OPERATIVE SURGERY BY JOSEPH D. BRYANT, M. D. Professor of the Principles and Practice of Surgery, Operative and Clinical Surgery, University and Bellevue Hospital Medical College ; Visiting Surgeon to Bellevue and St. Vincent’s Hospitals; Consulting Surgeon to the Hospital for Rup- tured and Crippled, Woman’s Hospital, and Manhattan State Hospital for the Insane; Fellow of the American Surgical Association; former President of the New York Academy of Medicine; President of the New York State Medical Association, etc. VOL. I GENERAL PRINCIPLES, ANESTHETICS, ANTISEPTICS, CONTROL OF HEMORRHAGE. TREATMENT OF OPERA- TION-WOUNDS, LIGATURE OF ARTERIES. OPERATIONS ON VEINS, CAPILLARIES, NERVOUS SYSTEM, TENDONS, LIGAMENTS, FASCIE, MUSCLES, BURSE, AND BONES. AMPUTATIONS, DEFORMITIES. PLASTIC SURGERY THIS VOLUME CONTAINS SEVEN HUNDRED AND FORTY-NINE ILLUSTRATIONS FIFTY OF WHICH ARE COLORED NEW YORK D. APPLETON AND COMPANY 1899 Copyright, 1886, 1899, By D. APPLETON AND COMPANY. All rights reserved. TO THE GRADUATES IX MEDICIXE WHOM IT HAS BEEN MY PLEASURE TO INSTRUCT IN ANATOMY AND SURGERY DURING THE LAST TWENTY YEARS, AND IN RECOGNITION OF THE UNIFORM COURTESY SHOWN BY THEM TO THE AUTHOR, THIS WORK IS RESPECTFULLY INSCRIBED. PREFACE TO THIRD EDITION. The flattering reception of the second edition, and the requests of many interested friends that a third be written, prompted me about four years ago to begin the task. But the frequent and somewhat extended interruptions begotten of the demands of life’s activities, together with the determination to extend the scope and size of the work, have unexpectedly delayed its publication. Besides, the rapid advance in the last few years of surgical endeavor has greatly increased the amount and complicated the character of the labor required for the purpose. The general policy of arrangement of the work is maintained, and, as in the past, frequent references are made to the labors and sayings of others, to all of which credit is given in the text or in the index. Special effort is made to eliminate from the faces of the illustrations all evidences suggestive of commercial thrift. Much is gained in this respect by the introduction of half-tone groups of instruments and by the gracious co-operation of Mr. Ford. An index of illustrations, in which due credit is given to all, is introduced. The operations peculiar to the female sex, and of the eye and ear, are omitted in this, as in the preceding editions, and for similar reasons. The valuable services of Professors George D. Stewart and William C. Lusk, in connection with proof reading and indexing, are especially valuable, and are gratefully acknowledged. The artists, Messrs. Mason (photographer to Bellevue Hospital) and Senior, vied with each other in their efforts to produce proper illustrative effects. In conclusion, it is hoped and believed that the reader will find in the following pages sufficient of interest and importance to justify the use of the time employed by himself and the author in their consideration. Joseph D. Bryant, M. D. 54 West Thirty-sixth Street, New York, July 1,1899. PREFACE TO SECOND EDITION. The frequent request on the part of those whom it has been my pleasure to instruct in operative surgery during the past few years, to make a book based somewhat on the plan I have employed in teaching this subject, is the principal incentive to my action. The field of operative surgery is too well cultivated already for one to do more in this brief space than aid the student of surgery to acquire established facts. The works of Ashhurst, Agnew, Gross, Erichsen, Holmes, Smith, Esmarch, Packard, Stimson, and many others, together with the current medical literature, have been consulted. The illustrations, which are numerous, have been selected in most instances from standard works, although a considerable number of original and modified illustrations have been introduced. Mr. W. F. Ford, of the reputable firm of Caswell, Hazard & Co., of this city, kindly provided the instrumental cuts, as is to be seen by the Index of Illustrations. The author desires to acknowledge the aid derived from the above-mentioned sources, and trusts the reader will find something to commend in the pages that are to follow. The author regrets that sufficient data are not at hand to permit the “ results ” to be given in all instances as modified by the antiseptic method of treat- ment. The operations peculiar to the female sex, and the eye and ear, have not been considered, since they are entitled, in the opinion of the author, to a more extended consideration than the intentional scope of this work will admit. The author desires to acknowledge the valuable services of Drs. Glover, C. Arnold, and Hermann M. Biggs, in connection with the proof reading, and of I)r. Arnold also for the complete indices of the book. The assistance of Dr. A. II. Doty in preparing many of the original illustrations is likewise gratefully acknowledged. Joseph D. Bryant, M. D. 66 West Thirty-fifth Street, New York, October 28, 1886. VI CONTENTS OF VOLUME I. CHAPTER I. PAGE Definition of operative surgery—Facts to be ascertained before operating—Time for operation—Place for operation—Sick-room—Nursing—Diet—Requirements relating1 to operations—How to prepare patient for anaesthesia—How prepare administrator of anaesthetic—Treatment of anaesthetic poison—Dangers of use of anaesthetic—Inhalers—Chloroform—A. C. E. mixture—Nitrous oxide—Mor- phine with anaesthetics—Moderate inebriation—Oxygen anaesthesia—Repeated respiration—Intestinal anaesthesia—Local anaesthesia—Infiltration anaesthesia— Cocain—Eucain—Instruments necessary for operations—Methods of holding scalpel—Blunt dissection—Incisions—Antiseptic and aseptic methods—Operat- ing tables—Antiseptic solutions—Sponges—Wipers, etc 1 THE GENERAL CONSIDERATIONS. CHAPTER II. AGENTS FOR THE CONTROL OF HAEMORRHAGE. Artificial haemostatics—Styptics—Position—Bandages—Compresses—Digital pres- sure—Tourniquets—Davy’s lever—Trendelenburg’s rod—Wyeth’s method— Torsion—Forceps—Forcipressure—Cautery—Ligatures—How made—How tied —Assistants—Preparation of patient—Field of operation preparation . . 53 CHAPTER III. THE TREATMENT OF OPERATION-WOUNDS. Sutures—Needles—Needle holders—Various forms of sutures—Drainage tubes— Catgut drainage—Canalization—Protective dressings—Antiseptic spray—Anti- septic douche—Antiseptic dressings—Objections to use of iodoform—Objections to bichloride gauze—Common preparations for a modern operation—Diagram of arrangements—Open dressing—Precautionary requirements of operations— Special emergencies of operations 82 CHAPTER IV. THE LIGATURE OF ARTERIES.—GENERAL CONSIDERATIONS. Guides to ligaturing—Making primary incision—Opening sheath of a vessel—Pass- ing ligature—Instruments required for ligaturing—Ligature of abdominal aorta—Of common iliac artery—Of internal iliac artery—Of gluteal artery—Of pudic artery—Of dorsalis penis artery—Of external iliac artery—Of deep epi- gastric artery—Of deep circumflex iliac artery—Of superficial femoral artery— VII VIII OPERATIVE SURGERY. PAGE Of deep femoral artery—Of external circumflex artery—Of popliteal artery—Of anterior tibial artery—Of dorsalis pedis artery—Of posterior tibial artery—Of peroneal artery—Of innominate artery—Of subclavian arteries—Of internal mammary artery—Of inferior thyroid artery—Of axillary artery—Of brachial artery—Of radial and ulnar arteries—Of palmar arteries—Of common carotid artery—Of both common carotid arteries—Of the common carotid artery—Tem- porary ligature of common carotid—Ligature of the internal carotid—Of the superior thyroid artery—Of the lingual artery—Of the facial artery—Of the temporal artery—Of the occipital artery 107 CHAPTER V. OPERATIONS ON VEINS, CAPILLARIES, ETC. Ligature of veins—Operations for varicose veins—Injection—Acupressure—Subcu- taneous ligaturing—Excision—Venesection—Transfusion—With blood—With saline solution—Mother’s mark, treatment of—Naevi, treatment of—Cirsoid growths, treatment of 179 f CHAPTER VI. Operations for chronic hydrocephalus—For acute hydrocephalus—For meningocele —For encephalocele—Craniotomy, instruments employed in—Important con- siderations in—Craniotomy in meningeal haemorrhage—For microcephalus— For cerebral tumor, instruments employed in—Craniotomy for epilepsy—For evacuation of pus—For cerebellar tumor—For thrombosis of lateral sinus and jugular vein—For general paralysis of the insane—Opening the mastoid an- trum, instruments employed in—Trephining the frontal sinus—Gunshot wounds of the cranium—Location of the missile—The precautions—The results. Special operations on nerves—Nerve section or neurotomy—Nerve resection or neurectomy—Nerve stretching or neurectosy—Suture or neurorrhaphy—Nerve grafting or neuroplasty—The methods of practice—The results. Operations on special nerves—Operations on supra-orbital nerve—on supra-trochlear nerve—On infra-orbital nerve—On superior maxillary nerve—On Meckel’s ganglion—On inferior dental nerve—On lingual nerve—On gustatory nerve— On auriculo-temporal nerve—On buccal nerve—On trunk at the foramen ovale. Intracranial neurectomy,"instruments employed in—Rose method—Hartley-Krause method—Stages of—Precautions—Complications—Results and sequels—Doyen’s method—Horsley’s intradural method—Operations on the facial nerve. Operations on the spinal cord and spinal nerves—Laminectomy, instruments em- ployed in—Examination of the contents of the canal—Opening of the dura— Results—Operation on spinal meningeal drainage—Parkin’s operation—Spina bifida, operations for—Injection—Excision—Meningocele, operations for—Men- ingo-myelocele, operations for—Tumors of the spinal cord—The operation— The results—Spinal accessory nerve, operations on—Branches of the cervical nerves, operations on—Roots of the spinal nerves—Intraspinal, division of— Branches of the brachial plexus, operations on—On musculo-cutaneous nerve— On musculo-spiral nerve—On circumflex nerve—On median nerve—On ulnar nerve—Branches of the sacral plexus, operations on—On great sciatic nerve— On internal popliteal nerve—On external popliteal nerve—On plantar nerves— On brachial nerves—On tibial nerve, etc.—Branches of the lumbar plexus, operations on—On anterior crural nerve—On obturator nerve—On long saphe- nous nerve—On short saphenous nerve 191 OPERATIONS ON THE NERVOUS SYSTEM. CONTENTS. IX CHAPTER VII. PAGE OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, MUSCLES, AND BURS.E. Tenotomy, instruments employed in—Rules for—Tenotomy of tendons of flexor sublimis and flexor profundus digitorum muscles—Of extensor communis digi- torum muscle—Of extensor brevis longus and ossis metacarpi pollicis muscles— Of flexor carpi radialis muscle—Of flexor carpi ulnaris muscle—Of the biceps muscle of the forearm, etc.—Of the tibialis posticus muscle—Of the flexor longus digitorum muscle—Of flexor longus pollicis muscle—Of tendo Achillis— Of peroneus longus and brevis muscles—Of tibialis anticus muscle—Of ex- tensor proprius pollicis muscle—Of extensor longus digitorum muscle—Of peroneus tertius muscle—Of hamstring tendons—Of gracilis and sartorius mus- cles—Of quadriceps extensor—Of adductor longus muscle. Myotomy—Of pectineus muscle—Of tensor vaginae femoris muscle—Of multifidus spirne muscle—Of latissimus dorsi muscle—Of erector spinae muscle—Of trape- zius muscle—Of sterno-mastoid muscle, etc. Tenorrhaphy, special considerations in—Tendon lengthening—Tendon shortening— Tendon transplantation—The results. Myotomy, oblique division in—V-shaped division in—Syndesmotomy—Fasciotomy —Dupuytren's contraction, treatment of—Bursae, treatment of—Thecitis, treat- • ment of 283 CHAPTER VIII. OPERATIONS ON BONES. Gouging, instruments employed in—Sequestrotomy, instruments employed in—Ex- cisions of extremities, instruments employed in—Treatment of excision wounds —Excision of upper jaw, instruments employed in—Partial and complete ex- cision—The lines of incision—Removal below the floor of the orbit—Various methods of practice—After-treatment—Results—Excision of lower jaw—Ana- tomical considerations—Remarks—Excision of central portion—Of a lateral portion—Of lateral half—Of alveolar process—Immobility of inferior maxilla, operations for—Excision of sternum—Excision of clavicle—Excision of entire scapula—Excision of body of the scapula—Excision of glenoid angle of scapula —Subperiosteal excision of scapula—Remarks—After-treatment—Results—Ex- cision of humerus—Excision of upper end—Subperiosteal excision of head— Excision of shaft—Excision of lower extremity—After-treatment—Results— Excision of elbow joint—Anatomical points—Hilter’s method—Langenbeck’s method—Lister’s method—Ollier’s method—After-treatment—Results—Exci- sion of ulna—Excision of radius—Excision of lower extremities of bones of forearm—Excision of wrist joint—Langenbeck’s method—Ollier’s method— Lister’s method, etc.—Precautions—After-treatment—Results—Excision of metacarpo-phalangeal joints—Excision of phalangeal joints—Excision of pha- langeal joints of tarsus—Of metacarpo-phalangeal joints—Of dorso-metatarsal joints—Of dorsal joints—Of calcaneum—Of astragalus—Excisions of ankle joint—Langenbeck’s method—Busch’s method, etc.—Comments—After-treat- ment—Results—Wladimirow-Mikulicz operation—Excision of bones of leg— Excision of knee joint—Anatomical points—Mackenzie’s method—Bird’s meth- od—Langenbeck's method—Ollier’s method— Remarks—After-treatment— Results. Arthrectomy—Of knee—Of ankle—Results—Excision of patella—Excision of great trochanter—Excisions of hip joint—Anatomical points—Langenbeck’s method —Barker’s method—Sayre’s method—General remarks—After-treatment—Re- sults—Excision of coccyx. X OPERATIVE SURGERY. PAGE Osteotomy, instruments employed in—Comments—Subcutaneous division of the neck of femur—With saw—With chisel—Volkmann’s method—Sayre’s method —Congenital displacements of hip—Iloffa’s operation—Lorenz’s modification of —Remarks—Results—Bony anchylosis of knee joint—Linear osteotomy in— Cuneiform osteotomy in—General remarks. Genu valgum—Anatomical points—Macewen’s method of treatment—Results—Og- ston’s method—Reeves’s method—Chiene’s method. Genu varum—Linear osteotomy in—Cuneiform osteotomy in—Hallux valgus— Methods of treatment of—Osteotomy for talipes—Davies-Colley method—Brad- ford’s method—Phelps’s open-incision method—Enucleation of astragalus, etc. Osteoplasty—Preparation of bone—Preparation of cavity—Filling of cavity and treatment of wound 310 CHAPTER IX. AMPUTATIONS.—GENERAL CONSIDERATIONS. General considerations—Serviceable stump—Proper lengths of flaps—Division of tissues—Classification of flaps—Instruments employed in amputation—Com- parative merits of different flaps—Periosteal flap—Manner of grasping ampu- tating knife—Of carrying it around limb—Sawing the bone—Use of retractors —Metal retractor—Catching and tying bleeding points. Amputations of upper extremities—General remarks—Amputation at phalangeal articulations—At metacarpo-phalangeal articulations—Amputation of thumb— Of little and index fingers—Amputation through metacarpal bone—Amputa- tion of last four metacarpal bones—Amputation of inner three metacarpal bones—Amputation of four metacarpal bones with fingers—Amputations at wrist joint—Circular-flap method—Single palmar-flap method—Double-flap method—Radial-flap method—Remarks—Results—Amputations at forearm— Circular skin-flap method—Equilateral skin-flap method—Musculo-cutaneous- flap method—Comments—Results—Amputation at the elbow joint—Anatom- ical points—Elliptical-flap methods—Circular method—Anterior single-flap method—Comments—Results—Amputations of arm—Circular-flap method— Irregular double-flap method—Antero-posterior-flap method—Long anterior- and small posterior-flap method—Teale’s method—Amputations at surgical neck of humerus—Anatomical points—Oval method—Single external-flap method—Remarks—Results—Amputations at shoulder joint—External- and internal-flap method—Circular method—Racquet methods of Larrey and Spence—Wyeth’s method of prevention of haemorrhage in—Remarks—Results —Amputation above shoulder joint—Results 396 CHAPTER X. AMPUTATION AT THE LOWER EXTREMITY. Amputation of phalanges of toes—Amputation of first phalanx of great toe—Of last phalanx of great toe—Amputation of single toes—Of great and little toes— By single-flap method—By oval-flap method—By internal plantar-flap method —Amputation of two adjoining toes—Of all toes at metatarso-phalangeal joints —Amputations of metatarsal bones—Amputation through all these bones—Of great toe and metatarsal bone—Of little toe and metatarsal bone—Of whole or part of metatarsal bone—Lisfranc’s amputation—Remarks—Modifications of— Chopart’s amputation—Remarks—Results—Forbes’s modification of—Irregular tarsal amputation—De Lignerolles’s amputation—Verneuil’s amputation— Hancock’s operation—Tripier’s operation—Amputations at ankle joint—Syme’s method—Modifications of—Fallacies in—Results—Roux’s method—Pirogoff’s CONTENTS. XI PAGE operation—Remarks—Results—Fergusson’s modification of—Le Fort’s modifi- cation of—Bruns’s modification of—Esmarch’s modification of Le Fort—Am- putations at leg—Amputation of leg at lower third—Guyon’s method—Duval’s method—Author’s method—Teale’s method—Large posterior-flap method— Bilateral-flap method—Hood-flap method—Amputation of leg at middle third —By large posterior-flap method—By long external-flap method—Amputation of leg at upper third—By long external-flap method—By circular-flap method— By bilateral-flap method—Amputations at knee joint—Anatomical points— Amputation by bilateral-flap method—By elliptical-flap method—By circular- flap method—By long anterior-flap method—S. Smith’s amputation at knee joint for gangrene of toes and foot—Amputation of thigh through condyles by Carden’s method—By Gritti’s method—By Sabanojelf’s method—Amputations of thigh—Special considerations—Amputation by equilateral-flap method—By bilateral-flap method—By antero-posterior musculo-integumentary-flap method —By circular integumentary-flap method—By high circular-incision method— By long anterior-flap method—By long antero-posterior-flap methods—General remarks—After-treatment—Results—Amputations at hip—Methods of control of haemorrhage in—Pancoast’s, Esmarch’s, and Lister’s tourniquets—Trendel- enburg’s rod—Davy’s lever—Brandis’s method—Wyeth’s method—McBurney’s method—Senn’s method—Amputation at hip by external-racquet method—By anterior-racquet method—By long anterior- and short posterior-flap methods— By circular-flap method—By Furneaux Jordan method—By antero-posterior- flap method—By single-flap method—After-treatment—Results . . . 440 CHAPTER XI. DEFORMITIES. Congenital or acquired—Brisement force in anchylosis—Barton’s operation in anchy- losis—Curvature of the spine—Sayre’s apparatus for—Deformities dependent upon perverse muscular action—Torticollis, treatment of—Hammer-toe, treat- ment of—Snap finger, treatment of—Deformities due to fusion—Polydactylism —Syndactylism—The various methods of treatment—Diday's method—Ag- new’s method—Zeller's method—Fowler’s method, etc.—Ingrown toe nail—The operation for—Anger's method—Cotting’s method—Dowd’s experience—Bun- ion, complications and treatment of 496 CHAPTER XII. Definition of—The preparation of patient—Size of flap—Instruments employed in —Methods of practice in—Sliding in direct line—Four varieties of—Sliding in curved line—Dieffenbach’s methods—Burow’s methods—Jaesche-Dieffenbach’s method—Littenneur’s method—Bruns's method—Weber’s method—Jumping —Pedicle not twisted—Pedicle much twisted—Inversion—Eversion—Tagliaco- tian operation—Grafting—With heteroplastic substances—Skin grafting—Re- verdin’s method—Thiersch’s method—Krause’s method—Lusk’s method— Croft’s operation for cicatricial contraction—Flaps with single and double pedicles—Rhinoplasty—the French method—Syme’s operation—Ellis’s method —Langenbeck’s method—Denonvillier’s method—Buck’s method—Repair of columns—Dieflenbach’s method of restoration of nose—Verneuil’s method— Indian method—Thiersch’s method—Langenbeck’s and Ollier’s method—Trian- gular flap in—Dieffenbach’s flap in—Langenbeck’s flap in—Keegan’s method— Italian method—Osteoplasty—Rhinoplasty—Ollier’s method—Konig’s method —Israel’s modification of—Sabine’s method—Pancoast’s subcutaneous method PLASTIC SURGERY. XII OPERATIVE SURGERY. PAGE —Saddle-back and angular deformities of the nose—Konig’s method—Martin’s method—The use of gold, silver, rubber, etc., in—Comments—Disfigurements of nose—Morbid growths—Author’s case—Harelip—Age of operation—Control of patient—Instruments employed in—Steps of—Single harelip—Mirault’s method—Malgaigne’s method—Ilagedorn’s method—Simon’s method—Dieffen- bach’s method—Konig’s method—Giraldes’s method—Double harelip—Com- plicated harelip—Management of projecting intermaxillary bones—Blandin’s operation—Rose’s operation—Operation for double harelip—Hagedorn’s meth- od—Cheiloplasty—Celsus’s method—Estlander’s method—Langenbeck’s method —Bruns’s method—Syme-Buchanan method—Syme’s method—Buck’s method —Malgaigne’s method—Sedillot’s method—Deformities of the upper lip— Buck’s method—Sedillot’s method — Dieffenbach’s method — Szymanowski’s method—Ledran-Mackenzie method—V anzette’s method—Stomatoplasty— Buck’s method—Serre’s method—Meloplasty—Grussenbauer’s method—Tren- delenburg’s method—Israel’s method—Kraske’s method—Lallemand’s method, etc.—Operations upon palate—Instruments employed in—Staphylorrhaphy— Comments—Rose’s position in—Steps of operation of staphylorrhaphy—Results —Uranoplasty—Langenbeck’s method—Steps in—Dieffenbach-Fergusson meth- od—Lannelongue’s method—Davies-Colley method—General comments—After- treatment—Results—Mechanical means employed in—Staphyloplasty—Schon- born’s operation—Elongated uvula 507 ILLUSTRATION S PAGE Amputation, circular method. Fig. 416. Esmarch. 398 Amputation, dissection of flap. Fig. 417. Esmarch. 399 Amputation, how not to dissect flap. Fig. 418. Esmarch. 399 Amputation, circular division of muscles. Fig. 419. Esmarch. 400 imputation, circular, stump of. Fig. 420. Esmarch. 400 Amputation, modified circular flap. Fig. 421. Gross. 401 Amputation, flaps by transfixion. Fig. 423. Gross. 402 Amputation, part removed by transfixion. Fig. 424. Gross. 402 Amputation, skin flaps, equilateral. Fig. 427. Esmarch. 403 Amputation, improper periosteal flap. Fig. 428. New. 404 Amputation, instruments employed in. Fig. 429 (half tone). Original. 405 Amputating knives. Fig. 430. W. F. Ford dk Go. 406 Amputating knife, how held. Fig. 431. Original. 407 Amputating knife, how carried around limb. Fig. 432. Original. 407 Amputating knife, another method, carrying around limb. Fig. 433. S. Smith. 408 Amputating knife, common method, carrying around limb. Fig. 434. Esmarch. 408 Amputation, sawing bone. Fig. 438. Esmarch. 410 Amputation, catching and tying bleeding points. Fig. 445. MacCormac. 413 Amputation at wrist, Dubrueil’s method. Figs. 474, 475. Esmarch. 424 Amputation, arm, Langenbeck’s method. Fig. 482. Esmarch. 429 Amputation of arm, flaps. Figs. 483, 484. Esmarch. 430 Arteries of neck, linear guides to. Fig. 199. New. 141 Axillary artery, ligature of, first portion. Fig. 206. Mott, modified. 155 Axillary, brachial arteries, ligature of. Fig. 207. Kocher. 157 Ankle joint, excision of. Fig. 370. Treves, modified. 356 Ankle joint, anatomy of. Fig. 371. Esmarch. 357 Ankle joint, excision of. Fig. 373. Treves, modified. 358 Ankle joint, anatomy of. Fig. 374. Esmarch. 359 Ankle joint, splint for excision. Fig. 375. Esmarch. 360 Adams’s saw. Fig. 396. W. F. Ford dk Co. 378 Anderson-Makin’s lines. Fig. 249. Mills. 211 Astragalus, excision of. Fig. 370. Treves, modified. 356 Anaesthesia, intestinal. Fig. 20. Smith. 29 Anaesthesia, infiltration. Fig. 25. W. F. Ford dk Co. 32 Atomizer, Richardson’s. Fig. 21. W. F. Ford & Co. 29 Acupressure. Figs. 86-88. Thomas Bryant. 61 Artery, torsion of. Fig. 90. Esmarch. 62 Antiseptic dressings in position. Fig. 156. Watson. 95 Approach to vessels. Fig. 164. Original. 108 Aneurismal needle, student’s. Fig. 171. W. F. Ford dk Co. Ill Aneurismal needle, Mott’s. Fig. 172. W. F. Ford dk Co. Ill Abdominal vessel, linear guides to. Figs. 174, 175. Original. 113 Boston surgical cushion. Fig. 53. W. F. Ford dk Co. 42 Brachial artery, pressure digital. Fig. 79. MacCormac. 58 Brachial artery, tourniquet applied to. Fig. 82. Esmarch. 59 XIII XIV OPERATIVE SURGERY. PAGE Bobbins for ligatures. Fig. 118. W. F. Ford & Co. 72 Bottles for ligatures. Figs. 120,122. W. F. Ford db Co. 72 Brain tumor, instruments in operations on. Fig. 252 (half tone). Original. 214 Bullet forceps. Fig. 258. W. F. Ford db Co. 228 Broad-bladed saw. Fig. 435. W. F. Ford db Co. 409 Butcher’s bone saw. Fig. 437. IF. F. Ford db Co. 409 Baudens’s amputation. Fig. 510. Modification. 446 Brandis’s method of compression. Fig. 586. Esmarch. 483 Barton’s operation. Fig. 604. Gross. 497 Bunion and hallux valgus. Fig. 622. Gross. 506 Buck’s needle conductor. Fig. 89. IF. F. Ford db Co. 62 Buck’s method. Figs. 657, 658. Buck. 521 Buck’s incision. Fig. 699. Buck. 544 Brain, puncturing of ventricles. Fig. 235. Keen. 192 Brain, topography of. Figs. 251a, 2515. Dalton, modified. 213 Crural nerve, anterior. Fig. 294. Agnew. 282 Chain saw. Fig. 329. W. F. Ford db Co. 317 Chain saw carrier. Fig. 330. W. F. Ford db Co. 317 Carpus, synovial membranes of. Fig. 358. Gray. 347 Carpus, ligaments of dorsal surface. Fig. 359. Esmarch. 347 Carpus, ligaments of palmar surface. Fig. 360. Esmarch. 347 Carpus, transverse section of. Fig. 361. Treves. 348 Craniotomy, for fracture of the skull, instruments used in. Fig. 326 (half tone). Original. 196 Craniotomy, circular. Fig. 237. Esmarch, modified. 197 Craniotomy (trephining). Fig. 238. Jacobson, modified. 197 Cranial bones, section of. Fig. 242. Chipault. 205 Cranial fissures and sutures, relation of in adult. Fig. 244. Morris. 207 Cranial fissures and sutures, relation of in child. Fig. 245. Morris. 208 Craniotomy, sites for. Fig. 254. Treves. 221 Counter-opening, locating of, author’s method. Fig. 259. Original. 228 Counter-opening, located, author’s method. Fig. 260. Original. 229 Chopart’s amputation. Figs. 516-521. Esmarch. 449, 450 Carden’s amputation. Fig. 567. Stimson. 472 Celsus’s, amputation of thigh. Figs. 574, 576. Esmarch. 478 Cutting skin grafts. Fig. 643. Dennis. 514 Cutting skin grafts. Fig. 644. Esmarch. 515 Croft’s operation. Fig. 645. Treves. 516 Columna, repair of. Fig. 659. Treves. 521 Celsus’s method. Figs. 491, 692. Few. 541 Cheiloplasty, Estlander method. Fig. 693. Tillmanns. 541 Cheiloplastv, Langenbeck and Brilns. Figs. 694, 695. Tillmanns. 542 Cheiloplasty, Langenbeck, Syme-Buchanan. Figs. 696, 697. Tillmanns. 542 Chin, cheek, and lip, repair of, Vanzette’s method. Fig. 708. Terrier. 548 Cheeks drawn aside by elastic traction. Fig. 721. Dennis. 555 Carotid, vertebral and facial arteries. Fig. 205. Kocher. 151 Carotid, common, ligature of. Fig. 216. Sedillot, modified. 168 Compress, pyramidal. Fig. 75. Esmarch. 57 Compress, oblong. Fig. 76. Esmarch. 57 Compress, conical. F'ig. 77. Esmarch. 57 Cautery, actual, blowpipe and irons. Fig. 100. W. F. Ford db Co. 65 Cautery, galvanic, electrodes. Fig. 102. W. F. Ford db Co. 66 Catgut in glass tubes. Fig. 121. W. F. Ford db Co. 73 Closure of vessel en masse. Fig. 124. Esmarch. 82 Common iliac, ligaturing of. Fig. 176. Modified from Otis. 115 Davy’s lever applied. Fig. 84. Davy. 60 Drainage tube, rubber, thread fastening. Fig. 149. Original. 91 Drainage tube, rubber, pin fastening. Fig. 150. Original. 92 Drainage strips, iodoform gauze. Fig. 151. W. F. Ford db Co. 92 Drainage, catgut. Fig. 152. Wyeth. 92 ILLUSTRATIONS. XV PAGE Drainage, base of skull. Fig. 288- Parkin. 271 Douching bottle. Fig. 154. W. F. Ford db Co. 95 Douching bottle, extemporized. Fig. 155. W. F. Ford db Co. 95 Diagram of arrangements. Fig. 161. Treves. 102 Doyan’s method. Fig. 274c. Doyan. 252 Doyan’s method, opening side of skull. Fig. 280. Doyan. 262 Doyan’s method, opening base of skull. Fig. 281. Doyan. 263 De Lignerolles’s amputation. Figs. 522,-527. Esmarch. 451, 452 Denonvillier’s method. Fig. 656. Tillmanns. 520 Dietfenbach’s method. Fig. 660. Stimson, modified. 522 Dietfenbaeh’s Hap. Fig. 667. Treves. 525 Dieffenbach’s method. Fig. 681. Treves. 536 Dorsalis pedis, ligature of. Fig. 196. Kocher. 137 Dupuytren’s contraction. Figs. 322, 323. Abbe. 305 Excisions of extremities, instruments employed in. Fig. 328 (half tone). Original. 316 Excision of bones of the face, instruments employed in. Fig. 331 (half tone). Original. 319 Elbow joint, excision, Htiter’s incision. Fig. 351. Esmarch. 342 Elbow joint, ligaments of. Fig. 350. Gray. 342 Elbow joint, excision, Langenbeck’s incision. Fig. 353. MacCormac, modified. 343 Elbow joint, excision, Ollier’s incision. Fig. 353. MacCormac, modified. 343 Elbow joint, excision, Liston’s incision. Fig. 354. Esmarch. 343 Elbow joint, excision, exposing internal condyle. Fig. 355. Esmarch. 344 Elbow joint, excision, splint applied. Fig. 356. Esmarch. 345 Elbow joint, amputation at, elliptical flap. Fig. 477. Treves. 426 Elbow joint, amputation at, circular method. Figs. 478, 479. Esmarch. 427 Elbow joint, amputation at, by transfixion. Figs. 480, 481. S. Smith. 428- Esmarch’s tourniquet. Fig. 582. Esmarch. 481 Esmarch’s tourniquet applied. Fig. 583. Esmarch. 482 Esmarch’s elastic bandage. Fig. 68. Esmarch. 55 Esmarch’s elastic bandage applied. Fig. 69. Esmarch. 55 Ellis’s method. Fig. 654. Roberts. 520 Ethyl chloride, spray. Fig. 22. W. F. Ford db Co. 30 Extemporized retractors. Fig. 170. Modified from Esmarch. Ill Epigastric artery, ligature of. Fig. 183. Kocher. 12£ Fasciatome. Fig. 320. W. F. Ford db Co. 303 Fasciatome, short. Fig. 324. IV. F. Ford dc Co. 305 Fascia palmar. Fig. 321. Morris. 304 Fibula, removing end of. Fig. 372. S. Smith. 358 Femur, lower end of, transverse section Fig. 405. Treves, modified. 388- Fissure of Rolando, locating, Chiene’s method. Fig. 247. Keen. 209 Fluhrer's probe. Fig. 256. W. F. Ford, & Co. 227 Forceps, serre-fine. Fig. 95. W. F. Ford & Co. 64 Forcipressure, patterns of. Fig. 99. W. F. Ford db Co. 65 Forceps, tongue-holding, Mathieu’s. Fig. 2. W. F. Ford & Co. 13 Forceps, isolation, anaesthesia. Fig. 24. W. F. Ford db Co. 30 Forceps, thumb. Fig. 33. W. F. Ford db Go. 35 Forceps, claw-bite. Fig. 35. IV. F. Ford db Co. 35 Forceps, cutting between. Fig. 34. Lbbker. 35 Foulis’s fastening. Fig. 72. Esmarch. 56 Foulis’s fastening, in position. Fig. 71. Esmarch. 56 Femoral artery, digital pressure on. Fig. 78. MacCormac. 57 Femoral artery, tourniquet applied to. Fig. 81. Esmarch. 59 Femoral artery, superficial, ligature of. Fig. 184. Kocher. 126 Femoral artery, deep, ligature of. Fig. 188. Kocher, modified. 130 Finger stalls, rubber. Fig. 160 (half tone), Original. 101 Fingers, amputation of, appearance of flaps. Figs. 455, 456. Esmarch and Jacobson. 418 Forearm, stump after circular amputation of. Fig. 476. Esmarch. 425 Flap, single pedicle. Figs. 646, 648. Wyeth. 517 Flap, single pedicle, author’s case. Fig. 649. Original. 517 OPERATIVE SURGERY. XVI PAGE Flaps, double pedicle. Fig. 647. Tillmanns. 517 Framework of nose, formation of. Fig. 665. Tillmanns. 524 Gouging, instruments employed in. Fig. 326 (half tone). Original. 311 Genu valgum. Fig. 404. Poore. 387 Genu varum. Fig. 413. Poore. 390 Girdner’s electric probe. Fig. 257. W. F. Ford db Co. 227 Grooved director. Fig. 36. W. F. Ford db Co. 36 Granny knot. Fig. 108. Heath. 68 Grad knot, tying of. Figs. 113-116. Grad. 70 Grad, method of ligature removal. Fig. 117. Grad. 71 Gloves, canton flannel. Fig. 159 (half tone). Original. 101 Gluteal and sciatic arteries, guides to. Fig. 178. MacCormac. 118 Gluteal artery, ligature of. Fig. 179. Kocher. 119 Gritti’s amputation. Fig. 568. Stimson. 474 Giraldes’s method. Fig. 683. Tillmanns. 537 Gross’s needle forceps. Fig. 722. Gross. 556 Gross’s artery compressor. Fig. 97. W. F. Ford db Co. 64 Ilartley-Krause method, lines of incision. Fig. 277. Chalot. 257 Hartley-Krause method, making bone flap. Fig. 278. Chalot. 257 Hartley-Krause method, branches fifth nerve. Fig. 279. Chalot. 258 Hand, palm of, surface markings. Fig. 446. Treves. 414 Hand, appearance of. Fig. 464. Watson. 420 Hand-lamp for illumination. Fig. 103. W. F. Ford cb Co. 67 Hancock’s amputation, bones sawed through. Fig. 526. Esmarch. 452 Hip joint, amputation of, Wyeth’s method. Figs. 587-590. Wyeth. 484 et seq. Hip joint, amputation of, Menec’s method. Figs. 591-594. Esmarch. 488 et seq. Hip joint, amputation of, Hieffbnbach’s method. Figs. 595-598. Esmarch. 490 et seq. Hip joint, amputation of, Furneaux Jordan method. Fig. 599. Treves. 492 Hip joint, amputation of, Guthrie’s method. Fig. 600. Treves. 492 Iiip joint, amputation of, Malgaigne. Figs. 601, 602. S. Smith. 493 et seq. Hip joint, White’s incision in excision of. Fig. 390. Esmarch. 372 Hip joint, nerve and rotary muscles of. Fig. 391. Esmarch. 572 Hip joint, sawing off head in excision of. Fig. 392. Esmarch. 173 Hip joint, Langenbeck’s incision in excision of. Fig. 393. Esmarch. 174 Hip joint, Sayre’s incision in excision of. Fig. 393. Esmarch. 374 Hammer-toe. Fig. 609. Tubby. 500 Harelip, instruments employed in. Fig. 676 (half tone). Original. 513 Hagedorn’s method. Fig. 679. Tillmanns. 536 Harelip, double. Fig. 684. S. Smith. 518 Harelip, complicated. Fig. 685. Gross. 556 Harelip, double, operation for. Fig. 687. Tillmanns. 539 Harelip, double, Hagedorn’s operation. Fig. 688. Tillmanns. 540^ Harelip, pins inserted. Fig. 689. Gross. 540 Holding knife, first position. Figs. 27, 28. Bernard <& Jluette. 34 Holding knife, second position. Figs. 29, 30. Bernard - artery at the THE LIGATURE OF ARTERIES. 131 The Fallacies.—The profunda may arise from the inner or back portions of the common femoral. If it be not found in the usual place, it should be sought for at the latter situations. Ligature of the Popliteal Artery.—The intimate association of the poplit- eal artery with the posterior surface of the knee joint should not be forgot- ten, especially in excision. The author knows of an instance of the wound- ing of this vessel in excision of this joint. The Anatomical Points.—The popliteal is continuous with the femoral artery, and begins at the junction of the middle and lower thirds of the thigh, at the termination of Hunter’s canal, and passes with a slight obliquity down- ward and outward to the lower border of the popliteus muscle. The Contiguous Anatomy. —At the upper third of the space the internal popliteal nerve is more superficial than the vein and artery. The vein lies in close contact with the artery and between it and the nerve. The artery is the inner- most of the three, and is the most deeply situated, resting close to the posterior surface of the femur. At the lower third the nerve is still the most super- ficial, but lies upon and to the inner side, and more superficial than the artery, which rests upon the popliteus muscle. The artery should not be tied at its middle third, on account of the large number of branches given off at this point, together with the fact of its contiguity with the knee joint (Fig. 190). The Linear Guide.—The lin- ear guide to the vessel begins a little tothe inner sideof the mid- dle of the upper portion of the popliteal space, and passes midway between the condyles of thefemur (Fig. 189). The Muscular Guides.—The artery at the upper third lies to the inner border of the semimembranosus, at its lower third, midway between the heads of the gastrocnemius muscle. The artery can be ligatured at three situations—upper and lower thirds, and below the inner tuberosity of the tibia. The position of the limb for ligaturing, the linear guide, and the anatomy are substantially similar at the last situation as in the upper part of the posterior tibial. Ligaturing here is rarely practiced. Fig. 190.—Transverse section through the right knee joint. A. Bursa patellae. B. Internal saphenous vein. C. Semimembranosus. D. Gracilis. E. Seini- tendinosus. F. Popliteal artery. 6. Popliteal vein. H. External saphenous vein. I Inter- nal popliteal nerve. J. External popliteal or perineal nerve. 132 OPERATIVE SURGERY. The Operation at the Upper Third (Fig. 189).—The patient can be placed on the face or the back; if on the latter, the thigh should be well flexed and rotated outward. The former position is more convenient for the surgeon, but is objectionable on account of greater difficulty in the adminis- tration of the anaesthetic. The patient may be placed on the side corre- sponding to that of the artery to be tied, with the thigh extended and the opposite one flexed on the pelvis. An incision is made, about four inches in length, along the outer border of the semimembranosus through the integument and fascia, and is deep- ened by separating the areolar tissue with the handle of the scalpel. The nerve will be first seen, and, when drawn outward, the vein will be found lying more deeply and internal to it; if the vein be now carefully isolated and drawn outward, the artery will be noted at the inner side, and is then carefully separated from the surrounding tissues and the needle carried around it from without in- ward. The Operation at the Lower Third (Fig. 191).—Make an inci- sion midway between the heads of the gastrocnemius, carefully avoid- ing the external saphenous vein and nerve, as they pass between the heads of that muscle ; separate the connective tissues with the handle of the scalpel, draw the vein and nerve to the inner side, and pass the needle from within outward. The Fallacies.—The tendon of the semitendinosus may be mis- taken for the tendon of the semi- membranosus muscle. The semimembranosus has a large fleshy belly, which extends much nearer to the median line of the popliteal space than does the semitendinosus. Sometimes there are two popliteal veins, one on either side of the vessel, and rarely two popliteal arteries. The Results.—The popliteal is seldom ligatured unless it be ruptured, then both ends must be tied. Of the three or four cases thus reported all terminated unfavorably, due, however, to the nature of the injury. Ligature of the Anterior Tibial Artery.—The anterior tibial artery is often injured in severe fracture of the bones of the leg. The Anatomical Points.—The anterior tibial arises from the popliteal just below the lower border of the popliteus muscle, passes forward between the bones of the leg above the interosseous membrane, then downward on the anterior surface of this membrane to the ankle joint, w'here it becomes the dorsalis pedis artery. Fig. 191.—Ligature of popliteal artery at the lower third. THE LIGATURE OF ARTERTKS. 133 The linear guide to the vessel is drawn on the an- terior surface of the leg from the inner border of the head of the fibula (*) to midway between the malleoli (Fig. 192). The muscular guide is the outer border of the tibialis anticus muscle. This vessel can be tied at three situations — at its upper, middle, and lower thirds ; but two—the mid- dle and lower thirds—are more than sufficient for all practical purposes. The Operation. Upper Third (Fig. 192,a).—Liga- ture at this situation is te- dious and difficult, on ac- count of the great depth of the vessel, and should not be attempted unless circumstances demand it. Fig. 193 shows the deep relations of the vessel. The Middle Third (Fig. 192, b).— The artery in this situation lies quite deeply, and a good light must be had to see the entire ex- tent of the operation- wound (Fig. 194). The Operation.—Place the patient on the back with the thighs extended, the leg turned inward, and the foot forcibly extended to mark the outlines of the tibialis anticus mus- cle. Make an incision four or five inches in length on the line indicating the course of the artery, down to the fascia, which is then carefully divided. The / TIBIALIS. {ANTICUS M. —ANT.TIBIAL N. VEN/E COMITES I EX TEN. (. LONG US DIGIT. -ANT. TIBIAL A. Fig. 192.—Ligature of anterior tibial artery. Pig. 192.—Ligature of anterior tibial artery. OPERATIVE SURGERY. 134 aponeurotic structure is then severed along the line of apposition between the tibialis anticus and the extensor longus digitorum muscles; it should likewise be divided trans- versely inward to a limited extent, to admit of the wider separation of these muscles. The foot is then flexed, and, with the finger, or the handle of the scal- pel, the Hue of separation is extended directly down to the vessel; separate the surfaces of the wound with spatulae, then the artery with its nerve and accom- panying veins will be seen (Fig. 194), the nerve being in front and on the outer side; separate the veins from the artery, and pass the ligature from without inward. The Operation at the Lower Third (Fig. 192, c). —With the limb as in the preceding operation, ex- tend the foot to mark the course of the tendon of the tibialis anticus; make an incision along the external border of the tendon on the linear guide about three inches in length. Divide the fascia, and seek with the finger for the space between the tibialis anticus and the extensor proprius pollicis muscle, which latter muscle is at the inner side of the vessel below; flex the foot, separate the muscles from each other, and the artery will be seen accom- panied by its veins and nerve, the latter lying in front and a little to the outer side (Fig. 195); isolate the artery, and place the ligature by passing the needle from without inward. The Fallacies.—The outer surface of the head of the tibia is very liable to be mistaken for the head of the fibula, which error will locate the linear guide too far to the inner side of the leg, and cause the incision to be made over the belly of the tibialis anticus muscle. To avoid this error it must be remembered that the head of the fibula is more posteriorly, and constitutes the most external bonv prominence at this part of the limb. The septum between the tibialis anticus and the extensor longus digi- torum may be indistinct or absent; then the outer border of the tibialis anticus muscle should be sought for and determined—1, by the forcible ex- tension of the tarsus; 2, by the resistance to lateral pressure; 3, by the line Fig. 193.—Transverse section at upper third of right leg. A. Anterior tibial artery and veins. B. Anterior tibial nerve. C. Internal saphenous vein. B. Internal saphenous nerve E Posterior tibial artery, veins and nerve, b. lendon of plantaris. Gr. External saphenous vein. H. Short saphenous nerve. I. Ex- ternal cutaneous nerve. J. Perineal nerve. THE LIGATURE OF ARTERIES. 135 indicating the interspace which may be seen at the lower extremity of the incision when invisible above. The anterior tibial artery may be rudimentary or absent; it may run more superficially than common. So long, however, as it keeps in the proper line the pulsations will lead to its detection. The venae comites cling so closely to the vessel that persistent efforts at separation almost invariably lacerate the veins, and therefore it is better, on the whole, that they be tied along with the artery than that the efforts of separation be prolonged. Ligature of the Dorsalis Pedis Artery. The Anatomical Points.—This vessel is a continuation of the anterior tibial (Fig. 196). It begins at the ankle joint and passes downward between the metatarsal bones of the great and sec- ond toes. The dorsalis pedis is tied in but one situation, which is on the lin- ear guide directly continuous with that of the anterior tibial artery (Fig. 192). The muscular guide is the outer border of the tendon of the extensor proprius hallucis (Fig. 196). . TlLe Operation.—Extend the tarsus and forcibly flex the great toe to make prominent the tendon of the extensor proprius hallucis; make an inci- sion about three inches in length along the outer border of this muscle, com- mencing at the bend of the ankle; divide the fascia and expose the fleshy inner portion of the extensor brevis digitorum muscle; draw the muscle outward, when the artery and its satellite veins will appear; separate the artery from the veins, and pass the needle as best suits the con- venience of the operator. The Fallacy.—The ar- tery may pass outside of the line indicating its proper course. Ligature of the Poste- rior Tibial Artery.—The posterior tibial artery is sometimes ruptured in fracture of the tibia. The Anatomical Points. —The posterior tibial is an artery of considerable size which comes from the popliteal at the lower border of the popliteus muscle. It passes obliquely to the tibial side of the leg, there goes downward between Fig. 194.—Transverse section of right leg at middle third. A. Extensor proprius hallucis. B. Anterior tibial artery, veins, and nerve. C. Posterior tibial artery, veins, and nerve. I). Flexor longus digitorum. E. Inter- nal saphenous vein. F. Internal saphenous nerve. O. Tendon of plantaris. H. External saphenous vein. I. Muscular branches. J. Peroneal artery and veins. K. Flexor longus hallucis. 136 OPERATIVE SURGERY. the superficial and deep layers of muscles to a point midway between the internal malleolus and inner tuberosity of the os calcis, terminating a little further on in the external and internal plantar arteries. The linear guide to the vessel is drawn from the middle of the popliteal space to midway between the inner malleolus and the tuberosity of the os calcis. This guide is not a feasible one, since to reach the artery by cutting upon the guide necessitates the division of the fibers of the muscles of the calf of the leg. The linear guide to the operation is a line located three fourths of an inch behind the internal border of the tibia at the middle and lower thirds of the leg (Fig. 197). The Muscular Guide.—At the middle third the artery lies beneath the soleus; at the lower third, to the outer border of the flexor longus digi- torum. It may he ligatured at three situations: at the middle third, at the lower third, and as it passes behind the inner malleolus. The Operation at the Middle Third (Fig. 197, a).—Place the patient on the back, flex the leg on the thigh and the thigh on the pelvis, rotating the thigh outward so that the leg will lie on the outer side. Make an incision on the linear guide to the operation about four inches in length; divide the deep fascia, recognize the inner border of the gastrocnemius, beneath which will be seen the fibers of the soleus, which should be divided carefully transversely or longi- tudinally—the latter preferable—down to the pale yellow aponeurosis on its under surface; draw apart the fibers of the soleus, and make an opening through the aponeurosis about an inch and a half from the inner border of the tibia, of sufficient size to expose the artery, which is found beneath attended by its veins and the posterior tibial nerve (Fig. 194); draw the nerve to the outer side, separate the vessel from the veins, and pass the needle from without inward. The Operation at the Lower Third (Fig. 197, h).—Place the limb as before; make an incision in the course of the linear guide about three inches in length ; divide the integument and fascia in the usual manner; separate the borders of the wound, then divide the aponeu- rosis (which binds down the deep layer of muscles) at about one inch from the internal border of the tibia, push aside the fat, and the vessel with its nerve and veins will be found at the outer border of the flexor longus digitorum (Fig. 195); separate the artery from the veins if prac- Eiu. 195.—Transverse section through right leg at lower third. A. Musculo-cutaneous nerve. B. Pero- neal artery and veins. C. Peroneus longus. D. External saphenous vein, E. External saphenous nerve. F. lendo Aehulis. O. Tendon of plan- taris. 11. Posterior tibial artery. veins, and nerve. 1. Internal saph- enous vein. J. Internal saphenous nerve. K. Anterior tibial artery, veins, and nerve. THE LIGATURE OF ARTERIES. 137 ticable, push the nerve to the outer side, and pass the needle from with- out inward. The Operation between the Os Calcis and Internal Malleolus.—Place the foot on its outer surface and make a curved incision about three inches in length, with the concavity uppermost and the center at a point midway between the malleolus and the inner tuberosity of the os calcis (Fig. 197, c). Divide the fascia and the internal annular ligament on a director, using caution, since the artery lies directly beneath the ligament; isolate the vessel from the veins, and pass the needle from without inward. In going through the superficial tissues, small branches of the saphenous vein will be divided unless care be taken. In old people both these and the venae comites often become varicose, which condition increases the difficulty of finding and iso- lating the artery. It is better not to at- tempt to ligature the artery in this situa- tion if marked evidence of varicosities are present. The Fallacies.—The posterior tibial may be double, rudimentary, or absent. In either instance the peroneal is usually increased in size. If the veins are closely associated with the artery they should be tied along with that vessel. Carefully avoid opening the sheaths of the tendons that are contiguous to the vessel. Ligature of the Peroneal Artery.— The peroneal artery is rarely ligatured except at the seat of the injury demand- ing it. The Anatomical Points.—The peroneal artery arises from the posterior tibial at about one inch below the popliteus muscle, passes obliquely outward to the inner border of the fibula (Figs. 194 and 195), along which it de- scends to the lower third of the leg, and is finally distributed to the outer side of the ankle. It may be ligatured at the middle and at lower thirds of the leg. The linear guide to the vessel is a line drawn from the posterior border of the head of the fibula (Fig. 198, *) to the external border of the tendo Achillis at its insertion. The Operation.—Extend the foot and make an incision about four inches in length along the guiding line parallel with the external border of the fibula (Fig. 198, a). Separate the attachments of the soleus and the flexor longus hallucis from each other, and the artery will be found at the inner side 11 Fig. 196.—Ligature of dorsalis pedis artery. 138 OPERATIVE SURGERY. Fig. 197.—Ligature of posterior tibial artery. THE LIGATURE OF ARTERIES. 139 Fig. 198.—Ligature of peroneal artery. 140 OPERATIVE SURGERY. of the flexor longus hallucis close to the fibula. The venae comites may be included in the ligature. The Fallacies.—The peroneal artery is rarely absent. It may be over- looked, and the posterior tibial tied instead. If its close relation to the fibula be remembered this mistake will not occur. Ligature of the Innominate Artery.—The innominate artery is invested with great significance on account of its relation to aneurism and its resist- ance of the curative effects of the ablest surgical endeavor. The Anatomical Points.—The innominate artery arises from the begin- ning of the transverse arch of the aorta in front of the left common carotid, passes obliquely upward and outward to the upper border of the right sterno- clavicular articulation, where it divides into the right common carotid and right subclavian arteries. The Contiguous Anatomy. The Relations of the Innominate Artery. (Gray.) In f ront. Sternum. Sterno-hyoid and sterno-thyroid muscles. Remains of thymus gland. Left innominate and right inferior thyroid veins. Inferior cervical cardiac branch from right pneumogastric nerve. Right side. Right vena innominata. Right pneumogastric nerve. Pleura. Left side. Remains of thymus. Left carotid. Left inferior thyroid vein. Trachea. Innominate artery. Behind. Trachea. While this vessel has no practical linear or muscular guides, still a line drawn from the junction of the first two pieces of the sternum to the right sterno-clavicular articulation indicates the substernal course of the vessel. However, it should not be forgotten that this course is not an invariable one, for in many instances it bifurcates above or below this point, more fre- quently at the latter situation. The remaining guides to the vessel are the trachea, common carotid, and subclavian arteries. The trachea lies immediately behind the artery and is crossed obliquely by it. The carotid and subclavian arteries lead down to the point of the bifurcation of the innominate. Numerous incisions are described for gaining access to tbe vessel. The one limited to the soft parts, which is best calculated to afford the greatest amount of room, was employed in 1818 by the late Valentine Mott, when the vessel was ligated first. The Operation.—Place the patient on the back, with the shoulders some- what raised and the head turned backward and to the left side. This posi- tion draws the artery upward from behind the sternum. An incision is then made three inches in length, extending along the upper border of the clavicle to opposite the center of the episternal notch, which is joined by another of THE LIGATURE OF ARTERIES. 141 similar length directed along the anterior portion of the sterno-mastoid mus- cle (Fig. 199, d). The triangular flap thus formed, consisting of the integu- ment, superficial fascia, and platysma, is turned upward and outward. The portions of the sterno-cleido-mastoid muscle corresponding to the horizon- tal incision, and the sterno-hyoid and sterno-thyroid muscles, are divided on a director and turned aside. The inferior thy- roid veins, if they now come into view, are cautiously drawn aside, the deep cervical fascia is torn or cut through, and the sheath contain- ing the common carotid artery, pneumogastric nerve, and internal jugu- lar vein is brought into view. Open the caro- tid compartment of the sheath, draw the vein and nerve to the outer side, and follow the caro- tid down to the subcla- vian, the origin of which should be promptly exposed. The upper portion of the innominata is then separated from its important connections by the finger or a blunt director; the left vena innominata is depressed, and the right vena innominata, right internal jugular, and the pneumogastric nerve are carried to the right, and the aneurism needle is passed from below up- ward, and from behind forward and inward, in close contact with the vessel. It was proposed some time ago to remove a sufficient portion of the upper end of the sternum to admit of a direct opening into the sheath of the innominata (Fig. 200). It was thought that this measure would the better Fig. 199.—Linear guides, BRACHIAL PLEXUS. TRANSVERSAUS COLL! A. -STERNO-THYROID M, TRAPEZIUS M. -THYROID GLAND. STERNO- MASTOID M. -TRACHEA. ANTERIOR SCALENUS M: STERNO-MASTOID M. SUPRA-SCAPULAR A STERNUM. CUT END OF CLAVICLE. FIRST RIB. Fig. 200.—Right subclavian and innominate arteries. preserve the nutritive integrity of the coats of the vessel by leaving its vas- cular connections with the sheath undisturbed above. Kocher’s incision (a) 142 OPERATIVE SURGERY. begins at the junction of the lower and middle thirds of the anterior border of the sterno-mastoid and passes downward in a slightly curved manner and terminates on the anterior surface of the first portion of the sternum. Ligature with resection of the sterno-clavicular articulation and the upper end of the sternum, although suggested some years before and practiced by Cooper, Bardenhauer, and the author on the cadaver, was not practiced on the living subject until 1895, when Burrell, of Boston, carried it into effect with eminent success—a success emphasized by the fact that the patient re- covered, lived one hundred and four days, and then died suddenly from chronic heart disease and arterial sclerosis. On account of the importance of the case, liberal quotations will be made from the report of Dr. Burrell (Transactions of the American Surgical Association, vol. viii, 1895). The Operation.—“ An incision was made at the anterior edge of the right sterno-cleido-mastoid muscle extending from the level of the cricoid carti- lage to two inches below the upper border of the sternum. From this point another incision extended outward four inches in length to the junction of the outer and middle thirds of the clavicle. This skin-flap with the fascia and platysma muscle was turned back. The sterno-mastoid was severed close to its insertion into the clavicle and sternum. The sterno-thyroid, sterno- hyoid, and omo-hyoid muscles were also divided. This brought to view a fusiform aneurism in the right subclavian and right carotid arteries, extend- ing down and on to the innominate. It was believed that enough of the innominate could be exposed to place a ligature between this fusiform aneu- rism and the aorta. By means of a half-inch trephine operated by a surgi- cal engine, the right sterno-clavicular articulation and the right half of the notch of the sternum for about an inch down from the top were honey- combed. The bony parts were by this means weakened, and the removal of the articulation and the piece of the sternum were easily completed by bone forceps. A flat copper retractor wras slid underneath the sterno-clavicular articulation and the sternum while the trephine was being used to protect the underlying parts. “ When this block of bone was removed there was exposed the right in- nominate vein and the left innominate vein going down to form the superior vena cava, with the vagus and recurrent laryngeal nerves resting on the in- nominate artery, all plainly to be distinguished. The wound at this time was filled with bubbling air, which had been sucked into the areolar tissue which surrounds the great vessels at the base of the neck. Its presence was ominous, and it was felt at this step by all of those who were present that if any large vein were pricked a fatal result would be inevitable. Precautions were taken to prevent the entrance of air by keeping the wound filled with sterile water. “ The sheath of the vessel was opened and the innominate artery was isolated. Then came the problem of how the ligatures should be passed. The rule, of course, is to pass the ligature away from danger. This was im- possible, owing to the size of the vessel and the fact that it was surrounded by important structures on every side. The separation of the sheath of the artery was finally completed by means of the forefingers placed on either THE LIGATURE OF ARTERIES. 143 side of the vessel. The artery was estimated to be an inch and a quarter in circumference. The ordinary curved aneurism needle was too small to pass about the vessel, and the blunt point of the aneurism needle, it was felt, might wound important structures posterior to the vessel. A flat (three quarters of an inch in width) copper spatula, curved on itself, was passed about the vessel. As soon as this copper spatula was in position a flat braid- ed silk ligature was passed around the vessel by an aneurism needle and tied in a square knot. It was feared that the extra turn in the first part of a surgeon’s knot might tear the vessel. Fully three minutes were taken in se- curing the first ligature. Gradually it was drawn tighter and tighter until the circulation was completely cut off. The coats of the vessels were felt to give way while tying this first ligature, which was placed three quarters of an inch from the aorta. “ The second ligature of silk was placed in the same manner one half inch higher up, but was not drawn as tightly as the other, for the coats were felt to give way, and the possibility of a tear of the innominate artery was recognized. Both ligatures were tied in square knots and cut short. It was my intention to sever the innominate artery between these ligatures, to place the vessel at rest by avoiding the tracheal tug; but the size of the ves- sel, and the feeling that came to my fingers while tying the second ligature that the artery was not completely closed at this point, led me to give up this step in the operation. “ The overlying muscles were sutured in approximately their original positions, and the wound was closed as rapidly as possible. An aseptic dressing was applied. The operation lasted one hour and a half.” Another method of procedure, but unemployed as yet in the living sub- ject, contemplates the utilization of the intimate relationship of the trachea to the artery in question ; and also, incidentally, the ability to separate with but limited danger of bleeding the pretracheal muscles down to the sternum. The Operation.—Raise the shoulders and cause the head to fall suffi- ciently backward to freely expose the median line of the neck. Make an incision in the median line from the episternal notch upward four inches in length, through the integument and superficial fascia; separate from each other and draw apart the sterno-hyoid and sterno-thyroid muscles. Care- fully expose the first part of the right common carotid and the bifurcation of the innominate artery with a blunt instrument, cautiously avoiding injury of the deep veins of the neck ; expose the trachea and follow it down to the middle of the innominate, and carefully pass the ligature in the direction already noted. The absence of venous engorgement in the neck makes this line of attack a seemingly wise and advantageous one. The Fallacies.—If the innominata be shorter than usual, the lower ex- tremity of the common carotid may be tied instead. If the aorta arches to the right side, the innominata will be on the left side instead of the right. The Remarks.—Rigid antiseptic measures should characterize each detail of the preparation for the operation, and also the operation itself. The wound should be promptly and thoroughly closed, and the inner surfaces kept 144 OPERATIVE SURGERY. cautiously applied to each other by means of graduated compresses held in position, if need be, by a rubber cushion. The pain and irritability of the patient excited by the operation and the after-treatment should be relieved by hypodermics of morphin given at regular intervals until the wound is properly healed. The use of a broad ligature, so tied that the knot shall not cause the ligature to make uneven pressure on the walls of the vessel, appears to be an important desideratum and one difficult of attainment. A drainage tube ought not to be employed at all, as its presence invites ulceration of the contiguous tissues and the establishment of a sinus in the course of its place- ment. Textile-fabric drainage only is proper for the wound, and this should not be used except when the attainment of primary union is defeated al- ready. Simultaneous ligature of the common carotid along with the innominate, and possibly also the vertebral, then or subsequently appears to be a justi- fiable and perhaps necessary step of the procedure. The surgeon should carefully consult the experience of the preceding efforts before attempting the operation, as by such means only can the lessons of the past be properly utilized. The Results.—The innominate artery has been ligatured thirty-one times, with two recoveries. Five instances of unfinished operation are noted (Bur- rell). It is difficult, indeed, to establish a time limit of cure, since death from haemorrhage has happened in cases at a later period than that re- garded as indicating a cure in other instances. Ligature of the Subclavian Artery.—The subclavian artery has for a con- siderable time afforded a field replete with occasions for varying surgical en- deavor. The Anatomical Points.—The subclavian artery, on the right side, arises from the arteria innominata, opposite the junction of the right clavicle with the sternum; on the left side, it arises from the arch of the aorta. These vessels, therefore, differ in the first part of their course in length, direction, and in relation to the contiguous anatomical structures. The right sub- clavian is abont three, and the left about four inches in length, and each arches upward into the neck to the level of the sixth cervical vertebra. Each vessel is divided into three portions: the first portion is situated be- tween the origin and the inner border of the scalenus anticus muscle, the second lies immediately behind this muscle, and the third is limited by the outer border of the scalenus anticus and the lower border of the first rib. The Guides.—The posterior border of the sterno-mastoid muscle is the superficial and the scalenus anticus the deep muscular guide. The first rib and its scalenus tubercle are the deep bony guides. The scalenus anticus muscle is inserted into the tubercle of the first rib, and the tubercle varies in its physical characteristics, being sometimes high and pointed and easily felt, at other times scarcely discernible, and again being imperceptible. Either artery may be ligatured at any one of its portions. The Ligature of the First Portion, Left Side.—This division has no definite superficial linear or muscular guide. The inner border of the sca- lenus anticus is important as leading to and being the outer limit of this portion of the vessel which, owing to its origin from the arch of the aorta and THE LIGATURE OP ARTERIES. 145 its great depth, is almost beyond the reach of a ligature. The close relation of the vessel to very important structures, the injury of which may be more grave than the condition calling for ligature of the vessel, renders the performance of the operation at this situation difficult and of questionable expediency. The Contiguous Anatomy. The Relations of First Portion of Left Subclavian Artery. (Gray.) In front. Pleura and left lung. Pneumogastric, cardiac, and phrenic nerves. Left carotid artery. Left internal jugular and innominate veins. Sterno-thyroid, sterno-hyoid, and sterno-mastoid muscles. Inner side. Trachea. (Esophagus. Thoracic duct. Outer side. Pleura. Left subclavian artery, first portion. Behind. (Esophagus and thoracic duct. Inferior cervical ganglion of sympathetic. Longus colli muscle and vertebral column. The Operation.—Place the patient on the back with the head extended and turned to the opposite side, the left shoulder well depressed ; make an incision three inches and a half in length along the inner border of the sterno-cleido-mastoid down to the sternum ; another, two inches and a half in length along the inner extremity of the clavicle, meeting the former near the trachea. It is seen that this incision is substantially the same as that for ligaturing the innominate artery (Fig. 199, d). The flap, consisting of Pig. 201.—Left subclavian vein and artery. the integument, superficial fascia, and platysma, is turned aside; one half of the clavicular portion of the sterno-mastoid and its whole sternal portion are then divided on a director, bringing into view the sterno-hyoid and sterno-thyroid muscles, and, to the outer side, the omo-hyoid. The sterno- thyroid and sterno-hyoid should be divided with great care after being liber- ated from the fascia which covers them. The inner edge of the scalenus 146 OPERATIVE SURGERY. anticus muscle is now sought for; when found, it will guide the finger directly to the vessel. The important contiguous structures are now drawn inward and*pressed away from the artery, using great caution to avoid the thoracic duct, which will be in the line of search, as it goes behind the jugular vein at its junction with the left innominate vein. The needle is carefully passed from before backward. The great depth of the vessel makes it difficult to pass the common needle, therefore the one with the adjustable extremity (Fig. 171) should be employed. The Results.—This portion was tied by Dr. J. Kearney Rogers in 1845; the patient died from secondary hsemorrhage on the fifteenth day. It has been ligatured successfully by Ilalsted in extirpation of a tumor, and by Schumpert for cure of aneurism.* The Ligature of the First Portion, Right Side.—The inner border of the anterior scalenus leads to this portion on the right the same as on the left side of the body (Figs. 200 and 201). This muscle may be called, there- fore, the deep muscular guide to this portion of the artery. The Contiguous Anatomy. The Relations of First Portion of Right Subclavian Artery. (Gray.) In front. Integument and superficial fascia. Platysma and deep fascia. Clavicular origin of sterno-mastoid muscle. Sterno-hyoid and sterno-thyroid muscles. Internal jugular and vertebral veins. Pneumogastric, cardiac, and phrenic nerves. Beneath. Pleura. S Right subclavian artery, i first portion. Behind. Recurrent laryngeal nerve. Sympathetic nerve. Longus colli muscle. Transverse process of seventh cervical or first dorsal vertebra. The Operation.—The position of the head and neck of the patient are re- versed in the operation, but the primary incisions and dissection are substanti- ally the same in this as in the preceding operation. The internal jugular should be pressed aside and the needle passed from below upward, and from be- fore backward, carefully avoiding the pleura, recurrent laryngeal, and phrenic nerves. The ligature of the vertebral and internal mammary arteries at the same time will lessen, it is believed, the danger of secondary haemorrhage. The Fallacies.—The right subclavian may arise from the arch of the aorta, when it will be more deeply situated ; it often passes behind the oesophagus, or between it and the trachea. As at the left, the artery may perforate the scale- nus anticus or pass in front of it, the vein being behind. It may rest on a cer- vical rib and be located higher, and be more prominent for this reason, or ex- tend an inch or so above the clavicle, or lie behind it even. The supra-scapular artery may take origin from the third portion instead of from the thyroid axis. * Medical Record, September 3, 1898. THE LIGATURE OF ARTERIES. 147 The Results.—The third portion has been ligated twenty-one times; nineteen of the cases proved fatal, of which eight died of haemorrhage. Clutton, of St. Thomas’s Hospital, cured an aneurism of the third portion of the subclavian by ligature with floss silk at the inner border of the scalenus anticus of the first portion, followed the next day by ligature of the first portion of the axillary artery.* Curtis, of New York, reports a case cured by ligature with two strands of catgut drawn sufficiently tight to occlude the lumen but not divide the inner coats of the vessel, f The Ligature at the Third Portion, Either Side. The Contiguous Anatomy. The Relations of the Third Portion of Subclavian Artery. (Gray.) In front. Integument and superficial fascia. Platysma and deep cervical fascia. External jugular, supra-scapular, and transverse cervical vein. Descending branches of cervical plexus. Subclavius muscle and supra-scapular artery and clavicle. Above. Brachial plexus. Omo-hyoid. Below. First rib. Subclavian artery, third portion. Behind. Scalenus raedius. The linear guide to the operation upon this portion of the vessel at either side is drawn just above and parallel with the upper border of the clavicle, between the posterior border of the sterno-cleido-mastoid and the ante- rior border of the trapezius muscle, and for convenience should be about four inches in length (Fig- 202, a). The Muscular Guides to the Artery, Second and Third Por- tions.—The second and third por- tions of the vessel have no direct superficial muscular guide. The deep muscular guide is the outer border of the scalenus anticus. The posterior belly of the omo- hyoid, while not in close contact with the artery, serves an import- ant purpose in directing the atten- tion of the surgeon to the artery. The situation of the outer border of the scalenus anticus is well in- Pig. 202.—Linear guides and spinal accessory nerve. * Medico-Chirurgical Transactions, vol. lxxx, 1897. f Annals of Surgery, April, 1898, p. 540. 148 OPERATIVE SURGERY. dicated by the lower part of the posterior border of the sterno-cleido- mastoid, provided the latter muscle be not uncommonly developed. The junction of the inner two inches of the clavicle with its outer portion is a far more unvary- ing indication of the approximate deep lo- cation of the outer border of the sca- lenus anticus than is the posterior bor- der of the sterno- cleido-mastoid mus- cle (Fig. 203). The Bony Guide. —The tubercle on the first rib, into which the scalenus anticus is inserted, is the bony guide to the vessel here, the artery being directly behind it. As al- ready stated, the tubercle varies considerably in its physical characteristics. The Operation. Third Portion.—Place the patient on the back with the shoulders elevated, head bent backward and turned to the opposite side. Draw the shoulder of the corresponding side firmly downward to the side of the patient, and retain it in that position. Compress the ex- ternal jugular vein above the clavicle long enough to cause its distention, thereby indicating its exact situation. The integument is drawn evenly downward and incised upon the clavicle, and it will, when allowed to retract, carry the incision upward to its proper situation—half an inch above the clavicle (Fig. 202, a); divide the superficial fascia and platysma on a director, being careful not to sever the external jugular, which can be either pulled aside or divided between two ligatures. The supra-scapular and transverse cervical veins should be treated in the same manner. The omo-hyoid is now sought for and drawn upward, if necessary, and the supra-scapular artery avoided. The deep cervical fascia is torn asunder by the director, and the outer border of the scalenus anticus felt for on a line with the outer margin of the sterno-cleido-mastoid, if the latter have not been divided ; if so, it should be located as described under the head of Muscular Guides to the Second and Third Portions of the Artery (page 147). If the head be turned forcibly to the opposite side, the scalenus anticus will be made tense and more prominent. When found, the muscle is followed downward along the outer border to the tubercle of the first rib, immediately behind which the pulsa- tion of the artery is felt. The vessel is now carefully exposed and the needle passed from before backward (Figs. 203 and 204). Great caution SUPRA-SCAPULAR VESSELS PECTORALIS MINOR Pro. 203.—Anatomy of the third portion of the right subcla- vian and right axillary arteries. THE LIGATURE OF ARTERIES. 149 should be taken not to interfere with the subclavian vein, which lies in front of and on a lower plane than the artery. The Fallacies.—The sterno-cleido-mastoid muscle may have an unusual breadth of origin from the clavicle, thereby causing the incision to be made too far posteriorly. Attention to the clavicular measurement (two inches from the sternal end) will prevent this error. The tubercle on the anterior surface of a transverse process of one of the lower cervical vertebrae may be mistaken for the tubercle of the first rib. This mistake, however, is easily rectified by remembering that the first rib extends downward and out- ward, and that neither pulsation nor the outline of the scalenus anticus is found contiguous to a transverse process. The tubercle of the first rib may be absent, then the muscular insertion into the rib must be relied upon as a guide to the vessel. Fig. 204.—Subclavian and external carotid arteries. The artery may perforate the scalenus anticus or pass in front of it, the vein being behind the muscle. It may rest on a cervical rib and be located higher, and be more prominent for this reason. It may extend an inch or so above the clavicle or lie behind it. The scapular arteries may come from the third portion instead of the thyroid axis. The artery may be in front of the tubercle and the vein behind it. The pulsation, as well as the anatomical appearances, will determine the inter- 150 OPERATIVE SURGERY. change of situations. The inner cord of the brachial plexus may be mis- taken for the artery. A little attention to the distinctive physical charac- teristics between nerves and arteries will quickly settle this doubt. The Results.—Two hundred and fifty cases are tabulated, of which one hundred and thirty-four, or fifty-three per cent, died. The Ligature of the Second Portion.—The linear and muscular guides are practically similar to those of the preceding portion. The Contiguous Anatomy. The Relations of Second Portion of Subclavian Artery. (Gray.) In front. Integument and superficial fascia. Platysma and deep cervical fascia. Sterno-mastoid. Scalenus anticus. Phrenic nerve. Subclavian vein. Above. Brachial plexus. Subclavian artery, second portion. Below. Pleura. Behind. Pleura and middle scalenus. The Operation.—The steps essential to arrive at the proper site in this instance are not varied from those given for the third portion until the outer border of the scalenus anticus is well determined; the phrenic nerve and subclavian vein should then be pushed aside and the muscle divided (Figs. 200 and 201), when the retraction of its fibers will expose the artery to view. The needle is then passed as before, closely hugging the artery to avoid the pleura below and posteriorly. The Remits.—Thirteen cases are reported, of which nine, or sixty-nine per cent, were fatal. Ligature of the Vertebral Artery.—The vertebral artery is rarely liga- tured, and then usually for purposes of problematical utility. The Anatomical Points.—The vertebral artery arises from the upper and back part of the first portion of the subclavian artery close to the inner border of the anterior scalenus muscle, passes directly upward along the anterior surface of the vertebral column, and enters the foramen in the trans- verse process of the sixth cervical vertebra. It then ascends through the foramina in the transverse processes of all the vertebrae above this, inclining outward and upward between the transverse process of the axis and atlas, and finally runs in a deep groove on the upper surface of the posterior arch of the atlas, and ascending pierces the posterior occipito-atloid ligament. The Contiguous Anatomy. The Relations of the Vertebral Artery. (Gray.) In front. Internal jugular vein and its sheath. Inferior thyroid artery. Thoracic duct (left side). Aponeurosis between longus colli and the scalenus anticus. Vertebral vein. THE LIGATURE OF ARTERIES. 151 Outer side. Scalenus anticus. Vertebral artery. Inner side. Longus colli. Behind. Cervical nerves. Vertebral column. The linear guide to the artery in the first situation is drawn from the junc- tion of the inner fourth with the outer three fourths of the clavicle to the posterior border of the mastoid process. This vessel has deep muscular and bony guides. The deep muscular guide is the inner border of the scalenus anticus, because the artery lies between it and the longus colli. The tuber- cle on the transverse process of the sixth cervical vertebra is the direct bony guide to the vessel. The vessel enters this process at a point just below the tubercle and the inner border of the scalenus anticus. Fig. 205.—The common carotid, vertebral, inf. thyroid, and facial arteries. The vertebral artery can be ligatured at three situations : 1, before enter- ing the vertebral canal; 2, between the atlas and axis; 3, between the atlas and the occipital bone. At the first situation about an inch and a quarter in length of the vessel is available for ligaturing. The artery can be tied at the first situation through an incision made either behind or in front of the sterno-mastoid. The former is practiced more frequently. The Operation at First Situation.—With the shoulders raised and the head turned to the opposite side as in ligature of the subclavian, an incision four inches in length is made through the superficial tissues along the ante- rior border of the sterno-mastoid down to the clavicle. This incision is carried carefully down to the deep cervical fascia, which is cautiously divided. The jugular vein in its sheath and the sterno-mastoid are drawn gently to the outer side, and, if necessary, the size of the wound is increased by a suffi- 152 OPERATIVE SURGERY. cient division of the fibers of the clavicular attachment of the sterno-mastoid muscle (Fig. 205). The deep connective tissue is separated with a blunt in- strument, and the interval between the scalenus anticus and the longus colli muscles is sought for. The head is now flexed sufficiently to permit the borders of the wound to be drawn widely apart; deeper structures are carefully drawn asunder, and the tubercle of the sixth cervical vertebra is located, below which the pulsations of the artery can be felt. The artery is exposed, and the needle is passed from within outward. The inferior thyroid artery, vertebral veins, and the thoracic duct on the left side are in front of the artery and should be carefully avoided. An incision at the poste- rior border of the sterno-mastoid affords perhaps better access to the vessel. The Precaution.—In exposing the vessel caution is exercised to prevent unnecessary injury of the sympathetic nerve, thus avoiding as much as possible the modification (contraction) of the corresponding pupil. It is proper to say that contraction of the pupil is so certain to follow ligature of the vessel that its occurrence is regarded as evidence of successful ligation. Mr. Alexander, whose experience in tying these vessels on the living sub- ject is greater than that of any other surgeon, describes his method of oper- ating in the following language : “ An incision three or four inches long is made in an upward and outward direction along the hollow which exists between the scalenus anticus and the sterno-mastoid muscles. The incision should begin just outside and on a level with the point where the external jugular vein dips over the edge of the sterno-mastoid muscle, or, if the vein is invisible, about half an inch above the clavicle. The external jugular vein is drawn inward with the sterno-mastoid muscle. The connective tissue now appearing, the wound is opened by a blunt director, until the scalenus anticus muscle, the phrenic nerve, and the transverse cervical artery are seen. It can not be too well remembered that the pleura is at the inner side of the wound, while below lies the subclavian artery. It is now only pecessary to separate the edges of the scalenus anticus and the longus colli muscles to see the vertebral artery lying in the space between them. The artery is gener- ally completely covered by the vein, which is drawn aside and the artery is then ligatured.” At the second situation the artery lies in a triangular space formed by the rectus posticus major and superior and inferior oblique muscles. It is covered by the rectus posticus major and the complexus muscles. ♦ The Operation at Second Situation.—With the head turned to the oppo- site side and inclined forward, make an incision three inches in length along the posterior border of the sterno-mastoid, beginning half an inch below the mastoid process. A second incision is then made, beginning at the upper fourth of the first one and carried backward and downward one inch. The splenius muscle appears as soon as the integument and fascia are divided and pulled aside. The fibro-muscular structure of the splenius is divided, its borders separated, the layer of fat that now appears is pushed aside by the finger or handle of the scalpel, and the vessel is seen; its branches are drawn aside together with those of the second cervical nerve, the artery isolated, and the needle passed from without inward. THE LIGATURE OF ARTERIES. 153 At the third situatioti the incisions are the same as in the preceding method, except that the first one begins half an inch above the mastoid process instead of half an inch below it. The skin, fascia, and splenius are divided as before, the occipital artery appears at the upper angle of the wound, and is held aside; divide the aponeurosis and cellular tissue, sep- arate the wound borders, enter the triangle, separate the fatty tissue, and the artery will be exposed. Pass the needle from behind forward. The Fallacy.—The vertebral arteries may enter the transverse processes of the fifth cervical vertebra, instead of the sixth. The Results.—These vessels have been ligatured forty-two times, in thirty- six of which three died—one each from haemorrhage, embolism, and pleurisy. When done for the cure of epilepsy, about twenty per cent were benefited, some of which it is claimed ultimately recovered. The permanent benefit derived thus far in such cases has not been sufficient to warrant the adoption of this measure for the treatment of epilepsy, and Dr. Alexander himself has ceased to advocate it for this purpose. Ligature of the Internal Mammary Artery.—The internal mammary artery is ligatured most frequently in connection with operations on the ribs. The Anatomical Points.—The internal mammary arises from the first portion of the subclavian. It descends behind the internal jugular and sub- clavian veins to the inner surface of the anterior wall of the chest, lying beneath the costal cartilages and about half an inch from the margin of the sternum. It can he ligatured in any of the five upper intercostal spaces. The Linear Guide.—A line parallel with and located about half an inch to the outer side of the sternum is a fair linear indication of the course of the artery. At this situation the vessel is midway between the borders of the costal cartilages. It has no muscular guide. The Operation.—Make an incision two inches in length along the upper border of a costal cartilage and rib. The integument, fascia, and pectoralis major musde are divided down to the intercostal muscles. Beneath the in- tercostal, surrounded by the connective tissue, the artery, accompanied by the venae comites, will be found. The vessel is isolated, and the needle care- fully passed to avoid penetrating the pleura. If the vessel be tied in the uppermost intercostal space, a single vein will attend it. Ligature of the Inferior Thyroid Artery.—The inferior thyroid artery is ligatured in operations on the thyroid body. The Anatomical Points.—The inferior thyroid arises from the thyroid axis, and passes in a somewhat irregular course upward and inward behind the sheath of the common carotid and internal jugular vein to the thyroid body. It passes in front of the vertebral artery and the longus colli mus- cle. The middle cervical ganglion rests upon it. The recurrent laryngeal nerve and the thoracic duct at the left side should be carefully avoided. The Contiguous Anatomy.—In front, the common carotid sheath and its contents, and the sympathetic nerve ; behind, the recurrent laryngeal nerve, the oesophagus, and the vertebral artery ; at the left side, if low in the neck, carefully avoid the thoracic duct. The linear guide to the operation is located along the anterior border of 154 OPERATIVE SURGERY. the sterno-mastoid, as for ligature of the common carotid. An approximate bony guide to the vessel is the body of the fifth cervical vertebra, opposite to which the artery enters the thyroid structure. The Operation.—Make an incision three inches in length along the inner side of the sterno-mastoid, as for ligature of the common carotid. The car- otid sheath and its contents, along with the sterno-mastoid, are drawn out- ward and the artery is found behind the carotid, running inward near the body of the fifth cervical vertebra (Fig. 205). The needle is passed from within outward, carefully avoiding the recurrent laryngeal nerve. The Fallacies.—The vessel may be double or absent; it may arise from the vertebral or common carotid. The Results.—The results are excellent, as no dangers attend the liga- turing other than those incurred by the manipulation necessary to reach the vessel. Ligature of the Axillary Artery.—The axillary artery is ligatured for rupture and for cure of aneurism more often than for any other reasons. The Anatomical Points.—The axillary artery begins at the lower bor- der of the first rib and extends to the lower border of the tendon of the latissimus dorsi. It gives origin to numerous branches and is intimately associated with the brachial plexus. This artery may be tied at three situa- tions—1, above the pectoralis minor; 2, behind ; 3, below that muscle (Fig. 203). The first and last situations, however, are the only ones at which the vessel can be practically secured without ligature of collateral branches. The Contiguous Anatomy. The Relations of the First Portion of the Axillary Artery. (Gray.) In front. Pectoralis major. Costo-coracoid membrane. External anterior thoracic nerve. Acromio-thoi’acic and cephalic veins. Outer side. Brachial plexus. Axillary- artery, first portion. inncr side. Axillary vein. Behind. First intercostal space, and intercostal muscle. Second and third serration of serratus magnus. Posterior and internal anterior thoracic nerve. The First Portion.—There is no linear guide to the vessel at this por- tion. The linear guide to the operation is located about half an inch below the lower border of the clavicle, extending from within an inch or so of the sternal extremity, outward three or four inches. The muscular guides are superficial and deep. The former is the space between the contiguous borders of the deltoid and pectoralis major muscles. The latter is the pectoralis minor, its upper border indicating the first por- tion, etc., as before stated. The vessel is rarely tied at this point on account of the great depth and the nearness to the seat of ligature of collateral branches. The third portion of the subclavian is tied instead. THE LIGATURE OF ARTERIES. 155 The Operation.—Place the patient upon the back, with the head turned to the opposite side; elevate the shoulder, and carry the arm a little distance from the side of the chest. Make an incision about four inches in length on the linear guide through the integument, fascia, and pla- tysma; separate the fibers of the pectoralis major from the deltoid, or divide those of the former muscle the full length of the wound (Fig. 206); tear apart the costo- coracoid fascia at the upper border of the pectoralis minor muscle; bring the arm to the side to relax this muscle, which is then drawn outward ; displace the areolar tissue carefully with a di- rector, then the vein will be seen, which should be carried downward and in- ward with a blunt hook, and the artery will be noticed beneath it and in close contact with the inner cord of the brachial plexus, which lies to its outer side and above. The needle is then passed from below upward. The cephalic vein, which empties into the axillary vein, should be cautiously avoided, as it passes between the borders of the pectoral and deltoid muscles to its termination. The Fallacies.—The inner cord of the brachial plexus may be mis- taken for the artery. If, before tightening the ligature, pressure be made upon the vessel, and the effect upon the radial pulse noted, this fallacy is eliminated. The vessel may be reached through an incision carried between the del- toid and pectoral muscles about three inches in length, which should con- nect with the one previously made at the lower border of the clavicle. The fat and cellular tissue can then be removed or displaced, as in the previous instance. The Results.—No definite records are given of the results of this op- eration. Tl\e Second Portion.—The artery can be ligatured at this situation through the preceding incision, or through the space created by separation of the contiguous borders of the deltoid and pectoral muscles. The pec- toralis minor is exposed, pulled downward, artery isolated, collateral branches tied, and main vessel ligatured in the usual manner. Ligature in the Third Position.— The linear guide to the artery at this portion is a dotted line extending upward into the axilla corresponding to the junction of the anterior and middle thirds of this space (Fig. 207). UPPER BORDER OF. PECTORALIS MINOR. \deep FASCIA (COSTO- CORACOID MEMBRANE) Fig. 206.—Ligature of axillary artery ; first portion. 156 OPERATIVE SURGERY. The Contiguous Anatomy. The Relations of the Third Portion of the Axillary Artery. (Gray.) In front. Integument and fascia. Pectoralis major. Inner head of the mediate nerve. Outer side. Coraco-brachialis. Median nerve. Musculo-cutaneous nerve. Inner side. Ulnar nerve. Internal cutaneous nerve. Axillary vein. i Axillary < artery, ( third portion. Behind. Subscapular is muscle. Tendons of latissirnus dorsi and teres major. Musculo-spiral and circumflex nerves. The Muscular Guide.—The inner border of the coraco-brachialis muscle. 1 Vie Operation (Fig. 207).—With the arm abducted and rotated out- ward, make an incision three inches in length along the inner border of the coraco-brachialis muscle in line of the arterial pulsation, observing that its center be placed above the anterior fold of the axilla, cautiously divide the superimposed tissues, draw the median nerve and the axillary vein to the inner side, and pass the needle from within outward. The Fallacies.—Large branches may be given off from the axillary at this situation, which will confuse the operator as to the identity of the ves- sel. Pressure made upon the vessel with the fingers prior to the tightening of the ligature will determine the influence of pressure on the circulation beyond. A nerve may be mistaken for the artery. The Results.—The results are favorable, since the operation implies in itself no particular danger to the patient. Ligature of the Brachial Artery.—The exposure to injury of the bra- chial artery calls for frequent ligaturing of this vessel. The Anatomical Points.—The brachial artery extends from the lower border of the tendon of the latissimus dorsi to about an inch below the bend of the elbow joint, and is closely associated with the veins and nerves of the arm. The Contiguous Anatomy. The Relations of the Brachial Artery. (Gray.) In front. Integument and fascia. Bicipital fascia, median basilic vein. Median nerve. Outer side. Median nerve (above). Coraco-brachialis. Biceps. Vena comes. Inner side. Internal cutaneous and ulnar nerve. Median nerve (below). V ena comes. Basilic vein (upper half). Brachial artery. Behind. Triceps. Musculo-spiral nerve. Superior profunda artery. Coraeo-brachialis. Brachialis anticus. THE LIGATURE OF ARTERIES. 157 The linear guide corresponds to the dotted line extending from the junction of the middle and anterior thirds of the axilla to midway between the apices of the bony condyles of the humerus (Fig. 207). The Muscular Guide.—At its upper third the artery lies at the inner border of the coraco-brachialis, at the middle third at the inner border of the biceps, and the lower third it lies at the inner border of the biceps ten- Fig. 207.—Ligature of axillary and brachial arteries. Exposure of the profunda. 158 OPERATIVE SURGERY. don. The brachial artery may he ligatured at three situations—at its upper, middle, and lower thirds. The Operation, Upper Third.—Abduct tbe arm and rotate it outward. Make an incision about three inches in length along the inner border of Fig. 208.—Transverse section of right arm at axilla. A. Cephalic vein. B. Pectoralis major. G. Biceps tendon. D. Musculo-cutaneous nerve. E. Internal cutaneous nerve. F. Median nerve. G. Basilic vein. H. Brachial artery. I. Ulnar nerve. J. Brachial vein. K. Musculo-spiral nerve. the coraco-brachialis muscle. The artery, being very superficial, is quickly reached (Fig. 208). The median nerve is drawn to the outer side, and the ulnar nerve and basilic vein to the inner side; separate the artery from the vein, and pass the needle from within outward. Jhe Operation, Middle Third.—Place the arm as before. Make an in- cision three inches in length along the inner side of the biceps muscle (Fig. 207, a). The median nerve is found lying upon and a little to the inner side of the vessel (Fig. 209). Push it aside, isolate the artery from the venae comites, and pass the needle in the same direction as before. The Operation, Lower Third (Fig. 210,/).—Abduct the arm and supinate the forearm. Compress the arm above to distend the median basilic vein. Make an incision about three inches in length along the inner border of the tendon of the biceps; draw aside the median basilic vein, and the artery will be felt pulsating beneath the bicipital fascia. A suitable-sized opening THE LIGATURE OF ARTERIES. 159 is now cut through this fascia (Fig. 211, E), the forearm partially flexed, the vessel separated from its veins, and the needle passed from within outward. The importance of the bicipital fascia in connection with flexion and pro- nation of the forearm should limit as much as possible any destructive inter- ference with it. The Fallacies.—The arteries of the forearm may come from the axil- lary, or the brachial may bifurcate high up, thereby increasing the number of the large vessels in the arm. This fact is determined by the compara- tive size of the brachial, and the influence of pressure on its circulation at the distal side of the proposed ligature. The brachial artery may run behind the inner condyle along with the ulnar nerve. If the artery be not in its normal site, deep pressure on the arm may detect arterial pulsation else- where, which, together with the effect of the pressure on the circulation be- yond, will determine the size and site of the vessel. Each of the pro- funda branches has been mistaken for the main vessel. The incision at the upper two thirds may be made too far inward, causing the surgeon to mis- take the ulnar for the median nerve. If the forearm be flexed and gentle Pig. 209.—Transverse section of right arm at the middle third. A. Superior profunda artery and veins. B. Museulo-spiral nerve. G. Cephalic vein. D. Musculo-cutaneous nerve. E. Brachial artery and veins. F. Median nerve. G. Internal cutaneous nerve. H. Basilic vein. /. Ulnar nerve. upward traction be made upon either, the course of the nerve will be deter- mined, and the danger of this will be easily avoided. The median nerve may pass behind the artery instead of in front of it; then, if the circulation from above be obstructed, the artery may escape 160 OPERATIVE SURGERY. BRACHIAL A. & VEN/E COMITES. MEDIAN N. -BICIPITAL FASCIA. BRACHIALIS ANTICUS Mr MUSCULO-CUTANEOUS Nr SUPINATOR LONGUS M.- -MEDIAN BASILIC V. i INT. CUTAN. N. TENDON OF BICEPS. RADIAL A. WITH VENfE COMITES. RADIAL N.- I FLEXOR SUBLIMIS DIGIT. M. lFLEXOR CARPI ULNARIS M. [FLEXOR PROFUNDUS DIGIT. M. ULNAR A. -ULNAR N. SUPINATOR LONGUS M.- PRONATOR RADII TERES Mr FLEXOR CARPI RADIAL IS Mr RADIAL A. WITH VEN/E COMITESr -ULNAR N. -ULNAR A. -FLEXOR SUBLIMIS DIGIT. M. ■FLEXOR CARPI ULNARIS M. RADIAL /V.„ FLEXOR LONGUS POLLICIS M.. SUPINATOR LONGUS Mr TENDON OF FLEXOR CARPI RADIAL IS: RADIAL Ax *ULNAR N. yULNAR A. 'ANT. ANNULAR LIG. TENDON OF FLEX.CARP.ULNAR1S. -PISIFORM BONE. -PALMARIS BREVIS M. TENDON OF FLEXOR CARPI RADIALIS. EXTEN.OSStS AND PRIMI INTERNODII POLLICIS. SUPERFIDIALIS VOL/E A Fig 210.—Ligature of radial and ulnar arteries. THE LIGATURE OF ARTERIES. 161 notice. The artery not infrequently lies deeply between the brachialis an- ticus and biceps muscles. Anomalous muscular slips and unusual muscular development may ob- scure the artery in its normal course. In such instances the pul- sation will determine the location. Occasionally, espe- cially in female sub- jects, when the upper extremity is markedly concave on its outer surface, due to an un- usual length of the in- ternal condyle, the pri- mary incision may be made unintentionally to the outer side of the vessel. If, however, it be made midway between the apices of the bony condyles, ir- respective of the over- hanging soft parts,this error will not arise. The Results.—The brachial artery has been ligatured seventy-six times for haemorrhage, with fifty-five recoveries. Ligature of the Radial Artery.—The radial artery on account of the exposed position is frequently injured. The Anatomical Points.—It arises from the brachial, is an apparent continuation of it, and is superficial in its entire route. The Contiguous Anatomy. Fig. 211.—Transverse section through the right elbow joint A. Radial nerve. B. Cephalic vein. C. External cuta- neous nerve. D. Median vein. E. Brachial artery and veins. F. Basilic vein. (I. Internal cutaneous nerve. II. Median nerve. I, J. Ulnar nerve. K. Ulnar vein. The Relations of- the Radial Artery. (Gray.) In front. Integument—superficial and deep fascias. Supinator longus. Inner side. Pronator radii teres. Flexor carpi radialis. Outer side. Supinator longus. Radial nerve (middle third). Radial artery- in forearm. Behind. Tendon of biceps. Supinator brevis. Pronator radii teres. Flexor sublimis digitorum. Flexor longus pollicis. Pronator quadratus. Radius. 162 OPERATIVE SURGERY. The linear guide (Fig. 210) to this vessel is drawn midway (dotted line) between the apices of the bony condyles of the humerus to the inner side of the extremity of the styloid process of the radius. The muscular guide, at the upper portion, is the inner border of the belly of the supinator longus muscle, beneath which the vessel usually lies. At the lower portion of the course it lies at the inner side of the tendon of the same muscle. The pulsation of the vessel at the wrist is the best practical guide to it in this location. In fact, it is only when abnormali- ties in size or situation occur at this position that the other guides are taken into serious consideration in the living subject, and under these cir- cumstances they are of but little aid to the operator. This same statement will apply with equal force to all arteries that are similarly associated with the superficial structures of the body. While the artery may be ligatured in any portion of its course, it is, how- ever, usually ligatured at three situations—at the upper and lower thirds, and at the apex of the styloid process. The Operation, Upper Third (Fig. 210, a).—Supinate the forearm ; press upon the arm above the seat of operation to distend the superficial veins; make an incision about three inches in length along the linear guide to the vessel. After going through the fascise, the inner edge of the supinator A. Posterior interosseous nerve. B, F. Radial veins. (7. Anterior interosseous vessels. D. Radial nerve. E. Radial artery and veins. O. Ulnar vein. II. Median nerve. I. Ulnar nerve. J. Ulnar artery and veins. Pig. 212.—Transverse section of right forearm at upper third. longus will be found extending beyond the line and overlapping the artery; separate and pull this muscle outward, when the artery will be seen lying THE LIGATURE OF ARTERIES. 163 between its veins, with the nerve to the radial side (Figs. 212 and 213); iso- late the artery, and pass the needle from without inward. Pig. 213.—Transverse section of right forearm at middle third. A. Anterior interosseous artery, veins, and nerve. B. Tendon of extensor carpi radialis longior. G. Radial nerve. D. Pronator radii teres. E. Radial artery and attend- ing veins. F, G. Superficial radial veins. H. Median nerve. I. Palmaris longus. J. Ulnar artery, veins, and nerve. K. Superficial ulnar vein. L. Extensor longus pollicis. The Operation, Lower Third, Upper and Lower Limits (Fig. 210, b, c).— At these situations the vessel is very superficial, its well-known pulsation be- ing the best guide to it. With the arm placed as in the preceding position, make an incision, in either instance, two inches in length along the course of the vessel. After the division of the integument and fascias the artery will be seen surrounded by loose areolar tissue, accompanied by its veins, and lying to the inner side of the tendon of the supinator longus. Separate the tissues and ligature the artery, passing the needle from the nerve. The Operation at Apex of Styloid Process (Fig. 214).—At this situation the vessel is found in a triangular-shaped space, bounded internally by the tendon of the extensor primi internodii pollicis, externally by that of the extensor secundi internodii pollicis, and the base corresponding to the apex of the styloid process of the radius. If the thumb be forcibly extended, the outlines of the space will be well marked. The Operation.—Place the hand midway between supination and pro- nation, and, having ascertained the exact situation of the tendon of the ex- tensor primi internodii pollicis, make an incision near to its outer border about an inch in length; use care not to divide the superficial veins. The areolar tissue and the extensor primi internodii pollicis are pulled aside, and the vessel found somewhat deeply situated. The needle can be carried in either direction. 164 OPERATIVE SURGERY. The Fallacies.—The radial artery may lie upon the fascia and supinator longus instead of beneath them; it may pass over the extensor tendons of the thumb instead of beneath them. The artery may be mis- taken for a radicle of the radial vein. The latter is superficial, and has likewise other character- istics of a vein. In ligaturing the vessel at either of the last two positions sheaths of contiguous tendons will be opened if incau- tious vigor be exercised. The Results.—During the late civil war the radial artery was tied twenty times, with four fatal results. Ligature of the Ulnar Artery. —The ulnar artery is less fre- quently injured than the radial, and requires therefore less opera- tive interference than the latter. The Anatomical Points.—The ulnar artery is larger than the ra- dial. It is given off from the brachial about one inch below the bend of the elbow, passes oblique- ly inward and downward deeply beneath the superficial flexors of the forearm, and gains the ulnar side of the forearm a little above its middle; becoming more superficial, passes along the radial side of the flexor carpi ulnaris to the radial side of the pisiform bone, where it terminates in the superficial palmar arch. The Contiguous Anatomy. Iig. 214. Ligature of radial at apex of styloid proces.. The Relations of the Ulnar Artery. (Gray.) In f ront. Superficial layer of flexor muscles. ,, ,. • Median nerve. Upper half. Inner side. Outer side. Superficial and deep fasciae. Lower half. Flexor carpi ulnaris. Ulnar nerve (lower two thirds)- Ulnar artery in forearm. Flexor sublimis digitorum. Behind. Brachialis anticus. Flexor profundus digitorum. The linear guide to the lower two thirds of the vessel is drawn from the apex of the internal condyle (Fig. 210 *) to the radial side of the pisiform bone. The muscular guide is the radial border of the flexor carpi ulnaris. THE LIGATURE OP ARTERIES. 165 The vessel may be ligatured at three situations: 1, At the junction of the upper and middle thirds; 2, at the lower third ; 3, at the wrist. It can be ligatured at its upper third, but such a step has no practical utility except when required on account of a direct injury of this portion of the vessel; it is then tied at the seat of injury. The Operation, Junction of Middle and Upper Thirds (Fig. 210, a).— Supinate the forearm, and make an incision on the linear guide to the vessel, beginning at about four finger breadths below the internal condyle of the humerus, about three inches in length. Divide the fascia on a director; seek for a line of connection between the borders of the flexor carpi ulnaris and the flexor sublimis digitorum. It is of a yellowish-white color. Divide it in the long axis and pull the muscles apart, when the ulnar nerve will be seen, to the outer side of which will be found the artery with its accom- panying veins; separate the artery and pass the needle from within out- ward. The Operation in the Loiver Third (Fig. 210, b).—Place the forearm as in the preceding operation; extend the hand to make the tendon of the flexor carpi ulnaris tense; make an incision about three inches in length along the radial border of this muscle down to the fascia. Divide the fascia, exposing the tendon of the flexor carpi ulnaris, which is drawn inward, and the artery is seen beneath it. Isolate the vessel from its veins and pass the needle from within outward. The Operation at the Wrist (Fig. 210, c).—Place the hand on its dorsal surface, and make an incision about two inches in length along the radial side of the pisiform bone, with its convexity outward; carry it downward along the side of that bone through the fascia and fatty tissue to the vessel. Flex the hand and pass the ligature from within outward. • The Fallacies.—For an operation wdthout special gravity the ligaturing of the vessel at the upper portion is attended with confusing circumstances that often defeat the object of the surgeon. Between the upper and middle thirds, the interspace between the flexor carpi ulnaris and flexor sublimis digitorum muscles may be mistaken for that between the flexor carpi ulnaris and the palmaris longus muscles, or the one between the palmaris longus and flexor carpi radialis. The “white” or “yellowish-white” interspace between the proper muscles may be indistinct, and even absent. It is best marked in muscular subjects; least observable and most frequently absent in aged and emaciated persons. The upper extremity of the linear guide should begin at the apex of the internal condyle. If the carpus and fingers be moved independently of each other after the division of the integument and fasciae, the septum between the flexor carpi ulnaris and the flexor sub- limis digitorum muscles can be easily ascertained. In the upper third the vessel runs downward and inward to the ulnar side of the forearm to meet the linear guide of the lower two thirds; there- fore an attempt to find the artery by the linear guide, in the upper third, will be futile. The artery may run beneath the fascia, or otherwise vary in its direction; if it be not in the normal situation, deep pressure may locate its presence and define its course. 166 OPERATIVE SURGERY. The Results.—The ulnar artery was ligatured during the late war ten times, with three deaths. Ligature of the Palmar Arches.—The superficial and deep palmar arches are liable to injury from traumatic violence, and it is from this cause that ligature of them is principally demanded. The free communication of the arches with other arteries through their numerous branches greatly exposes the patient to the danger of secondary haemorrhage. The Contiguous Anatomy. The Relations of the Superficial Arch. (Gray.) In front. Integument. Palmaris brevis. Palmar fascia. Superficial palmar arch. Behind. Annular ligament. Origin of muscles of little finger. Superficial flexor tendons. Division of the median and ulnar nerves. The Linear Guide.—The linear guide to the superficial arch is a line ex- tending across the palm di- rectly along the palmar bor- der of the thumb when ab- ducted to a right angle with the index finger (Fig. 215). This line indicates the low- er limit of the arch. The deep arch is from half to three quarters of an inch nearer the wrist joint than the superficial one. The Operation. — Make an incision an inch in length at the seat of the injury, parallel with the nerves and tendons of the palm, through the superimposed tissue down to the vessel. Ligature all bleeding points, and also all uninjured branches arising close to the seat of the in- jury of the main vessel, to avoid the possibility of sec- ondary luemorrhage. The deep palmar arch is treated in a similar manner. However, a greater degree of caution is necessary, for the vessel is more intricately and deeply placed than is the former. Fig. 215.—The palmar arches. THE LIGATURE OF ARTERIES. 167 Irrespective of the seat of the injury the superficial palmar arch can be exposed through an incision extending from the junction of the thenar emi- nences toward the ring finger. The deep palmar arch can be tied opposite the middle of the base of the thumb through an incision beginning at the junction of the thenar eminences and extending along the crease of the opponeus pollicis toward the little finger. The Precautions.—All incisions should be carefully made in the long axis of the palm, to avoid as far as possible injury of subjacent nerves, tendons, and arteries. Branches arising immediately adjacent to the seat of ligature should be tied, to afford room for the establishment of proper blood clots in the ligatured vessel. If the vessel be injured, it should be tied at either side of the seat of injury. Ligature of the Common Carotid Artery.—The common carotid artery is the most important vessel in the neck, and frequently demands operative procedure. The Anatomical Points.—The right common carotid arises from the in- nominate artery, and the left from the arch of the aorta. The left is con- sequently longer and more deeply situated in the chest. The left, after leaving the aorta, passes obliquely upward to a point opposite the left sterno- clavicular articulation; and from this point onward the right and left com- mon carotids maintain substantially the same course to the upper border of the thyroid cartilage, where each divides into the internal and external carotids. The Contiguous Anatomy. The Relations ok the Common Carotid Artery. (Gray.) In front. Integument and fascia. Omo-hyoid. Platysma. Descendens noni nerve. Sterno-mastoid. Sterno-mastoid artery. Sterno-hyoid. Superior thyroid, lingual, and facial veins. Sterno-thyroid. Anterior jugular vein. Externally. Internal jugular vein. Pneumogastric nerve. Internally. Trachea. Thyroid gland. Recurrent laryngeal nerve. Inferior thyroid artery. Larynx. Pharynx. Common carotid artery. Behind. Longus colli. Sympathetic nerve. Rectus capitis anticus major. Inferior thyroid artery. Recurrent laryngeal nerve. The linear guide to the vessel is a line drawn from the sterno-clavicular articulation to midway between the angle of the jaw and mastoid process. The muscular guide to the operation is the anterior border of the sterno- cleido-mastoid muscle. 168 OPERATIVE SURGERY. Each vessel may be ligatured at three situations: 1, At the root of the neck ; 2, just below the omo-hyoid muscle; 3, above that muscle. The last two are the situations commonly selected, the first not being employed ex- cept under forced requirements. The Operation below the Omo-hyoid (Fig. 216, 1).—Place the patient on the back, with the shoulders slightly elevated, and the head turned to the opposite side; make an incision three inches in length, beginning a little above the level of the cricoid cartilage, on the line stated, and carry it down- Fia. 216.—Ligature of common carotid artery. ward along the anterior border of the sterno-mastoid (Fig. 199, c); divide the superficial fascia, platysma, and deep fascia on a director, thus expos- ing the anterior border of the sterno-mastoid muscle. If the sterno-mastoid artery be divided, ligature it. If not injured, push it aside, together with the thyroid vein; draw the sterno-mastoid muscle outward and the sterno- thyroid and hyoid muscles inward, then the lower border of the omo-liyoid will be seen above; divide the fascia beneath these muscles and draw the borders apart, when the descendens noni nerve will be seen resting upon the inner portion of the common sheath of the carotid artery, internal jugular vein, and the pneumogastric nerve, the artery being to the inner side, the pneumogastric nerve behind and between the two and out of sight. Place the finger upon the sheath, to ascertain the exact location of the artery ; raise the portion of the sheath corresponding to the site of the artery at the inner side with a tenaculum or the thumb forceps, cut a small opening into it, grasp and hold apart the borders with thumb forceps, and pass the needle from without inward, cautiously insinuating it between the vessel and the sheath (Fig. 21G, 1). The manipulation should be carefully done, else either the vein, pneumogastric, or recurrent laryngeal nerves may be injured. The Operation above the Omo-liyoid (Fig. 216, 2).—The vessel is more THE LIGATURE OF ARTERIES. 169 superficial here than below the omo-hyoid, and this situation is therefore de- nominated “ the site of election.” Place the patient as before, and make an incision along the anterior border of the sterno-mastoid, beginning at about the angle of the lower jaw, and ex- tending it to a little below the cricoid cartilage (Fig. 199, b); divide the super- ficial fascia, platysma, and deep fascia on a director, carefully avoiding the small veins; expose the anterior border of the sterno-mastoid, and slightly flex the head to relax the tissues of the neck ; draw the edges of the wound apart, and the artery will be felt pulsating in its sheath. If the jugular vein over- lap it, the vein should be emptied by pressure made above and below, and be drawn outward; then carefully open the sheath as before, avoiding the de- scendens hypoglossi nerve; pass the needle cautiously from without inward. It is well to observe the upper border of the omo-hyoid muscle before opening the sheath, so that the exact location to apply the ligature may be assured. The Fallacies.—The artery may bifurcate at the cricoid cartilage, and even lower; however, this bifurcation is extremely rare; under such cir- cumstances both branches should be secured. If the vessel be pressed upon before the ligature is tied, the pressure will determine the influence of the ligaturing upon the branches above, and thus obviate an error of application. The jugular vein may be much dilated, overlie and receive the impulse of the artery, and therefore be mistaken for it. This fallacy will be avoided if the vein be emptied of its blood in the manner before described. The thyroid body may be enlarged and obscure the artery by displacing or over- lapping it. Under these conditions it should be pushed aside. It is re- ported that the omo-hyoid muscle has been mistaken for the artery; the fact of its being muscular, taken in connection with the direction of the fibers, together with its anatomical relations, should eliminate any liability of this mistake. A large branch arising from the main trunk may be mis- taken for the external carotid. However, the comparative size of the vessel and the influence of pressure on the circulation of the branch will effectually solve the question. If branches be given off from the common carotid near the site of the proposed ligaturing, they should be tied also. A broad sterno-mastoid may cause confusion by the placing of the inci- sion too far inward ; if narrow, or the head be turned far outward, the mus- cle may again misdirect the incision, this time to the outer side of the vessel. Kespiratory movements of the tissues of the neck, inflammatory processes, morbid growths, and dilated veins, each contribute more or less to the difficulties of the occasion. It should not be overlooked that liga- ture of the common carotid for haemorrhage from either the internal or external divisions will not likely be effective, on account of the free commu- nication of these two vessels at the point of bifurcation of the main trunk, to say nothing of the collateral flow from the opposite side. The Results.—This vessel has been tied seven hundred and eighty-nine times for various reasons, of which three hundred and twenty-three, or about forty-one per cent, have died. Ligature of Both Common Carotids.—Ligature of both common carot- ids, either simultaneously or at variable intervals, has been done thirty-six 170 OPERATIVE SURGERY. times. The shortest interval between operations in which recovery has taken place is four and a half days. Instances where the interval varied from thirteen to thirty days are reported, with recovery of the patients. Temporary Ligature of the Common Carotid.—The carotid may be tem- porarily ligatured. The procedure has been resorted to bv Rivington and others, with the view of arresting heemorrhage arising from branches of the common carotid without exposing the patient to the dangers of brain compli- cations incident to permanent closure. The operation consists in exposing the vessel in the usual manner and passing around it a broad catgut or other ligature, which is tightened or raised sufficiently to close the lumen of the vessel and arrest haemorrhage. A ligature then may remain in place two or three days, then be removed without subsequent trouble. If in troublesome bleeding during operation a ligature is passed around the vessel that supplies blood to the operative field, and raised from time to time sufficiently to con- trol the blood current, finally being removed, much blood will be spared and valuable time gained. Ligature of the External Carotid Artery.—The external carotid artery is tied at one or both sides to prevent the free loss of blood that so often attends operations within the field of its supply. The fear of secondary hemorrhage can not be urged in opposition to the measure if the collateral branches near to the seat of the ligature be tied at the same time. The author has practiced this plan repeatedly, and with eminent success in each instance but one. In this one the facial arose from the common carot- id, just below the bifurcation, and the patient died from secondary haemor- rhage, caused by sloughing of a malignant growth in which the facial was involved, and for the amelioration of which both external carotids had been tied simultaneously. The Anatomical Points.—The external carotid artery arises from the common carotid at or just above the upper border of the thyroid cartilage. It ascends in a slightly curved course, with the convexity forward, to a point midway between the neck of the condyle of the lower jaw and the external auditory meatus. The upper part of its course lies in the substance of the parotid gland. The Contiguous Anatomy. In front. Integument, superficial fascia. Platysma and deep fascia. Hypoglossal nerve. Lingual and facial veins. Digastric and stylo-hyoid muscles. Parotid gland, with facial nerve and temporo-maxillary vein in its sub- stance. The Relations of the External Carotid. (Gray.) Behind. Superior laryngeal nerve. Stylo-glossus. Stylo-pharyngeus. Glosso-pharyngeal nerve. Internal carotid artery. Parotid gland. Internally. Hyoid bone. Pharynx. Parotid gland. Ramus of jaw. THE LIGATURE OF ARTERIES. 171 The linear and muscular guides are substantially the same as those of the common carotid. The bony guide is the greater cornu of the hyoid bone, which lies to the inner side of the vessel, above the bifurcation of the common carotid and near to the origin of the lingual artery. If pressure be made on one side of the hyoid bone the greater cornu will be made prominent on the opposite side and easy of determination. The artery may be tied at two situations: above and below the posterior belly of the digastric muscle. The latter situation is the one to be selected, if possible. The Operation beloio the Digastric Muscle.—With the patient on the back, head slightly extended and turned to the opposite side, make an in- cision along the anterior border of the sterno-mastoid, beginning opposite the angle of the lower jaw, and carry it downward to a point nearly opposite the cricoid cartilage (Fig. 202, b). Divide the superficial fascia, platysma, and deep fascia, and expose the anterior border of the sterno-mastoid. The edges of the wound should be drawn well apart, when the hypoglossal nerve and the digastric and stylo-hyoid muscles will come into view (Fig. 204). The end of a grooved director should now be employed to separate and push aside the lingual and facial veins, together with the areolar tissue and lymphatic glands that rest upon the vessel. Expose the artery and pass the ligature from without inward. The internal jugular vein ofttimes overlaps the vessel, and should be carefully drawn aside, or treated as recommended in ligaturing the common carotid. The Precautions.—Before the ligature is tied the following facts should be carefully observed : 1. If it be the external carotid around which the ligature is passed, this can be ascertained by raising the ligature and observ- ing the effect upon the circulation of the facial. 2. The distance of the seat of the ligature from collateral branches; this fact can only be determined by carefully exposing the vessel for half an inch or so above and below the seat of the ligature. If vessels be found within this extent, they, too, should be ligatured independently to destroy the possibility of any interference with the formation of the internal clot. 3. That the ligature be not carried around the external and internal carotids at or just above their point of bifurcation; if it be around both, pressure or traction will check the pulsa- tion of both; if but one, it will control only the circulation of the vessel acted upon. The Fallacies.—Enlarged lymphatic glands resting on the vessel may be mistaken for it. They need cause but momentary thought, since their cir- cumscribed outline and mobility will determine their nature. If enlarged, they should be removed, otherwise they can be pushed aside. The superior thyroid branch may be confounded writh the lingual. If the course of the respective vessels be observed, they can be readily distinguished from each other; the superior thyroid arises nearest the bifurcation, arches upward and forward, then passes quite directly downward. The lingual does not arch downward, but passes upward and inward to gain the upper border of the greater cornu of the hyoid bone, which can be easily outlined by the finger. 172 OPERATIVE SURGERY. The Operation above the Digastric.—Make an incision from the lobule of the ear to the greater cornu of the hyoid bone, along the anterior border of the sterno-mastoid, carefully avoiding the parotid gland. Divide the super- imposed tissues as before, down to the digastric muscle; pull it, together with the stylo-hyoid, downward, and if the jugular vein be in the way, push it outward, and pass the ligature from without inward. The Results.—The external carotid has been ligatured one hundred and thirty-one times, with four deaths from the operation. Ligature of the Internal Carotid Artery.—The internal carotid artery is tied sometimes at either side of the bleeding point, to arrest haemorrhage due to ulceration or to injury of its walls. The Anatomical Points.—The internal carotid begins at the bifurcation of the common carotid, at or a little above the upper border of the thyroid cartilage, and passes perpendicularly upward in front of the transverse processes of the three upper cervical vertebras, to the carotid foramen in the petrous portion of the temporal bone, through which it enters into the cranial cavity. At its origin and in the lower portion of its course it is comparatively superficial, and lies externally and posteriorly to the external carotid artery. The Contiguous Anatomy. The Relations of the Internal Carotid Artery. (Gray.) In front. Skin, superficial and deep fascia1. Platysma. Parotid gland (above the angle of the jaw). Stylo-glossus and stylo-pharyngeus muscles. Glosso-pharyngeal nerve. Hypoglossal nerve. Externally. Internal jugular vein. Pneumogastric nerve. Internally. Pharynx. Superior laryngeal nerve. Ascending pharyngeal artery. Tonsil. Internal carotid artery. Behind. Rectus capitis anticus major. Sympathetic. Superior laryngeal nerve. The linear and muscular guides of the external carotid artery are suita- bly adapted to properly locate the internal carotid. The angle of the jaw is located directly externally to the tonsil, and it therefore may become a practical bony guide to the incision for ligaturing the artery in this situation. Although it may be ligatured in any part of the course between its origin and the angle of the lower jaw, still the point of election is that just above the bifurcation. It may become necessary to ligature this artery on account of a penetrating wound received from without or from within the mouth. Ulcerations of and operations on the tonsils have been complicated with injuries to this vessel that have caused death THE LIGATURE OF ARTERIES. 173 from haemorrhage. It is therefore very important to recall the relations of the tonsil and pillars of the pharynx to this artery, in connection with all injuries and morbid processes of their structures. The Operation.—The position of the neck of the patient and the location of the primary incision are similar to those for the ligaturing of the external carotid. The respective tissues are carefully divided on a director down to the muscles, which are separated and pulled aside, and the ligature is passed from without inward, carefully avoiding the jugular vein and the pneumo- gastric nerve at the outer, and the pharynx at the inner side. The Fallacies.