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                     '1
AN   ESSAY
OPERATION  FOR   CLEFT  PALATE
■litHimi
P
BY  GEORGE  BUSH^
'     F-
x
            NEW.YORK:




PUBLISHED BY WILLIAM JACKSON,



             53 CIDAR-STREET.






                1835.
4 
V.A
\
\ 
 
 
AN   ESSAY
OPERATION  FOR  CLEFT   PALATE.
                   N
BY  GEORGE  BUSHE.




        it-t02Jz7,
         NEW.YORK:


PUBLISHED BY WILLIAM JACKSON,

          53 CEDAR-STRKET.
1885. 
JAMES VAN NORDEN, PRINTER, 19 WILLIAM-STREET.
           I






I
I 
                                     TO






                      PHILIB-JOS.   ROUX,





       CHIRURGIEN  DE  L'HOPITAL DE  LA CHARITE,  <fcc.











  Sir,




             As your success, in removing the congenital Cleft of the Palate, induced




me  to devise and  practise  the  method of operating,  recommended  in the following




pages, I feel great  satisfaction in dedicating them to you,






                          I have the honour to be, Sir,






                                     Your obedient  servant,






                                                    GEORGE BUSHE.








    o^ Walker-street,



       New.York,  June 16th, 1835. 
 
                 AN  ESSAY

                        ON THE

OPERATION   FOR  CLEFT  PALATE.
   It has fallen to my lot to have performed this operation, perhaps, a*
often as most surgeons actively engaged in the practice of their profes-
sion ; and, from tolerably extensive experience  and much  reflection, I
have been led to  devise plans for its execution, which have proved so
effectual, that, I feel  it incumbent  on me to lay them before the profes-
sion : a task which I should  have  long  since performed, had not  other
avocations occupied the few hours I have occasionally been enabled to
devote to study and composition.
   It is of the utmost importance that the surgeon should avoid operating
indiscriminately, on all cases, as they may occur to him, else his failure*
will not only very  seriously affect his reputation, but, what is  of  para-
mount importance, prejudice the public against  one of  the most useful
operations in surgery.  An exposition,  therefore,  of the causes which
contra-indicate it, shall first occupy our attention.
    2 
6
  1st. Infancy, childhood, and boyhood—girlhood are very unpropitious
periods for the  performance of this  operation, as  we shall now demon-
strate.
  Firstly.—The mouth is too small to allow of that exactness so neces-
sary in all our manipulations.
  Secondly.—More resolution and acquiescence with our wishes is indis-
pensable,  than  persons during those periods can summon  to their aid,
when suffering  under protracted pain and irritation of the fauces.
  Thirdly.—In consequence of the greater extent and rapidity of nutri-
tion, as well  as the more exalted sensibility of the stomach in young
persons, they can but ill  bear the long continued abstinence that must
be observed after this  operation.
  Fourthly.—From the greater expenditure of the  thinner parts of the
blood, in consequence of the abundance of the secretions in the earlier
periods of life, the fauces are more likely to  suffer from inflammation
when drink is withheld, an occurrence which will either prevent or de-
stroy adhesion.
  2d. Disease  of the  respiratory organs cannot fail to mar our success,
by producing cough, and  thus dislodging the sutures.
  3d. Enlargement of the tonsils, or other disease of the fauces, as also
polypi and various affections  of the nose, by impeding the passage of
air to and from the lungs, and creating irritation, vitiated and abundant
secretions, will prostrate our best exertions.
  4th.  Disorder of the stomach, giving rise to vomiting, extrication of
gas and regurgitation of food, must exert a baneful influence  on the
issue of the case, by the  traction of the sutures during each of these
efforts.
  5th.  Excessive irritability is one of the greatest annoyances we  have 
7
to encounter, not only during the operation, but afterwards ; for then the
patient is continually coughing, expectorating and endeavouring to detach
mucus from the posterior part of the mouth and fauces.  We may ge-
nerally be able to ascertain this condition of the system, by passing in-
struments into and detaining them in the pharynx for a moderate length of
time, when, should the patient be irritable, his anxiety and restlessness will
become apparent ; much also may be  learnt by studying his character?
and inquiring  into his conduct in any illness he may have had. Operating
surgeons know well, that although this state depends much upon organi-
