COLUMBIA LIBRARIES OFFSITE HtA,•-■^ t NCES S^ANDAPD HX64054993 RD31St5 1885 a manual of operaliv RECAP m m •t-r mh iji^i'ii^n hill [i-Ui iiy^'fii^i ?,»: m if: <:/ R031 gpf^ CoUegc of ^ftpsiicians; anb ^urgeonsf Hibrarp r Digitized by tine Internet Arcinive in 2010 with funding from Columbia University Libraries http://www.archive.org/details/manualofoperativOOstim A MANUAL OPERATIVE SURGERY. BY LEWIS A . STIMSON, B.A., M.D., 8UHOEON' TO THE PRESBYTERIAN A.VD BKLLETUE HOSPITALS, PROFESSOR OF CLINICAL SCRGERY IN THE MEDICAL FACULTY OF THE VMVERSITY OF THE CITY OF XEW YORK, CORRESPONDING MEMBER OF THE SOClflTf: DE CHIRURGIE. OF PARIS. SECON D EDITION. WITH THREE HUNDRED AND FORTY-TWO ILLUSTRATIONS. THILADELPHIA: LEA BROTHERS c'c C O. 1885. 'Rl)3l Entered according to Act of Congress, in the year 1885, by LEA BROTHERS & CO., In the Office of the Librarian of Congress, at Washington, D. C. All rights reserved. DORNAN, PRINTER. ,\\ TO Professor WILLIAM H. VAN BUREN, IN RECOGNITION OF HIS EMINENT MASTERY OF THE ART AS WELL AS THE SCIENCE OF SURGERY, AND TO Dr. EDWARD L. KEYES, IN AFFECTIONATE REMEMBRANCE OF A PERSONAL FRIENDSHIP U^^NTERRUPTED FOR TWENTY YEARS, AXD OF AN INTIMATE ASSOCIATION IN MUCH PROFESSIONAL WORK, ||his Jjolume IS INSCRIBED BY THE AUTHOR. i VV PREFACE TO THE SECOND EDITION. In preparing the second edition of this Manual I have sought to indicate the changes that have been effected in operative methods and procedures by the adoption of the antiseptic method of treating wounds, and to describe such additions and substitutions as have been favorably received and can be systematically presented. The descriptions of most of the formal operations that can be rehearsed upon the cadaver remain unchanged ; the chief alterations and additions will be found in the passages treat- ing of the excision of joints and bones, and of operations in which the peritoneal cavity is opened. LEWIS A. STIMSON. New York, 34 East Thirty-third Street. November 9, 1885. A^ PREFACE TO THE FIRST EDITION. In preparing this Manual, I have sought to render it suffi- ciently complete, as regards both the number of operations described and the details of the descriptions, to meet the wants of the practitioner and of the student; but, on the one hand, I have excluded operations, such as the removal of tumors, which can be described only in general terms ; and, on the other, I have tried to avoid that minuteness of detail in non-essentials, which Mr. Syme condemned so vigorously in the teaching of the present day, as " the fiddle-faddle in- structions, not only for using, but even for holding, the knife, which sufficiently denote the poverty of intellect whence they proceed, and the lowness in aspiration to which they are ad- dressed." Whenever a knowledge of details, however, has seemed essential to the correct understanding and performance of an operation, I have not hesitated to describe them very fully, and the same principle has governed the introduction of descriptions of the anatomical relations of the parts. It goes without saying that in the preparation of a work of this character very large drafts must be made upon the results of the labor of others, and that the efforts of the writer must be limited, except on rare occasions, to making judicious selec- tions and judicial comparisons. The list of methods and processes is now so large that the surgeon is more likely to advance the science and art of his profession by elaborating the materials and mastering the results already acquired, than by inventing new practices or reinventing old ones. It is not desirable, even if it were possible, to include in a manual every operation, and still less every modification, that has been suggested, and it has been my aim, therefore, either to Vlll PREFACE TO THE FIRST EDITION. select for description in each case that method or process which seemed the best, and then simply to indicate the varia- tions which came well recommended, or which might be re- quired under exceptional circumstances, or else fully to describe methods which differed radically from each other, and then to indicate their respective merits and disadvantages. It is only proper to add that in making such selections and comparisons, I have not relied solely upon my own judgment and experi- ence, but have fortified them by reference to the practice and opinions of acknowledged leaders in the profession. Whenever it was practicable, I have gone to original sources ; and, while not making the question of priority in the invention of any method a prominent one, or spending much time in solving it, I have placed the credit where it seemed to belong, and have given references to the authority, so that any error can be readily corrected. The works most freely consulted have been those by Sedil- lot, Velpeau, Guerin, Bell, Dubrueil, and Chauvel on Oper- ative Surgery; Oilier and Von Langenbeck upon Excisions; Buck and Verueuil upon Plastic Surgery; Wells on the Eye; Roosa on the Ear ; Van Buren and Keyes on the Urinary Passages; Peaslee on Ovariotomy; Thomas on Diseases of Women ; Tillaux and Richet on Topographical Anatomy, and the Bulletins de la Societe de Chirurgie. Many of the illustrations are modifications of those in Du- brueil, Chauvel, and Tillaux ; others have been taken from Holmes's and Erichsen's Surgeries, Wells, Thomas, Wood on Rupture, and Wales on Bandaging ; and a few representing instruments have been furnished by Tiemann and Reynders. I have to thank Dr. Vandervoort, the accomplished librarian of the New York Hospital, for many facilities af- forded me by him, and Dr. Keyes, Dr. Roosa, and the late Dr. Peaslee, for their kind revision of portions of the manu- script. LEWIS A. STIMSON. 72 Madison Avenue, N. Y., June 7, 1878. LIST OF ILLUSTRATIONS. NO. Pi 1. Artery forceps, 2. Square knot, 3. Torsion forceps, 4. Effects of torsion upon the coats of an artery, 5. Acupressure, 6. Acupressure, 7. Acupressure, 8. Forcipressure forceps, 9. Forcipressure forceps, 10. Tourniquet, 11. Tourniquet, 12. Tourniquet, 13. Needle holder and curved needle, 14. Interrupted suture, 15. Continuous suture, 16. Twisted suture, 17. Harelip pin, 18. Harelip pin with movable point, 19. Buck's pin conductor, 20. Nippers for cutting off pins, 21. Twisted suture, with rubber ring in place of thread, 22. Quilled suture, 23. Serre-fine, 24. Continuous or spiral bandage, 25. Reversing the turns, 26. Spica of the shoulder. 27. Spica of the groin, 28. Four-tailed bandage for knee, 29. T-bandage, 30. Capelline or scalp-bandage, 31. Four-tailed bandage for head, 32. Triangular bonnet, 33. Suspensory bandage, 34. Suspensory apparatus for plas ter jacket, 35. Tripod, 36. Patient suspended ready for the plaster, 37. Three steps of ligature of an artery, iGE NO. PAGE 29 '. 38. Aneurism needle, 54 29 j 39. Inner coat of artery ruptured 30 by ligature, 55 40. Ligature of innominate, sub- 30 clavian, vertebral, and ax- 31 1 illary arteries, 58 31 41. Ligature of axillary and bra- 31 chial arteries, 64 32 42. Transverse section of the 32 arm, 66 34 ' 43. Ligature of brachial artery, 67 34 I 44. Ligature of radial and ulnar 34 I arteries, 68 45. Ligature of common carotid 38 at place of election, 70 40 46. Ligature of lingual, external 41 carotid, occipital, temporal, 41 and facial arteries. 73 41 47. Anatomical relations of lin- I gual and facial arteries, 75 41 48. Ligature of iliac and femoral 41 arteries, 79 42 49. Ligature of gluteal, sciatic, and pudic arteries, 81 42 50. Ligature of femoral artery, 83 42 I 51. Transverse section of leg, 86 42 52. Ligature of anterior tibial 43 artery, 87 44 53. Ligature of posterior tibial 45 I artery, 88 45 j 54. Amputations of fingers, me- 45 tacarpal bones, and wrist, 96 46 55. Amputation at elbow-joint, 101 46 56. Disarticulation at the shoul- 47 der, 104 47 i 57. Disarticulation at the shoul- 48 i der, Spence, 106 58. Relationsof the web and me- 50 ' tatarso-phalangeal joint, 107 50 59. Amputations of toes and me- I tatarsal bones, 108 51 60. Amputation of great toe, 108 161. Lisfranc'sand Chopart's am- 53 I putations, HI LIST OF ILLUSTRATIONS. NO. P 62. Chopart's, Syme's, and sub- astragaloid amputations (outer side), 63. Chopart's, Syme's, and sub- astragaloid amputations (inner side), 64. Amputation at ankle bj' in- ternal flap (Roux). 65. Amputation at ankle (Piro- goff), outer side, 66. Amputation at ankle (Piro- goff ), inner side, 67. Amputation of leg, 68. Amputation of leg, 69. Amputation of leg, 70. Amputations at knee and lower third of thigh, 7L. Amputations at knee and of thigh, 72. The exsector, 73. Excision of the shoulder. Oi- lier, 74. Excision of the elbow-joint, Oilier, Yon Langenbeck, 75. Excision of the elbow-joint, Nelaton, Hueter, 76. Osteoplastic excision of the elbow, 77. Excision of wrist, Lister. Portions of bone removed, 78. Excision of wrist. Lister. Relation of incisions to tendons, 79. Excision of wrist. Lister. Oilier, Von Langenbeck, SO. Excision of the hip, 8L Subcutaneous division of neck of femur, 82. Adams's saw for subcutaneous division of neck of femur, S3. Lines of section in Sayre's — •* operation for anchylosis of hip -joint, 84. Excision of the knee-joint, cutaneous incisions, 85. Excision of the knee-joint, lines of section of bone, 86. Excision of the knee-joint, lines of section of bone, 87. Excision of ankle, 88. Osteoplastic excision of the foot, Mikulicz, 89. Excision of superior maxilla, 90. Excision of superior maxilla, 91. Removal of naso-ptiaryngeal polyp. Oilier, 92. Excision of inferior maxilla, 93. Excision of scapula. 112 NO. 94. 95. 113 1 96. 1 97. 118 1 98. 119 : 99. 119 100. 122 122 101. 124 102. 13U 103. 132 104. 144 105. 146 106. 151 107. 108. 152 109. 153 110. 158 HI. 112. 159 113. 162 114. 165 115. 167 \ 116. 168 117. i 118. 169 119. , 120. 170 121. 122. 172 123! 172 124 174 125. 177 126. 180 J 181 127. 185 ' 189 128. 196 1 1 PAGE Resection of tibia, protec- tion of periosteum against saw, 201 Excision of calcaneum and astragalus, 205 Trephine, 209 Hey's saw, 2u9 Resection of supra-orbital and superior maxillary nerves, 212 Cheiloplasty, V-incision, 224 Cheiloplasty, oval horizon- tal incision, 225 Cheiloplasty, Celsus's in- cisions, 225 Cheiloplasty, Celsus's flaps in place, 225 Cheiloplasty, Dieffenbach, 226 Cheiloplasty, Syme-Buch- anan, incisions, 226 Cheiloplasty, Syme-Buch- anan. flaps in place, 226 Cheiloplasty, 227 Cheiloplasty, 227 Restoration of lower lip, Buck's incisions, 228 Restoration of lower lip. Buck's flaps in place, 228 Cheiloplasty, Malgaigne, 229 Cheiloplasty, Sedillot, 230 Lengthening of the mouth. Buck, 231 Cheiloplasty, upper lip, Se- dillot, incisions, 232 Cheiloplasty, upper lip, Se- dillot, flaps in place, 232 Cheiloplasty, upper lip, Buck, 233 Simple single harelip, 234 Simple single harelip, Ne- laton, 235 Harelip, single flap, 236 Harelip, Giraldes, 236 Double harelip, 237 Cheek compressor, 238 Rhinoplasty, lateral flaps, 240 Rhinoplasty, lateral flap, Von Langenbeck, 240 Rhinoplasty, Denonvilliers, 240 Rhinoplasty, Diefifenbach's operation, 243 Rhinoplasty, double layer or superposed flaps, Ver- neuil, 245 Rhinoplasty, Indian me- thod, 247 Rhinoplasty, Ollier's osteo- plastic method, 250 LIST OF ILLUSTRATIONS. XI xo. Page xo 129. Rhinoplasty, Italian uie- 173. thod, 261 174. 130. Canthoplasty, 253 175. 131. Ectropion, Wharton Jone.«, 254 132. Ectropion, Alphonse Guerin, 254 176. 133. Ectropion, Von Graefe, Knapp, 255 177. 134. Ectropion, Dieffenbach, Adams, Amnion. 135. Ectropion, Ricbet, 136. Ectropion, Burow, 137. Ectropion, Dieffenbach, 138. Ectropion, modified Indian, Riehet, . 139. Ectropion, Hasner d'Artha, 140. Ectropion, Denonvillier'?, 141. Entropion, ligature, 142. Entropion, lower lid, 143. Entropion, upper lid, 144. Desmarre's forcep.-, 145. Entropion, Streatfeild, 146. Symblepharon, 147. Symblepharon, incisions, 148. Symblepharon, flaps in place, 149. Pterygion, 150. Eye speculum, 151. Stop needle and probe for cornea, 152. Beer's knife, 153. Iridectomy knife, straight, 154. Iridectomy knife, bent, 155. Iridectomy forceps, 156. Iridectomy forceps, 157. Iridectomy scissors, 158. Iridectomy, incision of cor- nea, 159. Iridectomy, excision of iris, 160. Tyrrell's hook, 161. Broad needle for incising cornea, 162. Canula forceps, 163. Iridesis, 164. Streatfeild's spatula hook, 165. Coaching needle, 166. Depressing cataract, 167. Bowman's fine stop needle, 168. Hays's knife needle, 169. Sichel's knife, 170. Von Graefe's cystotome and curette, 171. Flap extraction of cataract. Fixing the eye andmaking the incision, 172. Flap extraction of cataract. Removal of lens by pres- • sure, 284 i 210. 256 256 257 258 258 259 260 261 262 262 263 263 264 264 265 266 267 269 269 272 272 273 273 273 273 274 274 275 275 276 277 279 279 280 280 282 282 283 178. 179. 180. 181. 182. 1S3. 184. 185. 186. 187. 188. 189. 190. 191. 19L'. 193. 194. 195. 196. 197. 198. 199. 200. 201. 202. 203. 204. 205. 206. 207. 208. 209. PAGE Von Graefe's cataract knile, 285 Iridectomy forceps, 285 To show method of making Von Graefe's incision, 286 Line of Von Graefe's in- cision, 286 Diagram of correct and faulty sections of iris, 287 Critchett's scoop. 289 Bowman's scoop, 289 Bowman's scoop, 289 Curette and mouthpiece for removal of cataract by suction, 290 Fine-toothed forceps for strabotomy, 294 Strabotomy hook, 294 Mode of estimating the de- gree of squint, 296 Double operation for stra- bismus, 295 Extirpation of lachrymal gland, 297 Sharp-pointed canalicalus director, 297 Bowman's probt -pointed canaliculus knife, 299 Puncture of the lachrymal sac, .300 Stilling's knife, 301 Tonsilotome, 304 Smith's gag, 307 Staphyloraphy, 308 Staphyloraphy, incisions, 308 Staphyloraphy, sutures, 308 Staphyloraphy, division of muscles of soft palate, 309 Staphyloraphy, passing the sutures, 310 Incisions in uranoplasty, 314 Lee's clamp for the tongue, 318 Ecraseur, 322 Hutchinson's gag, 322 Bivalve canula, closed, 331 Bivalve canula, with tube in place, 331 Vacca - Berlinghieri's oeso- phageal sound, 332 Paracentesis of thorax, 335 Anatomical relations of stomach with reference to gastrotomy, 340 Right inguinal enterotomy, Nglaton, 344 Dupuytren's enterotome, 348 Suture of intestines, Lem- bert, 351 Sotare of intestines, G€\j, 352 Xll LIST OF ILLUSTRATIONS. 352 354 358 368 369 211. Suture of intestines, Bouis- son, 212. Suture of intestines, B^ren- ger-Feraud, 213. Suture of intestines, Jobert ftransverse wound), 214/ Hernia knife, 215. Inside view of internal ab- dominal and femoral rings, 360 216. External abdominal ring and abdominal layers, 361 217. Variations in origin and cour?e of obturator artery, 364 218. Wood's knife and needle for radical cure of hernia, 219. Wood's radical cure of in- guinal hernia; 1st punc- ture, 220. Wood's radical cure of in- guinal hernia: 3d punc- ture, 221. Radical cure of large her- nia ; withdrawing nee- dle, 222. Radical cure of inguinal hernia : wires in place, 223. Radical cure of inguinal hernia : vertical section, 224. Pins used in the pin opera- tion for radical cure, 225. Placing the 1st pin, 220. Pins in place, 227. Radical cure of femoral her- nia. Wires in place, 228. Radical cure of femoral 1st and 2d punc- 239. 240. 241. 242. 243. 244. 245. 246. 247. 248. 249. 250. 229. 230. 231. 232. 233. 234. 235. 236. 237. hernia. tures. Radical hernia. Radical cure of umbilical Instruments, cure of umbilical hernia. Passing 1st wire, 379 Radical cure of umbilical hernia. Passing 2d wire, Radical cure of umbilical hernia. Passing second ends of wires, Radical cure of umbilical hernia. Wires in place, Extirpation of anus. Reca- mier. Method of surrounding rec- tum with ligatures, Extirpation of rectum. Maisonueuve, Vidal's operation for vari- cocele, 238. Vidal's operation for vari- cocele. PAGE Vidal's operation for vari- cocele. The wires, 395 Ricord's method of tying wires in varicocele, 395 Circumcision. 1st incision, 399 Circumcision. Raw surface left by retraction. Circumcision. Delavan 1st incision, Circumcision. Delavan Fitting in the triangle Circumcision. Keyes, Epispadias. Nelaton, Thiersch, Thiersch. Epispadias Epispadias, .step, Epispadias. 399 400 400 401 403 404 2d 405 405 37U 251. 252. 253. 371 254. 255. 373 256. 373 257. 374 258. 374 375 259. 260. 376 261. 377 262. 263. 379 264. 265. 379 266. 379 267. i 268. ,380 269. .380 270. 387 271. 388 272. 273. 388 274. 394 275. 395 276. Thiersch. Transverse section. Hypospadias. Theophile Anger, 409 Hypospadias. Duplay, 411 Urethroplasty, 414 Urethroplasty. Xelaton, 414 Syme's staff, 417 Tunnelled staff and whale bone guide, 417 Clover's crutch, 418 Exstrophy of bladder. In- cisions, 421 Exstrophy of bladder. Flaps in place, 421 Mercier's elbowed catheter, 423 McBurney'fi instruments for y>uncture of bladder per rectum, 425 Thompson's lithotrite, 427 Keyes's lithotrite, 427 Scoop lithotrite, 428 Bigelow's lithotrite, 429 Bigelow's lithotrite, 429 Bigelow's evacuating appa- ratus, 431 Thompson's evacuating ap- paratus, 432 Keyes's tube, 432 Position of viscera at outlet of pelvis, 434 Lateral lithotomy. Extent of incision of urethra, 435 Lateral lithotomy. Incision of neck of bladder, 436 Lateral lithotomy staff, 437 Lateral lithotomy scalpel, 437 Lateral lithotomy. Bliz- zard's knife. 437 Lateral lithotomy. Blunt gorget, 437 Lateral lithotomy, scoop, 437 LIST OF ILLUSTRATIONS. Xlll NO. PAGE 277. liiitenil lithotomy, forcep.'', 4;^H 27S. Lateral lithotomy, forceps, 4H8 279. Laternl lithi>tomy, forceps, l.'iS 2.H0. Shirted oanula, i:W 2SI. Lateral lithotomy. Position of patient and incision, l.'.'.i 282. Lateral lithotomy. Rela- tions of the incisions to each other anil to the pros- tate, 440 283. Median lithotomy. Staff, 442 284. Median lithotomy. Ball- pointed director, 442 285. Median lithotomy. Double- edged scalpel, 442 286. Median lithotomy with rect- angular staff, 44.''> 287. Dupuytren's double litho- tome cache, 444 288. Dolbeau's dilator, 448 289. Guyon-Duplay dilator, 448 290. Catheterization of the fe- male; holding the cathe- ter, 450 291. Emmet's buttonhole opera- tion on the urethra, 450 292. Emmet's buttonhole scis- sors, 451 293. Sims's speculum, 452 294. Curved .scissors, '455 295. Emmet's scissors, 455 296. Thomas's toothed forceps, 455 297. Sponge holder, 455 298. Diagram showing the line of union and direction of the sutures, 456 299. Appearance at completion of the operation, 457 300. Diagram showing area of de- nudation. The parts bear- ing corresponding figures are brought into apposi- tion by the sutures, 458 301. Emmet's operation for di- minishing the vaginal out- let by e.xternal sutures, 458 302-305. Diagramniatic of method of closing complete rup- ture of perineum, 459 306. Ruptured sphincter. 1st suture, 460 307. Ruptured sphincter. 1st and 2d sutures in place, 40i) 308. Half section through the pubes, showing the direc- tion of the uterus in lacera- tion through the sphincter ani. 461 NO. I'AOK 309. Vesico-vaginal fi.«tula. Line of paring, 462 ."'10. Vesico-vaginal fistula. Drawing the uterus down, 463 ;>11. Vesico-vaginal fi.stula. Needle holder, 461 ;112. Vesico-vaginal fistula. Course of the needle, 464 3i:!. Vesico-vaginal fistula. Passing the needle, 464 314. Vesico-vaginal fistula. Shield, 465 ;U5. Vesico-vaginal fistula. Fork, 465 Ml 6. Vesico-vaginal fistula. Blunt hook. 465 317. Vesico-vaginal fistula. Twisting sutures, 465 318. Vesico-vaginal fistula. Simon's method of placing suture?, 466 319. Vesico-vaginal fistula. Incision united, 467 320. Sims's catheter, 467 321. Obliteration of the vagina; kolpokleisis, 468 .■]22. Emmet's operation for pro- cidentia, 470 323. Thomas's dilating forceps, 471 324. Toothed clamp, 471 325. Lacerated cervix, side view, 472 326. Lacerated cervix, denuded surface and sutures, 472 327. Sims's knife for section of the cervix, 474 328. Posterior section of the cer- vix, 474 329. Spencer Wells's trocar, 477 330. Spencer Wells's clamp, 479 331. Ligatures of the pedicle in- cluding each other, 480 332. Method of passing the liga- ture, 480 333. Genu valgum; section of in- ternal condyle, 491 334. Genu valgum ; internal con- dyle forced upwards, 491 335. Subcutaneous ligature of na;vus, 493 336. Ligature of nivjvus, 494 337. Ligature of nit'vus, 494 338. Ligature of nievus, 494 339. Ligatuie of n^evus, 495 340. Web fingers, 496 341. Web fingers, 497 342. Ingrown toenail, 498 CONTENTS. .PART I. THE ACCE© SOEIEri OF AN OPERATION'. p.vr.E PAGE Anesthesia, 25 A ntiseptic treatment of surgi - Local, 25 cal wounds, 35 General, 20 S utures. 39 Administration of the an- Interrupted, 40 esthetic, 27 Continuous, 40 Rectal, 28 Twisted, 40 Arrest of hemorrhage, 29 Quilled, 42 Ligature, 29 Serre-fine, 43 Torsion, 30 Bandages, 43 Acupressure, 30 Continuous or spiral. 44 Forcipressure, 31 Figure-of-eight or spica, 44 Cautery, 32 T-bandagc, 46 Coagulating application ?, 33 Capelline or scalp. 47 Cold, 33 Triangular bonnet. 47 Posture, 33 Immovable, 48 Artificial ischaemia, 33 PAR T Sayre's plaster jacket, II. 49 LIGATURE OF ARTERIES. General directions, Anatomy of the supra-clavicu- lar region, Ligature of the innominate artery. Anatomy, Operation, Ligature of artery, 1st portion, left subclavian, 1st portion, rightsubclavian, 2d portion, 3d portion, Anatomy, the subclavian 53 ! Ligature of the subclavian i artery — 3d portion, 50 ' Operation, j Ligature of the inferior thy- 57 1 roid, 57 I Anatomy, 58 ' Operation, Ligature of the vertebral 59 artery, oO Anatomy, Gl Operation, (U Ligature of the axillary 61 artery, 61 j Anatomy, Ligature under the clavicle. 