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SHORT TREATISE
OPERATIVE SURGERY,



          &c. 
<J
                 RECOMMENDATION S.

  ft 1 have perused with pleasure a small treatise on Operative'
Surgery by Avbbjll, which appears to me well calculated fop
Students.                             W. GIBSON, M. D.
       Professor of Surgery in the University of Pennsylvania."
  Oct. 9, 1823.
 Gentlemen,
      I have examined Aterill's treatise on Operative Surgery*
at your request, and am happy to find that it is excellently suited
for the use of Students of Medicine.  They will doubtless be
glad to obtain a work which combines the advantages of a concise.
and perspicuous style with the additional recommendation of
cheapness.
                                   JOHN D- GODM'AN.
MESSRS. H. C. CARET AND I. LEA, 
                  A

       SHORT TREATISE

                  ON

OPERATIVE  SURGERY,

             DESCRIBING THE

  PRINCIPAL OPERATIONS AS THEY ARE

              PRACTISED IN

        England and France,

 'lESlQNEI) FOR THE USE OF STUDENTS IS OPERATINfl

                ON THE

           DEAD BODY.
Br CHARLES ATERILL,  Surgeon, Cheltenham,
 Fellow of the Uoffi College of Surgeons, London.
  ■* Elle" (Chirurgie Operative) " sera toujours l.» parlie la plus
efficace de l'art de guerir entre les mains des liommes qui la
cultiveront avec ^application qu'elle mdrite et avec les lumieres
qu'elle exige."
            MEMOIRES DE L'ACADEMIE HOTALE DE CRIRURSIE.
CJ
FIRST AMERICAN EDITION,

      WITH ADDITIONS
BY JOHN BELL, M. D.
m°l
               PHILADELPHIA.
II. C. CARET AND I. LEA, CHESTNUT STREET; AND WELLS AND LILLI,
              COURT STREET, BOSTON.

                    1823. 
 Eastern District of Pennsylvania^ to -wit:
   BE IT REMEMBERED, that on the tenth day of November,
 in the forty-eighth year of the Independence of the United States
 of America, A. D. 1823, H. C. Carey and I. Lea, of the said dis-
 trict, have  deposited in this office the title of a Book, the right
 whereof they claim as proprietors in the words following, to wit:

   " A Short Treatise on Operative Surgery, describing the prin.
 cipal operations as they are practised  in  England and France*.
 designed for the use of students in operating on the dead body.
 By Charles Averill, Surgeon, Cheltenham, Fellow of the Royal
 College of Surgeons, London."
  " Elle" (Chirurgie Operative) " sera toujours la partie la plus
 efficace de l'art de  guerir entre les  mains des hommes  qui la
 cultiveront avec l'application qu'elle me rite et avec les lumieres
 qu'elle exige."
              MEMOIRES DE L'ACADEMIE ROTALE DE CHIRURGIE.
  " First American edition, with additions by John Bell, M. D."

  In conformityto the act of the Congress of the United States, in-
 tituled, " An act for the encouragement of learning, by securing
 the copies of Maps, Charts and Books to the authors and proprie-
 tors of such copies, during the times therein mentioned:"-and also
to the act, entitled, "An act supplementary to an act, entitled "An
act for the encouragement of learning, by securing the copies of
 Maps, Charts and Books to the authors and proprietors of-such
copies during the time  therein mentioned," and extending the
benefits thereof to the arts of designing, engraving, and etching,.
historic^ and other prints."
                                       D. CALDWELL,
                    Clerk of the Eastern District of Pennsylvania
J. CRISST AND 0. GOODMAN, PRINTERS. 
                      xo

     SIR ASTLEY COOPER, BART.

           FELLOW OF THE ROTAL SOCIETV,

                     -AND

            SURGEON  TO THE KING,

                  &C. &.C. &c.

                 THE  FOLLOWING

    SHORT TREATISE ON OPERATIVE SURGERY

                      is,

            With his Permission,

          RESPECTFULLY DEDICATED;

                     DEIN'G

     A SMALL 11CT SINCKTIB TESTIMONY OF ADMIllATION

                     FOR

           SURGICAL  ATTAINMENTS

        OF THE  HIGHEST  O R D E R,

                     FROM

              HIS FORMER PUPIL

                     AND

     STILL OBLIGED FRIEND AND SERVANT.

                             THE AUTHOR
Cheltenham,
  Mar 1st, 182 j. 
 
CONTENTS.
Introduction,     ....
Of Incisions,      ....
To make a straight Incision,
---------a crucial Incision,
---------Elliptical Incisions,
To Puncture an Abscess,
To dilate a Sinus on a grooved Director,
Ligatures on  Arteries,
To tie the Radial Artery at the Wrist,
---------Ulnar Artery at the Wrist,
---------Ulnar Artery in the middle of the Fore
     arm,......
To tie the Radial Artery near the Elbow Joint
To tie the Brachial Artery near the Elbow
-----------------------in  the  middle of the
     Arm,.....
To tie the Axillary Artery,   .     .
To tie the Subclavian Artery below the Clavicle,
     ■                       above the Clavicle,
Page.
 xiii
  19
  20
  22
  23
  25
  ib,
  26
  28
  ib.

  29
  30
  31

  32
  33
  34
  35 
viii
CONTENTS.
 To tie the Carotid Artery,                          ^7
 _________Posterior Tibial Artery at the Ankle,    38
 To tie the  Posterior Tibial Artery rather below
      the middle of the Leg,   ....    ib.
 To tie the Posterior  Tibial Artery high up in the
      Leg,.....
 To tie  the  Popliteal Artery,
 ----------Peroneal  Artery  rather  below the
      middle of the Leg,
 To tie the Anterior  Tibial Artery in  the middl
     of the Leg,        .
 To tie the Femoral  Artery in the middle of th
     Thigh,       .      .     .
 To tie the Femoral Artery in the Groin,
 ---------External  Iliac Artery,
 ---------Internal Iliac Artery,
---------Aorta,       ....
 Extirpation  of the  Breast,
 Bronchotomy,     .....
iEsophagotomy,    .....
Hare  Lip,    .     .     .     .     .
Operation with the Bistoury,
---------with Scissars,
Removal of a part  of the Inferior maxillary Bone
Wry  Neck,  the operation as performed by M
     Dupuytren,   ....
Paracentesis Abdominis,
French Method,
Paracentesis  Thoracis,       .     .
Puncturing the Pericardium,
---------the Bl •  Mt-r,
Operation by the Rectum, 
CONTENTS.
IX
Operation above the Pubes,    ....    80
—■------by the Perineum,    ....    83
Lithotomy,        .....         84
Lateral Operation,.....85
----------------with the Knife,   ...    88
----------------with  the  Lithotome  Cache,    91
Lateral Operation with the Gorget,      .     .    93
The high Operation,.....94
Lithotomy on the Female,     ....    99
M. Lisfranc's Method,                          ib.
Castration,        .'.....100
M. Lisfranc's  Method,       .     .     .     .103
German Method,       .          .     .     .104
Amputation of the Penis,     ....   105
French Method of retuining the Catheter in the
     Bla.Mer.......106
Amputation of the Extremities,     .     .     .108
Amputation of the second or third  Phalanx of a
     Finger,       .     .     .     .     .     .110
M. Lisfranc's  Method,       .     .     .     .112
Amputation  of a  Finger at its first Phalanx or
     Junction with the Metacarpal Bone,     .   113
Amputation of the Metacarpal Bone of the Thumb,   115
Amputation of the Metacarpal Bone of the Little
     Finger,......117
Amputation at the Wrist Joint,     .     .     .118
M. Lisfranc's Method,       .     .     .     .120
Amputation of the Lower Third of the Forearm,
     with two Flaps,.....122
Manner of using the Saw,     ....   124
Amputation at the middle of the Forearm,         ib. 
X
CONTENTS.
Amputation at the Elbow-Joint, as performed by
     M. Dupuylreii,.....126
Amputation at the middle, or at the lower part
     of  tlie Humerus,
Amputation at the Shoulder-Joint,
Baron Larrcy's Method,
M. Lisfranc's  Method,
Amputation of the  Toes, as performed by M.
     Lisfranc,    .....
Amputation of a  part of the  Metataisal Bone of
     the Great Toe, as performed by M. Lisfranc,
Mr. Hey's  Method,.....
Partial Amputation of the Foot at the Junction
     of the Tarsal with the Metatarsal Bones, as
     performed by Mr. Hey,
M. Lisfranc's  Method,
Amputation at the Articulation of the Astragalus
     and Os Calcis, with the  Scaphoid and Cu-
     boid Bones,
Amputation a little below the  middle of the Leg,
     with a Flap,       ....
Amputation below the Knee,
Removal of the Knee-Joiot,
Amputation of the lower third of the Thigh,
Amputation at the Middle of the Thigh with two
     Flaps,......
Amputation at  the Hip-Joint, as  performed  by
     M. Lisfranc,       ....
Fistula Lachrymalis,     ....
M. Dupuytren's Method,
Extirpation of the Eye,
-----------------------with the Palpebra?," 
CONTENTS.	xi
i Trephining,.....	. 160
French Method,.....	. 164
Conclusion, .....	. 166
^Cataract, . . . . .	. 169
*Couching, .....	. 170
'Extraction, . . .	. 173
*---------by Sir William Adams's Meth	Dd, . 179
*Saunders's Operation for Congenital Cata	ract, 183
*Sir William Adams's Operation,	. 186
* Artificial Pupil,	. 189
#Ectropion, or everted eyelid,	. 193
*Entropion or Trichiasis,	. ib.
*Extirpation of Schirrous Tonsils,	. 194
*------------Haemorrhoidal Tumours,	. 199
^Removal of Polypi.	
♦Polypus in the Nasal Surfaces,	. 204
^Polypus of the Uterus,	. 206
^Stricture of the Urethra,	. 207
^Stricture of the Rectum,	. 209
*Hydrocele, ....	. ib.
♦Hernia, ....	. 213
♦Scrotal, or Inguinal Hernia,	. 214
♦Epiplocele, ....	. 221
*Crural or Femoral Hernia,	, 222
*Exomphalos, or Umbilical Hernia,	. 226
♦Hydrocele bis,	. 230
 
ERRATA.
Page  69, For Abdominus read Abdominis.
     229, line 15, for and through the navel read and not through
        the navel.
  This last error only prevails in some copies of the work. 
INTRODUCTION
   The most cursory description of the opera-
tions  of Surgery, is more than  sufficient to
demonstrate, that the art of performing them,
with a proper regard to the lives and  necessi-
ties of  patients, can neither be learned by a
spectator, nor acquired by any prescribed rules,
without actual and frequent practice.
   The  Surgeon is required to know the form,
structure, situation, and uses, of every organ in
the living body; and he acquires this knowledge
principally by dissection of the dead: but to over-
come  that disgust, and distraction, which invari-
ably attend the study of Human. Anatomy, to
          o 
 Xiv            INTRODUCTION.
 familiarize the mind with the different opera*  ,
 tions, and the best mode of performing them,
 is indeed,  to him, when a  student, a difficult
 and laborious task; yet it has been acknowledg-
 ed from antiquity, that he must dissect; and  it
 is expedient he  should dissect, with  all the
 guidance and assistance, which the experience
 and  instruction  of others  can  supply.   The
 knowledge of anatomy, and the art of operating
 on the human body,are, however, distinct; and
 depend upon the principles of different sciences.
 The latter is especially derived from Mechanics,
 as well as from Anatomy, and is regulated by
the doctrines of Surgery, which at once inform
the  practitioner  what will be  the  state of his
patient after any operation, and suggest to him,
the means of rendering that state, as favourable
as possible.
  The ultimate benefits of any surgical opera-
lion, must,  of necessity, depend greatly  on the
dexterity of the operator, and any failure from 
               INTRODUCTION.             XV
a deficiency in this respect, is not less disgrace-
ful  to him, than  unfortunate  for  his patient.
The  importance therefore to  the student, of
actual practice on  the dead body, can not be
too highly estimated.
  If the Surgeons of France retain, in any re-
spect, the superiority  they were formerly  ac-
knowledged to possess over those of this country,
it is as operators only; which can  alone be ac-
counted for, by the attention paid in the French
schools, to  the practice of operating on  the
dead.   This single branch of the science seems
to be less insisted on, than might be  wished or
expected, by most English  students in the dis-
secting room.  It is usually taught in London,
as  collateral  to the courses of anatomical lec-
tures, (ew of which are devoted to the subject:
while the practical knowledge  is chiefly obtain-
ed  from cases furnished by the hospitals.  These
are the only public opportunities of acquiring a
qualification  so  essential to  the  professional
character, so  important to society. 
 XVJ             INTRODUCTION.
   The Author is not aware that any concise
 work exists, the sole object of which, is to ena-
 ble the student to practise surgical operations
 upon the dead subject, preparatory to perform-
 ing them on the living; and he has, in common
 with several of his  friends, frequently felt the
 want of some  such  guide to direct his studies.
 Descriptions of approved methods of operating
 on  the living  body,  are,  indeed, to be  found
 dispersed  through various surgical works, but
 all of them are too voluminous, and  too expen*
 sive, to be used in the dissecting room.   By the
 publication of  the following Treatise,  this de
 sideratum is attempted to be supplied.   For its
 contents, the Author's chief responsibility is that
 of a faithful narrator; the  methods of operating
here described, not resting upon his authority,
 as the best adapted for every possible case, but
 as the most approved,  and such as are now
generally pursued.   Several  of  the  operations
 are prefaced by historical remarks, which strik- 
               INTRODUCTION.            Xvti
itigly exemplify the improved state of Surgery;
and the whole is arranged in a manner consis-
tent with the Author's wish of presenting the
greatest  number practicable upon  one dead
body: this being always a desirable object, and
now rendered  too  imperative, by the  impedi-
ments  so  injuriously opposed to  the supply  of
subjects.
   Those  operations,  which every  Surgeon
ought  to be  able to perform dexterously, are
here  described, in conformity  with the rules
adopted in the hospitals of England and France;
according  to  the  methods taught by  Mons.
Lisfranc,  Surgeon  to the first Dispensary, and
Professor of Operative  Surgery at the Hospital
of la Pitie in Paris; as  the Author himself has
been accustomed to perform them, some on liv-
ing subjects, and all on  the dead  body, in the
course of his private anatomical studies.
   The operations which are requisite  for the
cure  of Strangulated  Hernia,  for Hydrocele,
                     2* 
XVhi           INTRODUCTION.
for diseases of the eye, for contractions of the
^Esophagus, Urethra, and Intestinum Rectum,
for Polypus in the nose, and some others, are
omitted, as they can not, in general, be practis-
ed on the dead body: but since the confidence
of the Surgeon in performing them, chiefly de-
pends on his anatomical knowledge, the neces-
sary  qualification is  now justly enforced, and
ably  explained by  the Teachers of Anatomy
in London. 
             A

       SHORT TREATISE

             ON

OPERATIVE SURGERY.
               OF INCISIONS.
  Though it  may  appear superfluous  to  lay
down rules for performing the first  and most
simple of  all surgical operations, yet, it is uni-
versally allowed, that, if strict attention be  not
paid by the  learner to the principles of any
science, little  hope can be  entertained of his
ultimate success.   It is not sufficient, however,
that the student be able to perform  these pri-
mary operations,  by any fixed rules, unless he
acquire also,  that ease and facility, which so
strikingly distinguish  the dexterous from  the
clumsy operator.   Hence, the necessity is mani-
fest, of careful and minute attention to a pro-
per method of holding the bistoury, or scalpel, 
20         THE STRAIGHT INCISION.
while making the various incisions about to be de-
scribed.  Quickness, and flexibility of hand, are,
indeed, generally obtained, by long and frequent
practice; yet a proper method of holding an in-
strument, tends, in no small degree, to facilitate
these desirable  attainments: and,  to show  that
this  point is not too trifling  to be insisted on,
the words of a distinguished  Professor are  here
introduced."   " When that which is  simple is
fully attained, that which is more complex will
be easier understood, and better performed;
and it will often be found, that the final success
of that which is great, very  much depends on
the accurate execution of that which is little."
     TO  MAKE A STRAIGHT INCISION.
  With the fingers and thumb of the left hand,
put the integuments on the stretch, and in the
right, take the scalpel or bistoury, holding it
between  the thumb and middle  finger,  at that
part where the blade and handle unite, resting
the fore-finger on the back of the blade, and
applying  the ring and little fingers closely round 
          THE STRAIGHT INCISION.        21
the handle,  the extremity of which  will rest
against the side of the metacarpal bone of the
little finger.   In this form, pass the instrument
perpendicularly through  the integuments, and
when it has penetrated to the necessary depth,
lower the handle  gradually, till  the  blade  be
almost horizontal, continuing the cut from left
to right.  When near the point at which it  is
intended to terminate  the incision,  raise the
handle, so as to bring the instrument perpen-
dicular,  in order  that the incision may be  of
equal depth from one extremity to the other.
   In making  this  incision,  care  should  be
taken  not to introduce the instrument so deep,
as to wound any important part, which may be
situated  beneath; particular  attention should
also be  paid  to the state of the integuments,
which, if not  kept tense, roll before the instru-
ment, prolonging the operation, and  causing
unnecessary pain to the patient.
   These precautions being attended to, nothing
more will, in general, be requred to make the
first incisions  in  the  operation  for hernia, m 
22    STRAIGHT AND CRUCIAL INCISION.
cutting upon arteries, for the removal of small
subcutaneous tumors, &c, &c.
      TO MAKE A CRUCIAL INCISION.
   This  is formed of two straight incisions, the
 first of which is made  from left to right, as di-
 rected ; the second consists of two cuts, each of
 which, (supposing a circle drawn round the
 first,)  is made from the circumference to the
 centre, or middle of the first incision, and at
 right angles to it  By making the  second in-
 cision in two opposite directions, the integu-
 ments are kept tense during the operation, and
 the cut is  made with less pain to the patient,
 than if performed at  once.
   The second incision may also be made thus.
 The bistoury is to be held flat in the hand, with
 its cutting edge turned towards the operator's
 right; it is then to be pushed under the integu-
ments, from the middle of the farther border of
the first incision, till its point arrives at the  spot
where it is  intended  to commence the second.
The cutting edge, being now  turned  towards 
     CRUCIAL AND ELLIPTICAL INCISIONS.  23
the surface, is to be protruded through the in-
teguments from the point to the heel,  and half
of the incision finished, by drawing the bistoury
from  heel to point.  In the same manner the
opposite half is to be made, the operator thrust-
ing the  bistoury beneath the  integuments to-
wards himself.   This method is more tedious
and painful than the former, which, if cautious-
ly performed, is always preferable.
   In  dissecting back the flaps, as in the opera-
tion of  Trephining, the bistoury is to  be held
like a writing pen, the point of the nearest an-
gle is to  be raised between the thumb and fore-
finger of the left hand, and dissected back with
the point of the bistoury; then the cutting edge
of the knife is to be turned in a contrary direc-
tion,  and  the opposite angle dissected back;
again  the direction of the cutting edge is to be
changed, and so on alternately, for either of the
remaining  angle.

    TO  MAKE ELLIPTICAL INCISIONS.
  These are frequently employed in Surgical 
24         ELLIPTICAL INCISIONS.
operations, as in the removal of schirrous breasts,
tumors of considerable size, and in all cases in
which a portion of integument is to be taken
away with the diseased part.
  The Operator with his left  hand draws the
integuments towards him away  from the line
which the incision is to take;  whilst an assist-
ant keeps them  tense  by pulling them in an
opposite direction.  The inferior half of the
ellipsis is to be first formed, the course and ex-
tent of which being fixed, the cut is to be made
from left to right.  The superior is then to be
finished in the  same manner, taking care that
it correspond  at  every point  with  its fellow,
The part may now be dissected out, and  the
lips of the wound brought in contact, to ascer-
tain whether they exactly coincide.
  The parietes of the abdomen, and the gluteal
region are the parts best  adapted  for  practis-
ing these incisions, there being generally more
fat  between the  integuments  and muscles in
those situations, than in any  other parts Of the
body. 
              ABSCESS.--SINUS.           25
       TO PUNCTURE AN ABSCESS.
  A collection of matter,  when superficially
seated,  is generally evacuated by a  puncture
made with a lancet; but when the abscess is a
considerable distance from the surface, a straight
bladed bistoury is the best instrument for per-
forming the operation,  which should be done
thus.
  The bistoury is to be held nearly perpendi-
cular,  with its point downwards, grasping  the
heel between the thumb and fore-finger of the
right hand, the middle  finger being  placed on
the side of the blade, at the same distance from
its point,  as the matter is supposed to be from
the surface.  The hand being supported by the
ring and little fingers, the bistoury is to be pass-
ed through  the integuments into  the abscess:
the situation of the middle finger thus prevents
the instrument from puncturing too deep.
                     TO
DILATE A SINUS ON A GROOVED DIRECTOR.
  The handle of the director is to be held be-
         3 
 26        LIGATURES ON ARTERIES.
 tween the index,  the middle fingers, and the
 thumb of the right hand, and its point introdu-
 ced into the sinuous opening: then the handle is
 to be taken in the same manner in the left hand,
 and  a Phymosis knife, or  a straight narrow
 bladed bistoury, is  to  be  held  in the right.
 with its cutting edge directed upwards; and in
 this  way passed along the groove, lowering the
 handle of the director as the knife is pushed
 forwards, till it reaches  the extremity of the
 sinus; then it  is to be forced upwards through
the integuments, and the operation  finished by
cutting towards the left hand; withdrawing the
director as the incision is terminated.
        LIGATURES ON ARTERIES.
  The art of applying ligatures on arteries with
a proper degree of constriction, so as to ensure
the certainty of their  action on the tied vessel,
is of the utmost importance in the practice of
Surgical operations.   It is  requisite that  the
following cautions be observed  in  all cases.
That the fingers of the left hand be applied  pa- 
LIGATURES ON ARTERIES.        27
  rallel to the direction of the incision, so as not
  only to mark its course and extent, but also to
  keep the  integuments tense.  The ligatures
  should be  round and compact; those composed
  of a single waxed thread are generally strong
• enough  for securing  any  artery.   The eyed
  probe slightly curved, and the aneurismal nee-
  dle, are the  instruments best adapted for pass-
  ing the ligature beneath the vessel, which should
  be  separated  from  its lateral connections  as
  little as possible, yet  dissected clean at that part
  where it is about to be secured.*   The ligature
  should be applied horizontally, and drawn with
  an even force, so  as to divide the  internal and
  middle coats of the artery;  taking  care  that no

   * An instrument  has lately  heen invented  by Mr.
 Weiss, Surgical Instrument Maker, in the Strand, for
 the purpose  of passing  the ligature under the artery,
 when very deeply seated, without raising it from  its
 natural situation.  I  have once seen  it  used by Mr.
 Travers at St. Thomas's Hospital, in t}ing the Subcla-
 vian nrtrry above the  clavicle. 
28     RADIAL ARTERY AT THE WRIST.
accompanying nerve or vein  be included with-
in it.  As it is an extraneous body, it should be
rendered as  small as possible;  one of its ends
should therefore be removed, unless Mr. Law-
rence's method be preferred, of cutting off both
extremities close  to the knot.   If the  patient
faint during the  operation, the wound should
not  be closed till he recover, in order to see if
haemorrhage takes place from any other vessel.
                    TO
TIE THE RADIAL ARTERY AT THE WRIST.
  Feel for the styloid process of the  radius, at
which point begin  your incision; continue it
through the  integuments for two inches, in the
direction of a line which if continued would pass
between the condyles of the os humeri; the ar-
tery will be found superficially situated, having
the tendon of the supinator radii longus muscle
on its outer side.
   ULNAR ARTERY AT THE WRIST.
Feel for the Pisiform bone,  half an  inch 
       ULNAR ARTERY IN THE FOREARM.    29
 above which, and on the outer side of the flexor
 carpi ulnaris muscle, make a straight  incision
 of two inches in extent through the integuments;
 cut through the fascia, an assistant drawing the
 internal  edge of the wound to the  inner side;
 dissect carefully by the side of the tendon, and
 you find  the artery situated on the outer side of
 the nerve.   The colour of these smaller arteries
 remote  from the heart, may occasionally lead
 the student to  mistake them for  veins, as  the
 blood frequently remains in  them after death,
 especially in old subjects.

 ULNAR ARTERY IN THE  MIDDLE OF  THE
                 FOREARM.
  About three fingers breadth from the inter-
 nal  condyle of the  os humeri, on the anterior
 surface of the ulna, but near its inner edge,  be-
gin the  incision; continue it in the direction of
 that bone for three  inches; divide the fascia to
the same extent, separate the  presenting  mus-
cles, which are, on the outer side, the palmaris
longus lying more superficial, and  the flexor
                     3# 
 SO   RADIAL ARTERY NEAR THE ELBOW.
 sublimis deeper; and on the  inner, the flexor
 carpi uln 'ris.   The  nerve will  be found situa-
 ted deeply in the inter-space,  on the outer side
 of which the artery is placed.

 RADIAL ARTERY  NEAR THE ELBOW JOINT,
   In the axis of  the angle formed by the two
 condyles of the os humeri, and the extensors
 and  flexors of  the hand,  an  incision  is to be
 made through the  integuments, commencing a
 a little below the joint, and  continued down-
 wards for three  inches.   This exposes the fas-
 cia of the forearm,  which is to be divided to the
same extent; when the artery  will be laid bare.
  In wounds of these small arteries, which have
free  anostomosing  branches, two ligatures are
 required to suppress the haemorrhage;  one
 above, the other below the wounded part; these
are most readily applied  by enlarging the inci-
 sion,  and  thus  exposing the bleeding vessel.
 But if the artery be completely  divided, its cut
 extremities retract to a  considerable  distance,
 the blood continues to flow into  the neighbour- 
    BRACHIAL ARTERY NEAR THE ELBOW.  31
ing cellular membrane, and it becomes extreme-
ly difficult to find the bleeding orifice.  In such
a case, it is bettei first to cut down on the ves-
sel at one of the  before  mentioned points, be-
tween the wound and the heart, and apply the
first ligature; the lower bleeding extremity will
then be more readily discovered.