zation, yet that it is frequently produced, and always increased, by mental
and bodily indisposition; therefore,  wc ought to postpone the opera-
tion, until, by air, exercise, diet, appropriate remedies, and the constant
exercise of moral restraint over his  feelings, the infirmity be  either re-
moved or palliated.
   6th. Preternatural  thirst, whether  the  result of disease,  habit or
idiosyncrasy,  constitutes an insurmountable obstacle to success; for in
a very short  time, the heat,  dryness and sense  of constriction in the
fauces, as well as the diminution and viscosity  of the saliva and mucus,
will become so intolerable  that the patient cannot resist drinking.  In-
deed, should a surgeon commit so glaring an oversight as to operate on
a patient thus affected, he ought not to withhold drink in moderate quantity,
else the  very slender chance of success  which exists will be destroyed,
by the inflammation that must inevitably ensue, attended with excessive
restlessness,  fever and delirium.  It therefore  becomes our duty, when
such a patient consults us,  to ascertain whether the affection be the re-
sult of disease,  habit or organization.  If the consequence of disease,
appropriate means must be employed to combat it; if of habit, moral
discipline should be strictly enjoined ; and if  of organization, the ex- 
8
 periment ought to be made, whether,  by repeatedly  injecting fluid in
 small quantities into  the rectum, and bathing the surface, the thirst can
 be sufficiently allayed for a length of time equal to that during which
 we are generally compelled to withhold drink after the  operation.   Pro-
 vided, then, in the first case, that the disease be removed; in the second,
 that the habit be broken ; and, in the third, that the experiment succeeds,
 we may undertake the operation, but not otherwise.
   7th. Hot weather,  because of the restlessness which it gives rise to,
 and  above all, the continual wasting  of the thinner parts of the blood by
 cutaneous exhalation, will operate seriously to the patient's disadvan-
 tage.
   8th. Finally, complete separation of the bony palate to the extent of
 an inch,  will  render  the case  unfit for operation; because, in  such
 instances, each half  is  directed considerably upwards and inwards  ;
 which  renders the approximation of the sides of the velum difficulty
 and creates such tension, that the sutures are  torn out  in  a short time,
 generally before there is any union.
   When none of these objections exist, and the operation is determined
 on, the four following points should be attended to.
   1st. For a few  weeks previous  to  the operation, the patient  should
 take regular exercise  in the open air, being careful to avoid taking cold  ;
 and by regulating his diet and clothing, to establish a healthy state  of the
 skin and mucous membranes.
   2d. At least a month before  the appointed  time, two thirds of  each
 half of the uvula ought to be removed ; otherwise, after the coaptation of
the velum, they will  be  separated in this manner, ^     /v ^\ by the
pressure  of the base of the tongue ; and, being swollen, will irritate the
fauces and thus give rise to cough and constant efforts to swallow. 
9
  3rd. During the  week preceding the operation, blunt  instruments
should be passed into the pharynx daily, with  a view  of accustoming
the parts to their presence.  The patient ought also, to separate his jaws
and retain them so for as long a period as he can, in order to habituate
the submental muscles to the protracted duty they will have to  perform,
during each stage of the operation.
  4th.  The operation  ought  to  be commenced  four  hours  after  an
ordinary meal; for when the patient eats heartily immediately before its
performance,  should the irritation of the fauces give rise to vomiting,*
our proceedings will  be deranged and the  patient deprived  of the
advantages of the repast he has taken.   At all  events digestion will  be
disturbed, and flatulence, eructations and a train of disagreeable symp-
toms ensue.
  These different measures are of more importance, than  may appear
at first sight; and the advantages I have derived from observing them
have contributed, in no small degree, to my success.
  I divide the  operation into two  stages, viz; the section of the  palate
and the insertion of the sutures; these I fix at the interval of four hours.
In the commencement of my career, I inserted the sutures first,  as had
been recommended by others,  but  soon discovered that the  irritation
thus produced threw the muscles into such violent action, that it was