61 62 62 62 63 63 63 63 63 64 XVI CONTENTS. Ligature of the axillary ar- tery- Ligature in the axilla, Anatom}^, Operation, Ligature of the brachial artery, Anatomy, Operation, Ligature of the radial artery, Anatomy, Operation, upper third, Operation, lower third. Ligature of the ulnar artery. Anatomy, Operation at the junction of the upper and middle thirds. Operation in the lower third. Ligature of the common caro- tid. In its 1st portion, At the place of election. Ligature of the external caro- tid, Anatomy, Operation, Ligature of the internal caro- tid, Ligature of the lingual artery, Anatomy, Operation, Ligature of the facial artery. Ligature of the occipital ar- tery, 64 64 65 65 65 67 67 67 68 68 69 69 69 69 70 70 70 71 71 73 74 74 74 74 76 PAGE Ligature of the temporal ar- tery, 76 Ligature of the abdominal aorta, 77 Ligature of the common iliac, 77 Anatomy of the common, internal, and external iliac arteries, 77 Operation, 78 Ligature of the internal iliac, 80 Ligature of the external iliac, 80 Ligature of the gluteal, scia- tic, and internal pudic arte- ries, 81 Ligature of the femoral ar- tery, 82 Anatomy, 82 Operation, 82 At the apex of Scarpa's triangle, 83 In the middle of the thigh, 84 In Hunter's canal, 84 Ligature of the popliteal ar- tery, 85 Ligature of the anterior tibial, 85 Anatomy, 85 Operation, 86 Ligature of the dorsalis pedis, 87 Ligature of the posterior tibial, 87 Guthrie's method, 88 Lateral method, 88 In the lower third and be- hind the ankle, 89 PART III. AMPUTATIONS. Circular method, 1st time, 2d time, (6) Alanson's method, (c) Cutaneous sleeve, 3d time. Oval method, riap method. Modified flap, Teale's method. Long anterior flap. Amputation of the fingers, 90 Amputation of the fingers — 90 Phalanges, 94 90 Through the metacarpo- 91 phalangeal articulation, 95 91 Amputation of the metacar- 91 pal bones, 96 92 Amputation at the wrist, 97 92 Circular method, 97 93 Antero-posterior flaps, 97 93 External lateral flap, 98 94 Amputation of the forearm, 98 94 Amputation at the elbow-joint, 100 CONTENTS. XVll Amputation ut theelbow-joint Anterior flap, {a) The joint opened from behind, {(i) The joint opened from in front, Lateral flap. Circular, Amputation of the arm, Amputation at the shoulder- joint, General considerations, Oval method (Baron Lur- Double flap method (Lis- franc), Spence's method, Amputation of the toes, Distal phalanx of the great toe. Disarticulation of the great toe, Two adjoining toes, Amputation of a metatarsal bone, Disarticulation of the 1st or 5th metatarsal, Disarticulation of all the meta- tarsal bones (Lisfranc's amputation), Modifications, Medio-tarsal amputation (Cho- part), Sub-astragaloid amputation, Amputation at the ankle-joint (Syme), Modifications, A Internal lateral flap (Roux), B. Pirogoft"'s amputa- tion, Comparison of the diflerent methods of partial and total amputation of the foot, Amputation of the leg, A. Lower third, 1. Circular method, 100 100 \(M\ 101 102 102 102 102 103 105 100 107 107 108 109 109 110 110 111 111 113 114 117 118 119 121 121 121 123 Comparison of the different methods of partial and total amputation of the foot — Amputation of the leg— 2. Modified circular, 3. Long anterior flap (Bell), 4. Elliptic posterior flap (Gujon) B. Middle third, 1. Longanteriorcurved flap, 2. Long anterior rect- angular flap (Teale), 3. Long posterior rect- angular flap (Lee), 4. Single posterior flap, C. L'pper third. Circular, 2. Rectangular, ante- rior, and posterior flaps, 3 External flaps (Se- dillot), 4. Modified flap (Bell), Comparison of the ditierent methods, Amputation at the knee, A. Disarticulation, Oval method. Long anterior flap, B. Amputation through the condyles, Anterior flap (Carden), Grilti's modification, Amputation of the thigh, Teale, Carden, Modified flap, in lower third (Syme), Long anterior flap, Amputation at the hip-joint, Anterior oval method ( Ver- neuil). Circular, Anterior flap, Modified oval 123 123 123 124 124 125 125 126 126 126 126 127 127 127 128 129 129 129 129 130 131 133 133 133 133 134 135 137 138 138 139 B* XVlll CONTENTS, PART IV. EXCISION OF JOINTS AND BONES General considerations, Major articulations, Excision of the shoulder-joint, General considerations, Ollier's method. Yon Langenbeck's method, By a transverse incision, Excision of the head of the scapula, Excision of the elbow-joint, General considerations, Central longitudinal inci- sions (v. Langenbeck), Ollier's method, Xelaton's method, Long radial incision (Hue- ter), Osteoplastic method, Bilateral incisions, Vogt, Partial excision, Excision of anchylosed elbow, Ollier's method, P. Heron Watson's method. Excision of the wrist, Bilateral incisions (Lister), Kadial incision (Oilier), Dorso-radial incision (Von Langenbeck), Excision of the hip-joint, Say re's method, Ollier's method. Anterior incision, Anchylosis of the hip-joint, treated by subcutaneous division of the neck of the femur (Adams), Division below the trochan- ter. Excision, Establishment of a false joint (Sayre), Excision of the knee-joint, Semilunar incision, Ollier's subperiosteal me- thod, Transverse incision, Extirpation of knee-joint, Excision of the ankle-joint. 141 145 145 145 14G 147 148 148 149 14i» 150 151 152 152 153 154 155 155 155 156 156 159 162 164 164 104 165 16G 166 168 168 169 170 170 171 171 172 173 PAGE Extirpation of the ankle joint — Operation for total excision, 171 Vogt's method by removal of the astragalus, 175 Osteoplastic excision of foot (Mikulicz), 176 Excision of the bones and smaller articulations, 178 Excision of the superior max- illa, 178 General conditions, 178 Operation by one of the me- dian incisions, 180 Subperiosteal excision (Oi- lier), 181 Simultaneous excision of both superior maxillae, 182 Partial and temporary exci- sions of the superior max- illa to facilitate the re- moval of naso-pharyngeal polyps, 183 Eesection of posterior por- tion of hard palate (N^la- ton), 183 Resection of the upper por- tion (Von Langenbeck), 183 Other methods of gaining access to the pharynx through the nose, 184 Boeckel, 184 Oilier, 185 Excision of the inferior maxilla, 186 General considerations, 186 Pvesection of the anterior portion of the body, 188 Resection of the lateral por- tion of the body, 188 Resection of the ramus and half the body, 189 Excision of the entire bone, 190 Subperiosteal method, 190 Anchylosis of the jaw, 191 Excisicn of the condyle, 191 Resection of the sternum, 192 Resection of the ribs, 192 Estlander's operation for empyema, 192 CONTENTS. XIX Excision of the clavicle, 192 Resection of the shaft of the Excision of the scapula, 194 tibia. 201 Subperiosteal method (Oi- Resection of the fibula, 202 lier), 195 Of its upper extremity, 208 Partial excisions of the sca- Of the lower portion. 203 pula, 197 pjxcision of the entire fibula. 20:{ Resection of the humerus, 197 Excision of the bonesof the foot , 204 Upper portion, 197 Calcaneum, 204 Middle portion, 197 A. Holmes's method. 204 Lower portion, 197 B. Subperiosteal method Total excision, 197 (Oilier), 205 Excision of the ulna. 198 Astragalus, 206 Excision of the radius. 198 Ollier's method, 206 Partial excisions of the ulna When dislocated. 206 and radius. 199 When shattered, 206 Excision of the metacarpal Metatarsal bones and pha- bones and phalanges. 199 langes. 207 Resection of a phalanx, 199 Trephining, 207 Resection of the bones of the Of the cranium, 207 pelvis, 200 General considerations, 207 Excision of the coccyx, 200 Operation, 209 Resection of the shaft of the Of the frontal sinus. 210 femur, 201 Of the antrum. 210 PAR T V. I\^EUROTOMY A SD TENOTOMY. Division and resection of Inferior dental nerve — nerves, 211 B. W^ithin the canal. 217 Supra-orbital nerve. 211 C. Before its entry into the Subcutaneous division, 212 canal. 217 Excision of a portion. 212 1. From within the mouth ,217 A. Above the eyebrow, 212 2. Through the cheek. 217 B. Below the eyebrow, 212 Buccal nerve, 218 Siipra-trochlear nerve. 213 Lingual nerve, 218 Superior maxillar}' nerve. 213 Moore's method. 218 A. Division of the nerve on Facial nerve. 219 the face. 213 Tenotomy, 219 1. Subcutaneously, 214 General considerations, 220 2. Through the mouth. 214 Tendo Achillis, 220 3. By external excision. 214 Tibialis posticus, 220 B. Resection of the infra- A. Above the malleolus. 220 orbital portion, 214 B. On the side of the foot, 221 Tillaux's method, 214 Tibialis anticus, 221 Malgaigne's method. 215 Peronei, 221 Liicke's method. 215 Flexor tendons at the knee, 221 Inferior dental nerve, 216 Sterno-cleido-mastoid, 221 A. At the mental foramen. 216 Levator palpebrie. 221 XX CONTENTS. PART VI. PLASTIC OPERATIONS OX THE FACE. The different methods and their history, General principles, Cheiloplasty, A. Lower lip, 1. Y-incision, 2. Oval horizontal inci- sion, 3. Method of Celsus or Serres, 4. Dieffenhach, 5. Syme-Buchanan, 6. Buck's method, 7. Square lateral flaps, Malgaigne, 8. Square vertical flaps, B. Angle of the mouth (sto- matoplasty), Buck, C. Upper lip, 1. Vertical flaps, 2. Infero-lateral flap, Harelip, Single harelip, simple, 1. Double flaps, 2. Nelaton's method, 3. Single flap, 4. Giraldes's method. Double harelip, simple. Complicated harelip. Rhinoplasty, 1. Superficial defect, not in- volving the bones or septum, Lateral, oblique, and ver- tical flaps, Denonvillier's method, Von Langenbeck's me- thod, Michon's method. Restoration of columna, 2. Loss of the septum and nasal bones, the skin remaining entire, Dieffenhach 's case, OUier's osteoplastic me- thod, Rhinoplasty — 222 Double layer, or super- 223 posed flaps. 244 224 Pancoast's subcutaneous 224 method, 245 224 3. Loss of more or less of the surface and the sep- 225 1 tum, 246 i A. Indian method, 246 225 Modifications, 248 226 B. Ollier's osteoplastic 226 method. 249 227 C. Alquie's method. 251 D. Italian method. 251 229 Operations upon the eyelids. 252 230 Blepharoraphy, 252 Canthoplasty, 253 230 Blepharoplasty. 253 231 1. In ectropion. 253 232 "Wharton Jones, 254 232 Alphonse Guerin, 254 232 Von Graefe, 255 234 Dieftenbach, Adams, 234 and Ammon, 255 234 Richet, 256 235 Knapp, 257 235 Burow, 257 236 Dieftenbach, 257 236 Indian method. 257 237 Richet, 259 238 Hasner d'Artha, 259 Denonvilliers, 260 Ectropion due to excess 239 of conjunctiva, 260 2. Entropion, 260 240 Canthoplasty, 260 240 j Ligature, ! Excision or cauteriza- 261 241 tion of a fold of the 241 skin, 261 241 Spasmodic entropion, Von Gi'aefe, 261 Excision of a portion 242 of the orbicularis. 262 242 Division of tarsal car- tilage, 262 244 Vertical division. 262 CONTENTS. xxi PAGE i PA'iK •erations upon the ey elids — Operations upon the eyelids — Longitudinal divi- Ledentu's method, 265 sion (Amnion ), 2»i'J 4. Pterygion, 265 Excision of part of tar- Excision, 265 sal cartilage, 263 Ligature, 265 3. Syniblepharon, 2G3 5. Trichiasis, 265 Ligature, 2»53 Yon Graefe, 266 Arlt's method, 2»i4 Anagnoslakis, 266 Teale's methi d, 264 •PART VIL SPECIAL OPERATIONS. CHAPTER I. OPERATIONS UPON' THE EYE AND ITS APPENDAGES. The cornea, Removal of a foreign body, Puncture of the cornea, Removal of a sLaphvloma, The iris, Iridotomy, Simple incision (Chesel- den, Bowman), Simple iridotomy, Wecker, Double iridotomy, Wecker, Iridectomy, Antiphlogistic iridectomy, Optical, Iridorhexis. Iridesis, Corelysis, Operations undertaken for the relief of cataract, Depression or couching, Scleronyxis, Keratonyxis, Division, Discission, or So- lution, Division through the cor- nea, Division through the scle- rotic (Hays), Extraction, 2G7 Operations undertaken for the 267 relief of cataract — 208 Flap extraction. 282 208 Von Graefe's method, 285 270 Gayett and Knapp, 287 270 Linear extraction. 288 Sco«.)p extraction. 289 271 Removal by suction. Removal of the lens in its 290 271 capsule. 291 Pagenstecher's method. 291 271 Secondary cataract, 292 271 Operations for the relief of 272 strabismus. 293 273 Anatomy, 293 274 Internal rectus, 293 274 Subconjunctival method, 295 277 Secondary strabismus, 296 Enucleation of the eyeball. 296 277 Extirpation of the contents 277 of the orbit, 297 277 Operations upon the lachry- 279 mal apparatus, Extirpation of the lachr^'- 297 279 mal gland. Lachrymal sac, duct, and 297 27C canaliculi, 298 Slitting up the canaliculus ,299 281 Puncture of the sac, 300 281 Stricture of the nasal duct, ,301 XXll CONTENTS. CHAPTER ir. OPERATIONS UPOX THE EAR AND ITS APPENDAGES. PAGE I PAGE Occlusion of the external an- ! Incision of periosteum, and ditorj' canal, 301 j trephining of mastoid pro- Introduction of speculum, 301 cess, 302 Paracentesis of the drum- Catheterization of the Eusta- head, 302 chian tube, 303 CHAPTER III. OPERATIONS UPON THE MOUTH AND PHARYNX. Excision of the tonsils, Staphj'loraphy, Uranoplasty, Fergusson's osteoplastic me- thod, Laniielongue's method. Staphyloplasty, Excision of the tongue, Billroth, 30J Excision of the tongue — 305 Kocher, 320 312 SediUot's method, 321 By the ecraseur, 322 315 Division of the frenuni. 328 315 Ranula, 824 316 Salivary fistula, 324 317 Deguise's method, 324 320 Van Buren's method, 325 CHAPTER lY. OPERATIONS PERFORMED UPON THE NECK. Bronchotomy, Subhyoid laryngotomy. Thyroid laryngotomy, Crico-thyroid laryngotomy, Laryngo-tracheotom}', De Saint Germain's me- thod. 325 Bronchotomv — 326 Tracheotomy, 329 326 By galvano- or thernio- 327 cautery, 331 328 (Esophagotomy, 331 Lateral incision, 332 328 J Median incision, 333 CHAPTER V. OPERATIONS PERFORMED UPON THE THORAX. Amputation of the breast. Paracentesis of the thorax, 333 Paracentesis of the pericar- 334 dium, 335 CHAPTER VI. OPERATIONS PERFORMED UPON THE ABDOMINAL WALL, STOMACH, AND INTESTINES. Paracentesis of the abdomen, 336 Right inguinal enterotomy Gastrotomy and gastrostomy, 337 (Xelaton), 343 General considerations and 1 Colotomy, 345 anatomy, 337 j Littre's operation, 345 Operation, Laparotomy, 340 341 Lumbar colotomy, 346 CONTENTS. XXlll Closure of an artiBcial iiniis or fecal fistula, Suture of tl)e intestine, Lonj^itudinal wounds, Key bard, Jobert, Lembert, Gely, Bouis-on, Berenger-Feraud , Dubrueil, Transverse wounds, Herniotomy, kelotomy. General directions, A. Recognition of the sac and bowel, B. Opening of the sac, C. Division of the stric- ture, D. Examination and re- turn of the bowel, E. Treatment of the omentum. Strangulated inguinal her- nia, Anatomv, Operation, 348: 349 350 350 351 351 351 352 353 353 353 354 355 355 350 357 859 :]00 3G0 361 Herniotomy, kelotomy — Malgaignc's method, Strangulated femoral her- nia. Strangulated umbilical her- nia. Strangulated obturator her- nia, Radical cure by incision. Radical cure of inguinal hernia (Wood), Pin operation (Wood), Radical cure of femoral her- nia (Wood), Radical cure of umbilical hernia (Wood), Heaton's method, Imperforate anus or rectum. Prolapse of the rectum. Recto tomy, Excision of anus and part of I the rectum, A. Removal by the knife, B. Removal by ligature, C. Removal by the ecra- seur, : Hemorrhoids, PAOF. 303 303 363 366 366 307 373 376 378 381 381 383 384 385 :.85 387 389 389 CHAPTER VII. OPERATIONS UPON THE GENITO-URINARY ORGANS OF THE MALE. Castration, 390 Hydrocele, 391 Puncture of the sac, 392 Radical cure, 393 Varicocele, 393 Excision of the scrotum, 393 Division and excision of the veins, 398 Compression b}" pins, 394 Compression by wires, Vi- dal's method, 394 Subcutaneous ligature, 395 Ricord's method, 395 Rigaud's method by expo- sure, 396 Amputation of the pi-nis, 396 Operations for phimosis, 397 Dorsal incision, 397 Circumcision, 398 Paraphimosis, 401 Division of the frenum, 402 Epispadias, IS^^laton's method, Thiersch's method, Hypospadias, Urethroplasty, 402 4U3 404 406 408 Th^ophile Anger's method, 408 Duplay's method, Urethral fistula, General considerations, Urethroraphy, Urethroplasty, Nelaton's method, Reybard, Dieffenbach, and Delore, Delpech and Alliot, Sir Astley Cooper, Arlaud, Sedillot, Rigaud, Theophile Anger, Scymanowski, 410 411 411 413 414 414 415 415 415 415 416 416 416 416 XXIV CONTENTS, External perineal urethroto- my, 417 A. With a guide, 417 B. Without a guide, 419 Perineal incision for explora- tion of the bladder, 420 Exstroph}^ of the bladder, 420 Catheterization, 422 Puncture of the bladder, 424 Above the pubes, 424 Under the pubes, 424 Through the rectum, 424 A. From without in- wards, 424 Puncture of the bladder — B. McBurney's method, 425 Lithotrity, ' 426 Litholapaxj", 431 Lithotomy, 434 General considerations. 434 Lateral lithotomy, 437 Median lithotomy, 442 Bilateral lithotomy, 444 Pre- rectal lithotomy, 445 Recto-vesical lithotomy, 446 Supra-pubic lithotom}-, 446 Perineal lithotrity, 446 CHAPTER YIII. OPERATIONS UPON THE GENITO-URINARY ORGAXS OF THE FEMALE. Catheterization, 449 External urethrotomy, 450 Lithotomy, 451 Urethral lithotomy, 451 Yesico-vaginal lithotomy, 452 Occlusion, or atresia vaginae, 453 Perineoraph}", 453 Prolapse of the posterior wall of the vagina, 455 1st variety, 455 2d variety, 455 Laceration of the perineum and sphincter ani, 458 Yesico-vaginal fistula, 462 Creation of a vesico-vaginal fistula, 4G8 Obliteration of the vagina ; kolpokleisis, 469 Narrowing of the vagina; eh^troraphy, 469 Lacerated cervix, 472 Posterior section of the cervix, 474 Amputation of the cervix, 475 Bistoury or scissors, 475 Ecraseur, 475 Galvano-cautery, 475 Ovariotomy, 476 Incision, 476 Search for adhesions, 479 Tapping of the cyst and rupture of adhesions, 477 Removal of the sac and treatment of the pedicle, 479 Cleansing of the peritoneum, 481 Closure of the external wound, Yaginal ovariotomy, Yaginal hysterectomy, Hysterotomy (Ca?sarean sec- tion), Gastro-elytrotomy, Removal of Fallopian tubes. 481 483 483 484 485 487 CHAPTER IX. MISCELLANEOUS OPERATIONS. Splenotomy, 488 Extirpation of the kidney, 489 Fixation of the kidney, 491 Subcutaneous osteotomy, 491 Genu valgum, 491 Shaft of a long bone, 492 Erectile tumors, 493 Birth-mark, 495 Web-fingers, 496 Cicatricial flexion of the pha- langes, 497 Ingrown toenail, 498 OrERATIVE SURdERY. PART I. THE ACCESSORIES OF AN OPERATION. ANESTHESIA. Local ancesthesia may be obtained (1) by the action of cold, or (2) by the application of an agent which exerts locally a benumbing effect upon the nerves. (1) The low temperature which produces local anaesthesia may be obtained by the application to the parts of a freezing mixture (ice and salt), or by the vaporization of ether. The former is applicable to larger surfaces than the latter. A mixture of cracked ice and salt is put in a muslin bag and laid upon the part, and a folded compress or towel laid over it to intensify its action. After it has been in place two or three minutes it should be removed, the sensibility of the skin tested, and the bag reapplied if the desired effect has not been produced. When chilled to insensibility the skin is white and puffy. When ether is used for local anjjesthesia it should be directed upon the parts in a fine spray, or its rapid vapor- ization should be aided by fanning or blowing upon the surface. It is inefficient when the skin is very vascular. (2) Carbolic acid is an efficient and convenient means of producing local annesthesia. A cloth thoroughly wet with a three per cent, solution of the acid should be kept upon the skin for fifteen minutes, and then the undiluted acid applied with a brush along the line of the proposed incision. This is applicable to the opening of abscesses, felons, etc., and to many minor operations. 3 26 THE ACCESSORIES OF AN OPERATION. Hydroehlorate of Cocaine. — The injection under the skin or into a nerve of a few drops of a two or four per cent, sokition of the hydroehlorate of cocaine produces a tem- porary local ani^sthesia, sufficient to permit the painless performance of an operation involving only the skin or the layers immediately underlying it. A deeper injection into a nerve produces anaesthesia of the region supplied by it. As this agent acts upon the nerve-fibres, the injection should be made on the proximal side of the region to be operated upon, and should be directed toward and into that region. G-eneral Ancesthesia. — The agents in common use for producing general anaesthesia are (1) ether, (2) chloroform, and (3) nitrous oxide. The great merit of ether is in safety. Chloroform is more rapid in its action at first, as usually given, at least, less liable to cause vomiting, less disagreeable in its after- efi'ects, but it is certainly more dangerous. On account of its inflammability, ether should be used with caution at night, and as its vapor is heavier than air, the lights should be held above the bed. Nitrous oxide is suitable only for very short operations. Its use to obtain anaesthesia for any length of time is as dangerous as that of chloroform, per- haps more so. Ether endangers life through suffocation, which may be the result of paralysis of the respiratory muscles, or of obstruction of the air-passages by the tongue, or by a foreign body, such as vomited matter. Chloroform kills by exerting a special influence upon the ganglionic nerve-centres presiding over respiration and circulation. Arre£t of the breathing and Hvidity of the surface give timely notice of danger from ether. Chloroform may kill without a moment's warning. If during ani^sthetization by ether the respiratory muscles cease to act, artificial respiration should be kept up, and stimulants administered; but the patient should be kept quiet, should not be whipped oi- excited to muscular action. The danger comes from the weakness of his muscles, and they must not be called upon for any extra exertion. If, as is much more common, the diaphragm acts, but the air- passages are obstructed, and the fiice becomes livid, the obstruction must be removed, and the breathing will then ANAESTHESIA. 27 take care of itself. If tlie ohstriietion is due to the presence nf a foreign body in tlie glottis or trachea (false teeth, vomited matter), the sh(»uldei*s and head must be lowered, and the hips raised. It may become necessary to resort to trache- otomy. If the oltstruction is due to the fallinir back of the tongue in c(»nse«|uence of the relaxation of the muscles of the pharynx and floor of the mouth, a stout piece of wood should be put between the patient's teeth and his tongue drawn forward. The most [)rompt and efficient Avay of doing this is for the operator to hook the terminal joint of his fore- finger behind the root of the tongue ane pressed upward an*] inward from below the angles of the jaw. When operating upon the mouth and nasal passages, hemorrhage may interfere seriously with respiration and aniesthetization: By placing the patient on his back, and allowing his head to hang down over the end of the operating table, the blood will be made to flow awav throucrh the nos- trils, and the larynx will remain clear. During the inhalation of chloroform, death may occur either suddenly by syncope, or more slowly with signs of cerebral congestion and arrest of hi^matosis. In the first case the heart stops, the patient becomes pale, the respira- tion superficial ; the other usually happens after conscious- ness has returned, the face suddenly becomes livid, the patient loses consciousness again, and dies within half an hour. In the first variety, death can generally be averted by lowering the head, slapping the breast and fiice with wet towels, and applying the galvanic or faradic current. When the galvanie current is nse- f«»!x>*iiBJ. with artery forceps (Fig. 1), drawing it slightly fi'om its sheath, and then throwing the ligature about it. The knot Fig. 2. S|)cd two or tiirec times about tlie limb, at the upper limit of the banda00 sublimate solution and provided with a rubber tube and stopcock, is conveniently placed at an elevation of three or four feet above the bed. Besides holding sponges, wet towels, and the strouf^ solution for the hands of the sur- geon should be within reach. If hemorrhage is not prevented by a tourniquet, all bleed- ing points should be immediately secured with self-fastening forcejts which are left in place until the cutting is ended or until so many have been applied that their presence becomes an inconvenience. They are then taken up in turn, and a catgut ligature thrown about each point. If a tourniquet is used, all recognizable vessels that have been severed are tied, then the tourniquet removed and all bleeding points caught and tied. Every effort should be made absolutely to arrest all bleeding. Some surgeons, when usino- Esmarch's elastic bandacre, the removal of which is followed by much troublesome oozing, close the wound and complete the dressing before removing the cord, trusting to pressure to prevent oozing. This method is not proper after amputation. Fig. 13. Halsted's needle-holder, with ueedle curved across the flat. The bleediiiLT having been completely arrested, the wound is thoroucrhlv Avashed, drainaire tubes inserted or counter- openings made, and the edges of the wound brought together with sutures. If the wound is large and irregular, it is well to fasten its deeper parts together with buried catgut sutures passed by means of a curved needle, Fig. 13, and to attach SUTURES. 