  BRACHIAL ARTERY NEAR THE ELBOW.
   This artery is occasionally punctured in the
operation of venesection; producing an aneu-
rism at  the bend of the arm, which requires for
its cure the obliteration  of the vessel.   Piiila-
grius is said to be the first who tied this artery
for an aneurismal swelling; he secured it above
and below the tumor, which he extirpated, and
filled the  wound with such dressings as tended
to promote  suppuration.   Dominique Anel, a
French military  surgeon, first tied  the artery
without opening the  sac.  The operation may
be performed as fojlows.
   Begin the incision half an inch above the  in-
ner condyle of the os humeri;  continue it up- 
32     BRACHIAL ARTERY IN THE ARM.
wards along the  inner edge of the biceps mus-
cle  for at least two inches; when,  having cut
through the integuments, and generally, a little
fat,  you find the median nerve rising before the
artery, which  has an accompanying vein  on
each side.  Pass the ligature beneath the ves-
sel  from its inner side,  by which  means the
nerve is readily excluded.
BRACHIAL  ARTERY IN  THE  MIDDLE OF
                THE ARM.
  Make an  incision  through the integuments
two inches long on the inner edge of the biceps
muscle; this first exposes the median nerve,
which has the artery  on  its inner side between
its two accompanying veins; the internal  cuta-
neous nerve is situated on the inner side of the
artery, diverging from it, as  it descends in the
arm.
  The operator may be occasionally confused
by this artery dividing unusually high in the arm;
in the last extremity that I dissected, the  sepa-
ration took place in the axilla; the two trunks 
           . AXILLARY ARTERY.           33

ran down the arm parallel to each other, till they
reached the tendon of the biceps, where they
diverged into radial and ulnar.
             AXILLARY ARTERY.
   A wound  or, aneurismal tumor of the upper
part of the brachial artery would  require the
application of a ligature on the axillary, which
may be applied  as follows.
   The part being shaved, or the hairs cut close-
ly off with a pair of scissars,  place the patient
on his side, and let the arm be raised up by an
assistant; then feel  in the axilla for the  head of
the bone, which is thus lowered by  the position
of the  arm; over it  make an incision, in the di-
rection of the limb, three inches long, the mid-
dle part of which should be  exactly  over the
head of the bone; this will expose a part of the
axillary plexus, behind the largest nerve of which,
the median, the  artery will  be found: the vein
passes rather below the artery  at this part.  Af-
ter the first  incision through  the integuments,
use the blade of the knife as  little  as possible, 
 34         SUBCLAVIAN ARTERY.
 to avoid wounding any of the branches of the
 vessel.

 SUBCLAVIAN ARTERY BELOW  THE  CLA-
                  VICLE.
   This artery has been successfully tied by the
late Mr. Keate, Surgeon  general  to the army,
and by Mr. Chamberlaine  of Kingston, Jamai-
ca, both in cases of axillary aneurism.
   The following on  the dead subject, I have
found the  most ready method of securing this
vessel.  Put the pectoral muscle on the stretch
by raising the arm and extending it backwards;
then observe the depression formed by the junc-
tion of its clavicular with its sternal  portion,
the direction of which must  be the course of
the incision.   Begin  it half an inch from the
sternal extremity of the clavicle, and continue
it through the  integuments for three inches in
the above  direction;  separate the  two  portions
of muscle from each other exactly in the course
of its fibres,  then  bring the  arm to the  side,
which, by allowing of a wider separation, ex- 
            SUBCLAVIAN ARTERY.          35
poses more readily the parts beneath: at exact-
ly one third of the length of the clavicle  from
its sternal extremity,  you find the vein which
is situated directly anterior to the artery, often
concealed by fat and cellular membrane.   To
avoid wounding the vein the greatest care is re-
quisite.  For  this  purpose the dissection  had
better be carried on with the handle of the scal-
pel, after having divided the muscle.

SUBCLAVIAN ARTERY ABOVE THE CLAVI-
                   CLE.
   This artery has been tied with success by
Dr. Post of New York; a history of the case is
published  in  the ninth volume  of the Medico
Chirurgical Transactions.   I believe it has  also
been once successfully tied in Dublin, and once
in Edinburgh.  In England the  operation has
never  succeeded.   The  late  Mr.  Ramsden,
Surgeon to  St.  Bartholomew's Hospital,  was
the first who  tied it;  since which it  has been
secured at the London Hospital by Sir William
Blizard; at Winchester by Mr. Mayo, in March 
S6
SUBCLAVIAN ARTERY.
  1822.  I saw it tied at Guy's Hospital by  Mr.
 Aston  Key for a large aneurismal tumor extend-
 ing from below the clavicle into the axilla; and
 in January  last, for a similar disease, I saw it
 secured by Mr. Travers at St. Thomas's Hospi-
 tal.
   Make an incision three inches long just above
 the upper border of the clavicle, beginning half
 an inch from its sternal extremity, or immedi-
 ately on the outer edge of the origin of the ster-
 no mastoid muscle;  continue it through the in-
 teguments and platysma myoides, taking care
 not  to   wound the  vein,  which  is  situated
 before  the artery,  crossing it nearly at  right
 angles;  having separated  it  from the  artery, it
 should be held on one side by an assistant; then
 feel for  the eminence formed by the junction of
 the bony, with the cartilaginous portion of the
 first rib, on the outer side of which you find the
 artery;  the nerves forming the axillary plexus
 are situated rather behind and to its outer side.
 Owing to the  depth of the vessel  considerable
difficulty will be found in passing the ligature. 
              CAROTID ARTERY.           37
             CAROTID ARTERY.
   Till within the present century the operation
of tying the carotid artery for the cure of aneu-
rism had never been performed; a case requir-
ing it was considered hopeless as being beyond
the reach of remedy by surgical operation.
   Harder  relates an instance in which it was
once attempted at the hospital of la Charite in
Paris, according to the old  method of opening
the sac, and tying the vessel above and below;
but so great was the haemorrhage that  the pa-
tient  died  under  the hands of the surgeon.
Sir Astley Cooper was the first who secured
the vessel by ligature for this disease, since which,
the operation has been many times performed
with success.
   Begin the  incision at the  lower edge of the
Thyroid cartilage;  continue  it upwards and
outwards through the integuments and platysma
myoides for two inches and a half, immediately
on the inner side of the sterno mastoid  muscle,
so as  to form  an angle with  the Thyroid carti-
lage:  dissect very carefully  by the edge of the
         4 
 38   POSTERIOR TIBIAL AT THE ANKLE.
 muscle, drawing it a little outwards, and the ar-
 tery is  found where it emerges from beneath
 that muscle and the Omo-hyoideus.  Be care-
 ful not to  wound the  internal jugular vein,
 which is situated on the outer side of the arte-
 ry, and  rather anteriorly;  the nervus vagus is
 behind and to its outer side, and the descendens
 noni runs  down  the front of the  artery:  the
 whole is surrounded by condensed cellular mem-
 brane forming a kind of sheath.

    POSTERIOR TIBIAL AT THE ANKLE.
   The patient being placed with his face down-
 wards, make an  incision two inches long be-
 tween the inner malleolus and tendo Achillis,
but nearer the  former; cut  through the apo-
neurosis, and you find the  artery nearly under
the malleolus, having the tibial nerve rather be-
hind and to its  outside, and an accompanying
vein on each side.
POSTERIOR TIBIAL  RATHER BELOW THE
           MIDDLE OF THE LEG.
  A little below the middle of the leg, begin an 
    POSTETIOR TIBIAL HIGH UP IN THE LEG. 39
incision on the inner edge of the gastroc nemius;
continue it obliquely for three inches in the di-
rection of that muscle, so as to separate  it from
those beneath; elevate it with  the upper part of
the tendo Achillis, and on the first division of
the muscle beneath, you find the artery with
the nerve rather behind  and  to its outer side,
and an accompanying vein on each side.

  POSTERIOR TIBIAL HIGH UP IN THE LEG.
   Begin the incision below  and between the
condyles of the femur;  continue it through the
integuments four inches down the middle of the
calf of the leg; cut through the aponeurosis and
gastrocnemius externus nearly to the same ex-
tent till you come to the internus, on the inner
side of the outer head of which you find  the ar-
tery, with the nerve situated anteriorly  and to
its outer side, and the vein rather before it.
           POPLITEAL ARTERY.
  Begin an  incision  between the condyles of
the femur, and continue it upwards for three 
40    PERONEAL AND ANTERIOR TIBIAL.
inches; the artery will be found deeply imbedded
in fat, with  the tibial nerve  and popliteal vein
situated more superficially.

PERONEAL ARTERY RATHER BELOW THE
          MIDDLE OF THE LEG.
  Let the incision be three inches long parallel
with the fibula,but behind its outer edge; a few
muscular fibres will require to  be divided; the
artery may then be felt by passing the finger
across the bone to its posterior and inner bor-
der, where it is situated, as it is small and deep-
ly seated,  there will be some difficulty in pass-
ing the ligature.
  Mr. Guthrie, in the  seventh volume of the
Medico-Chirurgical Transactions, has related a
case in which he secured this artery higher up
the leg, to suppress the haemorrhage caused by
a gun shot wound.
            ANTERIOR TIBIAL
       IN THE MIDDLE OF THE LEG.
  Begin an incision rather below the middle of
the tibia on its outer edge; continue it upwards 
  FEMORAL ARTERT IN THE MIDDLE OF THE THIGH. 41
 and outwards, for three inches, in the direction
 of the interspace of the tibialis anticus, and ex-
 tensor longus digitorum muscles; cut  through
 the fascia to the same extent, then separate the
 muscles, between which on the interosseus liga-
 ment, you find  the  artery,  having  before it  a
 branch  of the peroneal  nerve, and an accom-
 panying vein on each  side.  These arteries,
 like the smaller  of the upper extremity, require
 when wounded,  to be secured by two ligatures.

 FEMORAL  ARTERY  IN THE  MIDDLE OF
                THE THIGH.
  The  operation of tying the femoral artery
 where it is situated in  the middle third of the
 thigh, for the cure of  popliteal aneurism, was
 first performed  by Mr.  Hunter,  and it is  the
 operation now generally practised.
  Put the Sartorius in  action by placing the leg
 in the tailor's position;  then make an incision,
 three inches in length,  rather above  the middle
of the thigh, iti  the oblique direction of the
 muscle,  and on  its inner  edge; continue  it
                    4* 
42    FEMORAL ARTERY IN THE GROIN.
through the integuments and fat, till the border
of the muscle  is exposed.   Observe  the di-
rection of the fibres to ascertain that you  have
not come upon  the  Vastus,  then  elevate the
Sartorius,  drawing it a little outwards, which
brings the  femoral sheath into view; open this
with care,  by a small incision,  and then dilate
it by cutting from within outwards;  this ex-
poses the artery, which  has the  vein rather
behind and to its outer side.
    FEMORAL ARTERY IN THE GROIN.
  The patient being placed on his back,  sep-
arate the thigh to be operated on from the other,
and let the leg hang over the edge of the table;
this renders the artery more superficial, by put-
ting the integuments and sartorius muscle on
the stretch.  Begin the incision half an inch be-
low the middle of Poupart's ligament; continue
it downwards for three inches, inclining it slight-
ly to the inner side of  the thigh, to avoid the
saphena vein which is rather superficially  seat-
ed, and nearly over the artery.   Having cut 
EXTERNAL  ILIAC.
40
through the integuments, fat, aponeurosis, and
fascia lata, you come to the sheath of the ves-
sels.  This being cautiously opened, as in  the
last operation, exposes the artery, which has the
vein on its inner side, but  separated from it by
a process of the sheath:  the anterior crural
nerve, not included in the sheath, is a  little to
its outer side.  An interesting case of  ligature
on this artery, for a wound of the vessel caus-
ed by a hay-fork, is related by Mr. Norman of
Bath, in  the tenth  volume of the Medico-Chi-
rurgical Transactions.

             EXTERNAL ILIAC.
   Mr. Abernethy  was  the first who tied  this
vessel for inguinal  aneurism.  He made his in-
cision in the direction of the artery, and secur-
ed it by two ligatures.  The operation has since
been repeatedly performed with success. From
the number of cases published, the following ap-
pears to  be the  most general method of secur-
ing the vessel.
   The hairs being previously shaved from the 
44            EXTERNAL  ILIAC.
part, begin the incision about an inch within,
and rather below,  the anterior  and superior
spinous process of the ilium;  continue it, in a
semilunar form, in the direction of Poupart's
ligament, for a little more than three inches, so
as to make it terminate just above the external
abdominal ring: this exposes the tendon of the
external oblique muscle, which being divided to
the same extent, and turned aside, lays  bare
the internal oblique  where it arises with the
transversalis from the outer half of Poupart's
ligament.   With  your finger,  or the handle of
the scalpel turn up the borders of these  mus-
cles  and the spermatic cord becomes exposed;
pass your finger behind it, push the  peritoneum
upwards, and  you feel the artery with the vein
on its inner side; they are closely connected by
cellular membrane, and must be carefully  sepa-
rated with  the handle of the scalpel, or a  blunt
probe.  After having cut through the tendon of
the external oblique, be careful to use the  knife
as little as possible, lest you wound the epigas-
tric artery, which is generally situated near the 
INTERNAL ILIAC.
45
 inner extremity of your incision, crossing be-
 hind the spermatic cord.   This accident hap-
 pened to the celebrated  surgeon Mons. Dupuy-
 tren, when performing the operation at the Ho-
 tel Dieu in Paris, in  the Autumn of 1821: the
 haemorrhage was so  copious, that two ligatures
 were required on the wounded vessel:  the pa-
 tient afterwards  died of peritonitis.

             INTERNAL ILIAC.
   This artery has been tied by Mr. Stevens of
 Santa  Cruz in the West Indies, and by  Mr.
 Atkinson of York; the former case terminated
 successfully, and is published in the fifth volume
 of the  Medico-Chirurgical  Transactions.   I
 shall give the operation in the words of Mr. Ste-
 vens.
  " An incision about five inches in length, was
made on the left side, in the lower and lateral
 part of the abdomen, parallel with the epigas-
tric artery; and nearly half an inch on the outer
side of it.   The  skin, the superficial fascia, and
the three thin abdominal muscles were succes- 
46            INTERNAL ILIAC
 sively divided; the peritoneum  was  separated
 from its loose connection with the iliacus inter-
 nus and psoas magnus, it was  then  turned al-
 most directly  inwards, in a direction from the
 anterior superior spinous process of  the ilium,
 to the division of the common iliac artery.  In
 the cavity which I had  now made I felt for the
 internal iliac, insinuated the point  of my fore-
 finger behind it, and then pressed  the  artery
 between my finger and thumb.   I  then  passed
 a ligature behind  the vessel and tied it about
 half an inch from  its origin.   I  found no diffi-
 culty in avoiding the ureter: when I turned the
 peritoneum inwards the  ureter followed it. Had
 it remained over the artery I could easily have
 turned it aside with  my finger.   The woman
 did not complain of much pain, and  I am cer-
 tain  she did  not lose one ounce of blood."
  This artery is also said to have been success-
 fully tied in  Russia, by an army  Surgeon, upon
whom the Emperor  Alexander  has since  set-
tled  a pension, as a reward  for the  dexterity
and skill, displayed in the treatment of the case. 
THE  AORTA.              47
                THE AORTA.
   In a case of aneurism of the common  iliac
 artery, which had given  way, and when there
 was no other hope, or chance of saving the pa-
 tient than by obliterating the  aorta,  Sir Astley
 Cooper put a ligature on that vessel, he having
 been previously satisfied  by experiments on the
 canine  species  that the circulation  could be
 carried on, by  collateral  branches, when  that
 artery was closed.   The case is published in
 the first volume of his Surgical  Essays, from
 whence I extract the following account of the
 operation.
  " The patient's shoulders were slightly ele-
vated by pillows, in order to relax as much as
possible, the abdominal muscles; for I expected
that a protrusion of the intestines would pro-
duce embarrassment in the operation, and  was
greatly gratified to find that this was  prevented
by their empty state, in consequence of the in-
voluntary evacuation of the faeces; and here let
me  remark that I should, in a similar operation,
consider it absolutely necessary, previously to
empty the bowels by active aperient medicines. 
48             THE AORTA.
   I then made an incision three inches long
into the linea alba, giving it a slight curve to
avoid the umbilicus: one inch  and a half  was
above, and the remainder below the navel, and
the inclination of the incision  was to the left
side of the umbilicus in this form ()> ).  Having
divided the linea alba, I made a small aperture
into the peritoneum, and introduced my  finger
into the  abdomen;  and then, with a probe-
pointed bistoury, enlarged the opening into the
peritoneum to  nearly the same extent as  that
of the external wound.  Neither the omentum
nor intestines protruded;  and during the pro-
gress of the operation, only one small convolu-
tion projected beyond the wound.
   Having made a sufficient opening to admit
my finger into the abdomen, I then  passed it
.between the intestines to the spine, and felt the
aorta greatly enlarged, and beating with exces-
sive force.  By means of  my finger  nail, I
scratched through the peritoneum on the left
side of the aorta, and gently moving my  finger
from  side to side, gradually passed it between 
                 THE AORTA.              49
 the aorta and spine, and again penetrated  the
 peritoneum on the right side of the aorta.
   I had now my finger under  the artery, and
 by its side, I conveyed  the  blunt  aneurismal
 needle armed with a single ligature  behind it;
 and my apprentice, Mr.  Key, drew the ligature
 from the eye of the needle to the external wound;
 after  which the  needle was immediately with-
 drawn.
   The next circumstance, which required con-
 siderable care, was the exclusion of the intes-
 tine from the ligature, the ends of which were
 brought together at the wound, and the finger
 was carried down between them, so as to  re-
 move every portion of the intestine from  be-
 tween the threads:  the ligature was  then tied,
 and its ends were left hanging from the wound.
 The omentum was drawn behind the opening
 as far as the ligature would admit, so as to faci-
 litate  adhesion;  and the edges of the wound
 were  brought  together by means of a quilled
suture and adhesive plaster."
          .5 
50     EXTIRPATION OP THE  BREAST.
      EXTIRPATION OF THE BREAST.
  In the history of the principal  operations of,
Surgery,  translated from  the  German  into
French,  Leonidas of Alexandria is stated  to
have been the first  who prescribed this opera-
tion as requisite in all cases in which the gland
was cancerous.  He adopted the following me-
thod of operating.  Having  placed his patient
on her back, he made his first incision through
the healthy integuments, to  which cut he im-
mediately applied the actual  cautery to prevent
haemorrhage, and then made a second deeper
than the first, which he burnt in a similar man-
ner, and thus  continued cutting, and cauterizing
alternately, till he had removed the breast; when
he finished the operation by again burning the
whole  surface of the wound,  so  as to destroy
any portion of disease which might have been
remaining.   On so cruelly painful a process no
comment is necessary.
  A schirrous enlargement of the gland is the
cause which  most frequently  necessitates the
performance  of the operation,   in executing 
       EXTIRPATION OP THE BREAST.      51
which it  is requisite to bear in  mind, that all
the skin directly connected with the tumor, and
the cellular membrane surrounding it, to the
extent of half an inch, should be taken away:
on this the happy result of the operation, in a
great degree, depends.
  The patient being seated on a chair, the ope-
rator places himself before her, when an assist-
ant puts  the pectoral muscle on  the stretch by
raising the arm from the  side.   The operator
then, with  the fingers of his left hand  placed
parallel to the course of his first incision, draws
the integuments tense, and  makes the cut on
the outer and under side of the tumor, of a
semilunar form, extending obliquely from above
downwards.   The corresponding incision  is
then to  be  made, beginning and terminating
at the same points as the former,  but passing on
the other side of the tumor,  enclosing as much
of the integument as may be  deemed sufficient,
which the operator puts on the stretch by press-
ing it from him with his left  thumb.   The dis-
section,  commenced at the  upper  and outer 
52     EXTIRPATION  OP THE BREAST.
part, is  to  be continued obliquely from above
downwards, in the direction of the fibres of the
pectoral muscle till the tumor is separated.
  If  the  dissection  be attempted from below
upwards, it is probable that the lower edge  of
the pectoral muscle will be raised; and if it be
continued  from  the inner  incision, the blood
collects before the point of the knife, obscuring
the dissection and rendering it more tedious.
   Should a gland in the axilla be enlarged, the
incision must be  extended so as to remove it
with its connecting medium.  It  should first  be
raised from  its seat with a double  tenaculum,
and then  cut away.   This, pulling  it from  its
situation, prevents the artery leading to it from
retracting so as to escape detection  after being
divided.  Haemorrhage occurring  during  the
operation, may be  restrained by the assistant
pressing  his finger  on the bleeding orifices  till
it is completed, when the divided arteries must
be secured by ligatures, and  the borders of the
 wound approximated by adhesive plaster. 
BRONCHOTOMY.             53
              BRONCHOTOMY.
   This operation is said to have been first per-
 formed in the time  of Cicero, by  Asclepiades;
 and a great number of patients are said to have
 been then saved by it, who were  in danger of
 perishing from suffocation.
   When  respiration becomes impeded by dis-
 ease, as in severe cases of croup; or when some
 extraneous  substance  is deposited in the air
 tube, this operation is found to be most effec-
 tual in either restoring the one, or removing the
 other.   It is also occasionally adopted  in cases
 of suspended  animation from  drowning, to al-
 low of more readily inflating the lungs, when a
 proper apparatus for that purpose is not at hand.
 For the first of these cases it may be  done as
 follows.
  Place the patient on his back, with his head
resting on pillows and inclined  backwards as
much as the difficulty of breathing will permit.
The operator then, sitting on the right side, feels
for the space  between  the  thyroid and cricoid
cartilages, directly  over  which,  in the inter-
                   5* 
54             BRONCHOTOMY.
muscular  division, he  makes  a perpendicular
incision from half an inch to an inch in length.
He then places his left fore-finger on the liga-
ment connecting the thyroid to the cricoid car-
tilage,  along which he directs the straight bla-
ded  bistoury into the air tube and cuts a little
laterally on each side  between the  two carti-
lages.   Should this opening  not be sufficient
for a free admission of air, it  may be enlarged
by continuing the incision downwards so as to
divide  the cricoid cartilage, a  small portion of
which  Mr. Lawrence  cuts   away to prevent
the wound closing; that being preferable to the
introduction of a tube  which  often causes ex-
cessive irritation.
   When there is a foreign body to be extracted,
the opening is to be made in the same manner,
but  continued  through the first  two or  three
rings of the trachea, according to the substance
to be withdrawn; feeling  with the  fore-finger
to avoid wounding the superior branch of the
thyroideal artery, or the thyroid gland.  If the
substance  be not immediately expelled by the 
               /ES0PHAG0T0MY.            55

 force of the air passing from the lungs through
 the  artificial  opening,  it  should  be seized,  if
 practicable, by a small pair of forceps and taken
 away.  The lips of the wound should then be
 brought together and the  patient kept at rest.

             iESOPHAGOTOMY.
   When any foreign substance is lodged in the
 ^Esophagus that can neitiier be withdrawn  by
 the fingers nor forceps, nor pushed onwards to
 the stomach by the probang; but continues to
 prevent deglutition, and by  its pressure on the
 back part of  the trachea  or  larynx threatens
 suffocation,  an operation  for its removal be-
 comes requisite, which Mons.  Lisfranc recom-
 mends to be thus performed.
   The patient should be seated in a chair, with
 his head reclining backwards on the breast of
 an assistant; the operator placing  himself in
 front, takes the scalpel or bistoury, and, holding
 it like a pen, commences his incision on the in-
ner border of the left  sterno mastoid muscle,
opposite the  superior edge  of the thyroid carti- 
 5G            JJS0PHAG0T0MY.
lage. and  continues it down to the lower edge
of the cricoid.   An  assistant now draws  the
carotid sheath to the outer edge of the wound to
secure it  from the knife; while the operator,
cutting  carefully  through  the cellular tissue,
exposes the aesophagus, where it inclines to the
left side  from  behind the  trachea.  A  canula
with a grooved stilet, or the sonde a dard form-
ed  like  a female  catheter,  but considerably
longer, is to  be passed by the mouth down the
aesophagus, inclining its point to the left side,
which causes it to be readily felt from  the ex-
ternal wound.   The stilet is now to be  pushed
forwards  through the coats of the aesophagus,
when  the operator feels  with his  finger along
 its concave edge, to ascertain that no large ar-
 terial branch be situated on it, and then passes
 a bistoury into the groove, which directing it
 onwards  opens the aesophagus.   He now feels
 for the foreign substance, which is to be ex-
 tracted by a pair of dressing forceps passed along
 his finger.
   During the  operation, an assistant should 
HARE-LIP.               57
carefully sponge away the blood after each cut
of the knife, and should any arterial branch be
divided, though little haemorrhage followed, it
should be immediately secured, or it would ren-
der the operation much more tedious and ob-
scure.   The edges of the wound are to be ap-
proximated  and a light bandage applied.  The
patient is to  be kept at rest and no nourishment
given him by the mouth for a few days, but his
strength must be kept up by nutritious clysters.

