the bladder-wound may be closed at once. 
 In suturing, retract the upper and lower angles of the bladder-wound by wound- 
 hooks, thus approximating and paralleling the margins of the vesical wound. 
 Withdraw the silk traction-sutures as soon as the wound-hooks are in place. 
 The margins of the bladder are then neatly and closely brought together with 
 fine chromic gut, upon a curved needle — placed interruptedly and passing 
 through all the coats except the mucous membrane. It is probably well to 
 reinforce this line of suturing with a second tier of interrupted Lemberts of silk 
 or fine gut — the roughened connective-tissue coat of the bladder, being ap- 
 proximated in the Lembert fashion, uniting. Some surgeons use a first layer of 
 sutures through the mucous membrane — and a second layer through the outer 
 coats. Still others use a row of Lemberts through the outer coats only. (6) 
 The superficial wound is now closed — except to a small extent immediately 
 over the center of the bladder- wound — where temporary drainage is established 
 for thirty-six or forty-eight hours, in case of leakage. Two tiers of sutures are 
 used in the superficial wound — a buried chromic gut interrupted or con- 
 tinuous tier, uniting the divided muscle tissue, — and a superficial silkworm- 
 gut, or silk, placed interruptedly through the skin and fascia. The sutures 
 opposite the site of drainage may have been placed — and simply tightened 
 upon the withdrawal of the drain. 
 
 Comment. — (1) The incision, superficial and deep, especially where done 
 for exploration, may be less extensive than the above. (-2) If in doubt about 
 the position of the bladder, use an exploratory syringe. (3) Avoid detaching 
 the anterior bladder-wall from the posterior surface of the symphysis. (4) If 
 the peritoneum be accidentally wounded, immediately close it with fine gut 
 sutures of the Lembert type. (5) Special forms of hooked gorgets have been 
 made to hold up the bladder while exploring or operating upon its cavity. (6) 
 Use round needles in suturing the bladder. (7) In some cases, for drainage, or 
 other reason, the suprapubic wound is left open — and then the edges of the 
 bladder are sutured with chromic gut to the deeper edges of the superficial 
 
LATERAL PERINEAL CYSTOTOMY. 
 
 1099 
 
 wound. (8) Some surgeons leave a catheter in the bladdei for two or three 
 days — to avoid overdistention and pressure upon the sutures. (9) In children, 
 the bladder is naturally higher in the abdomen. 
 
 LATERAL PERINEAL CYSTOTOMY 
 
 FOR REMOVAL OF VESICAL CALCULUS. 
 
 Description. — Incision of bladder through left lateral region of perineum 
 — generally performed for the removal of calculi. The operation is sometimes 
 less correctly called Lateral Lithotomy. It is always performed upon the left 
 side because the manipulations upon that side are more convenient to the 
 surgeon. The operation, as here carried out, is applicable to any purpose for 
 which it is indicated to approach and open the bladder by this route — but it is 
 generally done for stone, although less frequently now than formerly. Calculi 
 of moderate, but not the largest, size may be removed by this route. The 
 special instruments required are: — a left dorso-laterally grooved lithotomy 
 staff; probe-pointed knife (if preferred to straight-pointed ) ; stout bistoury with 
 cutting edge of about 5 cm. (2 inches); Clover's crutch, or some provision for 
 maintaining the lithotomy position; wristlets and anklets (may be used). 
 
 Fig. 804. — Incisions for Perineal Cystotomy: — A, Lateral perineal 
 
 perineal cystotomy. 
 
 cystotomy ; 
 
 Median 
 
 Preparation. — Rectum empty and irrigated. Perineum shaved. Rec- 
 ognition of calculus by sound. 
 
 Position. — Patient rests upon back, and, in this position, is brought down 
 to end of table, so that buttocks come well over the edge of the table. "While 
 steadied in this position, the special staff is passed into the bladder and given 
 into the charge of an assistant, who, henceforth, holds it steadily and unvary- 
 ingly in the middle line. Clover's crutch (and anklets and wristlets, if de- 
 sired) are then adjusted, and the thighs flexed back upon the abdomen— or an 
 assistant on each side may hold a limb in the above position, without the use of 
 the crutch — and the patient remains in the characteristic lithotomy position 
 throughout the operation. The surgeon sits at the end of the table, facing the 
 patient's perineum. The assistant, standing on the left, who holds the staff in 
 his right hand, holds up the penis and scrotum with his left. Up to the en- 
 trance of the knife into the groove of the staff, the staff is held so that its handle 
 
iioo OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 is nearly parallel with the abdominal wall, so that its convexity causes the 
 membranous urethra to round out more prominently and nearer to the peri- 
 neum, making it more accessible to the operator. When once the knife has 
 entered the groove and the deeper part of the incision is being made, the staff is 
 held with its handle perpendicular and its concavity up against the pubic arch 
 and its point well in the bladder. When all is ready for the incision, and the 
 staff is in position, the surgeon should examine, by rectum, for staff, prostate 
 and ischial tuberosities — and then change gloves. 
 
 Landmarks. — Central tendinous point of perineum; median raphe; anus; 
 ischial tuberosities. 
 
 Incision. — From a point about 8 mm. ($ inch) to left of median raphe and 
 just posterior to the central tendinous point of the perineum (which is 3.2 to 3.8 
 cm., or 1 \ to 1^ inches, anterior to the adult anus) — to a point between the 
 ischial tuberosity and the posterior portion of the anus, and one-third nearer the 
 
 Fig. 805.— Surface View of Perineum and Ischiorectal Regions: — Superficial structures 
 are seen on right, and deep on left. A, Incision for lateral perineal cystotomy ; B, Incision for median 
 perineal cystotomy ; C, Bulb; D, Membranous urethra ; E, Prostate gland ; F, Vas deferens, vesicula 
 seminalis, and base of bladder ; G, Internal pudic artery ; H, Superficial perineal vessels and nerves ; 
 I, Hemorrhoidal vessels and nerves ; J, Anus. (Modified from Gray.) 
 
 tuberosity than the anus (according to others, midway between the tuberosity 
 and the anus) — making a total incision of from 5 to 7.5 cm. (2 to 3 inches). 
 (See Fig. 804. A, and Fig. 805, A.) 
 
 Operation. — (1) With the staff in the first of the positions indicated above, 
 the superficial incision is made in the form of a thrust — the operator steadying 
 the perineal tissues with his left fingers — and directing the point of his knife at 
 a right angle to the perineum, with its back uppermost, enters its point at the 
 upper limit of the above incision — and aims directly for the groove upon the 
 lateral aspect of the staff, but does not attempt to actually reach it, though he 
 may do so and enter it at once. The incision is made as the knife is withdrawn, 
 following the above line of incision — is about 7.5 cm. (3 inches) in length, and 
 grows less deep as it passes backward and outward. The structures cut in the 
 superficial incision are, in order — integument; superficial and deep layers of 
 
LATERAL PERINEAL CYSTOTOMY. hoi 
 
 superficial fascia; transversus perinasi muscle; transverse perineal artery, veins, 
 and nerves; lower margin of superficial layer of triangular ligament; hemor- 
 rhoidal vessels and nerves. (2) With the staff now in the second one of the 
 positions indicated above, the left index is introduced into the upper angle of 
 the wound and feels for the staff — and, with this finger held in position as a 
 guide, with the nail turned so that it enters the groove, or is directly over it, the 
 knife is passed, with the back of the blade uppermost, along the back of the 
 forefinger and nail straight into the groove — either the knife with which the 
 superficial incision was made, or a special probe-pointed lithotomy knife. 
 The point of the knife having been well engaged in the groove of the 
 staff, the second or deep incision is now made — by pushing the knife down- 
 ward and backward, depressing the handle as the knife goes forward to pre- 
 vent its leaving the groove, the point kept constantly in the groove, and the 
 
 Fig. 806.— Sectional View of Perineal and Pelvic Regions:— The knife is seen passing 
 through the perineal structures, and incising the membranous urethra between the bulb, in front, and 
 the prostate gland, behind. (Modified from Gray. ) 
 
 sides of the knife parallel with the edges of the now deep wound, and inclined 
 to the left— until the lower end of the knife passes through the prostate gland 
 and neck of the bladder — as evidenced by a gush of urine. The deep opening 
 into the bladder is then enlarged to the extent considered necessary by bearing 
 gently upon the cutting end as the knife is withdrawn — and ceasing to use pres- 
 sure, and, therefore, cutting force, as the knife reaches the more superficial 
 planes of the wound. The structures cut in the deep incision, are, in order- 
 membranous and prostatic parts of the urethra; superior or deep layer of tri- 
 angular ligament; compressor urethra? muscle; anterior portion of levator ani 
 muscle; left lateral lobe of prostate gland. The incision through the urethra 
 and prostate will be from near the median line obliquely backward and out- 
 ward (Fig. 806). (3) In the case of a stone, the lithotomy forceps are intro- 
 
no2 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 duced closed, along the finger in the bladder as a guide, preceded or not by the 
 dilatation of the bladder, as indicated — and the stone is grasped and removed, 
 aided or not by the fingers in the bladder. (4) The interior of the bladder may 
 be then irrigated — if debris or other cause call for it. (5) A perineal lithotomy 
 drainage-tube is inserted — and the wound left open, or closed only at its ex- 
 treme ends by suture. 
 
 Comment. — (1) Where the calculus is lodged behind an enlarged pros- 
 tate gland, or held by the bladder-walls in some unusual position, or embed- 
 ded, special manipulations of the lithotomy forceps is necessary. (2) Large 
 stones may be broken by the lithoclast and removed in pieces. (3) Contra- 
 indications to lateral perineal cystotomy for the removal of stone, are — a large 
 stone; enlarged prostate, and deep perineum — under which circumstances a 
 suprapubic cystotomy would be done. (4) Hemorrhage during the steps of 
 the operation is controlled by ligature, clamping, pressure, and hot douching. 
 (5) Avoid cutting the bulb and its artery in front — the rectum behind — and the 
 pudic artery laterally. (6) Incision too far posteriorly will cut the ejaculatory 
 ducts. (7) Draw the penis well up over the staff as the deep cut is made — so 
 as to pull the bulb up. (8) Incision through the neck of the bladder should not 
 exceed about 2 cm. (f inch). (9) Stick to the groove in the staff, after once 
 reaching it. (10) Some difficulties, peculiar to the smallness of the parts, are 
 encountered in lateral lithotomy upon children. 
 
 MEDIAN PERINEAL CYSTOTOMY 
 
 FOR REMOVAL OF VESICAL CALCULUS. 
 
 Description. — Incision of bladder through median perineal region — 
 generally performed for the removal of calculi. The operation is sometimes 
 less correctly called Median Lithotomy. The bladder is reached by incising 
 through the apex of the prostate gland and the membranous portion of the 
 urethra. A less free and extensive opening is thus given than by either the 
 suprapubic or lateral perineal cystotomy. Resorted to, especially formerly, 
 for small calculi — which are generally now treated by litholapaxy. The 
 special instruments required are: — a medially grooved lithotomy-staff, and a 
 long, narrow, straight knife with a double cutting-point. The advantages of 
 the median over the lateral cystotomy are the following: — smaller wound; less 
 hemorrhage; quicker healing. There is better drainage than in the supra- 
 pubic operation. The disadvantages are: — that only small calculi can be 
 removed — and that the bulb of the corpus spongiosum and rectum are more 
 apt to be injured. 
 
 Preparation. — As for lateral perineal cystotomy. 
 
 Position. — As for lateral perineal cystotomy. The medially grooved staff 
 is held as in the second position assumed in lateral perineal cystotomy (see 
 page 1099). 
 
 Landmarks. — Central tendinous point of perineum; median raphe; anus. 
 (See Fig. 804, B, and Fig. 805, B.) 
 
 Incision. — Begins at a point about 1.3 cm. (^ inch) anterior to the anus, 
 in the median raphe — and extends upward for 2.5 cm. (1 inch). 
 
 Operation. — (1) The operator puts his left gloved index-finger into the 
 rectum and presses it against the staff, which has already been inserted and 
 held as just mentioned — pressing against the staff at the apex of the prostate 
 gland — thereby steadying and recognizing the deep relations, guarding the 
 rectum, and following the penetration of the knife. (2) The long, narrow, 
 
CVSTORRHAPHV. 
 
 1103 
 
 double-edged knife, with the main cutting-edge upward, held at a right angle 
 to the perineum, is first thrust directly inward and made to at once strike and 
 enter the grooved staff at the apex of the prostate, passing through the apex of 
 the gland itself where the finger steadies it within the rectum. The knife is 
 then made to cut upward in the groove of the staff — and, in the act of with- 
 drawal, makes a wound in the soft parts of about 2.5 cm. (1 inch) — depressing 
 the handle of the knife in cutting the urethra and elevating it in cutting the 
 superficial parts, — incising the following structures: — integument; both layers 
 of superficial fascia; anterior portion of external sphincter ani; central ten- 
 dinous point of perineum; lower margin of triangular ligament; membranous 
 urethra ; compressor urethra' ; apex of prostate gland. (3) As the knife is with- 
 drawn, the index-finger is introduced into the bladder directly upon the original 
 staff — or such an instrument as a Little's director is introduced upon the staff 
 through the perineal wound and the original staff then removed — and the 
 finger introduced upon the second director through the neck of the bladder, 
 which is often entered with difficulty. The bladder cavity is thus examined 
 through the original wound — or the opening through the neck of the bladder 
 may be first dilated, if necessary. (4) The special object of the operation is 
 then accomplished in the same manner as described under the lateral perineal 
 cystotomy. (5) In completing the operation, a perineal lithotomy drainage- 
 tube is not usually used — the wound being simply left open — protected by a 
 thick perineal dressing. 
 
 CYSTORRHAPHY. 
 
 Description. — Suturing of bladder. Indications: — following cystotomy 
 operations (the suprapubic only) ; wounds, occurring during operation or at 
 other times; rupture of the organ; etc. 
 The peritoneal or non-peritoneal aspects 
 of the bladder may be involved — or both. 
 
 Operation. — The wound may be con- 
 nected with any of the conditions men- 
 tioned above. The exposure of the wound, 
 therefore, will be determined by the nature 
 of the incision or injury. It will involve 
 either the peritoneal or the non-peritoneal 
 region of the bladder — or may involve 
 both. The same form of suturing is used, 
 whether peritoneal or non-peritoneal sur- 
 face be the site of operation. Several 
 methods of approximating the edges are 
 in use: — (a) The margins of the bladder- 
 wound are brought together and carefully 
 adjusted by means of a single tier of fine 
 chromic gut, interrupted or continuous. 
 carried upon a curved needle, and passing 
 through all the coats except the mucous, 
 (b) The mucous membrane may be first 
 united by interrupted or continuous gut 
 suture — followed by the approximation of 
 the outer coats by the stitch just described 
 
 under "a," either fine gut or silk being used, (c) By interrupted chromic 
 gut Lembert sutures passing through the outer coats only, extending slightly 
 
 Fig. S07. — Cystorrhaphy : — First 
 tier of sutures passes through outei coats 
 and involves edges of bladder-wound 
 (shown in upper sutures). Second tier 
 consists of Lemberts through outer coats 
 (shown in lower sutures-— which are here 
 also seen burying in the first tier). 
 
no4 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 beyond the wound at both ends. In the case of the peritoneal surface of 
 the bladder, the serosae adhere and unite. In the case of the non-peritoneal 
 surface of the bladder, the raw connective tissue covering the surface unites, 
 (d) By a combination of method "a" as a first tier — followed by method "c," 
 as a second tier. (Fig. 807.) 
 
 Comment. — (1) Method "a" is probably the best — or method "b." (2) 
 Gut should always be used in sutures passing through the mucous membrane. 
 (3) In no form of suturing should the mucous membrane be included in a 
 suture which, at the same time, will pass through the other coats. (4) If the 
 circumstances of the wound and the technic of closure be such as to make the 
 operator feel confident of result, the external wound may be closed as usual. 
 In all cases of doubt — and the safest in all cases — the external wound may be 
 closed in greater part — and temporary drainage be carried down to the bladder 
 wound. (5) The bladder may be drained by the catheter for two or three 
 days — to avoid distention of the organ and strain upon the sutures. 
 
 LITHOTRITY. 
 
 Description. — Crushing of vesical calculi at one or several intermittent 
 sittings (from seven or eight, to three or four days apart) without general 
 anesthesia — the debris of the stone being left to be evacuated by nature's 
 efforts. The instrument used is an ordinary lithotrite — and the manner of 
 using it is the same as in Litholapaxy, except no evacuator follows its use. The 
 patient rests in bed, or may even remain up, while the disturbance of each 
 sitting is passing by. The operation is now almost obsolete. 
 
 LITHOLAPAXY. 
 
 Description. — Crushing of vesical calculi and recrushing of the resulting 
 fragments, followed by removal of the debris by irrigation, at one sitting, under 
 general anesthesia. The crushing and removing are accomplished by special 
 instruments — the lithotrite and evacuator. 
 
 Preparation. — Presence of stone verified by sound; bowels emptied; blad- 
 der and urethra in an aseptic condition and bladder moderately distended with 
 a sterile fluid (about 4 or 5 ounces). 
 
 Position. — Patient supine, with buttocks well raised by support, to cause 
 the gravitation of the stone to the fundus of the bladder — resting near the right 
 edge of the table, with thighs separated. Surgeon stands upon the patient's 
 right. Assistant opposite. 
 
 Operation. — (1) The lithotrite, with closed blades, is introduced into the 
 bladder just as a sound would be — with the modification required by the 
 straighter instrument more abruptly curved near its end — that is, when the 
 bulbous portion of the urethra is reached, the handle of the lithotrite, instead 
 of being at once depressed (which would cause the point of the instrument to 
 hook against the roof of the bulbous urethra in front of the triangular ligament), 
 is held upright, so as to allow its more sharply curved point to gravitate be- 
 neath the triangular ligament and glide into the membranous urethra and 
 reach the prostate — and then only is the handle depressed, and slightly twisted 
 from side to side, causing the tip to ride up through the prostatic urethra into 
 the bladder — and glide along the trigone to the posterior wall of the organ. (2) 
 Slow, methodical movement in the opening and closing of the blades, with a 
 
LITHOLAPAXY. 1105 
 
 pause between each movement — together with a systematic search of the blad- 
 der cavity, should be the method adopted. Hurried movements cause bladder- 
 currents, which generally keep the stone moving and make the grasping of the 
 calculus difficult. Irregular, random movements in directing the grasping 
 blades of the instrument are unsurgical and generally futile. The instrument 
 mav encounter the stone immediately — and, if so, its position may be indicated 
 and the blades opened for its seizure. If not, as the instrument rests quietly in 
 the middle line of the base of the bladder, and steadily held in the one position, 
 its blades are 'separated (by withdrawal of the male blade) — then followed by a 
 few seconds' cessation of all movements (to allow stone to gravitate into the 
 grasp of the instrument) — succeeded by a gentle screwing back of the male 
 blade (the instrument being kept steadily, immovably in one position) — when 
 
 Fig.808.— Litholapaxv IN thk Male: — The lithotrite in position. 
 
 the stone will often be felt in the grasp of the separated blades. "Open — 
 pause — close" is the formula of movement. If unsuccessful, open again — ■ 
 turn blades to right side, through an angle of 45 degrees ("right oblique"), still 
 keeping the instrument in the median line — close. . Or turn it, from a vertical 
 plane, through an angle of 45 degrees to the left ("left oblique") — open — close. 
 Thus the instrument may pass from the vertical to a right or left oblique, or a 
 right or left horizontal. It is better to open the blades before turning — as the 
 stone may be pushed away by an opening blade. Depress the handle, keeping 
 in the middle line or turning laterally — thus examining the anterior wall and 
 sides of the bladder. Reverse the direction of the blades, so that they point 
 downward, especially where the prostate is enlarged — and examine the floor of 
 the bladder and behind the prostate gland — assuming the positions of reversed 
 vertical, reversed right and left horizontal, and reversed right and left oblique. 
 
no6 
 
 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 Thus the entire cavity of the bladder is systematically searched. (3) Having 
 grasped a calculus, the male blade is steadily and slowly screwed down into the 
 female blade — until the stone is felt to break into two or more pieces. After 
 pausing a moment, the blades are opened, kept quietly apart a few seconds, 
 then closed — when probably several of the. fragments will be caught and further 
 crushed. This is repeated until the debris are considered to be fine enough to 
 come through the tube of the evacuator. The blades of the lithotrite are then 
 closely approximated while in the bladder and the instrument is withdrawn. 
 (Fig. 808.) (4) The tube of the evacuator is then introduced into the bladder 
 
 Fig. 809.— Litholapaxy in the Male :—The evacuator in position. 
 
 and the urine or other fluid of the bladder is in part withdrawn. The opening 
 of the evacuator lies in the lowest part of the fundus of the bladder — so as to 
 catch the gravitating stones. The bulb of the evacuator is then filled with 
 warm boric acid solution and attached to the evacuator-tube. While the left 
 hand steadies the rigid tube in the bladder, the right hand compresses the bulb 
 and throws a part of its contents into the bladder (about 2 or 3 ounces). On 
 relaxing the bulb, as much fluid as was thrown in is drawn out again (so that 
 the original amount always remains in), and, with it, more or less of the debris 
 of stone are brought out in the outflowing current. Wait a few moments and 
 
LITHOLAPAXV 
 
 1107 
 
 then repeat the evacuating process — until all debris seem to have come away. 
 If too large a fragment remains for evacuation, as determined by its ineffectual 
 clicking against the evacuator, the lithotrite must be again introduced, the 
 stone recrushed, and the evacuator reintroduced and the debris further re- 
 moved. Removal of all debris is generally determined by the absence of 
 clicking — which is often heard at a distance, but is generally to be detected by 
 the ear placed near the bladder — and by the coming away of perfectly clear 
 and clean water. The bladder may be finally irrigated — and the evacuator 
 withdrawn (Fig. 809), (5) The patient is generally kept quietly in bed for a 
 few days. 
 
 Comment. — (1) Avoid grasping the mucous membrane of the bladder in 
 the instrument, the construction of which usually makes it impossible or diffi- 
 
 Fig. 810— Litholapaxy in the Female :— The lithotrite in position. 
 
 cult. At any rate, before finally forcibly closing the blades, always shift the 
 blades, so as to feel that they are free and have not included the bladder-wall. 
 (2) In evacuating debris, the bladder should not be allowed to get empty of 
 fluid — as the walls of the organ would have a tendency to be drawn into the 
 evacuator by suction. (3) If air enter the bladder, depress the handle of the 
 evacuator so as to raise its tip above the level of the bladder fluid, and suck the 
 air out with the bulb. (4) If the instrument clogs and cannot, by persistent 
 though gentle effort, be freed, it must be exposed and cleared through a supra- 
 pubic cystotomy. (5) Only a lithotrite with fenestrated blade should be used, 
 thus lessening the chances of clogging. (6) It may be necessary to slightly 
 incise the urinary meatus in order to get the beak of the instrument to enter the 
 urethra. (7) Instruments of special size, as well as particular care, are neces- 
 
no8 OPERATIONS UPON THE ABDOMINO-PELVIC REGION. 
 
 sary in operating upon children. (8) Litholapaxy in women is much more 
 easily performed than in men, because of the shorter, larger urethra (Fig. 810). 
 (9) A simple instrument has been devised for combined crushing and evacua- 
 tion bv Chismore. 
 
 VESICAL DRAINAGE. 
 
 Description. — By vesical drainage is meant the drainage of the bladder 
 contents through a natural or an artificial channel. While the bladder is being 
 drained for consecutive days, daily irrigations with aseptic or mildly antiseptic 
 solutions may be used. Where the bladder cavity is made directly continuous 
 with the suprapubic or perineal regions, suprapubic or perineal cystotomy may 
 be said to be done. Bladder drainage may be urethral, perineal, or supra- 
 pubic. 
 
 Urethral Bladder Drainage. — Consists in drainage by a soft catheter 
 passed through the urethra into the bladder. Indicated for only brief drainage 
 — not over three or four days, the usual limit of bladder toleration. A soft 
 catheter is introduced until its eye has just entered the bladder, which is as- 
 certained by withdrawing the catheter and retaining it in the position in which 
 it was just before cessation of flow. Various devices are used for holding the 
 catheter in the urethra. A 1 cm. (or h inch) widtli of rubber-plaster may be 
 passed three-fourths of the way around the penis (to allow of expansion of the 
 organ) just behind the corona, and to this the tube may be tied by silk suture 
 passed with-a needle through the outer wall of the tube and upper border of the 
 plaster band. 
 
 Perineal Bladder Drainage. — Consists in drainage of the bladder through 
 the perineum by means of a tube, or through the bare wound resulting from 
 perineal cystotomy. Indicated, chiefly, in operations upon the bladder by the 
 perineal route, and in cases of impervious urethra. Where the drainage is the 
 primary consideration (as in aggravated cystitis and in other conditions of 
 prostate, bladder or urethra) tire membranous urethra is opened by median 
 perineal incision, just as in external urethrotomy (page 1123) — the catheter is 
 carried through the prostatic urethra into the bladder, until its eye rests just 
 within the bladder-cavity — and is then fastened to a T-bandage by a silk suture 
 carried on a needle through the outer wall of the catheter. A long rubber tube 
 is then connected with the catheter and carried to a bottle at the foot of, or 
 under, the bed, and drains by siphonage. 
 
 Suprapubic Bladder Drainage. — Consists in drainage of the bladder 
 through a suprapubic cystotomy wound. Indicated in some operations upon 
 the bladder, aggravated cystitis, etc. The drainage may be accomplished by 
 simple siphonage by catheter — or by various devices, some mechanical, and 
 others by methods of suturing, (a) By Siphonage Tube ordinarily Sutured 
 into the Bladder: — Following the suprapubic cystotomy, a pliable rubber tube, 
 with large eye, is introduced through the bladder-wound, which has been partly 
 closed from both ends — and so adjusted that its lower end barely reaches the 
 lowest part of the bladder-cavity but does not press upon it. A safety-pin 
 passed through its outer wall, at the skin level, rests transversely across the lips 
 of the partially sutured wound and maintains the fixed depth of the tube. A 
 large gauze-pad, with central perforation, is then placed around the tube, and 
 a second safety-pin passed in just above the second pad to steady the tube. 
 The free end is connected with a rubber tube, emptying into some reservoir for 
 drainage. Where much hemorrhage is expected, or, for other reason, irriga- 
 tion is needed, two parallel tubes may be used — one serving the above purpose, 
 
PARTIAL CYSTECTOMY 
 
 1 109 
 
 and the other being used for throwing irrigating fluid into the bladder, which 
 then siphons out by the first tube, (b) By Siphonage through a Tube in- 
 troduced by Gibson's Method: — This is an application of the Kader Gastros- 
 tomy method to the bladder (see page 964). The bladder -wall is exposed as 
 in the suprapubic cystotomy — an opening is made in the middle line of the 
 bladder sufficiently large to admit the tube 
 snugly — in the median line, in front and be- 
 hind the tube, a Lembert suture of chromic 
 gut is placed so as to closely embrace the 
 tube. These sutures form the first tier. 
 Then, a second tier of four sutures, two in 
 front and two behind, is applied. (If neces- 
 sary, a third tier might be used.) The 
 tube is thus buried in — in a valve-like man- 
 ner — so that when the tube is removed, the 
 opening is closed by the tendency of the 
 folds — and can be again readily re-intro- 
 duced. A long tube is attached to this for 
 siphonage and conducted to a reservoir, as in 
 the other methods (Fig. 811). 
 
 PARTIAL CYSTECTOMY. 
 
 Description. — Removal of a limited por- 
 tion of the bladder. Generally performed 
 for the removal of a tumor involving a part 
 of the bladder-wall. The site of the tumor 
 may be extraperitoneal or intraperitoneal — 
 or both. 
 
 Operation. — The general features of the 
 operation may be gotten from the description 
 of the total removal of the bladder. The 
 steps of the partial removal will depend upon the site of the growth demand- 
 ing partial cystectomy. (1) When the tumor is upon the upper part of the 
 bladder and the peritoneum can be pushed back, the involved portion of the 
 bladder-wall is excised with scissors — and the lips of the wound then brought 
 together and sutured (see Cystorrhaphy). (2) When the tumor is similarly 
 placed but its removal involves the opening of the peritoneal cavity — the 
 peritoneal wound is closed by suture and the bladder-wound dealt with as 
 just described. (3) If the tumor be above the ureters, upon the posterior 
 aspect of the bladder, it may be exposed through a suprapubic cystotomy and 
 removed from within the bladder, followed by the approximation and suturing 
 of the edges of the wound left and the establishment of drainage. (4) When 
 the area involved lies upon the anterior bladder-wall, behind the symphysis, 
 partial resection of the symphysis, or symphysiotomy, may be necessary. 
 (5) If the involvement be at the mouth of a ureter, the site should be ex- 
 cised — the healthy ureter, after excision of its vesical end, should be implanted 
 into a neighboring part of the bladder — and the wound made by the original 
 excision closed. (6) Where the base of the bladder is involved and the open- 
 ings of the ureters are healthy, these should be excised, en masse, and trans- 
 planted into the rectum — and the bladder removed. Following all partial ex- 
 cisions, the remainder of the bladder-walls should be brought together by 
 
 Fig. 8 1 1. — Suprapubic Bladder- 
 drainage (Gibson's Method) : — The 
 first tier of sutures are shown tied. 
 The second tier are placed ready to be 
 tied and further bury in the tube. The 
 remaining structures are same as given 
 in Fig. 519. 
 
I no OPERATIONS UPON THE ABDOMTNO-PELVIC REGION. 
 
 suture — temporary drainage established down to the sutured bladder — and 
 a catheter introduced into the bladder for drainage, and to prevent overdisten- 
 tion and tension upon the sutures. 
 
 TOTAL CYSTECTOMY 
 
 BY SUPRAPUBIC MEDIAN VERTICAL AND TRANSVERSE INCISIONS. 
 
 Description. — Complete excision of the bladder, followed by implantation 
 of the ureters. Indicated in malignant disease limited to the bladder. The 
 operation as performed by Tuffier and Dujarier will be here described — con- 
 sisting in an extraperitoneal abdominal excision of the bladder, followed by an 
 implantation of the ureters in the sigmoid colon. 
 
 Preparation. — Bowels emptied; pubes shaved; bladder distended with 
 aseptic fluid at an early stage of the operation. 
 
 Position. — Patient in the Trendelenburg position, near the edge of the 
 table. Surgeon on patient's left. Assistant opposite. 
 
 Landmarks. — Median line; symphysis pubis; inguinal canals. 
 
 Incision. — _L-shaped — the vertical incision is made in the median line, 
 beginning at the symphysis pubis and passing upward for 10 to 12.5 cm. (4 to 5 
 inches). The transverse incision unites the inguinal canals, along the supra- 
 pubic border, to the vertical incision. 
 
 Operation. — (1) Incise vertically carefully in the median line, especially 
 over the position of the peritoneum. Expose the bladder and the reflection 
 of peritoneum — pushing the latter upward well off of the bladder. Clamp and 
 tie all bleeding vessels. (2) Make the horizontal incision from one inguinal 
 canal to the opposite, just above the border of the pubic bone and Poupart's 
 ligament. Clamp or tie bleeding vessels in this line of incision. Dissect up 
 the rectangular flaps thus outlined — and retract them upward and outward on 
 both sides — thus giving free access to the bladder. (3) Separate the anterior 
 aspect of the bladder from the pubis, down to its neck, by blunt dissection — ex- 
 posing and isolating its neck — moderate traction being exercised upon the 
 anterior and lateral walls by vulsella. (4) The neck of the bladder is clamped 
 and divided above the clamps. (5) The peritoneum is carefully peeled off of 
 the superior, posterior, and lateral aspects of the bladder, avoiding making any 
 opening into the peritoneal cavity. (6) The inferior vesical arteries and 
 ureters are secured close to the bladder, in curved clamps, and divided en masse. 
 (7) The base of the bladder is separated from its remaining connections and 
 the viscus removed. (8) The urethral and the ureteral openings are cau- 
 terized. (9) The vesical arteries are tied and the clamps relaxed. (10) The 
 ureters are implanted within the sigmoid colon, (n) The deep wound is 
 packed with gauze — drainage being brought out just over the symphysis pubis 
 — all of the transverse and most of the vertical incisions being sutured. 
 
 Comment. — (1) Avoid opening the peritoneum if possible — and, if opened, 
 suture at once — or, if the opening be too large, pack with gauze. (2) The 
 authors, Tufher and Dujarier, made the uretero-sigmoidostomy with Chalot's 
 buttons. Fowler's method (page 870) may also be used. 
 
CHAPTER VI. 
 
 OPERATIONS UPON THE MALE GENITAL 
 ORGANS. 
 
 I. THE PENIS. 
 
 SURGICAL ANATOMY. 
 
 Description. — Consists of glans, body, and root. Body is composed of 
 two corpora cavernosa and the corpus spongiosum. 
 
 Corpora Cavernosa. — Connected, side by side, in the median line, for 
 their anterior three-fourths — an imperfect fibrous septum intervening. Sep- 
 arated, posteriorly, to form the crura, or roots. The crura are attached by 
 their blunt, fibrous, posterior ends to the antero-internal aspects of the two 
 rami of the pubes and ischia, above the tuberosities. The anterior ends of the 
 cavernosa are received into the fossa formed by the base of the glans penis, or 
 head. The superior median groove of the corpora cavernosa lodges the dorsal 
 vein of the penis. The inferior median groove lodges the corpus spongiosum. 
 
 Corpus Spongiosum. — Encloses the urethra, which passes into the bulb 
 nearer its superior aspect. It is received into the inferior median groove of the 
 corpora cavernosa. It ends, anteriorly, in the glans penis, or head of the 
 organ. It ends, posteriorly, in the bulb of the corpus spongiosum — between 
 the diverging crura of the corpora cavernosa, and between the deep layer of the 
 superficial fascia and the superficial layer of the deep fascia — being covered by 
 a fibrous process from the anterior layer of the deep perineal fascia and sur- 
 rounded by the accelerator urinae muscle. 
 
 Suspensory Ligament of the Penis. — A fibrous band passing from the 
 front of the symphysis pubis to the adjacent portion of the penis, merging with 
 its fascial sheath. 
 
 Muscles of Penis. — Erector penis; accelerator urina?; compressor ure- 
 thra?; transversus perinrei. 
 
 Arteries. — (a) Of the corpora cavernosa: — arteries of the corpora caver- 
 nosa; dorsal arteries of the penis. All from internal pudic. (b) Of the corpus 
 spongiosum: — artery of the bulb, from internal pudic. 
 
 Veins. — Some of the veins empty into the dorsal vein, which ends in the 
 prostatic plexus. Other veins empty directly into the prostatic plexus, pudic 
 plexus, pudic veins, and obturator veins. Others empty into the cutaneous 
 veins of the penis and scrotum. 
 
 Lymphatics. — The superficial empty into the inguinal glands. The deep 
 empty into the pelvic glands. 
 
 Nerves. — From the dorsal and superficial perineal branches of the pudic 
 and from the hypogastric plexus of the sympathetic. 
 
 INSTRUMENTS. 
 
 Scalpels; narrow, straight bistoury; scissors; retractors; tenacula; dissecting 
 and toothed forceps; artery-clamp forceps; blunt dissector; periosteal elevator; 
 
ii 12 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 rubber tourniquet (rubber catheter); needles, straight and curved; needle- 
 holder; ligatures and sutures, silk and gut. 
 
 CIRCUMCISION. 
 
 Description. — Removal of greater portion of redundant or contracted pre- 
 puce. The amount of foreskin to be removed should be so calculated that 
 two objects be accomplished: — first, that enough foreskin be removed to insure 
 easy exposure of the entire glans penis, even during erection; — secondly, that 
 enough foreskin be left to insure constant covering of the prominent corona 
 glandis during relaxation of the organ, thereby securing retention of greater 
 
 sensitiveness of the papillae 
 than when the corona is 
 worn constantly bare, and, 
 therefore, dry. Many me- 
 chanical contrivances have 
 been devised for aiding in 
 circumcision — but the oper- 
 ation can generally be more 
 satisfactorily done with scis- 
 sors alone — and, by this 
 means, greater accuracy is 
 usually obtained in provid- 
 ing the exact amount of pre- 
 puce which it is well to leave. 
 Preparation. — A con- 
 strictor, usually a rubber 
 band, is applied around the 
 base of the penis. 
 
 Position. — Patient su- 
 pine, near the left edge of 
 table. Surgeon on patient's 
 right. 
 
 Landmarks. — Position 
 of sulcus at junction of head 
 and body of organ. 
 
 Operation. — (i) As 
 there will be a much 
 greater tendency for the 
 skin-aspect of the prepuce 
 to retract more than for the 
 mucous-membrane-aspect, it 
 is well, in all methods of cir- 
 cumcision, as a preliminary 
 step to the actual division 
 of preputial tissue, to take the skin and mucous surfaces of the foreskin be- 
 tween the left index and thumb (or between the blades of a pair of toothed 
 forceps) and so dispose the parts that the mucous membrane is drawn slightly 
 forward and the skin pushed slightly backward— so that there will be somewhat 
 less disparity when the section is made. (2) Taking the foreskin in the left 
 fingers, the surgeon inserts the lower blade of a pair of straight scissors beneath 
 the upper aspect of the foreskin, between it and the dorsum of the glans— and 
 
 Fig. 812. — Circumcision :— I. Scissor-blade between 
 glans and prepuce, cutting foreskin in median dorsal line 
 up to level of its removal. 
 
CIRCUMCISION. 
 
 1113 
 
 cuts through the prepuce with one stroke, up to the height upon the dorsum 
 which it has been calculated will leave sufficient prepuce to cover the corona 
 during relaxation of the organ (Fig. 812). (3) The scissors are then with- 
 drawn from the vertical incision — and the position of the hands then changes. 
 The left fingers grasp the left flap, the one nearer the surgeon, and, holding it 
 slightly away from the glans, the scissors are made to cut through one-half of 
 the circumference of the organ — the guide for the cut being that it should pass 
 about parallel with the corona glandis, crossing the median line upon the under 
 aspect of the prepuce just in front of (distal to) the fraenum (Fig. 813). (4) 
 The right flap is now dealt 
 with in the same manner — 
 completing the encircling 
 of the organ. The incision 
 will, therefore, slope ob- 
 liquely from above down- 
 ward and from behind for- 
 ward. (5) Four primary 
 chromic gut sutures are 
 then applied in the mid- 
 points — above, below and 
 laterally — closely approxi- 
 mating the margin of mu- 
 cous membrane to the 
 margin of skin. These are 
 followed by four or eight 
 secondary sutures evenly 
 distributed between the 
 primary ones (Fig. 814). 
 (6) The dressing is so ap- 
 plied as to leave an opening 
 for urination. 
 
 Comment. — (1) The 
 usual error is to remove 
 too much foreskin. A pre- 
 puce, appearing to be suffi- 
 cient after the completing 
 of the operation, often gets 
 entirely and permanently 
 behind the corona in sub- 
 sequent retraction — at the 
 expense of considerable 
 loss of sensitiveness of the 
 papillae. (2) If any ques- 
 tion arise, during opera- 
 tion, as to the width of the 
 
 opening being too narrow, the vertical incision may be extended upward ad- 
 ditionally high — the lateral incisions then being sloped downward so as to 
 come just in front of the fraenum. (3) The redundancy of the mucous mem- 
 brane is apt to be much greater than that of the skin. (4) In using all forms 
 of circumcision-clamps too much or too little prepuce is apt to be cut away. 
 (5) If the penis is to have a preliminary constrictor applied, which would 
 tend to draw back the foreskin into a somewhat unnatural position, greater 
 accuracy in measurements may be obtained by first (before applying toumi- 
 
 si.3- 
 
 -Circumcision :— II. Division of the entire thick- 
 ness of the prepuce transversely, at the upper limit of the 
 median incision. While the entire redundant portion of pre- 
 puce is being drawn downward, the left thumb and index so 
 manipulate the parts that more of the mucous membrane than 
 of the skin is removed. 
 
iii4 
 
 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 quet) marking the site at which the removal is desired with a nitrate of silver 
 stain. (6) Sometimes one or more vessels have to be twisted or gut-ligatured. 
 
 (7) Do not leave too great an amount 
 of tissue near the fra^num. (8) It may 
 be necessary, before suturing, to trim the 
 edges somewhat with scissors, especially 
 of the mucous membrane. (9) Where 
 there is firm adhesion between prepuce 
 and glans, especially in children, the pre- 
 puce must be carefully peeled off — by 
 means of the fingers, aided by toothed 
 forceps and the flat portion of a probe. 
 (io) Often, in adherent prepuces, no in- 
 strument can be slipped up between the 
 prepuce and glans — and the opening of 
 the prepuce is too small to allow of re- 
 tracting the membrane far backward — in 
 which cases the redundant portion must 
 be put upon tension and cut off trans- 
 versely, after which the separation of ad- 
 hesions may be more easily accomplished. 
 (ii) In operating in adherent cases, re- 
 adhesion is prevented by removing an 
 excess of mucous membrane and leaving 
 a slight redundancy of skin. In com- 
 pleting the operation, the skin is sutured 
 to the very short mucous membrane — 
 and, being quite long, is doubled upon 
 itself, and the part in contact with the 
 glans eventually becomes of the nature, somewhat, of mucous membrane. 
 