39 the central ]X)rtions of tlie skin flaps to the underlyinfr raw sui'faces in the same manner. The outer surface of tlie skin sh«nihl not be ineludtMl in the l«x>p of such a suture, for the tension is apt to cause pain. If the skin is in, alioiit tlie two ends of which a stout thread is then twisted. The pins may have niova))Ie l)oints, as shown in Figs. 17 and 18, or stout '\sol id-headed" Fig. 15. Fio. k;. C'ontiiiuou.s suture. Twirtti'il suture Fig 17. O Ilarulip ijin. Fig. 18. Harelip piu with muvable point. pins may be used and passed either in the usual manner, or with the aid of Buck's pin-conductor (Fig. 19). Their Fig. 19. Duck's pill conductor. 4* 42 THE ACCESSORIES OF AN OPERATION. points should he cut off" Avith nippers (Fig. -0), after they have been inserted, and the skin protected at each end by a Fig. 20. Nippers for cutting off pins. strip of adhesive plaster. Instead of thread, a rubber ring is sometimes used (Fig. 21). Fig. 21. Fig 22. Twisted suture. A rubber riug is used in the place of thread. 4. The quilled or button su- ture (Fig. 22), in which the wire or thread is passed'double and tied over pieces of gum catheter Fig. 28. / Serre-fine. Quilled suture or ivory rods r)r buttons. This is employed when the tension is great, or when the deep parts tend to drag asunder, and allow the secretions to collect. The points of entry and emergence of the sutures should be at a considerable distance from the incision. BANDAGES. 43 Fio. 24. The serre-Hne (Fiir. 28) mav be used wlien tlie tension is slifrht, and when tlie edores of the incision will not needtoI)e held together for more than twenty- four hours. It is a small self-retain- inir force} ><. with toothed blades, and is made of silver wire. The blades ir are separated by pressing upon the sides, and spring together when the pressure is removed. . For other kinds of sutures see Wounds of the Int^'stines. BANDAGES. Ordinary roller bandages should be made of strips of strong un- bleached muslin from 2} to 3J inches in width and about four yards long, rolled up snugly from one end. Narrower and shorter strips may be required for the smaller and more irregular por- tions of the body. The selvage edge should always be removed. •'Double-headed" rolls are made of longer strips rolled from each end towards the middle ; they are used only for compound dressings in whicli the turns cross each other at right angles (Fig. 30). A bandage should be so applied that it will press evenly upon all portions of the part covered by it. and not so tightly as to cause oedema of the distal portion when applied to a limb. When firm pressure is needed at any point on a limb, the bandairin^ should beL^in at its lower extremity and be carried up to the necessary height. The methods of L'ontinauue or spiral bandage. 44 THE ACCESSORIEIS OF AN OPERATION. application in common use are the continuous or spiral^ the fi(jure of-S or spira. the T-bandage, the capelUne^ and the triangular bonnet. The eontinuous or spiral bandage (Fig. 24), when ap- plied to a limb, should be fixed by one or two circular turns about the foot or hand, and then carried regularly up the limb, each turn covering the upper half of the preceding one. The increase in the thickness of the limb makes it necessary to reverse the turns in order that they may lie snug and keep their place ; this is done by fixing the centre of the Fig. 25. " Eeversing" tlie turns. band with the finger (Fig. 25), and turning over that edge of the bandage which lies upon the thicker side. The figure-of-S, or spiea, bandage is represented in Figs. 26 and '27; successive turns are taken about two adjoining parts, crossing from one to the other over the point which it is especially desired to secure. At the groin the bandage is fixed by one or two turns about the thigh, then carried around behind the back and across the hypogastrium to the thifh again, and thence over the same course as often as is necessary. The knee, shoulder, elbow, or ankle can be dressed by BANDAGES. 45 means of overlji])])iiio; turns of a figui'c-of-8 bandage, or in tlio innnncM" slioAvii i)i Fiu:. 28, by tearinL^ an oblong piece of Fi(i. ii(i. Fici. '11. Spica of the shoulder. Spica of the groiu. muslin down tbe middle at each end, leaving a square un- divided portion in the centre. The square portion is placed Fig. 28. Four-tailed bandage for the kuee. over tlie knee, and the four ends crossed under it brought in front and tied. 46 THE ACCESSORIES OF AN OPERATION. The T-bandage (Fig. 29) is composed of a transverse and one or two vertical bands. Sometimes the transverse hand covers the dressing, and the vertical band serves only to Fig. 29. T-bandajre. keep the other in place; but generally the reverse is the case, and the vertical band supports a dressing or an instru- ment, and is itself supported by the transverse one. This Fig. 30. Capelline or scalp baiKlage. bandage is most commonly employed in dressings applied to the anus, perineum, and lower portion of the trunk. 15ANDAGES 47 The rapelUne or scalp handatje (Fig. 30) is ap|ilie7 \ ^^ cross-barred muslin or crinoline, \^yj^// 1 and rub the dry plaster well into ■^ ' them before rolling them up. When I'equired for use the roller is thor- oughly wet by placing it in a basin of water, gently squeezed, and then rapidly applied to the limb, while the successive turns are rubbed smooth with the wet hand. Before the plaster is applied the limb should be covered with a thin layer of raw cotton, or with a few turns of an ordinary bandage. If crinoline cannot be obtained ordinary bandages must be unrolled, drawn through a thin mixture of plaster, rolled up again, and rajiidly applied before the plaster has had time to set. Starch should be spread upon strips of coarse paper, which are then applied longitudinally to the limb ; silicate of soda or potash, dextrine, and glue are employed by first rolling up the orthnary l^andages in the solution, and then applying them in the usual manner, or the band may be applied dry and the mixture rubbed on each successive layer. The skin must be protected by a layer of cotton or a few turns of a dry bandage. The silicates and the glue dry quite rapidly, the starch and the dextrine much more slowly. The dextrine can only be dissolved by first mixing it with alcohol, and then adding hot water and stirrinir it until it is reduced to the proper consistency. Two, or at most three, layers of bandase are usually sufficient. A convenient method of employino: plaster in the fonn of BANDAGES 49 splint without covering tlie liuib t-ntirely, is one in general use in the Paris hospitals. A strip of crinoline, folded in six or eight thicknesses of the proper length and breadth, is dniwn through the liquid plaster, stripped down rapidly to remove the excess, applied to the limb, and fixed with a few- turns of an onlinarv roller banda^re. Instead of a sintrle strip two may be used and applied on opposite sides of the limb. Such a splint fits the limb accurately, and will not make undue pressure at *iny point. Sayre's Plaster of Paris Jacket} — In connection with this subject, and in view of the importance and recent origin of this method of treating spinal disease, it ha.s been thought proper to add a description of the method of applying the Plaster of Paris jacket. The bandacres are made of strips of crinoline three vards long and from two and a half to tliree inches wide, accord- ing to the size of the patient, filled with dry plaster as before described, and put up in rolls which are moistened by setting them on end in a basin of water just before they are to be applied. For the purpose of strengthening the jacket and diminishing the amount of plaster required, narrow strips of tin, roughened on both sides like a nutmeg grater, are placed longitudinally around the body at inter- vals of two or three inches between the turns of the plaster bandage. The skin should be protected by an elastic, closely fitting undei^shirt of some soft woven or knitted material, without arms, but with tabs to tie over the shoulders. As it is difficult for an assistant to hold the patient sus- pended during the application of the dressing, the apparatus shown in Fig. 34 has been devised. It consists of a curved iron cross-bar, to which are attached an adjustable head and chin collar and axillaiy bands. To a hook in the centre is attached a compound pulley, the other end of which is secured either to a hook in the ceiling or to the top of a tripod eight or ten feet high (Fig. 35). The collar and bands having been carefully adjusted, the patient is drawn up until the feet swing clear of the floor, and a wedge-sha]»e'ith a retractor. Flex the head slightly to relax the parts, feel with the finger for LIGATURE OF THK AXILLARY ARTERY. 63 tlio carotid tu])cTC'U', and seek tlic arlcry Ik'Iow it, scjtaratiii;!; tlic cellular tissue with a director. i*ass the needle between the artery and vein. LIGATURE QF TJIE VERTEBRAL ARTERY. Anatomy. — The vertebral artery passes from the first portion of the subclavian upward and backward to the transverse process of the sixth cervical vertebra. It is ac- companied by a vein which lies in front, and is covered by the deep cervical fascia. The guide to it is the carotid tubercle. Operation. — The first incision is the same as for ligature of the inferior thyroid (Fig. 40, D). The anterior edge of the sterno-cleido-mastoid is exposed and drawn outward. The middle fiiscia is divided, and the carotid and jugular drawn inward. The gap between the longus colli and the scalenus anticus is then felt for about half an inch below the carotid tubercle, the deep fascia covering it torn through, the muscles separated, the vertebral vein pushed aside, and the artery exposed. Chassaignac prefers an incision along the posterior border of the mastoid muscle, and reaches the carotid tubercle by drawing the muscle and vessels inward. If the muscle is very broad some of its clavicular fibres must be divided. LIGATURE OF THE AXILLARY ARTERY. Anatomy.— T\n2 axillary extends from the middle of the clavicle to the lower edge of the tendon of the teres major. The axillary vein lies on the inner side and in front of it. and the brachial nerves invest its lower portion closely. It can be tied below the clavicle in the clavi-pectoral triangle formed by the clavicle, inner border of the i)ectoralis minor, and the thorax, or in the axilla. The strong fascia which unites the coracoid ])rocess and clavicle, and forms the sus- pensory ligament of the axilla, the costo-coracoid fiiscia, sends a prolongation about the upper portion of the axillary vein which keeps its walls from sinking in ; the cephalic 64 LIGATURE OF THE ARTERIES. vein ascending in the groove between the deltoid and pec- toralis major perforates this fascia and joins the axillary vein at the inner border of the tendon of the pectoralis minor, close by the origin of the acromial thoracic artery. A. Ligature under the Clavicle. — (Fig- 40, U.) Make an incision extending from the summit of the coracoid pro- cess four or four and a half inches along the lower border of the clavicle. Divide successively the skin, subcutaneous tissue, superficial fascia, and pectoralis major, and then tear carefully through the costo-coracoid fascia, avoiding injury to the cephalic vein at the outer part of the wound. The pectoralis minor is noAV exposed, and after separating the cellular tissue with the point of a director the axillary vein is seen crossing from the upper edge of the muscle to the clavicle. The artery is completely hidden by it, lying on the outer side and a little behind. The vein must now be drawn inward, the needle entered between it and the artery, and the ligature applied as near as possible to the clavicle on account of the proximity of the acromial thoracic branch. B. Ligature in the Axilla. Anatomy. — The tissues and organs on the outer side of the axilla are arranged in the Fig. 41. neurosis, which may be very tliin. Raise tlie submaxillary ghmd, find tlic posterior belly of the digastric, its attachment to the hyoid bone, the posterior border of the mylo-hyoid, and the hypo- glossal nerve accompanied by the lingual vein. Draw the ' Fia. 47. r>_ Pucial Veiv 'lllllr^ ■ / Facial Art. Ilyo^lossHS JMylo-hyoid Digastric Us Ilyoidts Anatomical relations of the lingual and facial arteries. (Tillaux.) hyoid bone slightly downward with a blunt hook fixed in the lower angle of the triangle bounded by these organs, and then, pinching up the fibres of the hyoglossus with a pair of forceps, divide them carefully along a line parallel to the nerve, and midway between it and the bone. As the cut fibres retract, the artery is disclosed below them ; sepa- rate it from its vein, if there be one, and pass the ligature. LK4ATURE OF THE FACIAL ARTERY. The facial artery crosses the inferior maxilla just in front of the anterior edge of the masseter, from which it is sepa- 76 LIGATURE OF THE ARTERIES. rated by the facial vein (Fig. 47). A depression, in which it is lodged, can usually be felt on the lower edge of the bone. The artery can be exposed by a vertical incision along its course, or by a horizontal one along the lower border of the maxilla. Operation (Fig. 4(3, E). — Beginning at the lower edge of the maxilla make an incision one inch in length along the course of the artery ; divide the skin, subcutaneous tissue, and fascia ; separate the artery from the vein and pass the needle between them. If the horizontal incision is used, it should extend three- quarters of an inch on each side of the artery, the anterior edge of the masseter should be recognized, and the vessel sought for immediately in front of it. LIGATURE OF THE OCCIPITAL ARTERY. At the Mastoid Process. — The guides to the vessel are the apex and posterior border of the mastoid process, the digas- tric groove on its inner surface, and the digastric muscle. Operation (Fig. 46, C). — Starting from a point half an inch below and in front of the apex of the mastoid process, carry the incision two inches obliquely backward parallel to the border of this process. Divide the skin and enveloping fascia, and then the sterno-mastoid and its insertion through- out the entire length of the incision. Then divide the splenius and its shining aponeurosis, and feel for the digas- tric groove. Pinch up and carefully divide a thin fascia which covers the anterior face of the splenius. Starting from the belly of the digastric, separate the cellular tissue in the anterior angle of the wound with a director, denude the artery and tie. {Ohauvel.) LIGATURE OF THE TEMPORAL ARTERY. (Fig. 46, D.) — Make a transverse incision one inch long, extending from the tragus of the ear forward over the zygomatic arch. Separate the subcutaneous cellular tissue, which is very dense and fibrous, with a director, and seek the artery embedded in it about a quarter of an inch in front LIGATURE OF THE COMMON ILIAC. 77 of tlie ear. Press the vein backward, j)ass the needle from beliind forward, takinLT eare not to include in the li('iriiinini»; over tlic outer side of tlic urtery a fiii<^or's breadth above I'oiipart'.s ligament, make an in- cision tliree or four inches in lengtli, at first parallel with Poupart's lion the sides. Amputation through the 3Ietacarpo-phalan(jeal Articula- tion. — The articular depression can be found very easily by passino; the thuml) and forefinger along the sides of the finger, especially if the latter be at the same time draAvn forcibly away from its metacarpal bone. The incision should be commenced over the dorsum of the metacarpal bone a quarter of an inch above the articu- lation, carried through the interdigital web, and then back on the palmar face to a point a quarter of an inch above the flexor fold (Fig. 54, (7); a similar incision, beginning and ending at the same points, is made on the other side of the finger, the flaps dissected back, the lateral ligaments divided while the finger is drawn first to one side and then to the other so as to facilitate access to them and at the same time make them tense, and then the tendons and the re- mainder of the capsule divided as flie finger is withdrawn. Or an incision may be made only on the side correspond- ing to the right hand of the operator, the flap dissected back to the joint, the lateral ligament divided, the knife carried transversely through the joint, dividing the tendons and the other lateral ligament, and the other flap cut from w^ithin outward, care being taken to make it sufiiciently broad. The head of the metacarpal bone should be removed only in cases where it is more desirable to diminish the deformity than to preserve the strength of the hand. An artery on each side will have to be secured, and the wound closed with sutures. The incisions may be advantageously modified for the index and little fingers by making a full lateral flap on the free side and carrying the incision transversely across the 96 AMPUTATIONS, palmar surface to the angle of the web, and thence obliquely back to the knuckle (Fig. 54, E). AMPUTATION OF THE METACARPAL I30NES. As the articulations of the 1st and 5th metacarpal bones with the carpus do not comnninicate with the other and larger synovial sacs, these bones may be entirely removed without much danger of setting up inflammation within tlie Fig. 54. A. Disarticulation of phalanx, anterior flap B. Amputation in continuity, circular. C. Metacarpo-phalangeal disarticulation, h. Amputation of a metacarpal bone in con- tinuity. E. Disjirticulation of little finger, F. Disarticulation of 5th metatarsal. G. Amputation of wrist, circular. H. Amputation of wrist. (Dubrueil.) wrist-joint, l)ut in the case of the otlier three amputation in continuity is preferable to disarticulation. The relations of the synovial sheaths of the flexor tendons are also of im- portance in the operation. There is no communication AMPUTATION AT THE WRIST. 97 between the main slieatli in tlic palm of the hand and the sheaths of tlie -d, 'Jd, and 4tli fiiit^ors, and consequently, if the tendons are divided as low down as the metacaijMt-pha- langeal articulation, inflammation of the main sheath with all its disastrous consequences will pi-obably he av(^ide!• After tlie bone has been thus dis- engaged, the knife is passed through the articulation, and the plantar flap cut from within outAvard. Modifications. — The plantar flap nuiy be cut (1) from without in- ward, or (2) by transfixion, before the articulations have been opened. Instead of disarticulating it, the base of the second metatarsal may be cut oft* with pliers or a saw ancl left in place. Hey sawed off" the projecting part of the first cuneiform after dis- articulating, but this weakens the attachment of the tibialis anticus, a disadvantage which is not offset by the improvement in the outline. MEDIO-TARSAL OR CHOPART S AMPUTATION. ^-,, . ... A. Lisfianc's amputation. Ihis name is given to the opera- b. chopart's amimtation. tion of disarticulation throuirh the joints formed by the astragalus and calcaneum behind, the scaphoid and cuboid in front. The guides to the joint are the tubercle of the scaphoid on the inner side of the foot, the head of the astrasjalus on the dorsum, and the anterior end of the calcaneum on the outer border. Tlie first named is one-eighth of an inch in front of the articulation, and is the first bony prominence felt on drawing the finger from the inner malleolus forward along the side of the foot ; the 112 AMPUTATIONS. sliarp edge of the second can be readily felt when the ante- rior portion of the foot is forcibly depressed ; the latter can usually be made out by adducting the toes and inverting the sole, nearly midway between the tip of the external mal- leolus and the base of the fifth metatarsal bone, or nearer the latter. When the foot is at rio-ht angles with the les:, the anterior articular surfaces of the astragalus and calcaneum are in the same plane, one crossing the foot transversely at the points indicated. Operation. (Figs. 61, 62, 63.) — The surgeon places the thumb and forefinger of his left hand upon the tubercle of Fig. 62. Outer side A (hoparf r- amputatiuii. B. Syme's amputittion C. Line of section of the bones in Syme's amputation. D. Siibastragaloid amputation. the scaphoid and the lower and outer border of the cuboid, with the palm against the sole, and makes a curved incision from one to tlie other passing an inch anterior to the head of the astragalus, and terminating on each side just below the level of the joint. The plantar flap is next marked out by an incision beginning and ending at the same points as the first, and crossinor the sole of the foot four or five finorer- breadths nearer the toes. The dorsal flap is next dissected up, the joint entered at either of the points mentioned as guides (preferably between the astragalus and scaphoid on the inner side, after dividing the tendons of the tibiales). SUlJ-ASTRAQALOIl) AMPUTATION 113 opciKMl ^vi(l(']y by dividing tlic dorsal and interosseous liira- ments and depressing tlie toes, and tlie plantar !lap cut from Avithin outward. Synie })referred to make the plantar llap by transfixion before disarticulating. The anterior tendons should be stitched with catt^ut to the deep tissues, and the dressing should keep the foot in extreme dorsal ilexion at the ankle in order that these ten- dons may so unite with the stump that their nmscles will prevent the heel from being raised by the unopposed action of the muscles of the clilf. SUB-ASTRAGALOID AMPUTATION. (Figs. 62, i), and 63, C.)- — The guides to this operation are the tip of the external malleolus and the head of the The joint must be entered from in front on the astragalus Fig. 63. Inner side. A. Chopart's amputation. B. Sj'me's amputation. C. Suluuitragaloid amputation. fibular side, and the strong interosseous ligament which forms the key to the articulation must be divided step by step from before backward and inward. The posterior tibial vessels lie behind the inner malleolus, and must be carefully avoided. 