PANCOAST^S OPERAIOT WITH 8 0 PLATES Columbia SnitiErsitp intljECitpof Jlttogoci^^ ^ College of $li;sicians anti ^ucgeiins Eeferemc ILibrarp ) VALUABLE WORKS ON MEDICINE, SURGERY, CHEMISTRY, &c. &.c HAVE RECENTLY PUBLISHED. PRICE FOUR DOLLARS, ELLIOTSON AND STEWARDSON'S PRACTICE, PRINCIPLES AND PRACTICE OF MEDICINE, BY JOHN ELLIOTSON, M.D., F. R. S. Preaideniof Ihe Koyal Medical and Chinirgical Society; Ule Professor of the Principles and Fraciiceof Medicine, and of Clinical Medicine, and Dean of the Faculty of Medicine in UniyeraUy- Collegej Loudon; Iwe Senior Physician la the Univeraity-ColUge Hospital; FeUow of the Koyal Coilese of Physicians, and President of the Royal Medical Society of Edinburgh. Edited by Nathaniel Rogers, M. D. Member and late President of ihe Hunterian Society of Edinburgh, and Corresponding Member of the Medico-Cliirurjical Society of Dublin, And ALEXANDER COOPER LEE, Esq. of University College, London. Greatly Unlarged, Improved, and Adapted to the United l^tatcs, BY THOMAS STEWARDSON, M. D. Physician to the Pennsylvania Hospital, elc. COMPLETE IN ONE VOLUME ROYAL OCTAVO-FULL UOLJND-J030 PAGIiS. PRICE FOUR DOLLARS. PREFACE OF THE SECOND LONDON EDITION. Whbs this work first appeared, it had to compete with several long established favourites, and to encounter some deeply rooted prejudices on the part of men who strongly dissented from Dr.Elliotson's views on certain subjects. In spite of these obstacles, however, its reception has been more flattering than we dared to antici- pate. The first impression was rapidly exhausted; it became the favourite class-book in the majority of our medical schools; and even those who were formerly strongly prejudiced against it, have since acknowledged the practical information they have derived from its perusal. All this is highly satisfactory; and were any- additional proof of its sterling worth required, it would be furnished by the fact that the Germans have published a translation. In entering on the task of preparing for publication a second edition, we have been stimulated by the success of the first to fresh exertions, in order to render it (if possible) still more worthy of the approbation it has received. With a view to the accompUshment of this object, we have ventured on making certain additions and alterations; which, without materially increasing the size of the book, will (as we believe) materially enhance its ralite. Much care and discrimination were neces- sary in making these additions, — both as to the material to be selected, and the mode of its insertion; otherwise the book would have been injured, rather than im- proved. We have therefore been careful only to remedy obvious deficiencies, and to make such other additions as more recent researches have rendered necessary. The sources whence this supplementary matter has been taken are various; but we have of course been guided to a great e.xtent, by public opinion; — making our selections from those works which seemed best entitled to our confidence, for their general accuracy and soundness of doctrine. For the purpose of rendering these additions as useful as possible, it has been deemed advisable to insert them within brackets, in the text; — taking care, however, to preserve the continuity of the whole; and Ki acknowledge, in a foot-note, the source whence each quotation was derived. Some other ilhtstrative extracts, often very interesting in a literary point of view, and all bearing ou some medical observations in the text, have been inserted as foot notes. The alterations that have been made, though few, are such as have been dictated by a desire to consult the convenience of the reader. The subjects have been grouped together, in conformity with Dr. Elliotson's own views ; and divided into parts, books, chapters and sections. Page-headings and side-titles have been intro- duced: which, together with a copious index, will (it is hoped) enable the reader to refer to any particular passage with perfect ease. We may also add, that the work has been printed with a smaller, though clear and distinct type; — for the purpose of enabling us to add about two hundred and fifty pages of new matter, without materially enhancing the size or price of the book. These are the alterations we have deemed it necessary to make. In the performance of our task, we have been actuated (at every step) by a sincere and ardent wish to render the volume worthy of the reputation which Dr. BUiotsou has so justly acquired, both as a teacher and physician. In working out this design, we have received every assistance from the enterprising publisher, who has spared no expense either in the literary or the printing department; — being anxious to raise this distinguished member of his series of medical text-books to a degree of excellence commensurate with the favour it has received. Whatever approbation or censure may be bestowed on our labours as editors, we feel quite certain that the valuable materials contained in this book, will always meet with the respectful consideration due to genius and industry, when directed to the alleviation of human misery. OPINIONS OF THE PKESS. Almost every subject exhibits great research and acumen, original and comprehensive views, and an extensive acquaintance with Physiology, Pathology, and all Ihe known resources of the healing art. Some affections which are scarcely noticed in other works (such as Glanders, Hay-Asthma, &c,) are also considered; and tliere is much interesting detail connected with these topics. In addition to sterling practical matter, in which the work everywhere abounds, we have all the charm of varied and lively illustration; — drawn, not merely from writings strictly Medical, but from the pages of History, Poetry, and general literature; so that the casual reader would be surprised to find many parts of the book as entertaining as a novel : for instance. Idiocy, Insanity, and other topics. The Doctor has not thought it necessary to be crabbed and technical, dry and repulsive. He has evidently striven to render his subject inviting to his auditors, that he might win their affections and attention, and thus inculcate the more successfully the important truths he had to convey. We are also happy to bear testimony to the spirit of candour and fairness that the work exhibits. After a diligent perusal, we have formed the highest opinion of this edition of Dr. ElHotson's " Principles and Practice of Medicine." It is the most modern work on the subject; and is every way calculated to represent to foreigners the present slate of practical medicine among the best practitioners of our country. We think it unnecessary to recommend it; because it will recommend itself, and command success by its own intrinsic merits. The Editor, Dr. Eogers, has acquitted himself in a very admirable manner; and we cordially assent to all that he claims in the Preface. He also deserves the negative commendation of not encumbering the text wiih multifarious notes. Most readers prefer to judge and compare for themselves. We have only to add, that itforms a goodly volume, containing upwards of 1100 octavo pages, printed in a bold and clear type, and published at a very moderate price. — Medico-Ckirurgical Review. It is very gratifying to meet with a work replete with sound and valuable matter; — with golden rules of precept and practice, derived from the writer's long expe- rience and observation ; and in which all the resources of a well-cultivated mind are brought to bear upon and illustrate the subject lo which its energies are addressed. Such a work is the one before us; in the production of which Dr. EUiotson has been induced to acquiesce, under the editorship of one who has proved himself well worthy of the ofiice. — Dublin Medical Press. It will be generally admitted, that lo an extensive acquaintance with physiology and pathology. Dr. EUiotson unites the faculty of accurate diagnosis, and acute discrimination of the best methods of treating disease. Few, we ihink, will be disposed to question his zeal and activity as a physician, and as a teacher of the prin- ciples and practice of medicine; or the judicious views, philosophical deductions, and sound methods of treatment here developed. Almost every page teems with valuable informadon. The details connected with insanity, and some other topics, are so illustrated and enlivened by curious facts from the writings of poets, histo- rians, and philosophers, as to render them highly entertaining, apart from the important practical matter with which they are interwoven. Much praise is due to the Editor, for the exemplary manner in which he has acquitted himself. He has not overloaded the text with superfiuous notes ; but has appended just so much as was necessary for the purpose of illustration, and to fill up some hiatus. He has also considerably improved the language. We strenuously recommend the work to all who feel interested in the advancement of Practical Medicine. — London Medical Gazette, The auihor has been long honourably distinguished as standing in the foremost rank of those who have formed a corps of obser\-ation for the purpose of exploring the recesses in which those terrible foes of the human race, phthisis and its allies, had hitherto reigned in almost undisturbed dominion. His language is simple and nervous, and remarkably free from lechnicahties, and inflated epithets; while his style is of that pleasant, faiTiiliar kind — neither too bold nor loo florid — which accords well with the subject and the occasion. The medical world is under great obligations to Dr. Rogers, for having undertaken the editorship of this work. He has evidently bestowed great pains in amending the text, correcting reporters' mistakes, and supplying deficiencies; — in every way proving himself a faithful Achates. We cannol entertain a doubt, that this work — embodying as it does, the mature experience of an able and accomplished physician — will be welcomed by all classes of the profession. We predict for it a wide circulation, and the warm encomium of every one who becomes possessed of it. Less than this wiil not be commensurate with its high deserts, — Dublin Journal. The best work for the study of diseases is "ElUotson's Practice of Medicine," by Rogers. — Lancet. As a bold and original thinker, an eloiiuenl and forcible writer, a judicious and experienced practitioner and teacher, his reputation was already established : so that his lectures only required more systematic arrangement, and filling up in cerlain portions, which had been but briefly treated of, to give them immediate cur- rency as a standard work on the practice of medicine. This was accordingly done under the superintendence of editors, who have added much valuable matter from various sources. Under such circumstances we cannol but congratulate the profession in this country that it has now been placed wilhin their reach, under the auspices of an editor whose ample experience and especial study of fevers, have enabled him to add several chapters and notes, which materially enhance the usefulness of ihis treatise. We refer, in particular, to Dr, Stewardson's chapter on Remittent and Yellow Fevers, diseases so prevalent in many sections of this country, and which had received but very cursory notices in the original work. Dr. Stewardson has given an account of Cholera Infantum, a disease peculiar to this country, and which therefore rarely attracts the attention of European writers. — Arnerican Medical Journal, January 1844. NOW COMPLETE IN ONE QUARTO VOLUME, [Second Edition,) QUAIN'S ANATOMICAL PLATES. . FOR FIFTEEN DOLLARS. A SERIES OF ANATOMICAL PLATES, TVith References and Physiological Comments illustrating the struc- ture of the different parts of the Human Body. Edited by JONES QUAIN, M. D., Member of the Senate of the University of London. W. J. ERASMUS WILSON, Lecturer on Anatomy and Physiology at the Middlesex Hospital. With Notes and Additions by JOSEPH PANCOAST, M. D., Professor of Anatomy in the Jefferson Medical College of Philadelphia, Surgeon to the Philadelphia Hospital, &c. &c. The Plates are accompanied by letterpress, containing detailed references to the various objects delineated. But with a view to render them intelligible to a greater number of persons, a running commentary on each plate is given, stating in general terms, and divested, as far as can be, of all technicality, the uses and purposes which the different objects serve in the animal economy. The work consists of the following divisions: — THE MUSCLES OF THE HUMAN BODY; Fifly-one Plates. THE VESSELS OF THE HUMAN BODY; Fifty Plates. THE NERVES OF THE HUMAN BODV; Thirty-eight Plates. THE VISCERA OF THE HUMAN BODY, including the Organs of Digestion, Respiration, Secretion and Excretion; Thirty-tn:o Plates. THE BONES AND LIGAMENTS; Thirty Phles. TERMS OF PUBLICATION. This work is now complete in one splendid Royal Quarto Volume four hundred and fifty pages of Leiierpress Description, and two hundred splendidly engraved Plates, containing seven hundred and twenty-six figures, and executed with the greatest accuracy, under the supervision of Professor PANCOAST. The price, neatly bound in Full Cloth, and Lettered, is FIFTEEN DOLLARS a copy, payable on delivery. Even in these days of cheap literature, no work has been offered to the public on such moderate terms, and it is only by an extremely large sale that the pub- lishers can hope lo be repaid for their great expenditure. Although the publishers deem any further remarks unnecessarj', they cannot refrain from requesting the gentlemen of the Medical Profession to compare the Work, both as lo price and style of execution, with any other thai has appeared in this country, feeling assured that such comparison will prove the truth of their remark, that it is the CHEAPEST WORK EVER OFFERED TO THE AMERICAN PUBLIC. CCj* Persons desirous of subscribing to this work are requested to address CAREY & HART, Publishers, Philadelplm, {post paid,) enclosing FIFTEEN DOL- LARS, COMPANION TO QUAIN'S ANATOMY, NOW READY, OPERATIVE SURGEHY; Or a Description and Demonstration of the various processesof the Art; including all the new Operations, and exhibiting the state of Surgical Science in its present advanced condition: with Eighty Plates, comprising four hundred and eighty- six separate illustrations. By JOSEPH PANCOAST, M.D., Professor of General, Descriptive, and Surgical Anatomy, in Jefferson Medical College, Philadelphia .■ Lecturer on Clinical Surgery, and one of tlie attending Surgeons at tfte Philadelphia Hospital, S(c. S(c. TERMS OF PUBLICATION. The work is completed in one splendid Royal Quarto Volume of 390 pages of Letterpress Description, and Eighty splendidly executed Plates, many of which contain several Figures, and execuied with the greatest care, by P. S. Duval, under the direction of Phofessor Pancoast. The price of the work, neatly bound in cloth, lettered, will be Tbs Dollaiis a copy, payable on delivery. As specimens of both letterpress and plates can be had on application, it is of course unnecessary for the publishers to say more than thai the entire work will he found lo correspond in every respect with the specimens. CAREY & HART, Publishers. May 1, 1844. (Xj" Persons desirous of subscribing to this work, are requested to address CARE Y ^ HART, Publishers, Philadelphia, (post paid,) enclosing Ten Dollars. CAREY & HART WILL SHORTLY PUBLISH A TREATISE ON THE DISEASES OF THE GENITO-URINARY ORGANS, Including the affections of the Kidney, Bladder, Frosiale, and Urethra, by MEREDITH CLYMER, M. D., Lecturer on the Institutes of Medicine, Physician to the Philadelphia Hospital, Fellow of the College of Physicians, etc. etc. laOREAU'S GREAT WORK ON SOIDWIFERT. A COMPLETE SYSTEM OF MIDWIFERY, BY F. G. MOREAU. Translated from the French, and edited by PAUL BECK GODDARD. In one large 4to. volume, with Eighty splendid Plates. Uniform with "Quain's Anatomical Plates." CODDARD OJV^THE TEETH. THE ANATOMY, PHYSIOLOGY, AND DISEASES OF THE TEETH AND GUMS. Willi the most approved melhofis of Treatment, including Operations, and a general account of the method of making and setting Artificial Teelh, BY PAUL BECK GODDARD. M.D., Demonstraior of Aiialomy in the University of Pennsytoania. In one Quarto Volume. Illustrated by thirty beautifully executed Plates, each coiiiaining numerous Figures, handsomely bound in Cioth Gilt. Unilbrm with "Quain's Anatomy," and "Pancoast's Surgery." Price Six Dollars, full bound in cloth. This work is designed to furnish the practical Dentist and country Physician with a full account of the Anatomy, Fhysiohgy, and Pathology of the Teeth, with the remedies proper in each case. It also contains full directions for the making and setting of Artificial Teelh, The Anatomy contains an account of the micro- scopic structure, which has recently been so highly developed, and which throws much light on (he changes produced by various agencies, chemical and me- chanical. The physiological portion contains the description and development of the growth of the teeth, both temporary and permanent. The pathology comprises the diseases of the leeih, with the appropriate treatment, including scaUng, filing, plugging, extracting, &c. &c. The last portion is devoted to the making, colour- ing, and setting artificial teeth, particularly those known by the title of Incor- ruptible. The practical details included in the last section were furnished by a Dentist who is thoroughly acquainted wilh his profession. The plates which illustrate every point of value or importance are of the full quarto size, and in almost every instance are given from nature, and their execution is of the best character. The pubhshers refer with pleasure to " Quain's Anatomical Plates," to which the present volume is intended as a companion. Notice from ike American Journal of Medical Science; "The account of the structure of the teeth is a very valuable one, and is illus- trated by some remarkably well executed views of their microscopic structure. The chapter on the origin and development of the teelh, is an extremely interest- ing one, and contains a full account of Mr. Goodier's recent investigations. The causes of decay are very fully stated, and the explanation of the manner in which the ivory of the tooth is destroyed, whilst the enamel seems almost perfect, is the most satisfactory we have seen offered. We must add, that the work is got up in the handsomest manner. The plates are indeed the best specimens of litho- graphy we have seen executed in this country." CURLING ON THE TESTIS AND SPERMATIC CORD. A PKACTICAL TREATISE ON THE DISEASES OF THE TESTIS, AKD f)F THE SPERMATIC CORD AND SCROTUM. BY .T. B. CURLING, Lecturer on Surgery, and Assistant Surgeon to the London Hospital, and Author of "A Treatise on Tetanus," EDITED BY P. B. GODDARD, M.D., Demonstrator of Anatomy in the University of Pennsylvania. 1 vol. 8vo. Pull bound. Price $3 25. " Mr. Curling has been at great pains to collect correct and useful information on the diseases of the testis from all the best sources, and his work must be allowed to be the fullest and most correct systematic treatise on the subject ex- tant. The illustrations with which the volume is accompanied cannot fail to be extremely useful to the student of surgery and surgical pathology." — Edinburgh Medical and SurgicalJoumal. "The revolutions produced by time in every fresh age are as remarkable in literature as in all other things. Our forefathers' heavy tomes, muHum in parvo dictionaries;, and " general treatises" have quite passed away, and a new class of works has taken their place. Such is the past and present. Of what the future will produce may be inferred from the writings of the young and rising men of our profession, who are now our cotemporaries. The advance will be imnorlant. At present the inclination amongst them is to devote the mind to some one object, in the study of which excellence may, wilh talent and perseverance, be ultimately attained. We have shown that spirit in exercise in a recent review of an original treatise on that previously ill-treated subject, the diseases of the skin, by M. E. Wilson; and we have another instance of it in the work of Mr. Curling, a diligent labourer, who has carefully collected every fact within his reach, relative to the diseases of the testis and spermatic cord, producing a volume thai may jor many years be the standard work on those diseases. We shall conclude our notice wiih an extract relative to a new and promising method of treating varicose veins, and take leave of the volume by warmly recommending that it be added to the library of every surgeon." — London Lancet, August, 1843. " Goddard's Cur/in^.— Messrs. Carey & Hart, Philadelphia, have unquestiona- bly the credit of publishing the most beautifully executed Surgical work that has yet appeared on this side of the Atlantic. The printer, Mr. Sherman, has proved that wood engravings may be as well printed here as in Europe. "This faithful reprint of Curling's admirable volume supplies a desideratum to the surgical literature of the day, having been carefully revised and enriched by several judicious notes by Dr. Goddard. All surgeons and practitioners who have occasion to treat patients suffering from hydrocele, orchitis, or other diseases of the same locality, will be glad to possess this volume, being filled as it is, wilh practical instruction for the management of some of the most afflicting diseases man is heir to. " This intimation of the existence of a valuable and beautiful surgical book ought to be sufficient to induce practitioners, as well as students, to seek for, and ex- amine it themselves." — North American. ENCYCLOrEPIA OF CHEMISTRV. NOW READY NO. 1, PRICE 25 CENTS. THE ENCYCLOPEDIA OF CHEMISTRY, THEORETICAL AND PRACTICAL. Presenting a complete and extended view of the present state of Chemical Science, wilh its numerous and important applications to Medical Science, Agri- culture, the Arts, and Manufactures; based upon the plan of the Dictionary of Chemistry, by Dr. Ure, and the Dictionary of Theoretical and Practical Chemistry, now publishing by Liebig, Poggendorf, Woehler, &c. BY JAMES C. BOOTH. Member of the American Philosophical Society, and of the Academy of Natural Sciences, Professor of Technical Chemistry in the Franklin Institute, and of Elementary Chemistry in the Philadelphia High School,- MARTIN*H. BOYE, Member of the American Philosophical Society. The facility for easy reference oflered by the Dictionary, (rendering that form preferable to any oiher for works on science and the arts,) has induced the author to adopt it in ihe publication of an ENCYCLOPEDIA OF PRACTICAL AND THEORETICAL CHEMISTRY, which, while it will embrace all the latest discoveries in the pure science of chemistry, shall at the same time exhibit the manifold applications of chemical principles and theories to every department of the useful arts. The rapid advancement of chemical science in the path of discovery within a few years, has created a demand for treatises upon this subject which has not been fully answered by the several elementary works lately issued from the English press. While these works must be mentioned with unqualified praise as text-boobs for the student of chemistry, it must at ihe same time be acknowledged that since they offer little more than an outline of the science, they cannot satisfy the thirst for more extended treatises, which may be employed as valuable works of refer- ence by the advanced scholar, while their practical tendency shall enable the uninitiated to enter actively into the vast field of research. The ENCYCLOPEDIA OF CHEMISTRY is designed to meet the varied wants of the student of science, the physician, the agriculturist, and the manu- facturer. The first and second will find the whole theory of chemistry fully de- veloped, as contained in the original essays of all the great and leading chemists, among whom we place Berzelius, Liebig, Woehler, Rose, Mitscherlich, Zeisse, &c., Dumas, Pelouze, Fremy, &c., Graham, Kane, Hare, and many others in Eu- rope, and in our own country. They will find all the important recent discoveries in organic and inorganic chemistry, and practical treatises on the several branches of analysis. The sciences of Mineralogy and Geology will receive their full share of atten- tion, more especially in their chemical relations, and where they admit of such application. It will be seen from the hasty sketch of Ihe design of the work presented above, that it is intended as a complete Encyclopedia of Chemistry both in theory and practice, and that while the pure theoretic nomenclature will be adopted in the one part, the second shall be so developed as lo bring it within the reach of those not fuiiy conversant with chemical principles. TERMS OF PUBLICATION. This work will appear in semi-monthly numbers, and in addition to numerous wood cuts, will contain many beautifully engraved plates, and will be completed in Twenty Numbers, at 25 cents each, CAREY & HART, Publishers. IN PRESS, A WORK ON SURGICAL DISEASES. With about seventy finely engraved Plates, illustrative of the Pathology, and various methods of treatment. In one 4to. volume. CATALOGUE OF AN EXTENSIVE COLLECTION OF BOOKS ON MEDICINE, SURGEEY, CHEMISTRY, BOTANY, &o. FOR SALE BY BOOKSELLERS, PUBLISHERS, AND IMPORTERS, CORNER OF FOURTH AND CHESNUT STS., PHIIiASSIiPHIA. C. & H. receive immeJiately on publication, every new work on Medicine, Surgery, and the collateral Sciences, Books imported to order from England, at the rate of 25 cents the shilling retail, and from France at ihe rale of 25 cents the franc. Oif' The prices annexed lo the catalogue, are those usually charged in Philadelphia for a single book, A liberal discount will be made from those prices to those who purchase to a large amount. Armstroug's Lectures on Acute and Chronic Diseases. Ediied by J. Bell, M. D, 3 vols. 8vo. 3 00 Abercrombie on the Diseases of the Stomach. 8vo. 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Price, well bound in leather, only Four Dollars. Published by CAREY & HART, Philadelphia, and for sale by all BookseDers. A TREATISE OPEKATIYE SURGEKY; COMPRISING A DESCRIPTION VAEIOUS PROCESSES OF THE AET, INCLUDING ALL THE NEW OPERATIONS; EXHIDITINO THE STATE OF SURGICAL SCIENCE IN ITS PRESENT ADVANCED CONDITION; COSTAnnc four IIIJNDRED AUD EIBniT-SIX SEPJffiATB ILMSmTWIlS. BY JOSEPH PANCOAST, M.D., PEOFESSOR OF OENERAL, DEaCBIPTrVE AUD BUBOICAL ANATOM:? W JEFFEBSON MEDICAL COLI^EGE, PHILADELPHIA, LECTUREE ON CLINICAL SURGERY; ONE OF THE ATTENDmO BUEOEONS AT THE PHILADELPHIA HOSPITAL, ETC. ETC. PHILADELPHIA: CAREY AND HART, 126 CHESNUT STREET, FOR G. N. LOOMIS. 1844. P/? Entered, according to the act of Congress, in the year 1844, by JOSEPH PANCOAST, M.D. in the Office of the District Court of the United States in and for the Eastern District of Pennsylvania. T. K. & P. G. COLLINS, PKINTERS. ADVERTISEMENT. The necessity of thoroughly illustrating the operations of Surgery, has been felt from the earliest periods of the art, as a means of rendering the processes for their performance, intelligible to the student. Almost every modern surgeon of distinction, and especially Camper, Scarpa, Cooper, Hesselbach, Bell, and Dupuytren, have, in par- ticular departments of the science, contributed much to the attainment of this most desirable end. The attempt to collect the newest and completest modes of illustration into a continuous whole, has been made but in two instances,' — by M. Froriep of Berlin, who has issued them in numbers without any other regard to order than the time of their appearance, and by M. Bourgery of Paris. The voluminous and expensive character of these works, and especially of the latter, which is as yet but little more than half completed, as well as their being clothed in a foreign language, renders them in a great degree inaccessible to the American surgeon. With these admirable treatises before him as a guide, and having at hand the greater portion of the surgical works, which have recently appeared in various languages, and with the advantage which nine years continuous service in one of the largest hospitals of North America has given him, not only in comparing to a certain extent the value of the different methods, but in enabling him to obtain a large number of accurate drawings of operations which have been done by his own hand, the author has endeavoured to furnish a work that shall represent, so far as its limits will allow, the operative surgery of the day. In pursuance of this desire to portray the actual state of the science, many processes of operation have been given, for which the author cannot hold himself any farther responsible, than of having made of them a clear and impartial statement, drawn from the most authentic sources. The description of processes, too often given obscurely by their inventors, is confessedly difficult, and the author has not hesitated, when he believed he could thereby render their details more plain, to risk occasional repetition. The drawings, in almost every instance, have been represented in such a point of view, that the examiner may, in the stage of the process immediately shown, consider himself as the operator. In order to render the work still more useful to the practitioner, a brief but comprehensive description of the surgical anatomy of the parts immediately concerned has been added, as well also as some account of the patholo- gical changes, when this was deemed necessary to the comprehension of the operation in question. It has not, however, been possible to enter into a discussion of the claims of different surgeons to particular processes, or to detail in full the therapeutical management of surgical affections, which would have expanded the work to an immoderate size. Some brief observations have, however, in the latter respect been given, in order to assist those in forming opinions who have not other means at hand for consultation, but without invalidating the claims of this work to be especially considered as a Practical Treatise on Operative Surgery. In the prospectus, the work was announced as consisting only of seventy plates, containing two hundred and fifty separate figures, with from two hundred to two hundred and fifty pages of illustrative text. But as these limits were found too restricted for so copious a subject, the publishers, with a liberality that does them honour, have consented, without increasing the price to subscribers at the time of publication, to its extension to its present dimensions, which will be found to consist of eighty quarto plates, comprising four hundred and eighty-six separate illustrations, and three hundred and eighty quarto pages of description. I CONTENTS. PAET FIRST. ELEMENTARY AND MINOR OPERATIONS. t. Division of parts with the bistoury and si With the bistoury, .,.-.-! Straight incisions, - - - • - - i: Compound incisions, - - - - ■ - 1 : Incisions from within outwards and from right to left, - - 1! Incisions with the bistoury upon a director, ■ - - 1' IncisioQ with the scissors, ... - - i; Punctures, i; n. Division of parts by ligature, ..... H III. Phlebotomy or blood.lelting in general, , . . . li Venesection at the bend of the arm, [. . - - II foot, II neck, ..... II near the part affected, . . . - 1! Bleeding by incisions from the cephalic vein, . . - 1! IV. Arleriotomy, - - - - - - - 1! V. Cauterization with potential cauteries, - - - - 2i with the metallic or actual cautery, or surgical pyro- technics, 2: VI. Reunion by suture, 2 Rules for the application ofsutures in general, . - - 2 Individual sutures, ...... 2. VII. Of the seton, ....... 2 VIII. On the formation of an issue or fontanel, - • - - 2 IX. Moxa, 2 X. Acupunc I u ration, 2 XI. Means of preventing hsemorrhage or surgical hcemosiatics, - 2 1. Of (he mode of compression in general. With the hand, - 2 Mechanical compression, - .... 2 Compression of the individual arteries, . . - 3 2. Means of arresting heemorrhage during operation, - - 3 3. Means of arresting arterial htemorrhage after operation, - 3 4. Means which have been applied to the arteries of small and medium size only, ...... 3 PART SECOND. GENERAL OPERATIONS, OR THOSE PRACTISED WITH REFERENCE TO ONE OR MORE PARTICULAR TISSUES. I. OpERATIOSS CPOW THE VeISB, ..... 3 Transfusion of blood, 3 Varicose veins, 3 11. OpERATioss UPON TUB Arteries, . . - - . 3 Ligature of the arteries in their course, - - - 3 different arteries, .... 3 — arteria innominata, - - - - 4 common carotid. Place of election, - - i at the place of election or upper third of the carotid, . 4 ■■ ' ' at its lower part. Place of necessity, - - 4 of ihe external carotid, - ... 4 2 Ligature of the superior thyroid, .... lingual artery, - facial ..... — occipital ..... posterior auris, ..... temporal ..... Ligature of the arteries of the upper extremity, - Ligature of the subclavian artery, .... outer portion of the artery or over the first rib, - — between the scaleni, .... within the scaleni, .... of the branches of the subclavian, ... — . axillary artery, . - - - . 1. above the pectoralis minor, called the high operation upon the axillary, and sometimes spoken of as ligature of the subclavian below the clavicle, 2. behind the pectoralis minor, (Desault) . . - 3. in the armpit, ..... Ligature of the brachial artery, - .... at the middle part of the os humeri, . - - immediately above the elbow joint, ... at the bend of the elbow, . - . , of the arteries of the forearm, .... radial artery, ..... arteries at the upper third of the forearm, middle or lower third, on the back of the wrist, .... of the ulnar artery, ..... near the termination of its upper third, ■ either at the middle or inferior third, below the pisiform bone, of the anterior inlerosseal in the lower half of its course, Ligature of the arteries of the trunk, .... Ligature of the abdominal aorta, .... iliac arteries, ..... internal iliac, ..... primitive or common iliac, ... external iliac, ..... epigastric artery, .... gluteal artery, ..... — ■ ischiatic artery, - internal pudic, ..... Ligature of the femoral artery, - . . - . 1. above the profunda or at the crural arch, 2. at the upper fourthofthe thigh below the profunda, 3. in the middle third or under the sartorius, 4. at the inferior third as the artery passes through the sheath of the adductor magnus, Ligature of the popliteal artery, ..... 1. usual process for the upper part of the popliteal, 2. by incision upon the inner side of the ham, . Ligature of the arteries of the leg, .... Ligature of the anterior tibial upon the leg, in the middle or upper third, on the dorsum of the fool, posterior tibial, .... - — — — in the upper third of the leg, at the middle third of the leg, CONTENTS. • Ligature of the posterior tibial behind the malleolus internus, 81 — ^ peroneal artery, - - - - - 82 III. Opehatioss roit Diseases op tkb Bonbs akd Joints, . - 83 Hydrarthrosis — articular dropsy, - - . - 83 Foreign bodies or movable cartilages in the joints, - - 84 Foreign bodies or movable cartilages in the bursal sheaths of the tendons, ... - . - 85 Ganglions or synovial cysts — hydatiform cysts, - - - 85 Hygroma — enlarged bursEe mucosre, . - - - 87 Dropsy of tbe bursEe, ------ 87 Anchylosis, ,.-----87 Complicated fractures and luxations, - - - - 91 Pseudo-Arthrosis — False joint — Ununited fracture, - - 92 Deformities from the irregular union of fractured bones — Vicious or deformed calius, - - - - - 95 Eiostosis, 96 Cysts in the bones, 97 Caries and necrosis, ------ 98 Spontaneous and artificial cure of necrosis, - - - 99 Extraction of the sequestrum, ----- 100 Operation for caries, . - . - . 100 Trepanning or Trephining of the bones of the cranium, - 101 ResecHon of Ike bones, 106 General rules for resection, ----- 107 Resection of the bones of the trunk, . - - - 108 , jace in general, - - - 108 lower jaw, - - - - - 112 — upper jaw, ----- 108 Partial resection of the sternum, - - - - 1 15 of the ribs, - - - - - 1 15 of the pelvic bones, - - - - 117 Resection of the clavicle, ----- us Partial resection of the scapula, - - . - , 119 Resection of the shoulder joint, - - - - - 119 of the elbow joint, 121 of the radius, - - - - - - 125 of the wrist joint, ----- 135 of the metacarpal bones, - - - - 127 of the me tacarpo -phalangeal joints, - - - 127 of the head of the os femoris, . - . 128 of the knee joint, ----- 139 of the fibula, ------ 139 of the ankle joint, - - - - . 130 of the tarsal bones, - - ' - - - 131 of the first metatarsal bone, - - - - 132 of the metatarso-phalangeal articulation, - - 132 of the metatarsal bones entire, - . - 133 IV. Ampctatiohs, 133 Amputatiom in general, ------ 133 Place of election, 133 Instruments, 133 The position of the patient, the surgeon and his assistants, - 134 Method of operation, - - - - - - 134 Ligature of the vessels and dressing of the stump, - - 136 Mfeciai. amputations — Uppbh extremity, - - - . 137 1. Of the Hand, ------- 137 Amputation of the phalanges, ----- 137 at the two phalangeal joints, - - . 137 i of ihefingersincontinuityorthrough the phalanges, 139 in the metacarpo-phalangeal articulations, - - 139 of the four fingers together, - - - 140 -,. - . in the continuity of the metacarpal bones, - - 141 of the metacarpal bones separately, - - 141 in the metacarpo-carpal joints, - - - 141 in the metacarpo-carpal joint of the thumb, - 141 of the metacarpal bone of the little finger, - 143 of the metacarpal bones of the 2ii, 3d, and 4lh fin- gers at their junction with the carpus, - 143 Amputation of the four metacarpal bones of the fingers together at their metacarpo-carpal joints, in the radio-carpal articulation, - . - 2. Of the Forearm. Amputation in the continuity of the forearm, the elbow joint, - 3. Of the Arm. Amputation i. the continuity of the arm, the lower two thirds of the arm, : the upper third of the arm, the shoulder joint, ■ the shoulder blade with the arm, Of the lower 1. Amputations of the Amputation at 2. Of the Leg. Amput! Foot. the metatarso-tarsal joints, . . , t the middle tarsal joint, (Chopart) t the ankle joint, - - - - - n the continuity of the leg, - - - ■t the first place of election, ... it the place of necessity or through the condyles of the tibia, - . . . . Ll the knee joint, ..... 3. Of the Thigh. Amputation in at the continuity of the thigh, the hip joint. PART THIRD, SPECIAL OPERATIONS, OR THOSE WHICH ARE PRACTISED UPON COMPLEX ORGANS IN PARTICULAR REGIONS OF THE BODY. I, Opehations phactised rpou the eteball jlsb its accessokt ohgahs. Operations practised on the accessori/ organs of the eye. - - 179 Lachrymal apparatus, 179 Treatment of lachrymal tumour and lachrymal fistula, - - 181 Formation of an artificial canal, - - - , igs Obliteration of the lachrymal puncta and canals, - - 188 Operations for various diseases of the eyelids, - - - 189 Operation for Ectropion, ..... isa Entropion or inversion of the eyelid, - - lO.'J Trichiasis and distichiasis, - - . 194 ■ Blepharoptosis, ----- igs Adhesionof the lids. Ankyloblepharon. Hynblepharon. 195 Tumours of the lids, - - . . jgg Coloboma palpebrEe, .... Epicanlhis, - - - . - !9 6 Operations practised through the confunctiva. - . . . 197 Operation for Excrescences — Encanthis — Pinguecula, - 197 Pterygium, - 197 Pannus — Varicose condition of the conjunctiva — Vascular cornea, . - - - , 197 Operations on the ball of the eye. . - - . - 198 Cataract, - - - - - - - I9B Operations for the removal of cataract, - - - - 200 1. Depression. Couching or displacement, including Rever- sion and Reclinaiion, - . . - . 20O 2. Division, 204 3. Extraction, - 305 On secondary cataract, ----- 211 Operation)) for artificial pupil, - - . . - 211 1. Incision — corectomia — iridotomia, - - - . 313 2. Excision — iridectomia, - - - - . 214 3. Detachment of the iris at its outer margin, - - 314 4. Extension of the natural pupil, - . . . 215 Staphyloma corneas, ------ 317 scIeroticEe, ----- sja CONTENTS. 7 II. OPEBATIONS as THE BAB, ..... 223 1. Foreign bodies in Ihe audilory passage, - - - 224 2. Polypous tumours, fungous excrescences, etc., - - 224 3. Closure of the auditory passage, .... 225 4. Catheterism of Ihe Eustachian lube, ... 325 5. Perforation of Ihe membrana lympani, ... 228 6. of the mastoid cells, .... 228 lU. Opehatioss upon the nose asd xasal cAriTies, - . - 229 Tumours of the nose, 230 Extraction of foreign bodies, ..... 231 Plugging or tamponing in nasal hEemorrhage, - - 231 Polypous tumours, ...... 233 Catheterism and perforation of the frontal and maxillary sinuses, 238 IV. Operations upon the mouth and its bepemjest BTRtrcTUEES, - 241 Of the lips and cheeks, 241 Hypertrophy of the lips, ..... 241 Atresia oris — contraction of the orifice of the mouth, - - 241 Harelip, ....... 242 Cancer of the lips, ...... 244 Anchylosis of the lower jaw, ..... 245 Salivary fistula, ...... 246 FistulEB of the parotid gland, ..... 249 Extirpation of the parotid gland, .... 249 of the submaxillary gland, - - - .251 Ranula, 252 Operations on the tongue, ..... 253 Ankyloglossum — adhesion of Ihe tongue — longue-lie, - - 253 Stammering, ....... 253 Removal of the tongue, ...... 254 Excision of the uvula, 256 Extirpation of ihe tonsils, ..... 256 Staphyloraphy, 257 V. Operations upon the neck, . - . . . 36I Bronchotomy, - 261 1. Tracheotomy, ...... 263 2. Laryngo-tracheotomy, - - . . . geg 3. Laryngolomy, ...... 263 Catheterism of ihe CEsophagus, ..... 264 Stricture of the esophagus, - . - . . 265 Removal of foreign bodies from ihe oesophagus, - . 265 (Esophagotomy, 266 VI, Operations upon the thorax, ..... 267 Extirpation of the mammary gland, .... 267 Empyema — paraceniesis thoracis, - . . . 2^2 Paracentesis of the pericardium, .... 372 VII. Operations upon the abdomen, ..... 573 Operations for the cure of ascites, .... 373 Penetrating wounds of the abdomen, - - - . 274 Wounds of the intestine, ..... 275 Operations for hernial tumours of the abdomen, . - 279 Treatment of hernia, - 2gj Radical cure of hernia, ..... 232 Of particular forms of hernia, - ... - 285 Inguinal hernia, 285 Strangulated inguinal hernia, - - - . . 287 Operation for inguinal hernia, - * - - . sgg Crural or femoral hernia, - . . . - 291 Operation for strangulated crural hernia, ... 293 Umbilical hernia, . - . . . - 291 Operation for strangulated umbilical hernia, ... 295 \ III. OPEHATIONS UPON THE ASPS AND RECTUM, - . . . 296 For imperforate anus, 296 Polypous tumours of the rectum, .... 328 Prolapsus ani, - For prolapsus of the mucous membrane, - - - 299 Proiapsusof the rectum with invagination, - - - 300 Cancer of the rectum— extirpation, - - . - 300 HEemorrhoidal tumours or piles, .... gpg Abscess by the side of the anus, .... 305 Fistula in ano — complete anal listula, .... 306 incomplete externa! and internal fistula, - 307 Fissure of the anus, 307 Stricture of ihe anus, 307 IX. Operations upon the cenito-urinaht organs — (in the malk,) - 307 Operatiwis upon ihe scrotum, - - . . . 308 Hydrocele of the tunica vaginalis testis, - . . 308 Hydrocele of the spermatic cord, .... 310 Encysted hydrocele, - - - - - . 311 Hydrocele in the female, - . . - . 311 Sarcocele, - 311 Castration, 311 Varicocele and Cirsocelc, ..... 312 Operations upon the penis, 315 For Phimosis, 315 Paraphimosis, 316 Cancer of the penis — amputation of the penis, . - 317 Hypospadias, 317 Epispadias, 318 Operations on the urethra and bladder, ■ - - - 319 Stricture of the urethra, . - . . , '319 Puncture of the bladder, - . . . . 333 Operations for stone— {lithotomy in the male,) - . . 325 Operation through the perineum, .... 325 Lateral operation. ggg Bilateral operation, 331 Recio-vesical or median operation, .... 33^ Super-pubic, hypogastric or high operation, . - . 333 Liihoirily, - ggg Lithotripsy, 333 Operations upon the genital organs in tite female, ... 33s Lithotomy in the female, - - . . , 335 through the vestibulum, - - . -336 urethra, .... 337 Suture of the perineum. - ■ - - . 337 Recto-vaginal fistula, - - . . . . ' 335 A'esico- vaginal fiaiula, 350 PART FOURTH. PLASTIC AND SUBCUTANEOUS OPERATIONS. /i.??iefi by Careji £ Mart. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 91 tion of the artery, the limb is to be somewhat straightened by substituting for tlie first splint another with an angle less obtuse. By thus varying every few days the angle of the splint, the limb is brought by degrees into a position nearly straight. To protect the popliteal vessels from all chance of pressure, two long bran bags are laid lengthwise on the sphnt, with a vacancy of four or five inches between them, (which is to be filled with carded cottouj) opposite the lesion of the bone. Protracted suppuration and constitutional irritation, such as are attendant on compound fractures, to which the wound of the operation may be compared, must necessarily be expected to follow, and during the treatment particular care should be observed, that in straightening the limb the lower fragment should not be allowed to slide backwards, so as to shorten the leg, and render it nearly impossible to give it the requisite degree of straightness. Four months after the operation, the patient of Dr. Barton was able to stand erect, with his feet in their natural position; and at the end of eight, conld walk with ease, notwithstanding the loss of motion at tlie knee, from forty to fifty miles a day, and mount his horse with facility. The same procedure has been repeated by Professor Gibson on a patient in the Philadelphia Hospital. This case was also successful; and, with the former, constitutes the only instances, within my knowledge, for which this truly valuable American method for the treatment of anchylosis has yet been employed. In fifty-six days after the operation, in the second case, firm union had taken place at the place of section, and though the thigh was shortened about an inch, the limb was nearly straight, and the patient could sustain himself upon it with ease. COMPLICATED FRACTURES AND LCXATIOIVS. In occasional instances, these aft'ections require the aid of ope- rative surgery. 1. In extensive laceration of the Jlesh emd skin, with projection of bone, arising either from comminuted fractures, or compound fractures and luxations. In such cases, if a projecting fragment or the head of a protruding bone, is not easily reduced, the wound should be enlarged by an incision, and a subsequent effort made to reduce it. If this fail, the end of the bone is to be cut off with a saw, or a pair of strong forceps. The bones are then to be adjusted, and the wound treated so as to reduce it as much as possible to the state of simple fracture. 2. Where ike fracture is attended with the separation of splinters or scales from the bone.— In such cases, if the frag- ments are completely or nearly loosened from the bone, and driven into the soft parts, an operation is required for their re- moval, An incision should be made opposite the irritating body, at the point where the bone is most superficial, selecting the in- termuscular spaces when it is possible, and avoiding the side upon which the great vessels are located. The fragments are then to be removed with the forceps. Sometimes the splinters I or scales are firmly attached to the periosteum by one end, while i the other is lodged in the muscles. In such cases, they will re- \ quire to be loosened with the knife before they can be twisted out with the forceps. Simple fissures in the bone, without dis- placement of parts, call for no operation, as they readily become consolidated by the subsequent efi'usion of callus, under the ordi- I nary plan of treatment for fracture. \ 3. Where there is laceration of the vessels and nerves. — When the vessels are lacerated, the different means of arresting hEemorrhage suited to the peculiarities of each ease, already no- ticed, have to be put in requisition. If the branches of the nerves be partially lorn and exposed, they should be divided completely across with the bistoury. Hut extensive injuries of this descrip- tion indicate the necessity of immediate amputation, a subject which will be hereafter considered. {Fig. 5.) . EXTRACTION OF A SEQUESTRUM, OR NECROSED PIECE OF THE CLAVICLE. A quadrilateral flap has been turned down from over the bone. The shell of new bone, or involucrum, has been opened with the cutting pliers, so as to allow the loosened sequestrum to be grasped with the forceps and withdrawn. {Fig. 6, 7, and S,) REMOVAL OF A WEDGE-SHAPED PIECE OF BONE FOR TRUE ANCHYLOSIS OF THE KNEE JOINT. {Process of Bartoyi.) a. Patella, adherent to the face of the condyles, b. Tendon of the extensor muscles, cut off near its insertion on the patella. c. Lower end of the femur; the two black lines crossing the bone meet together a little short of the posterior surface of the bone, and indicate the two tracks of the saw by which the wedge-shaped piece is removed. d. The tongue-shaped flap of integument, muscle, and tendon, raised by two semi-oval incisions, and reverted on the inner side of the knee. Fig. 7, is a sketch illustrating the manner in which the limb is made straight, by gradually bringing up the leg, so as to throw the knee upwards till it effaces the space made by the removal of the wedge-shaped portion. a. Femur. b. External condyle. c. Adherent patella. d. Head of the ttbia, e. Fibula. Fig. S represents the limb in its state of angular deformity. g. Is the outline of the wedge of bone removed. The other references correspond to the same parts as in fig. 7. 92 GENERAL OPERATIONS. PSEUDO-ARTHROSIS.— FALSE JOINT.— UNUNITED FRACTURE. P'ai'kties. —From the appearances revealed by dissection, fractures in which no bony union has taken place, may wifh pro- priety be divided into three classes, 1. Those in which the ends of the fragments, rounded and thinned by ihe action of the ab- sorbents, are connected by an intermediate fibro-ligamentons tissue. This constitutes by far the largest class. 2. Where the end of one of the fragments has become rounded into a head, and the other converted by the constant motion of the parts, and the thicUeitiiig and condensation of the surrounding tissues, into a cup or socket; both portions being surrounded by an adventi- tious capsular membrane, and lined by a new formed synovial tissue. 3. Wiiere the fragments Iiave not been brought into apposition, but are kept separate by a portion of muscle, or a portion of a detached or necrosed bone. Catiscs.—The. causes of the failure in regard to the third va- riety, is surficienily obvious. In respect to the first and second, they arise from a number of circumstances very difierent in their character; and in some cases tlie accident occurs in despite of the most judicious treatment, and wliere no apparent cause can be assigned for the want of bony union. Among the most common causes, may be placed a maladjustment of the ends of the bones, imperfect support from the splints or other dressings applied, indocility on the part of the patient in keeping the limb at rest, meddlesome interference of the surgeon by too frequently changing the dressings without cause when they have once been properly adjusted, some morbid alteration of the bone, as of caries or necrosis, the development of hydatids in its cavity, advanced age, or an impaired or exhausted state of the constitution. Some- times, even after the bony matter has been deposited so as to unite the bones, it has been removed by absorption, leaving only a flexible cartilaginous bond of union. Remcwks. — The period within which we may expect a perfect consolidation of a broken bone to take place by i!ie usual method of treatment, varies so much in regard to difl'ercnt individuals, as to be scarcely subject to any general rule. Nevertheless, we may ordinarily consider that a false joint has been formed, when, after the lapse of six montlis from the occurrence of the fracture, the fragments still remain movable at the point of injury. False articniaiions have been observed in most of the bones; but they are more frequently met with in those which are most movable, as the humerus and the lower jaw. In fracture of the neck of the thigh bone within the capsule, where bony union in general is not to be expected, a false joint near the former centre of motion may be viewed as the best result tiiat can follow. In most olhei instances, the integrity of the bone, by which it serves as a lever for the muscles to act with, is destroyed; and the limb to which it belongs (if it occur on an extremity) becomes nearly useless. But cases may occur, as rare exceptions to the general rule, especially where two bones are associated in nearly similar offices, as in the forearm and leg, in which an attempt on the part of the surgeon to solidify the false joint would be most injudicious. One of this description occurred in my service during the past winter at the Philadelphia Hospital. A man from the west had received from a Hill a shock on the forearm, which dis- located the radius and carried it upwards on tfie humerus, and at the same time produced a fracture of the ulna about two inches and a half below the joint, with considerable angular displace- ment; the lower fragment being brought up in close contact with the radius. No attempt at reduction was made; the limb being merely put up in its deformed condition in splints. The conse- quence was that bony union took place between the ulna and radius at the point where they come in contact, and a false ball and socket joint formed between the broken ends of the ulna. In flexion and extension, both bones moved together as far as they were permitted by the end of the radius resting on the humerus. In pronation and supinalion, which was very well performed, the radius and lower fragment of the ulna moved together, the latter rotating in the new formed articulation. Under such cir- cumstances, the solidification of ihe false joint would have im- paired to a great extent the utility of the limb; and the result here accidentally produced indicates tlie propriety of attempting to effect some analogous artificial meausof relief in certain states of deformity and loss of use of the forearm, that occasionally arise from ill-treated fractures. Treatment. — The general conslilntional, as well as the local measures of treatment, must vary according to the causes which have led to the defect. 1. Of the local yneasiires. — It is hero only necessary to note briefly the more important of the multitude that have been de- vised. No one of these in all cases being entirely sufficient to accomplish the object desirerl, it becomes advantageous to com- bine them, or try them in succession, according to the degree of action which they are capable of exciting in each case. 2. Friciion of the ends of the bones. — This process, which is as old as the time of Cclsus, consists in rubbing forcibly together the two fragments, in order to excite a degree of inflammatory action that may lead to the deposit of earthy matter in the new (issue. This procedure is only applicable where the ends of the bones do not overlap, when there has been a mere transverse fracture, and when it is attempted at so early a period, — say six, eight to ten weeks alter the injury, — that the false joint cannot be considered as fairly formed. The limb is then to be done up in splints, or wliat answers admirably well, the immovable appa- ratus prepared with dextrine or starch, and kept perfectly at rest for two or three weeks. After this period, it is to be re-examined, and, if the measure has been at all successful, repeated as before. If not, some of the succeeding processes are to be applied. Compressioti. — A method somewhat analogous to the above was introduced by White, and has been occasionally found very advantageous. It consists in applying round the fractured limb a strong support, — such as that of an envelope of stout leather, well padded, and firndy secured with straps and buckles, — the patient to use the limb as much as possible, and if it be the lower extremity, even to move about upon it. As soon as a sufficient degree of action is provoked at the place of injury, as manifested by soreness and swelling, the limb is to be kept completely at rest, as directed for friciion of the ends. Simple compression of the ends of the bones together, by the fracture apparatus, while the limb was kept at rest, has succeeded in two cases in my hands, as late as the third and fourth months after the reception of the injury. 3. Cuianeoiis b'ritanls — The application of blisters frctpicntly OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 93 renewed, of caustic potash, tinct. iodine, and analogous subsiances, immediately over the point of fracture, has been much praised by Wardrop and others. It may be considered a useful process where the work of ossification proceeds slowly, and the bones lie superficial, as in the forearm and leg; but according to my own observation, has little effect, even in these cases, if not em- ployed within six or eight weeks after the injury. . 4. Selon. [Process of Physick. Pi. XVII. fig. 1.)— The use of the seton, for wliich we are indebted to the practical wisdom of the late Dr. Physick, is a measure which may be relied on with considerable certainty for the cure of false joint in the jaw and upper extremity. In the lower extremity, the resulis of its employment have not been equally successful. Extension and counter e.Ytension having been wade upon the limb, so as to cause a separation of the fragments, Dr. Physick passed the ordinary seton needle through the limb, traversing the interval between the bones — cautiously avoiding the track of the principal blood-vessels and nerves, and selecting the points at which the bone was least covered with flesh. A stout cord or a skein of silk, which has been previously attached to the eye of the needle, is then to be drawn through after the instrument. The wound is to be simply dressed, and the limb, after suppuration is estab- lished, placed in an appropriate fracture apparatus. The seton is then to be daily moved in the wound, and retained even for a year or more, if so long a time be required for the limb to become sufficiently stiffened by the deposiiion of callus to admit of its executing its usual movements. If the necessary degree of irri- tation is not maintained by the simple seton, it may be smeared from time to lime with some stimulating ointment. The first case of Dr. Physick was an ununited fracture of the humerus. At the end of twelve weeks the consolidation begun, and at the termination of five months and a half, the cure was complete. Professor Horner, of this city, has employed the sail- maker's needle in place of the ordinary instrument for carrying the seton. This is less liable to divide important parts, and I have found it to answer well, particularly in fracture of the lower jaw. Ill the latter affection, it should be carried from the cavity of the mouth, downwards and outwards, through the integuments covering; the base of Ihe jaw. Modification of fVardrop. — Tins gentleman has proposed to modify the method of introducing the seton where the bone is deeply seated, as in the upper third of the thigh, by previously dividing with a bistoury the soft parts over it, and introducing the needle inclosed in a sheath down to the bottom of the wound, when it is to be passed through as in the process of Physick. Modification of Oppenlieim. — This consists in the introduction of two setons, so that one shall come in contact with each of the ends of the bones. Both may be introduced at the same time, or the second a few days after the first. When suppuration is fully established, they are to be withdrawn. By this means, this sur- geon believes a sufficient degree of inflammaiion will be excited to insure a bony union without incurring the same risk of erysipelas and abscess, which has in some cases carried olf the patient, when the seton has been maintained a long time in the wound. He does not consider it absolutely necessary that the seton should traverse the tissue between the bones, the same advantageous effects being produced when they are placed merely in proximity j 24 or contact with the periosteal covering of the ends of the bones. The value of this opinion has not perhaps been as yet sufficiently attested in practice. In some instances, it is found exceedingly difficult, if not im- possible, to pass the selon, either in consequence of the obliquity or overlapping of the fragments, or from the risk of injury of important parts; and under such circumstances. Professor Fergu- son observes, he has seen a needle or probe left sticking in the fissure between the bones, followed by all the benefit that could have been expected if a cord had been carried through in the usual manner. In those cases where the fragments are held asunder by a necrosed portion of bone or a piece of muscle, the use of ihe selon would probably be attended with no benefit. So7n?nt's modification. Section of the fibro-ligamentous union by means of a wire. — In an ununited fracture of the femur, this surgeon pierced the limb from willhu outwards, with a long delicate trocar, grazing the inner surface of the end of the lower and the front portion of the upper fragment. The stilet was with- drawn and a silver wire passed through the canula, and left in the wound, after the canula was taken away. A second puncture was made with the trocar, but in the opposite direction, from without inwards and forwards, and brought out at the place of the first puncture. The end of the wire, which had previously passed through the limb, was again carried through the canula; this instrument was then drawn through at the inner side of the limb and removed. The loop of the ligature thus surrounded the false joint, including the muscle and integument between the two posterior punctures, which was divided across with the bistoury to let the wire down t^the bones; the lips of the incision were then brought together so as to unite by first intention. liy gradually tightening from time to time the loop which embraced the liga- mentous tissue, this was by degrees divided, and an effusion of callus followed so as to consolidate the fracture at the end of six weeks, so far as to justify the removal of the wire. Three months after the operation, the patient was able to walk. 5. ^citpunctitration.~M. Malgaigne has suggested, in place of the seton, lo introduce a number of acupuncture needles through the fibrous tissue between the ends of the bones. The trials which have been made of this process do not, however, prove it to have been very efficacious. 6. Cauterization of the ends of the bones. {Process of Green.)~An incision through the soft parts having been made so as to expose the ends of the fragments, the fibrous tissue uniting them is to be divided with the knife, and each end rubbed with a cylinder of caustic potash, till it becomes of a black hue. Especial care must be taken to protect the surrounding parts from the action of the caustic, which is to be applied in ilie depth and without turning out the bones through the wound. Earl has advised, in order to render the process more efficient, to pre- viously scrape ofl' the fibro-cariilagiiious, or fibro-ligameutous covering of the ends of the bones, and apply the caustic directly upon tiie osseous tissue. Some operators have salisfiud them- selves with merely cutting down and scraping the ends of the bone. Numerous instances of ihe successful application of the caustic are recorded. The process is not, however, unattended with danger, as the fracture is rendered compound by the incision through the soft partsj and though rather less likely to produce 94 GENERAL OPERATIONS. severe constitutional symptoms, it is not in general so certain a means of effecting a cure, (the fragments often overlapping so that the caustic cannot be made to act on the proper point,) as resection of the ends. 7. Resection. (PI. XX. fig. l.)~The ends of the fragments are to be exposed as in the last process, by a longitudinal incision through the soft parts, and the intervening fibrous tissue divided across. The two extremities are then to be luxated as it were, and made to project one at a time through the external wound, separating with the knife so far only as is absolutely necessary the adhering soft parts, The arteries are to be tied as they are cut. It will be found most convenient to protrude first the inferior fragment. The rounded ends of the bones are then to be re- moved with the saw or cutting forceps, after the manner of White. The raw ends of the bones are then to be replaced, with their extremities exactly in contact, and the subsequent treatment becomes precisely the same as in ordinary compound fractures. The risk following the operation may be considered even greater than that attendant upon these aff'ections; hence, when the thigh forms the seat of injury, it is so very dangerous that' it should not be ligiitly undertaken. Sometimes, when the fragments are deeply placed, one is found so short and so little movable, that it is impossible to cause them both to protrude. Under such circumstances, Du- puytren has found that the resection of the end of one of the bones suffices for the cure, if the extremity is put immediately in contact with the other fragment, which may at the same time be rasped or shaved, or irritated with caustic potash. When the fracture has been very oblique, it is necessary to remove a suffi- cient portion of the bevelled extremities, to prevent any unnatural lengthening of the limb, which would in the thigh or leg, be pro- ductive of considerable inconvenience. M. Flaubert, of Rouen, has proposed after resection to unite the ends of the bones by passing a wire in the manner of a suture through the fragments themselves. But the risk of necrosis or abscess round the boue, and consequent constitutional disturbance attendant upon this process, would, it appears to me from what I have observed in one case, be so great as to render the measure as dangerous as it is unneeded. In the forearm and leg, we select, for the purpose of exposing tiie ends of the bones, the surface which is nearest the skin. In the thigh and arm, the longitudinal incision is made on the outer side of the limb, for the purpose of avoiding the vessels and nerves. In tiie arm, the incision is made in the intermuscular space, separating the outer margin of the biceps from the muscles on the fore part of the limb. At the middle part of the arm, the musculo-spiral nerve is on the outer side, from between the triceps and biceps; it pierces subsequently the septum between these muscles, and must be carefully avoided by keeping it behind the line of incision. Its division, as shown in a case from the country, recently under my charge for resection of the ends of the bones, may be attended by permanent palsy of the extensor and supi- PffATE IXI.-OPERATIONS ON THE BONES. {Fig. 1.) REMOVAL OF AN EXOSTOSIS, OF THE EBURNATED SOLID KIND, FROM OVER THE LAMBDOIDAL SUTURE. The tumour was of a globular form, and projected for about an inch above the bone. It has been divided vertically in two lines by the saw, so as to render its removal with Hey's saw more easy by dividiug it into throe portions. One portion has been removed, and the saw is shown in the act of dividing the middle part. (Fig. 2.) REMOVAL OF A TUMOUR OF THE SAME DESCRIPTION FROM THE UPPER THIRD OF THE HUMERUS. a. A triangular flap of the whole thickness of the deltoid has been raised between two incisions which run down parallel with the fibres of the muscles. The flap is reverted toward the shoulder so as to expose the diseased surface of the humerus. b. A wooden ruler, which is placed on the inner side of the tumour so as to press inwards the biceps muscle and the brachial vessels out of the way of Hey's saw, with which the tumour is divided at its connection with the arm bone. {Fig. 4.) FORMATION OF AN ARTIFICIAL JOINT, FOR ANCHYLOSIS OF THE ARTICULATION OF THE HIP. {Process of Barlon.) The patient is laid upon the sound side. A crucial incision has been made, with its centre over the trochanter major. The four flaps are dissected up and reverted. The bone, after being denuded in its circumference with the knife, has been divided nearly across with the saw, the section being made partly through the trochanter and partly through the lower end of the neck of the bone. The figure represents the last stage of the operation, when, after the section of the bone, the limb has been swung inwards in order to snap the thin portion left unsevered by the saw. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. .95 nator muscles of the hand. The previous operation, which had failed ill tliis instance, consisted of the application of caustic pot- ash to the ends of the bones. In the thigh, the opening should be made hetween the biceps flexor cruris and the margin of the vastus exteriuis, where we may reach the bone, by following the intermuscular septum, without dividing n single muscular fibre. For the purpose of introducing a setou between the ends of the bones, Wardrop cut down along the external border of tlie rectus femoris, and brought out the needle at the external border of the vastus externus. The method of resection for ununited fracture of the iiumerus is shown at Plate XX, and fully explained in all its details. By the use of Heines' saw (see PI. XXX.) the resection of the ends might readily be made without dislocating either fragment from its bed, and cousequeutly diminish tiie risk attendant on the operation. The section of the lower fragment is, when protruded, readily effected by the ordinary saw, as the limb can be rotated during its action, so as to make the division complete without disturbing the muscles on the other side. A strong pair of pliers, or a stout pair of dentist forceps I have found convenient in re- moving the pieces in cases where it was not deemed expedient to compleie the section with the saw. A few touches of the knife may also be at times required to detach the adhering ligamentous shreds. In ttie arm, it is more difficult to make the complete sec- tion of tlie upper fragment with the saw without doing violence to the surrounding parts, in consequence of the resistance made by the muscles of the armpit, even where these muscles are relaxed by carrying the arm upon the chest to bring out the end of the bone. The bone, however, may be always deeply notched on its surface with a narrow saw, and the section may then be finished willi Listen's cutting forceps, acting in the track of the former instrument. The wound should be carefully closed with adhesive strips covered with a compress, and the limb surrounded with a roller bandage, to endeavour to produce union of the lips of the incision by first intention. The limb should be kept per- fectly at rest in a well adjusted fracture apparatus, and all pres- sure of the resected ends of the bones for several weeks carefully avoided. Within a few months I have performed an operation of this description before the class of the Jefferson Medical College, in a case where, from causes wholly unconnected with the operation, death took place at the end of the fourth week, when the patient was about preparing to leave the city. The wound liad healed completely by first intcnlinn, and no more pain or sulfering had been experienced from the limb than occurs in ordinary fracture. The examinalion of the parts which I now have in my cabinet, shows a rigid thickening of the cellular tissue, aponeurotic layers, and neighbouring muscular fibres, about the place of fracture, which had given a considerable degree of solidity to the limb. The two ends of the bones were already coated over with a layer of tough, gray matter, and adhered to each other by a tenacious filamentous lymph, which parted as the fragments were forced asunder. DEFORMITIES PROM THE IRREGULAR iriVION OF FRACTURED BONES.— VICIOUS OR DEFORMED CALLUS. It is not unusual to meet with cases in which, from accident or mismanagement, the consolidation of a fracture has taken place with shortening of the limb from the fragments riding over each other, or with a deformity in its direction owing to a maladjust- ment of the ends of the bones during the progress of cure, or from its becoming bent or curved by a premature use of the limb, while the callus was yet soft and yielding. Without going into detail in reference to the different theories of the formation of callus, it will suffice to state tiiat it passes through difi'erent stages of development, from that of fibro-carti- lage to bone; that it forms a temporary connection for holding the bones together, which, even when most consolidated, does not attain to the density of solid bone; and that the per- manent callus which is formed between the surfaces of the divided bone, and when it becomes solidified the true bond of union, is the last portion developed. The period requisite for these progressive changes varies in difi'erent bones, but does not even in the larger, consist of more than sixty or ninety days, beyond which period we may, under favourable circumstances, regard the union by permanent callus as having taken place. The longer, therefore, the callus has been in forming, the greater will be the difficulty of correcting the defects in the position of the bones. In general the temporary callus does not, before the fiftieth or sixtieth day, acquire so much solidity but that it may be readily made to yield by pressure and extension; but it is most desirable that all deformities should be corrected as early as possible after they become known. Dupuytren has, however, furnished in- stances where the deformity has been removed by such measures, as late as one hundred and twenty days after the occurrence of the injury. Cases will present themselves that have been ne- glected for periods much longer than this, in which relief can only be afforded by other means more severe and hazardous, but which are nevertheless perfectly justifiable, when the use and symmetry of an important part is destroyed. There are three principal methods for cure of the deformities referred to under this head. 1. Pressure and permanent extension. — If not more than a few weeks have elapsed from the time of the injury, we may be able at once to straighten simple angular deformities by the hands without the aid of machinery, especially if they are found in the forearm or leg, the operator using his knee as the point of resistance; but if there be shortening from obhque fracture, it will in addition be necessary to bring down the bones by exten- tension and counter-extension. Having once got the limb straight, the treatment is to be continued as in ordinary cases of fracture. But if a longer period has passed — thirty, forty, fifty, or sixty days — pressure and extension must be made gradually with ap- propriate fracture or orthopedic apparatus, and repealed every second or third day, strict care being observed to retain, by the steady use of the instrument, what has been gained by the force applied. If the callus has become too solid to yield to these measures, it has been proposed to soften it previously by passing a setou through it so as to provoke a sudden inllammaiion, which is commonly attended with some softening of the new siructure, U.^e of Ihe se/on. (Process of JVdnhold.)—\\i a case of frac- tured thigh of three months' standing, firmly consolidated with a great exuberance of callus, and with a shortening of two inches, 96 GENERAL OPERATIONS. this surgeon was so successful as to ultimately restore the limb to within two lines of its natural length. With a sort of trepan needle, mounted on a joiner's brace, entered through the soft parts, an inch to the outer side of the femoral artery, he perfo- rated the mass of callus. The needle was then carried out through the opposite side of the limb, dragging after it the ordinary seton. At the end of seven weeks the callus began to yield; and the ordinary extension apparatus was applied. 3. Rupture of the callus. — This may sometimes be effected by straining tlie limb over the knee, and rupturing the new union as we would break a stick. Velpeau has proposed to place the deformed limb with its concavity upon a solid plane, while pressure is made suddenly and forcibly with the knee or hands on its convex surface. There is, however, always more or less danger of splintering the bone, or fracturing it at a new point, so that this plan, where much resistance is offered, is but little fol- lowed. It is considered better surgery under such circumstances, especially where there is mere angular deformity, to endeavour to effect the object by the aid of machinery, properly padded and braced, so that the force shall be applied only over the new formed union. A double inclined plane, truncated at the top, and opening with a joint at a similar angle wilh the limb it supports, answers a purpose nearly or quite as good as the com- plicated apparatus of ffisterlcn, in which a pad, attached to a solid piece of board, is forced downwards with a screw, so as to press on the convex surface of the callus. (Esterlen has reported forty cases of success by this method of treatment. 3. Section of the callus. — This is the only means left for remedying a deformity that has resisted the judicious application of the preceding measures, or for the treatment of a thoroughly consolidated fracture. It consists in laying bare the surface of the callus by incisions, and, instead of breaking, dividing it across with a saw, or the gouge and mallet. It is the only method left for managing the confused solidification which sometimes takes place after fracture of the bones of the forearm. It converts the deformity into the state of a compound fracture, and is attended by the same risk to the patient, and requires subsequently similar treatment with that affection. A judicious surgeon would not, therefore, attempt a cure by this means, except in cases where it was urgently indicated. P/'ocess of Wasscrfiihr. — For a fracture, in a child of five years, of the upper third of the femur of three weeks' standing with a salient angle at the outer side of the thigh and a great shortening of the limb, this surgeon made a transverse incision over the prominent point, equal to one-fourth the circumference of the limb."^ The calUis, exposed by the retraction of the divided muscles, was cut nearly through with a fine saw, and the sepa- ration completed by fracture. The limb was then placed in an extension apparatus, and complete success is said to have fol- lowed the operation. In many instances the American method of cure for anchylosis, by removing a wedge-shaped portion of bone, and subsequently straightening the limb, will be found available in relieving this * The solid state of the callus at this early period is to be explained by the youth of the patient — the process of bony reunion taking place more rapidly in children than in adults. class of deformities. This principle has been successfully em- ployed in a case of great deformity of the leg by Professor Mutter, of the Jefferson Medical CoUege.t If, in treating injuries of this description, the muscles on the concave surface of the limb have so shortened themselves as to refuse to yield readily to distension, a section of their tendons, especially in the lower extremities, made as described in this work under the head of subcutaneous operations, may occasionally be attended wilh advantage. EXOSTOSIS. (PL. XXL) The tumours bearing this name may be distinguished; i. Ac- cording to their original seat, which may be either between the periosteum and the surface of the bone, or between the medul- lary lining membrane and the cancellated structure. 2. Accord- ing to their nature — as they are cartilaginous, eburnated, porous, or osteo-sarcomatous. 3. According to their form and size, whether they are styloid, rounded, pediculated, circumscribed, diffused, etc. The proper periosteal exostosis, formed on the free surface of the periosteal membrane (periostosis), as shown by Professors Albers and Rognetta, are first formed like epiphysis, though they become ultimately solidly attached to the bone on which they rest. To all of these varieties, surgical operations for their re- moval are by no means applicable. If they are in their forming state, fibrous, or cartilaginous, they need not be interfered with, except they produce great deformity. If they have degenerated so as to become soft and spongy, as in growths from the walls of the antrum maxillare, nothing short of resection of the bones involved, or amputation of the member, will suffice. Simple ob- long enlargements on the surface of a bone are ordinary occur- rences; and if no other inconvenience than slight deformity results from their presence, they should not be interfered with. Nothing in fact justifies their removal by operation, except the tumour from its great size or vicious direction interferes with the fiuictions of surrounding organs. Such as arise from syphilis, from scrofula, (as is so common in children,) and other constitu- tional affections, are curable usually by appropriate general and local treatment; and, if touched at all, cannot be taken away with safety till after the removal of the constitutional disorder. Modes of operation. — The application of the actual cautery and caustic articles so much in use among the ancients, and still employed for a like purpose in farriery, is now abandoned in the treatment of these atfections — surgeons limiting themselves almost exclusively to the employment of mechanical measures, and using the cautery only as a means of arresting haemorrhage after the operation, or destroying a portion which cannot be readily extirpated. If the exostosis is entirely cartilaginous, in- termixed with plates of bone, and periostea! in its origin, it does not adhere at first very firmly to the bone, and may be prized off from it after having been exposed by incisions. Large tumours of this description I have found readily removed from round the base and ramus of the lower jaw. If the tumour has become ossi- fied, making a continuous structure with the bone below, it may be detached if pediculated by section with the saw, forceps, or chisel. If adherent by a large base, it must be separated in por- tions, either by frequent applications of the trephine, or divided \ American Jouru. Med. Sciences, April, 1843. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 97 perpendicularly in various directions with the saw, and the por- tions detached at their base with the cutting forceps, or the mallet and cliisel. If the bone below be merely inflamed, vascular, and expanded in its areolsE, it may be left to the influence of general and local therapeutic measures, on the same principle that we would treat similar affections in the soft parts, when the offending cause had been removed. If there are grounds for suspecting its degeneration, an exploratory perforation may be made with a trephine, after the manner of Dapuytren, in order to decide whether it will be necessary to proceed to resection or amputa- tion. If the seat of the tumour be in the medullary cavity of a long bone, the soft parts are to be dissected off, the expanded shell of the bone laid open with the trephine— the mallet and chisel, a Hey*s saw, or the cutting forceps often answering well to enlarge the space — and the nucleus turned out from the cavity it occupies. The soft parts are then to be brought together, and a slip of linen interposed at the depending portion of the wound, so as to permit a free escapeH)f the purulent secretion, and allow of the introduction of detersive fluid injections. As an after treatment I have derived great benefit from compression applied by the means of a roller or of adhesive straps, as in Baynton's method for the cure of ulcers, which, though acting directly on the soft parts, exercise considerable influence on the bone. Remarks. — The mode of proceeding in the removal of exos- tosis will be more or less varied, not only by the nature and form of the tumour, but also by the character and peculiar arrange- ment of the parts which surround or support it. As these diffi- culties, as well as the means of surmounting them, cannot be subjected to any positive general rules, but will become apparent from the exigencies of each individual case, it will not be neces- sary to describe their ablation in the various portions of the body. By reference to Plate XXI, the general method of proceeding will be well understood. The saw and the trephine will be found most appropriate in the removal of cranial exostosis, as the concussion attending the use of tiie mallet and chisel might inju- riously affect the brain. In the removal of tumours deeply situ- ated, the obvious necessity of protecting the neighbouring parts increases the difficulty of the operation; and it is in these cases when we act in a narrow space, that great advantage may be obtained from the use of a chain saw, or the different steotomes that have been devised, the best of which is that of Heine. In laying bare the tumour, the rules generally laid down of avoiding the vessels and nerves are to be carefully followed. In many respects the method of incision can be advantageously modified so as lo spare more or less the parts, according to the nature of the case and the ingenuity of the surgeon. In an exostosis with a narrow base, seated below the deltoid, M. Roux made two parallel incisions in the direction of the fibres of the muscle, isolated the tumour below the bridge formed between the two incisions, and detached it at its base with a saw, without any transverse division of the muscle. In some cases where the am- putation of the exostosis is dangerous or impracticable, and the tumour is neither large nor attached by a broad base, it has been recommended to lay it bare and strip off its periosteum, in order to deprive the external part of its nourishment from the periosteal vessels, and cause the surface and the subjacent parts to slough away. The result of such a method would necessarily be tedious 25 and more or less uncertain; but yet, instances may arise in which its application would be advisable. CYSTS IN THE BONES. Tills peculiar form of degeneration has been frequently ob- served in the upper and lower maxillse. It has also been occa- sionally met with in the extremities of the long bones and the bodies of the vertebrK. The cavity of the cyst is most com- monly filled with a mass of fibro-cellular matter, but sometimes its place is supplied by serum, pus, hydatid vesicles, gelatinous or colloid masses, etc. etc. The fibro-cellular cysts of Dupuy- tren may be considered the same affection as that ranged by Sir Astley Cooper under the head of cartilaginous medullary exostosis. The size of the cysts in the bones vary from that of a musket bullet to that of the fist. The peculiar nature of the substance they contain it is exceedingly difficult to discover, except by an exploratory puncture, or during the progress of an operation for their removal. This, however, is not a matter of great import- ance, as the indications of treatment are nearly the same in all. That which is more easy, however, and more important, is to distinguish them from the cancerous degeneration of the bones, called osteo-sarcoma, in which the operation for the removal of the disease is nearly as unpromising as it is successful in the former. An osteo-sarcomatous affection is announced shortly after its commencement by a varicose tumour, and by a simulta- neous affection of the surrounding soft and hard parts that are disposed to take the character of fungoid degeneration, and by irregularities over its surface. Osteo-sarcomatous tumours grow with great rapidity, and are traversed in their interior by frag- ments of bones, which are never observed in the cysts. These latter are slowly developed, smooth on the surface, and never involve the surrounding parts in disease, unless the cotUained substance has in the end degenerated into cancer. Their walls, which appear to be formed by a separation of the compact por- tions of the bone, grow thin in consequence of their expansion, and yield to pressure of the finger like a piece of parchment, followed in many instances by a crackling or crepitating sound, which, according to Dupuytren, is pathognomonic of this affec- tion.* Four principal methods have been employed in the treatment of these bony tumours. 1. By compression, — This has been attempted, but the trial has not been attended with any permanent advantage. 2. By incision. — The mere laying open of the cysts, and evacuating their contents, even when these are of a fluid nature so as to admit of the process, has not succeeded in effecting a cute. It is necessary to destroy or change the iiaiure of the membrane lining the cyst, without which the orifice will close, and the contents accumulate anew. 3. By the stton. — A seion passed through the centre of the cavity, offers in the serous cyst a somewhat belter prospect of a cure, by producing suppuration of its walls, and the elimination of the contained substance. This has succeeded happily in my hands in one case of a cyst developed in the lower jaw. It is, ' Lemons Orale de Clini(i«e Chiriirgicale, t. iit. GENERAL OPERATIONS. however, much less to be reHed on than the followhig process, which has received the sanction of more general use. 4. Excision. — It is usual to commence with an exploratory puncture to ascertain the nature of the contents. An incision through the soft parts is then to be made over the surface of the tumour. In many of the cysts of the jaw bones, the incision for the purpose of avoiding a scar is made on the side of the mouth. A strong bistoury is then lo be pushed through the walls of the cyst, at its most depending portion, laying it open throughout its whole extent. With the scissors or cutting forceps, two oblique incisions are to be made so as to take away a triangular portion of the wall. The contents of the tumour having been turned out, its cavity is to be stuffed with charpie or lint to excite suppu- ration. Stimulating injections into the interior, or the passing of a seton through it, conjoined with external compression, become useful measures in the course of the after treatment, and some- times are absolutely necessary to affect the complete obliteration of tlie cavity. Hemarks. — Scrofulous enlargements of the phalanges of the fingers and toes, and of the metacarpal and metatarsal bones, with such softening of the bones as to be readily perforated with a needle, are frequently, and especially in children, met with, that might without attention be mistaken for this affection, In several instances, I have been called to cases of this description in which propositions had been made to lay open or amputate the parts. Such bony enlargements are usually got rid of without much difiiculty, by the ordinary treatment for the cure of scrofula. CARIES AND HECROSIS. These affections are essentially different^in their nature — caries consisting of the ulceration, and necrosis of the mortification of the bony structure. Yet in their general outlines there is such similarity, that advantage will be derived in briefly studying them in conjunction, inasmuch as they are often found combined in the affection of the same bone, or the one is found preceding tlie other, exactly in the same manner as ulceration and mortifi- cation of the soft parts. Both caries and necrosis are commonly preceded by the symptoms of deep-seated inflammation, which is after a time manifested on the surface, and may be produced by external causes, such as a blow, contusion or wound, but more generally is the effect of some constitutional affection, as scrofula, syphilis, and scurvy; in short, every thing which gives rise to ulceration and mortification in the soft parts, may similarly affect the bones, the symptoms only being modified by the difference of texture in the latter. In caries, there is undoubtedly inflam- mation of the osseous tissue; in necrosis, on the other hand, the periosteum is frequently alone involved; which, detaching itself from the bone, the latter mortifies, in consequence of its nou- PLATE IXIL— OPERATIONS ON THE BONES FOE NECROSIS. [Fig. 1.) EXTRACTION OF A SEQUESTRUM FROM THE OS HUMERI. An incision is made down to the bone, on tlie outer part of the arm, between the brachialis anticns and triceps muscles. The muscles have been dissected off from the bone, and the forearm somewhat flexed so as to admit a wide separation of the lips of the wound. Two perforations have been made with the trephine through the new shell of bone, or invohicrum, so as to expose the sequestrum or dead piece of bone inclosed by the involucrum. In the plate, the surgeon with his left hand supports the Hmb, and draws away the inner lip of the wound, (the external supposed to be drawn outwards by an assistant,) while, with a Hey's saw in his right he begins one of the lines of section of the involucrum, between the two places of perforation, in order to remove the intervening bridge, and get hold of the sequestrum with the forceps. {Fig. 2. A. C.) EXTRACTION OF A SEQUESTRUM FROM THE UPPER AND MIDDLE PART OF THE TIBIA. (A). A wound in the shape of a T has been made, and tlie two angular flaps dissected up and turned back from the inner face of the bone. Two perforations have been made through the involucrum, and the intervening bridge removed as described in fig. 1. The perforator of Dupuytren, which consists of a pair of serrated forceps, and a drill enclosed in a canula, is seen applied for the purpose of dividing the sequestrum, so as to facilitate its removal with the forceps. (C). A crucial incision has here been made, and the four triangular flaps dissected from the bone and reverted. The drawing represents the parts as seen in one of the author's operations. The involucrum, which was soft was opened with the gouge and mallet as seen in the plate. After a free passage was made through this part, the sequestrum was divided with a strong pair of cutting forceps, and the fragments subsequently removed with the pliers. The two instruments are shown at the same time merely for the purposes of illustration. (B). EXTRACTION OF A SEQUESTRUM FROM THE METATARSAL BONE OF THE GREAT TOE. A T shaped incision has been made, and the involucrum opened as in the operation last described. The dead bone is seen in the act of being withdrawn with the forceps. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. rishmeiit being iiiterruptecl. Formerly, it was thought that col- lections of pus produced both caries and necrosiSj by infecting the bone. This is not commonly the case; and in general, when- ever either caries or necrosis is found after the opening of an abscess, we may fairly presume that they have been the cause and not the consequence of the purulent deposit. The osseous tissue is not everywhere in like manner disposed to either of these affections. The more compact bones, and especially the bodies of the long bones, on account of their low vitality, are more liable to mortify than ulcerate, though it is not true, as has been asserted, that the spongy textures, such as the apophyses and epiphyses, are never affected by necrosis. The spongy bones, and the spongy portion of the long bones, in consequence of the looseness of their texture, and their vascularity, are generally the seat of caries. This latter affection, moreover, seldom penetrates to a great depth in the bone; necrosis, on the contrary, except it be the result of an extraneous injury, affects as often the inner table as it does the outer surface of the bone, and has therefore been properly divided into centi-al and peripheral neci'osis, as the disease depends primarily on the affection of either the in- ternal or external periiasteum. But, as mentioned already, the same bone may be afl'eeted by both caries and necrosis,— a com- plication which is most frequently found attendant on the venereal affection of the osseous tissue. Long before either of the diseases appears on the surface of the body, they are preceded by deep-seated pain; that which is antecedent to caries, is usually less violent, raking, burning or shooting, and is attended with less feeling of heaviness in the limb, than that precursory to necrosis. As soon as the ulceration or caries of the bone is established, and an accumulation of sa- nious ichor takes place, the parts around will participate in the inflammation, become swollen and indurated; and an accumula- tion of sanious fluid forms, which makes its way to the surface. This is attended with only partial relief, and sometimes without diminution of the symptoms. But if the bone has mortified, or become necrosed, the pain may altogether subside for some length of time, no symptom being left behind, except a great weakness and heaviness of the limb concerned. But as soon as an effort is made by nature to discharge the dead portion from the system, tumefaction and inflammation follow, confined usually to the region of the necrosed part, but generally of a more chronic character than that accompanying caries. The abscess thus slowly formed round the dead bone, opens early if the bone be superficially seated, but sometimes not for months if it be deep; or if the constitution of the patient be weak, it may not be possible for nature without assistance to evacuate it at all. When the abscess opens, pus of a more healthy character is discharged than in cases of caries. The appearance of the ex- ternal fistulous orifices, as well as the quantity of the discharge, vary in the two forms of disease so as to constitute the character- istic symptoms, by which they may be distinguished from each other. In caries, the orifices are few in number, (and very fre- quently there is no more than one,) funnel-shaped, narrow, and surrounded by prominent callous margins. Exuberant and un- healthy granulations, which bleed from the slightest touch, spring from the canals into which these orifices lead. On passing down the probe through these canals, which are very sinuous, the bone is found from the hypertrophy of its vascular tissue, soft, spongy, porous, and gives to the end of the probe a sensation as though the latter was passing through a bag of sand or wetted sugar. The secretion is usually copious, compared with the extent of the ulceration, and blackens the silver of the probe. In necrosis, the apertures are generally numerous, irregularly shaped, and lead either directly to the seat of the disease, or through the cavity of the abscess, if the parts above the bone have not yet sunk in, as is generally the case after the opening of the abscesses, when the bone is superficial. When the bone is more remote from the surface, sinuous cavities form, which communicate with the outer apertures. The granulations which are sometimes found stud- ding these orifices, as well as the matter discharged, present a more healtliy appearance than those observed in fistulce formed from carious bones. If a probe be introduced through one of these orifices, the bone will be found bare, and gives a ringing sound when struck. In their further progress, the two diseases vary greatly. Caries goes on uninterruptedly in the destruction of the osseous tissue, unless arrested by treatment. In necrosis, on the other hand, the disease, properly speaking, is extinguished with the mortification of the bone; and llie troublesome symptoms which subsequently arise, proceed from the efforts of nature to cast off the dead portion. This result has, therefore, always been considered a favourable circumstance to the disease of the bone, and has been made the basis of a treatment for the cure of caries, by changing the ulceration into necrosis. SPONTANEOUS AND ARTIFICIAL CURE OF NECKOSIS. To remove the dead portion of bone, a two-fold action is set up on the part of the system; firstly, to reconstruct neW bony matter for the use of the limb, and, secondly, to detach or expel the old. The new bone is formed slowly from the periosteum, and in consequence the insertions of the muscles remain un- changed. In the interior of the new bone, which is called the invohicrum, is lodged the dead portion or shaft, which after a time becomes completely isolated through the action of the ab- sorbents, and takes the name o[ sequestrum. If the whole shaft is struck with necrosis, it is detached also at its ends from the spongy extremities of the bone; and in cases of long standing, is frequently, as I have had occasion to witness, separated from the involucrum as well as the heads, by an exceedingly vasctilar pyogenic membrane, which lines the interior of the involucrum and stretches across between the heads and the dead portion. The sequestrum, acting as a foreign body, provokes a constant suppurating discharge from the membrane, and becomes itself diminished in bulk, though it is never wholly destroyed. The matter finds its way from the cavity through the orifices, impro- perly named cloaca, which it keeps open in the involucrum, and from these escapes by various sinuous channels leading to open- ings in the skin, and which are placed most tisiially in the principal intermuscular spaces. In a long series of years, it is possible that the sequestrum, either in pieces or in mass, may be detached through these channels, especially when, as sometimes happens, the limb bends so as to place one of the cloacx opposite one of the ends of the dead piece, which then advances itself to the surface, and may be at once removed— the cavity of the new 100 GENERAL OPERATIONS. bone from which it has been taken afterwards closing up. This is what is called the spontaneous cure for necrosis. It is, however, a process upon the occurrence of which the snrgeon cannot rely, and which is never acconnplished but at an expense of time and strength, which the patient in most instances can but illy bear. Cases have, however, come under niy observation, where the ne- crosed piece was of limited size," the source of little or no irrita- tion, and (he discharge so limited as to constitute little more than the drain from an ordinary issue, when, from the peculiarity of constitution, it has been deemed wisest to leave it undisturbed. As a general rule, however, the work of nature should be abridged by the interposition of the surgeon. This is to be done by methodically opening the involucrum and removing the dead portion by a process of art. EXTRACTION OF THE SEQUESTRUM. This is not to be attempted until the dead portion is completely isolated from the living, as is made obvious by the application of probes through the fistulous openings upon the bone. As soon as the sequestrum is ascertained to be loose, the operation ought to be undertaken, lest by waiting, the system should become ex- hausted, and the new-formed bone acquire, as it does in the end, so excessive a degree of hardness as to increase seriously the difficulty of the operation. Nor should it be attempted earlier, for fear that the new bone may not have become stifficiently firm to prevent the limb from bending under muscular action, after the removal of the sequestrum. In several instances after the removal of the shaft of the tibia in persons below the age of puberty, I have observed that the new-formed bone grew, so as to give to the affected limb a lengfii greater than that of the other side. Operation.— \( the sequestrum is small and visible through a large fistulous orifice, it can at times be seized with the forceps and withdrawn. Generally, however, it will be found necessary to enlarge the cloaca, by opening the involucrum, and break or divide the sequestrum, to facilitate its extraction. For this pur- pose the patient is to be placed horizontal, and properly secured. A semilunar, T, or crucial incision is then to be made, so as to lay naked a superficial portion of the bone by turning back the flaps. The surgeon is then to enlarge one of the cloacae by the gouge and mallet, the catting forceps, the trephine, or even a Hey's saw, as is found most convenient, so as to get at the se- questrum. If no cloaca presents itself, the use of the trephine becomes nearly indispensable, and may be employed to make two or more perforations, dividing the bridge between with the saw, as seen in Plate XXII. If the bone is soft, the hand gouge or a strong scalpel sometimes may answer to open the passage to the dead bone. Having reached the sequestrum, it is to be seized at one end with a pair of forceps, and inclined from side to side to detach it from its bed. If it does not yield to the trac- tion, it must be broken or divided near its middle with the cutting forceps, a small trephine, or the perforator of Dupuytren, and the fragments removed separately. Considerable caution should be used in this step, neither to break nor bend the new bony shell, nor tear the membrane lining its interior. The after treatment must be such as is suited to ordinary suppurating wounds. The cure will necessarily be protracted; and even after the wound is closed, the patient should begin cau- tiously to use the limb, for fear it may become curved or break. OPERATION FOR CARIES. This consists of two methods: — cauterization and resection. Caiiterization. — Preparatory measures. — The affected por- tion of bone must be thoroughly uncovered by reflexion of the flaps, after a crucial, a T, V, or elliptical incision. Ail the fun- gous growths are then to be first removed with the bistoury and scissors from the surface of the bone, and the diseased fungous structure of the bone itself, with the gouge and mallet and the rasparatory, till we reach a surface which is natural in regard to colour and organization. If a portion of the soft parts has undergone degeneration, it is also removed, taking care, however, to preserve enough to form a covering for the denuded bone. Waiting till the bleeding ceases, and carefully absterging the bone, cauterization is to be next employed. This may be done either with caustic substances or the heated iron, carefully pro- tecting the surrounding soft parts from injury. Caustic stihstances. — The soluble nitrate of mercury, as well as various other liquid articles, was formerly employed by dipping a piece of lint or charpie in the solution, and applying it for several times, at intervals of many days, upon the surface of the bone, till the exfoliation of a necrosed lamina took place; a result which seldom occurred under fifteen or twenty days. By this method it is difhcult to prevent the liquid from acting injuriously on the soft parts. The newer caustic preparations, as the zinc or Vienna paste, are more active and far less likely to run, and should always be used in preference to the liquid articles. They should, as observed at page 21, be employed in many cases in preference to the actual cautery, where, from the nature of the parts, the latter cannot be used without danger. When the caustic is removed, the wound should be carefully cleansed, and dressed flat with a roll of charpie or lint, so as to keep the flaps everted. The tediousness of the cure ordinarily by the use of caustics, and the difficulty of their application, have induced many surgeons to give a decided preference to the actual cautery, as the most prompt and certain method of arresting the progress of caries. Actual cautery. — The mode of employing the heated iron has already been described at page 24. The disk-shaped cautery will be found most appropriate where a large surface is to be acted on; the conical or cylindrical where there are mere excavations or fistulous channels in the bone. After reflexing the flaps of skin from the carious surface, to protect them from the heat a sort of caiiula should be formed with a piece of moistened card, which is easily adjusted to the particular configuration of the diseased part. Having arranged this, and carefully removed all moisture from the face of the bone, the cautery heated to a white heat is to be^ carried rapidly and slightly over the latter. The heat causes at first the blood, sanies, or pus, which fills the spongy tissue of the diseased part, to boil up as it were from the surface; this fluid should be carefully removed as it rises, with a sponge or roll of charpie held in the left hand of the surgeon, or applied by an assistant. Two, three, or if necessary four irons, according to the extent of the disease, will be required; carrying one of the irons into such fistulous passages as come into view, in order to destroy as effectually as possible every remnant of the caries. In order OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 101 to dirainish the pain of the operation, the iron should be changed as soon as it loses colour, which occurs speedily when there is much fluid in the carious structure. A sharp pain is felt in the bone as soon as the carious portion is destroyed, which serves as a proof that the cauterization has been carried to the requisite extent. The pain soon ceases on the removal of the iron. Simple dressing with dry lint or charpie is all that is required for a few days following the operation. At the end of a week sup- puration is established, and the dark eschar left by the iron begins to be detached by the development of granulations from the healthy surface of the bone. If on the contrary partial exfolia- tion only takes place, attended with sanious suppuration and fungous growths at the end of the second week, the cautery must be re-applied. If any fungous granulations spring from the edges of the flaps, they may be repressed with the hmar caustic or the soluble nitrate of mercury. Eesectioii. — The object of this operation is to completely re- move the carious portions of the bone with a cutting instrument. For the removal of small and superficial portions, the parts are to be exposed by the elevation of flaps, and the altered bone removed with the gouge, the saw, or other fi.tting instrument. No particular rules need be given in cases of this description. The mode of resecting larger portions of bone will be particularly detailed, in a section devoted to that subject. TREPANNING OR TREPHINING OF THE BONES OF THE CRA- NIUM. (PL. xxmo The object of this operation is the elevation of a depressed bone, the removal of a fractured or diseased porlion, the eslrac- tion of foreign bodies, or the evacuation of blood, serum, or pus, which has been effused within the cavity of the cranium, The use of the trephine dates from the time of Hippocrates, who has given in respect to it some very judicious instructions; but in no other operation have the opinions of the older and more modern surgeons differed so much in respect to its value. This is in a great measure owing to the delicacy of the structure and the important offices of the brain, the only circumstances that give to injury of the bones of the cranium any peculiar importance, and which may become deeply involved in such a variety of ways, either from the direct or secondary effects of the injury itself, j or as the immediate or remote consequences of the operation. The proper indications for l!ie use of the trephine, in depression, fracture, compression, etc., can not here be satisfactorily shown, without going more extensively into a consideration of the effects of injuries of the brain than would accord with the limits of this work. Referring the student, therefore, to the treatises on this subject, I shall, after a few brief remarks, proceed to consider the operation. i Marchetti, Sala, La Motte, and several modern sugeons, as- sert that they have employed the trephine with success in cases of epilepsy; and Panarotti and Fabricius Hildanus, for chronic cephalalgia and hypochondriasis. Were such afifections obviously : dependent on the presence of a foreign body, a tumour, or an exostosis of the iimer surface of the cranium, there would be some indication for the operation. But in cases of this descrip- tion, even where the affection can be directly traced to local injury of the cranium, it is exceedinglv difficult to make out the 2G diagnosis with suflicient certainty to warrant the resort to so serious a proceeding. It is, therefore, only in respect to injuries of the brain, that the operation will be considered. As late as the eighteenth centnVy trephining was, as a general precept, practised without distinction in almost all sorts of wounds and injuries of the head, not only as a means of cure for the symptoms of irritation or compression to which they might give rise, but as a means of protection before they were developed. The gross abuse of the application of the trephine, to which such indications wonld lead, has been vigorously opposed, especially by Desault, Abernethy, Langenbeck, Physiclc, Gama, Cooper, and others, who restricted its use to cases where the secondary symptoms of irritation and compression were strongly manifested, waiting always as regards the operation to see if these should appear. This doctrine was founded chiefly upon the serious nature of the operation, and upon the well-known fact that elTased blood may be completely removed by absorption under the influence of appropriate treatment, and that even the depression of a piece of bone will occasionally be borne without injurious consequences. The reaction thus produced mainly by the influence of Desault and his school,* established on the oiher hand an excessive repug- nance to the operation, and trephining came to be considered as a desperate resource, which, if used at all, was apt to be applied too late. But the careful opening of the walls of the cranium, where no inflammatory symptoms prevail, is not of itself an operation of very serious danger; and the success which the older surgeons met with after its employment, compared with the almost con- stant fatality which has followed its use in later times, goes to show tliat the cause of death in the latier instances is to be found in the restriction of the operation to the worst class of cases, and partly perhaps in the fact that the affection of the brain and membranes consequent to the injury had been allowed to de- velope itself previous to resorting to the operation. Though in every respect opposed to the prodigal use made of the trephine by the older surgeons for the purpose preventing inflamma- Hon, I believe, from what I have myself witnessed, that it would be well, (notwithstanding the excepli(Jnal cases reported, of " i?n.viarcl, more than one hnndi-ed years ago, found that most of ttie patients frcpliined at the Hotel Dieii, (when many surgeons, not yet having learned the value of saving the integuments to cover the wound, cut away the scalp from over the place of operation,) died soon afterward in that unhealihy insiiiuiion of what was called the fever of the hospital. He objected to the use of ihe trephine. Desault followed more warmly on the same side, rejecting it almost in toto. Abernethy look up the subject on a different ground, and, without abandoning the operation, endeavoured to distinguish the cases suited for it; and laid down the rule, that the surgeon was not to trephine merely because there was fracture, depression, etc., but only for the consequences that these had produced. This has since been the ruling doctrine among British and American surgeons. Sir A. Cooper, Sir B. Brodie, and others, have receded slightly from the ground taken by Abernethy, and admit the immediate use of Ihe trephine in cases where there is fracture and depression complicated witli external wound. So little a matter, however, is the existence or the non-existence of an external wotiud in so serious an alfection, that the admission would seem to imply that a more frequent use of the trephine would be found advantageous; and Velpeau, in a more decided tone, advocates its employment. The subject, however, requires to be studied anew, with careful reference to the statistics of the operation, before full and precise indications can be laid down for the various cases that occur; for as yet some consider it doubtful whether indiscriminate trephining immediately after fracture and depression, would not be attended with nearly as good results as the modern practice of Abernethy and Desault. 102 GENERAL OPERATIONS. musket bullets and splinters of bone becoming encysied within the cranium without producing serious results,) if the attention of the profession in this country was brought to a less unfavourable view of the operation early after the Qccxtrre.nct of the injury, when, according to the principles established by Pott, it would enable us to get rid of an obvious cause of irritation, whether that be a foreign body, a depressed bone, a splinter from the internal table, or a mass of effused blood. I cannot but recall cases to mind, and every surgeon of experience in all probability can do the same, where the early use of the trephine might have saved life — such, for instance, as that of a depressed bone with a splinter from the external table sticking into the substance of the brain, and ex- citing abscess; the crista galli of the ethmoid driven by a blow on the forehead into the anterior lobe of the brain; various fissures of the skuil from external violence, leading to effusion, compres- sion, and meningeal inflammation; and ruptures of the middle artery of the dura mater, by a blow even with the fist, and with- PLATE XXIIL— TREPANNING Ofi out fracture of the bones. The admirable cures effected by Larrey in many cases of injury to llie head, are well known; and the advice of this experienced surgeon is, if we are called in within the first twenly-four hours after the reception of the injury, to proceed at once to the removal of such foreign bodies, splinters, or extravasated fluids, as the case may render necessary; but if not summoned until after the inflammatory symptoms are set in, to defer an operation till they have been abated by treatment. If, however, the removal of an irregular-shaped fragment sunken in the brain cannot be made without inflicting much additional irri- tation, it will be better for the surgeon to desist and trust the case to the eff'orts of nature, after having obtained a free outlet for the fluids which may form. Sir P. Crampton* was obliged to give over an attempt of this sort, where the fragment of bone was lodged in the substance of the brain, in consequence of the " Dublin Journal of Med. Sciences, vol. ii, p. 42, TREPHINING OF THE CRANIUM, Fig. 1. — The patient is represented in a state of coma, in a horizontal positioti, with his head elevated and placed with the injured part uppermost. The hair has been removed from the place of operation, and the four flaps formed by a crucial incision reverted, so as to expose the bone in the fronto-parielal region. Three instruments, for the purpose merely of exhibiting their use, are shown applied upon the wound; but it must be recollected that one only is to be employed at a time, and that so extensive a removal of the bone is rarely justifiable in the living subject. a. The left hand of the surgeon, holding between the thumb and fore finger the top part {h) of the French trepan, upon which the surgeon rests his chin in order to steady the instrument. c. Thumb and fingers of the right hand grasping the rounded part of the brace, with which the surgeon gives the circular movement. Four circular pieces or disks have already been removed in this case, which is supposed to be one of extensive hemorrhage over the dura mater, and the trepan is shown as on the point of being removed after a fifth application, in order to give free issue to the fluid, as directed by many surgeons. d. Surface of the dura mater, exposed by the removal of the four first disks, e. The cutting pliers, applied to cut out the angular projections left by the removal of the disks. / The right hand of the surgeon, removing with the lenticular knife the rough edges of the under surface of the divided bone. Fig. 2. — Same region of the head as shown in fig. 1, with the flaps similarly reverted after a crucial incision. The injury has been inflicted with the corner of a brick bat, whicli has comminufed and depressed a portion of the bone. A small central fragment has been detached with the point of the perforator (fig. 9), so as to make room for the end of the elevator, with which all the loose fragments are to be removed and the depressed margins elevated. Cases of this description frequently occur, in which the use of the trephine is not needed. ' Fig. 3.— This represents a fracture of the right parietal bone, with extensive longitudinal wound of the scalp, which has been enlarged by a vertical cut at either end, so as to allow the operator to expose the bone (c), by reverting two flaps (h and h), one upwards and the other downwards. The bone is extensively fissured, and a central fragment that was depressed has been removed by the application of a trephine, which has left the rounded edge at the lower part of the opening through the bone; the pyramid or centre pin of the trephine having been applied near the lower margin of the longitudinal fissure seen in the bone. T!ie dura mater {(/), thus exposed by the removal of the fragments, and found covering a mass of blood or pus eft'used below it, is to be opened ■with a bistoury from below upwards as directed in the text. Fig. 4.— This sketch is intended to illustrate the manner of holding the English or ordinary trephine, as well as the rules for determining in many cases the proper point for its application, when it is deemed best either to raise or remove the depressed fragment. The os frontis has been fissured, and a fragment of considerable size depressed. The bone has been exposed by a crucial incision and the reflection of four large flaps, The trephine was first applied at h, and the disk removed; an attempt was then made without success to raise the depressed portion. Another disk was then removed at a, and a second attempt made with like want of success, on account of a shelving piece from the inner table being attached to tlie fragment, as is most commonly the case at the margin et-j-^- CchowsJci PhUade^fua., PubUahed by Carey ^ Hart OPERATIONS FOR DISEASES convulsive movements and meanings excitedj in which instance the fragment was subseqnenily discharged by suppuration. Fractures of the bone, with or without depression, it is fre- quently by no means easy to discover, when there has been no opening in the scalp. In such cases, it is well to follow the ad- vice of Cooper, Brodie and others, and not, unless the symptoms are of such a nature as fairly lo indicate it, proceed from mere surgical curiosity to lay open the scalp, as the incision would necessarily be attended with an increased risk of erysipelatous inflammation. A proper distinction should be made as to the effects of depression, in reference to the age of the patient; for in children, the skull is more yielding, more readily depressed with- out fracture, and has a greater natural tendency to restore itself lo its previous state. The following are the indications for the use of the trephine in recent injuries, as given by M. Bourgery, one of the latest writers on the subject, — though his first division, as it would ap- pear to most surgeons, should be accepted with some qualification. i. In all fractures of the cranium, with or without depression. 2. Whenever the tissue of tbe bone is much broken up. 3. In every case where the dura mater has been involved in a pene- trating or punctured wound. 4. In gunshot wounds, complicated with the presence of foreign bodies. To which may be added: 5. When coma and compression come on in a few Iiours after the injury, especialiy after a blow over the temple. 6. When epilepsy follows in a case where there is a prominently depressed portion of bone, attributable, without chance of mistake, to the injury which the bone has suffered.* In many of liic indications included in this category, the application of the trephine may not be needed, if the offending portions of bone are so loose as to be readily removed with the elevator, or the male branch of a pair of scissors; or if the wound of the bone is sufliciently large to permit the extraction of any foreign body lodged in it, or to give issue to the products of hceniorrhage and suppuration. Instruments required for the operation. — 1. The common English hand trephine, seen at fig. 4, Plate XXII; or the instru- ment of Hildanus, known by the name of the French trepan, fig. 1, which is worked like a joiner's brace. 3. A Tirefond or • Vide a valuable paper on injuries of the head, by Prof. Dudley, in the 1st >No. of Transj'lvan. Journ. of Med.; and (among others) a case by Dr. D. L. Sogers, New York Med. and Phys. Journ., Vol. V, OF THE BONES AND JOINTS. 103 bone screw, like the tooth screw of the dentist. 3. A strong len- ticular knife, with different sorts of elevators. 4. Dressing and cutting forceps. 5. A small brush to clean out from time to time the circular groove of the trephine, and a piece of quill or ivory to measure occasionally its depth. 6. A straight Hey's saw and some bistouries. To these might be added, at the will of the operator, the osteotome of Heine or Martin, which are particularly useful here, as well as in trephining other portions of the bony structures for abscess or necrosis. It will also be found advantageous to have at hand an oblong piece of sole leather or cork, with a crevice cut in it, if we expect to use the Hey's saw; or a circular opening for the crown of the trephine, if we are disposed to apply the instrument on any point where the use of the pyramid would not be considered prudent. Points of application. — Authors in general direct the operator not to apply the trephine over the frontal sinuses, where the separation of the two tables of the bones render the operation more difficult; nor at the anterior and inferior angle of the parietal bone, which lodges in a groove or canal formed in its inner table, the middle artery of the dura mater; ^nor upon the track of the sagittal suture, for fear of wounding the longitudinal sinus; nor upon the middle of the temporal fossa, where several vessels and a large muscle are found; nor over the common junction of the sinuses at the occipital protuberance. These rules are good, and should always be respected, unless a well-founded indication exists for their violation; for the accidents liable to accrue from the operation at these excepted points may be easily guarded against. Hjetnorrhage from the artery of the dura mater may be arrested by a ligature, as was done by Dorsey; if lodged in a canal, by plugging as practised by Physick; or by cauterization with a heated stilet, in imitation of Larrey. The slightest pressure with a piece of lint suffices to check hsemorrhage from the sinuses. By using the precaution of Sir. C, Bell, to open the anterior wall of the frontal sinus with a large trephine, and the inner with a smaller, depressing the handle of the latter so as to act square on the bone, we may cut in the supra-orbital region with nearly as much safety, as regards the diira mater, as any other portion of the cranium. The separate removal of the external table is not, however, in all cases practicable, in consequence of the incom- plete development of the sinus in young persons. The selection of the point for operation will depend upon the location of the injury, and the object we have in view; for some- wliere the depression is greatest, A third application of the trephine was then made at c, and the fragment taken away without ditficulty, its removal being necessary in consequence of the complete insulation of the piece and its pressing by its rough edge on the dura mater. This is the only place at which the perforation should have been made. The two former perforations were not only unnecessary, but contributed to enlarge the gap in the bone, and increased the risk of hernia cerebri, which in a case analogous to this, described by Sir C; Bell, actually occurred and destroyed the patient. Fig. 5.— A portion of bone, which exfoliated after the use of the trephine in consequence of the dura mater having been detached from its under surface by injury. Fig. 6 and 7. — Two portions of different skulls, removed from the same site in each, showing the variable degree of thickness of the bone in different individuals, and the necessity of always proceeding cautiously in the use of the trephine, lest the dura mater should be injured. Fig. 8.— A circular piece of bone, showing the two tables and the intervening diploic structure. The last four figures are taken without alteration from Bell. Fig. 9.— The perforator. This is frequently a very useful instrument in enlarging a fissure where small fragments are depressed. It may be attached to the handle of a trephine. 104 GENERAL OPERATIONS. times it htis been found necessary to apply the trephine upon the side opposite to the external injury, when, from the effect of coun- ter stroke, an effusion of blood or a gradual accumulation of pus or serum has occurred there. In simple fracture, we should apply the instrument with the pyramid resting near one margin of the fissure, so that the section may extend upon both its sides. In fractures with depression, care must be taken that the crown of the trephine does not act upon a loosened bone, for fear of causing irritation or laceration of the parts below. When a foreign body is wedged in the wound of the bone, and the frac- ture is but limited, the crown of the trephine should embrace the whole solution of continuity. If a musket or rifle bullet pene- trate the cavity of the skull, the smallness of the aperture which it leaves will lead the inexperienced to doubt the fact of its pas- sage. The osseous fibres, yielding to the impulsive force of the ball, diverge many of them without breaking, and rebounding after it has passed, nearly close the aperture. In young subjects, where the bones are most elastic, this is particularly the case. In old individuals, the fibres are more disposed to break, and the ball takes out a portion of__lIie bone at least equal to one-half its diameter. A ball or similar foreign body, when its direction is such as to keep it between the bone and dura mater, may lodge at a spot a little remote from its place of penetration, without the extraction of it being thereby rendered impossible, or the case entirely hope- less.* In such instances, it has been advised, in order to ascertain the location of the foreign body, (when ils presence gives rise to symptoms of pain or compression, so as to render surgical interference justifiable,) to introduce a caoutchouc probe along its track, the contact of which with the foreign body, will be made known by the feeling of resistance and roughness com- municated. Withdrawing then the probe, and measuring the distance in the same direction on the outside, we find the place for the application of the trephine. In cases of extravasated fluids, we operate immediately over the supposed seat of effu- sion, and sometimes more than one perforation at the distance of an inch or more apart will be required. When the effnsion exists over each of the hemispheres, it has in some cases been deemed proper to make an opening on the two sides of the skull, but the chance of relief under such circumstances is nearly hopeless. In caries and necrosis, it is usually deemed most prudent to let the diseased portions separate of themselves, until they can be seized with the forceps and extracted. But if there should be such an accumulation of pus (which usually, however, flows without difhculty^ by some external opening,) as to give rise to symptoms of compression, a few applications of a small trephine may be made, and the interspaces divided with a Hey's saw or the ordi- nary cutting forceps. Operation. (PI. XXIII. fig. 1,2, 3.) — The point of the cra- nium upon which we are about to operate having been shaved, and the head supported on an inclined plane, and well secured by assistants, we proceed to the first step of the operation, which consists in — I. The demidaiion of ike bone. — No fixed rules can well be given for the division of the soft parts for the purpose of exposing '* Vide CampagEe de Constaniine, 1337, by Sedillot. the bone. If there already exists a wound of the scalp, this is to be enlarged in such a way as to admit the application of the tre- phine, by forming a V, A, T, or oval-shaped opening. Where there has been no external wound, the V shaped incision of Physick, with the point downwards, the flap dissected up to- wards its base and reverted, will uncover the bone with the least division of the vessels in operations over the temporal region. In other portions of the head, I have found the crucial or semi- lunar incision most appropriate. In making these incisions, the scalp should be divided at once by a single cut down to the bone^ care being observed in ease of fracture, that the knife does not penetrate below the surface. If the bone be much comminuted, it would be most judicious to make first a slight incision of the scalp, and open it subsequently to the requisite extent on a grooved director. The flaps are then to be dissected up, reverted, wrapped with fine linen, and held out of the way by an assistant. Formerly, it was directed to detach the periosteum for a space equal in size to the crown of the trephine, with the rasparatory, a practice now justly abandoned. If the divided vessels bleed freely, and do not shortly contract under tlie astringent aclion of the air and sponging with cold water, they are to be pinched, twisted or tied, as in other parts of the body. 3. Perforation of the bone. — This is to be accomplished either with the hand or English trephine, or the trepan instrument of Hildanus, which may be made to revolve either with a brace, or like a drill by the means of a bow. The operation is the same with all. The hand trephine is usually preferred in this country and in England, and no possible objection can be urged against its use, except the slowness with which it cuts when the bone is solid. The pyramid or centre bit is to be protruded beyond the level of the crown of the instrument, and firmly secured with the screw attached upon the side for the purpose. The point is then to be entered into the bone with a semicircular motion of the hand, made by alternate pronation and supination, the arm being held immovably fixed. This motion is to be continued till the teeth of the crown come in contact with the bone, and furrow for themselves a groove in the external table sufficiently deep for the instrument to run in securely. The pyramid, as it is no longer of any use, is now to be retracted, lest it should injure the dura mater by perforating the bone in advance of the teeth of the crown; and the operation is to be continued with the crown alone. This must be kept perpendicularly applied, in order that it may act at an equal depth on all the points of its circumference. The division of the diploe can be recognised by the ease with which the trephine cuts, rather than by the bloody detritus re- moved, usually given as the sign of this stage of the operation by writers. For on the living subject, blood constantly flows in sufficient amount to redden all the particles loosened by the saw. In old subjects and in children, the diploic structure of the bone is deficient, and the crown of the trephine must be withdrawn from time to time in order to clean the teeth with the brush, and furnish an opportunity to sound the depth of the groove, to see if it be equal in all its parts. We then resume the use of the trephine, remitting it after every third or fourth turn to sound the depth afresh, as we suppose we are approaching the under surface of the bone, which is very variable in its thickness in different indi- viduals. If the motion of the crown be impeded in one direction. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 105 we make a lialf turn backward, and continue the operation with siiglitcr pressure. If, on examination, the bone is perforated partially, but tiie piece still immovable, we are to continue the use of the trephine, inclining it on the adherent side, and avoiding carefully all pressure on the divided point, for fear of injuring the dura mater. When the furrow is cut liirough at several points, the finger nail or an elevator introduced into the groove, will serve to effect the separation of the remaining portion of the internal table, which takes place with a crackling sound. If, however, the depressed fragment is found to rnn somewhat shelving under the edge of the trephine, so mucli motion of it might be caused by the turns of the instrument as to lacerate with its rough edges the dura mater. As soon as this fact is ascertained, the trephine is to be laid aside, and the disk detached by two elevators applied upon opposite sides, to prevent the tilting of the fragment on the membrane. If the trephine has to be applied so as to cover a small frac- tured portion, or a ball or other foreign body lodged in the bone, the centre pin or perforator cannot be used to start the crown, A piece of sole leather or cork, with a hole of the proper size cut in its centre, and firmly held by an assistant, will serve to retain the crown until it cuts a groove deep enough for its own support. Use of the Hey's saio — Ci'anial saiv — Bridge saw of Graefe. — In fractures with depression where the margin of one bone slides over the other, or in depression without fracture which I have observed in children when a bone has been driven in at the sutures, or when the mere enlargement of an angular fissure becomes necessary, an opening may be made with this instrument more quickly and more conveniently than with the trephine. It is also applicable to cases where a large piece is to be cut out, the trephine being applied at the two angles, and the bridge between the perforations divided with the saw. A piece of leather or cork, with a crevice cut in it, is to be placed on the skull, within which the straight edge of the saw is to play, till it cuts a groove suffi- ciently deep to lodge itself. As the instrument approaches the inner surface of the bone, the circular edge of the saw alone is to be used, as less likely from the rounded shape of the cranium to inflict injury on the dnra mater. The same precautions, as to sounding from time to time, above given, must be attended to, and it will be found belter to break the last points of union, than to divide them completely with the saw. Rasparatory, or 7'iigine. — Rasping or scraping a point of bone with this instrument, or at need witii a piece of glass, untii the bone is so thinned that an aperture may be formed large enough to admit the point of a lever or a pair of forceps, so as to break out a piece, was formerly recommended, especially in injuries of the head in children. But the practice has justly gone out of use. When it becomes necessary, (which is more rare by far in children than in adults,) to interfere by operation, the trephine is to be preferred if complete ossification has taken place; and in case it has not, the point of the knife or a pair of scissors may supply the place of any other instrument by opening one of the sutures. 3, Removal of the detached piece of bone.—\i is directed to fasten the bone-screw into the orifice made by the centre pin, and by a few lateral motions loosen and detach the piece. The plan, however, generally preferred, is to apply the elevators on tiie 27 opposite sides of the piece, so as to detach and lift it out. Occa- sionally it will be brought away with the trepiiine. If the edges of the opening left be sharp and rough, they are to be smoothed off' with the lenticular knife, or, which answers better, as having less tendency to disturb the dura mater, the point of the common elevator. If there exist the necessity of applying several times the crown of the trephine, (PI. XXIII. fig. i,) it should be so disposed as to cut into the space from which a piece had been previously removed, so as lo leave but a small osseous angle, which can readily be divided by a Hey's saw or the cutting pHers. 4. Removal of the cause of compression. — If there is fracture with depression, the end of the common elevator, or the hook- shaped lever of Graefe, is to be introduced below the sunken piece, which is to be gradually elevated by using as a fulcrum for tlie instrument the opposite margin of the opening; or if this be not firm, the finger placed as a bridge across it. To prevent a too sudden elevation, which might detach the piece, it is well to make a little counter pressure on its outer face. If we cannot thus succeed in elevating the fragment, or the inner table is found shattered, it may be removed altogether with a Hey's saw, or another application of the trephine. Loose portions of the bone are to be picked away with the fingers or forceps. But in case one should be imbedded in the brain, and any disturbance of it attended by pain and convulsion, we might imitate the conduct of Sir P. Crampton, and leave it to be detached by suppuration through the external orifice. If the operation has been early done for extravasation or eff'usion, the fluid if it lay on the outer side of the dura mater will usually come away of itself But if it be coagulated blood, it will require to be broken up with the finger or probe, and it has even been directed to wash it out with a syringe and warm water. If the dura mater rise as the fluid is discharged it is a happy circumstance. But in none of these cases is the prognosis favourable. If the extravasation extend too far for this rising to be efl'ected, it has been recommended by Sa- batier to apply the trephine on another point, on the principle of a counter opening. If the effused fluid lay below the dura mater, this membrane will be found detached from the bone, and of a livid or brownish hue, and in most instances shares less than is natural in the pulsatile hcavings of the brain. It is apt also to bulge in the opening and present a feeling of fluctuation below; but this is a sign which might lead into error, for the soft cerebral substance in the healthy state gives on pressure of the membrane a somewhat similar sensation. The presence of the effusion having been detected below the dura mater, this is lo be opened, by pushing a straight sharp-pointed bistoury obliquely through it; then depressing the handle so as to raise the point of the in- strument, tiie membrane is to be divided in a direction parallel with its vessels. Another parallel puncture, or a cross cut, is usually required. If the operator find the seat of the fluid not on the inner surface of the meninges, but in the substance of the brain— the result usually of a contusion that has terminated in abscess he may, if from the change of colour and consistence of the brain and a sense of fluctuation there be unequivocal evi- dence of its existence, be justified in following the example of Dnpuytren and Begin, and pass a bistoury for an inch even into the cerebral substance, if the fluid lie so deep. The punctures of these surgeons, however, were ultimately followed by death. GENERAL OPERATIONS. Ill a case of this description on which I operated during the past winter before the class of the Jefferson Medical College at the Philadelphia Hospital, the altered dura mater puffed up through the opening made by the trephine. On incising this, the softened pultaceous cerebral substance pouted through the orifice, and gave to the finger a distinct feeling of fluctuation below. The wound was lightly dressed, and all proceeding suspended for the time, as life was not immediately in danger, in the hope that the abscess would spontaneously open, which it did on the following day, so as to relieve at once to a considerable extent the coma under which the patient laboured. More or less purulent discharge continued for sixteen days, during which time the patient improved so as to be able to wall: about the wards and converse rationally on most subjects. At the end of this period it ceased entirely, and the cessation was followed by a return of delirium, succeeded by coma, of which the patient sunk. On dissection the orifice in the dura mater, which had not been made sufficiently large, was found blocked up with fungous granulations from its margins, and the cavity of the abscess filling up with pus had opened into the posterior horn of the lateral ventricle, oppo- site to which the injury had been received and the perforation made with the trephine, 5. Dressing and after treatment. — The dressing must be light and unirritaling. A cribriform piece of linen spread with cerate is to be placed over the opening in the bone, with its angles doubled iu, to maintain elevated the flaps of the soft parts, and form a sort of channel for the discharge of the secretions. A pledget of lint or charpie is laid above this, and secured with a few turns of the roller or coxivre chef bandage, or even a close fitting cap. The stnfling of the aperture with hnt, and the use of thick tight bandages are to be particularly avoided. Cold fomentations are to be applied to tlie head, and a rigid antiphlo- gistic treatment instituted. It is well not to remove the first dressing till it becomes loosened by suppuration. Subsequently the wound should be twice dressed daily. If after the extraction of a fragment, or the evacuation of an elfused fluid, the symptoms of compression immediately cease, the parts may be closed with adhesive straps as in ordinary wounds, and reopened again if the symptoms return so as to render it necessary. If the operation has been done on a young subject, it may happen that a layer of new substance is secreted by the dura mater, which will ossify and supply the place of the removed portion of bone. But in the greater number of cases there is a very limited reproduction of bone, a tough resisting membrane supplying its place, through which the movements of the brain may be felt. It has been recommended to wear over the part, as a protection against external injury, a leather or metal covering. The trephine has also been employed with advantage in some cases of abscess in the mediastinum, accompanied with caries or necrosis of the sternum. It has also been three times .resorted to in injuries of the spine— by Ctine, Tyrrel, and Barton. But the result in each case was unsuccessful, and the method cannot be considered one of legitimate application. In the bones of the extremities the trephine and the Hey's saw become most useful adjuvants in several forms of disease, but partictilarly for the removal of sequestra in cases of necrosis. RESECTION OF THE BONES. The resecdon of a bone consists of its partial amputation. It is an operation done without destruction to tiie soft parts, so as to enable us to preserve, to a greater or less degree, the form and usefulness of the part from which the piece of bone is taken. It is in many cases the only alternative against amputation. Though not of particularly recent origin, it has mainly been brought into favour by the address and ingenuity with which it has been practised by modern surgeons. It is an interesting and fruitful department of the art, and under many circumstances becomes the means of saving not only the limb, but even the life of the patient. Operations of this class cannot, however, on ac- count of the varying nature of the causes which render them necessary, and the necessity of their performance at the diseased point, be subjected to the same definite and prescribed regulations as are given for amputation, and ligature of the arteries. The immediate method of proceeding in very many cases must be left to the judgment and ingenuity of the surgeon, and should be adjusted to the character and extent of the pathological changes in the parts surrounding the bone. The operations for resection may be arranged into three groups. 1. Those which are practised in the continuity of the bones; that is, at some point between their articular extremities. 2. Those in tlie contiguity, or at the articular extremities of the bones. 3. Those in which a bone is extracted in its whole extent. Indications. — The causes for which resection is practised are very various. 1. Caries of the articular extremities of the limbs, and of some of the bones of the trunk, when all other means have proved insnflicient for its cure, and life is endangered by the progress it is making. 2. Osteosarcoma, spina ventosa, medullary fungus, and other affections of a malignant character, when they involve ])arts, as the upper and lower jaw bones, to which amputation cannot be applied. 3. Compound or commimited fractures, in which a fragment has becndriven through the skin, and cannot otherwise be replaced in consequence of the obliquity of the fracture, the retraction of the muscles, or the inflammatory engorgement of the surrounding parts; or wiien a portion denuded of its periosteum has been ex- posed for some days to the air, and menaced with necrosis. The rule of treatment in such cases is both simple and easy — to en- large the wound if it be necessary, glide a piece of cord or some otiicr means of protecting the soft parts below the bone, and remove the protruding portion with a saw. 4. Gunshot injm'ies near the heads of the bones, and especially those of the upper extremities. These accidents, even when there has been extensive injury of the soft parts, have furnished again and again, occasion for the most gratifying and successfnl employment of the resection of the shattered portion, with pre- servation of the limb. 5. Compound luxations; when the period which has elapsed from the occurrence of the injury, or the engorgement and inflam- mation of the soft parts, or other causes, present an insurmount- able obstacle to reduction of the protruded head of the bone. In OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 107 cases of this sort resection has been many times done with suc- cess for most of the bones of the upper extremity. The end of a bone projecting beyond the margin of a stump after amputation, necrosis, some forms of exostosis, or foreign bodies lodged in a bone, are all causes for which resection can frequently be practised with advantage. Counter indications and prognosis.' — The resection of bones, especially when done for a chronic affection of the joints, consti- tutes nearly always a long, difficult, painful, and complicated operation, in consequence of the anatomical derangement of the parts, the enlargement and preternatural adhesion of the bones, and the tiiicUened and callous nature of the surrounding struc- tures, which render it difficult to distinguish the vessels and nerves, and produce a greater risic of tetanus, protracted suppu- ration, fistulous sinuses, purulent absorption, erysipelas, gangrene, and necrosis, than ordinarily follows amputation. In regard to the fitness or unfitness of each particular case for the operation, no precise rules can be laid down. The many and various cir- cumstances of the case, the age of the patient and his powers of endurance, and the particular joint atlected, must all be duly considered by the surgeon. Though cases seemingly very un- promising may eventuate well after resection, still-, not even the hope of saving a limb should lead the surgeon to prefer it to the more simple, easy, and rapid process of amputation, when the patient suffers from one of the cachexite, possesses unusual ner- vous susceptibility, or is in an advanced state of marasmus. Time of performance. — The time when resection could be practised with the greatest certainty of success is most frequently allowed to pass by, before the ordinary resources of the art have been satisfactorily tested. As soon, however, as the prospective loss of limb or life becomes apparent lo the surgeon, it should be undertaken, for fear that the soft parts should become too exten- sively involved to subserve the purpose of flaps. Nevertheless it is important to know, that if the tissues be indurated, lardaceous, or even perforated with fistulous openings, they will often, in consequence of the removal of the source of disease and the establishment of liealthy suppuration, be afterwards restored to a healthy condition. The elder Munro believed such a restoration possible, if they possessed even the lowest degree of vitality. But such has by no means been always the result. The chances of success will vary much according to the condition of the soft parts, as well as to the seat of operation. In the continuity of the long bones, and in the thin or flat, as the shoulder blade, the consecutive inflammation is usually moderate and the cure rapid. In the spongy tissue of the heads of the long bones, and in the bodies of the short or thick, the results of the operation are more to be dreaded, and in a degree proportioned to the extent of structure removed. Instruments and apparatus. — Besides the ordinary scalpel, there should be at hand a sharp-pointed and a probe-pointed bis- toury, a double-edged amputation knife for the larger joints, the common dissecting and torsion forceps, saws of various descrip- tions, the bone-cutting forceps of Listen and MuUer, blunt hooks, a trephine, the mallet and gouge or chisel, rollers, compresses, and strips of leather or flexible splints of wood, card, or metal, to glide between the bone and soft parts in order to protect the;n against the action of the saw — with sponges, ligatures, and the other necessary appurtenances for ordinary surgical operations. The tourniquet is not usually needed, as the large vessels are to be cautiously avoided, since their division would seriously com- promise the success of the operation. GENERAL KULES FOR RESECTION. The operation is divided into three stages. 1, The incision to expose the bone. — Two objects are to be kept in view — to expose the bone freely with the least injury to the muscles and tendons — and to avoid the route of the great vessels and nerves. For this reason, in operations on the arm and thigh, and over the orbicular joints, the incision is made on the outer aspect of the limb. In the hinge joints two lateral incisions are made, as the vessels and nerves are always found either on the anterior or posterior face of the joint. The incisions, however, must frequently be varied in regard to number, form, and extent, according to the size and depth of the bone, and the peculiar anatomy of the region. Considerable difficulty will often be en- countered in dissecting the soft parts from the bone, and in iso- lating the vessels and nerves, in consequence of the thickening, induration, and even partial ossification of the surrounding cellu- lar tissue. If an articular extremity is to be removed, tiie direc- tion of Professor Syme, (which I find usually the most convenient in practice,) is to penetrate at once into the joint, by dividing at the same time the superficial covering and the ligaments with the knife. 2. Section of the bone. — The soft parts are to be separated with blunt hooks, and the diseased heads of the bones loosened with the knife, turned out between the lips of the wound, and divided with the saw or culling forceps; or if there be a diffi- culty in turning them out, they may be cut in their bed witli the rotary saw of Heine or Charri&re, or the chain saw of Jeff"rey. In the removal of the detached extremities, the bone screw of the trephine case fastened into the spongy tissue, will furnish a convenient command of the fragments. All the cartilaginous structure of the joint must be carefully removed. If the caries is found to extend beyond the place of division, another portion may be removed, or the advice of Jager followed, wliich is to apply the actual cautery to the end, in order to arrest the caries by producing necrosis. It will seldom, however, be found neces- sary, in cases of caries, to remove more than the epiphysis; but, if the case be one of caries of the body, or necrosis of the shaft of a bone, the proceeding must be different. The extent of the caries will be determined in a great measure by the separation of the periosteum, which is to be opened, wilh the overlaying soft parts, by the probe-pointed bistoury, and the bone divided at the height at which the membrane is detached. If the caries involves but a part merely of the spongy slrncture, it is to be cut away with the gouge and mallet; but it is a law of the first importance when the operation is once commenced, to remove completely all the part actually carious, preserving as far as possible the periosteum. If the case be one of necrosis, the trephine, per- forator or gouge may require to be used, according lo the indica- tions already given. In resection of the bones of the forearm and leg at the ankle and wrist, it will be best in most cases to remove both at the same level, to prevent the subsequent deviation of the limb. GENERAL OPERATIONS. 3. Dt^essing. — Union by first intention is seldom effected to much extent. In one instance, however, in which I resected the elbow joint, it look place except at one point throughout the whole extent of the external wound, and the cure was proportionallj' rapid and satisfactory. An attempt, therefore, should always be made to accomplish it by closing the wound neatly with the interrupted suture, (to which I give the preference,) or the twisted suture — aided by adhesive straps, compresses, and bandages. The limb is to be steadied in addition with the apparatus for fracture, and placed at rest on a bolster or pillow. In the lower extremity, where we desire a solid union, the limb is to be laid out in the straight or extended position. In the upper, tlie elbow must be flexed, as a position !ess constraining to the patient, and likely to be much more serviceable in case the operation, if it be at a joint, should be followed by anchylosis. The first dressing should not be disturbed till the purulent discharge renders it necessary. The after treatment must be apportioned to the symptoms that arise. I have derived, it appears to me, very great advantage by keeping the wound steadily wetted for the first week with cold water merely, or a strong lotion of lead water and laudanum, placing the patient during this time under the sustaining influence of opium; thus limiting the amount of constitutional irritation by keeping down inflammation, and ob- viating the chief source of danger — the development of tetanus. RESECTION OF THE BONES OF THE TRUNK. The resection of the bones of the cranium, whatever be the cause that renders the operation necessary, — tumours, caries, or necrosis, — must be practised according to the methods which have been detailed under the head of trephining. RESECTION OF THE BONES OF THE FACE IN GENERAL. The upper and lower maxillary bones are far more subject than any others of the pile which constitutes the framework of the face, to structural degenerations, wiiich render their removal wholly or in part necessary. From the size and complicated structure of these bones, the disease, whether it consist of caries, cancer, medullary fungus, osteo-sarcoma, or tumours of a iess malignant character, is very often, even after it has attained great development, comprised within the limits of the tower or upper maxilla. Definite and fixed rules have, therefore, been given for the separate resection of these bones. But in many instances the other bones of the face, — particularly those forming the walls of the orbit and nose, as the malar, the unguis, the palatine, and the lateral portions of the ethmoid, — if not primarily aff'ected, become so involved in the progress of the disease as to ; require removal. But the intimate connection of these bones, their comparatively small size, and the varying degree of altera- tion to wliich they are subjected, renders it impossible to fix any general rule for their removal; the surgeon finding it necessary to modity or improvise, as it were, a plan suited to the exigen- cies of each particular case, instances may occur where the tumour, especially if it have its origin in the upper part of the antrum, will be found developing itself in the upward direction (in which it meets with less resistance), obstructing the cavity of the nostril and pushing the eye from its socket without materially impairing the integrity of the paiatine and alveolar processes. , In such instances, the outer wall of the antrum has been opened, (he contents of its cavity scooped or dissected out, and such por- tions merely of the bones above and around it as were affected taken away, leaving a part of the upper maxilla to preserve the proportions, and to a considerable degree the usefulness of the jaw. Tumours of a fibro-cellular character may even grow from the periosteum on the outer wall of the antrum, producing great deformity of the face, without altering the shape or specifically affecting the bones, which require no metiiod more severe for their removal, as has been shown by Dupnytren and Bieffenbach, than simply stretching the commissure of tlie mouth with hooks, (which may if necessary be extended by an incision,) dividing the buccal mucous membrane, drawing down the tumour with a hook and removing it from over the face of the bone. Frequently, moreover, we meet with instances where the tumour, as in epulis, has had its origin in the gums, or the sockets of the teeth, in which it suffices merely to remove with the saw and cutting forceps the parts immediately involved, not inter- fering to any great degree with the bony contour of the face, or leaving a greater breach on the side of the mouth than can be hidden by the mechanism of the dentist. OF THE UPPER JAW. (PL. XXIV.) In most instances, patients afflicted with malignant tumours of the jaws are unwilling to submit to an operation apparently so fearful as resection, until the upper maxilla of one side has become so much involved, as to require to be wholly taken away, and the other bones of the face so extensively implicated in the affection, that the saw and the bistoury will not alone suffice — the cutting forceps, the gouge and mallet, or the incan- descent iron, being required to complete the extirpation, without regard to the anatomical connections of the bones. General Rides. There are, however^ certain general rules for resection, as applied to any portion of the bones of the face, which must be constantly observed, as far as the nature of the lesion will allow. 1. To avoid injuring the parotid duct, or the branches of the portia dura nerve which give motion to the muscles of the face, by opening the soft parts in a direction as much as possible pa- rallel with their course. 2. To protect from unnecessary injury the facial artery and the infraorbital and mental nerves. 3. To carry the line of incision or amputation in a part of the bone which is perfectly free from enlargement or other indication of uniiealtiiy action. 4. To lie the arteries, which are commonly small, as they are divided and come into view, arresting the hemorrhage if it be profuse, until the ligature can be applied, by pressure on the common carotid or the temporal artery, and using the actual cautery to suppress capillary bleeding, as well as to destroy any diseased portion that cannot be reached by cutting instruments. The great improvement of modern surgery, in reference to the malignant growths of the upper maxillary bone, consists in its amputation entire at its points of articulation, instead of attempt- ing to cut out with saws, forceps and gouges, the diseased mass alone. If, by so doing, we get rid of the whole site of the dis- OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 109 ease, (he prospect of the return is infinitely less than when we have to attack in addition the palate, unguis and malar bones. Surgical anatomy. — The upper maxillary is united with the other bones of the face at four separate points, which, though well calculated to support pressure in mastication, may never- theless be readily separated. But three of these, however, as has been observed by Gensoul, merit tiie particular notice of the surgeon. 1. "Above and in front, where the nasal process of the maxillary joins with the frontal, nasal, lachrymal and ethmoid bones, 2. Upwards and outwards, where it unites with the malar bone, and through this is connected with the zygoma and with the external angular process of the os frontis. 3. In front and below, where it comes in contact with the corresponding maxillary and palate bones. The fourth, where it unites behind with the pterygoid process and the palate bone, presents no obstacle to the separation, yielding readily when the maxillary bone is depressed toward the cavity of the mouth. The arteries divided are small, and consist of the branches of the internal maxillary and the facial. The trunk of the former is not usually injured, but if cut can readily be tied after the removal of the bone. But one important nervous trunk is necessarily involved — the superior maxillary — and the division of tliis may be readily made, so as to prevent traction upon it, previous to the luxation of the bones. Methods hj. general. — Various methods have been employed for laying bare the bone, when the soft parts have not been so involved in the lesion as to determine necessarily a particular mode of incision. If the alveolar margin of the bone only re- quires to be removed, it will suflico in many cases to draw the lip upwards and outwards, and divide the mucous membrane which attaches it to the bone; and if more space is required in order that the saw or forceps should work with advantage, the mouth may be widened by division of the commissure: or, wliich is usually to be preferred, the upper lip divided near its middle by a vertical incision extended as far as necessary along the outer margin of the ala, the triangular flap being subsequently dissected off from the bone. It has been advised, if the portion of bone aflected be between the incisor and third or fourth molar tooth, and extends upwards towards the orbit, to divide the cheek in the direction of the inner border of the zygomaticus major, from near t[ie angle of the mouth upwards and outwards to the margin of the masseter, without injury to the duct of the parotid. If the tumour be broad and the dissection of the soft parts in either direction do not sufficiently expose its surface, a vertical incision through the lip and by the side of the ala nasi may be added so as to form a sort of V shaped flap, which is to be dis- sected up towards its base. If the disease is located behind the third or fourth molar tooth, the outer incision, instead of passing along the course of the zygomatic muscle, should run out trans- versely to the masseter, leaving the duct of the parotid on the upper flap. M. Gensoul recommends, especially where the entire bone is to be removed, the formation of a square flap as detailed in the process below, Mr. Ferguson* advises the V shaped flap above described, with the addition of an incision extended from the external an- * Practical Surgery, Amer. edit. p. 520. 28 gular process of the frontal bone, towards the neck of the lower jaw, so as to form an outline of this description N. Velpeau has proposed to substitute for the complicated incision of Gensoul a simple division of the cheek, (see PI. XXIV. fig. 3,) extended from the corner of the mouth to the external canthus of the eye, or the region of the temple immediately behind it, leaving the duct of the parotid in the lower flap. The cicatrix following this process is more regular and less deforming than that following the process of Gensoul. Dietfenbach* has proposed a new method of turning olT the soft parts, which he has applied to the resection of the bones of the face in general. Whatever is the seat of the disease, even if it were placed in the posterior region of the cheek, he dissects up and throws back a large flap, which is marked out above by a horizontal incision passing from one ca7ithus to the other, leaving entire the lower eyelid; and on the median line by a vertical incision through the middle of the upper lip and over the back of the nose, through both skin and cartilage, so as to divide the latter into two equal parts. Care must be observed to pre- serve the conjunctiva with the upper lidj and, in dissecting at the internal canthus, to separate the tissues from the bone, so as to avoid injury of the lachrymal passages. In dissecting back the flap, the infra-orbital nerve is the only part of importance divided; but although the facial nerve, the duct of the parotid, and the facial artery, are preserved uninjured in the thickness of the flap, it is very questionable whether, from the risk of injury to the eye, and of the chance of deformity in reconstructing the nose, it will ever be much employed by any other surgeon. Process of Gensoul. (PI. XXIV. fig. 4.) — The patient is to be seated on a low chair, with his head thrown back and sustained against the breast of an assistant. A vertical incision is to be dropped from near the inner canthus of the eye, so as to divide the upper lip completely through over the dens caninus. A second transverse incision is to be carried outwards from this, com- mencing on a level with the nostril, and terminating a third of an inch in front of the lobe of the ear. To the outer end of this incision a third is carried down nearly vertically, beginning at a point about half an inch to the outer side of the externa! canthus. The whole side of the face is thus divided into two flaps; the upper one, which is square, is to be dissected and turned over the forehead, and the lower, somewhat triangular in shape, re- versed merely upon the angle of the jaw. The bone is now fully exposed. If a portion only is to be taken away, it may be done with a knife if the bone be soft, or by the use of a Hey's or a narrow-bladed saw, the strong cutting forceps, or if need be, the mallet and chisel. But if it requires to be taken away entire, it will be necessary to detach it with five blows with the mallet and chisel, or as many applications with the cutting forceps, which will usually be found to answer the purpose as efTectually and with less yhock to the brain. First, we divide the union of malar bono to the external orbital process of the os frontis. Sec- ondly, the zygomatic process of the malar bone. Thirdly, the os unguis and the nasal process of the upper maxillary. Fourthly, all the soft parls uniting the ala of the nose to the bone; removing the first incisor tooth of the same side,and entering a chisel at this point, * La Cliirurgie de Dieffenbach, par Ch. Pliillips, Berlin, part. L p. 133. 1840. no GENERAL OPERATIONS. but in the direction of the eye of the affected side, so as to separate the diseased bone from tlie place of jnnctioii with the one of the other side. (The maxilla is now loosened at its three principal points of attachment, and is held by no other bones than the palate and the pterygoid process of the sphenoid.) Fifthly, the chisel is to be directed obliquely upon the floor of the orbit from above down- wards and before backwards, in order to destroy its connections with the pterygoid process, to divide the upper maxillary nerve, and at the same time gain a point of support, so as to poise the loosened bone over in front. The snrgeon has then only to divide with the curved scissors or bistoury the soft parts connected witli the bone, and especially the attachments of tJie velum palati to its lower and back part, which is to be left entire. The mass of bone, which now readily comes away, consists of the upper maxillary and the malar bone, and a part of the unguis, ethmoid, and palatine. A large excavation, (PI. XXIV. fig. 3,) limited within by the septum of the nose, witiiout by the buccinator mus- cle, above by the inferior rectus muscle of the eye, (the origin of which has been divided,) and the fat of the orbit, communicating below with the mouth, and beiiind with the pharynx, above the velum palati. This operation, formidable as it appears, may nevertheless be quickly done. Gensoul, has operated in eight cases without losing a patient; and in one instance the removal of the bones was effected in two minutes and a half. U is seldom PLATE XXIV,— RESECTION OF THE UPPER JA¥. (Process as empJoytd hij Warren, and modified by Velpeau.) Fig. 1 and 2.- — A semilunar incision has been made from the commissure of the lips to the middle of the space between the external canthus of the eye and the point of the ear, as shown in fig. 3, and the flap rapidly- dissected off from the bones, and reverted with the undivided upper lip upon the forehead, where it is held by the two hands of an assistant (d and e). The zygomatic process, the external angle of the orbit, the nasal process of the upper maxillary, and the palatine arch between the second incisor and canine teeth, have all been successively divided, as well as the fat of the orbit carefully detached from the floor of the orbit without injury to the ball. The next stage of the operation is that shown in the figure in which the surgeon loosens the bone with his left hand, while with a knife in his right he detaches from above downwards the soft parts from the bone on the side of the zygomatic fossa. fi Section of the zygomatic arch. g. Section of the external orbital process. h. Section of the nasal process of the upper maxillary bone. i. Section of the palatine arch. J. Eyeball, surrounded with its mass of fat. k. Maxillary bone, moved by the left hand of the surgeon (l) for the purpose of shaking it from its remaining attachments, while it is detached with the knife (m) from its connection with the soft parts in the zygomatic fossa. In fig. 2, the surface of the wound is exhibited after the removal of the bone. The space from ii to o shows the portion of undivided lip reflected upwards with the flap. p. Section of the upper maxillary bone. (J. Palatine arch. r. Nasal septum, aboi;'e which is seen the middle turbinated bone and the os planum of the ethmoid. s. Posterior opening of the nasa! fossa, comprised between the septum within, and the zygomatic process without. t. Border of the temporal muscle. u. Section of the zygomatic attachment of the raasseter. V. Surface of the tongue. Fig. 3, — Wound closed after the preceding operation. Fig. 4,— Closure of the wound, after the removal of the bone by incisions made according to the process of Gensoul. Fig. 5.— Excision of upper jaw bone, as practised by Lizars, Syme, Liston, and others. a, b, b. Line of incision of the upper lip, extended from the nostril through the ala of the nose, Liston prefers to make Ihe incision from the margin of the nostril along the line of junction of the ala with the cheek. d. Horizontal incision from the corner of the mouth. The triangular flap thus formed is to be dissected up rapidly from the face of the bone, and reflected upwards and outwards. Fig. 6. — View of the parts after the elevation of the flap, formed as seen in fig. 5. a, b, b. Vertical line of incision in the lip and side of the nose. d. Horizontal incision, c, e, i. Flap reflected off' from the tumour of the maxillary bone (g). h. Nasal process of the upper maxillary bone, sawn or cut across with the forceps, k. Palatine portion of the upper jaw bone, cut through into the nostril after the removal of the canine tooth. T. The facial artery, divided ia the horizontal incision, and secured with a ligature. Plate OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. Ill that more than oiio or two small arterial branches require to be tied. Necrosed portions of bones will be frequently thrown oft' for some time after the operaiion. More or less paralysis of the face follows, a result which can only be avoided by opening the soft parts after the manner of Dieffenbach. Dressing. (PI. XXIV. fig. 4.) — The wound is kept open for half an hour or an hour, in order to allow the capillary bleeding to cease, and to facilitate, according to Dieffenbach, union by first intention. If there is any morbid or even suspicious tissue left after the removal of the bones, the actual cautery is to be used to destroy it. If it be found even on the under surface of the flaps, DieiTcnbach does not hesitate, when it can be removed by this means, to pass the cautery rapidly over it, in preference to removing any portion, which would increase the amount of the deformity. The flaps are to be brought together with the twisted suture, and the parts are to be supported according to the direc- tion of Velpeau, by a retaining bandage. Cold applications are to be made over the face. The bones left will gradually approximate during the progress of the cure, and the deformity following the operation will be much less than would be pre- viously supposed. A troublesome incident during the operation is the fall of the blood into the throat, and it is for tlie purpose of obviating it as much as possible, that the patient is placed in the sitting posture, and that the detachment of the bone is commenced on the side of the cheek. The cavity between the tongue and the eye bait, is to be filled with lint orcharpie, to prevent the former sinking too low, and withdrawn at subsequent dressings through the orifice of the mouth. Process of Lizars. (PI. XXIV. figs. 5 and G.) — The surface of the bone is exposed up to the margin of the orbit, by the ele- vation of the triangular flap, referred to at page 109, formed by a horizontal incision from the mouth and a vertical one through the side of the nose and the upper lip. The soft covering of the bone is then to be divided at the parts where it is to be sawed, by ap- plying the knife; first, upon the floor of the nostril; secondly, over the nasal process; thirdly, upon the gum and mucous membrane of the mouth, near the palatine suture, keeping in view the preservation of the palatine plate of the palate bone; and lastly, round the bone on the side of the pterygoid fossa. The nasal, the malar, and palatine processes, are now to be notched with a saw. One blade of a large pair of cutting forceps is introduced into the nose, and the other into the orbit, so as to divide the nasal process of the maxillary bone. The conneclion of the maxillary with the inalar bone is then separated in the same way; and finally, after having removed one of the incisor teeth, (provided it had not previously come away,) the alveolar process and palatine plate is to be similarly divided near the point at which the two maxilla come into conjunction. The principal attachments of the bone being now destroyed, its removal is to be completed as in the process already described. In large tumours of the bone, this incision of the soft parts will not be found to give the surgeon sufficient freedom. The process of Mr. Liston for exposing the bone in cases of large tumour, is somewhat different. He forms his flaps by three incisions; one of which extends from the external angular pro- cess of the frontal bone, through the cheek to the corner of the month, one along and down the zygoma at right angles to this, and a third from the nasal process of the maxillary bone, dividing the ala from the bone at its connection with the cheek, and passing through the middle of the upper lip. Professor Ferguson, after turning off" the soft parts, by a flap formed by the vertical incision of Liston, and a semilunar one from the corner of the mouth, which terminates on the zygomatic process of the malar bone, directs first a division of the mucous lining of the hard palate, on the diseased side of the median line, as far back as the velum which is also to be separated on the same side from the hard palate. The alveoli and palatine plate are to be deeply noiclied with a small saw, near the median line from below upwards, and the section completed with the cutting forceps. If the malar bone and the orbital plate of the maxillary are sound, neither is to be removed. A notch is to be made across with the saw from the nasal process of the maxillary to the outer margin of the malar bone, and the forceps used as before to complete the separation, as well as to divide the nasal process of the maxillary. But if the orbital plate and malar bone are diseased, the forceps are employed to divide the difi'erent attach- ments of the bones, at the points indicated in the process of G ensoul. If the reflexion of the triangular-shaped flap in the preceding process does not sufliciently expose the bone, Dr. Ferguson makes another cut from the external angular process of the os fronlis, in the direction of the neck of the lower jaw, so as to fall upon the outer end of the incision from the corner of the mouth. Process employed loilh success by Professor Warren'^ a7id M. Velpeau. (PI. XXIV. fig. 1.) — This process is of all others attended with the least mutilation of the soft parts of the face. It affords in all ordinary cases sufficient room for manipulation on the bone, and is therefore entitled to a preference. A single semilunar incision is extended from the temporal margin of the outer canthus down to the angle of the mouth. The large flap thus marked out is dissected up rapidly fi'om the face of the bone, and the ala of the nose detached at its root so as to admit of being drawn upward with the rest of the flap toward the forehead, as shown in the plate. At the lower part of the wound, the soft parts are to be dissected off" and turned downwards, so as to ex- pose the malar and maxillary bones as far back as the pterygoid processes of the sphenoid. The origin of the inferior rectus muscle of the eye and the parts surrounding the ball, are to be carefully separated from the floor of the orbit. Tiic subsequent detachment of the bone is made with the aid of the saw and forceps, nearly as in the manner already described. In a case of extensive cancer of the jaw, M. Velpeau followed, however, more nearly tlie process of Dietl'enbach. He made a horizontal incision of an inch, from the external cantluis of the eye to the zygomatic arch. A vertical one was dropped from the inner angle of the eye, which divided the soft parts covering the back of the nose and the middle of the upper lip, exposing the cavity of the nostril. Joining then the two incisions at their upper part, he lowered the inferior eyelid by dividing the con- junctiva at its point of reflexion along the inferior margin of the " Vide Walsh on Cancers, iv-ith additions by J.Mason Warren, M.D. Boston, 1S44. 112 GENERAL OPERATIONS. orbit. He dissected the flap from above downwards, and reversed it in the direction of the angle of the lower jaw. The zygomatic process was then divided with a chain saw, and the malar bone with a chisel cut near its junction with the orbital process of the OS frontis. An incision was next made through the velnm palali for the passage of one end of the chain saw, which was drawn outwards; and the arch of the palate severed with this instru- ment from before backward. The nasal process of the upper maxillary was divided whh the cutting forceps, and the maxillary bone wrenched from its connections with the palate bone and the pterygoid process. The operation was successful, RESECTION OF THE LOWER JAW. (PL. XXV.) The resection of the lower jaw, either in whole or in part, is an easier and much less formidable operation than that of the upper. Partial resection. — The partial resection of the lower jaw PLATE XXV.