  * This once occurred to me, and proved very troublesome.   It may be argued, however, that
nausea is more easily induced when the stomach is empty.  This, I am ready to admit; but four
hours after an ordinary meal, the stomach is not empty; and it should not be forgotten  that
plenitude, though not quite so favourable  to nausea, is more favourable to the effort of vomiting,
than vacuity of the stomach.  Very moderate distension of this viscus towards  the close of
chyrnification, may be said to be its state of greatest tolerance.
    3 
10
 only by good management  or accident the  velum  could  afterwards
 be divided in a regular manner; besides, I  observed that  the ligatures
 were occasionally in danger of being cut, and that they interfered  in
 no small degree with the movements of the  knife.  I then reversed the
 order of proceeding, incising the edges of the velum before inserting the
 sutures; but this method,  though preferable to the former, proved ob-
 jectionable from the irritation of the muscles which ensued, and embar-
 rassed me in passing the needles, as well as a lesser annoyance produc-
 ed by the bleeding.  I therefore now prefer waiting for four hours after
 making the sections of the velum, before inserting the sutures;  recom-
 mending the patient, in the interval, to gargle his throat with iced water.
 By this method, the inflammation  is diminished  and the parts obtain
 their ultimate degree of tumefaction, so that we are enabled to avoid all
 risk of tying the ligatures  either too tight or  too slack.  Finally, the
 spasm  induced by  the  knife,  will have had time to subside before the
 insertion of the sutures is commenced.
   The excision of the borders of the velum should be performed with
 great care, so that each cut surface may be perfectly smooth,  and equal
 in depth to the thickness of  this curtain. By not attending to these
 points,  surgeons  who perform the  rest of  the  operation well, have
 the chagrin of seeing the adjusted surfaces separate, when the sutures
 are either removed or torn  out by the  action of the muscles.*  The
 idea that it is only necessary  to redden the edges, coupled with the de-

  * When adhesion does not take place, even though the edges of the velum be brought easily
 into contact, the sutures will generally be torn out.  When union does take place,  the plasticity
of the effused lymph gives steadiness to the velum, and counteracts  the traction which  the mus-
cles exert, until this lymph becomes organized. 
11
sire  to save as much as possible  of parts  already too scanty, has led
surgeons to trim off merely the more convex portions of each border of
the cleft velum, while the inaptness of the instruments used, and  the
mobility of this curtain, have caused them to make the sections uneven.
It is, therefore, of the first consequence to  remove as much as  may be
necessary to render each cut  surface equal to the  thickness of the ve-
lum, and, by great caution, to make it vertical and even.  The distance
of the  incision from the edge of the velum to effect this object, will vary
in different subjects, from half a line to a line, or even more.
   To accomplish this part of the operation, I use two instruments, viz;
a knife and forceps, both of which are  represented in the plates.  The
blade  of this knife is one inch and  a quarter in length,  one sixth of an
inch in breadth at its widest part, and sharp on the back for a quarter of
an inch from the point.  The handle is rather delicate,  and about  five
inches long.  I prefer  this to the double edged  lancet-shaped scalpel.
used by Dieffenbach, because, being more narrow and blunt on the back,
it is free from all danger of cutting the velum without the line of incision,
as we  approach the angle.*  The forceps is seven inches in length, and,
with the exception of its curve and extremities, resembles the instrument
used for extracting nasal polypi.  It is so bent, that the operator's hand
may correspond to the side of the'patient's face; thus, permitting a clear
view of the interior of the mouth,  an object  of  great importance,  and
which  cannot be satisfactorily obtained, when the instruments recom-
mended by Graefe, Ebel and  others, are used.  The extremity of each
chop of this forceps is half aninch long, three eighths broad, and one  six-