10* ,114 AMPUTATIONS. Bc'frinninir at the outer side of the heel, nearly an incli below the tip of the external malleolus, an incision, extend- ing through to the bone, is carried straight forward to the base of the fifth metatarsal bone ; thence, curving forward, across the dorsum of the foot to the base of the first meta- tarsal ; thence obliquely backward and outward across the sole of the foot and around its outer border, rejoining the first and horizontal part of the incision at the calcaneo- cuboid articulation. The soft parts must be separated from the outer surface of the calcaneum and cuboid with division of the peroneal tendons, the dorsal flap dissected back to the head of the astragalus, and, on the inner side, beyond the tubercle of the scaphoid, thus dividing the tendon of the tibialis anticus and the anterior portion of the internal lateral ligament. The interosseous ligament can then be easily reached by depressing the toes, passing the knife be- tween the astragalus and scaphoid, and cutting backward and inward along the under surface of the fomier. The soft parts on the inner side are then separated from the cal- caneum, injury to the vessels being avoided by keeping close to the bone, between it and the tendon of the flexor com- munis, the foot depressed, and the tendo Achillis divided. This last is a very difficult part of the operation, and great care must be taken to keep the edge of the knife close to the bone so as not to cut through the skin. The posterior tibial nerve should be dissected out and cut off" as high up as possible, so that it shall not be pressed upon in the stump. AMPUTATION AT THE AXKLE-JOINT. Same's Amputation^ Tibio-tarsal Ainjjutotion. (Figs. 62, 63, B.) — Amputation through the ankle-joint by the circular method, lateral flaps, or a long anterior flap taken from the dorsum of the foot, as proposed by Baudens, did not meet with favor, because the delicacy of the coverings or the vicious position of the cicatrix rendered the stump practically useless ; and, although occasional successes were reported, the choice still lay between Chopart's operation AMPUTATION AT THE ANKLE-JOINT. 115 and amputation of the Irg, until Prof. Syme, in 1S4-J,' showed how the excellent plantar tla]) could he ohtaincd. Ahout the same time Jules Koux, of Toulon, met the same indication bv means of a large internal lateral flap carried across the plantar aspect of the heel. By greatly restricting the necessity for amputation of the leg this o})eration has become one of the most important and frequently performed of all amputations. The objec- tions urged against it, and the unfavorable results that have sometimes followed its use, seem to have had their origin in a failure to understand- or carry out all the details of its execution, or in the introduction of improper modifications. It has seemed desirable, therefore, to reproduce here Prof. Syme's directions for performing it, as published in 1848," six years after he had first put it into practice. '• Succeeding experience taught me that a much smaller extent of fiap than had oriixinallv been considered necess;irv was sufficient for the purpose, and that hence the operation could not only be simplified in perfornianee. but increased in safety from bad effects. '- The foot being placed at a right angle to the leg, a line drawn from the centre of one malleolus to that of the other, directly across the sole of the foot, will show the proper extent of the posterior flap. The knife should be entered close up to the fibular malleolus,^ and carried to a point on the same level of the opposite side, which will be a little below the tibial malleolus. The anterior incision should join the two ppints just mentioned at an angle of 45° to the sole of the foot, and long axis of the leg. In dissecting the posterior flap, the operator should place the fingers of his left hand upon the heel, while the thumb rests upon the edge of the integuments, and then cut between the nail of the thumb and tuberosity of the os calcis, so as to avoid lacer- ating: the soft parts which he at the same time ijentlv. but steadily, presses back until he exposes and divides the ^ Lond. and Edin. Monthly Journ. of ^led. Science, Feb. 1S43. ' Contributions to the Path, and Practice of Surijerv. Ediuburs^h, 1848. ' "The tip of the external malleolus, or a little posterior to it; rather nearer the posterior than the anterior margin of the bone." — Syme, in Lancet, 1850. 116 AMPUTATIONS. tendo Achillis/ The foot should be disarticiihited before the malleolar projections are removed, -which it is always proper to do, and which may be most easily effected by passing a knife round the exposed extremities of the bones and then sawing off a thin slice of the tibia connecting the two processes." Disarticulation is accomplished by opening the joint in front and dividing the lateral ligaments by entering the point of the knife between the sides of the astragalus and the malleoli. The essentials of the method, as pointed out by the more recent Scotch writers (Lister, Spence, and Bell), are that the plantar incision should run from the tip of the external malleolus directly across the heel, should on no account in- cline forward, and should terminate at least half an inch below the tip of the internal malleolus (behind and below, according to Lister). In case the heel is unusually long the incision may even incline backward. It is not only unnecessary, but actually dangerous, to make the flap longer than this, for it then becomes impossible to dissect out the calcaneum without scoring the subcutaneous tissue in all directions, and increasing the chances of sloughing. If the incision is made further back and carried any higher on the inner side, the posterior tibial will be cut before its division into the two plantar arteries. Erichsen and Lister both claim that the integrity of the posterior tibial is not of great importance, the vitality of the flap depending mainly upon anastomosing branches of high origin which lie quite near the bone. Erichsen^ calls attention to the existence of a "branch of considerable size w^hich arises from the posterior tibial artery, about one and a half to two inches above the ankle-joint, and passes down to the inner side of the os calcis," communicating freely above, below, and behind this bone with the peroneal artery on the other side. As these anastomosing loops lie much nearer the bone than the skin, great numbers of them will be divided, and the vitality of the flap endangered, un- 1 It is now generally considered better to divide the tendon from above downward, after disarticulating, keeping the edge of the knife close to the upper and posterior aspect of the bone. 2 Science and Art of Surgery, vol. i. p. 77. Lea, Phila., 1873. AMPUTATION AT TIIK A N K L K -,J () I N T . 117 less the {'(l^o of llic kiiilc is kc'})t close against the hoiic (luring the disseetioii. Jiister goes so far as to say that sloughing of the ihip is always the fault oF the surgeon, and r>ell intimates the same thing. lioux' has shown that this close dissection is not witiiout its daniT:ers from the other side. In two of his cases osteo- })hytes developed within the stump from portions of the ])eriosteum left adherent to the Hap. The autopsy in one of these eases shoAved that six osteophytes had formed and become carious within a year after the operation. A short longitudinal 'incision through the dcej) ])arts along the middle of the plantar aspect of the calcaneum will some- times render this step of the operation easier, and be less disadvantageous than the employment of great force. Modifications. A. Internal Lateral Flap. — When the outer side of the foot has been so altered by injury or dis- ease that the heel flap cannot be obtained, a very good sub- stitute may be had in the large internal flap suggested by Jules Roux, and adopted with slight changes by Sedillot, Mackenzie, and others. Prof. Spence says this stump can hardly be distinguished from Syme's. An incision (Fig. 64) is commenced at the outer side of the tendo Achillis, a little above its insertion, carried straight forward under the outer malleolus, then in a curved line across the instep half an inch in front of the anterior articu- lar edge of the tibia, and backward to a point just in front of the inner malleolus ; thence directly downward to the sole, across it obliquely backward to its outer border, and then backward and upward around the heel to the point at which it began. The edges of the flaps are next dissected up for a short distance, the joint entered at the outer side, and the internal flap completed from within outward after disarticulation. Sedillot's modification of this consists in making the flap more quadrilateral than triangular, by a semicircular incision across the dorsum three finger-breadths in front of the mal- leoli, and by carrying the posterior end of the external hoi-i- zontal incision across the tendo Achillis to its inner border. ^ Bull, de la Soc. de Chirurgie, torn. iii. p. 491, 1853. 118 AMPUTATIONS. Mackenzie's method differs only in beginning the incision at the inner border of the tendon and a little higher up. It is probable that a serviceable external flap could be made in the same way, although its vascular supply would be scantier. B. Pirogoff's Anqmtation. — This is a much more im- portant modification, since it involves not merely the method of performing the operation, but also the retention of the posterior portion of the calcaneum, and its ultimate union Fig. 64. Amputation through the ankle-joint by large internal lateral flap (Roux). with the tibia. The only additional anatomical point that needs mention in connection with it is that the long axis of the calcaneum is directed upward as well as forward. An incision (Figs. 65 and QQ, A) is made from the tip of the inner malleolus to a point a little above and in front of the tip of the outer malleolus, crossing the instep half an inch in front of the anterior edge of the tibia. A second incision crossing the sole at the level of the calcaneo-cuboid articulation unites the extremities of the first, and should be carried boldly down to the bone. The plantar flap is then dissected back for a quarter of an inch, and the dorsal flap to the edge of the joint, the malleoli well exposed, and the joint opened widely by dividing the lateral ligaments. By drawing the foot forward and depressing it a narrow AMPUTATION AT THE ANKLE-JOINT. 119 rmtc-liers or a chain saw can be passed tliron^li tlie joint, and ap})lied to the Ciilcaneum l)ehind the posterior lip of the astratjahis, and the bone sawn throu*di downward and for- Fig. 05. PirogrofTs amputation. A. Cutineous incision (outer side). B. Line of section of the bones. Fig. 66. PirogrofTs amputation. ^4. Cutaneous incision (inner side). B. Parallel soction of the bones (Sedillot's modification). ward in such a direction that the section will tenninate half an inch behind the lower ed^re of the calcaneo-cuboid articu- lation. The malleoli and a slice of the tibia are then re- 120 AMPUTATIONS. moved as in Syme's operation, and enough of the anterior anorle of the calcaneum removed to make the length of its surface of section correspond with that of the tibia. Some surgeons prefer to reverse this order, and remove the mal- leoli before sawinof throuo;li the calcaneum.^ The cut surface of the calcaneum must then be brouofht up against that of the tibia, and if the section of the former has been suflSciently oblique, and has commenced far enough back, this can be done without making excessive tension upon the tendo Achillis, otherwise another slice must be removed from one of the bones or the tendon divided subcutaneously. Suturing together of the bones has been occasionally tried, as has also fastening them together by a long steel pin driven through the skin of the sole and the calcaneum into the tibia. Several modifications of this operation have been sug- gested, but they can hardly be considered as improvements. Vertical division of the calcaneum, as originally proposed by Pirogoff and Ure,^ deprives the stump of the advantages of the heel pad by swinging the latter too far forward, and bringing the weight of the body upon the thinner skin cover- ing the insertion of the tendo Achillis. It also causes undue tension of the tendon when the bones are brought together. Sedillot suggested an oblique section of the tibia upward and backward, parallel to that of the calcaneum (Fig. 66, B). This avoids any stretching of the tendon, and insures a well-placed pad under the heeL but it shortens the limb somewhat, and places the point of support behind the axis of the leg. Pasquier saws both tibia and calcaneum hori- zontally; this is difficult of execution, endangers the flap, and also leaves the point of the heel too far back. The sug- gestion which is occasionally made to retain the malleoli is unsurgical and unprofitable, — unsurgical, because union between two cut surfaces of cancellous bone is speedier, stronger, and not exposed to greater risks than when one ^ Pirogoft^'s incisions were nearly identical with Syme's. He also divided the calcaneum vertically, and left in the articular surface of the tibia unless it was diseased. 2 Ure's conception of the operation seems to have been original with him. His case was published in the Lancet about the time of the appearance of Pirogoff's book at Leipzig, 1854. AMPUTATION OF THE LEG. 121 surface is covered witli articular cartilage: unprofitalde. be- cause notliing is gained in accuracy of adjustment or length of limb. CohiparisoH of tlw Different Methods of Purthil and Total Amputation of the Foot. — As an offset to the advan- tage of their less extensive mutilation, Lisfranc's and Cho- })art's ani])Utations are open to the objection that the unop- posed action of the muscles of the calf may raise the heel permanently, and bring the weight of the body upon the end of the stump and the cicatrix ; and, furthermore, when these amputations have been performed for disease of the bones, those bones whieh were left behind, even if entirely healthy at the time of the operation, have ultimately become affected. Syme's amputation gives an excellent stump, and the shortening of the limb is no more than is necessary to per- mit the adaptation of an artificial foot and a spring under the heel, but it is comparatively difficult of execution, and the flap is liable to pouch and favor retention of the pus. Piroiroft "s method is easier of execution and mves a lonixer limb, but an artificial foot cannot be fitted to it so advanta- geously, and in cases of amputation for disease it is contrary to sound principles of surgery to leave in the stump any bone which is apt to become subsequently affected : it brings the heel pad a little too far forward, and requires a longer time for recovery from the operation. The subastragaloid disarticulation gives a longer limb and a good stump, but disease is very apt to recur in the astragalus. (See also Mickulicz's osteoplastic excision of the leg.) AMPUTATIOX OF THE LEG. A. Lower Third. — This may be done by the pure cir- cular or by a modified circular method, with a long anterior flap made to overhang the square-cut posterior segment of the limb, or with a long elliptic posterior flap, including the whole of the tendo Achillis. The two former result in a central adherent cicatrix ; in all the coverings are liable to be thin and tender, and the artificial limb must be so ad- justed that the weight will be received by the sides of the 11 122 AMPUTATIONS leg and not upon the face of tlie stump. The compensatoi-y advantaores are that the control of the limb is more perfect Fig. 67. Fig. G8. Fig. 07.— Amputatiou of leg. A. Modified circiilar. B. Eectangular flaps, Teale. G. Antero-posterioi flaps, upper third, Bell. Fig. 68.— Amputation of leg. A. Long anterior flap. B. Supra-malleolar amputation by long posterior flap, Guyon. C. At the upper third, Sedillot. than with a shorter stump, and the mortality consequent upon the operation less. AMPUTATION Ol-^ THE LEG. 123 1. Circular 3Iet] I Oil. — A circular incision is made tlii(uii;li the skin, and a cutaneous sleeve one inch lon«r behind, two inches in front, is dissected \x\) ; the soft parts are cut straight through to the boiu' at the base, and then retracted with n two- or three-tailed hand, according to the breadtli of tlie interosseous membrane, and the bones sawn through, beginning and ending with the tibia. '1. Modified Circular. Fig. 07, A. — Circular incision through the skin, met by a liberating longitudinal one on the antero-external aspect. The soft parts of the posterior portion are divided rathCr lower than those of the anterior portion, and all are dissected back to the line at which the bones are to be divided. Instead of a single liberating incision two may be made, one on each side; and then by rounding off the corners we may have double skin flaps with circular division of the muscles, the "modified flap" operation. 3. Long Anterior Flajp (Bell). Fig. 68, A. — An ante- rior flap, equal in length to the diameter of the leg at its base, is marked out by a curved incision through the skin, beginning at the posterior edge of the tibia on the inner side, a little below the point at which the bones are to be divided, and ending at a point directly opposite over the fibula. The anterior muscles are divided transversely half an inch above the lower end of the flap, and carefully dissected off" the bones and interosseous membrane as high as the base of the flap. The separation from the interosseous membrane should be made with the finger or handle of the knife, in order that the anterior tibial artery which lies immediately upon the membrane may not be injured. The posterior flap is then made by transfixion and cutting transversely outward, and, the soft parts being retracted, the bones are sawn across a little higher up. The resulting cicatrix is posterior and not adherent to the end of the bone. BelP reports five cases, in all of which there was complete and rapid recovery, with a useful stump. 4. Elliptic Posterior Flap (Guyon^). Figs. 68 and 69, B. — The incision is made in the form of an ellipse, whose lower end crosses the heel below the insertion of the tendo ^ Manual of Surg. Operations, 3d ed., p. 85. Edinburgh, 1874. * Bulletins de la Society de Chirurgie, 1868, page 337. 124 AMPUTATIONS. Fig. 09. Achillis, and whose upper end is about an inch above the anterior articular edge of the tibia. Beginning at the lower end and dividing the tendo Achillis at its insertion, and hugging the bone all the way, the flap is dis- sected up posteriorly as high as the upper end of the ellipse. The ante- rior muscles are then divided by trans- fixion, the bones sawn through, and the posterior tibial nerve resected. In this operation the sheath of the tendo Achillis is not opened, and the tendon itself serves afterward as a covering for the end of the bone. The retraction of the muscles of the calf tends, in course of time, to draw the cicatrix downward and backward, and Faraboeuf has proposed to meet this tendency by carrying the anterior end of the ellipse still further up the leg, so that that part of the incision through the skin shall be an inch or so above the line of division of the bones and anterior muscles. B. Middle Third. — 1. Long an- terior curved flap. 2. Long anterior rectangular flap (Teale). 3. Long posterior rectangular flap (Lee). 4. Simple posterior flap. 1. The long anterior curved flap is made according to the method de- scribed for its use in the lower third. Amputation of the leg and at Xhc principal poiuts to 1 »e bome in the knee. A. Long posterior ^-^^ .^^.^ ^^ Separate the anterior rectangular flap, Lee . B Supra- in i • malleolar, Guyon. c. At the musclcs from the mtcrosscous uicm- upper third, Sediiiot. D. Dis- braue with the finger or handle of the articulation at the knee, oval j^^^jf^ ^^ ^^^^ ^|^^ n^ j^^^ eUOUgh to fall over and cover the broad posterior surface of section without tension, and to saw off obUquely the prominent angle made by the crest of the tibia. AMPUTATION OF THE LEG. 125 2. Lonj Anterior Jiecta)iiiig was as follows: 1st. a layer of small pieces of tarlatan covering the entire raw surtace;. -«L a thiek layer of charpie saturated with an antiseptic solution, alcohol, carbolic acid, or camphor ; 3d, a layer of cotton batting covereicondyles, the ulna at the luise of the coronoid process, and the radius through its neck. The extent of the disease may make it necessary to surpass these limits, but the result will then be less perfect, and in any case every eftbrt should be made to preserve the continuity between the periosteum and the tendons of the brachialis anticus and biceps so as to provide for future flexion of the forearm. An exception to the rule of total excision may be found in the preservation under some circumstances of all the olecranon except its articular surface; the joint thus obtained is firmer, and active extension more powerful. Reproduction of bone takes place less completely at the elbow-joint than at any other of the major articulations, and consequently the greater the amount removed the greater the danger of the formation of an imperfect, loose, and in- efficient joint, even when the subperiosteal method has been thoroughly carried out. Von Langenbeck^ removed four and a half inches of the humerus and two inches of the ulna subperiosteally in a case of gunshot injury, and says the result was the w^orst he ever saw, the connection be- tween the arm and forearm being so very loose that the patient was obliged to use a supporting brace, by the aid of which he was able nevertheless to make excellent use of his hand. Ordinarily anchylosis is to be preferred to a very loose joint. In cases of gunshot injury Yon Langenbeck and Oilier remove as little as possible, making a partial (semi-articular) excision when either the humerus or the bones of the fore- arm alone are injured. The English authors think the danger in cases of excision for disease is rather of removing too little than too much, and reconmiend that the humerus be sawn through above the condyles. J Loc. cit., p. 443. 