— RESECTION OF THE LOWER JA\V. {Fig. 1.) RESECTION OF THE CHIN. This portion of the bone alone being diseased, the middle of liie lip has been divided iu the middle line, and the section continued down to the os hyoides. The flaps have been dissected otf and reverted, and the two canine teeth extracted, to give passage to the saw with which the jaw is divided vertically on either side of the chin. Previous to detaching the piece, a fuie silver wire has been passed through the substance of the genio-hyo- glossus muscles, iu order the prevent the convulsive retraction of the tongue backwards. In the stage of the operation shown, an assistant holds the wire thread («), while the surgeon draws downward with the left hand [b), the fragment of the jaw, and with the bistoury (c), is about to divide the insertions of the genio-hyoglossus, and genio and mylo-hyoid muscles. {Fig. 2.) RESECTION OF THE BODY OF THE LOWER JAW ON THE LEFT SIDE. The points for dividing the bone being at the canine tooth of the same side, and at the origin of the ramus, a vertical incision (a) has been made through the lip to the base of the chin. Another incision {b), starting from the middle of the posterior part of the ramus of the jaw, is carried first down to the angle, and then along the base of the jaw to the vertical incision at the chin. The flap (c) has been dissected ofl" from the bone, and reflected upward upon the cheek. The first molar tooth has been removed to give room to the saw in dividing the bone. The bone has next been separated by dissection from the soft parts on its inner face, and a guttered instrument (e) passed below the bone, on the groove of which the chain saw of Jefi"rey has been passed, as seen in the drawing, for the purpose of making the last section of the bone. {Fig. 3.) RESECTION OF THE WHOLE LOWER JAW. A single incision, commenced below the lobule of the ear at the posterior part of the ranms of the jaw of one side {a), has been carried first down to the base of the jaw of the same side, then around the base {b, c), and ascending on the ramus of the opposite side, to a height corresponding with its place of commencement. The facial artery wili be divided in this incision, and must be secured with a ligature. The immense flap {d) thus circumscribed, is dissected from below upwards off from the bone, loosening it first in its middle portion, and then on its sides, by cutting the attachments of the masseters (e). The flap is then reversed upon the face, so that (he edge of the lower lip (/) becomes inverted. Tiie jaw is next isolated below and within by dividing the platysma muscles {6, c), and the mylo-hyoid {g). Then, before cutting the attachments of the tongue, a wel! annealed silver wire is passed through the substance of the genio-hyoglossus muscle, brought out between the lips, and given in charge to an assistant; after which the attachments of the tongue may be divided with impunity. The jaw thus isolated on its inner side, is sawed through at the symphysis, to facilitate the disarticulation of each branch. In the drawing, the left half has been already removed, and the right, forced outwards, displays the gutter (e) from which the jaw has been removed, the under surface of the tongue {m) the sides of the tongue {n), placed within the upper dental arch, and the seclion of t!ie left pterygoid muscles {o\ Between these muscles the trunk of the internal maxillary artery has been tied, so as to prevent hjemorrhage from its various branches— the inferior dental, the masseier and pterygoid, which have been cut in the operation. The assistant, who holds with his hands {jhP) flap, is to make pressure previously on the trunk of the temporal artery till the stage of the operation arrives in which the internal maxillary can be secured. In the last step of the operation, as represenled in the drawing, the surgeon, after having isolated the coronoid process, forces out the right half of the jaw with one hand, while he divides with the knife in the other, the insertion of the internal pterygoid near the condyle, which presents the last obstacle to the disarticulation of the bone. ■ OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 113 has been many times successfully performed, without leaving any very great deformity of the face, or much defect in speech or deglutition. Of one hundred and sixty cases collected by Vel- peau, one hundred and twenty have been reported as successfnl. a. Jieseclion of the chin. — When it has been necessary to remove only the gums and alveolar processes of this region I have been enabled to sufficiently expose the bone by dissecting the under lip off from the gums, and having it strongly drawn downwards by an assistant. But if the tumour project much laterally, it will be necessary in addition to drop two vertical lines tlirough the lip from either commissure. The two teeth corresponding with the outer margin of the disease, are then to be removed if they have not previously fallen out, and the sur- geon standing behind the patient, divides the alveoli vertically at these points with a strong pair of straight cutting forceps; but if angular forceps be used, he may keep his position in front. With a pair of large and strong cutting nippers, applied so as to grasp the bone anteriorly and posteriorly, the piece is detached. A Hey's saw, or that of Barton, may be made to serve in place of the former instruments. The wounds in the lip are to be closed with the twisted suture. If the whole mental protuber- ance is involved, the following method is to be employed. Ordinary process. (PI, XXIV. fig. 1.) — The patient is to be seated; for in this position he is less exposed to the feeling of suffocation from the blood flowing back into the throat, as well as to the convulsive retraction of the tongue when its anterior attachments are divided, which is the most serious inconvenience attendant on this operation. An assistant placed behind com- presses the facial artery under the angles of the jaw, as directed at page 33, and sustains at the same time the head of the patient against his breast — the feet of the latter resting over the top of a stool, so as not to furnish a point of support sufficiently firm to enable him to raise from his position during the operation. \st step. — The surgeon takes hold of the lower lip by one of its angles, and an assistant the other; the lip is drawn upwards so as to make it tense, and at the same time held outwards from the jaw. With a single cut, it is to be divided in the middle hne, and the incision subsequently extended down through the skin and cellular tissue merely, to the top of the os hyoides. The lip is now to be detached to the right and left from the surface of the bone, and the flaps held outwards and upwards by as- sistants. 2d step. — The limits of the disease are now to be carefully ascertained, the periosteum divided on the points at which the section is to be made, and the corresponding teelh removed, so as to favour the action of the saw. The bone is then to be deeply notched from above downwards with one of the small saws previously mentioned, the tongue and tlie soft parts behind being protected by a piece of pasteboard or leather, a spatula, or, which 1 have found sufficient, the finger of the surgeon. If the saw is used only in the vertical position, tiie surgeon places himself so as to lean over the patient. It is not necessary to do more on either side than notch the bone deeply with the saw, as the remaining part may be readily divided with the forceps. If the chain saw is used, it is to be passed round the inner surface of the bone, through an opening previously made for it with the bistoury. If the disease will admit it, the bone is always to be divided on the inner side of the mental foramen, in order to spare the nerve which this orifice transmits. If possible, the bone is also to be sawed through obliquely, so as to remove less from the inner than the outer side. 3d Step, — The removal of the piece. — The surgeon, standing in front, passes from below upwards, behind the bone, a sharp- pointed bistoury, with which he carefully shaves the inner surface from left to right, so as to divide all the muscles and soft parts connected with it, the tongue being held back as above directed, to keep it from coming in contact witli the knife. As soon as the muscles of the chin are severed and the bone is removed, the stylo-glossus and genio-hyoglossus muscles draw the tongue strongly backwards, so as to involve, if their action is not resisted, a risk of suffocation by closing the glottis. Magendie lost a patient under such circumstances, and Lallemand in another in- stance was compelled to resort to tracheotomy. This distressing symptom, attendant on the contractile effort of these muscles, usually however quickly disappears, especially if the head be inclined forwards. Nevertheless it is best to obviate it by caus- ing an assistant to seize it with a towel or a pair of hooked for- ceps and hold it for a few moments; or, which is to be preferred, with a ligature previously passed through its point or freiium, as seen in the accompanying plate. When the chin can be tilted forwards the muscles can sometimes be conveniently detached from the bone, by dividing them from above downwards. Any diseased glands in the vicinity are also to be removed. 4. Dressing. — The wound is to be sponged clean, and the bleeding arteries tied. If hiemorrhage occurs from the dental artery, the orifice in the bone may be stopped with a plug of wax. If bleeding continues from the spongy tissue below the tongue, and the arteries have retracted so as not to be discovered, the surface is to be touched with the heated iron. The flaps are to be brought together and secured with the hare-lip suture. It is usually recommended to introduce a mesh of lint or charpie into the bottom of the fissure, in order to give vent to the secretions which follow; but this is a measure of doubtful utility. The thread which has been passed through the frenum, after the manner of Delpi^ch, it is advisdfl by the same surgeon to bring between the flaps and secure it to one of the hare-lip pins, until the tongue has had time to form new attaciiments. To prevent the falling of the sides of the bones inwards, Mr. Nasmyth, of Edin- burgh, has devised an ingenious little instrument — a double silver case to contain the upper and lower molar teeth, which shonld be made to fit on, previous to the operation. Each step of the usual operation as here described may require to be more or less modified, to suit tlie exigencies of particular cases. If the disease of the bone be too extensive to admit of its being thoroughly exposed by the triangular flaps formed by the vertical section of the lip, it will be necessary to divide the parts by an incision in the sliape of the letter J_ reversed, the base running along the under surface of the chin, and dissect up a quadrilateral flap on either side. If the disease is cancerous, it will usually he found to have commenced upon the lip, and therefore necessitates the removal of a portion of the latter in a V shaped flap, the apex of which shall point to the os hyoides. If the entire lip is so in- volved in the disease, or a considerable portion of the cheek, as to require to be taken away, the breach is to be filled up by 114 GENERAL OPERATIONS. one of ilie plastic processes hereafter to be described, and the success of the case will depend very much on the ingemiiiy and skill with which the surgeon accomplishes the latter proceeding. Wiien merely the anterior or external table of the bone is invaded by the disease, the posterior part may be left, as directed by Del- pech, to preserve the normal contour of the jaw, and the attach- ment of the iingual muscles. When it has been necessary to remove a considerable portion of the bone, the flaps will be found occasionally too large to make a neat closure of the gap, and it will become necessary to retrench them by the removal of a V shaped portion. Gensoiil recommends that this should be taken off by an oblique cut from the margin of one of the flaps only, so as to get a lateral cicatrix, and thus avoid the tendency which a directly linear cicatrix has to gradually lower the lip by its long continued retraction. In my hands, however, this has not proved a very satisfactory modification, as it only in part accomplishes the object, and distorts more or less one of the angles of the mouth. In favourable cases, and when but a small portion of the bone has been removed, the two ends will become solidly united together. When the interval left between the extremities is of considerable size, granulations may shoot out from the divided surfaces, forming a fibro-cartilaginous band of union, which subsetpiently becomes solidified by a deposit of calcareous matter, so as to restore the usefiihiess of the jaw in mastication. In cases where solid union cannot be brought about, the patient will be compelled to restrict himself to the use of liquid aliments. b. Resection of I he horizontal portion of one side. (PI. XXV. fig. a.)— The nature and degree of alteration of the soft parts may render necessary some peculiar form of incision for uncovering the bone. But when the bone alone is the part principally affected, one of the four following processes must be employed. 1. Process of Cloquet. Formation of an inferior sqitare- shaped flap, — The cheek is to be divided wiili a knife or strong pair of scissors, from the corner of the mouth horizontally back- wards to the posterior border of the ramus of the jaw. From the extremities of this, two vertical incisions are to be dropped; one in front to the base of the jaw — one posteriorly, descending from behind the ramus of the jaw to a few lines below the angle. The flap thus marked out is to be dissected oft' from the outer face of the bone, and reversed from above downwards. The tongue is then to be detached from the alveolar ridge, and the bone. cut across, first at the symphysis and afterwards at the origin of the ascending ramus. 3. Process of Molt. Formation of tloo flaps. — A semilunar incision, convex posteriorly, was made in one instance by this surgeon from over the temporo-maxillary articulation, and termi- nated upon the chin below the labial commissure. From the posterior and upper end of this incision, another was carried downwards to the back part of the angle of the jaw, and for a little distance along the anterior border of the sterno-cleido-mas- toid muscle. Two fiaps are thus formed; the superior, which is semilunar, is to be dissected and turned upwards— the inferior, or triangular, raised and turned downwards. The outer surface of the bone is now fully exposed. After dividing the inferior dental nerve at its place of entrance into the bone, and pressing the lingual nerve inwards, the resection of the bone is to be made. 36? Process. — An incision is to be dropped from the corner of the mouth to the base of the jaw; from the lower extremity of this another is to be carried along the base of the jaw for a quarter of an inch beyond its angle, when it should be curved for half an inch in the direction of its ramus. The flap is to be dis- sected loose from the bone, and drawn upwards and backwards by an assistant — and the facial artery, which had been previously compressed, secured by a ligature. This process, when the tumour is not too large, or the integuments extensively diseased, has incontestable advantages over the others, as the flaps after the removal of the bone fall so neatly into place, as to be followed by little deformity. In each of the processes it is necessary to divide the attachment of the masseter and internal pterygoid muscles upon the bone, as well as the trunk of the inferior maxil- lary nerve, previous to dividing the bone at either one of its extremities, with the saw or forceps. The section is made in the body of the bone, much in the same manner as directed for resection of the chin. The attachment of the genio-hyoglossus muscles is not in this operation disturbed, and there will conse- quently be no doubling back of the tongue. A deviation of the chin to the opposite side is, however, almost inevitable. c. Resection of the horizontal portion of both sides. — An inci- sion is to be carried horizontally along the inferior border of the maxillary ione and round the chin, from one angle of the jaw to the other. The large flap thus formed is to be dissected loose from the bone, and raised upwards by an assistant. After hav- ing separated the muscles from the posterior part of the bone, as described at page 113, the bone is to be divided in the manner and with all the precaution detailed in the preceding pages. If the tumour is very large it will be found very convenient to divide the flap into two portions, by a vertical section of the lower lip. (/. Resection loith disarticulation of one-half of the loiaer maxillary bone. — The form of incision must of course vary ac- cording to the size of the tumour and the condition of the integu- ments covering it. In ordinary cases, however, the following plan as practised by Cusack and Lisfranc will be found to answer weU. Divide the integument along the base from the symphysis of the jaw to the angle. A vertical incision is then to be made through the middle of the lower lip to the anterior extremity of the first. Another incision descending from the zygomatic arch behind the ramus of the jaw, falls upon the posterior termination of the horizontal cut. The facial artery is to be tied, and the four- sided flap thus formed is to be dissected and turned upwards and forwards, carefully avoiding all injury of the parotid gland and duct. The maxilla is then to be divided whh the saw and for- ceps at the symphysis, and the soft parts detached as far back as the angle, by shaving with the bistoury the posterior face of the bone. The masseter is to be loosened from its attachment to tlie jaw. The temporo-maxiilary articulation then comes into view. A button or probe-pointed bistoury is now to be passed behind the coronoid process and below the zygomatic arch, in order to divide the tendon of the temporal muscle; the jaw being lowered at the same moment, so as to bring down the coronoid process and eflect the hixation of the condyle. Carrying next the blade of the knife along tiie upper surface of the fossa be- tween the coronoid and condyloid processes up to the articulation, OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 115 the external pterygoid muscles and the articular ligaments are to be cut, tlie bone being drawn well forwards at the same moment, so as to remove it as far as possible from the vessels which lie behind the ramus. The condyle is then to be pushed outwards and the knife passed through the joint, to divide the internal late- ral ligament and a portion of the internal pterygoid muscle. This step of the operation is the most difficult. A great number of vessels will be cut, some of which require to be tied, before the operation is completed. The fear of wounding the internal max- illary, which winds round the neck of the jaw, has induced Graefe, Dzondi, and others, to tie the external carotid previous to commencing the operation; whilst other surgeons, as J^ger and Schindler, consider the precaution useless and ineffectual, and prefer to tie the arteries as they are cut. e. Removal of Ihe entire lower jaw. {PI. XXV. fig. 3.)— This is said to have been once successfully effected by Walter, of Bonn, the patient recovering without any permanent d'ljJicuUy in respij-aiion or deglutition. A horizontal incision is to be traced around the base of the bone, extending from one angle of the jaw to the other. A descending incision, parting from the root of the zygomatic arch behind the ramus, is to be dropped on either side, so as to meet the posterior extremities of the first. The huge flap thus formed is to be dissected loose from both sides of the jaw, and raised up over the face like a mask, as directed for the removal of the body of the bone. The maxilla is then to be divided at the symphysis, and each half loosened and disarti- culated, as described in the preceding article. But one case oidy has been reported, and that but imperfectly authenticated, of this frightful operation, wiiich has been well described by Vidal as the ne plus ultra of the surgeon. It is diOicult to conceive of any aft'ection, save that of a wound from a grape shot or a cannon ball, that could render it in the estimation of a judicious practi- tioner at all justifiable; for a morbid affection which had gra- dually involved the entire bone to such an extent, as to render any other process inapplicable, could hardly be expected to have left the parts within its arch, or the integuments covering it, so free of disease as to furnish a rational prospect of cure. f. liesection of one of the margins of the Jaw. (Process of Barton.) — The alveolar margin of one or botli sides of the jaw, if alone involved in the disease, may be removed successfully without destroying the continuity of the bone. The great advantage to be derived from this form of partial resection, in cases that allow of its performatice, consists in the preservation of the parabolic form of the jaw, the complete re- tention of its uses as a lever, as well as a more speedy cure and a diminution of the deformity that attends the removal of any portion of the base. The soft parts are to be opened by a ver- tical incision through the lip, and a horizontal cut at the base of the jaw. The flap is to be dissected upwards, and the alveolar margin removed with the saw and forceps, as directed in resection of the chin. The base of the jaw, if superficially affected, might be exposed and resected in the same manner, leaving a rim of bone above to preserve the contour of the face, and serve as a basis for granulations. PARTIAL EESECTIOX OF THE STERNUM. (Ph. XXYl) Caries and necrosis resulting from scrofula, syphilis, abscess of the mediastinum, or external injuries, are the common causes which require the resection of this bone. When the affection is chronic, as is usually the case, tlie pleura becomes thick and resist- ing, and is pushed away from the bone by the purulent fluid which accumulates to more or less extent below it, so as to give space for the performance of the operation, without risk of injury to the pulmonary organs. I have on three occasions resected parts of this bone, the superficial position of which renders the operation by no means difficult. One of the cases permanently recovered ; the other two patients, who were black, ultimately died of phthisis, a termination which those familiar with hospital practice must have frequently observed in this aflection, where the operation has either not been attempted at all, or deferred too long. No fixed plan of proceeding can be established for resecfion of the sternum; but resort may be had to some of the various metliods common to resection of other bones. The soft parts, which will be found thickened, often lardaceous, and loosened from over the bone at diflerent points, are to be opened by a T or crucial inci- sion, and the angles dissected back. The trephine, Hey's saw, the cutting forceps, the gouge, and a pair of strong pliers, are the instruments which will be found most useful. The position of the pericardium behind the lower and middle portion of the bone, the pleura at the sides, and that of the internal mammary artery, must all be borne in mind by the surgeon. The dressing and after treatment should be so managed as to leave a free place of exit for the suppuratory discharge. After the cure it has in some instances, wliere the cicatrix was yielding, been found necessary for the patient to wear a plate of horn or leather as a measure of protection. PARTIAL RESECTION OF THE RIBS. (FL. XXYI.) Resection of the ribs and sternum were both practised by Galen. Kicherand was the first lo revive the operation on the former, which had fallen into desuetude. In ISlS he removed the middle parts of four ribs of tiie left side, affected with osteo-sarcoma. A portion of the pleura, which was thickened and fungous, was cut away with the scissors, so as to lay open the cavity of the chest, expose the pericardium, and render the action of the heart visible. The lung of the left side collapsed, on the entry of the air, jiroducing momentary symptoms of suftbcation. The opening in the pleura was closed by the surface of the pericardium becoming adherent to its margins, and the wound healed. The patient, however, died three months after, of a return of the cancerous disease. Jaeger enumerates fourteen cases of excision of the ribs, of which eight were successful. The operation is not in itself difficult or dangerous, as the pleura is always found thickened and often loosened from the ribs, in consequence of the disease of the latter whicli renders the operation necessary. Operalion. — The patient must be placed on his side, back, or abdomen, according to the part on which the operation is to be practised. The first step is to uncover the diseased rib. In a case in which I resected during the last winter a cadous portion of the ninth rib of the right side, two inches and a half long, I found the periosteum separated from the bone by an accumula- tion of pus, so that I could pass a director under it after I had divided the soft parts on a level with the upper surface of the bone. The incision was prolonged to the extent of three inches, 116 GENERAL OPERATIONS. and then on the side next the spine, turned at right angles so as to cross llie rib from above downwards. The flap thus formed was turned off from the bone, the intercostal muscles and the fascia covering them divided carefully on the upper margm of tlie rib, and the thickened pleura separated from the latter, partly with the fore finger and partly with the handle of the scalpel insinu- ated flatwise. The finger could now be passed between the pleura and the bone, so as to make room for one blade of tlie large cutting forceps with whicli the section was made. Tlie cartilaginous extremity of the rib was next divided with the knife, and the piece raised up and removed with a few touches of the edge on its inferior margin, in order to loosen it from its adhesion below without injury to the intercostal vessels. A Hey's or a Barton's saw, or a chain saw, may be used instead of the forceps to divide the bone, but in such cases it is necessary to pass a compress underneath, in order to protect the pleura. A crucial or T incision will in some cases be required to open the soft pans, or even two quadrilateral flaps as in the process of Jaiger may be raised over the rib, and reversed in opposite direc- tions. In one case Mr. McDowell, after dividing the rib towards its middle, disarticulated it from the vertebra, carefully avoiding any lesion of the spinal nerves. The wound is to be closed with adhesive straps, and covered willi simple dressings; a roller should be passed round the chest. •Occidents. — Bleeding may occur from the intercostal artery; but there could be little difficulty in securing the vessel, even if it were necessary to dilate the wound posteriorly for the purpose. If the pleura should be perforated so as to admit air into its PLATE XXVL— RESECTION OF THE RIBS, SCAPULA AND CLAVICLE. {Fig- 1.) RESECTION OF THE RIBS. The operation at the upper part of this figure is supposed to be practised upon a woman after the removal of a cancerous breast — the malignant affection having extended so as to involve the pectoral muscle and the anterior portion of the third and fourth ribs. Under these circumstances, it is easy witliout increasing the external incision, to resect portions of the subjacent ribs. In the stage of the operation shown in the drawing, the surgeon, after having made the outer section of the ribs, raises the fragments willi his left hand (A), and having divided the intercostal muscles, detaches the portions of the two ribs by another cut, near tho junction with their cartilages. To protect the pleura from the action of the saw (B), a greased compress (C) has been introduced below the ribs, where it Is sustained by the fingers of an assistant. The very common tendency of cancer of Ihe breast to return after operation, especially where it lias involved parts beyond the structure of the gland, will seldom justify any attempt at removal when either the muscles or ribs are implicated. 1, 1. Line of incision through the integuments. 3,3. Section through the pectoralis major and minor muscles, the diseased portion of which in front of the ribs, has been removed. 4. Perpendicular cut of the great pectoral muscle on the side next the axilla. In many cases it will be necessary, when the operation is undertaken, to remove this portion of the muscle, and prolong the incision of the skin towards the axilla, so as to remove the lymphatic glands, if these have been implicated in the disease. 5. Fifth rib, which is supposed lo be healthy. 6. Place of the section of the two diseased ribs. 7. Fragment of the ribs united by the interosseous muscle and fascia, which have suffered from the disease. 8. Surface of tlie costal pleura, below the portion to be resected. 9. 10. Ligature of the thoracic and intercostal arteries. The lower operation upon this drawing represents the partial resection of the ninth rib for caries, as practised by the author during the winter of 1842-3. An incision of the integuments and periosteum, (which was loosened frotn the carious bone by suppuration,) has been made along the upper margin of tlie rib, and a flap turned down- wards. The thickened pleura was then loosened with the handle of a scalpel from the posterior face of the rib, so as to allow, first, the insinuation of the finger between it and the rib; and, secondly, the introduction along the finger of one blade of a pair of cutting forceps, with which the first section of the rib is made. a. Left fore finger of the surgeon. b. Flap reverted from the face of the rib. c. Anterior margin of the bony part of the rib, which is seen roughened and carious. d. One blade of the forceps with which the division is made inserted behind the rib. After this section, the fragment of the rib was raised and detached with the knife by a cut through its cartilage at the inner end of the wound. {Fig. 2.) RESECTION OF THE UPPER HALF OF THE SCAPULA. {Process ofJanson.) This operation is called for only in cases of osteo-sarcoma, to which the upper half of the bone is exposed, in OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. 117 cavity, the wound must bo immediately closed with a linen com- j press covered with cerate and overlaid by a mass of charpie. Partial resection of the vertedrx. — A part of one or more of j tlie arches with the spinous processes of llie vertebra; have been removed in cases wiiere ihey had been fractured and depressed on the medulla, or witere injury followed by au irregular growth of callus, had produced syinploms of spinal irritation or paralysis. The prognosis in siicli cases is always doubtful, in consequence of the injury previously iiiflicled on the niednlla, as well as from ihe inflammation of the iheca that is liable to follow the -opera- tion. Jaeger relates six instances in which it has been done, but in two only of these with any advantage. In four well-known cases, those of Cline, Tyrrel, IJarton, and A. G. Smith, the ope- ration did not eventuate successfully. Operation. — The patient is to be placed on his belly. An incision from three to six inches long, according to the thickness of the muscles by the side of the spine and the number of ver- tebrse affected, is to be made over the tops of the spinous pro- cesses, This is to be crossed at each end by a transverse incision two to three inches long, which should divide the soft partsdown fo the bone. The flaps are then to be dissected off on either side j from within outwards, so as to expose the spinous and transverse processes, and iield asunder with blunt hooks. The vertebral j arch is next to be divided on each side witli a Hey'ssaw, between the roots of the spinous and transverse processes, but near the latter, and the ligaments connected with the isolated piece cau- tiously severed with the knife. The flaps are then to be reunited by two sutures and some adhesive straps. Tyrrel and Barton applied the trephine upon the arch; but the surface is too unequal, even after the spinous process is cut off with a chain saw, to allow it to act with effect. PARTIAL RESECTION OF THE PELVIC BONBS. Tiie removal of small portions of these bones in cases of caries, exostosis, and, as is asserted, osteo-sarcoma, has been successfully accomplished. But when the extent of bone affected was large, with the development of a tumour of considerable size on its inner face,, death has been known to follow almost immediately the completion of the operation. In 1818, Sir A. Cooper removed successfully, in a case of exos- tosis, a part of the descending ramus of the pubis, with a Ma- chell's and a Hey's saw. Van Onsevoort, in an instance of anal consequence of its superficial position. In the drawing, the operation is represented at the moment of its conclusion. 1, 1. Section of the integuments on the back of the shoulder. 2. Section of the upper part of the trapezius muscle. 3. Section of the levator scapulas. 4. Section of the deltoid. 5. Section of the rhomboideus. 6. Section of the infra-spinatus muscle. 7. Section of the subscapularis. 8. Perpendicular cut through the acromion process, 9. Angular division of the body of the scapula below its spine— the glenoid cavity and the articulation of the shoulder joint being preserved. 10. Bottom of the wound occupied by the superior heads of the serratus major anticus muscle. 11. The tendon of the supra -spinatns muscle divided — the muscle itself being removed, with the portion of bone excised. 12. Ligature of the superior and posterior scapular arteries. (Fig. 3.) RESECTION OF TIIE EXTERNAL HALF OF THE CLAVICLE. The case is supposed to be one of caries of the acromial extremity of this bone. An operation somewhat analogous may be required in cancer of this bone, but in which case, if the tumour is large and irregular, the dilficuUy of resection will be singularly increased. A crucial incision has been made, so that in the reflection of the flaps the acromial half of the clavicle is completely exposed. The clavicle, after having been isolated upon its sides, and a compress passed below it so as to protect the subjacent parts, has been divided near its middle with a chain saw. The stage of the operation shown, represents the proceeding of the surgeon after this section of the bone. 1. 1, 1, 1. The four flaps of the skin, formed by the crucial incision. 2. Insertion of the trapezius muscle separated from the upper margin of the bone. 3. Separation of the deltoid from the lower margin of the bone. 4. Subclavius muscle. 5. Place at which the clavicle has been divided with the chain saw. a. A band with which the operator raises with his left hand the outer fragment (i), while he isolates it from its connections with the bistoury (c), and finally detaches it by a cut through the acromio-clavicnlar articulation. If necessary, it would be perfectly easy to remove the outer end of the acromion by the same process. 118 GENERAL OPERATIONS. fistula, kept up by caries of the os coccygis, resected the whole of this bone. Leaut6 removed, in another case of caries, the whole of the crest of the ilium with success. Tlie seat and ex- tent of the affections requiring such operations, vary so much, that no fixed rules can be given for their performance. The proceeding of the surgeon must be determined according to the rules already given for the treatment of aifections in other parts. The removal of a carious portion of the crest of the ilium, may often be effected with advantage. An incision should be made along the edge of the crisia, and the outer covering dissected off in the form of a flap from the surface of the bone. The abdomi- nal muscles are to be detached along its top, (if not already loosened by the disease, as I have found them in one instance,) and drawn inwards by an assistant; carrying with them the pe- ritoneum and the edge of the iliacus intcnins. With the lley's saw and the cntting forceps, a V shaped or quadrangular piece may then be easily detached. KESECTION OF THE CLAVICLE. (PL. XXVI. Fib. 3.) Surgical anatomy. — Small and snperficial as the clavicle is known to be, no bone in the body has more important surgical relations. Below it, and nearly in contact with it, pass the subclavian artery, vein, and the brachial plexus of nerves; just above it is found the termination of the internal and external jugular veins; and on the left side, though somewhat deeply placed behind it, is found the thoracic duct. Many arterial branches are found on its upper and lower surface, which are often increased in size, when the clavicle has become so en- larged by disease as to make pressure on the subclavian vessels. Muscles of large size, as the sterno-mastoid, the pectoral, the trapezius and the deltoid, — all of which cover important parts, — have their attachments upon this bone. The surgeon, therefore, should have a precise knowledge of the position of these parts, and especially of those connected with its internal extremity, which cannot be disarticulated witljont more or less difficulty and danger; the least slip of the knife being liable to open a vein so as to allow the entry of air into the circulation, or give rise to haemorrhage that it would be difficult or impossible to staunch. Partial resection^sternal extreviiiy. — Davie and Wutzer have both performed this operation with success. The former, in a case where the sternal extremity was so much luxated or forced backwards in consequence of a curvature of the spine, as to press on the cesophagus and render deglutition almost imprac- ticable. The latter, in a case of caries. Davie divided the in- teguments for three inches along the internal end of the clavicle, separated as far as possible its surrounding ligamentous connec- tions, and divided the bone across with a Hey's saw, at the distance of an inch from the sternum, previously introducing beneath it a piece of thin sole leather, so as to protect the parts below from the action of the saw. The end of the bone still remained attached by the interclavicular ligament; this he was obliged to break, using for this purpose the handle of a scalpel as a lever. In case the end of the bono be enlarged from disease, the simple incision of the integuments over the bone would not suf- fice to expose it. A square-shaped flap, with the base above, should be dissected and turned upwards; or a crucial incision may be made, as directed by Velpean, for the acromial extremity, A chain saw carried round the clavicle by the aid of a silver stilet, would be very convenient for the division of the bone. Scapular extremity.— \\\ a case of necrosis of the external end of the bone, Velpean made a crucial incision over the dis- eased portion, each branch of which was about four inches long. After the flaps were dissected back, and the acromio-clavicular ligaments, and some fibres of the deltoid and trapezius divided, he was able, by pressing a wooden splint iiUo the articulation and using it as a lever, to raise the diseased bone, and thus de- tach it from the sound parts. In cases in which it could not be raised in this manner, he proposes to divide it from above down- wards with a hand saw, a lley's saw, or from below upwards with a chain saw passed previously round it. Roux,* under analogous circumstances, naade a longitudinal incisioji over the clavicle, isolated tlie parts surrounding the bone, which he divided with the English chain saw adroitly passed below tlie bone. He subsequently divided the acromio-clavicular ligaments, and removed the piece, which was an inch and a half long. Resection of the clavicle entire. — Cuming, in a case of gun- shot wound, extirpated, after disarticulation of the arm, not only the clavicle, but the whole scapula with it, and tlie patient re- covered. Meyer removed, in 1823, the whole clavicle for caries, and in seven weeks afterwards the wound healed. The peri- osteum, which was in this case detached from the bone, and allowed to remain, formed a new ossific deposit; and at the time of the patient's death, which occurred five years afterwards, a thin bone was found to have been formed sufhcient to support the movements of the arm, three inches and three-quarters long, united to a fibro-cartilaginous ligament, extending from the ster- luim to the acromion. Professor Mott removed the clavicle of the left side nearly entire, in 1827, for au osieo-sarcomatous affection, which had enlarged the bone nearly to the size of the double fist, and occu- pied the greater part of the space between the top of the shoulder, the OS hyoides and the angle of the jaw. This surgeon circum- scribed the diseased mass by two incisions, one of which was convex below, and extended from the sternum to the acromion, and the other convex above, running from the acromion round the upper part of the tumour, as far as the external jugular vein. Along the line of llie last incision, he divided the platysma my- oides and a portion of the trapezius muscle; and insinuated a director under the bone near the acromion, along the groove of which he passed a chain saw and divided the bone between the acromion and the coracoid processes. He now united the sternal extremities of the two first incisions; divided the external jugular vein between two ligatures; cut across the external portion of the sterno-cleido-mastoid, two inches above its insertion, and turned the lower section over thestenunn; next pushed upwards and backwards the omo-hyoid, below which was found the in- ternal jugular, which was also tied and divided. The diseased mass was then separated from the subclavian vein and thoracic duct with the handle of a scalpel. The pectoral muscle, the costo-clavicular ligament, and the subclavius muscle, were sepa- • These, par M. Ilurleaiix. Paris, 1S34. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. rated in succession from the lower surface of the tumour, and tlie bone filially removed by disarticulating it at the sternum. The operation was long and difficult, and more than forty ligatures were applied upon the divided vessels. The wound healed in the course of a month and a half, and the patient, by the aid of an appropriate apparatus, preserved to a considerable extent the movements of the shoulder. PARTIAL EESECTION OF THE SCAPULA. (PL. X.YVI. Fie. 3.) Resection of portions of tlie scapula has frequently been made in cases of comminuted fracture of that bone. Larrey, Hunt, and others, liave removed in this maimer the acromion, the coracoid process, and even the neck of the bone; opening the soft parts for the purpose by a process similar to that for excision of the head of the OS humeri. Portions of the bone have also been removed in cases of caries, tumours, and other chronic affections. Jajger and Champion removed the spine; Sommeiller tlie inferior angle of the bone; and Janson nearly the whole of the body, in a case of degenerated tumour. Process of Janson. — The tumour in the case operated on by this surgeon was large, weighing nearly eight pounds when re- moved, and occupied the subscapular fossa. He circumscribed it by two semi-elliptical incisions nine inches in length, saving the integuments as much as possible by dissecting them oft" from the lips of the incisions towards the base of the tumour, which was dissected bare. He next divided the attachments of the trapezius, supra and infra-spiiiatus muscles, and discovering that the scapula above the spine was healthy, he divided the bone below the spine with the saw, thus leaving uninjured the articu- lation of the arm. The tumour was then loosened and removed. The wound left was sis inches broad and nine inciies long, RESECTION OF THE SHOULDER JOINT. (PL. XXXVII.)* Comminuted fractures of the upper end of the bone with wound of the integuments, complicated luxations, caries, necrosis, and the various incurable organic afl'eclions, form the cases in which resec- tion of this articulation may be practised with advantage, and for which there is no other alternative than that which was its substi- tute in former times — amputation of the arm at the shoulder joint. In none of the joints is resection more frequently called for, and in no one has it been attended with more beautifid results, the upper extremity being preserved nearly entire, and in some few instances a new articulation reproduced. In the cases where the end of the bone has remained suspended after the cure in the midst of the muscles, without having formed a new connection with the scapula, the former usefulness of the limb has been in a great measure restored by an appropriate apparatus for sustain- ing its motion at the shoulder, Several instances, however, have been reported, even where no direct connection with the scapula was found, in which such an apparatus was not needed. t General observations. — All the various processes devised for this operation may be arranged in two classes. • The surgical anatomy of this region will be described under llie head of ampiitalion at the joint. ■\ Syrae, Moreau, Chaussier. 1. Those in whicli a mere incision of the soft parts is made. 2. Those in which a flap is raised up, JVhile, whose |)roccss has been adopted by Larrey, Guthrie, and others, directed a simple longitudinal incision to be made down to the bone, from the point of the acromion, for four or five inches towards the insertion of the deltoid, so as to divide this nmscle in half. The lips of the wound being then held asunder by an assistant, the articulation comes into view, Tlie capsule is to be opened transversely, and the insertions of the four articu- lar muscles carefully cut with a probe or button-pointed bistoury, rolling the bone so as to bring them successively under the action of the knife. The long tendon of the biceps may usually be saved, though its division if necessary maybe made without any disadvantage. The elbow is then to be forced inwards and up- wards, in order to luxate the head of the bone and make it pro- trude at the wound, and the knife is to be carried behind it so as to separate the soft parts on its inner face. A compress or a piece of card or wood is to be passed between the humerus and soft parts, and the diseased portion cut oif with a saw. This process is the most simple and the most ancient, and at the same time one of the most difficult, except in cases where the joint has been previously opened, or the head separated from the body of the bone as in a gunshot wound. To facilitate the division of the tendons, and the protrusion of the head, — the most difficult step of the operation, — M. liaiideus has proposed to divide the deltoid across, at each angle of the vertical cut, below the skin and without cutting the latter, Textor modified this process so as to give to the external wound the shape of the letter L, or that of a |— , the longitudinal incision passing down on the outer side of the biceps, and the transverse across the deltoid, Bromfield crossed the lower end of the longitudinal incision of White, with a transverse incision through the deltoid, forming a _L reversed. Bent made a short transverse incision over the acromion at the top of the longitudinal, T, which when the triangular flaps are dissected off exposes largely the joint, and serves particularly ! well when it is necessary to remove in addition a part of the j acromion process or cervix scapula. 1 The process of Sahatier modified by Goyratid consists in raising up a V siiaped flap of the deltoid at the anterior and su- perior part of the shoulder, the apex pointing downwards, which is to be dissected up and turned over the acromion. Moreau and Manne formed a quadrilateral flap by means of two vertical incisions; one passing down from the acromion and the other from the coracoid process. These were united by Mo- reau by a transverse cut immediately below the acromion; by Maiuie at their lower extremities. I3e![ and Morell formed a semilunar flap with the base upwards. Buzaires adds to the longitudinal incision of White, in cases where this does not yield room enough to effect the extraction of the head of the bone, a transverse cut made from the acromion cither along the spine of the scapula or in the direction of the clavicle, or in both directiorjs, if it is at the same time wished to resect a portion of the scapula. Alalgaigne proposes to modify the longitudinal incision of White, by commencing higher up and a little more to the inner 120 GENERAL OPERATIONS, side: viz. at the top of the coraco-clavicular triangle. He extends the incision downwards for five inclies, dividing at one stroliteni of the disease, dividing the skin and peroTiei muscles down lo the bone. The lips of the incision were held asunder by an assistant, while the surgeon separated tliem on either side from the bone; a compress was then introduced below, so as to protect the soft parts, over which he passed the chain saw and divided the bone from within outwards, at either end of the diseased portion. The 130 GENERAL OPERATIONS. cutting forceps would, however, answer well for the division of the bone. If the soft parts are shaved carefully from the surface of the bone, the peroneal vessels will not be injured; and the wound, which is regular and superficial, will be quickly found to cicatrize. RESECTION OF THE ANKLE JOINT. This is an operation which has been many times performed by the older surgeons in cases of caries, white swelling, and complicated fracture and luxation. But the operation, even when the wound healed, left the limb so stiff and weak that the patient was only able to move about with the aid of a pair of crutches or a cane. The proceeding may, therefore, be considered PLATE mi,— RESECTION OF obsolete; or, if employed at all, proper only in cases of traumatic injuries of the joint. Many processes have been devised, but the following has been the most often followed. Process of Moreau. Two incisions in [ ]. (PI. XXXI. fig. 4.) — A longitudinal incision three inches long is to be made over the external border of the fibula, terminating a little below the external malleolus. A transverse incision is to be extended in front from the lower end of this round the malleolus, as far as the tendon of the peroneus tertius. The flap of skin is to be dissected and turned up; the tendons of the two lateral peroneal musclefe are to be separated from the bone, and the latter divided across just above the level of the joint with a mallet or chisel, or, which THE BONES OF THE AMLE AND FOOT. {Fig. I.) RESECTION OF THE ANKLE JOINT. {Right side.) In this operation either one or both the lower ends of the two leg bones may be resected, as well as the upper end of the astragalus, in case the latter should also be found diseased. Independently of the danger and difliculty attending this operation, it leaves even when successful a limb of but iittle utility. Amputation is, therefore, justly preferred by most surgeons. The separate resection of the end of the fibula is perhaps all that would ever be justifiable. Lower end of the tibia. — This operation, which is shown chiefly for the purpose of illustrating its serious nature, is represented at the moment of termination. a. A rectangular flap of skin, reflected forwards on the leg. b. Section of the shaft of the tibia. c. Tendons of the anterior tibial and extensor muscles. d. Tendons of the flexor longus and posterior tibial muscles. e. Portion of the inferior end of the fibula. / Peroneus tertius. g. Long flexor of the great toe. h. Internal saphena vein. i. Surface of the astragalus. k. Inferior end of the tibia luxated, about to be separated with the bistoury {/). Resection of the other bone of the leg is shown at fig. 3. On the same drawing is shown the extirpation of the metatarsal bone of the great toe. A flap of skin (7?z) is reverted on the back of the foot, exposing the extensor tendon of the great toe {n), and that of the long flexor (o). The bone has been disarticulated at either end and drawn outwards, bringing into view the interosseous muscle {p), the first cuneiform bone {q), and the first phalanx of the great toe [r) with its sesamoid bones. At the bottom of the wound are seen the interosseous vessels. {Fig. 2.) RESECTION OF THE METATARSO-PHALANGEAL ARTICULATION OF THE GREAT TOE, AS PRACTISED WITH SUCCESS BY THE AUTHOR IN A CASE OF CARIES OF THE JOINT. a. Semilunar flap, reverted on the inner face of the bone. The line of incision has run through two fistulous orifices (/,/). b. End of the metatarsal bone, which has been loosened at the joint, isolated, raised on a thin splint, and divided with the saw. c. Posterior end of the first phalanx of the toe; carious, and subsequently removed. d. e. Extensor and flexor tendons of the toe. (Fig. 3.) RESECTION OF THE LOWER END OF THE FIBULA. The operation is shown at the moment of making the section of the shaft with a chain saw. a. Cutaneous flap reverted. OPERATIONS FOR DISEASES OF THE BONES AND JOINTS. would be found to answer better, the chain saw/or large cutting forceps. The fragment is now to be swung out from its bed and detached from its ligamentous connections with the knife. In order to remove the tibia, a similar flap is to be formed over the inner side of the joint — the transverse incision extending in this instance as far as the tendon of the anterior tibial muscle. The flap having been reflected upwards, the muscles and vessels are to be carefully separated from the anterior and posterior faces of the bone, as far up as it may be considered necessary to remove the piece. The division of the bone may then be made from behind forwards, or from before backwards, as is found most convenient, with a narrow-bladed saw, which is to be conducted through the wound on the surface of the finger — tlie soft parts on the opposite side of the bone being protected by a compress against injury from the teeth of the saw. The fragment is then to be pulled over and detached from its ligamentous connections as in the former case, taking care to avoid injuring the posterior tibial nerve and vessels, as well as the three large tendons which pass downwards to the hollow of the os calcis. If the surface of the astragalus participates in the disease, it may be cut avray with the gouge or the chain saw. If the tibia only be diseased, it is considered best to remove with it the end of the fibula, in order to prevent a tendency in the foot to deviate to the other side. Dressing. — The flaps are to be fastened down with some points of suture, the osseous surfaces brought together, and held immovably fixed in an appropriate apparatus. RESECTION OF THE TARSAL BONES. Caries, compound fractures, and complicated dislocations, are the more ordinary causes for which excision has been practised upon the various tarsal bones. Though success has in several instances succeeded the operation for caries of these bones, it has on the whole been so little common, in consequence of the extent to which the synovial membranes of the dilferent joints of the tarsus are involved, the afl"ection of the surrounding tissues, and the liability of the disease to return from the difliculty in extir- pating it completely, tiiat the operation has not received by any means the general sanction of the profession. Still, nnder favour- able circumstances, it might be tried with propriety as an alter- native against amputation. Tiie partial excision of the back part of the OS calcis, as it involves no joint, may be often practised with the greatest advantage in cases of caries of that bone. In severe traumatic injuries of the bones, the operation offers greater prospect of success, and especially in cases where the astragalus is broken in pieces or thrown forwards upon the dorsum. Two instances of comminuted and compound fracture of the astragalus in young persons have nevertheless done well in my liands with- out operation — the adherent pieces of bone which were allowed to remain being subsequently consolidated so as to preserve the foot, though the cure was attended with anchylosis and an out- ward convexity of the ankle joint. Resection of the astragalus. — For the excision of any of the tarsal bones, general rules only can be given. In cases of luxa- tion this bone will form a prominent tumour on the back of the foot, over which the skin will be tightly strained. This must be opened at any point most favourable to the extraction of the bone, taking care to avoid at the time any injury of the neighbouring tendons or the anterior tibial vessels. Some difficulty will be found in separating the interosseous ligament, which unites it to the calcis, in cases where it is not to a considerable extent torn in the displacement. After the cure, the joint wdl most usually be found anchylosed. Mesection of the os calcis. (PI. XXX. fig. 2.) — From the great size of this bone, and its position directly below those of the Jeg, excision is practised only for the diseases of its posterior promi- nence, or of its outer or inner margins. The skin is to be laid open by an incision in T, or a crucial cut, and the flaps dissected off from the surface of the bone. If the caries be superficial, it may be removed with a strong knife, the gouge, or a Key's saw. If more deep, the whole protuberance may be removed as seen in the drawing — by dividing it first with the saw from above downwards, so as to leave the attachment of the tendo achillis; and again from below upwards, so as not to disturb the attach- ment of the plantar muscles; the piece finally being detached with anarrow-biaded saw, or with a chisel. If the caries extend into the body of the bone, it is to be scooped out with a gouge or a curved scalpel. Velpeau recommends for the purpose of opening the skin, a semilunar incision, as more likely to unite better, and leave a less troublesome cicatrix. But whatever course be pursued in this re- spect, the scar remains tender to pressure, and is liable to ulcerate. Resection of the cuboid and cuneiform bones, (PI. XXX. fig. b. Tendons of the two large peroneii muscles. c. Band passed below the bone to protect the soft parts, over which the chain saw [d) has been passed for the purpose of dividing the bone. The bone is subsequently to be raised and detached with the bistoury in the manner shown at fig. l. [Fig. 4.) RESECTION OF THE ANKLE JOINT ENTIRE. {Process of Moreau.) The objections to this operation are the same as those noticed in relation to fig, 1. By the operation seen at fig. 4, but a small portion only of the ends of the bones can be removed. It is shown at the moment of termination. If necessary the articular surface of the astragalus may be removed by the same process. Two L shaped incisions have been made over either bone of the leg, and the two cutaneous flaps [a, b) reverted. On the side of the wound (c) are seen the tendons and flexor muscles of the toes, as well as the posterior tibial vessels and nerve, and the peroneal vessels. The internal saphena vein is seen passing down on the inner face of the flap {a). The place where the two bones of the leg are divided is seen at (/, The articular surface of the astragalus (e) may, if found diseased, be readily removed by the osteotome of Heine. 132 GENERAL OPERATIONS. 1,3.)— In a case of caries of the bones on the outer side of the foot, accompanied with a fistulous nicer, the elder Moreaii raised a quadrilateral flap of skin, with its base inwards, and turned it over the dorsum of the foot. The tendon of the peroneus longus was drawn outwards, and the belly of the short extensor of the toes cut and turned inwards, so as to expose the affected hones. From the extent of the caries he was obliged to remove the cu- boid, the third cuneiforme, the posterior extremity of the fourth metatarsal bone, the internal side of the extremity of the fifth, and lastly the articular surface by which the calcis was united to the cuboid. The operation was successful; the great cavity formed was in a great measure subsequently filled up with osteo- fibrous matter, and the patient regained the movements of the foot so as to be able to walk with facility. In a nearly similar case, Velpeau excised in the following manner one-half of the cuboid and the bases of the fifth and fourth metatarsal bones. A longitudinal incision was made along the external border of the foot; another was drawn per- pendicularly from this over the junction of the tarsus and meta- tarsus, and the two triangular flaps thus formed dissected up. The bones were then denuded, cut througli with the wheel saw, and removed. The cavity left was about three-quarters of an inch deep. The wound was filled with charpie, and the flaps closed over it. At the end of three months, the cicatrization was complete, and the patient recovered almost without deformity. RESECTION OF THE FIRST METATARSAL BOKE. In regard to the four smaller metatarsal bones, excision with preservation of the corresponding phalanges is never attempted, amputation of the whole being preferred, as the toes if left could only serve as an incumbrance. But for disease limited to the first metatarsal bone, partial excision has been occasionally prac- tised, in order to preserve more effectually the points ofsustenla- tion of the foot. A quadrilateral, a crucial, or T shaped flap is to be turned from oft" the bone. The extensor tendon is then to be pushed to one side, and the metacarpo-phalangeal articulation opened. The head of the bone is next to be luxated, and a knife passed behind it so as to separate its body from the soft parts so far as the disease extends. A protectii7g compress is then to be passed below, and the bone divided with a saw or cutting forceps, RESECTION OF THE FIRST METATARSO-PHALANCEAL ARTICULA- TION. (PL. XXXL Fic. 2.) Process of the mithor.—ln 1836, 1 removed at the Philadel- phia Hospital the entire metatarso-phalangeal joint of the first toe, preserving two-thirds of the first and the whole of the second phalanx. The case was one of caries, caused by a spike nail run through the joint, The whole structure of the articulation was swollen and thickened, and two fistulous openings existed low down on the sides of the foot. I made a semicircular inci- sion, which traversed these openings, and dissected the flap, the base of which was towards the heel, so as to turn it backwards upon the foot. This exposed completely the inner surface of the joint, and about half ilie length of the metatarsal bone. The joint was next opened, the metatarsal bone isolated from the tendon and the' surrounding parts, and divided across near its middle with the metacarpal saw. On the removal of the fragment, the end of the phalanx was found carious; this was pushed out through the wound, and a portion a quarter of an inch long re- moved with the saw. The interior structure of the adjoining part of the phalanx, which was soft and spongy, was scooped out with the end of the scalpel. The ends of the divided bones were then put in contact, and the flap brought down and secured with adhesive straps and a retaining bandage. Some suppurative discharge continued for three weeks at the posterior angle of the wound; but it ultimately healed up well. SoHd union took place between the divided bones, and the patient preserved his toe, which was found after the cure about three-quarters of an inch shorter than the other. The only difficulty encountered in the after treatment, was the tendency of the extensor muscle to ele- vate the point of the toe. Should I again have occasion to excise this joint. 1 would prefer to divide this tendon, in case I approxi- mated the bones, inasmuch as the necessity for its use wonld be greatly diminished afterwards; the middle phalangeal joint, in regard to position and office, supplying the place of tlie one ex- cised ; and there would be reason to expect that the reunion of the divided tendon would be sufficiently perfect to prevent (ia conjunction with the dressing) the flexor muscle from drawing the point downwards. M. Petriquin reports a similar operation done by Professor Regnoli, of Pisa, in the case of a girl twenty years of age, and which he saw in the progress of cure. By this mode of opera- lion we preserve well the shape of the foot. In cases where I have removed the metatarsal bone and phalanges of the great toe, there has been a tendency in the remaining toes to turn in- wards, from the want of resistance. In one case, so much incon- venience was felt from the second toe rubbing against the side of the boot, that I was compelled to extirpate it at the root. RESECTION OF THE FIRST METATARS.U. BONE ENTIRE. (PL. XXXL Fig. 1.) The bone is to be uncovered on its side by the raising of a quadrilateral flap, with its base upwards, unless there be some fistulous openings in the skin, through which it is desirable to jiass the knife, making it necessary to modify the shape of the flap raised into that of a T, an X, or an L. The bone is to be carefully isolated from its extensor tendon and the interosseous vessels, which are to be drawn to one side and separated from the phalanx at the metatarso-phalangeal joint. It is then to be drawn from its bed, loosened from all its connections on the outer face with the knife, and removed at its articulation with the cuneiform bone. Velpeau finds it more convenient to divide the bone in the middle with the chain saw, and remove each frag- ment separately. In the only instance which has come under my notice of the entire removal of this bone,— that of a gentleman from Pittsburg, in this state,— no fibro-osseous substitute for the bone had been formed, and the toe perfectly loose posteriorly, was placed by the action of the extensor muscle nearly upright on the dorsum so as to form a useless incumbrance. On the whole, it would be un- questionably better, when there is no portion of metatarsal bone left to sive the phalanges a solid support, that these should be removed at the same time with the former. AMPUTATIONS. IV. AMPUTATIONS. The operations for amputations of the extremities ahe divided into two great classes, according as the final separation is iiadb across the continuitv of the bones, or at the places of the joints where the ends of the bones ahe merely contiguous. AMPUTATIONS IN GENERAL. In a treatise on operative surgery like the present, it must be evident that an attempt to point out the kind of accidental injuries and diseases that render amputation proper, would lead far be- yond its proper scope. To state, as is common with authors, that the affections which more or less frer|nenlly require amputa- tion are malignant diseases, such as the various forms of cancer, many non-malignant tumours that have become incurable, or have destroyed the usefulness of a limb; some of the severer forms of necrosis, caries, gangrene, white swellings, compound or complicated fractures, and dislocations and wounds, would be but a mere barren enumeration of causes, of little value to the student. The question involved in determining as to the propriety of a resort to amputation is, in many cases, one of ex- ceeding delicacy and importance, and rests upon circumstances so numerous and variable, that it is impossible briefly to point them out, — the nature, the seat, the extent, the duration of the lesion, the degree to which the system has already sympathized with the disease, the age and constitution of the patient, the fa- vourable or unfavourable circumstances in which he is placed, — each one of which may, on particular occasions, exercise a go- verning influence in tiie judgment of the surgeon. The reader, therefore, is referred, in respect to the indications of amputation, to the various treatises on surgery, in which he will find a particular consideration of the ditTerent forms of injuries and diseases that necessitate this operation; and especially is he re- commended to embrace every occasion for the study of surgical pathology; a subject of the most vital importance to the practi- tioner, and which, though it has not yet received the due degree of cultivation to which it is entitled, has done much toward teaching the mode of curing numerous diseases, that formerly sub- jected the patient to the mutilation of the amputating knife. To come to a right decision in every case submitted to his judgment, it is necessary for the surgeoji to determine as positively as pos- sible, the present condition of his patient, what are the exact parts involved, how far extensive and what is the Tiatnre of the altera- tion, local and general, that has been brought about; and to look as it were into the future, in order to see in what in the course of time, despite the aid of appropriate treatment, the disease will in all probability result; and, if the operation be resorted to, what is likely to be the ultimate fate of the patient. Balancing these important questions in bis mind, he should calmly decide in favour of that course that gives the greater prospect of good, recollecting the rule of Sanson, as modified by Dr. King,* " that • Cydop. Pract. Surg., art. Amputalion. 34 amputation ought only to be performed when the danger and in- convenience to which it exposes the patient, are less than those of the disease treated otherwise." Even when fully imbued with the knowledge of his profession, the surgeon will often find himself placed in a most responsible and delicate position, in which he will require the counsel of a professional friend; as where a large limb is the part involved, and there is hope that the operation may be avoided, as well as great danger that delay may render it impracticable or futile. It is not, perhaps, saying too much, when I aver, from the frequent opportunities which I have had of witnessing their performance, and the fair share that has fallen to my own lot, that from a combination of erroneous judgment and a mistaken motive of humanity, the performance of these operations is frequently deferred until their chances of success when practised have been considerably com- promised. PLACE OF ELECTION. When the amputation of a limb is considered requisite, it be- comes necessary to decide at what point it should be practised. This has led to the distinction, by the French surgeons, of, 1, the place of necessity, when there is no choice of site, there being but one spot where the operation can be performed at all without serious inconvenience; 2, the place of election, when there is a choice of several positions at which the limb may be amputated. In truth, that should be considered the place of necessity which combines the best chance of the patient's recovery, and the for- mation of a sound and serviceable stump; but while there exists such a difference of opinion among surgeons in reference to this subject, it will be found convenient to retain these terms. INSTRUMENTS. The instruments that have been used for this operation are very numerous. They may be classed under the following heads:— 1. Those for arresting the circulation in the arteries. — These consist of the common tourniquet, the compressor of Uupuytren, and the garot of Morand.* Many surgeons, however, dispense with these instruments altogether, inasmuch as they dam up and cause a waste of the venous blood, and sometimes fetter the movements of the operator, and trust to pressure made on the great arterial trunk of the limb by the fingers of an experienced assistant. The possibility of an inadvertent relaxation of the force applied, and an unusual bifurcation of the main artery, often found in the arm, are causes which render pressure with the finger less suited for general adoption than the use of the tourni- quet. In certain cases, however, as in amputation at the top of the thigh and the shoulder, it is employed in preference to any other means of stopping the circulation in the vessels. 2. Of those for dividing the soft parts. — These should consist of four amputating knives of different shapes and dimensions, and one or two common scalpels. Of the amputating knives, I prefer one, for the circular operation on large hmbs, eight inches • The English tcjuroiquet may be seen applied ai PI. XLII. The other instru- ments at PI. VP. GENERAL OPERATIONS. long in the blade, straight on the edge so as to cut from the heel to the point, and sufficiently thick on the back to be firm and re- sisting; the handle should be nearly as heavy as the blade and not too long, in order that it shall feel well in the hand and be readily manteiivred. A sharp-pointed knife, seven inches long in the blade, and double edged near the point, will be con- venient for circular operation on the arm, and the formation of flaps in various positions, but especially from without inwards. Two narrow catlings will be needed; one of which should be ten inches long, for the cutting of flaps from within outwards, and the disarticulation of the two great joints; and one five inches long for the division of parts in the interosseous spaces. 3. Those for dividing the bone. — These should consist of one large saw, resembling that of the joiner, widely set on the edge, for the section of the large bones; a smaller and finer one, either with a "bow back or a simple straight blade, for the division of splinters and the smaller bones; a pair of cutting forceps, which may also be used for the latter purpose, and an ordinary pair of bone nippers for the snipping away of any splintered edges re- maining after the section of the bone. 4. Those for secia-ing the vessels.-— Thesa will consist of the dissecting or artery forceps for securing the large vessels, — to do which neatly two will be required; one for seizing the artery on the surface of the stump, and the second for separating it from the nerves and other surrounding parts, to facilitate the proper application of the ligature: — two tenacnla for the raising of the lesser arteries, and a few snture needles, furnished with ligatures of different sizes, to make the mediate ligature of some of the smaller vessels after the manner of Pare, when their orifices cannot be discovered, or their walls are so softened as not to bear the knot; scissors curved and straight; and a large linen compress, split for half its length into two or thi'ee strips, ac- cording as the part to be amputated is provided with one or two bones. Dressing. — The apparatus required for the dressing of the stump, is nearly similar to that needed after other extensive ope- rations: warm water and sponges, adhesive straps of various lengths, and a vessel containing boiling water, against the sides of which the straps are to be warmed; two or more small pieces of linen, in which to enclose the ends of the ligatures; lint, linen compresses, and two roller bandages, each two or more yards in length. The Malta cross may, if desired, be used to cover the stump; but the pad ofcharpie, tow, and even the cushion of down, formerly used with the object of soaking up the discharges, are now properly abandoned. THE POSITION OF THE PATIENT, THE SURGEON, AND HIS ASSISTANTS. The room where the operation is to be performed ought to be well lighted, and not far distant from where the patient is after- wards to be placed in bed. It is commonly the custom previous to subjecting the patient to the amputation of a large limb, or any other severe operation, to administer a full dose of opium, for the purpose of allaying excitement and diminishing the sus- ceptibility to pain. This is not, however, universally practised. The bowels ought to have been thoroughly opened the day before the operation, so as to render their action unnecessary soon after, as well as to diminish the risk of constitutional irritation. When the patient has made up his mind to the operation, he should not be kept in suspense, but all the necessary preparations made as quickly as possible. If the operation is to be performed on the up- per extremities, he may be seated on a chair; if on the lower, he is placed on a convenient table or bed, and the diseased extremity drawn aside so as to be easily accessible; but the position will vary more or less according to circumstances, and depends greatly upon the part which is to be removed. For the amputation of smaller limbs but one or two assistants are required, the operator himself taking hold of the part to be removed with his left hand. In that of the larger limbs from four to six are necessary, some of which at least ought to be professional men, or at least well acquainted with all the particulars of the proceeding. One has to regulate the compression of the principal artery either with the tourniquet or with his fingers. If the tourniquet be chosen, it ought not to be tightened till the operator is ready to begin. In cases where the artery cannot be felt from its being deeply covered by fat or enlarged lymphatic glands, where instead of one main branch the limb is abnormally supplied with several arterial trunks, and in places where no bone lies close to the vessel, the use of this instrument is positively indicated. The second assist- ant is to hold the limb with both hands above the place of ampu- tation, to retract the skin and the divided muscles, and in general has to give the limb the most convenient direction for the operator to use the knife with freedom. The third assistant holds the limb below; his attention should be particularly directed to keep it fixed, and when the bone is being sawed through to prevent its being inclined either upwards or downwards, which might bind the saw or cause a splintering of the bone. It is recom- mended that he should kneel down, and as soon as the hmb is separated remove it out of sight of the patient. A fourth hands successively the instruments to the operator; and one or two more are sometimes needed, especially in operations at the hip or shoulder joints, to assist in the ligature of the vessels, to hold the patient or attend to his restoration. The position of the operator himself varies according to the part to be amputated; it depends also in a great measure upon the method he intends to follow, and will, therefore, be noticed in the description of the different processes. METHODS OF OPERATION. These are three in number: — the circular, the flap, and the oval or oblique; and are distinguished merely by the manner in which the soft parts are divided. Circular method. — This is the oldest of all, and dates its origin from the time of Celsus — is apparently the most simple, and is still perhaps the one most frequently employed. The soft parts are here divided by circular incisions, carried completely round the limb; and, to form a good stump, it is requisite in the first place that the knife be applied and carried along exactly at a right angle with the longitudinal axis of the bone; secondly, that the end of the incision fall straight on the point where the knife was first applied; and lastly, that the skin and muscles saved on the outside be sufficient completely to cover the end of the bone AMPUTATIONS. 135 after the limb has been removed. According to the old method of Celsus, all the parts were divided at once down to the bone, dissected off from it for some distance, then retracted and the bone sawn through. But in this way it was found impossible to preserve skin and muscles enough to cover the stump; Mursinna, Rust, and Dupuytren have, however, in certain cases attempted to revive the practice under some modifications. To attain the above-mentioned object with greater certainty, Cheselden and Petit practised a division of the soft parts by two separate circular incisions, the first dividing the skin and fat down to the aponeurosis; the skin was then retracted, and the muscles divided somewhat higher up by a second circular cut. To this 13. Bell added the advice, previously given by Celsus, to dissect the mus- cles from the bone for some distance, so as to be able to use the saw higher up; and Louis, who had observed that the outer layer of the muscles contracts more during the operation than that attached to the bone, recommended to divide the superficial layer with the first incision through the skin, and the deeper muscles somewhat further up by the second. Dupuytren modified this proceeding by cutting through at once down to the bone; and then, after the skin and superficial muscles had retracted, dividing by another circular incision the deeper-seated layer again some- what higlier up. The plan most commonly followed now is gene- rally ascribed to Desault, though his original proceeding has been somewhat modified. The first incision is carried through the skin and cellular tissue alone, at a distance proportioned to the thickness of the limb below the point at which the bone is to be cut. The operator holds the knife firmly in his hand, passes his arm under the limb so as to encircle it, and applies the edge of the knife, near the iieel, perpendicularly upon that side of the limb which is directed towards him; and then, drawing the knife with a suffi- cient degree of pressure in a circle round it, brings up the heel perpendicularly at the place where the incision first began. Some surgeons divide first the upper part of the skin in a semicircle, and then tiie lower half in the same manner; and tliis undoubt- edly is more easily done, though neither so sure, so neat, nor so rapid. That the skin may be retracted more readily, its cellular attachments to the fascia are now divided with the point of the amputating knife or a bistoury; if it cannot be retracted far enough, it will be better to turn it completely back like the cuff of a coat, as first recommended by Alanson. Besides this, some slit it open at the sides, or unwisely remove a triangular piece out of it, for the purpose that it may cover the stump more smoothly, since the re- traction of the cicatrix and the action of the absorbents will remove the puckered angles left at the time of operation. About half an inch below the retracted skin, the muscles are next cut through by a circular incision down to the bone. The cone which projects in consequence of the deep-seated muscles having contracted less than the superficial, is then divided again on a level with the superficial layer. With a smaller knife the operator then pro- ceeds to dissect off the muscular fibres from the periosteum for about an inch farther upwards, so that the divided bone may be afterwards imbedded, as it were, in the muscles; but care should be taken not to denude it farther than it is to be sawn off, as it would otherwise be liable to mortify, exfoliate, and seriously disturb the cure. The retractor is then placed around the bone. If there are two bones, as in the leg and forearm, the interosseous ligament has to be divided first, and each of the bones separately circumscribed with the knife. In the former case a retractor with two heads; in the latter one with three heads, will be neces- sary, the middle one being drawn through between the bones. After the parts are sufficiently retracted by the assistant, the ope- rator places the thumb nail of his left hand upon the place where the bone is to be divided — close to the retractor — and then saws it through with light and steady motions of the instrument, per- pendicularly to its axis. If the bone has been splintered by any incautious movement of the limb by the assistant, the splinters have to be removed with a pair of bone nippers or the knife; but if a neat section has been made, it is not good surgery to smooth off the edges with either of these instruments, which unnecessarily denudes the bone; the smoothing being far better accomplished by the action of the absorbents. Another mode of performing the circular amputation of limbs was recommended by Alanson, and after him extensively prac- tised by Graefe. The object of this method is to give to the face of the stump the shape of a hollow cone, a result gained with greater certainty by the usual procedure. It is accomplished by cutting circularly through the muscles in an oblique direction upwards. As this is very difficult to accomplish with a straight knife, Graefe invented a particular instrument, which, however, no one else has used. This mode is justly becoming obsolete. Flap method. — The origin of this method may properly be re- ferred to Lowdham, an English surgeon, who employed it at London in 1679. Somewhat later, Verduin and Sabourin also practised amputation of the leg with a single flap. Ravaton and Vermale afterwards devised the method with two flaps, and ap- plied it to the limbs generally. In some cases, particularly where the soft parts are very thick, as in the upper part of the thigh and arm, the flap method has undoubted advantages over the circular, and, as a general method, is preferred by several dis- tinguished surgeons of the present day. The flaps are formed either from without inwards, after the manner of Langenbeck, by drawing the soft parts off from the bone at the part where the flap is to be formed, and then carrying the knife obliquely up- wards as far as necessary, from the surface toward the bone: or, (which is usually preferred,) from within outwards, when a long narrow, sharp-pointed knife, either single or double edged, is first passed through the soft parts at the point of amputation, perpen- dicularly upon the bone; around the semi-circumference of the bone the point is next to be carried till it emerges through the skin of the opposite side; the edge being next brought with a sawing motion downwards and outwards to form the flap. The parts on the opposite side of the limb are to be divided by a semicircular incision, if one flap only is made, which should then be long enough completely to cover the stump. If two flaps are formed, they must be of equal length, to meet after- wards in the middle of the stump; or, if of unequal, so as effec- tually to cover it. That containing the large vessels is cut the last. After the flaps are formed, the remaining soft parts around the bone are divided with a circular incision, the flaps turned back, and the bone sawed off as high as possible between them. One of the most important points in the application of this method, is to form the flaps sufficiently long; and, in making a calculation for this purpose, something should be added to the diameter of 136 GENERAL OPERATIONS. the limb, on account of the retraction which immediately takes place in the severed parts. Where it is possible to obtain from the soft parts two flaps of good dimensions, this method, as giving a larger cushion for the stump, and being better suited for union by first intention, is with good reason preferred by very many surgeons over the circular amputation. In many cases, we resort to it as a matter of necessity, rather than choice; when, for in- stance, the skin and soft parts have been lacerated or otherwise destroyed higher up on one side of the limb than the other, and where, if we were compelled to employ the circular method, a greater portion of the extremity would have to be removed than is desirable. Tilt obUfjue or oval method. — This is in a manner a combina- tion of both the circular and flap. Langenbeck first employed it for (he removal of the metacarpal and metatarsal bones, Guth- rie for the shoulder joint, and Scoutetten afterwards extended the practice into a method for amputations in general. The incisions by this method are carried around the limb in a sloping direc- tion, which is oblique in reference both to the longitudinal axis and the perpendicular diameter of the limb. All the soft parts are cut through at once, except they be very voluminous, when another incision in the same direction will be required. The flaps formed in this manner present an oval surface, angular at the starting point, but more rounded ofi" at (he far end, so as to resemble In shape a common kite, or the letter V, terminated by a rounded Incision at tiie base. This method Is decidedly prefer- able to the two preceding in many operations through the joints. It is, however, but seldom employed in operations through the continuity of the bones. LIGATURE OF THE VESSELS AKD DREfJSEVG OF THE STUMP. When (he limb has been removed, the first thing to be done is to tie the vessels, and this Is frequently more difficult to accom- plish than the operation itself. Not only a minute anatomical knowledge of the situation of the larger branches between the parts forming the surface of the stump is required, but a steady hand, and much practice to find tliem in the interstices of the muscles into which liiey have retracted, and isolate them from the accompanying veins and nerves. The mode of accomplish- ing this object has been particularly detailed at page 34. The principal branches, the position of which Is known, should be tied first, and then the place of the smaller and Irregular may be the more readily detected by slackening the tourniquet, or relax- ing the pressure of the finger upon the main trunk, to allow them to throw out a jet. One end of the ligature is to be cut off as soon as applied, in order to leave as little foreign matter as possi- ble in tlie wound. After all the bleeding vessels are secured, the remaining ends of the ligatures are to be collected and brought straight out of the wound at the nearest and most convenient place, to interfere as little as possible with the union of the lips. For a long time suppuration was considered necessary to Insure the life of the patient against the consequences arising from the loss of the larger limbs; but all English and American surgeons since the time of Hunter have considered (hat this opinion is founded merely on prejudice, and prefer to unite as much of the wound as possible by first intention. Its margins are therefore brought, immediately afier the operation, In close contact. In | circular amputations, when a pouch of skin is left at the bottom of the wound, it will be found useful to introduce a short piece of greased linen between the lips to prevent any dannnlng up of the secretions. To effect union by first intention, great care and nicety is required. The surfaces of the divided parts. In the first place, ought to be smooth and even, and the care of the operator in this respect Is of the utmost importance as regards the healing of the stump. If flaps have been formed, they are to be brought together in the way in which they will best fit. After the cir- clrcular amputation, we may give to the line of the cicatrix any direction that Is desired, and though the choice may occasionally be varied from the locality of the wound, a more or less perpen- dicular direction In general will be preferred as furnishing a free outlet to the purulent secretion, and more readily allowing the opposite sides of the incision, (which is a matter of much im- portance,) to come closely into contact. An assistant then com- presses the stump with both his hands, and at the same time holds it up, while (he surgeon closes the wound nearly with adhesive straps passed from one side of the limb to the other, leaving small spaces between for the escape of the fluids. The adhesive straps may then be lightly covered with some lint, or fenestrated linen spread over with simple ointment, and a com- press placed on the top. Two light compresses are then to be placed at the sides, and a roller applied over the stump, and for some distance up the extremity, to hold the dressings, and at the same time exert a good degree of compression upon the limb — suflieient to prevent the retraction and spasm of the muscles. Sutures are now never used, at least in circular amputation, as (hey cause unnecessary pain and Irrhatlon. In flap amputation they may, iiowever, sometimes be found advantageous. The most formidable accident liable to arise, either during or after the operation, is hemorrhage. If It occur during the opera- tion. It is the consequence of an imperfect compression of the main trunk, or of an Irregular distribution and dilatation of the branches, or may even arise from the veins, if these are in a va- ricose condition. In either case, if the bleeding is very profuse, the operation has to be terminated speedily, and the vessels tied as quickly as possible. If several torsion forceps are at hand, the principal branches may be seized and held until the operator is more at leisure to tie them. If the bleeding arise from the veins. It generally ceases spontaneously, or is readily controlled by the pressure of the dressing: the tying of these should If pos- sible be avoided, though it may become necessary where a vein Is diseased and has been obliquely opened In a flap amputation. Not unfrequently, the hsemorrliage comes from the cavity of the bone, in consequence of a morbid development of the nuiritlous artery, and its having been divided close at Its entrance in the bone. This is a troublesome incident. To tie the vessel is mostly impracticable. Plugging the orifice in the bone, tam- poonlng (he wound with lint, styptics, or even (he hot iron In case of necessity, are the means (o be employed in arresting the discharge. Secondary hasmorrhage may also occur; and in (he after (rea(ment, oughc to be most carefully guarded against. If it proceeds from any open vessels, either left untied, or which have been reopened from the ligatures having slipped or ulcer- ated off, they must be again secured, if the flow of blood cannot be arrested by compression and the use of refrigerants and styp- AMPUTATIONS. 137 tics. If it be more of the nature of parenchymatous bleeding, it will prove troublesome, and must be managed as directed in Part First of this work. If the disease is found to extend higher up than at first ex- pected, the plan of operation has to be changed immediately, and a greater portion of the Hnib removed. Among the numerous occurrences which may delay or defeat the successful issue of the operation, are to be mentioned, fistulous and sinuous cavities around the stump, exfoliation and mortification of the bone, the formation of a conical stump, inflammation of the stump, and phlebitis. But all these the surgeon may usually guard against by judicious after treatment. SPECIAL AMPUTATIONS.— UPPER EXTREMITY. It has commonly been the practice of writers, to describe under separate divisions the amputations at the joints, and those in the continuity of the bones. But inasmuch as these operations "are practised for similar affections, and the processes of the two are in many respects analogous, it will be obviously proper as well as found more convenient for reference, to have them described together. The surgical precept already referred to as of general applica- tion, that of amputating at the farthest possible point from the trunk, in order to save as much as we can of the limb, is of espe- cial value in regard to the upper extremity, This will determine the order in which we ^hall lake the operations up. And it may be well, also, to observe, in connection with this part of the sub- ject, that such is the importance of preserving as entire as possible the upper extremity, that even the opponents of amputation at the joints usually sacrifice their opinions in reference to the upper extremity, when hy disarticulation they are enabled to preserve a greater length of the member. I. OF THE HAND. AMPUTATION OF THE PHALANGES. (_PL. XXXE.) Surgical anatomy. — The anterior extremities of the first and second phalanges present an articular surface slightly concave in the middle, and bounded upon each side by condyloid projections, while the posterior extremities of the adjoining phalanges present a conformation exactly the reverse. In this way, a true hinge joint is formed, with a reciprocal interlocking of the opposing surfaces. Two strong lateral ligaments connect the bones, which must be first divided iu the attempt at disarticulation, before a bistoury can be passed through the joint. The back of the pha- langes is rounded, covered with the expansion of the extensor tendon, which supplies the place of ligament on that surface of the joint, and is overlaid by thin and movable integument. On the flattened palmar surface of the fingers, pass the two flexor tendons, one of which is inserted into the base of the second, and the other into that of the third phalanx. Between them and the joint, there is a layer of fibro-cartilaginous matter, which forms the palmar ligament; and around them, in order to confine them near the bone, is the vaginal or sheath-like ligament, the inner surface of which, as well as the tendons themselves, are lined hy a double reflected synovial membrane, more or less connected 35 with the great synovial sheaths in the palm of the hand, and forming altogether so extensive a surface as to make their in- flammation a subject of serious importance. On the palmar face, the skin is thick, as well as the subcutaneous cellular tissue, in which run the arteries and the nerves, From this surface the flap must be principally obtained for the purpose of covering the stump. The arteries do not require to be tied, the bleeding stopping spontaneously, or being readily arrested by the pressure of the dressing. If the two lower phalanges are removed, it might be supposed that the flexor tendons would not act upon the remain- ing one; but experience has shown that ihey become firmly blended with the parts on the face of the stump or the surface of the bone adjoining. An assistant is to support the hand of the patient, keep the other fingers bent in the palm, and present the one to be operated on, extended to the surgeon. The amputation may be done either at the joints or in the continuity of the bone. The exact position of the joints is shown by the flexion of the fingers; the prominent point in the flexed position belonging to the bone behind. It is also, and still better, indicated by the dorsal and palmar creases; in the former, which are numerous and con- centric over the back of each articulation, we usually find a deep central one which corresponds to the line of the joint. Bnt the palmar folds are the surer guides. There are two of these at the junction of the first with the second phalanx; the inferior or distal one will be found opposite the joint. The union of the second with the last phalanx, is two lines below the simple palmar crease. AMPUTATION AT THE TWO PHALANGEAL JOINTS. fPL. XXXII. Fig, 1 and 3.) This may be done by the circular method, or by the flap: the latter is, however, usually preferred. Circular operation. — The finger is to be held extended while the surgeon divides the skin circularly three or four lines in front of the joint. It is then to be well flexed by an assistant, who at the same time draws back the divided skin; the surgeon next divides the extensor tendon just in front of the joint, and carrying the knife along with a slight sawing motion, opens the back of the articulation, passes the blade through the cavity, rocks the loosened phalanx from side to side as he divides the lateral liga- ments, and finishes by cutting square through the flexor tendons. Dressi7ig. — The edges of the skin arc then to be brought in a line from side to side over the head of the phalanx, and secured by two strips of adhesive plaster, and a few turns of a small roller. Flap operaiion.— 'There are several processes by the flap. The best are those of Lisfranc, slightly modified by giving more length to the dorsal skin. \st Process of Lisfranc. (PI. XXXII. fig. 1.)— An assistant retracts the skin from the place of operation towards the palm. The surgeon, holding the phalanx to be removed with its palmar face downwards, between the thumb and finger, flexes it at an angle of 45 degrees, and draws a straight, narrow bistoury from heel to point half a line in front of the projection formed by the head of the phalanx, so as to divide the skin and extensor tendon. The handle of the instrument is then raised and inclined towards 13S GENERAL OPERATIONS. the surgeon, so as to bear the point downwards and divide the left lateral ligament before entering the joint; the right is next divided by carrying the handle downwards, inclined from him. The joint being now opened, the phalanx is to be luxated back- wards, and the bistoury carried round its head so as to cut a flap on the palmar surface sufficiently large to cover all the face of the wound. Remarks. — This process is neat and rapid. But in operations on the Hving subject, I find that a better stump is formed by making the dorsal incision of a semilunar shape, with the con- vexity in front of the joint. It is frequently difficult to avoid notching the flap as the knife is turned round the head of the bone. By cutting previously one side of the flap, and rocking the phalanx sideways, this difliculfy maybe obviated. It is also better to imitate the process of Delpech, and measure the palmar flap on the face of the stump before we cut it from the bone. In cases of necessity, the flap for covering the end of the bone may be taken either from the back or sides of the joint. 2d Process of Lisfranc. (PI. XXXII. fig. 3.)~The hand is held with the palm upwards, and all the fingers closed but the one to be operated on. The surgeon applies his left thumb upon the end of this finger, and bis middle finger behind the articulation to be opened. Placing his bistoury flatwise, and so as to be supported on the pulp of his middle finger, he passes the point through, shaving the bone, below the crease already described as indicating the palmar line of the joint. As the bistoury enters. PLATE Xlin.— AMPUTATIONS OF THE PHALANGES OF THE HAND. [Fig. 1.) (A). AMPUTATION OF THE SECOND PHALANX OF THE FORE FINGER IN THE CONTINUITY OF THE BONE. The soft parts have been divided circularly with the knife, and the skin retracted by two small strips of linen, which are crossed on the opposite side of the wound. A small saw-knife, edged upon the back, such as is frequently employed for the sake of convenience in these cases, is seen lying on the bone, after it has made a complete section of the tendinous structure. The instrument is to be reverted, and the bone divided with the serrated edge. An assistant draws the integument towards the palm with the band {a); the surgeon with the left hand supports the end of the finger to be removed. (G). AMPUTATION THROUGH THE FIRST PHALANGEAL JOINT OF THE RING FINGER. (Process of Lisfranc. Flap on the -palmar surface.) The end of the finger is held in the left hand (c) of the surgeon, and the bistoury, which has been carried through the articulation, is about to divide the palmar flap, the surgeon favouring its action by luxating the first phalanx upwards. (C). AMPUTATION AT THE FIRST PHALANGEAL JOINT OF THE THUMB. {Circular operation.) The operation is represented at its completion. The dressing of the stump is shown at fig, 6. {Fig. 2,) (D). AMPUTATION IN THE FIRST PHALANGEAL JOINT OF THE MIDDLE FINGER. {Double flap — palmar and dorsal. Modified operation of Lisfranc.) d. Hand of an assistant, holding the other fingers out of the way. c. Left hand of the surgeon, supporting the end of the finger. The palmar flap has been cut and drawn back- wards, and the knife is seen passed through the joint, and about to separate the flap on the dorsal surface. (E). AMPUTATION AT THE FIRST JOINT OF THE LITTLE FINGER BY A SINGLE DORSAL FLAP. (Process of Lisfranc.) The drawing represents the parts at the conclusion of the operation. (Fig. 3.) (F). AMPUTATION AT THE METACARPO-PHALANGEAL JOINTS, BY THE OVAL METHOD. ^Process of Scouletien.) The hand of an assistant ( /) sustains that of the patient. At F the surgeon with the left hand (g) grasps the end of the middle finger, while with the right he carries the bistoury round the articulation in an oval direction. The. moment of the operation shown, is when the knife, after having been carried round so as to cut the palmar fold of skin, is being brought up heel foremost to join the dorsal incision near its place of commencement. At AMPUTATIONS. 139 the handle should be a little depressed: it is then to be brought horizontal as it crosses the phalanx, and elevated as the point passes out at the other side, so as to give the largest breadth pos- sible to the base of the flap. The bistoury is next to be pushed forward up to the heel, and the flap finished as it is withdrawn, cutting from heel to point. The bistoury is now to be carried to the base of the flap, so as to divide across the anterior portion of the capsule and the two lateral ligaments, and finish by cutting the skin and tendon on the dorsum level with the joint. Remarks. — This second process of Lisfranc is more frequently employed than the first; it does not, however, appear to me to possess any advantages over the first when this is practised with the modification that has been mentioned in the last page. Dressing. — This is very simple. The flap is to be fastened over the surface of the stump with adhesive plaster, and the finger surrounded with a few turns of a roller; — the arm to be carried in a s)ing. AMPUTATION OF THE FINGERS IN CONTINTTITY OR THROUGH THE PHALANGES. (PL. XXXII. Fio. 1.) This is to be preferred to disarticulation, when it can be prac- tised, so as to preserve a greater length to the stump of the fin- gers. The instruments required, in addition to the bistoury, will be a small, fine saw, or the cutting forceps of Listen, for dividing the bone. The old practice of cutting the bone with a chisel has, even in modern times, been employed by Graefe. The circular method is the one most generally used in this amputation, and is to be employed precisely as described for dis- articulation, at page 137, with the exception of the division of the bone with the saw or forceps. The flap operatio7i employed in this amputation, is also, with the same exception, similar to the process of Lisfranc last de- scribed. Some surgeons, however, prefer to cut the flap from withont inwards towards the bone, rather than to raise it by a previous puncture with the bistoury. AMPUTATION IN THE METACARPO-PHALANGEAL ARTICULATION. (PL. XXXII. Fig. 3 and 4.) Surgical anatomy. — The construction of the knuckle joint is that of a ball and socket; the ball is formed by the prominent end of the metacarpal or knuckle bone, immediately in front of which lies the joint. The capsular ligament is loose, so as to render the situation of the joint visible in a healthy state, by drawing on the finger. When the fingers are extended the line of articulation will be found nearly an inch above the interdighal web or commissure, and a very little below the deep transverse line of the palm formed by the flexion of the fingers. imputation of a single flnger.—The only methods suited to this operation are the flap and the oval. Frocess of Lisfranc. (Pi. XXXII. fig. 2.)— This is but a modification of that of Ledran. The hand placed in pronation, and the adjoining fingers separated by an assistant, the operator, having ascertained, by the rules above described, or by moving it, the exact position of the joint, seizes the extremity of the digit to be removed with the thumb and finger of the left hand, and bends it at the metacarpo-phalangeal joint at an angle of 45 de- grees. A narrow, straight, long-bladed bistoury, held in the third position, is laid nearly over the middle of the knuckle bone, so as to divide by pressure and a slight sawing motion all the parts through to the bone, from a quarter of an inch above the joint, down to the commissure of the finger on the surface of the palm; the knife being held as we reach the commissure as if we were about to cut directly across the head of the phalanx. The handle is now to be depressed towards the palm, to make a neat section of the end of the flap, and the blade, held nearly vertically, run up in a sort of sawing movement closely in contact with the bone, so as to divide the soft parts on the palm opposite to the point at which the incision was commenced on the back. The instrument without being withdrawn is then turned with its cutting edge directly upon the joint, which it opens by the same sawing mo- G the same kind of operation, after its termination, is shown upon the little finger. The wound is to be closed whh a couple of narrow adhesive straps. (7^/-. 4.) FLAP AMPUTATION AT THE METACARPO-PHALANGEAL JOINTS. The two hands of an assistant (A, i) are seen applied; the one to sustain the member, and the other to draw the fingers into the palm of the hand; while the left hand of the surgeon (k, I) grasps the end of the finger to be removed in each of the processes shown in this drawing. At B, the amputation of the fore finger is shotvn according to the process of Petit. The stage of the operation shown, is when, after having formed the two lateral flaps, the knife is carried through the joint to finish the disarticulation. On the little finger is seen the double flap operation of Lisfrai\c. The knife has been carried up on the radial side of the joint, so as to form one flap; has opened and passed through the joint, and is seen descending on the other side so as to cut the second flap and at the same time detach the finger. {Fig. 5.) AMPUTATION OF THE FOUR FINGERS TOGETHER, AT THE METACARPO- PHALANGEAL ARTICULATIONS. The hands of an assistant (m, n) are applied so as to secure that of the patient, and present its dorsal surface upwards. The left hand (o) of the surgeon grasps the ends of the fingers. The period of the operation shown, is that when the knife, after having cut the skin and tendons on the dorsal siuface, and opened ail the articu- lations, is employed to finish the section on the palmar face. 140 GENERAL OPERATIONS. tion, and should be so lightly held as to slip over the inequality of the bones and fall into the joint. An assistant at the same time draws up the skin on the back of the wrist, to keep it from being nicked by the knife as it divides the flexor and extensor tendons in its passage across the joint; the surgeon at the same moment pulls upon the finger and carries it in a direction oppo- site to that of the knife. The first flap is now formed; and the second is completed and the finger detached by bringing the knife down on the opposite side of the linger, which it shaves from the joint to the commissure. By this process the digital arteries will only have been divided after their bifurcation, and usually soon cease to bleed. If the h33niorrhage continues, they are to be twisted or tied. If this operation be performed for the removal of the index or the litlie finger, it is necessary, on account of its greater tendency to re- traction, to cut the marginal flap considerably the longer of the two, the appropriate length of which may readily be ascertained by measuring it over the surface of the joint before detaching it from the phalanx. This process is rapid and showy. But it is attended by a deep incision into the sensitive palm, and is apt to be followed by a painful cicatrix. It has in fact, in reference to its application to the living subject, but little to recommend it over the older processes of Sharp and Petit. Sharp made a circular incision at the level of the commissure, from which two lateral ones were extended upwards so as to form a dorsal and palmar flap. Petit cut two lateral flaps, the extremities of which met on the back over the metacarpal bone, and on the palm just above the commissure. But the method of all others best suited for (he removal of a finger at this joint, is the oval method or process of Scoutetten. (PI. XXXII. fig. 3.) The finger held in the manner indicated in the method of Lisfranc, the surgeon takes the bistoury in the right or left hand, according to the limb on which he acts, and lays it so that the point shall rest a quarter of an inch above or beyond the dorsal face of the joint. Then, pressing it down to the bone, he makes an incision obliquely downwards to the com- missure of the finger of the same side; nest raising the finger as far as possible, he sweeps it round the palmar face to the com- missure of the other side; and now, flexing the finger, draws it rapidly up from heel to point, so as lo make a second oblique incision terminating on the first, two lines, below its commence- ment; the bistoury dividing the skin completely in its course. He now cuts llie extensor tendon and opens the back of the joint, divides the lateral Hganicrils, luxates the phalanx backwards, and, carrying the knife below the head, separates the finger from all its remaining connections. An oval or sort of V shaped wound is left. The division of the soft parts is but little extensive, and the palm is wholly uninjured. In removing tlie index or little finger the bistoury must be carried so as to cut a flap longer on the border of the hand. Di'essing. — This is very simple. The arteries rarely require to be tied. The fingers are merely to be brought together (which will suflice to close the wound) and secured with a roller band- age. The hand is to be carried in a sling. For the index or little finger, adhesive straps must, however, be used to approximate the edges of the incision. There is no fear in this operation of leaving too much integument, as this wiU thicken and contract to the requisite extent during the progress of cicatrization. Uupuytren proposed to excise in addition the head of the me- tacarpal bone, for the purpose of allowing the adjoining fingers to come nearer together. But experience has shown that this is a measure wholly unnecessary. AMPUTATION OF THE FOUR FINGERS TOGETHER. This is but a modification of the process for the removal of a single finger, applied to ail the fingers of the hand. The process of Lisfranc, (PI. XXXil. fig. 5,) to whom we are indebted for the establishment of this operation, is as follows. The surgeon grasps tlie fingers with the left hand, with his thumb and fore finger applied to the opposite ends of the range of joints; an assistant at the same time drawing up the skin of the back of the hand. He then commences his incision at one margin, and car- ries it just over the basis of the phalanges, a quarter of an inch in front of the metacarpal bones, If^ing bare the extensor ten- dons in its course. The retraction of the skin by the assistant opens the wound. The skin is then loosened with the knife, till the joints are exposed, over which the extensor tendons are to be cut. The operator then divides the lateral and palmar ligaments of each joint in succession; and gliding the knife under the base of the phalanges, shaves their inferior surface, and forms the palmar flap by cutting along the fold which separates the fingers from the palm. Circular method. Process of Cornnau. (PI. XXXIH. fig, 1.) ■ — The surgeon, grasping the fingers with the palmar surface up- wards, makes at one cut a semicircular incision, convex in front, which crosses the commissural line of the fingers, dividing the skin, aponeurosis, flexor tendons and vessels, so as to expose the heads of the metacarpal bones. He then, without loosening his hold, turns the hand in pronation, and makes a similar incision on the back, continuous at its extremity with the former, which divides the skin and extensor tendons. He next luxates the phalanges backwards, and removes them by cutting across in succession the lateral and anterior ligaments of each joint. The dorsal incision should pass across about a quarter of an inch in front of the head of the metacai'pal bones, in order to leave sufli- cient integument for the dorsal flap. This circular process has been applied to the removal of a single finger, but is better suited to the operation just described, in which it has a decided supe- riority over that of Lisfranc in respect to the greater regularity of the palmar flap. The eight digilal arteries are divided by either process. When these require to be tied, which is very unusual, the ends of the ligatures are to be brought out at the ulnar and radial margins of the wound. The dorsal and palmar flaps are to be drawn together by straps of adhesive plaster. There is some danger to apprehend in case there should be developed any inflammation of the synovial sheaths of the ten- dons which extend up into the palm. The risk of this occurrence is to be obviated as much as possible by a compressing bandage about the palm, an elevated position of the limb, and a constant irrigation of the parts with a stream of cold waier. But if it follow, and the hand becomes painful and swells to a consider- able extent, free and deep scarification must be employed, in order AMPUTATIONS. 141 to stop the 'progress of the hiflammationj which might involve the risk of a second amputation, or even the loss of life. AMPUTATION IN THE CONTINUITY OF THE METACARPAL BONES. Whenever the nature of the lesion allows the clioice, it is better to amputate through the metacarpal bones than at their ar- ticulations with the wrist. If we amputate the four metacarpal bones of the fingers together, they may be sawed directly across. But if either one be removed separately, it is better to divide it obliquely so as to leave a bevelled surftice, making the bevel at the expense of the radial side for the third and fourth, and of the ulnar for the first and second. The last four metacarpal bones may be removed together either by the circular method or the flap. Circular melhod. (PI. XXXIII. figs. 1, 2, 3,)— The wrist is to he held by an assistant, {who at the same time draws upon the skin,) the fingers supported by another, and the thumb well separated from the palm. The operator divides the integuments circularly an inch at least below the point at which he wishes to cut the bone. The divided integuments are to be further drawn upwards for half an inch by the assisiant, who continues his trac- tion on the skin, while the surgeon loosens it with his knife. The tendons are then to be divided on a level with the edge of the skin, and the interosseal muscles cut by a narrow knife in- sinuated between the bones. The soft parts are next to be drawn back by a five-tailed compress, the three middle strips of which are passed between the bones. The bones are then to be divided either with the saw or the cutting forceps. The arteries are to be twisted or tied, and the wound closed with adhesive straps passed from the palm to the back. By a double Jlap. — Velpeaucuts a dorsal flap convex in front, which he dissecls up. He then passes his knife from one angle of the incision to the other along the front surface of the meta- carpal bones so as to cut a palmar fiap. By a single Jlap. — Onsenoort cuts a flap on the palmar surface only, either by dissection downwards, or from within outwards; plunging the knife in the latter case along the face of the bones, and cutting obliquely outwards into the palm. In either of these modes, care must be taken to leave the margins of the flap a little more prominent than t!ie middle, in order that it may be made to cover completely the ends of the second and last metacarpal bones. AMPUTATION OF THE METACARPAL BONES SEPARATELY IN THEIR CONTINUITY. Of the metacarpal bone of the thumb. — The anterior ex- tremity of this bone may be very readily removed by the common circular process described at page 137, dividing the skin at the level of the metacarpo-phalangeal joint. If it be necessary to remove a larger portion, the oval process will be found prefer- able to any other. The apex of the oval or V shaped incision should in this case rest upon the radial side of the metacarpal bone, and its base circumscribe the palmar fold of the thumb. The soft parts are then to be loosened on the palmar face of the bone, and the latter divided obliquely across from above down- wards and inwards with the saw. Of the second or fifth metacarpal hone. (PI. XXXV. fig. 1.) — 36 Either of these may be amputated in its course in a similar manner by the oval process, with the exception that the bone should be divided obliquely in a direction opposite to that re- commended for the thumb. For the removal of the third and fourth metacarpal bones, the oval process may also be applied with advantage. I have twice employed it with success, and the division of the bone, which is the more difEcuU part of the operation, was readily effected with the cutting forceps of Listen. This process enables us to avoid the division of the vessels, nerves and tendons, in the palm of the hand, — an object of very serious consideration. The following, however, is the process more generally recom- mended. The hand held in pronation is to be transfixed from the dorsal to the palmar face with a narrow, sharp-pointed bis- toury, which is to enter just above the diseased part, and shave down the side of the bone till it cuts through at the correspond- ing commissure of the fingers. The skin on the hack of the bone that is to be amputatedj is to be drawn as far as possible under the edge of the knife, so tliat the surface of the bone may be exposed after the incision. The skin and soft parts are then to be drawn to the opposite side away from the untouched surface of the bone; along this surface the bistoury is again to be cntersd, falling into the former line of incision, so as to separate the bone from its remaining connections without any new division of the skin, except at the place of the commissure of the other side of the finger. A short V shaped wound is thus formed, wiili,its base towards the phalanges. A small piece of wood, card, or a com- press, is to be introduced on one side of the finger, and a narrow saw at the other, with which the bone is to be divided obliquely across, and the finger with the anterior part of the bone removed. If the palmar arches are divided or the digital arteries before their subdivision, they will require to be tied; but if the vessels are only cut near the commissures, simple coaptation of the sides of the wound, and gentle compression with a roller, will alone snfljce to arrest the bleeding. AMPUTATIONS IN THE METACARPO-CARPAL JOINTS. The five bones of the metacarpus may be disarticulated in a mass from the inferior row of carpal bones, or any one may be removed alone. But it is seldom that any but the two first and the fifth require to be taken away separately. AT THE METACARPO-CARPAL JOINT OF THE THUMB. Surgical anatomy. — The superior extremity of the first meta- carpal bone is slightly convex and triangular in shape, and is attached by a loose capsule in its articulation with the trapezius, where it is separated only by a space of one or two lines from the base of the metacarpal bone of the fore finger, which rests against the trapezoides and the inner face of the trapezium. On the back surface, the bone of the thumb is coated only by the skin and extensor tendon; on its palmar surfixce, it is covered thickly by the mass of nuisclcs. Its junction with the trapezius may in the healthy state of the joint be readily ascertained by pressing the thumb towards the indicator and running a finger back along its dorsal edge, till we fee! the tubercle formed by its head, imme- 142 GENERAL OPERATIONS. dialely behind which is the joint. More or less motion may also be felt at this joint in flexing and extending the metacarpal bone. Care must be observed, however, not to confound the tubercle of the metacarpal bone with the projection of the scaphoid, which will be found nearer the wrist. In cases where there is so much tumefaction as to completely mask the joint, its position will be found to correspond very nearly with a point an inch below the styloid process of the radius. The line of articulation between the trapezius and metacarpal bone, along which the knife is to pass, is directed obliquely downwards and inwards to- ward the root of the little finger. The radial artery dips down into the palm between the bases of the metacarpal bones of the thumb and index finger, and is sometimes divided in the operation. Remarks. — The great object of the operation is to fill up well with a flap the space from which the bone is removed, and avoid a cicatrix in the palm, which is apt subsequently to become pain- ful upon pressure. These results are much better obtained by the oval method than the flap; to the former, therefore, I give the preference. Oval method. (PI. XXXIV. fig. 1.) — In operating on the right side, the hand should be placed in pronation, and the incision commenced on the radial border a line or two above the joint. For the left, on the contrary, the hand is to be placed iu supina- tion. The wrist supported and the fingers abducted by an as- sistant, the surgeon, taking hold of the point of the thumb, carries a sweeping incision with a long straight bistoury over the back of the metacarpal bone down to the line which indi- cates the junction of the first phalanx with the palm; turns his knife round this hue so as to form two-thirds of a circle, dividing all the parts as deeply as possible, and carries another incision up to the point at which he started, forming with the two an angle of about thirty degrees. Detaching rapidly the covering from the back of the bone, the surgeon divides the extensor ten- PLATE IIXIIL-AMPUTATIONS OF THE METACARPUS, Figs. 1, 2, 3.— Circular amputation in the continuity of the four metacarpal bones of the fingers of the right side. [Process of Cornuau ) (Fig. 1.) SECTION OF THE SOFT PARTS ON THE PALMAR SURFACE. a. Left hand of an assistant sustaining the palm. b. Right hand of the same assistant holding the thumb out of the way of the knife. c. Left hand of the surgeon grasping the fingers while he divides with the knife (d) the flesh and tendons of the palm. {Fig. 2.) DIVISION OF THE METACARPAL BONES WITH THE SAW FROM THEIR DORSAL SURFACE. The circular section of all the soft parts having been completed, and the interosseous muscles divided with a narrow knife, five narrow bands have been employed (three of which pass through the interosseous spaces) in order to draw back the divided tissues and admit of the application of the saw (h). e,f The two hands of an assistant supporting that of the patient. g. The left hand of the surgeon supporting the fingers. Ftg. 3.— Adjustment of the flaps over the divided ends of the bones, after the preceding operation^ by the aid of four strips of adhesive jilaster. The interosseous and digital arteries have been twisted instead of tied, hence no ligature threads appear in the wound. {Fig. 4.) AMPUTATION THROUGH THE METACARPO-CARPAL JOINT OF THE LEFT HAND. The operation is shown at the moment when the surgeon is about to complete it by cutting the palmar flap. The ends of the metacarpal and of the lower range of carpal bones appear in the wound. i. Hand of an assistant sustaining the wrist of the patient. j. Left hand of the surgeon supporting the fingers of the patient, while with the knife {k) in the other, he finishes the operation. {Fig. 5.) SKELETON OF THE HAND SHOWN FOR THE PURPOSE OF ILLUSTRATING THE ARTICULATION OF THE DIFFERENT JOINTS. c, b. The two ranges of carpal bones. c. Five metacarpal bones. d. First range of phalanges. e. / Second and third ranges. rialc :i3 AMPUTATIONS. 143 dons at the angle of the wound, opens the dorsal surface of the joint, depresses the iowei' end of the bone, and completes the division of the ligaments with the point of the bistoury; tlie blade of the knife is then to be passed through the joint behind the bone, so as to detach it completely by shaving its palmar face down to the base of the oval. In order to prevent the liability to projection of the end of the trapezius through the back of the wound, Malgaigne has pro- posed to modify the operation by first making a linear vertical incision over the back of the joint, and beginning the two in- cisions to form tlie oval half an inch below the johit. Flap operation, (PI. XXXIV. fig. 2. Common process.) — The hand held as above described, and an assistant drawing the integuments to the radial border of the thumb to give as great dimensions as possible to tlie flap, the bistoury is placed verti- cally at the angle of the commissure between, the thumb and the fore finger, and carried by the surgeon up at once to the meta- carpo-carpal joint, (where it is arrested by the internal projection of the trapezius,) shaving the whole ulnar side of the bone in its course. Arrived at this point, the edge of the knife is to be turned outwards towards the bone, in order to prevent its pass- ing between the trapezius and the second metacarpal bone. With a sawing motion, it now passes into the joint. The sur- geon next luxates the bone backwards by inclining forwards its ulnar edge, and draws upon it so as to stretch the capsule, in order that he may carry the bistoury round the convex head of the bone. The operation is then completed by shaving down- wards the radial edge of the bone, cutting out a little beyond the metacarpo-phalangeal joint, in order to obtain a flap suffi- ciently long to cover the wound. To form the flap as large and fleshy as possible, it is well in making the first incision, to incline the liandle of the bistoury toward the little finger. The dressingi 'm either mode of operation, is very simple. The blood-vessels are to be tied, or well twisted, and the wound closed by adhesive straps, supported by a few turns of a roller. OF THE METACARPAL BONE OF THE LITTLE FINGER. Surgical anatomy. — The internal border of the fifth metacar- pal bone does not form the margin of llie hand. It is overlapped by the mass of muscles, which renders easy the formation of a lateral flap. The oval method is, however, in this, as in the ope- ration last described, the preferable method. By carrying the finger along the edge of the metacarpal bone, we feel a promi- nent tubercle at its posterior extremity. Immediately behind this is the joint, marked by a little depression, by which it is articu- lated with the unciform bone. The outline of the articulation is somewhat curved, but is found nearly in the direction of a line drawn from the ulnar side of the joint to the middle of the second metacarpal bone. It forms also another small articulation, by a lateral facet which meets with another on the adjoining metacar- pal bone. Oval method. — This process for the disarticulation of the fifth metacarpal bone, is so similar to the first, that it needs to be but briefly described. The hand turned prone, and the fingers con- veniently secured, the oval incision is to be commenced a line or two above the joint, brought round the commissure of the finger, and carried back again to the starting point, so as to form there au acute angle. The bone is then to be loosened from the soft parts, or its sides disarticulated Irora the unciform bone, and separated by a sweep of the bistoury on its palmar face. Flap operation. {Process of Lisfranc.) — The hand is to be pronated. An assistant, or the surgeon himself with the left hand, draws the soft parts on the back and palm to the ulnar side, so as to allow the formation of as large and fleshy a flap as possible. The bistoury is passed from tlie back to the palm, perpendicularly through, on the inner side of the bone, exactly opposite the metacarpo-carpal joint, and is carried downwards, shaving the ulnar edge of the bone, so as to finish the flap a little below the commissure with the adjoining finger. The flap is then to be drawn upwards by an assistant, and the bistoury carried along so as to free the radial side of the bone. This may be done by drawing away the little finger from the one next to it, and cutting from the commissure upwards— or by carrying the integuments and extensor tendon towards the thumb, passing the knife between them and the bone, and cutting from above downwards to the commissure, between the ring and little finger. The lateral ligaments are then to be cut, and the joint opened on the back or palm; the bone is then to be removed by cutting the interosseous ligament, which will be facilitated by rocking the bone at the same lime a little outwards. Palmar fiap, (PI. XXXIV. fig. 3.)— This bone may also readily be removed by a palmar flap formed by dissection, as shown in the drawing. The oval method will, however, of all, be found the most appropriate. OF THE METACARPAL BONES OF THE SECOND, THIRD, AND FOURTH FINGERS, AT THEIR JUNCTION WITH THE CARPUS. The flap and oval methods have both been employed for the separate removal of these hones; and the processes are nearly the same as those for the removal of the first and fifih metacarpal. The chief embarrassment in these operations consists iu the dis- articulation, and arises partly from the form and number of the articular surfaces, and partly from the difliculty of attacking the joints upon their sides. The second metacarpal, the removal of which is most difficult, forms a triple articulation — a sort of mortise and tenon joint — the middle part of its base uniting with the trapezoid bone; and the two projecting processes at its side unite one on the radial side with the trapezius, and the other on the ulnar with the os mag- num and the third metacarpal. These articular surfaces are all connected by ligaments, and a strong interosseous ligament unites the second and third metacarpal bones. But the key of this compound joint is an anterior or palmar ligament, fastening the process on the inner side of the head of the bone to the os mag- num and the third metacarpal, without the previous division of whicli disarticulation is almost impossible. We may mark out the line of articulation as follows;— Carry the finger along the radial margin of the second metacarpal bone, till it is arrested by a prominence. This is formed by the head of that bone, and immediately behind it is the inner side of the joint, distant about an inch and a quarter from the styloid process of the radius. The third metacarpal forms a single line of articulation ob- liquely downwards and inwards. That of the fourtli metacarpal is nearly transverse. From the size of the vessels likely to be 144 GENERAL OPERATIONS. divided, a tourniquet should be applied to the arm; or, what is more convenient, pressure made by an assistant on the radial and ulnar arteries. Oval method. — The hand is to be placed in pronation, and the bistoury, starting from a point a little above the middle of the articulation, is to be carried obliquely downwards and across the bone to one of the commissures, thence round the digito- palmar groove, and up again over the dorsum to tiic place of comuiencemeiit, so as to form an oval-shaped incision with an acute angle above, Tiie lips of the wound are now to be sepa- rated by an assistant; the surgeon cuts with the front of the bis- toury the dorsal and interosseous ligaments, luxates the head of the bone by pressing its anterior extremity into the palm, and gliding the knife under its palmar face, detaches the bone in its whole extent. In disarticulating the second metacarpal, it is necessary in- di- viding the ligaments to follow particularly the angular lines of the joint; and in severing the strong anterior ligaments, it is di- rected by Sedillot to carry the point of the bistoury four lines behind the union of this metacarpal bone with the third, and cut upon the bone at the same time that its anterior extremity is pressed downwards, in order to effect the luxation. Flap method. (PI. XXXIV. fig. 4.)— The bistoury is to be car- ried vertically, so as to divide one of the interosseous spaces from the commissure of the fingers up to the carpal bones, prolonging the incision in the skin a little above the joint both on the dorsal and palmar faces. Drawing upon the finger about to be removed, while the adjoining one is held separate by an assistant, the surgeon passes the bistoury a second time from the back to the paim at the upper angle of the wound and on the opposite side of the bone, and brings it downwards, shaving the bone, so as to cut a second flap, emerging at the commissure on the other side of the finger. In making this second incision, the skin and soft parts are to be drawn to the opposite side, so as to diminish the amount of the structures removed. The bone is next to be dis- articulated as in the oval process. It is occasionally in our power, by removing two or more of the metacarpal bones together, to retain a portion of the hand that ultimately becomes very useful. I have removed, in a case of gunshot injury, the os magnum with the corresponding meta- carpal bone and finger, and the hand has been preserved with its uses but little impaired. Benahen has taken away the first two metacarpal bones with the trapezium, trapezoidcs, and scaphoides; and M. Sully the last two metacarpal bones with the unciform, PLATE miV.— AMPUTATIONS THROUGH THE METACARPO-CARPAL JOINTS. {Fig. 1,) OVAL AMPUTATION THROUGH THE CARPO-METACARPAL JOINT OF THE THUMB OF THE RIGHT HAND. The incision of the skin and muscles having been completed, the operation is shown as the surgeon is about to complete the disarticulation of the bone. «, b. Hands of an assistant sustaining that of the patient. c. Left hand of the surgeon sustaining the thumb, while he cuts the ligameuls of the joint with the knife [d] in his right. {Fig. 2,) FLAP AMPUTATION OF THE THUMB. The bistoury {/*) has been passed up on the ulnar side of the metacarpal bone, carried through the joint, and is brought down on the opposite side of the bone so as to form the flap. t,f. Hands of an assistant. g. Left hand of the surgeon. {Fig. 3.) AMPUTATION THROUGH THE METACARPO-CARPAL .JOINT OF THE LITTLE FINGER. {Process of Lisfranc.) The internal or palmar flap having been cut by puncture, or dissection from the ulnar border of the hand, the knife is shown in the act of being passed into the joint. i. Hand of an assistant. /. Left hand of the surgeon grasping the finger to bo removed, while he employs the knife with his right hand (m). {Fig. 4.) AMPUTATION OF THE THIRD METACARPAL BONE. The bone has been isolated by two lateral incisions, forming a V with the base towards the fingers. The knife {a) is shown as applied to complete the section of its ligamentous attachments. n. Left hand of an assistant. p. Left hand of the surgeon. AMPUTATIONS. 145 pisiform, and cuneiform. No distinct formula, however, can be given for such irregular operations. Dressing. — Tlie vessels, whicli are numerous and important in the palm, must be carefully tied. The removal of the fourth metacarpal bone, by the flap operation especially, is attended with a division of the terminal branch of the ulnar arterial arch and the second radial inlerosseal artery, — the middle finger, with that of the ulnar and radial arches or their digital branches. The parts are to be closed by adhesive straps and bandages, and kept constantly irrigated with cold water or some cooling lotion, in order to keep down inflammatory action. AMPUTATION OF THE FOUR METACARPAL BONES OF THE FIN- GERS TOGETHER, AT THEIR METACARPO-CAHPAL .lOINTS. (PI- X-XXm. Fjfi. 1.) The amputation of these bones in a mass is attended with less difficulty than the disarticulation of a single bone. It is neces- sary, however, for the surgeon to have a precise knowledge of the position, strncture, and zigzag direction of the line of articu- lation, else he will become embarrassed, or be compelled, as I have had occasion more than once to observe, to use the saw in their separation. An outline of this articulation is seen at PI. XXXIII. fig. 5. It is most essential to ascertain at tiie commence- ment of the operation the terminal points of the line, and for which the directions have already been given in the process for the dis- articulation of the second and fifth metacarpal bones. The course of the line in the main is strictly convex, with an inclination downwards and inwards. The articular heads of the second and fourth metacarpal bones are nearly on the same level. The ar- ticular surface of the third is about a line in front of these; that of the fifth on the contrary is about half a line nearer to the wrist. The space between the metacarpal bones of the thumb and index finger is large, and these bones may be said to be at their bases merely in juxtaposition. By examining the outline drawing above referred to, it will be seen that the metacarpo-carpal joint of the thumb is directed obliquely forwards and inwards, and is found at its inner edge about the sixth of an inch lower than that of the fore finger. All the metacarpal bones of the fingers are united together by dorsa! and palmar ligaments. Their joints are connected, by an extension of the synovial membranes, with those of the proper carpal bones, the inflammation of wliich, following amputation, may be attended with sertotis conse- quences. Operation. — An assistant presses on the radial and ulnar arteries so as to command the circulation. The surgeon grasps the fingers with the left hand applied over the dorsal surface, which should be uppermost,and makes a semilunar incision con- vex downwards a little more than half an inch in front of the articulation, commencing at the joint of the fore finger if it be the left hand, or at that of the little finger if it be the right, and ending at the opposite margin of the articular line. The skin is then to be i'jtracted by an assistant, and the extensor tendons divided by another incision on a line with the joints. The ope- rator is now to raise the knife nearly to a vertical position and run the point along the line of articulation, following exactly the zigzag direction above described, so as to cut the dorsal liga- ments, but without attempting to penetrate into the joints. When 37 they are all divided, he presses the end of the metacarpal bones downwards so as to luxate them at their base. He next passes his knife into the gaping joints so as to complete the division of the ligaments, and insinuating the blade flatwise under their heads, shaves their anterior surfaces, and cuts outwards into the palm, so as to form a flap an inch to an inch and a half in length in front of the carpal bones. This process may, at the will of the surgeon, be reversed, first cutting the palmar flap, then the dorsal, and luxating tlie bones in the manner described. In cases of necessity, the metacarpal bone of the thumb may be removed with those of the fingers. The operation terminated, it only remains to tie the trunks of the radial and ulnar arteries, and bring the flaps together with adhe- sive straps and a roller bandage. AMPUTATION IN THE RADIO-CARPAL ARTICULATION. This has latterly, notwithstanding the amount of prejudice usually entertained against disarticulation, become avery common operation. It is especially applicable in all such injuries or dis- eases of the hand as have spared the articulation of the wrist and its integuments; and the great success which has attended lis per- formance, shows that it should always be resorted to in such cases in preference to amputation in the continuity of the forearm. Surgical anatomy. — Of the four bones of the upper carpal row, the three outer only enter into the structure of the joint — the scaphoides, the lunare, and the cuneiforme. The upper sur- faces of these bones form together an oblong polished head, which is received iruo a corresponding shallow socket or depres- sion on the conjoined extremities of the radius and ulna, the sty- loid processes of which may be readily distinguished through the skin bounding tiie two sides of the joint. The exact seat of the joint may be readily determined by the following indications. Draw a straight line from the point of one styloid process to the other, and the joint will be found in the direction of a curve, the highest point of which passes about a quarter of an inch above the middle of the straight line. This curvature in the direction of the articulation should be well un- derstood; for if the disarticulation should be made directly across, the separation will be found to have taken place between the two ranges of carpal bones. The palmar face of the wrist in a state of flexion presents three lines, which may serve as a guide to the articulation. The one next the palm (the hand being held straight) corresponds to the joint between the two ranges of carpal bones. The middle one, half an inch above the former, indicates the position of the radio-carpal joint; and the third, which is an inch above the middle one, and sometimes very faintly marked, is on a line with the junction of the epiphyses with the shafts of. the bones. When the hand is bent firmly back, the summit of the angle, as observed by Malgaigne, which it forms with the forearm, corresponds exactly with the position of the joint. It is well, also, to notice that the scaphoid bone projects a little higher up than the lunare or cuneiforme, and that the pisiform of the lower row protrudes a little in front of the carpus, and that the knife of the surgeon during the operation nuist turn around these bones. The capsular ligament of the joint is in itself thin and mem- 146 GENERAL OPERATIONS. braiious, but is strengthened by lateral ligaments on its sides, and by the fibrous sheaths of the tendons on its dorsal and palmar faces. The circular method or the flap may either be employed in amputation at this joint, but in consequence of the absence of muscular tissue, and the liability of the styloid processes Eo be- come uncovered at the angles of the flaps, the former will be found to yield the most satisAictory results. Circular method. (PI. XXXV. figs, 2 and 3.) — An assistant retracts circularly the skin, and at the same time commands by pressure the circulation in the radial and ulnar arteries. The surgeon, grasping with his left hand the one about to be operated on, places it in semi-pronation, with the back turned towards him. With a small straight-edged knife, he then makes a circular incision through the integuments, which shaves the thenar and hypothenar eminences of the hand, following the lower of the three lines on the palmar surface of the wrist. The skin, which is alone to be divided, is then to be dissected up and reverted as high as the articulation, taking care not to loosen with it the pisiform bone. By another circular cut carried round from the lower edge of one styloid process to the other, the tendons and lateral ligaments are divided completely across. All that sustains the articulation now, is the thin capsular ligament. This may be opened with a scalpel at the will of the operator, either on the front, back or side, and the wrist luxated and detached by follow- ing with the blade of the instrument the curved line of the joint. By the formaiion of two fiaps. (PI. XXXV. figs. 4 and 5.) — The hand placed and sustained as above described, the surgeon makes on the back a semilunar incision through the integuments, commencing half an inch below one styloid process, and termi- nating the same distance below the other, — the middle part of the curve being about two inches lower. The flap of skin thus formed, and loosened by one or two cuts of the knife, is to be raised and drawn back by an assistant. The surgeon then divides on a level with the joint the extensor and radial tendons, the pos- terior part of the capsular ligament, the lateral ligaments and the tendon of the carpal extensor. He next presses downwards the palm so as to luxate the carpus, and carrying his knife through the joint, detaches the extremity by cutting a flap on the anterior surface an inch or more in length. It has been directed to raise the handle of the knife in this last step, so as to avoid including the pisiform bone in the flap. But it is probable little inconvenience could result from its being left with the skin, and we would thereby preserve the attachment of the flexor carpi radialis. This process may be often conveniently modified according to the peculiar seat and the extent of the lesion for which the ope- ration is performed; and it is perfectly easy to cut either a dorsal or palmar flap of sufficient dimensions to cover the ends of the bones, if the integuments have been destroyed on one of the faces of the wrist. The process of JAsfranc, (fig, 5,) which is inferior in value to either of the others, consists in passing a catling or double-edged knife across the anterior face of the wrist, from a point just below one styloid process to the lower edge of the other, and shaving PLATE XXXV.— AMPUTATIONS OF THE WRIST, AND OF THE THIRD METACARPAL BONE. {Fig. 1.) AMPUTATION IN THE CONTINUITY OF THE THIRD METACARPAL BONE. An incision has been made on either side of the metacarpal bone, so as to form a V. The hand of the patient is sustained by that of an assistant [a), who at the same time grasps the little bands which have been applied to separate the soft parts from the bone and protect them from the action of the saw. The surgeon with his left hand [b) holds the end of the metacarpal bone, while he divides it with a narrow saw near its junction with the carpus. {Figs. 2, 3.) CIRCULAR AMPUTATION AT THE RADIO-CARPAL JOINT. Fig. 2. — The stage of the operation shown is that when, after the circular division of the skin, the knife has cut the extensor tendons and passed through the joint for the purpose of dividing the ligaments on the palmar side. a. Left hand of an assistant, sustaining the stump. b. Left hand of the surgeon holding that of the patient, while with his right (c) he finishes the disarticulation. Fig. 3. — This shows the surface of the stump after the operation in fig. 2. The surgeon seizes the mouth of the radial artery with the forceps {d)y around which the hands of an assistant (e,/) are seen applying the ligature. The hand of another assistant (§■) sustains the stump. Fig. 4. — Closure of the loound loith three adhesive straps, after the amputation at the same joint by two flaps, the larger one being formed by incision over the dorsal surface. [Fig. 5.). DOUBLE FLAP AMPUTATION AT THE RADIO-CARPAL JOINT. {Process of Lisfra7ic.) The forearm is sustained with the hand of an assistant («); the left hand of the surgeon (5) grasps that of the patient. The palmar flap has been cut by puncture, with the hand in a state of supination, and the operation is shown at the moment the surgeon is about to finish cutting the dorsal flap with the hand in a state of semi-pronation. AMPUTATIONS. downwards the surface of the wrist bones, so as to form an an- terior flap. A semicircular incision is then made by puncture on the dorsum, and the flap thus formed dissected up. The knife is next passed under the styloid process of the radius, and swept along the curved line of the joint, so as to complete the disarticu- lation. Dressing. (Fig. 4.) — The radial and ulnar arteries are to be tied. It has happened, however, that these vessels have retracted so much that their orifices could not be found; and experience has shown that under such circumstances no secondary haemor- rhage is liable to follow. The integuments are to be closed by adhesive straps passed from the back of the arm; and a roller bandage is to be carried from the elbow downwards, in order to overcome the excessive tendency to retraction of the skin and muscle. At the lower extremity of the forearm it is also well to apply some longitudinal compresses, in order to flatten the syno- vial sheaths and prevent suppuration of their cavities. 2. OF THE FOREARM. AMPUTATION IN THE CONTINUITY OF THE FOREARM. Surgical anatomy. — The forearm, like the leg, is covered with muscles that degenerate in their inferior portion into tendons, which are enveloped by synovial sheaths more or less continuous with those of the palm. The presence of these tendons and their synovial sheaths, the liability to the propagation of inflammation upwards along the latter, and the fear that in the absence of tile muscular structure the skin would cicatrize liglitly over the ends of the bones, so as to make painful pressure on the extremities of the nerves, deterred the older surgeons from ampulating in the lower half of the arm. But the experience of latter times has shown that the general rule of removing as small a portion as possible, is as applicable to the amputation of the forearm as to any other part of the body, that the extension of synovial inflammation may be prevented by judicious treatment, and the tight adhesion of the cicatrix to the bone avoided, by giving a sufficient degree of extent to the cutaneous covering. In the amputations of the forearm, circular, oval, and flap methods are all occasionally employed. In a surgical point of view, tlie forearm may be divided into three sections. The inferior, which is flattened somewhat like the palm, is well suited to the flap operation, provided care is observed to turn back the flaps so as to reverse a portion of the uncut skin above the angles of the wounds, in order to cut the bones higher up and prevent their edges subsequently protruding at tliese points. Either of the other methods may be employed at the will of the surgeon — but in my hands they have not served to form so neat a stump. In the middle region the arm is coni- cal, and the flap is particularly appropriate here, in consequence of the difficulty of dissecting up and turning back towards the base of the cone the sleeve-like fold of skin. The upper third of the arm is round and muscular, and well suited for either form of amputation, though the circular has been more generally em- ployed. In the forearm, where there are two bones, to which the muscles are extensively connected, it has been observed that the muscles retract but little after their division, and the surgeon must bear this in mind in the operation, so as to cut his covering of skin of sufficient length, and if necessary, as it usually is, dis- sect off" the muscles from the bones for a little space before ap- plying the saw. Circular method. (PI. XXXVI. figs. 1, 2, 3.)— The patient is to be placed upon the edge of his bed, or seated on a chair. The brachial artery is to be compressed with a tourniquet, or the fingers of an assistant, and the forearm partly flexed and put in the middle state between pronation and supination, and well supported by assistants. The surgeon, placing himself at the inner side— a position that gives him a greater facility in dividing the bones — grasps with his left hand the forearm above or below the point of operation, according to the limb upon which he acts. A straight-edged amputating knife is then carried, with the right hand well pronated, under the arm to the upper surface of the radius, and the integuments divided down to the fascia in a cir- cular sweep, the knife coming round to the point from which it started, by allowing the hand which holds it to turn during the circuit into a state of supination. The integuments are to be dis- sected from the fascia for an inch or more, according to the thick- ness of the limb, and reversed. If on account of the conical shape of the limb difliculty should occur in turning back the skin, it may be slit over the radial and ulnar bones. By another circular incision the muscles are divided down to the bone nearly on a line with the base of the reflected skin. When the tendons are strong, there is a diliiculty in dividing them in the circular sweep, and it is well to follow instead the practice of Cloquet, by running a catling through on each face of the interosseous ligament, and cutting outwards. The cut muscles now retract; a narrow inter- osseous knife or catling is passed into the gap to divide the inter- osseous ligament and the interosseous muscles, both on the front and back of the bones. The retractor is next adjusted with the middle tail passed between the bones, and the muscles and skin drawn back out of the way of the saw. The saw is now to be applied on the face of both the bones, the radius being held in the middle state between pronation and supination, in order that it may noi be left too long; and the section of the ulna completed, last, in consequence of this bone being most firmly connected with the humerus. The retractor is then removed; the radial and the ulnar arteries, and occasionally the interosseal, tied. The wound is to be closed with adhesive straps, and supported with a roller bandage, so as to make the line of reunion the same as that of the end of the bones. Malgaigne has lately proposed, as a modification of the circu- lar operation, to form a flap of the muscles, about an inch long, on each side of the arm after the reflexion of the skin, by passing the catling flatwise on each face of the interosseous ligament. Flap method. Single Jlap.—Gmefe, following the process of Verdnin and Ruysch, passed the catling through from side to side in front of the bones and interosseous ligament, and cut out so as to form a semi-elliptical flap on the front part of the forearm. The skin and soft parts on the back were then divided down to the bone by a semicircular incision. The remaining muscular fibres and the interosseous ligament were then divided, the soft parts retracted, and the bone sawed in the usual maimer. Doulile flap. (PI. XXXVI. fig. 4.)— This method is more fre- 148 GENERAL OPERATIONS. quently employed than the preceding, and is of very easy execu- tion. The forearm placed in the middle state between pronation and supination, so as to render the two flaps of more eqnal size, the surgeon glides the knife across the arm either from the ulnar or radial edge, shaving the faces of the bones and the inte'rosseous Hgament, and cuts downwards and outwards so as to form an anterior flap two inches or more in length according to the size of the arm. The lips of the wound are then to be drawn backwards, and the knife carried over to the opposite side of the bones, and passed from the upper angle of the incision to the other without making a new puncture in the skin, so as to form a posterior flap nearly of the same size as the anterior. An assistant then raises the flaps, the surgeon cuts the interosseous ligament and remain- ing muscular fibres, and divides the bones with a saw. To prevent any possibility of the subsequent exposure of the bones at the angle of the wounds, I am in the habit of further loosening the flaps at the base with a knife, but without dividing the skin — an assistant at the same time drawing them strongly upwards — then applying the three-tailed retractor, and finally di- viding the bones, so that after their section they shall be half an inch above the upper angles of the flaps. Sir Charles Bell preferred to cut the flaps with a common am- putating knife from without inwards, in order to avoid the irregu- lar division of the tendons and muscles which will sometimes take place by the opposite mode of cutting the flaps, to such an extent as to require subsequent trimming. He made his anterior flap much larger than the dorsal, and observed the precaution lo divide the bones high up. I have employed this process, and found it to form a handsome and most serviceable stump. The only objection to it, which is not one of much moment, is, that the muscles recede to some extent into the interosseous hollow before the edge of the knife, leaving a considerable amount of fibres to be cut with the catling in the second step of the operation. Mixed process. — M. Sedillot cuts a thin, short flap, on either side of the forearm, elevates them, and divides the muscles circu- larly, or with a slope upwards at their base, down to the bone, which he cuts in the usual manner with the saw. M. Baiidens, in the inferior two-thirds of the arm, prefers to divide the skin circularly, to dissect and turn it upwards to the amount of three fingers' breadth, and then passing his knife through at the base of the fold on either surface of tlie bones, cut from within out- wards two short, thick muscular flaps an inch in length. These are to be drawn upwards by an assistant, while the operator isolates the bones and divides them in the usual manner with the saw. AMPUTATION AT THE ELBOW JOINT. The amputation at this joint, first executed by Ambrose Pare, has been revived and practised to a considerable extent in latter times. It has not, however, by any means, received the general sanction of the profession, though it was warmly supported by Dupuytren and others, and is considered by Velpeau as less dangerous than the amputation of the arm, the only alternative when we reject the operation at the joint. It is, however, a great advantage to the patient to be able to preserve the entire length of the arm, and it is at least certain that the disarticulation PLATE IXXYI— AMPUTATIONS OF THE FOREARM. {Fig. 1, 3, 3.) CIRCULAR AMPUTATION OF THE FOREARM OF THE LEFT SIDE. Fig. 1, represents the first stage of the operation. A circular incision has been made, and tiie integument is seen raised with the left hand of the surgeon [a), while it is detached from the aponeurosis with the knife in the right {b). Fig. 3, shows the face of the stump at the conclusion of this circular operation. The stump is supported by the left hand of an assistant (c). The three ligature threads {d) which have been applied lo the radial^ ulnar, and' anterior interosseal arteries, are seen hanging from the side of the wound. Fig. 3, represents the appearance of the stump after the closing of the wound with four adhesive straps. {Fig. 4.) DOUBLE FLAP AMPUTATION OF THE FOREARM AS PRACTISED BY THE AUTHOR. The surface of the stump is shown after the completion of the operation. f. Right hand of an assistant supporting the stump. g. Anterior flap reverted; which, in consequence of the greater thickness of the soft parts on this side, has nearly twice the length of the posterior flap (A). {Fig. 5.) CIRCULAR AMPUTATION AT THE ELBOW JOINT. {Process of Velpeau.) A circular section has been first made of the skin, and secondly one of the muscles, so as to give to the stump the appearance of a hollow cone, as in the modification of M. Cornuau. Tlie operation is shown at the moment when the knife (m), which has been passed through the joint, is applied so as to divide the tendon of the triceps above the head of the olecranon process. The right hand {i) of an assistant compresses the humeral artery, the left hand of the surgeon {k) sustains the forearm; The sloping direction of the section of the muscles of the forearm, which leaves the heads of the radius and ulna prominent, is seen at /. Ffi.ita.delj>h.ia., I'u.blished. by Car-ay B.i.ri AMPUTATIONS. 149 has been attended with a fair average of success. In cases of injury of the forearm, when there is no chronic affection of the joint, and tlie structures about the humerus are uninjured, tlie surgeon might feel himself justified, in the hope of preserving a more useful member, to encounter the difficulties of disarticu- lation at this joint, and the dangers attendant upon the extensive and slowly healing wound which it necessarily leaves. Surgical anatomy. — The exact position of the joint may be ascertained by the careful observance of the following rules. The lateral prominences or tuberosities at the lower extremity of the OS humeri, too often considered by those deficient in ana- tomical knowledge as being on a level with the joint, are placed at unequal distances above it. The internal one, which is most prominent, is nearly an inch above the junction of the ulna with the pulley of the humerus; the external, about half an inch above the articulation of the radius with the condyle of the hu- merus. The tuberosities are placed nearly on the same hori- zontal level; and in consequence the articular line is directed from within obliquely outwards and upwards. The base of the an- terior flap, therefore, should be cut obliquely, and never so high as the tuberosities, lest it should be found too short to cover the end of the bone. When the integuments are not diseased, the head of the radius may be felt rolling in its joint, so as to serve as a guide to the general articulation. The articular surfaces of the radius and ulna being nearly on the same level, and forming a line in front interrupted only by the slight elevation of the coronoid process, we are enabled at once to carry a knife by a single cut directly into the anterior portion of the joint. Between the radius and the humerus, the knife may be readily passed from the outer side into the joint; but on the internal side, its entrance is resisted by tlie olecranon and coronoid processes. On its pos- terior face, the line of the articulation is of a shape Hke that of the letter reversed, the body of which is formed by the olecra- non; the internal transverse branch, which is the shortest and highest of the two, by the internal side of the coronoid process; and the external branch, by the condyle of the humerus which articulates with the radius. A strong lateral ligament is found on either side of the joint; in front and behind, the capsule is thin and membranous. After the ablation of the forearm, the end of the humerus presents a large surface, which will require a considerable extent of skin or flap to cover it thoroughly, and prevent the exposure of the bone. The oval, circular and flap methods, have all been employed for this disarticulation, and rank in regard to appropriateness in the order in which they are enumerated. In the circular, there will be but one artery to tie, — the brachial; in the flap operation, several ligatures will be required. Circular method. (Process of Velpeau.) — The surgeon, standing at the outer side of the limb, divides the skin circularly in the ordinary manner, at the distance of three fingers' breadth below the line of the articulation, or that of four fingers below the tuberosities of the humerus. He then dissects and turns back the skin to the level of the joint, and by a second circular inci- sion, divides at this height the soft parts down to the bone. The forearm is then to be strongly extended, and the anterior and lateral ligaments divided with the knife, rocking the joint from side to side as the latter are cut. Drawing downward upon the 38 forearm so as to separate the head of the two bones from the articular surface of the humerus, the knife is carried backward so as to cut the tendon of the triceps at its insertion upon the olecranon, divide the posterior ligamentous fibres, and thus com- plete the disarticulation. If found more convenient, the olecra- non process may be divided at its base with the saw, and left adherent to its tendon. Its removal, however, gives more regu- larity to the surface of the stump, and diminishes the extent of the wound; and it has been ascertained that the triceps will contract new adhesions, so as to move the arm perfectly after it has been detached from the process. The covering of the stump will consist merely of the skin and subcutaneous cellular tissue, and the edges are to be drawn to- gether so as to form a linear wound from side to side. In order to leave some fleshy covering for the ends of the bones, M. Cornuau, who follows in other respects much the same process, cuts the muscles a little distance below the joint. The brachial artery will then be divided after its bifurcation into the radial and ulnar, and two ligatures will be required. Oval method. (Pi'ocess of liaudens.) — The patient is seated on a chair, with the forearm extended and turned so as to present its external face upwards; draw with ink round the arm an oval- shaped line, commencing at the external border of the radius, four fingers' breadth below the outer tuberosity of the humerus, carrying it so as to cross the ulna two fingers' breadth nearer the joint, in order to leave less skin on the ulnar side, and admit the escape of the watery discharges which occur during the progress of the cure. Divide the integuments along the traced line down to the fascia, and dissect up and turn back the internal semilunar flap as high as the iiUernal margin of the oval. On a level with this point cut with a circular sweep of the knife the superficial layer of muscles; then, drawing upwards the divided portions with the left hand, apply a second time the knife so as to cut the remainder of the muscles on a line with the joint, entering the knife at the termination of the sweep, between the head of the radius and the os humeri. Divide next the liga- ments, as in the circular operation, and detach the forearm by sawing the olecranon at its base. At the bottom of the wound will be seen the end of the humerus, surrounded by the divided muscles, and bordered by a large external flap, wliicli will abun- dantly suffice for the covering of the stump. A patient upon whom this process of disarticulation was performed, was per- fectly cured at the end of one month. Flap method. {Process of Dupiiytren slightly modified. PI. XXXVII. fig. 1.)— The forearm supinated, and one-third flexed, the operator, standing on the inner side, ascertains with the thumb and middle fingerof the left hand the position of ihetwoiuberosities of the humerus, and grasping tlie soft parts immediately below, raises them so as to facilitate the passage of a double-edged knife or catling across the face of the bones from the inner to the outer side immediately over the line of the articulation. In order to get as large an anterior flap as possible, the handle of the knife should at first be depressed so as to enter the point through the integuments posterior to the front face of the ulna, then raised horizontally as it crosses the joint, and again elevated as it emerges in order to pierce the skin as far back as possible on the outer face of the radius. The knife is to be carried downwards, 150 GENERAL OPERATIONS. shaving the face of the bones, so as to cut, according to the thickness of the limb, a flap three or four inches long, which is to be drawn upwards by an assistant. The knife is now shifted to the posterior part of the limb, in order to make a horizontal division of the soft parts there on a level with the base of the flap. The forearm is next to be extended, the anterior and late- ral ligaments divided as above described, and the division of the iimb effected either by cutting the tendon of the triceps or sawing the olecranon at its base. Brasdor began the operation by making a semicircular division of the skin, convex downwards, a few lines below the top of the olecranon. He then cut the tendon of the triceps, the lateral Hgaments, and running the knife through on the face of the bones of the forearm cut a large anterior flap. Sedillot, holding the arm semiflexed, opens the integuments nearly in the same manner on the back, by making a semicircu- lar incision which covers about one-third of the circumference of the limb, crossing it at its middle, one inch below the lop of the olecranon. An assistant draws up the skin so as to allow the operator to divide the tendon of the triceps and the posterior and lateral ligaments, and lay open the radio-humeral articulation by following the line of the joint. From the external extremity of the flrst incision, he then (before attempting to luxate the bones) drops a vertical cut two inches long. He now carries the fore- arm, still flexed, backwards and inwards, and disarticulates it by dividing the remaining portion of the ligaments. A knife is then carried through the joint to the front of the bones, and the opera- tion is terminated by cutting an anterior flap, which comprises the remaining two-thirds of the whole circumference of the limb. In operating on the le/l elbow, the vertical incision is to be made and the disarticulation commenced on the internal side. The value of this process has not, however, yet been tested by its application to the living subject. Dressing. — -In the flap operation there are always two arteries at least to tie, and occasionally the trunk of the brachial is injured by the puncture with the catling, so as to require a ligature. The flaps are to be drawn together, or the circular fold of skin closed with adhesive straps, in the manner which will cover the most completely the end of the humerus. 3. OF THE ARM. AMPUTATION IN THE CONTINUITY OF THE ARM. Surgical anatomy. — The arm has but a single bone, which is everywhere completely enveloped with muscles, except at the neighbourhood of the elbow joint. These muscles may be ar- ranged into two classes — those which have for their chief oifice to move the forearm, and those which move the arm. The first class consists of the two flexors on the front and inner part of the arm, the biceps flexor, and the brachialis anticus, and one exten- sor — the triceps extensor cubiti. ^ The brachialis and the triceps are attached to the bone throughout their entire length, and are therefore susceptible of little secondary shortening after division in an amputation. But the biceps lays loose in its whole extent, and, like several muscles of the thigh, shortens itself to a great degree when cut. In amputation in the lower two-thirds of the PLATE XXXVII -AMPUTATIONS OF THE AEM. (Fig. 1.) FLAP AMPUTATION OF THE RIGHT ARM AT THE ELBOW JOINT. {Process of Dupuylr en) The anterior flap has been cut by puncture and reverted upon the arm, the soft parts divided on the back part of the joint, and the ligaments of the joint severed so as to eff'ect the disarticulation of the arm. The saw is seen applied for the purpose of dividing the olecranon, which in this process is left attached to the tendon of the triceps. a. The hand of an assistant compressing the artery. b. The left hand of the surgeon sustaining the forearm. c. The saw with which the olecranon is cut. (Figs. 2, 3, 4.) CIRCULAR AMPUTATION AT THE MIDDLE OF THE ARM OF THE LEFT SIDE. Fig. 2. — Section of the soft parts. A circular section has been made of the skin, and of the two layers of muscles, as described in the text. An assistant compresses the brachial artery with his right hand {(/), while with his left (e), he sustains the upper part of the arm, and at the same time retracts the divided tissues. / Left hand of the surgeon supporling the lower end of the arm. The conical projection of the divided muscles on the inferior fragment, is shown at {g). The conoidal hollow of the end of the upper fragment [h), is partly eff'aced by the retraction of the soft parts made by the assistant. The knife (i) is shown as it is brought round by the right hand of the surgeon, so as to complete the section of the layer of deep-seated muscles over the bone. Fig. 3. — Surface of the stump raised hy the hand of an assistant {k). It presents the appearance of a hollow cone, and shows the ligatures applied upon the divided arteries. Fig. A.— Coaptation of the lips of the wound over the end of the done, by means of four strips of adhesive plaster. The ends of the ligatures project from its inferior angle. Plate 37. AMPUTATIONS. arm, it is therefore advised to put the forearm in a moderate state of flexion, and to cut the biceps a little iower than the other mus- cles. In the upper third the bone is surrounded with the second class of muscles, that consist, besides the articular — which are concerned only in the operation for disarticulation at the shoulder joint — of the powerful deltoid, the coraco-brachialis, and the mus- cles of the armpit — the great pectoral, the latissimus, and the teres major. lu amputation in the upper third, the action of these muscles forms a subject for consideration. If the operation is performed so as to leave in part the insertion of the muscles of the armpit, the deltoid, coraco-brachialis, and biceps are cut off from their insertion, and are liable to retract so as to leave a conical stump, and retard by drawing up the integuments the healing of the wound. If the section be made above the inser- tion of the armpit muscles, the latter will retract upon the chest so as to leave the bone nearly naked, and the stump will oc- casionally be made to stand straight outwards by the unresisted action of the supra and infra-spinatus muscles. For these reasons Lafaye and Larrey preferred amputation at the shoulder joint to that through the upper third of tlie arm. But this practice has been generally and justly rejected by most surgeons; it has been found that it is more dangerous than amputation through the arm; that every inch of the humerus that can be preserved con- sistent with the formation of a good stump becomes of great value to the patient; and moreover that the two other articular muscles, the subscapularis and the teres minor, prevent most commonly the permanent elevation of the stump. Others have with better reason preferred the operation with a single large external flap. In cases where the amputation is made at the lower border or through a part of the insertions of the muscles of the armpit, we obviate much of the inconvenience above mentioned in reference to this operation, by raising the arm to the horizontal position, so as to shorten the deltoid before it is cut, and then dividing the bone at a height proportioned to the degree of retraction of the deltoid, the biceps, and coraco-brachialis, which will be found to vary in different cases according to the activity of the muscles. The circular and flap methods are both perfectly applicable to amputations of the arm in any part of its course, except near the elbow joint, where integument may be gained to cover the bone by the circular process, though there would not be room for the flap without removal of a larger portion of the bone. The oval method has also been advantageously employed by Guthrie for amputation on a Hue with the armpit. AMPUTATION IN THE LOWER TWO-THIRDS OP THE ARM. A knife of middling length, a scalpel, saw, and a two-tailed retractor, with the ordinary apparatus for dressing, are all that are required in the operation. The patient is placed in a sitting posture, and, if possible, in a chair, to which he may if necessary be secLU-ed with a towel. The arm is to be extended at a right angle with the body, and the forearm a little flexed if the nature of the lesion will allow it. The circulation in the brachial is to be commanded with a tourniquet, or by pressure with the fingers of a competent assistant in the armpit, who is at the same time to be charged with drawing upwards the soft parts after the division. Another assistant supports the portion of the limb to be removed. The surgeon places himself at the right side of the limb, so as to be able to grasp with his left hand the parts above the place of operation. Circular method. (PI. XXXVII, figs. 2, 3, 4.) — I. An as- sistant drawing the skin upwards, the surgeon grasps with the left hand the limb, and carrying the knife below, begins the circular incision on the edge of the biceps, dividing the skin and adipose membrane all round at a single cut down to the fascia. The integuments are then to be dissected from the fascia and turned backwards like a sleeve, for an inch or an inch and a half, according to the thickness of the arm. 2. The biceps may then be divided across separately, so as to allow it to contract; then placing the knife at the level of its shortening, divide cir- cularly all the remaining muscles down to the bone. The as- sistant draws the cut edge of the muscles upwards, which then presents the appearance of an elongated cone. The point of the cone, consisting of the deep-seated fibres, is now to be cut anew by a second circular incision down to the bone, and the deep-seated fibres subsequently separated from the bone for the space of half an inch or an inch if the arm be large, with the point of the knife, 3. The surgeon next runs his knife round the bone to divide the periosteum as well as the musculo -spiral nerve in its gutter, if this has not been previously cut, applies the retractor to draw the soft parts upward, and divides the bone with a saw at their base. Many surgeons do not deem it necessary to make the previous section of the biceps, but complete the circular division of all the muscles at the same time. In my own practice, I have found a better stump formed by fiirst cutting the biceps with a single stroke of the knife about three quarters of an inch below the point at which the general circular incision is to be made. On the dead subject, where the biceps cannot shorten itself, and must be pushed up to represent the actual operation on the living, the process will not appear so neat as without the use of this pre- cautionary measure. Dressing. — The brachial artery, which is found on the inner side of the bone between the biceps and triceps, is to be tied. If any of its branches bleed, they are also to be secured with liga- tures. The muscles are to be pressed downward with the Iiand, in order to cover the end of the bone, and the wound closed with adhesive straps, so as to form a line from front to back. Some surgeons, however, prefer to unite the integuments in an oblique and others in a transverse direction. The roller is to be applied from above downwards, in order to prevent the spasm of the muscles, and their .subsequent retraction from the end of the bone. Flap method.— In amputation in the lower two-thirds of the arm, the operation with double flaps is very commonly preferred in Germany and England to the circular, and is employed by many of the surgeons of this country. It is more rapid, and at- tended with less pain during its performance, but has no other advantage over the method last described. As the bone of the arm is circularly surrounded with muscles, we may in particular instances of disease cut the flaps with their base in any direction that will enable us to preserve the greatest length of the limb. The flaps are commonly cut by puncture and division from within outwards, but they may be also well formed in the oppo- site direction from without inwards. Common pi'ocess. — The patient is to be placed in the sitting 152 GENERAL OPERATIONS. posture and the limb extended and well sustained by assistants. The surgeon grasps wiiii his ieftliand the muscular mass fornaed by tlie biceps and bracliiahs amicus, and passes tlie donbie-edged catling across the anterior face of the bone, — entering it at the internal side for the right arm, and the external for the left, — and cuts from above downwards an anterior flap two inches and a half long, wliich should be regnlarly bevelled from the centre to the circumference. The flap is now to be raised by an assistant. The lips of the wound are then to be drawn backwards with the left hand, and the. knife passed behind the bone through the two angles of the wound in the skin, so as to cut a posterior flap of the same form and length as llie first. Both flaps are now to be well drawn upwards, while the surgeon divides with a circular turn of the knile, the remaining fibres about the bone. When the bone is snfliciently isolated, the surgeon applies the saw close to the base of the flap. A double-tailed retractor may, if it is preferred, be employed to draw back the flaps. Process of Langenbeck and Bell. Seciiori/rom ivit/iout in- loards. — The integuments drawn strongly upwards by an assist- ant, the surgeon standing at the inner side of the arm, sustains with one hand the arm below the place of operation, and with the other applies the amputating knife upon the skin, so as to cut from below upwards and towards the bone two flaps in suc- cession, one on the internal and the other on the external side of the arm, each of which should be from two and a half to three and a half inches long. The assistant then raises the flaps, and the surgeon isolates and divides the bone at their base. 13y this process, the surgeon is required to be ambidextrous. But if he has not practised the use of the knife with his left hand, he may place himself at the outer side in operating on the left arm. One objection to this process by vertical flaps is, that it may allow the end of the bone to sink to the lower angle of the wound, so as to be exposed during the progress of cure. Mixed process of Sedillol. — This is analogous to the one of the same author described in reference to the forearm. Two small superficial flaps are cut by puncture with a double-edged knife; the one on the external side of the limb is short, and consists but of little more than the skin and adipose tissue. The integuments are now drawn inwards, and the point of the knife carried through from the upper to the lower angle of the wound, so as to form a second flap like the first, but in which the brachial artery is not included. The flaps are next to be elevated, and the deep-seated muscles divided as in the process of Alanson, — obliquely upwards, — so as to form on the face of the stump a hollow cone, at the apex of wliich the bone is to be cut. This process leaves a wound very regular on its surface, and of but limited extent. It is more dillicult of performance, and seems to be attended with no greater advantages than the circular method, which is remarkably well adapted to the amputation of the arm. AMPUTATION AT THE UPPER THIRD OF THE ARM. From the excessive tendency to shortening of the divided del- toid, and otiier reasons which have already been detailed, the common circular process is not so well suited as either the flap or the oval to amputations between the insertion of the deltoid on the ann and the head of the bone. The common causes that render this operation necessary, are gunshot or other injuries which have directly involved the bone, the effect of which may be found, during the course of its performance, to have extended higher than was at first supposed, so as to make it necessary to remove the bone immediately below its head, or to detach it at the shoulder joint. Under such circumstances either of the latter processes, but especially the flap, ofl'ers facilities for going above the intended place of section of the bone, without rendering ne- cessary a second general division of the soft parts. Process of Louis and Sabatier. (PI. XXXVIII. fig. 4.)