 Fig. 814.— Circumcision : — III. Plac- 
 ing of interrupted sutures — which approxi- 
 mate the free edge of the skin (A) to the 
 free edge of the mucous membrane (B). 
 
 PARTIAL AMPUTATION OF PENIS 
 
 BY FLAP METHOD. 
 
 Description. — Consists in the amputation of more or less of the free por- 
 tion of the penis by a long anterior and short posterior flap — the freed urethra 
 being brought through and sutured into the anterior flap. The stump is thus 
 covered by two bluntly rectangular flaps. 
 
 Preparation. — A rubber tourniquet (usually a rubber catheter) is placed 
 around the base of the organ. A short piece of soft catheter is passed into the 
 urethra, down to the tourniquet, to emphasize the furrow between the corpora 
 cavernosa and corpus spongiosum — or may be passed just before the trans- 
 fixion. 
 
 Position. — Patient supine, at edge of table. Surgeon on patient's right. 
 Assistant opposite. 
 
 Landmarks. — Line of section. Furrow between cavernosa and spongio- 
 
 Incision. — The anterior flap will have a width of one-half the circum- 
 ference of the penis at the line of division, and a length of about one diameter 
 of the penis. The posterior flap will have the same width of base, and a length 
 of about a half diameter of the penis. 
 
 Operation. — (1) Having decided upon the line of section of the penis, an 
 
PARTIAL AMPUTATION OF PENIS. 
 
 i"5 
 
 anterior or dorsal flap, of skin and connective tissue, is cut, having a width of 
 half the circumference of the organ at the line of division, and a length about 
 equal to the diameter of the organ (Fig. 815). This is raised up by dissection 
 
 Fig. 815.— Partial Amputation of Penis by Flap Method:— I. Outlining of flaps; A, Long 
 anterior flap ; B, Short posterior flap. 
 
 Fig 816 -Partial Amputation of Penis by Flap Method :— II. Transverse section of stump ; 
 A Lone anterior flap turned back, showing slit for urethra ; B. Short posterior flap; C, Dorsal vein 
 arid arteries ; D. Corpora cavernosa and vessels; E, Corpus spongiosum ; F, Urethra dissected out, 
 and ready to be sutured into slit of anterior flap. 
 
 and turned back— the dorsal arteries being tied with gut. (2) On a level with 
 the base of the anterior flap, the divisional groove between the corpora caver- 
 nosa and corpus spongiosum is recognized, aided by the soft catheter in the 
 
OPERATIONS UPON THE WALE GENITAL ORGANS. 
 
 urethra. A narrow-bladed knife, held flatwise, with back of blade backward, 
 is thrust horizontally through the organ, between the cavernosa and spongio- 
 sum — and cuts its way through, passing at first directly forward in the groove 
 and then rounding abruptly downward — thus forming an inferior flap of about 
 one-half the diameter of the penis in length, composed of corpus spongiosum, 
 with its included urethra and skin. (3) The urethra is now dissected out from 
 the small inferior flap, back to a line with the base of the flaps. (4) The cor- 
 pora cavernosa are divided transversely from within outward and upward, on a 
 
 line with the highest point 
 of transfixion (base of 
 flaps) (Fig. 816). The 
 arteries of the corpora 
 cavernosa are tied with 
 gut, or twisted. (5) Make 
 a vertical incision in the 
 center of the long anterior 
 flap, opposite the urethra 
 and just large enough to 
 receive the urethra. The 
 urethra is then drawn 
 through this opening. If 
 the urethra be much too 
 long, the redundancy is 
 cut off, leaving a protru- 
 sion of about 7 mm. (\ 
 inch) — which is slightly 
 slit above and below— and 
 sutured into the margins 
 of the opening in the ante- 
 rior flap. (6) The two 
 flaps are then united by 
 suture, both where their free ends meet — and where in apposition laterally 
 (Fig. 817). (7) A dressing is applied, leaving room for urination — at the 
 same time exercising pressure of the flap against the stump of the penis. 
 
 Comment. — The arteries of the corpus spongiosum and of the septa may 
 need ligating. 
 
 Fig. 817. — Partial Amputation of Penis by Flap 
 Method: — III. The parts sutured; A, Suture-line of flaps; 
 B, Urethra sutured into slit in long anterior flap. 
 
 TOTAL AMPUTATION OF THE PENIS. 
 
 Description. — In the total amputation the entire organ is removed, ex- 
 cept the posterior portion of the corpus spongiosum — the proximal portion of 
 the urethra being made to open in the perineum. 
 
 Preparation. — Shave pubis and perineal region. 
 
 Position. — Patient supine, at end of table, in lithotomy position. Surgeon 
 between limbs. Assistant to surgeon's right. 
 
 Landmarks. — Subpubic arch; scrotal and perineal raphe. 
 
 Incision. — The incision circularly surrounds the base of the organ, at its 
 junction with the abdominal wall — and is then continued down the median line 
 of the scrotum and into and along the median line of the perineum. 
 
 Operation.— (1) Incise the scrotal tissues exactly in the median line, from 
 che under surface of the penis, at its junction with the scrotum, to and into the 
 perineum. Separate the two scrotal sacs by blunt dissection, until the corpus 
 spongiosum is reached. All bleeding vessels are clamped and ligated as en- 
 
TOTAL AMPUTATION OF THE PENIS. 1117 
 
 countered. If a metallic sound be previously introduced through the urethra, 
 the incision and subsequent dissection are made easier (Fig. 818). (2) If a 
 sound have not been previously introduced, a large-sized metallic sound is now- 
 passed through the urethra up to the triangular ligament, to aid in defining the 
 corpus spongiosum. The corpus spongiosum is then dissected out until free 
 in its entire circumference. The sound is then withdrawn — and the spongy 
 urethra is divided well in front of the triangular ligament — and the proximal 
 end of the spongy urethra is then freed back to the triangular ligament. (3) 
 Carry the upper end of the vertical incision circularly around the base of the 
 
 Fig. 818.— Total Amputation ok Penis :— A, A, The two halves of scrotum split and retracted 
 outward ; B, Penis drawn downward and to one side, thus aiding separation of its crura ; C, Corpora 
 cavernosa (crura); D, Ramus of ischium; E, Periosteal elevator detaching left crus of penis from 
 ascending ramus of ischium by blunt dissection ; F, Dorsal vessels of penis divided and ligated. The 
 suspensory ligament of penis and concavity of pubic arch are seen just below; G, Distal end of 
 corpus spongiosum and urethra ; H, Proximal end of urethra dissected out and ready to be sutured 
 into perineum. 
 
 penis. Divide the suspensory ligament — and expose the corpora cavernosa. 
 (4) The corpora cavernosa are to be followed down to their attachment to the 
 rami of the pubes and ischia — and freed from their attachment chiefly bv blunt, 
 but partly by sharp, dissection. The dorsal arteries are tied after cutting 
 through the suspensory ligament, and the arteries of the corpora cavernosa 
 generally require ligation when the cavernosa are freed from the bone. Bleed- 
 ing from the vesico-prostatic plexus of veins is often considerable, and is to be 
 controlled by pressure and hot water. (5) The proximal end of the urethra is 
 now turned downward and sutured into the perineum — the mucous membrane 
 of the former being sutured to the skin of the lips of the perineal wound. If 
 necessary, the urethra may be split so as to enable its lips to be more readily 
 sutured into the perineal wound. (6) The remaining perineal and all the 
 
iii8 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 scrotal portions of the wound and the circular area formerly occupied by the 
 base of the penis, at the peno-abdominal junction, are all sutured in one straight 
 antero-posterior line with continuous silk suture. (Figs. 819 and 820.) 
 
 Fig.819.— Total Amputation of Penis : — Scrotum drawn up on to abdomen ; A, suture-line 
 uniting scrotal sacs ; B, proximal end of urethra sutured into perineum. 
 
 Fig. 820. — Same; Scrotum in normal position (patient on back); C, suture-line uniting scrotal 
 sacs ; D, interrupted sutures about to be tied, converting circular incision around base of penis into a 
 linear cicatrix continuous with scrotal suture-line. 
 
 Comment. — (1) The urethra should be so sutured into the perineum that 
 in the act of urination, in a sitting posture, the urine will not wet the scrotum. 
 (2) The early passage of the metallic sound greatly aids in the splitting of the 
 scrotum. 
 
 II. THE URETHRA. 
 SURGICAL ANATOMY. 
 (A) Male Urethra. 
 
 Description. — Extends from bladder-opening to external urinary meatus 
 — from 20.5 to 23 cm. in length (8 to 9 inches). It consists of muscular, erec- 
 tile, and mucous tissue. It is divided into prostatic, membranous, and spongy 
 portions. 
 
 Prostatic Portion. — About 3.2 cm. (ij inches) long. Passes through the 
 prostatic gland, near its upper aspect, from base to apex. The following ob- 
 jects are upon the floor of the prostatic urethra, from behind forward; — (a) 
 verumontanum, an elevation of mucous membrane in the middle line; — (b) 
 prostatic sinuses, one upon each side of the verumontanum, with the orifices 
 
THE URETHRA— GENERAL SURGICAL CONSIDERATIONS. 1119 
 
 of the prostatic ducts opening into them;— (c) sinus pocularis, a cul-de-sac 
 lying in front of verumontanum and passing backward for about 1.3 cm. 
 (J inch) into the substance of the prostate gland, beneath the central lobe;— (d) 
 openings of the two ejaculatory ducts into the orifice of the sinus pocularis. 
 
 Membranous Portion.— Portion of urethra between the two layers of 
 the triangular ligament — about 2 cm. (f inch) long upon its anterior, and 1.3 
 cm. (| inch) long upon its posterior aspect. Extends between apex of pros- 
 tate gland and posterior aspect of bulb of corpus spongiosum. Its anterior 
 surface is about 2.5 cm. (1 inch) below the pubic arch — the dorsal vessels 
 and nerves and some muscular fibers intervening. It pierces both layers 
 of the triangular ligament, receiving an investment from each. It is sur- 
 rounded by the compressor urethral muscle. 
 
 Spongy Portion.— About 15.5 cm. (6 inches) in length. Extends entire 
 length of corpus spongiosum, from bulb to external meatus. The portion 
 within the bulb is sometimes called the "bulbous urethra." The ducts of 
 Cowper's glands open upon the floor of the bulbous portion. The glands 
 of Littre open upon the mucous membrane of the penis, especially upon 
 the floor of the spongy portion. One of these, the lacuna magna, opens upon 
 the roof of the fossa' navicularis, about 2.5 cm. (1 inch) from the external 
 urinary meatus. The fossa navicularis is situated within the glans penis. 
 
 Narrowest Portions of Urethra.— At external meatus; in the mem- 
 branous portion; at the neck of the bladder. 
 
 Vessels and Nerves. — See under " Penis." 
 
 (B) Female Urethra. 
 
 Description.— About 3.2 to 3.8 cm. (i| to i| inches) in length— from 
 neck of bladder to external urinary meatus. Its diameter is about 6 mm. 
 (\ inch), undilated. It pierces the triangular ligament and is directed upward 
 and backward, with concavity slightly forward. It is surrounded anteriorly 
 and laterally by a plexus of veins (plexus of Santorini). It lies under the 
 symphysis pubis — its posterior wall being closely connected with the anterior 
 wall of the vagina. The bladder-opening lies about 2 cm. (f inch) behind the 
 center of the symphysis pubis. The external urinary meatus is a vertical 
 slit lying about 2.5 cm. (1 inch) posterior to the clitoris, just anterior to the 
 entrance of the vagina, and inferior to the lower edge of the symphysis pubis. 
 The female urethra is composed of muscular, erectile, and mucous tissue — 
 and is embraced by the compressor urethrae muscle, between the layers of the 
 triangular ligament. 
 
 Vessels and Nerves. — From the same source as those of the vagina (q. v.). 
 
 SURFACE FORM AND LANDMARKS. 
 
 The base of the triangular ligament can be felt through a thin perineum. 
 
 The membranous urethra pierces the triangular ligament about 2 cm. 
 (| inch) below the subpubic ligament — and about 2 cm. (f inch) in front of 
 the central tendinous point of the perineum. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Stricture never occurs in the prostatic urethra — and is very rare in the 
 membranous — hence one may generally count upon finding a patulous urethra 
 
H20 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 after cutting down upon that portion emerging from the apex of the prostate 
 gland. 
 
 For other general considerations, see Urethrotomy. 
 
 INSTRUMENTS. 
 
 Scalpels; bistouries; scissors; forceps, dissecting, toothed, and artery- 
 clamp; tenacula; grooved director; sounds; catheters; filiforms; tunneled 
 sounds; grooved and tunneled guides; probe-pointed scalpels; sponge-holders; 
 retractors; thread-retractors; bulbous bougies; dilating bougies; prostatic 
 catheters; medially and laterally grooved staffs; urethrotomes; Clover's 
 crutch, wristlets and anklets; gorget; urethral dilator; dilating urethrotome; 
 penis syringe; female catheters; needles, straight and curved; needle-holders; 
 ligatures and sutures, of silk and gut; silkworm-gut; drainage-tubing; gauze. 
 
 INTRODUCTION OF SOUNDS AND CATHETERS. 
 
 See Introduction of Sounds and Catheters into the Bladder, page 1094. 
 
 MEATOTOMY. 
 
 Description. — Incision of external urinary meatus. Indicated in con- 
 tracted meatus, especially in cases where it is necessary to pass a full-sized 
 instrument. 
 
 Preparation — Position. — As for Internal Urethrotomy. 
 
 Operation. — The penis is taken in the fingers of the operator's left hand 
 — the lips of the meatus are parted by the index and thumb — a probe-pointed 
 bistoury is passed just within the canal, its cutting-edge downward — and an 
 incision made, as far as necessary, downward along the median line of the 
 floor of the meatus, increasing the size of the meatus to the desired dimen- 
 sion. The lips of the wound, until healed, must be kept apart with a strip 
 of gauze. 
 
 Comment.— The operation may be done by a meatome, a special instru- 
 ment, which is inserted closed and the meatus is cut in the act of opening the 
 instrument. 
 
 URETHROTOMY IN GENERAL. 
 
 Urethrotomy consists in the incision of the urethra, generally in its long 
 axis. 
 
 Varieties of Urethrotomy. — Internal Urethrotomy and External Urethrot- 
 omy. 
 
 Internal Urethrotomy: — division of a strictured urethra from within the 
 canal, by means of a special instrument, a urethrotome, introduced into the 
 canal. Where simultaneous dilatation is indicated, a dilating urethrotome 
 is used. Internal urethrotomy is usually confined to the penile portion of 
 the organ, and the incision is generally made into the roof of the urethra. 
 
 External Urethrotomy: — division of a strictured urethra from without 
 inward. External Urethrotomy is indicated — (a) In impermeable strictures 
 anywhere and everywhere in the canal — (b) All strictures, whether permeable 
 or not, at or posterior to the subpubic urethra. 
 
 Several grades of permeability of the urethra may exist — calling for ex- 
 
INTERNAL URETHROTOMY. II2I 
 
 ternal urethrotomies of several grades of severity. These grades of stricture, 
 and the measures for their relief, are, in order :— (I) Grooved staff can be 
 passed entirely through the strictured urethra, — and, upon this, the stricture 
 is divided — constituting External Urethrotomy by Syme's Method. (2) 
 Grooved staff cannot be passed, but a filiform guide can be introduced through 
 the stricture into the bladder, and, over this guide, Gouley's grooved tunneled 
 sound can be carried down to the stricture (but not through it), — and, upon 
 this, the upper end of the stricture is exposed, and the filiform followed into 
 the bladder and the stricture thus divided — constituting External Urethrotomy 
 by Gouley's Method. (3) Grooved staff cannot be passed through stricture, 
 nor can filiform be passed through, but a grooved staff can be passed down 
 to the stricture (not through it), — and, upon this, the urethra is opened just 
 in front of the stricture, a fine grooved director passed, and the stricture 
 divided upon this — constituting External Urethrotomy by Wheelhouse's 
 Method. (4) Neither grooved staff nor filiform can be passed through the 
 stricture, the urethra being, practically, impassable to instruments of all kinds 
 — therefore no attempt is made to use any form of guide — the urethra is 
 opened, by the sense of touch and relations, posterior to the stricture and 
 immediately anterior to the prostate — constituting External Perineal Ure- 
 throtomy without a guide (Perineal Section, or Cock's Operation). 
 
 The bladder is kept partly full in all urethrotomy operations, in order 
 that entrance to it may be recognized by the escape of fluid. 
 
 For the anatomy involved in the perineal operations, see the description 
 of Median Perineal Cystotomy. 
 
 INTERNAL URETHROTOMY 
 
 BY DILATING URETHROTOME. 
 
 Description. — Division of a strictured urethra from within the urethra, 
 by means of a special instrument, a dilating urethrotome, introduced into 
 the canal. If simultaneous dilatation be not indicated, a plain urethrotome 
 may be used. Internal urethrotomy is generally confined to the penile por- 
 tion of the organ, and the incision is usually made from behind forward, upon 
 the roof of the urethra. 
 
 Preparation. — Locate the exact position of the stricture by a bulbous 
 bougie, in the following manner, — introduce the largest-sized bulbous bougie 
 which will pass the stricture — draw it back until its shoulder is felt against 
 the posterior end of the stricture — bend the free portion of the bougie at the 
 external meatus — draw the instrument outward until the bulb slips through 
 the stricture — then push it back until the tip of the bulb rests against the 
 anterior end of the stricture — then again bend the free portion of the bougie 
 at the external meatus — and withdraw the instrument entirely — when the 
 portion of the handle between the two bends will represent the extent and 
 distance of the stricture from the meatus. A more accurate means of getting 
 the desired position and extent of the stricture is accomplished by the ure- 
 thrometer. The urethra should be irrigated with a mildly antiseptic solution 
 before instrumentalization — and a cocain, or other anesthetic solution, thrown 
 into the canal. 
 
 Position. — Patient supine at edge of table. Surgeon upon left, facing 
 patient's penis. 
 
 Landmarks. — Previous data gotten from urethrometer, or bulbous bougie. 
 Known anatomy of urethra. 
 
H22 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 Operation. — The dilating urethrotome, with closed blades and concealed 
 cutting-edge, and well lubricated with aseptic lubricant, is introduced into 
 the urethra after the fashion of a sound, until the concealed cutting-edge has 
 passed directly opposite the posterior aspect of the stricture, as determined 
 by the previous measurements of the urethrometer corresponding with the 
 measurement and distances marked on the urethrotome. The dilating blades 
 ire then put upon the stretch until the strictured urethra is tensely distended 
 — then the cutting-edge, turned toward the roof of the urethra, is sprung 
 by the controlling screw in the handle — and drawn through the stricture, to 
 its anterior limit, from behind forward. (Fig. 821.) It is then caused to 
 sink below the blades — and the dilating blades again separated. If the 
 
 Fig. 821. — Internal Urethrotomy: — A dilating urethrotome is shown within the urethra — the 
 limbs of the instrument being moderately dilated — and the knife-blade sprung so as to incise roof of 
 spongy urethra anterior to the triangular ligament. 
 
 cutting has allowed of sufficient dilatation, it is not repeated — if not, while 
 the urethra is under dilatation, the blade is sprung a second time, and again 
 caused to sink — after which the dilating blades are again separated, to see 
 if sufficient dilatation has been secured, as indicated by the dial upon the 
 handle. If so, the blades are permanently closed and the instrument is 
 withdrawn. If there should be marked bleeding, a large sound, dipped in 
 sterile cold water, is passed into the urethra and the penis bound to it. 
 
 Comment. — The incision may be made from before backward — but 
 from behind forward is better. It may also be made upon more than one site 
 of the same stricture, but upon the roof generally suffices, and is safer than 
 
EXTERNAL PERINEAL URETHROTOMY 
 
 1123 
 
 upon the floor. Several strictures may be divided simultaneously. If the 
 external meatus be too small to admit the urethrotome, meatotomy should 
 be done. The subsequent passage of sounds is necessary, until healing is 
 complete — and, at intervals, for a considerable time afterward. 
 
 EXTERNAL PERINEAL URETHROTOMY 
 
 UPON GROOVED STAFF — SVME'S METHOD. 
 
 Description — A grooved staff can be passed entirely through the stric- 
 ture — and, upon this, the stricture is divided from the perineum. 
 
 Special Instruments Required. — Syme's grooved staff, or an ordinary 
 lithotomv staff of small size, grooved medially upon its convex aspect. Gorget, 
 or grooved director, for entering tHe bladder from the perineal wound. 
 
 Preparation — Position. — As for median perineal cystotomy. 
 
 Fig. 822. — External Perineal Urethrotomy: — The perineum is shown incised and retracted. 
 A Syme's shouldered, grooved staff is seen engaged within the membranous urethra — while the edge 
 of a knife is shown incising the constricted urethra upon the groove of the instrument. 
 
 Landmarks. — Median perineal line; position of grooved staff in urethra, 
 and especially the position of the stricture to be divided, as ascertained by 
 previous use of the urethrometer, and also verified by the shouldered portion 
 of the staff corresponding with the urethrometer measurements and resting 
 against the anterior end of the stricture. 
 
 Incision. — Having introduced Syme's grooved staff, or a small, centrally 
 grooved lithotomv staff, well lubricated, into the urethra and through the 
 stricture — so that its shouldered projection rests against the anterior aspect 
 
1 1 24 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 of the stricture, an incision is made in the median line of the perineum, so 
 placed that the shoulder of the staff (that is, the anterior end of the stricture) 
 will be exposed in the depth of the incision. 
 
 Operation. — (I) The steps of the operation are, practically, those of 
 median perineal cystotomy, as to structures incised and the manner of dividing 
 them. The cut is made directly toward the shoulder of the instrument — 
 the groove is entered — and, with the back of the point of the knife in the groove, 
 its cutting-edge is pushed in the direction of the neck of the bladder, until 
 the entire stricture is felt to be divided along its floor. (Fig. 822.) (2) A 
 gorget, or grooved director, is now passed along the grooved staff on into the 
 bladder — and the staff is then withdrawn. (3) A soft-rubber catheter is 
 passed through the urethra from the meatus — its end being guided through 
 the perineal wound by the operator's fingers and on into the bladder, upon 
 the grooved director, on the proximal side of the perineal gap. (4) The 
 perineal wound is allowed to heal by granulation around this catheter — 
 being left open in whole — or sutured only at the ends. 
 
 Comment. — (1) If the catheter cannot be constantly retained, a tube may 
 be carried into the bladder through the perineal wound. But an instrument 
 should be daily passed from the meatus into the bladder during healing, even 
 though a full-length instrument cannot be constantly worn. (2) An ex- 
 tensive perineal wound should be closed in part, from the ends — leaving the 
 center open for the tube and drainage. 
 
 EXTERNAL PERINEAL URETHROTOMY 
 
 UPON A FILIFORM GUIDE — GOULEY'S OPERATION. 
 
 Description. — In cases in which the grooved staff cannot be passed, and 
 only a filiform whalebone guide can be made to enter the bladder — a grooved 
 tunneled guide is carried over the filiform down to the stricture (but not 
 through it) — and, upon this tunneled guide, the upper end of the stricture 
 is exposed — and the filiform is then followed on down into the bladder and 
 the stricture divided. 
 
 Special Instruments — Filiform whalebone guides; Gouley's (or other) 
 grooved tunneled staff. 
 
 Preparation — Position. — As for median perineal cystotomy. 
 
 Landmarks. — Median raphe; scroto-perineal junction ; anus. 
 
 Incision. — In median line, from base of scrotum to a point about 1.3 cm. 
 (^ inch) anterior to the anus. 
 
 Operation. — (1) Having succeeded in getting a filiform whalebone 
 guide into the bladder, Gouley's tunneled grooved staff is threaded upon this 
 and carried down into the urethra upon it, with the right hand, while the left 
 hand holds the filiform — until it is arrested at, or within, the strictured urethra. 
 An assistant now takes the filiform and metallic staff in his right hand, and 
 draws up the scrotum with his left. (2) The surgeon incises directly in the 
 median line of the perineum, beginning at the scroto-perineal junction, and 
 ending about 1.3 cm. (^ inch) in front of the anus. The incision at first 
 passes only through skin and fascia. The lower end of the instrument in the 
 urethra is then felt for, the surgeon's left index nail depressing the intervening 
 structures over the groove — and all the intervening tissues are now divided 
 down to and into the groove — in the same manner and order as in median 
 perineal cystotomy. (3) A silk traction-loop is placed in either lip of the 
 urethral wound and the lips are then drawn apart — thus clearly demon- 
 
EXTERNAL PERINEAL URETHROTOMY. 1125 
 
 strating the interior of the urethral canal, from its normal lumen above to 
 where it disappears below into an almost imperceptible lumen. (4) The 
 metallic staff is now partly withdrawn and steadied by an assistant, using care 
 to retain in situ the filiform, by holding it in the perineal wound as the staff 
 is withdrawn over it. Nothing now remains at the immediate site of the 
 operation but the whalebone guide passing into the bladder. (5) With a 
 probe-pointed bistoury, the filiform is carefully followed backward and the 
 stricture thus divided throughout its length and slightly beyond. The tun- 
 neled staff is then thrust into the bladder over the whalebone guide. (6) The 
 filiform is then withdrawn. A grooved director or gorget is passed into the 
 bladder, through the perineal wound, over the grooved staff — and the staff 
 withdrawn. (7) The remaining steps are the same as in Syme's operation 
 (see sections (3) and (4), including " Comment," page 11 23). 
 
 EXTERNAL PERINEAL URETHROTOMY 
 
 UPON GROOVED STAFF PASSED DOWN TO STRICTURE — WHEELHOUSE'S 
 
 OPERATION. 
 
 Description. — In these cases the grooved staff cannot be passed through 
 the stricture — nor can a filiform be passed through — but a grooved staff can 
 be passed down to the stricture — and, upon this, the urethra is opened just 
 in front of the stricture and a fine grooved director is passed through it — ■ 
 and the stricture is divided upon this last director. The urethra is thus 
 opened in the median line about 6 mm. (J inch) in front of the stricture — the 
 feature of the operation being that at least this much of the sound urethra 
 should be exposed in front of the stricture. 
 
 Preparation. — Perineum shaved. Lubricated grooved sound introduced 
 down to the stricture and steadily held in the median line. 
 
 Position. — Patient supine, in the lithotomy position at the end of the 
 table. Surgeon seated opposite the perineum. Assistant on patient's left, 
 holding staff. 
 
 Landmarks. — Median line; perineo-scrotal junction; anus. 
 
 Incision. — From reflection of superficial perineal fascia, at perineo- 
 scrotal junction — to anterior border of sphincter ani. 
 
 Operation. — (1) Incision is made in the median line to the above extent, 
 and the tissues of the perineum are divided as in median perineal cystotomy 
 — separating the tissues in the direction of the sound until the urethra is 
 reached. (2) The urethra is then divided to a limited extent upon the grooved 
 sound — especial care being taken that the urethra is opened about 6 mm. 
 ({ inch) in front of the stricture — the opening not extending down to the 
 stricture. Looped silk traction-ligatures are then put in through the lips 
 of the divided urethra, upon either side, and the two lips of the urethra are 
 thus drawn apart. (3) The grooved sound is then withdrawn a short dis- 
 tance — just far enough to free its end from the remaining 6 mm. (J inch) of 
 intact urethra in which it had been, up until then, engaged — the sound is 
 then turned through a half revolution upon its axis, so that its extremitv now 
 points outward — and thus hooks up upon its concavity the upper limit (angle) 
 of the urethral wound. The urethral opening is thus stretched apart in a 
 lozenge-shaped manner, by the hooked sound above, by the traction-ligatures 
 on each side, and by the attachment of the intact urethra below. (4) While 
 thus held apart and well exposed, a fine probe-pointed grooved director, or 
 gorget, is insinuated into and along the strictured urethra, with its groove 
 
1 1 26 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 uppermost. Even often when the opening cannot be seen, the director will 
 find its way toward the bladder among a mass of distorted tissue. (5) The 
 groove of the director is now turned downward — and the strictured portion 
 of the urethra is divided upon its floor by a knife passed along the director. 
 The knife is withdrawn and the groove of the director, still in the urethra, is 
 turned upward — and a metallic catheter, or sound, is then passed from the 
 meatus, and is guided through the opened urethra by the fingers in the perineal 
 wound — and thence on to the groove of the director — and thus into the bladder. 
 (6) The metallic instrument is allowed to remain in situ for three or four days 
 during granulation of the parts around the new canal — and is then passed 
 daily until the perineal wound heals. (7) The perineal wound may be partly 
 closed by suture — but is left unsutured in part, at least, for drainage. 
 
 Comment. — If the staff hooked into the incised urethra be in the way, 
 it can be dispensed with. 
 
 PERINEAL SECTION, OR EXTERNAL PERINEAL URETHROTOMY 
 
 WITHOUT A GUIDE — COCK'S OPERATION. 
 
 Description. — In these cases neither a grooved staff, nor even a filiform 
 bougie, can be passed through the stricture. The urethra is practically im- 
 passable to all instruments (from the presence of several strictures, false 
 passages, rupture, disease, and the like). No attempt is made to use any 
 form of guide. The urethra is opened posteriorly to the stricture and imme- 
 diately anteriorly to the prostate. The bladder is thus relieved — and the 
 anterior portion of the urethra is subsequently treated. 
 
 Preparation. — Perineum shaved. Bladder partly full. 
 
 Position. — Lithotomy position at edge of table. Surgeon seated facing 
 perineum. Assistant holds penis and testes out of the way. 
 
 Landmarks. — Median line; perineo-scrotal junction; anus. 
 
 Incision. — In median line, from perineo-scrotal junction, to within about 
 1.3 cm. (h inch) of the anus. 
 
 Operation. — (1) The surgeon introduces the left index-finger into the 
 rectum, with nail to the sacrum, and keeps the tip of his finger against the 
 apex of the prostate gland. (2) A knife is then made to cut directly and 
 boldly, in the median line of the perineum, toward the tip of the left index- 
 finger — the entire cut being made with one sweep of the knife, the incision 
 beginning above near the perineo-scrotal junction, passing inward to the 
 prostatic urethra, and ending below about 1.3 cm. (J inch) anterior to the 
 anus. The incision of tissues is, practically, the same as that for median 
 perineal cystotomy. The deepest part of this triangular incision will be at 
 the apex of the prostate gland, and the most superficial at the upper and lower 
 ends of the base of the triangle upon the perineum. The knife is at no time 
 withdrawn until the full depth of the wound and apex of the prostate gland 
 are reached, as its reinsertion would be uncertain. In the depth of the wound 
 the knife-point is guided by the tip of the left index-finger — and the urethra, 
 at the posterior part of the membranous portion, is divided in its median 
 aspect, or slightly obliquely — the anterior part of the prostate often also being 
 divided. (3) Having incised the urethra, the knife is withdrawn — but the 
 left index is kept in the rectum in contact with the apex of the prostate. (4) 
 While the edges of the deep perineal wound are well retracted, a fine probe- 
 pointed director is inserted into the opened urethra, guided by a finger in the 
 rectum — and pushed on into the bladder. (5) Perineal drainage is estab- 
 
URETHROSTOMY. 1127 
 
 lished by passing a soft catheter, through the wound in the perineum, into 
 the bladder — the catheter being held in place by the perineal bandage. 
 (6) This operation is generally resorted to where the urethra is very ex- 
 tensively involved or destroyed. If, therefore, the perineal opening is not to 
 be a permanent one, steps may be taken subsequently, after restoration of 
 the structures in whole or in part, with reference to the opening up of the 
 anterior portion of the urethra by dilatation or urethrotomy. 
 
 Comment. — While the original operation by Cock was done in this 
 manner, and generally abandoned if the urethra was not reached in two or 
 three attempts, there is no reason why (and this is now generally done) the 
 tissues should not be divided more deliberately and the urethra more per- 
 sistently sought for. One should be guided by an intimate knowledge of 
 the anatomy of the parts, in the face of great difficulties — for often the struc- 
 tures are unrecognizably altered. 
 
 URETHRORRHAPHY. 
 
 Description. — Suturing of the urethra. Indicated in incised and rup- 
 tured wounds and in fistula. 
 
 Preparation — Position. — As for Urethrotomy. 
 
 Landmarks — Incision. — Determined by nature and site of wound. 
 
 Operation. — Having exposed the site of the wounded urethra, by ex- 
 ternal incision — a metal sound or soft catheter is passed through the urethra, 
 using special care not to increase the wound. With fine chromic gut, or 
 fine silk, carried in a curved needle held in a holder, the opposite edges of 
 the wounded urethra are united by interrupted sutures passing through the 
 entire thickness of the lips of the wound — except the mucous membrane. A 
 soft catheter is worn for two or three days, until time has been given for the 
 shutting-off of the wound from the interior of the urethra, The external 
 wound is left open, being packed with gauze until the urethral wall has healed 
 — to avoid the danger of urinary infiltration. 
 
 Comment. — There are several plastic operations which may be done for 
 urinary fistula. 
 
 URETHROSTOMY. 
 
 Description. — Making of a more or less permanent opening of the 
 urethra upon the perineum. Indicated where the anterior portion of the 
 urethral canal is impermeable, as for stricture, — or in case of amputation 
 of the penis. 
 
 Preparation — Position — Landmarks. — As for median perineal cys- 
 totomy. 
 
 Incision. — Determined by the special circumstances of the case. 
 
 Operation. — (a) For the establishment of Urethrostomy following ampu- 
 tation of the penis, see section 5, under " Operation," page n 17. (b) In per- 
 forming Urethrostomy in connection with a strictured urethra: — Having 
 exposed the strictured site, divide the urethra transversely, just behind the 
 stricture, and free the proximal end of the urethra to a limited extent. 
 Slit the proximal end slightly upon its floor, or upon floor and roof — and 
 suture the lips thus formed by slitting, into the skin of the perineum. 
 Suture up the proximal end of the distal portion of urethra — and close the 
 wound up to the margins of the implanted urethra. 
 
1128 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 III. THE SCROTUM AND TESTES. 
 
 SURGICAL ANATOMY. 
 (A) The Scrotum and Coverings of Testes and Cords. 
 
 Description. — The scrotum is a cutaneo-musculo-areolar sac, investing 
 the testes and part of the spermatic cords. It is composed of skin and dartos 
 — the remaining layers mentioned below being, more properly, coverings of 
 the testes and cords. 
 
 Skin. — Of characteristic appearance. Continuous with the general 
 Integument. Marked in the middle line by a raphe, which divides the 
 scrotum into two lateral halves superficially. 
 
 Dartos. — Proper tunic of the scrotum — composed of reddish, elastic, 
 and unstriped muscle tissue — continuous with the superficial and deep layers 
 of the superficial fascia. Septum scroti — formed by the dartos — extending 
 from the raphe to the inferior surface of the penis — dividing the scrotum 
 into two cavities for the two testes, the left cavity being the longer. 
 
 Intercolumnar or External Spermatic Fascia. — Derived from borders 
 of pillars of external abdominal ring. Continuous with superficial perineal 
 fascia and superficial fascia over the symphysis pubis. Loosely (Gray — 
 closely, according to Morris) adherent to the dartos. Intimately adherent 
 to the cremasteric fascia. 
 
 Cremasteric or Middle Spermatic Fascia. — Fibro-muscular layer de- 
 rived from lower border of internal oblique muscle. 
 
 Infundibuliform Fascia (Fascia Propria, or Internal Spermatic 
 Fascia). — Connective-tissue layer derived from both the infundibuliform 
 process of the fascia transversalis and also from the subperitoneal connective 
 tissue (which latter may be considered a separate or sixth layer). 
 
 Tunica Vaginalis. — Closely connected with the testicles, with which it 
 is described. 
 
 Arteries. — Superficial and deep external pudic of femoral; superficial 
 perineal of internal pudic; cremasteric of epigastric. 
 
 Veins. — Correspond with arteries and empty into pudic, long saphenous, 
 and dorsal vein of penis. 
 
 Lymphatics. — End in innermost set of inguinal glands. 
 
 Nerves. — Ilio-inguinal; superficial perineal branches of internal pudic; 
 inferior pudendal branch of small sciatic; genital branch of genitocrural. 
 
 (B) The Testes. 
 
 Description. — The testes consist of the testicles proper and the epi- 
 didymes, the latter also being the beginnings of the vasa deferentia. The 
 coverings of the testicles are — the tunicae vaginalis, albuginea, and vasculosa. 
 
 Tunica Vaginalis. — A closed serous sac originally derived from the 
 peritoneum, surrounding the testicle with two layers; — (a) Visceral Layer — 
 closely adherent to testicle proper, to globus major, to external part of body 
 of epididymis, and to lower 1.3 cm. (h inch) of spermatic cord. Nearly all 
 of the globus minor and inner and back parts of epididymis are uncovered, 
 and here the vascular communications exist between the testis and coverings, 
 (b) Parietal Layer — continuous with and reflected from the visceral layer at 
 the posterior and inferior aspects of the testis and at the spermatic cord — 
 adherent to the inner surface of the infundibuliform fascia, to which it is 
 
PARTIAL EXCISION OF THE SCROTUM. 1129 
 
 attached by the prolongation from the subperitoneal areolar tissue — and 
 extends up upon the antero-internal aspect of the cord and below the testis, 
 (c) Cavity of the tunica vaginalis — interval between visceral and parietal 
 layers. 
 
 Tunica Albuginea. — The dense, inelastic fibrous covering of the testicle 
 — reflected into the interior of the testicle at its posterior aspect to form an 
 incomplete septum and trabecular, the mediastinum testis. 
 
 Tunica Vasculosa. — A layer formed by a plexus of vessels running in 
 the areolar tissue. Lines the tunica albuginea and trabecular. 
 
 Lobuli Testis. — Consist of tubuli seminiferi, resting in the trabecular 
 spaces — forming the glandular structure of the testis. 
 
 Arteries. — Spermatic, of abdominal aorta (divides into branches which 
 pierce the tunica albuginea at the back of gland). 
 
 Veins. — Spermatic (begin in testis — leave it posteriorly — and ascend cord, 
 forming pampiniform plexus). 
 
 Lymphatics. — Follow spermatic vessels and empty into lumbar glands. 
 
 Nerves. — From aortic and hypogastric plexuses. 
 
 PARACENTESIS TUNIGE VAGINALIS. 
 
 Description. — Penetration of the tunica vaginalis sac with a hollow 
 needle or an exploratory trocar and cannula — for the purpose of withdrawing 
 or injecting fluid. Generally indicated in hydrocele. 
 
 Preparation — Position — Landmarks. — As in operating for Hydrocele. 
 
 Operation. — The scrotum is grasped posteriorly by the surgeon's left 
 hand in such a way as to render the anterior aspect of the tumor tense. The 
 needle or trocar is so held with the right index near its point as to fix the 
 maximum depth to which it can enter. Thus held, it is thrust sharplv into 
 the antero-inferior aspect of the sac, at about the upper limit of its lower 
 third — passing, at first directly backward — and then upward (thus missing 
 the testicle). The fluid having been withdrawn (or injected), the instrument 
 is withdrawn — the opening sealed with sterile collodion and cotton — and 
 the testicle supported by a compressing dressing. 
 
 Comment. — The testicle usually lies posterior to a tunica vaginalis filled 
 with hydrocele fluid — but sometimes lies below — and sometimes lies in front. 
 
 PARTIAL EXCISION OF THE SCROTUM. 
 
 Description. — Removal of the lower portion of the scrotal tissues. Gen- 
 erally resorted to in relaxation and elongation of the scrotum, and as an aid 
 in varicocele. 
 
 Preparation. — Scrotum shaved. 
 
 Position. — Patient supine, at edge of table. Surgeon on side of involved 
 sac, or on patient's right. Assistant opposite. 
 
 Landmarks. — Lower limit of testicle. 
 
 Operation. — The testicle is pressed upward toward the external abdom- 
 inal ring, to be well above the possibility of injury. The lower portion of 
 scrotal tissue is clamped with special forceps (or clamps), or any pair of long 
 forceps whose blades will close lightly and parallel with each other — so that the 
 lower border of the clamps will be on a level with the line upon which it is 
 desired to remove the scrotal sac (Fig. 823). Clamp sufficiently firmly to 
 
ii30 
 
 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 control hemorrhage. Divide the scrotal tissues with a knife, cutting along the 
 lower border of the clamps. Unclamp slightly, to reveal the position of bleed- 
 ing vessels — which are then ligated with gut, that no subsequent bleeding may 
 
 Fig. 823. — King's Scrotal Clamp. 
 
 take place into the loose tissues. While the edges are still held in the clamps, 
 they are sutured together, interruptedly or continuously — after which the 
 clamps are relaxed. No drainage is used. The part is well supported and 
 compressed by the dressing. 
 