13* 150 EXCISIOX OF JOINTS AND BONES. As the joint is covered anteriorly "svith soft parts, among which lie nearly all the principal arteries and nerves, and is almost subcutaneous posteriorly, it must be approached fi'om the latter side, and the incisions must be made with especial reference to the safety of the ulnar nerve, where it runs between the olecranon and the epitrochlear. The orig- inal method, and the one used almost exclusively for many years, was the H-incision, composed of two longitudinal in- cisions connected midway bv a transverse one crossincr the tip of the olecranon. It has the disadvantage of dividing the ulnar nei've or exposing it in the wound during the period of suppuration, and. having been superseded by less complicated ones, does not need to be described. Although excellent joints have been obtained by the old operations the preference should be given to the modem subperiosteal method, not only on account of the greater certainty of the reestablishment of a useful limb, but also because the danger of diffuse inflammation and purulent infiltration is much less when it is employed. These dangers are greater at the elbow than at any other joint, except the hip, and secondary amputation is more frequently required. The other methods have been devised with the view of sparing the nerve, presernng the attachment of the triceps and the continuity of the lateral ligaments with the perio.s- teum, and facilitating the operation. Although the central longitudinal incision has been extensively used the prefer- ence .seems now to be due to methods of approach from the radial .side, such as Olliers, Nelaton's, and Hueter's. Central LonfjitiLdinal Incision. Fig. 74. A. (Yon Lan- genbeck.) — The forearm being slightly flexed, a longituchnal incision 3J inches long is made a little to the inner side of the median line of the triceps and ulna, and carried down to the bone. The inner edge of the divided periosteum is raised from the ulna, the corresponding half of the tendon of the triceps detached with it, and the dissection continued toward the internal condyle, the knife beincr kept constantly against the bone, and the flexion of the arm increased as the dis.section advances. As the epitrochlea is approached the greatest care is needed to preserve the connection be- tween the periosteum, the muscular attachments, and the EXCISION OF THE EL150 W-.J OINT . 151 Fiu. 74. internal lateral ligament, and it may be neeessary to \)\'() long the first incision upward so as to get more room. After the inner half of the joint has thus heen laid open and the epitrochlea bared, the soft parts are replaced and a similar dissection made upon the outer side Avith the same precautions. The humerus is then dislocated back- ward through the wound and sawn through at, or as near as possible to, the epicondyles, according tt) the lesion. If the condition of the soft parts does not allow of this projection of the humerus the chain or keyhole saw must be used. The ulna is then cleaned circularly as far as necessary and sawn through, and the head of the radius removed with the saw or cutting pliers. Excision of the elbow- joint. A. Von Langen- OlUers Method.' (Fig. 74, ^.)— The forearm is slightly flexed, and an incision is commenced two inches above the tip beck. b. oiiier. of the olecranon on the outer side of the arm at the interstice between the triceps and supinator longus. This incision, involving the skin only, is carried downward to the epicondyle, thence dowmvard and inward in the line of the upper border of the anconseus to the ole- cranon, and thence, the point of the knife touching the bone, directly downward along the inner side of the poste- rior aspect of the ulna for one or two inches. The fascia is then divided in the line of the incision, and the interstice between the triceps on one side and the supi- nator longus, radial extensor, and anconseus on the other, followed down to the capsule and bone. The capsule is opened, and the humerus denuded on its anterior and poste- rior faces as far inward as possible, care being taken to maintain the relations of the muscular and ligamentary attachments. The tendon of the triceps and the periosteum of the ulna 1 Traite de la Regeneration des Os, p. 340. 152 EXCISION OF JOINTS AND BONES, are next detached, and in separating the former it is hetter to begin inside the joint at the free edge of the olecranon. The denudation of the external condyle and tuberosity of the humerus is then completed, and the external lateral ligament entirely detached, the forearm flexed on its inner side, and the end of the humerus dislocated outward into the wound, thus rendering the difficult dissection of the project- ing epitrochlea easier. When this latter has been com- pleted, the periosteum of the humerus is raised circularly to the proper height, and the bone sawn through. The head of the radius is then removed, the denudation of the ulna completed, and the bone sawn T'iG. 75. through perpendicularly to its axis. Nelatons Method. (Fig. 75, A.) — A longitudinal incision is begun on the outer border of the humerus be- tween the triceps and supinator lon- gus, IJ inches above the end of the olecranon, and carried downwards for a distance of 3 inches. A transverse incision cutting through to the bone is t \B Excision of the elbow-joint. A Nelaton. B, 0. Hueter. next made, from the lower end of the first, across the ulna to its inner border. The triangular flap thus formed, including the periosteum of the ulna, is dissected up, the external lateral and orbicular ligaments divided, and the head of the radius removed. The tendon of the triceps is detached and the denudation of the ulna completed. The ulna is projected through the incision by bending the forearm toward its inner side, and is sawn off. The humerus is then easily turned out through the in- cision, denuded from below upward with tlie usual precau- tions, and sawn oft' at the desired height. Long Radi F' mur (Adams^). — The only special instrimient needed is a saw somewhat resembling a tenotomy knife, the cutting part beinof one and a half inches lonor and three-eio;hths of an ^ A new operation for bony anchylosis of the hip-joint with mal- position of the limb, by subcutaneous division of ilie neck of the thigh bone, by William Adams. London, 1871. Reprinted from the British Medical Journal for December 24, 1870. 168 EXCISIOX OF JOINTS AXD BOXES. inch wide, and the shank about two and a half inches long. (Tig. 82.) A tenotomy knife is entered a little above the top of the great trochanter and pushed straight into the neck of the femur, dividing the muscles and opening the capsule freely. The soft parts being fixed by the thumb and fingers of the left hand, the knife is witlidrawn and the saw passed promptly down to the bone through the track made by it. Fig. 82. Adams's saw for subcutaneous division of the neck of the femur. The bone is then sawn through from before backward, so that the line of section shall be at right angles to the long axis of the neck, care being taken to avoid cutting obliquely through the neck, or in a direction parallel with the shaft of the bone. Division helow tlie Trochanter. — This operation, often includinir the removal of a wedcre of bone from the outer side, has been much more frequently empl'oyed for the re- lief of a faulty position, especially of flexion and adduction. One orreat advantacje is that in it the bone is divided below the attachment of the anterior ligament and capsule, the retraction of which maintains the faulty position. The objection to it, because of which some prefer to excise the joint, is that it only substitutes one fixed position for an- other. Operation. — The trochanter is exposed by a longitudinal incision on its outer, posterior aspect, the peritoneum divided and raised in front and behind, and a wedge of bone re- moved by chiseling while the limb rests on a sandbag, or with the exsector or saw. Excision. — Posterior incision as above described, with such modifications as may be made necessary by dislocation : division of the neck with the saw, if possible, otherwise with the chisel ; then removal of the head, or what remains of it, by chiseling. EXCISION OF THE HIP-JOINT 169 The upper end (if the bone is then lodged in the aeetabii- lum, after suht-utaneous division of sueh muscles and soft parts as interfere and removal of the upper part of the trochanter, if necessary. Extension by weight and })ulley must be kept up for a long time. Operation for Estahlishinnit of a False Joint (Sayre). — A longitudinal incision six inches in length is made over the irreat trochanter, commencino: iust above its crest and as near as possible to its centre, and carried directly down to the bone. A transverse.incision is then made through the skin and fiiscia only at the centre of the posterior lip of the first. The anterior surface of the bone is next cleaned with an elevator until the trochanter minor can be felt with the finger, the posterior surface similarly treated, and the chain- saw passed just above this process. Fig. 83. Linei! of section in Sayre's operation for anchylosis of hip-joint. A curveti section of the bone is made by sawing fii*st up- ward and outward, then outward, and finally outward and downward. The saw is passed a second time around the bone, and the lower fracrment divided transversely one- eighth of an inch below the beginning of the first line of seA2tion. (Fig. 88.) The portion of bone thus removed is about three-fourths of an inch thick at its thickest part. Probably two parallel sections one-half or three-quartei*s of an inch apart would answer equally well. 15 170 EXCISION OF JOINTS AND BONES. EXCISION OF THE KNEE-JOINT. This should always be complete to this extent, that a slice should be taken from each bone, but it is not always neces- sary to remove the entire articular surface of the femur. In children the amount removed should be as small as is consistent with removal of all that is diseased. It is recom- mended by Spence and some others that the patella should be retained if not diseased, but experience has shown this to be unwise, for it does not add materially to the strengtli of the subsequent union, and the bone itself is likely to become carious. As anchylosis should always be aimed at. the incision may cross the front of the joint and divide the ligamentum patella or the patella. Some surgeons provide for drainage by making a dependent opening in Fig. 84. the popliteal space, but this seems to be unnecessary. li.-J- — '. Semilunar Incision. (Fig. 84, A.) — The knife is entered on one side of the limb at the posterior part of the condyle, and carried across midway between the patella and the tuberosity of the tibia to a corresponding point upon the other side. This incision should extend down to the bone throughout, dividing the ligamentum patellae. The flap is reflected, the crucial ligaments divided close to their attachment to the tibia, the lateral lic^aments divided, the end of the femur cleared as far as may be neces- sary, with especial care for the safety of the popliteal vessels, protruded through the wound, and sawn off" at the point indicated in Figs. 8o and ^(S. The line of section must be parallel to the line of the articulation, not at a right angle to the axis of the shaft, for that is directed inward and downward. If necessary, additional slices of the bone Exci&iuu ol tile kuee-juint. A. Semilunar incision. B. Oilier" s incision. EXCISION OF THE KNEE-JOIXT. 171 arc ronioved, or tlio irouge is used. All tlio articular carti- lage slioiiM l»c removed. The end of the tibia is next projected, cleaned, and sawn off about half an inch below its upper surface. In sawing the bones it is best not to make a complete section with the saw, but to stoj) a little short of the poste- rior surface and complete the separation by fracturing what is left. Finally, the patella is taken out, anoth together than one alone in this way. In simultaneous excision of both superior maxilli^, the same incisions mav be made on both sides, as for the re- moval of only one, or Dieffenbach"s median incision may be made alons the ridire of the nose and the middle of the upper li}) I). 180 EXCISION OF JOINTS AND BONES. Operation by one of the Median Incisions. (Fig. 89.) — The incision is made in the direction selected, the knife penetrating to the bone throughout except at the lip. The cartilage of the nose is separated from the bone and reflected inward with the small internal flap, the edge of the orbit cleared, and the external flap dissected outward as far as to the malar bone above and the tuberosity of the maxilla below if possible, the infraorbital nerve being divided at its point of emergence from the foramen. The periosteum of the floor of the orbit is then detached with the handle of the knife, as far as the spheno-maxillary fissure, the malar process or bone cut through with the saw or forceps, and the thni plate of bone forming the floor of Fia. 89. Excision of superior maxilla. A. External incision. B. Xelaton's incision. C. Boeckel's incision. the orbit divided with the knife obliquely inward and forward fi'om the anterior end of the spheno-maxillary fissure. The superior maxillary nerve, which can be readily distinguished through the bone, should also be divided as far back as pos- sible. Finally, the nasal process is divided. The incision is then carried through the lip, and the de- tachment of the external soft parts completed. The mucous mem])rane of the roof of the mouth is divided transversely on a line with the last molar tooth, and longi- tudinally in the median line. An incisor tooth is then drawn, and the hard ])alate divided with saw or forceps close to the septum. EXCISION OF THE SUPERIOR MAXILLA 181 If the mucous membrane (»f the roof of the mouth is not diseased it may be retained. Instead of the incisions tlimutrh it just mentioned, one is made along tlie inner border of the alveolar process, its edge raised, and the membrane de- tached inward and backward to the median line. After the removal of the hnne it unites with the cheek, closes in the mouth as before, and may become strengthened bv a deposit of bone. Finally, the bone is grasped with strong forceps, twisted downward to break its posterior connections, and removed, generally bringing with it part of the palate bone, the hamular process of the pterygoid and some attached mus- cular fibres. Subperiosteal Excision (Oilier). — This method can be employed with any of the median incisions above mentioned, but Oilier prefers an external one (Fig. 90, B). Fig. 90. Excision of superior maxilla, ii Gaerio's incbion. B. OUier's inci^on. C. Dieffenbach'* incision fi>r removal of both bones. 1. Cuttntt'ous In'ision. — An incision is made from the middle of the malar bone to a point on the upper lip one- third of an inch from the angle of the mouth. If neces.sar3% a second incision must be made at the middle of the lip and carried upward around the nostril. 16 182 EXCISION OF JOINTS AND BONES. 2. Incision of 3Iucous Membrane. — The incision is be- gun on the outer surface at the interval between the second incisor and the canine tooth (he does not remove the inter- maxiUary bone, that whicli supports the incisor teeth) close to the ed«:e of the o-um, carried back around the last molar, then forward on the inside to a point corresponding to that at which it was begun, and thence obliquely backward to the median line. A short incision through the periosteum is next made from the anterior external extremity of the former upward and inward to a point a quarter of an inch external to the anterior nasal spine. 3. Separation of the Periosteum. — The periosteum of the anterior surface is then detached with an elevator, care being taken, however, to divide the infraorbital nerve with a knife at its point of emergence, and the denudation is carried along the floor of the orbit. Unless it is necessary to re- move the nasal process of the maxilla, the lachrymal sac and duct can be left uninjured and adherent to the periosteum. The periosteum of the roof of the mouth is then separated from without inward as far as the median line. 4. Section of the Bone. — The nasal and malar processes are divided with forceps, chisel, or chain-saw as before de- scribed, the canine tooth drawn, the edge of the chisel in- serted in the gap left by it, and pressed gently backward and inward to the median line, thence directly backward along the suture. The bone is then twisted out, the palatal sutured to the external periosteum, and the wound closed. SIMULTAXEOUS EXCISION OF BOTH SUPERIOR MAXILL.E. An incision may be made from each angle of the mouth to the malar bone and the broad flap reflected toward the forehead, or Diefi"enbach's incision made along the ridge of the nose (Fig. 90, C). with or without a transverse one pass- ing across it and below the margin of each orbit. The bones are removed together, not separately. The malar processes or bones are divided in the usual manner, the nasal processes divided with a chain saw passed from one orbit to the other through the lachrymal bones, and the vomer separated with cutting forceps. The periosteum of EXCISION OK SUPEKIOH MAXILLA. 183 tlic hard palate is se})arat('(l IVoin the gums hy a seiiiicircii- hir incision and dissected back, the ])ostei-i(H- connections broken and tlie bone removed by twisting it downward ami forward. PARTIAL AXJ) TEMPORARY EXCISION OF TlIK SPPKRIOR MAXILLA TO FACILITATE THE P»F.M()V\I. OF NASO-PIIARYX(}EAL POIA'Pr<. Resection of Posterior Portion of Hard Palate (Nela- ton). — Tlie soft palate is first divided fi'om before backward along the median line,, and the incision prolonged forward through the periosteum of the hard palate as far as may be judged necessary. A transverse incision is next made on one side from the anterior extremity of the first toward the teeth, and the flap, including half the soft palate, dissected off the bone from the median line outward. The mucous membrane on the floor of the corresponding nostril is then divided close to the septum, the bone perforated at the an- terior corners of the denuded surface, and the separation of the quadrilateral piece accomplished with cutting forceps. After removal of the polyp the soft parts are replaced and stitched together. The bone is sometimes reproduced. Resection of the Upper Portion^ leaving the Hard Palate and Alveolar Process (Von Langenbeck). — The following is somewdiat abridged from the description in the Deutsche Klinik^ 1861, page 288: An incision convex downward, from the ala of the nose to the malar bone, and along the zygoma backward. A second incision from the nasal process of the frontal along the lower border of the orbit, meeting the first at the middle of the malar bone. He worked down to the bone through the first incision and separated the attachments of the masseter to the malar bone. As soon as the tense fascia hucealis was cut the tumor appeared. Drawing the inferior maxilla away with a speculum, he easily passed his finger between the tumor and the superior maxilla through the pterygo-maxillary fissure 'n\U^ the Sidieno-maxillary fossa, both of which had been enlarged by pressure, and then through the dilated foramen spheno-palatinum to the cavity of the nose. 184 EXCISION OF JOINTS AND BONES. A fine elevator and then a fine keyhole saw were passed by the same route, and the superior maxilla sawn through horizontally from behind forward, while the left forefinger, passed through the mouth into the })harynx, covered the point of the saw and kept it from striking against the sep- tum of the nose. The second incision was then carried down to the bone and into the orbit, and the soft parts divided in the angle between the frontal and zygomatic processes of the malar bone. The second cut with the saw was then made from below upward through the zygomatic process of the temporal and the frontal process of the malar bone to the spheno-maxillary fissure, and thence across the floor of the orbit to the lach- rymal bone. The resected portion was thus left attached only to the nasal bone and the nasal process of the frontal by its own uninjured nasal process. The hard palate and alveolar pro- cess had not been touched. He then passed an elevator under the malar bone and turned the piece slowly upward upon its connections as upon a hinge until the malar bone had nearly reached the median line of the face, and the spheno-maxillary and nasal fossie were completely accessible. The bleeding was severe, but stopped spontaneously, the arteria spheno-palatina alone was tied at its entrance into the foramen spheno-palatinum. The bone was replaced and nicely adjusted, its tendency to rise being restrained by pressure until the metallic sutures had been set in the skin. OTHER METHODS OF GAINING ACCESS TO THE PHARYNX THROUGH THE NOSE. These may here be described, although, properly speak- ing, they are not resections of the superior maxilla. Boeckel makes two transverse cuts across the nose, and unites their extremities by a third along its side. The cuts are carried to the bone, and the (juadrilateral osteo-cutane- ous flap thus formed turned back upon the cheek, the other TO GAIN ACCESS TO TUK I'UAKYNX. 185 nasal process wliidi \nnn^ its base liaviii;: first been broken witli iia(kl('(l tbnt'ps, one blade of wliicli is ]»asse(l into tbe nostril. Oilier turns the wliole nose downward, lie be'^ins bis incision at the ed«ie of the bone close l)ehind tbe ala of tbe nose carries it upward along its side to the highest part of the depression between the eyes, then across and down to tlie corresj)onding point on the other side (Fig. 1)1, A). The bone is sawn through in the line of the incision, the necessary liberating incisions made in the septum or the sides, and the nose turned down. Fig. 'JL ■^ Ollier's operation fur removal of a naso-pharyngeal polyi.. B. .