— The arm is to be applied against the side of the body, so as to extend the deltoid, permit its being cut at its greatest length, and enable the surgeon to judge of the degree to which it will shorten itself, before he divides the soft parts on the inner side of the limb. The artery is to be compressed against the second rib above the clavi- cle, as in disarticulation at the shoulder joint. A transverse inci- sion down to the bone is to be made immediately across the inser- tion of the deltoid, and a converging longitudinal one, two inches in length, along either border of the same muscle, joining at their lower end the two extremities of the first. The flap thus marked out is to be dissected loose and raised, and the remaining soft parts cut by a circular incision on a line with its base, the re- tractor applied, and the bone isolated and divided wiih the saw. From the uncertainty of the assistant's preserving ihe steady command of the circulation by pressure above the clavicle, it would be safer to seize and tie the extremity of the axillary ar- tery previous to ilie division of the bone. The oval method has been employed by M. Guthrie for ampu- tation of the arm in its upper third. The mode of making his incision is precisely the same as in his operation for disarticula- tion of the shoulder joint, with the exception that the apex of the V is to be placed two fingers' breadth below the acromion. In fact most of the various processes for disarticulation might be employed for this amputation. The dressing of the wounds after amputation of the arm is so simple, as not to need description. To obviate the tendency of the muscles to shortening, the arm should be placed on the pillow in a state of half extension. AMPUTATION AT THE SHOULDER JOINT. Although the disarticulation of the arm at the shoulder joint was practised by Ledran more than a century ago, it is only within the last half century that it has been admitted as a regular process of the art, chiefly through its very successful and frequent performance by the great School of Military Surgery, of wliich Baron Larrey was the head. Surgical analomy. — In no amputation is a thorough know- ledge of the structures concerned in tlie operation of greater im- portance, than in that of the shoulder joini. The articulation differs considerably as to form and arrangement, from all the other joi[its. The glenoid cavity of the scapula is an oval with a su- perficial hollow, an inch and three-eighths in length, and an inch broad at its widest part, which is at the inner and lower portion. The head of the humerus is nearly hemispherical, about an inch and three quarters in diameter, and is rather applied against than filled to the socket of the scapula, in which not more than one- third of the circumference of the head of the bone can be at one time received. The depth of the glenoid cavity in the recent slate AMPUTATIONS, 153 is about a quarter of an incli, and its face is presented outwards and slighily forwards and upvvards. Ha!f an inch above the top of the glenoid cavity is found a sort of arch or roof, formed by the acromion and coraeoid processes, and the strong hgament which is stretclied between Ihem, This arch projects more than an inch and a quarter in front of the glenoid cavity, and protects the ante- rior and part of the lateral surl'aces of the joint, covering as it does at least one- third of the circumference of (he articulation, and pass- ing back about a quarter of an inch more on the posterior and external than on the opposite surface of the joint, in consequence of the sloping form of the base of the acromion process. The length or base of tliis arch is full two inches and a half. When the arm is close by the side, there is a distance of nearly an inch between the greater tuberosity of the humerus and the point of tlie acromion. When it is elevated, the tuberosity is brought up immediately under the acromion, close to the margin of the glenoid cavity, and more than an inch of the articular surface of the humerus projects on tlie opposite side beyond the glenoid cavity, between the teres minor and subscapularis, pushing before it the capsule which is tliere thin and weak. At the anterior and internal side of the joint, between the tendons of the subscapularis and the supra-spinatus, the capsule is also thin and feeble. At the outer side the capsule does not descend lower than the upper margin of the tuberosities; but on the inner it descends, or may readily be depressed, for a quarter of an inch below the line of the neck of the humerus. Above, the capsule is not only attached to the margin of the glenoid cavity, but also to the outer edge of the coraeoid process, by a strong band of accessory fibres, called the coraco-humeral or accessory ligament. If we roll the arm out- wards we put these fibres on the stretch, and give Ihem the ap- pearance of a band going lo both the tuberosities, but especially to the outer. This renders the coraeoid process really a part of the articulation. It will appear from this that the strength of the capsule is principally at its anterior and outer portion, the part upon which the point of the knife is first to cut in the process for disarticulation. The articular tendons also offer the greatest re- sistance in [he same position; those of the supra and infra-spinatus and the teres minor occupying the outer semicircumference of the joint, and which by rotating tlie arm strongly inwards may be brought forward so as to come readily under the action of the knife. In front there is but one tendon — that of the subsca- pularis;— rotation in the opposite direction does not so much influence this tendon, and it is therefore usually found the most troublesome to divide. The projection of the acroniio-clavicular arch makes the prin- cipal ditliculty of the articulation. In several of the processes, the point of the knife must be passed under this projection, as thougli it was going to pierce the scapula, in order that it may divide the external rotator tendons which are lodged below the arch. This arch, it must be recollected, forms an irregular osse- ous interval open in front, bounded by the coraeoid process on its inner side, by the acromion on its outer, and the neck of the scapula behind; the interval, which is quadrangular and an inch in extent in all its directions, is occupied by the coraco-acromtal ligament, which readily admits the passage of the point of the knife. It may be necessary to observe, that from the projection of this arch, unless the integuments be divided at least three 39 fingers' breadth below the pectoral border of the armpit, the sides of the section will not meet after the disarticulation so as to form a linear wound. The stump of the shoidder is more thickly covered with the muscnlar structure on the back surface than the front, and if two flaps are formed with the superior angle at the acromion, the posterior will consequently be much larger than the anterior. The acromion and coraeoid processes remain for a long time uuossified; — a fact which is to be remembered, as it facilitates the disarticulation of the arm in young subjects. The circular, flap, and oval methods, have all been employed in amputation at this joint, and the processes have been so mul- tiplied, that more than twenty may be enumerated: those en- titled to the most favour only will be given. In each case, pressure is to be made upon the subclavian artery above the clavicle with the thumb, the compressor of Bourgery, the handle of a large key, or a boot hook; but since, as has been before observed, it is exceedingly difficult to maintain a thorough command of the cir- culation, an intelligent assistant should always be prepared to seize the artery eitlier before or at the moment of its division. Circular melhod. This melhod, which was employed by Alanson m 1744, has been advantageously modified by Graefe, Cornuau, and Sanson, and is well suited to cases where there is much emaciation, or the muscular system is but little developed. Process of Sanson. (Pi. XXXIX. fig. 1.) — The patient is to be put in a sitting posture. One assistant compresses the artery, above the clavicle, and another, placed on the side opposite to the limb afi'ected, passes one arm in front and one behind the trunk, so as to grasp the top of the shoulder with both hands, and draw backwards the skin, especially that of the armpit, as strongly as possible. The surgeon, standing in front of tfie pa- tient if he operate on the right arm, and behind for the left, grasps the iinib with the left hand, and raises it nearly to the horizontal position. He then passes his knife under the limb, so as to rest its edge over the tendons of the armpit, at the distance of an inch and a half below the point of the acromion, and divides with a single circular incision all the soft parts down to the bone; these are immediately to be separated from the head of the humerus so as to expose the joint. He next cuts with a semicircular incision the rotator tendons and the capsule, draws the arm downwards, and carrying the knife through the joint, turns it around the head of the bone, which he detaches from ilssocket by dividing the posterior and lower portion of the capsule. This process is very rapid when well executed, but in fleshy subjects, does not leave suflicient integument to cover well the point of the acromion; and if the arm be raised too high during the first part of the operation, leaves a wound too exten- sive on the side next the thorax. There is also great danger that excessive haamorrhage may occur from the divided vessels, in consequence of the ditFiculiy of making effectual compression of the artery above the clavicle. The following process, though more tedious in the execution, is therefore entitled to a preference. Process of Cornuau. — The arm disposed as above directed, the surgeon divides the integuments by a circular cut four fingers' breadth below the point of the acromion. The skin being still further drawn upward by an assistant, he divides by a single 154 GENERAL OPERATIONS. cut the soft parts on the anterior, outer and back parts of the limb— from the coraco-brachialis muscle to the tendon of the latissimus dorsi, or from the latissimus to the coraco-brachialis, according as it be the left or right arm — leaving the axillary artery untouched. The divided muscular mass is then to be loosened and raised, the rotator tendons and the capsule cut, and the head of the humerus luxated backward. The knife is next carried round the head of the bone, so as to shave the inner side of its neck. An assistant passes his thumb or fore finger into the wound so as to grasp the artery between them, and the surgeon detaches the limb, by cutting out into the armpit so as to com- plete the circular incision. If difficulty should occur in opening the joint, in consequence of the lengtli of the integnments below the acromion, they may be split up, as was originally directed by Alanson, Dressing. — The axillary, the posterior and anterior circumflex arteries, and the acromial, are to be tied in succession. The lips of the wound are to be brought together in a vertical line, and secured by adhesive straps and an appropriate bandage. Flap method. The processes by this method are the most numerous, and PLATE XXXYIII.-AMPUTATION AT TIIE SHOULDEE JOINT-AT THE UPPEE THIED OP THE AEM. {Figs. 1,2,3.) AMPUTATION OF THE LEFT SHOULDER JOINT. {Process of Lisfranc.) Fig. 1. — a. Hand of an assistant compressing with the end of the middle finger the subclavian artery as it passes over the first rib, — the thumb taking a support at the same time from the posterior part of the shoulder, so as to steady the trunk of the patient. b. Left hand of the surgeon grasping the arm so as to place it in the requisite positions during the operation. c. Right hand of the surgeon passing the long double-edged catling in order to form the outer and posterior flap. The knife has been entered in front of the posterior angle of the armpit, and passed up between the head of the humerus and the belly of the deltoid. The point has then been lowered in order to open the capsule of the articulation, and again raised so as to be brought out through the triangular space formed at the top and front part of the shoulder, by the coracoid process, the acromion process, and the clavicle. The point and edge of the knife is subsequently to be brought downwards, so as to cut the outer and posterior flap, which is imme- diately to be raised by an assistant. {Fig. 2.) FORMATION OF THE INTERNAL AND POSTERIOR FLAP. The blade of the knife has been carried into the articulation through the wound in the capsule made by the puncture as shown in fig. 1, and brought round so as to divide the remains of the capsule, and shave ihe inner side of the neck of the bone. At this stage of the process, which is that shown in the drawing, an assistant grasps the axillary vessels between his thumb and fingers [d.) The surgeon then completes the section of the flap with the knife (/), and with his left hand effects the necessary movements of the limb. {Fig. 3.) SURFACE OF THE WOUND SHOWN AFTER THE COMPLETION OF THE OPERATION. The glenoid cavity, with half of its capsule about it, is seen in the apex of the wound. The anterior flap is formed by the pectoral muscle, the heads of the biceps, the coraco-brachialis, the latissimus dorsi, the teres major, and the rotator muscles of the joint. The posterior and outer flap is formed by the deltoid alone. The arteries have been seized and tied. g. Axillary artery tied at the point at which it takes the name of brachial. h. Inferior scapular artery. i. Posterior circumflex. {Fig. 4.) AMPUTATION AT THE UPPER PART OF THE ARM. {Process of Sabatier.) The operation is shown near its completion. A flap has been cut at the external and upper part of the arm through the substance of the deltoid, the soft pans on the inner side have been divided by a section downwards and inwards, and the saw is shown applied upon the bone. a. Left hand of the surgeon sustaining the inferior part of the arm. b. Artery pad applied by an assistant to compress the subclavian artery over the first rib. c. The other hand of the same assistant raising by the aid of a compress the flap out of the way of the saw (e). d. Line of the horizontal section of the soft parts downwards and inwards on the side of the axilla. AMPUTATIONS. 155 have been arranged by Velpeau into two classes, according as the flaps are cut from without inwards, or from within outwards. Process of Lcdran. Single axillary fiap. — The patient is to be seated in a cliair, and the arm held horizontally. The surgeon divides transversely, two fingers' breadth below the acromion, the deltoid and the two heads of the biceps muscle; then, lower- ing the arm, he continues the incision so as to cut the outer part of the capsule and the rotator tendons, and carries the knife through the articulation in order to bring it down on the poste- rior part of the neck of the bone. A temporary ligature is then passed with a needle round the bundle of vessels in the axilla, and the knife is brought down so as to detach the limb by cutting a flap three to four inches long on the posterior and internal side of the shoulder, in which are comprised the great vessels and nerves. It is difficult to retain the large internal flap sutEciently well elevated to cover the acromio-clavicular arch; this process is therefore justly abandoned, except in cases where, from the destruction of the soft parts on the exterior of the shoulder, no other could possibly be applied. Process of Lafaye. External and superior flap, formed from the deltoid.— A tmnsverse incision down to the bone is made across the deltoid, five fingers' breadth below the acromion. Two other deep incisions nearly vertical, converging a little below like the margins of the deltoid, one on the internal and anterior surface, the other on the external and posterior, are dropped upon the extremities of the first. The flap is then to be dissected from the bone and raised by an assistant, the capsule opened, and the head of the bone luxated upwards. Tiie axillary artery is next to be denuded and tied at the inner margin of the wound; the surgeon then brings down the knife so as to divide the soft parts on the interior of the bone upon a level with the fold of the armpit. Grosbois and Dupiiytren modified this process by elevating the arm at a right angle with the trunk, raising the mass of the deltoid with the left hand, and pushing a double-edged knife be- tween the head of the humerus and the acromio-clavicular arch, so as to cut from within outwards an external superior flap of sufficient length. This flap is to be raised by an assistant, so as to expose the joint, and the surgeon, grasping the arm with the left hand, approaches it to the trunk, and rolls the elbow inwards so as to extend the rotator tendotis. Tiiese he divides with the knife, and enters the articulation under the acromion process. He then rolls the elbow so as to turn the head of the bone out- wards, while the knife, pressed in the opposite direction, cuts the inner portion of the capsule and the tendon of the subscapularis. The head of the bone is now to be luxated outwards, and tlie knife slid down upon its neck. The surgeon then pauses for a moment, till the assistant, who has raised the flap with one hand, grasps the axillary artery with the thumb and fore finger of the other, introduced — one into the wound — and the other into the cavity of the axilla. The knife is finally carried downwards so as to cut outwards at the axillary borders, inclining it however a little forwards, in order to make the flap pointed in front, and leave the whole hollow of the armpit remaining on the stump. Lange7ibecle and Onsenoort perform the operation in a manner similar to that just described, with the exception that they cut the flap from without inwards, at a single sweep with a knife curved on the flat. Remarks. — Th? single flap formed out of the deltoid by these various processes, falls after the operation on the glenoid cavity, and etfectuaUy covers the arch above the socket. But the flap is thin at its base, and the muscular tissue of which it is composed is slow to unite with the subjacent parts; it wrinkles and con- tracts, and, from the difficulty with which it is maintained in contact with the inner and lower margin of the wound, the heal- ing process is rendered protracted. In certain cases, however, of injury of the structure on the axillary side of the joint, it is the method to be preferred. But in circumstances admitting of a choice, the process by a double flap will be found to form a better stump. Double fiap. Process of Sir Charles Bell. One sxipei'ior and one inferior flap y which tmite so as to form a transverse wound. — The artery compressed between the scaleni muscles above the clavicle, and the arm raised, the soft parts are to be divided by a circular incision down to the bone, three fingers' breadth below the point of the acromion. The arm is then to be lowered, and two vertical incisions are to be dropped from the level of the joint down upon the transverse cut — one on the anterior and one on the posterior part of the limb. The flap thus marked out upon the external part of the shoulder is to be dissected from the bone and raised, and the disarticulation accomplished in the usual manner. This process may be considered a good one — it forms regular and well-shaped flaps; but is not so rapid in its perform- ance as the following, which is commonly preferred to it, though, as it appears to me, upon no very satisfactory grounds. Process of Lisfranc. (PI. XXXVIII. flgs. 1, 2.)— Posterior external and posterior internal flaps. Left arm. — The patient is seated on a chair, and an assistant placed behind him, ready to raise the flap first formed, and com- press the orifice of the posterior circumflex artery with one hand, and the axillary with the other previous to its division in the formation of the second or internal flap. To prevent still further the effusion of blood, the assistant may, during the formation of the first flap, compress with his middle finger the artery above the clavicle, steadying the shoulder with the same hand. 1. The arm is to be raised nearly horizontal. The surgeon standing behind the patient, embraces the stump of the shoulder with his left hand — the thumb resting on the posterior part of the head of the bone, and the ends of the two first fingers over the coraco-acromial triangle; then taking in the other a narrow, dou- ble-edged knife or catling, which should be eight inches long, and held parallel with the humerus, he enters the point just at the external side of .the posterior fold of the armpit, in front of the tendons of the latissimns dorsi and teres major muscles, with the upper cutting edge a little turned in front, so that the flat of the blade shall lay nearly parallel with the broad surface of the ten- dons of the above muscles. The knife is then to be passed up along the outer and posterior surface of the humerus, till the point touches the head of the bone; the handle is now to be inclined a little downward to carry the point over the head, and then ele- vated again with a rocking motion so as to depress the point and open the capsule: now shifting the fingers of the left hand down the arm, he carries the point through in the centre of the space between the coracoid and acromion processes, with the handle raised the distance of two or three inches from the arm. The 156 GENERAL OPERATIONS. most difficult part of the operation — the puncture — is now aceom- phshed. Holding the hand nearly immovable, the surgeon next cuts with the point of the knife, inclining it a little from within outwards and from below upwards, so as to disengage the edge from below the acromion, and turn it round the head of the bone. The knife is now brought down along the external face of the bone, and subsequently inclined towards the skin, so as to cut a posterior external flap three inches long, which includes the tendons of the latissimus dorsi and Ihe teres major. This flap is to be instantly raised by the assistant, and the stream of blood from the posterior circumflex artery, if not arrested by pressure above the clavicle, is to be checked with the thumb and finger of his left hand. 3. The articulation is already laid open, and tlie outer rotator tendons cut across, if the process as described has been exactly followed. The operator now carries the knife from the outer side through the joint, keeping the handle inclined low, so as to cut from heel to point, and brings it round to the internal side of the head of the bone, which is to be luxated as the knife is slid behind it. The handle is then further depressed so as to become | vertical, — the blade is brought down so as to shave the internal side of the bone, — and as soon as sufficient room is made above the knife, the assistant grasps the artery in the "liickness of the flap, and the surgeon detaches the limb by cutting out at the level of the armpit, so as lo divide the tendon of the pectoralis major and form an internal and posterior flap, of the same length as the preceding. liighf arm. — In (he operation for the right arm, some modifi- cation of the process is required, in order to enable the surgeon to employ the knife with the right hand. In forming the first flap, he may stand behind the patient and proceed as in the case last described. Then shifting his position to the side of the patient, and holding the handle upwards, he carries the knife through the joint and forms the second flap. Or if he finds it more convenient, he may form the first flap by entering the knife between the coracoid and acromion processes, and carry it down nearly parallel with the bone till the point emerges under the tendons at the posterior fold of the armpit, and finish the section of the flap by bringing the handle downwards. This process of LisCranc is very rapid when skilfully per- formed; the flaps are well disposed for reunion, and furnish a ready outlet below for Ihe discharges that attend the progress of the cure. The acromion is not always, however, sufficiently well covered, and in young subjects, when the muscles are large and I act with force, it is not easy to pass the knife in the space be- tween that process and the coracoid. In the latter case, it might answer to make the puncture at the outer side of the acromion, and divide by a separate incision the external rotator tendons and the capsule, rolling the arm inwards so as to bring them more readily under the action of the knife. But on the whole, this PLATE XXXIX.— AMPUTATION AT THE SHOULDER JOINT. {Fig. 1.) CIRCULAR AMPUTATION ON THE RIGHT SIDE. {Process of Sanson.) The integuments Iiave been firmly drawn up by an assistant towards the joint, and the amputation knife, which has been applied over the insertion of Ihe armpit tendons, is seen as it is brought round to finish the circular section of the skin and soft parts down to the bone. The right hand of an assistant {a) applies the artery pad upon the subclavian as it passes over the flrst rib. The hand of another {h) retracts the soft parts towards the shoulder. The surgeon sustains the limb with his left hand {<:) while he makes the circular sweep with the knife (f Baiidens.—\. The leg is to be ex- tended on tlie thigh. The surgeon starts, five inches below the patella, a semicircular incision of the integuments, which is to be carried obliquely upwards upon one of the sides of the leg. and turned round the ham one finger's breadth below the top of the tibia; the incision is then to be brought downwards in the same manner on the other side of the leg, so as to terminate at the place of commencement. The oval section of the skin in front is now to be dissected and turned up so as to expose the circumference of the joint. 2. The ligaments, muscles and vessels, are next to be divided by a circular incision on a level with the joint. 3. The articulation is then to be opened, and the semi- kinar cartilages and crucial ligaments detached as in the circular process. By this process, which may be rapidly executed, the surface of the condyles can be covered by a large cap of integument, which leaves the line of union behind so as to form a ready outlet for the discharges, and be posterior to the point of pressure after the cure. Relative value of these methods. — As the chief accident to dread is the exposure after the operation of one or both of the condyles, the oval, which leaves the larger fold of skin in front, is usually preferred to the circular. But in most cases admitting of its employment, we might, except there be some injury or dis- ease of the bone extending high up, advantageously substitute for it the flap operation of Liston for the leg, sawing through the 170- GENERAL OPERATIONS. tubercle of the tibia. The operalioii by three flaps, such as has been described on the preceding page, will, I believe, be found to form a still neater and better fitting covering to the uneven sur- face of the bone than the oval, and is moreover applicable to cases where the disease of the integuments of the leg has extended so near to the joint as to prevent the employment of the latter. Dressing. — The popliteal is the only large artery to be tied. The gastrocnemial and some small branches from the articular arteries, will also require the ligature. The parts are to be brought together with adhesive straps, so as to leave the cicatrix as much as possible behind and between the condyles, and a roller brought from above downwards on the thigh, in order to overcome the tendency of the muscles to retract. In case the covering should be found insufficient for the end of the bone, the condyles might, PLATE XLIL— AMPUTATIONS OF THE LEG AND THIGH. {Fig. 1.) CIRCULAR AMPUTATION OF THE LEG OF THE RIGHT SIDE. {Modified by an oval incision of the skin. First place of election.) The two first steps of the operation have been accomplished— 1, the oval incision {d) of the integuments, (as in the process of Sedillot;) (the skin has been subsequently dissected loose from the fascia and turned back); 3, the circular section of the muscles at the base of the fold of skin, the division of the interosseous muscles and ligament with the catling; the retractor is also shown applied. The drawing represents the period of the operation when the surgeon is about to apply the saw for dividing the bones, a. The hand of an assistant sustaining the leg at its lower end. bfC. Left hand of the surgeon grasping the upper end of the leg, so as to steady it for the saw. The hand is applied over the three-tailed retractor, with which another assistant draws up the divided soft parts; one of the tails has been passed between the bones. {Figs. 2, 3, 4.) AMPUTATION AT THE KNEE JOINT. {Process of the. Mhor.) Fig. 2. — interior incision. The patient has been laid on the abdomen, and the leg raised so as to flex it on the thigh. A semilunar incision convex downwards has then been made across the front half of the leg, three fingers' breadth below the tubercle of the tibia, so as to mark out an anterior flap of skin. Fig 3. — Posterior incision. The position of the patient remaining unchanged, the leg is brouglit down so as to be placed in a state of extension. The scalpel has then been entered on the back part of the leg, just below the popliteal fossa, so as to make a vertical incision in the middle line; from the lower end of this a semilunar incision convex down- wards, has been directed on either side to the rounded track of the first or anterior incision. Two posterior lateral flaps are thus formed, one of which is seen dissected up from the fascia of the leg, and partially reverted. Fig. 4.— This drawing represents the mode of closing the flaps over the condyles of the thigh. The three flaps are attached together at their place of junction by sutures. A small greased compress is placed between the lips of the posterior flaps on the popliteal surface of the stump, to give vent to the sero-purulent discharge which attends the softening and exfoliation of the cartilage on the face of the condyles. The rounded upper portion of the figure is the end of the femur and patella covered by the anterior flap. The stump of the patient upon which this operation was performed, still presents very much the same appearance as seen in the drawing. The whole line of the cicatrix is over the notch at the posterior surface of the condyles, behind the point of pressure upon the wooden leg, and the patella is now immovable upon the femur. {Fig. 5.) DOUBLE FLAP AMPUTATION IN THE MIDDLE OF THE LEFT THIGH. {Process of Listen.) The circulation in the femoral artery is to be arrested by pressure by an assistant, or with the tourniquet. The soft parts have been grasped in the left hand of the surgeon, and drawn as much as possible in front of the bone, and the knife passed from the outer side— first down upon the bone; then the handle has been inclined down- wards to allow the point to slide over the anterior surface, and again raised to let the point descend on the inner side of the bone and pierce the skin as far back as possible on the inner side to give breadth to the anterior flap. The knife has then been carried down with a sawing motion to form the anterior flap. In the period of the operation shown in the drawing, the flap has been raised by the hand of an assistant {a), /•■«/. 3. AMPUTATIONS. 171 I believe, be amputated with great propriety, iVtus reducing the operation to that of the ordinary amputation of the thigh, but preserving nearly the whole length and the action of most of the muscles of the limb. 3. OF THE THIGH. AMPUTATION IN THE CONTINUITY OF THE THIGH. Surgical anatomy, — The structure of the thigh is in many respects analogous to that of the arm. It con jsts of a single bone, surrounded on all sides by a mass of rauscles, which are more or less capable of shortening themselves after division in amputaiion, according to the degree in which they are con- nected with the shaft of the bone. On the inner and posterior surface the built of muscles will, however, be found the greatest. There are three classes of muscles: — those which connect the limb with the trunk — those that stretch loosely along it, connected below only with the bones of the leg, and above with those of the pelvis— and those which, having their origin from the pelvis, cover and are connected only with the surface of the thigh bone. They are all, however, for practical purposes, arranged into two groups — a superficial and a deep-seated. The superficial are those which have little connection with the femur, and are stretched mainly between the pelvis and the leg. In consequence of this and of their greater length, they will retract more after amputation than the deep-seated, which are connected with the bone; the extent of the retraction will also be the greater the longer the muscles are left, or the nearer the operation is done to the knee joint. In the circular amputation, if all the muscles were divided on a circular line, this inequality in the degree of retraction of the two sets would render the bone prominent, pro- ducing the painful and annoying result of a conical stump. This dilficnlty is obviated by the Ibllowing plan; viz. to cut first, by a circular sweep, all the layers of the superficial group, and divide the deep-seated by a second incision at a point a little higher than that to which the first iias retracted, dividing the bone at a little distance still further up. If the first incision should be carried down to the bone, we insure more completely the division of the outer set, and the disadvantage of making a second cut of the deep-seated is of but little moment compared to the general result. In the flap operation the same arrangement of parts must be held in view, and the flaps cat of a length apparently unneces- sarily great, in order to admit of the subsequent shortening from muscular contraction. At the end of the cure the cicatrix is nearly always carried inwards and backwards, and the bone pressed towards the upper surface. This may be remedied by dividing the muscles lowest on the posterior and inner face of the limb; especially the seraitendinosus and semimembranosus, as these are found susceptible of the greatest degree of shorEenmg. The skin is loosely united to the fascia of the thigh, everywhere, except at the popliteal region. It is sometimes in obese indi- viduals doubled with so thick a layer of adipose tissue, that the surgeon will find the cure of the wound facilitated by leaving a portion of it adherent to the deep fascia. The extent of the fold of skin required for the circular process must be calculated ac- cording to the diameter of the limb, without reference to the shortening of the muscles, for the base of the fold will be found to ascend nearly in proportion to the retraction of the latter. In general it should be about equal to its distance from the bone, whether we operate at the upper or lower part of the ieg;— at the upper in consequence of the thickness of the muscles, and at the lower on account of their retraction. There is no place of eleciion, admitted by common consent, for amputation of the thigh. The general rule is to preserve as much of the limb as possible, and the danger to life is certainly proportioned to the height at which the operation is performed. Mr. Listen has, however, recommended that the division of the bone, for the greater convenience of fitting the stump to the arti- ficial leg, should not be made below the middle of the thigh. Circular method. — The patient should be placed nearly hori- zontally upon the table, with the pelvis resting over its edge, and the same instrumental and other preparations made as in ampu- tation of the leg. In order to diminish the degree of the subse- quent shortening of the muscles, the leg may be slightly bent on the thigh, and the latter on the pelvis. The position of the sur- geon will be found most convenient on the right side of the limb, exposing the front half of the bone {b), and the knife has been again passed across between the two angles of the wound, but behind the hone, for the purpose of forming the posterior flap, which should be an inch longer than the anterior. {Fig. 6.) FLAP AMPUTATION OF THE LEFT LEG. Process of Liston slightly modified by giving a greater length to the covering in front of the tibia, so as to obviate any liability to the projection of the crest of this bone during the cure. The knife lias been entered on the outside of the leg, so as to make a short vertical cut on the posterior face of the fibula, and then brought round over the tibia in a semi-elliptical sweep and passed through the leg, shaving the posterior face of both bones, as seen in the drawing. The common tourniquet is applied just above the knee, with a compress in the ham, so as to command the popliteal artery. The surgeon grasps the calf of the leg with his left hand in order to draw back the soft parts, while he employs the knife with his right to make the incisions and puncture above described, and cut out so as to form the posterior flap. In making the transfixion on the left leg, the handle of the knife should be kept more elevated than the point, to prevent the latter getting entangled between the bones. If he operate on the right leg, and stand on the outer side, the handle may be depressed a little, so that the point of the knife may shave the posterior surface of the bones. 172 GENERAL OPERATIONS. so that he may grasp it with the left hand above the place of operation. The skin and muscles are to be well drawn upwards by an assistant, who at the same time renders the limb steady. The surgeon carries the amputating knife below and around the limb, and divides the integument down to the fascia, with one circular sweep of the knife, as in the amputation of the leg. The skin and adipose tissue are to be still further retracted by the assistant, and such bands divided as oppose their ascent; or, what is still better, dissected up for the space of two or three inches, and turned back in the form of a cuff. For though the ample provision of skin can in no manner prevent the tendency to the formation of the conical stump— that depending on the division ' of the muscles— it is well understood that there ought to be enough to freely cover the wound, in order that cicatrization may go on rapidly. The muscles are next to be divided circularly at the base of the elevated skin down to the bone, or the cut must at least extend down to the deep-seated group. The superficial muscles are now to be retracted upwards; this is to be done with the fingers of the assistant, especially if the tourniquet has been applied, which by its pressure interferes with their tendency to spontaneous contraction. By a third circular sweep of the knife, the deep-seated muscles are then to be divided on a level with the retracted end of the first set. A two-tailed linen retractor is next to be applied, and the tails crossed on the cut surface above the bone. The assistant, laying hold of the ends, draws the divided mass strongly upwards. The surgeon divides with a circular turn of the knife any fibres yet remaining attached to the bone, and s:tws the latter four inches above the point, at which the first incision was made in the skin. If (here be any fear that the deep-seated muscles are not cut sufficiently high, we may run a scalpel round the bone, in the manner of B. Bell, so that they may be drawn an inch still further upwards with the retractor before the saw is applied; or we may follow the advice of Sir C. Bell — raise the limb to the vertical position, which exposes a greater portion of the bone, and apply the saw horizontally. Some little care is be observed in dividing the bone, in order to prevent the splintering of the little crest found on its back part. If any prominent spiculee are left, they are to be removed with the cutting pliers. If the great sciatic nerve is left unduly prominent, so as to involve the risk of its being compressed against the end of the bone, it must be retrenched by a second incision. Dressing. — The arteries to be tied will vary in number accord- ing to the height at which the operation is performed. After these are secured, the soft parts are to be brought down with the palms of the hands, and if the operation has been well done, the end of the bone, as observed by Sir C. Bell, will be hidden by the central mass of the muscles. The sides and lips of the wound are then brought together, so as to form a transverse line; or, which I think still better, in a direction obliquely from above downwards, and secured in the usual manner with adhesive straps and a roller bandage. Flap method. — When the tissues on one side of the Umb have been destroyed by injury or disease, the thigh may be success- fully amjJUtated by a single tlap taken from the anterior surface, — which is to he preferred, as it allows the flap to fall by its own j weight upon the face of the wound,- or if need be either from | the posterior or lateral. Under other circumstances the double flap operation will be found the more appropriate. The flap method will be found to present more advantages for amputation in the upper part of the thigh than the circular, in consequence of the greater facility with which the flaps may be kept approximated, as the shortness of the stump renders the dressing more difficult after the circular operation. By two lateral flaps. — These may be made by transfixion from the anterior to tlie posterior part, and cutting out to the sur- face, as practi^d by the French surgeons; or they may be raised by incisions in the opposite direction, cutting from the skin to- wards the bone, after the manner of Langenbeck. Whichever plan is pursued, the operation is done so nearly like the processes already described for the arm and leg, that it is not necessary to fepeat the description. The only important modification is that of inclining (he knife so as to cut the flaps larger on the posterior part of the limb than the anterior, in order to allow for the greater shortening of the muscles in the posterior region. The surgeon may form first, either the inner or outer flap, as is most conve- nient to him, provided the circulation is well commanded with a tourniquet at the upper part of the thigh, or by pressure on the artery over the pubis. In the operation by two lateral flaps tliere is a strong tendency (which by great care in the dressing may partially be obviated) in the end of the bone to approach too nearly the anterior angle of the wound, partly from its rising upwards under the action of the muscles inserted on the trochanter minor, and partly from the retraction of the posterior margins of the flaps towards the hip. For these reasons preference is commonly given, in this country and in Great Britain, to the formation of flaps in the opposite direction, by a lateral or oblique transfixion of the thigh, leaving the posterior flap considerably longer than the anterior, in order to compensate the greater tendency to contraction in the posterior — the operator standing on the outer side of the limb. Anterior and posterior flaps. {Process of Liston. PI. XLII. fig. 5.) — "The surgeon places himself on the tibial side of the right limb, on the fibular side of the left; and, every thing being ready, he lays hold of the soft parts on the anterior aspect of the bone, lifts them from it, enters the point of his knife behind the vena saphena, in operating on the right side, passes it liorizonlally through to the bone, carries it closely over the fore part, and brings out the point on the outward side of the hmb, as low as possible: tiicn by a gentle and quick motion of the blade, a round anterior flap is completed. The instrument is again entered on the inner side, a little below the top of the first incision, passed behind the' bone, brought out at the wound on the outside, and directed so as to make a posterior flap a very little longer than the former. The anterior flap is merely lil'ted up after it is formed; but now that both have been made, they are drawn well and forcibly back, whilst the surgeon sweeps the knife round the bone, so as to divide smoothly the muscles by which it is immediately in- vested. The bone, grasped by the left hand, is sawn close to the soft parts, the saw being directed perpendicularly. The femoral artery will be found on the posterior flap, is tied along with the other vessels, and the stump is treated as recommended after the other amputations. Great care must be taken, during the securing of the vessels, and in steadying the bone for that purpose, not to AMPUT injure the medullary web; to this cause may often be attributed inflammation and consequent necrosis. The proceeding is, in all respects, the same on the left limb, only the incisions are com- menced from the outer side. After the lapse of six or eight days, or sometimes earlier, a roller should be applied and made to em- brace the whole face of the stump, iii order to cause reduction of any cedematous swelling that may remain, and bring the parts into a good form. This is the only interference with the part j after the first dressing, and is unattended with pain."* The inixed method and the oval method have both likewise been employed iu the amputation of the thigh — but not as yet to a sufficient extent to prove that they possess any peculiar advantages over those already described, which have been sanc- tioned by general experience. The process for employing the mixed method, as given by Baudens and Sedillot, is as follows. Cut by transfixion two small lateral flaps, which shall involve only the superficial layer of muscles; draw them upwards and divide circularly at then- base and at the same time sloping up- wards the deep-s(!ated muscles down to the bone, so as to leave a conical hollow, at the upper part of which the bone is to be cut. The oval process, as described by Malgaigne, consists in making an oval or rather elliptical incision of the skin — one extremity of which oval rests on the anterior and outer portion of the thigh, and the other at the posterior and inner part, an inch and a quarter lower down than the former. The skin is to be dissected up, and the surgeon proceeds precisely as in the common circular amputation, with the exception that both layers of muscles are to be divided in the same manner as the skin — obliquely from above downwards. The sole object of this method is to divide the muscles on the back part of the limb lower than those in front, so that after their retraction the slump may be left square and even. The principle involved in this method seems well founded in the anatomical structure of this limb, but 1 am not aware that it has ever been applied upon the living subject. AMPUTATION AT THE HIP JOINT. Amputation at the hip joint, though by no means very difficult, is undoubtedly to be classed among the mostsevere and dangerous surgical operations. The idea of attempting this fearful mutila- tion originated with Morand in the early part of the eighteenth century. Since that time fifty-four cases in all have been re- corded of the operation, of which nineteen only have been claimed as successful. Though it may be difficult to collect the true statistics in regard to this amputation, the danger attending it may be well understood when we consider the extent of the wound necessarily inflicted; the huge mass of divided muscles; the difficulty of eflecting union by first intention at the part; and the shock to the nervous system, which has in some cases been almost immediately fatal, arising from the loss of a limb which represents nearly a fourth part of the whole structure of the body. It may be important, however, to observe, that nearly all the successful cases have been those in which the operation was practised for traumatic injuries, and almost immediately after their infliction; while the greater number of fatal results have been ATIONS. 173 consequent to the operation on subjects previously exhausted to more or less extent by disease. Still the surgeon may in some cases be justified in performing it as a last resort, under circum- stances analogous to the following, which have been laid down by Barbet in a prize memoir as the indications for the operation; viz.: where from sudden violence, as by gunshot wounds, or crushing from machinery, a comminuted fracture is produced of j a healthy bone at its head, neck, or upper part: where the limb is carried away or extensively injured by a cannon shot near the trunk; or wiiere gangrene has so far extended, or threatens to extend its ravages, as to render it impossible to obtain a sufficient covering of the stump by other means. And to ifiese, as the principal cases in which the operation is likely to be attended with a favourable result, have been added those for which exci- sion is recommended in other joints, caries, necrosis, osteo-sarcoma, spina ventosa, or other incurable affections beyond the chance of relief by amputation in the continuity of the thigh. But in regard to this latter class it is almost indispensably necessary, in order to render the operation justifiable, that the diseased action should be limited to the head of the femur, and not have invaded the structure of tiie pelvic bones. But the extreme difficulty of de- termining this point beforehand, and the rareness in fact of such limilatiou in caries — the more common disease of the part — must restrict its performance in the hands of careful surgeons to very narrow grounds. If, however, after the operation has been un- dertaken, the surgeon should find the margins of the cotyloid cavity carious or necrosed, he would be justified in removing them, as in resection, with the cutting forceps, gouge, or chisel, before closing the wound. The operation has, however, been recommended for caries of the head of the bone following coxal- gia, &c. In a case said to be of this description, its removal was successfully eff'ected by Dr. J, W. Duffee, of this city. But the observations of Mr. Pott, who witnessed a like operation by Mr. H. Thompson, the first that was ever performed, are in the main so just in reference lo the practice, that they can scarcely fail to meet the sanction of-every practitioner familiar with surgical pa- thology. He observes, "that the parallel which is drawn between this operation and that in the shoulder will not hold. In the latter it sometimes happens that the caries is confined to the head of the OS humeri, and that the scapula is perfectly sound and un- atfected. In the case of a carious hip joint this is never the fact; the acetabulum and the parts about are always more or less in the same state, or at least in a distempered one, and so indeed are most frequently tlie parts within the pelvis."** Surgical anatomy of the joint.— Th^ hip joint, which is every where surrounded by muscles, can only be felt in the anterior region of the thigh, where the head of the femur, covered by the tendon of the psoas and iliacus internus muscles, forms a globular prominence under Poupart's ligament. On its outer side lies the rectus muscle, which crosses the neck of the bone, and behind and within lies the great muscular mass of the limb. The crural artery crosses the joint on a line with the junction of the inter- nal with the middle third of the head of the femur, but only becomes parallel with the bone at a distance of three or four inches below, leaving between it and the greater part of the neck * Listen's Prac. Surg., Am. ed., p. 383-4. • Poll's Surgery, vol. III. p. 374. 174 GENERAL OPERATIONS. the space of at least an inch. The profunda descends in nearly the same antero-posterior line. Space is thus left for the safe passage of the knife in some of the processes for amputation, as well as for the seizure of the trunk of the vessels in the internal flap. The position of the joint may be determined with con- siderable precision by the following rules. 1. If we draw an imaginary line between the anterior superior spine of the ilium and t!ie tuberosity of the ischium, it will cut the cotyloid cavity a little behind its middle. 2. If we drop a vertical line an inch and a quarter long from the anterior superior spinous process of the ilium, the external and upper portion of the joint will be found half an inch to the inner side of the termination of the line. 3. If we draw in like manner a line half au inch long from the anterior i^yer/oT" spinous process, its extremity will rest on the superior part of the- joint. 4. The great trochanter is stiperfieial and easily felt: it takes a direction upwards and inwards, and is then turned a little back- wards. It forms a prominence about half an inch or a little more above the neck of the femtir, and a line drawn horizontally from its top crosses the upper third of the joint. 5. The trochanter minor projects nearly half an incli from the inner side of the bone, so as to form with its upper surface nearly aright angle with the axis of the shaft. Its under surface is about an inch long, and is continued obliquely into the shaft, with which it forms an angle of about 50 degrees, opening upward. 6. When the patient is lying on his back, the tuberosity of the ischium will be found to project an inch and a quarter in ad- vance of the margin of the acetabulum, a fact of much import- ance to remember, especially in the translixion for the piu'pose of forming flaps. The acetabulum or cotyloid cavity is about two inches in di- ameter, and is Inclined obliquely downward, inward and forward. The spherical head of the thigh bone is of equal size; a large part, especially of its posterior portion, is received into the ace- tabulum — but it is not entirely sunk in the socket. The capsular Hgament, which is very thick and strong, springing above from, the margin of the acetabulum, covers the remainder of the head, and shrinks closely round it to embrace the narrow neck, upon which it is inserted. If in the disarticulation, the ligament is divided round the neck, the head still remains fast closed within its cavity; and hence the rule always to divide it over the circum- ference of the head of the bone. The interarticular or round ligament, which connects the top of the head to the corresponding portion of the cavity, is put on the stretch when the thigh is ab- ducted, and presents itself to the knife over the inner edge of the socket. Hence, the most favourable point for opening the cap- sule to effect luxation of the head, is on its inner and lower por- tion. The surgical neck of the bone is about an inch and a Iialf long, and occupies the space between the trochanter and the head; it is directed downward and outward, and affords room on its sides for the passage of the knife in amputation. At its base, the knife becomes arrested against the trochanter of either side, around which it must be made to turn, except the subject be under twelve or fifteen years of age, when these processes are found so cartilaginous as to be readily divided. From the position which, as has been shown, the muscles occupy about the limb. it would be impossible lo split them into two equal flaps, unless we could pass the knife from the anterior spine of the ilium to the tuberosity of the iscliium. As this cannot be done, the in- ternal flap must be made much the larger of the two; and it is well to remember, that the muscles are cut short and will not therefore diminish much in length. The operation is performed by the different methods— flap, circular and oval. Some fifteen different processes have been devised for this disarticulation; but it will only be necessary to detail those which are most esteemed. Flap me.ihod. This method is the most ancient, and has in consequence been practised the greatest number of times. It may be done with the single or double flap. The patient is to be placed either on the back or the opposite hip, according to the process employed, resting upon a stout narrow table, which should be covered with a couple of pillows and a folded blanket. The pelvis must be advanced so as to extend a little over the edge. Several assistants will be required in order to steady the patient and assist in the operation. One should secure the pelvis and keep the trunk from slipping down- wards and forwards; one sustains the shoulders so as to prevent the patient's rising; another holds the diseased iimb, (that of the opposite side being secured to the leg of the table, or held by the assistant who secures the pelvis,) and a fourth controls the circulation by pressure on the artery above the groin, and holds himself in readiness to raise the first flap. In the earlier accounts of the operation, it was recommended as a proper precaution against hiemorrhage, to make a previous ligature of the femoral artery, close to Poupart's ligament and above the origin of the circumflex and profunda. This method of proceeding is deemed by many nimecessary and superfluous, as the circulation may effectually be controlled by pressure over the pelvis, or in the thickness of the flap; but it was strenuously inculcated by Lar- rey, and is still advocated by Blandin and others. It does not, however, in any way compromise the chance of cure; and as it effectually guards against hemorrhage from this large trunk, it is a step wtiich I believe should always be taken when an assistant is not at hand on whom implicit reliance can be placed, or when the patient is already weakened so as to render it important to prevent as far as possible all effusion of blood — leaving as it does another hand of the assistant free to close the mouths of the larger arteries (which come from the back of the pelvis) on the surfaces of the flaps, until they can be secured with ligatures. From the anatomical arrangement of the parts, it is difficult to apply any form of tourniquet that shall securely compress the vessel without presenting too much embarrassment in the way of the operator. Double Jlap, formed from the outer and i?iner sides of the limb. Process of Lisfranc modified. (PI. LXIII. fig. 3.)— The surgeon stands on the outer face of the thigh, or by the side of the trunk, according as he is to operate on the left or right limb. The assistant, holding the limb, flexes it slightly on the pelvis, 1. Formation of the outer flap. — The surgeon then, having ail his assistants placed, and fixing in his mind the relation of Ihe difi'erent parts, enters perpendicularly the point of a stout but AMPUTATIONS. 173, narrow double-edged knife, ten inches long in the blade, on the outer side of the neck of the femur, with the lower edge looking towards the summit of the trochanter major. The point of the knife should graze the neck of the bone, or rather the top of the trochanter, and as it advances towards the inferior surface of the limb, the handle must be inclined upwards and outwards, so as to form behind widi the axis of tlie trunk (which is sup- posed to be horizontal) an angle of 50 degrees, in order to bring ont the point half an inch below the tuberosity of tiie ischium — the surgeon with liis other hand, or an assistant, drawing out- wards at the same time the mass of flesh on the posterior part, so as to allow the knite to penetrate more within and give greater dimension to this outer flap. The surgeon, still holding the flesh outward, keeps the knife in the same state of inclina- tion, and by a sawing motion, descends along the outer face of the great trochanter, and raising the handle, shaves the thigh bone for two inches, and cuts directly outwards so as to complete the external flap. The flap is to be raised by the assistant, and tlie divided ghiteal and ischiatic arteries either immediately tied or secured temporarily by pressure with the fingers, of com- pressed after the manner of Baudens, with a couple of pair of artery forceps, which are left pendant. 2. I'Wmution of the inner fiap. — The surgeon inclines the soft parts inwards with the left hand, enters the point of the knife at the top of the first incision, and carries it on the internal side of the neck of the bone, with the handle inclined as before towards the abdomen of the patient, so as to bring the point out at the posterior angle of the wound without touching the bones of the pelvis. The knife is now raised perpendicularly to the horizon, by bringing the heel downwards so as to shave the neck of the bone — but without carrying backwards the point; it is then made to cut directly towards the surface of the trochanter minor, and shaving the iniernal side of the bone is brought out so as to finish the internal flap at (he same height as the outer, leaving a A shaped portion of skin remaining on the front of the femur. As soon as the structures during this incision are sufficiently loosened from the neck of the bone, the surgeon is to pause for a moment {provided the artery has not been previously tied) in order to allow the assistant to introduce his thumb or fingers for the purpose of compressing the vessels at the base of the flap. This flap, as soon as completed, is also to be raised, 3. Disarticulation. — The surgeon grasps the thigh with the left hand, and presents the edge of the catling or a stout scalpel vertically at the inner side of the head, which he circumscribes as far as possible, dividing the capsular ligament without attempt- ing to penetrate into the joint, «^ if about to cut the head of the bone in tivo, and have one-half in the. cavity of the aceta- bitlum. The limb is now held in a stale of abduction, and the point of the knife carried into the opened joint to divide the round ligament. The knife is next placed vertically on the inner side of the joint, and the remaining portion of the capsule, and the few muscular fibres left uncut, are to be divided from within out- wards and downwards. The process as described difl'ers a little from that of Lisfranc, inasmuch as it leaves a A shaped piece of skin in front—the con- sequence of carrying the knife directly from the neck of the bone to the top of ihe two trochanters; the directions of Lisfranc being to carry the knife along the fossa so as to turn round the tip of the trochanters, which can scarcely be done, especially for the outer flap, without haggling the skin both at the top and bottom of the incision. By the process as described above, the operation is perfectly easy, and the removal of the A shaped piece is found rather a benefit than disadvantage in the subsequent approxi- mation of the flaps. If the artery be thoroughly compressed or previously tied, the operation may also be done by forming the internal flap first, disarticulating the bone, and then carrying the knife through the joint in order to cut the flap on the outer side. Flaps formed from the anterior and posterior part of the thigh. Process nf Beclard as modified by Liston and Fergus- son. — Tliis is in general to be preferred to the operation by late- ral flaps, as it is quite as readily performed, and, from the fact of its splitting the muscular mass of the thigh in its narrowest dia- meter, does not leave so deep and extensive a wound, and fur- nishes flaps which are more readily kept in juxtaposition by the dressing. The femoral artery will, however, be divided in the first step of the operation. "The surgeon, standing on the outside of the limb, should insert the point of a long catling about midway between the an- terior superior spinous process of the ilium and trochanter major, keeping it rather nearer the former than the latter; he should then run it across the fore part of the neck of the bone, and push it through the skin on the opposite side, about two or three inches from the anus; next, he should carry it downwards and forwards, so as to cut a flap from the anterior aspect of the thigh, about four inches in length. When the blade is entered, the limb should be held up, and even slightly bent at the joint; the instrument will then pass along more readily than if all the textures were thrown on the stretch, and moreover, there is greater certainty of passing it behind the main vessels, and even dividing some of the fibres, if not the whole, of the iliacus internus and psoas mus- cles. As the knife is carried downwards, the assistant, who stands behind the operator, should slip his fingers into the wound and carry them sufficiently far across to enable him to grasp the femoral artery between them and tiie thumb: this he may do from the inside or ouiside at will, and with the right or left hand, as may be most convenient, the same grasp enabling him to raise the flap as soon as it is completed. ^ * * The flap being raised, the point of the knife should Ihen be struck against the head of the bone, so as to divide the anterior part of the capsular ligament and any textures in this situation which may not have been included in the flap. To facilitate this part of the operation, the knee should be forcibly depressed by the assistant who holds it; the head of the bone will thus be caused to start from its socket, and if the round ligament is not ruptured by the force, a slight touch with the edge of the Icnife will cause it to give way. At this period, depression being no longer required, the assistant should bring the head of the femur a little forwards, to allow the knife lo be slipped over it, -pijg jfuife should then be carried downwards and backwards in the course of tlie line, so as to form a flap somewhat longer than in front, the last cut completing the separalion of the limb. "By means of the fingers of assistants (and here one or two more than those referred to may be of service) and the applica- tion of sponges, the bleeding may in some degree be restrained GENERAL OPERATIONS. until ligatures are applied. If the vessels seem large on the pos- terior flap, it will be best to secure them first, and then t!ie femo- ral and such other branches as may require ligature in the front flap sliould be attended to. If, however, there is any fear of the main vessel eluding the grasp of the assistant, there will be greater safety in tying it first. If, in making the anterior flap, the knife is kept close to the femur for some way down, the superficial femoral will not be divided until the incision is nearly completed, and this branch with those of the profunda may all be sufficiently compressed whilst the hand is used in the manner above de- scribed."* Mr. Guthrie directs the anterior and posterior flaps to be formed in a soraewliat dhfereut maimer. He divides at first the ' Fergussoii's Practical Surgery, Am. ei, p. 391-393. integuments only — on the inside and next on the outside of the limb — from a point in front of the spinous process of the pubis, ' to another point near the tuberosity of the ischium, where the in- cisions are again to meet. The skin is raised and reflected on each side, and the muscles cut at the base of the fold from the surface to the centre obliquely upwards towards the articulation. An obvious advantage obtained by this process of Mr. Guthrie, is that of leaving more integument and less muscle in the wound, disposing the parts better for reunion, which, in an operation of such magnitude as this, is a consideration of greater importance than the facility of its performance. Single flap. — T!ie operation with a single flap is the only one that can be performed in certain cases, when the soft parts have been impaired on one of the surfaces of the limb. The flap may be taken from the anterior and internal, or internal and PLATE ILIIL— AMPUTATION AT THE HIP JOINT. {Fig. 1.) PROCESS OF liARON LARREY. mixed process between the oval and circular, shown upon the right leg, loiih a previous incision to secure the femoral artery.') A longitudinal incision [a), commencing just below Poupart's ligament, is made over the track of the femoral vessels, which are to be tied temporarily over a strip of linen, cut below the knot, and reversed as seen at h; the ligature by which tliey are drawn up being secured to the surface by a strap of adhesive plaster, and the fingers of an assistant (c), to keep it out of the way of the knife. The surgeon then takes his position on the inner side of the limb, and divides the integuments with an oval sweep of the Ictiife round the limb, leaving them the longest on tlie posterior face of the limb, as described in the text, and showed by the outline {e,g). The oval section commences on the outer side {d), at the lower end of the longitudinal cut («), and the knife, in the right hand of the surgeon (/), is brought round posteriorly and up again in front to the place of beginning, as shown in the drawing. The gcnilal organs are lo be drawn by a compress towards the opposite groin, so as to be out of the way of the kihfe. The subsequent steps of the operation are described in the text. {Fig. 2.) PROCESS OF M. CORNUAU. {Oval process.) A veriicat incision has been first made from over the joint down to the trochanter. This incision is then branched below like the letter ^ inverted, according to the modification of M. Malgaigne, the course of the anterior branch being from a to b, the posterior from a to c. Through the lips of this double incision the surgeon proceeds to open the joint and disarticulate the head of the femur. Then gliding the knife under and to the inner side of the head of the bone, he brings it down to the extremities of the ^ incision made in the skin. An assistant, as soon as sufficient space is obtained, grasps the femoral vessels in the thickness of the inner lip of t!ie wound. The surgeon now coniinues the course of the knife, (as seen in the drawing, where it has already cut a great part of the large internal oval flap,) holding the handle in a direction inwards and downwards, sp as to cut out on the posterior part of the leg, and give the greatest length to the inner part of the covering for the stump. d. Hand of an assistsnt, compressing the femoral vessels, e. Left hand of the surgeon, controlling the movements of the limb. / Knife, employed in his right hand. g. Acetabulum, from which the head of the femur {h) is detached. i. Branches of the first ^ incision continued down through the soft parts, on either side of the trochanter major, to reach the capsule of the joint. A-. Section of the mass of abductor muscles. {Fig. 3.) PROCESS OF LISFRANC, {Double flaps.) The process of Lisfranc is shown somewhat modified, for the purpose of obviating the difficulty which attends the turning of the knife round the trochanters, leaving on the external and anterior part of the limb a V shaped flap, with the base towards tEie knee. The stage of the operation shown, is the disarticulation of the femur. The surgeon has first transfixed the limb on the outer side of the joint with a long catling, as described in the AMPUTATIONS. 177 posterior parts of the limb, but the anterior and internal ia to be preferred when admissible, as the flap will tlieti fall by its own weight upon the surface of [he stump, afford a ready outlet be- low for the pus, and loaves a chance of cure as good at least as that by any other prc(Cess. The flap must be cut at least eight inches in length, and rounded at its extremity, to suit the form of the limb. If taken from the posterior part of the limb, in order to keep it well applied upon the surface of the stump, a matter of considerable diflicully, it should be secured with the twisted suture to the integument of the opposite side, as well as supported with llie ordinary dressings. The flap may be first formed by transfixion and cutting outwards, then opening the joint and carrying the knife around the bone so as to divide transversely or with such obliquity as the state of the parts will allow, the tissues on the opposite surface of the limb. Or an incision may at once be made on the outer side of the thigh, so as to expose the joint, and terminate near the tuberosity of the ischium; the joint opened from the outer side, and the flap cut last upon the ante- rior and inner face of the limb. Dr. Wm. Ashmead, of this city, prefers to cut the anterior and internal flap first, by an incision from the surface towards the joint, and has suggested the important modification of first dis- secting up the skin so as to tie the artery before proceeding to the section of the muscles. Circitla7' method. The circular method, as well as the plan of arresting the cir- culation by pressure over the pubis, was first proposed by Aber- nethy for amputation at this joint. It has subsequently received the sanction of many eminent surgeons, and every one who has amputated the thigh so high as to divide the bone through the trochanters, must be made aware of the possibility with which by this method the soft parts might be separated IVom the neck, and the head itself detached from the joint. The process is so nearly similar to that for circular amputation in the continuity of the bone, described at page 171, that it will not be necessary to give it in detail. The parts divided will not, however, be precisely the same, and it will be necessasy to con- trol the circulation by pressure on the femoral artery abovq the pubis. The retraction of the muscles is also less in this region, and it is therefore usual to divide them with a single cut down to the bone. Graefe preferred to hollow them out in the form of a cone, with a concave knife, broad toward the point. The lips of the wound are to be closed in a line from above downwards with adhesive straps. Mixed Viet hod. Process of Larrcy. (PI, XLIII. fig. 1.) — Tiiis process, which has been received with considerable favour, cannot properly be classed under either of the three more com- mon methods. It consists of an ovoidal section of the skin,with a division of the muscles into two lateral flaps. The surgeon, standing at the inner side of the thigh, begins with a vertical in- cision over the course of the vessels, in order to make a previous temporary ligature of the artery and vein over a strip of linen or some similar material; he then divides the vessels, and has them drawn upwards as shown in the plate. The skin of the thigh is next to be divided nearly circularly on a line with the lower end of the incision, dissected from the fascia and turned upwards. The long catling is now to be entered on the internal side of the neck of the bone, half an inch below the pubis, and carried through in the usual manner, so as to cut the internal flap first. This is to be raised up, the capsular and round ligament divided, and the knife carried round the joint and brought down on the outer side so as to complete the second flap. Oval method. This is but of recent invention, and has in consequence been only a few times applied upon the living subject. It is of easy execution, and leaves a linear wound well disposed for union. Process of Cornuau as modified by Malgaigne. (PI. XLIII. fig. 3.) — The patient rests upon the hip of the other side, the pelvis is brought to the edge of the table, the artery compressed above the pubis by one assistant, and the limb—extended and slightly abducted — supported by another. The surgeon, standing behind tiie patient, rests three fingers of the left hand on the top of the trochanter major, makes a first incision from a point three quarters of an inch above the tro- chanter directly downwards for three and a half inches below this projection, cutting to the bone. From the lower end or the middle of this incision, according to the size of the Yimh, a. second incision is carried obliquely in front, to a point where a vertical line brought down from the anterior superior spine of the ilium, would form a right angle with a line drawn horizontally from the tuberosity of the ischium, — cutting in like manner down to the bone, — and leaving the greater vessels to the inner side of the end of the incision, A third, incision down to the bone is started from the same point as the second, and carried obliquely down- text, formed the external flap {a), and tied tlie ischialic and gluteal arteries on its bleeding surface. Secondly, he has passed the knife on the inner side of the head of the femur, and formed the large internal flap [d), an assistant gliding his hand into the track of the knife, so as to compress tiie femora! artery before it is divided in the completion of the flap. The bleeding vessels on the surface of the flap are then likewise to be tied. In the last step of the operation the flaps are raised bv an assistant, the surgeon opens the capsule with the point of the knife, abducts the limb, as shown in the drawing, so as to divide the round ligament, and finally carries the knife round the head of the bone to detach the limb by cutting the remaining part of the capsule. h. Small triangular or V shaped flap, left between the two incisions, c, e. Ischiatic and femoral arteries, lied. f g. Hand of an assistant, sustaining the internal flap while the surgeon disarticulates the bone. h. Left hand of the surgeon, grasping the thigh so as to make tlie proper changes of position to favour the action of the knife [i). 17S GENERAL OPERATIONS. ward and backward to the inferior border of llie gluteus inaxi- mus muscle. By raising a little the upper flaps, the articulation, will be exposed on its anterior external and outer surface; di- vide circularly the capsule over this space, luxate the head of the femur, cut the round ligament, and carry the knife round the head so as to divide the inner portion of the capsule and descend upon the neck. An assistant is then to pass the thumb or fingers above the knife so as to compress the femoral artery between the surface of the wound and the skin; and the surgeon, grasping the thigh with the left hand, carries the knife down the inner face of the bone to the lower angles of the two oblique incisions, and finishes by cutting squarely at a single sweep the remaining soft pals. Dressing. — By whatever process the operation is done, ihe assistants should compress as much as possible the bleeding orifices of the large vessels, until there is time to secure them with the ligature. On the inner side of the limb will be found the femoral artery, the profunda commonly, and the branches of the obturator and circumflex. On the outer and back part of it are the ischiatic, and the branches of the gluteal and internal pudic. The lips of the wound are to be brought together to form, if the process will allow it, a line oblique from above downwards and from without inwards, and secured with adhesive straps and a few points of the interrupted or twisted suture. The ends of the hgatures are to be brought out at the lower angle, in which should also be lodged a greased linen compress, to maintain a free outlet for the discharges, A roller bandage may be applied round the pelvis, and a few turns brought over so as to support the divided soft parts. P AET THIRD. SPECIAL OPERATIONS: OR THOSE WHICH ARE PRACTISED UPON COMPLEX ORGANS IN PARTICULAR REGIONS OF THE BODY. UNDER THIS GENERAL HEAD ARE CONSIDERED: 1. OPERATIONS-UPON THE EVE; 2. THE EAR; 3. THE NOSE; 4. THE MOUTH AND ITS ACCESSORY ORGANS; 5. THE NECK; 6. THE THORAX; 7. THE ABDOMEN; 8. THE RECTUM AND ANUS; AND, 9. THE GE NIT 0- URINARY I. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. These operations may be arranged into four groups, according to the parts upon which they are performed: 1. those for affections op the lachrymal apparatus; 2. those for the protecting organs op the ete ; 3. those for the ball op the eye; and, 4. those involving the orbit, and the parts contained within it not specified above. — These groups will be taken up in succession. It may be well to observe, that in general the operations upon the left eye are directed to be performed with the right hand, and those upon the organ of the opposite side, with the left — the surgeon standing, in both cases, in front of the patient. But to render the surgeon capable of using the left hand with sufficient precision and adroitness in operations delicate and important as these, it is necessary that he should have practised them very many times, with all their evolutions, upon the dead body. To obviate the inconveniences arising from this want of ambi- dextrousnessj surgeons have invented elbowed instruments, so as to allow them to act over the bridge of the nose, and admit of the employment of the riglit hand in all cases. But such instru- ments have an awkward appearance at best; and it is much better for the operator, when he has not a perfect mastery over the instruments with his left hand, to place himself either behind or at the side of the patient, who may, if it is found more con- venient, be laid horizontal. In this way the right hand may at need be employed in all cases in which he is directed in the pro- cesses for the operations to employ the left. OPERATIONS PRACTISED ON THE ACCESSORY ORGANS OF THE EYE. Lachrymal apparatus. Surgical anatomy. — This apparatus is composed of two dis- tinct portions— the orbital and nasal. \. The orbital portion. — The lachrymal gland, wliich is placed between the conjunctiva and bone, at the outer and upper portion of the orbit, throws its fluid by seven or eight minute ducts upon the free surface of the corresponding portion of the conjunctiva. With this lachrymal secretion is mixed the fluid coming from the meibomian glands, the cai'uncida lachrymalis, and the free surface of the conjunctiva, to form the proper Uibri- cating liquid between the lid and the ball, which, when it flows over the cheek, receives the name of tears. 2. The nasal portion. — This is composed of parts for the pur- pose of carrying off the fluid, and preventing in the ordinary state of the functions any of it escaping between the lids, viz. the lachrymal punct a and canals, and the lachrymal sac and nasal duct. The puncta are orifices with elastic rims, by which the two canals open on the free surfaces of each lid, near the inner can- thus. From these capillary points, the canals run at first for a line obliquely upwards or downwards, according to the lid in which they are placed, and then turn at a right angle and run for a quarterof an inch— embracing the caruncula between them —to open close together through the infernal wall of the lachry- mal sac, so as to throw into this cavity the fluids which they carry. In all their track, these canals are covered by the orbicu- laris muscle and the skin, and lined within bv a reflection of the ISO SPECIAL OPERATIONS. conjunctiva, which is thrown, near the angle described, into a valvular fold that sometimes presents an obstacle to the passing of instruments into the sac. The lachrymal sac is of an oval or oblong shape, with its long diameter directed downwards and a little inwards and backwards. It is lodged in the groove formed by the os unguis and the nasal process of the npper maxillary bone. The root of this nasal process, which extends outwards to form the inner part of the lower brim of the orbit, has upon it a projection called tlie lachrymal tubercle, (readily fell when tlie integuments are not too mucli thickened,) which is exactly opposite the junction of the inferior with the middle third of the lachrymal sac, and serves as an index to guide the course of the knife in the puncture of the sac. Besides its internal mucous lining, which is continuous with that of the puncta, the sac has an external fibrous tunic, wliich is thick and resisting, and is closely united to the neigh- bouring bones. Across and in front of the sac passes the round tendon of the orbicularis palpebrarum muscle, which feels like a grain of rice below its mucous covering, and divides the sac into unequal parts. The superior portion is lodged behind the carun- cula, and is covered by a firm expansion of the orbicular tendon. Tiie inferior, wliich is tlie larger, is found between them and the lachrymal tubercle, is covered only by a few fleshy fibres and the skin, and yields readily to distension from accumulation of the fluid within. Occasionally, however, we find the whole sac distended, and then the pressure of the round tendon near its middle gives it a bilobular shape. Where it meets the floor of the orbit, the lachrymal sac terminates in the nasal duct, by which in a healthy state of the parts it throws its fluid into the nose. The nasal duct is formed of two membranes like the sac, and is iodged in a delicate and fragile bony canal formed by the inner wail of the maxillary sinus, and a portion of the os unguis and inferior turbinated bone. The canal is directed with a double inclination from above downwards — bending from the perpen- dicular outwards, so that a probe introduced through it from above downwards crosses at its upper end the middle line of the forehead about an inch above the nasal bone, so as lo form with that line an angle of ten or twelve degrees — and at the same time running backwards so that the probe will form with the forehead in that direction an angle of twenty to twenty-five degrees. The canal is of equal length with the sac, each being about five lines long, and opens below under the inferior turbinated bone, in the lower meatus of the nose. Its inferior orifice, which is bevelled at the expense of its inner wall, and looks a little backwards, terminates about half an inch above the floor of the nostril. The .whole space from the floor of the nostril to the top of the sac varies from an inch to an inch and a quarter, and the nasal duct occupies about the middle third of this space. The caliber of the duct is smallest in its middle part, where it is cir- cular, and has a diameter of little more than a hue; at its upper and lower termination, it is larger by half a line, and somewhat oval, so that in shape it resembles two small cones joined at their summits. The diameter of the lachrymal sac is about the sixth of an inch. Lachrymal tumour and lachrymal fistula. These two affecilons, which are often treated of as separate morbid conditions, are in fact but different stages of the same, and in many coses have for their origin a chronic affection of the mucous membrane of the eye or nose, which has spread by con- tinuous sympathy along the adjoining passages for the tears, so as to involve the lining membrane of the lachrymal sac. Caries of the OS unguis, exostosis of the bony passage for the nasal duct, pressure from polypous tumours, and analogous affections, fre- quently occasion it; and it sometimes seems to arise from primi- tive inflammation of the sac from the common causes which aflect the other mucous membranes. In some few instances, of which one has come under my notice in the case of a young architect of this city, it has been owing to a congenital deficiency of the nasal duct. A lachrymal tumour is a collection of fluid within the cavity of the lachrymal sac, forming a rounded elevation of the integu- ment at the internal canthus of the eye. This is at first a mere passive swelling, without redness or pain, and may be emptied by pressure with the finger upon it, the contained fluid escaping upwards by the lachrymal puncta, as is most common, or down- wards by the nasal duct. In this state the tumour will often remain for months or even years, giving rise to but little incon- venience except that occurring from the necessity of occasional pressure on the sac in order to empty it of its contents, and a flow of tears (epiphora) over the face, when the eye is exposed to causes a little more than usually excitative of this secretion, as exposure to bright light, or going from a warm room into the open air when tlie latter is cold and sharp. Under such circumstances the distending liquid may consist merely of the lachrymal fluid mixed with mucus, or with a puriform secretion from the surface of the sac. Sooner or later, however, this catarrhal state of the parts, if not relieved by appropriate treatment, is followed by acute phlegmonous inflammation. The tumour enlarges more, becomes highly painful and red, can be no longer entirely emptied by compression, and the fibrous or outer membrane of the sac and the integument covering it, if not opened with the knife, ulcerate so as to give exit to the fluid within, which will then be ' found purulent. A complete lachrymal fistula is now formed. In some cases an internal fistula is developed; the os unguis be- comes softened and ulcerates, and allows the fluid to escape into the nasal cavity. This result sometimes follows as a secondary effect after tlie external opening has been formed through the skill; and if the external orifice should then close up by cicatri- zation, a cure may be produced by the efforts of nature alone. This has led to the institution of processes, in order to effect arti- ficial relief in a manner somewhat analogous. The cause of obstruction will commonly be found in the nasal duct, and, though this may occasionally be physical, it is importarit to remember that in a vast majority of cases it is simply owing to an inflammatory swelling or thickening of the lining membrane, and amenable to the common methods of treat- ment for strictures of the other narrow raucous canals; viz. such general remedies as are used in local inflammations — topical bleeding, purgation, and discutient applications, — and those that are used locally — injection, catheterisra, compression, to which some have added cauterization. Of the latter class of remedies only, as coining within the scope of this work, we shall proceed to treat. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 181 TREATMENT OF LACHRYMAL TUMOUR AND LACHRYMAL FISTULA. It has already been observed, that the iuflaramEitory thickening of the lining membrane of the lachrymal passages, is in its first stage the cause of the watery eye and the discharge of tears over the cheek; in its second, of the formation of a tumour in addition, ill consequence of the distension of the lachrymal sac; and that in the third stage, the tumour is opened by ulceration so as to form a lachrymal fistula. The mode of treatment of the first and second stages will be very nearly the same, and may be divided into the medical and surgical. When the medical treatment — which consists of the application of mildly stimulating ointments and collyria to the conjunctival membrane, for the purpose of altering the character of its secretion, the use of local bleeding, (and of venesection, if there be any arterial excitement,) the application of emoUient poultices, and the administration of alteratives and cathartics- have been fairly tried without effecting a cure, we proceed to the employment of surgical measures. These consist of injection, catheterism, and compression. Injections through the puncta. Process of n. — With ihe fore finger of the left hand, depress the lower lid opposite the punctum, so as to reverse it and expose the orifice. 'I'aking the syringe in the other hand, and resting the two smaller fingers below the superciliary arch, insinuate the end of the capillary tube through the orifice of the punctum obliquely from above downwards and backwards, so as to bury it to the extent of a line. It has now arrived at the turn of the lachrymal canal, and the instrument is to be inclined downwards in order to efface the curvafure, and make it take the ascending direction of the canal. The tube is now to be passed on half a line farther, and the piston pushed gently down with ttie thumb or finger, to throw the fluid forwards. Some surgeons direct the capillary tube to be buried for a quarter of an inch, so that it may enter the sac; but this does not increase the facility of injection, and exposes the lining membrane of the sac to irritation from the point. Wlien assured by the flow of the fluid from the upper punctum that the superior canal is free, pressure may be made upon its orifice by an assistant, or with the -fore finger of the other hand of the operator, so as to cause the fluid to accumulate in the sac, and find its way by the nasal duct into the nostril. Its entry into the latter cavity will be made known by the trickling of the fluid forwards upon the lip, or by its passing backwards into the pharynx, so as to produce an effort to swallow; the one or the other result following accord- ing to the degree of inclination which is given to the floor of the nostril. 46 2. Injection by the upper punctum. — The upper lid is to be ■ elevated with the thumb of the left hand; the fingers resting upon the forehead. The mode of introduction of the lube in this case, is in all respects similar to the process just described, except that the two last fingers of the right hand are to rest on the cheek bone, and that the instrument is to be raised in order to pass the point of the tube beyond the angle, as the course of the canal on the inner side of this curvature is from above downwards. Remarks. — The injection by the lower punctum is almost the only process employed— the injection through the upper being chiefly resorted to only in cases where some obstruction is met with in the passage of the lower lid, or there is fear of irritating it by too frequent repetition of the process. It is directed by many surgeons to hold the syringe in the right hand for the eye of the right side, and in the left hand for the other. But the operator will find it perfectly easy, by placing himself either in front or behind the patient, to employ the same hand for the eye of either side. The fluids for injection may be simply aqueous or mucilaginous, if we wish merely to wash out the irritating contents of the sac and soothe the lining membrane of the passages; or they may be medicated by the addition of a few drops of the wine of opium; or with the sulphate of zinc, in the proportion of a grain or more to the ounce, or of corrosive sublimate, or lunar caustic in that of a lialf to one and a half grains to the same quantity of the fluid. It is by its tendency to remove inflammation rather than by the force of distension, that we may hope by this means to re- store the free passage of the tears into the nose. But from the rude manner in which it is too commonly practised, it is not per- haps (00 much to say, that this process of Anel, which by proper management and repeated at intervals of not less than one or two days, may be occasionally rendered very useful, has on the whole been productive of more injury than good. Many practitioners have in consequence abandoned its use altogetiier, and rely for the introduction of fluids into the sac upon the natural process of absorption through the puncla, first pressing upon the sac so as to evactuatc its contents, and then introducing an astringent so- lution between the lids. In many cases the fluid will not find iis way into the nose until tlie injection has been frequently practised, and in some others, before it can be effected at all, it will be necessary to re- sort to one of the following operations in ord^r to remove the obstruction in the nasal duct. Catheterism, or the introduction of solid sounds or hollow catheters through ihe laclirymal passages. 1. From above doionwards by the upper lachrymal punc- tum. Process of Jinel — The patient is to be seated, with his head inclined backwards and rested against the chest of the sur- geon, who stands behind him. The operator then raises the upper lid with the end of the fore finger, and inserts into the punctum the rounded head of the delicate probe of Anel, in the same manner as directed for tiie tube in the process for injection. Having passed it beyond the curvature, he lessens the traction with the fore finger upon the lid, and carries the probe down- wards into the sac, following the direction of the canal, and ren- dering in consequence the skin tense toward the root of the nose. On its arrival at the sac, a result which will be known by the 182 SPECIAL OPERATIONS. extent of the probe hidden, and the freedom with which its end moves, the instrument is to be raised vertically and the head passed on along the internal side of the sac, inclined outward as much as possible so as to follow the tract of ihe nasal canal and glide gently through into the cavity of the nose. The manipula- tion must be delicately done. The probe is apt to get arrested in a follicle, or in a fold of the mucous membrane which it raises before it. It must then be withdrawn a little, and again passed forward with its direction a little altered. If after some trials we do not succeed in getting it clear of the obstruction, it is better to withdraw it, and repeat the attempt at a subsequent period, rather than run the risk of lacerating the lining membrane, which is usually found somewhat softened and thickened in these cases by the previous disease. This method was devised exclusively by Anel for the purpose of freeing a passage for the injection downwards into the nose. It is now, however, frequently employed for two other objects. Firstly, as a preparatory step to the process of Mejean shortly to be noticed. Secondly, for the purpose of dilating t!ie strictured portion of the nasal duct, on the same principles that bougies are employed in the urethra, in which it is warmly recommended by Mr. Travers, and Dr. Hays,* of this city. In my hands, it has proved occasionally useful, and if the size of the punctum was such as to admit of the introduction of a probe of sufficient diameter, it would be unquestionably the most efficacious treat- ment that could be practised. It has not, however, received the sanction of either Dr. Mackenzie or Mr. Lawrence, 2. Cathelerism of the nasal duct thi'oiigh the nostril. This is called the method of Laforest, from the surgeon who first put it into practice. It is applicable to various diseases of the nasal duct and lachrymal sac, and allows of the introduction of sounds and catheters of considerable size, without any previous opening made with the knife. It has latterly been much em- ployed, esjieciaily by the French surgeons. The operation is one, however, which requires accurate knowledge of the structure of the parts, and considerable practice on the dead body. Remarks. — The instrument employed first enters by the lower meatus of the nose, and penetrates from below upwards through the interior or nasal orifice of the nasal duct, and follows the course of the latter up to the lachrymal sac, so as to he felt at the internal canthns of the eye. In the adult the lower orifice of the nasal duct, which is under the inferior turbinated bone, will be found on the average at a point about two-thirds of an inch in a vertical line above the floor of the nostril, and about three quar- ters behind the lower and lateral border of the anterior opening of the nose. The length of the nasal duct itself, whicli is rather less than haif an inch, and the direction in which it runs, have been before described. Every instrument passed by this method from below upwards into the lachrymal sac, should penetrate through the anterior narcs to the extent of nearly an inch and three quarters, and have such a curvature as is calculated to turn the angle that the axis of the canal forms with the inferior meatus • Tide Lawrence on the Eye, with addiiions, etc., by Dr. Hays. Lea & Blandiani. 1843. of the nose, which angle opens forwards, and is found to measure about 28 degrees. Process of Laforest. (PI. XLIV. fig. 1.) — The instrument em- ployed is a small silver sound or hollow tube, of which the precise size and shape are shown at figs. 1 and 6. A wooden handle introduced into the tube serves to direct it with more precision. The same hand may be used to introduce it on either side, but in general it will be found more convenient to employ the right hand for the left duct, and the left for the right,— a little practice rendering the manipulation with either hand perfectly easy. The patient is to be placed in a sitting posture, with his head thrown back and sustained by an assistant, l. The surgeon then, seated in front, holding the sound or probe between the thumb and fore finger, rests the middle finger on the cheek bone, presents hori- zontally the point to the opening of the nostril, with the convex portion of the curve turned towards the septum, upon which he glides it back until the whole curved portion is entered; this curved portion should be exactly of the same length as the dis- tance of the duct from the orifice, which, as has been observed, is about three quarters of an inch. 2. He then turns gently up- wards the handle of the instrument, describing an arc of about 40 degrees, passes it a Httle forward upon the pulp of the middle finger, so that it is placed exactly in a line between the eye of the operator and the middle of the superciliary ridge. By this move- ment the beak of the instrument is made to ascend from the floor of the meatus, under the turbinated bone, so as to present to the lower orifice of the duct — the convex portion resting by its mid- dle on the maxillary border of the meatus. 3. If the point has entered the duct, which may be readily ascertained by attempting to slide it slightly backwards and forwards, the handle is to be gently lowered by rocking it over the thumb in the direction of a plane extended between the caruncula lachrymalis and the external margin of tiie first incisor tooth of the opposite side. If the point lias lairly entered the duct, and this passage is free, it will have traversed its whole length, so as to be felt with the finger, and make the skin tense over the lachrymal sac at the lower and inner side of the caruncle, by the time the handle lias been brought in front of the incisor tooth of the ojiposite side. The sound having been thus introduced, Laforest injected fluids through it, securing it in its position by a tliread passed through the ring at its free extremity; afterwards he substituted for it a flexible sound or catheter, which was passed through its cavity and left in the canal. Process of Geiisoul.—The instrument (PI. XLIV. fig. 6, i, c,) employed by this surgeon is more easy of introduction than that of Laforest, and is the one which the author has found most con- venient and useful. It is modelled on the form of the passage, and is curved at an angle of about 100 degrees, which renders its introduction easy by a single easy and prompt manceuvre. An instrument is required for each nostril; each one consists of a curved sound for the opening of the passage, (PI. XLIV. fig. 6, b;) and a flexible catheter, (fig. 6, c,) through which passes a slilet, supporting a little porte-canstiqve at the end. Tii.e sound is graduated in order to show the depth to which the instrument penetrates. This apparatus, devised for the purpose of applying caustic to the duct, answers equally well for injection and dilata- tion. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 183 Tlie instrument is to be held as a writing pen, and presented at first a little obliquely, with the beak of the horizontal portion supported upon the septum. By a quarter rotation of the handle, the extremity glides from behind forward over the septum and the floor of the inferior meatus. By this movement the handle is placed nearly vertically downwards, but inclined a little so as to be in front of the inferior canine tooth of the same side, while the point is brought at the outer side of the meatus exactly under the orifice of the duct. Carrying the handle then in a direction upwards and outwards, so as to describe SO degrees of the arc of a circle, the point, which has glided during this movement from below upwards on the external wall of the meatus, will be found at the orifice of the nasal duct. Then by a rocking or balancing movement, which shall be at the same time from above down- wards, from without inwards, and from before backwards, the handle is brought to a horizontal position, and in the direction of a plane extended between the caruncula lachrymalis of the same, and the first incisor tooth of tlie opposite side; and the point, which has moved in an inverse direction, will, if the duct be free, have entered the lachrymal sac. This process is very rapidly executed, and may be rendered very easy by a little practice. Other instruments have been employed for the cathe- terism of this duct, by the process of Laforest, but they are merely modifications of the two already described. To the sound of Gensoul, Manec has added a little dart {Pt. XLIV. fig. 2, B), for the purpose of penetrating the sac from within outwards, and allow of the introduction of a mesh, with the object in view of effecting a gradual dilatation of the passage. The repetition of the use of the sound of Gensoul or Laforest, for the purpose either of dilatation, employing injection, or the cautious application of lunar caustic, should be made at intervals of not less than three or four days, for fear of exciting too much irritation in the lining membrane of the nose and duct. If none of the measures above alluded to succeed in removing the obstruction to the course of the tears, the infianimation of the lachrymal tumour may sooner or later be expected to terminate in ulceration and form proper fistula lachrymalis. When the opening of the tumour has taken place spontaneously, I have on two occasions, in subjects which were young and otherwise healthy, known the engorgement of the sac relieved by the sup- puratory discharge, and the nicer subsequently to cicatrize and leave the passages perfectly free witliout the aid of instrumental treatment. But so happy a termination is not commonly to be expected, and it is better as a general rule, when the opening appears unavoidable, lest the pns should burrow and excite ulce- ration of the skin at a point not opposite to that of the sac, or involve the delicate bones in the vicinity, to discharge it by punc- ture with the knife. If the case has been of long standing, and there is great thickening and induration of the lining membrane of ihe duct, the restoration of the passage for the tears is not likely to be effected except by instrumental measures. These consist o{ compression, dilalation, cauterization, and the form- ation of an artificial canal. Compression. — This is suited only to the lighter cases of dis- ease, and when ihe inflammalion has been so far reduced that pressure may be borne without pain. It is employed both for lachrymal tumour and lachrymal fistula. It may be made tempo- rarily with the finger for the purpose of evacuating the contents of the sac, or permanently with a little pad or graduated compress, secured by a bandage, or one of the instruments newly devised for compressing the arteries of the face. In itself it is little to be relied on, as it acts only upon the lachrymal sac, but I have found it occasionally very useful in conjunction with the employ- ment of antiphlogistics and the injections of astringent fluids through the puncta or nasal duct. Dilatation. — The object in view in dilatation is, by the intro- duction of some foreign body, to etfect a permanent compression of the thickened lining membrane of the nasal duct from within outwards, so as to remove its tumidity, and limit and restore the dnct to its usual patulous condition. Concurrently with thij mea- sure, antiphlogistic remedies and different topical applications are to be employed in order to facilitate the cure. The various modes in which dilatation is employed, may be thus classed: — 1. The introduction of some foreign body by the natural orifices— the puncta or the nasal duct, — a method which has also been occa- sionally employed for the cure of lachrymal tumour. S. The introduction of some foreign body through an orifice in the an- terior wall of the sac, which orifice is either kept open round the instrument, and the latter allowed to project above the skin; or the instrument is so pressed in that its upper extremity is lodged in the cavity of the sac, and the wound by which it was intro- duced closed above it. 1. Dilatation by ihe natural orifices. By the upper laclirymal punctum. Method of Mejean. — This has been employed only in cases of lachrynial tumour, where, though there has been no fistulous opening of the sac, it was thought desirable to try permanent compression from within outwards, — as a sort of appendix to the treatment with the in- strument of Ariel. The delicate probe of Anel, (with an eye near the end armed with a silk thread,) is to be carried by the process for catheterism, described at page 181, from the punctum into the nose. The thread thus carried into the meatus, is to be seized and brought out through the anterior nares and tied to a small seton. The probe is then to be retracted, drawing out with it again through the punctum the thread, which now pulls after it the seton so as to lodge the latter in the nasal duct. To the lower end of the seton a thread is to be left attached, so that the surgeon may withdraw it at will, for the purpose of renewal or of augmenting its size. The thread of the upper end of the seton, which traverses the punctum, is secured upon the forehead with a piece of adhesive plaster, and left of sufficient length to admit of being drawn down for the purpose of renewing the seton from time to time. This process is difficult of performance, and a variety of means have in former times been suggested to render it more easy. But it is scarcely necessary to enimierate them, as the permanent pre- sence of the thread is found to excite so much irritation and ulceration of the punctum, that the process has been almost wholly laid aside. Dilatation hy the loicer orifice of the nasal duct, called the process of Laforest. — This surgeon insinuated a solid sound, as far as the obstruction would permit, by the process already de- scribed, page 182. This he allowed to remain till it became SPECIAL OPERATIONS. movable by the retreat of Ihe walls of the duct, resulting from the secretion excited by the presence of the sound. A hollow- sound or catheter was then substituted for the former, introduced with a movable handle, and secured with a thread as before mentioned. Through this he also practised injectioiiSj upon the efficacy of which he mainly I'elied for the cure, f'hign/i fol- lowed the same method, gradually augmenting the size of the instrument up to that of the natural dimensions of the passage. He employed a gum elastic catheter, which was introduced on a curved stilet. Some difficulty will, however, be experienced PLATE XLIV.— OPERATIONS UPON THE EYE. LACHRYMAL PASSAGES. Pig, 1, — The usual posilioii of the head in operations upon the eyes and through the nasal fossse is here shown. The patient is seated, with his head slightly inclined upwards and backwards, and secured by the hands {a, b) of an assistant standing behind him. The head of the patient should also be a little inclined to the side opposite to that on which the operation is to be performed. The instruments shown refer to the three principal operations performed on the ball of the eye and the lachrymal passages. c. The cataract knife held ready to begin the puncture of the cornea in the operation for extracting the cataract. d. Bistoury of Petit, applied in the direction proper for the puncture of the lachrymal sac and nasal duct in fistula lachrymalis. e. The sound of Laforest introduced into the nasal duct from the side of the nostril. {Fig. 2.) PERFORATION OF THE INTEGUMENTS OVER THE LACHRYMAL SAC FROM WITHIN OUTWARDS, WITH THE TROCAR OF MANEC. The canula in which the trocar is concealed has been introduced from the nasal fossa after the manner of Laforest. (A, B). Introduction of ihe tube or canula after the manner of Dupuyt7'en. The bistoury has entered through the sac as shown in fig. 1, and is represented here as partly withdrawn and at the same time inclined forward and outward so as to widen the orifice and facilitate the introduction of the tube, wiiich is seen descending into the passage on the mandrin or stilet as the knife is being withdrawn. {Fig. 3.) INJECTION THROUGH THE INFERIOR LACHRYMAL PUNCTUM, WITH THE SYRINGE OF ANEL. . The surgeon depresses Ihe lower lid with the fore finger of one hand, so as to render the punctum prominent while he insinuates the point of the syringe into its orifice, and makes the injection with the other. {Fig. 4.) PERFORATION OF THE WALL OF THE ANTRUM MAXILLARE, WITH THE TROCAR OF M, LAUGIER. This operation is intended to make a new route for the tears, and can only be proper in cases of closure of the nasal duct by exostosis. {Fig. 5.) INTRODUCTION OF THE NAIL-HEADED STILET. The puncture of the sac has been made as shown in figs. 1 and 2, and the stilet has been partially introduced as the bistoury was withdrawn. {Fig. 6.) INSTRUMENTS EMPLOYED IN THE TREATMENT OF OBSTRUCTIONS OF THE NASAL DUCT. a. Silver catheter of M. Serres d'Uzes, with the proper curvatures for its introduction into the nasal duct from the left side of the nostril. It is introduced in nearly the same manner as that of Gensoul. A separate instrument is required for the two sides. b. Sound of Gensoul— on account of its double curvature an instrument will be required for either side. c. Graduated flexible sound or catheter of Gensoul, enclosing a stilet which has a ^mrte'Caustiqxic at the end for the cauterization of the passage, from below upward. d. Sound of Laforest — the external orifice closed by the handle. e. Tube or canula of Dupuytren. / Tube or canula of M. Malgaigne. g. Canula of Gerdy, The two last instruments are devised as substitutes for the tube of Dupuytren, and from the irregularity of their surfaces, are less liable to become displaced. h. Naii-headed leaden style of Scarpa. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 1S5 frequently in the substitution of the larger instruments for the smaller, which Malgaigne has proposed to obviate by introducing a curved stilet into the one to be reraoveil while yet in place, withdrawing the latter over it, and making it serve as a means of conducting the new one into the passage. Tlie sound and catheter of Gensoul answer for this purpose at least as well as that of Laforest. But by this process, and all the various modi- fications of it which have been devised, the cure is slow, the necessary manipulation disagreeable to the patient, and relief by no means so certain as by the methods about to be described. Dilatation through an orifice in the sac. (PI. XLIV. figs. Sand 5.) — Introduction of a foreign body from above down- wards. — If the sac has ulcerated spontaneously so as to leave a free route to the nasal dnct, tlie dilating instrument may be passed at once from above downwards. But if the ulcerated opening of the sliin do not correspond with that of the sac, or it is thought judicious to resort to this method of cure before the ulceration has taken place, the sac is to be opened by puncture in the fol- lowing manner, which is but an improved modification of that of Petit. The patient is to be seated in front of a good light, with his head supported against the chest of an assistant, who with one hand sustains his forehead, and with the other draws upon the external border of the orbit, so as to stretch the lids and render the round tendon of the orbicularis muscle prominent in front of tlie sac. The operator, seated in front of tiie patient, feels with the pulp of the index finger of one hand, below the obvious promi- nence of the orbicular tendon, for the ridge of the nasal process of the maxillary bone, which confronts the lachrymal sac. Resting his nail upon this, a small rhomboidal space will be observed between the nail and the tendon, and between the rising swell of the lower lid and the bone. If the parts be much swollen or painful, it may not be possible to feel the ridge of the nasal pro- cess, but it is not difficult to ascertain the position of the sac, which it must be recollected is to be opened below the orbicular tendon, and seemingly the nearer to the nose the less sloping are the bony sides of the upper part of the nostril. The want of know- ledge of this apparent change of position of the sac, dependent upon the varying shapes of the nose, I have known the cause of considerable embarrassment in this sunple operation. Through the centre of this rhomboidal space, guided by the nail of the finger resting on the ridge of bone, the surgeon lowers the point of a bistoury (PI. XLIV. figs. 1, 2) held as a writing pen, with the back to the nose and the edge directed outwards and slightly downwards, so as to divide the space in the direction of its dia- gonal. The point is first to be passed from without inwards and from before backwards, as if we were about to strike the os un- guis behind the sac. When it has pierced the wall in front and fairly entered the sac, the handle is to be raised, describing an arc of a circle from below upwards and from without inwards, till it comes in front of the internal end of the eyebrow, and in the direction of a line drawn from this point to the outer side of the ala of the nose. It now corresponds with the long axis of the sac and nasal duct, and is to be passed, lightly held, down- wards without changing the double oblique direction of the blade and handle. The bistoury enters the orifice of the duct, and is arrested of itself against the margin. It is not usually necessary 47 to enter it for more than half an inch, though some surgeons prefer in ail cases a knife narrower than the one represented in the plate, in order that it may pass freely into the duct, and divide any stricture that may exist within it. By following the process above described, the surgeon will freely open the sac, and avoid the chance (a result whiciil believe occasionally happens) of the knife passing down on the anterior surface of the sac — the cavity of which is often diminished by thickening of the lining mem- brane — rendering the introduction of the dilating body almost useless, as it would under such circumstances in all probability merely separate the membranous wall of the duct from the bone. After the incision of the sac, the mode of proceeding is varied by different surgeons. Petit tilled the bistoury so as to make the wound gape; and, as he withdrew it, directed down along the channel near its back a grooved sound, which he passed through the duct into the nose to open the way, and finally substituted for it a small conical wax bougie, which was allowed to remain, and secured against sliding into the nostril by a thread fastened to its upper free extremity, attached upon the face by a strip of adhesive plaster. The bougie was renewed from time to time, and gradually increased in size, and when the duct had become restored to its natural diameter, removed altogether and the ex- ternal wound allowed to close. Tliis may still be considered an excellent method of treatment, and is advocated by some judi- cious practitioners of the present day.* Some surgeons, after the artificial opening of the sac, have preferred the practice of Mejean, of introducing the dilating body, consisting of a seton or a piece of catgut, from below upwards through the nostril, with the exception that they passed their conducting instruments, of which various kinds were contrived, from above downwards through the orifice in the sac. This method, though advocated by Desanlt and Boyer, is now how- ever almost entirely abandoned, as it illy accomplishes the efi'ects desired, and the manipulation through the nosiril proves both tedious and painful. Beer introduced catgut from above downwards, beginning with the size of the smaller strings of the violin, and ending, as the passage became more open, with the largest. The lower end was passed completely into the nose, and a few hours after, when it had become softened, it was blown or hooked out from the nostril and secured upon tiie cheek. ■ The introduction of a nail-headed style, (PI. XLIV. fig. 5,) after the manner of Scarpa and Ware, is the means employed most commonly by practitioners for effecting dilatation by this process. The former employed one of lead, the latter of silver, about an inch and a quarter long and the twentieth of an inch in diameter. The style is to be introduced much in the same manner as the bougie of Petit, care being taken to push it at first from before backwards, especially if a common probe of the pocket case— which answers very well — has been used to clear the dnct, so as to get the point well within the sac before the style is raised in the proper direction, to be carried down into the nose. In pressing down the probe to clear the way for the style, no force • Vide au article on the cure of fistula laclirymalis, by Dr. Parrish: Philad. Med. E.xarainer for July 1843. 186 SPECIAL OPERATIONS. should be used, for fear of lacerating the os unguis or breaking into the antrum. If a probe of small size will not pass through, it should be entered as far as it will readily go under gentle pressure, and secured in its position by a strip of plaster to the forehead. In a day or two the opening may be thus enlarged by frequent trials till the probe or style will pass. The following judicious directions are given by Mr. Mackenzie for the management with the style, nearly after the manner of Ware. "It is an instrument which generally may be worn for an un- limited time, not only without annoyance to the patient, but with a great degree of comfort. The probe being withdrawn, and a little tepid water injected, the style, previously passed through a bit of court plaster, is introduced from tlie sac into the dnct, and pushed down so that the bit of plaster comes into contact with the integuments, The plaster serves to bring the edges of the incision as much together as the presence of the style will permit, and prevents the style from sinking into the wound. The wound closes gradually round the style, which is not to be entirely taken out for the first four or five days, but merely raised a little daily, so as to allow the parts to be cleaned. After the wound has healed so much that the opening closely embraces the style, this is to be taken out every morning, the nasal duct injected with tepid water, or some weak astringent solution, and then replaced. The aperture through the integuments into the sac soon becomes fistulous, having no disposition to close. "During the time that the style is worn, the previous symp- toms disappear almost completely. The style dilates the duct in the same way as a bougie dilates the urethra. The tears and mucus, absorbed by the lachrymal canals, appear to be attracted between the surface of the style and the hning membrane of the nasal dnct, and thus the function of the parts being restored, the inflammation, watery eye, and blenorrhceal discharge quickly subside, " It frequently happens that a patient, after wearing a style for three or four months, has it removed, thinking the disease per- fectly cured. After a time, however, the blenorrhrea returns, the style is re-introduced, and the symptoms again subside. After three or four months more, it again becomes a question, whether the style should be removed. The patient often- objects to its removal. He knows the inconvenience of the disease, and the little trouble of the remedy, and prefers continuing the use of the style, rather than run the risk of the blenorrhcea returning. I have known even ladies object to giving up the style, having once experienced a relapse from its removal. "The style should be gold or silver gilt, to prevent it from becoming oxydized, and should have its head japanned of a skin colour, so that it may scarcely be observed, or blackened with sealing wax, so as to look like a little patch. The edges of its head should be rounded off, lest by pressure it cut the skin. It must on no account be left without regular removal and replace- ment. A patient in the lower ranks of life called upon me, with a silver style, which had been introduced by the late Dr. Mon- teath, and which had not been taken out for more than six mouths. It was all but corroded through, about a quarter of an inch below the head. "In one instance, I witnessed profuse bleeding from the nos- tril dnring the day and night after pushing down a style. A short one had been worn, but not reaching the nostril, a longer one was introduced, and was followed by this effect, " It is important to remark, that the style itself is occasionally a cause of irritation. It often is so, for some days after it is first introduced. We are obliged to apply an emollient poultice over the sac, or even to withdraw the style. Months after it has been introduced, and proved highly serviceable, we sometimes find that the patient complains of matter being still discharged by the side of the style. In such eases we should consider how far the style itself is a cause- of this discharge; and if the Meibomian follicles, conjunctiva, and lachrymal passages, appear in every other respect sound, except only in the puro-mucous discharge by the side of the style, let it be gradually shortened, and at length removed, and a trial made whether every thing will not, now that the passage is patent, go on as it ought to do. "By shortening the style bit by bit, we try the state of the lower portion of the duct. If matters go on well with a short style, we may conclude that the passage is healthy, and think of removing it entirely; but if the disease returns under the use of the short style, we must reintroduce one of the original length. When we withdraw the slyie, with the intention of no longer replacing it, the edge of the opening through the integuments must be made raw; for if this is not done, it is apt to contract to an almost capillary fistula, very difficult to close. Sometimes, indeed, this minute callous opening may, in itself, furnish a pal- liative cure for chronic dacryocystitis. A lady consulted me, who had long been under the care of Dr. Monteath, for blenor- rhcea and relaxation of the sac. She had worn a style for a length of time, but without a cure being effected. Dr. Monteath proposed laying open the sac and stuffing it, as is recommended in certain cases by Scarpa, but the patient declined this. The style was removed, the opening did not close, but continued patent for years; mucus continued to collect in the sac, and kept it greatly dilated; the eye was strong, and the patient thought nothing of the inconvenience of being obliged several times a day to press out the mucus through the callous orifice."* Mr. Liston, after the tube is worn for a short period, directs the style to be taken away entirely, the passage being kept clear by the occasional introduction of a probe or sound from the side of the nostril; or causes the patient to wear for some time, during the night, a very small style, which there will seldom be any difficulty of inserting through the minute and almost impercepti- ble fistulous aperture that remains in the front part of the sac. Permanent dilatation with a tube, the wound cicatrized above it. This is an old practice which was revived by Dupuytren, and has since been extensively employed. It consists in the intro- duction of a small gold or silver gilt tube into the canal through a puncture of the sac, which is allowed immediately to heal, as in the case of the wound after venesection. The tears find their way at once by the'cavity of the tube, and the epiphora ceases. In the lapse of time — weeks, months, or even years, as it may be ■ A Practical Treatise on the Diseases of the Eye, by Wm. Mackenzie, M. D. London, 1840, p. 256-8. OPERATIONS PRACTISED UPON THE EYEBALL AND ITS ACCESSORY ORGANS. 187 — the tube gets loose in the duct, which has become enlarged in consequence of its presence, and falls finally into the nasal fossa, from whence it is readily expelled. This may be the result in fortunate cases, but it by no means invariably follows. The tube may fall prematurely, and before the dilatation had been pro- tracted for a sufficient length of time to remove the stricture of the duct, thus rendering it necessary to repeat the operation. Occasionally it has been found so loose as to rise up when the nose was blown, and become by its pressure against the top of the sac a source of so much irritation, as to require to be cut down upon and removed. To obviate these inconveniences various modifications have been given to its form, rendering it more bulbous and irregular on its surface, so as to prevent its too easily sliding in either direction. Occasionally it happens that the very presence of the tube in an inflamed cavhy like that of the sac under circumstances requiring the operation, has been a cause of so much irritation as to require its speedy removal. To obviate this necessity J. Cloquet and Malgaigne, after the puncture .of the sac, dilate the passage for a few days with a mesh or sound, before the tube is introduced. The tube has been known many times to descend, so as to press by its lower end and excite ulce- ration through the palatine arch. It has in a few instances given rise to such inflammation as to produce a carious condition of the delicate bones about it. The tube itseif is exceedingly liable to be choked up with mucus from the side of the sac, by calcareous concretions within its cavity, or by snuff" on the side of the nos- tril, when the tears must find their way by its side, as in the case of the style; the good which it then eff"ects accruing only from the dilatation, as in the case of the latter instrument. The comparative merits of the two instruments have not yet perhaps been fully decided. With the tube the operation is rapid, but little painful, and at once finished. There is no deformity left, and though there is some risk of the contrary, it may be fol- lowed with no further trouble or inconvenience. The tube is not, however, suited to cases where there is much thickening or ulceration of the sac, as the parts will not under these circum- stances close above it. With the style there is a mark for obser- vation left upon the cheek, the cure may be less complete or followed even with a fistulous nicer of the sac, but the operation is unattended with risk, and the instrument is always under the control of the surgeon — a circumstance which weighs strongly in its favour with the profession. Mr. Travers, who asserts that he has introduced the tube fifty times with excellent success without having been required to remove it in more than two instances, nevertheless, for reasons analogous to the above, gives preference to the mode of cure by the style. The process of Dupuytren for introducing the tube is as fol- lows; — The instruments required are, 1. A tube (PI. XLIV, fig. 6, e.) three quarters of an inch to an inch long, slightly curved, and tapering gently to its lower extremity, which should be bevelled on the side corresponding with the concavity of the curve. At the top it should be furnished with a rim to lodge against the surface of the os unguis, a sixth of an inch in diame- ter, and diminish to about half the same dimensions at its lower end. 2. A mandrin or steel stilet for introducing it (fig. 3), with a handle joining it at an angle of 125 degrees; and 3. A narrow- bladed bistoury (fig. 2). The tube should in addition have a groove sunk along the inner side of the head for the purpose of affording a hold to a small hook or a bifurcated spring stilet, with a catch at each extremity for the purpose of withdrawing it if such a measure should become necessary. The sac having been punctured, as in the process of Petit, the tube, carried on the mandrin, is glided along the groove on the back of the bistoury into the upper orifice of the nasal duct. The bistoury is then gradually withdrawn, and the tube finally carried through the sac completely into the duct, upon the orifice of which the rim is to rest. Pressure is then to be made with a finger nail upon the lower part of the sac, so as to allow the mandrin to be withdrawn without raising the tube. If, on causing the patient now to blow through the nose, a few drops of blood appear in the nostril, or some blood mixed with air escapes from the wound, the operation has sticceeded. If these signs do not appear, the instrument has made a false passage, or it is sunk too deep, or the curve does not hold the proper direction of the duct. In the first case the tube must be withdrawn and introduced anew. In the latter it will only require to be raised a little in the sac, and turned to its proper position. The operation being done, the wound is to be accurately closed with a piece of court plaster; the patient may resume his usual occupations, the course of the tears is re-established, and in a few hours all sensation of uneasiness at the angle usually subsides. It may be mentioned here that Pouteau has proposed to open the lachrymal sac by an incision different from that of Petit, though the suggestion has not to any extent been carried into practice. His object was the avoidance of a scar upon the face, 'but the plan proposed incurs the risk of a still greater deformity in the infernal canthus. He directs the internal canthus to be drawn inwards, and the lower lid depressed. The bistoury is then to be passed in between the earuncula lachrymalis and the border of the lid. By the plan of Petit no very obvious mark of deformity follows — unless the operator should be so ignorant or heedless as to divide with the bistoury the round tendon of the orbicularis muscle. This result has occurred in one instance within my knowledge, and was attended with singular deformity. The internal canthus being loosened in a great measure from its attachments, it was started a little outwards by the orbicular muscle towards the middle of the orbit. By cauterization. This is a practice of ancient date, which has been latterly revived, in consequence of the advantages alleged to attend the treatment of strictures of the urethra by the same means. But the analogy between the cases of obstructions of the two organs is only approximative, and the results Ibllowing the use of caustic for the cure of fistula lachrymalis have proved as often injurious as useful. Cauterization has been employed from above downwards, after puncture of the sac — and from below upwards through the lower orifice of the nasal duct. 1. Cauterization after punciure. Process of Harneng. — A small conducting tube is introduced into the nasal duct. Through this is passed down a heated stilet, or an instrument with a vertical groove, charged with 18S SPECIAL OPERATIONS. argentum nitratiim. The inflammatory symptoms which follow are to be treated as under ordinary circumstances^ the process has commonly to be several times repeated. Caustic potash has in a similar manner been introduced, and very serious conse- quences have followed the rashness of the practice. 2, Cauterizaiion from below iipwa7'd. It has been done by M. Bermond, by attaching the thread of Mejean (sec page iS3) to a seton covered with a caustic paste. The only method of, cauterization entitled to any credit as a means of cure, is the following, and by which it has been said considerable success has been obtained. Process of Gensoid. — The instruments employed are those already described under the head of catheterism of the nasal duct (page 182). A porte-ccmstique^oh^xT^GA with the nitrate of silver, which is securely lodged in the little cup by being, por- phyrized over the flame of a candle, is introduced through the curved tube which has been previously passed into the duct^and applied to the seat of stricture. The operation requires to be frequently repeated, and may be aided by the occasional use of the sound as a dilating body, and by injections thrown up through the tube. FORMATION OF AN ARTIFICIAL CANAL. This was a method in common use with Celsus and the Ara- bian surgeons before the structure of the lachrymal passages was ■ well understood. It is now employed only as a dernier resort in cases of absence of tlie nasal duct, or when it has been oblite- rated by a diseased condition of the bone, or by the efi'usion of iymph between the opposite surfaces of the duct. A new canal has in some instances been spontaneously esta- blished by the ulceration of the os unguis, through which ihe lachrymal secretion passed readily into the nose. Three methods have been devised for the ibrmation of the new passage. 1. By perforation of the OS unguis. 2. By the maxillary sinus. 3. By the old route of the duct or at least in its direction. 1. Through ihe os unguis. — This is the process of the older surgeons, who made the opening through the bone with a heated iron, a trocar, or the end of a quill. The sac should be freely laid open in the ordinary manner, and lo render the operation at all likely to succeed, it will be necessary, in order to prevent the subsequent closure of the new opening which is likely to happen, lo remove a portion of this delicate bone, and introduce a gold tube, bulbous at its two extremities, which is to remain permanently, and over which the wound is to be immediately closed as in the process of Bupuytren. To remove the piece of bone, Jno. Hunter recommended the use of a punch with a plate of horn or wood passed up through the nostril to serve as a point of resistance. But this method may be considered imprac- ticable in consequence of the shape of the nasal fossa. The removal will be much better accomplished, and without fracture, by the ingenious instrument of M, Fabrizi, of Modena, for the perforation of the membrane of the tympanum. 2. Through the maxillary bone. Process of Picot and Laugier. ■ (PI. XLIV. fig. 4.)— The mandrin of Dupuytreu, (fig. 2,) or a small trocar, similarly bent at an angle, is to be passed down upon the groove of the bistoury afier the puncture of the sac. When the point has entered as far as it will into the duct, break through into the sinus by carrying the handle of the instrument upwards in the direction of the middle of the frontal suture, and enlarge the opening by movement with the point before its withdrawal, A tube is subsequently to be introduced. The operation has not, however, been employed intentionally on the living subject, and it is not known how the presence of the tears would be borne on the lining membrane of the sinus, or how great would be the risk of inflammation and caries. In the direction of the natural duct. Process of PVathen. — An opening is to be made as much as possible in the direction of the duct, with a small drill, which is to be introduced through a puncture previously made in the sac. The gold tube of Bupuy- tren is then to be introduced and firmly fixed through the new made passage, and the wound immediately closed above it. This method, it is said, has been employed in one instance, with entire success by Bupuytren. In a case somewhat similar, M. Malgaigne succeeded in making a perforation in the direction of the natural passage by forcing down the steel mandrin of Bu- puytren, for the introduction of the tube. The gold tube of Pellier, with an enlargement at each end, was inserted as usual to keep the passage open. From the little resistance encountered in making the new passage, it is very probable that in this case of Malgaigne, the occlusion of the duct was owing merely to the inflammatory adhesion of the inner surfaces of its lining membrane. OBLITERATION OF THE LACHRYMAL PI;NCTA AND CANALS. This obliteration may be either congenital, or which is much more frequently the case, the result of long continued inflamma- tion of the margins of the lids. It is an aflection exceedingly diflicult to remove, and for which no method of treatment yet devised has given very satisfactory results. 1. The imperforalion or atresia of the puncta, is usually con- genital, A thin pellicle is found closing the orifices, the position of which is marked by a slight depression, the construction of the canals below usually being perfect. It suffices in these cases to pierce the pellicle with a needle after the manner of Hiester, and keep the orifice open for some time with a fine metallic thread, or a slender piece of catgut. If any little fungous growths arise about the orifice, they are to be repressed by the application of astringent washes, or by being lightly touched with lunar caustic. When the obliteration is the result of chronic inflammation, or is occasioned by ulceration from the injudicious use of the instruments of Anel and Mejean, the same method is to be pursued, but the cure will be more uncertain. 2. Obliteration of the lachrymal canals. — This njay likewise be either congenital or acquired. That which is acquired as a consequence of disease, occurs usually only in the passage of the lower lid. In a case of double obliteration, J. L. Petit is said to have completely restored the canal of the lower lid, that had been closed only at a few points, by the introduction of a fine gold thread, which was allowed to remain until it moved freely in the passage. Where no remains of the canal can be discovered, it has been proposed to form a new passage from the border of the lid to the lachrymal sac. OPERATIONS FOR VARIOUS DISEASES OF THE EYELIDS. Pellier made the perforation from witliout inwards, and relied upon the use of simple injections to keep it open. Monro pro- posed to open the sac and make the perforation from within out- wards, a measure certainly not likely to be followed by much benefit. Malgaigne advises the use of the elastic dart stilet of Manec, (PI. XLIV. fig. 2, A,) which is to be passed through the catheter of Gensoiil, previously introduced from the nose into the sac, and then pressed forward so as to penetrate as nearly as pos- sible in the natural direction of the canal, from the sac towards the free edge of the iid. The process of Pellier is perhaps of all the most rational. But none of these measures have been suc- cessful in my hands except where the obliteration has been slight. Besides the difficulty attending the first formation of the canal, it is scarcely probable that it should ever become endowed with the active absorbing function of the natural passage. Operations to tffect the obliteration of the puncta and sac. — It has been observed in some obstinate cases of fistula lachry- malis, incurable by the ordinary means of treatment, that the epiphora has gradually ceased after a destructive inflammation of the sac, the lachrymal puncta and canals. This led the two Nanoni, father and son, to open the sac with the knife and oblite- rate its cavity. The one effected the obliteration with the actual cautery, the other with a mixture of alum and precipitate. This is a measure, however, which the surgeon should not lightly undertake, so great is the uncertainty of its being followed by atrophy of the gland. Bosche recommends under such circumstances, the obliteration of the puncta by exciting ulceration with a pointed slick of lunar caustic, a process which seems entitled to a preference over that above described. For if the sac remained of its full size, and should afterward fill up with its secretions so as to form a muco- cele, it might be laid open and dressed with stimulating sub- stances like an ordinary cyst. I have had under my care during the past year, a young gen- tleman with a congenital deficiency of the sac and its nasal duct, the puncta and lachrymal canals being perfect, and communica- ting together at the interna! canthus of the eye. In this case, a style inserted in the usual manner and worn during nine months, has established a passage to the nose, and removed all the inconvenience arising from the epiphora which had been troublesome from childhood, except when the eye becomes sud- denly exposed to (he influence of a cold wind or is otherwise unduly excited. In some instances, after the treatment of fistula lachrymalis with the nail-lieaded style of Ware, a considerable difficulty is en- countered in efl'ecting the closure of the fistulous orifice through the skin. If the use of caustic to the edges, compression, and the application of a heated needle, should fail in effecting the cicatri- zation, it may be closed by excising its edges with the point of a small bistoury, and engrafting upon it after the manner of Dieffen- bach, a piece of skin raised from the adjoining surface of the nose, but left attached at one point so as to keep up its supply of blood. The flap should be fastened with a few stitches, and cold applica- tions kept assiduously applied for the first few days. The wound on the side of the nose should be allowed to close by granulation, JEgylops or Anchylops. — This is an abscess at the internal angle of the eye, immediately in front of the lachrymal sac, but 48 without involving the apparatus for the transmission of tears. The ulcer which it occasions in its second stage, gives to the eye somewhat the appearance of that of the goat, from whence the disease has received its name. In its first stage it may readily be mistaken for lachrymal tumour; it requires, however, a very diff'erent mode of treatment. If the nature of the disease he not recognized, it may, in the end, not only excite ulceration of the skin, but open also backwards into the lachrymal sac so as to establish a fistula of that organ. In its early state, the eegylops may be readily distinguished; the seat of the disease is superficial, and accompanying it there is redness of the skin and conges- tion of the subcutaneous cellular tissue, whilst the flow of tears continues uninterruptedly along their proper channels. In this first stage, recourse must be had to local depletion by leeches, the use of emollients, and the employment of the antiphlogistic regimen. As soon as matter forms, it is to be evacuated; and if the practitioner be not called to the case till it has advanced to suppuration, the diagnosis will be rendered obscure in conse- quence of the collection of pus pressing upon the sac so as to pre- vent the passage of injections, or the introduction of the probe of Ane! through its cavity. The character of the pus discharged by puncture will assist to disclose its seat— for if it does not come from the sac, it will be unmixed with mucus; and in gene- ral, it will be found that the sac, as soon as relieved from the compression, will admit the passage of the injected fluid from the puncta to the nostril. After the pus of the ^gylops is dis- charged, the abscess is to be dressed with dry lint, touched, if its edges become fungated, from time to time with caustic, and the thin edges of the ulcer subjected to gentle but steady pressure, by the aid of a small graduated linen compress and a monocuhis bandage. The administration of tonics will also in general be required. OPERATIONS FOR VARIOUS DISEASES OF THE EYELIDS. These consist of Ectropion, Entropion, Trichiasis, Distichiasis, Blepharoptosis, Adhesion of the Lids, Tumours of the Lids, Coloboma Palpebrs, and Epicanthis. ECTROPION. In this aff"ection the lid is drawn away from the eyeball, its lining membrane more or less everted, and the ciliary margin displaced upwards or downwards according as the seat of the deformity is in the upper or lower eyelid. In a great majority of cases it is, however, confined to the lower. When it involves the upper lid so as to keep the eye permanently open, it consti- tutes the disease which has been called lagophthalmia or oculus leporinus. There are three principal varieties of Ectropion. 1. One, and the only variety which may be considered acute, depends upon an inflammatory swelling of the conjunctival membrane which presses upon the lid so as to cause its eversion. 2. One, which depends upon the morbid contraction either of the lid itself or the surrounding integuments. This occurs frequently after burns or ulcers, the eversion then being produced either by the short- ening of the skin or by a loss of its substance. 3. One, which SPECIAL OPERATIONS. depends upon caries or tumour of the margin of the orbit, by ■which the lid is pressed off from the eyeball and everted. 1. Of eclropion by tuviefaction of the conjunciiva. — In its recent state this affection may usually be cured without any form of cutting operation, by resorting to the ^lsual modes of treatment for conjunctival inflammation, conjoined, when the case proves more obstinate, with the use of lunar caustic or the mineral acids, so as to whiten for the moment the surface of that membrane, and dispose it to contraction. But when the disease does not yield readily to these means, or the tumour is very considerable, or of long standing, one of the following operations is to be employed. The method of operation is varied according as the seat of the alteration is confined to the conjnnctiva~or when there is, in addition to this, as often occurs iu the progress of the disease, a preternatural lateral elongation of the skin of the lid and the tarsal cartilage, so that if the lid was restored to its proper po- sition it would not adjust itself accurately over the ball. For the first, a simple excision of a part of the thickened and sarco- matous conjunctival membrane will suffice — but in the case of the latter complication, it will often be necessary to excise also a portion of the substance of the lid, including the tarsal cartilage. Excisio7i of the conjttnctiva. — This is an ancient and simple process. The patient is to be seated with the head inclined backwards. The lid is to be depressed or elevated according as it is the lower or upper upon which we act. With a pair of good flat forceps, raise upon the middle of the conjunc- tival tumour a portion just sufficiently large to bring the cilia to their proper direction, and excise with a pair of scissors curved on the flat, or a small scalpel, a portion of an elliptical shape PLATE XLV.— OPERATIONS FOR ECTROPION AND BLEPHAROPTOSIS. ECTROPION. Fig. X.—Excision of the middle portion of the tarsal cartilage for the cure of ectropion of the lower lid. {Method of IVelkr.) Figs. 2, 3. — Excision of a triangular or V shaped piece of the lower lid for the cure of the same affection. (Process of Dorsey and Sir TV. ^dams.) In fig. 2 is represented the mode of removing the piece, A first incision has been made on the side next the outer canthus, and the forceps and scissors are seen applied for the purpose of making the second cut. In fig. 3, the triangular wound left has been closed with the twisted suture, so as to turn the shortened lid inwards in its proper relation with the ball. {Figs. 4,5.) CURE OF DOUBLE ECTROPION. {Process of Dieffenbach.) In fig. 4, an incision slightly curved has been made through the integuments of the upper lid down to the conjunctiva. The conjunctiva is shown drawn out through the wound for the purpose of having a portion of it removed with the scissors. In fig. 5, a similar operation is represented as having been performed on the lower lid. The cut margins of tlie conjunctiva are to be attached to the lips of the cutaneous wound with harelip sutures. The lower lid is seen raised by the shortening of its conjunctival lining to its natural position. BLEPHAROPTOSIS. Figs. 6, 7. — Eemoval of an elliptical portion oj skin from over the superciliary ridge and the tipper part of the eyelid. {Process of Hunt, of Manchester.) In fig. 6, the portion of integument is represented as removed with the knife, exposing the fatty layers below, and some of the muscular fibres over the superciliary ridge. In bad cases of blepharoptosis, I have found it necessary to remove a larger portion of the integument of the lid than is here shown in order to render the operation completely successful. In fig. 7, the lips of the wound are seen united by three harelip sutures, which raise the upper lid and open the eye. The lower segment of skin gets an attachment after the cure to the muscular fibres over the orbit, so that the lid can subsequently be raised at will by the action of the occipito-frontalis muscle. The use of the common interrupted suture has appeared to me to be attended in these cases with less irritation than that of the harelip pins. Figs, g, 9. — Excision of an elliptical portion of skin from the middle of the outer surface of the lid. (Ordinary process, suited to less extreme cases of blepharoptosis or palsy of the levator muscle of the lid,) In fig. 8, a longitudinal fold of skin is seen raised with a pair of forceps, so that it may be removed at one cut with the scissors. In fig. 9, is represented the closure of the wound after the removal of the skin. OPERATIONS FOR VARIOUS DISEASES OF THE EYELIDS. 191 parallel with the free border of the lid, culling from the external towards the inner canthus. The piece removed should be nearer the ball than the free edge of the lid. The subsequent treatment is to be the same as in ordinary acute ophthalmia — except that the bleeding from the woupd will obviate the immediate necessity of local depletion. Benefit will often be derived after the bleeding has ceased by bringing the cilia towards the ball by a strip of adhesive plaster, and supporting the parts with a compress and monoculus bandage. Excision of a ivedge-shaped piece of the loimr lid. [Process of Dorsey and Jldams. PI. XLV. figs. 2, 3.) — This is usually employed in addition to the excision of the conjunctiva; but in cases where the deformity arises merely from the lateral elongation of the lid, the operation in question alone is needed. This consists in the removal of a wedge-shaped piece comprising the whole thickness of the lid, the base of the piece corresponding to the free margin, and the apex descending a iittle below the inferior border of the tarsal cartilage. The breadth of the piece should be such as will reduce the margin of the lid to the proper length, and cause it to rise up to its natural position. The excision should be made rather towards the external canthus than in the middle of the lid, in order to render the mark of the cicatrix less appa- rent, and interfere less with the movement of the organ. Having determined on the size of the piece to be removed, the surgeon lays hold of the Hd with a pair of forceps, and draws it out from the ball. With a pair of strong straight scissors he cuts out the piece completely at two strokes—one on either side of the scis- sors — the two meeting below at an acute angle; or if he prefers, he may, in making the second cut, take a new hold of the lid, and apply the scissors on the outer side of the forceps. The lid is then to be restored to its proper position, and the edges of the wound united with two twisted or interrupted sutures. The first suture should be passed close to the ciliary margin, at the distance of about the tenth of an inch from the cut surface, in order to render the edge of the lid even. The other is to be introduced lower, and "the lid supported with strips of adhesive plaster and a compress and bandage. The pins should be removed on the second day, lest they should cut out and produce lateral cica- trices. Excision of the conjunctiva through the skin. [Method of Dieffenbach. PI. XLV. figs. 4, 5.)— This may be applied upon either lid. The object of the process is to remove a portion of the conjunctiva, and attach the edges to the skin by a common cicatrix, so as to prevent its subsequent morbid elongation. It is done as follows: — The inverted lid being placed as much as possible in its natural positiou, the operator makes with a short straight bistoury, about a quarter of an inch from the ciliary margin, a semilunar incision of the skin, parallel with the edge of the lid, and occupying the middle two-thirds of its length. He next dissects the skin down a iittle towards the free edge of the lid, and divides the orbicularis muscle and the adjoining conjunc- tiva parallel with the orbital edge of the tarsal cartilage, to the same extent with the previous wound. Through this opening he seizes with a pair of forceps the cut edges of the palpebral con- junctiva and the tarsal cartilage which is adherent to it, and draws that membrane out through the wound. The redundant portion of the mucous membrane is then excised above the level of the skin. The margin of the ]id is at the same time turned in by the traction on the membrane, so as to have its proper rela- tion with the ball. The wound is now to be closed with the twisted suture, the pins fastening together the two lips of the cutaneous incision and the included portion of conjunctiva, which is rendered raw by the previous incision. The pins are to be twisted outwards at their extremities, and cut off near the threads. They are to be removed between the third and sixth days, according to the judgment of the surgeon. After the cure a linear cicatrix only is left. This is an ingenious operation. It may, however, be observed that it is not in any way better calcu- lated to remove the deformity than the simpler method above described. Partial excision of the tarsal cartilage. [Process of Weller. PI. XLV. fig. 1.) — It has been observed that in old cases of ec- tropion, the tarsal cartilage is elongated with the other consti- tuents of the lid. This surgeon, in order to bring it to its proper dimensions, after the excision of the hypertrophied conjunctiva, removed with the bistoury or scissors about a third of an inch of the middle part of the cartilage, so managing, however, as to leave at this point the palpebral margin of the cartilage entire, by splitting it near the edge. This operation resembles that known under the name of the .process of Antylus, It leaves no cicatrix upon the surface of the lid, but is not on the whole deserving of so much reliance as the process of Dorsey and Adams already described. We meet frequently with cases of excoriation and shrinking of the skin of the lid, accompanying and aiding in the first form of ectropion, which is kept up by the irritating secretion from the diseased membrane. This complication requires the same treat- ment as mentioned on the last page, with the addition of the ap- plication of the oxide of zinc ointment to protect the excoriated surface, and restore it to a more healthy condition. Cases of partial eversion are also occasionally met with in old subjects, the conse- quence either of palsy of the ciliaris muscle, or a relaxation of the palpebral ligaments that attach the tarsal cartilages to the two canthi, for which iittle can be done except by medical treatment. 2. Ectropion from shortening of the skin, the consequence of bad cicatrices. This may affect, 1st, either lid singly according to the site of the cicatrix; or,Sd, it may afiect both — especially if the injury be upon the temple near to or involving the outer canthus. In the variety of ectropion now under consideration, the eversion is generally very complete : sometimes when a single lid is affected the ciliary margin is found drawn downwards so as to be lost in the cheek, or upwards so as to occupy the position of the eyebrow. Ectro- pion of the upper lid, as will be obvious, leaves the eyeball more exposed than ectropion of the lower. If it be caused by a cicatrix on the side of the temple, the canthi may be drawn outwards, and one or both of the lids at the same time more or less everted. Of the eversion of the free margin of the lids. Method of Cheliits. >/J modification of the old operation of Celsus. — An incision is to be made through the skin along the whole breadth of the eyelid, and as near its tarsal edge as possible. The edges of the wound are to be dissected from the subjacent cellular tissue, so that all tension of the skin may be removed, and the 192 SPECIAL OPERATIONS. eyelid brought into its natural position. The fibres of the orbi- cularis are then to be divided by several vertical incisions, and if the tumefaction of the conjunctiva is so great as to interfere with the replacement of the lid, a portion of it is to be snipped away with the scissorSj and the external commissure of the eyelids slit up to the extent of some lines in a horizontal direction. Two loops of thread are then to be drawn through the skin near lo the tarsal edge of the lid, and the ends secured with sticking plaster to the cheek or forehead according to the lid atTected. By these means the eyelid will be kept in its proper relation with the ball. The wound of the eyelid and that of the canthus are to be covered with charpie, which is to be sustained in its position widi strips of adhesive plaster. No other dressing is to be applied. This process is said by Professor Chelius, even in cases of very consi- derable shortening of the skin of the lid, to have been successful beyond expectation. If there is accompanying the deformity a considerable transverse elongation of the tarsus, the removal of a wedge-shaped portion in addition, after the plan of Adams, might be practised with advantage. Process of T. Wharton Jones."^ — The peculiarity of this plan, accordingto its author, consists in the following particulars. "The eyelid is lo be set free by incisions in such a way, that when brought back into its natural position the gap which is left may be closed by bringing its edges together by suture, and thus obtaining immediate union. The flap of skin embraced by the incisions is not separated from the subjacent bone; but advantage being taken of the looseness of the cellular tissue between the skin and the bone, the flap is pressed downwards, and thus the eyelid is set free. The success of the operation depends very much on the looseness of the cellular tissue. For some days before the operation, therefore, the skin should be moved up and down over the frontal bone, to render the tissue more yielding." The operation was done as follows (on the upper eyelid). "Two converging incisions were made through the skin, from over the angles of the eye upwards to a point where they met, somewhat more than an inch from the adherent ciliary margin of the eyelid. By pressing down the triangular flap thus made, and cutting down all opposing bridles of cellular tissue, but without sepa- rating the flap from the subjacent parts, the eyelid was brought down nearly into its natural situation, by the mere stretching of the subjacent cellular tissue." A piece of the everted conjunctiva is also to be snipped olf, and in some instances it will be neces- sary to take away a piece of the tarsal cartilage, in order to bring the free edge of the lid in its proper relation with the ball. The edges of the gap left by the drawing down of the flap are to be closed by suture, and the eyelid retained in its place by plasters, compress, and bandage. This operation has been several times repeated, but with very variable results. Sanson modified it by dissecting completely up to near its base the long V shaped flap. He then drew the lid at once to its proper position, united the two edges of the open fissure by suture, and left the flap loose, with the intention of removing at a later period all the redundant portion. Method of Dieffenbach. Employed in eversion of the loiotr lid.~llQ includes the cicatrix in an incision of a triangular shape, • Cyclopedia of Practical Surgery, art. Ectropiam. London, 1841. and dissects it away — the base of the triangle being towards the ciliary margin of the lid, and concentric with it; the apex directed downwards. He then extends the line of incision which forms the base of the triangle, by another short incision at each end in the form of a crescent, and directed slightly downwards. Two lateral portions are thus marked out on the sides of the triangle, which are to be loosened a little by dissection, brought over to- wards each other, and secured together in the middle line by four or five small twisted sutures. As they come together they press up the remains of the lid, to the divided skin of which they are to be attached by their upper surfaces, iluis being made to supply with new skin the place of the old cicatrix. This method by itself has not in my hands proved satisfactory. But in some bad cases of ectropion, I have found it highly useful conjoined with the excision of the wedge-shaped piece after the manner of Adams.* Process of HornerA — Professor Horner has succeeded in re- lieving a case of ectropion of the lower lid by the following operation: — The whole tarsus was permanently everted, the con- junctiva of the lid exposed nearly half an inch in breadth, and inflamed, ulcerated, and thickened. "An incision, two inches in length and down to the bone was made parallel with and at the inferior margin of the orbicularis muscle. The whole thickness of the eyelid was then dissected up from the adjoining bones. From about the middle of that incision started another, of an inch in length, downwards towards the angle of the jaw. From the termination of the latter another incision of the same length was directed towards the root of the nose. The last two incisions consequently defined an angle of integuments, which, being dis- sected up as far as its base, was then turned into the beginning of tiie first incision. "An almost immediate correction of the deformity ensued. Common dressings were put on, and at the end of two weeks the cure was accomplished, with the exception that the margin of the lid was rather loose, but still leaving the prospect of that being corrected by a natural process of shortening in due time. The patient, in fact, was so far well, that he was discharged from the wards a week or two afterwards." The above processes will answer in many of the cases of ectropion which occur from shortening of the integument. But in the more extensive cases of deformity, where the lid has been in a great measure destroyed, or it has been requisite to remove it on account of lupus or cancer, it is necessary to reconstruct the lid by one of the plastic processes detailed in Part Fifth of this work. It may be well to observe, that whenever we can at the same time preserve the ciliary margin of the lid and lift it iip to its place so as to form with it one line for the attachment of the flap, the result will be rendered more satisfactory. On the lower lid, the deformity will be found more readily removed than on the upper. For in regard to the upper, thongh the substituted Hd may serve to cover and protect the ball, it cannot ordinarily be made to play upwards and downwards, as it will want the muscular structure necessary to the execuiion of these movements. " Vide Amer. Jonrn. of Med. Sciences for 1 842. f Vide ditto, Nov. 1837, for a communication by W. E. Horner, M. D. OPERATIONS FOR VARIOUS DISEASES OF THE EYELIDS. 193 Eversion of the external commissure and the outer part of the lids, the cotisequence of a cicatrix in the region of the temple. — A difterent method of operation is required in this spe- cies of ectropium. Tarsoraphy. Process of JValther. — This surgeon excised the tarsal edges of both eyelids including the commissure and a part of the neighbouring integument, in the form of a V shaped flap, the base of which was towards the eye and the apex to- ward the ear. The piece was about tliree-eighths of an inch broad at its base. The wound was closed with two harelip sutures. In a case of extreme deformity of this kind, [ practised with entire success the following modification of this process, sug- gested by Dieff"enbach. After the removal of a large wedge- shaped piece, two semilimar incisions were carried from the cut edges of the Uds — one upwards and inwards — and one down- wards and inwards. The two cresceniic flaps thus marked out were then raised, and after the closure of the wound in the temple, adapted as new lids to the remaining conjunctiva. 3. Ectropion from caries of the orbit and from tumours. In eversion occasioned by carious ulceration of ihe margin of the orbit, no attempt is to be made to relieve the deformity by operation until the cure of the bony structure has been effected. It will usually then be found necessary, in consequence of the destruction of the lid, to resort to one of the plaslic processes for relief. Dr. Ammon has observed that considerable deformity is sometimes produced when but a small part of tijc skin is tucked in and rendered adherent to the bone. In such cases, without removing the little cicatrix, he circumscribes it by an elliptical wound, and detaches the neighbouring integuments by dissection from ihe lines of incision so as to set the lid free, and allow it to take its proper shape. Tiie wound is then closed over the old cicatrix. Wlien ectropium depends upon the presence of a tumour within or below the lid, the removal of the tumour by extirpa- tion or otherwise, is the obvious means of cure. ENTROPION, OR INVERSION OF THE EVELID. This affection involves most frequently the upper lid, is exactly the reverse of the one described under the name of ectropion, causes greater suffering than the latter, and is much more apt to be attended with an impairment of the vision. Tlie free margin of the lid with its cilice are turned inwards upon ilie eyeball, and from the friction they exert upon it, keep it in a continual state of irritation. In trichiasis, the eyelashes only are inverted upon the lid, without any morbid change of the tarsal cartilage; but in entropion, the cartilage is inverted to a greater or less extent in the same direction with the hairs. There are two principal forms of entropion— one depending upon a great relaxation of the skin of the eyelid, so that the skin, no longer reacting with the conjunctiva to hold the lid in its proper state of equilibrium, allows it to roll inwards when the mucous membrane sutlers from chronic disease; — the second, upon a contracted and deformed state of Ihe tarsal cartilage, the consequence more usually of ophthalmia tarsi or of protracted 49 scrofulous or catarrhal conjunctivitis, without any preternatural laxity of the skin of the lid. Plence, there are two principal indications for operation,— to restore the margin of the lid to its proper direction,— or If this cannot be accomplished, to destroy the bulbs from which the eyelashes— the cause of irritation— grow. 1. Entropion from relaxation of the integument. In the lighter and more recent forms of this affection, we may frequently succeed in restoring the lid to its right direction by the use of straps of adhesive plaster, conjoined with the employ- men of such other local remedies as the state of the lids may indicate. Use of adhesive straps. — The eyebrow having been shaved, three narrow strips of adhesive plaster are to be attached to the back of the upper lid near its tarsal margin. The lid is now to be raised, and the other ends of the straps stuck upon the forehead in a divergent direction to maintain it in that position. Another strip of plaster, laid crosswise, secures the upper extremities of the three \viiich raise the lid. The eye should be thus main- tained artificially opened for the space of fifteen or twenty days, in order to give time for the establishment of a proper equilibrium between the skin and mucous membrane. The plasters will require to be reapplied every two or three days. Excision of a portion of the integument of the lid. (PI. XLVIII. fig. 2.) — This is a process very commonly practised and suited to the great majority of cases. The portion removed should be of an elliptical shape, and of such a breadth, that when the edges of the gap are brought together, the tarsus will assume its proper direction. The breadth of the piece necessary to be removed, depends upon the state of the parts. In some instances, it has required to be an inch in breadth; but if a portion unne- cessarily broad is taken away, ectropion might follow. Seize between the thumb and middle finger of the left hand, or with a pair of flat-b!aded curved forceps, a told of skin parallel with the margin of the lid, sufficient ly large when thus grasped to bring the lid to its natural position. Having carefully ascer- tained that the fold is of proper dimensions, the operator snips it away with a pair of strong scissors. One line of the incision should come close to the palpebral border, leaving, however, a strip Ibr the passage of sutures. The edges of the wound are to be drawn together by two or three stitches. Langenbeck removes the sutures at the end of twelve hours; Weller, after eighteen hours. Much beyond this period, they should never be left, as they would then have a tendency to excite a phleg- monous cedema of the lids, which might lead to ulceration. For fear of such a result, Scarpa pursued the opposite extreme, and allowed the woUnd to cIo.se by granulation without suture. If the latter course were pursued, the orbicular muscle should be kept depressed by the aid of a compress and bandage as directed by iVIalgaigne. Dzondi has occasionally found it advantageous to add to this transverse excision, another made in a vertical direction. Janson, of Lyons, trusts to the excision of a vertical fold of skin alone, the broadest part of which should be near the palpebral margin. Jiy cauterization. Process of (^«f/f/7*/.— This is particularly applicable to slight and rather recent cases, where the skin is not 194 SPECIAL OPERATIONS. very redundant. The object is to effect a contraction, or at most a slight ulceration of the surface of the skin. The escharotic most frequently employed is the concentrated sulphuric acid. But either of the mineral acids, or one of the solid forms of caustic, may be made to answer. The lid is to be carefiUly cleansed. The eye is tlien to be closed, and held in that position by a narrow strip of adhesive plaster laid along its longitudinal fissure, in order to prevent the introduction of any portion of the caustic between the lids. By means of a pencil of wood, a drop of the acid is to be rubbed over an oval portion of the integument, for an extent propor- tioned to the degree of inversion, and about a quarter of an inch ,in breadth at its middle. Care must be observed to keep the acid at the distance of at least the tentli of an incii from the edge of the lid. After a few seconds the eyelid is to be dried with a piece of lint, and the application of the acid repeated again and again, until a sufficient contraction of the skin is produced to restore the eyelid to its proper direction. The lid is then to be washed and dried, and (he plaster removed. It may be necessary after a time to repeat the application of the acid. It has also been directed that tiie straiglitened cilia should be collected into little bundles, around which fine silk ligatures should be passed, and the ends fastened down upon the cheek; in order to retain the edge of the lid iu its proper position. But this is a step not likely to be at- tended with much advantage. ' 2. Inversion from a contrucled and deformed stale of the airtilage. In this variety of entropion, the larsal cartilage is indurated and shortened as well as turned inwards, and cannot by any degree of traction be brought back to its natural position. The margin of the lid is also in common thickened and uneven, and the cilia, which are few and dwarfish, are turned inwards directly on the ball, adding to the entropion the form of disease called trichiasis. Siitiple section of Ike tarsal cartilage and lid. Process of Wfire and Tyrrel. — As the transverse shortening of the tarsus is the principal cause of this deformity, JVIr. Ware recommended the following operation for its relief, which Mr. Tyrrel states he has performed in many cases, including those of both lids, and in every instance with perfect success. The lid is to be drawn out from the ball, and divided perpendicularly through its whole substance, either at its middle or at its temporal extremity; the middle, except in cases of partial entropion of the outer portion, being preferred. The section is immediately followed by a sepa- ration of the edges of the wound, forming a gap shaped like the letter V. If the lid becomes immediately straight, nothing fur- ther is required, the wound is allowed to heal gradually by gra- nulation, and very little deformity will result. If it should not become straight at the time, or should show subsequently a ten- dency to turn in, an oval portion of the imegument may be removed in addition from the back of the lid, in the manner described at page 193. Double vertical section of the lid. {^Process of Crampton, modified by Guthrie. Pi. XLVIII. fig. 3.)— One vertical incision is to be made with the bistoury or blunt-pointed scissors, through the whole sitbstance of the lid, just at the outer side of the lachrymal punctntn; and the other at about the same distance from the external canthus, in order — as regards the upper lid — to avoid the lachrymal gland. The incisions need not' extend higher into the lid than necessary to divide the tarsal cartilage; the object of the operation being in part to remove this from under the influence of the orbicular muscle. The loosened middle portion of the lid is now to he raised up; if it docs not immediately become straight it is to be nicked by a transverse incision on the side. A transverse fold of integument is then to be removed from the back of the piece, according to the usual process, and the edges of the incision drawn together by three silk ligatures. These are to be left long, and are drawn up — raising witii them the middle loosened portion — and fastened to the forehead by two strips of adhesive plaster. To prevent luiion by first intention in the lines of incision, the piece is kept inverted by means of tlie threads for eight or ten days or imtil they cut 0[it. The incisions are then allowed to heal slowly by granu- lation. During the time the lid is maintained in its elevated position, the ball must be protected with a fold of linen spread with cerate. Tills operation is a serious one, from the apparent havoc which it makes with the lid. It has, however, been praised by Mr. Guthrie as successfid. Excision of the tarsal cartilage. [Process of Satinders. PI. XLVIII. fig. 1.) — Introduce between the lid and the ball a thin plate of horn or silver; over tins the lid should be held tense with a pair of forceps. Divide tiien the integument and the orbicular muscle, just above the roots of the eyelashes, parallel with the margin of the lid, and down to the tarsal cartilage. Dissect up, so as to Iny bare the orbital edge of the cartilage; detach it from the tendon of the levator palpebrie and the conjunctiva, and excise with the bistoury or scissors the part exposed, leaving only the portion next to the palpebral margin, in which are lodged the bulbs of the cilia. The object of the operation was to diminish the vertical diame- ter of the lid, by taldtig from it part of the structure which serves to keep it extended; the author of it believing that the levator would still continue its action, from its connection with the other membranes of the lid. The process was, however, usually followed by deformity, and it is now with great propriety laid aside. The amputation of the edge of the lid, and the operations for the removal or destruction of the bulbs, belong properly to the suliject of trichiasis, which so frequently complicates entropion; under that head they will be considered. TRICHIASIS AND DISTICHIASIS. Trichiasis has already been described as a vicious direction of the eyelids inwards upon the ball of the eye, which may or may not be accompanied by an introversion of the free edge of the tarsal cartilage. It is an aftection apparently of minor con- sequence; but is in reality exceedingly painful, troublesome, and persistent, and may even lead to loss of vision, by causing struc- tin-al disease of the cornea. Distichiasis is ofien congenital, and consists in the multiplica- tion of the rows of cilia, which assume a vicious inclination on the ball. The accidental development of hair (pseudo-cilia) from some part of the mucous surface of the lids, may be considered OPERATIONS FOR VARIOUS DISEASES OF THE EYELIDS. 195 as closely allied to the same afTectiou. Whatever is the cause of the vicious direction of the hairs, and whether or not there is introversion of tlie border of the lid, t!ie indication for removing them and preventing their reproduction is the same. Exh'actian and caiilerizalion. — Tear out one hy one with a steady pull the deviated cilia with a pair of forceps square at the point, roughly ground on their adjoining surfaces, but without teeth. To find the smaller hairs, which are often colourless, a lens will be required. By a repetition of this measure from time to time, the bulbs may become at length atropliied, so as to cease to develop the hair. In general, however, it will be found more certain and satisfactory to proceed at once to cauterization after the extraction of the deformed cilia. For this purpose, the edge of the lid is to be everted, and a small plate of horn or metal introduced between it and the hall. Some apply at once the fine point of a stick of lunar caustic, or the end of a heated needle, to the orifice left by the extracted hairs. Neither can, however, be made to act upon the bulb, which is seated at a little distance from the orifice. It is better, therefore, to open the bulb at once with the point of a lancet or iris knife, and apply the caustic to its interior, so as to destroy the secreting smface. Dr. James Hunter has recommended the inlrodnction of pow- dered tartarized antimony, which is to be collected on the moist- ened end of a darning needle and carried into the sac. Extraction after incision. Tiie lid having been raised on a thin plate as above mentioned, the operator makes two vertical incisions through the skin merely, a sixth of au inch in length, immediately above the free edge of the lid, so as to include be- tween them the bulbs of the deformed cilia, The vertical cuts are to be united by a transverse incision near the edge of the lid, and the little rectangular flap dissected and turned up, so as to espose the bulbs, which are to be torn away one by one with the forceps or excised with the scissors. In case of doubt as to their complete extirpation, the seat of the bulb may in addition' be touched with caustic. .imputation or excision of the tarsal margin. Process of Schreger. — Seize and reverse with the forceps the 3dge of the lid, and remove a semi-elliptical portion of the edge, so as to in- clude the diseased parts, with a pair of curved scissors or a bis- toury. The loss of substance should extend only to the cutaneous border, and not involve the cartilage. The process, however, is justly but little practised. In cases of distichiasis, the extraclion merely of the pseudo- cilia will usually suffice, as there is less likelihood of their being reproduced. BLEPHAROPTOSIS. Ptosis, or falling of the eyelid. This affection consists of the fall of the upper lid in front of the eye, as in a person asleep, without the ability of the patient to raise it. The loss of power may be congenital, owing to a de/ect in the structure of the levator muscle, or in the distribu- tion of its nerve. It may be the consequence of palsy, forming the part of a more extended paralytic aff'ection, or depend solely upon a considerable elongation of the skin of the lid, with a weakened power of contraction in the levator muscle. In the slighter cases, where it is dependent on chronic disease of the lid, we may succeed in removing it by tlie use of astringents, and such other topical applications as the case seems to indicate. If upon a relaxation of the integuments, the process of Quadri, or the excision of an elliptical piece of skin, as directed in page 193, may be resorted to. But if the ptosis be a congenital de- fect, or the consequence of palsy, the process of Hunt, of Man- chester, is the only one that offers much chance of relief, and which has in my own practice proved highly satisfactory.* Process of Hunt. (PI. XLV. figs. 6, 7.) — This process is in- genious. Its object is to attach the superciliary border of the occipito-frontalis muscle to the skin of the lid, so as to make it perform the office of the impaired levator. The eyebrow is to be shaved, and immediately below it a curvilinear incision made, corresponding with the direction of the orbit, and of a length equal to that of the fissure between tiie iids. From the ends of this another incision is to be made, convex in the 'oppo- site direction— towards the free edge of tiie lid. The dimension of the piece of skin thus included must depend upon its state of relaxation, and will sometimes require to be more than an inch in breadth. The circumscribed integument must then be extir- pated with the kiife. I have occasionally removed it at a single cut with the forceps and scissors, as in the common process for entropion. The edges of the divided skin are next to be drawn together with three twisted or interrupted sutures. The eye will be opened hy this forced elevation of the lid; and after cicatrization, the edge of the occipito-frontalis muscle will be found to have contracted an indirect adhesion to the lid, so as to endow the patient with a voluntary power of raising it, while the orbicularis oculi retains its office of lowering it as under ordinary circumstances. ADHESION or THE LIDS. ANKYLOBLEPHARON. SYNBLEPHARON. The adhesion of the lids together at the palpebral fissure con- stitutes the deformity known under the name of ankyloblepharon. Synblcpharon, consists in the adhesion of the lids to that surface of the ball, which is usually free. Either of these may be con- genital, the result of some excoriating disease, or of the ulceration following variola or burns. Both atfections occasionally exist together. In ankyloblepharon, the union may be either direct or by the interposition of a thin membrane. It may be partial, or complete. If the union is only partial, a small director may be passed beneath, and tiie adhesion divided with the knife or scissors. If complete, raise the eyelids so as to remove them from the ball, and make a puncture at the external commissure to allow the grooved director to pass, wliich should be bent to the form of the ball; on the director, the preternatural connection is to be divided with the knife. The lids should then be kept separate till the divided edges cicatrize, by raising the upper one with strips of adhesive plaster as described at page 193. In synblepharon, the union between the palpebral and ocular surfaces of the conjunctiva must be separated by dissection with the knife. A renewal of the adhesion is to be prevented as far as possible, by the introduction of unguents, frequent motion of the lids, and the occasional use of tlie blunt end of a probe. • Vide Phil. Med. Examiner for 1843. 196 SPECIAL OPERATIONS. The acute sensibiiity of the parts forbids the permanent inter- position of any foreign body. TUMOURS OF THE LIDS. There are three descriptions of tumours commonly found in the lids, requiring operation. The encysted, (by far the most common,) the cellular, and the cancerous. The two first are seated in the skin and subjacent cellular tissue. Occasionally, however, they are observed on the surface next the conjunctiva. The other most commonly affects the whole thickness of the lids inclusive of the conjunctiva. Encysted iiimours. — These are the natural follicles of the part, the cavity of which has been enlarged by disease, and dis- tended by the accumulation of their secretions. The size to which they may attain varies from that of a large shot up to a hazelnut. They are to be removed according to the side on which they are most prominent either through the skin or con- junctiva. 