 Fig. 824. — Partial Excision of the Scrotum: — The lateral aspects of the scrotum are 
 held apart by traction sutures. Interrupted through-and-through sutures prevent the testicles 
 from escaping from the scrotum and also partly control hemorrhage. The overhand sutures 
 of the free margins complete the operation, also controlling hemorrhage. (Redrawn from 
 Hartmann.) 
 
 Comment. — The first and second fingers of an assistant's right and left 
 hands, separated to clasp the scrotum, the index-fingers crossing each other in 
 front, and the second fingers crossing each other behind, the scrotum, make 
 satisfactory clamps. The operation may be done without any form of clamp 
 by first introducing retention and hemostatic sutures, as shown in Fig. 824. 
 
OPERATION FOR HYDROCELE. 
 
 1131 
 
 OPERATION FOR HYDROCELE 
 
 BY INCISION OF TUNICA VAGINALIS — VOLKMANN'S OPERATION. 
 
 Description. — The tunica vaginalis is incised vertically in its anterior 
 aspect and stitched to the scrotal skin — its cavity being then packed with 
 gauze and allowed to heal by granulation. 
 
 Preparation. — Scrotum shaved. Penis wrapped in gauze and held away 
 from the field of operation. 
 
 Position. — Patient supine, at edge of table. Surgeon on side of opera- 
 tion. Assistant opposite. 
 
 Landmarks. — Position of the testicle proper. 
 
 Fig. 825.— Volkmann's Operation for Hydrocele: — A, Lip of scrotal wound; B, Tunica 
 vaginalis, incised ; C, Testis ; D, Suture passing through tunica vaginalis and entire thickness of lip of 
 scrotal wound. 
 
 Incision. — About 5 cm. (2 inches) in length — along the anteroinferior 
 aspect of the tumor. 
 
 Operation. — (1) The assistant so grasps the tumor as to render tense 
 and prominent its anterior aspect — and, at the same time, keeps the testicle 
 out of the way of injury. (2) An incision of about 5 cm. (2 inches) in extent 
 is made along the anteroinferior aspect of the tumor — passing through the 
 tissues overlying the tunica vaginalis (skin, dartos, intercolumnar fascia, 
 cremasteric fascia, and infundibuliform fascia) through the tunica vaginalis 
 and into its cavity. (3) After the escape of the hydrocele fluid the edges of 
 the tunica vaginalis are sutured to the edges of the scrotal skin by from four 
 to eight chromic gut sutures — and the cavity itself, of the tunica vaginalis, 
 is packed with gauze — and heals by granulation, thus obliterating the cavity. 
 The scrotum is well supported and compressed by the dressing. (Fig. 825.) 
 
117,2 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 OPERATION FOR HYDROCELE 
 
 BY EVERSION AND SUTURING OF THE TUNICA VAGINALIS — JABOULAY's 
 
 METHOD. 
 
 Description. — After having freed the testicle from the tunica vaginalis, 
 the edges of the tunica are displaced backward and sutured behind the testicle. 
 
 Preparation — Position — Landmarks — Incision. — As for Volkmann's 
 operation, page 1131. 
 
 Operation. — Having incised the tunica vaginalis longitudinally, the 
 testicle proper is pressed forward in such a way as to evert the entire vaginal 
 tunic. The everted sac is then displaced backward and its margins sutured 
 behind the testicle in such a manner as to bring the serous surface of the 
 tunica vaginalis everywhere into contact with the tunica dartos (Fig. 826). 
 
 Fig. 826. — Operation for Hydrocele by Eversion of the Tunica Vaginalis: — 
 The incised tunic is everted and its margins sutured together behind the testicle and cord. 
 (Redrawn from Hartmann.) 
 
 The testicle and everted tunica vaginalis are then replaced within the scrotum 
 and the skin wound sutured. Thus the cavity of the tunica vaginalis is 
 entirely obliterated. 
 
 Comment. — (1) Care is to be exercised that the structures of the cord be 
 not too tightly compressed in the act of suturing the everted tunic around it. 
 (2) It has happened that the everted tunic has gone on secreting its fluid into 
 the scrotal tissues. (3) Andrews incises the tunica vaginalis anteriorly — 
 and in the act of expressing the testicle through this opening he everts the tunic 
 ■ — which remains everted without suturing. 
 
OPERATIOX FOR HYDROCELE. 
 
 ^33 
 
 OPERATION FOR HYDROCELE 
 
 BY INCISION, WITH PARTIAL EXCISION OF TUNICA VAGINALIS— VON BERGM ANN'S 
 
 OPERATIOX. 
 
 Description. — Incision of the tunica vaginalis, with removal of its parietal 
 layer, followed by closure of the scrotal wound, with or without drainage. 
 
 Preparation — Position — Landmarks — Incision. — As for Volkmann's 
 operation. 
 
 Operation. — (i) While the scrotum is held as in Volkmann's operation, 
 
 Fig. 827.— Von Bekgmann's Operation for Hydrocele :— A, Margin of incised tunica vagi- 
 nalis ; B, Testis ; C, Portion of visceral layer of tunica vaginalis being excised with curved scissors, 
 while being drawn upon with forceps ; D, Inner aspect of scrotal sac from which tunica vaginalis has 
 been separated. 
 
 an incision is made over its antero-external aspect, about 7.5 cm. (3 inches) 
 in length, down to the tunica vaginalis. (2) The tunica vaginalis is then 
 incised in the same line, at first to the extent of about 1.3 cm. (\ inch). 
 Through this opening the finger is introduced and the cavity of the tunica 
 vaginalis and the position of the testicle examined. (3) The collapsed tunica 
 vaginalis is then incised to the full extent of the external wound with scissors. 
 All bleeding vessels are clamped and tied. (4) The parietal layer of the tunica 
 vaginalis is seized and partly peeled, partly dissected away from the scrotum, 
 by fingers and forceps — nearly up to the epididymis, externally — and nearly 
 
"34 
 
 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 up to the testicle internally — along which lines it is cut away with scissors. 
 Bleeding from this step is controlled by pressure, hot douching, and gut- 
 ligature. (Fig. 827.) (5) A drainage-tube is then usually inserted into the 
 cavity and the lips of the scrotal wound closed by suturing up to the drainage- 
 tube. Drainage may be omitted in favorable cases. The scrotum is well 
 supported by the dressing. 
 
 ORCHIDECTOMY. 
 
 Description. — Orchidectomy, or castration, consists in the incision of 
 the scrotum, followed by excision of the testicle and the structures of the 
 lower part of the cord — and closure of the scrotal wound. 
 
 Preparation. — Scrotum and pubis shaved. 
 
 Fig. 828. — Orchidectomy: — A, Superficial vessel in lip of incised scrotum; B, Testis; C, Sper- 
 matic artery and pampiniform plexus of veins, ligated ; D, Vas deferens and artery, ligated ; E, Cre- 
 masteric artery and posterior spermatic veins, ligated. 
 
 Position. — Patient supine, near edge of table, with thighs separated. 
 Surgeon to patient's right, in operating upon either side. Assistant opposite 
 
 Landmarks. — Testicle; cord; external ring. 
 
 Incision. — Vertical incision, from just below the external abdominal ring 
 to the lower end of the scrotum, upon the antero-external aspect of the cord — 
 the scrotum being held in the palm of the left hand, with the index and thumb 
 extending upward on either side and rendering the parts slightly tense. Where 
 redundant or diseased tissue exists, an elliptical incision may be made — in- 
 cluding and removing the redundant or involved tissue. 
 
 Operation. — (1) The vertical incision above described is made directly 
 
SURGICAL ANATOMY OF THE SPERMATIC CORD. II35 
 
 down through the overlying parts (skin, dartos, intercolumnar fascia, cremas- 
 teric fascia, infundibuliform fascia) to the cord and tunica vaginalis. (2) By 
 blunt dissection, the testicle, surrounded by the unopened tunica vaginalis, is 
 shelled out of its bed. The structures of the cord are similarly isolated, en 
 masse, chiefly by blunt dissection, as high up as necessary — generally about 
 2.5 cm. (1 inch) below the external abdominal ring. (3) The component 
 structures of the cord (see anatomy of the cord, page 1135) are now ligated — 
 which is best done by teasing them apart to the extent of dividing them up into 
 three or four bundles of vessels and ligating each bundle separately with 
 chromic gut, independently of whether composed of arteries, veins, or vas 
 deferens. This is better than to include the entire mass in one or even in 
 two ligatures, and is, practically, as satisfactory as attempting to recognize and 
 tie the vessels separately. (Fig. 828.) (4) All bleeding vessels are con- 
 trolled by clamping or ligation with gut — and are, usually, the superior ex- 
 ternal pudic, inferior external pudic, superficial perineal, and artery of the 
 septum scroti. (5) The scrotal wound is then put upon a slight stretch 
 and sutured throughout, so approximating the edges as to prevent in-turning 
 — using interrupted sutures of chromic gut or silkworm-gut. If indicated, 
 temporary drainage may be used in the lower part of the scrotal wound. 
 The scrotum is well supported by dressing. 
 
 Comment. — (i) The tunica vaginalis is frequently opened before removing 
 the testicle, for the purpose of examination. (2) In other cases the testicle and 
 visceral layer are cut away from the parietal layer of the tunica vaginalis and 
 removed, leaving the latter. (3) The cord may first be clamped and cut — and 
 the vessels tied later. (4) If the arteries can be recognized and separately tied, 
 it is somewhat more surgical. 
 
 IV. THE SPERMATIC CORD. 
 
 SURGICAL ANATOMY. 
 
 Structures of Cord. — Consist of the vas deferens (which begins in the 
 globus minor of the epididymis), arteries, veins, lymphatics, nerves, processus 
 vaginalis, and internal cremaster of Henle — all connected by areolar tissue and 
 surrounded by the fascia: which descend, together with the testes, from the in- 
 ternal abdominal rings, through the inguinal canals, into the scrotum to the 
 summit of the testes. 
 
 Arteries of the Cord. — Spermatic, of abdominal aorta — lying anterior 
 to vas deferens and surrounded by pampiniform plexus of veins; artery of vas 
 deferens, of superior or inferior vesical — accompanying vas deferens upon its 
 lateral aspect; cremasteric artery, of deep epigastric — lying superficially and 
 upon the external aspect. 
 
 Veins. — Most of the spermatic veins pass through the inguinal canal and 
 emptv into the inferior vena cava on the right — and into the renal vein on the 
 left. They may be divided into three sets;— (1) Anterior Set— much larger, 
 form pampiniform plexus, accompany the spermatic artery and ascend the 
 cord anterior to the vas;— (2) Posterior Set — much smaller, surround the vas 
 deferens and accompany the artery of the vas;— (3) Some independent 
 veins. 
 
 Lymphatics. —Empty into the Lumbar Glands. 
 
 Nerves. — From the spermatic and pelvic plexuses. 
 
1 136 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 Vas Deferens. — Lying posteriorly and recognized by its cord-like feeling. 
 
 Processus Vaginalis. — Remnant of obliterated tube of communication 
 between tunica vaginalis and peritoneum. 
 
 Internal Cremaster of Henle.— Scattered bundles of muscle-fibers. 
 
 Fatty Areolar Tissue. — Connecting constituent structures of cord. 
 
 Epididymes. — Formed by vasa efferentia — which pierce the tunica al- 
 buginea and, becoming convoluted into the coni vasculosi, form the globus 
 major, at the upper, inner aspect of the testicle. The vasa efferentia thus unite 
 to form the body of the epididymis, along the inner aspect of the testicle — end- 
 ing below in the globus minor, at the lower inner aspect of the testicle — which 
 terminates in the vas deferens. 
 
 Vasa Deferentia. — Continuation of the epididymes — extending from the 
 globus minor to the prostatic urethra. Ascends on the inner side of the epididy- 
 mis and back of the testis — passing vertically up the cord, posterior to the sper- 
 matic vessels — enters the external abdominal ring — runs through the inguinal 
 canal — emerging from the internal abdominal ring, it passes around the outer 
 side of the origin of the deep epigastric artery and runs downward and inward, 
 crossing the external iliac vessels into the pelvis to the side of the bladder, 
 running under the peritoneum — thence curves backward and downward to the 
 postero-lateral surface of the bladder — crossing over the cord of the obliterated 
 hypogastric artery, and lying internal to the ureter, passing between the ureter 
 and bladder — thence it ceases to be covered by peritoneum, running forward 
 to the base of the prostate, lying between the bladder and rectum and attached 
 to the former (bladder) — being placed internal to the vesiculae seminales. 
 Near the base of the prostate, each vas enlarges somewhat (ampulla) and joins 
 the duct of the corresponding seminal vesicle, to form the ejaculatory duct of 
 that side — the ejaculatory duct opening into the sinus pocularis of the pros- 
 tatic portion of the urethra. After the vas ceases to be subperitoneal, it is 
 invested by recto-vesical fascia and a prolongation of the subperitoneal tissue. 
 The efferent ducts consist of cellular, muscular, and mucous coats. Its artery 
 is the artery of the vas deferens, a branch of the superior vesical of the internal 
 iliac. Its lymphatics end in the iliac glands. The angle of approximation of 
 the ejaculatory ducts lies immediately above the prostate. For the anatomy of 
 the ejaculatory ducts, see the vesiculae seminales. 
 
 INSTRUMENTS. 
 See those mentioned under the urethra and penis. 
 
 PARTIAL VASECTOMY. 
 
 Description. — A division of the vas deferens, with a limited excision of its 
 trunk. Sometimes resorted to in cases of hypertrophy of the prostate gland. 
 
 Preparation — Position — Landmarks. — As in operating for varicocele. 
 
 Incision. — In the course of the spermatic cord, beginning just below the 
 external abdominal ring and extending downward for about 4 cm. (i-J- inches). 
 
 Operation. — Incise skin and fascia — clamp and ligate superficial vessels. 
 Expose the spermatic cord just below the external abdominal ring — locate the 
 vas — and isolate it from the accompanying structures. Place two gut ligatures 
 upon it, about 2 cm. (f inch) apart, and excise about 1.3 cm. (h inch) of its 
 length. Close the wound with gut or silkworm-gut. 
 
OPERATION FOR RADICAL CURE OF VARICOCELE. 
 
 "37 
 
 OPERATION FOR THE RADICAL CURE OF VARICOCELE. 
 
 BENNETT'S MODIFICATION OF HOWSE'S OPERATION. 
 
 Description. — Consists in an incision of the scrotum and cord, with a 
 partial excision of the pampiniform plexus of veins (which is the set chiefly 
 involved in varicocele) — followed by suturing of the proximal and distal ends 
 of the severed plexus together. 
 
 Preparation. — Pubis and scrotum shaved. 
 
 Fig. 829. — Bennett's Modification of House's Operation for Varicocele : — Between 
 retracted lips of scrotal wound are seen two stumps left by excision of bulk of scrotal veins. A, One 
 end of upper ligature being threaded through upper stump laterally ; B, Same of lower stump and 
 ligature. The long limbs of this ligature are tied together — and the short limbs together. C, Suture 
 carried through the stumps antero-posteriorly and tied. The stumps are approximated by tightening 
 the sutures. 
 
 Position. — Patient supine, at edge of table. Surgeon on side of operation. 
 Assistant opposite. 
 
 Landmarks. — Site of varicose tumor. Position of testicle and cord. Ex- 
 ternal abdominal ring. 
 
 Incision. — Longitudinal incision, about 4 to 5 cm. (i\ to 2 inches) in 
 length, made over the structures of the cord, with its center over the site of the 
 greatest varicosity. 
 
 Operation. — (1) As soon as the incision is made through skin and fascia, 
 the bleeding vessels are damped and tied — and two silk retraction-loops are 
 put into the lips of the wounds and these lips well retracted — thus exposing the 
 
1 138 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 structures of the cord. (2) The vas deferens is the first structure of the cord 
 to be identified — and this is done for the purpose of henceforth avoiding in- 
 juring it This structure and its artery, and the posterior set of veins accom- 
 panying it, are kept as much out of the field as possible. (3) The pampini- 
 form plexus of veins, together with the surrounding fascia especially preserved 
 and unopened, are isolated from the more important structures and are freed 
 for about 4 to 5 cm. (15 to 2 inches), according to the size of the varicocele, by 
 blunt dissection. (4) Strong chromic gut ligature is carried, up on an aneu- 
 rism-needle, around the lower portion of the freed part of this plexus of veins 
 and tied tightly, both ends being left long. The same is then done at the upper 
 portion of the freed part — the ligatures being about 4 cm. (i\ inches) apart. 
 About 2.5 cm. (1 inch) in extent of this venous plexus is now removed with 
 scissors, which cut about 6 mm. (j inch) from each ligature. (5) One of the 
 free ends of each ligature is now threaded and carried through its own end, so 
 as to come out opposite the knot. The two ends which were threaded are then 
 tied together. The other two ends are similarly treated and tied. The free 
 ends of the venous plexuses left by the excision are thus approximated, together 
 with their sheaths of surrounding fascia — thus shortening the cord and partially, 
 perhaps, taking the weight of the lower part of the cord from the scrotum. (6) 
 The wound is then gut-ligatured throughout. (Fig. 829.) 
 
 Comment. — (1) As much in length of the plexus may be removed as con- 
 sidered necessary in the special case. (2) Isolation of the veins to be ligated 
 is aided by passing a director above, and one below, between the veins to come 
 away and the structures to remain — and then separate the parts upward and 
 downward in this line. (3) Especially avoid opening the fascial sheath sur- 
 rounding the veins of the pampiniform plexus to come away — as they are 
 much more readily manipulated when intact. (4) Avoid cutting the cremas- 
 ter muscle. (5) Avoid removing an excess of vascular structures — for fear 
 of damaging the blood-supply of the part too greatly. 
 
 V. THE VESICULiE SEMINALES AND EJACULATORY DUCTS. 
 
 SURGICAL ANATOMY. 
 
 (A) Vesicul/E Seminales. 
 
 Description. — Two diverticular, membranous, seminal reservoirs placed 
 between the bladder and the rectum — lying external to the ampulla? of the vasa 
 deferentia — their upper extremities being subperitoneal. They average, in 
 length, about 6.3 cm. (2^ inches) — breadth, about 1 cm. (y^-inch) — thickness, 
 about 6 mm. (\ inch). 
 
 Relations. — Superiorly; base of bladder, from near entrance of ureters 
 to base of prostate gland. Inferiorly; rectum, with the recto-vesical fascia 
 intervening. Anteriorly; converging, unite with vasa deferentia (which 
 lie to their inner side) to form the ejaculatory ducts. Posteriorly ; the free 
 ends diverge, overlapping the ureters, which pass between the vesiculae semi- 
 nales and the bladder. The recto-vesical pouch of peritoneum covers the 
 upper part of the posterior aspect of the seminal vesicles. 
 
 (B) Ejaculatory Ducts. 
 
 Description. — Formed by union of vasa deferentia and vesicula? seminales 
 
TOTAL EXCISION OF VESICUL^ SEM1NALES. 1 139 
 
 of each side. They are about 2 cm. (f inch) in length. Beginning at base of 
 prostate, they pass forward and downward between the middle and lateral 
 lobes — perforate the prostatic fissure — and empty at or within the margins of 
 the sinus pocularis, in the prostatic portion of the urethra. Its coats are 
 fibrous, muscular, and mucous. 
 
 Arteries of Vesiculae Seminales and Ejaculatory Ducts. — Artery of vas 
 deferens, of superior vesical branch of internal iliac; inferior vesical, of internal 
 iliac; middle hemorrhoidal, of internal iliac; middle vesical, of internal iliac. 
 
 Veins. — Accompany arteries. 
 
 Lymphatics. — End in pelvic glands. 
 
 Nerves. — From hypogastric plexus. 
 
 INSTRUMENTS. 
 See those used in operating upon the bladder. 
 
 TOTAL EXCISION OF VESICUL^ SEMINALES AND PART OF EJAC- 
 ULATORY DUCTS 
 
 F.V SUPRAPUBIC RETROCVSTIC EXTRAPERITONEAL ROUTE — YOUNG'S OPERATION 
 
 Description. — The total excision of the seminal vesicles (Spermatocys- 
 tectomy) and the partial excision of the ejaculatory ducts, by a suprapubic 
 T-shaped incision. The posterior aspect of the bladder is exposed by a median 
 suprapubic, incision, with the addition of a transverse incision at its upper end. 
 Through this incision, which does not pass into the peritoneal cavity, the 
 peritoneum is peeled away from the posterior wall of the bladder, until the 
 vesicular seminales are exposed. The seminal vesicles are then removed — and 
 the ejaculatory ducts are traced to the internal abdominal rings and also re- 
 moved at this point. 
 
 Preparation. — Bowels emptied. Bladder partly filled. Pubic and supra- 
 pubic regions shaved. 
 
 Position. — Patient in Trendelenburg position. Surgeon to patient's left. 
 Assistant opposite. 
 
 Landmarks. — Symphysis pubis; median line; known relations of the parts. 
 
 Incision. — T-shaped. The median suprapubic incision is made from 
 just above the umbilicus to the symphysis pubis. The transverse incision, 
 about 7.5 cm. (3 inches) in length, extends across the upper end of the vertical 
 incision, just above the umbilicus and in the linea transversa. The median 
 incision passes between the recti muscles — and the transverse incision divides 
 them as far as it extends. 
 
 Operation. — (I) The median incision is carried down in the median line 
 just as in median abdominal section- — passing through the fascia posterior to 
 the recti — down to but not through the peritoneum. (2) The peritoneum, 
 having been exposed, is carefully separated from the posterior wall of the blad- 
 der in the median line — keeping comparatively near the median line, to avoid 
 severing many of the nutrient vessels of the bladder by separating the perito- 
 neum too far laterally. Upward traction of the posterior bladder-wall — while, 
 at the same time, pressing backward the rectum — aids the separation of the 
 peritoneum from the back of the bladder. (3) The vasa deferentia are thus 
 
U40 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 exposed and freed from the bladder by blunt dissection — during which the 
 vesiculae seminales are encountered, lying slightly to the outer side, and are 
 similarly freed. (4) Both vesiculae seminales and vasa deferentia are divided 
 by blunt dissection close to the upper border of the prostate gland. The vasa 
 deferentia are then traced on outward over the lateral aspects of the bladder 
 to the internal abdominal rings — and there ligated and divided. (5) In con- 
 cluding the operation, the transversely divided recti are repaired with chromic 
 gut. The longitudinal wound is sutured as in abdominal section — leaving the 
 lower portion open — through which a temporary gauze drainage is usually 
 conducted. 
 
 Comment. — (1) Hemorrhage is controlled by gut-ligaturing and gauze- 
 packing. (2) Briefly summarizing the operation, the steps are: — Separation 
 of peritoneum from base of bladder — Separation of rectum from base of blad- 
 der — Excision of vesiculae seminales and of the vasa deferentia as far out as the 
 internal abdominal rings. (3) Guard the ureters by adhering to the area as 
 near the middle line as possible. They are made easier of detection by up- 
 ward traction upon the bladder. (4) A sound introduced into the bladder 
 during the progress of the operation will often be of aid. (5) The incision may 
 pass through the upper half of the prostate and a portion of the prostate be thus 
 removed, attached to the seminal vesicles — which is accomplished by an in- 
 cision beginning at the upper part of the prostate, anterior to its junction with 
 the vesiculae seminales, and passing obliquely posterior to the urethra and 
 terminating about the center of the posterior aspect of the prostate. (6) The 
 seminal vesicles may be exposed by a transverse perineal incision — and also by 
 the sacral route, as in the operations for excision of the rectum. 
 
 VI. THE PROSTATE GLAND. 
 
 SURGICAL ANATOMY. 
 
 Description. — A fibro-muscular glandular body in front of the neck of the 
 bladder and surrounding the beginning of the urethra, placed posteriorly and 
 inferiorly to the symphysis pubis and posteriorly to the triangular ligament, and 
 resting upon the rectum. Its measurements are the following: — transversely 
 at base, about 4 cm. (1^ inches); antero-posteriorly, about 2.5 cm. (1 inch); 
 depth, about 2 cm. (f inch). The prostatic urethra pierces the gland generally 
 one-third nearer the posterior than the anterior aspects, — though it sometimes 
 passes nearer the anterior aspect, — and sometimes only the inferior three- 
 fourths of the urethra is surrounded by the prostate. The ejaculatory ducts 
 pierce the gland obliquely forward between the middle and lateral lobes, open- 
 ing into the prostatic portion of the urethra. The glands of the prostate 
 open into the prostatic sinuses. The prostatic sinuses lie upon either side 
 of the verumontanum, in the prostatic part of the urethra. 
 
 Capsule of Prostate Gland. — Firm, thin, fibrous membrane derived from 
 the recto-vesical portion of the pelvic fascia — separated from the superior layer 
 of the deep perineal fascia by a plexus of veins. 
 
 Divisions of Prostate Gland. — (1) Two Lateral Lobes — deeply notched 
 posteriorly and slightly furrowed anteriorly. (2) Middle Lobe — a small, ir- 
 regularly shaped prominence upon the posterior aspect of the gland, between 
 the two lateral lobes, lying above the sinus pocularis and between the ejacu- 
 latory ducts — and placed directly under the neck of the bladder, posterior to 
 beginning of urethra. 
 
PROSTATECTOMY, IN GENERAL. 1141 
 
 Fixations. — Held in place by the anterior or pubo-prostatic ligaments of 
 bladder; by the superior layer of the triangular ligament; and by the anterior 
 part of the levatores ani. 
 
 Base of Prostate. — Directed upward and backward. Lies somewhat 
 above level of center of symphysis pubis, resting upon and connected with neck 
 of bladder. 
 
 Apex. — Directed downward and forward, resting upon superior layer of 
 triangular ligament. Lies about 1.3 cm. (h inch) behind and slightly inferior 
 to the subpubic angle. By rectal examination, about 3 cm. (ij inches) above 
 the edge of the an is. 
 
 Anterior Surface. — Convex. Lies about 2 cm. (f inch) posterior to lower 
 aspect of symphysis. Covered by prostatic plexus of veins, by pubo-prostatic 
 ligaments, and by vesico-pubic muscle. 
 
 Posterior Surface. — Flattened. Rests upon anterior aspect of rectum, 
 some dense connective tissue and muscular fibers intervening. 
 
 Lateral Surfaces. — In relation with superior surfaces of levatores ani and 
 the lateral portions of the venous plexuses. Extend upward as two indistinctly 
 defined lobes. 
 
 Arteries. — branches of inferior (and probably middle) vesical, from an- 
 terior trunk of internal iliac; branches of hemorrhoidal arteries; branches of 
 internal pudic. 
 
 Veins. — Receive dorsal vein of penis and form plexuses about anterior and 
 part of lateral aspects of gland — and empty into branches of internal iliac 
 vein . 
 
 Lymphatics. — End in pelvic glands. 
 
 Nerves. — Form hypogastric plexus. 
 
 INSTRUMENTS. 
 See those used in operating upon the Bladder. 
 
 PROSTATOTOMY. 
 
 Description. — Incision of prostate gland. Indicated in abscess — and 
 sometimes resorted to for division of the prostatic bar or collar at neck of 
 bladder. 
 
 Operation. — While the prostate gland may be exposed by a median peri- 
 neal incision, as in Cock's operation for perineal section, a more complete and 
 satisfactory exposure may be obtained by the transversely curved perineal in- 
 cision described under proctatectomy. For the exposure of the prostate by 
 either of these incisions, therefore, see pages 11 26 and 1143. 
 
 PROSTATECTOMY, IN GENERAL. 
 
 Description. — Consists in the removal of part or the entire prostate gland. 
 Indicated chiefly in marked hypertrophy of the prostate. Prostatectomy 
 may be complete or partial — dependent upon the amount of gland removed. 
 
 Varieties of Prostatectomy. — (1) Suprapubic — applicable to smaller 
 growths, and especially applicable to enlargement of the middle lobe alone, or 
 to enlargement of middle lobe together with the intravesical part of the lateral 
 lobes. (2) Perineal Prostatectomy — applicable to larger involvements, and 
 especially of the lateral lobes and to sub-urethral growths. Affords excellent 
 
1 142 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 drainage. (3) Combined Suprapubic and Perineal Prostatectomy — giving 
 freest access to largest growths. This method is probably the best. Even if 
 the perineal operation be done immediately after, a suprapubic cystotomy 
 enables the vesical aspect of the prostate to be thoroughly examined. 
 
 SUPRAPUBIC PROSTATECTOMY 
 
 BY MEDIAN VERTICAL INCISION. 
 
 Description. — Consists in the removal of the prostate gland through a 
 median suprapubic incision. This operation is frequently only a partial pros- 
 tatectomy, consisting in the removal of the median lobe of the prostate and the 
 intravesical parts of the lateral lobes. 
 
 Preparation — Position — Landmarks — Incision. — As for suprapubic 
 cystotomy (page 1096). 
 
 Operation. — (1) Having irrigated the bladder, and partly filled the rectal 
 bag with fluid (which should not be more than six or eight ounces if the pros- 
 tate be large and hard), the operation is conducted precisely as in suprapubic 
 cystotomy, up to the opening of the bladder, control of hemorrhage, and re- 
 traction of the lips of the bladder-wound with silk traction-loops. (2) This 
 much having been accomplished, the condition of the prostate and urethral 
 opening are carefully examined with the finger — using great care in all manip- 
 ulations not to detach the bladder from its connective-tissue plane. (3) 
 Enucleation of the enlarged prostate accessible from the bladder is now ac- 
 complished by fingers, blunt dissector, curved blunt scissors, a curette, and 
 forceps (the instruments all having long handles). The mucous membrane 
 overlying the hypertrophied middle lobe is incised vertically with scissors — and 
 the enlarged growth is shelled out of its bed. The mucous membrane should 
 be divided, as nearly as possible, in the median line, to allow of subsequent 
 suturing, where feasible, though suturing is not absolutely necessary. Often 
 pedunculated parts are simply cut away at their pedicles. Where a collar-like 
 bar of hypertrophied gland around the beginning of the urethra is encountered, 
 it is divided by inserting a blade of the scissors into the urethra and severing it 
 by closure of the blades (if special scissors with serrated edges be used, hem- 
 orrhage will be less) — the forefinger is then inserted into the wound thus made 
 — and, while an assistant pushes the prostate upward into the bladder by 
 counter-pressure from the perineum, the surgeon continues the process of 
 enucleation, removing as much of the lateral lobes as possible, in mass or in 
 piecemeal — and as much of the sub-urethral prostate as can be reached and 
 removed by sweeping the finger around the urethra and enucleating from be- 
 tween the urethral wall and capsule of the gland. (4) At the end of the opera- 
 tion, the edges of the mucous membrane should be sutured with catgut, if 
 possible. If inaccessible, or too much torn up, they may be dropped into place 
 without suturing. Patency of the urethra should be ascertained by the passage 
 of a sound through the meatus and by digital examination of the prostatic 
 urethra. (5) A large drainage-tube is inserted into the bladder through 
 the suprapubic wound — around which the edges of the abdominal wound 
 are closed as in suprapubic cystotomy. 
 
 Comment. — (1) The Trendelenburg position is convenient after opening 
 the bladder. (2) Intravesical hemorrhage is controlled by hot douching and 
 gauze pressure. In some cases excessive hemorrhage may necessitate the 
 packing of the bladder with gauze. (3) The operation should be planned so 
 as to secure a level, low floor at the bladder opening of the prostatic urethra. 
 
PERINEAL PROSTATECTOMY 
 
 "43 
 
 (4) Some operators make a counter-opening in the perineum after the opera- 
 tion — which should be resorted to if much damage have been done — and both 
 perineal and suprapubic drainage be used. 
 
 PERINEAL PROSTATECTOMY 
 
 BY TRANSVERSE CURVED INCISION'. 
 
 Description. — The prostate is exposed by a transversely curved incision — 
 the capsule of the gland being divided transversely and the gland tissue enu- 
 cleated with the finger. 
 
 Preparation — Position. — As for perineal cystotomy (page 1102). 
 
 Landmarks. — Ischial tuberosities; subpubic arch. 
 
 Incision. — Extends from one ischial tuberosity to the opposite, curving 
 convexly forward toward the inferior margin of the subpubic arch (Fig. 830, A). 
 
 Operation. — (1) Incise the skin and superficial fascia — divide the ischio- 
 rectal fattv areolar tissue in the line of incision, passing clown to the levatores 
 ani. (2) Retract forward the superficial perineal vessels and nerves, the 
 artery and nerve to the bulb, and the transversus perinaei muscle — and retract 
 backward the inferior hemorrhoidal vessels and nerves — clamping and tying 
 bleeding vessels. (3) Recognize the bulb and central tendinous point of the 
 
 Fig. 830.— Perineal Routes for Exposing Prostate Gland: — A, Transverse curved incision; 
 
 B, Median perineal incision. 
 
 perineum (from which latter the transverse perineal muscles extend outward), 
 all exposed in the wound. Divide transversely the external sphincter just 
 posterior to its junction with the accelerator urinas at the central tendinous 
 point. Retract the bulb, transverse perineal muscles, and central tendinous 
 point all forward. (4) Incise more deeplv still along the transverse curved 
 incision — and expose the compressor urethra 1 muscle, surrounding the mem- 
 branous urethra from the prostate behind, to the bulbous urethra in front. 
 Above the compressor urethra? lies the inferior aspect of the prostate gland, 
 surrounded by dense connective tissue continuous with the pelvic fascia and 
 forming a portion of the capsule of the gland. (5) Draw this fascia downward 
 and the rectum backward, and incise the capsule of the prostate transversely, 
 thereby exposing the posterior surface of the prostate gland. (6) The index- 
 finger is then inserted through the incised capsule and the process of enucleation 
 
1 144 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 of the gland substance from below upward to its upper border is accomplished 
 in the same general manner as in Alexander's operation (paragraph 6, page 
 1 145). (7) The vasa deferentia lie a little deeper — and the vesiculse seminales 
 lie just to the outer sides of the vasa deferentia — both of which structures may 
 be exposed and removed by this incision. (8) The prostate having been enu- 
 cleated, a sound is passed through the entire urethra from the meatus — and 
 especially the condition of the prostatic urethra examined. The urethra is not 
 opened up, supposedly, by the perineal manipulations. (9) Drainage through 
 the perineal wound is established — the lateral extensions of the wound being 
 sutured from either end toward the median line. 
 
 PROSTATECTOMY BY THE COMBINED METHOD 
 
 BY MEDIAN SUPRAPUBIC AND MEDIAN PERINEAL INCISIONS — ALEXANDER'S 
 
 OPERATION. 
 
 Description. — The prostate is first exposed through a regular suprapubic 
 incision, for the purpose of examining the gland and to enable downward dis- 
 placement of the prostate during the perineal operation — and the gland is then 
 removed, as far as required, through the median perineal incision. The ob- 
 jects of the operation are to remove the obstructing portions of the prostate 
 with the minimum damage to the bladder and urethra, and to furnish good 
 drainage. The special method of Alexander involves the following anatomical 
 features emphasized by its author (whose writing is largely followed in the sub- 
 sequent description): — (a) The prostatic urethra consists of two parts; — (1) 
 Vesical portion — which lies above the openings of the seminal ducts into the 
 prostatic urethra; and which has thicker, stronger walls, permitting the freeing 
 of the prostate without damage to the urethral mucous membrane. (2) Ure- 
 thral portion — which lies below the openings of the seminal ducts into the 
 prostatic urethra; and which has thinner, weaker walls, largely supported by 
 prostatic tissue, (b) Fibrous trabecular extend from the central fibrous part 
 of the prostate, behind the urethra, laterally outward to the fibrous capsule — 
 dividing the lateral lobes into anterior and posterior parts by forming cleavage 
 lines between them. (1) Anterior portion — placed in front of the fibrous 
 trabecular, at the side of the urethra — which are the only parts of the lateral 
 lobes whose hypertrophy causes interference with urination. (2) Posterior, 
 or inferior, portion — placed posterior to the fibrous trabecular, posterior and 
 inferior to the urethra and seminal ducts — the hypertrophy of which does not 
 cause interference with urination, (c) Summary — the anterior portions of the 
 lateral lobes, whose hypertrophy causes urinary obstruction, may, therefore, 
 be enucleated en masse, without injury to the posterior portions or to the 
 capsule. 
 
 Preparation. — Bowels emptied. Bladder irrigated and then distended 
 with 8 or 10 ounces. Pubic and perineal regions shaved. 
 
 Position. — Patient as for suprapubic cystotomy, during the opening of the 
 bladder — and in the lithotomy position during the perineal incision. Surgeon 
 to patient's left at first — and then seated opposite the perineum. Assistant at 
 first opposite surgeon and then to his right. 
 
 Landmarks- — Those for suprapubic cystotomy (page 1096) and for 
 median perineal cystotomy (page 1102). 
 
 Incisions. — Same as for median suprapubic cystotomy (page 1096) and 
 for median perineal section (page 11 23). (Fig. 830, B.) 
 
 Operation. — (1) A median suprapubic cystotomy is done — making an 
 
PROSTATECTOMY BY THE COMBINED METHOD. 1145 
 
 opening into the bladder large enough to insert the index-finger. The lips of 
 the bladder wound are temporarily sutured to the lips of the abdominal wound, 
 by one or two stitches on each side. The intravesical portion of the prostate is 
 examined. The bladder wound is then protected with gauze. (2) A fairly 
 large, centrally grooved sound is then passed into the bladder from the meatus 
 of the penis — and steadily held in the middle line by an assistant. (3) The 
 median perineal section is made just as in Syme's operation (page 1123) — ex- 
 posing the membranous urethra. Its floor is divided upon the grooved sound, 
 from just posterior to the bulb in front, to the apex of the prostate gland be- 
 hind. (4) As the sound is being withdrawn, the finger is passed into the 
 bladder through the prostatic urethra, which is dilated by the finger. (5) The 
 left index is introduced through the suprapubic wound into the bladder — and 
 presses the prostate firmly toward the perineum, to bring it as fully into the 
 perineal wound as possible. (6) The right index passes through the perineal 
 wound into the prostatic urethra and begins the enucleation of the prostatic 
 gland tissue — beginning by feeling along the lateral aspect of the prostatic 
 urethra for the prominence caused by the inward bulging of the enlarged lateral 
 lobe. The mucous membrane is broken through by the finger just in front of 
 this eminence caused by the intrusion of the lateral lobe. The finger then 
 works its way along the cleavage line of the fibrous trabecular, between the 
 anterior and posterior parts of the lateral lobe. The obstructing part of the 
 lateral lobe is separated with comparative ease laterally and posteriorlv from 
 the posterior portion of the gland and capsule. The obstructing mass is then 
 separated from the mucous membrane at the neck of the bladder and from the 
 superior part of the prostatic urethra — aided by being grasped with forceps and 
 drawn toward the perineal wound — while the left index in the bladder aids 
 in guarding the mucous membrane against being torn. (7) The procedure 
 just described upon one lateral lobe is repeated upon the other lateral lobe, if 
 indicated. (8) If an enlarged "middle lobe" exist, it is pressed down, by the 
 finger in the bladder, into the perineal wound, into the area formerlv occupied 
 by the enucleated lateral lobes, when it is also enucleated in the same way from 
 beneath the mucous membrane and without further injury to the mucous mem- 
 brane — by sweeping the finger around through the space left by enucleating the 
 lateral lobes. Thus the only part of the urethra which is torn during the opera- 
 tion is that portion just anterior to the opening of the seminal ducts. And no 
 injury is done to the bladder or urethral mucous membrane except that done to 
 the mucous membrane of the prostatic urethra above the openings of the vesi- 
 cular seminales. (9) Hemorrhage is controlled by hot water and gauze pres- 
 sure. The bladder and perineal wounds are irrigated with hot salt solution. 
 A stout rubber catheter is passed into the bladder through the perineal wound — 
 and another rubber drainage-tube is inserted into the bladder through the 
 suprapubic wound. The suprapubic bladder wound is sutured about the tube 
 by Gibson's method (page nog) — .similar, in principle, to Kaders gastrostomy 
 method. The perineal wound is partly closed by suture. The bladder is ir- 
 rigated daily. The suprapubic tube is generally removed in four days and the 
 perineal in seven — complete healing of both wounds being expected in about 
 five weeks. 
 