                HARE-LIP.
  This malformation may be either single or
double.  When there  are two fissures it is
thought best to operate on each separately, and
not  endeavour to unite both at the same time.
As it is mostly congenital, it becomes a question
at what period after birth  the operation may be
performed so as not to  endanger the welfare of
the patient,  and at the  same time give the most
reasonable hope of success.   On this there have
been various opinions, some having postponed
the operation till the child has been five  or six 
58               HARE-LIP.
years old, others having operated as early  as
six weeks after birth: among the latter number
is Roonhuysen, a surgeon of Amsterdam  who
lived in  the seventeenth century, and who is
said to have  had extraordinary  success.  For
many hours previous to the operation he  inva-
riably prevented  the child from sleep, which
generally caused it  to remain quiet  for  some
time after.  This method of operating soon  af-
ter birth is now however seldom followed, it
having in some cases brought on convulsions, of
which the children  have died;  it is  therefore
now rarely performed before  two years of age,
and if it be postponed to a later  period the suc-
cess may be said to be more  certain, as the  lip
becomes better adapted for supporting the  su-
tures, and there is less danger of its speedy  ul-
ceration, which would require the operation to
be repeated.
   In England the operation  is  generally per-
formed with  the knife, and the cut edges ap-
proximated by sutures;  at the  Hotel Dieu in
Paris  I have  always seen the  borders of the 
HARE-LIP.               59
 fissure removed by the  scissars, and  needles
 with the twisted  suture  used for keeping its
 edges in apposition.  Each mode may  have its
 advantages;  the wound made  by the knife be-
 ing cleaner  and more regular throughout its
 whole surface, of course  is better adapted for
 uniting readily by adhesion; while with the scis-
 sars  the operation  is  more quickly performed,
 and less blood lost; which latter circumstance
 may  be of consequence if the subject  be very
 young.
   At St.  George's Hospital  the  operation is
 performed with the knife edged scissars, made
 by Mr Stodart in the Strand, to which the above
 objection  does not apply.
   In operating with the knife, the patient is to
 be seated  on  a chair,  or,  if a chifd,  placed on
 the knees of an  assistant, whose breast forms a
 support for the head, while his hands placed on
 the cheeks, keep it steady, and his index fingers
 pushed forward  approximate the edges  of the
 fissure.   The operator then,  with  a straight
sharp pointed bistoury, divides any  unnatural 
60               HARE-LIP.
 adhesions between the lip and gum, and places
 under the right side of the lip, a thin piece of
 polished wood, which he supports by the index
 and middle fingers of the left hand below, and
 the  thumb pressing on the lip above.
   Holding  the bistoury as a  pen,  he now
 thrusts it through the lip, above the  angle of the
 fissure, as high up as the inferior margin of the
 nostril, or the septum of the nose, and removes
 the border by cutting obliquely through the lip
 towards  himself.   He then places the wood be-
 neath the other side of the fissure, and supports
 it with two fingers, the assistant pressing the
 half lip above towards its fellow;  the bistoury
 is to be thrust through at the same point as be-
 fore and the other border removed,  leaving a
 cut corresponding at every part with the oppos-
 ed, and forming an angle more or less acute.
 The suture, formed of a double waxed thread,
is now to be passed from without inwards; in
doing which the needle is to be held between
the thumb and middle finger of the right hand,
the index resting on its top, and pushed through 
HARE-LIP.
61
 the left side of the lip at the junction of the vil-
 lous part with the integument, and  about  half
 an inch from the cut border; it is then continu-
 ed  from  within  outwards at  a  corresponding
 point on the opposite side.  The needle with a
 part of the  thread is then cut away1:  the operas-
 tor takes hold of the ends of the  suture, and by
 drawing them downwards, approximates  the
 edges of the wound; an assistant keeping thertv
 in that position, the second suture must be pass-
 ed  midway  between the first and the apex of
 the angle, in the same manner as the former.
 The lower suture is then secured, and  after-
 wards the upper, taking care that the cut sur-
 faces be in  exact contact.  No plaster or ban-
 dage  is  required  till the  sutures  are  removed,
 which should be about the fifth day, when they
 are to be snipt with the scissars; a bandage may
then  be applied and continued for a  few days
till the union has become more solid.
  OPERATION WITH THE SCISSARS.
The patient being fixed as in the former ope-
       6 
62               HARE-LIP.
ration; the operator takes hold of the right side
of the lip between the thumb and index finger
of his left hand;  and opening the scissars he
places the lip between the blades and cuts away
the border of the  fissure at  one snip: then tak-
ing the inferior part of the  left border between
the thumb and finger, he removes it in a similar
way, observing that the two cuts  unite at the
apex of the angle.
   The needles are now to be applied; common
steel ones are said to be as good as any; at one
of the largest hospitals in France,  the  Hotel
Dieu at Lyons, these only  have been employed
for many years.   The point being  previously
greased, it is held between the thumb and mid-
dle finger of the right hand, the index resting
 on its top, and  pushed into the lip about a quar-
 ter of an inch from the cut border,  and just
 above the junction of the  villous part with the
 integument; it is continued forwards obliquely,
 so as to  pass through about two  thirds of the
 substance of the lip, and make its appearance
 just above the inner border of the cut surface; it 
                 HARE-LIP.              63
is then made to enter the opposite side of the
wound at a similar point, and is pushed onwards
till  it has  pierced the integuments,  its course
corresponding to the preceding.
  The extremities of this needle  are to be en-
circled by a  waxed thread passed behind them,
which an assistant draws downwards, so as to
bring the cut edges in contact at the upper part,
where  the second needle is  applied in a similar
manner.   The ends of the thread are now car-
ried round the extremities of the lower needle
several times, crossing each time on its middle
and forming a figure of  8;  they are then to be
made cross each other between the two needles,
and carried round the ends of the upper one,
on which  a  similar figure is to be formed pass-
ing the threads under its extremities and over
its  middle as  before.  This being repeated a
sufficient number of times to keep the edges of
the wound in  contact, the  ends of. the thread
are to be made fast, and a small bolster of  soft
linen placed beneath  the needles  on each side
the wound,  to prevent  the extremities giving 
64        REMOVAL  OF THE  CHIN.
pain by pointed pressure on the lip.  The nee-
dles are remoyed about the fifth  or  sixth day,
the inferior one being first taken away.

REMOVAL OF  A PART  OF  THE INFERIOR
            MAXILLARY BONE.
  This operation has been performed with com-
plete success by ]VJ. Dupuytren, Surgeon to the
Hotel Dieu in  Paris: the whole of the chin was
the part  taken away.  I  am  not certain as to
the nature of the disease for  which the opera*
tion was  had recourse to; but it appears that it
may be  required for exostosis,  necrosis, or a
cancerous affection of the bone.   Each of these
diseases would  perhaps call for a slight variety
in the operation according to the  circumstances
of the case.
   The following is  the  method in which  M.
Lisfranc recommends it to  be practised on  the
dead subject.
   The body being placed on its back with its
head lowered, and chin  elevated, an  assistant
takes hold of one side of  the  lower lip between 
REMOVAL  OP THE  CHIN.
65
his thumb and fore finger, while the operator,
standing behind  the head, in like manner fixes
the other.   An  incision is then made from the
middle down to  the os hyoides; if it be only the
chin that is  to be removed this cut will be suf-
ficient,  but  if a  larger portion be to be taken
away, another will be necessary, made along
the anterior part of the bone so as to form a
cross.   The skin, which adheres firmly, is to be
dissected back on both sides, and the bone de-
nuded,  by  dividing  the  periosteum with  the
knife at the part to  be  sawed  through.   M.
Dupuytren directs the periosteum on  the  pos-
terior part of the bone to be cut, by thrusting
the knife upwards behind it, and turning its edge
towards  the bone; but M. Lisfranc objects to
this, as it may probably wound vessels which, in
the living subject, would  furnish considerable
and even dangerous haemorrhage.
  The saw is now to be applied, and the bone,
being steadily fixed  by  an  assistant, sawed
through  obliquely that it may come  in perfect
contact with its opposed portion, which is to be
                     6* 
66         REMOVAL OP THE CHIN.
cut through at the corresponding point.  In or-
der to avoid  wounding the nose or upper lip
while  sawing through  the bone,  those  parts,
should be shielded from the teeth of the instru-
ment by a pad of soft cloth.  The  division of
the bone bejng effected, its separation from thei
soft parts is to  be completed with the knife.
The haemorrhage produced by such an operation
on the living subject, should  be suppressed by
drawing out the tongue,  seizing with a tenacu-
lum such  arteries as can be detected,  and se->
curing them by ligatures,  after which, if blood
still continues to flow from invisible sources, the
actual cautery is directly  to be applied   The
 extremities of the bone are then to be placed
 in perfect coaptation,  and the edges of the
 wound brought into contact; pads of liut are to
 be placed so as to produce  compression, and
 the whole kept together by a roller judiciously
 applied.   Previous to the operation, it will be
 requisite  to extract one or two  teeth on each
 side,  at the part where  the bone is to be sawn
 through. 
WRY NECK.
67
                WRY NECK.
  When this deformity is occasioned either by
spasmodic contraction of one of the sterno mas-
toid  muscles, or paralysis of the other, it may
sometimes  be relieved by an operation.   In a
case of the former kind it would  be requisite to
divide some of the fibres of the diseased muscle;
in the latter a sufficient quantity of the corres-
ponding  healthy one would require  to be cut,
in order  to establish an uniformity of action be-
tween the two.
  The history of the following case may serve
as a guide in practising the operation, as well
as one proof of its success.
  A little girl  about ten years of age, whose
neck, or  rather whose head, had been awry for
three years, owing  to  a permanent spasmodic
contraction of the sterno mastoid muscle of the
right side, was  admitted  into the  Hotel  Die**,
Paris, early in January 1822.  On the 16th of
that month  the  operation  was performed by M.
Dupuytren as follows.
  The patient  reclined against an assistant,  a 
68               WRY NECK.
puncture was made with a straight narrow bla-
ded bistoury, through the integuments  just on
the inner  border of the sternal  extremity of
the contracted muscle.   The blade of the bis-
toury, being flatly opposed to the muscle, was
pushed cautiously behind it, the point being di-
rected forwards and outwards till it protruded
just on the outer side of the clavicular border.
The edge of the bistoury was  then turned to-
wards the muscle, and a sufficient  quantity of
its posterior fibres cut to allow of the head  be-
ing placed erect: the instrument was then with-
 drawn
   In this  way the integuments escaped  being
 divided, and a future scar prevented; a very de-
 sirable object, the patient being a female.
   The cut edges of the muscle were kept asun-
 der by depressing the clavicle, and inclining the
 head to the  left side.  The former was effected
 by binding the right hand firmly to the foot, the
 knee being  bent; thus the clavicular fibres of
 the deltoid drew the bone downwards; the lat- 
PARACENTESIS ABDOMINIS.
69
 ter by a roller passed round the head and un-
 der the left axilla.
    The patient was kept in bed; and at the end
 of thirteen days the punctures were healed, and
 she had free motion of the neck, though  from
 long continued habit, she still turned her face
 to the left  side.  The bandages were reapplied,
 and the same bodily position maintained till the
 twenty-first of February, when they were  final-
 ly taken  away,  and  the patient  pronounced
 eured, the head being but very slightly inclined
 to the  right  side, and having free motion  in
 every direction.
   In operating on the male, the fibres may be
 eut on the anterior surface of the muscle, an in-
 cision  being first made through the integuments.
 Inclining the head to the opposite side by a roll-
 er, and filling the  wound with lint, will then be
 sufficient to keep  its cut edges asunder.

        PARACENTESIS ABDOMINUS.
   When medical treatment is found insufficient
for removing the fluid collected within the pe-. 
70        PARACENTESIS ABDOMINIS.
ritoneum in  cases of abdominal dropsy, the ope-
ration of tapping the belly is had recourse to in
order to evacuate it.  This operation appears
to have been performed in the earliest days of
Surgery,  and never to have been considered
either very dangerous or difficult to execute, as
it is related  that Peter the Great once perform-
ed it, and drew away forty measures of fluid.
However simple it may be deemed., it  is not
wholly without  danger, as  well authenticated
cases are related in which the epigastric artery
has been wounded and  the  patient has died of
haemorrhage.
  The patient  being seated on a high chair, a
long cloth or towel should be passed round the
upper part of the abdomen, and fixed securely
behind by an assistant; this presses the  fluid
downwards, and at the same time gives support
to the diaphragm,  preventing its  sudden de-
scent,  which would otherwise be  very apt to
produce syncope. The operator, seated in front
on a low chair, takes the common  straight ab-
dominal trochar, previously smeared with  oil, in 
          PARACENTESIS  ABDOMINIS.        71
his right hand, and  holding the handle firm  in
the palm,  he places on the canula his index fin-
ger, which not only prevents the trochar enter-
ing too far, but also serves as a guide to the in-
strument.   In this manner, about an inch and
a half below the umbilicus in the  linea alba, it
is to  be  steadily thrust through the integuments
and other abdominal parietes,  giving it a  slight
rotatory motion, as it is pushed forwards.  Its
entrance into the abdomen is rendered evident
by the cessation of resistance.   By making the
puncture at this part, the danger of wounding
the epigastric artery is avoided, unless  it devi-
ates considerably from its natural course.
  The operator then, with the thumb and  index
finger of the left hand, gradually pushes forward
the canula, while, with the same  fingers of the
right, he withdraws the stilet.   The  fluid is to
be received in a vessel of sufficient size to con-
tain the whole; the  towel or cloth which encir-
cles the abdomen being proportionably  tighten-
ed as it flows away.   Should the  orifice of the
canula  be stopped by lymph  or omentum, it 
72       PARACENTESIS ABDOMINIS.
must be removed by introducing a blunt probe
or director along the tube.   The water being
evacuated, the canula is to  be taken between
the  index and middle fingers and the thumb of
the  right hand,  and withdrawn  slowly, white
with the same  fingers of the left,  pressure is
made on the borders of the wound.  A pad of
lint  should be placed on the puncture,  a broad
flannel roller applied round the abdomen to give
the  requisite support, and the patient returned
to bed.
   Some of  the French surgeons in puncturing
the abdomen, employ a curved  trochar similar
to that used in England for puncturing the blad-
der  by the rectum.   This they  plunge through
the  abdominal parietes at the middle point be-
tween  the umbilicus, and anterior and superior
spinous process  of  the ilium; the patient lying
on the edge of  the bed,  on the side on which
the puncture is made.  They choose the right
side, as they say the large intestines are more
floating at that part on the left, and therefore
are in some danger of being wounded. 
          PARACENTESIS  THORACIS.        73
        PARACENTESIS THORACIS.
  The recovery of persons from wounds which
had penetrated the chest, first led  to the per-
formance  of this  operation, which, although
many instances are related  of its  success, it
would by no means be prudent to attempt in all
cases of hydrothorax; that disease being gene-
rally accompanied  by some  organic affection,
cither of the chest or abdomen.  When hydro-
thorax is the result of an acute disease, as pleu-
risy, or pneumonia,  or follows the suppression
of some long continued discharge, and the  pa-
tient is young or middle aged, and in other re-
spects healthy; it would  be  wrong  not to per-
form the operation, as the case holds out every
probability of terminating well.   Baron Larrey
in his Memoires de Chirurgie Militaire, relates
nu nerous instances in which he has performed
the operation; both for effusions of blood, and
matter within the cavity of the chest, in many
of which cases his  patients recovered.  The
space between  the sixth and seventh true ribs,
where the digitations of  the external  oblique
          7 
  74       PARACENTESIS  THORACIS.
  muscle join those of the serratus magnus, is the
  part at which it is  recommended to make the
  puncture, provided  there  be no other rendered
  prominent by the pressure of the fluid, which,
,  if there be, should always be preferred. A tro-
  char should not be used, as there would be dan-
  ger of  wounding the lungs or diaphragm; a
  straight bistoury, or a scalpel is the only instru-
  ment required, and the operation may be done
  as follows.
     Place the  patient in  the half-erect position,
  and make an incision  upon the  seventh rib, by
  taking up a fold of integument and cutting in
  the direction of the bone for two inches.   Dis-
  sect the integument upwards from the rib and
  intercostal muscles.  The left index finger may
  then be introduced  if  necessary to feel the su-
  perior  border of the  rib, and the intercostal
  muscles divided close upon it,  to the  extent of
  half an inch,  and a  small opening made in the
  Plura Costalis, taking  care that the point of the
  knife does but just enter the chest.   The flap
  is then brought down,  the wound closed, and a 
PARACENTESIS THORACIS.
director carefully passed through it so as to eva-
cuate the fluid without allowing the admission
of air into the cavity of the Pleura.  This is
afterwards avoided by a compress on the valvu-
lar flap, which, if skilfully applied, will serve to
prevent the occurrence of Emphysema in those
cases in which the lung has been opened by the
bursting of an abscess into the Pleura: and by
the above mode of operating the intercostal ar-
tery, running along the lower  margin of the
sixth rib, can not be endangered.
   If there be much fluid in the thorax a part
only should be evacuated,  and then the com-
pr ss placed over the wound till the next day,
when it  may be  removed, and the remainder
let out;  by this gradual  evacuation, the lungs
will  return by degrees to  their original state,
and  thus the presence of air in the chest will
be the more surely prevented.  When there is
fluid collected in  both  Plurae, an operation on
each side will be required, which must be per-
formed at distant periods, or the patient may be
suffocated by the admission of air into both sides
of the chest at the same time. 
76     PUNCTURING THE PERICARDIUM.
    PUNCTURING THE PERICARDIUM.
  Mons. Boyer, in hisTraite des Maladies Chi-
rurgicales,  observes;  when without swerving
from the path of prudence it is thought neces-
sary to perform this operation, the method re-
commended  by  M.  Skielderup, Professor  of
Anatomy at the University of Christiana in Nor-
way, should be preferred, it being less  hazard-
ous than  any other.  It consists in  making a
crucial  incision  through the  integuments, re-
moving a portion of the sternum by means of
the trephine, and  then puncturing the pericar-
dium.  The operation is directed to be perform-
ed immediately below the part where the carti-
laginous portion of the fifth rib unites with the
sternum.  Here the approximating layers of the
two plurae leave an intervening triangular space,
which is part of the anterior mediastinum, situ-
ated a little  more to  the left than to the right,
and which is filled by  cellular  membrane; its
apex rising as high as the fifth rib, its base rest-
ing on the diaphragm.  Thus, after having tre-
phined the sternum at the  part above mention 
       PUNCTURING THE PERICARDIUM.      i I
ed, the  pericardium  may  be opened  without
wounding  the  pleura; consequently the  chest
will not be penetrated.  The crown of the tre-
phine used should be of sufficient size  to leave
an opening in the sternum, the dimensions  of
which will admit the left  index finger; this fin-
ger at the same time that it discovers the part
at which fluctuation is  most discernible, serves
as a conductor for the bistoury,  with which the
pericardium is to be punctured.   After having
cut through the bone of the sternum, the con-
densed  membrane or  ligament lining its inner
surface, will offer considerable resistance to the
crown of the trephine, which should then  be
laid aside, and the adhesions divided by  the bis-
toury.   Should any  ha3inorrhage  follow,  the
operation should  not  be continued until it has
ceased.   Before making  the  puncture  in the
pericardium the body of the patient should  be
inclined forwards.
  M Richerand has supposed it possible to per-
form a radical cure for dropsy of the pericar-
dium, by making  a large  opening in the ster-
                   7* 
78       PUNCTURING THE BLADDER.

num, opposite to the  heart, and  incising a por-
tion of the membrane, between the  layers of
which he conceives the admission of atmosphe-
ric air would be a sufficient stimulant to excite
adhesive inflammation.
       PUNCTURING THE BLADDER.
  In cases of retention  of urine in which relief
can not be obtained by  medical  treatment, and
when the introduction of the catheter is found
impracticable, the distention must be removed,
or inflammation may speedily ensue; the urine
may escape by means of ulceration or gangrene,
and being effused  into the cellular membrane
produce extensive  sphacelation  if not death:
the operation of puncturing the bladder there-
fore becomes necessary.
  There are three methods of performing this
operation; by the rectum, above the pubes, and
through the perineum.  Each of these methods
may have its advantages, and each has its parti-
cular advocates.  The  late Mr  Hey, Sir Eve-
rard Home, and Mr. Forster, being in favour 
         PUNCTURING THE BLADDER.       79
of the first. Mr. Abernethy of the second, and
Sir  Astley  Cooper  generally  preferring the
third.

      OPERATION BY THE RECTUM.
  The patient being seated on the edge of the
bed, with his legs held up as in the operation for
the  stone, an assistant, with his left hand, press-
es on the abdomen just above the  ptibes, and
with his right raises the scrotum.  The operator
kneeling on his right knee, or sitting on a low
chair passes his  left index  finger, previously
greased, into the rectum; and feeling behind the
prostate gland, he discovers that part of the dis-
tended bladder which is situated between the
vesiculae seminales.  Half bending his finger,
he rests its extremity on this point,' and passes
along its  anterior surface the  curved trochar,
which should be from four to five inches long:
this he pushes obliquely forwards into the blad-
der in a direction, which, if continued,  would
puncture the parietes of the abdomen midway
between the umbilicus and pubes,  in the linea 
80       PUNCTURING THE BLADDER.
alba.  The finger is now withdrawn from the
rectum; wlien, holding the canula between the
thumb and  first  two fingers of the left hand,
with the  right the operator  takes away the sti-
let, and the  urine flowing away, is received in
a bason.   The canula should be retained in the
bladder for a day or two, when it may be re-
moved, and the  urine  allowed to flow by the
rectum,  if the natural  passage  continues ob-
structed.
   The principal objections to this operation are
the following.   The Vesiculae  Seminales may
chance to be wounded; the presence of a canu-
la in the rectum often  causes tenesmus, or in-
flammation of that gut; a small portion of faecal
matter may  pass  by the opening into the blad-
der, and form a nucleous for a future stone;
and lastly the passage of the urine by the rec-
tum mostly produces great irritation and exco-
riation of the surrounding parts.
   OPERATION ABOVE THE PUBES.
The same trochar as used in the last opera- 
PUNCTURING  THE BLADDER.       81
 tion is required for puncturing the bladder above
 the pubes.   This is the method generally pre-
 ferred  by  French surgeons, who perform it
 thus.
   The patient being placed on the edge of his
 bed reclines backwards against  an  assistant,
 with his thighs slightly bent towards the abdo-
 men.   The surgeon standing in front can ob-
 serve, if the patient be thin,  the circumscribed
 prominence formed by  the distended bladder
 above the pubes; he then places his left index
 finger on the point where he purposes introduc-
 ing the  trochar, which is one inch and a half
 above the pubes in the linea alba.   The handle
 of the instrument being held in the palm of the
 right hand, with the index finger resting on the
 canula,  the trochar is pushed through the inte-
 guments,  directing its point backwards and
 downwards  in the direction of the axis of the
 bladder, its entrance into which is  made mani-
 fest by the cessation of resistance, the easy mo-
 tion of the instrument, and the dribbling of a
little urine.   The canula is now held between 
 82      PUNCTURING THE BLADDER.
 the thumb and first two fingers of the left hand,
 while the  stilet  is withdrawn with  the  right,
 the patient resting on either side, and reclining
 forwards as the urine flows  away.  In propor-
 tion as the bladder is emptied its coats retract;
 it is  therefore requisite to push forwards the
'canula to  prevent its slipping off its extremity.
 As soon as the fluid  is completely drawn away,
 the open end of the canula is stopped by a cork;
 and by means of tape, passed through the rings
 of its outer extremity, round the pelvis, it is fix-
 ed in the  bladder.   In the course of seven or
 eight days it is withdrawn, as calculous concre*
 tions are  apt to form round it, first passing
 through its tube an elastic gum catheter.   The
 chief objection to this operation is the possibility
 of the bladder escaping from the  instrument,
 and  thus  producing  extravasation in the sur-
 rounding cellular membrane, as well as the ne-
 cessity of constantly wearing  a catheter, or
 canula in the bladder.
   Mr.  Abernethy in performing the operation,
 first  separates  the  musculi  pyramidales from 
         PUNCTURING THE BLADDER.       83

each other, by making an incision about  two
inches in length through the integuments and
between the muscles.   By this opening the dis-
tended bladder is readily felt,  into which the
trochar is introduced as before.   The danger
of extravasation into the surrounding cellular
membrane is thus removed, by the urine pass-
ing readily off through the external wound.
     OPERATION BY THE PERINEUM.
   The patient being placed in the same posi-
tion as in the operation for the stone, an assist-
ant presses the bladder downwards from above
the pubes.   The operator, seated  on  a low
chair, takes the scalpel, and, holding it  like a
pen, commences the incision on the left side of
the raphe, between the bulb andcruspenis, and
continues it obliquely downwards and outwards
for an inch  and a half.   Having reached the
bulb, he presses it with his left index finger, to
the right side, and feels forwards for the prostate
gland  and  distended  bladder.  The trochar,
which should be straight and not less than three 
84              LITHOTOMY.
inches and a half in length, is to be pushed into
the bladder,  by the side and at the base of the
prostate gland.   The stilet  being withdrawn
and the bladder  emptied of its contents, the
canula may be removed, and a female  catheter
substituted, which should be  there retained by
means of tape passed through  its rings round
the pelvis, from  before backwards, and vice
versa.
  This operation  is the most difficult to perform
of the three,  and  requires considerable  caution,
with an exact knowledge of the relative position
of the parts, to enable the operator to steer clear
of the surrounding danger, otherwise  he may
wound the vas deferens, the vesiculae seminales,
the ureter, the prostate, or the rectum; or he
may pass the trochar between the rectum and
bladder, and  be foiled on withdrawing the stilet
by finding no urine issue from the tube.
               LITHOTOMY.
  A stone may be removed from the bladder by
an incision made into that viscus, either through 
LITHOTOMY.              85
the perineum or above the pubes.  The former
operation, when the prostate  gland is cut side-
ways, is denominated the lateral; the latter, the
high operation.

           LATERAL OPERATION.
   The method of opening the bladder by  cut-
ling the prostate gland laterally, was first  per-
formed  towards the close of the seventeenth
century  by Jacques Baulot,  commonly called
Frere Jacques, a French  monk, who, without
any knowledge of anatomy, journeyed about the
country performing the operations of Lithotomy
and Hernia.   He executed the  former by  first
passing  a catheter and then, with a double  edg-
ed knife, cutting by its  side  through the pe-
rineum, straight forwards into  the bladder.  By
this opening he introduced his finger or a direct-
or, passed  the forceps along its surface,  and
having pulled out the stone, left  the patient ex-
claiming " L'operation est achevee; Dieu vous
guerise? In this way he operated, at the hos-
pital of la Charite and the Hotel Dieu in Paris, 
86              LITHOTOMY.
on sixty patients, twenty-five of whom died; and
on examining the parts after death it  was found
in many cases, that he had not only opened the
bladder but had also  made  free  incisions into
the rectum.
  In the hands of Cheselden, a well educated
man,  a good anatomist, and  an experienced
surgeon, this operation was considerably im-
proved.  He divided the urethra from its mem-
branous  portion to the prostate gland,  by  cut-
ting with the  knife  on a  grooved  staff,  and
opened the bladder with the blunt gorget, push-
ing it through the substance of the prostate
gland.  His knowledge of anatomy  kept  him
from committing the blunders of Frere Jacques;
consequently his operations were followed by
more  happy results; indeed  his  success  was
most extraordinary, as out of fifty-two  patients
on whom he operated at St Thomas's hospital,
two only died.
  The operation is at  present said to  be per-
formed with the greatest success in the Norfolk
and Norwich hospital.   Mr. Martineau, senior 
LITHOTOMY.
87
surgeon to that institution, has, in the eleventh
volume of the Medico-Chirurgical Transactions,
given  a  statement of  eighty-four unselected
cases, being all those on which he has operated
between the years 1804  and 1820; out of which
number two only died.   Mr.  M. in executing
the operation, divides the  prostate gland with
the knife and uses the blunt gorget merely as
a conductor for the forceps.
   There are three instruments invented for cut-
ting the prostate gland in this operation; each
of which  has its particular advocates  among
Surgeons  of the present day.  First, the knife,
the most ancient method, is preferred by many;
second the lithatome cache, invented by Frere
Come, a French surgeon, is generally employ-
ed in the hospitals at Paris; and third, the cut-
ting  gorget, first used by Sir  Caesar Hawkins
at St. George's hospital; this last is perhaps the
instrument in most frequent use among English
surgeons.   Of the first and last again, the form
is  varied;  the knife  invented by Sir  Astley
Cooper, and that of Mr. T. Blizard, each of 
88
LITHOTOMY.
which  has a beak  at its  extremity, are pro-
bably most commonly employed; while the gor-
gets of Mr. Cline, Sir Astley Cooper, and Mr.
Abernethy, have each of  them respective de-
fenders among Surgeons who give the prefer-
ence to that instrument.  The operation with
the knife may be performed thus.