1. JExcision by the skin. — Make a transverse incision concen- tric wiih the wrinkles of the Ud over the tumour, extending a little beyond it on either side, but without cutting into its cavity. Separate the circumference of the tumour with the point of the knife, raise it with the forceps or hook, and detach it from its inner connections. The wound is to be united by first intention. I seldom fail in effectually obliterating these sacs when small without excision, by merely pushing the point of a small bis- toury through their centre, and culling afterwards from within outward so as to make a small opening in the skin; through this the contents of the sac are to be pressed out and the point of a caustic pencil or the end of a probe dipped in nitric acid, intro- duced to destroy the secreting surface. When they are large, however, it is best to extirpate them. I recently removed one of the largest size from a patient of Professor Meigs, which had developed itself in the lower lid and sent up two processes, in the furcu of which was lodged the tarsal cartilage; the processes were prominent on both surfaces of the lid, and rose considerably above its margin. • The conjuneliva on its inner face presented a suspicious fungus-like aspect. An attempt to dissect it out niight have involved the integrity of the tarsus and a portion of the conjunctiva. I therefore split it with the bistoury on its cutaneous surface, and detached the irregular- shaped sac from its bed with a couple of pair of forceps and a few touches with the point of the knife. The cure took place with a cicatrix so small as to be scarcely obvious. Excision by the conjunctiva. — Take hold of the cilia, and evert the lid over the finger, or the side of a largo probe, in which position it is to be held by an assislanl. Open the con- junctiva by a transverse incision, and proceed in other respecls to dissect and remove the tumour as in tiie process above described. Tumours of a similar description, and requiring excision through the skin, are frequently found, especially in children, on the tem- ple near the outer canthus of the eye. Little tumours of a like character are occasionally developed on the tarsal cartilage, the result of disease of the Meibomian glands, forming small external swellings, often reddish coloured, on the lids. By everting the lid, the cartilage below will be found thinned and yellower than natural at the point opposite the tumour. It will suffice for the cure to make a puncture through the thinned cartilage into the interior of the sac, and irritate its cavity with the probe. Cellular tumours. — Chalasion. — Grando. — Under this name are comprised little indurated masses seated near the edge of the lid, the result it is said of a hordeolum or stye, which has become hardened without running into free suppuration. They produce chronic irritation of the lids, and often form a small abscess which opens by a fistulous orifice through the conjunctiva, at one of the borders of the tarsal cartilage. They are very analogous to the class of tumours last described, and may be cured by a similar treatment. The plan of Carron du Villards is to dilate the fistu- lous orifice with the point of a knife, and carry on a small grooved director a little lunar caustic into the interior, so as to excite sup- puration. Cancerous tumours. — These if large will require the complete excision of the lid, and the immediate formation of a new one by a plastic process. Cancroid tubercles of limited dimensions occa- sionally form on the lid, and admit of extirpation without de- struction of the organ. I have frequently succeeded in removing tiiem by the application of caustics, and especially by the use of the two mauagable forms, known under the names of the arsenious, and the Vietma paste. In general, however, the acute sensibility of the lid, and the risk of irritating the conjunctiva, render ex- tirpation preferable. If the tumour involve only the skin and subcutaneous cellular tissue, it may be removed by a simple elliptical incision, cauterizingif it bedeemed necessary,in addition, the bleeding surface of the wound. If the tumour occupy the whole thickness of the lid witliout having much breadth, it can sometimes be completely removed by the excision of a V shaped piece of the lid, the base of which shall be towards the palpebral fissure; the divided parts of the lid being subsequently united by the twisted suture, as in the ordinary hare-tip operation. COLOBOMA PALPEBRiE. This term, though usually limited to the fissure of the iris, has been applied to a gaping cleft through one of the lids, the result of an accident by which the lid has been divided through and the edges allowed to cicatrize separately, or consisting, as has in some few cases been observed, of a congenital defect. The operation required will be precisely the same as in hare-lip — the excision of the edges, and closure by the twisted suture. EPICANTHIS. This name has been given by Von Ammon to a congenital peculiarity, which consists in the extension of a crescentic fold of skin from the side of the nose over the interna! canthus of the eye, existing when met with commonly on both sides, and giving to the countenance somewhat of the expression belonging to the Calmuck. The operation performed by Dr. Ammon for the re- moval of these folds, consists in the excision of an elliptical piece of skin over the root of the nose, and bringing the edges of the wound together by suture. The folds, however, usually disap- pear as the child's nose increases in prominence. I have observed an analogous deformity accidentally produced, as a consequence of the loss of the nasal bone by syphilis and ozcena, and have succeeded in relieving it by a similar operation. OPERATIONS FOR DISEASES OF THE CONJUNCTIVA. 197 OPERATIONS PRACTISED THROUGH THE CON- JUNCTIVA. The diseases of this membrane of which we shall treat, con- sist of different Fungous Excrescences, Pingueculaj Encanthis, Pannus, and Pterygium. EXCRESCENCES.— ENCANTHIS.— PINGUECULA. The excrescences of various kinds which form on the tree sur- faces of the ocular or palpebral conjunctiva, are to be laid hold of with the forceps and removed with the bistoury or scissors. As they have a strong tendency to redevelopment, the surface from which they are removed sliould be at once touched witli blue stone or lunar caustic. ■ Encanlhis is the name given to a tumour formed in the mu- cous and glandular structure of the caruncula iachrymalis. It may consist merely of a simple hypertrophy of the part, or a cyst, or a cancerous growth. It must be excised, and, if possible, without doing injury to the lachrymal passages. The Pinguecula is a little yellowish tumour developed over the sclerotic coal. Its nature is not well known. It seems from its colour to indicate the presence of fat, though it contains none. It is not subject to degeneration like the affections just mentioned; but if it becomes inconvenient or unsightly from its bulk, it may be removed by excision. PTERYGIUM. Pterygium consists of a vascular and membranous develop- ment in the subconjunctival mucous tissue. It is triangular in its shape, witii its apex presenting towards the cornea, over which it has a tendency to grow, and covers the insertion of one of the recti muscles. In a hundred out of a hundred and five cases it was found by Riberi* occupying the internal canthus. Its pathological structure is not thoroughly understood. It comes on insensibly and grows very slowly, existing sometimes for years without making any apparent advance — and seems confined to the middle and latter periods of life. It is loosely connected with the ball, but inseparably with the conjunctiva. It first appears under the guise of a few varicose vessels in tiie sclerotic conjunctiva, which it slightly elevates — the vessels being directed parallel with each other towards the centre of the cornea, Pterygium has been usually described as consisting of three varieties, viz. 1. Pterygium tenue, which is thin, semi-transpa- rent, and striated with blood-vessels. 2. Pterygium crassum, which, from its redness, opacity, and consistence, presents the appearance of a thin muscle. 3. Pterygium pinguc, which con- sists of the little masses apparently fetty, described above under the name of pinguecula; as this docs not become red, and has no tendency to spread over the cornea and interfere with vision, it cannot properly be considered as belonging to the disease under consideration. The first and second varieties are evidently mere stages of the same aff"ection, and require no specific differ- ence of treatment. As tiie pterygium, when its point reaches the cornea, becomes " Blepharophthalmo-terapia Operativa, p. 110. 50 stationary, or advances so slow that its progress is almost imper- ceptible during a course of years, it does not require operation, except for the purpose of getting rid of the unsightliness which its presence produces. But when it threatens to advance rapidly over the cornea, or has ah'eady covered this structure so as to impair vision, its removal is more imperative. To effect this when it has resisted the use of the nitrate of silver, the wine of opium, and such other remedies as have been recommended, three processes have been employed — excision, iticision, and the liga- ture—the last two of which have, however, gone out of use. Excision. (PI. XLVIH. fig. 4.)~Place the patient as in the operation for cataract, and lay hold of the pterygium with a good pair of rat-toothed strabismus forceps, at the distance of a line or two from its corneal extremity. Raise it until the little cellular bands which attach it to the cornea are felt to give way, when it is to be excised from its point towards its base with the bistoury or scissors. However long the pterygiutn may be, the excision should not extend so far back as the point of reflection of the conjunctiva from tlie ball to tlie lid, lest adhesion should follow, so as to obstruct the movements of the eyeball. The base of the pterygium may be left under such circumstances, and will disap- pear under the suppuration which follows from the wound. Scarpa's practice was indeed in ail cases, to excise merely in the manner above described, the triangular point which covered the cornea, a little beyond the periphery of the latter, with the expectation that the remainder would shrink and disappear. Demours, after raising the pterygium, separated it from the sclerotica by passing in the lancet flatwise, detaching it first from over the cornea, and then dividing it across near its base. Riberi pinches up the pterygium, divides it across near its base with the scissors, and then dissects it in the direction of the cornea with a fine scalpel. If the portion of the pterygium covering the cornea be thin and transparent, it has been found sufficient to excise it up to the margin of the cornea; not detaching it above tliis latter structure for fear of weakening it so as to give rise to staphyloma, or pro- ducing interstitial inflammation; trusting after tlie extirpation of the base to the action of the absorbents for the removal of the adventitious layer left upon the cornea. PANNUS.— VARICOSE CONDITION OF THE CONJUNCTIVA.— VAS- CULAR CORNEA OF THE ENGLISH SURGEONS. Pannus consists in a state of general varicose dilatation of the vessels of the conjunctiva, with thickening of its tissue, and is the consequence of chronic inflammation of this membrane. It usually covers the whole anterior portion of the ball of the eye, including the cornea. It is found at various degrees of develop- ment, either as a thin vascular veil over the cornea, or a thick red layer obstructing vision. The vascular cornea of the English surgeons is nearly allied to the same disease, but differs from it in its primitive seat. It begins as an inflammation of the sub- stance of the cornea in which the vessels become large and vari- cose, and subsequently spreads to the conjunctiva. The treatment to be relied on in these affections at their early and middle stages is chiefly medical, in which may be included ihe free use of lunar caustic to the membrane, and various stimu- lating ointments. 198 SPECIAL OPERATIONS. Excision. — When a fasciculus of vessels are observed feeding the pannus with blood, advantage will occasionally be derived by removing with the forceps and scissors the middle portion of their tract. It has also been advised, when the cornea is thickly covered, to extirpate a circular fold round its base. But even after this operation, the central layer will be noiu"ished from the vessels of the cornea. For this reason, Rogneiia has advised tlie excision of the pannus from over the surface of this mem- brane, as well as over about a line of the corneal margin of the sclerotic coat. But even after the performance of such operations, it is the medical treatment which is mainly to be relied on for effecting a cure. OPERATIONS ON THE BALL OF TPIE EYE. These consist of operations for Cataract, Artificial Pupil, Sta- phyloma, and Strabismus. CATARACT. The term cataract is used to designate that slate of the eye- ball in which an opaque body, situated between the iris and the vitreous humour, interrupts the entrance of light so as to impair or completely obstruct vision. This constitutes true cataract. The seat of the alteration is found either in the lens alone, forming lenticular cataract — in the capsule alone, form- ing capsular calaracl; or involving at the same time both lens and capsule, constituting the capsulo-lenticnlar cataract.* These constitute the three generic divisions of this alfection. An effusion of opaque lymph in front of and in contact with the capsule, which has become organized like an ordinary false membrane without diseasing permanently the tissue upon which it is seated, is denominated adventitious or spurious cataract — a term which it is useful to retain, as a specific operation may sometimes be successfully practised for the removal of this ad- ventitious body. The term of false or spurious cataract has, however, by many writers been very loosely and improperly applied to any accidental collection of pus, or blood, or lymph, within the anterior chamber. Under the term of congenital cataract is included that form of true cataract which makes its appearance at birth or a few months after — a term of which it is also important to preserve the use, as the existence of the affection at this early period in- fluences considerably the general principles of treatment. Another division useful to retain in practice is that of second- are/ cataract, which consists in the opacity of some portion of the capsule, developed subsequently to an operation on the lens. 1. Lenticular cataracts. These constitute the most common form of the disease, and as they vary greatly in tlieir degree of consistence, have been di- vided into the hard, the soft, the mixed, and the JIuid. The hard cataract is met with in common only in advanced life— the lens is diminished in size, flat on its anterior surface, • Many writers admit the liquor morgagni as another seat of cataract, which ihey suppose to become opaque. But I believe there is no such fluid in the healthy state between the lens and its capsule. and convex behind. It is usually of a steel-gray colour, and has sometimes been observed of a yellowish brown or black. The opacity begins in the centre, is slow, even years in attaining such a size as to destroy vision. There is a faint amber-coloured appearance of the lens common to old persons that interferes liitle or not at all with vision, which has been most unfortunately often mistaken for cataract, especially when it has been attended by an impaired slate of vision from other causes. The hard cata- ract appears as if it had shrunk away from the iris, the margin of which when the pupil is dilated throws a shade upon it. The soft or caseous cataract is large, and frequently comes in contact with the iris so as to bulge forwards its pupillary margin, and interfere with its play. There is then no shade thrown by the iris on the lens, but on the contrary the edge of the iris is a little everted so as to show in the form of a ring the black border of its pupillary orifice. These cataracts are usually of a milky, a light or bluish gray colour, often streaked or cloudy, and are Ibund chiefly in early and middle life. When the cataract is swollen much above its natural size, it often gaps open in front, forming three fissures, which pass iVom its central point to the circumference like rays. This variety is distinguished as the dehiscent or gaping cataract. Mixed lenticular cataract. — This is denominated the demi- hard, or demi-sofl, by Sichel, according to the degree of its con- sistence. The central nucleus is found round and hard, while the outer portion of the lens is of a tenacious jelly-like consist- ence. The colour of this variety corresponds with the soft — its size is intermediate between the hard and the soft. It is diificult in many cases to distinguish this variety satisfactorily before the needle is brought in contact with the lens. ■ In my own practice, I have several times observed the dehiscence to accompany this form of cataract. Fluid cataract. — This is rarely if ever a primitive form of the disease, and appears to be the result of a loss of consistence in the structure of the soft cataract. Its colour is grayish, whitish, or yellowish, and the lens looks like a sac filled with thick gruel, cream or pus. The capsule will often be found bagged out a little at its lower border, and on shaking the head, litile opaque par- ticles may occasionally be seen fioating through the fluid. Though the soft and liquid cataract is usually confined to persons below the middle period of life, including infatits, and constituting the congenital form of the disease, it is nevertheless occasionally met with in advanced age. 2. Of capsular or membranous cataract. This is found in individuals of all ages, and forms rapidly when the consequence of wound or inflammation. It is usually sealed on the anterior half of the capsule which invests the lens. Here it is easily recognized, whether it involves as is common a part merely, or the whole face of the capsule. When partial only, it will form a whitish disk, if at the margin; a pearly spot, if in the centre; or if spread more generally over the lens, bril- liant white stria:, which appear under various forms, and have received different appellations, as arborescent, inarbled, etc. When it covers the whole surface, it has a glistening grayish aspect, and is usually marked with strire; if not distinguished by these marks, it is in general difficult to discriminate between OPERATIONS ON THE BALL OF THE EYE. 199 it and the hard steel-coloured lenticular cataract. The opaque surface will, however, always be found more in contact with the iris tiiaii in cases of hard cataract. Opacity of the posterior half of the capsule is rarely met with as a separate afleclion. When the fluid lenticular cataract has been removed spontaneously by absorption, as is sometimes though rarely observed in childhood, or in consequence of an operation upon it ia its soft or fluid state, in which the capsule has been but imperfectly divided, the an- terior and posterior portions of the capsule are liable to become opaque, thickened, shrivelled, and adherent together, so as to constitute the secondary cataract, which will be found tough and parchment-like when touched with the instrument. 3. Capsulo-lenticular cataract. Whenever the whole anterior surface of the capsule has be- come opaque, the lens behind it, according to the observations of Weller, will be found more or less in the same condition. In very many cases, the lens will also be found opaque when the capsule is but partially alfected. This form of cataract is very common to all ages of life, and especially when the afl'ection has been developed as a consequence of inflammation of the mem- brane of the aqueous humour, or of disease of the iris. The texture of the lens may be found in any one of the various con- ditions above described. Remarks, 1. ^ge of the patient. — The operation for the removal of cata- ract may be performed successfully at any age; but as a general rule the restoration of vision will be found the more perfect the younger the subject. It has been proved by dissection that the place of the lens will be partially supplied by a central prominence of the vitreous humour, the amount of this fluid being after the de- struction of tlie lens increased in bulk— a change which may be expected to lake place more readily in young than old subjects. The operation has, however, many times been successful at the age of eighty — one instance of which has occurred in my own practice. In congenital cataract it is of the utmost importance that the operation should be done early, and at least within the second year. According lo Middlemore, it should be practised between the sixth and eighth months; and Mr. Lawrence has operated so early as between the first and second. 'I'he princi- pal reasons which direct to this early operation are, tlie tendency of the capsule to become tough and flexible, either with or with- out absorption of the lens, so as to be not easily cut up; and that of the irregular action of the muscles to bring on a stale of oscillation of the ball, which is not afterwards easily corrected, even when, by the destruction of the cataract, the entrance of light gives a fixed point for the direction of the eye. Saunders found the operation in cases of congenital cataract, at the age of fifteen, only partially successful. 2. Season of the year.—\i was formerly the practice among surgeons to defer operation for cataract to the temperate periods of the year— spring and autumn. Any portion of the year, how- ever, when the weather is fine, except at periods of extreme heat, is found equally to answer, 3. Maturation of the cataract. — The older surgeons dwelt much on the necessity of waiting for what is called the ripening or maturation of the cataract before proceeding to operate. By this they meant till it should become sufficiently hard to sufler couching or extraction without breaking up. But if we modify the meaning so as to understand a postponement till all inflam- matory symptoms have subsided, wlien such have been the cause of the affection, or have been accidentally developed during its course, the injunction is still one of the highest moment. Every cataract, when it interrupts all useful vision, is in truth to be considered ripe and fitted for operation, unless there exists some specific counter-indication. 4. one or both eyes are affected. — It has long been a rule among ophthalmologists, not to operate for calaract of one eye while vision remained perfect in the other, lest the latter should sympathetically sutler, so as to have its powers impaired; and that even if the operation should be most successful on the affected organ, the two eyes would be left with unequal powers of refrac- tion. This maxim is still to be considered the only proper gene- ral rule of conduct. But it must be recollected that it had its birth at a time when couching and extraction were the only methods of operation known — the safer and less perturbating manipulation with the needle for the cure by absorptioti being of later invention. Cases of single cataract in young persons of both sexes are frequently presented, when the removal of so conspicuous a deformity is strenuously desired, and in which the operation is perfectly justiHable. In my own practice I prefer in such cases to operate early — as soon indeed as the cataract ob- structs the sight and becomes a visible defect, as it will then in general be found less tough and resisting than at a later period, limiting myself to the method by absorption, the operation for which, in the hands of any one familiar with the structure, and skilled in the treatment of the diseases of the eye, should not be attended witK sull'ering or danger. The inconvenience arising from the difference of refracting power is of but little moment, the best eye being the one that will be employed in vision, as in the cases in whioli this difl'erence naturally exists; — or, if neces- sary, glasses of a suitable description could be worn, the use of which would even be preferred to the retention of the defect arising from the cataract. When, after complete calaract has ex- isted in one eye, the symptoms of its appearance are manifested in the other, it has been recommended (J. Bell, Stevenson, Scar- pa, Weller, Hitnly, Travers, etc.) to operate early upon the one already formed, not only for the purpose of gelling rid of a posi- tive defect, but of arresting the cataracious affection in the other. The author has operated several limes under such circumstances, and in two instances with the result apparently of checking the progress of the alfeciion in Ihe better eye. But as such a result caimot with any positive certainly be relied on, the practice is not warrantable unless the slate of the cataracious eye is such as to present the usual chances of success in the operation. When double cataract exists, it is a qucslion yet undetermined whether it is best to operate on both eyes at the same sitting, or only one, deferring that of Ihe other to a later period, when all the disturb- ance arising from the first shall have completely subsided. The latter plan is attended often wiih an inconvenient loss of time on the part of the patient, protracted anxiety, a double amount of seclusion and medical treatment, and exposes, at the operation upon the second eye, at least to as great a degree, that of the 200 SPECIAL OPERATIONS. opposite side to the visk of sympattietic injury. It is, however, the practice advised by Physick, Dupuytren, Lawrence, and others, and becomes an obligatory rule when the operation is fendered more difficult and disturbing, from preternatural adhe- sions of the iris or the peculiar state of the ball, or when there is any infirmity of the constitution. Under other circumstances I follow the example of Beer, Sichel, Vidal, Mackenzie, and others, and operate on both organs at the same sitting, it being under- stood liiat the removal is effected by couching or the process by solution: double extraction, though practised usually by Ronx, unquestionably exposing the eyes to greater risk of destruction by inflammation. By this plan I have had good success in both eyes, and with little if any additional pain or inflamma- tion, The only instance within my recollection in which any sinister consequences have occurred in my practice at all attri- butable to tiie double operation, was that of an elderly gentleman of Saletn, in North Carolina, who sufl'ered on the following day with obstinate sickness and vomiting after I had couched both lenses. Such a result, however, often follows the couching of a single lens; and in this case the recovery was perfect and rapid in both eyes, and without any other untoward symptom. The propriety of the single or double operation must, however, be determined in reference to individual cases as Ihey come before the practitioner; but as a rule applied generally, it would be the part of prudence to act only on one eye at a time. 5, Previous preparalion. — Jf the patient is in good health and of temperate habits, no previous preparation will be required, except rest if he has taken a fatiguing journey, farther than moderate diet for a short time previously, and some cathartic medicine on the day before the operation. If there be derange- ment of the digestive organs, or inflammatory tendency, or any analogous implication of the health, they must be removed by appropriate remedies. Mr. Middlemore recommended the inser- tion of an issue in one or both arras before operating by extrac- tion on a gouty subject. OPERATIONS FOR THE REMOVAL OF CATARACT. These are of three kinds:—!. Those having for their object the depression of the cataract below the axis of vision. 2. Those for its removal by solution and absorption. 3. Those for its extraction. No one of these operations can by any general rule be adapted for all cases, and it is requisite for the sur- geon to render himself familiar with all, to be adequate to the thorough management of this affection. Each one, it will be shown, has its advantages and its objections; and the selection of the process made should depend on the nature of the case. The order in regard to frequency in which they are in this country employed, will be that of the second, first, and third, in the above classification. The success of this delicate operation, it must be remembered, will depend, more than in most other aft'ections, on the dexterity with which it is accomplished, and the skill of the surgeon in preventing or subduing the inflammation of the organ. 1. Of Depression, Couching, or Displacement, including Reversion and declination. There are three distinct varieties of this method, which differ from each other chiefly in regard to the place at which the instrti- ment is introduced for the performance of the operation, viz: 1. Scleratonyxis, or the posterior operation, in which the needle is inserted through the sclerotica near its anterior edge. 2, 'Kera- tonyxis, or the anterior operation, when it passes through the cornea; and 3. Hyalonyxis,in which the puncture is made farther back through the sclerotic coat, and through the anterior portion of the vitreous humour. They are all commonly executed with a needle. This instrument has been extensively modified as to shape and dimensions, according to the will or caprice of different surgeons, so that more than seventy different varieties may be enumerated, of which however but a very few have received the sanction of general use. Those generally deemed most appro- priate will be noticed in connection with each mode of operation. In each of the three methods of depression, the operation consists alike of four separate manceuvres. 1. The introduction of the needle. 2. The placing of its point between the lens and iris. 3. Its action on the lens and its capsule; and 4. Of its withdrawal from the eye. Position. — The position of the patient and the operator in all operations for cataract is nearly the same. The patient may be seated on a low chair or a music stool, while the ope- rator, occupying one somewhat higher, is placed directly in front, so that he may retain between his own the knees of the patient. One foot of the operator may, according to the direc- tion of Scarpa, be rested on a stool so as to raise the knee, in order that it may serve as a rest to the elbow of the same side with the hand that holds the needle. This is the position recom- mended by the greater number of surgeons who operate much on the eye. It is the one which I have found most satisfactory, as it seems to leave the movements of the hand more free, and gives a better sense of the direction in which the lens is to be pressed. It is necessary, however, in order to act on both eyes by this plan, that the surgeon should have practised with both hands on the dead body, so as to be completely ambidexter. Many surgeons, however, of great distinction, prefer the patient in all cases to be placed in the horizontal posture, with the head and shoulders elevated, shifting their own position so as to act with the right hand on the eye of each side. Others preserve the use of the right hand, by acting on the left eye in the sitting, and on the right eye in the recumbent posture, placing themselves for the latter purpose behind the head of the patient. The pupil should be previously well dilated with belladonna, the extract having been smeared as a paste round the brow or temple, or a few drops of a strained solution of twenty grains of the extract to half an ounce of water, introduced between the lids some hours before the period of operation. The dilatation of the pupil will serve to diminish the risk of wounding the iris, and show more clearly the progress of the point of the needle. Closing the other eye. — The eye of the opposite side should be closed with a compress and broad ribbon, or a handkerchief folded as a cravat, or with a few small strips of adhesive plaster above the lids in the manner of Professor Quadri, of Naples. Some, however, prefer to leave it uncovered altogether, as they believe by the patient directing it steadily forward, it may be made the means of keeping tlie one to be operated on more com- pletely in the proper direction. In children and timid persons, it OPERATIONS ON THE BALL OF THE EYE. 201 is much better, however, that the opposite eye sliould be closed, and especially if it be capable of vision. Light. — The patient is to be so placed that the liglit will fall obliquely on the cornea; that of the north, side ofa room is to be preferred when it can be conveniently obtained, and the best way of admitting it is by a window, of which the lower half is closed. Sclerotoiii/xis. — Posterior operation. (Process usually em- ployed. PI. XLVI.) — The instrument usually preferred in this posterior operation for the couching or rcclinalion of the lens, is the lance-iieadcd needle of Scarpa, curved at the point to the extent of about a fifth of an inch. It has been variously modi- fied, the curve at the end for the purpose of embracing tiie lens being retained as the essential part of its construction. The shaft of Scarpa's instrument is made somewhat cotiicai, in order to fill up the puncture in the sclerotica, and prevent the exit of any globules of vitreous humour from the cells divided in the operation. But the escape of a small portion of tins humour from cells already lacerated, or even a somewhat larger amount, as might happen if the vitreous humour was unusually fluid, has been fairly proved to tie a matter of little moment. In my own practice I give a decided preference to a needle of Scarpa's form, but of smaller dimensions, modified by taking away the crest on the concave surface of the curve, as in the manner of Dupnytren, perfectly sharp at the point and sides, and with a stallc slender and entirely cylindrical, as in the needle of Sichel. ■ An instru- ment of this description will not become bound in the orifice of the rigid sclerotic coat, like one of a conical shaft. It admits of the point being freely moved in all directions without producing pressure upon the punctured sclerotic and choroid tunics; is sufficiently strong for all purposes, as no force whatever is to be employed, and is seldom followed by any discharge of the vitreous humour. Tlie straight spear-pbinted needle somewliat reduced in size, cutting on both edges near the point, is one also frequently etnployed, and answers an excellent purpose. It is occasionally even to be preferred, when on inspection of the lens through the cornea, the operator cannot be certain of its consist- ence—whether it will be found so soft as to admit of being cut up for the cure by solution, which can be rather more readily done with a straight tiian curved needle — or so hard as to require to be couched, which may be done with cither. The surgeon and patient are placed as above directed. An assistant sustains the head of the patient in a position a little oblique upwards and backwards, and raises the upper lid with the two fore fingers of one hand, placing their pulpy extremities on the ciliary border, so as to be able at will, after the elevation of the lids, by a hide downward pressure, to restrain the movement of the ball. But when the patient is indocile, or there is spasm of the lids the assistant may instead employ an elevator or spe- culum to raise the lid. The surgeon, with the same fingers of one hand, depresses the lower lid in a similar manner; and with the other hand, in which the needle is held between the thumb and two first fingers like a writing pen, he gets a point of support by resting the liiile finger, slightly curved, on the cheekbone. The patient is now directed to look towards the nose; and it will be well to touch the front of the cornea with the curved back of the needle, in order to relieve the patient of the first sensation of fright at the contact of the instrument. The operator, holding the needle 51 with the convex portion of the curve upwards, the cutting edges presenting front and back, directs the point upon the sclerotic coat, about tiie sixth of an inch behind the cornea, in the horizontal diameter of the ball, and with the handle of the iivstrument inclined downwards, so that the curved end shall enter perpendicularly (figs. 5, 6) at this point; the eye being at the same moment fixed by a little pressure with the fingers of the surgeon and assistant, which should act in unison. The puncture should be made with gentle but steady pressure, the long axis of tile needle di- rected as if it were to go behind the lens, in order to avoid wounding the ciliary processes of the choroid, which lie a little in front of the place of entry.* As soon as the curve has penetrated, the needle is to be rolled to the extent of a quarter of a circle between the thumb and finger, so as to present its convex portion forward, as indicated by the black spot placed for this purpose on the handle; and at the same time the handle is to be raised to the horizontal position without the little finger leaving its place of support. The handle is next to be inclined a little backward without advancing the point, when the iris, especially if the pupil do not remain well dilated, will be bulged slightly forward by the convex portion of the curve. The needle is now to be passed on between the iris and the anterior portion of the cataract till the point shows itself in the pupil (fig. 9..) Then, by several slight movements with the point, the operator incises the capsule — first, at its internal semi- circumference, thou across its middle— with an ascending and descending cut in the shape of the letter A, finishing by a divi- sion of the external circumference of the membrane, so as to form the letter N; lowering the handle at this last step and raising the point so as to leave the concave part of the curve resting on the upper margin of the lens.t The handle is now to be lightly raised upwards, forwards and inward-s, so as to stand at an angle of 45 degrees, without attempting to make any stress with the • It has been direcled by Mr. Tyrrel and others, to make the puuctme the six- teenth of an inch only behind the cornea; but this will render the choroid pro- cesses more liable to injury, a result which is supposed to be the cause of the obstinate sickness and vomiting thai is apt to follow depression. Scarpa, in making the puncture of the tunics, directs the needle to be held with the handle inclined to the temple, and the cutting edges vertical. In this positiuo of the in- strmnent, there is much greater risk of tlividing the long ciliary nerve or artery, and we might as a consequence see the anterior chamber filled with blood during the operation. This it is desirable to avoid, though when such an accident has occurred, the blood has usually been removed by absorption, without injury following. Much difference of opinion exists as lo whether the puncture should be made in the equator of the eyeball or at a half line .above or below it, in order to avoid more surely the ciliary vessels. The more common direction is to make it just below the equator. Mr. Mackenzie and Mr. Wharton Jones have deemed it importantthat it should he made in the equator. It has been well known since the publication of Zinn's plates of the eye, that the long ciliary artery divider into two forking branches at the distance of two and a half to three lines from the cornea. The question, therefore, may be thus solved: if the puncture be made near the cornea it may be made in the equator, though there is usually breadth sufficient between the forks to admit of the puncture half a line lower. At the distance of two and a half to three liaes back, which is advised by some operators, the lower puncture is preferable. -|- With the cylindrical needle, which moves freely in the sclerotic wound,! find it much more simple and easy to follow the practice of Sichel; — make a few slight horizontal incisions with a sawing motion, and cross them once or twice in the opposite direction. With the conical shaft of the ordinary needle, it is better to follow the direction in the text. 202 SPECIAL OPERATIONS. point. By Ihis elevation of liie handle merely, Ihe point will descend, sinking the lens before it till both disappear behind the lower margin of the pupil; the lens being carried downwards and slightly backwards and outwards, so as to be lodged in the vitreous humour, {figs. 4, 6.) The lens is now couched^ or displaced, and is to be held with the needle in this situation for twenty or thirty seconds to allow the vitreous humour to close around it and prevent its rising. The needle is then to be gently disengaged from the lens by slightly rolling it between the thumb and finger; the handle is next to be raised to the horizontal position. If the lens should be found to rise, it is to be depressed anew, (but without force, for fear of doing violence to the delicate retinal membrane,} and held for a little longer period in that position. The needle is now to be withdrawn, reversing the position in which it was entered — the convex portion being turned first towards the iris — then so as to present upwards— and the handle depressed as the curve leaves the sclerotic coat. The operation, though long in the description, is quickly performed. It must, however, be done without the least haste or nervous- ness. As the lens descends, the pupil becomes clear, and if the PLATE XLVI.— CATARACT. OPERATIONS BY DEPRESSION AND DIVISION. DEPRESSION OR COUCHING. Fig. 1. — Infrodnction of ihe needle. The upper lid is raised by the fingers of an assistant, and the lower depressed by those of the surgeon. A slight pressure from the pulpy extremities of the fingers, serves at the same time to fix the ball. The needle of Scarpa, held as a writing pen, is presented in the direction of the lens, {a, b, fig. 5,) so that the curve near the point shall pass perpendicularly through the sclerotic coat as seen in the drawing. If a needle of a less curve than Scarpa's is used, and which is greatly preferred by the author, the direction of the handle should of course be more horizontal. The place of puncture, according to the author's views, is represented a little too far behind the cornea. Fig. 2. — Division of the capsule. The needle, with the convex surface of the curve in front, is seen gliding between the front surface of the capsule and the posterior face of the iris, in the direction of the line c, d, (fig. 5,) so as to get at the centre of the pupil, which has been previously dilated with belladonna. The point, which is turned toward the lens, now begins the section of the capsule. Fig. 3.— The needle is here shown resting at the top of the lens in the direction of the line e, /, (fig. 5,) after it has completed the division of the capsule. Figs. 4, 6. — Depression or couching of ihe cataract. In fig. 6, the act of depression is shown at its commencement. The concavity of the curve of the needle rests on the top of the lens, the handle is slightly raised from its position seen in fig. 3, and the point is seen descending carrying the lens before it. In fig. 4, the depression is seen completed, the handle has been raised to the direction of the line h, (fig. 5,) and the lens has been carried down out of view before the point, rendering the pupil clear. Fig. 5. — Outline drawing, showing the changes of direction in the needle above mentioned. Fig. 7. — RecUnation or reversion of ihe lens. After the introduction of the needle, and the division of the capsule as above described, the needle, with its curve resting on the anterior surface of the lens above its middle, is seen reversing the lens, so as to make its anterior surface present upward, and its inferior margin in front. By continuing the elevation of (he hand, the lens will be couched in this position. Fig. S.— Side view of a vertical section of the eye, showing the same position of the needle in reclination as seen in fig. 7. DIVISION AND SOLUTION. Fig. 9, — Division. The delicaie, straight, sharp-pointed needle, double-edged near the point, described in the text, is represented as seen in one of the operations of the author for soft cataract. The needle has been introduced somewhat nearer the anterior margin of the sclerotic coat than in the preceding operations for depression, in order that it may act better on the face of the lens. The same place of puncture as here shown, is also chosen by many surgeons in the operation for depression. The surface of the lens has been freely divided with delicate strokes of the needle, and a few of the fragments pushed forwards into the anterior chamber. The fragments are represented lower in the anterior chamber than their actual position at the close of the operation, in order to leave the broken surface of the lens exposed to view. Flale, 4^6. On-Ston-e by Jo.' gueeit T.5J}aval,LT.tlt. ThW OPERATIONS ON THE BALL OF THE EYE. 203 retina be in a healthy condition, vision is instantaneously restored. The eye is not, however, to be immediately used. It should be carefully covered, or, which is better, the patient confined to a dark room. The diet must be restricted, and belladonna extract freely applied around the temple and orbit to keep the pupil dilated and prevent any adventitious adhesions. If retinal or iritic infianmiation follow, the antiphlogistic treatment must be freely carried out combined with the internal administration of calomel and opium. licmai'ks. — 1. Some operators neglect altogether the previous division of the capsule. If it should be couched along with the lens, an occurrence which is not to bo relied on, all might be well, though it would diminisli greatly the chance of the subse- quent absorption of the lens. If it should be left without being well broken up, it is exceedingly prone to become opaque and form a secondary membranous cataract, more difficult to get rid of than the primitive alTection. Others follow the directions of Scarpa, first couching the lens, and then bringing the needle back so as to break away the capsule behind the pupil. But when the capsule is transparent, it cannot be well seen after the lens has been displaced and the point of tlie needle is liable by doing injury to tlie neighbouring parts, to increase the sub- sequent irritation. When cut up, as in the process described, the capsule, though it does not in general become absorbed, rolls up towards its outer margin and shrinks away so as to be of no future inconvenience. 2. If the cataract should prove of the fluid kind, its liquid contents will escape on the first incision of the capsule into the anterior chamber; if the capsule should not be wholly obscured, it may slill be further divided before the instrument is with- drawn — but if it should be hidden by the turbid humour, no movemeuls of the point should be made at random, for fear of wounding the iris— it being much better to resort to a future operation for its removal if any should be needed. In several instances, however, of this description, I have found a perfect cure to follow a single semicircular cut upon the capsule. The posterior part of the capsule is so thin and delicate, that it is not apt to give rise to any inconvenience, unless uselessly lacerated with the needle, and it need not, except it be opaque, be inter- fered with. If the cataractous lens should be hard at the centre and soft at the circumference, I have several times found it ad- vantageous to cut up the anterior soft portion, push the fragments gently into the anterior chamber, and couch the central nucleus. If it should prove altogether friable, the attempt at depression should be abandoned, and the cure trusted to the ordinary pro- cess by division and solution. In passing the needle between the iris and lens, great care must be observed, in sweeping the curve forwards, not to spit or trans- fix the latter, which might be prematurely unseated should this happen. At all events it would serve to embarrass the move- ment of the instrument, unless the accident was discovered, and the needle slightly retracted and correctly passed. This trans- fixion is not likely to take place unless the cataract is large, so as to render the space for the passage of the needle unusually narrow, and when such is the case the ciliary processes are like- wise much more liable to be injured. In this state of the parts, which may be determined by careful inspection beforehand, ivhen 1 use the curved needle with the expectation of couching, I adopt the precaution in passing the curve forwards recommended by Mackenzie and others, to raise or lower the handle so as to gain room by lettnig the point sweep over a more distant portion of-the circumference of the lens. When the right hand is used I find it more convenietu to raise the handle and carry the point below — when the left, to depress it and carry the point of the needle above. To avoid this transfixion, Mr. Mackenzie directs the needle to be passed to the centre of the posterior surface of the lens, and as the depth to which tlie instrument penetrates cannot be seen, he has the proper distance for insertion marked by a groove upon the needle. Then raising it to the top of the lens he divides vertically the posterior part of the capsule, and proceeds to act on the anterior," by carrying the instrument un- derneath the lens to its front surface. But the directions for the division of the posterior part of the capsule appear to me less judicious than those given in most other instances by this expe- rienced practitioner. 3. In case the lens should be dislodged and escape through the pupil, the operator may, in imitation of the practice of Dupuytren and Lusardi, follow it with the needle, replace and couch it, or, which is generally to be preferred, especially if the lens has been found hard, and therefore more likely after couching to irritate the retina, to leave it for the moment in the anterior chamber; then allowing a Htlle time to elapse, so that the pupil may contract, and tluis diminish the probability of escape of the vitreous humour, cut down upon it through the cornea and re- move it by a small opening. 4. If the cataract be of the capsulo-lenticular kind, the capsule cannot readily be cut up with the needle without doing some violence to the eye, and it is better then to couch both it and the lens in one mass together. Under these circumstances it will be necessary to retain the cataract a few seconds longer than usual, [ and disengage the needle from it with much caution. For it is in these cases that the cataract is particularly prone to rise after couching, in consequence of its still retaining unbroken some shreds of its old means of attachment. 5. If any adhesions exist between the posterior surface of the iris and the capsule, the margin of the pupil will be deformed by the attempt to couch. If the adhesions do not readily give way, it will be necessary to divide them cautiously with the edge of the needle before depressing the lens, for fear that tlie traction which they would make on the iris might detach it at its outer margin. 6. Reclination. (PI. XLVI. fig. 7.)— This is effected by pres- sure with the needle on the top'part of the lens, so as to reverse it, making its anterior surface present directly upwards, and then proceeding to couch it flatwise below the lower edge of the pupil. It is difiicult, however, to prevent its reascent without doing ex- tensive injury to the vitreous humour. This mode of couching is, therefore, but seldom practised. It may, however, be found of useful application, when the lens continues to rise after de- pression by the usual method. For if it should after being re- clined afterwards float up in the axis of vision, its narrow edge will present forwards, allowing the rays of light to pass by on its upper surface. In attempting to reverse the lens, however, it ' Treatise, page 673. 204 SPECIAL OPERATIONS. \vil] sometimes be found to revolve on its axis; in such instances the lens should be merely depressed in tlie usual manner. Keratonyxis. — ,dnierior operation. — Depression and recli- nation through the cornea. — It is qnile easy to effect tiie recli- natiou antl partial displacement of the lens by a needle introduced through the cornea; the complete depression or couching of the lens is accomplished with more dinicuity, and is apt to be accom- panied by injurions pressure with the instrument upon the lower border of the iris, Tlie wound of tlic cornea left has also been frequently followed with opacity. The operation of depression can, therefore, in almost all instances, be more safely and suc- cessfully accomplished by puncture through the sclerotic coat. The anterior operation has, however, been advised in cases wiiere the eye is small, deeply sunken, and unsteady. A needle curved near the point like that of Scarpa, but more delicate in its strnc- tnre, will in general be found best suited to this operation. Lan- genheck, Walther, and other German surgeons, employ one with a greater curve. Sicliel gives the preference to a needle of which the head is bent at an angle with the shaft. The needle, with its point presented perpendicularly, is to be introduced through the lower part of the cornea at the distance of about a line from its margin, the concave side turned upwards and the convex downwards. It is then to be pushed onward to the cataract through the pupil, which sliould be previously dilated. After lacerating the capsule, the hollow part of the curve of the needle is to be rested on the top of the lens, somewhat to the inner side of the middle line. By raising the handle the lens is then carried downwards and outwards, and imbedded in tlie vitreous humour. In this position it should be held for a few seconds before the needle is withdrawn. The operation may also be accomplished by puncture either of the upper or outer portion of the cornea, and in case there be any existing opacity, it will be better to select that as the point for the iniroduciioii of the needle. Hyalonyxis — or jmncture through the vitreous humour. — This process differs but little from that of sclerotonyxis, except in the introduction of the needle, which is passed through the scle- rotic coat at the distance of two lines and a half behind the cornea — or at the usual place, giving then the instrument a more back- ward direction, that it may be carried through the vitreous Ini- mour in order to avoid all chance of wounding the iris or choroid processes, and be made to act upon the back part of the cataract, somewiiat as in the operation of Mr. Mackenzie described in the preceding page. It has been praised by a travelling English oculist of the name o[ Bowen,as a successful method of couching secondary or membranous cataract, which by this process may be lodged so deeply in the viireons humour as to prevent its tendency to rcascend — a diiiiculty encountered in its displace- ment by the ordinary operation through the anterior margin of the sclerotic coal. Travers also accorded to it a decided prefer- ence in the operation for congenital cataract. Bretonnean and others have likewise employed it as a means of couching in lenticular cataract, making with the needle a previons downward incision of the hyaloid tissue, in which they lodged the lens in order to keep it from contact with the iris and choroid coal, and effectually prevent its rising. If the needle be entered far back, it necessitates, however, a puncture of the anterior end of the retina, which cannot be wholly free from the risk of evil conse- quences. The method has not been much employed, and scarcely deserves the name. The edge of the vitreous humour is nearly always pimctured.in the ordinary posterior operation, or sclero- tonyxis, wliich for that reason has likewise by some been deno- minated hyalonyxie. Second method. Removal of cataract by its division into fragmeiits, which subsequently disappear either by solution in the aqueous hu- mour, or by absorption. — This is of all others the mode of ope- ration most frequently practised; the one which inflicts the least injury upon the eye, it being sometimes unattended with the slight- est irritation; maybe safely repeated from time to time if it be necessary, and is on the whole to be considered the most success- ful. To cases of hard cataract, or long-standing capsular, whether primary or secondary, it is not however suited; but in ordinary congenital cataract, in that of young persons following injury, and in all the great majority of cases in which the cataract is soft or fluid, it is decidedly the most appropriate. It is not, Iiowever, always the one most immediately satisfactory to the patient, who is anxious at once to experience the benefit of the operation. ■ The period at which the cure is attained must depend much on the state of the lens. If this be fluid, it may be perfect in the course of a week. If it be consistent and gelatinous, several weeks or months even may elapse before vision is restored, though it may be perfect in the end. It is not necessary, how- ever, in these protracted cases, to wait the result of a single ope- ration, as the process of division when properly performed may if necessary be several times repealed, and almost with impunity, at intervals of two, three, or four weeks. It has even been ob- served that a sort of tolerance of the eye to succeeding operations becomes eslablished, provided these are not repealed until all irri- tation following a previous one has disappeared. The younger the subject the more rapid in general will the process of solution be found to go on. The object of the operation is to open freely the anterior part of the capsule and expose the lens to the action of the aqueous Inimour, the lens being itself divided into fragments, or, in the language of Sir C. Bell, puddled or converted into a paste. It it be of such a consistence as to break into fragments, these are to be passed with the needle through the pupil into the anterior chamber, where the process of sdlniion will be more readily effected. The operation may be performed eiihcr by the intro- duction of a needle, as by the anterior operation, through the cornea — or by the posterior, through (he sclerotic coat. The posterior operation is the one most generally preferred, as belier admitling the free division of the lens and the dislodg- ment of the fragments, exposing the iris quite as little to injury, and not liable to be attended by the opacity of the cornea and the inflammation of the membrane of aqueous humour that sometimes follows the puncture through the cornea. In either operation the pupil must be previously well dilated with bella- donna, stramonium, or hyoscyamns. If the curved needle is used for the posterior operation, it is to be introduced in front of the lens, precisely in all respects as directed at page 201. The sub- sequent manipulation is different; instead of attempting to couch OPERATIONS ON THE BALL OF THE EYE. 205 or recline the lens, we merely after lacerating the capsule divide the lens into fragments by several horizontal and some vertical or oblique movements of the point, pushing at the conclusion the fragments a little forward with the curve of the needle. In common with many other practitioners, I decidedly prefer for this operation a slender, straight needle, flattened and lancet- shaped near the point, and with a sharp cutting edge extending back on each side for the sixth of an inch. This must be intro- duced with the flat corresponding with the antero-posterior dia- meter of the eye, and in a direction as if it were to be passed to the centre of the ball. As soon as the cutting edge has penetrated the tunics, the handle should be rolled between the thumb and finger so as to present the flat surface of the needle forward, and the point, which should be directed between the iris and lens, passed on till it nearly reaches the opposite side of the pupil. One of the cutting edges is then to be turned upon the cataract for the purpose of dividing it. This should be done by retract- ing the needle a little, pressing its cutting edge at the same time against the opaque mass — again pushing forward the needle, and again retracting it in the same manner, but in a different direction, until the whole cataract is divided into small portions, which are to be passed with tlie needle through the pupil into the anterior chamber. This is the operation peculiarly well suited to the lenticular cataract of infants, and seldom in such cases, when thoroughly performed, requires repetition. The needle is to be retained, however, but for a very brief period in the eye; and if the pnpil does not remain well dilated, or the aqueous humour becomes opaque so as to mask the movement of the needle, the surgeon should content himself with doing less, recollecting that if the capsule only be freely divided, so as to let in the aqueous humour upon the lens, the latter sooner or later becomes dissolved; and that it is much better to repeat the ope- ration at a subsequent period, than to incur the risk of injuring either the iris or ciliary processes. In operating upon an infant, several assistants will be re- quired. The arms should be bound to the side by a piece of muslin pinned around the chest, or by a pillow-case drawn over from the feet upwards, and tightened round the neck. The child thus secured should be laid upon its back on a pillow; one assistant, taking hold of the arms, confines the upper part of the trunk — and another embraces with his hands the side of the head and face, so as to keep it in the right position. The upper lid is to be raised with a speculum by a third assistant, or by the surgeon himself, if in operating he wishes to employ the right hand for the right eye, when he is to seat himself behind the child, and rest its head against his breast. Keratonyxis, or anterior opieralion. — This process is seldom resorted to for the cure by solution, save in those exceptional cases referred to on the preceding page. The needle should be small and delicate, and the shank of a diameter just sufficient to fill the puncture of the cornea and prevent the escape of the aqueous humour. The straight or curved needle may be used, but the latter will be found the most eflicient form. Mr. Jacobs, of Dublin, employs for this operation the common sewing needle, of the size known in the shops as No. 7, set in a cedar handle, ground or honed flat near the point, and curved. The operation is in most respects the same as that 52 described at page 201. The pupil is to be previously well dilated, and the needle, passed through the cornea, is made to lacerate the capsule freely, and break up the structure of the lens as far as can be readily done without disturbing the iris. The needle may be entered either at the centre or near the circum- ference. The practice of Saunders and Himly, of passing it through the centre, allows a freer action upon the lens without risk of injuring the iris, but is apt to leave a sort of gauze-like central opacity upon the cornea, as I have observed in several cases which had been operated on by Himly. Ur. Jacobs pre- fers to enter it near the circumference — a practice which I have followed in the few cases in which I have performed this ope- ration. Operation by drilling ivhen the capsule is opaque and the pupil adherenl.~\n cases of this description Mr. Tyrrell fre- quently employed with success a modification of the anterior operation for solution, which he denominated drilling. A fine straight needle is entered near the outer edge of the cornea, and carried through the narrowed pupil, through the capsule, and for the sixteenth of an inch into the substance of the lens. The handle is then rotated like a drill between the thumb and fingers, to enlarge the opening and let in the aqueous fluid to absorb the lens. The operation is to be repeated every three or four weeks, drilling at each time a new orifice in the cataract. *'I think," says Mr. Tyrrell,* "upon the average, I have had to repeat the operation seven or eight times before I have been satisfied that tlie lens has been removed; consequently the cure has been extremely tedious; but as the plan incurs very little risk, and does not confine the patient for more than three or four days after each operation, there can be no further objection than the slowness of its effects, which is more than counterbalanced by the success of the treatment." Third 7nethod. Bxlraction.~Th\s method consists in the extraction entire of the cataract through an opening in the cornea made with a knife of a peculiar shape, and is denominated Keratomy. Though apparently known to the ancients, and practised by Antyllus and Lathyrion, as would appear from the writings of Rhazes and Avicenna, this operation of extraction through the cornea was only brought into general notice by Daviel, who gave the first complete description of it about the middle of the last century. Since that time, it has been brought nearly to perfection by the labours of Wenzel, Richter, Barth, and espe- cially of Ware and Beer. Extraction of the tens by an incision through the sclerotic coat, {scleroticolomy,) as recommended and practised by B. Bell, Quadri, and others, need only be mentioned as an historical fact, as the process has with great propriety been utterly abandoned. There are three modifications of this operation for extraction through the cornea, [keratomy^ which are designated according to the part of the cornea which is divided, viz: the inferior, the one most commonly employed, in which tlie lower half of the cornea is incised; the superior, in which the upper half is cut; " Practical Work on the Diseases of the Eye, &c. By Frederick TjTrell: London, 1940. Vul. 2, p. 464. 206 SPECIAL OPERATIONS. and the oblique, in which the outer portion is divided in a slant- ing direction from above downwards and slightly inwards. The operation in each of these modifications is divided into three stages: 1. the incision ihroiii^h the cornea; 2. the opening of the capsule; 3. the removal of the lens. When the section of the cornea is made, ihe capsule freqnently gives way before the iens so as to allow ihe latter to escape. The first and second stages of the operation then appear but as one; and in the process of Wcnzel, tlie same resnlt is obtained by making tiie point of the cataract knife during the section of the cornea act on the front of the capsule. Instruments. — The instruments required consist, 1, of a knife or kerafomefor the section of the cornea. Two of these should be at hand for fear tliat, bysome inadvertency, the point or edge of one might get blunted. Knives of various forms have been devised, but those most commonly approved are the triangular knife* of Richier and Beer, shown at Plate XLVII., and the elliptical one of Wcnzel. To enlarge the opening of the cornea, when the regular section has been interrupted by a fixed pro- lapsus of the iris before the edge of the knife, the scissors of Daviel, or a small knife, shaped at the end like a probe-pointed bistoury, should be at hand. 2. One for division of the capsule, called the cystilome. A couching needle may be employed for this purpose, or the small hooked-knife or serpette of Boycr, which has a small curette at the other end of the handle occasionally useful in the removal of fragments of tlie lens. 3. Those for the removal of the lens and capsule,— rThese are required in case it should not be deemed prudent, as in injury of the vitreous humour, to apply pressure to expel the lens, or if any opaque shreds of the capsule remain after the escape of the lens. A delicate hook, or cataract tenaculum, should be at hand for the extraction of the lens, and a pair of slender forceps for the removal of the shreds of capsule. 4. Those for separating ihe lids and steadying the ball. — All the mechanical measures for this purpose have, as a general rule of practice, been discarded by modern surgeons, as the object can be much more safely accomplished by the fingers of the surgeon and his assistant. But in case the fissure of the lid be narrow, or the eye a little sunken, Pellier's elevator or Adams's speculum will be found useful, though especial care should be observed during the operation, that they do not make pressure on the ball so as to cause the escape of the vitreous humour. The chief points to be observed in the operation of extraction, are, that the incision through the cornea shall be snlTiciently large, extending from a third to a little more than half of its circumference, smooth and semilunar in shape, and made in the cornea near its place of junction with the sclerotic coat, — that the opening of the capsule be elfected without unnecessarily lifting the flap of the cornea, and without injury or contusion of the iris, and that the removal of the lens be efi'ected slowly and carefully — to prevent the protrusion of the vitreous humour. • The triangular kiiife of Richter, such as is shown in ihe drawing, may be advanlageously modilied by rendering it shorter, and thus increasing relatively its breadth. As thus modified, it will be less likely to wound the parts in the inner cauthus, or have ihe iris to fall before it in a fold. 1. Inferior section of the Co?'nea. {Inferior Keratoniy. PI. XLVII. fig. 1.) 1. Section of t lie cornea. — The patient and assistant being conveniently placed, and the eye steadied as described above, the surgeon, holding the knife like a pen between the thumb and two first fingers, and resting the hand by the two smaller fingers on the zygotnatic arch, enters the point perpendicularly to the rounded margin of the cornea, a little above the transverse diameter of the eye, and the twentieth of an inch from the anterior margin of the sclerotic coat — the handle of the knife standing in a hori- zonial direction, and the edge presenting downwards. As soon as the point becomes visible in the anterior chamber, the blade of Ihe knife is to be brought in a direction perfectly parallel with the iris, and pushed by a sort of extension movement of the fingers steadily across the clear space of the anterior chamber, till the point touches the opposite side of the cornea, which it traverses from within outward, at ihe same distance as before from the sclerotic margin, as shown in fig. 1. The knife is then to be carried on in the same direction, until the incision is nearly completed. But to avoid injuring with the point, the carnncula lachrynialis and other pans at tlie internal canthus, the handle of the instrument (the blade of which by its hold on the cornea commands the eye) is to be inclined gently during the step last described, towards the temple, by a slight rotation of the hand over the joints of the phalanges which rest on the zygomatic arch. The incision of the cornea is now to be completed. The surgeon pushes the knife slowly on, pausing a moment before he divides the last attachment of the corneal flap in order to carry the end of a finger into the internal canthus to protect the parts, as well as to allow the contraction into which the muscles of the ball Iiave been thrown by the incision to subside, as this might otherwise cause the sudden protrusion of the lens and vitreous body on the completion of the cut. As soon as the knife is re- moved, the upper lid is allowed to descend, and the eye kept closed for a few moments before the other steps of the operation are proceeded with. During the section of the cornea, the opera- tor must be particularly cauiious not to retract or twist the blade, as this would occasion a premature loss of the aqueous humour, and bring the iris under (he edge. The cut must be made with- out sawing or pressure downwards, merely by a gentle onward movement, so as to divide the inferior segment of the cornea at the same distance from the sclerotic margin at which the knife was entered. When the patient has sufficiently recovered from the emotion caused by the section of the cornea, we proceed to the second stage of the operation. 2. The division of the capsule. (Fig. 2.) — The assistant again raises the upper lid, observing the greatest care to avoid making any pressure on the ball. The operator depresses the lower with his fore finger, and bears softly with the end against the lower part of the ball, in order to cause a slight elevation of the cor- neal flap, and render easier the introduction of the instrument for (Jpening the capsule, as seen in fig. 2. The pressure serves also to advance the cataract toward the pupil, so as to facilitate the division of llie capsule. If the serpette or cystolome of Boyer is employed, as shown at fig. 2, it must be insinuated gently with its back upward, and OPERATIONS ON THE BALL OF THE EYE. by a sliglit rotatory movement under the corneal flap, so as to carry liie blade flat to the upper part of the pupillary opening. The edge is then to be turned downwards, and the capsule divided I'reely with some gentle movements of the point from side to side, as well as over each semi-circumference, avoiding carefully all pressnre upon the lens, or any lesion of the iris. If the spear-pointed needle be employed, to which a decided preference is given by the German surgeons, the neck of it is to be passed under the lower margin of the flap, with the point directed towards the inner canlhus, and the edges looking up- wards and downwards. The needle is then to be retracted hori- zontally till the spear point comes opposite the pupil; the point is next turned on the capsule, so as to divide it into several square pieces. The needle is then to be withdrawn flatwise, obliquely, and without lifting the flap. Jiingken merely divided the capsule by a single incision — but this, though it admits readily enough the escape of the lens, is an objectionable practice, inasmuch as it renders the patient more liable to secondary cataract. 3. Expulsion of the cataract. (Figs. 3, 4.) — If the incision in the cornea has been made sufficiently large, and the capsule freely divided, the lens is commonly dislodged immediately be- hind the cystotome, either by the contraction of the muscles of the ball, or the retraction ofj'the divided capsule. If such should not be the case, the operator is to press gently against the ball, with the finger sustaining the lower lid, until the lens stands with its largest diameter in the pupil and its margin slides through, as shown in fig. 3. If deemed necessary, the scoop or curette may be introduced to favour the exit of the lens, or remove any fragments into which it may have been broken by its passage through the pupil. As a general rule, however, it is best not to employ the curette for either of these purposes, from the danger of giving rise to increased irritation. Tlie fragments must neces- sarily be soft, and if they are not large will speedily become dissolved; and the expulsion of the lens can be more safely effected by slight pressure with tiie handle of the cysloiome over the upper lid, as shown in fig. 4. If by this means the lens is not readily made to lift the cortieal flap and fall upon the finger nail of the surgeon, it may be removed from the lips of the wound with the needle or curette. If the pupil is clear, the operation is now terminated. Very frequently, however, the remains of the capsule, especially if it be opaque and more firm than natural, will be seen floating in the pupil, or more or less adherent to its margin. These may be removed with a pair of delicate forceps, carefully introduced as seen in fig. 5, the lids being again separated for the purpose, either with the thumb and fore finger of the surgeon's other hand, or by the aid of an assistant. But it would be a saler practice to follow the advice of Mr. Tyrrell, and allow such portions to ■remain as are firmly adherent, and trust to getting rid of them subsequently by a needle operation. Dressing. — As soon as the operation is completed the eyes are to be closed, care being taken that the fiap of the cornea lies in its proper position, and that no air has entered between the lips of the wound. If any bubble of air should be observed, it is to be driven out by a slight pressure upon the cornea with David's scoop, or by merely rubbing the eyelids. The parts are to be wiped dry with a fine linen cloth, a small strip of adhesive plaster is to be applied over the eyelids, and a linen compress fast- ened by adhesive straps over the eyebrows, so as to form an easy but perfect sliade for the eye. The patient is then put to bed in a darkened room, and the after-treatment conducted according to the principles laid down in the treatises upon this subject. Simple and safe as this operation would appear from the de- scription, it is subject during its performance to many dangers and difficulties, which cannot always be obviated by the most skilful and practised hand. The flap of the cornea should never, under any circumstances, exceed the five-eighths of its circum- ference, as it would otherwise increase the risk of the loss of the vitreous humour, and form a flabby fold liable to gangrene. If made too small, on the other hand, there is danger that the iris may become contused in the transit of the lens. The entering puncture ought also to be made nearly a line above the transverse diameter of the cornea, and the point of exit on the opposite side of the membrane usually as much below, in order that the flap may be less liable to be disturbed by the action of the lower lid. In piercing the cornea, it is possible that the point of the knife may be managed so badly as to enter in an oblique direction and get between the lainiuK: this is more likely to occur if at the moment of transfixion the eye should be turned towards the inner canthns. If the error is soon detected, the knife may be retracted and entered anew; but if it has penetrated far between the laminee, all further proceeding should be suspended till the wound has completely healed. If the point should catch the iris, the knife should be slightly retracted so as to free this membrane. If, from the premature escape of the aqueous humour, the iris pro- lapses before the edge, it was the advice of Beer to press quickly with the end of the fore finger upon the cornea over the blade of the knife, so as to cause the iris to recede, and allow the incision to be completed without injuring that membrane. Jiingken preferred to excise the portion of the iris prolapsed before the edge of the knife ; but it would be belter in such cases, as well as those still more embarrassing, where the iris falls forward so as to stick to the cornea, to withdraw the keratonie, and finish the incision with a small curved and probe-pointed knife, or a fine pair of curved scissors. Should the assistant allow the upper eyelid to slip from under his fingers, the operator should stop the progress of the knife until the lid is again raised. If this accident happen in the method by incision of the upper half of the cornea, tlie canthns is liable to be injured by the upturned edge of the knife, or if it occur during the lower section, it will most likely invert the flap formed, and cause a sudden prolapse of the lens and vitreous humour. The loss of the humour may occur, also, as the consequence of undue pressure upon the eyeball with the finger, or from muscular contraction merely, especially if it be found more fluid than usual. The eyelids in either case have to be closed immediately, and retained in that condition with adhesive plaster, as no attempt to restore the prolapsed humour will be found beneficial. A loss of a small portion of the vitreous humour may not be attended with any disadvantage. The loss of a third or even a half of it, ac- cording to Sichel, will occasionally be replaced by the secretion of aqueous fluid, or a redevelopment of the vitreous humour, to such an extent as to restore the function of the organ. During the opening of the capsule also many circumstances 208 SPECIAL OPERATIONS. may arise embarrassing to the operator. The pupil may contract and prevent the discliarge of the lens; ilie cataract may crumble into pieces, or if soft becopie difrnsed; parts of the capsule may be left beiiind, or the iris and vitreous body prolapse. If tlic conlraction of the pupil is only the consequence of too strong a light falling into the eye, this may be easily remedied; but if it should not dilate sufficiently after tlie eye is more shaded and has recovered from irritation, the margin of liie iris may be divided with Waunoir's scissors, and, according to Rosas, without any ill consequences, the small wound closing after a few days. If the eye be very restless, it is hardly possible to open the cap- sule without injuring other parts; in such cases Jiingken lias given the very doubtful advice, to perform this operation in a darkened room, taking care to give the needle the proper direction. Sometimes the cataract adheres more firmly to the capsule, and cannot be detaclied, either by slight pressure or by Daviel's scoop. Here it becomes necessary to lake hold of the lens with a fine hook, and draw it out. If the posterior wall of the cap- sule is also found opaque after the removal of the lens, Moren- heim and Beer have directed it to be divided with a cataract needle in different directions, initil part of the vitreous body enters between the lips of the incisions, so as to hold them asunder; or to insert the cataract hook into the capsule and turn it several times round on its axis, in order that this with a part of the adherent vitreous body may bo extracted from the eye. If the iris prolapse and is retained between the margins of the wound in the cornea, we will best promote its retraction by gently rubbing the closed upper eyelid upon the bnib, and then suddenly opening itj let a strong light fall into the eye. 2. Oblique section of the Cornea. {^Oblique Keratomy.) Process of JVenzcl. — This process does not differ from the preceding but by the direction in which the cornea is cut, and in the incision of the capsule being made at the same time with that of the cornea. The knife used is of an elliptical shape. It is held between the thumb and first two fingers, and inclined obliquely, so as to form above an angle of about AS degrees with the horizontal diameter of the ball — its point presenting perpen- dicularly to the surface of the cornea at the middle of its supe- rior and external fourth. The knife is then to be entered through the cornea and passed across, so that the point shall emerge exactly opposite at the middle of the lower and internal fourth. When the point in traversing the anterior chamber comes oppo- site the outer edge of the pupil, it is to be inclined backwards so as to cut the capsule; then brought again to its first direction and carried on to make the counter puncture. When the section of the cornea is completed, it is semicircular, and will differ from the preceding only in its direction being diagonally across the ( eye. In its other stages, the operation is precisely the same as the one jnst described.* The oblique section constitutes an eligible operation, but is now employed less frequently than the inferior, which is the most easy, or the superior, which possesses in a still greater degree, all the advantages attributed to the oblique. Wenzel's plan of opening the capsule with the point of the knife during the section of the cornea, is considered hazardous; and as it presents no peculiar advantage, save that of shortening the operation, it has been entirely abandoned — surgeons prefer- ring to open the capsule at a second step, as in the operation already described. The operation by oblique section of the cor- nea may, therefore, be considered as divided into three stages, like the other modes of extraction. • By Mr. Lawrence and many other disiinguished surgeons, the lancet-pointed or elliptical knife of Wenzel is, in the various modes of extraction, preferred to the triangular knife of Beer, in consequence of its entering, as they believe, the cornea more reatlily. PLATE XLVIL— CATARACT. OPERATION BY EXTRACTION.— INFERIOR SECTION OF THE CORNEA. Fig. 1. — Section of the cornea with the triangular knife of Richfer and Beer. In the stage of the operation shown, the punctuation of the cornea has been made at its outer margin, and the point of the knife (e), glided across the anterior chamber in front of the iris, is brought out by a counter puncture on the side next the nose. The lids are separated by the fore and middle fingers of an assistant (a) and the fingers of the surgeon {h). The pressure of the ends of the fingers serves to steady the ball. The knife by being carried on cuts out at the lower semi-circumference of the cornea. Fig. 2. — Incision of the capsule with the cystotome or serpette of Boyer, which is introduced with the right hand of the surgeon, A cataract needle, as observed in the text, is very commonly substituted for this instunient. Fig. 3. — Vertical section of the ball, seen from the side. This drawing exhibits the tract of the lens in its expulsion from its seat, by the double influence of the pressure of the fore finger {d) on the lower lid, and the handle of the cystotome (c) on the upper. At / the lens is represented in its natural position, before its dislodgment. At^ the same lens is represented as having left its seat, with its lower edge tilted forwards by the slight force applied hy the finger (rf), pressing downwards and backwards the inferior segment of the iris [h), upwards and forwards the superior segment {i), and raising the fiap of the cornea as it falls from the eye upon the nail of the finger below. Fig. 4. — Expulsion of the lens. — Front view of the same process described under fig. 3. Fig. 5. — Removal of any opaque portions of the cajmile, seen remaining after the expulsion of the lens. Pla te 4<7. On-Stone byJa' ARTIFICIAL PUPIL. The formation of an artificial pupil consists in the establish- ment of a new opening through the iris, and is required in a variety of cases, which, for convenience, may be divided into the simple and complicated. The simple consists of the closure or the accidental obliteration of the natural pupil {atresia pitpillas) resulting from the eifusion and organization of lymph between its edges, or that of a layer covering the front of the iris; or when, the pupil remaining natural, the central portion of the cornea has become opaque, so as to prevent the rays of light entering in such a direction that they may impinge upon the retina. The cases of complication are, 1st, those in which the pupil is closed and tiie iris adherent by its posterior face to the capsule of the lens {synechia posterior), the whole iris, and particularly the new membrane closing the pupil, being more or less concave on the front surface, and the afiection almost always in addition accompanied with capsular cataract; 2d, those in which the iris is adherent by its anterior face to the cornea {synechia ante- rior), the consequence of inflammation merely, or the result of a prolapsus of the iris through a woimd or ulcer of the cornea, and which may or may not be complicated with cataract. Either of these cases of synechia may be complicated with flattening of the cornea, with opacity of this membrane to a greater or less extent, with staphyloma of the cornea or sclerotic coat, or with glaucoma, amaurosis, or great atrophy of the vitreous humour {synchisis). The latter three, however, are complications which render useless all attempts at operation, for they necessarily imply a destruction of the function of the retina. The conditions necessary to success, or rather those which jus- tify the operation for artificial pupil, are the following. 1. That the eye should be free from existing inflammation, or any serious alteration of its deep-sealed contents, such as atrophy or dropsy of the ball, varicose condition of the choroid coat ac- companied with thinning of the sclerotica, and the system clear of any general taint, such as that of syphilis or scrofula. 2. That the cornea should be transparent over at least a fourth or third of its surface, free from staphylomatous projection, and without any opaque effusion within the anterior aqueous chamber. 3. That the retina should have preserved its sensibility, and be capable of distinguishing beticeen light and darkness, whatever is the degree of morbid alteration for which relief is demanded. 4. That the other eye should be incapable of useful vision; for if it were, the new pupil of the opposite side could not be estab- lished in parallelism with the other, and the patient, without seeing better, would be exposed to the risk of sympathetic inflam- mation of the better eye, which might result in its destruction. Jiemarks. — The age of the patient infhiences also considerably the prospect of .success. In young subjects, in consequence of their indocility during the operation, and the proneness of the eye to consequent iuflaniination, the chance of ultimate success, all other circumstances being the same, is not so great as in the adult; and in very old persons, though inflammation is little liable to follow, the result has usually been still less happy. In the simple cases requiring operation, we sliould, when the cornea is wholly transparent, make the new pupil as near as possible upon the site of the old, in order to avoid any liability to strabismus. In that variety in which the cornea is merely opaque at the centre, we have a choice of the whole periphery of the iris for operation. An artificial pupil formed in the lower hemisphere of the iris, will be found to admit the greatest amount of light. One on its outer side will, if the cornea be opened, be most easily formed, and with the least implication of instrumental injury 212 SPECIAL OPERATIONS. affords a wide range of vision, and if strabismus follow, it will be of the internal and least disagreeable kind. From these consider- ations I have always under such circumstances preferred, in my own operations, the external hemisphere for the seat of the new pnpil, and have had good reason to be satisfied with the choice. If it be made on the side next the nose, the prominence of that organ will intcrlere with the sight, and an external squint will be sure to follow. If it be formed in the upper segment of the iris, the upper lid will shade it to a greater or less extent. But when the opacity involves not only the centre but the adjoining part of tlie structure of the cornea, we have not the same freedom of choice, as it is necessary to make the opening opposite the clearest portion of this membrane. And if the cornea be opened for the purpose, ilie puncture should be made though its opaque portion, as this heals as readily as any other, and we avoid the risk of increasing tlie extent of the opacity. The section of the iris should, how- ever, be made if possible on a part which has not suflered from previous disease, as the orifice will be found less likely to close up by subsequent inflammation. But when the opacity extends from one side but a small degree beyond the centre of the pupil, we may sometimes avoid the necessity of this delicate operation by a division of one of the recti tendons and its adjoining /a. yielding tissue — cases of which are occasionally met with — the eye is fixed in its deformed position, so as to be but to a limited degree movable. If the degeneration is complete, the eye is thoroughly fixed; and this deformity, when it takes place as it usually does at the internal canthus, has received the name of htscitas. Occasionally the deformity of the eye is purely spasmodic or intermittent, the consequence of mental excitement or gastric irritation. This variety rarely justifies the operation. Sometimes we notice an alternate spasm of the two antagoniz- ing muscles, such as to keep the eye steadily moving inwards and outwards, and greatly to interfere with vision. This is denomi- nated nystagmus bulbi, and has been treated by Dieff"enbach by the simultaneous division of the tendons of the two muscles at fault. Operation. — The operation for the division of the tendons of the ditlerent straight muscles, I find perfectly easy by the pro- cesses given for the internal rectus, the one most usually the subject of operation. The operation upon the internal is, there- fore, the only one that will need description here. There are two distinct methods of operation — one, that most commoidy em- ployed, consists in a division of the tendon, after having laid it bare by a section through the conjunctiva; in the other, which has been introduced by Mr. Guerin, and called the sub-conjunc- tival method, the muscle is divided below the conjunctiva by a puncture through that membrane, 1. Operation by the usual method. The processes peculiar to this method are very numerous; and as they essentially are very nearly the same, it will be necessary to notice only a few, and these but briefly. The position for OPERATIONS ON THE BALL OF THE EYE. the patient preferred by almost every operator, is that of the sitting posture, the head being supported as in the operation for cataract. The operator should be seated on a chair higher than that of the patient, or, if he prefers, he may operate in the stand- ing position. Process of D'tejfenbach. — This surgeon causes the eyelids to be separated with a Pellter's specukim applied to each. A fold of conjinictiva is then raised with a couple of sharp hooks near the place where the conjunctiva meets the ball; between the hooks tlie fold is divided vertically with a pair of scissors, so as to expose the toiidon. The tendon is next to be raised with a blunt hook, and the muscle divided with the scissors on a flat probe, either near the place of its tendinous insertion on the sclerotic coat, or farther back through the anterior part of the lielly. In some cases where he divided the front part of the belly of the muscle, he excised all th? anterior portion by delachiiig it from the sclerotic coat, in order to prevent the reunion of the divided ends of the muscle and a reproduction of the deformity. But the division of the belly of the muscle and the excision of any part of it have both been abandoned, inasmuch as they have been ibund to destroy the action of the muscle, which by other means can be preserved. The removal, moreover, of any part of the structure at the internal canthus, so as to cause a depression in that region, allows the carnncula lachrymalis and plica semihinaris to fall back and leave an obvious deformity which it is vL-ry difficult to correct. The process of Jirmnon is nearly tlie same as that of Dieffen- bach. He raises, however, the conjunctiva with a pair of forceps, and divides the fold with a knife as well as the tendon after having raised it on a grooved and curved probe. Velpeau has the lids separated as described above, or with a self-acting dilator (blephareirgon),and applies two hooked forceps upon ihe conjunctiva — one of which — that next the reflection of the conjunctiva fro.u tiie bull lo fhe lid, grasps at i!ie same time the ninscle and the membrane. With a pair of blunt-pointed scis- sors he then divides the conjunctival fold, as well as the portion of the muscle included in it. He next examines with the blunt hook (0 see whether there is any portion of the muscle left undi- vided, to require the further use of the scissors. Baudens raises the muscle with a pair of forceps, and inserts between it and the bail a small sickle-shaped bistoury, curved likewise on the flat, so as to open the conjunctiva and fascia on either side of the tendon. A small hook is then introduced below the tendon, and the division completed with one stroke of the scissors. Process of Listen. — One assistant holds the head of the patient, and raises at the same time the upper lid with the speculum of Pellicr. The operator depresses the lower lid with one of the fingers of his left hand, and attaches a pair of flat-toothed spring forceps on a fold of the conjunctiva at the point at which tliis membrane is reflected from the ball to the lid. The forceps are left pendent, and by their weight serve to keep the lower lid de- pressed, A small double hook is fixed into the conjunctiva on the inner side of the cornea, by which the assistant draws the eye outwards. The operator now seizes the conjunctiva close to the caruncle with the common forceps, and divides it freely with [he strong-pointed scissors. Another hook is placed in the 56 sclerotic coat, which is now exposed, and the first Iiook removed. The tendon of the ituernal rectus is now laid hold of with the forceps and divided with the scissors, and the whole inner surface of the ball cleared of the tissue inserted upon it. The author has tried the diff'erent plans proposed for tlie per- formance of this operation, and is free to admit, that they can all be made to answer the object desired. He has even found it perfectly easy with a pair of good rat-toothed forceps to raise the conjunctiva, fascia and muscle, in a single fold, and divide tliein all at once by a single stroke with [lie scissors; — save, how- ever, as regards its celerity of execution, which is a matter of but trifling importance, there is nothing to recommend the plan. He relies now upon the following process, which he has employed in about three hundred cases, a considerable portion of the whole having been operated on in public, and has no hesitation in re- commending it to the favourable notice of the reader, as one combining the greatest ease, precision and success. Process of the Author. (PI. XLIX. figs. 1, 2, 3, 4.)~The in- strumenis which will be found most convenient, consist of the spring dilator seen applied at fig. l,an elevator and depressor of the kind seen at fig. G, — required only in cases to which the spring elevator is not applicable, — a double hook well opened between its prongs, a pair of long, delicate, rat-toothed forceps, a pair of angular scissors, blunted at one of the points, and a blunt hook. The eye of the other side is to be covered witli a compress and ribbon, or by an assistant, who, at the same time that he stands behind so as to support the patient's head, covers the opposite eye with one hand, while he aids in the separation of the lids of the other. By thus closing the eye which is not to be operated upon, the patient instinctively turns the other one to- wards the middle of the orbit, and in this way facilitates the first steps of the operation. If the patient be young and un- manageable, it may be necessary to lay Inm in the lap of one assistant, against whose shoulder his head should be held by another, his arms being iti addition firmly bound to the sides. But as a general rule, it is best not to operate on patients under seven or eight years of age, for at this period of life, the desire to get rid of the deformity induces them, especially if inspired with confidence by the tact and kindness of the surgeon, to submit cheerfully to the operation, provided it be done, as it may be, quickly and almost without pain. The operation, for the pur- pose of description, may be divided into four stages: 1, the sepa- ration of the lids; 2, the division of the conjunctiva so as to expose the tendon; 3, the raising and division of the tendon; and,, 4, the division or dilatation of the fascia. Division of the internal rectus of ihe right eye. — The sepa- ration of the lids sliould be effected with the spring speculum as seen in fig. 1, which usually holds the lids securely, and enables the surgeon at want to operate without an assistant. The in- strument should be made to act on the cuticular surface of the lids merely, as its application will then be unattended with pain, and far less likely to excite spasmodic action of the orbicular nuiscle. Bnt in case the patient be indocile or spasm of the lids follow so as to unseat the dilator, it will be necessary to introduce the hooks between the lids and the ball; or if the spasm, as now and then happens, be so very violent, as to cause the spring SPECIAL OPERATIONS. to yield, (which must be made but of a certain degree of stiffness only, so as not to give pain in ordinary cases,) resort must be had to the elevator of Pellier (fig. 5) for the upper hd, and a depres- sor of a somewhat similar shape for the lower, which, like the spring specnhim, it may also occasionally be found necessary to introduce between the lid and ball. It should, however, be re- membered, that the use of the instrnments iu this position occa- sions infinitely more pain than all the rest of the operation together. The operator must be prepared to meet with great difference in various cases, as to the facility of separating the lids. So little, in many instances, is the resistance offered, that it will answer to have the lids merely separated with the fingers of an assistant. In this way, I have operated on more than thirty cases without difficulty. Having the lids separated, and the opposite eye closed, the ope- rator now directs the patient to look outwards, and inserts the doublei hook as shown in fig. 1, through the conjunctiva into the fibrous expansion of the tendon, at the distance of two and a half to three Hues behind the margin of the cornea. With the hook he has now a perfect command of the eye; bnt he should not, as has been directed, force the ball strongly outwards, as this would occasion unnecessary pain, and lay the tendon to be divided too flat upon the bail to be easily raised with a blutik hook. It is sufficient to turn the cornea a little beyond the mid- dle of the orbit — steadying it securely in that position. With a pair of angular scissors, slightly opened, and held as seen in the drawing, he next raises a fold of the conjunctiva and subjacent fascia, and divides it at one stroke by closing the blades, so as to expose the tendon. The fold is readily raised by inserting the sharp point of the scissors into the membrane a little below the lower edge of the tendon, and pushing it up before the blade a little higher than the horizontal diameter of the ball. The cellnlar tissue and intermuscular fascia may next be snipped with the scissors at the npper and lower edge of the tendon, and the wound in the conjunctiva widened if it do not sufficiently expose the parts beneath. A blunt hook, which may for conve- nience be held in the mouth, should now be passed under the nmscle, either from below upwards, which I find most conve- nient — or from above downwards, as has been recommended by several operators. With this instrument he has now complete control of the eye, and the sharp hook, which is no longer useful, may be removed. The surgeon now turns the scissors in his hand, introduces the blade with the blunt or probe point below the tendon, as seen in fig. 2, and divides the tendon at one stroke by the side of the hook. All the instruments are now to be removed, and in many instances the operation will be found complete. Little more than the efi'usion of a few drops of blood takes place, provided the patient does not struggle so as to cause a congestion in the vessels of the part, and the surgeon is careful to cut on the outer side of the plica semilunaris. If blood should flow so as to mask the parts during the operation, it must be removed with a sponge, in order that the surgeon may see clearly what he is about, and avoid all laceration or mangling of the membrane, which is found lo interfere with the speedy healing of the wound. After a few moments' repose, the blood whicli may have again collected is to be carefully sponged away from between the lids, and the position of the eye examined. If it has become straight, the patient will have lost the power to a great degree of turning it in the direction of the previous deformity, and will have regained that of rolling it outwards to the natural extent, so as to hide at least all the outer portion of the adnata. If it has not become straight, it becomes necessary to dilate the fascia — above the place at which the tendon was divided, as will be most frequently re- quired — or below it, in case the squint has been inwards and PLATE XLII.-STRABISMUS. DIVISION OF THE INTERNAL RECTUS OF THE RIGHT EYE. {Process of the Mhor.) Fig. I. — Division of the mucous membrane and the subconjunctival fascia in order lo expose the le7ido}i.^The head having been supported as directed in the text, and the other eye closed with the hand of an assistant, or wilh a compress and ribbon, the spring speculum is applied upon the cutaneous surface of the lids, so as to hold them asunder and fully expose ihe ball. In (lie drawing, the eye not operated on is left uncovered to show the manner in which the forceful traction of the squinting eye outwards causes llie other to diverge likewise in the outward direction. The surgeon then enters a double hook about two lines and a half at the inner side of the cornea so as to steady the ball, and turn it slightly outwards, while he raises wilh the lower point of the scissors a fold of the membrane over the tendon, which he divides with one or more strokes of the instrument, so as to expose the tendon just behind its place of insertion. Fi^. 2. — Elevation of the muscle on the blunt hook. — Without changing the hold of the sharp double hook, the blunt hook is passed round the muscle, as seen in the drawing. The operator has now the command of the eye wilh the latter instrument, and the sharp hook may be removed. Fig. 3. — Division of the tendon. — The operator holds the eye with the blunt hook, and reverses the scissors so as to pass the other point which should be blunted underneath the tendon whicli he divides across. Fig, 4, — Division of the intermuscular fascia. — In case this is found shortened so as to present an obstacle to the eye becoming straight, it is to be raised with the blunt hook and divided to the requisite extent with the scissors but most cautiously, for fear that by dividing it too freely the eye may be made to protrude from the socket, or turn in the opposite direction. Fig. 5.— Speculum, or eyelid elevator of Pellier. ON THE EAR. 223 downwards. This must be accomplished as shown at fig. 4. The lids are to be again separated with the specuhim, or with the fingers, and the blunt iiook introduced through the flap of the conjunctiva under the fascia, so that the eye may be drawn a little outwards and give room for the division of the fascia to the requisite extent with the scissors, the probe point of wliich is to be passed below precisely as in the section of the tendon. In bad cases of the mixed upward and inward squint in persons of middle age, it may be necessary in addition to divide a part of the insertion of the superior rectus or to sever some of the deep- seated bands of condensed cellular tissue at their place of con- nection with the inner surface of the ball. This is the stage of the operation which calls for the greatest exercise of judgment on the part of the practitioner. If he divide tlie parts lo the ex- tent proper to each individual case, he will be certain to produce a perfect cure of the deformity. If he divide them too freely, he may have the vexation to see the ball turn sooner or later in the opposite direction, and produce an external squint; and perhaps, by too far loosening the fascia and muscles which serve to stay the ball in the orbit, encoutUer the still greater misfortune of a protrusion of the organ. And if the section is not carried sufli- ciently far, the relief of the deformity will not be complete. In these cases the surgeon must recollect, that provided there has been a double scimnl, iahic/i 7)iay always be told by a care- ful iiispeclioii of the eyes beforehand, it will not be safe lo at- tempt to cure a deformity more or less common to both eyes by operating upon one— and that in these cases of double squint the whole amount of the distortion in the two eyes may be accu- mulated in one while the other is turned directly in front, or if neither eye be turned exactly in front, divided between them. Ill bad cases of double squint it will usually become necessary to perform a corresponding operation on the other eye, provided it does not subsequently become straight by a sort of self-adjust- ing power, which the eyes, when properly exercised after the section of one tendon, unequivocally possess. One advantage attending this double operation, especially if the eyes have ap- peared, in consequence of retraction of the muscles, unduly sunken, will be that of restoring both to the same degree of pro- minence. In case of doubt as lo the propriety of making the section of the fascia at the lime of the operation, and especially if there is reason to believe that the external rectus will speedily gain an increase of poWer afier the division of ihe antagonist, it will be well to defer the section of the fascia for two or three days, wlien if necessary it may readily be raised and divided without any new incision in the conjunctiva. Division of the internal rectus of ihe left eye.— In this ope- ration, the lids are to be separated and the scissors and blunt hook employed precisely as on the right. But as liie use of the sharp hook for the purpose of holding the ball outwards, would render it necessary to employ the scissors in the left hand, in which they do not cut well, it will be found advantageous to substitute a pair of rat-toothed, forceps for the double hook. With the forceps, a fold of the conjunctiva is to be raised just on the outer side of the plica semilunaris; this fold is then lo be divided with the scissors, and the operation continued precisely as on the other eye. Sub-conjunctiva I method. {Process of Guerin.) — The me- thod upon which this surgeon mainly relies is the following. The lids are to be separated in the ordinary manner. Two double hooks are employed to raise a fold of the conjunctiva over the ocular extremity of the muscle— one of which is held by an assistant and the other in the left hand of the surgeon. One of these hooks, that nearest the cornea, should take hold of the sclerotic coat, the other must be inserted through the mucous membrane so as to raise the subconjunctival fascia below it. The surgeon then passes the perforator, which consists of a small spear-headed knife, through one side of the base of the fold, and between the muscle and the ball; ihe knife, after being moved a little laterally in order to enlarge the space, is then withdrawn, and through the puncture thus made a small elbowed, blunt-pointed myotome is inserted flatwise so as to get completely between the muscle and the ball. ■ The hook nearest the canthus may now be removed. The surgeon with the other hook, which is inserted into the sclerotic coat, rolls the ball in the opposite direction so as to make the inuscle tense. The myotome, which previous to this movement upon the ball should be turned with its edge upon the muscle, is now by a slight sawing movement made to divide the muscle and a portion of the subjacent fascia across, but without cutting the conjunctival mucous membrane. The division of the muscle is accompanied with a snapping sound, and a sense of yielding of the parts on the same side of the ball. The object of this operation is to avoid a wound in the con- junctiva. I have several times tried this process, and though it is of sufficiently easy execution, it does not, as it appears to me, possess any peculiar advantage over the one more commonly employed, in which from the 'parts being more fully exposed to view, the operation can be done with greater precision. It is, moreover, accompanied by an effusion of blood, which, as it cannot readily escape externally, forms a clot below the mem- brane lining the lower half or two-thirds of the ball of the eye, which is but slowly absorbed. II. ON THE EAR. The auricle is sometimes the seat of boils, tumours and cancer, and has been found enlarged by simple hypertrophy, so as to constitute a serious inconvenience from its bulk. Boils, especially if near the auditory passage, require somewhat more than usual attention, as they have sometimes, when protracted in their course, been found to impair tiie hearing. Cancerous tumours of the auricle, though but seldom met with, may render the amputa- tion of the diseased part necessary, and several cases have been related, in which this proceeding was successfully employed. Hy- pertrophic enlargement of the auricle has also been removed by catting away the superabundant part. Wounds, if small, heal readily, but if more extensive and irregular, require to be stitched and supported by a proper dressing. The complete loss of the auricle, not a very unfrequent occurrence, will affect the hearing to a greater or less extent, and may be partly remedied by oto- plasty, though the experiments made for this purpose have as 234 SPECIAL OPERATIONS. yet furnished but very imperfect results. {Vide Plastic Opera- tions.) The external auditory meatus sufl'ers from a number of dis- eases, requiring the aid of the surgeon. It may be closed, either from congenital imperforation, or in consequence of some in- flammatory or ulcerative disease; by foreign bodies introduced into the passage; by a hardened accumulation of the secretion from the mucous lining membrane; or by the growth of poly- pous or encysted tumours. The membrana tympaiii is also occasionally found in a morbid condition, seriously impairing the function of the organ, for which relief has been attempted by operation. Many of these different complaints, to be diagnosticated with certaintyj require the exploration of the auditory passage by means of the speculum. This consists of two concave branches, which may be separated by means of a locked handle. That used by Kramer is narrowed near the point; that of Itard is merely conical, shaped like the specula for other portions of the body, but of smaller dimensions. But, inasmuch as the cartila- ginous portion of the passage only can be dilated with this in- strument, its precise shape is but of minor consequence. The introduction of the speculum may be facilitated by the patient opening his mouth, as the condyle of the lower jaw, when the mouth is closed, presses against the meatus. Care, however, must be observed, to avoid pushing it in too far, as this would cause unnecessary pain; and the branches should be made to press against tlie upper and lower walls, as these are found the most yielding. If tlie light falls properly into the ear, after the speculum is applied, we will be able to scan the whole meatus as well as the membrani tympani, which in a healthy state is found glistening at the bottom of the passage. 1. Foreign bodies in the auditory passage. — Before any attempts are made to extract foreign substances from the pas- sage, the surgeon ought to satisfy himself of their actual presence and their exact situation by examination. This may be best done by pulling the external ear outwards, upwards and back- wards, so as to let as much light fall into the meatus as possible; and if the object cannot then be perceived with the eye, a small probe may be cautiously applied to sound the passage. The speculum w^ill but seldom, in such cases, be of any use, and we incur by using it the risk of pushing the foreign substance farther inwards. The instruments for e.xtraclion will vary ac- cording to the nature of the foreign substance. If it be round and completely fills the passage, a delicate hook, a small curved spatula, or a Daviel's scoop, may be used. If the object be of the nature of a splinter, or a dead insect, it may be extracted witii a pair of forceps; but if a living insect has entered, it will be well to drop in a little almond oil, which will either kill it at once or drive it out into view. Hardened cerumen or ear wax will sometimes require to be softened by tepid injec- tions, before it can be removed with a scoop. If the presence of foreign bodies in the ear has already excited considerable inflammation, this has first to be subdued by blood-letting, emollient cataplasms, injections of warm milk, etc., before any attempts can be made at extraction. If any foreigu substance has entered into the cavity of the tympanum, the only thing which can be tried is to force it out by a stream of water, in- jected through the Eustachian tube, a proceeding which Deleau suecessfnlly employed in a case where a small pebble had en- tered the tympanum. After extraction of these foreign sub- stances, the function of hearing is often painfully acute, so that the meatus has to be closed with some wool or lint, until the sensibility of the nerve becomes reduced. 2. Polypous tumours, encysttd tumours, and fungous ex- crescences in the auditory passage. — These morbid productions may be developed as a consequence of some constitutional dis- ease, as scrofula or syphilis, or arise from local irritation merely. They spring either from the lining mucous membrane, or the sur- rounding tissues. The deeper their place of origin, the more dif- ficult will be their removal. Most frequently, however, they are found at the entran-'e of the meatus, where the structure of the passage is the least firm and resisting. Polypous growths occur here of the same character as in other parts of the body, and are generally covered with a vascular integument, disposed to bleed on the slightest pressure. Those of the vascular kind, by some, are called "sarcomatous polypus," by others, "encysted tu- mours;" but the soft, smooth, vesicidated tumour, of t n; nature of mucous polypus, is more frequently met with in the ear. Either may cause deafness, in consequence merely of their ob- structing the passage, or by being complicated wiiii some aflec- tion of the internal ear; when the latter is the case, though their removal may be efi'eeted, it will but little improve the hearing. If the polypus be pedunculated and not seated upon or near the membrana tympani — which, before any operation is undertaken, should be ascertained by the examination of its basis with a probe — it may be pulled out as far as possible with a hook or forceps, and cut o(f with a pair of scissors or a small probe- pointed bistoury. In many eases it will answer well to twist it off at its root with a small polypus forceps. TI.e removal of these tumours will in common cause but little bleeding; but if nnich htemorriiage follow, it is to be arrested by touching the bleeding root with lunar caustic, a measure which lias moreover the good etfect of preventing the reappearance of the growth. If cauterization should be relied on solely for the destruction of the polypus, the hot iron is to be employed, tiiough its applica- tion is diilicult, and atten :ed with danger as regards the neigh- bouring parts. This we may in a degree obviate. The mem- brana tympani may be protected to a considerable extent by the introduction of a ball of wetted cotton to wi ich a thread is at- tached, so that it may be pulled out after application of the cautery. The hot iron should, moreover, be introduced through a tube, so as to be made to act with more precision upon the polypous timiour alone. The ligature has also been employed for the removal of tliese tumours from the ear, but its application is fotmd very difficult when the polypus is deep-seated, and is attached by a thick root; cases to wliich, if it could be successfully applied, the operation seems particularly appropriate. Various complicated instruments have been invented for this purpose, constructed on the plan of Levret's double canula, and the other instruments devised for the ligature of nasal polypi. Sir C. Bell recommended in pre- ference to the ligatiu'e the pinching of the polypus between the blades of a pair of forceps, which were closed with a screw, and allowed to remain until the tumour dropped off. Krukenberg ON THE EAR. has succeeded in many instances in destroying tumours of this class hy merely pinching them frequently with the common for- ceps. The application of the liquid caustic by means of a brush, as recommended by Blancard, has been generally disapproved in consequence of the injury inflicted on the surrounding parts. To prevent their reproduction after removal, a solution of the acetate of lead was found useful by Kramer, as well as in mere cases of fungous excrescence, wliere the application of caustics was not thought advisable. Fungous, cancerous, and encepha- loid growths sometimes appear in the meatus as the consequence of caries of the bones, or of an alfection of the dura mater which has gradually removed the walls of the tympanum. Little can be done in cases of this description — the application of the cau- tery, the means usually resorted to, having been in most in- stances found more hurtful than beneficial. 3. Closure of the auditory passage. — This occurs sometimes as a congenital defect, and occasionally as the consequence of ulceration. In the former case, the obliteration is usually owing to a membranous septum drawn across the canal anterior to the merabrana tympani; in some few instances the septum has been found thick and cartilaginous. When the closure is produced by a membrane only, the passage may be restored. The membrane is to be divided by a crucial incision, tlie flaps cut otT, and the raw edges touched with caustic, so as to prevent iheir forming a prominent cicatrix. But when the meatus is obstructed by a solid cartilaginous growth, the attempt to open it has been un- successful, the case being usually found in addition complicated with some malformation of the internal ear. 4. Catheierism of the Eustachian tube is found one of the most eflicient means of treating cases of deafness that depend either upon an obstruction of this duct, npon an accumulation of mucus in the cavity of tlie tympanum, or an impaired condition of its nerves. Surgical anatomy. — The Eustachian tube forms a passage of communication between the cavity of the tympanum and the throat. Through it the mucous fluid secreted by the tympanic lining membrane is discharged, so as to prevent under ordinary circumstances its accumulation in that cavity. Along it the air likewise passes freely backwards and forwards, so as to preserve that retained in the cavity in a state of equilibrium with the atmosphere, in order to allow the membrana tympani, placed at the bottom of the auditory meatus, and forming tiie outer wall of the tympanic cavity, properly to vibrate under the impulsion of the surrounding air. The tube is about an inch and a half in length, and is directed from the cavity of the tympanum obliquely downwards, inwards, and forwards, and opens on the lateral -part of the pharynx, a quarter of an inch behind the nostril, by an oblong, trumpet- mouthed orifice, the posterior lip of which is prominent in the cavity of the pliarynx. The greater diameter of this orifice is vertical, and about half an inch long; its upper and lower angles correspond with the upper and lower boundaries of the inferior meatus of the nose. The canal leading to the ear starts from the upper angle of this orifice, on a level with the back part of the inferior turbinated bone, and is of a dimension very different from that of the orifice. The lower and inner two-thirds of this tube including the orifice is formed of a membranous cartilage, 57 lined with a mucous membrane continuous with that of the throat, and thickly studded with mucous glands, especially about its open orifice. The upper third is bony; through this part the mucous [nembrane — converted into a fibro-mucous tissue, so as to serve the part of periosteum — passes up to be continuous with that lining the tympanic cavity. The cartilaginous portion of the tube gradually diminishes in size up to its junction with the osseous, where the diameter is only about the thirtieth part of an inch — so small as barely to admit the passage of a small probe. From this point the calibre again gradually enlarges up to its opening in the tympanum. In the state of rest the parietes of the membrano-cartilaginous portion of the tube He in contact, the trumpet-shaped orifice alone remaining more or less open, so as to forma sort of long valve patulous at both extremities; this valve, however, is so lightly closed and so elastic as to admit of being readily forced by the breath and the action of the small palatine muscles tliat surround it, and admits of the passage of air in either direction, The direction of this canal is such as to form with the axis of the inferior meatus of the nose an angle of 135 degrees, which opens obliquely upwards and outwards, and designates the shape of the curve to be given to the instruments intended for introduction. The trumpet-shaped orifice of the lube, as has already been said, is found just behind the inferior turbinated bone; it will also be observed a little to the outer side of the ex- ternal wall of the nostril of the same side, in consequence of the contraction of the posterior naris, made by the projection inwards of the internal plaie of the pterygoid process. The posterior end of the inferior turbinated bone slopes downwards so as to form a cul-de-sac; — was it not for this, a catheter or sound having the proper curve, could be conducted along the inferior edge of the lower turbinated bone, and passed at once without changing its course into the tube. But in attempting the introduction in this way, we find the point arrested against the cuUde-sac, and it is necessary to lower it so as to pass it over the inner plate of the pterygoid process, and then raise it again to get it into the tube. But if the point of the sound be carried, with the curve vertical, along the floor of the meatus till it is found to glide over the edge of tlie posterior naris, a rotation of a quarter of a circle, so as to carry the point outwards and upwards, will lodge it in the tube. The distance of the orifice of the tube from the anterior opening of the nostrils varies in different subjects; its medium length is about two inches and a half Rules have been given in order to ascertain its distance in each case by measurement of the space between the front incisor tooth of the upper jaw — which corres- ponds with the anterior orifice of the nostril— and the soft palate — which is immediately below the opening of the Eustachian tube. There are three objects to be effected in the catheterism of the Eustachian tube:— 1, The forcing up of air with an appropriate apparatus, for the purpose of aiding in the diagnosis of the dis- eases which have caused the deafness. 2, The forcing up of atmospheric air, in order to remove obstructions in the tube, or dislodge the mucus that has accumulated in the cavity of the tympanum, 3. The introduction of medicated fluids, whether gaseous or liquid, to remove the morbid condition of the lining membrane of the tympanum, or to stimulate its nerves when (hey are found obtunded or partially paralyzed, as in cases of atonic deafness. 226 SPECIAL OPERATIONS. The introduction of the catheter is to be made through the inferior meatus of the corresponding nostril. But should any irremovable cause of obstruction exist in the nostril of the same side, it is possible also to reach the Eustachian tube through the nostril of the opposite side, by giving a longer curve to the instru- ment; or even from the mouth, by carrying the catheter upwards behind the soft palate. The last method, however, is abandoned in consequence of the great difficulty attending it. Ordinary process by the corresponding nostril. — The catheter should be graduated so as to allow the actual distance of the trumpet-shaped orifice to be measured in each case in order to facilitate the reintroduction of the instrument, which is usually many times required. It may be flexible,— made of gum elastic, as the instrument of Deleau, (PI. L. fig. 1, 3, B,) — and will then require a stilet; or it may be inflexiblej — made of silver or gold. Of the latter, (to which preference is usually given, as they are more readily introduced, though decidedly more liable to irritate the passage,) there are several varieties, the best of which, according to my own experience, are those of Piicher, (fig. 6.) and Kramer, (fig. 5.) The practitioner who devotes his attention to aural surgery should, however, supply himself with the three instruments above named, as he will occasionally meet with cases in which, either from the small dimension of the nostril, the inclination of the nasal septum to one side, or the great irritability of the passage, one of these instruments which differ so much in their form, can alone be readily introduced. The peculiarity of that of Kramer, is the shortness of its beak; it can be passed therefore but a small distance into the tube, and allows of the regurgitation of the air and the removal of mucus by its side, so as to prevent any extreme compression of the parts in the tympanic cavity, which is far from being unattended with danger — death having in one case suddenly followed this operation. For the same reason, the tube of Kramer is liable to displacement, and requires an apparatus to fix it in its position, and may in many cases be advantageously superseded by that of Piicher, which is moulded to the shape of the parts, so as to sustain itself when once introduced. The other iustrumenls required will be a frontlet, to which is PLATE L.— OPERATIONS UPON THE CAVITIES OF THE FACE AND THROAT. {■Figs. 1 and 2.) INTERIOR OF THE NASAL FOSSyE, MOUTH AND PHARYNX. The head has been sawed through the middle line, so as to take away with the half removed the septum of the nose. References common to Jig. 1 and 2. ' Line of section of the bones. — a. Bones of the base of the craniutn. b. Six first cervical vertebrte. c. Upper maxillary bone. e. The second large molar tooth, which is removed in fig. 2, in order to bring into view the orilice of the duct of Steno. d. Inferior maxillary bone. e. Os hyoides. /. Cartilages of the larynx. Section of the soft parts. — g. The nose. h. The upper lip. i. Epiglottis, k. Lower lip. /. Tongue presenting a side view of the genio-hyo-glossus muscle. Section of the cavities. [Nasal cavity.) — m. Superior turbinated bone. n. Middle turbinated bone. o. Inferior turbinated bone. p. Cu!-de-sac at the top of the naso-pharyngeal cavity, q. Inferior orifice of the nasal duct, r, Trumpet-shaped orifice of the Eustachian tube. {Cavity of the motit/t.)—s. Superior dental arch, t, t. Half arches of the palate, u. Cavity of the pharynx, opening above into the. nose and mouth, and continuous below with the cesophagus, v. OPERATIONS. (A) . Cafheterism of the 7iasal duct wi(h Ike sound of Laforest. — In fig, 1, ihe end of the instrument is hidden in the duct by the inferior turbinated bone. In fig. 2, a portion of the turbinated bone and mucous membrane is removed to show the sound in the whole length of the duct. (B) . Culheterism of the Eustacliian tube tvith the sound of Deleatt. — In fig. 2, a portion of the body of the sphenoid bone is removed in order to show the continuation of the Eustachian tube toward the cavity of the tympanum, below and in front of the curvature of the carotid artery. An opening is likewise made in the wall of the tube to show the position of the end of the sound. (C) . Catheter i}i(roduced into the antrum maxillare, shown in fig. 1. (D) . Probe introduced into the duct of Steno. seen in fig. 2. (E) . Sound of Bellocq, shown in fig. 2, as employed for the purpose of plugging the posieriornares. — The instru- ment has been introduced through the lower meatus of the nose, and the spring pushed onward so as to bring its probe-point into Ihe cavity of the mouth. A plug of lint is attached to the point by a thread, ready to be drawn back with it and lodged in the posterior opening of the nostril. (F) . Calheterism of the cesophagus, (fig. 1,) as employed for the purpose either of dilating a stricture of this passage or removing poisons from the stomach. puac so. ON THE EAR. 227 attached a pair of forceps moving on a ball and socket joint for the purpose of retaining the instrument of Kramer in position; an apparatus for the condensation and transmission of air, and another for the generation of ethereal vapour, which will be found described in liie various treatises on the diseases of the ear. Gairal has advised the use of a large gum caoutchouc bottle for air injection merely-j the air being forced in by pressure with the hand. The patient is to be sealed on a low chair, with his head thrown a little back and supported against the breast of an as- sistant. The operator, seated on a higher chair in front and a little to one side, takes in his hand the catheter, well coated with cerate or mucilage, blows through it to see if the passage is perfectly free, and passes it held like a writing pen rapidly but gently through the inferior meatus;— the point of the instrument gliding over the floor of the meatus, the curve of the beak presenting its convex part upwards, and turned a Utile in- wards to keep it away from the inner surface of the inferior turbinated bone. The right hand may be used for either nostril, but if the operator is dexterous in the use of the left, he will fiud it most convenient to employ that in the operation on the left nostril. If any impediment is encountered in the introduc- tion not readily removed by a little furllier inclination of the point outwards, the instrument is to be at once withdrawn and a smaller one substituted. When it has passed to the extent of two or two and a half inches, tlie point will be felt sliding as it were, or rather about to slide, over the rounded margin of the nostril, and there will be an involuntary effort at degluliiion, showing that the instrument lias come in contact with the velum palati. The beak of the sound -without being carried any fur- ther backward is now to be turned by a quarter rotation between the thumb and fingers, so that the point shall present upwards and outwards in the direction of a line between the auditory meatus and the first incisor tooih of the other side, with which direction should correspond the ring on the outer end of the catheter. The surgeon then, pushing the instrument gently on, first feels it jut against the posterior lip of the orifice and then slide into the cavity of the tube. To the practised hand its position here is at once made manifest by the absence of uneasi- ness to the patient, by the iusirunient becoming gradually more fixed as it glides in, and by a sort of elastic resistance given by the walls of the orifice in attempling to rotate the instru- ment. The forceps of the frontlet are now to be fastened upon the catheter, which, by this means, is now so securely held that the patient cannot by talking or even swallowing dislodge it. This manipulation, however, should be so delicately done, and with such close attention to the sensation communicated to the fingers, as to avoid even the slightest laceration of the lining membrane, else when the condensed air is allowed to pass up the catheter, it might get through^ the place of rupture into the submucous cellular tissue, so as to produce an emphysematous swelling of the palate, the uvula, or of the side of the neck as far down even as ilie angle of the jaw. If in introducing the instrument we attempt to make the turn before it has arrived at the posterior border of the nostril, the point will be brought up against the back end of the inferior turbinated bone, so as to occasion pain, and, in case any violence should be used, even fracture of the part. If, again, after making tlie rotation, the point instead of entering the caviiy slip over the posterior mar- gin of the orifice of the tube, a sensation of elastic yielding in the part makes the circumstance known to the surgeon. The instrument, if then carried back, comes in contact with the walls of the pharynx, and excites to convulsive contraction, the mus- cles of deglutition. If it be rotated in this position, it either swings round clear in the cavity or becomes hooked in one of the angular depressions of the pharynx — a state of things which the young operator should early learn to detect. When hooked in this way, he will discover his error by noticing that the direc- tion of the ring on the outer end is too vertical; that the instru- ment as shown by the graduated scale has entered too far, and by observing on attempting to rotate the instrument, that it does not meet with the peculiar elastic membrane of the carti- laginous orifice while it increases the spasmodic action of the muscles of deglutition. He is then to retract the catheter. If he discover the error the moment it slides over the posterior lip, a slight backward motion is all that is required, and the instru- (Fig. 3.) TAMPONING THE NASAL FOSS^. In the section of the head shown here, the septum narinm has been left. The operation — the first step of wliich is seen at E, fig. 2— is here represented completed. The horizontal dotted line represents the track of the thread; the curved ones at the two extremities of the nostrils, show the depth to v/lnch the plugs (/, m,) are lodged in the passage. (Fig. 4.) PERFORATION OF THE ANTRUM MAXILLARE. (A). Through the external wall.—The corner of the month is carried outwards and the upper lip raised by the two hands of an assistant, {o,p.) The mucous membrane has been divided at its place of reflection from the gum, and the soft parts separated upwards from the bone so as to give room for the application of the small crown of a trephine. lit/ the sockets of one of the molar teeth.— The first small molar tooth having been lost, the point of a perforator is applied in this case to drill a passage into the antrum. Fig. 5.— Kramer's catheter for injeciion into the Eustachian tube,— this instrument is made of various sizes. Fig. 6. — Mr. Pilcher's catheter for the same object, reduced one-third in size. Fig. 7.— Shaft of Fabrizi's instrument. A spiral screw at the end. A coiled wire spring near the handle. Mg. 8. — Canula of the same, made of silver, with a circular steel point which is sharp and cutting. Fig. 9. — Shaft placed in the canula, the spiral point projecting two turns beyond the canula. 238 SPECIAL OPERATIONS. ment, if again passed forwards with the handle a little more indiiied to the otiier nostril, sUps into the proper position. If he do not find his mistake till the point has touched the back wall of the pharynx, he is to turn the handle till the ring comes into its proper direction, and then withdraw the instrument for half an inch, which brings the point nearly opposite the tube, when a second elfort to pass it may be made. If not successful now, the instrument must be brought backwards with the point in the position at which the turn was made in the first instance, and the manceuvre repeated anew. When the nostril is of good size, I often find it more easy for the patient — in introducing the catheter of Pilcher — to carry it with the convex part of the curve downwards on the inner and lower angle of the meatus, the point directed upwards under the inferior edge of the lower turbinated bone, so as to correspond with the direction of the Eustachian tube. If there is no resist- ance at the posterior end of the turbinated bone, no turning of the instrument is required; the point will be found sliding over the rounded edge of (he internal pterygoid process, and dropping at once into the proper opening. If there be resistance, the point must be turned a little downwards till it passes, and then raised again to the proper direction. If the elastic catheter of Deleau is employed, it is to be carried on the siilet in the manner above directed into the orifice of the tube. (PI. L. figs. 1,2.) The stiiet, which projects a little beyond the catheter, is then to be carried alone along the tube, and the catheter afterwards advanced upon it. The stilet is then wholly withdrawn, leaving the catheter in place, to the end of which a mouth-piece of silver is to be fixed, and subsequently fastened to the aire of the nose by a metallic thread bent so as to act as a pair of forceps. Introduction of the catheter by the opposite nostril. {Process of Deleau.) — The catheter employed in this process must have a longer curve than the one ordinarily used, and is more conve- nient if made of gum elastic. It should also in addition be slightly curved on the side of its convexity. It is to be passed, held as a writing pen, through the nostril of the other side, with the concavity of its beak looking downwards and inwards. As soon.as the point has passed the boundary of the posterior naris, it is to be rotated inwards so as to pass behind the vomer. In this direction it is to be continued on till it enters the orifice of the tube of the opposite side. Perforation of the membrana tympani. This operation was introduced by Sir A. Cooper and it is said successfully employed by him in 1800. The perforation is made either by puncture or excision. The only indications commonly believed to justify this operation, are permanent and irremediable closure of the Eustachian tube, extravasated blood in the cavity of the tympanum, and, according to Kramer, a thickened and unyielding state of the membrane. The success of the operation, which has been very frequently practised, has not however been such as to realize the expectation once formed from it. "Nothing is more rare," says Iiard, "than the cure of deafness by perfora- tion of the membrana tympani."* I have several times per- • Memoires de I'Academie Royale de Medecine, Tom. V. Paris, 1836. formed the operation, but have seldom found it attended with much lasting benefit. Puncture. — Coo/jer and Buchanan, after inclining the head of the patient in a good light and straightening the meatus in order to render the membrane visible, punctured the membrane with a small trocar at its anterior and inferior portion, so as to avoid the manubrium of the malleus — care being taken that the point of the instrument should not come in contact with the opposite wall of the tympanum. The puncture, however, even when first attended with benefit, was found soon to close upas in ordi- nary wounds of the part, by adhesive inflammation. Hence the introduction of the following process for the removal of a piece. Excision. — This process was first devised by Himly, and exe- cuted with a simple circular punch of small size, cutting out like that of the shoemaker, a circular piece. With this instrument the delicate membrane is more apt to break away than be clearly cut, the broken portions subsequently rising up when inflamed, so as to diminish or obliterate the orifice. For these reasons the pimch of Himly has been modified by Deleau, for the purpose of bringing away the piece, and further improved by Fabrizi, of Modena. By the instrument as modified by the latter surgeon, the removal of the piece is readily accomplished. Process of M. Fabrizi. {PI. L. figs. 7, 8, 9.) — The structure and mechanism of this ingenious auricular trephine of M. Fabrizi, will be understood by reference to the plate. It is used in the following manner:— Holding the instrument in the right hand as a writing pen, with the point of the spiral directed upwards, it is to be passed along the inferior wall of the meatus, and brought in contact with the anterior and inferior part of membrana tym- pani at a point about half a line from its circumference. Pres- sure is then to be made on the instrument till the point of the spiral traverses the membrane. The whole instrument is then to be rotated on itself for a turn and a half. The handle, to which the shaft with the cork-screw termination is attached, is then to be secured with the fingers of the left hand, while with those of the other hand the canula is rotated a turn and a half in a direction opposite to that which had previously been made. The screw fixes the membrane so as to give the requisite point of support, and the sharpened edge of the steel canula cuts out a round piece about a line in diameter, which is left attached to the screw, and is withdrawn with the instrument. This mode of excising a portion of the membrane is incontestably superior to any which has yet been devised. Perforation of the mastoid cells. This operation was proposed by Itard, and has been many times practised for abscess of the tympanic cavity with supposed effusion of pus in the mastoid cells, and for the purpose of throw- ing injections into the tympanum in cases of obstruction of the Ensiachian tube. But the method has never met with much favour, and though a plea has recently been started in favour of its resumption,* it may be considered as completely laid aside in reference to the above indications. For if, under such circum- stances, the purulent fluid cannot be evacuated by injections • M. Deseimeris. — De la Perforation tie Apophyse Mastoid, etc. etc. L'Expe- rience 10th Avril, 1838, No. 32. OPERATIONS UPON THE NOSE AND NASAL CAVITIES. 229 through tlie Eustachian tube, it is generally conceded that it is better to make an opening througlt the membrane of the tym- panum. The only cases in which the perforation of ihe cells would be admissible, are those in wliich tlie abscess within is complicated with caries or necrosis of the outer wall of these culls. The point on the surface which corresponds to the position of the larger of these cells is a little in front of the masioid pro- cess, and in the adult a little more than half an inch from its apex. The operation would consist in laying the bone at this point bare, by a crucial or T incision, and employing a small trephine to open into the cells. Tlirough the opening the pus is to be disciiarged, and injections cautiously tlirown in from day to day, til! a cure is effected. III. OPERATIONS UPON THE NOSE AND NASAL CAVITIES. Sin'ffical analoiny.—iha bony sirnclure of the root of the nose is formed by the two nasal bones, which are attached upon each side to the nasal process of the upper maxillary, and by their posterior face to the perpendicular lamella of the ethmoid bone. From this junclion of parts, it follows that in fracture or depression of the nasal bones the shock may be transmitted to the cribriform plate of tlie ethmoid, so as to break it and cause injury to the brain and olfactory nerves which are lodged above it. If the fracture involve the nasal processes of the maxillary bone, the nasal duct for the discharge of the tears is hable to injury, and epiphora or even fistula lachrymalis may follow. The inferior half or expanded portion of the nose, called the alfE, is composed mainly of two lateral cartilages, separated by a third, which completes the nasal septum. The skin of the nose is thick and movable over the bones, but thin and closely adherent over the lower cartilaginous portion. The subcutaneous cellular tissue contains no fat, but is richly supplied, especially at its inferior part, with sebaceous follicles, the orifices of which are so nume- rous as when enlarged to give the skiu a cribriform appearance. The integuments of the nose are so very vascular as to render easy the cicatrization of wounds of the part, and make it the frequent seat of erectile tumours. A case is reported by Garen- gwt, in which the re-application of the extremity of the nose, after it had been completely separated, was followed by solid union. Nasal cavities, — Each of these cavities are included w.ilhin the bony and cartilaginous walls of the nose just described, and ihe upper surfaces of the horizontal processes of the maxillary and palate bones which form the roof of the mouth, and are separated from each other by a partition partly bony and partly cartilaginous — consisting of the vomer, the perpendicular plate of the eihmoid bone, and tlie triangular cartilage wliich is lodged in front of the bony portion. Each of the nasal cavities or nos- trils thus formed with resisting walls, present an opening in front called the anterior naris, and one behind leading into the pharynx and closed at times by the velum palati, named the posterior naris. •Jlnttrior nares. — Each of these openings is about three quar- ters of an inch long and a quarter broad. Their walls, which are cartilaginous and extensible, may be further enlarged by a section of the ala with the knife, so as to be equal lo that of the bony orifice of the nostril which it masks, and which is about half an inch in its transverse diameter. Each of the anterior openings is circumscribed — on its outer side by the ala, on its inner by the nasal column, on its lower or posterior by the origin of the lower lip, and on its upper or front by the nasal lobe or point. It is well to observe, in reference to the introduction of instruments through this opening, that the point of the nose descends much lower than the origin of the upper lip, so that instruments in entering should be first directed upwards, and then brought to the horizontal position. The posterior nares, or openings of the noHrih, are of a regu- lar oval shape, each fully three quarters of an inch in its vertical diameter, and Iialf an inch in its transverse, opening obliquely backwards and downwards into the pharynx. The walls of these orifices are bony and unyielding. The size and shape of the orifices should be well noted by the student in reference to plug- ging them in case of epistaxis, or the passage of instruments for the removal of polypous tumours. In looking in a section of the lioad from behind forwards through the posterior opening of the nostrils, we find these cavities formed of four walls — the ex- ternal, which is irregular in consequence of the presence of the turbinated bones on that side, the two lower of which may be seen from the posterior orifice; the superior, or the roof; the internal, or the septum; and the inferior, or the floor. This inferior is about two inches long, formed into a sort of gutter on its Ufiper face, winch, when the head is placed horizon- tal, is found inclined backwards and slightly downwards. By its posterior part it supports the vehnn palati, a sort of movable valve, which when elevated obstructs the posterior orifice, and forms one of the difficulties in the introduction of instrumenis from the mouth into the nose. Tlie mucous membrane lining this inferior wall is fibrous, little sensitive or vascular, and is seldom or never the place of origin for polypous tumours. The internal wall or septum is lined by a very dense, vascu- lar, and sensitive mucous membrane, which favours tiie develop- ment of syphilitic or scrofulous ulceration, and is the almost exclusive seal of fibrous polypi. The septum is, iu a large pro- portion of eases, found bulged more or less to one side, so as to render one nostril smaller than the other. When this takes place to a great degree, the front end of the triangular cartilage of the sepltuu will form a red and rounded tumour, interfnring with the passage of air. I have frequently been consulted in regard to this displacement of the cartilage, the patient believing it to be a polypous formation; but if a bent probe be passed in these cases into the other nostril, it falls into a corresponding concavity, and reveals at once the nature of the afi'ectioii. The superior wall or roof of the bony portion is very narrow — little more than a sixth of an inch broad. It is formed in front by the nasal bones and the septum. In its middle part it is hori- zontal, and is formed by the grooves of the ethmoid and the cribriform plate of that bone, the fragility of which is so great that an instrument improperly directed, especially in the softened state in which the bone is found in disease, might readily peiie- 330 SPECIAL OPERATIONS. trate into the brain. This horizontal portion is lined by a delicate mucous membrane, and is the common seat of vesicular or mu- cous polypi. At its back part the wall inclines downwards, and terminates directly at the orifice of the sphenoidal'cell. The ex/eimaiwal] is irregular in sirncture, and is formed chiefly by the ihree turbinated bones and the three meatuses which they cover. The inferior turbinated bone begins from the very margin of the nasal process of the maxillary, nearly on a Vine with the bulging part of the alae, and runs back, a little arched in its mid- dle, to tlie front part of the inner plate of the pterygoid process. Its upper margin, by which it is attached to the nostril, is nearly on a line with the front margin of the orbit, and about five- eighths of an inch above the floor of the nostril. This bone is curved inwards and downwards, so that its inferior edge comes usually within a quarter of an inch of the floor, and sometimes is provided with a fold of mucous membrane so pendulous as to reach, especially at its back part, nearly down upon the floor. In the inferior meatus, which is found below it, opens the nasal duct, the anatomy of which has already been described. , The middle turbinated boue begins about half an inch further back, and nearly an inch higher, being nearly on a line with the inter- nal canthus of the eye. The space between the lower margin of this bone, and the upper margin of the inferior, which forms the middle meatus, is only about three-sixleenths of an inch broad. In the front part of ibis space, and under the inferior turbinated bone, open the anterior ethmoidal cells and the frontal sinus— and at a point a little farther back, at the distance of about an inch and a half from the anterior nares is the orifice of the antrum highmorianum. Professor Warren''* has observed, that an uiinsu- ally large turbinated bone is liable to be mistaken for a polypous growth. The middle turbinated bone is convex and curved inwards like the lower, but does not come so far forwards as the latter. Its convex surface is, however, nearer to the septum — often so near, when the septum is curved a little in that direction, as not to leave more than the eighth of an inch between them, and present an obstacle to the introduction of instruments through the nose. The back part of this middle turbinated bone is curved a little downwards. The upper or small turbinated bone is directed a little upwards, and seems like a detachment from this, starting on a level with the internal canthus of the eye. The space thus left between them forms what is called the superior meatus, and is conserfuently found only in the posterior half of the nose, and is about three quarters of an inch long. In it is the opening of the posterior ethmoid cells. In the skeleton it presents also the orifice called the spheno-palatine foramen, through which, by constant pressii e and I'ilalation, large polypi occasionally insinuate themselves, so as to project in the pterygo- maxillary fossa below the masseter. All these parts are covered by a red, soft, mucous membrane, very vascular, especially at its upper part, where it beconp.ss, in consequence of its high organi- zation, the seat of coryza, haBmorrhages, and bleeding polypi. In the extraction of nasal polypi, it is necessary to be familiar with the structure of this exierual wall of the nose, though wiien the tumours are large it will be found more or less distorted by their pressure. They rarely arise from the inferior turbinated • Surgical Observafions on Tumours, p. 470. bone — but when they do, they may readily be removed by a pair of forceps either straight or slightly curved. The most common seat of such as spring from the outer wall, is the middle turbinated bone, though they are not unfrequently found attached to the upper bone. The instrument for the removal of these by grasping their root must necessarily be curved, and carried up nearly on a level with the lower side of the nasal bones. " Who- ever looks," says a most judicious writer,"^ "at the position of these bones, even in the dead skull, and the relations of a polypus, must at once be convinced that its eradication by any plan what- ever is rather to be desired than promised, and the rapid reap- pearance of polypi, after the nostril has been conjectured to be cleared, is easily to be explained by an excresence expanding from a spot where it had been confined by the portion removed. The destruction of bone, and dreadful spreading of the disease, may also be readily understood. It sometimes destroys the nasal bones, forming an external tumour, enters into the antra, and swells the face laterally as well as in front, penetrates into the frontal and sphenoidal cells, swelling the forehead, and pressing on the brain protrudes the eyes and pushes forward the conjunc- tiva, descends into the piiarynx, encroaches on the palate, and perhaps carries the velum forwards almost to the front teeth." TUMOURS OF THE NOSE. These may consist of a mere enlargement of the sebaceous follicles, of a growth of erectile tissue; or they may be of the na- ture of lupns or cancer. The processes for their removal will not in common differ from that required when the same affections are fouiid in other parts of the body, with the exception that it will be necessary to avoid cutting into the nasal cavity, for fear of leaving a fistulous opening or a deforming cicatrix. But in cases of malignant disease, as when a wart over the ala has unequivo- cally become cancerous, the extension of the disease inwards renders it often necessary tp remove by an elliptical incision a portion of the entire wall, the orifice of which, if small, should be closed at once with the hare-lip suture; or if large, by the imme- diate transplantation of a flap from the cheek, forehead, or arm. If a tumour, malignant or otherwise, grow from the middle column of the nose, separating the two ovai cartilages, it may be removed by the following process, so as to leave very little deformity. Process of Rigal. — This consists in circumscribing the tumour of the column by two lateral incisions united in front, and di- vergent backward in the form of the letter \^ reversed. The branches are next to be united by a transverse incision nearly on a level with the lip. The iiUeguments then are to be dissected off' from the place of these incisions, and the two oval cartilages separated so as to expose the seplnm within and allow the dis- eased mass to be enucleated from between them. Lipomatous tumours of the nose. — The skin and subcuta- neous cellular tissue covering this organ as well as the numerous sebaceous follicles they contain, sometimes become so thickened and irregularly expanded, as to form a mass of insensible lobu- lated tumours, pendent from the part, though attached by broad bases. The cellular tissue below is loaded with serum so as to * Principles of Surgery, Vol. 2, p. 327. By John Burns, M.D., F.R.S. London, 1638. OPERATIONS UPON THE NOSE AND NASAL CAVITIES. 231 augment the size of these swellings, the growth of which, if not removed by operation, goes on increasing without definite limits, producing great deforiniiy and inconvenience, hanging down so as to obstruct the orifices of the nose and monih; and in two in- stances have been known to descend as low as the chin and chest.* They are mostly of a reddish or violet Iiue from the accumulation of blood in the veins, though the arteries of the part are but little enlarged. The masses are separated by fis- sures, in which the sebaceous secretion lodges and becomes rancid and offensive. The affection is not malignant, and the cartilaginous basis of the nose is usually uninvolved, from which the growths may be readily removed by operation. Process of Mr. Listen. — "An incision should be made through the diseased integument and cellular tissue in the mesial line, upon the cartilages of the apex and columna — not, however, so as to injure them. An assistant places his fore finger in one nostril, and the surgeon, seizing the mass either in his fingers or with a small vulsellnm, (toothed forceps,) proceeds to dissect it oi\ with a scalpel. The incisions must be carried close to the cartilages of the ala until the one side is cleared — the edge of the opening being well observed, and not encroached upon. Tiie assistant will give warning if the knife at any stage of the proceeding, approaches his finger. The surface is trimmed a little, if occasion requires, with a pair of thin, slightly curved, or knife-edged scissors, A similar proceeding is observed on the opposite side so as to make the part as symmetrical as possible. A few vessels bleed, bnt the flow is easily restrained during the dissection by placing the small spring forceps (Graefe's) upon tlieir mouths, or compressing them with the point of the finger. Liga- tures are afterwards applied if they still persist in bleeding. Should the ligatures not hold, the cut ends of the vessels not being readily drawn out from the condensed tissue, a fine cambric needle may be passed across the bleeding point, and a ligature tied under it, the ends of both the needle and the thread being afterwards cut off. Any troublesome general oozing may be stopped by plugging the anterior nares, applying a compress of lint ontside,and retaining it by a double-headed roller. Difficulty and pain, however, are experienced in removing this dressing, and it is much better, if possible, to apply frequently and assidu- ously for a few liours, pledgets of lint moistened with cold water; and after coloured discharge has ceased, to substitute the tepid dressing, and thus encourage suppuration. The exposed surface in this situation soon becomes clean, and presents small, pointed, and florid granulations; after a time the zinc or other lotions, well diluted, arc employed with advantage, Cicatfizatiou very soon takes place, and the surface at first glazed and discoloured, soon assumes a perfectly natural appearance, "t Occlusion or nan-owing of the anterior nares. — Diseases snsceptible of altering the form of the nose may obliterate or contract the nostrils, so as to interfere with the function of re- spiration. As in the occlusion of the other natural passages, this is to be treated by the common processes of dilatation, in- cision or excision, which, to be effectual, have frequently to be employed in combination. • Vidal, Train de pathologic eMerne, Vol. IV. f Practical Surgety, edited by Dr. Is'orris, p. 285, In cases of simple narrowing, make with the bistoury many small radiated incisions at the margin of the nostril. If the closure be complete, run the bistoury in the place of the former opening so as to form a longitudinal fissure, and if the structure be unyielding and resistant, excise the margins so as to leave an oval opening. The new orifice is to be kept open till the raw edges are completely cicatrized, by a roll of charpie, a canula, or a stick of lead formed into a flattened ring. NASAL CAVITIES. The affections which require operation in the cavities of the nose, consist chiefly in the lodgment of foreign bodies— epistaxis and polypous tumours. Extraction of foreign bodies. — Foreign bodies, such as peas, beans, small stones, sticks, &c,, are mostly introduced accidentally or in childish sport, through the anterior nares, and become after a short time firmly fixed, either by their own enlargement from the imbibition of the moisture of the part, or from the tumefac- tion of the surrounding membranes, which keeps iheni as it were enclosed. Many instances are narrated of foreign substances which liave been developed in the passages, and become tlie source of great irritation. Weppcr has seen a nasal calculus, for which a tooth, the only one that remained in the mouth, pro- jected so high as to form by its root the nucleus of the concretion. Kern speaks of having seen a nasal calculus the size of a nut, and Graefe has met with two — one in a gouty subject, and another which was developed round a cherry stone. Leeches may escape up the nostril, so as to produce excessive haemor- rhage; but they seldom require tlie iuiroduclion of instruments for their removal, as they are readily killed by the snufling up, or the injection of salt and water. Simple measures will usually suffice for the removal of these substances. A pair of ear, or small nose forceps, with the blades carried up vertically on each side of the substance to be removed, the scoop end of a director, or a blunt hook made by bending the end of a probe, will usually answer. If living insects occupy the cavity, injections of olive oil, by closing their spiracula, will usually d-slodge or destroy them. Plugging or tamponing the nostrils in nasal hemorrhage. "Plugging the nostrils," says Professor Ferguson, "for epis- taxis, is often a more troublesome process than might be ima- gined; bnt if the student practice this a little on the dead body, or have an accurate knowledge of the direction of their passage, or do not employ insiruments too comi)licated, he will, I believe, find but little dilhculty in accomplisiiing his object. The vessels from which tlie haimorrhage proceeds are usually high up, and consist of capillary branches from the lateral nasal artery, the trunk of which enters at the spheno-palatine foramen. The trunk near its place of entry may be nearly reached by a flat- tened probe slightly bent outward at the end, and carried for two inches and a half from the root of the septum, obliquely upward and backward, and close to the side of the septum. But it can- not here be effectually compressed without using such force as might endanger the structure of the delicate bones at this part; and it is best, therefore, so far as local means are concerned, to trust to such measures as will produce a coagulation of blood in 232 SPECIAL OPERATIONS. the passage — for, from the description of the structure which has aheady been given, and the site of the hxmorrhage, it will be seen that even when the nose is apparently fully stopped, it is not by direct compression on the bleeding surface, which cannot be made to act so high that tlie bleeding is arrested, but by tiie indirect compression resulting from the coagulation of the blood in the passages." When the therapeutic measures usually directed for tiie pur- pose of overcoming the determination of the blood in cases of sanguine congestion, fail of their object; or wlien in the bleeding which arises IVom local causes, as the removal of polypi or trau- matic injuries, the ordinary topical remedies, such as the snuffing or injection of cold water or astringent or acidulated sohuions through the nostrils — or the insufflation through a quill of pow- dered gum arabic, alum, gall-nuts, catechu or charcoal, which coagulate the blood and produce with it an adhesive mass that acts as a plug upon the bleeding surface of the mucous membrane — are likewise found ineffectual, as they are apt to be when they produce violent sneezing, it becomes necessary to plug the nasal fossa. The most simple method of effecting ibis object is to wind a piece of lint of the length of the inferior meatus, and well wetted in a sohuion of alum, round a probe, so as to form a bulk suffi- cient to fill this cavity, into wiiich it is to be introduced and allowed to remain for two or three days. It is not, however, uniformly successful, as we cannot close thoroughly by this means the posterior orifice, which, it has been shown, is larger than the anterior. This process is, moreover, even when suc- cessful in arresting the discharge, liable to be followed by trou- blesome irritation of the mucous membrane. Common process. — The method altogether the most eflicacions, prompt and least irritating for arresting the flow, consists in the plugging of the two orifices merely. This may readily be eflecled in the following manner with the catheter of Bellocq. (PI, L, fig. 2.) This instrument consists of a silver tube of the size and curve of a female catheter, open at the ends, through which a watch spring passes, and furnished at the entering extremity with a smooth rounded button, provided with an eye for tlie purpose of carrying a thread. Through the eye is passed a small but strong waxed thread, the lower ends secured with a knot, so as to prevent their escape and form a loop. The instrument is in- troduced through the bleeding nostril with the button drawn up. When the end with the curve downward has reached behind the palate, the spring is pushed onward so as to make the but- ton tnrn round the velum and present itself to view in the cavity of the month. The loop of thread is now to be quickly drawn out between the lips, but without detaching its connection with the button, and to its end is affixed a pledget of lint, or a small piece of sponge, of a size sufficient to close the posterior naris, and ,withont being so large when applied as to interfere with re- spiration by the mouth; to this plug a single thread should have been previously attached for the purpose of being left hanging from the mouth to aid in its subsequent extraction. The spring is now to be drawTi forwards, so as to bring the button again to the mouth of the catheter. The instrument is then extracted, drawing with it the plug to the posterior naris, the plug being aided by the end of the finger in its passage round the velum. The thread is next to be detached from the button, and drawn with a little force, so as (o lodge the plug securely in the posterior opening; the two ends are then to be separated in front, and knotted over another pledget introduced between tliem into the anterior orifice. The two orifices are now completely closed, and no more blood can flow than is sufficient to fill the nostril, when it must coagulate and make compression against the bleeding surface. The thread iianging by the month is to be drawn out loosely at one of the corners and attached by a strip of adhesive plaster to the cheek. When the plugs have remained a sufficient time, the anterior is removed by cutting the knot, and the posterior dislodged by a probe carried through the nostril and drawn ont thr-ongh the month with the string left for that purpose. The usual direction in regard to the use of Bellocq's instrument is not to thread the button till after it is projected into the mouth, when it is to be seized and drawn forwards for the purpose. This plan, however, renders the operation more protracted, and more distressing to the patient, in consequence of t!ie pressure which is necessarily made on the irritable velum. The pro- ceeding above recommended I, have found decidedly more ad- vantageous in practice. The instrument of Bellocq is not, however, always at Iiand, nor is it absolutely necessary in plugging the nostrils. A piece of bent wire, a long probe, a strip of whalebone — bent by heating one surface over a candle, a curved bougie or catheter, may be made to carry a thread into the throat, when it can bo seized through the mouth with a blunt hook or a pair of instruments. Process of the Author. — I have very often employed the fol- lowing simple process, which is easy of execution, attended with as little inconvenience to the patient as any other, and requires no instrument that is not wanted for other purposes, and which may be carried in the pocket case. Pass the ordinary catheter for the injection of the Eustachian tube through the nostril, and let the curved end project downwards into the pharynx. Through the cavity of this introduce a piece of catgut, the end of whicli is to be seized below the velum and drawn out through the mouth with a pair of forceps. The tnbe is then to be withdrawn from the nose, leaving the other end of the catgut projecting from the nasal orifice, and the loop lying loosely round the palate. The extremity projecting from the mouth is to be doubled down, and to this the two ends of the double thread which have been tied upon the pledget are to be firmly attached. The catgut is then to be withdrawil through the nostril so as to bring out these ends; the pledget being carried up, and the operation completed as with the instrument of Bellocq. The loop of calgul does not produce the same irritation in the fauces as the spring stilet of the latter instrument, which is too sharp and cutting on the edge. To avoid altogether the inconvenience of passing instruments by tlie mouth, Mr. Martin St. Ange has devised the following ingenious and complicated apparatus. " It consists of a straight canula, four inches in length, widened into the form of a cone at the extremity which is not engaged in the nose, and termi- nating' at the other by a small perforated nipple. The widened extremity has two rings like a catheter, and a small cock at the distance of five lines. Beyond this a slide plays, which may be tightened at pleasure by a screw. Fur the extent of an inch from the outer extremity, circular grooves are made, and a small bladder, formed of the csecum of a sheep, is fixed OPERATIONS UPON THE NOSE AND NASAL CAVITIES. on ihe grooved extremity by a firm ligature. To be still more sure that the bladder may not be thrown off from the tube, it is connected by a thread with one of the rings of the handle. The bladder, being softened and folded round tlie tube, is introduced towards the pharynx, and filled with air or water by injection, which is retained by turning the cock. Slight traction is then employed to draw the small bag closely against the posterior aperture of llie nares. A piece of linen is placed in the orifice of the nares, ou which the screw is to be advanced, and the instrument fixed by its pressure. The whole apparatus can be withdrawn at will by opening tlie cock when the bladder, more or less empty, brings forward the clots contained in the nose."* POLYPOUS TUMOURS. These are growths varying in structure and consistency, mostly pear-shaped, and attached by a stem, frequently developed in the cavity of the nostrils, and found occasionally in all the other passages which open on the surface and are lined by a soft membrane. Their causes and pathology are but imperfectly known. Those of the nose are divided into two classes— the soft and the hay^d. The former are yielding in their structure, mould themselves to the shape of the nostrils, and if they attain to a size too great to be accommodaied in the region in which they grow, advance so as to appear or even project at the aiUerior or posterior nares, without producing in common ixny very great deformity of the nose. The soft includes several varieties:— 1. The vincous or vesicular, consisting of an elongated sac, which is hygrometrical, and filled with a mucous duid; the sac becoming more distended and prominent during damp weather. This va- riety is caused, according lo Deschamps, originally by a collection of lUiid in the submucous cellular tissue; or more probably, as staled by Heisler and Dr. Watsoii,t by the muciparous follicles, which, becoming obstructed in tlieir orifices, enlarge from a col- lection of fluid, and become pendulous so as to form the tumour. 2. The lardaccous, which resembles the former except that its interior is divided into cells and filled with a concrete, friable, albuminous fluid; both these varieties have an oyster-lilce appear- ance, and are pale or straw coloured; they commonly grow, as before observed, from the roof and upper part of the externa! wail. 3. Fungous or bleeding polypus, usually distinguished as malignant. These are of a red or livid colour, and are spongy in their structure. They are very liable to bleed when irritated, and often give rise to spontaneous hiemorrhage. They occupy the ■whole thickness of tlie lining membrane, and sometimes invade the bone. When removed they are exceedingly prone to sprout anew, and have a strong tendency to cancerous degeneration. 4. Granular. These are not usually of large size, consist of a col- lection ofgrayisli or rose-coloured granules, and resemble closely the sypliililic vegetations which grow from the mucous surfaces of the genital organs, to Ihe nature of which they are believed to be allied. The first two varieties of this class fortunately form the greater portion of the polypous tumours met with in practice. • Episfasis, by T. S. Wells, Cyclop. Pract. Surg, and Journ. des Connaissances Medicate, lom. ii, 1834-5. t Vide Amer. Jour. Med. Sciences, April, 1842, for an interesting commnnica- lion by Dr. J. Walson, of New York, on the Pathology and Treatment of Polypous Tumours of the Nasal Fossa, etc. 59 The second class or the hard consists also of several varieties — the fibrous, the sarcomatous, and the cartilaginous or os- seous. The fibrous polypi are pediculated, grow from the fibrous tissue of the part, are smooth on the surface, of a grayish-white colour, and covered with delicate arteries and veins which spring from larger trunks that enter through the root. These are rarely pedunculated, and may grow from any portion of tlie walls of the nostrils, though their more common seat appears to be the two upper turbinated bones. They grate under the scalpel, mould themselves at times more or less upon the cavities of the part so as to have a lobniated appearance, but are so firm in structure as to deform the nose and produce pain by the pressure they occa- sion. Of al! others these acquire the largest size, and are most liable to disunite or perforate the bones of the face. They give rise to hEeinorrhage, and when they become themselves inflamed, are liable to soften and ulcerate, and occasion ichorous discharges, the swallowing or aborption of which may become the cause of death. Their cancerous degeneration is considered rare. They usualty grow from the back part of the nostril. In one case Dr. Mott removed two polypi of this description, which were attached to the floor of the same nostril. The sarcomatous or fleshy polypi are less hard than the fibrous, and are usually attached by a broad base, moulding themselves to some extent on the cavities, and deforming the parts as they grow. They are red or brown coloured, and very vascular, the veins being frequently in a varicose condition. They bleed spontane- ously or from slight irritation, and give rise when much deve- loped to excessive pain. Next to the fungous polypi, they are the kind most liable to cancerous degeneration. They are usually found near the anterior termination of the nostrils;— in two in- stances I have found them occupying the side of the septum near the anterior orifice. Cartilaginous polypi are those of the preceding kind which, instead of falling into malignant degeneration, have in course of lime been converted partly into cartilage or bone. They are rarely met with. Sometimes their more solid portions are mixed up wiih cysts and hairs, so as to form what has been called by M. Gerdy the mixed or compound polypus. It is necessary also lo observe, that the polypi which spring from the lining membrane of the fronial and maxillary sinuses, are also found not unfrequently to advance so as to occupy the nasal cavities. When the nasal polypi become cancerous, or are of that nature from their commencement, as is believed by some writers occasionally to be the case, they grow with prodigious rapidity, involve the bones, and may be mistaken for malignant tumours of the upper jaw.* Little reliance is placed in the action of therapeutic remedies for the cure of polypous tumours. The vesicular or mucous polypi, if discovered sufliciently early, may however — by the use of astringent or weak caustic injections, calomel and sugar in the Ibrm of snuff, or powerful errhines, such as the powdered root of Sanguinaria Canadensis, etc., by modifying the state of the • It is difficult to form a satisfactory classification of nasal polypi. That which I have given will not be found to dilfer in its leading particulars IVoin the classifi- cation of (ierciy, which has generally been welt received by surgeons. SPECIAL OPERATIONS. membrane — be occasionally cured, or at least checked in their growth. Measures of this sort are at least useful in prevent- ing their reproduction after their removal by operation. To facilitate the action of these remedies when employed for the removal of the excrescencesj especially when the patient is un- willing to submit to the use of more efficient measures, it is well to follow the practice of the judicious surgeon already quoted, Dr. Watson, and open them freely with the knife, when they will discharge their contents, and shrink into much smaller di- mensions. Cauterization. — The older surgeons made frequent use of active caustics of nearly all descriptions, including the hot iron, and it is probable, notwithstanding the repugnance properly felt against their employment, and the additional resources for the PLATE LL— MSAL POLYPI-HAEE-LIP. POLYPI. Fig. 1. — Eemoval with the forceps by torsion and traction. — In the process here represented, the surgeon has seized the tumour between the blades of the forceps (a), and after having twisted it upon its root, has brought it by a strong traction to the opening of the nostril. In case it should prove too large to be brought out by this orifice, an incision (b) may be made for the purpose of enlarging it, as in the manner of Dupuytren, between the ala and the upper lip. {Figs. 2, 3.) REMOVAL BY LIOATURE. Fig. 2. — Process of Dubois. — The external surface of the nasal fossa of the left side is shown by a vertical section through the head — the septum narium being removed completely with the exception of two small strips. At the period of the operation shown, the three ends of the threads — those of the ligature (e, c), that of the coloured thread {d), which controls the movement of the segment of the gum catheter — have been drawn out by the anterior orifice of the nostril. The third thread (e), designed to draw back at will the loop of the ligature, is pendent from the monih. The left fore finger of the surgeon (/) is passed through the mou(h and curved upwards behind the velum palati, for the purpose of carrying the loop of the ligature behind and around the polypus, so as to embrace its root. When this application of the ligature has been effected, the segment of the catheter is to be withdrawn by pulling on the coloured thread. The ligature is then to be tightened by the introduction of a se7-re-nmud or knot-tier over its extremities (c, c). If the loop in the attempt is not drawn over the polypus, it is to be pulled back by the third thread (e), and the manceuvre repeated. Fig. 3. — Process of M. Felix Hatin. — The anatomy of the parts represented is nearly the same as in fig. 3. The period of the operation shown is that in which the instrument [g) has been carried from the mouth behind the palate, til! the extremities (A) have reached the top of the palate. All that then remains to be done, is to have the two ends of the ligature {i, i) drawn by an assistant over the polypus so as to embrace its root ik). ^ HARE-LIP. Figs. 4, 5. — Simple harc-lip. — In fig. 4, the rounded margin of the lip is represented as having been removed on the right side of the fissure, and the surgeon, who is placed behind the patient, extends the left margin with his left hand, while he excises the rounded edge with a bistoury in his right. In fig. 5, the fissure is shown closed after the excision of the edges, by the two hare-lip sutures. {Figs. 6, 7, S.) DOUBLE HARE-LIP. COMPLICATED HARE-LIP. Fig. 6. — This shows the state of the parts immediately after the excision of the four edges, two of which (c, d) are on either side of the middle line. The central portion is the incisive or intermaxillary tubercle, consisting partly of a bony prominence on the front of the two middle incisor teeth, and partly of a thickened mass of gnm and skin. This tubercle (o) was adherent by its cutaneous surface to the column of the nose {h), from whence it has been detached with the knife. The incisor teeth, which had diverged from each other, have been partially loosened in their sockets so as to allow of their approximation with a metallic thread. Fig. 7. — This represents the forcing backwards with a pair of flat-bladed forceps of the prominent portion of the jaw, in which the two incisor teeth are lodged. This attempt to bring the teeth down to their proper level is commonly attended with slight fracture of the bone. Fig. 8. — This shows the appearance of the parts at the completion of the operation, after they have been closed with three twisted or hare-lip sutures. The pins are not represented as having taken a sufficiently deep hold. The wrapping of the pins is left incomplete for the purpose of showing better the adjustment of the raw edges. F,g 7 riaie sr. 0>, Slo'ie by^ .A"rwsam OPERATIONS UPON THE NOSE AND NASAL CAVITIES. 235 removal of this affection possessed at the present time, tliat cases may occasionally occur to justify their application. Waliher speaks very favourably of the process of an empiric named Jensch, who employed an energetic caustic composed of the butler of antimony, nitrate of silver, and sulphuric acid. His practice was to make use of a long pin with a head the size of a large pea; this was covered with the paste and applied five or six times to the prominent part of the tumour. A solution of aUim was thrown up an hour previously, and again an hour after the operation. The cauterization was repeated daily until the tu- mour was destroyed. Any remains left were touched witli the nitrate of silver, and the aluminous injections continued for two months, in order to prevent the redevelopment of the tumour. To restore the sense of smell, says the narrator, the patient was directed to employ the powder of napeta (leucrium verum) in the form of snuff. It is fay no means unlikely, in cases where the timidity of the patient is snch as to prevent the prompt and efficient extraction of the tumour, that this measure might succeed where the polypus was neither deep seated, large, nor malignant in its character. The actual cautery, if carefully applied as recommended by Richter and Deschamps, would no doubt effect the prompt de- struction of even large polypi. But the inflammatory symptoms that might follow, and the risk of cerebral irritation, especially when the seat of its attachment is high, constitute the objections to its application. The use of the hot iron may indeed be con- sidered as limited to the destruction of the basis of the fungous or malignant polypus after the bulk of the tumour has been re- moved by extraction. The measures to be relied on for the cure of polypi are extrac- tion, excision, and strangnladon. Before proceeding to apply either of the methods, the operator should determine as nearly as possible the place of attachment of the tumour. If the tumour be pendulous, the individual should be directed to blow strongly through the affected nostril, by which means it will at times be brought forwards so as to be completely in view. For a thorough examination of the passage the patient should be placed so as to let a bright light fall upon the inner surface of the nostril, which should be dilated by draw- ing the ala to one side, introducing the blades of the dressing forceps, or the funnel-shaped silver canula, called the speculum nasi. A whalebone or silver probe may then be passed up along the two sides of the tumour, which should be drawn for- wards so as to render it tense, in order to ascertain iis place of origin. If there is reason to suspect that the tumour hangs from the posterior nares, or is attached near it, the finger may be carried up behind the velum to serve as an exploring sound. Exiractio/i. This is the method most commonly used, and is indicated in all cases where the polypus is not too deep seated, nor its basis too broad and firm. It is inapplicable when the tumour is affixed by a strong tendinous root to a soft bottom, as the velum palati; or its position and extent be such as not to allow the application of the forceps, or a small canula and wire loop. Extraction may be made by twisting the tumour upon itself, so as to rupture its point of attachinent. This is called the re- moval by torsion. It can only be effected when the straight or slightly-curved forceps are applied, as there is not room in the nostril for the rotation of a curved instrument on its long axis. Extraction may also be accomplished by evulsion, grasping the tumour securely, and moving it suddenly either forward or back, and in some instances in both directions. Both these modes may very frequently be combined with advantage. 1. ffith a ligature. [Process of Theden.) — It is a process employed by the ancients. Thread the two fenestra of the poly- pus forceps (which will serve the same purpose as the double ring forceps of Theden) with a strong silk or hempen ligature, and carry them from the anterior naris below the tumour; open then and carry the blades up on the sides of the tumour. The lig- ature is to be left behind the tumour, and as high up as possible as the blades are withdrawn. A serre-nccud or a small cylinder is then slid over the two ends of the string, so as to tighten it on the tumour and allow of the necessary traction. This process is, however, seldom used, for if the forceps can be carried round the tumour, they may also be made to grasp it either for the purpose of torsion or evulsion. 