 Comment. — (1) The perineal hemorrhage may require temporary gauze 
 packing. (2) Guard against injury to the rectum, especially during work near 
 the anterior portion of the prostatic urethra. (3) In conjunction with the 
 regular suprapubic cystotomy, some surgeons make the transverse curved 
 perineal incision. The prostate is exposed through the suprapubic bladder 
 wound and depressed through the bladder into the perineum. The capsule of 
 
1 146 OPERATIONS UPON THE MALE GENITAL ORGANS. 
 
 the gland is then divided transversely through the perineal wound and enu- 
 cleated by this route. 
 
 NOTE. 
 
 Other operations upon the Penis, Urethra, Scrotum, Testes, Spermatic 
 Cord, Vesicula? Seminales, Ejaculatory Ducts, and Prostate — as well as the 
 operations upon the Epididymis, Vasa Deferentia, and Cowper's Glands — be- 
 longing more particularly to special Genito-Urinary Surgery, will not be con- 
 sidered here. 
 
CHAPTER VII. 
 
 OPERATIONS UPON THE FEMALE GENITAL 
 
 ORGANS. 
 
 I. THE UTERUS. 
 SURGICAL ANATOMY. 
 
 (i) Uterus. 
 
 Description. — Situated in pelvic cavity, between bladder and rectum, 
 supported by its ligaments — its cervix projecting into superior part of vagina, 
 downward and backward — and its base upward and forward. Communicates 
 with fallopian tubes and vagina. Consists of serous, muscular, and mucous 
 coats. Length, about 7.5 cm. (3 inches) — breadth, about 5 cm. (2 inches) — 
 thickness, about 2.5 cm. (1 inch). Its divisions are — fundus, body, cervix, 
 uterine cavity, internal and external os, and openings of fallopian tubes. 
 
 Relations of Fundus and Body. — Anteriorly; covered by peritoneum 
 and separated from posterior aspect of bladder by utero vesical peritoneal 
 pouch (generally occupied by coils of intestine). Posteriorly; covered by 
 peritoneum and separated from anterior aspect of rectum by recto-uterine 
 pouch of peritoneum (in which are generally some coils of intestines). Lat- 
 erally; broad ligaments; fallopian tubes (above); round ligament (below); 
 ligaments of ovaries (behind). Superiorly; covered by peritoneum. 
 
 Relations of Cervix Uteri. — (1) Intravaginal Portion; — surrounded by 
 vagina, which extends higher posteriori}- than anteriorly — and presents opening 
 of os externum. (2) Supravaginal Portion ; — one-half of entire cervix is supra- 
 vaginal posteriorly, and two-thirds anteriorly. Presents opening of internal os. 
 The relations of supravaginal portion are the following: — Anteriorly; bladder 
 (areolar tissue intervening). Posteriorly; peritoneum of Douglas's pouch. 
 Laterally; broad ligament; uterine vessels; ureters (which are about 1.3 cm., 
 or ^ inch, away). (3) Vaginal Portion; zone of vaginal attachment — oblique 
 — higher posteriorly than anteriorly. 
 
 Relations of Peritoneum. — Invests whole of posterior aspect of uterus, 
 but only upper three-fourths of anterior aspect. 
 
 Ligaments. — Three pairs peritoneal — four pairs muscular (three of latter 
 lying between folds of broad ligament and one between folds of posterior liga- 
 ment). Two Lateral or Broad Ligaments (peritoneal): — duplication of 
 peritoneum extending transversely outward from sides of uterus and vagina to 
 sides of pelvis — the two peritoneal layers being continuous above at free bor- 
 der, but diverging below and laterallv, and including various structures be- 
 tween their folds (v. Broad Ligament, page 1148). Two Anterior, or Vesico- 
 uterine (peritoneal) : — reflected from top of bladder to anterior wall of uterus, 
 at junction of supravaginal cervix. Two Posterior, or Recto-uterine (peri- 
 toneal): — peritoneal folds reflected backward from intraperitoneal part of cer- 
 vix and vagina, on to second part of rectum — forming lateral boundaries of 
 Douglas's pouch. Two Utero-sacral (muscular): — muscular bands lying 
 
 1147 
 
1 148 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 between folds of the posterior or recto-uterine ligaments. Extend from second 
 and third pieces of sacrum forward and downward to sides of uterus at junc- 
 tion of body and supravaginal cervix (opposite os internum), crossing the sides 
 of the rectum opposite the junction of its first and second parts. Two Utero- 
 pelvic Ligaments (muscular) : — muscular expansions, extending between 
 folds of broad ligaments, from fascia over obturator internus muscles to sides 
 of uterus and vagina, surrounding the utero-vaginal vessels and nerves. Two 
 Utero-ovarian Ligaments (Ligaments of the Ovaries) (muscular) : — pro- 
 longations of uterine muscular fibers in the form of round cords, extending 
 between folds of broad ligaments, from upper angles of uterus to inner aspects 
 of ovaries. Two Round or Utero-inguinal Ligaments (muscular) : — fibro- 
 muscular cords, 10 to 12.5 cm. (4 to 5 inches) long, placed between folds of 
 broad ligaments, extending from superior angles of uterus through inguinal 
 canals to labia majora (v. Round Ligaments, page 1149). 
 
 Arteries. — Ovarian, of abdominal aorta — carried into broad ligament by 
 infundibulo-pelvic ligament — divides into tubal artery and ovarian artery 
 proper. Uterine, of internal iliac — runs downward along pelvic wall to base of 
 broad ligament — thence inward near floor of pelvis toward cervix, which it 
 reaches at junction of vagina, passing in front of ureter — and runs up side of 
 cervix and uterus between folds of broad ligament, communicating with oppo- 
 site uterine and branches of ovarian. 
 
 Veins. — Correspond with arteries. Veins from ovarian plexuses empty — 
 right, into inferior vena cava — left, into left renal. Veins from uterine plexuses 
 empty into internal iliac veins. 
 
 Lymphatics. — Those from body empty into lumbar glands — and those 
 from cervix into pelvic glands. 
 
 Nerves. — From third and fourth sacral — and from hypogastric and renal 
 plexuses. 
 
 (2) Broad Ligament.* 
 
 Description. — Duplicative of peritoneum, extending transversely from 
 sides of uterus and vagina outward to sides of pelvic wall — the two layers being 
 continuous superiorly at their free border — and diverging laterally and infe- 
 riorly to envelop various structures (v. i.). 
 
 Relations. — Superior or free Border (mesosalpinx): — summit of dupli- 
 cative, where it envelops fallopian tube. Extends from side of uterus toward, 
 pelvic wall, to beyond the fimbriated extremity of fallopian tube. Infundibulo- 
 pelvic ligament — that portion of superior border of broad ligament between 
 fimbriated extremity of fallopian tube and lower attachment of broad ligament 
 — a concave, rounded border — the ovarian vessels being conveyed in this liga- 
 ment. Inferior Border : — attached to levator ani muscle and recto-vesical 
 fascia. Ureters, vessels, and nerves pass through the subperitoneal areolar 
 tissue between its layers. Internal Border : — attached to lateral walls of 
 uterus and vagina. Utero-vaginal vessels and muscular bands pass between 
 the two lamina?. External Border : — In contact with obturator fascia. 
 Transmits uterine vessels and round ligament. 
 
 Structures between Two Layers of Broad Ligament. — Ovary — pro- 
 jects from posterior lamina. Ligament of ovary — from angle of uterus to 
 lower or internal aspect of ovary. Fallopian tube — in upper free margin. 
 Round ligament — forms a ridge beneath anterior lamina, on its way to inguinal 
 canal. Parovarium (fetal relic) — between ovary and outer part fallopian tube. 
 Duct of Gaertner; hydatid of Morgagni; small cysts — all fetal relics. Uterine, 
 
 * Here described because involved in Hysterectomy. 
 
SURGICAL ANATOMY OF THE VAGINA. 1149 
 
 ovarian, and funicular vessels; lymphatics; and uterine plexus of nerves. Sub- 
 peritoneal fatty areolar tissue. Involuntary muscular fibers — from obturator 
 fascia to sides of uterus and vagina. 
 
 Broad ligament divides pelvic cavity into : — Anterior part — containing 
 bladder, urethra, and vagina; — Posterior part — containing rectum. 
 
 Boundaries of Douglas's Recto-uterine Pouch. — Anteriorly; posterior 
 wall of uterus, supravaginal cervix, upper fourth of vagina. Posteriorly; 
 rectum, sacrum. Laterally; sacro-uterine ligaments. Superiorly; small in- 
 testines. 
 
 (3) Round Ligaments.* 
 
 Description. — Two flat, cord-like bundles of muscular, fibrous, and areo- 
 lar tissue, vessels and nerves, continuous with uterine fibers, attached to supe- 
 rior angles of uterus just below and in front of fallopian tube — each passes 
 upward, outward, and forward between layers of broad ligaments to pelvic 
 wall, raising the anterior layer of broad ligament into a fold — curves around 
 deep epigastric artery on inner side of external iliac artery — enters internal 
 abdominal ring — passes through inguinal canal — emerges from external ring 
 — its fibers then becoming lost in tissues of labia majora and mons veneris. 
 May be accompanied by an invagination of peritoneum, the canal of Nuck 
 (analogous to pouch of peritoneum accompanying descent of testes), which 
 may remain patulous. Receives fibers in transit through inguinal canal — and 
 gives off few fibers to pillars of ring. Average length — 10 to 12.5 cm. (4 to 5 
 inches). Supplied by funicular branch of superior vesical of internal iliac. 
 
 (4) Vagina. 
 
 Note. — Vagina is here described in connection with Vaginal Hysterectomy. 
 
 Description. — Extends from orifice below through an opening in tri- 
 angular ligament, to neck of uterus above— completely surrounding the cervix. 
 Extends upward much further beyond posterior lip of uterus (about 2 cm., 
 or f inch) than beyond anterior lip. Length of anterior wall, about 6.3 cm. 
 (2^ inches), — posterior wall, about 9 cm. (3^ inches). Fornices, anterior and 
 posterior — consist of angles of reflection of vaginal on to uterine mucous mem- 
 brane. Transverse section of vagina is H-shaped, when collapsed. Struc- 
 ture — fibrous, muscular, and mucous coats. 
 
 Relations. — Anteriorly; Base of bladder — loose subperitoneal fascia 
 intervening. Urethra — subperitoneal areolar tissue intervening in upper one- 
 third, but closely connected in lower two-thirds. Ureters — which enter blad- 
 der 3.2 cm. (i| inches) below level of os uteri. Posteriorly ; Rectum — Doug- 
 las's peritoneal cul-de-sac intervening for about 2.5 cm. (1 inch) above — and 
 subperitoneal areolar tissue intervening lower. Perineal body — below (sepa- 
 rating vagina and rectum). Laterally: — Vaginal branch of uterine artery. 
 Subperitoneal venous plexus at base of broad ligament. Ureters crossing 
 upper third obliquely. Levatores ani, in relation with lower two-thirds. 
 
 Arteries. — Vaginal, internal pudic, vesical, and uterine branches of in- 
 ternal iliac; external pudic branches of femoral. 
 
 Veins. — Correspond with arteries — but form vaginal plexuses on each side 
 of vagina. 
 
 Lymphatics. — Empty chiefly into pelvic — some into inguinal glands. 
 
 Nerves.- — From fourth sacral and pudic nerves — and from hypogastric 
 plexus. 
 
 * Here described because involved in Hysterectomy. 
 
1150 
 
 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 Fig. 831. — Diagram Showing Some of the Relations of the Uterus: — A, Uterus; B, Os 
 uteri; C, Vagina ; D, Ovary; E, Utero-ovarian ligament; F, Fallopian tube; G, Round ligament; 
 H, H, Ureters; I, Ovarian artery; J, Internal iliac artery; K, Uterine artery; L, L, L, Vaginal 
 arteries; M, Infundibulo-pelvic portion of broad ligament. The position of the ligatures about the 
 vessels and broad ligament is shown (here shown as interlocking, which is unessential) as applied 
 in total abdominal hysterectomy. 
 
 SURFACE FORMS AND LANDMARKS. 
 
 Utero-vesical fold of peritoneum is about on a level with the internal os 
 uteri. 
 
 Utero-rectal fold of peritoneum is reflected for nearly 2.5 cm. (1 inch) on 
 the posterior wall of the vagina. 
 
 The cervix may be divided into three zones: — the lower third is intra- 
 vaginal; — middle third is, anteriorly, supravaginal (united to base of bladder) 
 — and intravaginal posteriorly; — upper third is supravaginal — united to blad- 
 der anteriorly — and in relation with peritoneum posteriorly. 
 
 The ureters, in the case of a normal uterus, with empty bladder, lie nearly 
 1.3 cm. (J inch) from the cervix. They pass parallel with the cervix and nearly 
 1.3 cm. (J inch) away — running through the plexus of uterine veins and under- 
 neath the broad ligament — and, continuing near the vagina, run between the 
 vagina and bladder, and enter the bladder about on a level with the center of 
 the anterior wall of the vagina. The uterine arteries run over them, upon their 
 inner aspect. For further description of the female ureter, see page 1074. 
 For the course of the uterine and ovarian arteries, see page 1148 (also see 
 Fig. 831, H, H). 
 
 INSTRUMENTS. 
 
 See those given under Abdominal Section (page 801) — in addition to which, 
 may be mentioned: — vaginal retractors; broad ligament clamps; vulsella for- 
 ceps; pedicle clamps; pedicle needles, straight and laterally curved; aneurism- 
 needles, straight and laterally curved; tenaculum-forceps; long artery-clamp 
 forceps; long scalpels; long scissors, straight and curved; long forceps, toothed 
 and dissecting; uterine sound; urethral catheters. 
 
PARTIAL ABDOMINAL HYSTERECTOMY. 
 
 PARTIAL ABDOMINAL HYSTERECTOMY, TOGETHER WITH REMOVAL 
 OF OVARIES AND TUBES. 
 
 I PARTIAL ABDOMINAL HYSTERO-SALPINGO-OOPHORECTOMY.) 
 
 Description. — The supravaginal portion of the uterus, together with the 
 ovaries and tubes, are removed through a median abdominal incision. In 
 Partial Abdominal Hysterectomy the supravaginal portion of the uterus only 
 is removed, and the vagina is not opened. In Total Abdominal Hysterectomy 
 the entire uterus, including the cervix, is removed, and the vaginal vault is 
 opened. The ovaries may or may not be removed, in either case — thev should 
 be left when possible. 
 
 Preparation. — Bowels and bladder emptied. Median line and pubis 
 shaved. 
 
 Position. — An upward tilt of patient's pelvis, of about 30.5 cm. (12 inches), 
 in the Trendelenburg position aids by causing the intestines to fall awav from 
 the uterus. Surgeon stands on patient's right during most or the entire opera- 
 tion. Assistant opposite. 
 
 Landmarks. — Median line; navel; symphysis pubis; position of bladder 
 and ureters. 
 
 Incision. — In median line, extending from umbilicus downward towards 
 symphysis pubis. It may be extended above the umbilicus, passing directly 
 through the navel, or may pass around it to the left. It averages from 10 to 
 15 cm. (4 to 6 inches) in length. 
 
 Operation. — (1) Median Abdominal Section: — Perform a median abdo- 
 minal section in the usual manner — control hemorrhage — retract the edges of 
 the abdominal wound — displace the small intestines and the sigmoid coil of the 
 large intestine and keep them out of the pelvis with gauze pads, aided bv the 
 Trendelenburg position. Examine the contents. of the pelvic cavity and learn 
 the condition of the organs and the presence and extent of adhesions. (2) 
 Freeing Uterus, Tubes, and Ovaries from Adhesions: — The weakest adhesions 
 are separated by the fingers — firmer adhesions by scissors — the most extensive 
 are divided between double chromic gut ligatures, as near the uterus as possible. 
 The fundus of the uterus is seized with vulsella and drawn toward the pubis, 
 and the rectum displaced backward, while freeing the posterior aspect — then 
 to the right, while freeing the left aspect of the uterus, ovary, tube, and broad 
 ligament, — and to the left while freeing the right aspect of the same structures. 
 Dense adhesions are sometimes more easily broken up by following down the 
 fallopian tubes and working up under the tube and ovary, than from above 
 downward. Free more closely to the organ to be removed than to the struc- 
 tures to be left. A sound in the uterus will often aid in outlining the cleavage- 
 lines of dense adhesions, along which separation must be accomplished by dis- 
 section with knife and forceps, or scissors. If completion of the freeing of 
 adhesions in the usual way offers insuperable difficulties, it is sometimes best to 
 stop and ligate the ovarian vessels and round ligament (in the manner and 
 order described below) and divide the upper part of the broad ligament, making 
 it possible to reach and free the tube and ovary from in front. (3) Enuclea- 
 tion : — (a) Ligate the left ovarian vessels with silk, at the outer end of the broad 
 ligament, beneath the sigmoid colon — either dividing them between two silk 
 ligatures, or between a clamp on the uterine and a ligature upon the pelvic side 
 — cutting obliquely across the broad ligament to the round ligament, (b) The 
 round ligament is similarly ligated with chromic gut, or clamped and ligated, 
 and divided about 1.3 cm. (h inch) from the uterus, (c) The vesico-uterine 
 
1152 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 peritoneum is detached from the uterus, by first incising the peritoneum along 
 the concave line of its reflection, from left round ligament to right round liga- 
 ment. While the uterus and adnexa are drawn up and to the opposite side, the 
 vesical peritoneum is pushed off of the cervix with gauze or sponge grasped in a 
 holder — thus separating bladder from cervix and baring the latter for about 
 3 cm. (ij inches) and exposing the uterine vessels, (d) Grasp the cervix be- 
 tween the left index and thumb, and verify its lower termination and the site 
 of the uterine arteries on each side. Ligate the left uterine vessels by silk liga- 
 ture carried under them upon a curved aneurism-needle, passing from before 
 backward and near to the cervix — but not carried too deeply alongside of the 
 cervix, for fear of including the ureter. Place a clamp, or a second ligature, 
 on the uterine side, and divide between them, (e) Amputate the cervix trans- 
 versely, just above the vaginal attachment — so as to leave the stump of the 
 cervix cupped antero-posteriorly and laterally. Protect the cut uterine canal 
 with gauze from emptying its contents into the wound site. Cauterize the 
 cervical canal — and stuff with gauze down into the vagina, (f) The uterus 
 is drawn upward and to the opposite side — the right uterine vessels are exposed 
 and are ligated and divided as on the left (or may be clamped at first and tied 
 later), (g) The uterus is still further drawn up and to the opposite side — and 
 the round ligament ligated as on the left and divided (or may be first clamped, 
 and ligated later), (h) Cut obliquely across the broad ligament to the right 
 ovarian vessels in the infundibulo-pelvic ligament — ligating and dividing them 
 (or clamping first, and ligating later). The enucleation is now complete — and 
 there is left a crescently denuded area in the pelvic cavity, broadest at its center, 
 opposite the cervical stump, and coming to points at the brim of the pelvis, on 
 either side, where the ovarian vessels were ligated. (4) Closure of the Cer- 
 vical Canal: — The cupped surface of the cervical stump is sutured with chro- 
 mic gut in such a way as to approximate the anterior and posterior aspects by 
 from four to six interrupted sutures — entering the anterior lip exclusive of the 
 vesical peritoneum, and emerging from the anterior lip anterior to the cervical 
 canal — then passing over the cervical canal and entering the posterior lip just 
 behind the cervical canal and emerging on the posterior peritoneal aspect of the 
 cervical stump — thus closing the cervical canal, approximating the lips of the 
 cervical stump, and controlling hemorrhage. The sutures are cut short and 
 the stump dropped back into place. (5) Repair of the Pelvic Floor: — Having 
 seen that all bleeding vessels are ligated (with chromic gut) — the denuded sur- 
 faces are entirelv covered in, by suturing together the peritoneal surfaces with 
 continuous gut — uniting the edges of the anterior peritoneal layer of the broad 
 ligament and reflected vesical peritoneum in front, to the edges of the posterior 
 peritoneum behind — beginning and ending at the stumps of the ovarian vessels 
 — and suturing the vesical peritoneum opposite the cervical stump to the pos- 
 terior peritoneum which has been included in the stitches which closed in the 
 cervical canal. (6) Closure of the Abdominal Wound: — The abdominal 
 wound is closed as usual — without drainage, unless specially indicated. 
 
 Comment. — (1) The broad ligament is everywhere divided between liga- 
 tures. Where the ligatures for the ovarian vessels, round ligament, and uterine 
 vessels, above mentioned, do not extend entirely across the broad ligament, in- 
 tervening separate ones are placed. (2) Especially guard against injuring 
 the ureters while ligating the uterine arteries (see Anatomy, pages 1074 and 
 1 150). 
 
TOTAL VAGINAL HYSTERECTOMY. 1153 
 
 TOTAL ABDOMINAL HYSTERECTOMY, TOGETHER WITH REMOVAL 
 OF OVARIES AND TUBES. 
 
 (TOTAL ABDOMINAL HYSTERO-SALPINGO-OOPHORECTOMV.) 
 
 Description. — The entire uterus, including the cervix, as well as the 
 ovaries and tubes, are removed, and the vaginal vault opened — all through a 
 median abdominal section. The ovaries should be left when possible. 
 
 Preparation — Position — Landmarks — Incision. — As for Partial Abdo- 
 minal Hysterectomy. 
 
 Operation.— The technic is so similar to that for Partial Abdominal 
 Hysterectomy that only those points will be mentioned in which the technic 
 of Total Abdominal Hysterectomy differs from the operation just described. 
 
 (1) The lips of the cervix are closed with strong silk sutures applied through 
 the vagina, before the operation is begun — to protect the abdominal cavity 
 from infection. The vagina is packed with gauze. (2) When the peritoneal 
 reflection has been pushed away from the supravaginal part of the uterus, and 
 the uterine arteries tied, as described in Partial Hysterectomy (clown to 3 — d, 
 page 1 15 1) — instead of cutting through the cervix transversely, the upper limits 
 of the vagina, anteriorly and posteriorly, are determined — and the vaginal 
 vault is then opened in front, about 1 to 2 cm. (f to f inch) below the vaginal 
 attachment of the uterus, by means of the thermocautery or scissors — aided 
 by a vaginal sound passed into the anterior fornix, if necessary — the incision 
 being continued around each side until the cervix is freed. The margin of the 
 cut vagina isligated. pari passu, with chromic gut at a right angle to its long 
 axis, using interlocking ligatures if necessary — the sutures being placed parallel 
 with and at a short distance from its margin. The sites of the ligatures re- 
 quired in total abdominal hysterectomy are shown in Fig. 831. All exposed 
 areas are protected with gauze. (3) The anterior and posterior edges of 
 peritoneum bordering the denuded area are sutured with continuous gut in a 
 transverse line from one pelvic brim, across the pelvic floor, to the opposite 
 pelvic brim, thus repairing the floor of the pelvis. The peritoneal edges are 
 closed over the vaginal opening — but the opening in the vaginal vault is not 
 sutured together — but, instead, a loose gauze pack is pushed through the 
 opened vaginal vault up to the sutured overlying peritoneum. (4) The 
 abdominal wound is closed in the ordinary manner. 
 
 Comment. — (1) If ureteral catheters are passed into the ureters prior to 
 the operation, the positions of the latter are made more evident during opera- 
 tion. (2) The uterine arteries may be ligatecl further back in the pelvis, nearer 
 their origin from the anterior branches of the internal iliacs — first assuring one's 
 self of the position of the ureters by [ticking up the uterine artery and parallel 
 tissues between the index and thumb — and then allowing them to slip out of 
 the grasp. If this be done, the artery is caught and drawn up and the dis- 
 section of the connective tissue is carried on down to the uterus. (3) Veins, 
 large single ones, and in plexuses, are apt to be encountered in the broad liga- 
 ment and on the pelvic floor. 
 
 TOTAL VAGINAL HYSTERECTOMY. 
 
 Description. — Removal of entire uterus through the vault of the vagina — 
 the incision being made from within the vagina. Indicated chiefly for 
 malignant growth of the cervix, or for malignant disease limited to cervix 
 
 and fundus. 
 
i '54 
 
 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 Preparation. — Pubis, labia, and perineum shaved. Vagina cleansed. 
 Bowels and bladder emptied. 
 
 Position. — Patient supine, at end of table, in lithotomy position. Surgeon 
 sitting at foot of table. Assistant to surgeon's right, retracting posterior vagi 
 nal wall with large Sims or other retractor — while the lateral vaginal walls 
 are retracted by lateral vaginal retractors. 
 
 Landmarks. — Anterior and posterior vaginal fornices; known position of 
 ureters and uterine vessels. 
 
 Operation. — (i) The lips of the cervix are caught and drawn down with 
 
 Fig. 8^52. — Vaginal Hysterectomy: — I. A, Sutures closing lips of uterus and serving as trac- 
 tion-loops, by which uterus is drawn out of vagina ; B, Knife making incision through mucous mem- 
 brane around cervix, at level with vaginal vault; C, Irrigator washing away blood. Vaginal walls 
 are well retracted by four retractors. (Modified from Kelly.) 
 
 vulsella, or tenaculum-forceps — and are sutured together with strong silk (to 
 prevent escape of contents). The silk ligatures may be left as long traction- 
 loops. The uterus is thus drawn well down into the outlet (by forceps or 
 loops) — while the vaginal walls are retracted downward and outward, as de- 
 scribed above (Fig. 832). (2) With a knife, or sharp curved scissors, an in- 
 cision is made entirely around the cervix, passing through the thickness 
 of the vaginal vault down upon the substance of the cervix. (3) With 
 the right index, the cellular tissue plane is opened up in front (between uterus 
 
TOTAL VAGINAL HYSTERECTOMY 
 
 "55 
 
 and bladder) and behind (between uterus and Douglas's cul-de-sac) — by push- 
 ing up and peeling back the tissues with the pulp of the finger always directed 
 against the cervix, to prevent the fingers from slipping off violently in the 
 wrong direction (Fig. 833). This separation is done anteriorly and posteriorly 
 — but not done laterally, where the vessels enter from the broad ligament. 
 Posteriorly, Douglas's cul-de-sac is recognized by a slight amount of fluid 
 present within its cup-like cavity and by the smooth surfaces gliding over each 
 other. This is caught with forceps, drawn down and incised with sharp 
 
 Fig. 833 —Vaginal Hysterectomy :— II. Index-finger opening up cellular tissue plane between 
 uterus and bladder, anteriorly ; and between uterus and Douglas's cul-de-sac, posteriorly. (Modified 
 from Kelly.) 
 
 scissors to a slight extent, the opening being increased to the broad ligaments 
 on each side by two fingers introduced and separated. Anteriorly, the sepa- 
 ration is continued until the anterior vesico-uterine peritoneal fold is reached — ■ 
 which is recognized by its gliding surfaces — and which is drawn down with 
 forceps and incised with sharp scissors to a limited extent — the opening being 
 increased to the broad ligament on each side by fingers introduced and sepa- 
 rated, guided, if necessary, by a sound in the bladder. The peritoneal cavity 
 is thus opened in front and behind and the uterus is left hanging from the broad 
 
1156 
 
 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 ligaments (4) The broad ligaments are now tied off. The uterus is drawn 
 well down and to the side opposite that upon which the ligature is to be passed, 
 while the corresponding vaginal wall is retracted. The left index-finger is 
 passed in through the posterior opening behind the broad ligament and near 
 the cervix. A strong silk ligature, carried by a laterally curved aneurism- 
 needle, is passed from before backward, and from above downward, and about 
 1 cm. (f inch) to the outer side of the cervix, and including about 1 cm. (f inch) 
 of broad ligament tissue (Fig. 834). The ligature is firmly tied and the broad 
 ligament included is immediately divided with scissors, rather nearer the 
 
 Fig. 834. — Vaginal Hysterectomy: — III. Ligating off the left broad ligament. (Modified from 
 
 Kelly.) 
 
 uterus — being careful not to make the division higher than the ligature has 
 gone. Two or three ligatures can generally be applied to one side before plac- 
 ing the same number on the opposite side, during downward traction of the 
 uterus to the side where the first ligating was done (always drawing it to the 
 side opposite the one upon which the greatest exposure is wished). Or the 
 ligating may be continued up one side as far as convenient, even to the cornu 
 of the uterus, and then upon the other side. The uterine vessels are generally 
 included in the second or third ligature, being found close to the cervix uteri 
 near the os internum. The position of the uterine artery should be determined 
 
TOTAL VAGINAL HYSTERECTOMY. 
 
 "57 
 
 as soon as the opening through the posterior fornix is made. Especial care is 
 here taken to avoid the ureter (see Surgical Anatomy, pages 1074 and n 50). 
 When the ligating and division have progressed nearly to the cornu of that side, 
 the finger can be passed in behind and hooked over the remaining broad liga- 
 ment, fallopian tube, and round ligament, and these brought down and ligated 
 — this last ligature being tied particularly well and the tissues cut at a distance. 
 Often it is easier to alternate — by tying two or three ligatures on one side — then 
 on the opposite, and so on. 'When all of one side and nearly all of the oppo- 
 site broad ligament has been tied, the finger may be introduced and hooked 
 around the fundus of the uterus and the organ delivered sidewise — the remain- 
 
 Fig. 835.— Vaginal Hysterectomy :— IV. Delivering the uterus by means of a finger introduced 
 from behind and below. The right broad ligament has been entirely ligated and cut. (Modified 
 from Kelly.) 
 
 ing ligatures being applied either from below upward or from above downward, 
 as most convenient, while the organ lies in the vulval fissure (Fig. 835). Or, 
 after progressing a part of the way, the fundus may be brought down, carrying 
 the cervix up into the pelvic cavity and doubling the broad ligament upon 
 itself — and thus applying the remaining ligatures in the reverse direction. But 
 it is better, and more surgical, to deliver the uterus in its normal axis — continu- 
 ing the ligating and division upon the two sides as first described. (5) The 
 right and left groups of sutures are separated and held aside and the lower pel- 
 vic cavity irrigated and mopped or sponged out. Each line of broad ligament 
 ligatures must be inspected — suspicious ones replaced — and additional ones 
 
u?8 
 
 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 applied where indicated. The ligatures of each side are tied together in one 
 group and cut near the knot, closely within the vagina. (6) The cut edge of 
 the vesico-uterine peritoneal fold in front is sutured at its middle with gut to the 
 middle of the cut edge of the utero-rectal peritoneal fold behind — either by a 
 single mattress suture bringing the central portions of the two peritoneal folds 
 together, or by a continuous suture bringing together the central portion — 
 leaving, in either case, a gap at either side for possible drainage in cases where 
 the vaginal vault is not sutured, or only sutured in part. Where the vaginal 
 vault is entirely sutured, the two edges of the peritoneum should be sutured 
 together throughout. (7) The vaginal vault may be left entirely unsutured — 
 
 Fig. 836.— Vaginal Hysterectomy: — V. Peritoneal and vaginal suturing; A, Vesico-uterine 
 peritoneal fold ; B, Utero-rectal peritoneal fold. A transverse line of interrupted sutures unites the 
 central portion of these folds. C, C, Vessels and broad ligament ligated. D, Vault of vagina ; E, 
 Sutures approximating cut edges of anterior and posterior vaginal fornix, thus repairing dome of 
 vagina ; F, Each lateral vaginal suture also passes through broad ligament stump, and thus brings it 
 into lip of vaginal wound. (Modified from Kelly.) 
 
 in which cases it is packed loosely with gauze, and the vagina is then packed 
 rather snugly. In other cases, which method is to be preferred, the vaginal 
 vault is entirely closed by a line of continuous or interrupted gut sutures bring- 
 ing the cut edges of the fornices together and crossing the dome of the 
 vagina from before backward. But at each side the lower portion of the ligated 
 broad ligament is caught and drawn down into the upper part of the vagina, 
 and the sutures which pass through the lips of the vaginal vault also pass 
 through and include some of the broad ligament stump — the stumps on the 
 two sides thus projecting into the vagina, thus insuring drainage. (Fig. 836.) 
 
SURGICAL ANATOMY OF THE OVARIES. 1159 
 
 Comment. — (1) Up to the opening of the peritoneal cavity, blood is re- 
 moved by constant irrigation through a special glass tube held just above the 
 vulva, — after opening the peritoneum, by gauze mops. (2) Catheters passed 
 into the ureters before the operation enable the position of the ureters to be 
 readily made out and guarded during operation. (3) If it be found, during 
 operation, that it is desirable to remove the tubes and ovaries, ligatures are 
 placed on the outer side of these. These ligatures are somewhat more difficult 
 to apply and tighten than the others. (4) Especially guard the ureters near 
 the cervix and behind the uterine arteries, while working near the cervix. 
 
 II. THE OVARIES. 
 
 SURGICAL ANATOMY. 
 
 (1) Ovaries. 
 
 Description. — Placed one on each side of the pelvis — connected with the 
 posterior layer of the broad ligament, posterior and inferior to the fallopian 
 tubes. Rests against the lateral wall of pelvis, with long axis nearly vertical 
 in erect position of body (His). Length, about 3.8 cm. (ih inches) ; — breadth, 
 about 2 cm. (f inch); — thickness, about 1.3 cm. (J inch). Position of ovary 
 corresponds with a point about 5 cm. (2 inches) internal to the anterior superior 
 iliac spine. In the position and relations given by His, the fallopian tube and 
 fimbria almost completely envelop the ovary. In structure, the ovary con- 
 sists of peritoneal serous covering and stroma. 
 
 Relations. — Mesial Surface; — Is free. Fimbriated extremity of fallo- 
 pian tube is in contact to various extent. Mesosalpinx is also in relation. 
 Coils of jejunum and ileum often to inner side of right ovary. Sigmoid colon 
 may be to inner side of left ovary. Lateral Surface ; — Lies in fossa ovarii, a 
 peritoneal depression upon the lateral pelvic wall, generally just below the 
 external iliac vessels — with the ureter often bounding the fossa below and be- 
 hind. Posterior Border; — Is free. Directed toward rectum. Partly em- 
 braced by fimbriated end of fallopian tube. Anterior Border; — Furnishes 
 attachment to broad ligament. Presents hilum (between two layers of broad 
 ligament) for entrance of vessels and nerves. Fallopian tube. Upper Ex- 
 tremity ; — Ovarian fimbria of fallopian tube are attached. Ligamentum sus- 
 pensorium ovarii (ligamentum infundibulo-pelvicum) passes from brim of 
 pelvis to upper extremity — conveying the ovarian vessels and nerves. Lower 
 Extremity ; — Ligament of ovary — from angle of uterus to lower or inner end 
 of ovary. 
 
 Arteries. — Ovarian of abdominal aorta; anastomotic branches of uterine 
 and internal iliac. The ovarian artery, crossing brim of pelvis, enters broad 
 ligament and runs in infundibulo-pelvic ligament — and, passing between 
 layers of broad ligament, runs to the ovary and upper part of uterus. 
 
 Veins. — Follow the arteries — and form the pampiniform plexus. 
 
 Nerves. — From ovarian plexus; from pelvic plexus; from uterine nerves. 
 
 Lymphatics. — Empty into prevertebral glands, in front of aorta and vena 
 cava. 
 
 (2) Fallopian Tubes. 
 
 Description. — Average length, 10 to 12.5 cm. (4 to 5 inches). Begin at 
 superior angle of uterus and extend — enclosed in upper free border of the 
 
u6o OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 broad ligament — to the sides of the pelvis, ending in the fimbriated extremities, 
 which are in relation with the corresponding ovaries. After enveloping the 
 fallopian tubes, the layers of the broad ligament are continued down to the 
 ovary. The tubes are made up of — the isthmus (inner third) — ampulla (from 
 isthmus to neck) — neck (or ostium abdominale) — and fimbriated extremity. 
 They are composed of serous, muscular, and mucous coats. 
 
 Course and Relations. — From the superior angles of the uterus, the}' run 
 nearly horizontally outward, for about 1.3 to 2.5 cm. (J to 1 inch) to the 
 pelvic wall — thence ascend, sometimes tortuously, anteriorly to their ovaries — 
 then curve backward over the ovaries, lying internal to the suspensory liga- 
 ment — and end by passing downward along the inner and posterior borders 
 of the ovaries. Ileo- jejunal convolutions are sometimes above and to inner 
 side of right fallopian tube. Sigmoid rectum is sometimes in the same relation 
 to the left tube. 
 
 Artery. — Tubal branch of ovarian. 
 
 OVARIECTOMY, OR OOPHORECTOMY, WITH REMOVAL OF FALLO- 
 PIAN TUBE. 
 
 (SALPINGO-OVARIECTOMY, OR SALPINGO-OOPHORECTOMV.) 
 
 Description. — Ovariectomy (or, less correctly, Ovariotomy) consists in the 
 removal of the ovary through, generally, an abdominal section. When the 
 fallopian tube is simultaneously removed, the operation becomes Salpingo- 
 ovariectomy, or Salpingo-oophorectomy. The ovary may be removed alone, 
 or the tube may be removed alone. In the operation here described, 
 the following structures will be removed: — entire ovary, entire fallopian tube, 
 part of utero-ovarian ligament, and the arteries, veins, lymphatics, and nerves 
 belonging to these structures. 
 
 Preparation. — Median line and pubis shaved. Bowels and bladder 
 emptied. 
 
 Position. — Patient supine near edge of table at first — and subsequently 
 elevated into slight Trendelenburg position after the abdomen is opened. Sur- 
 geon on side of operation — or always on patient's right, independently of ovary 
 operated upon — or may prefer to cut upward, and then stands on patient's left 
 in both cases. Assistant opposite. 
 
 Landmarks. — As for median abdominal section (page 801). 
 
 Incision. — In median line — about 5 to 10 cm. (2 to 4 inches) in length — 
 extending upward from a point about 2.5 cm. (1 inch) above the symphysis 
 pubis. 
 
 Operation. — (1) Perform a median abdominal section — control hemor- 
 rhage — and retract lips of abdominal wound. (2) Pass the first and second 
 fingers into the wound, with the back of the hand to the abdomen — follow 
 down the under surface of the abdominal parietes to the symphysis — thence 
 down on to the bladder and uterus — and thence out laterally over the superior 
 cornu of the uterus, with the palm of the hand still downward, to and along the 
 broad ligament — along the posterior superior aspect of which the fallopian tube 
 is found — and, just posterior to the tube, the ovary. These structures are 
 drawn toward the median line, into an accessible position in the abdominal 
 wound. (3) The ovarian artery and veins are first tied, with silk — the ligature 
 being carried, upon a laterally curved aneurism-needle, through the clear space 
 of the broad ligament and tied over the top of the infundibulo-pelvic ligament, 
 outside of the fimbriated end of the fallopian tube, and close to the brim of the 
 
OVARIECTOMY. 
 
 1161 
 
 pelvis (Fig. 837). (4) The utero-ovarian ligament, lying behind the fallopian 
 tube, is ligated with chromic gut, rather nearer the uterus, carried upon a later- 
 ally curved aneurism-needle. (5) The inner end of the fallopian tube and the 
 upper free part of the broad ligament are ligated with silk near the horn of the 
 uterus — which ligature also controls the branches from the uterine artery. (6) 
 The structures are now removed by cutting through the broad ligament well 
 within the outer ligature of the ovarian vessels — and cutting through the fallo- 
 pian tube and ovarian ligament well to the outer side of their ligatures — and 
 
 
 Fig. 837.— Ovariectomy, with Removal of Fallopian Tube: — A, Uterus; E, Aneurism- 
 needle carrying ligature around utero-ovarian ligament; C, Ligature passing through broad liga- 
 ment and surrounding fallopian tube and ovarian artery ; D, Ligature passing through broad 
 ligament and over top of infundibulo-pelvic ligament and surrounding ovarian artery; E, Round 
 ligament; F, Bladder ; G, Colon. 
 
 carrying the incision through the broad ligament well below the hilum of the 
 ovary. Any doubtful ligature is strengthened, and any bleeding point is sur- 
 rounded by an additional gut ligature. (7) The edges of the anterior and pos- 
 terior layers of the broad ligament, left by the removal of the above structures, 
 are sutured together with gut. The patient is lowered to the horizontal posi- 
 tion — and the intestines and omentum are replaced. (8) The abdomen is 
 closed, as after median abdominal section. 
 
 Comment. — (1) The main danger in the operation is from uncontrolled 
 
n62 OPERATIONS UPON THE FEMALE GENITAL ORGANS. 
 
 hemorrhage. Where there is any danger of a ligature slipping, one end of the 
 ligature may be carried through neighboring tissue and knotted to the oppo- 
 site end. (2) The non-vascular portion of the broad ligament between the 
 ligatures of the special structures may be left free — or, if ligated, should be so 
 ligated as not to bind the pelvic and uterine aspects of the broad ligament 
 together. 
 
 NOTE. 
 
 Other operations upon the Uterus and Ovaries, and the operations upon 
 the Fallopian Tubes, Broad Ligaments, Round Ligaments, Labia Majora and 
 Minora, Clitoris, Hymen, Glands and Ducts of Bartholin, Bulbi Vestibuli, 
 Vagina, Female Perineum, Female Bladder, Female Urethra, and Female 
 Ischio-rectal regions — all belonging more particularly to special Gynecological 
 Surgery, will not be considered here. 
 