  *This accident once occured to me in using Dieffenbach's knife. In spite 01 my best efforts, I
could not prevent the posterior edge cutting outwards as I advanced forwards and inwards. 
12
teenth thick;  they stand out at nearly a right angle from the curve, and
are furnished, one with a groove, and the other with a projection, adapt-
ed to the groove.   By this construction of the instrument, the surgeon
is enabled to seize a considerable portion of the entire thickness of the
velum, and to hold it horizontally, so as to insure a smooth and vertical
section of this curtain.   Thus, it possesses  a great  advantage over the
instruments employed by Graefe and others, for the same purpose ; be-
cause, with them, the mucous  membrane is  merely secured, and that
only to a very limited extent;  while the traction  exercised by the mus-
cles on the velum,  withdraws it from this membrane, which is made
steady by the forceps, consequently  the incision is rendered  superficial,
irregular and partly convex.
   The patient being seated near a lofty window, with his mouth open
and his head fixed by an assistant, I take hold  of one side of the velum
with the  forceps, being careful to embrace as much and no  more than
will prevent the muscles retracting this curtain from the mucous mem-
brane.  With the back of the knife  turned  towards the pharynx, I now
transfix the velum obliquely upwards  and backwards close  to  the ex-
tremity of the forceps, and by a steady sawing motion, divide it beyond
the angle ;  then, turning the edge of  the knife inwards and downwards, I
complete the section with the same  sawing motion.   In a few minutes,
when, by ablution with iced water, the hemorrhage ceases,  I treat the
opposite  side in a similar manner.   Should a portion of the bony palate
be deficient, we ought to detach a few lines breadth of the velum on each
side, according to circumstances, from the posterior border of the palate
bone; a procedure first adopted by Roux, and  which  enables us to ap-
proximate the edge's  of this  curtain  with  comparative ease.   These
transverse wounds granulate and heal  without any trouble. 
13
   In case the patient be unsteady and  cannot keep his mouth  open, I
 employ a speculum,  which answers the desired end most effectually.*
 This instrument is represented in plate i.   It consists of two transverse
 bars, a prolongation  of  each of these bars, a common or vertical bar,
 screw, semilunar bar, roller and handle.   Each transverse bar is three
 inches and three quarters in length,  flattened at the  extremities where
 they correspond to the teeth, and curved in the centre ; the superior being
 adapted to the shape of the palate, and the inferior to the floor of the
 mouth. The extremities f of these bars are seven eighths of an inch long,
 five twelfths broad, and one twelfth thick, with the exception of the prox-
 imal extremity of the inferior bar,  one third of which  is a quarter of an
 inch thick, being in this part pierced with the screw.   These extremities
 are  also perforated with small holes, so that they  may be capped with
 caoutchouc, to protect the teeth ; while the central portions  are not more
 than half as stout and  rather round.   The spatula is attached to the lower
 transverse bar, and, as I frequently use the instrument without it, or, as
 plates of different sizes may be required, I have it secured by a screw, so
 as to enable me to change or remove it at pleasure.   The handle, which
 is about the size of that of a speculum ani, is attached to  a  continuation
 of the superior transverse bar.   This portion of the instrument  is tra-
 versed  by  the extremity of the screw, and, still nearer the handle, con-