—The internal carotid may arise from the arch of the aorta, and when this occurs haemorrhage from it can be checked only by ligaturing the internal carotid itself. If but one ligature be applied to the internal carotid for haemorrhage, or if the common carotid be ligatured alone for the same reason, the collateral circulation may cause a continuation of the bleed- ing. A ligaturing of the internal carotid at both sides of the bleeding point is the only certain means of arresting the haemorrhage permanently. The internal carotid may lie internal to the external carotid. It may be tortuous, or even be absent. The Results.—This vessel has been tied singly three or four times; with either the common or external carotid, or both, fifteen times. Six of these patients died, but from causes demanding the procedure. According to recent investigations cerebral sequels cause death in fifteen per cent of the cases. Ligature of the Superior Thyroid Artery.—The superior thyroid is liga- tured in the removal of some morbid growths and for the arrest of bleeding due to direct injury of the structure. The Anatomical Points.—The superior thyroid vessel comes from the external, or from the common carotid near the point of its bifurcation. It passes upward and forward, at first quite superficially, then runs downward and less superficially to enter the thyroid gland. The artery is closely asso- ciated with the superior laryngeal nerve. The vessel may be absent, single, or double in arrangement. The Operation.—Make an incision about three inches in length along the anterior border of the sterno-mastoid, its center corresponding to a point opposite the thyro-hyoid space. The carotid sheath should be exposed as in the ligature of the carotid, and the artery sought for along the inner bor- der (Fig. 204). The ligature is applied near to the origin of the vessel or close to the larynx, the latter being the better situation. Cautiously avoid the superior laryngeal nerve. Ligature of the Lingual Artery.—The lingual artery is ligatured more often to control haemorrhage during removal of the tongue than for any other purpose. The Anatomical Points.—The lingual artery arises from the external carotid opposite the hyoid bone, about three quarters of an inch above the bifurcation of the common carotid, and runs upward and inward to about a quarter of an inch above the upper border of its greater cornu, passes hori- zontally inward parallel with it, resting upon the middle constrictor of the 174 OPERATIVE SURGERY. pharynx, and covered first by the digastric and stylo-hyoid muscles, and more internally by the hyoglossus muscle. It then ascends between the hyoglossus and genio-hyoglossus muscles, and terminates in the ranine artery. It has no superficial muscular guide ; a linear gu ide may be drawn paral- lel with and a fourth of an inch above the greater cornu of the hyoid bone (Fig. 202,/); practically, however, the upper border of the greater cornu of the hyoid bone marks its location. The vessel can be ligatured at three situations: 1, At the apex of the greater cornu ; 2, between the greater cornu and the posterior belly of the digastric; 3, in the triangle made by the digastric and mylo-hyoid muscles and hypoglossal nerve. The Ligature at the First Situation.—In this situation the vessel is tied between the point of origin and the tip of the greater cornu of the hyoid bone (Figs. 204 and 217). The Operation.—Make an incision three inches in length running ob- liquely downward and forward as for ligature of external carotid, its center corresponding to the greater cornu. The various tissues are carefully divided, as for ligature of the external carotid, and the hypoglossal nerve is exposed. The numerous veins located in the course are now pushed aside, and the artery carefully sought for at the point of the cornu and ligatured. This operation, on account of the absence of a definite deep guide to the location of the vessel, and the uncertainty of its point of origin, together with the great number of large veins in the course of the search, is much less feasible than either of the other two. While ligature at this portion controls the circulation of the dorsalis linguae, yet the difficulty attending the step is in excess of the advantages gained by its employment. The Ligature at the Second Situation.—Place the patient on the back, and turn the head to the opposite side; carefully define the greater cornu of the hyoid bone. If the neck be fleshy this will be somewhat difficult. The cornu can be made more prominent on the side of the operation by pushing against the body of the bone on the opposite side, being careful to press the bone directly toward the cornu, otherwise the operator may be misled. After the patient is thoroughly anaesthetized (to prevent spasmodic movements of the muscles attached to the hyoid bone) make a slightly concave incision just above and along the upper border of the greater cornu of the hyoid bone, downward and outward to nearly the anterior border of the sterno- mastoid muscle, about three inches in length (Fig. 202, /). Divide the superficial fascia, platysma, and deep fascia on a director; drawr upward the submaxillary gland and divide the deep aponeurosis transversely, when the digastric and stylo-hyoid muscles and the hypoglossal nerve will be exposed. Accurately locate the greater cornu with the finger, and fix and drag it forward into the wound with a tenaculum ; draw up the digastric and the stylo-hyoid muscles and hypoglossal nerve with a blunt hook; push aside the lingual vein if seen, and pick up the fibers of the hyoglossus with forceps, and incise them for three quarters of an inch in the direc- tion of the external incision, about a quarter of an inch above the greater cornu; beneath them will be found the vessel, sometimes accompanied by the lingual vein. Ordinarily the vessel will “ elbow ” itself into the incision THE LIGATURE OF ARTERIES. 175 as soon as all the intervening muscular fibers are divided (Fig. 217). Pass the needle from the vein. Before tying ascertain if traction on the liga- ture will stop the pulsation of the artery. Fig. 217.—Ligature of lingual artery. First and second situations. The Ligature in the Third Situation.—The third situation is often called “ the place of election.” Make an incision transversely two inches long, concavity upward, and its center just within the middle of the greater cornu of the hyoid bone. Divide the integument, superficial fascia, and platysma, carefully avoiding the superficial veins; sever the deep fascia and pull upward the submaxillary gland, when the posterior belly of the digastric will come into view, as will also the posterior border of the stylo-hyoid muscle, the mylo - hyoid muscle, and the hypoglossal nerve, accompanied usually by the lingual vein (Fig. 218). Carefully outline the triangle before men- tioned ; pinch up the fi- bers of the hyoglossus, and divide them midway between the hyoid bone and the nerve, when the artery will be seen be- neath. Separate it from the vein if the vein lie beneath the muscle, and pass the ligature from above downward. The Fallacies.—The hypoglossal nerve may be mistaken for the artery. The nerve rests on the hyoglossus, the artery runs beneath it. These facts, together with the pulsation of the artery and other distinctive anatomical features, should render the discrimination easy. It is well to know, however, Fig. 218.—Ligature of lingual artery. Third situation. 176 OPERATIVE SURGERY. that the movements of the tissues dependent on the acts of respiration make it somewhat difficult, and often impossible, to detect the arterial impulse. If, however, the supposed artery be carefully isolated, the ligature passed around it, and a good light thrown into the wound, its tortuous outline will be noticed with each pulsation. The pulsation can be seen best in the inter- val of the respiratory acts when the tissues are quiet. However, firm fixation and forward traction of the cornu by means of a tenaculum will prevent movements of the tissues, render them superficial, and otherwise greatly aid in the exposure, recognition, and ligature of the vessel. The lingual vein may be mistaken for the artery, especially in old people with heart lesions, as in old age the coats of the vein are usually much thick- ened, and pulsation in the vein may attend heart disease. The vein some- times runs with the artery behind the hyoglossus muscle; more frequently, however, it rests on this muscle. It has the characteristic color of a vein, and is larger than the artery. The lingual artery may be absent, run higher than common, or lie in the structure of the hyoglossus. After the division of the fibers of the hyoglossus muscle the search for the vessel must be con- ducted cautiously to avoid opening into the pharynx. If the vessel can not be found above the cornu, and ligation be imperative, it should be sought for at the origin. The Results.—This artery has been tied repeatedly with great advantage, for the purpose of controlling haemorrhage from the tongue and delaying the development of morbid growths of that structure. Ligature of the Facial Artery.—The facial artery is one of the large branches of the external carotid, and is divided into a cervical and facial part. The Anatomical Points.—The artery arises just above the tip of the greater cornu, or about an inch from the bifurcation of the common carotid, passes forward and upward beneath the horizontal ramus of the lower jaw, going through the substance of the submaxillary gland, and gains the ex- ternal surface of the ramus at the anterior inferior angle of the masseter muscle, lying there in a groove at the outer border of the bone. The masse- ter, therefore, is the muscular guide at this portion of the course of the vessel. It may be ligatured at three situations—in the neck, and as it crosses the ramus of the jaw and near the angle of the mouth, the second being the best situation. The Operation in the Neck.—The head is turned to the opposite side, and an incision of about three inches in length is made obliquely downward and forward a little in front of the anterior border of the sterno-mastoid, its center being at a point about a third of an inch above the tip of the greater cornu (Fig. 204). The dissection is carefully made, as in ligaturing the lingual at the first portion, by pushing aside the facial and other contiguous veins, drawing up the digastric, and passing the ligature. The Operation at the Ramus of the Jaw.—Place the patient as before; draw the integument upward over the ramus, so that when retraction of the tissues occurs the cicatrix will fall beneath the jaw; make an incision about two inches in length along the border of the jaw; divide the tissues on a THE LIGATURE OF ARTERIES. 177 director (Figs. 202, c, and 205) down to the vessel, isolate it, and pass the ligature from behind forward away from the vein. If a resulting cicatrix be of no moment, the primary incision can be made in the long axis of the vessel along the anterior inferior angle of the masseter muscle (Fig. 202, c). It is rarely tied at the angle of the mouth (Fig. 272). The Fallacies.—At its origin this vessel may be mistaken for the lingual. Interruption of the circulation will easily make the distinction if the respec- tive areas of supply be examined. Ligature of the Temporal Artery.-r-The temporal artery is one of the terminal branches of the external carotid. The Anatomical Points.—The temporal artery begins in the substance of the parotid gland between the neck of the lower jaw and the external meatus, and passes upward across the root of the zygoma, subcutaneously, where its pulsation can be distinctly felt. About two inches above the zygomatic process it divides into its terminal branches. This artery has no muscular guide. The zygomatic process is the bony guide. The Operation (Fig. 202, d).—Make an incision in the line of the vessel, as indicated by its pulsation, an inch in length ; about one fourth of an inch in front of the tragus divide the skin and fascia; avoid the vein lying be- hind the artery, the temporo-facial nerves lying in front, and the auriculo- temporal nerve beneath the vessel; expose the vessel and pass the needle from behind forward (Fig. 272). Ligature of the Occipital Artery.—The occipital artery is often severed in injuries of the scalp. The Anatomical Points.—The occipital artery arises from the external carotid a trifle above the facial, and passes upward and outward to the inter- val between the transverse process of the atlas and the mastoid process of Fig. 219.—Occipital artery and great occipital nerve. the occipital bone. It then passes over the posterior portion of the skull midway between the external occipital protuberance and the mastoid process 178 OPERATIVE SURGERY. (Fig. 202, e). It has no intimate bony or muscular guide. It is tied at its origin and behind the mastoid process. The Operation at the Origin (Fig. 204).—Make‘an incision along the anterior border of the sterno-mastoid, about three inches in length, the cen- ter corresponding to a point a little above the apex of the greater cornu of the hyoid bone. Divide the superficial tissues carefully on a director, sepa- rate the areolar tissue with its blunt extremity, push aside the veins, and find the posterior belly of the digastric. A little below will be seen the ninth nerve winding around the object of search. Pass the needle from the nerve. The relation between the hypoglossal nerve and the vessel is constant, irrespective of the deviations from normal in other regards of either of these structures. Very rarely, indeed, the occipital artery arises from the internal carotid. The Operation behind the Mastoid Process (Fig. 219).—Make a transverse incision about two inches in length, beginning half an inch behind and a little below the mastoid process and extending inward. Divide the integu- ment and attachments of the sterno-mastoid and the splenius muscles; feel for the pulsation at the bottom of the wound. Isolate the artery and pass the ligature. CHAPTER V. OPERATIONS ON VEINS, CAPILLARIES. ETC. Veins and capillaries often require vigorous treatment, not only for the purpose of arresting haemorrhage, but also to remedy the troublesome and distressing symptoms and the unsightly deformities that arise from unusual development incident to obstructed circulation and telangiectatic growth. Veins are ligatured principally to arrest haemorrhage and cure phlebectasy. The Ligature of Veins.—Veins, like arteries, may be ligatured in their continuity or at their divided extremities. Large venous branches, when divided in the course of an operation, should be tied, otherwise they may give rise to an objectionable amount of bleeding, w’hich will hinder the operator, interfere with the rapidity of union, and possibly require reopening of the wound to arrest haemorrhage. If a large vein—as the internal jugular, the femoral, etc.—be nicked during an operation, a ligature may be thrown around it, above and below the opening, or the nicked portion only may be sewed or tied. Tying the opening exposes the patient to greater danger of secondary haemorrhage than does sewing, especially if the catgut ligature be applied. A fine, firm silk ligature is better for this purpose, as it can be more securely tied. The practice of sewing the divided borders with fine catgut, is highly extolled by many writers. The application to a cut in a vein of a ligature is followed quite surely by thrombosis and closure of the vessel. The repair by suture in the manner of intestinal sewing is not often followed by a similar result. If it be determined to tie the vessel, it should be done above and below the wound, otherwise troublesome haemorrhage may follow. In the instance of complete ligature of the femoral vein, it is advised that the femoral artery be not ligatured at the same time. The Results.—In fifty-one cases of ligature of the internal jugular, six died of secondary haemorrhage, the result of infection. With complete asepsis but little danger attends the procedure. According to Braun, death from secondary haemorrhage followed lateral ligature of the internal jugular in three of twelve cases. In one case each of the external jugular and subclavian veins and in five of the axillary all re- covered. In eight of lateral ligature of the femoral, six died—five caused by pyaemia. Simultaneous ligature of the femoral vessels in twenty-four cases was followed by gangrene of the limb in fourteen. In twenty-five instances of ligature of the vein alone gangrene did not occur. Operations for Varicose Veins.—When the veins of the lower extremities and elsewhere become too much distended to be amenable to palliative meas- ures, it is often necessary to resort to operative interference, with the view of 179 180 OPERATIVE SURGERY. occluding the distended canals. Injection, acupressure, ligaturing, and ex- cision are the common means employed for this purpose. Injection.—The vein is compressed at points an inch or less above and below the seat of operation with the fingers, or by small pads confined in position with adhesive plaster. The latter plan is the better. Before the injection is introduced the selected portion of the vein is emptied by diver- gent pressure of the fingers upon the vessel, after which it is allowed to fill again. The emptied portion is allowed to fill from below—not from a col- lateral branch—and then the operation is completed by injecting slowly into the isolated portion twenty or thirty drops of a twenty-per-cent solution of subsulphate of iron and water. Almost immediately the contents of the vessel become coagulated, when the limiting pressure can be removed. The patient should be kept quiet for a few days, and any tendency to undue in- flammation combated. It is wise to remember that portions of the vein hav- ing collateral branches should not be injected for fear of embolism. This method is rarely employed. The Results.—Of the one hundred and three cases some time since reported, seventy-nine were cured, one died, and of the remainder, sixteen were failures. Acupressure.—Acupressure is applied here in substantially the same man- ner as for arresting the circulation of arterial trunks (page (il). Thoroughly purified needles or pins, which may or may not have been constructed for the purpose, are carried beneath the vein at intervals of an inch or so, and caused to compress the superimposed tissues by means of carbolized silk or cotton yarn wound over their protruding ends. The pins are removed on the sixth or seventh day, depending on the degree of ulceration produced. Caution should be observed that the pins be not passed through instead of beneath the vein, or a serious phlebitis may follow. Subcutaneous Ligaturing.—Subcutaneous ligaturing is employed less now than formerly. It is best applied to veins of the lower extremities, and the use should be supplemented with vigorous antiseptic measures. The location of the veins can be indicated by marking the integument over them with iodine, while they are fully distended by upright posture, or by obstruction of the return circulation with the patient in the recumbent position. The latter method is the better, because it brings the vessels more directly under command and reduces the liability of their puncture or the involvement of contiguous important structures to a minimum. The Operation.—Pass a common straight or curved sterilized needle, armed with a catgut ligature, beneath the vein, through the skin, causing it to emerge at the opposite side of the vessel, then re-enter the needle at the point of emergence, pass it in front of the vein, after which the direc- tion is changed so as to carry it in front of the vessel and out at the point of entrance. The ligature is tied, cut short, and the wound treated antisep- tically. Often these ligatures are applied at intervals of an inch or so the entire length of the dilated vessel. The limb is then surrounded with anti- septic dressing, elevated somewhat, and the patient kept in bed for a week or ten days, and longer if indications demand it. If the blood in the inter- OPERATIONS ON VEINS, CAPILLARIES, ETC. 181 vening spaces becomes necrosed, giving rise to fluctuation, it should be evacuated. If ligature abscesses appear, the offending ligatures should be removed and the suppurating foci kept well cleansed. A special straight or curved unthreaded needle, with an eye at the end provided with a handle, is admirably fitted for this purpose (Fig. 220). The needle is threaded after Pig. 220.—Keyes’ needle for treatment of varicocele. the passage, behind and in front of the vessel respectively, and the ligature placed by its withdrawal in each instance; thus a prompter and better ap- plication of the ligature is secured than by the former implement. The Precautions.—In the subcutaneous ligaturing of veins, as the long and short saphenous, the accompanying nerves may be accidentally included in the ligature. However, if the vein be drawn forward (Fig. 194, e,f) away from the nerve and the needle passed as closely as possible to the vessel, but little trouble will result from their association. In many instances it is difficult to properly outline the dilated vessels, owing to their depth and tortuous course, and in such cases the passage of the needle is followed by brisk haemorrhage, notwithstanding the great caution exercised in the insertion. The lack of surgical precision in the application of the ligature, the fre- quency of stitch-hole abscess and increased temperature following it, are strong objections to the method, as they suggest the possibility of phlebitis and thrombotic infection—complications that are reported to have ensued and been followed by death from pyaemia in rare instances. The Results.—As yet there is no good reason known to us to regard this method as less annoying or more effective than treatment bv excision. Incision and ligaturing (excision) is a wise plan of treatment in all in- stances, more especially in those cases where the veins are tortuous or ill de- fined. The dilated vessels are exposed by incision along the course of greatest tortuosity, tied above and below, excised, and the wound closed in the usual manner. Many authorities advise excision as preferable to any other method of treatment. The writer has simultaneously tested on several occasions, as far as possible, the comparative worth of this and the preceding method on the same patient. The recovery was prompter, the pain and annoyance less in the limb subjected to the latter method in every instance. The final re- sult can not yet be estimated. The ligature of the internal saphenous vein (Trendelenburg), near to the saphenous opening, is advised for the cure of varices involving the branches of this vessel. Ligaturing the vessel relieves it of the pressure of the column of blood below the point of tying, and thereby permits the restoration of vas- cular tone. The experience in this measure thus far encourages the belief that it is entitled to further trial, since it promises to become one of the rational methods of treatment of varicosities at this situation. As in all oper- ations on veins, strict asepsis should be practiced. The wound is closed, the extremity wrapped in cotton, snugly bandaged, and immobilized for ten days. The fact, as reported, that pad pressure on the saphenous vein (Landerer) 182 OPERATIVE SURGERY. cures the discomfort in ninety per cent of the cases emphasizes the impor- tance of ligaturing the vessel. In the experience of the author this method is unreliable in those cases with free communication between the superficial varices and deeper venous circulation, and for apparent reasons. Ferguson ties the saphenous vein at two points near the femoral and cuts out a section, then makes a semilunar incision through the skin, from the lower part of the thigh along the inner side of the leg, forming a flap which overlies the varicosities. The incision is deepened, the vessels severed and tied, the flap turned over, the normal and abnormal veins and their branches dissected away, the flap restored, borders united, the limb dressed and confined as before. Schede makes a circular incision around the leg down to the veins, which he exposes for a distance above and below by means of circular flaps. The vessels are tied between two ligatures, the portions excised, the flaps replaced, borders united, and limb dressed and confined as usual. The long and short saphenous nerves should not be divided, if possible to avoid them. Venesection.—Although venesection can hardly be classed as an operation of much moment, in a surgical sense, yet the infrequency of its employment at the present time is apt to render a knowledge of the details connected therewith somewhat uncertain in the minds of a majority of the practitioners of the present generation. The veins selected for the procedure are the in- ternal saphenous at the ankle, the median basilic, or median cephalic at the bend of the elbow, and the external jugu- lar vein. The instruments re- quired for the purpose is the ordinary thumb lancet, or a curved or straight sharp-pointed bistoury. The first, however, possesses the greatest number of traditional virtues. If the region of the elbow be selected, the median cephalic vein is pre- ferred, on account of its greater distance from the brachial ar- tery and the posterior relation to cutaneous nerves. The arm should be constricted by a band- age drawn sufficiently tight to obstruct venous return without interfering with arterial circu- lation ; this will cause the veins to appear prominently distend- ed, unless the patient be very fleshy, in which case the sense of touch must be relied on to indicate the exact situation of the vessel. The vein should be well defined by the finger, and held in position by the thumb or finger placed just below the point of Fig. 221.—Opening the vein with scalpel. OPERATIONS ON VEINS, CAPILLARIES, ETC. 183 incision. After thorough cleansing, the incision is made obliquely to the transverse diameter of the vein, and of sufficient depth to freely open the vessel without severing it (Fig. 221). The flow of blood may be increased by causing the patient to grasp firmly a stick or broom handle; it may be impeded by the interposition of the subcutaneous fat, which should be pushed aside. The amount of blood taken will be regulated by the strength of the patient, whether he be standing or lying, and by the demands for de- pletion. If standing or sitting, the effects will be sooner felt than if in a recumbent posture. Usually, however, from half a pint to a pint will suffice. The flow is arrested by removing the bandage above and applying the finger to the bleeding point, after which a small aseptic compress is placed over the incision, and confined in position by adhesive plaster so arranged as not to impede the venous return. If the external jugular vein be selected, the compress is placed just above the clavicle, and confined in position by a bandage carried under the oppo- site axilla. The pressure is then applied to the vessel above the point of proposed incision, and the vessel is opened at a right angle with the fibers of the platysma myoides muscle. The finger must always be placed on the incision before the compress is removed, in order to prevent the entrance of air into the circulation. Transfusion.—Transfusion is a means employed to overcome the exhaustion caused by disease and shock from the loss of blood. In the latter, however, it is of the greatest practical utility. Blood, defibrinated blood, and saline solu- tions are employed to meet the demands of transfusion. The employment of saline solutions has, however, superseded almost entirely the use of blood. Transfusion with blood consists in conveying the blood from one person to another, either directly, or by collecting it in a suitable receptacle, remov- ing the fibrin, and introducing the plasma and corpuscles. The dangers are the introduction of air, blood-clots, and too great a quantity of blood. From six to eight ounces are usually sufficient, and this amount should be thrown in slowly and carefully, watching the effects upon the circulation, respiration, and sensorium of the patient. If the administration causes a depression of the pulse, or gives rise to nervous tremors or difficulty of breathing, the introduction should cease at once. The blood to be trans- fused should be taken from a person of strong physique and free from any constitutional taint. Direct Transfusion from Arm to Arm (Immediate Transfusion).—The requirements for this method are an apparatus for the transmission of the blood from arm to arm, together with a forceps and a scalpel to open the vessels, and a basin of water or saline solution at a temperature of about 105° F., into which the apparatus should be laid to give to it the requisite warmth and exclude the air. The arm of the donor and receiver are con- stricted above the point selected for incision, as in phlebotomy. The integu- ment covering the distended vein is pinched up, transfixed, and cut through, leaving the vessel exposed at the bottom of the wound. Each vein is then seized in turn with a forceps, and a Y-shaped opening made into it with the scissors for the purpose of introducing the tube (Fig. 222). The tube C 184 OPERATIVE SURGERY. (Fig. 223) is then taken from the basin, and, with the thumb applied to its larger extremity to keep it filled and thus exclude air, it is inserted into the opening in the vein of the receiver, directed in the course of the flow. The tube B is inserted in like manner into the vein of the donor, di- rected against the venous cur- rent, after which the pro- pelling power—the bulbs—like- wise filled with fluid, are at- tached to the two tubes; the fluid contained in the instru- ment is thrown into the circula- tion by squeezing the bulb 1, while the tube B is compressed. After the bulb 1 is emp- tied, and before it is permitted to ex- pand, the compression should be changed from B to C. If the bulb be now allowed to expand, it will be- come filled with the blood of the donor, which can be injected into the circulation as in the preceding in- stance. The capacity of the bulb should be known; it should be allowed to fill slowly, and the amount introduced is estimated by counting the number of times it is emptied. After the opera- tion is completed the incisions are treated the same as in phlebotomy. The instrument devised by Fryer is cast whole, with an additional bulb, which does away with the metallic couplings, and presents a smooth surface to the blood current; and, moreover, the additional bulb saves time by producing Fig. 222. Introducing the tube in transfusion. Fig. 223.—Fryer’s transfusion apparatus. an almost continuous current. It will be seen that a funnel is added to this instrument, which allows it to be employed in mediate transfusion. OPERATIONS ON VEINS, CAPILLARIES, ETC. 185 In venous transfusion the vein of the receiver may be tied with two ligatures in the following manner : Tie the distal one, open the vein, intro- duce the tube, then tie the proximal one, including the tube; in the donor the proximal ligature is tied first, and the distal last, including the tube ; this will prevent all loss of blood. Mediate transfusion is the col- lection of the blood in a vessel, and the injection of it, as in the direct method, into the circula- tion, either with or with- out the re- moval of the fibrin. For this purpose the instrument devised by Collins (Fig. 224) can be espe- cially recommended. It consists of a pump attached to a funnel in such a manner as to discharge the blood readily and without danger of coagulation or the introduction of air. This instrument can be used equally well with defibrinated and with unwhipped blood; with the latter it is particularly convenient, since the blood can be caught in the funnel and injected while flowing from the donor, which saves time and avoids the blood changes induced by exposure. In the use of this and all other implements brought in contact with the blood the temperature of the instrument and of the blood injected should be kept at 100° F. by means of warm water or a warm saline solution. If defibrinated blood be em- ployed, it should be collected in a vessel of the temperature stated, prepared by agitation (Fig. 225), then strained (Fig. 226) into the funnel of the instrument, and pumped into the vessel. The introduction into the fun- nel or the bulbs of two or three ounces of a saline solution, or of a carbonate-of-ammonia solution, four to six grains to the ounce, prevents the entrance of air into the instrument, and also has a stimulating effect upon the patient. Fig. 224. Collins’ instrument. Fig. 225.—Removing fibrin. 186 OPERATIVE SURGERY. Injection of Saline Solutions.—The introduction into the veins or the arteries of various saline solutions, the chief ingredients of which are com- mon salt and carbonate of soda, is highly recommended. Szumann recommended the fol- lowing : I£ Water, sterilized... 32 ounces; Common salt drachm ; Carbonate of soda. 15 grains. M. Heat to 110° or 112° F. The outfit devised by Dr. W. T. Bull for saline injection is an ad- mirable one (Fig. 227). The ordi- nary fountain syringe with a small tube attachment meets the require- ments promptly and well. In no instance should the fluid be thrown in rapidly, a half to three quarters of an hour being taken for the pur- pose. A simple and prompt method of practicing saline transfusion is de- scribed by Dr. Dawbarn. The saline solution is quickly prepared by add- ing a heaped teaspoonful of table salt to a quart of warm boiled water. The method requires “an ordinary Davidson’s syringe, an ordinary soft-rubber catheter, or a small rubber drain- age tube and an ordinary hypodermic needle—large size preferred, though this is not essential.” After thorough aseptic preparation, the needle is pushed slowly into the radial, posterior tibial, or femoral artery until arterial blood appears at the outer extremity, the catheter is then slipped over the base of the needle and tied, the nozzle of the syringe is inserted into the eye of the catheter, the needle is held firmly in place, and the fluid is pumped slowly and cautiously into the arterial current. A fountain syringe elevated six feet will answer the pur- pose equally well. A pint of this fluid can be thus introduced within half an hour. If the shock from loss of blood be profound, it is ad- vised that the fluid be as hot as the hand can well bear (118° F.). In any event the temperature of the fluid should be not less than 110° F. Fig. 226.—Straining the blood. Fig. 227.— Bull’s apparatus for injection of saline solutions. OPERATIONS ON VEINS, CAPILLARIES, ETC. 187 The Fallacies.—The needle may not enter the vessel, or it may be uncon- sciously withdrawn from it. Under either of these conditions the injected fluid will cause distention of the connective tissues adjacent to the point of puncture. If the salt be omitted, the effect of the water on the blood cor- puscles will quickly kill the patient. If minute foreign bodies be present in the fluid, the needle may become obstructed; therefore, the fluid should be strained before it is used. The introduction of air into the circulation will not happen with the use of a fountain syringe, but care should be taken or air will be introduced with the use of Davidson’s, especially if the valves be defective; then the instrument should be immersed in a saline solution while in operation. The saline fluid will become cooled before it is en- tirely used, unless the vessel containing it be placed in another filled with fluid kept still hotter than this by frequent additions of boiling water. Subcutaneous injection of saline fluid is frequently practiced independ- ently of the preceding method of use, and supplemental to it. A pint or two in divided portions can be injected at different situations into the con- nective tissue of the thighs, or in the female beneath the breasts (Kelly), accompanied by rubbing with the hand to disperse the fluid, for the pur- pose of relieving shock. If time will permit, only sterilized fluids should be employed and antiseptic methods practiced in other respects. Saline fluids seem to meet the indications of transfusion quite as well as blood, are easily obtained, and do not expose the patient to many of the dangers attendant on the use of the latter. Copious eneniata of warm saline fluid, carried high up into the large intestine by means of a tube, are now employed frequently in cases of shock from loss of blood of a lesser degree than that calling for its injection into the tissues and vessels. Arterial transfusion has been advocated on the basis that it conveys the blood more equably to the heart, and therefore with less danger of exciting undue disturbance of the circulation. The admission of a small amount of air does no great harm, and the danger of phlebitis is avoided. The vessel selected should be the radial at the wrist or the posterior tibial at the ankle, either one of which is exposed, and three ligatures are placed around it at a little distance apart; the distal one is tied, and the proximal one tightened sufficiently to interrupt the circulation in the vessel. The vessel is now opened and the tube inserted and tied in position by the third or middle ligature, then the proximal one is loosened and the fluid injected into the circulation. ' It is better to inject the fluid against than with the natural flow of the blood current, to avoid over-distention of the capillaries. As soon as the injection of the fluid is completed the proximal ligature is tied, and the intervening portion of the vessel removed along with the tube. Arterial transfusion is practiced less often than venous. Permanent dilata- tion of the walls of the artery, and even sloughing of the soft parts, have fol- lowed the practice. Kelly no longer employs it in females, but advises submammary infusion instead. Operations on the Capillaries.—The capillary system of vessels, like the venous, may undergo dilatation of sufficient degree to create distinct but slowly developing and painless deformities and tumors. The morbid process 188 OPERATIVE SURGERY. is limited usually entirely to the capillaries of the integument; however, the deeper and larger vessels are not infrequently involved also, not only at the beginning, but during the development of the growth. These growths vary in situation, size, shape, and color. The simplest variety is known as the “ mother’s mark,” “ birthmark,” etc. A birthmark can be treated by pressure, caustics, hot needles, vaccina- tion, and galvano-cautery, depending upon its size and situation and the fancy of the operator. It is not well to interfere at all in early life except by simple means, unless the growth increases rapidly in size. The majority of these growths will disappear of themselves before their presence becomes a source of annoyance or regret to the possessor. There are, however, sev- eral means which will often hasten their departure—as the use of simple compresses, repeated application of collodion, or vaccination if the birth- mark be located suitably for the act. The following method, introduced by Dr. Squire, which seemed likely at one time to meet the desired end in the great majority of cases, can be employed : The “ mark ” is frozen with an ether spray, and numerous superficial parallel incisions are made about one sixteenth of an inch apart, and the whole is covered with blotting paper, which is pressed upon with sufficient force to prevent any gaping of the cuts or haemorrhage; after fifteen or twenty minutes the paper is thoroughly wet with water and removed. Some- times a thin underlying clot of blood will be found ; this must be washed away carefully with water aided by a soft brush, and the part dressed asep- tically. When it is necessary to repeat the operation the incisions should be made at right angles to the previous ones. In simple cases and with proper care a perfect cure is secured by this method, without scarring. The injection of ergot, the solution of subsulphate of iron, and various other astringents, has been recommended. They are, however, uncertain in their action, and are liable to be followed by inflammation, ulceration, and sometimes by embolism. The solutions can be injected by the ordinary hy- podermic syringe, three or four drops at a time, in various portions of the growth. This method can not be commended. The use of red heat around the base and over the surface of the growth by means of the Paquelin cau- tery is an admirable method, provided the growth involves the skin alone or only the capillaries in the tissue immediately beneath it. If vigorously ap- plied it is usually followed by more or less disfigurement, depending, of course, upon the degree and extent of the cauterization. Needles heated to a marked degree of redness, either by electricity (see Fig. 102) or the ordinary means, are admirable agents of cure in pronounced cases. They are thrust into the vascular growths and allowed to remain until the tissues and fluids adjacent to them are cooked, after which they are carefully withdrawn and inserted as before at another part of the growth. The number of insertions is controlled by the size, vascularity, and situation of the abnormality. Usually five or six introductions will suffice, and these should be made at the border rather than at the center of the growth, the idea being to establish a cure by gradual encroachment from the border rather than by direct attack. OPERATIONS ON VEINS, CAPILLARIES, ETC. 189 The Comments.—Needles heated by electricity are far better agents of treatment. A needle should be introduced and removed slowly and cautiously, as a rapid introduction will bend and destroy it. A rapid removal will often cause unnecessary haemorrhage on account of the adherence to the needle of the cooked tissues that environ the point of puncture. The pa- tient should be kept quiet for a few days after the employment of galvano- puncture, and the seat of the operation should be treated antiseptieally. Subcutaneous Ligaturing.—If the naevus be of large size, persistent, of a dark color, and markedly elevated, it is of suitable nature for the employ- ment of subcutaneous ligature. Subcutaneous ligaturing is performed in several ways, depending not a little on the size and shape of the tumor and the fancy of the operator. Fig. 228 represents a simple method. In this the needle, armed with a strong, well-earbolized silk or catgut ligature, is thrust beneath the integument at the base of the tumor and carried subcutaneously as far as possible around the base, and then passed out through the integument, to be again introduced at the point of exit and carried still farther around and pushed through as before, and so on until the needle is caused to emerge at the point of primary insertion. The ends of the ligature are then tied in a firm, hard knot. Fig. 229 represents a double ligature carried through the base of the growth and divided ; each portion of the ligature is then carried subcuta- neously around half of the base and tied independently of the other part. This method of procedure is applicable to growths having large bases. Fig. 230 represents the application of the ligature to quarter sections of the Fig. 228. By a single ligature, Fig. 229. By a double ligature. Fig. 280. Ligation in quarter sections. base. It is employed in still larger growths. Pass a double ligature through the center of the base, cut the loop near the middle, leaving one end of the divided thread in the eye of the needle ; then, after threading the needle besides with the other end emerging at the opposite side which cor- responds to that portion of the ligature which was liberated by the division of the loop (Fig. 231), pass it through the base at right angles to the pri- mary course. Before tightening the ligature the integument in the course of constric- tion should be deeply incised, not only for the purpose of avoiding the pain and ulceration incident to the pressure, but also to allow the proper adjust- ment of the constricting agents (Fig. 232). It will simplify the discrimi- nating and tying of the extremities if one half the ligature be colored before the primary introduction. Fig. 233 represents the ligation of a growth with an elongated base. In this instance a double colored ligature is required, 190 OPERATIVE SURGERY. which is passed through the base from side to side, commencing and ter- minating just outside the extreme limits of the growth; if the white loops be now divided on one side and the black on the other, independent sets of ligatures will be formed, which should be firmly tied after the skin falling Fig. 231. Quarter sections, second step. Fig. 232. Tying ligature. Fig. 233. Ligature of elongated base. within the grasp of each ligature has been first incised. The separation of the growth is hastened by the use of a rubber ligature applied in a similar manner. The introduction into the vascular growth of threadlike setons which are charged with a solution of subsulphate of iron from time to time, and drawn into the vascular structure with the view of causing coagulation of the fluid contents, is advised, and thus far the results of this method of treatment justify its further employment. It is open to the same objection as the introduction of constringing fluids by other means—the liability of infection from the presence of the opening in the integument for the pas- sage of the threads. Division and Ligature.—Cirsoid growth of the scalp can be successfully treated by making a free incision outside and nearly around it, down to the periosteum, leaving that portion of the growth that contains the largest vessel undisturbed to form a pedicle to nourish the flap. The flap is raised and all bleeding points are tied, after which it is kept separated from its for- mer bed by antiseptic gauze until the surfaces granulate. The surfaces are then apposed and soon unite, thus destroying the growth without loss of substance. If the pulsations in the flap continue for four or five days, the dilated vessel entering it should be tied at a distance from the pedicle. The haemorrhage attending the operation is controlled to a degree during the primary operation by a strong rubber band passed around the head, be- neath which compresses corresponding to the course of the main vessels that supply the scalp are placed. The bleeding can also be arrested by direct pressure against the underlying bone; yet, notwithstanding these means, the loss of blood may be quite severe, and the operation should not be attempted if the patient be already exsanguinated or otherwise debilitated. Care should be taken to form a pedicle of sufficient width to nourish the flap; from half an inch to an inch, depending on the size of the flap, has, in the author’s experience, been ample for the purpose. If the dressing be ap- plied too firmly, the integrity of the flap will be endangered. The author has practiced this method in three cases of cirsoid change of the vessels of the scalp with prompt and entire success. In one instance—involvement of the occipital—the loss of blood during the operation was considerable but not alarming. CHAPTER VI. OPERATIONS ON THE NERVOUS SYSTEM. The brain, spinal cord, and the nerves arising from the cerebro-spinal axis, together with their coverings, are often the seat of important surgical procedures addressed to the relief of traumatic and pathological conditions that not infrequently affect these tissues. The delicate nature of the tis- sues and their important functions demand not only cautious manipulation, but also the strictest aseptic technique. Chronic Hydrocephalus.—Tapping the ventricles for the purpose of re- moving the fluid incident to this disease is as yet the only operative pro- cedure to which it is amenable. The tapping is done with a small trocar or aspirating needle, and often the needle is supplemented by the aspirator it- self. In either instance the puncturing agent may be introduced through the anterior fontanelle close to its outer bor- der to avoid the lon- gitudinal sinus, and passed perpendicular- ly into the fluid, cau- tiously avoiding the cerebral lobes when possible (Fig. 234). If the fontanelle be closed the fluid is reached through a small trephine open- ing made at one of various situations. In the selection of a site for entry, the motor zone, the Sylvian fis- sure on account of the meningeal and mid- dle cerebral arteries, and the sense centers generally, should be avoided. Also the dangers of punc- ture of a vein lying on the surface of the brain should be anticipated by careful scrutiny of the part after opening the dura. The situation usually chosen for tapping is at a point one inch and a quarter above and the same distance be- hind the external auditory meatus, as drainage is thus facilitated by depend- Fig. 234.—Antero - posterior section of the head half an inch from the median line. It. Fissure of Rolando. I. Inion. A and B. (Solid) lines of puncture, the dotted lines showing their imaginary continuation to the fixed points. 191 192 OPERATIVE SURGERY. ent position (Keen). If the trephine be placed a half inch higher the lateral sinus is more surely avoided. Also a point an inch and a half above the meatus is advised (Fig. 254, II). The puncturing agent, after the dura has been incised sufficiently to admit it, is introduced and pushed toward the oppo- site side, the extremity being directed toward a point two inches and a half above the oppo- site external auditory meatus (Keen) until the fluid is reached (Fig. 235). In the normal brain the dis- tance to the lateral ventricle is about two and a half inches. In the hydrocephalic, this distance is lessened proportionately to the degree of the fluid dis- tention. In the latter method the point of the needle is directed away from the basal ganglia; in the former it approaches the ganglia on account of the higher point selected for the introduction. The fluid should be evacuated slowly and the flow attended with moderate and equable pressure on the cranium by a skull-cap bandage. If unpleasant manifestations happen during the with- drawal of the fluid, the flow is promptly arrested for a time, after which it is permitted to begin again cautiously, or is stopped entirely, as circumstances demand. Often the removal of three or four ounces of fluid or less will cause feebleness of the pulse, contraction of the pupil, and evidences of approaching convulsion. The injection into the ventricles of a moderate amount of an ordinary saline solution at the temperature of the body is advisable if alarming evidences of cerebral disturbance arise at the time of operation. The almost certain reaccumulation of the fluid has prompted the employment of drainage and the injection into the distended ventricles of a weak solution of iodine, of Thiersch’s or other suitable medicated fluids. The drainage agents are introduced at the time of the evacuation through the canula used for withdrawing the fluid. Either a small rubber tube, wicking, horsehair, or gauze can be utilized for this purpose. Horsehair is the best drainage agent; it is not too stiff and a portion of it can be withdrawn from time to time, thus meeting the demands of the case, and, moreover, it inhibits the escape of the fluid in a manner consistent with the greatest security to the patient. However, the employment of drain- age favors additional risk of infection and meningitis without materially adding to the recovery of the patient. The completion of the operation Fig. 235.—The direction of puncturing agent. OPERATIONS ON THE NERVOUS SYSTEM. 193 is followed promptly by closure of the wound, the application of aseptic dressings, and the establishment of gentle and uniform pressure on the skull by the aid of bandages, adhesive plaster, or a tightly fitting rubber cap. If the borders of the fontanelles and sutures have been widely separated, the squeezing of the brain incident to the combined pressure of the accumu- lating fluid and of the dressings applied to the skull may provoke alarming symptoms. The cases best suited for tapping are those in which severe pressure attends recent simple meningitis, the later stages of the tubercular variety, hydrocephalus with inherited syphilis and chronic meningitis with much expansion of the head, and cases with loss of functions, such as vision, etc. (Baltzie). It has been proposed recently to drain the ventricles by tap- ping the membranes of the spinal cord (vide page 270). The Results.—The rate of mortality from the operation alone is small indeed if aseptic care be taken. The percentage of cures is variously stated at five, ten, and even greater rates; the results are much influenced by the care taken in the selection of cases. Cures need hardly be expected to fol- low a single tapping; so-called cures are often transient. Acute Hydrocephalus.—There is good reason to believe that the symp- toms of cerebral compression incident to an acute collection of fluid in the subarachnoid and ventricular spaces dependent, usually, on tubercular men- ingitis can at least be temporarily relieved by drainage. To effect this a small trephine can be applied to the cranium as in the preceding instance and the ventricles evacuated in a similar manner. If the fluid be sub- arachnoid a free opening is made through the membranes of the brain and the fluid is encouraged to flow by the employment of aseptic textile fabrics placed in contact with the opening and covered by a generous pad of aseptic gauze. If centrally located tapping of the ventricle may be advisable. The Results.—As yet the data of the operation are insufficient to com- mend the procedure except as one calculated to offer temporary though per- haps trivial relief from the cerebral compression, thus gaining time which may contribute to final recovery. Meningocele.—Meningocele is a protrusion of the meninges of the brain caused by an accumulation of hydrocephalic fluid in the ventricles, and oc- curs, therefore, before closure of the fontanelles. Meningocele may be pres- ent at any point of separation of the cranial bones, but it occurs more fre- quently at the posterior fontanelle than elsewhere. When at the sinciput it is the most favorably located for treatment. The communication be- tween the protrusion and the cranial contents may be large, quite small, or be closed entirely, and upon the dimensions of this passage much, indeed, depends, since the freer and shorter is the communication the greater are the dangers of operation, and consequently the more guarded should be the prognosis. The tumor should be protected from irritation at all times by a covering of cotton wool or of other suitable material, to which may be added also another measure, the employment of gentle, equable pressure applied to the tumor by means of suitably adjusted cloth pads and bandages. The oper- ative measures are ligature, puncture or tapping, injection, and excision. 194 OPERATIVE SURGERY. Ligature.—In the instances of small openings into the cranium, the iso- lation of the neck of the sac and its ligature with silk or chromicized cat- gut offers a favorable outlook, as not infrequent trials have demonstrated. Puncture or Tapping.—Puncture or tapping is employed as a palliative measure rather than with the hope of establishing a cure. The removal of the fluid in this manner often mitigates and may relieve entirely for a time the unpleasant symptoms attendant upon a rapid development of the tumor, thereby prolonging life directly, and also affording the surgeon an oppor- tunity to act with deliberation and forethought in the selection of sterner measures of relief. The fluid should be withdrawn slowly and with strict aseptic care, to avoid, as far as possible, cerebral disturbance and subsequent meningitis. Injection.—The injection of a drachm or two of equal parts of the com- pound tincture of iodine and water—or a similar amount of the iodoglycerin solution*—can be safely employed if all communication be shut off between the tumor and the cranial cavity. If the channel be not occluded already, or the lumen easily controlled by pressure or other simple means, during the process of injection, this measure of treatment should be regarded as unwise and not permissible, except for special reasons. Before the introduction of the curative agent into the sac of the tumor a small portion of the fluid should be withdrawn. The amount of the curative fluid introduced should equal that withdrawn. After the injection of the fluid the patient should be kept quiet, and great care exercised to prevent the entrance into the cranial cavity of any of the medicated contents of the sac. Excision.—Excision of the tumor with proper care is the most satisfactory method of cure. The Operation.—The head and the tumor should be shaved and rendered thoroughly aseptic. An incision is then made down to the dura through the scalp and fascias at the neck of the tumor, and so located as to admit of the formation of flaps of ample size and proper shape to cover the final wound. These flaps are separated carefully from the dura and pulled aside. A sufficient amount of fluid is then withdrawn from the tumor to permit the walls of the neck of the sac to be readily approximated with each other on a line with the cranial bones. While thus held with a clamp or the fingers the neck of the sac is divided cautiously for a short distance with scissors, and the serous surfaces of the divided borders are approximated by fine silk or catgut sutures applied in a continuous overhand manner. The cutting and sewing are repeated alternately until the neck of the sac is finally severed and the divided borders of the membranes are united com- pletely and securely. If the neck of the sac has been already occluded, the operative measure is much simplified. The wound is closed in the usual manner and dressed with an abundance of antiseptic gauze confined some- what tightly in place. The Precautions.—Carefully distinguish between meningocele and enceph- alocele. If possible avoid a too free escape of fluid since convulsions and death * The iodoglycerin solution is made by dissolving ten grains of iodine and thirty grains of iodide of potassium in an ounce of glycerin. OPERATIONS ON THE NERVOUS SYSTEM. 195 may follow as the result. If evidences of impending misfortune arise for this reason, the introduction into the sac of a small amount of warm aseptic saline solution may give prompt relief. As meningitis is to be feared most, antisepsis before and after exposure of the membranes is commended. Drainage should not be employed unless bruising or tearing of the tissues has attended the operation. The Results.—The number of reported cures following treatment by ex- cision encourage continued trial of the measure in similar cases, especially as no other method offers like favorable results. Encephalocele.—Encephalocele is located in like situations as meningo- cele, and must be distinguished from the latter. The contents of encephalo- cele are composed of cerebral substance and dropsical membranes attended often with more or less fluid. The operative measures are quite futile, but in general are similar in character to those for meningocele. Itepeated puncturing with a fine needle, followed by pressure carefully and uniformly applied, offers the safest and most rational method of practice for cure of this infliction. The Operation of Craniotomy.—Craniotomy is a term commonly applied to the opening of the cranium for obstetrical purposes. It is used here to denote the opening of the cranium for the purpose of relieving cerebral pressure, of stimulating mental development, etc. Surgically speaking, craniotomy may be divided into the circular, linear, and irregular varieties, according to the outline of the opening made in the cranium. Circular Craniotomy.—Circular craniotomy consists in making a cir- cular opening in the cranium, usually with a trephine, and therefore is called trephining the cranium. There are two patterns of trephines with similar handles (Fig. 236) deserving of special attention—the crown or circular (e) and the conical or Galt’s (c, d). The latter is a much safer instrument, because as soon as the inner table of the cranium is sawn through, the instrument, on account of the conical shape and spiral periph- eral teeth, assumes a screwlike character and is arrested in its track. In the case of the former pattern, the arrangement of the teeth is different, and for this reason the membranes are promptly torn and the brain injured, unless great caution be exercised in the use. The diameters of these instruments vary from one half inch to two inches and a half. Circular craniotomy with a trephine of small caliber is commonly practiced for relief of depressed frac- ture of the cranium and epidural hgemorrhage. The large sizes are used in operations for brain tumors. Craniotomy for Fracture of the Skull.—Circular craniotomy is commonly practiced for this injury. The field of operation is prepared by cutting the hair short, scrubbing and disinfecting the scalp, and shaving it for a consid- erable distance around the seat of the injury. The patient is anaesthetized if not completely unconscious, preferably with chloroform, as it causes less cerebral excitement. However, the choice of an anaesthetic is a matter of opinion. The head is conveniently raised and supported by a firm pillow. The Operation of Circular Craniotomy (Trephining).—With a scalpel (Fig. 236, a) make an oval incision of the scalp, through sound tissue if a. Scalpels, b. Periosteotome. c, d, e and g. Trephines and handle. /, g. Gouges, h, i. Gigli-Haertel saw. Jc. Bone elevator. I, m. Bone-gnawing forceps, n, p. Sequestrum forceps, o. Serreflnes. r. Probe, s. Rawhide mallet (don't boil it), t. Trephine brush. Fi«. 236.—Instruments used in craniotomy for fracture of skull. OPERATIONS ON THE NERVOUS SYSTEM. 197 possible, down to the pericranium (Fig. 237), of adequate size to expose the fracture and well suited for drainage. The crucial, T- or Y-shaped incision can be substituted for the oval if injury of the soft parts be extensive, or the loss of blood incident to the formation of the oval flap be especially objectionable. The bleeding can be quickly ar- rested by clamping the scalp at the seat of the flow with serre-fines (Fig. 236, o); later ligatures are applied. Raise the periosteum with a periosteotoine (Fig. 236, b) at the seat of fracture suffi- ciently to permit the proper application of the trephine. Select a trephine of moderate caliber—say one half to three quarters of an inch — push down the pin for about an eighth of an inch below the teeth of the instrument; fas- ten the pin firmly in position, and place the point on solid bone (a) as near to the line of depression as is wise (see p. 199, Important Considerations), and at the point best calculated to facilitate elevation (Fig. 238), provided it be not located above an important vessel. Bear firmly on the trephine to intro- duce the point into the bone; turn the instrument quickly and lightly from right to left, and the reverse until a groove is made in the bone of suffi- cient depth to re- tain the instrument in place during fur- ther action. Dur- ing this step of the operation it is wise to hold the head of the trephine in place with the thumb and index finger of the disengaged hand, or by the index finger of the other extended along the trenhine down to the skull. When a suitable track is made withdraw Fig. 237.—Circular craniotomy (trephining). Fig. 238.—Trephining. 198 OPERATIVE SURGERY. the center pin and fasten it back in place, to prevent puncturing the mem- branes of the brain. Continue the operation, raising the instrument from the track and freeing it from bone dust with a brush provided for the purpose (Fig. 23G, t). Ordinarily the appearances of bone dust vary according to the advance of the trephine; that of the diploe being deeply stained with blood, while that of the tables of the cranium is grayish in color. The passage through the diploe is marked by bloody detritus, by an easier and more rapid advance of the instrument, and is attended with a softer sound. While going through the internal table less pressure should be made on the instrument, and the circular movements should be made lighter and quicker than before to avoid a precipitate entry of the cranium. At frequent intervals the end of a grooved director or of a trephine probe (Fig. 236, r) is introduced into the track of the instrument to ascertain if any part of the circle be deeper than another, and if the bone be cut through at any point. If the button be percussed with a light metal instrument it gives forth a low-pitched sound if complete division to any extent be present. When but a moderate pene- tration of the inner table is present, the button can be moved and perhaps tilted out by an elevator, or possibly it may come away with the trephine, if the latter be carefully tilted. If, after the removal of the button, additional room be required, the rongeur (Fig. 236, l or m) is brought into use. The removal of the button of bone enables the surgeon to insert the point of the elevator (Fig. 236, k) beneath the depressed portion (Fig. 238) and to pry it into place through the agency of the finger or the solid bone border (a), acting as a fulcrum. Great care must be taken in doing this or the sudden giving way or tilting of the fragment will injure the soft parts, and also disconnect the fragment from nutrient associations. The utilization of the rongeur and the mallet and gouge (Fig. 236,/, g, s) to liberate the points of impaction and binding makes the elevation of the fragments easier and safer. Projecting points of bone are cut away and loose portions are sought for, especially beneath the bony border of the wound. The loose pieces of bone are kept and fitted to each other to ascertain if any portion of bone be missing, especially if the membranes have been lacerated, for then a por- tion of bone may be driven into the brain and remain there unsuspected. Rents of the dura are closed with fine catgut stitches. After proper scrutiny of the wound the technique of closing and dressing it must be considered. Much difference of opinion is expressed regarding the best plan of procedure. The cranial opening may he repaired by replacement of the fragments, by the introduction of a foreign body, or by allowing Nature to cure it after her own manner. If the first proposition is to be adopted, the fragments, as fast as removed, are wrapped in an aseptic towel saturated with hot sterilized water to preserve their vitality and purity. Whether the replacement of the button intact or the fragmentation of it and return of the pieces is the better plan has caused some discussion. The experience of the author emphasizes a preference for the latter plan since the bony fragments when bathed in blood are more viable than is the button, which often necroses. The intro- duction into the opening of a metallic, gutta-percha, or celluloid plate is a refinement in surgery which often is successful under strict asepsis. The OPERATIONS ON THE NERVOUS SYSTEM. 199 conditions that make success attainable in this instance will quite likely achieve a similar result in the use of bone fragments, and provide for the patient a vitalized rather than an inanimate repair. The too frequent occur- rence of necrosis of the fragments and the little practical utility gained by the success of the measure in the majority of cases, has led to its discontinu- ance, except for special reasons (page 219). The torn borders of the dura and the borders of the reflected periosteum are united with fine catgut, the flaps are placed in proper position and united, horsehair or silkworm-gut drainage is provided, antiseptic dressings are loosely applied, the head is elevated, and the patient kept quiet by anodynes if need be, followed by a brisk cathartic. The Important Considerations.—Cranii vary in thickness, the average in the adult being about a fifth of an inch,. In youth and old age they are much thinner. The irregularities of the inner table for the reception of the convolutions of the brain cause inequalities in the thickness of circum- scribed portions of the bone at numerous situations. Some cranial bones are thinner than others—for example, both in early life and in the aged the diploe is absent from the squamous part of the temporal, the contiguous portion of the parietal and the fossae of the occipital bone. If these facts be not recognized during operation the danger of injury to the cranial contents is manifest. Holden’s maxim for using the trephine—“ Think that you are operating on the thinnest skull ever seen, and thinner in one half of the circle than in the other ”—is a good one. The trephine should be applied vertically to the plane of the part of the skull attacked and kept in this relation to maintain an equality in the depth of the circular cut, thus avoid- ing as far as possible injury of the membranes from a premature division of one side of the button. Free haemorrhage from the divided bone is usually arrested by elevating the fragment. If not, temporary tamponing with sponge or gauze will quite easily overcome it. However, if this be not the case, plugging, ligature, crushing and actual cautery (page 214) are yet available for the purpose. If the bone be comminuted and the fragments movable, they may be ele- vated without the use of the trephine. In any event the trephine should be so placed (Fig. 238, V) as not to disturb movable fragments (c), for fear of causing them to cut or puncture the tissues lying beneath. In such cases the fragments should be removed with sequestrum forceps (Fig. 236, w, p) and the trephine placed on solid bone. In a case with firmly depressed fragments (Fig. 238, d), the application of the trephine should not be de- layed by attempts with less effective means. In punctured fracture a large trephine is usually employed and so placed over the fracture, if possible, as to provide by a single button ample room for the removal of the fragments of the internal table. The lodgment in fissures and in bony asperities of hairs, threads, etc., should be noted, and their removal secured to prevent infection. Trephining over the course of important vessels should be avoided, ex- cept for special reasons. The middle meningeal artery and its branches, and the cerebral sinuses are of special significance in this regard. The Middle Meningeal Artery.—After entering the cranium the middle 200 OPERATIVE SURGERY. meningeal divides into two branches, anterior and posterior. The anterior branch runs in a canal or groove on the inner surface of the antero-inferior angle of the parietal hone (Figs. 239 and 241), upward and a little backward to the sagittal suture lying about three quarters of an inch behind the coronal suture. At this angle of the bone it is about one inch and a half behind the external angular pro- cess of the frontal bone, and one inch and a half to one and three quarter inches above the zygoma (Fig. 254, F). The pos- terior branch passes up- ward and backward along the inner surface of the squamous j:>ortion of the temporal bone, lying in a shallow groove (Fig. 241), at an angle of about 9° with the upper border of the zygoma (Figs. 239, B, and 254, G). If the men- ingeal branch be severed with the trephine, the luemorrhage may be arrested by ligature, by tampon- ing, by instrumental pressure of the bleeding point against the inner table, trephining and tying the vessel at the proximal side of the injury, and by ligature of the external carotid. The simpler methods usually are sufficient for the purpose in all instances except when the bleeding complicates a fissured fracture of the skull. The presence of the anterior branch of the meningeal artery in a canal (Fig. 240) exposes the vessel to much greater danger of injury from fracture or trephining at that situation than when run- ning in a groove (Fig. 241), for obvious reasons. The location of the sinuses are indicated sufficiently, to avoid in- jury to them, under the heading of “Dangers” on page 20G and “ Precautions ” on page 223, and by Fig. 254, A, B. If a sinus be opened the wound is tied or sewed with catgut, or closed by com- pression with aseptic gauze. The Results.—The nature of the injury, delay in the perform- ance of the operation, and the inability to execute tbe proper technique are the important factors that modify the prognosis. A fatality of from four to Fig. 239.—Course of middle meningeal artery. a, b. Reid’s base line, c, d. Kronlein’s line, e, f. Ver- tical line, inch and a half behind external angular pro- cess. g, li. Vertical line at posterior border of mastoid process (page 202). Fig. 240.—Anterior branch of middle menin- geal artery occupying a canal at anterior- inferior angle of parietal bone. OPERATIONS ON THE NERVOUS SYSTEM. 201 fifteen per cent is a fair estimate of the results in civil practice. The death rate from trephining alone is scarcely two per cent. Craniotomy for Meningeal Haemorrhage.—Meningeal haemorrhage may be either epidural or subdural. The former is much more amenable to treat- ment and offers by far the better prognosis. Either variety is commonly Fig. 241.—Anterior branch of middle meningeal artery occupying a groove on anterior- inferior angle of parietal bone. associated with severe injuries of the head, such as fracture of the skull, lac- eration of the brain, etc. In depressed fractures the blood often escapes ex- ternally, or is easily removed coincident with elevation of the bone. Fissured fractures of the cranium are complicated frequently with extradural haemor- rhage, especially when the fissure passes through the route of the branches of the middle meningeal artery. This variety of haemorrhage, although circum- scribed, is frequently extensive. After the localization of the seat of the blood clot, the preparation of the patient is the same as in trephining for other pur- poses (page 197). The formation of the flap, the control of the haemorrhage, and the general technique are similar. The operation should be done prompt- ly—and with chloroform when practicable—if anaesthesia is required. The Operation.—Make a flap of large size at the seat of injury, provided the injury corresponds with the seat of the haemorrhage, as indicated by the symptoms. After exposure of the cranium seek for a fissure of the skull. Apply a full-sized trephine to the cranium—in the line of the fissure if prac- ticable—and expose the blood clot beneath. Remove the blood clot carefully with the finger or with a scoop—a teaspoon will do—aided by flushing with hot sterilized water. If all haemorrhage has ceased, drain the cranial wound with horsehair or silkworm gut, return the soft parts to the normal places, unite and dress the wound in the usual manner. If haemorrhage be progressing at the time of operation the occurrence is indicated by the following facts : 1. The presence of extensive extravasation of the soft parts with fluid blood. 2. The free escape of blood from a fissure fracture. 3. The pulsation of the epidural clot. 4. The appearance of fluid blood in the epidural cavity after removal of the blood clot. 202 OPERATIVE SURGERY. 5. The discovery of the bleeding point itself. The prompt arrest of the bleeding is of obvious importance. If the bleeding point can be seen when it lies in the bone tissue the flow may be stopped by plugging the point with catgut; by tying or by pressure of the vessel against the internal table by means of properly curved long-bladed forceps, one blade being placed without and the other within the cranial cavity. If the bleeding point can not be seen the application of cold to the head, temporary sponge or gauze pressure, or pressure on the common carotid should be tried. However, in either case, if the bleeding persist, it can be arrested by ligature of the external carotid, or perhaps by trephining, and ligaturing the vessel at the proximal side of the bleeding point, after which the wound is drained and treated antiseptically. If the compression symptoms be of indefinite character and no fracture be found Kronlein advises as follows : “ Draw a line around the skull from the upper margin of the orbit (Fig. 239, c, cl) parallel throughout with Reid’s base line (Fig. 239, a, b). At a point from one inch and a quarter to one inch and a half—according to the size of the head—from the external angu- lar process, apply the trephine (A) and explore for haemorrhage. If the con- ditions indicate involvement of the posterior branch, the latter may be exposed by a trephine opening (R) on the same line where it is intersected by a vertical line drawn from the posterior border of the mastoid process.” The Precautions.—The absence of a fissure of the cranium at the seat of external injury is no proof that a fissure is not present. Not infrequently in these cases the fissure begins at an extreme limit or even outside of the external wound, therefore the injured and adjoining areas should be carefully searched, otherwise the fracture will escape notice. A minute fis- sure may be confounded with a suture, or with an incision through the peri- cranium. The irregularity and direction of the former and the shallow and fickle borders of the latter will readily discriminate between them. The tamponing of the clot cavity to arrest haemorrhage should not be favorably regarded, since to be effectual the tampon must exercise as great pressure at least as did the blood clot itself. Ligature of the common carotid should not be entertained in this connec- tion because of the high rate of mortality (forty per cent) following this pro- cedure ; the external carotid should be tied instead, as the rate following its ligature is less than four per cent. If no epidural clot be present a subdural one should be sought for. The Results.—The results depend very much indeed on the character and extent of cerebral complications. However, the statistics of Weisman amply demonstrate the wisdom of the measure. According to his report 89T per cent died with the expectant treatment, and but 32*7 per cent died after operative treatment. Subdural Hemorrhage.—Subdural haemorrhage arises from the effects of traumatism, from pachymeningitis, and from unknown causes. The clot may be a recent or an old one, and may be of arterial, venous, or capillary origin. If arterial the middle meningeal or basilar vessels are usually at fault. If venous it is frequently associated with abnormalities of the veins OPERATIONS ON THE NERVOUS SYSTEM. 203 connected with the superior longitudinal sinus. If capillary it is often the result of local traumatism. It is of special importance to note the possibility of the presence of free blood beneath the dura subjacent to a fracture of the skull. Subdural haemorrhages are rarely indeed circumscribed, and often cover the entire surface of a cerebral hemisphere. If subdural haemorrhage complicate a fracture of the skull the elevation of the bone or the removal of the epidural clot gives but little if any relief to the patient. In such cases the exposed dura bulges into the cranial opening somewhat, and the brain pulsations can not be seen or felt, or are present only in a limited degree. The Operation.—Increase the size of the opening in the cranium so as to correspond to the recognized area of compression; at the most dependent point make an oval incision in the dura with a curved bistoury a quar- ter of an inch from the bone margin; arrest all bleeding; carefully draw aside the dural flap with a tenaculum ; incise the arachnoid membrane cau- tiously with bent scissors, and draw it aside so as to expose the blood clot, which is then, with bits of sponge, wiped carefully away. If firmer agents than these be employed to remove or dislodge the clots, great care is needed to prevent injury of the brain and increase of haemorrhage. Haemorrhage of the dura is promptly and finally controlled by a catgut ligature passed by the aid of a needle through the membrane near to the border around the vessel and tied. Haemorrhage from the pia is commonly arrested by patiently applied sponge or gauze pressure. Serre-fines (Fig. 236, o) and fine catgut ligatures are employed if pressure be inefficient. Haemorrhage from the brain is usually controlled by sponge or gauze pressure; if these fail the actual cautery can be employed. Park advises a solution of 1 to 40 of antipyrine, and Keen a solution of cocaine 1 to 100 for this purpose. After the removal of the blood clot and the arrest of haemorrhage, the bor- ders of the divided dura are united by a continuous suture of fine catgut, except for a short distance at the most dependent portion; at this point horsehair drainage is provided and the remaining portion of the wound lightly packed with aseptic gauze, which is in turn covered with an abund- ance of carbolic or bichloride gauze, bound tightly in position. The head and shoulders are elevated and the patient is quieted by anodynes if necessary. Subdural haemorrhage unassociated with fracture, when the seat of the extravasation is established, and when the condition of the case will justify, should be treated in a similar manner. The author has in two instances re- moved what was possible of an extensive subdural extravasation of blood. In one instance only was there evidence of fracture. In both cases temporary amelioration of the symptoms followed the escape of an abundance of sero- sanguinolent fluid. In each instance the patient succumbed, on account of extensive fracture of the base of the skull and the extravasation of blood. The Results.—The not infrequent favorable reports of operations for relief in subdural hemorrhage of both recent and remote occurrence are sufficiently assuring to justify continued efforts in this direction in proper cases and with strict aseptic technique. Craniotomy (Linear) for Microcephalus.—The term microcephalus is ap- plied to an abnormality of the brain characterized by diminished size, and 204 OPERATIVE SURGERY. also enfeebled and distorted functions of the organ, associated with congen- ital and premature closure of the fontanelles and sutures of the cranium. This unnatural closure of the osseous envelope of the brain was regarded at first as the chief cause of the singular mental exhibitions of these patients, and they were thought to depend on the arrest of cerebral development coin- cident with the pressure imposed on the organ by the limited capacity of the cranial cavity. In the presence of this belief, it is not strange that operative measures contemplating the loosening of the brain from the unnatural beset- ment were promptly planned and executed. It is to be regretted, however, that the operative procedure itself often proves unexpectedly and unac- countably fatal, and that the curative outcome is very disheartening. Having carefully determined the case to be a proper one and in suitable condition for operation, prepare the patient in the manner proper in crani- otomy for fracture (page 195). Before making the scalp flap, suitable meas- ures should be taken to avoid unnecessary loss of blood. Elastic pressure made by strong rubber bands resting on and holding in position small firm compresses placed over the main arteries supplying the scalp, or the control of these vessels by acupressure and digital pressure are advised. However, if the bleeding points be promptly caught the loss of blood from the scalp will play no important part in the result. The Operation of Linear Craniotomy.—The site of the operation is ex- posed by a free incision of the scalp down to the pericranium, and from the hair line in front backward to the occipital protuberance, an inch from and parallel with the sagittal suture. This incision is supplemented by a short one at either end passing downward and outward. The scalp flap is drawn aside and held with loops of silk passed through the border at two or three situations. A button of bone about an inch in width is removed from the center of the operation field by a trephine applied not less than one inch and a half from the sagittal suture. Beginning at the opening first made, separate the dura from the bone with a narrow, flexible spatula (Fig. 252, i), allowing it to remain in position to protect the dura from injury (see Menin- gitis, page 206), the bone is cut through parallel with the sagittal suture nearly to the limits of the incision of the soft parts by means of Hofmann’s bone-cutting forceps, rongeur (Fig. 236, l, m), chisel and mallet, or by saw- ing. The use of the chisel and mallet requires the employment of much force, causing objectionable vibration of the structures of the head; they are therefore used now less frequently than before, the saw and bone-cutting forceps being employed instead. Sawing is the quicker and, perhaps, the safer means, and should be employed when practicable. In order to secure a prompter and greater increase of capacity of the cranial cavity, lateral divisions of the skull are sometimes made. Various other forms of bone incision are also recommended (Chipault) (Fig. 242). If the lateral bone sections are to be made by sawing, the removal of a small button of bone at the point of beginning of each will enable the operator to apply the saw more satisfactorily and effectively at these points for obvious reasons. The immediate and forcible elevation of a parietal bone when thus divided does not commend itself as wise or essential in a known degree to the purpose of OPERATIONS ON THE NERVOUS SYSTEM. 205 the operation. But that the bone may be sprung upward at this time suffi- ently to test its yielding nature with no harm, and perhaps with benefit, is a reasonable conclusion. Whether or not a narrow strip of bone should be re- moved along the antero-posterior line of section must be decided at the time of the operation, for certainly it should not be attempted if the safety of the patient will be compromised by the act. The removal en masse of large Fig. 242.—Sections of cranial bones, areas (Fig. 242, a) of bone corresponding to a depressed surface is practiced with comparatively no unfavorable results, and seemingly with prompter bene- fit than from more limited removal. Powell’s electric saw, driven by an easily portable motor, is a capital contrivance for the purpose (Fig. 243). When a change in the direction of the sawing is desirable, an additional trephine opening at the proper site meets the requirement. The dental engine can be used to drive the saw, but is less effective in all respects than is the former. The Gigli-Haertel wire saw (Fig. 236, i) is a recent and valuable addi- tion to the armamentarium of bone sawing. In the instance of craniotomy the saw is carried through the trephine openings beneath the bone and above the spatula employed in the detachment of the dura by means of a long Fig. 243.—Powell’s electric saw. probe with string attachment. The handles (Fig. 236) are then affixed and the instrument operated as is the chain saw. Bone flaps of varying size and shape can be formed with this instrument. It may happen in this operation that the bone section should extend farther to the front than has been described above or be limited to the an- 206 OPERATIVE SURGERY. terior part of the cranium or to the motor area alone, depending on the manifestations exhibited by the patient; and, too, exploration beneath the dura mater may be regarded as admissible and even necessary in some cases. After the arrest of haemorrhage the skin wound is closed with silkworm gut and dressed antiseptically. The patient should be kept quiet by the use of the bromides, if advisable, until the wound is healed. Drainage need not be employed unless for some special reason. The Dangers.—The danger from haemorrhage is considerable, especially in those cases possessed of highly vascularized diploeic structure. In such cases it is sometimes necessary to stop the operation on account of the great loss of blood. The author once encountered a case of this kind. If the bleeding come from definite points of the cancellous tissue, it can be arrested by plugging the opening with catgut, or by aid of the actual cautery or the heated point of a probe (see page 214). If the bleeding from the bone be general the gauze tampon firmly applied along the line of section will arrest it. Injury of the longitudinal sinus will cause free haemorrhage. Fortu- nately, however, the demands of the operation do not require a close ap- proach to this important vessel. It is not amiss to recall the fact that the sinus is quite narrow in front and increases in width as it passes backward, and also that it encroaches more on the left than the right parietal bone at the posterior part. Shock is an important element of danger in these cases. It is caused sometimes by the loss of blood and also by the violence inflicted in the oper- ation. In not a few instances the depth of the shock can not be satisfac- torily accounted for. While cases differ much in this regard, still the rule is, the longer the time employed in the operation and the greater the meas- ure of violence, the more profound is the degree and the danger from shock. For this reason, operation on both sides of the head at the same sitting is not favorably regarded ; and, moreover, if a considerable interval between the operations be allowed, one is enabled to judge of the advisability of a second operation by the results arising from the first. Meningitis.—Meningitis is an infrequent sequel of the operation, and is often provoked by the rough handling or carelessness of the operator. The danger of injuring the dura, except with the saw, is trivial, and can be easily obviated by passing between it and the cranium a thin, flexible strip of metal which is held firmly in position during the act of sawing (Fig. 252, i). If the strip of metal be grooved along the uppermost surface sufficiently to leave an appreciable space between it and the bone, the bone can then be divided entirely with a minimum danger of injury of the soft parts. Thrombosis and Pyaemia.—If the wound becomes infected and the can- cellous tissue of the cranial bones is involved, then much danger from pyaamia arises. If proper aseptic precautions are taken at the outset and maintained during the operative and subsequent treatment, there is no likelihood of infection. The Results.—While the ultimate results do not as yet establish the oper- ation on a firm basis, still it offers to many cases the only known hope of even a temporary improvement. The present inability to determine the patholog- OPERATIONS ON THE NERVOUS SYSTEM. 207 ical condition of the brain before exploration has much to do with the un- favorable results that follow it. Still, the hopelessness of the condition, and the undoubted benefits that have followed operation in isolated cases, should encourage a studied perseverance in this direction until a better means of relief is ascertained. Promptly after the operation the temperature reaches a high figure in some cases, and with fluctuations remains there for days, unless death ensues. The author has in mind a case of his own in which death, with high temperature, happened within a week, with no physical or bacteriological evidence to account for it. The death rate from the operation is variously stated as being from two to seventeen per cent. The best results occur in those over ten years of age. Craniotomy for Brain Tumor.—The brain, like other tissues of the body, suffers from the presence of nearly every variety of morbid growth. The as- certainment of the functions of certain portions of the encephalon enables the diagnostician to locate the situation of tumors in many instances by a careful analysis of the disordered manifestations provoked by the presence of these growths in the brain. In order to indicate on the cranium the proper seat of operation for the removal of brain tumors, it is necessary to recognize the situation of certain established points of reckoning, and, from a knowledge of these, indicate the definite part of the cranium that covers the disordered brain center. Craniocerebral Topography.—The expression craniocerebral topography applies to the localization of important brain fissures and centers by aid of FISSURE OF ROLANDO, INTRA-PARIETAL \ FISSURE.] \ POSITION OF | PARIETAL , EMINENCE. I POSITION OF FRON- | TAL EMINENCE. I FISSURE OF [SYLVIUS. SUPTEMPORAL FISSURE. EXTERNAL) PARIETD-l OCCIPITAL j FISSURE) I MIDDLE TEMPORAL FISSURE. LATERAL SINUS. Fig. 244.—Relation of cerebral fissures to the cranial sutures in the adult. the bony landmarks of the skull. The prominences, ridges, sutures, and the specially designated points of reckoning need not be considered in detail now, since their location and importance will develop during the cranial 208 OPERATIVE SURGERY. survey. In order to locate important cerebral parts it is necessary to make definite measurements of the cranium. The relations of the sutures to the cerebral fissures and convolutions are matters of great consequence in these measurements (Fig. 244). It is wise to note at the outset that the relations between sutures and eminences of the skull and the fissures and convolution of the brain are not unvarying. For instance, the squamous suture may be above, below, or quite on a line with the Sylvian fissure. The parietal eminence may vary half an inch in the vertical and an inch in the horizontal direction (Ander- son and Makin). The relation between the bregma and lambda and gla- bella and inion vary considerably in different cases. The Sylvian fissure is more oblique in children up to the third or fourth year, and lies farther above the squamous suture (Fig. 245) (Foulhauze). At this age, too, the upper end of the Rolandic fissure is usually a little anterior to its site in adults. I FISSURE OF \ ROLANDO. INTRA- PAR I ETA L FISSURE. EXTERNAL PARIETO- OCCIPITAL FISSURE. POSITION or PARIETAL EMINENCE. FISSURE OF SYLVIUS. SUP. TEMPORAL FISSURE. Fig. 245.—Relation of cerebral fissures to cranial sutures in the child. The Central or Fissure of Rolando.—The central or fissure of Rolando is the most important of the fissures connected with cerebral localization. It passes downward and forward on the outer surface of the cerebrum be- tween the ascending frontal and parietal lobes, about three and a half inches, forming an angle of sixty-seven degrees with the median line of the cranium (Figs. 244 and 251). It is located by either of the following topo- graphical plans (Figs. 247, 248, 249, and 250) or by mechanical means (Fig. 246) devised for the purpose. Horsleif s fissure meter is calculated to fulfill the requirements of each class of cases. Horsley, finding that the angle between the central and longitudinal fissures varied somewhat with the shape of the head, as modified by the cephalic index, devised an instrument provided with a rotating arm corresponding to the central fissure, which can be varied to meet the deviations of the various cranial indices. The degree of the cranial index is determined by dividing the transverse diameter of the head by the antero-posterior diameter. According to Horsley, in a head with a cranial index of 0-75 the central fissure runs at an angle of 69°, the angle increasing OPERATIONS ON THE NERVOUS SYSTEM. 209 or diminishing one degree for every two degrees increase or decrease in the cranial index. The instrument is so applied to the head (Fig. 246) that the movable arm at its center of rotation will correspond to the upper end of the central fissure. The arm can be rotated to conform to the cranial index as established by measurements already stated. Cliiene’s method of determining the position of the fissure is ingenious, available, and ef- fective (Fig. 247). lie folds a square piece of paper once, so as to form a triangle A E C, the corners B and D coinciding. The angle B A C is one of 45°. The dotted edge D A is folded back so that the dotted edge D A is applied to the dotted line C A. Each of the angles DAE and E A C is evidently half of 45°—that is, 22'5°. Leaving the flap DAE folded, the paper is unfolded at the line C A, forming the figure A B C E. The angle B A E being made up of one of 45° and one of 22-5°, is evidently 67‘50°, which is, for prac- tical purposes, near enough to the direction of the fissure of Rolando. The side A B (B in front) is then applied to the middle line of the head, the angle A being placed half an inch behind the midpoint between the glabella and inion, when the line A E corresponds to the fissure of Rolando. * In all in- stances the lower third of the fissure is more nearly vertical than the remaining portion of it. In children under nine years of age the fissure lies farther forward, and is placed more obliquely than as just described. The Fissure of Sylvius.—The fissure of Sylvius is located promptly by drawing a line parallel with Reid’s base line (Fig. 248, A) back- ward from the external angular process of the frontal bone, e. a. p., an inch and a quarter, then directly upward to a point a quarter of an inch above. From this point draw a line backward and upward to a point three quarters of an inch below the most prominent part of the parietal eminence + ; the line between the two points lies over the fissure of Sylvius (Reid). The first three quarters of an inch of this line lies over the main fissure, and the remainder over the horizontal por- tion. The main fissure bifurcates, therefore, two inches behind and a quarter of an inch above the external angular process of the frontal bone. The as- cending arm of the fissure (Sy. a. /.) is about three quarters of an inch long, and lies directly behind the coronal suture. The horizontal arm is about four inches in length. The schemes of Anderson and Makin (Fig. 249) and Lucas- Championniere CFisr. 250) are commended for the localization of this fissure. Fig. 246.—Horsley’s fissure meter. Fig. 247.—Chiene’s method of locating the direction of the fissure of Rolando. 210 OPERATIVE SURGERY. The Parieto-occipital Fissure.—The portion of this fissure on the upper surface of the cerebrum runs outward for about an inch at right angles with the longitudinal fissure (Figs. 245 and 271). If the line indicating the loca- tion of the fissure of Sylvius be extended directly to the median line (Fig. 248, A) of the cranium, the last inch of the line (p. o.f.) lies above the upper portion of the parieto-occipital fissure. The external portion of the fissure varies more in location than any of the other important fissures. However, the whole or some portion of it is easily exposed through a properly located opening an inch in diameter. Fig. 248, A and B.—Reid’s Lines. A base line (Fig. A) is formed extending from the lower margin of the orbit to the cen- ter of the external auditory meatus, ihence directly backward, E, G. F, G, D, E are two perpendicular lines drawn from the longitudinal fissure to the base line, one pass- ing across the depression in front of the ear, the other along the posterior border of the mastoid process. F. II a line drawn from the upper end of the posterior perpen- dicular line to the point of junction of the anterior perpendicular one with the line indicating the course of the fissure of Sylvius, and corresponding to the central or fissure of Rolando; e. a. p., external angular process. + The parietal eminence; a (Fig. B), convex line indicating lower boundary of the parietal lobe: 1. fr. c., first or superfrontal convolution; 1. fr. /., first frontal or superfrontal fissure separating the first from the second frontal convolution (2. fr. c.); 2. fr. /., second frontal fissure separating second (2. fr. c.) from third (3. fr. c.) frontal convolutions; /. R., central or fissure of Rolando; asc.fr. con. ascending frontal convolution; a,sc. par. con., ascend- ing parietal convolution; Sy. f. fissure of Sylvius; Sy. h. /., horizontal, and Sy. a. /., ascending limb of Sylvian fissure; p. o. /., parieto-occipital fissure; i. par. /., inter- parietal fissure; any. g.. angular gyrus; s. m. c., supermarginal convolution ; 1. t. s. c., supertemporal convolution; 1.7s./., supertemporal fissure, separating first supertem- poral convolution (1. t. s. c.) from the second temporo-sphenoidal convolution (2. t. s. c.); third temporo-sphenoidal convolution (3. t. s. c.) separated from the second (2. t. s. c.) by the second temporo-sphenoidal fissure (2. t. s.f.); 1. 2. and 3. o. c., first, second, and third occipital convolutions; p.p. 1., superior parietal convolution (post-parietal lobule). The Longitudinal Fissure.—The longitudinal fissure is situated beneath a line drawn from the glabella to the inion (Fig. 249, G, 1). The Transverse Fissure.—The position of this fissure is indicated by a line drawn directly from the outer auditory meatus to the inion. The line OPERATIONS ON THE NERVOUS SYSTEM. 211 corresponds with the superior curved line of the occipital bone, and marks, therefore, the junction of the head and neck posteriorly—a fact of great importance in connection with operations directed to the cerebellar fossae. The Intra-par ietal Fissure.—Preparatory to localizing this fissure (Fig. 251), define the positions of the central, Sylvian, and parieto-occipital fis- sures and the parietal eminence (Fig. 248, B). This fissure corresponds to a curved dotted line drawn from a point four fifths of an inch behind the bend of the fissure of Kolando (Fig. 248, B) upward and backward midway between this fis- sure and the parietal emi- nence, thence downward and backward in a curved manner midway between the parietal eminence and the longitudinal fissure to and a little below the outer end of the parieto- occipital fissure. The Precentral or Ver- tical Frontal Fissure.— This fissure lies nearly parallel with and just be- hind the coronal suture. Its lower end is two fifths of an inch (one centi- metre) above the Sylvian fissure and a twelfth of an inch behind the coronal suture. It is placed about four fifths of an inch in front of the central fissure (Figs. 244 and 251). The suhfrontal fissure extends from the precentral fissure to a little above the superior Stephanion, thence forward, corresponding nearly to the frontal part of the temporal ridge (Figs. 244 and 251). The super frontal fissure commences at a point four fifths of an inch in front of the central fissure and about an inch and a half from the longi- tudinal fissure (Figs. 244 and 251), and passes forward in a varying line practically parallel with the latter, and ends opposite the supra-orbital notch. The posterior cornu corresponds to a point one and three-quarter inches Fig. 249.—Anderson and Makin’s Lines. G, glabella ; I, inion ; G I, sagittal line ; M, mid-sagittal line point; A, external angular point (most external point of the external angular process, and on a level with the superior border of the orbit): S, squamosal point (at intersection of frontal line, E M, and mid- dle and upper thirds of the oblique line, 4P); P, parietal point (termination of oblique line and equi- distant with b from squamosal point, S); E, preau- ricular point (just in front of the ear and at the level of the upper border of the meatus); a, beginning of the fissure of Sylvius (five twelfths of the distance from A to »S'); b, bifurcation of the fissure of Sylvius (seven twelfths of the distance A to S; an inch and a half to two inches from A); d. termination of the fissure of Sylvius (half an inch above P. in direction parallel with frontal line, E M); Ce, central fissure (the upper end, C, three eighths of an inch behind mid-sagittal point, Jf); e, lower end of central fissure (three eighths of an inch in front of squamosal point, S); 0, parieto-occipital fissure (seven twelfths of the distance from M to I); A P, oblique or squamosal line; E Jf, frontal line. 212 OPERATIVE SURGERY. below the parietal eminence (-{-) and two inches and a quarter from the surface. (Agnew.) The angular gyrus corresponds to the point of junction of the posterior perpendicular line (Fig. 248, B) with a direct extension to it of the Sylvian line (Agnew.) Poirier’s Nasolambdoidal Line.—Beginning at the naso-frontal groove, draw a line outward around the base of the skull, passing a quarter of an inch above the external auditory meatus to a point two fifths of an inch above the lambda, or to a point two and four fifths inches above the inion if the lambda can not be felt. This line passes over Broca’s convolution, one and a half to two and a half inches of the posterior limb of the Sylvian fissure, the inferior border of the supra-marginal convolution, base of the angular gyrus, and terminates at the parieto-occipital fissure. Inasmuch as the relations of the foregoing fissures to all the intracranial areas now open to surgical approach can be definitely determined, any further elucidation in this direction is not necessary. The ability to fix the seat of operation by cranio-cerebral topography only leaves for consideration the technique of opera- tive procedure. The Prepara- tion of the Patient. —The administra- tion of bromides for a week or so be- fore the operation and of morphin or ergot a short time before, is sometimes practiced with the belief that both ce- rebral vascularity and excitability are lessened by these means. Certainly a judicious use of these agents can do no harm, and they are likely to do good. The bowels should be moved freely the night be- fore the operation, and light diet only should precede it and at a proper interval. The pa- tient’s scalp should be closely shaved, scrubbed, disinfected thoroughly, and surrounded with antiseptic gauze bound firmly in place with antiseptic bandages on the day before the operation, if possible. Before the admin- istration of the anaesthetic the situation of important fissures and the pro- Fig. 250.—Lucas-Championniere’s Lines. A B. Horizontal line extending from outer angle of orbit (two and four fifths inches long). B C. Line extending upward to lower end of central fissure (one and a fifth inches long). D. Upper end central fissure (half inch behind mid-sagittal point). CD. Course of central fissure. 1. Speech center. 2, 3, and 4. Centers of arm, leg, and face respectively. Parieho - occip ' Fissure. Fissure of Rolando Fig. 251.—Cortical centers, outer surface. Fissure of Silvius* Fig. 251a.—Cortical centers, median surface. OPERATIONS ON THE NERVOUS SYSTEM. 213 posed seat of the operative attack should be indicated on the scalp with tinc- ture of iodine, an aniline pencil, fine cautery lines, or by other suitable agents. Put the patient on the operating table, with the head elevated, exposed to a good light and placed on a firm support covered with an antiseptic rubber sheet. Chloroform is the preferable anaesthetic in these cases, because the administration is followed by a minimum of cerebral congestion and excite- ment. Morphin should be given more cautiously with chloroform anaesthesia than with that of ether. The markings on the scalp should be made indelible with delicate actual cautery lines, and the cranial surface beneath them vig- orously punctured at frequent intervals of their course by a sharp-pointed instrument. If these precautions be not taken, the final scrubbing of the scalp will blur or erase the markings before their presence can be utilized, and the elevation of the scalp flap will expose an unmarked surface beneath on which the seat of operation can not then be satisfactorily traced. The author has not infrequently driven through the scalp into the skull at the proper places short, sharp, headless steel brads, to indicate the site of oper- ation. The scalp slips over them readily, and they are left standing firmly fixed in the skull. The final cleansing of the scalp, the placing of the anti- septic towels around the head, the arrangement of the assistants, instru- ments, etc., should be completed by the time the patient is jiroperly anaes- thetized, in order to avoid unnecessary delay, as promptness of action in these cases is an important element of success. The Operation of Craniotomy for Cerebral Tumor.—Make a skin flap of large size, horseshoe shape, with the base so formed and directed as to afford good drainage of the ivound, proper vitality of the flap, and complete oppor- tunity for the scrutiny and technique of the surgeon. The flap should be of sufficient size to permit the removal of an ample amount of the cranial bone without undue encroachment on the soft parts. The haemorrhage attending the formation of the flap is profuse and persist- ent, owing to the great vascularity and peculiar structure of the scalp. While the loss of blood can be limited somewhat by elastic circular constric- tion and by acupressure, still it is controlled best by prompt digital and in- strumental pressure. Serre-fines (Fig. 236, o), forcipressure, bulldog and T-shaped forceps are interchangeably employed for the arrest of haemor- rhage. In any event the bleeding points are controlled as fast as they appear, and are tied thereafter when it suits best the desire of the operator. The periosteum covering the portions of bone to be removed is reflected by a crucial incision, and may thereafter be replaced or cut away according to the demands of proper drainage and closure of the wound. The desired amount of bone is removed by repeated applications of a large-sized trephine, supplemented by those of the rongeur or chisel. The forming and turning aside—with or without raising the superimposed soft parts—of a beveled-bor- dered ZD-shaped bone flap with the saw, or of a one in the manner devised by Ilartly (Fig. 277), can be done if practicable. However, separa- tion of the dura from the bone by means of a spatula (i) or dural separators (Fig. 252,/, g) should precede the use of the saw. Haemorrhage from the bone is arrested by pressure with antiseptic gauze or sponge; by plugging 214 OPERATIVE SURGERY. a. Scalpels, b, c. Large trephines, d, e. Bone-cutting forceps, f, g. Horsley’s dural separators, h. Tenaculum, i. Flexible spatula, k, l. Flexible retractors, m. Curved probe-pointed scissors, n. Probe, o. Scoop. P, Q. Mouse-tooth forceps and grooved director. R. Silver teaspoon. Fine curved needles. Fig. 252.—Instruments used in operations for brain tumor. the bleeding point with eatgnt or a bit of aseptic wool; by means of actual cautery, or by crushing together the tables of the skull with a strong forceps at the seat of haemorrhage. The manner of division of OPERATIONS ON THE NERVOUS SYSTEM. 215 the d lira mater and the control of haemorrhage are described, elsewhere (page 203). Fashion and pull aside the dural flap and observe the cerebral character- istics. In making the flap insert a small tenaculum (Fig. 252, h) into the dura at the most dependent part—if consistent with the vascular integrity of the flap—about a quarter of an inch from the border of the bone. Eaise the dura from off the brain and make a small incision through it with the point of a scalpel. Introduce through the opening the blade of a small, curved, blunt-pointed scissors (Fig. 252, m), and divide the membrane equally at either side of the tenaculum a quarter of an inch from the bone for four fifths of the entire circumference of the opening, if this amount of space be needed, and the nutrition of the flap be not imperiled. If the membranes be cedematous, congested, or adherent; if the brain bulge into the opening and its pulsations be feeble or absent, its structure unduly firm and the convolu- tions flattened, intracranial pressure is indicated and the morbid process will be in sight or near to hand. Further exploration of the brain can be made by puncturing it with a small probe, a hypodermic needle, or by free incision with a bistoury. Punctures and incisions of the brain should begin at the apex of a convolution and be continued in the direction of the commissural fibers, not dividing but separating them as much as possible, thus preserving their function. Exploration with needles and probes is often quite unneces- sary, even useless, and perhaps dangerous. Unnecessary when the solidity of the tumor permits the finger to determine its presence; useless when the growth is so soft that touch can not detect its existence, and dangerous from the liability of the wounding of vessels, ganglionic centers, etc. Therefore the educated finger is the best means of exploration and can be safely intro- duced an inch or more beneath the skull and carried around the bor- ders of the opening for this purpose. The employment of the faradaic cur- rent by means of the electrode (Fig. 253) devised for the purpose of stimu- lating the motor centers with which it is brought in contact, to indicate the relations of the resultant movements to the seat of the disease, and also the degree of excitability of the diseased center, is a commendable practice. These manifestations, while both interesting and instructive, bear no necessary association with an operation not directed to the removal of a motor center. Divide the pia in the long axis of the tumor if possible and carefully draw it aside. The haemorrhage arising from a division of the pia can be reduced to a minimum by raising the membrane from the sulci and surface carefully and drawing it aside, or by ligature en masse. If drawn aside, it can be returned to the original site if circumstances will permit. The treatment of the tumor depends on the environment, etc. If the tumor be in view and encapsulated, it should be enucleated with the curved blunt-pointed Fig. 253.—Keen’s electrode. 216 OPERATIVE SURGERY. scissors or a spatula, aided by the finger of the operator. If it be not encapsulated, it may be if desirable removed with a knife, sharp scoop, or a spoon (o, R, Fig. 252). If the tumor be located beneath the brain surface, a free incision is made down upon it and the wound borders held apart with retractors while the tumor is enucleated or cut away as before. The cavity in the brain caused by the removal of the tumor should be lightly packed with a single long narrow strip of iodoform gauze cleared of loose threads, and so placed at the bottom and sides of the cavity that it can be removed gradually or promptly without hindrance. A cystic tumor of the surface is dissected away when possible; if not advisable, the superficial portion is removed, the interior cauterized with nitrate of silver and packed with gauze; if beneath the surface of the brain, it is opened, cauterized, and packed as before ; when of unusual size, of indefinite outline and association, it can be tapped, drained with horsehair or a small rubber tube, and lightly packed with long strips of gauze. In all instances of packing, the gauze should be so introduced that it can be removed slowly and at intervals to avoid any undue disturbance of the brain. If packing of the wound be dispensed with, the dural opening should be closed with fine catgut, leaving an opening at the most dependent part through which horsehair, a strip of gauze, or of lightly rolled rubber tissue is introduced for drainage purposes. If the brain wound be packed with gauze, the sewing of the dura is limited to the proper accommodation of the protruding gauze and its subsequent withdrawal. The scalp, like the dura, is closed in conformity with the demands of drainage, silkworm gut being employed for the purpose in this instance. After a final cleansing, the wound is covered with rubber tissue, upon which is placed in turn layers of aseptic gauze, loose gauze, and aseptic cotton, all of which is held in posi- tion with antiseptic bandages. Horsley and Macewen divide the operation into two stages to avoid the ill effects of the shock so often due to continuous effort. In the first stage the dura is exposed and the wound packed with gauze. In the second stage—some days later—the operation is completed. The Precautions.—The strong tendency of brain matter to escape and to the development of hernia cerebri requires that the gray matter be disturbed as little as possible, that infection be prevented, and that the opening of the dura be promptly and securely closed. If the proper sewing of the mem- brane be opposed by brain pressure, it should be restrained if practicable by counter pressure with a single broad or two narrow spatulae until the sew- ing is completed. If two narrow spatulas be passed beneath the dura, while lying on each other, and separated, like the blades of scissors, the area of re- sistance will be correspondingly decreased; a manifest advantage is thus gained in aid of the complete closure of the membrane. If it be impracti- cable to close the gap in the dura with stitches, the advisability of restraining further escape by means of a thin celluloid plate placed in contact with the opening in the dura and so fitted to the divided borders of the skull as to prevent further protrusion, should be considered. If brain have escaped already beyond the opening in the skull further advance may be prevented OPERATIONS ON THE NERVOUS SYSTEM. 217 by the application to it of a closely fitting metallic cover confined in place with straps. The shaving off of the protruding brain should be regarded as an after and final step rather than as an early and unavoidable one, especially when the portions to be removed possess functional activity and have not yet been subjected to repressive influences. Not long since the author in a case of threatening protrusion following immediately the removal of a cicatrix from the brain and dura applied a thin celluloid plate at once to the lesion in the manner described (see page 219), with a successful out- come so far as the control of the tendency to protrusion was concerned. If the electrode (Fig. 253) be used, it is important to recall that, 1, a strong current burns the cortex, and that one of a strength to cause contraction of the thenar muscle is sufficient for the test; 2, that antiseptics, especially bichloride in solution, prevent electric reaction, and that sterilized water is the best agent for use at this time; 3, that not infrequently the reaction can be excited if the electrode be applied to the uncut dura, and that this fact is important as the brain substance is not then exposed ; and, 4, that the electrode should be thoroughly aseptic when applied to the brain. The Results.—The results of operation for brain tumor depend on the sit- uation, the depth, the nature, and environment of the growth. Encapsulated, non-malignant, and superficial cerebral tumors are the most favorable for operation. Infiltrating tumors are of bad prognosis on account of the loss of brain and blood attending the removal, and the frequent and prompt re- turn of the growth. Cystic growths offer a fair prognosis if they be excised, or be treated by caustic, or drainage and packing. The bare emptying of the cyst and closure of the wound is useless, as it rapidly refills. The prompter the operation the better the prognosis will be in all cases. Cere- bral. Cere- bellar. Total. 81 16 97 26 9 35 1 2 3 89 8 42 15 2 17 Total Results of Operation for Brain Tumor {Starr). Somewhat later Starr reports two hundred and twenty similar operations, in seventy-three of which the tumors could not be found, and in seven could not be removed. The death rate for removal of the remaining one hundred and forty cases was -f- 34 per cent, which is no doubt much too small to represent the outcome of all cases operated on, as many indeed are not reported. McCosh believes that seventy-five per cent is much nearer the true figure. Craniotomy for Cerebellar Tumor.—Owing to the difficulty of diagnosti- cating the exact situation of a cerebellar tumor, a surgical operation for the patient’s relief is largely of an exploratory character. The differences in the technique of this and the operations for cerebral tumor consist in the 218 OPERATIVE SURGERY. formation of the flap and the entrance to the cranial cavity. In other re- spects their technique is substantially similar. The flap of the soft parts is limited above by the upper border of the superior curved line of the occipital bone, below it terminates opposite the second cervical vertebra, the median line of the head limits the inner border, and the posterior margin of the mas- toid process the outer. It is horseshoe shaped, and the incision forming it is carried down to the bone. The flap is reflected, the periosteum remaining undisturbed except at the area of entrance to the cranium; here the mem- brane is turned aside before division of the skull is made. The opening through the skull is formed with a chisel and mallet, is about two inches in diameter, and may be increased thereafter by a rongeur (d e, Fig. 252) as circumstances demand. On account of the thinness of the bone at this situation the surgeon must exercise great care. The dura is divided, the cerebellum explored with the finger or aspirator, etc., and the tumor ma- nipulated as in cerebral cases. The deep soft parts are united with catgut independently of the main flap, which is sewed with silkworm gut after necessary drainage is provided. The usual antiseptic dressings are bound in place with gauze bandages. The Precautions.—As before remarked, the bone at the site of operation is very thin and devoid of diploeic structure, hence thoughtless use of force is likely to injure the soft parts beneath. The lateral (A, B, Fig. 254) and occipital sinuses may be invaded if'the crest and superior curved lines be en- croached upon in opening the skull. Care must be taken not to disturb the middle lobe of the cerebellum, unless the removal of the tumor requires that it be done. The Results.—The results of the operation for the removal of these growths are registered already under the preceding topic. Craniotomy for Epilepsy.—When the motor center primarily involved in the epileptic convulsion can be determined, or when the disease has been preceded by a head injury that is manifest, craniotomy is often performed, and usually with a large-sized trephine. The electrode plays an important part in these cases, as it often serves to locate the center primarily affected. The technique of the use of the trephine and of the removal from the brain and its membranes of a morbid exciting cause has already been sufficiently discussed. The scalp flap should be large enough to afford a broad margin between its borders and those of the bone opening, in order that the healing of each may be entirely independent of the other. Primary union of the entire wound should be sought for as the cicatrization following delayed union may become a provoking element in the production of convulsions thereafter. The introducing into the cranial opening and placing on the freshened surface, of a metallic substance, of gutta-percha, or of rubber tissue, celluloid, decalcified bone plate, etc., for the purpose of preventing or limiting cicatricial action, is advised in those cases where the irritation is thought to have arisen from the influence of previous cicatricial contraction. In the opinion of the author, the stable qualities of thin celluloid plate (^5-inch) establish its worth for this purpose above that of 'otlTer foreign substances of a simple nature. OPERATIONS ON TIIE NERVOUS SYSTEM. 219 Gold-leaf, gutta-percha, and rubber tissues are placed in contact with the pia, the edges underlying somewhat those of the cranial opening, to prevent extending cicatrization. These substances, however, are not trustworthy, as they often become disarranged and disintegrated by the vital influences to which they are subjected. A reliable substance for this purpose is a great desideratum. If, after the removal of the bone, a small cut be made through the dura and a silver probe properly curved be passed through the opening and be- neath it, and swept around, the presence of adhesions can often be deter- mined. The removal from the brain of a cicatrix or motor center for relief from epilepsy is rarely followed by cure, since the repair of the wound pro- duces a cicatrix which, later, usually causes the convulsions to recur. The Remarks.—No patient should be operated on unless the attacks have been scrutinized as to the part first affected and the order of advance of the convulsion by one competent to make the observations. The statements of relatives and of sympathetic and ignorant observers can not be relied on in these cases. A motor center is removed cautiously in the direction of the fibers (page 215) with knife or scissors, and the removal should be complete, or the attempt at cure will be useless. If the condition of the membrane will permit, the pia should be raised up and pushed aside, rather than torn or cut; thus haemorrhage will be lessened, and then, if advisable, the mem- brane can be replaced. The bleeding from large vessels of the pia can be controlled if the vessels be tied independently in two situations with fine catgut ligatures passed around them by the aid of a needle, and cut between the points of tying. The Results.—The procedure itself is not devoid of danger by any means, and the results of operations for the Jacksonian, focal, and long-standing trau- matic varieties of this disease are almost invariably followed by grievous dis- appointment. It is difficult, indeed, to say as yet whether the removal of a motor center of the brain for the cure of epilepsy is justified by any other fact than that of the sad hopelessness of the case. Operation for traumatic epi- lepsy offers better results than in other forms, especially if performed before the development of the convulsion habit that too often complicates the cases of long standing. As a whole, the results from operative procedures in the latter variety of cases may be regarded as quite satisfactory. However, those reports announcing a cure of fifty per cent should be accepted with great re- serve, as much time should elapse before the final estimate of a case is made. Craniotomy for the Evacuation of Pus.—A knowledge of the presence and situation of abscess following injury of the cranium is based on the facts of the location of the injury, the local and constitutional symp- toms of inflammation and suppuration, and the later development of the symptoms of cerebral compression. The proper site for operation in trau- matic abscess is over the area of cerebral compression irrespective of the seat of the injury. If hemianopsia be the first symptom to occur, the tre- phine should be applied over the occipital lobe involved in the morbid manifestation. If the pus be between the dura and cranium, the removal of a button of bone affords a prompt discharge of the fluid and relief to the 220 OPERATIVE SURGERY. patient unless pyaemia complicates the recovery. The pus cavity should be thoroughly flushed with a five-per-cent solution of carbolic acid, loosely packed with iodoform gauze, and covered with a moist antiseptic dress- ing. If the pus be not found at this situation, raise a flap of dura and explore the brain with an aspirator, passing the needle in various directions until pus is found, being careful to withdraw the needle and insert it at a different point each time the direction is changed. If pus be found deep in the brain, the needle should be left in position as a guide to the puru- lent collection. If the pus be superficially located, the needle is with- drawn. Before evacuation of the pus the diploeic structure should be pro- tected from the danger of infection by smearing it with a compound of glycerin and iodoform or some other antiseptic mixture. The pus is then liberated directly or by careful separation of the brain along the course of the needle with a grooved director or dressing forceps. The liberation of the pus is quickly followed by the introduction into the abscess cavity of a double-barreled drainage agent formed by placing two small soft drainage tubes parallel with each other and fastening them together. The cavity can then be quickly washed out through one tube by pouring through the other a gentle stream of warm sterilized water or a boric-acid solution. The tubes are fastened in position with a large safety pin to prevent their further en- trance into the cavity. The wound is then packed loosely a little beyond and around the tubes with iodoform gauze, the whole covered lightly with anti- septic gauze and confined in place with gauze bandages. If the discharge be free, at the next dressing one tube can be removed and the other short- ened if necessary. The wound is dressed once or twice daily to insure free drainage, the remaining tube being shortened from time to time to keep pace with the closure of the cavity. Two or three weeks are sometimes required to effect this process. The opening in the dura and the scalp should be closed as soon as possible to avoid the formation of hernia cerebri. Cerebral abscess is usually a sequel of otitis media and of suppurative processes of the orbital and nasal cavities. About half of all cases of cere- bral abscess of either the acute or chronic form are due to otitis media. Ab- scess also develops in the cerebellum as the result of this disease. The com- parative rate of occurrence is about four in the temporo-sphenoidal lobe of the cerebrum to one in the cerebellum, and much more often at the right than the left side of the cerebrum. Barely do they appear in the pons and crura cerebri. Abscess from this cause often develops insidiously, and the diagnosis is frequently obscure and delayed. Cerebral abscess may be con- founded at first with sinus thrombosis or meningitis, either of which is as frequent a sequel of otitis media as is abscess. The Operation for Cerebral Abscess.