CHAPTER VIII. 
 
 OPERATIONS FOR HERNIAE. 
 
 I. INGUINAL HERNIA. 
 
 SURGICAL ANATOMY. 
 
 The structures encountered in the operations for inguinal hernia? and 
 those in the immediate neighborhood of the site of operation, will be here 
 briefly described — chiefly in the order encountered, from without inward. 
 
 Superficial Fascia. — Divisible into two layers, between which lie super- 
 ficial arteries, veins, lymphatics, and nerves of the inguinal region. 
 
 Superficial Layer of Superficial Fascia. — Continuous with superficial 
 fascia of abdomen, thigh, penis, scrotum, labia, and perineum. 
 
 Superficial Arteries. — Superficial epigastric branch of femoral. Super- 
 ficial circumflex iliac of femoral. Superficial external pudic of femoral. 
 
 Superficial Veins. — Accompany arteries and end in internal saphenous 
 vein. 
 
 Superficial Lymphatics. — Superior group, along Pouparfs ligament. 
 Inferior group, around saphenous opening. 
 
 Superficial Nerves. — Hypogastric branch of Iliohypogastric, Ilio-inguinal. 
 
 Deep Layer of Superficial Fascia (Scarpa's Fascia). — Attached to 
 linea alba — continuous with superficial fascia over trunk — connected with 
 fascia lata — helps form dartos — continuous with deep layer of superficial fascia 
 of perineum. 
 
 External Oblique Muscle. — 
 
 Pcupart's Ligament. — That portion of aponeurosis of external oblique 
 extending from anterior superior iliac spine to spine of os pubis. 
 
 Gimbernat's Ligament. — That portion of aponeurosis of external oblique 
 which is reflected from Poupart's ligament, at spine of os pubis, along the 
 pectineal line. 
 
 Triangular Ligament. — That portion of aponeurosis of external oblique 
 which is reflected from Gimbernat's ligament, at the pectineal line, upward and 
 inward beneath the spermatic cord and behind the internal pillar of the ex- 
 ternal ring and in front of the conjoint tendon, to the linea alba, where it inter- 
 laces with its fellow of opposite side. 
 
 External or Superficial Abdominal Ring. — A triangular opening in 
 aponeurosis of external oblique immediately above and just external to crest of 
 os pubis. Bounded, interiorly, by crest of os pubis, — Superiorly, by inter- 
 columnar fibers, strengthened by intercolumnar fascia, — Internally, by inner 
 or superior pillar, — Externally, by outer or inferior pillar. Transmits sper- 
 matic cord in male, and round ligament in female. 
 
 Internal Oblique Muscle. — 
 
 Conjoint Tendon of Internal Oblique and Transversalis. — Inserted 
 into crest of os pubis and pectineal line, directly behind external abdominal 
 ring. 
 
 Cremaster Muscle. — Corresponds with inferior fibers of internal oblique 
 
 1163 
 
1164 OPERATIONS FOR IIKRM.K. 
 
 — arising from center of Poupart's ligament, where they are continuous with 
 the interno-inferior aspect of that muscle — descend along external and anterior 
 aspect of spermatic cord — curve around testicle — and, ascending along inner 
 aspect of cord, are inserted into crest of os pubis and anterior surface of sheath 
 of rectus. The fascia cremasterica increases the strength of these fibers. 
 
 Transversalis Muscle. — 
 
 Transversalis Fascia. — 
 
 Inguinal Canal. — Transmits spermatic cord in male — and round ligament 
 in female. Extends obliquely downward and inward for about 3.8 cm. (1^ 
 inches) — parallel with and slightly above Poupart's ligament — beginning at the 
 internal abdominal ring and ending at the external abdominal ring. Anterior 
 boundaries, — skin; superficial fascia; aponeurosis of external oblique (through- 
 out) ; internal oblique (outer third). Posterior boundaries, — triangular liga- 
 ment; conjoint tendon of internal oblique and transversalis; transversalis fascia; 
 subperitoneal fat; peritoneum. Superior boundaries, — curved fibers of in- 
 ternal oblique and transversalis. Inferior boundaries,- — junction of fascia 
 transversalis and Poupart's ligament. 
 
 Internal or Deep Abdominal Ring. — An oval opening lying in the trans- 
 versalis fascia, half-way between the anterior superior iliac spine and symphy- 
 sis pubis, and about 1.3 cm. (^ inch) above Poupart's ligament. Superior and 
 External boundary, — curved fibers of transversalis. Inferior and Internal 
 boundaries, — deep epigastric vessels. Transmits spermatic cord in male — and 
 round ligament in female. Infundibuliform process of fascia transversalis 
 strengthens its opening. 
 
 Subperitoneal Areolar Tissue. — 
 
 Deep Epigastric Artery, of External Iliac. — 
 
 Other anatomical points, necessary to the thorough understanding of the 
 Inguinal Hernia?, are given under General Surgical Considerations. 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Definition of Inguinal Hernia. — Hernia passing through the abdominal 
 wall in the inguinal region. 
 
 Varieties of Inguinal Herniae. — (1) External or Oblique Inguinal 
 Hernia, — neck of sac lies external to deep epigastric artery, — follows course of 
 spermatic cord through inguinal canal. (2) Internal or Direct Inguinal 
 Hernia, — neck of sac lies internal to deep epigastric artery, — hernia pene- 
 trates some portion of abdominal wall internal to deep epigastric artery. 
 
 (a) Oblique or External Inguinal Hernia. — 
 
 Coverings of Oblique Inguinal Hernia : — The hernia enters the external 
 inguinal fossa (v. i.) — and, passing down from the abdominal cavity, receives 
 the following coverings, in order; — (1) At Internal Abdominal Ring: — perito- 
 neum; subserous areolar tissue; infundibuliform process of fascia transversalis; 
 ■ — (2) In Inguinal Canal: — (passes under curved fibers of internal oblique 
 and transversalis, but does not receive a covering from them); cremaster 
 muscle; — (3) At External Abdominal Ring: — intercolumnar fascia; — (4) In 
 Scrotum: — superficial fascia; skin. 
 
 Position of Oblique Inguinal Hernia. — This variety of Inguinal Hernia 
 always lies to the outer side of the deep epigastric artery — and generally lies 
 anterior to the vessels of the spermatic cord — and rarely descends below the 
 the testis (because of adhesion of the hernial coverings to the tunica vaginalis). 
 
INGUINAL HERNIA— GENERAL SURGICAL CONSIDERATIONS. 1 165 
 
 Seat of Stricture in Oblique Inguinal Hernia. — Most frequently at the 
 internal ring, — may occur at the external ring, — or may occur in the canal, by 
 fibers of internal oblique and transversalis. 
 
 (b) Direct or Internal Inguinal Hernia. — A correct understanding of 
 this form of hernia depends upon a knowledge of the anatomy of the lower 
 abdominal wall: — 
 
 Cord-like Structures upon Inner Aspect of Lower Abdominal Wall. — 
 Seven cord-like structures are seen upon the inner aspect of the lower abdom- 
 inal wall — ranging from near the median line upward: — (a) Plica Urachi — 
 remains of fetal urachus in median line; — (b) Two Plica? Hypogastrics — 
 obliterated hypogastric arteries on each side of median line, running upward 
 toward the median line; — (c) Two Plicae Epigastrica? — deep epigastric arteries 
 running upward and toward median line; — (d) Two Poupart's Ligaments — 
 running upward and outward. 
 
 Fossae upon Inner Aspect of Lower Abdominal Wall. — Eight fossa? are 
 formed by the peritoneum stretched over these prominent cord-like structures 
 — by the depressions between them: — (a) Two Internal Inguinal Fossa? — be- 
 tween plica? urachi and plicae hypogastrics; — (b) Two Middle Inguinal 
 Fossa? — between plica? hypogastrica? and plica? epigastricae; — (c) Two Ex- 
 ternal Inguinal Fossa? — between plicae hypogastrica? and Poupart's ligaments; 
 (d) Two femoral fossa? — below Poupart's ligaments, to inner side of femoral 
 vein. 
 
 Relations of Herniee to Fossae upon Inner Aspect of Lower Abdom- 
 inal Wall. — (i) Through the External inguinal fossa, an oblique inguinal 
 hernia occurs; — (2) Through either the Internal or Middle inguinal fossa, a 
 direct inguinal hernia comes; — (3) Through the Femoral fossa, a femoral 
 hernia occurs. 
 
 Fossae within Hesselbach's Triangle through which direct Inguinal 
 Hernia may come. — Hesselbach's Triangle is bounded — Externally; by deep 
 epigastric artery; — Internally; by outer border of rectus muscle; — Interiorly; 
 by Poupart's ligament. The conjoint tendon of the internal oblique and trans- 
 versalis is stretched across the inner two-thirds of Hesselbach's triangle. The 
 remaining outer one-third has only the subperitoneal areolar tissue and trans- 
 versalis fascia between the peritoneum and the external oblique aponeurosis. 
 The plica hypogastrica divides Hesselbach's triangle into an internal inguinal 
 fossa (which is the region of the conjoint tendon) and a middle inguinal fossa. 
 Two forms, therefore, of direct inguinal hernia may occur — dependent upon 
 whether the hernia escapes through the inner two-thirds or the outer one- 
 third of Hesselbach's triangle. 
 
 Commoner Form of Direct Inguinal Hernia. — In which the hernia en- 
 ters the internal inguinal fossa, and either forces its way through the conjoint 
 tendon, in the inner two-thirds of Hesselbach's triangle — or carries the con- 
 joint tendon before it — and escapes into the lower part of the inguinal canal. 
 This form of direct inguinal hernia has the following coverings, in order: — (1) 
 Within Abdomen: — peritoneum; subserous areolar tissue; general layer of 
 fascia transversalis; — (2) On its way to lower part of Inguinal Canal; — con- 
 joint tendon of internal oblique and transversalis (instead of cremaster muscle) ; 
 and then enters lower part of inguinal canal, which it traverses to emerge at 
 external abdominal ring;— (3) At External Ring: — intercolumnar fascia; — (4) 
 In Scrotum: — superficial fascia; skin. 
 
 Rarer Form of Direct Inguinal Hernia. — In which the hernia enters the 
 middle inguinal fossa, and escapes through the outer third of Hesselbach's tri- 
 angle — external to the conjoint tendon — and enters the upper part of the in- 
 
n66 OPERATIONS FOR HERNLE. 
 
 guinal canal. This form of direct inguinal hernia has the following coverings, 
 in order: — (i) Within abdomen: — peritoneum; subserous areolar tissue; gen- 
 eral layer of fascia transversalis (instead of infundibuliform process of trans- 
 versalis fascia, as in the oblique form); — (2) In Inguinal Canal: — (which it 
 now enters at its upper part, instead of entering at the internal abdominal ring, 
 and travels through the rest of the way); cremaster muscle; — (3) At External 
 Ring: — (from which it exits as does oblique hernia) ; intercolumnar fascia; — (4) 
 In Scrotum: — superficial fascia; skin. 
 
 Position of Direct Inguinal Herniae. — Both of the varieties of direct in- 
 guinal hernia; lie upon the inner side of the deep epigastric artery. They do 
 not enter the upper opening of the inguinal canal, but pass through the tissues 
 over the os pubis and then enter the canal lower down — but make their exit 
 at the external abdominal ring. Both these direct hernia 1 generally descend 
 along the inner and anterior aspect of the spermatic cord. 
 
 Seat of Stricture in Both Forms of Direct Inguinal Herniae. — Most 
 frequently at the neck of the sac, — may occur at the external ring. Where the 
 hernia pierces the conjoint tendon, the stricture may be at the margin of the 
 fissure. 
 
 Direction of Incision for Relief of Stricture. — Whether in operating 
 for the relief of constriction in oblique inguinal hernia, or in either form of 
 direct inguinal hernia — divide directly upward — which would be external to the 
 deep epigastric artery in oblique inguinal hernia — and interna] to it in direct 
 inguinal hernia:. 
 
 INSTRUMENTS. 
 
 Scalpels; bistouries, straight and curved, sharp and blunt; scissors, straight 
 and curved, sharp and blunt; forceps, dissecting and toothed; artery-clamp 
 forceps; tenacula; grooved director; special hernia knife; special hernia-director 
 retractors; probe; needles, straight and curved; needle-holder; ligatures and 
 sutures, silk, plain gut, chromic gut, kangaroo tendon, silkworm-gut. 
 
 OPERATION FOR THE RADICAL CURE OF OBLIQUE INGUINAL 
 
 HERNIA. 
 
 BASSINI'S METHOD. 
 
 Description. — Consists in the transplantation of the cord from its old to a 
 new bed — between the internal oblique below, and the external oblique above 
 — formed by suturing the lower borders of the conjoint tendon and the trans- 
 versalis and internal oblique muscles above, to the shelving portion of Pou- 
 part's ligament below — and covering these by suturing the aponeurosis of the 
 external oblique, fascia and skin over them. The hernial sac is ligated and 
 removed at its neck. The constituents of the cord are not disturbed. 
 
 Preparation. — Bladder and bowels are emptied and pubic region shaved. 
 
 Position. — Patient supine near edge of that side of table upon which 
 hernia is. Surgeon on side of hernia, cutting from above downward on right, 
 and from below upward on left, — or he may stand upon the right in both cases. 
 Assistant opposite. 
 
 Landmarks. — Internal and external rings; inguinal canal; spermatic cord; 
 Poupart's ligament; anterior superior iliac spine. 
 
 Incision. — Begins at a point to the inner side of the anterior superior iliac 
 spine, and about 1.3 cm. (\ inch) above Poupart's ligament — passes obliquely 
 
BASSINI'S OPERATION FOR OBLIQUE INGUINAL HERNIA. 1167' 
 
 downward parallel with and about 1.3 cm. (£ inch) above Poupart's ligament — 
 and ends over the middle of the external abdominal ring — being about 7.5 to 
 9 cm. (3 to 3^ inches) long (Fig. 838, A). 
 
 Operation.— (1) Divide skin and superficial fascia, clamping bleeding 
 vessels — and retract edges of wound, exposing aponeurosis of external oblique. 
 (2) Demonstrate the external abdominal ring and pass a grooved director 
 through its opening and carry it obliquely upward in the line of the fibers of the 
 external oblique aponeurosis, and immediately beneath its surface, for a dis- 
 tance of about 6.3 cm. (2^ inches) — the instrument showing through its thin 
 texture (Fig. 839). Slit up the fibers of the aponeurosis of the external oblique 
 upon the grooved director with a scalpel, traveling in the cleavage line of the 
 fibers. Dissect, by blunt separation, the upper edge of the cut aponeurosis in- 
 
 Fig. 83S.— Incisions for Radical Cure of Oblique Inguinal Hernia:— A, Incision for Bassini'j 
 Operation; B, Incision for Halsted's Operation. 
 
 ward and upward nearly to the outer edge of the rectus sheath. Similarly dis- 
 sect, by blunt separation, the lower edge of the cut aponeurosis of the external 
 oblique downward and outward to the shelving portion of Poupart's ligament. 
 The inguinal canal, except that part covered by the internal oblique, is thus 
 exposed. (3) Grasp, with forceps, aided by the fingers, the mass of soft 
 tissues just within, or emerging from the external abdominal ring, composed 
 of cord and hernial sac — and, pushing aside the muscle-fibers with a blunt 
 dissector, or closed ends of blunt, curved scissors, lift upward and out- 
 ward the hernial sac and cord — drawing them partly from the direction 
 of the inguinal canal, and partly from the direction of the scrotum — the 
 hernia lying anteriorly, surrounded by the infundibuliform fascia, and the 
 cord posteriorly — the sac and cord being more or less intimately adherent. 
 
1 68 
 
 OPERATIONS FOR IIERNLF. 
 
 (4) Isolate the sac from the cord by blunt dissection — and carry on the free- 
 ing of the sac upward, retracting the internal oblique muscle outward to 
 expose the outer aspect of the inguinal canal, until the sac begins to open 
 out into the general peritoneum. If it be certain that the sac contains no 
 adherent intestines or omentum, it need not be opened. If there be any ques- 
 tion — and it is probably better in all cases to do so, whether question or not 
 — the sac should be opened at some distance below the point of intended closure 
 and examined. The contents of the sac, if any, are returned to the abdom- 
 inal cavity. The sac is then to be treated in one of two ways: — If it be small, 
 a double chromic gut ligature is carried through the center of that portion 
 which is to form the line of occlusion — these two ligatures are crossed and are 
 
 Fig. 830 — Bassim's Operation for Oblique Inguinal Hernia:— I. Splitting aponeurosis of 
 external oblique; A, Aponeurosis of external oblique; E, External abdominal ring; C, Cord; D, 
 Grooved director passed beneath aponeurosis of external oblique. (Modified from Bull and Coley.) 
 
 firmly tied on each side — and the sac cut off a safe distance from the ligatures. 
 If the sac be large (so that ligating would cause too much puckering and prob- 
 ably slip off), its surfaces are to be sutured with chromic gut on a level with 
 the site of division — and then -cut off with scissors at a safe distance distal to the 
 suture line. The sac is thus disposed of and returned to the abdominal cavity 
 (Fig. 840). (5) The cord is now taken up in the left thumb and index and 
 isolated from external to internal ring, en masse, without disturbing its com- 
 ponent structures, and a strip of gauze is passed beneath it — whereby it is held 
 up by an assistant well out of the way, until its new bed is made for it. (6) The 
 lower borders of the internal oblique and transversalis muscles are now sutured 
 to the shelving portion, or border of Poupart's ligament, with interrupted su- 
 
BASSINI'S OPERATION FOR OBLIQUE INGUINAL HERNIA. 1169 
 
 Fig. 840. — BassinTs Operation for Oblique Inguinal Hernia: — II. Isolation of sac ; A, 
 External oblique muscle; B, B, Aponeurosis of external oblique; C, Internal oblique muscle; D, 
 Conjoint tendon of internal oblique and transversalis ; E, Cord ; F, Sac, incised and drawn outward ; 
 G, Neck of sac surrounded by ligature; H, Ilio-inguinal nerve ; I, Genitocrural nerve. (Modified 
 from Bull, Coley and Kelly.) 
 
 Fig.841— Bassini's Operation for Oblique Inguinal Hernia:— III. Forming new floor for 
 cord, A, A, Aponeurosis of external oblique; B, Shelving portion of Poupart's ligament; C, Cord, 
 drawn out of canal by hook ; 1>. Internal oblique and transversalis retracted strongly outward ; E, 
 Needle carrying sutures approximating internal oblique and transversalis, above, with shelving por- 
 tion of Poupart's ligament, below. (Modified from Bull and Coley.) 
 
 74 
 
OPERATIONS FOR HERN I.E. 
 
 tures of kangaroo tendon or chromic gut, taking a good hold of both structures, 
 using a curved needle, preferably of the Hagedorn type. Prior to the insertion 
 
 Fig. 842.— Bassini's Operation for Oblique Inguinal Hernia : — IV. New floor for cord com- 
 pleted ; A, A, Aponeurosis of external oblique; E, Shelving portion of Poupart's ligament; C, In- 
 ternal oblique and transversalis; D, Sutures forming new bed for cord, by approximating internal 
 oblique and transversalis, above, to shelving portion of Poupart's ligament, below ; E, Cord drawn 
 outward by hook. (Modified from Bull and Coley.) 
 
 A, 
 
 Fig. 843. — Bassini's Operation for Oblique Inguinal Hernia: — V. New roof of canal 
 formed ; A, Sutures uniting split fibers of external oblique aponeurosis over cord ; B, Cord emerg- 
 ing from new external ring. (Modified from Bull and Coley.) 
 
 of the sutures uniting internal oblique and transversalis above, to Poupart's liga- 
 ment below, the lower borders of the internal oblique and transversalis should 
 
HALSTED'S OPERATION FOR OBLIQUE INGUINAL HERNIA. 1171 
 
 be isolated by the surgeon's fingers from the transversalis fascia, beginning at 
 the conjoint tendon and extending outward to the internal abdominal ring. 
 While passing the sutures, the surgeon's left index should be carried behind the 
 conjoint tendon and also behind the lower borders of the internal oblique and 
 transversalis muscles, so as to guide the needle-point. The first suture, near 
 the upper end of the wound, pierces the internal oblique almost as far outward 
 as the external border of the rectus muscle. It should just come in contact 
 with the inner aspect of the cord when the latter is held at a right angle to the 
 plane of the internal oblique muscle as it emerges from opposite the internal 
 ring. A second suture is placed just above the cord, to strengthen the internal 
 ring, the cord thus emerging between two sutures. As many similar sutures as 
 are indicated (generally six or seven altogether) are thus placed. The last, 
 lowest, suture passes through the conjoint tendon of the internal oblique and 
 transversalis above, and the shelving portion of Poupart's ligament below. 
 (Fig. 841.) (7) The cord is now dropped down upon its new bed made by su- 
 turing the conjoint tendon and the internal oblique and transversalis muscle to 
 the shelving border of Poupart's ligament (Fig. 842) . (8) The separated edges 
 of the aponeurosis of the external oblique are now sutured directly over the 
 cord with continuous kangaroo or chromic gut sutures — carefully avoiding too 
 tightly suturing the edges over the cord at the lower end, the new external ring, 
 where the cord escapes into the scrotum (Fig. 843). (9) The skin is closed 
 throughout with interrupted sutures of fine catgut. No drainage is used. 
 The first dressing usually comes off at the end of a week. 
 
 Comment. — No muscle tissue, except aponeurosis of external oblique, is 
 cut. 
 
 OPERATION FOR THE RADICAL CURE OF OBLIQUE INGUINAL 
 
 HERNIA. 
 
 halsted's method. 
 
 Description. — Like Bassini's operation, which it resembles in many 
 respects, Halsted's original method consisted not only in a transplantation of 
 the cord from its natural to a new canal, but also in the making of a new, 
 closely fitting internal ring. It differed from Bassini's technic in the following 
 respects: — (a) a new internal ring was made; — (b) most of the veins of the 
 cord were excised; — (c) the internal oblique and transversalis muscles and 
 transversalis fascia were incised; — (d) the cord was finally made to lie between 
 the aponeurosis of the external oblique and the skin; — and (e) silver wire 
 mattress sutures were extensively used. The original technic has been con- 
 siderably modified — as described under Operation. 
 
 Preparation — Position — Landmarks. — As for the Bassini operation. 
 
 Incision. — Begins about 3 cm. (i| inches) to the outer side and above the 
 internal abdominal ring — and extends thence in a straight line to the spine of 
 the pubis. 
 
 Operation. — Incise skin and fascia and split the fibers of the muscular 
 and aponeurotic portions of the external oblique along this line, to and through 
 the external ring. Retract the borders of the incision, thus exposing the cord, 
 cremaster muscle and fascia, vessels, and hernial sac. The fibers of the 
 cremaster muscle (which constitutes the lower part of the internal oblique 
 muscle) are split somewhat above the cord. The vessels, especially the redun- 
 dant veins, are isolated, grasped with forceps at either end, and ligated and 
 divided at the internal and external rings — and are carefully dissected away 
 
1172 
 
 OPERATIONS FOR HERNLE. 
 
 between the sites of ligation, retracting and guarding the vas deferens (Fig. 
 844). Having freed the hernial sac, incise it and return its contents to the 
 
 Fig. 844. — Halsted's Operation for Oblique Inguinal Hernia: — I. — The aponeurosis 
 and fibers of the external oblique have been split and retracted. The fibers of the cremaster 
 (internal lower part of internal oblique) have been retracted and split somewhat above the cord. 
 The hernial sac, spermatic cord, and veins are seen in the mass of connective tissue, being retracted 
 upward by catch-forceps. 
 
 abdominal cavity. Having especially freed the neck of the sac, transfix and 
 ligate it with chromic gut, leaving both ends of the ligature long. Each end 
 
 Fig. 845. — Halsted's Operation for Oblique Inguinal Hernia: — II. — The median 
 aspect of the internal oblique sutured (interrupted mattress sutures) to the outer aspect of the 
 split internal oblique — causing the former to overlap the latter. 
 
 of this ligature is threaded with a curved needle — both of which are carried 
 upward and inward under the internal oblique, 1.3 cm. (\ inch) apart, and 
 
HALSTED'S METHOD FOR OBLIQUE INGUINAL HERNIA. 1 1 73 
 
 passed through the muscle and tied so as to draw the neck of the sac up and 
 anchor it. Mobilize the median aspect of the split internal oblique sufficiently 
 
 Fig. 846. — Halsted s Operation' for Op.lique Inguinal Herxia: — III. — The free edge 
 of the internal oblique and conjoint tendon sutured (plain interrupted sutures) to the shelving 
 portion of Poupart's ligament. 
 
 to subsequently enable its edge to reach to Poupart's ligament — and suture 
 it to the outer aspect of the split internal oblique by several mattress sutures 
 
 Fig. S47.— Halsted 's Operation for Oblique Inguinal Hernia: — IV. — The inner 
 aspect of the external oblique is sutured (mattress sutures) to the outer aspect of the external 
 oblique — causing the former to overlap the latter. 
 
 of fine silk (or chromic gut) — in such a way as to cause an overlapping of the 
 median upon the outer aspect of the internal oblique (Fig. 845). Suture 
 
H74 OPERATIONS FOR HERNLF. 
 
 the free edge of the internal oblique, the conjoint tendon (and a part of the 
 sheath of the rectus, if necessary) to the shelving portion of Poupart's liga- 
 ment by interrupted chromic gut sutures (Fig. 846). Suture, with chromic 
 gut mattress sutures, the inner aspect of the aponeurosis of the external oblique 
 to the outer aspect of the external oblique aponeurosis — causing the former 
 to overlap the latter (Fig. 847). And then suture, with plain, interrupted 
 
 Fig. 848. — Halsted's Operation for Oblique Inguinal Hernia: — V. — The free border 
 of the inner aspect of the external oblique is sutured to the outer surface of the outer aspect of 
 the external oblique. 
 
 chromic gut stitches, the free border of the inner aspect of the external oblique 
 aponeurosis down to the outer surface of the outer aspect of the external 
 oblique (Fig. 848) . The skin-wound is closed with a subcuticular silver-wire 
 suture. The suture line is covered with silver foil — which is removed in two 
 weeks, at which time the subcuticular suture of wire is withdrawn. 
 
 II. FEMORAL HERNIA. 
 
 SURGICAL ANATOMY. 
 
 The structures encountered in the operations for Femoral Hernia, and those 
 in the immediate neighborhood of the site of operation, will be here briefly de- 
 scribed, chiefly as encountered, from without inward. 
 
 Superficial Fascia. — Between whose layers are superficial arteries, veins, 
 lymphatics, and nerves. 
 
 Superficial Layer of Superficial Fascia. — 
 
 Superficial Arteries. — Superficial external pudic; superficial epigastric; 
 superficial circumflex iliac — all from the femoral. 
 
 Superficial Veins. — Internal or long saphenous — receiving superficial ex- 
 ternal pudic, superficial epigastric, and superficial circumflex iliac. 
 
 Superficial Inguinal Glands. — Superior set — along Poupart's ligament. 
 Inferior set — around saphenous opening. 
 
 Superficial Nerves. — Uio-inguinal; crural branch of genito-crural. 
 
SURGICAL ANATOMY OF FEMORAL HERXIA. 1175 
 
 Deep Layer of Superficial Fascia. — Cribriform fascia — that portion 
 attached to borders of saphenous opening, in fascia lata. 
 
 Fascia Lata. — Iliac portion — outer portion of fascia lata. Pubic portion — 
 inner portion of fascia lata. 
 
 Saphenous Opening. — Opening in fascia lata formed by iliac and pubic 
 portions uniting — through which opening a femoral hernia escapes after tra- 
 versing the crural canal. 
 
 Poupart's Ligament or Crural Arch. — See Inguinal Hernia. 
 
 Gimbernat's Ligament. — See Inguinal Hernia. 
 
 Crural or Femoral Sheath. — Formed by continuation downward of trans- 
 versalis fascia in front and iliac fascia behind the femoral vessels — the two 
 layers being united and continuous directly to the outer side of the vessels; but 
 at a short distance from these vessels, upon the inner side, a space intervenes, 
 usually occupied by a lymphatic gland, between the femoral vein and the inner 
 limit of the sheath, constituting the crural or femoral canal. The femorai 
 sheath is redundant and funnel-shaped opposite Poupart's ligament, but is ad- 
 herent to the areolar sheath of the femoral vessels about 2.5 cm. (1 inch) below 
 the saphenous opening. 
 
 Relations of Crural or Femoral Sheath. — Anteriorly: — iliac portion of 
 fascia lata. Posteriorly: — pubic portion of fascia lata. Externallv: — genito 
 crural nerve pierces. Internally: — internal saphenous vein and lymphatics 
 pierce. 
 
 Septa of Crural or Femoral Sheath. — Outer antero-posterior septum — 
 between femoral artery and femoral vein. Inner antero-posterior septum — 
 between femoral vein and femoral canal. 
 
 Compartments within Crural or Femoral Sheath. — Three compart- 
 ments are formed by the two above septa. Outer compartment is occupied by 
 femoral artery. Middle compartment — by femoral vein. Inner compart- 
 ment — constitutes femoral canal — which is generally filled up by lymphatic 
 glandular and areolar tissue in the normal state. 
 
 Deep Crural Arch. — A thickened portion of fascia transversalis, passing 
 from center of Poupart's ligament, across the anterior aspect of the crural 
 sheath, to be attached to the pectineal line posterior to the conjoint tendon. 
 
 Crural or Femoral Canal. — Space between femoral vein and inner wall of 
 femoral sheath — that is, the inner compartment of the sheath of the femoral 
 vessels. Anterior wall— formed by transversalis fascia covered by falciform 
 process of iliac portion of fascia lata. Posterior wall — formed by iliac fascia, 
 resting upon pubic portion of fascia lata. External wall — formed by internal 
 septum between it and femoral vein. Internal wall — formed by union of 
 transversalis and iliac fascia? bounding the femoral canal and resting against 
 the base or outer border of Gimbernat's ligament. Upper opening of femoral 
 canal — is the femoral or crural ring, and is closed by the septum crurale (con- 
 densed areolar tissue). Lower opening of femoral canal — is the saphenous 
 opening, and is closed by the cribriform fascia. 
 
 Crural or Femoral Ring. — Superior opening of the femoral canal into the 
 peritoneal cavity — oval, transverse in direction, about 1.3 cm. (i inch) in ex- 
 tent — and having following boundaries: — Anteriorly: — Poupart's ligament; 
 deep crural arch. Posteriorly: — os pubis; pectineus; pubic portion of fascia 
 lata. Internally: — external border of Gimbernat's ligament; conjoint tendon; 
 transversalis fascia; deep crural arch. Externally:- — inner antero-posterior 
 fibrous septum on inner aspect of femoral vein. 
 
 Relations of Structures in the Near Neighborhood of the Ring. — Supe- 
 riorlv: — spermatic cord in male (round ligament in female); deep epigastric 
 
\l]6 OPERATIONS FOR HERXEE. 
 
 vessels. Externally: — femoral vein; deep epigastric- vessels. Anteriorly: — com- 
 municating branch between deep epigastric and obturator arteries. Inter- 
 nally: — no important structure. Posteriorly : — no important structure. 
 
 Obturator Artery.-- Arises in common with deep epigastric once in every 
 three and one-half subjects — and in such cases it follows one of two courses: 
 — (i) Runs down upon inner aspect of external iliac vein, along the outer side of 
 crural ring — and is, therefore, in safety. (2) Runs along free border of Gim- 
 bernat's ligament, along the inner side of crural ring — and, therefore, is apt to 
 be cut in an outward incision for relief of stricture. 
 
 Septum Crurale. — Condensed areolar tissue closing upper opening of 
 femoral ring. 
 
 Subperitoneal Areolar Tissue. — 
 
 Peritoneum. — 
 
 GENERAL SURGICAL CONSIDERATIONS. 
 
 Course of Femoral Hernia. — Coming from within the abdominal cavity 
 outward, the hernia passes at first vertically through the femoral canal," from 
 the femoral ring to the saphenous opening — thence (because the femoral sheath 
 here narrows and is more closely connected to the vessels, and because of the 
 closer connection of superficial fascia and crural sheath to the saphenous open- 
 ing) forward through the cribriform fascia — thence upward upon the falci- 
 form process of the fascia lata and Poupart's ligament. In manipulation for 
 the reduction of such a hernia, pressure should be applied in the reverse direc- 
 tions. 
 
 Coverings of Femoral Hernia. — Passing from within outward, the hernia 
 carries with it the following structures, in order: — (1) Within the abdomen: — 
 peritoneum; subserous areolar tissue. (2) At femoral ring: — septum crurale. 
 (3) In Femoral canal: — femoral sheath. (4) At saphenous opening : — cribri- 
 form fascia. (5) Upon thigh : — superficial fascia ; skin. 
 
 Seats of Stricture. — (1) At the border of the saphenous opening; — (2) At 
 the union of the falciform process of the fascia lata and the curved edge of 
 Gimbernat's ligament; — (3) At the femoral ring. 
 
 Direction of Division of Stricture. — Upward and inward — for 4 to 6 mm. 
 (2 to 3 lines). 
 
 OPERATION FOR THE RADICAL CURE OF FEMORAL HERNIA. 
 
 BASSINI'S METHOD. 
 
 Description. — The hernial sac is exposed, emptied of contents, ligated, 
 excised, and the neck returned to the abdominal cavity. The femoral canal 
 is then closed by suturing Poupart's ligament and the falciform process of the 
 fascia lata, above and externally — to the pectineal fascia (pubic portion of 
 fascia lata) below and internally. 
 
 Preparation. — Pubic region and region of the saphenous opening shaved. 
 
 Position. — Patient supine at edge of table. Surgeon on side of hernia. 
 Assistant opposite. 
 
 Landmarks. — Poupart's ligament; femoral vessels; saphenous opening. 
 
 Incision. — Parallel with and just below Poupart's ligament, with its center 
 over the saphenous opening. 
 
 Operation. — (1) Incise skin and superficial fascia — clamp and tie vessels 
 — retract edges of wound — and expose the saphenous opening. (2) Dissect 
 
BASSIXFS OPERATION FOR FEMORAL HERNIA. 
 
 1177 
 
 out the hernial sac from its canal, as high up as possible. Open its lower part 
 and return its contents to the abdominal cavity. Draw the sac well down and 
 transfix its neck with double chromic ligature. Cross the ends of the ligatures 
 and ligate and cut off the neck safely below the ligature — the stump receding 
 into the abdomen. (3) Pass kangaroo tendon, or chromic gut sutures, in a 
 curved needle, in the following manner: — (a) Pass three sutures to approxi- 
 mate Poupart's ligament to the pectineal fascia — the first, near the pubic 
 spine — the second, about 5 mm. (nearly % inch) to the outer side of the first — 
 and the third, about 1 cm. (f inch) to the inner side of the femoral vein — each 
 passing through the pectineal fascia below. These sutures are left tempora- 
 rily untied, (b) Pass three or four other sutures through the falciform process 
 of the iliac portion of the fascia lata, externally — and the pectineal fascia (which 
 is the same as the pubic portion of the fascia lata) internally — the lowest su- 
 
 Fig. 849. — Eassini's Opkration for Femoral Hernia: — A, Poupart's ligament; B, Falci- 
 form process of fascia lata ; C, Pectineal fascia (pubic portion of fascia lata;; D, Internal saphenous 
 vein. Three sutures to right approximate Poupart's ligament to pectineal fascia. Remaining sutures 
 pass through falciform process of fascia lata externally, and the pectineal fascia internally. (^N'ote — 
 the femoral opening is represented somewhat too far outward .) 
 
 ture passing just above the saphenous vein. (4) The upper sutures are then 
 tightened and tied, bringing Poupart's ligament backward to the linea pectinea. 
 The lower sutures are next tightened and tied, approximating the anterior and 
 posterior walls of the femoral canal. (5) The skin incision is closed with silk. 
 No drainage is used. (Fig. 849.) 
 
 Comment. — The closure of the femoral opening may also be made by a 
 purse-string suture. Kangaroo tendon, upon a curved needle, is passed 
 through the inner aspect of Poupart's ligament, or through the roof of the 
 femoral canal — thence passes downward, taking a firm hold upon the pec- 
 tineal fascia and underlying muscle — thence outward and upward through 
 the fascia lata, covering the femoral vein — thence upward, coming out through 
 
1178 
 
 OPERATIONS FOR HERNEE. 
 
 the roof of the femoral canal 6 cm. (| inch) from its place of entrance. When 
 this suture is tied, the floor of the femoral canal is brought up into contact with 
 its roof, thus obliterating the femoral opening. (Fig. 850.) 
 
 Fig. CS50. — Closure of the Femoral Caxal by a Purse-string Suture. 
 
 III. UMBILICAL HERNIA. 
 
 SURGICAL ANATOMY. 
 
 Parts Passing through the Umbilicus Early in Fetal Life.— Urachus; 
 umbilical arteries; umbilical vein; some of the fetal membranes and part of the 
 digestive tract. 
 
 Congenital Umbilical Hernia. — A form of hernia existing at birth — 
 owing to an error of development — the above conditions persisting. 
 
 Infantile Umbilical Hernia. — A form of hernia occurring in the early 
 years of life (generally prior to ten years of age). It is that form of hernia 
 where, after birth, the intestines protrude through the umbilicus, which, in the 
 latter part of fetal life, transmits only the umbilical vessels. 
 
 Method of Normal Closure of the Umbilicus. — (a) Several changes in 
 the component structures take place: — (1) Contraction and shrinkage of the 
 umbilical ring after birth — dividing, by its closure, the umbilical vessels run- 
 ning through the ring. (2) Clotting of the vessel contents — proliferation of 
 connective tissue — and contraction of the muscle-fibers of the vessels, (b) As 
 a result, a firm, fibrous scar is thus formed at the site of the umbilicus, with two 
 sets of fibers decussating about it; — (1) One set of fibers decussating in the 
 median line; — (2) Two sets of circular fibers interlacing upon the lateral 
 aspects of the umbilicus. 
 
 Site of Umbilical Hernia. — Thus it is seen that the umbilical vessels and 
 ring unite to form scar-tissue — which, remaining weak for a time — or subse- 
 
OPERATION FOR RADICAL CURE OF UMBILICAL HERXIA. 1 179 
 
 quently submitted to strain — may yield to hernia. Hernia occurring after 
 birth, therefore, may make its appearance by two routes: — (1) Exceptionally, 
 hernia comes through the abdominal wall near to, but not through, the um- 
 bilicus. (2) Ordinarily, hernia comes through the umbilical ring — and usually 
 through its upper third (where is the weaker scar-tissue about the umbilical 
 vein) — and but seldom through the lower two-thirds (where is the stronger scar- 
 tissue of the umbilical arteries and urachus). 
 
 Coverings of Umbilical Hernia. — (From within outward) — peritoneum; 
 subserous areolar tissue; transversalis fascia; stretched and distended umbilical 
 scar-tissue; superficial fascia, deprived of fat; integument. 
 
 A- 
 
 -■ 
 
 Fig. 851. 
 
 -Mayo's Operation for the Radical Cure of Umbilical Herxia: — I. — Clearing 
 the neck of the hernial sac. 
 
 OPERATION FOR THE RADICAL CURE OF UMBILICAL HERNIA 
 
 P,V EXCISION OF SAC AND SUTURING OF FRESHENED EDGES OF RING. 
 
 Description. — The hernial sac, together with the redundant tissues cover- 
 ing it, is excised by an elliptical incision — followed by the suturing together of 
 the freshened margins of the abdominal ring. 
 
n8o 
 
 OPERATIONS FOR HERNLE. 
 
 Preparation. — Site of hernia thoroughly scrubbed and shaved. Bowels 
 emptied. 
 
 Position. — Patient supine at edge of table. Surgeon to patient's right. 
 Assistant opposite. 
 
 Landmarks. — Site and form of hernia; umbilicus; median line. 
 
 Incision. — Elliptical in outline, with upper and lower ends in median 
 line — and maximum separation of limbs of ellipse opposite the greatest width 
 of the hernia, and determined by the size of the tumor. Laterally the lines of 
 incision generally come near the base of the tumor, so as to remove the excess 
 of skin. 
 
 Fig. 852. — Mayo's Operation for the Radical Cure of Umbilical Hernia: — II. — ■ 
 Suturing of the margins of abdominal aponeuroses and muscles, mattress sutures of Pagen- 
 stecher thread in the center and of chromic catgut laterally. 
 
 Operation. — (1) Incise, at first, through skin and fascia only. (2) Care- 
 fully deepen the wound on one side until the abdominal aponeurosis (sheath 
 of the recti) is reached — aiming to come down upon it a short distance to the 
 outer side of the hernial neck. (3) Having once reached the rectal aponeuro- 
 sis, similarly expose this aponeurosis and the neck of the hernial sac all around 
 the outline of the ellipse. All bleeding is controlled by clamp and ligature. 
 (4) The hernial sac is now incised and its contents dealt with as indicated. 
 