2. With a loire ligature and the double canula of Levret. [Process of Randolph.) — The ends of a well-annealed iron wire are to be passed separately through the two tracts of the canula, leaving an oblong loop about an inch long in its greater diameter. One of the ends is to be secured to the corresponding arm of the instrument. The loop should be bent so as lo form a slight angle with the canula, and introduced first vertically into the nostril, and then turned upon the floor of the nostril so as to receive within it the pendent portion of the polypus, np which it is to be carried as far as possible towards its place of attachment. By drawing firmly on the loose end of the wire the loop is tightened on the polypus, seldom cutting it even when soft, and furnishes a secure hold for its removal by evulsion. The process is to be repeated till all the tumours arc removed, and the passage ren- dered free. I have seen this process admirably executed by Dr. Randolph, of this city, and it has succeeded well on many occa- sions in my own hands. In deep-seated polypi this plan may be considered more safe and certain than that with the forceps, as the turbinated bones from their shape cannot be included in the loop. 3. With the fingers. (Process of Morand.) — This process is susceptible of application only in cases where the polypus is firm and small, and attached by a slender pedicle. The fore fingers of the two hands are to be introduced— one by the aiUerior and the other by the posterior naris, and the polypus pushed between their ends backwards and forwards till it breaks away at the root; it is then to be removed with a pair of forceps or a hook through the anterior orifice — or by the posterior, if that should be found most convenient. This process is but seldom now em- ployed; but in combination with the use of the forceps the intro- duction of the finger in the posterior naris may be found highly advantageous, not only in changing the position of the tumour so as to render it more easy to be seized, but in pressing it for- wards so as to assist the action of the forceps in rupturing its pedicle. 4. With the forceps. — This is the process most commonly employed. It is advised for some days previous to the operation SPECIAL OPERATIONS. to dilate (lie anterior orifice of ihe nostril with sponge tent, gentian root, &c., in order to render more easy the introduction and mani- pulation of instruments in the passage. The instruments required will be several pairs of polypus forceps of dififerent sizes, straight or very slightly curved for operation through the anterior orifice, and curved more or less lilte the letter S for introduction through the month into the posterior orifice. Occasionally it will be found most convenient to have at hand the forceps of Josophi, which are formed in separate branches, and are to be applied separately and locked like the obstetric forceps. A good hook, a pair of toothed forceps, a probe-pointed bistoury, a pair of curved scis- sors, and the apparatus for suppressing bleeding, as described at page 332, should also be at hand. Whatever process of extraction is followed, it is often necessary to suspend the proceeding from time to time when the patient is fatigued, in order to clear the cavities of the nose and mouth of blood, and give the patient time to recover. If profuse haemor- rhage follow, not arrested by the extraction of tiie tumour at its root, it may become necessary to plug the cavity and defer com- pleting the operation to another day. By the anterior naves. (PI. LI. fig. 1.) — The patient should be seated before a window, and the head thrown back, and sup- ported against the chest of one assistant, while the hands are em- braced by another. The operator then introduces the blades of the instrument closed, and with their edges vertical. He carries it onward, using it as a probe to ascertain the seat, size, and direction of the polypus, and opening the blades, grasps it as near as possible to the root. If the polypus be not too large, it should be drawn forwards, and tlie instrument then rotated several times on itself; if Ihe root do not then give way, it is at the same time to be pulled or jerked forward. If the tumour is large, or for other reasons cannot be twisted, it is to be steadily drawn forwards, and a half turn given to the instrument. If there is much resistance fell in bringing it forward, the fore finger of the left hand should be placed under the forceps so as to give them more eflect, or convert them into a lever of tiie third kind. When the tumour comes out elongated from the nostril, it should be seized nearer its root, with a second pair of forceps, before the first is removed; and if necessary, the application of tlie instrument may be a third time repealed. If the root then give way, the ex- traction is effected. If it be loo strong to rupture, it will probably be stretched down so as to come in sight from the orifice, and may be severed with the probe-pointed bistoury or curved scissors. If it be so soft as to give way in its middle, the instrument must be again and again introduced to remove the portions left. If from the size of the polypus the resistance is so great as not to yield to repeated strong traction and torsion with the forceps, aided by pressure with the finger through the posterior naris, an attempt to rupture its root may be made by pushing it backwards and forwards, after having mashed and lacerated the root by closing the instrument firmly on it with both hands. If the difficulty arise from the narrowness of the anterior orifice, as in cases of large polypus where the nasal bones have been absorbed, this may be enlarged, as has been done by Dupuytren, Serres and Velpeau, by dividing the ala at its connection with the lip and cheek; or, as has been suggested by Vidal, instead of the ala we may divide the inferior attachment of the septum, which gives as much room as the section of the ala, and leaves no external cicatrix. By ihe posterior nares. — When the tumour is situated at the same time in the nostril and upper part of the throat behind the velum, it is to be extracted through the cavity of the mouth. The jaws should then be widely separated, and a piece of wood interposed between the molar teeth. The straight forceps can here also occasionally be used, by preparing the velum a few days previously, so as to accustom it to the contact of instru- ments, and should, when they can be applied, be preferred to the curved, as they admit of the employment both of torsion and evulsion. If curved forceps be used, evulsion alone can be practised, and from the shape of the parts, it is upon these in general that we are compelled to rely, of which several of different forms should be at hand. The left fore finger should be introduced behind the velum, along which the blades of the instrument should be conducted with the other Iiand, so as to seize the polypus near its root. I found it in one instance, con- venient, to pass the first two fingers of the left band behind the velum, so as to get the polypus between them, over which the blades of the opened forceps were readily slid upon the pedicle. If the tumour does not readily yield to moderate traction down- ward, a spatula may be passed through the nostril from before backward, to aid the eflbrt by pressing against the root. Care must be observed to avoid injury of the velum, and al! pressure upon the root of the tongue, as the latter would be likely to produce vomiting. By these measures, success will in general be attained; but if the polypus rest upon Ihe soft palate, and fill up the space be- hind it so as not to be grasped with the forceps, or has its neck within the posterior orifice of the nostril, it is recommended to divide the velum in two by the side of the uvula, (where it is least vascular,) with the bistoury or scissors. Through the fissure thus made, it will be easy to seize the polypus near its root, or, if necessary, remove it in fragments with the bistoury or curved scissors. After the complete removal of Ihe tumour, the suture of the velum is to be at once made. By both orijices. — If the polypus has grown in both direc- tions, the extraction of the nasal portion through Ihe anterior orifice is to be first made, and the posterior growth removed afterwards as above direcied through the mouth. But in some rare instances, cases are met with in which the polypus attains great size, moulds itself on the irregular surface of the nostril, and penetrates even into the antrum by its opening, or through the spheno-palatine foramen or both, and erodes and makes new passages in various directions through the bones. For such cases, no prescriptive method can be given ; but a combination of the various processes may be made, or new ones devised suited to the exigencies of Ihe case, all which must be left to the inge- nuity and the skill of the operator. Dupuytren, and Cliaumet of Bordeaux, have succeeded under circumstances of this de- scription, ill dividing the polypous growth and removing it in fragments, partly by the anterior and partly by the posterior nares. In some instances. It may even become necessary to remove a portion of Ihe bones in order to get at the seat of the tumour,— as recently done in one instance by Professor Molt.* • Amer. Jour. Med. Sci. Jan. 1843. OPERATIONS UPON THE Nl :OSE AND NASAL CAVITIES. 237 Excision. This is a method at present but seldom employed, though ihe one most frequently used by the ancients, who devised for its performance particular cutting instruments in the form of a spatula or chisel. Fabricius employed a sort of forceps with a double cutting edge; Wathely a sheallied bistoury or syringo- tonie — but modern surgeons, in the few instances in which they resort to excision, employ in common nothing but the ordinary long branched scissors curved on the flat, or a probe-pointed bistoury wrapped round with adhesive plaster, so as to leave a cutting surface only near the end. Excision is only indicated iu cases where the root of the poly- pus is small but inVyielding, is accessible to vision or touch, and seated near one of the orifices of the nostril; or when it is employed for the purpose of dividing in pieces a polypus so large as to prevent the introduction of any instrument for extrac- tion or ligature. I havo on several occasions removed by exci- sion, sarcomatous or caruncular growths near the anterior orifice, but have generally found it necessary to resort to innnediate plugging to check the hemorrhage, and the subsequent use of caustic to prevent the reproduction of the tumour. If the operation is practised by the anterior orifice, the poly- pus is to be drawn forward with a pair of forceps or a hoolc till its neck or root is visible, which is to be divided with the straight probe-pointed bistoury, guarded as above directed. If the section is made through the posterior nares, and by the mouth, a pair of curved scissors is the only instrument applicable. Process of Wathely. — In a case of very large polypus with a broad root, this operator first carried around it tlio loop of a ligature, leaving the two ends hanging out from the anterior nares. One of these ends was held by an assistant; the other he slipped through a ring adjusted to the end of the sheathed bis- toury or syringotorae, which served as a conductor, so as to enable hiui to bring the knife upon the pedicle of the tumour and divide it. By strangulation ivitk a ligature. This method — after extraction — is the one most commonly employed, especially for hard polypi, which have their seat near the posterior part of the nostrils, and project into the throat. When judiciously employed it will obviate in almost all cases the necessity of dividing the velum. The object of the method is to strangulate the pedicle by a ligature tightly applied around it, when the polypus, which is nourished from the vessels of the root, sloughs ofl'. I3leeding is effectually prevented by this method, but its execution is always more or less difficult, sometimes even im- practicable, and the treatment necessarily protracted and tedious. Occasionally violent pain and inflammation follow. The polypus, if it does not separate at once on the tightening of the ligature, as sometimes happens, swells up in the first place, and iu the end becomes a putrid mass— rendering necessary the rinsing of the passages from time to time with cold water, or a weak solution of the chloride of soda, to remove the odour and prevent the offensive fluids from accumulating and passing into the stomach. To ob- viate still more effectually this latter accident, the patient should lie on his face. This position, at the period of separation of the - 60 polypus, will also diminisli the risk of the tumour falling back- wards, and either passing into the pharynx or obstructing the ■ orifice of the larynx. It is also considered advisable, when prac- ticable, to pass with a curved needle a thread through the body of Ihe tumour, bringing out the thread and securing it upon the cheek, so that ttie patient or an assistant can raise the tumour at the moment of its loosening and withdraw it through the mouth. Various instruments and processes have been devised for the application of the ligature, a practice which was known to the Greeks and Arabs. The best of these are the followin?. Process of Levret. — This consists in the application of a wire ligature and a double canula, as described for evulsion at page 235, with the exception that the pedicle — which could not be broken without the application of a force that might be injurious — is to be strangulated by tightening the second end of the liga- ture, and leaving the instrument in place, tightening the ligature further from day to day till the separation is effected. Process of Brasdor. — This is very superior to the process just described. A portion of well-annealed silver wire, eighteen inches long, is to be doubled so as to form a loop in the middle, and passed through the nostrils till the loop is seen in the back part of tlie pharynx, from whence it is to be drawn a little forwards, so that a strong tliread may be attached to it on the side of the mouth. The two ends of the wire are then to be drawn for- wards from the nostril, while one or two fingers glided behind the velum directs the loop round the tumour, so that it may slip up and embrace its neck. If the attempt to catch it fail, the thread from the mouth serves again to draw down the loop, and the manceuvre is to be undertaken anew. When the neck is embraced, the two ends of the ligature are to be passed through a serre-noeud, or a double canula tightened firmly on the root and left in place. An additional lightening will be required daily, and in the course of seven or eight days the separation is usually effected. This process has been more or less modified by various sur- geons. Desault conducted the metallic ligature through the nos- tril by means of a canula. Boyer preierred either the catgut liga- ture or a silk cord, which he introduced with the aid of liellocq'S instrument. Liston and others employ in place of the catgut a piece of slender whip cord. Dubois (PI. LI. fig. 3} made use of a stout silk ligature, and devised the following means for getting the loop round the poly- pus. Previous to introducing it, the end of a gum catheter, from half an inch to an inch and a half long, according to the size of the tumour, is slid over one end of the ligature, so as to rest on the portion which is to. form the loop. A coloured thread, for the purpose of distinction, is to be attached to one end of this piece of catheter, and another, uncoloured, to its middle. The uncoloured thread is subsequently to be brought out from the mouth, as in the process of Brasdor. The apparatus being ready, an ordinary gum catheter is introduced into the pharynx through the nostril, and its end brought out with the finger through the mouth. To the eyes of this catheter is attached the coloured thread and the two extremities of the silk cord, all which are to be drawn back with the catheter through the nostril. The three ends now hang from the anterior nares, from which the catheter, being no longer useful, is to be detached. The surgeon next SPECIAL OPERATIONS. carries one or two fingers beyond the polypus in tlie throat, so as 10 direct the loop behind it, while an assistant draws at the same moment on the two ends of the silk cord and the coloured thread. If the loop meet with firm resistance as it rises up, it has embraced the tumour. If it does not, it is to be drawn down again by the thread hanging from the month, and tiie attempt repeated. When once well embraced, the buccal thread may be cut, and the segment of the catheter, which served the purpose of spreading the loop, withdrawn as no longer of any use, by pulling on the coloured thcead. The strangulation of the pedicle is then to be made with the aid of a serre-nceud or cauula, as in the process above described — the former being preferred to the canula, as the latter is cumbersome, and irritates the nostril. iStib-process of Rigaiul.—\n 1S29 this surgeon devised a port- ligature, which has been employed with considerable success, and been variously modified by ditferent surgeons. It consisted of three sioel branches, curved at their extremity, and enclosed in a canula, and which admitted of being separated and closed at will. Each of the branches is pierced at its extremity with a hole, continuous with a slit, the sides of which are elastic and yielding. Through these holes or rings is passed the ligature, which is liirown into a loop by the separation of the branches. Bellocq's instrument is to be carried through the nostril into the mouth, and to the button of the stilet the two ends of the ligature are to be attached and drawn with the instrument out of the nostril. As the two ends of the ligature are drawn through the nostril, the port-ligature is carried in its expanded state behind the velum, so as to embrace the polypus in the loop; further traction expands the slit in the elastic rings, so as to detach the instrument and bring the ligature round the root of the polypus. M. Hathi has modified the port-ligature of Rigand, by making the two lateral steel branches move upon the middle one by a screw, so as to be opened at will. This modification has been many times successfully used. When the ligature is once fairly applied, the choice of a serre- nceud, is a matter of some importance, as it is desirable to obtain such a one as will produce the least pain and irritation in the fauces. That of Graefe as modified by Dupuytren will answer well; but the chaplet of Roderick or Mayor is entitled to a pre- ference, as from its flexibility it accommodates itself to the curva- tures of the passages. Whatever method lias been employed for the removal of the tumour, the final success'of the operation should be tested by causing the patient to blow through the diseased nostril in order to see if the air passes freely, or whether there are any tumours remaining that require to be removed. . Jf the passage is found free, it is an indication that the operation has succeeded in re- moving not only the tumour itself, but a large part of its root. CATHETERISM AND PERFORATION OF THE FRONTAL AND MAXILLARY SINUSES. These are cavities annexed to the nasal passages, and lined l?y a continuation of the same mucous membrane. From the position of the orifices of communication in the nostril, shown at page 230, it will be readily perceived that a tumour developed ui either cavity may encroach on that of the nose, or one de- veloped in the latter, in its turn encroach upon or obliterate those passages. Frontal sinuses. These cavities are the more developed in size in proportion to the age of the patient; they are hollowed out in the interior of the internal orbital processes of the frontal bones — those of the two sides being separated by a perpendicular bony septum — which is frequently found incomplete — placed in most in- stances in or near the median line. The cavity of the sinus often extends far in the diploic structure of the bone, and has in some instances been found to reach the external orbital pro- cess. The orifice by which it communicates with the nose is funnel-shaped, extending down through the anterior ethmoid cells, and may, if occasion requires it, be traversed by a flat probe or catheter. The cavity of the sinus can be reached also by applying the trephine or perforator upon its anterior wah, or upon its inferior or orbital. This is an operation, however, sel- dom or never required. The anterior wall is thick and covered by the root of the eyebrow; the orbital, though thin and yielding, has passing over it the frontal branch of the fifth pair of nerves, and a small artery, which would be more or less exposed to injury in the use of the trephine. In case of obliteration of the orifice of communication with the nose, it would be possible to restore it by introducing the needle trephine of Weinhold up- wards from the nostril into the sinus, retaining the new orifice patulous by the introduction of a piece of catgut string, or the repeated use of astringent injections. In abscess of the frontal sinuses, the aflection to which these cavities are most subject, the pus finds usually after a time a spontaneous passage into the nose. Polypous tumours, which sometimes though rarely form in these cavities, tend naturally to show themselves iu the nasal fossa;, from whence, according to Heister, it is possible to extract them. Cases, however, may occur, where this communication with the nose is permanently obliterated, so as to render one of the following operations ne- cesary. Catheterism. — The channel by which the frontal sinus com- municates with the nose is about half an inch long, and runs from above downward and backward, and opens, under the anterior extremity of the middle turbinated bone. A flat probe or catheter slightly bent forward at the end and carried in this direction up- ward and backward, pressing at the same time upon the lip near the root of the septum, may be made to enter the lower end of the channel. Worms sometimes lodge in this passage, and if their presence is detected, some oil or a bitter infusion may be injected through the catheter. If the needle trephine of Wein- hold be used, it must be applied in the same direction in which the probe is passed. Perforalion through the walls of the sinus. — This may be made with the trephine or the ordinary perforator. Occasionally a fistulous orifice is found in the bone, which needs only to be enlarged in order that we may wash out by injections the matter of the abscess, or extirpate a polypous tumour. In other cases, it is advised by Velpeau to uncover the bone below the eyebrow, between the groove above the upper margin of the orbit and the root of the nose; and from this point, direct the small crown * OPERATIONS UPON THE NOSE AND NASAL CAVITIES. 239 of a trephine or the ordinary perforatoTj backwards, upwards and inwards, so as to open the sinus at its most depending point, and at a place where its walls are thinnest and the vessels and nerves least exposed to injury. The opening, whether made by ulceration of the bone, or by operation, is apt to become fistulous and allow the escape of the air from the nose in respiration. Its closure is in consequence somewhat difficult, but may be effected by one of the plastic processes. If the communication with the nostril does not exist so as to allow the discharge of the secretion from the sinus in the usual manner into the nose, it must be established by the use of the probe, and by the injec- tion of fluids, before an attempt is made to close the outer orifice. Maxillary simis. This is a triangnlar-shaped cavity, occupying the centre of the body of the upper jaw bone, the base of which is turned toward the nasal fossa. In a surgical point of view, it may be considered as bounded by four walls. 1. The internal or nasal, formed by the external face of the nasal fossa, begins half an inch behind the bony border of the anterior orifice of the nostril, a little posteriorly to the tract of the nasal duct, and the nasal process of the maxillary bone. This wall is thin and delicate, and divided into two portions by the inferior turbinated bone; — the inferior portion is formed by the walls of the inferior meatus; the upper one by that of the middle meatus, at the top of which, as has been before observed, and immediately under the middle turbinated bone, is the orifice by which the sinus commu- nicates with the nostril. 2. The superior or orbital wall is formed by the floor of the orbit, and is so ihin, especially at its back part, where it is traversed by the infra-orbital vessels and nerves, as to offer little resistance to the expansive force of a tumour growing within the sinus. 3. The external wall is on the side of the cheek, and is divided into two portions by the root of the malar process of ihe maxillary bone. ■ In front of this process is the depression called the fossa canina, about half an inch above the two small molar teeth, in which the external wall is most thin. 4. The inferior or alveolar wall consists only of the breadth of the alveolar ridge; the sockets of the first and second large molar teeth are opposite the lowest point of the sinus, and the roots of these teeth frequently penetrate into the cavity, so as to be separated from it only by its lining membrane. When the maxillary sinus is distended by a tumour, or cyst, the nasal and orbital walls are the first to yield; the distortion of the former may be such as to push the septum of the nose over to the other side, and that of the latter, so as to protrude the eye upon the cheek. T[ie anterior wall, sooner or later, yields so as to become prominent under the flesh of the cheek, and the in- ferior in the end descends so as to efface more or less the bony arch of the palate. In this way, the cavity of the sinus is often found dilated in all directions, and attended most commonly at the same time with softening of the texture of the expanded bone. Catheterism of ihe maxiUary sinuses. {Pi'ocess of Jour- dan.) — This was first proposed and practised by Jourdan as fol- lows, in a case of accumulation of fluid within the sinus. The patient was seated in a chair with the head thrown back, and sustained against the chest of an assistant. A small silver tube. like that for the nasal duct, but two inches longer and somewhat less curved, was introduced through the corresponding nostril to the under surface of the middle turbinated bone. The point having been carried upon the fold formed by the pituitary mem- brane lining the orifice, he elevated the wrist so as to press the point outwards and pass it into the cavity. The natural orifice was found in this instance obliterated, as mostly occurs in these cases of retention of the secreted fluids. The tube was left in till the following day, and served both for the discharge of the fluid and the introduction of appropriate injections. It was then removed, and the patient on blowing the nose discharged a large quantity of mucus. By a repetition of these measures, the pa- tient was finally cured at the end of six weeks, Malgaignehas given the following more precise directions for the introduction of the tube, viz: carry it obliquely upwards, backwards and beneath the middle turbinated bone, so as to penetrate to the depth of an inch and a half and on a level with the upper fold of the ala of the nose. Then gliding the beak of the instrument under the turbinated bone, it falls naturally upon the orifice, and by a movement of rotation is made to enter the sinus. But the introduction is always more or less difficult, and sometimes altogether impracticable. The method of Jourdan is therefore in a great measure abandoned, preference being given by a majority of practitioners to the formation of an artificial opening by perforating one of the walls^of the sinus. Perforation of Ihe maxillary sinus. — This operation may be required for dropsy or abscess of the sinus, or in cases of the development within its cavity of polypous, fungous, or carcino- matous tumours. The opening may be made either by the mouth or cheek. The perforation of the nasal wall has been made, and it is said with success, by Gooch and Richter, but the process has not been generally adopted. The perforation of the orbital wall has been made by Laugier, as stated at page ISS, in cases of obliteration of the nasal duct. By the rnoiiik. 1. Perforation through the socket of a tooth. (PI. L. fig. 4.) — This process is indicated in cases of accumulation of mu- cous or purulent fluids in the sinus, and especially if any of the molar teeth have been lost or found carious, or the socket itself is in a state of disease. It has the advantage of furnishing an opening at the lower point of the sinus, but cannot be made sufficiently large for the removal of polypous or other tumours, without the complete excision of one or more of the alveola with the cutting forceps or the saw. The operation consists in the extraction of one of the molar teeth, and penetrating through its socket into the sinus with an ordinary trocar or the perforator. On the choice of the tooth to be extracted, there is much variety of opinion. All the molares, however, with the exception of the first, correspond to the floor of the sinus, and if either of these be carious, that is the one which should be drawn. But if one has been previously lost, the ne- cessity of extraction is of course removed. If a selection has to to be made, the second small or the first large molar should be removed. Malgaigne, inasmuch as the large molar is more im- portant for the purposes of mastication, prefers to take away the second small molar as its removal will be found to yield sufficient 240 SPECIAL OPERATIONS. room for tlie use of the trocar, in cases simply of accumulated fluid. To keep the passage open, so as allow the discharge of the secre- tion and the injection of simple fluids, a wooden plug, a leaden style, or a canula like that employed for the nasal duct, have been recommended. In my own practice I have seldom found these useful beyond the first few days, except during meal time, to prevent the introduction of alimentary substances, as the passage afterwards remains open of itself, or is easily kept free by the occasional introduction of a probe. The patient is able also to carry the fluid by suction through the sinus, especially when the natural orifice has become free, to more advantage than it can be thrown in by the use of the syringe. When all morbid symptoms cease on the side of the sinus, the orifice may be allowed to close. 2. Perforation by the external wall. (Process of Lamorier. PL L. fig. 4.) — This consists in penetrating into tlie sinus between the malar process of the upper maxillary bone and the third molar tooth. The corner of the mouth is to be drawn outwards, upwards and backwards by an assistant, with the blunt hook or with the finger. The mucous membrane is then to be divided at the point of its reflection from the jaw to the lip, and the bone perforated with a trephine, or witli a stout scalpel if its tissue be softened. The orifice may afterwards be enlarged at will, to admit of the introduction of the forceps and knife for the extraction or excision of tumours, or the introduction of lint, styptics, or cauterizing irons, which are sometimes required to arrest the haemorrhage which follows. If the reflected mucous membrane should prove so redundant as to come in the way, as I have found it in one instance, it may be divided by a crucial incision, and the angles snipped off. This process, however, is but seldom employed. Desualt preferred to penetrate into the sinus by the fossa ca- nina, where the wail is most thin; and a strong knife, in cases requiring the operation, will ordinarily suffice to make the open- ing. Having denuded the bone by a previous incision above the gum and elevated the lip, he entered the scalpel, and turned it four or five times on its axis to make the opening sufficiently free. When the teeth are all sound this process might be em- ployed in place of extraction of a tooth and perforation through its socket. But in case of a large polypous or fungous tumour of the antrum it is unquestionably preferable, as an opening may be made large, and of an oblong shape, above the roots of the teeth. If further room should be required, Dupuytreu recom- mended that a vertical incision through the bone should in addi- tion be made up to the base of the orbit, along the outer side of the nasal process of the upper maxillary bone. Process of Stevens. — Dr. A. H. Stevens, of New York,* suc- cessfully removed a tumour of the antrum complicated with dis- ease of the floor, iu the following ingenious maimer. He removed first the second incisor and second molar teclh, then denuded in the usual manner the anterior face of the maxillary bone, which he perforated with a long, slender trocar, as in the manner of. Weinhold, from the digital fossa through into the mouth at the junction of the palatine processes of the maxillary and palate bones. A delicate saw was next introduced along the track of * Vide Notes to Slerling's Translation of Velpeau's Surgical Anatomy. the trocar, and tiie bone divided downwards through the empty socket of the incisor tooth. A flexible double hand-saw, made of a clock spring, was then employed to divide the bone down- wards and backwards from the place of perforation through the socket of the second molar tooth; thus removing all the diseased portion, and making the section through the sound structure beyond the limits of the disease. 3. Perforation of the palatine arch. (Process of Callisen.) — This method is only applicable to cases in which a distinct fluctuation is felt through the thinned and softened bone, and ■where there is a considerable lateral enlargement of the antrum. The opening may be made with the bistoury; very frequently a fistulous orifice will be formed through the arch near the gum, which merely requires enlargement. In a case of this description Ruffel introduced a trocar by the palatine orifice, brought it out above the gum on the opposite side of the ridge, and passed a seton through the track. Nerri has advised as an ordinary- process, the passing of a seton in this manner in cases of abscess or mucous dropsy of the antrum. By the cheek. Difl^erent processes are given by Weinhold for perforation through the cheek. If the object be only to remove collected fluids, the needle trephine is thrust, in the direction of the nose, through the cheek into the maxillary fossa at a point a third of an inch from the root of the malar process and at the same dis- tance from the margin of the orbit. The instrument is carried by a drilling motion through the anterior wall of the sinus, some- what obliquely downwards. If the object be to destroy any pseudo-production in the sinus, the needle with a thread previ- ously passed through its eye, is carried in the same manner into the sinus, and pushed on through its cavity so as to perforate the palatine arch a few lines to the inner side of the third molar tooth, the finger of the operator guarding at the time the tongue from injury. As soon as the thread becomes visible, it is pulled out through the mouth by means of a hook. The instrument is then removed, leaving the thread in its track, which is now to serve as a conductor to a strong cord, or a roll of charpie, which is to be smeared with various stimulating and caustic applica- tions, and drawn into the centre of the mass. A small piece of sponge is to be attached to the thread, so as to close the lower orifice and prevent the constant escape of purulent fluids into the mouth. Molinetti and others have made a crucial incision of the cheek, in order to expose and open the antrum. But in all ordinary cases this measure, which leaves an unsightly cicatris, may well be supplied by some one of those already mentioned. In some instances, however, the bones are found so extensively disorganized from disease seated in the antrum, that all the pro- cesses for perforation will be found insufficient, and a resection of the walls of the cavity to a greater or less extent will be ren- dered necessary. It is impossible, however, to give any general rules for such proceedings — many of which must be conducted according to those laid down for the partial resection of the upper jaw— every case becoming in fact a subject for particular study, in which a modification or combination of the various processes above given may be made with advantage. OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 341 IV. OPERATIONS UPON THE MOUTH AND ITS DE- PENDENT STRUCTURES. The organs which form the gustatory apparatus are very different in their anatomical structure, and vary much in refer- ence to the operations which their diseases or malformations render necessary. Tliey may be arranged for practical purposes into four classes: — The Lips and Cheeks; the Salivary Organs; the Tongue, and the VuUim Palati. OF THE LIPS AND CHEEKS. HYPERTROPHY OF THE LIPS. This is usually a congenital affection, without alteration of texture, and is to be considered a faulty conformation rather than a disease. In some few cases it has been observed to follow an attack of scrofnla in which the lips have become permanently thickened by interstitial deposit. It produces a disagreeable ex- pression of coinitenance, and exists in various degrees more or less susceptible of relief by operation. 1. Tumour of the mucous membmne. —This is usually limited to the mucous membrane lining the iiuier surface of the upper lip, but is occasionally found upon the lower. It consists usually of a transverse red luinour, extending no farther back than the point of reflection of the mucous membrane, which is exposed over the incisor teeth and causes the hp to be more or less reverted up- wards in speaking or laughing, producing a deformity commonly known as the double lip. Sometimes the oblong tumour, or portion of thickened membrane, is cleft on its free surface, so as to appear as two separate portions. The excision of this tumour was first practised by Boyer, and has since become a legitimate operation where it is productive of great deformity. Excision.— An assistant standing behind the patient supports his head, and drawing up the commissures of the nioutii, reverses the lip so as to expose the hypertrophied mass. The surgeon seizes it with his fingers, or a pair of broad-bladed forceps, and excises it at a single sweep with the straight bistoury or scissors curved on the flat. The bleeding is to be suppressed by holding ice water in the mouth, and the wound usually cicatrizes in a few days. In some instances the healing is only effected at the end of two or three weeks; to avoid such a protraction of the cure, Velpeau has proposed the following modification of the operation, viz, to intro.luce before excising the tumour three or four ligatures through its base, and remove the tumour without loosening their attachments. The threads are then to be knotted so as to close the wound, and removed on the second or third day, when union will be found to have taken place. 2. Ili/perlrophy or thickening of the tipper This en- largement of the lip— usually one of the signs of scrofula— is sometimes met with unconnected willi that affection. It depends upon a thickening and serous infiltration of the cellular tissue, lire enlargement of the sub-mucous or labial glands, and a tumefac- tion of the mucous membrane. The muscles of the lips are found pale and thin, like those of an old man. Excision of the tumefied parts for the cure of this deformity was first practised by M. Paillard in 1826, and has since then been several times repeated successfully by different surgeons. One of the commissures of the mouth is to be drawn upwards by an assistant, while the surgeon seizing the other begins the ope- ration by making a cut parallel with the free border of the lip, so as to remove a portion of its substance sufficient to bring it down to its natural dimensions. The flap is to be dissected back towards the union of the lip with the gum, and cut olf horizon- tally at its base with the knife or scissors, removing the whole thickened membrane with its bed of glands. At first the haemor- rhage is abundant; but it comes only Ironi small vessels, and soon ceases spontaneously, from the retraction of the tissues. No dressing is required. As the cicatrization is going on, the cuta- neous margin descends, so that the lip gradually assumes a natu- ral appearance. ATRESIA ORIS.— CONTRACTION OF THE ORIFICE OF THE MOUTH. This is sometimes a congenital defect; but far more frequently it is the result of unnatural adhesions of the free surfaces of the lips and the contraction following ulcerated burns, as in a case successfully operated on by Professor RlCUter, and reported by him in the American Journal of the Medical Sciences for Aug. 1S37; or from the destruction of parts following syphilis, scrofula, or cancer, as in another operated on by the author, reported in the same journal for Oct. 1842, and represented at PI. LXXII. fig. 2. In botli these cases the restoration of the orifice to its proper size, was accomplished by the process of Dielfenbach described below. Various plans have been devised for the purpose of preventing the tendency of the raw edges to progressive cicatrization, after the mouth had been restored to its proper dimensions by incisions at the commissures. Most of these processes were attended with protracted suffering, the operation requiring to be several times repeated, and were seldom finmd more than partially successful. The following ingenious process of the distinguished Berlin sur- geon accomplishes the object more effectually, and is the only one to be relied on when the mouth is contracted to a consider- able extent. It consists in the removal of a strip of skin and muscle, preserving the mucous membrane, which is to be turned over so that it may serve as a lining to the raw edges of the divided parts, and act as a bar to cicatrization. Process of Dieffenbach. — On one or both sides of the narrow aperture, according to the nature of the deformity, a flap two to three lines broad is cut out through all the soft parts except the mucous membrane, which is to be left uninjured. The removal of this piece is best effected with a pair of scissors; the left fore fitiger is to be passed into the mouth so as to elevate and distend the cheek; the pointed blade of the scissors is then inserted at the margin of the mouth between the mucous membrane and the other structures in front, and iu this manner pushed on to the distance to which it is wished to extend the conunissure. The parts in front of the membrane are divided tiy closing the scissors; another incision is then made in the same way parallel with the first; and both are then united at their outer ends with a small semilunar incision. The flap is next to be carefully dissected off from the mucous membrane, The same proceeding is to be repeated if necessary on the other side of the month. As soon as the bleeding is checked, the lower jaw is to be strongly drawn down so as to stretch the mucous membrane, which is to be sepa- rated a couple of lines farther from the checks, and then divided 243 SPECIAL OPERATIONS. through the middle nearly up lo the new-formed angle of the mouth. Each section of the mucous membrane is then drawn over the corresponding raw margins of the new portion of the Hps, and secured to tlie outer surface by fine needles and the twisted suture. At ihe angles it should be drawn out and ad- justed willi particular care lo the margin of the semilunar inci- sion, so as to prevent any portion of ilie two raw surfaces from coming into apposition. AU inflammatory swelling is to be kept down with a steady application of cold water. Tiie sutures are to be removed between the second and fnurlli day. I have employed this ingenious process wiih entire success, the union of the mucous membrane to the raw edges talcing place by lirst intention, so as to insure the permanency of the oral orifice. I give, however, a decided preference to the coramou interrupted suture over the hare-lip or twisted, in binding the mucous mem- brane over the raw borders. In one case I have, after the manner of Mr. Campbell, employed the bistoury in place of the scissors for the excision of the piece, but did not find it so convenient as the latter instrument. In that species of deformity, where the lips are altogether de- stroyed, so as to expose the teeth and maxillary bones, and the lower jaw is immovably fixed by adhesions or surrounding cicatrices, the form of operation required must depend upon the nature of the individual case. The excision of the indurated cicatrices, the division of the adhesions between the jaws, and a judicious transplantation of the skin from the neighbouring parts, are the chief means by which we may, in a good degree at least, correct the deformity and relieve the patient. HARE-LIP. {PL. LI.) This affection consists in a vertical division of one of the lips, usually the upper, commencing at the free margin, and may be either congenital, or the result of accidental injury. The con- genital defect, of which alone we shall treat, is always restricted to the upper lip. There are tin'ee varieties of this aftection, the simple, the double, and the complicated. Simple hare-lip consists of a cleft in the lip upon one side, commonly the left, of the median line, extending frequently up into the margin of the corresponding nostril. In double hare-lip, there is a vertical fissure upon either side of the median line, including between them an irregular and somewhat triangular-shaped portion of the structure of the lip. Complicated hare-lip consists of a single or double division of the lip, with a cleft of the corresponding part of the upper jaw and palate, so as to unite the cavities of the mouth and nostril; or of a double fissure of the lip and the development of an osseous tubercle on the front of the jaw, from which grow irregularly the incisor and sometimes the canine teeth. The tubercle has received the name of the incisive or intermaxillary tubercle, from its occupying the position of the bone of that name in quadrupeds, Operalinns for simple hare-lip. (PI. LI. figs. 4, 5.) — The object of the operation is to unite the edges of the fissure with as little remaining deformity as possible. In former times an attempt was made to effect this by removing the edges with tlie application of caustics or the use of the knife and scissors, and the approximation of the sides of the fissure with bandages. stitches, sticking plasters, double-hooked forceps, etc., of various descriptions. All of these measures, however, have given way to the more modern process of merely adjusting the raw edges after incision with the twisted or hare-lip suture. ,/3ge at ivhich the operation should be performed. — Tliis is a point mooted by the older writers, and which is not yet so well settled as to lead to uniformity in the practice of diflereni sur- geons, Dionis, Lassns, Sabatier, etc., deferred the operation till the child had reached its third or fourth year. Sharp, Ledran and Heister, advised its performance from a few days lo a few weeks after birth. Between the ages of two and four years, children are found so indocile, and so apt, however closely watched, to pull upon the sutures and disturb the process of union, that a great proportion of modern surgeons have with good reason reconmiended the performance of the operation- between the second month and the second year after birth, I have on several occasions operated within the shorter period, when causes have existed to render it particularly desirable, and the cases have done well — complete union taking place, even when the child after the operation had been continued at the breast. The author gives a decided preference to the period under six months, as we then avoid the necessity of having lo extract any delbrmed teeth, and are less likely to be troubled with the irritation attendant upon the teeth making their way through the gums, which acis unfavourably on the union of the parts. Instruments required. — \. For the excision of the edges. — Two instruments are employed for this purpose, the bistoury and the scissors, either of which answers perfectly well. The use of the bistoury is the more ancient, it having been employed by Severin, Louis, and Percy. Excision with the scissors has been objected to as being more painful, and leaving a wound slightly contused and less readily disposed to union by first intention; but the fiilsily of this assertion has been clearly shown by the expe- riments of Bell and liesault. In my own practice, I give a pre- ference to the scissors in these cases, and all analogous ones, where soft and flabby edges are to be removed. When there is a deficiency of structure, and the margins of the fissure are dis- proportionately short, scissors curved on the flat wilt be found the most convenient, as they enable us by making the incision concave to increase the relative lengtli of the raw surface, so as to prevent after the cure any depression at the middle of the free border of the lip. 2. Reunion of the edges. — For this purpose, pins will be re- quired, and waxed threads for wrapping them, of the kind ordinarily employed in the ligature of the arteries. It is little important of what material the pins are made, (vide p, 26,) pro- vided they are not too large, so as to cause compression of the substance of the lip, or so dull at the point as to contuse it in their introduction, A hook or a pair of dissecting forceps, which will be convenient for seizing the margins of the lip, and a pair of cutting pliers for removing the projecting ends of the pins after their application, complete the apparatus. Strips of adhesive plaster and some small compresses should also be at hand, as their application may in some cases, when there is ereat tension upon the pins, be thought advisable. Operation. Excision with the scissors. — The patient is to be OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 343 seated in a good Hgltt, with the arms and feet well secured, and the head pressed against the chest of an assistant, who with his hands compresses the facial artery of eacli side under the edges of the jaw, and with the thumb pushes the cheek in toward the middle line. The surgeon sits or stands in front. If the frenum of the lip descends loo low, it is to be separated from the gum with a bistoury. The left angle of the lip is then to be grasped with the thumb and fore finger, and the whole of the rounded edge on the side next the fissure removed with tlic scissors, to a point a sixth of an inch above the top of the cleft. The right angle of the lip is next seized with the hooked forceps, and its margin simi- larly excised by piacmg the scissors on the outer side of the forceps, and cutting up to a point a line below the top of the first incision, so as to give without any contusion or laceration an acute angle to the wound. The entire rounded edge should be taken off by these incisions, so as to leave a broad surface for union. The ex- cision should also extend well down upon the labial edges. In these cases, the mistake most frequently committed is that of ml making tlie cut of sutficient length. A sponge welted in cold water should now be applied to the raw edges to remove the clotted blood and diminish the capillary oozing. The hare-lip pins are then to be introduced, and wrapped with the ligatures as described at page 26. Two, three, or four pins may be em- ployed, according to the length of the wound. The larger the diameter of the pins, the fewer does it answer to introduce. The capillary oozing and the bleeding from the divided coro- nary arteries usually cease when the raw edges are fairly placed in contact. The ligatures, however, should not be drawn tighter than is necessary merely to accomplish this object, as otherwise, from the slight inflammatory swelling that follows, they will irritate and cut into the parts by ulceration, so as to diminish the chance of union. If there be a considerable jet from the arteries, as is sometimes the case in large children, one of the pins may be introduced behind the open orifices, so as to compress them when the ligature is applied. If the operator prefer to excise the edges of the fissure with the bistoury, he places himself behind the patient, and if it be a child, takes its head between his knees. He then extends the margins of the fissure with his left hand, as shown at fig. 4, en- tering the bistoury with the back to the nose, and cutting from above downwards. Double Hare-lip. The mode of proceeding in the cure of this variety of the defor- mity will depend upon the size of the intermediate part. If it be less than a third of an inch broad, and tiiin, it should be excised near its base, and the operation proceeded in as in ordinary cases of simple hare-lip. If the intermediate substance be of larger dimension it must be preserved, as it will be of great importance in the reconstruction of the lip. If there is no particular deficiency of structure in the lip, the operation may be completed at once, very much as in ordinary cases of single fissure— by detaching the frenum, paring the edges of the middle portion so as to bring them to a sharp angle below — excising the margins of the two lateral portions — and introducing the pins so as to bring fairly together the four raw surfaces, causing them to traverse the middle portion. If the middle portion, as is very commonly the case, should not be long enough to reach the labial margin, the wound left after the introduction of the hare-lip pins will have the shape of the letter Y. When the middle portion has not been long enough for this purpose, but unusually thick, the author has in some cases derived advantage by detaching it from the sockets of the teeth, splitting it on the raw surface from above down- wards to near the free margin, and straightening the fold so as to increase the length of the middle portion. In case there be such a state of the parts that the four surfaces cannot be brought together without applying so much tension with the threads as to make them act as a dividing ligature, (vide page 34.) it will be more prudent to unite the parts by two separate operations at an in- terval of two or three weeks, excising two of the adjoining edges, and uniting one of the lateral fissures at a time. It will be par- ticularly well to observe this precaution provided there be any bony tubercle over the roots of ttie incisor teeth, giving an undue prominence to the front of the jaw. Any deformed or prominent teeth, which would be likely to irritate the margins of the divided surfaces, must be extracted, or, which in some cases of slighter deviation might answer, modified in their position by a twist of the forceps. If the point of the nose should be adherent to the middle portion, so as to cause a flattening of the organ, it is to be detached at the lime of the operation with the knife, or at a sub- sequent period, as practised by Dr. J, R. Barton, by embracing it with a ligature, which should be tightened from time to time till it cuts through. Complicated Hare-Hp. As a complication of Iiare-lip, especially the form last described, we often meet with a congenital fissure extending backwards from the surface separating the two maxillary and palate bones, and running downwards so as to divide the velum. The fissure of the velum and the lip may coexist without that of the hard palate — but when the hard palate is divided at birth, it is found attended with fissure of the velum. The fissure of the hard palate is always in the median line; that of the lip to one side, and terminating in one of the nostrils, most usually the left. Sometimes the complication in cases of double hare-lip consists merely in the projection of a thick, bony tubercle, called the inci- sive or intermaxillary, from over the roots of the front teeth, which is covered with a thick, hardened mass of gum and skin, and has on its lower border the teeth irregularly developed, standing frequently directly forward. In some instances we find existing with the tubercle the fissure of the hard palate, which may open by a single cleft in the alveolar ridge— or by two, which branch so as to include the tubercle between them. The mode of operation must be varied according to the nature of the defect. If there is hut a single cleft through the palate, without any strongly marked incisive tubercle, the common ope- ration for double hare-lip is all that is required. Experience has shown, that in these cases the early closure of the divided lip gives a disposition to the palate bones to approach each other as the growth of t!ie face goes on, and thus narrow down or even close the fissure, which without the union of the lips has a ten- dency to increase in size. In my own practice I have preferred in these cases, when I have had the choice of time, to operate within the third month. To faciUtate the approximation of the 244 SPECIAL OPERATIONS. sides of the fissure, M. Roux has advised the application of j pressure by an apparatus over the malar bones, and Velpeau upon the two sides of the dental arch. I have contented myself with directing the pressiire over these regions to be daily made with the hands of the ntu'se, a measnre which has apparently been attended wilh benefit. The closure of the fissure in the soft palate must be deferred till the child arrives at such an age tis to comprehend the importance of the operation, and allow of the free use of instruments in tlie cavity of the mouth. In case the incisive tubercle is large, the operation is more complex. The teeth in these instances, if the child is over seven or eight months old, will usually have a vicions direction. It is usually advised to remove them; but in case they belong to the permanent set, it has been latterly the practice to force them by means of a silver wire into their proper position, loosening them in their sockets if necessary for this purpose with a pair of forceps. There are four processes of operation in tliese highly complicated cases. 1. J2ncient p7-ocess.—T\\\s. consisted in the removal of all the prorainent portion of the tubercle with a pair of cutting pliers, and the closure of the fissures in the lip either immediately or a few days subsequently by the ordinary operation for hare-lip. By this process the incisor teeth were removed, and when the two sides of the jaw were approximated so as to diminish the space, the upper was found so much smaller in its arch than the inferior, as to interfere seriously with mastication. This result led Desault to the institution of the following process. 2. Process of Desault. — This surgeon, instead of excising the tubercle forced it backwards to its proper level, by compression wilh a bandage steadily kept up for eighteen days, and subse- quently closed the opening in the soft parts. This measure is not likely always to answer, and has proved inefFectuai in my hands. 3. Process of Dvpuytren. — The following process was applied by this surgeon in the more ordinary cases, when with the pro- minent incisory tubercle, the middle labial portion stood in an upward direction, viz: to separate the labial from the bony tubercle with a knife, and turn it with its raw surface upwards, and attach it by two points of suture to the lower edge of the septum narium — which is usually imperfect in these cases — after excising the cutaneous covering of the latter. The remainder of the operation consisted in removing the bony tubercle with the cutting pliers, and uniting the lateral portions of the lips as iu ordinary cases. 4. Process of Gensoitl. (PI. LI. fig. 7.) — This consists in the dissection of the soft parts from the outer face of the tubercle, and reflecting them towards the nose, and slowly forcing by the application of a pair of flat-bladed forceps, the projecting portion of bone down to its proper perpendicular direction. The canine teeth if deviated are to be removed. The fissures of the lips are then to be closed immediately, in the usual manner, as shown at fig. 6. This process lias in several instances proved successful. No dressings ader the operation for simple or complicated hare- lip will in general be required, as they have a tendency to heat and irritate the parts, and dispose them rather to suppuration than union by first intention. Jifler-trealment. — The patient should be kept iu a slate of perfect repose, and avoid as far as it is praclicable, all movement of the jaws for the first three or four days. If a child, it may be I necessary to quiet it with anodyne, and to examine carefully if there be any ha:;morrhage from the back part of the united sur- faces, which, when it has existed and been kept up by the suc- tion efforts of the child, has in some few cases been the alleged cause of death. The bleeding arises from the raw edges not being properly confronted on the mucous surface, to obviate which, as well as to facilitate the process of union, ihe pins are directed to be entered in the operation so as to cross the line of Ihe wound at the junction of the anterior two-thirds with the posterior third of the lip. Drinks. — Liquid aliment alone should be allowed, and should be introduced into the mouth after depressing the lower lip, with a spoon or some vessel of a convenient shape. On the third day, the upper or one of the middle pins should be removed, and on the fourth or fifth, the remainder. The pins should be loosened by a slight rotation before an attempt is made to with- draw them. If there has been no suppuration from the wound, and the ligatures remain adherent by the coagulation of the blood of the operation, they are to be left undisturbed till they loosen spontaneously, when their place is to be supplied by a strip of adhesive plaster. But if at the time of withdrawing the last pins, the coil of threads are either loose or infiltrated with a dried mixture of pus, blood and serum, they should be at once removed and the new union of the lip protected by a strip or two of adhesive plaster nicely adjusted. In case the new union should be broken up by accident, or from being left in a fretful child unprotected by an adhesive strap after the removal of the pins, the operator will generally succeed in causing them to ad- here a second lime by the use of the strips of adhesive plaster, and must on no account recur to the use of the pins till the in- flammatory consequences of the first operation have subsided, when the edges are to be again excised. CANCER OF THE LIPS. Cancerous tubercles and cancerous ulceration are very com- monly met with in the substance or the free border of the lips; the lower lip, however, being by far most commonly the one affected. If the tumour be small and movable, it may be re- moved as in ordinary cases by simple excision. If the degene- ration extend so as to involve merely the free border of ihe lip, it may be removed, if very superficial, by cauterization; or if deeper, by excision by the free edge, which is afterwards to be allowed to fill up by granulation. But if the .substance of the lip is more generally involved, or the maxillary bone affected, it will be necessary in the one case to extirpate so much of the lip as to render it necessary to supply its place wilh a new one, by one of the various plastic processes, and in the other to resect in addition the afi'ected portion of the bone. Cauterization. — Various caustics have been employed in su- perficial degeneration of the skin or mucous border of the lip. The arsenical paste so strongly recommended by A. Dubois and Dupuytren, and that of the chloride of zinc introduced by Can- quoin, (see page 21,) are the caustics most commonly preferred. Dupuyiren used the arsenic in Ihe form of powder as well as paste; — his powder was composed of four to six parts of arsenious acid, with nineiy-six lo ninety-four of calomel. 1 The treatment of superficial cancer of this part by caustic OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 245 applications, and especially by the arsenical paste— which has always been more or less in favour with the profession — has latterly been much employed by Fleury, Chelins, Heyfelder, and others. The author has employed it with advantage in cases of degeneration of the cutaneous and mucous surfaces merely, and to such cases he believes it should be strictly limited when relied on solely for the cure. The operation by excision is so successful ivhen early employed m accomplishing a radical cure, that it is unwise when the substance of the lip is affected, (o tamper by any protracted course of treatment with a disease which is so speedily disposed, after the mucous membrane becomes involved, to affect the neighbouring lymphatic glands, and render every method of relief unavailing. After extirpation, and when all haimorrhage has ceased, the use of the caustic becomes in some cases advantageous, in order to sear any portion of the surface iu which there is particular reason to fear a return of the affection. Excision in form of V. — ^In cases of small tubercle, or wliere the ulceration of the border is of limited extent, the diseased portion may be removed by a V incision, with the base towards the free margin, and the apex directed either to tlie chin, the cheek, or nose, according to the position occupied by the tumour. The incisions must be carried beyond the limits of the disease, which must be wholly extirpated with the piece removed. The incisions may be made either with the sharp-pointed bistoury entered so as to cut towards the mouth, or, which answers nearly as well, a pair of good cutting scissors. The raw edges are then to be closed with the twisted suture, as in ordinary hare-lip ope- rations. Excision in form of a crescent ^ — '. — The removal of tlie margin of the lip by a semilunar or crescentic incision, is particu- larly applicable to cases in which the free border is extensively affected by a superficial cancer. The incision may be made either with a pair of curved scissors, cutting from one commissure to- wards the other, or with a bistoury. In many cases the latter will be decidedly preferable, when for instance it is desirable to remove tlie central substance of the lip deeper than either the cutaneous or mucous surfaces; this may be readily accomplished by raising the diseased margin with a pair of toothed forceps, and making two elliptical incisions with the bistoury — one on the inner and one on the outer surface, meeting in the substance of the lip; the wound is afterwards to be closed by suture, so as to effect union by first intention. When the free border is simply excised, and no portion of great vertical depth removed, the skin and mucous membrane should be united by interrupted suture over the bleeding surface, By this plan we obtain a much more rapid cure and a more even margin than when the wound is allowed to close by granulation and cicatrization. Though an unseemly gap in the lip may remain for some time after the ope- ration, it will usually be found in the course of a few months surprisingly diminished by that sort of natural modelling process aided by the contraction of the surrounding muscles, by which an interstitial deposit of lymph raises a depressed surface of the kind nearly to its ordinary level. Dupuytreu and Richerand were Under such circumstances in the habit of dressing the raw margin, so as to allow it to granulate. This would be necessary if a large portion was removed. Even where the lip has been excised in its whole extent they have confided the cure to the process by 62 granulation, and have under such circumstances seen the cica- trized margin, covered by the reverted mucous meiflbrane, ulti- mately rise as high as the root of the teeth. But this is a result which does not generally follow; the saliva dribbling over the part prevents healthy granulation and retards the interstitial growth, and a breach remains which impairs the voice, and compels the patient to keep it covered with an apparatus, for the purpose of arresting the flux of the saliva. Under sucli circum- stances it is best at once when the excision of the entire free portioLi of the lip is practised, to resort to a restoration of the part by one of the plastic processes. (Vide Cheiloplasty.) ANCHYLOSIS OF THE LOWER JAW. The closure of the lower jaw may be only partial, and movable within narrow limits, or it may be complete and per- fectly rigid. This arises from a variety of causes. 1. From a destructive mercurial or syphilitic ulceration of the gmn and cheek without exterior opening, which leaves these parts in the end firmly united together by broad and resisting cicatrices— the masseter from want of use and partly at times from having been involved in the disease, becoming rigid and unyielding. Cases of this sort are susceptible of cure by operation. 2. From a similar destruction and morbid adhesion of parts, complicated with a loss of a portion of the entire substance of the cheek. Beside the usual operation for anchylosis, cases of this description require a plastic operation for the closure of the abnormal orifice. I assisted Professor Mutter in a complicated operation of this sort iu the winter of 1841-2, before the class of the Jefferson Medical College, which was successful in restoring a considerable degree of motion to the jaw, and in removing to a very great extent the hideous deformity of the cheek. 3. When there is a true bony anchylosis of the teinporo- maxillary articulation limited to this joint. In such instances, no measures of relief have been attempted beyond that of re- moving some of the teeth, for the purpose of facilitating alimen- tation. But it admits of a question, whether in cases of limitation of the affection to one articulation, it would not be feasible to establish a false joint by a section of the neck or condyle, after the plan proposed by Dr. J. R. Barton. I was consulted two years ago by a gentleman from Ten- nessee, in reference to an anchylosed condition of his jaw, com- plicated with a most extensive destruction of the cheek and bone — the result of gangrene from the use of mercury in the earlier part of his life. The posterior alveolar processes and part of tiie ramus of the lower jaw of that side had been destroyed, as well as all the superior back part of the upper maxillary bone, a part of the ethmoid, and the whole of the boues forming the inferior floor of the orbit, so as to allow the ball of the eye (in which vision was lost) to drop down below its proper level, where it remained hidden in a great measure from view. The jaw was rigidly anchylosed, and the individual was obliged to feed himself exclusively through a huge cicatrized opening that occupied the original site of the cheek, and exposed to view the extensive cavity formed within by the destructive ulceration. The palate, however, was unimpaired, and when the abnormal orifice was closed, the patient could speak distinctly. The case, as is apparent, was beyond surgical relief — other than the adjust- 246 SPECIAL OPERATIONS. ment of a niceiy filling, movable metallic plate, wliich should close the op'ening and restore the proportions of tlie face. 4. Anchylosis depending upon rigidity or permanent contrac- tion of the temporal and masseier muscles, without bony union or fibrous adiiesions. Cases of this description may arise, when in consequence of disease about the temporo-maxitlary joint, or from the presftuce of a tumour impeding the movement of the jaw or involving the muscles, the muscles have remained so long in their state of contraction as to become retracted, and keep the jaw rigidly closed. Instances of this sort, though not of very frequent occurrence, have been reported by Bonnet, Cruveilhier, Walter and Kuidiollz. If not found susceptible of relief by the use of warm douches, frictions, and mechanical means of dilata- tion, it will be found necessary to make a section of the temporal muscle alone, or of that in conjunction with the masseier; the proper processes for the performance of which will be found under the head of subcutaneous operations. After the section of one or both of these muscles, the use of a screw dilator will never- theless be for some time required. Operaiions for the relief of caaes of (nichylosis belonging to the first class. Simple dilaialioji. — Allempls have been made to dilate the jaws by the use of sponge tent, or wedges of wood, gradually increased in size in cases where the jaws could be slightly opened, so as to admit of their introduction. Litile permanent benefit has resulted from the use of such means alone, so great is the resistance oHered to the distension by these cicatrices, and their tendency to shorten again even when once stretched. Section of the adhesions and cicatrices. — It becomes neces- sary to divide these bands, or to excise lliera completely, which in my own practice has produced the most successful and per- manent result. If the jaws admit of any separation, they are to be kept asunder as far as possible with a spring speculum, or the dilator of Heister, or with a wooden wedge. The dilator of Heister is, however, an objectionable instrument, as it presses on the teeth in such a manner as to be apt to loosen or dislodge them — a serious imperfection, from which the speculum is en- tirely free. Process of Mighels. — The patient is to be seated in a chair with the face turned to the light, and the lips widely separated by assistants. The operator glides flatwise a long, narrow, double- edged bistoury between the cheek and the alveolar ridges, as far back as, and if possible behind, the angle of the jaw, and care- fully divides the indurated mass from its attachment to the gum. He then turns the edge of the knife outward, so as to cut com- pletely across and as far back as possible, the central portion of the prominent cicatrix, carrying the knife through into the healthy tissue on its outer side. The operator is now enabled to separate the jaws a little so as to introduce the speculum or screw dilator between the molar teeth. With one of these instruments, the jaws are to be separated to the natural extent, and the space gained preserved by the introduction of a wedge of soft wood between the back teetli of each side. The cheeks are to be kept separated from the gums, so as to prevent any reimion of the divided parts, by the interposition of a small piece of sjionge or a pledget of linen. The forcible separation of the jaws should bo persevered in for the first week steadily, with the occasional use of the dilator, and continued at intervals for the space of a month- otherwise, the surgeon may have the mortification, after the in- cisions in the cicatrix have healed, of finding the rigidity return. This method, however, in cases of extensive cicatrices adherent to both jaws, will not be found to answer. It failed completely in the hands of an intelligent surgeon of this city, in the case of a young lady from Delaware, in which I obtained complete success by the adoption of the following measures in addition to those above directed. I made a third section of the cicatrix at its point of connection with the upper jaw, and completely dis- sected out the prominent fibrous band, which had been divided into three portions, and carried the knife back on the outer side of the ramus of the jaw, so as to detacii from the bone a part of the anterior insertion of the masseier. The jaw then yielded with the application of moderate force by the screw dilator. A tho- rough division of the masseier cannot, however, be readily made from the month, nor is it usually desirable. The chief muscular resistance to the dilator is made, as will be obvious from inspect- ing its manner of insertion, by the temporal muscle. In cases in which I could not otherwise succeed in obtaining a good separa- tion of the jaws, or at least without the application of force that would endanger the bone or the alveolar processes, from which the gums are usually found to have receded in these cases, I should not hesitate to make a subcutaneous section of the temporal mus- cle on the afl"ecled side. A complete section of the masseier would I believe rarely be necessary. It is advisable to touch daily with a solution of lunar caustic the wound left by the removal of the cicatrix, in order to prevent the growth of fungous granulations. Excisio7i of the cicatrix through the cheek. — Tenon recom- mended, in order to prevent the return of the rigidity, to extend the oral orifice by an incision carried from the mouth out through the thickness of the cheek, in. order to facilitate the employment of a lever or dilator. Dr. Mott has had recourse to the same process; he moreover allowed the edges of the incision to cicatrize separately, and, after the motion of the jaw was rendered free, removed the cicatrized borders, and united them with the hare- lip suture. But such a proceeding, which entails a visible de- formity, can I believe seldom be rendered necessary. SALIVARY APPARATUS. SALIVARY FISTULA. (PL. LH.) Salivary fistula are the consequences usually of wounds, ulcers, or abscesses. In some few instarices they have been occasioned by the development of a calculus in the duct. They consist of an opening on the surface, which communicates within, either with the duct of Sleno in some part of its course as is most common, or directly with the substance of the parotid gland. Fistulous opening in the duct of Sleno. — Surgical anatomy. (PI. LII. fig. 1.) — This duct is rather loss than a line in diameter; its walls are composed of two membranes, the outer one of which is thick and cellulo-fibrons, and the inner formed by a prolonga- tion of the nuicous membrane of the mouth. It leaves the ante- rior portion of the parotid gland at the junction of the upper j with the middle third of this organ, and opens into the mouth I opposite the second large molar tooth of the upper jaw. Its OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 247 buccal orifice is without any valvular fold of the lining mem- brane. Its course is nearly in the clirectioii of a line drawn from the lobe of the ear to the front incisor toolh of the upper jaw, as designated by Dr. Physick. The precise point at which it leaves the gland, is directly in the course of a line drawn from the ante- rior orifice of the nostril to ihe end of the lobe of the ear. It crosses the anterior portion of the masseter muscle, covered by the skin and subcutaneous fatly matter, attended by a small branch of tlie transverse artery of the face and a branch of the facial nerve, which runs at a distance of a line below it. It dips towards the mouth round the edge of the masseter and over the facial vein, and after traversing the mass of fat at this point, opens into the mouth through the buccinator about a quarter of an inch in front of the anterior edge of the masseter. Remarks. — The facility and success of the treatment, as well as the choice of the method for the cure of a fistula of this duct, depends much on the fact of the orifice being the result of a wound or a recent nicer; or if it be of long standing, whether the skin is healthy or diseased at its margin, whether tlie passage of the duct on the inner side of the fistula is open or closed, or in fine, whether the fistula is situated anteriorly or posteriorly to Ihe edge of the masseter. The various processes for the treatment of the fistula, may be ranged into four methods, according to the objects they are de- signed to fulfil, viz. 1. Those for cicatrizing the fistulous orifice. 2. For dilating the inner portion of the natural duct, which in a fistula of long standing is usually found diminished in its diame- ter, or entirely obliterated. 3. For establisihng a new opening into the mouth, or forming a new portion of the canal, where a part of the old has been completely obliterated. 4. For producing atrophy of the parotid gland, when all measures fail to restore a passage for its secretions. 1. Cicatrization of the Jistiilous orifice. This method presupposes that the fistula has been produced by some temporary cause which has ceased to act, and that the passage which leads from the diseased opening to the mouth remains free and undiminished in size. And if such is not the case, it will be necessary before proceeding to close the orifice, to dilate the passage by one of the processes belonging to the second method. a. By the twisted suiitre.^Xn case of a recent wound, the twisted suture and a compressing bandage may be at once applied. But if the fistula is of long standing, the cicatrized edges must be first excised. Percy, Flajani, and Zang, direct that the pin should be introduced through the integuments vertically rather than crosswise. b. By cnnterizalion.~T[\\s may be done with the ordinary caustic articles, or by an application of the hot iron to the edges of the orifice so as to produce an eschar. Before the eschar, which for the time stops up the external opening, has been detached, the saliva is said in several cases reported by Louis, Langenbeck, and others, to have resumed its natural channel, the cure becoming permanently effected through the closure of the woUnd by the granulations that sprung up. Gensoul, however, has failed under similar circumstances, and is disposed to tliink that in these cases a fistula of the gland itself has been mistaken for one of the duct. In that of the former, cauterization is known to every surgeon to be an efficient process. c. By compression. — The cure of the fistula has been sometimes attempted by compression of the duct between it and the gland, both in recent and old cases. This is a painful and unscientific process, certain to produce an inflammatory swelling of the gland, and liable, even if successful in arresting the flow of the fluid through the orifice for a sufficient space of time — fifteen to twenty days— to allow it to close, to lead to permanent oblitera- tion of the duct, and the abolition of the function of the gland. Malgaigne has proposed a simpler process, the efficacy of which has not, however, been tried; viz. the application of a piece of gold leaf, fastened by pitch, and covered with a piece of court plaster, for the purpose of off'eriug a barrier to the saliva, and turning it into its natural channel, in the hope that under this covering the orifice might close. 2. Dilatation of the natural passage ivhen this is found contracted. Seton. Process nf Morand. (Fig. 3.) — This consists in the introduction of a seton from the buccal orifice. For this purpose the inside of the cheek is to be turned out as far as possible, in order to expose the buccal orifice, into which the lachrymal probe of Anel, armed with a silk thread, is to be introduced. This instrument is to be gradually insinuated along the duct until it appears at the fistulous orifice, bringing with it the thread, which latter drags in its turn a seton cord well oiled attached to its end. The other extremity of the cord is then to be brought out at the month, and the two knotted on the cheek as seen at fig. 3. The size of the cord is to be increased from time to time till the duct regains its natural caliber, and the ulcerated orifice begins to contract upon the cord. The end of the seton should then be cut off on a level with the fistulous opening, and drawn a little way within it, where it is to be allowed to remaui until cicatrization takes place externally, which is to be aided by occa- sional touches with the nitrate of silver, and the application of adhesive straps. 3. Formation of an artificial passage, in case of the oblitera- tion of ihe anterior or internal part of the canal. Method of Deroy.-^This consisted in traversing the cheek from the place of the fistula with a heated wire, and is said to have been successful. Of Duphenix.^K long, straight, and sharp-pointed bistoury was insinuated from the opening downwards and forwards, in the direction of the natural passage through into tiie month. The handle was then rotated between the fingers, so as to render the passage round. The bistoury was next withdrawn, and a short metallic canula of the proper length inserted, terminating by a bevel at its inner end. so as to correspond with the plane of tlie mucous membrane. The margins of the fistula were then excised, and the wound closed over the outer end of the cylinder, by the twisted suture. The canula, which was left in the wound, came away on the sixteenth day, and the patient was cured, Monro simplified the method by forming the new passage with a shoemaker's awl of proper size. Tessard and Flajani introduced first a thread by means of a needle, to which was SPECIAL OPERATIONS. next attached a small silk cord, for the purpose of dilating the previous pnticture. In the progress of improvement, these ruder instruments have yielded to one more neat and efficacious. The place of the awl and the bistoury have been supplied by a delicate trocar and canula. The perforation is to be made from without inwards, as nearly as possible in the direction of the natural passage — a finger covered with a compress being passed inside the cheek to receive the point of the instrument and prevent the tongue from being wounded. The trocar is then to be withdrawn, and a silk cord, a piece of catgut or lead wire, conducted through the canula, which is then to be re- moved, and the dilating body it had conducted left in its place. If either of the two last be used, the outer end is to be secured so as to prevent its being drawn into the mouth, by a silk thread fastened round the ear or bound down by a piece of adhesive plaster. The inner end of the cord is to be rendered stationary in like manner by a knot, or even tied round a pledget of lint; or if lead wire is used, the end is to be bent down on the lining membrane. As soon as the walls of the new track are suffi- ciently organized, the external orifice is to be closed, as in the process of Morand. In case the new passage is disposed to contract, a gold canula should be introduced into it, and left to remain a long time before closing the fistulous opening. 71/. ^(ti always employed the lead wire, which he secured on the outside in the usual manner with a silk thread, and on the inner, by dividing the extremity into three longitudinal slips, wliich were folded down in different directions on the mucous membrane. When the track was believed to be sufficiently organized, the outer thread was cut, and the fistulous orifice closed over the lead wire, as in the manner above described. In all these various processes, no attempt is made to hoal the fistulous orifice, till the artificial canal is thoroughly established. In the one next to be detailed, the closure of the orifice is made immediately after the insertion of the new substance, which is to be left in place in order to establish the new channel. Process of Deguise. (Fig. 3,) — In this, the new passage is made branching so as to open with two orifices on the lining membrane, and in the form of the letter Y. A small trocar is passed from the bottom of the fistula, in the direction of the edge of the masseter, which is not, however, to be wounded, and then carried if possible through the posterior wail of the natural passage into the month, where the point is to be received between the two fore fingers of ilie other hand. The trocar is withdrawn, and the canula left until a fine lead wire is passed through, and it also is then removed. The canulated trocar is again intro- duced from the orifice, and carried downward and forward— at PLATE LII.— SALIVARY FISTULA. Fig. 1. — Surgical anatomy of the parotid gland, — A dissection has been made on the side of the face, in order to expose the relations of the parotid gland and its duct, as well as that of the submaxillary gland with the surrounding parts. 1. Superior extremity of the sterno-cleido-mastoid muscle. 2, 3, 4. Masseter, zygomaticus major and buccinator muscles. 5, 6. Facial artery and vein. 7. Branches of the facial or portia dura nerve, which run parallel with the parotid duct. a. Parotid gland. b. Parotid duct, or duct of Steno. The reference [b] is placed on the duct at the point at which salivary fistula is most frequently found to occur. c. Submaxillary gland. d. Commencement of the duct of this gland, or duct of Wharton. Fig. 9. — Dilatation by the seton. (Process of Morand.) — With the probe of Anel a selon composed of several silk threads has been passed from the fistulous orifice, and brought by the buccal orifice of the duct out through the mouth. The two extremities of the seton have then been knotted upon the cheek. Figs. 3, 4. — Puncture for the purpose of making a neiv passage. (Process of M. Deguise.) — A first puncture has been made from before backwards, bringing out one end of a cord upon the cheek, and leaving the other end in the mouth. At the period of the operation shown, a second puncture in the direction of the duct is made from behind forwards, with the canulated trocar of M. Grosserio. A small pledget upon the fore finger of the surgeon, serves to receive the point of the trocar and protect the tongue from injury. The outer end of the cord is then to be passed through the canula after the stilet is removed, and the canula with the cord brought out through the orifice of the mouth. Fig. 4. — Tlie two ends of the cord are then to be knotted in the cavity of the month. The loop of the cord or ligature rests at the bottom of the fistulous orifice of the canal, the outer opening of which is now to be made to cicatrize. Fig. 5. — Same process^ executed with two needles introduced from the fistulous orifice, each of which has a separate direction, and is carried through into the cavity of the mouth, bringing with it one of the ends of the cord. Fig. 6. — Horizontal section of the cheek, showing the circular loop formed by the cord in the inner substance of the cheek, and the fistulous passage from the duct opening externally, through which the needles and the ends of the cord have been introduced. OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 249 this time in a different direction — which is that of the obUterated duct, and a waxed silken or thread iigaliire carried through the caniila into the mouth. The canula is then lo be withdrawn, as in the case of the first puncture. By fastening together the two outer ends of tlie wire and ligature, and drawing upon the buccal end of the latter, tlie wire is carried through the second track of the trocar, so as to present both its extremities in the mouth, embracing the substance included between the two branching passages in its loop, the middle part of the loop resting in the bottom of the fistula. The ends of the wire are then linked to- gether in the mouth, shortened and laid down flat upon the membrane, and the external fistula closed at once, by the exci- sion of its edges and the application of the twisted suture. After this has united completely, the wire may be removed, or, if pre- ferred, left till it divides in the manner of a ligature tlie little fleshy bridge within ils loop. A stout silk cord may, however, be employed instead of the wire, and will be found more manageable. M. Vernhes made use of a gold wire, and suggests — which is a matter of import- ance — that the trocar should in both instances be directed from above downwards, but in different tracks, so as to avoid more surely the edge of (he masseter, and the facial vein which runs by its side. Another useful modification lias been suggested by M. Gi'os- serio, viz: to substitute for the ordinary small hydrocele trocar employed by Deguise, one from which the button of the canula unscrews, so as to permit of its being drawn out through the mouth, carrying with it at once the end of the wire or ligature, which is to be left in the track. Maigaigne has proposed to carry simply the ends of a silk ligature from the bottom of the fistula through into the cheek, by means of a couple of ordinary needles. The ends are to be knotted on the mucous membrane, as seen at PI. LII. fig. 4. The fistula is to be closed, and the treatment in' other respects conducted as in the process of Deguise. Process of Bon?iaJ'ons. — In a case* of fistula of the duct, occasioned by abscess, which had resisted several attempts to cure it by operation, M. Bonnafous succeeded by means of the following method. Having laid bare the ulcerated extremity of the duct with a knife, he passed a slender cutting blade into the mouth in the direction of the obliterated duct, and intro- duced a canula along the track. A ligature passed through one side of the free end of the duct, was then carried through the canuta,aud fastened to its buccal end in order to keep the canula in its place. The external wound was closed in the ordinary manner, and the cure was completed on the fifteenth day. 4. Obliteration of the natural duct for the purpose of sup- pressing the salivary secretion by producing atrophy of the parotid gland. This may be attempted as a last resource when the fistula is formed on the outer surface of the masseter, near its origin from tlie gland, and when the means of cure above advised have proved unavailing. It may be accomplished either by steady compression of the duct on the parotid side of the fistula, or by cutting down upon it at the same point, isolating it from the * Annales de Chirurgie Fraii^aiKe et Sirangere, 1841. C3 branches of nerves, and tying it as we would an artery. The latter measure would be the most rational and effectualj^and least likely to produce an inflammatory engorgement of the gland. Neither, however, has as yet been tried upon the human subject. But the ligature has proved successful in experimental trials upon the horse, wiihout any inconvenience arising from the altered physiological condition of the gland. When the attempt is made to close the external orifice by suture, the jaws should be kept closed and the patient forbear to speak until union is effected, taking only liquid aliments, so as to avoid any discharge of the saliva witich would interrupt the healing process. Fistula; of the parotid gland. These are of two descriptions, according as they involve one or more of the smaller ducts on the back part of the parotid, or the larger branches of the duct of Steno as they emerge from the gland. The former are easily cicatrized by cauterization with the nitrate of silver, or the repeated application of small blisters as advised by Velpeau. If the latter prove intractable to these measures, a trial may be made of the gold leaf, made adiierent by pitch, as advised by Maigaigne; — or the ulcer ex- tirpated by being enclosed between two elliptical incisions, as proposed by Velpeau, and the lips of the wound closed with the twisted suture or adhesive straps, EXTIRPATION OF THE PAROTID GLAND. Surgical anatomy of the gland. — The surgical region of tlie parotid is bounded — anteriorly, by the posterior border of the ramus of the lower jaw, and the internal pterygoid muscle; — posteriorly and inferiorly, by a sloping wall, formed by the mas- toid process of the temporal bone, the anterior border of the sterno-cleido-mastoid, and the posterior part of the digastric, stylo-hyoid and stylo-glossus muscles. The space thus bounded in front, behind and below, is of a pyramidal or prismatic shape, with its base presenting externally to the skin, and its apex to the styloid process and the outer wall of the pharynx. The posterior and inferior wall forms a sloping plane up to this point. The pterygoid muscle, which chiefly forms the anterior wall, slopes backward and inward, but is directed a little above and in front of the base of the styloid process, to reach the pterygoid fossa. Thus, at the apex of this prismatic space, there is left a sort of fissure between its walls, filled either with fat or a pro- cess of the gland on the side of the pharynx, just behind the attachment of the velum palali. The sheaths of the muscles forming these walls are continuous with one another, and form a cellular lining for the cavity, which is connected with the stylo- maxillary ligament and the iiiiernal lateral ligament of the arti- culation of the jaw. The gland is lodged in this space, which it fills up completely, and moreover in the healthy state sends processes which extend beyond ii. The whole mass of the gland may for the sake of description, be considered as divided into two portions — one superficial, which, extending beyond the limits described, overlaps the edge of the masseter muscle, ex- tends below the angle of the jaw, and embraces the upper, ante- rior and lower surfaces of the external auditory meatus — and one 250 SPECIAL OPERATIONS. deep-seated, continued inward from the former, which not only- fills up the triangular space above described, but surrounds the neck of the gondyle and the articulation of the jaw, and dips under the internal edge of the internal pterygoid muscle. The gland is surrounded by a fibrous capsule, which sends processes between its lobes, so as to penetrate it in all directions, fix it firmly in the excavation, and render it adherent posteriorly to the sheath of the sterno-cleido-mastoid muscle. The external carotid artery passes up in a curve, concave for- wards, through the inner portion of the substance of the gland, surrounded ordinarily by a small portion of its structure, and divides at the head of the condyle into its two branches, the temporal and internal maxillary, both of which are more or less embraced at their roots by the substance of the gland. The posterior auris is given off' usually from the carotid as it traverses the gland. The transverse facial artery usually runs on the posterior face of the gland between it and the masseter, and the occipital is merely in contact at the place of its origin with the posterior surface. The veins of the part follow the course of the arteries. The internal carotid artery- and the internal jugular vein, though not included in the parotid region, are placed, it should be recollected by the operator, so near its inner boundaries as to be in danger of injury if a cutting instrument is carried even to a little extent beyond tiie inner limit of the space above described. Tlie facial nerve divides into a plexus in the substance of the gland, and traverses it from behind forwards and from above downwards, exterior to the external carotid artery and external jugular vein, leaving about one-third of the substance of the gland on its posterior face. The superficial temporal nerve traverses the front of the gland just behind the condyle of the lower jaw. The more important nerves of the neck, the pneu- mogastric, glosso-pharyngeal, hypoglossal, spinal, and chorda tympani nerves are not included in the parotid region, though they are placed but at a little distance from its inner surface, covered by the posterior belly of the digastric muscle and the internal jugular vein. The lymphatic glands of the region vary in number in different individuals; from two to six or seven are usually found on the surface of the gland partly imbedded in its interlobular spaces. One or two deep-seated lymphatic glands are usitally found by the side of the external carotid artery and external jugular vein. It would seem from this brief sketch of the anatomy of this region, that the parotid gland was too deep seated and sent off too many irregular prolongations wrapped round the parts at its inner surface, lo admit of its thorough extirpation. This is un- questionably the case in reference to the gland in its healthy state — and if it was alike true in its scirrhous condition, the at- tempt at its extirpation would be a useless operation, inasmuch as some of the degenerated portion necessarily left would serve to reproduce the disease. But, as has been observed in the first instance I believe by Dr. Jacob Randolph of this city, the scir- rhous affection of the gland is attended by a contractiou of its capsular investment, by which the deep-seated and irregular prolongations are made to recede from their beds, so as greatly to facilitate the process of extraction. Though the operation was considered impracticable by Boyer and the greater part of the older surgeons, there is no question that it has been many times completely removed, both by the surgeons of this country, of whom may be enumerated in refer- ence to this operation, Drs. M'Clellan, Warren, Mott, Randolph, Smith, and by many of those of Europe. About forty cases of its extraction have been enumerated by Velpeau, twenty to twenty-five of which are stated as having been successful; but that the complete extirpation of the gland has in this number of instances been effected, has been seriously questioned by M. A. Berard,* in a careful examination of the reports of the operations. Many of the alleged cases of successful extirpation of this gland there is every reason to believe have not, however, been true scirrhous degeneration of its structure, but a mere tumour of the parotid region formed by the enlargement of the common lymphatic glands of the region, which, as they increased in size and encountered resistance from the skin and superficial fascia, pressed inwards so as to cause the gradual removal by absorption of the true parotid gland, and bring themselves in the end so as to occupy the same position. When it has been merely the morbid development of the superficial glands that has caused this change in the parts, the parotid tumour, to whatever depth it may have reached, would have pressed in before it both the portio dura nerve and the external carotid artery, thus rendering its extrac- tion by no means difficult, and necessarily involving no important parts. The cases of alleged extraction of the scirrhous parotid, of which there are many on record, unattended by hemorrhage or the necessity of tying any important arteries or the division of the portio dura nerve and consequent palsy of the face, have, it is most connnonly believed, been cases merely of this description. Operation. — Some surgeons have deemed it proper to tie the external carotid artery at the commencement of the operation, by a previous incision in the neck; others to expose the carotid and throw a ligature loosely round ii, which could be knotted if at any moment such a proceeding should be rendered necessary by the effusion of blood during the removal of the tumour. It is more generally advised, however, to proceed to the operation without any previous ligature of the vessel, tying it as the trunk becomes obvious during the extraction of the tumour, or securing the bleeding orifices as they are opened with the knife, obviating the possibility of profuse haemorrhage by adopting the precaution of Dr. Warren, to have an assistant prepared, in case of its divi- sion, to make compression on the trunk of the primitive carotid in the neck, until the surgeon could secure the wounded vessel. The patient should be laid on an inclined plane, with his head turned to the sound side and well supported by assistants. The form of the external incision must depend upon the size and shape of the tumour. That of a T or a crucial incision has been most generally preferred. The cutaneous flaps are to be reverted from over the tumour, and the ear with its lobule drawn strongly upwards and backwards by an assistant, so that the concha may not be cut in the subsequent steps of the operation. The surgeon now grasps the tumour with his left hand if it be large, or with a pair of hook forceps if small, and draws it off from the side at which he is at the time detaching the tumour. It an- • Maladies de la Glande Parotide, etc., par M. A. Berard: Paris, 1841. This author has collected fifty-two cases of operations for tumours of the parotid; in only five of which does he think it certain that tlie gland has been removed entire. OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 251 swers best to pursue the process of detachment with the knife, first at the superior border of the gland, tlien at the posterior border where its limits are most definite^ taking care to avoid cutting into the meatus, or into tlie ligaments of the temporo-maxillary articulation, keeping close to the anterior edge of the mastoid process, so as to leave tlie external carotid to the inner side of the track of the knife. When the gland is in part separated at these points, the detacliment of the cellular connection of the tumour may be continued with the handle of the scalpel instead of the blade, which will diminish the risk of injuring the im- portant vessels or nerves. In loosening tlie gland in this way from the fossa behind the ramus of the jaw, additional precaution must be observed not to injure the trunk of the external carotid or eitlier of the branches into which it subdivides. The smaller arteries of the part — branches of the auricular and the occipital — must be tied as they are cut. The surgeon proceeds now cau- tiously, using partly the point and partly the handle of the scalpel, and feeling from time to time with the finger for tlie pulsation of the external carotid, so as to expose this vessel, which is found enveloped in a portion of the diseased gland. A needle with a double ligature should be carried below the artery, which is, to be tied at two points a few lines apart, and divided between them. The anterior margin of the gland may then be detached from over the masseter mnscle as far as the ramus of the jaw. (Though this, if the surgeon prefers it, may be made as the initiatory step of the isolation.) The tumour now holds only by its middle and deep-seated parts, and its dissection must be continued from below upwards. At the inferior angle of the wound we encounter the external jugular vein, which is often of considerable size. When it is necessary, as is sometimes the case, to cut this vein, it should be previously compressed below the place of division, in order to prevent the entry of air into the circulation. As the operator proceeds upwards in the detachment of the gland, he is to guard against cutting the submaxillary gland or the facial artery, which lie at its anterior and inferior part. Having once loosened it so as to raise its lower end, the final separation of the tumour is to be effected as far as possible with the handle of the scalpel, which will best enable the operator to isolate the morbid from the healthy parts, and even to detach the prolongations of the gland without risk of injuring the neigh- bouring vessels. If the tumour is firm and encysted, it may be wholly detached in this way with the handle of the knife. But if it be not encysted, and the prolongations are too hard and resisting to be loosened with the handle, they must be separated with the point, observing the precaution however to keep the edge of the blade turned to the side of the tumour rather than towards the surrounding parts, which might otherwise be cut. In this way we run a risk of leaving at the moment a portion of the degenerated structure; but this may be subsequently removed after the detachment of tlic mass of the gland and the suppression of the haemorrhage. If ihe external carotid should be cut before it was exposed and tied, the assistant should instantly compress the primitive trunk in the neck,- and the surgeon grasp the bleed- ing vessel just below its orifice with the forceps in one hand, whilst with the other he passes a needle with a double ligature below it, for the purpose of tying the vessel. The trunk of the facial nerve will in most cases have to be cut; this will be found running in the direction of a line from the anterior groove of the mastoid process to the angle of the jaw. When the gland is almost entirely detached, it may be found holding by one of its prolongations which forms a sort of pedicle at tlie bottom of the fossa^ dipping into one of its recesses. .This lias been found to contain vessels which, when divided across, occasion a haBuiorrhage that it has been found very trou- blesome to arrest. It will therefore be found better, as recom- mended by M. Begin, to tie it and divide it on the outer side of the ligature. After the removal of the tumour, it will be proper to examine carefully whether any portions of the degenerated gland have been left. If such should be found, they are to be detached with a spatula, the handle of a scalpel, the point of a director, or the finger nail, and if soft, as they are commonly found under such circumstances, may, with care to avoid the injury of the internal jugular vein and other important parts, usually be removed. Such arteries as have been divided are to be carefully tied. If the gland has been detached from below upward, and the external carotid tied at the bottom of the wound, the number requiring ligature will not be great. The capillary oozing, and that from the divided veins, is to be ar- rested by the pressure of Ihe dressing of lint or charpie, which may if necesssry be applied so as to fill up the wound. The use of the actual cautery, wliich has been sometimes resorted to to arrest bleeding, can rarely be required, and should, if used at all, be employed with extreme caution, for fear of injuring the in- ternal carotid, the important veins of the part, or the bones at the base of the brain. When the hasmorrhage is completely arrested, the flaps, if the wound left be not deep, should be brought together with the hare-lip suture, leaving, however, an opening for the exit of the fluids at the bottom of th'e wound. But if the cavity left is deep, or the skin has been involved in the disease, so as to necessitate the removal of a portion of it along with the tumour, the wound must be dressed from tlie bottom, and allowed to close by granulation. The difliculty of swallowing in consequence of the injury or division of the sty- loid muscles, the risk of secondary hemorrhage, and neuralgia of the teeth and face, are among the circumstances that will re- quire the attention of the surgeon during the cicatrization of the wound. Such in ordinary cases of scirrhous parotid, will be found tiie best process for its complete extirpation. The rules cannot, however, be positively traced for all cases, and each individual one will be found to present some peculiarity in the course of the process, which the surgeon, who is master of the general plan of operation, will be able to meet. Removal by the ligature.— Mayor has proposed, after laying bare the gland, and reflexing the cutaneous flaps, to pass ligatures through it in different directions, and strangulate it in separate portions. The proposition of this surgeon has not, ho w- ever, been received with lavour. EXTIRPATION OF THE SUBMAXILLARY GLAND. The removal of this gland, which is but seldom required, may be readily effected. An incision should be made of a length pro- portioned to tiie size of the enlarged gland, along the base of the jaw, commencing at the angle. A vertical incision is to be dropped 252 SPECIAL OPERATIONS. from the posterior extremity of this, anil the sldn and platysiiia muscle dissected up in a triangular flap and reverted forwards and downwards. The gland, with the lymphatic ganglions which surround it, is now exposed to view; it is to be raised with a pair of hooked forceps, and partly by dissection and partly by tearing enucleated from its bed. The facial artery, if too much involved in the tumour to be readily separated from it, is to be tied and cut. The wound may be closed at once m order to bring about union by first intention. RANULA. This is a tumour, in its early stage, of the colour of the sur- rounding parts, situated under the side of the tongue, and be- tween it and the floor of the mouth; usually soft, fluctuating and transparent, but sometimes hard and firm. The tumour may be single, or there may be two, one upon either side of the tongue. If of small size, it causes but little inconvenience, but if forming a larger bulk, it presents a serious obstacle to mastication and speech. In some instances, it has been found so large as to drive the incisor teeth outward, and protrude the parts below the chin. The nature of the affection is not as yet fully under- stood. Many of the older surgeons, Camper, Louis, Desault, Chopart, Richter, Boycr and Chelius, were of opinion that it originated from an obstruction of the excretory duct of the sub- maxillary gland, — the ductus wharlonianus, — and the consequent accumulation of saliva; but this opinion has not been supported by accurate anatomical examination, and the chemical analysis of llie contents of the tumour. That such an obstruction oc- casionally docs occur, and gives rise to calcareous deposits, is beyond doubt; but, according to Dupuytren, it has nothing in common with ranula, except an apparent similarity of its seal. The fluid of ranula is oily, brownish, viscid and albuminous, and is deficient in the principal constituents of the saliva. I have found the whartoniau duct permeable in many cases of ranula, and in the instances in which it has been closed, this result has appeared, according to Reissinger, more as a conseciuence of the pressure of the tumour upon it, than as the primitive cause of the disease. It is very probable that ranula, in many instances at least, belongs to the class of cystic tiunours, developed in the substance of the salivary lobules, or by the side of tlieir excretory duct. More accurate observation, however, is required to settle its pathology. Tlie modes of treatment in this aff'ection are nearly as discordant as the pathological opinions entertained respecting it. Par£: opened the tumour with tire actual cautery, applied through a hole in an iron plate. Ileister opened it largely witli the lancet, and to prevent a new accumulation of the fluid, washed it out dai^ with mel rosatum and sulphuric acid. The incision, however, has to be large, or the cyst fills again quickly, and is never alone to be relied on for a radical cure. Van der Haan drew a seton tlirough it to produce suppuration, and Callisen opened the cavity and stuffed it with lint. When the tumour was very large, and protruded the parts below the chin, Sabatier opened it by a puncture with a trocar, from below upwards through the skin, and kept the orifice open with a mesh. Acrel merely opened the tumour, and applied muriatic acid to the surface of tiie cavity. Camper and Vogei opened the tumour, extirpated a part of its walls, and touched the re- mainder of its inner surface with caustic. Louis excised an oval portion of its walls, and touched the orifice with lunar caustic to prevent its closing. Chopart and Desault endeavoured to keep the salivary duct open by the introduction of a fine lead or silver wire; failing lo cure by these means, they punctured the tumour and introduced through the orifice a thick Lead wire, which was taken out from time to time to discharge the fluid that had collected. Dupuytren, instead of the wire, inserted through the puncture made with a lancet, a silver, gold or pla- tina cylinder, with a small elliptical button at eacli end to keep it permanemly in place, by the side of which the fluid, as it formed, was discharged. The instrument, when once inserted, was not afterwards to be removed. Graefe found these various measures frequently insufficient for a cure, and objected to its total extirpation, as proposed by Marchetti, particularly if the tumour was large, on account of its causing excessive hemor- rhage and inflammation, and recommended the following process, (that of Petit,) which I have several limes practised with success when the walls of the cyst were thick and resisting. The mouth is lo be opened wide, and a sharp hook inserted into the most prominent part of the tumour, so as lo raise its anterior wall, which is then to be excised along with the mucous membrane that covers it, with a small pair of scissors. The removal of a small piece will be found insufficient— at least the half of the tumour should be taken away. The operation should be per- formed quickly, and before the contained fluid is allowed alto- gether to escape, for the tumour collapses after the discharge of the fluid, and it is difllcult then to define its extent. The bleed- ing after this operation is generally but trifling. The remaining portion of the cyst, according to Graefe, should be daily touched twice with muriatic acid. This may in some cases be necessary, but in general the obliteration of the cyst will be complete with- out the use of any irritant or caustic application after the excision of a large part of the wall. Kyll excised the prominent part of the tumour in the manner of Graefe, and in addition, when it was found firm and hard, depressed the bottom of the cyst with a grooved director, until he could feel the end of the instrument below the chin, and from this point introducod a seton needle upwards and outwards through the cavity of the cyst, allowing the cord to remain, which was moved from time to time so as to excite suppuration and ultimate obliteration of the cavity. If not found suflicicntly exciting without, some irritating oiiument was smeared upon the seton. Richter recommended in children simply the touching of the whole periphery of the tumour with caustic, repeating the process until a cure was efl'ected, which, according lo him, never required more than ten applications. Of the various processes above mentioned, those of Louis and Graefe appear the most appropriate— the former in the soft, or- dinary ranular tumour, the latter wliere the walls are ihick and resisting. The author, however, has latterly been induced to give a decided preference over that of Louis to the following operation for the cure of this afl'ection. Pass vertically through the anterior portion of the walls of the cyst, a sharp tenaculum, which is to penetrate at first into the bottom of the cavity, and pierce the wall a second time above. A broad curved needle, cutting on the edge, is then passed horizontally across the cyst, entering upon one side and emerging upon the other side of the OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 253 tenaculum, so as to lodge a stout ligature completely in the cavity of ihe sac, and include, according to the size of tlie tumour, half an inch to an inch of the wall between the places of puncture. The tenaculum is then to be removed and the ligature firmly knotted upon tfie wall of the cyst, and the tails cut ofT, leaving the knot till it is discharged by ulceration. The gaping of the puncture made by the closing of the knot gives space for the discharge of the fluid, and the ulceration, which is necessary to loosen the thread, keeps the orifice effectually from closing; and by the time the knot is thrown ofl", all semblance of a cyst has usually disappeared. C^/sts of a somewhat analogous description to that of ranula, filled with a colourless albuminous fluid, are occasionally met with in other portions of the wall of the month — as, for instance, in the substance of the lips and cheeks, between the gums and the cheek and between the gums and the tongue. Excision of a portion of these walls, with cauterization of the remaining part, or complete extirpation, are the common means resorted to for their cure. OF THE TONGUE. ANKYLO-GLOSSUM, OR ADHESION OF THE TONGUE.— TONGUE-TIE. To/jgue-iie.—h will suffice to notice this subject briefly. It is conmionly a congenital defect caused by the frenum being too short, or extending too near to Ihe tip of the tongue. It embar- rasses ihc child in sucking, and may afterwards prove an impe- diment to speech. The defect is easily remedied, The tongue is to be raised by two fingers passed, one on either side of the fre- num, which is to be snipped with a pair of blunt-pointed scissors in a downward direction, to avoid wounding the raninal or other vessels of the tongue. A split spatula may, if preferred, be used in place of the fingers to raise the tongue and expose the frenum. Some surgeons direct only the outer margin of the frenum to be cut, and leave the fold to become stretched afterwards by the motions of the tongue. Ttie operation is often uiniecessarily performed, it being by no means of such frequent occurrence as mothers and nurses fancy. In case bleeding of any consequence should follow, a white-hot knitting needle may be applied to the mouth of the divided vessel, or a small compress — which is to be supjiorted by a forked slick as directed by Dr. Physick, one end of ihe stick resting upon the incisor teeth, and the branches of the other upon the compress; the mouth of the child should be main- tained open for a time by some substance between the gums, to prevent its keeping up the liEemorrhage by suction. If the least suspicion esi&ts of any occult bleeding from suction, the child should always be applied to the nipple immediately as it awakes. If the tongue is rendered adherent, as is sometimes the case, by lateral bridles, tliey are to be divided in a similar way with the scissors or the knife. General adhesion of ilpe /ongtte.—The whole under surface of the tongue is sometimes found adherent to the bottom of the mouih. This occurs sometimes as a congenital defect, but more frequently as Ihe consequence of burns or ulcerations. Nothing here is to be done but lo loosen the tongue with the knife in the following manner, as cautiously as possible, and as fur inwards as necessary. The mouth should be held open by placing pieces Gi of cork between the teeth; an assistant should sustain the head of the patient, and at the same time lift up the tip of the tongue with the fingers, so as to stretch _the parts slightly. The operator then loosens the adhesion of the poiiu and sides of the tongue from the bottom of the mouth with a convex bistoury, beginning at the sides and avoiding as much as possible the larger vessels. Those which bleed profusely have either to be tied or treated with styptics or Ihe cautery. If the operation be performed on an infant, it might happen, if loosened to any considerable extent, that the tongue in sucking would become inverted upon the glottis so as to produce suffocation. To prevent tliis, it is necessary to put a thick compress upon Ihe tongue, and secure it with a tape around the chin. STAMMERING. Tiie following operations have been, within a few years past, practised for the cure of stammering; but as they were rarely fomid attended with permanent benefit, and in some instances proved to be so serious as lo involve life, they have been, with the exception below mentioned, entirely abandoned. Brief men- tion is made of them here merely as a matter of history. 1, Siujple transverse division of the nuiscular structure of the base of the tongue, either by a direct or subcutaneous incision. (Die^lfeiibach.) 2, Transverse division wiih excision of a wedge-shaped por- tion from the base of the tongue. {Dieffenbach.) 3, Excision of a triangular piece of the bodies of the genio- hyo-glossi nuiscles. {Mr. Lucas.) 4, A simple incision in the bodies of the genio-iiyo-glossi mus- cles. [Jimvssat, Philips^ and P'elpeau.) 5, Division of the attachment of the tendons of the genio-hyo- glossi, and sometimes also of t!ie hyoglossi muscles, [Bonnet and liaudens.) 6, Simple division of the mucous and subjacent tissue of the floor of the mouth, said to have been found sufficient, [^Imussat.) 7, Excision of a portion of the apex of the longue, {I'elpeau.) S. The excision of the uvula and tonsils. (Mr. Yeai-sley.) In nearly all cases the immediate cause of stammering will be found in the irregular and convulsive action of the muscles of phonation, remediable not by any process of operation, but by well-directed and long-continued exercise in the practice of elo- cution. Instances, however, now and then occur in which, from a permanent shortening or unyielding contraclion of the genio- hyo-glossus muscles, the front portion of the longue is held so low that the point cannot with ease be applied to the roof of the mouth, and has a constant tendency to protrude between the teeth. In such instances there is a muscular lie of the longue, and the division of the tendons of llie genio-hyo-glossus muscles may be made with advantage. Three cases of this description have come under my notice, in which the defect was traceable to a previous cerebral atfection. In two I practised the following operation, with the efl'ect of improving in one of them very con- siderably his powers of speecli. Section of the genio-hyo-glossus muscles. — The patient is to be seated with the head thrown back. The operator, seated in front, places the left fore finger in the mouth below the tongue, with the end resting against [he tubercles on the imier face of the 254 SPECIAL OPERATIONS. chin, with wliicli the tendons of those muscles are connected. A puncture is then to be made opposiie to this point through the integuments and platysma muscle below the chin, and in the in- terval between the digastric and mylo-hyoid muscles. A blunt- pointed tenotomy knife is then carried up througli the puncture with its edge forward, so as to separate the tendons of the genio- hyo-g!ossi of the two sides, and be felt by the finger directly below the mucous membrane. The blunt point of the instrument should be made to project even between the folds of the frenum, so as to insure the division of the upper fibres of the muscles, which it is most important to cut. The edge of t!ie knife is now turned obliquely outwards, first to the left, and then to the right, so as to cut in succession the tendons of the two muscles with the handle depressed close to the skin of the neck, in order to keep the edge in contact with the inner surface of the maxillary bone. The division of the muscles is made known by a slight snap, ac- companied with a yielding of tlie part. The extent of the lateral section either way should be to the outer edge of the external incisor tooth, and great care should be observed to not cut through the mucous membrane into the cavity of the mouth, as this would give a ready outlet to the blood, and aid in keeping up the bleeding. The knife should be kept with its edge close to the bone, for fear of wounding a small arterial branch that crosses just behind the jaw. If the division of the muscle has been complete, the patient will have lost to a great degree the power of protruding the tongue. The blood accumulated below the mucous membrane is removed by absorption in the course of a few days. OPERATIONS ON THE TONGUE. Carcinoma and other malignant affections of the tongue, chro- nic hypertrophy, fungous and erectile tumours of the organ, are the causes which in some instances require the removal of a part, or in extreme cases even the whole of the organ. Some of these affections are dependent on a general derangement of the alimen- tary organs, or form a part of a disease which has involved the regions of the neck and throat, and will require to be managed by a well-regulated system of internal treatment. In such as are merely local affections, the removal of portions of the tongue either by excision or ligature may be resorted to, especially if they occasion great inconvenience, or are Hkely to endanger life. When the apex of the tongue is the seat of the affection, its re- moval by incision has in general been preferred to the ligature, as the bleeding to which it gives rise is but of little moment and easily controlled. B6gin even recommends the use of cutting instruments in all cases, as the ligature is frequently followed by extensive sloughing and suppuration, and the swallowing of offensive fluids endangering life. Removal loith emitting instruments. 1. Hi/ incision. — Small pediculated and encysted tumours, and * horny excrescences of various sizes, sometimes occur upon the surface of the tongue, which may be removed at once with the bistoury or scissors. It will be well aftervvards to touch the surface with caustic, for fear of a redevelopment of the disease. If tumours of the encysted kind are imbedded, as is sometimes PLATE LIII.-OPERATION FOR CANCER OF THE TONGUE, Fig. 1. — Removal of one half the tongue ivith the scissors. (Process of Boyer.) — The healthy border of the tongue is drawn outwards with the left hand of the surgeon (c), and the diseased portion with the hook {d). A longitudinal incision has been made down the middle of the tongue, and at the period of the operation shown, a pair of strong scissors (/) are seen applied for the purpose of making a second incision, so as to detach the whole of the diseased mass in a triangular piece. Fig. 2. — Removal of the anterior part of the tongue with the bistoury. — The tongue is drawn out with a pair of hook forceps (forceps of Museux) (g) applied to the point, which is the seat of cancer. An assistant grasps with his thumb and fore finger, one of the margins of the tongue. The surgeon with the bistoury (h) has completed one of the branches of the A incision from before backwards, and is seen completing the second by bringing out the instrument from behind forward so as to detach the piece. In this operation the scissors might be made to serve in place of the bistoury. Fig. 3. — Closure of the wound after the preceding operation, by means of an interrupted suture behind, and a twisted or hare-lip suture in front. Figs. 4, 5. — Removal by ligature. — In fig. 4 is shown the introduction of the needle according to the proposition of M. Maingault through the cavity of the mouth, from the base of the tongue towards its dorsal surface, so as to avoid any external wound, as in the processes more commonly employed. The head is thrown well back- wards, and the surgeon stands behind the patient. The first ligature, which is intended to be carried out over the tip of the tongue, has already been inserted. A curved needle has been insinuated under the base of the tongue, and brought out at the orifice made by the first puncture on the dorsum, so as to apply the second ligature, which is to strangulate tiie side of the tongue. In fig. 5, both the longitudinal and lateral ligatures are shown tightened with the serre-nceud of Roderic as modified by M. Mayor, which consists of a series of small pierced balls strung on the two ends of each ligature, and tightened by a sort of tourniquet at the end. Between the two the diseased portion of the tongue is circum- scribed, so that we may at will effect the complete sphacelus, or the mere atrophy of the organ as has been proposed by MM. Mirault and Maingault, according to the force of constriction applied. f/a/e S3 OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 255 the case, in the substance of the tongue, they must be loosened and turned out by dissecting them off from their ceUular attach- ments, partly with the point and partly with the handle of the knife. 2. By excision. — This may be practised either with the bis- toury or a pair of strong scissors, according to the nature of the case. TFi/h ike bistoury. — For an operation of any moment on the tongue, the patient should be placed on a chair with his head supported against the chest of an assistant, and his mouth kept well open with a cork, compress, or the blades of a speculum between tlie teeth of.the sonnd side. When there is a superficial linear degenerated ulcer of the free surface, or of one of the borders of the tongue, two elliptical incisions may be made with the bistoury through the healthy structure, so as to detach all the diseased portion, which should be seized and raised up for the purpose with a pair of hooked forceps. If there is a cancerous affection of the point, or of one of the margins of the tongue, extending a little way into its substance, the tongue should be drawn out from the mouth with the fingers or a pair of hook forceps, and the tumour detached in a A shaped piece, by two incisions, as shown in fig. 2, leaving a wound readily united, as seen in fig. 3. With the scissors. (Process of Boyer, P!. LIII. fig. 1.) — The sound side of the tongue is to be seized with the thumb and fore finger of the left hand, so as to allow of the use of the scissors in the right. The first incision should be made in the longitudinal direction of the tongue, beyond the extent of the disease, and, if possible, by a single stroke with the scissors. The patient is now to be allowed to clear his moiHh of the blood. The surgeon lays hold of the diseased portion with a hook, and has it made tense by an assistant, while he makes a lateral cut with the scissors, joining the longitudinal at an acute angle, so as to completely circumscribe a triangular portion of the tongue, including all the diseased mass. A sort of A shaped wound will be left. The mouth is to well rinsed out with iced aluni water, and the lips of the fissure adjusted as nearly as possible with the interrupted suture, which will suffice to arrest the htemorrhage. The cica- trization of this vascular structure may be expected to be com- plete between the sixth and the tenth day. In a case of cancerous ulcer affecting one margin oi the poste- rior part of the tongue, and the anterior haJf arch of the fauces, Lisfranc effected excision in the following manner, viz : he had the tongue drawn strongly outwards, then grasping the diseased mass with the hooked forceps, he notched the border of the tongue with a pair of straight scissors, and finally detached the diseased portion by a semicircular cut with a pair of curved scissors. The large gap made in the tongue was greatly diminished by the immediate retraction of the parts, which served also to check the haemorrhage from two divided arteries that it was found impossible to tie. Occasionally we meet with cases of chronic hypertrophic en- largement of the tongue [glossocele], so great as to keep the organ protruded from the mouth, give a disgusting appearance to the face, and occasion troublesome excoriation of the integuments by the constant dribbling of the saliva, Lassus recommended the application of leeches and pressure in these cases, in the hope of gradually bringing down the tongue to its natural dimensions. This practice, conjoined with the interna! use of iodide of potas- sium, &c. may succeed when the enlargement is not extreme. But if it be of considerable magnitude, and of several years' standing, as in a case related by Dr. T. Harris,^ it is best to extirpate the protruded part by one of the processes above men- tioned. Dr. Harris, finding the attempt to detach it by ligature unsuccessful and excruciatingly painful, on account of his not being able to completely suspend the circulation in the included part, excised a A shaped portion with a catling. The ha;raorrhage which followed was not profuse, and the recovery was complete. Removal and atrophy by ligature. The isolation and sirangnlalion of -a diseased portion of the tongue has been practised with two objects in view; — that of effecting sphacelus, where the affection was of such a nature that it was impossible to restore the part to a healthy condition; and that of merely obstructing the circulation, so as to cause atrophy, and by that means arrest the progress of a disease that was not believed to be positively malignant. The latter propo- sition has been carried into practice by MM. Mirault and Main- gault, but experience has not yet decided it to be a measure deserving of much reliance. Erectile tumours are sometimes observed on the dorsum and sides of the tongue. These, when small, it has been directed to remove in the ordinary manner — by the introduction of a double ligature under their base with a curved needle, dividing it at the loop, and lying a ligature on either side of the tumour so as to strangulate the base. In consequence of the firm structure of the tongue, the autlior has found it difficult to effect complete strangulation in this manner, and gives a decided preference to the use of the double canula of Levret with a well annealed iron wire. In this way he has successfully removed two tumours of considerable size, occupying one border of the tongue near its base. Process of the Author.— Tv^o tenacula are to be hooked in deeply at different points through the base of the tumour, so as to elevate the diseased structure and at the same time draw the tongue forwards. Over the bandies of the instrument, the wire loop is to be passed, and placed so as to grasp the base of the tumour below the hooks. The wire is then to be drawn as tight as possible with a pair of forceps, and secured to one arm of the instrument as directed at page 14. If the base of the tumour is by this means pinched up into a narrow pedicle, the hooks may be at once removed — if not, one of the hooks should be left in place for a few hours, with the point retracted so as not to irritate the palate, after which time the wire is to be again drawn and the hook definitely removed. The wire is afterwards to be daily tightened, till the loop is loosened by the sloughing of the mass, which takes place in from three to five days, according to the size of the part embraced. Process of Jirnott and Cloquet for the destruction of the late- ral half of the tongue by ligature. — A small incision is to be made in the middle line between the jaw and os hyoides, and the genio-hyoid, and the genio-hyo-glossus muscles of the two * Am. Jour. Med. Sci., Nov. 1830. S56 SPECIAL OPERATIONS. sides separated sliglUly from each otiier. A curved needle, mounled on a handle, and pierced with an eye near its point, is' passed upward so as to be brought out in the middle part of the base of the tongue. Two strong hgatures are now to be passed through the eye, and the needle retracted so as to bring the ends of the ligatures through the substance of the tongue to the open- ing below the chin. From the same place, the needle is again to be carried upward and brought out near the frenum. The other ends of the ligatures which hang from the mouth are now to be passed into the eye of the needle, and likewise drawn down to the orifice of the cutaneous incision. Two loops of ligature now rest upon the dorsum of the tongue. One of these is made to embrace the organ in a longitudinal direction, and the other in a transverse, so that when firmly lightened, they will strangulate a portion of tiie tongue between them. A small incision should be made in the point of the tongue for the longi- tudinal loop, to keep it from slipping. M. Miraull has modified this process, with the object of pro- ducing atrophy of the diseased part by a partial strangulation. From the puncture be!ow the chin, he introduced a large needle threaded with a strong ligature upwards through the base of the tongue — the tongue being forcibly drawn forwards. The needle was again passed, but in tlie opposite direction from above down- wards, and from the side of (he tongue to the orifice below the chin. A single loop was thus thrown laterally over the tongue, the ends of which loop were tightened below by a serre-nosud. t4 modification of /his process of ligaliire 2}roposcd by 31. Mairtgaidt, appears to be entitled to a preference over the two preceding, and requires the making of no external incision. The needle and ligatures are to be passed through the tongue from the cavity of the mouth, as shown in fig. 4; the process is fully detailed in the explanation of the plate. EXCISION OF THE UVULA. This operation is rendered necessary in various chronic affec- tions of the lining membrane, followed by elongation, hyper- trophy or degeneration of this pendent part. A merely dropsical swelling, resulting from the accumulation of serum in the sub- mucous cellular tissue, which I have seen sometimes so large as to form a semi-transparent floating tumour, blocking up the fauces, irritating the tongue by its pressure, and producing a sense of suffocation, may be removed by merely clipping or puncturing the membrane freely with the scissors or bistoury. Excision may be practised simply with the angular uvnla-scis- sors of S. Cooper; but the pinching action of the scissors drives the uvula backwards against tlie bar, so that it is seldom neatly divided at a single stroke: or the point of the uvula may be seized and drawn forwards with a pair of toothed forceps or a hook, and the section made with the common scissors or the probe-pointed bistoury. Except in cases of degeneration, where ail the diseased part must be extirpated, the division should be made a few lines below the corresponding margin of the velum, as this will suffice to remove all the irritation arising from its elongation and enlargement. The tongue, if necessary, may be held down with the finger or a spatula, and it m^y possibly be requisite in cases of children, though I liave never found it so, to keep the teeth asunder by wedges between the grinders. A variety of instruments have been devised to render this little and common operation easy. By far the best of these, ac- cording to my own experience, is the proper nvula-scissors, with a pair of serrated spring forceps attached below the blades. The forceps are to be opened with the blades, and set by a movable lever attached to the shanks. In this state, the instru- ment is carried into the mouth, with the blades on either side of the uvula. The operator now pauses a moment till the levator muscles, which are at first excited, relax and drop the uvula between the blades, which are tiien to be slowly closed. As the handles move towards each other, the lever recedes, so as to loosen the spring forceps, the teeth of which close upon the lower part of the uvula, and hold it firmly while it is cleanly excised without risk of slipping from the scissors, or any necessity of repeating the attempt. When the spring has closed, which is at once known to the operator, the instrument should be slightly retracted, bringing with it the tightly pressed uvida, so as to re- move the ends of the scissors from the back part of the palate; and this should be done without interrupting the stroke. The detached piece of the uvula is brought away in the grasp of the forceps, EXTIRPATION OF THE TONSILS. The tonsils, though frequently inflamed, suppurating, enlarged and indurated, are very seldom the seat of malignant disease; and if such should be the case, but little relief can be expected from their removal by operation. In alfections of the former class, the surgical aid required may be employed with nearly a positive certainty of success. If the parts be recently inflamed and swollen, so as to obstruct deglutition and breathing, scarifi- cation will sometimes be found beneficial; if an abscess have formed in its substance, this may be opened and its contents discharged. Both these operations may be performed with a bistoury cache, or even with a scalpel somewhat longer and narrower than usual, care being taken to make the incisions on the most prominent place, so as not to injure the neighbouring parts. Tumours of the tonsils from hypertrophy and chronic in- duration, is a very common consequence of repeated cynancheal inflammation, and from their situahon at the union of several most important cavities, will require to be removed, if so enlarged as to obstruct and impair the functions of these parts. Complete extirpation, however, is rarely necessary. The wound heals kindly, without reproducing the tumour, and it usually suffices to cut away that portion only which protrudes beyond the pillars of the velum pendulum palati. If an attempt be made to ex- tirpate the base between the pillars, the internal carotid, which is only separated from it by the thickness of the wails of the pharynx, will be in danger of injury—a circumstance which formerly induced practitioners to employ in place of cutting instruments, strangulation by ligature, or destructive cauteriza- tion; these methods, however, have been found so difficult, tedious and painful, as well as dangerous, from the protracted irritation they occasion, that they have been utterly abandoned. The follawing is the usual method of operation resorted to by European surgeons. The patient is seated on a chair, his head held by an assistant, and the face turned toward the light. The mouth is opened as widely as possible; a piece of cork may be OPERATIONS UPON THE MOUTH AND ITS DEPENDENT STRUCTURES. 257 introduced between the molar teeth, and the tongue held down wilti a spatula, if the subject of the operation be a child. The enlarged gland is then drawn off from the palate with a tenacu- lum, or, which is better, with the hook forceps of ISIuseux, as the latter is less likely to tear out. The division is effected with a scalpel or probe-pointed bistoury, wrapped half-way from its heel to the point with a strip of adhesive plaster. Great care must be.observed to avoid wounding the palate. If the incision is not made too deep, the bleeding is usually inconsiderable, and readily checked by gargling with cold water. As the common straight knife is used here to great disadvantage, various modifications of its shape have been suggested, the best of which perhaps is that of Mr. Yearsley. The knife of this operator consists of a short strong blade, with a hawk bill, and is angularly bent in the handle. The use of the scissors is by some surgeons preferred to that of the knife. The best instrument of this kind is that invented by Professor Smith, of Baltimore, the blades of which are curved on the flat, and bent like a hawk bill towards each other so tliat tlie points cross when the instrument is shut. Two small steel points are in addition attached to the side of each blade so as to catch the portion excised, and prevent its falling on the glottis. The use of the hook and knife has been objected to as hazardous, on accoinit of ihe general spasm of the muscles of the mouth following the introduction of the hook. Various in- struments have in consequence been devised to render the opera- tion more safe and easy, the best of which are of American iTivention. Of these, the only ones which are really well suited to the operation, according to the experience of the author, are the guillotine instrument of Dr. Physick as modified by Dr. J. K. Mitchell; the ring instrument of Fahnestock, with a knife nearly circular in shape; and another — a modification of this, consisting mainly of the attachment of a pair of forceps with a spring upon the front, which of tiiemselves draw out the tumour from be- tween the half arches so as to insure the removal of a suflicienlly large portion, and with such an alteration in the shape of the handle, that the two first fingers can retract the sliding blade. Tiie instrument last described, which is shown applied at Plate LIV. fig. 6, has moreover the advantage of requiring the use of but one hand. It is employed in the following manner. The instrument is to be set, with ihe knife (d) hid between the narrow elliptical plates of steel («) which cover it, and the forceps (e) opened and pressed down upon the spring (,§■), and secured in this position by the insertion of the shanks into a mortise (/) in the sliding bar (c) which moves the blade (d); it is then carried into the mouth and over the protuberant gland, which will be fonnd sometimes with a process pendent on ihe side of the pha- rynx, round which the instrument must be slid. When the instrument fairly embraces the gland, and is well pressed up to its base, the vertical bar (c) is retracted by the first two fingers which rest upon it. This loosens the forceps, which close upon the tumour by the action of the spring between their shanks, and at the same time draw it farther within the circuit of the knife by the reaction of tlie spring (g), which Iiad been forcibly depressed in setting the instrument. The continued retraction of the blade excises the tumour, which is brought away in the grasp of the forceps. For the tonsil gland of the right side, it will be most convenient to apply the itislrunienl with the left hand. 65 No instrument is required to depress the tongue or hold the mouth open— the fore finger of the other hand answering better than any thing else when any depression is needed. All the precaution necessary in the operation, is to accustom the fauces to the contact of instruments, by having them touched frequently for several days previously with the handle of a spoon, and to avoid wounding the half arches of the palate, which, as shown by Dr. I. Parrish, might be followed by some defect in enunciation. The ring instrument of Dr. Fahnestock will, from the smallness of its dimensions, be found particularly appropriate in operations upon children, when ihe tumour is somewhat pendulotis. Wheii it is merely round and large, without being pendulous, there is sometimes with this inslrnment, which has no contrivance for drawing the tumour through the ring, a difficulty in removing a sufficiently large portion. In the formhig state of these tumours, and especially in scrofulous children, astringent applications and occasional touching with lunar canslic, will frequently suffice for their removal, without resorting to the use of cutting instruments. STAPHTLORAPHY. This operation is an invention of modern surgery. Though the idea of reuniting the two edges of a fissured velum palati was entertained by ihe older surgeons, and is said to have been successfully performed by M. Le Monnier in 1764, it is to Graefe, of Berlin, and Roux, of Paris, who performed their first opera- tion of the kind in IS 16, that we are indebted for the examples which introduced the practice into general use. A congenital division of the palate, a fissure resulting from a wound of the organ, or a destruction of a part of tlie substance by ulceration impairing the clearness of articulation, are ihe com- mon causes which require the performance of this operation. In simple staphyloraphy the principle of the operation is the same as in simple hare-lip, viz. to remove the margins of the fissure with a cutting instrument, and to hold the raw edges in contact wilh each other till there is time for union to take place. The operation may consequently be divided into iliree stages. I. The removal of liie old margins of the fissure. 2. The drawing in of the ligature; and 3. The uniting of the fissnrd As the per- formance of the operation is somewhat difficult, and requires not only careful and delicate manipulation on the part of the surgeon, but perfect willingness and self-command on that of ihe patient, it cannot be attempted with advantage much before the age of puberty. For a week or two previous to the operation the root of the tongue and the velum palati should be touched frequently with a spatula or spoon, in order to dlmiuisii the natural irrita- bility of the parts, and dispose them better to the manipulation necessary during ihe operation. If ihe fissure extend but a little distance above the uvula, or in ease it reach near to the hard palate and the velum is not found so defective in extent of struc- ture but that its separate portions may easily be drawn together, the operation is comparatively easy, and offers a fair prospect of success. If, however, the fissure be very large, and the lateral margins of the velum so much contracted as to be almost lost in the mucous membrane of the fauces, the difficulties will be greatly increased, and the chance of success diminished, in con- sequence of the tendency to muscular spasm and ulcerative in- tiammalion occasioned by the tension which has been necessary SPECIAL OPERATIONS, lo bring the parts together. Cases of this description may, not- withstanding, be made by proper management to miite perfectly in the end ; two of wliich, successfully treated, have been reported by the author in the Amer. Journ. of the Med. Sciences for June, 1843. Of the various processes that have been devised for the cure of this deformity, it will suffice to mention the following, in which are contained the leading peculiarities of the whole. Process of Hoiix. (PI. LIV, fig. 1.) — The apparatus required consists of three flat ligatures, each formed of two or three threads waxed together; six small curved needles affixed lo the ends of the hgatures; a needle holder, or port-ciguille; a pair of ring- handled dressing forceps; a straight button-pointed bistoury, and a pair of angular scissors. 1. Jipplication of the ligatures. — The patient is to be seated with his face to the light, his head thrown back and supported on the chest of an assistant, and the mouth maintained wide open with a linen compress or a speculum between the teeth, unless sufficient confidence can be reposed in the voluntary efforts of the patient to keep the mouth open. The surgeon, with the forceps in his left hand, takes hold of the right half of the velum, and introduces with the right hand, through the cavity of the fissure, the port-aiguille armed with one of the threaded needles. PLATE LIV.-STAPHYLORAPHY, BRONCHOTOMY. STAPHYLORAPHY. Fig. I.— {Process of Boux.) Passing of Ihe needle from the haek to the front portion of the palate.— Two ligatures {a, b), Ihe upper and lower, are represented already inserted. They have been passed from behind forwards with a needle attached to each end, precisely as in the process shown for the introduction of the middle thread. The right lip of the fissure is seized and held firm with the ring-handled forceps [c) in the left hand of the surgeon. The needle, which has been securely fixed in the needle holder or port-aiguille (d), has been passed through the velum from behind forwards. The slide, against which the thumb of the hand (c) rests, is now loosened, and the port-aiguille detached from the needle. The needle is then drawn through, bringing after it one end of the ligature, which is attached to its eye. Figs. 3, 3, 4. — {Process of the author.) Fig. 2.— Excision.— The operator takes hold of the uvular end of the fissure with the spring forceps of Assaliiii (a), and passes the point of the double-edged knife (b) through the velum, and runs it up to the apex of the fissure so as to detach all the rounded edge. Fig. 3.— Introduction of the needles.— In this drawing, which was taken at an operation of the author, the fissure was of the largest size. Four perinanent ligatures were employed. The one shown as an example of the mode of introduction, is the second one counting from the bottom, and is intended merely as a conducting thread. c. Physick's artery forceps, grasping the heel of the needle. d. A pair of convenient toothed dressing forceps, with which the needle is grasped and withdrawn, bringing with it the ligature. Fig. 4.— Lateral incisions after the manner of Dieffenbach, to facilitate the approximation of the edges of the fissures.— The three ligature threads, which were all that were applied in this case, are seen knotted over the middle line, causing by the tension they exert the gaping of the incisions on the front part of the velum. STAPHYLOPLASTY. Fig. 5.— {Process of the author.)— A hole existed in this case near the centre of the hard palate, establishing a communication between the mouth and nose. Two irregular quadrilateral flaps were raised, as seen in the drawing, from the mucous covering of the side of the roof of the inouth. These were reversed upon the orifice with their mucous surface upwards, attadied to each other by two points of interrupted suture, and forced firmly up against the margin of the bony orifice, which had been previously made raw with the knife by a curved hare-lip pin, the convexity of which presented upwards and corresponded with that of the palatine arch The wrapping of the ligature round the pin carried the flaps firmly up against the orifice, so as to facilitate their adhesion to the raw margin of the latter. The mucous membrane of the sides of the flaps was partially shaved with the knife before they were reflected upwards. EXCISION OF THE TONSILS. Fig. S.— Excision of enlarged tonsils with the improved tonsil instrument.— Yot want of space the handle of the instrument is not shown. The handle is formed by giving to the end of the shaft two rectangular turns, so as to suit it well to the grasp of (he hand. a. Shaft of the instruiiient, continued on so as to form one of the elliptical plates between which the knife slides. OPERATIONS UPON THE MOUTfl AND ITS DEPENDENT STRUCTURES. 259 Pausing a moment for the spasm occasioned by this step to sub- side, the operator passes the needle from behind forward through the velum at the distance of three or four liues from the margin of the fissure. It is then seized with the dressing forceps; the hold which the pori-aiguille has of the heel is relaxed by the retraction of the slide, and the needle is drawn out through the mouth, bringing with it the ligature. The patient is now allowed to rest for a time, and to rinse out the mouth. The needle at the opposite end of the same ligature is next fitted to the other margin of the port-aiguille, and carried by a similar process through the right half of the velum. The two ends of the thread are left hanging at the corresponding angles of the mouth. The lower ligature, or that near the free border of the palate, is to be placed first. The two other ligatures are introduced in a similar manner, the middle one being inserted last. 2. Excision of the edges.— loops of the three ligatures are to be depressed downward and backward into the pharynx, so as to avoid cutting them in the removal of the edges of the fis- sure. The operator then seizes the left angle of the velum with the forceps, so as to make it tense, and begins with the angled scissors the incision of the edge, which he completes with the button-pointed bistoury, run.iing the latter instrument up with a sawing motion two or three lines above the apex of the fissure, in order to detach a piece from half a line to a line broad, com- prising the rounded edge of the fissure. The same process is then to be repeated on Ihe other side. 3. Knotting the ligatures.— M. Roux effects this with the fore finger of each hand introduced back to back. The lower ligature is to be secured the first. When the first fold of the knot is drawn, an assistant is to grasp it with the forceps to prevent its relaxation, while the second and final turn of tlie thread is made. The upper and middle ligatures are successively knotted in the same manner— the surgeon observing the precaution to draw each knot tighter than would be necessary merely to close the fissure at that point, in order that the intervening spaces may be brought completely in contact. The operation is now terminated. The patient is to be kept perfectly quiet, to maintain the mouth closed, to take no solid aliment, and nothing scarcely but a little flnid, and that at long intervals — a piece of ice or a slice of lemon taken from time to time will serve in a good degree to subdue the feeling of thirst. All coughing and sneezing, or even spitting, is to be obviated as much as possible, and every thing in fact that will be likely to excite motion of the muscles of the velum — even so much as the swallowing of the saliva, which should merely be conducted out with the tongue and received upon a c\qlU between the teeth. On the third or fourth day, the knots of the two upper ligatures may be cut, and the ligatures carefully withdrawn. The lower- most ligature, or that near the uvula, should be left for two or three days more. If after the division of the knot, the ligature does not readily slip, it is belter to postpone its removal to the following day than run tlie risk of breaking up the adhesions by the effort. A gap, even when the case has gone on well, is fre- quently left at the upper part of the fissure. This is subsequently b. Second plate, attached to the shaft of the instrument by screws. c. Vertical bar, with which the elliptical knife {d} is retracted by tlie first two fingers, which, when the knife is applied, rest upon the bar. e. Shanks of the spring forceps, (the spring being included between the shanks,) intended when the instrument is set to be pressed together and held in the mortise (/) of the vertical bar (c). The forceps terminate at the other end in serrated curves. g-. Elastic spring, fastened upon the body of the instrument with a transverse bar on the end next the knife, intended to throw up the toothed forceps and cause them to protrude the gland within the circuit of the knife. The instrument is shown as in the act of excising the gland. The vertical bar (c) has been retracted; this loosened ilie shank of the spring forceps, so as to allow its serrated extremities to come together, and the spring (g), which had been depressed to raise the shanks of the forceps up to the mortise in the vertical bar, reacts so as to protrude the gland. These movements, which take place instantaneously, are succeeded by the continuous retraction of the knife and the excision of the tumour, BRONCHOTOMY. Fig, 7. — Two modes of performing this operation are shown in the figure, the upper one of which is denominated Laryngotomy, the lower Tracheotomy. (A) . Laryngotomy. — Tlie operation is supposed to have been performed for the removal of a piece of coin, resting in the opening of the glottis. An incision has been first made through the skin and superficial fascia; the sterno-hyoid muscles have then been separated, and the thyro-hyoid membrane and the thyroid cartilage cut through on the middle line. The margins of the wound have next been drawn asunder with blunt hooks, so as to expose the interior of the cavity of the pharynx. A pair of forceps has been introduced for the removal of the foreign body. (B) . Tracheolomy.— The canula of M. Bretonneau, (seen in full at fig. 8), shown inserted after the performance of tracheotomy according to the process of this surgeon. It is secured by two ribbons attached to its rings, and knotted behind the neck. Two strips of adhesive plaster are applied in the form of a cross over each sterno- cleido-mastoid muscle, to keep the anterior extremities of the ribbons in place. 260 SPECIAL OPERATIONS. to be closed by cicatrization under the stimulating: influence of lunar caiisiic, (Roux), or the soluble nitrate of mercury, (Cloquet). The objections made to the process of Roux, are, 1, the awk- wardness, irritation and imprecision, necessarily attendant upon the passing of the needles from before backwards, and from a surface to which the eye cannot reach; 2, the difficulty of ex- cising the margins after the introduction of the ligatures, which, by the depression of their loops in the pharynx, keep up a con- stant feeling of nausea and irritation; 3, the great length of time required, from these various causes, in the performance of the operation, which lias frequently been known to occupy one and a half to two hours. These difficulties will be found dissipated in a great degree by the following process, in which the author has been enabled to complete it under favourable circumstances in less than half an hour.* Process employed by the Author. (PI. LIV. figs. 2, 3, 4.) — The apparatus necessary is very simple, A pair of Assalini's spring forceps, a double-edged knife, or the ordinary cataract knife of Wenzel with a handle somewhat longer than usual, Physick's artery forceps, a pair of ordinary dressing forceps, and six stout short curved needles,t lancet-shaped at the point; the needles should be arranged in a cushion in two rows, three being threaded with a fine silk conducting thread, and three with broad ligatures, with which the closure of the fissure is to be perma- nently made. A vessel of alum water should be at hand for the purpose of ' arresting the bleeding, which would obscure the parts. The patient is to be placed as in ibe process just described. 1. Excision. (Fig. 2.) — The operator, with the spring forceps in the left hand, takes hold of the uvular margin of the right portion of the velum, and puts it on the stretch. The point of the double-edged knife is then to be entered just above the point of the forceps, from before backwards, and the knife carried up a line above the apex of the fissure, so as io detach the rounded border of the fissure in a narrow strip. The knife as well as the forceps is then withdrawn, leaving the strip as yet adherent at its upper and lower ends, so as to have no floating point to irritate the passages. The patient is now to rinse out the moulh. A similar operation is then repeated on the opposite margin of the fissure; but at this time the knife is run up to cut into the former incision near its top, and then bronglit down so as to de- tach the lower end of the loosened strip by cutting at the outer side of the bold of the forceps. The forceps, which retains its hold of the A shaped marginal strip, is now retracted so as to Mraighten out the piece, which remains attached only at the point of the uvula of the left side, from whence it is at once to be separated with the point of the knife. The excision of the edges, which is considered by Roux the most difficult part of the operation, is in this way readily effected. 2. Introduction of the ligatures. (Fig. 3.) — These are all to be introduced from before backwards, so that the surgeon can see that they are placed exactly opposite to each other in order • Vide Amer. Jour. Med. Sci. for Jan. 1843. ' f When the fissure is large, I have found it better to have eight needles, and ■ apply four sutures for the purpose of closing it. to avoid any puckering of the velum when they are tied, and at the proper distance from the excised margin. As soon as the bleeding is checked by the astringent gargle, the introduction of the ligatures is cotnmenced. The three needles threaded with the permanent ligatures are to be first passed, and on the left side, and in the same order of insertion as in the process of Roux. The needle held by its shank in the grasp of the artery forceps,* is then presented with its point perpendicular to the velum, the haijdle of the forceps being carried for this purpose to the oppo- site corner of the mouth. If the needle is sharp at the point, it passes in this way readily through, without the necessity of making any tension of the part with the forceps, thus obviating one great cause of irritation and the disposition to cough or clioke when restraint is made upon the velum. As the needle pene- trates, the handle of the forceps is brought towards the opposite corner of the mouth; the point of the needle, which is now ob- vious in the fissure, is grasped with the dressing forceps held in the other hand for the purpose; the artery forceps is removed, and the needle is carried through so as to be detached behind the palate, and brought out either with the heel or point foremost, as is found most convenient. Having passed the three permanent ligatures in this way through the right side of the palate, the fails are to be brought out and lodged separately between the fingers of an assistant. The same process U repeated on the opposite side for the passage of the three fine temporary or con- ducting ligatures. It now remains to bring the posterior ends of the three broad or permanent ligatures of the right side through the punctures which have been made with the needles on the left. This is readily efl'ecled by knotliiig together the back ends of the corresponding ligatures of the two sides— which are drawn out of the mouth for this purpose — flattening the knot with a squeeze of the forceps, and pulling upon the fine conducting thread so as to carry the knot and the back end of the ligature of the opposite side with it, the end of the fore finger being pressed as a point of support upon the velum as the knot is passed with a slight twitch through the puncture. 3. Knotting the tigatures. — The permanent ligatures have now been carried through both sections of the velum, and no- tiiing remains to be done but to wipe away the glairy mucus from Ibe threads, and tie them as in the process of Roux. The ends of the ligatures, as each respective one is lied, are to be detached close to the knot with a pair of curved scissors. Remarks. — Though there are many difficulties to encounter in the after-treatment that may render the operation fruitless, as the neglect on the part of the patient to observe absolute silence, the occurrence of paroxysms of coughing, sneezing, etc., yet when the patient is docile, and the simple plan above described is employed, it will not be foiuid one of any peculiar difficulty to any person accustomed to the performance of such as require some nicely of touch. 1 can readily conceive, however, from the delicacy of the operation, and Ihe length of time required to perform it, that great dexterity and skill on the part of the sur- geon, and firm resolution on the part of the patient, will all be * To Dr. Wells, of Columbia, S. C, and Professor Mtitter, belongs the credit of having, introduced the use of this simple instrument for the passing of the needles, in place of the more cumbersome contrivances commonly used^ — Vide Am. Joum. nf Med. Sci. 1841, OPERATIONS UPON THE NECK. needed, as described by writers, when the complicated and cum- bersome instruments frequently advised are employed, five of which were used by Graefe merely for tying the knot. The most difficult part of the operatiou is considered, as has been before mentioned, to be the excision of the edges of the fissure. But this is dependent on the method in which it is done, and will especially be found the case where the ligatures are first com- pletely passed, the loops depressed in the throat, and the edges made raw with the scissor%and bistoury, as practised by M. Koux. The leaden ligature of Dieffcnbach, the simple long curved needle set in a handle used by many surgeons, the inge- nious modifications even of the old porl-aiguilk by Messrs. Dapierris and Guyol, cannot be compared with the instruments I have described above, in respect to the facility and rapidity with which the ligatures can be passed— in reality the only diffi- cult part of Ihe operation. Modijication of the operation,rendercd necessary token /here is deficiency of structure or the fissure is unusually large. (PI. LIV. fig 4.)— If it is found impossible to bring the margins of the fissure together at all, or without producing excessive tension, it is necessary to find some method of elongating the soft parts. For this purpose, M. Roux made a transverse sec- tion of the palate along the posterior border of the palatine bones. M. Bonfils made a plastic operation after the Indian method, by dissecting up a flap of a proper shape from the mucous membrane of the arch of tfie palate, reversing it so as to allow it to hang by its posterior part, and fastening it by suture to the margins of the fissure of the velum. To remedy this deficiency of structure in extreme cases, Dr. Mcttauer,*^ of Virginia, lias recommended as a preparatory step, repeated lateral incisions through the substance of the velum, leaving spaces to fill up by granulation, after inter- posing a piece of buckskin or soft sponge between their edges. By this means, as he asserts, the pliable surfaces of the velum will be increased in extent so as to ailow of their being after- wards drawn together, without causing the ligatures to cut out. The plan of Bieft'enbach, (fig. 4,) which is but an imitation of the Celsian plastic method, is Ihe one which the author has been most disposed to rely upon in practice, and has found to answef' well in two cases of large fissure of the palate. This consists iu making lateral longitudinal incisions of a length proportioned to that part of the palate found most deficient. These incisions should be at the distance of four or five lines from the margin of the fissure. The edges of the fissure are then to be excised and secured as in the ordinary process, and if any difficulty should be still found iu closing it, the elongation may be increased by dissecting a little at the inner margins of the incisions. In one instance, after closing the parts, the author, finding the tension so great as to induce him to think that the ligatures would cut through before union could take place, made an inci- sion with a double-edged knife, passing the instrument entirely through eitlier half of the velum, so as to relieve tlie tension, as was shown by the gaping orifices left, and cut oil" the tendons of the palate muscles which, from iiaving been unduly stretched, there was reason to fear, would contribute to the strain upon the • Amer. Joum. of Med. Sci., Feb. 1838. ligatures. The relief afibrded by these incisions seemed to facili- tate the process of cure; this did not take place perfectly, how- ever, without the necessity of having to repeat partially the process of operation. Fissures or openings existing in the bony portion of the palate (PI. LIV. fig. 5,) are seldom thought to require an operation, as they may be closed by an obturator, so as to pre- vent any very obvious imperfection of speech. But in some in- stances, an operatiou of the kind shown in the drawing may be practised with advantage for the purpose of closing them up with living tissue. This, however, belongs to tlie class of plastic operations, and will be noticed under that head. V. OPERATIONS UPON THE NECK. Under this head are considered, 1, Bronchotomy; 2, Callieler- ism of the ffisophagus; and 3, (Esophagotomy. BROXCHOTOMY. This term, though etymologically inappropriate, has been long employed as a generic appellation for operations upon the air passages, whether the opening made be in tlie trachea ( Trache- otomy), in the larynx (Laryngotomy), partly through both these structures {Laryiigo-iracheotomy), or in, the crico-tii yroid or hyo-tliyroid membranes. Bronchotomy is an old operation, and is neither difficult of performance nor directly dangerous as to its immediate results. But as it is performed usually only in cases of extremity, the fatal consequences that ensue from the previous condition of the patient, are liable without explanation to be placed to the responsibility of the operator. The performance of the operation has been recommended for the fulfilment of several indications. 1. For the removal of foreign bodies from the air pas- sages, when they cannot be dislodged by exciting expectoration or vomiting, or by suddenly reversing the patient with the iiead downwards. 2. For the removal of the false membrane, or diphtheritic effusion of croup, in which the ordinary methods of treatment have failed to afford relief. The opening of the trachea has latterly been strongly recommended, under these circumstances, by MM. Bretonneau and Trousseau. The success of the prac- tice, however, in the hands of these gentlemen, does not appear to have been great, as they were enabled to save, according to their own reports, only one case in three of those operated on; and in the hands of most other surgeons the proportion of cures effected has been still less.* The advocates of the operation assert, however, that the cause of its not succeeding more fre- quently, is nearly always the consequence of its not have been performed sufficiently early. We may not only succeed in re- moving by this operation, according to M. Bretonneau, the mem- • Of a hundred and foriy cases 'collected in Froriep's Noiizen for Feb. 1840, in which the operation was performed for ivjlammatory ajediona of ttie air pas- sages, only Iwenty-eight of the patients recovered, and a hundred and twelve died. £62 SPECIAL OPERATIONS. branous concretions already formed, but, by keeping a tube in the orilice, get access to the passage so as to take away those subseqnenUy developed, and check their tendency to reproduction by the introduction of calomel in powder, or the instillation of a few drops of a solution of lunar caustic. 3. For anginose affections, aiiended luith im7ni>ieni danger of suffocation. — In cases of acute inflammatory swelling of the tonsils, or of the upper surface of the larynx, relief will usually be aff'orded by some deep longitudinal incisions in the swollen surface, without recurring to bronchotomy, which has been re- commended in these affections when the turgescence has been so great as to threaten suffocation. If the swelling is seated at the top of the larynx, the incisions should be made in tlie upper sur- face of the back part of the tongue. In cedematous angina, where there is a serous effusion under the mucous folds of the lips of the glottis, so as to more or less obstruct the chink, the danger oi suffocation is more immediate. It has been advised in cases of tills sort, when other remedial measures fail to afford relief, either to scarify the tumefied membrane with a sharp-pointed bistoury wrapped with a thread to near the point, and carried along the finger over the back of the tongue,— to introduce a tube through the glottis from the mouth, — or to perform the operation of bron- chotomy and insert the canula. The last process is, in this serious affection, the most to be relied on, as it insures the freedom of respiration, and gives time for the removal by absorption of the fluid effused round the lips of the glottis; little hazard appears to attend its performance, and it has proved successful in almost every case in which it has been resorted to for this indication. 4. For diseases of the larynx. — Wounds, syphilitic ulcers of the larynx, and strictures of the glottis, which in general are so little amenable to the ordinary plans of treatment, are said by Purdon, Velpeau, BulUard, Porter and others, to have been cured after the insertion of the canula by the operation of bronchotomy. Pressure on the air passages from foreign bodies in the oeso- phagus, from alimentary matter lodged in the upper orifice of the larynx, or from tumours on the exterior, have likewise in some cases rendered this operation necessary. Ojoera^/OTJS.— There are three principal varieties of the opera- tion described, viz: Tracheotomy; Laryiigo-tracheotomy; and Laryngotomy properdin which the opening may be made either in the crico-thyrotd or liyo-thyroid membrane, or through the thyroid cartilage. 1. Tracheotomy. Surgical anatomy of the trachea.— 'The cervical portion of the trachea is from two to two and a half inches long. It is covered, by the skin and superficial fascia; 2, by the sterno-hyoid and thyroid muscles; 3, by the isthmus of the thyroid gland, which lies usually over the three or four upper rings of the trachea, and sometimes extends as low as the fifth. Between the lower edge of the isthmus and the sternum, is found a plexus formed by the inferior thyroid veins, several of which are of large size, and occasionally an artery known as the middle thyroid artery of Ne.iibaiier. The presence of these vessels is the chief cause of difficulty in the performance of tracheotomy. The trachea as it descends in the neck, it must be remembered, recedes from the surface so as to be nearly an inch behind the top of the sternum. Operation.—The instruments required consist of a small scal- pel, a probe-pointed bistoury, a pair of blunt hooks or some other contrivance for separating the lips of the incision, a canula, and a pair of forceps for the removal of foreign bodies. The patient is to be placed in the recumbent posture, with his chest raised and the head thrown back so as to extend the neck and draw up the trachea as much as can be done without increasing the dyspnoea. The operator, placed upon the right side, steadies the larynx with his left hand, and makes in the middle line an incision through the skin and superficial fascia, from the cricoid cartilage to a point a little distance above the fossa at the top of the sternum. He now separates the two sterno-thyroid muscles, partly with the ponit and partly with the handle of the knife, and finding no large vessels in the way, divides the isthmus of the thyroid gland. If the blood which flows from the veins necessarily divided in the last step is not soon checked, the vessels should be tied. Before opening the trachea, the operator should ascer- tain by feeling with the finger whether it is covered by'any large vessels, or if there is any displacement of the lateral lobes of the thyroid gland, and if such be the case, have them carefully drawn aside before making the puncture. Previous to open- ing the trachea, it is well to follow the advice of Mr. Porter,* and excise a circular portion of the cellular sheath covering the trachea, for fear that if the trachea and fascia were opened to- gether by a longitudinal incision, the orifices in the two struc- tures would not correspond, and thus present a dilBcully in keeping the new passage open. He now opens the third, fourth, and fifth rings of the Iracliea, puncturing the tube with the point of the knife below the fifth ring, and running the scalpel upwards with the handle a tittle inclined to the sternum, so as to avoid injuring the posterior wall of the trachea. For fear of this latter result, some have recommended the use of a probe or button-pointed bistoury, to make the incision after the puncture of the tube. Dr. Murray has proposed to excise a circular portion of the skin over the trachea, bending the patient's head forward for the purpose of raising a fold of the skin with the thumb and finger, and cutting it off with one sweep at the base. A te- naculum is then to be inserted between two of the rings so as to allow a circular piece of the trachea to be removed with the knife. He believes that this process, which has not yet been tried upon the living subject, would facilitate the performance of the operation, diminish the risk of the blood entering the trachea, and render it easier to keep the orifice open. The checking of the hemorrhage, from the veins and arteries divided in the operation, requires particular attention. From six to eight ligatures are usually employed; they should be applied in general as above directed, as the vessels are cut, and before the opening of the trachea. But when the danger of asphyxia is great, it has been advised to puncture the trachea without stop- ping to tie the vessels. In such case the blood might be drawn by respiration into the trachea, so as to cause danger from suffo- cation, as happened in a patient of M. Roux, whose life was saved solely by the promptitude of the surgeon in applying his mouth over the tracheal wound, and clearing the trachea and • Surgical Anatomy of the Larynx and Tractiea. OPERATIONS UPON THE NECK. 263 bronclii by suction. But the principles wliich it appears to the author should goveru the conduct of the surgeon in regard to this operation, would be, under ordinary circnnistances, to tie tlie vessels as directed in the text, and when from the urgencv of the symptoms, time was not afforded for this, to puncture instanta- neously the crico-thyroid membrane. The separation of the lips nf the tracheal tcoiind is to be made with a pair of blunt hooks, or with a pair of forceps, or a sort of spring speculum. To diminish the elastic reaction of the divided rings, M. Malgaigne has advised a cross cut of the fibrous membrane between the rings, at the two extremities of the in- cision. If there is a foreign body to extract, and it be small and movable, it may be driven out by an expulsive cough, particu- larly if the membrane be excited by the introduction of a finger into the trachea; or, as it moves up and down with the respira- tory efforts, it may be fixed by placing a small curette below it, and then withdrawn with a pair of small polypus forceps. But if the foreign substance is placed more deep in the orifice of one of the bronchi, and is found fixed, the wound is to be kept open, lightly covered with gauze to prevent the entry of crude particles floating in the air, and the patient placed in a room, as directed by Mr. Listen, in which the air is raised to the temperature it usually acquires in respiration, when drawn through the natural passages. The foreign body will usually be found by the follow- ing day dislodged spontaneously, and ejected through the lips of the wound. If it should not become spontaneously detached, it may be loosened and drawn forward with a bent probe or re- moved with a pair of forceps. Mr. Key succeeded in removing a sixpence from one of the bronchi of a lad, with a pair of for- ceps constructed for the purpose, long and slender in the blade, curved a little near the point, and bent at an angle in the handle. If the object of the operation be to inaintain respiration by an artificial orifice, a silver cauula must be introduced into the wound and secured as shown at PI. LIV. fig. 7. At the moment of inserting the cauula, the patient should be told to swallow the saliva, as the effort at swallowing raises the trachea and renders the place of puncture more superficial. It is of primary import- ance in reference to the success of the operation that the canula should be properly curved so as not to irritate the lining mem- brane, and be of such a caliber as will admit of the entry of a large column of air which can alone render respiration easy. Those in common use are too flat and narrow. That of Breton- neau, which will be found most serviceable, is shown at fig. 8. it has been advised to cut out a circular piece of tlie trachea, for the lodgement of the tube, but this is seldom necessary. The pre- cautions in reference to the protection of the opening and the warming of the air above mentioned, are to be particularly ob- served, after the insertion of the canula. For a short time afier its introduction, an assit-taut should be on the watch, to prevent tlie obstruction of the tube by the secretions from the membrane, clearing them away as may be necessary, with a stout feather, or a small piece of sponge attached to the end of a small whale- bone probe, as recommended by M. Trousseau. The canula in a few days ceases to irritate the trachea, and the wound cicatrizes round it; it is to be worn for a length of time sufiicient for the cure of the disease which has called for the operation, whether that be a few weeks, six months, or a year. In some few in- stances, it has been necessary to retain the canula in the wound for several years together. Several surgeons have endeavoured to simplify this operation by the employment of a tracheolome-trocar. The best of these is one of a curved shape, devised by Mr. Hilton.