—Shave and scrub the scalp; draw Beid’s base line; indicate on the scalp a point located an inch and a quarter above and the same distance behind the center of. the meatus. At this point, according to Barker, a space three quarters of an inch in diameter corresponds to the location of nine tenths of the abscesses of the temporo- sphenoidal lobe. Birmingham adds half an inch to the perpendicular line to avoid more certainly the lateral sinus (Fig. 254). The technique is simi- OPERATIONS ON THE NERVOUS SYSTEM. 221 lar here to that for abscess elsewhere in the brain, until after the button is removed. Then place the finger lightly on the dura. If pulsation be absent or feeble, the presence of abscess is indicated, especially in the absence of a depressed circulation. Open the dura sufficiently to expose the brain surface, and if pus be not seen introduce a good-sized aspirating needle inward, for- ward, and downward toward the apex of the petrous bone, about two inches. The pus in these cases is usually too thick to jmss through other than a fair- B’io. 254.—Diagram of adult skull, illustrating various points for craniotomy. Horizontal measurements are made from the centers of the auditory meatus along Reid’s base line, R R. Vertical measurements meet this line at a right angle. A. Sigmoid portion of lateral sinus, a point on the base line three quarters of an inch from the center of the meatus. B. Transverse portion of the sinus, a point an inch behind the meatus and a quarter of an inch above the base line. C. Mastoid antrum, the point of meeting of a line drawn along the upper wall of the meatus parallel with the base line, and one drawn at the posterior wall at right angles with the base line. D. A point for cerebral abscess (temporo-sphenoidal), three quarters of an inch above the base line at posterior border of meatus. E. A point for cerebellar abscess, an inch and a half behind the meatus and a quarter of an inch below the base line. F. A point for anterior branch of middle meningeal, at an inch and a half behind external angular process of frontal bone and the same distance above zygoma. G. A point for posterior branch of middle meningeal, one inch and three quarters behind ex- ternal angular process and a quarter of an inch above zygoma. H. A point for tap- ping the lateral ventricle, an inch and a half above center of meatus. Note.—It will be noted that some of the measurements indicated above vary consider- ably from those of the text, but inasmuch as all are the outcome of extended experi- ence and observation of competent men, it is difficult indeed, even if wise, to express a decided preference. If either prove unsatisfactory, another should be tried, using the trephine again, or extending the primary opening with the rongeur. The illus- tration (Fig. 254) can be utilized for other measurements than those stated in the description, and with equal facility and exactness. sized needle ; for this reason the use of ordinary hypodermatic needles should be discouraged. Failing to find pus with the first insertion, the effort is repeated in different directions as described on the preceding page. If pus be not found thus, the presumption should be that it is not present. However, 222 OPERATIVE SURGERY. if the evidence of intracranial pressure, as indicated by flattened convolu- tions, congested vessels, marked protrusion of the brain into the opening, modified pulsation, etc., be noted, a needle of larger caliber should be intro- duced ere the procedure is relinquished. If pus be found, the manner of evacuating, draining, and the subsequent treatment of the abscess and wound are the same as already described. The fact that these abscesses are due to direct infection and contain foul and offensive pus should stimulate at- tention in the highest degree to antiseptic care. Frequent washing out of the abscess cavity with Thiersch’s fluid is required for some time if the offensive discharge continues. The anterior surface of the petrous portion of the temporal bone, roof of the tympanum, and the petro-squamous fissure can be examined for abscess through a half-inch opening located directly above the external meatus seven eighths of an inch. Through this opening the entire anterior surface of the petrous bone can be explored by passing a small probe cautiously along between the dura and the bone. If pus be found, it should be liberated and the pus cavity thoroughly drained. If necrosed bone is present, it should be removed if loose ; if not, thorough drainage and cleanliness should be established until the diseased bone comes awTay or is removed, after which the wound is treated in the manner usual in cases of this nature. The Precautions.—If the needle be inserted too far, the basal ganglia may be injured ; if misdirected and carried too far, the petrosal sinuses may be en- tered. The use of a needle of small caliber is unresponsive and therefore undecisive and deceptive. However, if the aspiration be negative, the exam- ination of the contents of the lumen of the needle with a microscope may disclose the presence of pus. A small opening only should be made in the dura before the detection of pus, for if pus be not found, the opening can be easily closed. The oval flap of the dura should be made after pus is found and in the manner before described (page 215). Great cleanliness and care are necessary to prevent secondary meningitis from purulent contact. Cerebellar abscess from otitis media can be reached through a half-inch opening in the cranium made either at a point an inch and a half behind and a quarter of an inch below the center of the meatus (Fig. 254, E), or two inches behind and an inch below this opening (Birmingham), to avoid the occipital artery. At the former place the anterior border of the trephine rests directly behind the posterior border of the mastoid foramen. An escape of pus from the mastoid foramen, due to lateral sinus involvement, should be looked for at the time, since a diseased sinus may be mistaken for a cere- bellar abscess. The Results.—The insidious development, the late recognition, and the persistency of the exciting cause in abscess of the brain invest the outcome with a somber hue. The death rate from all causes after operation is forty per cent. The rate from abscess due to middle-ear disease alone is much greater than this. Craniotomy for Thrombosis of Lateral Sinus and Jugular Vein.—The operative measures for this condition are the recent outcome of increased diagnostic acumen and of improved surgical technique. The thrombosis is OPERATIONS ON TIIE NERVOUS SYSTEM. 223 a sequel of otitis media, and it happens quite as frequently as does abscess of the brain. Inasmuch as these cases terminate fatally if unaided, operative measures should be prompt and decisive. The Operation.—In the presence of rigid antiseptic technique, carefully expose the lateral sinus through a trephine opening, three quarters of an inch in diameter, the center of which is located a quarter of an inch above and an inch behind the middle of the bony meatus (Fig. 254, B). This opening can be extended as circumstances require by aid of the rongeur. An extension forward (A, C) is advised, so as to open the sigmoid portion of the sinus and the mastoid antrum to permit removal of diseased tissues. Examine the sinus with the finger and explore it with a hypodermic syringe also, if any doubt exists as to a thrombotic condition of the vessel. If thrombosed, it is advised by some to expose the internal jugular vein in the neck and ligature it, to prevent the escape into the circulation of loosened clots from the sinus. It is possible, however, for the disease to extend in- ward through the upper tributaries of the vein, in spite of every preventive effort. Then open the sinus and remove the thrombi with a small scoop aided by antiseptic douching. If severe lnemorrlmge occurs, plug the bleed- ing point instantaneously with a strip of iodoform gauze already prepared for the purpose. If haemorrhage from the sinus is feared on account of incom- plete closure with thrombi, ligature the sinus before opening it. If feasible the clots are removed from the vein and sinus and the lumen is cleansed by a through-and-through stream of antiseptic fluid. If the thrombi can not be safely removed, the wounds are then drained with small rubber tubes and packed with iodoform gauze. They should be cleansed and dressed fre- quently during the course of treatment, especially if thrombi still remain in the vessels. The Precautions.—If severe haemorrhage occurs from the sinus, apply a tampon to the bleeding point and allow it to remain for two or three days until further bleeding is obviated. Be careful not to shut into a sinus or vein any of the thrombosed contents by tying through a diseased point. In the removal of the central thrombus, cleanse thoroughly the parts as the clot is removed, so that the stopping of a sudden gush of blood with the tamponade will not push inward loose infecting agents, nor will the previous site of an infected clot provoke infection of one newly formed. If the cen- tral clot be firm and inoffensive, presenting no evidence of disintegration, the question of the wisdom of its removal may properly arise, and it should be decided by the other circumstances that attend the case. The Results.—About fifty per cent of cases recover with operation ; without it a recovery need not be expected. Craniotomy for General Paralysis of the Insane.—The trephine has been applied to the parietal region and at the seat of defined headache in a few instances with and without opening the dura for drainage pur- poses to afford relief in this condition. Tapping the ventricles has been practiced also, but little encouragement has resulted from either method of practice. Opening the Mastoid Antrum.—The mastoid antrum is opened to relieve 224 OPERATIVE SURGERY. it of inflammatory products that enter from an inflamed middle ear or re- sult from inflammation of the antrum and mastoid cells themselves. The Important Facts.—In the infant, the mastoid process is not present, but the mastoid antrum is, and in the form of a cell communicating with the middle ear. Later the mastoid process appears and the antrum becomes more deeply placed, until at the age of ten when the outer wall is about two fifths of an inch in thickness. At puberty numerous other cells are present in the process. In the adult the area of cell development is limited below by the masto-occipital suture ; anteriorly it extends above the meatus, Pig. 255.—Instruments employed in opening the mastoid antrum. a. Small crown trephine, i. Ordinary gimlet, c. Mallet, d. Ordinary brad awl. e, f. Gouges, g. Scoop. Forcipressure, ligatures, and drainage agents may be needed. and superiorly to within half an inch of the temporo-parietal suture. At this time the antrum is the size of a pea and is separated from the cranial cavity by a wall one twenty-fifth to six twenty-fifths of an inch in thickness, and from the lateral sinus and the external surface of the mastoid process by walls one half to three quarters of an inch in thickness. It now corresponds to a point immediately behind the meatus and below the level of its upper border. The lateral sinus varies somewhat in its relations with the mastoid bone (Fig. 254). It approaches to within one inch and a half behind and three quarters of an inch above the center of the bony meatus, then turns more or less abruptly downward and passes one half inch behind the external meatus, and runs to a point one sixth to one quarter of an inch below the floor of this opening before reaching the base of the skull. OPERATIONS ON THE NERVOUS SYSTEM. 225 The Operation.—Shave and cleanse the external surface much beyond the seat of operation, also cleanse and tampon with antiseptic gauze the external ear; make an incision with a scalpel down to the bone in the median line of the mastoid process, from the base to the apex; push aside the periosteum, penetrate the bone at a point just below the level of the upper border of the meatus and as near as possible to its posterior border in the direction of the long axis of the external auditory canal, for three quar- ters of an inch, with a carpenter’s gimlet (Treves), a drill, a small sharp gouge, or a quarter-inch trephine. A perception of diminished resistance, and the appearance of pus on the withdrawal of the instrument, indicate the attainment of the object. The opening is enlarged with a gouge, dis- eased tissue is removed with a scoop, and the wound thoroughly cleansed by means of a syringe and a strong antiseptic solution. The cavity is then drained and dressed with iodoform gauze, supplemented with dry antiseptic gauze and bandages. The dressing should be changed often that the wound may be properly cleansed. The Precautions.—If the incision of the soft parts be carried too far up- ward, the posterior auricular artery will be severed. If the penetration of the bone be not made parallel with the long axis of the auditory canal, either the lateral sinus, the external ear, or the cranial cavity may be entered with the instrument. The depth of the penetration and the penetrating force employed must be carefully estimated, otherwise the cranial cavity will be entered and infective meningitis will follow. The use of the trephine de- vised for this purpose should be limited to adults, owing to the small size of the petrous bone in infants and children. Gouges and drills are inferior to the gimlet for this purpose, as the latter may be used slowly and deliberately while the force necessary to drive the former is estimated with some diffi- culty. If the index finger be placed along the side of the instrument, or it be grasped firmly with the disengaged hand, the advance of the instrument will be properly controlled. The cavity of the external ear should be cleansed and tamponed with gauze at each dressing of the wound, to main- tain proper cleanliness. The Results.—The results are favorable if the operation be done with suffi- cient promptness to anticipate the development of the important sequels. The operation itself is devoid of danger. Trephining the Frontal Sinus.—Trephining the frontal sinus is practiced for the removal of foreign bodies, necrosed bone, etc., from this cavity. The frontal sinuses are absent in the infant, rudimentary in children, and have no surgical significance until after puberty. They differ much in size and extent in adults, and sometimes communicate with each other at the median line. The Operation.—Cleanse and shave the surface; make a vertical incision down to the bone, an inch and a half in length, from the root of the nose upward or one transversely outward so that the eyebrow will hide the cicatrix (Fig. 203) ; push aside the periosteum at the point of attack ; open the sinus with a small trephine or sharp gouge applied to the anterior wall; cleanse the cavity with Thiersch’s fluid, remove foreign bodies, diseased products, 226 OPERATIVE SURGERY. etc. If the infundibulum be closed or constricted, open it with a bougie. Drainage can be made through this canal into the nose or through the ex- ternal wound, and perhaps through both, according to circumstances. The external wound is treated in the usual way. The Precautions.—Strong antiseptic fluids should not be employed here, neither should the unrestrained escape of inflammatory products be permit- ted, on account of the proximity of the eyes. Gunshot Wounds of the Cranium.—Much change has taken place in the treatment of this form of injury since the advent of antiseptic surgery and the localization of brain centers. The consecutive steps of treatment divide themselves quite naturally into, 1, the aseptic technique ; 2, the ar- rest of haemorrhage; 3, the enlargement of the opening and the eleva- tion of depressed fragments of bone; 4, the removal of foreign bodies from the wound; 5, the establishment of good drainage; G, the control of inflam- mation. The antiseptic technique should be rigid throughout in all respects and in each detail. The scalp is shaven, and thoroughly scrubbed and cleansed, and the face, neck, ears, and auditory meatus made thoroughly clean, and the latter plugged with iodoform gauze. The surgeon and the entire outfit are antiseptically prepared. Ilcemorrhage from the scalp, skull, and membranes of the brain are con- trolled as already indicated (page 214). Haemorrhage from a sinus, if acces- sible, can be arrested promptly by an antiseptic tampon and thereafter the wound in the sinus can be closed by sewing or tying the opening, or by con- tinued tamponing, as the character of the injury suggests. Haemorrhage from the brain substance will likely have stopped before the patient is seen by the surgeon. Haemorrhage from the wound track in the brain is diffi- cult, indeed, to arrest, especially if it be severe. In fact, ligature of the carotid of the same side is advised by some in obstinate cases., The careful introduction along the track of the wound to the bottom by means of a probe of a long, thin, infolded strip of iodoform gauze serves not only to arrest the haemorrhage in the great majority of cases, but also acts as a drainage agent at the same time, which is a matter of great importance, especially if the wound requires tamponing before being cleansed. However, as soon as the patient’s condition permits, steps should be taken to measure the surgical aspects of the case. The Operation.—Chloroform anaesthesia is advised if the patient be not already unconscious or at least insensible to manipulative procedures. Place the patient in a good light; make a liberal-sized, oval scalp flap, leaving the pericranium in place; with the rongeur increase the size of the cranial opening sufficiently to permit the arrest of the bleeding points of the bone and membranes of the brain; also, to permit of a suitable exam- ination of the extent of the injury. All depressed and loose fragments of bone and foreign bodies that appear on the surface of the brain and at the wound are removed, except when the depressed bone can be properly restored. The foreign "bodies found within the brain are the bullets, fragments of OPERATIONS ON THE NERVOUS SYSTEM. 227 bone, and perhaps hair and textile fabrics. The bullet must be located before it is removed, and probes are the agents employed for this purpose. The probe should be light, about a quarter of an inch in diameter at the advanc- ing end, and when used carried along the track of the ball with a degree of gentleness and care that will lead to a prompt appreciation of a change Fig. 256.—Fluhrer’s probe. in the course or the presence of increased opposition to the passage. Ruth has determined that a probe a quarter of an inch in diameter is caused to penetrate normal brain tissue by a pressure equaling two and a half to three ounces. Of course a smaller end lessens proportionally the amount of pres- sure required for penetration. The probe devised by Fluhrer, composed of aluminium (Fig. 256), and the one devised by Girdner, known as the tele- phone probe, are as yet by far the best for the purpose. Fluhrer’s probe is so light and blunt that its passage along the wound can do no harm, and, too, it can be manipulated with a delicate, unweighted touch. Girdner’s Fig. 257.—Girdner’s electric probe. telephone probe is already so well known as not to require a detailed de- scription (Fig. 257). The author is indebted to Dr. Girdner for the fol- lowing brief statement of the use of his probe: “ Place the metal bulb (a) in the patient’s buccal cavity between the teeth and cheek. Hold the receiver (b) to the (your) left ear with the left hand. Take the probe 228 OPERATIVE SURGERY. handle (c) in the right hand and explore the wound for the bullet or other metallic substance. No sound will be heard in the receiver when the probe (d) touches soft tissues or bone, but the slightest contact of the probe with a metallic body produces a sharp clicking, grating, or rustling sound in the receiver. No bat- tery of any kind is used. The current which operates the instrument is de- rived from the body of the patient; in other words, each patient supplies from his own body the current necessary to locate the missile it contains.” Not only will this instrument indicate the site of the bullet, but it will locate also the lead fragments that are shed by it along its passage through bone, a fact that may mislead the surgeon, unless the probe with the insulated stem be used. This instrument finds its most significant use in locating missiles in the brain, since it responds to the most delicate touch of a metal substance. If the bullet be located, the question of removal through the point of entrance, through a counter-opening, or leaving it alone must be considered. If it be in the opposite hemisphere of the brain, Fig. 258.—Bullet forceps. Fig. 259.—Author’s method of locating site of counter-opening. and can be reached with forceps (Fig. 258), carefully introduced, grasped and withdrawn without force, well and good. However, it is better practice, in my judgment, to make a counter-opening promptly, remove the missile and establish good drainage, than to encounter the dangers of prolonged and uncertain effort that too often attend attempts of direct approach and re- OPERATIONS ON THE NERVOUS SYSTEM. 229 moval. If the missile have gone through the head, good drainage can then be easily established. This is accomplished by passing the Fluhrer probe carefully along the track of the wound, and out through the opposite open- ing, attaching a thread to the end, withdrawing the probe, and leaving the thread in the track of the wound, by aid of which a No. 9 or 10 French fenestrated catheter, thoroughly disinfected, is drawn into the wound and left for drainage purposes. If a bullet can be approached safely through a counter-openiing, the proper site for this opening can be found by pushing a long probe past the bullet through the brain to the skull (Fig. 259, «, b). Now, if a string be attached to the outer end of the probe, and be carried across the head at various points (Fig. 259, c, c, c, c), while placed each time in a direct line with the protruding portion of the probe, it is manifest that the point of crossing of these lines will correspond to the point of impingement on the skull of the intracranial end of the probe, at which point the opening should be made (Fig. 260, d). The end of the probe is then carried through the opening, and the bullet is sought for by a grooved director passed suc- cessively through the tissues on all sides of the probe. When found the bullet is removed by forceps passed along the grooved director. After this the fenestrated catheter is drawn into position the same as before. This plan which was devised in 1887 by the author and employed at once with success on a case in Bellevue Hospital is eminently practical and can be promptly util- ized, requiring only a long probe and a string for the purpose. If the bullet strikes the oppo- site side of the skull, the probe is introduced to the point of impinge- ment, and the seat for the counter-opening is indicated and made as in the preceding instance. However, the bullet in this instance is likely to be at a distance of an inch or so from the point of impingement, in the direction indicated by the angle of incidence. In such cases the counter-opening should be not less than an inch and a half in diameter, to admit of easy exploration for the ball. The course of the re- flected ball through the brain is sometimes apparent; again, it may be neces- sary to locate it with the aid of a sharp needle passed into the brain in the direction of the line of incidence. In efforts of this kind the needle probe of the Girdner apparatus is of great value, as by its use the bullet can be located with certainty and with a minimum injury of the brain. If a deep- Fig. 260.—Site of counter-opening (d) located by authors method. 230 OPERATIVE SURGERY. seated bullet be touched with a probe, and the direction of the wound be such that the establishment of a counter-opening in its course is impossible or unwise, then perhaps a large opening can be made through the skull at a point nearest to the ball. Through this opening the ball is sought for and located with the needle probe of Gardner, which if left in position in the brain affords a certain guide to the missile, which can then be removed as before. In such instances as this suitable drainage for each portion of the wound is necessary, as a drainage agent can not be carried through an angular wound of the brain for obvious reasons. If a bullet can not be found, or if removal be inadvisable, a small fenestrated rubber tube is introduced gently into the wound as far as practicable, fastened in position, and flushed gently with warm Thiersch’s fluid or the warm saline solution. After-treatment.—After the tube is fastened in position and the wound is carefully dressed with dry antiseptic gauze bound lightly in place, the patient’s head is so arranged, if feasible, that the force of gravity will favor the escape of discharges from the wound. The controlling of inflammation requires that the head and shoulders be raised, a cold water coil applied to the head, bowels freely moved, and that anodynes be administered according to circumstances. The wound should be dressed as often as proper cleanliness requires for the purpose of hastening repair and the prevention of septic meningitis. Thiersch’s fluid and the saline solution used warm are the best agents for flushing purposes, as they are unirritating. After the repair of the wound is well under way, horsehair as a drainage agent should be sub- stituted for the rubber tube. The interchange can be easily and safely made by pushing into the end of the rubber tube for a short distance a small wisp of aseptic horsehair, which is then left in position by the with- drawal of the tube. As the wound heals, the increase in repair is accom- modated from time to time by the withdrawal of a proportionate amount of the hair. The Precautions.—Avoid the cranial sinuses in making counter-openings, and also the basal ganglia in explorations. If a bullet be in the lateral ven- tricles it is dangerous and useless to attempt the removal. If a bullet be near the ventricles it is very liable indeed to be pushed into them by efforts of removal. A much spent bullet will not rebound at an angle equal to that of incidence, but will remain in contact with the skull and membranes at a point near to that of primary impingement. Fragments of bone and other foreign bodies lying in the course of the wound must be carefully sought for and removed before using the Fluhrer probe, to avoid their being carried still farther into the brain by the introduction of this agent. In fact, after the removal of these bodies, the introduction along the track of the ball of a small fenestrated rubber tube and the backward flushing incident to the careful introduction into it of a warm saline solu- tion, may not only cleanse the wound but check the oozing from the brain substance. The Results.—The following tables, which were a part of a paper read before the New York State Medical Society in 1888 by the author, speak for themselves of the wisdom of operative procedure, although not OPERATIONS ON THE NERVOUS SYSTEM. 231 with sufficient emphasis, as these results are not the product of aseptic method : Lobes of Brain Implicated. BALLS REMOVED AND ES- CAPED PRIMARILY. BALLS NOT REMOVED. No. Died. Recov- ered. No. Died. Recov- ered. Frontal 33 17 16 27 13 14 Parietal 6 1 5 5 4 1 Temporo-sphenoidal 15 3 12 9 6 3 Occipital 8 3 5 6 3 3 Cerebellar 4 4 0 2 1 1 Frontal and parietal 3 1 2 1 1 0 Frontal and temporo-sphenoidal 6 3 3 0 0 0 Frontal, temporo-sphenoidal, and occipital.... 5 3 2 3 3 0 Parietal and occipital 2 1 1 0 0 0 Temporo-sphenoidal and occipital 2 1 1 2 1 ■1 Temporo-sphenoidal, pons, and crura cerebelli 1 1 0 0 0 0 Total 85 38 47 55 32 23 Tabulated Statement of the Cases in which the Missiles Escaped Primarily. From No. Died. Recov- ered. Frontal lobes 3 1 2 Parietal lobes 0 0 0 Temporo-sphenoidal lobes 8 1 7 ()ceipital lobes 3 1 2 Cerebellar lobes 3 3 0 Frontal and parietal lobes 0 0 0 Frontal and temporo-sphenoidal lobes 6 3 3 Frontal, temporo-sphenoidal, and occipital 3 2 1 Parietal and occipital lobes 1 1 0 Temporo-sphenoidal and occipital lobes 1 1 0 Temporo-sphenoidal, pons, crura cerebelli 1 1 0 Total 29 14 15 The showing favoring surgical interference in this series of cases is greater than that of many others, notably those of Huhn, which only slight- ly favor removal. Fowler, however, reports sixty cases treated under aseptic and antiseptic methods with the following results : Bullet removed in twenty- four cases, mortality sixteen per cent; not removed in thirty-six cases, mor- tality fifty-nine per cent. THE SPECIAL OPERATIONS ON NERVES. It often becomes necessary, on account of neuralgia, spasm, tremor, vio- lence, etc., to operate on the trunk of the nerve involved after other means have failed either by, 1, nerve-section or neurotomy; 2, nerve-resection or neurectomy ; 3, nerve-stretching or neurectosy; 4, nerve-suture or neuror- rhaphy ; 5, nerve-grafting. Nerve-section and nerve-resection differ in the extent of the operative 232 OPERATIVE SURGERY. procedure. In the former, the nerve is divided at one point; in the latter, at two separate points, and the intervening portion of the nerve is removed. Either of these measures can be practiced singly or in conjunction with nerve-stretching, the latter always taking precedence. The portion of the trunk of the nerve attacked either in section or resection should, 1, be healthy at the seat of operation; 2, be located at the proximal side of the seat of the disease calling for the operation; 3, should command the sen- sory fibers of the diseased area, for otherwise the operation can not be en- tirely successful; 4, should not include important motor fibers. Nerve- section is not much employed now, as it affords but temporary relief, owing to the more or less prompt repair of the divided nerve. Nerve-resection is commonly employed instead, and the length of the portion removed de- pends, of course, on the size and length of the nerve trunk involved; not less than two inches should be removed if practicable; and even then in some instances the divided extremities are turned away from each other, or tissues are interposed between them to fortify against the possibility of a future reunion. Nerve-section is done by either the subcutaneous or open methods; the latter is the more successful measure and less liable to cause injury of contiguous structures; but it invites the presence of cosmetic defects. While in the great majority of instances these operations assume no special magnitude, still strict aseptic measures should be a part of the entire procedure. Nerve-stretching.—Nerve-stretching has a greater range of application than has the division of nerves, and its employment usually antedates the use of the severer operative measures. A failure of this means of treat- ment is not followed by a long or grievous disturbance of function, as the immediate effects are of comparatively short duration. The following facts relating to this procedure are of practical interest: Nerves can be stretched about one twentieth of their length; nerves in central locations are less extensile than are those in peripheral; nerves near to the spinal cord are more extensile than are those at a distance; those of the upper are more so than those of the lower extremities. The traction is made with the thumb and finger, the finger alone, or with a hooked instrument; it is made gradually and forcibly, the force employed corresponding to the size and seat of the nerve, and is directed to the central and peripheral extremities If a sense of a limited and sudden giving away happens traction should cease at once, as rupture of the entire nerve may quickly follow. Aseptic measures should attend this operation, where the nerves are exposed through a free incision. In dry stretching these measures are unnecessary. The degree of traction exercised by the surgeon in individual instances and the results will be expressed in connection with the operations on the respective nerves. Nerve Suture.—There is now no question of the fact that the ends of divided nerves should be united with each other, when possible, with sutures. Although this course is not followed by restoration of function in all in- stances, still the frequent happy results that follow the measure admonish the surgeon to be prompt and urgent in the treatment of these cases. OPERATIONS ON THE NERVOUS SYSTEM. 233 Primary and secondary suturing are practiced ; the former relates to recent, the latter to old cases of nerve division. In both instances, however, only recently divided or freshened nerve extremities are united with each other. In primary suturing (Fig. 261), with no loss of substance, the ex- tremities can be united at once with two fine catgut or silk sutures passed through the ends of the nerves at right angles to each other (a) with a fine needle and tied. The sutures should be passed as near to the periphery of the nerve as is consistent with proper repair, even if the sheath of the nerve only be transfixed (6). Any tension at the line of junction of the extremi- ties should be avoided, as it greatly prejudices the chances of cure. The tying of the ends (c) is seldom practicable, and in no event a suitable substi- tute for sewing. Tension of a nerve is commonly the result of a loss of sub- stance or retraction of the nerve, due to injury, or is the outcome of the freshening of the divided ends for reparative purposes. Tension or separa- tion of the extremities may be lessened, or overcome entirely, by stretching the nerve, by flexion of the part containing it, and by nerve-grafting. The shortening of a limb by excision of the bone to meet curtailment of the nerve is such a harsh method of action that it should not be contemplated, except under the most urgent demands. Variously arranged sutures are ad- vised for the union of divided nerves, but usually the one just described is quite as good as any. Fig. 261, d, e, f, shows another and a serviceable method of repair. Pig. 261.—: ■Primary suturing of nerves, In a few instances and under favorable circumstances, union has taken place in three or four days, as indicated by returning sensation. However, a like number of weeks is the common period, and in some cases months and even years may elapse before the evidences of union appear, if at all. Secondary suturing is applicable to cases of old injury of nerves in which loss of function and atrophy have supervened. The ends of the nerve are usually widely separated, and are adherent to the contiguous tissues. The proximal end is bulbous, the distal atrophied, and both are imbedded in cicatricial tissue. The operation is aseptic in every detail. The Esmarch bandage is sometimes employed. The nerve ends are exposed, the nerves 234 OPERATIVE SURGERY. stretched, and cicatricial tissue removed. Thin layers are sliced off from the end of the bulbous extremity until healthy nerve tissue is reached. If any part of the bulbous extremity remain, it is utilized as a firm basis for Fig. 262.—Gleiss’s method of secondary suture. sewing purposes. The distal end is trimmed but little, scarcely a quarter of an inch, for, says Bowlby, “ It is seldom necessary to remove as much as a quarter of an inch, and, however unhealthy the section may look, no good is ever to be gained by a further sacrifice.” From three to four sutures of fine catgut, silk, or kangaroo tendon, are passed through the nerve at about a quarter of an inch from the extremities and tied. A cambric needle or any small needle with non-cutting borders should be employed to carry the sutures. Owing to the cicatrix it may expedite matters if the nerve be iso- lated outside of the cicatricial tissue, and then followed to the seat of injury, rather than that it be directly approached at that point. Gleiss advocates the following methods of union in these instances, and reports ten complete cures in eleven cases—grafting is practiced in one instance («); linear di- vision (b), followed by approximation and sewing in the other (c) (Fig. 262). The wound is closed without drainage and the tissues are relaxed by posture, if possible, and the limb firmly fixed by an immovable splint until the wound is healed. After this, massage and galvanism should be employed to restore the tone of the parts. The Results.—The results are flatteringly exhibited in the following table (Bowlby) : Suc- cessful. Im- proved. Fail- ure. Total. Primary suture 32 34 14 80 Secondary suture 32 26 15 73 Neuroplasty is utilized to fill in the gap between the ends of nerves which nerve-stretching, position of the limb, etc., have failed to accom- plish. Single (a, a) and double (b, b) flaps of the extremities of the nerves are made as occasion demands, and are united with each other or with the OPERATIONS ON THE NERVOUS SYSTEM. 235 nerve extremity, as indicated in the illustration (Fig. 263). In neuroplasty for cure of old injuries the method of Duncan commends itself for trial (Fig. 264). The connection of the ex- tremities by one or several strands of fine catgut by sewing (Fig. 265), and Fig. 263.—Neuroplasty. Secondary suturing of nerves. the grafting of one nerve to another (Fig. 2G6) and the ingrafting the gap with recent human or animal nerve tissue by means of sutures are sometimes followed by results which offer encourage- ment for continued effort in this direction. Fig. 264. Duncan’s method of neuroplasty. Fig. 265. Repair of nerves by catgut. Fig. 266.—Grafting of adjacent nerves for a nerve defect. C. Central or- gan. P. Peripheral. 236 OPERATIVE SURGERY. OPERATIONS ON SPECIAL NERVES. In the consideration of special nerves only such points as are distinctly applicable to each of them will be stated, as the general technique of opera- tions on nerves has been considered sufficiently already. The Supra-orbital Nerve.—The supra-orbital nerve can be divided, re- sected, and stretched at its exit from the supra-orbital foramen or notch located at the junction of the inner and middle thirds of the supra-orbital arch. If a notch be present, it can be readily felt with the finger. At this FIRST DIVISION OF THE TRIFACIAL NERVE. SUPRA- TROCHLEAR N. SUPRAORBITAL' A. AND N. ) ORBICULA RI5\ PALP. M. I Fig. 267.—Supra-orbital and infra-orbital nerves and frontal sinus. situation the nerve is covered by integument, fascia, and the combined fibers of the orbicularis palpebrarum, occipito-frontalis, and corrugator supercilii muscles. It is accompanied by vessels of the same name as itself. The OPERATIONS ON THE NERVOUS SYSTEM. 237 nerve often divides into two branches before reaching the seat of operation. It may be divided by the subcutaneous or by the open method. If by the former, steady the eyebrow and locate the notch with the left hand ; then pass the point of a narrow bistoury beneath the integument from within outward, turn the edge, and cut strongly across the notch toward the upper boundary. A firm compress should be applied to the wound at once to control the bleeding from the supra-orbital vessels. The nerve can be divided, resected, or stretched through either of the following cutaneous incisions : The First Operation.—Steady the eyebrow with the left hand ; with the right draw the eyelid downward and hold it with the thumb of the left. Make a horizontal incision about an inch in length along the superior mar gin (Fig. 267, c) of the orbit—the center corresponding to the notch— through the tissues down to the nerve; expose and treat the nerve, avoiding the vessels. A vertical incision (Fig. 270, a) at the notch would be the bet- ter one, were it not that a freer division of the muscles is made and a greater danger of scarring incurred. The Second Operation.—Elevate the brow with the left hand; with the right draw down the lid and hold it as before. Make an incision between the brow and the lid one inch in length through the tissues down to the site of the nerve (Fig. 271, a). Push aside the connective tissue and isolate the nerve. In stretching, seize the nerve with an aneurism needle curved at the side. Since in the dead subject this nerve parts under a six-pound strain much caution must be exercised in stretching it in the living, otherwise it will rupture. The nerve can be pulled out from the roof of the orbit with a small, blunt hook, and treated before it enters the foramen or notch. The Supratrochlear Nerve.—The supratrochlear nerve is stretched in certain cases of glaucoma and ciliary neuralgia. The nerve escapes from the orbit above the pulley of the superior oblique muscle (Fig. 267, c). A line drawn from the angle of the mouth through the inner cantlms to the margin of the orbit indicates the course of the nerve at this situation. The Operation.—Make an incision with the convexity downward at the upper part of the inner angle of the orbit (Fig. 267, e) directly below the eyebrow; draw apart the borders of the wound; locate the pulley of the superior oblique, and find the nerve just above it; raise the nerve with a hook and stretch it cautiously. SECOND DIVISION OF THE TRIFACIAL. The Infra-orbital Nerves.—The infra-orbital nerves are the terminal branches of the second or supra-maxillary division of the fifth pair. They are present at the infra-orbital foramen, which is located about four lines below the lower edge of the orbit, and nearly on a line extending from the bicuspid teeth to the supra-orbital foramen. The infra-orbital nerves (nasal, palpebral, etc., Fig. 268) can be divided through the mouth by first recognizing the location of the infra-orbital fora- men and placing the finger upon it. Then turn up the cheek and make a narrow incision, beginning at the fold of the cheek and maxilla, and carry it upward in the line of the foramen until within a short distance of it, when 238 OPERATIVE SURGERY. the nerves are divided with a sharp-pointed scissors as they appear at the opening. The nerves can be exposed through an incision made as follows: The Operation.—Make an oblique incision one inch in length below the lower margin of the orbit, with the center at the infra-orbital foramen (Fig. 267, a). Divide the orbicularis and levator labii superioris; pull asunder the margins of the wound and expose the nerves, avoiding the infra-orbital vessels. The nerves can now be treated as indicated. It is wise to remem- ber, however, that these nerves arise from the superior maxillary in the infra-orbital canal but a short distance behind the foramen. The division at the foramen can do no good if the lesion be behind the point of section. Fig. 268.—Divisions of the trifacial nerve. Even the sensation of the teeth supplied by the anterior dental branch of the superior maxillary is not disturbed by it. This nerve can be divided subcutaneously at its exit from the foramen by a short, thin knife directed against the posterior wall of the opening. The division of the infra-orbital vessels will cause quite severe haemorrhage. The Superior Maxillary Nerve and MeckeVs Ganglion.—The superior maxillary nerve is one of the divisions of the great sensory nerve of the OPERATIONS ON THE NERVOUS SYSTEM. 239 face. It has three portions of much surgical interest—1, the infra-orbital portion ; 2, the spheno-maxillary portion, with Meckel’s ganglion; 3, the intracranial portion. The first or infra-orbital portion lies in a canal or groove of the floor of the orbit, which extends from the spheno-maxillary fossa to the infra-orbital foramen. The walls of this passage are exceed- ingly thin, except at the terminal foramen. The dental branches arising from the nerve as it passes along the floor of the orbit are the anterior, mid- dle, and posterior (Fig. 268), -the first and last of wdiich, respectively, come from the extremes of this portion of the nerve. The infra-orbital portion of the nerve can be exposed in the infra-orbital canal by one of two or more procedures. However, the presence in the posterior wall of the antrum of the posterior dental branches demands that great care be taken, or they will re- main undisturbed. The nerve can be divided at the floor of the orbit by passing a sharp-pointed tenotome backward on the floor in the course of the nerve for an inch or so, then turning the edge downward and cutting through the bony walls of the canal at a right angle with the antero-poste- rior axis of the orbit. The infra-orbital foramen is then exposed, the nerve grasped and pulled out, leaving behind the posterior, and perhaps middle dental branches. The nerve can be stretched at any situation in its course, after elevation from the canal, by means of a blunt hook passed along the floor of the orbit through a narrow incision of the soft parts, made at the lower margin of the orbit with a sharp-pointed bistoury. The nerve is hooked up and stretched, then resected if need be. The breaking strain in the dead subject is twelve pounds. The division and removal of the nerve at the anterior border of the spheno-maxillary fissure is a brilliant procedure, although not commonly practiced on account of the guarded manipulation essential to success. An Operation for Division and Removal.—Through either a vertical in- cision an inch in length made from the lower margin of the orbit, or a curved one of the same length made at this margin, expose the infra-orbital nerve on the face. Isow, through a narrow incision made below the inferior tarsal ligament at the outer angle of the orbit, introduce a curved, blunt, narrow- bladed tenotome and pass it along, with the edge downward, in the direc- tion of the apex of the orbit, until it reaches the posterior part of the spheno-maxillary fissure;* then press the edge downward and draw the blade forward and outward along the anterior border of the fissure to near its outer extremity, thus dividing the submaxillary nerve at the entrance to the groove. The nerve is then carefully pulled away by gradual trac- tion addressed to the infra-orbital branch. The coincident division of the infra-orbital artery causes considerable haemorrhage, which is often fol- lowed by a transient exophthalmos. The ultimate results of this method are better by far than are those of the other infra-orbital methods, as it assuredly severs the dental branches from any central connection. How- ever, the depth of the wound, the importance of the structures of the orbit, the delicacy of the operative technique, and the liability of severe haemor- * See Articulated Bones of Orbit. 240 OPERATIVE SURGERY. rhage and of missing the nerve entirely, make this plan of action so risky and uncertain that the following mode of procedure for division and re- moval of the nerve is recommended : The Operation.—Make an oblique or Y-shaped incision (Fig. 267,/) be- low the lower border of the orbit down to the bone, so as to expose the nerve ; isolate and tie with a strong ligature the terminal branches of the nerve as they emerge from the infra-orbital foramen ; cut away with a chisel or ron- geur the orbital border of the foramen (Fig. 268); separate the periosteum from the floor of the orbit back to the spheno-maxillarv fissure with a thin periosteotome; raise upward the periosteum and the contents of the orbit with a thin right-angled retractor; raise the nerve upward into the orbit as it is liberated from its channel with scissors, back to the fissure; carry be- neath the nerve from before backward as far as possible a hook with a right- angled upward curve, thus freeing the nerve from the canal and rupturing the smaller branches; carry backward around the nerve as far as possible a strong silk ligature and tie it; stretch the nerve by strong traction on the string; carry along the under surface of the nerve in the course of the hook a fine pair of short-bladed, blunt-pointed scissors sharply curved on the flat; cut the nerve as close to the foramen as possible, and remove it; arrest haemorrhage, remove the spatula, and allow the contents of the orbit to return to the natural position; close the wound and apply a soft compress to the eye and wound, and fasten in place with a bandage. The Precautions.—The only bleeding of any account comes from the infra-orbital vessels, and this can be easily controlled with sponge pressure. The periosteum beneath the orbital plate must not be torn, since blood will then escape into the antrum of Highmore. The manipulation of the tissues of the spheno-maxillary fossa should be practiced with care to avoid injury of the internal maxillary artery, causing haemorrhage which may require liga- ture of the external carotid to arrest. The optic nerve, lying some distance above and to the inner side, should be carefully avoided. The Remarks.—If the hook have an advancing cutting border calculated to sever the branches of the nerve (Fig. 269) at their origin, then the nerve can be removed back to the foramen with no danger to the contiguous tis- sues. In this instance the ganglion is not removed, but its branches and those going to the superior maxilla are severed. Subconjunctival eccliy- mosis of a moderate amount appears, but is rapidly absorbed, and the parts resume their usual appearance in a few days, only a trivial cicatrix re- maining at the seat of incision. If the nerve be divided behind the roots of the ganglion and firm traction be made, the ganglion and its branches are stretched, and perhaps the ganglion may be drawn into the orhit and re- moved along w'ith the nerve. The disfigurement from this operation is trivial; and the technique is simple and attended with lit- tle danger and perplexity. In the experience and observation of the author the outcome also is quite as favorable as when the ganglion is removed. Inasmuch as some doubt exists as to whether the benefit comes Fig. 269.—Author’s curved cutting hook. OPERATIONS ON THE NERVOUS SYSTEM. 241 from removal of the ganglion or the nerve trunk associated with it, it seems wise to cultivate this the simpler method and establish its status rather than practice the latter and graver one with an unwarranted faith. The following operations have the decided advantage of being applicable to the surgical treatment of both the first and second portions of the nerve and also of Meckel’s ganglion : Kocher’s Operation.—Make an incision from a point located about a quarter of an inch below the bony margin of the orbit and half an inch inside the infra-orbital foramen, obliquely downward and outward to the lower part of the body of the malar bone, as far as the zygomatic arch (Fig. 267, a, b); divide the periosteum between the lower border of the orbicularis palpebrarum and the origin of the levator labii superioris muscles; detach the periosteum upward and downward, exposing the infra-orbital nerve, Fig. 270.—Resection of the second division of the trifacial nerve. which is liberated and secured with a ligature. Draw the zygomatic mus- cles downward and detach the anterior fibers of the masseter from the malar bone; elevate the periosteum from the outer and inner surfaces of the ma- lar bone; bare the anterior surface of the malar process of the upper jaw (Fig. 270) to the infra-orbital foramen and its upper surface back to the 242 OPERATIVE SURGERY. spheno-maxillary fissure; draw the upper border of the wound upward, so as to expose the fronto-malar suture ; so chisel through the fronto-malar suture toward the posterior part of the spheno-maxillary fissure that its up- per border, the orbital process of the malar, a portion of the orbital plate of Fig. 271.—Exposure of the second division of the trifacial at the foramen ovale. the sphenoid, and a part of the zygomatic crest can be raised; draw up the orbital nerve and chisel from above the infra-orbital canal downward and outward (Figs. 270 and 271) to below the anterior border of the origin of the masseter, then upward through the outer wall of the antrum, so as to meet posteriorly the preceding division of the orbital structure, thus permit- ting the outer wall of the orbit, the supero-external wall of the antrum, and its posterior angle to remain connected with the malar bone when the latter is pried outward. Dislocate the bony mass upward and outward with a strong hook, raising the orbital fat with a blunt retractor; expose backward to the foramen rotundum the nerve; pass a small hook behind the descend- ing spheno-palatine nerves around the main trunk, which can then be di- vided or twisted out. The bony flap is returned to and fastened in place by sutures, and the borders of the wound are closed in a similar manner. With careful adjustment of the parts, but little disfigurement results. OPERATIONS ON THE NERVOUS SYSTEM. 243 The Remarks.—The incision is an extension to that for exposure of the infra-orbital nerve (Fig. 267, «, b). The infra-orbital artery may be pushed aside or ligatured, as seems best. Carnochan-Chavasse Operation.—Through a Y-, U-, Y-, or I-shaped in- cision (Fig. 267,/), the center corresponding to the infra-orbital foramen, expose the infra-orbital nerves at that point, and tie a silk ligature carefully around them ; raise the periosteum from the bone and perforate the anterior wall of the antrum, including the floor of the foramen, with a trephine or gouge and mallet, making the opening about three quarters of an inch in diameter (Fig. 268, A). Make an opening in the posterior wall of the antrum half an inch in diameter, as near to the roof as possible, in a similar manner. Control the haemorrhage from the antrum with aseptic gauze packing and from the soft parts with ligatures; raise the periosteum from the roof of the antrum in the line of the orbital canal till the canal can be localized with a probe; divide the mucous membrane of the roof of the antrum in the line of the canal in the floor, and with a small, short chisel, brad awl, or with scissors, break through the floor of the canal from before backward, draw- ing down on the nerve, with the string, as it is liberated from the bony canal. With a blunt end of a director, guided by the liberated nerve, gently disengage the second portion of the nerve from the tissues of the spheno- maxillary fossa back to the foramen rotundum (Fig. 268, B), into which the point of the instrument can be readily inserted. After a thorough stretch- ing the nerve is divided at the foramen rotundum with sharp curved scissors. Gentle traction on the divided nerve brings the ganglion (Fig. 268, C) for- ward into the antrum, and, after division of its branches of distribution, the ganglion is drawn away with the nerve which is about two inches in length. The wound cavity is packed with gauze till bleeding is arrested, then the gauze is removed, the wound drained, closed, and dressed in the usual man- ner. In the opinion of the writer, it is better to adopt the plan of Abbe and pack the wound with gauze for eight hours to control hasmorrhage than to take much time in arresting haemorrhage, or the risk of orbital infiltration from persistent oozing of blood, especially since the delayed measures of treatment, sewing, etc., will cause no pain after division of the nerve. The Precautions.—Almost invariably severe haemorrhage is caused by the opening of the posterior wall of the antrum, due to the rupture of vessels running in the posterior dental canals at that situation. At the outset this haemorrhage is quite brisk, leading one for the moment to fear injury of the internal maxillary artery; but the patient application of firm pressure with sponge or gauze checks the flow and reassures the surgeon. If care be not exercised in the making of the opening at the posterior wall of the antrum the internal maxillary artery will be torn. In this instance the bleeding will be both severe and persistent, and can be more wisely and surely con- trolled by prompt ligature of the external carotid than by any other means. The antrum must be well lighted during operation, if the surgeon expects to see the ganglion or to remove the nerve entirely from its canal, without dividing it in the attempt. Although the electric headlight (Fig. 103) is the best means for the purpose, still, in its absence, the reflections of a 244 OPERATIVE SURGERY. laryngeal mirror will be of great service. Thorough drainage of the wound is necessary, and frequent cleansing as well, since the free communication between the nasal meatus and the antrum exposes the latter to infection. Liicke reached the splieno-maxillary fossa and the foramen rotundum through a quadrangular-shaped flap limited below by the lower border of the zygoma, above and in front by the frontal process of the malar bone, and behind by a vertical line an inch in length crossing the origin of the zygoma, Divide the masseter at the lower border of the zygoma, saw the zygoma at either end, turn the flap upward, remove intervening structures, separate the two heads of the external pterygoid muscle, and expose and resect the nerve at the point of exit from the foramen. Although the mas- seter muscle is united thereafter with sutures, it does not unite kindly, and a crippling of the movements of the jaw from this cause is quite sure to follow. Lessen was led by this sequel to advise that the temporal fascia be divided instead of the masseter, and the zygoma turned downward, instead of upward, as before, and the divided borders of the temporal fascia united subsequently with sutures. The reversal of this portion of the original plan obviates the crippling effects of division of the masseter muscle. Not a few modifications contemplating an attack on the nerve from this quarter are advised. However, while the opportunity for open work is often en- hanced by these methods, still they are severe in character and expose large surfaces to the action of the suppurative and infective processes incident to faulty technique. The Results.—Section of the nerve in any part of the course is usually of temporary use only, and it should not be done except with that understand- ing. Stretching before section may add somewhat to the time of exemption from pain in many instances, and stretching alone will often afford relief. Removal of the entire infra-orbital portion of the nerve is of much greater benefit than the removal of any part of it, as in the latter procedure some of the dental nerves may remain behind, and, moreover, regeneration is prompter in this than in the former instance. Removal of the entire nerve with or without the ganglion is frequently followed by cure, and merits pro- fessional confidence and prompt action. Number of cases. DURATION OF RELIEF. 6 months. 6-12 mos. 1-2 years. 2-3 years. 3 years. Nerve and ganglion removed. ... 20 5 3 9 6 3 Nerve only removed 26 4 7 7 3 5 Total 52 9 10 16 9 8 —Fowler. The intracranial and extracranial portions of the third division of the fifth nerve, together with the dental, lingual, auriculo-temporal and buccal branches, are each amenable to surgical procedure. The Inferior Dental Nerve (Fig. 268).—The inferior dental nerve is the largest of the branches of the third division. It passes downward, along with, THIRD DIVISION OF THE TRIFACIAL NERVE. OPERATIONS ON THE NERVOUS SYSTEM. 245 at the front, and to the inner side of the inferior maxillary vessels, beneath the external pterygoid muscle, then between the internal lateral ligament and the ramus of the jaw to the dental foramen. It passes forward in the dental canal of the lower jaw, supplying the teeth, and finally terminates at the mental foramen in the incisor and mental branches. The inferior den- tal nerve can be exposed at three situations : 1, before entering the dental foramen; 2, in the dental canal; 3, at the mental foramen. Operation at the first situation is the only one of the three methods that affords the patient satisfactory relief. At this situation the nerve can be reached by either of two methods, known respectively as the internal or buccal route, and the external or facial route. The Internal or Buccal Route.—Although the nerve is deeply situated in the mouth, yet it has superficial and deep guides that lead to it unerringly. The superficial guides are the anterior border of the ascending ramus of the jaw and of the internal pterygoid muscle. These guides can be easily distinguished with the finger through the widely opened mouth, before the operation. The deep guides are the spine of Spix and the internal lateral ligament which is inserted into the spine. Although the deep guides can be located with the finger before the operation, still they are of far greater significance after the making of the primary incision. After a thorough cleansing of the teeth and buccal mucous membrane at the site of the operation, with anti- septics and scrubbing, the patient is anaesthetized, placed in a good sunlight, or an electric headlight is provided. The Operation (Paravicini).—Fix the mouth widely open with a Denhard (Fig. 4), Goodwillie (Fig. 734, Yol. II), or extemporized mouth gag, placed at the side opposite to the operation. With two narrow retractors pull the cheek backward and away from the field of operation ; pull the tongue to the oppo- site direction; locate the inner edge of the anterior border of the ascending ramus of the jaw, and of the internal pterygoid muscle with the finger; make an incision through the mucous membrane between these guides, about an inch in length, close to the bone, with a long-handled scalpel. Separate the tissues with a firm spatula or a small periosteal elevator, aided by the finger, from the bone down to the spine of Spix. The periosteum is not dis- turbed. The spine of Spix is usually well developed and, consequently, is easily located at this time, along with the internal lateral ligament which is inserted into it. At the base of the spine the foramen can be felt, and occa- sionally also the nerve and vessels as they enter it. If additional space be re- quired divide the internal lateral ligament with scissors; draw inward the in- ternal pterygoid with a retractor; sponge out the wound cavity and expose it to a strong light. A blunt hook, curved at the side, or an aneurismal needle, curved in the same manner, is passed into the wound, the nerve hooked up, if possible at a point half an inch from the foramen, and drawn forward. Re- move the artery from the hook if included with the nerve, and then pass around the nerve at this point a strong silken ligature, and tie it firmly to the nerve. The nerve is then stretched by means of the ligature and divided with scissors above and as near to the internal maxillary artery as is safe. 246 OPERATIVE SURGERY. The lower end is then stretched and cut off at the foramen in the same manner, carefully avoiding the dental artery. About three quarters of an inch to an inch in length can thus be resected. The Precautions.—The lingual nerve, which may be mistaken for the dental, can be easily differentiated by making upward traction ; then, if the latter be the one grasped, firm resistance is noted; if the former, the tongue and its contiguous tissues are easily and freely moved by the traction. The dental nerve may be ruptured if too severe traction be made upon it; a Fig’. 272.—Resection of inferior dental nerve. The temporal and facial arteries. resistance of from ten to fifteen pounds is safely borne. Division of the inferior dental or of the internal maxillary arteries will cause troublesome haemorrhage. Pressure of the vessel against the bone will control the former; for control of the latter, ligature of the external carotid may be necessary. The Comments.—During the after-treatment the mouth should be kept thoroughly cleansed to obviate or lessen, as far as possible, subsequent in- flammatory action at the seat of the operation. If suppuration occur, we regard it wise to establish drainage externally by means of a small rubber tube carried through an opening made from the bottom of the wound out near the angle of the jaw, by means of a curved, sharp-pointed scissors thrust while closed through the tissues at this situation. The patient should be thoroughly anaesthetized before the operation is commenced, or his struggles will delay the procedure, cause undue injury of the soft parts, and otherwise embarrass the surgeon. Since the operation is a troublesome and annoying one at the best, the surgeon should claim for his support the advantage of every resource at his command. The External or Facial Route.—In this route an opening is made through the cheek, and sometimes through the ascending ramus of the jaw, at a point corresponding to the situation of the inferior dental foramen. The guides to the operation are the masseter muscle, the angle of the jaw, and the anterior OPERATIONS ON THE NERVOUS SYSTEM. 247 and posterior borders of the ascending ramus. The chief objections to the external route are: 1, the difficulty in dividing satisfactorily the soft parts without injury of some of the infra-maxillary branches of the facial nerve; 2, the crippling of the jaw that may follow interference with the masseter muscle; 3, the production of an objectionable cicatrix. The first objection can be met by carefully locating the line of incision. Keen recommends that an incision two inches in length be made along the lower border of the jaw, beginning a little behind the angle (Fig. 274, d), and so located as to reduce to a.minimum the expanse of the scar. Through this incision the masseter muscle is raised from the ramus with a sharp periosteal elevator. The tissues are pulled aside and a half-inch opening is made with a trephine one inch and a quarter above the angle and directly below the sigmoid notch— i. e., at about the middle of the perpendicular ramus of the jaw (Fig. 272). Through this opening the nerve is exposed as it enters the foramen, is hooked up with a needle and stretched, and as much as possible of it removed with- out injury to the contiguous tissues. If removal of the nerve farther for- ward be desired, the incision can be extended anteriorly, even to the mental foramen (d, /), after tying, or by careful avoidance of the facial vessels. Kuhn, through an incision around the angle of the jaw corresponding to the borders of insertion of the masseter (Fig. 274, e, d) muscle, and after resect- ing a portion of the angle of the jaw, exposed the nerve from below. Lucke, through a similar incision, raised the insertion of the internal pterygoid and other soft parts from the jaw with a periosteotome, until the nerve could be felt with the finger, when it was hooked, drawn down and resected. Horsley has proposed to accomplish the purpose by raising a flap composed of the skin and subcutaneous tissue only, limited behind by a vertical incision ex- tending from just above the zygoma to the angle of the jaw, followed by its continuance forward beneath the jaw in a horizontal direction to the facial artery. The flap is lifted and turned aside, leaving Stenson’s duct and the branches of the facial nerve undisturbed. The masseteric fascia is then di- vided between Stenson’s duct and the temporo-facial branch of the facial nerve, and the opening increased to an inch and a quarter in diameter; the parotid is drawn toward the ear, and the situation of the posterior border of the jaw defined. Now the posterior two thirds of the masseter muscle are divided, and the outer surface of the bone is exposed until the sigmoid notch is clearly seen, when, with the aid of a bone drill, trephine, etc., the sigmoid notch is prolonged directly downward to the inferior dental foramen. With this method the nerve can be followed up and resected to within one third of an inch of the foramen ovale. The nerve can be reached promptly from the outer surface through a vertical (Linhart) (Fig. 274, a) or U-shaped incision, made directly down to the bone, beginning just below Stenson’s duct and extending downward about two inches. The periosteum is then raised along with the associated masseteric fibers, sufficiently to expose the center of the ramus; the soft parts are drawn aside and the nerve is exposed at the foramen by aid of the trephine, or farther forward, if desired, by re- moval of the external table of the jaw with the chisel and mallet. In either case the nerve is stretched and as freely resected as possible. 248 OPERATIVE SURGERY. The Precautions.—The external incisions expose to danger Stenson’s duct and the branches of the facial nerve. The former runs forward on the ex- ternal surface of the masseter to the buccinato rmuscle, which it enters op- posite the second molar tooth, parallel with, and a finger’s breadth below the zygoma. The directions of the branches of the nerve should be carefully studied before making the external incision, to avoid any motor paralysis of the face that may follow their division. On opening through the ramus of the jaw, the mylo-hyoid nerve may be mistaken for the inferior dental. However, the former is much the smaller, and if pulled upon is unfixed and enters soft intrabuccal tissues, while the latter is fixed when pulled upon, as it supplies bony tissues. The separation from the bone, or the division of the fibers of the masseter, must be performed carefully and asep- tically, otherwise the advent of suppurative processes will prolong the recov- ery and impair the movements of the jaw. In resections of this nerve at either aspect of the jaw, the divided ends should be turned aside or tissues interposed between them so as to prevent regenerative union. The inferior dental nerve can be exposed in the dental canal from the inferior dental to the mental foramen, if need be, by making a free incision down to the bone along the under surface of the jaw (Fig. 274, d, /), then raising the soft parts along with the periosteum with the elevator, drawing aside the flap, and exposing the nerve in the canal by the use of the electro- motor trephine, chisel and mallet, etc. The exposure of the nerve here is more a matter of labor than of skill; the final removal, however, is easily accomplished with scissors and forceps. The wound should be closed promptly, the same as are incised wounds in other situations. If undue violence be employed in the use of the chisel and mallet, the jaw may be fractured. The termination of the inferior dental nerve and its mental branch can be treated surgically by exposure of them at the mental fora- men. In stretchwg, the breaking strain of the mental nerve is five and a half pounds. The mental nerve escapes from the mental foramen along with the mental vessels, opposite to the interval between the bicuspid teeth of the same side. The Operation.—Draw the angle of the mouth downward and outward ; make a horizontal incision one inch in length at the buccal fold, with the center opposite the interval before mentioned, through the mucous mem- brane down to the bone; raise the mucous membrane and periosteum with a director, so as to expose the mental foramen ; dissect out the nerve, seize and stretch or remove it. If a trephine or chisel be applied to the jaw posteriorly to the foramen, and the outer table be removed, then the anterior extremity of the inferior dental can be exposed and resected, thus exercising some com- mand over the incisive branches of that side. The Lingual or Gustatory Nerve.—The lingual nerve is the sensory nerve of the anterior two thirds of the tongue. It is often treated sur- gically for the relief of the pain and sialorrhoea incident to cancer of the tongue. The Anatomical Points.—The nerve passes between the internal pterygoid muscle and the internal lateral ligament of the lower jaw, and is located OPERATIONS ON TIIE NERVOUS SYSTEM. 249 internally and anteriorly to the inferior dental nerve. Although deeply placed at first, it becomes quite superficial as it reaches the floor of the mouth. The guides to the nerve are the last molar tooth of the lower jaw and the pterygo-maxillary ligament. The nerve is situated half an inch below and behind the last molar tooth, and in front of the pterygo-maxillary ligament, where, with the mouth widely opened and the tongue placed on the stretch, it can be felt as it passes beneath the mucous membrane to gain the anterior portion of the tongue. The pterygo-maxillary ligament is easily noted beneath the mucous membrane just inside the coronoid process, and it is somewhat tightened by opening the mouth widely. The lingual nerve can be reached by either the intrabuccal or extra- buccal routes, the former being employed much the more frequently. The Operation (intrabuccal route).—Open the mouth amply with the gag; draw the cheek aside with the retractor, and the tongue forward and to the opposite side with a tongue forceps; indicate the location of the nerve with the index finger placed at the point of insertion of the pterygo-maxil- lary ligament, then with a scalpel make a longitudinal incision one inch in length through the mucous membrane from this point forward, or make a vertical one of the same length over the nerve midway between the tongue and the gum at the root of the last molar tooth, thus easily exposing the nerve, which can be drawn forward with a hook and stretched or resected. Neurotomy may be practiced on this nerve by means of a bistoury passed through the mucous membrane at a point three quarters of an inch behind and below the last molar tooth, and curved forward and upward toward the jaw on an imaginary line extending between the last molar tooth and the angle of the jaw for the distance of half an inch. The comparatively brief relief afforded by this method does not commend its employment except as a temporary expedient. The Operation (extrabuccal route).—The nerve can be reached through the submaxillary triangle by an incision extending from the anterior border of the masseter muscle to near the symphysis menti. The facial artery is exposed but not tied ; the submaxillary gland is liberated of its facial con- nections and drawn downward and forward, thus exposing the mvlo-hyoid vessels and nerves as they lie on the mylo-hyoid muscle. This muscle is drawn forward by means of a retractor applied to the posterior border. The lingual artery is displaced downward, and the lingual nerve then appears at the posterior border of the muscle, lying beneath the mucous membrane near to the last molar tooth. This method of procedure is not advisable on ac- count of the intricate technique, unless the lingual artery is to be tied for malignant disease of the tongue, when the nerve can be wisely resected through the same opening. This nerve can be reached from without by the same procedures as those addressed to the inferior dental (page 245). The auriculo-temporal nerve is easily exposed, as it crosses the base of the zygoma through a short vertical incision made immediately in front of the pinna (Fig. 272). Here the nerve lies behind the temporal artery, the pul- sation of which serves as an excellent guide to it. Care should be exercised in the dissection at this point, otherwise the parotid gland will be injured. 250 OPERATIVE SURGERY. The Buccal Nerve.—The buccal nerve can be exposed through either an intrabuccal or extrabuccal incision, the former being the preferable. Two methods of intrabuccal exposure are noted, hi one the nerve is bared as it reaches the buccinator muscle, through a vertical incision in the mu- cous membrane and fibers of the muscle, made with its center at the mid- dle of the anterior border of the ascending ramus of the lower jaw. The nerve at this situation divides into two branches; therefore care must be ex- ercised in observation lest one or both branches, and even the trunk itself, escape notice. The operation will be futile unless the trunk of the nerve be secured and treated. In the other method open the mouth widely and make an incision along the anterior margin of the coronoid process through the mucous membrane, and grasp the nerve as it crosses this margin of the process. The fact that the nerve sometimes reaches the buccinator by pass- ing through the temporal muscle invests the latter method with a reason- able degree of uncertainty, since then the nerve is not found at the anterior border of the coronoid process. The Extrabuccal Method (Zuckerkandl).—The extrabuccal method con- sists in making a short incision forward from the anterior margin of the masseter muscle between the zygoma and Stenson’s duct down to the fatty cushion of the cheek. The cheek fat is pushed aside so as to expose the anterior border of the coronoid process along the inner surface of which the nerve is found to pass. This method of procedure exposes to the danger of injury the transverse facial artery and branches of the facial nerve. The Results.—The results of division and excision are similar here to those of the preceding trials and like those results justify the trial before the others of graver import are attempted. Stewart, of Montreal, contributes the following conclusions regarding nerve-stretching in inveterate trigeminal neuralgia: “ 1. Nerve-stretching gives either complete or great relief in the majority of cases. 2. Relief is not permanent in more than five per cent of cases. 3. If pain should return, the operation should be repeated, even several times, before resorting to neurectomy or ligature of the com- mon carotid. 4. If the pain is not strictly and always limited to one branch of the nerve, several branches should be stretched. 5. As relief does not always immediately follow stretching, a second operation should not be undertaken until some time has elapsed/’ TRUNK OF THE NERVE AT THE FORAMEN OVALE. The important anatomical points connected with the nerve at this situa- tion are: 1, the large size—larger than either of the other divisions of the fifth; 2, the junction of the motor and sensory roots just after leaving the foramen ovale; 3, the numerous branches given off from the common trunk after the junction ; 4, the relations of the middle and small meningeal arteries, the external pterygoid muscle and pterygoid plexus of veins and internal maxillary artery, all of which should be carefully studied before attempting the operation. The localization of the foramen ovale is a mat- ter of the greatest importance. Bony and muscular guides indicate the situation with practical accuracy. The junction of the zygoma and emi- OPERATIONS ON THE NERVOUS SYSTEM. 251 nentia articularis is located about an inch and a quarter directly outside of the foramen; the free edge of the external pterygoid plate at the root of the process is just in front of the opening; the pterygoid muscles cover in the foramen and the trunk of the nerve. If the finger be inserted into the zygomatic fossa in front of the eminentia articularis, the nerve is Fig. 273.—Incision for exposure of third division of trifacial nerve at foramen ovale and of facial nerve. found between the base of the external pterygoid plate and the spinous process of the sphenoid, either of which can be easily felt. If now, as MacCormac says, “ a knife be passed along the outer surface of the greater wing of the sphenoid and between the middle meningeal artery and the nerve trunk, the latter may be divided from behind forward with perfect safety.” However, if the middle meningeal artery escape injury at this time, the small meningeal and the lesser superficial petrosal nerve will quite surely be divided along with the motor root of the third division. Motor paralysis of the muscles of mastication, the mylo-hyoid and anterior belly of the digastric, the tensor tympani and tensor palati muscles, on the side of the section, will follow, attended with loss of sensation and relief from pain if the central end of the divided nerve be not involved. How- ever, the motor paralysis has not sufficient significance to contraindicate the operation. 252 OPERATIVE SURGERY. Koclier’s Operation.—An incision beginning just behind the frontal process of the malar bone is carried obliquely downward and backward to the posterior extremity of the zygomatic arch, thence upward and backward in front of the ear at nearly right angle to the first part of the incision (Fig. 273) dividing fibers of the orbicularis, the superficial and temporal fascife at the first, and all tissues down to the bone at the second part of the incision. Draw the borders of the wound apart; expose the malar bone behind the frontal process and divide it vertically with a chisel; divide the zygoma ])osteriorly close to its anterior root, and draw the fragment down SAWN SURFACES OFTHF ROOT OF [THE ZYGOMA Fig. 274.—Exposure of the third division of the trifacial in its course and at the foramen ovale. with a strong hook; expose the outer surface of the temporal muscle, sepa- rate its posterior and lower border from the skull, and draw it forward with a hook (Fig. 274); divide the periosteum from the anterior edge of the root of the zygoma forward along the pterygoid ridge; detach with it the soft parts from the under surface of the great wing of the sphenoid down to the base of the pterygoid process with a periosteotome; locate the fora- men ovale with the finger, and expose the nerve to view, carefully avoid- OPERATIONS ON THE NERVOUS SYSTEM. 253 ing the middle meningeal artery lying posteriorly ; stretch and resect the nerve; place and wire in position the zygomatic arch, unite the borders of the wound, and dress antiseptically. This plan of procedure exposes the vessels to the minimum amount of danger, and therefore gives rise to the least amount of haemorrhage. Pa/icoast's Operation.—Make a horizontal incision, near to where the ramus joins the body, the entire breadth of the perpendicular ramus of the lower jaw down to the bone; connect to the extremities of this incision two perpendicular ones of a similar depth as the first, carried upward to Sten- son’s duct, then superficially from that point to the zygoma and malar bone, carefully avoiding the duct (Fig. 274, b); raise the flap and saw through the coronoid process at the base, and remove the fragment along with the insertion of the temporal muscle ; push the temporal muscle upward beneath the zygoma, and take away the fatty tissue thus exposed to view; tie the internal maxillary artery as it passes close to the internal surface of the neck of the jaw in two places and divide the nerve between the ligatures; detach the upper head of the external pterygoid from the great wing of the sphenoid with the finger; check hasmorrhage and expose the nerve at the bottom of the fossa and divide it with scissors close to the bone. Kronlein's Modification.—In the modification of Kronlein the temporal fossa is uncovered by means of two flaps, a superficial and a deep one. The former corresponds in all essential respects to that of Pancoast. The latter is of similar shape and dimensions as the former, is composed of masseter muscle and the zygoma, the bone being sawn across anteriorly downward and forward through the zygomatic process of the malar at the point of articulation, and posteriorly, immediately in front of the articular tubercle, and the whole reflected downward on the masseter as a hinge. The inner flap is stretched rather than divided, to avoid injury of Stenson’s duct and the facial nerve. The infra-maxillary nerve is then exposed and resected without loss of other essential structure. Through the pterygo-maxillary fissure the second division is then resected with a thin cutting instrument, and if possible without widening the fissure by chiseling. The separated structures are returned into position and fastened there; thus the aim is attained without the sacrifice of an essential part. Crede's Modification.—In Crede’s modification the nerve is reached through the sigmoid notch while the temporal muscle is drawn backward with a blunt hook. The internal maxillary artery is not seen. In other respects the procedures are similar. Saber's Modification.—In Salzer’s modification the free end of the flap is formed a finger’s breadth above the zygoma, going through the temporal mus- cle down to the bone. After the arrest of haemorrhage, the flap is raised, including the zygoma, and carried down sufficiently to expose the roof of the zygomatic fossa. The upper part of the external pterygoid muscle is removed from the sphenoid with the finger, as before, and the nerve is exposed. The Precautions.—The internal maxillary, the meningeal vessels, and pterygoid plexus of veins must be carefully avoided. If exposed they should be ligatured at two places and severed between the ligatures to avoid 254 0 PE RATI V E SUIlG E RY. the possibility of haemorrhage. The middle meningeal is sometimes so closely associated with the nerve as to be scarcely separable from it. In such cases the contiguity can be determined with the finger by noting the pulsation. In fact, in each instance the artery should be thus located, if possible, before the nerve is divided. Pressure, direct ligature, and ligature of the internal maxillary and external carotid are the means for arrest of haemorrhage. The average relation of this nerve and artery will appear in connection with intracranial operations on the nerve. The facial nerve and Stenson’s duct have been mentioned sufficiently already to call for the exer- cise of extreme caution in this regard in the operative technique. The nerve should be divided close to the bone, to secure severance of all the branches. Free excision should be practiced, and the proximal end pushed upward into the foramen, when feasible, to secure as wide separation of the divided ends as possible. The treatment consists in closing the wound after bleeding is completely arrested, and applying a firm compress to it; then dress antiseptically. If oozing persist, tampon with gauze and unite borders, leaving room for with- drawal of the tampon. The Results.—The danger to life is not significant in this operation, un- less infection of the wound or severe haemorrhage supervene. Therefore asepsis should be practiced sedulously and all bleeding controlled. The curative outcome of the operation is not infrequently discouraging. INTRACRANIAL NEURECTOMY. The operation of intracranial neurectomy is employed for the purpose of curing intractable cases of trigeminal neuralgia that have resisted medici- nal and other operative means of relief. The operation contemplates the intracranial section of the second and third divisions of the trifacial nerve at the points of entry to the foramina of escape, the removal of the proxi- mal ends of the divided nerves, and excision of the ganglion itself. Two methods of attainment of these objects are frequently practiced, one devised by Rose, the other by Hartley and Krause. In both the operation field is extra-dural. Rose’s Method.—The patient is prepared by giving proper attention to the bowels, stomach, kidneys, etc. The side of the head corresponding to the side of the face involved is carefully purified, the ear cleansed and plugged with gauze, the conjunctival sac made aseptic, and the lids stitched together. The Operation.—For convenience of description the operation is divided into six stages. The First Stage (incision through the skin and reflection of the flap).— A semicircular flap is made extending from about half an inch below the external angular process of the frontal bone backward along the upper bor- der of the zygoma its entire length. From this point the incision is con- tinued downward over the parotid region of the jaw, to just in front of the angle of the jaw, then forward along the lower border of the horizontal ramus to the facial vessels (Fig. 277, A). This flap is raised, carried for- OPERATIONS ON THE NERVOUS SYSTEM. 255 ward, and fastened by a temporary suture to the upper part of the chin, and securely covered with protective gauze. The Second Stage (section of the zygoma and coronoid process, displace- ment of masseter and temporal muscles).—The zygoma is cut down upon at either extremity and bared by a periosteotome or raspatory. Two holes fitted to carry a silver wire of a twenty-two-inch gauge are drilled one third of an inch apart through the zygoma at the points of exposure —i. e., at the base of the projection and at the zygomatic process of the malar bone. The bone is then divided between the holes with a fine saw, the anterior section being directed obliquely downward and forward, the posterior more transversely, and as near to the root of the process as possible. The fragment of bone is now displaced care- fully downward along with the masseter as far as practicable; the coronoid process and the tendon of the temporal muscle are easily and promptly exposed by the displacement and removal of a small amount of interven- ing cellular tissue; the coronoid process and a portion of the attached muscle are re- moved by the aid of bone forceps, scissors, or the Gigli-Haertel saw, etc. The Third Stage (search for the fora- men ovale).—Displace the pterygoid fat, locate the internal maxillary artery as it passes between the heads of the external pterygoid muscle, tie it with two ligatures and divide the vessel between them. De- tach the external pterygoid muscle from the great wing of the sphenoid and the pterygoid plate with a periosteotome, and push it downward. The base of the posterior border of the outer pterygoid plate is carefully located with the finger, and at a distance posteriorly of sixteen (in female) to eighteen (in male) millimetres is found the foramen with the nerve escaping through it. The Fourth Stage (entering the base of the skull) —In order to effect this purpose, a half-inch trephine is applied a little anterior and external to the foramen, and in such a manner that the groove made in the bone will impinge on the outer wall of the foramen (Fig. 275). This opening can be enlarged subsequently in any direction by the use of bone forceps and chisels. The Fifth Stage (division of the nerves and removal of the ganglion). —After making the opening in the bone, the trunk of the nerve serves as a guide to the ganglion. The ganglion is removed with forceps or a small curette directed along the course of the nerve leading to it. The nerve is a better guide when cut as far back as possible, and traction be made on the stump. The traction draws the ganglion forward somewhat, and thus facili- tates the efforts at destruction. The posterior part of the ganglion can be displaced more readily and removed than can the anterior and upper part, as the latter is closely connected with the dural sheath of the nerve. The Fig. 275.—Trephining base of skull. 256 OPERATIVE SURGERY. second division is found and divided either before or during the removal of the ganglion (usually during) as best meets the indications for the accom- plishment of that act. The ophthalmic division is not disturbed. The Sixth Stage (replacement of structures and closure of the wound). a. Pyle’s chisel. b, c. Hartley’s chisels, d, e. Mallet and trephine. /. Gigli-TIaertel saw. g. Flexible spatula, h. Hartley’s brain retractor, i, j. A common flexible and a hooked retractor, k, l. Forceps to twist away and curette to scrape (?) away the ganglion. Fig. 276.—Instruments employed in intracranial neurectomy. OPERATIONS ON THE NERVOUS SYSTEM. 257 —The zygoma is replaced and wired in position, and the skin flaps are prop- erly approximated and sutured. If asepsis has been complete, no drain- age is necessary. Continu- ous pressure with sponges or properly arranged pads for two or three days will cause suitable apposition for prompt union. The eyes should be protected from light by unirritating asep- tic pads fastened lightly in position. The Hartley-Krause Meth- od. — The Hartley - Krause method can be divided into five stages, but, unlike the Rose method, it offers better opportunity for manipula- tion and aseptic technique, and, therefore, is followed by better results than the latter (Fig. 276). The First Stage (form- ing and raising the flap).— After thorough disinfection of the ear, scalp, etc., a horseshoe-shaped incision is made down to the bone in the course of a line drawn from just behind the external angular process Fig. 277.—Lines of incision in intracranial neurectomy. Fig. 278.—Making the bone flap. of the frontal bone upward with an anterior convexity to the supratemporal ridge, then backward and downward with a posterior convexity to just in 258 OPERATIVE SURGERY. front of the tragus of the ear (Fig. 277 ; B, Hartley; C, Krause). The base of the flap in this instance corresponds to the zygoma, and lies between the points of starting and termination of the curved incision. The flap thus formed is three inches in both the vertical and transverse diameters. Ar- rest the haemorrhage; retract the borders of the incision carefully; cut a groove in the line of periosteal division down to the inner table in a beveled manner (Fig. 278) at all parts except at the upper border, and here through both tables with the chisels of Hartley or that of Pyle (Fig. 276, a, b, c). The flap is now pried off by inserting beneath the bone at the completely divided border a bone elevator, which act causes fracture at the basal end Fig. 279.—1, 2, 3. Branches of fifth nerve. 4. The ganglion. of the undivided vitreous table. Expose the dura by turning down the flap (Fig. 279), the bony portion of which is securely held by a hinge composed of integument, muscle, and periosteum. The Second Stage (treatment of the middle meningeal artery).—Haemor- rhage from the middle meningeal and its branches often happens, and is fre- quently very troublesome. If the anterior branch happens to run in a canal instead of a groove at the base of the flap, it will be almost surely torn across (Fig. 240). In separating the dura from the bone at the entrance to the fossa, the main trunks may be ruptured. After exposure of the dura, the vessel should be isolated and tied as promptly and securely as possible. If the vessel be torn, prompt pressure is applied, the vessel exposed by cut- ting away the bone and then tied with silk. If the main trunk be rup- tured, and can not be otherwise secured, prompt pressure, followed by plug- ging of the foramen spinosum with gauze for three days, will permanently arrest the bleeding (Keen). The Third Stage (raising temporo-sphenoidal lobe).—Separate the dura from the bone carefully with the fingers; raise the brain cautiously with a broad spatula from the middle fossa preparatory to exposure of the Gasserian ganglion and the second and third divisions of the nerve. The separation of the dura is attended with quite free haemorrhage in nearly every case, but OPERATIONS ON THE NERVOUS SYSTEM. 259 in most instances patiently employed sponge pressure will arrest it. Fail- ing in this the fossa is packed with iodoform gauze and the wound closed and dressed ; the gauze is removed on the third day and the operation completed. Keen advises this course, and has practiced the introduction freely in three separate instances : in one, a strip 37 X 6 inches, in another 23 X 14 inches, in a third 16x6 inches, was introduced, and “in each instance the gauze remained in place for three days without any material symptoms.” The Fourth Stage (recognition and removal of ganglion and nerves).—It is very important at this time that a good light be at hand (Fig. 104), in order to enable the surgeon to act in an exact and intelligent manner. The carotid artery and the cavernous sinus may each be opened, if careless, blind, or mis- directed attempts be practiced in removal of the ganglion. Keen advises that the head rest on the occiput, and that a side light be employed, for in this position the blood flows away from the ganglion instead of obscuring it, as when the head lies on the side. Arrest the haemorrhage and locate the nerves by either the sense of sight or touch. The middle meningeal artery as it passes through the foramen spinosum lies from one fourth to one half inch outside of the foramen ovale which transmits the third division, and it is therefore a guide to this division. Lifting the dura will cause two lines of tension of the membrane, which will lead to the foramina of exit of the second and third divisions respectively. Expose and separate the nerves from the dura; follow the nerves backward to the ganglion, separating the mem- brane from them, and then from the ganglion itself by blunt dissection and traction of the membrane. Isolate the ganglion and the second and third divisions on all sides; seize the part of the ganglion corresponding to second and third divisions with haemostatic forceps, divide with scissors the second and third divisions at the foramina, then rotate the forceps gently and firmly, thus twisting away the ganglion and the divisions, including possibly the motor root. The Fifth Stage (closure of the wound).—After complete arrest of haemor- rhage and the introduction of drainage when required, return the temporal flap to its place and confine it there by sewing the borders of the divided periosteum and scalp independently of each other with catgut. Dress the wound aseptically, put the patient in bed, and treat indications as they arise. The Precautions.—In fashioning the skin flap in Rose’s method avoid going so deep as to injure the branches of the seventh nerve or Stenson’s duct. As the tendon of the temporal muscle is attached lower on the inner than on the outer surface of the coronoid process, more difficulty will be experienced in its division at the former situation. The possession of a strong electric light and reference to a dry skull will help much, indeed, in the localization and inspection of important parts. In making the opening with the tre- phine at the base of the skull, it must be remembered that the thickness of the bone at this situation is unequal, being thinner at the outer than at the inner margin of the trephine track. And, inasmuch as the instrument must be applied to the bone obliquely, the division of the outer part of the circle will be made more quickly. If these facts be not heeded or pro- 260 OPERATIVE SURGERY. portionate care be not exercised, the dura will surely be lacerated by the instrument. The Complications.—Haemorrhage is the only complication of special significance. The middle and small meningeal arteries may be injured during approach to the ganglion, and the cavernous sinus, during its removal. It has been demonstrated recently (Taylor) that the foramen spinosum is sufficiently far from the foramen ovale so that the approach to the latter can be safely made without injury to the middle meningeal artery in a majority of instances. However, in some cases the foramen spinosum is so nearly in the line of approach to the foramen ovale, that haemorrhage from the mid- dle meningeal is avoided only by finding, ligaturing, and dividing this vessel in advance of the extended procedure. Brisk haemorrhage from the small meningeal which jiasses through the foramen ovale is to be expected. If the vessel can be secured in advance, Avell and good; if not, then ligature at the time of the bleeding will suffice. Sometimes free haemorrhage arises at the time of removal of the ganglion, due, perhaps, to involvement of the sinus. For this reason, great pains should be taken to limit the manipulations to the ganglion alone, as a deviation therefrom may involve a contiguous sinus. If haemorrhage arise from this source, a tamponade of iodoform gauze should be applied and permitted to remain until the bleeding is finally arrested. The Remarks.—The right side is affected twice as often as the left; the third division alone, ten times; second, six times; all divisions, twenty-two times. The first division is never affected singly (Tiffany). If the bony opening be too small, it can be increased with a rongeur at will. Tiffany in his “ later operations ” has omitted replacement of the bone flap, and now sees “ no special reason for so doing—i. e., replacing it.” Evacuation of the cerebro-spinal fluid by limited incision of the dura, which is closed promptly thereafter, greatly facilitates the raising of the brain from the floor of the skull. An unusual depth of the anterior fossa and adhesion of the dura increase the difficulty of the operation. The first division of the fifth nerve should not be disturbed, as this part of the nerve is not affected singly. However, the second and third divisions and the corresponding parts of the ganglion should be completely removed, also the remaining part of the gan- glion if practicable. The saving of the motor branch of the third division is not necessary, except both sides be subjected to the operation, when, of course, the muscles of mastication would be incapacitated. Keen regards it scarcely possible to save this branch. The introduction of the electro-motor saw (Fig. 243) and Gigli-Haertel wire saw (Fig. 27G,/, i) inclines many surgeons to their use in making the bone flap, since the concussion incident to the use of the chisel and mallet is thus avoided. The employment of these saws is supplemented with that of a small trephine, which is so placed at intervals as to establish the size and shape of the bone flaps. The flaps can be made of a nearly square or a modification of this shape. The Results.—Keen reports twenty-two cases with four deaths from Rose’s operation, and fifty-one cases with five deaths from the Ilartley- Krause method. Tiffany reports one hundred and eight cases with a death OPERATIONS ON THE NERVOUS SYSTEM. 261 rate of twenty-two and a fifth per cent. Shock and sepsis each caused a third of the deaths. The recurrence of pain more or less severe after pre- sumptive removal of the nerves happens in four or five per cent of the cases. But recurrence of pain after “ known removal ” of the ganglion is not yet recorded (Tiffany). The Sequels.—Corneal ulceration is a sequel of significance, and per- haps may be due to too free meddling with the first division and the upper part of the ganglion. Loss of sensation of the face and meningitis are also sequels of this oper- ation. The former is inevitable, but sensation is regained in an astonishing manner. The danger of sloughing of the eye can be reduced to a minimum by exclusion of light and other forms of irritation, and the maintenance of cleanliness by stitching together the lids at the center and washing beneath them from time to time with a warm boric acid solution for four or five days, followed by their liberation and the use of a proper shield (Keen). The division with the nerves of the tubular meningeal prolongations that surround them exposes the meningeal space to danger of infection. Still, if the wound be aseptic, little fear of this complication need be entertained. Doyen’s Method.—Doyen’s method seems to offer proper access to the ganglion with less injury of the brain, and perhaps better observation than the preceding methods. However, the trials necessary to establish its worth are lacking. The following excellent description of the procedure is quoted from the Annals of Surgery, January, 1890 : “ 1. A sickle-shaped incision is made through the soft parts over the temporal region (Fig. 274, c). The vertical portion, corresponding to the handle of the sickle, is from five to six centimetres long and is made in the space between the external auditory meatus and the outer angle of the orbit. This incision should pass not more than fifteen millimetres be- low the zygomatic arch, and should avoid as far as possible the branches of the facial artery and nerve. “ 2. Resection of the zygomatic arch close to the condyle, division of the coronoid process, and denudation of the temporal fossa. “ 3. Identification of the inferior dental nerve, which divides two or three centimetres lower down; identification of the lingual nerve. Both are then divided and the cut ends held by toothed forceps. The internal maxillary artery is ligated close to the point of origin. “ As soon as the isolation of the trunk of the inferior maxillary division as far as its point of exit from the foramen is assured, the skull is opened by a trephine or other suitable means at the level of the splieno-temporal suture. By means of suitable cutting forceps the greater wing of the sphenoid and the squamous portion of the temporal bones are removed bit by bit over the entire area of the lower portion of the temporal fossa ex- posed by the previous resection of the zygomatic arch. “ As soon as the antero-posterior ridge formed by the union of the verti- cal portion of the greater wing of the sphenoid with its base is reached, the basal part is attacked, and progressively removed as far as the foramen ovale. The external semicircumference of this is removed by the final out 262 OPERATIVE SURGERY. of the forceps. The area of bone removed in the course of the operation is shown in Figs. 280 and 281. “ The forceps are still attached to the inferior dental and lingual nerves, and with their aid the trunk of the inferior maxillary is raised, and the in- tradural pocket in which the ganglion lies is opened from the outer side. Traction can then be made upon the ganglion itself, and with a little care its anterior and posterior aspects are exposed and freed from attachments. The superior maxillary division is made free in like manner as far as the foramen rotundum where it is divided ; finally, the ophthalmic division is cut at the sphenoidal fissure. “ When, as was the case in the first patient upon whom Doyen operated, the superior maxillary division has previously been severed beneath the orbit, Fig. 280.—Outline of bone removed at side of skull. a little tension and manipulation will usually suffice to remove the remainder of the nerve. “ The ophthalmic division is divided at its entrance into the sphenoidal fissure. By the aid of a small elevator the entire periphery of the ganglion is completely freed, and made movable by traction upon its efferent nerves, which renders it possible to expose the superior border of the petrous portion of the temporal bone and the dural canal which serves as a sheath for the pri- mary trunk of the trigeminus beneath the superior petrosal sinus. This last nerve trunk is isolated in its turn, and then divided instead of the ganglion upon the posterior aspect of the petrous bone beneath the venous sinus. “ The carotid artery is seen at the bottom of the wound protected by a thin, fibrous sheath. It is easy to avoid wounding the cavernous sinus, pro- vided the operator be careful and skillful.” Horsley’s Intradural Operation of division of the nerve at the base of the skull through an opening into the middle fossa made in the temporal region is a bold conception, which, however, appears to be needlessly dan- gerous for the purpose and even unnecessary, in view of the results and the increased thoroughness of removal by the extradural methods. OPERATIONS ON THE NERVOUS SYSTEM. 263 The Facial Nerve.—The facial nerve is exposed for the purpose of stretching to arrest spasm of the muscles supplied by it, and also it is bared not infrequently in some part of its course at the outset of an operation contiguous to the nerve, to avoid the effects of unnecessary injury of the trunk or the larger branches at that time. The bony guides to the nerve are the mastoid pro- cess, the zygoma, and the angle of the lower jaw. The insertions of the sterno-mastoid, the digas- tric, and the prevertebral mus- cles can be classed as the muscu- lar guides. A point about mid- way between the angle of the jaw and the zygomatic arch indicates the situation of the nerve as it passes forward from the foramen of exit. The nerve can be ex- posed through an incision made behind (Baum) (Fig. 273) or in front (Hueter) of the pinna. The former method is the better one. Baum’s Operation.—Begin the primary incision just behind the pinna and on a level with the external auditory meatus, carry it downward and forward to nearly the angle of the jaw, passing im- mediately below the lobule, and curve it upward slightly at this point. Divide the superficial and parotid fasciae; expose the pos- terior border of the parotid gland and the anterior border of the tendinous fibers of insertion of the sterno-mastoid muscle, and draw these structures apart with hooks. Expose carefully the anterior border of the mastoid process, and, at a point about one third of an inch in front of the center of this border the nerve is found at a point about half an inch from the fora- men of exit. The origin of the digastric muscle is seen close at hand, pos- teriorly. The nerve is then caught up and stretched by means of a blunt hook with a force equal in weight to five or six pounds. The Comments.—The operation is easy in those of spare development, but in fleshy and muscular subjects it is often accomplished only with consider- able difficulty. After the exposure and clearing of the space between the gland and the insertion of the sterno-mastoid, the employment of electricity by means of a wet sponge to the face and a fine wire electrode in the course of the nerve will promptly demonstrate the situation of the nerve, and thus avoid unnecessary delay and injury of the tissues (Keen). The irritating of Fig. 281.—Outline of bone removed at base of the skull. 264 OPERATIVE SURGERY. a, b. Scalpels, c, d, e, f. Retractors, g. Rongeur, h. Gigli-Haertel saw. i. Bone ele- vator. j. Periosteotome. k. Sequestrum forceps. 1. Keen’s bone-gnawing forceps. m. Liston’s bone-cutting forceps. Forcipressure and ligatures in abundance, drain- age agents, etc., are needed. Fig. 282.—Instruments employed in laminectomy. OPERATIONS ON THE NERVOUS SYSTEM. 265 the nerve in the wound with a probe will likewise cause diagnostic mani- festations of its presence there. If the nerve be seized too far down, the fibers of the posterior auricular and styloid branches will escape the full effect of the stretching, therefore the trunk should be followed upward and stretched at a point above the origin of these branches. A strong light, good retractors, and vigorous sponging greatly facilitate the securing of the nerve. The Results.—Temporary relief is secured promptly; but since the func- tion of the nerve is restored in from a few days (seven) to twelve months in the majority of cases, a satisfactory cure can not be promised. However, as a number of cases have been relieved for a year or more, the outlook can be regarded as justifying further attempts in this direction. OPERATIONS ON THE SPINAL CORD AND SPINAL NERVES. Inasmuch as approach to the spinal cord for the removal of agents or conditions that impair or annul its functions requires the displacement or removal of superimposed tissues at the seat of involvement, and since the character of these tissues is substantially similar throughout the entire course of the cord, the explorative operative procedure differs in no essential re- spect at the various parts of the spine. Laminectomy.—The operation of laminectomy is one of comparatively modern birth, and as yet of a limited application. It is employed to relieve the spinal cord of otherwise irremediable pressure. The dangers of the opera- tion are pronounced, and all available measures should be employed to fore- stall and counteract their occurrence. Sepsis, haemorrhage, shock, and im- paired respiratory force are each of decided significance, and if perchance they be combined in an individual case, the outcome is scarcely a matter of conjecture. While these dangers are not enumerated here in the order of probable occurrence, still the enumeration is one of logical sequence in the forethought of prevention. Sepsis.—Thorough antiseptic preparation of the patient and of the de- tails of the procedure will prevent infection, if it has not already happened as the result of the injury, or has been invited by the oversights and acci- dents of subsequent treatment. Considerate treatment of the tissues during the operation, and intelligent drainage and dressing subsequent to the act, are very important factors in this respect. Haemorrhage.—The haemorrhage is free and often persistent, on account of the size and great number of the vessels involved in the procedure. However, the prompt use of forceps and the liberal employment of hot water and sponge pressure robs this danger of grave significance. Shock.—The mutilation of the parts and the loss of blood attendant on the operation, combined with the mental and physical depression resulting from the original injury, should not be underestimated or considered lightly. When circumstances will permit, the patient should be prepared for the operation with due consideration to mental and physical complaisance, and the need of heart tonics. Physical warmth as provided by an abundance of hot-water bottles and woolen blankets should be employed. All unneces- 266 OPERATIVE SURGERY. sary exposure of the body or limbs should be avoided with sedulous care during operation. Impairment of Respiratory Force.—The impairment of the auxiliary forces of respiration dependent on interference of the functions of the spinal cord, together with the impediment to breathing incident to necessary ab- dominal decubitus of the patient, incite not infrequently troublesome and even dangerous respiratory manifestations. Therefore the patient should be so placed and supported as to interfere as little as possible with the respira- tory forces, the head being placed over the end of the table to meet the re- quirements of the anaesthetist. The Operation of Laminectomy.—Make an incision in the median line four or more inches in length down upon the apices of the spinous processes of the vertebrae, the center of the incision corresponding to the seat of the disease or injury. Separate the tissues at one side from the spinous pro- cesses and laminae of the vertebrae by carefully directed incisions made with a knife, drawing the structures aside with broad, thin retractors as soon as severed from their connections, thus exposing completely the posterior bony wall of the spinal canal. Arrest haemorrhage by forcipressure and packing with sponges saturated with hot water, withdraw the retractors, and allow the tissues to return toward the median line. Having treated the opposite side in a similar manner, again expose the primary wound to the fullest ex- tent, and with a raspatory scrape off and remove the muscular tissue remain- ing attached to the bones. Repack the wound, and repeat this procedure upon the opposite side (Fig. 283). Draw aside the tissues from the median line, and divide the supraspinous and infraspinous ligaments with a scalpel, carefully avoiding the membranes of the cord ; gnaw away successively the spinous process and lamina of one or more vertebrae with the rongeur forceps or remove with the Gigli-Haertel saw sufficiently to admit to the spinal canal the laminectomy forceps, with which the laminae are divided, and when removed the contents of the spinal canal are exposed to view (Fig. 284). A sharp haemorrhage often arises from the superficial plexus of veins at this time, but it is arrested easily by sponge pressure and hot water. Lying beneath the arches of the vertebrae and upon the dura there is a consider- able amount of closely woven connective tissue, supporting in its meshes a troublesome plexus of veins. This tissue is carefully divided in the median line down upon the dura, bleeding being arrested in the usual manner, as it occurs. The Examination of the Contents of the Cayial.—A posterior concavity of the spine should be established by a pad placed at either extremity of the trunk (Chipault) before examination is commenced. A bluish dura indi- cates the presence of blood, and a yellowish of pus beneath it; increased tension and firmness denote tumor; absence of pulsation indicates interfer- ence with the subdural space by adhesions, pressure, etc. After exposure of the contents of the spinal canal, and before opening the dura, a careful scru- tiny of the bony outline of the canal should be made at the various aspects, to detect the presence of any encroachment of bone or diseased products in a degree that causes symptomatic pressure of the cord. In fracture of the OPERATIONS ON THE NERVOUS SYSTEM. 267 spine and in Pott’s disease this step is of obvious importance, since it may be possible to remedy the impingement without division of the membranes. To obviate the danger of infection diseased products should be scraped away with a small spoon, aided by a gentle stream of hot sterilized water. The correction of the bony trespass is not so easily made, owing to the greater necessity of drawing the contents of the canal upward, out of the way of the instrumental manipulations necessary for the removal of the pro- jecting bone. To meet this indication properly, it may be necessary to sever the roots of one or more of the spinal nerves at one side of the canal. The offending bone structure is cut off at a proper line (Fig. 285) with sharp- Pig. 283.—Exposure of posterior structures of spinal column. Fig. 284.—Spinal cord exposed. curved chisels, or dug away with suitable scoops. After proper alignment of the bony surface and thorough cleansing of the parts, the divided roots of the nerves are united with sutures, and then, if advisable, the dura is opened. The Opening of the Dura.—In the majority of instances it is advisable to open this membrane to be assured of the condition of the cord. However, the principles relating to removal of depressing agents of the brain can be applied with satisfactory outcome to the cord. The dura may be opened at the median line with forceps and scalpel for a sufficient distance to permit the examination of its contents. The subdural space is explored carefully in all directions with a bent silver probe, to determine the presence of disease or injury. Tumors are removed if not infiltrating, and bony irregularities, spic- ulse, and diseased products are similarly treated. All efforts to repair the cord itself have as yet proved futile. Whether or not the theca should be sutured after treatment of the contents depends not a little on the nature 268 OPERATIVE SURGERY. and extent of the disease and the character of the products disclosed. In some instances of large tumors both Horsley and Keen omitted the closure. If infecting agencies be already present within the membranes, closure of the dural incision should be omitted and suitable drainage be established in- Fig. 285.—Removal of bone pressure. stead. The liability to fistulous formation, which may happen in any event, is increased with non-sewing of the membranes, and this occurrence invites infection and is often of perplexing duration. The escape of cerebro-spinal fluid in such cases is often excessive and dangerous, but not so much on account of the loss of fluid as of the irritation and annoyance imposed, and the increased liability of infection. A fine needle armed with silk or catgut is used for suturing. If a coarse one be employed, the punctures may permit the escape of the fluid, and thus invite fistulous formation, de- layed union, and consequent infection. Employ deep drainage for a day or two, and longer if advisable; unite the deeper layers of muscles with buried catgut sutures, close the integumentary wound with silkworm gut, apply abundant antiseptic dressings, fix them with a firmly applied binder, and place the patient on the back. Remove the dressings in twenty-four hours, or sooner if soiled. Thereafter renew them with aseptic care as often as is consistent with the comfort and security of the patient. The Osteoplastic Flap.—The making of an osteoplastic flap is preferred by some surgeons, with the view of securing greater solidity of the spine OPERATIONS ON THE NERVOUS SYSTEM. 269 after recovery. There appears to be as yet no good reason for this propo- sition, except perhaps in case of Pott’s disease, in which the bodies of the vertebrae are not sufficiently solidified to properly support the trunk in the absence of excised laminae and spinous processes. However, it is deemed proper to say, even in this connection, that a flap of this kind, when employed in stationary or advancing Pott’s disease, can scarcely be expected to unite at the bony points; and it will, moreover, be illy fitted to meet the demands of drainage and the prevention of infection, to say nothing of the greater operative dangers attending its formation. The osteoplastic flap is quadri- lateral, attached above, and includes the laminae or spinous processes which are cut away and turned upward along with it (Fig. 286). The construction Fig. 286.—Osteoplastic flap. of the flap is difficult and tedious, and necessarily attended with a greater loss of blood than is the former method. If the latter be employed, the bony asperities should be removed before replacement, and the osseous fragments sutured in place, if possible, before final union of the soft parts is made. 270 OPERATIVE SURGERY. The Results.—Of 270 cases reported by Genet, 53 recovered. Chipault analyzed 160 cases, with the following results: 20 were cured, 33 improved, 22 unimproved, 65 died, and in 20 the results are unknown. The death rate of laminectomy for Pott’s disease is about forty per cent. Spinal Meningeal Drainage.—The draining away of the cerebro-spinal fluid with a small trocar inserted between the lamina of the cervical or lumbar vertebrae, or at the seat of a primary laminectomy, for the relief of pressure in cerebral disease, has of late been practiced to a consider- able extent. The lumbar region is the one commonly selected for the purpose. The Anatomical Points.—As the spaces immediately connected with the lamina of the fourth lumbar vertebrae are the ones through which the pro- cedure is commonly conducted, it will not be amiss to direct attention to certain anatomical facts concerned in the operation at these points. In infants these spaces have a transverse diameter of about three quarters of an inch and a vertical of about half an inch, the latter being increased by flexion of the spine. The requisite depth of the puncture is about four fifths of an inch in infants; in adults it is twice that dis- tance. The lumbo-sacral space being the larger, and farthest removed from the spinal nerves, is recom- mended as a suitable place for puncture (Chipault). The Operation. — Ad- minister an anaesthetic; place the patient in the sit- ting posture with the body slightly flexed; make a short incision down to the bone at the point through which the puncture is to be made, and introduce the trocar slowly and con- tinuously into the spinal canal (Fig. 287). Various directions are given to the trocar, as, forward toward the median line, A (Quincke), upward and forward between and along the course of the spinous processes, B (Marfan), and upward and forward through the lumbo-sacral space at either side of the spinous process, C (Chipault). Parkin’s Operation (Fig. 288).—Parkin proposed, in lieu of spinal punc- ture, to enter the basal subarachnoidan space by trephining the occipital bone (c) at a point low enough to permit tapping of the subarachnoid space (ia, b) under the cerebellum. The comparative success thus far attained by Parkin certainly encourages continued elfort in this direction. The Results.—Five cases are reported, with three recoveries. Fig. 287.—Introduction of trocar in spinal drainage, OPERATIONS ON THE NERVOUS SYSTEM. 271 The curative effects of spinal drainage are not of a reassuring char- acter. However, amelioration of the symptoms frequently follows, which of itself is comforting, and may offer the way to the only chance for re- covery. The importance as a diagnostic measure appears to rest on a substantial foundation. The operation alone pre- sents no especial dangers if cautiously and aseptic- ally performed. Spina Bifida. — Spina bifida is a not infrequent defect, since it is noted in one in about eight hun- dred births. It may ap- pear at any portion of the vertebral column, but most frequently in the lumbo- sacral region. The defect may involve one or more of the laminae, and rarely, indeed, even the body of a vertebra itself. Three varieties of arrangement of the tissues involved are noted, viz.: 1, in which the membranes alone protrude (meningocele); 2, in which both the membranes and cord protrude (meningo-myelocele); 3, in which to the latter condition is added distention of the central canal of the cord, reducing the cord to a thin internal covering lying against the membranes (syringomyelia). These tumors vary also in size and shape, being large and small, and sessile and pedunculated in form. If, after two or three months, palliative treatment affords no relief or the symptoms increase in gravity, one of two measures of radical cure should be attempted—i. e., injection or excision. The Injection Method.—The iodoglycerin solution is advised especially for use in this method (page 194). After complete antiseptic preparation, the patient is placed on the side and an anaesthetic is given if necessary. The needle is introduced as far from the median line of the tumor as possible, in order to avoid puncturing the nervous tissue and also to utilize the soundest integumentary covering, and while pressure is made on the neck of the sac. A drachm or two of fluid is drawn from it—sufficient to cause perceptible relaxation—followed by the slow introduction of a drachm or a drachm and a half of the iodoglycerin fluid. This fluid may remain or be permitted to escape and distilled water be introduced, the needle withdrawn and the opening so closed as to prevent the escape of fluid and carefully protect the puncture. If the communication between the sac and the cord be small, long, or closed, the danger of the injection method is proportionately dimin- ished. If, however, the opening to the sac be large and the capacity of the sac be small, then the amount injected should be lessened and the caution in the use increased. The slight reaction that follows in favorable cases sub- Fig. 288.—The opening in the skull in Parkin’s operation. 272 OPERATIVE SURGERY. sides within two weeks, when a second injection may be employed. Spinal meningitis due to infection or to the medication may ensue. Ulceration may follow at the point of puncture, leading to the escape of the cerebro- spinal fluid and to death from convulsions or infective meningitis. The Results.—The death rate is from twenty-seven to twenty-eight per cent. Repeated injections are sometimes needed to effect a cure. In about seven per cent of the cases no effect is noticed. The Excision Method.—The treatment of spina bifida by excision is now regarded with comparatively great favor by the majority of surgeons. It is applicable, however, only to the first two varieties of the anomaly, the simple meningocele being the best adapted to the procedure. The advantages of thorough asepsis are of superlative importance in this operation. In meningocele an elliptical incision is made down to the sac, leaving sufficient integument at either side to close the defect. The sac is exposed down to the base, and if the neck be small it is ligatured with silk or strong catgut and removed, and the wound closed and dressed in the usual manner. If the neck of the sac be large it should be sutured through and through with silk or catgut, so as to bring the serous surfaces in apposition with each other, carefully avoiding in the meantime the escape of cerebro-spinal fluid, not so much on account of immediate as of subsequent danger to life from infective meningitis, the result of a fistulous communication with spinal membranes. The Results.