OPERATION FOR RADICAL CURE OF UMBILICAL HERNIA. Il8l 
 
 Adhesions are separated. Excess of omentum is ligated and excised. x\ll 
 remaining contents of the sac are returned to the abdomen — and kept in place 
 by a large, anchored gauze pad — which is removed just before closure of the 
 abdomen. (5) The entire sac, with the umbilicus and the coverings included 
 in the ellipse, is now excised—dividing the peritoneum in an elliptical manner 
 about the neck of the sac. (6) The peritoneum — or the peritoneum and trans- 
 versalis fascia together — is sutured with interrupted or continuous gut sutures. 
 
 (7) The borders of the abdominal ring — formed by the sheaths and margins 
 of the recti muscles — are freshened with curved scissors. The edges of the 
 ring are then brought together with interrupted sutures of kangaroo tendon or 
 chromic gut — using either the plain interrupted suture, or the mattress type. 
 
 (8) The skin and fascia (unless the fascia be thick enough to require separate 
 gut suturing) are sutured with interrupted silkworm-gut sutures. (9) The 
 part is then well supported by an abdominal dressing. 
 
 Comment. — Various forms of operation have been devised — including 
 die transposition of portions of the recti muscles over the site of hernia. 
 
 Fig. 853. — Mayo's Operation for the Radical Cure of Umbilical Hernia: — III. — 
 Overlapping of the aponeuroses, accomplished by the preceding tier of sutures, after which the 
 free edge of the upper margin of aponeuroses is stitched to the surface of aponeuroses of the 
 lower aspect of the wound. 
 
 OPERATION FOR THE RADICAL CURE OF UMBILICAL HERNIA. 
 
 MAYO'S " OVERLAPPING " METHOD. 
 
 Description. — Following the excision of the hernial mass, the abdominal 
 aponeuroses are overlapped transversely and sutured. 
 
Il82 OPERATIONS FOR HERNL-E. 
 
 Preparation — Position — Landmarks. — As for abdominal section. 
 
 Incision. — Two elliptical incisions are made transversely, surrounding 
 the neck of the sac and meeting on either side. 
 
 Operation. — Having carried the incision through skin and fascia down to 
 the abdominal aponeuroses, the neck of the hernial sac is cleared in its entire 
 circumference (Fig. 851). The sac is incised and its contents returned to the 
 abdomen — carefully separating adhesions from the sac-wall, and seeing that 
 no dangerous interintestinal adhesions are left. All protruding omentum is 
 tied off in segments, severed, and the stumps returned to the abdominal cavity. 
 The sac, including fascia and skin, are now excised — leaving a clean-cut 
 opening bounded by aponeuroses. A central mattress suture of stout Pagen- 
 
 
 K 
 
 Fig. 854. — Blake's Operation for the Radical Cure of Umbilical Hernia :- 
 vertical division of the parts and overlapping of the aponeuroses. 
 
 -Showing a 
 
 stecher thread is carried through the margins of the sac-opening — in such a 
 way as to cause the upper edge of the wound to overlap the lower — passing 
 through the entire thickness of aponeuroses, muscles, and peritoneum (Fig. 852) . 
 On each side of the central stitch a chromic gut mattress suture is similarly 
 placed. Upon drawing upon these three sutures, the lower flap is brought 
 upward and behind the upper flap — the two flaps being brought into close 
 approximation upon tightening the sutures. On retracting the upper flap 
 upward for examination, if any lack of approximation is found, the mattress 
 sutures are reinforced by interrupted chromic gut sutures. The free margin 
 of the upper flap is now sutured to the surface of the lower flap by interrupted 
 
OPERATION FOR RADICAL CURE OF UMBILICAL HERNIA. 1 183 
 
 or continuous chromic gut suturing (Fig. 853). The skin and fascia are 
 closed in the ordinary manner. The patient is kept in bed from twelve to 
 twenty davs. 
 
 Comment.— The same principle is carried out by Blake's operation— in 
 which a median incision is made and retracted and the margins of the apo- 
 neuroses made to overlap from side to side— instead of from above downward. 
 (Fig. 854.) 
 
NDEX 
 
 Abbe's operation for esophageal stricture, 
 
 716 _ 
 Abdominal aorta, anatomy of, 78 
 ligation of, 79 
 hysterectomy, partial, 1151 
 
 total, 1 153 _ 
 section, anterior, through rectal sheath, 
 811 
 anterolateral, Harrington-Weir pro- 
 longation of anterolateral intra- 
 muscular incision through rectal 
 sheath, Sio 
 inferior. Fowler's angular incision, 
 818 
 Meyer's hockey-stick incision, 817 
 McBurney's intramuscular incision, 
 
 807 
 superior, oblique subcostal incision, 
 818 
 lateral, Yischer's lumbo-iliac incision, 
 
 819 
 median, 801 
 
 complications during, 806 
 inferior, Pfannenstiel's incisions, 815 
 Abdominopelvic region, operations upon, 
 
 793 
 general considerations, 799 
 wall, anatomy of, 793 
 operations upon, 793 
 instruments for, 801 
 Abscess, cerebellar, operation for, 596 
 cerebral, operation for, 595 
 intra-abdominal, operative treatment of, 
 829 
 Acupressure for radical cure of aneurism, 
 
 139 
 of veins, 145 
 Albert's method of gastrostomy, 959 
 Alexander's method of prostatectomv, 1144 
 Allingham's operation for hemorrhoids, 944 
 Amputation, 271 
 
 about hands, general considerations, 339 
 adjustment and suturing of musculo 
 
 periosteal or periosteocapsular cover- 
 ing, 297 
 anesthesia in, 272 
 circular, 303 
 
 cuff method, 305 
 
 division of muscles in, 281 
 
 modified, 306 
 
 ordinary, 303 
 complications of, immediate, 320 
 drainage in, 300 
 dressing of wound, 301 
 elliptical, 315 
 
 75 
 
 Amputation, flap, 309 
 
 division of muscles in, 284 
 equal, of skin, 312 
 
 and muscle, 311 
 single, of skin, 311 
 
 muscles, 309 
 unequal, of skin, 314 
 muscles, 313 
 rectangular, of skin and muscles, 314 
 freeing and retracting muscles in, 288 
 
 skin and fascia in, 279 
 general considerations in, 271 
 hemorrhage in, control of, 272 
 incision of skin and fascia in, 276 
 instruments for, 271 
 interilio-abdominal, 460 
 intermediate, 319 
 irregular methods of, 317 
 ligating arteries and veins in, 295 
 location of limits of skin incisions in, 275 
 
 of line of bone-section in, 274 
 making musculoperiosteal or periosteo- 
 capsular covering, 289 
 methods of, 301 
 
 selection of, 317 
 of arm at surgical neck, 370 
 general considerations, 367 
 in general, 368 
 lower third, 368 
 together with scapula and part of 
 
 clavicle, 383 
 upper two-thirds, 370 
 of fingers, at first phalanx, 331 
 by palmar flap, 331 
 by short dorsal and palmar flaps, 
 
 33 2 
 at last phalanx, by palmar flap, 327 
 
 in general, 327 
 at second phalanx, by palmar flap, 330 
 by short dorsal and long palmar 
 
 flaps, 330 
 in general, 330 
 excluding thumb, with parts of meta- 
 carpals, 343 
 general considerations, 325 
 little, with part of metacarpal, 342 
 three innermost, with parts of meta- 
 carpals, 343 
 inside, with parts of metacarpals, 342 
 two contiguous inside, with parts of 
 
 metacarpals, 342 
 with parts of metacarpals, 341 
 of foot, general considerations, 401 
 of forearm, general considerations, 355 
 in general, 356 
 
 118.; 
 
u86 
 
 INDEX 
 
 Amputation of forearm, lower third, cir- 
 cular method, cuff variety, 357 
 modified circular method, 356 
 
 upper two-thirds, 358 
 of leg, at lower third, 420 
 
 femorotibial osteoplastic, 443 
 
 general considerations, 418 
 
 middle third, 424 
 
 osteoplastic, 422 
 at upper third, 429 
 
 supramalleolar region, 419 
 
 upper third, 425 
 
 bilateral hooded flaps, 427 
 of lower extremity, 385 
 of penis, partial, 11 14 
 
 total, n 16 
 of thigh, 440 
 
 at condyles of femur, 440 
 
 general considerations, 438 
 
 just above condyles of femur, 441 
 
 just below trochanters, 449 
 
 lower, middle, or upper third, 440, 44S 
 
 lower third, 444 
 of thumb, with part of metacarpal, 342 
 of toes, at first phalanx, 391 
 circular method, 392 
 oval method, 392 
 
 at last phalanx, 388 
 
 by plantar flap, 388 
 
 at metatarsus, 402 
 
 at second phalanx, 390 
 by plantar flap, 390 
 
 general considerations, 386 
 
 with part of metatarsals, 401 
 of upper extremity, 323 
 osteoplastic, 317 
 oval, 307 
 position of assistants in, 271 
 
 of patient in, 271 
 
 of surgeon in, 271 
 preparation of patient in, 271 
 primary, 319 
 quilting of muscles, 298 
 racket, 308 
 
 removal of dressings, 301 
 removing splintered bone, 294 
 retraction of skin and fascia in, 280 
 
 of soft parts preparatory to sawing 
 bone, 292 
 sawing bone, 292 
 secondary, 319 
 site of, in connection with resulting 
 
 stump and its adaptability to artificial 
 
 limb, 322 
 stump, 319 
 
 adaptability of, to artificial limb, 322 
 
 bad, characteristics of, 320 
 
 cicatrices of, position, 321 
 
 function of, 321 
 
 good, qualities of, 319 
 
 suturing, 300 
 
 tissues of, contractilitv, 321 
 
 vitality of, conditions influencing, 320 
 technic in, general, 274 
 treatment of nerves, tendons, and tags 
 
 of muscle, fascia, and skin in, 297 
 
 Amputation, trimming of flaps, 297 
 Anastomosis, facio-accessorv, for peripheral 
 facial paralysis, 196 
 faciohypoglossal, for peripheral facial 
 
 paralysis, 196 
 intestinal, 854. See also Entero-enteros- 
 
 tomy. 
 nerve-, 165 
 uretero-ureteral, 10S0 
 Anesthesia in amputations, 272 
 
 massive infiltration, with weak analgesic 
 solutions, Mata's modification of 
 Schleich's method, 172 
 regional, intraneural infiltration for, 169 
 Matas and Crile's operation, 169 
 paraneural infiltration for Mata's 
 method, 171 
 spinal, subarachnoid puncture for, 666 
 Aneurism, arteriovenous, radical cure of 
 Matas-Bickham operation for, 133 
 radical cure of, acupuncture for, 124 
 introduction of wire for, 139 
 ligation for, 139 
 Macewen's operation for, 139 
 Mata's operation for, 125 
 needling for, 140 
 Aneurismorrhaphy, 125 
 Ankle-joint, anatomy of, 412 
 
 disarticulations at, general considerations, 
 
 4_i3 
 excision of, 510 
 Annandale's osteoplastic resection of supe- 
 rior maxilla, 474 
 Anus, artificial, closure of, operation for, 927 
 permanent, left inguinal colostomy for, 
 
 _ 919 
 right inguinal enterostomy for, 914 
 fistula in, operation for, 947 
 Aorta, abdominal, anatomy of, 78 
 
 ligation of, 79 
 Aponeurotomy, 269 
 Appendicectomy, 900 
 Halsted's method, 910 
 McBurney's method, 900 
 non-intramuscular method, 911 
 through rectal sheath, 911 
 Appendicostomv, 912 
 Weir's method, 912 
 Arm, amputation about, general considera- 
 tions, 367 
 amputation of, 368 
 anatomy of, 365 
 Arterial forcipressure, 140 
 Arteriorrhaphy, 118 
 
 Bougie's method of, 123 
 Gluck's method of, 123 
 Murphy's method, 1 19 
 Salomoni and Tomaselli's method of, 123 
 Arteriostrepsis, 140 
 Arteriovenous aneurism, radical cure of, 
 
 Matas-Bickham operation for, 133 
 Artery, abdominal aorta, anatomy of, 78 
 ligation of, 79 
 axillary, anatomy of, 59 
 first part, ligation of, 60 
 third part, ligation of, 62 
 
INDEX 
 
 1187 
 
 Artery, brachial, anatomy of, 63 
 ligation of, 64 
 carotid, common, 'anatomy of, 32 
 left, anatomy of, 32 
 ligation of, 34 
 right, anatomy of, 32 
 external, anatomy of, 36 
 
 ligation of, 37 
 internal, anatomy of, 40 
 ligation of, 50 
 clearing of, for ligation, 22 
 dorsalis pedis, anatomy of, 107 
 
 ligation of, 107 
 exposure of, for ligation, 20 
 facial, anatomy of, 40 
 
 ligation of, 41 
 femoral, anatomy of, 91 
 common, ligation of, 93 
 superficial, ligation of, 96 
 gluteal, anatomy of, 87 
 
 ligation of, 87 
 iliac, common, anatomy of, 81 
 ligation of, 81 
 external, anatomy of, 88 
 
 ligation of, 89 
 internal, anatomy of, 83 
 ligation of, 84 
 innominate, anatomy of, 27 
 
 ligation of, 27 
 intercostal, anatomy of, 76 
 
 ligation of, 76 
 ligation of, 17. See also Ligation 0} 
 
 artery. 
 line of, 18 
 lingual, anatomy of, 38 
 
 ligation of, 39 
 mammary, internal, anatomy of, 57 
 
 ligation of, 58 
 maxillary, internal, anatomy of, 44 
 meningeal, middle, anatomy of, 44, 535 
 anterior branch, ligation of, 48 
 posterior branch, ligation of, 49 
 topography of, 542 
 trunk of, ligation, 47 
 occipital, anatomy of, 42 
 
 ligation of, 42 
 of cerebral hemorrhage, 535 
 opening sheath of, for ligation, 21 
 peroneal, anatomy of, 114 
 
 ligation of, 1 1 4 
 plantar, external, anatomy of, 115 
 ligation of, 116 
 internal, anatomy of, 1 1 7 
 ligation of, 1 17 
 popliteal, anatomy of, 99 
 
 ligation of, 100 
 pressure of, 140 
 profunda femoris, anatomy of, 94 
 
 ligation of, 95 
 pudic, internal, anatomy of, 85 
 
 ligation of, 85 
 radial, anatomy of, 66 
 
 ligation of, 69 
 sciatic, anatomy of, 84 
 
 ligation of, 84 
 subclavian, anatomy of, 50 
 
 Artery, subclavian, left, first portion, liga- 
 tion of, 52 
 right, first portion, ligation of, 52 
 second portion, ligation of, 53 
 third portion, ligation of, 53 
 suture of, 118 
 temporal, anatomy of, 43 
 
 ligation of, 43 
 thyroid, inferior, anatomy of, 56 
 
 ligation of, 57 
 tibia, anterior, anatomy of, 103 
 ligation of, 104 
 posterior, anatomy of, 108 
 ligation of, 109 
 torsion of, 140 
 ulnar, ligation of, 73 
 vertebral, anatomy of, 35 
 
 ligation of, 55 
 wounds of, closure, Brewer's operation 
 for, 124 
 by special rubber plaster, 124 
 Arthrectomy, 242 
 Arthrodesis, 242 
 Arthroplasty, 241 
 Arthrotomy, 241 
 
 Artificial anus, closure of, operation for, 927 
 permanent, left inguinal colostomy 
 for, 919 
 
 right inguinal enterostomy for, 914 
 larynx, introduction of, 702 
 Astragalus, excision of, 507 
 Auditory word area, localization of, 545 
 Auricle, right, of heart, paracentesis of, 787 
 Axillary artery, anatomy of, 59 
 first part, ligation of, 60 
 third part, ligation of, 62 
 lvmphatic glands, anatomy of, 154 
 removal of, 155 
 trunk, anatomy of, 154 
 region, anatomy of, 154 
 
 Bardexheuer's method of ligating innomi- 
 nate artery, 31 
 Barker's excision of hip-joint, 529 
 Bartholin's duct, anatomy of, 726 
 
 operations upon, 726 
 Basal ganglia, topography of, 541 
 Bassini's operation for femoral hernia, 1 1 76 
 
 for oblique inguinal hernia, 1166 
 Battle-Galaguier-Kammerer method of 
 
 anterior abdominal section, 811 
 Baum's method of exposing facial nerve, 195 
 Bell's cyrtometer in Chipault's cranio- 
 cerebral localization, 550 
 Bennett's modification of Howse's operation 
 
 for varicocele, 1 137 
 Berger's method of amputation of arm, 383 
 Bier's method of amputating leg at upper 
 
 third, 429 
 Billroth's method of pylorectomy, 997 
 Birth palsy, brachial, o] a-ration for, 199 
 Bladder, anatomy of, 1091 
 drainage of, 1108 
 perineal, 1108 
 suprapubic, 110S 
 
Ill 
 
 INDEX 
 
 Bladder, drainage of, urethral, 1 108 
 
 female, introduction of sound or catheter 
 
 into, 1095 
 implantation of ureter into, 10S5 
 male, introduction of sound or catheter 
 
 into, [094 
 operations upon, 1091 
 
 general considerations, 1093 
 instruments for, 1094 
 puncture of, 1095 
 
 stone in, lateral perineal cystotomy for, 
 1099 
 median perineal cystotomy for, 1102 
 suture of, 1 103 
 Blake's method of treating diffuse septic 
 
 peritonitis, 826 
 Bobroff's operation for spina bifida, 683 
 Boeckel-Langenbeck's excision of wrist- 
 joint, 491 
 Bone-grafting, 227 
 Bone-implantation, 227 
 Bones, operations upon, 210 
 osteoplastic resections of, 468 
 uniting of tendons to, operation for, 264 
 Bose's bloodless method of tracheotomy, 
 
 706 
 Bougie, esophageal, introduction of, 715 
 Bougie's method of arteriorrhaphy, 123 
 Bovee's method of uretero-ureterostomy, 
 
 1081 
 Brachial artery, anatomy of, 63 
 ligation of, 64 
 birth palsy, operation for, 199 
 plexus of nerves, anatomy of, 198 
 exposure of, in neck, 198 
 Brain, anatomy of, 533 
 areas, localization of, 543 
 bullet wound of, operation for, 591 
 parts of, 533 
 
 puncture of, exploratory, 584 
 ventricles of, lateral, puncture and drain- 
 age of, 594 
 topograph}- of, 542 
 Braun-Loessen method of exposing superior 
 maxillary nerve and Meckel's ganglion, 
 186 
 Breast, female, anatomy of, 736 
 excision of, ordinary, 745 
 partial, 737 
 
 radical, Halsted's operation, 741 
 Warren's operation, 744 
 Meyer's operation, 738 
 subcutaneous, 746 
 incision of, 737 
 operations upon, 736 
 
 general considerations, 736 
 Brewer's method of closing wounds of 
 
 arteries, 124 
 Broad ligament of uterus, anatomy of, 1148 
 Bronchi, anatomy of, 791 
 
 operations upon, 791 
 Bronchotomy, 791 
 Bryant's method of colopexy, 932 
 of posterior thoracotomv, 752 
 operation for esophageal stricture, 716 
 Bullet wound of brain, operation for, 591 
 
 Bursa:, excision of, 270 
 incision of, 270 
 operations upon, 276 
 puncture of, 270 
 
 Calculus, vesical, lateral perineal cystot- 
 omy for, 1099 
 median perineal cystotomy for, 1102 
 Carden's amputation of thigh, 440 
 ( lardiac orifice of stomach, dilatation of, 987 
 Cardiorrhaphy, 790 
 Carnochan's method of exposing superior 
 
 maxillary nerve, 185 
 Carotid artery, common, anatomy of, 32 
 left, anatomy of, ^ 
 ligation of, 34 
 right, anatomy of, 32 
 external, anatomy of, 36 
 
 ligation of, 37 
 internal, anatomy of, 49 
 ligation of, 50 
 Cartilages, nasal, chondroplastic resection 
 
 of, 473 
 semilunar, dislocation of, operation for, 
 
 244 
 Castration, 1134 
 
 Catheter, Eustachian, introduction of, 619 
 introduction of, into female bladder, 1095 
 into male bladder, 1094 
 Celiotomy veins, 800 
 Cerebellar abscess, operation for, 596 
 
 subarachnoid space, incision of, for 
 
 drainage, 595 
 tumor, operation for, 599 
 Cerebellum, anatomy of, 535 
 extent of, 539 
 function of, 545 
 Cerebral abscess, operation for, 595 
 hemispheres, extent of, 538 
 hemorrhage, artery of, 535 
 tumor, operation for, 597 
 Cerebrum, fissures of, 533 
 lobes of, 534 
 
 mesial fissures and lobes of, 534 
 Cervical esophagectomy, partial, 714 
 esophagostomy, 714 
 esophagotomy, external, 712 
 nerves, first, second, third, posterior 
 
 divisions, exposure of, 107 
 sympathetic ganglia and cord, anatomy 
 of, 208 
 •total exi ision of, 209 
 Cheever's method of tonsillectomy, 719 
 Chiene's method of determining Rolandic 
 fissure, 554 
 of exposing retropharyngeal space, 710 
 Chipault's method of craniocerebral locali- 
 zation, 546 
 Bell's cyrtometer in, 551 
 operation for spina bifida, 683 
 Cholecystectomy, 1029 
 
 Cholecystenterostomy by Murphy button, 
 1026 
 by simple suturing, 1028 
 Cholecystolithotrity, 1028 
 
INDEX 
 
 1189 
 
 Cholecystectomy, oblique or vertical sub- 
 costal incision, 1024 
 
 Cholecystotomy, vertical subcostal incision, 
 1022* 
 
 Choledochostomy, transduodenal, 1034 
 
 Choledochotomy, retroduodenal, 1034 
 supraduodenal, 1031 
 
 Chondroplastic resection of chest-wall, 734 
 
 Chopart's disarticulation of foot, 409 
 
 Circumcision, n 12 
 
 Cirrhosis of liver, operation for, 102 1 
 
 Clamp and cautery for hemorrhoids, 946 
 
 Clavicle, excision of, 4S0, 481 
 
 Coccyx, excision of, 468 
 
 Cock's method of external perineal ureth- 
 rotomy, 1 1 26 
 
 Coffey's method of entero-enterostomv, §§ 3 
 
 Colopexy, Bryant's method, 932 
 
 Colostomy, 916 
 inguinal, left, 917 
 
 for permanent artificial anus, 919 
 for temporarv fecal fistula, 918 
 intramuscular, anterior, 921 
 lumbar, left, 924 
 Mixter's method of, 921 
 
 Compression of nerve, operation for, 169 
 
 Connell's method of entero-enterostomv, 
 864 
 
 Convolution, frontal, ascending, topography 
 of, 541 
 inferior, topography of, 541 
 middle, topography of, 541 
 superior, topography of, 541 
 parietal, .ascending, topography of, 541 
 
 Cooper's metallic amputation retractors, 
 
 293 
 Cranial contents, relations of, to cranial 
 bones, 554 
 landmarks, 537 
 Craniectomy, partial, 581 
 Craniocerebral localization, Chipault's 
 method, 546 
 Bell's cyrtometer in, 550 
 Kroenlein's method, 553 
 Reid's method, 551 
 operations, instruments for, 557 
 
 surgical considerations, 554 
 region, operations upon, 533 
 topography, 538 
 Craniotomy, 557 
 circular, 558 
 
 for fracture of skull, 590 
 linear, 580 
 varieties of, 558 
 Crile and Matas' operation for regional 
 
 anesthesia, 169 
 Crura cerebri, function of, 545 
 Crural nerve, anterior, anatomy of, 205 
 
 exposure of, below Poupart's liga- 
 ment, 205 
 ( 'unciform osteotomy, 214 
 Cushing's exposure of Gasserian ganglion, 
 
 175 
 
 method of uretero-ureterostomy, 1080 
 right-angled continuous suture of intes- 
 tine, 846 
 
 Cyrtometer, Bell's, in Chipault's cranio- 
 cerebral localization, 550 
 
 Cystectomy, partial, 1109 
 total, 1 1 10 
 
 Cysticotomy, 1035 
 
 Cystorrhaphy, 1103 
 
 Cystotomy, 1096 
 
 lateral perineal, for vesical calculus, 1099 
 median perinal, for vesical calculus, 1 102 
 suprapubic, 1096 
 
 Czerny-Lembert entero-enterostomy by 
 interrupted suture, 867 
 interrupted suture of intestine, 844 
 
 Czerny's method of exposing tonsil, 720 
 
 D'Urso and Fabii's modification of Mon- 
 ari's method of uretero-ureterostomv, 
 
 1083 ; 
 
 Dawbarn's method of closing appendix 
 
 in appendicectomy, 907 
 Dental nerve, inferior, anatomy of, 191 
 
 exposure of, at mental foramen, 193 
 in mouth, 191 
 
 through ascending ramus of 
 inferior maxilla, 192 
 De Yilbiss' forceps, 563 
 Diaphragm, anatomy of, 755 
 exposure of, transthoracic, 756 
 operations upon, 755 
 Dilatation of cardiac orifice of stomach, 
 987 
 of esophagus, direct, for stricture, 716 
 retrograde, for stricture, 716 
 Disarticulation at ankle-joint, general con- 
 siderations, 413 
 at elbow-joint, anterior ellipse, 362 
 in general, 362 
 
 long antero-internal and short postero- 
 external flaps, 364 
 posterior ellipse, 363 
 at hip-joint, anterior racket method, 459 
 external racket method, 458 
 general considerations, 452 
 Wyeth's method, 456 
 at knee-joint, 433 
 
 bilateral hooded flaps, 434 
 by oblique curved incision, 435 
 general considerations, 432 
 at shoulder-joint, 377 
 
 anterior racket method, 378 
 external or deltoid flap, 382 
 
 racket method, 381 
 general considerations, 374 
 at wrist-joint, anterior ellipse, 351 
 external lateral, or radial flap, 353 
 general considerations, 350 
 in general, 350 
 palmar flap, 352 
 of fingers and thumb at carpometacarpal 
 articulation, 348 
 at first interphalangeal joint, by palmar 
 Hap, 331 
 by short dorsal and long palmar 
 
 flaps, 331 
 in general, 331 
 
1 190 
 
 INDEX 
 
 Disarticulation of fingers at metacarpo- 
 phalangeal joints, in general, 
 
 33 2 
 oval method, 332 
 at second interphalangeal joint, by 
 palmar flap, 329 
 
 by short dorsal and long palmar 
 
 flaps, 329 
 in general, 329 
 excluding thumb, with metacarpals, 
 
 348 
 index, at metacarpophalangeal joint, 
 
 335 
 with metacarpal, 344 
 inner, with metacarpal, 344 
 little, at metacarpophalangeal joint, 336 
 
 with metacarpal, 344 
 three innermost, with metacarpals, 346 
 
 inside, with metacarpals, 346 
 two contiguous inside, with metacar- 
 pals, 346 
 with metacarpals, 343 
 of foot, anterior part, at mediotarsal 
 joint, 409 
 at ankle-joint, heel flap, 414, 415 
 
 in general, 414, 415 
 at subastragaloid joint, 410 
 heel flap, 4 1 2 
 
 large internoplantar flap, 410 
 of lower extremity, 385 
 of thumb at metacarpophalangeal joint, 
 oblique palmar flap, 335 
 oval method, 334 
 with metacarpal, 345 
 of toes, at first interphalangeal joints, 390 
 oval method, 390 
 at metatarsophalangeal joints, 392 
 at second interphalangeal joint, 389 
 
 plantar flap, 389 
 at tarsometatarsal joints, by short 
 dorsal and long plantar flaps, 407, 
 408 
 en masse, at metatarsophalangeal 
 
 joint, 395 _ 
 general considerations, 386 
 great, at metatarsophalangeal joint, 
 
 393 
 
 with metatarsal, 404 
 little, at metatarsophalangeal joint, 394 
 
 with metatarsal, 406 
 second, third, or fourth, at metatarso- 
 phalangeal joint, 392 
 two adjoining, at metatarsophalangeal 
 
 joint, 395 
 two or three contiguous, with meta- 
 tarsals, 407 
 with metatarsals, 403, 404 
 of upper extremity, 323 
 Discission of pleura in chronic empyema, 
 
 Ransohoff's operation, 771 
 Dislocations complicating fractures, opera- 
 tive treatment of, 232 
 of semilunar cartilages, operation for, 244 
 of spine, operative treatment, 672 
 Divulsion of pvloric orifice of stomach, 
 Loreta's operation, 986 
 
 Dollinger's operation for spina bifida, 683 
 Dorsahs pedis artery, anatomy of, 107 
 
 ligation of, 107 
 Doyen's brace, 566 
 
 c nisei, 563 
 
 electric-motor drill and saw, 572 
 
 saw, 555 
 Drainage in amputations, 300 
 
 of pancreatic cavities, 1046 
 
 of subarachnoid space, spinal puni ture 
 for, 670 
 
 vesical, it 08 
 Dubrueil's method of disarticulation at 
 
 wrist-joint, 353 
 Dura mater, venous sinuses of, 536 
 
 Ear, operations upon, 618 
 
 speculum, introduction of, for exami- 
 nation of membrana tympani, 618 
 Edebohl's method of nephropexy, 1064 
 Ejaculatory ducts, anatomy of, 1138 
 Elbow-joint, anatomy of, 359 
 disarticulation at, 362 
 
 general considerations, 361 
 excision of, 494 
 Empyema, chronic, discission of pleura in, 
 
 Ransohoff's operation, 771 
 End-to-end entero-enterostomy by per- 
 forating mattress sutures knotted in 
 lumen, 864 
 Enterectomy, partial, 849 
 Entero-enterostomy, 854 
 by absorbable bobbins, 879 
 
 mechanical devices left within intestine, 
 878 
 by Coffey's method, 883 
 by Connell's method, S64 
 by Czerny-Lembert interrupted suture, 
 
 867 
 by Halsted's method of interrupted 
 
 mattress sutures, 868 
 by Harrington's segmented rings, 893 
 by Lee's intestinal holder, 895 
 by Maunsell's invagination method, 870 
 by mechanical means, 895 
 by Murphy button, 885 
 by non-absorbable mechanical devices 
 
 left within intestinal canal, 884 
 by simple continuous suture of all coats, 
 followed by interrupted or continuous 
 Lembert sutures of outer coats, 
 856 
 suturing, 855 
 by Ullmann's modification of Maunsell's 
 
 operation, 881 
 end-to-end, by perforating mattress su- 
 tures knotted in lumen, 864 
 lateral, by Jaboulay button, 892 
 Enteroplasty, 930 
 Enterorrhaphy, 841 
 
 by continuous suture of all coats, followed 
 bv interrupted Lembert suturing of 
 outer coats, 848 
 bv Cushing's right-angled continuous 
 suture, 846 
 
INDEX 
 
 1191 
 
 Enterorrhaphy by Czerny-Lembert inter- 
 rupted suture, S44 
 by Halsted's interrupted quilt or mattress- 
 suture, 845 
 bv Lembert's continuous suture, 846 
 
 interrupted suture, 843 
 for wounds of intestine, 848 
 Enterostomy, 913 
 
 inguinal, right, for permanent artificial 
 anus, 914 
 for temporary fecal fistula, 914 
 Enterotomy, 841 
 Enucleation of eyeball, 615 
 Epididymes, anatomy of, 1136 
 Epiphyses, separated, operative treatment 
 
 of, 232 
 Epiplopexy for cirrhosis of liver, 102 1 
 Epiplorrhaphv for cirrhosis of liver, 102 1 
 Erasion of joint, 242 
 Esophageal bougie, introduction of, 715 
 Esophagectomy, cervical, partial, 714 
 Esophagoscopy, 715 
 Esophagostomy, cervical, 714 
 Esophagotomy, cervical, external, 712 
 internal, 715 
 
 thoracic, by posterior mediastinal osteo- 
 plastic flap operation, 792 
 Esophagus, anatomy of, - 1 1 
 
 dilatation of, direct, for stricture, 716 
 foreign bodies in, operation for, 715 
 operations upon, 711 
 
 general considerations, 712 
 instruments for, 7 1 2 
 stricture of, division, by string friction, 
 Abbe's operation, 716 
 direct dilatation for, 716 
 
 divulsion of, 716 
 division, by string friction, Bryant's 
 
 operation, 716 
 permanent tubage, 716 
 retrograde dilatation for, 716 
 divulsion of, 716 
 Estlander's thoracoplastic operation, 765 
 Eustachian catheter, introduction of, 619 
 
 tube, operations upon, 61 S 
 Evisceration of eyeball, 616 
 Excision, 463 
 
 of ankle-joint, 510 
 
 external curved and internal angular 
 
 incisions, 5 1 1 
 transversely curved external incision, 
 
 5 11 
 of astragalus, external angular and inter- 
 nal curved incision, 508 
 curved incision, 507 
 of bones and joints about foot, 507 
 
 about toes, 505 
 of breast, female, ordinary, 745 
 partial, 737 
 
 radical, Halsted's operation, 741 
 Mever's operation, 738 
 Warren's operation, 744 
 subcutaneous, 746 
 of bursae, 270 
 
 of cervical sympathetic ganglia and cord, 
 total, 209 
 
 Excision of clavicle, 480, 481 
 of coccyx, 468 
 of elbow-joint, 494 
 
 by posterior bayonet-shaped incision, 
 
 median incision, 495 
 
 by vertically curved dorso-external 
 incision, 498 
 of femur, 526 
 
 diaphysis, parts of, 526 
 of fibula, 519 
 
 by posterior vertical incision, 520 
 of fingers, 483 
 
 first interphalangeal joints, 487 
 
 first phalanges, 487 
 
 metacarpals, 488 
 
 metacarpophalangeal joints, 487 
 
 second interphalangeal joints, 484 
 
 terminal phalanges, 484 
 general considerations, 463 
 of hand, 487 
 of hemorrhoids, Whitehead's operation, 
 
 945 . . 
 of hip-joint, 526 
 .by anterior straight incision, 529 
 by external straight incision, 528 
 bv posterior angular or curved incision, 
 
 53° 
 of humerus, 500 
 
 long external incision, 501 
 of ileocecum, 899 
 
 of index-finger, second interphalangeal 
 joint, 486 
 
 second phalanx, 486 
 of innominate bone, 531 
 of knee-joint, 521 
 
 by curved transverse anterior incision, 
 
 5 22 
 by vertically curved external incision, 
 
 '5 2 3 
 of little finger, metacarpal, 489 
 
 second phalanx, 48 7 
 of maxilla, inferior, 477 
 
 anatomy involved in, 475 
 
 superior, anatomv involved in, 469 
 median incision, 471 
 of nerve, 158 
 of os calcis, 510 
 of parotid gland, 722 
 of patella, 520 
 
 of radio-ulnar articulation, superior, 500 
 of radius, 494 
 
 total, 494 
 of rectum, 935. See also Rectrectomy. 
 of ribs, 479 
 
 and costal cartilage, 480 
 of scapula, 48] 
 
 total, 482 
 of scrotum, partial, 11 29 
 of seminal vesicles and part of ejaculatory 
 
 ducts. Young's operation, 1139 
 of shoulder-joint, 501 
 
 anterior oblique incision, 502 
 of sublingual gland through floor of 
 
 mouth, 726 
 of submaxillary gland, 725 
 
1192 
 
 INDEX 
 
 Excision of tarsus, 5 1 8 
 
 of temporomaxillary articulation, 476 
 
 of tendon-sheaths, 267 
 
 of thumb, metacarpal, 489 
 
 of tibia, 518 
 
 by internal vertical incision, 519 
 of toes, first interphalangeal joints, 506 
 first phalanges, 507 
 metatarsal bones, 507 
 metatarsophalangeal joints, 507 
 second interphalangeal joints, 506 
 second phalanges, 506 
 terminal phalanges, 506 
 of tongue, 619 
 
 general considerations, 620 
 instruments for, 621 
 limited portions, 621 
 through mouth after preliminary 
 ligation of lingual arteries, 624 
 
 without preliminary ligation of 
 lingual arteries, 622 
 together with cervical and submaxil- 
 lary glands, 627 
 with osteoplastic division of inferior 
 maxilla, 624 
 of ulna, 493 
 total, 493 
 of veins, 145 
 of wrist-joint, 489 
 
 by radial and ulnar dorsal incision, 
 
 490 
 by single dorsoradial incision, 491 
 dorso-ulnar incision, 492 
 open method, 467 
 subperiosteal, 464 
 Exenteration of orbit, 616 
 Eyeball, enucleation of, 615 
 evisceration of, 616 
 operations upon, 614 
 
 Facial artery, anatomy of, 40 
 ligation of, 41 
 nerve, anatomy of, 194 
 
 exposure of, in front of mastoid pro- 
 cess, 195 
 topography of, 542 
 paralysis, peripheral, facio-accessory 
 anastomosis for, 196 
 Fallopian tubes, anatomy of, 1159 
 Farabeuf's disarticulation at elbow-joint, 
 362 
 of foot, 410 
 of great toe, 393 
 
 of index-finger at metacarpophalan- 
 geal joint, 335 
 of little finger at metacarpophalangeal 
 joint, 336 
 toe, 394 
 of thumb at metacarpophalangeal 
 joint, 335 
 method of amputating leg at lower 
 third, 420 
 at upper third, 425 
 Facio-accessory anastomosis for peripheral 
 facial paralysis, 196 
 
 Facio-hypoglossal anastomosis for periph- 
 eral facial paralysis, 196 
 Fascia in amputation, treatment of, 297 
 
 operations upon, 269 
 Easciotomy, 269 
 
 by open method, 269 
 by subcutaneous method, 269 
 Fecal fistula, closure of, operation for, 927 
 temporary, left inguinal colostomy for, 
 918 
 right inguinal enterostomy for, 914 
 Femoral artery, anatomy of, 91 
 common, ligation of, 93 
 superficial, ligation of, 96 
 hernia, 1174. See also Hernia, femoral. 
 Femur, excision of, 526 
 Fergusson's excision of superior maxilla, 471 
 Fibula, excision of, 519 
 
 Finger, index-, disarticulation of, at meta- 
 carpophalangeal joint, 335 
 with metacarpal, 344 
 second interphalangeal joint, excision 
 
 of, 486 
 second phalanx, excision of, 486 
 inner, disarticulation of, with metacarpal, 
 
 344 
 little, amputation of, with part of meta- 
 carpal, 342 
 disarticulation of, at metacarpophalan- 
 geal joint, 336 
 with metacarpal, 344 
 metacarpal of, excision, 489 
 second phalanx, excision of, 487 
 Fingers, amputation of, at first phalanx, 331 
 at last phalanx, 327 
 at second phalanx, 330 
 excluding thumb, with parts of meta- 
 carpals, 343 
 general surgical considerations, 325 
 with parts of metacarpals, 341 
 anatomy of, 323 
 
 and thumb, disarticulation of, at carpo- 
 metacarpal articulation, 348 
 disarticulation of, at first interphalangeal 
 joint, 331 
 at metacarpophalangeal joints, 332 
 at second interphalangeal joint, 329 
 excluding thumb, with metacarpals, 
 
 348 
 with metacarpals, 343 
 excision of, 483 
 
 of first interphalangeal joints, 487 
 of first phalanges, 487 
 of metacarpals, 488 
 of metacarpophalangeal joints, 487 
 of second interphalangeal joint, 484 
 of second phalanges, 486 
 of terminal phalanges, 484 
 three innermost, amputation of, with 
 parts of metacarpals, 343 
 disarticulation of, with metacarpals, 
 
 34° 
 inside, amputation of, with parts of 
 metacarpals, 342 
 disarticulation of, with metacarpals, 
 346 
 
INDEX 
 
 "93 
 
 Fingers, two contiguous inside, amputation 
 of, with parts of metacarpals, 
 
 disarticulation of, with metacar- 
 pals, 346 
 Finnev's method of gastroduodenostomv, 
 
 .9 S 7' 
 Fissure, frontal, inferior, topogarphy of, 540 
 superior, topography of, 540 
 intraparietal, topography of, 540 
 longitudinal, great, anatomy of, 533 
 
 topography of, 539 
 mesial, and lobes of cerebrum, 534 
 of cerebrum, 533 
 parietooccipital, anatomy of, 534 
 
 topography of, 540 
 postcentral, topography of, 540 
 precentral, topography of, 540 
 Rolandic, anatomy of, 534 
 
 Chiene's method of determining, 554 
 topography of, 539 
 Sylvian, anatomy of, 533 
 
 topography of, 539 
 temporosphenoidal, superior, topography 
 
 of, 541 
 transverse, great, topography of, 539 
 Fistula, fecal, closure of, operation for, 927 
 temporary, left inguinal colostomy for, 
 918 ' 
 right inguinal enterostomy for, 914 
 Fistula-in-ano, operation for, 947 
 Foot, amputations about, general considera- 
 tions, 401 
 anatomy of, 397 
 anterior part, disarticulation of, at medio- 
 
 tarsal joint, 409 
 disarticulation of, at ankle-joint, 414, 415 
 
 at subastragaloid joint, 410 
 excision of bones and joints about, 507 
 osteoplastic resection of, externolateral 
 curved incision, 518 
 transversa upper and lower and 
 oblique lateral incisions, 516 
 Foramen of Winslow, anatomy of, 820 
 Forcipressure, arterial, 140 
 
 venous, 145 
 Forearm, amputation of, 356 
 general considerations, 355 
 anatomy of, 353 
 Foreign bodies in esophagus, operation 
 for. 715 
 in larynx, operation for removal of, 702 
 in trachea, operation for removal, 707 
 Fowler's method of inferior anterolateral 
 abdominal section, 818 
 of ureterorectostomy, 1086 
 thoracoplastic operation, 770 
 Fracture-dislocations of spine, operative 
 
 treatment, 673 
 Fractures, comminuted, operative treatment 
 of, 230 
 complicated, operative treatment of, 231 
 compound, operative treatment of, 230 
 delayed union of, operations for, 228 
 dislocations complicating, operative treat- 
 ment of, 232 
 
 Fractures involving joints, operative treat- 
 ment of, 231 
 mal-union of, operations for, 229 
 non-union of, operations for, 229 
 of skull, trephining for, 590 
 of spine, operative treatment, 670 
 operative treatment, in general, 214 
 simple, operative treatment of, 225 
 ununited, of olecranon, operation for, 
 by wiring or suturing of bone and 
 soft parts, 238 
 of patella, operation for, by encircling 
 suture of soft parts, 236 
 by suturing of soft parts, 233 
 by wiring or suturing of bone and 
 
 soft parts, 234 
 Stimson's operation for, 233 
 operation for, by combined ligature 
 and suture, 224 
 by frame ligature of bone, 224 
 by intramedullary pegging, 224 
 by ligation of bone, 223 
 by metallic nails or ivory pegs, 221 
 or bone ferrules, 222 
 plates and screws or screws, 222 
 Parkhill's clamp, 227, 
 by resection of ends of bones, 215 
 by suturing of ends of bones, 217 
 Frontal convolution, ascending, topogra- 
 phy of, 541 
 inferior, topography of, 541 
 middle, topography of, 541 
 superior, topography of, 541 
 fissure, inferior, topography of, 540 
 
 superior, topography of, 540 
 sinuses. See Sinuses, frontal. 
 