* This instru- ment, says Mr, H., renders all previous incision of the integu- ments unnecessary, though this may be made if preferred, pro- vided the necessity for immediate relief be not urgent. If in in- troducing the trocar and canula, by chance any vessel should be pierced, its walls, he believes, will be so effectually compressed by the sides of the cauula, as to prevent the possibility of any blood getiing into the trachea. 2. Laryngo-irachcotomy. This, which is sometimes denominated crico-trachcotomy, con- sists in a section of the cricoid cartilage and the upper rings of the trachea. The soft parts, including the isthmus of the gland, are to be divided as in the process above given, with the excep- tion that the incision is to be begun at the lower border of the thyroid cartilage, and not extended so low in the neck; fewer of the superior thyroid veins will in consequence be injured. As soon as the crico-thyroid membrane is exposed, the tittle artery which crosses it is to be pressed aside with the finger nail so as to admit of the puncture being made below it; the bistoury with the finger pressing on its bad; is then run with the cutting edge downward so as to divide the cricoid cartilage and the three upper rings of the trachea. This operation is more commonly performed for the removal of foreign bodies from the larynx, than for the insertion of the canula. From the elasticity of the cricoid, it would be necessary to introduce the canula between the divided rings of the trachea. 3. Laryngotojny. a. Section of the crico-thyroid membrane. — This is the ope- ration of Vicq-d'Azyr, and consists merely in a transverse section of the crico-thyroid membrane. It is in fact but the first stage of the preceding process, with the exception that the incision is made crosswise instead of longitudinal, for the purpose of avoiding cut- ting the cartilage. The puncture of this membrane may be some- times made with advantage in instances of sudden asphyxia, a penknife or a common lancet answering for its performance ui case of need. Under other circumstances the operation has been abandoned, as the opening it affords is found too small, when the object is to remove a foreign body, or insert a proper sized canula. b. Section of the thyroid cartilage. {Thyrotomy.) (PI. LI V, fig. 7.) — This method was devised by Desault, and is particularly well suited for the removal of foreign bodies lodged in the larynx. It consists in splitting the thyroid cartilage by an incision in the middle line, and separating the two halves so as to expose com- pletely the ventricle of the larynx and the opening of the glottis, in which the foreign substances are frequently found impacted. The operation is easy of performance in consequence of the cartilage being superficial. The incision is to be made in the middle line, from the os • Vide Guy's Hospital Reports. 264 SPECIAL OPERATIONS. liyoides down to the upper margin of the cricoid cartilage, tlirougli the skin and superficial fascia. The two sterno-hyoid muscles are next separated. The crico-thyroid artery may now be felt pulsating as it crosses the crico-thyroid membrane. Tbis vessel is to be pressed towards the cricoid cartilage with the nail of the left fore finger, and the operator then enters the point of a bistoury, with its back to the vessel, through the membrane above it. A probe-pointed bistoury is now introduced at the puijctuie, and run upwards in a slanting direction through the glottis, so as to divide the thyroid cartilage in the middle line up to the hyo-thyroid membrane. If the cartilage, as is frequently the case in tlie adidtjis found hard and resisting, the incision may be aided by pressure with the thnmb of the left hand against the back of the knife. In case the cartilage is completely ossified, it has been recommended to notch it in a linear direction with a saw, and complete the division with the knife in the manner above directed. The essential part of the operation is to keep the knife precisely in the middle line, so as to separate, without injuring, the anterior attachments of the thyro-arytenoid muscles and the vocal cords. After the section, the two halves of the thyroid cartilage are to be held asunder with blunt hooks, so as to leave a lozenge- shaped space, at the bottom of which is the ventricle of the larynx. If the foreign body is fixed, it is to be seized with the forceps and withdrawn as shown at Plate LIV. fig.7 , A, or, if found more convenient, pnshed upwards into the pharynx. But if it is merely loosely held, or hidden by the turgescence of the membrane so as to require to be searched for, some precaution will be required, in case of its sudden dislodgement, to prevent its falling into the trachea. The end of the little finger will serve as the most fitting sound, and will answer, after the discovery of the body, as a director for a pair of forceps with which it may be removed. As soon as the object of the operation is effected, the wound— provided there is no other obstruction in the air pas- sages — is to be closed with adhesive straps, for the purpose of uniting the parts by the first intention. It might possibly happen after tlie section of the cartilage, that the foreign body could not be detected; the same course is then to be pursued as directed in tracheotomy — to retain the wound open till the following day, and in case the body was not spontaneously dislodged, repeat the eff'orts for its removal. This operation is attended with little or no hsemorrhage, and is mainly relied upon for the removal of substances lodged in the cavity of the larynx. The risk of injury to the vocal cords which has been urged against the method appears to be but slight, for in none of the many cases in which it has been practised does the voice appear to have suffered any alteration. c. Seciion above the hyoid hone, through the thyro-hyoid membrane.— -"VX-iX?. is a method proposed by M. Malgaigne, the value of which has not been tested by its application to the living subject. It consists in making a transverse section of the thyro- hyoid membrane and base of the epiglottis. A transverse inci- sion an inch and a half to two inches long is to be made through the skin and superficial fascia, iuunediately below the inferior border of the os hyoides. A second incision is then made so as to divide the platysma and the inner half of the two sterno-hyoid muscles. The cutting edge of the bistoury is now directed back- wards and upwards so as to divide— above the branch of the thyroid artery which crosses this space— the hyo-thyroid mem- brane and the fibres which come from the epiglottis. The mucous membrane, which will be forced into the wound at each expiration, is to be seized with a pair of forceps and divided with the bistoury or scissors. The epiglottis is next to be drawn up- wards with a blnnt hook, and the cavity of llie larynx is exposed to view, so as to admit of the introduction of the finger or a pair of forceps for the removal of any foreign substance lodged in it. In case a Jistuloiis orifice is left on the removal of the canula after tracheotomy, it is to be closed by a plastic operation — either by sliding a flap of skin over the orifice after it has been made raw, or by inserting the flap as a plug into the opening and fastening it there with a hare-lip suture. CESOPHAGUS. The cesophagus is a long, muscular canal, flattened from before backwards, nearly an inch in diameter when moderately dis- tended, but susceptible of much greater local dilatation. It is a continuation of the pharynx downwards; as it descends in the neck it inclines a little to the left of the middle line of the verte- bral colunni, and keeps this inclination till it terminates in the cardiac orifice of the stomach, immediately after it has passed through its proper foramen in tlie diaphragm. In the upper third of its course it is immediately behind the trachea — in its lower two-thirds in front of the aorta. When its cervical portion is distended, as in the act of deglutition, the tube is opened by the advance of its anterior wall, which at the same time makes pressure against the yielding membranous structure at the poste- rior part of the trachea, so as to occasion, when its distension is miduly great, more or less sense of sufl^ocation. At two portions of its course, the cesophagus may suffer a spasmodic narrowing, independent of any permanent or organic stricture; viz. its upper orifice, where it comes off from the pharynx immediately behind the cricoid cartilage — and at its gastric or cardiac orifice. CATHETERISM OF THE CESOPHAGUS. This operation is required for the fulfilment of various indica- tions; the removal of foreign bodies — the dilatation of strictures — and for the purpose of throwing fluids into or the removing them from the stomach. The instruments employed in catheterism are introduced either by one of the nostrils or by the mouth. Introduction by one of the nostrils. — This is to be resorted to when the catheter or stomach tube is to be left long applied, or there are cogent reasons against its introduction by the mouth. If intended to be carried into the stomach, it must be from two to two and a half feet in length. The patient is to be sealed with the head thrown back; the tube, held like a pen, is tlien to be pressed slowly through the nostrils till it strikes against the posterior wait of the pharynx. If it does not turn of itself downwards in the direction of the pharyngeal passage, the surgeon introduces the fore finger of one hand through the mouth so as to give the point the proper direction, while with the other hand the introduction is continued through the nose. As the point approaches the glottis, care must be observed that it is directed well backwards, so as not to enter the glottis, which accident if it take place woiild be made known by a sense of suflbcation, cough, and the passing of air througli the tube. As the instrument in its descent reaches OPERATIONS UPON THE NECK. 265 ilie upper orifice of the ccsopliagLis, it will encounter resistance from the spasmodic contraction of the muscular fibres of the part. The snrgeon should llicn pause for a moment, until the spasm subsides, when the instrument may be passed with a gentle effort, and readily carried on into the stomach. The operator should use the precaution to introduce it slowly forwards, relaxing the pressure when any resisiance is manifested, and if this does not speedily subside, retract the instrument slightly and pass it on again with its direction a little varied, or wiili a slight rotatory motion given by a twist between the thumb and finger. Inlroduclion by the mouth. — The mouth is to be widely opened. The surgeon passes his left fore finger down to the epiglottis, so as to depress the tongue. This finger will then serve as a conductor to the sound or catheter, which, when passed over its dorsal surface, will be found slipping readily into the pharyngeal passage, from whence it is to be carried down- wards, according to the directions above given. The introduction of instruments by the mouth is much more easy than by the nostril, and is as a general process decidedly the most appropriate. It is the only one which admits of tlie passing of metallic or wax bougies for the dilatation of strictures of the oesophagus, or the gula forceps, hooks, or probangs for the removal of foreign bodies. If the employment of the stomach tube be rendered ne- cessary by a wound whicli has involved the lower portion of the pharynx or the upper part of the oesophagus, the point of liie instrument is apt to hitch against the lower segment of tiie cut. Under these circumstances I have found it necessary to support the lower lip of the divided gullet with a pair of forceps while the tube was passed by. When fairly introduced into the stomach, it is very easy with the stomach pump, or even with an ordinary syringe of large size with its tjozzie well fitted to the free end of the tube, to draw out by suction the contents of the stomach, and wash the organ free of noxious materials by the alternate injec- tion and withdrawal of warm water or some appropriate aqueous solution. If the object of the catheterism is to supply the patient with nourishment, this is to be thrown in in nearly a similar manner, by gentle injection with tiie syringe. Under many cir- cumstances, as that of a wound or stricture at the upper part of the passage, it will be unnecessary to have the tube of a greater length than fairly to pass by the affected part; and this shortening of it is especially desirable when the tube is to be kept for some time in the passage, as it might otherwise irritate the delicate lining membrane at the cardiac orifice of the stomach. Slrictitre of the (Esophagus. Catheterism for the purpose of dilatation or the application of caustics is resorted to for the cure of this affection. Dilatation. — Elastic or wax bougies and catheters have been employed for the cure of strictures of the oesophagus, upon the same principles as for those of the urethra. Various complicated instruments Iiave been devised for the same purpose, as the air dilator of Arnott, and the three-branched metallic dilator of Mr, Fletcher, but the use of the simpler instruments above mentioned has been found in general the most advantageous. In cases of simple muscular narrowing of the passage, the employment of the cesophagus bougie or catheter, introduced by the mouth, will commonly afford relief. In an elderly lady, Mrs. W., residing 67 at No. 309 Walnut street, who had been for many years affected with a gradually increasing difficulty in swallowing, supposed to be owing to paralysis of the muscles of deglutition, I succeeded by a single insertion of tho wax bougie in effecting the most decided relief, The narrowness was found at the pharyngeal orifice of the o:sophagus, and was so extreme, that none but minute particles of food or fluid in spoonful doses could be passed into the stomach; frequently after tlie conclusion of a meal, the food would be found to have lodged above the stricture, occasioning so much inconvenience as to cause the patient to dislodge it by the insertion of a finger into the throat. The bougie encountered considerable resistance at the strictured point; in a few minutes after the removal of the instrument, the patient to her surprise was enabled to drink oft' a tumbler of flaxseed tea with entire freedom, and on the same day took her meals without apparent inconvenience. More usually, however, even in siriclures of this description, it will be found necessary to repeat frequently the use of the bougie before the obstruction is overcome. Unfortunately, simple- muscular narrowing forms but a small proportion of the cases of cesophageal stricture. In most instances, the constric- tion of the passage will be found the residt either of tumours that press upon the outer wall of the cesophagus, or of some degeneration of its inner structure, susceptible only of temporary alleviation from the use of dilating instruments, which under such circumstances must be used with great caution for fear of causing a rupture of the tube, which, as slated by Sir C. Bell, has occasionally taken place. Cuuterizulioii. — From the experience of Paletti, Home, Sir C, Bell and Mr. Macilwain, it would appear that the application of lunar caustic might be made with advantage to those forms of stricture of the cesophagus, depondent upon induration from chronic infiammation. In strictures the consequence of degene- ration, the use of the caustic could, however, rarely fail to be injurious; and in the former class of cases, the employment of the bougie would furnish a fair prospect of relief. From the diffi- culty of diagnosis, and for the reasons above stated, the cauter- izing practice has been received with but little favour. Paletti cauterized the passage with a roll of linen steeped in a caustic solution and introduced on the end of a flexible whalebone stalk, like that of the ordinary probang. A small piece of the solid lunar caustic inserted into the end of the common oesophagus wax bougie in the manner of Sir E, Home, is considered the most appropriate method of cauterization. Removal of foreign bodies from the CEsophagus. Foreign bodies of various description may be lodged in the ceso- phagus. Tiie symptoms to which ilicy give rise, and the indica- tions for treatment, will vary according to their nature. Tliere are three methods for ilieir removal by manipulation tiiroughlhe cesophagus,— Propulsion into the stomach, extraction by the intro- duction of instruments through the mouth, and a third, which consists of an incision into the cesophagus [(Esopliagotomy). Propulsion. — When the obstruction consists in the lodgment of an alimentary substance, arrested in consequence of its forming a bolus of too large size, or from the deficiency of the proper lubricating secretions of the passage, or in consequence of a tem- SPECIAL OPERATIONS. porary spasm of the circular iibres, the operator, unless the neces- sity for rehef is urgent, should defer for some hours any decisive course of action, inasmuch as the substance from its digestibility, becomes softened on its surface so as ultimately to be driven into the stomach by the proper muscular contraction of the inbe. In temporary obstruction of this sort, slight taps upon the back and the ingestion of mucilaginous or oily liquids will often be found useful in facilitating its removal; or, these failing, an attempt may be made lo dislodge the impacted mass by exciting efforls at vomiting either by tickling the throat, or gargling with an emetic sointion. As a final resort, the operator may force it inward lo the stomach by the use of a probaug, an instrument which consists of a flexible strip of whalebone, with a piece of sponge or a roll of linen securely attached to it as a head. In some instances, when the alimentary substance is not deeply lodged, it may answer better to remove it by the following process. Extraction. — If the body is of an indigestible or irritating nature, as a piece of wood, coin, pin, etc., an efibrt is to be made to extract it through the opening of the mouth and pharynx. If it be lodged in the pharynx, or at the upper orifice of the cesophagus, it may be readily removed with the fingers or a pair of curved gula forceps. If the foreign body be deeper lodged in tiie cesophagus, its removal will be found more difficult. Various instruments are under such circumstances employed. One of those commonly used, consists of the probang, with the sponge-head elongated, and passed down without being previously imbued with fluid, with the hope of getting it below the foreign substance; if suc- cessful in this attempt, it is to be allowed to rest for a few moments till the sponge becomes expanded by soaking up the secretions of the part, and then retracted so as to bring with it the foreign body. The difficulty of getting this instrument past the impacted substance is such, that it will be found more likely to propel the substance forwards towards the stomach. Various other contrivances have been attached to the whalebone stalk; a silk bag, a movable blunt hook, loops made of bent silver or brass wire or bristles or thread or narrow ribbon. A long single or double wire, smoothly bent into the form of a hook at the en- tering end, occasionally answers a good purpose, and especially for the extraction of a piece of coin. With instruments of this description, extraction may sometimes be efiecied, but in general greater success will attend the use of such as are calculated to grasp the substance. The best of these, even when the body is deeply lodged in the cesophagus, is the long-branched gula forceps, devised by Dr. Henry Bond, of this city, and described in the North American Medical and Surgical Journal for 182S. The peculiar advantage of this instrument consists in the long narrow curved blades meeting by convex surfaces, serrated on the middle line so as to be incapable of doing injury to the walls of the tube, while they lay firm hold of any substance over which the opened blades can be slid, and allow it, in case it be an oblong body like a pin, to revolve so as to present its long axis parallel with that of the tube. Other instruments have been invented for the same object, but inferior to this in point of simplicity of con- struction and convenience for use— such, for instance, as a tube with a stilet moving in tiie centre, and made either lo throw out over the body a three-branched forceps like the Hthotrilic forceps of Civiale, or to pass below the substance, and spread out its branches like tlie inverted ribs of a parasol. (ESOPHAGOTOMY. This operation, which fortunately is one that is but rarely required, may be performed for the fulfilment of two indications —the removal of a foreign body that cannot otherwise be dis- lodged, or for Uie opening of a passage for the introduction of alimentary substances in the stomach, with the object of prolong- ing life in cases of complete obstruction of the pharyngeal orifice of the cesophagus. The operation is directed to be performed on the left side of the neck, as the tube is there most accessible; though in cases of necessity, arising from any peculiar morbid condition of that side, it may be accomplished upon the right. The incision'shouid be made, as directed by Boyer, between the sterno-cleido-mastoid, and the outer edge of the bundle formed by the sterno-hyoid and thyroid muscles. If a foreign body is lodged in the cesophagus, the tumour it forms will serve as a guide to direct the course of the incision; but even incase a tumour can be felt, and more especially when the operation is performed for organic stricture, it is important to introduce an cesophagus sound or bougie by the month, so as to project the side of the cesophagus, and render its position obvious to the surgeon. In the removal of foreign bodies, many surgeons employ a hollow canula, witii a dart stilet that can be forced from the interior through the wail of the cesophagus after the externa! incision has been made. Vacca Berlinghieri devised an instrument for the purpose, in which the dart stilet was grooved upon one side so as to direct the point of the bistoury in the incision of the tube, in the manner in which it follows the grooved staff in the cut for stone. Operation. — The patient is to be placed semi-recumbent on a narrow bed, with the head reversed toward the right side. The operator stands upon the left of the patient. An incision two and a half to three inches long is then made through the skin and superficial fascia along the groove between the sterno-cleido- mastoid and the sterno-thyroid muscles, commencing two fingers breadth above the sternum. The deep layer of fascia between these muscles is to be opened on the grooved director, and the muscles themselves separated with the end of the director, the finger, or the handle of the scalpel. To facilitate this operation, the surgeon depresses with his left liand the edge of the sterno- mastoid, and an assistant placed at the right draws gently in that direction the whole mass of the larynx and trachea, including the inner border of the wound. The omo-hyoid muscle now comes into view, and must be drawn backwards out of the way or divided across on the director. The celhilar tissue is to be further separated till we get to the bottom of the groove, at the outer side of which will be found the sheath including the carotid artery, the jugular vein and the par vagum nerve, which, as well as the sterno-mastoid, the surgeon is to press outwards with his left hand. At the inner margin of (he wound, the edge of the trachea and the thyroid gland may now be seen, and below these is the cesophagus recognizable by the rounded prominence it forms, its muscular aspect, and the contraction into which it is thrown when the patient makes an effort at deglutition. If dis- tended by a foreign body, or protruded by a sound passed from OPERATIONS UPON THE THORAX. 267 the mouth, the oesophageal tumour will now project into the cavity of the incision. If the sound has been introduced, the puncture is to be made over its end; if the sound with the dart stilet, this is now to be forced through the wall, and the tube opened by its side. In case no sound has been employed, the puncture may be made at once over the rounded prominence of the tumour. A discharge of mucus following the puncture shows that the cavity of the tube is opened. The wound may then be extended downward with the scissors or a probe-pointed bistoury, to a sufficient extent to allow of the introduction of a finger or a pair of forceps for the extraction of the foreign body. Dressing. — The lips of the incision are to be gently approxi- mated, and merely covered with simple dressings. No sutures or adhesive straps are to be immediately applied, on account of the deep-seated suppuration hable to follow, or from the fear of ulceration or even gangrene which may ensue when the tube has suflered severely from the long-continued distension to which it has been subjected. In the course of a day or two, if there is no counter-indication, the wound may be completely closed with adhesive straps or sutures. The stomach tube is to be inserted, to prevent the escape of any alimentary matter or drinks by the orifice of the wound, and should be kept in place for five or six days, or until union has had time to take place in the line of incision, in order to diminish the risk of an oesopha- geal fistula. VI. OPERATIONS UPON THE THORAX. The special operations described upon this region consist of those for the removal of the Mammary Gland, and of those for eifiisions into the cavities of the Pleura and Pericardium. EXTIRPATION OF THE MAMMARY GLAND. The removal of the breast is at times considered necessary in several benign or non-malignant affections, as well as those which are of a scirrhous or encephaloid character. In regard to the former class, extirpation with the knife is only to be resorted to after every judicious effort by general and local treatment has been found unavailing for their removal. In respect to the class of malignant affections of the breast, which of all others has been the most frequent cause of this operation, there has always been, from the period of Celsus to the present moment, great discordancy of opinions as to the propriety of its perform- ance. The experience of intelligent surgeons of the present day is so directly adverse in relation to this operation, that it is im- possible to reconcile their statements, except upon the supposition that all have not been equally careful in the rejection of such cases as the better informed of all practitioners now consider to counter-indicate the operation. Though the sweeping assertion of Monro, Delpech and others, that local cancer is a mere symp- tom of a general cancerous diathesis, is considered in the main untrue, every experienced practitioner must be constrained to admit, that some instances do occur in which the local and general affection can scarcely be separated in point of time, and that in many others, the system so soon becomes contaminated after the manifestation of a local cancer, as to leave but little chance for the thorough extirpation of the evil. On the other hand, it is equally well ascertained, that cancer of the breast as well as other portions of the body, does arise from purely local causes, and exists for months or years, or even (as in the form of horny or ligneous scirrhus, several times noticed by the author, though such must be considered rare cases of exception,) during the greater part of a long life without impairing the condition of the internal viscera, or developing the peculiar straw colour of the complexion pathognomonic of the cancerous diathesis. In- stances of exception, such as noticed above, have been arrayed as an argument against extirpation, especially of cancers in this region; but the argument is not one of much force, inasmuch as complete success is sometimes known to attend the operation, and it would be difficult to show that in these very cases, a similar favourable result would not have followed the use of the knife, and the operation for their removal upon the whole been a more judicious course than leaving ihe patient more or less exposed for years together to the risk of a constitutional affection. There is no question, however, that the indiscriminate ampu- tation of cancerous mamm;e, at all ages of life and in all their various stages of development, would be a most nefarious rule of practice, and that it would be far better for such as do not make a judicious selection of the cases that offer a fair chance of reco- very after extirpation, to trust altogether to the influence of thera- peutic remedies. The limits of this work forbid a full discussion of this most important subject, and it must suffice to state the general fact, which no one will gainsay, that perfect recovery oc- casionally takes place after the removal of a cancerous breast, but that in the greater number of cases a return of the disease is to be expected, either at the site of the cicatrix, or upon some of the internal viscera. The operation will consequently in many in- stances of local affection be justifiable, as it is easily and quickly practised, and but little painful. The essential principle in refer- ence to its success, is to remove the cancerous breast, while it yet forms a well-circumscribed and local tumour. If it has involved the chain of axillary glands, and especially if it has become ad- herent to the pectoral muscle, or has formed an open ulcer, the chances of success, even when there is a prospect of removing apparently all the tissue affected, will be considerably impaired, and the operation ought not to be undertaken without a candid statement on the part of the surgeon of the liability of the patient to suffer sooner or later a return of the affection. Operations, however, done even under these circumstances by the author's surgical friends, and by himself, have in some in- stances been entirely successful, and in other cases, served so far as all human reason could show to diminish suffering and prolong life. But when the disease has involved the substance of the pectoral muscle, or the rib, or a large portion of the integument, or the tissues at the top of the axilla, and especially if there be reason, from cough and from physical examination, to suppose that the organs of the chest are involved, or when the straw colour of the skin, and other general signs of the cancerous cachexia are apparent, the operation should be altogether proscribed. It may indeed be stated as a general proposition, that it is only when the 268 SPECIAL OPERATIONS. scirrhus of the breast forms a movable tumour, which under aU rational therapeutic methods of treatment continues to advance and threatens to involve the general system, that it can with perfect propriety be removed by an operation. The destruction of cancerous tumours of the breast wiih caus- tics, and even with the paste of the chloride of zinc— an article for a time so much lauded in these cases— as well as the attempt to remove them by systematic compression, as practised by Young and Rccamier, have in general been abandoned, as they have been found to present no advantages over the removal with the knife: the treatment they require being necessarily protracted, infinitely more painful, just as liable to be followed by a return of the disease,.and without the same certainty of arresting the direct progress of the affection, Ope7-aHon. —The patient may be seated on a chair, or laid upon a bed, supported by an inchned plane made of pillows, so as to keep the head and chest elevated. The arm of the dis- eased side is to be raised and rotated outwards to render the pectoralis major muscle tense; (he face should be turned towards the opposite shoulder. The operator sits or stands upon that side of the patient upon wliich the operation is to be performed. An assistant supports the head of (he patient, and makes pressure with his thumb upon the subclavian artery between the scaleni. With the other hand he may, if he is adroit, compress the arterial branches divided during the operation, provided the pressure on the subclavian should not, suffice to completely check the flow of blood; or another assistant may be placed at hand for' the latter object, unless the operator sliould prefer, as is the practice of Dr. Jacob Randolph — a most judicious surgeon of this city— to pause and tie the vessels as they are divided, with the double object of diminishing the waste of blood, and avoiding the risk of second- ary hEemorrhage, which sometimes arises from the retraction of the vessels and the inability to find them at the conclusion of the operation, when they have temporarily ceased to bleed. The form of cutaneous incision has been much varied — be- tween the crucial, the T, the vertical, and the elliptic. The last, however, is the only one usually found appropriate, as it enables us to remove at the first step such portions of the integuments as appear diseased, or would be found too redundant to close neatly over the wound after the removal of the tumour. The long axis of the ellipse should be directed from below outwards and up- wards towards the armpit, as this- corresponds with the longer diameter of the gland and the lower border of the pectoral muscle, and enables the operator to extend the opening by a linear inci- sion into the axilla over the course of the absorbent vessels, wheci it is desirable to remove the enlarged glands of that region. Having properly placed his assistants, the surgeon now raises, the breast with his left hand, so as to extend the skin below the tumour, and makes below the nipple a semi-elliptical incision, concave upwards — from above downwards on the right side, and from below upwards on the left. Then reversing the breast, he makes another similar cut, concave in the opposite direction, and continuous by an acute angle with the two extremities of the first. The space thus circumscribed should include the nipple, extend beyond the limits of the diseased integument, and even when this is healthy embrace as large a portion as would be requisite to allow the lips of the wound to fall neatly together after the removal of the tumour. The surgeon now dissects off the integuments at the lower edge of the gland, then raises the tumour with his left hand and detaches it from below upwards at the line of the lower incision, to avoid the embarrassment from the flow of blood which. would necessarily attend the dissection in the upper line of incision. The dissection- should be made rapidly and by long sweeps, in the direction of the fibres of the PLATE LV,— EXTIRPATION OF THE MAMMARY GLAND. Fig. 1. — The patient is to be placed semi-recumbent, with the head and shoulders raised, (or if preferred merely seated on a chair,) With the arm raised and abducted. An assistant presses with the thumb of one hand (a) upon the subclavian, and with the thumb and fingers of the other (b) closes the orifices of the vessels opened during the operation. An elliptical incision has been made through the integuments, and the tumour, which has been dissected loose from over the pectoral muscle — first at its lower margin and then at its upper — is, at the period of the operation shown, raised with the left hand of the surgeon (c), and on the point of being removed with the knife in his right (d). Fig. 2. — This is a drawing taken at one of the operations of the author during the publication of this work. The patient is seated in a chair. The chain of axillary glands being enlarged and scirrhous, were removed with the tumour. An elliptical incision was made as in fig. 1, whh the exception that the upper line of incision was carried along the lower border of the pectoral tendon into the hollow of the arm pit. The breast (a) has been dissected loose, and used as a sort of handle to draw down the chain of glands (A) connected by the bundle of absorbents and some cellular tissue to its outer margin. After the cautious isolation of the glands a ligature has been thrown round the pedicle (c) formed by the cellular tissue and vessels, and the knife applied below the ligature for the purpose of detaching the diseased mass. A blunt hook has been employed by an assistant for the purpose of raising the integuments over the tendon of the pectoral muscle. Fig. 3. — Bres-mtg of the wound n/ier the operation in Jig. 2.— The tails of the ligatures with which the arteries have been tied are drawn out at the lower and inner margin of the wound, as well as the end of a mesh introduced between the edges of the wound at the lower end of the incision, for the purpose of allowing a free exit to the fluids of secretion. These are confined in place by a short adhesive strap. Five adhesive straps are placed diagonally across the chest, to approximate the lips of the incision. OPERATIONS UPON THE THORAX. 269 pectoral muscle, with the bistoury in the sixth position, and the edge kept well inclined upon the healthy tissues, of which it is ali important to remove a part, so as to be certain of getting be- yond the limits of the affected structure. If the tumour is of medium size, it may be entirely detached in this manner from below upwards, especially if the patient be semi-recumbent on a bed. But if it be of large size, it is best to loosen it as far as convenient from below, and finish by dissection at the upper line of incision. As the vessels spring, their orifices are either to be closed by the fingers of an assistant, or tied. A second assistant clears away the blood as it escapes behind the track of the bis- toury, for the purpose of exposing the jetting orifices of the vessels, and keeping the surface for incision clearly in view. As soon as the tumour is removed, and the bleeding orifices of the vessels secured, the surgeon proceeds to make a careful exa- mination in order to ascertain if there be any diseased or suspi- ciously affected structure remaining in the surrounding cellular tissue or muscles, and if any such is found, carefully dissects it away. If one or two of the ribs should unfortunately be found involved in the disease, the affected portions are to be resected with the cutting forceps or a Hey's saw. If one of the edges of the rib be but superficially diseased, it has been advised to touch it merely with the heated iron. Removal of the axillary glands. (PI. LV. fig. 2.) — Such of the a.\illary glands as are supposed to be scirrhous, or are even indurated and enlarged, should be taken away. These are found in the two directions in which the thoracic absorbents run to the glands— at the top of the armpit on the outer surface of the serra- tus major anticus muscle, and under the edge of the pectoralis minor. They are separated from the axillary vessels and the brachial plexus of nerves only by the aponeurosis and a mass of cellular tissue which is usually found more or less diseased; are supplied by one of the external thoracic arteries, and require con- siderable caution in their removal. A second operation as it were is required for this purpose. It has been advised to detach the breast completely, and then make a new incision in the axilla over the chain of glands. But no surgeoLi who has extirpated these glands would forego the advantage of preserving ihem in their rope-like connection with the outer end of the breast, for this organ when once detached can be made to serve as a handle to draw them downwards, make them more superficial, and widen the space which separates them from the axillary vessels. When the glands are to be removed, the operator should therefore be careful to preserve their connection with the tumour of the breast. As soon as this is loosened so as to be raised from its bed, the surgeon makes a linear incision into the axilla from the upper angle of the wound along the edge of the pectoral tendon, as shown in fig. 3; the arm being raised as far as possible, and related outwards so as to carry up the vessels of the axilla and render the fossa superficial. The skiu over the tendon of the pectoralis major is to be raised with the blunt hook, and the ten- don itself may, as directed by Mr. Fergiisson, be partially divided with the knife if found to obstruct the dissection for the detach- ment of the glands. I have never, however, found this step necessary, though it might be needed, especially if any of the glands were enlarged under the edge of the pectoralis minor, or ail attempt was made to dissect away the lower axillary 68 chain, without observing the precaution to keep them in con- nection with the loosened mammary tumour. The chain of glands must be separated from their connection as far as possible with the finger or the handle of the knife, using the point of the knife with caution to detach here and there some more resisting cellular bands. When the uppermost affected gland is loosened, care should be taken, in order to avoid ha;morrhage from the vessels, which, when divided, would retract so as to be diflicult to discover, to apply a ligature, as shown in the drawing, just above the point at which the final separation of the diseased structure is made with the knife. Dressing. (Fig. 3.)— This ordinarily is very simple. The tails of the ligatures are to be brought out at the lower angle of the wound along with the end of a small greased compress, which should be inserted for the purpose of favouring the exit of such fluids as may form in the iiollow of the wound. The blood is to be carefully cleansed away with the sponge, and the lips of the incision approximated with five or six strips of adhesive plaster. Lint spread with cerate, and a soft thick compress, are to be laid over the wound, and the whole secured to the chest by a roller applied with moderate tiglitness,and kept from slipping by a few turns over the shoulder. If the skin prove a little too redundant, so as to pucker when flattened out under the use of the straps, the lips of the wound may be adjusted with a few sutures in place of the straps. In case the skin, in consequence of its being diseased, has been removed to such an extent as to leave a gap in the dressing, it has been directed by Lisfranc to dissect it up further back, till the flaps by stretching may be made to meet under the use of the adhesive straps. The plan of M. Martinet, which consists in dissecting up a flap of skin from the neighbouring parts, and turning it in at once so as to fill up the gap, as in one of the plastic processes, is considered preferable to the proposition of Lisfranc. If after the removal of the skin there should, as sometimes but not always happens, be cedema of the corre- sponding extremity, it will be necessary to make friction with a mild liniment, and apply a roller upwards from the hand. EMPYEMA. This term is varied from its proper etymological signification, and applied to every collection of fluid — air, water, pus or hlcwd — in the cavity of the chest, which, in defiance of all remedial applications, continues stationary or increases in bulk. The most common perhaps of these, that which is most fatal usually in its issue, and which the term empyema more properly implies, is an eflusion of purulent fluid. This may take place into the pleural cavity from several sources, and to its accumulation the lungs from their yielding nature, readily give place. It may be derived eilher Irom sources remote from the cavity or from the surface of its lining membrane. Abscesses of the mediastinum, vomicEc of the lungs, or phlegmonous abscesses of the lungs or liver, may gradually, by perforating the tissues which separate them from the pleural cavity, discharge their contents into this space, a result particularly liable to take place from the tendency to a vacuum produced in the thorax during the act of inspiration. In chronic or subacute inflammations of the pleura, either com- mencing in a latent form in subjects where the sympathies are so obtuse as not to reveal it in its early stages to the patient or 270 SPECIAL OPERATIONS. his attendant — or in acute inflammations which, ceasing to excite pain or to disturb greatly the action of the organs, instead of disappearing entirely have subsided into the chronic form — the serous membrane of the thorax may be so perverted as to per- form the office of a mucous lining, and discharge gradatim a purulent fluid for which there is no natural outlet. The depo- sition of the secretion, considered in itself, though exhausting to the economy is never directly fatal. But in the end the fluid, if it accumulates in great quantity, will occasion distress from its gravitation upon the diaphragm, may produce hectic symptoms, displace the heart and the lungs, and thus embarrass the two most vital functions, those of circulation and respiration. In contemplating the chances of recovery from this disease, every thing will appear to depend upon the origin of the inflammation which gives rise to the secretion — whether it is an idiopathic aff'eclion of the pleura, or whether it is secondarily induced by a neighbouring disease in the lungs or liver. Even under the most favourable circumstances, when the cause of the disease is found in the pleura, the event must necessarily sooner or later be fatal, unless the matter is discharged by spontaneous ulceration through the walls of the ciiest, or the surgeon takes measures to procure its evacuation. Surgical and pathological anatomy. — In the healthy state of the thoracic viscera, the lungs are always more or less filled with air, are in complete contact with the walls of each pleural sac, and descend at their lower and outer edge to within two or two and a half inches of the lower border of the thorax formed by the inferior ribs. The diaphragm, which gets its proper muscular attachment from the cartilaginous border of (he thorax, is never- theless, as it is reflected upwards, adherent by cellular tissue to the inner face of the ribs as far as the line to which the lower and outer edge of the lung descends. Thus, though there is in the healthy state no space between the angle formed by the ascending surface of the diaphragm and the thoracic walls, and the margin of the lung, one will be found to exist when the diaphragm is depressed at its place of attachment to the ribs, by an accumulation of fluid in the cavity of the chest. If the effusion take place to much amount, the fluid makes room for itself by a gradual compression of the lung of the same side towards its root; in some extreme cases, eff'acing by this means the areolar structure of the lung, filling completely the cavity of the chest, and pushing the heart and mediastinum off in the di- rection of the other pleural cavity. Until the cavity of the chest becomes fully distended, the upper hne of the fluid will be found, in obedience to the laws of gravitation, (unless it be confined, as it were, in cysts, by adhesion between the adjoining surfaces of the costal and pulmonary pleurje, or by layers of false membranes,) transverse to the chest in the upright, and vertical in the recum- bent posture of the patient. Not unfrequently tlie inner surface of the pleura will be found in these cases covered by a thick laminar efi"usion of false membrane. As soon as the compression of the efl'used fluid becomes so great as to suspend the action of the lung, the thoracic cavity itself becomes expanded; this is called effusion with dilatation. From the improved means of diagnosis now possessed in re- ference to these afl'ections, we are able to determine with very considerable precision, the causes, the seat, as well as the exact limits of every pleuritic effusion. It is only after the careful employment of these measures, that the surgeon is to determine as to the propriety of an operation, or the appropriate place for its performance. If the eft'usion is encysted, as it may be in any part of the walls of the chest, or there is an external pointing or protusion accompanied with cutaneous inflammation, the point for the operation is fixed, and is then called the place of neces- sity. But when the efl'usion is not thus restricted, the place of election for the puncture is at the will of the surgeon. Of the operation at the latter place, it will be necessary further to treat. Flace of election. — What part of the chest should be selected for the puncture, has been a point of much controversy among surgeons. Almost any portion of the side between the fourth and elevemh intercostal spaces may be made to answer; but the governing rule should be to select that at which there is the most unequivocal evidence of the existence of the effusion. The older surgeons were in the habit, from the peculiar arrangements of the external muscles, of selecting the space between the fifth and sixth or sixth and seventh ribs, on the antero-lateral aspect of the chest, where the digitations of the serratus major anticus and the external oblique muscles meet, as there is here the smallest amount of tissues to divide, and the fluid may readily be discharged by the puncture, provided the patient be inclined upon the side. But this reasoning is of little moment, inasmuch as the thickness of the walls is in no part great, and more ad- vantage will be derived from a puncture at a depending part of the distended cavity from the readier outlet afforded to the fluid in all positions of the trunk. French surgeons in general, and the experience of the author leads him wholly to coincide with their views, direct the puncture to be made in either the eighth or ninth intercostal spaces on the right side, or the tenth or eleventh on the left. The desired place for puncture is usually readily determined by counting the spaces from below upwards. But in case this should be rendered difficult, from the obesity of the subject, or from extensive cedema, it will answer to enter the trocar at a point five fingers' breadth below the inferior angle of the scapula, or three fingers' breadth above the cartilaginous border of the thorax, and as nearly as may be at the junction of the posterior third with the anterior two-thirds of the walls of the cavily — in front of the latissimus dorsi. Modes of operation. There are two modes of performing the operation — incision with the bistoury, or puncture with a trocar. It may moreover be observed that in cases where the empyema has shown a dis- position to point, it has been opened witii a lancet like any other abscess; the only peculiar precaution requisite being that of pre- venting the introduction of air during the act of inspiration. 1. Incision. ( Usual p7-ocess.) — The patient is to be seated or partly reclined on the sound side, and the arm elevated in order to make the soft parts tense over the side of the chest. The sur- geon stretches the skin between the thumb and two first fingers of the left hand, and makes an incision an inch and a half long over the edge of the rib, which is immediately below the space that he intends to open. He then raises the upper lip of the incision, and divides in succession, just above the edge of the rib, the layers of muscles as they come in view, feeling with the left fore finger OPERATIONS UPON THE THORAX. 271 whether there be any artery in the way that it is necessary to avoid. As soon as the pleura is exposed, the patient should be directed to make a full inspiration; this usually causes the pleura to bulge between the lips of the wound, so as to render it more readily punctured with the knife, which should be directed ob- liquely upwards and inwards. If distinct fluctuation is still felt with the finger, and the pleura does not protrude, it is owing to its being Ihicliened by layers of false membrane on its inner surface; the nse of the knife may still be cautiously continued, and the layers if they are thick finally opened by pressure obliquely up- wards with the end of the finger or the handle of the scalpel. If ill this way we do not readily reach the cavity of the abscess, the lung is in all probability adherent to the costal pleura at this place, and it becomes necessary for the operator to close the woimd and make a puncture at another point. An error of this description is, however, with the improved means of diagnosis we now possess, readily avoided. When the opening is made, the fluid is to be allowed gradually to discharge itself, unless the patient becomes faint from the sudden relaxation of pressure, when the finger or a compress may be temporarily applied upon the orifice. If the flow is interrupted by flocculent masses of lymph or grumous blood, the passage may be cleared with a probe. At the conclusion of the operation it has been advised to carry a mesh of linen or charpie into the wound, to serve as a conductor for the escape of the remaining fluid or such as may subsequently form. If the reaccumulation occurs rapidly, it is necessary to separate the lips of the wound again in the course of a few days, to allow the free evacuation of the fluid. Some surgeons Iiave directed the orifice in the pleura to be made of large size; but this is by most considered hazardous, as the entry of air which would almost necessarily follow, it is believed would be found injurious, especially in cases of purulent or san- guineous efl'usions. After the operation, the general state of the patient and the character of the fluid discharged, must be carefully observed. If the respiration becomes more free, and the pus in the course of a few days is found of thicker consistence, freer of odour, and at the same time less abundant, there is a fair prospect of a cure. But if on the other hand the discharge becomes thinner, more abundant, and more fetid, and the constitutional symptoms are more strongly marked, the prognosis is unfavourable. In the latter case, in which there is reason to fear that the vitiated secretion may be taken up by the absorbents, it has been recommended by MM. Billeret and Recamier to resort to the ancient practice of washing out the cavity with injections of warm water or mu- cilaginous or astringent solutions. In all cases in which the mesh is inserted, it is necessary to wait till all the tendency to the formation of fluid ceases, before the wound is allowed to close. Such is the process commonly advised for paracentesis of the chest, whatever be the nature of the fluid collected. In regard to the success attending it, there arc among difl'erent writers the most discordant statements — a certain evidence that in by far the greater number of cases the prognosis must be unfavourable. Some practitioners prefer to this continued discharge through an orifice kept open for the purpose, the evacuation of the fluid by successive operations, allowing the orifice to close after each punc- ture, as is the ordinary practice in ascites. But this method is considered objectionable, as it requires frequent repetition, in consequence of the unyielding nature of the thoracic walls and the slowness on the part of the lungs to re-expand when they have been held for a long time in a state of compression. Process of the ,/luthor. — The author has been led to adopt the following modification of the process above described, as one guarding more certainly against the entry of air into the cavity of the chest, and enabling the operator for any requisite length of time to maintain a daily evacuation of the fluid without a con- slant ofi'ensive discharge over the side of the chest. A case treated with perfect success by this process will be found de- scribed by the author in the Am. .Tourn. of Med. Sci. for 1S33. It consists first in making, near the lower boundary of the dis- tended cavity, a valvular opening for the outlet of the fluids, which was so much insisted on by the ancient surgeons. The skin is to be well drawn upwards from below, and the integu- ments incised over the middle of the rib below the intended place for puncture. The divided edge is now to be further raised with a blunt hook so as to expose the intercostal space above. After the division of the outer layer of muscles and the first range of intercostals, the fluctuation of the fluid can usually be distinctly perceived; a. good-sized trocar is then to be pushed into the cavity of the chest obliquely upwards, so as to avoid all risk of injury to the diaphragm. After the evacuation of the fluid the flap of integuments will be found to make a valvular fold extending for an inch and a half to two inches below the opening into the pleural cavity. The wound is to be dressed with a compress and bandage. A slight leakage of fluid from the chest prevents union by first Intention, or at least so far retards it that on the following day a female silver catheter may be insinuated under the valvular fold of skin into the cavity, so as to let off a portion of the re-accumulated fluid. By employing the catheter in this way, at first daily and then at longer intervals, the track is kept fistulous, and yet retains so completely its val- vular properties, that in inspiration it will be found when un- covered to sink in over the place of puncture, without allowing a particle of air to enter the chest. By this means a frequent discharge of the secreted fluids is kept up, and the lung is placed under the best circumstances for its gradual dilatation. In the course of a few weeks the patient is able to draw ofi" the fluid by the use of a gum elastic catheter, which should be carried along the passage without a stilet. In purulent effusions it may be necessary in this way to keep the orifice open for many months, before the discharge ceases, or the cavity previously formed becomes effaced by the gradual expansion of the lung, the rising of the diaphragm, and the sinking in of the ribs, the principal means by which this change is effected. 2. By puncture. — Velpean has proposed to evacuate the fluid by a direct plunge with the bistoury through one of the intercostal spaces, nearly as in opening an ordinary abscess. This would in many cases be necessarily attended with some risk of injury to the lung, whether it be free or adherent, and is considered an objectionable proposition. IVith the trocar. {Usual process.) — The integuments are to be drawn strongly upwards with the left hand, and the trocar pushed in obliquely upwards immediately over the upper edge of one of the ribs. In ordinary cases, even with this oblique SPECIAL OPERATIONS. direction of it, the trocar when buried to the extent of an inch is found to have entered the cavity. The length of the route may, however, be increased by the obesity of the subject, by the infil- tration of air or water under the skin, or from the existence of layers of false membrane upon tlie pleura. If, after malting the necessary allowance for these occurrences, the point of the trocar is not found to move freely as it ordinarily does when it has entered a cavity, the instrument if pushed on farther, should, in order to diminish the risk of wounding the lung, be turned still more directly towards the point, which from the physical exami- nation of the chest is considered the centre of the accumulation. If, however, after proceeduig cautiously in this way, the surgeon does not speedily strike the cavity, in consequence of the lung being found adherent at this point to the ribs, it will be more ■prudent for him to retract his instrument and repeat the puncture at another part of the cliest. After the evacuation of the liquid, the caiiula — slightly retracted and with a plug in its outer orifice — is directed to be left in the wound for the purpose of repeating the process of evacuation. M. Baudens employs a curved canula, with two stilets;— one sharp-pointed, for the purpose of introducing the canula; and another, which serves the purpose of a temporary plug. The curved form of the canula is well suited for the purpose of being retained in the wound. The chief objection to this process is the risk of the introduction of air into the chest. Several surgeons — Walsh, Bonnet, Guerin, Sanski, etc. — have proposed measures for removing, by an exhausting apparatus, the fluid from the chest after the introduction of the canula; a syringe used as a suction pump, and a canula provided with a stop-cock, is the ap- paratus that lias been most commonly employed for this purpose, Terebration of one of the ribs. — M, Reybard, of Lyons, has revived the practice noticed in the works of Hippocrates, of eva- cuating the fluid of empyema by an opening formed in one of the ribs. An incision is to be made so as to expose the rib, and from this a central piece is to be removed with a small trephine or a drill. Into this opening a small canula is to be neatly fitted, so that it will remain securely fixed when screwed in. The pleura is then to be punctured at the bottom of the opening in the rib, and the canula, which had been previously fitted, inserted so as to give exit to the fluid. To allow the fluid to dribble away as fast as it is reproduced, without risking the introduction of air into the cavity, several means have been devised by M. Reybard, the best and most simple of which is said to be the following. The intestine of a cat, several inches long, previously moistened so that its sides will fall together and efface iis cavity, is to be securely fastened to the outer end of the canula. When the fluid of the cavity escapes through the canula by its own weight, or as the consequence of a muscular effort, it is said to open tlie cavity of the intestine and flow out at its free end — the yielding walls of the intestine, which close immediately behind the descending stream of fluid, acting as a valve to prevent the introduction of air— the risk of which may be still further diminished if necessary by giving to the piece of intestine some spiral turns. JVound of (he intercostal artery. In case this artery or one of its large branches is divided in the process by incision, the open orifice should be tied before the pleural sac is punctured. If the vessel should have been opened in the operation by puncture, a circumstance which is but little likely to happen so as to occasion trouble, or by any accidental wound of the chest, the bleeding may be arrested by one of the two following plans. 1. Compression from within outivards by the process of Desault. — The external orifice of the wound, if not sufficiently large, may be slightly dilated. Through the wound, the middle of a fine linen compress is to be insiimated into the cavity of the chest in the form of a sac. This is to be stuff'ed from without by charpie. The free margin of the compress is then to be drawn strongly outwards, by which means the stuff'ed cavity of its sac will act as a tampon upon the vessel between the ribs, while it leaves a smooth surface on the side next the cavity of the chest. Another pad is to be laid upon the external wound, over which the edges of the linen compress are to be secured. In the course of a few days, the apparatus may be removed, by picking out the charpie piece by piece from the cavity of the sac, and then extracting its envelope. 2. By ligature. — The simple ligature of the wounded inter- costal artery would be, however, incomparably the surest means of arresting the bleeding, though, from the risk of injuring the pleura and admitting air into the chest, operators have in general shunned its performance. When the opening already exists, the ligature of the artery — which is a process not particularly difficult, though requiring the exercise of great caution — might, it appears to the author, -with propriety be attempted. The incision of the soft parts for enlarging the wound should be made by raising up the integuments with the left hand, so as to get a valvular fold over the course of incision. The external layer of muscles must be divided over the intercostal space. The external intercostal muscle must be raised and opened for the space of a few lines on the director; between this and the internal intercostal muscle, on the anterior two-thirds of the chest, will be found running the artery and the various branches which it sends off. If the trunk of the artery is sought for in the region of the posterior third of the chest, it will be necessary to divide cautiously both intercostal muscles on the director, feel- ing with the finger that there is no branch in the way of the knife, and look for the vessel on the surface of tlie pleura, and close to the under edge of the rib. A smooth blunt hook may now be pressed up against the lower edge of the rib, for the purpose of compressing the trunk of the vessel, and suspending the bleeding. The pleura is then to be cautiously separated from the muscles and edge of the rib with the finger, and the artery drawn out from the gutter in which it is lodged with the point of a curved director, and tied. PAKACENTESrS OF THE PERICARDIUM, This is an operation which has been advocated by some prao- titioners, though rarely ever performed. It is well understood that accidental traumatic injuries of the pericardium, or even of a portion of the substance of the heart itself, are not necessarily fatal, yet in the absence of positive experience as to the results of tapping the cavity when in a morbid condition, the operation would be one necessarily attended by a great weight of respon- OPERATIONS UPON THE ABDOMEN. sibility. In the cases of Desault and Larrey, who both atlempted its performance, it is beUeved the sac of the pericardium was not opened at all — a serous cyst attached to the mediastinum having been punctured by one surgeon, and a portion of the plenrat cavity by the other. The acknowledged diflicnlty of diagnosti- cating witliont risk of mistake the existence of dropsy of this cavity, deterred in a great degree the older surgeons from attempt- ing the operation. This diflicnlty of diagnosis has, to a very ■considerable extent, been diniiiiislied by the improved means of exploration which the science now possesses, so as to remove, as believed by some, one of the chief objections that have been urged against its performance. That, however, which in the estimation of the author should serve most as a counter-indication 10 tlie operation, is the fact that in dropsy of the pericardium, without organic lesion of the heart, there is always hope of re- moving the fluid by therapeutic remedies, and that where organic lesion exists its performance could at best effect merely temporary relief Two methods have been proposed for its performance — the perforation of the sternum, and the opening of one of the intercostal spaces. Surgical anatomy. — In its healthy state the heart is situated with its base at tiie middle line of the thorax and presenting to- wards the riglit shoulder, and with its apex turned to the left side, so as to correspond with a point between the fifth and sixth ribs, from two and a half to three inches to the left of the middle line. It is covered by the left half of the sternum, and the cartilages of the third, fourth, and fifth ribs, with their two intervening inter- costal spaces. Exterior to these parts are found the skin and superficial fascia, a portion of the origin of the pectoral muscle, and at the fifth rib, the attachments of the pectoraiis minor, ex- ternal oblique and rectus abdominis muscles. The internal mam- mary artery runs down about the third of an inch from the border of the sternum, and sends off" an external branch through each intercostal space. The pericardium, which is lined upon either side by the pleura, is attached by its inferior portion or floor to the tendinous centre of the diaphragm, and covered on its upper and front surface by a part of the left lung. When the pericar- dium is distended by a dropsical accumulation, it presses away the lungs in ail directions, lowers slightly the diaphragm, and extends laterally especially towards the right side, (where, on account of the interval of the anterior mediastinum, it meets with the least resistance,) so as to bring the point of the heart a little nearer to the left margin of the sternum. If there is no adhesion between the pulmonary and the pericardial serous lining, the distended pericardium may be placed in contact with a broad surface of the ribs; but if, as is most commonly the case where the aff"ection is of a chronic nature, such adhesion does exist, the thinned margin of the lung may be firmly attached like a cap over the pericardium, nearly up to the anterior mediastinum. Should this attachment have taken place, there would be risk of wounding the lung in paracentesis — a result which occurred in an operation of Desault. 1. Paracentesis by trephining the sternum. — A crucial incision is to be made over the left side of the inferior end of the sternum, and the cutaneous flaps reverted. The attachment of the pectoral muscle is to be loosened with the knife, and turned outwards. A piece of the sternum is then to be removed with a large trephine, and the posterior sternal aponeurosis below opened cautiously with the knife, at a point where the fluctuation of the pericardium can be felt; the patient being caused to lean forward to keep the pericardial sac in contact with the bone. 2, By perforation of one of the intercostal spaces. — Desault opened the space between the cartilages of the sixth and seventh ribs, and introduced a finger into the wound to distinguish the fluctuation of the fluid and serve as a guide to the bistoury. His patient died, and it was found on .examination that the surgeon had opened a serous cyst upon the side of the pericardium. The place of puncture in this process is considered to be too low and too far from the median line, and is attended by a risk of wounding the diaphragm. Senac proposed to make the puncture between the fifth and sixth ribs. Baron Larrey has suggested a plan of getting at the pericardium by opening the triangular space between the left margin of the xiphoid appendix of the sternum and the cartilage of the seventh rib. The after-treatment of paracentesis of the pericardium is the same as in tapping for empyema. VII. OPERATIONS UPON THE ABDOMEN. The operations described under this head consist — 1. Of those for Dropsy of the Abdominal Cavity. 2. Of those for Wounds of the Abdomen and Intestines; and, 3. Of those for Hernia. OPERATIONS FOR THE CURE OF ASCITES. The object of the various surgical measures proposed for the relief of this affection, are either the evacuation of the fluid by puncture, or the promotion of its removal by absorption. The fulfilment of the latter object— which has been attempted by a resort to compression with bandages, by blisters, and the insertion of five or six acupuncture needles repeated at intervals of four or five days — is but seldom accomplished. The evacuation ol the liquid by paracentesis is, when well directed therapeutic remedies fail to cause its removal, the only practice deserving of reliance. It may, conjoined with the continued use of the remedies just mentioned, lead in many instances to a successful result when the dropsy is purely idiopathic, and should be prac- tised if the swelling be large as soon as we are convinced that it has become stationary. When the dropsy is symptomatic of an incurable disease of one of the abdominal viscera, the operation will still be rendered necessary as a palliative measure, though the dropsical distension will in general be found sooner or later to return. In the latter case the rule of practice is the reverse of that in the idiopathic form of the afl'ection; and the operation is to be deferred until the discomfort of the patient renders it necessary for his relief. With this tendency to reaccu- mulation of the fluid, the operation may require to be repeated, and the records of the science show that it has been found ne- cessary to perform it on the same patient an almost incredible number of times in an extended series of years. The trocar, which may be either round or flat, according to 274 SPECIAL OPERATIONS. the will of the surgeon, is the instrument ordinarily used in making the puncture. It is to be introduced in the manner described at page 13 of this work. Dr, Physick preferred, in paracentesis of the abdomen, as a means of diminishing pain, to precede the insertion of the trocar by a vertical puncture with the thumb lancet. This modification of the common plan of puncture, the author believes highly useful when there is con- siderable accumulation of fat below the integuments. The canula, armed with the ordinary trocar, should be passed imme- diately on the withdrawal of the lancet. The introduction of the cannla on a blunt-pointed stilet, as practised by some opera- tors, is an objectionable proceeding, inasmuch as it is attended with no corresponding advantage, and may cause additional pain and irritation if it wanders from its route. Place of operaiion.— Among American and English practi- tioners, the linea alba is the point selected, as this involves no risk of injury to the epigastric artery, or any other important struc- ture, provided that care is taken that, the bladder be previously emptied. The lower portion of this line would appear prefer- able as facilitating best the discharge of the fluid, but for fear of injuring the bladder, the puncture is made within the space of two or three inches below the umbilicus, and exactly in the raid- die line, for the purpose of avoiding the injury of either of the recti muscles. In case of necessity, it may be made at the um- bilicus or in the course of the line above the umbilicus, though this, unless the distension be great, would involve some risk of injury of the liver, (if this organ, as is frequently the case, should be found enlarged,) or of tlie stomach or transverse arch of the colon. French surgeons in general follow the practice of Saba- lier, and make the puncture in the middle of a line drawn be- tween the umbilicus and the anterior superior spinous process of the left ilium. The epigastric artery will usuuUy be found to the inner side of this point, and the bladder and uterus at some distance below. It has lately been proposed by M. Recamier, to make the puncture in cases of females, at the posterior and upper part of the vagina, in order to reach the bottom of the peritoneal cavity between the rectum and uterus. This method, however, has not proved so successful in practice as to warrant its general use; and the fear of encountering the adhesions and displace- ments so usual in this region, appears to present insuperable objections to its adoption. When ascites is complicated with congenital hydrocele, it was advised by Morand and Ledran to discharge the fluid by a puncture of the vaginal tunics, a prac- tice to which the author has resorted with advantage. In cases of encysted dropsy or abscess of the peritoneal cavity, the most prominent point of the tumour at which fluctuation is manifest may be selected for the operation. Operation. — The patient is to be seated on the side of the bed, so placed as to render the region prominent upon which the puncture is to be made; and the projection of the part may furthermore be increased by pressure with the hands of an assistant stationed for the purpose behind the patient. The trocar is then to be inserted in the manner already described. The fluid flows spontaneously as soon as the stilet is withdrawn from the canula. If the canula becomes obstructed by any flocculent portions of lymph or albumen, or by the lodgment against its orifice of the omenlun or small intestine, the round end of a probe may be introduced to restore the current, when this cannot be effected by the inclination of the canula to one side. As the abdominal walls become lax from the discharge of the fluid, increasing p"essure is to be made with the hands of the assistant, or better still, by a body bandage drawn on the side of the spine for the double object of evacuating the remaining fluid, and supporting the walls of the ascending vena cava and other abdominal vessels, which, from the sudden cessation of pressure, are liable to become distended with blood, and give rise to syncope, by an interruption of the current to the heart. The canula is to be withdrawn at the completion of the opera- tion, and the wound closed with a piece of adhesive or soap plaster, A compress and a body bandage, or a flannel roller well applied, completes the dressing. The pressure with the bandage should be continued for a considerable period if it be well borne, in order to present an obstacle to the rapid reaccu- mulation of the fluid. M. Baudens evacuates the fluid gradually by a small cautila — inserted obliquely under a fold of skin, as in the manner of a subcutaneous puncture — which he allows to remain for several days in the wound — drawing off but a portion of the fluid at intervals of six or twelve hours, and keeping the orifice closed by a plug in the intervals. The author, in consequence of the favourable result attendant upon a constant dribbling of the fluid after the ordinary operation of tapping, was induced to employ a method similar to this some six or eight years ago in the Philadelphia Hospital, but abandoned the measure from its apparent tendency to excite peritoneal inflammation. PENETRATING WOUNDS OF THE ABDOMEN. (PL. LVI.) SIMPLE WOUNDS. In simple loounds of the abdomen an inch or more in length, which merely open into the peritoneal cavity, the intestines and omentum are liable to be protruded in the form of hernia. In these cases, the viscera are uninjured, and little is required to be done but to wash off' carefully with warm water all irritating or foreign substances with which they chance to be covered, and return them into the abdomen as speedily as possible. Tiie pro- cess for reduction is analogous to the taxis in the ordinary forms of hernia, care being taken to raise the hips and chest in order to relax as much as possible the abdominal wails. When the reduction is effi cted, the wound is to be closed by the interrupted or quilled suture, supported by adhesive straps and a body bandage. Wounds with strangulation of the protruded viscera. When a large mass of intestine has been protruded through a narrow wound — or in cases where the protrusion is not exten- sive, but the viscus, from the length of lime it has been out, has become swollen, distended, inflamed or gangrenous — some form of operation will be needed. Slrangulaiion of the omentum alone. — If the wound be but small, an4 there is simple strangulation merely of a little knot of omentum, occasioning no pain to the patient, or any uneasi- ness in different attitudes of the body, it is directed — provided it OPERATIONS UPON THE ABDOMEN. 275 cannot be reduced without dilatation of the wound— to leave it protruded, after having carefully ascertained that it contains no loop of intestine. If, ou tlie other hand, it is large, produces pain in attempts to straighten the trunk, or gives rise to tlie general symptoms of strangulation, the orifice is to be dilated with a probe-pointed bistoury and the viscus returned. The dilatation, according to Sabaiier, should be made at the inferior angle of the wound, in order to diininish the risk of wounding the omentum, which will be found stretched between the upper angle of the wound and its root of attachment to the stomacli and colon. Jf the s Iran giilat ion has been such as to produce gangrene of the omentum, the mass may either be left without till it sloughs away, as is commonly directed, or shaved off upon a level with the surrounding skin. If the latter course be pursued, it will be proper to tie the orifices of the divided vessels, for fear they would give rise to internal haemorrhage in case reduction spontaneously took place. Strangulation of the intestine alone. (PI. LVI. fig. 1.) — In simple strangulation of a loop of intestine, which it is impossible to return by a gentle trial of the taxis, it is necessary to enlarge the wound by an incision at its superior angle. The degree of enlargement should not, however, be more than absolutely ne- cessary to allow readily of the return of the intestine, for fear of increasing the risk of a subsequent hernial protrusion. Operation. — Tlie patient should be placed upon his back with his head and chest elevated, and his thighs flexed upon the pelvis, in order to relax the abdominal muscles. The surgeon depresses the mass of intestines with his left hand, and dilates the wound with a probe-pointed bistoury, introduced over the nail of the left fore finger, or along the groove of a director when there is sufficient space for the previous introduction of this instrument. If the wound has occurred in a muscular part of the abdominal parieies, the separate layers of muscles, fascia, and peritoneum should be divided in succession. Strangulation of the intestine through an opening made in the omentum by a wound involving the abdominal loalls. (PI. LVI. fig. 3.) — 'In instances of this description, the orifice in the omentum nnvst be dilated with the bistoury introduced on a grooved director, as shown in the drawing, before the intestine is returned into the cavity of the abdomen. Scarpa has noticed a case in which the strangulation occurred in this way, without the escape of the intestine through the external wound. If the intestine has become gangrenous from the effect of the strangulation, 3. result which seldom occurs in these cases ex- cept after the lapse of one or two days, the only hope of cure is in the formation of an artificial anus, and the mode of treatment will be the same as in ordinary forms of hernia, wliere the intes- tine is found in a similar condition. The surgeon is to wait — unless there is an urgent necessity for prompt relief— two or three days, so as to give time for the abdominal portion of the protruded intestine to become firmly adherent to the peritoneal margin of the orifice, when he is to open the intestine, and allow the contents of the bowels to escape. WOUNDS OF THE INTESTINE. (PL. LVI.) In penetrating wounds of the abdomen, it is oftentimes ex- ceedingly difficult to determine whether or not one of the intes- tines has been wounded. These organs are flaccid and movable, especially when not distended with alimentary matters or by an accumulation of gas, and somewhat prone, notwithstanding they are in contact with every part of the abdominal walls, to fly before the edge of a culling instrument, so that they may either be opened at one or nore points, or escape altogether in cases where from the nature of the injury such a result would seem almost impossible. In this state of uncertainty, we must, when the wound is too narrow — as in a sword thrust— to allow ua to determine the exact nature of the lesion, trust alone to the efficacy of appropriate medical treatment. Those cases alone demand consideration here, in which the wound is sufliciently large to admit of the protrusion of the intes- tine, or allow of the examination of the wounded part when it is retained in situ. Even under such circumstances the wound of the intestine, if it be but a mere puncture, or not more than three or four lines long, is susceptible of being closed spontane- ously, as shown by the observations of Sir A. Cooper and Mr, Travers; the mucous membrane— from the contraction into which the intestine is thrown by the stimulus of the wound— becoming everted through the orifice so as to block it up and prevent the escape of fascal matter, even where the intestine has been re- returned into the cavity of the abdomen. Though the lips of the wound in the intestine are prevented by the protruding mem- brane from directly uniting together—for two mucous surfaces never unite— the orifice becomes permanently closed by the effusion of lymph from the jjeriloneal lining of the intestine near the cut, which unites, even in the course of forty-eight hours, the injured organ to some adjoining serous surface, whether it be that of another portion of the bowel or the wall of the abdomen itself. In cases, however, where the intestine thus injured is protruded from the wound, it would be more prudent to close the orifice before returning it by a simple stiich, and cut off the ends of the thread, leaving the knot as directed by B. Belt to escape subsequently by making its way into the cavity of the bowel. Dieffenbach in these cases lakes up with the needle the outer tunics of the intestine, (Plate LVI. fig. 11,) so as not to include the mucous coat in the stiich. Sir A. Cooper was in the habit of raising the sides of the orifice on a tenaculum and sur- rounding it with a thread, (Plate LVI. fig. 6,) nearly as in the manner of tying an artery; this plan, however, is objectionable, inasmuch as the strangulation, even of a small part of the wall of the intestine, may give rise to the general symptoms of stricture, and even should the patient escape this risk, occasion a narrowing of the bowel. In wounds of larger size than those above noticed, in which there is greater risk of efl'usion of the contents of the intestines, the plan of treatment will depend much upon the direction of the cut. If the wound be transverse, the longitudinal fibres will con- tract so as to widen its orifice, and though the action of the circular fibres may cause an eversion of the mucous membrane, it will not be of such an extent as to block up the opening, and the faeces will escape unless the wound be closed by surgical aid. A longitudinal wound of the intestine is not on the whole attended with so much danger as a transverse one of the same extent, as there will be less widening of the orifice by the contraction of 376 SPECIAL OPERATIONS. tlie muscular fibres. Both will, however, if more than three or four Ihies long, require to be closed by suture. Various modes of applying sutures for this purpose have been devised so as to close the orifice without interruption of the intestinal tube. Such measures have been proposed even when the intestine has been in a great part or entirely divided across. It should, however, be remembered, that notwithstanding the great progress which has latterly been made in this department of surgery, the greater number of processes devised are to be considered rather as the fruits of theory, or of experiments upon inferior animals, than the results of actual experience on the human subject. As a general rule the simpler methods— those which are likely to be followed by the least irritation or inflammation— should be pre- ferred, on account of the high functional importance of the parts concerned. Though the author has given below the description of the ingenious processes for closing wounds of the intestines by the introduction of foreign bodies, such as rings and plates, into their cavity, he is disposed to tliinli the advantage to be derived from them is in a great measure problematical. The simpler methods to which he would give the preference, consist in the fastening of each of the orifices of the in jured intestine by means of a suture at the peritoneal margin of the wound, trusting to the effusion of plastic lymph to prevent the escape of fsecal matters into the abdominal cavity, or of drawing them in cases of com- plete division well into the outer wound for the purpose of forming an artificial anus. When the bowel does not protrude, and the opening in it is situated immediately behind the orifice of the external wound, a suture of no kind is required, (which could seldom in such cases be employed witiiout dilating the wound or disturbing the intestine,) inasmuch as there is little or no danger of the injured bowel changing its position, provided the patient be iiept perfectly quiet and in the horizontal posture. Longitudinal wounds of ike Intestines. Various forms of suture are employed for the closure of wounds of this description. 1. JProcess of Ledran. (PI. LVI. fig. 3.) — The intestine is to be extended longitudinally so as to bring the lips of the aperture together, through both of which, ligatures are to be passed across with a fine cambric needle at intervals of about two lines. The two ends of each thread are then to be brought out of the wound, and ti)e whole of those of each side twisted lightly into a cord, so as merely to bring the lips of the aperture together; the two bundles are then brought out as a single cord, and attached by PLATE LVI.— WOUNDS OF THE ABDOMEI, SUTURES OF THE SMALL INTESTINES. Fig. 1. — Dilatation of an abdominal ivound for the purpose of reducing a mass of the small intestines which had escaped without. The folds of intestine are represented as having been gently drawn down with the fingers of the surgeon's left hand, so as to admit the insertion of the fore finger into the top of the wound. Over the nail of this finger, the back of a probe-pointed bistoury is passed for the purpose of dilating the orifice. LONGITUDINAL WOUNDS OF THE INTESTINES. pig^ 2. — A longitudinal wound of a portion of the small intestine which has escaped through a cut in the abdomen, is here seen closed by the continuous or glover's suture. The surgeon is represented as holding the two extre- mities of the thread in his left hand, while with his right he returns the intestine. Fig. ^.—Suture of Ledran. Fig, 4, — Dilatation on the grooved director of an opening in the omentum, through which a hernial protrusion has taken place. The suture of the wound in the loop of the small intestine is made by the process of Beciard. Fig. 5. — Suture by the process of Johert. Fig, 6. — Suture by the process of Sir A. Cooper. Fig. 7. — Suture by one of the processes of Reybard. This may be welt understood by reference to the drawing. a. The wooden plate shown separate. b. The plate seen applied on the inner face of the intestine, to the wall of which it is attached by a ligature. Proposed in transverse wounds of the intestines. It has not been thought necessary to describe it in the text. Fig. 8. — Suture by iheprocess of Lembert. a. Application of the ligatures. b. Action of the suture in closing the orifice by bringing two serous surfaces in contact. This process is applicable both to transverse and longitudinal wounds of the intestines. TRANSVERSE WOUNDS. Fig. 9. — Invagination by one of the processes of Jobert, Fig. 10. — Process of Denans, in which the ends of an intestine divided across are approximated by the means of a cylinder and two rings. Fig. II. —Process of Diejfenbach, in which the ligature is passed merely through the outer coats of the intestine. Fig. 12. — Process of Jobert for invagination. — The two ends of the divided intestine are brought in contact so as to show the manner in which the invagination is effected by the tying of the hgatures. OPERATIONS UPON THE ABDOMEN. an adhesive strap near ihe internal margin of the wound. If the application of tlie process proves successful, tlie wounded surface of Ihe intestine will be found agglutinated, by means of lymph, to the adjoining surface of the peritoneum. The same object may be accomplished by the following process. 2. Processof /'a/^/t.— This consists simply in passing a thread across the middle of the wound, so as to bring the aperture of the intestine towards the orifice of the external incision. The ends of the thread are to be fastened to the skin by strips of ad- hesive plaster. 3. Bi/ the glover's suture. (PI. LVI. fig. 2.)— This was the process chiefly relied on by the older surgeons. It consists merely in stitching the two edges of the wound with a continuous thread, and will be well understood by reference to the drawing. It is important that the loops of the thread should not be drawn more tight than merely to close the fissure, lest they should cut the tissue by ulceration. The two ends of the thread should be loft long, as seen in the drawing. As soon as the thread is applied, the surgeon sustains it with his left hand (or gives the ends to an assistant) while he reduces the protruded intestine with the other, and finishes by drawing on the ligature, so as to retain the wound- ed surface of the bowel in contact with Ihe orifice of the abdomen, which is to be carefully closed. At the end of five or six days the thread is to be withdrawn by pulling gently upon one end, while a support is made with the fingers of the other hand upon the abdominal walls. 4. Process of Bee lard. (PI. LVI. fig. 4.)— This is a modifica- tion of the preceding, and consists in basting the edges with two threads of difterent colours passed at the same time through the eye of the needle. Au end of a different colour is retained with- out at either extremity of the wound. The only advantage arising from this modification is, tliat at the proper time for their removal the threads may be withdrawn by pulling at the same time on the two ends without wrinkling the bowel, and thus with less risk of breaking up its new adhesions. lu all the pre- ceding processes the mucous surfaces of the intestines are merely put in contact, and as these do not unite, the closure of the orifice in the bowel is only efl"ected by the medium of the lymph by which it becomes agglutinated to another peritoneal surface, as that of an intestine or tlie wall of the abdomen. In the succeed- ing process, the peritoneal surface of the two lips of the wounded bowel are brought in contact. 5. Intei-riipted suture. First process of Jobert. (PI. LVI. fig. 5.) — This surgeon presses together the two lips of the wounded intestine with the thumb and finger of the left hand, and with the needle in his right inverts the edges so as to bring the two serous surfaces in contact. Several interrupted sutures two or lliree lines apart, are then made through both the inverted edges, in order to keep the serous surfaces together. They arc to be knotted separately; one end of each ligature is to be cut off near the knot, and the remaining ends, after the intestine has been returned into the abdomen, brought out and retained at the ex- ternal wound. By the fourth or fifth day the knots cut loose, so that the threads may be withdrawn. If the operator prefers, the ends of the threads may be simply twisted, as in the process of Ledran— or both ends of the ligature may be cut off after they have been knotted, leaving the knot to fail by ulceration into the 70 377 cavity of the intestine, and escape with the ftecal matters. This last modification would allow of the immediate closing of the external wound, without the interposition of any foreign sub- stance between its edges. Its value, liowever, has not been tested by experience. 6. Process of M. Reybard.—T\\\s surgeon employs Ihe glo- ver's suture, but so modified as to leave the thread to detach itself spontaneously, and fall into the cavity of the intestine. He uses a small needle with a double thread, which is knotted at the end upon a small cylinder of linen. The thread is introduced from within outwards at one end of the cut, so as to leave the cylinder in the cavity of the intestine. The edges of the wound are then closed as in the ordinary glover's suture. When the needle is brought to the other end of the cut, one end of the double thread is slipped from the eye; a stitch more is made with the remaining end, and the two ends are finally knotted firmly together and cut away close to the knot. The intestine is then to be reduced, and the wound united. The cylinder is em- ployed for the purpose of offering more resistance to the contrac- tion of the intestine than would occur from a simple knot, thus facilitating the ultimate discharge of the thread, which is abati- doned in the wound. Transverse ivounds of the Intestines. Three principal methods have been employed in the closure of transverse or oblique wounds of an intestine; viz; suture upon a foreign body, suture with invagination, suture by the conjunc- tion of the serous surfaces. 1. Suture upon a foreign body. (Process of Duverger.) — This is but a modification of the process known under the name oi "the four master's,'' in which the orifices of the wound were stitched over a section of the trachea of some animal. M. Du- verger employed a section, two-thirds of an inch long, of the dried windpipe of a calf, steeped in oil varnish. This was intro- duced into the cavity of the bowel, so as to preserve its caliber, and fastened in its position by three loops of interrupted suture. The intestine was then to be returned, and some gentle laxative drink given to the patient. This operation has in several in- stances been followed by complete success, the foreign body having been evacuated by stool. A canula of isinglass, a cylin- der of tallow, or a piece of cord rolled in the form of a tube and steeped in the oil of hypericum to prevent its softening too speedily, have been respectively proposed by Watson, Scarpa, and Chopart, as a substitute for the foreign body of Duverger. The process has, however, gone out of use. 2. Suture ivith invagiriation. — In a case where the small in- testine was completely divided across, Rhamdor, of Brunswick, conceived Ihe idea of introducing the superior end of the intestine into the inferior, keeping them in conjunction by two points of suture, returning the bowel inmiediately afterwards into the ab- domen, and closing the external wound. This operation suc- ceeded completely in the hands of its projector. But on the dissection of this subject some years afterwards, it was found that the nnion which liad maintained the route of the bowel was made by adhesions between the surrounding serous surfaces, and not by a junction of the serous coat ol' one end with the mucous 278 SPECIAL OPERATIONS. coat of the other, which had been put in apposition. The ope- ration has been several times repealed since, but in the greater number of cases with an unsuccessful result. It has latterly been revived, with some modification, by Amussat. Two difficulties attend this process, which at times must render it wholly inapplicable: — 1. That of distinguishing tiie upper from the lower end of the divided tube, since, from the convoluted arrangement of tiie small intestines, that which is at the upper end of the wound will often be found the orifice leading to the inferior tract. The only means of determining this question positively, is to give the patient some milk or a slight laxative potion, and no- lice, by which orifice the discharge takes place — the two ends of the intestine being retained without for that purpose. In reference to the large inlesline, the liability to mistake is not so great, and in case of doubt, may be determined at once by the administration of a mild enema. 2. The second difficulty attends the process of invagination itself . This arises in part from the obstacle which the mesentery presents to the introduction of the superior extre- mity into the aperture of the lower, and is to be obviated by its detachment to a sufficient extent from the side of the bowel; or thcrlwo orifices, and especially the lower, may be found plicated or contracted with an eversion of the mucous membrane, so that the introduction of some foreign body is rendered necessary to keep the track of the bowel patulous after the invaginatioti. This latter difficulty has been met by the fnllowitig ingenious proposi- tion of M. Reybard, the value of which has not, however, to the knowledge of the author, been tested by its application to the human subject. Process of Beyhard. — This consists in introducing a piece of card, rolled in the form of a short cylinder, into the orifice of the upper end of the bowel, to which it is to be fastened by two loops of thread that embrace opposite portions of the cylinder; tlie ends of the threads are brought out through separate punc- tures in the wall of the intestine. The two ends of each of the threads are next passed separately from within outwards through the walls of the lower orifice, and are made the means of drawing the other end of the card and the upper orifice of the intestine into the lower end of the tube. The two ends of each of the threads are now knotted on opposite portions of the bowel. Another process of this surgeon, in which he employs a wooden plale instead of the cylinder, is represented at PI. LVI. fig. 7. Process of ^miissai. — This surgeon has proposed to bring to- gether the divided ends of a small intestine, by introducing a ring of cork, with a sort of hour-glass narrowing in the middle, into one of the orifices of the intestine. This end, kept patidous by the cork ring, is then well invaginated in the lower orifice, and a large thread is passed round and knotted so as to firmly attach the two coats of intestine to the groove in the cork. The ends of the thread are to be detached close to the knot, and the free por- tion of Ihe outer orifice pared away with the scissors close down to the thread. Tiiis process has not, however, yet been applied upon the human subject. 3. Suture with junction of the serous surfaces. Second process of Jobert. (PI. LVI. fig. 12.) — The only apparatus used is two threads, armed each with a needle at either end. The mesentery is first to be detached for a third of an inch on both ends of the intestine. One end of each thread is then to be passed from within outwards, tln'ough the wall of the upper orifice of the intestine, at a distance of three lines from its edge. The two loops of threads thus formed should be at opposite points of the intestine. They are to be held by an assistant, while the surgeon takes hold of the inferior end of the intestine and doubles in its border, so. as to make it present its serous surface externally. The needles at the ends of the two loops of thread are then brought at different points from within outwards through the folded edge of the lower orifice. By drawing upon these threads the upper end of the bowel is invaginated in the lower, so as to _place the two serous surfaces in contact. The threads are then to be knotted or merely twisted tight, and the intestine reduced. The value of this ingenious and somewhat celebrated process, has not yet' been tested in its application to man. Process of Denans. {Pi. LVI. fig. 10) — In the ingenious process of this surgeon, a silver cylinder is required about two- thirds of an inch long, and two flat rings a third of an inch broad, and sufficiently large in their diameter to slide over the ends of the cylinder and allow the edges of the bowel to be interposed between them and the cylinder, as seen in the longitudinal sec- tion shown in the drawing. The mesentery is to be detached from near the two orifices of the intestine, as in the process above described. The two rings are then introduced, one into each of the ends of the intestine. Over tiiese, the free edge of the orifice is doubled in, in the form of a fold two or three lines long. The two ends of the cyhnder are next inserted in the opposite orifices of the bowel, so as to compress the doubled edges agSinst the inner surfaces of the rings. The continuity of the intestinal passage is now restored, the free serous edges of the tied in- verted margins of the orifices being placed in apposition over the centre of the cylinder. It now only remains to fasten tlie rings together so that they shall not separate, before such an effusion of lymph has taken place, as will preserve the continuity of the tube. This is accomplished by a th.read armed at each end with a needle; one needle being passed through tiie intestine oppo- site the lower margin of the cylinder, carried into the cai^ity of the intestine, and brought out by another puncture through the intestine at the opposite end of the cylinder, bringing with it one end of the thread. In the loop of the ligature is now embraced the cylinder, the ring, and the portions of the intestine which rest upon these parts, all of which would, if the thread was knotted, unavoidably be strangulated. To avoid the strangulation, the second needle is to be entered and brought out at the same places of puncture as tlie first, but this lime passing beltoeen the mu- cous surface of the boivel and ihe external face of the rings. The two ends of the ligature which have been brought out at the same puncture, are nest to be knotted, cut off close to the knot, and the knot itself pushed through the aperture of the puncture into the cavity of the intestine, so that no foreign sub- stance shall be left on llie outer surface of the bowel when it is returned into the cavity of the abdomen. The result of this process, as shown by experiments upon dogs, is the union by adhesion of the serous layers upon the folded margins of the two portions of intestine, and the detach- ment by gangrene of the inner ends of the folds included between OPERATIONS UPON THE ABDOMEN. 279 the rings ^nd cylinder, so as to loosen these bodies, and allow them, with the loop of ligature, (o be evacuated hy stool. For fear that the metallic cylinder and rings might, if applied upon the human subject, become arrested in their passage down the bowels, it has been proposed to have them fabricated of some substance, as gelatin steeped in a drying oil, which, while it remained unchanged a sufficient length of time for the ad- hesion of the serous edges to take place, would in the end by becontiiig partially dissolved, be readily expelled. Process of Lembert, (PI. LVI. fig. S.) — This surgeon, with- out employing any foreign body, proposes to put the serous sur- faces largely in contact by a peculiar mode of applying the ligatures. Each ligature is to be passed with a needle — intro- duced from the serous coat four or five lines from the divided end of the bowel, and carried, not through into the cavilv of the bowel, but between the membranes of the parieies to within a line or two of the open end, when it is again brought liirough the serous membrane; taking as it were merely a stitch through the outer coats of the bowel. The needle is now passed in a similar way upon the oilier end of the intestine, with the excep- tion merely that the first puncture is made near the orifice and the needle brought out by a second a few lines furilier on the bowel. When the ligatures are thus applied and knoiied, it will be manifest that the ends of the bowel will be inverted, and the serous surfaces of both wrinkled up and put freely in contact. Three or four sutures are then to be applied around the intestine and cut close to the knot. The intestine is then to be returned into the abdomen. This process has been successfully employed by M. J. Cloquet upon tlie human subject, for the purpose of closing the wound of an intestine, made in the operation for hernia. OPERATIONS FOR HERNIAL TUMOURS OF THE ABDOMEN. GENERAL OBSERVATIONS ON HERNIA. The escape of one or more of the viscera from the cavity of the abdomen, by the dilatation of one of the natural passages which lead from this cavity, or by a rupture of some portion of its walls, constitutes a hernia. The small intestines and omen- tum, which are the most movable of all the viscera, form the greatest bulk, and are placed in contact with the largest extent of parietal surface, are so generally, either separately or in con- junction, the subject of hernial protrusion, that the escape of any of the other abdominal organs is to be looked upon as an excep- tion to the general rule; — the next to them in the order of fre- quency is the sigmoid llexure of tlie colon. The protrusion even of the liver, stomach and spleen, has been noticed in some rare cases of old and large hernia. Hernial tumours have received names in conformity with the points at which the viscera escape. We have thus "inguinal hernia," when the viscera pass by the inguinal canal; ''crural hernia," when protruded at the crural ring; and in like manner umbilical, perineal, thyroid, vaginal, ischiatic and diaphragmatic hernia, when these several regions become the seat of the pro- trusion; and in addition, ventral hernia, when the viscera escape by an accidental wound or rupture of any portion of the ab- dominal walls. The protrusions in each of these forms of hernia are specifi- cally named according to the nature of the organ displaced, viz:— "enterocele or intestinal hernia," when the intestine is protruded alone; "epliplocele or omental hernia," when the omentum only is the subject of displacement; "entero-epiplocele," when both intestine and omentum are protruded together; "cystocele," if the bladder, and "hysterocele," if the uterus has escaped by a hernial passage. The viscera protruded in hernia are not ex- posed naked, except in cases where the cavity of the abdomen has been opened directly by a wound. The different layers which form the covering of these several forms of hernia, constitute the most important feature in their surgical anatomy, and should be carefully studied by the surgeon, for he cannot, unless familiar with their arrangement, do any operation for the relief of stricture with proper precision, or with satisfactory prospect of success. The viscera as they are pro- truded in hernia, push before them, as a general ruJe, the perito- neal lining of the inner surface of the abdomen. This membrane with the cellular tissue upon its outer face, forms the inner and immediale investment of the tumour — that which has been called the hernial sac. This sac, with some exceptions hereafter to be noticed, is common to all herniai; but the other coverings — fascial, aponeurotic, or muscular — vary according to the place at which the hernia appears. Development of the sac. — This is formed, as just observed, by the protruding viscns, which, as it escapes through or by the side of one of the natural passages of llie abdomen, carries down the peritoneum before it as a sort of cowl or cap. This sometimes takes place suddenly and without previous gradual dilatation, wlien the passages are preternaturally large, or the fascia and muscles which should cover and protect them are unusually thin, or have been rendered preternaturally weak. In most instances, however, the complete protrusion of the viscus is more slowly effected. The pressure to which the viscera of the abdomen are subjected by the action of the diaphragm and abdominal mus- cles, which act in conjunction when great efforts are made so as to press the viscera between them, induces these organs to seek an outlet at any point which is not able to resist the pressure. When such a weakened point exists, it gradually yields or dilates more and more from each succeeding effort. The effort over, — the viscus and the cup-like process of peritoneum protruded before it, are in the early stages driven back by the reaction of the parts on the outer side of the dilating point. As the passage becomes more dilated ahd the parts protruded increase in bulk, the cup of peritoneum takes the form of a pouch or sac. This state of pre- paration for the complete hernial protrusion may go on without the consciousness of the individual, till, from sudden and violent nniscnlar effort, or from force applied externally, the viscus is so far protruded as to become visible by the formation of a tumour, or excite attention by the pain or functional disturbance it occa- sions. Under such circumstances, the sac for a time is still sus- ceptible of being returned into the abdomen with the tumour; but if the displacement frequently recurs, the sac becomes un- equally dilated; its bottom or protruded part meeting with the least resistance, enlarges more or less in all directions, while its 280 SPECIAL OPERATIONS. upper part, girdled by the more rigid structure of the wall of the abdomen, remains narrow, and constitutes what is called the neck of the hernial tumour, the expanded part being termed its body. If the orifice at the neck is large, so as to allow the viscus to freely enter and return, the sac elongates ilsclf by gradually drawing down more and more of the loosely attached peritoneum from the adjoining surface, and soon becomes so adherent to the parts on its outer face as to be incapable of being returned even after operation, without previous dissection with the knife. The enlargement of the sac may still subsequently go on, partly from a farther descent of the peritoneum, partly by its own interstitial growth, and at times even by a distension and thinning of the membrane, which renders it occasionally in old cases, only ob- vious as a distinct layer in the neighbourhood of its neck. As the body of the sac enlarges, it will extend in the direction in which it meets with the least resistance, however circuitous this may be, and sometimes from the same causes forms one or more pouches upon its sides, so as to give it a multilocular or cellular appearance. When the sac has in this manner attained consider- able size, been rendered firmly adherent especially at its neck, and has a large peritoneal orifice, it sometimes itself becomes the receptacle of another complete hernial protrusion — the lax peri- toneum around the margin of its inner opening descending before the intestine or omentum in the form of a second pouch into the first, so as to constitute what is called an encysted hernia. This occurrence usually takes places at a lime, when the first formed pouch is empty. A new pouch may even form by the side of the old, and thus two sacs exist with separate orifices; and there is noiliing to render it improbable, but that the orifice of the first may become so large as to admit the viscus into each sac so as to give rise to a double hernia at the same point. Such then, is a brief description of the usual manner in which the sac is developed. Its inner surface remains under ordinary circunisiances, smooth and polished, and retains its serous cha- racter. The fluid, however, which it secretes, varies in quality and amount in the various forms, and in the dilfurent stales of the same form of hernia. The ituier surface of ihe sac is subject to irritation i'rom the undue or long-continued pressure of the protruded viscera, from external violence, or from the imperfect action of a truss. From either of these causes it is apt to inflame, throw out lymph and agglutinate itself to the serous coating of the protruded viscera (which always share in the inflammation thus produced), so as to prevent the latter from being returned, and convert what is called reducible into an irreducible hernia; or may form bands across its cavity which become not unfre- quently the cause of strangulation. But the neck, which is the narrowest part, is the one most subjected to these changes. It is modelled upon the form of the opening in the abdominal wall, being annular when the protrusion takes place by a direct open- ing, as in crural or umbilical hernia, and more or less tubular, when it escapes by a canal, as in recent oblique inguinal hernia. In old cases of oblique inguinal hernia, the two ends of the canal are gradually approximated by the weight of the descending in- testine, so that the neck finally obtains the annular shape. hi the early stages of hernia, the peritoneum is arranged in the form of plaits at the abdominal orifice, which unfold when the sac is returned into the cavity. But when the sac becomes adherent, these folds are disposed to unite together, so as to narrow the opening, render it more rigid and inextensible, and present a sharp valvular prominence, which, by preventing the return of the tumour, becomes the most frequent seat of stricture. The pressure of a well-applied truss has a tendency to hasten this retraction of the orifice, and in some favourable cases may in the end eflect its obliteration so far as to prevent any subsequent protrusion. Sometimes the sac is thickened as a consequence of the inflammation; but more commonly than is generally believed the thickening which takes place is in the cellular structure on its outer side. Hernia ivithout a sac. — There are other forms of hernia, in which there is no separate protrusion of the peritoneum in the form of a sac. The most common kind of these is that to which, though without strict propriety, the term congenilal has been applied. In this variety the peritoneal passage of the foetus which leads down the spermatic cord to the vaginal tunic of the scro- tum, or that about the round ligament of the female, known aa the canal of Nuck, has not been as usual obliterated, and the intestine or omentum is found after birth sliding into the passage, as into the sac of an old hernia;— or the obliteration may have been only partial, so as to yield under the stronger efforts to which it is subjected as the individual grows up, and give rise to what is called congenilal hernia, even though it occur for the first time at the period of manliood. In these cases, which occur nearly always in the male, the protruded parts lie immediately in cotUact Willi the cord and testicle, and, though they do not pro- trude a peritoneal pouch before them, are nevertheless covered in front and on the sides by the reflected serous tunic of the tes- ticle. In some rare instances a hernia may be formed without the protruded parts having any serous covering, as when the caicum escapes by its posterior cellular surface through the crural or inguinal rings, or the top of the front surface of the bladder is elongated, so as to pass out through the same channels. Even in ordinary cases of hernia the sac may be ruptured by a blow, removed by absorption in consequence of the pressure of its contents, as has been observed by Sir A. Cooper and Breschet, or broken down by an abscess on its outer side, so that in case of operation the protruded parts will be found lying in contact with the cellular or fibrous envelopes of the sac Each hernial tumour is found in one of the four following con- ditions: — reducible, irreducible tvithout strangulation, stran- gulated ivithout adhesion, and strangulated ivith adhesion. A reduci/jle hernia, is one in which the displaced organs caa be returned into the abdomen by the patient himself, or by a methodical employment of the taxis on the part of the surgeon. When the parts are temporarily displaced and largely distended in consequence of a stationary accumulation of gaseous or solid matters in the protruded intestine, attended with pain, constipa- tion and nausea, we have what has sometimes been denominated obstructed or congested hernia. This is met with mostly in old hernia, and especially in those of old men. It may last several days, and terminate either by free evacuation per anum. or by inflammatory strangulation. An irreducible hernia, is one which cannot be made to return by the use of the taxis, in consequence usually of the adhesions OPERATIONS UPON THE ABDOMEN. 281 which the organs liave formed witli the sac. In some instances however, of this description, when the hernia is small, reduction may be eGTected by retnrniiig the sac and tiunonr together into t!ie cavVy of the abdomen. Tlie very bulk of the tumour in some cases of enormous hernia, even though there should be no adhesions, (which rarely fails to be the case,} presents an obstacle to reduction, and constitutes what has sometimes been called "incarcerated hernia;*' for when the bulk of the parts protruded is considerable, the abdominal cavity contracts in its dimensions, so as to accommodate itself to the loss of the organs, and presents an obstacle to their return. The simple irreducibihty of a hernia is not of itself, under ordinary circumstances, liable to compro- mise the health, and the tumour may be protected against further enlargement by the wearing of a hollow truss, or, if too large to be supported in this way, by a well-fitting buckskin pouch. A slrangiilaied hernia wifhout adhesion, is one in which the viscera recently protruded are rendered irreducible in consequence of being tightly constricted at or near the neck of the sac, so as to produce more or less general functional disturbance and local symptoms of inflammation, which may run on to gangrene. Strangulation, however, is not to be mistaken for that state of the tumour which has been denominated obstruction. In sl7-a7igulafed hernia with adhesion, which occurs in irre- ducible hernia, the mode in which the stricture is produced is much the same as that just described, and the importance of the distinction refers mainly to the treatment after operation. Strangulation may be owing either to the smallness of the neck of the sac, so that a mere loop of intestine or knot of omentum is strangulated almost as soon as it is displaced, or when the neck is only rendered relatively small in consequence of the great bulk of tlie parts displaced. In strangulation there is always inflammation of the sac and of the parts enclosed, and this inflammation, which has been occasioned by the stricture, reacts most injuriously in its turn by rendering the strangulation more light. It tends also to increase the quantity of fluid which is usually found in old hernial tumours, renders it turbid from the eflusion of lymph, or chocolate-coloured, if it has run on towards mortification. From the elfusion of lymph there is also more or less gelatinous agglutination of parts, if the strangulation has existed some hours, and even at the neck of the sac in those cases that have been most speedily operated on. These new adhesions are, however, easily ruptured with the end of the finger, or by slight traction, and may be distinguished from the older ones, which are more resisting. Another mncli more serious result of the strangulation and the inflammation which accompanies it, is the gangrene of the parts enclosed, produced oftentimes with the most extraordinary rapidity by the twofold effect of the inflammation and the subsequent arrest of the capil- lary circulation. It is important for the operator to be familiar with the diflerent appearances which the parts present between the first period of strangulation, and that which has resulted in gangrene. I. t/lppectrance of the intestine. — At the first period of stran- gulation the intestine will be found tense, smooth, and shining, with .1 violet tint, which, as it is merely the consequence of ob- struction in its circulation, soon diminishes, on the division of the stricture. At a later period of strangulation, or early even when 71 the stricture has been tight, the colour is of a deeper hue, and the vessels are distended with black blood. If it presents a deep chocolate-coloured appearance, which does not diminish speedily on the division of the stricture, nor the blood pass from the dis- tended veins, it is, even though it emit no oflensive odour, on the verge of gangrene. When the intestine, instead of being tense and sliiiiing, lias lost its polish, become llabby, exhibits phlycte- nular elevations of the serous membrane, has an ash-coloured tint, and spreads an offensive odour, it is already gangrenous. If the parts covering the tumour are found before the operation crepitant, and spreading an offensive odour, gangrene has un- questionably taken place. This efl'usion of odour through the skin I have several times observed when called too late, or the patient has resisted a timely performance of the operation. In one case of crural hernia, in the visit to which I was accompanied by Professor Mussey, of Cincinnati, an extensive irregular gan- grenous discoloration was observed, without apparent affection of the skin, resembling in appearance an extensive ecchymosis at the lower part of the abdomen. In a case of strangulated congenital Iiernia occurring in a young gentleman, for which I operated with the advice and assistance of the late Dr. Parrish, thirty-six hours only after the first protrusion of the intestine, this odour was perceptible through the skin, and seven inches of the small intestine was found in a state of almost dilTluent gangrene. In most instances, however, in which we have the misfortune to meet with gangrene, it is limited to a small extent of surface; sometimes it is in the form of spots upon the prominent portion of the intestine, and especially in those cases where the attempt to reduce it by taxis has been made too roughly, or continued too long. Occasionally it is found in separate points round the part embraced in the neck of the sac— sometimes it is preceded by a small abscess developed in the thickness of the tunics; in either of these latter cases, in attempting, for the purpose of dividing the stricture, to separate the adhesions which unite it to the neck, or in endeavouring to draw the intestine gently out after the division of the stricture, to examine its condition, the intestine may, without the greatest care is exercised, give way and discharge its contents. 2. Jlppearance of the omentum. — The characteristic appear- ances of gangrene in the omentum are neither so strongly marked nor so readily detected as those of the intestine. In the earliest stage we find the omentum gorged with blood, soft and puffy at points; when fully formed it is mottled with dark patches of ecchymosed blood, oflensive, and presents grayish sloughs that may be drawn out in strings with the forceps. It may, however, be observed, that strangulation of the omen- tum will be longer borne without its resulting in gangrene, and is therefore less frequently seen than that of the intestine. Death, notwithstanding, often follows as a consequence of strangulation either of intestine or omentum, even when it produces efl'ccls short of gangrene, in consequence of the inflammation of the peri- toneum, to which it gives rise after the return of the viscus, or that of the great mass of the omentum, which is prone to run into abscess. TitE.\T.MENT OF HERMA. 1. Of reducible hernia.— T\iQ treatment of this description of 2S2 SPECIAL OPERATIONS. Iieruia will consist merely of llie applicEition of a truss, for the purpose of palliating the pain and inconvenience of the affection by keeping the viscera from protruding after they have been returned into the cavity of the abdouien, or in the attempt to effect by specific means a radical cure. Of the application of the truss it is not necessary here to treat furtlier merely than to ob- serve, that in ordinary oblique inguinal hernia the pad or block of a spring truss should be applied over the track of ihe inguinal canal, so as to make pressure upon the internal ring; it is to bo placed upon the external ring over the pubis, in cases of direct inguinal hernia, in the congenital hernia of infants, and in those instances of oblique inguinal, in which the internal ring has been dragged down to the level of the external. Radical cure of Hernia. , In favourable eases, and especially in young subjects, this may be effected by the long-continued application of a truss. When it has not been accomplished by this means, a variety of different processes have been resorted to, to effect it by operation. Many of those practised by the older surgeons— which it will suffice merely to enumerate — have for a long time been entirely aban- doned; viz: Casiralioji; caideiHzaliun upon the surface of the PLATE LVII.-PKOCESSES FOR THE RADICAL CURE OF REDUCIBLE HERNIA. The object of these different processes is to obtain a radical cure of the hernia, by causing an adhesive inflammation of the walls of the sac, the viscera being previously reduced. Fig. 1.— (A). Process of J\J. Bonnet. — Tliis consists in enclosing the cord between two pins, the ends of the pins being fastened upon two hemispherical rolls of linen. a. The rolls of linen, attached to the two ends of the upper pin, which has been passed between the integuments and cord just below the level of liie external ring. b. The rolls of linen, for securing the ends of (he lower pin, which has been passed behind the cord. (B) . Process of Gerdi/. — A fold of skin is pushed with Ihe fore finger through the external inguinal ring into the inguinal canal. A curved needle has then been passed along the finger and carried through the double thickness of skin and the anterior wall of the canal wliich is found between them. This is the first step of the operation. (C) . In this drawing the operation of Gerdy is shown completed. The skin at the border of the opening made by tucking the fold of skin into the canal being united, as in a plastic operation, to a flap of skin which has been raised from below it. Figs. 8, 3, 4, 5. — Process of Belmas. — The needle of this surgeon, seen at the bottom of the plate immediately below fig. 2, and at the two smaller figures at the right hand of the plate, is complicated in its structure. It consists of a canula, separable at the middle {a) into two portions [b, 6), enclosing two fine stilets (c, c) provided with a joint at d, which admits of a quarter turn being given to the movable end, so as to make it at will serve the purpose of a hook. The blade or head of the instrument (e) may be detached from the shaft (c). Fig. 2. — First siage of I he operation. — Puncture with the instrument through the hernial sac, which has bepn raised with a fold of the skin. Fig. 3. — Second stage. — The surgeon now seizes the shaft of the instrument through the sac and skin, for the purpose of detaching the two portions of the instrument. Fig. 4. — Third stage. — The sac is represented as laid open on the dead body, in order to show more clearly what is effected on the living in the interior of the sac. The interior shafts (c, c) being removed, the two ends of (he canula are bent at d, d, so as to act the part of hooks, with which (he sides of the hernial *ac are separated in opposite directions. Through Ihe passage in the handle (f) threads of gelatine (g) are to be introduced, and allowed to remain so that they may be dissolved and ultimately absorbed, after having produced the requisite adhesive inflammation. Fig. 5. — Etasiic pad of Belmas, attached to a truss for the purpose of making permanent compression upon the sac. The several holes seen in the plate, allow the spring to be attached to vary the angle, in proportion to the existing prominence of the abdomen. Fig. Cy, — Process of Velpeait- — In this operation ihe integuments are pushed into the canal, as in the process of Gerdy — a flat strip of v/ood [a) being used for the purpose instead of the finger. Upon this strip the cutting head of a large needle-shaped instrument is carried, which M. Velpeau pushes through the integuments and the wall of the sac, and employs to scarify the neck. The two transverse dotted lines indicate the places of the external and internal abdominal rings. The dotted lines between the rings indicate the track of the instruments under the skin. Fig. 7. — The instrument employed by the author in the puncture of the sac. It consists of a stout acupuncture needle mounted on a gold canula; it is represented a third too large in the drawing. A small pin attaches the handle to the cnp of the canula, so as to allow the instrument to be iiUroduced by rotation, without the stilet turning in the canula. A small graduated syringe, for the purpose of throwing in the stimulating ffuid, com- pletes this simple apparatus. i OPERATIONS UPON THE ABDOMEN. sidn,or upon the neck of the sac after the slcin had been laid open so as to expose the cavity; ligature of Ihe neck of the sac with a gold thread (golden stitch) or an ordinary ligature — the royal stitch, which consisted in sewing up the neck of the sac, and excising all the body of the sac below the line of sutnre — the Spanish process, in which the sac was laid open for the purpose of pushing the testicle into the cavity of the abdomen and closing the neck with the golden stitch; and the reduction of the hernial sac entire after having previously dissected it up from its attachments. Various other methods have been resorted to by modern prac- titioners, but in inguinal hernia almost exclusively, some of which are entitled to more favourable conslderaiion, though in regard to no one has perhaps a sufficient amount of experience been acquired to entitle it to particular recommendation. 1. J3cnpuncturation. — This has been for the last fifteen or twenty years practised more or less in tiiis country. It consists in making from ihe surface of the skin one or two rows of punc- tures with a common acupuncture or large sewing needle across the neck of the sac immediately below the orifice of the external ring. The author made repeated trials of this practice about ten years ago, and though he found it insufficient of itself to effect a cure, in a few cases it appeared, by the irritation developed in the sac, to facilitate the obliieralion of the passage by the action of the truss. The partial success obtained by this means, induced him, in conjunction with Dr. Young, of Tennessee, then a student of his, to resort to the more positive means of exciting inflamma- tion by the instillation of a few drops of some highly stimulating fluid into the cavity of ihe sac. 2. Btj injection. — This process, as employed by the author, is as follows. The couienis of the hernia must be completely re- turned into the cavity of the abdomen — for the process is only appropriate to cases of reducible hernia, and those which are not of large size. The apparatus required is a minute trocar and canula, (PI. LVII. fig. 7,) a small graduated syringe, capable of containing a drachm of fluid, well fitted to the end of the canula, and a good-fitting truss for the purpose of making compression. The patient is to be placed on his back; the viscera are then to be reduced and the truss applied over the external ring for the purpose of keeping them up, as well as to prevent the possibility of the small quantity of fluid thrown in from getting into Ihe cavity of the abdomen. The surgeon then presses with the finger at the external ring so as to displace the cord inwards and bring the pulpy end of the finger on the spine of the pubis. At ihe outer side of ifie finger he now enters willi a drilling motion the trocar and canula, \ till be feels the point strike the horizontal portion of the pubis just to the inner side of the spine of that bone, The point is then to be slightly retracted and turned upwards or downwards; the instrument is then to be fiit'liier introduced till the point moves freely in all directions, showing it to be fairly lodged in the cavity of the sac. The point of the instrument should now be turned into the inguinal canal, for the purpose of scarifying freely the inner surface of the upper part of the sac, as well as that just below Ihe internal ring. The trocar is now to be withdrawn, and the surgeon, again ascertaining that the canula has not been dis- placed from the cavity of the sac, throws in slowly and cautiously with the syringe, which should be held nearly vertical, half a 283 drachm of Lugol's solution of iodine, or half a drachm of the tinc- ture of caniharides, which should be lodged as nearly as may be at the orifice of the external ring. The canula is now to be re- moved, and the operation is completed. A compress sliould be laid above the upper margin of the external ring, pressed down firmly with the finger, and the truss slid down upon it. The pa- tient is to be kept from changing his position during the applica- tion of the truss, and should be confined for a week or ten days to his bed, with his thiglis and thorax flexed, keeping up steadily as much pressure with the truss as can be borne without increasing the pain, in order to prevent the viscera from descending and breaking up llie new adhesions while they are yet in the forming state, or avoiding the risk of their becoming strangulated or being rendered irreducible by the lymph elfused into the cavity of the sac. The author has practised this operation in thirteen different cases, in but one of which was there any peritoneal soreness developed that excited the slightest apprehension, and in this case it subsided under the application of leeches and fomenta- tions. In several of these cases a single operation appeared to be perfectly successful. In others—where liie sac was larger, or the patient was less careful in keeping the truss steadily applied during the first week, or from a cautiousness in introducing in the first cases a more limited amomit of fluid — the cfl'ect was merely to narrow the sac, rendering a repetition of the process neces- sary for the cure. Of the permanency of the cure, during several years after the operation, the author is unable to speak, most of the patients operated on being temporary residents of the Phila- delphia Hospital, and passing after a few months beyond the reach of inquiry. While under the cognisance of the author, they were employed without a truss as labourers on the farm attached to the institution, and in no one of the cases, during this period, had the hernial tumour recurred. It would, however, be but a proper measure of precaution to direct the truss to be worn subsequeiuly for several moiuhs, in order to confirm the cure. The greater number of these operations were performed by the author eight years ago, before classes of students at the Phila- delphia Hospital, but as he was able to trace the future history of the cases but for a few months only, they were not deemed of snflicient importance for publication. Very recently M. Velpeau has published a process almost precisely the same as that just described. 3. Process of Bonnet. (PI. LVII. fig. 1, A.)— Two to four ordinary pins an inch and a half long, and twice the number of hemispherical rolls of linen about the size of the end of the finger, ! constitute all the aj)paratns required. Each i)in is to be pushed up to its head through one of these rolls of linen, so as to leave the rounded part of the latter prcseniing towards the point. The hernia is to be carefully reduced. The surgeon then grasps the integuments and the sac with the thumb and fore finger just below the external ring, so as to allow tiie cord to rise up in the circle formed by the grasp of these two digits, and passes a pin across below the envelopes of the sac, entering it on the margin of the ihunib nail near tlie suspensory ligament of ilie penis. The point which projects through ihe skin on the other side of the fold is to be passed through a second roll of linen, the convex edge of whicli looks towards the first. The two rolls are then pressed as lightly as possible towards each other, and the point of the pin 284 SPECIAL OPERATIONS. twisted in a spiral form to keep them in place. The surgeon next grasps the integuments in the saaie manner just above the margin of the external ring, so as to press the cord down upon the first pin, and passes the second piu across in front of (he cord, hut parallel with the first. It is to be secured precisely as the first pin. It will seldom be found necessary to apply more than two pins. They give rise on the fourth day to considerable pain and soreness, and are to be withdrawn some time between the sixth PLATE LYIIL— SURGICAL ANATOMY OF HERNIA. {Figs. 1,2.) OBLIQUE INGUINAL HERNIA IN THE MALE. Fig, 2. — A dissection has been made, so as to exhibit the different coverings of the tumour. a. a. Flaps of the skin and superficial fascia, reverted. h, b. Aponeurotic tendon of the external oblique muscle, a portion of which has been excised over the track of the inguinal canal. The edge of it (6, forming the external abdominal ring, is left undisturbed, and is seen dividing as it were the tumour into two portions—one of which is lodged in the scrotum, and the other in the inguinal canal. The muscular fibres immediately below this, at the top of the inguinal canal, and which have been in part removed, belong to the internal oblique and transversalis muscles. c, c. Cremaster muscle, a portion of which is removed in front of the tumour, and appears connected at the top with the origin of the internal oblique from Poupart's ligament. d, d. Section of the covering of the hernia in the region of the scrotum. e, e. Hernial sac, the front portion of which iias been removed to bring into view the small intestine andt he fold of the omentum (/) covering the intestine. Between the sac and the cremaster is another thin layer, which is the infundibular fascia from the internal ring. The intercolumnar fascia from the columns of the external ring has been removed. This, which is very thin, with the cremaster and the infundibular fascia, make the coat called the tunica vaginalis communis. Between the cut edge of the sac and the divided margin of the internal oblique and transversalis muscles, is seen a portion of the transversalis fascia forming the internal abdominal ring. h. Epigastric artery and veins, the direction of which, towards the rectus muscle, is shown by tiie removal of the soft parts above it. Fig, I. — Interior of the same sac, after the removal of the viscera. g. Femoral artery and vein. h. h. Epigastric artery, showing ihe direction of this vessel between the two rings and behind the canal. i. External abdominal ring, greatly dilated. ky k. The upper of these references points to the internal abdominal ring; the lower to the inguinal canal, the length of which has been diminished by the lowering of the internal ring under the weight of the hernial protrusion. m. Scrotal portion of the sac. The vessels, which are faintly seen lying behind the sac, belong to the spermatic cord. {Figs. 3, 4.) CRURAL HERNIA IN THE FEMALE. Fig. 3.— The covering of the hernia! sac has been turned off in flaps. The crural canal is shown entire; the sac of peritoneum, which has been pushed through it, has been opened merely at its superficial or subcutaneous portion. (7, a. Flaps of the skin and superficial fascia, turned off by a T incision. b. Edge of Poupart's ligament. c. Anterior portion of the sheath of the vessels. d. d. Hernial sac, opened at the top and reverted upon the sides. e. A knuckle of small intestine, and a portion of omentum, seen lodged in the crural ring. Fig. 4.— Interior of the sac in crural hernia, shown without the intestine or omentum. To make this exhibition, it has been necessary, in consequence of the depth at which the passage is placed, to remove the fascia lata and all the front covering of the hernia, c. Edge of the fascia lata, from which a portion has been removed. d. Section of the sheatli of the vessels. / Crural ring, through whicli the protrusion had taken place. g. Pouch of the sac, formed in (he sheath of the vessels. h. Point where the hernial sac has been pushed out by dilating the orifice in Ihe sheath of the vessels for the internal saphena vein, £, k. Femoral artery and vein. /. Internal saphena vein, surroimded by some lymphatic glands. PlafeSS. Fig. ^. OPERATIONS UPON THE ABDOMEN. 285 and twelfth day, when sufficient inflamination has been exciiecl, and the skin begins to ulcerate under tlie pressui'e. This process has been found at the end of three or four weeks to have com- pletely obliterated the external ring. M. Mayor, of LEiusaime, has substituted double waxed threads for the pins, though with- out any particular advantage. 4. Process of M. Gerdy. (PI. LVII. fi- 1, B.)— The appa- ratus required in the process of this surgeon is a long curved needle with an eye near the point; some sections of quills, or a bougie, for three quilled sutures; a vial of concentrated ammonia, and six double ligatures. The surgeon pushes with the fore finger the skin at the top of the scrotum through the external ring into the inguinal canal, but in front of the spermatic cord. Tiie long needle charged with a doable thread is carried along the finger up to the top of the cul-de-sac, and passed through so as lo come out upon the abdominal surface of the sidn, traversing the two thicknesses of skin and the anterior wall of the inguinal canal which is included between them. One end of the double ligature is now drawn out from the eye of t!ie needle and secured. The needle is then retracted from the wound, and passed a second time through the tissue by a new puncture, so as to come out at a place about half au inch distant from the first, carrying with it the other end of the double thread, which is now to be detached from the eye. The needle is then finally withdrawn. The inverted fold of skin is now kept in the canal by the loop of ligature just passed, which is to be secured as shown in tlie drawing over the barrels of a couple of quills, as in the ordinary quilled suture. Two other quilled sutures are applied in like manner — one at the internal and one at the external side of the first, but at the distance at least of half an inch apart. The cuticle of the inverted skin is now to be destroyed by reiterated applications of a pledget steeped in caustic ammonia, with the object of causing the opposite surfaces of the pouch to suppurate, and unite by granulation. The skin may now be excised from the margin of the cul-de-sac, and a flap of integument raised from the neighbouring parts, fastened by suture over the base of the cavity, as shown in the drawing. The sutures are to be removed between the sixth and eighth days. 5. Process of Dr. Jameson, of Baltimore. — This gentleman reports an instance of success in a case of crural hernia, in which he laid open the sac, and inserted into the orifice of the crural ring a flap of integument raised from the surrounding parts, and which was kept in position by the suture with which the external wound was closed. This plan of plngging up the outlet of a hernial tumour with a portion of skin, which, if it becomes adherent, must be converted into a species of cellular tissue, cannot possibly be very efficacious; for almost every surgeon must have been convinced by experi- ence, that even a large mass of inflamed and adherent omentum left in the cavity of the sac, after the operation for strangulated hernia, is but seldom found to prevent the redevelopment of the iiernial tumour, 6. Scurificaiion. Process of Velpeau. (PI. LVII. fig. 6.) — The old process of scarification has been revived by this surgeon. Tlie mode of its performance will be well understood by reference to the drawing. 7. Process of M. Belmas. (PI. LVII. figs. 2, 3, 4, 5.)— The process of this surgeon as last modified, consists in the introduc- tion into the cavity of the sac, as near as possible to the external ring, of narrow strips of gelatine, which are to be left in the sac for the purpose of exciting inflammation. They are said subse- quently to dissolve and disappear by absorption. The mode of performing the operation is fully explained in the reference to the plate. It is not, however, believed to ofl'er so fair a prospect of success as the process of M. Gerdy. OF PARTICULAR FORMS OF HERNIA. INGUINAL HERNIA. There are two forms of inguinal hernia, which have been dis- tinguished as the oblique and direct; the former of these is by far most frequently observed. Surgical anatomy. — In oblique inguinal hernia, the displaced parts escape by the passage called the inguinal canal, while this as yet nearly preserves its normal form, and its proper anatomical relations with the surrounding parts; but when it has been long subjected lo the weight and bulk of the hernial tumour, certain modifications of its structure are made, that it is absolutely ne- cessary should be well understood by the surgeon. It will be proper, therefore, to study the lieallhy structure of the canal, as well as lo note the changes produced in it by the long continued action of the hernial protrusion. Of the inguinal canal of the male. — This canal is from an inch and a half to two inches long, and traiismits the sper- matic cord. It pierces the abdominal walls in an oblique direc- tion from above downward and inward. The upper orifice or commencement of the passage is found on the inner face of the parietes, nearly at the middle point of a line, drawn from the anterior superior spinous process of the ilium to the spine of the pubis. The termination or inferior orifice of the canal is found immediately below the integuments at the outer side of the body of the pubis. The wall of the abdomen through which this oblique canal runs, is at this point somewhat complicaied in its structure. The boundary line between the abdomen and the top of the thigh, consists of a strong fibrous cord, known as Poupart's ligament or the crural arch,* which is tensely stretched between the anterior superior spine of the ilium and the spine of the pubic bone. A portion of the upper surface of this arch is grooved so as to form the floor or inferior portion of the ingui- nal canal. The internal lateral boundary of this inguinal region may be considered as formed by the rectus muscle of the same side, which is extended in the middle line between the pubis and the sternum. Between the outer edge of the rectus muscle and the obliquely placed ligament of Poupart, is the proper inguinal region, which is of a triangular form with the apex at the outer side of the body of the pubis and the base opening upwards and outwards. This space is closed by the inferior portions of the three broad abdominal muscles, and the transversalis fascia. Thi: aponeurotic tendon of the great oblique muscle as it descends downwards and inwards, is connected with the whole length of • For ihe salce of greater clearness in Ihe anatomical description of the parts, which must necessarily be brief, Poupart's ligament is represented as a separate cord, and not as it is usually considered, merely the lower edge of the aponeurotic tendon of the external oblique muscle. SS6 SPECIAL OPERATIONS. Poupart's ligament. As the sheet of tendon approaches the pubis, it splits so as to leave an elliptical or rather ovoidal open- ing—the larger end of the ovoid being formed by the body of the pubis, and its two sides by the margins of the tendon forming the split. The space formed by this split, though having the ovoidal shape as above mentioned, is the external abdominal ring. The margins of the split constitute ihe pillars or columns of the ring, the inferior one of which terminates upon the spine and crest of the pubis in close conjunction with the proper fibres of Poupart's ligament, and the superior or internal crosses over the symphysis so as to decussate with its fellow of the opposite side. The outer and upper extremity of the ring is crossed by the intercolumnar fibres, which are affixed in front of the apo- neurosis, and have for their object that of strengthening tl]e bond of union between the columns, so as to keep them from diverging and enlarging the ring. The iimer termination of the aj)oneu- rotic tendon of the external oblique muscle is upon the linea alba, where it meets the corresponding muscle of the other side. But for the existence of the ring formed by this split of the apo- neurosis, there would have been no opening by which the sper- matic cord could have passed in its route to the scrotum. On turning down this aponeurosis, we find immediately below it the lower edge of the internal oblique and transversalis muscles. These, beside their more extensive origin from the sides of the abdomen, arise in part from Poupart's ligament, to have the same general hisertion into the linea alba and the spine and crest of the pubis. If they had taken their origin from the whole length of Poupart's ligament, the cord could not have escaped except by a split in their muscular fibres, which, if such had been the case, would have been likely by their contraction to have impaired tlie function of the cord. Such a result is obviated by the fibres of these muscles taking their rise from the outer half of the ligament, and passing round in an arcii which is con- cave downwards, so as to leave a passage for the cord between iheir concave edge and the ligament of Poupart below. The arclies of the two are muscular where they cross in front of the cord ill the space between the rings, but soon afterwards they form a common or conjoined tendon, which curves round to be inserted upon the spine and crest of the pu^is, under the lower end of the inguinal canal and behind the external abdominal ring. This peculiar arrangement of the muscles appears admirably adapted for the purpose of preventing under ordinary circum- stances the occurrence of hernia at this region, the fleshy belly of the arch resting over and in front of the internal abdominal ring, and the conjoined tendon giving strength to the wall behind the external ring. On removing these muscles, we have next brought into view the transversalis fascia which lines the inner surface of the muscle of that name, and runs down to be con- tinuous with the whole inner border of Poupart's ligament. On the front of this membrane lies the spermatic cord in the whole length of the inguinal canal. The internal ring by which the cord gets from the abdomen into the canal, consists of an opening in this membrane of a semilunar shape, which is concave at its inner side. On this concave edge, sometimes called the internal pillar of this ring, which is sharp, resisting, and in some instances becomes the seat of stricture, rests the cord as it enters the canal. Tliis ring, in the healthy state of the parts, is closed behind by the peritoneum. If now we turn down the fascia transversalis, we find the peritoneum everywhere behind it — a layer of cellular tissue merely separating the two, in which the ditferent consti- tuents of the cord run. The epigastric artery, which comes off from t!ie femoral, runs up also in a direction nearly vertical through this cellular tissue behind the transversalis fascia, cross- ing behind the inguinal canal and between the rings, but rather nearer to the internal than to the external. In this cellular layer may also be observed the umbilical ligament, the remains of the umbilical artery of the fcetus. As the epigastric artery crosses between the rings in its ascent to the rectus muscle, it raises the peritonenm in a fold. On either side of this fold there is a fossa; the outer one of the two fossK is opposilc to the orifice of the internal ring; and the inner immediately behind the external ring but separated from it by the conjoined tendon of the internal oblique and transversalis muscles. These inguinal fossellcs, as they are called, are only obvious when a flap of the abdominal wall is turned down. Through the outer one of these, pushing the peritoneal lining before it, passes the intestine or omentum in the proper oblique inguinal hernia. Through the internal one, which is found between the epigastric artery and the umbilical ligament, the organs escape in that variety — called direct or ventro-inguinal hernia, from the route traversed being direct and not oblique like the passage of the proper inguinal canal. The inguinal canal, which lodges the spermatic cord, has then, as will be seen from the above brief description, for its floor the groove in the upper part of Poupart's ligament; for its anterior boundary, the aponeurotic tendon of the external oblique; for its posterior, the transversalis fascia; and is in addition, at its upper part, overhung or overlapped by the flesiiy edges of the internal oblique and transversalis muscles. The internal ring, the edges of these muscles, and the upper column of the external ring, as well as the thickened and plaited neck of the sac, are the points which may become the seat of stricture in oblique inguinal hernia. If we examine the cord, we shall find that as it passes through Ihc canal, it gets several coverings— 1st, from the internal ring, a tubular or fiinnel-shaped prolongation of cellular tissue, (called iiifLtndibiilar fascia or fascia propria^ which follows it down to tiie scrotum; 2, from the edge of the internal oblique, a covering of muscular fibres (the cremaster) which passes down on the outer face of the last, and surrounds the testicle; 3, a cellular fascia similar to the first, extended downwards from the column of the external ring, over the face of t!ie cremaster, and called the inter- columnar fascia. These three coverings are intimately connected together, and though susceptible of separation in the healthy state and in recent hernia, are nevertheless in old cases matted together, and known then under the name of tunica vaginalis communis. After the cord leaves the external abdominal ring, it is, in addi- tion to these parts, covered with the ordinary superficial fascia which extends down with it into the scrotum where it is some- what modified in its structure and takes the name of dartos muscle. The hernial tumour is usually found on the front and outer side of the cord. The epigastric artery will be found at the inner side of the neck of the sac. In direct inguinal hernia, or, as it is sometimes called, ventro- ingninal hernia, the protrusion takes place directly behind the OPERATIONS UPON TflE ABDOMEN. 287 external ring, and pushes before it the peritoneum, transversalis fascia and conjoined tendon, tlirongh the orifice of the external ring. The resistance made by the conjoined tendon is so great, that this form of hernia rarely attains mucli bullc, except, as now and then happens, the viscera slip under the concave edge of the tendon, and pass out at the external ring. The coverings of this form of hernia will then be, with the exception of the infundi- bular fascia, nearly the same as in the oblique inguinal. The hernial tumour usually descends on the front and inner side of the cord. In this form of hernia, the epigastric artery will of course be found to the outer side of the neck of the sac. The ingitiiial canal iji the fcetus, lodges till near the seventh month of intra-uterine life, nothing but the fibrous structure, called the giibernaculum testis, provided for the purpose of drawing down the testicle, which, prior to this period, is lodged in the abdomen below the kidney, and covered in front by the peritoneum. Toward the period of birth, the testicle is gradually drawn down through the caiml into the scrotum, bringing witli it a process of the peritoneum; so that when this change has taken place, the canal contains all the parts common to the adult, with a cylindrical prolongation of the peritoneum in addition. The cavity of the peritoneum at the externa! ring is usually found closed at birth; and the tubular process extending to the testicle is ordi- narily completely obliterated during the first month after birth — the fibrous structure of the gubernaculum becoming, as shown by Mr. Curling, the cremaster muscle. When the closure of the tabular passage does not take place by the adhesion of the peri- toneal surfaces and the conversion of the membrane into cellular tissue, the vaginal pouch of the testicle communicates by a free passage with the cavity of the abdomen, through which a hernial protrusion may take place, the viscera passing down into the vaginal tunic of the scrotum, and lying in immediate contact with the testicle. As this passage has naturally a tendency to become obliterated, the application of a truss is almost always, even when a hernia has descended in the child so as to have been the means of keeping the canal patulous, successful in accomplishing its closure. STRANGULATED IKGUINAL HERNIA. When the hernial tumour becomes strangulated, it is attended not only with suffering of more or less severity, but with great and immediate danger, and calls for prompt and decided mea- sures of relief on (he part of the surgeon, These consist, 1st, in an attempt to reduce the protruded viscera by a process called the taxis; and 2d, in an operation for the division of the part •which is the cause of strangulation, 1. Of reduction by tlie iaxl^. — The first object of the surgeon is of course, when practicable, lo effect reduction without resort- ing to the use of the knife. The manipulation by the taxis has been briefly described as follows by Professor Syme.** "The patient should be laid reclining, with his shoulders and pelvis slightly elevated, to relax the parietes of the abdomen; and with the same intention, the thigh of the affected side should be bent upwards and inwards, as the facia lata is thus pre- vented from causing any tension of the abdominal fascia to which Principles of Surgery, London, 1842, pp. 312-314. it is connected. The hernial tumour is then lo be grasped at its neck, and compressed with llie points of the finger and llmnib, which at the same time pull it slightly outwards. The size of the parts at the ring having been thus diminished, the pressure is to be directed gently but steadily upwards, in the direction of the inguinal canal. When, in consequence of this proceeding, the slightest gurgle is heard or felt, or the size of the swelling is perceptibly diminished, the reduction, in general, may be very soon completed. The larger the hernia is, the more may be expected from this manipulation, and vice vci-sa. There is almost always some serous effusion into the cavity of the sac, and in small tumours, especially those of recent production with acute symptoms, the bulk of the fluid hears a large proportion to that of the intestine or omentum. External pressure, consequently, however carefully employed, cannot possibly have its effect con- fined to the neck or any other portion of the strangulated parts, since, through the medium of the fluid, its force must be dilfiised over the whole surface, and therefore urge the entire mass against the narrow aperture by which it is required to return. While circumstances are thus opposed to the beneficial influence of pres- sure from without, it is obvious that the small size of the proh'u- sion, which is often not larger than the point of the finger, and seldom exceeds that of a walnut in most cases, will afford little resistance to an efl'ort in the opposite direction. It accordingly often happens that after the taxis has failed, the tumour suddenly and, as it seems, spontaneously disappears, no doubt through the operation of some internal change in the condition of the bowels or omentum. "Sncli being the case, in the event of the taxis failing, it is obviously proper to use means that may produce some efl'ect of the kind requisite for toithdrawi/ig the protruded parts into the abdominal cavity. Of these may be mentioned a change of posture, by elevating the pelvis and bending the shoulders back- wards, in order to make a drag on the strangulated viscera — the administration of enemata to evacuate the intestines, and thus lessen the resistance to return — bleeding largely (o diminish the contractile tone of the muscular fibres — using the warm bath with the same view — and in addition to it also employing opium or tobacco. The application of cold externally, and the internal use of tartrate of antimony, or purgatives, are means occasionally resorted to, but with more questionable advantage. "The choice of means for the purpose of promoting reduction must be determined by the circumstances of the case. When the patient is strong or plethoric, it will always be right, in the first instance, to abstract a considerable quantity of blood. Repeated injections, or the warm bath, if it can be procured, should also be constantly employed. In regard to tobacco it is necessary to be cautious, lest too great depression be induced by its use, so as to render the patient unable to bear an operation in the event of this measure proving necessary. The safest plan is to inject ten or twelve grains infused in an English pint of water, and I'epeat this if it seems requisite. The bovvels having been thus, if pos- sible, unloaded, and the spasmodic tension of the abdonjinal muscles, which is caused by the irritation of the disease, and reacts injuriously upon it by tightening the fascia; which produce the stricture, having been subdued or diminished, the taxis is again to be tried. If a patient and careful trial of it should fail. SPECIAL OPERATIONS. ill [h'3 more favourable circumstances that now exist, tlie surgeon musi tliinlc of removing the resistance by dividing the stricture witli the knife. It is difficult to determine how long the opera- tion may be safely deferred, as inflammation and gangrene su- pervene much more quickly in some cases than in others. The best course is to operate so soon as a fair trial has been given without success to the taxis, and the measures which promote it, especially bleeding, and the warm bath if it can be procured. It should be recollected, 1. That the danger of the operation itself is very inconsiderable; and that, consequently, the patient should not, for fear of incnrring it, be subjected to the greater risk, or rather almost certainty, of a fatal issue, which attends the disease when allowed to follow in iis course. 2. That the progress of the bad consequences is usually rapid, in proportion as the hernia is small, recent, and tense. 3. That in small recent hernias there is least advantage to be expected from waiting. 4. That in large hernias, strangulated in consequence of congestion, there is most assistance to be looked for from the continued use of purgatives and injections. 5. That the operation is attended with least danger in cases where the tumour is small and recent; and with most where it is large and of old standing." Ope7'ciiio7i for Inguinal Hernia. In the operation for strangulated inguinal hernia, the patient is to be placed on the right side of his bed, wiiii his chest and thighs elevated, or as is more commonly preferred by English and American surgeons, on the foot or side of the bed, with his thighs flexed, and his feet resting upon a couple of stools— the surgeon taking his position between the limbs of the patient. The operation is divided into five periods: — 1. The incision of the skin. 2. That of the layers between the skin and the sac. 3. The opening of the sac. 4. The division of the stricture; and 5. The reduction of the protruded viscera. Whether the opera- tion be for the oblique, direct, or congenital form of inguinal hernia, it will correspond in so many respects with that given below for the first of these varieties, that the modifications requi- site will, from what has been already said in reference to each form of the afiection, be readily understood without a special description. , 1. Incision of the sJdn. — The parts are, if they require it, to be carefully shaved. The incision may be made through the skin, over the axis of the tumour, from above downwards, or by raising a fold and dividing it from within outwards, as directed at page 12. The incision should always commence three quar- ters of an inch at least above the top of the tumour, in order that we may expose clearly the opening of the canal. If the hernia is one of the interstitial class, that is confined to the canal, it should extend also for about the same distance below the externa! ring; if scrotal, it should at least be from three to four inches in length. 2. Incision of the layers between the skin and the sac. — This part of the operation is to be executed with particular care. These layers, if the surgeon is sure of his hand, may be divided from above downwards with light strokes of the knife. But as a general rule,* it will be found safer and more expeditious to * II has already been observed, that from ilie agglutination of parts, produced by the effect of pressure on the coverings of the hernia, the number of distinct separable layers will vary in different cases of hernia — the infundibular fascia. raise up with the forceps the distinct tunics one by one at the lower end of the line of incision, open them by a horizontal puncture with the knife, through the opening thus made introduce a grooved director, and on this slit them up one after another the whole length of the external wound, until the surface of the sac and tlie tendon of the external oblique muscle above the ring become fully exposed. The arteria ad cutem abdominis and some branches of the external pudic vessels, will be divided in the section of the superficial fascia, and may require to be tied. The mode of proceeding will now vary according as the hernia is interstitial — confined between the two rings — or ingnino-scro- tal — extending through the canal into the scrotum, which is the form most commonly met with in practice. In the interstitial variety, the tendon of the external oblique is to be divided ou the director, which is to be introduced upwards from the external ring, or if found more convenient from above downwards through a puncture made at the top of the wound. This lays bare the sac for opening, which will be seen crossed by some of the fibres of the internal oblique and transversalis muscles, and covered by the thin infundibular fascia. In inguino-scrotal hernia, the sac may be at once opened up to the external ring, the necessity of any division of the aponeurosis of the external oblique being subsequently determined by the point at which the stricture is found. 3. Opening of the sere— In very many instances this will be found so adherent to the coverings on its outer face, that it must be raised up with them and divided on the director. The author has very frequently, when the general coverings of the hernia have been thin and adherent together, and especially in operations for inguinal henna in the female, after the section of the skin, penetrated at once by a cautious horizontal cut of a fold raised by the forceps into the cavity of the sac, and by introducing the director and lifting the parts well upwards so as to see that none of the viscera were raised, slit up all the remaining coats of the tumour at one stroke with the knife. But as a general rule, the surgeon must proceed cautiously and leave the sac as a last covering to be separately opened. This must especially be the practice in case the subcutaneous layers are found loaded with fat, contain enlarged or suppurating lymphatic glands, cysts resulting from an old hernial tumour, or any of the various com- plications which may occur at this region. Sometimes the mass of subcutaneous fat may be so great and so deeply placed as to cause a suspicion that it may be formed by the otuentum, which had become prominent in consequence of a breach in the sac itself Under such circumstances, the surgeon is to tear through a portion of its structure with the point of the director, for the purpose of determining with certainty the character of the parts which lie immediately behind it. In some rare instances, espe- cially in direct inguinal hernia, the cord has been found pushed in front of the sac, and occasionally even with its different con- stituents spread out in the form of a sheet. In all instances, therefore, where anomalous appearances present, the surgeon is to proceed with especial caution, raising every separate layer on the director, and examining it with the eye and by the touch before the cremaster muscle, and the intercolumnar fascia, usually forming one coat in old hernia;, called the tunica vaginalis communis. OPERATIONS UPON THE ABDOMEN. 289 applying the knife, in order to avoid the risk of injury to the pro- truded viscera, or the wounding of the spermatic arteries or dnct. The sac, when exposed on its outer surface, will be recognized by its smooth and shining appearance and the dark colour of the bowel seen though it, and will usually in this form of hernia be found to contain a considerable quantity of serum. If the case is one of congenital hernia, the sac will be formed by the tunica vaginalis, and the fluid collected will be analogous in its position to that of an ordinary hydrocele. The sac if thin and yielding may be opened as practised by Dr. Ilarishorne of this city, by embracing the back part of the tumour with the fingers of the two hands, and lacerating it in front by pressure in opposite directions with the ends of the thumbs, lu ordinary cases it answers best to elevate a fold with the forceps or the thumb and finger, and open it by a puncture as directed for the other cover- ings. The opening should be made a little to the outer part of the axis of the tumour — and llie membrane divided on the director upwards to the ring, and downwards sufficiently far to expose the contents of the tumour and prevent the formation of a pouch for the lodgment of pus. On the division of the sac, the bulk of the intestine rises up and appears greatly increased in vohmie. The protruded parts are now to be carefully examined. If ihey are united by soft and recent adhesions, the union may be broken with the finger; if by firmer filaments of old formation, divided with a pair of scissors: but if the viscera are rendered adherent to the sac by broad firm bands of attachment, the surgeon is to proceed, without disturbing them, lo the next step, which is that of determining the seat of strangulation. To effect tliis the sur- geon draws, if possible, gently outwards all the intestine lodged in the inguinal canal; but in doing this the greatest care must be exercised to employ only the slightest degree of traction, for fear of lacerating the bowel and causing an effusion of its contents, especially if the strangulation has been such as to be likely to have caused softening or gangrene. If the parts yield to the ellbrl, but go back again with a slight elastic rebound, the stricture is seated at the neck of the sac. If this does not take place, and the external ring is free, the stricture will be almost always found at the internal ring, it being but in rare instances formed by the edge of the internal oblique and transversalis muscles. If the stricture is at the external ring, which may be ascertained by the examination of that orifice with the finger nail, the bowei cannot be drawn out without a previous division of the ring. If, as sometimes happens, the strangulation is made by an accidental band of adhesion in the cavity of the sac, this becomes obvious in unfolding the part. If the viscera are free in the sac, the left fore finger with its back towards them, should be carried up under the front wall of the sac, for the purpose of ascertaining the pre- cise seat of strangulation, and the end of the finger, or at least tlie nail, insinuated under the stricture. 4. Division of the stricture. — On the palmer surface of the finger we now pass up flatlings a probe-pointed bistoury, which should be wrapped with a waxed thread, or a strip of adhesive plaster, to witliin half an inch of the point; or, which is much preferable, the probe-pointed hernia bistoury of Sir A. Cooper, which has a cutting edge of little more than half an inch in length. The probe point of the instrument is then to be insinuated under the stricturing baud, and the instrument turned with its edge 73 directly upwards, as shown at Plate LIX. fig. 2. The surgeon now, partly by rocking the point of the bistoury upwards and partly by pressing with the finger, nicks the resisting parts. As the border gives way, it allows the finger to be freely introduced, over which the orifice may then be safely enlarged to the requi- site extent with the instrument. If the stricture is at the neck of the sac, and to the inner side of the internal ring, it should, as directed by Sir A. Cooper, be drawn somewhat down by an assis- tant who for that purpose grasps the opened sides of the sac with a couple of pairs of forceps, in order to render its division with the knife more safe — another assistant at the same time raising the abdominal wall at the top of the incision. If the stricture is at the internal ring or the neck of the sac, and so narrow that neither the finger, which has to be passed under the anterior wall of the canal to reach it, nor the finger nail can be got between it and the bowel, more difliculty will attend its division. It is not advisable in scrotal hernia to slit upwards the orifice of the external ring for the purpose of ex- posing the deeper-seated parts, as this would increase greatly the difficnhy of retaining the hernia in place after reduction, when it is possible lo accomplish the division safely without. It may, however, occasionally be found necessary to enlarge the external ring even when it is not the seat of stricture, so as to admit the free examination of the part at the neck of the sac. In these cases of extreme tigiitness, it has been recommended to introduce a grooved director below the stricture, and divide the band with a probe-pointed bistoury passed along the groove. This cannot, however, be safely done in parts that are not exposed to view, as the intestine may bulge up and come in contact with the edge of the knife. The author prefers greatly in these cases, first to carry up the finger to the point of stricture, then slide over the finger the connnon spatula of the dressing case, which is to be insinu- ated between the intestine and the stricturing band. The pro- truded intestine should now be held down by an assistant, and the handle of the spatula will sufficiently protect the intestine to admit the introduction of the probe-pointed bistoury for the pur- pose of dividing the stricture. But in case the stricture is at the top of a long canal, even with this precaution the operation would be attended with risk of injury to the bowel, and it may become necessaryto incise the whole length of the anterior wall of the canal on a director. The division of the stricture, at what- ever point it is found, is always to be made in this form of hernia directly upwards, as directed by Sir A. Cooper, as this gives sufli- cient space for the return of the viscera, does not endanger the cord, and is in a course nearly parallel with the epigastric artery — of Ihe relative position of which vessel to the stricture we can- not, as has before been mentioned, be always positively certain. An incision of the stricture that will allow the finger to move freely in the passage, answers for the return of the protruded parts when they are not unusually bulky. An incision of the stricture for the sixth or the fourth of an inch in extent will usually suffice for this object, If greater space is required, it is considered safer, on account of the oblique course of the epigas- tric artery, to gain it by two, three, or more separate small inci- sions on the outer and inner margins of the stricturing band. 5. lieduction of the viscera. — It now remains to examine the condition of the viscus at the slrictured point, and return it, if 290 SPECIAL OPERATIONS. found in a suitable condition, into the cavity of the abdomen. For this purpose, if it is a case of entero-epiplocele, the omentum is to be turned off and the intestine gently drawn down. This enables us not only to examine the intestine at the point at which it is most liable to have suftered, but to diminish the tension at the protruded part by giving greater space for the difiusion of its contents, and thus facilitate the process of reduction. If the viscera admit of being at once reduced, the intestine is to be returned before the omentum, nearly as in the ordinary process for the taxis. It is to be gently compressed between the palms, to cause its gaseous contents to pass into the cavity of the abdo- men. The blood from the surface is then to be carefully wiped away. If the loop is small, it may be supported by the three first fingers of the hand, and pressed up through the ring, follow- ing it with the fore finger even into the abdominal cavity. If it is large, considerable difficulty will sometimes occur in its reduc_ tion. The walls of the abdomen should be relaxed as much as possible, and the surgeon, securing one end of the loop with the three first fingers of the left hand, introduces the other end, por- tion by portion, completely into the cavity of the abdomen with the index finger. The omentum should next be reduced. No attempt is to be made to return the sac. The wound is to be closed with a few sutures, passed merely through the integument and supported by adhesive straps. Lint spread with cerate, a stout compress, and a spica bandage, complete the dressing. The patient is to be kept carefully iu bed during the cure, with the thighs and thorax flexed, and must on no account be allowed to rise for the purpose of defecation, for fear of reproducing the hernia. If the intestine is found gangrenous to a limited extent, the affected portion should be retained at a level with the ring; PLATE LII.— OPERATIONS FOR STRANGULATED HERNIA. {Figs. 1,2.) STRANGULATED OBLIQUE INGUINAL HERNIA. Fig. 1. — Ope/ling of the sac. — The integument, superficial fascia, and turiica vaginalis communis, are laid open so as to expose the sac covering the protruded viscera, and a portion of the tendon of the external oblique muscle. At the period of the operation shown, the surgeon lifts a fold of the peritoneal sac from off the surface of the intestine, and punctures it with the knife held llatlings. Fig. 2.— Division of the siricture.—The sac has been opened its whole length on the director, and the point of the fore finger passed over the fold of the bowel, is insinuated under the edge of the external ring. Over the pulpy surface of the finger (a) is passed the back of the ordinary probe-pointed bistoury (6), for the purpose of dividing the stricture which is here supposed to be at the external abdominal ring. If the stricture is seated at the internal ring, or at the neck of the sac, the process for its division is the same, except that the hernia bistoury of Cooper (D) should be employed. But if the ordinary probe-poiiued bistoury is used in place of that of Cooper, it should be wrapped down to near its end with a waxed thread or a strip of adhesive plaster. (Figs. 3,4, 5.) STRANGULATED CRURAL HERNIA. Fig. 3. — Opejting of the sac. — The integument and superficial fascia have been opened by a T incision. The sac has been incised so as to expose the fold of intestine and omentum. The opening in the sheath of the vessels [a, a), which is here supposed to be the seat of stricture, has been dilated with the probe-pointed bistoury over the end of the finger, in order to relieve the strangulation. The lower end of the peritoneal pouch is shown on the point of being laid open with the bistoury [b) over the finger (c), so as to leave no cul-de-sac for the retention of the secretions during the cure. Figs, 4, 6.~Division of the. stricture by different processes, when the strangulation takes place at the ligament of Gimbernat, Key's ligament, or the neck of the sac. Fig. A.—e. Division of the edge of Gimberuat's ligament, Hey's ligament, the inner edge of the sheath of the vessels, or the neck of the sac, in the usual direction, upwards and inwards toward the umbilicus. The end of the finger (with its back surface toward the contents of the tumour) is inserted carefully under the edge of the stricture and along this is slid flatlings the probe-pointed bistoury of Cooper. As soon as the bistoury has passed below the stricture, its edge is turned upwards and inwards for the purpose of dividing it. ' f. Process of Pott for dividing with his curved bistoury the inner end of the crural arch directly upwards. g. Process of Sharp for its division obliquely upwards and outwards. This is attended with risk of cutting the femoral vein. Fig. 5. — h. Process of Sabatier for the division of the stricture upward and inwards. i. Process of Dupuytren for dividing the ligament of Gimbernat obliquely upwards and outwards, by an incision from the exterior with a convex bistoury. k. Process for dividing the stricture on a grooved director, which is to be entered by an incision through the upper part of Gimbernat's ligament, and brought out through the orifice of the crura] ring. /, /, /. Several small incisions, as in the process of Scarpa, for enlarging the orifice of the crural ring. OPERATIONS UPON THE ABDOMEN. 291 and the orifice left after tlie detacliment of the slough may in favourable cases be found to close spontaneously in the course of a few weeks. If the gangrene extends to a considerable part of the caliber of the intestine, or involves an entire loop, the bowel must be left unreduced, and a portion of its heallhy structure brought to the border of the ring. If the omentum is found gan- grenous, it is to be excised — the course to be pursued in regard to it being precisely the same as that already mentioned in reference to wounds of the abdomen, with strangulation of this structure. If, after the operation for stricture, the hernia is found irredu- cible in consequence of broad adhesions, which cannot be dis- sected up without danger of doing injury to the intestine, it is, even if in nowise affected with gangrene, to be left in place, the integuments brought together over it, and the wound merely covered with a pledget spread with cerate. It might under such circumstances be expected that an additional portion of the intes- tine would be liable to escape, but such has not been found by experience to be the result. For if the function of tfie boweisbe restored after the division of the stricture, and the patient be kept rigidly to the horizontal posture, the amount of the protrusion will gradually diminish, and the parts may even in the end be gradually withdrawn into the cavity of the abdomen. The same practice is also ordinarily to be pursued in case the caput cscum lias been forced down and for some time retained in the tumour, wiien, so far as the experience of the author goes, it will be found too firmly adherent to allow of its immediate reduction. When the tumour is very large, and known to be habitually irreducible, the exposure of its contents to the air, by laying open the whole of its coverings, will, as remarked by Sir A. Cooper, be attended with danger. In such cases, the practice recom- mended by this distinguished surgeon is to make a small incision over the neck of the tumour, and divide the stricture, leaving the viscera in place. The same practice has been adopted, especially by some Neapolitan surgeons, as a general rule for all hernial tumours without distinction, with the exception that they immediately return the vicera into the abdomen provided they are found redu- cible. A most serious objection to the practice is, however, the uncertainty in which the surgeon must remain in regard to the condition of the organs, as the narrow wound could scarcely give sufficient room for their thorough examination. Another process employed in small recent herniae, amenable to the same objection, consists in the reduction of the tumour, sac and all, after the division of the stricture on the outer side of the sac, and without the opening of its coverings. This practice was resorted to by Petit and Mom'o, and has lately been strenuously advocated by Mr. Key and Mr. Luke, of the London Hospital. It has not, however, received the general sanction of the profes- sion, though Mr. Fergnsson and M. Velpeau deem it worthy of more consideration than it has yet met with. CRURAL OR FEMORAL HERNIA. Surgical anatomy.