—The number of cases thus far treated is considerably over one hundred, with a rate of mortality varying from twenty to twenty-six per cent, showing somewhat better results than follow the injection method. Meningo-myelocele.—In this variety of infliction the spinal nerves play an important part, as it is necessary to eliminate them from the remainder of the tumor and return them to the spinal canal. More commonly the nerves are associated with the posterior wall of the sac, but when present within it they are more frequently adherent at either side of the median line of the tumor. In both instances the sac is approached the same as in me- ningocele, the nerves dissected out and returned to the spinal canal, and the sac treated as in the preceding instance. The difficulty attending the elim- ination of the nerves from the tumor without great damage to the sac, free escape of cerebro-spinal fluid and subsequent fatal meningitis, is manifest. Nerves that are limited to the tumor alone, or perchance pass outside, may be removed entirely; but all those that may he replaced in the spinal canal should be treated with scrupulous care and be returned to their normal en- vironment. If the establishment of a fistulous opening with the spinal canal be regarded imminent, suitable drainage should be provided, and every anti- septic measure rigorously enforced to prevent meningitis and lessen its dan- ger. In other respects the wound is treated by common aseptic methods. The great desideratum is the proper strengthening of the posterior wall of the spinal canal, and it is in this line of achievement that modern surgical effort has been directed. The union in the median line of detached muscles at either side of the spine (Bayer); similar union of the forcibly detached rudimentary arches of the dorsal (Dollinger) and sacral (Senenko) verte- OPERATIONS ON THE NERVOUS SYSTEM. 273 brae; the employment of a portion of the iliac crest (Bobroff) while attached to the erector spinae muscle; the utilization of foreign periosteum or bone, are each advised. The last has been tried, but the outcome can not be re- garded with the favor that characterizes autoplasty. The use of the celluloid plate, sprung into place, offers a comparatively encouraging outlook. The Results.—The operative outcome in meningo-myelocele is so un- favorable that many authorities discourage the attempt. Tumors of the Spinal Cord.—The prospect for relief in some forms of this affection is not discouraging. Tumors of the membranes of the cord and those outside are favorably situated for operation. Circumscribed tumors of the cord offer a degree of hope of relief over the diffuse variety. A knowledge of the technique of laminectomy, plus that of the removal of tumors of the brain, meets the requirements of surgical procedure of the cord. The Results.—About fifty per cent recover from the operation ; but as yet it is impracticable to express in numbers the functional benefits thus far received. The Spinal Accessory Nerve.—The spinal accessory nerve is subjected to the various surgical means directed to the cure of torticollis. The Anatomical Points.—After escaping from the jugular foramen, the nerve runs in front of the jugular vein, beneath the digastric and stylo-hyoid muscles and the occipital artery, and enters the deep portion of the anterior border of the sterno-mastoid at a point about two inches below the tip of the mastoid process. It then passes obliquely downward and backward in the structure of the muscle to the center of the posterior border, escapes and crosses the lower part of the occipital triangle, passes beneath the anterior border of the trapezius muscle at the upper part of the lower third, and disappears in the muscular structure. The nerve can be exposed at either the upper or lower portions. The Operation (upper portion).—Raise the shoulders, extend the head, and turn the face to the opposite side ; make an incision from the tip of the mastoid process along the anterior border of the sterno-mastoid muscle (Fig. 204) three inches in length ; divide the integument and superficial fascia expose the anterior border of the sterno-mastoid muscle and divide the deep cervical fascia; flex the head slightly, draw the sterno-mastoid outward,, thus making the nerve tense and appreciable to touch ; expose the nerve with thumb forceps and scissors and carry around it and tie a strong liga- ture ; stretch the nerve and divide it at either side of and as far from the ligature as is practicable. Close and dress the wound in the usual manner and keep the head quiet. The nerve can he exposed in the lower 'portion of the occipital triangle at the posterior border of the sterno-mastoid (Fig. 202). It is then followed upward until the posterior border of the sterno-mastoid is reached and resected ; or resection is done before it enters the sterno- mastoid, depending on the effect desired. The writer once approached the nerve by going between the anterior fibers of the sterno-mastoid. The nerve was quickly and easily reached before it entered the muscle, and the wound healed promptly. 274 OPERATIVE SURGERY. The Remarks.—Division of the nerve is followed quite soon by atrophy of the muscles, attended with drooping of the shoulder. Irritation of the nerve on exposure with the forceps will cause contraction of the trapezius, even with the patient under anaesthesia, a fact of manifest diagnostic im- portance. The Results.—Stretching and simple division of the nerve do but little good; neurectomy, however, is followed by a fair degree of success. Operations on the Branches of the Cervical Nerves.—Many of the branches arising from the anterior and posterior cervical plexuses are treated surgically for the cure of neuralgia and spasmodic affections. Excision of the Posterior Divisions of the First Three Cervical Nerves (Keen).—This operation is advised for the relief of spasmodic wryneck de- pendent on the action of the posterior rotator muscles of the head. The Operation.—Make a transverse incision three inches in length from half an inch below the lobe of the ear to the middle line of the neck pos- teriorly ; divide the trapezius transversely (Fig. 219); recognize the occipi- talis major nerve as it escapes from the complexus muscle half an inch below the line of incision; divide the complexus transversely on the level with the nerve ; expose the nerve down to its origin from the inner division of the posterior trunk of the second cervical nerve; resect this division as low as possible to paralyze the inferior oblique muscle ; recognize and divide the suboccipital nerve as it passes outward across the arch of the atlas, carefully avoiding the vertebral artery. An inch below the second is found the third branch of this plexus—i. e., the internal division of the posterior trunk of the third cervical nerve. This operation is one in which a knowledge of anat- omy will do much to facilitate the efforts and comfort the operator. The wound is dressed as in other cases, and the head fixed until repair takes place. The Results.—Nothing can as yet be said of this operation, except that in cases calling for it the outlook should be quite as favorable as in those cases already benefited by a similar proceeding elsewhere. The occipitalis major can be divided or stretched higher up in its course than is indicated above, if desirable. The Operation.—Locate the occipital protuberance, and, beginning about an inch above the protuberance, make an incision one inch and a half in length downward, forward, and outward at its anterior border; carefully separate the tissues in the line of the incision, and the nerve will be exposed where it escapes from beneath the trapezius muscle. The Auricularis Magnus Nerve.—This nerve is one of the ascending branches of the cervical plexus. It emerges at the posterior border of the sterno-mastoid muscle near its middle, and ascends on that muscle to the lobule of the ear (Fig. 204). The Operation.—Make an incision two inches in length obliquely up- ward and backward, its center corresponding to the lower extremity of the lobule of the ear. On dividing the skin and fascia the nerve will be found resting on the sterno-mastoid muscle, from which it can be raised with a hook and stretched or cut. OPERATIONS ON THE NERVOUS SYSTEM. 275 Intraspinal Division of the Roots of Spinal Nerves (brachial plexus).— This operative procedure was first performed by Abbe, and for the relief of intractable neuralgia of the brachial plexus. The Operation.—Locate the vertebral spinous processes that correspond to the nerves to be attacked; place the patient, and open the spinal canal and dura, as in laminectomy; identify the posterior roots of the affected nerves and resect from each as long a segment as practicable, dividing the corresponding anterior roots (Fig. 289); close the dura mater by sewing with catgut ; unite the wound as indicated in laminectomy. The Remarks.—The operation is in all essential regards similar to laminectomy aside from the sur- gical treatment of the roots of the nerves. Care- fully indicate on the skin the spinous processes that correspond to the nerves involved before be- ginning the operation. The Results.—Several cases have been thus treated, but with an outcome not at all encourag- ing so far as relief from pain is concerned. The operation itself can be regarded as free from dan- ger in the presence of proper aseptic technique. The Branches of the Brachial Plexus.—It may be necessary, on account of a severe neuralgia in- volving the branches of this plexus directly, or located in a painful stump, to excise or stretch the nervous cords near their origin. It is best done at the seat of the three primary branches. The Operation.—Place the patient upon the back, raise the shoulders, and turn the head back- ward and to the opposite side. Determine the course of the external jugular by pressure just above the clavicle; make an incision along the posterior border of the sterno-mastoid three inches in length extending down to the clavicle ; a second incision of the same length is made outward from this point, along the upper border of the clavicle, carefully avoiding the ex- ternal jugular; turn the flap upward and seek for the posterior belly of the omo-hyoid ; when found, draw it upward with a hook or ligature, push aside the loose connective tissue, and the cords will appear located above and to the outer side of the third portion of the subclavian artery, which should be carefully avoided. The inner cord is cautiously hooked up and a ligature applied to it, by which it can be raised from its bed and stretched, then divided with a pair of scissors near the outer border of the scalenus anticus muscle, being careful to avoid the muscle and the phrenic nerve. If gentle traction be made upon the ligature, the distal extremity will be raised, and can be again divided an inch or so from the point of the first section and Fig. 289.—Intraspinal divi- sion of the roots of spinal nerves. 276 OPERATIVE SURGERY. the portion removed. The remaining cords can then be divided in the same manner. The Musculo-Cutaneous Nerve.—The musculo-cutaneous nerve can be exposed at two situations: 1. As it escapes from the axilla. 2. Near to the elbow joint. The Operation.—At the first situation, carry the arm from the body and rotate it outward ; make an incision three inches in length along the inner border of the co- raco-brachialis muscle (Fig. 207); divide the skin and fascia on a director, draw the muscle inward, and the nerve will be easily found at its inner border. The nerve is exposed at a lower point than this, after perforating the coraco- brachialis muscle, by making the incision at the outer border of that muscle. At the second situation it is found by making an incision two and a half inches in length be- tween the biceps and the supina- tor longus, through the integu- ment, fascia, and aponeurosis; separate the muscles and the nerve will be readily seen (Fig. 210,/). The Musculo- Spiral Nerve.—The musculo-spiral nerve can be exposed at three situa- tions: 1. Make an incision about four inches in length between the outer border of the triceps and the brachia- lis anticus muscles (Fig. 290), beginning two and a half inches above the external condyle. Divide the fascia on a director, sepa- rate the connective tissues with a handle of a scalpel or the finger, and the nerve will be easily found. 2. Make an incision three or four inches in length at the inner aspect and upper third of the arm (Fig. 207). The tendon of the latissimus dorsi above, the long head of the triceps muscle at the inner, and superior profunda artery at the outer, mark the situation of the nerve. An incision made at the posterior and inferior aspect of the upper third of the arm, located below the deltoid and passing between the outer and long heads of the triceps, promptly exposes Fig. 290.—Musculo-spiral nerve, etc. OPERATIONS ON THE NERVOUS SYSTEM, 277 to view the nerve, attended by the superior profunda artery (Fig. 290). 3. Make an incision three inches in length in the space between the supinator longus and the brachialis anticus mus- cles; divide the fascia, sep- arate the connective tissues beneath it, and the nerve will be readily exposed. The Circitmflex Nerve. —Abduct the arm and press the posterior border of the deltoid muscle toward the surgical neck of the hume- rus, noting the angle formed by this and the posterior scapular muscles ; expose the posterior border of the deltoid through a longitu- dinal incision made at this point; draw the border for- ward and expose the lower edge of the teres minor and the long head of the triceps, and observe in the angle between them the circum- flex nerve attended by the posterior circumflex artery (Fig. 290). The circum- flex nerve can be exposed near its origin through an incision carried from the beginning of the arm along the axillary surface of the posterior axillary fold. Di- vide the fascia; separate the loose cellular tissue at the upper borders of the inser- tion of the latissimus dorsi and teres major muscles. At the upper end of the incision will be seen the circumflex nerve, with the scapular vessels and nerves on a lower plane (Fig. 207). Fig. 291.—Median nerve in the forearm. 278 OPERATIVE SURGERY. The Median Nerve.—The median nerve can be easily exposed in its course along the arm by modifying either of the incisions for ligaturing the brachial to correspond to the relations of the median nerve to that vessel (Figs. 207 and 210,/). In the forearm, the median nerve can be exposed at three situations: 1, at the upper third; 2, below the middle; 3, above the wrist joint. At the upper third, supinate the arm and make an incision as for liga- ture of the radial artery at that situation (Fig. 291); divide the pronator radii teres and the tendinous arch of the flexor sublimis digitorum, thus exposing the nerve contiguous to which lies the anterior interosseous branch. Below the middle the nerve is exposed through an incision made between the flexor carpi radialis and the palmaris longus muscles, after drawing in- ward the interposing fleshy belly of the flexor sublimis digitorum. The median artery is present at this situation. Above the ivrist joint the nerve is quickly seen through an incision of the skin and fascia made at the radial side of the palmaris longus tendon. The Ulnar Nerve in the Arm.—At the upper and the middle thirds of the arm this nerve lies near to the inner aspect of the brachial artery, and can be readily exposed at these situations by properly located incisions of similar dimensions to those employed to expose like portions of the artery (Fig. 207). The ulnar nerve at the elbow is of special importance because of its rela- tions to the internal condyle and to the olecranon process (Fig. 211,/) in connection with excision of the joint, and also its liability to injury and dis- placement at this situation. Displacement of the ulnar nerve is rare. However, this condition may complicate fracture or dislocation at the elbow, and it may arise from other causes. MacCormac advises that the nerve be exposed by a free incision, dividing the tissues back to the inner condyle, thus providing a bed into which the dislocated nerve is placed and fastened by sutures of kangaroo tendon passed through the borders of the wound and the triceps tendon. The radial and ulnar nerves in the forearm can be easily exposed through the incisions employed to ligature the vessels bearing similar names (Fig. 210). Branches of the Sacral Plexus.—The gluteal, pudic, and small sciatic nerves can each be exposed through the same incisions used to ligature the arteries of a similar name (Fig. 179). The Great Sciatic Nerve.—The great sciatic nerve, though lying deeply, can be reached through the incision for ligature of the sciatic artery (Fig. 179). At the posterior surface of the thigh this nerve can be exposed just below the gluteal fold and at the seat of bifurcation (Fig. 292); it is best approached after its escape from beneath the lower border of the gluteus maximus. The Operation.—Place the patient on the abdomen or side, and make an incision three or four inches in length, beginning at the gluteal fold, at a point midway between the tuber ischii and the trochanter major, or the ver- tical incision maybe joined by a short horizontal incision; divide the in- OPERATIONS ON THE NERVOUS SYSTEM. 279 tegument and fascia on a director, separate the connective tissue with the fingers and handle of the scalpel down to the nerve, bringing into view the biceps muscle, small sciatic nerve, etc. (Fig. 292). It can then be Fig. 292.—Exposure of great sciatic and popliteal nerves. stretched by passing one or two fingers around it and making firm and steady traction upon it (sufficient to raise the limb). The wound should be carefully closed and dressed under antiseptic precautions. 280 OPERATIVE SURGERY. IVie Bloodless Stretching of the Sciatic.—Administer an anaesthetic and place the patient on the back or side. Extend the leg fully on the thigh, and hold the pelvis firmly. Flex the thigh on the pelvis while full extension of the leg on the thigh is continued, thus causing extreme tension of the muscles and other structures on the posterior surface of the thigh, thereby stretching the nerve. The manipulation must be firmly yet cautiously made to attain the object, and at the same time not tear asun- der the hamstring muscles. At the Seat of Bifurca- tion (Fig. 293).—At this situation — just below the middle of the thigh—the nerve is exposed through an incision directed be- tween the semitendinosus and semimembranosus mus- cles internally, and the bi- ceps externally. It lies deep- ly, near the posterior surface of the femur, and may have divided already into its ter- minal branches (Fig. 186). The Fallacy. — Rarely this nerve divides into its ter- minal branches in the pelvis, presenting, therefore, two branches at either site of operation. Some confusion may occur in its detection and incomplete treatment of the affliction result, if this ab- normality be not discovered. The Results.—Obstinate sciatica has been relieved, and even cured, by stretch- ing. Not infrequently the degree of the resulting ec- chymosis indicates rupture of the muscular structures in bloodless stretching. The Internal Popliteal Nerve.—The internal popliteal nerve can be reached by the same method and with the same caution as the popliteal artery (Fig. 292). It is, however, less deeply situated and somewhat nearer the center of the popliteal space than are the vessels (Fig. 189). Extreme caution should be exercised in operating upon it, on account of its nearness to the popliteal vein, which lies beneath it and to the inner side. The External Popliteal Nerve.—The external popliteal nerve can be easily reached by making an incision two or three inches in length along Fio. 293.—Incisions in exposure of great sciatic and branches. OPERATIONS ON THE NERVOUS SYSTEM. 281 the inner side of the tendon of the biceps cruris (Figs. 292 and 293), when the nerve can be readily found beneath the fascia, surrounded by fat (Fig. 190, J). The anterior and posterior tibial nerves can be exposed and stretched through the incisions adopted in ligaturing the vessels of the same names (Figs. 192 and 197). The Plantar Nerves.—The plantar nerves are the terminal branches of the posterior tibial, and are given off just after the nerve winds around the internal malleolus. They can be exposed by making an incision about three inches in length, beginning just in front of the center of a line extending from the anterior border of the internal malleolus to the inner tuberosity of the os calcis, and carried forward along the external border of the ab- ductor pollicis. If the space between the short flexor and the abductor be now opened at the posterior portion, the nerves will be found accompanied by the arteries of a similar name. The Perineal Nerve.—The perineal nerve may be exposed in the perinseum of the male by making an incision along the ramus of the pubes and ischium at either side in the same manner as directed for ligaturing the pubic artery at this situation (Fig. 181). In the female perinaeum the nerve may be ex- posed either by an incision made ivithout or within the vagina. In the for- mer instance, make it through the superficial tissues, about three inches in length, in the groove between the labium and the perinaeum, just inside the rami of the pubes and ischium. The nerve is surrounded by connective tis- sue, and it is difficult to find in this situation; however, if the blade of the knife be turned inward and the outer coats of the vagina be divided down to the inner one, the nerve will not escape section. The nerve is more easily severed from within the vagina. If the finger be introduced an inch or more and lateral pressure be made, the nerve will be felt, cord like in character and sensitive to the touch. Make a vertical incision through the coats of the vagina, and the nerve will be exposed for division or excision. The Branches of Lumbar Plexus.—Operations on the branches of this plexus are not practiced as frequently as on those of the other plexuses. The Anterior Crural Nerve.—The anterior crural nerve is the largest branch of the lumbar plexus, and enters the thigh beneath Poupart’s liga- ment, about three quarters of an inch to the outer side of the femoral artery. It lies beneath the iliac fascia (Fig. 294). The Operation.—Make an incision three inches in length directly down- ward, beginning about an inch below Poupart’s ligament, in the line of the nerve. The superimposed layers of tissue are carefully divided on a director down to the groove between the iliac and psoas muscles, between which it rests. The pulsations of the femoral artery will always suggest the location of the nerve. The Obturator Nerve (Fig. 183).—The obturator nerve and artery, and the internal circumflex branch of the profunda artery, are each exposed through a vertical incision beginning just below and a finger’s breadth in- side of the center of Poupart’s ligament. The integument and fascia are 282 OPERATIVE SURGERY. divided carefully, avoiding the internal saphenous vein. Divide the pectineal fascia just external to the femoral vein, define the border of the pectineus muscle and separate the muscle from the pubis and obturator fascia, and draw it inward. Divide the obturator fascia, pass the finger above the upper border of the obturator muscle, and feel for the artery and nerve as they pass through the obturator foramen under the horizontal ramus of the pubis. The Internal or Long Saphenous Nerve is given off from the anterior crural, and supplies the inner surface of the leg. It is accompanied by a vein of the same name in its course along the leg. It can be reached easily at many situations, but practically, however, it is best exposed at the inner condyle of the femur, where it escapes from beneath the sartorius (Fig. 197), and at the middle of the leg. At the former situation recognize the tendon of the sartorius. Press upon the internal saphenous vein above this point to distend it; make an incision two inches in length close to and parallel with the vein, draw it aside, and the nerve will be found emerging from beneath the tendons of the sartorius and gracilis. At the middle of the leg (Fig. 194, F) make an incision three inches in length parallel with the prop- erly distended vein, which should then be pulled aside, and the nerve will be found close to and behind the vein. The External or Short Sa- phenous Nerve (Figs. 198, c, and 293) arises from the internal popliteal, escapes from between the heads of the gastrocnemius, pierces the fascia be- low the middle of the leg and becomes subcutaneous, and passes down on the fibular side of the posterior surface to the malleolus, accompanied by the external saphenous vein. Distend the vein by pressure; make an incision close to and parallel with it, near the border of the tendo Achillis; pull the vein aside, and the nerve will be seen. Fig. 294. — Anterior crural nerve exposed, a. Femoral artery, n. Anterior crural nerve. pi. Psoas and iliac muscles, s. Sartorius muscle. CHAPTER VII. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, MUSCLES, AND BURSAE. Tendons, muscles, ligaments, and fascias suffer often from the effects of strain and rupture, and from chronic disease, and various degrees of defor- mity and modified function of parts are frequent sequels. The remedial measures directed to the alleviation of the effects of these pathological con- ditions on tendinous and muscular tissues are tenotomy, tendon suture, tendon transplantation, tendon lengthening, tendon shortening, tendon anastomosis, and myotomy. The bursal structures are of great mechanical importance in the human economy, and are subject to different grades of inflammation and degrees of traumatic violence, for the relief from which various operations are prac- ticed. Tenotomy.—Tenotomy consists in making a subcutaneous or open divi- sion of a tendon for the purpose of overcoming or alleviating a deformity dependent usually on muscular contraction. Since the advent of antiseptic surgery open division can be practiced with com- parative impunity if a rigid adherence to its tenets be maintained. However, it is wiser to hold to the subcutaneous method than to invite unnecessarily the mishaps that may follow a faulty technique in the open one. In order to practice tenotomy suc- cessfully the exact location of the offending structure should be determined, together with the important contiguous vessels, nerves, etc. Many of the large tendons are easily located by their natural promi- nence. Others that ordinarily lie concealed become apparent if contraction and deformity have occurred, and still more conspicuous if placed upon the stretch by the surgeon. The principles governing tenotomy should be well considered before a tendon is divided, otherwise an expedient of great good may become mischievous and even destructive in its results. The instruments employed in tenotomy are few in number and simple in character. Fig. 295 represents the tenotomes in ordinary use. They are excellent instruments for the purpose. Fig. 296, representing the ordinary tenotome found in the pocket cases of the day, is usually too fragile to be safely employed in the division of tissues requiring any special outlay of Fig. 295.—Tenotomes. 283 284 OPERATIVE SURGERY. force, as the delicate point is liable to be broken if brought in contact with tough, fibrous or bony tissue; moreover, it is with difficulty made aseptic. The Operation.—The operation of tenotomy is simplified by attention to the following order of procedure : 1. Secure complete aseptic technique. 2. Indicate on the handle of the scalpel the direction of the cutting edge. 3. Carefully note the length of the blade, so as to regulate the extent of the division of the tissues. 4. Avoid, if possible, the division of a tendon as it passes through a special sheath. 5. Divide the tendon at the point of greatest forced prominence, pro- vided the division be consistent with the safety of important contiguous structures. If reflex spasm be provoked by “ point pressure,” the tendon should be divided at the point exhibiting the great- est reflex manifesta- tion (Sayre). 6. Make tense the structure to be divided, and so pinch up or push aside the skin at the point of proposed division that when the skin is relaxed the opening in it will not correspond to the divided tendon. 7. Insert the blade on the flat close to the surface of the tendon to be divided ; turn the edge toward the tendon and carefully sever it with a guarded sawing motion, aided by pressing the tendon on the cutting surface of the knife. If incautious force be made, not only the tendon but the superimposed tissue may be divided, thus complicating the treatment and recovery. 8. Carry the edge of the blade from important structures when possible. 9. Withdraw the blade while upon the flat; follow the withdrawal with firm pressure upon the parts with the thumb, which should finally rest on the incision. This act will press the blood and air from the wound, as well as prevent air from entering it. Close the wound with a catgut stitch and seal it with antiseptic collodion. The application and confinement to the wound of an antiseptic pad is often quite sufficient for the requirements of healing. 10. Rectify the deformity, and confine the part immovably until repair is well advanced. The degree of rectification is, according to some authorities, regulated by the size of the divided tendon; the smaller the tendon the completer should be the degree of restoration, and vice versa. If the tendon be closely asso- ciated with important structures, it is advised to use the sharp-pointed teno- tome to prepare the way for the blunt-ended one with which the abnormal tis- sues are then divided, and with less danger than if the former be used through- Fig. 296.—Pocket-case tenotome. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 285 out. The injection into the tissue adjacent to the tendon of an aseptic solu- tion of cocaine will reduce the pain of the procedure to a minimum. Tenotomy—Upper Extremities. The Division of the Tendons of the Flexor Sublimis and Flexor Profundus Digitorum Muscles.—These tendons can be divided at the middle of the first row of anatomical phalanges by a transverse, subcutaneous incision carried through them down to the bone. After division of the tendons, reduce the deformity and keep the parts quiet for five or six days till the danger from inflammation has subsided, when they may be cautiously moved. Aseptic precautions should be ob- served throughout, otherwise inflammation of the sheaths of the tendons will follow. The Division of the Tendons of the Extensor Communis Digitorum Muscle.—The tendons of this muscle can be readily divided as they pass along the carpus and upon the dorsum of the phalanges. In the former instance pinch up the skin, pass the knife beneath the tendon, as before directed, and cut toward the surface. They may be divided by passing the blade above the tendons and cutting down through them upon the bone. On the dorsum of the phalanges the blade should be passed beneath the skin and the tendons divided upon the bone. The Precautions.—In the division of the tendons of both flexor and ex- tensor muscles, the carpal joints, the palm of the hand above the transverse line (Fig. 44G), the course of the vessels, and the spaces between the meta- carpal bones should be avoided. The Division of the Tendons of the Extensor Brevis, Longus, and Ossis Metacarpi Pollicis Muscles.—These tendons can readily be made prominent simultaneously or in turn by forcible extension with alternate supination and pronation of the thumb, with the forearm midway between supination and pronation. The brevis and ossis metacarpi pollicis tendons form the inner boundary of the “ snulfbox ” at the apex of the styloid process of the radius, the ossis metacarpi pollicis being the more internal of the two. The tendon of the extensor longus pollicis forms its outer boundary. These tendons can be divided at this situation by making them as prominent as possible, then introducing the knife from the anterior surface of the wrist beneath the tendon and cutting toward the integument. The Precautions.—The radial artery is to be avoided as it passes be- neath them, and likewise the radicle of the radial vein as it crosses the in- tervening space. The Division of the Tendon of the Flexor Carpi Radialis Muscle.—The tendon of this muscle, at the lower third of the forearm, is situated imme- diately to the inner side of the radial artery, and can be readily divided there by passing the knife away from the artery beneath the tendon. The Division of the Tendon of the Flexor Carpi Ulnaris Muscle.—The tendon of the flexor carpi ulnaris, the most internal on the anterior sur- face of the forearm, is inserted largely into the pisiform bone and has the ulnar artery at the outer border. This tendon can be easily divided at a half inch or so above the insertion by passing the knife beneath it, away from the artery and nerve, and cutting toward the surface. 286 OPERATIVE SURGERY. The Division of the Tendon of the Biceps Muscle of the Forearm.—The tendon of insertion of this muscle may be divided either above or below the giving off of the bicipital fascia (Fig. 160,/). The former situation is the safer. Division at the latter point contemplates the leaving intact of the bicipital fascia. This is a matter of some importance, for if the fascia is contracted also, the deformity will be maintained in lesser degree after sec- tion of the tendon at the lower point. But when the fascia is not involved, some advantage will be gained in pronation of the forearm if the influence of the fascia be not impaired by section. The Operation.—Make the veins at the elbow prominent by constricting the arm above ; extend the forearm to make the tendon prominent and tense ; enter the knife at its inner border and pass it cautiously between the tendon and the brachial artery; cut outward, being careful not to injure the distended veins. Tenotomy—Lower Extremities. The Division of the Tendon of the Tibialis Posticus Muscle.—The tendon of this muscle is intimately associ- ated with the deformity of talipes varus. ' It runs along the inner border of the tibia, behind the internal malleolus, in a separate sheath, being the inner- most tendon at this situation ; after leaving the internal malleolus it passes beneath the calcaneo-scaphoid ligament to its insertions. In the normal foot it lies well concealed within a closely fitting groove, but it can be readily outlined between the tip of the malleolus and the astragalo-scaphoid articu- lation. In talipes varus the tendon is raised from its groove and becomes promi- nent above and below the tip of the internal malleolus. The tendon can be divided either above or below the malleolus, but it is better done at a point about an inch and a half above the tip in the adult, and one inch in the child or infant. The tendon is.made tense by strongly abducting the foot, and the knife is passed with the usual precautions between the internal bor- der of the tibia and the tendon ; the division is made by cutting backward. The division between the tip of the malleolus and the astragalo-scaphoid articulation is not advised on account of the contiguity of the ankle joint and the internal plantar artery. If, however, it be thought advisable to operate at this situation, the foot should be strongly abducted, the point of the tenotome carefully insinuated beneath the tendon between it and the plantar artery; the handle is then depressed so as to carry the point away from the joint, and the section made from within outward. In fat infants it often happens that neither the tendon nor the inner edge of the tibia can be located. In such cases a puncture is made in a line exactly between the anterior and posterior borders of the leg at the inner aspect with a sharp- pointed tenotome down to and through the sheath of the tendon. The sharp- pointed blade is then withdrawn and a blunt-pointed one is passed beneath the tendon, which is divided by cutting upward. It is wise to recall the fact that while the space between the tendon and the tarsal bones is of lim- ited extent, yet it is quite sufficient to admit the blade of the tenotome. The Division of the Tendon of the Flexor Longus Digitorum Muscle. —The tendons of this muscle are sometimes productive of flexion of the OPERATIONS ON TENDONS, LTOAMENTS, FASCIAS, ETC. 287 toes, after the correction of the deformity of the tarsus caused by the con- traction of the tibialis posticus. The flexor longus digitorum tendon lies immediately posterior to the tendon of the tibialis posticus, behind the inter- nal malleolus, and is often divided by the same cut which severs the tendon of that muscle. It can, however, be divided independently. If, after the division of the tibialis posticus tendon, the influence of the flexor longus digitorum muscle on the toes be objectionable, its tendon can be divided by introducing the tenotome beneath it through the same incision, and cutting toward the surface as before. The Precautions.—The posterior tibia! artery and its venae comites, which in the adult are often varicose in this situation, must be carefully avoided by pressing them outward with the finger. If for contraction of the toes, unassociated with deformity due to the tibialis posticus, it be deemed advisable to sever the tendon of this muscle, the posterior, tibial vessels must first be detected and pushed outward by the thumb, which should then be pressed firmly between them and the tendons at the inner side ; then pass the tenotome perpendicularly through the integument, midway between the internal margin of the tibia and the end of the thumb ; carefully insinuate it between the tendons of the tibialis posticus and the flexor longus digito- rum down to the bone ; turn the edge toward the surface, and carefully divide the tendon. The Division of the Tendon of the Flexor Longus Pollicis Muscle.—It may become necessary to divide the tendon of this muscle on account of the crippled action of the foot in walking dependent upon undue flexion of the great toe. The toe should be forcibly extended, and the knife carefully inserted beneath the tendon at the point of greatest prominence, which will be anteriorly at the inner border of the foot. The blade of the instrument should be passed from the internal plantar artery. The Tendo Achillis is the largest and most prominent tendon of the human system. It is about six inches long, three quarters of an inch broad, and a quarter of an inch thick, and is inserted into the lower part of the posterior tuberosity of the os calcis. The narrowest portion in the adult is at a point about two inches above the insertion. The posterior tibial ves- sels and nerves are to the front and inner side at a considerable distance from the tendon, and in no danger of injury if ordinary care be exercised. The short saphenous vein lies superficially and closely to the outer border. The Division of the Tendo Achillis.—Place the patient on a bed with the foot extending over the edge; forcibly flex the foot to make the tendon tense (Fig. 297); draw the skin outward away from the tendon to remove the saphenous vein from danger; introduce the blade of the tenotome with the flat surface parallel with the tendon close to its outer or inner border, as is most convenient; carry the point of the blade to the opposite side of the tendon and depress the handle to a horizontal position ; turn the edge toward the tendon and cut carefully through the structure with a guarded sawing motion, while the foot is firmly flexed and the tendon is pressed upon the edge with the finger. At the last stage of the procedure great caution is essential, otherwise a sudden giving way of the tendon may cause 288 OPERATIVE SURGERY. the severance of the superimposed tissues. All of the precautions pre- viously enjoined in tenotomy should be exercised in this instance. After carefully pressing the air and blood from the wound by carrying the thumb and finger of the left hand toward the cut, the wound is closed by a catgut stitch or by an antiseptic compress held in place by a fold of sterile gauze. When the position of the foot is properly rectified, it should be Fig. 297.—Dividing tendo Achillis. held thus (Fig. 298) by a long adhesive strip (2, 3) carried up the leg from a thin strip of wood (4) strapped (1) to the sole of the bandaged foot and held in position by adhesive plaster or bandages. A thin plaster-of- Paris splint applied to the leg and foot with the latter in the rectified po- sition will hold them in proper relation. If gradual rectification be practiced, these re- straining influences should not be employed until three or four days later. The Division of the Tendons of the Pe- roneus Longus and Brevis Muscles.—The tendons of these muscles pass in a common groove behind the external malleolus, and are inclosed by the same sheath, the brevis pass- ing the more anteriorly. The peroneus brevis leaves its fellow after passing behind the mal- leolus, and is inserted into the base of the me- tatarsal bone of the little toe at the outer side. The peroneus longus, after passing be- hind the malleolus, gains the sole of the foot, enters the calcaneo-cuboid groove, and is in- serted into the internal cuneiform and the base of the metatarsal bone of the great toe, at the outer side. The tendon of either mus- cle may be divided at two situations: 1, About an inch and a half above the tip of the malleolus ; 2, at three fourths of an inch in front of the malleolus. These tendons are commonly divided at the former situation, but can be severed connectedly or singly at either place. Fig. 298.—Foot, rectified and held in position. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 289 If it be decided to sever both simultaneously above the malleolus, seek the antero-external border of the fibula about an inch and a half above its tip; pass the knife between the bone and tendons; turn the edge outward and cut toward the surface. The short saphenous vein should be pushed inward to avoid injury. If either tendon is to be divided separately above the malleolus, push the integument aside with the thumb to protect the vein, then push the thumb down firmly to the bone behind the tendons; pass the tenotome perpen- dicularly at the end of the thumb and carefully insinuate it between the tendons, after which it is passed outward or inward, as the case may be* beneath the tendon to be severed, the edge turned toward the surface, and the division made as in the preceding instances. If the division is to be made below the malleolus, make the tendons tense enter the knife about one half or three fourths of an inch in front of the tip of the malleolus, between the tendons, when either may be divided by cut- ting outward or inward, as the case may be. The Division of the Tendon of the Tibialis Anticus Muscle.—The ten- don of this muscle, like the tibialis posticus, is of importance in connection with talipes varus. It is the innermost tendon of the leg and foot on their anterior surface, and can be easily outlined unless the foot be fat and chubbyy when some difficulty may be experienced. In well-marked cases of talipes varus the tendon is displaced considerably to the inner side, and, if the foot be abducted, will become quite prominent. It is best divided about one inch above its insertion into the internal cunei- form bone. Make the tendon tense and pass the knife from without inward,, to avoid the dorsalis pedis vessels. The Division of the Tendon of the Extensor Proprius Hallucis Muscle. —As the tendon of this muscle passes across the dorsum of the foot, it can, like the preceding tendon, be quite easily distinguished. It may be necessary to divide it after the division of the extensors of the tarsus, on account of its causing undue extension of the great toe. The toe should be forcibly flexed and the tenotome carried beneath the tendon from without inward, to avoid the dorsalis pedis vessels. The Division of the Tendons of the Extensor Longus Digitorum Muscle. —The tendons of this muscle may cause not only an obstinate extension of the toes, but may also aid in maintaining the tarsus in a state of forced flexion. They can be divided separately, as they pass along the dorsum of the foot, or all may be cut at once by flexing the toes, entering the knife beneath the tendons a little below the bend of the ankle, from within out- ward, to avoid the dorsalis pedis vessels. The Division of the Tendon of the Peroneus Tertius Muscle.—The peroneus tertius may be divided together with the extensor longus digitorum tendons. It can be divided separately before its insertion into the dorsum of the metatarsal bone of the little toe by extending the tarsus and passing the knife beneath it from without inward. It is the most external tendon on the dorsum of the foot in front of the external malleolus. 290 OPERATIVE SURGERY. Tice Division of the Biceps Tendon at the Leg.—The tendon of the biceps cruris forms the external hamstring, and is inserted into the head of the fibula and the outer tuberosity of the tibia. The external popliteal nerve is located immediately at its inner side (Fig. 190, J). To divide the tendon extend the leg, press the nerve aside with the thumb, and pass the tenotome from within outward beneath the tendon about an inch and a half above the head of the fibula, and divide the tendon toward the surface while it is sup- ported by the finger. The Inner Hamstring Tendons are the tendons of the semitendinosus, semimembranosus, gracilis, and sartorius muscles; the first two, however, are the ones principally concerned in deformities. The tendon of the semi- tendinosus is the longest, smallest, and nearest to the median line of the popliteal space; that of the semimembranosus is much deeper and runs parallel with the former. Either of these tendons can be divided by extend- ing the leg to make the tendon tense, and entering the knife beneath it from the outer side, at the most prominent portion, and cutting toward the surface. The Remarks.—Their division to relieve flexion of the leg will not al- ways admit of its complete extension, due, among other things, to the con- traction of the heads of the gastrocnemius, which are inserted into the condyles of the femur. The forced extension of the leg under these cir- cumstances often causes the tearing asunder of the attachments of this mus- cle, especially the inner head, which is the larger and stronger and is inserted higher than the external. The hamiorrhage resulting therefrom may be severe enough to infiltrate the tissues of the popliteal space, thus simulating rupture of more important vessels. The liability to this rupture and conse- quent bleeding may be lessened, if not obviated, by first dividing the tendo Achillis ; or, what is perhaps better, by first dividing the hamstring tendons, after which if, on attempting to straighten the limb, the foot becomes ex- tended, the tendo Achillis can then be divided. After division of the ham- string tendons, fibrous bands and bands formed by tense nerves and vessels may be apparent to sight and touch in the popliteal space. The external popliteal nerve is often made quite prominent by the act of extension, and for this reason may be mistaken for undivided fibers of the biceps tendon. Forced extension in the presence of great and vigorous deformity exposes the popliteal vessels to the danger of rupture, and often causes pain and other disagreeable modifications of sensation of the areas supplied by the overstrained nerves. The Division of the Tendons of the Gracilis and Sartorius Muscles.— The gracilis and sartorius tendons can be divided at the under side of the knee after forcible extension of the leg, by passing the blade of the tenotome close to the inner side of the tendon of the semimembranosus, between it and the gracilis, depressing the handle outward or inward, as the case may be, and dividing the structures toward the skin. The sartorius can be divided at a point two inches or so below its origin. For this purpose the thigh should be strongly abducted, and a blunt tenotome passed beneath the mus- cle and carried toward the surface. OPERATIONS ON TENDONS. LIGAMENTS, FASCIAS, ETC. 291 The Division of the Tendon of the Quadriceps Extensor.—The quad- riceps extensor tendon may be divided above the patella by making an in- cision down to the tendon parallel with the base of the patella; enter the point of the knife above the patella cautiously, and divide the tendon with a sawing motion. A careful and continuous effort to flex the leg should be made while the tendon is being cut, in order that its deepest fibers may be ruptured, thus avoiding, as far as possible, entering the synovial extension of the knee joint which lies beneath it. However, the limb should not be flexed further than is necessary for this purpose, and after the division it should be placed in a comfortable position till repair is well advanced. The Division of the Tendon of the Adductor Longus Muscle.—The ad- ductor longus muscle is situated at the inner side of the thigh, forming the inner border of Scarpa’s triangle. It is, however, located on about the same plane as the pectineus muscle. It is tendinous at its origin from the pubes, and can be easily divided when made tense by passing the knife beneath its outer border an inch or so from the origin, and cutting upward and inward. The Division of the Pectineus Muscle (Myotomy).—The pectineus mus- cle acts as a flexor and adductor of the thigh, and may require division on account of malposition of the limb. The pelvis is steadied, the thigh extended and abducted, which causes the fibers of the pectineus to become tense and prominent. A long-bladed myotome (Fig. 319) is then introduced at the outer border, about an inch below its origin, and carried inward and upward till the division is complete. The internal circumflex artery, which runs be- tween the psoas magnus and the outer border of the pectineus, is the only vessel of any size exposed to injury. The danger to this is insignificant unless it arises higher than usual. If the division be made downward and inward, the femoral vessels will be less exposed than when made in the oppo- site direction. The Tensor Vagince Femoris Muscle can be severed without difficulty by introducing a long-bladed tenotome beneath it, at either border, about an inch below its origin, and cutting toward the surface. The Muscles of the Trunk. The Multifidus Spince Muscle.—This muscle lies at either side of the spinous process, in the groove formed between the spinous and transverse processes, extending from the sacrum to the axis. It is quite superficial in the sacral region opposite to the posterior superior spinous process of the ilium. The Division of the Multifidus Spince Muscle (Myotomy).—Raise a fold of skin parallel with the long axis of the muscle; pass a long-bladed myotome from the spinous processes outward beneath the muscle to its outer border, and cut toward the surface. The Division of the Latissimus Dorsi.— The tendon of this muscle may be divided separately at the lower border of the axilla, or conjointly with that of the teres major muscle, a short distance below their insertion into the bicipital groove of the humerus. In either instance the arm is forcibly raised to render the muscle tense and prominent, and a long, narrow-bladed tenotome is inserted along the 292 OPERATIVE SURGERY. anterior border, the edge directed posteriorly, and either tendon is carefully severed by an outward sawing motion. The Latissimus Dorsi Muscle may be divided at the lower angle of the scapula in the following manner : Make the muscle tense as before, pass a long, strong tenotome beneath it, and cut carefully outward toward the sur- face ; close the incision with an aseptic compress. The Division of the Erector Spince Muscle (Myotomy).—The erector spin® muscle forms the principal portion of the muscular prominence at either side of the spine in the lumbar region. It is a thick, strong muscle, which arises from the sacrum and contiguous structures, and divides at the lower border of the last rib into the longissimus dorsi and sacro-lumbalis, which muscles are inserted respectively into the transverse processes of the dorsal vertebrae and the angles of the lower ribs. The erector spin® can be divided with a long tenotome passed from the outer border of the muscle, just below the last rib, downward and inward toward the spine. The Division of the Trapezius Muscle (Myotomy).—The trapezius mus- cle has an extensive origin. The portion which arises from the inner third of the superior curved line of the occipital bone is often divided on ac- count of abnormal deviations of the head. The division is readily accomplished by making the muscle tense, and severing it with a tenotome entered beneath it, just below the occipital protuberance, with the edge turned toward the integument. The Division of the Sterno-Cleido-Mastoid Muscle.—Division of this mus- cle is often necessary in cases of wryneck dependent upon abnormal muscular force. It is divided at its lower extremity, either at its sternal or its clavicu- lar attachment, often at both. For the division at either part, the muscle is put on the stretch by turning the head to the opposite side, a blunt-pointed tenotome is passed beneath it from the outer side, about half an inch above its insertion, and it is divided toward the surface. The Remarks.—The division of the clavicular portion may be ample to correct the deformity ; if not, the sternal portion should be severed in the same manner. It is necessary to hug closely the under surface of the por- tions to be divided, otherwise the deep-seated and important vessels may be injured. It is not safe to attempt a subcutaneous section of the muscle above this point on account of its relation to the common carotid artery and the internal jugular vein. Tenorrhaphy or Tendon Suturing.—Tenorrhaphy is employed for the purpose of uniting the divided ends of tendons by sewing. General an®s- thesia and entire absence of bleeding are essential to a satisfactory technique. Both recent and old divisions are amenable to this treatment, the more recent the better, however, as the older the division the greater the degree of the separation and the difficulty of uniting the divided extremities. It is very necessary that antisepsis be thorough, as a failure in this regard not only defeats the efforts of repair, but also may cause a destructive inflamma- tion of the sheaths of the tendons and contiguous tissue. The Special Considerations.—The chief difficulty of the operation con- sists in finding the divided ends of the tendons and uniting them with their OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 293 fellows. When any doubt arises regarding their identity, the ends of the tendons of those muscles having similar functions should be joined together. At all events, those having dissimilar functions should not be united. The distal ends are usually easily found, as they retract but little. The proximal ends are often found with difficulty, and may be lost on ac- count of strong retraction, especially in those cases where division takes place during great muscular effort. Sometimes simple flexion or extension of the limb, as the case may be, will bring them into view. The proximal ends can be forced downward by grasping with both hands the circumference of a limb, where muscles are divided, and drawing downward; also by the appli- cation of an Esmarch’s bandage from above down- ward to almost the seat of the injury. If these measures fail, a longitudinal incision is made par- allel with, but not over the tendon, for when thus approached the danger of subsequent adhesion of the superficial and deep tissues is reduced to a mini- Fig. 299.—Tenorraphy, sim- plest method. Fig. 300.—Tenorraphy, quilt suture. Fig. 301.—Witzel’s method. mum. If this plan be not feasible, then introduce into the vacant sheath up to the end of the tendon a probe, upon the end of which a short inci- sion is made from without down into the sheath; push the probe through the opening, and raise the end of the tendon through also; connect the end of the tendon with the end of the probe by means of a small cord tied Fig. 302.—a, b, c. Wolfler’s quilt suture, d, e. Hueter’s peritendinous suture. firmly; withdraw the probe, dragging the tendon after it down to the •open mouth of the sheath. Silver wire, chromicized catgut, fine silk, and OPERATIVE SURGERY. 294 kangaroo tendon are acceptable for tendon suturing. The ends of a di- vided tendon can often be held in proper place by means of one or more sutures passed through them and tied (Fig. 299). If there be danger of the sutures tearing out, another method of arrangement may be used instead (Fig. 300). Witzel’s method is a simple one and quickly utilized (Fig. 301). Witzel introduced a single tendon suture of medium sized catgut at a distance from the tendon ends, drew them together (A), and then supple- mented this one by smaller adjustment sutures (B). The quilt suture of Wolfler (Fig. 302) is suited to meet a considerable degree of tension. In in- stances of great tension, Nicoladoni advises that the central part of the tendon be fixed to the integument at some distance above the wound by a deep suture or an acupressure needle, after which the ends are united by ordi- nary sutures. The central part can be stitched to a contiguous unimpaired tendon with catgut for a similar purpose. The method practiced by Billroth is, however, better and simpler than Nicoladoni’s. Billroth tied a suture to a bundle of fibers (Fig. 303) at either side of each end of the severed tendon, and drew the ends together. When thus placed the suture grasps the fibers at a right angle with their long axis, and thus obviates the tearing out so much dreaded with great tension. Oblique division of the ex- tremities, and union by a su- ture carried directly through them (Fig. 304), can be prac- ticed when the sacrifice of the tendon structure in the accom- plishment of the coaptation does not cause undue shorten- ing. If but little tendency to separation be present, suturing together the peritendinous tissues of the extremities may suffice (Hueter, Fig. 302, d, e). However, this plan is of infrequent and un- certain utility. In order to bridge an unavoidable gap in a tendon, several strands of fine catgut are con- nected with and caused to extend between the separated ends, thus laying the foundation for a possible repair (Fig. 305, b). The introduction of a tendon graft in these cases, of sufficient length to fill the gap, taken from a cat or other suitable source, is entitled to further trial. How- ever, if the tendinous sheath have been destroyed, there is little chance, indeed, of benefit from the last-mentioned expedient. Tendon lengthening may be utilized to remedy deformities due to otherwise irremediable short- Fig. 303.—Billroth’s bundle- suture. Fig. 304.—Oblique coaptation of divided ends. Fig. 305.—a. Hueter’s method, single flap. b. Grluck’s meth- od, catgut repair. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 295 ening of tendons dependent on contraction and sloughing, which are often the sequel of traumatism and inflammation. A tendon can be lengthened by a single flap (Figs. 305, «, and 306), or it may require for the purpose the union of double flaps, one from the end of each extremity (Fig. 307). The making of alternate free inci- sions at the borders of a tendon—the accordion plan—so as to cause the tendon to assume an accordion-like appearance when lengthened (Fig. 309), is much more ingenious than practical. Less pronounced cutting (Fig. 310) followed by tendon length- ening is called the incision method (Fig. 311). Fig. 306.—Single-flap method. Fig. 307.—Double-flap method. Lengthening of the tendo Achillis to overcome contraction is sometimes practiced. Through a free incision the tendon is exposed and divided ac- cording to the plan of Anderson (Fig. 308), or by still another resembling Anderson’s. In this the ends a and b Fig. 308.—Anderson’s double-flap method. A. Longitudinal division. B. Flaps formed. C. Tendon lengthened, flaps united. are united together (Fig. 312), or the accordion method can be utilized. The former, however, is much the better. Transplantation upward of the Fig. 309.—A. Poncet’s accordion method. Pig. 310.—Incision method. 296 OPERATIVE SURGERY. tubercle of the os calcis can be practiced by division of the os calcis through a U-shaped incision (Fig. 313) made immediately behind the insertion of the tendon, followed by extension of the foot and the nailing together of the sawed surfaces, as a supplementary measure to the lengthening of the tendon by direct method of practice (Fig. 314). However, the small gain thus achieved by the former is not commensurate with the risks incurred, to say nothing of the ill effect of the measure on the functions of the heel. Fig. 313.—Incision for trans- plantation of tubercle of os calcis. Fig. 311.—Tendon lengthened in in- cision method. Fig. 314.—Transplantation of tubercle of os calcis; tendon already lengthened. Fig. 312.—Lengthening tendo Achillis. Tendon shortening is practiced for the purpose of improving the action of muscles where power is lessened by the elongation of their tendons. The removal of a proper segment of a tendon and union of the divided extremi- ties, can be accomplished by either a simple oblique division and lateral apposition and union (Fig. 304), or simple division followed by intergrafting of the extremities and union; i. e. the introduction of the wedge-formed ex- tremity of one into the split end of the other and fixation with sutures. Shortening of the tendo Achillis to remedy talipes calcaneus is some- times practiced. Gibney's Method.—Expose the tendon through a Y-shaped incision, di- OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 297 vide it from behind forward and below upward very obliquely; draw the upper portion downward as far as possible and suture it to the lower; con- fine the foot firmly in place until union of the divided ends to each other is secured. Willett's Method.—Make a Y-shaped incision two inches in length down to the tendo Achillis at its lower end; expose the tendon at the superficial and lateral surfaces only, corresponding to the stem of the Y; sever the tendon at the points of junction of the vertical portion with the arms of the Y; dissect along the deeper surface of the tendon and raise the proximal part with its connection to the integument intact for three quarters of an inch ; cut from the deep surface of the proximal end and the superficial surface of the distal one a wedge-shaped slice, with the base corresponding to the point of transverse division of the tendon in each instance; press the heel upward and draw down the proximal portion, thus apposing the cut surfaces of the respective portions with each other, and while the parts are thus held pass two sutures at either side through the integument, the ap- posed extremities of the tendon, and out through the integument, and tie them ; unite the borders of the integumentary incisions with sutures, leaving a Y-shaped appearance to the cut. Confine the foot until repair is complete. The Z Method (Fig. 315).—Expose the tendon through a vertical incision, dividing the skin horizontally at the upper and lower ends of this incision, if necessary; divide the tendon from one border half- way through (A B) ; split the tendon from this point downward far enough to meet the demands of the re- quired shortening (B C); then sever the remaining portion of the tendon at a right angle with the verti- cal incision (CD); remove A B A' B' and C D C D' from the respective extremities; unite the borders CD and C' D’ and the borders A B and A' B' with each other respectively with sutures, and also the vertical borders B C. Each part cut away is equal in length to the shortening required. The Remarks.—The union of the ends of the ten- don by sutures after the removal of a section by trans- verse division is of questionable utility, as the deformity may soon return on account of undue yielding of the bond of union and the stretching of the paralyzed muscles of the calf. In cases of infantile paralysis plastic operations on tendons are useless unless active fibers be present in the muscle, as indicated by electric stimulation. Transplantation downivard of the tubercle of the os calcis, to overcome lengthening of the tendo Achillis, can be practiced by nailing the posterior fragment to the lower rather than to the upper aspect of the sawed surface of the anterior fragment (Fig. 341). Tendon Transplantation (anastomosis).—By tendon transplantation move- ment is imparted to tendons of paralyzed muscles by grafting them with those of animated muscles having a similar action. Grafting was first prac- ticed by Yicoladoni in 1882. Fig. 315.—Z method of shortening tendo Achillis. 298 OPERATIVE SURGERY. In Figs. 31G and 317 the healthy tendon is situated on the right, and is of a uniform color, while the tendon of the paralyzed muscle is on the left and of a dotted appearance. In the first series (Fig. 316) the tendon of the muscle from which the power is derived is functionally unimportant. Fig. 316.—Tendon transplantation. First series. In the second series the tendon of the healthy muscle is functionally im- portant. In the first series one is warranted in diverting the muscle completely from its natural course and making use of the entire tendon. Fig. 317.—Tendon transplantation. Second series. A is employed where the muscle is completely paralyzed. B, C, and D are employed where some function still remains in the paretic muscle. In the second series (Fig. 317) power is obtained from muscles the nor- mal function of which can not be wholly spared and whose action therefore can not be entirely diverted into another course. The continuity of the healthy tendon is here preserved. In E the diseased tendon is completely paralyzed; the healthy tendon is completely intact. In F the healthy tendon is split in half; the diseased tendon is com- pletely paralyzed. In G the diseased tendon is paretic ; the healthy tendon is entirely intact. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 299 In H each tendon is split in half; the diseased tendon has still a little power left in it. In I the healthy tendon is split in half; the diseased tendon may be either paretic or completely useless. The arrows indicate the directions in which the loosened tendons and parts of tendons are drawn in the methods of transplantation. The arrows are arranged in three fashions : 1. The descending transplantation method shows the arrows pointing downward toward the diseased tendon (C, D, I). 2. The “ double-sided” transplantation method shows sets of arrows pointing toward each other (.4, B, I\ II). 3. The ascending transplantation method shows arrows pointing from the diseased tendon upward toward the healthy tendon (E, G). The Operation (Vulpius).—Lay open the tendon sheaths by long parallel cuts, so that the strengthening ligaments which hold the tendons in place are saved. The tendons to he transplanted are either entirely or partially loosened for some distance in order to permit of a considerable distortion. A piece of the muscle belly is perhaps separated by blunt dissection and left in connection with the tendon. If thick tendons lying close together are transplanted, the operation is simple. If they are widely separated, it is necessary to effect a blunt sub- facial dissection. A forceps is pushed beneath the soft parts, deep under the fascia, because here deformities of the tendons are less to be feared, rather than to await the quick building up of a tendon sheath. The bridge of soft parts must be of such a length that the tendon can be brought in a direct line to its new point of insertion. The diseased tendon need not be di- vided. When not divided, draw the healthy and diseased tendons toward each other, by means of instruments, and make a buttonhole in the dis- eased tendon at the proper place, into which the transplanted tendon can be slipped. Afterward a second similar slit could be made nearer the periphery, so as to make a true braid. Stitches fix the tendons at the situ- ations where they pass through slits and also between them. When divided they are joined as indicated in Fig. 318. The Remarks.— The presence of atrophy of tendons verifies the loss of power of their muscles and makes the diagnosis sure. It is recommended to bring the end of the muscle bundle in sight, which, if it presents a white, pink, or dark-red color, would indicate paralysis, pare- sis, or a normal condition respectively. In order to avoid tearing out of the tendons, employ a strong stitch, the tendons being put on the stretch. In correcting the deformity, as it is brought into normal and even over- corrected position, the extremity should obey light pressure. Fig. 318.—Tendon anastomosis; tendon divided. 300 OPERATIVE SURGERY. If the transplantation is well made, one should be able to recognize, while the patient is still under the anaesthetic, that the extremity no longer hangs as loosely as before, and no longer shows the strong tendency to a faulty position, but with a sure elastic tension, remains in at least a par- tially corrected position. Care must be exercised in the selection of a healthy muscle, the tendon of which is to be joined to the tendon of an un- healthy one, that its action be similar in nature to that of the paralyzed muscle. The Choice of Methods.—The descending transplantation method, if pos- sible, as well where the whole tendon is transplanted (IJ) as where it is par- tially transplanted (/), is the acceptable method. After eight days the patient is allowed to get up, wearing an “ overshoe,” and in all wears the bandage from four to seven weeks, according to the de- gree of the existing deformity. The after-treatment consists in the employment of massage, gymnastics, baths, electricity, etc., and the more faithfully they are practiced the quicker and more perfect is the recovery. The Results.— Vulpius reports twenty-one tendon transplantations on nineteen patients. One case completely failed as a result of suppuration of the tendon su- tures. Two cases failed on account of very extensive paralysis and unsatisfac- tory technique. The results of all the others were thoroughly good and satisfactory con- sidering the individual proportion of strength. Sometimes the result was a perfect one beyond expectation. Furthermore, it was shown that the result not only was lasting, but that in the course of months it improved still more. Tabulated Statement of Thirty-three Cases of Tendon Transplantation, with Results (Vulpius): Results good 20 cases. Results good, or satisfactory, but not perfect 4 “ Improved 3 “ Not improved 2 “ Doubtful or unknown results 4 “ Total 33 “ Nicoladoni grafted the peroneal tendons to a freshened surface of the tendo Achillis to restore motion to a paralyzed calf. Goldthwait connected the sartorius muscle with the fascia over the rectus femoris and vastus in- ternus portions of a paralyzed quadriceps extensor. An active extensor of the great toe can be caused to contribute a portion of its vitality to a power- less anterior tibial muscle by grafting. Numerous examples illustrating the idea are reported. Certainly there is much to encourage the belief that substantial benefit will follow the practice. The aforegoing figures suggest the method of pro- cedure. Thorough asepsis and strict quietude of the parts should be en- forced until union has taken place. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 301 Muscles and their sheaths are ruptured either conjointly or separately from the effects of muscular and other forms of violence. Muscles require division to overcome deformities incidental to their contraction. Myotomy, or division of muscle, is performed in substantially the same manner, and for similar purposes as the division of tendons. The liability to haemorrhage is greater in the former, on account of the greater vascularity of the divided tissues. The open and the subcutaneous methods of division can be employed, the latter being the better. The blade of the myotome should be long, narrow, and blunt, for obvious reasons (Fig. 319). The direction of the division in my- otomy is determined by the demands of the case. The transverse, oblique, and V-shaped sections are the ones in common use. If the transverse open incision be made, and the separation of the divided extremities be extensive, the space between them can be bridged with numerous catgut sutures connected with each end of the divided muscle. The sutures and the blood clots entangled in them after the closure of the wound soon lay the foundation of repair in favorable instances. The oblique division of a muscle consists in making the sec- tion of the entire structure in an oblique direction from without, inward and downward, or vice versa, as circumstances dictate. The length and the degree of obliquity will be regulated by the extent of the shortening of the muscle, as indicated by the degree of the deformity and the ability to correct it by division of the con- tracted muscle. This measure is practiced best through an open incision made parallel with but not in line of the proposed mus- cular section, for if thus placed the cicatrix of the skin may unite to that of the soft parts beneath and thus cripple the muscular action. After oblique division and rectification of the deformity, the divided borders are stitched together with fine catgut. If the contraction of the divided muscle be so pronounced as to narrow the line of repair to a serious degree, the muscle can be supplemented in width at this situation by the use of catgut threads employed at either side of the muscle in the manner already described. The external wound is closed care- fully, the limb bandaged and confined in a fixed position, that will contrib- ute to relaxation of the severed muscle. The V-shaped division is employed frequently in connection with the broader muscles with the idea of rectifying a deformity or fortifying a weak point. As an illustration of the former proposition, the quadriceps extensor is sometimes thus divided—after the necessary separation of the vasti portions—to enable one to approximate properly the upper and lower fragments of an old fracture of the patella attended with otherwise irredu- cible separation. This method is practiced best through an oval flap reach- ing down to the quadriceps itself. The length and obliquity of the arms of the V will depend on the degree of shortening of the muscle, i. e., the greater the shortening, the greater their obliquity and length should be. The sliding of a portion of a broad muscle by the agency of the V-shaped incision, for Fig. 319. Myotome. 302 OPERATIVE SURGERY. the purpose of strengthening a weakened point, as of the abdominal wall, is a measure that befits the repair of weakened points of this part of the body. The incision should be so placed with reference to the direction of the mus- cular fibers as to comply readily with the demands of repair, as referable to the extent of the sliding and the magnitude of the displaced tissue. In- cisions of other forms than those already cited can be devised for the pur- poses in question. The deltoid muscle can be divided at either border, at the central part, or through its entire thickness near the point of insertion, depending on whether or not the entire muscle or isolated portions of it are involved. In either case the muscle is relaxed, the myotome inserted beneath the fibers, which are divided by cutting toward the surface. The blood is squeezed out of the opening on withdrawal of the blade, as in tenotomy. The pect oralis major can be divided at the tendinous insertion or further inward at the axillary fold. In either instance the long, blunt-bladed teno- tome is pressed beneath the muscular tissue, and the division is made toward the surface. The rupture of a muscle or of its sheath often requires active surgical treatment, especially if the skin be involved. In the former injury, with skin involvement, the ruptured ends of the muscle are trimmed, united with catgut sutures, the wound is closed and the part immovably fixed in such a position as to relax the injured muscle. If the common method of introduction of sutures into the borders of the divided muscle be not effective, bundles of muscular fibers at either side of the wound may be tied separately by the ligatures, the loose ends of which are then drawn so as to bring the muscular surfaces together, and tied the same as in tenorrhaphy (Fig. 303). If the sheath be ruptured, the rent is exposed by an incision made at the seat of the injury. The muscular fibers are pushed back into the sheath and the borders of the rent are sewed together with fine silk or catgut. The re- maining dressing is the same as for the rupture of a muscle. Ligaments not infrequently become shortened, elongated, or ruptured, as the result of disease and traumatism. In order that the afflicted part may be promptly and properly restored to position, the ligaments must be divided and repaired in many cases. Syndesmotomy is the operation of the division of ligaments either by the subcutaneous or open method, the latter being more frequently practiced. The technique of this procedure will appear in connection with operative treatment of deformities of the foot, since it is most frequently employed in that class of cases. The best illustration of elongation or rupture of a liga- ment is seen when such conditions affect the ligamentum patella}. If elon- gated, it can be shortened in the same manner as in elongated tendons elsewhere, or the tuberosity of the tibia into which it is inserted can be displaced downward by means of a mallet and chisel, and fastened to the bone with nails or silver wire. If ruptured, a free incision should be made down to the rend in the long axis of the ligament, the extremities united together with kangaroo tendon, catgut, or silk, the wound closed and the OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 303 limb slightly elevated and confined firmly in the extended position for three or four weeks. If the tendon be so much damaged as not to permit proper apposition of the ends, the catgut bridging employed for the repair of the tendons can be utilized. Another plan is to displace upward the tubercle of the tibia with the mallet and chisel, and fasten it in the new position with small nails or silver wire. But little advantage, however, can follow this step on account of the limited bone surface above. Moreover, necrosis of the fragment may ensue for this reason. Our experience in this measure is not flattering. The part should then be dressed antiseptically and otherwise treated as for fracture of the patella. Fascia.—Although the entire body is wrapped in fascia, it is only to certain parts, as the palm of the hand, the sole of the foot, and to the fascia lata, that special attention is directed, on account of morbid mani- festations. The plantar fascia is an exceedingly dense, white fibrous membrane of great strength, with the fibers arranged longitudinally. It is divided into three portions, the middle and two lateral. The former is the one especially concerned in those deformities requiring division. It is narrow behind and attached to the inner tubercle of the os calcis; broader and thinner in front, and divides into five processes oppo- site the middle of the metatarsal bones, there being one for each of the toes. Each of these processes divides opposite the metatarso- phalangeal articulations into two slips, which embrace and are in- serted into the sides of the flexor tendons, blending with their sheaths and with the transverse metatarsal ligament. It likewise sends prolongations between the groups of the plantar muscles. This fascia serves the important function of assisting in main- taining the integrity of the plantar arch. It is frequently con- tracted in deformities of the foot, and requires division to accom- plish a cure. The Operation of Plantar Fasciotomy.—Extend the foot firm- ly, thus placing the fascia on the stretch. “ Point pressure ” is then made to establish the proper seat for division. Introduce beneath the inner border of the fascia at the point of greatest pressure-irritation a long-bladed, sharp-pointed fasciatome (Fig. 320), turn the edge toward the sole and cut through the fascia to the integument. If the foot is vigorously extended at this time, the last fibers of the fascia will be ruptured. Press out the blood, close the opening with a suture or an antiseptic pad, rectify the deformity, and confine the foot in proper position (Fig. 298) until the wound is healed. The internal plantar artery should be avoided by keeping the blade close to the inner border and deep surface of the fascia. The division of the bands at the phalangeal junction must be carefully made, or the digital arteries and nerves will be severed. Care should be practiced in overcoming a pronounced deformity, or rupture of the digital nerves will happen. Kelapse sometimes follows this method of Fig. 320. Fascia- tome. 304 OPERATIVE SURGERY. The Palmar Fascia.—The palmar, like the plantar fascia, is divided into three portions, the middle being of special significance. This portion is narrow above and is connected to the lower border of the annular ligament; below it is broader and thinner, and opposite the heads of the metacarpal bones divides into four slips, one for each finger. Each slip subsequently divides into two processes, which inclose the tendons of the flexor mus- cles, and are attached to the glenoid ligament and to the sides of the meta- Fig. 321.—Palmar fascia. carpal bones, and extend upward over the flexor tendons nearly to the tips of the fingers (Fig. 321). This fascia is intimately connected with the in- tegument of the palm, and sends vertical septa between its muscles. From various causes it may undergo structural changes which result in contrac- tions of the fingers on the palm, as well as shortening of the palm itself. The anatomical arrangement of the fascia fully explains the mechanism of these deformities. OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 305 Dupuytren’s Contraction.—This deformity depends upon the contraction of the elongations of fascia of the palm, connected with the digits (Fig. 322) the morbid process more frequently man- ifests itself in the ring and little fin- gers, ofttimes causing them to become op- posed to the palmar surface of the hand. Adams's Method. —Anaesthetize the pa- tient, render the con- stricting bands tense by a firm extension of the affected digits, and then, under antiseptic precau- tions, divide the restraining bands at short intervals, subcutaneously (Fig. 323), at unattached points of the skin, with a sharp-pointed, narrow-bladed, strong, short fasciatome (Fig. 324), the edge being directed from the surface of the palm. When sufficiently liberated the digits can be freely extended, in which condition they are to be confined by dorsal splints until repair is completed. Passive motion and forci- ble extension until the tendency to contraction is overcome, comprise the important elements of the after-treatment. The Fallacy.—This deformity may be con- founded with that dependent upon contraction of the flexor tendons. An examination of Fig. 322 will enable the surgeon to make a clear distinction between the two con- ditions. The Results. — Relapse not infre- quently takes place owing to the con- tinued presence of the primary cause and the inheritance by the new tissue of the characteristics of the old. Goyraud's Method.—Goyraud made longitudinal incisions over the tense digital elongations of the fascia, dissected the integument from them, after which they were divided transversely sufficiently to per- mit extension of the digits. He closed the integumentary incisions and confined the fingers in a straight position until healed. The success of this method is gratifying. liardiAs Modification of Goyraud's Method.—Apply an elastic bandage to the hand, make an incision from half an inch above the principal transverse fold of the palm to beyond the bone of the last phalanx involved down to the band, and carefully expose the con- Fig. 322.—Fascial contractions. a. Fascial contractions, b. Flexor tendons. Fig. 323.—Transverse inci- sions in Dupuytren’s con- traction. Fig. 324. Strong, short fascia- tome. 306 OPERATIVE SURGERY. tracted tissue ; sever the bands at the webs of the fingers between this and the adjacent contracted elongations; divide the main bundle at the upper end of the incision and completely extend the phalanx. If required, make transverse incisions opposite the bundle of the first and second phalanges, cut away portions of fascia that oppose complete extension of the finger, and remove entirely isolated projecting portions of fascia. Treat likewise the remaining fingers of the hand similarly deformed, remove the bandage, tie briskly bleeding points, drain the wound the entire length with horse- hair, close the incision with silver wire, apply an antiseptic pad to the palm and a straight splint to the fingers, and bandage both in position. The dressing is renewed on the following day, again applied, and not disturbed for a week without special reason. The use of the splint is continued for two or three weeks and the fingers are occasionally flexed and extended. Treves omits the elastic bandage and drainage and closes the wound with silkworm gut. He excises as much of the contracted fascia as can safely be removed, causes the splint to be worn for a month, after which massage of the palm and passive motion of the fingers is practiced until a satisfactory result is obtained. The Remarks.—Complete antiseptic technique should be practiced, as the wound is severe and exposes the patient to the danger of extensive and destruc- tive inflammation of the hand. Radical measures are the better, and expose the patient to no unusual dangers when practiced with thorough antisepsis. Adams’s method can be done well with cocaine anesthesia in many instances. The fascia in other situations may become contracted, as the fascia lata at its upper or lower extremities. Whenever these contractions cause a per- sistent deformity they should be divided, and upon the same principles as like tissues in other portions of the body. Bursse.—The synovial and mucous bursae are each liable to annoying enlargements, the result of chronic and acute inflammatory processes of trau- matic or idiopathic origin. The enlargements communicate so frequently with the general synovial cavity of a contiguous joint that they should be approached with great care and strict antisepsis. The characteristic patho- logical manifestations of this variety of infliction occur in connection with the synovial sacs of the carpus and the tendinous sheaths of the tendons of the wrist, and are known respectively as ganglion and chronic tliecitis, the latter being usually of tuberculous origin. Ganglion (Weeping Sinew).—Ganglion is developed on the dorsal surface of the carpus and is connected with the sheath of a tendon at this situation or with the synovial sac of a carpal articulation. The Operative Methods of Cure of Ganglion.—After the failure of sim- pler methods of relief the sac of the tumor may be ruptured by a sudden pressure of the thumb, by a sharp blow from the back of a book, or a similar agent. These measures cause rupture of the sac and the escape into the con- nective tissue of the contents, which are subsequently absorbed. However, they frequently recur when thus treated. Another simple and quite effective means of cure is the injection into the sac, after withdrawal of a portion of the fluid by a hypodermatic syringe, of a few drops of a five- or ten-per-cent OPERATIONS ON TENDONS, LIGAMENTS, FASCIAS, ETC. 307 solution of carbolic acid and glycerin. Not infrequently in this instance a quite severe inflammation follows the injection. Therefore, after the injec- tion the hand should be kept quiet, and, if indicated, cold lotions are applied to the part. If the sac be so tough as to withstand the force used for the purpose of rupture, it may be incised subcutaneously and under strict anti- septic precautions with a small, sharp-pointed tenotome. The fluid, when thus liberated, escapes into the connective tissue and is absorbed as in the first instance. Finally, if the tumor be very large or hard, or have resisted the simpler methods of cure, a free incision is made down upon it, and the sac is dissected from the tendon or cut away from the synovial membrane of the articulation. In the latter case a sufficient amount of the membrane should remain behind to permit of the sewing together of the borders with fine catgut or silk, thus closing the cavity of the joint. In every instance of free incision a strict antiseptic technique should be enjoined for obvious rea- sons. In the synovial burs* associated with other and larger joints of the body, attempts at cure by aspiration and the injection of antiseptic stimulat- ing fluids should be made before free incision is practiced. And in the lat- ter instances great care must be exercised to avoid the disastrous results incident to unwise aggression and faulty technique. Mucous Burses.—Mucous bursae are situated between the integument and subcutaneous bony prominences at situations exposed to friction or pressure. Those located over the patella and olecranon process are the best illustra- tions of the variety, and will suffice for the proper consideration of the mor- bid processes of this class of bursae. Prepatellar Bursitis (Housemaid’s Knee).—x\spiration, tapping, and in- jection, the seton or incision, are the methods of cure applied to this disease. Aspiration is simple and inefficient; tapping and injection are frequently successful; the seton is beneficial though troublesome ; incision is the surest of all means of cure. The withdrawal of a portion of the fluid, and the in- jection of a small amount of a solution of carbolic acid and glycerin, is fre- quently followed by cure. The patient should be kept quiet for two or three days, and cold lotions applied to the part when essential to comfort. The introduction through the tumor of one or two silken threads saturated with stimulating fluids, such as the compound tincture of iodine, solutions of carbolic acid, etc., frequently lead to satisfactory results. This plan is, however, often annoying and protracted, on account of the discharge and tardy therapeutical action. Free incision and packing with gauze after scraping the cavity is the surest plan of cure. The incision can be made at one or both sides of the tumor at the most dependent part, as may seem the best. The making of a straight or crucial incision at the summit of the tumor is sometimes practiced in order to reach the remotest limits of the sac, which can be dissected out if deemed advisable. However, this plan localizes not infrequently a sensitive scar at the point of common pressure. If the sac be dissected away, close apposition of the divided borders can be secured, and prompt union and rapid recovery will follow. If the sac re- main in situ the wound is usually packed with antiseptic gauze, and per- mitted to heal slowly from the bottom. 308 OPERATIVE SURGERY. Post-olecranon Btcrsitis (Miners Elbow).—Bursitis at this location can be cured by either of the methods directed to the relief of the prepatellar variety. In this instance, however, the dissection of the sac from its en- vironments must be carefully done, or the joint cavity will be invaded, or the tendon of the triceps impaired. Thecitis.—Thecitis is an obstinate and troublesome affection usually of the synovial sheaths of the flexor and extensor tendons of the carpus, char- acterized by a fluctuating deformity dependent on the presence in the di- lated sheaths of a fluid of varying character and consistency, and often con- taining the so-called rice or melon-seed concretions of fibrin. Tubercle bacilli, too, are frequently present in these cases. The extent and com- municability of the sheaths of the flexor tendons are well exhibited in Fig. 325. Operative treatment holds out the only reasonable hope of cure in these cases. Tapping and injection, evacuation and scrap- ing, and excision are the opera- tive measures employed. Tapping and the injection of curative fluids require but brief mention here, as their therapeutic efficacy and practical technique are properly measured by a like treatment of similar conditions elsewhere in the body. The introduction into the sac of a mixture of iodoform and glycerin is regarded by some ob- servers as having a special virtue. 'The operation of evacuation and scraping contemplates a free incision into the tumor at the most commanding point, and a thorough scraping of the sheaths of the tendons with properly shaped curettes and scoops. The strict- est antiseptic surveillance must be practiced, or serious inflammatory results will follow. The wound should be closed with silkworm gut and covered with firmly applied pads of anti- septic gauze combined with sponge pressure. Then the wrist joint is immov- ably fixed until inflammatory reaction is in abeyance, after which the fingers are frequently though carefully manipulated. Excision.—Excision offers the best means of cure, especially if the fibrous connections and tuberculous infection be present. The Operation.—Apply an elastic bandage to the hand and forearm, make a free incision into the tumor, and, if necessary to reach the disease, through the annular ligament as well. Carefully and patiently dissect away and re- move all diseased structure, harming as little as possible the contiguous Fig. 325.—Tendinous sheaths of digits, palm, and wrist. OPERATIONS ON TENDONS, LIGAMENTS, EASCIAS, ETC. 309 healthy tissues. If a portion of a tendon be involved, the diseased part should be excised and the tendon repaired. The ligaments, fascia, and in- tegument are each united independently with fine catgut or silk sutures, leaving a small opening at either end. An antiseptic compress is uniformly and firmly applied to the wound, and the extremity immovably fixed with a splint. This dressing need not be renewed for a week or ten days, except for some special reason. After the first forty-eight hours the patient is directed to move the fingers actively at intervals until repair is established, in order that the new tendinous tissue may become suitably fitted for use. Relapses of the disease may occur, and in fact the patient may succumb to tuberculous involvement of remoter and more important parts. CHAPTER VIII. OPERATIONS ON BONES. The injuries and diseases to whicli bones are liable, although not differ- ing in any essential particular from similar conditions of the soft parts, re- quire an independent consideration on account of the difference in function and structure of the osseous system. The integument and soft parts gen- erally are each the seat of inflammation, ulceration, and gangrene. Bony tissue is likewise afflicted by the same morbid processes, named, however, differently: caries of bone being comparable to ulceration of the soft parts, while necrosis of bone finds its synonym in gangrene of soft parts. The unimpaired preservation of the mechanical functions of tissues is the great aim in surgery. Therefore since the practical functions of bones are to sup- port the body, protect important organs, and serve as levers for purposes of prehension and locomotion, one has but to act with a knowledge of these facts and of the methods to maintain them, to give to the patient the full benefit of our art. The operations upon bone are denominated gouging, sequestrotomy, ex- cision, osteotomy, and osteoplasty. Gouging.—Gouging is applied to the removal of carious bone, and should not be attempted until the process has become chronic (Fig. 326). The Operation.—Having arranged the patient in a position suitable for the convenience of the operator, administer an anaesthetic, apply the elastic bandage if practicable, carrying it lightly over the site of the disease, locate the diseased bone with a probe, make a free incision down upon it, sepa- rate the soft parts with retractors, then with the gouge, bone burr, etc., re- move the diseased structure. , The Comments.—Dependent drainage and scrupulous care in the separa- tion of muscular structure without needless bruising of the tissues should always be practiced. It is important and often very difficult to determine the line between the healthy and diseased bone. If the portions removed when washed present a whitish, grayish, or blackish appearance, and are porous and fragile instead of being vascular, red, and tough, the operation should be continued. If the gouged surfaces bleed freely from numerous points and have a normal firmness and color, the operation should cease. It is important in gouging the extremities of bones to use extreme cau- tion or the joint cavities may be opened directly or become secondarily in- volved. 310 OPERATIONS ON BONES. 311 After the removal of the elastic constriction all haemorrhage should be arrested, the wound washed thoroughly with a suitable antiseptic solution, good drainage secured, the soft parts united, and dressed antiseptically. It frequently happens in these cases that a cavity in the bone of consid- erable size results from the operation. If the diseased tissue of both the Fig. 326.—Instruments employed in gouging. a, b. Strong scalpels, c, e. Retractors, d. Barker’s douching scoop. /, g. Scoops. h, i, k. Mallet and gouges. 1. Sponge holder, m. Bone burr. Forcipressure, sutures, needles, drainage agents, etc., are likewise needed. 312 OPERATIVE SURGERY. hard and soft parts can be removed, and there be no sinus communications with other diseased areas, an attempt should be made to repair the defect promptly by a method of healing devised by Schede. In this procedure the soft parts are not closed until the oozing of blood from the bone is nearly arrested or only sufficiently active to be arrested by closure of the soft parts, thus leaving the cavity filled but not distended with blood. The wound of the soft parts is then closely united with fine aseptic catgut or silkworm gut, and the surface covered widely with a layer of aseptic rubber tissue, which is bound firmly in place with antiseptic gauze. Additional dressings are ap- plied in the usual manner, confined in place, and the part is kept quiet. If the effort fail, local evidences of deep-seated inflammation will be manifest when the dressings are removed a few days later, and the lips of the wound should then be separated by the surgeon, the cavity cleaned out, and per- mitted to heal from the bottom. The canalization method of Iseuber may be employed instead of this one (page 93). Sequestrotomy.—Sequestrotomy is employed for removal of dead bone en masse, and is therefore applicable to the treatment of necrosis. Two methods of procedure are employed, depending on the nature of the case —V\z., the direct and indirect methods (Fig. 327). The Operation by the Direct Method.—Having determined the situation of the necrosed bone, and being satisfied either from the long course of the disease, or by movement of the dead portion, that detachment of the dead from the living bone has taken place, apply the elastic bandage if expedient, using care not to force deleterious matters into the circulation, select a strong scalpel, and connect the fistulous openings with each other down to the bone with the aid of a grooved director or a probe, choosing such openings as will cause the connecting incision to be consistent with good drainage, easy access to the diseased parts, safety to the underlying structures, and a mini- mum disfigurement. Separate the borders of the incision with retractors so as to fully expose the openings in the involucrum. If the sequestrum can be drawn out of the opening with suitable forceps (Fig. 327, d) it should be done carefully, otherwise the reparative tissue upon which it rests will be injured and the process of recovery delayed. If it be too large or interlocked with healthy bone, the opening must be increased sufficiently to admit of its with- drawal; or, if this be impracticable, another incision should be made cor- responding to the long axis of the sequestrum. The periosteum should be carefully raised on either side of the incision to permit the application of a crown trephine (i) to the involucrum, with which it should be perforated a sufficient number of times to permit of the easy removal of the dead por- tion either with or without chiseling (k) away the irregular bony borders. The gnawing forceps (c), chisels, and saws (/, g, i) may be used in lieu of or in conjunction with the trephine for removal of the sequestrum. If there be but one sinus opening, and evidences of disease exist above or below it, the center of the incision should correspond to the course of the sinus if the anatomical relations will permit. The Precautions.—It is necessary in making these incisions in the vicinity of joints to exercise great care to avoid opening contiguous synovial pouches. OPERATIONS ON BONES. 313 Fig. 327.—Instruments employed in sequestrotomv. a, a1. Strong scalpels and probe, b. Retractors, c. Bone-cutting forceps and rongeur. d. Sequestrum forceps, e. Mallet. /, g, l. Lifting back, keyhole, and Gigli-Haertel saws. h. Scoop, i. Large and small crown trephines, j. Peri osteotome. •/', k. Gouges and chisels. Grooved director, bone elevator (Fig. 236, k), forcipressure, ligatures, sutures, needles, drainage agents, etc., are required. 314 OPERATIVE SURGERY. When the portion of bone removed is large, or the remaining part is small and fragile, the limb must be supported by a splint, otherwise the bone may bend or break and thereby modify unfavorably the ultimate result. If the sequestrum be not wholly separated from the healthy bone it should be allowed to remain in part until the process of separation is com- pleted, then it can be removed. After the removal of the dead bone the cavity throughout its whole extent should be thoroughly scraped and cleansed, and suitable drainage pro- vided. The soft parts should then be closed and an antiseptic dressing ap- plied. The wound should be dressed as often as is necessary to secure proper cleanliness. The Indirect Method.—The indirect method is preferable when the bone is superficial and the disease progressive, as in osteitis of the lower jaw, clavi- cle, bones of the arm, forearm, or tibia; in fact all the long and many of the flat bones can be reproduced by this method. The indirect method con- sists in making a free incision through the periosteum down upon the dis- eased bone and separating the former by means of the handle of a scalpel, spatula, or periosteal elevator. The separation must be renewed at intervals and each time not extend beyond the diseased portion of bone. The length of the intervals will depend upon the activity of the morbid process and the rapidity of bone reproduction. This plan is necessarily tedious both in detail and in time, but, sooner or later, the dead bone can be raised from its new osseous trough, which will soon become filled with new bone that rarely fails to serve the purposes of its predecessor. The free incision necessary to expose the dying bone will provide good drainage. The wound is kept clean by ordinary antiseptic means. Excision.—Excision of bone is a conservative measure directed to the extraction of such portions of bone as are inconsistent with future useful- ness or the symmetry of the part, together with the removal of the diseased condition calling for operation. Excision is often employed in lieu of the more radical measure—amputation. It is practiced at the articular ex- tremities or the shaft of a bone, and in either instance it may be a partial or complete excision. The articular extremities or joints are excised on ac- count of injury, disease, or ankylosis in a faulty position. The General Remarks.—In estimating the prognosis as to life, the sur- roundings of the patient, the previous habits, present conditions, and the existence of constitutional taint must be considered, also the nature and extent of the cause demanding operative procedure. The prospective use- fulness of the limb will depend on the ability of the surgeon to leave the muscular attachments intact, and also upon the condition of the nerves that animate and the blood vessels that nourish the structures. If the patient be a manual laborer, or one oversensitive of deformity, it is well to consider whether additional advantages can be derived from artificial limbs and ap- pliances, and if so it may be deemed wiser to sacrifice the offending member by amputation. The incisions for the necessary exposure of the parts to be removed should be free, and, when possible, made in the long axis of the bone. They are often, however, varied to suit the peculiar demands of the OPERATIONS ON BONES. 315 individual cases. They are likewise varied in the different joints, being in one instance longitudinal, in another U-, H-, or V-shaped, according to the proposed extent of the operation and the importance of the contiguous structures. In every instance, however, they should be made with a view to securing good drainage, provided they will render the parts accessible, and not expose adjacent important structures to unwarranted interference. Future usefulness being one of the most important factors, the insertions of the muscles having especially defined functions, as flexion or extension, must if possible be carefully preserved. If it be necessary to divide tendons they should be incised obliquely, the better to facilitate subsequent union (Fig. 304). Should it be needful to remove the bony surfaces, into which tendons or ligaments are inserted, the periosteum covering these surfaces should first be carefully peeled off, together with the tendinous attachments. All diseased and loose pieces of bone should be removed, together with bony irregularities and isolated portions of articular cartilage. The syno- vial membrane should be preserved entire unless it be diseased, and if so the diseased portions should be cut or scraped away. The removal of the entire shaft of a bone may be necessary on account of injury or disease, notably the latter. In such cases the incision should be a free one and made over the most superficial aspect of the bone, provided that important structures do not intervene. The periosteum is then elevated proportion- ately to the extent of the disease, gradually or rapidly, as the circumstances indicate, and the diseased bone removed, in young persons, leaving intact, if possible, the epiphyseal extremities. If the epiphyseal cartilage be de- stroyed, the growth of the bone in its long axis will be interrupted. It is important to observe this fact in operations upon the bones of adolescents, since to destroy this cartilage will cause a subsequent shortening of the limb. The consultation of any standard work on anatomy will enable the surgeon to accurately locate the epiphyseal junctions, and will likewise in- form him of the age at which the shafts and epiphyses become united. The Time for Operation.—The time for operation must be governed by the condition of the patient and of the part to be operated upon. If the patient be suffering from shock, reaction should have taken place prior to operative interference. If inflammation of the bone and contiguous tis- sues have occurred, good drainage should be established, and the opera- tion deferred until the acute symptoms subside. If the operation be for necrosis, the diseased bone should have separated before the attempt is made. The instruments employed in excision are varied in number and shape, and must be selected according to the peculiarities of the case (Fig. 328). The scalpels should be broad and strong. The retractors must likewise be strong, and possess a hooklike curve, otherwise they will slip from the wound. The periosteotomes, elevators, and rugines vary in shape, but should possess a blunt, non-cutting edge. These instruments must be used with care, otherwise the function of the periosteum will be destroyed, and may even be followed by sloughing. The bone-cutting instruments are bone- cutting forceps and saws of various sizes and shapes. The straight bone 316 OPERATIVE SURGERY. Fig. 328.—Instruments employed in excisions of the extremities. a. Scalpels, b. Thumb forceps, c, e. Straight and curved bone-cutting forceps, d. Ron- geur. f. Sponge holder, g. Periosteotome. h. Faraboeuf’s bone-holding forceps. i. Jc. Strong straight and curved scissors. I, m. Rugines. n. Strong retractor. p. Spatula, q. Lifting back, keyhole, and Gigli-IIaertel saws. Forcipressure, liga- tures, etc., are required. OPERATIONS ON BONES. 317 forceps is the most available for general purposes. The gnawing forceps or rongeur is of inestimable value in removing bony projections. The Bone-holding Forceps.—The bone-bolding forceps vary somewhat in their grasping and holding powers, consequently the surgeon is governed Fig. 329.—Chain saw. in the selection of this instrument by its suitability for the purpose at hand (Figs. 328, h, and 331, c). The varieties of saws are numerous, among which are the chain saw and the straight saw with or without an adjustable back (Fig. 328, q). The chain saiv, as the name indicates, is composed of numer- ous links or sections, having a handle at each extremity on which to draw while sawing (Fig. 329). To apply the saw, remove the handle from the hook and carry the end beneath the bone—the cutting edge being upward— by means of a thread and a curved needle; or the “ chain-saw carrier ” (Fig. 330) may be employed instead. Readjust the handle, and carry the saw around the bone at an angle of about forty-five degrees and draw the instrument from side to side. The saw should not be jerked or be allowed to kink, but should be kept taut while being used for fear of clamping or break- ing. This instrument is employed in dividing bones which are nearly surrounded by the soft parts. The Gigli-Haertel saw bids fair to displace the chain saw, in minor work, as it is cheap, easily cleansed, not liable to clamp or bind; the latter being expensive, often of uncertain utility, and diffi- cult to cleanse. Fig. 382 represents a saw of great prac- tical worth. The blade is adjustable, and its cutting sur- face can be turned in any direction. It has therefore a uni- versal application which renders it superior to the chain saw except in isolated cases. The gouges, chisels, and mal- let are required to thoroughly remove all diseased bone. The former of these instruments differ in size and shape in order that the intricacies of the wound may be reached. The Surgical Engine.—The surgical engine is the out- come of the dental engine, the former being the stronger and provided with suitably constructed knives, burrs, drills, and saws. These addenda are connected to a hand piece which is attached to a flexible wire cable that permits the easy holding and directing of their rapidly revolving surfaces. The rapidity of their action—two to three thousand revolutions per minute—lessens the pain and the injury done to important parts. The engine can be used with advantage in bone surgery. It is expensive, somewhat cumbersome, and therefore better fitted for hospital than for general practice. The various Fig. 330.—Chain- saw carrier. 318 OPERATIVE SURGERY. appliances that characterize the surgical engine can be attached equally well to the electrical motor that propels the excellent saw devised by Powell (Fig. 243). The treatment of excision wounds in nearly all instances is at the outset substantially the same. Rest and thorough drainage, together with strict antiseptic measures, constitute the basis of treatment. Rest can be secured by the use of various forms of movable or immovable splints. The special treatment of individual instances will be stated in connection with the re- spective operations. EXCISION OF THE HONES OF THE FACE. The great vascularity of the soft parts of the face and the need of avoid- ing unnecessary disfigurement require ample preparation for the control of haemorrhage and call for localization of the incisions in the course of ex- isting and prospective facial lines. An abundance of ligatures and forci- pressure, together with assistants competent to catch bleeding points and control the escape of blood by digital pressure, should be at command. In some instances temporary or permanent ligature of one or both of the external carotid arteries to control bleeding may properly be considered (Fig. 331). Excision of the Upper Jaw.—Excision of the upper jaw is performed for various diseases connected either with the bone structure itself or the cavi- ties with which it is associated. In all instances the periosteum should be preserved except in those in which the bone is invaded by malignant disease. The Remarks.—The patient is anaesthetized and placed upon the back, either with the head slightly raised or markedly depressed (Rose). In the latter position the blood does not escape into the larynx, but into the upper and posterior part of the pharynx. This position impedes respiration some- what by undue stretching of the tissues of the anterior cervical region. However, if the foot of the table be raised, the need for depression of the head will be obviated in a degree. If the head be elevated, the blood can with care be kept from the larynx either by constant sponging, or tam- poning the pharynx around a large catheter or rubber tube, or permitting the patient to be sufficiently conscious to dislodge it. Still another method is to confine the patient in a rocking chair, tipped forward or backward as circumstances require. In this instance morphin-chloroform narcosis in- duced by a hypodermic injection of morphine followed bv the inhalation of chloroform until excitement is manifested when the chloroform is de- creased, can be employed. The patient suffers but little pain, is conscious and spits out or swallows the blood, as directed. However, the danger of cere- bral anaemia while in the upright position must be kept in view and its slightest manifestation heeded and the patient placed on the back with the head lowered during the remainder of the operation. The surest of all is to perform a preliminary tracheotomy and then tampon the floor of the pharynx. Preliminary tracheotomy is not, as a rule, necessary unless the operation be complicated with a very vascular morbid growth requiring re- OPERATIONS ON BONES. 319 Fig. 331.—Instruments employed in excision of bones of the face. a. Liston’s curved bone-cutting forceps, b. Rongeur, c. Fergusson’s lion-jaw forceps. d. Tooth-pulling forceps, e. Small crown trephine. /. Sponge holder, g. Keyhole saw. h. Sequestrum forceps, i. Volsellum forceps, fc. INlouth gag. 1. Trache- otomy tube. m. Bone drills, n. Rugine. p. Curved and straight scissors, q. Peri- osteotome. Scalpels, mallet and chisels (Fig. 246), harelip pins, silkworm gut, and aseptic cotton yarn for the pins, are required. 320 OPERATIVE SURGERY. moval. However, there seems to be little doubt of the fact that the post- operative dangers are lessened sufficiently by preliminary tracheotomy to warrant its frequent employment. Whether the operation of tracheotomy shall be merged with the profounder one or be practiced a few days in ad- vance of the latter, can not be wisely determined except by careful consid- eration of the demands in this respect of individual cases. If the important associated anatomy be carefully regarded before beginning the operation, much time and not a little loss of blood will be saved. Partial and complete excision of the upper jaw are practiced. In the former the seat of the operation, the means of accomplishment, and the method of practice will be suggested by the principles of action that char- acterize the more extensive operative procedures of excision. Complete Excision—Anatomical Considerations.—The bony connections to be divided are (Fig. 332): 1. Through the nasal process of the superior maxilla and the lachrymal and ethmoid bones (1,1J) ; across the floor of the orbit, then either through the malar process of the superior maxilla (2); or, if the malar bone also is to be removed, through the frontal process of the malar and the zygoma (2', 3'). Finally, division of the palate process of the superior maxilla and horizontal plate of the palate bone (3, 4') is re- quired. The internal maxillary artery in the spheno- maxillary fossa and the branches of the facial artery running through the external soft parts are the only vessels that will cause troublesome haemorrhage. Sten- son’s duct must be avoided, as it passes from the parotid gland on a line extending from the lobule of the ear to midway between the border of the lip and the ala of the nose to empty into the mouth opposite the second molar tooth. The superior branches of the facial nerve may be divided unnecessarily if the course of the incision be irregular or the extent or depth be too great. All anticipated complications should be care- fully studied and provision made for their prevention and treatment. Loss of blood, however, is the only one, in addition to the shock common to all operations, that demands close attention at the outset. IIa?morrhage from the facial and internal maxillary arteries, while often profuse, can be promptly controlled by pressure. The Lines of Incision.—The lines of incision may be made within or from without the buccal cavity (Fig. 333). The removal of the bone from within the buccal cavity is tedious, as the space is limited and the opportunity to control haemorrhage comparatively inadequate. At the present time ex- ternal incisions only are employed in all except special cases. These incisions can be classed as the outer and the median. The former (Lizar’s) is begun at the angle of the mouth and carried in a curved course upward and out- ward to the malar process (Fig. 333, a); if more room be needed the first incision may be extended (a'), and also a second may be made through the upper lip to the nostril. This method exposes Stenson’s duct and the Pig. 332.—Division of the bony connections of the superior max- illa. OPERATIONS ON BONES. 321 branches of the seventh nerve to injury, and is followed by a conspicu- ous scar. Liston made an incision from just below the external angular process of the frontal bone to the angle of the mouth (Fig. 333, c); if necessary, a sec- ond (c') along the zygoma joining the first, and even a third from the nasal spine of the maxilla downward through the lip in the median line (Fig. 335). Velpeau, like Lizar, made a single curved incision with the convexity downward from the angle of the mouth to the center of the malar bone, and even to the angle of the orbit (Fig. 333, a, a'), if necessary. Langenbeck made a U-shaped incision through the cheek, with the convexity extending downward to near the line of junction of the upper lip with the cheek, reaching from the point of attachment of the nasal bone with its cartilage to the middle of the malar bone (Fig. 337, a). In this operation Stenson’s duct may be cut and many branches of the facial nerve are divided, besides which a conspicuous scar remains. Another and an admirable incision, Fergusson's, begins from a point half an inch below the inner angle of the eye, and following the furrow between the cheek and the nose terminates by passing through the middle of the upper lip (Fig. 333, b). To this maybe added an incision (b1), at a right angle with the vertical one, an inch or so in length, extending outward half an inch below the orbit (Weber); it may be extended to the external angle of the orbit and the zygoma if necessary. In this incision the coronary and angular arteries only are divided. Fergusson sometimes supplemented the vertical median incision with an outer one similar to Lizar’s (Fig. 333, a). Gensoul, beginning just below the inner canthus, made a nearly vertical incision down to the bone, through the lip opposite the bicuspid tooth (Fig. 335, b); a second incision of similar depth and joining the first at a right angle on a level with the floor of the nose was made outward to the malar bone; a third was car- ried upward from this point to the external angular process, thus com- pleting a flap of commodious dimen- sions, but one followed by consider- able disfigurement and rarely em- ployed. The Operation by the Median Incisio7i; Removal of the Whole Bone (Fergusson).—The middle incisor tooth corresponding to the side to be operated upon is drawn, the facial artery compressed on both sides by an assistant, and the posterior nares are plugged. The primary hicision is begun half an inch below the inner angle of the eye, and carried along the side of the nose around the naso-labial junction to the median line of the lip, thence downward through its free border (Fig. 333, b). Firm sponge pres- Fig. 333.—Lines of incision in removal of upper jaw. a, a'. Lizar and Yelpeau. b, b'. Fergusson-Weber. c, c'. Liston. 322 OPERATIVE SURGERY. sure promptly follows the course of the knife. The haemorrhage, after the division of the lip, is controlled at either side of the incision with the thumbs and fingers of an assistant or by strong Langenbeck serrefines (Fig. 96, b). The latter are tireless, thoroughly elfective, and no hindrance to the operator. The secondary incisions along the border of the orbit (b'), etc., are made only when necessary. The knife is carried rapidly down to the bone, and the flap dissected outward as far as the malar bone above and the tuberosity of the maxilla below. During the dissection the bleeding points are controlled by the fingers of the assistant or by forci- pressure. The vessels should be ligatured with catgut be- fore the bone is removed. The cartilage of the nose is separated from the bone and turned inward ; the edge of the orbit is gained, and the periosteum on its floor sepa- rated and pushed backward and upward to the border of the spheno-maxillary fissure by means of an elevator or the handle of the scalpel. The malar process is now divided by a saw or with bone forceps from the outer extremity of the spheno-maxillary fissure (Fig. 334). The thin floor of the orbit is divided with a scalpel from the inner extremity of the spheno-maxillary fissure obliquely forward and inward to the nasal pro- cess, and the nasal process severed with forceps or strong scissors. The soft palate is separated from the hard transversely inward to the center, on a line with the last molar tooth; an incision is made through the mucous membrane from the center forward in the median line to the incisor teeth, also through the nasal mucous membrane at the side of the septum from behind forward. The hard palate is divided at the side of the septum corresponding to the bone to be removed by a saw or bone forceps (Fig. 334), and the bone is seized and pressed downward to break up its posterior connections, after which it is raised and twisted slightly from side to side and pulled out, bringing with it some portions of the palate bone and pterygoid process of the sphenoid, together with the muscular fibers connected with them. If the mucous membrane of the hard palate be not diseased, it can be saved by making an incision through it along the alveolar border and pushing it inward, together with the periosteum, to the median line. After the removal of the bone the periosteum and membrane can be stitched to the side of the cheek, thus excluding the mouth from the cavity above. The Operation by the Median Incision ; Removal below the Floor of the Orbit.—After the exposure of the external surface of the superior maxilla, as in the preceding method, perforate the anterior wall of the antrum with Fig. 334.—Division of processes of superior maxilla. OPERATIONS ON BONES. 323 a drill or trephine ; then, with the bone forceps or saw inserted into the open- ing, divide the bone inward to the nasal fossa, and outward through the malar bone. Aside from this the steps are similar to those of the preceding operation. The Operation by the Subperiosteal Method.—The subperiosteal method can be accomplished through either of the median incisions, although an external one is preferred by some surgeons (Fig. 335). The external inci- sion (Ollier) is made from the middle of the malar bone to a point at the upper lip, one third of an inch from the angle of the mouth (Fig. 335, a). It is sometimes necessary to make a second incision from the middle of the lip upward to the nose. The mucous membrane on the external surface of the alveolar process is divided down to the bone by an incision begin- ning at the line of junction of the lateral incisor and canine teeth, and carried backward to and around the posterior molar to the inner surface of the alveolar process, thence forward along this surface parallel with the external incision to a point opposite the commencement of the former incision, then obliquely backward and inward to the median line on a line corresponding to the intermaxillary suture of that side. The anterior ex- tremities of the external and internal incisions are now connected by a transverse incision carried between the lateral incisor and canine teeth. The periosteum is then peeled off from the external and orbital surfaces of the bone, and also from the inner surfaces of the alveolar process and the hard palate of that side; the soft palate is carefully separated from the hard. The nasal and malar processes are divided as before, the canine tooth is drawn, and the intermaxillary bone separated, together with the hard palate of the maxilla, from the contiguous bone borders, by the chisel, saw, or forceps. The max- illa is then twisted out, and the periosteal borders of the outer and inner surfaces of the alveolar pro- cess are united. Langenbeck’s incision admits of subperiosteal removal, but its limited extent hinders considerably the necessary manipulative measures, and corre- spondingly exposes the tissues to undue violence. The incisions— of Lizar, Velpeau, Langenbeck, Liston, etc.—are better adapted to removal of a limited portion of the maxilla than of the entire bone, because of the comparatively small amount of bone surface exposed by them; and, too, they are objectionable because of greater disfigurement and the danger of injury of the branches of the facial nerve and of Stenson’s duct. Although it is more dangerous and perplexing to remove the entire max- illa through intra-buccal incisions, still any part of it or the entire lower Pig. 385.—Lines of incision in removal of upper jaw. a. Ollier, b. Gensoul. 324 OPERATIVE SURGERY. half can be thus removed with but little additional trouble to the surgeon and danger to the patient. When cosmetic reasons dominate the policy of action, the latter method should be adopted, even though the entire jaw re- quire removal. The Removal below the Infra-orbital Foramen—Intra-buccal Method.