LATERAL OPERATION WITH THE KNIFE.
   The patient being seated on the  edge of a
table of convenient height, his back supported
by pillows,  his thighs separated,  elevated  to-
wards the abdomen, and the soles of his feet
grasped in the palms of his hands; a bandage
is looped  round each wrist, and continued, en-
circling each ankle, wrist, foot, and hand; so
as to bind firmly the hands to the  feet; another
bandage may be passed  from under  each ham
over the  shoulders, and  fastened behind the
neck.  The position will be still better preserv-
ed by an assistant standing on each side, giving
further support to the limbs, and keeping the
thighs separated by slightly pressing  the knees
outwards. 
LITHOTOMY.              89
   The operator then taking the grooved staff,
smeared with oil,  between the thumb and first
two fingers of his right hand, passes it into the
bladder, and having felt the stone, rests its ex-
tremity against it.   An assistant, standing  on
the patient's left side, takes hold, with his right
hand, of the handle of the staff, which he keeps
steadily fixed, nearly perpendicular, but slight-
ly inclined to the  right  side    The  operator,
seated on a low chair, with a double edged scal-
pel, held like a pen. makes his first incision
through  the  integuments  and  fat,  beginning
about an inch below the symphisis pubis,  close
to the raphe  on its left side, and continuing it
obliquely  downwards and  outwards, between
the anus and tuberosity of the ischium; dividing
the intermediate space into three parts,  it fin-
ishes exactly at the point where the outer and
middle parts join,  and from  whence a line,  if
passed across  the anus,  would  separate it into
two equal portions.   The next  incision is be-
tween  the crus and bulb of the penis, through
the accelerator muscle, which  lays the  bulb
                     8* 
90              LITHOTOMY.
bare; this being pushed aside by the left index
finger, the transversales pcrinsei  muscles are
divided in the direction of the external wound
With the same finger, beyond the bulb, the ope-
rator feels  the staff where it is situated in the
membranous portion of the urethra, by cutting
through  which with the point of his  knife, he
opens into the groove.   Keeping the nail of his
forefinger in the groove, he takes the knife with
which he purposes  dividing the  prostate,  and
passing it along his finger, fixes  its beak in the
groove of the staff; then,  rising from his seat,
he takes the handle of the staff between the
thumb and first two fingers of his left hand, and
bearing  it towards himself, slides the  knife for-
wards along the groove into the  bladder.  The
prostate is now to be divided by drawing out the
knife, at the same time  cutting through the
gland in a direction downwards  and outwards,
which being finished,  the staff may be with-
drawn.
   The  left  forefinger  is then to be  passed by
the wound  into the bladder, and  the  forceps 
LITHOTOMY.
91
flatly introduced along its surface, when it may
be removed The stone being felt for, with" the
blades of the forceps  closed, and  discovered,
should be  seized between them, if possible, in
the direction of its long diameter,  and drawn
slowly out; alternately raising and depressing
the instrument, or if the stone be irregularly
formed, inclining it from side to side, keeping at
the same time  the  first  two fingers of the left
hand between the handles, thus preventing the
stone from being broken by the too  forcible ap-
proximation of the  blades.

LATERAL  OPERATION  WITH  THE LITHO-
               TOME CACHE.
   This instrument,  generally  employed by
French surgeons,  is recommended to be used
as  follows.  The  patient is to be placed,  and
the operation proceeded with as before, till the
staff is laid bare, the operator keeping the nail
of his left  index finger resting in  the groove.
He then takes the  lithotome cache  by the han-
dle, its  blade being properly set, and passes it 
92
LITHOTOMY.
along his finger until its beak enters the groove
of the staff, which is proved by making its point
pass backwards and forw ards  along it  Now
rising he  takes hold of  the staff with his left
hand, and  whilst he depresses it  so as to make
it perform  a semi circle,  pushes the Lithotome
along the groove into the bladder, and then with-
draws the staff.  The instrument being in the
bladder is to be lifted upwards to  avoid the rec-
tum, and pressed towards the patient's right side,
to steer clear of the left  pudic  artery.  These
cautions being  observed,  and the concealed
blade inclined so that in coming forth  it will cut
the prostate downwards and outwards, the han-
dles are to be approximated, the  blade raised,
and the gland being cut as just directed, the in-
strument is to be withdrawn in the direction of
the external wound.  The forceps may then be
introduced along the finger; though M Lisfranc
recommends the introduction of a grooved con-
ductor in the form  of a blunt gorget.  He di-
rects it to be passed with its convexity upwards,
and when  in the bladder to be reversed, and 
LITHOTOMY.
93
the forceps introduced along its concavity: it is
then to be withdrawn in the same manner as it
entered, with its concave side downwards, and
the stone felt for and extracted as before.

LATERAL OPERATION WITH THE GORGET.
  The groove in the staff  being opened, and
the finger nail resting in it as in the former op-
erations,  the operator takes the gorget  in his
right hand with its cutting edge directed oblique-
ly downwards, and  passes it along his finger till
he fixes its beak in the groove of the staff; when
he moves it backwards  and forwards to ascer-
tain whether it is securely fixed.  Then rising
he takes,  as before, the handle of the staff in his
left hand, and having brought it towards him-
self, pushes  the gorget horizontally forwards in
the direction of the bladder and so cuts through
the prostate  gland.  The  urine immedia.ely
flowing over the  gorget, proves the entrance of
the instrument into the  bladder, when the staff
is to be withdrawn.   The forceps may be pass-
ed llatly along the surface of the gorget, which 
94              LITHOTOMY.
is then to be taken away, and the stone felt for
and extracted as before.

OPERATION ABOVE THE PUBES,  OR  THE
            HIGH OPERATION.
  This is the operation which it is supposed was
performed by Colot, an Italian,  in 1475, on a
freebooter of Meudon in Fiance, who was con-
demned to die for a robbery which he had com-
mitted; but it being discovered that he was af-
flicted with the stone, Louis the eleventh, at the
request of some French surgeons, gave Colot
permission,  by way of  experiment,  to try the
operation  upon him, in the  hope that it would
be serviceable to others who suffered from the
disease.  It is  related that  the  operation was
performed in the church of St. Severin at Pa-
ris, with such success, that the patient was cur-
ed by the end  of fifteen days, when he received
a free pardon.
  Pierre Franco is the first who wrote any ac-
count  of the operation.   He performed it in
1650 at Lausanne, on a child two years old; he 
LITHOTOMY.
95
had begun operating by the perinaeum, but find-
ing the stone too large  to be extracted  in  that
direction, and seeing that the distended  bladder
caused a prominence above the pubes,  he per-
formed the high operation, and  the  child got
well.  In the  last century it was frequently per-
formed by Douglas, and Cheselden in England,
and by Winslow,  and Frere Come in France.
Frere Come first made  an incision by the peri-
neum into the membranous part of the urethra,
through which he passed the sonde a dard, and
then opened the bladder above the pubes.  In
this way Sir  Everard Home,  about four  years
since, performed the operation at St. George's
Hospital; but he nowT practises it without mak-
ing any perineal opening.  After this latter me-
thod Mr. Evvbank has also performed the ope-
ration at St.  George's, for the history of which
process  I am obliged to my friend Mr. Cheva-
lier Jun. who was present at the operation: and
I also take this public opportunity of returning
him my sincere thanks for the many other pro-
fessional favours I have received through him. 
96              LITHOTOMY.
The following is the method in which the ope-
ration was performed.
  The groins being shaved, the patient's back
supported by pillows, and the  thighs slightly el-
evated, an incision is made through the common
integuments  in the direction of the linea alba,
and  extending,  in  the adult,  from  about  two
inches above the symphisis pubis, nearly to the
angle which  the skin forms in mounting upon
the  penis.   This  is  now continued deeper
through the external fascia, and as near as may
be divides the bellies of the pyramidales mus-
cles from each other.  Some few fibres of these
muscles, with the fascia beneath them, are now
deprived of their insertion into the arch  of the
pubes by  another incision close upon the bone
at right angles to the former, and extending into
that loose cellular membrane which lies between
the abdominal parietes, the bladder, and the pe-
ritoneum reflected from the former to the latter.
An incision may now be commenced from this
last in  the direction of the first, and the finger
of the operator being  introduced between the 
LITHOTOMY.              97
 peritoneum and the last mentioned fascia  im-
 mediately covering this, is to be fui ther divided
 as far upwards as may be  necessary.  If the
 bladder be very much distended, it is  now  laid
 bare: if not, the laxity of the cellular membrane
 which allowed  this viscus when full to remove
 the peritoneum to  a certain distance from  the
 pubes, will now admit of the same distention by
 the hand of the surgeon.   The sonde a dard
 (having previously received the proper curve,
 that is, a larger segment of a smaller circle than
 is usually given to the catheter) is now passed
 into the bladder, till its extremity is feJt through
 the coats close to  the symphisis pubis, when
 the stilet is pushed on into the external wound.
 The bladder, now  transfixed by the stilet, and
 resting on the end  of  the sonde itself,  is to be
 pushed  up towards  the navel, the whole sonde
 a dard being passed  further through the urethra.
 The surgeon now  having hold of the point of
 the protruded stilet, introduces in  the  groove
 on the lower or concave side thereof a probe
pointed bistoury into the cavity of the bladder,
         9 
98
LITHOTOMY.
the coats of which are thus divided downwards
as far as the bone, when the finger immediately
lays hold  of them, and supports them against
the lips of the  wound, while the sonde a dard
is withdrawn, and the other hand or the forcepi
removes the stone.  When it is ascertained that
the bladder contains no other calculus, an elastic
gum catheter is passed by the urethra and fixed
in the bladder.   A small piece  of  dressing is
placed on the wound so as to prevent any pre-
mature or inconvenient union in any part of it
and the operation  is concluded.  The urine
comes away chiefly through the catheter, which
is allowed to remain till the state of the wound
permits of its being permanently removed.
    An Italian surgeon has recommended the ex-
 traction of stones from  the  bladder by cutting
 into that  viscus through  the rectum.  M.  Du-
 puytren tried  the operation at the  Hotel Dieu
 but it did not succeed and therefore  was not
 repeated.  It is  still, however, said to be prac-
 tised successfully in Italy. 
LITHOTOMY  ON THE FEMALE.      99
   THE OPERATION ON THE FEMALE.
  In the rare cases in which it is found requi-
site to perform  the operation on the female, it
is generally done in the following way.
  The patient being securely bound, a straight
conductor or staff is passed by the urethra into
the  bladder, with its groove directed obliquely
downwards and outwards towards the patient's
left side, the back or convex part being pressed
upwards in an opposite direction, in order to
enlarge the caliber of the urethra.   The opera-
tor, holding the staff with his left hand,  passes
a  probe-pointed  bistoury  along  its  groove,
which cuts  through the  urethra  and neck  of
the bladder in the first named direction.  He
then withdraws the instruments and introduces
his left index finger to feel for the stone, which
having found, he passes the forceps, his finger
serving as a director, and extracts as before.
  M. Lisfranc recommends the incision through
the urethra and neck of the bladder to be made
upwards,  inclining  it  slightly to either side  to
avoid the symphisis pubis.   By making the cut 
100            CASTRATION.
in this way, he says incontinence of urine is not
so frequent a consequence of the operation as
when the  urethra  is divided  downwards and
laterally.  Should the opening be not sufficient-
ly large to allow the stone to  pass, he directs
another incision to be made downwards, and a
little inclined to one side, by which means the
largest calculus, the pubes will admit, may be
extracted.
               CASTRATION.
   This is said to be the most ancient of all op-
erations.  It is supposed first to have been per-
formed by the jealous  polygamists of the east,
who by it secured to  themselves a set of indi-
viduals to whom they could without fear commit
the care of their concubines; indeed it appears
still  to be practised for the same  abominable
purpose, as  Captain Henry Light, of the Royal
Artillery, who has  publisiied a  history  of his
travels through Egypt, Nubia, and  the Holy
Land  in 1814, relates that he saw two boats,
containing one hundred and fifty black boys, on 
CASTRATION.             101
 their way to Cairo, who had been totally emas-
 culated, and cured in  a month, at a village in
 the neighbourhood.  They had been attended
 by a  Franciscan monk; who described the ope-
 ration as easily performed  and without much
 danger; eleven only having died out of one hun-
 dred  and sixty.  They  were intended for  the
 Seraglio at Constantinople.
   Celsus is the first who describes the  opera-
 tion as necessary for the removal of disease; he
 points out three kinds of tumors which,  in  or-
 der to be effectually cured, require the extir-
 pation of the testicle.
   When the operation  is deemed requisite,  but
 there  is still an existing doubt  as to the exact
 nature of the disease, it is recommended imme-
 diately  previous to performing  it, to make a
 small incision through the forepart of the scro-
 tum into the tunica  vaginalis;  this caution  is
 given to  prevent the consternation and chagrin
 which surgeons are known to have experienced,
 who,  having  prescribed and commenced  the
operation, have suddenly ceased, when the flow
                    9* 
102
CASTRATION.
of water or blood from the tunica vaginalis has
proclaimed the disease to be either hyodrocele
or hematocele.   The  following is  the general
method of practising the operation.
   The hair being shaved from the pubes, place
the patient on a table of convenient height, and
let his back be supported by  pillows.   Com-
mence the first incision at the external abdomi-
nal ring  and continue it down the front of the
testicle to the posterior base of  the  tumor:  if
the skin  be diseased,  two elliptical incisions
must be made  and  the  diseased part  remov-
ed.  Having exposed  the spermatic  cord, and
deprived it of its cellular  connections, separate
the artery and vein from the vas deferens at the
upper part of the incision.  By means of a curv-
ed needle pass a ligature round the two form-
er and give it to an assistant to hold, to prevent
them  from being drawn  within the ring by the
action of the cremaster muscle, on  the division
of the cord.  This caution being observed, cut
through the  whole of the cord about the third
of an inch below the ligature; take hold of that 
CASTRATION.
103
portion attached to the testicle, and draw it for-
wards, when a few cuts with the scalpel through
the loose cellular  texture of  the  scrotum will
remove the diseased part.  The  spermatic ar-
tery, the vessel which accompanies the vas de-
ferens, and any others that bleed, are now to
be separately secured by ligatures, and the liga-
ture of the  cord  is to be  taken away.   The
edges of the wound should be approximated by
two  sutures, and straps of  adhesive plaster
applied
  M.  Lisfranc, after the  first  incision, recom-
mends the  tumor to  be dissected  from  below
upwards which prevents the blood collecting be-
fore the point of the knife in the cellular texture
of the scrotum.    He  secures the cord from
slipping within the ring, by directing an  assist-
ant to place his index  and middle fingers at a
little distance from each other behind, and his
thumb before it, opposed to the interspace; he
thus presses it against  each finger, which pre-
vents the possibility of its being retracted; he 
104             CASTRATION.
then cuts through it and ties such vessels as re-
quire ligatures.
  Vincent Karn a  German  surgeon recom-
mends the operation to be thus performed.  An
assistant with the fore-finger and thumb of one
hand takes hold of the cord, with the integu-
ments, above the part where  it is  to be cut
through, whilst with the other he separates the
diseased from  the healthy  testicle.  The ope-
rator then raises  the one diseased, and  by a
single stroke of the knife cuts it away with its
scrotal covering,  beginning the incision at the
raphe of the scrotum  and cutting obliquely up-
wards and outwards.  The arteries being taken
up and  the edges of the wound approximated,
the operation  is  finished.  This  method has
the  advantage  of being sh >rt; but as in  many
cases the  testicle is too much enlarged to admit
of being removed at one cut,  and as the  cord
can  not be securely fixed by being pinched up
within the integuments,  the  former must be
considered the  safest plan of performing the
operation. 
         AMPUTATION OF  THE PENIS.      105
   When the disease extends along the cord, it
 is cruel to submit the patient to the unnecessary
 pain of the operation: though M. Lisfranc says
 in cases of this kind he has seen M. Dubois pull
 down the cord and then divide  it, and M. Du-
 puytren cut up the inguinal canal to the internal
 ring, and there cut through the cord; but in  all
 the cases the patients have died.
   Again, it is a matter of opinion whether it is
 not tiie  better plan to secure the whole cord  by
 ligature, and thus do away with  the necessity of
 tying  each  vessel separately.   M  Richerand
 practises the operation in  this way; but  cases
 are related in  which a ligature including the
 whole cord, has produced  such excessive pain
 and irritation  as to necessitate its removal: the
 tying  of nerves and veins too,  has sometimes
 produced  fatal consequences,  therefore, the
method  of securing each  vessel  separately ap-
pears  to be that which may be most safely pur-
sued.

      AMPUTATION OF  THE PENIS.
  Cancerous and  malignant fungus  affections 
106      AMPUTATION OF  THE  PENIS.
are the diseases which give rise to the necessity
for this operation; if the extent of the disease
can be ascertained, it may  be thus performed.
   The  patient rests on his back, while the op-
erator, sitting by his left side, takes hold of that
part of the penis which is to be removed, be-
tween the  first two  fingers  and thumb of his
left hand,  and draws it slightly forwards,  then
with a straight bladed bistoury, or a catling, at
one  stroke, he cuts  through the  penis, about
half an  inch beyond the diseased part, directing
his incision from below upwards.   The bleed-
ing arteries being secured  by ligatures, an  elas-
tic gum catheter  is  to be  introduced by the
urethra and retained in the bladder; when dos-
sils of dry lint should be applied to the surface
of the  wound.
   The  following appears to me the most simple
and convenient method of retaining the catheter
in the bladder on this, or any other occasion: it
is the plan generally adopted in  the  French
hospitals.   A metallic ring,  the  circumference
of which should be more than sufficient to en- 
AMPUTATION  OF THE PENIS.      107
 circle the penis,  is to be covered with cloth,
 and four long pieces  of tape, with  the  same
 number of short ones attached to it.   This en-
 closing the penis,  is fixed against the pubes by
 the long pieces of tape, which, surrounding the
 pelvis in different  directions, meet and are tied
 posteriorly.   One of the short pieces is carried
 through the ring,  or round the groove of the
 catheter on each side,  and being tied to its fel-
 low, fixes the instrument securely in the bladder.
   When the penis is to be amputated near the
 pubes, it is best  to pass the catheter previous to
 commencing the operation, as the surrounding
 parts being  more  cellular, allow  the  blood to
 collect within them, which tends to obscure the
 orifice of the urethra, and renders the introduc-
 tion afterwards much  more difficult.  In  this
 case the incision must be  made round the pe-
 nis, as in amputating a limb; then  by slitting up
 the urethra with a  pair of scissars the separated
part is removed  from the catheter.   The ar-
teries being taken up  with a tenaculum  and
tied, dossils of lint are to be applied over the 
108  AMPUTATION  OF THE  EXTREMITIES.

surface of the wound, and the whole is to be
covered by pads of lint or soft cloth.   The  ring
is  to be fixed to the pubes  over  the  dressings,
and the  catheter retained  in the bladder as
before.
   AMPUTATION OF THE EXTREMITIES.
   Easy as the operation of amputation is ac-
 knowledged to be, we  seldom see it performed
 in a masterly  style; some parts being cut with
 which the knife has no  business to come in
 contact, or others, which  should be completely
 divided by that instrument, left partially sepa-
 rated, till the  mangling teeth  of the saw tear
 them  asunder.   As  the course of the  blood
 can be stopped by the application of the tourni-
 quet, the operation holds out no  immediate
 danger, and calls for but  little knowledge of
 anatomy; any  one may therefore undertake it,
and by practising it  a  few times on the dead
subject manage to perform it with considerable
dexterity.   These remarks apply chiefly to the
amputations of the leg, thigh, and arm; not to 
     AMPUTATION  OF THE EXTREMITIES.  109
the partial amputations of the foot, nor to those
between the articulations of bones,  as at the
different joints, which require a correct idea of
the anatomical structure  of the part,  to enable
the operator to perform them with skill.
   Active and ingenious assistants  are indispen-
sable requisites to the well  finishing of any of
the operations: however dexterous the operator
may be, he appears awkward  if his assistants
be not expert in the performance of their duty,
to effect which judiciously requires more art
than is necessary  for merely  cutting off the
limb.  T wo assistants at least should be present;
to the one belongs the business  of properly sus-
taining and fixing  that  part of the "extremity
which is about to  be removed, so that it  shall
neither excite action  in any  of the muscles
which are to be divided,  by calling on them for
support, nor by an unequal bearing, offer an
impediment to the  progress of the saw, during
the operation of cutting through the bone.  To
the  other devolves the  duty of retracting the
integuments, and  shielding the muscles  from
          10 
110   AMPUTATION OF PART OF A FINGER.
the teeth of the saw, as well as presiding over
the tourniquet, relaxing or tightening it as the
operator may direct.
   In all  the amputations at joints it has been
thought proper to cut off the whole surface of
the cartilage  exposed; with a view to prevent
any impediment to the process of union by a
secretion of synovia in the wound.
   I shall now proceed to describe separately
and successively each amputation, commencing
with those, which, though of least consequence
to the patient, will not be considered by the
operator as unworthy of particular attention.

AMPUTATION OF THE SECOND, OR THIRD
         PHALANX OF A FINGER.
   With us this operation is generally performed
by making a circular incision round the finger,
about a quarter of an inch nearer its extremity
than the joint at which you are  about to ampu-
tate ; then an incision  on each  side extending
back from  the first to the joint, so as to form
two flaps, which are  to be dissected back and 
     AMPUTATION OF PART OF A FINGER.   Ill
the tendons with  the lateral and capsular liga-
ments cut through, which finishes the operation.
   The following is the process adopted by M.
Lisfranc,  certainly more expeditious than  the
former; but as  it leaves only a single flap, it is
not probable that the wound  will heal so readily
by adhesion as when the operation is performed
in the manner already described; yet a case may
possibly  occur, in  which  the one  operation
could be performed, and the other not be prac-
ticable.
   The hand being prone is fixed by an  assist-
ant, who bends the other fingers and separates
them from the one to be operated on.  The op-
erator with the fore-finger and thumb of his
left hand, takes hold of the  phalanx to be am-
putated, placing his thumb on its dorsal and his
finger  on its palmar  surface, and having half
bent it, observes the situation of the small fissure
in  the integuments on the side  of the bone,
caused  by that position;  immediately  before
which the joint will be found.   At this point,
with a straight bladed bistoury, he makes his 
112   AMPUTATION OF PART OF A FINGER.
incision, and at one  sweep lays open the joint
by cutting  through the integuments and  liga-
ments on the sides and dorsum  of the  finger,
from left to right.   In cutting the ligaments at
the sides,  the edge of the  bistoury is directed
obliquely  towards himself, and  those on the
dorsum in the opposite direction.  The phalanx
is "now to be held by its sides, and the ligament
at the under part cut through, the  bistoury is
then  placed horizontally  with  regard  to the
phalanx, and a flap of sufficient length  formed
from its palmar surface by cutting between the
integuments and bone.
   In cases where the finger is so much  swollen
as to render demiflexion difficult and  painful,
M.  Lisfranc recommends the operation to be
reversed, and performed thus.
   The hand being supine and fixed by an as-
sistant, the operator extends the diseased finger,
and bends the others, that they  may be out of
the way of the  knife.  He  then takes hold of
the phalanx with his left hand, placing his thumb
 on the  palmar, and  fore-finger  on the dorsal 
          AMPUTATION OF A FINGER.      113
 side, while with his other fingers, he' forms a
 support for the bistoury; which is to be intro-
 duced horizontally immediately anterior to the
 fissure, in a  line with the joint, and pushed
 through beneath the integuments, to the opposite
 side, the point being directed obliquely upwards
 to avoid the bone, when a flap  is to  be formed
 by cutting forwards  and outwards.   This being
 done and  held back by the assistant, the heel
 of the bistoury is applied to the base of the flap;
 when, by drawing it from left to right, the joint
 is cut through, which removes the phalanx.  In
 operating in this way at the second phalanx, the
 point of the bistoury should be  passed  immedi-
 ately under the  fissure formed in the integu-
 ments on the palmar surface.  No ligature will
be required for the  divided  vessels;  pinching
their bleeding extremities with the forceps being
sufficient to stop the haemorrhage.

AMPUTATION OF A FINGER  AT ITS FIRST
   PHALANX OR JUNCTION WITH THE
           METACARPAL BONE.
  Put the  hand prone,  feel for  the  joint, and
                    10* 
114      AMPUTATION  OF A  FINGER.
slightly bend the  finger: then place  the thumb
of your left hand on its dorsal aspect, the fore
finger on its palmar surface.   With the heel of
the bistoury begin the incision about the middle
of the head of the metacarpal bone, or knuckle;
cut almost parallel to  the bone  of the finger,
lowering your hand till the knife is perpendicu-
 lar, then cut directly from you till you are  op-
 posite the joint towards which turn the edge of
 the bistoury; cut through it, and pass  the knife
 between the integuments and bone on the op-
 posite  side, where form a  corresponding  flap
 by cutting towards yourself.  For obvious  rea-
 sons never begin with the point of the knife, or
 raise your hand during the operation.
    If the finger be amputated  for  accident, no
 ligature will be required; but if for a  disease
 in which there has been long continued inflam-
 mation, the arteries should  be secured, as they
 are generally enlarged. The edges of the wound
 are brought in  contact by approximating the
 other fingers, and binding them together  with
 tape, if the one removed be either the ring,  or 
        AMPUTATION OF THE  THUMB.     115
middle finger.   On  either of these fingers this
operation should be preferred  to the amputa-
tion of the second  phalanx, as the remaining
stump, or first phalanx, in that case is not only
useless but a deformity; whereas after this op-
eration the  loss of  the finger can be scarcely
perceived by a superficial observer.
   The same operation does for the toes; with
this difference, that  you begin  with the point of
the bistourv and cut parallel with the bone, till
you arrive opposite  the joint which in  them is
very deep.

 AMPUTATION OF THE METACARPAL  BONE
              OF THE THUMB.
   When it is the right metacarpal bone to be
 removed,  the  hand is to  be placed supine and
 vice versa.
   The \iand being held firm by an assistant, the
 operator separates  the thumb from the index
 finger, and applies the heel of his bistoury to
 the middle of the space between them.   Then,
 keeping the point perpendicularly upwards, he 
116     AMPUTATION OF  THE THUMB.
cuts forwards between the metacarpal bones of
the thumb and fore finger; till his knife striking
against the trapezium he knows it to be oppo-
site the joint, towards which he turns the point
of his bistoury, and cutting through the capsu-
lar ligament opens  the joint   He now glides
his knife through  the joint, at the same time
pressing the head of the bone towards the hand,
and  forms a flap from  the  side of the bone by
cutting towards himself.   The proper  extent
of the flap may be known by approximating the
thumb to the index finger one or more times as
required.
   It  has been recommended to perform the
operation in the following way.   Feel for the
styloid process of the radius,  an inch  before
which you find the joint: thrust your knife into
it, and cut  inwards till you have cleared it; .then
cut along the middle space between  the thumb
and index  finger, thrust  the head of the bone
inwards, and form a flap from the side of the
bone as before.
   In this  manner the joint is not  so readily 
     AMPUTATION OF THE LITTLE FINGER.  117

opened as in the former: the point of the knife is
also in danger of being broken when thrust into
the joint as last directed.
AMPUTATION OF THE  METACARPAL BONE
         OF THE LITTLE FINGER.
  An assistant keeping the hand prone, fixes it
securely.  The operator,  with  the fingers  of
his left hand, draws the muscles  situated on the
side of the bone towards  the palm, and with his
right index finger feels  along the bone till he
finds its carpal head, on which  he  places his
left thumb.   Now raising his fingers, he allows
the muscles to return to  their natural situation,
and applies his left index finger beneath upon
the  point  opposed to his thumb, and  squeezes
the  muscles outwards.   Holding the bistoury
perpendicularly as a pen, he thrusts it from
above downwards, completely through the inte-
guments, and  muscles opposite the joint, and
close to the bone, along which he continues his
incision till he comes to its other extremity,
where he cuts out.   The flap thus formed being 
118  AMPUTATION AT  THE WRIST JOINT.
held aside by the assistant, the operator dissects
back the integuments from the dorsum of the
bone, leaving the tendon: having finished which,
he cuts into the side of the joint in an obfique
direction towards the thumb.  He then thrusts
the knife from above downwards, between the
fourth and fifth' metacarpal  bones, taking care
to avoid puncturing the integuments on the pal-
mar side,  and separates the  two bones  from
each other by cutting out towards himself. Now,
drawing the bone apart from its fellow, he di-
vides the  uncut  ligaments, dorsal and lateral;
and finishes the operation by turning the edge
of his knife upwards, and  cutting through the
palmar muscles and  ligaments.
   After both  these last operations the bleeding
vessels are to  be taken up  with a tenaculum
and secured, and the divided surfaces kept in
contact by adhesive plaster.