^lodification for a very large polyp. The septum is pressed aside, the polyp extracted, its base of implantation scraped, and the nose replaced. A modilication, which is sometimes desirable on account of the size of the polyp or the distance of its implantation, is indicated in Fig. 91, B. The incision runs more ob- liquely backward, and a transverse one is made from each end to the ala of the nose. The bone is divided in the direction of the cutaneous incisions, in the vertical one as l)efore described, in the horizontal one by i)assing a fine saw across the nostrils through holes made between the bone and cartilages, and sawing backward. This line of section must be high enough to avoid the roots of the teeth. In some cases it is sufficient to mobilize the loivcr nid of the )iose by an incision under the lip in the gingivo-labial 1G» 186 EXCISION OF JOINTS AND BONES. fold, and tlieii by carrying it and the lip upward very free access to tlie nasal fossae is obtained. EXCISION OF T'lE IXFEIUOR MAXILLA. This may be total or partial ; and partial excision may involve the removal of any part of the body of the bone or of the ascending ramus. Partial excision of the body may sometimes be accomplished through the mouth without the aid of a cutaneous incision, or l)y an incision along the lower border of the bone with or without another at right angrles to it extendinir toward or even throufrh the lip, or by two vertical incisions downward from the angles of the mouth when only the upper part of the body of the bone is to be removed. When the ascending ramus also is to be resected the in- cision should pass along the lower border of the bone to the angle of the jaw, and then upward along the posterior border of the ramus to the level of the lobule of the ear. If the incision is carried higher the fjicial nerve is neces- sarily divided with consequent paralysis of the muscles sup- plied by it, a complication which should be avoided, not- withstanding the assertion of some authors that the paralysis may disappear after a time. The horizontal portion of the incision should be a little below the border of the bone in order that the cicatrix may be less conspicuous. Syme removed the entire ramus with the condyle, without open- ing into the cavity of the mouth, by an incision slightly convex backward extendins: from the zvcroma to, and a little beyond, the angle of the jaw. The principal danger is of injury to the internal maxillary artery, which lies almost in contact with the inner side of the neck of the condyle. The lingual nerve also is in close relation with the inner side of the ramus, lying be- tween it and the internal pterygoid muscle. Maisonneuve introduced a modification of the method of operating which has rendered it almost easy and has diminished the above- mentioned danger. It consists in separating the attach- ments of the condyle by twisting and tearing out the bone after all the connections have been divided. If this modifi- EXCISION OF THE INFEKIOH MAXILLA 187 cation, which sounds, perhaps, rougher and less surgical tlian' it really is, is not adopted, the joint must he ap- proached from in front so as to av<»id the external carotid, which lies close behind the hone in the substance of the parotid. It is sometimes allowable to divide the neck of the condyle, or even the ramus below the sigmoid notch, with cutting pliers, and leave the upper fragment in place. Another danger is in the division of the attachments of jXcnio-hvo-Ldossus muscles to the bone. The toncrue, de- j)rived of its support, falls back upon and closes the glottis. As a preliminary, therefore, to any operation in which these attachments are divided; a stout ligature should be passed through the tip of the tongue and held by an assistant. After the operation it should be fastened to a harelip pin in the external incision, or to the skin of the face by a strip of adhesive plaster, and retained for a couple of days, at the end of which time the muscles will usually have formed new attachments. The bone should be sawn through with a chain or com- mon saw, according to circumstances, or merely nicked with the saw, and its division completed with cutting-pliers. The tooth occupying the proposed line of section should first be drawn. Ligature of one or both carotids has been proposed and performed as a preliminary operation to prevent excessive hemorrhage, but it has proved to be not only unnecessary but ineffectual. In Mott's case the main operation had to be adjourned to allow the patient to recover fi-om the shock of the preliminai-y one. In another case in which both carotids had been tied, the main operation had to be aban- doned on account of hemorrhaore.^ Svme says the pre- liminary ligation is unnecessary, because the only arteries that need to be divided are the facial and the transverse branches of the temporal, bleeding from which can be easily controlled, and, furthermore, all the advantages offered by ligation of the carotids can be obtained by their temporary compression during the operation. The attempt should he made, when possible, to get pri- ^ Mentioned by Syme in Contributions to the Pathology and Prac- tice of Surgery^ Edinb., 1848, p. 19. 188 EXCISION OF JOINTS AND BONES. mary union of the intra-buccal wound and to drain through the external one. This makes it easier to keep the wound sweet, diminishes the danger of purulent infection, and avoids the risks incident to the swallowinf; of the decom- posing discharges. The results of the operation are usually very good, and the deformity less than might be expected. Subperiosteal excision has been followed by reproduction of the entire bone with condyles and diarthrodial cartilages, and even when the periosteum is not preserved the cicatrix becomes very firm and fibrous, and able to support a plate with arti- ficial teeth. Resection of the Anterior Portion of the Body. — This may be done by means of a vertical incision in the median line, or of a horizontal one below the free border of the bone, or from within the mouth without any cutaneous in- cision. If one of the incisions is made, the external and internal surfaces of the bone are cleared through it, a tooth drawn at each of the proposed points of section, and the bone sawn throu2:h. If no external incision is made, the external surface of the bone is cleared, beginning at the edge of the gum or in the o-iugivo-labial fold, accordinor as the i)eriosteum is or is not to be preserved, and the lip drawn down under the chin so that the bone protrudes through the mouth. It can then be easily sawn through and freed from its attachments on the inner side. Resection of the Lateral Portion of the Body. — The in- cision extends along the lower border of the jaw from its angle nearly to the symphysis, and then is carried vertically upward to the base of, but not through, the lip. The flap is dissected up, the elevator being used, of course, if the periosteum is to be preserved, the inner surfiice of the bone cleared near the symphysis for the passage of a chain-saw, and the section made if possi1)le at a short distance from the median line, so as not to disturb the insertion of the genio-hyo-glossus. This section may be made with a nar- row saw from before backward if preferred. EXCISION OF THE INFERIOR MAXILLA 189 The bone is then drawn dowmvanl and outward, its inner surface cleared, and the saw aj)|»lie'2.) — An incision is beirun close to the posterior border of the ramus on a level with the lobule of the ear, carriec;:in- nin«^ five inches below the upper end of the first and endin-r about the same distance above its lower end, and removed the bone after sawing through tlie acromion and neck of the scapula. Velpeau' reconuiiends three incisions: one along the spine of the scapula, the others starting from the anterior ex- tremity of the first and i-unning, one toward the root of the neck, the other toward the axilla Ijchind. Syme made two incisions crossing each other near the centre of the tumor. Other surgeons have made triangular or semilunar flaps. In January, LSTS, Dr. George A. Peters removed, at the New York Hospital, the entire scapula for malignant disease, leaving the arm. He made an incision along the spine of the scapula, divided the fibres of the deltoid and trapezius, and exposed the tumor, which involved only the acromion and adjoining portion of the spine. He then made a ver- tical incision across the centre of the first, beginninf? two inches above it and extending to the inferior angle of the scapula, reflected the flaps, dissected out the under surface of the bone from behind forward, separated the acromion from the clavicle and humerus, and then, raising the lower angle of the scapula toward the head, approached the coracoid process from below, and found no difficulty in separating it from its attachments. Only two vessels re- quired ligation, the supra-scapular and a large branch of the subscapular. The operation was performed under the spray, and the wound treated antiseptically. The result was verv good ; six weeks afterward the wound had closed, and the patient possessed a certain degree of control over the humeinis. Subperiosteal Excision of the Scapula (Oilier). Fi9. 196 EXCISION OF JOINTS AND BONES about an inch. A short transverse incision may also be needed at the anterior end of the first. 2. Denudation of the Bone. — The attachments of the deltoid and trapezius to the acromion and spine are sepa- rated, the periosteum of the posterior border of the scapula divided in the interstice between the rhomboideus and infra- spinatus, and the infra-si>inous fossa carefully denuded. The Fig. 93. Excision of tlio .sraimla. periosteum is very thin in its lower third. The lower angle is freed by detaching the teres major and serratus magnus, the bone raised, and tlie subscapularis detached from below upward. If the marginal cartilage is not completely ossified and united with the bone, it should be separated and left adherent to the periosteum. The supra-spinous fossa is then cleared, care being taken not to injure the supra-scapular nerve in the supra-scapular notch, but to raise it up with the periosteum and its fibrous sheath. The posterior part of the bone is then carried up- ward and forward, and the denudation of its under surfiice and anterior border completed. If the extent of the disease permits, the denudation should RESECTION OF THE HUMERUS. 197 stop at the neck of tlie scapula, wliicli is tlien divided Avitli a cliaiii-saw or cutting f<)rce])S. o. Opening of the Scapulo-liumeral Joint. DetaeJunent of the Articular Capsule and Denudation of the Coraeoid Process. — The acromion is next separated from the clavicle, the scapuLi turned up^vard, the joint opened from below, and as the bone is pressed steadily u})ward everything that holds is detached with an elevator. After the coraeoid process has been thus separated from most of its muscular and ligamentary attachments, the few that remain can be broken by twisting the bone away. In suitable cases the coraeoid process may be* divided at its base and left in place, and thus tlie most difficult and hiljorious part of the operation done away with. TliC partial excisions of the scapuJa do not require de- tailed description. The acromion, spine, and posterior border are reached by straight or slightly curved incisions along the portion to l)e removed. A crucial or H incision is required at the angles. RESECTION OF THE HUMERUS. The position of the musculo-spiral nerve is the most im- portant element in this operation. In its passage around the posterior aspect of the humerus the nerve lies close to the bone within the sheath of the triceps muscle, and leaves the latter on the outer side of the arm to enter that of the supinator longus at its origin. In approaching the bone, therefore, on the outer side near the junction of the middle and lower thirds, the operator should lay bare the outer border of the brachialis anticus and follow down within its sheath to the bone. Upper Portion. — Same incision as in Ollier's method of excision of the shoulder carried further down along the outer edge of the biceps. The cephalic vein must be sought for and drawn aside. Periosteum and capsule divided, bone denuded and removed as in excision of the shoulder-joint (q.v.). Middle Portion. — Incision along the posterior border of the deltoid and outer edge of the biceps. Outer border of 17- 198 EXCISION OF JOINTS AND BONES. the bracliialis anticus laid bare and folloAved down to the bone. Division of the periosteum and denudation of the bone with especial care for the safety of the musculo-spiral nerve. Oilier prefers to seek the nerve and draw it aside. He also recommends that whenever it is ])ossible to leave a por- tion of the shaft connecting the extremities it should be done, as a precaution against shortening and the formation of a pseudarthrosis. If this is not possible the chain-saw^ is passed at two points, and the intermediate piece removed. Lower Portion. — Incision on outer side of the posterior aspect of the arm, between the triceps and supinator longus, as in Ollier's excision of the elboAV {q. v.). " Total Excision. — Combination of incisions for upper and lower portions. After the ends have been denuded of peri- osteum the middle portion can be cleared by pushing one end out through its incision and peeling the periosteum back like the finger of a glove until the middle is reached. The bone is then sawn off, and the other half removed in a simi- lar manner through the other incision. EXCISION OF THE ULNA. Longitudinal incision along the posterior aspect of the bone, joined at its upper end by a short one running ob- liijuely ujnvard and outward between the triceps and anco- ni>?us. The triceps is drawn to the inner side, and the olecranon freed. After separation of the periosteum the bone is sawn through in the middle, and each piece is dis- sected out in turn. EXCISION OF THE RADIUS (oLLIER). An incision involving the skin only is made from the styloid process of the radius along the outer border of the forearm to the radio-humeral articulation. The fascia is divided and the posterior border of the supinator longus found. By following it toward the wrist the knife can be kept between it and the extensor tendons of the thumb, KXCISION OK MKTACAKI'AL 1U>NES. 191) uliicli (';i!i tluMi 1»(' (liawn Icickwiiid and sav(Ml from injiii'v. l*y following it upward the interstic-e Ix'twccii it and tlic ex- teiisores carpi radialos is found, throiigli wliicli the operator pc'iietratos to tlic radius now covered only l)y tlie suj/inator l)revis. The latter nuiscle is tlieii divided loiiLdtudiiiallv aiul tlie ])criosteal sheath o})ened. The periosteum is detached latei'ally, the hone sawn throuii;h at its middle, and eaeli fragment removed se[)a- rately. Parttitl Excisioui^ of the Ulna and Radius. — The incisions and metliods are the saijie as those ahovc descrihed. EXCISION OF THE Min'ACARPAL BONES AND riIALAN(iES. The metacarpal bones should be exposed by a longitudinal incision along the dorsum. As the extensor tendons cross the bones obliquely this incision should involve only the skin at first, the tendon is then drawn aside, and the incision carried down to and through the periosteum, which must be retained when possible. It is advisable that the joints, especially the metacarpo-phalangeal, should not be opened. The bone is then divided in the middle with cutting for- ceps and each end dissected out, or the gouge alone may be used. The after-treatment is important. Extension must be made upon the corresponding finger for a long time to keep it from being drawn up into the hand. In the case of the metacarpal bone of the thumb lateral pressure must also be made. For resection of a phalanx the incision should be made on the side of the finger near the dorsum. For the ter- minal phalanx the incision should be U-shaped, the arms passing along the sides of the phalanx, the curve around its end. Resection of the different portions of the tluuub, even if not subperiosteal, is to be preferred to amputation, but the contrary is true of the phalanges of the other fingers. Lateral pressure, by means of splints or an India-rubber glovefinger, and extension by weight nnist be made to insure the necessary length and proper shape of the member. 200 EXCISION OF JOINTS AND BONES, RESECTION OF THE BONES OF THE I'ELVIS. Oilier' reports a case in which he removed the ascending ramus of the ischium and most of the pubis for supi)urative ostoo-arthritis of these bones and the pubic synchondrosis. The incision was about four inches Ions; and extended from a fistula in the genito-crural fold up toward the pubis. The periosteum was detached, the ascending ramus of the ischium removed, and then the ascending ramus, body, and part of the horizontal ramus of the pubis. The bone that was removed was eroded and rarefied, but not necrotic. EXCISION OF THE COCCYX (oLLIER). This may be required on account of disease of the coccyx, or as a preliminary to operations upon the rectum. Oilier has removed it for osteitis. Simpson and Xott for the relief of coccygodynia, and Verneuil in cases of imperforate anus, and to facilitate the removal of cancers of the rectum. The limits of the bone are determined by the finger in the rectum, and a longitudinal incision made through the skin and fibrous covering of the bone, from a quarter of an inch above its upper to the same distance below its lower end, and a transverse incision made at the u})per end of the first. The posterior surface of the bone is then denuded. The sacro-coccygeal articulation having been opened by this denudation, its fibro-cartilage is divided, and the cornua cleared on both sides. An elevator is then passed through the joint and used as a lever to force out the coccyx, peeling off at the same time the fibrous covering of its anterior surface. If the sacrum is also diseased, and the gouge is used upon it, it must be remembered that the sacral canal extends to its very end, and is there formed posteriorly not of bone, but of fibrous tissue. 1 De la Regeneration des Os, vol. ii. p. 180. RESECTION OE THE 811 A ET UE THE TIJ'.IA 201 RI'ISKCTION (JV 'I'llK SHAFT ol-' TIIK I'lOMUK. A loiii»;itu(liii;il incision is inudc on tlic oiHcr side in llic groove hetwcen the vastus extcrniis and hiceps, with a. trans- verse liberating incision ateachciio use of tlie knife, aiiU'd, if iK'^ossary, by tlie k-ver, lioii- f()rc*('[)S, etc., the soft parts are next to he cleaned off its inner side witli care, in order to avoid tlie vessels, and the hone will then come away. 1>. Suhperiosftui/ Mrt'/tod (OWicr). Fig. !>'>, A. — An in- cision involving only the skin is begun at the outer border of the tendo Achillis about an inch higher than the tip of the external malleolus, carried down below the outer tuberosity of the calcaneum and then forward and slightly upAvard to. the up- per ])art of the base of the fifth metatarsal. The edge of the ten- do Achillis and the ui)per border of the plantar muscles being recosruized, the incision is car- ried down to the bone, care being taken not to cut the peroneal tendons. The posterior half of the bone is then denuded with an ele- vator, and the tendo Achillis detached and pressed to the inner side. The under surface and posterior third of the inner surface are next cleai-ed, the peroneal tendons drawn aside with blunt hooks, the external lateral ligament detached, the anterior portion of the outer surface denuded, and the calcaneo-cuboid joint opened. The interosseous ligament is divided with a narrow l)is- toury, the bone grasped with lion-forceps and turned down- ward so as to open the calcaneo-astragaloid joints and give access to the calcaneo-scaphoid and internal lateral liga- ments and to the inner surface of the bone. It is difficult, if not impossible, to avoid opening some of the tendinous sheaths during the operation, but the damage is very much less than that inflicted by the former method. Resection of the posterior portion alone can be accom- plished nmch more expeditiously. The portion to be re- moved is denuded and then sawn oft', either directly or by IS A. Excision uf the calc;iiifuin. B Exci.sion of the astragahis. 206 EXCISION OF JOINTS AND BONES. perforating the bone and sawing it from above downward with a chain-saw. Astragalus. — Excision of the astragahis may be rendered necessary by dislocation, comminuted fracture, or caries, or it may be made as a preliminary step in excision of the ankle. Oilier considers this operation, under normal cir- cumstances, the most difficult of all excisions. He employs the following method on the cadaver. Operation (Oilier). Fig. 95, B. — Curved incision across the dorsum of the foot, with convexity directed forward, beginning on the inner side at the point where the tendon of tlie tibialis anticus crosses the tibio-tarsal articulation, running forward and outward to the middle of the scaphoid, and then backward to a point a little below the tip of the external malleolus. This incision must expose but not in- volve the tendons. The extensor tendons are lifted out of their sheaths and drawn aside, the extensor brevis cut across or detached at its origin, and the neck and outer non-articular surface of the astragalus cleared. The capsular and ligamentary attachments of the bone to the scaphoid and tibia are sepa- rated, the interosseous liojament divided, and the foot beino; turned inward the insertion of the strontr internal tibio- astrao-aloid ligament is detached. The remaininoj connec- tions are then ruptured by grasping the bone with strong forceps and twisting it out. Verneuil thinks the operation is made easier by sawing throuo-h the neck of the bone and first removino: the head. See also Yogt's excision of the ankle, p. 175. When dislocated the astragalus may be easily removed by a straight, curved, or crucial incision made over the most prominent part, and avoiding vessels, nerves, and tendons. When badly shattered^ as in gunshot injury, the fragments may be removed through a longitudinal incision between the extensor tendons of the first and second toes. For simultaneous removal of the calcaneum and astragalus see Osteoplastic excision of the foot, p. 170. TKlOrillNlNG. 207 Mi'tatitrstd Bours and J*/iale exposed ])y an iiieisioii along the dorsum involv- ing oidy the skin ; the tendon is then drawn aside, the periosteum divided, the bone denuded, sawn through, and removed. Whenever possible, the upper extremity of the bone should be left. For the first and fifth metatarsals it is better to make the incision more u})on the side than upon the dorsum. If the corresponding toe is to be preserved, extension must be made upon it for a long time, in the manner and for the reasons mentioned under excision of the metacarpal bones. The phalanges and their articulations are best excised by lateral incisions. TREPHINING. TrepMniiK/ of the Cranium may be undertaken for the evacuation of an intra-cranial abscess or hemorrhagic effu- sion, or for the removal of a suspected tumor of the bone or meninges, or for the cure of epilepsy, or after fracture to raise depressed portions of the bone. In all except the latter case the advisability of the operation is greatly diminished by the difficulty of determining the point at which the trephine should be applied. Among the more or less trustworthy indications, according to which the surgeon must make his selections of this point, may be mentioned : the history of an injury more or less recent,^ with or without pain and inflammation of the soft parts (Pott's puffy tumor) at the point where the injury was received, or at one dia- metrically opposite; constant, well-localized pain at any one point ; injury over the course of one of the larger arteries with rapidly supervening symptoms of compression, func- tional disturbance of certain groups of motor nerves. The results obtained by certain physiologists in their efforts to determine the location of motor centres in the cor- tex of the brain have inspired the hope that the injured or compressed portion of the brain might be localized exactly in any givTn case by consideration of the muscles or groups 1 In Dui.uytren's ca.=e there was no sign of the abscess until ten years after the receipt of the injury. 