— Extract the teeth in the line of proposed bone section ; pass a short retrac- tion suture through the upper lip; draw the cheek of the affected side backward with a buccal retractor, the fingers of an assistant, or an extempo- rized retractor; separate the mucous membrane of the cheek from the gum from the site of proposed section of the jaw back to the posterior molar tooth; push the soft parts upward in the line of the incision to the site of proposed section of the bone, being careful to avoid injury of the internal maxillary artery behind and the infra-orbital in front; break into the an- trum in front with a small chisel, and with a chisel and mallet cut the outer wall in either direction to the extent of proposed removal; sever the mu- cous membrane of the inferior meatus from behind forward at the objective side with a long-bladed knife; divide the soft parts at the roof of the mouth in the line of proposed bone section through the hard palate with a scalpel; separate the soft from the hard palate, and then with a long-bladed bone forceps or a bone chisel divide the alveolar process and hard palate, cutting toward the center with a quick, sharp action ; grasp the fragment with bone forceps and remove it in the manner previously described. Check hsemor- rhage by prompt, firm pressure, and pack the wound as in other methods. The Comments.—It is very important indeed to preserve the canine tooth in this operation, if possible, because the disfigurement is then not noticed from the front; the tootli also affords attachment and support to the compensatory appliance made by mechanical dentists for the correction of speech and disfigurement. When the bone-cutting forceps is carried cross- wise of the hard palate, the bone is liable to fracture at either side of the line of section; when applied antero-posteriorly, however, the division is easily made without fracture. The horizontal portion of the hard palate may escape notice and remain behind unless this contingency be anticipated and the parts examined with the finger after removal of the maxilla. The Partial removal of the bone is practiced for relief from limited disease of the jaw. The alveolar process can be readily removed with gnawing for- ceps, or chisel and mallet, through the mouth ; the hard palate by a saw or the chisel and mallet. The Removal beloiv the Infra-orbital Foramen—Extra-buccal Method.— Make a curved incision with the convexity outward from the ala of the nose to the angle of the mouth, lying if possible in the facial crease; dissect up the soft parts and open the nostril; expose the malar process of the superior maxilla; introduce a narrow saw into the nose and saw outward horizontally in a line just below the infra-orbital foramen to the outer surface of the bone and through the malar process; detach the soft from the hard palate; divide the hard palate antero-posteriorly and remove the bones with the lion jaw forceps as before. If the orbital plate alone is to be preserved, employ when practicable the vertical portion of Ferguson’s incision, the line of section of OPERATIONS ON BONES. 325 the bone being located just below the orbital plate. In other respects the procedure is substantially similar to removal of the entire jaw. The middle and upper portions of the jaw when diseased can be removed independently through a like incision of the soft and hard parts, supplemented with a hori- zontal section of the bone from the nose outward, just above the alveolar process, thence upward, when practicable, to the sawed malar surface. The superior maxillce may he removed simultaneously by either one of two methods (Fig. 336) : 1. Make an incision from the angle of the mouth to the middle of the malar bone on each side (Fig. 336, «, «), and dissect upward the intervening flaps; or, 2, make a vertical incision (h) along the ridge of the nose, beginning above at a point a quarter of an inch below the level of the lower borders of the orbit, and continuing through the lip (Dieffenbach). To this may be added a transverse incision passing through the upper end of the vertical one and extending on either side to a point a quarter of an inch below the middle of the orbit (e, e); the outer bony attachments are divided, as in the single operation; the nasal processes are divided either by forceps or the saw, and both bones are removed at once, not separately. In all operations for the complete removal, the superior maxillary nerve should be divided as far back as possible. The bones may be removed consecutively in the same manner as for the removal of a single superior maxilla. After operation the wounds are washed in each instance with anti- septic fluid, all bleeding points checked either by ligature, pres- sure, or cautery, and the cavity is packed with antiseptic gauze. The external incisions are closed with sutures and readily unite in three or four days. These cases make a satis- factory recovery from the operation, although some deformity wifi remain. The stitches are removed from the soft parts on the third or fourth day; union, as a rule, then being complete. The After-treatment.—The degree of success of these operations will de- pend on the cleanliness of the part and the nourishment and vigor of the patient. The wound is packed lightly with gauze, frequently cleaned with antiseptic fluid, and the patient’s head so placed as to prevent discharges collecting in the wound or entering the mouth and throat. The patient should be nourished freely with milk, eggs, etc., from the outset. If the taking of food by the mouth be inexpedient, rectal alimenta- tion and the employment of the stomach tube are enjoined. If food be taken in the usual manner, rinsing of the mouth and repacking of the Pig. 336.—Lines of incision in simultaneous removal of the superior maxilla, a, a. Lateral incision, b, e. Median transverse incision. 326 OPERATIVE SURGERY. wound should follow promptly to prevent decomposition. The strength of the patient ought not to be depleted by long or close confinement in bed. A prompt getting up is an important factor of success. Fresh air is needed, not only for the usual reasons, but also for the special purpose of purification of the upper respiratory passages. The Results.—The results of these operations are good so far as immedi- ate loss of life is concerned, as death rarely happens from the operation alone. If the removal be done for malignant growths the prognosis for ulti- mate recovery is unfavorable. In substantially complete removal primary haemorrhage caused death in four per cent; erysipelas, septicaemia, and other complications in about twenty-five per cent of two hundred and thirty cases, as analyzed by the author. The influence on speech arising from the defect in the hard palate can be completely remedied by the application of a rubber plate to the entire roof of the mouth by an expert mechanical den- tist. The plate should be placed on the surface and not in the opening, for if it be permitted to thus encroach on the latter the continuous and active tendency of the opening to closure by growth from the hard borders will be arrested by the appliance, to the great discomfort of the patient. If un- hindered, the opening will be reduced in a few years to at least one third or one fourth the original size by Nature’s efforts alone. In order that the artificial appliance may be held in proper place the canine tooth and the intermaxillary bone of the affected side should be preserved if possible. If the operation is done for the removal of malignant disease of the jaw no chafing of the roof of the mouth or side of the cheek by the plate should be allowed. Therefore, in these cases artificial teeth should be omitted, in order to avoid the pressure and friction of the plate incident to their use. About thirty per cent die when both bones are removed simultaneously. Excision of the Lower Jaw.—Excision of the lower jaw requires no ad- ditional instruments ; however, the precautions referable to the patient are of almost equal importance with those relating to excision of the upper jaw, and the contiguous anatomy is here even more important. The Anatomical Considerations.—The facial artery runs beneath and across the lower border of the bone on the outer surface, and at the anterior border of the masseter muscle; the parotid gland lies behind the ramus, and often overrides it. The external carotid artery, as it passes through the gland, is closely associated with the posterior border of the bone. The in- ternal maxillary artery runs closely behind and to the inner side of the neck of the condyle. The inferior dental artery passes along the inner surface of the ramus to enter the inferior dental canal. The superior division of the facial nerve crosses the outer border of the neck of the condyle. Stenson’s duct extends across the masseter muscle on a line parallel with and about an inch below the lower border of the zygoma, opening into the mouth oppo- site the second molar tooth of the upper jaw. The lingual nerve lies near the inner surface of the ramus, close to the bone, just below the last molar tooth. The genio-hyo-glossus muscles are attached to the superior genial tuber- OPERATIONS ON BONES. 327 cles, and, if incautiously detached, will permit the tongue to fall back- ward and close the glottis. It is important, when possible, to preserve the attachments of the muscles of mastication on account of their action on the lower jaw. Partial and complete removal is practiced; a partial removal may include any fractional portion of the bone. The Remarks.—The incisions for removal of the lower jaw may be made within the mouth or on the external surface. If the whole or a lateral half is to be removed, an external incision must be made. The portion in front of the molar teeth, and even that in front of the ramus, can be ex- cised through an internal incision alone ; the latter method is, however, often attended by vexatious difficulties, and is hardly warrantable except in selected cases. The ramus and portions of the body of the bone behind the teeth can be removed through an external incision without opening into the buccal cavity, provided the periosteum be carefully raised. In the same manner the body, or any portion of it, may be taken away if the corresponding teeth be absent. If the teeth be present the periosteum should be carefully de- tached and the bone with the teeth removed, after which the opening in the buccal membrane, caused by the withdrawal of the teeth, can be closed by sutures. If the jaw be the seat of phosphoric or other necrosis, it may be gradually enucleated from its surrounding involucrum through an external opening by the indirect method (page 314), and the teeth may even remain in the new growth of bone. Unfortunately, however, when processes of a malignant nature call for the operation, these conservative methods are of no avail, since the operation must be directed to the removal of all the dis- eased tissues. When possible the incision in the buccal lining should be closed and the wound drained externally. This course will keep the mouth clean and prevent swallowing the discharges. The Operation of Excision of the Central Portion of the Lower Jatv.— Pass a stout ligature through the tongue well behind its tip to prevent tear- ing out, and tie the ends to form a loop which will be convenient for keep- ing the tongue from falling backward. The assistant stands behind the head of the patient, holds the loop firmly, and at the same time compresses the facial arteries where they pass across the jaw, or seizes the lower lip at the angles, between the thumbs and fingers, rendering it tense, and at the same time arresting the circulation. The operator, standing in front, makes a vertical incision through the median line down to the bone, to the lower border of the symphysis menti, raises the periosteum, if practicable, to the extent of the proposed section, draws a tooth at each point where the bone is to be divided, saws the bone at these points, and, drawing the fragment forward, separates the attachments of the muscles as closely as possible to their insertion and removes the part. The flaps are united with silver wire or silkworm gut extending through the mucous membrane. The vermilion border of the lip is carefully adjusted and united with hare-lip pins or silk- worm-gut sutures. If the tongue falls backward its severed muscular attach- ments can be drawn forward and connected with the incision in the median line by a deep suture passed through the lip. The anterior portion of the 328 OPERATIVE SURGERY. bone can be easily reached through a curved incision made along its lower border, or by an internal one corresponding to the fold of the buccal mu- cous membrane. The lip is depressed over the symphysis menti, and the bone is divided and removed as before. In complete removal of a portion of the body of the bone, the bone need not be sawed through entirely at either place, but nearly so at both, and finally fractured at these points with bone- cutting forceps. The excision of the central or any part of the bone requires that the divided ends be subsequently kept properly separated, or their ap- proximation will destroy the contact of the biting surface with that of the upper jaw during mastication. A perfect approximation of the biting sur- faces is, however, almost impossible, and the operation should not be at- tempted with the expectation of securing complete functional restoration. If the condition of the tissues will permit, the separating agent can be properly fixed to the divided ends at the time of operation, and may serve for a time to keep the fragments apart. The interdental splint prepared before operation and applied to the remaining teeth afterward offers the best solution of the problem known to the writer. Even by this means the tendency to internal displacement of the posterior fragment is rarely entirely controlled. The Operation of Excision of a Lateral Portion of the Loioer Jaw.— Make an external incision along the under border of the portion to be re- moved down to the bone (Fig. 337). If necessary the incision may be turned upward anteriorly at a right angle toward but not through the lip. If the con- dition of the parts will permit, the peri- osteum is reflected off, the bone divided in front, external to the insertion of the genio-hyo-glossus muscle, and if possible turned outward, and the tissues separated back to the point of posterior section ; the bone is then divided at this latter situation with a saw, the fragment re- moved, and the wound dressed as before. The Operation of Excision of a Lat- eral Half of the Lower Jaw.—Commence the incision about an inch and a half below the zygoma, and carry it downward along the posterior border of the ramus and beneath the body of the jaw to the symphysis menti, carefully exposing the facial artery and tying it. If the operation be for necrosis this incision will be sufficient; if for other disease, the lower lip is cut perpendicularly through its center to meet the longi- tudinal incision (Fig. 337, b). The bone is exposed in front by peeling off the periosteum and sawed through just to the outer side of the insertion of the genio-hyo-glossus muscle (Fig. 338, G) if possible, the end of the por- tion to be removed is pulled outward, and the remaining attached tissues Fig. 337.—Lines of incision in the re- moval of upper and lower jaws. a. Langenbeck. b, b'. Removal of lower jaw. OPERATIONS ON BONES. 329 separated either by cutting or by a periosteotome, back to the beginning of the incision. Depress the fragment forcibly, and if possible detach the tem- poral muscle with scissors or the periosteotome, otherwise di- vide the coronoid process with a fine saw; turn the bone out- ward and sever the insertions of the pterygoid muscles, being careful to avoid cutting the lingual nerve; draw the bone forward forcibly and twist it from its socket (Fig. 339). If the primary incision be sufficient to expose the bone above the seat of the disease, the diseased portion is removed and the upper part allowed to remain. If, however, it be im- portant to accomplish the com- plete removal, extend the in- cision upward to the neck of the bone (Fig. 337, £'), avoiding, if possible, Stenson’s duct and the cervico - facial branch of the facial nerve, and enucleate the condyle. At this situation the condyle must be hugged close- ly, otherwise the internal max- illary artery may be injured, as it passes immediately behind it. The Operation of Excision of the Entire Lower Jaw.—Remove first the half of the jaw that best suits the convenience of the operator in the manner before described. A ligature is then passed through the tongue, given to an assistant, and the remaining half of the bone excised in a similar manner. Arrest all haemorrhage and close the wounds with sutures in such a way as to accurately coapt the divided buccal borders. The Operation of Excision of a Portion of the Alveolar Process.—When the extent of the disease will permit, the alveolar process can be removed down to the body of the jaw through either an external or internal incision, the former being the better, by rongeur, chisel and mallet, or saw (Fig. 338, II). The diseased part is then removed and the wound closed as before. The Comments.—In all situations, when the nature of the disease will permit, the periosteum should be reflected by a careful vet vigorous use of the elevator. The insertions of ligaments and tendons will offer the only obstacle, and these should be carefully detached by a sharp knife or rugine so that a continuity of the periosteal and fibrous tissues will remain. Fig. 838.—Lines of incisions in maxillae. A, B, C. Excision of the upper jaw. D. Boeckels’s in- cision. B, C. Guerin’s incision. F, F. Lan- genbeck’s incision. G. Incision in removal of lower jaw. H. Incision for removal of portion of alveolus. I. Esmarch’s incision in anchy- losis. 330 OPERATIVE SURGERY. The periosteum in young subjects may reproduce enough bony material to give a fair outline to the face and serve an important function in masti- cation. If bone be not reproduced, the periosteum will furnish a firm, fibrous base, which may be utilized for artificial appliances. If the anterior portion of either or both sides be removed, the gap may be filled in by an artificial den- tal appliance, which will often happily maintain the symmetry of the face and become useful in mastication. When prudent to do so, as much as possible of the body of the lower jaw should be preserved, since it will form an excellent foundation for a compen- satory dental appliance. Whenever the disease is malignant the periosteum should be removed with the bone and care be taken that none of the dis- eased membrane remains in the wound. It is also necessary in such cases to remove all associated structures when diseased, such as glands, floor of the mouth, and even a part or the whole of the tongue itself. The after - treatment in operations on the lower jaw differs in no essential respect from that of the upper. Cleanliness of the parts, lib- eral alimentation, and the avoidance of swallowing the discharges, appeal to the com- mon sense of all. The Results.—Out of two hundred and forty-six ex- cisions in the continuity forty- six died ; of one hundred and fifty-three disarticulations of half the bone thirty-six died ; in twenty operations for re- moval of the entire jaw one died. It will be seen that death has followed in twenty per cent of all the cases. Pyaemia, erysipelas, and exhaustion were the principal causes. Immobility of the Inferior Maxilla.—Immobility of this bone is over- come wholly or in part by the establishment of a false joint in front of the seat of the cause. The loss of function is usually dependent on cicatricial contraction, irreducible dislocation, or anchylosis. The removal of a wedge- shaped piece from the lower border of the jaw or from the alveolar process has been practiced, or transverse section of the ramus with a sharp chisel in- troduced through the mouth, or even fracture of the neck when the con- dyle is involved, with and without its removal of the latter, has relieved the condition. The Operation by Removal of a Wedge-shaped Piece (Esmarch).—Make an incision two inches in length down to the bone, along the lower border of the jaw, beginning at or in front of the angle, depending upon the location Fig. 339.—Severing connections of inferior maxilla. OPERATIONS ON BONES. 331 of the cause of the immobility. Avoid or tie all important vessels in the course of the incision, expose both surfaces of the bone up to the summit of the alveolar process, and pull a tooth at that situation if necessary. Divide the bone with a saw at one extremity of the exposed surface, force the other extremity through the wound, and remove a wedge-shaped portion (Fig- 338,1) with the rongeur or saw, the base of which should not exceed a third or half an inch. While the patient is still under the influence of the anaesthetic and before the wound is closed, ascertain the distance that the lib- erated portion can be separated from the upper jaw with moderate force. Provide suitable drainage, close the wound, and prevent union of the bones by passive motion. Rizzoli, of Bologna, recommends a simple section of the bone instead of the removal of a wedge-shaped piece. However, the results of this method do not warrant its substitution for the former. If the cause of the immo- bility be due to anchylosis of the temporo-maxillary articulation, the con- dyle should be removed, or the ramus be so divided as not to seriously impair the functions of the masseter muscle—that is, divided beneath that muscle. The division of the neck of the bone by a straight chisel introduced through the mouth (Grube) has been practiced. After either operation it may be necessary to divide the masseter muscle before the full benefit can be experienced from the division or the removal of the bone. If it be deter- mined to remove the condyle, an incision an inch and a quarter in length is made from the tragus along the lower border of the zygoma, the soft tis- sues, including the branches of the facial nerve, are drawn downward and the joint exposed, then by means of a chisel, saw, or forceps the neck of the bone is divided at the proper place, the fragment turned outward by forceps, its attachments divided, and the fragment removed. Passive motion should follow the same as before. Excision of the Sternum.—No definite plan for this operation can be out- lined. The form and length of the incisions must be governed by the loca- tion and extent of the disease. The diseased bone should be freely exposed and removed in the usual manner. Care must be observed and the bone closely followed, else the pleural cavity will be opened. When possible sub- periosteal excision should be done, as the bone is quite readily reproduced. The entire sternum is reported to have been removed by Konig on account of a sarcomatous tumor involving its structure, and although the pericar- dium and pleural cavity were opened the patient ultimately recovered. The Results.—Partial excision results most favorably; only one in eighteen has died. Excision of the Clavicle.—The clavicle is excised, entirely or in part, on account of various morbid conditions and extensive injuries of the bone. The anatomical relations are somewhat intricate and perplexing, especially when the normal relations are changed by extensive diseased action and traumatism. The muscular and ligamentous attachments of this bone must be carefully studied, for it is with a knowledge of them that the surgeon is enabled to remove the bone readily and safely from its more important rela- 332 OPERATIVE SURGERY. tions. With the patient in the proper position for operation, the important relations are well expressed by the following scheme: The Contiguous Anatomg. In front. Attachments of The pectoralis major muscle. The sterno-mastoid muscle. The trapezius and deltoid muscles. Above. The external jugular vein. The branches of the thyroid axis. Below. The cephalic vein. The subclavian artery. The bi’achial plexus. Clavicle. Behind. The internal mammary artery The subclavian vein - sternal half. The external jugular vein. The innominate vein at the right. The thoracic duct at the left. The pleura. The Operation of Excision of the Entire Clavicle.—Anaesthetize and place the patient in a position for ligature of the subclavian artery. If the operation is for necrosis, make an incision,the whole length of the bone parallel with its long axis. If necessary, short transverse incisions are added. Expose the clavicle, divide the periosteum, and with the elevator enucleate the diseased bone from the surrounding tissues. The clavicle can be divided through the center and each half removed separately, or the acro- mial end can be detached and the entire bone raised from without inward. In either instance the articular ends and their connecting ligaments should be preserved if possible. If the involucrum be weak and liable to bend or break after the bone is removed, the shoulder must be held outward, backward, and upward by means of the method employed in treatment of fracture of that bone. The indirect method of seqixestrotomy (page 9) can be performed in some in- stances. If the operation is for the removal of a tumor of this bone, especially of one acutely malignant and involving any considerable portion of its sur- rounding tissues, it is certain to be an exceedingly tedious and bloody pro- cedure. The smaller the size of the tumor and the less its vascularity the easier will be the removal. The Operation for Malignant Growth of the Clavicle.—Make an incision in the long axis of the bone from its sternal to its acromial extremity. If necessary, this is crossed by a vertical incision extending from the posterior border of the sterno-mastoid muscle to the upper third of the pectoralis major muscle. Make these incisions as deep as the nature of the growth will permit, and dissect the flaps from the tumor; separate the attachments OPERATIONS ON BONES. 333 of the deltoid and the trapezius muscles on a director, cutting them either with a knife or strong curved scissors, being careful to avoid the cephalic vein which lies at the anterior border of the deltoid muscle. Divide the coraco- and acromio-clavicular ligaments, raise the acromial extremity of the clavicle, and thus elevate the morbid growth, which should then be cautiously sepa- rated from the surrounding tissues. The nearer the approach to the sternal extremity of the clavicle the greater will be the necessity for caution, since the growth may be connected with the important structures located in this situation. Finally, divide the insertions of the sterno-mastoid and the pec- toralis major muscles and the rhomboid ligament, and carefully disarticulate the sternal extremity while the tumor is lifted upward and inward together with the clavicle. Either extremity, or a part, of the clavicle may be excised by making a crucial incision down to the bone, at a site corresponding to the portion to be removed, exposing and dividing it with a saw, and removing the frag- ment with the same precautions as before described. The Precautions.—At the middle third the large vessels lying beneath the bone should be considerately treated to prevent haemorrhage and the admission of air to the veins. The subclavius muscle at this situation is a valuable guide, as it lies between the vessels and the bone. The results of the operation of complete excision have been quite favor- able. Of seventy-three cases six died from the operation. Exhaustion, due to loss of blood, erysipelas, eta., may cause death. Norkur, and later Mc- Burney, have each had a case with perfect function of the arm after com- plete excision. Partial excisions give a death rate of about eight per cent from all causes. Excision of the Scapula.—The scapula is excised on account of gunshot injuries, necrosis, and morbid growths. The whole bone may be removed, or the body, angles, or spine may be removed sepa- rately. The contiguous anatomy is exten- sive, but not of the dangerous character of that associated with the clavicle. To its spine, borders, and surfaces numerous and powerful muscles are attached. At the upper border are found the suprascapular vessels and nerves. The pos- terior scapular artery passes down its verte- bral border, while at the axillary border the subscapular and dorsalis scapulas ar- teries, the axillary artery itself and the brachial plexus are in close association with the bone. The Operation of Excision of the Entire Scapula (Fig. 340).—Place the patient on the sound side close to the edge of the table. Make an incision from the tip of the acromion process along the spine to the posterior border Fig. 340.—Excision of entire scapula. 334 OPERATIVE SURGERY. of the scapula, a, b. Join it by a second incision extending from near the middle of the spine, c, to the inferior angle of the bone. If necessary, a third may be made from the base of the spine to the posterior superior angle. Dissect up and turn aside the flaps thus indicated. Divide the attachments of the deltoid and trapezius; disarticulate the acromio-clavicular articulation; secure the subscapular artery; divide the ligaments and tendons around the glenoid cavity; raise the coracoid process and carefully sever its ligaments and muscular attachments; raise the scapula by the inferior angle and divide its remaining muscular attachments with a knife or strong scissors, carefully avoiding the subscapular and posterior scapular ves- sels; remove the bone and tie all the bleeding points; wash with an aseptic solution; thoroughly drain and close the wound and dress antiseptically. Sir W. Ferguson and Mr. Pollock thought it better to raise the vertebral border of the scapula first that the subscapular artery might be the better controlled. Spence advised that the anterior angle should be raised first, the better to control the sub- clavian artery. MacCormac advises that the clavicle be divided with a fine saw just internal to the conoid ligament, “ for then time is not lost in detach- ing the outer extremity of the clavicle from its connection with the scapula.” All danger of haemorrhage during the operation is easily obviated by pres- sure on the subclavian artery above the clavicle by means of a short crutch or a large key (Vogel), also by direct pressure on the subclavian after the anterior angle of the scapula is elevated. The Operation of Excision of the Body of the Scapula (Fig. 341).—Make an incision the whole length of the spine, a, b ; begin a second incision at the posterior superior angle and carry it along the posterior border of the bone to the inferior angle, c, d; dissect the resulting triangular flaps from their corresponding fossa3, carefully avoiding the suprascapular artery and nerve; saw through the acromion process close to the body; divide the mus- cles attached to the anterior and superior borders of the scapula; raise the bone upward and saw through the angle just behind the coracoid process; turn the bone outward and sever its posterior connections with a knife or strong scissors. The acromion process and angles of the scapula may be removed sepa- rately. To remove the former make an incision, which is curved if necessary, along its upper border, expose the process, divide its muscular attachments, and with a bone forceps sever and remove the desired amount of bone. This process can also be removed by making a curved or crucial incision over it, exposing its upper surface, dividing the muscular attachments, dis- Fig. 341.—Excision of scapula, f, g. Subspino-glenoid excision, e, c, f. Retro-coraco-glenoid excision. OPERATIONS ON BONES. 335 articulating the clavicle, and removing the requisite amount of its structure with a chain saw. To remove an angle make a V-shaped incision over it, dissect off the flaps, separate the muscles from the bone, and sever the exposed portion with the bone forceps. Chalot favors removal of larger portions (Fig. 341, e, /, g). The Operation of Subperiosteal Excision of the Scapula (Ollier, Fig. 342).—Make an incision from the outer extremity of the acromion process along the spine of the scapula to its posterior border, a, b. Make a second incision from the posterior superior angle of the scapula along its posterior border, crossing the former incision to the inferior angle, c, b, d. Sever the muscular attachments to the acromion process and spine; divide the peri- osteum at the posterior border of the scapula between the attachments of the rhomboideus major and infraspinatus muscles and separate it from the infra- spinous fossa; remove the muscular attachments of the superior border of the scapula. The periosteum is then raised from the supraspinous fossa, being careful not to injure the suprascapular vessels, as they pass in close contact with the suprascapular notch ; cut the remaining muscles attached to the borders of the scapula, closely hugging the bone ; raise the bone upward by its inferior angle, denude the subscapular fossa, leaving the periosteum connected with the subscapularis muscle; liberate the posterior border, allow- ing the cartilaginous portion to remain when present. Turn the bone up- ward and forward, remove the remaining periosteum from its under sur- face up to the neck of the scapula, and divide the bone at the neck with the chain saw. If the extent of the disease will not permit the sawing at this situation, the neck can be enucleated, leav- ing the ligaments connected with the peri- osteum. Excision of the Glenoid Angle of the Scapula.—This operation is only applicable to those conditions of injury or disease that are limited to the articular surface of the glenoid angle of the scapula. If a pene- trating wound be present its course should be followed to reach the bone ; if not, then a curved incision is made around the pos- terior border of the acromion process, divid- ing the fibers of the deltoid and exposing the posterior and upper surface of the joint (Fig. 343, a). Commencing at the center of this one, a second incision is then made, from the upper margin of the glenoid cavity, and passing downward through the deltoid in the direction of its fibers, also through the capsule upon the center of the greater tuberosity, going between the tendons of the supra- and infraspinatus muscles. Open the wound widely by means of retractors and divide the tendons of the heads of the biceps and triceps above and below the cavity at their respective origins; separate the periosteum from around the neck of the scapula, if possible, leaving the attachments Fig. 342.—Subperiosteal excision of scapula. 336 OPERATIVE SURGERY. of the capsular ligament. Cut through the exposed bone with a saw, and remove the fragment carefully to avoid injury to the periosteum. The Remarks.—Excision of a considerable amount of the bone is quite as fatal as the complete excision, owing to the greater difficulty of catching the bleeding points in the former, which promptly retract between the bone and adjacent muscles, and also to the comparatively greater injury in- flicted by reason of the limited field of action. The glenoid cavity and the points of insertion of important muscles, as the acromion and the cora- coid processes, should be preserved when practi- cable, for manifest reasons. If the head of the bone be placed beneath the end of the clavicle, and the capsule connected with the upper end of the humerus be sewed to the under surface of the deltoid muscle, much gain in the use is thus accomplished. The After - treatment. — Complete drainage must be maintained with the patient in the re- cumbent posture, and with the arm and shoulder supported in a comfortable position. After heal- ing is completed the extremity should be supported by a sling until the tone of the parts is sufficiently restored to meet this indication unaided. The results of these operations are good. Of sixty-six cases of complete excision fourteen died. The rate of mortality is greater when removed for traumatic causes than for disease. Astonish- ingly good use of the limb frequently follows, especially in the performance of those requirements not connected with the function of the deltoid muscle. Fig. 343.—Incisions in exci- sions of angle of scapula and head of humerus. EXCISIONS OF TIIE UPPER EXTREMITY. Excision of the Humerus.—The humerus can be removed entirely or in part, as circumstances demand. This operation is done for the relief of old dislocations, caries, necrosis, gunshot injuries, arthritis, malignant disease, etc. The Anatomical Points.—In excisions of this bone the insertions of the muscles acting upon the upper end, the course of the superior profunda and circumflex arteries, the relations of the circumflex, musculo-spiral, and ulnar nerves, the points of insertion of the ligaments of the joints, together with the connections of the important muscles, must be carefully considered be- fore beginning the operation. The bicipital groove looks forward at all times in the normal arm, and with the arm at the side and forearm supinated it corresponds in direction with the palm. The surgical neck of the humerus is located between the tuberosities above and the insertions of the tendons of the pectoralis and teres OPERATIONS ON BONES. 337 major and the latissimns dorsi muscles below. The circumflex nerve and posterior circumflex vessels pass around the surgical neck at a point about one inch above the center of the deltoid. About one fourth of the epiphy- seal junction of the upper end is subperiosteal and located at the outer as- pect; the remainder is subcartilaginous and intracapsular (Fig. 344). The Operation of Excision of the Upper End of the Humerus—Vertical Incision (Langenbeck).—Place the patient upon the back close to the edge of the table, with the shoulders raised. Make an incision about four inches in length downward from the anterior border of the acromion process, close to its articulation with the clavicle, in the line of the bicipital groove (Fig- 345, b). The bone at this region is quite superficial. Liberate the long head of the biceps tendon from the groove by carrying the point of the knife upward in the groove at the outer side through the capsule to the acromion and raise the tendon out of the groove (Fig. 346); rotate the arm outward and divide the subscapularis tendon and inner portion of the capsule ; then rotate the arm inward and cut the external rotators at their insertions, also the posterior portion of the capsule (Fig. 347); force the head of the bone through the opening in the soft parts, seize it with a strong pair of bone-holding forceps, divide the inferior portion of the cap- sule, and remove the head of the bone Avith a chain saw, Gigli-Haertel, or Fig. 344.—A. Epiphysis. B, C. Attach- ment of capsular ligament. Epiphyseal junction noted. Fig. 345.—Incisions in excisions of end of humerus, a. Baudens, Hueter, Ollier. b. Langenbeck. c. U-shaped. a small straight saw (Fig. 348), carefully avoiding the circumflex vessels and nerves. The Operation of Excision of the Upper End of the Humerus—Oblique Incision (Baudens, Hueter, Ollier).—Place the patient as in the preceding operation; make an incision from the outer side of the tip of the coracoid process downward and outward along the anterior border of the deltoid three or four inches in length (Fig. 345, a) ; expose the coraco-acromial 338 OPERATIVE SURGERY. ligament and bare the capsule in the line of the incision; locate the biceps tendon, and divide the capsule at its outer side from below upward ; draw apart the borders of the wound and separate the soft parts from the upper end and outer surface of the bone with a knife as the bone is rotated inward ; divide the insertions into the great tuberosity of the supraspinatus, infraspinatus, and teres minor muscles; clear the inner aspect in the same way as the humerus is rotated outward; locate the lesser tuberosity; divide the subscapularis insertion and the attachment of the capsule beyond; flex the elbow and displace the biceps tendon inward ; cause the head of the bone to project through the wound; .seize the extremity with bone-holding for- ceps and sever it with a saw. The Comments.—Good drainage should be secured by posterior puncture, if need be. The tuberosities should be saved when possible, on ac- count of their important muscular insertions. In children carefully avoid injury of the epiphyseal cartilage, if practicable. Remove sharp, bony points and borders from the sawed end of the bone, so that they can cause no injury to the axillary vessels and nerves. A V- or the U-shaped (Fig. 345, c) incision should not be prac- ticed when the vertical or oblique ones can be utilized, as the former may needlessly damage the del- toid muscle. The circumflex nerve must be carefully avoided, because division or bruising will destroy or impair its function. MacCormac suggests excision through a posterior incision, when the bone need not be di- vided below the tuberosities. The Operation.—With the patient placed on the sound side, the arm abducted and rotated outward so that the outer con- dyle looks backward, and the forearm flexed, make, from the angular projection of the acro- mion downward through the posterior part of the deltoid and through the capsule, an incision four inches in length (Fig. 343, h); expose the great tuberosity Fig. 346.—Raising tendon, Fig. 347.—Attachments to tuberosities of hume- rus. a. Teres minor muscle, b. Infra-spi- natus muscle, c. Supra-spinatus muscle, d. Subseapularis muscle. /. Tendon of long head of biceps muscle in the groove, g. La- tissimus dorsi tendon. OPERATIONS ON BONES. 339 unci the bicipital groove, removing the muscles from the former at their attach- ment ; rotate the arm outward still farther, raising the periosteum and cap- sule till the bicipital groove is reached; dislodge the tendon and raise it up- ward ; rotate the arm strongly inward, bringing the insertion of the subscap- ularis into view, and separate it from its attachment; push the head of the bone through the wound and separate the remaining soft parts as the arm is rotated alternately outward and inward; extrude still farther the head of the bone and saw it off. The Comments.—The circumflex nerve (Fig. 349) will be divided in this method unless great caution be exercised. The Operation of Subperiosteal Excision of Head of Humerus (Langen- beck).—Expose the bicipital groove and split up the capsular ligament as in the non-periosteal operation (Fig. 345, b). Divide and raise the periosteum from the inner border of the bicipital groove, passing inward and separating it together with the subscapularis and the fibrous capsule from the lesser tuberosity. Rotate the humerus outward and complete the separation to the required extent with the elevator and knife ; rotate the humerus inward, displace the tendon of the biceps to the inner side of the head of the humerus, and separate the periosteum from the latter in connection with the capsule and the in- sertions of the external rotators, being very care- ful not to sever the connection of the periosteum with the bone below. The forcing of the head of the bone through the external opening is prac- tically impossible without destroying the peri- osteal connections. It is necessary, therefore, to divide the bone with a chain or narrow-bladed saw without displacement. Subperiosteal excision is practiced through the oblique incision of Baudens and others (Fig. 345, a) with almost equal facility to that of the vertical one. After exposure of the capsule and locali- zation of the biceps tendon, the former is divided upward vertically at the outer side of the tendon. The upper end of the bone is then freed of its periosteum and muscular attachments to the proper distance with a rugine, the humerus being rotated outward and inward as before described, to meet the requirements of the procedure. The Comments.—The removal of the periosteum along with muscular attachments is quite difficult, and must be carefully practiced, especially in the latter instances, to prevent destruction of tissues from too vigorous effort. Subperiosteal excision should be practiced whenever it is possible to do so, since the outcome obtained is superior to that of the less conservative methods. Partial removal of the upper extremity of the humerus is often necessary on account of disease or injury. The variety and extent of the incisions necessary to reach the part must be governed by the amount of the disease, which may be so great as to demand the U-shaped flap (Fig. 345, c). Fig. 348.—Sawing head of hu- merus. 340 OPEHATIVE SURGERY. The Operation of Excision of the Shaft of the Humerus.—In this opera- tion, unless great caution is observed, the musculo-spiral nerve and the supe- rior profunda artery will be injured in their course along the musculo-spiral groove, as will also the circumflex nerve and vessels, if the incision be ex- tended (Fig. 349) too far upward. The upper portion of the shaft is easily exposed by making an incision of sufficient length through the outer surface of the deltoid, commencing at its lower third and dividing it carefully up- ward, to avoid the circumflex nerve and artery. The bone denuded of its periosteum is then removed, or, should there be a morbid growth connected with it, the bone and tumor should be removed together. If the lower por- Fig. 349.—Musculo-spiral and circumflex nerves. Fig. 350.—Relation of ulnar nerve to elbow- joint. a. Inner condyle of humerus. 1. Ulnar nerve, c. Olecranon process. tion of the shaft is to be operated upon, make the incision along the outer border of the brachialis anticus muscle, carefully avoiding the musculo-spiral nerve. Expose the bone and remove it as before. The Excision of the Lower Extremity of the Humerus.—The relation of the ulnar nerve (Figs. 350, h, and 211, J) to the internal condyle, a, and of the brachial artery to the anterior surface must not be forgotten. Make an incision on the posterior and external surface of sufficient length to thor- oughly expose the bone ; elevate the periosteum and divide the bone with a saw; pull the upper end of the fragment downward and disarticulate it from without inward. OPERATIONS ON BONES. 341 If it be necessary to remove the entire humerus, make incisions as if to remove the upper and lower portions, observing the same precautions rela- tive to the anatomy of these parts as before expressed. The musculo-spiral nerve in this operation is to be cautiously avoided. The After-treatment.—In the preceding operations substantially the same treatment is required : Arrest the haemorrhage, provide drainage, close the lips of the wound, envelop the entire limb with antiseptic dressing, and place it upon a splint or a triangular-shaped axillary pad, affording an easy support at the proper angle. Thereafter redressing is practiced in the manner and with the frequency required. As early as practicable passive motion of the joints of the extremity, with massage and electricity, are carried into effect. Extension with a weight is often necessary during the early healing process in order to maintain the limb at a suitable length and to avoid anchylosis. The results depend much upon the nature of the injury or of the disease, the period of the operation, and the employment of antiseptics. Of gunshot wounds of the shoulder joint requiring excision about thirty-five per cent died, the rate of mortality being increased when the inflammatory stage exists at the time of operation. When excised for disease eighty-two per cent recovered, in three fourths of which cases the limb was useful. Thorough antisepsis will lessen this death rate at least fifty per cent. Excision of the Elbow Joint.—Excision of the elbow joint consists in the removal of the articular surfaces and more or less of the shafts of the three bones composing it. The Anatomical Points.—While the anatomical points associated with the elbow joint are numerous, yet the really essential ones can be quite briefly stated. The time of union and the lines of junction of the epi- physes should be carefully noted in order if possible to avoid disturbance of the epiphyseal structure. The internal condyle is longer, thinner, and more prominent than the outer. The olecranon and coranoid processes and the tubercle of the radius afford attachment to important muscles, and should therefore be preserved when possible. The triceps is inserted into the ole- cranon and the periosteum and is continuous with the fascia of the forearm posteriorly. The biceps through the agency of the bicipital fascia alone can flex and pronate the forearm. Through the influence only of the tendon of insertion flexion and supination are accomplished. The ulnar nerve lies in the groove between the olecranon process and the internal condyle close to the bone in a fibrous environment of its own (Figs. 211, J, and 350, b). The supinator brevis should be treated carefully in removal of the head of the radius, not alone for the preservation of its own function, but likewise for protection of the posterior interosseous nerve that passes through it. The Operation of Excision of the Elbow Joint (Iliiter).—With the fore- arm extended make a slightly curved incision about an inch in length down upon the tip of the internal condyle and carefully separate the muscular and ligamentous attachments to the condyle. Make a second longitudinal in- cision from three to four inches in length from above the outer condyle to 342 OPERATIVE SURGERY. just below the head of the radius (Fig. 351). Draw aside the soft parts and cut the external lateral and orbicular ligaments (Fig. 352, ligaments of elbow joint). Expose the head and neck of the radius and cut off the head with a saw or bone forceps. Separate the capsular ligament from its attachments on the anterior and posterior surfaces of the humerus and force the ex- tremity of the humerus out of the external wound. This movement admits of division of the bone and at the same time draws the ulnar nerve from its bed and away from the inner condyle. Saw off the lower end of the humerus and carefully expose and remove the olecranon. The Operation of Subperiosteal Excision of Elbow Joint (Langenbeck).—Beginning at a point a little to the inner side of the middle of the olecranon process, and about two inches and a half below the tip, make a longitudinal in- cision toward the humerus down to the bone about four inches in length, carefully avoiding the ulnar nerve (Fig. 353, a, Jjangenbeck’s incision). Remove the periosteum from the portion of the olecranon process and ulna at the inner side of the incision. Separate by short parallel incisions the attachments of the inner half of the triceps tendon to the olecranon process. Push the tissues at the internal condyle, together with the ulnar nerve (Fig. 355), inward toward the tip of the condyle, and elevate the periosteum from the inner condyle suf- ficiently to separate the internal lateral liga- ments and the attachments of the muscles from the bone and leave them connected with the periosteum. The liberated tissues are now permitted to return to their former position, and the outer portion of the tendon of the triceps is drawn outward and discon- nected from the olecranon process by short transverse incisions, closely hugging the bone and allowing it to remain continuous with the periosteum which is reflected upon the outer surface of the olecranon and shaft of the ulna. Expose the external condyle by separating the capsular ligament at its attachment above the trochlea and capitel- lum. The tissues, including the detached periosteum and tendon of the triceps, are separated well from the bone by retractors. Flex the forearm and force the extremities of the bones through the opening; saw off the head of the radius, then the lower end of the humerus, and finally the olecranon process. Fig. 351. — lliiter’s incision. P’ig. 352.—Ligaments of elbow-joint. OPERATIONS ON BONES. 343 The Operation of Excision of the Elbow Joint by the h- - Shaped Incision (Liston).—Flex the elbow to an obtuse angle, the operator facing its poste- rior surface; open the capsule between the olecranon process and internal condyle by a longitudinal incision about four inches in length made along the inner border of the olecranon (Fig. 354); dissect and draw the soft parts over the internal condyle with the thumb (Fig. 355), increasing the flexion gradually till the condyle is fully exposed ; divide the internal lateral liga- ment, extend the arm, and carry a transverse incision from the point of articulation of the radius with the humerus directly across to the center of the former incision. The periosteum on the inner surface of the olecranon process and ulna is raised and left connected with the tendon of the triceps, which is care- fully separated from the bone. Open the flaps widely and divide the external lateral ligament, flex the forearm, and the articular surfaces will separate. Seize and saw off the lower extremity of the humerus, the olecranon process, and finally the head of the radius. The Operation of Excision by the Bayonet-shaped Incision (Ollier, Fig. 353, b).—The terminal portion of the bayonet incision is vertical, begins two and one half inches above the line of the articulation, and passes downward between the triceps and supinator lon- gus muscles and terminates at the tip of the outer condyle. The middle or oblique portion of the incision extends from the tip of the condyle downward and inward to the base of the olecra- non, thence along the posterior border of the ulna for one and a half to two inches. An internal incision an inch in length is then made with the center at the internal condyle, the bone exposed, and internal lateral ligament de- tached. The external condyle, olecranon and coronoid processes and head of the radius are exposed in the usual manner, bones dislocated forward, lower end of humerus is entirely freed, and the bones are severed with a fine saw. The Remarks.—It would appear that the saving of synovial membrane exerts a more conservative influence on the usefulness of the joint than the saving of bone, provided, of course, that the bony insertions of the muscles acting directly on the joint be respected. If the operation be for trauma- tism, remove the fragments; if for disease, remove the diseased portion; and in both conditions trim the extremities of the bones so as to afford sym- metrical support to opposite bony surfaces. The wounds are closed in the usual manner, drained, and dressed antiseptically. It is necessary to remem- Fig. 353— a. Lan- genbeek’s inci- sion. 1). Ollier s incision Fig. 354.—Liston’s incision. 344 OPERATIVE SURGERY. her in all cases of excision of the elbow joint to respect the insertions of important muscles, such as those of the brachialis anticus, biceps, triceps, etc. To unnecessarily destroy the power of one of these is to be guilty of an unpardonable neglect. Variously formed incisions other than those described have been employed, as the II (Moreau), with the horizontal por- Fig. 355.—Exposing internal condyle. tion corresponding to the articulation ; U-shaped or semilunar, with the con- vexity downward. Either of these imperil the insertion of the triceps. The After-treatment.—Anchylosis and flail joint are not infrequent se- quels of excision of the elbow joint. The former depends very often, indeed, on a too limited and the latter on a too free removal of bone. At the outset the divided extremities should be, when undisturbed, not less than half to three quarters of an inch apart, with the forearm midway between supina- tion and pronation, and be thus maintained during the major portion of the healing by a properly constructed splint to avoid anchylosis. The splint should be light, easily cleansed, and have a movable joint corresponding to the elbow. A bracketed plaster-of-Paris splint with proper suspension is serv- iceable during confinement in bed (Fig. 356). At first the forearm is placed at a right angle or, better still, at one of one hundred and thirty-five degrees OPERATIONS ON BONES. 345 as suits the case, which angle is frequently varied during the healing process. Passive motion of all the joints of the extremity should be employed early and continued during recovery, along with massage and the use of electricity. Supination and pronation of the forearm and passive motion at the seat of the false joint is begun about the tenth or twelfth day, according to the demands of the case. It should not be forgotten that the aim is to secure a false joint, and that every consistent effort to that end must be exercised for the first two months after the operation, even though much pain be inflicted. The grasping and carrying of a weighted pail in the hand is an important measure of treatment to overcome obstinate flexion of the forearm. The Results.—Excision of the elbow joint has been performed with such good success that its high rank is thoroughly established. Although when due to injury the rate of mortality is about twenty per cent, when due to disease it is less than eleven per cent. Partial excisions are followed by better results, so far as motion is concerned, than complete excisions. The Operation of Excision of the Ulna.—In excision of the ulna an in- cision is made along the posterior border of sufficient length to expose the diseased bone, the periosteum is pushed aside, and section is made at the requisite point and the diseased bone is removed. The dorsal branch of the ulnar nerve at the lower third of the bone is carefully avoided. If it be a partial excision of the upper extremity, expose that portion by an incision in the same line as for removal of the entire bone ; elevate the periosteum, leaving if possible the attachments of the brachialis anticus and triceps muscles and avoiding the ulnar nerve at the inner condyle. The Operation of Excision of the Radius.—Make an incision extending from the styloid process of the radius, along the outer border of the anterior surface of the forearm to the radio-humeral articulation, through the integu- ment and fascia. Seek the outer border of the supinator longus, pass up- ward, separating it from the flexor longus pollicis, and going down to the hone ; divide the supinator brevis, also the periosteum in the long axis of the radius; elevate the periosteum ; divide the bone in the center and re- move each half separately. The insertion of the biceps and pronator radii Fig. 356.—Bracketed plaster-of-Paris splint for elbow. 346 OPERATIVE SURGERY. teres should be carefully preserved. If an extremity of the bone is to be excised, expose the portion to be removed by an incision made in the same line as the preceding; raise the periosteum with equal caution and remove the diseased portion. The results of excision of these bones are good, provided the excision be subperiosteal and the epiphyses be not disturbed. The Operation of Excision of the Lower Extremities of the Bones of the Forearm (Bourgary).—Make a longitudinal incision from just below the apex of the styloid process two inches in length along the dorsal surface of the ulna (Fig. 357, lateral incisions). Divide the periosteum at the interspace be- tween the extensor and flexor carpi ulnaris mus- cles and reflect it from the dorsum of the bone inward to the interosseous membrane. A second longitudinal incision is made from just below the apex of the styloid process two or three inches upward along the outer side of the radius. The periosteum is divided through the same incision, the attachment of the supinator longus separated, and the periosteum raised on the dorsal surface together with the sheaths of the extensor tendons. The periosteum is then elevated from the like portions of the palmar surface of the lower ends of both bones around to the interosseous mem- brane. Protect the soft parts carefully while the bones are being sawed through. The operation can be extended to the bones of the carpus if necessary by continuing the lateral incisions down- ward. Excision of the Wrist Joint.—Excision of this joint is associated with difficult and tedious de- tails. The wrist joint consists properly of the radius, articulated with the outer two of the first row of carpal bones. In cases where excision is necessary it is not usual to find the disease or injury limited entirely to these structures. It is important, however, to remove all bony structures involved even though they include the two rows of carpal and the contigu- ous extremities of the metacarpal bones. The Important Considerations '.—The intimate relation existing between the carpal bones and the continuity of their synovial surroundings renders them especially liable to progressive disease as well as to acute inflam- matory processes (Fig. 358). Therefore their relations to each other must be carefully scrutinized, to avoid needless involvement of contiguous synovial sacs, and to impress the necessity of their removal when dis- eased. A knowledge of the periods of development of the epiphyseal structures and the bones of the carpus is of pronounced significance in the conservative sense. The apices of the styloid processes are about Fig. 357.—Lateral incisions. OPERATIONS ON BONES. 347 half an inch below the radio-carpal line. The bones are firmly bound together by strong ligaments admitting of but limited movement be- tween their surfaces (Figs. 359, 360). They are in close relation to the tendons of im- portant muscles, which should be scrupulously preserved to- gether with their sheaths (Fig. 361). All diseased or detached bone should be removed. If a portion of a carpal bone be diseased it is better that the entire bone be removed. The insertions of the muscles acting on the carpus should be pre- served if possible. It there- fore becomes necessary for the surgeon to carefully observe the relations of important ten- dons, vessels, and nerves to the structures to be removed in order to secure the best re- sults. The trapezium, because of its relation to the thumb and the bases of the metacarpal bones of the index, middle, and little fingers, on account of the important muscles inserted there- Fig. 358.—Synovial membranes of the carpus. Fig. 359.—Ligaments of dorsal surface of carpus. Fig. 360.—Ligaments of palmar surface of carpus. into, are important. To avoid haemorrhage the relations of the deep palmar arch, anterior and posterior carpal branches, and dorsal interosseous branch 348 OPERATIVE SURGERY. to the osseous structures must be noted, as well as those of the radial artery to the dorsum of the wrist, to the styloid process of the radius and the carpal articulation of the thumb. Subse- quent adduction of the hand is op- posed by leaving the styloid process of the ulna behind. Tendons are not divided except they form an insurmountable ob- stacle to making the incision neces- sary for removal of the bones; if cut they should be promptly sutured. If the tendons be divided at a distance from the immediate seat of the operation and sutured, the chances of their union will be increased. The fact that subperiosteal tech- nique should be followed when prac- ticable in either partial or complete excision of the wrist, seems to be well established. The Operation of Complete Ex- cision of the Wrist Joint—Subperi- osteal (Langenbeck). — Place the forearm and hand of the patient with the palm downward on a table of convenient height for the operator and his assistants. Make an incision through the integument, beginning at the middle of the metacarpal bone of the index finger at its ulnar border, and extend it longitudinally to three fourths of an inch above the lower extremity of the radius at its middle (Fig. 362). The deeper course of the incision passes to the radial side of the extensor indicis without opening its sheath, upward, over the tendon of the extensor carpi radialis brevior to the radial side of its inser- tion ; push the tendons going to the index finger to the ulnar side and extend the incision upward to the tendons of the extensor longus pollicis and the extensor indicis, dividing the lower portion of the posterior annular lig- ament. Draw the tissues apart with suitable retractors and separate from the bone with a periosteal elevator the fibrous sheaths of the extensors of the carpus on the posterior surface of the radius ; the insertion of the supinator longus muscle and the annular and capsular ligaments are then disconnected and drawn to the radial side together with the periosteum ; the tendons, lig- aments, and periosteum on the posterior surface of the ulna are separated in the same manner and drawn to the ulnar side. Open well the radio-carpal joint, flex the carpus and expose the articular surfaces, and separate the bones of the first row from their connection with each other, leaving the periosteum if possible. Liberate the scaphoid from the trapezium and trapezoid, the semilunar from the os magnum, and the cuneiform from the unciform. Lift them out, together with the trapezium and pisiform bones. The inner bones of the second row are taken out if necessary after severing their con- Fig. 361.—Section through the wrist, a. Scaphoid, b. Os magnum, c. Semilunar. d. Semilunar, e. Unciform. /.Cuneiform. g. Pisiform, h. Compartment for flexor tendons, i. Flexor carpi radialis. j. Ex- tensor ossis metacarpi pollicis and extensor primi internodii pollicis. k. Extensor carpi radialis longior and brevior. 1. Ex- tensor longus pollicis. to. Extensores communis and indicis. n. Extensor mini- mi digiti. o. Extensor carpi ulnaris. p. Palmaris longus. a'. Ulnar vessels. V. Radial vessels, c'. Ulnar nerve. OPERATIONS ON BONES. 349 nections within the trapezium and the bases of the metacarpal bones. The extremities of the radius and ulna can now be forced through the wound, carefully exposed, and sawed off, avoiding the radial and ulnar vessels. The resulting wound is treated by antiseptic measures. The tendon of the extensor carpi radialis brevior lying in the course of the incision may require division to facilitate the proper separation of the deeper parts. Its insertion into the base of the second metacarpal bone may, however, be chiseled off instead, and repair by tenorrhaphy in the one instance and by nailing the bony insertion at the proper site in the other should be promptly practiced. When necessary for convenience of removal, the excision should be extended upward to the distance of an inch or an inch and a half above the line of the articulation. Boekel’s operation consists substantially in the extension of Langenbeck’s. The . Operation of Complete Ex- cision of the Wrist Joint; Subperiosteal (Ollier).—Place the patient as in the preceding instance, and, beginning op- posite the center of the second meta- carpal bone (Fig. 362, 2), make a radial incision along the radial side of the extensor indicis upward to a point an inch and a half above the line of articu- lation of the wrist joint; expose the tendon of the extensor indicis without opening the sheath, draw it gently out- ward by the aid of a hook, and locate the insertion of the extensor carpi radialis brevior; expose the base of the third metacarpal bone at the radial side of the last-named tendon; divide the posterior annular ligament and open the capsule of the joint between the tendons of the extensor indicis and extensor longus pollicis; draw the former tendon outward along with those of the extensor longus digi- torum ; make an ulnar incision down to the bones at the inner side of the tendon of the extensor carpi ulnaris, from a point an inch and a quarter above the tip of the styloid process to the same distance below the base of the fifth metacarpal bone, avoiding the nerves going to the little finger; through the incision already made di- vest the carpal bones of their ligamentous and periosteal coverings by small rugines preferably introduced first at the radial side; free the bones, expose Fig. 362.—Excision of wrist joint. 1. Langen beck’s incision. 2, 3. Ollier’s incisions. 1, 4. Boeckel’s incisions, a. Annular ligament, h. Extensor carpi radialis brevior. c. Extensor carpi radialis longior. d. Extensor longus pollicis. e. Extensor communis digi- tornm. /. Extensor indicis. g. Ex- tensor carpi ulnaris. 350 OPERATIVE SURGERY. and remove them through the corresponding incisions, saving if possible the pisiform, the unciform process, and the trapezium ; bare the radius and ulna of periosteum as high up as needful, protrude the ends through the opening and divide them with a saw. The Comments.—In recent injuries it is difficult indeed to separate the tissues from the bones, especially in adult subjects. In young subjects and in those in whom the parts are affected with chronic inflammation, the sepa- ration is easier. The tendons and their insertions are preserved much better in the subperiosteal than in the open method. The Operation of Complete Excision of the Wrist Joint; Subperiosteal (Lister).—Begin the first or radial incision at the middle of the dorsal aspect of the radius on a level with the styloid process, and carry it toward the inner side of the metacarpal articulation of the thumb parallel with the tendon of the extensor longus pollicis to the radial border of the second metacarpal bone, thence along that bone half its length (Fig. 3G3); cut the ten- don of the extensor carpi radi- alis brevior, detach with a knife the tendon of the extensor carpi radialis longior; push outward these tendons along with that of the extensor longus pollicis and the radial artery; separate the trapezium from the carpus in the line of the incision with cutting forceps, carefully avoid- ing the radial artery; bend the hand backward to relax the extensor muscles and dissect up the soft parts at the ulnar side. Begin the second or ulnar incision at the anterior aspect of the ulna, at a point two inches above its lower end, and bring it downward in a straight line between the bone and the flexor carpi ulnaris to the mid- dle of the palmar aspect of the fifth metacarpal bone ; raise the posterior lip of the incision ; expose at the insertion and divide there the tendon of the ex- tensor carpi ulnaris, dissect it from its groove without separation from the tissues overlying it; separate the extensors of the digits from the carpus, divide the dorsal and internal lateral ligaments of the wrist joint. Flex the Fig. 863.—Lister’s incisions. 1. Posterior radial incision. 1'. Anterior ulnar incision, a. Ex- tensor carpi radialis brevior. b. Extensor carpi radialis longior. c. Extensor longus pollicis. d. Extensor communis digitorum. e. Extensor indicis. OPERATIONS ON BONES. 351 carpus, expose the anterior surface of the ulna, closely hugging the bone to avoid injury to the ulnar vessels and nerves, open the articulation of the pisiform bone, and cut at the base the unciform process with pliers. Divide the anterior ligament of the wrist joint; sever the carpus from the meta- carpus with bone-cutting forceps; extract the carpus through the ulnar in- cision, dividing restraining ligamentous connections therewith at the same time; cause the ends of the radius and ulna to protrude through the ulnar incision by forcible eversion of the hand; remove from these bones all dis- eased tissue, disturbing as little as possible the extensor tendons of the thumb; remove disease from metacarpal extremities, seize and remove the trapezium without cutting the tendon of the flexor carpi ulnaris as it lies in the groove in the palmar aspect. All haemorrhage having ceased, suture the divided tendons and close the wounds, allowing the more dependent incision to remain open for drainage. Envelop the limb in antiseptic dressings, causing the whole to be properly supported by a splint (Fig. 364). The Precautions.—Avoid the radial artery in making the primary in- cision, and in the removal of the trapezium, which bone is removed last for this purpose. In attacking the heads of the metacarpal bones, recall their relation with the deep palmar arch. The intimate association between the tendons and their contiguous tissues must be disturbed as little as possible, otherwise the vitality of the tendons will be much impaired and perhaps destroyed. The radius and ulna should be maintained as nearly the same length as practicable, to suitably support the head. Therefore, as little as need be of healthy bone should be removed from either, the styloid process Fig. 364.—Esmarch's interrupted splint for exsection of the wrist. of both, that of the ulna especially, being preserved when possible. Any sound portion of the pisiform should be preserved on account of the relation of the bone to the anterior annular ligament and flexor carpi ulnaris. The metacarpal bone of the thumb should be held at the same level as those of the remaining digits, to secure better symmetry of the hand. In excision the adhesions ought to be broken before the operation is begun. In instances of local disease the application of the Esmarch bandages should be applied with caution, if at all. In traumatic cases the use of this agent may lead to a too scant regard for the safety of important vessels. The After-treatment.—The indications for this treatment are perfect cleanliness and the use of a splint that will keep the forearm midway between pronation and supination, thumb and fingers free, and the hand slightly ex- tended and abducted. The wound should be frequently observed and passive 352 OPERATIVE SURGERY. motion of the digits made early and often. After the wound is healed, pas- sive motion of the false joint and the use of massage and electricity should be persistently employed. The simple wooden splint devised by Lister and Fig. 365.—Esmarch’s splint applied. the splint of Esmarch (Figs. 364 and 365) are well adapted for the after- treatment. However, a plaster-of-Paris splint molded to meet the indica- tions and protected with oiled silk and suspended or not as required, can he employed instead (Fig. 366). Incisions of other shape are made through which to effect the removal of the wrist joint; but the longitudinal incisions are advisable, since the trans- verse, or any modification thereof, may cause the needless sacrifice of impor- tant structures. The Resvlts.—Ten per cent die after excision for disease, and fifteen per cent after excision for gunshot injuries without antiseptic treatment. In Fig. 366.—Bracketed suspended plaster-of-Paris splint for excision of the wrist joint. about thirty-three per cent of those who recover the operation is of no service, in about eleven per cent entirely satisfactory, in the remainder of an indifferent outcome. The prognosis for usefulness is better when excision is performed for injury than for disease. OPERATIONS ON BONES. 353 Excision of the Metacarpo-phalangeal Joints.—These joints can readily be excised by making an incision about one inch and a half in length along the dorsum of the bones composing the joint at one side of the extensor ten- don. The tissues in contact with the bone are carefully raised and turned aside, the joint exposed, and the requisite amount of bone removed by the chain or Gigli-Haertel saw, or bone-cutting forceps. The Comments.—The excision of these joints should not be practiced in the young, as the epiphyseal tissues are thus destroyed and a digit of ques- tionable utility soon becomes an absolute disfigurement. Even in adults they are often a source of greater inconvenience than of service. However, on account of its functional importance, these statements do not apply with equal force to the thumb. The operation is commended here, especially when the proximal epiphysis can be preserved. Excision of the Phalangeal Joints.—These articulations may be ap- proached either through a longitudinal incision made along the side of the joint or by a curved incision at the same situation with the convexity down- ward. In either instance separate the tissues carefully down to the extremi- ties of the bones, which when properly exposed can be caused to protrude through the incision by lateral flexion and the extremities can then be re- moved. A terminal phalanx is best excised by means of a U-shaped palmar incision, leaving if possible the base of the bone so as to preserve the attach- ments of the flexor and extensor tendons. The Remarks.—Excision of interphalangeal joints offers a fair outlook for symmetry and usefulness, especially if practiced after epiphyseal union has taken place. The removal of an entire metacarpal bone, even subperioste- ally, is not followed by pleasing success, except perhaps when associated with already established bone production dependent on periostitis. The re- moval of small portions of the shafts is followed with satisfactory outcome in the majority of instances. The after-treatment consists in placing the fingers in an immovable posi- tion properly protected by an antiseptic dressing, and when repair begins passive motion is made and continued until the recovery is complete. The principles of action governing excisions of the bones of the hand apply with equal force to excisions of the bones of the foot. The im- portance of the great toe especially, and of the other osseous structures of the anterior part of the inner arch of the foot in locomotion, gives to them and the operations directed to their relief a specific significance. The phalanges and metatarsal bones of the other toes are also invested with cosmetic and mechanical importance, and the former importance exceeds in degree that of the latter in the order of their location from within outward. The proximal interphalangeal joint of the second toe and the metacarpo- phalangeal of the third are removed for the cure of hammer-toe and of meta- tarsalgia respectively. The Phalangeal Joints of the Tarsus are removed in a manner similar to those of the upper extremity. EXCISIONS OF THE LOWER EXTREMITIES. 354 OPERATIVE SURGERY. A Metatarso-phalangeal Joint is removed through a longitudinal incision made over the dorsal surface of the bones constituting the joint, at the in- ner or outer aspect of the extensor tendon, which is pushed aside together with the remaining surrounding soft parts; the ends of the bones are then exposed, and severed by the chain or Gigli-IIaertel saw, or the bone for- ceps. The metatcirso-phalangeal articulation of the great toe is excised often through a U-shaped incision made at the inner side of the joint, with the convexity downward, the center corresponding to the middle of the joint, and of sufficient length to freely expose the portions of the bones to be removed (Fig. 367, a, U-shaped incision). Dissect the soft parts from the bones, carefully pushing aside the tendons; expose and remove the necessary amount of the articulation with a saw or forceps. If the operation be done for the correction of the deformity caused by prominence of the head of the metatarsal bone (hallux valgus), enough should be removed to permit the easy return of the dis- placed toe to its natural position, wrhere it is re- tained quietly till repair is wTell advanced, when passive motion is com- menced. The Tarso metatarsal Joints can be excised through a straight in- cision or by raising a semi- lunar flap over their dor- sal surfaces, avoiding division of the extensor tendons which are raised and pushed aside, while the dorsal ligaments connecting the bones are divided and the joint cavity exposed by forced flexion, after which the bones of the distal row can be divided with a saw or bone forceps. The corresponding extremities of the tarsal bones can then be treated likewise. The Remarks.—This joint of the great toe is removed best in the manner already indicated (Fig. 367, a). However, as in the other toes, it can be re- moved through a straight incision. The metatarsal bone of the great toe can be removed through an incision extending its entire length, connected at each end with short vertical incisions (Fig. 367, b), or through a flap of similar length as the preceding incision, turned up from below so as to se- cure good drainage and locate the scar in an unexposed position (Fig. 373, b). Operations on the Tarsal Joints.—When separate tarsal joints become in- volved by disease or the effects of traumatic violence they can be removed by making an incision over the injured or diseased portions, often following the line of the seat of violence or in the track of sinuses leading to the disease. This treatment is, however, better adapted to those joints having a lim- ited synovial membrane than to those where the membrane extends between Fig. 367.—Lines of incision for removal of head (a) and entire bone (b). OPERATIONS ON BONES. 355 several contiguous bone surfaces. In the latter case it is often better to re- move the bones entire by aid of the chisel, saw, or gouge. In either instance curved incisions are preferable, provided they do not divide important ten- dons and vessels (Fig. 368). Fig. 368.—Section of bones and synovial membranes of the tarsus. Excision of the Calcaneum.—It is necessary that as much as possible of this bone be saved, as it forms through important ligaments the posterior pillar of the arch of the foot and also gives attachment to the tendo Achil- lis which exerts a powerful influence in locomotion. A knowledge of the periods of ossification of the centers of this bone is important indeed in young subjects, and emphasizes the wisdom of being conservative and care- ful. When gouging fails to remove the diseased bone excision becomes the final resort. The Operation.—A horseshoe-shaped incision is begun a little in front of the calcaneo-cuboid articulation and carried backward along the side of the foot around the base of the os calcis to a corresponding point on the opposite aspect. This flap, with the knife hugging the bone, is dissected up, expos- ing the entire under surface of the os calcis (Fig. 369, excision of os calcis). A second perpendicular incision about two inches in length is then made through the middle of the tendo Achillis down to the preceding one. The Fig. 369.—Excision of os calcis. resulting flaps are dissected off close to the bone, the articulation between the calcaneum and the astragalus is opened posteriorly, the ligamentous con- nections are severed, together with those between the calcaneum and the 356 OPERATIVE SURGERY. other contiguous bones, the os calcis is taken away, and any additional dis- eased bone removed. Since the preceding incision is greater than is required to remove the bone, Forabeuf advised that the incision cease at a point about an inch and a half to the inner side of the median line of the foot and be met at the outer side by a vertical one two inches long located in front of and parallel with the tendo Achillis (Fig. 370, c). The vertical incision is carried down to the bone, and the peri- osteum along with the superimposed soft parts and tendinous insertions carefully separated in the usual manner. After ex- posure of the under sur- face, the bone is grasped at the anterior part with bone forceps, depressed, denuded of ligaments all around, and removed carefully, avoiding injury of the peronei tendons. The Remarks.—The direct relation which this bone bears to the poste- rior portion of the arch of the foot, and the attachment which it affords to important ligaments concerned in the maintenance of the arch, invests the bone with great importance in walking. The Results.—About sixty-five per cent of these cases recover with use- ful limbs; about one in twenty die from the operation. Excision of the Astragalus.—Removal of the astragalus can be accom- plished through incisions of various forms, as the oval, single, double, ver- tical, etc. The Anatomical Points.—The relation of the tuberosity of the scaphoid bone to the head of the astragalus must be carefully observed, as it is a cer- tain guide to the articulation just behind it, a matter of obvious importance. The interosseous ligament and its characteristics should be carefullv noted before operation. The operation by the oval incision is the oldest method, and is objection- able because of the great degree of disturbance it causes to the tendons on the dorsum of the foot. In this incision the tendons are either drawn aside or divided. If the latter, the ends are united after completion of the operation. The oval flap extends between the malleoli on the dorsum of the foot with the convexity downward. The tendons of the extensor muscles are carefully pushed aside, the ligamentous connections of the bone with the tibia, fibula, and os calcis’are severed, and finally those with the scaphoid as well. The foot is then extended, the bone removed from its site, and the calcaneum placed in the resulting gap between the malleoli. Fig. 370.—a. Excision of ankle joint (outer incision), b. Excision of astragalus (outer incision), c. Excision of os calcis. OPERATIONS ON BONES. 357 The Operation by the Double Incision (Outer and Inner).—The outer incision begins in front of the external malleolus, on a line with the articu- lar cartilage of the tibia, and extends downward and forward parallel with the outer border of the tendon of the peroneus tertius two and a half inches. A second is made at a right angle to the preceding, passing from the center of the same downward and backward, and terminating a little below the tip of the malleolus (Fig. 370, b). . The inner incision begins just below the tip of the inner malleolus and is carried in a curved manner up- ward in front of the anterior margin of the malleolus (Fig. 373, c). Through the outer incisions the ligamentous connections of the astragalus with the fibula, tibia, scaphoid, and os calcis are carefully divided, and through the inner one the remaining ligamentous attachments of the bone are severed. The astragalus is removed through the anterior incision with lion-jaw forceps. The flaps are united, the wound is drained, and the foot confined at right angles with the leg by a fenestrated plaster-of- Paris splint. The opera- tion by a single incision at either side can not be ad- vised on account of the limited room and the re- sulting increase in the in- jury of the tissues. The Results. — About seventy-five per cent of these cases recover with useful limbs. Excision of the Ankle Joint. — Excision of the ankle joint is now less frequently performed than formerly. The uncertain- ty of the result of the op- eration and of the final usefulness of the limb, to- gether -with the established utility of prothetic appli- ances after ankle-joint am- putation, have almost elim- inated the operation from the practice of many, espe- cially for the removal of diseased bone. In the instances of complicated fracture and of compound dislocation, the outlook is more promising, partic- ularly when practiced with antiseptic care. The ankle joint is a hinge joint and has no lateral movement except when the foot is well extended, which even then is very limited. The relation of the epiphyseal centers to the long bones, their periods of union, the arrangement of the ligaments of the ankle Fig. 371.—Outer side of ankle, a. Tendo Achillis. b. Peroneus longus. c. Peroneus brevis, d. Peroneus tertius. e. External malleolus. /. Extensor longus digitorum. g. Crucial ligament. h. Extensor longus pollicis. 358 OPERATIVE SURGERY. joint and its synovial membranes, are matters of special importance in exci- sion. The landmarks of the joint are stated under the consideration of am- putations at the ankle (page 455 et seq.). The indications calling for the opera- tion are numerous and should be well considered before it is attempted. As in all of these operations, those incisions which best preserve the ten- dons, vessels, nerves, and periosteum should be practiced, consequently longitudinal incisions are the ones that should be employed. The Operation of Subperiosteal Excision of the Ankle Joint (Lan- genbeck).—Make an incision about three inches in length along the posterior border of the lower ex- tremity of the fibula down to the bone (Fig. 370, a), carrying it forward in a hooked shape around the lower end and then upward along the an- terior border about an inch. The periosteum is reflected from the bone together with the tissues in contact with it, thereby exposing the lower extremity of the fibula without opening the tendinous grooves of the peronei muscles (Fig. 371). The fibula is then divided at the upper end of the incision with a narrow saw, the lower fragment is pulled outward, its liga- mentous attachments are severed (Fig. 372), and the bone is removed. A semicircular incision is then made about an inch and a half in length down to the bone, around the lower end of the inner malleolus (Fig. 373, a). A third and vertical one is next made about two inches in length down to the bone through the center of the internal malleolus, connecting below with the semicircular one. The triangular flaps, in- cluding the periosteum, are turned aside with the ele- vator, using care to raise the sheaths of all associ- ated tendons from their grooves and push them aside; the tibia is then di- vided at the upper end of the cut with a saw, the frag- ment is pulled outward with the forceps, freed from the interosseous membrane, and removed (Fig. 374). If it is necessary to remove a part or the whole of the astragalus it can be done through either incision ; the better, however, through the internal one on account of the greater amount of room. Fig. 372.—Removing lower end of fibula. Fig. 373.—a. Excision of ankle joint (inner incision). b. Excision of metatarsal bone of great toe. c. Ex- cision of astragalus (inner incision). OPERATIONS ON BONES. 359 Vogt recommends, when excision is performed for chronic disease of the ankle and the contiguous joints, with the view of getting a more extended insight into the diseased portions, that an incision be made anteriorly, midway between the tibia and fibula, beginning about twro inches above the articulation of the ankle and extending downward on the dorsal surface of the foot to the medio-tarsal joint. The long extensor tendons are care- fully drawn to the inner side, the tendons of the short extensor are divided and drawn to the outer side, the blood vessels carefully tied between two ligatures and divided, and the capsule of the joint is opened by a vertical incision; the anterior ligament is then detached and the head and neck of the astragalus is exposed. If the superior astragalo-scaphoid ligament be divided, the anterior and inner surfaces of this bone will be the better ex- posed. A transverse incision is now made at right angles to the primary one, extending outw’ard to the tip of the external malleolus, leaving the Fig. 374.—Inner side of ankle joint, a. Tibialis anticus muscle, b. Tendo Achillis. c. Tibialis posticus muscle, d. Flexor longus digitorum. e. Flexor longus pollicis. /. Posterior tibia! artery, g. Tuberosity of scaphoid bone. tendons intact. Divide the three fasciculi of the external lateral ligament close to the malleolus, and cut the interosseous and internal calcaneo-astraga- loid ligaments; force the articular surface of the astragalus outward ; seize the bone with lion-jaw forceps, separate its remaining connections, and remove it. All diseased portions can now be easily examined and removed with a minimum degree of disturbance of the healthy tissues. The Operation of Non-subperiosteal Excision of the Ankle Joint (Busch).— An incision is made down to the bone, from one malleolus to the other, across the sole of the foot. The sides of the joint are exposed by drawing the tis- sues forward. The os calcis is sawed through from below upward and for- ward to the anterior margin of the calcaneo-astragaloid articulation and pulled backward after the division of the opposing ligamentous structures. The entire astragalus can now be removed through the opening and also the lower extremities of the tibia and fibula. 360 OPERATIVE SURGERY. After the removal of the dead bone and the establishment of good drain- age the fragments of the os calcis are placed in position and held there by silver wire. The wound should be dressed antiseptically and no weight allowed upon the foot until the tissues are firmly united. The Comments.—This method is a very ingenious one, as it permits re- moval of the diseased joint without impairing the tendons or their sheaths. It is open to the objection, however, of weakening the arch of the foot on account of the division of the long calcaneo-cuboid ligament and the plantar fascia. The fact remains therefore that the method of subperiosteal exci- sion is especially adapted to the anatomical construction of this joint on account of the subcutaneous location of the lower ends of the tibia and fibula; and the excellent results that sometimes follow are dependent also on the greater security of the tendons and ligaments in this method. The after-treatment for excision of the ankle joint consists in applying an immovable dressing around the joint under antiseptic precautions. This Fm. ii75.—Bracketed suspended plaster-of-Paris splint for excision of ankle joint. dressing may be of plaster of Paris, suspended or not as seems desirable. The indications of cleanliness, extension, and preservation of the foot in the proper axis of the limb and the securing of sound ankylosis should be kept in constant view by the surgeon. Not infrequently after subperiosteal opera- tions a satisfactory degree of motion at the ankle joint is secured. The mobility of healthy contiguous joints contributes much to this satisfactory outcome. Later the ingenuity of the maker of orthoptedic appliances may add much to the serviceableness of the limb. The Results.—When excision of the ankle is done for disease about ten per cent die ; for gunshot wounds, about twenty-seven per cent; for other injuries, about thirteen per cent. The results are better from complete than from partial excision. Under strict antisepsis these results are considerably improved. The prognosis for life is most favorable between one and fifteen years of age; most unfavorable between thirty and forty years. A large proportion OPERATIONS ON BONES. 361 of the recoveries from this operation results in a more or less serviceable limb ; about nine per cent are useless. Osteoplastic Resection of the Tarsus (Wladimirow-Mikulicz).—This operation is sometimes practiced instead of amputation for relief from exten- sive disease and injury of the tarsal bones and for paralytic talipes. The Operation.—Beginning about half an inch behind the tuberosity of the fifth metatarsal bone, make a transverse incision down to the bone across the sole of the foot to a point immediately in front of the tuberosity of the scaphoid. Make an incision down to the bone at either side of the foot from each end of the transverse one upward and backward to the posterior borders of the respective malleoli. Unite the upper ends of these incisions by a posterior transverse one and divide the tendo Aehillis; flex the foot sharply; open the ankle joint from behind ; sever the lateral ligaments; enucleate and remove the astragalus and os calcis; saw thin disks Fig. 376.—Wladimirow-Mikulicz’s osteo- plastic resection of the tarsus, a. In- cision through the soft parts, i. Di- vision of the bone. c. Position of the foot after the operation. Fig. 377.—Result after osteoplastic re- section. of bone from the exposed extremities of the tibia and fibula, and from the exposed surfaces of the scaphoid and cuboid bones; divide subcutaneously the flexor tendons of the toes so that the latter may be extended to a right angle with the dorsum of the foot; bring in contact and fasten together the sawed bony surfaces with sutures, and close the wound of the soft parts (Fig. 376, c). The extremity is then dressed and confined by means of a plaster- of-Paris splint until healing is completed, after which it is fitted with a suit- ably constructed shoe (Fig. 377). The Comments.—Berger, in order to preserve the integrity of the pos- terior tibial artery and nerve, approached the ankle joint through a T-shaped incision made at the outer side. The present high degree of usefulness and oomfort secured by prosthetic appliances lessen decidedly the utility of such methods of practice. 362 OPERATIVE SURGERY. The Results.—In nineteen operations, of which thirteen were for tubercu- lar caries, two died of general tuberculosis eight months afterward; twelve made a good recovery, aud walked with more or less ease; in five, failure followed, three of which required amputation. Excision of the Bones of the Leg.—If it be desired to remove by ex- cision or otherwise portions of either of the bones of the leg, the location and extent of the incision is governed by the situation and extent of the injury or disease of the bone. The bone should, however, be reached by the shortest practicable course, which usually is between the individual mus- cles rather than through their structures. After removal of the bone, which should always be subperiosteal, the limb is confined so as to per- mit the new structure when completed to fulfill the functions of its predecessor. Therefore the patient must not be permitted to bear weight on the limb till the new bone becomes firm, else distortion or fracture will occur. The Precautions.—Careful avoidance of involvement of the knee joint and of injury to the anterior tibial and musculo-cutaneous nerves and the tendon of the biceps should be observed in dealing with the head of the fibula. Fig. 378.—Longitudinal section of the knee joint, a. Upper extremity of synovial sac. b. Tendon of the quadriceps extensors, c. Patella, d. Pre-patellar bursa, e. Inner condyle of femur. /. Ligamentum mucosum. g. Fatty tissue between ligamentum patellae and synovial sac. h. Bursa beneath ligamentum patella, j. Fatty tissue. k. Opening in synovial membrane behind crucial ligament leading into inner half of joint. 1. Synovial membrane reflected from crucial ligaments, m. End of anterior crucial ligament, n. Posterior crucial ligament, o. Ligamentum posticum Winslowii. Excision of the Knee Joint.—The knee joint can be excised with com- parative safety to the patient and with a fair prospect of recovery with a use- ful limb. As in the preceding, the nature of the cause demanding the oper- ation exercises a marked influence on the result. OPERATIONS ON BONES. 363 The Anatomical Pomts.—Much is said regarding these points in connection with amputations. Still, it will not be amiss to remind the reader that the popliteal artery is closely associated with the liga- mentum posticum Winslowii which separates that vessel from the joint cavity (Fig. 190,/). If ordinary care be exercised there is but little dan- ger indeed of injury to this vessel unless there be extensive disease and Fig. 379.—Mackenzie’s anterior curved incision, deformity of the ligament, when the vessel may be nicked in the removal of the diseased tissue in spite of great caution, as has once happened in the practice of the author. When it is necessary to remove diseased tissue at this situation the presence of pulsation of the popliteal artery will be of in- estimable aid, and therefore the circulation of the vessel should be unhin- dered at that time. The articular arteries should be avoided if possible, for their division causes free haemorrhage. The superior ones pass above the respective condyles of the femur; the inferior internal pass below the inner tuberosity of the tibia and beneath the internal lateral ligament; the external just above the head of the fibula and beneath the external lateral ligament. The synovial membrane of this joint is extensive and replete with small pockets, which may interfere with proper drainage and the removal of diseased processes. The bursa of the popliteus muscle communicates with the joint and not infrequently with the superior tibio-fibular articulation at the same time, therefore an unguarded interference with this articulation ex- poses the general cavity to the danger of inflammatory involvement. The synovial elongation upward beneath the tendon of the quadriceps is well ex- hibited in the illustration (Fig. 378). The relation of this extension to a similar and subsidiary bursa above is explained sufficiently in connection with amputation at the knee joint (page 468). With the leg extended this elonga- tion ascends beneath the quadriceps to its highest point, but when the leg is completely flexed it reaches scarcely above the anterior limit of the articular cartilage of the femur. Therefore the leg should be flexed to avoid opening the joint in incisions made at the lower and anterior aspect of the thigh. The lines of epiphyseal junction of the femur and tibia at the knee should be located carefully in the young before excision, so that, if possible, they may 364 OPERATIVE SURGERY. be left undisturbed and contribute still further to the growth of the bone. In a child of eight years of age, no more than two fifths of an inch can be Fig. 380.—Sawing off lower end of femur. removed from the tibia, nor more than three fifths from the femur, without invading the epiphyseal cartilage. At puberty three fifths of an inch can be removed from each. Very often, indeed, disease of the epiphyseal struc- ture modifies or destroys the power of subsequent development, and inevitable deformity follows. If the leg be slightly flexed, or the joint cavity distended, the apex of the patella corresponds to the articular line of the joint. There are two ivell-known methods of excision of this joint: 1, the non- subperiosteal, or ordinary; and 2, the subperiosteal method. The former is emplo}fed only when the tissues are too extensively destroyed or diseased to admit of the saving of the periosteum. The Operation of Non - subperiosteal Excision of the Knee Joint (Mackenzie).— Flex the leg to a right angle and make a curved incision from the posterior border and upper portion of the inner condyle around to a corresponding point on the outer, with the convexity downward and extending to the insertion of the liga- mentum patellae (Fig. 379). This incision divides the tissues down to and opens the anterior portion of the capsular ligament. The limb should now be still more strong- ly flexed, the flap turned upward, and the lateral and crucial ligaments divided. A retractor is then passed between the liga- mentum posticum Winslowii and the posterior surface of the condyles of the femur, the lower end of the femur bone pushed forward and cut off on a Pig. 381.—Sawing off upper end of tibia. OPERATIONS ON BONES. 365 plane at right angles with the long axis of the bone (Fig. 380) and parallel with that of the distal surface of the condyle, provided the extent of the disease will admit. The head of the tibia is then exposed, pushed forward, Fig. 382.—Szymanowski’s saw. and sawed in the same manner with similar care, being careful to avoid the articulation of the fibula (Fig. 381). The peculiarity of the saw devised by Szymanowski (Fig. 382, and page 317) makes it useful in sawing these and other bones of large size. In this operation it is better to remove the patella, since its means of attachment (the ligamentum patellae) has been severed. All inflamed or degene- rated synovial membrane should be dis- sected away; sinus tissues, too, should be thoroughly removed. The wound is then wiped or flushed with a hot aseptic solution, and drainage established from side to side behind the bones, the divided ends of the bone are wired or pegged together, the soft parts sutured, the whole limb is enveloped in antiseptic dressing, and immovably fixed in properly suspended bracketed plaster or a wire cradle splint. The Operation of Excision by a Trans- verse Incision (Bird).—Ascertain the line of junction of the articulation with the limb extended, if the condition of the joint will permit; make a transverse in- cision from one condyle directly across to the other, passing over the middle of the patella or its apex (Fig. 383); if the former, saw the patella through in the line of the incision, remove the frag- ments, after which the joint surfaces are exposed and removed as in the preceding operations. This incision affords the opportunity to establish good drainage, and exposes the joint with a minimum injury of the soft parts. Fig. 383.—Incision and exsection of the knee. 366 OPERATIVE SURGERY. The Operation of Subperiosteal Excision of the Knee Joint (Langenbeck). —Extend the limb and make a curved incision five or six inches in length on the inner side, commencing at the inner border of the rectus femoris and terminating below at the crest of the tibia. The convexity of this incision turned backward, corresponds to the posterior borders of the con- dyle and tuberosity, and its center to the line of the articulation (Fig. 384). if the flap be now raised, the vastus interims muscle and the tendons of the adductor magnus and sartorius will be seen (Fig. 385), and should be care- fully avoided. Divide the internal lateral ligament on a line with the articu- lation ; with the periosteal elevator separate the capsular ligament together with the internal semilunar cartilage and the periosteum from the anterior and posterior surfaces of the inner condyle of the femur and the tibia out- Fig. 385.—Tendons at inner side of knee joint, a. Vastus interims muscle, 0. Rectus femoris muscle, c. Sartorius muscle, d. Adductor magnus muscle. e. Gracilis muscle. f. Semi-mem- branosus muscle, g. Semi-tendonous muscle, h. Gastrocnemius muscle. Fig. 384.—Langenbeck’s incision. ward to the median line of the hones; flex the leg, then extend it slowly, and at the same time dislocate the patella outward with the thumb applied to its inner border; divide the crucial ligaments; also divide by a semi- lunar incision carried a few lines below the tip of the external condyle ; divide the external lateral and the adjacent portion of the capsular ligament; re- move the periosteum and its associated tissues from the outer aspect of the tibia and femur, the same as at the inner side; divide the posterior por- tion of the capsule and force the extremities of the femur and tibia in turn through the wound, and saw them as before. The patella remains unmo- lested, except it be diseased, when the diseased portion is removed with a gouge, or the bone can be enucleated from the periosteal surroundings by the elevator and scalpel. A small opening should now be made at the outer OPERATIONS ON BONES. 367 and one at the inner side of the wound posteriorly, for the purpose of estab- lishing thorough drainage. A drainage tube can be passed through the upper synovial pouch, or firm compression can be made thereon to prevent the col- lection of inflammatory products within it. The surfaces are then cleansed, all haemorrhage is arrested, the flaps are united, and the limb, surrounded by antiseptic dressing, is immovably fixed till future dressings become necessary. The Operation of Subperiosteal Excision of the Knee Joint (Ollier).—Make an incision through the soft parts, commencing two inches above and to the outer side of the patella, carry it down to the upper and outer angle of the patella, along the outer border toward the apex and thence along to the outer side of the ligamentum patellae as far as to its insertion (Fig. 38G); denude the outer condyle of the femur of its periosteum together with the lateral and cap- sular ligaments and the outer head of the gastrocnemius; denude the anterior and internal surfaces of the femur; cut the crucial ligaments ; displace the patella inward over the inner condyle; flex and carry the leg inward, causing the femur to protrude, when the end is isolated and sawed off. The upper end of the tibia is then denuded of its periosteum from above downward, pushed through the opening and likewise divided. If the patella be diseased, remove it, leaving its periosteum behind. The Remarks.—In sawing through the exposed extremity of either bone, the line of incision may be made to include the whole of the diseased os- seous tissue. If, however, carious bone or an ab- scess cavity extend in an isolated manner into the sawed extremity of the femur or tibia, it can be scooped out, and the resulting cavity drained by making an opening with a bone drill through the bottom and continuing it to the external surface, thereby saving the surrounding healthy bone tissue and thus contributing to the length of the limb. Deeply congested cancellous bone tissue should be preserved, especially if its removal will impair the epiphyseal cartilage (Fig. 388). Such diseased bone makes a good recovery, and contributes to the preservation of the growth of the femur. The lines of section of the sawed surfaces of the bones must be parallel with each other with the leg in the straight position (Fig. 387, a b, a' c), otherwise their union will cause an angular deformity. This fact applies more particularly to those cases where anchy- losis in the straight position is sought. If for any reason it be thought better to anchylose the limb with slight flexion, then the thicker portions should be taken from the posterior parts of the bones (hJc, ij). Fig. 386.—Olli- er’s incision. Fig. 387.—Saw lines in ex- cision of the knee joint. 368 OPERATIVE SURGERY. The limb should be firmly fixed, with the bone surfaces suitably in contact with each other, before the wounds of the soft parts are closed. If any diseased tissue remains it may produce a general infection of the wound, and, even if not causing a fatal issue, its non-removal would be followed by delayed and unsatis- Pig. 388.—Epiphyseal cartilage and line of section in excision of knee joint. factory recovery. Therefore, the synovial pouches and sawed surfaces should be carefully inspected for the presence of objectionable morbid products. If the limb be anchylosed in a flexed position, it should be corrected as much as possible by Buck’s extension before operation, to lessen the other- wise needless sacrifice of bone, and obviate undue stretching of the popliteal tissues incident to correction at the time of operation, and the common sequel in such cases—backward displacement of the head of the tibia. The use of the elastic bandage in excision of this joint enables one to distinguish the presence of disease of the synovial and osseous structures better than without it, and to complete the dressing of the part without the presence of bleeding, if such a course be advisable. Certainly the latter procedure should not be practiced unless competent surgical skill be at immediate call. It is far better and more secure to arrest all bleeding before closing and dressing the wound. Since diseased synovial membrane should be care- fully dissected away before the wound is closed, the anterior pouch should be cautiously explored for this reason. In all forms of excision of this joint, care must be taken to prevent the soft parts posterior to the bones from being caught between their sawed surfaces, since this occurrence will hinder union by preventing a proper contact of the surfaces. If the two wire sutures be carried from in front through to the posterior borders of the bones, and united at the anterior surface, this accident can not occur, neither will it happen if the surfaces be placed in contact and confined there by muscular contraction or a closely fitting splint. The fixation of the bones by metallic sutures and needles, bone pegs, etc., is open to the objection that it may be necessary later to remove them for relief of the irritation which their presence provokes. Pegs driven from without through the integument and bone in opposite directions, so as to hold firmly together the sawed surfaces, as practiced by Barker, Wyeth and others, are efficient in many cases. However, if the apposed surfaces can be firmly held in OPERATIONS ON BONES. 369 position with apparatus, the use of these devices can be properly omitted. If the patella be permitted to remain, its severed ligament may be united by suturing, or, if the bone have been sawed across, the bony fragments may be united by strong catgut or silver wire. It is thought, in cases of imperfect union of the tibia and femur, that the presence of the patella gives greater stability to the limb. The idea of confining the sawed surfaces (Konig) to each other by nailing the attached portion of the bisected patella to properly sawed surfaces of the femur and tibia is certainly ingenious, and in favorable cases can be em- ployed. If successful, it will offer a strong obstacle to backward displace- ment of the tibia. In fifteen cases of excision the wire was employed by the author, and in five nothing but the splint was used for this purpose; the results, so far as union was concerned, were equally satisfactory. The wire caused trouble in only three instances; in one, a necrosis along its course, in the remaining two a local irritation due to pressure, which was promptly relieved by removal of the wires. After-treatment.—The wire cradle splint and the fenestrated plaster-of- Paris splint confining the entire extremity, and properly swung with elastic bandages, were employed consecutively or singly in each of the author’s cases (Fig. 389). After the soft parts are united the application of a plaster- of-Paris spica, as in fracture of the thigh, and out-of-door exercise on crutches are very important measures of treatment. That strict antisepsis and good drainage are essential needs no remark. The Results.—The mortality following excision for diseased knee joint is about thirty per cent; when for injury, about forty per cent; when done with all antiseptic precautions, the rate is less than fifteen per cent. In the author’s twenty-one adult cases for disease, two died ; one expectedly. If excision is practiced for a gunshot injury, the mortality is increased to about seventy-five per cent. The age of the patient is a consideration not to Fig. 389.—Suspended bracketed plaster-of-Paris splint. be underestimated ; the results are best from five to ten years of age, whether the operation is for injury or disease; nearly twenty to twenty-five per cent die when done for gunshot wounds. Partial excision for disease gives a higher rate than complete. The removal of about three inches of bone 370 OPERATIVE SURGERY. insures the best prognosis for life, a lesser or greater amount increases the percentage of deaths. The removal of the patella, when not diseased, in- creases the rate of mortality slightly. The usefulness of the limb after the operation can be briefly summed up as follows: When done for disease, fourteen per cent of the results were perfect, forty-two were useful, and the remaining useless; of which latter eighteen per cent required amputation. For injuries, about eighteen per cent were perfect, about sixty-five per cent useful, and in about twelve per cent amputation was performed. When for gunshot injuries, about sixty per cent were useful and twenty- four per cent required amputation, the remaining not accounted for. When done for deformity, nineteen and a half per cent of the results were perfect, and about sixty-eight per cent of the patients had useful limbs; the remainder not reported. It appears that the degree of usefulness does not depend upon the amount of bone removed. The removal of the patella seemed to increase the degree of usefulness of the limb. In excision of the knee joint for all causes, before the growth of the patient is completed, great care should be taken to preserve intact, if possible, the epiphyseal cartilages, especially that of the lower end of the femur (Fig. 388). This precaution markedly lessens thereafter the liability to failure of development of the length of the femur upon the diseased side, because this epiphyseal junction provides normally for much more than its proportionate share of the growth in length of the bone. Arthrectomy.—Arthrectomy, sometimes called evasion, is a conservative operation employed to remedy disease of a joint—usually the knee—in lieu of the more formidable procedure of excision. It is applicable especially to cases in which the disease of the joint structures is not extensive, nor of a tuberculous or suppurative nature, and displacement is not yet present. The conservatism of this method is shown in the young, since the epiphyseal structure need not be impaired by the measure. Such instruments as curved scissors, mouse-tooth forceps, surgical spoons and gouges, are required here in addition to the commoner implements of operation. The Operation of Arthrectomy.—The preparation and position of the patient, the extent of the incision, and the exposure of the joint cavity, are similar to the steps in excision. All diseased serous, ligamentous, cartilagi- nous and bony tissues are removed with scissors, scoop, and gouge, being careful to preserve especially the crucial and posterior ligaments. A careful exploration of the synovial elongations and pouches is necessary, in order to detect and remove the disease products. Isolated areas of diseased bone or cartilage should be cautiously removed by scraping and gouging. Arrest haemorrhage, flush the joint with a solution of aseptic fluid, drain the cavity at dependent points, unite the flaps with silkworm gut, surround the part liberally with antiseptic dressing, firmly bind in place, and confine the joint immovably as in excision. The Results.—If successful, a firm, stiff limb of normal length is pro- duced. At all events, the danger incurred is less than in excision, which OPERATIONS OX BONES. 371 can, if advisable, be resorted to later on. Painstaking efforts should be made to secure a stiff limb. Artlirectomy of the Ankle Joint (Brtins).—Make two incisions downward, one at either side of the anterior aspect of the limb, from about an inch and a half above the line of articulation to the medio-tarsal joint; separate the borders of the incisions and remove the diseased tissues from the anterior portion of the joint by the same means as at the knee. The posterior por- tion of the joint is then freed of diseased tissue through two vertical incisions made one at either side of the tendo Achillis. The part is then treated as after excision of the joint. The Excision of the Patella.—Excision of the patella, independently of the tibia and femur, may be necessary on account of necrosis or injury. In such cases the deep incisions must exactly correspond in extent to the diseased bone, for if they be greater, the synovial cavity may be opened. The peri- osteum should be raised, and the dead bone carefully removed, if possible with- out entering the joint. When the joint is not involved, recovery will be speedy and satisfactory if the limb be confined in the extended position till sufficient repair has taken place to warrant flexion without fracture of the new bone. The Precautions.—With the limb straight, the apex of the patella in a healthy joint is just heloiu the joint line, but with the limb slightly flexed, or with the joint distended, a puncture at the apex readily enters the joint. The results in eleven cases, of which eight were complete, and three par- tial, excisions, were two deaths and nine recoveries. Excision of the Great Trochanter.—Excision of the great trochanter is occasionally required on account of caries of that structure. A longitudinal or posteriorly curved incision is made down upon the bone, and the diseased portion removed with the usual instruments. The branches of the circum- flex vessels and the capsular ligaments are to be avoided. The periosteum should be saved when possible. Excision of the Hip Joint.—It is well before attempting this operation to give a brief survey of the important ligamentous and muscular attach- ments that are to be respected. The extent of this book is too limited to describe them in detail, and even to do so would hardly be in keeping with the scope of the work, therefore a standard work on anatomy should be con- sulted. The Anatomical Points.—The ilio-femoral, capsular, cotyloid, and even the teres ligaments, should be carefully considered in connection with their origins and insertions, so that their attachments to the involucrum and peri- osteum may be maintained. When practicable those muscles which are con- nected with the trochanters major and minor should likewise be preserved intact, in order that their association with the new bone growth may give to the new joint, so far as possible, the normal functions of the old. It is important to note the fact that the upper border of the trochanter major is on a level with the center of the hip joint, also that the epi- physes of the upper end of the femur contribute but comparatively little to 372 OPERATIVE SURGERY. the growth of the bone in length, which is the result almost entirely of those of the lower end. The hip joint may be excised by two quite distinct methods of procedure : 1. The radical method, when no effort is made to save the periosteum, and the muscular and ligamentous attachments about the joint are freely divided. This method is applicable to malignant disease of the bone, and to injuries causing extensive comminution and laceration. 2. The conservative method, in which scrupulous care is exercised in the peeling off of the periosteal tissue and muscular attachments worthy of preservation. Under all circum- stances the acetabulum should be closely scrutinized for the presence of dead bone, which should be removed cau- tiously to avoid injury to the pelvic contents by the manipulation. The Radical Operation of Excision of the Hip Joint (White).—This opera- tion is performed by placing the patient on the healthy side, and making a deep curved incision with a strong knife (Fig. 390), commencing at a point midway Fig. 390.—White’s posterior curved in- cision. Fig. 391.—Sciatic nerve and external rotator muscles. between the anterior superior spinous process of the ilium and the trochanter major, and passing backward around the top of the trochanter major, down its posterior border about three or four inches; then dividing the insertions of the muscles connected to the great trochanter (Fig. 391), drawing them aside with a spatula, and exposing the posterior surface of the neck of the femur and the acetabulum. The exposure will be still more complete if the femur be rotated strongly inward. If the cotyloid and capsular ligaments be now divided, and the thigh be flexed, adducted, and rotated outward, the head of the bone will be raised from the acetabulum sufficiently to admit of the OPERATIONS ON BONES. 373 division of the ligamentum teres, when the complete escape of the head of the femur will take place. The soft parts are then protected by a spatula, and the bone, exposed to the required extent, is sawed off (Fig. 392). A Conservative Method of Subperiosteal Excision of the Hip Joint (Langenbeck).—Place the patient on the sound side with the thigh flexed to Fig. 392.—Sawing off head of femur. an angle of 45°, and rotated slightly inward; make a straight incision five or six inches in length in the long axis of the great trochanter (Fig. 393), upward and backward toward the posterior superior spine of the ilium, passing through the fascia lata, fibers of the gluteus maximus, and periosteum of the trochanter; separate the surfaces of the wound with retractors, and with the elevator and knife raise the periosteum and the attachments of the muscles inserted into the trochanter major and the contiguous surfaces, being careful to preserve their connections with each other; next make a longitudinal in- cision along the neck of the femur, through the capsular ligament and the periosteum. The periosteum of the neck is then separated in connection with the attachments of the capsular ligament and the obturator externus in a careful manner. If an incision be now made through the cotyloid liga- ment, and the thigh be rotated outward and adducted, the head of the hone will be elevated from the floor of the acetabulum sufficiently to admit of the division of the ligamentum teres, if present, after which the head of the bone can be pushed through the opening and sawed off. All diseased products are now removed from the acetabulum with scoops, gouges, chisel and mallet, etc., and from elsewhere about the joint with proper means. After the con- trol of haemorrhage, the joint is flushed freely with an antiseptic solution 374 OPERATIVE SURGERY. and drained, and the borders of the wound are united with silkworm-gut sutures. Farabeuf\ after making the initial incision, located with the finger between the pyriformis and the gluteus medius muscles, drew the muscles apart and divided the periosteum between their insertions, also the cap- sular ligament, and the periosteum of the neck of the bone, all in the line of the primary incision. He then exposed the trochanter major and neck by reflecting the periosteal flaps and the muscular attachments on either side backward and forward respectively; divided the periosteum of the neck of the bone at the line of the articular cartilage; and then so manipulated the thigh as to expose and clear successively the remaining aspects of the neck and trochanter, after which the bone was dislocated, and the requisite amount removed with the saw. In other important regards Farabeuf adhered to the preceding method of action. A Conservative Method of Ex- cision of the Hip Joint (Barker). —With the thigh fully extended make an incision at the front, be- ginning an inch below the anterior superior spinous process of the ilium and going downward and a little inward for three inches, so as to separate the tensor vaginae femoris and glutei muscles at the one side from the sartorius and rectus at the other, down to the neck of the bone. Divide the neck with a narrow saw in the direction of the wound; lift out the head of the bone, search for additional disease and remove it if present with the flushing gouge de- vised by Barker himself. After any such disease is removed, flush and dry the cavity, place the sutures for closure of the wound, fill the wound with iodo- form emulsion, and then tie the sutures, at the same time pressing out what may come of the iodoform emulsion. Drain, if essential, dust the surface with iodoform, apply antiseptic dressings with firm pressure, and confine the limb with a spica bandage so as to force the remainder of the neck of the bone into the acetabulum, where it is retained to serve the important pur- pose of support. During the entire removal of diseased products, the wound is flushed with hot sterilized water (110°) through the agency of the gouge, which serves the double purpose of separating the diseased tissue and wash- ing it away simultaneously (Fig. 32G, d). Although the natural opportunity for drainage of the wound is indeed inadequate, yet, if drainage be urgent, it can be easily provided by separation of the deep dependent structures. Fig. 393.—Excision of hip joint, a. Langen- beck’s incision, b. Sayre’s incision. OPERATIONS ON BONES. 375 In this operation the short route and the minimum degree of damage to the soft parts, and of haemorrhage, certainly bespeak a favorable outcome in proper cases. A Conservative Method of Excision of the Hip Joint (Sayre).—The fol- lowing method of excision is recommended by Professor Lewis A. Sayre. It is subperiosteal in all essential particulars, and possesses an advantage over the one just described in that the primary incision is better suited for drainage. The following is substantially the description given by Professor Sayre. Place the patient on the sound side, with the thigh flexed, and make an incision with a strong knife down to the bone, commencing at a point midway between the anterior superior spinous process of the ilium and top of the trochanter major; carry it in a curved course upon the bone to the top of the great trochanter midway between its posterior border and center; complete it by carrying the knife forward and inward, making the length of the incision from four to six or eight inches, depending upon the size of the thigh (Fig. 393, h). If it be not certain that the periosteum of the trochanter have been divided by the first incision, the knife should be carried along the same line a second, and even a third time if need be. The soft parts are now drawn asunder, exposing the great trochanter, when, with a narrow, strong knife, a second incision is made through the periosteum only, at a right angle with the first, about an inch or an inch and a half below the top of the tro- chanter. At the junction of the periosteal incisions introduce the blade of the elevator, and carefully peel the periosteum from either side as far as pos- sible, together with the ligamentous attachments, until the digital fossa is reached. The insertions of the rotators into the trochanter major and digital fossa are so firm that it will be impossible to peel them off; they must there- fore be carefully separated by short, parallel cuts, so directed as to remove as well the periosteum with which they are blended. After the separation of the tendinous insertions, continue the elevation of the periosteum upon either side of the neck, using great care not to rupture it. Having separated the periosteum as far as can be done safely, adduct the thigh carefully, raise the head of the bone from the acetabulum, and detach the remaining portion. Adduct and depress the femur slightly, being careful not to tear the perios- teum, and lift the head of the bone out far enough to admit of a division just above the trochanter minor. Care should be taken not to expose a greater surface of bone than is necessary, since necrosis would follow and hinder re- covery. It is better to remove the trochanter major, even though it be not diseased, since its presence will impede the escape of discharges, and is not essential to obtaining a useful limb in cases where its periosteal covering and muscular attachments are preserved. In all cases after the operation, the wound should be well irrigated with a strong solution of carbolic acid. The General Remarks.