— \\\ this form of hernia the protrusion takes place below Pouparl^s ligament, through an opening called the crural ring. It has been already observed, in the description of the parts concerned in inguinal hernia, that Poupart's ligament is stretched from the anterior superior spine of the ilium to the spine and crest of the pubis, forming an arch over the concave front surface of the os innominatum. In its connection with crural hernia, it is important to have more particularly in view that portion of the ligament which is attached to the spine of the pubis, and for about three quarters of an inch to the crest of this bone, which forms a part of the linea ilio-pectinea. That de- pendency or reflection from the lower edge of Poupart's ligament, which arches down along the crest in a direction slightly back- wards and inwards, has received the name of Gimbernat, and presents a sharp concave edge which looks outwards towards the iliac vein. This concave edge forms the inner boundary of the crural ring. To ascertain what forms the outer edge of the ring, it will be necessary only to examine the parts which fill up the greater portion of the space between the concave face of the OS innominatum and Poupart's ligament. Commencing from the spine of the ilium, we find the space included between the outer half of Poupart's ligament and the outer half of the concave face of the bone below it, completely filled up by the psoas magnns and iliacus internus muscles, as they make their way in a com- mon musculo-tendinons mass downwards and inwards to their insertion on the trochanter minor of the thigh bone. The inner edge of this common tendon slopes onwards towards Gimbernat's ligament, so as to cover the pectineal protuberance, on which sloping edge rest the iliac artery and vein as they pass into a long triangular fossa at the top of the thigh, the base of which is formed by the inner half of Poupart's ligament. As the walls of the vein (which is placed immediately to the inner side of the artery) are but little resistant, and liable to be compressed by the yielding of Poupart's ligament to the traction of the muscles inserted upon it, a space has been left between its inner margin and the edge of Gimbernat's ligament. This space is crossed by some loose cellular tissue, called the crural septum by Cloquet, and fascia propria by Cooper — is pierced by the ascending ab- sorbent vessels, lodges one or two smalt lymphatic glands — and constitutes the proper crural ring. It is on the average about half an inch in diameter, and from the peculiar arrangement of the fascia, constitutes the only point at which the viscera can pro- trude in crural or femoral hernia. The fascia ihaca which covers the abdominal face of the iliac muscle, is continuous over the linea ilio-pectinea with the pelvic fascia, and extends downwards towards the top of the thigh to get a firm attachment between the spine of the pubis and the anterior superior spinous process of the ilium. In the outer half of this space it is connected with Poupart's ligament, which it firmly binds down upon the surface of the psoas magnus and iliacus tendon. In the inner half of this space it cannot, in consequence of being placed behind the iliac vessels, reach the ligament; it is accordingly reflected along the sloping inner surface of the muscles and the concave face of the bone up to the edge of Gimbernai's ligament, and is con- tinued down behind the vessels upon the thigh so as to make the posterior half of their sheath. The transversalis fascia, which, as has already been shown in the surgical anatomy of inguinal hernia, is connected to the inner edge of the whole length of Poupart's ligament, is in contact with the iliac fascia both at the outer margin of the artery and at the outer edge of Gimbernat's ligament, and is continued likewise down, but in front of the vessels, so as to form their anterior half of the sheath. Between 293 SPECIAL OPERATIONS. these two fasciae a partition passes across between the artery and vein. As the sheath of the vessels fortned by these two fascias is connected to the edge of Gimbernat's ligament, it must necessarily include the crural ring, and cause the hernia when it escapes by this opening to pass down into the sheath of the vessels. The sheath, which is larger on the side of the ab- domen than is necessary to embrace the vessels, is gradually narrowed so that at the distance of an inch and a half below Poupart's ligament — where the internal saphena penetrates its anterior wall to open into the femoral vein — it is found capable merely of embracing the artery and vein, and becoming like the ordinary sheaths which surround the vessels. It must necessarily be funnel-shaped in its form. Over the orifice of this funnel is spread the ordinary peritoneal lining of the abdomen, which, when a hernial proirnsion occurs, is necessarily pushed before the viscera as far as they can freely descend — which is to the end of the funnel — the place of entry of the saphena vein. If the viscera are suhjected to fnrther protrusion, as they cannot readily dilate the sheath of the vessels below this point, they widen the orifice made for the saphena vein or one of those for the passage of the large absorbent trunks in the anterior wall of the sheath, so as to escape through its opening. This orifice when dilated is sometimes, though improperly, spoken of as the accidental crural ring. The passage between this opening and the proper crural ring may with propriety be designated the crural canal. There is one part more that requires notice on the side of the abdomen, and that is the arrangement of the arteries. When these have their normal origin, none of them are placed in danger from the operation in this form of hernia, unless the inci- sion of the stricture be made of unnecessary length, or in the up- ward and outward direction towards the trunk of the epigastric. But occasionally — about once in six limes according to M. Bour- gery — the epigastric artery, instead of arising from the femoral, comes off from the obturator and winds over the passage of the crural ring as it goes to take its position on the abdominal mus- cles, so as to be placed over the neck of the sac; — or the obturator comes off from the epigastric, and occupies as it runs towards its foramen the same position in relation to the neck of the sac. Under either of these circumstances the vessel, in the division of the stricture at the neck of the sac, would, unless care was exer- cised, be more or less in danger of injury. If we examine the parts on the surface of the thigh below Poupart's ligament, we find the crural canal and the viscera which it lodges in hernia placed deeply below several layers in the triangular fossa before spoken of, the walls of which are at this point formed between the pectineus muscle, which runs from the body of the pubic bone outwards and downwards — and the common tendon of the psoas magnus and iliacns muscles, which runs downwards and inwards — these two parts being placed at the corresponding margins of the sheath of the vessels. If we begin toith the deeper seated of these coverings of the thigh, we find first the strong membrane called the fascia lata, which serves as an aponeurosis to embrace tightly the muscles, and is connected to all the bony margins of the pelvis, and to the inner and lower face of the ligament of Poupart and Gimbernat so as to keep in check the tendency of tlie abdominal muscles to draw the crural arch upwards. This fascia is simply spread cir- cularly over the surface of the muscles of the thigh up to the point about an inch and a half below Poupart's ligament, where the great saphena vein, which ascends on the external surface of the fascia, empties into the femoral. The arrangement of the fascia is here more complex for the purpose of giving to the vein a pas- sage sufficiently free to prevent its becoming constricted. Imme- diately under the place where the saphena vein turns inwards to the femoral, the fascia lata splits into two portions with a semi- circular edge, concave upwards, at the place of division. The inner one of these two portions is called the pectineal, as it covers that muscle up to the crest of the pubis, where it is attached at the place of insertion of Gimbernat's ligament. The outer por- tion, called the sartorial, continues at its place of separation from the pectineal the sweep of the semicircular curve formed under the saphena vein, so as to cross over the front part of the sheath of the vessels in a falciform or crescentic fold, in order to get its attachment along the inner edge of Poupart's and Gimbernat's ligaments, at the latter of which it again becomes continuous with the pectineal portion. The concavity of this falciform or crescentic process presents downwards and inwards. The inner end of it, which becomes narrow as it follows round the con- cave or outer edge of Gimbernat's ligament to join the pectineal fascia, crosses necessarily the crural ring, and presents a cutting edge downwards and backwards, which is adherent to the sheaih of the vessels. This thin prolongation of the crescentic process is considered one of the seats of stricture, and is known as Hey's ligament. From this description it will be seen that a sort of oval opening is formed on the inner and front side of the sheath of the vessels, by the separation of the fascia at the saphena vein, and their subsequent union at the point of insertion on Gimbernat's liga- ment and the crest of the pubis. Through this opening the her- nial protrusion makes its way, and becomes more superficial after it has dilated the saphenous orifice in the sheath of the vessels, pushing before it a thin cellular layer which is found spread between the opposite edges of the two portions of the fascia lata, and is enumerated as one of the coverings of hernia under the name of the cribriform fascia.* Over the fascia lata, and across the oval orifice formed in it, is spread the superficial fascia. This is frequently found loaded with fat, and is formed of two layers, between which are lodged the superficial lymphatic glands of the groin. The outer layer of this fascia is directly continnons with the superficial fascia of the abdomen; the other is attached to the inner edge of Poupart's and Gimbernat's ligaments, and lines the vertical fold which constitutes Hey's ligament, with which it is sometimes thickened in cases of strangulated hernia. In crural hernia, the viscera as they protrude push the perito- neum and the crural septum before them, first get into the crural ring between the edge of Gimbernat's ligament and the vein, then pass under the edge of the ligament, then under that of Hey's ligament, which is immediately adjoining the former, but still more sharp and prominent; and if stricture does not now take • The sartorial and pectineal portion of the fascia lata will also be found to be continuous with each other, behind the sheath of the vessels, by a thin layer which covers the tendon of the iliacus and psoas muscles, and is closely adherent to llie posterior part of ihe sheath. This part, however, is not concerned in the operation. OPERATIONS UPON THE ABDOMEN. 293 place, pass down the crural canal, and turning at a right angle in its course, dilate the orifice for the saphena vein, and raising up as its covering the cribriform fascia, the superficial fascia, and the skin. If the protrusion should be extended further, as observed in some old cases of hernia, it separates the superficial fascia from the fascia lata— in the direction in wiiich tlie connection is most loose towards the anterior superior spinous process of the ilium, so as to form a tumour overlapping Poupart's ligament. In doing this it may, after pushing outwards the cribriform fascia, dilate one of the openings by which the absorbents traverse this layer, and form a long sac divided into two cavities at the point where it is girdled by the fascia. Two cases of this description have occurred to me in operations on the living subject during the past year— one of which was performed during the last winter before the class of the Jefferson Medical College at the Philadelphia Hospital, and the other on a patient of Dr. Franklin, of this city. In both these instances the cysts or cavities of the sac— the etfect of previous protrusions — were filled with fluid, a small knuckle or loop of intestine being found strangulated by a thickened mass of omentum which had partly blocked up the ring. But the cutting edge formed by the septum between the cysts — a point of pathology that has not escaped the observation of Sir A. Cooper — was such as to show that it might readily, had the intestine passed through it, have been made the seat of stricture. Treatment of Crural Hernia. The reduction of the tumour in this form of hernia is to be attempted by the application of the taxis, very much as has already been described for inguinal hernia. It will, however, be necessary to recollect the circuitous route by which the viscera escape, and make the pressure first downwards to pass them through the opening in the sheath of the vessels, and then up- wards in the direction of the crural canal. A small knuckle of intestine, not larger than a hickory nut, is sometimes strangulated at the seat of the crural ring; this, when the patient is obese, it may be very diihcult to detect, If, with the rational signs of strangulation not relieved by the ordinary internal treatment, there is pain and soreness on pressure over the crural ring, though no distmct tumour is apparent, there is probably a hernia, and it will be the duty of the surgeon to cut down to determine the question. Even if with the prevalence of these symptoms, there should be merely a greater fulness of the region of one groin than the other, though no soreness or pain be developed on pres- sure, he will still be justified in making an examination with the knife— an operation of itself unattended with danger when pro- perly performed— as cases of fatal strangulation have, under such circumstances, been known to occur, one of which has come within the knowledge of the author. The general rule applied in strangulated hernia, that the smaller the parts protruded the greater is the danger of the early development of gangrene, is especially applicable to the crural form of the affection. Operation for Sb-angulated Crural Hernia. In many of its details, the operation for this form of hernia will correspond with that just described. It will, therefore, only be necessary to point out its peculiarities. A simple incision of the skin, made obliquely downwards in the axis of the tumour, 71 will usually suffice. If the hernia is of large size, this incision may, though I have rarely found it requisite, be crossed at its lower end by another, so as to convert it into a J_ reversed. In some instances a crucial incision has been employed, for the pur- pose of more readily uncovering the viscera, and facilitating the access to the stricture. The fascia snperficialis, which will often be found thick and loaded with fat and enlarged glands, is to be opened on the director to the same extent and in the same direc- tions as the skin. The fascia propria* is usually the layer which next comes into view; it is formed by the crural septum, which has been forced down before the sac, is moulded exactly upon the form of the latter, and is so thin and transparent that it might be mistaken for the sac itself, especially as the latter in this form of hernia is rarely distended with much serum, and is often coated on its outer surface with a layer of fatty matter, that has some resemblance to the omentum. The operator will, therefore, be required to examine closely in reference to cases of this descrip- tion, for if an attempt be made to divide the stricture on the outer side of this membrane, and thus reduce the sac without opening it — a process even more objectionable in crural than inguinal hernia — the stricture, if it had been formed as is some- times the case in the neck of the sac itself, or in the crural sep- tum, would be left undivided after the reduction of the viscera. In case the strangulation of a small hernial tumour of recent formation had taken place before it had dilated the opening in the sheath of the vessels, we would have the siieath as a third covering to divide before reaching the sac.t After the division of the fascia propria, we fall usually upon the sac; this is to be opened with great precaution on the direc- tor, by a simple longitudinal slit. The fore finger is now to be carried up towards tlie abdomen, to ascertain the seat of strangu- lation. If it is found in the dilated orifice of the sheath of the vessels, (the accidental crural ring, as it has been called,) its com- parative superficial position enables the operator readily to recog- nize it. If it is at the neck of the sac, at Gimbernat's ligament, or at Hey's ligament, or at that part of the sheath of the vessels immediately below Hey's ligament, where the sheath is thickened by a vertical fold of the superficial fascia, its precise seat is more difficult of detection, and is by no means important, as the same process for division is required in all, provided the cut be made from the interior of the sac. The mode of division at the orifice in the sheath of the vessels (accidental crural ring) is very simple, and is shown completed at Plate LIX. fig. 3. Even when a stricture has been found and divided at this place, it is necessary to carry up the finger • The cribrirorm fascia -will in most instances be found so blended -with the superficial, that it cannot be recognized in the operation as a distinct layer f In an operation which I have performed, since the printing of these sheets, on a patient of Dr. Wills, at Downingtown in this state, the strangulation of a small knuckle of intestine had taken place without the dilatation of the orifice in the sheath of the vessels, and the fascia propria was recognizable as a distinct layer over the sheath. The seat of the stricture was found just below Gimber- naf s ligament, and was rendered very accessible to the knife by drawing the sac downwards with a couple of pairs of forceps — a measure which will, in many of the cases where the patient is obese, he found highly advantageous. The liga- ment of Gimbernat was found less developed than usual, and of course without its usual reflection backwards, which is intended as the natural barrier against hernial protrusions at this place. \ 294 SPECIAL OPERATIONS. beyond it to ascertain whether or not there is a second narrowing at the cniral ring. In doing tliis, I have found on two occasions the bowel to slip at once into the cavity of the abdomen, showing conclusively that no stricture had existed at that point. In a great majority of cases it is, however, at this place that the stric- ture will be found, A variety of processes have been devised for the relief of the strangulation at this point. That which is most generally ap- proved of is shown at Plate LIX. fig. 4, e. The left fore finger is to be carried np in front of the viscera, and the endj or at least the nail, inserted under the stricture. An assistant now holds the bowel down, and the surgeon carries up a probe-pointed bistoury (that of Cooper being preferred) flatlings over the finger, engages the probe point under the stricture, then turns the cutting edge upwards and inwards in the direction of the umbihcus, and presses the knife with the finger till the resisting part yields, which usually gives way with a creaking sound, as in the division of a piece of parchment. A slight cut will usually suffice for the introduction of the finger in the ring; the bistoury should then be withdrawn. The surgeon now ascertains if the passage is sufficiently free to admit the finger to move freely, and allow of the return of the bowel without the employment of such pressure as would subject it to contusion. If not, his next object of inves- tigation is to determine whether there is the anomalous distribu- tion of the arteries round the neck of the sac, which has been described at page 292. If none is met with, the bistoury is to be introduced as before, and a further division of the stricture made. An incision to the extent of a quarter of an inch is much greater than usually required, and is the most that under almost any circumstances can be needed. If, on the introduction of the finger, the artery should be found throbbing round the margin of the ring, that point should be selected for the division of the stricture at which the artery is most distant, and it will be well, instead of a single incision, to gain the requisite space by nicking the border of the ring at several points, as shown at Plate LIX. fig. 5, /, according to the process of Richter and Scarpa. Whilst this work has been passing through the press, the author has operated in a case of old crural hernia, in which, after the division of a first stricture near the ring, another was detected apparently at the neck of the sac, in front of which a large artery could be felt pulsating round the anterior two-thirds of the ring, and equally near it at all points. The plan pursued was to blunt the edge of the bistoury by rubbing it with the forceps, wrapping it down with a wax thread, so as to leave a cutting surface of not more than a fourth of an inch in length, and proceeding with great caution, and without any sawing motion, in the division of the stricture upwards and inwards, pushing in the finger at the same time so as to keep the vessel elevated above the edge of the knife. In this way the division was safely effected without injury of the artery, and the patient made a rapid recovery. It appears to the author that this course would in most instances be found to answer where the vessel surrounds the ring, for the artery, which lies somewhat loose in the sub-peritoneal cellular tissue, is disposed to give way before the dulled edge of a knife, ■whilst the stricturing band is so firm as to receive the whole action of the instrument; and it is perhaps from this tendency to slip before the knife, that, notwithstanding the frequency _of the anomaly, the artery in this operation has been so seldom cut. In such cases it might answer well to resort to the practice of Le- blanc, which has been advocated by Malgaigne in all instances of stricture at the neck of the sac in crural hernia — that of dilating tlie orifice by pushing in, in front of the intestine, the small end of the ordinary spatula blunted on the edge, and rupturing the resisting band by pressing strongly on the circumference of the orifice. Various other plans have been devised for the division of the stricture in crural hernia. Pott practised the division of the crural arch directly upwards, as shown at Plate LIX. fig. 4, f. Sharp, its division obliquely upwards and outwards, (fig. 4, g.) Saha- tier, upwards and inwards, (fig. 5, h.) Dupuytren, upwards and outwards, (fig. 5, z',) with a curved probe-pointed bistoury cutting on its convex edge, tiie incision being made from above down- wards; and Scarpa, Boyer, and Lawrence following very nearly ilie method of Gimbernat, direct the incision to be made inwards upon the edge of Gimbernat's ligament, in a direction nearly parallel with the horizontal branch of the pubis. Sir A. Cooper rejected the process of Gimbernat, which ac- cording to him is not only difficult of execution from the depth at which it is performed, but exposes the intestine to a risk of laceration in the traction outwards that on account of the nar- rowness of the passage must necessarily be made to get room for the bistoury, and especially when a conductor, which is always deemed requisite, is employed, whether that be a finger, a grooved director, or a spatula. The space gained by it he also deemed in- sufficient in cases of large hernial protrusions. After having laid the sac open up to the sheath of the vessels, this surgeon intro- duced his finger in front of the viscera, and divided the sheath on its inner side up to the crural arch. If this was not found sufficient to permit the return of the viscera, he either divided simply the posterior edge of the ligament, or made a puncture through the upper part of Gimbernat's ligament, and introduced a grooved director from the opening through the crural ring, upon which the ligament was divided with the knife. This latter process, however, is complicated, and weakens the aponeurosis of the great oblique. Cases may however occur, in which this process, or some one analogous to it, will be found the most ap- propriate. One of this kind occurred in the wards of Professor Dunglison, and was operated on by the author in the winter of 1832-3. The hernia was of long standing, and had been ill- supported by a truss. A thick mass of omentum was found firmly adherent round the inner margin of a large crural ring, and to the front portion of the sheath in its vicinity, so as to leave within its girth a narrow orifice, in which a small loop of intestine had become strangulated. On laying open the sac, it was found impossible to divide the stricture without cutting through a thick mass of omentum, or dissecting it off from its firm attachment to the neck of the sac. It was deemed better to divide the stricture on the outer side of the sac, puncturing it at its edge of reflection from Poupart's ligament, so as to introduce the end of a probe-pointed bistoury. The nail of the left fore finger was then engaged between the sac and the resisting bands above it, and the edge of Gimbernat's ligament and Key's ligament cau- tiously divided close npon the finger nail. The intestine was then returned— but the omentum, in consequence of its firm ad- OPERATIONS UPON THE ABDOMEN. 295 hesion, was left in place. As a general rule of practice, how- ever, it will be found better to excise the omenlnm, especially if it be thickened and hardened, tying such vessels as bleed, than to leave it in place. The management of the viscera after relief from strangulation in crural hernia, and the subsequent dressing and treatment, are to be conducted on the same principles as after the operation for inguinal hernia, and will require no particular description here. UMBILICAL HERNIA. Surgical anatomy. — UmbiHcal hernia [omphalocele, exom- phalos) escapes sometimes by the umbilical ring, but more fre- quently at a weakened point in the linea alba, at a little distance below or above it. The hernia of the linea alba is the name ■which has been sometimes ajiplied to this latter variety. In the fcctus the umbilical ring is a nearly circular orifice, through which run the vein and arteries of the umbilical cord, and the urachus, a fibrous band which extends from the ring to the top of the bladder. When this opening is examined from the side of the abdomen, the peritoneum is seen to dip into it so as to form a sort of pouch. If at the same time some traction outwards is made on the cord, the pouch will be deepened so as to take the form of a funnel, the base of which opens into the abdominal cavity. After the separation of the cord, a solid cicatrix is usually found at the extremity of the obliterated um- bilical vessels, at the point at which they had passed through the umbilical opening or ring. If this solid obliteration of the pas- sage is tardily effected, and the child is fretful, one of the bowels is liable to protrude at the opening, constituting that form of umbilical hernia which is distinguished as the congenital. But when the tumour in umbilical hernia is developed subsequently to the solid closure of the passage, it is found to escape more fre- quently by a rupture through a weakened point of the linea alba just above or below the ring, than at the ring itself. When it takes place at the ring in an adult, or at any time subsequent to the closure of this opening, it dilates the centre or the side of the cicatrix, and may separate the cords formed by the obliterated vessels and the urachus, and carry them out with it — the tumour expanding in the intervals between them so as to have a lobulated appearance, and be covered merely by a thin peritoneal layer and by the cuticular investment of the cicatrix. More commonly the cords will be found adherent together, and the viscera have protruded between them and one of the margins of the ring. The author has met with a case in which an opening had been dilated on either side of the cord formed by the union of the umbilical arteries and the urachus, so that a loop of intestine which had escaped through one orifice and passed back into the cavity through the other, had become fatally strangulated over the inter- mediate vertical band. The causes which give rise to umbilical hernia, and the mode in which the protrusion takes place, correspond in general so much with those already described in reference to other forms of hernia, that it is not necessary to describe them here with parti- cular minuteness. Coveriiig of umbilical hernia. — It was formerly believed that there was in umbilical hernia no proper peritoneal sac. But the existence of the sac may always be discovered by careful exami- j nation. The author has often noticed it distinct and well formed in small hernial protrusions round the umbilicus, and has been enabled to detect it in large protrusions, though it is there found merely as a thin serous facing to the fibrous tissues on its outer aspect. The peritoneum in the neighbourhood of the umbilicus is far more closely connected to the parts which it lines than at the inguinal or crural regions, and in consequence of this the sac can only be formed in large hernia by the excessive expansion of a small peritoneal pouch. The fascia superficialis and the skin form the two principal tunics in this form of hernia. In obese subjects — especially in women, who are more prone to this affec- tion than men — a thick layer of fat will be found below the skin, masking the tumour, preventing its development forwards, and causing it to spread out as a rounded and somewhat flattened mass, which renders the detection of the hernia somewhat diffi- cult. Fatal strangulation now and then occurs under such cir- cumstances, undetected save by a post-mortem examination, and it will be well for the practitioner to examine closely into the condition of the parts at the umbilicus, in females labouring under hernial symptoms without any apparent cause observable in the crural or inguinal regions. The reduction of the hernia in its early stages of development, is readily effected by the ordinary process of the taxis, and the ring after the return of the bowel should be kept steadily closed by a proper umbilical truss. In the congenital form of the affection, the application of the truss, or even that of a section of a small ivory or gum elastic ball, or half a nutmeg so commonly employed by nurses, fastened upon the part with adhesive plaster and sustained with a body bandage, may be relied upon to effect a permanent cure — the parts at the ring having, as in congenital inguinal hernia, a natural tendency to cicatrization. The facility with which a radical cure can be accomplished in this way, renders unnecessary, at least in most instances, the ligature of the sac by crossing its root with a pin and surrounding it with a thread, a process which is sometimes, especially when the sac is long and tubular, successfully em- ployed for this purpose. In ail herniaj of large size the viscera are mostly, so far as the observation of the author extends, more or less adherent, so as to be rendered irreducible, and will require to be supported by a truss with a hollow pad or a properly con- structed girdle. Character of the viscera protruded. — In the congenital form of hernia, a knuckle of the small intestine is ordinarily alone found bulging through the ring. In the umbilical hernia of the adult, there is in almost every case a protrusion of the omentum, with or without a portion of the small intestine, the omentum lying in front of the bowel. Operation for Strangulated Umbilical Hernia. This, which is sometimes demanded, though less frequently than in the other forms of hernia, is practised in the following manner. A simple longitudinal incision, when the tumour is small, is to be made over its top; or a crucial or T incision if large over its neck. The skin is usually so tensely stretched, that it cannot be raised up in a fold and divided from the base. The incision is to be made from above downwards, and with extreme caution, in consequence of the usual thinness of the envelopes, the absence of any fluid in the sac, and the impossibiliiy of sepa- 296 SPECIAL OPERATIONS. rating the sac as a distinct layer. The first object encountered after the division of the tunics is the omentum. ' This is to be unfolded and the condition of the parts at the ring carefully examined, for even though no intestine be apparent in the body of the sac, a loop may be compressed at the margin of the ring, or even through an orifice in the omentum, or by the ligament- ous cord formed by the obliterated vessels, as in the case above noticed. It sometimes happens that the mere unfolding of the omentum for this purpose, relieves the intestine by efiecting a change in its position, so that it may be reduced without the necessity of dividing the stricture. When it is necessary to use the knife, the division of the stric- ture should be made upwards and to the left, for the purpose of avoiding the umbilical vein in infants, and the great lobe of the liver in the adult. A small incision will usually suffice. The in- testine is to be reduced first, as it has been the last part to escape. The after-treatment of the case will be precisely the same as that already given for "wounds of the abdomen with protrusion of the viscera." If the hernial tumour is large, and known to be irreducible, an incision should be made at its neck, of sufficient size only to allow of a safe division of the stricturing parts, in order to avoid the irritation which might arise from the exposure of a large mass of viscera to the action of the air. VIII. OPERATIONS UPON THE ANUS AND RECTUM. The diseases of this region, which require operations for their relief, are very numerous;— those described here consist of Imperforation of the Anus; Polypous Tumours of the Rectum; Prolapsus of the Mucous Membrane of the Rectum ; Invagination of the Rectum; Cancer of the Rectum; Haemorrhoids; Abscess by the side of the Rectum; Fistula in Ano; Fissure; and Stric- ture of the Anus. OF IMPERFORATE ANUS. (PL. LX. Fio. 2.) The imperforation of the anus arises from a defective develop- ment of the lower part of the rectum. This may consist, 1st, merely in the closure of the external orifice by a thin livid-coloured membrane, through which the dark hue of the meconium can be observed; 2c!, of the complete fleshy closure of the anus, the natu- ral hollow at this part of the peritoneum being filled out evenly with the surrounding skin, the rectum terminating in a blind pouch half an inch to an inch above the surface; 3d, the rectum may be developed only at its upper end, or altogether deficient, the colon terminating in a cul-de-sac attached to the promontory of the sacrum; 4th, the rectum may have an unnatural outlet, opening into the bladder, urethra, or vagina; and 5th, the rectum, though the proper external orifice exist, may be found closed some little distance above by a transverse membranous septum. 1. Of the membranous closure of the anus. — Happily the first variety is the one which is most frequently met with. It requires but simple treatment. A crucial incision is to be made through the membrane so as to discharge the meconium. The angirlar flaps thus formed are to be excised, and the new passage pre- served patulous by the daily introduction of the finger previously oiled. The employment of bougies and catheters for this purpose, as is commonly practised, is not unattended with danger, in con- sequence of the soft and delicate organization of the mucous membrane of the bowel at this early age. If the transverse septum forming tlie fifth variety is found obstructing the passage at some distance from the orifice, it is to be divided in a similar manner by a crucial cut, but the bistoury should be wrapped with a thread to near the end and cautiously carried into the passage on a groove director. I have succeeded in one instance, after puncturing the septum, in dividing it readily and safely with Cooper's hernia bistoury. Either of these instrii- menls are safer and more efficient than the trocar or pharyngo- lome, which have been recommended for this object. It will be found useful after the division of the membrane in this form of the affection, to introduce a mesh well oiled into the passage, which should be secured to a thread attached to one end, and fastened to the skin of the buttocks by adhesive plaster. 2. Of the complete fleshy closure or congenital deficiency of the anus. — If no trace of an outer orifice is found, the operation becomes more difficult and uncertain. If any, even an indistinct fluctuation of the meconium can be felt, it may however be un- dertaken with considerable prospect of success, and the surgeon, even when this is not the case, will under some circumstances be justified in cutting in the direction of the canal. A sound may be introduced into the urethra to determine the direction of the passage; this is a measure, however, especially in male children, sometimes difficult to accomplish, and is not absolutely necessary. The following process has been successfully employed by the author upon a female infant. Ordinary pj'ocess. — The child is to be placed as in the lateral operation for stone. A longitudinal incision of an inch and a quarter in length is to be made just in front of the os coccygis, traversing the point for the natural outlet of the anus. This is to be crossed at its anterior end by a horizontal incision, so as to allow the formation of two flaps, which are to be reverted out- wards by the fingers of an assistant. The longitudinal incision is then deepened little by little, introducing from time to time the fore finger of the left hand, to ascertain the position of the vagina or bladder, to feel for the fluctuation in the pouch of the rectum, and to serve as a guide to the knife. When the point of the rectum is exposed, it is to be opened by a crucial incision, and the meconium discharged. The freedom of the new passage is to be maintained by dilatation with a mesh of lint. Pj-ocess of t/imussat. — This surgeon has been successful in reaching the rectum when it had terminated in a female child two inches from the surface. After making the incision of the integuments as above directed, he ruptured with his finger the cellular tissue between the vagina, the coccyx, and the sacrum, using the knife only to divide the stronger bands. A sound placed in the vagina served to show the direction of that passage, and prevent its being injured. The end of the rectum when found, was seized with a double hook and drawn downwards, the surgeon loosening its attachment with his finger, applying the knife but upon one side — that next the vagina where the adhesions were OPERATIONS UPON THE ANUS AND RECTUM. 297 more firm and required great care in tlieir division. A double ligature was passed with a needle Ihrougli the pouch as soon as it was brought sufficiently low, by means of which and the hook the intestine was brought down through the new opening to the level of the skin. The pouch was then opened by a longitudinal incision, and the two edges fastened to the corresponding lips of skin by five or six points of sntnre, to prevent the ftecat matters escaping into the cellular tissue between the mucous membrane and the skin. If the operator should altogether fail to detect the end of the rectum, he will be justified — as death must inevitably follow unless the obstruction of the bowel be removed — as a last resort, to pass np a trocar a little space further in the presumed direction of the bowel, and if he does not succeed in finding the bowe!, recui', as has been several times practised latterly, to the establishment of an artificial anus in the left ilium or Inuibar region. In cases where the blind end of the rectum could not be detected in the wound of the perineum, it has been recommended by Mr. Martin, but not to the knowledge of the author carried into practice, to open the sigmoid flexure of the colon by the process of Little, and carry from the cavity of the bowel a probe or a sharp-pointed stilet down towards the anus. 3. The rectum opening by an abnormal orifice in the urinary passages or vagina. — If the rectum opens into the bladder or urethra it will form a kind of cloaca, as in birds, a malformation readily detected in consequence of the urine being tinged with the greenish meconium. This kind of malformation is most fre- quently observed in male children, and the operatioti for its relief is attended with some difficulty and danger. In females the abnormal passage generally opens into the vagina, aud an operation for the establishment of the natural route may be "attempted with better prospect of success. It is not, however, in this sex unattended with danger, aud it would in many cases be more prudent to desist from all active proceeding, inasmuch as in many instances, some of which have come under the observa- tion of the anthor, individuals have grown up to womanhood without any great apparent inconvenience, and been capable of bearing children — the circular fibres around the vaginal orifice of the intestine exercising perfectly the office of a sphincter muscle. But in case the infant should suffer from the insufficient size of the passage, or from other causes it be deemed prudent to remedy the deformity, the attempt may be made in the following manner, A bent grooved director is to be passed from the vaginal aperture into the rectum, and from the natural site of the anus a trocar or sharp-pointed bistoury thrust through the soft parts so as to strike the groove. The opening thus gained should be kept pervious and enlarged by dilatation. If it be found ditficuli to accomplish the latter object, it has been recommended to slit open upon the director the whole wall intervening between the abnormal and regular ana! orifice. After this division of the parts, no farther dressing will be required save the daily introduction of an oiled finger to keep the aperture open, and there is a prospect that the edges of the anterior margin of the wound may unite, so as ulti- mately to render the vagina perfect. Dieffenbach.in a case where the rectum terminated in the vagina, entered the knife imme- diately below the fossa navicularis, but outside of the vagina, into the groove of a director introduced from above, and without opening the rectum any farther, divided all the cellular and mus- 75 cular tissue between the point of the first punctnre and the os coccygis. He then dissected oS the rectum from the preternatural aperture, and detached it for some distance from the surrounding parts, so as to be able to draw downwards the end of the bowel, and attach it by a few sutures to the margins of the outer incision. The cut edge of the rectum united to the skin, and the fistulous openmg in the vagina closed after being touched once with lunar caustic. He afterwards formed in the same case an artificial perineum, by detaching the rectum still farther from the vagina, and fastening the soft parts between by two short hare-lip pins. If the rectum opens into the urethra, either in male or female children, a similar plan is to be followed. A sound is first intro- duced into the bladder, or if possible through the abnormal orifice into the rectum, and so directed that it may be felt from the perineum. An incision is then made upon it from near the os coccygis, and the rectum disaected off from the fistulous aperture, in order that it may be pulled out and fastened to the outer wound. The same method of operation has been practised by Mr. Fer- gusson when the rectum opens into the bladder, but the formation of an artificial anus by one of the following methods of operation will afford a better prospect of saving the life of the child. 4. Formation of an artificial anits. — This is rendered neces- sary when the rectum terminates in the lumbar region, and may be resorted to under the circumstances jnst noted. The method has also been employed by Dr. Wm. Ashmead of this city, and M. Amnssat of Paris,* in cases of adnlts, where the rectum or sigmoid flexure of the colon has been rendered impervious by stricture, or by a degeneration of structure not susceptible of relief by other measures of treatment. By the process of Little. Opening of the front part of the sigmoid flexure of the colon. — The infant is to be placed on the back, with its thighs held in the extended position. An oblique incision an inch and a half to two inches long is to be made on the left side, parallel with and a little above Poupart's ligament; the different layers of the abdominal walls, as well as the perito- neum, are to be divided in succession. The sigmoid flexure of the colon presents itself in the gap, of a livid hue from the meco- nium with which it will be found distended. The intestine is to be opened in the direction of the wound, and maintained attached to the skin by a ligature passed through its mesenteric folds. At the end of three or four days the intestine becomes adherent to the margin of the wound, when the thread may be removed. Process of Pillore. Opening of the front part of the ciecum. — This is, in fact — except as regards Ibe intestine opened, and the operation being on the right side— the same as the process just described. The lips of the incision in the coecum are to be fastened by several points of suture to the margins of the divided skin. Process of Callisen, Opening of the descending colon from the lumbar region, and without dicision of the peritoiieum. — This surgeon directed the incision to be made between the last rib and the crest of the ilium, immediately over the external or anterior edge of the quadratus luraborura muscle. In this direc- tion there are no vessels to be opened that will require ligature, • The date of tlie first of the two operations performed by Dr. Ashmead, was amecedem to the first of the sis which have been reported by M. Amnssat. The results of this operation in tlie adult have been by no means flattering. 29S SPECIAL OPERATIONS. as the tendons of the broad muscles of the abdomen merely are cut, and the surgeon falls upon the cellular space behind the colon, where this bowel is, especially in the adult, left to a certain extent uncovered by the peritoneum. The bowel is to be opened, and the edges fastened to the cutaneous incision, as in the process of Pillore. In infants, however, it is not unusual to find the colon floating, and surrounded by peritoneum like one of the small intestines. Under such circumstances the peritoneum would ne- cessarily have to be opened, and the operation would present but little advantage over that of Little. The process of Dr. Jlshmead, applied to the adult, is nearly the same as that of Callisen. The process of ^^mnssat '* is the same as that of Callisen, with the exception that the external wound is directed more trans- versely, so as to divide the fleshy bellies of the abdominal muscles. In the exhibition to my class of the various modes of forming an artificial anus on the dead body, the process of this surgeon has appeared to me entitled to a preference over the rest. It may be practised upon the left or right side, according to the site of the obstruction. The patient is to be placed so as to rest upon his knees and elbows, and a little inclined upon one side, in order to present uppermost the region of the loins, upon which the opera- tion is to be performed. An incision is to be made midway be- tween the last rib and the crest of the ilium, parallel with the ■ M^moire sur la Possibility d'Etablir un Anus Artificielle, &c. crest, commencing opposite the outer edge of the sacro-lumbalis muscle. The incision is to be extended down so as to divide the posterior margin of the three broad muscles of the abdomen, and the anterior portion of the latissimus dorsi and quadralus lumbo- rum. At the back part of the wound will be found the layer of fat which is extended downwards from the kidney, and at the front part the parietal peritoneum, through which may be discovered the small intestines. By tearing the fatty matter at the posterior third of the wound with the point of the director, the cellular extra-peritoneal surface of the colon is exposed, through which a couple of threads are to be passed with a needle in order to draw it to the middle of the external wound. The intestine is then to be seized with the forceps, and opened by a crucial incision with the bistoury, while an assistant separates with his fingers the lips of the external wound. The margin of the intestine is next to be fastened by four hare-!ip sutures to the surface of the skin in the middle tract of the wound, for the purpose of prevent- ing the escape of fiecal matters into the loose cellular tissue of the region of the colon. The other portions of the external incision are to be closed with hare-lip sutures, in order to eifect union by first intention. POLYPOUS TUMOURS OF THE RECTUM. (PL. LX. Fig. 1.) Tumours of this description are but rarely observed. When met with, they present the regular pyriform shape of tumours of this class, and are soft, smooth, and spongy. They may be simple PLATE LX.— OPERATIONS UPON THE RECTUM, Fig. 1. — Ligahire of a polypous tumour of the rectum. — The dilatation of the rectum is made with the two- branched fenestrated speculum of Charriere. The polypus is drawn down with a blunt hook, so as to allow the ligature to be thrown around its ueck. The ligature is to be tightened either with an ordinary double canula, or with a serre-nosud, as shown in the drawing. Fig. 3. — Fxcision of several folds of the integument at the circumference of the anus, for prolapsus of the bowel. (Pi'ocess of Dxipiiytren.) — A fold of the skin is siiown raised with a pair of forceps, so as to be readily snipped away with a pair of scissors curved on the flat. Three of the folds have been previously excised. The cicatri- zation of the raw surfaces narrows the orifice of the anus, so as to render it capable of restraining the prolapsus. Fig, 3. — Exciaion of a circular protuberance of the mucous membrane of the rectum. [Process of Ricord.) — The projecting ring of the membrane is sustained by two threads, held by an assistant. The excision is made by grasping the prominent part with the forceps, and shaving it off with the bistoury. Fig, 4. — Excision of the inferior part of the rectum, in cases of cancerous degeneration. (Pi-ocess of Lisfranc.) — The anal end of the rectum has been detached from the parts on its outer surface, by two semi-elliptical incisions upon its sides. The left fore finger of the surgeon is then introduced so as to draw the rectum down, in which position a couple of assistants secure it with hooks. The surgeon then, with a pair of scissors curved on the flat, incises circularly the intestine above the seat of cancerous degeneration. {Figs. 5, 6.) OPERATIONS FOR IMPERFORATE ANUS, AS PRACTISED ON A FEMALE INFANT. Fig. 5. — {Process ofAmussat.) — A longitudinal incision has been made across the usual place for the orifice of the anus, and this crossed at its anterior end by a horizontal cut, so as to allow of the formation of two flaps, which are to be reverted outwards by the fingers {a,b) of an assistant. A sound (e) is then introduced into the vagina to serve as a guide in the extension of the incision towards the cnl-de-sac, by which the rectum has terminated at some distance above the skin of the perineum. The loop of a ligature (c), passed with a needle, serves to draw downwards the pouch of the rectum, while the surgeon opens it by a crucial incision with the bistoury. Fig, 6 shows the conclusion of this operation. The horizontal wound is closed by sutures. The margins, of the longitudinal wound are united to the divided porlions of mucous membrane, and converted into an anal orifice. O'l Slone. by H Cti-hoHi.skt, ri,ll-ey^.Bart. FS DtLVCLl.htlfi FhW OPERATIONS UPON THE ANUS AND RECTUM. 299 or lobulated, and spring from the lining membrane of the bowel by a narrow ])edicle or a broad root. They vary in size from a pea to a pullet's egg, and may, in consequence of their shape and vascular character, be readily mistaken for a htemorrboidal tu- mour. They usually arise near the margin of the anus, lliough in some instances their place of origin has been found so high as to be beyond the reach of the finger. The method for their removal is very simple: they may be strangulated with a liga- ture, as shown in the drawing; or they may be merely drawn out with the forceps and tied at the neck, and the bulk of the tumour removed at once below the place of the ligature— or, if the neck is small and situated high up, it will answer well to remove them by torsion and evulsion, as practised for similar affections of the nasal passages. Dupuytren excised them with the scissors; but this is a practice liable to be followed by internal hemorrhage, and much less safe than the ligature. If the tumour have a large base, a double ligature should be passed through its place of attachment, and each thread tied upon the corresponding half of the base, as in the removal of a large hajmorrhoidal tumour. PROLAPSUS OF THE RECTUM.— PROLAPSUS ANL There are two varieties of this aifection, which are not unfre- qnently confounded together: — I. That of simple relaxation of the mucous membrane at the lower end of the bowel, which protrudes through a relaxed or paralyzed sphincter, (prolapsus ani). 2. That of the inversion and protrusion outwards of all the tunics of the rectum, and at times even of a part of the colon, {invagination milk prolapsus). 1. Of prolapsus of the mucous membrane. In this affection the mucous membrane alone is everted in the form of a ring. It may project one or more inches beyond the margin of the anus in refaxed and feeble individuals, and espe- cially iu children who have suffered from irritation of the mucous membrane. The immediate cause of the protrusion is commonly the remaining long upon the feet, or making long-continued straining eflbrts at stool in the sitting posture. The mucous membrane near the anus is naturally everted in the act of defe- cation, as may be seen in some of the domestic animals, and returned again spontaneously by the elastic reaction of the cellu- lar structure on its adherent face, aided by the contractile efforts of the sphincter muscle. When either of these parts lose their natural tone, the eversion becomes permanent, presenting a soft red annular tumour, but little painful on pressure, and wliich admits a linger to be readily passed through its central opening, but not upon its outer side where resistance is encountered from the sphincter muscle, which is continuous by its lining membrane with the mucous surface of the tumour, serving as the diagnostic marks to distinguish this affection from the invagination of the entire wall of the rectum. Prolapsus of the mucous membrane is in the adult very frequently found complicated with hfemor- rhoidai tumours, and is then usually curable only by the measures practised for the latter affection. In simple prolapsus while the membrane is yet readily returned by sliglit pressure, simple measures will often suffice for the cure; t;nch as a well-regulated regimen, careful attention to the state of the bowels, the administration of bitters and tonics, frequent application to the parts of cold water or astringent preparations, causing the child to go to stool in a semi-erect position, so as to retain, as pointed out by Dr. Physick, the supporting influence of the glutei muscles on the sides of the perineum, or having the sides of the anus supported by the fingers of the nurse during the act of defecation. But in case these measures fail, the mem- brane — being allowed to remain permanently everted — from its exposure to the air, and to the contact with foreign substances, becomes tumefied, ulcerated, and bleeding— is returned with greater difficulty, and is sometimes found wholly irreducible, from the tightness with which the irritated sphincter embraces the protruded parts. But in most cases under these circum- stances a return of the tumour may be eflected, so as to palliate the patient's sufferings. It may be accomplished by inclining the body of the patient downwards, and making steady and uni- form pressure with the fingers upon the tumour, which should be covered for the purpose with a piece of fine linen. In case the sphincter is found to offer great resistance, it might be divided as practised by Delpech, with the knife By a compress and band- age, or a rectal truss, we may, in conjunction with the therapeutic treatment above mentioned, sometimes succeed in preventing the return of the protrusion. More positive measures will, howeverj be commonly required for this purpose. These consist — i, of the excision or cauterization of some folds of the lining membrane of the anus; 2, of the removal of the protruded portion by the liga- ture or with the knife, when it either cannot be returned or is so much altered in its character as to require excision. Excision of radiated folds of the skin of the anus. (Process of Hey and Dupuytren.) — In the normal state the skin around this orifice is thrown into folds, which converge from the circum- ference to the centre of the opening. When the anus is exces- sively and habitually dilated, these folds become effaced in con- sequence of the impaired condition of the cellular and muscular structure below. The operation consists, as shown in Plate LX. fig. 3, in grasping up flatwise these relaxed folds with a pair of good forceps, and snipping them away from the outer to the inner margin of the anus with a pair of scissors curved on the fiat. Two, three, four, five, or six of the folds, according to the degree of relaxation, must be removed at different points of the opening. No haemorrhage is liable to follow, unless the operator should extend the incision too far in the direction of the bowel. No dressing was applied by Dupuytren. The cicatrization of these little wounds will usually be found to produce so much narrowing of the widened anus, as to prevent the recurrence of the prolapsus. To facilitate the performance of the operation, the patient should be placed on the abdomen, the pelvis rendered prominent by several pillows under the hypogastrium, and the thighs well separated by assistants. Cauterization. — This is an old process, and but little practised, tliough it was revived by Sabatier, and has been latterly employed by Mr.* Benj. Phillips. The patient is to be placed as directed in the operation just described, and directed to bear downwards so as to render the tumour as prominent as possible. The edge of the halbert-shaped cautery, heated to a white heat, is then to be drawn in a radiated direction over the tumour from the centre of the opening to the base of the fold, and at a number of point 300 SPECIAL OPERATIONS. proportionecl to the extent of the protrusion. The object to be accomplished in this operation is the same as in the excision of the folds of skin ; but the pain, inflammation, and protracted sup- puration, which follow the use of the iron, have caused it to be supplanted by the process just described. Ligature. — When the prolapsus of the membrane is caused by a hiemorrhoidaL tumour, or becomes itself so prominent at various points as to admit of being raised up as separate tumours, the ligature may be employed witii advantage, as in the ordinary operation for hiemorrhoids. Excision. — This process was successfully employed by Saba- tier. Fie raised the hardened fold of the tumour with hooks or forceps, and excised its prominent portions with scissors curved ■ on the flat. * This operation is liable to be followed by hemor- rhage, as the intestine is disposed to retract so as to render it difficult to secure the bleeding vessels. liicord (PI, LX. fig. 3) has niodified this process. He begins the operation by introducing two loops of thread through the base of the tumour, so as to prevent its too early retraction. He then with a bistoury makes a circular section of the ring of pro- truded mucous membrane, pausing to tie each artery as it is opened, so as to prevent the haemorrhage that would be likely to happen in case the part were removed at one sweep of the knife, and an attempt subsequently made to secure the vessels. 2. Pi'olapsus of the rectum with invagination. This is a much more serious affection than the one just de- scribed. It is a case of intussusception not unfrequently observed in children, and occasionally in adults, in which the upper end of the rectum, or even the colon, may become inverted into the pouch of the rectum, and protrude externally through the orifice of the anus. Its development is usually accompanied with nau- sea, colic, and vomiting, after several attacks of which, the inva- gination of the bowel becomes, as the immediate consequence of any strong effort, or of straining at defecation, discoverable at the opening of the anus. It may form at the exterior a soft, round, cylindrical tumour, several inches in length, pierced at the extremity with an orifice through wliich a sound may be carried up into the bowel. Between it and the sphincter the finger may be freely passed, showing that the parts are merely contiguous. The treatment consists in the reduction of the protruded parts by a sort of taxis, pressing with the fingers so as to return first the parts last protruded, very much as in the reduction of a her- nial tumour. If the parts can be returned within the orifice of the anus, they are to be retained by the use of a rectal truss, and the careful avoidance of all measures likely to reproduce the prolapsus. To be certain that the invagination of the bowel lias been completely reduced, it will be well to follow the intestine up with a wax or gum elastic bougie, and leave the instrument for a few hours in the passage. It is sometimes found impossible in old cases of invagination to reduce the bowel, in consequence of the adhesions which have formed at the place of intussuscep- tion. In these cases nature sometimes effects a cure, by causing gangrene of the protruded part. An attempt to remove the pro- jecting portions by operation which would involve the entire wall of the bowel, is not deemed justifiable, as the surgeon could not be assured that such adhesions had taken place as would prevent in so doing his laying open the peritoneal cavity of the abdomen. CANCER OF THE RECTUM.— EXTIRPATION. Cancerous disease is manifested in the rectum under various forms, and has not unfrequently been confounded with other affections, as simple hypertrophy or induration, which are much less serious in their nature, it may exist either as a primary affection, or be extended secondarily from the region of the anus, the vagina, or the uterus. It is usually of the scirrhous or colloid species, and is found very commonly unaccompanied with the general cancerous diathesis. The morbid matter may be effused into the substance of the bowel, causing either a local or general thickening of its parietes, or it may form a prominent tumour or a distinct ring round the bowel. The diseased structure usually terminates abruptly at its upper and lower borders, and it is only by examination with the finger that we are able to ascertain the nature of the affection. The effusion of morbid matter has a rapid tendency to increase, to throw out projecting masses into the cavity of the gut, to ulcerate upon the surface, and finally, if the patient does not previously sink from constitutional irritation, to open the wall of the bowel and destroy him by the effusion of fa:cal matters into the cavity of the pelvis. No disease is attended with more terrible suffering than this, which till lately was regarded as wholly incurable. The only means susceptible of affording any chance of relief, as shown by Lisfranc and Dieffenbach, is early extirpation. Simple tumours, especially if they are more or less pediculated, may be removed with a silk or wire ligature. Tiie removal of a mass encircling the bowel — the common form in which the disease presents itself — is an operation of more serious import, and requires the use of cutting instruments. The two conditions necessary for the suc- cess of this operation, are, 1st, that tiie disease should be limited to the rectum, and not extend so far up but that the finger may be passed beyond it; for if it extend higher than this, there is great danger that it may have involved the uterus and ovaries if the patient be a female, or the peritoneal pouch which lies in front of the rectum in either sex: and 2d, that the surrounding cellular tissue be unafl'ected, so that the intestine may be readily drawn down. Should the entire substance of the parietes be involved, the case, according to Mr. Waish, is unfit for operation if the disease extend more than an inch above the anus. An inch and a half of the entire circumference is said, however, to have been successfully removed by Paget in IS39 — defecation taking place readily and without pain in the new anus, which had been formed after the thorough removal of the sphincter; and Lisfranc and Dieflcnbach assert that they have removed in several instances much more extensive portions of the bowel. It is well, however, to recollect that the peritoneum terminates in the male ?t the distance only of four inches from the anus, and at the distance of from five to six in the female. The rectum is so loosely attached by cellular tissue to the sacrum behind, and to the bladder, the prostate, and the urethra in front, that it may be readily separated with the finger, and drawn down when loosened by an oval incision at its inferior extremity. "The merit of reviving this operation in the present century," OPERATIONS UPON THE ANUS AND RECTUM. 301 says Mr. Walslie,* "rests with Lisfranc. Among nine operations of the kind performed hy this surgeon before 1830, five termi- nated by a cure; in one instance the issue was doubtful; three cases ended falally. In two of the latter, purulent efTusion in the peivis and phlebitis were the causes of death; the body of the third subject was not opened. Mr. Mayo has, also, removed in one instance a portion of the entire cylinder of the rectum; the patient was exceedingly benefited by the operation; she had prolapsus afterwards, however, and died of inllammation in the abdomen two years after. It is indispensable for success that the limits of the disease be within easy reach of the finger (three inches have been removed), and that the. surrounding cellular tissue be healthy, so as to permit the bowel to be drawn down with facility during the operation. Should the entire substance of the parietes be affected, the case is unfit for operation if the disease extend more than an inch above the anus. "Velpeau describes the steps of the operation as follows. The patient having been placed on his side, as in the operation for fistula in ano, with the thighs kept apart by a pillow and flexed at a right angle on the trunk, the anus is encompassed by two semilunar incisions joining anteriorly and posteriorly, and the resulting flaps dissected up to the edge of the sphincter. Tiie left index finger is then introduced for the purpose of bringing down the diseased mass as low as possible, while an assistant draws the dissected ellipse of integuments in the same direction. The surgeon then cuts away the adhesions of tlie diseased gut by semicircular sweeps of the knife, and finishes hy dividing the intestine transversely either with the bistoury or with curved scis- sors. Wlien the cancer is deeply seated or extensively adherent, Lisfranc divides the posterior angle of the dissected ellipse with strong straight scissors, extending this division tolerably high along the rectum: the dissection is facilitated by an assistant drawing down the gut with hooks or strong forceps. The knife of the operator is guided by a finger in ano, and by the thumb placed on the external surface of the flap. One of the most important points to bear in mind, is the position of the hollow organs in front of the gut. Their situation may be marked by the finger of an assistant in the vagina, or by a sound in the male urethra; but these guides will be of little value unless the ope- rator possess perfect anatomical knowledge. M. Costatlat states that 'an autopsy which took place at the Venereal Hospital shows, that through the action of a cancer situated at the inferior part of the rectum, the cul-de-sac of the peritoneum may be brought within sixteen lines (Fr.) of the anus; whereas in the normal state, it is double or even treble as far from the orifice of the bowel.' This is an anatomical fact of most serious import- ance. The arteries should be tied when divided; when this precaution has been taken there is rarely any severe hemorrhage, or such as resists the application of lint steeped in cold water. A thick roll of shredded lint is introduced after the operation, and iti order to prevent the tendency of the intestine to coarctation from becoming troublesome, the use of some contrivance of the kind should be persisted in for a time — say, a few weeks at least. The wound commences to contract from the fifteenth to the twentieth day,— the external and internal parts approximate, and • Cyclopaedia of Practical Surgery, article Cancer. 76 eventually the visible loss of substance does not amount to more than an inch in width. The fibres of the levator ani, the apo- neuroses and the end of the rectum form a sort of substitute for the sphincter: the patient, however, has commonly no control over liquid fteces, though the individual operated upon by Faget could even retain ffatns. Whatever may have been the success of Lisfranc, opinion is far from being strongly favourable to this operation, even in Paris: Amussat affirms that it 'rarely suc- ceeds.' It may be observed, however, that the indication for removing a portion of the rectum obstructed by cancer is infi- nitely stronger than for the amputation of a cancerous breast. In both situations, it is true, the disease must destroy life, unless removed — but in the case of the rectum the free discharge of the function is demanded for daily existence. The comparative rarity of visceral contamination in rectal cancer, is a general argument in favour of excision." Process of Dicjfcnbacli. — The patient is to be placed upon a table with the abdomen downwards, which sliould be well sustain- ed with pillows, so as to render the anal region prominent. Two semicircular incisions are first made— one at the superior part of the anus, and the other upon the perineum. The finger is then introduced into the anus, to serve as a guide during the remainder of the operation, which is to be finished with the scissors. When he has penetrated to the depth of half an inch, he causes the buttocks to be separated by a couple of blunt hooks in the hands of an assistant. He next inserts a double hook into the inferior end of the rectum, and causes an assistant to draw the bowel down, as he detaches its connections cautiously with the scissors beyond the limits of the disease. By this method he has removed in one instance, two inches and a half of the rectum, and in an- other four inches; but in the latter he opened the cavity of the peritoneum — the patients in both cases finally recovering accord- ing to the reporter of the cases.* The subsequent steps of the operation consisted in removing with the hand the fxcal accumu- lations in the bowel above the place of narrowing, washing out carefully the wound, and seizing the edge of the divided rectum with hooked forceps, after loosening it farther by dissection, and drawing it down to a level with the skin, to which, after being well opened, it was finally attached by suture, so as to form a new anus. By this modification of the operation of Lisfranc, the Berlin surgeon believes the patient is protected against the risk of excessive suppuration, and tliat contraction of the passage which would be liable to result from cicatrization, in case the intestine was not drawn down so as to have its mucous surface connected with the skin of the buttocks. The dressing consists in the appiicatiou of compresses and masses of cbarpie steeped in cold water to the perineum and the margin of the new anus. The value of this bold method of operation is yet, however, to be decided. There remains yet another mode of affording probable relief — that of the formation of an artificial aiuis, which has been referred to at page 297, in cases of desperate disease, where the rectum becomes thoroughly obstructed, "and symptoms of stercoral tym- panitis and strangulation, with momentary risk of rupture of the intestines, have set in." "When the indications for performmg • Chirurgie de Dieffenbach, par C. Phillips: Berlin, 1840. 303 SPECIAL OPERATIONS. this operation arise," says the author last qiioteci, "the patient should be allowed to choose for himself between certain death and the prospect of life with the inconveniences of an artificial anus, which the formation of such an opening affords. When the disease is cancerous, the chances of ultimate advantage are, of course, vastly less than in cases of retention from simple indu- ration; but even here it may be justifiably performed, provided the patient, after having been made fully acquainted with the nature and likelihood of the benefit to follow, still desires to un- dergo it." The mode of performing the several operations for the estab- lishment of an artificial anus, has already been referred to under the head of "Imperforate anus." H.EMOERHOIDAL TUMOURS, OE PILES. Tumours of very various appearances have been described under the name of hemorrhoidal tumours or piles — different writers taking unfortunately some particular variety as the pecu- liar type of the affection, so as to render the pathological anatomy of this very common disease, confused and imprecise. It may suffice in this place to state, that the substantive disease in a hEemorrhoidal affection from whatever cause produced, is the determination of blood to the mucous membrane of the lower extremity of the rectum. This, if not checked in its early and forming stages, as it readily may be by proper regimen and therapeutical applications, gives rise in the end to submucous inflammation, thickening of the tissues by the deposit of lymph, to the varicose enlargement and dilatation of the vessels of the part, to the eversion of thickened folds of the mucotts membrane, &c. &c. so that when the disease is allowed to run on uninter- ruptedly, it may in different individuals present in either one of the following forms, under which they have been considered by Professor Warren.* "1st. An internal tumour; 2d, a tumour occasionally appearing without the anus; and, 3d, a tumour permanently external. The two first are arterial tumours of the mucous membrane, and differ only in degree. The third is an enlargement of the veins of the rectum, with an intermixture of small arterial vessels. "The internal tumour is often formed long before its existence is known. The first evidence of it is a moderate discharge of blood with the evacuations, and without pain. On examining by the finger, in the early stage, it is difficult to detect an altera- tion from the ordinary state. By the speculum, we discover an unusual redness, with an appearance of a vertical fold of the membrane. "If the disease continues, the raucous membrane becomes swollen and elongated, protrudes beyond the anus when the rectum is evacuated, and forms a red tumour— usually retiring, in a short time, into the cavity of the rectum, especially after a discharge of blood, which relieves the swelling. In this way is generated the second form of the disease, which is much more troublesome than the first; for the tumour is, at length, difficult to return, and while it remains out, being pinched by the sphinc- * Surgical Observations on Tumours, by J. C. Warren, M. D., Prof, of AoaC. and Surg, in Harvard University: Boston, 1837 : pp. 453-45Q. ter muscle, gives great pain, and uneasiness in sitting and moving. The vascular organization of the rectum, and the loose cellular connection between the mucous and sub-mucous coat, allow the extension of the tumour to the circumference of the rectum; and, at length, a circular portion of the membrane is protruded, and constitutes prolapsus ani. This state of the complaint is formi- dable. The difficulty of returning the swelling is greater, the consequent pain is now more distressing, and the haemorrhage considerable. The blood is thrown out at the time of evacuation in a gush, sometimes to the amount of a gill or more at one time. — The patient becomes much reduced by this constant discharge of blood, and, if it continues, may at length sink under it. This result, however, rarely occurs, unless he has neglected the proper means of relief — The tumour formed in prolapsus, in many persons, becomes indurated after a time. Then the copious dis- charge of blood is prevented by the pressure on the vessels, made by the indurated substance. But in this case, an evil arises scarcely less annoying. The tumour descends in the common movements of the body, so that the patient is unable to walk without bringing it down; and the consequence is, that he is obliged to wear a bandage, acting like a truss, to retain the* swelling in its place. "The third and most common form is the external tumour, known by the name of piles. This is originally a swelling of the hemorrhoidal veins, covered by the extreme verge of the mucoits membrane, and by the skin connected with it. It is, at first, a soft, compressible tumour. By times, it becomes hard, and forms one or more nipple-like eminences about the anus. In its early stage, it is of a blue colour, like other venous tumours. As the skin over it thickens, and the veins harden, their cavity is dimi- nished, the blue colour disappears, and they assume the colour of the skin of the part. "The causes of these different forms of affection are of the same nature. They are either such as, by compressing the h^emor- rhoidal veins, prevent a free return of blood from them, or such as, by over-exciting the vessels of the rectum, produce accumu- lations of blood in the small arteries. Among the former are costiveuess and pregnancy; and of the latter, dysentery, and the continued use of strong cathartic medicines." The internal hsemorrhoidal tumours sometimes come down so as to be strangulated by the sphincter muscle, and give rise to ex- treme local suflering and much sympathetic disfurbance. They are to be carefully returned into the abdomen by the same mea- sures as are resorted to for the return of the prolapsed bowel. In case this should be found difficult, from the great sensitiveness of the inflamed and protruded tumour, or from the spasm of the sphincter, the parts should be previously well fomented or covered with warm poultices. The curative treatment of htemorrhoidal tumours is divided into the medical and surgical. Of the latter only, as coming within the scope of this work, we sliall here treat — premising first, that no operation is to be undertaken during what is called a fit of the piles, the consequence of temporary inflammation and tumefaction of the paris, but only after the symptoms have been relieved by appropriate therapeutical applications. There are three methods of operation employed in the removal of these tumours — incision, ligature, and excision. OPERATIONS UPON THE ANUS AND RECTUM. 303 Of Incision. This is applicable only to that form of external piles in which the tumours are seated at ilie oiilcr margin of the anus, covered partly by skin and partly by mncous membrane thickened by inflammation, and conlaiiiing in their interior an oblong or rounded mass of clotied blood, lodged in the dilated extremity of a heemorrhoidal vein, or in the cellular tissue of the part. The colour of the clotted blood is obvious frequently through the skin, and gives a blnish grape-like appearance to the tumours. The operation for their ciu'e is very simple. An incision is to be made through the thickness of the tumour witli a lancet or com- mon bistoury, and the Httle mass of clotted blood turned out. Simple dressing with careful ablution of the part from time to time is usually all that is required for the cure. If the little wounds are slow in cicatrization, or become troublesome from their itching, the tannin ointment, or a wasli of lunar caustic, or some astringent lotion, may be employed with advantage. In chronic cases, where the clotted blood in these grape-like tumours lias been removed by absorption, the skin presents merely a prominent thickened fold, and if found subject to occa- sional inflammation, should be extirpated with the knife or scissors. Ligulure and Excision. The process by ligature is particularly applicable to all spongy and vascular tumours of the rectum, especially if they are con- nected to the surface of the bowel by a base of considerable size. Some surgeons employ it even in all cases of internal piles, as it effectually prevents hemorrhage — a result particularly to be dreaded in vascular tumours, inasnuich as the bleeding may take place internally, and distend the rectum and colon without show- ing itself without, and has in some instances proved fatal. But if the tumours have lost their vascular character, become hard from the interstitial effusion of lymph, and are pedunculated, they may be snipped off at their root with perfect safety — and it is to cases of this description, and to tumours rendered so far external, that the bleeding vessels may be secured with ligatures or obliterated with the heated iron, that the author believes it most safe to restrict the operation by excision. The excision of liiemorrhoidal tumours is, however, the common rule of practice at the present day among French surgeons, though it has been lately strenuously opposed by M, Mayor, of Lausanne. For either mode of operation, it is necessary to have the bowels pre- viously well evacuated by the administration of a mild cathartic or an enema. It will be necessary, moreover, in most instances, for the patient to seat himself over a vessel of warm water, so that he may protrude the tumours, and make them more acces- sible to the surgeon. He may be placed for either process upon the side, with the buttocks projecting over the margin or foot of a bed, or made to lean upon the abdomen over the side of a bed, the back of a sofa or chair. Ligature. — There are two modes of effecting strangulation — with a wire ligature and the double canuta of Levret, and with the ordinary waxed silken or hempen ligature— the tumour being in both cases returned within the ring of the anus. With the wire ligatxiTc and double cunulci. (Process of Dr. P/ii/sick.)— This is a process formerly much employed in this country, and stilt used to a considerable extent, though it has fallen latterly into much disfavour, in consequence of the severe pain which attends its application, the occasional development of symptoms that for a time simulate those of strangulated hernia, and the necessity of leaving the wire canula— a separate one of which has to be employed for each large distinct hEemorrlioidal tumour— dangling for a series of hours together at the margin of the anus. The wire should be of iron and well annealed, and the canula not more than two inches in length. The 'loop of the wire is to be slid over the free portion of the tumour up to its neck, and drawn as lightly as possible with a pair of dressing forceps, with a view of cutting off' the circulation of blood to the tumour, and lessening the amount of pain, which would be wholly unendura- ble if the strangulation was incompletely effected so as to allow the tumour to inflame and swell over the ligature. The free end of the wire is then to be secured to the arm of the canula as described at page 13. When there are several tumours, the larger ones only are to be strangulated in this manner. The removal of a single one it is said has proved sufficient to cause the disappearance of the rest, the inflammation developed by the operation blocking up the spongy structure by an effusion of lymph. This is a result, however, which by no means always follows. At the end of twelve or twenty-four hours, the wire is to be unwound from the arm and pressed through the canula, so as to enlarge its loop and allow of its being withdrawn over the tumour. Each of the tumours will be found insensitive, shri- velled, and dark-coloured. Poultices are to be applied to the parts. The tumours in a few days — from four to six — separate by a sloughing process at the part where they have been pinched by the wire. The great improvement suggested by Dr. Fhysick in the use of the ligature, consists mainly in its removal before the fall of tiie tumour, up to which period it was left by the older surgeons. Ligature toit/i the ordinary silk or hempen thread. — This process consists merely in grasping the tumours with a thumb and finger or a pair of forceps, and surrounding them as tightly as possible with a thread, returning the tumour again into the cavity of the bowel. The thread has to be left till the tumour sloughs off, as the swelling of the structures which follows, as well as the augmented irritability of the parts, renders it impossible to reach it with the knife. This process, which is in common use with many surgeons, is decidedly inferior to the one just noticed, for although the patient is not left encumbered with a pendent cauula, it is difficult to effect thorough strangulation with the thread, even when it is passed double with the needle through the pedicle of the tumour and tied on either side. In consequence of this and the necessary retention of the thread for several days together, the patient is kept in a constant state of suffering, ag- gravated to an almost insupportable amount at the periods of defecation, when the tumour is made to drag upon its inflamed and partially detached neck. The plan which the author has found decidedly preferable lo either of these, and which is in common use among many surgeons, is the combination of the Ligature tvith excision. — After lying the neck of the tumour. 504 SPECIAL OPERATIONS. ■when this is pedunculated, in the manner above mentioned, the protuberant portion is to be excised with a pair of scissors curved on the flat, just in advance of the Hgature. All the tumours, even if they are as many as five or six in number, are to be raised, or if necessary drawn down with the forceps, tied, and removed. When the pedicle is not very narrow, the aulhor prefers always to pass the ligature double, with a needle and a thread on either side, in order to prevent with certainty any displacement of the ligature for two or three days, by giving it a hold upon the parts. In case there is difficulty in reaching the tumour, the author has pressure made with the fingers of an assistant on the sides of the sphincter, so as to invert the lower end of the gut; and if by this means the root of the tumour or the base of the prolapsed and thickened folds of the mucous membrane, which sometimes alone constitute the offending body, cannot be brought fairly to the surface, he passes a double ligature with the apparatus devised by the late Mr. Bushe.* This consists of a small curved needle threaded near its point with a double waxed thread, and inserted into a groove at the end of a needle-carrier, which is bent some- what like the common aneurismal needle. The tumour is to be raised and drawn slightly downwards with a pair of toothed forceps; the armed needle-carrier is then passed into the orifice and the needle brought downwards again so as to pierce the base of the fold of membrane or the broad attachment of the tumour, and present its point without. The needle is next grasped with a pair of ring-pointed forceps, lo sened from the needle-carrier, and withdrawn. The loop of thread is then to be cut, the liga- tures tied upon either side of the necl;, and the tumour excised with the scissors. This apparatus of Bushe will be found most convenient in many cases of disease where the thickened and vascular membrane presents no round and prominent tumour tliat could be grasped with the wire loop. The elevated folds at the margin of the anus should also be removed by simple excision, so as to leave none of the parts which when inflamed had pre- viously occasioned the fits of piles, to be afi'ected by the inflam- mation which to more or less extent must necessarily follow the removal of the tumours. Each of the ligatures applied upon the tumours is to be cut otf close to the knot. The protruded parts are to be carefully returned within the sphincter. Warm fomen- tations are to be applied upon the anus and perineum, the patient should be placed under the influence of morphia, and take from time to time copious draughts of some mucilaginous preparation conjoined with drachm doses of the sp. ether, nitrosi, in order to diminish the tendency to retention of urine which now and then takes place, especially when the seat of the tumour is on the side of the bowel next the bladder. On the third day the bowels are lo be moved by an oleaginous enema; and with the feculent matters the tiu'eads which have been applied to suppress the bleeding will commonly be discharged. I have no hesitation in recommending this mode of managing ha3morrhoidal tumours, as I have practised it at least thirty times within the last five or six years, frequently with but very little suftering to the individual, and in every instance without any bad consequences. The cicatrization of the raw surfaces left will sometimes demand the use of astringent washes or ointment, * Bushe on the Diseases of the Rectum, New York. or the injection of a solution of lunar caustic, as well as careful regulation of the regimen. P?'ofessor Horner'* has suggested the following modification of the use of the wire ligature. Having made the usual prepa- ratory measures, and caused the patient to protrude the piles, he is laid on the side corresponding with the tumour, and near the edge of the bed. "A thick sail needle armed with a large liga- ture, is then passed transversely through the upper part of the base of the tumour; the needle being removed from the ligature, the two ends of the latter are tied together, so as to form a loop. A stout awl then transfixes the lower part of the base of the tumour in a line parallel with the ligature above. "In a large protruded pile, the usual anal pouches or sacs are much enlarged, and have their orifices pointing downwards. The awl when placed as intended, is between these sacs and the adjoining margin of the anus, and makes the part so firm, that it is more easily operated on subsequently. The inferior third of the base of the tumour is now detached from the anus with a scalpel, the anal sacs, and a corresponding loose fold of skin which commonly exists at the same time with large hoemorrhoids, going along with the tumour. Should tlie tumour recede, the loop above, and the awl below, enable the operator to draw it out, A wire noose is then thrown round the adherent base of the tumour, and drawn perfectly tight, by the aid of a double canula. This noose occupies the previous incision and it may be placed with great accuracy, from the command of the pile derived from the first ligature and the awl. "The tumour, if very large, may now be punctured so as to disgorge its blood. At the end of five hours, the part is perfectly dead by strangulation, the tumour may then be cut off near the wire noose, say three lines from it, for which act in the process of operating, a pair of scissors will do; but what is still better. Dr. Physick's tonsil instrument, owing to the accuracy of its line of incision. The wire noose itself may then be taken away, as the vessels are so compressed and deadened, that no blood will pass through them. "The awl should be removed directly after the wire noose is applied and fixed, but the first loop should be retained for the final act, to wit: the excision of the tumour, as it assists very much. The operation thus completed, an injection of tinct, opii gi, in two ounces of thin starch, puts the patient at ease, and he falls into a tranquil sleep." By Excision. Process of Professor Warren, — "The parts, being sufficiently protruded, are to be seized by a double-pointed forceps, drawn down sufficiently to give tension to the membrane, and then, with one or two strokes of a round-edged dissecting knife, the tumour removed. If there are tumours on both sides, as com- monly there are, the same is to be done on the opposite side; and the co-existing external piles are to be excised in the same way. It is necessary to avoid taking off a circular piece of the anus, as this is apt to be followed by a contraction, which may require another operation. The patient should be carefully watched for three or four hours; and if he has an inclination to * Am. Jour, of Med. Sci., Oct. 1842. OPERATIONS UPON THE ANUS AND RECTUM. 305 stool, let him indulge it, and he will probably discharge a large quantity of blood, showing that an internal hemorrhage has been going on. Fainting at the distance of half an hour or more after the operation, indicates bleeding. In both of these cases, the introduction of sponge will be required. For this purpose, take a piece of sponge, of cjiindrical form, two inches long, and au inch in diameter. Pass a thread through one end of it, and then introduce it so far that it shall scarcely appear externally. This I have never known to fail of checking the hemorrhage. When there is no dangerous bleeding, so that the sponge is not neces- sary, a piece of oiled lint should be introduced to separate the opposite parts of the anus. "The patient should be kept in the horizontal posture a longer or shorter time, according to the degree of disease under which he has laboured; for although no confinement is required by the operation itself, it is proper to aid it by giving the affected vessels time to contract. In none of these cases are all the disordered parts excised, so that we must trust much to the salutary opera- tion of nature to finish the cure, and must allow opportunity to perform her work unembarrassed by the movements of the body. — The most annoying symptom after this operation, arises from the effort of the intestines to expel their flatus. When the im- pulse thus given reaches the wounded part, it brings on a spas- modic contraction of the sphincter, which is excessively painful. The flatus is resisted, and driven back into the colon, and accu- mulates to a distressing amount. The interposition of the oiled lint commonly allows the flatus to pass down. When it fails to do so, the patient must subnnt to the use of a mild injection, which, however painful to the wounded part, soon affords relief. Sometimes it becomes necessary to remove these contractions by the use of opium. — On the third day a cathartic of castor oil is administered; and this, with bathing the part daily with warm water, and applying some unctuous substance, is all the treat- ment required." Dupiiytren simply raised the internal tumours with the for- ceps, and excised them with scissors curved on the flat. In case there was any tendency to hemorrhage, he immediately touched the bleeding surface with the actual cautery. This, however, it is not always easy to accomplish, especially when the bowel has retracted, and it becomes necessary to make it again protrude. In one instance, in which hasmorrhage followed the removal of a tumour by this process, I succeeded in transfixing the bleeding surface with a couple of hare-lip pins, and securing it with a ligature. Baron Boyer, when the tumours were distinct and separate, raised them with hooks, or with a loop of ligature passed through the base of each with a needle. These were held by assistants, in order to prevent the retraction of the parts before the process of excision was completed. When the protrusion was in the form of a circular rim with irregular depressions, he passed the loops at the base of the several prominent points. Taking each loop in succession in his left hand, he then excised the tumours one after another with the bistoury, laying the instrument with the back towards the bowel and cutting outwards. A mesh was then introduced into the bowel, consisting of many portions of charpie doubled at their middle for the purpose of making pressure on the bleeding vessels, and preventing a contraction of the parts 77 during the process of cicatrization. A pad of charpie pressed strongly up upon the anus with a T bandage, completed the dressing. There would still, however, even with this precau- tion, be a risk of internal hjemorriiage that might endanger the patient's life, and render necessary a more thorough tamponing of the rectum, or the application of the ligature or the actual cautery. J'elpeau, for the purpose of preventing hemorrhage, inflam- mation, and the risk of purulent absorption, has proposed to traverse the root of each tumour with several ligatures, and in front of these remove the tumour with the bistoury or scissors, subsequently knotting the threads so as to close the wound. Lisfram causes the mucous membrane and the tumours which stud it, to descend as far as possible by gentle traction with the fingers. He then seizes the circular fold between the thumb and finger of the left hand, and makes a vertical incision through it with the scissors. An assistant now grasps in the same manner the opposite side of the vertical cut, and the surgeon shaves off horizontally the projecting portion of the fold, stopping as the divided vessels spring to twist or tie them effectually. He con- tinues the incision in this way to the opposite extremity of the circle, and before he makes the final incision to detach the piece, surrounds the narrow attachment left with a Ugature, if it be found on examination to contain pulsating vessels. No dressing is required, except the occasional introduction of the finger after the fifth or sixth day, to prevent any vicious adhesions. M.ccord~ ing to Lisfmnc, tliis process in thirty cases has been unaccom- panied by hjemorrhage. ABSCESS BY THE SIDE OF THE ANUS. From the abundance and vascularity of its surrounding cellular tissue, from the absence of valves in its veins which are placed at the lowest point of the portal system, and from its intimate sympathy with the genito-uriuary organs, the anal region is par- ticularly prone to congestion, inflammation, and abscess. Ab- scesses of the anus may for practical purposes be divided into the deep-seated and the superficial, the former of which are alone of very serious import. The distinction between them is not usually difticult. The superficial abscess is readily known by its prominent pouting form, and by the shortness of the period in which the fluctuation of pus becomes manifest. In sensitive subjects, however, even small superficial deposits of pus may produce symptomatic disturbances of the prostate, ure- thra, and bladder, so as to render the diagnosis more obscure. Abscess of the anus rarely terminates widiont an opening through the skin, or into the anus. The fsscal odour of the pus is no undeniable proof of the opening into the rectum, for it may be transmitted through the thinned mucous membrane. Though it is nearly impossible to effect the resolution of the in- flammation and hardening of the cellular tissue by the side of the anus, the extent of the suppuration may be limited by judicious therapeutical treatment. As a general rule the superficial abscess should be opened at the first appearance of fluctuation. An early and prompt incision is still more strongly indicated in the deep- seated. The author has found it advantageous to lay freely open with a curved sharp-pointed bistoury the thickened and hardened mass before it runs on to suppuration, thereby facilitating the 306 SPECIAL OPERATIONS. process of cure, and diminishing greatly the risk of the establish- ment of burrowing passages round the rectum, or the formation of an anal fistula. FISTULA IN ANO. The pathology of anal fistula is closely connocied with that of abscess of the anus, when this, from whatever cause produced, has become chronic and fistulous. If a fistulous abscess by the side of the anus communicates by one or more orifices internally with the rectum, and opens externally through the sidn, it con- stitutes a complete anal fistula. If there is only one opening, it is called incomplete or blind; if that opening is internal only, it is called a blind internal fistula: if external, it is a blind external fistula. Complete Anal Fistula. In the greater number of cases there is but one internal open- ing, and that at a distance of less than an inch from the margin of the anus, formed — through the substance of the external sphinc- ter — in the cellular interstice between the internal and external sphincter muscles — or through the walls of the bowel between the internal sphincter and the insertion of the levator ani muscle. In some cases (and especially in phthisical subjects in which no operation is considered indicated) more than one opening may be found, and occasionally at the distance of two or three inches from the anus, as in the case of which a drawing has been given by Matthew Baillie. The external fistulous opening is commonly found at some part of the outer circumference of the anal opening, though it may exist at any portion of the structure of the perineum, between the margin of the buttocks of either side, or between the os coccygis and the bulb of the urethra. Tliere may be several external orifices, the sinuses of which communi- cate with one another through a mass of hardened tissue, so as to render their exploration by no means easy. The internal orifice can frequently be seen on the eversion of the edges of the anus, or may be felt by a finger introduced into the anus, or rendered manifest by a probe iinroduced from the external opening and pushed obliquely in towards the bowel. In sounding with the probe I have seen again and again erroneous deductions drawn as to the depth of the fistulous passage, from the introduction of the instrument in a direction nearly paralle! with the bowel; for the cellular and fatty tissue on the outer side of the rectum is so soft and yielding, even in its healthy state, as to render but little resistance to the passage of the probe to the extent of three or four inches between the levator ani and the obturator muscles. Treatment. — The indications to be fulfilled are the laying open of the fistulous tracts, and the division of the sphincter muscle which dams up the faecal matter, turns it into the cavity of the abscess, and keeps up sueh frequent motion of the parts as to prevent the tendency to heal. The division of the sphincter is considered by Sir Benjamin Brodie so necessary to the cure, that he effects it even if necessary from within outwards with the knife, when the ithernal fistulous orifice is found below its upper border. The division of the sphincter and the callous tracts is made either by incision or ligature. Incision. — This operation is exceedingly simple, though a variety of instruments have been devised for its performance. In a great majority of cases a narrow probe-pointed bistoury is ail that will be required. The patient is to be placed in the usual position for operations on this region. The fore finger of one hand, oiled, is to be introduced into the bowel, with the pulpy portion turned to the fistulous orifice; with the other the bistoury is to be gently introduced from the external orifice till the probe point is felt in the bowel, and can be covered with the finger over its back. A double motion is now given to the bistoury. The point is drawn outwards with the finger, while the blade is slid on with the other hand so as to cut out by a sliding stroke. All the various superficial fistulous passages are to be laid open so that they may be dressed from their bottom and solidly closed up by granulation. If the skin from the extent of the abscess is rendered shelving, callous, and dark-coloured, the angles formed by the incisions may with advantage be snipped away. If there are several internal orifices opening above the sphincter, it does not answer to divide the muscle, according to the observation of the author, at more than two points, for fear of too much dimin- ishing the resistance which the sphincter is intended to make against the retraction of the levator ani. Two instances have come under my notice where the sphincter had been divided at three or four difterent points, in which, after the healing of the fistula, the divided portions of the muscle and the skin of the anus were drawn up by the levator, so as to destroy the action of the sphincter. The division of the sphincter should, if pos- sible, always be made upon the side, as we thereby more com- pletely produce a temporary loss of function in the muscle, than if the incision is made at its coccygeal or perineal points. A single thin mesh of greased lint or linen pushed gently into the boHom of the wound with the end of the finger or a spatula, is all the dressing that is required. In case much bleeding should follow, it may be necessary to tampon the rectum, apply cold lotions, or, if it should become necessary, tie tlie bleeding vessels. Incision on the gorgeref.- — Pott introduced a piece of hard wood, concave upon one side and convex on the other, (called a gorgerei,) into the rectum, passed a grooved director from the external orifice down the sinus, and along this slid a sharp-pointed bistoury, with which the parts including the sphincter were di- vided from within outwards upon the groove of the gorgcret, which should be steadied with the other hand. This process is still employed by many surgeons, and the author has found it ad- vantageous in cases where — from the callousness of the structure, the winding track of the sinus, or the unusual height at which it terminates — it has proved difficult to find the internal orifice. In many cases it will suffice to introduce the narrow-bladed knife without the use of the director. Bi/ ligature. — This, which is an ancient practice, was warmly advocated by Desault. It consists in passing a waxed thread or a leaden wire through the track of the sinus with a bent eyed probe along the groove of the director, the canula of a trocar, or with some one of the instruments especially devised for this pur- pose. The inner end of the ligature is then to be brought out from the orifice of the anus, and the two ends loosely tied or twisted together over the external surface, ( which should be protected by a pledget of lint,) so as to include the sphincter. The ligature is tightened anew every second or third day, until the parts are fairly cut through. In some cases the track cut by the ligature OPERATIONS UPON THE ANUS AND RECTUM. 307 heals up by granulation as the ligature makes its way to the surface. This is a result, however, which by no means always follows; not unfrequentiy, and especially in subjects of bad habits of body — those most subject to this affection— the ligature acts as a foreign substance, keeping up constant irritation and pain, and causing offensive discbarges from the rectum and extensive suppurative inflammation in the cellular tissue round the anus. It is a protracted process, requiring to effect a cure from four, five, or six weeks, to as many months. It does not necessarily cause the patient to )ay by, and this, with the obviation of all risk of hieniorrliage which might attend t!ie cure by incision in cases where the fistula opened iiigh up in t!ie bowel or was accom- panied with great hKmorrhoidat enlargement of the veins, are the only features to recommend its employment. Compression has of late been resorted to for the cure of anal fistula, but with little success. It is effected by means of a dou- ble cylinder introduced up the rectum— the outer cylinder serving to compress the wall of the bowel against the track of the sinus so as to prevent the passage of the ftecal matter through it; the inner cylinder serving merely as a stop, to be temporarily with- drawn for the purpose of defecation. Incomphie External Fistula. This is but a chronic abscess by the side of the rectum, rendered fistulous, and kept from healing by the action of the sphincter muscle. The only peculiarity of treatment it requires arises from there being no internal orifice, and the necessity of making one so as to convert it into a complete fistula, like which it is then to be treated. The puncture is to be made at a part where, on the introduction of a finger, the wall of the bowel is found most thin and yielding. The sheathed bistoury of Physick, or the bistoury of Cruikshank provided with a stilet at the end, has been employed for this purpose. In niy own practice I never find it necessary to employ any other than an ordinary narrow, but strong, curved probe-pointed bistoury, with half the probe point ground away so that it may be made to cut through the coats of the rectum upon the finger — the point of the instrument remaining suffi- ciently blunt to protect the finger from injury when it is covered by the latter during the division of the bridge of soft parts. In case of need, the division may be effected with the gorgeret and sharp-pointed bistoury as above described. Incomplete Internal Fistula. This form is more rarely met with. It is usually the result of an ulcer of the bowei, occasioned by the suppuration of a hemor- rhoidal tumour, or by the irritation arising from the lodgment of some foreign substance. Ftecal matters are apt to escape under such circumstances into the cavity of the sinus, and convert it into a stercoraceous abscess. If the fluctuation can be felt from without, it is to be converted into a complete fistula by a punc- ture through the skin. If the pus is discharged so freely into the gut as not to be felt externally, a bent probe is to be inserted through the orifice of communication with the bowel. The end of the probe when detected from the skin is to be cut down upon with the bistoury. The treatment subsequently becomes the same as in complete fistula. In one instance of large stercoraceous abscess which occurred in a patient with a vitiated constitution, crepitant on pressure, and exhaling a gangrenous odour, I succeeded in effecting a cure by a single free application of the actual cautery. The change of structure effected by the iron obliterated 'the sinus which led to the bowel, leaving an ordinary abscess which permanently closed in three weeks. Enlargement of the mucous sacs. — The small semilunar sacs formed at the termination of the mucous membrane of the rectum, are, as first noticed by Dr. Physick, sometimes so enlarged by disease as to be the source of much suffering or annoyance. These pouches open upwards, and when enlarged and viewed from below present at times the appearance of vascular tumours. A small probe, bent at the end, is to be hooked from above into the cavity of each one in succession, so as to render its wall pro- minent and allow of its being clipped away with the scissors. FISSURE OF THE AA'US. This affection is less frequently observed in this country than in those where the use of clysters is more habitual. It is mostly complicated with spasm of the sphincter, and then causes the most excruciating pain during defecation. When observed as the consequence of syphilis it is less painful and serious, and is known under the name oi rkagades ani. Si[nple chaps, involving only the skin around the anus with- out extending into the mucous membrane, or exciting spasm of t!ie sphincter, may be cured readily by appropriate topical treat- ment like other unhealthy sores. But when the fissure is accom- panied habitually with severe spasm, the division of the sphincter muscle is the only measure that will afford relief. It is to be made with the bistoury, which should be. carried directly through the fissure so as to convert it into an open wound. If the muscle is divided at another point, as some have directed, though the spasm may be relieved, the fissure will be little disposed to heal witiiout the repeated use of caustic. STRICTURE OF THE ANUS. This occasionally occurs in consequence of the cicatrices and indurations following operations on this region, or from rigidity of the sphincter muscle, and often precedes the formation of fissures. If not extreme, relief may be derived from the habitual use of laxatives, and the introduction of steel bougies, the size of which should be gradually augmented till a permanent dilatation is effected. If the stricture is more completely formed, it may be necessary to make some incisions at the margin of the anus with a bistoury, or to divide the sphincter muscle. IX. OPERATIONS UPON THE GENITO-URINARY ORGANS. IN THE MALE. The operations described under this head consist of those prac- tised — 1. On the Scrotum; 2. On the Penis; and, 3. Those on the Urethra and Bladder, including the operations for Stone. SPECIAL OPERATIONS. OPERATIONS UPON THE SCROTUM. These comprise operations for Hydrocele, Sarcocelej and Vari- cocele. HYDEOCELE. This term signifies a tumour formed by a collection of water in the cavity of the tunica vaginalis testis, or in one or more serous cysts placed along the cord, between the testicle and the external inguinal ring. Simple osdema of the subcutaneous cel- lular tissue of the scrotum, in consequence of its occasionally forming a large pallid tumour, is sometimes designated as hydro- cele by infiltration. The first two varieties alone, as requiring particular treatment, will be considered here. Hydrocele of the Tunica Vaginalis Testis. This is the most common form of the affection. The more characteristic symptoms by which it may be distinguished from other tumours of this region, are its fluctuation, its transparency, the permanency of the swelling, and the progress! veness of its development from the bottom of the scrotum upwards. An effu- sion of serum into ihe vaginal tunic, arising as an epiphenomenon in orchitis, has been denominated acute hydrocele, and usually disappears under the treatment calculated to dissipate the en- largement of the gland. In the chronic form of hydrocele there is little prospect of relief except by operation. The amount of fluid collected will be found to vary, according to tlie size of the tumour, from a few ounces to several pints. Mr. Cline is said to have removed six quarts from Gibbon the- historian at a single operation. Chronic hydrocele may be complicated with several aff'ections, rendering particular attention necessary in reference to the diagnosis. If the testis is found enlarged, either as the cause, the consequence, or an attendant upon the effusion, the tumour is denominated hydro- sarcoceh. If the collection of fluid is complicated with a hernial tumour, it is denominated an oscheo-hydroceh, the sac of water lying mostly to the outer side of the hernial protrusion. A dis- tinction of much practical importance is made between the hydro- cele of the adult, and the congenital form of hydrocele which occurs in the child before the peritoneal orifice of the vaginal tunic has been obliterated. Operations for hydrocele of the adult. — These are divided into two classes — the palliative, which consists merely in the evacuation of the fluid, and the curative, which comprises the several methods by incision, excision, introduction of the seton or other foreign bodies, and the injection of some stimulating liquid. Palliative cure. Evacuation of Ike fluid by puncture loith a trocar. (PI. LXI. fig. 1.) — The patient is to be seated on the side of his bed. The surgeon determines carefully the position of the testicle, which may be detected either by the peculiar sensation it gives on pres- sure with the finger, or by its appearing as an opaqne mass on examination in a darkened room, with a candle held on the opposite side from which the organ is viewed. This is a step which should not be neglected; — for I have several times, as in a case upon which I recently operated at the Philadelphia Hos- pital, found the testicle lying at the front and inner side of the vaginal tunic, and liable to have been injured in the operation if its unusual position had not been detected. The scrotum is to be grasped with the left hand as shown in the drawing, so as to render the integuments tense, and press the testicle out of tlie way, and the trocar entered at the middle front part of the tumour in such a direction as not to strike the gland. The stilet is then to be withdrawn and the fluid evacuated through the canula. Some direct the insertion of the trocar at the lower part of the tumour; but I find this a less eligible position, in consequence of the con- traction of the scrotum which follows the escape of the fluid ren- dering the direction of the instrument so oblique as to increase the risk of its slipping out from the vaginal sac into the surrounding cellular tissue, a result particularly to be avoided when it is the intention to follow up the puncture by the process of injection. The fluid is nearly always reproduced, so as to render the repe- tition of the puncture necessary every four, five, or six months — and it is merely from the temporary relief aff'orded that the term palliuHvc has been applied to this method of treatment. It is seldom, therefore, to he trusted to except in cases of children, where there is more reason to expect from it a permanent cure — or in the very large hydrocele of old men, where the fluid is found of a chocolate colour, and the vaginal tunic has undergone such pathological alteration as to render any of the more irritating methods for the radical cure liable to be followed by extensive suppuration and acute cedema of the scrotum. In the large hy- drocele of old men whose constitutions have been much broken up, simple puncture has in some instances been followed by sloughing and abscess. In making the puncture it is necessary to avoid the course of the large veins of the scrotum, and the arterial branches when these are so large as to be felt pulsating. I saw a few years ago, in consultation with Dr. Rutter of this city, an old gentleman who was in the habit of tapping himself with a lancet. He had performed the operation a hundred and thirteen times in the course of some years, but finally on intro- dacing the lancet in a transverse direction divided the spermatic artery. Profuse hremorrhage followed, which filled up the cavity of the vaginal tunic converting it into an hematocele, and injected the subcutaneous cellular tissue of the scrotum, groin, back part of the pelvis, and top of the thigh. The absorption of the blood from the cavity of the vaginal tunic, which was efi'ected at the end of a couple of months, was followed by a radical cure. Puncture at several points with an acupuncture or iarge sew- ing needle has latterly been employed. A small bead of scrum forms over each place of puncture with the needle. The fluid of the sac becomes effused into the subcutaneous cellular tissue, and is taken up by the absorbents so as to cause the speedy disap- pearance of the tumour. A radical cure is, however, but seldom effected by this process, which is now chiefly employed merely as a means of determining in doubtful cases the nature of the swelling. Radical cure. By injection. — After the evacuation of the fluid by the puncture with the trocar as above described, various stimulating fluids (by means of a gum elastic bag or a syringe the nozzle of which is well fitted to the canula) are thrown into the sac, and allowed to remain OPERATIONS UPON T^E GENITO-URINARY ORGANS. 309 a sufficient length of time to develops some sensation of heat and pain in the part, as well as shooting pain in the loins and in the direction of the spermatic cord. This requires, according to the nature of the fluids used, from two to six minutes, at which time they are to he carefully withdrawn again either by forcing them out by pressure through the canula, or by suction with the same instrument that has been used for the injection. Port wine, diluted alcohol, solutions of sulphate of zinc, copper, etc., and Lugol's tincture of iodine, are the materials that have been com- monly employed in injection. Of all these various preparations, that of the tincture of iodine, in the proportion of one part of the tincture to two, three, or four of water, is so incomparably supe- rior to all the rest that it has completely supplanted their use. In thirty cases in which the author has employed it, it has proved completely successful, and without producing — but in one single instance where the tumour extended nearly to the knee, and was of many years standing — any results calculated to excite serious apprehensions. The tincture of iodine may be considered the only fluid capable of exciting the requisite degree of inflam- mation in the vaginal tunic without some risk of suppuration and gangrene. The manner of employing it is as follows. From three to four ounces of diluted tincture, according to the size of tumour, is to be placed at hand. The water is then to be evacu- ated by puncture, as in the palliative treatment. A caoutchouc bag, with a brass nozzle exactly fitted to the canula lodged in the puncture, is then emptied of air by pressure, and t!ie nozzle introduced into the fluid, which will be sucked up by the elastic expansion of the walls of the bag. The surgeon then presses with the bag till the fluid appears at the mouth of the tube, and, ascertaining positively that one end of the canula is still lodged in the cavity of the vaginal tunic, fits the nozzle into the free end of the canula, and forces the fluid by gentle pressure into the sac. If there is reason to fear that the vaginal tunic communicates with the peritoneum, either from a congenital defect, or in consequence of the distension of the fluid which in large hydrocele is sometimes found to dilate the inguinal canal, pressure should be made either with the fingers of an assistant or a truss over the internal ring. After the fluid has remained for a minute in the sac, the bag should be allowed to expand to draw the fluid out, and allow of its being again injected. By distending the sac in this manner two or three times, and press- ing with the fingers upon different parts of the scrotum, all the folds of the collapsed serous bag are brought into contact with the fluid. As soon as the patient begins to complain of some heat and shooting pain, the fluid may be finally withdrawn by the bag. The canula is then removed, and the place of puncture covered with a small pledget. The sero-iymphatic effusion which resuhs from the inflammation excited by the iodine, in the course of a day or two enlarges the tumour again to half or two-thirds of its former size. But the serum is speedily removed by absorp- tion, and the lymph remaining unites the surfaces of the vaginal sac and eff'ects a radical cure. If there is so much pain or in- flammation excited as to cause suff'ering, which is but seldom the case, the parts may be leeched and fomented. The following processes were formerly much employed in the cure of hydrocele, though the greater success which has attended the iodine injections, has caused their nearly total abandonment. 78 By excision. (PI LXI. fig. 3.) — The excision of a piece of the scrotum and vaginal tunic, is a practice noticed by Celsus and Abulcasis. With the exception of Dupuytren, it has been viewed with but little favour by modern surgeons. It is painful and liable to be followed by violent inflammation and sloughing. The mode of its performance will be sufficiently well understood by reference to the drawing. v3 modijication of this operation has been successfully prac- tised by Kinder Wood, which is entitled to much greater favour. It consists merely in making a puncture through the skin with a broad-shouldered lancet, drawing out the vaginal tunic, and ex- cising a portion of it with a pair of scissors. The author has in three instances operated successfully by a process (PI. LXI. fig. 5,) nearly similar to this, in the hydrocele of children; but in one of the cases it was found necessary to repeat the operation. Bt/ incision.^This is also an old operation. It was the one very commonly employed, till the introduction by Sir James Earle of the principle of cure by injection. It however exposes the patient to pain and protracted suffering, and should only be practised, according to Sir A. Cooper, when the hydrocele is complicated with hernia, or with a suspicious state of the testicle, or, as mentioned by Mr. Curling, in cases (which are of but rare occurrence), where loose cartilages are found in the sac, like those of the bursal membranes. The skin and sac at the upper two- thirds of the tumour are to be laid open with the bistoury. For- merly flour was sprinkled in the cavity of the sac, or a mesh of lint introduced, in order to excite sufficient inflammation to cause the obliteration of the sac by granulation. A simple poultice applied over the wound, as directed by Cooper, will however usually be found sufficient. Some practitioners have combined with the simple incision above described, the partial or complete excision of the loose portion of the tunica vaginalis. The results of this modified operation are rather uncertain. It sometimes answers well — sometimes is followed by violent inflammation, and in other in- trances fails to effect a cure. By tents and c«n^^/^.— This is an old operation, and was practised by Sabatier, Boyer, and Larrey. It consists in making abroad puncture into the tumour, and after evacuating the serum introducing a mesh of lint or a gum elastic canula, for the pur- pose of producing active inflammation of the serous tunic. Baudens (PI. LXI. figs. 4, 8,) has modified this process by covering a long needle (fig. S, c, b) with a canula (a), pierced with a lateral orifice at its middle part. The little trocar is car- ried through the cavity of the tumour "by making two punctures of the skin at the distance of an inch and a half apart. The stilet is then withdrawn, and the canula secured in its position by a thread passed from the two free extremities in the form of the figure 8. The fluid of the tumour enters through the lateral orifice of the canula, and flows from the lower end of the tube as shown in the drawing. In the course of six or eight days the fluid secreted from the vaginal tunic, makes its way round the sides of the canula. The canula may then be withdrawn, and a fistulous orifice will remain which, according to Baudens, will close up spontaneously at the end of eight days more, when the radical cure will be found complete. By the seion.— This process was brought particularly into SPECIAL OPERATIONS. notice by Poit, It consisted in tapping the tumour at its lower part with the ordinary canulated trocar. Through the canula of this instrument he next introduced the proper seton canula — a silver tube five inches long, which was pushed up till its point could be felt through the integuments at the upper part of the tumour. Through the seton canula a long-eyed stilet charged with the seton, was passed up and brought out through the in- teguments, bringing with it the seton. The second canula was then withdrawn and the seton alone left in the wound, where it was retained till it had excited a sufficient degree of inflammation to cause the obliteration of the vaginal pouch. This process oc- casionally excites a continued suppurating discharge. It is, after injection, the process most commonly employed. In cases of children, when external stimulating apphcations failed to effect the absorption of the fluid, Sir A. Cooper introduced the aeton with a common curved needle transversely across the tumour. Hydrocele of the Spermatic Cord. In this variety of hydrocele the tumour is of a more cylindrical shape than in the more common form just described; from the latter it may, however, readily be distinguished, as it is developed downwards towards the scrotum, and never, however great is the enlargement, draws the integuments over the penis to the same extent. It might without care be mistaken for irreducible PLATE LXL-HYDROCELE. SARCOCELE. HYDROCELE OF THE LEFT SCROTAL CAVITY. Fig. 1. — Puncture of the hydrocele ivith a trocar. — The tumour is embraced with the left hand of the surgeon, in such a manner as to render its lower portion prominent. The trocar covered with its canula is introduced with the right hand in a direction obliquely upwards and backwards, so as to avoid the testicle. The fore finger is extended upon the instrument in order to limit the extent to which it penetrates. Fig. 2. — Excision of a portion of the skin and tunica vaginalis testis. — ^This old operation was practised by Dupuytren where, as he thought, the integuments were so abundant as to render it necessary to remove a part. The fluid is to be first evacuated by puncture, and the puncture itself extended upwards by an incision. A portion of the skin and serous sac is then to be removed, as shown in the drawing, with the forceps and scissors. Fig. 3. — ^ trocar laced as iii the ordinary operation for tapping. a. Lines of direction of the trocar; the oblique direction in which it is first entered is changed to the perpendicular, as shown by the dotted lines [b). As the fluid escapes and the cavity of the scrotum diniinishesj the canula as shown at «, is raised towards the pubis, c, d. Pott's method of introducing the seton, shown for convenience on the same figure. c. A canula, which has been introduced on a trocar in the ordinary manner, though entered more at the bottom of the scrotum. d. A pointed stilet which is entered through the canula, passes through the skin above and draws after it the seton. e. Usual position in which the testicle is found. Fig. 4. — Process of Baudens. — Puncture with the canula of this surgeon shown at fig. S, a, b, c. a. The canula, pierced with a hole upon its side, represented sheathing the trocar-stilet, the projecting handle of the stilet not being shown. b, c. The stilet shown separate and in two portions, for the sake of convenience of representation. The trocar and;canuta arc to be introduced into the sac in the ordinary manner, and then made to pierce the walls again at the bottom part of the cavity. The canula is allowed to remain after the evacuation of the fluid, as seen in the drawing. It serves the part of a foreign body to excite adhesive inflammation in the sac, and discharges the fluid as it accumulates by the orifice in its side seen at fig. 8, a. Fig. 5. — Extirpation of the thin reflected portion of the sac in cases of children. (Process of the Author.) — A puncture is made into the sac with the ordinary thumb lancet. As the fluid escapes it bulges before it a fold of the serous tunic. This is to be seized with the forceps, drawn out as far as it will readily come, snipped half across at its base, and again drawn out and the process repeated tilt a considerable part of the serous lining is removed. SARCOCELE. Fig. 6, — Ligature of the arteries of the cord, proposed as a means of arresting the groioth of a commencing sarcocele by causing atrophy of the organ. (Process of Maunoir.) — One of the spermatic arteries is represented tied — the other is raised on the grooved director, ready to be embraced by the ligature. Fig. 7. — Castration; or, extirpation of the left testicle for sarcocele. — A longitudinal division having been made of the coverings of the testicle, an assistant draws oR" one lip of the wound with the thumb and fore finger of each hand, while the surgeon loosens the attachments between the vaginal tunic and integuments with the knife. The cord is finally to be divided, and the organ detached as described in the text, Plate S7. On- SJoTLC by S CichoH-ski.. Fb-LLadKlphia., Published hy Ca-rey .& U.i.rt I'S.D. OPERATIONS UPON THE GENITO-URINARY ORGANS. 311 omental hernia, though the swelling is generally smoother and fluctuating, especially at its lower part. The diagnosis must be clearly made out in this affection before any operation can be warranted. The introduction of a seton, and the incision of the sac, are the processes generally resorted to for the cure. The author, however, has succeeded more satisfactorily in these cases by the use of the iodine injection — on one of which he has ope- rated during the past winter at the Philadelphia Hospital. Great care, however, is required in introducing the injection, to keep the canula from getting displaced from the sac, and in using but little force, for fear of rupturing the walls of the serous cyst, and filling the surrounding cellular tissue. For fear of this result, no other fluid but the diluted iodine can be deemed appropriate, as this would be but little likely to produce serious inconvenience, even though it were left in the cellular structure. Encysted Hydrocele. This form of the disease, in which the fluid is collected in cysts or vesicles, may be developed in the substance of the epididymis, between the tunica albuginea testis and its serous layer, or in the cellular structure of the spermatic cord. In the latter position we sometimes encounter a string or chaplet of separate cysts. These tumours, when so large as to produce inconvenience, are to be treated by simple puncture merely, by the seton, incision, or iodine injections. Hydrocele in the Child. — -Congenital Hydrocele. Congenital hydrocele consists in the accumulation of scrum in the vaginal tunic, before the peritoneal orifice of this passage has been closed at the internal ring. It is distinguished by the facility with which the fluid may be forced by pressure into the cavity of the abdomen. It may show itself at any period between birth and the sixth or eighth year. The pressure of the fluid into the abdomen, and the nice adjustment of a common hernial truss, usually suffices for its cure. If it should not, the palliative cure by puncture might be tried, or the process of Kinder Wood as modified by the author. Desault and Velpeau have effected a cure in some instances by the process of injection, using the pre- caution to make pressure at the ring, in order to avoid the escape of the fluid into the cavity of the abdomen. In a young child this process fortunately is seldom needed, and would be attended with more or less danger. In many instances of hydrocele in children the peritoneal passage will be found closed, and the tumour, corresponding in appearance with that of the adult, indicates the same method of treatment. The milder processes, however, that simply by punc- ture with the lancet, trocar, or acupuncture needle, and iodine injection, are chiefly relied on where the tumour cannot be dis- persed, as it frequently may be, by local applications. In four instances the author has employed with advantage the following process, which he has since discovered to be analogous in many respects to that of Kinder Wood. p7-ocess of the Jiittkor.* — The swelling is to be punctured iu front and below Its middle with a broad thumb or abscess lancet. As the serum flows, a little pressure causes the thin serous tunic • Vide Americaa Med. Library and Intelligencer, June, 1843. to protrude in the form of a cyst. This is to be laid hold of witii the forceps, and drawn out as far as it will yield. The lower half of the cyst nest the skin is then to be divided with a pair of scissors, and making traction again upon the cyst, still more of its wall is to be drawn out and snipped in like manner as before with the scissors. By repeating this process, a large part of the loose vaginal tunic may be removed.. The operation is attended with scarcely any pain, and the child may be allowed to run about as usual. Hydrocele in the female. — It maybe well to observe here, that hydrocele is occasionally found in the female, either in the course of the round ligament or in the cellular substance of the labia majora. A case of the latter description I have had recently under charge at the Philadelphia Hospital. The evacuation of the fluid contents by puncture is usually attended with only temporary benefit. The injection with the diluted tincture of iodine, is the process principally to be relied on for the cure. SARCOCELE. This vague term is applied to any chronic degeneration of the testicle, whether tuberculous, syphilitic, or encephaloid — affec- tions which are very different in their nature. The operations which have been employed in these cases, ivhen all medical measures have proved unavailing^ consist of ligature of the ves- sels of the testicle, and castration; the latter being the only one that can with any confidence be relied on in unequivocal cancer. Though the nature of this work does not allow the auliior to enter into the particular study of these affections, it may be well to observe that the researches of modern pathologists have greatly narrowed the proportion of cases in which so serious an operation would be justifiable. Ligature of the spermatic vessels. (Process of Mamioir, PI. LXI. fig, G.) — An incision an inch and a half long is to be made so as to expose the cord just below the external abdominal ring; the spermatic and other arterial branches of the cord are to be isolated by a careful dissection. Each artery is to be tied with two ligatures, and divided across. Maunoir also recommends the complete section of the cord after the ligature of the vessels, leaving the testicle in place, which subsequently becomes atro- phied. This process, which has been successful iu some in- stances, has not yet been sufficiently tested to entitle it to much consideration. Process of Morgan. — This consists merely in the excision of a portion of the vas deferens an inch or two long, and closing the wound by first intention, without disturbing the other vessels. Castration. This operation may be divided into three periods — the division of the coverings, the dissection of the testicle, the division of the spermatic cord and the ligature of the vessels. The patient should be placed semi-recumbent on a table or a bed, with his legs separated and supported on a couple of stools. The hair should be shaved from the parts, and the rectum and bladder emptied prior to the operation. ■ In cases of doubt as to the state of the testicle in hydro -sarcocele, a small exploratory incision may be made with the bistoury, to evacuate the fluid and determine the character of the glandular affection. 312 SPECIAL OPERATIONS. Incision of ike integuments. — The operator takes the scrotum in the palm of his left hand, and with the tliiimb and fingers stretches tense the coverings in front of the gland. These are now divided, with one stroke of the knife, from the external ab- dominal ring to the bottom of the scrotum. An incision to this extent is required partly for the convenient removal of all the diseased parts, and partly foj- the purpose of leaving no sac at the bottom of the pouch as a receptacle for pus. If any portion of the skin is diseased or even adherent in front of the gland, it is to be embraced by two elliptical incisions. Some of the branches of the external pudic arteries which are found enlarged, may require to be tied. Dissection of ike testicle. — An assistant now grasps the skin of the scrotum, as shown in the drawing, and if possible everts or enucleates the testicle with its investing vaginal tunic. If the tumour is small, the attachments of the gland will be slight, and found at the posterior and inferior part of the scrotum. If the adhesion is more extensive, the surgeon draws the tumour to one side with his left hand, and detaches it upon the other with the knife, taking care to avoid cutting the urethra, the septum scroti, or the gland of the other side. An assistant next draws the testicle in the opposite direction, and the surgeon, pressing down the margin of skin, loosens the remaining attachments with the knife. Division of the cord. — An assistant is now to sustain the weight of the tumour and prevent its dragging on the cord, while the surgeon raises and divides the cremaster muscle on the front of the cord, and isolates the latter by passing his finger below it. Having ascertained that the disease has not extended beyond the point at which the cord is exposed, the surgeon either ties it firmly at once in a mass with a strong ligature and completes the ope- ration by dividing it below the ligature and detaching the tumour; — or adopts the practice of Desault, and divides it obliquely over the finger little by little with the knife, pausing to take up sepa- rately each one of the arterial branches as they bleed; for if the cord was divided at a single stroke, it would be disposed to retract (and more especially if not well loosened from the cremaster) into the inguinal canal, so as to render it difficult to check the hemor- rhage from the divided vessels. The ligature of the cord in a mass is more certain to prevent bleeding, and though it has been objected to as more painful and more liable to be followed by tetanus, the author, after repeated trials of both processes, is dis- posed with Velpeau and Malgaigiie to accord to it the preference. Many surgeons prefer to divide the cord previous to the isola- tion of the gland, as a means of diminishing the pain attendant on the operation. This is a practice that may be adopted at the will of the surgeon, when he is certain that the disease does not extend along the vas deferens or other constituents of the cord above the external ring. But when it becomes necessary, either by drawing it down or slitting np the tendon of the external oblique, to divide the cord above this point, or it is desirable to remove some of the glands in the vicinity of the root of the penis, the author has found it most advantageous to retain the testicle in connection with the cord. Dressing.— ThQ ligatures of the cord are to be brought out at the upper angle of the wound. The divided arteries of the scro- tum should be tied and the threads brought out at the nearest ■ point. A strip of oiled linen maybe interposed between the lips at the inferior end of the incision, and the wound closed with a couple of sutures and one or two adhesive straps, supported with a compress and a T bandage. The patient is to be placed in bed, with his thighs and thorax in a flexed position. The sutures should be removed on the sixth or seventh day. The wound usually closes in the course of three or four weeks. In case a hernial tumour should unexpectedly be discovered behind the testicle, as in one or two instances has been the case, considerable embar- rassment might arise, as the hernial contents if not injured in the operation would be liable to protrude after the division of the cord. When, therefore, the cord appears unusually large and tumid, the surgeon should examine it with particular attention previous to dividing it with the knife. A few cases are on record in which it has been found necessary to remove a testicle which had remained above the external ring — the principal peculiarity of the operation being that of beginning the operation higher up, and extending the incision through the tendon of the external oblique. VARICOCELE AND CIRSOCELE. Varicocele consists m a varicose enlargement of the veins of the scrotum. Cirsocele is an analogous enlargement of the proper venous plexus of the cord, known under the name of corpus pampiniforme. Though these affections are occasionally the source of much physical and moral suffering, they neither of them involve the risk of life. In a majority of cases the symp- toms to which they give rise may to a great extent be palliated by the habitual use of a well-fitted inelastic suspensory truss, and it is only in instances where this simple contrivance fails to afford relief, that the attempt to effect a radical cure by bolder measures can be deemed justifiable, since the various processes by which the radical cure is achieved are, as experience shows, occasionally attended with more or less risk of phlebitis and atrophy of the gland. These several processes may be arranged under four principal heads — 1, division or excision of the veins; 2, ligature; 3, compression ; 4, shortening of the scrotum. 1. By division or excision. — This is an old process. Celsus cut down upon the veins, and, according to circumstances, either tied or extirpated the whole cluster of varicose vessels. This practice, in which he was followed by most of the older surgeons, has been rejected by the modern. Sir Benj. Brodie, however, advises the division of the varicose vessels with the knife. He exposes tiiem by an excision at the posterior part of the scrotum, and simply cuts them across with a sharp-pointed bistoury. The haimorrhage which follows is readily checked by cold applica- tions, and the wound is left open to allow the blood to escape. Some inflammation and swelling, but no serious symptoms ac- cording to this surgeon, follow the operation. 2. By ligature. — The old practice of cutting down upon the vessels for the purpose of tying them has long been abandoned, in consequence of its liability to be followed by phlebitis, which under such circumstances has been the cause of death. Various ingenious processes have latterly been devised for applying the ligature so as to diminish this risk. I^rocess of Davat. — This surgeon first proposed to pass a needle or pin under the veins, (between them and the vas defe- OPERATIONS UPON THE GENITO-URINARV ORGANS. 313 rens)— strangulating them by surrounding the pin with a thread, as described in the operation for varicose veins of the leg. The vas deferens, in consequence of its wiry hardness, can usually be readily distinguished from the veins, and should be carefully separated. The process of Uavat, however, is not found so well suited to the veins of the scrotum as to those of the leg. Process of Reyncnid. — This surgeon separates the spermatic nerves and vessels from tlie vas deferens with the thumb and fin- gers of the left hand, and between them passes a waxed thread with a needle, through the two sides of the fold of skin. When the fold is relaxed, the places of puncture should appear about an inch part. The two ends of the thread are then tied in a bow knot over a short but thick cylinder of linen, so that the compres- sion may be subsequently increased or relaxed at the will of the surgeon. A simple compress laid over the apparatus is all the dressing required. If much pain or intlammation immediately follows, the thread may be slightly loosened. Tliis, however, is seldom requisite. The thread is to be successively tightened at intervals of two or three days. In the course of fifteen or twenty days the vessels and nerves of the cord are usually found divided. The thread is then to be withdrawn, and the portion of skin included between the punctures severed with the knife. M. Vidal has modified this process by substituting in place of the thread a silver wire, which he merely twists over the cyHnder. Process of Ricord. Subcutaneous operation. — The loop of a double ligature is carried with a lance-pointed needle between the veins and the vas deferens, as in the process just described. A needle charged with another double ligature is then entered from the puncture last made, and brought out at the first place of puncture of the skin, but passing so as to lodge the second ligature between the veins of the cord and the skin. The loose ends of each ligature are then passed through the corresponding loop of the other, which is lodged in the same place of puncture. The ends arc then drawn in opposite directions; the loops slide in through the cutaneous punctures, and all the constituents of the cord, with the exception of the vas deferens, is constricted be- tween them. The constriction is kept up and gradually increased from time to time by a sort of tourniquet shaped like a horseshoe, over the ends of which the threads are brought up to avoid the strangulation of the skin intermediate to the places of puncture. At the end of from ten to twenty days the ligatures are found to move freely from side to side, and may be withdrawn. Modification of this subcutaneous process by the Author. — In four instances I have employed with success the following pro- cess, described in the Philadelphia Medical Examiner for March 4, 1S43. "Previous to the operation, the patient is to be directed to walk about for an hour or two with the scrotum unsupported, so as to cause an accumulation of blood in the enlarged veins. He is to be seated on the side of his bed, with the legs separated. The thumb and fore finger of the left hand are then to be pressed in, so as to lift up the enlarged veins, and thus separate them from the vas deferens. This duct is readily distinguished by its hard and wiry feel, and is to be pressed otF with the nail of the left fore finger towards the os pubis. A long, round, lancet- pointed needle, curved near the point like that of the sail-makers, and threaded with a piece of fine but strong hempen twine passed double through the eye, is then carried between the bundle of 79 veins and the vas deferens; entering it on the side of the thumb, and bringing out the point against the pulpy portion of the finger. The loop of the double ligature is to be detached from the needle; the ligature being left in the track of the wound. The needle, without being threaded, is again to be entered through the same orifice of the skin as before, but carried this time between the skin of the scrotum and the veins of the cord, and its point brought out through the other puncture made in the skin on the side next the pubis. To facilitate this step, the skin should be lightly raised up from above the veins with the thumb and finger. If there is any enlargement of the subcutaneous veins of the front part of the scrotum, as there was in one of my cases, I carry the point of the needle so as to scrape the under surface of the skin, and get it in front of these veins. The needle is now to be left in the wound. I manage to have the place of entry of the needle lower than its place of exit; so that the point of the instrument, which should be pushed well through, may lie undisturbed, without pressing over the root of the penis. The course of the instrument across the cord will be, therefore, rather diagonal than trans- verse. The loop of the ligature (which lies nest the pubis) is now to be thrown over tlie point of the needle. Traction is next to be made upon the other side, upon the loose ends of the liga- ture, so as to draw the loop along i!ie needle, through the orifice in the skin. One tail of the ligature is now to be drawn out for four inches, so as to shift the portion of the thread, forming the loop over the needle, for fear that this might have been cut by the point or edge of the needle, so as to break when subsequently knotted. The loose ends of the ligature are then to be tied with a single knot over the shank of the needle; this is to be drawn as tightly as possible, so as to completely strangulate the veins of the cord, which will be thus enclosed by the double ligature on its back part, and the needle in front. To make the stran- gulation more eff"ectual, the two ends of the loop thus formed over the needle may be slid towards each other, by pressure through the skin, and the knot again tightened. This step is followed by severe pain, which gradually diminishes, and at the end of half an hour ceases almost entirely. To be able to tighten the ligature again at the end of two or three days, when it will be found loosened by having partially cut through the compressed mass of veins, I slide an oblong piece of sole leather pierced in the centre and notched at the ends, over the heel of tlie needle, and make a firm double bow knot of the ligature above it. The point of the needle is to be sheathed in a small cork, and a com- press placed below it to prevent its worrying the skin. A piece of thick tape is to be passed through the eye of the needle and knotted, in order to prevent the needle when it becomes loosened by suppuration, from being pressed through the hole in the leather by the movements of tlie thigh, so as to detach the loop. The scrotum is to be slightly supported by a couple of silk handker- chiefs, folded, and placed below it. No dressing is required. If neuralgic pains arise, they are to be soothed by hot fomentations, and the administration of anodynes. I untie the ligature over the leather every third day for three successive periods, tightening it again as much as possible at each time. On the eleventh I remove the needle; the loop, which is then left detached, and will be found but small from the successive tightenings, is at the same time withdrawn. Above the place of the ligature, the condition 314 SPECIAL OPERATIONS. of the cord will be found perfectly natural; below it, will be found a hardened mass of the size of a walnut, formed by the effusion of lymph, between, and in all probability in the cavities of the veins, causing their complete obliteration. The pain attending this process of cure is but trifling, except at the periods when the loop is tightened. There is no injury done to the integument, such as to leave an obvious scar after the cure is completed, for the needle, if introduced in the manner I have mentioned, lies so completely at rest, as to cut but very slightly at the places of puncture; and as it makes no pressure in the downward direction, cannot by any possibility impair the integrity of the vas deferens. After the withdrawal of the needle, a light poultice may be laid for a few days over the part, to promote suppuration from the points of puncture, and to facilitate the resolution of the tumour left — a result which is quickly effected. "The advantages of this method of operation will, I think, be found sufficient to recommend it to the notice of practitioners. The plan of cure recommended by Sir A. Cooper, which involves the excision of a part of the scrotum, is severe, dangerous, and inefficacious. The methods of Breschet and Ricord are compli- cated by the use of a cumbersome apparatus. Tiiat of Reynaud is attended with a division of the integuments, which leaves, like the three former, a permanent cicatrix, and the modification of this, as suggested by M. Vidal, appears by no means free from objections. "By the modification which I have proposed, it is possible at any moment, in case the strangulation of the veins and nerves of the cord should give rise to obstinate neuralgic pains or retention of urine, to relieve the patient by slackening temporarily the liga- ture, and to shorten the period of treatment by removing the ligature, when the effusion of lymph has completely obliterated the diseased veins, without waiting for it to cut entirely through the enclosed parts. But should it be deemed necessary in certain extreme cases to have this division effected, thereby to present an additional obstacle to the return of the disease, as when the effusion of lymph does not seem sufficiently abundant, we can accomplish the result the more readily by this melbod, which gives us the power to tighten the loop from time to time, in pro- portion as it becomes loosened. " By keeping the cavity of the veins in the grasp of the ligature thus constantly closed, the risk of purulent absorption from the veins below is greatly diminished, if not entirely removed; for the constituents of the cord above the site of the operation are scarcely at all affected. The details of the operation are given for the left side, for it is upon that, almost exclusively, that the disease is found to exist, in consequence, it is most probable, of the entry of the left spermatic veins into the emulgent at a right angle to the course of the latter; while those of the right open into the vena cava nearly parallel with the direction of that vessel." 3. By compression. (PI. LXII. fig. 5.) — This is thought by many a safer means of obliterating the veins than either of the foregoing, inasmuch as the risk of phlebitis is diminished, by the instruments employed not being brought in immediate contact with the coats of the veins. The following method, lately de- vised by M. Breschet for this object, has been received with considerable favour. A pair of forceps, well padded, the con- struction of which is shown in the drawing, is to be tightened with a screw over an elevated fold of skin which includes the enlarged veins, so as to force the sides of the vessels together, and cause the obliteration of their cavities by the coagulation of their contents, and the inflammation which the pressure developes. Before the application of the instrument, the patient should take a warm bath, or walk about with the scrotum unsupported, to aOow the veins to become distended, as they will in this stale be better retained within the grasp of the forceps. Two of these instruments will usually be required. They should be applied transversely over the scrotum, but so as not to include the septum scroti nor the vas deferens, which should be carefully held out of the way by an assistant. The instrument is to rest over the scrotum upon a pad of lint or a light compress, and be supported by some adhesive straps attached to the abdomen. This opera- tion, though protracted, causes little pain. The compression is to be gradually increased from time to lime, till it transforms the parts embraced into a dry, thin, parchment-iike eschar. The PLATE LXn,— OPERATIONS UPON THE PENIS AND SCROTUM, Fisr^ 1. — Sppearance of the penis in a case of hypospadias, in wiiich the urethra opened by a longitudinal sUt immediately in front of the scrotum. No urethral canal existed in front of this abnormal orifice. The penis was held bent downwards by the contracted skin of the scrotum. Pig, 2. — Operation for the cure of the deformity shoivn in Jig. 1. — A transverse incision is made in front of the skin of the scrotum, for the purpose of dividing the contracted tissues, and allowing of the straightening of the penis. A trocar and canula has been passed from the fistulous orifice under the skin to the apex of the glans, in order to form a new urethral passage. Fig, 3. — In this figure the steps subsequent to the operation in fig. 2, are shown. The edges of the fistulous orifice have been made raw and closed as well as the transverse wound with two points of the hare-lip suture, over a sound, left in the passage to preserve it patulous. Fig. 4. — Jl?npiitation of the penis for caficer. Fig. 5. — Operation for varicocele. (Process of Breschet.) (A). The peculiar forceps devised by this surgeon for the cure of varicocele. They are shown appUed at two different points of the scrotum, so as to embrace the skin and the bundle of varicose vessels raised with it. A compress is interposed between the skin and the instrument, the blades of which are tightened by a couple of screws. OPERATIONS UPON THE GENITO-URINARY ORGANS. 315 ulcer which follows the detachment of the slough usually cica- trizes in a short time. A neio and singular method of effecting a cure by compression has recently been proposed, but which has not as yet been suffi- ciently tested to entitle it to much consideration. It consists in "wearing a truss, so constructed as to exert a constant pressure upon tlie spermatic vessels just below the abdominal ring. It is said that the varicose veins, which enlarge by a slight pressure against the abdominal ring — a circumstance that enables us to distinguish varicocele from hernia — become actually diminished in size under firm and constant pressure. If this effect should be owing to the obstruction of the spermatic arteries by the pres- sure, it would be a question whether it would not be safer and attended with less risk to the spermatic duct, to cut down upon and tie the spermatic arteries, as practised in these cases by Maunoir and Amussat. 4. Shortening of the scrotum.— The only object of this pro- cess is so to diminish the dimensions of the scrotum, as to make it serve the part of a suspensory bandage. The following operation was devised for this purpose by Sir A. Cooper, but it has been and probably will be followed but little by any other surgeon, since nearly as good palliative results may be attained through the use of the ordinary bag truss. It consists in drawing out the relaxed part of the scrotum with the left hand, and removing it with the knife or scissors; the testicle being protected from injury by an assistant who draws it up towards the external abdominal ring. The bleeding vessels are nest secured, and the wound closed by sutures. A suspensory truss is then applied, and the patient confined to his bed for a week or ten days. Process of Lehman.— ThXs consists in invaginating a portion of the scrotum on the finger, and fastening it by sutures at the abdominal ring, as in Gerdy's operation for the radical cure of hernia. It is, however, but little to be relied on. Process of fVormald. — This process is at least ingenious and simple, and is said to have been attended with benefit. It con- sists in drawing the lower and loose part of the scrotum through a ring of soft silver wire, an inch in diameter, well padded, and covered with wash leather. The sides of the ring are then pressed together, so as to prevent the included portion from escaping and give permanent support to the dilated mass of veins. The ring should be constantly worn during the day, and laid aside at night. OPERATIONS UPON THE PENIS. These comprise operations for Phimosis, Paraphimosis, Can- cer, Hypospadias, and Epispadias. FOR PHIMOSIS. This aflection may be either congenital, or acquired as the result of gonorrhceal inflammation or preputial chancres. In the former case it is termed natural, in the latter preternatural phimosis. The operations for the relief of this aflection, consist of incision, excision, and circumcision. Of incision. — This is but a simple operation, A grooved director is to be passed between the prepuce and the glans, up to the collum of the penis. Along this the surgeon glides a straight sharp-pointed bistoury, pierces the upper part of the prepuce, and divides it from within outwards to its free border. An assistant previous to the incision should draw the skin of the penis back- wards, so as to prevent the division of the integuments to an un- necessary extent. The mucous membrane is found divided to a less extent than the skin, and requires to be opened farther with the scissors. A large open wound results, which may be dimi- nished by stitching together the edges of the skin and mucous membrane. By the ordinary process, the section is made over the upper surface of the glans. This, however, leaves two flapping dog's-ear-like appendages, which will in many cases require to be subsequently excised. As a means of rendering the deformity less obvious, J. Cloquet directs the incision to be made on the under surface of the glans by the side of the frenum. In introducing the director for this object, care must be observed that it does not pass into the urethral orifice, the wall of which has in some in- stances been split with the bistoury in the operation. When the margin only of the mucous membrane is thickened, the process of CuUerier and Coster, which consists merely in introducing a probe-pointed bistoury, so as to nick the margin at several points at equal distances from each other, and thus unbridle the orifice, may be found to answer. By excision. Process of Lisfranc. — This consists in the remo- val of a semilunar portion of the prepuce from over the dorsum of the glans, with a pair of strong sharp scissors curved on the flat. The top of the piece removed should correspond with the middle portion of the glans. Process of the Jiuthor. — Having in the operation for phymosis usually found the mucous membrane thickened, rigid, and short- ened, so as to be deprived of its natural degree of elasticity, I have within a few years past been in the habit of performing the following operation, which has furnished results infinitely supe- rior to any with which I am acquainted. Three of these opera- tions have been performed before the class of the Philadelphia Hospital during the past winter. The patient is to be seated upon a chair or on the end of a table, with his legs separated and supported by a couple of stools. An assistant supports the organ and draws back the prepuce, so as to distend its narrowed orifice as much as possible against the end of the glans. With a pair of straight, sharp, strong, but blixut-pointed scissors, one blade of which is passed between the glans and the prepuce, I excise a A shaped piece at two cuts over the dorsum of the organ. The base of the piece corresponds with the orifice, and should be left as broad as the orifice will admit; the apex should reach to the middle of the glans, and the incision extend through the skin and raucous membrane. On the removal of the piece, the assistant draws the skin back as far as possible; to this no resistance is now offered, unless there should be some adhesions between the glans and prepuce that require division. The rigid mucous mem- brane will be left covering the base of the glans; it is to be opened from the lop of the A incision up to the corona, and each segment of it raised separately with the forceps, and clipped away at a sin- gle running stroke with a pair of curved scissors completely down to the side of the frenum, leaving of it nothing but a narrow rim a line in breadth at the point at which it is reflected over the glans. The flaky secretion usually observed in these cases over the glans, is to be washed away. The assistant still retains the 316 SPECIAL OPERATIONS. divided skin of the prepuce inverted over the body of the organ, while the surgeon introduces with a deUcate needle three slender sillv ligatures on either side of the glans, each one passing through the rim of mucous membrane left and the margin of the divided sldn. The complete success of the operation depends on the nice adjustment of the sutures. The object of them is to invert the skin and make it serve the place of the thickened mucous mem- brane which has been removed, and at the same time draw the divided edges of the dorsal portion of the prepuce, which is loose and movable, downwards towards the gians, so as to give to the orifice at once its natural rounded appearance. This is effected by introducing the two lower sutures through the mticous rim close to the frenum, and carrying the threads obliquely upwards, passing them next through the edge of the skin at the distance of a quarter or three-eighths of an inch from the frenum. The two middle threads are to be attached on either side to the mucous rim at the junction of the lower with the upper two-thirds of the gland, and to the skin at the same degree of obliquity with tlie first. The two upper threads pass from the mucous rim at the junction of the upper third with the lower two-thirds of the gland, to the skin about a quarter of an inch on either side of the middle line on the dorsum of the penis. The two lower threads are to be tied first, and the others in succession, and all the ends cut off close to the knot. The cut margins of the skin and mucous membrane are now brought in apposition. The surgeon rolls the prepuce with his thumb and finger over the glans, and the operation is completed. In case the rules just given are closely followed, no raw surface will be presented, and the orifice — which will be from a half to five-eighths of an inch in diameter — will appear at once almost perfectly natural. No dressing will be required except keeping the parts wetted by a cold lotion, as a measure of precaution against erections. Union takes place by first intenlion, and will in four or five days be found complete. The prepuce may then be inverted, and the ligatures, if not already detached, cut and withdrawn ; previous to this period the parts should not be disturbed. If the lower thread be not adjusted as above directed, a pouch of skin may be formed by the side of the frenum which will be distended by an albuminous eff'usion. In one of the instances in whicli I performed the operation during the past winter, such a result followed. It is, however, a circumstance of little moment, as the tumour to which it gives rise is in a little lime removed by the absorbents. In cases where the orifice of the phimosis is too narrow to give a base to the A shaped piece, it should be dilated by a slight incision on either side. I liave, however, under such circumstances, succeeded nearly as well by simply making a vertical incision over the dorsum; though it then becomes necessary in excising the mucous membrane to clip away with it the entire fold which it forms with the skin by the side of the frenum. This operation of the author wUl be found suited to almost any form of natural phimosis, and is certainly the one attended with the least amount of suffering, and the most speedy cure. In preternatural phimosis, where the margin of the prepuce forms a hardened ring, the following process will be found the most appropriate. Circumcision. Process of Ricord. — This consists in the am- putation of the prepuce, by a slight modification of the rite as practised by the Jews. Ricord directs the prepuce to be drawn forwards, and the line of incision to be traced wkh ink or nitrate of silver. Then relaxing the hold of the prepuce, the surgeon is to notice whether the Hne for the incision falls too far behind the corona. Having determined the proper line, the prepuce is again drawn in front, and grasped between the blades or handles of a pair of long forceps, which should rest against and parallel with the face of the glans; the part in front of the instrument is to be shaved off at one stroke with the bistoury. The skin is then to be retracted, and the mucous membrane slit up to the corona and excised with the scissors at its hne of attachment to the glans, as in the process just described, except that it is necessary in this operation to clip away also the fold of the frenum. No sutures are directed by Ricord, but the cure will be considerably accelerated by attaching the skin to the margin of the mucous membrane by five or six stitches. The parts are to be kept wetted by a cold lotion, and the patient should be put under the occasional use of camphor and opium, to prevent the occurrence of erections. In dissecting the parts in these cases, I have commonly found the mucous membrane so thick and unyielding, as to feel when grasped between the thumb and finger like a fibrous cord, and so inextensible that all the elongation of the prepuce by traction in front of the glans, is made by the inversion of the proper skin of the penis. In consequence of this, if the operator simply ' grasps the end of the prepuce within the thumb and finger draws it in front, and then applies the forceps and amputates the part before the instrument, he will in some cases find that he has merely skinned the penis behind the glans. To obviate this risk, I consider it better, though somewhat more painful, to draw the prepuce forwards by a couple of small hooks inserted into the skin near its junction with the mucous membrane. PARAPHIMOSIS. This is a more troublesome and more serious affection than the preceding, and consists commonly in the strangulation of the glans, when in cases of phimosis the narrow orifice of the pre- puce has been retracted and become fixed behind the corona. If relief be not speedily afforded, there will in many cases be immi- nent risk of mortification of the glans. In recent cases, the glans may be readily reduced by pressing it steadily and firmly for some time between the thumb and fingers of one hand, so as to diminish its size by emptying its swollen vessels, grasping the organ with the other behind the place of constriction and pressing in opposite directions. If this process does not prove successful, the integument of the penis may be embraced behind the place of strangulation between the index and middle finger of each hand, and drawn forwards while the two thumbs make pressure backwards upon the glans. In case of failure by this means, a stream of cold water may for some lime be poured upon the part, some punctures made in the prepuce to diminish the oede- matous swelling, and the processes again repeated. In some instances it may become necessary to relieve the stricture with the knife by one of the following processes. Process of Hunter. — Draw the skin on the two sides away from the stricture so as to expose it fairly, and divide it by pass- ing under its edge a sharp-pointed curved bistoury with its back to the glans. The incision has in some cases to be repeated at OPERATIONS UPON THE GENITO-URLVARY ORGANS. 317 several points. This, however, is not easily accomplished, in consequence of the bulging crown of the swelled glans. Process of Richler. — This consists in raising a fold of skin behind the stricture with a pair of forceps, incising the fold, and introducing from the opening a grooved director strongly curved at the end, under i[ie margin of the narrowed prepuce, which is then to be divided with a knife run along the groove. Even after the strangulation is relieved by the division of the stricture, it will in many cases be found difficult to bring down the fore- skin, in consequence of the distension of its cellular structure by a consistent albuminous effusion. I have under such circum- stances, as well as in simpler forms of the disease in children, found warm fomentations highly advantageous in soothing and relaxing the parts, and gradually rendering the prepuce movable. When paraphimosis has been suddenly developed in gonor- rhosa, as a consequence of acute oedema of the lower part of the prepuce, active antiphlogistic measures, with warm mucilaginous applications to the part, have in my hands sufficed in a short time for the cure. CANCER OF THE PENIS. When the prepuce merely is affected with cancer, the swelling of its loose cellular structure pushes the glans backwards, so that at first sight the body of the organ appears involved. It has been asserted by Cailisen and Lisfranc, that cancer of this organ usually commences in the integuments, and remains so long without involving the fibrous involucrum, as to enable the surgeon in some instances to extirpate the disease by the following process, without shortening the essential structure of the penis. But under any circumstances the operation for genuine cancer of the penis is, from the rapidity with which the glands of the groin and pelvis become involved, according to the experience of the author, one of the most discouraging in surgery. Process of Lisfranc. — When the cancer is seated at the end of the penis, a longitudinal incision is to be carefully made over the back of the organ, through the whole extent of the affected portion, down to tlie involucrum. If (he involucrum is not in- volved, the diseased tegumentary layers merely are to be dissected off. If there are any suspicious points upon the involucrum, they are to be raised with the hook or forceps and carefully shaved away. If the body of the organ is invaded by the disease, it is necessary to resort to amputation. tdmpiitatioJi. (PI. LXII. fig. 4.)— This operation is chiefly re- quired in cases of cancer, though it has in some few instances been deemed necessary for aneurism of the cavernous structure, and in instances of gangrene. In consequence of the great exten- sibility of the integuments of the part, and the tendency of the cavernous body to retract after division, the common rule in amputation for saving as much of the skin as possible, does not apply here, it being found most advantageous to divide both structures upon the same level. Various processes have been devised, but the following will be found the most appropriate. An assistant, standing behind the patient, grasps the penis near its root between his thumb and finger, so as to compress its vessels. The surgeon takes in his left hand the diseased extremity of the organ, which should be 80 covered with a piece of linen, and with a long-bladed bistoury in his right divides the skin immediately behind the limits of the disease. He then examines carefully into the condition of the body of the organ which is now exposed, and divides it as far forwards as the affection will admit, with one stroke of the knife, from below upwards. The arteries, divided— the dorsal and cavernous of either side— are now to be drawn out and se- cured as under ordinary circumstances. Cold applications and slight compression will usually suffice to check the oozing from the spongy structure. A flexible gum catheter should be intro- duced into the bladder, for the double purpose of preventing the narrowing or closure of the urethral orifice, and keeping the urine from coming in contact with the wound. The catheter is to be secured in its place with tapes, and the skin merely drawn over ihe stump and retained in place by two adhesive straps crossed in front. HYPOSPADIAS. This consists in a congenital malformation of the urethra, in which the canal opens, at some point on the under surface of the urethra before it reaches the glans. There are three varieties of this affection: — 1, when the abnormal orifice is found behind the frenum, the fossa navicularis opening directly on the surface, the prepuce being cleft back beyond this pouch; 2, one in which the urethra opens at some point between the fossa navicularis and the scrotum; and, 3, when the scrotum is split in the median line, so as to form two portions like the labia majora of the female, and the urethra opens at the bottom of the fissure. The first two varieties alone alford any prospect of relief by operation. First variety. — This is the one by far most frequently ob- served. It is seldom that any operation is called for ?nerely on account of ihe shortening of the nrethra; and such as have been proposed — the perforation of the under part of the glans with a trocar, retaining a catheter in the passage till the abnormal orifice can be made to close— or the splitting of the glans from the orifice outwards, and uniting the margins of the incision over a catheter introduced into the bladder— allbrd but little prospect of improving the patient's condition. In some instances, however, in consequence of the relative shortness of the corpus spongiosum compared with the cavernous body, the glans in erection is bent downwards at an angle so as to form a club-shaped extremity, thus rendering the subject of the defect virtually impotent. A deformity of this description was remedied by Dr. Physick by the removal of a wedge-shaped piece from the back of the corpus cavernosum by two sloping cuts with a razor. During the pre- sent winter I have, with the assistance of Professor Horner, been completely successful in a case of much interest in relieving a similar deformity by the following operation. In the case alluded to the curvature was abruptly made just behind the junction of the glans with the point of the cavernous body. On a close examination of the organ it was found that it would be necessary, in order to raise the face of the depressed glans up to the level of the dorsal line of the cavernous body, to remove from the latter a wedge-shaped piece which should have the breadth of an inch upon the upper surface of the organ. As the glans receives its blood in a great degree from the arteries which advance to it along the corpus spongiosum, it was but little 318 SPECIAL OPERATIONS. likely the operation could endanger its vitality. Tlie patient was seated in a chair. A longitudinal fold of the integuments was raised over the dorsum, and divided transversely by a bistoury entered at its base, about half an inch behind the corona. The divided portions of the integuments were then separated so as to expose the cavernous body. The cavernous body was next flattened by being grasped transversely with the thumb and finger, and a straight sharp-pointed bistoury passed across it at a distance of about a fourth of its thickness above the corpus spongiosum, and about three quarters of an inch behind the glans. The bistoury by a sawing movement was then carried upwards and backwards in a slanting direction, so as to make the first sloping cut on the side next the root of the penis. The bistoury was dropped again into the bottom of the incision, and a second sloping cut made obliquely forwards and upwards, coming out a little behind the glans. In making the last section the edges of the divided corpus cavernosum were steadied by a couple of pairs of forceps. Little bleeding took place, and that chiefly from the vessels of the divided prepuce. The glans was now raised, and it was found necessary to remove a thin slice more from the back of the corpus cavernosum, to give the organ its exactly natural form. The edges of the section of the corpus cavernosum were kept in apposition by three sutures on either side. The wound of the prepuce was closed in like manner. The organ was then placed in a hollow splint well padded, and so- cured in its position by a few light turns of a roller, and kept wetted with a cold astringent lotion containing some laudanum. At the close of the third day the dressing was removed. The wound of the corpus cavernosum appeared to have united by first intention. The prepuce, which was congenitalty deficient at its tower portion, and had been deprived to a considerable extent of its vessels by the incision of the integuments, was found ununited, cedematous, and dark coloured on its middle line. In the course of three weeks the cure was complete; its protraction to this period being owing chiefly to the separation of a slough on the upper surface of the prepuce, which did not, however, extend to the mucous membrane, and was in the end even bene- ficial in reducing the excessive dimensions of the prepuce The glans penis at no time suflered either by a diminution in its supply of blood or nervous influence. The risk of gangrene of the prepuce might readily in a similar case be avoided by dividing the integuments on the side of the organ, and loosening the pre- puce so as to turn it backwards and uncover the corpus caverno- sum — a plan which I had first proposed in this case, but for various reasons was induced to change. Second variety. — In these cases the portion of the urethral canal in front of the abnormal orifice is usually imperforate; though in some instances it may be found, even when the opening is far back, as in the case of a soldier reported by Marestin, that the canal is continuous up to the glans, terminating there in a cul- de-sac. In cases of the latter sort, a cure may be eff'ected by the following process. Process of Marestin. — This surgeon introduced a probe from tlie congenital orifice which existed in the perineum, and found the urethral passage obliterated at its extremity merely by a fleshy septum. He cut through the septum upon the end of the probe, and introduced a catheter into the bladder. The edges of the perineal orifice were then excised, and united by the hare-Hp suture.* In instances of this second variety of hypospadias, where the urethra is completely obliterated between the abnormal orifice and the end of the glans, tlie cure may be attempted by the pro- cess shown at Plate LXII. figs. 2, 3, which was found successful in a case communicated to liourgery by M. D'Aremberg, where the urethra opened by a cleft, half an inch long in front of the scrotum, through some thickened integuments which acted as a bridle in keeping the penis drawn downwards. The mode of operation will be well understood by reference to the plate. Dr. J. P. INIettauer, of Virginia, has recently reported the cure of a highly interesting and complicated case of hypospadias of the second variety. The penis was of unusual length; the anterior three-fifths of it consisting of the integuments, the glans, and an expanded and non-erectile portion of the urethra capable of con- taining two ounces of fluid which was appended to an erectile stump, that formed the posterior two-fifths of the free portion of the organ. The first step of the process consisted in laying open the pouch of the urethra on the rapheal line, removing from the interior of the cavity a belt seven lines in width, consisting merely of the urethral wall, immediately behind the base of the glans. A similar belt was then removed immediately in front of the end of the erectile stump. Upon the end of this slump, which was care- fully denuded, the glans was transplanted and attached by "eight points of the glover's suture.'* On the third day union had taken place between the glans and the stump. The unsightly fold of integuments left by the shortening of the organ in thus transpos- ing the glans, was reduced to the proper dimension by excision three months after the first operation. Several months after this the third step of the operation was completed — that of opening a new passage for the urethra with a trocar, introducing a catheter, and closing the abnormal orifice in the perineum. The closure of this orifice was accomplished by a process which Dr. M. has em- ployed with advantage in many other cases— that of cauterizing the surfaces with argentum nitratum, scraping away the eschar, and immediately uniting the parts with the interrupted suture. t EPISPADIAS. The congenital deformity distinguished by this appellation is much less frequently observed than the preceding. It consists in the termination of the urethra by an orifice on the back of the penis arising from the imperfect development of the upper surface of this organ ; or of an unusual prolongation of the crura of the penis, the urethra ascending in the form of a gutter between them. The atfection may be considered incurable. When the epispadias is accidentally developed, there is a better prospect of cure. I have now under my charge a patient in whom, in consequence of a destructive chancrous ulceration of the glans and inner surface of the urethra, the passage of the latter has been obliterated for some distance back from its exter- nal orifice, and a new route established for the urine by the way of the cellular structure of the cavernous body of the penis, which " If in the infant the urethra be found simply imperforate, as is sometimes observed, it may readily be opened by a puncture with a bistoury when distended with urine. t Vide Amer. Journ. of Med. Sciences, July, 1842. OPERATIONS UPON THE GENITO-URINARY ORGANS. 