  * The insertion of corks between the teeth, as a means of keeping the mouth open, is a misera-
ble contrivance.  They not only shut out the light and entangle the saliva, mucus and blood, but
so far diminish the interdental space,  as to interfere very considerably with our manipulations.
  f The term extremity is not strictly applied, as what are considered the proximal extremities,
are not strictly so, being continuous with the other portions of the instrument.  However, without
such license, I could not so well convey a just idea of a very complicated instrument.
      4 
14
nected with the vertical bar.  This last is two inches and seven eighths
long, half an inch broad, and one sixth thick.  It passes vertically from
the point of junction of the handle and superior bar, and, three eighths
of an inch from its inferior extremity, is bent at a right angle parallel to the
transverse bars.   This portion has attached to its extremity by two small
screws, the semilunar bar, which is half an inch in length, and one sixth in
breadth and depth.   These, together, constitute a foramen, which trans-
mits the screw. The centre of the vertical bar is open superiorly for two
inches in length,  and one sixth in  width, forming a slit, through which
passes, a prolongation of the inferior transverse bar, corresponding in size
to the  diameter of the slit.   Having traversed the slit, this prolongation
is bent downwards for seven eighths of an inch,  and expands into an ex-
tremity furnished with a roller one third of an inch long and half an inch
in circumference, which works on the vertical bar.  The screw is four
inches in length and seven eighths of an inch in circumference, terminat-
ing inferiorly in a large button.  It is retained between the superior  and
vertical bars, as before mentioned, and works in a worm of the inferior,
which, through the medium of the roller moving on the vertical bar,  is
thrown steadily upwards or downwards, at  the will of the operator.
   When the second period of the operation arrives, I complete it with
the following apparatus,  viz: suture instrument and knot-maker.   The
suture instrument is represented in plate ii, and consists of three  parts;
the first, which is inserted into a*handle similar  to that of an aneurism
needle, is  four inches and one quarter in  length, one sixth of an inch
broad, and one eighth thick, except about an inch and three eighths from
its distal extremity, where  it is contracted  to one half its size, becomes
circular, and is bent, nearly  corresponding to the curve of a dissecting 
                                 15