 Gall-bladder, anatomy of, 102 1 
 operations upon, 102 1 
 
 general considerations, 1022 
 instruments for, 1008 
 Gall-ducts, anatomy of, 1030 
 operations upon, 1030 
 
 general considerations, 103 1 
 instruments for, 103 1 
 Ganglion, basal, topography of, 541 
 
 cervical sympathetic, and cord, anatomv 
 of, 208 
 total excision of, 209 
 Gasserian, anatomy of, 175 
 
 exposure of, by direct infra-arterial 
 route, 175 
 by orbital route, 1S6 
 by trephining through pterygo- 
 
 maxillarv fossa, 181 
 through temporal fossa, 177 
 maxillary, anatomy of, 188 
 Meckel's, anatomy of, 182 
 
 exposure of, by antral route, 185 
 by pterygomaxillary route, 186 
 operations upon, 157 
 otic, anatomy of, 188 
 Gasserian ganglion, anatomy of, 175 
 
 exposure of, by direct infra-arterial 
 route, 175 
 
ir 9 4 
 
 INI MX 
 
 Gasserian ganglion, exposure of, by tre- 
 phining through pterygomaxillary 
 
 fossa, i Si 
 through temporal fossa, 177 
 Gastrectomy, partial, of median portion, 
 
 999 
 total, 1001 
 Gastric ulcer, operation for, 1002 
 
 perforated, operation for, 1003 
 Gastroduodenostomy, Finney's operation, 
 
 987 
 Gastroenterostomy, 967 
 
 anterior, by Murphy button, followed by 
 Jaboulay-Braun method of intes- 
 tinal anastomosis, 971 
 Wolfler's operation, 968 
 posterior, by Murphy button, 978 
 by von Hacker's method, 974 
 Gastrogastrostomy, Wolfler's method, 979 
 Gastrolysis, 983 
 Gastropexy, 983 
 Gastroplasty, 984 
 Gastroplication, 981 
 
 Moynihan's modification of Bircher's 
 
 operation for, 983 
 Weir's modification of Bircher's operation 
 for, 981 
 Gastrorrhaphy, 955 
 Gastrostomy, 956 
 Albert's method, 959 
 Hahn's method, 959 
 Kader's method, 964 
 Marwedel's method, 962 
 Ssabanajew-Franck's method, 957 
 Witzel's method, 959 
 Gastrotomy by median incision, 952 
 by oblique subcostal incision, 954 
 Genital organs, female, operations upon, 
 1147 
 male, operations upon, 1 1 1 1 
 Gimbernat's ligament, anatomy of, 1163 
 Gliick's method of arteriorrhaphy, 123 
 Gluteal artery, anatomy of, 87 
 ligation of, 87 
 nerve, superior, exposure of, 205 
 Gouley's method of external perineal ure- 
 throtomy, 1 1 24 
 Grafting, bone-, 227 
 nerve-, 165 
 omental, 832 
 tendon-, 261 
 Gritti-Stokes' method of amputating thigh, 
 
 441 
 Gunshot wounds of spinal cord, operative 
 
 treatment of, 675 
 Gustatory nerve, anatomy of, 193 
 
 exposure of, in mouth, 104 
 Guvon's supramalleolar method of ampu- 
 tating leg, 419 
 Gyrus, angular, topography of, 541 
 
 Haasler's method of retroduodenal chole- 
 dochotomy, 1034 
 
 Hacker's method of posterior gastroenter- 
 ostomy, 974 
 
 Hahn's method of gastrostomy, 959 
 Halsted's interrupted mattress-suture of 
 intestine, 845 
 method of appendicectomy, 910 
 
 of entero-enterostomy by interrupted 
 mattress-sutures, 868 
 operation for oblique inguinal hernia, 
 
 1171 
 radical excision of breast, 741 
 Hand, amputation about, general consider- 
 ations, 339 
 anatomy of, 336 
 excision of, 487 
 Harrington's segmented rings, entero-enter- 
 ostomy by, 893 
 Harrington-Weir method of anterolateral 
 
 abdominal section, 810 
 Hartley-Krause exposure of Gasserian gan- 
 glion, 177 
 Hartley's double osteoplastic flaps, 583 
 electric motor, 575 
 
 method of ligating intercostal artery, 78 
 preliminary excision of spinous process 
 in osteoplastic resection of spine, 647 
 sterilizable compressed-air motor, 576 
 Head and face, bony air sinuses of, opera- 
 tions upon, 600 
 operations upon, 533 
 Heart, anatomy of, 785 
 
 and pericardium, exposure of, by excision 
 of left fifth costal cartilage, 784 
 by thoracoplastic flap, 788 
 operations upon, 785 
 puncture of, 787 
 
 right auricle of, paracentesis of, 787 
 ventricle of, paracentesis of, 787 
 suture of, 790 
 Heineke-Mikulicz method of pvloroplastv, 
 
 984 
 Hemorrhage, cerebral, artery of, 535 
 control of, in amputations, 272 
 intracranial, operation for, 585 
 Hemorrhoids, clamp and cautery for, 946 
 excision of, Whitehead's operation, 945 
 ligation and excision of, Allingham's 
 method, 944 
 Henle's internal cremaster, anatomy of, 1136 
 Hepatectomy, partial, 1019 
 Hepaticotomy, 1036 
 Hepatopexy, 10 19 
 Hepatorrhaphy, 1019 
 Hepatotomy, 1009 
 
 anterior subcostal transperitoneal, 1010 
 Hernia, femoral, anatomy of, 1 1 74 
 Bassini's operation for, n 76 
 operations for, 1174 
 
 for radical cure of, 1176 
 upon, general considerations, 11 76 
 inguinal, anatomy of, 1163 
 
 oblique, Bassini's operation for, 1166 
 Halsted's operation for, 1171 
 operation for radical cure of, 1166, 
 1171 
 operations for, 1163 
 
 general considerations, 1164 
 instruments in, 1166 
 
INDEX 
 
 11 95 
 
 Hernia, operations for, 1163 
 umbilical, anatomy of, 1 1 78 
 Mayo's operation for, 1181 
 operations for, 11 78 
 
 for radical cure of, excision of sac, 
 1179 
 Hey's disarticulation of toes, 408 
 
 method of amputating leg at middle 
 third, 424 
 Hip-joint, anatomy of, 450 
 
 disarticulation at, general considerations, 
 
 45? 
 
 excision of, 526 
 Humerus, excision of, 500 
 Hydrocele, Jaboulay's operation for, 1132 
 Yolkmann's operation for, 1131 
 Von Bergmann's operation for, 1133 
 Hypochondriac regions, exposure of, by 
 chondroplastic resection of chest-wall, 819 
 Hysterectomy, abdominal, partial, 1151 
 total, 1 153 
 vaginal, total, 1153 
 Hysterosalpingo-obphorectomy, abdominal, 
 partial, 1151 
 total, 1 153 
 
 Ileocecum, excision of, 899 
 
 Ileostomy for permanent artificial anus, 
 
 for temporary fecal fistula, 914 
 Iliac artery, common, anatomy of, Si 
 ligation of, 81 
 external, anatomy of, 88 
 
 ligation of, 89 
 internal, anatomy of, 83 
 ligation of, 84 
 Implantation, bone-, 227 
 
 intestinal, 854. See also Entero-enter- 
 
 ostomy. 
 nerve-, 165 
 of ureter, 1084 
 into bladder, 1085 
 into large intestine, 1086 
 upon skin, 1089 
 tendon-, 261 
 Infiltrator, Matas', 172 
 Infra-orbital nerve, exposure of, 188 
 Inguinal hernia, 1163. See also Hernia, 
 inguinal. 
 lymphatic glands, anatomy of, 155 
 removal of, 156 
 Innominate artery, anatomy of, 27 
 ligation of, 27 
 bone, excision of, 531 
 Intercostal artery, anatomy of, 76 
 ligation of, 76 
 nerve, anatomy of, 204 
 
 exposure of, between angle and middle 
 of rib, 204 
 thoracotomy, 761 
 Interilio-abdominal amputation, 460 
 Intestinal anastomosis, 854. See also 
 Entero-enter ostomy. 
 approximation, 854. See also Entero- 
 enterostomy. 
 
 Intestinal implantation, 854. See also 
 
 Enter o-enteroslomy . 
 Intestines, adhesions to, operations for, 824 
 large, anatomy of, 836 
 
 implantation of ureters into, 1086 
 operations upon, 833 
 
 general considerations, 840 
 instruments for, 840 
 small, anatomy of, 833 
 suture of, S41. See also Enter orrhaphy. 
 wounds of, enterorrhaphy for, 848 
 Intraneural infiltration for regional anes- 
 thesia, 169 
 Matas and Crile's operation, 169 
 Intra-orbital structures, exposure of, 617 
 Intraparietal fissure, topography of, 540 
 Intravenous infusion of salt solution, 146 
 Intubation of larynx, 701 
 Intussusception, Jessett-Barker operation 
 for, 930 
 operation for, 930 
 Island of Reil, anatomy of, 534 
 topography of, 541 
 
 Jaboulay-Braun's method of multiple 
 lateral intestinal anastomosis, 891 
 
 Jaboulay's button, lateral intestinal 
 anastomosis by, 892 
 operation for hydrocele, 1132 
 
 Jessett-Barker operation for intussuscep- 
 tion, 930 
 
 Jobert's operation for ligating popliteal 
 artery, 100 
 
 Joints, erasion of, 242 
 
 fractures involving, operative treatmeat 
 
 of, 231 
 operations upon, 241 
 osteoplastic resection of, 468 
 puncture of, exploratory, 241 
 
 Jonnesco's operation for excision of cervical 
 sympathetic ganglia and cord, 209 
 
 Kader's method of gastrostomy, 964 
 Keen's interilio-abdominal amputation, 460 
 operation for exposure of posterior 
 divisions of first, second, and third 
 cervical nerves, 197 
 Kidneys, anatomy of, 1048 
 
 exposure of, by abdominolumbar opera- 
 tion, 1059 
 extraperitoneal, and entire ureter, 1076 
 retroperitoneal, by Koenig's angular 
 lumbo-abdominal incision, 1056 
 by lumbar intramuscular method, 
 
 1057 
 by oblique lumbar incision, 1053 
 transperitoneal, by median abdominal 
 section, 1059 
 by vertical incision in linea semi- 
 lunaris, Langenbuch's operation, 
 1057 
 operations upon, 1048 
 
 general considerations, 1052 
 instruments for, 1053 
 
1196 
 
 INDEX 
 
 Kidneys, puncture of, exploratory, 1060 
 
 suture of, 1063 
 King's scrotal (lamp, 1130 
 Knee-joint, anatomy of, 430 
 disarticulation at, 433 
 
 general considerations, 432 
 excision of, 521 
 Kocher's excision of elbow-joint, 498 
 of hip-joint, 530 
 of knee-joint, 523 
 of tongue, together with cervical and 
 
 submaxillary glands, 627 
 of wrist-joint, 492 
 incision of innominate bone, 531 
 median excision of tongue, 624 
 method of complete thyroidectomy, 729 
 of exposing inferior maxillary nerve, 
 188 
 superior maxillary nerve, 183 
 of partial thyroidectomy, 727 
 of pharyngotomy, 708 
 of pylorectomv, 994 
 of transduodenal choledochostomy, 
 
 resection of shoulder-joint, 503 
 Koenig's method of exposing kidney, 10^6 
 Kraske's method of rectectomy, 935 
 Kroenlein's method of craniocerebral local- 
 ization, 553 
 of exposure of intra-orbital and 
 retrobulbar structures, 617 
 
 Lambotti's operation for Pott's disease, 691 
 Laminectomy, 661 
 
 general considerations, 642 
 Langenbeck's excision of elbow-joint, 495 
 of hip-joint, 528 
 osteoplastic resection of superior maxilla, 
 474 
 Langenbuch's method of exposing kidnev, 
 
 io 57 
 Lange's operation for uniting tendon to 
 
 periosteum, 263 
 Larry's disarticulation at shoulder-joint, 
 
 38i 
 Laryngectomy, complete, 699 
 
 partial, 700 
 Laryngoscopy, 702 
 Laryngotomy, 697 
 
 suprathyroid, 702 
 Laryngotracheotomv, 702 
 Larynx, anatomy of, 695 
 
 artificial, introduction of, 702 
 
 foreign bodies in, operation for, removal 
 of, 702 
 
 intubation of, 701 
 
 operations upon, 695 
 
 tamponing of, 702 
 Lauenstein's excision of ankle-joint, 5 1 1 
 Lee's intestinal holder, entero-enterostomy 
 
 by, 895 
 Leg, amputation of, at lower third, 420 
 femorotibial osteoplastic, 443 
 general considerations, 418 
 middle third, 424 
 
 Leg, amputation of, osteoplastic, 422 
 at upper third, 429 
 supramalleolar region, 419 
 upper third, 425 
 
 bilateral hooded flaps, 427 
 anatomy of, 416 
 Lembert's continuous suture of intestine, 
 846 
 interrupted suture of intestine, 843 
 Ligaments, broad, of uterus, anatomy of, 
 1 148 
 lengthening of, 268 
 operations upon, 268 
 round, of uterus, anatomy of, 1149 
 shortening of, 268 
 suturing of, 268 
 Ligation of abdominal aorta by retroperi- 
 toneal operation, 80 
 by transperitoneal method, 79 
 of artery, 1 7 
 
 after-treatment, 26 
 
 closure of wound, 26 
 
 comment, 26 
 
 control of circulation preliminary to, 
 
 18 
 dangers, 26 
 en masse, 118 
 
 for radical cure of aneurism, 139 
 general considerations, 17 
 in amputation, 295 
 incision, 19 
 indications, 18 
 instruments for, 17 
 intermediate, 118 
 materials for, 18 
 passing ligature, 22 
 position of patient, 17 
 preparation, 17 
 provisional, 118 
 results, 26 
 temporary, 118 
 tying ligature, 24 
 varieties, 17 
 of axillary artery, first part, 60 
 
 third part, 60 
 of brachial artery, at bend of elbow, 65 
 
 in middle of arm, 64 
 of carotid artery, common, 34 
 
 above omohyoid muscle, 34 
 below omohyoid muscle, 35 
 external, above digastric muscle, 38 
 
 below digastric muscle, 37 
 internal, near origin, 50 
 of dorsalis pedis, just below ankle-joint, 
 
 107 
 of facial artery, near origin, 41 
 over inferior maxilla, 41 
 of femoral artery, common, at base of 
 Scarpa's triangle, 93 
 superficial, at apex of Scarpa's 
 triangle, 96 
 in Hunter's canal, 98 
 of gluteal artery, on buttock, 87 
 of iliac artery, common, by retroperi- 
 toneal operation, 81 
 by transperitoneal operation, 83 
 
INDEX 
 
 1197 
 
 Ligation of iliac artery, external, by retro- 
 peritoneal route, 89 
 by transperitoneal method, 91 
 internal, by retroperitoneal opera- 
 tion, 84 
 by transperitoneal operation, 84 
 of innominate artery, 27 
 
 Bardenheuer's method, 31 
 by angular incision, 27 
 by oblique incision, 30 
 by partial bony resection through 
 transverse and vertical incisions, 
 
 3 1 . 
 
 by splitting of manubrium sterni, 31 
 
 Mutt's method, 27 
 of intercostal artery by intercostal inci- 
 sion, 76 
 by subperiosteal excision of rib, 78 
 of lingual artery, beneath hypoglossus, 39 
 
 near origin, 39 
 of mammary arterv, internal, in second 
 
 intercostal space, 58 
 of meningeal artery, middle, anterior 
 branch, 48 
 posterior branch, 49 
 trunk of, 47 
 of occipital artery, behind mastoid 
 process, 42 
 near origin, 42 
 of omentum, 831 
 
 of peroneal artery, in middle of leg, 114 
 of plantar arterv, external, in sole of foot, 
 
 I if) 
 
 internal, at origin, 1 1 7 
 in sole of foot, 117 
 of popliteal artery, in lower part, 101 
 
 in upper part, 100 
 of profunda femoris, near origin, 95 
 of pudic artery, internal, in perineum, 85 
 
 upon buttock, S5 
 of radial artery, deep palmar arch, 72 
 in lower third of forearm, 70 
 in upper third of forearm, 69 
 of sciatic artery, upon buttock, 84 
 of sinus, lateral, 586 
 
 of subclavian artery, left, first portion, 52 
 right, first portion, 52 
 second portion, 53 
 third portion, 53 
 of temporal artery, just above zygoma, 43 
 of thoracic duct, 149 
 of thyroid artery, inferior, 57 
 of tibial atery, anterior, in lower third 
 106 
 in middle third, 105 
 in upper third, 104 
 posterior, behind internal malleolus, 
 112 
 in lower third, 112 
 in middle third, no 
 in upper third, 109 
 of ulnar arterv, in lower third of forearm, 
 
 .76. 
 
 in middle third of forearm, 73 
 of veins, en masse, 145 
 in amputation, 295 
 
 Ligation of veins, lateral, 143 
 temporary, 144 
 transverse, 144 
 of vertebral artery, near origin, 55 
 Ligature, passing, in ligation of artery, 22 
 
 tying, in ligation of artery, 24 
 Linea alba, anatomy of, 796 
 Linear craniotomy, 580 
 
 osteotomy by open method, 213 
 by subcutaneous method, 211 
 Lingual artery, anatomy of, 38 
 ligation of, 39 
 nerve, anatomy of, 193 
 
 exposure of, in mouth, 194 
 Lisfranc's disarticulation of toes, 407 
 Lister's modification of Carden's amputa- 
 tion of thigh, 440 
 Litholapaxy, 1104 
 Lithotrity, 1104 
 Liver, anatomy of, 1004 
 
 cirrhosis of, operation for, 102 1 
 exposure of, by anterior subcostal trans- 
 peritoneal route, 10 1 2 
 by chrondroplastic resection of right 
 
 costal arch, 1017 
 by lateral subcostal transperitoneal 
 
 route, 1013 
 by subpleural route, 1014 
 by transpleural route, 1016 
 operations upon, 1004 
 
 general considerations, 1006 
 instruments for, 1008 
 puncture of, exploratory, 1008 
 suture of, 1019 
 Lobe, occipital, topography of , 541 
 parietal, topography of, 541 
 temporal, topography of, 541 
 Lobuli testis, anatomy of, n 29 
 j Loreta's method of divulsion of pyloric 
 orifice of stomach, 986 
 Lumbar puncture for diagnosis and thera- 
 
 peusis, 669 
 Lungs, anatomy of, 772 
 operations upon, 772 
 Lymphatic glands, axillary, anatomy of, 154 
 removal of, 155 
 inguinal, anatomy of, 155 
 
 removal of, 156 
 of neck, isolated, removal of, 153 
 
 removal of, 751 
 operations upon, 148 
 trunk, axillary, anatomy of, 154 
 vessels, operations upon, 148 
 
 Macewen's operation for radical cure of 
 aneurism, 139 
 trephining-brace, 556 
 Mammary arterv, internal, anatomy of, 57 
 ligation of, 58 
 gland, female, operations upon, 736. See 
 also Breast, female. 
 Marion's gigli-saw conductor, 569 
 Markoe's method of uretero-ureterostomv, 
 
 to8i 
 Marwedel's method of gastrostomy, 962 
 
1198 
 
 INDEX 
 
 Mastoid antrum, anatomy of, 600 
 
 exposure of, antrum operation of 
 Schwartze, 604 
 Schwartze-Stacke operation, 606 
 operations upon, 600 
 
 general considerations, 603 
 instruments for, 604 
 cells, anatomy of, 600 
 operations upon, 600 
 
 exposure of, antrum operation of 
 
 Schwartze, 604 
 Schwartze-Stacke operation, 606 
 general considerations, 603 
 instruments for, 606 
 Matas and Crile's operation for regional 
 
 anesthesia, 169 
 Matas' infiltrator, 172 
 
 method of paraneural infiltration for 
 
 regional anesthesia, 171 
 modification of Schleich's method of 
 
 massive infiltration anesthesia, 172 
 operation for radical cure of aneurism, 
 
 Matas-Bickham operation for radical cure 
 
 of arteriovenous aneurism, 133 
 Maunsell's invagination method of entero- 
 
 enterostomy, S70 
 Maxilla, inferior, excision of, 477 
 anatomy involved in, 475 
 osteoplastic resection of, 479 
 osteoplastic resection of, Annandale's 
 method, 474 
 Langenbeck's method, 474 
 superior, excision of, anatomy involved 
 in, 469 
 median incision, 471 
 osteoplastic resection of, 473 
 Maxillary ganglion, anatomy of, 188 
 artery, internal, anatomy of, 44 
 nerve, inferior, anatomy of, 188 
 
 exposure of, at foramen ovale, 188, 
 190 
 superior, anatomy of, 182 
 
 exposure of, at foramen rotundum, 
 183, 190 
 by antral route, 185 
 by orbital route, 186 
 by ptervgomaxillarv route, 186 
 sinuses. See Sinuses, maxillary. 
 Mayo's method of pylorectomy, 991 
 
 operation for umbilical hernia, 1181 
 McBurney's method of anterolateral 
 abdominal section, 807 
 of appendicectomy, 900 
 point, 808 
 Meatotomy, 11 20 
 
 Meckel's ganglion, anatomy of, 182 
 exposure of, by antral route, 185 
 by orbital route, 186 
 by ptervgomaxillarv route, 186 
 Median nerve, anatomy of, 201 
 
 exposure of, at bend of elbow, 202 
 in middle of arm, 201 
 Mediastinotomy, Milton's method of, 748 
 Mediastinum, anterior, anatomy of, 748 
 operations upon, 748 
 
 Mediastinum, middle, anatomy of, 752 
 operations upon, 752 
 posterior, anatomy of, 752 
 
 operations upon, 752 
 superior, anatomy of, 747 
 operations upon, 747 
 Medulla, function of, 545 
 Membrana tympani, anatomy of, 618 
 
 introduction of ear speculum for 
 examination of, 618 
 Meningeal artery, middle, anatomy of, 44, 
 
 535 
 anterior branch, ligation of, 48 
 posterior branch, ligation of, 49 
 trunk of, ligation of, 47 
 topography of, 542 
 Mesentery, anatomy of, S33 
 operations upon, 833 
 
 general considerations, 833 
 Meyer's radical excision of breast, 738 
 Mid-tarsus, osteoplastic resection of, 514 
 Mikulicz's method of exposing tonsil, 720 
 Milton's osteoplastic anterior medias- 
 tinotomy, 748 
 Mixter's method of colostomy, 921 
 
 of exposing inferior maxillary nerve, 
 190 
 Motor areas, localization of, 544 
 
 center, exposure of, operation for, 593 
 Mott's method of ligating innominate artery, 
 
 2 7 
 Moynihan's modification of Bircher's 
 
 operation for gastroplication, 983 
 
 Murphy button, anterior gastro-enterostomy 
 
 by, followed by Jaboulay-Braun 
 
 method of intestinal anastomosis, 
 
 971 
 
 cholecystenterostomy by, 1026 
 
 entero-enterostomy by, 885 
 
 posterior gastro-enterostomy by, 978 
 
 Murphy's method of suturing arteries, 119 
 
 of treating diffuse septic peritonitis, 825 
 
 Muscle in amputation, treatment of, 297 
 
 Muscle-lengthening, 246 
 
 Muscles, operations upon, 245 
 
 suture of, 24O 
 
 Musculospiral nerve, anatomy of, 203 
 
 exposure of, below middle of arm, 203 
 
 Myer's method of inferior anterolateral 
 
 abdominal section, 817 
 
 Myorrhaphy, 245 
 
 Myotomy, 245 
 
 Nasal cartilages, chondroplastic resection 
 
 of, 473 
 cavities, operations upon, 619 
 
 Nasolambdoidal line, topography of, 542 
 
 Neck, anatomy of, 695 
 
 anterolateral aspect, anatomy of, 149 
 lymphatic glands of, isolated, removal 
 
 of > 153 
 
 removal of, 151 
 operations upon, 695 
 
 instruments for, 696 
 Needling for radical cure of aneurism, 139 
 
INDEX 
 
 1199 
 
 Neoplasms, vascular, injection of water at 
 
 high temperature in, 141 
 Nephrectomy, partial, by oblique lumbar 
 incision, 1072 
 subcapsular, 1072 
 
 total, by anterior transperitoneal opera- 
 tion, 1072 
 by oblique lumbar incision, 1070 
 Nephrolithotomy, 1062 
 Nephropexy by simple suturing, 1069 
 Edebohl's method, 1064 
 Turner's method, 106S 
 Nephrorrhaphy, 1063 
 Nephrotomy, 1061 
 Nerve, crural, anterior, anatomy of, 205 
 
 exposure of, below Poupart's liga- 
 ment, 205 
 dental, inferior, anatomy of, 191 
 
 exposure of, at mental foramen, 193 
 in mouth, 191 
 
 through ascending ramus of infe- 
 rior maxilla, 192 
 excision of, 158 
 facial, anatomy of, 194 
 
 exposure of, in front of mastoid 
 
 process, 195 
 topography of, 542 
 gluteal, superior, exposure of, 205 
 gustatory, anatomy of, 193 
 
 exposure of, in mouth, 194 
 in amputation, treatment of, 297 
 infra-orbital, exposure of, 188 
 intercostal, anatomy of, 204 
 
 exposure of, between angle and middle 
 of rib, 204 
 lingual, anatomy of, 193 
 
 exposure of, in mouth, 194 
 maxillarv, inferior, exposure of, 188 
 at foramen ovale, 188, 190 
 superior, anatomy of, 182 
 
 exposure of, at foramen rotundum, 
 183, 190 
 by antral route, 185 
 by orbital route, 186 
 by pterygomaxillary route, 186 
 median, anatomy of, 201 
 
 exposure of, at bend of elbow, 202 
 in middle of arm, 201 
 musculospiral, anatomy of, 203 
 
 exposure of, below middle of arm, 203 
 obturator, exposure of, 205 
 popliteal, external, anatomy of, 207 
 
 exposure of, behind tendon of biceps, 
 207 
 internal, anatomy of, 206 
 
 exposure of, at lower part of popliteal 
 space, 206 
 pudic, exposure of, 205 
 sciatic, great, anatomy of, 205 
 
 exposure of, at lower border of 
 gluteus maximus, 206 
 spinal accessory, anatomy of, 195 
 
 exposure of, at anterior border of 
 sternomastoid muscle, 195 
 supra-orbital, anatomy of, 182 
 exposure of, 182 
 
 Nerve, suture of, 160 
 
 tibial, anterior, anatomy of, 208 
 exposure of, near origin, 20S 
 posterior, anatomy of, 207 
 
 exposure of, behind internal malleo- 
 lus, 207 
 between origin and ankle, 207 
 trifacial, exposure of, by direct infra- 
 arterial route, 175 
 by trephining through pterygo- 
 maxillary fossa, 1S1 
 through temporal fossa, 177 
 ulnar, anatomy of, 202 
 
 exposure of, above internal condyle 
 of humerus, 203 
 above middle of arm, 202 
 Nerve-anastomosis, 165 
 Nerve-avulsion, 159 
 Nerve-grafting, 165 
 Nerve-implantation, 165 
 Nerve-stretching, 158 
 
 Nerves, brachial plexus of, anatomy of, 19S 
 exposure of, in neck, 198 
 cervical, first, second, third, posterior 
 
 divisions, exposure of, 197 
 compression of, operation for, 169 
 operations upon, 157 
 Neurectasy, 158 
 Neurectomy, 158 
 
 intraspinal, partial, of posterior nerve- 
 roots, 679 
 Neurolysis, 169 
 Neuroplasty, 163 
 Neurorrhaphy, 160 
 Neurotomy, 157 
 Nose, operations upon, 619 
 
 Obturator nerve, exposure of, 205 
 Occipital artery, anatomy of, 42 
 ligation of, 42 
 lobe, topography of, 541 
 O'Dwyer's method of intubation of larynx, 
 
 ' OI 
 Olecranon, fracture of, ununited, operation 
 
 for, by wiring or suturing of bone and 
 
 soft parts, 238 
 
 Ollier's excision of elbow-joint, 497 
 
 of wrist-joint, 490 
 
 Omentum, adhesions to, operations for, S24 
 
 anatomy of, 830 
 
 grafting with, 832 
 
 ligation of, 831 
 
 operations upon, 830 
 
 general considerations, 831 
 
 Oophorectomy, 1160 
 
 Orbit, anatomy of, 614 
 
 exenteration of, 616 
 
 Orchidectomy, 11 34 
 
 Os calcis, excision of, 510 
 
 Osteitis, vertebral tubercular, anterior, 
 
 operative treatment of, 685 
 
 posterior, operative treatment of, 685 
 
 Osteoplastic amputations, 317 
 
 resection of foot, externolateral curved 
 
 incision, 518 
 
INDEX 
 
 Osteoplastic resection of foot, transverse 
 upper and lower and oblique lateral 
 incisions, 516 
 of mid-tarsus, 514 
 of skull, 505 
 of spine, 648 
 
 formation and turning hack of flap 
 
 in, 65 1 
 general considerations, 642 
 Hartley's preliminary excision of 
 spinous process in, 647, 649 
 of tarsus and tarsometatarsus, 513 
 posterior, 515 
 Osteoplasty, 240 
 Osteotomy, 210 
 cuneiform, 214 
 indications for, 210 
 instruments for, 210 
 linear, by open method, 213 
 
 by subcutaneous method, 211 
 position in, 2 1 1 
 
 preparation of patient for, 211 
 varieties of, 210 
 Otic ganglion, anatomy of, 188 
 Ovariectomy, 1100 
 Ovaries, anatomy of, 1159 
 operations upon, 1159 
 
 Pancreas, anatomy of, 1043 
 operations upon, 1043 
 
 general considerations, 1044 
 instruments for, 1040 
 Pancreatectomy, partial, 3047 
 Pancreatic cavities, drainage of, 1046 
 Pancreatotomy by gastrocolic route, 1046 
 Paracentesis abdominis, 824 
 thoracis, 761 
 of right auricle of heart, 787 
 
 ventricle of heart, 7S7 
 pericardii, 781 
 tunica? vaginalis, 11 29 
 tympani, 619 
 vesicae, 1095 
 Paralysis, brachial birth, operation for, 199 
 facial, peripheral, facio-accessory anasto- 
 mosis for, 196 
 Paraneural infiltration for regional anes- 
 thesia, Matas' method, 171 
 Paravicini's intrabuccal method of exposing 
 
 inferior dental nerve, 191 
 Parietal convolution, ascending, topog- 
 raphy of, 541 
 lobe, topograph}- of, 541 
 Parieto-occipital fissure, anatomy of, 534 
 
 topography of, 540 
 Parkhill's bone-clamp, 223 
 Parkin's incision of cerebellar subarachnoid 
 
 space for drainage, 595 
 Parotid gland, anatomy of, 721 
 excision of, 722 
 operations upon, 721 
 Patella, excision of, 520 
 
 fracture of, ununited, operation for, by 
 encircling suture of soft parts, 
 236 
 
 Patella, fracture of, ununited, operation for, 
 by suturing of soft parts, 233 
 by wiring or suturing of bone and 
 soft parts, 234 
 Pelviotomy, 1062 
 
 Penis, amputation of, partial, n 14 
 total, 1 1 id 
 operations upon, 1 1 1 1 
 
 instruments for, 11 n 
 Pericardiocentesis, 781 
 Pericardiorrhaphy, 785 
 Pericardiotomy through intercostal incision, 
 
 782 
 Pericardium, anatomy of, 780 
 
 and heart, exposure of, by excision of left 
 fifth costal cartilage, 784 
 by thoracoplastic flap, 788 
 operations upon, 780 
 puncture of, 781 
 suture of, 785 
 Perineal cystotomy, lateral, for vesical 
 calculus, 1099 
 median, for vesical calculus, 1 102 
 prostatectomy, 1143 
 
 urethrotomy, external, Cock's operation, 
 1 1 26 
 Gouley's method, n 24 
 Syme's method, 1123 
 Wheelhouse's method, 11 25 
 Periosteum, uniting of tendon to, operation 
 
 for, 263 
 Peritoneum, adhesions of, operations for, 
 822 
 anatomy of, 820 
 operations upon, 820 
 
 general considerations, 822 
 septic, diffuse, Blake's method of treating, 
 826 
 Murphy's method of treating, 825 
 operative treatment of, 825 
 Peroneal artery, anatomy of, 114 
 
 ligation of, 1 14 
 Pfannenstiel's method of median inferior 
 
 abdominal section, 815 
 Pharyngotomy, lateral, 708 
 median, 708 
 subhyoid, 709 
 Pharynx, anatomy of, 707 
 operations upon, 707 
 
 instruments for, 707 
 Phlebectomy, 145 
 Phleborrhapl.v, 142 
 Phlebostrepsis, 145 
 Phlebotomy, 141 
 
 Pirogoff's disarticulation of foot at ankle- 
 joint, 415 
 Plantar artery, external, anatomy of, 115 
 ligation of, 116 
 internal, anatomy of, 117 
 ligation of, 117 
 Pleuracentesis, 761 
 Pleura, anatomy of, 759 
 
 discission of, in chronic empyema, 
 
 Ransohoff's operation, 771 
 operations upon, 759 
 puncture of, 761 
 
INDEX 
 
 Pleurectomy, partial, Estlander's method 
 of, 765 
 Schede's method of, 768 
 total, Fowler's method of, 770 
 Pleurotomy, 761 
 Plexus, brachial, of nerves, anatomy of, 198 
 
 exposure of, in neck, 198 
 Plexuses, operations upon, 157 
 Pneumectomy, partial, through cutaneo- 
 musculo-osseous thoracoplastic flap, 776 
 Pneumotomy through cutaneomuscular 
 
 thoracoplastic flap, 774 
 Poggi's method of uretero-ureterostomy, 
 
 1081 
 Pons, function of, 545 
 Popliteal artery, anatomy of, 99 
 ligation of, 100 
 nerve, external, anatomy of, 207 
 
 exposure of, behind tendon of biceps, 
 207 
 internal, anatomy of, 206 
 
 exposure of, at lower part of pop- 
 liteal space, 206 
 Postcentral fissure, topography of, 540 
 Pott's disease, Lambotti's operation for, 691 
 operative treatment of, 685 
 Treves' operation for, 687 
 Poupart's ligament, anatomy of, 1163 
 Precentral fissure, topography of, 540 
 Pressure of artery, 140 
 Proctectomy, 935. See also Rectectomy. 
 Proctopexy, 933 
 Proctotomy, 934 
 Profunda femoris, anatomy of, 94 
 
 ligation of, 95 
 Prostate gland, anatomy of, 1140 
 operations upon, 1140 
 
 instruments for, 1141 
 Prostatectomy, 1 r4 1 
 
 Alexander's operation, 1144 
 perineal, 11 43 
 suprapubic, 1142 
 Prostatotomy, 1141 
 Psychical area, localization of, 545 
 Pudic artery, internal, anatomy of, 85 
 ligation of, 85 
 nerve, superior, exposure of, 205 
 Puncture and drainage of lateral ventricles 
 of brain, 594 
 exploratory, of joints, 241 
 of kidney, 1060 
 of liver, 1008 
 of spleen, 1038 
 lumbar, for diagnosis and therapeusis, 
 
 669 
 of bladder, 1095 
 of brain, exploratory, 584 
 of bursie, 270 
 of heart, 787 
 of pericardium, 781 
 of pleura, 761 
 of tunica vaginalis, n 29 
 spinal, for drainage of subarachnoid 
 
 space, 670 
 subarachnoid, for spinal analgesia, 666 
 Pyelotomy, 1062 
 
 76 
 
 Pylorectomy, 991 
 
 followed by end-to-end gastroenteros- 
 tomy, Billroth's method, 997 
 followed by independent gastro- 
 jejunostomy, Mayo's method, 991 
 followed by posterior gastroduodenos- 
 tomy, Kocher's method, 994 
 Pyloric orifice of stomach, divulsion of, 
 
 Loreta's operation, 986 
 Pyloroplasty, Heineke-Mikulicz method, 
 984 
 
 Radial artery, anatomy, 66 
 
 ligation of, 69 
 Radius, excision of, 494 
 
 total, 494 
 Radio-ulnar articulation, superior, excision 
 
 of, 500 
 Ransohoff's method of discission of pleura 
 
 in chronic empyema, 771 
 Re-amputation for improperly made flaps, 
 
 297 
 Rectectomy, 935 
 
 by perineal route, 942 
 by sacral route, 935 
 Kraske's method, 935 
 Rehn-Rydygier osteoplastic flap method, 
 940 
 Rectopexy, Verneuil's method, 933 
 Rectotomy, external, 934 
 internal, 934 
 posterior, 934 
 Rectum, anatomy of, 838 
 
 excision of, 935. See also Rectectomy. 
 Rehn-Rydygier osteoplastic flap method of 
 
 rectectomy, 940 
 Reid's method of craniocerebral localiza- 
 tion, 551 
 Reil, island of, anatomy of, 534 
 
 topography, 541 
 Resection, chondroplastic, of chest -wall, 734 
 of nasal cartilages, 473 
 osteoplastic, of bones and joints, 468 
 of foot, externolateral curved incision, 
 
 transverse upper and lower and 
 oblique lateral incisions. 516 
 of lower jaw, 479 
 of mid-tarsus, 514 
 of shoulder-joint, 503 
 of skull, 565 
 of spine, 648 
 
 formation and turning back of flap 
 
 in, 648 
 general considerations, 642 
 Hartley's preliminary excision of 
 spinous process in, 647, 649 
 of superior maxilla, 473 
 
 Annandale's operation, 474 
 Langenbeck's operation, 474 
 of tarsus and tarsometatarsus, 513 
 posterior, 515 
 Retrobulbar structures, exposure of, 617 
 Retroduodenal choledochotomy, 1034 
 Retropharyngeal space, exposure of, 710 
 
1202 
 
 INDEX 
 
 Retzius' space, anatomy of, 1092 
 
 Rib and costal cartilage, excision of, 480 
 
 excision of, 471) 
 Rivinus, ducts of, anatomy of, 726 
 Robson's method of uretero-ureterostomy, 
 