208 EXCISION OF JOINTS AND BONES. of muscles paralyzed. This hope has been in })ai-t realized and surgical interference has been successfully based upon paralytic svniptoms in fracture of the cranium,' abscess of the brain, "^ and tumor of the brain. ^ As the motor centres which Broca, Ferrier, liitzig, and other physiologists claim to have localized lie under the anterior half of the parietal bone and along or near the fissure of Kolando, and as these are the only ones Avhich it has been proposed to seek, it is perhaps desirable that direc- tions should be mxen for findino- this fissure. According to Lucas-Championniere^ the fissure of Kolando corresponds to a line drawn from a point on the sagittal suture five and a half centimetres posterior to the bregma (junction of the sagittal and coronal sutures), forward and outward to a point seven centimetres l)ehind and three cen- timetres above the external angular process of the frontal bone. According to Pozzi^ the starting-point of this line should be only four and three-quarters centimetres behind the bregma. The line may be more simply described as the hypothe- nuse of a right-angled triangle whose base is the upper half of a line drawn from the bregma to the meatus auditorius externus, and whose perpendicular extends two inches back- ward from the bregma along the median line. The bregma is situated at the point where a vertical plane passing through both external auditory canals intersects the sagittal suture when the head is held exactly upright. Whenever it can be avoided, the trephine should not be applied over a sinus or the middle meningeal artery near the anterior inferior angle of the parietal bone. Bleeding from a sinus may be arrested by plugging it with antiseptic gauze, but a fatal result is likely to follow. The middle meningeal artery lies enveloped in the thickness of the dura mater, adhering to it so closely that, when cut, its walls cannot retract sufiiciently to arrest hemorrhage. For the same reason it is very difficult to apply a ligature to this ^ Lucas-Championniere, La trepanation guid^e par les localisations cerebrales, 1878. 2 Stimson, Archives of Medicine, April, 1881. 3 Bennett and Grodlee, Lancet, 1885, i. p. 23. * Bulletin de la Societe de Chirurgie, 1877, p 121. 5 Archives Gen. de Med., Ayril, 1877, p. 4')0. TKEIMl INING. 209 vessel, and, as tlie actual cautery cannot 1)C safely used, the lu'st means of st()p})inLr the flow of hlood is that proposed hy Tillaux, of seizing the vessel and dura mater with s})ring forceps, and keeping it thus compressed for twenty-four or forty-eight hours. The {nstnuih'7}ts used in trephining are a stout knife, periosteum elevator, trephine, and a screw-pointed elevator which is intended to be screwed into the hole made by the centre-pin of the trephine, and used to lift out the circular piece of bone after it has been sawn through. Operation. — A crucial, V or T-shaped incision, one and a half to two inches long, is made through the soft parts down to the bone, and the flaps, including the pericranium, raised by means of the periosteum elevator. The iirobability of a reproduction of the bone is increased by preserving the connection of the pericranium with the soft parts. Fio. 96. Fig. 97. \ L *^ ^. i*.r***A Trephine. Hev's saw. The centre-pin of the trephine having been protruded one-sixteenth of an inch, and fastened in its place by the binding screw on the side, it is forced by to-and-fro rotary movements upon its point into the bone at the place selected, and these movements continued until the circular edge of the trephine has cut a groove sufficiently deep to insure its steadiness without the aid of the pin, which must then be withdrawn so as to avoid injury by it to the dura mater. The hole made by the pin is then enlarged, and made to fit the point of the screw-pointed elevator so that this instru- ment can be applied afterward without making too much pressure upon the loose disk of bone. 18* 210 EXCISION OF JOINTS AND BONES. The rotary movements are repeated very cautiously, and all parts of the groove frecpiently examined, as its depth increases, -with a probe, pen, or quill tooth] >ick, so as to have timely notice of complete perforation. The teeth of the trephine must be freed from the bone dust from time to time by means of a brush or by dipping the instrument into water. If, as is usually the case, perforation takes place upon one side of the groove before it does upon the other, the trephine must be slightly inclined so as to act only upon the unsawn portion, or the elevator may be used to lift out the disk, breakins: the thin shell which remains. If the removal of a much Jaryer piece of hone is desired the trephine should be apj^lied successively at two, three, or more points, and the intervening portions sawn through with a Hev's saw (Fis:. 97). In a case of depressed fracture the trephine must l)e applied to the sound bone in such a manner as to overlap the edge of the fracture. The depressed portion is after- ward raised by means of an elevator passed through the opening left at the edge of the sound bone by the removal of the incomplete disk. In puncturing for a deep-seated cd>s<-ess a grooved knife or a trocar is to be preferred to the ordinary flat blade. Frontal Sinus. — As the walls of the frontal sinus are not parallel to each other, Larrey has proposed to use two tre- phines of different diameters, the larger for the outer, the smaller for the inner table. Antrum. — A very small trephine should be used, and, in order to avoid a scar, it should be applied through the mouth after dividinfr the dndvo-labial fold, and dissecting up the soft parts as far as to the infra-orbital foramen, just below and to the outer side of which the opening into the antrum should be made. The antrum may also be opened by drawing the first or second molar tooth, and enlarging its socket with a drill. No additional directions are needed for trephining the fiat hones or the eptipJiyscs (f the Jong ones. PAllT Y. Ma i;OTOMV AND TENOTOMY. DIVISION AND RESECTION OF NERVES. Division of a nerve, of sensation, or even of a mixed nerve in extreme cases, may be required for the relief of neuralgic pain. It is seldom that simple division is more than temporarily sufficient. At least half an inch of the trunk of the nerve should be excised, and, as additional security against reunion, the end of the distal segment may be bent l)ack upon itself Prof. Weir ^litchelP has seen severe constant pain follow the bending back of the end of the proximal segment. supra-orbital nerve. The frontal nerve, main l)ranch of the first division of the trigeminus, divides just behind the upper margin of the orbit into the supra-orhital and supra-trochlear nerves ; both branches are distributed to the forehead, the former emerging from the orl>it through the supra-orbital notch or foramen, the latter a little nearer the nose. The former is much the larger and more important of the two, the latter supplying only a narrow strip of integument near the me- dian line. The supra-orbital notch or foramen is found at the junction of the inner and middle thirds of the supra- orbital arch, or a little to the inner side of the junction. When it is a notch it can be readily felt through the skin, and is then an important guide in the operation. The nerve may be divided subcutaneously after its emer- gence from the notch, or it may be exposed by a transverse incision above or l)elow the eyebrow. ^ Oral communication. 212 NEUROTOMY AND TENOTOMY. Subcutaneous Division. — A tenotomy knife is entered between the eyebrows midway between tlie nerve and the median line, and passed horizontally beneath the skin until its point has passed beyond the nerve. Its edge is then turned backward and pressed against the bone, and the nerve, Ivino: between it and the bone, divided bv with- drawinfr the knife. Or the knife mav be entered at the same point, but passed close to the bone instead of just under the skin, its edge turned downward toward the margin of the orbit, and the nerve divided by sweeping the knife downward across the mouth of the supra-orbital foramen. Excision of a Portion of the Nerve. — A. Above tlie Eye- brow. (Fig. 08, A.) — An incision one to one and a half Fig 0^ A, B. Resection of supra-orbital nerve. C Resection of superior maxillary nerve. inches long is made just above and parallel to the eyebrow, its centre corresponding to the position of the nerve. This incision is carried down to the bone, the distal end of the nerve recognized, seized with forceps, dissected out, and cut off. B. Below the Eyebroiv. (Fig. 98, B.) — The eyebrow ])eino: drawn up and the evelid down, the surv;is six eeutinietres. Dolheau' divided tlie nerve with eiirved scissors on tlic central side of the branches <2:oin<^ to tlie splieno-pahitine o^anglion, and tore out tlie ganglion by drawing upon the nerve. Mahjidgncs Method. — I*ass a stout tenotome along the floor of the orbit for nearly an inch in the direction of the nerve ; cut transversely with its point through the Hoor of the orbit, the bone being thin will offer no resistance. This divides both canal and nerve. Expose the nerve at the infra-orbital foramen by a simple transverse incision, seize it with forceps and tear it out of the canal. The first part of this operation has been modified by Von Langenbeck and Hueter as follows: A strong tenotome with slightly blunted point is entered close below the external palpebral ligament and pushed backward and downward along the outer wall of the orbit until its point is felt to leave the bone and enter the fissure ; its edge is then turned forward against the sharp border of the orbital i>rocess of the superior maxilla and made to scrape along it as the knife is brought forward. Lilekes 3Iethodr — An incision, beginning one centimetre above the outer angle of the eye and close behind the margin of the orbit, is carried downward and slightly forward across the malar bone, dividing its periosteum ; from its lower end a second incision is carried . backward and forward, termi- nating over the outer surface of the zygoma about a quarter of an inch behind its junction with the malar bone. This bone is next divided in the line of the first incision by means of a chain-saw, after preliminary division of the soft parts and periosteum on its under and inner surface with a small knife, and then severed from the zygoma with cutting- pliers. The attachments of the masseter to the intermediate piece are then separated, and the flap of bone and soft parts raised with a sharp hook. If necessary, some of the anterior fibres of the temporal muscle should now be divided in order to expose the spheno- ^ Oral communication. ■^ Deutsche Zeitschrift fiw Chirurgie, voL 4, p. 322. 216 NEUROTOMY AND TENOTOMY. maxillary fossa tliorouglily, the fat occupying the fossa pressed backward with a retractor, and tlie spheno-maxil- larv fissure recognized Avith a probe. The nerve and artery can be distinguished by the difference in their course, the former running downward, outward, and forward, the latter upward, inward, and forward. The nerve is seized with forceps and divided with a tenotome well forward in the fis- sure, and then again with scissors as near as possible to the foramen rotundum. The flap is then put ])ack, and the wound drained at its lower angle. An objection to this method is that, in consequence of its interference with the masseter and temporal muscles, the mouth subsequently cannot be freely opened. Lossen and Braun^ proposed to avoid this difficulty by leaving the at- tachments of the masseter untouched and turning the flap downward instead of upward, after making the second inci- sion from the upper end of the first instead of from its lower end, and separating the temporal fascia from the malar bone. Czerny^ has employed this modification five times with good results. If wounded vessels cannot be seized and tied, the hemor- rhage must be arrested by plugging with antiseptic gauze. INFERIOR DENTAL NERVE. This nerve may be divided (A) after its exit from the dental canal, (B) in the canal, (C) before its entrance into the canal. The nerve enters the canal by the inferior dental foramen on the inner side of the ascending ramus of the lower jaw at the level of the crowns of the lower teeth ; the canal runs obliquely downward and forward just below the alveoli, and the nerve emerges through the mental fora- men which lies midway between the alveolar process and the lower margin of the jaw below the second bicuspid tooth. A. At the Mental Foramen. — An incision is made in the o-ino-ivo-labial fold above the foramen, and the soft parts ' Centralblatt fur Chirurgie, 1878, pp. 65 and 148. 2 Ibid., 1882, p. 249. INFERIOR DENTAL NERVE. 217 dissected oft' until the nerve is leuelied, usually about one- third of an ineh below the bottom of the foM. B. WltJiiii till' Canal. — An incision is made through the skin down to the bone along the course of the nerve in front of the masseter, the periosteum raised, and the canal opened with a chisel or small trephine. After removal of the outer table of the br pucker in the lip. The harelip pins must be deeply })liice(l, passing close to the mucous membrjme on tlie inside. Tliis insures confron- tation of the raAV surfaces throughout their entii'e l)readth, and the pressure of the twisted sutures prevents hemorrhage. Fio. 100. Oval liori/.onhil iiicisiun. 2. Oval Horizontal Incismi (Fig. 100). — When the tumor covers a considerable extent of surface, but does not pene- trate deeply, it may be safely excised by cutting under it with curved scissors. The mucous membrane and skin may then be stitched together, or the wound allowed to heal by granulation. Fig. 101. Fig. 102. Cheiloplasty, Celsus's incisions. ('heiloi)lasty, C'elsus's flaps in plac( 3. 3fethod of Orlsusor Serves (Figs. 101 and 102).— The Y-incision is supplemented by a horizontal one on each side carried outward from tJie angle of the mouth for about two inches, and comprising the whole thickness of the cheek for 226 PLASTIC OPEKWTIONS ON THE FACE. tlie first two-tliirds of its length, lout dividing tlie mucous membrane at a somewhat hiHier level than the skin. The lower ffino'ivo-labial fold is divided close to the a;um on both sides, and the dissection carried downward close to the peri- osteum, and backward toward the angle of the jaw until the edges of the gap in the lip can be brought together without tension. The sides of the Y are then brought togetlier, and the lip formed from the lower parts of the horizontal incisions (Fig. 102). The mucous membrane and skin are stitched toi^ether alonsx the ediic of the new lip. and the remainino; portion of the lower flap on ^^^- 100. each side (that which remains external to the new angle of the mouth) is reunited to the upper flap. The mucous mem- brane at the outer end of the horizontal incision is stitched to the skin and covers the angle. 4. Dieffeyihach (Fig. 103) adds a vertical incision at the end of each horizontal one, thus marking out two quadri- lateral flaps which are brought together in the median line. The gaps left in the cheek by the transfer are allowed to close by granulation. Cheiloplasty, Diefifcubach's method. Fig. 104. Fig. 105. Syme-Buclianan incisions. Syme-Buchanan flaps in place. 5. Synu'-Bw'lianan (Figs. 104 and 105). — The method ])y latero-inferior flaps is ascribed by some to Syme, by others to Buchanan, of Glasgow. CHEILOTLASTY 227 After llic tumor li;is been removed Ity llie usiimI V-iiK'isioii, the iiK'isioiis are })rol()i);^e- the line of the vermilion border circumscribing the circular half of the mouth, and extending to an equal distance on the upper and lower lips (a to b). This incision should only divide the skin, without involving the mucous membrane. A shar})-pointed, double-edged knife should then be inserted at the middle of this curved incision, and directed flatwise toward the cheek, between the skin and mucous membrane, so as to separate them from each other as far as the new angle of the mouth re- FiG. 112. Lengthening of the month, Buck. quires to be extended. The skin alone is next divided from the commissure of the mouth outward toward the cheek. The underlying mucous membrane is then divided in the same line, but not so far outward. The angles at the outer ends of the two incisions are then accurately united by a sinojle thread suture. The fresh-cut ed<2;es of skin and mucous membrane above and below, that are to form the new lip borders, are shaped by paring first the skin and 1 Reparative Surgery, p. *J8, et seq. 232 PLASTIC OPERATIONS ON" THE FACE. then the mucous membrane in such a manner that the hitter shall overlap the former, after they have been secured together hj fine thread sutures inserted at short intervals. C. Upper Lip. — The V-incision and the oval horizontal incision (p. 225) may be used when the loss of tissue will be small. Also the square lateral flaps (p. 229) when the gap to be filled is in the centre of the lip and rather large. 1. Vertical Flaps (Figs. 113 and 114).— These maj- be made with the base directed upward (Sedillot), or down- ward (Chauvel). Chauvel claims that the latter method is Fig. 1L3. Fig. 114. Cheiloplasty of tipper lip. Sediilot. Sedillot Flaps in place. to be preferred because the retraction of the cicatrix in the former tends to draw the new lip upward and expose the teeth. The flaps comj^rise the entire thickness of the cheek, are turned inward at right angles to their former position and united in the median line. The gaps left in the cheek by their removal are brouojht toojether with sutures or left to ixranulate. 2. Infero-lateral Flap (Buck). Fig. 115. — For loss of the right half of the upper lip Dr. Buck employed the fol- lowins: method, enlarorinc' the mouth afterward and reestab- lishing the angle by tlie inethod described above (p. 231). The extremity of the under lip, where it joined the right cheek, was divided throucrh its entire thickness at rio-ht CHEILOJ'LASTY. 283 angles to its border, and tlie division eaiiied to tlie extent of one ineli from tlie border (a to ^s Fig. lir>). A second incision was made from tlie terminus of the first parallel to the lip border for a distance of one inch and a half toward the chin, b to c. The rpiadrilateral flap thus formed from the under li}) was folded edgewise upon itself, and made to meet the remaining half of the up})er li}), ;ind l)e adjusted to it by its free extremity. In order, however, to make this fold, the under lip had first to be divided obliipiely half across its base, c to d. Fig. 115. Repair of upper lip by infero-lateral flap. Buck. The left half of the upper lip was prepared for the new adjustment hj dividing the buccal mucous membrane close to the jaw and detaching the parts above toward the orbit from the underlying periosteum, and secondly by paring a strip of vermilion border from the extremity of the half-lip of sufficient length to permit the end of the half-lip to be matched to the free extremity of the under-lip flap. The parts concerned having been thus jirepared, the under-lip flap was doubled edgewise upon itself, and its free extre- mity adjusted to the half of the upper lip, and the two secured to each other in a vertical line below the columna nasi by sutures. The space between the newly adjusted 20* 234 PLASTIC OPERATIONS OX THE FACE half of the mouth and the neighboring cheek was closed by approximating the opposite parts and securing them to each otlier by sutures after their edges had been carefully matched. (Fig. 112 .• which remains attached at its lower extremity to the lip (Fig. IIG, A). A similar flap is then made ui)on the other side, the two are turned down, so that their raw- surfaces face each other, and a thread passed through their free ends (Fig. 116, JE).' The freshened edges of the cleft are then confi'onted, a harelip pin jtlaced near the vermilion border and another near the nostril, and two or three fine silk or silver sutures inserted between them. The ends of the dependent flaps are then cut ofi" obli(iuely, enough being left to form a dis- tinct projection on the lip after they have been unite•'>), and united witli fine sutures. If the })arts arc too scanty to permit the use of this Fig. liU Double harelip. method, liberating incisions must be made around the alge nasi, or flaps obtained from the cheek. (See Upper Lip, p. 282, et seq.) Complicated RareJip. — Harelip may be complicated by fissure of the palate and alveolar process. When the fissure is single the bone on the long side of the lip projects beyond its proper line. In very young children, it may sometimes be forced back into place by making pressure upon it with the thumb, but it is easier to fracture it first with Butcher's pliers ; the bent blade of this instrument being applied upon the anterior surface near the further nostril. The two por- tions of the alveolar arch soon unite after they have been brought into contact, especially if the opposing surfaces have been pared. Sutures are not needed. When there is double fissure, the intermediate portion of bone containing the incisor teeth projects so far that it seems to be an appendage of the nose rather than of the mouth. In order to restore it to its place, it is necessaiy to divide the vomer with strong scissors, or, better, to cut a triangular piece out of the septum of the nose. It is not necessary to fasten the bones together with sutures. The portion of skin covering the projecting bone must be dis- secte"ether gave rise to complications, which endangered the patients life. The operation itself was not without dang(3r. Dieffenhach lost two out of six patients upon whom he ope- rate* I in l*aris. The opc)'((tf07i was originally performed as follows (Fig. 127) : A flap, the size and shape of which were determined ])y a pattern previously made of paper or card, was marked out ui)on the forehead immediately above the nose. Care Fig. 127. Rhinoplasty. Indian method unmodified. was taken to make it at least a quarter of an inch broader and half an inch longer than the space it was to fill. Its base was situated between the eyebrow^s, and was half an inch broad. At the upper end of the flap was a projecting tab intended to form the columna. The flap, including all the tissues down to, but not through, the periosteum, was then dissected up, brought down by twisting the pedicle, placed in its new position with its raw surface inward, and attached by sutures to the freshened edges of the gap it was to fill. Prominence was given to the ridge by stuffing the nostrils with plugs of oiled lint, or drawing the cheeks toward the median line by means of long pins passed transversely through the edges and under the nose. The gap in the 248 PLASTIC OPERATIONS ON THE FACE. forehead was left to heal by granulation. After the flap had united, the pedicle was divided, and returned to its ori- ginal position. Modifications} — Larrey (1820) pointed out the desira- bility of saving even the smallest fragments of the original nose, especially if they belonged to the free border of the ala. Prof. Bouisson" formulated this principle, and extended it to the other methods, as follows : 1st. Save as much as possible of the septum. 