319 is distended by every effort at micturition — two ulcerated open- ings in the involucrum, one at the top and the other at the anterior portion of tlie organ, having been formed for the escape of the fluid. In this case I propose to open the urethra in the perineum, and make an effort to restore the passage with a trocar, nearly as in the process exhibited in Plato LXII. OPERATIONS ON THE URETHRA AND HLADDER. These comprise— Operations for Stricture of the Urethra; for Retention of Urine; and those for Stone. STRICTURE OF THE URETHRA. No class of surgical diseases demands more attentive study on the part of the practitioner, than that which involves as one of its consequences a retention of urine. The lining membrane of the urethra is directly continuous with the internal mucous lining of the bladder, the ureter and pelvis of the kidneys, with the ducts of the prostate, the vesiculte seminales, the vasa deferenlia, and the glandular substance of the testes, all of which parts are in consequence liable, in ill-managed cases of recent or old stricture, to become diseased. The morbid sympathies of these parts witli the rest of the economy, are also direct and extensive — and from them may in many cases be traced derangement of the digestive organs, paroxysms simulating intermittent fever, functional de- rangement of the heart, and extreme moral depression. Strictures of the urethra are commonly classified under three heads — the acute or injlammatory , the spasmodic, and the or- ganic or permanent. As regards the pathology or general methods of cure of these various affections, the limits of this work will not allow me to treat. It must suffice here briefly to observe, that the common cause of the acute or inflammatory stricture is gonorrhoea, though the affection may also arise from the introduction of rough or pointed instruments into the canal, from the passage of fragments of calculi, or from a kick or blow in the perineum. The more usual seat of this stricture is at the curve, though it may be met with at any part of the canal. The measures to be relied on mainly for its cure, consist in the employment of appropriate general and topical medical treatment, as in the case of any other local intlammatiou. The acute or the injlammatory is the common cause of the two succeeding varieties of stricture. From the inflammation developed by it, the mucous membrane is not only rendered turgid, but has its sensibility highly augmented, so that the contact of the urine as it passes through the narrowed portion of the canal near its curve, produces a sensation of heat or burning. This occasions the urethral or perineal muscles to be thrown into spasmodic ac- tion, by which the caliber of the passage is still further diminished, and the jet of urine becomes feeble, small, and at times completely interrupted. In this way the inflammatory and spasmodic stric- tures are often seen in a state of combination. The spasm may occur suddenly when, in an inflammatory affection of the internal part of the urethra, an attempt is made to pass a bougie rudely along the membranous portion— or even in the act of micturition ■when the urine is rendered acrid and irritating by a superabun- dance of lithic acid or phosphatic gravel, or by the absorption of cantharides, or the profuse administration of lerebinthinate or balsamic preparations; or it may even arise from the simple voluntary retention of the healthy urine for an unusual period, during which the intentional resistance made with the sphincter muscles against the continued efforts of the bladder, becomes in the end converted into a state of spasm. The treatment of these cases of spasmodic stricture must likewise, as in the preceding variety, be in a great measure merely medical, the practitioner recollecting that to the inflammatory there is added a spasmodic element of disease, to be met by the additional use of opiates, warm baths, fomentations, &c., commonly directed under such circumstances. It is only in extreme cases of this description, rarely occurring, that instrumeiUal interference beyond the cau- tious attempt to introduce a catheter — such as cauterization of the passage in front of the stricture, or the tapping of the bladder, can be deemed justifiable. In every case of much severity, the inflammatory swelling of the mucous membrane of the urethra extends to the submucous cellular tissue, and very frequently to the membranous and spongy structures on its outer side, and is attended with an effu- sion of blood and serum which in the end may be replaced by lymph, so as to produce an organic or permanent stricture. If the lymph effused either in the mucous membrane or in the submucous tissue, extend even half an inch or two inches along the passage, the swelling will be found greatest in the centre, declining gradually to the anterior and posterior boundaries of the inflammation. It may extend to the whole circumference of the urethra, or be limited merely to a segment of its wall. But in either of these cases, the mucous membrane will be found pro- jected inwards in the form of a valvular swelling, constituting either a ctrcuiar rim, or a segment of a circle forming a kind of bridle. If the disease is not managed with sufficient attention in its early stages, and with forbearance and delicacy in reference to the use of bougies and cauterizing instruments — a matter in which the most grievous errors are but too commonly committed — the effused lymph will become solidly organized, so as to make its removal a work of considerable time and difficulty. It is in cases of organic or permanent stricture that the following pro- cesses have been particularly directed, the use of which should at the same time be aided by appropriate general treatment. These consist of dilatatioji in the various ways in which it is practised, cmiterization, scarification, and incisions made eitlier from within the urethra or from without. The last three of these methods cannot, however, be used ex- clusively in any case — it being necessary to employ dilatation in conjunction, for the purpose of producing a flat cicatrix which shall leave no prominence in the urethral passage. It may also be well to observe, that in a great majority of cases the judicious employment of dilatation will suffice without either of the other processes, to restore the urethra to its natural dimensions. Stric- ture, as has been observed, may occur at any portion of the ure- thral canal, though its more ordinary seat will be found at the region of the curve, which is the most sensitive part of the pas- sage, and the most narrow with the exception of the external orifice. From the uncertainty that may exist in regard to its precise seat, it becomes necessary to resort to the most direct 320 SPECIAL OPERATIONS. means of diagnosis. The sound or bougie is commonly employed for the purpose of exploring the passage. The exploration, however, requires to be done with such lightness and delicacy of touch, especially in diseased states of the passage, that it needs a practised hand to perform it with entire safety to the patient, and to draw from it the proper therapeutic indications. For if the exploration be made roughly, or with unsuitable instru- ments, or persevered in at improper times, the suffering from the affection may be greatly aggravated. If a bougie does not rea- dily enter the bladder, it does not necessarily follow that there is a stricture. It may be arrested by spasm — its point may catch in one of the lacnnse of the passage or hitch against the edge of the triangular ligament — or there may be some swelling of the prostate, or some tumefaction or abscess of the perineum which has caused a narrowing of the canal. Mistakes have in these respects been frequently committed, and patients subjected to treatment for imaginary strictures — and especially by the popular process of cauterization — so as to occasion much disorder of the urethra, and not unfrequentiy lay the foundation of a real stric- ture or some disease of the prostate or bladder, that has been entailed on the patient for the remainder of his life. The exploring sound of Ducamp, (PI. LXIII. fig. 3,) has been devised for the purpose of taking an impression of the stricture. This jyort-empreinte, or impression taker, consists of a graduated flexible catheter, made open at both extremities, though the an- terior is left smaller than the other. A small skein of silk, knotted at one end, is passed through the tube and out at its anterior ex- tremity till the knot becomes arrested at the terminal orifice. The skein is then detached, leaving the divided ends of the threads projecting about half an inch beyond the end of the canula. These are knotted together, trimmed into the form of a pencil, and steeped in a mixture made of equal parts of yellow wax, diachylon, shoemaker's wax, and white rosin. The sound thus prepared is carried down to the stricture, allowed to rest a mo- ment till the material at its end becomes softened, and is then pressed gently and steadily against the face of the contraction. The softened wax penetrates into the cavity of the stricture, and on the withdrawal of the instrument brings away a tolerably accurate mould of the part against uihich it has been pressed. The advantage of this instrument, in the opinion of the author, has been greatly overrated — as it gives rise to considerable pain and irritation, and is often arrested at a wrong point, or gets bent in the passage, so as to bring away a false print. Sir Charles Bell employed a small silver stilet, terminated at the ends by balls of variol^s sizes like the gunshot probe, for the pur- pose of ascertaining the seat, extent, and number of the strictures. It is to be passed down to the stricture to ascertain its anterior termination, and the same, or one with a smaller head, passed through the narrowed portion and retracted again so as to hitch against the back margin of the stricture, for the purpose of de- termining its posterior boundary. This process of exploration is, however, attended with much pain, and is liable from the spasm it excites to impair the accuracy of the diagnosis. The exploring sound devised by Amussat is more simple than the preceding. It consists of a silver canula terminated by a mobile lenticular-shaped button. The cavity in which the stilet turns that moves the button is not in the centre, but nearer to the outer margin of the instrument. The stilet is soldered to the heel of the button, so that in turning the stilet the button, which pre- viously covered smoothly the end of the instrument, revolves so as to project on the opposite margin of the canula. The instru- ment is introduced, closed, up to the prostate; the button is then made to project, and, as the instrument is slowly withdrawn, it catches against the posterior end of the stricture. The value of this instrument the author believes has been over estimated; it may lead to erroneous diagnosis, either by the bar not being turned upon the side of the stricture and thus missing it alto- gether, or by its hitching up some fold of mucous membrane, ■which does not actually constitute a stricture. The wax or plaster bougie will, according to the experience of the author, be found the least irritating and most serviceable in- strument. It should be slightly warmed, and a little curved at the end by being rubbed between the thumb and finger, well oiled, and introduced slowly and gently. After having been pressed steadily, but with little force, against the face of the stricture, it may be withdrawn, and will bring away a mould of the narrowed part sufliciently accurate for all purposes; the distance of the stricture from the orifice being ascertained by the extent to which the urethra has received the instrument. Dilatatioi^. This is commonly effected by the use of bougies, which are formed of different materials. Those in most common use con- sist: — 1, Of the ivax or plaster-cloth bougie, cut into strips of the proper size and rolled into form between two hard and polished surfaces. 2. Of gum elastic instruments, which may either be solid or hollow, though the latter kind is usually preferred, 3. Catgut or gelatinous hongxes: these are of small size, and are intended merely for the permanent dilatation of the narrowest kind of strictures, which the bougies formed of other materials PLATE LXIII.-OPERATIONS ON THE URETHRAL CANAL, For greater clearness, all these operations are represented on a section of the pelvis. Fig. 1. — Gradual dilatation of a stricture, with the flexible ivory sound. Fig. 2. — Forced dilatation, with the three-branched dilator. The branches are separated by a mandrin or stilet passed down the interior of the instrument. Fig. 3. — Imjwession of a stricture, taken with the porte-empreinie of Ducamp. Fig. 4. — Cauterization, with the instrument of Ducamp. Fig. 5. — Cauterization, with the instrument of Lallemand. Fig. G.— Scarification, with the instrument of M. Leroy d'EtioUes. OPERATIONS UPON THE GENITO-URINARY ORGANS. 321 cannot so rciidily be made to pass. 4. Bougies made of the bark of the American elm. These have within a few years past been introduced and employed with much success by Dr. McDowell, of Kentucky, in the hands of the author they have not, how- ever, appeared to possess any peculiar advantage. 5. Of ivory, sofiened by a chemical process, the introduction of one of which is shown at Plate LXIII. fig. 1. 6. Metallic bougies: these are made of flexible metal, of silver, gold, platina, or steel plated with silver. Tlie flexible metallic bougies are not susceptible of high polish, and therefore objectionable. If small, they are apt to bend in using, so as to worry and irritate the passage. The silver bougie, iiighly polished, will be found the most useful of this class. They are, however, according to the author, better fitted for diminishing the irritation of the passage and for com- pleting the cure, (which should be commenced with oiher instru- ments when the passage is much narrowed.) and especially for preventing the recurrence of the stricture, as this is to be looked for even after the narrowing appears to have been entirely effaced by the previous treatment. The mode of using these instruments may be understood by reference to the various treatises on this subject, and to the repre- sentations in the plate. It will be necessary here merely to observe that, Temporary dilatation is effected by introducing a bougie of such size through the stricture as to give a sensation of tightness, at intervals of one, two, or three days, according to the degree of irritation which it appears to excite, allowing it to remain from ten minutes to half an hour at each time. At each successive operation the size of the bougie is to be gradually increased in proportion as the narrowing yields. This is the process which in ordinary cases is found the most successful. Permanent or continuous dilatation. — This consists in the introduction of a bougie or catheter of the largest size that can by a slight effort be made to pass the stricture, leaving it for hours together in the passage, and then withdrawing and imme- diately replacing it by one of somewhat larger size. When the stricture is exceedingly narrow, it may be possible only to pass a catgut or gelatine bougie of the smallest size; these by their imbibition of moisture quickly swell and dilate the narrowed passage, and must be withdrawn and replaced by another when the desire of micturition becomes urgent. In all cases where a catheter even of small size will pass, this is to be preferred, as it will allow the urine to How through it, and may be kept in for twenty-four hours together. At the end of this time it will be found loose in the passage, when one of somewhat larger size is to be substituted. By repeating this process, we may often in a short time succeed in restoring the passage to its natural dimen- sions. The principal objection to this process, (and it is one of much moment,) is the fear that the continual presence of the instrument, and the pain and irritation it occasions, may excite inflammation of the testicles or bladder, and in the end, if perse- vered in when these symptoms of intolerance to its use exist, an extension of the disease to the ureters and kidneys. In many instances, however, it will be found useful to commence the dila- tation by this means, and complete it by the temporary use of iustrnments. Vital dilatation.—Th'is consists in the employment of a large 81 silver sound, in cases where there is an organic stricture accom- panied with so much spasm as to prevent the introduction of small instruments. The sound or bougie is to be pressed against the stricture daily for a quarter or half an hour, by which means we may in some instances so diminish the sensibility of the part, or soften it by the excitement of a muco-purnlent discharge, that a small bougie or catheter may be passed. Dupnytren even ad- vised their being held pressed against the stricture by strings or springs, and gradually advanced as the parts were found to yield. This mode of employing the bougie has, however, been received with but little favour. Forced dilatation. — This consists in an attempt to overcome the stricture by a sudden efl"ort. A variety of means have been resorted to for this purpose: Forced injections {Amussat) have been employed in cases of retention of urine following stricture, on the belief that the narrow opening was clogged up with mucus or blood; a three-branched dilator, (PI. LXIII. fig. 2,) in which the distension is made by passing down through the canula stilets of gradually increasing size; a solid sound {Mayor) introduced down to the stricture and forced on iu the direction of the natural passage; a director {yirnott) made of a tube of varnished silk, which is to be introduced into the stricture and then distended with air impelled into it with a syringe. Though these various measures have occasionally proved successful, they are generally proscribed, on account of their liability to occasion rupture or laceration of the urethra or the formation of (iilse passages, and from the fact that greater success is attendant upon the judicious employment of the processes of dilatation above noticed. Cauterization. The practice of employing cauterizing substances in the ure- thra for the cure of stricture is of ancient date. It has been revived, practised extensively, and much abused in modern times. The nitrate of silver is the caustic commonly used, in consequence of the greater certainty with which it may be ap- plied to the diseased spot. Mr. Whately, (who has had but few followers,) gave, however, Ihe preference to the caustic potash, a minute piece of which may be employed pure or diluted with soap. The cauterization may be made from before backwards upon the face of the stricture, as in the manner of Wiseman and Hunter — or from within the stricture outwards, as in the process devised by Ducamp and modified by Lallemand. Cauterization from before backwards. — The practice of Hun- ter as improved by Home, consisted in arming an ordinary large wax bougie, by inserting into the centre of its entering end a small piece of lunar caustic. The end of the instrument was pressed for an instant against the stricture, and then withdrawn. This process, which was much lauded for a time, occasioned in many instances irreparable mischief. It was found impossible to confine the action of the caustic so as to prevent the injury of the walls of the urethra anterior to the stricture, and in cases where tliis was seated at the curve, haemorrhage was no uncom- mon result from its use, in consequence of the caustic burning into the structure of the bulb. Cauterization from ivithin outwards. {Process of Ducamp. PI. LXIII. fig. 4.) — The improvement suggested by this surgeon consisted in taking a mould of the stricture with an exploring 322 SPECIAL OPERATIONS. bougie, (PI, LXIII. fig. 3,) and passing down subsequently a complicated instrument, called the porie-caiisligue, to the face of the stricture. A little cup altaciied to the stilct of the instrument, containing the caustic porphyrizcd over the flame of a candle, was then projected from the insii ument into the stricture so as to effect the cauterization of its inner surface. This process is more beau- tiful in theory tlian easy in practice. It is difficult to hit exactly the narrow orifice— the end of the instrument being apt to hitch against the margin of the sirici are, press it backwards or even rupture the membrane, and defeat the object by confining the action of the caustic to the liealthy portion of llie canal. Process of Lallemand. (PI. LXIII. fig. 5.)— This is a decided improvement over that of Ducamp. The instrument employed is a cauterizing sound, straight or curved according to the portion of the urethra ou which it is designed to act, constituted much on tiie same principles as that of Uucamp, with the exception tliat it is designed to pass the stricture, and allow the caustic cup to be brought in contact with the inner surface of the strictw'e, not hy pushing the stilct forwards, but by retracting the ca- mtla. It is evident, however, that the cavity of the stricture for this purpose must be of a size that would allow of the introduc- tion of a wax bougie, an instrument tliat passes more readily than any other, so as to render the cure practicable by tiie process of dilatation. Even by the methods of Ducamp and Lallemand, a final resort has always to be made to the bougie to elfect the cure. Great contrariety of opinion has existed in regard to the degree to which the action of the caustic should be carried. Some have applied it boldly, behoving that it may, do good by the detachment of a slough, so as physically to enlarge the opening. Others direct its slighter application, for the purpose merely of modifying the vital properties of the membrane — by diminishing the exalted sensibility of the part, softening the tissue by exciting a purulent discharge, and thus preparing the way for dilatation. In the latter sense, the author lias found it in numerous instances higlily advantageous, and to this he believes its use in stricture should be aliogeiher limited. Several cases have come under liis notice, where, from the bold- ness of the application, or its loo frequent repetition, the stricture has been rendered more callous and resisting, and a chronic inflammation developed in the mucous lining of the prostate, bladder, spermatic ducts, and testicle, producing a complication of disease exceedingly difficult to eradicate.* hicisions and scarifications from loithin the urethra. — These are ancient processes which, with some modifications, have been revived and practised to a considerable extent by many surgeons. Dr. Physick devised an instrument from which a lancet, cutting on its lower edge, could by means of astilet be projected from the entering end. Tlie instrument was straight or curved according us the object was to divide the stricture at tlie straight or curved portion of the urethra. A variety of instruments have been de- vised for this purpose, of which it may suflice to mention those of Chew, Amussat, and Leroy. The ingenious instrument of Dr. Chew, {late of New Orleans.) made In this ciiy by Mr. Sbively in 1S2S, consists of an ordinary • The ancient process of employing meiiicaled boug;ies has been to a certain extent revived by Jobert, Breionneaii, and Velpeau, The medicating material which these surgeons have chiefly employed, is pnwdered alum. silver sound, eitlier straight or curved, and split at the enleritig end, so that an elliptical double-edged knife can be projected for a few Hues by pushing on a button which is attached to the siilet of the instrument. The point of the knife is blunt, and pierced for the passage of a silver wire. The wire is to be introduced from the anterior end of the instrument, and is arrested at the point of the ktiife by a rounded head, its other extremity project- ing at the opposite end of the sound. The mode of usitig it is as follows. The instrument, with the knife retracted and the probe end of the wire closely drawn up to the blade, is carried down to the stricture. The probe head of the wire is then gra- dtially pushed on separately through the stricture, which it readily passes on account of the central position it necessarily occupies in the canal. The probe point of the wire may be carried on even into the bladder. The knife, guided in the right direction by the wire, is next ptishcd on and the stricture divided. As soon as the division is made, the knife is retracted and tlie body of the insirument carried forwards. If one or more additional strictures are encountered, the same process may be repeated for each. In this way I iiave repeatedly divided several strictures in the same subject at one sitting, and completed the operation by passing at once, on the withdrawal of the instrument, a mo- derate sized catheter into the bladder. The cure is to be finally completed by the process of dilatation. This is a ,'jpeedy and efficacious uieihod. No inconvenience iias followed in my hands save in one instance, when it gave rise to a sympathetic inflam- mation of the testicle. In irritable subjects it would, liowever, be attended with danger. Death has followed its use in the hands of a surgeon formerly of this city. Three instruments have been devised by Amussat, the pecu- liarity of which consists in their cutting upon a sliding oval button, which is made to hook behind the stricture, 1. One called an urethrotome, consisting of a conical steel cylinder a little more than half an inch long, armed with eight longitudinal cutting crests, projecting to the extent of a quarter of a line from the surface. This is carried down upon a mandrin previously passed through the stricture, and the incision made from before backwards, 2, One called a bridle cutter, (coupe-bride.) resem- bling the exploring sound of the same surgeon, described at page 320, with tiie exception that the end of the canula corresponding to the button, is sharp and intended to efl'ect the excision of the bridle or mucous fold, by being puslied from before backwards upon the button. 3. One more complicated than the other two, consist- ing of a canula cleft laterally for about half an inch at its anterior extremity for a sliding semicircular blade, and notched upon the opposite side to the depth of a quarter of an inch, to accommodate the rod which moves the little bar at the end. The instrument with tlie knife concealed is carried down to the narrowed part. The oval bar is first pushed on with the rod, and then retracted so as to hitch against the bridle. A turn is then given to the canula in order to bring the knife upon the same side with the fold, which is to be divided by pressing the blade from before back- wards against the bar. A variety of other instruments have been devised for incision atid scarification. The one most used by Leroy d'Eiiolles, is shown in action at PI. LXIII. fig. 6. Incision from- loilhout inwards. — This is particularly appro- priate to cases of old stricture near the curve, Ihroiigli which. OPERATIONS UPON THE GENITO-URINARY ORGANS. 323 from tlie moibid altcralions of the part, no instrument can be passed, and especially if complicated with fistulous openings in ilie perineum by whicli the urine in part or altogether escapes. In the latter case, an attempt should be perseveringly made to dilate the perineal sinuses, so that a probe may be passed up to the bladder; a guide of this description will greatly facilitate an operation that otherwise will in certain states of the part be found one of the most difficult in surgery. The patient is to be placed in the position for the lateral ope- ration for stone. A moderately curved silver catheter is then to be passed down to the stricture, and firmly lield in the middle line by an assistant. If there be no callous growths or tiiicken- ing of the tissues, the point of the sound may be felt in the peri- neum, so that the surgeon can cut directly down upon it. If the point cannot he felt, the difficulties are much increased. The surgeon is then to divide the parts in the middle line, and should have a perfect knowledge of the anatomy of the region. The urethra is to be opened on the end of the sound in front of the slriclure. A small director is then to be passed through the stricture up to the bladder, and the stricture itself divided with a probe-pointed bistoury. The sound is then to be passed on to the bladder, and the operation is completed. If there has been an urethral fistula, through which a probe could be passed into the bladder, it will be necessary to divide the bridge between the probe and the end of the catheter. If the orifice of the stricture is so small that it cannot be detected afier the deep incision of the perineum — the fistulous tracts so sinuous as to prevent the iiuro- duction of tlie probe — and the structure of the perineum caiious and irregularly tumid, as has been the case in five histances in which I have successfully peformed this operation, tiie following course is to be pursued. The lips of the wound are to be well separated and sponged clear of blood. The patient is now directed to urinate, and the surgeon carries a probe into the bladder from the point at which the urine escapes. If the patient is so agi- tated as to be unable to expel any urine, or to distend the urethra so tliat it may he felt from the wound, or the bladder is empty in consequence of a previous inability to retain the urine, there are two courses to be pursued; the operation may be deferred for an hour or more, till the flow of urine can be detected in the wound, or the surgeon is to proceed at once and cut by his ana- tomical knowledge in the direction of the passage towards the bladder. The author has practised both these plans, the former of which is ordinarily to be preferred. But if the case be one of great suflering from retention of urine, the latter course is to be pursued. The incision is to be carried backwards and upwards in the middle line, and if the urethra behind the stricture be, as is usually fotmd the case, dilated to two or three times its natural extent, it will as soon as it is tapped with the knife give rise to a gush of urine. But in case there be retention without this expansion of the urethra, I have found it most advantageous when the membranous portion was too much disorganized to be discovered by dissection behind the bulb, to tap the urethra and the prostate by au incision from within outwards. This is ac- complished by introducing the left fore finger through the anus up to the prostate, and passing up from the wound a curved sharp-pointed bistoury exactly in the direction of the passage, keeping it about a quarter of an inch above the finger, so as to clear the rectum and strike the front part of the prostate, and then depressing the handle of the knife so as to make a tolerably free incision as tiie point is withdrawn. The urine may now be discharged, and a grooved director or probe should be entered as it flows, to serve as a guide for the passage of the sound into the bladder. In one instance only out of five have I failed to pass up the sound at once. When this cannot be accomplished, the sound is to be brought out at the perineal wound, and a short catheter well secured externally, passed from the same point up to the bladder. At the first dressing of the wound, the sound itself may usually be slid in on a director. The perineal wound should be healed over the silver sound, which is to be withdrawn for the purpose of cleansing on the sixth or seventh day, when the incised portion of the urethra will be found sufficiently patu- lous to allow of its re-introduction, provided this be effected be- fore the patient makes any change in his position. In case it should be necessary to withdraw the catheter at an earlier pe- riod, tlie conducting sound of Amussat will he found a useful in- strument in replacing it. The healing of the wound will usually take place in from two to three weeks. In one of the five cases above alluded to, deatli took place from diarrhoea a month after the complete healing of the wound. On dissection, the kidneys were found disorganized from a chronic affection, but the new made membranous portion of the urethra, (the specimen of which I liave now in my possession,) was lined with mucous membrane, and, with the exception of its being of a dark hue, perfectly natural. PUNCTURE OF THE BLADDER. This is an operation required but rarely, and only in cases of complete retenlion of urine which liave withstood every judi- cious effort for relief by other measures, and are attended with imminent danger of gangrene or rupture of the bladder, or a fearful stale of nervous prostration. The causes of the retention conmionly consist either of stricture of the urethra, enlarged prostate, or morbid growths at the neck of the bladder. In addi- tion to these may be mentioned as an occasional cause, extensive inflammation or swelhng resulting from accidental injuries of the perineum. In reference to the retention following urethral stric- tures, the process of incision from the perineum, just described, will be found usually more appropriate than any of the methods of tapping the bladder recommended in these cases, inasi^iuch as it is attended with less danger to life, and affiirds a prospect of removing at the same operation the accumulated urine and the evil which has occasioned its retention. In cases of retention from other causes, there are three methods of puncturing the bladder more or less employed by surgeons: — 1. Puncture, through the prostate from the urethra: 2. From the rectum: 3. Through the linea alba above the pubis. Puncture f rum the urethra through the prostate. — This was made by Boyer with blunt instruments, and denominated forced catheter ism. Process of Boyer. — The patient is to be laid upon the left margin of the bed. A medium sized conical silver catheter, slightly curved near the point, with a slilet sulliclenily large to fill its cavity and keep it iVom bending, is to be passed down tlie urethra to the seat of obstruction. The surgeon Iheii carries his left fore finger into the rectum till he feels the end of the cuiheter 324 SPECIAL OPERATIONS. ihroiigh the walls of tlie bowel. He next extends the penis upon the catheter; and, grasping the latter between the thumb of the right hand and the radial margin of the fore finger which should be half flexed, pushes on the sound with a degree of force pro- portioned to the resistance encountered, as much as possible in the direction of the urethra, keeping the instrument exactly in the median line. As the instrument advances, the outer end is to be depressed towards the thighs. The finger which is retained in the rectum serves as a guide to the instrument, and may aid by elevating the point so as to give it a right direction through the prostate, whether it merely re-opens the natural passage which is the object proposed in the operation, or makes a new one, as is not unfrequently the case, through the substance of the en- larged gland. The depth to which the instrument penetrates, the facility with which the outer end can be depressed between the thighs, and the flow of urine after the withdrawal of the stilet, are the signs that the catheter has entered the bladder. Process of La/aye. (PI. LXIV. 5.) — The sole object in tliis process, which is older than the preceding, is the perforation of the gland. It is practised precisely as in the preceding process, with the exception that the catheter is to be converted into a curved trocar, the stilet of which terminates in a triangular point capable of being projected a quarter of an inch beyond the ca- nula, when the instrument is brought in contact with Ihe gland. With the projection of the stilet, the whole instrument is advanced till it enters the bladder. The stilet is then withdrawn. The canula is retained for ten or fifteen days in the bladder, when it may be withdrawn and replaced by one of larger size, for the purpose of establishing an artificial canal. The outline drawings in Plate LXIV. show the necessity of holding the instrument in the proper direction, to avoid a puncture of the prostate at its upper or lower border, or even of missing altogether the cavity of the bladder — an accident which might readily occur to one not thoroughly familiar with tlie anatomy of the parts. Puncture through ihe rectum, (PI. LXIV. 1,2, 3.) — On the lower and posterior surface of the bladder, at the distance of half an inch above the upper border of the prostate [ivhen the gland is of its natural size), will be found a triangular space bordered on either side, by the vasa deferentia and vesicuiEe seminales, and above, by the bottom of the peritoneal pouch formed between the bladder and the rectum. This portion of the bladder in cases of extreme retention is found depressed towards the cavity of the rectum, and if t!ie prostate gland is not at the same time unusually enlarged in its antero-posterior diameter, may be readily reached with the finger. At this triangle, which is sufficiently large to be readily struck with the trocar, the bladder and the rectum are so intimately united by dense cellular tissue, as to render it little likely tliat the urine will escape by infiltration between their walls after the operation. Operation. — The instrument commonly employed is the canu- iated trocar of Fleurant, four to five inches long, and curved so as to form the segment of a circle of eight inches diameter. The stilet or trocar proper of the canula terminates, as the latter name imports, in a triangular point. Tlie author believes, however, from the result of two operations on the living subject, that a lancet-pointed stilet as recommended by Dr. Watson would be less liable to be followed by inflammation of the mucous lining of the bladder. The patient is to be placed as in the lateral operation for stone. The surgeon then introduces the left fore finger as far as possible PLATE Lm-PUSCTUKE OF THE BLADDER. Surgical anatomy of the bladder. — The walls of the abdomen and pelvis have been removed on the left side, a portion of the bladder excised, and the penis and prostate cut through on the middle line. The prostate is represented greatly enlarged, especially at the middle lobe, so as to have caused a retention of urine, as shown in a preparation of the author taken from a patient who had died of this affection. (A). Rectum. (B). Bladder. (C). Cavity of the bladder. (D). Perineum. a. Line of section of the abdominal wall. b. Section of the posterior wall. c. Symphysis pubis, d. Small intestine above the bladder, e. Sigmoid flexure of the colon, f. Pouch of the rectum, g. Line of section of the peritoneum, which is seen reflected round the posterior face of the bladder down to the bottom of the pouch (i), which it forms between the bladder and rectum, k. Parietal peritoneum, as it passes up to line the iliac fossa. I. Ureter, m. Vas deferens, running down on the inner side of the vesicula seminaiis (?i). p. Internal sphincter muscle of the rectum. Levator ani, divided near its insertion into the rectum, immediately below which is seen the externa! or anal sphincter, t. Penis, split through the median line. y. Membranous portion of the urethra, z. Prostate, divided in the middle line. 1, 2, 3. Puncture of the bladder from, the rectitin. — 1. Left hand of the surgeon, the fore finger introduced through the anus and seen outlined with the point behind the prostate. 2. Right hand of the surgeon, holding the trocar, which has been passed up in front of the left fore finger; the point of the stilet is projected into the bladder with the thumb of the right hand (3). 4. Puncture of the bladder above the pnlns. — The position of the trocar is outlined above the pubis; the projecting point of the stilet and the end of the canula are seen in the cavity of the bladder. 5, 6, 7. Puncture from the urethral passage. — 5. Proper position of the trocar or sonde a dart, in making the puncture in the normal direction of the passage. C. Line of direction in which the puncture would be made through the lower part of the prostate. 7. Line of direction which would carry the trocar above the prostate. TUle 64. OPERATIONS UPON THE GENITO-URINARY ORGANS. 325 into the rectum, till he can distinguish clearly with the point the fluctuating tumour formed behind the prostate by the lower fun- dus of the bladder. On the front or palmar surface of this finger the trocar with the point retracted within the canula is carried up and firmly pressed against the bladder at the distance of an inch behind the prostate, and exactly in the middle hne. The outer end of the canula is then depressed, so that the anterior portion of the curve shall move in the direction of a point half-way be- tween the umbilicus and the symphysis pubis. The stilet is then thrust forwards by pressure with the thumb, as shown in the draw- ing, and carried — the canula advancing with the same effort — for an inch and a half into the cavity of the bladder. The surgeon now withdraws his finger from the rectum, retracts the stilet, and discharges the fluid. In most instances the trocar is to be retained in the wound till the natural route for the urine is restored — or at least for one, two, or three days, so as to diminish the tendency of the orifice to close on the withdrawal of the instrument. It is to be secured with tapes passed through the loops in its shield, and attached to a bandage round the pelvis. The edges of the inner orifice of the canula are hable to irritate the lining mem- brane of the bladder after the escape of the urine. This should be avoided by the introduction of a second silver canula, termi- nating like the ordinary urethral sound, through the interior of the first. Great inconvenience, however, arises from the tenes- mus excited by the presence of the instrument in the rectum, or in the attempt to assume the vertical position. When the incon- venience thus occasioned is great, a gum elastic catheter might be introduced through the canula and the latter wholly withdrawn. Puncture above the pubis. (PI. LXIV. 4.)— When the blad- der is distended with urine it rises above the pubis, pushing the peritoneum before it, and brings itself in contact with the hnea alba and the rectus and transversus muscle of each side. The tumour which it forms gives a dull sound on percussion, and the fluctuation of the fluid within may at times be felt. The patient should be placed upon the right side of the bed, with his shoulders elevated and his thighs slightly flexed. The usual place of puncture is in the linea alba, at tlie distance in the adult of an inch and a half above the symphysis pubis. The instru- ment directed in the preceding operation, though a little longer than necessary, will suit for the puncture above the pubis. The operator merely places the nail of the left fiire finger over the linea alba, or, if the patient be extremely fat, divides the integuments previously by a longitudinal incision an inch to an inch and a half long, and, taking the trocar in his right hand, enters it wiih its cavity turned towards the pubis, as shown in the drawing, and the point in a direction at right angles with the axis of the abdomen. The trocar should be inserted to a depth between two and a half and four inches, according to the size and obesity of the patient. As soon as the resistance ceases and the point of the instrument is felt to penetrate the bladder, it should be turned somewhat more in the direction of the axis of the bladder to avoid the injury of the posterior wall of the organ. The stilet is now withdrawn, and the urine discharged through the canula, the patient facili- tating its escape by inclining himself upon one side for that pur- pose. A compress is to be placed under the shield of the canula, and the instrument secured with tapes to the horizontal part of a T bandage. The mouth of the canula is to be plugged; the plug 82 being withdrawn at intervals of two or three hours to allow the urine to escape and prevent the over-distension of the bladder. In this case it would not be safe, as in the puncture of the rectum, to substitute a flexible catheter for the canula under the space of a week, as the former instrument would lie too loose in the wound to obviate the risk of infiltration of urine on the outer side of the bladder, which when it takes place gives rise to sloughing. At the end of a week, provided the catheter cannot earlier be passed by the urethra, this change may be made— the flexible catheter, which should he well secured without, being found to cause less irritation in the bladder than the silver canula — since by this time the track of the instrument will be surrounded by a deposit of lymph, so as to prevent infiltration. At the end of eight or ten days the track of the wound is rendered completely fistulous, and some surgeons have advised the complete removal of the canula after this time, allowing the urine to escape simply by the fistu- lous passage. But this course is not advisable, as it would still be attended with risk of inflammation and abscess of the cellular tissue of the pelvis, unless the urethra! passage has been rendered pervious, and it is desirable to allow the artificial outlet to close. Puncture from ihe perineum. — This was practised by Dionis and some of the older surgeons, by entering a straight trocar at the middle of a line, drawn from tlie tuberosity of the ischium to a point in the raphe of the perineum two lines in front of the anus. The point of the trocar is to be pushed on in such a direction as to meet the axis of the trunk at the distance of two or three inches from the place of entry. The operation has, however, been abandoned in consequence of the risk which it involves of wounding one of the vesiculse seminales, one of the deferent ducts, or even of missing altogether the bladder, the position of the fundus of which varies considerably in different individuals, and in various states of disease. If practised at all, it should be preceded by an incision of the soft parts as in rtie lateral operation for stone, or by the opening in the middle line recommended in cases of retention from stricture. In females it is seldom necessary to puncture the bladder. But should it be, as has sometimes been the case in cancerous affec- tion involving the urethra, the operation is to be practised above the pubis, or through ihe anterior wall of the vagina. OPERATIONS FOR STONE. LITHOTOMV IN THE MALE. There are many processes for the removal of calculi by a cut- ting operation, all of which may be arranged in three classes: — 1. By a cut through the region of (he Perineum. 2. Through the partition between the Reciura and Bladder. 3. Through the Hypogastrium. Operation through the Perineinn. Surgical anatomy of Ihe perineum. — The inferior outlet of the pelvis is usually considered as divided into two triangles by an imaginary line, extended between the two ischiatic tuberosi- ties and crossing just in front of the margin of the anus. Each of these triangles is nearly equilateral, the sides being about three inches in length. The anterior triangle circumscribes the region of the perineum— the posterior, that of the anus and rec- SPECIAL OPERATIONS. turn. The lateral margins of the perineal triangle are formed by the rami of the ischium and pubis, and the apex presents to the symphysis of the pubic bones. But this region has depth as well as superfices. Its vertical depth at the symphysis pubis is about an inch — between the extremity of the recto-vesical pouch of the peritoneum and the skin in front of the anus, about three inches in an adult ordinarily fat, making the perineum somewhat triangular when examined on the side of a vertical cut through the median line. When we turn off the skin and common superficial fascia from the surface of the perineum, and strip away also the peri- toneum from the bottom of the cavity of the pelvis, we have tlie parts of the perineum requiring particular study, included within spaces formed by three proper perineal fascia — the inferior, the middle, and the superior — the last of which is formed by the pelvic aponeurosis. The inferior perineal fascia, (sometimes though improperly called superficial fascia of the perineum,) is found immediately below the skin and common superficial fascia. It is extended between the crus of the pubis, crus of the ischium, and ischiatic tuberosity of either side. It is prolonged ante- riorly so as to be continuous with the cellular tissue of the scro- tum and penis, and terminates posteriorly in a sort of crescent which spans the front surface of the lower end of the rectum, where it will be found on turning down a V shaped section of the fascia, (cut so that the apex of the A shall present to the scrotum.) to be continuous with the middle fascia of the perineum by being folded inwards and backwards round the posterior face of the transversalis perineii muscle. In the space between the inferior perineal fascia and the middle, are lodged several parts for consideration. 1. We have on either side the crura of the penis, covered by the erector penis muscles. In the middle line the corpus spongiosum and bulb of the urethra, completely hid by the accelerator urinEc muscles, which extend backwards from the junction of the crura with the body of the penis to the peri- neal centre just in front of the anus, where several muscles of the perinenm meet. Between the erector penis muscle of either side and the accelerator urince there is necessarily a triangular space, bounded on its upper surface by the middle perineal fascia or triangular ligament of the urethra, the apex of which is near the junction of the crus with the body of the penis. In the triangular space on the left side the cut is made in the lateral section for stone. The transversalis perinei muscle is extended across, just in front of the line which divides the perineal from the anal region, between the tuberosity of the ischium and the perineal centre, accompanied frequently by the artery of the same name, both of which are necessarily divided in the cut in lithotomy when this is extended well back between the centre of the anus and the ischiatic protuberance. If we clear away the muscles, leaving only the bulb and spongy portion of the urethra, we have a full view of the front surface of the Unangiilar ligament of the urethra or middle fascia of the perineum. This consists of a membrane stretched between the crura of the ischium and pubis, so as to serve as a partition across the perineum extending for an inch and a half below the symphysis of the pubis. At the distance of an inch below the symphysis, and half an inch above its lower border, it is pierced by a small opening thi-ough which passes the mucous canal of the urethra. At its lower border it is united with the posterior edge of the inferior perineal fascia just described, and both together are reflected upwards and backwards between the prostate gland and rectum. On cutting through this lower sur- face of the triangular ligament, we find it a double fascia, the upper layer of which is at the symphysis nearly in contact with the lower, from which it diverges as it passes backwards and slightly upwards over the membranous part of the urethra to the top surface of the prostate gland and the neck of the bladder. At this point the upper layer is coniinuous with the layer of pelvic fascia, which lines the superior surface of the levator ani, forms the anterior ligament of the bladder, and dips down to the front part of the neck of this organ. The lower layer of the middle perineal or triangular ligament which is reflected back between the prostate and the rectum, is continuous upon the sides with that portion of the pelvic fascia lining the inner surface of the levator ani muscle. An irregular triangular interval is thus left between the two layers of the middle perineal fascia. In this interval are lodged, 1st, the membranous part of the urethra, which is about five-eighths of an inch long, surrounded by its two sphincter muscles — the muscles of Wilson and Guthrie; 2d, the whole substance of the prostate gland, through which the canal of the urethra is continued behind the membranous portion backwards and upwards into the bladder; 3d, the internal pudic artery, which runs up close to the margin of the bones, and sends an artery across to enter the bulb; and, 4th, the glands of Cow- per, which, though unimportant in a surgical point of view, will be found on the upper surface of the lower layer of the ligament. If the prostate gland be dissected up from the surface of the rectum, it will be found separated from it by the reflection of this lower layer, which runs upwards to the bladder forming a part of the recto-vesical fascia covering the bottom and sides of the prostate, and continuous with that layer of the superior perineal or pelvic fascia, reflected off' from the surface of the levator ani muscles to the upper part of the prostate and the bladder.* By this arrangement the prostate gland gets a complete capsular investment, and is left out of the cavity of the pelvis by being kept below the superior perineal or pelvic fascia. At the angles where these two layers meet, is lodged the prostatic venous plexus, the veins of which communicate directly through large orifices in the superior perineal or pelvic aponeurosis, with the vesical plexus lodged between the peritoneum and the side and lower fundus of the bladder. If this lower layer as it ascends on the side of the prostate is cut high up, as is commonly the case in the lateral operation for stone, no particular danger arises, provided the superior fascia which covers the base of the prostate is left uninjured. It necessarily involves, however, a lesion of the prostatic veins, and as these are large, especially in old men who have long suffered from disease of the parts, and are unprovided with valves, they become, from the anastomosis with the vesical plexus, a frequent source of venous hremorrhage. On dissecting the prostate gland loose from the rectum and pushing it upwards, it will be found lodged in the angular fossa formed by the anterior edges of the two levatores ani muscles. If the dissection is continued farther backwards, it will be seen that * Vid. Quain's Anatomy or Paneoast's Wistar, edit, of 1843. This upper layer may, according to the will of the surgeon, be considered as belonging to the middle or upper perineal fascia. OPERATIONS UPON THE GENITO-URINARY ORGANS. 327 the inferior layer of the prostate is continued from the base of that organ, as just described, where the two fascia meet over the vesiculai seminalcs, (which are found nearly at the centre of its back part,) and diverge upwards and backwards on the has fond of the bladder. As the levator ani of either side bends in- wards from the top of ilie perineal region, so as to embrace the lower extremity of the rectum and be inserted in the middle line, a triangular space is left between the muscle of either side and the ischium, wiiicli has beeu denominated by Velpeau the ischio-rectal fossa. This is found partly in the perineal and partly in the anal region, and has its apex extended upwards to the point wiiere the internal obturator muscle is in close apposition with the origin of the levator ani from the pelvic fascia. This fossa is lined on its surface with a thin fascia, and is filled with fat in which exist a great number of veins. Some arteries are also observed in it— the inferior hemorrhoidal, which cross it as they go transversely from the internal pudic to the rectum — and the superficial perineal, which from the same arterial trunk is sent oil parallel at first with the ischium underneath the common integuments, to reach the raphe of the scrotum and supply the dartos muscle, sending a branch up in the septum scroti. The trunk of the internal pudic, as before observed, is continued up between the two layers of the middle fascia or triangular ligament, sending off a transverse vessel to the bulb, a branch which enters the cavernous structure at the crus of the penis, and terminates by becoming the dorsal artery of the penis. In some rare instances of anomaly, the dorsal artery is not the terminal branch of the pudic, but is sent off from the trunk of the latter lower down in the perineum, so as to cross on the lower surface of the prostate the track for the incision in the lateral operation for stone. The object to be kept in view in the operation by the perineum, is to open a free passage to the stone without dividing any im- portant arteries or womidiiig the rectum. The posterior part of the bulb is found usually eight or ten lines distant from the anus, and sometimes much less, especially in old men. There are four arteries more or less liable to be wounded — the trtiii/c of the in- ternal pudic, the superficial artery of the perineuvi, the trans- verse artery, and the artery of the bulb.* The first is closely attached by fascia to the crura of the ischium and pubis, and is not liable to be injured unless the cutting instrument is brought nearly in contact with the bone. The superficial artery of the perineum runs superficially in front and to the inner side of the erector penis muscle; the transverse artery crosses the perineum with the trasversalis muscle, and in many instances sends a branch obliquely forwards from near its place of origin to the bulb. From this arrangement of the vessels, the operation, if the external incision is begun behind the bulb, does not necessarily involve any of these vessels except the transverse branch, which is usually too insignificant in size to occasion any trouble, and is so superficial that it can if necessary be readily tied. Many surgeons, however, begin the incision higher up, dividing usually the bulb and the artery which supplies it, and thougli the larger external wound which they by this means get gives ready access to the bladder, they are sometimes inconvenienced by bleeding • The last two frequenLly come off from the pudic by a common trunk. from the bulb, which it is occasionally found dilficuU, especially in old men, to arrest, save by the ligature of the trunk ox the internal pudic as it ascends along the rami of the ischium and pubis. In cases of wound of the dorsal artery of the penis, where the vessel has the anomalous origin above described, the trunk of the internal pudic may be tied under the ischium, provided pressure on this vessel is found to check the hEemorrhage. But if the branch ' comes olT from the artery before it reaches the perineum, and the ! ha;morrhage cannot be arrested by tamponing the wound, the di- vided orifice of this vessel is to be tied if possible at the top of the incision — or, this failing, resort is to be had to the means of arresting the circulation in the trunk of the pudic on the back of the pelvis, described at page 73. If the external incision have the proper direction, and be not carried farther back than is directed in the text, the rectum, provided it has been previously well emptied of its contents, will not be liable to injury from the knife. If it be found greatly dilated, as is sometimes the case in old men, it may as a measure of precaution at the time of making the external incision, be forced backwards by a finger introduced into the anus. In extending the incision from the bottom of the external wound to the neck of the bladder, the principal point of im- portance to be divided is the prostate gland, which necessarily involves a section of the membranous portion of the urethra, and the triangular ligament or middle perineal fascia. The pros- tate is sufficiently large to admit of a section which will allow of the escape of a stone from an inch to an inch and a half in dia- meter, according to the manner in which the division is made. In calculating the extent of space to be gained by an incision of a particular width through the substance of the gland, the dimension of the prostatic portion of the urethra, which in the adult will be found rather more than the third of an inch in diameter, or an inch in circumference, is to be added to the ex- tent of the cut in the prostate. Thus if an incision of three- quarters to seven-eighths of an inch be made through one side of the prostate, which in the adult can be done with entire safety through either one of the lobes of the gland, we would have on separating it the inch and a half of its circumference to be added to that of the urethra, furnishing a space sufficiently large for the withdrawal of a stone three quarters of an inch or even an inch in diameter. If on account of the size of the stone this space should be found iusuflicient, it might be increased by a transverse or oblique incision of the opposite lobe of the gland, as in the process of Dupuytren, or a quadruple incision may be made by adding to the two lateral incisions two vertical cuts in the middle line — one upon the upper and one upon the lower segment of the gland, as recommended by M. Vidal. When the prostate is sound its tissue will be found to stretch by the application of moderate force in the withdrawal of the stone, and if it be found diseased, it will usually at the same time be enlarged so as to admit of an incision more extensive than that just referred to. Stones are, nevertheless, occasionally met with too large to be extracted through any opening that can be made through the prostate, or even to pass between the limits of the pubic arch — rendering it necessary to break them in the bladder and remove them piecemeal, or extract them by the high operation. There are three modes of operation through the perineum— the 338 SPECIAL OPERATIONS. lateral, the bilateral, and the median, so named from the respec- tive portions of the prostate gland through which the incision is made. LATERAL OPERATION. There are several modes of effecting the division of the prostate gland in the lateral operation, in all of which the section is made on the left side of the perineum in consequence of the greater facility this affords in the use of the right hand: — 1st. Those in ■which the cut is made from before hackwards, with a stout scalpel -, 2d, with a gorget; and a third, in which the prostate is divided from without inwards, by the retraction of the liihoiome cach& — the primary division of tiie external parts, and the position in which the patient is placed, being the same in all. The division of the prostate with the knife. — This is the favourite method of operation with most British surgeons of the present day, and with many of those of this country. It is well described as follows, in the recent work of Professor Syme. "The instruments required are — 1. A grooved staff to guide the knife in cutting into the bladder. It ought to be of the largest size that the urethra will readily admit, which is usually No, 11 of the bougie scale,* and the groove should be very wide and deep, * "Equal to No. 14 of the scale generally used in London." In the operation with the gorget or the lithotome, the groove should be exactly on the convex surface. neither on the side nor convex surface, but in the intermediate space, so as to correspond with the direction in which the incision is carried. Mr. Aston Key has recommended a straight staif,— which certainly has the advantage of conveying the knife more directly than a curved one, but is liable to the objection of occu- pying the operator's left hand, while the section is made, instead of leaving it at liberty to press aside the rectum, and ascertain when the incision has been carried far enough. In children, where the prostate is easily divided, and where, from the neces- sarily small size of the instrument that is introduced, the difficulty attending a curved direction of the groove is greatest, the straight staff may be preferable. 3. A knife, which, including both the handle and blade, should he between seven and eight inches in length. The blade ought to have its cutting part at least two inches long, not very broad, and sharp enough at the point to permit its being pushed through the skin and other parts. 3. Forceps for extracting the stone, of two or three different sizes, of which the blades should be broad, moderately hollowed, and destitute of projecting teeth, which are apt to break the calculus. 4. A scoop to remove fragments or gravel; and, 5. A flexible tube, about six inches long, and half an inch wide, to convey away the urine after the operation, and prevent its infiltration into the cellular substance. "When the operation is to be performed, the patient should PLATE LXV,— LITHOTOMY, LATERAL OPERATION, Fig. 1. — External incision. — An assistant steadies the staff by grasping the end of it with the right hand, while he sustains the scrotum with the other (a). The external incision has been made, as directed by the French surgeons, of little extent, commencing in front of the anus and just behind the bitlb. At the period of the operation shown, the surgeon has introduced the fore finger of his left hand [b) so as to sink the nail into the groove of the staff, to serve as a director to the point of the bistoury (c), with which he opens the membranous part of the urethra. Fig. 3. — Division of the prostate loith the simple lithotome cacM. — The parts are shown reduced only a third in size, and the integuments and perineal fascia, with a portion of the triangular ligament, cut away to give a better idea of the more important part of the operation. (A). Union of the two accelerator nrinoe muscles, which cover the bulb of the urethra in the median line of the perineum. (B). Anus, in front of which the anterior edge of the sphincter and the anterior margin of the levator ani muscles have been cut away. (C). Prostate gland, covered by the middle perineal fascia or triangular ligament of the urethra. (D). Incision made in the left lobe of the prostate by the withdrawal of the lithotome. Fig. 5.— Large external incision, made with the scalpel as directed by the greater number of British and Ame- rican surgeons. — The parts are of the same scale of dimensions as in fig. 2. The proportionate length of the cutaneous incision is purposely exaggerated, to give a clearer view of the deeper seated parts. a. Section of the skin, ordinary superficial fascia, and proper superficial or inferior perineal fascia, c. Incision deepened at the posterior part through the mass of fat in the ischio-rectal fossa, in which is usually divided the transverse perineal miiscle and the anterior fibres of the levator ani. b. Incision made with the scalpel into the membranous part of the urethra, so as to expose the groove in the staff into which the beak of Physick's gorget has been directed on the finger nail. The incision into the membranous portion of the urethra has involved a part of the structure of the bulb~a result which at least very commonly takes place. / The anus. Fig. 4. — Lateral viezo of the section of the prostate with the gorget, shoion at the moment of its completion. — a. Section of the abdominal walls in the middle line in the subject from which the author has had the drawing taken, b. Symphysis pubis, c. Section by which the left crus of the penis has been removed, d. Prostate. e. Vesicula seminalis of the left side; above this a portion of the left side of the bladder has been removed in order to expose to view the stone, the staff, and the entering point of the gorget. / Rectum. g,g. Line of reflection of the peritoneum, h. Staff, grasped with the left hand of the surgeon and depressed, while with his right hand [k) he pushes in the gorget so as to divide the membranous portion of the urethra (i) and the left lobe of the prostate. OPERATIONS UPON THE GENITO-URINARY ORGANS. have his bowels freely evacuated by a laxative administered the day before. He should be placed reclining on a table about two feet and a half liigli, covered with a folded blanket, and under his head a "pillow or two may be laid, but nothing to raise the shoulders. He is then to seize the soles of his feet, one in each hand, which shonid rest on the fibular or outer edge, and by means of a strong tape or bandage have the limbs secured in this position, after which they are to be confided to two assistants, one standing on each side of the table. The staff" having been introduced, is now to be committed to a third assistant, who holds it up in one hand, and the scrotum in the other. Tlie surgeon then seats himself on a chair, shaves off the hair from the peri- neum, feels the diiTcrent parts that determine the place of his incision, and resting the fingers of his left hand on the skin so as to prevent any displacement of it, pushes iiis knife directly in- wards at the anterior point of incision to the depth of the peri- neal muscles. He cuts in the direction above mentioned, making an incision about three inches long in the adult, extending from the raphe of the perineum to a point midway between the anus and the tuberosity of the ischium, so as to divide the skin, fat, superficial fascia, and transverse muscle, gradually diminishing the deptli of iiis incision until it reaches its posterior termination; then introducing the fore finger of the left hand into the centre of the wound, to serve as a guide for the knife and protection to the rectum, he cuts from this point upwards and downwards so as to divide the anterior part of the levator ani, and expose the membranous portion of the urethra, into which he makes an opening, and then, keeping the knife in the groove, while he satisfies himself, by taking the staff in his left hand, that it is held properly in the mesial plane close up against the pubis, he gives it again to the assistant, and pushes the knife steadily into the bladder, and fairly through the prostate; at the same time, with his left hand, holding down the rectum, and feeling what way is made with the knife. He then introduces his finger into the bladder, desires the staff to be withdrawn, and conducts in the forceps. He searches for the stone wiili the blades closed, and, liaving found it, opens them very wide, depresses, and then closes them. By gently relaxing his hold, and renewing it, he shifts the position of the calculus, if unfavourable for extraction, and, with the assistance of his left fore finger, proceeds to draw out the stone, not directly, but by a motion in alternate directions, so as to dilate the margin of the wound without tearing. Forcible efforts ought never to be used in doing this; and it is much better to introduce the knife again, if the opening proves too small. After one stone has been removed, the bladder ought to be searched for more, with a sound introduced through the wound; and if any are detected, they must be removed in the same way as the first. Should the calculus be broken, its fragments must be carefully extracted with the scoop, if small, or the forceps if large. The tube is then to be introduced, cither alone, or, if there is much tendency to hemorrhage, with some folds of lint wrapped round its middle; after which the patient may be placed in bed, on his right side, with the limbs moderately bent. "The after-treatment in cases that proceed favourably is ex- tremely simple. Means must be employed to prevent the urine which distils through the tube from soaking the bed, by inter- posing a piece of oiled cloth between the breech, and a folded 83 blanket laid under it, and applying tow or sponge at the orifice to imbibe the fluid. The diet, during the first three or four days, should be sparing, and of a farinaceous kind. Gentle laxatives, such as castor oil,are to be administered as occasion may require. The tube may be withdrawn at the end of two or three days. About the ninth day a little urine is generally observed to issue from the urethra; and when the natural passage thus begins to be resumed, the discharge by the wound very soon ceases, so that by the thirteenth or fifteenth day the whole is evacuated by the penis." Division of the prostate ivith the gorget. — This instrument, as modified by the late Dr. Physick, in rendering the blade shift- ing so that it may be separately sharpened and made to bear the keenest edge, is the one generally employed in this country for the division of the prostate. It has probably been employed in two-ihirds of all the cutting operations for stone done in this city for the last thirty or forty years, and which, as shown by the statistical reports of the Pennsylvania Hospital, have been attended by as large an average of success as those by any other mode of operation. It is the favourite instrument of Professor Dudley, of the Transylvania University, who has operated a greater number of times than any other American surgeon, and with a success that has been unexampled. By the sound, by examination through the rectum, and by the use of the lithniriptic instruments, we have the means of determining with very considerable precision, the size and cha- racter of a calculus previous to the operation; and as it has been shown in the brief account of the surgical anatomy of the peri- neum, that we can determine the requisite dimension of the wound necessary for its withdrawal, which in a large majority of cases may be limited to one lobe of the prostate, the gorget, by choosing a blade of appropriate dimensions, furnishes to the surgeon a surer means of accomplishing at once a section of the necessary extent than any other instrument. The direction in which the blade of the instrument is affixed to the shaft, insures that the section of the gland shall be made obliquely downwards ■ — the direction in which it may be most freely cut. As it slides along nearly at right angles with the various portions of the curve of the staff, it moreover cuts the substance of the gland somewhat concentric lo the curve of its lower surface; this rather facilitates the extraction of the stone by rendering the cut portions more dilatable, and places the parts at the same time under the most favourable circumstances for reunion, and for the prevention of the sad consequences that sometimes ensue — incontinence of urine and urinary fistula. It iias been objected to the gorget — that it makes the incision too mechanically and too blindly, it having no guide for its direction but the groove in the staff — that if it slide from the latter instrument it may plunge between the bladder and the rectum, and that the cutting edge of the gorget, even when it keeps the proper direction, may enter so far as to wound the posterior surface of the bladder. These objec- tions, which might have been tenable against the imperfectly sharpened instrument heretofore employed in Great Britain, are wholly inapplicable to the keenly-set gorget of Physick, which requires but a gentle effort for its inlroduclion, and in the hands of no one who understands the use of culling instruments can possibly either slip from the staff or wound the posterior wall of 330 SPECIAL OPERATIONS. the bladder. In at least a hundred instances in which the anthor, after making the cnt with [lie gorget on the dead body, has sub- sefjnently examined the parts by dissection, he has not noticed either of these results. The sensation of resistance overcome, the gush of urine from the bladder, and the contact of the gorget with the stone which is sometimes felt, suffice as the signs for the arrest and retraction of the instrument. To obviate any pos- sibility of injuring the posterior wall of the bladder, Dr. George P. Norris of this city, a skilful and successful litliolomist, as an additional measure of precaution extends the thumb upon the upper face of the blade so as to limit the extent of its introduc- tion. Operation. (PI. LXV. figs. 3, 4.) — The difference between this operation and the preceding one consists merely in the substitu- tion of the gorget for the knife, in the incision of the prostate at the last stage of the process. As soon as the staff can be felt through the membranous portion of the urethra, the surgeon sinks the nail of the left index finger into the groove, directs the scalpel along the naii so as to open freely the membranous por- tion and bring the edge in contact with the stalF. He then sinks the nail through the puncture last made till he feels it rub against the groove of the staff. Changing the knife for the gorget, he carries the beak of the latter along the nail into the groove at right angles with the curve, as shown at fig. 3, and slides it up and down till he is well assured from the peculiar grating sensation it gives, that it is fairly lodged in the groove. Now, taking the staff from the assistant, and grasping it firmly with the left hand as shown at fig. 4, he brings down tlie outer end 'in order to lift the prostate from the rectum, while the right hand acting in unison keeps the gorget firirily applied in the groove. Then, moving the beak a little to and fro to be assured that it is still in the groove, he carries the gorget — with the edge of the blade in- clined downwards and outwards—onward with a imiform steady effort, till the instrument enters, the bladder. The cessation of resistance and the gush of fluid from the bladder, show that the prostate is divided. As the gorget moves on towards the blad- der, the handle is to descend in front of (he anus, so as to keep the beak in its nearly perpendicular direction upon the groove, and prevent the possibility of its slipping. As the gorget ascends, I find a still farther and consentaneous lowering of the outer end of the staff with the right hand to render the section more neat and easy. The surgeon now withdraws the gorget, passes the left fore finger up the wound into the bladder, and removes the siatT which can no longer be of any service, with the right hand. The introduction of the forceps and the extraction of the stone are practised precisely as in the preceding process. In case the size of the stone should prove too great for the orifice in the prostate, this is to be enlarged by prolonging downwards the incision of the gland with a curved probe-pointed bistoury. If sufficient room cannot in this way be gained without cutting beyond the limits of the prostate, it will be necessary to break the stone in the bladder with a pair of strong screw forceps, and remove the larger fragments with the ordinary forceps, the iever, or a curette, and wash out the smaller through the wound by the injection of a mucilaginous fluid. Lateral .section loith the single lithotome cache. — The pecu- liarity of [his operation consists, as in the gorget operation, in the mode of dividing the prostate. The lithotome, with the knife concealed in the groove, is carried, with its concave surface up- wards, from the wound in the membranous portion of the urethra into the bladder. The surgeon now disengages the lithotome from the staff, and removes the latter from the urethra. He next. PLATE LXVI.-LITHOTOMY. BILATERAL OPERATION. VESICO-RECTAL OPERATION. Fig. 1. — Mode of withdratoing the stone by the forceps, after either of the operations shown in the preceding plate. — a. Hand of an assistant sustaining the scrotum, b, c. Hands of the surgeon, as applied at the period of the operation shown, when the stone is on the point of being withdrawn through the external wound, Fig. 2. — Section of the prostate vnth the double lithotome cachL [Process of Diipuytren.) — The parts have been exposed by dissection nearly as in Plate LXV. fig. 3. (A). Bulb of the urethra, beneath which is seen part of the remains of the triangular ligament. (B). Anus. (C). Internal pudic artery and vein. (D). Double section of (he prostate, made by the withdrawal of the double lithotome with the right hand of the surgeon {a). This instrument is slightly modified from that of Dupuytren, so as to render the section of each half of the prostate more sloping downwards, in order to diminish the risk of wounding the pudic vessels. Fig. 3. — Rccto-vesical section. {Processes of Vacca Berlinghicri and Sanson. — An assistant holds the staff verti- cally in the left hand {a), and supports the scrotum with the other. The surgeon divides first the integuments by an incision from the anterior angle of the anus made from below upwards. He then plunges the point of the bistoury into the groove of the staff, and, running the knife upwards and backwards along the groove, divides the prostate in the middle line, as shown in the succeeding figure. Fig. 4. — Vertical section of the prostate.— {A.). Bulb of the urethra. (B). Orifice of the anus. (C). Internal pudic vessels. (D). Vertical incision of the prostate, exposing the groove in the staff {d). (E), Bistoury, employed in the riglit hand of the surgeon, with which at the period of operation shown the sphincter and the anterior wall of the rectum to the extent of eight lines have been divided, and the bistoury, which has been carried along the groove into the bladder, is about to complete the section of the prostate. lUatt tftf OnStone /i^ .-f ^-l-^fivsaj/i- OPERATIONS UPON THE GENITO-URINARY ORGANS. 331 with the stalk of ilie litliotoine, endeavours to determine the size of liie stone, in order lo judge if it will be necessary to nicrease llic extent to whicli it is intended to open the blade, which should not, however, according lo 13oyer, even in cases of old men, exceed tlie numbers 9, 10, or 11, which are marked on the iiisirnment. The surgeon now raises the point of the stalk so as to lift it from tlie bottom of the bladder and bring it under llie arch of the pubis, and inclining it at the same time against the crus of the pubic bone, springs ihe blade by pressing on wiiat is called its tail. He then turns the blade in the course of the exter- nal incision, and incises (lie neck of Ihe bladder and the prostate by drawing the instrument out, opened, in a perfectly horizontal direction, as shown at Plate LXV. fig, 2. As soon as the resist- ance from the prostate ceases, the blade may be allowed to fall a little back into its groove, for fear of wounding the rectum, or dividing, if brought out at its full expansion, the two branches or the trunk of the internal pndic artery. Except in a well-prac- tised hand, the incision of the prostate with this instrument is accompanied with considerable risk of wounding the has fond of the bladder, or the vas deferens, as from the varying depth of the perineum in different subjects, the surgeon cannot positively tell when he springs the blade the exact extent of the instrument (which should not exceed an inch) projecting into the bladder.* BILATERAL OPERATION. The principal peculiarity of this operation consists in making a lateral section on either side of the prostate, so as to gain the greatest opening possible through tlje gland, prevent the contusion and laceration of that organ in the extraction of the stone with the forceps, reach the bladder by the nearest route, and diminish the risk of wounding the internal pndic artery. This operation, the first idea of which is found in Celsus, was brought into favour by Dupuytren, and is believed by many to olfer peculiar advan- tages, especially in the removal of calculi of large size. Process of Diiptajlreti. (PI. LXVI, fig. 2.} — The patient is to be placed precisely as in the ordinary lateral operation. The sound is passed in like manner into the bladder, and should be held exactly in the median line. The surgeon makes a semilunar incision, convex in front, which crosses three quarters of an inch in front of the anus, and extends frqm the middle point between the anus and the ischium of either side. The membranous |)ortion of the urethra is then opened as in the lateral operation, and the double-bladed lilhotome, shown in the drawing, entered with its concave surface upwards, the blades being concealed in Ihe grooves. The slaff is then withdrawn, and the lithotome inrned so as to present its concave face towards the rectum. The blades are now sprung, and the instrument is withdrawn with the handle inclined a little downwards, making, as shown in the drawing, a • Professor N. R. Smith, of the Unirersity of Maryland, has devised an instru- inenl by means of which the point of a bistoury can be thrust at once into the groove of the statT behind the bulb, and then carried on into the bladder without making a previous external incision, the wound being enlarged obliquely down- wards to the usual extent as the instrument is wiihdrawii. By this process, as asserted by this distinguished surgeon, a great improvement is made in regard lo "the simplicity, safety, and celerity of the operation." — (Vide Med. and Surg. Memoirs, by Nathan Smith, M. D., with addenda by N.R.Smith, M.D., Professor of Surgery in the University of Maryland, Baltimore, 1931. double section of the prostate gland. The finger is then passed into the wound, and the forceps introduced to seize the stone. In case the stone is found too large to be withdrawn through the space thus gained, a probe-poiiited bistoury may be introduced to extend the cuts further upon the sides, or, as advised by I^idal de Cassis, for the purpose of incising the vesical surface of the prostate, first upwards and then downwards from the urellira, so as lo convert ihe bilateral into a quadrilateral section of the prostate, which not only serves to enlarge the space, but renders the structure of the gland more distensible and yielding. Objection has with some reason been made to this process of Dupuytren, besides the increased risk of culling the walls of the bladder by arming the lithotome wjlh a second blade, the dimeusious of the opening made cannot positively be determined beforehand, since it is ditlicult to construct the blades so that they will not spring inwards towards the sialic when the structure of the prostate is foiuid unusually dense and resisting. To obviate this difficnily. Dr. A. H. Stevens, of New York, employs a doti- ble-liladed gorget, (prostatic bisector,) and makes with move precision a double section of the prostate from without inwards, as in the ordinary mode of using the gorget. Professor Warren, of lioslon, has judiciously modified the pro- cess of Dupuytren in tiie following manner. The stati' introduced iiUo liie bladder should be so held iu the middle line as to press the bulb and prostate downwards, and render them more acces- sible in the early steps of Ihe operation. A crescentic incision is then made, and the membranous portion of the urethra opened as iu the process of Dupuytren. Into the groove iu the statF a straight probe-pointed bistoury is passed. The assistant next by acting with the handle of the staff, raises the prostate in the direction of the symphysis pubis. The bistoury, with its edge looking obliquely downwards and to the left, is now to be carried along the groove of the staff into the bladder, the surgeon follow- ing it with the fore finger of the left hand applied upon its back. If the prostate is not as freely divided on its vesical as its outer face, (as I have commonly found to be the case in repeating this process on the dead body,) the bistoury is to be pressed with the finger resting on'its back, and the incision enlarged as it is with- drawn. We iiave now au incision through the prostate as in the cotnmon lateral operation. If the stone is ascertained to be of small size, the opening already made will sulfice for its removal with the forceps. But if the slone be of large dimensions, the bistoury before it is withdrawn from the wound is to be carried with its back foremost over the finger, and made in a similar manner to divide the right half of the prostate. We have now a bilateral incision of the prostate, as in the operation of Dupuytren, made by a process whicli is more simple, and in all its stages under the control of the operator. RECTO-VESICAL OR MEDIAN OPERATION. In this method the surgeon divides the sphincter ani, a small portion of the lower end of the rectnin, the cellular triangular space between the anus and the membranous portion of Ihe ure- thra, and the inferior portion of the prostate gland. The opera- tion is attended with biu liiile risk of luxmorrhage, and has, in the instances in which it has been prarlised, been attended with perhaps not more than the ordinary ratio of dcaiiis. But from 332 SPECIAL OPERATIONS. its liability to cause the obliteration of the excretory ducts of the testicle, and leave a fistulous communication between the rectum and bladder, it has been received with but little favour. Process of Sufison and Vacca Berlinghie7"i. (PI. LXVI. figs. 3, 4.) — The patient is to be placed, and a staff introduced into the bladder, as in the lateral operation. The surgeon then intro- duces his left fore finger into the rectum with the palmar surface forwards. Upon this he glides flatlings the ordinary- straight sharp-pointed bistoury, and, at the distance of three quarters of an inch from the margin of the anus, punctures the anterior wall of the rectum in the median line. The handle of the knife is now raised, and the blade, with its edge towards the symphysis pubis, is made as it is withdrawn to divide exactly in the middle line the sphincter, the portion of the rectum in front of it, and the triangular perineal space between the anus and the membranous part of the urethra. The membranous portion of the urethra is next opened with the knife over the groove of the staff, and a probe-pointed bistoury passed into the bladder along the groove. The surgeon then depresses the handle of the bistoury and divides the prostate backwards and downwards in the median line, using the precaution not to cut beyond the circumference of the gland, or to extend further the incision in the rectum. Tiirough the opening thus made the forceps may be passed into the bladder and the stone withdrawn. Various modiScations of the recto-vesical operation have been devised, but as they are now considered obsolete, it will be unne- cessary to describe them. SUPER-PUBIC, HYPOGASTRIC, OR HIGH OPERATION. This is an ancient method, which is designated by the name of Franco, its inventor, and was frequently practised by Frere Come. It consists in making an opening above the symphysis pubis, so as to reach the bladder when distended with fluid, without wounding the peritoneum. It is alike practicable upon the male and female. It is repudiated as a general method by nearly every surgeon of reputation and experience, though it is still practised as such by Souberbielle of Paris, and it is said with the ordinary average of success. The only peculiar advantage which it offers is the practicability of removing such calculi as are found of a size too great to be extracted safely by an incision through the perineum. Before undertaking the operation, the surgeon should mode- rately distend the bladder by the injection of water, (or air as has been recently proposed by M. Baudens,) so as to raise its top to the distance of several inches above the symphysis pubis. It should be remembered, that it is only when distended that the bladder projects above the top of the pubis, or presses the perito- neum away from the lower extremity of the linea alba. If the bladder be found undilatable, so as to be incapable of retaining more than one or two ounces of fluid, as I have several times observed it in cases of stone, an indefeasible objection is presented to the high operation, whatever may be the size of the calculus. Usual process. (PI. LXIX. figs. 1, 3, 3.)— The patient is to be placed as in the ordinary operation for hernia, but with the pelvis a little more elevated. The surgeon stands on the left of the patient, and makes from the symphysis pubis, in the direction of the umbilicus, an incision which in the adult should be three inches long. As soon as the iinea alba is bared, it is to be opened by a short incision near the pubis. Into this opening the left fore finger is introduced, and the incision prolonged upwards with a probe-pointed bistoury. The fluctuation of the distended bladder may now be felt from the bottom of the wound. But to render its position more manifest, a curved sound introduced from the urethra may be pushed upwards, so as to project its anterior wall. With the left fore finger we now break away the cellular tissue, so as to expose the wall of the bladder; then, hooking this organ upwards with the finger so as to render its front surface tense, the surgeon passes the straight bistoury in a nearly vertical direction into its cavity with its edge towards the symphysis, as shown in fig. 2, and prolongs the incision downwards towards • PLATE LIVIL— LITHOTRIPSY. The operation is represented on tlie dead body, and a portion of the bladder removed to exhibit the mode of action of the instrument. The subject is placed on the back, the thighs separated and the pelvis elevated with a pillow. The anterior wall of the hypogastrium has been removed down to the root of the penis, and the pubic bones detached with the saw from the border of the psoas muscle of either side nearly down to the arch of the pubis, so as to expose the anterior face of the bladder. (B). The lower portion of the interosseous substance, uniting the portions of the pubic bones left. (C). The bladder, represented with its cavity distended, and the upper half of its walls removed. (D). Peritoneal lining on the back part of the bladder, the middle portion of it cut away between the two umbilical ligaments. Fig. 1. — Operation with the lithotriptor ofCiviale. — The calculus has been seized between the blades of the instru- ment, raised from the bottom of the bladder; the instrument, which has been turned so as to present the ends of the blades upwards, is steadied with the left hand of the surgeon {a), while the screw is forced down with his right [b) to crush the stone. Fig. 2. — Second step of the operation, in which one of the larger pieces left by the first application of the instru- ment is again grasped for the purpose of reducing it into smaller fragments. This constitutes the first method of using the instrument in cases where the disease consists of many small and separate calculi. Fig. 3. — application of the brise-pierre of Jacobson, shown in a side vieio of the pelvis. — a. Symphysis pubis. b, c. Section through the middle line of the scrotum and perineum, d. Button which is screwed down so as to crush the stone (/) seen enclosed in the loop of the instrument. OPERATIONS UPON THE GENITO-URINARY ORGANS. 333 the pubis. As soon as sufficient space is made with the bistoury for the finger, this is to be hoolfed into the bladder to prevent the collapse of its walls. With the forceps we may now search for the stone. It will be found, however, more convenient to raise the stone np to the orifice with a curette or spoon, as seen in fig. 2; then giving the curette to an assistant to hold, the surgeon removes the calculus with the forceps. The search for the stone will be facilitated by having one margin of the vesical incision drawn off by an assistant with a blunt hook, as shown in fig. 1. In the other operations for stone above described, no dressing is to be applied, for fear of damming up the urine and causing its infiltration into the cellular tissue of the pelvis. But in this they are absolutely necessary, to prevent the urine escaping through the wound in the anterior wall of the bladder into the loose cel- lular structure behind the pubis. The proper dressing consists in the introduction of an elastic catheter by the wound, and covering the sides of the incision with a couple of graduated compresses, secured with a body bandage. It is nearly impossible, however, to avoid altogether the infiltration of urine. For the purpose of guarding more effectually against this accident, M. Vidal has recommended the making a previous incision down to the blad- der, filling up the wound with charpie, and at the end of a week, when the wound has suppurated freely, and there is reason to believe that the cellular structure on its sides is blocked up by a deposit of lymph, proceed to the opening of the bladder and the extraction of the stone. LITHOTRITY. The principles involved in this operation, of which some faint traces may be found in the ancient writers, consist in the me- chanical reduction of the calculus into minute portions by a drill- ing or grinding process, with instruments introduced through the urethral passage, without resorting to any cutting operation. To Gruithuisen, who in 1S13 demonstrated the facility with which straight instruments could be introduced by the urethra into the bladder, is due the honour of having made the first step towards the scientific establishment of this operation. The contrivance of this surgeon was, by the successive improvements made upon it by Amussat, Civiale, and Leroy, brought to a surprising degree of mechanical perfection. In its improved state it consisted of a straight silver canula, through which slid another of steel divided at its anterior extremity into three branches, which expanded by their own elasticity when pushed beyond the outer tube. While thus expanded they were placed over the stone, upon which they firmly closed on being again retracted. This internal steel canula in its turn enclosed a steel rod terminating in a head of variable shape, but so constructed as to act destructively on the calculus when put into rotatory motion by the string of the drill bow. The use of these straight instrumenis, distinguished by Velpeau as the rectilinear method, was found to be attended with great difficulty of manipulation, and even in the hands of so expe- rienced an operator as M. Civiale, (who first employed it success- fully upon the living subject,} with such injury to the organs and risk of life, as to present little if any advantage over the cutting operation. When the stone was reduced by excavation to the form of a thin shell perforated at several points, another instru- ment, called the brise-cogue ovhheW breaker, shaped like a slightly 84 curved sound, and having strong jaws at its extremity which could be made to separate and embrace the stone, was employed to crush it by the force of a screw or by the blow of a hammer applied against its outer end. In course of time it was found that the crushing instruments, as employed by Jacobson and Henrte- loup,*' were of themselves sufficient to effect the demolition of the stone; and as they were more easy of introduction, and more readily made to embrace the stone in consequence of their curved form, the lithotritic operation has been completely supplanted by the following, denominated the lithotriptic or crushing process. LITHOTRIPSY. An infinite number of most ingeniously contrived instruments have been devised for this operation. To a few of these only will it be necessary to refer. The author has found four or five of the different kinds, but of varying sizes, sufficient in every emer- gency for the performance of the operation. Three of these are exhibited in the drawing— the brise-pierre of Jacobson, (Plate LXVII. fig. 3,)— the improved lithotriptor of Leroy d'EtioUes, by which the crushing may be effected by the rack and pinion, or by percussion with the hammer when the stone is found unusually resistant — and the instrument as last modified by M. Civiale, seen in Plate LXVII. fig. l, with which the crushing may be effected with a screw, or if necessary by resort to percussion. This latter instrument, which is well manufactured by Messrs, Schively and Rorer of this city, the author has found admirably adapted to the operation. The handle of the hammer, as shown in Plate LXVIII. should be made thin and elastic. The two other instru- ments absolutely necessary to complete the lithotriptic apparatus, consist of the sliding duck-billed forceps of Civiale, worked merely by the force of the palm, which will be found most con- venient for the pulverizing of small fragments or larger-sized gravel, and the articulated curette of M. Bonnet for the removal of fragments lodged in the urethra. The latter instrument is constructed somewhat like the exploring sound of Amussat de- scribed at page 322; the principal difference being that the curette is introduced straight with the slender shaft of the instrument, and turned so as to form a right angle, by acting on the screw of the slilet after it has been passed behind the fragment. In several instances I have found a long slender pair of ear polypus forceps answer admirably well in the removal of fragments from the anterior part of the urethra. Operation. Preparation. — Previous to instituting the operation, the pa- tient should be placed in as good a state of health as the nature of the disease will admit, and the urethra well prepared by the • The instrament of Heurteloup, with the three-hranched or windlass screw, I have several limes employed with success, and consider on the whole, ihough less neai in its construction, superior to that of Leroy. The objection to the latter, distinguished by its inventor as the percuteur perfecUotine, is the narrowness of the space for the application of the pinion, in individuals where there is much embunpoint, and the thighs are muscular and large. This may be obviated in many cases by turning the instrument after it has grasped the stone, so as to allow of the vertical application of the pinion. But in attempting this I have occasionally been embarrassed by the bladder being excited to spasm, so as to drive some of its contents out through the urethra, and bring its walls around the end of the instrument. 334 SPECIAL OPERATIONS. previous use of the bougie, especially if found at all narrowed al any part, or unduly sensitive. When there is much irritability of the bladder, it will be found occasionally useful to tiirow in mucilaginous injections from time to time through an ordinary catheter, during the course of preparatory treatment. Position. — The patient should be placed with his buttocks on the side of the bed, his feet supported on a couple of chairs, the knees widely separated, and the trunk supported in a semi-recnm- beut position with pillows. The surgeon is seated on a chair between the patient's knees. If the patient be a female, she may be placed nearly horizontally, with her hips elevated on a pillow, and near to the foot of the bed— her feet resting on a couple of stools. If the patient has not been able to retain his urine for several hours previously, the operator is to inject a mucilaginous decoction througii a catheter till some tendency to pain is felt, or some fulness is apparent in the hypogastrium. The surgeon should never attempt to manipulate in an empty bladder, as the spasm excited under such circumstances would not only interfere with the seizing of the stone, but would expose the lining mem- brane of the organ to injury. In those instances, in which the stone has for a long period occasioned incontinence of urine, and the bladder could not be made to retain an injection of more than a couple of ounces of fluid, I have found the manipulation upon the stone greatly facilitated by filling the cavity with sweet oil thrown in through a catheter. One of the lithotriptic instruments above mentioned is to be introduced with the jaws closed into the bladder, in the same manner as a sound or bougie. When assured by the freedom with which the curved part can turn, that it is fully within the cavity of the organ, it is to be gently moved onwards, and if ne- cessary depressed till tlie heel of the curve is felt in contact with the stone. The surgeon then opens the instrument. This is to be done without giving any shock to the bladder, by grasping the lithotriptor firmly with the left hand near the pubis, and drawing on the movable slide with the right. A quarter turn is now made with the instrument. This places the stone between the jaws. The sliding blade is then pressed down with the right hand, and the stone is firmly seized, and is now ready for division after having been moved a little from side to side to ascertain that the mucous membrane is not included in the grasp. If, as is fre- quently the case, the stone is found soft, an attempt may be made to crush it by pressure with the palm. If it yield to the effort, the blades may again be opened and one or more of the larger fragments further comminuted. When the bladder is tolerant, the stone, though large, may, if soft, by two or more repetitions of this process, be so thoroughly crushed as to leave little to do at a second silting. But when much pain is excited or spasm of the bladder ensues, the operation must be no longer protracted. From ten to twelve or fifteen fragments have in this way in favourable cases been separately crushed at a single sitting. But in no case should the operation be protracted over ten or twelve minutes, and in most instances it would be imprudent to continue it for half this length of time. If the stone is found too hard to yield to pressure with the palm, the screw or the pinion, according to the instrument used, is to be employed to close the blades for the purpose of crushing it. If the stone should be found too solid — an occurrence but rarely met with — to yield without the application of such force as would incur a risk of bending or breaking the instrument, then only will it be necessary to resort to percussion. For this it is necessary to give a quarter turn to the instrument so as to present its curved end upwards, and raise the stone, now tightly grasped between the jaws, from the bottom of the bladder. The surgeon then secures the insinuiient, so as to render it perfectly immovable, by one of the processes shown in Plate LXVIII. and strikes with the little hammer a few slight rapid blows upon the button at the outer end till the stone is felt to yield, Tlie fragments into which it is divided are now to be separately seized and broken with the screw. After the completion of the operation, the fragments are to be shook or displaced by some rapid movements of the sliding or male branch from between the jaws of the instrument, so that it may be completely shut — as made manifest by the examination of the outer end — before an attempt is made to withdraw it. If it be withdrawn with the jaws held more or less asunder by granu- lar or triangular portions of the stone, the urethra is liable to be lacerated, and the instrument may even stick so tightly in the membranous or navicular portions of the canal as to occasion the patient much pain and give no little trouble to the surgeon. The brise-pierre or Hthoclast of Jacobson is to be employed almost precisely as in the process just given. From the more regular catheter-like curve of its end, it is introduced with great facility. When in the bladder, the chain loop is expanded by pushing down the sliding blade. The loop is then made to sweep lightly over the bottom of the bladder till it embraces the stone. The movable blade is then retracted, and the stone if soft may be crushed in the efl'ort thus made to close the loop. More com- monly it will be found necessary to apply the screw. With this instrument percussion cannot be practised. Tlie brise-piej've is at present much less employed than the instrument more com- monly designated as the proper lithotriptor. The author has, PLATE LIVIIL— LITHOTKIPSY, The exhibition of the parts is the same as in the preceding plate. (A). Line of section of the hypogastrium. (B). Os pubis. (C). Posterior surface of the bladder. (D). Peritoneum. Fig. 1. — Operation by percussion, after the mannei- of Lcroy d'Etiolles. — The stone is seized between the teeth of the percuteur perfectionnk of this surgeon. The instrument is grasped firmly in the left hand of the operator (a), and is furthermore sustained by the two hands of an assistant (i, c), so as to resist the shock which t!ie surgeon gives to the male blade by striking its end with the hammer [d). Fig. 2. — Another method of the same surgeon, of holding the instrument with the two hands of the operator {e,f), the hammer being applied by an assistant. I'lnU 6fi^ OPERATIONS UPON THE GENITO-URINARY ORGANS. 335 however, seen it, as well as the latter instrument, most skilfully employed in many instances by Dr. Jacob Randolph of this city, and has used it advantageously himself. The principal objec- tions which he has noticed in regard to its use are, the strain which it makes on the neck of the bladder by the disposition of the lower end of the blades to separate on the expansion of the loop, (especially observable when the bladder is Luit moderately distended,) and the difliciilty at the conchision of the operation in closing the instrument completely, in consequence of the gra- nular portions of the stone getting in between the blades. When the operation is over, the patient urinates and discharges the detritus and some of the smaller fragments of the stone. If it be convenient, he should in the course of an hour or two take a warm bath, and again empty the bladder. He should be placed on a mild diet, take mucilaginous drinks, and keep his bed at least for the day succeeding the operation. If on the third or fourth day he continues to urinate frequently and with a sensa- tion of pain, it is probable that some large fragments still remain. The instrument may then be re-introduced, and the operation repeated as before. Many successive repetitions of the crushing process may in some instances be required. When the fragments are small and numerous, the use of the duck-billed instrument of Civiale will as before observed be found particularly appropriate, from the ease with which it scoops up the pieces, and the facility with which it may be opened and shut. It is not necessary, however, that the fragments should be pulverized, as pieces of considerable size will be driven out with the flow of urine, and ordinarily with but little risk to the urethra, as the sharp edges left on their separation from the parent calculus will be found rounded off' by exposure to the urine in the cavity of the bladder. If much blood, in consequence of injury to the prostate, should accumulate in the bladder, it as well as the detritus of the stone may if deemed necessary be washed out by injections into the organ with a common catheter, or, which answers much better, one with a double current. Of the various accidents which may follow the operation, the retention of urine, fracture of the instruments when those of an inferior sort have been employed, inflammation of the prostate, bladder, testicle, or peritoncuin, it will not be necessary here to speak, as they will require to be managed nearly in the same manner as when developed under other circumstances. "Like many other novelties," says Professor Fergusson,* "litho- trity has undoubtedly been too much vaunted by its professed advocates and performers; but it is equally clear that in many instances it forms an admirable substitute for lithotomy. Not- withstanding the reputed success of Civiale, it seems to me that in the present stage of its history we have not sufficiently authentic data by which to determine the comparative safely of lithotrityt to that of lithotomy ; but regarding the applicability of the former, and even its superiority in many instances, there need be no doubt. Years must yet elapse, and the operation must be tested in our public hospitals by the same class of surgeons as those on whose proceedings the statistics of lithotomy have been founded, ♦ Practical Surgery, pp. 601-603. f By many writers lithotrity or lithotricy is applied to designate both the ori- ginal grinding or drilling operation, and that of crushing or lithotripsy. In the latter sense it has been employed by Mr. Fergusson. before an unbiassed professional judgment can be given on the subject. "There are certain circumstances adverse to the success of lithotrity, which should always be inquired into, ere it is deter- mined to resort to this operation. The diameter of the urethra before the age of puberty is most unfavourable, both on account of the smailness of the instrument which must of necessity be used, as also that the fragments cannot pass away in such large portions. Besides, in early years the urethra and bladder are more irritable — less callous to the contact of tlie needful apparatus. At any period of life a small urethra is objectionable on the above grounds, whether there be stricture or a natural want of deve- lopment. Any obstruction to the free passage of instruments or of urine, must be a great hindrance, and in advanced years the natural enlargement of the prostate, and what may be termed the diseased enlargement, present impediments which the utmost skill may not be able to surmount. Shoidd the bladder be sac- culated — a condition which can scarcely be ascertained on the living subject — the chances of success will be further diminished; for, supposing the stone to be broken into various fragments, the probability of some of these lodging in such pouches must always render the results of the proceeding uncertain. But from my own experience I should say, that the most formidable objection to lithotrity is the apparent irritability of the urinary organs; if the patient does more than wince while being sounded; if the application of the steel to the urethra seems to occasion pain— I mean more than that sensation which patients usually have on such occasions— if the mucous surface of the bladder is so tender as to cause the contact of the instrument to be borne with diffi- culty; and if the muscular fibres are excited to such violent con- traction as to occasion the evacuation of the fluid contents along the side of the instrument, or to excite an irresistible desire to micturate, then assuredly the circumstances are peculiarly unfa- vourable to the proceeding. A stricture may be cured; the na- tural caliber of the urethra may be increased by dilatation; even in certain cases the objectionable state of the prostate may be in some measure overcome by means of large catheters, scoops, and proper position whilst voiding urine; but the irritability — excita- bility, I may call it— and tendency to inflammation, which are almost certain accompaniments, cannot so readily be coped with. It is very certain that in some instances the organs become more and more callous after the application of instruments; but it is equally certain that the conditions above referred to often rather increase than otherwise, after the first, second, or third sitting; and, in addition, that in certain cases, where the conditions have not been by any means conspicuous before the operation, they have become so developed as to retard the whole proceedings, making each succeeding attempt more painful than the preceding one, so that the cure (if cure it can be called) is ultimately com- pleted amidst the most miserable sufferings — miserable to the patient, and disheartening to the surgeon,— when, from time to time, as a favourable opportunity presents, he has again to resume liis attacks upon the original cause of the suffering— the stone— which may at this time be already comminuted into a variety of fragments, "While I do not hesitate to assert that the above picture is by no means overdrawn, it must be admitted that (he effects are very 336 SPECIAL OPERATIONS. different in the majority of cases in wliich lithotrity is properly applicable: and here, be it remarked, there is a vast difference between such examples and those in which, unfortunately, it is attempted; for when the circumstances are favourable, viz., when there is a large and callous urethra, a capacious and apa- thetic bladder, (if I may so call it,) with good muscular power, a healthy prostate, and a small or moderately-sized sione, the ope- ration may be done once, twice, or as often as may be required, with as little annoyance to the patient as if he were only un- dergoing the treatment for stricture." OPERATIONS UPON THE GENITAL ORGANS IN THE FEMALE. These will comprise operations for Stone; Suture of the Peri- neum; Vagino-rectal and Vagino-vesical Fistula;. LITHOTOMY IN THE FEMALE. In the female it can seldom be necessary or justifiable to cut for stone. The shortness of the urethral passage, the facility with which it may be distended by the calculus itself, by the introduc- tion of a sponge tent, or by dilating force more suddenly applied, render possible the discharge of stones of considerable size through the urethral canal by the natural efforts of the bladder. The author has in two instances succeeded in removing stones from the external orifice of the urethra, of a diameter three or four times as great as the undilated canal. In case the stone is not in this way dislodged, the surgeon has a resource nearly infallible in the lithotriptic or crusiiing operation. It is difficult in truth, now that the operation just referred to has been brought to its present high degree of perfection, lo lay down any positive indi- cation for the perforniance of lithotomy in the female. It is, nevertheless, occasionally practised by some surgeons, and espe- cially in children, who do not as a general rule bear as well as older subjects the frequent introduction of the lithotriptor into the bladder. The extreme repugnance with which surgeons of experience regard lithotomy by a perinea! operation in the adult female, is not from any immediate danger accruing from t!ie operation, but the almost certain entailment for life of inconti- nence of urine — one of the most disgusting and loathsome atfec- tions. In consequence of this, if any cutting operation were deemed requisite in the adult female, the super-pubic or high operation, described at page 332, is deemed the most appropriate. In infants the incontinence of urine follows much less frequently than in adults, as a result of the division of the neck of the bladder from the perineum. This operation is performed in the female by four different processes — by an incision through the vestibuluni; by a lateral cut from the urethral passage; and by an incision from the urethra downwards into the vagina, or up- wards towards the symphysis. Jit the Vtstihulum. Surgical anatomy. — The object of the incision of the vestibu- lum, is to reach the bladder without dividing the urethra. The vestibule is a triangular space included between the clitoris, the nymphie, and a transverse line drawn across the anterior boun- dary of the urethra. The urethral canal in the adult is from an inch to an inch and a quarter long, runs obliquely upwards and backwards, and is slightly concave on the surface next tlie pubis. It gradually increases in diameter from the external orifice up lo the bladder. Its structure is simple, and may be compared to the membranous portion of the urethra in man, but is surrounded by no prostate gland. It rests on the anterior face of the vagina, to which it is united by some dense semi-erectile cellular tissue. It is found about a third of an inch below the sub-pubic ligament, to which it is united by some elastic cellular tissue, that yields on depressing the canal, so that the distance between the latter and the symphysis can be increased to an inch. In cutting PLATE LXIX,— LITHOTOMY IN THE FEMALE. Figs. 1, 3. — Super-pubic or high operation, as practised in either sex. An incision has been made through the linea alba above the pubis, and an opening made through ihe anterior wall of the bladder. In the stage of the operation shown, the surgeon sustains the upper angle of the vesical incision with the fore finger of the left hand (a). An assistant draws off one of the lips of the wound in the bladder with the blunt iiook {h), while the surgeon with the curette in his right hand (e) raises the stone from the lower fundus of the bladder. The surgeon then, as shown in fig. 3, gives the curette into the hands of an assistant (c), who sustains the stone while the operator grasps and removes it with the forceps applied with both hands [a, b). Fig. 2. — Puncture of thi bladder in the above ojieration^ shown after the incision of the linea alba, in a section of the male pelvis. (A). Symphysis pubis. (B). Line of section of the abdominal walls. (C). Reflection of the peritoneum on the top and posterior surface of the bladder. (D). Bladder, in a state of partial distension. (E). Left fore finger of the surgeon, which breaks away the cellular tissue so as to expose the front surface of the bladder, and serves as a guide to the bistoury (F), with which the bladder is punctured between the finger and the symphysis pubis. Fig. A. — Vestibular operation. — The labia majora are separated by the two fingers of an assistant (n, 6). A catheter passed through the urethra is depressed with the left hand of the surgeon (c) so as to make the vesti- bulum tense while he incises it with the bistoury in his right hand. Fig. 5. — Incision of the urethra upwards. — The mens veneris is pressed upwards with the right hand (A) of an assistant, (B). A grooved director; with this the surgeon depresses the urethra with his left hand towards the vagina, and divides its upper wall with a bistoury in his right. OPERATIONS UPON THE GENITO-URINARY ORGANS. 337 tliroiigli this space up to the bladder, we divide in succession the vestibular mucous membrane, the elastic cellular tissue, the cou- striclor vagiiine muscle, the anterior ligaments of the bladder, and lastly the neck of the bladder itself. Operation. {Process of Lisfranc. PI. LXIX. fig. 4.)— Tiie patient is to be placed as for tiie lateral operation in man. Two assistants separate the margins of the vulva. A sonnd is intro- duced into the urethra, and pressed downwards with the left hand of the surgeon towards the vagina so as to distend the ves- tibular space. The surgeon then makes a semilunar incision in front of the urethra, as shown in the drawing. In making this incision the handle of the bistoury should be kept lower than the blade. The layers are to be divided in succession up to the bladder; the lower lip of the wound is then depressed with the finger, and the bistoury is plunged into this organ so as to open it transversely. Through the transverse opening thus made the forceps are introduced for the removal of the stone. Neither the superficial, perineal, nor internal pndic arteries rnn much risk of being wounded. The process, however, is not, according to the author, deserving of much reliance, as it does not alford snlEcient space under the arch of the pubis for the extraction of a large stone, and would be liable to give rise to an effusion of urine in the cellnlar tissue behind the pubis. Urethral Operation. There are several processes for the division of the urethra. 1. Division i/i the median fine towards the symphysis pubis. [Process of Collot, PI. LXIX. fig. 5.)— An assistant applies t!ie ulnar margin of the right hand upon the mons veneris so as to extend the vestibntum. The surgeon then introduces a grooved director tlirough the urethra, runs a straight probe-pointed bis- toury along the groove, and incises the upper wall of the urethra, the cellular tissue above it, and the neck of the bladder in the direction of the symphysis pubis. The instruments are then withdrawn; the left fore finger is introduced into the bladder, and serves as a guide to the passage of the forceps for the with- drawal of the stone. This operation has been many times per- formed with success, and is less liable to be followed by incon- tinence of urine than either of the two succeeding processes. 2. Division of the xirethra in the direction of the vagina. — This is a very simple operation. It differs only from the pre- ceding in that the incision is directed downwards in the median line so as to divide the lower surface of the urethra, a part of the wall of the vagina, and the lower part of the neck of the bladder, 3. Lateral operation. — This consists in the introduction of a bistoury through the urethra on a grooved director, and incising the parts obliquely downwards in the same direction as in the lateral cut for stone in the male. This process has, Iiowever, been but little practised; it involves the division of the constrictor vaginse muscle, the transversus muscle, the margin of the levator ani, as well as the urethra, perineal fasciae, and neck of the bladder. The internal pudic artery occupies the same relative position as in the male, and is more or less exposed to injury. To get a freer opening suited to the extraction of a larger stone than this process would allow, Dnpuytren made a bilateral inci- sion with a doable lithotome, by a method nearly allied to that employed in the male. 85 SUTURE OF THE PERINEUM. Surgical anatomy.~\n obstetrical language, the perineum of the female comprises the whole of the space included within the bony outlet of the pelvia Its aniero-posterior and transverse diameters are each about four inches, tliongh the former may be somewhat increased by the retrocession of the point of the os coccygis. The perineum proper, however, consists of the trian- gular space between the vagina and the rectum. The base of this triangular portion presents to the skin, and is there from three quarters of an inch to an inch and a quarter broad; its vertical diameter is about an inch and a half. Above this triangle the walls of the rectum and vagina are closely united by dense cellular tissue, up to a point where the peritoneum is reJlected off from between these organs, abont three inches from the surface, constituting a part which may be distinguished as the recto-vaginal seiitum. The perineum of the female comprises the same fasciae, vessels and nerves as the male. The fascise, Iiowever, especially the middle and inferior which are found in the perineal triangle, are rednced to a cellular state, and are bifurcated in front for the purpose of surrounding the vagina. The cellular structure of the perineal triangle is distended into a lliin layer during parturition, to allow of the passage of the head of the fcetus. When it does not yield properly to the dis- tension, or the child's head is unusually large and the labour rapid, the triangle, with the anterior margin of the sphincter ani muscle, may be ruptured near the median line; in some instances an opening has been made in it by the incautious use of the forceps or the crotchet. If the laceration extend further, so as to involve likewise the recto-vagitjal septum, and lay the two passages of the vagina and rectum into one, it will constitute a deformity of the most distressing kind. If the degree of lacera- tion be limited — extending merely to a little distance beyond the posterior commissure of the vagina — the cure will in most in- stances take place spontaneously, especially if, as directed by Clielius, the patient be laid upon the side for the purpose of ' keeping the parts in closer approximation. In case the laceration be more extensive, the patient may be placed in the same position, with a towel pinned round the liips and thighs to keep the parts more completely at rest. The contused nature of the injury, the character of the discharges which inundate the part, but too commonly in these cases prevent union by first intention. It has been proposed by M. Danyau, [Joiirn. de Chirwg. IS43,) to unite the parts immediately by suture. In some instances it miglit be deemed advisable to apply at once a single stitch, which should take deep hold of the perineal margins. But if there be much swelling, and there is reason to believe that the vitality of the lacerated structures is greatly impaired, this course would be highly injudicious, it being infinitely better under such circum- stances to wait till the parts have recovered their vital energies. The interrupted, the twisted, and the quilled suture, and the leaden wire ligature,* have been employed for the purpose of holding the sides of the fissure together. The quilled suture has, how- ever, in the main, been found to answer best, as it not only t " In the Amer. Joiirn, of MecL Sci. for 1833, a case is reported by Dr. J. P. Meltaiier of Vii^inia, in which the leaden ligatures were employed wiiU success. 338 SPECIAL OPERATIONS. keeps tlie surfaces more deeply in contact, but diminishes the tendency of the threads to cut out, which usually it is desirable to keep in place till a sohd cure is obtained. This is always effected more or les>s by second intention, and is sometimes not accom- plished under t!ie space of a month. When the cure seems tardy, it will frequently be necessary to resort to washes or ointraenis of a stimulating character, to promote (he growth of granula- tions. Operation as practised hy the JJuthor. (PI. LXX. fig. 1.) — The patient is to be placed as in the perineal operation for stone. The borders of the fissure, if they have become callous or lace- rated, are to be excised with the knife or scissors. From three to four or five double ligatures are to be passed with a needle deeply through the edges, embracing the integuments of either side (o the extent of an inch. These are to be secured, as sliowii ill the drawing, over portions of a bougie or quill. In case the fissure has extended up through the recto-vaginal septum, two interrupted sutures should be introduced with a fine needle, to approximate the edges previous to the closure of the perineum. If much tension of the integuments is made by the quilled suture, it should be relieved, as recommended by Dieffenbach, by a semihuiar incision on either side, as shown in the drawing. In the after-treatment the greatest care is required to preserve the parts in a state of perfect cleanliness. The urine should be drawn off whh a catheter, and for the first few days succeeding the operation the action of the bowels should be arrested by the use of opiates and astringents. When it becomes necessary lo have the bowels open, the accumulated fseces may be washed out through a tube by repeated injections of soap and water. Even after the cure has been completed the patient has for a considerable time to continue the use of baths and emollient ap- plications in order to soften the cicatrized parts, and should for a long period avoid any occurrence liable to produce a new lace- ration. KECTO-VAGINAL FISTULA. A fistulous passage communicating between the vagina and rectum may result from the incomplete laceration or contusion of the septum in ditficult parturition, from unskilful use of the forceps or crotchet, or simply from the opening of abscesses in the direc- tion of the two passages. Cases arising from the latter two causes have repeatedly come under the charge of the author. When small, he has with but little difficulty made them close under the occasional application of the actual cautery. If larger and placed immediately behind the anterior end of the sphincter, he has found it necessary to resort to the division of this muscle with the bistoury or ligature, Process of Roitx. — When the fissure is longitudinal, Roux has recommended the incision of the edges and the closure of the opening by two or more interrupted sutures, as shown in Plate LXX. fig. 4. Where the opening is transverse, the same distin- guished surgeon has dissected np a quadrilateral flap from the posterior part of the vagina, closing the opening by drawing the flap down over the fissure, and fastening it by suture below the margin of the posterior vaginal commissure, as shown in Plate LXX. fig. 2. Process of VeJpeau. — In cases of large transverse opening, this surgeon, in imitation of the process of Jobert, (page 3^12,) dissects up a flap of integument from the outer surface of llie labium externum, twists it upon its pedicle, and afBxes it by suture over the vaginal orifice of the fistula, the edges of which have previously been inflamed by the application of caustic. Process of Barton, — The following ingenious operation was devised by Dr. J. R. Barton of this city, in the case of a young unmarried lady, for a fistulous passage which had formed as the consequence of an acute abscess in the region of the rectum and vagiuLi. "The fistula was found commencing about three-fourths of an inch within the labium of the right side, thence passing by a very irregular course up the pelvis and inclining towards the rectum; into which cavity it finally opened, about three and a half or four inches from its inferior aperture in the vagina. Through this sinus there issued fluids in suflicient quantity to keep the genitals continually moist. Flatus also at times found its way through this channel. "The discovery of the real nature and the extent of this sinus, passing as it did from one to another important cavity, and estab- lishing a communication between them, presented an embar- rassing view of the case as to the mode of cure. It was now clear that the complaint must be treated with reference to its connection with the rectum, and upon the same principles that govern ns in the cure of fistula in ano— for in fact it was virtually such a case modified by the unfortunate implication of the vagina. "It was nevertheless apparent that this sinus could not be included in a seton and ulcerated through, nor be laid open, as usually done in the common fistula in ano, without destroying the perineum and laying these two great cavities into one! — thereby causing a more unhappy state of the parts than had pre- viously existed. The duty, tlierefore, of the surgeon was very clear — either to consign the patient to a continuance of her loath- some complaint, or to adapt an operation to her peculiar case. The latter was successfully done, as follows. "A fine tent was inserted, for a few days, to dilate the sinus, and to render its course less tortuous. A seton was then intro- duced, with an eyed probe, into the sinus per vaginam; thence passed through its whole extent, until it had penetrated the rectum by tlie orifice into that cavity. It was then brought down and out per ami?}!. The two ends were then loosely tied together merely for security against its slipping out. After a few days the loop was opened, and the end of the seton passing out of the vagina was put through the eye of a probe which was previously crooked at the other end. This probe was then inserted into the orifice in the vagina; thence about an inch and a half up the sinus, tiien its point directed towards the perineum, just exterior to the sphincter ani muscle. Here a small but somewhat deep incision was made, and the probe pusiied through it; bringing along with it the end of the seiou wbich had been doubled upon itself "The seton now instead of passing out of the vagina, as at first, after coming down from the bowel, through only part of the sinus, descended through the new channel which I had made for it. The ends, lying almost side by side, were now tied to- gether — thus forming a loop in which were included the parts between the outer surface of the sphincter ani muscle and the OPERATIONS UPON THE GENITO-URINAKY ORGANS. 339 reclum. Tliis seton or ligainre was subsequently drawn and twisted tighter and tighter from time to time in order to cause its ulceration through the inchided parts, as we do in common fistula in ano, wlien operating by tlie ligature or wire. So soon as by these means, the new and direct channel was formed and had attained a larger size llian that penetrating the vagina, the dis- charges from the rectum deserted tiiat portion of the route which led into the vagina, and took the course of the seton. This was exactly the end which I designed to accomplish by operation; believing that if I could eslahlisli a freer and more direct passage for the escape of the fluids of the rectum than that per vaginam, the sinus opening into the cavity would heal sua sponte, and become permanently obliterated. My opinions were confirmed — for long before the setoii had made its way out by ulceration, the vaginal portion of tlie sinus had healed, and the integrity of this organ had been restored. I had now only to pursue the treatment of this case as I should have done had it been a simple case of fistula in ano— viz., by continuing to tighten the ligature every day or two, until it finally came so nearly away that a slight clip by the scissors divided the insignificant intervening portion yet retaining it, when it was released. These parts healed up in a few days."* VESrCO-VAGINAL FISTULA. In tilis aiTection there is a fistulous communication between the bladder and vagina, by which the urine escapes either continu- ously or at intervals through the latter passage, constituting one of the most afflicting and disgusting maladies to which the female can be subjected. If the opening exist at the junction of the urethra with the neck of the bladder, and is not of large size, the bladder is capable of retaining a small amount of urine in its lower fundus; the condition of the patient is then less distressing, as the urine escapes only at intervals, and the patient by unusual cleanliness and care may preserve a certain degree of comfort. But if the opening is at the bas fond of the bladder, the urine in most instances dribbles away as it falls from the ureters, irritates and excoriates the vulva, the perineum, and the inner surface of the thighs, and spreads an offensive penetrating odour which causes the patient to exclude herself from the world, and in the end breaks down the general health by its synipaiiictic disturbance of the nervous system. The fistula may be occasioned by ulceration from llie lodgment of foreign bodies in the bladder, or from syphilitic sores; but in the great majority of cases it arises either from the unskilful use of obstetrical instruments, or from the detachment of a slough, the consequence of the long-continued pressure of the child's head in the lesser pelvis during parturition. The author has had two cases under his charge in which the alleclion was fairly attributable to laceration with the crotchet. When it is the result of a slough accompanied by the pressure of the f(Etal head, or by that of a pessar}', which has been known to produce it, the flow of urine by the vagina does not immediately follow the inflictioji of the injury, as the slough is in many cases not detached till after the lapse of ten or twelve or fifteen days. The diagnosis of this form of fistula is usually easy. When • Amer. Joura. of Med. Sci., Au^. 1840. the urine is found to escape from the vagina, the nature of the affection is at once manifest. But this sign the author has found more dithcuit to recognize than would at first be imagined. In case of doubt, a coloured fluid may be injected into the blad- der, which, if the opening exist, will readily be noticed in the vagina: or the vaginal passage may be explored with a bivalve speculum. The means of diagnosis which I have found most eflicacious, consists simply of the examination of the vaginal pas- sage with the finger conjointly with the introduction of a conmion catheter through the urethral passage. Lallemand recommends the insertion of a cylinder of softened wax into the vagina, for the purpose of taking an impression of the size and form of the stricture; but this process, though I have made repealed trials of it, has never afforded me any material assistance. Of all the classes of surgical operations, those devised for this aflection have been attended with the least satisfactory results. Prior to the time of Petit and Desault, it appears to have been deemed wholly incurable — and the great degree to which modern surgeons have taxed their ingenuity in the inventioii of processes lor its cure, without having established any that has received general confidence, serves to show the difficulties encountered in the treatment. These difficulties in recent cases consist in the deleterious influence of the urine on one side, and of the leucor- rhceal discharges (which are nearly constantly observed) on the other, both of which offer obstacles to union either by first or se- cond intention. In addition to these, when the fistula is large and of long standing, the bladder becomes diminished in its capacity, and frequently has its upper fundus inverted through the open- ing; tiie vagina is moreover liable to become narrowed, and have its surface as well as that of the bladder covered with calculous concretions. Though small fistulous orifices may be obliterated without any particular difiiculty, large openings from the causes above mentioned present obstacles to the cure that are nearly insurmountable. The various plans of treatment which appear entitled to the most confidence, may be classed under the following heads: — cauterization,suture and instrumental approxi- mation, and plastic operations. Cauterization. — This is efi'ecied either by the application of the nitrate of silver or the actual cautery, winch are to be applied after distending the vagina with the speculum. If the former is employed, the walls of the fistula are to be touched with it from day to day, so as to develope a growth of grauutalions which may in the end block up the opening and solidly unite together. In this way the author has succeeded in occluding a fistula of the diameter of a large goose quill, seated near the neck of the blad- der. If the actual cautery is used, the round or olive-headed iron should be chosen, and applied but for an instant merely to the vaginal surface of the fistula, as otherwise we might by the destruction of the margins increase the size of the opening. The object of the iron is to contract the opening, and at the same time excite the adhesion of its edges. If the orifice is large, it should be applied at a white heat at long intervals — if small, repeated every third or fourth day, Leroy advises tlie application first at a little distance around the margin of the orifice, for the purpose of diminishing its size by wrinkling the tissue, and subsequently to touch lightly the edges of the orifice with the iron. The author has tried this process, and in one instance with success. 340 SPECIAL OPERATIONS. when the fistula was of such a size as to receive llie end of the Httlc finger; but the prhicipal advantage appeared to be derived from the action on the margin of the orifice. When during the treatment the fistulous passage becomes obstructed by the swell- ing of its orifice, or by the granulations developed, the urine should be prevented from accumulating in the bladder, either by the retention of a catheter in the urethra or by resorting to its frequent introduction. If the fistulous orifice is of very large size, neither of tlie processes of cauterization will be found eff"ective. The other forms of operation must then be Iiad recourse to, an abridged account of which has been given as follows by Mr. Costello. Suture. (PI. LXX. figs. 5, 6.)— "The suture in these cases is only employed as a means of keeping the fistulous edges in con- tact; and these must be previously disposed to unite by adhesion, either by the application of a caustic, or by paring with a Itnife. This operation of paring or resecting the edges of a fistulous opening in a movable fleshy wall, and deeply seated like the vagina, is extremely difficult; and this, indeed, is one of the rea sons why the application of caustic is so often preferred, "Various methods and insirumenis have been employed for this purpose. Sanson thought that the difilculty would be ob- viated by dividing the urethra with a bislouri cuclU; and then introducing his finger and drawing the fistulous edges down- wards to the orifice of the vulva. In this manner the paring of the edges was readily effected, and the sutures applied; but the cure was not effected. In another case, treated by Malagodi, of IJologna, he was enabled, by introducing his finger into the ori- fice of the fistula, to bringdown gradually its two sides, and pare off the edges with a bistoury. M. Roux employed in another case two pairs of forceps, constructed to hold the right and left sides of the opening. When applied, the under blade of each instrument being wider than the upper, presented a fixed surface, on which the edges were easily cut. A curved suture needle PLATE LXX.-SUTUIiE OF THE PERINEUM. YAGmAL FISTULA, SUTURE OF THE PERINEUM. Fig. 1. — Suture of the perineum tvith the lateral incisions of Celstts as modified by Dieffenbach. — The edges of tlie lacerated wound have been excised with the knife, and brought together by three points of the quilled suture. In order to allow the more perfect approximation of the surfaces, two lateral incisions have been made through the integuments. RECTO-VAGINAL FISTULA. Fig. 2. — Cure by the process of Roux. — The opening in this case existed between the vagina and rectum, a little distance from the cutaneous surface of the perineum. A quadrangular flap has been detached from the posterior wall of the vagina, and drawn downwards for the purpose of being fastened by suture to the margin of the fourchette, which has been made raw to receive the flap. Fig. 3. — Closure of a longitudinal fstuki by suture. — The vagina is distended with a bivalve speculum. The edges of the fissure, previously inflamed by the application of caustic, have been rendered raw with the knife. The needle is passed with a 2^orie-aiguille [a), tlie surgeon steadying one of the lips of the fissure with a pair of rat-toothed forceps in his left hand (6). VESICO-VAGINAL FISTULA. Fig. 4. — Plastic operation for the closure of the opening between llie vagina and bladder. [Elytroplasty. Process of Jubert.) — A flap has been detached from the surface of the labium externum, turned upon its pedicle, and fastened by sufure over the margins of the opening. Fig. 5. — Suture of a transverse fistula. {Process of M. Deyher.) — A catheter («), inclosing a dart stilet, is intro- duced through the urethra. On the right side the stilet has been passed through the anterior lip of the opening, so as to lodge one of the sutures in the wound, and is shown passed again through the posterior lip to allow the other end of the ligature to be detached with the forceps. Fig. 6. — Excision of the edges of a longitudinal fissure by the aid of the forceps of M. Fabri, one blade of which is constructed like the prongs of a fork. The upper blade, which is single and flat on its lower surface, is intro- duced by the urethra, and serves as a support to the pressure made by the forked blade on the edges of the fissure. The knife is seen applied for the excision of the edges. Figs. 1, S. — Closure of the orifice by a plastic operation. (Process of Leroy d'Etiolles.) — In fig. 7 is shown the outline of a flap [a), detached from the posterior face of the vagina at the anterior extremity of the canal. In fig. S, which is a profile view on a section of the pelvis, the flap (a) Is reversed, so as to present its raw surface to the margins of the fistulous opening, which have been previously inflamed with caustic. The end of the catheter [b), passed from the bladder into the vagina through the fistula, is made to receive the threads of a double quilled suture, by means of which the flap is held against the vesico-vaginal septum. OPERATIONS UPON THE GENITO-URINARY ORGANS. 341 was then passed, followed by its wire, by means of a port-aiguille or needle-holder, from the left edge into the bladder, coming out through the right edge. Three points having been thus placed, they were twisted and protected with a pledget of charpie. The operation, which lasted nearly two hours, was unfortunately fol- lowed by an attack of peritonitis, which ended fatally. The methods just mentioned, however, were only applicable to cases in which the direction of the aperture was longitudinal. "The method recommended by Velpeau is thus described by him: 'The patient is placed on an elevated bed or table; a rolled mattress is placed under the belly, so that she may bend Iier thighs while she lies on the abdomen. An assistant keeps the vagina dilated by means of a wide groove of wood, horn, or metal; the posterior and anterior angles of the opening are di- vided, the former with a straight scissors, the latter with a bis- toury, to the extent of a line or two, in order to facilitate the seizure of the edges on cither side with a good staphyloraphy forceps, and their resection by means of scissors, either straight or curved, on the fiat. The points of suture are then placed three or four lines outside the resected edges; the edge is held with the forceps while the needles are being passed, and each point is twisted or tied by means of the fingers. If the opening be transverse, the edge may be easily resected by means of a bis- toury curved on the flat, and very sharp near its point, the edge being raised or lowered by means of a proper pair of forceps.' "The difficulties attending the placing of points of suture are, however, it is to be hoped, in a fair way of being removed, or at least diminished considerably. With M. Colombat's spiral needle, a suture-seam can be easily made in the vaginal wall; and this, as well as the improved port-aiguille, may lead to more nume- rous successes in this embarrassing point of surgery. "To place before the reader some of the most practical of the modes proposed and practised, we shall take them in the order of their succession as to time. At the commencement of the present century, M. Lewziski proposed, in a case of transverse fistula, to place the sutures from within the bladder, by means of a needle fashioned like a sonde d, dard, and introduced through the urethra. This instrument was subsequently improved by M. Deyber. "In 1S25, M. Lallemand, of Montpellier, invented an instru- ment whereby the lips of a transverse fistula could be brought into, and maintained in contact during th.e time necessary for their adhesion, without sutures. This instrument, which he termed sonde-higne, consists of a thick canula, four inches long; a double hook, or two double opposing hooks, that can be pro- jected from, or drawn into, the canula at pleasure; a circular disc at the outer end of the cannla, to prevent its slipping into the bladder; and a spiral ring, by means of which the hook intro- duced into the posterior lip of the fistula can be brought forward. The canula is introduced through the urethra, and the hook is projected through the vesico-vaginal wall, just beyond the pos- terior lip of the fistula, and upon the surgeon's fingers. The front of the urethra is protected from any undue pressure which the disc might make on it, by means of a pledget of lint. The spiral ring then acting, brings the lips of the fistula in contact, by bringing the hook forward, and forcing the anterior lip backward. The degree of apposition necessary to union can be nicely regu- 86 lated, by means of a particular mechanism. The vagina should also be protected from the contact of the iiook, by a pledget of lint. M. Lallemand states, that he has succeeded in seven cases with this apparatus. He does not refresh the edges of the fistula by incision; he simply cauterizes with the mtrale of silver. "Dupuytren invented an instrument also, for the purpose of approximating and holding the lips of the fistula in contact, which, being previously cauterized, were thus disposed to unite. This instrument was a large female catheter, furnished at its sides with two flaps or wings, that could be expanded or closed at pleasure by a central rod. When this sound was introduced into the bladder and the wings developed, on being drawn out- wards, the posterior edge of the fistula was drawn towards the anterior, which was also pressed backwards by means of a pledget of charpie. " Cure by the application of a flap taken from the neigh- bouring integuments. (PI. LXX. figs. 7, 8.) — The idea of ex- tending the application of plastic surgery to the loss of substance in the vesico-vaginal wall, was first propounded by M. Jobert, in 1S36. In effect, there is no greater diflicully in obtaining a flap from the labia, groin, or buttocks, for the purpose of closing a solution of continuity in the vagina, than there would be in detaching one from the forehead, in the operation of rhinoplasty; and although the object of the transplantation is difi'erent, the steps of the operation itself are nearly the same. "The edges of the fistulous aperture are first refreshed by inci- sion, which M. Jobert affirms to be of easy execution, as they can be brought down by moderate well directed traction, or by introducing the finger into the aperture. When the edges of the opening are pared, a flap of proper size and thickness (the skin alone would not suffice) is then formed, with a pedicle of suffi- cient substance to insure nourishment for the flap; and it should be of such a length as to make allowance for the retraction whicli takes place in it during the stage of suppuration. "In order to secure the flap in its place while the points of suture are being placed, a thread is passed through its upper edge, and a catheter being introduced through the urethra and fistula into the vagina, the thread is passed through the eyes of the catheter, and is thus drawn out and given to be held to an assistant. *I then introduce,' says M. Jobert, *my finger along the flap, sliding over it a curved needle, fixed in the port-aiguille used in the operation for staphyloraphy, or I direct it solely with the hand. At one stroke the angle of the flap and the edge of the fistula are transfixed, and the needle, armed with a ligature, is withdrawn by means of a pair of dressing forceps. The same is done with the opposite angle. As soon as the points of suture are placed, they should be tied at once, to secure perfect contact. The threads are secured externally; and they come away from the tenth to the fourteenth day.' "The next thing is to prevent the accumulation of urine in the bladder, and to secure for it a free and constant flow. This can only be effected by placing and keeping in the urethra a catheter of full size. The thread first employed should be passed down this catheter, as the ulceration it might occasion in the urethra will thus be prevented. The patient is placed in the horizontal position, and strict rest is enjoined. " The period for the division of the flap must, of course, depend 342 SPECIAL OPERATIONS. on the sufficient vitality and adhesion of its npper portion, as well as the patient's state of health. The safest course is, not to be in a hurry. M. Jobert does not divide it till the thirtieth or fortieth day; and even this may be premature. In malcing the division, due allowance must be made for the further retraction which will take place; it should not be divided higher up than one-half of its entire length. The external wound resulting from the transplantation, may be treated by adhesive straps or sutures; but care should be taken that no pressure be made at the lower part of the wound, that might interfere with the due supply of blood to the pedicle of the flap, " M. Jobert thus describes the consecutive phenomena observed by him: *As soon as the parts are brought into contact, an exu- dation of blood takes place in the bladder, which is voided by the catheter; the same oozing occurs also in the vagina. The wounded surface of the flap soon becomes covered with lymph; the urine becomes turbid, owing to the pus given out from the upper part of the flap; and this continues for an indefinite period, or until the upper part of the flap contracting, it becomes levelled with the surface of the bladder. I have seen it persist for twenty- five days. "'The section of the pedicle gives rise to more or less hemor- rhage; and both ends of the flap soon retract. The transplanted portion, now living in its new situation, is liable, like other tissues, to various diseases; and hence it inflames, not only from the slightest contact with the urine, but even by the effects of the incision; and hence, when red and swollen, it is observed to ex- tend out of the vagina. In this state it is engorged; suppuration soon takes place; and as this diminishes, it retracts within tlie vagina. Thus I have seen the flap, when divided, retract, to come forth again during the inflammatory stage, and again retract to such a degree, as not to be seen without expanding the labia, and depressing the posterior commissure, «'It is worthy of remark, that the flap, though enjoying life, no longer possesses sensibility, all communication with the great nervous centres being cut otf.' "* Process of Velpecm. — This consists in seizing with a double hook the posterior wall of the vagina, opposite the fistula, push- ing the wall forwards by a finger introduced into the rectum, and * Cyclopedia of Praciical Surgery: London, July, 1843, raising up with the bistoury a bridge, an inch to an inch and a half long, from the floor of the vagina, without penetrating into the rectum. The edges of the fistula are then made raw and closed by sutures, which are made to pass, before they are tied, under the bridge, so as to elevate the arched or bridge-shaped flap, and cause it to project into the bladder. This process has failed, however, in its application upon the hving subject. Process of Leroy. (PI. LXX. 7,8.) — In place of the processes of Jobert and Velpeau, which he looks upon as little more than mere speculations, this surgeon has proposed the following. To raise a flap from the posterior wall of the vagina, as shown in fig. 7, penetrating only with the knife into the cellular space be- tween the vagina and rectum, and stopping where the point of union between these passages becomes more intimate at the recto-vaginal septum. A short thick flap may thus be obtained, which is to be applied by its raw surface to the edges of the fis- tula, which should be made raw and bleeding. The flap is to be fastened by a double quilled suture, as shown in fig. S, Despairing of success in cases of large fistulEs by any of the processes known, M. Vidal has proposed to excise the mucous membrane at the anterior orifice of the vagina, and cause the surfaces to unite by the application of the quilled suture, so as to leave but a small outlet for the urine, and turn the vagina into a common urinary pouch, from which the urine can only escape by the urethra. As there are but too many cases in which all methods of cure fail, it becomes necessary to devise some measures to palliate the inconvenience arising from the constant flow of urine. Leroy points out a mode of tamponing the vagina with caoutchouc in leaves or in paste — a substance which is elastic and unalterable, and, as he says, freer from the objections which to this day have rendered all permanent plugging of the vagina nearly impracti- cable. Mr. Barnes, of Exeter, (Eng.) employs an elongated caout- chouc bottle, which, when placed in the vagina, presents an opening corresponding to the fissure. The author has, however, had better success, with a sort of boot-shaped silver or silver-gilt trough, devised by M, Feburier of Paris, which, when accurately fitted to the vulva, is easily held in position, and effectually pre- vents the escape of urine by any other channel. PAET FOUETH. PLASTIC AND SUBCUTANEOUS OPERATIONS. IIWDER THIS GENERAL HEAD ARE CONSIDERED: 1. THE SUBJECT OF PLASTIC OPERATIONS, AS APPLIED TO THE CURE OF DEFORMI- TIES ARISING FROM THE LOSS OF SUBSTANCE; AND, 3. THAT OF THE SUBCUTANEOUS DIVISION OF MUSCLES, TENDONS, AND FASCIA, FOR THE DISTORTIONS WHICH ARISE FROM THE RETRACTION OR SHORTENING OF THESE PARTS. I. PLASTIC OPERATIONS. Plastic surgery has lor its object the restoration of parts that through accident or disease have been partially or altogether lost, by the traiisplanlation of a portion of healthy integnment. The birth place of this branch of science appears to have been in India, where the reconstruction of the nose with a flap of integu- ment talien from the forehead — loo often rendered necessary by the barbarous modes of punishment in vogue among the orien- tals — has been practised from time Immemorial, by certain low caste priests, who derived their origin from the Brahmins. From some remarlts of Galen, it would appear that the making of noses was practised by the priesthood of Egypt, though of their method, which was Icept secret, nothing is known. About the middle of the fifteenth century another form of plastic operation was brought into vague by some Italian surgeons, the most dis- tinguished and successful of whom was Tagliacotins, Professor of Medicine and Surgery at Bologna, whose principles and mode of practice have been handed down in his Chiriirgia Ciirtorum per Insitiomtm.* This received the name of the Italian or Tagliacotian metliod, and differed from the Indian, inasmuch as the integument from which the nose was made was borrowed from over the biceps muscle of the left arm. After enjoying high favour for a considerable period, this Italian meliiod sunk into disesteem, and Tagliacotius became the subject of ridicule of Van Helmont and Butler;— silver, wooden, and waxen noses being resorted to, to hide a deformity which the surgeons of the sixteenth and seventeenth centuries lacked the skill or the enter- prise to relieve by a plastic operation. During the war with Tippoo Saib, in 1793, the attention of the British surgeons was strongly attracted by the skill exhi- * A copy of tliis admirable work is to be found in the Loganian Library of this city. bited by the Indian priests in the reparation of the nose, and the process, under the name of the Indian method, was introduced into Europe by Lynn and Carpiie, of London, who operated in ISlSand 1814. In the latter year, Graefe, of Berlin, revived the process of Tagliacotius with some modifications, and the opera- tion thus modified received the name of the German method. Some ingenious modifications of the plastic art were introduced by the surgeons of France, consisting mainly in the restoration of parts partially lost by the raising or sliding of flaps from the injured organ itself or from the neighbouring structures, which has received the name of the French method. Many of the surgeons of Europe, and some of those of this country, have employed these various processes with distin- guished success. But to Diefl'enbach the credit is due of having generalized and simplified their application, and especially that of the Indian method, which he has clearly shown to possess such advantages over the rest, that these, except in cases of smaller deficiencies, are seldom now employed. For practical purposes, all plastic operations may be noticed under two divisions— where the integument is brought from a distant part — and, where it is derived from the structures adjacent. First class. — This comprises operations for the restoration of the nose and lips in which the integument is brouglit either from the arm after the Italian or Tagliacotian method, from the fore- arm as practised by Graefe, Delpech, and Diefienbach, or from the back or paiin of the hand, as has been done by Rous and Labat. The two latter modifications have been devised for the purpose of rendering the necessary confinement of the arm to the defective part less painful and fatiguing; the flap in all these cases being left adherent to the arm, till union had taken place at its other end with the part to which it had been attached by suture. In several instanceSj a portion of integument has been entirely detached from the arm or thigh, and at once applied on the surface of the defective organ, the edges of the latter having 344 PLASTIC AND SUBCUTANEOUS OPERATIONS. been previously freshened with the knife. By this means small breaches of surface have been filled up by Dr. John Mason Warren of Boston and others, though it has generally failed in the practice of Graefe and Bunger, who made frequent trial of it. This practice is founded upon the fact, that pans completely severed by accident from the body, have after many minutes or even half an hour had elapsed and they had become perfectly pale and bloodless, occasionally been found still to retain a suffi- cient degree of vitality to accept of union after nice adjustment to the organ from whence they had been removed. It has been successful in the hands of the author where the lobe of the left ear had been torn completely off. Second class. — Of the mode of operation, in which the flap is taken from the immediate neighbourhood of the part to be sup- plied, there are many varieties. 1. Raising the flap and twisting it upon its pedicle as in rhino- plasty, after the Indian method. v 2. Rotaiion of lamina toithout tioisting. This consists in raising a flap, the root or pedicle of which is left attached at a point adjoining the breach to be filled up. An incision is first made from what is to be the outer side of the pedicle, carried in such a direction as to circumscribe a flap of the proper form, and terminating again in the breach at the opposite side of the pedi- cle. The flap is then to be raised by dissection, rotated upon its pedicle, and fixed by sntiire to the raw margin of the defective part. After union the pedicle in general does not require to be divided. Mr. Liston has applied this process to the restoration of one of the alas of the nose ; Dieffenbach and Von Ammou to the reconstruction of the eyelids ; Jobert and Velpeau to the closure of vesico-vaginal fistulEe ; Professor Mutter to the filling up of the denuded surface left by the division of cicatrices, &c. &c. 3. Simple sliding of the flap. Glissement du lamheau. — The flap to be raised forms by its free edge, one of the margins of the solution of continuity to be filled up. It is to be dissected back from the breach sufliciently far to enable the operator to stretch it, without rotation or twisting, in order to cover the place upon which it is to be applied. It has been frequently employed in replacing lost portions of the alas of the nose, and in repairing deficiencies of the lips and eyelids. It has been a favourite me- thod with the French surgeons, but is in fact little more than the old operation of Celsus, wiio, in addition, practised a semicircular incision through the skin, at some distance beyond the pedicle, so as to allow the flap to yield the more readily to the traction. A modification of this has been made by Mr. T. Wharton Jones, for shortening and ectropion of the upper eyelid, as described at page 142, 4. By rtfleciion of the flap. The flap is to be raised from a surface near to the point on which it is to be applied, and carried by simple reflection to the defective part, upon the margins of which it is to be affixed by suture. In this way fissure through the hard palate, complicated with hare-lip, has been closed by Sanson ; a flap being separated from one margin of the divided lip, and bent in upon the fissure. The column of the nose has been restored by separating a vertical flap from the whole thick- ness of the upper lip, and reflecting it upwards to the apex of the nose; the mucous membrane of the reflected flap becoming ex- ternal, and gradually taking on the appearance of skin. Where the lip was short, Dieff'enbach has allowed its mucous membrane to remain undivided for the growth of granulations. 5. By demirotation and traction. The flap is to be cut up some distance above or below the defective part, and partly rotated and partly stretched, so as to be made to fill up the vacancy. In this way, deficiencies of the lips, lids, palate, &c., Iiave been supplied by various snrgeons. In some cases, the flap consists of the skin and subcutaneous tissue, sometimes of mucous membrane only, and sometimes, as where the entire lower lip is to be supplied, of the whole thickness of the cheeks. 6. By rolling of the flap. An elongated rectangular portion of integument is to be cut up and rolled upon its cutaneous sur- face in order to form a plug, and then introduced so as to make a solid closure of openings which are rounded, and not of great size; the edges of which have been first shaved ofl'. Velpeau has applied this plan to the cure of fistulse left after the operation of tracheotomy; Sanson and others to artificial anus ; Jamieson to the radical cure of hernia after operation. 7. By successive migration of lamina. This is a modifica- tion of the method of Tagliacotius. A flap is raised from a re- mote part, and brought by successive graftings and transplanta- tions to the vacancy to be filled up. This has been employed by Roux, in supplying lost portions of the cheeks. Prof Mutter and others have also employed with success this plan of the migra- tion of lamina. But it has not proved in my hands in general a satisfactory process, as it is attended with much sufl'ering to the patient, some difficulty on the part of the operator, and great lia- bility to failure from sphacelation of the retransplanted flap. 8. By hj'idgC'like elevation of the flap. This consists in rais- ing two elongated flaps, one on each side of the preternatural ori- fice ; the two ends of each flap are to be left adherent. The flaps are then to be dissected underneath, so that they may be slid as bridges over the opening; the proximate edges of the flaps are then to be fastened by suture. This plan has been employed by Velpeau and others, in fistula opening into the cavities of the mouth, vagina and rectum, and by Dietfenbach in the cure of urethral fistula in the male. An ingenious modification of this process has been made by Dr. Mettauer of Virginia, and has been successfully employed both by him and Professor Mutter in the closure of small openings in the palate. It consists simply in addition to the operation as above described, of the insertion of some soft substance, as a roll of bucksin, into the new sulcus formed on each side of the flaps, so as to raise a growth of granu- lations from its bottom, and sustain the flaps in their new position. In the above classification is found displayed all, or nearly all of the principles which have been variously employed in the cure of deformities by plastic surgery. It is necessary that the operator should be familiar with the resources of this department of the art, though there can exist, in general, no prescriptive plan of treatment. The deformities requiring operations of this class are necessarily so dissimilar in different cases, that every new one becomes a separate subject of study to the surgeon, and opens a fresh field for the exercise of his ingenuity in restoring the lost or deformed parts, with the best success and the least injury to the neighbouring tissues. General rules can therefore only be given for the application of the various principles of plastic operations above detailed. PLASTIC OPERATIONS. 345 since from the limits of this work but little room is afforded for the description of individual cases.* EHIKOPLASTY. This term is applied not only to the reconstruction of a nose entire, but to the restoration of parts of the orgau—the ala;, the «eptum, or the back. The former may be accomplished by the Indian or Italian methods, or the modification inirodnced by Graefe— the latter by the Indian or French, according to the greater or less extent of the deformity. Indian method. — Reconstruction of the entire Nose. This method— in which, as before observed, the new nose is formed by taking a flap from the forehead — is, in the opinion of the author, always to be preferred in this operation, provided the frontal integuments be healthy and somewhat movable, and the forehead itself not so low as to render it impossible to raise the flap without cutting the greater portion of it from the hairy scalp. It will be found particularly appropriate in cases where the nasal bones have been destroyed, it being in fact the only process which enables us under such circumstances to give the new organ sufficient firmness at its root, to retain its natural elevated position. Youth, old age, any impaired state of the general health, or habitual proneness to erysipelas, are to be viewed as counter-indications to the operation. Before proceeding to the operation, it will be necessary to mark out upon the forehead a flap of the proper size and shape for the case in question. A model may be fitted on the face out of paper or leather, and then outlined upon the forehead with ink or lunar caustic. The plan which the author prefers, is to cut out a second model in adhesive plaster, after the first has been properly shaped, and apply it, with the apex between the eye- brows, upon the forehead either perpendicularly, or, if the fore- head be low, in an oblique direction, so as to avoid as inneh as possible cutting up into the region of the scalp. The shape of the pattern which will be found most appropriate is seen at Plate LXXI. fig. 4; but the shape of the flap is of less importance than the cutting it of suflicient magnitude, as it changes much by the concentric contraction which occurs during the process of cicatri- zation. It should be at least a quarter or a third larger than the exact model of the new nose required, to allow of the shrinking which necessarily follows. Dieffenbach has in some instances raised a flap of an oval shape, cutting out the septurn after the flap has been turned down and secured, by two parallel incisions with the scissors at its lower end. When the integuments on the forehead are Ihin, this mode of forming the septum will be found advisable, as it gives additional solidity to the point of the new nose. Under other circumstances the author prefers greatly to bring down the septum from the " Various terms hare been applied to this department of the art, but the author believes the name of Plastic Surgery, (from nhara-ai, to mould or model,) will be found the most simple and appropriate. Using this as the generic term, we will have then Rhinoplasty for the nose, Chdhplasty for the lips, etc. etc. M. Blandin has employed the term Autoplasty,- M. Velpeau, Anaplasty,- and several of the German writers Morioplasty, in the same generic sense in which the words Plastic Surgery have been used by Zeis and by the author of this work. 87 forehead. Delpech made the base of the flap three-pointed, in order to facilitate the closure of the wounds on the forehead; but this plan is not so well suited to give a proper form to the nose. Some surgeons bring down a flap from the forehead without any middle slip for the new septum or column, as in the old Indian process, and subsequently, after the new nose has been fairly united, raise a column from the middle portion of the upper Hp. The author has tried this process, but considers it objectionable, inasnnich as it has a tendency, during cicatrization, to produce mutual distortions of the upper lip and the point of the nose. After the flap is delineated on the forehead, the places for the sutures, with corresponding points on the sides of the nasal opening, should be dotted with ink or coloured varnish. The peduncle of the flap over the root of the nose should be left half an inch or five-eight!is wide, as this is snfliciently narrow to allow us to rotate and loosely twist the flap, and at the same time preserve for its nourishment one or both of the angtflar arteries of the nose. The incision for circumscribing the flap sliould be carried down between the eyebrows, as directed by Lisfranc, a little lower upon one side than the other — the one opposite to that upon which we intend to make the twist — as it gives additional facility to this manoeuvre. In the usual process the pedicle, after the flap is twisted and secured, is left as a loose bridge over the skin below it, exposed on all sides to the air, and liable from this cause to shrink, so as to interrupt to more or less extent the nourishment of the flap. To obviate this danger, Liston and Dieffenbach lodge the pedicle in a groove cat in the integuments upwards from the chasm of the nose, Tiie bulky prominence formed in this way by the adhesion of the pedicle in the groove, requires not merely cutting ofi" and smoothing down (as in the ordinary operation), but to be extirpated from its bed in the after stages of the process, thus increasing the extent of the cicatrix. A better result will be obtained by the process of the author given in the case described below, in which a small triangular flap with its base downwards is removed at the root of the nose for the attachment of the pedicle. This, with the peculiar mode of inserting the edges of the flap therein mentioned, will, judging at least from the author's success in six cases of rhinoplasty, insure without risk of failure, the union of the flap by first in- tention with the lateral grooves in which it is lodged. Having made all necessary arrangements, the surgeon proceeds to the operation. The patient should be placed reclining upon a bed or table, with the head supported by a pillow, and the nos- trils closed by lint, to prevent the blood flowing back into the cavity of (he throat. The Jirsi step of the operation consists in the paring off the edges of the stump of the nose, so as to leave a bevelled raw sur- face for the reception of the flap. But if the nose is altogether deficient, a groove cut for it, as in the case described below, will be found decidedly preferable. A notch sutReiently wide is to be formed in the upper lip for the new column, or the lip may be drawn out as practised by Dr. J. Mason Warren, and transfixed with the bistoury at its connection with the superior maxillary bones, so as to give room for the insertion of the end of the column, The ligatures are to be introduced round the margin of the opening. 346 PLASTIC AND SUBCUTANEOUS OPERATIONS. The ^e(7o;i(/ ^/c/j consists in rnnniiig tlie scalpel rapidly round the outline of the flap cutting to the bone, and subsequently dis- secting the flap loose from the periostemn down to the root of the nose, with a few strokes of the knife. The flap is then to be turned down over the face, and the wound in the forehead closed as far as the case will well admit with twisted or interrupted sutures, and covered with a compress and bandage. The third step consists in the twisting of the flap upon its pedicle, and attaching it by the interrupted suture to the surface prepared for it. Hare-lip pins, though preferred in many in- stances by Dieffenbach, will not be found, on account of the ele- vation of the nose above the surrounding integument, so conve- nient as the simple stitch. After securing the side and septum of the nose, Dieff'enbach ties a tape round the septum so as to roll its margin inward, give it greater firmness, and prevent its form- ing adhesions with the alar margins of the new nose. In from four to sis weeks, according to the constitution of the patient, the new nose will become so well nourished at its lateral attachments, that its pedicle may be safely divided. This is accomplished by introducing a grooved director below it, and cut- ting it across with a probe-pointed bistoury. The end of the pedicle thus detached is then to be neatly trimmed into the form of a semicircle or triangle, and smoothly laid down in a notch cut for it in the integuments below. If the pedicle has been healed in a groove after the manner of Liston and Dieffenbach, the pro- tuberant part is to be raised with a pair of forceps, and detached with one sweep of the bistoury; or a lancet-shaped piece may be cut out so as to bring it down to the proper level, and the edges united by the hare-lip suture. Such are in general terms the rules laid down for this operation, by surgeons who have had most experience in this peculiar branch of surgery. The details of the operation and the modification employed by the author, will be best understood by reference to a brief description of the following case, which is reported in full in the American Journal^ of Medical Sciences, for October, 1843. The author has selected this one of his cases, in consequence of its exemplifying the re- sources of this department of surgery, as not only the nose, but the upper lip and the month required to be reconstructed anew. Total destruction of the upper Up, the soft parts of the ?iose, the sepimn narium, and turbinated bones. Cheiloplaslic and lihinoplastic operation. (PI. LXXI. figs. 1 to 7.) — John Glover, the unfortunate subject of this deformity, was a native of Bridge- water in England, 53 years of age, but had the appearance of being much older. All the soft parts of the nose, and the whole of the upper lip from the commissures of the mouth up to the fossa canina of each side, as well as the septum narium and the turbi- nated bones were removed. The cavities of the antrum highmo- rianum were opened on each side by destruction of bone, so as to form a mere superficial cavity in which the ball of the thumb could be placed. The opening of the sphenoidal sinuses were distinctly seen through this cavern. The mucous membrane lining the parts seemed healthy, though covered with lymphatic exuda- tions. The teeth with their corresponding alveolar processes were removed from both jaws, the upper of which, instead of its usual PLATE LXIL— PLASTIC OPERATIONS. CHEILOPLASTY. RHINOPLASTY. {Processes of the Jluthor.) Fig. I. — Representation of a patient, before the operation and with the month closed, who had lost the entire upper lip, all the soft parts of the nose, the septum narium, and the turbinated bones. Figs. 2, 3. — CheiJopIastic operation. — In fig. 2 is given an accurate view of the face of this patient, with the chin depressed. The mouth, from the entire destruction of the upper lip and a portion of the lower, was drawn by the cicatrization into a rigid narrow orifice, surrounded witli a cicatrized border. This was first enlarged by extending the commissures laterally, by the stomatoplastic process of Dieffenbach for atresia oris, described at page 241. The black lines upon the cheeks represent the outlines of the flaps with which the upper lip was reconstructed as shown in fig. 3. Figs. 4, 5, 6. — Rkinoplastic operation. — After the new lip had become solid and firm, the nose was restored by a flap taken from the forehead. In fig. 4 the outline of the flap and new column is shown on the forehead. The dark spots represent the points at which the sutures were subsequently passed. The pedicle of the flap is placed between the brows, the incision upon one side of which is extended lower down than the other, to faci- litate its twisting. By the sides of the nasal chasm are seen the two fissures cut for the reception of the edges of the flap. The spots represent the points for the insertion of the sutures corresponding with those on the flap. Two of the sutures alone are shown partly introduced, as described in the text. The wound of the forehead was closed with harelip sutures, so as to leave a raw surface of but small extent The edges of the new nose were secured in the fissures by three interrupted sutures on either side, which are seen in fig. 5, tied on small rolls of adhesive plaster after the manner of Graefe. The end of the septum is also attached to the middle of the upper margin of the new lip. In fig. 6 is a lateral view of the flap after being adjusted with the sutures. The twist of the pedicle is seen over the nose. Fig. 7.— This is an accurate representation of the face of the same patient, taken on his visit to town sixteen months after Ire had left the hospital, by Mr, S. Willits of this city. On Stone. &}■ ^ . .A-rlvsam 2'S -D-iLPal,I-f a hller frnni Peter S. Duponccati, F.sq. " In addition to Ihia it has been jii=ilv -h^i ru-I, ilial ureal chanyBs linvn i.ikpn place in llic two lan- guages, since the beginning of the jin j-ni n iiini v. Ii is i curious fnci tbni Ihe uvn idioms have in a creal niL-a^ure inigrnlod. and ore slitl iiii.'t Li mm; i\iin r:rt, t,\\wr. It is iln; r..siili of the jsreai inlercoiirmi— which during the last 25 years, has i;it,i u i Ik tu r r ii ihe iwo riHiioiis, 'I'hese rh.iiigcfi are nnl not iced in any other existing bilingual DioiiMn.m , u im-li is pofspsseJ imly hy iliu one you have piiblishfiri. The Bddttiutift of Messrs. DobHon and Picui, atu very vnhialile, and assure Ihu euptriority of your uditioii," " Ever since Ihe ftrslinipnrlalion of Fleming and Tibbina' French and English Dictionary. I have constantly hnd il on my table, and have found il belter than all olher French Dictionaries. I am therefore rejoicerl to iwe an American abridged edition of so excellent a wnrk. I find that all which is raOEl EESenlial in the French edition is retninnd. and many decided and valuable improvempnls are made. The mode in which the pronunciation ia indicated is admirably plain and thorough ; a va«t n amber of words not to he found in other Dictionaries is introduced ; an eicellent arrangerncnt of Ihe verbs is fiven ; and il is prinleil in u large and easily legible type. Altogether, il is decidedly the best French Dictionary I have Eeen. " Respectfully yours. B^ton, January 23, 1844." '• Geo. B. Ehersoh." "Beaton EngUili Hieh &haal, Febmary 1. 1F44. " Genilpmen,— I have devoted some time and ettention to the examinaiion of FItming and Tibbins' Frnnch and English Dictionary, lately published hy your Arm : and, alihongh the merits of such a work can he Uinrnuglily testiHt only by long use and a careful collation of it with kindred works, yet I must say thai this dictionary bears evident marks of its superiority to any other that has been introduced into this country. ■■ By comparison. I find its vocabulary very copious and the idiomatic phrases quite numerous. The tech- nical terms are a very important addition, and Ihe conjugation of verbs will prove of great u«e to the I'-arner. Tlic mechanical eieculion of the wnrk, which is highly important in a dictionary, ts a r«com- iiii^iidaiinn which immediately impresses itself on the eye. " A complete and secnrate dictionary is of the ul most' im porta ace in the acQuisilion of a foreign language, and I feel justified in recommeuding this as one of great e.\celleuee. 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