..   AMPUTATION AT  THE WRIST JOINT.
   The tourniquet being applied to  the lower
part of the upper arm, the forearm is held by an 
      AMPUTATION  AT THE WRIST JOINT.  119
 assistant in a state between pronation and supi-
 nation ; while the  operator  with  his left hand
 takes hold of the hand to be amputated, and fix-
 es it by placing his thumb on its palmar,  and
 fingers  on its dorsal surface; if it be the right
 hand, and vice versa.   Then with the thumb of
 his right hand, he feels  for the styloid process
 of the radius, an inch  before which, at the root
 of the thumb, he commences his incision.  From
 this point, with a catling or small amputating
 knife, he makes a circular cut through the in-
 teguments round   the wrist.   The  assistant
 drawing the integuments upwards, the operator
 dissects them back as far as the styloid process;
 when, directing the edge of his knife obliquely
 towards  the radius, he opens the joint by cutting
 through  the ligament passing from  the  styloid
 process  to the scaphoid  bone.  Bearing the
 hand slightly downward he continues his incision
 through the joint, at the same time cutting the
 tendons on both sides as close  to the  radius as
possible,  till the hand is removed; the assistant
shielding the  reflected integuments from the 
  120 AMPUTATION AT THE WRIST JOINT.
  edge of the knife by holding them back.   The
.  operation when performed in this way leaves an
  excellent stump.
     The following is M. Lisfranc's method.
     The tourniquet being applied and the fore-
  arm fixed by an assistant  with the hand prone;
  the operator places his two index fingers above
  the joint, one on the radius, the other on the
  ulna.   He then bends  and extends the hand,
  whilst doing which he draws his fingers down
  the bones till he feels the styloid process of the
  radius, on the extremity of which he places the
  fore finger  of his left hand, and his thumb on
  the corresponding point of the ulna, if it be the
  right hand to be removed, and the reverse if it
  be the left.  With a catling he makes a semilu-
  nar incision through the integuments, with its
  convexity towards the  hand, beginning at the
  point before the thumb, and ending at the op-
  posite one.   Then, directing the point  of his
  knife obliquely downwards, he cuts through the
  ligaments on the ulnar  side, and by depressing
   the handle  continues his incision  through the 
      AMPUTATION AT THE WRIST JOINT.  121
 tendons and ligaments on  the  dorsum, to^the
 styloid process, at the  same  time bending the  9
 hand so as  to expose the  articulatory surface
 of the bones of the wrist.  Having glided his
 knife through the joint, and divided the capsu-
 lar ligament, and tendons below, he forms a flap
 of the integuments, of sufficient length to  cover
 the stump, from the palmar surface, by cutting
 towards hjraself, taking care to avoid the pisi-
 form bone.
   This latter operation may be  reversed and
performed thus.   Having found the extremities
of the radius and ulna as before, place the fore-
arm in  a state between pronation and  supina-
tion, and thrust the point of the catling beneath
the integuments  from the anterior and  inner
edge of the ulna,  till it appears just before the
styloid process of the radius, and form a suffici-
ent flap by cutting  towards the palm.   Then
cut through the integuments and tendons on the
dorsal side, and finish the operation by cutting
through the joint, from before the styloid  pro-
cess of the radius downwards.
         11 
122 AMPUTATION OF PART OF THE FOREARM.
  Three arteries generally require to be secur-
ed after  this  operation: the  radial,  the ulnar,
and the interosseal.  The cut surfaces are  to be
approximated by adhesive plaster and the arm
kept in a sling.
AMPUTATION  OF THE  LOWER  THIRD OF
   THE FOREARM, WITH TWO  FLAPS.
   The tourniquet being applied as before, and
the upper part of the forearm fixed by an assist-
ant,  the hand being in a  middle state  between
pronation and  supination, the  operator  stands
on the inner side of the arm.  Holding the part
to be removed between the thumb and palm of
his left hand, he thrusts the catling  beneath the
integuments from below upwards, pushing it in
at the anterior and inner  edge of the ulna close
to the bone, and thrusting  it on till it appears
at a  corresponding point  on the outer edge of
the radius, when he  forms  a flap half an inch
or more in length, by cutting towards the wrist
He then passes the instrument under the inte-
guments, behind the  bones, from the  point 
   AMPUTATION OF PART OF THE FOREARM. 123
where it came out before the radius, to that on
the inner edge of the ulna where it was first in-
troduced,  and forms a  flap posteriorly of the
same length as the former.   These being held
back by the assistant, the operator introduces
the point of his knife between the bones from
the  anterior side;  divides the  muscular fibres
and  interosseous ligament, and draws  it out by
cutting round the ulna.  He again passes it be-
tween the bones from  the  posterior  surface,
and  withdraws it in a similar manner by cutting
round the radius.   By this  figure-of-eight-like
incision he cuts through  all the muscular fibres,
interosseous ligament and periosteum, on, and
between, both bones; then,  putting the arm in
a stale of pronation, he saws through the radius
and  ulna.   As the radius at this part is  rather
larger than the ulna, it should be sawed through
first, the latter bone, from its  connection with
the humerus, being better adapted to bear the
weight of the saw.
  In using the saw, the operator  marks with
his left thumb the point  at which the bone is to 
124 AMPUTATION OF PART OF THE FOREARM.
be sawed through; this not only serves as a guide
to the instrument, but, with the  fingers  of the
same hand, assists in keeping the bone steady.
Then by slight motions of the saw, he forms a
small  channel in the bone; having done which,
he gives a greater degree of mobility to the in-
strument, drawing  it from  heel  to  point, and
vice versa, till the bone is sawed through.   In
doing this he makes no pressure on the saw, he
merely puts it in motion; its own gravity being
sufficient to enable it to make  its way.
   Four arteries generally require ligatures, the
radial, the ulnar,  and the two interosseal.   The
cut surfaces are kept in contact as before.
   In performing this amputation on the left arm,
the operator begins by thrusting the  knife from
above downwards  anteriorly, that is from the
radius to the ulna; and the reverse posteriorly.
  AMPUTATION AT THE MIDDLE  OF  THE
                  FOREARM.
    The tourniquet  being applied to  the lower
*  part of the  upper-arm, the forearm is fixed by 
AMPUTATION OF PART OF THE FOREARM.  125
 two assistants in a middle state between prona-
 tion and supination; one  supporting the bones
 at the elbow, the other at the wrist.
    The operator, standing on the inner side of
 the extremity, makes, with a catling, a circular
 incision  through  the  integuments round  the
 limb, and then dissects them back for one inch
 and a half, more or less, according to the muscu-
 larity of  the subject, the assistant who supports
 the elbow at the same time drawing them  up-
 wards.   Then holding  them back, out of  the
 way of the knife; the operator makes another
 circular  incision round the limb, applying  the
 catling close  to  the base of the reflected inte-
 guments, and cutting through  the  fascia, and
 muscles down to the bones.  He  then  passes
 the catling between the bones and cuts through
 the remaining muscular fibres, interosseous lig-
 ament  and periosteum, by the figure-of-eight-
 like incision as in the last operation.   Having
 ascertained by  passing his finger  round the
 bones that they are denuded  at the part  to be
sawed through, and that the soft parts are  all 
126  AMPUTATION AT THE ELBOW JOINT.
Cut, he places the hand prone, and saws through
both bones at the same time, the assistant care-
fully retracting the muscles and integuments so
as to leave the course  of the saw clear.  The
same vessels require ligatures as in the last op-
eration.
   The flap operation as last described may be
performed at  this part; and this at the lower
third of the forearm: they may also be perform-
ed nearer to the elbow joint.
  AMPUTATION AT THE ELBOW JOINT.
  Though the stump after this operation is not
more useful than when the amputation  is per-
formed at the lower  part of the humerus,  and
though the healing process is longer protracted,
and attended with  greater risk  to the patient,
yet it has been performed by M. Dupuytren in
Paris.  M. Lisfranc  relates that in one case of
which he was a witness, the wound was several
months before it was completely healed.
  The following is  the  method  of  operating
adopted by M. Dupuytren. 
      AMPUTATION AT THE ELBOW JOINT.  127
   The brachial artery being compressed by the
 tourniquet, and the extremity fixed by assistants
 above and below the elbow: the operator thrusts
 a catling beneath the integuments and  muscles
 of the forearm  just below the condyles of the
 humerus, at the bend of the elbow, and forms
 a flap three inches in length by cutting towards
 the hand.  This flap being  held back, he  cuts
 through  the integuments and  muscles on the
 posterior side of the arm, by an incision level
 with  the  extremity of the  olecranon.   Then
feeling with his left thumb for the head of the
 radius, he separates it from  the humerus by di-
 recting his knife  obliquely between  the  two
 bones, and  removes the ulna by cutting round
 its sigmoid cavity, taking  away as much of the
 capsular ligament  as  possible.   The bleeding
vessels being tied, the  condyles of the humerus
are covered by the flap, the edges of the wound
approximated by adhesive plaster, and a ban-
dage applied. 
128 AMPUTATION OF PART OF THE HUMERUS.
AMPUTATION AT THE MIDDLE, OR AT THE
     LOWER PART OF THE HUMERUS.
  The patient being seated on a low chair, the
brachial artery  is to be compressed by the tour-
niquet at the upper part of the arm, the extre-
mity raised from  the side, and fixed horizontal-
ly by two assistants, one  supporting it at the
upper part, the other at the elbow.
   The operator places himself  on the outer
side of the limb,  kneels on his right knee, keep-
ing his left  bent in advance.  Resting in I his
position, he holds the amputating knife  above.
the arm, its point being directed  towards the
tip of his right shoulder, and, while the assistant
keeps the skin tense by drawing it upwards, he
cuts through the integuments, gradually raising
•himself as he continues the incision, till he has
formed a circle round the limb.   He then dis-
sects back the skin for an inch or more, as may
be  required, and whilst the  assistant keeps it
reflected, he stoops as before, and, level with its
base, makes a circular cut through all the mus-
cles down to the bone.  He again applies the 
    AMPUTATION AT THE SHOULDER JOINT.  129
 knife to the deeper seated muscles, and direct-
 ing its edge obliquely up  the limb,  he makes
 another circular incision so as to expose the
 bone a little higher up, to which part, the peri-
 osteum being cut through, and the muscles and
 integuments held carefully back, the  saw is ap-
 plied, and the bone sawed through.  The bra-
 chial artery, the deep humeral and others, if re-
 quisite, are secured by ligatures; the edges of
 the wound approximated, and a roller applied.

 AMPUTATION AT THE SHOULDER JOINT.
   The  subclavian artery being pressed by an
 assistant on the first rib from above  the clavi-
 cle, so as to interrupt the circulation  in the ex-
 tremity,  another  assistant supports the arm in
 an horizontal position.
  The  operator with a bistoury or scalpel,
 makes an  incision through  the integuments
along the inner border of the deltoid muscle,
extending from its upper part nearly  to its in-
sertion; then a corresponding one on its outer
border.   These two  he connects by  a third of 
130 AMPUTATION AT THE SHOULDER JOINT.
a semilunar form, with its convexity downwards,
passing across the muscle, just above its inser-
tion, from the lower extremity of the first inci-
sion to that of the second, and cutting through
the integuments and muscle down to the bone.
He then dissects back the  muscle,  an  assistant
keeping it  reflected,  he lowers the arm,  and
with a catling or small amputating knife, opens
the joint at its upper surface by cutting through
the capsular ligament and tendon of the biceps.
Then cutting round the articulatory surface of
the head of the bone, he removes the extremi-
ty by dividing the remaining ligament,  muscles
and integuments; cutting last through that part
where the axillary artery is situated as he fin-
ishes his incision.  The  axillary artery is im-
mediately seized and  tied, and such of the cir-
cumflex and others secured as require ligatures;
the glenoid  cavity is covered  by the flap,  and
the edges of the wound kept in  contact by ad-
hesive  plaster.
   Baron  Larrey,  during his  military cam-
paigns, remarked that after the operation when 
    AMPUTATION AT THE SHOULDER JOINT. 131
 thus performed, the healing process  was long
 protracted, owing  to the small number of ves-
 sels which the flap  received  for its  nutriment;
 and that sinuses often formed.  He also observ-
 ed that  those cases healed  sooner  where no
 flap was saved, than where a single one was on-
 ly preserved; he therefore, with a slight varia-
 tion, adopted Desault's plan of making two flaps,
 and states that out of an hundred and odd  cases
 in which the operation was performed,  more
 than ninety  recovered.   The following  is the
 method in which the Baron at present performs
 the operation.
   The patient being seated on a low chair, an
 assistant presses the subclavian  artery on the
 first rib, another assistant fixing the arm at the
 elbow, and raising it a  little from the  side.  The
 operator thrusts a long catling through the in-
 teguments and deltoid muscle, immediately be-
 low the acromion process, till it strikes on the
 head of the humerus, on the posterior side of
which he makes it pass, drawing the arm slight-
ly forwards, and pushing the  catling  onwards 
 132 AMPUTATION AT THE SHOULDER JOINT.
 till it appears in the axilla opposite to the point
 at which it was introduced.  He then forms the
 posterior  flap by cutting downwards and out-
 wards, separating half of the deltoid muscle and
 the latissimus dorsi from  the humerus.  He
 again introduces the catling at the same place,
 and drawing  back the  arm, pushes it onwards
 till it appears at the former point in the axilla,
 but in this instance passing it on the anterior
 side of the bone.   He  then forms the anterior
 flap, corresponding at every point to the poste-
 rior, dividing the artery as the knife cuts out.
 The flaps being held back, he divides the tendon
 of the biceps at the superior part of the glenoid
 cavity, raises  the  arm, and finishes  the opera-
 tion by cutting through the  remaining  adhe-
 sions.  The vessels being tied, the cut surfaces
 are kept in contact by adhesive plaster.
  During the operation the  artery may be com-
pressed between the fingers and thumb  of an
assistant, when the knife has formed the second
flap; but where it can be pressed securely on
the first rib, less blood  is lost, and the fingers 
   AMPUTATION AT THE SHOULDER JOINT.  133
of the assistant are out of the  way of the op-
erator.
   M.  Lisfranc recommends the  following me-
thod, which, if dexterously executed, is certainly
the most expeditious; it however  requires con-
siderable practice  to accomplish it skilfully.
   Supposing the left extremity  is to be remov-
ed ; the patient is placed on an elevated seat, one
assistant pressing  the artery above the clavicle
on the first rib,  whilst another draws the arm
forwards.  The operator standing behind the
patient, with  a long bladed catling, pierces the
integuments on the inner edge of the latissimus
dorsi  muscle, opposite the middle of the axilla,
and pushes it obliquely upwards and forwards,
till  its point strikes against  the  under surface
of the acromion; then by  raising  the handle of
the knife  its point  is lowered,  and protruded
just before the clavicle, at  the part where it
joins the acromion.   He then, by cutting down-
wards and  outwards, forms  a flap from the su-
perior and  posterior part of the arm, including
the whole breadth  of the deltoid muscle, and a
          12 
134 AMPUTATION AT THE SHOULDER JOINT.
part of the latissimus  dorsi.  This  being held
back by the assistant, the joint is cut through
by passing the knife  between  its articulatory
surfaces from behind forwards, and a corres-
ponding flap is formed by cutting downwards
and outwards between the muscles and bone
on the  inner  side of the aim.  The vessels
being tied, and the flaps placed  in contact with
each other the operation is  finished.
   In operating on the right side, the patient
should be  seated on a low chair, and the cat-
ling thrust from above downwards, introducing
it just before the  point  where  the clavicle is
connected to  the acromion, and  raising the
hand as  it is thrust backwards and downwards,
till it appears on the inner edge of the latissimus
dorsi, when the flap is to  be formed, and the
operation continued as before.
   M. Richerand observes " by this method a
dexterous operator can separate the arm from
the trunk as quickly  as an expert carver de-
taches the wing of a partridge." 
         AMPUTATION OF THE TOES.      135
       AMPUTATION  OF THE TOES.
  Accidental causes, or mortification produced
by exposure to cold, may give rise to the neces-
sity of removing the toes.  In either of these
cases, to remove each toe separately, would be
a more tedious and painful process than  is re-
quisite.  M. Lisfranc  has therefore proposed
the following method.
  Supposing it the left  extremity to be operated
on, and the foot  steadily fixed by an assistant,
the operator feels for the head of the first pha-
lanx of the great toe, which joins the metatarsal
bone, and on  it  places his left thumb; on the
same extremity of  the  little toe, he places  his
left index finger, the toes resting in the palm of
his  hand.  He then, with a narrow bladed cat-
ling, or amputating knife, makes a semicircular
incision from the point  marked by his thumb,
to that before his index finger, cutting through
the  integuments aud tendons.  By  a second
cut  in the same direction, he opens the joints,
and, bending the toes downwards, cuts through
the  ligaments  surrounding the  articulations. 
136       AMPUTATION OF THE TOES.
Keeping the toes still bent, he passes the knife
horizontally a  little  way beneath the under sur-
face of the bones, so as to get clear of the articu-
lations.  Then, raising  the toes  and pressing
them upwards, he lowers the handle of his knife,
and,  with the point, completes  the flap from
their under surface, by  cutting to the commis-
sure of each separately,  beginning at the great
toe; the assistant raising them in regular order
as the knife cuts through the integuments below.
In this way a  flap is formed of sufficient size to
cover the  heads of the  metatarsal  bones, and
unite with the divided integuments above.  The
arteries which require ligatures being tied, the
cut edges are to be kept in contact by adhesive
plaster.
   In performing the operation on the right foot,
the first incision is made from the little toe in-
wards, and finished in the same manner, the op-
erator cutting from left to right.
  In  cases in  which it is requisite to remove
all the fingers, the operation is to be performed
in a similar way; keeping in mind that the first 
AMPUTATION OF THE GREAT TOE.    137
incision, instead of being semicircular,  is to be
oblique.
 AMPUTATION OF A PART OF THE METATAR-
      SAL HONE OF THE GREAT TOE.
   This operation is required when a portion of
 the  bone becomes  carious.  If the extent of
 the caries can be ascertained, M. Lisfranc per-
 forins the operation in the following manner.
   The  foot resting on  a table, and being fixed
 by an assistant, the operator, with his thumb on
 the dorsal surface, and fingers on the plantar,
 presses  the integuments and muscles to the side
 of the bone, opposite the pait where it is to be
 sawed through.  Regaining them in that situa-
 tion  by  the fingers and thumb of his left hand,
 he thrusts a  straight  bladed bistoury through
 them, from above downwards close to the bone,
 and forms a flap by cutting along its side till he
 has passed the joint which connects it to the toe.
 From the base of the  flap, which is held back
by the assistant, lie makes another incision ob-
liquely  across the bone, and  continues  it  be-
                    12* 
138    AMPUTATION OF THE GREAT TOE.
tween the first two bones so as to separate them
from each other; he then divides the remaining
integuments and muscles on  the sole by a cir-
cular cut, applies a retractor, and saws through
the bone, in an oblique direction, from  the base
of the flap towards the extremity of the little toe.
   The digital  branches of  the  inner plantar
artery being secured, if ligatures are required,
the flap is kept in contact with the cut surface
by adhesive plaster.
   A similar operation may be performed on the
 metatarsal bone which supports the little toe.
   The late Mr. Hey, in his Practical Observa-
 tions  in Surgery, speaking of caries of the rne«
 tatarsal bones, says: " When the caries has been
 confined to the metatarsal  bone of the great
 toe, it has been usual I believe, after making a
 longitudinal and transverse incision, to saw off
 that  part  of  the bone  which  has  been found
 carious.   But as it is sometimes difficult to  as-
 certain the extent of the caries, I think it is a
 more  advantageous method of operating, to dis-
 sect out the whole of the metatarsal bone at its 
AMPUTATION OF PART OF THE FOOT.  139
junction  with  the  cuneiforme bone.   I have
done this after  a  simple  incision through the
soft parts; but now prefer the removal of a por-
tion of the integuments, in a longitudinal direc-
tion, as they are usually in  a thickened state,
and leave a large cavity which rather  prevents
the speedy healing of the wound."
PARTIAL  AMPUTATION  OF THE FOOT  AT
  THE JUNCTION OF THE TARSAL WITH
        THE METATARSAL BONES.
  The late Mr.  Hey, in the work last quoted,
relating the case  of Mary  Stanfield, whose me-
tatarsal bones were carious, gives the following
as the method he adopted in performing this
operation.
  " I made a mark across the upper part of the
foot to point out as exactly as I could the place,
where the metatarsal bones were joined to those
of the tarsus.   About half  an  inch from  this
mark, nearer the toes, I made  a transverse in-
cision through the integuments and muscles co-
vering the metatarsal bones.  From each  ex- 
140  AMPUTATION OF PART OF THE FOOT.
tremity of this wound, I made an incision along
the inner and outer side of the foot to the toes.
I removed  all the toes at their junction with the
metatarsal  bones, and then separated the integ-
uments  and  muscles, forming the sele  of  the
foot, from  the inferior part of the metatarsal
bones; keeping the edge of my scalpel as near
to the edge of the bones as I could that I might
both expedite the  operation, and preserve as
much muscular flesh in the flap as possible   I
then separated with the scalpel the four smaller
metatarsal  bones, at their junction with the tar-
sus; which was easily effected, as the joints lie
in a straight line across the  foot.   The project-
ing part  of the first cuneiforme bone, which
supports the  great toe, I  was obliged to divide
with the saw.  The arteries which required a
ligature  being tied, I applied  the flap, which
had formed the sole of the foot,  to the  integu-
ments which remained on the upper  part;  and
retained  them in contact by sutures.  A very
speedy union  of the  parts took place,  and  the 
      AMPUTATION OF PART OF THE FOOT.  141
 wound was healed, except a very small  super-
 ficial sore at the expiration of a fortnight."
   M. Lisfranc performs this operation without
 leaving any of the integument which is situated
 on the upper part of the metatarsal bones: he
 adopts the following process.
   The tourniquet being  applied to the femoral
 artery, just before the part  where that vessel
 passes through the tendon of the  triceps mus-
 cle, the heel is supported, and the  foot securely
 fixed by an assistant.   The operator passes the
 index finger of his left hand along the metatar-
 sal bone  of the little toe, till he feels its tube-
 rosity joining the os  cuboides, on which he
 places his left thumb.  In like manner be  car-
 ries the fore-finger of his right hand along the
 metatarsal bone which supports the great  toe,
 till he finds its head,  where  he places his left
 index finger,  and grasps the  sole of  the  foot
firmly in the palm of his hand.  He now, with
a narrow bladed amputating knife, makes a se-
milunar incision,  with its convex edge  towards
the toes, through the integuments and tendons,
• 
142   AMPUTATION OF PART OF THE FOOT.
beginning about half an inch before, and a little
below the point marked by his thumb  on the
outer side of the foot, and continuing across its
dorsum to about two lines, or one sixth of an
inch, before his index finger.  Keeping the foot
firmly giasped  in the palm of his hand, with the
point of his knife he cuts through the ligaments
connecting the fifth metatarsal to  the cuboid
bone, in an oblique direction, which, if continu-
ed, would pass through the head of the first me-
tatarsal bone.  Having cut the ligaments, which
join the two  next metatarsal to the cuneiforme
bones, less obliquely, he commences on the in-
ner  side of the foot by cutting the ligaments,
which connect the first metatarsal to the first
cuneiforme bone.  Then turning the point of his
knife  obliquely downwards and from him. the
handle being above and towards him, and using
considerable  force,  he cuts through the liga-
ment connecting the second metatarsal  to the
side of the first cuneiforme bone:  in doing this,
his  knife passes between  the two bones, its
handle describing the arch of a circle from him. 
CHOPART's OPERATION.         143
With the point of his knife, he now cuts through
the ligament connecting  the  upper part of the
second metatarsal to the second  cuneiforme
bone,  bending all  the metatarsal bones down-
wards to lay open the articulations,  when  he
divides the  ligaments on the under surface,  by
cutting obliquely across them.   Having sepa-
rated the metatarsal from the tarsal bones,  he
glides his  knife between the former  and the
muscles of the sole of the foot, and forms a flap,
of sufficient length, by cutting towards  the toes.
The arteries  being tied, the edges of the flap
are to be kept in contact with the integuments
on the  upper part of the foot, by sutures, or ad-
hesive plaster.
   In performing the operation  on the left ex-
tremity, the operator commences on the inner
side of the foot, making his first incision from
the great toe outwards.

AMPUTATION AT THE ARTICULATION OF
 THE ASTRAGALUS AND OS CALCIS, WITH
   THE SCAPHOID AND CUBOID BONES.
  M. Chopart was the first wh0 amputated at 
144        chop art's operation.
this part, it is  therefore called Chopart's «p-
reation.
   The articulation is  readily found by tracing
with the index finger from the  inner malleolus,
forwards  and  downwards, till the projecting
part of the scaphoid bone  is felt, which marks
the situation  of the joint on the inner side of
the  foot.  On  the outer side, it is  found an
inch from the tarsal head of the metatarsal bone
which supports the little toe.   These two op-
posed points being marked, one by the thumb
of the left  hand, and the other  by the index fin-
ger, while the  sole of the foot is grasped firmly
in the palm, and the leg steadily fixed by an as-
sistant: the operator, with a narrow bladed ampu-
tating knife, makes a semilunar incision through
the integuments  and  tendons,  extending from
the point before his thumb,  across the dorsum
of the foot,  to that  before his index finger.
Then, bending the foot, he opens  the  joint by
dividing the ligament which connects the Astra-
galus to the  Scaphoid bone.  He cuts through
the strong  ligaments  which join the  Calcis to 
          AMPUTATION OF THE LEG.      Hi
the Cuboid with the point of his knife, holding
it perpendicular, cutting transversely, and bend-
ing the part to be removed farther downwards.
Having cut through the articulation, he forms
a flap of sufficient length to cover the stump
from the sole of the foot, by cutting towards the
toes, between  the muscles and metatarsal bones.
The bleeding arteries being tied, the  edges of
the flap are to be kept in  contact with the inte-
guments surrounding the dorsum of the foot by
straps of adhesive plaster  or sutures.