2d. Give lateral support to the flaps by means of the healthy portion of the cartilage of the alag. 3d. Insure the regularity of the outline of the nostril by giving the lower border of the flap cartilaginous support. Dupuytren and Dieff"enbach opposed the retraction and closure of the nostrils by folding back upon itself that por- tion of the edge of the flap Avhich was to form the free border. The torsion of the pedicle involves more or less danger of gangrene by obstructing the return of the venous blood. Lisfranc (1826) was the first to attempt to diminish this defect. By lengthening the incision on one side, the base or attachment of the pedicle was made oblique instead of transverse, and the torsion correspondingly diminished at that point. Of course, the total amount of torsion remained the same, but, by being spread along the pedicle, it was made more spiral and less abrupt. Von Langenbeck (be- fore 1856) went a step further, and put the base upon the side of the nose close to the eye, the upper incision ending at the eyebrow, the lower just below the tcndo oculi. Lab- bat did about the same thing in 1827. Auvert, a Russian surgeon (date unknown, but long be- fore 1850), made the flap oblique instead of vertical, still keeping the base between the eyebrows. Alquie, of Mont- pellier (1850), proposed to make the flap horizontal, the lower incision being hidden by the eyebrow ; and Landreau even curved it somewhat upward at the end, so that the base of the pedicle w^as hardly twisted at all in bringing down the flap. Ward (1854) made a flap which was directed ob- 1 The dates of these modifications, and the award of credit for their suggestion are mainly taken from Yerncuil's C/ur?). — Tagliacozzi made two nearly parallel incisions tilong the anterior surface of the Fig. 129. Rhinoplasty. Italian meth(xl. arm, their length and the distance between them varying according to the size of the gap the Hap was to fill. The apex of the flap was directed toward the shoulder. The intermediate strip of skin was dissected up, but left adherent at both ends, and a piece of oiled lint passed under it and 252 PLASTIC OPERATIONS ON THE FACE. kept there until siippumtion was established. The strip was then cut free at its upper end, and dressed carefully for about a fortnight, or until its under surface was nearly cica- trized. It was then considered fit to be applied, having undergone the necessary shrinking and thickening. Its edges and those of the nasal aperture were pared and fast- ened together with sutures, and the arm bound fast to the head. When union had taken place between the tAvo. the lower end of the flap Avas cut loose from the arm and its edges trimmed to the proper shape. Graefe did not let the flap suppurate, but tried to get primaiy union. Dr. Thomas T. Sabine has successfully filled by the im- plantation of a finger the gap left by the destruction of the nose. PLASTIC OPERATIONS UPON THE EYELIDS. In these operations it is important to save as much as possible of the original tissues, especially the free border of the lid, the conjunctiva, and the orbicular muscle. As the skin is thin and delicate, the flaps must bave broad bases to insure their vitality ; they must also be so placed that their natural retraction will not tend to reestablish the previous defect. Blepharorapliij. — Suture of the eyelids has proved a very valuable adjunct of many of the plastic operations upon the eyelids, and has even taken the place of some of them, for experience has shown that a loss of substance in either eye- lid may be safely allowed to fill and heal by granulation if the borders of the lids are kept fastened together. The eye must be kept closed in this way for six months or a year, after which time the scar, in most cases, shows no tendency to retract. AVhen the time comes to separate the lids, this should, at first, be done for only half an inch in the centre, and the opening subse(|uently enlarged at long intervals of time, any indication of cicatricial retraction being meanwhile watched for. The prolonged occlusion does no harm to the eye ; on the contrary, it may be sufficient in itself to cure a com- mencing keratitis occasioned by ectropion. PLASTIC OPERATIONS UPON TIIK EYKLIDS. 258 Operation. — A imnow strip of conjiuicliva is excised from tlie border of eaeli lid on llie conjuiK'tivMl side of tlic laslies, beiriiiniiiii: and eiidiiiii" a sliort distance from the com- missures, so as to leave a space for the lh)W of the tears. The two raw surfaces are tlien hrouglit toj^ether accurately wit) I silver sutures. To separate the lids afterward a director should he en- tered at the openiui;- left at one of the angles, its point pressed against the centre of the line of iniion, and cut down upon the two rows of lashes. Canthoplasty. — Enlargement of the palpebral opening (Fig. 180). The external angle of the eye is divided hori- FiG. 130. Canthoplasty. A. Straiglit iiici-siou. B. Richet's modification. zontally with scissors, and the skin and conjunctiva united along the sides of the incision by three points of sutures, one of them being placed at the angle. Richet's modification^ (^^g- 1*^^7 ^)- Richet marks out a small flap by two incisions through the skin, beginning at opposite points on the upper and lower lids near the outer angle and meeting at a point external to that angle. The flap, including everything except the conjunctiva, is then ex- cised, the conjunctiva split horizontally, and its two portions trimmed and fastened to the edge of the cutaneous incisions. Blepharoplasty^ to prevent or remedy — 1. Ectropion. — The descriptions will be given for the lower lid only, that being the more frequent seat of the de- formit}^ Blepharoraphy (q. v.) is often sufficient in itself ^ Anatomie Medico-Chirurgicale, 4th edition, p. 88. 22 254 PLASTIC OPERATIONS OX THE FACE to prevent ectropion, and is ahvays a useful adjunct of a plastic operation. The lids should be kept united during the process of cicatrization of the wound left by the loss of substance, and for several months tliereafter. Wharton Jones (Fig. 131). — Wharton Jones included the contracted cicatrix in a triangular flap one inch high, it? base occupying nearly the whole length of the lid border. Fig. 131. lx;ti'oi>iou. Walter Jones. By dividing the bands of cellular tissue, but without dis- secting up the flap, he restored the lid to its normal position, and held it there by uniting the edges of the incisions below, thus giving it the form of a Y. . AJphonse G-uerin^ (Fig. 132) makes two incisions form- ing an inverted V, the point of which lies just below the Fig. 132. Ectropion. Alphonse Guerin. centre of the free border of the lid. From the lower ex- tremities of these incisions he makes a third and fourth ' Chirurgie Operatoire, 4th edition, p. 318. PLASTIC OPK RATIONS ITI'ON THE EYKLIDS. 255 ])arallc'l to tlie bonier of the lid. The two triaiiL^ilar Haps boiindcd by the 1st and 8d, and the '2d and 4th incisions are then dissected up, the lid raised to its normal position, and held there by uniting the adjoining sides of these two Haps in such manner tliat their apices and that of tlie in- verted V meet at a connuon point. The gaps left by tlie removal of the two flaps are allowed to granulate. For greater security Guerin also unites the borders of the lids (blepharoraphy). Vo7i Grarfe (Fig. 138, A). — Make an incision along the border of the lid just outside of the lashes from the lacli- P^ia. 133. Ectropion. A, Von Gracfe's metliod. B. Knapp's inetliod. rymal point to the external commissure. From each ex- tremity of this make a vertical incision downward from one- half to three-quarters of an inch in length. These incisions should involve only the skin. Cut oft" the upper inner cor- ner of this flap, not by a straight incision, but by one form- ing an angle, as show^n in the figure, and fasten this angle by a suture to that formed by the border of the lid and the inner vertical incision. Reunite the edges of the transverse incision, cuttino; the ends of the sutures lonfii; enoufjh to reach to the forehead, and then fastening them there with adhesive plaster. The excision of the inner angle of the flap raises the eyelid by shortening its border. Dieffenbach, Adams, and Ammon have proposed other methods of shortening the lid. They are indicated in Fig. 134, where the shaded spaces represent the portions of skin to be removed, and the threads the manner in which tlie edges arc afterward l>i'ought together. Adams's excision included the Avhole thickness of the lid. 256 PLASTIC OPERATIONS OX THE FACE Richet (Fig. 135). — Richet makes an incision parallel to the border of the lid, half an inch below it, and extending nearly from one angle of the eye to the other. The lid, having been freed by this incision, is then united to the other { blepharoraphv ). Fig. l?A. a i^ B Ectropion. A. DiefFenbach. B. Adams. C. Amn.fn. The shaded qiaces indicate the portions of ekin remored : the threads show liow their edges are brought together. He next makes a second incision parallel to the first and one-third of an inch below it, divides the intermediate strip of skin vertically in the middle and dissects up its two halves. Immediately below the lower end of this vertical Fig. 135. Ectropion. Bichet. incision he removes fr( jui the lower border of the second incision a V-s?haped flap of skin, its point directed down- ward. He then raises the two halves of the middle flap, brings them again into contact with the border of the lid, excises their su})erfluous length, and unites them. The sides of the Y are then brought together and the edges of the incisions reunited. PLASTIC OPERATIONS UPON TlIK KYKLIDS 257 Kwipp (Fig. 1'3:>, B). — Kii;i|)}) c'lnploytMl the loll(nv- ing method to remove an epitlielioma occupying the inner portion of the h)wer eyelid, the free border of which was involved. He circumscribed the tumor In' two vertical and two horizontal excisions and excised it. The horizontal in- cisions were then prolonged on both sides, the lower external one being inclinetl downward so as to make the base of the flap broader, the two Haps dissected up, drawn together and united by their vertical edges. Burow (Fig. 1-^0). — The loss of substance is made triangular in shape, the apex directed downward ; the base is then i)rolonged horiz(intally outward, and an equal and similar triangle marked out upon the upper side of the pro- FiG. 13(3. Ectropion. Burow. longation. The skin contained within the second triangle is then excised, and the irregular flap bounded by the outer sides of the two triangles and the prolongation of the hori- zontal incision dissected outward and downward, and then moved toward the median line until it covers both the open spaces. It is not necessary that the two triangular spaces should touch at one corner ; they may be an inch, or even more, apart; but they must of course be connected by the hori- zontal incision. Dieffenbach (Fig. 187). — When the cicatrix or tumor was larore Dieffenbach jjave the loss of substance a trian- gular shape, the apex directed downward. He prolonged outward the horiz(jntal incision forming the base of the 22* 258 PLASTIC OPERATIONS ON THE FACE triangle, and carried another incision downward and inward from its outer extremity. The (juadrilateral flap thus marked out was dissected up and carried inward to cover FiQ. 137. Ectropion. Dieffenbach the loss of substance. The gap left by its removal was then drawn partly together with sutures, and the remainder left to granulate. Indian Method. — Sedillot refers the first blepharoplasty by the Indian method to Von Graefe in 1809. As this was previous to the introduction of rhinoi:)lasty by the same Fig. 138. Ectropion. A. Modified Indian ^Metliod. B. Eichet. method, the idea was probably entirely original with Yon Graefe. The case is mentioned in his BJiinopIastik^ 1818, but without details. The flap can be taken from the fore- head or cheek ; it should be very large and should include the subcutaneous cellular tissue. Fricke, of Hamburg, took a vertical flap from the temporal region to restore the upper eyelid. PLASTIC OPERATIONS UPON THE EYELIDS. 259 Olio of tilt' modifications of tliis method, intoiidc Knapp's modification of Desmarres's forceps. Excision of part of the Cartilage (Streatfeild), (Fig. 145.) — The eyelid is fixed with DesmaiTess forceps (Fig. 144), the flat blade against the conjunctiva, and an incision made parallel to the border of the lid at the distance of one line from it, and carried to a depth sufficient to expose the bulbs of the eyelashes. The sur- geon, raising the edge of the skin, passes around the bulbs to the tarsal cartilage, and then makes a second incision at a greater distance fi'om the bor- der of the lid than the first one was, meeting the .\ fii*st at its two extremities and inclosing with it an ' ; oval strip of skin. These two incisions are carried *" ^j into the cartilage, circumscribing a longitudinal ^ wedge-shaped strip, the apex of which reaches Entn..piun. nearlv to the conjunctival side of the cartilage. ^»'^tf«"«*"'' The wound is left to heal by granulation, with the expectation that the contraction of the cicatrix will overcome the entropion. 3. Symhhpharon. — AVhen the adhesion between the two layei*s of the conjunctiva is incomplete, that is, when it does not extend to the bottom of the sulcus between the lid and eyeball, it is sufficient to throw a ligature around it. After the ligature has cut through, the tabs are successively 264 PLASTIC OPERATIONS ON THE FACE excised, and the borders r>f each wound drawn together or left to heal bv crranulation. To avoid reunion of the sur- faces, the second tab should not be removed until after the wound left by the removal of the first ha,s healed. When the adhesion is complete, but not broad, a thread or silver wire may be passed through its Ijase and tied loosely around it. After the hole made by the wire has cicatrized the adhesion is divided. The narrow line of cica- trix left at the bottom of the fold by the wire favors the separate healing of the two sides of the incision. Arlt's JletJiod. — A thread is passed through the fold close to tlie cornea, and the symblepharon dissected away from the eyeball. Each end of the thread is then attached to a needle and passed through the lid from within outward at the bottom of the wound. By drawing upon the thread and tying it outside the lid the symblepharon is folded upon itself and its point fixed at the bottom of the sulcus. The edcres of the Avound on the eveball are then drawn tou;ether with sutures, the conjunctiva being loosened by dissection, if necessarv. Tealc's Method (Figs. 14u, 147, 148j.— The symble- pharon is separated from the ball of the eye by an incision Fig. U k Fig. 147 Symblepliaiou. 7>/ x M^, B, C The flaps along the line of its union with the cornea and dissected down to the bottom of the fold as in Arlt's operation, its apex, however, being left upon the cornea. Two long, nar- row conjunctival flaps, B and (7, are then dissected up on opposite sides of the eyeball, their bases directed toward the symblepharon. their borders parallel to that of the cornea. These flaps should not include the subconjunctival tissue. PLASTIC OPERATIONS UPON THE EYELIDS. 2(j5 The inner llap H is Idoiiulit down and fastened to the de- nuded surtace of the eyehd, the outer llap covers that of the eyehall. fhey are fastened in place hy means of lin(i sutures, and the edij;es of the i^aps h-ft hy their i-enioval l)rou«fht toujether in the same niunner. Flaps in place. Ledcntus Operation. — Where one lid was adherent throughout its entire lenL!.th, Ledentu divided the adhesion to a depth e(|ual to that of the normal fold, dissected a long conjunctival flap from the other half of the eye, leaving it adherent at both ends, brought it down across the cornea, and applied it to the raw surface left on the eyeball by the division of the adhesion. This flap should be at least one- third of an inch broad. 4. Pterygion. Excision. — The pterygion is pinched up with forceps, a knife passed flatwise under it close to the cornea, and the portion of the growth which corresponds to the latter shaved off". The edges of the conjunctival wound are then drawn together with sutures. Scissors may be used instead of the knife : in that case the incision must begin at the point of the growth. Ligature^ Szokalski (Fig. 14*J). — A thread is pjissed under the pterygion by means of two small curved needles, as shown in Fio". 149. The thread is cut close to the nee- dies, and thus made to furnish three ligatures, one at each end, encircling the crrowth at riu'ht anijles to its long axis, and one in the middle, encircling its implantation upon the sclerotic. The ligatures are tied tightly, and the inclosed portion falls in a few days. o. Trirhiasis. — Temporary removal of the deviated la.slies is seldom eff'ectiial. Permanent removal by destruction of 23 26') PLASTIC OPERATIONS OX TIfE FACE their bulbs, or excision of tlie border of tlie lid, is now con- sidered unjustifiable. The direction of the lashes may be changed by operation upon the lid. The retraction follow- ing excision of an oval strip of skin, or the use of ligatures Fig. 149. Pteryofiou ; liorature. as in entropion, is sometimes sufficient, but it may be neces- sary to act more directly upon the lashes. Von Graefes Metliod. — An incision is made along the free border of the lid on the conjunctival side of the devi- ated lashes. From each end of this a vertical incision is next made through the free border and the skin. The flap thus circumscribed and containing the lashes is dissected up a short distance. It is then easy to fasten it with sutures in such a position that the lashes can no longer touch the eyeball. Anafinostakis made a cutaneous incision parallel to the border of the upper lid and one-eighth of an inch from it, exposed the orbicular muscle by drawing the skin up, and excised that portion of it which corresponded to the upper part of the tarsal cartilage. The lower edge of the cuta- neous incision was then drawn up and fixed to tlie fibr<:)- cellular laver coverino; the cartilasje bv means of three or four sutures, which were then allowed to cut tliem.selves out. PvVllT YIl. 8PEC1AJ. 01M<:ilAT10NS. CILArTEll I. OPERATIONS UPON THE EYE AND ITS APPENDAGES. Ix most operations upon the eye the lids should be held back by an cye-speculuni (Fig. 150), and the eyeball Fig. 150. Eye speculum. fixed by pinching up a fold of the conjunctiva with toothed forceps. The instillation of a few drops of a four per cent, solution of the hydrochlorate of cocaine under the lids will make most operations painless, but the sensitiveness of the iris is not thereby abolished. THE CORNEA. Removal of a Foreign Body. — When the foreign body has penetrated to only a slight depth, it may be easily removed 268 OPERATIONS UPON T H R EYE. with the point of a kniib or fine forceps ; hut. if it lies so near the posterior surface of the cornea that there is danirer of forcin^o; it through into the anterior chamber b}^ the efforts made for its extraction, a lance-shaped knife must be entered very obli([uely and passed behind it, between the layers of the cornea if there is sufficient space, otherwise Avithin the anterior chamber. If the foreign body falls into the anterior chamber, not- withstanding these efforts to prevent it, the surgeon must wait until the aqueous humor has reaccumulated, and then make an incision three or four millimetres in length at the lower portion of the periphery of the cornea, in the hope that the foreign body will be washed out durinir the flow of the liquid. Puncture of the Cornea. — This may be made with broad needle or a well-worn Beer's knife. It is advisable to em- ploy anesthesia, and to steady the eyeball with fixation forceps. The surgeon stands behind the patient, raises the upper lid, and fixes it against the margin of the orbit with two fingers of his left hand, Avhich also rest against the inner side of the eyeball and prevent it from rotating inward. The needle or knife is then entered a little in front of the edge of the cornea at the outer side. Its direction must be sufficiently oblique to avoid injury to the iris, and not so much so that the instrument Avill remain between the layers of the cornea and fail to penetrate to the anterior cham- ber. By partly withdrawing the instrument and twisting it slightly, the incision is made to gape and allow the escape of the liquid ; or a fine blunt probe may be passed into the incision after entire withdrawal of the needle. Subse([uent tappings are effected by reopening the original wound with the probe. Figure 151 represents a combined needle and probe. The needle is provided with a shoulder to prevent its introduction to too great a depth. Removal of a Staphyloma. — The best treatment is now thouo-ht to be enucleation of the eve. but evisceration of the globe is sometimes done. Evisceration. — The sclerotic is incised with a Beer's knife just in front of the insertion of the external rectus: into the TllK CORNEA. 269 Fig. 151. Fiu. 152. Stop nettlle and probe for pancturiDg the cornea. Beer's knife. 2a* 270 OPERATIONS UPON THE EYE. opening is passed one blade* of a pair of small blunt-pointed scissors, and the anterior portion of the glol)e is cut a^vay, with the lens and all tlie vitreous humor. The Avound is then closed witli catgut sutures passed through the con- junctiva alone. THE IRIS. Iridotomy. — Incision of the iris may be performed for tlie purpose of establishing an artificial pupil. As its success depends upon the retraction of the divided fibres, it should be undertaken only when their contractility is not interfered with by too extensive adhesions, or has not been destroyed by disease. The more common lesions to Avhich the opera- tion is applicable are central opacity of the cornea, occlusion of the pupil, and excessive prolapse of the iris after removal of a cataract ; but the danger of injury to the lens is so great that the operation is practically restricted to the class of cases last mentioned. The best place for an artificial pupil is in the lower inner (juarter of the iris, the second best in the lower outer quarter. As the portion of the cornea traversed by the knife or needle is likely to become more or less opaque in consequence, the incision in it should be made as far as possible from the point where the pupil is to be created. Simple Incision. — Cheselden, who was the first to per- form this operation, entered a narrow-bladed knife through the sclerotic just anterior to the insertion of the external rectus, the point directed toward the centre of the globe of the eye. After the point had penetrated to the depth of one-eighth of an inch it was directed forward, passed through the iris to the anterior chamber and transversely across the latter, its edge looking backward. By pressing the edo-e against the iris and withdrawincr it a horizontal incision was made in that membrane. Bowman punctured the cornea midway between its centre and external border, passed a narrow blunt-])ointed knife through the puncture into the anterior chamber, and thence through the pupil to the posterior surfoce of the inner half of the iris, which he then divided bv cutting- forward. The danger of injury to the cornea during the last step of the operation is very great. 'I' UK IK IS. 271 Hell' uses a (l()iible-e«lgc(l iiccdk! Avliich is " iiitrodiircil througli the cornea near its ni;!r