 1082 
 Rolandic fissure, anatomy of, 534 
 
 Chiene's method of determining, 554 
 topography of, 539 
 Rose's exposure of Gasserian ganglion, 1S1 
 Rotter's method of exposing heart and 
 
 pericardium, 788 
 Rouge's chondroplastic resection of nasal 
 
 cartilages, 473 
 Round ligaments of uterus, anatomy of, 
 
 1 149 
 Ruptured tendon-sheaths, repair of, 265 
 
 Salomoni and Tomaselli's method of 
 
 arteriorrhaphy, 123 
 Salpingo-obphorectomy, 1160 
 Salpingo-ovariectomy, 1160 
 Salt solution, intravenous infusion of, 146 
 Scalp, anatomy of, 533 
 Scapula, excision of, 481 
 
 total, 482 
 Scarpa's fascia, anatomy of, 1163 
 
 triangle, anatomy of, 155 
 Schede's thoracoplasty operation, 768 
 Schopf's method of uretero-ureterostomy, 
 
 1080 
 Schwartze's antrum operation, 604 
 Schwartze-Stacke operation for exposing 
 
 mastoid antrum and cells, 606 
 Sciatic artery, anatomy of, 84 
 ligation of, 84 
 nerve, great, anatomy of, 205 
 
 exposure of, at lower border of 
 gluteus maximus, 206 
 Scrotum, anatomy of, 11 28 
 excision of, partial, 11 29 
 operations upon, n 28 
 Section, abdominal. See .4 bdominal section. 
 Semilunar cartilages, dislocation of, opera- 
 tion for, 244 
 Seminal vesicles, anatomy of, n 38 
 
 and part of ejaculatory ducts, total 
 excision of, Young's operation, 1139 
 operations upon, 1138 
 
 instruments for, 1139 
 Sensory areas, localization of, 544 
 Sequestrotomy, 239 
 Shoulder-joint, anatomy of, 372 
 disarticulation at, 377 
 
 general considerations, 374 
 excision of, 501 
 osteoplastic resection of, 503 
 Sight area, localization of, 545 
 Sinus, lateral, anatomv of, 536 
 ligation of, 586 
 
 thrombosis of, operation for, 588 
 longitudinal, inferior, anatomy of, 536 
 ligation of, 586 
 superior, anatomy of, 536 
 topography of, 542 
 
 Sinus, straight, anatomy of, 536 
 Sinuses at base of skull, 536 
 
 bony, air, of head and face, operations 
 
 upon, 600 
 frontal, anatomy of, 608 
 
 exposure and drainage of, 610 
 operations upon, 608 
 
 general considerations, 609 
 instruments for, 610 
 lateral, topography of, 542 
 maxillary, anatomy of, 611 
 
 exposure of, through facial aspei!, 
 above alveolar margin, 613 
 second molar tooth, 614 
 operations upon, 611 
 
 general considerations, 612 
 instruments for, 613 
 venous, of dura mater, 536 
 Skin, implantation of ureter upon, 1089 
 
 in amputation, treatment of, 297 
 Skull, anatomy of, 533 
 
 fracture of, trephining for, 590 
 osteoplastic resection of, 565 
 Smell area, localization of, 545 
 Smith's disarticulation at knee-joint, 434 
 method of amputating leg at upper 
 third, 427 
 Snuff-box, anatomy of, 67 
 Sound areas, localization of, 545 
 
 introduction of, into female bladder, 1095 
 
 into male bladder, 1094 
 
 Speech aeas, localization of, 545 
 
 Speculum, ear, introduction of, for 
 
 examination of membrana tympani, 618 
 
 Spence's disarticulation at shoulder-joint, 
 
 378 
 Spermatic cord, anatomy of, 1135 
 operations upon, 1135 
 
 instruments for, 1136 
 Spina bifida, 679 
 
 Bobroff's operation for, 683 
 Chipault's operation for, 683 
 Dollinger's operation for, 683 
 varieties of, 680 
 Zenenko's operation for, 683 
 Spinal accessory nerve, anatomy of, 195 
 
 exposure of, at anterior border of 
 sternomastoid muscle, 195 
 analgesia, subarachnoid puncture for, 666 
 cord, anatomy of, 630 
 
 gunshot wounds of, operative treatment, 
 
 6 75 
 incised and penetrating wounds of, 
 
 operative treatment, 674 
 operations upon, 630 
 
 general considerations, 642 
 tumors of, operations for, 677 
 puncture for drainage of subarachnoid 
 space, 670 
 Spine, anatomy of, 630 
 
 dislocations of, operative treatment, 672 
 fracture-dislocations of, operative treat- 
 ment, 673 
 fractures of, operative treatment, 670 
 localization of, 632 
 operations upon, 630 
 
INDEX 
 
 1203 
 
 Spine, operations upon, general considera- 
 tions, 642 
 osteitis of, tubercular, anterior, operative 
 treatment of, 685 
 posterior, operative treatment of, 685 
 osteoplastic resection of, 648 
 
 formation and turning back of flap 
 
 in, 651 
 general considerations, 642 
 Hartley's preliminary excision of 
 spinous process in, 647, 649 
 Spleen, anatomy of, 1036 
 
 exposure of, by subpleural route, 1039 
 operations upon, 1036 
 
 general considerations, 1037 
 instruments for, 1038 
 puncture of, exploratory, 1038 
 suture of, 1039 
 Splenectomy, partial, 1040 
 
 total, 1 04 1 
 Splenopexy, 1039 
 Splenorrhaphy, 1039 
 
 Splenotomv, oblique subcostal incision, 1038 
 Ssabanajeff's femorotibial osteoplastic 
 
 amputation of leg, 443 
 Ssabanajew-Franck's method of gastros- 
 tomy, 957 
 Stenson's duct, anatomy of, 721 
 
 operations upon, 721 
 Stimson's operation for ununited fracture 
 
 of patella, 233 
 Stomach, anatomy of, 950 
 
 cardiac orifice, dilatation of, 987 
 operations upon, 950 
 
 general considerations, 951 
 instruments for, 952 
 pyloric orifice, divulsion of Loreta's 
 
 operation, 986 
 wall, suture of, 955 
 Stomach-tube, introduction of, 952 
 Stone in bladder, lateral perineal cystotomy 
 for, 1099 
 median perineal cystotomy for, 1102 
 Stricture of esophagus, direct dilatation 
 for, 716 
 divulsion of, 716 
 division, by string friction, Abbe's 
 operation, 716 
 Bryant's operation, 716 
 permanent tubage, 716 
 retrograde dilatation for, 716 
 divulsion of, 716 
 Subarachnoid puncture for spinal analgesia, 
 666 
 space, cerebellar, incision of, for drainage, 
 
 595 
 drainage of, spinal puncture for, 670 
 Subcapsular nephrectomy, 1072 
 Subclavian artery, anatomy of, 50 
 left, first portion, ligation of, 52 
 right, first portion, ligation of, 52 
 second portion, ligation of, 53 
 third portion, ligation of, 53 
 Subhyoid pharyngotomy, 709 
 Sublingual gland, anatomy of, 726 
 
 excision of, through floor of mouth, 726 
 
 Sublingual gland, operations upon, 726 
 Submaxillary gland, anatomy of, 724 
 excision of, 725 
 operations upon, 724 
 Sudeck's fraise, 576 
 Supraduodenal choledochotomy, 1031 
 Supra-orbital nerve, anatomy of, 182 
 
 exposure of, 182 
 Suprapubic cystotomy, 1096 
 
 prostatectomy, 1142 
 Suprathvroid laryngotomy, 702 
 Suture of artery, 118 
 
 of bladder, 1103 
 
 of heart, 790 
 
 of intestines, 841. See also Enter- 
 orrkaphy. 
 
 of kidney, 1063 
 
 of ligaments, 268 
 
 of liver, 10 19 
 
 of muscle, 245 
 
 of nerve, 160 
 
 of pericardium, 785 
 
 of spleen, 1039 
 
 of stomach-wall, 955 
 
 of tendon, 251 
 
 of thoracic duct, 148 
 
 of ureters, 1079 
 
 of urethra, 1 127 
 
 of veins, 142 
 Sylvian fissure, anatomy of, 533 
 
 topography of, 539 
 Syme's disarticulation of foot at ankle- 
 joint, 414 
 
 method of external perineal urethrotomy, 
 1123 
 Syndesmotomy, 268 
 
 Tabatiere, anatomy of, 67 
 Talma-Drummond operation for cirrhosis 
 
 of liver, 102 1 
 Tamponing of larynx, 702 
 
 of trachea, 707 
 Tarsus and tarsometatarsus, osteoplastic 
 resection of, 513 
 
 excision of, 5 1 8 
 
 mid-, osteoplastic resection of, 514 
 
 posterior, osteoplastic resection of, 5 1 5 
 Taste area, localization of, 545 
 Teale's method of amputation bv unequal 
 
 rectangular flaps, 314 
 Temporal artery, anatomy of, 43 
 ligation of, 43 
 
 lobe, topography of, 541 
 Temporomaxillary articulation, excision of, 
 
 476 
 Temporosphenoidal fissure, superior, anat- 
 omy of, 541 
 Tendon-grafting, 261 
 Tendon-implantation, 261 
 Tendon-lengthening, 254 
 Tendon-sheaths, excision of, 267 
 
 operations upon, 249 
 
 ruptured, repair of, 265 
 Tendon-shortening, 259 
 Tendon-transplantation, 261 
 
1204 
 
 INDEX 
 
 Tendons in amputation, treatment of, 297 
 operations upon, 249 
 
 suture of, 251 
 
 transplantation of, with their osseous 
 
 insertions, 265 
 uniting of, to bone, operation for, 264 
 to periosteum, operation for, 263 
 Tendoplasty, 254 
 Tenorrhaphy, 251 
 Tenotomy, 249 
 open, 250 
 subcutaneous, 250 
 Testes, anatomy of, 1128 
 
 operations upon, 11 28 
 Thigh, amputation of, 440 
 at condyles of femur, 440 
 general considerations, 43S 
 just above condyles of femur, 441 
 just below trochanters, 449 
 lower, middle, or upper third, 446, 448 
 third, 444 
 anatomy of, 436 
 Thomas' forceps tourniquet for controlling 
 
 hemorrhage, 455 
 Thoracentesis, 761 
 Thoracic duct, anatomy of, 148 
 ligation of, 149 
 suture of, 148 
 esophagotomy, by posterior mediastinal 
 
 osteoplastic flap operation, 792 
 tracheotomy, 707 
 
 by posterior mediastinal thoracoplastic 
 flap operation, 791 
 wall and contents, anatomy of, 731 
 operations upon, 736 
 chondroplastic resection of, 734 
 Thoracotomy by partial excision of one or 
 more ribs, 763 
 intercostal, 761 
 
 mediastinal, anterior, by long median 
 incision, 748 
 by osteoplastic resection of part of 
 sternum, 750 
 posterior, 752 
 Thorax, anatomy of, 731 
 operations upon, 731 
 
 instruments for, 734 
 Thrombosis of lateral sinus, operation for, 
 
 588 
 Thumb, amputation of, with part of 
 metacarpal, 342 
 disarticulation of, at metacarpophalan- 
 geal-joint, 334 
 with metacarpal, 345 
 metacarpal of, excision of, 489 
 Thyroid artery, inferior, anatomy of, 56 
 ligation of, 57 
 gland, anatomy of, 727 
 operations upon, 727 
 Thyroidectomy, complete, 729 
 
 partial, 727 
 Thyrotomy, 698 
 Tibia, excision of, 518 
 Tibial artery, anterior, anatomy of, 103 
 ligation of, 104 
 posterior, anatomy of, 108 
 
 Tibial artery, posterior, ligation of, 109 
 nerve, anterior, anatomy of, 208 
 exposure of, near origin, 208 
 posterior, anatomy of, 207 
 
 exposure of, behind internal malleo- 
 lus, 207 
 between origin and ankle, 207 
 Toes, amputations about, general con- 
 siderations, 386 
 amputation of, at first phalanx, 391 
 at last phalanx, 388 
 at metatarsus, 402 
 at second phalanx, 390 
 with part of metatarsals, 401 
 disarticulation of, at first interphalangeal 
 joints, 390 
 at metatarsophalangeal joints, 392 
 at second interphalangeal joint, 389 
 at tarsometatarsal joints, 407, 408 
 en masse, at metatarsophalangeal 
 
 joints, 395 
 general considerations, 386 
 with metatarsals, 403, 404 
 excision of bones and joints about, 505 
 of first interphalangeal joints, 506 
 
 phalanges, 507 
 of metatarsal bones, 507 
 of metatarsophalangeal joints, 507 
 of second interphalangeal joints, 506 
 
 phalanges, 506 
 of terminal phalanges, 506 
 great, disarticulation of, at metatarso- 
 phalangeal joints, 393 
 with metatarsals, 404 
 little, disarticulation of, at metatarso- 
 phalangeal joints, 394 
 with metatarsals, 406 
 second, third, or fourth, disarticulation 
 
 of, at metatarsophalangeal joints, 392 
 two adjoining, disarticulation of, at 
 
 metatarsophalangeal joint, 395 
 two or three contiguous, disarticulation 
 of, with metatarsals, 407 
 Tongue, anatomy of, 619 
 excision of, 619 
 
 general considerations, 620 
 instruments for, 621 
 limited portions, 621 
 through mouth, after preliminary 
 ligation of lingual arteries, 624 
 without preliminary ligation of 
 lingual arteries, 622 
 together with cervical and submax- 
 illary glands, 627 
 with osteoplastic division of inferior 
 maxilla, 624 
 operations upon, 619 
 Tonsillectomy, complete, through mouth, 
 718 
 through neck, 719 
 partial, through mouth, 71S 
 Tonsillotomy, 717 
 Tonsils, anatomy of, 717 
 operations upon, 717 
 
 general considerations, 717 
 instruments for, 717 
 
INDEX 
 
 1205 
 
 Torsion of artery, 140 
 Trachea, anatomy of, 702 
 
 foreign bodies in, operation for removal 
 
 of, 707 
 operations upon, 702 
 
 general considerations, 703 
 instruments for, 703 
 tamponing of, 707 
 Tracheolaryngotomy, 706 
 Tracheoscopy, 707 
 
 Tracheotomy, Bose's bloodless method of, 
 706 
 high, 704 
 low, 706 
 thoracic, 707 
 
 by posterior mediastinal thoracoplastic 
 flap operation, 791 
 Transduodenal choledochostomy, 1034 
 Transplantation, tendon-, 261 
 
 with its osseous insertion, 265 
 Trendelenburg's rod for controlling hem- 
 orrhage in amputations near hip-joint, 
 
 455 
 Trephining, 558 
 
 for fracture of skull, 590 
 linear, 580 
 varieties of, 558 
 Treve's operation for Pott's disease, 687 
 Trifacial nerve, exposure of, by direct infra- 
 arterial route, 175 
 by trephining through pterygo- 
 
 maxillary fossa, 181 
 through temporal fossa, 177 
 Trigonum vesicae, anatomy of, 1092 
 Tubercular osteitis of spine, anterior, 
 operative treatment of, 685 
 posterior, operative treatment of, 685 
 Tuffier's method of nephropexy, 1068 
 
 of uretero-ureterostomy, 1081 
 Tumor, cerebellar, operation for, 599 
 cerebral, operation for, 597 
 of spinal cord, operations for, 677 
 Tunica albuginea, anatomy of, n 29 
 vaginalis, anatomy of, n 28 
 
 puncture of, n 29 
 vasculosa, anatomy of, n 29 
 
 Ulcer, gastric, operation for, 1002 
 perforated, operation for, 1003 
 Ullmann's modification of Maunsell's 
 
 method of entero-enterostomy, 881 
 Ulna, excision of, 493 
 
 excision of, total, 493 
 Ulnar artery, ligation of, 73 
 nerve, anatomy of, 202 
 
 exposure of, above internal condyle of 
 humerus, 203 
 above middle of arm, 202 
 Umbilical hernia, 11 78. See also Hernia, 
 
 umbilical. 
 Ureterei tomv, 10S9 
 
 partial, by oblique lumbar incision, 1090 
 total, with removal of kidney, 1090 
 Ureterocystostomy, 1085 
 Ureteroplasty, 1080 
 
 Ureterorectostomy, 10S6 
 Ureterorrhaphy, 1079 
 Ureterotomy, 1078 
 Uretero-ureteral anastomosis, 1080 
 Uretero-ureterostomy, 1080 
 Ureters, anatomy of, 1073 
 
 and kidneys, extraperitoneal exposure of, 
 
 1076 
 exposure of, 1076 
 implantation of, 1084 
 into bladder, 1085 
 into large intestine, 1086 
 upon skin, 1089 
 operations upon, 1073 
 
 general considerations, 1075 
 instruments for, 1076 
 suture of, 1079 
 Urethra, anatomy of, 111S 
 female, anatomy of, n 19 
 male, anatomy of, 111S 
 operations upon, n 18 
 
 general considerations, 1 1 19 
 instruments for, n 20 
 suture of, 1127 
 Urethrorrhaphy, n 27 
 Urethrostomv, 1127 
 Urethrotomy, n 20 
 external perineal, n 26 
 
 Cock's operation, 11 26 
 Gouley's method, n 24 
 Syme's method, 1123 
 YVheelhouse's method, n 25 
 internal, by dilating urethrotome, n 21 
 Uterus, anatomy of, 1147 
 
 broad ligament of, anatomv, 1148 
 operations upon, n 47 
 
 instruments for, 11 50 
 round ligaments of, anatomy, 1149 
 
 Vagina, anatomy of, 1149 
 Vaginal hysterectomy, total, 1153 
 Van Hook's method of uretero-ureteros- 
 tomy, 1082 
 Varicocele, Bennett's modification of 
 Howse's operation for, 1137 
 operation for radical cure of, 1137 
 Vas deferens, anatomv of, 1136 
 Vascular neoplasms, injection of water at 
 
 high temperature in, 141 
 Vasectomy, partial, 1136 
 Veins, acupressure of, 145 
 celiotomv, 800 
 excision of, 145 
 
 infusion of salt solution into, 145 
 ligation of, en masse, 145 
 in amputation, 295 
 lateral, 143 
 temporary, 144 
 transverse, 144 
 operations upon, 142 
 suture of, 142 
 Venesection, 142 
 Venous forcipressure, 145 
 Ventricles, lateral, of brain, puncture and 
 drainage of, 594 
 
1206 
 
 INDEX 
 
 Ventricles, lateral, of brain, topography 
 of, 542 
 right, of heart, paracentesis of,. 787 
 Verneuil's method of rectopexy, 933 
 Vertebral artery, anatomy, 55 
 ligation of, 55 
 tubercular osteitis, anterior, operative 
 treatment of, 685 
 posterior, operative treatment of, 685 
 Vesical calculus, lateral perineal cystotomy 
 for, 1099 
 median perineal cystotomy for, 1102 
 drainage, 1108 
 Vesicnlae seminales. See Seminal vesicles. 
 Vischer's method of lateral abdominal 
 
 section, 819 
 Visual word area, localization of, 545 
 Volkmann's operation for hydrocele, 1131 
 Yon Bergmann's operation for hydrocele, 
 
 \ on Hacker's method of posterior gastro- 
 enterostomy, 974 
 
 Warren's radical excision of breast, 744 
 Weir-Harrington method of anterolateral 
 
 abdominal section, 810 
 Weir's method of appendicostomy, 912 
 modification of Bircher's operation for 
 gastroplication, 981 
 of Murphy's button, lateral anastomo- 
 sis with, 890 
 Wharton's duct, anatomy of, 724 
 
 operations upon, 724 
 Wheelhouse's method of external perineal 
 
 urethrotomy, n 25 
 Whitehead's excision of tongue, 622 
 
 Whitehead's operation for hemorrhoids, 945 
 Winslow's foramen, anatomy of, 820 
 
 method of uretero-ureterostomy, 1082 
 Wirsung's canal, anatomy of, 1043 
 Witzel's method of gastrostomy, 959 
 Wladimiroff-Mikulicz resection of foot, 516 
 
 modification of, 518 
 Wolff's operation for uniting tendon to 
 
 bone, 264 
 Wblfler's method of anterior gastroenter- 
 ostomy, 968 
 of gastrogastrostomy, 979 
 Wounds, bullet, of brain, operation for, 591 
 gunshot, of spinal cord, operative treat- 
 ment of, 675 
 incised and penetrating, of spinal cord, 
 
 operative treatment of, 674 
 of artery, closure of, Brewer's operation 
 for, 124 
 by special rubber plaster, 124 
 of intestine, enterorrhaphy for, 848 
 Wrist-joint, anatomy of, 348 
 disarticulation at, 350 
 excision of, 489 
 Wyeth's disarticulation at hip-joint, 456 
 operation for vascular neoplasms, 141 
 pins in amputating at hip-joint, 453 
 in controlling hemorrhage in dis- 
 articulation at shoulder-joint, 374 
 
 Young's method of total excision of seminal 
 vesicles and part of ejaculatory ducts, 
 "39 
 
 Zenenko's operation for spina bifida, 683 ' 
 
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 volved, and the amount of indemnity justified in given cases. The work is 
 indispensable to every physician who sees cases of injury due to accidents, to 
 advanced students, to surgeons, and, on account of its illustrations and statistical 
 data, it is none the less useful to accident-insurance organizations. 
 
 The Medical Record, New York 
 
 " This volume is upon an important and only recently systematized subject, which is grow- 
 ing in extent all the time. The pictorial part of the book is very satisfactory." 
 
 Stoney's 
 Materia Medica for Nurses 
 
 Practical Materia Medica for Nurses, with an Appendix containing 
 Poisons and their Antidotes, with Poison-Emergencies ; Mineral Waters ; 
 Weights and Measures ; Dose-List, and a Glossary of the Terms used 
 in Materia Medica and Therapeutics. By Emily M. A. Stoney, of the 
 Carney Hospital, South Boston. i2mo of 300pages. Cloth, #1.50 net. 
 
 RECENTLY ISSUED— NEW (3rd) EDITION 
 
 In making the revision for this new third edition, all the newer drugs have 
 been introduced and fully discussed. The consideration of the drugs includes* 
 their sources and composition, their various preparations, physiologic actions, 
 directions for administering, and the symptoms and treatment of poisoning. 
 
 Journal of the American Medical Association 
 
 " So far as we can see, it contains everything that a nurse ought to know in regard to drugs. 
 As a reference-book for nurses it will without question be very useful." 
 
SAUNDERS' BOOKS ON 
 
 Hoxie's Medicine for Nurses Recently issued 
 
 Practice of Medicine for Nurses. A Text-Book for Nurses and Students 
 of Domestic Science, and a Hand-Book for All Those Who Care for the Sick. 
 By GEORGE HOWARD Hoxie, .M. J)., Professor of Internal Medicine, Uni- 
 versity of Kansas. With a Chapter on Technic of Nursing by Pearl L. 
 Laptad, Principal of the Training School for Nurses, University of Kansas. 
 I2mo of 284 pages, illustrated. Cloth, $1.50 net. 
 
 I his work is truly a practice of medicine for the nurse, enabling her to recognize any 
 signs and changes that may occur between visits of the physician, and, if necessary, to 
 combat them until the physician's arrival. This information the author presents in a way 
 most acceptable, particularly emphasizing the nurse's part. There are also special chapters 
 on the diseases of infancy and childhood, diseases of the eye, ear, nose, and throat, 
 venereal diseases, nervous and mental diseases, surgical nursing, nursing in skin diseases, 
 emergency measures, and the care and management of the sick-room and the patient. 
 
 McCombs' Diseases of Children for Nurses e £ued 
 
 Diseases of Children for Nurses. By Robert S. McCombs, M. D., 
 Instructor of Nurses at the Children's Hospital of Philadelphia. i:mo of 
 430 pages, illustrated. Cloth, g2.oo net. 
 
 Dr. McCombs' experience in lecturing to nurses has enabled him to emphasize just those 
 points that nurses most need to know. He has given a short but clear description of each 
 disease, so that the nurse will be enabled to know what symptoms to expect and what 
 complications to guard against. The nursing side has been written by head nurses, 
 especially praiseworthy being the work of Miss lennie Manly. 
 
 Wilson's Obstetric Nursing Recently issued 
 
 A Reference Hand=Book of Obstetric Nursing. By W. Reynolds 
 
 Wilson, M. U., Visiting Physician to the Philadelphia Lying-in Charity. 
 321x10 of 258 pages, illustrated. Flexible leather, $1.25 net. 
 
 Dr. Wilson's work discusses the subject of obstetrics entirely from the nurse's point of 
 view, presenting in detail everything connected with pregnancy and labor and their man- 
 agement. The entire subject is covered, from the beginning of pregnancy, its course, 
 signs, on to the approach of labor, its actual accomplishment, the puerperium, and care 
 of the infant. The text is copiously illustrated. 
 
 Aikens' Training-School Methods Recently issued 
 
 Hospital Training=SchooI Methods and the Head Nurse. By Char- 
 lotte A. Aikens, Late Director of Sibley Memorial Hospital, Washington, 
 D. C. i2mo of 267 pages. Cloth, $1.50 net. 
 
 This new work is indispensable to all those who aspire to become head nurses. It sug- 
 gests plans that have been tested personally, and gives definite help to those beginning 
 the work of teaching and supervising in hospitals. It tells the head nurse how to teach, 
 it tells what should be taught the nurse and how much. 
 
NURSING. 
 
 De Lee's Obstetrics for Nurses 
 
 Obstetrics for Nurses. By Joseph B. De Lee, M.D., Professor 
 of Obstetrics in the Northwestern University Medical School; Lecturer 
 in the Nurses' Training Schools of Mercy, Wesley, Provident, Cook 
 County, and Chicago Lying-in Hospitals. i2mo volume of 512 pages, 
 fully illustrated. Cloth, $2.50 net. 
 
 JUST ISSUED— NEW (3d) EDITION 
 
 The illustrations in Dr. De Lee's work are nearly all original, and represent 
 photographs taken from actual scenes. The text is the result of the author's many 
 years' experience in lecturing to the nurses of five different training schools. 
 
 J. Clifton Edgar, M. D., 
 
 Professor of Obstetrics and Clinical Afidwi/ery, Cornell Medical School, N. Y. 
 " It is far-and-away the best that has come to my notice, and I shall take great pleasure in 
 recommending it to my nurses, and students as well." 
 
 Davis* Obstetric and 
 Gynecologic Nursing 
 
 Obstetric and Gynecologic Nursing. By Edward P. Davis, A.M., 
 M. D., Professor of Obstetrics, Jefferson Medical College and Philadel- 
 phia Polyclinic. i2mo of 436 pages, illustrated. Buckram, $1.75 net. 
 
 JUST ISSUED— THIRD REVISED EDITION 
 
 The Lancet, London 
 
 " Not only nurses, but even newly qualified medical men, would learn a great deal by a 
 perusal of this book. It is written in a clear and pleasant style, and is a work we can recom- 
 mend." 
 
 Reference Handbook for Nurses 
 
 A Reference Handbook for Nurses. By Amanda K. Beck, of 
 Chicago, 111. 321110 of 177 pages. Flexible leather, S1.25 net. 
 
 RECENTLY ISSUED 
 
 This little book contains information upon every question that comes to a 
 nurse in her daily work, and embraces all the information that she requires to 
 carry out any directions given by the physician. 
 
 Boston Medical and Surgical Journal 
 
 "Must be regarded as an extremely useful book, not only for nurses, but for physicians " 
 
SAUNDERS' BOOKS ON 
 
 Stoney's Nursing 
 
 Practical Points in Nursing: for Nurses in Private Practice. By 
 Emily M. A. Stoney, Superintendent of the Training School for Nurses 
 at the Carney Hospital, South Boston, Mass. 466 pages, fully illus- 
 trated. Cloth, $175 net. 
 
 THIRD EDITION, THOROUGHLY REVISED— RECENTLY ISSUED 
 
 In this volume the author explains the entire range of private nursing as dis- 
 tinguished from hospital nursing, and the nurse is instructed how best to meet the 
 various emergencies of medical and surgical cases when distant from medical or 
 surgical aid or when thrown on her own resources. An especially valuable feature 
 will be found in the directions how to i?nprovise everything ordinarily needed in the 
 sick-room. 
 
 The Lancet, London 
 
 "A very complete exposition of practical nursing in its various branches, including obstetric 
 and gynecologic nursing. The instructions given are full of useful detail." 
 
 Stoney's Technic for Nurses 
 
 Bacteriology and Surgical Technic for Nurses. By Emily M. A. 
 Stoney, Superintendent at Carney Hospital, South Boston. Revised 
 by Frederic R. Griffith, M. D., Surgeon, of New York. i2mo, 
 278 pages, illustrated. Cloth, $1.50 net. 
 
 RECENTLY ISSUED— NEW (2d) EDITION 
 Trained Nurse and Hospital Review 
 
 " These subjects are treated most accurately and up to date, without the superfluous reading 
 which is so often employed. . . . Nurses will find this book of the greatest value both during 
 their hospital course and in private practice." 
 
 Spratling on Epilepsy 
 
 Epilepsy and Its Treatment. By William P. Spratling, M. D., 
 Medical Superintendent of the Craig Colony for Epileptics, Sonyea, 
 New York. Octavo of 522 pages, fully illustrated. Cloth, $4.00 net. 
 
 The Lancet, London 
 
 " Dr. Spratling's work is written throughout in a clear and readable style. . . . The work 
 is a mine of information on the whole subject of epilepsy and its treatment." 
 
CHILDREN AND HYGIENE. 13 
 
 Griffith's Care of the Baby 
 
 The Care of the Baby. By J. P. Cro«er Griffith, M. D., Clinical 
 Professor of Diseases of Children, University of Penn. ; Physician to the 
 Children's Hospital, Phila. 121110, 455 pp. Illustrated. Cloth, $1.50 net. 
 
 RECENTLY ISSUED— THE NEW (4th) EDITION 
 
 The author has endeavored to furnish a reliable guide for mothers. He has 
 made his statements plain and easily understood, in the hope that the volume 
 may be of service not only to mothers and nurses, but also to students and practi- 
 tioners whose opportunities for observing children have been limited. 
 
 New York Medical Journal 
 
 "We are confident if this little work could find its way into the hands of every trained 
 nurse and of every mother, infant mortality would be lessened by at least fifty per cent." 
 
 Crothers' Morphinism 
 
 Morphinism and Narcomania from Opium, Cocain, Ether, Chloral, 
 Chloroform, and other Narcotic Drugs ; also the Etiology, Treatment, 
 and Medicolegal Relations. ByT. D. Crothers, M. D., Superintendent 
 of Walnut Lodge Hospital, Hartford, Conn. Handsome i2mo of 351 
 pages. Cloth, $2.00 net. 
 
 The Lancet, London 
 
 "An excellent account of the various causes, symptoms, and stages of morphinism, the 
 discussion being throughout illuminated by an abundance of facts of clinical, psychological, and 
 social interest." 
 
 Abbott's Transmissible Diseases 
 
 The Hygiene of Transmissible Diseases : Their Causation, Modes 
 of Dissemination, and Methods of Prevention. By A. C. Abbott, M. D., 
 Professor of Hygiene and Bacteriology, University of Pennsylvania. 
 Octavo, 351 pages, with numerous illustrations. Cloth, $2. 50 net. 
 
 SECOND REVISED EDITION 
 
 During the interval that has elapsed since the appearance of the first edition 
 investigations upon the modes of dissemination of certain of the specific infections 
 have been very active. The sections on Malaria, Yellow Fever, Plague, Filariasis, 
 Dysentery, and Tuberculosis have been both revised and enlarged. 
 
 The Lancet, London 
 
 " We heartily commend the book as a concise and trustworthy guide in the subject with 
 which it deals, and we sincerely congratulate Professor Abbott." 
 
i 4 SAUNDERS' BOOKS ON 
 
 Register's Fever Nursing Recently issued 
 
 A Text-Book on Practical Fever Nursing. By Edward C. 
 Register, M. I)., 1'rofessor of the Practice of Medicine in the North 
 Carolina Medical College. 121110 of 352 pages. Cloth, $2.50 net. 
 
 The work completely covers the field of practical fever nursing. Just sufficient of 
 pathology, symptoms, and treatment is given to enable the nurse to care for the patient 
 intelligently. The work is thoroughly practical and nurses will find it most valuable. 
 The illustrations show the nurse how to perform those measures that come within her 
 province, such as bathing, hypodermoclysis, pulse and temperature taking, etc. 
 
 Hecker, Trumpp, and Abt on Children Recently issued 
 
 Atlas and Epitome of Diseases of Children. By Dr. R. Hecker 
 
 and Dr. J. Trumpp, of Munich. Edited, with additions, by Isaac A. 
 Abt, M.D., Assistant Professor of Diseases of Children, Rush Medical 
 College, Chicago. With 48 colored plates, 144 text-cuts, and 453 pages 
 of text. Cloth, $5.00 net. 
 
 The many excellent lithographic plates represent cases seen in the authors' clinics, and 
 have been selected with great care, keeping constantly in mind the practical needs of the 
 general practitioner. These beautiful pictures are so true to nature that their study is 
 equivalent to actual clinical observation. The editor, Dr. Isaac A. Abt, has added all new 
 methods of treatment. 
 
 Lewis' Anatomy and Physiology New $?&££ 
 
 Anatomy and Physiology for Nurses. By LeRoy Lewis, M.D., 
 Surgeon to and Lecturer on Anatomy and Physiology for Nurses at the 
 Lewis Hospital, Bay City, Michigan. 121110 of 347 pages, with 146 
 illustrations. Cloth, $1.75 net. 
 
 A demand for such a work as this, treating the subjects fro?n the nurses' point of view, 
 has long existed. Dr. Lewis has based the plan and scope of this work on the methods 
 employed by him in teaching these branches, making the text unusually simple and clear. 
 
 The Nurses Journal of the Pacific Coast 
 
 " It is not in any sense rudimentary, but comprehensive in its treatment of the subjects 
 in hand. The application of the knowledge of anatomy in the care of the patient is 
 emphasized." 
 
 Friedenwald and Ruhrah's Dietetics Recently issued 
 
 Dietetics for Nurses. By Julius Friedenwald, M.D., Clinical 
 Professor of Diseases of the Stomach, and John Ruhrah, M.D., Clinical 
 Professor of Diseases of Children, College of Physicians and Surgeons, 
 Baltimore. 121110 volume of 365 pages. Cloth, $1.50 net. 
 
 This work has been prepared to meet the needs of the nurse, both in the training 
 school and after graduation. It aims to give the essentials of dietetics, considering briefly 
 the physiology of digestion and the various classes of foods and the part they play in 
 nutrition. 
 
 American Journal of Nursing 
 
 " It is exactly the book for which nurses and others have long and vainly sought. A 
 simple manual of dietetics, which does not turn into a cook-book at the end of the first 
 or second chapter. 
 
NURSING AND CHILDREN. 15 
 
 Paul's Fever Nursing Recently issued 
 
 Nursing in the Acute Infectious Fevers. By George P. Paul, 
 M.D., Assistant Visiting Physician to the Samaritan Hospital, Troy, N. Y. 
 121110 of 200 pages. Cloth, $1.00 net. 
 
 Dr. Paul has taken great pains in the presentation of the care and management of each 
 fever. The book treats of lovers in general, then each fever is discussed individually, and 
 the latter part of the book deals with practical procedures and valuable information. 
 
 The London Lancet 
 
 " The book is an excellent one and will be of value to those for whom it is intended. 
 It is well arranged, the text is clear and full, and the illustrations are good." 
 
 Paul's Materia Medica for Nurses Recently issued 
 
 Materia Medica for Nurses. By George P. Paul, M.D., Assistant 
 Visiting Physician to the Samaritan Hospital, Troy. 121110 of 240 pages. 
 Cloth, $1.50 net. 
 
 Dr. Paul arranges the physiologic actions of the drugs according to the action of the 
 drug and not the organ acted upon. An important section is that on pretoxic signs, 
 giving the warnings of the full action or the beginning toxic effects of the drug, which, 
 if heeded, may prevent many cases of drug poisoning. 
 
 The Medical Record, New York 
 
 "This volume will be of real help to nurses; the material is well selected and well 
 arranged, and the book is as readable as it is useful." 
 
 _ , , _ , __ Recently Issued 
 
 Pyle s Personal Hygiene The New (3d) Edition 
 
 A Manual of Personal Hygiene: Proper Living upon a Physiologic 
 Basis. By Eminent Specialists. Edited by Walter L. Pvle, A.M., 
 M.D., Assistant Surgeon to Wills Eye Hospital, Philadelphia. Octavo 
 volume of 451 pages, fully illustrated. Cloth, §1.50 net. 
 
 To this new edition there have been added, and fully illustrated, chapters on Domestic 
 Hygiene and Home Gvmnastics, besides an appendix containing methods of Hydro- 
 therapy, Mechanotherapy, and First Aid Measures. There is also a Glossary of the 
 medical terms used. 
 Boston Medical and Surgical Journal 
 
 " The work has been excellently done, there is no undue repetition, and the writers 
 have succeeded unusually well in presenting facts of practical significance based on sound 
 knowledge." 
 
 Galbraith's Four Epochs of Woman's Life JSffiSSS 
 
 The Four Epochs of Woman's Life. By Anna M. Galrraith, 
 M.D. With an Introductory Note by John H. Musser, M.D., Univer- 
 sity of Pennsylvania. 121110 of 247 pages. Cloth, $1.50 net. 
 Birmingham Medical Review 
 
 ■ We do not as a rule care for medical books written for the instruction of the public ; 
 but we must admit that the advice in Dr. Galbraith's work is in the main wise and whole- 
 some." 
 
 Starr on Children second Edition 
 
 American Text-Book of Diseases of Children. Edited by Louis 
 Starr, M.D., assisted by Thompson S. Westcott, M.D. Octavo, 1244 
 pages, illustrated. Cloth, $7-°° net; Half Morocco, $8.50 net. 
 
a 6 SAUNDERS' BOOKS ON CHILDREN. 
 
 . . Fifth Edition, Revised 
 
 American Pocket Dictionary Recently issued 
 
 American Pocket Medical Dictionary. Edited by W. A. New- 
 man Dorland, M. D., Assistant Obstetrician to the Hospital of the' 
 University of Pennsylvania. Containing the pronunciation and defini- 
 tion of the principal words used in medicine and kindred sciences, with 
 64 extensive tables. Handsomely bound in flexible leather, with gold 
 edges, $1.00 net; with patent thumb index, $1.25 net. 
 
 " I can recommend it to our students without reserve." — J. H. HOLLAND, M. D., Dean 
 of the Jefferson Medical College, Philadelphia. 
 
 Morrow's Immediate Care of Injured Recently issued 
 
 Immediate Care of the Injured. By Albert S. Morrow, M. D., 
 Attending Surgeon to the New York City Hospital for the Aged and 
 Infirm. Octavo of 340 pages, with 238 illustrations. Cloth, $2.50 net. 
 
 Dr. Morrow's book on emergency procedures is written in a definite and decisive style, 
 the reader being told just what to do in every emergency. It is a practical book for every 
 day use, and the large number of excellent illustrations can not but make the treatment to 
 be pursued in any case clear and intelligible. Physicians and nurses will find it indispensible. 
 
 Powell's Diseases Of Children Third Edition, Revised 
 
 Essentials of the Diseases of Children. By William M. Powell, 
 M. D. Revised by Alfred Hand, Jr., A. B., M. D., Dispensary 
 Physician and Pathologist to the Children's Hospital, Philadelphia. 
 i2mo volume of 259 pages. Cloth, $1.00 net. hi Saunders' 
 Question- Compend Series. 
 
 Shaw on Nervous Diseases and Insanity SE3*S£ 
 
 Essentials of Nervous Diseases and Insanity : Their Symptoms 
 and Treatment. A Manual for Students and Practitioners. By the late 
 John C. Shaw, M. D., Clinical Professor of Diseases of the Mind and 
 Nervous System, Long Island College Hospital, New York. i2mo of 
 204 pages, illustrated. Cloth, $1.00 net. Jn Saunders' Question- Com- 
 petid Series. 
 
 " Clearly and intelligently written ; we have noted few inaccuracies and several sug- 
 gestive points. Some affections unmentioned in many of the large text-books are noted." 
 — Boston Medical and Surgical Journal. 
 
 Starr's Diets for Infants and Children 
 
 Diets for Infants and Children in Health and in Disease. By 
 Louis Starr, M. D., Consulting Pediatrist to the Maternity Hospital, 
 Philadelphia. 230 blanks (pocket-book size). Bound in flexible leather, 
 $1.25 net. 
 
 Grafstrom's Mechano-Therapy secon^RevTsidEdition 
 
 A Text-book of Mechano-therapy (Massage and Medical Gymnas- 
 tics). By Axel V. Grafstrom, B. Sc, M. D., Attending Physician to 
 the Gustavus Adolphus Orphange, Jamestown, New York. i2mo, 200 
 pages, illustrated. Cloth, $1.25 net. 
 
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