hook.  Two small rings are attached to it, one being situated on the most
convex part, and the other one inch and an eighth nearer the handle.
These rings are for transmitting the ligatures, which are thus prevented
from becoming entangled or interfering  with the sliding bar.   The se-
cond, or needle, is three eighths long, and consists  of three parts, viz:
the blade, which is one sixth of an inch in length, triangular and furnish-
ed with shoulders ; the middle, which is  one  eighth of an inch long and
perforated for the transmission of the ligature ;  and the upper blunt or
narrow prolongation, which is one twelfth of an inch long, and is lodged
in the  extremity of the curve of the first part.   The third and last part of
this instrument is a sliding bar, five inches and five eighths in length, one
twelfth of an inch thick, and one sixth broad, terminating at its proximal
extremity, in a small handle, and furnished, at the other, which is round
and five eighths of an inch in circumference,  with a spring and cavity for
the reception of the blade and middle portion  of the needle.  This bar
is connected with the body of the instrument by two bands, about an inch
apart,  and one inch and an half from its distal extremity, which stands
outwards, so as to range with the needle.
  The ligatures should consist of two threads of three twist silk, and be
three feet in length :  having passed the extremity of one ligature through
the eye of the needle, then carried both extremities through the rings,
and twisted them round the handle so as to  secure the needle firmly in
its socket, the curved extremity of the instrument should be carried be-
hind the velum at the base of the uvula, and then brought forwards through
this curtain three or four lines from its  border, forcing it  from behind
forwards and from above downwards.   When  the point of the needle
appears through the velum, the sliding bar should be  pushed onwards 
16
until it embraces the needle, and, through the medium of the spring-catch,
holds it firm while withdrawn.  The other extremity of the ligature is to
be carried through the  opposite side of the velum in the same manner.
Another ligature should then be passed between the first and  the angle
of the wound, which in the majority of cases will be  sufficient.  I am
of opinion that surgeons are in the habit of inserting loo many sutures
in these cases;  for, then the wound becomes puckered, the inflammation
is increased, as well as the number of ulcerated points, and,  above all,
the surface of union is  less; for I have rarely seen a case, where, the
parts included  in  the ligature adhere, a  circumstance which  depends,
either, upon the immediate mortification  of this delicate structure when
the ligatures are too tight, or, when the knot is more judiciously  made,
upon the absorption which the parts undergo from the necessary pressure
and the contact of the ligature.
   The last part of the operation consists in tying the knots;  and this  I
accomplish with the instrument represented in  plate ii.  This instru-
ment consists of two parts, viz: one for making the noose and the other
for retaining it  in close contact while the second knot is  made.  The
first part, or that for tying the knot, is fixed in a handle like  the suture
instrument, is three inches and three quarters in length, one sixth of an
inch broad and one twelfth thick.   It forks about one inch and a quarter
from its distal extremity, the ends of the prongs being five eighths of an
inch apart and bored for the transmission of the ligatures.   About three
quarters of an inch from the handle on its anterior face, is a ring with the
superior portion cut out to the extent of one tenth of an inch; another
arises from the prongs, seven eighths of  an inch from their extremities,
for the accommodation of which, they are compressed  in  this situa-
tion.  The second  portion consists  of a slender bar,  four  and a half 
17
 inches long, furnished at the  proximal extremity with a small handle,
 and at the distal with the forceps.  For three eighths of an inch from the
 handle and the same distance from the forceps, this bar is square and one
 twelfth of an inch in diameter; between these portions, it is one eighth
 of an inch broad and one sixteenth deep.  The forceps is seven eighths
 of an inch long, the inferior portion of which is continuous with the bar
 just described, but, on a line one twelfth of an inch below it; while the
 proximal extremity of the superior portion is furnished with a  strong
 spring that works upon the inferior.   Both portions are connected  by a
 semilunar joint, and the chops are three eighths of an inch long.   This
 second portion of the instrument is placed on the first and secured in the
 brackets above described, with the chops of the forceps open, because of
 the pressure of the distal bracket on the superior portion of the forceps.
   Before tying the ligatures, we ought gradually to draw each of them
 forwards, and, while holding them steadily so as to prevent any drag on
 the palate,  an assistant should  wax them anew; a  proceeding of the
 utmost importance, for by their long stay in the mouth they are apt
 to  collapse and  the knots to  give way.  This being done,  the lower-
 most ligature should be  tied first, in the following maimer:—the ends
 being passed through the holes in the prongs of the instrument, the latter
 should be pushed onwards until the edges of the palate are approximated,
 taking care not to tie too tight, else the ligatures will destroy the vitiality
 of the parts included;  and here we find the advantages of allowing the
 velum to swell before we pass the sutures, as then we know how tight
we ought to tie. The  knot being made, the forceps should be pushed for-
wards, so that it may grasp the knot by virtue of its spring, the counteract-
ing force being removed by change of position. By the greater narrow-
ness of the bar near the forceps and handle, it will  now  slip out of the
     5 
18
brackets and remain hanging from the mouth, while  we make another
noose, which is to be treated in the same manner. The second ligature
ought then to be secured like  the first,  and thus the operation will be
completed.
  The  subsequent  management of  the patient is  of  great  import-
ance.  Besides enjoining him to avoid coughing, swallowing and speak-
ing, we ought to advise him to sit erect,  to keep his mouth shut,  and
avoid sleeping;  for when in a  horizontal position, the breathing is labo"
rious, and there is a tendency to sleep. When such patients are allowed
to sleep, they breathe heavily and keep the mouth open, in consequence of
which, the throat dries and they are apt to start up and tear out the sutures
in an effort  to swallow.  If there be a tendency  to cough, I order five
drops of laudanum occasionally,  which either checks or moderates it.
The mucus, which collects in the throat, will increase as the inflammation
subsides, and on the third or fourth day will  be easily evacuated, if the
patient  will  lie on his side, hold his head low and make moderate efforts
to dislodge it.  In order to subdue the inflammation, the mouth should
be kept cool and clean by rinsing it with iced water, an expedient which
will greatly  contribute to allay the thirst.
  The superior suture should be removed on the fourth, and the inferior
on the fifth  day;  for by this time, they have become  loose, and by  col-
lecting vitiated secretions, as well as by  their presence, are apt to create
erysipelatous inflammation  and ulceration.
  After the  operation, we ought to inject  a cup full  of strong beef tea
every two or three hours into the rectum, which will not only sustain the
patient, but, by supplying the blood with fluid, will diminish the inflam-
mation of the fauces, a consequence  which is sure to ensue,  when  the
system  is not supplied  with fluid.  If the quantity here recommended
purges,  it should be diminished. 
 