AMPUTATION A LITTLE BELOW  THE MID-
      DLE OF THE LEG, WITH A FLAP.
   The femoral artery being compressed by the
tourniquet, the limb  is raised  and supported
by two assistants, one fixing the foot,  the other
the leg, at its upper part.  The operafor, stand-
ing on the inner side of  the limb, places the
thumb of his  left hand  on the inner border of
the tibia, and his fingers on the fibula; and with
a catling makes an incision through the integu-
ments, across the fore part of the leg, extending, 
146      AMPUTATION OF THE LEG.
from the outer edge of the fibula, to the inner
of the tibia.   He then pushes the catling behind
and close to  the bones, from the  inner to the
outer extremity of this incision, and forms a flap
of sufficient length, by cutting  down the leg.
This being held back by the assistant, the ope-
rator places the edge of his knife on  the poste-
rior surface of the fibula, and cuts  across it till
the point of his instrument reaches the interos-
seal space, through which he pushes it and cuts
through the muscles and ligament  situated be-
tween the bones.   Without raising  the knife
from the tibia, he draws it round that bone, cut-
ting through the muscular fibres and periosteum,
till he comes to its anterior  border;  where he
again passes it between the bones,  from above
downwards,  cuts through such fibres as were
not before divided, and withdraws the instru-
ment by cutting to  the posterior and outer edge
of  the fibula.  Having  ascertained  that the
bones are properly denuded, by passing his fin-
ger round them, he applies the saw; saws through
one third of the substance of the tibia, and then 
       AMPUTATION BELOW THE KNEE.    147
cuts both bones at the same time.  The ante-
rior and posterior tibial, and the peroneal arte-
ries being secured, the cut surface of the bones
is  covered by the flap,  and the edges of the
wound approximated by steaps of adhesive
plaster.
     AMPUTATION BELOW THE KNEE.
   The tourniquet is applied, and the extremity
 fixed by two assistants, as in the last operation.
 The operator  rests on his right knee,  on the
 inner side of the limb; and with a catling or an
 amputating  knife, makes a  circular incision
 round the leg through the integuments, six inch-
 es below the point  of the  patella, rising from
 the ground as he finishes the incision.   The as-
 sistant now draws  the integuments  upwards,
 while the operator reflects them back for  two
 inches, or more, according to the muscularity
 of the subject, by cutting through the cellular
 tissue which connects them to the fascia below:
then kneeling as before, he makes another cir-
cular incision, level with the base of the reflect- 
148    REMOVAL OF THE KNEE-JOINT.
ed skin, through the fascia and muscles down
to the bones.  He  passes the catling through
the interosseal space, draws it round the tibia,
and fibula, as in  the last operation; and removes
the leg, by sawing through both  bones  at the
same time. Ligatures being applied to the bleed-
ing vessels, the lips of the wound are to be kept
in contact by adhesive plaster; the line of union
extending from above downwards.

      REMOVAL OF THE  KNEE-JOINT.
   Mr. Park of  Liverpool performed this  ope-
ration twice.  One of his patients after linger-
ing four  months died; the other, who  was a
robust sailor, after many months confinement,
recovered.   Should the operation  be success-
ful, the limb would be but little better than a
wooden  leg; while  the situation in which the
patient would remain during  the  tedious and
protracted cure, would be infinitely more ha-
zardous than that after the operation of ampu-
tation above the knee.
   It may be practised in the following manner, 
          REMOVAL OF THE KNEE-JOINT.    149
 on the dead subject, for on the living I should
 scarcely believe  it would ever  again be  at-
 tempted.
    An assistant raising the thigh fixes it secure-
 ly, while the operator half bends  the leg; and,
 w ith a small amputating knife, makes a semi-
 lunar incision through the integuments, extend-
 ing from the side of the outer condyle of the
 femur, below the apex of the patella,  to an op-
 posite point on the  inner condyle,  if it be the
 right leg, and the reverse, if it be  the left.  He
 then makes a corresponding cut, beginning and
 terminating at  the same  points as the  former,
 but  passing above the  patella.  Now, cutting
 across the joint below  the patella in  the course
 of the first incision, he  exposes  the articular
 surfaces of the   bones, and divides the crucial
 ligaments with the point of his knife, taking care
 not to touch the popliteal artery.   These being
 divided, the assistant raises the thigh  nearer the
 body; while the operator presses the leg back-
 wards against it, and cuts round the posterior
part of the femur just above the condyles, so as
                    13* 
150  AMPUTATION OF PART OF THE THIGH.
to denude the bone at that part; still having a
watchful eye to the popliteal artery.  The mus-
cular and tendinous structure, on  the anterior
and lateral parts of the  bone, is now to  be  cut
in the  direction of the  incison,  passing above
the patella; and the bone, being  denuded, is to
be sawed through  immediately above its con-
dyles.   The lower part of  the femur and  the
patella being taken away, the upper part of the
tibia is to be carefully laid bare just below its
articulatory surface, by  cutting round the bone:
its cartilaginous surface is then to be sawed off,
beginning at the posterior part of the joint and
 sawing forwards, the leg being still bent on the
 thigh, and both securely fixed by  assistants.
 The upper extremity of  the tibia may  then be
 brought in contact with the lower end of the fe-
 mur, and the edges of the wound approximated.

 AMPUTATION OF THE LOWER THIRD OF
                 THE  THIGH.
   The patient should  be seated  on a  table of
 Convenient height, his back supported by pillows, 
    AMPUTATION OF PART OF THE THIGH.   151
the tourniquet applied as high up the limb as
possible, or the artery pressed against the pubes,
where it passes over that bone; and the extremi-
ty fixed by two  assistants, one supporting the
thigh,  the other the leg.   The operator, plac-
ing himself on the outer side of the limb,  and
kneeling on his right knee,  with a  full-sized
amputating  knife, makes  a circular  incision
through the integuments round the thigh, about
two inches above the patella in the same man-
ner as directed in the  amputation at the lower
part of the humerus.
   He then dissects back the skin for about three
inches, by cutting through the cellular texture
which  connects it to  the fascia and muscles be-
neath ; and while the assistant keeps it reflect-
ed, he makes  another circular incision close to
its base, through the more superficial muscles;
the deeper seated he  cuts through by a third in-
cision, a little higher up the limb,  which lays
bare the bone  at the  part where it is to be saw-
ed through.   A linen retractor is now applied,
and held by the assistant, to shield the divided 
 152 AMPUTATION AT MIDDLE OF THE THIGH.
 muscles from  the teeth of the saw, while the
 operator saws through the bone.   The femoral
 artery,  and others that bleed, being secured,
 the lips of the wound are to be kept in contact
 by straps of adhesive plaster,  and a roller ap-
 plied.

 AMPUTATION AT  ThE MIDDLE  OF THE
         THIGH, WITH TWO FLAPS.
   The  extremity should be fixed  by two assist-
 ants as  in the last operation, while a third press-
 es on the artery in the groin so as to interrupt
 the circulation.   The operator, standing on the
 outer side of the limb, makes the inner flap first
 by thrusting a  long bladed catling  from  the
 middle of the anterior, to the posterior surface
 of the thigh, passing  it on the  inner side of the
 femur close to the bone; and forms  the flap,
from two or three inches in length, by cutting
out obliquely.
  The femoral artery, divided by this incision,
is instantly to be secured.  The operator then
forms the outer flap, of the same length and
shape as the other, by passing the knife in and 
   AMPUTATION AT MIDDLE OF THE THIGH.  153
 out at the same points as before, but carrying
 it on the outer  side of the bone.
   The  undivided  muscular fibres  attached to
 the bone are divided by a circular incision close
 to the base of the flaps,  the edge of the knife
 being directed  obliquely towards  the  trunk,
 while the flaps are held back by the assistant
 The bone is then to be sawed through, observ-
 ing  that  the muscles  are protected from  the
 teeth of the instrument either by a retractor, or
 the  fingers of an assistant.  Any other vessels
 which require ligatures being taken up with a
 tenaculum, and secured,  the  flaps are to be
 placed in contact  with each other;  and so re-
 tained by straps of adhesive plaster and a roller.
  I  have heard it stated by a German surgeon,
 who had seen the practice, that Dr. Rock, Pro-
fessor of clinical surgery at the hospital of Mu-
nich in Bavaria, after performing this operation,
approximates the  flaps without securing  any
vessel; as he  finds keeping the cut surfaces in
perfect  coaptation sufficient to prevent after
bleeding. 
154   AMPUTATION  AT THE HIP-JOINT.
     AMPUTATION AT THE HIP-JOINT.
   Baron Larrey in the history of his  military
campaigns, mentions eight cases in which he
performed this operation; out of the number two
recovered; a third lived for a  month, at which
time the wound was nearly healed, when, owing
to the scarcity and badness of provisions, which
consisted of unripe fruits, bad potatoes, and sour
beer, he, with many other wounded,  died of
dysentery.   The operation has also been per-
formed  by British military surgeons during the
late wars.  On the dead  subject, I have  seen
M. Lisfranc perform it with amazing dexterity,
executing it  in  less  than ten  seconds.  He
adopts the following process.
   The nates of the patient resting on the edge
of the table, and the extremity being supported
by an assistant;  the operator  draws a  line, an
inch in length, from the anterior and superior
spinous  process of the ilium, straight down the
thigh.   From this point he marks another in-
wards towards the pubes, of half an  inch, so as
to form  a right angle.   On the inner extremity 
       AMPUTATION AT THE HIP-JOINT.    155
of the last, he places the point of a long bladed
catling,  and pushes it perpendicularly  down-
wards, till  it  strikes against  the head of the
femur: then, passing it on  the outer side of the
bone, he thrusts it  onwards, till it protrudes  at
about an inch from the margin of the anus.  He
now cuts outwards,  for near an inch, in order  to
get clear of the great trochanter, and forms the
external  flap, four or  five  inches in length, by
cutting down the limb between the musles and
bone.  The femoral artery, which may now be
seen, is to be compressed  between the  fingers
and  thumb of an assistant; while the operator
thrusts the knife in and out, at the same points
as before; but carrying it on the inner side  of
the head of the bone, he forms a smaller flap on
that  side  of the extremity.   He then, with the
point of his knife,  cuts through the capsular
ligament  surrounding the head of the femur,
dislocates the bone, and removes the limb by
dividing the round ligament, and the remaining
adhesions.   The blood vessels being secured
and  the  flaps approximated, the operation  is
concluded. 
156        FISTULA  LACHRYMALI9.
         FISTULA  LACHRYMALIS.
  A  narrow  straight bladed bistoury  with  a
groove near its back will be found the best in-:
strument for opening the duct, and affording a
ready passage for the probe or style.  The sit-
uation of the lachrymal sac may be discovered,
and  the  operation practised in the  following
manner.
   The patient being seated, and his head fixed
upright by an assistant; the operator places the
fore-finger of his left hand on the outer  angle
of the orbit, and stretches  the integuments by
drawing them outwards.   Then, with the same
finger of his right hand,  he traces  along the in-
ferior border  of the orbit,  till he  arrives near
the inner angle, where he  finds the sac situated
behind the tendon of the orbicularis muscle, just
within the orbitar margin.   Marking this  spot
and  holding his bistoury nearly perpendicular,
with its edge directed externally, its point down-
wards, backwards, and a little inwards towards
the os  unguis, he passes it through the  integu-
ments into the duct, and moves its  point slightly 
            FISTULA LACHRYMALIS.        157
 backwards and forwards, to certify that the in-
 strument has entered the canal; which is known
 by resistance being felt on  all sides.  Then,
 holding the bistoury with his left hand, he takes
 a small probe  between the  fore-finger  and
 thumb  of his right,  and sliding  it down the
 groove in the  bistoury, passes it into the nasal
 duct, withdrawing the bistoury as the probe
 enters the canal.   A nail headed style may af-
 terwards be worn in  the duct; should  the sur-
 geon deem it requisite.
   M. Dupuytren uses a conical tube, or hollow
 style, which he passes down  the groove of the
 bistoury into the duct, by means of a small iron
 instrument in form of a right angle, pointed at
 one extremity to  receive and support the tube,
 which being passed into the  duct, the instru-
 ment or support is withdrawn.  An engraving
 of the tube and its support may be seen in  the
notes to Mr. Travers's excellent work on  the
 Diseases of the Eye.
14 
15$      EXTIRPATION OF THE BYE.
       EXTIRPATION OF THE  EYE.
  Cancerous and malignant fungus diseases are
thoser for the removal of which,, this operation
is most generally required.
  Bartiach, a German oculist, was the first who
 published any account of the operation.  In per-
 forming  it he used a concave instrument with
 cutting edges, whkh he passed beneath the up-
 per  eyelid, and then scooped the eye from the
 orbit.
   When it is the eye only which is to be extir-
 pated k  may be done as follows.  The patient    '
 should either lie on his back with his head rest-
 ing  on pillows, or sit on a chair and support bis
 head against  the breast of an assistant.  The
 operator stands on  the opposite side of the pa-
 tient, to  that on which he is about to operate,
 and, with the fingers of his left hand placed at
 the external angle of the orbit, he draws the in-
 teguments outwards, while  with his right, he
 passes a straight bladed bistoury horizontally   f
 beneath the outer  angle formed by the  union
 of  the two palpebrae, and by turning its edge 
         EXTIRPATION OF  THE EYE.      159
and cutting out, he separates  them from each
other, and divides the integuments to the outer
angle of the orbit.  He then takes liold of the
globe of the eye  with a  hook, and  draws it a
little way out of the orbit, and keeping it in that
situation, passes his bistoury beneath tlie upper
eyelid  about  the middle  of the orbit, from
whence he  cuts  inwards,  and  completes  the
circle by carrying the instrument at one sweep
round  the globe of the eye; an assistant raising
and depressing alternately  the upper and under
eyelids.   My this circular incision the muscles
attached to the globe are cut through; when the
optic nerve, and other adhesions, are best divid-
ed  by  a pair of curved scissars.   The lachrymal
gland,  situated on the upper and outer side of
the orbit, is now to  be hooked down and cut
away.   The hemorrhage which follows the ope-
ration  will be suppressed by the application of
lint within the  orbit.   Light dressing should
then be applied.
   When the palpebraj partake of the disease it
is necessary to extirpate them with the eye: to 
160             TREPHINING.
effect this the hook should be passed from above
downwards through both lids, as well as a part
of the  globe  of the eye, which is  to be drawn
forwards, when the bistoury is introduced above
the upper eyelid and the operation  concluded
as before.
   In those cases M.  Dupuytren is  very par-
ticular in recommending that all the cellular
tissue within the orbit be removed,  in case it
should partake of the disease.
               TREPHINING.
   A fracture  of  the  skull,  with a portion of
bone depressed on the brain producing comatose
symptoms, is  one cause which frequently re-
quires  this operation.  It is also occasionally
necessary for  the removal of extravasated blood
or  purulent matter, or for the extraction of a
foreign substance lodged in the brain.
   There are certain parts of the skull on which
it  has been recommended not to apply the tre-
phine; such are the anterior and inferior angle
of the parietal  bone, where the middle artery of 
TREPHINING.
161
the dura mater  is situated, and  which, when
running  through a canal  in  the bone,  must
necessarily be wounded: but as in this case the
hemorrhage may be stopped by the application
of a little lint, or the vessel may be secured by
a pair of fine forceps should it be situated only
in a groove, the  danger arising from its division
ought not to be  placed  on a par with that of
permitting the cause of pressure,  or  irritation
to remain.  Over the different sutures and sin-
uses too, some surgeons have refrained to tre-
phine, in consequence  of the injury  the  dura
mater would sustain from its intimate connection
with the  bone at these parts being torn through,
or the danger which would arise from opening
the sinus itself;  but as  many  successful  cases
are related by Pott  and  others  in which the
operation has been performed over these  parts
the above objections appear to be  overruled.
  In order to practise the operation  as conve-
niently as possible the patient should  be placed
close to the edge of the bed, his head resting on
a thin  pillow, which should be  supported by
                     14* 
162             TREPHINING.
some solid substance, as a thick book, or a piece
of board, taking care, if possible,  to have  that
part of the  head where the trephine  is to be
applied the highest.
   The head  being  securely fixed by an assist-
ant, the scalp is to  be divided: if there be no
depression of bone,  a longitudinal incision made
in the direction of the fracture will be sufficient,
but if the bone be depressed, a crucial one will
 be required.  When there is no fear of wound-
 ing the brain in dividing the  integuments, the
 cut through them should be continued down to
 the bone, so as to raise, if possible, the pericra-
 nium  with the integuments.  If this be  not ef-
 fected the  pericranium must be divided  in the
 same  direction, and the bone  denuded  by dis-
 secting back that membrane.  The  trephine,
 having its central pin properly  arranged, is then
 taken by the  operator, who. holding the handle
 firm in the palm of his hand, rests his index
 finger on  the crown which he places over the
 portion of the bone that is to  be removed, the
 instrument being perpendicular to that  part of 
TREPHINING.              163
the scull on which it rests.   He now by a half
rotatory motion of his hand turns the instru-
ment, which  saws  into the substance of the
bone.  As soon as a sufficient channel is form-
ed to confine the  crown unassisted by the  cen-
tral pin, it is to be removed; or, as in the tre-
phines of  modern make, to be drawn up into
the column of the instrument. The crown now
used is so made as to clear itself of (he dust or
sawn particles, consequently there  is  no neces-
sity for brushing it as formerly;  however it will
be proper for the assistant either to brush, or
blow away the small portions  of  bone which
may lie round the edge of the groove.  The tre-
phine being again applied, the bone is to be far-
ther  sawed,  till the external table of the  scull
is cut through,  which is often to be known by
hemorrhage  from the diploe.   But as there is
frequently no diploe, especially  in  very young
or old subjects, it is always proper to examine
with  a  probe  to  what  extent the  bone  is cut
through.   The operation  is to  be continued
with  more caution,  lest the membranes of the 
164             TREPHINING.
brain be injured by the teeth of the trephine.
It will therefore be necessary to examine, from
time to time,  with a probe to ascertain if the
bone be sawn through at any one part.  As soon
as that is discovered to be the case, the elevator
is to be applied, and being used as a lever, with
the hand  for its fulcrum, the circular piece of
bone is, if possible, to  be raised.  Otherwise
the sawing is to be very cautiously prosecuted
where  the piece of bone appears most firmly
connected with the rest of the cranium; and for
this purpose,  if there be one at hand, the half-
trephine is the best instrument that can be used.
Should a  portion, splintered from the circular
piece, remain projecting from the inner table,
it should be broken off by a pair of forceps, or
cut away  with the lenticular knife.   The flaps
should  be placed smoothly over the circular
opening,  a mild dressing  applied  with  a soft
compress of lint, and a double-headed roller.
  In performing this operation the French sur-
geons  use the Trepan.   On the top or head of
the instrument,  which is constructed like a car- 
TREPHINING.
165
penter's whimble, or centre-bit, the operator
rests his chin, and  turns the instrument from
right to left till he has sawed through the bone.
Tbey say they give the preference to this instru-
ment because it does not require so much man-
ual force or pressure, as the trephine; in conse-
quence of which there is less danger of wound-
ing the membranes of the brain. 
166             CONCLUSION.
               CONCLUSION.
  The  author  trusts he has now fulfilled the
engagement made  in the  outset of his work,
and that the operations, though not detailed in
the most elegant language, are so described as
to be perfectly  intelligible to every professional
reader.   It may not be out of place to observe,
that,  with regard to the ultimate result of Sur-
gical operations in England and France, as far
as the author has had an opportunity  of noting,
a greater proportion of patients recover after
air6perarto«w in rhft r-nnaon, than in  the Paris
Hospitals:  this  may, in part, be accounted for
by the fact of patients being submitted to ope-
rations in Paris, on whom, in London, it would
be considered  useless to operate; at  the same
time it must not be forgotten, that some of the
leading French surgeons  are very jealous in
adopting any surgical improvement which may
have had  its origin on this side of the water;
witness the reluctance on their part to the heal-
ing of wounds  by adhesion.   After the opera-
tion for hernia, the lips of the incision  are not 
CONCLUSION.
167
brought in contact but remain asunder, and the
wound, filled with charpie, is left to granulate:
in consequence of this, peritoneal inflammation
generally succeeds,  to which the patient fre-
quently falls a victim.   Out  of  seven  cases of
this kind, which the author witnessed  at the
Hotel Dieu during the winter of 1821, one on-
ly recovered.  Nevertheless, in quickness and
dexterity of operating, the Surgeons of France
may rank before us; this, however, as is before
stated, must  be attributed to the  facility with
which they procure subjects, and the attention
they bestow upon the practice of operating ou
the dead. 
 
ADDITIONS
           BT THE

AMERICAN ED1TOB.
                CATARACT.
  The operations for the cure of obstructed
vision from this cause are performed by depress-
ing the opake lens into the lower and posterior
part of the eye; or by extracting  it entirely
through an incision made in  the cornea,  or
finally by  breaking down the lens and trusting
to its gradual absorption and disappearance.
  Until within some years past, the  discussion
ran on  the comparative merits of couching or
depression, and extraction, for the removal  of
cataract, but now, the most popular  method in
Britain and the United States is to introduce a
needle into the eye and break down the lens, as
recommended and practised by Saunders and
Adams.
         15 
170              COUCHING.
                COUCHING.
  The operation by couching or depression is
preferred in most cases by M  Dupuytren.
  The needle should be  slightly convex, sharp
at both edges, smooth on its convex  dorsum;
with one or more dots black or white according
to the colour of the  handle, on that side of it
corresponding to the convexity of the instru-
ment.  The patient being seated in a chair with
a high back to it, or, as M. Dupuytren prefers,
slightly raised in his bed. his head is supported
by an assistant, who at the same time fixes the
eye with his fingers, or a speculum, or elevator,
(the  first method is preferable).   A  piece of
linen or a napkin is thrown over the other eye.
The  assistant, if no  instrument is used for the
purpose, puts the points  of his fore and middle
finger on the  upper eyelid and raises it, at the
same time that he gives a slight  pressure te
the eyeball, but rests his fingers on the margin
of the orbit, so that  what pressure they give to
the eye may be steady.
   The surgeon sitting down before the patient, 
COUCHING.             171
 places his foot  upon a  stool of such a height,
 that when the elbow rests on the knee, the hand
 may be opposite to the eye.  Now with the fin-
 gers of one hand, he presses down the lower
 eyelid, and when he wishes  to fix the eye, as
 be is about to introduce his needle, be pushes
 upon the  eyeball with the point of his fingers.
 It is to be particularly observed, that any change
 of the degree of pressure on the eyeball, during
 the operation, is to be made by the  motion of
 the operator's fingers, the assistant has  only to
 keep steady.   So far the preliminary and by no
 means unimportant directions of Mr. Charles
 Bell.   The operation itself is we  think more
 clearly described by Lisfranc than  by  any other
 surgeon—It is as follows.
   Having  dipt the needle in oil, and taking it
 as you  would a  writing  pen, the  little finger
 resting on the cheek, introduce the instrument
 through the sclerotica, at a  small distance, a
line and a half to two lines from the border of the
cornea, in  the line of the transverse diameter of
the pupil, the edges of the needle being  outwards 
172              COUCHING.
and inwards  until the sclerotica is perforated.
When the point is in, let  the handle  rotate
gently on  the fingers till the dots on the handle
are turned towards you, that is, till the convexity
or back of the  needle is outward: pass it along
in this direction horizontally two  thirds of the
distance across the cornea., when it is distinctly
seen through the pupil; rotate the instrument
on the lens, so as to break adhesions and rupture
the capsule of the lens: pass on then the  needle
in its original position, with the dots outwards,
until the point has reached  the opposite, or in-
ner  angle of the eye: depress the handle,  turn
the dots upwards, then raise the  handle gradu-
ally giving it  a  sernirotation, so that when it has
got on a line with the upper part of the eye, the
dots, at first  upwards, may be turned outwards.
By this movement the concavity of the needle as
the handle is raised, presses the cataract down-
wards, and its sernirotation makes the convexity
turn slightly  outwards,  so that the  lens, while
 depressed, is also carried rather  backwards, as
 well as downwards,  thereby making allowance 
                 EXTRACTION.            173
for the figure of the globe of the eye, and the
curved course which the lens has to pursue in
its descent into  the vitreous  humour.  These
objects attained,  the needle is  carefully with-
drawn from the eye in a direction opposite  to
that in  which it had been introduced.
               EXTRACTION.
  The patient is  to  be seated in  a  low chair
before a  moderate light which strikes the eye
obliquely, aud a cloth put over the other eye:
an assistant standing  behind, brings his breast
so as to support the back of the head, puts his
left hand under the chin and with  his right tak-
ing the elevator of Pelier, or with his fingers he
raises the upper eyelid by pressing in the inte-
guments  of the eyelid betwixt the eyeball  and
margin of the orbit.   The operator, with the
tips of his fingers,  presses the  lower eyelid
against the eyeball, or, as Wathen. directs, he
is to place the fore and middle finger of his left
hand upon  the tunica  conjunctiva jost below
and a little on  the inside of the cornea.   The
                    15* 
174             EXTRACTION.
other hand holds the knife, the  elbow rests on
the knee, and the little finger on the outer side
of the eye, or on the cheekbone.   The point
of the knife is to enter  the cornea on the side
next  the  lesser angle  of the  eye, about one
tenth of an inch above its transverse diameter
and a little anterior to its connexion with the
sclerotica: the knife, thus introduced, is to be
pushed  on slowly but steadily in a straight di-
rection, with its blade parallel to the iris; so as
to pierce the cornea towards the inner angle of
the eye, on the side opposite to that which it
first entered, till one third part  of it is  seen to
emerge beyond the inner margin of the cornea,
and the point of the knife approaches the com-
missure of the eyelids  in  the greater angle of
the eye.  When the knife has reached  so far,
the puncturation or that part of the operation
which is preparatory to the section of the cornea
is completed. The broadest part of the blade is
now between the cornea and  iris; and its cutting
edge  below the pupil,  which, of consequence,
is out of all danger of being wounded by it. 
                EXTRACTION.             175
At this time, as every degree of pressure must
be taken off the globe of the eye, the  fingers
both  of the operator and his assistant, are to be
instantly removed from that part, and shifted to
the eyelids; these are to be  kept  asunder, by
pressing them gently against the edges of the or-
bit, and the eye itself is to be left entirely to the
guidance of the knife; by  which it may be rais-
ed, depressed or drawn on either side as shall
be found  necessary.   The  aqueous humour
being now partly, if not entirely evacuated, and
the cornea of course rendered flaccid, the edge
of the blade is  to be pressed slowly downward,
till it has cut its  way out and separated a little
more than half of the cornea from the sclerotica,
following the semicircular direction marked out
by the attachment of the one to the other.
  The incision  being finished, the eyelids are
to be shut; as it is desirable that the eye should
then  have rest for a few  minutes.   When the
iris is unusually convex, and in making the sec-
tion of the cornea  becomes entangled  before
the knife, the cornea is to be pressed on gently 
176             EXTRACTION.
with the finger, which  disengages it: or when
the eye-ball moves before the knife, we must
suspend, as it were, the progress of the knife,
but not in the slightest degree withdraw it; we
wait a little for the ceasing of the spasm, and
then with the knife bring back the eye to its ori-
ginal position.   Sometimes, from these causes,
the  opening is  insufficient;  then scissars are
used to enlarge it.   The cornea being divided,
it will-be found that the eye, which, before and
during the incidon, could not without difficulty
be kept from motion,  becomes  now quiet and
passive.
   The  next part  of  the operation consists in
puncturing Ihe  capsule of the lens, which is ef-
fected by introducing a needle made for the pur-
pose, through the wound iu the cornea,  into the
pupil, or in its  place,  the kistitome.  The an-
terior portion of the capsule is to be then open-
ed by either of these instruments; and a gentle
degree of pressure being made  on the eye the
pupil is observed gradually to enlarge, and one
edge of the lens is observed escaping through 
                EXTRACTION.             177
it; all  pressure  is to be immediately removed,
and the cataract escapes.
  Sometimes it is necessary to assist its escape
through the aperture in the cornea, by the use
of the  needle or scoop, by which  last, or the
concave end of the curette, are removed any
gross particles of the cataract or of the pigmen-
tum nigrum which remain in either of the cham-
bers of the aqueous humour,  or between the
lips of  the wound in the cornea, or between the
globe and lower eyelid.
  This being accomplished, the flap of the cor-
nea is to be smoothed, and the edges of the
wound  exactly adjusted to each other, by the
convex extremity of the curette, and by gently
rubbing the end of the finger over  the upper
eyelid when shut. The window shutters should
now be closed  in part, or the curtains drawn;
but if both these be wanting, the patient may be
turned  from the light,  and having continued in
that situation with his eyes shut for some  little
time, may then be permitted to open them again.
This will be a  good test of  the  success of the 
178             EXTRACTION.
operation; for if it has answered its end, the
patient will, with transport, immediately pro-
claim the return of his sight.
  If, however, we do not experience this hap-
py result, and find on examination that the cap-
sule of the  lens is opake,  it may now  be ex-
tracted by means of a small pair of forceps: but
in attempts of this nature, the utmost caution is
required, that the vitreous humour does  not es-
cape.  The eye should not be kept open long
at a time, and the attempts to extract the por-
tion of opake capsule should be repeated as of-
ten as necessary, but not continued more than
a minute at a time, and the eye, in the intervals,
should be covered with a small compress of fine
linen, wet with clear cold water.
  When the capsule, though lucid at the time
of the operation, becomes subsequently opake,
forming what is called secondary cataract, we
are directed to repeat the section of the cornea
and  remove  the opake membrane.
  After both couching and extraction,  the pa-
tient should  be kept  in a recumbent posture in 
EXTRACTION BY SIR WM. ADAMS' METHOD. 179
a room  somewhat daikened, with no dressing
to the eye, but a simple compress  loosely  ap-
plied.