—The period between five and fifteen years of age is regarded as the proper one for excision. Not a little conflict of opin- ion exists regarding the stage of the disease hest suited for operation. At the present time, however, the consensus of opinion favors the later rather than the earlier operative attacks. Whether or not the trochanter major 376 OPERATIVE SURGERY. should be left entire or removed wholly or in part is not agreed upon by experienced authorities. When the leaving of it intact would interfere with drainage, expose to recurrent disease, or become a source of irritation thereafter, as is apt to be the case, it should be removed wholly or in part at the time of operation. When the points of insertion of muscles and liga- ments are cartilaginous, a thin layer of the cartilage may be removed, leav- ing the attachments undisturbed. The preservation of the integrity of the periosteum is regarded as important in the prevention of infiltration into the surrounding tissues, to provide attachments for serviceable ligaments and muscles, and to furnish a basis for the reproduction of the bone, which it is hoped will take place, each of which factors will exercise an important influence in the establishment of a useful joint. However, much of the aforegoing will prove fanciful when addressed to excision in adults for relief from the effects of traumatic violence, since then the separation of the periosteum will be exceedingly difficult and perhaps hazardously slow, and too often attended with a degree of mutilation that will destroy so much of the membrane as not only to defeat the purposes for which it is saved, but also to hinder subsequent repair. The saving of the periosteum in the instance of infective disease is of questionable utility, because in- completeness of removal of the infective process may be followed by a prompt return of the primary infliction. In all instances of excision as prompt healing as practicable should be sought for. Therefore, after secur- ing suitable drainage, quite firm pressure on the surface should be made by carefully applied sponges and soft antiseptic dressings, which are fixed securely in place with bandages. The After-treatment.—Extension, cleanliness, and nutritious food are essential. Extension in bed should be as limited as possible, on account of the evil influences of confinement in these cases. However, extension with the wire breeches (Sayre) or the Thomas splint will enable the patient to leave the bed at an early period, affording also an opportunity for dressing the wound and providing the extension necessary, to prevent the end of the bone from pressing upward against the acetabulum. The results of excision of the hip joint are substantially as follows : When •done for gunshot injuries, about ninety-two and a half per cent die from the primary, about ninety-one per cent from the intermediary, and ninety and a half from the secondary operation. When done for disease, the mor- tality is reported variously from thirteen (Sayre) to forty-five per cent. The most favorable age is between five and ten years, and the best results are said to occur when the disease has existed several months. The rate is about three per cent greater from complete than from partial excisions. The rate of mortality is a little improved by the removal of the trochanter major and the upper portion of the shaft; it is diminished, however, in proportion to the amount of diseased bone removed from the head of the femur down- ward, and is increased in proportion to the extent of the disease of the ilium. About ninety-four per cent secure useful limbs when excised for disease. Complete excision is followed by a more useful limb than partial •excision. The advent of strict asepsis and improved technique with judi- OPERATIONS ON BONES. 377 cious selection of cases has led to the startling results of only three (Wright) to five per cent mortality. The usefulness of the limb will depend very much on the amount of bone removed—the less the better—other things be- ing equal. However, the majority secure serviceable limbs and walk unaided. Excision of the coccyx is oft-times done, though sometimes ineffectually, for the relief of coccyodynia. The operation exposes the patient to no danger and can but remove a comparatively useless appendage. The Operation.—Place the patient on the side and expose the bone by a straight incision in the middle of its long axis; isolate the bone carefully and remove it with bone forceps. In the liberal acceptation of the term, osteotomy may be defined as a section of bone. OSTEOTOMY. Fig. 394.—Instruments employed in osteotomy, a. Scalpel, b, c, d. Chisels, e. Mallet. /, <7, h. Osteotomes, i, k. Retractors. I, m. Sponges wet with a solution of carbolic acid to hold over incisions. In a limited sense, however, it is applied to the divisions of bone that are made for the relief of deformities dependent on anchylosis, rickets, badly 378 OPERATIVE SURGERY. united fractures, etc. The bone may be divided either through a free or an abridged incision of the soft parts. In the former, a liberal incision of the soft parts is made down upon the bone, and it is therefore called the open method. If the opening in the soft parts be of only sufficient size to admit Fig. 395.—Langenbeck’s saw. the entrance of the instrument, thereby preventing observation of the act, it is denominated the abridged or subcutaneous method. If the bone be divided directly through, in either an oblique or transverse direction, at one situa- tion only, the act is denominated linear osteotomy, and is usually of the abridged or subcutaneous variety. When, however, a wedge-shaped piece is removed, the procedure is called cuneiform osteotomy, and is practiced through a free incision. The instruments employed in osteotomy consist of especially designed saws, chisels, osteotomes, mallets, blunt hooks, and sand pillows (Fig. 394). Variously formed saws are employed, named usually for the one who designed them, as Langenbeck’s (Fig. 395) and Adams’s saws (Fig. 396). The Fig. 396.—Adams’s saw. Fig. 397.—Shrady’s bone saw. blades are short and strong, a quarter of an inch in width, and an inch and a half in length, connected to the handle by a strong shank three inches long. The deviations from these varieties are to meet special indications rather than to limit the use of the instruments. OPERATIONS ON BONES. 379 The objections to the use of the saw not only relate to the danger of lacerating the contiguous tissue, but more forcibly to the retention in the wound of the bone dust which, failing to be absorbed, is apt to be followed by suppuration ; therefore the osteotome and chisel are better than the saw. The saw devised by Dr. George F. Shrady, of this city, is a good instrument, and is described by himself as follows: “ (Fig. 397.) The instrument consists of a staff with a handle and blunt extremity. A portion of this shaft at a short distance from the extremity is flattened, one edge (B) being made into a knife blade, and the other (0) being provided with saw teeth. When in position (3) either the saw (0) or the knife edge of the shaft, according to the way the latter is turned, corre- sponds with the opening of the cannula. The saw or knife can then be worked to and fro within the cannula by a pistonlike movement, the cannula being steadied by grasping the flange or handle (D) (Fig. 398) at its base. If it be necessary to work the instrument as an ordinary blunt-pointed sheathed saw or knife, the shaft can be fixed in the cannula and made into one piece by a thumbscrew in the handle. The portion of the cannula at the back of the opening is made extra strong, and is of the same thickness as the blade, Fig. 398.—Shrady’s improved bone saw. so that in sawing there is no stoppage of the passage of the instrument through any thickness of the bone. The soft parts are protected from in- jury, no matter which way the instrument may be w'orked. The saw blade is blunt at its extremity, and is guarded on all sides except in its limited cutting surface. The same may be said of the knife. The working of the saw to and fro in the cannula is sufficient in sweep to insure the division of any bone having a diameter less than the cutting edge. Still, as this pro- cess is much slower than when the saw is used in the ordinary way, it is perhaps better to restrict its employment to operations on the smaller bones, to cramped localities, and to situations where there is special danger of wounding some neighboring vessels. All that is necessary in using this saw is to thrust the trocar and cannula into the limb, the fenestrum of the cannula being alongside of the bone upon which the operation is to be performed. The trocar is then withdrawn, the staff introduced in its place and worked as already described.” The chisel resembles the carpenter’s chisel in form, but differs from it in quality ; it has two parallel margins extending to its cutting edge, which is 380 OPERATIVE SURGERY. beveled on one side. The base of the bevel should be an eighth of an inch in thickness; if thicker than this it may splinter the bone. The width varies according to the size of the bone to be divided—half an inch being suitable in the majority of cases. For narrow bones, a quarter of an inch in width is better (Fig. 394, b, c, d). The width should be less than that of the bone to be operated upon. The temper given to the tools of the hardwood or ivory turner is best suited for the purpose of this instrument, and its efficacy should be tested upon the thigh bone of an ox or a like animal before being used for its special purpose. The chisel should be sharp, and leave a smoothly cut surface. This instrument is employed only to remove a wedge-shaped piece from the bone, since the shape of its cutting extremity will, like that of the carpenter’s chisel, cause it to go awry if a straight section be attempted. The Osteotome.—The osteotome is beveled at the end on both sides, resembling, therefore, a slender wedge, with the handle and the blade con- tinuous and of the same material. One border of the blade should be delicately marked in inches or otherwise, to determine the depth of the wound. The edge should be sharp enough to cut a finger nail, and the temper of a character to withstand the strain required. The strength of this instrument can be tested the same as in the preceding instance. Osteo- tomes vary in thickness in order that a section begun by one of a given thickness may be continued on its withdrawal by the substitution of another of a lesser thickness. The tops of the osteotome and chisel should each have a round head against which the thumb is pressed to steady the instru- ment (Fig. 394,/, g, h). The mallet is made of hard wood, or rawhide constructed for the pur- pose ; or an extemporized one may be employed (Fig. 394, e). The scalpel is a long one with a sharp point suitable for penetrating at once to the bone (Fig. 394, a). Blunt hooks are employed to draw the edges of the incision apart without force (i, k). The Sand Pillow.—The dimensions of the sand pillow are usually about twelve inches by eighteen, made of stout cloth, and filled with sufficient fine sand to permit the contents to be moved from one part of the bag to another without leaving any portion empty. It should be dampened before use, covered with a carbolized cloth, and the limb laid upon or rather imbedded in it. It forms an efficient support, and prevents the impulse of the blow from causing injury to the soft parts. The Comments.—The opening in the soft parts leading down to the point of proposed section should be limited in extent and so located as to avoid the division of important structures or injury to a joint. It should be made when practicable in the long axis of the fibers of the muscle through which it passes down to, but not through, the periosteum. The blade of the scalpel should remain in the incision till muscular contraction ceases, and then the chisel, osteotome, or saw is passed into the wound by the side of the blade acting as a guide, after which the knife is withdrawn. It is better that the wound be large enough to admit the finger, or even OPERATIONS ON BONES. 381 to permit inspection of the bone, than that the tissues around a small in- cision be treated with violence in introducing the chisel or osteotome. If chips of bone are to be removed, a larger incision is required than if a simple section be intended. The patient should in all instances be anaesthe- tized, and if advisable the limb rendered bloodless by the elastic bandage. However, the wound should not be finally closed until the surgeon is assured that no significant degree of haemorrhage is liable to take place. In all re- spects the operation must be performed with antiseptic care. When the blow is delivered, the osteotome or chisel should be firmly grasped and steadied by the lower border of the hand placed in contact with the soft parts (Fig. 399). If either instrument be held loosely, or be applied to the bone indifferently, the blow of the mallet will be both futile and dan- gerous. The edge of the osteotome should not be so pointed or placed as to endanger important structures by a direct or deflected curve in the course of the instrument. The first blows should be lighter than the succeeding ones so that the edge of the instrument may be first safely fixed in the bone. If the osteotome be removed, it should be re- placed in the origipal track for obvious reasons. If the instrument be fixed in the bone, it should be loosened by careful rocking in the direction of the long axis of the cutting edge, and not the short, as by the latter move- ment the edge is liable to be nicked and broken. The greater liability of the laceration of the soft parts, and of the entrance of air into the wound and the deposit of bone dust in it, are valid objections to the use of the saw as com- pared with that of the osteotome. Subcutaneous Division of the Neck of the Femur.—Subcutaneous divi- sion of the anatomical neck of the femur is practiced to remedy faulty position of the thigh incident to anchylosis following hip disease, etc. The division can be made with the saw or osteotome. The Division ivith the Saiv (Adams).—Place the patient upon the sound side, with the bone to be treated uppermost. Locate the upper border of the trochanter with the finger. Introduce about an inch above the top of the center of the great trochanter, on the flat and at a right angle with the neck, a long scalpel or tenotome straight down to the neck of the femur; divide the muscles and open the capsule freely on the anterior and upper surface so as to permit the easy entrance of the saw, which is passed by the side and along the track of the knife down to the anterior surface of the neck, which is then sawed transversely through (Fig. 400) from before back- ward sufficiently to be easily broken. The limb is then placed in the proper position, the wound irrigated to render it aseptic and to wash out the bone dust; haemorrhage is checked, a small drainage tube introduced, the remain- Fig. 899.—Method of holding osteotome. 382 OPERATIVE SURGERY. ing portion of the incision closed, the whole area enveloped in antiseptic dressings, and the limb placed in an immovable apparatus. The tendinous contractions that may prevent the limb from being properly corrected should be divided subcutaneously. The Remarks.—This method of practice is best suited to those cases in which the neck of the femur has undergone no especial change. If this portion of the bone have been shortened, thickened, or eburnated, or be sur- rounded with indurated tissue, or the head of the bone be displaced, the use of the saw is contraindicated, and the osteotome should be employed instead. Aside from these facts, the deposit in the wound of bone dust and the probable bruising of the tissues with the end of the saw are regarded as objectionable features. The Results.—This operation has been successful in thirty-one out of thirty-four cases. The Division ivith the Osteotome.—Place the patient on the sound side, expose the upper border of the neck of the femur to the osteotome through an incision extending upward from the upper border of the great trochanter three quarters of an inch. Introduce the osteotome before removal of the knife; turn it so as to divide the neck in the direction of the short diameter. A few sharp blows with the mallet will permit restoration of the limb with fracture of the undivided portion of bone. The Remarks.—Special care must be exercised in the use of the osteotome, and in the handling of the limb during the use, so as not to cause fragments of bone to be loosened or pushed into the soft tissues by the advancing end of the instrument or by in- cautious movement of the fragments. The instru- ment should be so held and the blow so directed as to limit the effect to the bone alone. Maunder, Billroth, and others have used the chisel for forcible fracture with good results. Division of the Neck of the Femur; Formation of False Joint (Volk- mann).—While false joints are often fickle, and in many instances afford no great advantages over those gained by an increased compensatory move- ment of the spine, still by this operation good results are reported to have been so common as to merit a more frequent trial of the method. The Operation.—Make an incision along the posterior border of the great trochanter four or five lines in length down to the bone. The femur is then cut through about an inch below the great trochanter with a chisel, the wall of the cervix femoris broken, and the upper portion of the bone removed. The thigh is then adducted to make the upper end of the distal frag- ment of the femur more accessible, then the latter is cut across and rounded off to fit the new socket made by chiseling out the head of the femur and increasing the area of the acetabulum by the same process, being careful not to open into the pelvic cavity. The upper end of the femur is placed in Fig. 400.—Sawing neck of femur. OPERATIONS ON BONES. 383 the newly formed cavity, and extension is applied to the limb to keep the cut surfaces sufficiently separated to prevent bony union. Early passive motion should be made. The Results.—Volkmann has performed this operation several times, obtaining useful limbs in each instance. The Division by Inter-trochanteric Osteotomy (Sayre’s modification of Barton).—This operation consists in exposing the anterior, outer, and posterior surfaces of the femur through an incision about six inches in length, beginning just above the tip of the trochanter major, and carried longitudi- nally through the center of its outer surface. A short, transverse incision is then joined to the center of the posterior lip of the first; the respective sur- faces of the bone are then exposed with an elevator, until the trochanter minor can be felt, when a chain saw is passed around the bone immediately above this process. The first or curved section (Fig. 401) is made by first sawing upward and outward, until the bone is half severed, then changing the direction to downward and outward, and completing the section. The second or straight section is made by sawing directly through the upper end of the lower fragment in its transverse axis so as to exsect a piece of bone an eighth of an inch thick at the outer and inner bor- ders, and three quarters of an inch at its central part. The upper end of the lower fragment is then rounded to fit the concavity above. The limb is straightened and the wound treated like a compound fracture. The Results.—The removal of a disk of bone in this situation has been quite frequently practiced, but with indifferent success. Out of the seventeen cases reported, seven died. Volkmann’’s Modification.—The modification in- troduced byArolkmann in 1873 consists in making an incision along the posterior border of the great tro- chanter and upper portion of the shaft of the femur about three inches in length, and removing the peri- osteum from two thirds of its circumference at the lower part of the incision, when with chisels and gouges a wedge-shaped piece is taken from just below the great trochanter (Fig. 402), and the bone broken, straightened, and placed in proper position until union takes place. The Results.—Of the twelve operations thus performed, all recovered. The Division of the Shaft below both Trochanters (Gant).—This method of procedure is performed in the following manner: The Operation.—Make a longitudinal incision down to the bone on the outer aspect of the femur corresponding to the situation of the lesser Fig. 401.—Sayre’s lines Fig. 402. — Volkmann’s section. 384 OPERATIVE SURGERY. trochanter. Through this opening introduce the osteotome down to the bone and divide the bone transversely just below the lesser trochanter (Fig. 400, a). The Remarks.—The ease of approach to the bone, the comparative sim- plicity of the division, and the uniformly favorable outcome thus far secured, bespeak the adoption of this method when practicable, instead of either of the more complicated and less favorable ones already stated. After-treatment.—In all instances of division of the neck of the femur thorough drainage and aseptic cleanliness should be practiced. If a false joint be the desideratum, extension and passive motion should be made to prevent bony union. The latter is begun as soon as the wound is well healed, and the former is continued while the patient is in bed, and even later if need be, by special apparatus. If bony union be unobjectionable, the limb is treated by immobilization apparatus, the same as for fracture. The choice of operation will be governed largely, indeed, by the nature of the desired outcome—mobility or immobility at the seat of division. Congenital Displacement at the Hip (Iloffa’s operation).—Place the patient on the sound side; flex the thigh to an angle of forty-five degrees, make an incision three or four inches in length in the long axis of the great trochanter, upward and backward toward the posterior superior spinous process of the ilium through the tissues, down to the bone. Kemove the periosteum and muscular attachments from the great trochanter with a peri- osteotome ; cut away the capsular ligament if it oppose reduction; enlarge the acetabulum with bone scoops; reduce the displacement by manipulation, stretching or dividing muscular structure opposing reduction; drain the wound, dress antiseptically, abduct and extend the thigh, and confine the limb with a plaster-of-Paris spica until the wound is healed. The Remarks.—In children under six years of age the muscles can usu- ally be stretched sufficiently to bring the limb into proper position for confinement during healing. In those of six and upward stretching rarely avails, and subcutaneous division of the muscles attached to the tuber ischii and of the adductor muscles is practiced, together with open division of the fascia lata and of the soft parts attached to the anterior superior spine of the ilium, as the need for such divisions is demonstrated by putting the tissues successively on the stretch. The ligamentum teres, the cartilages, the fatty and a good portion of the cancellous tissue of the acetabulum should be re- moved, disturbing as little as possible the margins of the cavity. The A fter-treatment.—If the acetabulum be shallow, the head of the bone should be held in place with extension or by means of a padded strap buckled around the pelvis and over the trochanters. If the acetabulum be deep enough the head will remain in position without mechanical aid. Iloffa advises that the limb be at first moderately inverted, abducted and extended, then after a few weeks brought into the normal position. The first fixation dressing is retained in place three or four weeks if practicable. For weeks and perhaps months afterward the patient should not stand or walk without the support of an apparatus directed to maintaining the length of the limb while permitting motion at the hip joint. OPERATIONS ON BONES. 385 The Results.—Hoffa reports 112 operations on 82 patients. Anchylosis of the hip followed in 9 and return of the displacement in 11 cases. Death followed in 3 cases: in 2 from the effects of shock; in 1 from iodoform poi- soning. Lorenz's Modification of Hofei’s Operation.—Place the patient on the back, with the limb abducted and rotated outward ; make an incision between the outer border of the tensor vaginae femoris muscle and the anterior bor- der of the glutaeus medius from the front of the anterior superior spine of the ilium oblicpiely downward and outward to below the femur, crossing the trochanter major at about the middle of its external surface; draw apart the borders of the tensor vaginae femoris and glutaeus medius muscles, divide the fascia lata in the line of the incision, supplementing the division by a cru- cial cut if necessary ; find the rectus femoris muscle and locate its reflected tendon at the point of insertion into the bone just above the acetabulum; uncover the capsular ligament and incise it longitudinally so as to expose the head and neck of the bone; cause the assistant to flex the thigh to a right angle with the body, and free the insertions of the capsular ligament from the anterior and posterior surfaces of the bone so that the finger can be passed completely around its neck; throw the head of the bone outward; divide the ligamentum teres if present, and turn the bone aside, thus ex- posing to view the underlying capsule and the acetabulum ; deepen the acetabulum with a curette, preserving as much as practicable its bony rim. The Remarks.—If the head of the bone be conical, a portion should be removed, preserving, however, as much as is possible of its articular cartilage to obviate the anchylosis that is liable to follow the removal of cartilage in deepening the acetabulum. The finding of the socket is sometimes difficult, on account of the presence of fibrous tissue and of the overlying adherent portion of the capsule. Portions of tissue that prevent reduction of the head and of its retention in place with the limb abducted or in a straight position should be severed. A short neck of the bone, contraction of the adductor muscles, or a narrow acetabulum may further prevent reduc- tion or proper retention in place. When reduction attends adduction of the limb, forcible abduction may be employed to stretch the tissues hin- dering the proper placement of the limb in the normal position. Brad- ford in some instances divided the Y-ligament to effect a proper reduc- tion. After satisfactory reduction the divided tissues may be united with buried catgut sutures, and the wound carefully drained, or it may be packed with gauze at the outset, as circumstances demand. Prior to opera- tion in any method the restraining tissues should be stretched for some time with the limbs in an abducted position by weight and pulley. Objec- tionable internal or external rotation of the limb after recovery can be remedied by division of the femur below the trochanter, followed by rectifica- tion of the deformity and the application of the plaster-of-Paris spica until union ensues. The Results.—Lorenz reports excellent results in a series of 100 cases. Two cases were followed by slight fibrous anchylosis, and one by suppuration and complete anchylosis. Schauz reports 135 cases operated on by twenty-one 386 OPERATIVE SURGERY. different operators. Death occurred from operation in 7 and from complica- tions in 4 cases. Eight were not satisfactory, 6 perfectly so, and 109 were ex- cellent results. If a rudimentary acetabulum be not present, Ogston advised that an opening be chiseled through the ilium and the head of the bone adjusted to it. The results in these operations appear to be excellent when measured by the depth of the inherent difficulties to which they are addressed. The na- ture of the infliction necessarily renders infrequent perfect cure. Lorenz’s method may be regarded as the simplest and least dangerous of the effective operative procedures. Bony Anchylosis of the Knee Joint.—Bony anchylosis of the knee joint may be associated with flexion, or with internal or external deflection of the leg. In either instance the deformity can be practically overcome, and the usefulness of the limb enhanced by supracondyloid osteotomy of either the linear or cuneiform variety. The anatomical points bearing on the are in all respects similar to those relating to correction of genu valgum. And, too, the methods of procedure in cases of deflexion present no substan- tial differences from those employed in the operation for that deformity. The Operation by Linear Osteotomy.—When performed from the outer aspect, make a longitudinal incision down upon the bone at the outer border of the rectus tendon, one finger’s breadth above the upper portion of the outer condyle, sufficient to admit the osteotome. The osteotome is intro- duced and turned so that its cutting surface corresponds to the transverse axis of the bone at the point to be divided ; with the limb resting upon the sand bag the anterior two thirds of the femur is divided and the posterior third broken or bent. If performed from the inner aspect, the incision is made half an inch in front of and parallel with the anterior border of the tendon of the adductor magnus, beginning one inch above its insertion. The remaining steps of the operation are similar to the preceding. It may be necessary to supplement the section of the femur with that of the tibia, in order to suf- ficiently correct the deformity. This is done by making an incision through the skin over the tibial crest, just below the tuberosity. Through this open- ing, the subcutaneous and posterior surfaces of the tibia are divided suf- ficiently to permit of a fracture of the bone and the consequent correction of the deformity. The fibula, owing to its mobile association with the tibia, does not require division at this situation. It is often necessary, however, to cut the hamstring tendons before the deformity can be properly corrected. The Operation by Cuneiform Osteotomy.—Although this variety of oste- otomy may be applied to deflected curves, the linear is much the better, and the cuneiform method should be rather employed in instances of anchylosis of the knee with marked flexion of the leg. It can be employed above (Barton) or through the joint. The latter is much the better plan. The size of the piece to be removed can readily be estimated by noting the course of two imaginary lines dropped perpendicularly to the long axes of the tibia and femur respectively (Fig. 403). If these lines be so dropped as to join at the angle of the deformity, they will indicate the minimum amount of bone that should be removed. A still greater saving of bone can be made OPERATIONS ON BONES. 387 if the cuneiform section ceases at the posterior third of the transverse diameter, which part is then overcome by fracture as the limb is straight- ened. In all instances the lines of division of the two bones must be made so as to be parallel with each other when the leg is brought into the cor- rect position, otherwise a new deformity will be created —deflection of the leg. If the degree of flexion be a minor one, linear osteotomy will suffice for the rectifica- tion. The General EeinarJcs.— Care must be observed that the osteotome does not in- vade the popliteal space as the vessels and nerves may be directly injured thereby, or from the resulting sharp fragments of bone. In the case of fibrous anchylosis the use of the weight and pulley should be employed to overcome as much as possible the de- formity, and also to stretch to the fullest extent the opposing soft parts before osteotomy is done. In no instance, either before or after operation, should these tissues be so stretched as to imperil their integrity, benumb the limb, or interfere materially with the circulation. Cuneiform division is practiced here with the saw, especially when done through the joint. Genu Valgum.—The opera- tions for the relief of genu valgum can be practiced with comparative impunity in the presence of antiseptic meas- ures and anatomical knowledge (Fig. 404). Care should be taken to avoid the popliteal vessels, especially the anasto- motica magna and superior in- ternal articular arteries. The Anatomical Points.— The limit of the epiphyseal junction is on a line with the tubercle of the adductor mag- nus. The preponderance of the bony structure here corre- sponds to the external surface (Fig. 405). The synovial mem- brane of the knee joint ex- tends upward above the articular surface for an inch or more with the limb extended. Fig. 403.—Cuneiform incision for bony anchylosis of knee joint. Fig. 404.—Genu valgum. 388 OPERATIVE SURGERY. The Operation of Osteotomy for Genu Valgum, Supracondyloid (Mac- Ewen).—Flex the leg on the thigh to draw down the synovial pouch ; place the limb on a sand pillow; make an incision down to the bone through the soft parts at the inner side of the limb, beginning a finger’s breadth above the insertion of the tendon of the adductor magnus into the spine at the upper portion of the internal condyle and half an inch in front of the tendon, and carry it upward sufficiently to admit the osteotome; or, the lowest limit is made to correspond to a line drawn transversely across the limb in front, beginning an inch above the external condyle, which will, if the internal condyle be much elongated, prevent the osteotome from being driven into the external condyle instead of above it. The course of the incision (Fig. 40G, a) avoids as far as possible any interference with the anastomotica magna and the articular branches. The osteotome may be applied to the bone transversely at the site indicated by the transverse dotted line (h), and so directed that its course will correspond to a line extending across the posterior aspect of the femur to a point one finger’s breadth above the external condyle. The extent of the osseous incision will depend upon the density of the bone; if the subject be young, the bone can be cut through two thirds of its diam- eter, and then be bent or broken; if it be dense, it will be necessary to carry the incision to the outer wall. The posterior and inner surfaces of the bone are first cut, when, if neces- sary, a thinner chisel is employed to complete the opera- tion. When the bone is sufficiently divided, the limb is straightened, all haemorrhage arrested, and the part treated as indicated. Fig. 407 shows the long internal condyle of genu valgum; Fig. 408 represents a section of about three fifths of the diameter; Fig. 409 illustrates the ap- pearance of the bone with the line of section closed, showing the curvature as rectified. The prognosis of this operation, with reference to usefulness of the limb, cure of the deformity, and danger to life, is most flattering. The Results.—In about six hundred and fifty supra- condyloid osteotomies but three fatal cases are reported that can be attributed to the operation: one each from septicaemia, haemorrhage, and carbolic-acid poison- ing. All the patients were benefited, and many were enabled to take an active part in affairs from which they had been debarred. The Operation of Osteo-arthrotomy for Genu Valgum (Ogston).—The operation of osteo-arthrotomy consists in dividing the elongated condyle of the femur by saioing (Ogston), or by cutting (Reeves), sufficiently to admit of the rectification of the deformity (Figs. 410 and 411). Fig. 405. — Transverse section near epi- physeal junction at lower end of femur. a. Anterior surface. b. External surface. c. Posterior surface. d. Internal surface. Fig. 406.—Supraeondy- loid osteotomy, a. Direction of incision of soft parts, b. Line of bone section. c. Epiphyseal junction. d. Epiphysis. OPERATIONS ON BONES. 389 The Operation hy Salving.—Place the patient in the dorsal position; flex the leg upon the thigh fully. At a point two or three inches above the tip of the inner condyle introduce a tenotome upon the flat, carry it down- ward, forward, and outward until its point can be felt anteriorly in the inter- Fig. 407. Figs. 407, 408, 409.—Macewen’s method Fig. 408. Fig. 409 Fig. 410. Figs. 410, 411.—Ogston’s method. Fig. 411. condyloid space. The cutting edge is then turned downward, and the tissues divided down to the bone as it is withdrawn. A small Adams’s saw is then introduced along the course of the incision, and the condyle is sawed, from above downward, and before backward, through about three quarters of its thickness. If the limb be now straightened, the remaining portion is frac- tured and the deformity is rectified. The Results.—In forty-six operations two patients have died of septi- caemia. The Operation by Cutting.—By this method the elongated condyle is divided or loosened with a chisel or osteotome, the intention being to divide the condyle to the greatest depth without opening into the joint. Even though the cut be made to meet this indication, the joint is no doubt in- volved (except possibly in the very young) by the displacement upward of the frag- ment necessary to correct the deformity. Chiene’s Method of Osteo-arthrotomy.— Mr. Chiene, instead of sawing or cutting off the condyle, corrected the deformity by the removal of an oblique transverse wedge of bone from the body of the condyle, which, when pressed upward by straightening the limb, remained attached by its apex to the shaft (Fig. 412). Not infrequently, how- ever, the condyle is detached by this manipu- lation, and the joint opened. The details attending this method are omitted, since it can not be compared favorably with the much simpler and equally efficient one—supracondyloid osteotomy. Genu Varum.—This deformity, too, is relieved by osteotomy. In osteotomy in these instances the operative proceedings are directed to the outer instead Fig! 412.—Chiene’s method. 390 OPERATIVE SURGERY. of the inner side of the bones of the leg and thigh. The procedure, pre- cautions, and treatment are like those for genu valgum. The division of the bone through a small external opening can be made almost indiscriminately in such as present this deformity, always remembering that thorough and complete antiseptic precautions should be taken. The results are most flattering and commend this operation to the con- sideration and practice of the profes- sion. Genu Varum (Fig. 413) or Bowlegs may depend on an outward curvature of the bones of the leg, wholly or in part. In either instance the deform- ity of the leg can be corrected by oste- otomy of the tibia. The tibia and fibula can be divided at any part of their course by either the linear or cuneiform methods; the linear for the lesser, and the cuneiform for the greater, degrees of deformity, is the rule. If the patient be young enough, a green-stick fracture of the fibula will obviate the necessity for its division. The Operation by the Linear Method.—Cleanse the part thoroughly, apply the elastic bandage, place the limb on the sandbag, and at the point of the Fig. 413.—Genu varum. Fig. 414.—Linear osteotomy: c. Bone divided, d. Deformity corrected. Cuneiform osteotomy: a. Cuneiform piece removed, b. Deformity corrected. greatest curvature make a longitudinal incision down to the periosteum, midway between the borders of the subcutaneous surface of the tibia at the OPERATIONS ON BONES. 391 point of proposed division and of ample length to admit the osteotome which is then turned so as to divide the bone transversely sufficiently to admit of its being fractured (Fig. 414, c, d). Cut or bend the fibula, correct the de- formity, close the wound in the soft parts with catgut, dress antiseptically, and confine the limb in a temporary dressing until all danger of haemor- rhage, inflammation, etc., has subsided, when it may be placed in an immov- able plaster-of-Paris dressing and retained until union has taken place. If a double section is to be made at different points, an antiseptic sponge (Fig. 394, l, m) should be bound over the incision in the soft parts of the first while the second operation is being made. This affords an opportunity to determine the severity of the haemorrhage and the ease with which it can be controlled. If it be necessary to divide one bone in two situations to correct a deformity, the second division should be deferred until the former has healed, when it should be done at the remaining point of greatest convexity. The Operation by the Cuneiform Method.—If the bones be much curved, it may become necessary, in order that the deformity be properly corrected, to remove a wedge - shaped piece (Fig. 414, a, £), which is best accomplished with the chisel. The base of the cu- neiform section corresponds to the crest of the tibia and the apex to the posterior sur- face, or as much farther in front of it as the surgeon’s idea of fracture versus sec- tion may suggest. The rule for the formation of the proper sized section is indi- cated in the consideration of the treatment of anchylosis of the knee. The After-treatment and Results.—All osteotomies should be performed under strict antiseptic pre- cautions, and the incision of the soft parts closed with a catgut suture. The limb must be immovably fixed and the patient kept quiet; in fact, the measures applicable to a compound fracture are in order, since oste- otomy resembles that condition more nearly than any other. The Results.—The results of all osteotomies performed with antiseptic precautions are extremely satisfactory. As yet, I have no personal knowl- edge of a death from the operation, and of fourteen hundred osteotomies but about one per cent only are reported to have died in consequence of it. Hallux Valgus.—Hallux valgus is practically limited to the great toe, and is usually caused by improperly fitted boots and shoes. Fig. 415 (Tubby) represents the condition more graphically than words can. In this con- dition the first phalanx (anatomical) articulates with the outer portion of the distal extremity of its metatarsal bone and is rotated inward on its long Fig. 415.—Hallux valgus. 392 OPERATIVE SURGERY. axis. The principal portion of the head of the metatarsal bone projects in- ward, and its extremity is surmounted by a sensitive bunion. The indication is to place the toe in its normal axis and retain it in that position. In pro- nounced cases this can not be accomplished without division at the least of restraining fibrous tissues. If the deformity be great, little else than an operation on the bone will be of any practical value. Two methods of opera- tion can be recommended : 1. The removal of the head of the metatarsal bone, together with enough of the shaft to permit the great toe to be easily replaced and held in its normal axis (Fig. 367, a). Under strict antiseptic precautions this operation results in quick recoveries and useful toes. 2. The deformity can be corrected by removing a Y-shaped piece (cunei- form osteotomy) from the inner portion of the distal extremity of the meta- tarsal bone, as near the head as possible without involving the joint cavity. This, too, must be done under strict antiseptic precautions, and is accom- plished through an incision made along the inner side of the metatarsal bone. The soft parts are retracted, and the Y-shaped piece of the bone is removed without dividing more than three quarters the diameter of the shaft. The thickness of the base of the triangular piece to be removed is estimated by the degree of deflection of the toe from its normal position, in the man- ner practiced for cuneiform osteotomy. The bone wedge can be removed by means of a saw or chisel and the toe brought into position, causing fracture of any undivided portion of the bone. Horsehair drainage and immobility under antiseptic dressing will be fol- lowed by speedy union and a satisfactory recovery. If the deformity be less marked, then a simple linear osteotomy, followed by rectification and con- finement, will secure a satisfactory outcome. The author has on three occa- sions operated on both toes simultaneously, employing excision of the head of the bone in one, and cuneiform osteotomy in the other instances. They all healed promptly, each resulting in a serviceable limb with no appreciable difference except that the cases treated by osteotomy were followed by freer movement. Osteotomy for Talipes.—The operation methods devised for remedying the deformities of talipes are quite numerous, and often as fanciful as those directed to amputation at the shoulder joint. The following only will be considered as representative of the series. Cuneiform Osteotomy of the Tarsus for Talipes Equino-varus (Tarsec- tomy, Davies-Colly). The Operation.—After careful antiseptic preparation and application of the elastic bandage, place the foot on a sand bag, with the outer border uppermost; make a straight incision down to the bone along this border from the middle point of the os calcis to the base of the fifth metatarsal bone; make a second incision through the superficial tissues from the dorsum of the foot to the center of and at right angles with the first an inch in length. Reflect the flaps, draw aside the tendons and vessels upon the dorsal and plantar surfaces, raise the periosteum, and remove with saw or chisel a wedge-shaped piece, composed of adjoining portions of the os calcis and cuboid, and, if the case be severe, the entire cuboid and even the OPERATIONS ON BONES. 393 base of the fifth metatarsal bone. After removal of the bone, arrest haemor- rhage, rectify the deformity, unite the borders of the wound, dress antisep- tically, and confine the part in an immovable position with a plaster-of-Paris, or other suitable splint. The Comments.—It is thought better that the second incision pass into the sole of the foot rather than onto the dorsum (Tubby). The primary in- cision should be extended downward sufficiently to meet the operative re- quirements of the deformity. Since the cause of the deformity exists at the inner aspect of the foot, and the effect at the outer, the removal of the bone at the latter situation can not be regarded as rational except as a final expedient. The Results.—In about ten per cent of the cases suppuration has oc- curred, followed by death in one instance. The operation should not be practiced, except as a final resort, and then with certain antiseptic technique. The Operation of Linear Osteotomy of the Neck of the Astragalus for Talipes Equino-varus (Bradford).—This operation is not attempted until after the beneficial effects of division of contracted tissues and manipulation have failed to correct the deformity. The Operation.—After strict antiseptic preparation and application of the elastic bandage, make an incision through the soft parts from the top of the inner malleolus to the inner border of the head of the first metatarsal bone; draw apart the borders of the opening, adduct the foot strongly, and expose the scaphoid bone and the head and neck of the astragalus; intro- duce and place an osteotome across the inner aspect of the neck of the as- tragalus and sever it with a few sharp blows of the mallet. If the bone be incompletely severed, the rectification of the deformity will cause fracture of the remaining portion. Correct the malposition of the foot, unite the borders of the wound, dress antiseptically, and confine the part in position until union occurs. The Remarks.—The line of section of the neck should be in a plane such that when the deformity is corrected the gap at the site of section will be of the smallest possible size. Although simple in practice this plan often proves inefficient. The Open Incision Method (Phelps).—The free open incision method is practiced when the integument at the seat of the deformity is too short to per- mit of rectification after a free subcutaneous division of the constricted tissues. The Operation.—After the employment of thorough antiseptic precau- tions and the application of the elastic bandage, make an incision beginning directly in front of the inner malleolus and passing downward to the inner side of the neck of the astragalus. Through this incision divide respect- ively such of the following structures as offer resistance to the rectification of the deformity: the tendon of the tibialis posticus muscle, the abductor pollicis muscle, flexor brevis digitorum muscle, tendons of long flexor muscles, the elongations of the deltoid ligament and of the plantar fascia, and the calcaneo-scaphoid ligament, avoiding if possible the internal plantar nerve and artery. The wound should be dressed to secure organization of blood clot (page 312) if possible, or treated in the usual manner of open 394 OPERATIVE SURGERY. wounds. At once or a few days later the raw surface may be covered with skin grafts. Phelps advises that if the elastic constriction be employed the dressing be applied before its removal, and that the extremity be slung in a perpendicular position for from four to six hours thereafter. The deformity must be corrected before application of the dressing, and be immovably con- fined in the rectified position by plaster of Paris or other acceptable means. The Results.—Phelps reports one hundred and sixty-one operations, of which ten cases were found to have relapsed one year after, due, it is claimed, to neglect. The cases heal promptly with but few exceptions, and service- able limbs are secured. The Enucleation of the Astragalus (Lund).—This procedure is practiced and with much success, in inveterate cases of clubfoot. As the method of excision has been described already (page 350) nothing further need be added at this time, except that the foot be confined immovably at right angles with the leg until healing is complete. The Results.—In twenty-one cases all did well. In two suppuration occurred. Other operative methods are employed for the relief of talipes, as, for in- stance, through an incision extending from the front of the lower end of the internal malleolus to the internal cuneiform bone, a wedge-shaped piece of bone can be taken from the inner border of the foot formed of the scaphoid alone or including the head of the astragalus (Bird), or the astragalo-scaphoid joint may be excised or erasion practiced upon it in such a manner as to form a wedge-shaped space (Ogston). Recently the removal of the astragalus- lias been practiced successfully (Vogt). Each of the aforegoing methods has been employed with varying success for the relief of flat foot. In either instance, after operation the foot is corrected and held properly in place with pegs, wire, etc., or, what is still better, a properly moulded plaster-of-Paris splint. The removal of a wedge-shaped piece of bone from the inner side of the head and neck of the astragalus (Stokes), followed by correction and the usual treatment of these operations, is a useful expedient for the relief of talipes valgus. The treatment applicable to compound fractures should, furthermore, be addressed to each of these operations. Osteoplasty.—Osteoplasty or transplantation of bone has not yet gained the prominence as a general surgical expedient that the knowledge of the laws governing the growth of bone seemed likely to secure for it. Bone along with its periosteal and fibrous connections has been pushed to one side—transverse displacement—as in the case of the operation on the hard palate for the closure of a fissure. The closure of the spaces between fragments and borders of bone, by filling such spaces with freshly sawed sections from the main structure with bone chips, or decalcified bone frag- ments, is in many instances wisely and successfully practiced. The condi- tions necessary for a successful issue are numerous and exacting, the chief one of which is a most rigid adherence to the antiseptic methods. In the employment of bone chips, whether decalcified or not, the intra- vention and organization of blood clot is essential to success. The tech- nique of this procedure is the following: OPERATIONS ON BONES. 395 The Preparation of the Bone.—Saw into longitudinal strips about an eighth of an inch in thickness the compact tissue of the tibia or femur of the ox, entirely stripped of periosteal and marrow tissue; immerse the bone strips in a ten- to fifteen-per-cent solution of hydrochloric acid and water, which is changed daily for from one to two weeks; then wash the strips in a weak al- kaline solution ; cut into small pieces, and immerse them for forty-eight hours in a l-to-1,000 bichloride solution, after which store them finally in a saturated solution of iodoform and ether. The Preparation of the Cavity.—Cleanse the cavity by thorough and repeated curetting and flushing with a l-to-2,000 bichloride solution supple- mented by scouring with aseptic gauze and dusting with iodoform. If the cavity be filled with olive oil and the oil be raised to a boiling point by the introduction of a thermo-cautery, the cavity is made aseptic. The Filling of the Cavity ivitli the Chips.—Place a capillary drain at the most dependent point of the cavity; carefully fill the latter with the bone chips and unite the soft parts over them with buried and subcuticular sutures and dress antiseptically. Before using, the bone chips of proper size to fit the cavity should be selected, wrapped in aseptic gauze, and immersed in alcohol to remove the ether and iodoform. Just before using, they are washed in a l-to-1,000 bichloride solution, and cautiously wiped with iodo- form gauze. If employed in cranial openings, they should be freely per- forated to hasten drainage. If the soft parts be too scanty to cover the grafts, aseptic rubber tissue should be employed to remedy the defect. The feasibility of bone transplantation en masse is not yet sufficiently established to warrant its being considered a matter of great practical utility. CHAPTER IX. AMPUTA TIONS.—GENERAL CONSIDERATIONS. Amputation consists in the cutting off of a limb in the continuity of the bone structure or at an articulation ; the latter is often termed disarticula- tion. The aims sought for in amputation are : 1. The saving of the life of the patient. 2. The securing of a serviceable stump. If the prospects of recovery be annulled by the presence of a badly diseased or a mangled limb, it is no opprobrium to the art of surgery to remove the limb. If a limb be so badly injured or diseased as to require removal, it is wise that the me- chanical ability of the designer of compensative appliances be considered, so that the patient may reap the combined benefit of the art of the surgeon and the ingenuity of the mechanic. A stump, to be serviceable, should be sound, unirritable, with good circu- lation and abundant leverage. The first three qualities depend very largely upon the length, shape, vascular supply, and sensibility of the flaps; the last one depends entirely upon the length of the bone. The flaps at the extremity of the stump after healing is completed should be freely movable —except at the seat of the cicatrix—over the subjacent tissues, not tightly drawn and smooth like a baseball cover. Flaps that are tightly drawn at the initial dressing soon become more tense, on account of tissue retraction and inflammatory action. The increased tension causes pain, early and rapid ulceration at the seat of the sutures, followed by separation of the flaps, union by granulation with a broad scar, and finally a troublesome stump ; or the normal shrinkage of the integument draws the flaps against the end of the bone, to which they, together with the cicatrix, become immovably united, causing similar difficulties. Integument normally exposed to pressure—as that of the palm of the hand and sole of the foot—makes the best covering. The proper leyigth of flaps, therefore, becomes an important point in estimat- ing the prospective usefulness of the limb and the comfort of the patient. As a general proposition, in flap amputation both flaps should be made the same length, each equaling not less than one fourth the circumference of the limb at the point where the bone is to be divided. If one flap only is employed it should equal in length the two flaps. Any decrease in the length of one flap should be accompanied bv a proportionate increase in the length of the other. The lengths of the flaps control largely the site of the cicatrix. It is advisable that the cicatrix be so placed, when practicable, as not to be subjected to undue pressure or friction. If, however, the flaps be made of sufficient length to admit of the formation of a non-adherent 396 AMPUTATIONS. 397 or movable cicatrix, its location is a matter of secondary importance. The length and situation of the flaps largely influence their circulation. If they are too long, the circulation will be enfeebled ; if, on the contrary, they are too short, it will be impeded by the tension, causing in either instance a blue, cold, and shiny surface sensitive to the slightest injury. While the general rules just stated are a fair guide in establishing the proper length of flaps, still it is necessary not to lose sight of the fact that certain natural and acquired characteristics of the structure of a stump so modify its useful- ness as to compromise the result of amputation unless these characteristics be given due recognition at the time of operation. The contractility of the integument and subcutaneous tissue is lessened by infiltration of inflam- matory products, overdistention, old age, and atrophy. Integument thick- ened by friction, or naturally dense, contracts but little. On the other hand, if the integument be thin, or have scanty subcutaneous tissue, or be disconnected from bony or abnormal subjacent structure, the contraction is well marked. It is a matter of common observation that muscles contract when severed. The amount of their shortening is influenced by the length, size, vigor, and freedom of the muscle. Short, small, weak, or atrophied muscles, and those of limited movement, contract comparatively little. The degree and duration of primary and secondary muscular retraction often modify the final aspects of a stump, as will appear hereafter in the con- sideration of special amputations. The nutritive integrity of a flap and the freedom of the circulation are enhanced by attention to the proper degree of arterial supply and care in the preservation of the vessels. A too great compression with bandages, a vigorous bending or the undue traction of a flap to bring it into position, contribute fatally often to the integrity of the structure. The severed ends of tendons should not extend below the division of the remaining soft parts, nor should they be cut so short as to cause the empty sheaths to harbor deleterious products. The nerves should he severed high enough to prevent their ends entering directly into the cica- tricial and reparative tissue at the end of the stump. The periosteum should he neither bruised nor lacerated, but cut neatly through at the point of bone section. The hone itself should he sawed carefully and squarely and not denuded of periosteum, otherwise circumscribed necrosis will occur. The re- moval of the cicatrix from direct pressure irritation suggests that those of the lower extremity have a lateral, and those of the upper a central location. However, it should not be forgotten that, notwithstanding the exercise of the greatest care in each of the foregoing respects, an untidy stump, or one belonging to a dissipated person, is very liable indeed to become the cause of great annoyance, if not of physical incapacity. The circulation even in a normal limb, or a portion of it, may be such as to predispose to a small and sluggish blood supply and thus impair flaps constructed from it. The flaps are classified, according to the kind of tissues entering into them, as the cutaneous or integumentary or shin flaps, musculo-cutaneous, and periosteal, either variety of which may be single or double. The integumen- tary variety is commonly employed in this country. The outlines and struc- ture of flaps have been changed so often, and yet so slightly on the whole, that 398 OPERATIVE SURGERY. it is difficult indeed to assign rational reasons for the multiplication of terms and methods born of these alterations. Which makes the better flap, the skin and subcutaneous tissue alone or when combined with muscular tissue, is not yet definitely settled. It is fair to say, however, that the flaps of skin are less vital than when fortified with subjacent muscular structure. However, this fact is not of great significance except in the enfeebled circulation of the old, or in the presence of the necessity for an inordinately long flap. While it is true that the muscular tissue of a flap soon atrophies, yet it can not be denied that the fibrous residue of the muscle exercises a serviceable influence at the end of the stump. At all events, the integumentary portion should be considerably longer than the muscular part. Surely there can be but little doubt of the fact that the dangers incident to infection are less pro- nounced in integumentary than in muscular flaps. Flaps are fashioned by, 1, transfixion, 2, by free deep cutting from without, and, 3, by superficial division and separation of their tissues. The Fig. 416.—Circular method. first two methods provide musculo-cutaneous flaps, the last one integumen- tary. The novice in surgery and the conceited surgeon regard it as deroga- tory to their attainments to trim or shape a flap after its division. It is far wiser, however, to make flaps of excessive length and suitably trim them thereafter, than to make them too short at the expense of the comfort and usefulness of the limb. The great danger is that flaps will be made too short rather than too long. The methods of amputation are classified, according to the outlines of the incisions, into circular, modified circular, elliptical (page 460), oval or racket, and common and special flap methods. The flaps of these methods may be composed of integument alone, or combined with muscular tissue, and even with periosteum. The Circular Method.—The circular method gives an admirable stump. It is easily and consequently frequently made, and is recommended especially AMPUTATIONS. 399 in the field operations of military surgery, since the lightness of the flaps per- mits transportation of the wounded with the minimum degree of disturbance at the seat of the amputation. It is performed by making an incision around the limb (Fig. 416) through the integument and subcutaneous tissue Fig. 417.—How to dissect up the flap. down to the fascia of the muscles, at a distance not less than one fourth the circumference of the limb at the point of proposed division of the bone, and so directed that after contraction of the integument a circular flap will remain. The flap is then separated from the muscles with an ordinary scalpel, the edge being directed toward the muscles (Fig. 417) rather than parallel with them (Fig. 418), so that the capillary connection between the integument and the deeper tissues will not be injured un- Fig. 418.—How not to do it. necessarily. The separation should be done by circular sweeps of the scalpel and upward traction of the skin with the hand, rather than by mincing cuts, which hack the tissues and hinder union. 400 OPERATIVE SURGERY. If the limb be of a conical shape, much difficulty will be experienced in turning over the sleeve of integument, which can, however, be obviated by a longitudinal division of the flap made usually at its most dependent por- Fig. 419.—Division of the muscles close to reflection of flap. tion. The flap should be turned upward to the point where the bone is to be divided ; then, with a suitable knife, make a circular division of the muscles down to the bone, beginning far enough below the reflection of the flap to allow for the retraction of the divided mus- cles. AVhile no definite law can be assigned as a guide to this part of an amputation, still, as already stated, muscles retract according to their size, length, degree of irritability, etc. The points of section of special muscles will be stated in the description.of the ampu- tations requiring it. Not infrequently the muscles are cut just below the reflection of the flap, as in Fig. 419 ; this plan is not, however, as good as that in which a lower division is practiced, since sensitive stumps are more liable to result therefrom (Fig. 420). A conical stump is a not infrequent sequel of this method of amputation, and is the result of an equal division of unequally retractile tissues. In those parts where the bone is located centrally—in the arm and thigh—the superimposed muscular structure should be divided by repeated circular cuts, so as to create a funnel-shaped stump with the end of the bone at the summit (Fig. 571). A stump thus fashioned affords good drainage, and reduces the liability of protrusion of the bone to a minimum. The bone should be sawed at its highest point of exposure. Fig. 420.—Stump after circular amputation. AMPUTATIONS. 401 The Modified Circular Method.—The circular method may be modified by making one or more longitudinal incisions through the integumentary structure down to the circular cut. A posterior longitudinal incision (trans- Fig. 421.—Modified circular flap. verse racket flap) facilitates the turning up of the flap, and offers an ad- mirable opportunity for drainage. An anterior longitudinal incision is not to be commended. One made at either side of the limb down to the circular cut forms square antero-posterior flaps which possess no advantage over the lateral variety. The following plan was suggested by Mr. Liston. He made semilunar flaps, which were dissected up to their points of junction with each other, at which level the muscles and bone were divided, as in the circular method. Liston’s method Avas afterward modified by Mr. Syme, who dissected a short distance above the points of juncture of the flaps, and divided the muscle and bone as before (Fig. 421). In either instance, however, it amounts substantially to slitting up the cuff of a circular flap on opposite sides and trimming off the angles caused thereby. The Oval or Racket Method.—The oval or racket method is in reality a modified circular amputation, the flap being slit up at one side and the angles trimmed off (Fig. 422). This flap is employed principally in disarticulations, and will be described in connection with those operations. flaps may be either uni- lateral, bilateral, anterior, or posterior. The Single-flap Method.—The single flap is suited to those cases where the tissues of one side of a limb only are available for the purposes of a flap, as in the case of unilateral lacerations, ulcera- Fig. 422. — Racket flap at shoulder. 402 OPERATIVE SURGERY. tions, etc. This fiap may be composed of the muscular tissues and integu- ment, or of integument alone (Fig. 557), and can be made either by trans- fixion or division from without. If possible, a short convex flap is made on the opposite surface of the limb. The double-flap method is performed by transfixion, and includes the muscles down to the bone on either aspect of the limb (Figs. 423 and 424). The tissues to be transfixed are raised slightly by the left hand of the operator, who then enters the point of the knife at the side nearest him- self, pushing it through slowly in close contact with the anterior surface of the bone, slightly raising the handle as it passes in front of the bone, thereby causing its point to emerge at the opposite side of the limb at a point exactly opposite to that of entrance ; the flap is then made by cut- ting with a sawing motion obliquely upward and forward. This flap is pulled backward by an assistant, and the knife is reinserted at the original point of entrance, carried behind the bone, handle depressed to cause the Pig. 424.—Removal by transfixion. Fig. 423.—Flaps by transfixion. point to emerge at the same situation as at the anterior transfixion, and the posterior fiap made by cutting obliquely upward and backward. Each flap should correspond in length to at least one half the diameter of the limb. The retractor is then applied, the soft tissues are drawn well upward, the remaining fibers in contact with the bone are severed by a cir- cular sweep of the knife, and the bone is carefully sawed through. When lateral flaps are made, the flap containing the lai'ge vessels should be con- structed last. The mixed double flap is a modification of the preceding, and sometimes called Sedillot’s method. The flaps are made by transfixion, as before, but are more superficial, the knife not being brought in contact with the bone. The remaining muscles and vessels are divided by a circular incision, and the amputation completed as before described. In this instance the flaps are thinner and shorter than in the preceding. AMPUTATIONS. 403 Langenbeck's Method.—Langenbeck’s method differs from the last one only in the manner of obtaining the result, the flaps being cut from the sur- face toward the center of the limb, thus affording a better opportunity to shape them. Another modification of this method consists in cutting the Fig. 425.—Teale’s method. Fig. 426.—Teale’s stump. anterior flap from the surface, and making the posterior flap afterward by- transfixion. The Rectangular Flap (Teale’s Method) (Figs. 425 and 426).—In Teale’s method two rectangular flaps are employed, one being four times longer than the other; both flaps include the structures down to the bones. The longer flap is taken from the surface of the limb w'here the bone is the most superficial. The shorter contains the important vessels. The length and breadth of the long flap each equals half the circumference of the limb at the point of proposed amputation. The width of the short flap is a half, and its length an eighth, of the circumference of the limb at the point of bone section. Both flaps should be carefully marked out before beginning the operation. This method makes an admirable stump, but sacrifices fulcrumage, and therefore can be employed only at special parts of the body, and when the tissues at one aspect of the limb only are healthy and suitable for flaps. Mr. Lister recommends that the longer flap be made a third and the shorter flap a sixth of the circumference of the limb in length, thus bringing the cicatrix at the edge of the stump; also that the posterior flap shall consist of the integument and subcutaneous tissues alone. Lister’s, like Teale’s, method may be employed when the loss of tissue is greater upon one side of a limb than upon the other. The Hood Flap.—The hood flap resembles very closely in- deed the racket flap (Fig. 558). There is therefore no sub- stantial difference in the plan of construction of this and that of the circular flap, if the latter be slit up at the most dependent part and the resulting corners rounded off. This method meets the indications requisite for a good stump variety of flap. The Equilateral Flaps (Fig. 427).—Equilateral flaps are formed of skin and are oval in outline, the posterior angle being located somewhat farther Fig. 427. — Bi- lateral - flap method. as well as any 404 OPERATIVE SURGERY. up the limb than the anterior, to improve the drainage. The muscles are cut by a circular sweep at a suitable distance below the point of reflection of the integumentary flaps, and the bone is exposed and sawed somewhat above the anterior point of junction of the flaps. The Periosteal Flap.—A periosteal flap is properly made by raising the periosteum, in conjunction with the tissues which rest upon or are attached to it (Fig. 575), so as to cover the end of the divided bone, after which it is allowed to fall into place. If a periosteal flap be raised independently of superimposed tissues, it is very liable to waste away or slough outright (F ig. 428, a). This variety of flap is adapted best to those bones subcutaneously located, like the tibia, and will be again referred to in connection with am- putations of the leg. A periosteal flap will, if it become adherent to the end of the bone, preserve it from atrophy, and lessen the danger of the formation of a conical stump ; it likewise prevents the adhesion of the scar to the bone, thereby forming the basis for a mova- ble cicatrix. If the patient be young, new bone may be developed from the periosteal flap, which will add much to the usefulness of the stump. It is claimed by some that bony spiculge often shoot into the soft tissues at the end of the stump, and require a second operation for their removal. It is our opinion, however, that if the perios- teum be removed entire and remain connected with the superimposed tissues, and be so placed that the force of gravity will aid in holding its bone-producing surface in contact with the di- vided end of the bone, this danger will be obvi- ated. The Comparative Merits of Different Forms of Flaps.—The princi- pal aims sought in making flaps are: 1. To secure good drainage. 2. To make the flaps of suitable length, that the circulation and move- ment of the integumentary cushion at the end may be unrestrained. 3. To place the cicatrix beyond the point of friction, and prevent its adhe- sion to the end of the bone. 4. To guard against any danger of undue sensibility, by making the flaps of proper length, and by drawing down and cutting off the cutaneous and other nerves of larger size that may exist in them. With these aims in view, it will be seen that the old-fashioned circular flap affords equal advantages, in proper sites, to the others, and is commend- able for its simplicity and rapidity of execution. It is true that in this method the scar will fall on the end of the stump, but with proper precau- tions as to the length of the flaps and suitable surgical attentions, any dan- ger from this source is reduced to a minimum. As Treves very justly says, “ It is difficult to claim an unreserved superiority for any one method.” While in one situation the circular amputation is undoubtedly the best, in Fig. 428.—Improperly made periosteal flap. AMPUTATIONS. 405 another it is with equal certainty the least efficient method of procedure. The same may be said of any one method of performing amputation by the cutting of Haps. The main commendatory points in the selection of a method of ampu- tation are the following: 1. The method should be one attended with the Fig. 429.—Instruments employed in amputation. a. Scalpels, b. Forcipressure. c. Thumb forceps, d. Curved and straight rongeurs, e. Periosteotome. f. Lion-jaw forceps, g. Liston’s bone-cutting forceps, h. Aneur- ism needle, i. Rugine. j. Tenaculum. Jc. Lifting-back and Gigli-Haertel’s saws. Retractors (page 38), needle-holders (page 86), needles, sutures, drainage, etc., are required. least sacrifice of the healthy tissues of the limb, while providing a good and permanent covering for the bone. 2. One causing as small a wound area as is consistent with its proper performance. 3. One securing a good blood supply to the flaps and tissues which form the stump. 4. One fol- lowed by a well-adjusted and painless cicatrix. Therefore the line of coap- 406 OPERATIVE SURGERY. tation should be so placed as not to interfere with the healing process, while securing at the same time efficient drainage, and removing the cicatrix from pressure as far as possible when the stump is healed. 5. One providing easy exposure of the bone at the saw line, and having simplicity of method. 6. One permitting of the cutting of the main vessels transversely, and allowing of rapidity in the operation. Since many of the preceding forms of flaps are but modifications of the circular variety, they inherit the advantages of their distin- guished progenitor. However, the circular method is not the best if the soft parts near to the injury, disease, or distortion be unequally involved, as then a sacrifice of the healthy tissue of the opposite side of the limb is required. It is clearly obvious that an irregular flap method is suited for these cases. The agents required for ampu- tation are those for arresting haem- orrhage, for the division and trim- ming of the soft parts and the bone, and those for uniting and dressing the wound. The prepa- ration of the surgeon (page 89, et seq.) and patient for the operation, the agents for controlling and ar- resting haemorrhage (page 53, et seq.), together with the various methods of securing and main- taining the coaptation of the cut surfaces (page 82, et seq.), drain- age, and various forms of dressing, antiseptic and otherwise, have been heretofore considered, therefore, there remain to be enumerated under this heading only those in- struments especially adapted to the requirements of amputation. The instruments (Fig. 429) are amputating knives, scalpels, saws, lion-jaw forceps, periosteal elevator, special metal retractor, tenaculum, and a support for the stump. The Amputating Knives (Fig. 430).—The modern amputating knives can be used for making circular flaps, or for transfixion. Some are single- Fig. 430.—Amputating knives. AMPUTATIONS. 407 edged, others may be double-edged (a, b) entirely (Catlin), or only for an inch or two from the point. The length of the knife selected will depend upon the size of the limb to be operated upon, and should be about one and a half times the diameter of the limb. While it may be inconsistent with good taste, it is entirely consistent with good judgment and economy to amputate an arm or fore- arm with the knife intended for use at the thigh, and the result will be equally satisfactory. On the other hand, the absence of the stereotyped amputation knife constitutes no good reason for the deferment of operation in the presence of the wisdom of prompt action and the possession of one or more scalpels. The manner of grasping the amputating knife, prior to and during the division of the soft parts, may add much to the general effect of the procedure and to the comfort of the operator. The knife should be grasped lightly at first with the edge looking for- ward, near enough to the extremity of the shank to permit the upper end of the handle to play between the heads of the metacarpal bones of the thumb and index finger when swung backward and forward (Fig. 431). Tivo methods are employed of carrying the knife entirely around the limb : 1. Stand with the left side toward the patient, seize the limb above the point of intended operation with the left hand, an assistant holding its distal extremity ; place the left foot forward, slightly bend the right knee, and with the knife held by the right hand, as before described (Fig. 432),. Fig. 431.—How to grasp amputating knife. Fig. 432.—How to carry knife around limb. stoop downward and forward sufficiently to carry first the knife and fore- arm under, and then the knife over the limb, placing its heel as near to the upper surface of the limb as is convenient, when, with a sawing motion, the knife is drawn toward the operator beneath the limb, then upward 408 OPERATIVE SURGERY. between it and the operator, and so on around until it joins the begin- ning of the cut, making a complete circular division. If the knife be properly grasped, the handle will pass readily between the thumb and forefinger as the hand passes around the limb, enabling the surgeon to make the section with perfect ease, and without the least mani- festation of stiffness. 2. The method may be reversed by first passing the hand and knife over instead of under the limb (Fig. 433) ; otherwise the ma- nipulations are the same. The latter plan, however, is less natu- ral, besides which it exposes the arm of the operator, and the integument to be divided last, to the flow of blood. If the handle of the knife be grasped firmly between the thumb and two fingers, and carried around the limb with a deliberate long sawing motion, accompanied with firm application of the edge to the tissue, the cutting depth can be easily regulated. If the operator be not acquainted with the technique of this method he can soon familiarize himself with it by passing the knife around the limb as described with the back of the blade against the surface. The method com- monly employed and figured in text-books (Fig. 434) is stiff and awkward at the outset, and as the knife advances in its course the operator’s posture and expression become both unnatural and labored. The Catlin (Fig. 430, «, b).—The Catlin is employed chiefly to divide the tissues in the interosseous space in am- putations of the leg and forearm. It can be readily supplanted for this purpose by the single-edged narrow knife, pro- vided the latter be withdrawn to com- plete the division of the interosseous tissues instead of changing the direction of the cutting edge while the blade yet remains between the bones. The latter act will bruise and tear the interosseous tissues. The Scalpels.—Two or three ordinary scalpels should be at hand for use in separating the flaps (Fig. 429, a). Fxo. 433.—Another method. Fig. 434.—A common method. AMPUTATIONS. 409 A knife with a long narrow blade is the better for amputating at the phalangeal articulations. The Saws.—The ordinary broad-bladed saw (Fig. 435) and the bow- backed (Fig. 436) are in common use. The first meets all requirements Fig. 435.—Broad-bladed saw. except in certain excisions, when either the chain saw (Fig. 329) or Butcher’s saw (Fig. 437) must be employed. The Gigli-Haertel, and the narrow, lift- ing-back saws (Fig. 429, Jc), are of use in severing small bones and spiculse. Fig. 436.—Common bone saw. The proper method of using a saw should be given some attention (Fig. 438). After the division of the soft parts the surgeon grasps the saw firmly, places its heel on the bone close to the border of the retracted muscles in a Fig. 487.—Butcher’s bone saw. line made through the periosteum by the knife, and, while guided by the thumb nail applied at the saw-point, slowly and carefully draws it backward along the first four or five inches of its edge, then raises it from the track, and places it as before, repeating the operation until a track of sufficient 410 OPERATIVE SURGERY. depth is made to retain the saw in place during to-and-fro movements; these should be made by quick, sharp, but not rapid strokes, until the bone is nearly severed, when care must be taken, or the saw will be clamped and the remaining portion of bone broken off. If the handle of the saw be raised and the remaining portion be divided at a different angle with the bone, the danger of the breaking is lessened. When two bones are to be sawed off, the saw should be started in the less movable bone and then turned so as to include both for a time, when either may be sawed inde- pendently of the other. If the movable bone clamp the saw, cut off the solid one Fig. 438.—Sawing the bone. Fig. 439.—Retractor for two bones. first; this course gives better final command of the movable bone. The proximal and distal portions of the limb should be firmly supported during the division of the bone, care being taken not to hold the limb in such a manner as to clamp the instrument during the final act of the sawing. The Bone Forceps.—Liston’s cutting forceps are used for trimming off rough bony prominences. Ferguson’s lion-jawed and Farabeuf’s forceps (Figs. 328 and 331) are excellent instruments for grasping the bone to steady the part, and are also used for removing bone by twisting, wThen great force is required. The Periosteal Elevator and Rvgine (Fig. 429, e, i).—Although these instruments are convenient for the purpose of raising periosteum for flaps, yet they are not necessary, as the same can be accomplished with the end of the metal handle of a scalpel. AMPUTATIONS. 411 The Cloth Retractor.—The cloth retractor is made of linen or ordinary muslin, fashioned, by tearing, according to the size and anatomical arrange- ment of the limb to which it is applied. If for two bones, one extremity of the retractor should be torn into three strips (Fig. 439), the middle one for use between the bones (Fig. 440), the remaining ones to be carried around them. If but one bone be pres- ent the retractor is torn partially through the mid- dle (Fig. 441), and applied as shown in Fig. 442. Fig. 440.—Three-tailed retractor applied. Fig. 441.—Retractor for one bone. A special metal retractor, devised for use at the thigh and arm, is worthy of employment. It consists of two thin slotted plates of metal so fashioned that they will simultaneously grasp the bone and retract the flaps when properly joined and firmly held by the rings (Fig. 443). After the soft parts are divided down to the bone, the bone is grasped at that point by the opposing slots of the respective plates, which are then drawn upward by the rings against the muscular tissue (Fig. 444). This re- tractor protects the muscles during division of the bone, is an admirable guide for the saw, and enables the assist- ant to firmly hold the proxi- mal portion of the limb while the bone is being severed. Fig. 442.—Two-tailed retractor applied. 412 OPERATIVE SURGERY. A tenaculum should be at hand for the purpose of picking up small bleeding points of severed vessels for the purpose of ligature when necessary. The Aneurismal Needle (Figs. 98, 99, and 100).—Not infrequently this implement is needed to aid the surgeon in tying collateral branches which arise so close to the ligature as to imperil the formation of a proper clot. In dis- eased vessels this pre- caution is of greater significance than in healthy. A support for the stump composed of wood, or pads of special device, or an ordinary pillow, should be provided and confined to the limb with rollers. This support steadies the limb and at the same time affords a ready means of handling the stump. In lieu of this the limb may be swung from a cradle by elastic or inelastic suspension, which, although it adds to ease of movement and comfort, does not always control properly muscular contraction. The Comments.—Before beginning an amputation the operator should rehearse, in his mind at least, the entire operation, as he contemplates it; by doing this he will be quite certain to anticipate the details and complications of the procedure. The surgeon should plan his work with careful precision, even to marking out on the limb the outlines of the flaps, and such other incisions as may be required. We are aware that this is sel- dom practiced, even by the most experienced surgeons; but, within our own observation, had it been done better results might have been secured. The- young surgeon, too, often fancies that to do this proclaims himself as igno- rant and inexperienced; such, however, is not always the case; it rather serves to ‘emphasize his cautious and painstaking qualities. An amputa- tion should be done without haste, when the safety of the patient will per- mit, remembering that it is done quickly when it is done well. The operator should stand in such relation to the patient that the left hand can readily con- trol any undue haemorrhage by compression or otherwise. The primary incision should be located, if possible, so that the escaping blood will not ob- scure the course of the incisions subsequently made. The division of important vessels should be made last, when possible. The tissues should not be retracted until after complete division, if practicable. In flaps made by transfixion the tissues constituting them are raised or Fig. 443.—Metal retractor, open. Fig. 444.—Metal retractor, closed. AMPUTATIONS. 413 depressed, according to the aspect of the limb from which the flaps are made. Those in front of the bone are raised, those behind depressed. After the limb is removed, the open mouths of the vessels should be caught by forcipressure, forceps, etc., after which the control of the circu- Fio. 445.—Catching and tying bleeding points. lation is slowly relaxed, and all bleeding points arrested as they appear by suitable means (Fig. 445). The surgeon can then proceed deliberately to ligature the vessels thus secured. AMPUTATIONS AT UPPER EXTREMITY. The General Remarks.—In amputations at the carpus and digits it is important to remember that usefulness and symmetry are the ends to be attained. If strength and usefulness be the desiderata, the insertions of the muscles and ligaments that endow the part with important functions should be preserved. It is therefore imperative that the surgeon carefully study the func- tions of the important muscles associated with the hand, and preserve if possible their points of insertion. The surface markings of the palm and of the digits (Fig. 44G) and the relation of the web of the fingers to the heads of the metacarpal bones and to the vessels are important. It is a well-estab- lished principle that every portion of the hand of a laboring man which pos- sesses motion and can become of service to him should be saved. In the case of one whose circumstances or vocation will permit, the sacrifice of use- fulness to symmetry may, with the concurrence of the patient, be made. Amputation at the Phalangeal Articulations. (Disarticulation.) The Anatomical Points.—The first row of surgical phalanges is flexed by the ter- 414 OPERATIVE SURGERY. minal insertions of the flexor profundus digitorum ; the second, by those of the flexor sublimis digitorum ; the third, by the flexor sublimis, through the vincula accessoria tendinum, by dense fibrous bands connecting the tendons of the flexor sublimis with the distal extremity of that row (Fig. 447), also by the secondary action of the lumbrical muscles and interosseii on the ex- tremities of the bones of this row. The terminal phalanx is amputated by seizing and flexing it to a right angle with the second (Fig. 448); an incision which opens the joint is then made on its dorsal surface, on a line corresponding to the transverse diam- Fig. 446.—Surface markings of the palm of the hand. eter of the second phalanx. Divide the lateral ligaments with the point of the knife; separate the articular surfaces, and pass the blade between them; cut along the under surface of the phalanx to be removed, close to the bone (Fig. 449), far enough to make a palmar flap of sufficient length to easily cover the end of the stump (Fig. 450). The application of the rule previ- ously given regarding the length of flaps will enable the operator to meet this requirement. If the base of the flap be first formed by dividing the tis- sues at each side of the phalanx, for three or four lines down to the bone, the knife will then hug the under surface of the bone in making the flap without cutting the base of the flap too narrow, which otherwise would oc- cur on account of the proximal extremities of the phalanges being thicker AMPUTATIONS. 415 than their bodies. Remove the flexor tendon from the flap, tie the vessels, close the open end of the tendinous sheath with a suture, confine the flap in position with two or three fine sutures, and dress antiseptically. The amputations at the second row can be performed in precisely the same manner as the first; or, with the finger extended, transfix the soft parts on Fig. 447.—Attachments of tendons to phalanges, a. Extensor communis digitorum. b. First surgical phalanx, c. Fibrous bands between common flexor tendons and distal extremity of the third surgical phalanx, d. Tendons of flexor sublimus digitorum. e. Tendon of flexor profundus digitorum. /. Vincula accessoria tendinura. g. Head of metacarpal bone. h. Joint between second and third surgical phalanges, i. Joint between first and second surgical phalanges. the palmar surface opposite the joint, and cut downward until a well- rounded flap of proper length is formed (Fig. 451). Then carry the knife upward between the articular surfaces and through the soft parts on the dorsum. The transfixion method is objectionable, because the vessels may be split or the flap be imperfectly formed (Fig. 452). The Remarks.—Either of the phalanges may be amputated at the center Fig. 448.—Flexed phalanx. Fig. 449.---Making flap. Fig. 450.—Flap completed. by a short dorsal and a long palmar flap. If a third surgical (first anatomi- cal) phalanx be amputated at the center, the power of flexion is limited to the lumbrical and interosseii muscles and the vincular tendons connecting the base of the phalanx with the flexor sublimis digitornm. These connections can be supplemented wisely by stitching the divided tendons to the contigu- 416 OPERATIVE SURGERY. ous theca. The division at this situation is regarded by many as objection- able practice, disarticulation being preferable. These anatomical facts have led the writer to amputate frequently in the continuity of this phalanx, and always with entirely satisfactory results. If symmetry be a primary considera- tion, this method of amputation can not be commended. In the case of the thumb, the index and little fingers, whatever adds usefully to the length of the digits should be saved, as the range of motion of the thumb and little finger is more extensive than that of the others, and the presence of the index finger or its stump greatly aids a crippled thumb in the performance of its functions. However, it should not be forgotten that it is not wise to make unnecessary sacrifice of a portion of any phalanx, as this portion may be of great prehensile service in conjunction with a crippled thumb— at all events of more use than the most ingenious artificial device. The phalanges are amputated frequently by flaps fashioned according to the demands of the case. Unequal flaps at both surfaces of the finger, and those of single or lateral pattern, can be employed when required. It is better at all times to subordinate symmetry to the attainment of pre- hensile advantage. It is better that transfixion in making flaps from the digits be not practiced, be- cause when thus made they are often ill fashioned and may contain tendinous tissue. The Gigli-Haertel saw is the best agent for dividing the bone; bone-cutting forceps often crush and splinter it. The free communication of the synovial tendinous struc- tures of the little finger and the thumb with those of the carpus (Fig. 325) explains the occasional ex- tensive inflammation which follows injury of these digits. It suggests also closing their open ends with a suture, or by sewing the divided tendons to them. The open ends of the sheaths of the remaining tendons should be treated in like manner, although they terminate in blind, noncommuni- cating extremities at the lower part of the palm. Amputation at the Metacarpo-phalangeal Articulations.—It is recom- mended by some that this operation be practiced in lieu of amputation at the middle of the third phalanges (surgical) of the second and third fingers, or even disarticulation between the second and third phalanges. We are satisfied, however, that the hand will be far stronger if the stump be allowed to remain, since it is soon easily flexed and extended, and the continuance of these motions serves to stimulate and nourish the common muscles engaged in performing them, and thereby strengthens the power of the remaining fingers. Amputation of the Second or Third Fingers.—Amputation of these fingers at the metacarpo-phalangeal articulation is done by the oval-flap method, and the flap should be marked out before the operation is com- Fig. 451.—Flap by trails- Fig. 452.—Opening joint, fixion. AMPUTATIONS. 417 menced (Fig. 453). The flaps must be taken from the finger to be removed, and should be of generous dimensions. The limit of the incision above cor- responds to the head of the metacarpal bone, the lower limit to the transverse line of the palm joining the fingers to the web. Sep- arating widely the contigu- ous fingers, seize the con- demned finger, extend it well, and carry the incision transversely along the line beneath, then in a curved direction upward along the side of the finger to the head of the metacarpal bone. This incision is re- peated on the opposite side, the tissue carefully divided, and the finger removed (Fig. 454). The trans- verse palmar incision can be made (Fig. 456, c), and many prefer that variation. Better drainage will be se- cured if the flap be reversed by forming its retiring an- gle on the palmar instead of the dorsal surface of the hand (Figs. 455 and 456). The Lateral-flap Operation.—The lateral-flap operation is best adapted to the thumb, index, and little fingers (Fig. 455) ; it can, however, be em- ployed at the ring and middle fingers. The limit of the dorsal incision is the same as in the pre- ceding. The lower limit, after crossing the trans- verse line of the web, extends toward the palm about a third of an inch. The flaps are taken from the sides of the finger to be removed. In the case of the middle and ring fingers the flaps should be equilateral (Fig. 456, d). For the thumb, index, and little finger, that portion of each digit against which pressure is most constantly brought should be covered by the longer flap, which is taken respectively from the outer surface of the index finger, the inner surface of the little finger, and from the palmar aspect of the thumb, the base of the flap being 3ii a level with the joint (Fig. 456, a, h, e). The longer one is dissected off, Fig. 453.—Amputating second finger, oval flap. Fig. 454.—Finger removed. 418 OPERATIVE SURGERY. after which the smaller one is made. Divide the ligaments and tendons and remove the digit. Fig. 455.—Appearance of flap at palmar surface. Fig. 45G.—Flaps in disarticulation of fingers, a. Long palmar fiap. b. Long external flap. c. Circular method, dorsal incision, d. Lateral flaps, e. Long outer flap. Amputation of the Thumb, Little, and Index Fingers at the Carpo-meta- carpal Articulation. The Oval Method.—The oval method can be employed equally well with the thumb, index, and little fingers. The limit of the dorsal incision in either instance is the proximal extremity of the metacarpal Fig. 457.—Oval method. Fig. 458.—Opening the joint. Fig. 459.—Wound united, linear cicatrix. bone to be removed. The upper or palmar limit is the transverse lfne at the junction of the finger with the palm. On removing the thumb by this AMPUTATIONS. 419 method begin the first incision at the base of the metacarpal bone of the thumb (Fig. 457), carrying it along in a slightly curved direction to the outer side of the metacarpo-phalangeal articulation, then inward through the line of the web. The second one joins the first near the base of the metacarpal bone, and Fig. 460.—Lateral-flap method. Fig. 461.—Making outer flap. takes a corresponding course along the inner side, meeting the former at the inner extremity of the transverse line of the web. The flaps are dis- Fig. 462.—Amputation through fourth and fifth metacarpal bones. Fig. 463.—Amputation through one meta carpal bone. sected off, and the articulation between the metacarpal bone and the trapezium is opened from the ulnar side, to avoid injuring contiguous joints (Fig. 458). The union of the flaps leaves a linear cicatrix (Fig. 459). 420 OPERATIVE SURGERY. The Lateral-flap Method (Fig. 460).—The lateral-flap method can be more quickly and easily performed than the former, but leaves the cicatrix in a less advantageous situation. Abduct the thumb and enter the knife between the first and second metacarpal bones, carry it up between them with a sawing motion, till the head of the first is reached. Cautiously dis- articulate the digit from within outward, increase the abduction, and carry the blade through the joint and along the outer side of the metacarpal bone, thus making the outer flap, which should terminate opposite the web of the thumb (Fig. 461). Amputation through the Metacarpal Bones.—In amputation through two or more of these bones the principal flap should be taken from the pal- mar surface, although it may be taken from the border of the hand and palm as well (Fig. 462). If but one metacarpal bone be attacked, the inci- sions are the same as those for amputation at the metacarpo-phalangeal articulation by the oval method, the only difference being that their upper limit will correspond to the point of proposed section of the bone (Fig. 463). The bone is exposed by reflection of the soft parts up to the point of proposed division, after which it is sawed through with a chain, Gigli-llaertel, or metacarpal saw, separated carefully from its palmar connections, and removed with the finger attached. If a saw be not convenient, the bone-cutting forceps (Liston) can be used, although with some risk of splintering the bone. This operation is often per- formed in preference to disarticulation at its head, in order to give symmetry to the hand (Fig. 464). The Remarks.—The division of the transverse ligament, which extends between the heads of the metacarpal bones, lessens the strength of the grip. This operation is therefore not to be recommended except in those of sedentary habits, and even in these instances the subsequent atrophy of the soft parts and the separation of the metacarpal bones at the seat of the operation do much to lessen the cosmetic effect originally gained by the am- putation. If possible, the divided ends of the palmar transverse ligament should be sewed together, which will serve to lessen the tendency to the latter element of deformity. Amputation of the Last Four Metacarpal Bones. (Disarticulation.)— Make a semilunar flap from the tissue of the palm by a curved incision, beginning at the web of the thumb and terminating at the ulnar border of the fifth metacarpal bone (Fig. 465). This flap can be made by transfixion if desired (Fig. 466). The dorsal incision (Fig. 467) begins at the same point of the web of the thumb, and is carried to the upper third of the metacarpal bone of the index finger, and from there transversely across until it meets the ulnar extremity of the first incision. The flaps are reflected up to the carpo-metacarpal joints, the hand is strongly abducted, and the carpo-meta- Fig. 464.—Appearance of hand after amputation through third meta- carpal bone. AMPUTATIONS. 421 carpal joint opened from the ulnar side, using great caution not to injure the articulation of the trapezium and the metacarpal bone of the thumb. Without the thumb this operation would be of little avail in securing a use- Fig. 465.—Line of palmar in- cision. Fig. 466.—Making by trans- fixion. Fig. 467.—Line of dorsal incision. fnl stump. Unite the flaps with interrupted sutures, introduce at either angle of the wound drainage when needed (Fig. 468), and treat antiseptically. Amputation of the Inner Three Metacarpal Bones.—Begin the palmar incision at a little distance below the base of the fifth metacarpal bone, carry it downward and outward across the palm below and parallel with the transverse palmar fissure for about an inch and a half, then toward the base of the middle finger, finally dividing the web of the hand at the outer side of that digit. A like flap is then made on the dorsal surface, the bones are removed, and the flaps united and dressed in the usual manner. The principles embodied in the last two amputations are applicable to amputation of the metacarpal bones of the last two fingers. Amputation of the Four Metacarpal Bones with the Fingers requires a long convex palmar flap and a short concave dorsal one. The bases of the metacarpal bones are saved as they afford attachment to important flexors and extensors of the carpus. The Remarks.—Amputation of the fingers and of the metacarpal bones exposes the synovial sacs of the carpal bones and tendons (Fig. 325) to the dangers of inflamma- tion. It is fortunate for this reason that these sacs are not common to their respective tissues. The relations of the surface markings of the palm (Fig. 446) to the hones carpus are of much significance in amputation and excision. After-treatment.—The wounds of these amputations should be closed with silkworm gut or horsehair, and simple drainage should be employed Fig. 468.—Appear- ance of stump. and vessels of the 422 OPERATIVE SURGERY. for the first two or three days. If the tissues have been bruised or lacerated, freer drainage is advisable. The hand should be kept in an elevated posi- tion, and the wrist joint confined with a splint. The results of amputations of the thumb and fingers are favorable. Only three to six per cent, and even less, with antiseptic precautions, die. Amputation at the Wrist. (I)isarticulation.)—The bones entering directly into this articulation are the radius, scaphoid, and semilunar. The Anatomical Points.—The location of the joint can be determined, 1, by forcibly bending the carpus backward, when the angle on the dorsal surface formed by the hand and forearm indicates the radio-carpal joint; 2, by drawing a line transversely from one styloid process to the other the joint is about one fourth of an inch above this line. The tip of the styloid process of the ulna is nearly opposite the joint at that situation. The lowest trans- verse fold of skin on the anterior surface of the wrist is about three fourths of an inch below the joint; this fold indicates the upper border of the annu- lar ligament. The integument on the back of the wrist is thinner or more lax than is that on the front, therefore it retracts more than does the latter —a fact to be considered in the construction of flaps. The relations of the tendons, bones, and synovial sheaths with each other are well illustrated elsewhere (Fig. 361). Amputation can be done by either the circular, single palmar, radial-flap, or the douhle-flap method. The Circular-flap Method.—To establish the length of the flap ascertain one fourth of the circumference of the wrist at the articulation, and add Fig. 469.—Circular method. Fig. 470.—Flaps united. posteriorly to it about an inch to compensate for the retraction which char-, acterizes the integument on the posterior surface of the carpus. Measure downward from the articulation this distance and divide the soft tissues by an oblique incision which becomes circular by retraction ; dissect up the sleeve of integument until opposite the joint; pronate and forcibly flex the carpus, and open the wrist joint on the dorsal surface by AMPUTATIONS. 423 an incision extending between the styloid processes; divide the lateral liga- ments, pass the blade through the articulation, and sever the remaining struct- ures (Fig. 469). Join the flaps in the long axis of the joint, introduce drain- age and sutures, and dress antiseptically (Fig. 470). If for any reason the flap be made too short, the defect can be remedied by sawing off obliquely the styloid processes. The Single Palmar Flap.—The single palmar- flap method is easily performed, and makes a serv- iceable stump. Mark out on the palmar surface with a strong scalpel a semilunar flap about three inches and a half in length going down to the flexor tendons, the base being located just below the apices of the styloid processes (Fig. 471); reflect it up- ward ; divide the remaining tissues in front of the articulation; open the articulation, pass the knife through it, and make a short dorsal flap. The dorsal flap can be made first, the joint opened from behind, and the long anterior flap cut from the joint outward. The former is the better plan, however, as thus a more symmetrical flap is made. The Double-flap Method (Ruysch).—Mark out the distal limits of the flaps as in the circular method ; flex and pronate the hand ; carry a semi- lunar incision over its dorsum, beginning at the styloid process of the ulna, extending to the circular line indicating the dorsal extent of the flap, and terminating at the radial styloid process (Fig. 472). Dissect up the flap, Fig. 471. — Single palmar flap. Fig. 472.—Making dorsal flap. Fig. 473.—Making anterior flap. allowing the tendons to remain ; flex the carpus firmly, and open the articu- lation, as in the circular method ; carry the blade of the knife through the articulation (Fig. 473) and make the anterior flap by cutting downward and outward. 424 OPERATIYE SURGERY. The Radial Flap (Dubrueil).—Make a flap beginning on the dorsal sur- face at a point just above the articulation and at the junction of the outer third with the inner two thirds of that surface, and extending downward toward the thumb, crossing the middle of the metacarpal bone of that digit toward the palm, then curving upward and inward through the thenar eminence and terminating at a point on the palmar surface of the wrist diiectly oppo- site the site of beginning (Fig. 474). Separate the thumb flap, connect the sides of its base by an in- cision carried transversely around the ulnar side of the hand, draw the skin upward, open the joint as before, remove the carpus, and properly adjust the flaps (Fig. 475). The Remarks.—The pisiform bone is frequently removed from the flaps. If the tissues are not impaired by diseased or acute inflammatory pro- cesses, the sheaths of the tendons should be closed with sutures, even including the ends of the ten- dons, if not too much retracted, after which the flaps are united, suitable drainage provided, anti- septic dressings applied, and the limb placed on a retaining palmar splint to control the movements. If the tissues be infected, the wound should be packed lightly with gauze, dressed, kept clean, and when granulations ap- pear the surfaces should be united in a suitable manner. The Results.—The rate of mortality in amputations at the wrist joint is from fifteen to thirty per cent for gunshot wounds, being about eight per cent greater than for amputation through the forearm. In civil practice the rate is less than twelve per cent. It follows therefore that amputation at the wrist joint can not be recom- mended on the ground of safety to the patient. There are other objections of less importance, which, with the one just stated, places the operation in disfavor. It makes a stump which, owing to the feebleness of the circulation of the flaps often becomes cold and even chilblained, and the bulbous extremity often interferes with the application of the properly fitted socket of an artificial appliance. However, supination and prona- tion of the forearm are more nearly complete than in am- putations of the forearm, for obvious reasons. Amputation of the Forearm.—The forearm can be am- putated by either of the following methods : The circular skin- flap, the equilateral skin-flap, or the antero-posterior musculo-cutaneous flap. The Anatomical Points.—The insertions of the supinator muscles should be saved when possible, to preserve their function. During division of the interosseous structures the forearm should be supinated to atford as much room as possible for that purpose. The Circular Skim-flap Method.—Although this method can be em- ployed at all parts of the arm, yet it is best suited for the lower third. It Fig. 474.—DubrueiPs method. Radial flap. Fig. 475. — Ap- pearance of stump. AMPUTATIONS. 425 is performed by first carefully laying out the length of the flap equal to a little more than one fourth the circumference of the limb at the point of bone section. Then with a long knife divide the tissues by a circular inci- sion down to the fascia surrounding the muscles, and dissect up the integu- mentary cuff by repeated incisions directed toward the muscles (Fig. 417). If the integumentary cuff be too small to be turned up readily, it is slit up at the most dependent part. After the flap is reflected sufficiently, the muscles are divided half an inch or so below the line of its reflection by a circular sweep of the knife made down to the bone. The undivided tissues lying between the bones on both aspects of the limb are severed with a scalpel. It is wise that the interosseous membrane and its vessels should be divided a short distance below the point of proposed bone section, and its borders separated from those of the contiguous bones up to the point of section with the scalpel. And, too, the blade should be withdrawn with each section of the membrane; for to turn it while between the bones lacerates and unnecessarily injures the soft structures. This course avoids the risk of cutting the vessels too short, as occurs when they are divided at a level with the bones, which procedure permits them to retract above the point of easy access. The muscles are then drawn upward with the three-tailed retractor (Fig. 440), and the bones sawed at the highest point of exposure, the radius being divided first. Having secured the radial, ulnar, anterior and posterior inter- osseous arteries, the wound is then properly united (Fig. 476), drained, and dressed. The Equilateral Skin-flap Method.—With the fore- arm midway between supination and pronation the flaps are raised either from the radial and ulnar bor- ders or the dorsal and palmar surfaces of the forearm, the latter course being most frequently adopted. The length of the flaps is determined in the same manner as for the circular, plus an inch for special retraction ; in fact, if the incision be made first, and the angles of the cuff trimmed off down to near the site of muscular section, the flaps will thus be formed. It is better, however, to mark them out before incision, since to make each with the same curve and same breadth of base is not an easy task without this precaution. The remaining steps of the amputation are similar to those of the circular method. Jacobson advises that the posterior flap be made an inch longer than its fellow to provide for the greater retraction of the integu- ment of that aspect of the part. The Musculo-cutaneous-flap Method.—The musculo-cutaneous flap is made by transfixion and cutting outward, or cutting from without, the former plan being commonly employed. Either plan of action is best fitted for the upper half of the forearm, on account of the large muscular development at that situation (Fig. 212). Owing to the great degree of muscular retraction here, the making of the flaps should be carefully planned and executed. The Fig. 476.—Stump after circular operation. 426 OPERATIVE SURGERY. width of the base and the length of each should equal one half the circum- ference of the limb at the point of proposed amputation. It will not be amiss, in cases of large muscular development, to increase the length somewhat, on account of the unusual contraction incident to this class of cases. The remaining steps differ in no essential degree from those of other methods of procedure. The Comments.—The placing of the cicatrix at the end of the stump in the arm, even when followed by its adhesion to the underlying tissues, is less objectionable than at the end of a weight-bearing stump, for apparent reasons. The circular method is not advisable at the upper two thirds of the arm because of the large amount of muscular structure at that situ- ation. The Results.—The rate of mortality in amputation of the forearm is about fifteen per cent for all causes. Amputation at the Elbow Joint. (Disarticulation.)—The elliptical-flap, the circular, and the anterior single-flap methods are commonly employed. The Anatomical Points.—Before operation carefully define the location of the most prominent portions of the condyles of the humerus. The internal condyle is about one inch and the external about three fourths of an inch above the articulation. Just below the outer condyle is felt the movable head of the radius; about an inch below the inner condyle the ulna joins the humerus; the articulation is therefore oblique, the inner portion being about half an inch the lower, owing to the inner condyle being that much longer than the outer. The anterior crease of the integument is just above the joint. The integument on the anterior and radial sides of the joint retracts freely, while that on the posterior has little tendency to retract, and is well inured to pres- sure by previous use. The Elliptical-flap Method.—The elliptical method can be practiced by making the ellipse either on the anterior or posterior surface of the limb. The Anterior Ellipse.—In this method the olecranon process marks the highest point of the ellipse behind ; the anterior point of the ellipse is just above the middle of the forearm in front (Fig. 477). The flap is outlined by an incision made through the skin only, extending from the olecranon around in front and back to the point of starting. The forearm is then slightly flexed, the flesh pinched up and transfixed down to the bone close to the joint through the beginning of the preceding incision, and the knife carried downward and forward along the same line to the completion of the flap. The flap is then drawn upward and disarticulation is performed the same as before. The union of the borders of the wound results in a posterior cicatrix. The Posterior Ellipse.—In this method the points of the ellipse are reversed, the flap being taken from the posterior surface. There is nothing Fig. 477.—The ellip- tical-flap method. AMPUTATIONS. 427 to commend this plan in the place of the former. In this amputation a drainage tube should be employed for the first few days of the treatment. The Circular Method.—Lay out the flaps obliquely, measuring from the condyles—four inches below the outer and two and a half inches below the inner condyle. Divide the superficial tissues obliquely down to the fascia Fig. 478.—Circular amputation at elbow joint. Fig. 479.—Stump in circular amputation at elbow. surrounding the muscles; dissect the flap upward to a level with the joint, the bony landmarks to which should again be carefully determined. Forci- bly extend the arm and make an oblique incision in front on the line of the articulation into the joint; sever the internal and external lateral ligaments, and press the arm still farther backward ; draw the olecranon process for- ward into the wound, and sever its connection with the triceps (Fig. 478). Unite the borders of the flap as indicated in the figure (Fig. 479). The flaps can also be united from before backward, which causes the cicatrix to fall between the condyles, and likewise increases the drainage facilities— two very important indications. The Anterior Single-flap Method.—The single flap can be made either of integument and subcutaneous tissue alone or it may be musculo-cutaneous, and formed by transfixion. In either instance it should be taken from the anterior surface of the forearm. If made by transfixion (Fig. 480) supinate and flex the forearm slightly, raise the soft parts in front of the joint and enter the knife an inch below the inner condyle, pass it in front of the bones obliquely outward, causing it to escape about two inches below the outer condyle. Cut the anterior flap downward and outward, making it about four inches and a half in length, the radial side being the longer, because of greater retraction there; dissect and draw the flap up to a level with the joint in front. Make the posterior flap by connecting the extremities of the first incision by a slightly convex one of the skin alone, or including the 428 OPERATIVE SURGERY. muscular tissues (Fig. 481); dissect this up, after which the joint is opened in front, the lateral ligaments are divided, the olecranon process is displaced forward, and the triceps cut off. The Comments.—In all amputations at the elbow the variety and location of the flap must be regulated largely by the state of the tissue contiguous to Fig. 480.—Anterior flap by transfixion. Fig. 481.—Making posterior flap. the joint. Imperfect soft parts at one aspect will necessitate a proportionate increase of the flap of the opposite surface of the limb. Therefore, it should be remembered to seek flaps wherever they may be found, rather than impair the usefulness of the stump by sacrifice of bone. The comparatively large synovial area of the elbow joint contributes very much to the amount of the discharge of the wound. It is advisable, when possible, to saw olf the olecranon, allowing it to remain with the triceps attached. If it be possible to sever the ulna below the insertion of the brachialis anticus, allowing the fragment to remain along with its muscular attachments, the stump will be more serviceable. In amputations near the elbow, the tubercle of the radius, together with the biceps tendon inserted into it, should be carefully preserved when possible. The anterior elliptical and the anterior single-flap method each provides an ample and well-nourished flap, good drainage, and suitably locates the cicatrix. Of the two, the former is somewhat the better plan; each is the antithesis of the posterior elliptical in these respects. The circular method although causing a limited loss of the soft parts covers less satisfactorily the end of the stump and places the cicatrix there. Amputation of the Arm.—The arm can be amputated by the circular- flap method, the irregular double flap, the antero-posterior flap, the sin- gle circular incision of Celsus (Fig. 572) and by TeaWs method. The circular-flap methods are applicable especially to the lower portion of the arm; the remaining methods are better adapted to the upper portion,and each can be employed as the nature of the case or the experience of the sur- geon may elect. The Circular-flap Method.—The circular-flap method can be practiced in either of two ways: First, the length of the flap is made to conform to one fourth of the circumference of the limb, plus an additional inch to pro- AMPUTATIONS. 429 vide for retraction. Divide the superficial tissues down to the muscular fascia and turn the flap up as elsewhere (Figs. 417 and 418); then divide the muscles about an inch below the reflection of the flaps down to the bone. Apply the two-tailed retractor (Fig. 442), saw through the bone opposite the point of reflection of the flap, and unite the flaps in the direc- tion best calculated to provide dependent drainage. Second, divide the in- tegument the same as before, free it at the border from the intermuscular septa, draw the flap upward gently and with a long knife make a circular sweep around but not entirely through the muscles, draw up the divided muscular fibers and repeat the circular sweep, going this time down to the bone. This manoeuvre makes the cone-shaped arrangement of the end (Fig. 569). In other respects the operations are similar. The Irregular Double-flap Method.—If skin alone be employed, the un- equal flaps should be carefully mapped out upon the integument of the arm. Dissect these up, and an inch below the flap reflection make a circular section of the muscles down to the bone; unite the flaps and dress the stump. The Remarks.—The irregular- flap method is advantageous in the saving of bone, when irregular in- jury or disease of the surface of a limb requires either this kind of flap or else a sacrifice of leverage to secure uniform ones. The base of each flap should equal one half the circumference of the limb. If the condition of the soft parts will per- mit, the length of the anterior flap is made equal to the circumference of the limb, the posterior to half that distance. The Antero-posterior flap Meth- od.—The antero-posterior flaps can be made of skin alone or combined with muscle. In the former instance they are fashioned and raised as is already elsewhere indicated. If musculo-cutaneous flaps (Lan- genbeck) be desired, they can be made by transfixion and cutting from within outward with a long knife, or from without inward with a scalpel. The latter plan secures better uni- formity of outline of the flap. If made by cutting from without, outline them carefully (Fig. 482), and when dissected up the desired distance, finish the operation by a complete division of the muscles. Fig. 482.—Langenbeck’s method. 430 OPERATIVE SURGERY. The large anterior and small posterior skin-flaj) method is sometimes per- formed (Fig. 483), also one with a large anterior flap and a posterior circular incision (Fig. 484). These flaps possess the advantage of good drainage and of placing the cicatrix where it is well removed from irritation. The dimen- sions of the flaps can be easily estimated on the basis of reciprocal length—viz., if one be increased in length, the other should be proportionately shortened. Teale's Method.—Teale’s method when employed should be done at the lower portion of the arm, the long flap being taken from the antero-ex- ternal surface, in order that the short one shall contain the nerves and the brachial artery. Fig. 483.—Unequal skin flaps. Fig. 484.—Large anterior flap. Amputation at the Surgical Neck of the Humerus.—Tivo methods of amputation are practiced, in either of which the bone is divided just above the insertions of the tendons of the pectoralis major and the latissimus dorsi muscles. This amputation is characterized by special considerations, such as the avoidance of the line of epiphyseal junction, of the bursa of the sub- scapular tendon on account of its frequent communication with the shoulder joint, and of the vessels and nerves associated with the surgical neck of the bone. The operation can be employed for uncomplicated cases in those over eighteen years of age. The Anatomical Points.—The integument over the deltoid is thicker, more adherent, and less retractile than is that over the pectoral muscle and inner surface of the arm. With the arm hanging at the side and the hand supine, the bicipital groove looks forward, and the articular surfaces of the AMPUTATIONS. 431 head in the same direction as the inner condyle. The circumflex artery and nerve cross the humerus horizontally about three quarters of an inch above the vertical center of the deltoid muscle—an important fact, especially in excision (page 338). The Oval Method (Guthrie).—Arrest the circulation of the subclavian by direct or elastic pressure, raise the arm from the side of the body, begin the cutaneous incision two fingers’ breadth beneath the acromion process, carry it to the inner side of the arm just below the border of the pectoralis major muscle, then beneath the arm to the outside, where it is joined by a second incision carried backward from the beginning of the preceding one. The integument is retracted and the muscles of the flap are severed, the bone is exposed up to the great tuberosity, the circumflex vessels and nerves are drawn upward with a hook, and the bone is sawed through. The large nerves are cut short. If the circumflex vessels can not be withdrawn from danger they should be tied and divided. The Single Exterrial-flap Method (Farabeuf).—An integumentary IT- shaped flap with the base equal in width to one half the circumference and the length to the diameter of the extremity is made with the base two inches below the surgical neck. The muscular tissue is divided by trans- fixion, and cutting outward in the line of the integumentary incision. The tissues at the inner aspect of the limb are divided singly and with care as follows: Expose the bone below the bicipital groove; divide the periosteum at that point and detach it upward along the groove with an elevator, in- cluding the insertion of the greater part of the pectoral muscle; divide the tendon of the long head of the biceps low down, avoiding injury of the synovial sheath and also of the bursa of the subscapularis tendon. Expose and tie the main vessels before their division, cut short the nerves and sever the tendinous insertions close to the bone. The flaps are united and dressed in the usual manner. Amputations at this situation are regarded as less fatal than disarticulation at the shoulder joint, and, moreover, the rotundity of the joint is better preserved, and the stump offers a better opportunity for the attachment of an artificial limb. The Remarks.