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EXPLANATION OF THE  PLATES.
                                  PLATE I.

Figure 1.  The speculum.
     a. a.  The transverse bars.
b.  b. b. b.  The extremities of the transverse bars pierced with holes, so that they may
             be capped with caoutchouc.
        c.  The hole in the inferior transverse bar for  the small screw,  (Fig. 3,)  by
             which the spatula is attached to it.
     d. d.  The continuation of the transverse bars.
   e. e. e.  The vertical 6ar bent at a right angle near its inferior extremity.
        f.  The semilunar bar.  (Fig. 5.)
        g.  That portion of the prolongation of the inferior transverse bar which is bent
             downwards.  (Fig. 4.)
        h.  The roller attached to g.
        i.  The slit in the vertical bar, for the transmission of the prolongation of the
             inferior transverse bar.
        k.  The screw.
        1.  The handle.
Figure 2.  The spatula.
        c.  The hole for the transmission of the small screw.
     d. d.  Notches for the reception of small brackets placed on the superior surface of
             the inferior transverse bar.
Figure 3.  The small screw.
Figure 4.  The vertical portion of the inferior transverse bar.
        h.  The roller.
Figure 5.  The semilunar bar, which is attached by two small screws to the horizontal
             portion of the vertical bar.
Figure G.  The turn-screw for taking off and putting on the spatula. 
20
                                  PLATE II.

Figure 1.  The suture instrument.
        a.  The first part or body of the instrument.
     b. b.  Two small rings for the transmission of the ligatures.
        c.  The curve resembling that of a dissecting hook.
        d.  The needle (Fig. 2,) inserted into the extremity of the curve  c.
        e.  The sliding bar.----f. The handle of the sliding bar.
        g.  The other or inferior extremity of the sliding bar, which stands outwards
             so as to range with the needle.
        h.  The cavity in the extremity, g. for the reception of the needle.
        i.  The spring-catch for seizing and  retaining the needle when forced into the
             cavity,  h.
     k. k.  The bands by which the sliding bar is connected with the body of the instru-
             ment.----1.  The handle.
Figure 2.  The needle.
Figure 3.  The knot  maker.
        a.  The first part or body of the instrument.
     b. b.  The prongs perforated for the transmission of the ligature.
     c. c.  The cut rings or brackets, for the reception and retention of the  second part
             of the instrument.
        d.  The handle.----e.  The second part.
Figure 4.  The second part of the instrument.
        a.  The slender bar.----b.  The handle.
     c. c.  The reduced portions of the bar,  so that it may slip out of the cut rings or
              brackets on  the body of the instrument when pushed onwards.
        d.  The forceps.
        e.  The superior half.----f. The inferior.
        g. The joint.----h. The spring.
         i.  Shows how the inferior half is set back from the slender bar.
Figure 5.  The forceps.
     a. a.  The extremities.
        b.   The groove.----c. The projection fitted to the groove.
Figure 6.   The knife.
        a.  The cutting edge extending for a quarter of an inch on its back.
JAMES VAN NORDEN, PRINTER. 
PLATE IL.
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Palhsha/  iy William Jachon.jS''1 
 
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