               EXTRACTION
   BY SIR WILLIAM  ADAMS'S METHOD.
   Sir William Adams thinks that many of the
difficulties and unpleasant consequences attend-
ing the usual operation for extraction, may be
prevented by  the method  which he proposes,
and  which consists in the introduction of  the
needle,  as for couching, and forcing the lens
through the pupil into the anterior chamber of
the eye, from which it is extracted through an
opening made m the cornea.  The operation is
thus described.
  The eye is first prepared by the application
of a weak solution of belladonna over night, so
that the  pupil  may resume its natural  size as
soon as the opake lens has been placed in the
anterior chamber;  which would not be the case
were the solution made strong and applied but
a »hort time before the operation.   The first 
 180 EXTRACTION BY SIR WM. ADAMS' METHOD.
 part of the operation should be conducted pre-
 cisely as if the cataract were of the soft kind,
 by introducing the two-edged needle through the
 sclerotica, a line behind  the iris, with its  flat
 surface parallel to that membrane.   Its point is
 then to be directed through the posterior cham-
 ber, on a  line with the transverse diameter of
 the opake lens, when its edge should be turned
 backwards, and a complete division  of the cap-
 sule and lens be attempted.  If, upon trial, the
 lens be found too hard to admit of an immedi-
 ate division, the point of  the needle should be
 withdrawn a little, and then carried something
 below the  line of the transverse diameter of the
 cataract, when, upon making pressure with its
 flat surface against the latter body, it becomes
 dislocated,  and the upper part tilts forwards,
 through the pupil,  into the anterior  chamber,
 after  which, without any difficulty, it may be
entirely carried through the pupil, and with its
posterior part turned forwards.   When this is
effected, the operator, with the point of the nee-
dle, (taking care however,  not to wound the 
 EXTRACTION BY SIR WM. ADAMS' METHOD.  181
iris) should lacerate, or cut  in  pieces, the re-
maining part of the capsule,  throughout  the
whole extent of the circumference of the dila-
ted pupil, by which means" secondary cataract
is certainly avoided, unless an adventitious mem-
brane be formed,  in consequence  of inflamma-
tion.   Having accomplished this important part
of the operation, the needle is to be withdrawn,
when the operator should proceed to extract
the opake  body.
  The patient should  now be laid down on a
table on his back, with  the head somewhat rais-
ed, which is a far preferable position  to his sit-
ting in a chair, whereas the latter position is the
best for executing the primary  part of the ope-
ration, namely,  the bringing the opake lens in-
to the  anterior  chamber.  The operator then
makes ap  opening in the temporal margin of
the cornea, with a lancet or double edged ex-
tracting knife.   This opening is enlarged both
upwards and downwards, with  a small curved
knife,  in shape and size similar to the probe-
pointed knife described  by Baron Wenzel, with
         16 
182 EXTRACTION BY SIR WM. ADAMS' METHOD.
the button removed until it is made sufficiently
large to admit of the free passage of the lens;
through which a small hook is introduced, with
its flat surface between the anterior part of the
iris and the  posterior part of  the lens, which
should be carried to the centre of the pupil; the
curved point  is then turned forwards,  and the
cataract laid  firm nolo* of, when it is extracted
without any difficulty. By this means, the cata-
ract is extracted without any pressure being
made  upon  the ball,  and through  an opening
much smaller than what is required in the usual
operation of extraction.   Should the cataract
separate  while in the  act of extraction, which
is sometimes  the case if it be brittle, the frag-
ments may be extracted separately, either with
the hook or a small scoop.  Where, however,
the fragments are small, they  may be  suffered
to remain, as they are sure to sink to  the bot-
tom of the anterior chamber, where they usual-
ly dissolve before the opening in the cornea has
healed sufficiently to admit of the eye being
used; and as the opening is made vertically, at 
saunders's operation.
183
the outer margin of the cornea, they do not in-
terfere  with  its healing,  as would  be the case
were the section of the cornea made in the usu-
al manner.
  This operation is of course  only to be per-
formed when the lens is of too firm  a consis-
tence to be broken down and  passed into the
anterior chamber for absorption, which latter
is the favourite method of Sir William Adams,
to be hereafter described.
SAUNDERS' OPERATION FOR CONGENITAL
               CATARACT.
  This is also called Keratonyocia by the French
and German oculists.—We first prepare for the
operation by the use of the extract of bella-
donna, stramonium or hyosciamus diluted with
water to a moderate consistence, and dropped
into the eye.  In half an hour or an hour the
pupil is fully dilated, and the application should
be washed off.   The patient is confined in  a
proper position, and  in a  situation near the
window by a sufficient number of assistants, who 
184       saunders's operation.
take great care to fix the head motionless, and
to secure the limbs from moving.  The opera-
tor, seated on a high chair behind the patient,
takes the speculum in one hand and the needle
in  the  other.  He next secures the eye  by
making gentle pressure with a concave specu-
lum introduced under the  upper eyelid  with
his left hand, an assistant at  the same time de-
pressing the lower.  He then  penetrates the
cornea as near to its junction with the sclerotica
as it will admit the flat surface of the needle to
pass, in a direction parallel and close to the iris,
without  injuring  the  membrane.  When the
point of the needle has arrived at the centre of
the  dilated pupil, he proceeds with a gentle
lateral  motion working  with the  point  and
shoulders of the needle only on the surface and
centre of the capsule, in a circumference which
does not exceed the  natural  size of the pupil.
This object is permanently to destroy the cen-
tral  position of the capsule; merely to pierce it
would  not answer the intention, because the
adhesive, process will readily  close the wound. 
           saunders's  operation.       185
 Having acted upon the centre of the anterior
 lamella of the capsule to the desired extent, he
 gently sinks the needle into the body of the lens
 and moderately  opens  its texture.  In  doing
 this the edge of the needle may be inclined, by
 which motion the aqueous humour will escape,
 and the lens will approach his instrument; but
 at the same time the field  for operating will be
 diminished by  the contraction  of the pupil.
 The needle and  speculum are now  to be with-
 drawn, the eye is to be lightly covered and the
 patient put to bed.*
  In  some cases Mr. Saunders punctured the
 sclerotica and perforated the capsule from be-
 hind,  and  this  is the method more usually fol-
lowed at present.  It gives the surgeon  more
power and prevents the escape of the aqueous
humour, and consequent capsular adhesion to
the ins, while the process of absorption is also
accelerated.

      ' Dorsey's Surgery, Vol. I, page $40.
                    16* 
186         adams's operation.
    SIR WILLIAM ADAMS'S OPERATION.
  Sir William Adams at first followed the prac-
tice of Mr. Saunders, but has subsequently ob-
jected to it, on the ground that by leaving the
opake lens to be absorbed in situ, after lace-
rating the capsule, and  loosening  its  texture
with the needle, an  uneven pressure is made
by the broken fragments of that body  against
the  posterior surface  of  the  iris, frequently
giving rise to severe and dangerous inflamma-
tion, besides which, solution  and absorption of
them are by no means effected so rapidly,  as
when they are placed in  the anterior chamber.
   Sir William Adams thinks his improved ope-
 ration  for  "solid  cataract  in  children and
 adults" perhaps more extensively applicable, and
 one which has proved more generally successful,
 than any other, either ancient or modern.   It
 is thus performed:
   " Having secured the eye by making a gentle
 pressure with the concave speculum, introduc-
 ed under the upper eyelid, I pass the two edged
 needle through/ the sclerotic coat, about a  line 
ADAMS'S  OPERATION.         187
behind the iris, with the flat surface parallel to
that  membrane, it  is  then carried  cautiously
through the posterior chamber, without in the
slightest  degree interfering with  the  cataract
or its  capsule   When the point  has  reached
the temporal margin of the  pupil, I  direct it
into the anterior chamber,  and carry it^on as
far as  the nasal margin of the pupil, in a line
with the transverse diameter of the crystalline
lens.  I then turn the edge backwards and with
one stroke of the instrument, cut in halves both
the capsule and cataract.   By repeated cuts
in different directions, the  opake  lens and  its
capsule are divided in  many pieces, and  at the
same time I take particular care  to detach as
much of the capsule as possible from its ciliary
connexion.  As soon as this is accomplished, I
turn  the instrument in the same  direction  as
when it entered the eye, and, with its  flat sur-
face, bring forward  into the anterior chamber,
as many of the  fragments as I am able:  by these
means, the upper part of the pupil  is frequently
left perfectly free from opacity.  By cutting in 
188         ADAMS'S OPERATION.
pieces the capsule and lens at the  same time,
not only is capsular cataract generally  prevent-
ed, but the capsule is also much more easily di-
vided into minute portions than when its con-
tents have been previously removed.
   The needle which I employ in this operation,
is eight-tenths  of an  inch  long,  the thirtieth
part  of an  inch broad, and has a slight degree
of convexity through  its whole blade, in order to
give  it  sufficient strength, to penetrate  the
coats of the eye, without bending.   It is spear-
pointed, with both edges made as  sharp as pos-
sible to the extent of four tenths  of an inch.
Above the cutting part it gradually thickens, so
as to  prevent the  escape of the  vitreous  hu-
mour."*  Adams on Cataract, pp. 255-6.

   * Doctor Gibson has invented and used with success,
a scissar  so delicate as hardly to exceed in size the iris
knife of Sir William Adams.  Its edge is so construct-
ed as to operate like a knife, and of course it perforates
the coat  of the eye with great facility.   Its peculiar
advantages are, that when introduced, the blades may
be opened, and the leus being kept in situ, by one edge 
              ARTIFICIAL PUPIL.          189
             ARTIFICIAL  PUPIL.
    SIR WILLIAM ADAMS'S OPERATION.
  u For the purpose of dividing the iris,  I in-
troduce  the point of the instrument, through
the coats of the eye, about a line  behind that
membrane.  The point is next brought forward
through  the iris, somewhat  more than a line
from its  temporal ciliary attachment, and  cau-
tiously carried through the anterior  chamber,
until it nearly  reaches  the inner edge of that
membrane,  when it should be drawn nearly out
of the  eye,  making  gentle  pressure with the
curved part of the cutting edge of the instru-
ment, against the iris, in a line  with' its trans-
verse diameter.  If, in the first attempt, the divi-
sion of the fibres of the iris is not sufficiently ex-
tensive, the point of the knife is to be again car-
ried forward, and similarly withdrawn, until the
before and the other behind, it is cut to pieces without
injury to the iris or vitreous humour, while its remains
can be afterwards forced, by the shut blades, into the
anterior  chamber for dissolution.  See the Philadelphia
Medical and Physical Journal, No. 5. 
190          ARTIFICIAL PUPIL.
incision is of  a proper length.  I take care,
however, very freely at the same time to cut the
cataract in pieces. Some of these pieces I bring
into the anterior  chamber,  and leave the re-
maining portions in  the newly formed openings
of the iris.  These act as a plug in preventing
its  reunion by the first intention, and assist the
radiated fibres, in keeping the pupil more ex-
tensively open; by the time these fragments are
 dissolved,  the iris has lost  all disposition, or in-
 deed  power, of again contracting; its divided
 edges having by that time become callous, and
 being drawn  considerably apart by the perma-
 nent contraction of the radiated fibres."
    " In order to prevent the escape of the aque-
 ous and vitreous humour,  more especially in the
 very fluid state of the latter, I carry the instru-
 ment, with the edge turned backward, through
 the sclerotica and  iris, as when the  aperture
 through  these coats is made by turning the in-
 strument in  the way described by  Cheselden,
 (in a different position to that in which it enter-
 ed) it is thereby so much stretched open, that 
              ARTIFICIAL PUPIL.           191
the vitreous  humour escapes  in  great  abun-
dance, rendering the coats of the eye so flaccid,
that it is almost impassible afterwards to divide
the iris, there being then no sufficient counter-
resistance afforded to the action of the instru-
ment  to accomplish this object.  Instead, also,
of withdrawing  the  instrument out of the eye
at once, as recommended by him, I repeatedly
carry it forwards,  and then withdraw it  in the
same  line with the iris, making as gentle pres-
sure as if I were dividing fibre after fibre, un-
til the opening is full  two thirds  the extent of
the diameter of that  membrane; by this means
there  is no hazard of its reclosure, and little
fear of the iris becoming detached from the ci-
liary ligament, which  were, I conceive, the two
principal  sources of failure, when the  process
recommended by Cheselden was pursued."
  Adams employs, for this operation, " a small
curved-edged  iris  scalpel;  the cutting part of
which is similar in  form  to that of a dissecting
scalpel, and evidently much belter adapted to
divide the iris with  facility than the spear point- 
 192          ARTIFICIAL PUPIL.
 ed knife of Cheselden; until my present instru-
 ment was  constructed, I repeatedly failed with
 the other,  to accomplish the object intended."*
   The operation, as performed by Dr. Physick
 for artificial pupil, unites simplicity with facility;
 and is applicable also to cases of opacity of the
 cornea, where it is desirable to make an opening
 through the iris, opposite the lucid part of the
 cornea.
   The operator makes a section of the cornea,
 as for the extraction of cataract, and afterwards
 removes a portion of the  iris, by means  of a
 pair of forceps terminating in narrow extremi-
 ties, upon one of which is fixed a sharp circular
 punch.  The iris, in cases where the pupil  is
 obliterated, must  be punctured by the  point
 of the  knife, in making the section of the  cor-
nea, and then the  forceps can readily seize it.
  To  prevent  the obliteration  of  the pupil,
where the iris is inflamed, the use of belladonna
or stramonium  has been  recommended.  A

         * Op. citat. p. 269-70-74-75. 
          ECTROPION. ENTROPION.       195
great  dilatation of the pupil is  by this means
produced.

    ECTROPION, OR EVERTED EYELID.
  The operation for the relief of this disease,
i; consists in cutting out a portion of the lower
eyelid, resembling the letter V. The piece thus
removed, is one third of an inch wide at its up-
per part, the sides of the wound are  approxi-
mated by a stitch, and the diseased conjunctiva
cut off.   This effects invariably a complete and
speedy cure."

       ENTROPION OR TRICHIASIS.
  The eyelid, in  this disease is inverted upon
the eye,  and keeps up  a constant and violent
inflammation.   In the simpler kind of Trichia-
sis, which is owing to the growth or relaxation
of the outward  skin and cellular membrane of
the eyelid, the operation consists in simply cut-
ting out with the scissars a ply or double of the
skin of the eyelid of an oval form, which is held
         17 
194        SCHIRROUS TONSILS.
between  the finger and thumb, care being ta-
ken to avoid seizing the orbicularis muscle.
   But if  this  inversion  be a  consequence
of  ulcers  and contraction  of the  inner  and
cartilaginous  edge of the eyelid,  forming a
kind of stricture which prevents the inner edge
from rising  fully over the eyeball, and  which
drags in, and inverts the margin of the eyelid,
then a different  operation becomes  necessary.
The following is that recommended and suc-
cessfully  performed by Dr. Dorsey.  " A hook
is passed through the edge of the eyelid in  or-
der to gain a secure hold of it, and with a pair
of sharp  scissars the necessary portion of the
eyelid is removed by two or three cuts.  The
punctum lacrymale must be carefully avoided."
   The portion to be removed comprises all that
from which the cilia proceeded.

  EXTIRPATION OF SCHIRROUS TONSILS.
  Lisfranc  has recommended the extirpation
of schirrous tonsils by excision.  The  diseased
gland is to  be  seized with a hook, and dissect- 
             SCHIRROUS TONSILS.         195
ed out with a blunt pointed bistoury.  But the
difficulty of applying a cutting instrument, and
the risk of wounding important parts, (the dis-
tance between the tonsils and the carotid artery
being only half to three quarters of an inch  in
fleshy persons, and one third of an inch in thin-
ner  ones)  renders this  operation troublesome
and  hazardous.
   A much safer method is that by ligature, the
manner of applying which we borrow from Dr.
Physick, whose success  is the best guaranty for
the propriety of the means  he employs.
   The instrument which he describes and con-
stantly uses is a double canula about four inch-
es long, with short arms soldered  on the sides,
near one end of the instrument at right angles
to it.  Through the tubes is passed  a doubled
iron  wire, one end of which is fastened round
one of the arms of the  instrument  having the
other free and projecting five or six inches; by
which  the size of the noose may be increased
or diminished at pleasure.  The selection  of 
196
SCHIRROUS TONSILS.
a proper piece of wire is of much  importance.
It should be tough and flexible, formed of soft
pure iron, having firmness enough to allow of
its being pushed backwards and forwards in the
canula, without  bending too  easily, so that the
noose  may be  enlarged or  diminished.  The
wire Dr. Physick uses is about one twenty-fourth
part of an inch in diameter, or perhaps rather
less.   A pair of flat pliers should also be pro-
vided to take  hold of and move the wire con-
veniently.  Dr.  P. after enumerating the evils
attending the  usual method of applying  the
canifla, and indicated in  nearly the above words
the kind of instrument he uses, proceeds to de-
tail the different steps of the operation as follow.
   " —The noose formed by  the doubling of the
wire projecting beyond  the end of the instru-
ment, is to be made  large enough to pass easily
over the enlarged tonsil, and should  be bent a
little  to one side, in order that  it may  more
easily  be pushed down  upon the base of the
tumour.
   " The patient is to be seated opposite a win- 
             SCHIRROUS TONSILS.         197
dow,  and his tongue must be held down by an
assistant with the handle of a large spoon or
with^a spatula.  The surgeon is then to slip the
noose  over the tonsil,  and  down to its base,
taking care not to include the uvula,  which,
when the swelling is large, is  apt to be  in the
way.   The wire is then to be drawn sufficiently
to fix it loosely on the part, and the  surgeon  is
to satisfy  himself, by an attentive  inspection,
that it is properly applied.  This being accom-
plished, the wire  is to be taken hold of with the
pliers, and drawn through one side of the canu-
la, so as to secure it at once, on the base of the
tonsil as firmly as possible, and  then to  fasten
it on the arm  of the  instrument, and  thereby
prevent all entrance of fresh blood into  the tu-
mour.   This method of stopping the circulal ion
of blood in the swelling, necessarily occasions
severe pain at the moment, but the severity of
it soon ceases.
  u On examining the tonsil after a few miuutes,
its colour will be  observed to be  changed to  a
deep purple or almost  black,  and its  surface
                    17* 
198         SCHIRROUS TONSILS.
smooth  and polished,  owing  to  the exterior
membrane being stretched..
  " It has hitherto been my custom to allow the
instrument to remain thus applied for  twenty-
four hours,  with  the view of  destroying com-
pletely the life  of the  enlarged gland.   I am,
however, of opinion, that  a much shorter time
would be sufficient, as eight or twelve hours,
which I propose soon to ascertain.   After hav-
ing destroyed  the  life of the swelling by the
above means, the next step of the operation is
the removal of the instrument, which  is  very
easily accomplished in the  following manner.
Take a firm hold of the end of the canula pro-
jecting   from  the mouth, then  disengage the
wire  on one side  from the  arm of the instru-
ment; straighten  it, and with the pliers push a
small portion of it back through the canula, and
repeat this until the noose is so much enlarged
as to slip off the tonsil.
   The  operation  is now completed; the tumour
appears shrivelled  and of a dull white colour;
the patient suffers no pain;  the inflammation is 
         HEMORRHOIDAL TUMOURS.      199
moderate, and, after a few days, the dead parts
are separated and thrown off, either entire  or
in fragments, which are sometimes  spit out,
sometimes swallowed.  Until the separation is
completed, the breath is somewhat offensive.
I have never had any  trouble with the small
ulcer remaining after the separation of the tu-
mour   It has healed so rapidly as generally to
escape notice."

               EXTIRPATION
      OF  ILEMORRHOIDAL TUMOURS.
   Whatever difference of opinion may have for-
merly existed among surgeons, respecting the
comparative merits of removing haemorrhoidal
tumours by  ligature or by excision, the weight
of authority and experience is now decidedly
in favour of the first mentioned method, whether
we regard safety or  success.  Mr. Abernethy
does indeed still incline to the use of the knife,
and there are cases, as where the tumours are
completely  external,  which  may  justify  this
practice.  But,  remembering that the upper 
200      HEMORRHOIDAL TUMOURS.
haemorrhoidal veins empty into the lower mes-
enteric, and consequently, that from the former
to the liver there is no valve, we can never, un«
der the use of the knife or the scissars, be se-
cure  from  alarming and fatal  haemorrhages,
instances of which are  recorded  by Petit and
others,  especially from  cutting some  internal
haemorrhoids. " The operation is moreover in-
complete  unless the  whole  diseased parts are
taken  away and the  extremity of the gut con-
solidated by inflammation. This intention is best
fulfilled by the use of the ligature."   Such is
the language of Mr  Charles Bell; but we must
leape him, when we  would  describe  the  best
kind of ligature and  the simplest and happiest
method of applying it.  On this point we again
take the liberty of borrowing the directions of
Dr. Physick  as given in the same communica-
tion* from which we extracted for the steps of
the last operation.