—The circular method is better adapted to the lower and the flap method to the upper half of the arm. In amputations of the hume- rus during childhood the disproportion of the growth in the bone and soft parts is liable to result in a conical stump. It happens not infrequently in these cases that repeated exsection of the distal end of the elongating bone is required to relieve pain and discomfort at the end of the stump. The Results.—The death-rate from amputation of the arm varies some- what according to the seat of the operation. It is about eighteen per cent when done in the upper third, sixteen per cent at the middle third, and about twenty-six per cent at the lower third—the greater per cent in this situation being due, no doubt, to the greater degree of the injury calling for amputation at this point. If amputated for disease, the percentage would no doubt be reversed. At the elbow joint the results are somewhat better. Amputation at the Shoulder Joint. (Disarticulation.)—There are various methods recommended for amputation at this joint. It is hardly necessary 432 OPERATIVE SURGERY. to enter into the details of more than those which are commonly recognized and employed. The remainder, while ingenious in many instances, do not present sufficient practical differences to entitle them to introduction into other than cyclopaedic treatises of operative surgery. Four methods of amputation will be described: The external- and in- ternal flap-method, the circular method, the racket methods of Larrey and Spence. The special considerations incident to disarticulation at this joint may be briefly stated as follows: 1, The control of haemorrhage; 2, the main- tenance of the symmetry of the shoulder; 3, the transverse division of the axillary vessels and high division of the nerves; 4, the prevention .of entry of air into the veins; 5, the establishment of good drainage; 6, the least possible division of tissue ; 7, the easy disarticulation; 8, the formation of a serviceable stump. Hcemorrliage may he prevented by direct pressure of the subclavian on the first rib by the thumb, a padded key, or the padded extremity of a short crutch, or the artery may be ligatured here for the purpose. Which expe- dient is the best, depends very much indeed on the quietude and condition of the part; for, if the shoulder be pushed upward during the operation, Fig. 485.—Shoulder-joint amputation. Pins and rubber-tube tourniquet in position. The Esmarch bandage is removed from arm. the compressing agent may be displaced by movements of the clavicle, if the tissues be thickened by disease, or otherwise, direct pressure may be inef- ficient for the purpose. The employment of elastic constriction, as figured (Fig. 487), or with the aid of Wyeth’s needles (Figs. 485 and 48G), may answer well throughout unless the vessel be compressed against the head of AMPUTATIONS. 433 the humerus. When thus compressed, hemorrhage will probably occur when the bone is removed. Before division of the vessels, however, the tis- sues containing them can be firmly grasped by the hand above the point of section, and thus the bleeding will be prevented in any instance. Symmetry is maintained to the fullest extent by the preservation of the deltoid, the Fig. 486.—Appearance after disarticulation and ligature of the vessels. acromion process, and the circumflex nerves and arteries; division of these nerves and arteries—the former especially—leads to muscular atrophy. Transverse division of the vessels is easily made by cutting the tissue con- taining them at right angles while taut. High division of the nerves is easily performed by pulling down upon them before section. The entrance of air i3 prevented by prompt closure of the open mouths of the veins (page 105). The remaining four special considerations will be recalled in connection with their exemplification by operative method. The External- and Internal-flap Method (Dupuytren).—Place the pa- tient at the edge of the table, and turned toward the healthy side, with the body raised; make an external oval flap by an incision extending from the coracoid process downward and outward to the insertion of the deltoid, then upward and backward, terminating at the junction of the acromion process with the spine of the scapula (Fig. 487). Itaisfe the flap, including the deltoid muscle, as far as the acromion, expose the capsule of the joint, push upward the head of the humerus, and divide the capsule above ; rotate the arm outward, sever the subscapularis; then inward, and divide rapidly the external rotators attached to the greater tuberosity. While the arm is 434 OPERATIVE SURGERY. rotated internally, divide the capsule still further, together with the tendon of the long head of the biceps; tilt the head of the humerus outward, pass the blade of the knife beneath it (Fig. 488); seize the head of the bone and draw it outward, carry the knife along its inner surface until within about four inches below the axillary fold, then turn the edge inward and complete the flap. The last sweep of the knife severs the prin- cipal vessels. This flap should be seized by an assistant and tightly grasped before it is divided. The ap- pearance of the wound after the operation is represented in Fig. 489. The Circular-in- cision Method.—Con- trol the circulation as before. Abduct the arm and make a circular incision en- tirely around it sever- ing all the tissues, down to the bone, at a level corresponding to the insertion of the deltoid. Ligature the vessels and saw off the bone. Make a second incision lon- gitudinally from the anterior border of the acromion the whole length of the stump down to the bone. The bone is first held firmly and the soft parts are separated from it (Fig. 490), then it is rotated out- ward and inward, to admit of the division of the muscular and fibrous attach- ments to its head after which it is removed. The Remarks.—This operation is a good one, well calculated to provide Fig. 487.—Disarticulation of shoulder joint, making outer flap; elastic circular compression. AMPUTATIONS. 435 Fig. 488.—Making inner flap. Fig. 489.—Appearance of the stump. Fig. 490.—Circular incision method, removing bone. 436 OPERATIVE SURGERY. favorable drainage (t ig. 491), and is done witn a minimum amount ot injury to the soft parts. If the periosteum be separated from the bone without disturbing the surrounding soft parts there will be less danger of the exten- sion of inflammatory action be- yond the line of the longitudinal incision ; moreover, a greater de- gree of firmness will be given the stump even though new bone be not produced. The Oval-flap Method (Lar- rey).—The oval method is well regarded, and is performed by making a vertical incision from just below the extremity of the acromion process, with the arm extended, about three inches in length, down to the bone; this incision should terminate about two inches below the head of the humerus. Two oblique incisions are then made, each beginning near the middle of the vertical cut, one on the anterior and the other on the posterior aspect of the limb, and are carried through the lower borders of the struc- tures comprising the anterior and posterior walls of the axilla, at the points where these borders connect with the arm, thus severing their attachments to the humerus (Fig. 492). The soft parts at the inner aspect of the humerus still remain undivided. The borders of the wound are now drawn apart, the joint is ex- posed and opened above, the bone is drawn downward to separate the joint surfaces, the blade of the knife passed behind the luxated bone, and the operation is completed by cutting the tissues remaining at the inner side of the humerus (Fig. 493). The Racket-flap Method (Spence).—The racket-flap method has attracted considerable attention, and is certainly entitled to great consideration. The operation is performed in the following manner: Abduct the arm slightly, rotate the humerus outward, cut down upon the head of the bone, beginning immediately external to the coracoid process, thence directly downward through the fibers of the deltoid and pectoralis major to the lower border of the latter, which is divided; carry the incision with a gentle curve outward across and through the lower fibers of the deltoid, to, but not through, the posterior border of the axilla (Fig. 494). Begin the inner incision at the lower extremity of the vertical one, carry it around the inner side of the arm, through the skin and fat only, to meet the one. made at the outer side. If Fig. 491.—Flaps united, drainage introduced. AMPUTATIONS. 437 the fibers of the deltoid have been thoroughly divided, the flap, together with the posterior circumflex artery, can be easily separated by the finger from the bone and joint, and drawn upward and backward until the head of the bone Fig. 492.—Larrey’s method. Fig. 493.—Forming inner flap. is exposed; then the ligaments and muscular attachments are divided, dis- articulation is accomplished, and the limb removed by dividing the remain- ing soft parts at the axillary aspect. The Remarks.—Spence’s method is valuable because it admits of a choice between excision and amputation. In very muscular subjects a redundancy of muscular tissue in the flap can be avoided by dissecting the integument and subcutaneous tissues a short distance upward over the deltoid, and divid- ing its fibers high up. It will be noted that the external- and internal-flap method (Fig. 487) meets very many, indeed, of the considerations regarded as wise in amputa- tion at the shoulder joint. The oval method damages the deltoid muscle considerably. The circular and Spence’s methods are not much removed from each other in operative advantages. However, the latter is the more artistic, and is the more commonly employed of the two. The Results.—The rate of mortality in amputation at the shoulder joint varies from twenty-five to thirty-eight per cent for gunshot wounds, but is less in the instance of non-traumatic cases. Amputation above the Shoulder Joint.—It may be- come necessary, on account of malignant growths and severe injuries, to amputate the scapula together with a portion or the whole of the clavicle. The operation is often tedious and attended with great loss of blood. Inasmuch as the situation of the dis- ease or injury calling for operation will modify the location and direction of the incisions no definite plan can be prescribed. The aims should always be to save enough healthy integument to cover the wound, and to avoid haemorrhage. Fig. 494.—Spence’s method; racket flap. 438 OPERATIVE SURGERY. However, in view of the fact that the necessity for the amputation is often urgent, it is deemed wise to describe as briefly as possible the method pre- sented by Berger in 1887. According to Treves, Berger divided the amputa- tion into four stages: “ 1. The clavicle is exposed and divided at the junc- tion of the middle with the outer third. The middle third of the bone is exsected. The subclavian vessels are exposed and secured by double liga- tures and divided. 2. The antero-inferior flap is fashioned and the brachial plexus severed. 3. The postero-superior flaps are fashioned. 4. The extrem- ity is removed by dividing the tissues still connecting the scapula with the trunk.” The Operation.—The patient is placed on the back close to the edge of the operating table, with the shoulders elevated upon a hard cushion. The clavicular incision begins on the clavicle at the outer border of the sterno- mastoid muscle, and is carried outward down to the bone to just beyond the acromio-clavicular articulation (Pig. 495). The periosteum is separated from the underlying surface of the middle portion of the bone with a periosteal elevator. The clavi- cle is then drawn forward and steadied by a blunt hook passed beneath it while it is sawed through at the junction of the inner and middle thirds with a keyhole, Gigli-Haertel, or fine chain saw. The inner end of the outer fragment is then seized with the forceps and drawn for- ward, the remaining periosteum removed from the middle third, and the middle third removed by sawing at its junction with the outer third. The subcla- vius muscle is isolated and divided opposite to the inner section of the bone. It is then dissected up, the intervening fascia divided, and the deep vessels are thus exposed. The artery is tied with two ligatures at the outer border of the first rib, and divided between the ligatures. The vein is treated in a similar manner. The entire scapular region should now be freed from the table, the limb carried away from the body, and the head drawn in the opposite direction. An incision is then made, beginning at the center of the clavicular one, and curved downward and outward just outside the coracoid process, thence along parallel with the anterior border of the deltoid muscle to where the anterior fold of the axilla joins the arm, then across the lower margin of the pectoralis major transversely through the skin upon the inner surface of the arm to the lower margin of the tendons of the latissimus dorsi and teres major muscles. The arm is then raised and the incision completed by carrying the knife downward and inward along the groove formed by the vertebral border of the Fig. 495.—Anterior and posterior (dotted) lines of incision in amputation above the shoulder. AMPUTATIONS. 439 scapula and the muscular mass formed by the teres major and the latissimus dorsi muscles, to the posterior surface of the inferior angle of the scapula. The flap is dissected forward, the pectoralis major divided at the tendinous part, the pectoralis minor close to the coracoid process, the brachial plexus is exposed and the nerves are divided in a line with the main vessels. The latissimus dorsi is severed on the line of incision, and the shoulder falls out- ward from the body. The arm is now carried across the chest so as to expose the scapular region. An incision is then made, beginning at the upper por- tion of the preceding one near the acromio-clavicular articulation, and is carried backward behind the shoulder and downward by the shortest route over the spine of the scapula to join the termination of the anterior incision at the inferior angle of the scapula. This flap is laid back so as to expose the trapezius muscle which is then divided close to its attachments to the clavicle and scapula. The flaps are now held aside and the superior and vertebral borders of the scapula are rapidly freed from their muscular attach- ments by large scissors applied close to the bone and the part is removed. The flaps are united with sutures, and dressings are firmly applied so as to obliterate all dead spaces. The Results.—Fifty-one cases are reported, with a mortality of twenty- five and a half per cent. CHAPTER X. AMPUTATIONS AT THE LOWER EXTREMITY. No better or more comprehensive statement can be made bearing on the duty of the surgeon in amputations of the lower extremity, than that “ Under all circumstances, except where poverty, advanced age, and con- firmed dissolute habits so combine in the individual as to render it cei'tain that mechanical appliances would be of little service, the patient should be given the stump best adapted to the most useful artificial limbs. In all amputations of the lower extremity, the surgeon should be governed in the selection of the point of operation and the method to be adopted by the mor- tality of the operation in question; by the adaptability of the stump to the most serviceable artificial limb for locomotion.” * Amputation of the Phalanges of the Toes.—Amputation is practiced in the continuity of the bone (Fig. 496, a), or through the articulations (disar- ticulation), and is done in the same manner as amputation of the fingers (page 415), and therefore need not be considered here. In the case of the toes, however, it is often difficult to open the joints on account of the changes induced in them, and in the contour of the bones, by the pernicious influence of ill-fitting boots and shoes. The flaps are usually made from the plantar surface. In amputation at the metatarso-phalangeal articulations, it must be re- membered that the web of the toes is about an inch below the joints in ques- tion. The tendinous sheaths, the tendons, and the flap, are treated here as in amputation of the phalanges of the fingers. On account of the vast importance of the great toe in connection with the power of serviceable and symmetrical locomotion, the amputations of this member are given a detailed attention. The remaining toes play a subsidiary part, indeed, in comparison with the great. Owing to the impor- tance of the latter, a stump as long and as serviceable as possible should be constructed. Amputation of the First Phalanx of the Great Toe.—Flex the phalanx to a right angle with its fellow, as in amputation at the fingers make a transverse incision with a narrow-bladed knife in the dorsum of the toe on a line with the center of the long axis of the second phalanx; this will open the joint. Sever the lateral ligaments separately with the point of the knife, then pass the blade through the articulation, and carry it * From report of Drs. Valentine Mott, Gurdon Buck, John Watson, A. C. Post, Wil- lard Parker, Ernst Krackowizer, W. H. Van Buren, and Stephen Smith. 440 AMPUTATION AT THE LOWER EXTREMITY. 441 forward, making a long plantar flap. If short incisions be made down to the bone at each side of the first phalanx, the flap can then be formed with- out the danger of too great narrowing of the base. Another Method.—With the phalanx extended make an incision down to the bone across the dorsal surface of the first phalanx, then forward along the outer side, nearer to the dorsal surface, to the distal extremity and around this extremity to the inner side, then backward in a similar manner to the inner end of the transverse incision. This incision is made down to the bone throughout the entire course. Hyperextend the phalanx, dissect off the flap, open the joint from beneath, and sever the re- maining structures by passing the blade upward between the articular surfaces. Amputation through the last phalanx of the great toe should be practiced when possi- ble, in order to preserve the proximal frag- ment for the purposes of leverage, and the points of insertion of the flexor and extensor ten- dons. The racket incision is best suited for this amputation. The handle of the racket begins at the head of the metatarsal bone and terminates near the middle of the phalanx on the dorsal sur- face in lateral incisions at each side, which meet on the plantar surface near the distal extremity of the phalanx (Fig. 496, h). The phalanges of the remaining toes can be removed in a similar manner. Amputation of Single Toes. (Disarticulation.)—Single toes can be re- moved by the oval or by the lateral-flap method (Figs. 497 and 498). The former is the better, and is done as follows: The operator grasps the condemned toe, while the assistant pulls aside its fellows. Commence the incision on the dorsum over the metatarso-phalangeal joint, carry it downward along the side of the phalanx to be removed, beneath the toe, through the transverse line of the web on the sole of the foot. A second incision is then made of a similar extent and outline on the opposite side of the toe. The tendons are severed, the plan- tar and lateral ligaments divided, and the bone removed by cutting from below. If the extremities of the divided tendons remain exposed they are cut off on a level with the divided border of the soft parts. The removal of either the second, third, or fourth toes can be well effected at this situation by making a transverse incision on the dorsum over the joint, and passing the knife through it and along the under surface of the bone a suf- ficient distance to make the necessary plantar flap, which is then turned upward and united. However, the preceding methods are preferable. Fig. 496.—Amputation through last phalanx, great toe, and second of the adjoining (racket methods). Fig. 497.—a. Re- moval of sin- gle toe, oval flap. b. Re- moval of toe with metatar- sal bone. 442 OPERATIVE SURGERY. Amputation of the Great and Little Toes. (Disarticulation.)—Either of these toes can be promptly and suitably amputated by a single lateral-flap method. The amputation is performed by abducting the toe and entering the knife vertically between it and the contiguous toe, and cutting upward Fig. 498.—Lateral-flap method. Fig. 499.—Completion of operation, lateral flap, little toe. through the web till the line of the articulation is reached, when the knife is turned from the median line of the foot, the joint opened, the blade passed through it, and the lateral flap made of sufficient length by cut- ting along the opposite side of the toe (Figs. 498 and 499) to be removed. The importance of the great toe as a lever in propelling the body requires that even a part of a phalanx shall be saved when practicable. With the remaining toes, however, it is not a matter of so much importance. The prominent head of the metatarsal bone of the great toe, which remains after disarticulation, has so frequently become the seat of painful bunions that many surgeons advise that the bone be amputated be- hind the head by making either a transverse or oblique section of the metatarsal bone. Of one fact there can be no doubt: the boot or shoe should be kept from contact with the stump in these cases, otherwise great annoyance and needless crippling will result. The Square-flap Method.—The great toe can be am- putated by a large square internal flap (Fig. 500). Begin the longitudinal incision at the outer side of the extensor tendon a little below the joint; carry it through the tissues down to the first phalanx (surgi- cal) ; make a transverse incision from the termination of this one around the inner side of the toe to a point opposite, on the plantar surface; extend the toe and make another incision from the termination of the last toward the foot along the outer side of the tendon of the flexor longus pollicis to the web; connect this incision with the center of the dorsal one by a transverse cut carried around the outer side of the base Pig. 500.—Square-flap method. AMPUTATION AT THE LOWER EXTREMITY. 443 of the toe ; dissect off the flaps and divide the ligaments and remaining soft parts from within outward. The Oval-flap Method.—In the oval-flap method the incision is commenced just above the joint on the dorsal aspect in the median line, and is carried down to the center of the proximal phalanx and around it, avoiding the web, up to the point of beginning (Fig. 501). The joint is opened from below. The cicatrix is vertical and at the end of the bone. The Internal Plantar-flap Method (Farabeuf).—Make an incision, beginning at the head of the metatarsal bone at the line of junction of the internal and dorsal surfaces of the toe, downward parallel with the extensor pollicis tendon for about one inch ; thence over the inner surface and across the plantar aspect of the toe to the web be- tween it and the contiguous toe; then between the toes by the shortest route to the point of starting. The flap is dissected back, the joint opened from below, the ex- tremity removed, leaving the sesamoid bones behind. This method provides a most admirable flap of inured tissues, and places the cicatrix quite without the range of irritation (Figs. 502 and 503). Amputation of Two Adjoining Toes.—Begin the dorsal incision between the metatarsal bones of the toes to be removed, just below the metatarso-phalangeal joints; carry it to the further side of one of the toes, making a good-sized flap from it, thence through the digito-plantar fold to the opposite side of the other toe back to the point of starting. Remove each toe separately in the usual manner and close the wound. Fig. 501.—Oval-flap method. Fig. 502. — Incision Fio. 503.—Stump of for plantar flap. internal plantar flap. Fig. 504.—Amputation of all the toes, plantar incision. Amputation of all the Toes at the Metatarso-phalangeal Joints. (Disar- ticulation.)—Forcibly extend the toes with the left hand, and make a curved incision on the plantar surface from the inner side of the articulation of the great toe to the outer side of the corresponding joint of the little toe, carry- ing it through the groove between the sole of the foot and the bases of the 444 OPERATIVE SURGERY. toes (Fig. 503). Flex the toes and join the extremities of the first incision by a similar one carried across the dorsum (Fig. 505). Dissect up the flaps, expose the joints, and remove each toe separately, allowing the sesamoid bones of the great toe to remain. If the flaps be too short, the heads of Fig. 505.—Amputation of all the toes, dorsal incision. the metatarsal bones should be cut off sufficiently to permit proper adjust- ment, and uniting of the divided surfaces of the stump (Fig. 506). The Comments.—Since the head of the metatarsal bone of the great toe is the one most difficult to cover, the flap at that situation should be ex- tended downward along the inner side of the toe to the center of the proximal phalanx, and thence transversely outward across the plantar sur- face so as to utilize a suitable portion of the plantar tissue of the great toe for the purposes of the main flap. The sheaths of the flexor tendons should be closed in the manner already advised (page 416). The flaps should be united with silkworm-gut sutures, the stump loosely dressed, the limb elevated somewhat and required to rest upon the side to facilitate drainage, which may be encour- aged for the first three days by the use of wisps of horsehair or silkworm-gut introduced at either extremity of the wound. Irregular flaps may be employed and thus avoid sacri- fice of bone for leverage purposes. Careful scrutiny from time to time is advisable to de- tect the first indication of inflammatory ex- tension along the sheaths of the tendons into the foot. Evidences of such extension call for prompt release of the flaps and cleansing and drainage of these channels. The Results.—The general rate of mortal- ity in amputation of toes is about six per cent. Amputation through the Metatarsal Bones.—Amputation through all of these hones is best accomplished by a short dorsal and a long plantar flap. Make the plantar flap first by dissecting the tissues down to the bones back- ward from the junction of the toes with the sole to the point of amputation. Fig. 506.—Appearance of stump. AMPUTATION AT THE LOWER EXTREMITY. 445 A short dorsal flap (Fig. 507) is then made with the convexity downward, its extremities being united to those of the preceding. Divide the interosseous tissues with a sharp, narrow-bladed knife; employ an antiseptic six-tailed retractor; draw the soft parts upward, and divide the bones with a fine saw, turn the plantar flap upward, and unite it with the dorsal flap in the usual manner. Amputation of the Great Toe xoith the Metatarsal Bone.—This ampu- tation is best done by the oval or racket method (Fig. 508), similar to that for removal of the thumb. In this in- stance the incision is begun on the dorsal aspect of the metatarsal bone at the base, and* carried downward along the bone at the inner side of the tendon of the exten- sor proprius hallucis to near the lower end of the bone, thence around the outer side of the toe to the web, and across the plantar aspect in the groove between the toe and the sole, finally curved upward across the inner surface of the toe to meet the dorsal incision at the center of the metatarsal bone. The flaps are laid off, and the extensor tendons divided at the upper limit of the incision. The flexor tendous are then severed, the base of the bone is exposed, the peroneus longus cut, the bone still further exposed, the remaining tendinous attach- ments are divided, the tarso-metatarsal joint is opened, and the extremity taken away. It is recommended, in order to gain room, on account of the width of the base of the metatarsal bone of the toe, to make a short trans- verse incision across it at the tarso-metatarsal joint. Fig. 507.—Sawing the bones. Fig. 508.—Amputation of great toe with the metatarsal bone (oval method.) Fig. 509.—Amputation of little toe with metatarsal bone (lateral-flap method). Amputation of the Little Toe with the Metatarsal Bone.—Amputation can be done by either the oval- or the lateral-flap method; the steps of the former method are in all respects similar to those for the removal of the great toe with its metatarsal bone. The lateral-flap method is performed by separating the fifth from the fourth toe, at the same time carrying a narrow-bladed knife upward from the web between the fourth and fifth metatarsal bones until it is arrested, 446 OPERATIVE SURGERY. when the knife is withdrawn, and the incision prolonged upward on the dorsal and plantar surfaces on a straight line about one inch. Strongly ' * ' abduct the metatarsal bone to be removed, separating it from its fellow and from the cuboid ; carry the knife around the base to the outer side, and, keep- ing close to the bone, downward to the metatarso-phalangeal ar- ticulation (Fig. 509); remove the bone, and the tongue- shaped flap will fit the inter- metatarsal incision. Amputation of the whole or part of a metatarsal bone of either the second, third (Fig. 497, b), or fourth toes can be readily accomplished by ex- tending the stem of the racket or oval incision employed for the removal of the toe upward on the dorsal surface of the metatarsal bone to the point at which the bone is to be divided for removal. Caution is essential here to avoid in- jury to the underlying soft tis- sues duriug removal. There- fore the manipulative proce- dures should be directed espe- cially toward the bone itself. The Comments.—In ampu- tation through all of the meta- tarsal bones dorsal and plantar flaps of equal length can be made. A single dorsal flap is not advisable, because of its thinness and the unfavorable site of the scar. A flap taken from the inner and also one from the outer margin of the foot may be serviceable in this emergency. Amputation at the Tarso- metatarsal Joints (Lisfranc’s). —It will very much expedite matters, save considerable an- Pig. 510.—a, a. Line of Lisrfanc’s amputation. b. Line of Hey’s modification of Lisfranc’s amputation, c. Line of Skey’s modification of Lisfranc’s amputation, d. Line of Bau- dens’s modification of Lisfranc’s amputation. 'd. Amputation through metatarsal bones, e, e. Line of Forbes’s amputation. /,/;/,/. Lines of Miculicz’s amputation, g, g. Lines of Cho- part’s amputation. AMPUTATION AT TI1E LOWER EXTREMITY. 447 noyance to the operator, and preserve the edge of his knife, if the relations of the bones entering into the joints be fully noted before attempting dis- articulation (Fig. 510). The articulation between the cuboid and the fifth metatarsal is seen to be to the inner side of the tuberosity of the metatarsal bone. The articulation of the in- ternal cuneiform and the meta- tarsal bone of the great toe is about an inch and a half in front of the tuberosity of the scaphoid, and the base of the second meta- tarsal bone is seen lodged be- tween the three cuneiform bones. In every instance these joints must be carefully located. The Operation.—Flex the foot and mark out on the plan- tar surface a large semilunar flap, the base of which shall cor- respond to the distance between the tarso-metatarsal joints, first and fifth, as just indicated, and its distal extremity to the heads of the metatarsal bones. Extend the foot, and draw a short dorsal flap with the convexity forward, its base connecting with and corresponding to that of the plantar flap (Fig. 511). Divide and draw the small dorsal flap upward, and commence the disarticulation at the outer side of the tarsus just behind tuberosity of fifth metatarsal. Strongly extend and adduct the bones, which will better mark the lines of the articulation ; separate the fifth, fourth, and Fig. 511.—Dorsal flap. Fig. 512.—Articulation of second metatarsal. Fig. 513.—Separating the second metatarsal. Fig. 514.—Making plantar flap. third articulations; skip the second and open the first. The articulation of the second with the cuneiform bones is peculiar in that it is about two fifths of an inch higher than the first and third (Figs. 512, b, and 513). However, with the bones depressed, a short transverse incision liberates its dorsal con- OPERATIVE SURGERY. 448 nections with the middle cuneiform, after which it is disconnected from the internal and external cuneiform bones, as well as its contiguous metatarsal, by cutting upward (Fig. 513). Open all the joints well, divide the liga- ments at the sides and plantar surface, carry the knife along the sole, and make the plantar flap as previously laid out (Fig. 514). If the flap contains all of the muscular tissues of the sole it will be too bulky; therefore a part should be omitted, more especially that portion at the hollow of the foot. The plantar flap may be made by transfixion before the articulations are opened; this method can not be recommended, however, as the flap thus formed must await the completion of the operation without facilitating it. Moreover, if the plantar flap be made by transfixion before disarticulation, .the transverse arch of the foot will be intact, causing the center of the flap to be made thin, since the knife can not come sufficiently close to other than the first and fifth metatarsal bones to properly form the flap. After the removal of the part, the flap appears as seen in Fig. 515. The Remarks.—This method has been variously modified, the modifica- tions in some instances becoming confused with the original method. Hey sawed off the projecting portion of the internal cuneiform (Fig. 510, h); this, however, is not expedient, as it lessens the attachment of the tibialis anticus and shortens the leverage of the foot. Skey sawed off the base of the second metatarsal, leaving it in the mor- tise (Fig. 510, c). This adds nothing to the usefulness of the stump, and exposes the remaining fragment to the danger of necrosis. Baudens (Fig. 510, d) proposed that the first metatarsal bone only should be disarticulated, and the remaining ones sawed off transversely on a level with the internal cuneiform. Smith (R. W.) practiced a modification of the operation which required the removal of the four lesser metatarsal bones close to the proximal articulations through an oblique incision extending from a point three fourths of an inch in front of the base of the fifth metatar- 1 / sal bone to the metatarso-phalan- / / / geal articulation of the great toe. The plan adds to the leverage of the stump and preserves the in- ner and outer supports of the transverse arch of the foot better than any of the preceding modi- fications. Amputation through the Me- dio-tarsal Joint (Chopart’s).— The medio-tarsal joint is formed by the astragalus and os calcis behind and the scaphoid and cuboid bones in front (Fig. 510, g g). This compound articulation can be readily located by drawing a trails- Fig. 515.—Appear- ance of flap (Lis- franc’s amputa- tion). Fig. 516.—Chopart’s amputation, inner incision. AMPUTATION AT THE LOWER EXTREMITY. 449 verse line across the dorsum of the foot, the inner extremity beginning just behind the tuberosity of the scaphoid, the outer extremity terminating about an inch behind the tuberosity of the fifth metatarsal bone. The Operation.—The foot is raised and a curved incision is carried around the sole, extending from the articulation of the scaphoid with the astragalus (Fig. 516) forward to within a thumb’s breadth of the heads of the metatarsal bones (Fig. 517), then across the sole and backward along the fifth metatarsal bone to the outer ex- tremity of the articulation of the cuboid and os calcis (Fig. 518). Forcibly extend the foot and make a slightly curved incision, through the skin only, the convexity down- ward, across the dorsum, connecting the extremities of the plantar incision (Fig. 519). Turn the dorsal flap upward, open the joint on the dorsal sur- face, beginning from within, depressing the metatarsal bones toward the heel, and severing the ligamentous connections thus made tense. Fi- nally, pass the knife through the articulation to the plantar surface, turn the edge toward the toes and complete the plantar flap by cutting downward (Fig. 520). Fig. 521 represents the stump after the flaps are united. The Remarks.—This operation is objectionable on account of the liability of the stump to become ex- tended, causing the patient to wralk on the cicatrix at the anterior extremity. The division of the tendo Achillis during or subsequent to the operation is practiced to counteract this tendency, but frequently without permanent success. If the stump be confined in a flexed position during the healing, and for a time afterward, there is less danger of this annoying sequel. No preventive expe- dient addressed to this se- quel has as yet afforded the patient practical immunity. The operation can not be recommended as a substitute for those that are to follow in point of comfort and usefulness. Better service is secured with an arti- ficial appliance after the Syme amputation than after Chopart’s. The Results.—The mortality is about eight per cent. Forbes's Modification.—While this modification is accomplished through Fig. 517.—Plantar incision. Fig. 518.—Outer incision. Fig. 519.—Dorsal incision. 450 OPERATIVE SURGERY. substantially the same incisions as Chopart’s operation, still, it is, in point of fact, a different method rather than a modification. In this the scaphoid and cuneiform bones are separated, and the cuboid is sawed through on the line of their articulation (Fig. 510, ee). Inasmuch as the stump by this operation is given no additional power of flexion, but retains much of the power of extension of the tibialis pos- ticus muscle, and all the disad- vantages of Chopart’s operation, this method can not be com- mended. Irregular Tarsal Amputations (Molliere).—In view of the great advantages to be gained by strict use of antiseptic measures in pro- moting union by first intention, limiting suppuration, and lessening the danger of necrosis, it is sug- gested that amputations across the bones of the foot be made irre- spective of the articulations; in other words, that the foot be treated as if it contained but one bone. Heretofore, such measures have been followed frequently by necrosis of the fractional portions of the tarsal bones remaining in the stump. Sub-astragaloid Disarticulation.—The sub-astragaloid amputation leaves Fig. 520.—Severing the posterior flap. Fig. 521.—Appearance of stump. Fig. 522.—De Lignerolles’s amputation, external incision. behind the astragalus only, which forms the end of the stump. Several methods of procedure are practiced. AMPUTATION AT THE LOWER EXTREMITY. 451 De Lignerolles's Amputation.—Make two lateral flaps by an incision begin- ning immediately above the tuberosity of the os calcis on the inner side, which divides the tendo Achillis and is carried along the outer side of the os calcis in a curved direction, convexity downward, about an inch below the external malleo- lus ; thence extending obliquely upward across the middle of the cuboid to the dorsum of the foot (Fig. 522); then vertically down- ward across the inner border of the scaphoid (Fig. 523), till it reaches the center cf the sole of the foot; it is then turned directly backward at a right angle with the pre- ceding cut, and joins the beginning of the incision at the inner border of the tendo Achillis (Fig. 524). Dissect up both flaps till the lateral surfaces of the os calcis and the astra- galo-scaphoid joint are exposed, being careful not to injure the tibio-tarsal joint; remove the bones in front of the medio-tarsal junction; seize the anterior extremity of the os calcis with bone forceps, depress and turn it in- ward, and divide the external lateral ligaments with a narrow knife about a third of an inch below the tip of the malleolus; then divide the interosseous ligament between the os calcis and astragalus; finally, the talo-calcanean ligament is divided an inch below the internal malleolus (Fig. 525). The Fig. 523.—Internal incision. Fig. 524.—Plantar incision. Fig. 525.—Internal ligaments. os calcis is then removed (Fig. 526) and the flaps are united in proper position. Fig. 527 shows the appearance of the stump after union of the flaps. 452 OPERATIVE SURGERY. The Results.—Over twelve per cent are reported to have died from the operation alone. VerneuiVs Method.—In Verneuil’s operation the incision is begun at the outer tuberosity of the os calcis about an inch below the external malleolus and carried forward to within three fourths of an inch of the base of the fifth meta- tarsal bone; then over the dorsum to the middle of the internal cuneiform; thence obliquely across the sole by the shortest route to the commencement of the in- cision. The flap is raised and disarticu- lation accomplished in the usual manner. If the head of the astragalus be too prom- inent it should be sawed off. The Heel-flap Method.—In the heel- flap operation begin the plantar incision half an inch below the external malleolus, carry it transversely across the sole to within an inch of the internal malleolus. The dorsal in- cision is begun at one end of the plantar incision and is carried down- ward and forward in a curved manner to the astragalo-scaphoid joint; thence backward and downward, still curved, terminating at the opposite end of the plantar incision. The heel flap is dissected back to the insertion of the tendo Achillis, the dorsal flap is raised to the astragalo-scaphoid articula- tion, which is then opened, and the blade passed backward through the calcaneo-astragaloid joint and laterally so as to separate the soft parts from the os calcis down to the tendo Achillis, which is then divided. As before, the head of the astragalus should be removed if necessary. Hancock's Operation.—Hancock’s method of pro- cedure may be considered as a combination of the sub- astragaloid and Pirogoff methods. The operation can be made through incisions similar to those of the latter; the flaps, however, should be somewhat longer. The os calcis is sawed as in Pirogoff’s method. A hori- zontal section of the astragalus is made (Fig. 526) and the detached fragment removed, together with the asso- ciated part of the os calcis, after which the sawed sur- face of the remaining portion of the os calcis is placed in contact with the under surface of the articulated portion of the astragalus. Tripier's Operation.—By this method of practice it is thought possible to prevent the retraction of the flap and extension of the stump by the powerful muscles attached to the heel, as happens after Chopart’s operation. The os calcis is divided on a level with the sustentacu- lum tali and at a right angle with the long axis of the tibia, which makes the cut surface of the bone parallel with the ground. Fig. 526.—Bones separated (De Ligne- rolles). Bones sawed (Hancock). Fig. 527.—De Ligne- rolles’s method, appearance of the stump. AMPUTATION AT TIIE LOWER EXTREMITY. 453 The Operation.—Begin the incision of the soft parts at the outer border of the tendo Achillis, on a level with the outer malleolus, carry it along the outer border of the foot to the base of the metatarsal bone of the little toe, thence directly across the dorsum of the foot to the base of the metatarsal bone of the great toe; from this point it passes across the sole of the foot, forming there a convex flap at least one inch longer than the dorsal one, finally joining the outer incision at an oblique angle. The flaps are dis- sected up sufficiently to admit of the disarticulation of the medio-tarsal joint and of a horizontal section of the os calcis just below the sustentac- ulum tali. If the bone be divided from without inward, the posterior tibial artery is less likely to be injured. The wound is drained, the flaps are united, and the stump is dressed antiseptically. After-treatment.—The wounded part should be kept raised, well venti- lated, and lying on the side. It is better that drainage agents be limited to the openings than that they should extend through from side to side. Heel flaps may be punctured longitudinally for drainage. The Results.—According to some records all forms of amputation through the foot show a death-rate of about twenty-three per cent. How- ever, in this respect, the records of American surgery in these operations are but little in excess of ten per cent. Amputation at the Ankle Joint—Removal of the Entire Foot. (Syme’s Method).—Syme’s amputation may be considered one of the most practical Fig. 528.—Syme’s method, outer incision. Fig. 529.—Inner incision. of the operations on the foot and ankle. It is followed not only by a low rate of mortality, but also by a most serviceable stump, either with or without an artificial appliance. The patient is placed upon a table with the leg over- hanging it, the thigh raised by an assistant, who at the same time flexes the condemned foot upon the leg by seizing and pulling upward on its anterior portion. The outlines of the respective flaps should now be carefully drawn before the incisions are commenced. The line indicating the proper course of the plantar incision begins at the apex of the external malleolus, and with a slight backward inclination passes around the foot (Fig. 528) to a point opposite to its beginning, which is about a finger’s breadth below the apex of the internal malleolus (Fig. 529). The second or dorsal line is drawn directly across the instep, and con- nects the extremities of the plantar incision. 454 OPERATIVE SURGERY. The Operation.—The surgeon selects a large scalpel with a strong shank, and inserts the point at the commencement of the incision down to the bone at a right angle to its outer surface, with the edge undermost; carries it along the guiding line in contact with the bone to its inner extremity; places the fingers on the heel and the thumb within the cut, and draws firmly back- ward on the heel flap, at the same time liberating it from the outer surface and sides of the os calcis, back to near the insertion of the tendo Achillis. An incision is now made down to the bone on the anterior line; the joint is opened in front; the foot is well extended, lateral ligaments are divided, and the foot is removed by liberating the remaining tissues attached to the posterior surface of the os calcis, including the tendo Achillis; always remembering to closely hug the bone, else the flap may be perforated and its integrity impaired. After the removal of the foot, dissect up the soft parts around the malleoli a sufficient distance to permit the articular ends of the bones to be sawed off (Figs. 530 and 531) ; cut off the extremities of the tendons even with the cut Fig. 530.—Bones of leg sawn through. Fig. 531.—Heel flap. Fig. 532.—Flaps united, Fig. 533.—Side view of stump. surfaces of the soft parts, bring the flap into position, unite it in front (Fig. 532), and dress with care (Fig. 533). The Modifications.—Sawing the malleoli obliquely with a transverse section of the posterior lip of the tibia (Fig. 534) instead of removing them, together with a thin transverse section that includes the entire articular AMPUTATION AT THE LOWER EXTREMITY. 455 surface of the tibia as recommended by Mr. Syme, is a modification which has been long and somewhat extensively practiced. It is believed to give a better-shaped stump, and to be attended with less danger to life than if the bony canals of the tibia be freely opened, as in the case of complete transverse section. Wyeth carries the inner part of the plantar incision as far forward as practicable to add to the nutritive safety of the flap. Many surgeons, after making the plantar incision, open the joint in front, as before described, disarticulate, and then dissect the heel flap from behind forward. This course affords more room and leverage to aid in the removal of this flap, but increases the danger of cutting it, and also permits the blood to flow downward and interfere with the final separation of the heel flap. The removal of the periosteum from the sides and the posterior surface of the os calcis, including the insertion of the tendo Achillis, has been practiced. If this can be done without too much laceration of its structure, it is a commendable modifica- tion. Before puberty the epiphysis of the tuberosity of the os calcis may be detached and allowed to remain connected to the heel flap. The articular cartilage remaining on the extremity of the tibia is scraped off by some operators; this procedure is thought to hasten the healing process. Many methods, adapted to various forms of injury to the soft parts, have been devised to modify the construction of the flaps so as to cover the end of the stump. When the formation of the heel flap is impos- sible, tissues can be taken from all or either of the three remaining aspects of the foot, being ever cautious to avoid injuring the posterior tibial artery where it lies below the inner mal- leolus. The Fallacies.—The incision across the in- step lies below the line of articulation between the astragalus and the tibia; therefore, unless care be taken to locate the joint, the operator will cut down upon the neck of the astragalus, and, not finding the joint, will become much confused; or he may even open the articulation between the scaphoid and astragalus. If the plantar flap be made too long, it will be impossible to carry it back over the point of the heel; therefore, if it be necessary to make a long heel flap, the joint should be opened at once from before backward, and the heel flap dis- sected off from above downward. If the dorsal flap be lengthened for any reason the heel flap must be decreased correspondingly. The saw line for removal of the articular surface of the tibia should be made close to the Fig. 534.—Oblique division of malleoli and removal of pos- terior lip. 456 OPERATIVE SURGERY. dome of the articulation, thus avoiding needless sacrifice of bone in the adult or involvement of the epiphyseal cartilage in the young. The Results.—The rate of mortality from Syme’s operation is from five to nine per cent; the functional results are admirable. Roux’s Method.—Begin the incision at the outer side, a little above the insertion of the tendo Achillis; carry it straight forward beneath the outer Fig. 535.—Roux’s method. Outer incision. Fig. 536.—Inner incision. malleolus (Fig. 535); then in a curved line across the instep an inch in front of the articular edge of the tibia passing backward and downward on the inner side of the foot between the inner malleolus and the tuberosity of the scaphoid to the sole (Fig. 536); thence obliquely backward to a point about an inch behind the tuberosity of the fifth metatarsal bone; and finally backward and upward over the outer surface of the heel to the point of beginning. Dissect up the external flap, open the joint at the outer side, and complete the internal flap after disarticulation of the foot. The bones of the leg should then be divided as in Syme’s method, flaps united, and the wound dressed antiseptically. The Remarks.—This operation, while more difficult and less satisfactory than Syme’s, can be wisely employed when for any reason the latter is of doubtful utility. Fig. 537.—Pirogoff’s amputation. Lines of section of os calcis. Fig. 538.—Pirogoffs amputation. Inner incision. Fig. 539.—Outer incision. PirogofTs Amputation.—Pirogoff’s operation is osteoplastic in character, and consists in the application of the sawed surface of the posterior portion of the os calcis (/Pig. 537) to the sawed surfaces of the bones of the leg. The AMPUTATION AT THE LOWER EXTREMITY. 457 length of the limb is well preserved, and, without the use of an artificial appliance, the stump is often superior to that of Syme’s operation. The Operation.—Flex the foot at a right angle with the leg; make an incision from the tip of the internal malleolus across the sole a little in front of the long axis of the tibia (Fig. 538), to a point in front of the apex of the external malle- olus down upon the bone (Fig. 539), and dissect the flap backward from the os calcis for about a quarter of an inch. Connect the extremities of this incision by another carried down to the bone half an inch in front of the lower extremity of the tibia. Open the joint in front, divide the lateral ligaments (Fig. 540), expose the upper surface of the os cal- cis, draw back the detached portion of the heel flap, and with a narrow saw divide this bone obliquely downward and forward parallel with and a little posterior to the line of the plantar in- cision. Kaise the anterior flap, dissect up the tissues around the lower ends of the bones, and saw through the lower extremities of the tibia and fibula, from just above their articular surfaces in front to a point half an inch above the articular surface of the tibia posteriorly. Cut off the divided tendons on a level with the wound. The cut surface of the os calcis is then brought forward and placed in contact with that of the tibia, the wound united and dressed antiseptically. The Remarks.—If the posterior border of the os cal- cis be cut too thick, the divided bone surfaces can not be properly apposed without force, which will cause the fragment to tilt backward. The tilting can be remedied by removing more bone from the posterior border or bv dividing the tendo Achillis. Whenever this tendon in- clines to tilt the bone, it should be divided. The bone fragment can be united to the tibia by silver wire, thus retaining the sawed surfaces firmly in apposition. The os calcis is sawed at different angles by different operators (Fig. 537), but the one just considered has given the most satisfactory results. Fig. 541 shows the appearance of the stump after Pirogoff’s operation. The bone in the flap may become displaced by the muscles of the calf, may necrose, or fail to unite. The lat- ter contingencies are referable especially to elderly subjects. The Results.—The death-rate from this operation is about ten per cent. The Modifications of Firogoff's Operation.—These modifications are not a few and are of fanciful utility in some instances. Fergusson's Modification.—This modification consists in retaining the Fig. 540.—Separating articu- lar surfaces. Fig. 541.—Appear- ance of stump. 458 OPERATIVE SURGERY. malleoli, unless diseased, and placing the sawed end of the os calcis be- tween them after having divided the tendo Achillis. Turnipseed and others practiced this modification and advised it. We are not disposed to commend it. Le Fort’s Modification.—In Le Fort’s modification the incisions for the flaps are quite similar to those of Syme’s amputation. The ankle joint is ex- posed by raising the dorsal flap, keeping close to the bone so as not to injure the anterior tibial artery. Divide the external lateral ligament and the liga- ments between the astragalus and os calcis. Turn the foot inward, and remove the anterior portion of the foot at the medio-tarsal joint. Seize the as- Fig. 542.—Sawn bones in Le Fort's modification. Fig. 543.—Appearance of stump. tragalus with strong forceps, make tense and cut the ligaments connecting it with the bones above, and then remove it. Push down the os calcis, and with a narrow saw remove its upper third horizontally from behind forward, begin- ning just above the insertion of the tendo Achillis. Saw off the malleoli and Fig. 544.—Sawn bones in Bruns’s modi- fication. Fig. 545.—Esmarch’s modification. Outer incision. the articular surface of the tibia also horizontally (Fig. 542); place the sawed surfaces in apposition, and dress in the usual manner. This modification permits the preserved fragment of the os calcis, when placed in position, to maintain the same axis relative to the end of the stump that it held in the foot; consequently, the direct pressure is received upon integumentary AMPUTATION AT THE LOWER EXTREMITY. 459 covering already adapted to that purpose (Fig. 543). It also provides a broader support, and for these reasons is regarded by some as superior to the Pirogotf method. Fig. 546.—Plantar incision. Fig. 547.—Inner incision. Bruns recommended that the sawed surface of the os calcis be made con- cave and that of the tibia convex (Fig. 544). Esmarch's modification of Le Fort's operation consists of making two incisions: one across the sole, the other across the dorsum of the foot. The former commences about four fifths of an inch below the tip of the external malleolus, and passing forward (Fig. 545), runs under the cuboid and scaphoid bones (Fig. 546), ending at the inner side, one inch below and just in front of the internal malleolus (Fig. 547). The curved dorsal in- cision (Fig. 548), with its convexity forward to the tuberosity of the scaphoid, connects the extremes of the plantar one. Dissect up the dorsal flap to the tibio-tarsal joint, open the joint, depress the foot, expose the upper surface of the os calcis sufficiently to apply a small saw behind the upper margin of its posterior surface, and saw the Fig. 548.—Dorsal incision. AMPUTATIONS AT THE LEG. Amputation at the leg is a matter of great importance, as it involves the comfort and usefulness of the patient more directly than does any other amputation. The unequal arrangement of tissues and the necessity of providing a bearing surface suitable to meet the demands both of the burdens and pleasures of life, add emphasis to the importance of considering the occupation of the individual in connection with amputation here. However, the local arrangement of tissues has not all to do with the final outcome of amputation, for while a badly constructed stump is a serious affliction, yet if to this be added the local effects of intemperance and those the result of inattention to the part, the full measure of physical disaster in this regard is realized. The amputations of the leg can be divided into those of the lower, middle, and upper thirds. 460 OPERATIVE SURGERY. Amputation of the Leg at the Lower Third.—At this situation the crest of the tibia and the interosseous space are reduced to a minimum, and ten- dons predominate throughout nearly the entire location. The following methods of amputation will be considered : Guy on's method, Duval's method, the Author's method, Teale's method, the large posterior-flap method, the bilateral-flap method, and the hood-flap method. The Amputation by Guy on's Method (supramalleolar).—In Guyon’s amputation two incisions are made, one at either side of the foot, each be- ginning in front at the center of the ankle joint, and passing downward and backward in a curved direction just anterior to the respective malleoli and terminating at the summit of the curve of the heel (Fig. 549, a). The heel flap is dissected upward, carefully avoiding the posterior tibial vessels, the tendo Achillis severed, and the bones of the leg are exposed for two inches above the tips of the malleoli (a1), and then sawed horizontally at that situation. This method properly locates the cica- trix and provides good tissue for the flap. Drain- age, however, is faulty unless a small slit be made in the flap posteriorly, or the limb be so placed as to facilitate the escape of the discharges. The Amputation by Duval's Method (supramal- leolar).—In Duval’s amputation the place at which the bones are to be sawed is higher than in the preceding; the point of amputation is first deter- mined in order to estimate properly the outline of an elliptical incision in forming the flap to cover the end of the stump. The posterior extremity of the ellipse is located at a point below the place of sawing, a distance equal to one and a half times the antero-posterior diameter of the limb at the site of proposed section (b'), and the anterior ex- tremity of the ellipse, at a point below the same place, a distance equal to three fourths of the same diameter. This incision crosses the leg laterally at an angle of about 45° (Fig. 549, b). The skin is reflected upward carefully to just above the line of proposed bone division, the bones are sawed horizontally, and the borders of the ellipse united antero-posteriorly with sutures. The tendo Achillis is cut near its insertion. It is advised by some that its extremity be united by deep sutures to the extremities of the tendous in front. This operation places the cicatrix nearer the end of the stump and provides a flap less in- clined to friction than does the former method. Amputation by the Author's Method.—This method comprises the mak- ing of a circular integumentary flap provided anteriorly with an attached peri- osteal lining. If the site of operation can be chosen it should be about three or three inches and a half above the lower extremity of the tibia, or, more definitely speaking, just below the point where the tapering of the limb Fig. 549. — a. Guyon’s su- pramalleolar amputation. a1. Saw line of same. b. Duval’s supramalleolar amputation, b’. Sawline of same. AMPUTATION AT THE LOWER EXTREMITY. 461 ceases. The length of the flap should exceed by one inch a fourth of the circumference of the limb at the proposed point of bone section.' The Operation.—Lay out the flap as just indicated; make a circular incision through the integument and subcutaneous tissue down to the fascia of the muscles and the subcutaneous surface of the tibia. Dissect the sleeve upward for about an inch, then divide the periosteum at the subcutaneous surface of the tibia by a transverse incision at the level of reflection of the flap; also divide it longitudinally at the outer and inner borders of the sub- cutaneous surface of the tibia a sufficient distance—half an inch—to allow the periosteum to be reflected upward while attached to the inner surface of the flap. These longitudinal incisions are increased as often as it becomes necessary to detach the periosteum to keep pace with the turning up of the remaining part of the flap—that is, instead of turning up from the subcutaneous sur- face of the tibia an integumentary flap only, the periosteum of this surface is detached from a proper area of the bone up to the Line indicating antero posterior coaptation of flaps. Fig. 550.—Reflection of the periosteum Fig. 551.—Oblique coaptation scar. saw line, being raised along with, and not separated from, the integument which overlies it, thus forming a limited lining of the flap. Fig. 550 shows the extent of the reflection of the periosteum from the tibia, the other soft parts having been removed. The tibia is sawed carefully through at the high- est point of the periosteal reflection, the fibula is exposed one fourth of an inch higher up and divided separately by sawing toward the tibia. The flaps are then united obliquely, in a line parallel with the margin of the subcutaneous surface of the tibia, so that not only will the line of union fall between the bones, but, what is more important, the periosteal lining of the flap will fall and lie smoothly across the divided extremity of the tibia (Fig. 551). It will be necessary in order to reflect the sleeve flap that it be divided longitu- dinally at a point that will be lowermost when the flaps are obliquely joined. The Remarks.—The limb should be dressed carefully, cautiously main- taining the oblique direction of the flaps till the healing process is complete. The periosteal flap grows to the end of the tibia, lessening the liability of 462 OPERATIVE SURGERY. atrophy of the bone and likewise obviating the adhesion of the cicatrix to the end of the tibia. Fig. 552 shows a vertical section through the flap made three months after operation by the writer. The Results.—Of the fourteen cases performed by the writer all have resulted in exceptionally serviceable stumps. In no instance has bony spiculae appeared, and in each the stump has given entire satisfaction. The Amputation by Teale’s Method.—Teale’s amputation has not been practiced to any extent in this country. The details of the method are comparatively intricate, and the high division of the, bones often cause an unwise sacrifice of leverage, especially important in connection with modern prosthetic appliance. However, if the method be employed, the lower third of the leg affords the best site, as there the long flap can be extended well downward. The flaps are rectangular, and should be carefully marked out before the incisions are made. The length of the anterior flap is one half the circumference of the limb at the point of amputation, and the posterior one eighth. The anterior flap is made by two lateral incisions going down to the bone, supple- mented by a short transverse one at the lower margin of the flap. The posterior flap is made by a vigorous cut down to the bone. The anterior includes all of the tissues in front, and the pos- terior all of those behind the bones. The bones are sawed through in the usual man- ner, and the stump is care- fully dressed. Although a good cushion is provided at the end of the stump and the cicatrix is re- moved from direct pressure, still, the stump is not a more serviceable one than can be secured by more conservative methods. The Amputation by the Large Posterior-flap Method.—In this method the length of the posterior flap is made to exceed one half the circumfer- ence of the limb at the proposed point of bone section, and the anterior is a little more than one eighth of the same circumference. The posterior flap is limited by an outer and an inner incision carried through the integument and fascia from the saw line to near the insertion of the tendo Achillis (Fig. 553, a). The inner one passes in front of the inner border of the tibia; the outer passes behind the fibula; they join together in a curved manner near the insertion of the tendo Achillis. The muscles at the outer and posterior surfaces of the tibia are then disconnected from that bone, by Fig. 552.—Dissected specimen showing the relation of parts. AMPUTATION AT THE LOWER EXTREMITY. 463 cutting and blunt dissection for a distance of two inches. The soft parts at the back of the limb are now grasped by thrusting the thumb and finger into the gaps caused by the separation, and the posterior flap is completed by cutting from without inward (Fig. 554). During the division of the muscles the foot should be somewhat flexed. The anterior flap is now made down to the bone and dissected up, the interosseous membrane is divided, retractors are adjusted, bones sawed, and the posterior tibial nerve is divided to above the point of bone section. The muscu- lar structures of the respective surfaces of the limb can be joined with deep sutures. The Amputation by the Bilateral-flap Method. —The bilateral-flap method (Fig. 558, a) con- sists of equilateral flaps constructed from the integument and subcutaneous tissue at the outer Fig. 553. Fig. 554. Fig. 553.—a. Amputation, lower third, large posterior flap. b. Amputation, upper third, large external flap. c. Carden’s amputation, d. Lister’s modification. Fig. 554.—Making large posterior flap. and inner surfaces of the limb. The operation may be performed in this method with or without the periosteal lining. The circular method, with oblique coaptation, is far the better if the periosteum be raised, since in antero-posterior coaptation the periosteal flap is tilted, and is more liable to eversion and the production of bony spicular growths. The length of the bilateral flaps is estimated in the usual manner. There- fore, the width of each flap at the base is equal to half, and the length is in excess of one fourth the circumference. Each one is nearly semicircular, and the points of junction should be at the center of the limb, anteriorly 464 OPERATIVE SURGERY. and posteriorly, thus bringing the anterior point of union to the inner side of the crest of the tibia ; it should also be well below the point of the proposed section of the tibia. The posterior point of junction is considerably above that of the anterior, to provide for suitable drainage. After having been properly outlined, each flap is dissected upward to near the point of bone division; the muscles are divided by a circular incision, then pushed upward above the anterior point of union of the flaps, and the tibia is sawed off on a line corresponding to the junction of the flaps posteriorly. The fibula is sawed a fourth of an inch the shorter. If there be an un- due amount of muscular tissue behind, it can be trimmed off until it admits of the ready union of the borders of the flaps. Suitable drainage, antero- posterior coaptation, and an antiseptic dressing comprise the immediate attentions in the case. The amputation by the hood-flap method is a modification of the circular, the skin cuff being slit up posteriorly to the point at which the bone is to be divided, and the corners trimmed off to resemble the outlines of the lower portions of the bilateral flaps. This flap is then reflected upward, and the muscles and bones divided as before. The line of coaptation is antero-posterior (Fig. 558, a). The advantages claimed for this method are: perfect drainage; the loca- tion of the cicatrix on the posterior surface of the stump; and the falling of the integument over the end of the bone, thus obviating the presence of a cicatrix at that point. Like the bilateral, it can be employed in connec- tion with the periosteal flap; still, as it is joined to form an antero-posterior line of union, it is open to the same objections as the bilateral with refer- ence to the proper application to the bone of the periosteum. The Results.—The rate of mortality from amputation in the lower third of the leg is variously estimated at from thirteen to twenty-two per cent, being, however, less than at any other part of the limb. Amputation of the Leg at the Middle Third.—The limb can be ampu- tated at this part by the methods employed at the lower third, and the principles applicable to the lower third have an equal force at this situ- ation. The presence of the calf offers an additional difficulty in obtaining the oblique coaptation, but does not interpose an insurmountable obstacle to it. Care in dressing the stump will maintain the obliquity of the line of coaptation in the periosteal-flap method. The bilateral- (Fig. 558) and hood-flap methods, either with or without the periosteal lining, present to the surgeon the means of making a serviceable stump. Amputation here can also be performed by either the large posterior- or the large external- flap method. The Amputation by the Large Posterior-flap Method (ITey).—In this method first ascertain the circumference of the limb at the point of pro- posed amputation; then mark off two U-shaped flaps, posterior and ante- rior, the base and length of the former equaling one half the circum- ference of the limb, and the length of the latter one sixth. The leg is flexed on the thigh, and the skin and subcutaneous tissues are divided with a scalpel along the line of the posterior flap as indicated. Flex the foot and divide AMPUTATION AT THE LOWER EXTREMITY. 465 the gastrocnemius in the line of the incision; separate the remaining soft parts at this situation from the posterior surfaces of the bones, grasp them with the thumb and fingers and sever them from within outward with a sharp transverse cut; separate further the soft structures from the bones up to the saw line; make the anterior flap by dividing first the integument and subcutaneous tissue, and then severing the muscles down to the bone and displacing them upward to the saw line in front; divide the interosseous membrane ; apply the three-tailed retractor and saw the bones transversely. The triangular projection of the crest of the tibia is then removed to prevent its impingement on the anterior flap. Lee practiced amputation at this part of the limb after the method of Teale, except the long flap was placed posteriorly, and only the muscles of the calf were included in it. Both flaps were reflected upward to the point of bone section, the remaining soft parts were divided transversely, the re- tractor was adjusted, and bones sawed through as before. Both methods provide serviceable stumps; the latter is more easily performed, but requires higher division of the bones than the former method. In neither method is good drainage provided. The long external-flap method, having a semicircular incision on the inner side, offers good drainage, and carries the cicatrix beyond the point of pressure. These flaps may be either integumentary or muscular ; the latter are made by transfixion or the reverse ; the former by external incision with the ordinary scalpel, and circular section of the muscles with the long knife. The prin- ciples controlling the length of the flaps are the same as previously stated for single flaps. The long flap should be made from the outer side of the leg, having a base equal to one half the circumference of the limb. The inner or short flap is semicircular in outline (Fig. 555). The bones are sawed off just above the an- terior point of junction of the flaps, united, and the wound is dressed as before. The Results.—The rate of mortality of am- putations in this portion of the limb is about twenty-seven per cent. Amputation of the Leg at the Upper Third. —Amputation at the upper third involves much more tissue than at either of the preceding parts of the limb. Either variety of flap employed at the middle third can be utilized at the upper, but modifications of procedure are advisable on account of the difference in the bulk and relation of the tissues at the upper third. The Amputation by a Large External Flap (Farabeuf).—The flap is U-shaped, and the length is equal to one third the circumference of the limb at the point of bone section. It is marked out carefully before division, beginning in front at the level of the proposed bone section, and passing downward the proper distance along the inner border of the crest 1' Fig. 669.—Keegan’s operation. efgh) downward almost to the free margin of the bones, which part is left undisturbed. An obliquely placed flap of proper size and corresponding to the one depicted in the cut (Fig. 669, a), with the pedicle at the inner angle of the eye, is now raised from the forehead. The nasal flaps already described are turned downward at the bases (c d and g h) and properly fitted by the cut- ting off of overlapping portions, thus leaving their raw surfaces uppermost. The main flap (a) is now turned downward and placed in position. The free margins of the frontal and nasal flaps are united with horsehair sutures, the columnar segment is properly joined below, and the lateral nasal incisions are suitably fitted to accurately meet the main flap, to which they are joined carefully with horsehair sutures. The wound of the forehead, the newly formed nostrils, and the final dressings are managed in all substantial respects as in the preceding instance. The pedicle is divided at the end of two weeks. The tendency of the flap to slide downward has been combated in various ways—such as connecting the pedicle with a longitudinal incision at the side PLASTIC SURGERY. 527 of the nose, the attachment of its whole length to a newly formed raw sur- face at its base, and grafting the sharpened pedicle into the integument at its base. In these operations, after the columna and alae are fashioned and sutured in place, the end of the nose presents from below a quite natural appearance (Fig. 670). The Italian Method.—The Italian method, although an old one, has many virtues, and, were it not for the great difficulty of keeping the parts in position, would be much more employed than now. The flap is taken from over the biceps, with its apex toward the shoulder. It is first dissected up, and its extremities allowed to remain attached until suppuration is established, when the proximal end is separated and the dressing con- tinued until the flap is well shrunken and the under surface cicatrized. It is then applied to the gap after the borders have been freshened (Fig. 642). When union is completed the pedicle is cut, and the flap is fashioned so as to relieve the deformity in the best pos- sible manner. The tedious associations of this operation do not commend its employ- ment except in those cases in which the necessary material for repair can not be suitably secured by other methods. The cosmetic qualities of the integument of the arm are not as well suited to the repair of facial deformi- ties as are those of the integument of the face itself. However, the facial disfigurement incident to transplantation of integument in the former in- stances is avoided by this latter procedure, a fact, that will largely com- pensate for its irksomeness. One who contemplates the performance of this method should consult the experience of Sir William MacCormac, as set forth in the Transactions of the Clinical Society for 1887, vol. xli, p. 181. Osteoplastic Rhinoplasty.—The periosteum has been removed frequently from a part of the frontal bone in connection with the flap, and con- signed to the gap with the hope that the formation of new bone might occur, so as to give solidity as well as prominence to the new nose. The removal of the periosteum from the frontal bone is not by any means devoid of danger. Osteomyelitis has arisen therefrom, followed by pyaemia and death. The periosteum may be used to form a portion of the flap first ap- plied in the double-flap method illustrated in Fig. 661. It is true that the relation of its surfaces will be reversed, but this can not change its bone- producing value; moreover, if bone be formed, it can be easily shaped by manipulation to suit the proposed outline of the organ. Ollier''s Method.—An operation was performed some time since by Ollier for a deformity caused by the loss of the alae, columna, cartilage, lobe, and a portion of the septum, due to lupus. The nose was not more than an inch long, due to the arrest of development of the ossa nasi, to which was attached a strip of cartilage. The integument of the lip and cheeks had been in- volved, and could not therefore be depended upon for flaps. Ollier commenced two diverging incisions in the median line of the Pig. 670.—View of the new nose from below after being sutured into the defect. 528 OPERATIVE SURGERY. forehead two inches above the eyebrows, and carried them downward to a fourth of an inch from the outer sides of the nasal orifices (Fig. 671). The upper portion of the triangular flap included the corresponding portion of periosteum down to the upper ends of the nasal bones. The dissection was continued along the right nasal bone, omitting the periosteum, down to its lower end, from which the cartilage was separated, though remaining at- tached to the flap. The left nasal bone was separated from its bony connec- tions with a chisel, leaving it attached to the flap by its anterior surface; the cartilaginous septum was then divided from before backward and downward with scissors, and left attached by its base to the cutaneous cartilage, that a central support might be provided for the new structure. The whole flap was then drawn downward until the upper border of the loosened nasal bone (left) came opposite to the lower border of the right one, when they were fastened together with a metallic suture. The sides of the flap were then united to the cheek and the frontal incision closed above its apex. In this case, the space remaining after the removal of the left nasal bone Fig. 671.—Ollier’s method. Fig. 672.—Konig's method. was filled by bone developed from the periosteum that had been slid down from the forehead. Konig's method (Fig. 672) of treatment consists in separating the car- tilaginous from the bony portions of the nose by a transverse incision, and turning the end downward sufficiently to remedy the outline of the defect, then filling in the gap by an osteoplastic flap taken from the forehead and placed with the bony surface upward. A second flap is then raised from the forehead and turned downward on the former with the cuticular surface upward, thus bringing the raw surfaces in contact with each other. Each flap is united separately with the borders of the gap. After firm union is established, the pedicles are cut and the part is so fashioned as to make an acceptably formed member. Israel modified this operation by closing the wound in the forehead at once and permitting the bone flap to granulate and heal by cicatrization, when the contraction following healing so drew forward the skin of the under surface of the bone flap as to cover two thirds of the circumference PLASTIC SURGERY. 529 of the upper surface of the newly formed dorsum. Quadrilateral-shaped flaps were then dissected from the outer surfaces of the deformed nose, also from the healed upper surface of the newly formed dorsum, and turned out- ward. The latter flaps, with the raw surfaces upward, supported, and were covered in by, the former, which were united at the median line with each other. If later the bridge of the frontal flap be severed, and the end inserted lower down, and the flap itself have only a ridge of bone at the center of its long axis, the remaining upper surface being periosteal, the cos- metic effect would be improved. This variety of deformity has also been relieved by attaching a finger to the sides of the nasal chasm. The nail was first removed, and the palmar surface of the finger denuded, by the formation of lateral flaps, down to the distal third of the first phalanx. The finger was then fastened in po- sition upon the freshened borders of the deformity by means of sutures passed through the lateral flaps, and, when union was sufficient to sustain the nutrition of the part, the finger was amputated at the juncture of the middle and distal thirds of the third surgical phalanx, and the distal end of the latter turned downward, to form the end of the nose and its columna. The detail essential to the proper description of this operation, which was done with success by the late Prof. T. T. Sabine, is too extensive to be considered here. A full account of this very interesting case can be found in the April number of the Illustrated Quarterly of Medicine and Surgery, 1882. Pancoasf’s Subcutaneous Method.—The subcutaneous method consists in the subcutaneous division of the depressed tissues, so that they are sep- arated from their bony connections, as was done by Professor Pancoast in 1842. The operation can be best described in his own language: “ A long, narrow-bladed tenotomy knife was introduced on either side by a puncture through the skin over the edge of the nasal process of the upper maxillary bone. The knife was pushed up under the skin to the top of the nasal cavity, and then brought down, shaving the inner side of the bony wall so as to detach the adherent and inverted nose upon either side. The point of the nose could now be brought out. The nose still remained adherent to the top of the nasal chasm. The knife was a third time intro- duced under the skin, in a direction corresponding nearly to the long diam- eter of the orbit of the eyes, and the adhesions separated from the nasal spine and the internal angular processes of the os frontis. The soft parts and the cheeks were loosened, by sweeping the knife outward along the sur- face of the bone, so far as to divide the infra-orbital nerve and artery on each side down toward the median line, and held together with sutures passed through the cavity of the nose.” The saddle-back and angular deformities of the nose are of not infrequent occurrence, and are either of acquired or congenital origin. These defects can be rectified by Konig’s method (Fig. 072), and by the use of various mechanical expedients. Martin’s platinum support (Fig. 673), as employed by Weir and others, is representative of this class of mechanism. 530 OPERATIVE SURGERY. The Operation.—A flap composed of the upper lip and of the nose, up to the transverse center of the nasal bones, is raised by free division of the mucous membrane at the gingival fold, and separation of the soft parts of the nose from the bony borders of the meatus with a small scalpel. A platinum support so constructed as to meet the cosmetic requirements is anchored in position beneath the flap by inserting the ends of the legs (c h) into small openings made into the bone at the outer borders of the meatus with a fine awl. The nasal flap is then properly adjusted to the support (a), the borders of the gingival fold are united with fine sutures, and moderate pressure is applied to the upper lip to secure prompt union. Within a week or so the post-operative irritation disappears, and the patient will be relieved of the deformity for a variable period without material personal discom- fort. The introduction beneath the integument at the seat of deformity of a properly shaped piece of celluloid is easy and comparatively satisfactory in the experience of the author. The incision is made in the median line of the nose down to the periosteum, the soft parts are turned aside sufficiently to permit of the introduction into the depression of a celluloid bridge so shaped as to remedy the defect. The flaps are closed with horsehair sutures and the patient kept quiet till union occurs. Properly shaped pieces of gold, sil- ver, platinum, rubber, etc., placed on the bridge of the nose, or supported by artificial septa, are occasionally em- ployed as described. The Comments.—The consideration of these expedients is introduced with the full knowledge of the fact that, as yet, but temporary success from their use can be assured. However, even this may be of great value in certain cases and it is not impossible that the improved technique of extensive practice may greatly increase the benefits. The dangers attending these procedures when offset by aseptic precautions are of little moment. I can not refrain from expressing the belief that in many of the instances of non-traumatie, so-called nasal deformities, the out- line of the nose is in accordance with the demands of the architecture of the face, and therefore should not be condemned for contributing its share to the “ best that can be done under the circumstances.” In such cases as these, the morbid imaginings of the patient and the complaisant co-operation of the enterprising surgeon may make an agreeable face grotesque by the fashioning of an incongruous nose. The angular nose can be made shapely often by the removal of the super- abundant tissue at the seat of deformity with a sharp chisel or knife. The incision for this purpose is located in the median line of the deformity, and Pig. 673.—Martin’s nasal support. PLASTIC SURGERY. 531 is of proper dimensions to permit exposure of the enlargement without undue injury of the contiguous soft parts. After removal, the incision is closed in the usual manner. Disfigurement of the nose dependent on morbid growths frequently re- quires treatment. So long as the bony and cartilaginous framework of the nose remain intact, the removal of the disfigurement and the grafting of the raw surface resulting therefrom can, in the great majority of cases, be carried to a satisfactory issue. The following case illustrates the idea in an emphatic manner : This patient came under the observation of the writer while suffering from a large and highly vascular angioma involving nearly all of the superficial structures of the nose and the columna (Fig. 674). The growth began in infancy as a “mother’s mark ” and had increased rapidly in size during the last three or four years. Re- peated severe haemorrhages had occurred from an ulcerating point on the surface, which greatly weakened the patient. The following plan of treatment was carried into effect. The circulation was controlled at either side of the nose by long-bladed forceps so applied as to compress the upper lip and cheek; that of the frontal vessels was controlled by direct external pressure. The growth was split in the median line down to the bony and cartilaginous framework the entire length with a scalpel, and the respective halves were turned aside with a blunt instrument carried along the bony and cartilaginous tissues to the outer limits of the growth, where they were ligatured with the cobbler’s stitch and cut away with cautery. The alse were not involved suf- ficiently to require removal. After the cutting away of the ligatures the granulating surface was covered with skin grafts taken from the thigh of the patient, and quickly healed (Fig. 675). The remaining points of angiomatous structure were treated with galvano-puncture. Harelip.—The deformity of harelip constitutes a large proportion of the congenital defects calling for operations upon the face. The operations for its relief can be practiced at any age, but the best time is as soon after birth as the infant becomes sufficiently well educated to take its food and enabled to bear the loss of blood. If the infant be plump and robust operation can be practiced earlier than if weak and puny. The exceptions are rare when operation is not admissible at four months of age. The complete control of the patient during the operation is important. For this purpose an anaesthetic should be given, chloroform being usually selected. The arms of the patient are placed at the sides and held in position by a napkin surrounding the body and pinned sufficiently tight to prevent their withdrawal, being careful, however, not to constrict the chest during anaesthesia. One assistant takes the child in his lap, another stands behind him and holds the infant’s body. The head of the patient is held by the hands of the first assistant, so as to enable him to control the movements of the head, and likewise the circulation in the facial arteries with the fingers, and at the same time to bend the head forward, that blood may escape from the mouth. He can, if necessary, also administer the anaesthetic with a small sponge held between the index fingers. The success of the operation will depend in a very large degree upon the entire absence of tension of the parts when placed in position. To prevent tension, it is often necessary to separate the lip and cheeks to a considerable extent from their bony con- 532 OPERATIVE SURGERY. Fig. 674.—Before operation (£ size). Fig. 675.—After operation (£ size). PLASTIC SURGERY. 533 nections. In some instances, owing to the difficulties of the case, the loss of blood will be considerable, unless every precaution be taken. The cor- onary vessels usually supply the bleeding points, but they can be easily con- trolled by grasping the lip at both sides of the incision between the thumbs and fingers. By this procedure, the same force that puts the part upon the stretch also checks the flow of blood. As the fingers of the assistant often hinder the operator, especially if the cleft be large, their action can readily be supplemented by passing through the lip, at each side of the proposed cut, a strong silk ligature, which, when looped, make it possible to keep the parts on the stretch without inconvenience, and which can be so placed that when made tense the coronary vessels will be compressed. Either Milne’s artery compression forceps or Langenbeck’s serre-fines (Fig. 96) will control the haemorrhage admirably if fixed at the angle of the mouth on each side. If the blades of the ordinary dressing forceps be sur- Fig. 676.—Instruments employed in operation on harelip, a. Double-edged and blunt- pointed knives, b. Thumb- and mouse-toothed forceps, c. Sharp-pointed curved, and blunt-pointed straight scissors, d. Harelip pins (not frequently used now). e. Langenbeck’s serre-fines. /. B’orcipressure forceps. rounded by adhesive plaster and closed upon the lip by rubber bands passed around the handles, a useful substitute will be had for the instruments just mentioned (Fig. 676). The borders may be pared with a sharp-pointed scalpel, strong scissors, or the triangular cataract knife; the latter is very useful for this purpose. It is not permissible to sacrifice certain of the parings taken from the free borders of the cleft, except in cases with but little deformity ; they therefore should remain attached and be utilized in filling in the gap, this being the only satisfactory manner of avoiding the occur- rence of the objectionable notch often seen after operations for harelip. The pins and sutures should perforate the flaps at least a third or fourth of an inch from the borders of the wound, and even farther, if there be any degree of tension. One or two of either will be sufficient in the majority of cases. Neither pins nor sutures are carried entirely through the flaps, but are passed near to their under surface. The sutures may be inserted nearer to 534 OPERATIVE SURGERY. the edges of the wound than the pins, and in sufficient number to properly connect the lips. The pins are removed within two or three days, the sutures remain longer. If ulceration around the pins be threatened, they should be removed after others have been inserted at new points to receive any strain that may be present. The operation for all forms of harelip can be divided properly into three steps. The First Step.—In the first step the possibility of the occurrence of tension with union of the borders of the defect, is combated by freely separating the lip and perhaps also the cheek backward and upward from the bone at either side with scissors or scalpel. A restraining ala should be separated from its bony connections in a similar manner. Unusual bony projection should be remedied by instrumental or manual force at this time. The Second Step.—The second step consists in making the borders of the cleft tense with mouse-tooth forceps and cutting them of equal thick- ness with a small, sharp-pointed scalpel, or with scissors, in accordance with the plan of the operation. When possible, the preparatory cutting should be planned so as to utilize the parings in the final closure, thus lessening tension and obviating a notched vermilion border. The performance of this step is attended with more or less hasmorrhage, which can be easily controlled by pressure at either side of the lip with the fingers, by Langen- beck’s serre-fines, or properly adjusted traction sutures. The Third Step.—The third step relates to the approximation of the divided borders. The borders are apposed by forward pressure directed from the cheeks by the assistant. A single, long harelip pin is then carried through the flaps at the center of the lip at considerable distance from the borders, and its influence supplemented with a figure-of-eight aseptic cotton- yarn suture applied moderately tight. The vermilion borders of the flaps are now carefully adjusted and united with silkworm-gut sutures; the upper border is similarly treated. The pin is then withdrawn and the intervening space suitably joined with similar sutures. Two or three sutures of fine catgut or silk are next applied to the vermilion border and mucous mem- brane. If tension be marked, the pin or needle employed in the primary adjustment of the borders can again be used, and its influence supplemented with the cotton-yarn suture, until danger of ulceration at the points of perforation is feared. If still further restraint be needed, the pin may be reapplied at a different site. The wound is then dressed with iodoform or acetanilid and still further supported if necessary with adhesive strips which are applied far back on either cheek, drawn forward, crossed, and attached to the opposite sides simul- taneously. If there be a cleft in the hard palate also, the application of iodoformized collodion to the surface of the wound will prevent the food and buccal discharges from soiling its borders. The wound is redressed at the end of the second or third day. The sutures are removed successively from the fifth day on, the lip being fortified by adhesive-plaster restraint over the site of removal if advisable. When union fails in part or entirely, the borders ought still to be held as nearly together as possible, during such PLASTIC SURGERY. 535 a degree of repair as may take place. An attempt to remedy a secondary defect of this sort by operation should not be made until some time has elapsed, in order that the borders shall again become well healed, and the condition of the patient improved. In all instances, carefully avoid closure of the nostrils unless the patient is able to breathe easily through the mouth when they are obstructed. Single Harelip.—Single harelip can be treated bv superficial or deep paring with direct union of the borders of the cleft either by the single- or Fig. 677.—Mirault’s method of freshening and suture, double-flap methods. The simplest method consists in paring with a knife the borders of the cleft, loosening freely the labial connections to the bones, and bringing the edges directly into contact with each other. Unless the operation is carefully performed this method is often followed by a notch at the border of the lip where the flaps are joined. The Single-flap Method (Mirault) (Fig. 677).—Draw down both borders of the cleft and freely sever their connections with the bone; pare the bor- der of the longer portion, and make the flap from the shorter; turn down the flap, and approximate and unite the borders as before described. The Double-flap Method (Malgaigne).—Pass a silk ligature through each angle of the fissure; divide the sublabial connections; make one side tense; Fig. 678.—Malgaigne’s method of freshening and suture, transfix it near the border of the fissure, and cut upward to and over the apex of the same; repeat the operation on the opposite side of the fissure; draw both flaps thus formed downward, bringing their cut surfaces in con- tact with each other (Fig. 678); close the cleft with a pin or suture passed near to the vermilion border, and with another above if necessary; unite the everted flaps by a fine silken thread or horsehair; cut off their extrem- ities obliquely, leaving enough tissue to form a prominent projection at the 536 OPERATIVE SURGERY. margin of the lip in order to obviate the formation of a notch. If the cleft be shallow the flaps should remain connected above and be turned downward and united as before. Fig. 679.—Hagedorn s method of freshening and suture. llagedorn's Method (Fig. 679).—Loosen the lip and fix the borders of the cleft with traction sutures; make a curved incision on either side by transfixion from above downward along the outer limit of the convex muco- Fig. 680.—Simon’s method. cutaneous borders of the cleft to near the vermilion border of the lip, the incision in the major border of the cleft being slightly the longer; from near to the lower end of the shorter incision and from the lower end of the longer one, two short incisions are made, the one passing horizontally outward, and the other obliquely upward and outward. Short incisions are then made outward from the free borders of the cleft to the long ones. The upper extremi- ties of the primary incisions are united by short trans- verse incisions, and the mar- ginal tissue is removed. The borders are brought in con- tact and united with silk- worm-gut. Simon’s Method (Fig. 680).—Simon made an L-shaped incision in the border opposite the median one, and a recumbent -<-shaped incision at the median border(A); the tis- sues were removed, the upper limits of the freshened borders were united first, and the remaining portions subsequently, in the usual manner. Fig. 681.—Dieffenbach’s method, liberating incisions. PLASTIC SURGERY. 537 Dieffenbach's Method.—In cases with wide and complete clefts, liberating incisions passing around the alas (Fig. 681) and outward for a short distance into the cheeks, or made transversely directly below the nose, are of much service in securing ready and proper coaptation of the borders of the cleft. These incisions enable the surgeon to make more readily the needed detach- ment of the lip from the jaw. Konig's Method.—Konig removes the borders of the cleft entirely, and then forms a flap at either side by means of incisions directed downward and outward from near the middle points of the vertical ones (Fig. 682). The Fig. 682.—Konig’s method of freshening and suture. incision at the outer side of the cleft is somewhat the longer. The flaps are tilted downward in sewing, thus obviating the liability of a notch in the vermilion border. Giraldes's Method.—G-iraldes’s method is principally employed when the deformity extends into the nasal cavity, and the flaps are constructed so as to provide a floor to its entrance (Fig. 683). When the flap (1) is carried upward to repair the floor of the nostril, the angle of this flap is then brought in contact with the angle at the upper extremity of the Fig. 683.—Giraldes’s method of freshening and suture, border (3), the cut surfaces thus brought into apposition being of a similar length (3, 4). The freshened border (5) then comes in contact with (2) the point of the flap resting upon the undermost cut, in which position the margins are united. The cuticular border of the end of the inner flap (1) is partially removed so that a freshened wedge of tissue is inserted at the horizontal incision of the flap. This is an admirable operation, and can be employed on all occasions where extensive deform- ity exists. 538 OPERATIVE SURGERY. Double Harelip (Simple).—Pare the central portion (Fig. 684) on both sides; make lateral flaps with their attachments below at the outer borders (a b); liberate the labial con- nections, and approximate the raw surfaces by the aid of silkworm-gut sutux*es. Complicated Harelip.—Harelip is often complicated by a fissure through the alveolar process, which sometimes extends to the hard palate, and even beyond, and through, the soft parts. For a time before the operation, it is well for the parents or nurse to make gradual pressure upon the more promi- nent bony portion, combined with outward traction on the depressed side, endeavoring thereby to cause the alveolar arch to assume as nearly as possible a normal outline. A reasonable degree of patience in making these painless manipulations will, in time, effect a more satisfactory result than the appli- cation of sudden force by means of forceps. The practice of forcing the alveolar extremities into position, paring and wiring them, is pernicious, since to do so still further shortens the outline of the arch of the superior maxilla, and does not result in a bony union of the extremities. The gentle but constant traction exerted by the united lip will in time as certainly reduce the projecting bone to the proper place as the more vigorous measures. It is better to allow the deformity of the hard parts to remain un- molested until the teeth appear, when the outline of the biting surface of the upper may be compared with that of the lower jaw, and made to meet it by rectifying the upper, and introducing, if neces- sary, additional teeth upon a plate to fill any gap in the biting surface. Giraldes’s method (Fig. 683) offers the best means of closing the fissure in the lip in these cases. The fissure may be double, and involve both the hard and soft parts, back to and through the soft palate. The intermaxillary bone in these cases may project freely, and even be adherent to the soft parts covering the end of the nose (tig. 685). If such be the case, division of the vomer may be practiced, after which the projecting portion is forcibly pressed into position, and the soft parts are united, as in the simpler forms; except, perhaps, it may not be prudent to unite both sides simultaneously for fear of causing too great traction. The Management of a Projecting Intermaxillary Bone.—Many plans to remedy an excessive projection of this bone have been devised. Blan- din advised the free removal of a.properly estimated triangular-shaped piece from the vomer (Fig. 686). But attendant haemorrhage and failure of union caused many surgeons to advise rather its subperiosteal resection. The subperiosteal method is readily accomplished by raising the periosteum Fig. 684.—Double harelip. Fig. 685. — Complicated harelip. PLASTIC SURGERY. 539 and superimposed mucous membrane simultaneously with a delicate peri- osteotome through incisions made along either side of the edge of the vomer. After a proper extent of denudation, the elevated tissues are drawn aside by retractors, and the triangular section is made with strong scissors; the projecting portion is forced into place, and the soft parts are properly retained by suitably ar- ranged intra-nasal and supra-labial restraint. Rose advised that a single vertical incision be made through the bone after denudation. When the protruding portion is connected to the nose, it should be separated with care or the columna will be impaired. Bardeleben divided the bone after denudation for about three-quarters of an inch and then reduced the deformity with but trivial bleeding. The reduction of the deformity then causes an overlapping of the borders of the vomer, which is followed by union of the apposed surfaces. The Operation for Double Harelip (Complicated).—After proper reduc- tion of the intermaxillary bone, the central strip of integument is pared at the margins so as to form a quadrilateral-shaped flap. After this is ac- complished the outer borders of the cleft are pared, the lower portions of which are provided with flaps similar to those in Malgaigne’s operation. The borders of the upper portions are removed entirely. The attached flaps are turned downward, trimmed, and properly united with each other, coinci- dent with the proper adjustment of the remaining corresponding borders of the wound (Fig. 687). The author in two cases of this character has Fig. 686.—Projecting intermaxillary bone. Blandin’s operation, triangular incision. Rose’s operation, dotted line. Fig. 687.—Operation for double harelip. turned outward the parings of the vertical borders of the central segment, and inserted the distal ends respectively into transverse incisions made one beneath either ala, as in Giraldes’s method. This plan provides a good floor to the entrance of the nostrils. Hagedorn’s Method (Fig. 688).—Hagedorn’s method, although not so simple as the preceding one, requires no special description to explain it. The teatlike projection at the median line of the upper lip is longer than necessary. 540 OPERATIVE SURGERY. The After-treatment.—In such cases as these care must be taken not to obstruct the nasal openings, hence cumbersome dressings should be avoided, and the wround treated with iodoformized collodion supplemented with a scanty gauze covering. The mouth and the nostrils, especially Fig. 688.—Ilagedorn’s operation for double harelip. the latter, should be kept well cleansed and free from all discharges, food, etc. In other respects the treatment is similar to that of the preceding cases. The Results.—The rate of mortality depends on the severity of the opera- tion, age, condition, and environments of the patient, etc. About five per cent, die in the first two weeks after operation, and about forty to fifty per cent, during the first year. However, the operation can not alone be blamed for this high rate. Cheiloplasty is an operation directed to the cure of deformities of the lips dependent on disease or congenital defects. The general technique of cheiloplasty differs but little from that of harelip. The former operation is addressed mainly to the defects of adults and those amenable to discipline. Therefore, the re- quirements of cleanliness are better observed, and the final results are correspondingly im- proved. Deformity of Lower Lip. The V Incision. —The V incision is employed for the removal of epitheliomata or other morbid growths that do not require the elimination of more than one third of the lip. The whole thickness of the lip is divided, the length of the arms of the Y being increased proportionately to the width of its base. The usual liberating incisions may be required. The cut surfaces are united by the same means, and cared for in the same manner, as in operations for hare- lip (Fig. 689). The Horizontal Incision.—When the mor- bid process does not involve the free border of the lip, it can be removed by an oval incision horizontally situated, and the gap closed in the usual Fig. 689.—V incision: union with harelip pins. PLASTIC SURGERY. 541 manner (Fig. 690). If the space be too large to admit of closure, it can be left to heal by granulation, or be remedied by the sliding process, either with or without parallel or transverse incisions. (Jehus's Method.—When the morbid growth involves the whole or half of the lip, the broad-based V incision is supplemented by transverse ones extending outward from each angle of the mouth a sufficient distance to admit the easy joining of the V borders after the tissues have been freely lib- erated from their bony attachments (Figs. 691 and 692). If difficulty Fig. 690.—A method of removal of superficial epithe- lioma of lip. Fig. 691.—Celsus’s method, flap formed. Fig. 692. Celsus’s method, flap united be experienced in sliding the naps, it may be overcome by making short vertical incisions through the cheek at the outer extremities of the hori- zontal ones (e, e). The most ingenious feature of this method consists in dividing the buccal mucous membrane at least a fourth of an inch above the incision made through the cheek and parallel with it, so that when the outward cuts are completed, and the parts joined in the median line to form the lip, the raw border of the latter can be covered by turning the pro- cesses of mucous membrane over it, thereby forming an excellent vermilion border. The angles of the mouth are also to be formed bv stitching the membrane and buccal cuts to each other. Estlander's Method.— Estlander’s method is ef- ficient when the loss of lip is partial, located at one side, and encroaches on the skin over the chin (Fig. 693). A triangular flap, having the coronary artery in the pedicle, is turned downward from the Fig. 693.—Partial cheiloplasty (Estlander). 542 OPERATIVE SURGERY. cheek and fitted to the gap below prepared for its reception. This method provides a vermilion border and results in a prompt and satisfactory cure. LangenbecJc's Method (Circular).—Langenbeck’s method is addressed to a defect limited to any part of the lower lip not exceeding half its length (Fig. 694), and involving the movable portion only. The incision passes along the inferior limit of the defect, and is extended outward at either side around the angles of the mouth and into the upper lip to a distance conforming to the width of the gap to be closed. The separated portions of the lip are loosened and so adjusted as to fill the gap when united by Fig. 694.—Cheiloplasty with displacement of the border of the lip (Langenbeck). Fig. 695.—Cheiloplasty with the formation of two flaps from the cheeks (Bruns). sutures below. The remaining portion of the gap is closed with sutures, always remembering to begin the suturing opposite the angles of the newly formed mouth, that the oval outline may be maintained. Bruns's Method.—Bruns’s method is applicable to the restoration of the entire lower lip (Fig. 695). After the gap is properly fashioned, two quadrilateral flaps, comprising the thickness of the cheek are formed, one at either side of the mouth. These flaps are loosened and turned down- ward into the gap, to the borders of which they are carefully united with sutures. If the buccal mucous membrane be divided on a line a quarter of Fig. 696.—Cheiloplasty with the formation of a flap from the chin. After suture (Langenbeck). Fig. 697.—Cheiloplasty (Svme- Buchanan). an inch or so posterior to the division of the cheek, a vermilion border may be formed by sewing the membrane to the integument after the flaps are properly placed and united. The resulting wounds of the cheeks are closed with sutures. PLASTIC SURGERY. 543 Langenbeck's Method.—Langenbeck devised this method to meet those cases in which the tissues of the chin only are available for use (Fig. 696). The flap may be made single or double, according to the de- mands of the case. In the single-flap method the oblique margin of the defect is made to correspond to the proximate part of the new lip. The ob- lique incision is then prolonged downward, and in other requisite directions, sufficiently to construct a flap of suitable dimensions to fill the gap. It will be noticed that minor disfigurement follows the union of the borders. It is an obvious fact, however, that it is impossible to construct a complete ver- milion border in this instance. The Syme-Buchanan Method.—This method is adapted to restoration of the lip when the loss of tissue is sustained mainly by the central part, and at the lower border. Two quadrilateral flaps are made at either side of the Y-shaped incision employed for the removal of the defect, each correspond- ing to half the length of the lip, by carrying downward at either side an incision continuous with the border of the gap (Fig. 697). The width of the flaps should correspond after shrinkage to the width of the lip. The flaps are loosened, carried upward, and united at the median line, thus effect- ing the restoration. Syme’s Method.—In Syme’s method the operation is performed by con- tinuing the sides of the V-shaped incision (Fig. 697) downward and outward along the lower portion of the cheek in a curvilinear direction for about two inches, dissecting up the flaps in the usual manner, raising them up to form the lip, uniting them in the median line, and allowing the remaining portion to heal by granulation. The mucous membrane should be stitched to the integument to provide a suitable border. Buchanan’s method differed from Syme’s in making the extremities of the flaps straight. In other respects no radical difference between these methods exists. Buck's Method.—Buck first removed the morbid growth by the Y-shaped in- cision, and united the parts in the usual manner. After union had taken place, the short lower lip was overhung by the upper, giving to the patient a sucker- mouthed appearance (Fig. 698). The steps taken to relieve this deformity can best be described in Dr. Buck’s own lan- guage : “ In order to insure precision in making the requisite incisions, their course should first be designated by pins temporarily inserted erect in the skin at certain points, as shown by Fig. 699. The letters a a represent two pins inserted at one finger’s breadth below the under-lip border, one at either side of the chin, a little to the outside of the angle of the mouth, and both equidis- tant from the median line; h h are also two pins inserted, one on either side, into the upper lip, at the margin of the vermilion border, both equidistant Fig. 698.—Operation for contracted lower lip. 544 OPERATIVE SURGERY. from the median line and at such a distance apart as to include between them sufficient length of lip border with which to form a new upper lip. The steps of the operation are, then, the following: with the forefinger of the left hand placed on the inside of the moiith, the cheek is held moderately on the stretch, while with a sharp-pointed knife it is transfixed at the point a, as marked by the lowTer pin in the side of the chin. An incision is then carried through the entire thickness of the cheek upward and a little out- ward, a distance of one inch and a half to a point e, near the middle of the cheek. The upper lip should next be transfixed at the point b, marked by a pin on the vermilion border, and the incision carried through the lip and cheek outward and a little up- ward to join the first incision at its terminus c in the middle of the cheek. A triangular patch, b c a, will thus be formed which will include the entire thickness of the cheek, writh its apex free and disconnected while its base remains attached toward the mouth. The next step is to transfer the patch from the cheek to the side of the chin. For this purpose an incision should be made on the side of the chin from the starting-point of the first incision a, vertically downward to the edge of the jaw and to the depth of the periosteum. The edges of this incision, retracting wide apart, afford a Y-shaped space for the lodgment of the triangular patch, which is now to be brought around edgewise and adjusted by sutures in the new location. By this transfer, the portion of the upper-lip border that formed a part of the base of the patch is brought into a transverse line con- tinuous with the lower lip, and forms an extension of it. The space upon the cheek, from which the triangular patch was taken, is closed by bringing its edges together and securing them by sutures. By this adjustment a new and naturally shaped angle is formed for the mouth at the point b, where the lip was transfixed in commencing the second incision of the cheek. The incisions must be made with the utmost precision, and special care taken that the mucous membrane is divided exactly to the same extent as the skin. The same procedure may be applied to the other side of the mouth and executed at the same operation.” Malgaigne's Method (Fig. 700).—In Malgaigne’s method the growth is removed by means of one horizontal and two vertical incisions. The vertical incisions begin at the angles of the mouth, the horizontal one is located be- tween the angles and below the disease. Two additional horizontal incisions are subsequently made on each side to permit the closure of the gap by the sliding method. The flaps are freely separated, brought forward, united in Fig. 699.—Buck’s incision. PLASTIC SURGERY. 545 the median line, and the mucous membrane of their upper borders is stitched to the integument. The mucous membrane can in this instance be taken with the cheek flap to form the vermilion border, as in Celsus’s method. Fig. 700.—Malgaigne’s method. Sedillofs Method (Fig. 701).—The diseased portion is removed as in the preceding method, after which the vertical incisions are extended to the lower border of the jaw, then backward far enough to make flaps of sufficient Fig. 701.—Sedillot’s method. width to fill the gap; thence directly upward to a point opposite the angle of the mouth. These flaps are dissected up and united in the median line by the usual means. Deformities of the Upper Lip.—If the deformity here be slight, it can be remedied by the simple means employed upon the lower lip. Buck's Method—Intero-lateral Flap.— Buck practiced this method to restore one half of the upper lip and the adjacent por- tion of the cheek (Fig. 702). He divided the under lip, where it joins the cheek, by a vertical incision, a b, one inch in length, at right angles to its border. He made a second incision, b c, one inch and a half in length, beginning at the lower end of the first, a b, and running forward parallel with the border of the lower lip. An oblique in- cision, c d, about half an inch in length, was then made upward and forward from the end of the horizontal one, leaving the flap with a good attachment Fio. 702.—Buck’s method, intero- lateral flap. 546 OPERATIVE SURGERY. at the point of finishing. He pared the edges of the deformity and the ad- joining end of the half lip above, and separated the latter from its bony attachments by free section of the underlying tissues directed upward toward the orbit. The under-lip flap was then tipped endwise, and its upper extremity connected by sutures with the freshened end of the half upper lip. The remaining space between the flap and cheek was closed by sutures. Fig. 707 shows the result of this operation. Entire Loss of the Upper Lip.—This deformity may be repaired by semi- circular vertical flaps or by the lateral-flap method. Buck's Semicircular Vertical- flap Method (Fig. 703).—Commence an incision at the median line on a level with the floor of the nasal cav- ity ; carry it outward and downward in a semicircular direction around one side of the mouth to a point below the lower lip corresponding to the junction of its outer and middle thirds, a b; make a similar incision, a c, around the other side of the mouth. These incisions are carried through the entire thick- ness of the cheeks and lips at a uniform distance of an inch and a quarter from the border of the opening. Dissect the remaining portions of the cheeks freely from their attachments beneath, that they may be easily brought forward. The upper extremities of the semicircular flaps are trimmed off at a proper angle, e d, after which they are united in the median line by the usual means. The interval between the cheeks and the newlv constructed mouth is closed by sutures. Fig. 703.—Semicircular-flap method. Pig. 704.—Sedillot’s vertical-flap method. Sedillot's Vertical-flap Method (Fig. 704).—The bases of the flaps in this method may be made either upward or downward, the former being the better plan. They should comprise the entire thickness of the cheeks; their length and width corresponding to the dimensions of the proposed new lip, plus an allowance of one fourth for shrinkage. They are carried PLASTIC SURGERY. 547 into position and united in the median line. The gaps in the cheek may be closed by sutures or allowed to heal by granulation. Dieffenbach's S-shaped-ffap Method.—Freshen the lower border of the remaining portion of the original lip, then raise two S-shaped flaps, one at each side of the nose, extending down to the angle of the mouth, turn them across the space in front of the alveolar process, unite them to each other and also to the freshened border beneath the nose (Fig. 705). Dieffenbach's Carved-flap Method (Fig. 681).—This method of Dieffen- bach is employed where the central part of the lip is gone and the gap Fig. 705.—Dieffenbach’s S shaped method, is covered with mucous membrane. Two flaps are formed by curved in- cisions, each beginning at the apex of the defect and carried one at either side of the alee of the nose. The mucous membrane of the gap is partially detached from above and turned downward. The flaps are liberated, brought together in the median line, united, and so joined with the reflected mu- cous membrane as to provide for the new lip a vermilion border. Szymanowski's Method.—In this method a lateral flap the width of the lip is cut from the cheek at either side (Fig. 706). The outer extrem- Fig. 706.—Szymanowski’s method, ities are curved downward so as to lessen the tension. The flaps are liber- ated the entire length, brought forward into position, and united at the median line. If the buccal mucous membrane be divided a quarter of an inch below the inferior incisions in the cheeks, it can be utilized for the formation of a vermilion border after the flaps are properly united. 548 OPERATIVE SURGERY. Ledran-Mackenzie Method (Fig. 707).—The ingenious method of repair of the loss of a large portion of the lips of one side and of the corresponding cheek by flaps taken from the chin and neck, and united to the extremities of the upper (a' to a) and the lower (b’ to h) lips respectively, is easily compre- Fig. 707.—Ledran-Macken- zie method. Fig. 708.—Repair of chin, cheek, and lips. (Vanzette). bended. Another and quite complicated method of practice for repair of the chin, cheek, and lips is presented (Fig. 708). This demonstrates the cosmetic result that may be attained when the use of highly vitalized tissues is supplemented by ingenious surgical planning. Stomatoplasty.—The operation of stomatoplasty is employed to increase the size of a narrowed mouth, or to regulate a mouth that is abnormally shaped, from deformities either incident to disease or resulting from pre- vious operative procedure. The deformity can be corrected by an operation already described when the lower lip is the contracted portion. In any instance the angles of the new mouth may be formed by means of transverse incisions made at the proper situations. Whenever these incisions are made the mucous membrane must be stitched over the raw surfaces to prevent them from becoming united. Buck's Method.—The method described by Buck for restoring the angles of the mouth is simple and effective (Fig. 709). A curved incision is made with great exactness along the line of the vermilion border, circumscrib- ing one lateral half of the mouth, and extend- ing to an equal distance along the upper and lower lips a to h. This incision should only divide the skin and not involve the mucous membrane. A sharp-pointed, double-edged knife is inserted at the middle of this curved incision, and directed toward the cheek, flat- wise, between the skin and mucous membrane, so as to separate them from each other as far outward as the new angle of the mouth is required to be placed. The skin alone is next divided outward on a line with the commissure of the mouth, d to c. The underlying mucous membrane is then divided in Fig. 709.—Stomatoplasty. PLASTIC SURGERY. 549 the same line, but not so far outward. The angles at the outer ends of these two latter incisions are accurately united by a single-thread or fine silk- worm-gut suture. The freshly cut edges of skin and mucous membrane, above and below, that are to form the new lip borders, are to be shaped by paring first the skin and then the mucous membrane in such a manner that the latter shall overlap the former after they have been secured together by fine sutures at short intervals. Serve’s Method.—Serre’s method is practiced for the restoration of the angle of the mouth (Fig. 710). Three incisions are made, a superior, external, and inferior. The first is placed horizontally in a line with the upper border of the mouth ; the second, beginning at the outer extremity Fig. 710.—Serre’s method. of the first, passes downward and inward near to the angle of the de- formity, and then directly downward for a short distance ; the third passes from the border of the lower lip just within the deformity, down- ward and outward to join the lower end of the second, thus forming a smaller triangle below with its base opposed to that of a larger one above. The circumscribed tissues are removed, the bases of the triangles caused to meet at the angle of the mouth, and the borders are joined with sutures. Meloplasty.—Meloplasty relates to the restoration of defects of the cheek dependent on cicatricial changes caused by noma, etc. The rules of action in this operation are substantially similar to those employed in plastic repairs of other parts. The utilization of skin from the neck and of that ad- jacent to the eyelids and the lips for flaps is objectionable, because of the disfigurement incident to con- traction, and when thus employed the probable need of a supplement- ary procedure should be well under- stood. In the instance of locked jaw from cicatricial tissue, the tis- sue must be dissected away freely and sound structures alone em- ployed in repair. Two flaps, the upper taken from the cheek and the lower from the cheek, neck, and chin, are employed sometimes to cure a crippling defect (Fig. 711). Fig. 711.—a. Meloplasty by the use of two pedunculated flaps from the cheek and chin. b. Condition after suture. 550 OPERATIVE SURGERY. Gussenbauer's Method.—This method is commended for those cases of locked jaw dependent on contraction caused by extensive ulcerations and sloughing of the mucous membrane of the cheeks. It is of no avail, how- ever, in those cases in which the integumentary structures of the cheek are involved. The Operation.—Fashion from the cheek and reflect backward to the anterior border of the masseter a skin flap about an inch and a quarter broad in front and two inches and a half broad behind ; remove the subcutaneous soft parts of the cheek and the scars back to the anterior border of the masseter ; so turn into the defect the superficial flap that its anterior border and the sides can be united with those of the divided mucous membrane lying beneath and in front of the masseter, thus bringing the epithelial surface innermost; divide the pedi- cle of the flap at the end of the fourth week and turn the superficial part of the flap forward; unite it to the borders of the remaining part of the defect, thus closing the defect entirely ; cover the outer surface of the flap with a rec- tangular-shaped one slid into place from the lower jaw (Fig. 712). Trendelenburg advises the application of one or two flaps, as the case may be, taken from the cheek, temple, lower jaw, or chin, to defects due to removal of cicatricial tissue involving the entire structure of the cheek. The cuticular surfaces are turned innermost, and the outer or raw surface is skin-grafted, or instead covered with an independent flap slid into place from a contiguous surface. Israel closed a defect of the skin and mucous membrane of the cheeks by means of a single long flap raised from the side of the neck and supra- Fig. 712.