  * The Philadelphia  Medical and Physical Journal,
No. I. Art.  2. 
         HEMORRHOIDAL TUMOURS.      201
  The length of the canula  should not exceed
two inches—we have seen it not longer than
one inch.   The wire, the same as that already
spoken of,  is to be drawn at once tight  round
the base of the tumour, by means of this instru-
ment, and " at the end of twenty-four hours, and
probably sooner, the wire may be removed, in
the  manner above explained. The tumour will
be found  shrivelled and black, and in a few
days will be separated and  thrown off,  under
the  application  of a soft poultice of bread and
milk."
  The degree of pain experienced by different
patients, varies  very much, without any assign-
able cau?e; ■" some patients making  no com-
plaint v\ hatever, even though two or three tu-
mours are operated on at the same time, while
others exclaim violently  from its intensity."
  " As soon as  the  wire is removed, the patient
is relieved from almost all  uneasy  sensations,
and the ulcer heals very  readily, as after the ex-
tirpation of the tonsil.   No one can  properly
appreciate the  advantages  resulting from the 
202     HEMORRHOIDAL TUMOURS.
above  method  of  removing haemorrhoidal tu-
mours, who has not seen them treated by allow-
ing the ligature to remain during the separation
of the  part. Under that mode of operating, the
patient is never at  ease during the whole time;
the discharge of the faeces is often excruciating;
even moving  in bed is dreaded; and in the last
case in which I performed the operation in that
manner,  the convulsive twitchings of the lower
extremities which were induced, became so fre-
quent and so violent, that I was uneasy, through
an  apprehension  of tetanus being  the conse-
quence.  It seems to me probable that one rea-
son of the difference between the  effect of a
wire and a common ligature may be. that how-
ever firmly the waxed ligature may be drawn
round, and tied on  the base of the tumour, be-
fore a second knot can  be tied to secure the
first, the elasticity of the parts compressed opens
the first a little, and of course the exclusion of
blood and nervous influence is not so complete
as when the wire is used, which can be fasten-
ed on the arm of the instrument, at the time 
         HEMORRHOIDAL TUMOURS.      203
when it is drawn round the swelling, as tight
as possible.   The pinch given by the wire is
soon destructive, and any degree of restoration
is rendered impossible.
  It might be supposed, if a thread were used,
it could be cut off after a short time; but the
swelling comes on so speedily, the parts retract
so much within the anus, and are so extremely
tender to the touch, that it is difficult to find the
noose: when found, the operation of dividing it,
either  with  knife or scissars,  is productive of
so much pain, that I have known some patients
refuse to submit to it. The removal of the wire
occasions no pain.
  It may be proper to mention that when the
tumour happens to be attached to the  inside of
the  anus anteriorly, some difficulty of voiding
urine is often complained of; but this symptom
always, in my patients, has subsided immediate-
ly after the removal of the wire." 
204         REMOVAL OP POLYPI.
           REMOVAL OF POLYPI.
   POLYPUS IN THE NASAL SURFACES.
  For the removal of this tumour the  forceps
is generally preferred.  The index finger of the
left hand is introduced into the posterior  nasal
fossae to protrude the polypus forwards, if it be
large,  and  with the right band and the forceps
applied as near the root as possible, it is seized
and extracted.
  Where it adheres so obstinately as not to per-
mit removal by traction,  a ligature is to be ap-
plied,  by means of the double canula,  which is
introduced along  the floor of the nostril, until
the wire appears in the throat behind the velum
palati.  It  is then seized  with the forceps or a
blunt hook, and by means of the fore and mid-
dle fingers of the right hand is pushed  beyond
the pendulous tumour and hooked up behind it,
so that the wire be applied round the root. The
ends of the wire are now, supposing the canula
to have been withdrawn, to be put  into the
tubes,  and  the instrument carried along until it
pushes  against  the forepart of the  root of the 
            REMOVAL  OF POLYPI.        205
tumour, and  has drawn  the noose or ligature
tight around the root.  It is then fixed by twist-
ing it about the wings of the nearer end.
   On the  second and every succeeding day the
noose is to be drawn tighter, until the root of
the tumour being cut  through  the instrument
comes away.   We are told to watch  when the
polypus becomes loose,  as it has  occasionally
separated  in the night time and endangered suf-
focation by falling over the glottis.
   The following case is worthy of every atten-
tion.  " A gentleman having suffered many un-
successful attempts for the removal of his poly-
pus, came to  Philadelphia and  consulted Dr.
Physick: he  found a large tumour projecting
behind the soft palate,  as low as the  extremity
of the. uvula, and filling completely the poste-
rior nares and cavity of the nose.  After vain
attempts to extract it in the usual manner  with
ligature and forceps, a piece of tape  was made
stiff by passing silver wire through it, and this
was fixed  on  the projecting part of the tumour
by a firm knot: the tape was now pulled forci-
          18 
206      POLYPUS OF  THE UTERUS.
bly and with it came away the polypus,  which
was of prodigious size."

        POLYPUS OF THE  UTERUS.
   The best and perhaps we  might add the only
instrument for removal of uterine polypus is the
double canula, the tubes  of which are made to
separate and  unite at pleasure, by means of a
connecting base or  third piece which can  be
adapted to them like a sheath.   The ligature is
to be passed through the tubes, which are to be
placed close together, and no loop is  to  be left
at the middle.   They are then to be carried up
along the tumour, generally  betwixt it and the
pubis.  Being slid up along  the finger  to the
neck  of  the polypus, one of them is firmly re-
tained in its situation by an  assistant,  and the
Other carried completely round the tumour, and
brought again to meet its fellow.  The two tubes
are then to be united by means of the common
base.   The ligature is thus made to encircle the
polypus, and, if necessary,  it may afterwards
be raised higher up with  the finger alone,  or 
        STRICTURE OF THE URETHRA.     207
with the assistance of a forked probe.   If the
first tightening of the ligature, by way  of  trial,
give no pain, it is to be drawn firmly,  so  as to
compress the neck of the tumour sufficiently to
stop the circulation.  It is then to be'  secured
at the extremity of  the canula; and as  the part
will become less in some time, or may not  have
been very tightly acted on  at first, the  ligature
is to be daily drawn tighter, and in a few  days
will make its way through.   After the  polypus
is tied, it is  felt to be more turgid and  harder;
and if  visible, it is found of a livid colour, and
presently exhales a fetid smell.  These are fa-
vourable signs.

     STRICTURE OF THE URETHRA.
  Of the different kinds of strictures,  those of
the  urethra  most  frequently engage  the atten-
tion of the surgeon.   The  three methods prac-
tised for their  relief are;  1st, Introduction of
the  bougie  or  catheter alone; 2nd, Introduc-
tion of the  bougie,  armed  with caustic;  3rd,
Section of the stricture by a cutting instrument. 
20S     STRICTURE OF THE URETHRA.
As the two first come rather under the head of
the manupilations of surgery than operations,
strictly so called,  we shall only notice the last.
  The division of a stricture,  by means  of a
cutting instrument, was first performed by Dr.
Physick in 1795, and in several instances since
that  time, he has repeated  the operation  with
success.  The instrument employed for the pur-
pose is a lancet,  concealed  in a canula:  when
the stricture is  seated anteriorly to the  bulb
of the urethra,  no danger or difficulty attends
the division of it by means of this instrument;
but if the stricture be situated at the bulb,  a ve-
ry accurate knowledge of  the anatomy of the
parts will be necessary, and  great caution in the
operation.  A small wound, however, of the
urethra,  made  with a  sharp lancet,  would oc-
casion  no great  trouble,  and would probably
heal  very readily.  The  urethra is generally
distended behind  the stricture, and of course it
is not easy to pass the  knife in a wrong direc-
tion.  After the stricture is cut through, a  flexi-
ble catheter should be introduced and kept in 
 STRICTURE OF THE RECTUM. HYDROCELE. 209
the bladder three or four weeks; after it is re-
moved,  a bougie should be frequently  intro-
duced."
  The success of this operation, and the exten-
sion of  a nearly similar  method  for  relieving
strictures of the rectum, are the  best answers
to the heedless censures of Mr. John Bell, on
introducing a cutting instrument  into the ure-
thra.
      STRICTURE OF THE RECTUM.
  Mr. Brodie has successfully operated for this
disease, by the cautious introduction of a straight
blunt-pointed bistoury, and slowly dividing the
strictured portion of the gut.

               HYDROCELE.
  Various operations have been proposed and
practised at different times for the radical cure
of hydrocele,  viz. Incision, Excision, Caustic,
Seton, Injection.
  The first,  or that -by  incision, consists  in
making a longitudinal incision, the length of the
                     18* 
210             HYDROCELE.
tumour, and filling up the cavity with lint, or
lint dipped in oil, or covered with cerate.  This
method was  recommended by  Celsus, and is,
we are told by Professor Giuntini, in his course
of operative Surgery, the favourite  one of the
surgeons of Florence.
   The operation by excision is executed by ex-
posing the tunica vaginalis testis and cutting off
as  much of it as possible so as to produce an
entire obliteration of the cavity.  This was also
proposed by Celsus.  It has been  practised by
 some  modern surgeons and was resorted to by
 Dupuytren in the case of a young man, with a
 large hydrocele, in the Hotel Dieu, in the month
 of July 1819.  He died on the eighteenth day
 after  the  operation  from  mortification of the
 testicle and scrotum and extensive inflammation
 of the chord, accompanied by tenderuess of the
 abdomen and inflation of the intestines.
    The operation by  the caustic and seton may
 be placed on the same  footing  as that by exci-
 sion and forbidden as hazardous and cruel.
    The practice of Injection first recommended 
HYDROCELE.             211
by Earle is now most generally adopted, and is
thus performed.  After having the patient seat-
ed on an elevated chair, the tumour is grasped
in the left hand of the operator so as to make it
tense, and  the trochar is passed  into the dis-
tended sac, in a direction rather obliquely up-
wards than directly forwards, care having been
taken  to ascertain the situation of the testicle
posteriorly.  Before the trochar is withdrawn,
it is necessary to ascertain the complete intro-
duction of the canula, which is to be held steadily
in, by slightly pinching up the scrotum against
its sides, until the sac is entirely emptied, so as
to prevent the effusion of the fluid into the cel-
lular membrane of the scrotum.
   If a  lancet be preferred to the trochar, for
 making the  opening, the introduction  of the
 canula  should be prompt to guard again the ef-
 fects just stated.
   A syringe, the pipe of which fits the canula,
 is then to be applied, and a portion of what-
 ever fluid  may be  preferred on the occasion is
 to be injected into the sac so as  to distend it to 
O]0
HYDROCELE.
its former dimensions.   Or a bag of gum elastic
with a pipe and stop cock may be adapted to
the canula,  and vvhen its contents are emptied
into the cavity of the sac, it may be unscrewed
from the pipe and the fluid suffered  to remain
in the requisite time, which varies from five to
ten minutes: it is then let flow out and the canu-
la withdrawn.
   The most critical part of the whole operation
is the injecting the sac, for unless the  canula be
well in the cavity, and kept there, the contents
of the syringe will be forced into  the cellular
membrane of the scrotum, and give rise to ex-
tensive sloughing, endangering the testicle and
even the life of the patient.  This  accident has
actually occurred in the hospital of the Charite at
Paris, with the two present celebrated surgeons
of that establishment.
  The method of cure proposed by Mr. Hunter
is very similar to that by incision.  It consists
in making an incision an inch in length at the
anterior  part  of the scrotum;  and,  after the
water is evacuated to introduce a quantity of 
HERNIA.                213
dough into the cavity, an assistant  keeping the
aperture sufficiently wide by two hooks—Inflam-
mation  followed  by granulations takes place;
and the cavity is  gradually filled  up.
                  HERNIA.
  The three most common kinds of hernia are,
1st,  Inguinal, or  Scrotal,  called  Bubonecele;
2nd,  Femoral, or Crural, called Merocele; 3d,
Umbilical, called Exomphalos. The minor sub-
divisions are named according to the  part pro-
truded, as Enlerocele or intestinal hernia; Epi~
plocele or omental hernia, &c.
  The difficulties of the operations for strangu-
lated  hernia have been much exaggerated, and
real   obstacles  created  by too  nice and  often
subtle division of membranes and fasciae cover-
ing the protruded  intestine.*  Two  or  three
  *The dangerous consequences of strangulation must
not be confounded with the difficulties of the operation.
The former are always great.   Out of six persons ope-
rated  on for hernia,  by  M. Dupuvtren,  (who ranks
among the very first surgeons in Europe) in the space
of tea days, four died. 
214    SCROTAL OR INGUINAL HERNIA.
dissections of hernia, and having been a wit-
ness to an operation for this  disorder, will  do
more to instruct the student, than the longest
lessons and most minute explanations.  But we
are not to be understood as  undervaluing  the
advantages, or denying the necessity, of correct
anatomical knowledge of the parts concerned
in hernia; the position and relative situation of
which ought to be  familiar to every  surgeon.
In lieu of the practical advantages just stated,
the plates of Cooper and Scarpa may be con -
suited.
     SCROTAL OR INGUINAL HERNIA.
  An attentive examination of the patient, and
study of the symptoms, presenting sufficient mo-
tives for the operation, it is conducted as follows:
  The patient is placed on a table, with  his
legs  hanging over its  end, his shoulders and
knees being a little raised by pillows,  in order
to relax the abdominal  muscles;  though some
surgeons prefer operating on the  patient in his
bed.  The pubes are next shaved; and we are 
       SCROTAL OR INGUINAL HERNIA.    215
directed in those cases, where no symptoms of
gangrene are present, and there is no stricture
at the neck of the sac, to limit the operation to
making an  incision with the scalpel through the
skin and cellular membrane, beginning an inch
from the abdominal ring, in the direction of the
fibres of the external  oblique muscle,  and ex-
tending nearly to the  bottom of the tumour, so
as to expose the abdominal ring and the portion
of the tendon forming it.  A small hole is to be
scratched with  the point of a scalpel  or bistou-
ry, through the tendon, half an inch  above the
ring,  in  a direction  upwards and  outwards,
towards the spine of the ilium: a director should
now be passed through the hole under  the ten-
don and out at the ring, on the groove of which
a bistoury is carried along, so as to divide the
tendon. This operation was first performed by
Petit, and has been practised by many surgeons
since his time. Dr. Physick, among others, re-
commends  it, urging,  with  great propriety, in
its favour the fact,  that  the surgeon,  could he
have accomplished the  return of the intestine 
216   SCROTAL OR INGUINAL HERNIA.
by the taxis, anterior to his dividing the tendon,
would have rested satisfied, without thinking of
opening  the hernial sac.
   Others with much plausibility and  apparent
caution prefer, in all cases, opening the sac and
seeing the condition of the strangulated intes-
tine.   The operation is thus conducted.   The
patient being properly placed and the  pubes
shaved, the surgeon takes hold of the tumour
with his left hand, and makes with a scalpel a
first incision  through the common integuments
only, beginning about an inch and a half above
the base of the tumour and reaching very near
the bottom of the scrotum.   The different apo-
neuroses or layers covering the hernial sac are
then in succession to be  slightly scratched, and
divided by pushing  a grooved director  under
them,  and carrying in its groove a bistoury up-
wards  and downwards, in the direction and to
the extent of the first incisions. In no instance,
after the first incision through the skin and loOse
cellular membrane, is the scalpel or bistoury to
be used with its edge downwards or on the lu- 
        SCROTAL  OR INGUINAL HERNIA.    217
 mour;  but always upwards, cutting out on the
 director.  In this  as in all other operations, safe-
 ty is more to be studied than despatch.   Some-
 times one or more small arteries are cut in the
 first stage of the operation,  which if they bleed
 freely may be  tied.   The sac being now expos-
 ed, it is to  be pinched up with the fingers or
 forceps, and a small opening made in it with the
 edge  of the instrument directed horizontally; a
 director is then introduced into the cavity,  and
 the opening enlarged by running a blunt point-
 ed bistoury on it both upwards and downwards.
 The finger next carried up to the neck of the
 sac enables the surgeon to ascertain the degree
 and extent of the stricture, and to choose whe-
 ther he will merely cut the strictured tendon., or
 the neck of the peritoneal sac,  or both.   Sir
 Astley Cooper  recommends dividing the stric-
 ture by passing the knife (bistoury) between the
 ring and the sac:  assigning as "a reason, that by
 thus leaving a larger portion of the peritoneum
 uncut, the cavity of the abdomen is more easily
closed.   But the common practice, at least on
          19 
218   SCROTAL  OR INGUINAL HERNIA.
the Continent,  is to carry up the blunt pointed
bistoury till it meet the stricture, when the blade
of the instrument, hitherto lying flat on the fin-
ger, is gently turned with its edge forwards, and
the stricture cut  by a slight raising of the  in-
strument  in  a direction directly upwards, nei-
ther inclining to the ilium nor the pubis.  Where
the  neck of the sac  will not  admit the end of
the finger, a director is  to be passed into it, and
the  probe pointed bistoury moved cautiously a-
long it, till it meets the stricture, and the mouth
of the sac and  the ring are to be cut in the di-
rection and  with  the precautions already given.
   A frequent situation, however, of the  stric-
ture, according to Sir A.  Cooper, is higher up
in the mouth of the sac, where it opens into the
abdomen, that is, an inch and a half to two inch-
es above and to the outer side of thering: it is
there produced by the  pressure of  the tendon
of  the  transversalis muscle  of  the abdomen,
which passes over it, and by the resistance of
the border of fascia which passes under it.  The
following is  in such a case the manner of ope- 
       SCROTAL OR INGUINAL HERNIA.   219
rating.  " The surgeon passes his finger up the
sac and through the  abdominal ring,  until  he
meets with the stricture;  he then introduces the
probe pointed bistoury with its flat side towards
the finger, but anterior to the sac, and between
it and the abdominal ring, his finger being still
a director to  the knife.  Thus he  carries the
knife  along  the fore  point of the sac  until  he
insinuates it under  the stricture formed by the
lower edge of the transversalis and oblique mus-
cles, and then turning the edge of the knife for-
wards, by a gentle  motion of its handle, he di-
vides the stricture  sufficiently to  allow the fin-
ger to slip into the  abdomen: the knife is then
to be withdrawn with its flat side  towards the
finger, as it was introduced to prevent any un-
necessary injury of the  parts.  The direction
in which this orifice  is divided is  straight up-
wards, opposite the middle of the mouth of the
sac, as  in this way  the  epigastric artery can
scarcely be cut,  whatever  be  its relative  situa-
tion with respect to the sac."
   It has been remarked  by some experienced 
220    SCROTAL OR INGUINAL HERNIA.
surgeons, particularly  Mr.  Charles Bell, that
this is a difficult operation, owing  to the firm
pressure of the transversalis muscle, and when
accomplished it is of doubtful efficacy, as it  is
probable  that  in  all cases above  a  few days
standing, the sac is more or less condensed, and
that when inflammation or compression has last-
ed for any considerable time, although the stric-
ture  may have been originally on the  outside  of
it, it is no longer entirely so.   In case the in-
cision then  of the neck of the herniary sac be
required, it is to be made, as in all the others,
directly upwards.
   If the  intestine and sac be connected by ad-
hesions, the greatest  caution and delicacy are
required  in opening the sac, and subsequently
in separating the intestines either from the sides
or neck of  the sac.  If the adhesions are new,
they  may be separated by the fingers; if con-
firmed, the sac should be dilated to its mouth,
and the tendon of the internal oblique should be
slit up to  the part at which the hernia descends
from  the abdomen. 
EPIPLOCELE.
221
               EPIPLOCELE.
  Where the hernia is entirely or part omental,
it may be returned, if after the operation the
omentum be in a healthy state;  but if gangrened
and dead, or very bulky,  a part of it should be
removed as follows.  " The surgeon raising the
omentum, whilst an assistant grasps it higher
up to prevent its return into the abdomen, cuts
it off near  the mouth  of  the sac. *  Some  small
arteries always bleed,  which are to be tied by a
fine ligature; and when the ha3morrhage is stop-
ped, the omentum is to be returned into the ab-
domen,  with its divided surface applied to uV
mouth of the sac, from which  the ligatures *re
suspended,  and it thus forms  a plug that shuts
up its cavity."   The  practice of tyinj tne ena*
of the omentum is now  generally abandoned,
for, as has  been correctly obs^ed, it " is but
substituting a ligature for the stricture  of the
omentum;  so that resuVsness, anxiety and fe-
ver;  pain of the bell/,  "ausea and vomiting;  in
short, peritonei inflammation and death  may
follow this."
                   19* 
222     CRURAL OR FEMORAL HERNIA.
  The treatment of the wound after the reduc-
tion of hernia consists in bringing together the
integuments,  (but  not the sac) by one or two
stitches, which  may be supported by adhesive
strips.   Above this a soft compress of lint and
of old linen is placed, and the whole secured by
a roller passed as a spica bandage.  It has been
very properly recommended, that when the pa-
tient is inclined to  cough, or  to have his bed
clothes  changed, he should  apply his hand on
the dressing.
     CRURAL OR FEMORAL HERNIA.
  The  patient is to  be placed on  a bed or  a
table *f a common height, with  the body lying
in a  hor'r^ontal direction  but the shoulders  a
little elevated-, the legs as high as  the  knees,
hanging over fw, edge of the table; and  the
thighs  a little bent v, order to relax the abdo-
minal muscles.   The ladder must be emptied
and  the diseased side  shaded.  A crucial in-
cision in the form of a T.  inverted h  then  to
be practised over the hernial tumour, by draw- 
        CRURAL OR FEMORAL  HERNIA.    22$
ing up a portion of the skin laterally betvveen
the fingers, and cutting this obliquely from above
inwards, an inch and a half above  the crural
arch in a  line with the  middle  of the tumour,
and downward to the centre of the tumour be-
low the arch.   A second incision nearly at right
angles with  the other is next made,  beginning
from the middle of the inner side of the tumour
and extending it across  to the outer side.   The
external pudendal artery is  sometimes divided
in the longitudinal incision and it is proper to
secure it before proceeding any farther.
   Having next disentangled the tumour from
the binding of  the general fascia of the  thigh,
we proceed as in the bubonecele by lifting up
the laminae with the fingers and carefully dis-
secting them one by  one, or by introducing the
director under each, and cutting on it.   Some-
times after the very first incision the sac  is laid
bare, and at  other times, if the hernia be very
small, may be  involved  in the inguinal glands
and again covered  by  cellular membrane in
a  state of  suppuration.  The last  investing 
224    CRURAL OR FEMORAL HERNIA.
membrane of  the sac, the fascia propria is lia-
ble without great attention to be mistaken for
the sac itself
   The sac being fully exposed it is to be open-
ed, and the cavitv exposed in the same manner
and with the same precautions as in the inguinal
or scrotal  hernia.
   A difference of opinion exists as to the direc-
tion in which the tendon causing the stricture
is to be cut.   Sir Astley Cooper directs the bis-
toury to be carried  obliquely upwards and in-
wards at right angles with the crural arch, and
Dupuytren, though formerly  in the practice of
cutting directly upwards, now makes his  inci-
sion in the same direction.   Mr. Charles Bell
says, that the incision  must be straight upwards
is  evident, neither  inclining inwards for we
will cut the cord, nor outwards where the epi-
gastric artery is before the knife: and Lisfranc
cites to his class, a surgeon of Lyons who has
operated eight or ten times in  femoral  hernia
with success and in all  cut  directly upwards.
The fact is, that if the edge of the  bistoury  be 
        CRURAL OR FEMORAL  HERNIA.    225
only slowly and steadily pressed against the ten-
don, till it be cut. without  interesting the ^oft
parts,  there  will be little danger by pursuing
either  of these methods.  In proof of this, we
may adduce  a case of crural hernia in which
" no part of the neck of the sac could be felt
free from the pulsation  of a very considerable
artery.  Dr. Physick very promptly divided the
stricture by cutting in the usual direction, but
taking great care to make a very small incision
or rather scratch with the point of the bistoury,
through the stricturing tendon."
  In the male subject,  where the hernia is so
large as not to be reduced after the incision of
the sheath  and  posterior edge of  the  crural
arch, and that it is required to divide the anterior
edge, the surgeon must proceed by making u an
incision through the tendon  of the external ob-
lique muscle over the mouth of the hernial sac,
about a quarter of an inch  above the crural arch,
which  will expose  the spermatic cord.   This
being drawn by thn finder,  ar by a curved line
and removed from the direction of tho i*^isioji^_
t he surgeon carries his finger into the sac, with 
226  EXOMPHALOS, OR UMBILICAL HERNIA.
the bistoury upon it, and the anterior edge of
the crural arch is cut without the smallest risk
to the spermatic cord."

  EXOMPHALOS, OR UMBILICAL HERNIA.
   The  method proposed by Dr. Physick, and
practised  by him and  Dr.  VVistar, is perhaps
preferable to any other. "' It consists in making
a crucial  incision  through the integuments of
the tumour, and dissecting the four angles thus
formed down to the neck of the sac; an opening
is next made into the sac, at its upper part, of
a sufficient size to afford a view of its contents;
should these be sound they are to be reduced,
if  practicable, without  dilating  the  umbilical
aperture; but if this can not be done,  that aper-
ture is to be enlarged outside of the sac, taking
care not to wound the neck of the sac.   When
the contents of the  sac are reduced,  a ligature
is to be  tied round its neck."
  Umbilical hernia in young subjects has been
treated by Desault with success,  in upwards of
fiftV case* kj* tt H^ature. The process ia a sim-
ple one: The protruded viscera being returned 
    EXOMPHALOS, OR UMBILICAL HERNIA.   227
into the cavity of the abdomen, the opening is
pressed on by the surgeon with one hand, while
with the other he raises the sides of the sac,
and ascertains that no part remains unreduced.
A waxed  ligature  is then to be passed  several
times round the basis of the empty sac,  and se-
cured  at each  turn by a double knot, drawn
tight  enough to occasion an  inconsiderable de-
gree of pain.   " The tumour  is to be covered
with lint,  over which compresses are to be ap-
plied, secured by a bandage and shoulder straps.
In a day after the first  ligature is applied, the
parts enclosed within it shrink, and it becomes
necessary to tie a second ligature considerably
tighter. A third ligature, some  days after, often
becomes necessary.   In eight  or ten days the
tumour falls off, and leaves a small ulcer, which
speedily heals.   Although  the  umbilicus  is by
this time sufficiently firm to resist  the  protru-
sion of the  viscera,  yet prudence dictates the
propriety of a bandage and compress for seve-
ral months.*   The  probability of the cure di-
  *Dr.  Physick,  with his characteristic attention to 
 228  EXOMPHALOS, OR UMBILICAL HERNIA.
 minishes with the age of the patient, and in De-
 sault's hands, it failed in a girl aged nine years.
 The operation should therefore be recommend-
 ed and performed early."
   The use of the ligature is thought unneces-
 sary and even improper by some surgeons, who
 assert that compression 'carefully and  steadily
 applied, is sufficient to bring about the  gradual
 obliteration of the hernial orifice in young sub-
jects.
   In the disease, as it is met with in adults, omen-
tum is the part most  generally protruded, and,
in some  cases of long standing, is adherent to
the sac; and even where this last is absorbed, it
is joined by adhesion to the common external
fat. All surgeons concur then in directing great
caution to be used in exposing the contents of
the tumour, by incisions made on it. They, par-
every circumstance which can possibly impede the cure,
after a surgical operation, urges the propriety and neces-
sity of keeping the abdomen as relaxed and of as redu-
ced a size as possible, by restricting tbf f oung patient to
soft food, principally rye mush, and sugar and water. 
     EXOMPHALOS, OR UMBILICUS HERNIA. 22^
liculaily Scarpa and C. Bell, recommend a se-
micircular incision on one side of it;  and by a
cautious dissection of the outer lamina, to en-
deavour, without opening the sac, to get within
the margin of the  tendon,  which, being cut by
the probe-pointed  bistoury, the hernia  may be
reduced, or the last portion of the intestines,
which has perhaps fallen into the interstices of
the old  contents, may be returned.  The direc-
tion usually recommended for cutting the stric-
turing tendon  is upwards.  Scarpa  advises it
downwards in the true umbilical hernia, and
transverse or laterally in a line perpendicular to
the linea alba,  when the protrusion is between
the parts of that tendon and not through the navel.
   If the opening  thus  made be still  too small
for the  return of the contents of the sac, that
part of the latter embraced by the stricture, may
also be  cut, so as to admit the finger.
2.0 
220
HYDROCELE.
             HYDROCELE BIS.
   We omitted to notice, under this head, the
very neat and mild method of Baron Larrey,
for the cure of  hydrocele.   The first^ steps of
the operation are the same as for injection.
Puncturing the  sac with a trochar, introduction
of the canula, and evacuation of the contents.
But in place of a stimulating fluid, a small flat
tube of gum elastic, is passed in through the
canula, into the sac, and the canula being with-
drawn, the tube is left in for twenty-four hours,
nipre or less, according to circumstances, so as
to excite inflammation,  followed by adhesion,
and thereby  accomplish a radical cure.   If the
parts  be slow in taking on the inffammatory
process, the  tube may be gently  moved about,.
so as to irrftato the tunica vaginalis.

                 THE END. 
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