—Restoration of the cheek and mouth. (Gussen- bauer.) Fjg. 713.—Meloplasty. (Israel.) scapular region down to the clavicle, with the pedicle just below the angle of the jaw (Fig. 713). The flap was turned into the defect and sutured in place and the wound closed. After seventeen days the pedicle was divided and the raw surface of the posterior portion was applied to that of the ante- rior by doubling the flap, thus providing a cuticular outer surface to the PLASTIC SURGERY. 551 cheek. The remaining border of the flap and those of the defect were closely adjusted with sutures and an extended mucous border provided from the mucous membrane of the lips. Hahn closed a like defect in a similar manner by a long flap taken from the chest. Czerny raised a very long large flap from the cheek and neck with the pedicle corresponding to the zygoma. The flap included the platysma and was carried upward and so folded on itself as to permit the apex to be sutured to the posterior part of the defect, with the cuticular surface innermost. The borders of the flap were united to those of the defect and the wound closed with sutures. Later the pedicle was divided and the operation completed. Gersuny used a flap for a similar purpose having a pedicle of subcu- taneous tissue only. Flaps with these pedicles are admirable and can be turned directly into place or indirectly through a slit made in the skin. Fig. 714.—Meloplasty. (Kraske.) Fig. 715.—Lallemand’s method, with- out inversion of the flap. Kraske closed a defect in the cheek by a flap taken from the immediate locality (Fig. 714). The flap was turned over and stitched in place with the integumentary surface innermost, and the raw surfaces covered at once with Thiersch’s skin grafts. Lallemdnd carried a flap from the neck into a defect of the cheek and lips resulting from removal of a neoplasm, joining a' to a, b' to b, c' to c, therefrom without inversion of the cuticular surface (Fig. 715). However, inversion with prompt grafting of the raw surface is the better when prac- ticable. The Remarks.—In those cases in which plastic measures afford no relief, either extraction of the teeth, excision of the jaw from the corner of the mouth to the articulation, and possibly excision of the zygoma, may be required. Operations upon the Palate.—The operations employed to relieve the de- formities of the hard and soft palate are denominated staphylorrhaphy, uranoplasty and staphyloplasty (Fig. 716). The armamentarium usually OPERATIVE SURGERY. 552 Fig. 716.—Instruments employed in operations on the palate. a. Goodwillie’s knives, b. Langenbeck’s knives, c. Curved needles with eye at the end. d. Periosteal elevators slightly and much curved, e. Suture adjuster. /. Curved, sharp-, and blunt-pointed scissors, g. Curved, toothed and hooked forceps, h. Tenaculum, i. Suture twisting forceps, k. Whitehead’s mouth gag. 1. Cheek retractors minus connecting elastic (Fig. 721). m. Silkworm gut. n. Horsehair, o. Fine silver wire. Forcipressure, sponge holders, sponges, ligatures, etc., are also required. Any suitable mouth gag can be used (Fig. 4). PLASTIC SURGERY. 553 assigned to these operations is quite elaborate, and in many respects needless. Ordinary tenotomes and knives meet the indications quite well indeed. Staphylorrhaphy.—Staphylorrhaphy consists in closing an abnormal opening in the soft palate by bringing its freshened borders in contact with each other. These openings vary in extent from a simple cleft of the uvula to a complete fissure of all the soft parts (Fig. 717). Fig. 717.—Degrees of deformity. The Comments.—The length of the cleft is of less significance than the width, as narrow clefts are more easily closed than wide ones. However, the condition of the tissues of the soft palate is of importance in either case, for if they be contracted or atrophied the difficulties are increased, espe- cially in connection with the wider clefts. Spoiled children, and those with bad tempers and of indifferent health, are ill suited for the operation. Ac- cording to Mr. Thomas Smith, simple clefts of the velum may be closed at the third year of life in proper cases. If a limited involvement of the hard pal- ate be present, the operation should be deferred for three or four years longer. The simultaneous closure of both hard and soft parts is regarded as the better practice. While strong solutions of cocaine may be sufficient- ly potent for closure of short, narrow fissures, without pain, in older chil- dren or adults, still, except perhaps in the simplest cases, it is wiser to em- ploy an anaesthetic in all sensitive patients. Horsehair sutures for re- laxed tissues, and silkworm gut and fine silver wire for tense ones, are sufficient. The position of the pa- tient during operation is a matter for the comfort and expediency of the operator, and often of safety to the patient. The patient should be placed on a narrow table of suitable height, with the head raised and thrown back. Rose advises that the head be thrown far backward (Fig. 718), so that the blood will collect in the upper part of the pharynx rather than enter the Fig. 718.—Rose’s position. 554 OPERATIVE SURGERY. trachea. Inasmuch as in this position the manipulations of the surgeon are hindered, and the cranial circulation of the patient is somewhat obstructed, a reasonable doubt as to the wisdom of the posture can be entertained. Some time prior to the operation, the patient should be instructed by manipula- tion to control properly the fauces, so that the surgeon may handle the parts without causing involuntary movements of them. If the cleft extends through the whole of the soft palate, or even en- croaches somewhat upon the hard portion, it will be necessary, especially if the gap be wide, and the muscles controlling it be active, to overcome the muscular influence before attempting to unite the cleft. The tensor- and levator-palati muscles, together with the palato-glossi and palato-pharyngei, are the ones that exercise contractile influence on the part, and if they be prop- erly severed the velum will remain motionless and flaccid. The accompany- ing illustration shows their rela- tions to the important contiguous tissues (Fig. 719). The palato-pharyngei muscles can be cut with a pair of blunt- pointed scissors, by dividing the posterior pillars of the fauces, of which they form the principal part. The palato-glossi muscles, compris- ing the anterior pillars, may be cut in a similar manner. The remain- ing muscles, after first passing a silken thread through the velum on each side of the cleft at points corresponding to the origin of the uvula, looping the extremities of the threads and making the velum tense with a tenaculum (Fig. 716, h), are divided. The Tensor Palati.—Kecognize the hamular process around which the tendon of the tensor palati runs; it is located a little behind and internal to the upper posterior molar tooth. Make tense that segment of the velum by the traction suture just introduced, and enter the point of a narrow-bladed knife (Fig. 716, a and h) a little below and at the inner side of the process, with the edge upward ; carry it upward, backward, and inward, until the point is seen through the gap ; this divides almost the entire width of the velum, with the main, if not the-entire, portion of the tendon of the tensor palati. The Levator Palati.—Many of the lowermost fibers of this muscle will be cut in the division of the preceding one. If a greater section be required, depress the handle of the knife and carry it outward, so as to make an oblique incision on the posterior surface of the velum as it is withdrawn. The Remarks.—It is well to allow two or three days to elapse after division of the muscles before attempting the union of the cleft, so as to Pig. 719.—Muscles of the soft palate, a. Line of division of muscles, b. Line of incision, c. Palatine vessels. PLASTIC SURGERY. 555 permit haemorrhage and inflammatory action to subside, and to determine more clearly whether further section will be required. The levator muscle, if it be made tense by drawing the velum toward the incisor teeth by means of the silken thread, may be cut with blunt scissors under direct observation, especially if the cleft be deep. The Operation of Staphylorrhaphy.—There are three steps to the operation of staphylorrhaphy: 1. Freshening the edges of the cleft. 2. Passing the sutures. 3. Goaptating the divided borders and tying the sutures. First, apply a solution of cocaine to the palate, if advisable, and then, placing the patient in a chair or on a table which will permit the head to be thrown well back so as to expose the parts to a strong light, insert the gag and draw the cheeks aside (Fig. 720). The lower point of one border of the cleft is then seized with the forceps, made tense, and the border freshened from below upward (Fig. 721), or the reverse if desired. Treat the opposite side in a similar manner. Fig. 720.—Whitehead’s mouth gag. Fig. 721.—Freshening the borders of the cleft. Cheeks drawn aside by elastic traction, Sutures supported by hooks on band around head. Fig. 720. Fig. 721. If an anaesthetic has not been employed, the patient is allowed to rest after the completion of the first step, until the haemorrhage ceases and self- control is regained. The sutures should be half a yard in length, doubled before passing, and thoroughly aseptic. Either horsehair, silkworm-gut, or metallic sutures can be employed. Three or four are usually sufficient. The first should be introduced at the middle, the second at the lower ex- tremity, of the gap, while the remaining ones close the spaces between. They can be passed from before backward on one side, and from behind forward on the other, by means of the needle holder and the ordinary short-curved needle (Fig. 722), or in the following manner by means of a curved needle with the eye near the point (Fig. 716, c). Seize the left side of the cleft with forceps, and carry the needle through it at the point selected, from 556 OPERATIVE SURGERY. before backward ; draw one end of the suture through between the borders of the cleft; withdraw the needle, arm it with another suture, and pass it on the opposite side in the same manner; catch the thread and withdraw the needle, leaving the looped suture in the border of the cleft (Fig. 723); then pass the end of the ligature first inserted through the loop, which is forthwith drawn out, carrying the single thread through the right side. The remaining sutures are passed in a similar manner. Each one is tied somewhat loosely, to allow for the swelling, with a reef knot, or, what is better, the slip knot held in place by a second knot tied over it. The suture last passed should be always left uncut so that the borders can be steadied by traction upon it during the passage of the next succeeding one. Perforated shot may be passed over the sutures and held in position by compressing them, or by the ordinary knot. If silver wire be used, it must be very fine and flexible, and applied with an adjuster. The sponging during the operation must not be done with any form of antiseptic fluid of a poisonous nature, since the patient may swallow a certain portion of it with an objectionable result, and, too, sponging should be done sparingly, as it excites movements of the parts and hinders operation. The sutures are left sufficiently long to admit of their easy removal, which is done at the end of a week. The diet should be plain, and all conversation interdicted. The Results.—The prospect of union of the parts is very favorable, scarcely more than five per cent of the operations being failures. The time necessary to acquire a distinct voice is variable, and often this is not attainable. The death rate in cleft-palate operations before the fourth month is about fifty per cent. The unfavorable condition of the patient adds much to this result. Uranoplasty.—Uranoplasty is performed to close a fissure in the hard palate. It is divided into two stages: 1. The formation of the flaps; 2. The ar- rest of haemorrhage and the adjustment and uniting of the flaps. The patient is anaesthetized, and so placed in a chair or on a table as to permit of a good light, and the gag is introduced. Langenbech's Method—the First Step.—If there be sufficient tissue, pare the mucous edges of the cleft, otherwise omit the paring and proceed at once to raise the muco-periosteal flaps from the bone. This is done by first making an incision down upon the bone (Fig. 724) with a scalpel at the margin of the alveolar border of suffi- cient length to admit a slightly curved elevator (Fig. 71G, d). The instru- ment is thrust through the incision inward on the bone to the cleft, causing a limited separation of the muco-periosteal flap at that situation. It is then Fig. 722.—Gross’s needle forceps. Fig. 723.—Looped suture and slip knot. PLASTIC SURGERY. 557 withdrawn, and another with a greater curve is inserted into the opening at the border, and with this the flap is separated from the bone by to-and-fro movements the entire length of the cleft. The soft palate is drawn forward and its connection with the bone divided the entire width of the flap with scissors. Repeat the operation on the opposite side. Arrest haemorrhage and renew the anaesthetic preparatory to the next step of the operation. The Second Step.—Freshen the adjoining borders of the flaps and unite them with fine silver-wire or silkworm-gut sutures. If tension of the flaps be noted, the external incisions for primary introduction of the elevator should be extended backward even into the tissue of the soft palate itself, to secure easy adjustment of the borders of the flaps. The sepa- ration of the flaps can, however, be made by an ex- tension of the primary incisions at the outset, instead of as before described (Fig. 724). Haemorrhage is more easily controlled and the blood directed away from the fissure by the latter plan. The Comments.—If the fissure be very broad and one that can not be covered with the flaps already de- scribed, then flaps are made by beginning the incision at the posterior border of the last molar tooth, or, practically, in front of the hamular process, and carrying it through the periosteum, forward along the inner margin of the alveolar process to the interval between the lateral and middle incisors (Figs. 725, 719, h). If the curvilinear incision were made along the base of the alve- olar process, or were carried forward to the central incisors, the posterior and anterior palatine vessels would be divided. These flaps are now to be carefully detached by a periosteotome, from without inward and from before backward until the edges of the fissure are reached ; they are then carried toward the Fig. 724.—Langenbeck’s method. Flaps raised, adjusted, and united. Fig. 725.—Curvilinear incision and cleft with borders freshened. Fig. 726.—Borders of cleft united. median line, and, if no degree of traction be noticed, united throughout to each other by silkworm-gut or silver-wire sutures (Fig. 726). The displaced 558 OPERATIVE SURGERY. periosteum fills in the gap and often develops sufficient bone to produce an admirable degree of firmness. The sutures are allowed to remain in posi- tion ten days or so; the patient is fed on liquid food; any cough is re- lieved by anodynes, and the parts are kept clean. The Dieffenhach-Fer- gusson Method (Fig. 727). —Pare the edges of the cleft; make an incision on one side through the soft parts down to the bone, parallel to the cleft and midway between it and the alveolus (a); di- vide the bone along the line of incision with a chisel (ee) and displace it to the median line of the cleft; treat the opposite side in a similar man- ner, bringing the pared borders of the soft parts in contact with each other (c) and uniting them with sutures. These sutures can be fortified by others passed entirely around the displaced portions. The lateral openings are lightly packed with antiseptic gauze. If the cleft be located only at one side of the vomer, the osteoplastic or muco-periosteal flap is taken from the side of the defect. In these instances the passing of sutures is greatly hindered. If several openings be made through the hard palate in the line of incision (£) with a brad awl, the use of the chisel is facilitated. The Remarks.—Differences of opinion exist among competent authorities regarding the wisdom of this plan of practice, it being claimed that hasmor- rhage, sloughing, necrosis, and septicaemia are quite prominent factors in its history, especially in children of lessened vigor. Mears uses Adams’s sawr after drilling an opening for its entrance, and claims less injury is thus done to the bone than by any other means. The haemorrhage is quite severe during the separation of the muco-periosteal flaps, but it is readily controlled by pressure and cold. When the osteo- plastic flaps are made the bleeding is usually still greater. Lannelongue's Method.—In unilateral cases Lannelongue constructed a quadrilateral-shaped flap proportionate to the dimensions of the gap from the mucous membrane of the contiguous surface of the nasal septum. A long horizontal and two short perpendicular incisions outline the flap, which is then detached with a thin periosteotome and reflected downward, its base remaining attached below to the septum. The free border of this flap is then joined to the freshened outer border of the cleft with sutures. While this ingenious measure can be wisely employed as a dernier ressort, still, it may be also useful as a supplementary step in the other methods of closure. Pig. 727.—Dieffenbach-Fergusson method, a. Incision over hard palate, b. Punctures for chisel, c. Suture holes in palate, d. Margin of hard palate, ee. Incision through hard palate. PLASTIC SURGERY. 559 The Davies- Colley Method.—In this method a triangular-shaped flap {ah c), including the whole of the soft parts, is cut from the wider portion of the hard palate (Fig. 728). The apex of the flap is located just behind the in- sertion of the incisor teeth; the base {a c) extends from the border of the alveolus of the last molar tooth inward and backward to near the border of the cleft of the soft palate close to its attachment to the bone. A somewhat similarly shaped flap is formed at the other side of the cleft, the inner border of which {cl e) remains continuous with the soft parts at the border of the defect. The flap last formed is raised from the bone with an elevator and turned over across the cleft while remaining attached at its inner border by a hinge of muco-periosteal tissue {cl e). This flap is now joined to the fresh- ened opposite border of the defect with two or three catgut sutures. The first flap {a he) is now raised in a similar manner and jumped across to the Fig. 728.—Davies-Colley method. Flaps marked out. Fig. 729.—Davies-Colley method. Flaps in position. opposite side and its apex joined with the outer margin of the opposite gap by two or three silver-wire or silkworm-gut sutures. The Remarks.—This operation is much less severe than the preceding, and therefore can be employed at an earlier date. Less haemorrhage attends it and the dangers of necrosis and septicaemia are not so distinct. The pres- sure of the tongue against the roof of the mouth is less harmful. The General Comments.—The palatine vessels running along the base (see Fig. 719, c) of the alveolar process will be divided unless great care be exercised. Since these vessels run between the periosteum and mucous membrane they are much less likely to be injured in the formation of muco- periosteal than mucous flaps. However, the bleeding can be readily con- trolled by pressure and ligature. In order that the undermost flap may be easily and smoothly swung into place, it may be necessary to loosen its base quite freely from the underlying tissues. The opposed raw surfaces promptly unite, since the pressure of the tongue holds them firmly in contact with each other. Any remaining defects can be closed at another time. OPERATIVE SURGERY. 560 This method is adapted especially to young subjects—one and two years old—and those with broad defects, and in failures by other methods. The length of the cleft in the hard palate has less to do with the cure than has the width of the palatine arch. If the latter be naturally narrow, or be narrowed on account of the width of the fissure, the difficulty of closure is correspondingly increased. The more arched is the palate the easier the closure; the flatter it is the more difficult the closure because of the lack of tissue for substantial flaps. A fissure with a pointed extremity is more readily closed than one with a rounded extremity. Fissures extending to the incisor teeth are difficult of closure at that point because of the limited supply of soft parts and the difficulty of separating the periosteum at times. A rectangular knife is sometimes used for the purpose. The suitable age is about six years, provided the health of the patient be satisfactory. Operation at two or three years of age is not advisable, since interference at this time may forestall Nature’s efforts at closure, and therefore prove harmful. It can be completed at one or more sittings, depending on the obstacles to be overcome. If the deformity in the hard palate be complicated with a complete cleft of the soft palate, each defect may be treated separately. If, however, the cleft of the soft palate be partial, both can then be closed at the same sitting. The soft portion should be united first, in the manner before described, to prevent it from being obscured by the blood associated with the operation on the hard palate. The A fter-treatment.—Anodynes to relieve pain and secure quiet may be needed; ice-water for the first four or five hours, followed by iced milk and barley water for the first day or two, supplemented by nutrient enemata, are commended. The mouth should be thoroughly rinsed with a mild, innocent, antiseptic fluid after eating, and talking should be interdicted. Great pains should be taken by the parents to educate the child in speaking, otherwise the chief aim of the operation will fail of realization. In those instances in which the united borders of the cleft render the velum so tense as to prevent it from touching the posterior wall of the pharynx, and those in which on account of the great width of the fissure such a result can be foreseen, an artificial appliance should be employed at once. The Results.—Closure of the cleft does not cure the defect in articulation. However, closure aids much in the attainment of better speech, and often contributes greatly to the benefits of time and effort in this regard. Pro- longed vomiting and unskillful pulling or bruising of the borders contribute actively to failure of operations. Mechanical means are employed, not infrequently, to fill the opening in both the hard and soft parts, and to provide even an artificial uvula. The apparatus is made of vulcanized rubber, and is held in position by being attached to a plate fitted to the roof of the mouth. Defects in the biting line can be remedied by regulation of the teeth, and by the introduction into the gap of false teeth attached to the plate closing the fissure. An expert dental surgeon must be consulted, since he is, as yet, the only one fully com- petent to treat cases by this method. The ability to speak and to otherwise PLASTIC SURGERY. 561 control the action of the throat and pharynx with this contrivance is very satisfactory, in the majority of instances equaling, if not exceeding, the best results from an operation. Staphyloplasty.—Staphyloplasty consists in filling in the gap of the soft palate, and as much as possible of the hard, by a flap taken from the pos- terior wall of the pharynx. Schonborn’s Operation.—Anaesthetize the patient, perform a preliminary tracheotomy, and introduce the tampon cannula into the trachea. The flap from the posterior wall of the pharynx is made with the base downward, and the apex is carried as far upward as possible to permit of its introduction into the cleft without tension. The width and shape of the flap must be determined by the size and outline of the deformity, allowance being made for its normal shrinkage. It should consist of the mucous lining of the pharynx along with the subjacent muscular tissue. The fibro-mucous cov- erings of the hard palate are dissected up until its tissues and those of the velum are freely movable. The borders of the cleft are freshened, and the flap is brought in place and united by several sutures. The tampon cannula can be removed as soon as haemorrhage has ceased, or, at the farthest, on the day following the operation. The parts should be cleansed frequently and care- fully with a mild antiseptic fluid, to wash away the abundant secretions. The sutures should be removed on the sixth or seventh day following the operation. The Results.—The inconveniences in breathing, and the interference with hearing and smelling following a successful operation do not commend its adoption. Elongated Uvula.—An elongated uvula is easily shortened by seizing the end of the uvula with the forceps, and removing the required amount with scissors, after the patient has withdrawn the tongue by the aid of a dry towel. The little pain that may be caused by the operation can be relieved by the application to the part of a solution of cocaine. INDEX. Abdominal aorta, ligature of, 112. linear guide to, 112. Abscess, cerebral, 219. from infection of a clot, 87. in dead spaces, 83. A. C. E. mixture, 26. Acid, boric, 49. carbolic, solutions of, 48. oxalic, in cleansing hands, 100. sulphurous, 49. tartaric, in preparation of catgut, 78. Actual cautery, 65. Acupressure, 61. for varicose veins, 180. pins, 62. Adams’s operation for Dupuytren’s contrac- tion, 305. operation for subcutaneous division of the neck of femur, 381. Adductor longus, tenotomy of, 291. After-treatment of operations, 103. Agents for control of haunorrhage, 53. Agnew’s operation for webbed fingers, 504. Air in the veins, 105. Albolene, sterilization of catgut in, 73, 76. Alcohol, as antiseptic, 50. in cleansing field of operation, 80. in cleansing hands, 100. preservation of catgut in, 73. Alcoholism, as affecting results of opera- tions, 6. Allis’ inhaler, 20. Alum, 54. Ammonia, 14, 103. in shock, 105. Amputating knife, manner of grasping the, 407. knives, 406. knives, the Catlin, 408. saw, proper method of using, 409. saws, 409. Amputation, agents required for, 406. circular method, 398. circular method, modified, 401. double-flap method, 402. equilateral flaps, 403. flaps, 396. hood-flap, 403. Langenbeck’s method, 403. mixed double-flap, Sedillot’s method, 402. oval or racket method, 401. periosteal flap, 404. rectangular flap, Teale’s method, 403. retractors used in, 411. Amputation, single-flap method, 401. stump, 396. Amputation at ankle joint, Syme, 453. Bruns’s modification of Pirogoff’s opera- tion, 459. Esmarch’s modification of Le Fort’s oper- ation, 459. Fergusson’s modification of Pirogoff’s op- eration, 457. Le Fort’s modification of Pirogoff’s oper- ation, 458. Pirogoff’s method, 456. Roux’s method, 456. Wyeth's modification of Syme's opera- tion, 455. Amputation of the arm, 428. antero-posterior-flap method, 429. circular-flap method, 428. irregular double-flap method, 429. large anterior and small posterior skin flaps, 430. musculo-cutaneous flaps, Langenbeck, 429. Teale’s method. 430. Amputation of the arm at the surgical neck of the humerus, 430. by oval method, Guthrie, 431. by single external-flap method, Farabeuf, 431. Amputation at the carpo-metaearpal articu- lation, of thumb, little, and index fin- gers, 418. by lateral-flap method, 420. by oval method, 418. Amputation at the elbow joint, 426. anterior single-flap method, 427. circular method, 427. elliptical-flap method, 426. Amputation of the fingers, 413. Amputation of the forearm, 424. circular skin-flap method, 424. equilateral skin flaps, 425. musculo-cutaneous flaps, 425. Amputation at the hip joint, 481. anterior-racket method, 487. antero-posterior flaps, Guthrie, 493. circular method, Dieffenbach, 490. external-racket method, 487. Furneaux Jordan’s method. 492. Lister’s modification of external-racket method, 487. long anterior and short posterior flaps, Manec, 488. single-flap method, Malgaigne, 493. 563 564 OPERATIVE SURGERY. Amputation at the knee joint, 467. bilateral-flap method, Stephen Smith, 468. circular flap, 470. elliptical flaps, Baudens, 470. Farabeuf’s modification of Carden’s, 473. Lister’s modification of Carden’s, 472. long anterior and short posterior flaps, Pollock, 471. Stephen Smith’s, for gangrene of foot and leg, 469. Stokes’s modification of Gritti’s, 473. through condyles, Carden, 472. through condyles, Gritti’s osteoplastic, 473. through condyles, Sabanejeff, 474. Amputation of the leg, lower third, 460. author’s circular, with periosteal flap, 460. bilateral flaps, 463. Duval’s supramalleolar, 460. Guyon’s supramalleolar, 460. hood-flap, 464. large posterior flap, 462. Teale’s method, 462. Amputation of the leg, middle third, 464. large posterior flap, 464. Lee’s modification of Teale’s, 465. long external flap, 465. Amputation of the leg, upper third, 465. bilateral flap, 467. circular flap, 466. large external flap, Farabeuf, 465. Amputation at the lower extremity, 440. Amputation through the medio-tarsal joint, Chopart, 448. Forbes’s modification of Chopart’s, 449. Amputation through the metacarpal bones, 420. Amputation of the last four metacarpal bones, 420. Amputation of the inner three metacarpal bones, 421. Amputation of the four metacarpal bones, with the fingers, 421. Amputation at the metacarpo-phalangeal articulation, 416. by lateral-flap operation, 417. of second or third fingers, 416. Amputation through the metatarsal bones, 444. Amputation, at the metatarso-phalangeal joints of all the toes, 443. Amputation at phalangeal articulations of hand, 413. Amputation of the phalanges of the toes, 440. Amputation at the shoulder joint, 431. circular incision, 434. external and internal flap, Dupuytren, 433. oval flap, Larry, 436. racket-flap, Spence, 436. Amputation above the shoulder joint, 437. Amputation, subastragaloid, De Ligne- rolles, 451. Hancock’s method, 452. heel-flap method, 452. Tripier’s method, 452. Amputation, subastragaloid, Yerneuil’s method, 452. Amputation, tarsal, irregular, Molliere, 450. Amputation at the tarso-metatarsal joints, Lisfranc’s, 446. Baudens’s, 448. Skey’s, 448. Hey’s, 448. Smith’s, (R. W.), 448. Amputation of the thigh, 474. antero-posterior, musculo-integumentary flaps, 476. bilateral flaps, 475. circular integumentary flap, 477. equilateral-flap method, Vermale, 475. long anterior and short posterior flaps, Farabeuf, 479. long anterior flap, Sedillot, 479. single circular incision, Celsus, 478. Syme’s modification of integumentary flap, 477. Amputation of the thumb, 418. Amputation of the toes, all, at the meta- tarso-phalangeal joint, 443. Amputation of the great toe, with its meta- tarsal bone, 445. Amputation of first phalanx of great toe, 440. Amputation through last phalanx of great toe, 441. Amputation of the great and little toes, 442. by internal-plantar-flap method, Fara- beuf, 443. by oval flap, 443. by square-flap method, 442. Amputation of the little toe, with its meta- tarsal bone, 445. Amputation of single toes, 441. Amputation of twTo adjoining toes, 443. Amputation at the wrist joint, 422. circular-flap method, 422. double-flap, Ruysch, 423. radial-flap, Dubrueil, 424. single palmar-flap, 423. Amputations, 396. Amputations of the upper extremity, 413. Anaesthesia, by rapid respiration, 28. coughing and swallowing in, 12. degree of, 16. facies during, 14. how to prepare a patient for, 10. infiltration (Schleich), 31. instruments for, 13. intestinal, 29. local, 29. pulse during, 14. pushing jaw forward in, 15, 16, 79. reflexes as guides in, 15. respiration during, 14, 16. stimulants in, 14. vomiting in, 12. Anaesthetic, administration of, 14. A. C. E. mixture, 26. chloroform, 23. choice of, 4, 10. dangers from use of, 15. ether, 18. ether and chloroform, 26. INDEX 565 Anaesthetic, local, 29. moderate inebriation preceding, 28. morphine with, 28. mortality from use of, 18. nitrous oxide, 27. oxygen with, 28. Schleich’s method, 27. Anaesthetics, poisoning from, treatment of, 16. Anaesthetist, choice of, 12, 13. duties of, 79. Anchylosis of knee-joint, brisement force for, 496. Anchylosis, bony, of knee joint, 386, 496. Barton's operation for, 496. cuneiform osteotomy for, 386. linear osteotomy for, 386. Anchylosis of inferior maxilla, 330. Aneurism needle, 111. Fletcher’s, 112. the “ movable immovable,” 112. the “student’s,” 112. Anger’s operation for ingrown toe nail, 505. Ankle joint, amputation at, 453. Briins’s modification of Pirogoff’s, 459. Esmarch’s modification of Le Fort’s, 459. Fergusson’s modification of Pirogoff’s, 457. Le Fort’s modification of Pirogolf’s, 458. Pirogotf’s, 456. Roux’s method, 456. Syme’s method, 453. Wyeth's modification of Syme’s, 455. Ankle joint, arthrectomy of, Briins’s, 371. disarticulation at, 453. excision of, 357. excision of, non-subperiosteal, Busch, 359. excision of, subperiosteal, Langenbeck, 358. Annandale’s modification of Iliday’s oper- ation for webbed fingers, 503. Antisepsis, 38, 80. Antiseptic dressings, 96. bichloride gauze, 97, 99. improvised. 98. iodoform gauze, 96. of jute, wood wool, wood pulp, moss, peat, sawdust, 98. strength of, 96. Thiersch’s gauze, 97. Antiseptic gauze in Lister’s method, 93, 94. improvised, 98. Antiseptic gloves, 100. Antiseptic mittens, 100. Antiseptic solutions, 9, 47. for cleansing hands, 48, 100. Antiseptic spray in Lister’s method, 93. Antiseptic towels, to cover hands, 100. to pin over gown, 101. Aorta, abdominal, ligature of, 112. linear guide to, 112. Aortic-tissue ligatures, 79. Apparel of surgeon and assistants, 101. Apron, rubber, 101. Arches, palmar, ligature of, 166. Aristol, 96. Arm, amputation of the, 428. antero-posterior-flap method, 429. circular-flap method, 428. Arm, amputation of the, irregular double- flap method, 429. large anterior and small posterior skin- flap method, 430. musculo-cutaneous flaps, Langenbeck, 429. Teale’s method, 430. Arm, amputation of, at the surgical neck of the humerus. 430. by oval method, Guthrie, 431. by single-external-flap method, Fara- beuf, 431. Armamentarium of a surgeon, 33. Arrangement for operation, diagram of, 101. Arteries, ligature of, 107. guides to, 107. operations on special, 112. Artery, abdominal aorta, ligature of, 112. axillary, ligature of, 154. brachial, ligature of, 156. carotid, common, ligature of, 167. carotid, external, ligature of, 170. carotid, internal, ligature of, 172. carotids, common ligature of both, 169. circumflex, external, ligature of, 130. dorsalis pedis, ligature of, 135. dorsalis penis, ligature of, 120. epigastric, deep, ligature of, 122. facial, ligature of, 176. femoral, ligature of, 124. femoral, common, ligature of, 125. femoral, deep, ligature of, 130. femoral, superficial, ligature of, 127. gluteal, ligature of, 118. iliac, circumflex, deep, ligature of, 124. iliac, common, ligature of, 113. iliac, external, ligature of, 120. iliac, internal, ligature of, 117. innominate, ligature of, 140. lingual, ligature of, 173. mammary, internal, ligature of, 153. meningeal, middle, location of branches of, 199, 200. occipital, ligature of, 177. perineal, ligature of, 137. popliteal, ligature of, 131. profunda femoris, ligature of, 130. pudic, internal, ligature of, 119. radial, ligature of, 161. sciatic, ligature of, 118. subclavian, ligature of, 144. temporal, ligature of, 177. thyroid, inferior, ligature of, 153. thyroid, superior, ligature of, 173. tibial, anterior, ligature of, 132. tibial, posterior, ligature of, 135. ulnar, ligature of, 164. vertebral, ligature of, 150. Arthrectomv, 370. of the ankle-joint, Bruns’s, 371. . Artificial ha;mostatics (see Hmmostatics), 53. Artificial light, 67. in ligature of arteries. 111. Artificial respiration, 17, 104. Laborde method of, 18. Asepsis, 38, 80. Aseptic gauze, improvised, 98. Aseptic gauze pads, 51. 566 OPERATIVE SURGERY. Aseptic gauze sheets, 45. solutions, 47. towels, 45. Assistants at operations, 9, 79. apparel of, 101. duties of, 79. number of, 79. preparation of, 9, 79. Astragalus, enucleation of, 394. excision of, 356. Atheromatous vessels, pin pressure for haemorrhage from, 62. Auricularis Magnus, nerve, operation on, 274. Auriculo-temporal nerve, operations on, 249. Axillary artery, ligature of, 154. Axillary artery, first portion, ligature of, 154. Axillary artery, third portion, ligature of, 155. Balsam of Peru in open dressing, 103. Bandages, antiseptic, 103. elastic, as haemostatic, 55. Esmarch’s, in shock, 105. inelastic, 54. Barker’s excision of the hip joint, 374. Barton’s operation for bony anchylosis of the knee joint, 496. Battery, storage, 67. electric, 104. Baudens’s amputation at knee joint, 470. modification of Lisfranc’s amputation at tarso-metatarsal joint, 448. Baum’s operation on facial nerve, 263. Benzine vapor, 65. in preparation of catgut, 78. Beta-naphthol for instruments, 40. solutions of, 49. Bichloride of mercury as an antiseptic, 49. compressed tablets of, 99. in preparation of catgut, 77,88. Bichloride of mercury gauze, preparation of, 97. Bichromate of potassium in hardening cat- gut, 76. Biniodide of mercury, 49. Bird’s excision of knee joint by transverse incision, 365. Birthmark, treatment of, 188. Bistouries, 33. Bleaching powder, 100. Blood, transfusion with, 183. defibrinated, 185. Blunt dissector, 36, 37. Blunt hooks in ligature of arteries, 111. Boldt’s operating table, 43. Bone grafting, 198, 395, 513. transplantation, 394. Bone-holding forceps, 317. Bones, chicken, decalcified for drainage, 92. Bones, operations on, 310. excision of, 314. gouging, 310. sequestrotomy, direct, 312. sequestrotomy, indirect, 314. Boric acid, 49. Bourgary’s excision of bones of forearm, lower extremities of, 346. Bowlegs, 389. Brachial artery, ligature of, 156. linear guide to, 157. muscular guide to, 157. Brachial plexus, operations on branches of, 275. Bradford’s linear osteotomy of neck of as- tragalus for talipes equino-varus, 393. Brain, exploration for tumor of, 215. fissures, 207, 213. location of bullet in, 228, 229, 230. removal of bullet from, 228, 229, 230. topography of, 207. tumor of, 207, 216. Brisement force, 496. Bruns’s arthrectomy of ankle joint, 371. method of cheiloplasty on lower lip, 542. method of flap transfer in plastic opera- tions, 511. modification of PirogofFs amputation at ankle joint, 459. Bryant’s (J. D.) amputation of leg with periosteal flap, 460. Buccal nerve, operations on, 250. Buck’s operation of cheiloplasty on lower lip, 543. intero-lateral-flap method of cheiloplasty of upper lip, 545. operation of stomatoplasty, 548. pin conductor in acupressure, 62. pin conductor in twisted suture, 89. semicircular-vertical method of cheilo- plasty of upper lip, 546. Bullet in brain, location of, 227. Bunion, 506. Buried suture, 89, 90. Bursae, 306. Bursitis, prepatellar, operations for, 307. post-olecranon, 308. Busch’s non-subperiosteal excision of ankle joint, 359. Burows’s method of flap transfer in plastic operations, 511. Button suture, 89. Calcaneum, excision of, 355. Canalization, 93. Capillaries, operations on, 187. Carbolic acid for instruments, 40. in Lister’s method, 93, 94. in oozing, 82. in open dressing, 103. on fiefd of operation, 80. solutions of, 48. Carbonate of soda, 40, 50. in cleansing hands, 100. Carden’s amputation through condyles of femur, 472. Carnochan-Chavasse operation on superior maxillary nerve, 243. Carotid artery, common, ligature of, 167. common, linear guide to, 167. external, ligature of, 170. external, linear guide to, 171. internal, ligature of, 172. internal, linear guide to, 172. Carotids, common, ligature of both, 169. Catgut for drainage, 92. INDEX. 567 Catgut for subcutaneous ligaturing, 180. for suturing nicks in veins, 179. Catgut, ligatures of, 67, 71, 72. preparation of, 73, 77, 78. sterilization of, 73. * Catgut suture, 71, 72, 83. Cautery, actual, 65. galvano-, 65, 66. thermo-, 65. Celluloid plate in circular craniotomy, 198. Celluloid plate, for closure of openings in the dura, 216, 218, 219. Celsus’s method of cheiloplasty on lower lip, 541. Celsus's single circular incision in amputa- tion at thigh, 478. Cervical nerves, operations on, 274. Cheeks, meloplasty, for deformities of, 549. Cheiloplasty, 540. Cheiloplasty of lower lip, 540. Bruns’s method, 542. Buck’s method, 543. by horizontal incision, 540. by V incision, 540. Celsus’s method, 541. Est lander’s method, 541. Langenbeck’s circular method, 542. Langen beck’s skin-flap method, 543. Malgaigne’s method, 544. Sedillot’s method, 545. Syine’s method, 543. Syme-Buchanan method, 543. Cheiloplasty of upper lip, 545. Buck’s method, mtero-lateral flap, 545. Buck’s method, semicircular-vertical flap, 546. Dieffenbach’s S-shaped-flap method, 547. for entire loss of the lip, 546. Ledran-Mackenzie method, 548. Sedillot’s vertical-flap method, 546. Szymanowski’s method, 547. Chiene’s aethod of locating fissure of Ro- lando, 209. Chiene’s osteo-arthrotomy for genu valgum, 389. Chloride of ethyl, 29. Chloride of lime in cleansing hands, 100. Chloride of zinc, 48. Chloroform, 23. administration of, 24. dangers of, 23, 24. ether and, 26. following cocain, 31. inhalers, 25. maceration of catgut in, 74. poisoning by overdose of, treatment of, 16. Chromieized catgut, 76. durability of, 83. Cicatricial contraction, Croft’s operation for, 516. Circulatory failure, 104. Circumclusion, 62. Circumflex arterv, external, ligature of, 130. Circumflex nerve, operations on, 279. Cirsoid growth of scalp, 190. Clamps, Langenbeck’s, 55. Clavicle, excision of, 331. Cleveland’s operating table, 42, 43. Clover’s inhaler, 21. Coaptation and relaxation suture, 90. of wounded surfaces, 82, 83, 90. Cocain, as a local anaesthetic, 30. in infiltration anaesthesia, 31. in major operations, 31. Coccyx, excision of, 377. Collapse, 105. Collodion, 54, 87. in treatment of birthmark, 188. Combined dressing, 94. Compresses, 56. graduated, 57. in occluding dead spaces, 83. in treatment of birthmark, 188. simple, 57. Cone, cloth and paper, 19. Conjunctival reflex, 15. Continuous suture, 88. Cotting’s operation for ingrown toe nail, 506. Cotton-batting dressing, 94. Craniotomy, circular (trephining), 195. for brain tumor, 207, 213. for fracture of the skull, 195. for meningeal haemorrhage, 201. linear, for microeephalus, 203. Craniotomy, for cerebellar tumor, 217. for epilepsy, 218. for evacuation of pus, 219. for paralysis, general, of the insane, 223. for thrombosis of lateral sinus and jugu- lar vein, 222. Cranium, gunshot wounds of, 226. Crede’s operation on trifacial nerve at fora- men ovale, 253. Croft’s operation for cicatricial contraction, 516. Crural nerve, anterior, operations on, 281. Cumol in sterilization of catgut, 77. Curvature of the spine, 498. Davies-Colley osteotomy, cuneiform for tali- pes equino-varus, 392. method of uranoplasty, 559. Davy’s lever, 59, 482. Dead spaces, 83-91. Decalcified drainage tubes, 92. Dec’s operation for webbed fingers, 502. Deformities, 496. Deformities of cheek, 549. of lower lip, 540. of mouth, 548. of palate, 551. of upper lip, 545. De Lignerolles’s subastragaloid amputa- tion, 451. Deltoid muscle, myotomy of, 302. Denhard’s mouth gag, 13. Diday’s operation for webbed fingers, 502. Dieffenbach’s amputation at hip joint, 490. cheiloplasty of upper lip by S-shaped flap, 547. cheiloplasty of upper lip by curved flap, 547. method of flap transfer in plastic oper- ations, 510. operation for single harelip, 537. OPERATIVE SURGERY. 568 Dieffenbach’s operation of rhinoplasty, 522. Dietfenbach-Fergusson method of urano- plasty, 558. Digital pressure, 56, 57. Digitalis, 14, 104. in shock,105. Disarticulation at t he ankle joint, 453. at the carpo-metacarpal joint of the last four metacarpal bones, 420. at the carpo-metacarpal joint of the three inner metacarpal bones, 421. at the elbow joint, 426. at the hip joint, 481. at the knee joint, 467. at the medio-tarsal joint, 448. at the metacarpo-phalangeal joints, 416. at the metatarso-phalangeal joints, 443. at the phalangeal articulations of foot, 440. at the phalangeal articulations of hand, 413. at the shoulder joint, 431. at the tarso-metatarsal joints, 446. at the wrist joint, 422. subastragaloid, 451. Dissector, blunt, 36, 37. Dorsales pedis artery, ligature of, 135. linear guide to, 135. Dorsales penis artery, ligature of, 120. Douching, 102. apparatus for. 94. Doyen’s intracranial operation on trifacial nerve, 261. Drainage agents, 91-93. in chronic hydrocephalus, 192. Drainage of operation wounds, 82,90-93,103. Drainage of septic cases, 81. Drainage, spinal meningeal, 270. Dressing, by Lister’s method, 93. combined, 94. cotton-batting, 94. “ open,” 103. peat, 98. Dressings, antiseptic, 96-103. protective, 82, 93, 99. Dubrueil’s amputation at the wrist joint, 422. Duncan’s method of neuroplasty, 235. Dupuytren’s amputation at the shoulder joint, 433. Dupuytren’s contraction, 305. Adams’s operation for, 305. • Goyraud’s operation for, 305. Hardie’s modification of Goyraud’s opera- tion, 305. Dura, closing rents in, after circular crani- otomy (trephining), 198, 199. closure of, after craniotomy for brain tumor, 216. closure of, after subdural haemorrhage, 203. opening of, in craniotomy for brain tu- mor, 215. Duval’s supramalleolar amputation of leg, 460. Edebohls’s operating table, 44. Elastic bandages, 55. Elastic bandages, contraindications to nse of, 56. Esmarch’s, 55. in shock, 105. Martin’s, 56. uses of, 55, 56, 104. Elastic pressure, circular, 61. transverse, 61. Elbow joint, amputation at, 426. anterior single-flap, 427. circular method, 427. elliptical flap, 426. Elbow joint, excision of, Iliiter, 341. excision of, Liston, 343. excision of, Ollier, 343. excision of, subperiosteal, Langenbeck, 342. Electric battery, 104. Electricity, for cautery, 66. for illumination, 67. Electro-cautery, 65. Electrode in locating centers primarily af- fected in epilepsy, 218. Emergencies, special, 105. air in veins, 105. Encephalocele, 195. Enemata, hot stimulating, in shock, 105. saline, 187. Engine, surgical, 317. Epigastric artery, deep, ligature of, 122. linear guide, 123. Epilepsy, craniotomy for, 218. Epileptics, operations on, 6. Erasion, 370. Erector spinas, myotomy of, 292. Erysipelas, 6. Esmarch’s inhaler, 25. modification of Le Fort’s amputation at ankle joint, 459. operation for anchylosis of inferior max- illa, 331. splint for excision of the wrist, 351. tourniquet, 482. Estlander’s method of eheiloplasty on lower lip, 541. Ether, 18. administration of, 23. administration of, by rectum, 28. amount required to produce anaesthesia, 22. as a local anaesthetic, 29. by hypodermic, 14. contraindications, 18, 19. following cocain, 31. in preparation of catgut, 73-76. iodoform and, 49, 95. nausea following, 18. over field of operation, 80. poisoning by overdose of, treatment, 16. vomiting following, 18. with chloroform, 26. Ether inhalers, 19. Allis’, 20. Clover’s, 21. Fowler’s modification of Allis’, 21. Ormsby’s, 22. simplest form, cloth and paper cone, 19. Squibb’s, 22. INDEX. 569 Etherization, intestinal, 28. Eucain, 31. Eucalyptol as an antiseptic, 50. Excision of ankle joint, 357. non-subperiosteal, Busch, 359. subperiosteal, Langenbeck, 358. Excision of astragalus, 356. by double incision, 357. by oval incision, 356. Excision of bones of forearm, lower extrem- ities of, Bourgarv, 346. Excision of bones of leg, 362. Excision of calcaneum. 355. Excision of coccyx, 377. Excision of the clavicle, 331. Excision of the elbow joint, Hiiter, 341. of the elbow joint, Liston, 343. of the elbow joint, Ollier, 343. of the elbow joint, subperiosteal, Langen- beck, 342. Excision of great trochanter, 371. Excision of hip joint, 371. subperiosteal, Barker, 374. subperiosteal. Langenbeck, 373. subperiosteal, Sayre, 375. subperiosteal, Wliite, 372. Excision of humerus, 336. lower extremity of, 340. partial, of upper end, 339. shaft of, 340. subperiosteal, of upper end, Langenbeck, 339. upper end, by oblique incision, 337. upper end, by vertical incision, Langen- beck, 337. Excision of knee joint, 362. by transverse incision, Bird, 365. non-subperiosteal, Mackenzie, 364. subperiosteal, Langenbeck, 366. subperiosteal, Ollier, 367. Excision of maxilla inferior, 326. a lateral half, 328. a lateral portion, 328. alveolar process, 329. central portion, 327. whole, 329. Excision of maxilla superior, 318. below floor of orbit, 322. below infra-orbital foramen, extra-buccal method, 324. below infra-orbital foramen, intra-buccal method, 324. complete, by median incision, Fergusson, 321. partial removal, 324. simultaneous removal of both maxillae, 325. subperiosteal method, 323. Excision of meningocele, 194. Excision of the metacarpo-phalangeal joints, 353. Excision of metatarso-phalangeal joints, 354. Excision of patella, 371. Excision of the phalangeal joints of foot, 353. Excision of the phalangeal joints of hand, 353. Excision of radius, 345. Excision of the scapula, 333. acromion process of, 334. glenoid, angle of, 335. of body, 334. of entire bone, 333. subperiosteal, Ollier, 335. Excision of sternum, 331. Excision of tarsal joints, 354. Excision of tarso-metatarsal joints, 354. Excision of ulna, 345. Excision of varicose veins, 181. Excision of the wrist joint, 346. of wrist joint, complete, subperiosteal, Langenbeck, 348. • of wrist joint, complete, subperiosteal, Lister, 350. of wrist joint, complete, subperiosteal, Ollier, 349. Extensor brevis pollicis, tenotomy of, 285. Extensor communis digitorum, tenotomy of, 285. Extensor longus digitorum, tenotomy of, 289. Extensor longus pollicis, tenotomy of, 285. Extensor ossis metacarpi pollicis, tenotomy of, 285. Extensor proprius pollicis, tenotomy of, 289. Facial artery, ligature of, 176. Facial nerve, operations on, 263. Baum’s operation on, 263. False teeth, removal of, before anaesthesia, 11. obstruction of respiration by, during an- aesthesia, 16. Farabeuf’s amputation of arm by single external-flap method, 431. amputation of leg, upper third, 465. amputation of thigh by long anterior and short posterior flaps, 479. amputation of toes, great and little, 443. modification of Carden’s amputation at knee joint, 473. Fascia lata, operations on, 306. Fascia, palmar, 304. Dupuytren’s contraction of, 305. Fascia, plantar, division of, 303. Fasciotomy, 303. Femoral artery, ligature of, 124. common, ligature of, 125. deep, ligature of, 130. linear, guide to, 125. muscular guides to, 125. superficial, ligature of, 127. Femur, intertrochanteric division of, Sayre, 383. neck of, division of, Yolkmann, 382. neck of, subcutaneous division of, Adams, 381. subtrochanteric division of, Gaul, 383. Fergusson’s complete excision of superior maxilla, 321. modification of Pirogoff’s amputation at ankle joint, 457. Finger stalls, rubber, 101. Fingers, amputations of, 413-421. 570 OPERAT1 YE SURGERY. Fingers, supernumerary, 501. Fingers, webbed, operations for, 501. Agnew’s method, 504. Annandale’s modification of Diday’s method, 503. Dec’s method, 502. Diday’s method, 502. Fowler’s method, 504. Norton’s method, 502. Zeller’s method, 504. Fissure, intra-parietal, 211. longitudinal, 210. of Rolando, 208, 209. of Sylvius, 209. parieto-occipital, 210. precentral or vertical frontal, 211. subfrontal, 211. superfrontal, 211. transverse, 210. Fissures of brain, 207-213. Flap, osteoplastic, in laminectomy, 268. Flaps, amputation, 396. circular, 398. classification according to outline, 398. classification according to tissue, 397. comparative merits of different forms of, 404. double, 402. equilateral, 403. hood, 403. length of, 396. methods of transfer in plastic operations, 509. ‘ mixed double, Sedillot, 402. modified circular, 401. oval or racket, 401. periosteal, 403. rectangular, Teale, 403. single, 401. size and shape of, for plastic operations, 507. Flask, Erlenmeyer’s, 74. Flexor, biceps cruris, tenotomy of, 290. biceps cubiti, tenotomy of, 286. carpi radiales, tenotomy of, 285. carpi ulnaris, tenotomy of, 285. longus digitorum, tenotomy of, 286. longus pollicis, tenotomy of, 287. profundus digitorum, tenotomy of. 285. sublimis digitorum, tenotomy of, 285. Fluhrer’s probe, 227. Food before anaesthesia. 11. Forbes’s modification of Chopart’s amputa- tion, 449. Forceps, bone-holding, 317. Hamilton’s artery, 63. Liston’s mouse-tooth, 63. Liston’s spring-catch fenestrated, 63. mouse-tooth, 111. needle, 85. sequestrum, 199. serre-fine, 64. thumb, 34, 111. tongue, 13, 104. Forcipressure, 64, 111. Forearm, amputation of, 424. circular skin-flap method, 424. equilateral skin-flap method, 425. Forearm, amputation of, musculo-cutane- ous-flap method, 425. Foreign bodies, in air passages during an- aesthesia, 16. Foulis’s fastening, 56. Fowler’s modification of Allis’ inhaler, 21. operating table, 43. operation for webbed fingers, 504. Fracture of skull, craniotomy for, 195. of skull, comminuted, 199. of skull, punctured, 199. Friction knot, 68, 87. Furneaux Jordan’s amputation at hip'joint. 492. Galvano-cautery, 66. in treatment of birthmark, 188. Galvano-puncture, 188, 189. Ganglion, 306. operations for cure of, 306. Gangrene, after ligature of both femoral vessels, 179. after operations in glycosuria, 5. Gant, osteotomy, subtrochanteric, 383. Gauze, absorbent, 98. antiseptic, improvised, 98. antiseptic, in Lister’s method, 93, 94. aseptic, improvised, 98. bichloride, 97, 99. drainage by, 92. dry, in oozing, 82. iodoform, 96, 97. pads, aseptic, 51. Thiersch’s, 97. General considerations in ligature of ar- teries, 107. distinction between arteries and veins, 108. guides to arteries, 107. kind of instruments required, 111. modes of ligaturing, 107. opening of sheath, 109. passage of ligature, 109, 110. position of part, 108. primary incision, 108. selection of site for ligature, 108. tying of ligature, 111. General considerations of operative sur- gery, 1. diet, 9. nursing, 9. patient prior to operation, 2. place for operation, 7. relation of surgeon to patient, 1. requirements for operations, 9. sick-room, 8. time for operation, 7. Genu valgum, 387. osteo-arthrotomy for, Chiene, 389. osteo-arthrotomy for, Ogston, 388. supracondyloid osteotomy for, MacEwen, 388. Genu varum, 389. cuneiform osteotomy for, 391. linear osteotomy for, 390. Gersuny’s method of meloplasty, 551. Gibney's method of shortening tendo Achil- lis, 297. INDEX, 571 Gigli-IIaertel saw, 205. 317. Giraldes's operation for single hare-lip, 537. Girdner’s probe, 227. Gleiss method of nerve suture, 234. Glover’s suture, 88. Gloves, antiseptic, 100. cotton, 101. rubber, 101. Gluteal artery, ligature of, 118. linear guide to, 118. Glycerin, in preparation of catgut, 76, 77. Glycosuria, 5. Goodwillie’s mouth gag, 245. Gouge, 198. Gouging, 310. Gout, 5. Gown, 101. Gracilis, tenotomy of, 290. Grad knot, 70. Graduated compresses, 57. Grafting, bone, 198, 395, 513. Grafting, skin, 513. Krause’s method, 515. Lusk’s (Z. J.) method, 515. Reverdin’s method, 513. Thiersch’s method, 514. “ Granny knot,” 69. Green soap, confined, in preparation of operation area, 80. Grittrs amputation through condyles of femur, 473. Grooved director, 35. in ligature of arteries, 111. Gross’s artery compressor, 64. Grube’s operation for anchylosis of inferior maxilla, 331. Guide, bony, to carotid artery, external, 171. to gluteal artery, 118. to lingual artery, 174. to subclavian artery, 144. to subclavian artery, third portion, 148. to temporal artery, 177. to thyroid artery, inferior, 154. to vertebral artery, 151. Guide, linear, to abdominal aorta, 112. to axillai-y artery, third portion, 155. to brachial artery, 157. to carotid artery, common, 167. to carotid artery, external, 171. to carotid artery, internal, 172. to dorsalis pedis artery, 135. to epigastric artery, deep, 123. to femoral artery, 125. to gluteal artery, 118. to iliac arteries, common, 114. to iliac artery, external, 120. to innominate artery, 140. to lingual artery, 174. to mammary artery, internal, 153. to palmar arches, i66. to peroneal artery, 137. to popliteal artery, l3l. to pudie artery, internal, 120. to radial artery, 162. to sciatic artery, 119. to tibial artery, anterior, 133. to tibial artery, posterior, 136. to ulnar artery, 164. Guide, linear, to vertebral artery, 151. Guide, muscular, to axillary artery, first portion, 154. to axillary artery, third portion, 156. to brachial artery, 157. to dorsalis pedis artery, 135. to femoral artery, 125. to iliac artery, common, 115. to iliac artery, external, 121. to popliteal artery, 131. to radial artery, 162. to sciatic artery, 119. to subclavian artery, 144. to subclavian artery, first portion, left side, 144. to subclavian artery, first portion, right side, 146. to subclavian artery, second and third portions, 147. to tibial artery, anterior, 133. to tibial artery, posterior, 136. to ulnar artery, 164. to vertebral artery, 151. Guides to arteries, 107. Gussenbauer’s method of meloplasty, 550. Guthrie’s amputation, of arm by oval meth- od, 431. at hip joint, 493. Guyon’s supramalleolar amputation of leg, 460. Guyrand’s operation for Dupuytren's con- traction, 305. Haemophilia, 6. Haemorrhage, agents for the control of, 9, 53. arrest of, by douche, 94, 103. epidural, 201. from brain substance, 226. from lateral sinus, 223. from oozing surface, 82. from palm, etc., 61, 62. from pia, 203. from scalp, 197. from sinuses, 200, 226. in craniotomy, circular, 199. in craniotomy, linear, 206. meningeal, operation for, 203. meningeal, trephining for, 201. secondary, 53, 58, 63, 65, 68, 179. subdural. 202. Haemostatics, artificial, 53. acupressure, 61, 62. bandage, elastic. 55. bandage, inelastic, 54. cautery, 65. circumclusion, 62. compresses, 56. forceps, 63. forcipressure, 64. ligature, 67. position, 54. pressure, digital, 56, 57. pressure, instrumental, 58. retroclusion. 62. serre-fines, 63. solid rubber rings, 56. styptics, 54. tenacula, 63, 64. 572 OPERATIVE SURGERY. Haemostatics, artificial, torsion, 63. torsoclusion, 62. Trendelenburg’s rod, 60. Wyeth’s pins, 61. Haemostatics, natural, 53. Ilagedorn’s operation for single harelip, 536. Hallux valgus, 391. operations for, 392. Hamilton’s artery forceps, 63. Hammer-toe, 500. operations for, 500. Hancock’s method of subastragaloid ampu- tation, 452. Hands, cleansing of, 99, 100. by an efficient method, 100. by Johns Hopkins Hospital method, 100. by nascent chlorine method, 100. Hardy’s operation for Dupuytren’s contrac- tion, 305. Harelip, 531. operations for, 531. Harelip, complicated, 538. Harelip, double, 538. Hagedorn’s operation for, 539. operations for, 539. Harelip, single, 535. Dieffenbach’s method, 537. the double-flap method, Malgaigne, 535. Giraldes’s method, 537. Hagedorn’s method, 536. Konig’s method, 537. Simon’s method, 536. the single-flap method, Mirault, 535. Harelip suture, 88. Hartley-Krause intracranial operation on trifacial nerve, 257. Heart, condition of, before operation, 4. Heat, red, in treatment of birthmark, 188. Hemp ligature. 67. Hey’s amputation of leg, middle third, 464. Hey’s modification of Lisfranc’s amputation at the tarso-metatarsal joint, 448. Hip joint, amputation at the, 481. anterior-racket method, 487. antero-posterior flap, Guthrie, 493. circular-flap method, Dieffenbach, 490. external-racket method, 487. Furneaux Jordan’s method, 492. Lister’s modification of external-racket method, 487. long anterior- and short posterior-flap, Manec, 488. single-flap method, Malgaigne, 493. Hip joint, congenital dislocation of, 384. operation for, Hoffa’s, 384. operation for, Lorenz’s, 384. Hip joint, disarticulation at the, 481. Hip joint, excision of, 371. subperiosteal, Barker, 374. subperiosteal, Langenbeck, 373. subperiosteal, Sayre, 375. subperiosteal. White, 372. Hoffa’s operation for congenital displace- ment of hip joint, 384. Holders, needle-, 85. * Hooks, blunt, in ligature of arteries, 111. Horsehair, 71, 83, 84. drainage by strands of, 92. Horsehair, sterilization of. 84. Horsley’s fissure meter, 208. Horsley’s intradural operation on trifacial nerve, 262. Hot-water bags or bottles, after operation, 103. in shock, 105. “ Housemaid’s knee,” 307. Ilviter’s excision of elbow joint, 341. Humerus, amputation at surgical neck of, 430. Guthrie’s method, 431. Parabeuf’s method, 431. Humerus, excision of, 336. lower extremity, 340. shaft, 340. upper end, by oblique incision, 337. upper end, partial, 339. upper end, subperiosteal, Langenbeck, 339. upper end, by vertical incision, Langen- beck, 337. Hydrocephalus, acute, treatment of, 193. chronic, treatment of, 191. Hypodermics. 14. in shock, 105. Hysterical, the, operations on, 6. Ice, as local anaesthetic, 29. Iliac arteries, common, ligature of, 113. linear guide to, 114. muscular guide to, 115. Iliac artery, circumflex, deep, ligature of, 124. Iliac artery, external, ligature of, 120. Iliac artery, internal, ligature of, 117. Illumination, by electricity, 67. Incision, “ gridiron,” in ligature of external iliac artery, 122. Incisions, 37. in ligature of arteries, 108, 109. in linear craniotomy, 204. in trephining, 197. Inclined plane, portable, improvised, 44. Indian method of rhinoplasty, 523. Inebriation, moderate, with anajsthetics, 28. Infecting agents, removal of, by douche, 94. Infection, dui’ing operation, 46. in ligature of veins, 179. of a retained clot, 87. Inferior dental nerve, 244. operations on, 245-248. Paravicini’s operation, 245. stretching of, 248. Infiltration anaesthesia (Schleich), 31. Infra-orbital nerve, operation on, 237. Ingrowing toe nail, 505. Inhalers, chloroform, 25. Esmarch’s, 25. Junker’s, 25. Skinner’s, 25. Inhalers, ether, 19. Allis’, 20. Clover’s, 21. Fowler’s modification of Allis’, 21. Ormsby’s, 22. simplest form of, or cone, 19. Squibb’s, 22. INDEX. 573 Injection, of meningocele, 194. in treatment of birthmark, 188. of varicose veins, 180. of ventricles in chronic hydrocephalus, 192. subcutaneous, of saline fluids, 187. Innominate artery, deep guides to, 140. ligature of, 140. linear guide to, 140. Inorganic ligatures, 67. Inorganic sutures, 84. Insane, the, operations on, 6. Instrumental pressure for control of haemor- rhage, 58. Instruments, for anaesthesia, 13. assistant to care for, 79. construction and finish of, 32. for special purposes, 32, 33. in general use, 32, 33. necessary, for operations, 9, 32. receptacles for, 9, 39. selection of, 32. sterilizers for, 40. sterilization of, 40, 99. the standard of quality of cutting, 32. Interrupted suture, 87. making of, 87. removal of, 88. Intestinal etherization, 28. Intraspinal division of roots of spinal nerves, 275. Iodine, reaction, 95. as wash, 48. Iodoform, 95. agents to lessen odor of, 98. and ether, 49. etherial solution of, over operation field, 80, 95, 99. gauze, 96. in peat dressing, 98. objections to use of, 98. over wound, 103. pulverized, 95. symptoms of poisoning from, 98. Iodoglyeerin, injection of, in meningocele, 194. Iodol, 96. Iron, subsulphate of, 54. Irrigation, in open dressing, 103. Irrigator, fountain syringe as, 94. Israel’s method of meloplasty, 550. Israel’s modification of Konig’s operation of osteoplastic rhinoplasty, 528. Italian method of rhinoplasty, 527. Jaesche-Dieffenbach method of flap trans- fer in plastic operations, 511. Jaw, lower, anchylosis of, 330. Esmarch's operation for, 330. Grube’s operation for, 331. Rizzoli’s operation for, 331. Jaw, lower, excision of, 326. of alveolar process of, 329. of central portion of, 327. of lateral half of, 328. of lateral portion of, 328. of whole of, 329. Jaw, pressing forward of, in anaesthesia, 15, 16, 79. Jaw, upper, excision of, 318. below floor of orbit, 322. below infra-orbital foramen (extra-buccal route), 324. below infra-orbital foramen (intra-buccal route), 324. by subperiosteal method, 323. complete, by median incision, Fergusson, 321. partial, 324. Jaws, upper, excision of both, 325. Joint, ankle, amputation at, Esmarch’s mod- ification of Le Fort’s, 459. Pirogoff, 456. Pirogoff’s, Bruns’s modification of, 459. PirogofE’s, Fergusson’s modification of, 457. Pirogolf’s, Le Fort’s modification of, 458. Roux’s method, 456. Syme, 453. Wyeth’s modification of Syme’s, 455. Joint, ankle, arthrectomy of, Bruns, 371. Joint, ankle, disarticulation at the, 453. Joint, ankle, excision of, 357. non-subperiosteal, Busch, 359. subperiosteal, Langenbeck, 358. Joint, elbow, amputation at, 426. anterior single-flap method, 427. circular method, 427. elliptical-flap method, 426. Joint, elbow, disarticulation at, 426. Joint, elbow, excision of, Jliiter, 341, Liston, 343. Ollier, 343. subperiosteal, Langenbeck, 342. Joint, hip, amputation at, 481. anterior-racket method, 487. antero-posterior flap, Guthrie, 493. circular-flap method, Dieffenbach, 490. external-racket method, 487. Furneaux Jordan’s method, 492. Lister’s modified external-racket method, 487. long anterior- and short posterior-flap, Manec, 488. single-flap method, Malgaigne, 493. Joint, hip, congenital displacement of, 384. operation for, Hoffa, 384. operation for, Lorenz, 385. Joint, hip, disarticulation at, 481. Joint, hip, excision of, 371. subperiosteal, Barker, 374. subperiosteal, Langenbeck, 373. subperiosteal, Sayre, 375. subperiosteal, White, 372. Joint, knee, amputation at, 467. bilateral-flap method, Stephen Smith, 468. circular-flap method, 470. elliptical-flap method, Baudens, 470. Farabeuf’s modification of Carden, 473. Lister’s modification of Carden, 472. long anterior-, with a short posterior-flap, Pollock, 471. through the condyles, Carden, 472. through the condyles, Gritti’s osteoplastic, 473. through the condyles, Sabanejeff, 474. 574 OPERATIVE SURGERY. Joint, knee, amputation at, Stephen Smith’s method for gangrenous condition of foot and leg, 469. Stokes’s modification of Gritti’s, 473. Joint, knee, brisement force for anchylosis of, 496. Joint, knee, disarticulation at the, 467. Joint, knee, excision of, 362. by transverse incision, Bird, 365. non-subperiosteal, Mackenzie, 364. subperiosteal, Langenbeck, 366. subperiosteal, Ollier, 367. Joint, knee, osteotomy for bonv anchylosis of, 386, 496. cuneiform, 386. linear, 386. Joint, medio-tarsal, amputation at, Chopart, 448. Forbes’s modification of Chopart’s, 449. Joint, metacarpo-phalangeal, amputation at, 416. disarticulation at, 416. excision of, 353. Joint, shoulder, amputation above, 437. Joint, shoulder, amputation at the, 431. by circular-incision method, 434. by external and internal flaps, Dupuy- tren, 433. by oval-flap method, Larry, 436. by racket-flap method, Spence, 436. Joint, shoulder, disarticulation at the, 431. Joint, subastragaloid, amputation at, De Lignerolles’s method, 451. Hancock’s method, 452. heel-flap method, 452. Tripier’s method, 452. Verneuil’s method, 452. Joint, tarso-metatarsal, amputation at, Lis- franc, 446. Baudens’s modification of, 448. Hey’s modification of, 448. Skey’s modification of, 448. Smith’s (R. W.) modification of, 448. Joint, tarso-metatarsal, disarticulation of, 446. Joint, wrist, amputations at, 422. circular-flap method, 422. double-flap method, Ruysch, 423. radial-flap method, Dubrueil, 424. single palmar-flap method, 423. Joint, wrist,, disarticulations at, 422. Joint, wrist, excision of, 346. complete, subperiosteal, Langenbeck, 348. complete, subperiosteal, Lister, 350. complete, subperiosteal, Ollier, 349. Joints, metatarso-phalangeal, amputation of all toes at, 443. disarticulation of all toes at, 443. excision of, 354. Joints, phalangeal,of foot,amputation at, 440. disarticulation at, 440. excision of, 353. Joints, phalangeal, of hand, amputation at, 413. disarticulation at, 413. excision of the, 353. Joints, tarsal, excision of, 354. Joints, tarso-metatarsal, excision of, 854. Junker’s chloroform apparatus, 25. Jurymast, Sayre’s, 499. Kangaroo tendon, 71, 83. as buried suture, 89. Keegan’s operation of rhinoplasty, 526. Kidneys, condition of, before operation, 4. Knee joint, amputation at, 467. bilateral-flap method, Stephen Smith, 468. circular-flap method, 470. elliptical-flap method, Baudens, 470. Parabeuf’s modification of Carden’s, 473. Lister’s modification of Carden’s, 472. long anterior-, with a short posterior-flap, Pollock, 471. through the condyles, Carden, 472. through the condyles, Gritti’s osteoplastic, 473. through the condyles, Sabanejeff, 474. Stephen Smith’s method for gangrenous condition of foot and leg, 469. Stokes’s modification of Gritti’s, 473. Knee joint, brisement force, for anchvlosis of, 496. Knee joint, disarticulation at, 467. Knee joint, excision of, 362. by transverse incision, Bird, 365. non-subperiosteal, Mackenzie, 364. subperiosteal, Langenbeck, 366. subperiosteal, Ollier, 367. Knee joint, osteotomy for bony anchylosis of.' 386, 496. cuneiform, 386. linear, 386. Knife, amputating, manner of grasping the, 407. Knife, amputating, the Catlin, 408. Knives, amputating, 406. Knots, 68. Grad, 70. “ granny,” 69. reef or square, 69, 87. Staffordshire, 70. surgeon’s or friction, 68, 87. Kocher’s operation on superior maxillary nerve, 241. on trifacial at foramen ovale, 252. Ivonig’s method of osteoplastic rhinoplasty, 528. Konig’s operation for single harelip, 537. Kraske’s method of meloplasty, 551. Krause’s method of skin-grafting, 515. Kreolin, 49. Kronlein’s operation on trifacial at foramen ovale, 253. Laborde’s artificial respiration, 18. Lallemand’s method of meloplasty, 551. Laminectomy, 265. Langenbeck’s amputation of arm by mus- culo-cutaneous flaps, 429. Langenbeck’s chin-flap method of cheilo- plasty for lower lip, 543. Langenbeck’s circular method of cheiloplastv for lower lip, 542. Langenbeck’s clamp, 55. Langenbeck’s excision of ankle joint, sub- periosteal, 358. INDEX. 575 Langenbeck’s excision of elbow joint, sub- periosteal, 342. of hip joint, subperiosteal, 373. of knee joint, subperiosteal, 366. of the humerus, head of, subperiosteal, 339. of the humerus, upper end of, through vertical incision, 337. of wrist joint, complete, subperiosteal, 348. Langenbeck’s method of cutting flaps, 403. of uranoplasty, 556. Langenbeck’s operation of rhinoplasty, 520. Langenbeck’s serre-fine, 64. Lannelongue’s method of uranoplasty, 558. Larry’s amputation at the shoulder joint, 436. Laryngotomy, at operations, 104. Latissimus dorsi, tenotomy of, 291. Ledran-Mackenzie method of cheiloplasty for upper lip, 548. Lee’s modification of Teale’s amputation of the leg, 465. Le Fort’s modification of Pirogoff’s ampu- tation at ankle joint, 458. Leg, amputation of the, at the lower third, author’s method with periosteal flap, 460. bilateral-flap method, 463. Duval's supramalleolar method, 460. Guyon’s supramalleolar method, 460. hood-flap method, 464. large posterior-flap method, 462. Teale’s method, 462. Leg, amputation of the, at the middle third, large posterior-flap method, Hey, 464. Lee’s modification of Teale’s, 465. long external-flap method, 465. Leg, amputation of the, at the upper third, bilateral-flap method, 467. circular-flap method, 466. large external-flap method, 465. Leg, excision of bones of the, 362. Leucocythsemia, 6. Lever, Davy’s, 60, 482. Ligaments, 302. division of (syndesmotomy), 302. ruptured, repair of, 302. shortening of, 302. Ligature of arteries, general considerations in, 107. distinction between arteries and veins, 108. guides to arteries, 107. kind of instruments required, 111. modes of ligaturing, 107. opening of sheath, 109. passage of ligature, 109, 110. position of part, 108. primary incision, 108. selection of site for ligature, 108. tying of ligature, 111. Ligature of abdominal aorta, 112. Cooper’s method, 112. Murray's method, 113. Ligature of axillary artery, 154, first portion, 154. second portion, 155. Ligature of axillary artery, third portion, 155. Ligature of brachial artery, 156. in lower third, 158. in middle third, 158. in upper third, 158. Ligature of carotid arteries, common, both, 169. Ligature of carotid artery, common, 167. above the omo-hyoid, 168. at the root of the neck, 168. below the omo-hyoid, 168. temporary, 170. Ligature of carotid artery, external, 170. above the digastric, 172. below the digastric, 171. Ligature of carotid artery, internal, 172. of circumflex artery, external, 180. of dorsalis pedis artery, 135. of dorsalis penis artery, 120. of epigastric artery, deep, 122. Ligature of facial artery, 176. at the ramus of the jaw, 176. in the neck, 176. near the angle of the mouth, 176. Ligature of femoral artery, 124. common, 125. deep, 130. superficial, 127. Ligature of gluteal artery, 118. Ligature of iliac arteries, common, 113. extraperitoneal method, 115. transperitoneal method, 114. Ligature of iliac artery, circumflex, deep, 124. Ligature of iliac artery, external, 120. extraperitoneal method, 121. transperitoneal method, 122. Ligature of iliac artery, internal, 117. extraperitoneal method, 118. transperitoneal method, 117. Ligature of innominate artery, 140. with median-line incision, 143. with Mott’s incision, 140. with resection of sterno-clavicular articu- lation, etc., 142. Ligature of lingual artery, 173. at the first situation, 174. at the second situation, 174. at the third situation, 175. Ligature of mammary artery, internal, 153. Ligature of occipital artery, 177. at the origin, 178. behind the mastoid process, 178. Ligature of palmar arches, 166. of peroneal artery, 137. Ligature of popliteal artery, 131. at the lower third, 132. at the upper third, 132. Ligature of pudic artery, internal, 119. at greater sacro-sciatic foramen, 120. in the perineum, 120. Ligature of radial artery, 161. at apex of styloid process, 163. at lower third, 163. at upper third, 162. Ligature of saphenous vein, 181, Fergusson’s method, 182. 576 OPERATIVE SURGERY. Ligature of saphenous vein, Schede’s meth- od, 182. Trendelenburg’s method, 181. Ligature of sciatic artery, 118. Ligature of subclavian artery, 144. of first portion, left side, 144. of first portion, right side, 146. of second portion, 150. of third portion, 147. Ligature of temporal artery, 177. of thyroid artery, inferior, 153. of thyroid artery, superior, 173. Ligature of tibial artery, anterior, 132. at lower third, 134. at middle third, 133. at upper third, 133. Ligature of tibial artery, posterior, 135. at lower third, 136. at middle third, 136. between os calcis and internal malleolus, 137. Ligature of ulnar artery, 164. at junction of middle and upper thirds, 165. at the wrist, 165. in the lower third, 165. Ligature of vertebral artery, 150. at first situation, 151. at second situation, 152. at third situation, 153. Ligature, rubber, in treatment of naevus, 190. of veins, 179. of vessels, 67, 68. simultaneous, of femoral vessels, 179. Ligatures, 67. antiseptic, in Lister’s method, 93. assistant to care for, 79. catgut, sterilization of, 73-78. hemp, 67. in ligature of arteries, 111. passage of, around arteries, 109, 110. receptacles for, 76. removal of deep-seated (Grad), 71. silk, sterilization of, 71. tying, 67, 68, 111. varieties of, 67, 71, 79. whalebone tissue, 79. Ligaturing, subcutaneous, in treatment of mevus, 189. subcutaneous, of varicose veins, 180. Light, artificial, 67. Lime, chloride of, 100. Linear guide, to abdominal aorta, 112. to axillary artery, third portion, 155. to brachial artery, 157. to carotid artery, common. 167. to carotid artery, external, 171. to carotid artery, internal, 172. to dorsalis pedis artery, 135. to epigastric artery, deep, 123. to femoral artery, 125. to gluteal artery, 118. to iliac arteries, common, 114. to iliac artery, external, 120. to innominate artery, 140. to lingual artery, 174. to mammary artery, internal, 153. to palmar arches, 166. Linear guide to peroneal artery, 137. to popliteal artery, 131. to pudic artery, internal, 120. to radial artery, 162. to sciatic artery, 119. to tibial artery, anterior, 133. to tibial artery, posterior, 136. to ulnar artery, 164. to vertebral artery, 151. Linear guides to arteries, 107. Lingual artery, bony guide to, 174. ligature of, 173. linear guide to, 174. Lingual or gustatory nerve, 248. operations on, 249. Lip, lower, cheiloplasty for deformities of, 540. Bruns’s method, 542. Buck’s method, 543. Celsus’s method, 541. Estlander’s method, 541. horizontal incision method, 540. Langenbeck’s chin-flap method, 543. Langenbeck’s circular method, 542. Malgaigne’s method, 544. Sedillot’s method, 545. Syme-Buchanan method, 543. Syme’s method, 543. V-incision method, 540. Lip, lower, deformities of, 540. Lip, upper, cheiloplasty for deformities of, Buck’s intero-lateral-flap method, 545. Buck’s semicircular vertical-flap method, 546. Diefllenbach’s curved-flap method, 547. Dieffenbach’s S-shaped-flap method, 547 Ledran-Maekenzie method, 548. Sedillot’s vertical-flap method, 546. Szymanowski’s method, 547. Lip, upper, deformities of, 545. entire loss of, 546. Lisbon’s excision of elbow joint, 343. Lisfranc’s amputation at the tarso-meta- tarsal joint, 446. Lister’s excision of wrist joint, complete, subperiosteal, 350. Lister’s method of dressing wounds, 93, 94. Lister’s modification of Carden’s amputation at knee joint, 472. Lister’s tourniquet, 482. Liston’s mouse-tooth forceps, 63. Liston’s spring-catch fenestrated artery forceps, 63. Littenneur’s method of flap transfer in plastic operations, 511. Liver, condition of, before operation, 4. Lloyd’s method of controlling haemorrhage in hip-joint amputation, 486. Local anaesthesia, 29. Local anaesthetics, 29. chloride of ethyl, 29. cocain, 30. ether, 29. eucain, 31. ice, 29. infiltration (Schleich), 31. introduction into skin of sterilized fluids, 32. INDEX. 577 Loops, traction, 38, 111. Lorenz’s operation for congenital displace- ment of the hip joint, 385. Lossen’s operation on superior maxillary nerve, 244. Liicke’s operation on superior maxillary nerve, 244. Lumbar plexus, operations on branches of, 281. Lumbar puncture of spinal meninges, 270. Lungs, condition of, before operation, 4. Lusk’s, (Z. J.,) method of skin-grafting, 515. McBurney’s method of controlling haemor- rhage in amputation at hip joint, 486. Macewen’s supracondyloid osteotomy for genu valgum, 388. Mackenzie’s non-subperiosteal excision of knee joint, 364. Mackintosh, in Lister’s method, 93, 94. Malaria, 6. Malgaigne’s amputation at hip joint, 493. Malgaigne’s double-flap operation for hare- lip, 535. Malgaigne’s method of cheiloplasty on lower lip, 544. Mallet, 198. Mallet-finger, 500. Mammary artery, internal ligature of, 153. linear guide to, 153. Manec’s amputation at hip joint, 488. Martin’s elastic bandage, 56. Mastoid antrum, opening of, 223. Maxilla, inferior, excision of, 326. alveolar process of, 329. central portion of, 327. lateral half of, 328. lateral portion of, 328. whole of, 329. Maxilla, inferior, immobility of, 330. Esmarch’s operation for, 330. Grube’s operation for, 331. Rizzoli’s operation for, 331. Maxilla, superior, excision of, 318. below floor of orbit, 322. below infra-orbital foramen, extra-buccal route, 324. below infra-orbital foramen, intra-buccal route, 324. complete, by median incision, Fergusson, 321. partial, 324. subperiosteal, 323. Maxilla?, superior, excision of both, 325. Maxillary nerve, superior, operations on, 238. Meckel’s ganglion, removal of, 239. Median nerve, operations on, 278. Medio-tarsal joint, amputation at, Chopart, 448. Forbes’s modification of Chopart’s, 449. Meloplasty, 549. Gersunv’s method, 551. Gussenbauer’s method, 550. Israel’s method, 550. Kraske’s method, 551. Lallemand’s method, 551. Trendelenburg's method, 550. Meningitis, following linear craniotomy, 206. Meningocele, nature of, 193. operative treatment of, 193-195. spinal, 272. Meningo-myelocele, 272. Mercury, bichloride of, 49. in preparation of catgut, 77, 78. Mercury, biniodide of, 49. biniodide of, in chloroform, 74-76. Metacarpal bones, amputation of the four, with the fingers, 421. the inner three, 421. the last four, 420. Metacarpal bones, amputation through, 420. Metacarpo-phalangeal joint, amputation at, 416. disarticulation at, 416. excision of, 353. Metallic plate, in circular craniotomy, 198. Metallic sutures, 84. objections to, for burying, 89. Metatarsal bones, amputation through all the, 444. Metatarso-phalangeal joints, amputation of all toes at, 443. disarticulation of all toes at, 443. excision of, 354. Microcephalus, linear craniotomy for, 203. Milne’s serre-fine forceps, 64. Miner’s elbow, 308. Mirault’s single-flap operation for harelip, 535. Mittens, antiseptic, 100. Molliere’s amputation at ankle joint, 450. Morphin, with anaesthetics, 28. Mother’s mark, treatment of, 188. Mott’s retractors, 111. Mouse-tooth forceps, 111. Liston’s, 63. Mouth, preparation of, for operation, 81. stomatoplasty for deformities of, 548. Mouth gag, 13, 14, 104. Denhard’s, 245, 13. Goodwillie’s, 245. round pine stick as, 14. Mucous surfaces, preparation of, for opera- tion, 81. Multifidus spinae, myotomy of, 291. Muscle, ruptured, suture of, 302. Muscles, division of, 301. division of special, 291. rupture of, 302. Muscles and their sheaths, 301. Muscular guide, to axillary artery, first por- tion, 154. to axillary artery, third portion, 156. to brachial artery, 157. to dorsalis pedis artery, 135. to femoral artery, 125. to iliac artery, common, 115. to iliac artery, external, 121. to popliteal artery, 131. to radial artery, 162. to sciatic artery, 119. to subclavian artery, 144. to subclavian artery, first portion, left side, 144. to subclavian artery, first portion, right side, 146. 578 OPERATIVE SURGERY. Muscular guide, to subclavian artery, second and third portions, 147. to tibial artery, anterior, 133. to tibial artery, posterior, 136. to ulnar artery. 164. to vertebral artery, 151. Muscular guides to arteries, 107. Musculo-cutaneous nerve, operations on, 276. Musculo-spiral nerve, operations on, 276. Musk, 14. Muslin, in place of absorbent gauze, 98. Myotomy, 301. of deltoid, 302. of erector spin*,-292. of multifidus spin*, 291. of pectineus, 291. of pectoralis major, 302. of trapezius, 292. N*vus, treatment of, 188, 189. Nail, deformities of, 518. operations for, 519. Nail, toe, ingrowing, 505. Nails, cleansing of, 99, 100. Naphthalin, 96. Nascent chlorine method of cleansing hands, 100. Nausea in ether anaesthesia. 18. Needle, aneurism, Fletcher’s, 112. in ligature of arteries, 111. passage of, around arteries, 109. the “ movable immovable,” 112. the “ student’s,” 112. Needle forceps or holders, 85. Needles, hot, in treatment of birthmark, 188. Needles, surgical, in acupressure, 62. effects of, on tissues, 84, 85. uses of special sorts of, 85. varieties of, 84. Nerve, auricularis magnus, operations on, 274. auriculo-temporal, operations on, 249. buccal, operations on, 250. circumflex, operations on, 277. crural, anterior, operations on, 281. dental, inferior, operations on, 244. facial, operations on, 263. infra-orbital, operations on, 237. lingual or gustatory, operations on, 248. maxillary, superior, operations on, 238. median, operations on, 278. musculo-cutaneous, operations on, 276. musculo-spiral, operations on, 276. occipital, great, operations on, 274. obturator, operations on, 281. perineal, operations on, 281. plantar, operations on, 281. popliteal, external, operations on, 280. popliteal, internal, operations on, 280. radial, operations on, 278. saphenous, external or short, operations on, 282. saphenous, internal or long, operations on, 282. sciatic, great, operations on, 278. spinal-accessory, operations on, 273. supra-orbital, operations on, 236. Nerve, supra-trochlea, operations on, 237. tibial, anterior, operations on, 281. tibial, posterior, operations on, 281. trifacial, at foramen ovale, operations on, 250. ulnar, operations on, 278. Nerve resection, 231. Nerve section, 231. Nerve stretching, 232. Nerve stretching, dry, 232. Nerve suture, 232. primary suturing, 233. secondary suturing, 233. Nerves, branches of brachial plexus of, oper- ations on, 275. branches of cervical plexus of, operations on, 274. branches of lumbar plexus of, operations on, 281. branches of sacral plexus of, operations on, 278. Nerves, spinal, operations on, 273. intraspinal division of roots of, 275. Nervous guides to arteries, 107. Nervous system, operations on the, 191. Neurectomy, of trifacial, intracranial, 254. Neuroplasty. 234. Nitrite of amyl, 14, 103. Nitrous oxide, 27. Non-subperiosteal excision of ankle joint, Busch, 359. Non-subperiosteal excision of knee joint, Mackenzie, 364. Norton's operation for webbed fingers, 502. Nose, preparation of, for operation, 81. Nurses, preparation of, for operation, 9. Nursing, 9. Oakum, as cushion, 103. Obese, operations on the, 3. Obstruction, respiratory, in anaesthesia, 16. Obturator nerve, operations on, 281. Occipital artery, ligature of, 177. Occipitalis major nerve, operations on, 274. Ogston’s osteo-arthrotomy for genu valgum, 388 Oil, paraffin. 73. of turpentine, 73. Oils, essential, 50. Ollier’s excision of elbow joint, 343. of knee joint, subperiosteal, 367. of scapula, subperiosteal, 335. of wrist joint, subperiosteal, complete, 349. Ollier’s method of osteoplastic rhinoplasty, 527. Oozing, agents for the control of, 54. arrest of, 82. of extended surfaces, 65. Open dressing, the, 103. Operating table, 9, 41. Boldt’s 43. characteristics of a good, 42. Cleveland’s, 42, 43. drainage of. 42. extemporized, 41. Fowler’s, 43. portable, Edebohl’s, 44. portable, Pryor’s, 44. INDEX, 579 Operating table, preparation of, 9, 41, 99. Operation field, preparation of, 80, 99. Operations, assistants at, 79. after reaction, 4. care of patient after, 103. care of room after, 8. complications of, 5. cosmetic effects of, 2. determination of the propriety for, 10. diagram of arrangement for, 101. diet following, 9. during shock, 4. facts relating to patient prior to, 2. in old age, 2. in youth, 2. nursing after, 9. on athletes, 3. on men, 3. on semi-invalids, 3. on the obese, 3. on the plethoric, 3. on women, 3. place for, 7. preparation of assistants for, 9, 99. preparation of nurses for, 9. preparation of patients for, 9, 80, 99. preparation of room for, 8. preparation of surgeon for, 9, 99. preparation of table for, 9, 41, 99. prognosis of, 3, 5, 6. rehearsal by surgeon before, 104. requirements, essential, for, 9. requirements, precautionary, for, 9, 103. risks of, 2. special emergencies in, 105. summary of the common preparations for modern, 99. supervention of shock during, 4. time for, 7. treatment of patients after, 103. treatment preparatory to, 7. usefulness of a part after, 2. Operations on bones, 310. excision, 314. gouging, 310. osteotomy, 377. sequestrotomy, direct method, 312. sequestrotomy, indirect method, 314. Operations on the capillaries, 187. Operations on the nervous system, 191. Operations on tendons, ligaments, fascias, muscles, and bursae, 283. Operations on veins, capillaries, etc., 179. Operation-wounds, treatment of, 9, 82, 103. Operative propriety, 10. Operative surgery, general considerations of, 1. Operator, preparation of, 99. Opium, in shock, 105. Oral screw, 14. Organic ligatures, 67. Ormsby inhaler, 22. Osteo-arthrotomy for genu valgum, Chiene, 389. Ogston, 388. Reeves, 388. Osteoplastic resection of tarsus, Wladimiroff- Mikulicz, 361. Osteoplastic rhinoplasty, 527. Israel’s modification of Konig’s, 528. Konig’s method, 528. Ollier’s method, 527. Pancoast’s subcutaneous method, 529. Osteoplasty, 394. Osteotomy, 377. at neck of femur, Volkmann, 382. by open method, at neck of astragalus for talipes equino-varus, Phelps, 393. cuneiform, for bony anchylosis of knee joint, 386. cuneiform, for talipes equino-varus, Davies-Colley, 392. cuneiform, for genu varum, 391. for hallux valgus, 392. inter-trochanteric, Sayre, 383. linear, for bony anchylosis of knee joint, 386. linear, for genu varum, 390. linear, at neck of astragalus for talipes equino-varus, Bradford, 393. subcutaneous, at neck of femur, Adams, 381. subtrochanteric, Gant, 383. Oxalic acid, in cleansing hands, 100. Oxygen, following anaesthesia, 28. with anaesthetic, 28. Pads, aseptic gauze, 51. Palate, operations upon the, 557. Palladium, bichloride of, in alcohol, 79. Palmar arches, ligature of, 166. linear guide to, 166. Palmar fascia, 304. Dupuytren’s collection of, 305. Pancoast’s operation on trifacial nerve at foramen ovale, 253. Pancoast’s subcutaneous method of osteo- plastic rhinoplasty, 529. Pancoast’s tourniquet, 481. Paquelfn’s thermo-cautery, 65. Paraffin oil, heating of catgut in, 73. Paralysis, general, of the insane, craniotomy for, 223. Paravicini’s operation on inferior dental nerve, 245. Parker’s retractors, 111. Parkin’s operation for meningeal drainage, 270. Patella, excision of, 371. Patient, care of, after operation, 103. considerations relating to, prior to opera- tion, 2-6. giving of fluids to unconscious, 104. preparation of, for anaesthesia, 10. preparation of, for operation, 9, 80, 99. relation of surgeon to, 1. struggling of, under anaesthesia, 11. Peat dressing, 98. Pectineus, myotomy of, 291. Pectoralis major, myotomy of, 302. tenotomy of, 302. Pedicles, removal of ligatures from, Grad, 71. Pedicles, tying of, 70. with catgut, 72. with silk, 71. OPERATIVE SURGERY. 580 Perineal nerve, operations on, 281. Perineus brevis, tenotomy of, 288. Perineus longus, tenotomy of, 288. Perineus tertius, tenotomy of, 289. Periosteal flap, in amputation of leg by au- thor’s method, 460. in amputation of thigh, 478. Periosteal flaps in amputation, 404. Periosteotome, 197. Permanganate of potash, in cleansing hands, 100. Peroneal artery, ligature of, 137. linear guide to, 137. Peroxide of hydrogen, 49. use of, in septic cases, 81. Petit’s tourniquet, 58. Petrolatum, bath of, 76. Phalangeal articulations of hand, amputa- tions at the, 413. disarticulation at, 413. Phalangeal articulations of toes, amputa- tions at the, 440. disarticulation at, 440. Phalangeal joints, of foot, excision of, 353. of hand, 353. Phelps’s open method of osteotomy for talipes equino-varus, 393. Pia, control of haemorrhage from, 215. Pin conductor, Buck’s, in acupressure, 62. in twisted suture, 89. Pin pressure, 62. Pin, safety, to fasten drainage tube, 92. Pin suture, the, 88. Pins, acupressure, 62. Wyeth’s, 61. Pirogoff’s amputation at ankle joint, 456. Plantar fascia, fasciotomy of, 303. Plantar nerve, operations on, 281. Plastic surgery, 507. of cheeks, 549. of lips, 531. of lower lip, 541. Plastic surgery, methods of transferring flaps in, 507. grafting, 513. inversion and eversion, 512. jumping, 512. sliding in a curved line, 510. sliding in a direct line, 509. Tagliacotian operation, 512. Plastic surgery, of mouth, 548. of nose, rhinoplasty, 518. of palate, 551. of upper lip, 545. of uvula, 561. preparation of patient for, 507. size and shape of flaps in, 507. Plate, in circular craniotomy, celluloid, 198. metallic, 198. Plates, hot, in shock, 105. Plethoric, operations on the, 3. Plexus of nerves, brachial, operations on branches of, 275. cervical, operations on branches of, 274, lumbar, operations on branches of, 281. sacral, operations on branches of, 278. Poirier’s naso-lambdoidal line, 212. Poisoning, from anaesthetics, treatment of, 16. by chloroform, manifestations of, 24. Poliock’s amputation at knee joint, 471. Polydactylism, 501. Popliteal artery, ligature of, 131. linear guide to, 131. muscular guides to, 131. Popliteal nerve, external, operations on, 280. internal, operations on, 280. Position, in control of hannorrhage, 54. of patient, in anaesthesia, 11. Post’s pin-carrier, in twisted suture, 89. Potash, permanganate of, in cleansing hands, 100. Potassium bichromate, in chromacizing cat- gut, 76. Precautionary requirements relating to oper- tions, 9, 103. Preparation of assistants, 9, 99. of bichloride gauze, 97. Preparation of catgut, at Bellevue Hospital, 73. at the New York Hospital, 78. by von Bergmann’s method, 77. by Halsted’s method, 76. by the “Jefferson method,” 78. by Konig’s method, 77. Preparation of field of operation, 80, 99. epidermal area, 80. mucous surfaces, 81. parts already septic, 81. Preparation, of iodoform gauze, 96, 97. of nurses, 9. of operating table, 9, 41, 99. of patient for operation, 9, 80, 99. of room for operation, 8. of sponges, 51. of surgeon for operation, 9, 99. of Thiersch’s gauze, 97. Preparations for anaesthesia, 10. of anaesthetist, 12. of patient, 10. Preparations for a modern operation, sum- mary of the common, 99. Preservation of catgut in alcohol, 73, 75, 77, 78. in bichloride of palladium in alcohol, 79. in biniodide of mercury in chloroform, 74, 76. in sterile tubes, 78. Preservation of silk, 72. Pressure, digital, for control of haemorrhage, 56, 57. instrumental, for control of haemorrhage, 58. in treatment of birthmark, 188. pad, on saphenous vein, 181. pin, 62. Probe, in ligaturing arteries, 109, 111. Prognosis of operations, 3, 5, 6. Protective, 94. Protective dressings, 82, 93-99. Pryor’s operating table, 44. Pudic artery, internal, ligature of, 119. linear guide to, 120. Pulsation, as guide to arteries, 107, 108. Pulse, during anaesthesia, 14. INDEX, 581 Pulse, record of, after operation, 103. record of, before operation, 11. Puncture, galvano-, 188, 189. of meningocele, 194. Pupils, in ether anmsthesia, 23. Quadriceps extensor cruris, tenotomy of, 291. Quilled suture, 88. Radial artery, ligature of, 161. linear guide to, 162. muscular guide to, 162. Radial nerve, operations on, 278. Radius, excision of the, 345. Reaction, operations after, 4. Receptacles, for instruments, 39. for ligatures, 76. Rectal temperature, 11. Rectum, evacuation of, before anaesthesia, 11. preparation of, for operation, 81. Reef knot, 69. Reef knot, in interrupted suture, 87. Reeves’s osteo-arthrotomy for genu valgum, 388. Reflexes, as guides in anaesthesia, 15. Reid’s base line, 210. Relaxation and coaptation suture, 90. Requirements relating to operations, essen- tial, 9. precautionary, 9, 103. Resection of tarsus, osteoplastic, Wladimi- roIf-Mikulicz, 361. Resin, 54. Respiration, artificial, 17, 18, 104. during anaesthesia, 14, 16. failure of, in anaesthesia, 16, 104. obstruction of, in anaesthesia, 16. rapid, as anaesthetic, 28. record of, after operation, 103. record of, before operation, 11. temporary aiTest of, in anaesthesia, 23. where air in veins, 105. Results of operations, a knowledge of, essen- tial, 9 Retractors, 38. Retractors for amputations, 411. Retractors for ligature of arteries, 111. extemporized, 111. Mott’s, 111. Parker’s, 111. Retroclusion, 62. Reverden’s method of skin-grafting, 513. Rheumatism, 5. Rhinoplasty, 518. Dieffenbach’s operation, 522. for angular and saddle-back deformities, 529. for loss of the bony or cartilaginous sep- tum, with or without loss of nasal bones, 522. Indian operation, 523. Italian operation, 527. Keegan’s operation, 526. Langenbeck’s operation, 520. Syme’s operation, 519. Verneuil’s operation, 522. Rhinoplasty, Weber’s operation, 521. Rhinoplasty, osteoplastic, 527. Israel’s modification of Konig’s, 528. Konig’s operation, 527. Ollier’s operation, 527. Pancoast’s subcutaneous operation, 529. Rings, solid rubber, as haemostatics, 56. Rizzoli’s operation for anchylosis of inferior maxilla, 331. Rod, Trendelenburg’s, 61, 483. Rongeur, 198. Room for operation, 8. Rose’s intracranial operation on trifacial nerve, 254. position for staphylorraphy, 553. Roux’s amputation at ankle joint, 456. Rubber apron, 101. h ubber cloths, 9. Rubber cord for control of haemorrhage, 55. Foulis’s fastening for, 56. Rubber dam, 94. Rubber drainage tubes, 91. Rubber finger stalls, 101. Rubber gloves, 101. Rubber ligature, in treatment of naevus, 190. Rubber rings, solid, as haemostatics, 56. Rubber surgical cushions, 42. Rubber tissue, 94. Ruysch’s amputation at wrist joint, 422. Sabanejeff’s amputation through condyles of femur, 474. Sacral plexus, operations on branches of, 278. Safety pin, to fasten drainage tube, 92. Saline enemata, 187. Saline fluid, subcutaneous injection of, 187. Saline solution, 50. Saline transfusion, 105, 186, 187. Salzer’s operation on trifacial at foramen ovale, 253. Saphenous nerve, external or short, opera- tions on, 282. Saphenous nerve, internal or long, opera- tions on, 282. Saphenous vein, ligatui’e of. 181. Fergusson’s method, 182. Schede’s method, 182. Trendelenburg’s method, 181. Sartorius, tenotomy of, 290. Saw, amputating, proper method of using, 409. chain, 317. Gigli-Haertel, 317. Szymanowski’s, 317, 365. Saws, amputating, 409. Sayre’s excision of hip joint, 375. jury-mast, 499. osteotomy, inter-trochanteric, 383. plaster-of-Paris jacket for curvature of the spine, 498. Scalpel, 195. in ligature of arteries, 111. methods of holding, 33. Scapula, excision of, 333. acromion process of, 334. body of, 334. OPERATIVE SURGERY. 582 Scapula, glenoid angle of, 335. subperiosteal, Ollier, 335. whole of, 333. Schede’s method of healing by blood clot, 312. protective in, 94. rubber tissue in, 94. Schleich’s general anaesthetics, 27. Schleich’s infiltration anaesthesia, 31. Schonborn’s operation of staphyloplasty, 561. Sciatic artery, ligature of, 118. linear guides to, 119. muscular guide, deep, to, 119. Sciatic nerve, great, bloodless stretching of, 280. operations on the, 278. Scissors, 36. Screw, hard-rubber oral, 14. Scurvy, 6. Secondary haemorrhage, 53, 58. following actual cautery, 65. following ligature, 68. following torsion, 63. in ligature of veins, 179. Secondary suturing, 87. Sedillot’s long anterior-flap method, in am- putation at thigh, 479. method of cheiloplasty on lower lip, 545. mixed double-flap amputation, 402. vertical-flap method of cheiloplasty on upper lip, 546. Semi-invalids, operations on, 3. Semimembranosus, tenotomy of, 290. Semitendinosus, tenotomy of, 290. Senn’s method of control of haemorrhage in amputation at hip joint, 487. Septic parts, drainage after operation on, 81. preparation of, for operation, 81. Sequestrotomy, 312. direct method, 312. indirect method, 314. Serre-fine forceps, 63. Serre’s method of stomatoplasty, 549. Setons, in treatment of naevus, 190. Sewing of nicks in veins, 179. tension while, 85. Sheath of artery as guide, 107. opening of, 109. Sheaths of muscles, 301. Sheets, 9. clean aseptic, 45. Shock, 105. anaesthetics in, 16. causation of, 105. degree of, 105. in linear craniotomy, 206. operations during, 4. subcutaneous saline injection in, 187. supervention of, during operations, 4. time of occurrence of, 105. treatment of, 105. Shock from loss of blood, elastic bandages in, 104. transfusion in, 104. saline enemata in, 187. symptoms of, 105. Shoulder joint, amputation above, 437. Shoulder joint, amputation at, 431. circular-incision method, 434. external- and internal-flap method, Du- puytren, 433. oval-flap method, Larry, 436. racket-flap method, Spence, 436. Shoulder joint, disarticulation at the, 431. Sick-room, 8. Silk, 71. as buried suture, 89. as subcuticular suture, 90. catgut compared with, 72. durability of, 83. preservation of, 72. sterilization of, 71. Silk ligature, 67, 71. Silk suture, 71, 83. Silkworm-gut, 71, 83. durability of, 83. objection to, for burying, 89. sterilization of, 83, 84. strands of, for drainage, 92. tying of, with friction knot, 87. Silver wire, 71, 84. introduction of sutures of, 88. sterilization of, 84. Simon’s operation for single harelip, 536. Sinus, frontal, trephining the, 225. Sinus, lateral, control of hemorrhage from, 223. thrombosis of, treatment of, 222. Sinuses, control of haunorrhage from, 200. location of, 206. Skey’s modification of Lisfranc’s amputa- tion at the tarso-metarsal joint, 448. Skin coccus, in suturing, 90. Skin-grafting, 513. Krause’s method, 515. Lusk’s (Z. J.) method, 515. Reverden’s method, 513. rubber tissue in, 94. Thiersch’s method, 514. Skin surface, cleansing of, for operation, 80. Skinner’s inhaler, 25. Smith’s (R. W.) modification of Lisfranc’s amputation at the tarso-metatarsal joint, 448. Smith’s, Stephen, amputation at knee joint, 468. Smith’s, Stephen, method of amputation (disarticulation) for gangrenous condi- tion of foot and leg, 469. Snap-finger, 501. Soap, Castile, 80. green, confined over skin area, 80. green, tincture of, 80. soft, 80. Soda, carbonate of. solution of, for boiling instruments, 40, 50. in cleansing hands, 100. Soda, washing, for boiling silk, 72. Solutions, antiseptic and aseptic, 47. for injecting hydrocephalus, 192. for injecting meningocele, 194. for the surgeon, 45. labeling of, 45. of beta-naphthol, 40, 49. INDEX. 583 Solutions of bichloride of mercury, 49. of biniodide of mercury, 49. of boiled water, 50. of boric acid, 49. of carbolic acid, 40, 48. of carbonate of soda, 40, 50. of chloride of zinc, 48. of iodine, 48. of iodoform and ether, 49. of kreolin, 49. of peroxide of hydrogen, 49. of sulphocarbolate of zinc, 48. of sulphurous acid, 49. saline, 50. saline, for transfusion, 186. Thiersch’s fluid, 40, 49. Spence’s amputation at the shoulder joint, 436. Spina bifida, 271. excision of, 272. injection of, 271. Spinal cord, meningocele of, 272. meningo-myelocele of, 272. operations on the, 265-273. tumors of the, 273. Spinal accessory nerve, operations on, 273. Spinal meningeal drainage, 270. Spinal nerves, operations on, 273. Spine, curvature of, 498. Sayres’s plaster-of-Paris jacket for, 498. Sponge holders, 13, 14. Sponges, 9, 50. assistant to care for, 79. on holder in anaesthesia, 18, 14. preparation of, 51. Spools, 72. Spray, antiseptic, in Lister’s method, 93. Square knot, 69. Squibb’s inhaler, 22. Staffordshire knot, 70. Staphyloplasty, 561. Schonborn’s operation, 561. Staphylorrhaphy, operation of, 553. Bose’s position for, 553. Stephen Smith’s amputation at knee joint, 468. Stephen Smith’s method of amputation (dis- articulation) at knee joint for gangre- nous condition of foot and leg, 469. Sterilization of catgut, in albolene, 73, 76. by heating in a fatty liquid, 75. in alcohol, 73, 74, 78. in cumol, 77. in oil of turpentine, 73. in paraffin oil, 73. in solution of biniodide of mercury in chloroform, 74. in vaseline, 73. Sterilization, of horsehair, 84. of instruments, 40, 99. of kangaroo tendon, 83. of rubber dam, 94. of rubber tissue, 94. of silk, 71. of silkworm-gut, 83, 84. of silver wire, 84. Sterilizers for instruments, 40. Sterno-cleido-mastoid, tenotomy of, 292. Sternum, excision of, 331. Stick, round pine, as mouth gag, 14. Stimulants, in anaesthesia, 14, 103, 104. before anaesthesia, 11. in shock,105. Stokes’s modification of Gritti’s amputation through condyles of femur, 473. Stomatoplasty, 548. Buck’s method, 548. Serre’s method, 549. Storage batteries, 07. Stretching of nerves, 232. bloodless, of the sciatic nerve, 280. Strychnine, 14, 104. in shock, 105. “Student’s” aneurism needle, 112. Stump, serviceable, characteristics of a, 396. Styptics, 54. Subastragaloid amputation (disarticulation), De Lignerolles’, 451. Hancock’s, 452. heel-flap operation, 452. Tripier’s, 452. Verneuil’s, 452. Subclavian artery, guides to, 144. ligature of, 144. Subclavian artery, first portion, left side, ligature of, 144. muscular guide, deep, to, 144. Subclavian artery, first portion, right side, ligature of, 146. muscular guide, deep, to, 146. Subclavian artery, second portion, ligature of, 150. muscular guides to, 147,150. Subclavian artery, third portion, bonv guide to, 148. ligature of, 147. muscular guides to, 147. Subcutaneous injection of saline fluid, 187. Subcutaneous ligaturing, in treatment of mevus, 189. Subcuticular suture, 90. Sublimate, in cleansing hands, 100. Subperiosteal excision of ankle joint, Lan- genbeck, 358. of elbow-joint, Langenbeck, 342. of hip joint. Barker, 374. of hip joint, Langenbeck, 373. of hip joint, Sayre, 375. of hip joint, White, 372. of humerus, upper end of, Langenbeck, 339. of jaw, upper, 323. of knee joint, Lagenbeck, 366. of knee joint, Ollier, 367. of maxilla, superior, 323. of scapula, Ollier, 335. of wrist joint, Langenbeck, 348. of wrist joint, Lister, 350. of wrist joint, Ollier, 349. Subsulphate of iron, 54. in treatment of mevus, 188, 190. Sulphocarbolate of zinc, 48. Sulphurous acid, 49. Superior maxillary nerve, operations on, 238-244. Carnochan-Chauvasse operation, 243. OPERATIVE SURGERY. 584 Superior maxillary nerve, Kocher’s opera- tion, 241. Lossen’s operation, 244. Liieke’s operation, 244. Supramalleolar amputations of the leg, 460. Supra-orbital nerve, operations on, 237. Supratrochlear nerve, operations on, 237. Surgeon, antiseptic or aseptic solution for, 45. apparel of the, 101. armamentarium of a, 33. mental rehearsal by, before operation, 104. number of assistants of a, 79. preparation of, for operation, 9, 99. punctuality of, 7. relation of, to patient, 1. Surgeon’s knot, 68. Surgery, operative, general considerations of, 1. general principles of, 2. Surgical engine, 317. Surgical needles, 84, 85. in acupressure, 62. Suture, buried, 89. button, 89. continuous, 88. different forms of, 87. glover’s, 88. harelip, 88. interrupted, 87. pin, 88. quilled, 88. relaxation and coaptation, 90. subcuticular, 90. three-cornered wound, 90. twisted, 88. Suture of nerves, 232. primary, 233. secondary, 233. Sutures, buried, in dead space, 87. classifications of, 83, 84. deep, 84. deep through-and-through, 87. depth of passing, 85. distance between, 85. distance of, from edges of wound, 85, 86. durability of, compared, 83. inorganic, 84. introduction of, 85. metallic, 84. metallic, objection to, for burying, 89. organic, 83. superficial, 84. tension of, 86. time for, to remain in situ, 86. varieties of, 71, 83. Suturing of muscle, 302. of nerves, 232. of tendons, 292. Suturing, secondary, 87. Syme-Buchanan method of cheiloplasty on lower lip, 543. Syme's amputation at ankle joint, 453. method of cheiloplasty on lower lip, 543. modification of integumentary flap in am- putation at thigh, 477. operation of rhinoplasty, 519. Syncope, 105. Syndactylism, 501. Agnew’s operation for, 504. Annandale’s modification of Diday’s opera- tion for, 503. Diday’s operation for, 502. Dec’s operation for, 502. Fowler’s operation for, 504. Norton’s operation for, 502. Zeller’s operation for, 504. Syndesmotomy, 302. Syphilis, 5. Syringe, fountain, as irrigator, 94. Szymanowski’s method of cheiloplasty on upper lip, 547. Szymanowski’s saw, 317, 365. Table, operating, 9, 41. Boldt’s, 43. characteristics of a good, 42. Cleveland’s, 42, 43. drainage of, 42. extemporized, 41. Fowler’s, 43. portable, Edebohl’s, 44. portable, Pryor’s, 44. preparation of, 9, 41, 99. Tagliacotian operation, 512. Talipes equino-varus, osteotomy for, 392. Tannin, 54. Tapping of meningocele, 194. Tapping the ventricles, for acute hydro- cephalus, 193. for chronic hydrocephalus, 191. Tarsal joints, excision of, 354. Tarsectomy for talipes equino-varus, Davies- Colley, 392. Tarso-metatarsal joints, amputation at, Lis- franc, 446. Baudens’s modification of, 448. Key’s modification of, 448. Skey’s modification of, 448. Smith’s (R. W.) modification of, 448. Tarso-metatarsal joints, disarticulation at the, 446. Tarso-metatarsal joints, excision of, 354. Tarsus, osteoplastic resection of, Wladim.- roff-Mikulicz, 361. Teale’s amputation of lower third of leg, 462. method of amputating arm, 430. method of amputation, rectangular flap 403. Temperature, after operation, record of, 103. after operation, rise of, 103. before operation, record of, 11. of sick-room, 8. rectal, 11. vaginal, 11. Temporal artery, bony guide to, 177. ligature of, 177. Tenaculum, in control of haemorrhage, 64. in ligature of arteries, 111. Tendo Achillis, lengthening of, 295. Tendo Achillis, shortening of, 296. by Glibney’s method, 297. by Willet’s method, 297. by Z method, 297. INDEX 585 Tendo Achillis, tenotomy of, 287. Tendon, kangaroo, 71, 83. as buried suture, 89. sterilization of, 83. Tendon lengthening, 294. shortening, 296. transplantation, 297. Tenorrhaphy, 292. Tenotomy, 283. in lower extremities, 286. in upper extremities, 285. of adductor longus, 291. of biceps flexor cruris, 290. of biceps flexor cubiti, 286. of extensor brevis pollicis, 285. of extensor communis digitorum, 285. of extensor longus digitorum, 289. of extensor longus pollicis, 285. of extensor ossis metacarpi pollicis, 285. of extensor proprius pollicis, 289. of flexor carpi radialis, 285. of flexor carpi uinaris, 285. of flexor longus digitorum, 286. of flexor longus pollicis, 287. of flexor profundus digitorum, 285. of flexor sublimis digitorum, 285. of gracilis, 290. of latissimus dorsi, 291. of pectoralis major, 302. of peroneus brevis, 288. of peroneus longus, 288. of peroneus tertius, 289. of quadriceps extensor cruris, 291. of sartorius, 290. of semimembranosus, 290. of semitendinosus, 290. of sterno-cleido-mastoid, 292. of tendo Achillis, 287. of tensor vagina? femoris, 291. of tibialis anticus, 289. of tibialis posticus, 286. Tension, deep sutures to relieve, 87. of sutures, 86. of wound while sewing, 85. Tensor vaginae femoris, tenotomy of, 291. Thecitis, operations for, 308. TLermo-cautery, 65. Thiersch’s fluid, 49. fluid, for instruments, 40. gauze, preparation of, 97. method of skin-grafting, 514. powder, 97. Thigh, amputation of, 474. antero-posterior musculo-integumentary flaps, 476, bilateral-flap method, 475. circular integumentary-flap method, 477. equilateral-flap method, Vermale, 475. long anterior-flap method, Sedillot, 479. long anterior-, with short posterior-flap, Farabeuf, 479. single circular-incision method, Celsus, 478. Syme’s modification of integumentary flap, 477. Three-cornered wound suture, 90. Thrombosis following linear craniotomy, 206. Thumb, amputation of, at carpo-metacarpal articulation, lateral-flap method, 420. oval method, 418. Thumb forceps, 84. in ligature of arteries. 111. Thymol, as antiseptic, 50. Thyroid artery, inferior, ligature of, 153. Thyroid artery, superior, ligature of, 173. Tibial artery, anterior, ligature of, 132. linear guide to, 133. muscular guide to, 133. Tibial artery, posterior, ligature of, 135. linear guide to, 136. muscular guide to, 136. Tibialis anticus, tenotomy of, 289. Tibialis posticus, tenotomy of, 286. Tibial nerve, anterior, operations on, 281. posterior, operations on, 281. Tilden Brown’s clamp for controlling haem- orrhage in amputation at hip joint, 487. Tissues, divided, proper securing of, 82. uniting of, 84. Toe, great, amputation of first phalanx of, 440. of last phalanx of, 441. of last phalanx, by internal plantar-flap method, Farabeuf, 443. of last phalanx, by oval-flap method, 443. of last phalanx, by square-flap method, 442. with its metatarsal bone, 445. Toe, little or fifth, amputation of, 442. with its metatarsal bone, 445. Toe nail, ingrowing, 505. Toes, amputation of all, at metatarso-pha- langeal joints, 443. of the phalanges of the, 440. of single, 441. of two adjoining, 443. Toes, disarticulation of, 440. Tongue, in Laborde’s artificial respiration, 18. as respiratory obstructant, 16. Tongue forceps, 13, 104. Torsion, 62. Torsoclusion, 62. Torticollis, 499. operations for, open method, 499. operations for, subcutaneous, 292. spasmodic, 500. Tourniquet, Esmarch’s, 482. extemporized, 58. Lister’s, 482. Pancoast’s, 481. Petit’s, 58. Towels, 9. antiseptic, to cover hands, 100. antiseptic, to pin over gowns, 101. clean aseptic, 45. Tracheotomy, in anaesthesia, 16. performance of, at operations, 104. Tracheotomy tube, at operations, 104. Traction loops, 38. in ligature of arteries, 111. Transfusion, 183. arterial, 186, 187. at operations, 104. 586 OPERATIVE SURGERY. Usefulness of a part of the operation, 2. Uvula, elongated, shortening of, 561. Vaccination, in treatment of birthmark, 188. Vagina, preparation of, for operation, 81. Vaginal temperature, 11. Vascular guides to arteries, 107. Vein, jugular, external, venesection of, 183. median cephalic, venesection of, 182. saphenous, internal, ligature of, 181. saphenous, internal, pad pressure on, 181. saphenous, internal, resection of, 182. Veins accompanying arteries, 107. air in the, 105. distinguishing of arteries from, 107. ligature of, 179. nicks in, treatment of, 179. operations on, 179. Veins, varicose, operations for, 179. acupressure, 180. excision, 181. injection, 180. subcutaneous ligaturing, 180. Venae comites, 107. Venesection, 182. of external jugular vein, 183. of median cephalic vein, 182. Ventricles, injection of, in chronic hydro- cephalus, 192. tapping of, in chronic hydrocephalus, 191. Vermale’s amputation at thigh, 475. Verneuil’s operation of rhinoplasty, 523. subastragaloid amputation, 452. Vertebral artery, bony guide to, 151. ligature of, 150. linear guide to, 151. muscular guide, deep, to, 151. Vessels, atheromatous, occlusion of, by pin pressure, 62. color of, as guide to arteries, 107, 108. empty, 9, 45. large, condition of, before operation, 4. ligature of, 67, 68. Volkmann’s osteotomy at neck of femur, 382. Vomited matter as respiratory obstructant, 16. Vomiting in anaesthesia, 12, 16. in ether anaesthesia, 18. Vulpius’s operation for tendon anastomosis, 299. Water, boiled, 50. cold and hot, as styptic, 54. hot sterilized, in oozing, 82. Webbed fingers, operations for, 501. Agnew’s method, 504. Dec’s method, 502. . Diday’s method, 502. Fowler’s method, 504. Norton’s method, 502. Zeller’s method, 504. Weber’s operation of rhinoplasty, 521. Weeping sinew, 306. Wehr’s method of flap transfer in plastic operations, 512. Whalebone tissue ligatures, 79. Whiskey, 103. Transfusion for loss of blood, 105. saline, 105, 186, 187. sanguineous, 105. venous, 185. with blood, direct, from arm to arm (im- mediate), 183. with blood, mediate, 185. Trapezius, myotomy of, 292. Trendelenburg’s method of meloplasty, 550. Trendelenburg’s rod, 60, 483. Trephine brush, 198. Trephine, conical or Galt’s, 195. crown or circular, 195. technique of using, 197-199. Trephine probe, 198. Trephining (circular craniotomy), 195. Trephining for meningeal haemorrhage, epi- dural, 201. subdural, 202. Trephining frontal sinus, 225. Trifacial nerve, Crede’s operation on, 253. divisions of, 236-250. Kocher’s operation on, 252. Kronlein’s operation on, 253. Pancoast’s operation on, 253. Salzer’s operation on, 253. trunk of, at foramen ovale, 250. Trifacial nerve, intracranial neurectomy of, 254. Doyen’s method, 261. Hartley-Krause method, 257. Horsley’s intradural operation, 262. Rose’s method, 254. Tripier’s method of subastragaloid amputa- tion, 452. Trochanter major, excision of, 371. Tubercle of os calcis, downward transplanta- tion of, 297. upward transplantation of, 295. Tuberculosis, 5. Tubes, decalcified bone drainage, 92. rubber drainage, 91. tracheotomy, at operations, 104. Tumor of brain, craniotomy for, 207, 213. enucleation of, 215. Tumor of cerebellum, 217. Tumors of spinal cord, 273. Tupfers, 9, 51, 52. Twisted suture, the, 88. Tying a continuous suture, 88. a ligature, 67, 68. an interrupted suture, 87. pedicles. 70. Ulna, excision of, 345. Ulnar artery, ligature of, 164. linear guide to, 164. muscular guide to, 164. Ulnar nerve, operations on, 278. Union, by first intention, 83. delayed by tight sutures, 86. Uniting of divided tissues, 84. Uranoplasty, 556. Davies-Colley method, 559. Dieffenbach-Fergusson method, 558. Langenbeck’s method, 556. Lannelongue’s method, 558. Urethra, preparation of, for operation, 81. A TEXT-BOOK ON SURGERY: GENERAL, OPERATIVE, AND MECHANICAL. By JOHN A. WYETH, M. D., Professor of Surgery in the New York Polyclinic ; Surgeon to Mount Sinai Hospital, etc. THIRD EDITION, REVISED AND ENLARGED. 997 pages, with 938 Illustrations. Buckram, uncut edges, $7.00; sheep, $8.00; half morocco, $8.50. SOLD ONLY BY SUBSCRIPTION. From Author's Preface. The original edition of this work was published in 1886. It was revised and enlarged in a second edition in 1890. Within the period of seven years to this date (November, 1897) so many important advances have been made in surgical sci- ence and the operative technique that the author has found it necessary again to revise and practically rewrite this volume. To add all that was new and acceptable to that which experience had already demonstrated to be useful has of necessity increased the number of pages and size of the book. By careful elimination of matter which could with least disadvantage be left out, this volume, however, only exceeds the former by one hundred and twelve pages. It has been the author’s aim to retain those features of the original work which made it available to the busy practitioner for quick and ready reference, and to add to this edition some elementary pages which may commend it to teachers for their undergraduate pupils. With this end in view the matter has in great part been rearranged. The introductory section is devoted to surgical pathology, subdivided into six chapters. These chapters treat of inflammation and the process of repair in the various tissues of the body, and the differences in repair in a tissue affected with simple or non-infective and infective (or suppurative) inflammation. Specific and non-specific urethritis, erysipelas, actinomycosis, glanders, tetanus, malignant cedema, hydrophobia, tuberculosis, syphilis, leprosy, diphtheria, and typhoid infec- tion are also embraced in this portion of the work. Chapters VII and VIII are devoted to surgical dressings, sterilization, asepsis and antisepsis, and anfesthesia. In Chapters IX and X are given hemorrhage, wounds, burns, skin grafting, frostbite, furuncle, carbuncle, ulcers, and gangrene. Bandaging is given in Chap- ter XI. and Chapter XII is devoted entirely to amputations. Chapters XIII, XIV, and XV deal with the lymphatic vessels and glands, veins, arteries, aneurism, and ligation of the vessels. In Chapters XVI and XVII are given the lesions of the bones and joints, and the various operative measures for their correction. The chapters from XVIII to XXIX inclusive are devoted to regional surgery, and in that portion of this section in which the abdomen is considered many im- portant changes have been made and much new matter added. Chapter XXX takes up deformities and their correction, while the final chapter (XXXI) is devoted to the subject of tumors. D. APPLETON AND COMPANY, NEW YORK. TRAUMATIC INJURIES OF THE BRAIN AND ITS MEMBRANES. With a Special Study of Pistol-Shot Wounds of the Head in their Medico-Legal and Surgical Relations. By CHARLES PHELPS, M. D., Surgeon to Bellevue and St. Vincent’s Hospitals. 8vo, 582 pages. With 49 Illustrations. Cloth, $5.00. SOJLD BY SUBSCRIPTION. “ This work is a concise and systematic treatise on that division of brain sur- gery arising from injuries of the brain through external violence, and has been based almost exclusively on the observation of five hundred consecutive cases of recent occurrence. Although the cases were so numerous, it seems they were in- complete only in the illustration of secondary pyogenic infection, which is naturally a tribute to the skill of the surgeons in charge of the cases, inasmuch as they were kept from infection. This clinical deficiency has been supplied by excerpts from Macewen’s work on Inflammations of the Membranes of the Brain and Spinal Cord, with the permission of that gentleman. We have no hesitation in saying that it is the most complete work on this division of brain surgery which has yet appeared in America.”—Journal of the American Medical Association. “ This book will prove of great service to both physician and surgeon ; and to those interested in medical jurisprudence it will be of incalculable value. The author is not embarrassed by his great wealth of material; he studies it exhaustively, and arranges it clearly, concisely, and with great care and discrimination. The chapters on Pistol-Shot Injuries are particularly instructive, and the series of ex- periments on cadavers replete with interest. One of the strongest features of the book is the large number of photographic representations of cranial injury.”— National Medical Review. “ We have here a new work highly creditable to American authorship and add- ing a material contribution to our present literature upon Brain Surgery. The first part of the work is devoted to the consideration of traumatic lesions of Ihe cranium and its contents, embracing their pathology, symptomatology, diagnosis, prognosis, and treatment. Part II is an exceedingly interesting and original discussion of medico-legal and surgical relations and treatment of pistol-shot wounds of the head. Part III contains a condensed history of three hundred cases of intracranial traumatism verified by necropsy. A most interesting feature of the work is the introduction of a large number of full-page photographic illus- trations of the effects of pistol-shot wounds produced by those of different calibers and at different distances. The work will at once be appreciated as one of original investigation, and especially by those who are particularly interested in brain sur- gery.”—North American Practitioner. D. APPLETON AND COMPANY, NEW YORK. THE ANATOMY AND STTRGTCAL TREATMENT OF HERNIA. By IIENRY O. MARCY, A. M., M. I)., LL. D., LATE PRESIDENT OF THE AMERICAN MEDICAL ASSOCIATION, ETC. ILLUSTRATED With Seventy full-page Heliotype and Lithographic Reproduction* from Cooper, Scarpa, Cloquet, Camper, Darrach, Langenbeck, Cruveilhier, and others of the Old Masters, AND THIRTY-FOUR WOODCUTS IN TIIE TEXT. Sold only by Subscription. Half Morocco, $15.00. rPIIE author has reviewed, in extenso, the normal anatomy of the parts involved in Hernia, and the remote causes which tend to produce it. The pathological changes incident to the more marked condition are clearly defined, and the chap- ters devoted to the discussion of these subjects are very copiously illustrated. In- strumental supports are carefully discussed, and their better methods of application defined. All the various methods of modern operation are given in detail, and, as far as possible, a compilation of tne results obtained under modern antiseptic pro- cesses is made. The chapter devoted to the Animal Suture is worthy of especial consideration, since it clearly details one of the greatest innovations of modern surgery of universal value. It is estimated that there are between three and four millions of people in the United States alone suffering from Hernia. Hundreds of thousands of trusses are manufactured annually. Every physician is aware that a hernia is a gradually in- creasing disability, and that it is very rarely cured except by operative measures. Serious complications and dangers are ever present to the individual suffering from Hernia, and statistical tables show that the resulting mortality is very large. No other surgical disability is so liable to come under the notice of the physician as Hernia, and the author holds that it is in the highest degree the duty of every prac- titioner to familiarize himself thoroughly with the subject. The opinion that pro- fessional obligations are discharged when the patient suffering from Hernia is relegated to the instrument-maker is erroneous. The belief, as taught by authors of the last generation, that operative measures should not be taken except as a last resort, because of the attendant dangers, has been controverted by the achievements of modern surgery, among which none are more noteworthy than the perfected operations for the cure of Hernia. D. APPLETON AND COMPANY, NEW YORK. A New, Thoroughly Revised, and Enlarged Edition of QUAIN’S DICTIONARY OF MEDICINE. BY VARIOUS WRITERS. Edited by Sir RICHARD QUAIN, Bart., M. D., LL. D., etc., Physician Extraordinary to Iler Majesty the Queen ; Consulting Physician to the Hospital for Diseases of the Chest, Brompton, etc. Assisted by FREDERICK THOMAS ROBERTS, M. D., B. Sc., Fellow of the Royal College of Physicians, etc.; And J. MITCHELL BRUCE, M. A., M. D., Fellow of the Royal College of Physicians, etc. With an American Appendix by SAMUEL TREAT ARMSTRONG, Ph. D., M. D., Visiting. Physician to the Harlem, Willard Parker, and Riverside Hospitals, New York. IN TWO VOLUMES. Sold only by subscription. This work is primarily a Dictionary of Medicine, in which the several diseases are full) discussed in alphabetical order. The description of each includes an account of its etiolog and anatomical characters ; its symptoms, course, duration, and termination ; its diagnosis, prognosis, and, lastly, its treatment. General Pathology comprehends articles on the origin characters, and nature of disease. General Therapeutics includes articles on the several classes of remedies, their modes o action, and on the methods of their use. The articles devoted to the subject of Hygiene trea of the causes and prevention of disease, of the agencies and laws affecting public health, of the means of preserving the health of the individual, of the construction and management of hospitals, and of the nursing of the sick. Lastly, the diseases peculiar to women and children are discussed under their respective headings, both in aggregate and in detail. The American Appendix gives more definite information regarding American Mineral Springs, and adds one or two articles on particularly American topics, besides introducing some recent medical terms and a few cross-references. The British Medical yournal says of the new edition : 1 ‘ The original purpose which actuated the preparation of the original edition was, to quote the words of the preface which the editor has written for the new edition, ‘ a desire to place in the hands of the practitioner, the teacher, and the student a means of ready reference to the accumulated knowledge which we possessed of scientific and practical medicine, rapid as was its progress, and difficult of access as were its scattered records.’ The scheme of the work was so comprehensive, the selection of writers so judicious, that this end was attained more completely than the most sanguine expectations of the able editor and his assistants could have anticipated. ... In preparing a new edition the fact had to be faced that never in the history of medicine had progress been so rapid as in the last twelve years. New facts have been ascertained, and new ways of looking at old facts have come to be recognized as true. . . . The revision which the work has undergone has been of the most thorough and judicious character. . . . The list of new writers numbers fifty, and among them are to be found the names of those who are leading authorities upon the subjects which have been committed to their care.” D. APPLETON AND COMPANY, NEW YORK, INDEX. 587 White’s excision of hip joint, 372. Wicking, as drainage, in tapping ventricles, 192. Willet’s method of shortening tendo Achil- lis, 297. Wipers, 9, 51, 52. assistant to care for, 79. Wire, silver, 71, 84, 88. Wire serrefine, 64. Wladimiroff-Mikulicz’s osteoplastic resec- tion of tarsus, 361. Wounds, gunshot, of cranium, 226. Wounds, operation, antiseptics in, 48. closure of, 85. coaptation of, by adhesive strips, 83. douching of, 94, 102. douching of foul, 103. drainage of, 82, 90-93. dressing of, 82, 93-99. healing of, in glycosuria, 5. infected, open dressing of, 103. open method of dressing, 103. redressing of, 103. retentive coaptation of surfaces of, 82. secondary suturing of, 87. sloughing, open dressing of, 103. support of, by adhesive strips, 87. sutures for, 83, 87. three-cornered, sutures for, 90. Wounds, treatment of, 9, 82, 103. uniting of, 84. Wrist joint, amputation at, 442. circular-flap method, 422. double-flap method, Ruysch, 423. radial-flap method, Dubrueil, 424. single palmar-flap method, 423. Wrist joint, excision of, 346. complete, subperiosteal, Langenbeck, 348. complete, subperiosteal, Lister, 350. complete, subperiosteal, Ollier, 349. Wry neck, 499. spasmodic, 500. Wyeth’s method of controlling haemorrhage in amputation at hip joint, 483. modification of Syme’s amputation at ankle joint, 455. Wyeth’s pins, 61. Yarn, cotton, in acupressure, 61, 180. in harelip suture, 88. Z method of shortening tendo Achillis, 297. Zeller’s operation for webbed fingers, 504. Zinc, chloride of, 48. sulphocarbolate of, 48. Zuckerkandl’s operation on buccal nerve, 250. END OF VOLUME I.